https://journals.lww.com/anesthesia-analgesia/toc/9900/00000 en-us Tue, 05 Aug 2025 17:11:59 -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/toc/9900/00000 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/camera_based_photoplethysmography_for_measuring.1411.aspx BACKGROUND: Photoplethysmography has been used to assess vital signs since the late 19th century. Recently, camera-based photoplethysmography systems have gained attention due to their noninvasive nature. However, challenges such as low perfusion, motion artifacts, and ambient light interference limit their use during surgical anesthesia. This study evaluated the efficacy of a camera-based system (FaCare) compared with that of a conventional contact monitor (GE HealthCare CARESCAPE B850 patient monitor) in measuring heartbeat intervals during various stages of surgical anesthesia. METHODS: Thirty patients undergoing video-assisted thoracic surgery were included. Data were collected using a webcam and FaCare software at 4 stages: preanesthesia, postanesthesia, postanesthesia with a shadowless lamp, and postsurgery. Six remote photoplethysmography techniques using artificial intelligence algorithms processed the data. RESULTS: The results demonstrated a high level of agreement between the FaCare and GE HealthCare monitor. Pearson correlation analysis, Bland–Altman plots, and Welch’s t test indicated that 88.1% of the heart rate correlation coefficients between the 2 devices were >0.8. Furthermore, their heartbeat interval measurements showed strong agreement in the Bland–Altman plots. FaCare showed comparable functionality, offering a noninvasive alternative suitable for operating rooms. CONCLUSIONS: This study evaluated the FaCare camera-based photoplethysmography system, integrating 6 remote photoplethysmography techniques with artificial intelligence algorithms, and compared it to a conventional contact monitor for measuring heartbeat intervals during surgical anesthesia. The results showed strong consistency between FaCare and the GE contact monitor across different anesthesia stages. These findings indicate that the noninvasive FaCare system reduces infection risks and improves patient comfort. Future research is recommended to optimize artificial intelligence algorithms, data synchronization, and sampling frequency to enhance its clinical application.]]> Tue, 05 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01411 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/augmented_reality_in_airway_management__a_scoping.1412.aspx Augmented reality, which overlays virtual information onto the physical environment, is an emerging technology in health care with promising applications in education, diagnostics, and procedural support. Its use in airway management—an essential aspect of anesthesiology and critical care—remains underexplored. This scoping review evaluates the current literature on augmented reality in airway management, with the aim of identifying its benefits, limitations, and future potential. A systematic literature search was conducted using PubMed, Embase, and IEEE databases, after PRISMA-ScR guidelines. Studies were included if they focused on augmented reality-assisted airway training or procedures and excluded if they centered on virtual reality or lacked procedural relevance. Ten studies met inclusion criteria, including 8 observational studies and 2 randomized controlled trials. Most utilized head-mounted displays to support simulation-based training or procedural guidance across pediatric and adult populations. Outcomes assessed included objective measures—such as intubation success, timing, and procedural accuracy—and subjective metrics like user confidence, perceived usability, and educational value. Results varied across studies. Several reported enhanced anatomical visualization, improved procedural success, and increased realism in training. One randomized controlled trial demonstrated higher intubation success rates and reduced procedure times when augmented reality-assisted video laryngoscopy was compared to standard methods. Another randomized controlled trial using a head-mounted display to deliver a procedural checklist found greater checklist adherence but also longer intubation times. Subjective feedback from participants noted challenges including device complexity, learning curve, and equipment limitations. Despite these encouraging findings, the current evidence base is limited by small sample sizes, variability in study design, and a lack of standardized evaluation protocols. Importantly, no study directly assessed the safety profile of augmented reality in airway management or its impact on patient-centered outcomes. In conclusion, augmented reality has the potential to improve anatomical understanding, procedural accuracy, and educational engagement in airway management. However, its integration into clinical practice is still in early stages. More rigorous, large-scale clinical trials are needed to determine its efficacy, optimize usability, and clarify its role in enhancing patient safety and provider training in anesthesiology and critical care.]]