https://journals.lww.com/anesthesia-analgesia/pages/collectiondetails.aspx?TopicalCollectionId=69 en-us Thu, 24 Jul 2025 22:05:15 -0500 Wolters Kluwer Health RSS Generator https://images.journals.lww.com/anesthesia-analgesia/XLargeThumb.00000539-202508000-00000.CV.jpeg https://journals.lww.com/anesthesia-analgesia/pages/collectiondetails.aspx?TopicalCollectionId=69 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/08000/pharmacokinetics_of_methadone_in_adult_patients.23.aspx BACKGROUND: Cardiopulmonary bypass (CPB) induces profound physiological changes that may alter the pharmacokinetics of methadone. We aimed to describe the pharmacokinetics of an intravenous bolus of methadone racemate in adult patients undergoing heart surgery with CPB. METHODS: We prospectively studied 29 patients aged 45 to 75 years scheduled for cardiac surgery with CPB who received methadone 0.2 mg/kg after anesthesia induction. Arterial blood samples (n = 10) were taken, before, during, and after CPB. Pharmacokinetic analysis was undertaken using nonlinear mixed effects models. RESULTS: All patients completed the study. The median [interquartile range] methadone concentrations decreased from 34.8 [23.9–48.2] ng/mL (10 minutes before CPB) to 18.2 [9.9–26] ng/mL after 60 minutes of CPB (P < .001). A 3-compartment model adequately described the observed changes in methadone concentrations. The influence of CPB on methadone pharmacokinetics was best described by hemodilution in a fixed volume of 1.5 L (CPB circuit volume) and by sequestration from the CPB components (CLSEQ = 93.4 L/h, 95%CI 59–124, P < .01). The observed effect of CPB in methadone pharmacokinetics can be compensated by giving a supplementary bolus dose of 0.05 mg/kg at the end of CPB. CONCLUSIONS: Our results confirmed a decay in methadone concentrations during CPB, which, in our modeling analysis, was attributed to hemodilution and sequestration within the CPB components.]]> Thu, 21 Nov 2024 00:00:00 GMT-06:00 00000539-202508000-00023 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/08000/xenon_and_argon_as_neuroprotective_treatments_for.18.aspx Xenon and argon are currently being evaluated as potential neuroprotective treatments for acquired brain injuries. Xenon has been evaluated clinically as a treatment for brain ischemia with equivocal results in small trials, but argon has not yet undergone clinical evaluation. Several preclinical studies have investigated xenon or argon as treatments in animal models of perinatal hypoxic-ischemic encephalopathy (HIE). A systematic review of MEDLINE and Embase databases was performed. After screening of titles, abstracts, and full text, data were extracted from included studies. A pairwise meta-analysis of neuroprotective efficacy was performed using a random effects model. Heterogeneity was investigated using subgroup analysis, funnel plot asymmetry, and Egger’s regression. The protocol was prospectively registered on PROSPERO (CRD42022301986). A total of 21 studies met the inclusion criteria. The data extracted included measurements from 1591 animals, involving models of HIE in mice, rats, and pigs. The meta-analysis found that both xenon and argon had significant (P < .0001) neuroprotective efficacies. The summary estimate for xenon was 39.7% (95% confidence interval [CI], 28.3%–51.1%) and for argon it was 70.3% (95% CI, 59.0%–81.7%). The summary effect for argon was significantly (P < .001) greater than that of xenon. Our results provide evidence supporting further investigation of xenon and argon as neuroprotective treatments for HIE.]]> Fri, 25 Oct 2024 00:00:00 GMT-05:00 00000539-202508000-00018 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/07000/optimal_infusion_rate_of_norepinephrine_for.5.aspx BACKGROUND: Norepinephrine has recently been suggested to be as effective as phenylephrine for the prevention of hypotension after spinal anesthesia for cesarean delivery. Moreover, compared to phenylephrine, norepinephrine may be superior in maintaining heart rate (HR) and consequently, cardiac output (CO). A recent study demonstrated that norepinephrine given as a single intravenous bolus is approximately 13 times more potent than phenylephrine. However, it is uncertain whether this finding can be applied when these vasopressors are administered as infusions. Therefore, the optimum infusion rate of norepinephrine remains unknown. We aimed to determine the median effective dose (ED50; defined as the rate of vasopressor infusion required to prevent spinal hypotension in 50% of subjects) of both drugs needed to maintain maternal systolic blood pressure within 20% of the baseline after spinal anesthesia for cesarean delivery and to derive the relative potency ratio. METHODS: Sixty healthy patients undergoing elective cesarean delivery with standardized spinal anesthesia were randomized into 2 groups. The first patient in group 1 received phenylephrine 1200 µg in normal saline 0.9% w/v 60 mL at 60 mL/h infusion rate (20 µg.min−1). The first patient in group 2 received norepinephrine 96 µg in normal saline 0.9% w/v 60 mL at 60 mL/h infusion rate (1.6 µg.min−1). Using up-down sequential allocation technique, the vasopressor dose for every subsequent patient was determined by the response in the previous patient. If effective, the next patient received a dose reduced by 150 µg of phenylephrine (2.5 µg.min−1) or 12 µg (0.2 µg.min−1) of norepinephrine. If ineffective, the dose for the next patient was increased by the same amount. The ED50s were determined according to the Dixon-Massey formula. Stroke volume (SV), HR, and CO were also measured. RESULTS: The ED50 was 12.7 µg.min−1 (95% CI, 10.5–14.9) for phenylephrine and 1.01 µg.min−1 (95% CI, 0.84–1.18) for norepinephrine, giving a potency ratio of 12.6 (95% CI, 9.92–15.9). HR, SV, and CO did not differ between the groups. CONCLUSIONS: Norepinephrine is more potent than phenylephrine by a factor of approximately 13 when administered as infusion for equivalent maternal blood pressure control. Based on these findings, we recommend a variable rate prophylactic infusion of norepinephrine to be initiated at 1.9 to 3.8 µg.min−1 for the management of hypotension during cesarean delivery under spinal anesthesia.]]> Wed, 09 Oct 2024 00:00:00 GMT-05:00 00000539-202507000-00005 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/07000/effect_of_treatment_with_balanced_crystalloids.22.aspx BACKGROUND: Some studies suggest that balanced solutions may improve outcomes in critical care patients. However, in patients with traumatic brain injury (TBI) existing data indicate that normal saline may be preferred. We hypothesized that mortality in critically ill patients with and without TBI would differ with the use of balanced salt solutions versus normal saline. METHODS: We conducted a systematic review and meta-analysis to investigate the impact of balanced crystalloids versus normal saline on 90-day mortality in adult critical care patients with and without TBI. Secondary outcomes included length of hospital stay, renal complications, need for vasopressors or mechanical ventilation, and mortality in critically ill patients with sepsis. We followed the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) statement and estimated the odds ratio (OR) and 95% confidence interval (CI) with a random-effects model. RESULTS: We included 15 clinical trials involving 35,207 patients. The OR of mortality with balanced solutions versus saline in patients without TBI was 0.93 (95% CI, 0.87–0.98; P = .01; I2 = 0%), while the OR for mortality in patients with TBI was 1.31 (95% CI, 1.03–1.65; P = .03; I2 = 0%). We found no differences in secondary outcomes due to fluid choice although data were unavailable to calculate pooled estimates for some of the secondary outcomes for TBI patients. In patients with sepsis, the OR of mortality with balanced solutions was 0.92 (95% CI, 0.83–1.02; I2 = 0%). CONCLUSIONS: In comparison to normal saline, balanced solutions were associated with a reduction in mortality in critical care patients without TBI. However, balanced solutions were associated with an increase in mortality in patients with TBI. These findings suggest that the effect of fluid choice on intensive care unit (ICU) outcomes may depend partially on the type of critical illness and in particular in patients with TBI.]]> Mon, 20 Jan 2025 00:00:00 GMT-06:00 00000539-202507000-00022 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/06000/preoperative_atelectasis_in_patients_with_obesity.25.aspx BACKGROUND: Pulmonary atelectasis is present even before surgery in patients with obesity. We aimed to estimate the prevalence and extension of preoperative atelectasis in patients with obesity undergoing bariatric surgery and to determine if variation in preoperative Spo2 values in the seated position at room air is explained by the extent of atelectasis coverage in the supine position. METHODS: This was a cross-sectional study in a single center specialized in laparoscopic bariatric surgery. Preoperative chest computed tomographies were reassessed by a senior radiologist to quantify the extent of atelectasis coverage as a percentage of total lung volume. Patients were classified as having atelectasis when the affection was ≥2.5%, to estimate the prevalence of atelectasis. Crude and adjusted prevalence ratios (aPRs) and odds ratios (aORs) were obtained to assess the relative prevalence of atelectasis and percentage coverage, respectively, with increasing obesity category. Inverse probability weighting was used to assess the total, direct (not mediated), and indirect (mediated through atelectasis) effects of body mass index (BMI) on preoperative Spo2, and to quantify the magnitude of mediation (proportion mediated). E-values were calculated, to represent the minimum magnitude of association that an unmeasured confounder with the same directionality of the effect should have to drive the observed point estimates or lower confidence intervals (CIs) to 1, respectively. RESULTS: In 236 patients with a median BMI of 40.3 kg/m2 (interquartile range [IQR], 34.6–46.0, range: 30.0–77.3), the overall prevalence of atelectasis was 32.6% (95% CI, 27.0–38.9) and by BMI category: 30 to 35 kg/m2, 12.7% (95% CI, 6.1–24.4); 35 to 40 kg/m2, 28.3% (95% CI, 17.2–42.6); 40 to 45 kg/m2, 12.3% (95% CI, 5.5–24.3); 45 to 50 kg/m2, 48.4% (95% CI, 30.6–66.6); and ≥50 units, 100% (95% CI, 86.7–100). Compared to the 30 to 35 kg/m2 group, only the categories with BMI ≥45 kg/m2 had significantly higher relative prevalence of atelectasis—45 to 50 kg/m2, aPR = 3.52 (95% CI, 1.63–7.61, E-value lower bound: 2.64) and ≥50 kg/m2, aPR = 8.0 (95% CI, 4.22–15.2, E-value lower bound: 7.91)—and higher odds of greater atelectasis percentage coverage: 45–50 kg/m2, aOR = 7.5 (95% CI, 2.7–20.9) and ≥50 kg/m2, aOR = 91.5 (95% CI, 30.0–279.3). Atelectasis percent alone explained 70.2% of the variation in preoperative Spo2. The proportion of the effect of BMI on preoperative Spo2 values <96% mediated through atelectasis was 81.5% (95% CI, 56.0–100). CONCLUSIONS: The prevalence and extension of atelectasis increased with higher BMI, being significantly higher at BMI ≥45 kg/m2. Preoperative atelectasis mediated the effect of BMI on Spo2 at room air in the seated position.]]> Fri, 23 Aug 2024 00:00:00 GMT-05:00 00000539-202506000-00025 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/06000/lassen_s_cerebral_autoregulation_plot_revisited.23.aspx Niels Lassen’s seminal 1959 cerebral autoregulation plot, a cornerstone in understanding the relationship between mean arterial pressure (MAP) and cerebral blood flow (CBF), was based on preexisting literature. However, this work has faced criticism for selective data presentation, leading to inaccurate interpretation. This review revisits and validates Lassen’s original plot using contemporary data published since 2000. Additionally, we aim to understand the impact of vasoactive drug treatments on CBF, as Lassen’s referenced studies used various drugs for blood pressure manipulation. Our findings confirm Lassen’s concept of a plateau where CBF remains relatively stable across a specific MAP range in awake humans with normal brains. However, significant variations in cerebral autoregulation among different populations are evident. In critically ill patients and those with traumatic brain injury, the autoregulatory plateau dissipates, necessitating tight blood pressure control to avoid inadequate or excessive cerebral perfusion. A plateau is observed in patients anesthetized with intravenous agents but not with volatile agents. Vasopressor treatments have population-dependent effects, with contemporary data showing increased CBF in critically ill patients but not in awake humans with normal brains. Vasopressor treatment results in a greater increase in CBF during volatile than intravenous anesthesia. Modern antihypertensives do not significantly impact CBF based on contemporary data, exerting a smaller impact on CBF compared to historical data. These insights underscore the importance of individualized blood pressure management guided by modern data in the context of cerebral autoregulation across varied patient populations.]]> Mon, 04 Nov 2024 00:00:00 GMT-06:00 00000539-202506000-00023 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/05000/the_association_between_fluid_management_and.29.aspx BACKGROUND: Both intraoperative hypotension and excessive fluid administration can lead to detrimental perioperative complications. However, how much fluid is considered excessive and how is intraoperative hypotension related to major postoperative complications? METHODS: We conducted a single-center retrospective cohort study in 6243 patients undergoing complex spine surgery at the Cleveland Clinic Foundation between 2012 and 2022 and studied the relationship between intraoperative net fluid administration and intraoperative hypotension with major postoperative complications. The primary outcome was a collapsed composite of postoperative complications including acute kidney injury (AKI), myocardial infarction (MI), stroke, and intensive care unit (ICU) admissions. Secondary outcomes were in-hospital postoperative pulmonary complications, surgical site infections (SSI), and mortality. RESULTS: The study consisted of 6998 complex spinal surgery cases from 6243 patients. The median net fluid administration was 2100 mL (Interquartile range: 1450 to 3020 mL), and we found a change point in net fluid administration of 1865 mL (95% Confidence Interval: 1228 to 4710 mL). The odds ratio of developing postoperative complications for every 500 mL increase in net fluid administration was 1.16 (95% confidence interval [CI], 1.11–1.21; P < .0001) above and 0.87 (95% CI, 0.77–0.98; P = .026) below the change point. The odds ratio of developing postoperative pulmonary complications was 1.12 (95% CI, 1.07–1.18; P < .0001) for every 500 mL increase in net fluid administration. Intraoperative hypotension was detected in 2052 complex spine surgeries (29%). The odds ratio of developing any postoperative complication was 1.57 (95% CI, 1.37–1.80; P < .0001) and 1.30 (95% CI, 1.04–1.61; P = .019) for postoperative pulmonary complications. CONCLUSIONS: We discovered a change point in net fluid administration of 1,865mL. Above this change point, higher net fluid administration is associated with increased odds of developing postoperative complications. Intraoperative hypotension in complex spine surgeries was associated with increased postoperative complications.]]> Thu, 01 May 2025 00:00:00 GMT-05:00 00000539-202505000-00029 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/05000/risk_of_acute_complications_with_rocuronium_versus.2.aspx BACKGROUND: Neuromuscular blocking agents (NMBAs) play an integral role in modern anesthesia by facilitating endotracheal tube placement, assisting with mechanical ventilation, and creating optimal surgical conditions. However, NMBAs can have deleterious side effects. The purpose of this study was to retrospectively analyze acute complications of 2 pharmacodynamically similar but pharmacokinetically different NMBAs and their respective reversal agents. METHODS: The global research network database, TriNetX, was used to evaluate deidentified patient information from 63 health care organizations. Cohort A was defined as patients aged 18 to 80 years who had chronic kidney disease (CKD) and were administered rocuronium with sugammadex. Cohort B was defined as patients aged 18 to 80 years who had CKD and were administered cisatracurium with neostigmine. Cohorts were propensity matched for age at event, ethnicity, race, sex, and relevant confounding pathologies. All outcomes besides mortality were analyzed from the same day to 1 week after administration of the indexed drug. Mortality was analyzed from the same day to thirty days after administration of the indexed drug. RESULTS: A total of 95,740 patients with CKD-administered rocuronium with sugammadex were matched with 10,708 patients with CKD-administered cisatracurium with neostigmine. Patients administered rocuronium with sugammadex had a significantly higher associated risk of respiratory failure (risk ratios [RR], 1.98, confidence interval [CI], 1.71–2.29, P < .0001), acute respiratory distress (RR, 2.70, CI, 1.31–5.58, P = .0052), hypertensive crisis (RR, 1.85, CI, 1.37–2.49, P < .0001), heart failure (RR, 1.14, CI, 1.06–1.23, P = .0004), pleural effusion (RR, 1.30, CI, 1.14–1.49, P < .0001), and 30-day mortality (RR, 1.31, CI, 1.10–1.56, P = .0021). CONCLUSIONS: From 2003 to 2023, patients who were administered rocuronium plus sugammadex were at a significantly higher risk for acute cardiovascular and pulmonary complications when compared to patients who were administered cisatracurium plus neostigmine.]]