> Tue, 05 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01412 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/sagittal_computed_tomography_imaging_may_estimate.1413.aspx No abstract available]]> Tue, 05 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01413 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/education_and_training_in_perioperative_medicine_.1414.aspx No abstract available]]> Tue, 05 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01414 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_role_of_damage_associated_molecular_patterns.1415.aspx Perioperative neurocognitive disorders (PND), such as postoperative delirium (POD) and cognitive dysfunction (POCD), frequently affect older surgical patients and significantly impair postoperative quality of life. During surgical procedures, damage-associated molecular patterns (DAMPs) such as high-mobility group box 1 (HMGB1), mitochondrial DNA, and S100 proteins are released from injured cells and implicated in the pathogenesis of PND. These molecules activate innate immune pathways through pattern recognition receptors (PRRs) such as toll-like receptors (TLRs) and receptors for advanced glycation end products (RAGE). The systemic inflammatory response potentially compromises blood–brain barrier integrity, allowing peripheral immune cells to infiltrate the central nervous system. The resulting neuroinflammation disrupts synaptic function and neuronal connectivity, leading to cognitive impairments. Sustained activation of immune pathways creates a feedback loop where proinflammatory cytokines (eg, IL-1β and TNF-α) amplify DAMP release and immune activation, perpetuating chronic inflammation and cognitive dysfunction. Therapeutic strategies targeting DAMP-mediated pathways, such as glycyrrhizin (an HMGB1 inhibitor), dexmedetomidine (an anti-inflammatory anesthetic), and TLR4 inhibitors (eg, TAK-242), have shown promise in reducing neuroinflammation and protecting cognitive function in preclinical models. However, clinical translation requires validated biomarkers and further trials to ensure their safety and efficacy. This review offers a focused perspective on DAMP-specific mechanisms and emerging therapeutic interventions that modulate these pathways. By contributing to the current understanding of DAMPs in the context of PND, this work supports future research efforts aimed at developing biomarkers and targeted interventions to help mitigate postoperative neurocognitive complications in surgical patients.]]> Tue, 05 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01415 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/desflurane_s_effect_on_the_environment__climate.1403.aspx No abstract available]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01403 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1404.aspx No abstract available]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01404 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/emergency_trauma_anesthesia_care_and_outcomes_in.1405.aspx BACKGROUND: In the United States, firearm injuries are the leading cause of pediatric injury mortality. There is little information about anesthetic care and perioperative outcomes of children with firearm injuries. This study compares clinical characteristics, anesthesia care, and perioperative survival of pediatric patients with firearm and nonfirearm injuries. METHODS: We conducted a retrospective cohort study of injured patients <18 years admitted to a regional level 1 US pediatric trauma center between 2014 and 2022 who received anesthetic care within 2 hours of hospital arrival. Differences in clinical characteristics, anesthesia care including therapeutic intensity (arterial and central venous cannulation, blood product transfusion, vasopressor use, or hemostatic agent use) and outcomes (length of stay, mortality, and disposition) were examined between firearm and nonfirearm injury groups and by age groups. RESULTS: During the 9-year study period, pediatric firearm injury hospitalizations tripled, and 25.9% (69/266 trauma admissions) patients received emergency firearm injury anesthesia care. Six (8.8%) patients with firearm injuries were under 10 years. Polytrauma occurred