> Thu, 01 May 2025 00:00:00 GMT-05:00 00000539-202505000-00002 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/04000/the_association_between_perioperative_red_blood.7.aspx BACKGROUND: Packed red blood cell (pRBC) transfusions in patients undergoing surgery for cancer are given to treat anemia or acute hemorrhage. Evidence indicates that pRBC transfusions are associated with poor perioperative and oncological outcomes. The ARCA-1 (Perioperative Care in the Cancer Patient-1) study was designed to test the association between perioperative pRBC transfusions and postoperative morbidity and mortality in patients undergoing cancer surgery. The primary hypothesis of our study was that perioperative pRBC transfusions have a negative impact on postoperative morbidity and 1-year mortality. METHODS: ARCA-1 was an international multicenter prospective observational cohort study. Participating centers enrolled a minimum of 30 consecutive adult patients with cancer who underwent surgery with curative intent. The primary end point was all-cause mortality 1 year after major cancer surgery. Secondary end points were rates of perioperative blood product use, 1-year cancer-specific mortality, overall survival, and 30-day morbidity and mortality. We performed a propensity score matching analysis to adjust for selection bias. A multivariable logistic regression model was fitted to estimate the effects of significant covariates on 1-year mortality, cancer-related mortality, and overall survival. RESULTS: A total of 1079 patients were included in the study. The rate of perioperative pRBC transfusions was 21.1%. Preoperative comorbidities, including anemia, American Society of Anesthesiologists (ASA) score of III to IV, a history of coronavirus disease 2019 (COVID-19), myocardial infarction, stroke, need for dialysis, history of blood transfusions, and metastatic disease were statistically significantly more frequent in transfused patients compared to nontransfused patients. The 1-year mortality rate was higher in transfused patients before (19.7% vs 6.5%; P < .0001) and after (17.4% vs 13.2%; P = .29) propensity score matching. 1-year mortality was 1.97 times higher in transfused than in no-transfused patients (odd ratio [OR], 1.97; 95% confidence interval [CI], 1.13–3.41). The odds of 1-year cancer mortality for patients who had perioperative pRBCs was 1.82 times higher (OR, 1.82; 95% CI, 0.97–3.43) compared to those who did not receive perioperative pRBC transfusion. The effect of perioperative pRBC transfusion on overall survival was also significant (hazard ratio [HR], 1.85; 95% CI, 1.15–2.99). Transfused patients also had a higher rate of 30-day postoperative mortality before (3.5% vs 0.7%; P = .0009) and after propensity score matching (4.2% vs 1.8%; P = .34). CONCLUSIONS: This international, multicenter observational study showed that perioperative pRBC transfusion was associated with an increased mortality risk.]]> Wed, 06 Nov 2024 00:00:00 GMT-06:00 00000539-202504000-00007 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/04000/novel_cancer_therapeutics__perioperative.3.aspx Since the introduction of immunotherapy and targeted therapies, patients not only have adequate tumoral response to these treatments, but their quality of life has improved due to milder toxicities. However, due to their wide mechanisms of action, the toxicity profile for these therapies is broad, can have an insidious onset, and their recognition can be challenging. Rarely, some of these toxicities can cause significant morbidity if not diagnosed early and lead to intensive care unit (ICU) admission and death. Anesthesiologists are likely to encounter not only a wide spectrum of these toxicities but also a wide range of severity. In some cases, they could be the first to make the diagnosis and therefore need to be prepared to rapidly assess, establish differentials, perform a diagnostic workup, and evaluate the impact the toxicity could have on the patients’ care during the perioperative period. In this article, we set to review toxicities of novel cancer therapies such as checkpoint inhibitors and targeted therapies, that could present in the perioperative setting. This article will help as a guide for anesthesiologists to recognize their clinical presentation, the approach to their diagnosis, and their impact on patient care.]]> Fri, 25 Oct 2024 00:00:00 GMT-05:00 00000539-202504000-00003 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/03000/impact_of_sugammadex_versus_neostigmine_reversal.13.aspx BACKGROUND: Residual neuromuscular blockade can be associated with serious postoperative complications. Sugammadex is a newer neuromuscular blocking drug (NMBD) reversal agent that rapidly and completely reverses rocuronium. Whether sugammadex has any advantages over neostigmine in morbidly obese patients with obstructive sleep apnea (OSA) is unclear. We investigated whether sugammadex would reduce discharge time from the operating room (OR) compared with neostigmine in morbidly obese patients with OSA undergoing bariatric surgery. METHODS: This was a prospective, double-blinded randomized controlled superiority trial with 2 parallel groups. Patients were randomized 1:1 into reversal of NMBD with sugammadex or neostigmine. Our inclusion criteria were morbidly obese adult patients with OSA undergoing elective bariatric surgery under general anesthesia. Our exclusion criteria were allergy to rocuronium, sugammadex or neostigmine, malignant hyperthermia, hepatic or renal insufficiency, neuromuscular diseases, and an inability to give consent. The primary outcome was the time from administration of the NMBD reversal agent to discharge from the OR. Secondary outcomes included the time from administration of the NMBD reversal agent to the time the patient opened eyes to command, and the time to extubation. The Mann-Whitney test was used to compare the outcomes between treatment groups. RESULTS: We randomized 120 patients into 2 groups of 60 patients. Overall median body mass index (BMI) was 48.1 kg/m2 ([interquartile range, IQR]) [43.0–53.5]. The time from drug administration to discharge from OR was 13.0 minutes [10.0–17.0] in the sugammadex group and 13.5 minutes [11.0–18.3] in the neostigmine group (P = .27). The treatment effect estimate with a bootstrapped 95% confidence interval [CI] for time from admission to discharge from OR was −0.5 [−2.5 to 3]. No differences were observed in postoperative complications and other secondary outcomes. CONCLUSIONS: No difference was observed in OR discharge time in morbidly obese patients with OSA when sugammadex was administered instead of neostigmine.]]> Fri, 07 Jun 2024 00:00:00 GMT-05:00 00000539-202503000-00013 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/03000/respiratory_depression_following_intraoperative.5.aspx BACKGROUND: Methadone is used as a perioperative analgesic in the management of postoperative pain. Despite positive outcomes from randomized trials favoring methadone, concerns about its safety persist, particularly regarding respiratory depression (RD) and excessive sedation. In this study, we compared the incidence of naloxone administration between patients administered intraoperative methadone and those administered intraoperative morphine as a measure of severe RD. Time spent at the postanesthesia care unit (PACU) was used as a proxy variable for excessive sedation. METHODS: This was a retrospective cohort study including all patients aged ≥18 years who underwent surgery between March 2019 and March 2023 at Aarhus University Hospital, Denmark. We assessed the association between intraoperative administration of either methadone or morphine and postoperative naloxone administration within the first 24 hours using logistic regression (primary outcome). An analogous linear regression model was used for the secondary outcome of time spent in the PACU after surgery. Patients were weighted using propensity scores to adjust for potential confounding variables. RESULTS: A total of 14,522 patients were included in the analysis. Among the 2437 patients who received intraoperative methadone, 15 (0.62%) patients received naloxone within the first 24 hours after surgery compared to 68 of 12,0885 (0.56%) who received intraoperative morphine. No statistical difference was observed in the odds of naloxone administration between patients administered methadone or morphine (adjusted odds ratio 95% confidence interval [CI], 1.21 [0.40–2.02]). Patients who were administered intraoperative methadone had a mean PACU length of stay (LOS) of 334 minutes (standard deviation [SD], 382) compared to 195 minutes (SD, 228) for those administered intraoperative morphine. The adjusted PACU LOS of patients administered intraoperative methadone was 26% longer compared to those administered intraoperative morphine (adjusted ratio of the geometric means 95% CI, 1.26 [1.22–1.31]). CONCLUSIONS: The incidence of naloxone administration to treat severe RD was low. No difference was observed in the odds of naloxone administration to treat severe RD between patients administered intraoperative methadone or intraoperative morphine. Intraoperative methadone was associated with longer stays at the PACU; however, this result should be interpreted with care. Our findings suggest that intraoperative methadone has a safety profile comparable to that of morphine with regard to severe RD.]]> Fri, 14 Feb 2025 00:00:00 GMT-06:00 00000539-202503000-00005 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/02000/effectiveness_of_ventilation_via_an_endotracheal.9.aspx BACKGROUND: The difficult airway is frequently encountered across many scenarios. The extreme form is a “cannot intubate and cannot oxygenate” scenario, which lacks a reliable rescue technique. Previous case reports or studies with small sample sizes indicate the feasibility and efficiency of an endotracheal tube in the pharynx (TTIP) to ventilate patients. We hypothesize that ventilation via TTIP is an effective rescue technique for failed mask ventilation. METHOD: One hundred forty-seven patients with potentially difficult airways were randomly assigned to the sequence (Tube first) of tube first ventilation via TTIP for 1 minute after induction, followed by via mask ventilation for 1 minute or in reverse sequence (Mask first). The ventilation was done with pressure control mode, a peak inspiratory airway pressure of 20 cmH2O, an inspiratory to expiratory time ratio of 1:2, and a respiratory rate of 10 breaths/min. RESULTS: A total of 136 patients underwent final analysis. The overall success rate (primary outcome) of ventilation via TTIP and mask, defined as the presence of expired carbon dioxide, was 93.4% (127/136) and 84.6% (115/136), respectively (P = .02). The success rate, 85.7% (6/7), of mask ventilation rescuing a failed TTIP ventilation and 100% (13/13) of TTIP rescuing a failed mask ventilation were comparable (P = .35). CONCLUSIONS: The success rates of TTIP and mask ventilation are comparable. Ventilation via TTIP could be an alternative rescue technique for managing a difficult airway.]]> Fri, 20 Dec 2024 00:00:00 GMT-06:00 00000539-202502000-00009 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/02000/second_generation_supraglottic_airway_devices.7.aspx BACKGROUND: Second-generation supraglottic airway (SGA) devices are widely used, but thought to have inferior safety performance to endotracheal tubes (ETTs), but might be equally efficacious while improving patient-centered outcomes. We compared second-generation SGAs with ETTs for perioperative safety, efficacy, and quality of recovery in adults undergoing abdominopelvic surgery under general anesthesia. Our primary objective was to assess safety in the form of major airway complications. Secondary objectives were other safety, efficacy, and quality of recovery outcomes. METHODS: We searched 4 databases for randomized controlled trials of adult patients having abdominopelvic surgery comparing second-generation SGAs and ETTs. After 2-person screening and data extraction, pairwise meta-analysis was conducted and the grading of recommendations, assessment, development, and evaluation (GRADE) approach was applied to assess the certainty of evidence. RESULTS: A total of 51 studies, randomizing 5110 patients, were included. Second-generation SGAs significantly reduced the risk of major perioperative airway complications (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.23–0.71; P = .007; low certainty), with no clear clinically relevant difference in regurgitation or pulmonary aspiration (low certainty). SGAs significantly increased the risk of inadequate ventilation (RR, 3.36; 95% CI, 1.43–7.89; P = .011; very low certainty); however, postoperative sore throat (RR, 0.52; 95% CI, 0.38–0.70; P < .001; moderate certainty), hoarseness (RR, 0.32; 95% CI, 0.231–0.48; P < .001; low certainty), coughing at the emergence of anesthesia (RR, 0.17; 95% CI, 0.08–0.36; P < .001; low certainty), and postoperative nausea and vomiting (RR, 0.64; 95% CI, 0.42–0.98; P = .042; very low certainty) were all less frequent with SGAs. No other clinically relevant differences were observed for other remaining outcomes. CONCLUSIONS: Second-generation SGAs reduce the risk of major airway complications compared with ETTs in adults undergoing abdominopelvic procedures under general anesthesia, with no reported clinically relevant differences in the risk of regurgitation or pulmonary aspiration. Additionally, they improve the quality of postoperative recovery with lower risk of sore throat, hoarseness, and postoperative nausea and vomiting. These data provide an opportunity for clinicians to reassess the implications of conservative airway management, and potentially expand the role of second-generation SGAs in routine clinical practice.]]> Fri, 10 Jan 2025 00:00:00 GMT-06:00 00000539-202502000-00007 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/01000/association_of_intravenous_neostigmine_and.16.aspx BACKGROUND: Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine. METHODS: We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery. RESULTS: Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91–1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82–1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07–2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium (P = .637) or postoperative early delirium (P = .904). CONCLUSIONS: Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.]]> Mon, 16 Dec 2024 00:00:00 GMT-06:00 00000539-202501000-00016 https://journals.lww.com/anesthesia-analgesia/fulltext/2025/01000/magnesium_and_esophageal_pain_after_peroral.10.aspx BACKGROUND: Postoperative esophageal pain occurs in 67% of patients after peroral endoscopic esophageal myotomy (POEM). Magnesium can act as a smooth muscle relaxant. This study investigated whether intraoperative magnesium can reduce postoperative esophageal pain in patients undergoing POEM. METHODS: In this double-blind, placebo-controlled trial, 92 patients were randomized to receive either magnesium sulfate as a 50 mg.kg−1 (total body weight) bolus followed by an infusion at 25 mg.kg−1.hr−1, or 0.9% saline. Intraoperative analgesia was standardized in all patients. The primary outcome was the score from a validated, modified Esophageal Symptoms Questionnaire (ESQ) in the postanesthesia care unit (PACU). Pain scores, opioid requirements, and questionnaire scores were collected through postoperative day 1. RESULTS: ESQ scores were significantly lower in the magnesium group in the PACU (median [25th–75th], 24 [18–31] vs 35 [28–42]; median difference [95% confidence interval, CI], 10 [6–13]; P < .0001) and on postoperative day 1 (16 [14–23] vs 30 [24–35]; P < .0001). Less opioids were needed in the magnesium group in the PACU (mean ± standard deviation [SD] [99% CI], 4.7 ± 10 [1–9] mg vs 29 ± 21 [21–37] mg; P < .0001) and on postoperative day 1 (1 ± 3.7 [0–2.5] mg vs 13 ± 23 [4–23] mg; P = .0009). Pain scores were lower in the magnesium group in the PACU (0 [0–3] vs 5 [5–7]; P < .0001) and on postoperative day 1 (0 [0–2] vs 4 [3–5]; P < .0001). CONCLUSIONS: Patients undergoing POEM randomized to receive intraoperative magnesium had sustained reductions in esophageal discomfort severity and opioid requirements 24 hours after surgery.]]> Fri, 07 Jun 2024 00:00:00 GMT-05:00 00000539-202501000-00010 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/12000/substance_use_disorders_in_adolescents_and_young.19.aspx Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population.]]> Fri, 14 Jul 2023 00:00:00 GMT-05:00 00000539-202412000-00019 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/12000/the_2023_gerard_w__ostheimer_lecture__a.3.aspx The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiology. This is a narrative review of 2022 literature pertinent to maternal morbidity and mortality in all income settings globally. Themes associated with worse maternal mortality rate (MMR), challenges health care workers face, public health priority areas, and initiatives to help countries achieve the United Nations Sustainable Development Goal targets for MMR are discussed. MMRs are higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cesarean delivery rates are rising most rapidly in LMICs, warranting urgent maternal health care workforce planning efforts in these settings. Globally racial, ethnic, and geographical disparities in maternal mortality continue to be evident in global health care settings. In the United States, the MMR is rising. The evolving changes in abortion legislation in the United States may further negatively impact maternal morbidity and mortality. The need to implement American Society of Anesthesiologists–recommended obstetric anesthesia quality metrics to facilitate benchmarking and to improve patient experience and outcomes is discussed as well as the need for professional society guidance on minimum staffing levels in American labor and delivery units.]]> Fri, 15 Nov 2024 00:00:00 GMT-06:00 00000539-202412000-00003 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/11000/neurological_complications_after_transcatheter.14.aspx Transcatheter aortic valve replacement (TAVR) has become the dominant procedural modality for aortic valve replacement in the United States. The reported rates of neurological complications in patients undergoing TAVR have changed over time and are dependent on diagnostic definitions and modalities. Most strokes after TAVR are likely embolic in origin, and the incidence of stroke has decreased over time. Studies have yielded conflicting results when comparing stroke rates between TAVR and surgical aortic valve replacement (SAVR), especially due to differences in diagnostic criteria and neurocognitive testing. In this narrative review, we summarize the available data on the incidence of stroke, delirium, and cognitive decline after TAVR and highlight potential areas in need of future research. We also discuss silent cerebral ischemic lesions (SCILs) and their association with a decline in postoperative neurocognitive status after TAVR. Finally, we describe that the risk of delirium and postoperative decline is increased when nonfemoral access routes are used, and we highlight the need for standardized imaging and valid, repeatable methodologies to assess cognitive changes after TAVR.]]> Mon, 12 Aug 2024 00:00:00 GMT-05:00 00000539-202411000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/11000/a_propensity_matched_cohort_study_of_intravenous.12.aspx BACKGROUND: While preoperative anemia is associated with adverse perioperative outcomes, the benefits of treatment with iron replacement versus red blood cell (RBC) transfusion remain uncertain. We used a national database to establish trends in preoperative iron-deficiency anemia (IDA) treatment and to test the hypothesis that treatment with preoperative iron may be superior to RBC transfusion. METHODS: This study is a propensity-matched retrospective cohort analysis from 2003 to 2023 using TriNetX Research Network, which included surgical patients diagnosed with IDA within 3 months preoperatively. After matching for surgery type and comorbidities, we compared a cohort of patients with preoperative IDA who were treated with preoperative intravenous (IV) iron but not RBCs (n = 77,179), with a cohort receiving preoperative RBCs but not IV iron (n = 77,179). Propensity-score matching was performed for age, ethnicity, race, sex, overweight and obesity, type 2 diabetes, hyperlipidemia, essential hypertension, heart failure, chronic ischemic heart disease, neoplasms, hypothyroidism, chronic kidney disease, nicotine dependence, surgery type, and lab values from the day of surgery including ferritin, transferrin, and hemoglobin split into low (<7 g/dL), medium (7–<12 g/dL), and high (≥12 g/dL) to account for anemia severity. The primary outcome was 30-day postoperative mortality with the secondary outcomes being 30-day morbidity, postoperative hemoglobin level, and 30-day postoperative RBC transfusion. RESULTS: Compared with RBC transfusion, preoperative IV iron was associated with lower risk of postoperative mortality (n = 2550/77,179 [3.3%] vs n = 4042/77,179 [5.2%]; relative risk [RR], 0.63, 95% confidence interval [CI], 0.60–0.66), and a lower risk of postoperative composite morbidity (n = 14,174/77,179 [18.4%] vs n = 18,632/77,179 [24.1%]; RR, 0.76, 95% CI, 0.75–0.78) (both P = .001 after Bonferroni adjustment). Compared with RBC transfusion, IV iron was also associated with a higher hemoglobin in the 30-day postoperative period (10.1 ± 1.8 g/dL vs 9.4 ± 1.7 g/dL, P = .001 after Bonferroni adjustment) and a reduced incidence of postoperative RBC transfusion (n = 3773/77,179 [4.9%] vs n = 12,629/77,179 [16.4%]; RR, 0.30, 95% CI, 0.29–0.31). CONCLUSIONS: In a risk-adjusted analysis, preoperative IDA treatment with IV iron compared to RBC transfusion was associated with a reduction in 30-day postoperative mortality and morbidity, a higher 30-day postoperative hemoglobin level, and reduced postoperative RBC transfusion. This evidence represents a promising opportunity to improve patient outcomes and reduce blood transfusions and their associated risk and costs.]]> Mon, 22 Jul 2024 00:00:00 GMT-05:00 00000539-202411000-00012 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/10000/persistent_opioid_use_after_hospital_admission.5.aspx BACKGROUND: Persistent opioid use (POU) is common after surgery and is associated with an increased risk of mortality and morbidity. There have been no population-based studies exploring POU in opioid-naïve surgical patients in New Zealand (NZ). This study aimed to determine the incidence and risk factors for POU in opioid-naïve patients undergoing surgery in all NZ hospitals. METHOD: We included all opioid-naïve patients who underwent surgery without a concomitant trauma diagnosis and received opioids after discharge from any NZ hospital between January 2007 and December 2019. Patients were considered opioid naïve if no opioids had been dispensed to them or if they did not have a prior diagnosis of an opioid-use disorder up to 365 days preceding the index date. The primary outcome was the incidence of POU, defined a priori as opioid use after discharge between 91 and 365 days. We used a multivariable logistic regression to identify risk factors for POU. RESULTS: We identified 1789,407 patients undergoing surgery with no concomitant diagnosis of trauma; 377,144 (21.1%) were dispensed opioids and 260,726 patients were eligible and included in the analysis. Of those included in the final sample, 23,656 (9.1%; 95% confidence interval [CI], 9.0%–9.2%) developed POU. Risk factors related to how opioids were prescribed included: changing to different opioid(s) after discharge (adjusted odds ratio [aOR], 3.21; 95% CI, 3.04–3.38), receiving multiple opioids on discharge (aOR, 1.37; 95% CI, 1.29–1.45), and higher total oral morphine equivalents (>400 mg) (aOR, 1.23; 95% CI, 1.23–1.45). Conversely, patients who were coprescribed nonopioid analgesics on discharge had lower odds of POU (aOR, 0.91; 95% CI, 0.87–0.95). Only small differences were observed between different ethnicities. Other risk factors associated with increased risk of POU included undergoing neurosurgery (aOR, 2.02; 95% CI, 1.83–2.24), higher comorbidity burden (aOR, 1.90; 95% CI, 1.75–2.07), preoperative nonopioid analgesic use (aOR, 1.65; 95% CI, 1.60–1.71), smoking (aOR, 1.44; 95% CI, 1.35–1.54), and preoperative hypnotics use (aOR, 1.35; 95% CI, 1.28–1.42). CONCLUSIONS: Approximately 1 in 11 opioid-naïve patients who were dispensed opioids on surgical discharge, developed POU. Potentially modifiable risk factors for POU, related to how opioids were prescribed included changing opioids after discharge, receiving multiple opioids, and higher total dose of opioids given on discharge. Clinicians should discuss the possibility of developing POU with patients before and after surgery and consider potentially modifiable risk factors for POU when prescribing analgesia on discharge after surgery.]]> Wed, 04 Sep 2024 00:00:00 GMT-05:00 00000539-202410000-00005 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/10000/efficacy_of_single_bolus_administration_of.13.aspx BACKGROUND: Remimazolam is a recently marketed ultrashort-acting benzodiazepine. This drug is considered safe and effective during general anesthesia; however, limited information is available about its effects on patients undergoing cardiac surgery. Therefore, the present study was conducted to evaluate the efficacy and hemodynamic stability of a bolus administration of remimazolam during anesthesia induction in patients undergoing cardiac surgery. METHODS: Patients undergoing elective cardiac surgery were randomly assigned to any 1 of the following 3 groups: anesthesia induction with a continuous infusion of remimazolam 6 mg/kg/h (continuous group), a single-bolus injection of remimazolam 0.1 mg/kg (bolus 0.1 group), or a single-bolus injection of remimazolam 0.2 mg/kg (bolus 0.2 group). Time to loss of responsiveness, defined as modified Observer’s Assessment of Alertness/Sedation Scale <3, and changes in hemodynamic status during anesthetic induction were measured. RESULTS: Times to loss of responsiveness were 137 ± 20, 71 ± 35, and 48 ± 9 seconds in the continuous, bolus 0.1, and bolus 0.2 groups, respectively. The greatest mean difference was observed between the continuous and bolus 0.2 groups (89.0, 95% confidence interval [CI], 79.1–98.9), followed by the continuous and bolus 0.1 groups (65.8, 95% CI, 46.9–84.7), and lastly between the bolus 0.2 and bolus 0.1 groups (23.2, 95% CI, 6.6–39.8). No significant differences were found in terms of arterial blood pressures and heart rates of the patients. CONCLUSIONS: A single-bolus injection of remimazolam provided efficient anesthetic induction in patients undergoing cardiac surgery. A 0.2 mg/kg bolus injection of remimazolam resulted in the shortest time to loss of responsiveness among the 3 groups, without significantly altering the hemodynamic parameters. Therefore, this dosing can be considered a favorable anesthetic induction method for patients undergoing cardiac surgery.]]> Mon, 05 Feb 2024 00:00:00 GMT-06:00 00000539-202410000-00013 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/09000/care_of_the_pediatric_patient_for_ambulatory.8.aspx The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children’s hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.]]> Fri, 16 Aug 2024 00:00:00 GMT-05:00 00000539-202409000-00008 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/09000/society_for_ambulatory_anesthesia_updated.4.aspx This consensus statement is a comprehensive update of the 2010 Society for Ambulatory Anesthesia (SAMBA) Consensus Statement on perioperative blood glucose management in patients with diabetes mellitus (DM) undergoing ambulatory surgery. Since the original consensus guidelines in 2010, several novel therapeutic interventions have been introduced to treat DM, including new hypoglycemic agents and increasing prevalence of insulin pumps and continuous glucose monitors. The updated recommendations were developed by an expert task force under the provision of SAMBA and are based on a comprehensive review of the literature from 1980 to 2022. The task force included SAMBA members with expertise on this topic and those contributing to the primary literature regarding the management of DM in the perioperative period. The recommendations encompass preoperative evaluation of patients with DM presenting for ambulatory surgery, management of preoperative oral hypoglycemic agents and home insulins, intraoperative testing and treatment modalities, and blood glucose management in the postanesthesia care unit and transition to home after surgery. High-quality evidence pertaining to perioperative blood glucose management in patients with DM undergoing ambulatory surgery remains sparse. Recommendations are therefore based on recent guidelines and available literature, including general glucose management in patients with DM, data from inpatient surgical populations, drug pharmacology, and emerging treatment data. Areas in need of further research are also identified. Importantly, the benefits and risks of interventions and clinical practice information were considered to ensure that the recommendations maintain patient safety and are clinically valid and useful in the ambulatory setting.]]> Fri, 22 Mar 2024 00:00:00 GMT-05:00 00000539-202409000-00004 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/08000/perioperative_plasma_in_addition_to_red_blood_cell.2.aspx BACKGROUND: Perioperative red blood cell (RBC) transfusions increase venous thromboembolic (VTE) events. Although a previous study found that plasma resuscitation after trauma was associated with increased VTE, the risk associated with additional perioperative plasma is unknown. METHODS: A US claims and EHR database (TriNetX Diamond Network) was queried. We compared surgical patients who received perioperative plasma and RBC to patients who received perioperative RBC but not plasma. Subanalyses included (1) all surgeries (n = 48,580) and (2) cardiovascular surgeries (n = 38,918). Propensity score matching was performed for age at surgery, ethnicity, race, sex, overweight and obesity, type 2 diabetes, disorders of lipoprotein metabolism, essential hypertension, neoplasms, nicotine dependence, coagulopathies, sepsis, chronic kidney disease, liver disease, nonsteroidal anti-inflammatory analgesics, platelet aggregation inhibitors, anticoagulants, hemoglobin level, outpatient service utilization, and inpatient services; surgery type was included for “all surgeries” analyses. Outcomes included 30-day mortality, postoperative VTE, pulmonary embolism (PE), and disseminated intravascular coagulation (DIC). RESULTS: After matching the surgical cohorts, compared to only RBC, plasma + RBC was associated with higher risk of postoperative mortality (4.52% vs 3.32%, risk ratio [RR]: 1.36 [95% confidence interval, 1.24–1.49]), VTE (3.92% vs 2.70%, RR: 1.36 [1.24–1.49]), PE (1.94% vs 1.33%, RR: 1.46 [1.26–1.68]), and DIC (0.96% vs 0.35%, RR: 2.75 [2.15–3.53]). Among perioperative cardiovascular patients, adding plasma to RBC transfusion was associated with similar increased risk. CONCLUSIONS: When compared with perioperative RBC transfusion, adding plasma was associated with increased 30-day postoperative mortality, VTE, PE, and DIC risk among surgical and cardiovascular surgical patients. Reducing unnecessary plasma transfusion should be a focus of patient blood management to improve overall value in health care.]]> Wed, 28 Feb 2024 00:00:00 GMT-06:00 00000539-202408000-00002 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/08000/sugammadex_associated_anaphylaxis__summary_and.6.aspx No abstract available]]> Wed, 06 Mar 2024 00:00:00 GMT-06:00 00000539-202408000-00006 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/07000/positive_airway_pressure_in_surgical_patients_with.14.aspx Obstructive sleep apnea (OSA) is prevalent amongst surgical patients and associated with an increased incidence of perioperative complications. The gold standard treatment for moderate-to-severe OSA is positive airway pressure (PAP) therapy. Practice guidelines by the American Society of Anesthesiologists and the Society of Anesthesia and Sleep Medicine have recommended preoperative screening for OSA and consideration of initiation of PAP therapy for patients with severe OSA. These guidelines, developed mainly by the consensus of experts, highlight the adverse impact of OSA on postoperative outcomes and recommend the use of postoperative PAP in surgical patients with moderate to severe OSA. Since the development of these guidelines, there has been an increase in the number of publications regarding the efficacy of PAP therapy in surgical patients with OSA. Our review provides an update on the existing literature on the efficacy of PAP therapy in surgical patients with OSA. We focus on the postoperative complications associated with OSA, potential mechanisms leading to the increased risk of postoperative adverse events, and summarize the perioperative guidelines for the management of patients with OSA, evidence supporting perioperative PAP therapy, as well as limitations to PAP therapy and alternatives. An update on the existing literature of the efficacy of PAP therapy in surgical patients with OSA is critical to assess the impact of prior guidelines, determine when and how to effectively implement PAP therapy, and target barriers to PAP adherence in the perioperative setting.]]> Mon, 12 Feb 2024 00:00:00 GMT-06:00 00000539-202407000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/07000/identifying,_understanding,_and_minimizing.11.aspx Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.]]> Thu, 24 Oct 2024 00:00:00 GMT-05:00 00000539-202407000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/06000/adverse_events_of_peripherally_administered.13.aspx BACKGROUND: Perioperative treatment of hypotension by intravenous administration of norepinephrine in a peripheral vein can lead to adverse events, for example, tissue necrosis. However, the incidence and severity of adverse events during perioperative administration are unknown. METHODS: This was a prospective observational study conducted at 3 Swedish hospitals from 2019 to 2022. A total of 1004 patients undergoing surgery, who met the criteria for perioperative peripheral norepinephrine administration, were included. The infusion site was inspected regularly. If swelling or paleness of skin was detected, the infusion site was changed to a different peripheral line. Systolic blood pressure and pulse frequency were monitored during the infusion time and defined as adverse events at >220 mm Hg and <40 beats•min–1. In case of adverse events, patients were observed for up to 48 hours. The primary outcome was prevalence of extravasation, defined as swelling around the infusion site. Secondary outcomes were all types of adverse events and associations between predefined clinical variables and risk of adverse events. RESULTS: We observed 2.3% (95% confidence interval [CI], 1.4%–3.2%) extravasation of infusion and 0.9% (95% CI, 0.4%–1.7%) bradycardia. No cases of tissue necrosis or severe hypertension were detected. All adverse events had dissipated spontaneously within 48 hours. Proximal catheter placement was associated with more adverse events. CONCLUSIONS: Extravasation of peripherally administrated norepinephrine in the perioperative period occurred at similar rates as in previous studies in critically ill patients. In our setting, where we regularly inspected the infusion site and shifted site in case of swelling or paleness of skin, we observed no case of severe adverse events. Given that severe adverse events were absent, the potential benefit of this preventive approach requires confirmation in a larger population.]]