in both firearm (7%) and nonfirearm injury (14%) groups. Compared to nonfirearm injuries, patients with firearm injuries were older (P < .0001), had fewer American Society of Anesthesiologists (ASA) physical status I (P = .03) and had more injuries with injury severity score (ISS) 16–25 (P < .01). Abdominal injury (P < .001) was more common than traumatic brain injury (TBI; P < .0001) across age groups but all children 1 to 4 years had profound (ISS ≥25) TBI. Time to anesthetic care was shorter (P < .001), arterial cannulation was more common (P < .02), estimated blood loss (P < .001) was greater, and massive transfusion (P < .0001) was more common during firearm injury anesthesia care. Etomidate (P = .01), midazolam (P < .01) and tranexamic acid (P < .01) use were more common and crystalloid resuscitation was larger (P < .0001) during firearm injury anesthesia care but varied by age group. Lengths of intensive care unit (P < .01) and hospital (P < .01) stay were longer in the firearm injury group. Intraoperative mortality was 1% and 2%, and mortality after the first anesthetic was 6% vs 10% in firearm and nonfirearm injury groups, respectively. All children 1 to 4 years were discharged to advanced placement. CONCLUSIONS: Pediatric trauma patients required high intraoperative therapeutic intensity, which was higher during firearm injury anesthesia care. Postoperative firearm injury mortality was high but less than from nonfirearm injury. Firearm injury patterns, anesthesia care and outcomes varied by age group. Operating room team readiness and provision of timely and high intensity anesthetic care are needed to save lives of injured children.]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01405 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/pharmacodynamic_modeling_in_sedation_optimization_.1406.aspx No abstract available]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01406 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/faculty_diversity_trends_in_academic.1407.aspx BACKGROUND: This surveillance study sheds light on the demographic trends in academic anesthesiology and highlights the shifts that have taken place over 4 consecutive decades. METHODS: The data for academic anesthesiology faculty were self-reported and obtained from the annual Faculty Roster report of the Association of American Medical Colleges (AAMC) from 1977 to 2021. After determining the distribution of academic degrees, academic rank, chair position, and tenure status over time, the percentage composition for each category was calculated for 44 years. The temporal trends were depicted by plotting the counts and proportion changes. At the same time, the progress in terms of racial representation was illustrated by graphing the absolute changes in the percentage composition. RESULTS: Despite an overall increase in absolute composition and percentage of women in academic anesthesiology from 20.8% to 35.7%, women remained underrepresented in academic degree attainment, senior academic ranks, and leadership positions. Faculty identifying as Black or African American increased from 1.3% to 4.3%, while Hispanic, Latino, or Spanish-origin faculty grew from 1.2% to 5.2%, representing modest growth in these underrepresented groups over the span of 4 decades. CONCLUSIONS: Despite an increase in the count of women and underrepresented minority faculty within academic anesthesiology since the 1970s, the persistence of imbalances related to gender, ethnicity, and race was observed, in senior academic ranks and leadership roles.]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01407 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/rescue_echocardiography_and_point_of_care.1408.aspx No abstract available]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01408 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/burnout_syndrome_among_perioperative_healthcare.1409.aspx BACKGROUND: Many studies address health care provider burnout in high-income countries; however, there is little data on burnout in low-income countries. Our objectives were (1) to estimate the prevalence of burnout among perioperative health care providers and (2) to explore factors associated with burnout among perioperative health care providers in Rwandan public hospitals. METHODS: A cross-sectional study using a survey was conducted among perioperative health care providers working in 22 public hospitals across Rwanda. We used a purposive sampling method to represent all regions (4 provinces and the capital Kigali) and types of public hospitals in Rwanda conducting surgery, excluding major teaching centers. We used the Maslach Burnout Inventory Human Services Survey (MBI_HSS), a validated 22-item survey including 3 dimensions of burnout: (1) emotional exhaustion (EE), (2) depersonalization (DP), and (3) personal achievement (PA). We estimated the prevalence of burnout using Wilson’s method and we identified factors associated with burnout using a multivariate analysis. RESULTS: There were 221 responses from 402 surveys sent with a response rate of 53.7% including nurses 106 (47.9%), general practitioners 36 (16.3%), nonphysician anesthetists 33 (14.9%), midwives 25 (11.3%), and specialist surgeons and anesthesiologists 4 (1.8%). Forty-7 (21.3, 95% CI 16.1–27.3)% participants had burnout, 95 (42.9, 95 CI 36.6–49.6)% had high emotional exhaustion, 57 (25.8, 95 CI 20.5–31.9)% had low personal accomplishment, 15 (6.8, 95 CI 4.2–10.9)% had high depersonalization). Three major burnout profiles were identified among participants, including the overextended group 84 (38%), the engaged group 83 (37.6%), and the ineffective group 39 (17.6%). Among postulated predictors of burnout, only a lack of having the right equipment was strongly associated with burnout (adj-OR, 3.21; 95 CI, 1.18–8.73, P = .02). CONCLUSIONS: One in 5 perioperative health care providers in Rwanda report having burnout, which is consistent with previous data. This suggests that burnout is widespread across the Rwandan health care system, across different perioperative professions. The only factor that was associated with burnout was lack of access to essential equipment; however, other factors that have been identified in the literature, which are not statistically significant in this study, should not be overlooked. Addressing equipment shortages may reduce the risk of burnout among perioperative health care providers in low-resource settings, in addition to directly impacting the quality of care.]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01409 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/use_of_personalized_body_worn_alcohol_dispenser,.1410.aspx No abstract available]]> Mon, 04 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01410 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/evaluation_of_a_novel,_image_guided_robotic.1399.aspx No abstract available]]> Fri, 01 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01399 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/effect_of_anesthetics_on_the_occurrence_of.1400.aspx No abstract available]]> Fri, 01 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01400 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/reconsidering_iron_substitution_for_anemia_after.1401.aspx No abstract available]]> Fri, 01 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01401 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1402.aspx No abstract available]]> Fri, 01 Aug 2025 00:00:00 GMT-05:00 00000539-990000000-01402 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1391.aspx No abstract available]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01391 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/comparison_of_phonomyography_prototype_with.1392.aspx BACKGROUND: Quantitative neuromuscular monitoring has been advocated to deal with residual neuromuscular block. Phonomyography (PMG) is a technology that captures the acoustic signals yielded by muscle contraction, which is easy to use, anti-interference, and has multiple alternative monitoring sites. Our previous study has developed a PMG prototype for neuromuscular monitoring, and its feasibility was preliminarily verified, but further study on its clinical reliability with different neuromuscular blocking agents (NMBs) is needed. METHODS: This single-center, prospective, observational study compared the effect of a PMG prototype and TOF-Watch SX on neuromuscular monitoring of the ipsilateral adductor pollicis muscle with the use of non-depolarizing and depolarizing NMBs among 102 surgical patients. Patients were divided into 3 groups by NMBs, namely Group C (cisatricurium), Group V (vecuronium), and Group S (succinylcholine). The PMG prototype and TOF-Watch SX were placed at ipsilateral hand of each individual and measured data from NMBs administration to a stable train-of-four ratio (TOFr) ≥ 0.9 or T value ≥ 0.9 were compared. RESULTS: Eighty patients were included in the data analysis. For non-depolarizing NMBs, the PMG prototype recorded a longer onset time compared to TOF-Watch SX (median [interquartile range, IQR], 210 [180–240] seconds vs 150 [135–180] seconds, P < .001, mean bias 48 [40–55]; mean ± [standard deviation, SD], 197 ± 48 seconds vs 159 ± 36 seconds, P < .001, mean bias 38 [28–48]; for Group C and Group V, respectively) and a shorter full recovery time (4014 ± 511 seconds vs 5072 ± 713 seconds, P < .001, mean bias −1058 [−1215 to −901], 3352 ± 791 seconds vs 4931 ± 902 seconds, P < .001, mean bias −1084 [−1237 to −931], for Group C and Group V, respectively). For depolarizing NMBs, the results were similar (94 ± 26 seconds vs 80 ± 25 seconds, P < .001, mean bias 15 [10–19] for onset time; 447 ± 126 seconds vs 689 ± 223 seconds, P < .001, mean bias −242 [−294 to −191] for full recovery time). CONCLUSIONS: When non-depolarizing NMBs were administered, the PMG prototype measured a significantly longer onset and a shorter recovery time compared with TOF-Watch SX. The same trend was also found when depolarizing NMBs were administered. The PMG prototype is clinical feasible and stable but not interchangeable with TOF-Watch SX.]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01392 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/sugammadex_and_gastric_emptying__individualized.1393.aspx No abstract available]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01393 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/widefield_imaging_reveals_distinct_whole_cortex.1394.aspx BACKGROUND: Anesthesia-induced loss of consciousness (LOC) is associated with alterations in cortical synchronization and desynchronization in various cortical regions. However, the precise spatiotemporal dynamics across the entire cortex and their role in the LOC remain unclear. This study utilized advanced imaging techniques to investigate these cortical dynamics under the action of different anesthetics. METHODS: We used Thy1-GCaMP6s mice with surgically prepared transparent skulls to observe cortical Ca2+ signals using widefield microscopy. Functional connectivity analysis was performed, and the primary spatial representations of the different frequency signal components were examined under anesthesia induced by ketamine, propofol, and isoflurane. RESULTS: All drugs enhanced 1.5 to 2.5 Hz signal oscillations in the retrosplenial cortex (RSC), making the 1.5 to 2.5 Hz signal oscillation power in the retrosplenial cortex significantly higher than that in other cortical regions (ketamine (mean ± SD: 1. 58 ± 0.06 vs 0. 27 ± 0.10, −0. 44 ± 0.02 and −0. 36 ± 0.06 for the retrosplenial cortex (RSC) vs the primary motor cortex (MOp), the primary somatosensory cortex (SSp) and the primary visual cortex (VISp), P< .001; propofol: 1. 36 ± 0.06 vs 0. 50 ± 0.09, −0. 34 ± 0.04 and −0. 20 ± 0.11 isoflurane: 1. 39 ± 0.12 vs 0. 30 ± 0.07, −0. 14 ± 0.19 and −0. 20 ± 0.14). Moreover, ketamine and isoflurane was associated with a structured signaling pattern. CONCLUSIONS: The general anesthetics induced unique cortical signal patterns, with the RSC emerging as a key region in which specific oscillatory patterns manifested. The observed 1.5 to 2.5 Hz oscillations in the RSC under different anesthetic conditions suggest a common underlying mechanism for anesthesia-induced LOC. Understanding these spatiotemporal patterns can help improve the monitoring and management of anesthesia.]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01394 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/association_of_risk_of_suspected_ocular_injury.1395.aspx No abstract available]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01395 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/reevaluating_hemodynamic_targets_for_aki.1396.aspx No abstract available]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01396 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/intraoperative_methadone_versus_other_opioids__a.1397.aspx BACKGROUND: Findings of randomized controlled trials indicate that intraoperative methadone administration reduces postoperative pain and opioid consumption compared to other opioids in many patient populations. While concerns about potential risks persist, large retrospective studies may be able to assess risks from methadone versus other opioids. Recent retrospective studies in adult patients found no association between methadone administration and adverse outcomes. Similar studies in pediatric patients are lacking. This retrospective study investigates the association of intraoperative methadone with postanesthesia care unit (PACU) pain scores and other relevant postoperative outcomes compared to other opioids. METHODS: We conducted a retrospective cohort study of pediatric patients (≤18 years of age) undergoing 1 of 6 surgeries from January 1, 2018 to February 29, 2024: spinal fusion for scoliosis, laparoscopic sleeve gastrectomy, bilateral mastectomy with nipple reconstruction, knee surgeries, Nuss repair for pectus excavatum, and cleft palate repair. The primary outcome was maximum PACU