> Fri, 05 Jan 2024 00:00:00 GMT-06:00 00000539-202406000-00013 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/06000/causes_of_perioperative_cardiac_arrest__mnemonic,.11.aspx Perioperative cardiac arrest (POCA) is a catastrophic complication that requires immediate recognition and correction of the underlying cause to improve patient outcomes. While the hypoxia, hypovolemia, hydrogen ions (acidosis), hypo-/hyperkalemia, and hypothermia (Hs) and toxins, tamponade (cardiac), tension pneumothorax, thrombosis (pulmonary), and thrombosis (coronary) (Ts) mnemonic is a valuable tool for rapid differential diagnosis, it does not cover all possible causes leading to POCA. To address this limitation, we propose using the preload-contractility-afterload-rate and rhythm (PCARR) construct to categorize POCA, which is comprehensive, systemic, and physiologically logical. We provide evidence for each component in the PCARR construct and emphasize that it complements the Hs and Ts mnemonic rather than replacing it. Furthermore, we discuss the significance of utilizing monitored variables such as electrocardiography, pulse oxygen saturation, end-tidal carbon dioxide, and blood pressure to identify clues to the underlying cause of POCA. To aid in investigating POCA causes, we suggest the Anesthetic care, Surgery, Echocardiography, Relevant Check and History (A-SERCH) list of actions. We recommend combining the Hs and Ts mnemonic, the PCARR construct, monitoring, and the A-SERCH list of actions in a rational manner to investigate POCA causes. These proposals require real-world testing to assess their feasibility.]]> Tue, 03 Oct 2023 00:00:00 GMT-05:00 00000539-202406000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/05000/sugammadex_versus_neostigmine_for_reversal_of.17.aspx BACKGROUND: Sugammadex is not advised for patients with severe renal impairment, but has been shown in a variety of other populations to be superior to neostigmine for reversal of neuromuscular blockade. The objective of this study was to determine if reversal of rocuronium-induced neuromuscular blockade with sugammadex versus reversal of cisatracurium-induced neuromuscular blockade with neostigmine results in a faster return to a train-of-four ratio (TOFR) ≥90% in patients with severe renal impairment. METHODS: We conducted a prospective, randomized, blinded, controlled trial at a large county hospital. A total of 49 patients were enrolled. Inclusion criteria included patients age ≥18, American Society of Anesthesiologists (ASA) physical status III and IV, with a creatinine clearance <30 mL/min, undergoing general anesthesia with expected surgical duration ≥2 hours and necessitating neuromuscular blockade. Subjects received either cisatracurium 0.2 mg/kg or rocuronium 0.6 mg/kg for induction of anesthesia to facilitate tracheal intubation. Subjects were kept at moderate neuromuscular blockade during surgery and received either 2 mg/kg sugammadex or 50 µg/kg neostigmine with 10 µg/kg glycopyrrolate for reversal of neuromuscular blockade. Neuromuscular monitoring was performed with electromyography (TwitchView), and the TOFR was recorded every minute after administration of the reversal agent. The time from administration of neuromuscular reversal until the patient reached a TOFR ≥90% was recorded as the primary outcome. RESULTS: The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min (P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0–13.5 minutes). There were no major adverse events in either group. CONCLUSIONS: In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.]]> Mon, 08 Jan 2024 00:00:00 GMT-06:00 00000539-202405000-00017 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/05000/maternal_morbidity_according_to_mode_of_delivery.14.aspx BACKGROUND: Patients with pulmonary hypertension have a high risk of maternal morbidity and mortality. It is unknown if a trial of labor carries a lower risk of morbidity in these patients compared to a planned cesarean delivery. The objective of this study was to examine the association of delivery mode with severe maternal morbidity events during delivery hospitalization among patients with pulmonary hypertension. METHODS: This retrospective cohort study used the Premier inpatient administrative database. Patients delivering ≥25 weeks gestation from January 1, 2016, to September 30, 2020, and with pulmonary hypertension were included. The primary analysis compared intended vaginal delivery (ie, trial of labor) to intended cesarean delivery (intention to treat analysis). A sensitivity analysis was conducted comparing vaginal delivery to cesarean delivery (as treated analysis). The primary outcome was nontransfusion severe maternal morbidity during the delivery hospitalization. Secondary outcomes included blood transfusion (4 or more units) and readmission to the delivery hospital within 90 days from discharge from delivery hospitalization. RESULTS: The cohort consisted of 727 deliveries. In the primary analysis, there was no difference in nontransfusion morbidity between intended vaginal delivery and intended cesarean delivery groups (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.49–1.15). In secondary analyses, intended cesarean delivery was not associated with blood transfusion (aOR, 0.71; 95% CI, 0.34–1.50) or readmission within 90 days (aOR, 0.60; 95% CI, 0.32–1.14). In the sensitivity analysis, cesarean delivery was associated with a 3-fold higher risk of nontransfusion morbidity compared to vaginal delivery (aOR, 2.64; 95% CI, 1.54–3.93), a 3-fold higher risk of blood transfusion (aOR, 3.06; 95% CI, 1.17–7.99), and a 2-fold higher risk of readmission within 90 days (aOR, 2.20; 95% CI, 1.09–4.46) compared to vaginal delivery. CONCLUSIONS: Among pregnant patients with pulmonary hypertension, a trial of labor was not associated with a higher risk of morbidity compared to an intended cesarean delivery. One-third of patients who required an intrapartum cesarean delivery had a morbidity event, demonstrating the increased risk of adverse events in this group.]]> Mon, 15 Apr 2024 00:00:00 GMT-05:00 00000539-202405000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/04000/preoperative_renin_angiotensin_system_antagonists.12.aspx BACKGROUND: There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population. METHODS: Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives). RESULTS: Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives (P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives (P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension (P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1–7.1 and OR, 7.7; 95% CI, 3.7–14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group (P < .001). CONCLUSIONS: Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.]]> Thu, 18 Jan 2024 00:00:00 GMT-06:00 00000539-202404000-00012 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/04000/sepsis_induced_coagulopathy__a_comprehensive.2.aspx Physiological hemostasis is a balance between pro- and anticoagulant pathways, and in sepsis, this equilibrium is disturbed, resulting in systemic thrombin generation, impaired anticoagulant activity, and suppression of fibrinolysis, a condition termed sepsis-induced coagulopathy (SIC). SIC is a common complication, being present in 24% of patients with sepsis and 66% of patients with septic shock, and is often associated with poor clinical outcomes and high mortality.1,2 Recent preclinical and clinical studies have generated new insights into the molecular pathogenesis of SIC. In this article, we analyze the complex pathophysiology of SIC with a focus on the role of procoagulant innate immune signaling in hemostatic activation––tissue factor production, thrombin generation, endotheliopathy, and impaired antithrombotic functions. We also review clinical presentations of SIC, the diagnostic scoring system and laboratory tests, the current standard of care, and clinical trials evaluating the efficacies of anticoagulant therapies.]]> Wed, 07 Feb 2024 00:00:00 GMT-06:00 00000539-202404000-00002 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/03000/low_perfusion_and_missed_diagnosis_of_hypoxemia_by.11.aspx BACKGROUND: Retrospective clinical trials of pulse oximeter accuracy report more frequent missed diagnoses of hypoxemia in hospitalized Black patients than White patients, differences that may contribute to racial disparities in health and health care. Retrospective studies have limitations including mistiming of blood samples and oximeter readings, inconsistent use of functional versus fractional saturation, and self-reported race used as a surrogate for skin color. Our objective was to prospectively measure the contributions of skin pigmentation, perfusion index (PI), sex, and age on pulse oximeter errors in a laboratory setting. METHODS: We enrolled 146 healthy subjects, including 25 with light skin (Fitzpatrick class I and II), 78 with medium (class III and IV), and 43 with dark (class V and VI) skin. We studied 2 pulse oximeters (Nellcor N-595 and Masimo Radical 7) in prevalent clinical use. We analyzed 9763 matched pulse oximeter readings (pulse oximeter measured functional saturation [Spo2]) and arterial oxygen saturation (hemoximetry arterial functional oxygen saturation [Sao2]) during stable hypoxemia (Sao2 68%–100%). PI was measured as percent infrared light modulation by the pulse detected by the pulse oximeter probe, with low perfusion categorized as PI < 1%. The primary analysis was to assess the relationship between pulse oximeter bias (difference between Sao2 and Spo2) by skin pigment category in a multivariable mixed-effects model incorporating repeated-measures and different levels of Sao2 and perfusion. RESULTS: Skin pigment, PI, and degree of hypoxemia significantly contributed to errors (bias) in both pulse oximeters. For PI values of 1.0% to 1.5%, 0.5% to 1.0%, and <0.5%, the P value of the relationship to mean bias or median absolute bias was <.00001. In lightly pigmented subjects, only PI was associated with positive bias, whereas in medium and dark subjects bias increased with both low perfusion and degree of hypoxemia. Sex and age was not related to pulse oximeter bias. The combined frequency of missed diagnosis of hypoxemia (pulse oximeter readings 92%–96% when arterial oxygen saturation was <88%) in low perfusion conditions was 1.1% for light, 8.2% for medium, and 21.1% for dark skin. CONCLUSIONS: Low peripheral perfusion combined with darker skin pigmentation leads to clinically significant high-reading pulse oximeter errors and missed diagnoses of hypoxemia. Darkly pigmented skin and low perfusion states are likely the cause of racial differences in pulse oximeter performance in retrospective studies.]]> Mon, 18 Dec 2023 00:00:00 GMT-06:00 00000539-202403000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/03000/improving_neuromuscular_monitoring_through.8.aspx BACKGROUND: We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS: We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS: Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002–1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33–1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01–1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02–1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93–1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06–1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68–0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55–0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63–0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS: Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.]]> Fri, 16 Feb 2024 00:00:00 GMT-06:00 00000539-202403000-00008 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/02000/the_incidence_and_predictors_of_failed_spinal.20.aspx BACKGROUND: The incidence of failed spinal anesthesia varies widely in the obstetric literature. Although many risk factors have been suggested, their relative predictive value is unknown. The primary objective of this retrospective cohort study was to determine the incidence of failed spinal anesthesia for cesarean deliveries at a tertiary care obstetric hospital, and its secondary objectives were to identify predictors of failed spinal anesthesia in the obstetrics population and quantify their relative importance in a predictive model for failure. METHODS: With local institutional ethics committee approval, a retrospective review of our hospital database identified the incidence of failed spinal anesthesia for 5361 cesarean deliveries between 2010 and 2019. We performed a multivariable analysis to assess the association of predictors with failure and a dominance analysis to assess the importance of each predictor. RESULTS: The incidence of failed spinal anesthesia requiring an alternative anesthetic was 2.1%, with conversion to general anesthesia occurring in 0.7% of surgeries. Supplemental analgesia or sedation was provided to an additional 2.0% of women. The most important predictors of a failed spinal anesthetic were previous cesarean delivery (odds ratio [OR], 11.33; 95% confidence interval [CI], 7.09–18.20; P < .001), concomitant tubal ligation (OR, 8.23; 95% CI, 3.12–19.20; P < .001), lower body mass index (BMI) (kg·m−2, OR, 0.94; 95% CI, 0.90–0.98; P = .005), and longer surgery duration (minutes, OR, 1.02; 95% CI, 1.01–1.03; P = .006). Previous cesarean delivery was the most significant risk factor, contributing to 9.6% of the total 17% variance predicted by all predictors examined. CONCLUSIONS: Spinal anesthesia failed to provide a pain-free surgery in 4.1% of our cesarean deliveries. Previous cesarean delivery was the most important predictor of spinal failure. Other important predictors included tubal ligation, lower BMI, and longer surgery duration.]]> Tue, 04 Apr 2023 00:00:00 GMT-05:00 00000539-202402000-00020 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/02000/perioperative_fluid_and_vasopressor_therapy_in.8.aspx Intravenous (IV) fluids and vasopressor agents are key components of hemodynamic management. Since their introduction, their use in the perioperative setting has continued to evolve, and we are now on the brink of automated administration. IV fluid therapy was first described in Scotland during the 1832 cholera epidemic, when pioneers in medicine saved critically ill patients dying from hypovolemic shock. However, widespread use of IV fluids only began in the 20th century. Epinephrine was discovered and purified in the United States at the end of the 19th century, but its short half-life limited its implementation into patient care. Advances in venous access, including the introduction of the central venous catheter, and the ability to administer continuous infusions of fluids and vasopressors rather than just boluses, facilitated the use of fluids and adrenergic agents. With the advent of advanced hemodynamic monitoring, most notably the pulmonary artery catheter, the role of fluids and vasopressors in the maintenance of tissue oxygenation through adequate cardiac output and perfusion pressure became more clearly established, and hemodynamic goals could be established to better titrate fluid and vasopressor therapy. Less invasive hemodynamic monitoring techniques, using echography, pulse contour analysis, and heart-lung interactions, have facilitated hemodynamic monitoring at the bedside. Most recently, advances have been made in closed-loop fluid and vasopressor therapy, which apply computer assistance to interpret hemodynamic variables and therapy. Development and increased use of artificial intelligence will likely represent a major step toward fully automated hemodynamic management in the perioperative environment in the near future. In this narrative review, we discuss the key events in experimental medicine that have led to the current status of fluid and vasopressor therapies and describe the potential benefits that future automation has to offer.]]> Fri, 12 Jan 2024 00:00:00 GMT-06:00 00000539-202402000-00008 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/01000/anesthetic_considerations_in_adult_patients_on.25.aspx No abstract available]]> Fri, 15 Dec 2023 00:00:00 GMT-06:00 00000539-202401000-00025 https://journals.lww.com/anesthesia-analgesia/fulltext/2024/01000/cannabis_and_cannabinoids_in_the_perioperative.4.aspx Cannabis use is increasingly common, and with a growing number of jurisdictions implementing legalization frameworks, it is likely that providers will encounter more patients who use cannabis. Therefore, it is important for providers to understand the implications of cannabis use and practical considerations for the perioperative period. Cannabis affects multiple organ systems and may influence intraoperative anesthesia, as well as postoperative pain management. The effects of cannabis and key anesthetic considerations are reviewed here.]]> Sat, 13 May 2023 00:00:00 GMT-05:00 00000539-202401000-00004 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/12000/antinociceptive_agents_as_general_anesthetic.15.aspx The hypothesis “General anesthesia consists of producing both loss of consciousness and the inhibition of noxious stimuli reaching the brain and causing arousal” was used as a basis for the review of published data on general anesthetic interactions with antinociceptive agents: opioids, α2 adrenergic agonists, and systemic sodium channel blockers. This review is focused on a specific type of anesthetic interaction—the transformation of antinociceptive agents into general anesthetic adjuncts. The primary aim is to answer 2 questions. First, how does an antinociceptive agent transform the effect of an anesthetic in providing a certain component of anesthesia—hypnosis, immobility, or hemodynamic response to noxious stimulation? Second, does a combination of an anesthetic with an adjunct result in a simple summation of their respective effects or in a supra-additive or infra-additive interaction? The Medline database was searched for data describing the interactions of antinociceptive agents and general anesthetics. The following classes of antinociceptive agents were considered: opioids, α2 adrenergic agonists, and systemic sodium channel blockers. Drugs used in combination with antinociceptive agents were general anesthetics and benzodiazepines. The following terms related to drug interactions were used: anesthetic interactions, synergy, antagonism, isobolographic analysis, response surface analysis, and fractional analysis. The interactions of antinociceptive agents with general anesthetics result in a decrease of general anesthetic requirements, which differ for each of the components of general anesthesia: hypnosis, immobility, and hemodynamic response to noxious stimulation. Most studies of the nature of anesthetic interactions are related to opioid–general anesthetic combinations, and their conclusions usually confirm supra-additivity.]]