pain scores in patients receiving intraoperative methadone versus other opioids. Secondary outcomes were the incidence of moderate-severe PACU pain, opioid consumption, naloxone administration, emergence delirium, postoperative nausea and vomiting (PONV), and PACU length of stay (LOS). Results were analyzed using regression models, controlled for appropriate variables including procedure, age, sex, American Society of Anesthesiologists (ASA) score, body mass index (BMI), the number of pre/intraoperative adjuvants, and the use of regional anesthesia. Predefined subgroup analyses were conducted to compare patients who received methadone versus other opioids in the setting of (1) receiving preincision regional anesthesia; (2) receiving an intraoperative remifentanil infusion; and (3) in the methadone group, receiving a methadone dose ≥0.15 mg kg–1. RESULTS: 1794 patients were included; 528 received methadone. Patients receiving methadone had a lower maximum PACU pain score (3.9 [95% confidence interval {CI}, 3.6–4.2] vs 4.5 [95% CI 4.3–4.6]; P = .007), decreased PACU opioid consumption (0.06 vs 0.09 MEU kg−1; P < .001), decreased emergence delirium (9.60% vs 16.90%; P < .001), and no statistically significant difference in naloxone administration, PONV, and PACU LOS compared to the other-opioid group. CONCLUSIONS: In this large, single-center retrospective study, intraoperative methadone administered to pediatric patients was found to be associated with reduced postoperative pain scores, opioid consumption, and emergence delirium. Larger studies are needed to achieve the necessary power to assess adverse events in pediatric surgical patients who receive methadone versus other opioids.]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01397 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1398.aspx No abstract available]]> Thu, 31 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01398 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/suzetrigine_induced_metabolism_of_factor_xa.1390.aspx No abstract available]]> Tue, 29 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01390 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/trends_in_comorbidities_and_complications_among.1387.aspx BACKGROUND: With an aging population and gaining popularity of total knee and hip arthroplasty (TKA, THA), patients aged 80+ are likely to increase. These patients present unique challenges regarding perioperative risks. Large population data characterizing this group is lacking. The aim of this study was to offer an overview of trends in practices and outcomes among octogenarians and nonagenarians. METHODS: We utilized the Premier Healthcare database to identify patients undergoing TKA and THA from 2006 to 2022. Patients 80 to 88 years and 89+ years old were compared to those aged 65 to 70, the typical age group for TKA/THA recipients. We evaluated trends of practice pattern, patient demographics, and comorbidity burden. Multivariable models were applied to compare major complications. RESULTS: Neuraxial anesthesia was used more frequently among older patients undergoing TKA. Mean length of stay for both TKA and THA continuously decreased over time. Interestingly, octogenarian and nonagenarian TKA recipients had fewer comorbidities than 65- to 70-year-olds, while the reverse was observed among THA recipients. Multivariable analysis showed that among patients with similar comorbidity burden, octogenarian and nonagenarian patients had higher odds [95% CI] of major complications (TKA: OR 2.2 [2.0–2.4] and 2.7 [2.0–3.7] in 2006, OR 1.8 [1.6–2.1] and 2.0 [1.5–2.8] in 2022, respectively; for THA: OR 2.5 [2.1–3.0] and 3.7 [2.7–5.1] in 2006, OR 2.1 [1.8–2.4] and 2.7 [2.1–2.4] in 2022, respectively). CONCLUSIONS: Although THA/TKA patients appear to be in good health relative to 65- to 70-year-olds, age remains a significant risk factor for increased morbidity.]]> Wed, 23 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01387 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_academic_impediment__why_are_women_chairs_in.1388.aspx No abstract available]]> Wed, 23 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01388 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_disparities_and_the_imperative_for.1385.aspx No abstract available]]> Tue, 22 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01385 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1386.aspx No abstract available]]> Tue, 22 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01386 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/high_flow_nasal_oxygen_versus_mechanical.1383.aspx BACKGROUND: Apneic oxygenation with high-flow nasal oxygen is a novel