> Wed, 18 Oct 2023 00:00:00 GMT-05:00 00000539-202312000-00015 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/12000/exploring_the_pathophysiology_of_delirium__an.14.aspx Delirium is an acute brain disorder associated with disorganized thinking, difficulty focusing, and confusion that commonly follows major surgery, severe infection, and illness. Older patients are at high risk for developing delirium during hospitalization, which may contribute to increased morbidity, longer hospitalization, and increased risk of institutionalization following discharge. The pathophysiology underlying delirium remains poorly studied. This review delves into the findings from biomarker studies and animal models, and highlights the potential for tissue-engineered models of the brain in studying this condition. The aim is to bring together the existing knowledge in the field and provide insight into the future direction of delirium research.]]> Wed, 18 Oct 2023 00:00:00 GMT-05:00 00000539-202312000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/11000/overview_of_hypothermia,_its_role_in.9.aspx The current standard of practice is to maintain normothermia in traumatic brain injury (TBI) patients despite the theoretical benefits of hypothermia and numerous animal studies with promising results. While targeted temperature management or induced hypothermia to support neurological function is recommended for a select patient population postcardiac arrest, similar guidelines have not been instituted for TBI. In this review, we will examine the pathophysiology of TBI and discuss the benefits and risks of induced hypothermia in this patient population. In addition, we provide an overview of the largest randomized controlled trials testing-induced hypothermia. Our literature review on hypothermia returned a myriad of studies and trials, many of which have inconclusive results. The aim of this review was to recognize the effects of hypothermia, summarize the latest trials, address the inconsistencies, and discuss future directions for the study of hypothermia in TBI.]]> Fri, 28 Apr 2023 00:00:00 GMT-05:00 00000539-202311000-00009 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/11000/tris_hydroxymethyl_aminomethane_in_critically_ill.17.aspx Tris-hydroxymethyl aminomethane (THAM) is an amino alcohol used clinically to buffer acid loads and raise pH in acidotic conditions. Unlike sodium bicarbonate, which increases plasma sodium levels with use and produces carbon dioxide (CO2) as part of the buffering process, THAM does neither. Although not widely used in modern critical care and unavailable for clinical use in 2016, THAM has been available in the United States since 2020. Clinical experience and existing literature suggest that THAM may have clinical utility in acid-base management in conditions such as liver transplantation where rising sodium levels during perioperative care may be dangerous, and in managing acid-base derangements during care of patients with acute respiratory distress syndrome (ARDS). To clarify the evidence base supporting the clinical use of THAM, we conducted a systematic review to assess the efficacy and safety of THAM as a buffering agent in critically ill adults using Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus, and Web of Science Core Collection. Randomized-, crossover-, retrospective cohort-, parallel-designed clinical trials, case series, and case reports of adult patients who received THAM in the operative or critical care setting were included. Conference abstracts of qualifying study designs were also included. Two independent reviewers extracted the data regarding the study details, demographics, treatment, and outcomes data. A third reviewer adjudicated discrepancies. A total of 21 studies including 3 randomized controlled trials, 5 observational studies, 4 case series, and 9 case reports met inclusion criteria. Eight studies (38%) were abstracts published in conference proceedings. In total, 417 critically ill patients received THAM to treat acidosis in critically ill surgical and nonsurgical patients, during liver transplantation, and in ARDS. In general, THAM corrected acidosis with an efficacy equivalent to sodium bicarbonate and did so with less hypercarbia and hypernatremia. Adverse effects of THAM included hyperkalemia, hypoglycemia, ventilator depression, and tissue damage with extravasation. We conclude that THAM may have potential advantages in some critical care settings, but that clinical evidence is limited, and high-quality evaluations are necessary.]]> Wed, 19 Apr 2023 00:00:00 GMT-05:00 00000539-202311000-00017 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/10000/modified_manual_chest_compression_for_prevention.24.aspx BACKGROUND: We aimed to determine the preventive and therapeutic efficacy of modified manual chest compression (MMCC), a novel noninvasive and device-independent method, in reducing oxygen desaturation events in patients undergoing upper gastrointestinal endoscopy under deep sedation. METHODS: A total of 584 outpatients who underwent deep sedation during upper gastrointestinal endoscopy were enrolled. In the preventive cohort, 440 patients were randomized to the MMCC group (patients received MMCC when their eyelash reflex disappeared, M1 group) or control group (C1 group). In the therapeutic cohort, 144 patients with oxygen desaturation of a Spo2 < 95% were randomized to MMCC group (patients who subsequently received MMCC, M2 group) or the conventional treatment group (C2 group). The primary outcomes were the incidence of desaturation episodes with an Spo2 < 95% for the preventive cohort and the time spent below 95% Spo2 for the therapeutic cohort. Secondary outcomes included the incidence of gastroscopy withdrawal and diaphragmatic pause. RESULTS: In the preventive cohort, MMCC reduced the incidence of desaturation episodes <95% (14.4% vs 26.1%; RR, 0.549; 95% confidence interval [CI], 0.37–0.815; P = .002), gastroscopy withdrawal (0% vs 2.29%; P = .008), and diaphragmatic pause at 30 seconds after propofol injection (74.5% vs 88.1%; RR, 0.846; 95% CI, 0.772–0.928; P < .001). In the therapeutic cohort, patients who received MMCC had a significantly shorter time spent below 95% Spo2 (40 [20–69] seconds vs 91 [33–152] seconds, median difference [95% CI], −39 [−57 to −16] seconds, P < .001), a lower incidence of gastroscopy withdrawal (0% vs 10.4%, P = .018), and more enhanced diaphragmatic movement at 30 seconds after Spo2 <95% (1.11 [0.93–1.4] cm vs 1.03 [0.7–1.24] cm; median difference [95% confidence interval], 0.16 [0.02–0.32] cm; P = .015). CONCLUSIONS: MMCC may exert preventive and therapeutic effects against oxygen desaturation events during upper gastrointestinal endoscopy.]]> Mon, 03 Apr 2023 00:00:00 GMT-05:00 00000539-202310000-00024 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/10000/nitrous_oxide_use_in_australian_health_care_.20.aspx Nitrous oxide is a useful inhaled analgesic. Due to its high global warming potential and ozone-depleting properties, the nitrous oxide emissions related to health care are being increasingly scrutinized. In this narrative review, we will discuss the clinical uses of nitrous oxide relevant to anesthetists, in addition to its contribution as a greenhouse gas. Using available data from Australia, we will explore potential strategies for reducing the impact of those emissions, which are likely to be applicable in other countries. These include destruction of captured nitrous oxide, minimizing nitrous oxide waste and reducing clinical use. Anesthesia clinicians are well placed to raise awareness with colleagues and consumers regarding the environmental impact of nitrous oxide and to promote cleaner alternatives. Reducing use is likely to be the most promising reduction strategy without large-scale changes to infrastructure and subsequent delay in action.]]> Thu, 20 Jul 2023 00:00:00 GMT-05:00 00000539-202310000-00020 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/09000/substance_use_disorders__basic_overview_for_the.5.aspx Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.]]> Thu, 17 Aug 2023 00:00:00 GMT-05:00 00000539-202309000-00005 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/09000/perioperative_considerations_for_patients_exposed.3.aspx Concerns regarding the perioperative management of acute psychostimulant intoxication have been recognized for decades, but novel and diverse substances in this class continue to be developed. Despite the similarities in mechanisms of action among psychostimulants, each subclass within this broad category has unique receptor specificity and different mechanisms that play a role in patient clinical presentation. These issues present challenges to anesthesia providers when caring for patients with either acute or chronic exposure to psychostimulants during the perioperative period. Challenges result from both physiological and psychological effects that influence the action of the primary anesthetic agent, adjuvant anesthetics, and analgesics used for perioperative management of pain. The epidemiology, pharmacology, and perioperative implications of psychostimulant use are presented for amphetamines and similar acting nonamphetamines, cocaine, and, finally, the mixed-action drugs known as entactogens that share stimulant and psychedelic properties. This information is then used as the foundation for safe and effective perioperative management of patients exposed to psychostimulants.]]> Thu, 17 Aug 2023 00:00:00 GMT-05:00 00000539-202309000-00003 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/08000/narrative_review__is_there_a_transfusion_cutoff.15.aspx The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.]]> Fri, 28 Apr 2023 00:00:00 GMT-05:00 00000539-202308000-00015 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/08000/anesthetic_considerations_for_second_trimester.14.aspx Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients.]]> Mon, 19 Dec 2022 00:00:00 GMT-06:00 00000539-202308000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/07000/role_of_point_of_care_ultrasound_in_emergency.13.aspx Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.]]> Tue, 24 Jan 2023 00:00:00 GMT-06:00 00000539-202307000-00013 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/07000/analgesic_effect_of_buprenorphine_for_chronic.6.aspx BACKGROUND: Buprenorphine is a partial agonist at the µ-opioid receptor and an antagonist at the delta and kappa opioid receptors. It has high affinity and low intrinsic activity at the µ-opioid receptor. Buprenorphine demonstrates no ceiling effect for clinical analgesia, but demonstrates this for respiratory depression and euphoria. It may provide effective analgesia while producing less adverse effects, making it a promising opioid analgesic. A systematic review and meta-analysis were performed to examine the analgesic efficacy of buprenorphine for patients with chronic noncancer pain. METHODS: PubMed, MEDLNE, Embase, and the Cochrane Library were searched up to January 2022. Randomized controlled trials were included if they compared buprenorphine versus placebo or active analgesic in patients with chronic noncancer pain, where pain score was an outcome. Nonrandomized controlled trials, observational studies, qualitative studies, case reports, and commentaries were excluded. Two investigators independently performed the literature search, study selection, and data collection. A random-effects model was used. The primary outcome was the effect of buprenorphine on pain intensity in patients with chronic noncancer pain based on standardized mean difference (SMD) in pain score. Quality of evidence was assessed using the Grade of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: Two separate literature searches were conducted for patients with and without opioid use disorder (OUD). Only one study met the search criteria for those with OUD. Fourteen randomized controlled trials were included for those without OUD. Buprenorphine was associated with reduced pain score (SMD = –0.368, P < .001, I2 = 89.37%) compared to placebo or active analgesic. Subgroup meta-analyses showed statistically significant differences in favor of buprenorphine versus placebo (SMD = –0.404, P < .001), for chronic low back pain (SMD = –0.383, P < .001), when administered via the transdermal route (SMD = –0.572, P = .001), via the buccal route (SMD = –0.453, P < .001), with length of follow-up lasting <12 weeks (SMD = –0.848, P < .05), and length of follow-up lasting 12 weeks or more (SMD = –0.415, P < .001). There was no significant difference when compared to active analgesic (SMD = 0.045, P > .05). Quality of evidence was low to moderate. CONCLUSIONS: Buprenorphine was associated with a statistically significant and small reduction in pain intensity compared to placebo. Both the transdermal and buccal routes provided pain relief. There was more evidence supporting its use for chronic low back pain.]]> Fri, 16 Jun 2023 00:00:00 GMT-05:00 00000539-202307000-00006 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/06000/current_evidence_and_rationale_to_guide.14.aspx Sickle cell disease (SCD) is a collection of inherited hemoglobin disorders that results in chronic hemolytic anemia, vaso-occlusion, pain, and end organ damage. Surgery in the SCD population requires careful planning, as perioperative stressors can lead to increased sickling and risk of inducing or further exacerbating vaso-occlusive episodes (VOEs). Additionally, the underlying hypercoagulability and immunocompromised state due to SCD places patients at increased risk of both venous thromboembolism and infection. Judicious fluid administration, temperature regulation, thorough preoperative and postoperative analgesic planning, and preoperative transfusion are all crucial components of decreasing risks of surgery in patients with SCD.]]> Fri, 19 May 2023 00:00:00 GMT-05:00 00000539-202306000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/06000/effect_of_tulobuterol_patch_versus_placebo_on_the.10.aspx BACKGROUND: Perioperative respiratory adverse events are common in children. We aimed to evaluate the effect of the transdermal β-2 agonist, tulobuterol, compared with that of placebo on the incidence of perioperative respiratory adverse events in pediatric patients undergoing tonsillectomy. METHODS: In this triple-blinded (patient, anesthesia provider, and outcome assessor) randomized controlled trial, 188 patients were randomly allocated to receive tulobuterol or a placebo. The tulobuterol groups received a tulobuterol patch (1 mg) masked with a bandage, whereas the placebo only received the bandage. The assigned bandage was applied to the patients 8 to 10 hours before the surgery. The primary outcome was the occurrence of any perioperative respiratory adverse events: oxygen desaturation <95%, airway obstruction, laryngospasm, bronchospasm, severe coughing, or stridor. The outcomes were evaluated using the average relative effect test, which estimates the effect of individual components of a composite outcome and then averages effects across components. RESULTS: A total of 88 and 94 patients who received tulobuterol and placebo, respectively, were analyzed. The incidence of any perioperative respiratory adverse event was lower with tulobuterol (n = 13/88; 14.7%) than that with the placebo (n = 40/94; 42.5%), with an estimated average relative risk (95% confidence interval) across components of 0.35 (0.20–0.60; P < .001). The symptoms of airway obstruction were lower with tulobuterol (n = 8/88; 9.0%) than that with the placebo (n = 32/94; 34.0%), with relative risk (95% CI) of 0.31 (0.17–0.56; P < .001). The occurrence of severe coughing was lower with tulobuterol (n = 1/88; 1.1%) than that with the placebo (n = 8/94; 8.5%), with relative risk (95% CI) of 0.15 (0.03–0.68; P = .014). CONCLUSIONS: In preschool children undergoing tonsillectomy, the preoperative application of a tulobuterol patch could decrease the occurrence of perioperative respiratory adverse events. Further studies are needed to elucidate the effect of the tulobuterol patch in a broad spectrum of pediatric anesthesia.]]> Fri, 19 May 2023 00:00:00 GMT-05:00 00000539-202306000-00010 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/05000/factor_viii__a_dynamic_modulator_of_hemostasis_and.10.aspx A trace amount of thrombin cleaves factor VIII (FVIII) into an active form (FVIIIa), which catalyzes FIXa-mediated activation of FX on the activated platelet surface. FVIII rapidly binds to von Willebrand factor (VWF) after secretion and becomes highly concentrated via VWF-platelet interaction at a site of endothelial inflammation or injury. Circulating levels of FVIII and VWF are influenced by age, blood type (nontype O > type O), and metabolic syndromes. In the latter, hypercoagulability is associated with chronic inflammation (known as thrombo-inflammation).]]> Fri, 14 Apr 2023 00:00:00 GMT-05:00 00000539-202305000-00010 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/05000/comprehensive_management_of_the_patient_with.9.aspx Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.]]> Fri, 14 Apr 2023 00:00:00 GMT-05:00 00000539-202305000-00009 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/04000/maternal_cardiovascular_morbidity_events_following.18.aspx BACKGROUND: Patients with preeclampsia are at high risk for long-term cardiovascular events, yet the short-term, acute cardiovascular complications that follow preeclampsia are understudied. The objective of this study was to compare the short-term, acute maternal cardiovascular morbidity events after delivery among patients with a diagnosis of preeclampsia versus those without this diagnosis. METHODS: In this retrospective cohort study, the Premier inpatient database was used to examine a cohort of obstetric patients older than 18 years, who delivered from January 1, 2016, to September 30, 2020. A diagnosis of preeclampsia and preeclampsia with severe features during delivery hospitalization were the exposures of interest. The primary outcome was a composite of maternal cardiovascular morbidity events during delivery hospital admission. The secondary outcome was the occurrence of maternal cardiovascular morbidity events during a readmission within 90 days of delivery hospitalization. RESULTS: In total, 4,488,759 patients met inclusion criteria, of which 158,114 (3.5%) were diagnosed with preeclampsia without severe features, and 117,940 (2.6%) with preeclampsia with severe features. Adjusted odds of maternal cardiovascular morbidity events were higher in patients with preeclampsia and in those with preeclampsia with severe features compared with those without preeclampsia during delivery hospitalization (adjusted odds ratio [OR] [95% confidence interval {CI}] 1.87 [1.78–1.97] and 4.74 [4.44–5.05], respectively) and within 90 days (adjusted OR [95% CI] 2.01 [1.83–2.21] and 2.32 [2.10–2.57], respectively). CONCLUSIONS: Patients with both preeclampsia and preeclampsia with severe features have higher rates of maternal cardiovascular morbidity events than those without preeclampsia. Future studies are necessary to examine which patients with preeclampsia are at highest risk for cardiovascular complications.]]