intraoperative respiratory support strategy for patients undergoing general anesthesia, but data about its clinical effects are scarce. We conducted a randomized trial to assess whether high-flow nasal oxygen is noninferior to mechanical ventilation through a laryngeal mask in terms of success rate of intraoperative respiratory support among patients undergoing a 30-minute general anesthesia session. METHODS: Single-center, randomized, noninferiority trial conducted in Italy between May 2022 and June 2023 and involving American Society of Anesthesiologists class I and II patients undergoing general anesthesia for operative hysteroscopy. Participants were randomized to receive laryngeal mask ventilation (volume-controlled ventilation to obtain end-tidal carbon dioxide between 35 and 45 mm Hg, inhaled oxygen fraction to achieve peripheral oxygen saturation greater than 95%) or high-flow nasal oxygen (70 L per minute, inhaled oxygen fraction of 100%) for intraoperative respiratory support. Patients received general anesthesia with propofol target-controlled infusion without neuromuscular blockade. Primary outcome was intraoperative respiratory support success rate, which was defined as peripheral oxygen saturation greater than 94% and transcutaneous carbon dioxide lower than 65 mm Hg with no need for rescue airway interventions for the entire procedure. Secondary outcomes included the rate of airway-related complications (including need for bag-mask or laryngeal mask ventilation, or tracheal intubation), postoperative respiratory symptoms, and postoperative dyspnea. RESULTS: All 180 patients who were randomized completed the trial (90 patients in each group). Median [interquartile range] anesthesia duration was 25 [20–36] minutes in high-flow group and 32 minutes [27–44] in the laryngeal mask group. Intraoperative respiratory support was successful in 89 patients (99%) in both groups (absolute difference 0, unilateral 95% confidence interval, 3%, noninferiority P < .001). Incidence of postoperative respiratory symptoms was significantly lower in high-flow versus laryngeal mask group (2% vs 19%, P < .001), while airway-related complications and postoperative dyspnea were not different. Intraoperative transcutaneous carbon dioxide was significantly higher in high-flow group, with 43% of patients showing values greater than 55 mm Hg. CONCLUSIONS: High-flow nasal oxygen is noninferior to laryngeal mask ventilation for intraoperative respiratory support during 30-minute general anesthesia without muscle paralysis. The risk of hypercarbia warrants careful patient selection and monitoring.]]> Mon, 21 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01383 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/prevalence_of_point_of_care_ultrasound.1384.aspx BACKGROUND: Preeclampsia is a multisystem disorder associated with adverse maternal and fetal outcomes. A previous study in patients with late-onset preeclampsia (LOPE), showed an association between pulmonary interstitial syndrome (PIS), detected by lung ultrasound, and elevated left ventricular end-diastolic pressure (LVEDP), measured by transthoracic echocardiography (TTE). In early onset preeclampsia (EOPE); however, the cardiopulmonary status remains poorly characterized. METHODS: This prospective observational cohort study enrolled women with EOPE with severe features. Point of care ultrasound (POCUS) assessments included lung ultrasound, TTE, and sonographic assessment of the optic nerve sheath diameter (ONSD). PIS was defined as the presence of bilateral B-lines on lung ultrasound. An ONSD >5.8 mm was considered compatible with raised intracranial pressure. Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) and albumin levels were measured. The primary aim was to assess the association between PIS and elevated LVEDP in EOPE. Secondary aims included assessing the prevalence of POCUS abnormalities in EOPE and their association with serum NT-proBNP and albumin levels, and comparing the results with historical data from patients with LOPE. RESULTS: Sixty-4 patients completed the study. There was no association between PIS and elevated LVEDP (P = .53). PIS, diastolic dysfunction, systolic dysfunction, and elevated LVEDP were observed in 23% (95% CI, 14.4–35.4%), 52% (95% CI, 39.3–63.8%), 30% (95% CI, 19.9–42.5%), and 35% (95% CI, 24.2–47.6%) of women, respectively. Increased ONSD was noted in 2 women (3%). Median (IQR) NT-proBNP levels were significantly elevated (278 [119–678] ng/L) and associated with PIS (P = .015) and elevated LVEDP (P = .003). Using a threshold for NT-proBNP of 125 ng/L, the sensitivity and specificity for predicting PIS were 93.3% and 34%, and