> Tue, 13 Dec 2022 00:00:00 GMT-06:00 00000539-202304000-00018 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/04000/ultrasound_assessment_of_gastric_fluid_volume_in.16.aspx BACKGROUND: This study aimed to compare the gastric fluid volume (GFV) in children who fasted 1 versus 2 hours using ultrasound, after ingestion of a defined volume of clear fluid. METHODS: Children scheduled for elective surgery were enrolled in this randomized, double-blinded, controlled trial. After receiving 3 mL kg–1 clear fluid, participants were randomized to have a gastric ultrasound after fasting for either 1 hour (1-hour group, n = 116) or 2 hours (2-hour group, n = 111). Our primary outcome was the GFV. Other outcomes included the antral cross-sectional area, frequency of high risk and low risk of aspiration, and qualitative grading for the gastric antrum. RESULTS: Two hundred and twenty-seven children were available for final analysis. The median (Q1–Q3) GFV was higher in the 1-hour group versus the 2-hour group (0.61 [0.41–0.9] mL kg–1 vs 0.32 [0.23–0.47] mL kg–1; P value = .001). None of the study groups had GFV ≥1.5 mL kg–1. The frequency (%) of GFV ≥1.25 mL kg–1 was comparable between both groups (2 [1.7%] vs 0 [0%], P value = .165). However, the frequency of GFV ≥0.8 mL kg–1 was higher in 1-hour group than in 2-hour group (34.5% vs 4.5%), and grade 2 antral grading score was 56.9% in 1-hour group vs 0.9% in 2-hour group (P value <.001). CONCLUSIONS: In healthy children scheduled for elective surgery receiving 3 mL kg–1 clear fluid, the median GFV after 1-hour fasting was double the volume after conventional 2-hour fasting. These findings should be considered whether weighting the risk/benefit of a liberal approach to preoperative fasting versus the risk of pulmonary aspiration.]]> Sat, 16 Jul 2022 00:00:00 GMT-05:00 00000539-202304000-00016 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/03000/appropriate_duration_of_perioperative_intravenous.12.aspx BACKGROUND: Perioperative lidocaine infusion has been reported to alleviate pain intensity after colorectal surgery. However, there is no consensus on whether prolonged lidocaine infusion is more effective than short lidocaine infusion. This meta-analysis aimed to determine an appropriate duration of lidocaine infusion in patients undergoing colorectal surgery. METHODS: We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases to identify articles published before December 17, 2021. Randomized controlled trials comparing intravenous lidocaine with placebo for pain relief in patients undergoing colorectal surgery were included. The primary outcome was pain scores (visual analog scale [VAS], 0–10 cm) at 24 hours postoperatively at rest and on movement. Secondary outcomes included pain scores at 12, 48, and 72 hours postoperatively, analgesic consumption (mg), gastrointestinal function return (hour), length of hospital stay (days), and incidence of complications. According to the duration of lidocaine infusion, studies were grouped into infusion for at least 24 hours (prolonged lidocaine infusion) and less than 24 hours (short lidocaine infusion) to assess the impact of lidocaine infusion duration on the outcomes of interests. Quantitative analyses were performed using a random effects model. RESULTS: Eleven studies with 548 patients were included. Five studies used prolonged lidocaine infusion, while 6 studies used short lidocaine infusion. Prolonged lidocaine infusion reduced postoperative pain scores versus placebo at 24 hours at rest (mean difference [MD], −0.91 cm; 95% confidence interval [CI], −1.54 to −0.28; P = .02) and on movement (MD, −1.69 cm; 95% CI, −2.15 to −1.22; P < .001), while short lidocaine infusion showed no benefit. Compared with placebo, prolonged lidocaine infusion reduced pain scores at 12 hours at rest and at 12 and 48 hours on movement, but short lidocaine infusion did not. However, there was no significant difference in pain scores between the prolonged and short lidocaine infusion groups at these time points. Compared with placebo, prolonged lidocaine infusion shortened the length of hospital stay (MD, −1.30 days; 95% CI, −1.72 to −0.88; P < .001) and time to first postoperative defecation (MD, −12.51 hours; 95% CI, −22.67 to −2.34; P = .02). There were no differences between groups regarding the other outcomes. CONCLUSIONS: The analgesic effect of intravenous lidocaine may depend on the duration of infusion, and our results suggest that lidocaine infusion should be administered for at least 24 hours after colorectal surgery. Since overall evidence quality was low, further high-quality, large-sample trials are needed to explore an optimal lidocaine infusion strategy in patients undergoing colorectal surgery.]]> Fri, 20 Jan 2023 00:00:00 GMT-06:00 00000539-202303000-00012 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/03000/high_flow_nasal_cannula_for_apneic_oxygenation_in.11.aspx BACKGROUND: Obese patients desaturate rapidly during the apneic period after induction of anesthesia for elective surgery. Administration of oxygen using high-flow nasal cannulae (HFNCs) may prevent desaturation in nonobese patients compared to facemask (FM) preoxygenation. The aim of this meta-analysis was to compare the effectiveness of HFNC to FM preoxygenation techniques in reducing preintubation desaturation in obese patients undergoing elective surgery. METHODS: This study protocol was registered on PROSPERO (CRD42022309391). Adult studies that compared HFNC and FM preoxygenation in obese patients requiring general anesthesia for elective surgery were included. The primary outcome was desaturation resulting in oxygen saturation of <92% from induction of anesthesia until intubation. Secondary outcomes included the lowest arterial oxygen content before intubation expressed in mm Hg, safe apnea time expressed in seconds, the lowest oxygen saturation before intubation expressed as a percentage, patient-reported discomfort, the need for rescue ventilation, and the incidence of aspiration of gastric contents during intubation. Risk of bias was assessed using the Cochrane Collaboration tool. Certainty was assessed following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: Six studies including 351 participants were eligible for analysis. There was no difference in odds of oxygen desaturation <92% between HFNC and FM (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.15–1.63; P = .24). The HFNC group had a significantly longer safe apnea time (mean difference [MD], –124.20 with 95% CI, –200.47 to −47.93; P = .001). There was no difference between HFNC and FM in the lowest arterial oxygen content (MD, −23.90; 95% CI, −88.64 to 40.85; P = .47) and the lowest peripheral oxygenation saturation (MD, −0.47 with 95% CI, –5.07 to 4.12; P = .84). HFNC had a lower odd of discomfort than FM (OR, 0.13; 95% CI, 0.03–0.52; P = .004). There was no difference in the odds of aspiration of gastric contents between HFNC and FM (OR, 0.33; 95% CI, 0.01–8.21; P = .50). The risk of bias for our primary and secondary outcomes was low. The GRADE assessment for our primary outcome indicated a low level of certainty. For secondary outcomes, the GRADE assessment indicated a very low certainty for all outcomes except for patient discomfort, which was indicated as a moderate level of certainty. CONCLUSIONS: There may be no difference between HFNC and FM preoxygenation in preventing oxygen desaturation <92% or the lowest oxygen saturation before intubation. Preparation remains important to prevent and manage desaturation during induction of obese patients.]]> Mon, 05 Dec 2022 00:00:00 GMT-06:00 00000539-202303000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/02000/association_between_the_frail_scale_and.11.aspx BACKGROUND: Several frailty screening tools have been shown to predict mortality and complications after surgery. However, these tools were developed for in-person evaluation and cannot be used during virtual assessments before surgery. The FRAIL (fatigue, resistance, ambulation, illness, and loss of weight) scale is a brief assessment that can potentially be conducted virtually or self-administered, but its association with postoperative outcomes in older surgical patients is unknown. The objective of this systematic review and meta-analysis (SRMA) was to determine whether the FRAIL scale is associated with mortality and postoperative outcomes in older surgical patients. METHODS: Systematic searches were conducted of multiple literature databases from January 1, 2008, to December 17, 2022, to identify English language studies using the FRAIL scale in surgical patients and reporting mortality and postoperative outcomes, including postoperative complications, postoperative delirium, length of stay, and functional recovery. These databases included Medline, Medline ePubs/In-process citations, Embase, APA (American Psychological Association) PsycInfo, Ovid Emcare Nursing, (all via the Ovid platform), Cumulative Index to Nursing and Allied Health Literature (CINAHL) EbscoHost, the Web of Science (Clarivate Analytics), and Scopus (Elsevier). The risk of bias was assessed using the quality in prognosis studies tool. RESULTS: A total of 18 studies with 4479 patients were included. Eleven studies reported mortality at varying time points. Eight studies were included in the meta-analysis of mortality. The pooled odds ratio (OR) of 30-day, 6-month, and 1-year mortality for frail patients was 6.62 (95% confidence interval [CI], 2.80–15.61; P < .01), 2.97 (95% CI, 1.54–5.72; P < .01), and 1.54 (95% CI, 0.91–2.58; P = .11), respectively. Frailty was associated with postoperative complications and postoperative delirium, with an OR of 3.11 (95% CI, 2.06–4.68; P < .01) and 2.65 (95% CI, 1.85–3.80; P < .01), respectively. The risk of bias was low in 16 of 18 studies. CONCLUSIONS: As measured by the FRAIL scale, frailty was associated with 30-day mortality, 6-month mortality, postoperative complications, and postoperative delirium.]]> Tue, 29 Nov 2022 00:00:00 GMT-06:00 00000539-202302000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/02000/what_is_new_in_obstetric_anesthesia__the_2021.24.aspx The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiologists. In this review, some of the most influential articles discussed in the 2021 virtual lecture are highlighted. Themes include maternal mortality; disparities and social determinants of health; cognitive function, mental health, and recovery; quality and safety; operations, value, and economics; clinical controversies and dogmas; epidemics and pandemics; fetal-neonatal and child health; general clinical care; basic and translational science; and the future of peripartum anesthetic care. Practice-changing evidence is presented and evaluated. A priority list for clinical updates, systems, and quality improvement initiatives is presented.]]> Fri, 06 May 2022 00:00:00 GMT-05:00 00000539-202302000-00024 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/01000/relationships_between_body_mass_index,_allogeneic.18.aspx BACKGROUND: Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS: The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and 2018. Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5–24.9 kg/m2) after adjustment of potential confounding factors. RESULTS: Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60–2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47–3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47–0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21–1.54) for a BMI 40+. CONCLUSIONS: SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA.]]> Thu, 07 Apr 2022 00:00:00 GMT-05:00 00000539-202301000-00018 https://journals.lww.com/anesthesia-analgesia/fulltext/2023/01000/respiratory_adverse_events_after_lma__mask_removal.7.aspx BACKGROUND: The removal of the laryngeal mask airway (LMA®) in children may be associated with respiratory adverse events. The rate of occurrence of these adverse events may be influenced by the type of anesthesia. Studies comparing total intravenous anesthesia (TIVA) with propofol and sevoflurane are limited with conflicting data whether propofol is associated with a lower incidence of respiratory events upon removal of LMA as compared to induction and maintenance with sevoflurane. We hypothesized that TIVA with propofol is superior to sevoflurane in providing optimal conditions and improved patient’s safety during emergence. METHODS: In this prospective, randomized, double-blind clinical trial, children aged 6 months to 7 years old were enrolled in 1 of 2 groups: the TIVA group and the sevoflurane group. In both groups, patients were mechanically ventilated. At the end of the procedure, LMAs were removed when patients were physiologically and neurologically recovered to a degree to permit a safe, natural airway. The primary aim of this study was to compare the occurrence of at least 1 respiratory adverse event, the prevalence of individual respiratory adverse events, and the airway hyperreactivity score following emergence from anesthesia between the 2 groups. Secondary outcomes included ease of LMA insertion, quality of anesthesia during the maintenance phase, hemodynamic stability, time to LMA removal, and incidence of emergence agitation. RESULTS: Children receiving TIVA with propofol had a significantly lower incidence (10.8.% vs 36.2%; relative risk, 0.29; 95% CI [0.14–0.64]; P = .001) and lower severity (P = .01) of respiratory adverse outcomes compared to the patients receiving inhalational anesthesia with sevoflurane. There were no statistically significant differences in secondary outcomes between the 2 groups, except for emergence agitation that occurred more frequently in patients receiving sevoflurane (P < .001). CONCLUSIONS: Propofol induction and maintenance exerted a protective effect on healthy children with minimal risk factors for developing perioperative respiratory complications, as compared to sevoflurane.]]> Fri, 25 Feb 2022 00:00:00 GMT-06:00 00000539-202301000-00007 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/12000/hypobaric_unilateral_spinal_anesthesia_versus.20.aspx BACKGROUND: Hypotension during surgery is frequent in the elderly population and is associated with acute kidney and myocardial injury, which are, themselves, associated with increased 30-day mortality. The present study compared the hemodynamic effects of hypobaric unilateral spinal anesthesia (HUSA) to general anesthesia (GA) in patients ≥70 years of age undergoing hip fracture surgery. METHODS: We conducted a single-center, prospective, randomized study. In the HUSA group, patients were positioned with the operated hip above, and the hypobaric anesthetic solution was composed of 9 mg ropivacaine, 5 µg sufentanil, and 1 mL of sterile water. Anesthesia was adjusted for the GA group. Mean arterial pressure (MAP) was measured with a noninvasive blood pressure upper arm cuff every 3 minutes. Hypotension was treated with a bolus of ephedrine and then a continuous intravenous of norepinephrine to obtain a MAP ≥65 mm Hg. Primary outcome was the occurrence of severe hypotension, defined as a MAP <65 mm Hg for >12 consecutive minutes. RESULTS: A total of 154 patients were included. Severe hypotension was more frequent in the GA group compared to the HUSA group (odds ratio, 5.6; 95% confidence interval, 2.7–11.7; P < .001). There was no significant difference regarding the short-term outcomes between the HUSA and GA groups: acute kidney injury (respectively, 5.1% vs 11.3%; P = .22), myocardial injury (18.0% vs 14.0%; P = .63), and 30-day mortality (2.4% vs 4.7%; P = .65). CONCLUSIONS: HUSA leads to fewer episodes of severe intraoperative hypotension compared to GA in an elderly population undergoing hip fracture surgery.]]> Thu, 22 Sep 2022 00:00:00 GMT-05:00 00000539-202212000-00020 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/12000/narrative_review_of_kratom,_an_emerging.12.aspx Opioid overprescribing, with resultant overdose and death, has led to a national focus on alternative treatments for pain. With the decline in legal access to opioids, kratom has gained popularity as a legal, “natural,” and easily accessible nonprescription analgesic for consumers wishing to self-medicate for pain, opioid use disorder, and other mental health conditions. While implications of kratom use in patients with chronic pain and/or opioid use disorder have been published, information on perianesthetic implications is lacking. Anesthesiologists should be informed about kratom, including the potential for unexpected physiologic derangements and adverse drug interactions resulting from complex pharmacologic activity, cytochrome P450 interactions, and common adulterations of the drug that may result in unpredictable clinical effects. This article explores the relevance of kratom to perioperative anesthetic care, including suggestions for anesthesiologists extrapolated from published information in nonoperative settings that may improve patient safety in individuals using kratom.]]> Fri, 19 Aug 2022 00:00:00 GMT-05:00 00000539-202212000-00012 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/11000/context_analysis_of_continued_citation_of.16.aspx The continued citation of retracted publications from the medical literature is a well-known and persistent problem. We describe the contexts of ongoing citations to manuscripts that have been retracted from a selection of anesthesiology journals. We also examine how bibliographic databases and publisher websites document the retracted status of these manuscripts. The authors performed an analysis of retracted publications from anesthesiology journals using the Retraction Watch database. We then examined how the retraction information was displayed on bibliographic databases, search engines, and publisher websites. The primary outcome was the context of continued citation after retraction of flawed publications within the specialty of anesthesiology. Secondary outcomes included comparison of the documentation, bibliographic databases, search engines, and publisher websites used in identifying the retracted status of these publications and provision of access to the respective retraction notices. A total of 245 original publications were retracted over a 28-year period from 9 anesthesiology journals. PubMed, compared to the other databases and search engines, was the most consistent (98.8%) in documenting the retracted status of the publications examined, as well as providing a direct link to the retraction notice. From the 211 publications retracted before January 2020, there were 1307 postretraction citations accessed from Scopus. The median number of postretraction citations was 3.5 (range, 0–88, with at least 1 citation in 164 publications) in Scopus. Of the postretraction citations, 80% affirmed the validity of the retracted publications, while only 5.2% of citations acknowledged the retraction or misconduct. In 10.2% of the citations from original research studies, retracted manuscripts appeared to influence the decision to pursue or the methods used in subsequent original research studies. The frequency of citation of the 15 most cited retracted publications declined in a similar pattern during the 10 years after retraction. Citation of manuscripts retracted from anesthesiology journals remains a common occurrence. Technological innovations and application of standards for handling retracted publications, as suggested by coalitions of researchers across the spectrum of scientific investigation, may serve to reduce the persistence of this error.]]> Fri, 21 Oct 2022 00:00:00 GMT-05:00 00000539-202211000-00016 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/11000/ventilation_strategies_during_general_anesthesia.13.aspx BACKGROUND: The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes. METHODS: PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28–0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25–0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13–1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21–0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome. CONCLUSIONS: Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.]]> Fri, 21 Oct 2022 00:00:00 GMT-05:00 00000539-202211000-00013 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/10000/characterizing_the_heart_rate_effects_from.23.aspx BACKGROUND: Reversal of neuromuscular blockade (NMB) with sugammadex can cause marked bradycardia and asystole. Administration of sugammadex typically occurs in a dynamic period when anesthetic adjuvants and gas concentrations are being titrated to achieve emergence. This evaluation examined the heart rate (HR) responses to sugammadex to reverse moderate to deep NMB during a steady-state period and sought mechanisms for HR changes. METHODS: Patients with normal sinus rhythm, who were undergoing elective surgery that included rocuronium for NMB, were evaluated. After surgery, while at steady-state surgical depth anesthesia with sevoflurane and mechanical ventilation, patients received either placebo or 2 or 4 mg/kg of sugammadex to reverse moderate to deep NMB. Study personnel involved in data analysis were blinded to treatment. Continuous electrocardiogram (ECG) was recorded from the 5 minutes before and 5 minutes after sugammadex/placebo administration. R-R intervals were converted to HR and averaged in 1-minute increments. The maximum prolongation of an R-R interval after sugammadex was converted to an instantaneous HR. RESULTS: A total of 63 patients were evaluated: 8 received placebo, and 38 and 17 received 2 and 4 mg/kg sugammadex. Age, body mass index, and patient factors were similar in groups. Placebo did not elicit HR changes, whereas sugammadex caused maximum instantaneous HR slowing (calculated from the longest R-R interval), ranging from 2 to 19 beats/min. There were 7 patients with maximum HR slowing >10 beats/min. The average HR change and 95% confidence interval (CI) during the 5 minutes after 2 mg/kg sugammadex were 3.1 (CI, 2.3–4.1) beats/min, and this was not different from the 4 mg/kg sugammadex group (4.1 beats/min [CI, 2.5–5.6]). HR variability derived from the standard deviation of consecutive R-R intervals increased after sugammadex. CONCLUSIONS: Sugammadex to reverse moderate and deep NMB resulted in a fast onset and variable magnitude of HR slowing in patients. A difference in HR slowing as a function of dose did not achieve statistical significance. The observational nature of the investigation prevented a full understanding of the mechanism(s) of the HR slowing.]]> Thu, 15 Sep 2022 00:00:00 GMT-05:00 00000539-202210000-00023 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/10000/society_of_cardiovascular_anesthesiologists.17.aspx Cardiac surgery-associated acute kidney injury (CS-AKI) is common and is associated with increased risk for postoperative morbidity and mortality. Our recent survey of the Society of Cardiovascular Anesthesiologists (SCA) membership showed 6 potentially renoprotective strategies for which clinicians would most value an evidence-based review (ie, intraoperative target blood pressure, choice of specific vasopressor agent, erythrocyte transfusion threshold, use of alpha-2 agonists, goal-directed oxygen delivery on cardiopulmonary bypass [CPB], and the “Kidney Disease Improving Global Outcomes [KDIGO] bundle of care”). Thus, the SCA’s Continuing Practice Improvement Acute Kidney Injury Working Group aimed to provide a practice update for each of these strategies in cardiac surgical patients based on the evidence from randomized controlled trials (RCTs). PubMed, EMBASE, and Cochrane library databases were comprehensively searched for eligible studies from inception through February 2021, with search results updated in August 2021. A total of 15 RCTs investigating the effects of the above-mentioned strategies on CS-AKI were included for meta-analysis. For each strategy, the level of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Across the 6 potentially renoprotective strategies evaluated, current evidence for their use was rated as “moderate,” “low,” or “very low.” Based on eligible RCTs, our analysis suggested using goal-directed oxygen delivery on CPB and the “KDIGO bundle of care” in high-risk patients to prevent CS-AKI (moderate level of GRADE evidence). Our results suggested considering the use of vasopressin in vasoplegic shock patients to reduce CS-AKI (low level of GRADE evidence). The decision to use a restrictive versus liberal strategy for perioperative red cell transfusion should not be based on concerns for renal protection (a moderate level of GRADE evidence). In addition, targeting a higher mean arterial pressure during CPB, perioperative use of dopamine, and use of dexmedetomidine did not reduce CS-AKI (a low or very low level of GRADE evidence). This review will help clinicians provide evidence-based care, targeting improved renal outcomes in adult patients undergoing cardiac surgery.]]> Thu, 12 May 2022 00:00:00 GMT-05:00 00000539-202210000-00017 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/09000/update_on_applications_and_limitations_of.5.aspx Tranexamic acid (TXA) is a potent antifibrinolytic with documented efficacy in reducing blood loss and allogeneic red blood cell transfusion in several clinical settings. With a growing emphasis on patient blood management, TXA has become an integral aspect of perioperative blood conservation strategies. While clinical applications of TXA in the perioperative period are expanding, routine use in select clinical scenarios should be supported by evidence for efficacy. Furthermore, questions regarding optimal dosing without increased risk of adverse events such as thrombosis or seizures should be answered. Therefore, ongoing investigations into TXA utilization in cardiac surgery, obstetrics, acute trauma, orthopedic surgery, neurosurgery, pediatric surgery, and other perioperative settings continue. The aim of this review is to provide an update on the current applications and limitations of TXA use in the perioperative period.]]> Wed, 17 Aug 2022 00:00:00 GMT-05:00 00000539-202209000-00005 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/09000/risk_factors_and_consequences_of_acute_kidney.22.aspx BACKGROUND: Postoperative acute kidney injury (AKI) is a serious complication that is associated with prolonged hospital stay, high risk of short-term postsurgical mortality, need for dialysis, and possible progression to chronic kidney disease. To date, very little data exist on the risk of postoperative AKI among children undergoing noncardiac surgical procedures. We used data from a large multicenter cohort to determine the factors associated with AKI among children who underwent inpatient noncardiac surgical procedures and its impact on the postoperative course. METHODS: We utilized the National Surgical Quality Improvement Program Pediatric participant user files to identify a cohort of children who underwent inpatient surgery between 2012 and 2018 (n = 257,439). We randomly divided the study population into a derivation cohort of 193,082 (75%) and a validation cohort of 64,357 (25%), and constructed a multivariable logistic regression model to identify independent risk factors for AKI. We defined AKI as the occurrence of either acute renal failure or progressive renal insufficiency within the 30 days after surgery. RESULTS: The overall rate of postoperative AKI was 0.10% (95% confidence interval [CI], 0.09–0.11). In a multivariable model, operating times longer than 140 minutes, preexisting hematologic disorder, and preoperative sepsis were the strongest independent predictors of AKI. Other independent risk factors for AKI were American Society of Anesthesiologists (ASA) physical status ≥III, preoperative inotropic support, gastrointestinal disease, ventilator dependency, and corticosteroid use. The 30-day mortality rate was 10.1% in children who developed AKI and 0.19% in their counterparts without AKI (P < .001). Children who developed AKI were more likely to require an extended hospital stay (≥75th percentile of the study cohort) relative to their peers without AKI (77.4% vs 21.0%; P < .001). CONCLUSIONS: Independent preoperative risk factors for AKI in children undergoing inpatient noncardiac surgery were hematologic disorder, preoperative sepsis, ASA physical status ≥III, inotropic support, gastrointestinal disease, ventilator dependency, and steroid use. Children with AKI were 10 times more likely to die and nearly 3 times more likely to require an extended hospital stay, relative to their peers without AKI.]]> Thu, 27 Jan 2022 00:00:00 GMT-06:00 00000539-202209000-00022 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/08000/nonopioid_analgesics_for_the_perioperative.12.aspx Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting (N-methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials‚ and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.]]> Thu, 24 Feb 2022 00:00:00 GMT-06:00 00000539-202208000-00012 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/08000/extracorporeal_membrane_oxygenation_for_pregnant.11.aspx Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.]]> Thu, 27 Jan 2022 00:00:00 GMT-06:00 00000539-202208000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/07000/electroencephalographic_burst_suppression,.14.aspx Burst-suppression is an electroencephalographic pattern that results from a diverse array of pathophysiological causes and/or metabolic neuronal suppression secondary to the administration of anesthetic medications. The purpose of this review is to provide an overview of the physiological mechanisms that underlie the burst-suppression pattern and to present in a comprehensive way the available evidence both supporting and in opposition to the clinical use of this electroencephalographic pattern as a therapeutic measure in various perioperative settings.]]> Mon, 06 Dec 2021 00:00:00 GMT-06:00 00000539-202207000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/07000/effects_of_etco2_on_the_minimum_alveolar.12.aspx BACKGROUND: CO2 has anesthetic potency and effectively influences the circulatory system. We investigated the effects of Etco2 on the minimum alveolar concentration of sevoflurane that blunts the adrenergic response to surgical incision (MAC-BAR) in patients undergoing radical surgery for gastric carcinoma. METHODS: Ninety patients undergoing radical gastric-carcinoma surgery under general anesthesia were enrolled and randomly assigned into 3 groups. After intubation, the Etco2 in group L (n = 30), group N (n = 30), and group H (n = 30) was adjusted to 25 mm Hg ≤ Etco2 <30 mm Hg, 30 mm Hg ≤ Etco2 < 40 mm Hg, and 40 mm Hg ≤ Etco2 < 45 mm Hg, respectively, by changes in controlled ventilation. Hemodynamics and depth of anesthesia were observed before and after skin incision. The MAC-BAR of sevoflurane for each group was determined using an up-and-down sequential-allocation technique. RESULTS: To obtain 7 crossovers, 25, 26, and 26 patients were used in group L, group N, and group H, respectively. The MAC-BAR of sevoflurane using the up-and-down method for group H was significantly lower than that for group L (2.3% [95% confidence interval {CI}, 2.2–2.4] vs 2.9% [95% CI, 2.7–3.0]; difference, −0.6% [95% CI, −0.7 to −0.4], P < .001) and group N (2.3% [95% CI, 2.2–2.4] vs 2.8% [95% CI, 2.8–2.9]; difference, −0.5% [95% CI, −0.7 to −0.4], P < .001), while no significant difference was found between group L and group N (P = 1.000). CONCLUSIONS: Higher Etco2 levels (Etco2 values equal to 40 mm Hg or higher) can effectively decrease the MAC-BAR of sevoflurane in patients undergoing radical surgery for gastric carcinoma.]]> Thu, 16 Jun 2022 00:00:00 GMT-05:00 00000539-202207000-00012 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/07000/carbon_dioxide_as_the_other_therapeutic_carrier.11.aspx No abstract available]]> Thu, 16 Jun 2022 00:00:00 GMT-05:00 00000539-202207000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/06000/the_changing_face_of_cystic_fibrosis__an_update.18.aspx Cystic fibrosis (CF) is the most common fatal genetic disease in North America. While CF is more common among Whites, it is increasingly being recognized in other races and ethnicities. Although there is no cure, life expectancy has steadily improved, with the median survival exceeding 46 years in the United States. There are now more adults than children with CF in the United States. CF is caused by mutations in a gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR) protein, expressed in many epithelial cells. More than 2100 CFTR mutations have been linked to CF, and newer CFTR modulator drugs are being used to improve the production, intracellular processing, and function of the defective CFTR protein. CF is a multisystem disease that affects primarily the lungs, pancreas, hepatobiliary system, and reproductive organs. Anesthesiologists routinely encounter CF patients for various surgical and medical procedures, depending on the age group. This review article focuses on the changing epidemiology of CF, advances in the classification of CFTR mutations, the latest innovations in CFTR modulator therapies, the impact of the coronavirus disease pandemic, and perioperative considerations that anesthesiologists must know while caring for patients with CF.]]> Wed, 12 Jan 2022 00:00:00 GMT-06:00 00000539-202206000-00018 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/06000/association_between_perioperative_medication_use.7.aspx BACKGROUND: Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. METHODS: This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month. RESULTS: Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85–2.44), beta-blocker (RR, 1.38; 95% CI, 0.94–2.05), NSAID (RR, 1.12; 95% CI, 0.77–1.62), opioid (RR, 1.22; 95% CI, 0.82–1.82), or statin (RR, 1.34; 95% CI, 0.92–1.95) exposure and delirium. Postoperative hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10–4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74–2.94) nor opioid (aHR, 0.82; 95% CI, 0.62–1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed. CONCLUSIONS: Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.]]> Thu, 24 Feb 2022 00:00:00 GMT-06:00 00000539-202206000-00007 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/05000/pressure_regulated_ventilator_splitting_for.27.aspx The coronavirus disease 2019 (COVID-19) pandemic has revealed that even the best-resourced hospitals may lack sufficient ventilators to support patients under surge conditions. During a pandemic or mass trauma, an affordable, low-maintenance, off-the-shelf device that would allow health care teams to rapidly expand their ventilator capacity could prove lifesaving, but only if it can be safely integrated into a complex and rapidly changing clinical environment. Here, we define an approach to safe ventilator sharing that prioritizes predictable and independent care of patients sharing a ventilator. Subsequently, we detail the design and testing of a ventilator-splitting circuit that follows this approach and describe our clinical experience with this circuit during the COVID-19 pandemic. This circuit was able to provide individualized and titratable ventilatory support with individualized positive end-expiratory pressure (PEEP) to 2 critically ill patients at the same time, while insulating each patient from changes in the other’s condition. We share insights from our experience using this technology in the intensive care unit and outline recommendations for future clinical applications.]]> Mon, 20 Dec 2021 00:00:00 GMT-06:00 00000539-202205000-00027 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/05000/effectiveness_of_perioperative_opioid_educational.11.aspx BACKGROUND: Opioids are the most commonly prescribed analgesics in the United States. Current guidelines have proposed education initiatives to reduce the risk of chronic opioid consumption, yet there is lack of efficacy data on such interventions. Our study evaluates the impact of perioperative opioid education on postoperative opioid consumption patterns including opioid cessation, number of pills consumed, and opioid prescription refills. METHODS: The MEDLINE/PubMed, Embase, Cochrane Library, Scopus, and Google Scholar databases were systematically searched for randomized controlled trials (RCTs) assessing the impact of perioperative educational interventions (using either paper- or video-based instruments regarding pain management and drug-induced side effects) on postoperative opioid patterns compared to standard preoperative care among patients undergoing elective surgery. Our end points were opioid consumption (number of pills used), appropriate disposal of unused opioids, opioid cessation (defined as no use of opioids), and opioid refills within 15 days, 6 weeks, and 3 months. RESULTS: In total, 11 RCTs fulfilled the inclusion criteria, totaling 1604 patients (804 received opioid education, while 800 received standard care). Six trials followed patients for 15 days after surgery, and 5 trials followed patients up to 3 months. After 15 days, the opioid education group consumed a lower number of opioid pills than those in the control group (weighted mean difference [WMD], −3.39 pills; 95% confidence interval [CI], −6.40 to −0.37; P =.03; I2 = 69%) with no significant difference in overall opioid cessation (odds ratio [OR], 0.25; 95% CI, 0.04–1.56; P = .14; I2 = 83%). Likewise, perioperative opioid education did not have significant effects on opioid cessation at 6 weeks (OR, 0.69; 95% CI, 0.45–1.05; P = .10; I2 = 0%) and 3 months (OR, 0.59; 95% CI,0.17–2.01; P = .10; I2 = 0%) after surgery, neither reduced the need for opioid refills at 15 days (OR, 0.57; 95% CI, 0.28–1.15; P = .12; I2 = 20%) and 6 weeks (OR, 1.08; 95% CI, 0.59–1.98; P = .80; I2 = 37%). There was no statistically significant difference in the rate of appropriate disposal of unused opioids between both groups (OR, 1.99; 95% CI, 0.66–6.00; P = .22; I2 = 71%). Subgroup analysis by type of educational intervention showed a statistical reduction of opioid consumption at 15 days when implementing multimedia/audiovisual strategies (4 trials: WMD, −4.05 pills; 95% CI, −6.59 to −1.50; P = .002; I2 = 45%), but there was no apparent decrease when using only paper-based strategies (2 trials: WMD, −2.31 pills; 95% CI, −12.21 to 7.59; P = .65; I2 = 80%). CONCLUSIONS: Perioperative educational interventions reduced the number of opioid pills consumed at 15 days but did not demonstrate a significant effect on opioid cessation or opioid refills at 15 days, 6 weeks, and 3 months. Further randomized trials should focus on evidence-based educational interventions with strict homogeneity of material to draw a more definitive recommendation.]]> Fri, 11 Jun 2021 00:00:00 GMT-05:00 00000539-202205000-00011 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/04000/association_between_intraoperative_arterial.23.aspx BACKGROUND: It is unclear whether intraoperative arterial hypotension is associated with postoperative delirium. We hypothesized that intraoperative hypotension within a range frequently observed in clinical practice is associated with increased odds of delirium after surgery. METHODS: Adult noncardiac surgical patients undergoing general anesthesia at 2 academic medical centers between 2005 and 2017 were included in this retrospective cohort study. The primary exposure was intraoperative hypotension, defined as the cumulative duration of an intraoperative mean arterial pressure (MAP) <55 mm Hg, categorized into and short (<15 minutes; median [interquartile range {IQR}], 2 [1–4] minutes) and prolonged (≥15 minutes; median [IQR], 21 [17–31] minutes) durations of intraoperative hypotension. The primary outcome was a new diagnosis of delirium within 30 days after surgery. In secondary analyses, we assessed the association between a MAP decrease of >30% from baseline and postoperative delirium. Multivariable logistic regression adjusted for patient- and procedure-related factors, including demographics, comorbidities, and markers of procedural severity, was used. RESULTS: Among 316,717 included surgical patients, 2183 (0.7%) were diagnosed with delirium within 30 days after surgery; 41.7% and 2.6% of patients had a MAP <55 mm Hg for a short and a prolonged duration, respectively. A MAP <55 mm Hg was associated with postoperative delirium compared to no hypotension (short duration of MAP <55 mm Hg: adjusted odds ratio [ORadj], 1.22; 95% confidence interval [CI], 1.11–1.33; P < .001 and prolonged duration of MAP <55 mm Hg: ORadj, 1.57; 95% CI, 1.27–1.94; P < .001). Compared to a short duration of a MAP <55 mm Hg, a prolonged duration of a MAP <55 mm Hg was associated with greater odds of postoperative delirium (ORadj, 1.29; 95% CI, 1.05–1.58; P = .016). The association between intraoperative hypotension and postoperative delirium was duration-dependent (ORadj for every 10 cumulative minutes of MAP <55 mm Hg: 1.06; 95% CI, 1.02–1.09; P =.001) and magnified in patients who underwent surgeries of longer duration (P for interaction = .046; MAP <55 mm Hg versus no MAP <55 mm Hg in patients undergoing surgery of >3 hours: ORadj, 1.40; 95% CI, 1.23–1.61; P < .001). A MAP decrease of >30% from baseline was not associated with postoperative delirium compared to no hypotension, also when additionally adjusted for the cumulative duration of a MAP <55 mm Hg (short duration of MAP decrease >30%: ORadj, 1.13; 95% CI, 0.91–1.40; P = .262 and prolonged duration of MAP decrease >30%: ORadj, 1.19; 95% CI, 0.95–1.49; P = .141). CONCLUSIONS: In patients undergoing noncardiac surgery, a MAP <55 mm Hg was associated with a duration-dependent increase in odds of postoperative delirium. This association was magnified in patients who underwent surgery of long duration.]]> Mon, 13 Sep 2021 00:00:00 GMT-05:00 00000539-202204000-00023 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/04000/airway_ultrasound_as_predictor_of_difficult_direct.15.aspx BACKGROUND: Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia. METHODS: We searched the Medline, Scopus, and Web of Science databases from their inception to December 2020. The population of interest included adults who required tracheal intubation for elective surgery under general anesthesia without clear anatomical abnormalities suggesting difficult laryngoscopy. A bivariate model has been used to assess the accuracy of each ultrasound index test to predict difficult direct laryngoscopy. RESULTS: Fifteen studies have been considered for quantitative analysis of summary receiver operating characteristic (SROC). The sensitivity for distance from skin to epiglottis (DSE), distance from skin to hyoid bone (DSHB), and distance from skin to vocal cords (DSVC) was 0.82 (0.74–0.87), 0.71 (0.58–0.82), and 0.75 (0.62–0.84), respectively. The specificity for DSE, DSHB, and DSVC was 0.79 (0.70–0.87), 0.71 (0.57–0.82), and 0.72 (0.45–0.89), respectively. The area under the curve (AUC) for DSE, DSHB, DSVC, and ratio between the depth of the pre-epiglottic space and the distance from the epiglottis to the vocal cords (Pre-E/E-VC) was 0.87 (0.84–0.90), 0.77 (0.73–0.81), 0.78 (0.74–0.81), and 0.71 (0.67–0.75), respectively. Patients with difficult direct laryngoscopy have higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with a mean difference of 0.38 cm (95% confidence interval [CI], 0.17–0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01–0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08–0.39 cm; P = .004), respectively. CONCLUSIONS: Our study demonstrates that airway ultrasound index tests are significantly different between patients with easy versus difficult direct laryngoscopy, and the DSE is the most studied index test in literature to predict difficult direct laryngoscopy. However, it is not currently possible to reach a definitive conclusion. Further studies are needed with better standardization of ultrasound assessment to limit all possible sources of heterogeneity.]]> Mon, 07 Mar 2022 00:00:00 GMT-06:00 00000539-202204000-00015 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/03000/health_services_research_in_anesthesia__a_brief.15.aspx The use of large data sources such as registries and claims-based data sets to perform health services research in anesthesia has increased considerably, ultimately informing clinical decisions, supporting evaluation of policy or intervention changes, and guiding further research. These observational data sources come with limitations that must be addressed to effectively examine all aspects of health care services and generate new individual- and population-level knowledge. Several statistical methods are growing in popularity to address these limitations, with the goal of mitigating confounding and other biases. In this article, we provide a brief overview of common statistical methods used in health services research when using observational data sources, guidance on their interpretation, and examples of how they have been applied to anesthesia-related health services research. Methods described involve regression, propensity scoring, instrumental variables, difference-in-differences, interrupted time series, and machine learning.]]> Fri, 18 Feb 2022 00:00:00 GMT-06:00 00000539-202203000-00015 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/03000/the_triple_bottom_line_and_stabilization_wedges__a.8.aspx We present a narrative review of environmental sustainability aimed at perioperative clinicians. The review will familiarize readers with the triple bottom line framework, which aims to align the goals of delivering high-quality patient care, promoting environmental sustainability, and improving the financial position of health care organizations. We introduce the stabilization wedges model for climate change action adopted for the perioperative setting and discuss areas in which perioperative leaders can make sustainable choices. The goal of this review is to increase awareness among perioperative physicians of the environmental impacts of surgical and anesthetic care, promote engagement with sustainability efforts as a topic of professional concern for our specialty, and inspire new research in perioperative environmental sustainability.]]> Fri, 18 Feb 2022 00:00:00 GMT-06:00 00000539-202203000-00008 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/02000/cognitive_recovery_by_decade_in_healthy_40__to.23.aspx BACKGROUND: Postoperative delirium and postoperative cognitive dysfunction are the most common complications for older surgical patients. General anesthesia may contribute to the development of these conditions, but there are little data on the association of age with cognitive recovery from anesthesia in the absence of surgery or underlying medical condition. METHODS: We performed a single-center cohort study of healthy adult volunteers 40 to 80 years old (N = 71, mean age 58.5 years, and 44% women) with no underlying cognitive dysfunction. Volunteers underwent cognitive testing before and at multiple time points after 2 hours of general anesthesia consisting of propofol induction and sevoflurane maintenance, akin to a general anesthetic for a surgical procedure, although no procedure was performed. The primary outcome was time to recovery to cognitive baseline on the Postoperative Quality of Recovery Scale (PQRS) within 30 days of anesthesia. Secondary cognitive outcomes were time to recovery on in-depth neuropsychological batteries, including the National Institutes of Health Toolbox and well-validated paper-and-pencil tests. The primary hypothesis is that time to recovery of cognitive function after general anesthesia increases across decades from 40 to 80 years of age. We examined this with discrete-time logit regression (for the primary outcome) and linear mixed models for interactions of age decade with time postanesthesia (for secondary outcomes). RESULTS: There was no association between age group and recovery to baseline on the PQRS; 36 of 69 (52%) recovered within 60-minute postanesthesia and 63 of 69 (91%) by day 1. Hazard ratios (95% confidence interval) for each decade compared to 40- to 49-year olds were: 50 to 59 years, 1.41 (0.50–4.03); 60 to 69 years, 1.03 (0.35–3.00); and 70 to 80 years, 0.69 (0.25–1.88). There were no significant differences between older decades relative to the 40- to 49-year reference decade in recovery to baseline on secondary cognitive measures. CONCLUSIONS: Recovery of cognitive function to baseline was rapid and did not differ between age decades of participants, although the number in each decade was small. These results suggest that anesthesia alone may not be associated with cognitive recovery in healthy adults of any age decade.]]> Fri, 10 Dec 2021 00:00:00 GMT-06:00 00000539-202202000-00023 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/02000/the_relation_between_mean_arterial_pressure_and.16.aspx BACKGROUND: Cardiac output is an important hemodynamic variable and determines oxygen delivery. In contrast to blood pressure, cardiac output is rarely measured even in high-risk surgical patients, suggesting that clinicians consider blood pressure to be a reasonable indicator of systemic blood flow. However, the relationship depends on constant vascular tone and volume, both of which routinely vary during anesthesia and surgery. We therefore tested the hypothesis that there is no clinically meaningful correlation between mean arterial pressure and cardiac index in major abdominal surgery patients. METHODS: In this prospective observational study, we assessed the relationship between mean arterial pressure and cardiac index in 100 patients having major abdominal surgery under general anesthesia. RESULTS: The pooled within-patient correlation coefficient calculated using meta-analysis methods was r = 0.34 (95% confidence interval, 0.28–0.40). Linear regression using a linear mixed effects model of cardiac index on mean arterial pressure revealed that cardiac index increases by 0.014 L·min−1·m−2 for each 1 mm Hg increase in mean arterial pressure. The 95% Wald confidence interval of this slope was 0.011 to 0.018 L·min−1·m−2·mm Hg−1 and thus within predefined equivalence margins of −0.03 and 0.03 L·min−1·m−2·mm Hg−1, thereby demonstrating lack of clinically meaningful association between mean arterial pressure and cardiac index. CONCLUSIONS: There is no clinically meaningful correlation between mean arterial pressure and cardiac index in patients having major abdominal surgery. Intraoperative blood pressure is thus a poor surrogate for cardiac index.]]> Thu, 02 Dec 2021 00:00:00 GMT-06:00 00000539-202202000-00016 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/01000/perioperative_diabetes_insipidus_caused_by.14.aspx Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 29 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.]]> Wed, 06 Jan 2021 00:00:00 GMT-06:00 00000539-202201000-00014 https://journals.lww.com/anesthesia-analgesia/fulltext/2022/01000/leftover_opioid_analgesics_and_disposal_following.19.aspx BACKGROUND: Opioid analgesics are commonly prescribed for postoperative analgesia following pediatric surgery and often result in leftover opioid analgesics in the home. To reduce the volume of leftover opioids and overall community opioid burden, the State of Tennessee enacted a policy to reduce initial opioid prescribing to a 3-day supply for most acute pain incidents. We aimed to evaluate the extent of leftover opioid analgesics following pediatric ambulatory surgeries in the context of a state-mandated restrictive opioid-prescribing policy. We also aimed to evaluate opioid disposal rates, methods of disposal, and reasons for nondisposal. METHODS: Study personnel contacted the parents of 300 pediatric patients discharged with an opioid prescription following pediatric ambulatory surgery. Parents completed a retrospective telephone survey regarding opioid use and disposal. Data from the survey were combined with data from the medical record to evaluate proportion of opioid doses prescribed that were left over. RESULTS: The final analyzable sample of 185 patients (62% response rate) were prescribed a median of 12 opioid doses (interquartile range [IQR], 12–18), consumed 2 opioid doses (IQR, 0–4), and had 10 opioid doses left over (IQR, 7–13). Over 90% (n = 170 of 185) of parents reported they had leftover opioid analgesics, with 83% of prescribed doses left over. A significant proportion (29%, n = 54 of 185) of parents administered no prescribed opioids after surgery. Less than half (42%, n = 71 of 170) of parents disposed of the leftover opioid medication, most commonly by flushing down the toilet, pouring down the sink, or throwing in the garbage. Parents retaining leftover opioids (53%, n = 90 of 170) were most likely to keep them in an unlocked location (68%, n = 61 of 90). Parents described forgetfulness and worry that their child will experience pain in the future as primary reasons for not disposing of the leftover opioid medication. CONCLUSIONS: Despite Tennessee’s policy aimed at reducing leftover opioids, a significant proportion of prescribed opioids were left over following pediatric ambulatory surgeries. A majority of parents did not engage in safe opioid disposal practices. Given the safety risks related to leftover opioids in the home, further interventions to improve disposal rates and tailor opioid prescribing are warranted after pediatric surgery.]]> Wed, 31 Mar 2021 00:00:00 GMT-05:00 00000539-202201000-00019