for increased LVEDP, 90.5% and 40%, respectively. Receiver operating characteristic analysis showed limited diagnostic value of NT-proBNP for PIS (AUC = 0.78) and for elevated LVEDP (AUC = 0.68). No association was found between serum albumin and PIS, systolic dysfunction, or elevated LVEDP. The prevalence of systolic dysfunction was significantly higher (P < .01) and raised ONSD lower (P < .01) than in historical controls with LOPE. CONCLUSIONS: Lung ultrasound and TTE showed a high prevalence of PIS, systolic dysfunction, and raised LVEDP in women diagnosed with EOPE. PIS was not associated with elevated LVEDP. NT-proBNP level was significantly associated with PIS and elevated LVEDP, however clinical predictive value was limited. Women with EOPE had a higher prevalence of systolic dysfunction than those with LOPE.]]> Mon, 21 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01384 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/clinical_decision_making_and_process_complications.1374.aspx No abstract available]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01374 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1375.aspx No abstract available]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01375 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/deep_versus_moderate_neuromuscular_blockade_during.1376.aspx BACKGROUND: Deep neuromuscular blockade (NMB) enhances surgical working conditions in laparoscopic surgery. Whether this accounts for nonlaparoscopic surgery is not known. Additionally, the effect on clinical and patient-reported outcomes remains debated. In this study, the effect of deep NMB compared to moderate NMB during total hip arthroplasty (THA) on quality of recovery and postoperative inflammation is investigated. METHODS: This single-center randomized controlled blinded trial comprised 100 patients undergoing THA treated with deep NMB (posttetanic count 1–2) or moderate NMB (train-of-four 1–2). Continuous or bolus administration of rocuronium was used. The primary end point was quality of recovery on postoperative day 1 (POD1), measured by the Quality of Recovery-40 (QoR-40) questionnaire. The secondary end points were innate immune function and pain scores on POD1, measured by ex vivo production capacity of tumor necrosis factor (TNF) and interleukin (IL)-1β on whole blood stimulation with lipopolysaccharide and postoperative pain as rated by the numeric rating scale. RESULTS: There was no difference in QoR-40 score on POD1 (mean difference −4.1, 95% confidence interval −10.9 to 2.8, P = .241). On POD 1, there was no difference in ex vivo production capacity of TNF (moderate NMB median [quartiles] 890 [532–1605] pg/mL, deep NMB 1113 [651–1716] pg/mL, P = .34, Mann-Whitney U test, median difference −125, 95% confidence interval [CI], −440 to 155) and IL-1β (moderate NMB 1148 [545–1970] pg/mL, deep NMB median 1386 [826–1940] pg/mL, P = .36, median difference [MD] −135, 95% CI, −470 to 191) on lipopolysaccharide stimulation. On POD1, there was no statistically significant difference in pain scores at rest (MD 1.10, 99.6% CI, −0.53 to 2.74, P = .049) and on movement (MD 0.94, 99.6% CI, −0.63 to 2.50, P = .080). CONCLUSIONS: No evidence was found for a beneficial effect of deep NMB compared to moderate NMB in THA regarding quality of recovery or postoperative inflammation.]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01376 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/ketamine_and_traumatic_memory_after_intensive_care.1377.aspx No abstract available]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01377 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1378.aspx No abstract available]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01378 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/haiku_suite.1379.aspx No abstract available]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01379 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/ketamine_and_traumatic_memory_after_intensive_care.1380.aspx No abstract available]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01380 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/remote_continuous_vital_sign_monitoring_of.1381.aspx BACKGROUND: Scoliosis surgery patients often require continuous postoperative monitoring in intensive care (ICU) or high-dependency units (HDU). We implemented a 24-hour remote continuous monitoring service for high-risk inpatients (HIVE) to allow monitoring in general wards. This study aimed to evaluate the cost-effectiveness of the HIVE service. METHODS: We compared scoliosis surgery patients admitted pre- and postimplementation of the HIVE service and applied multivariable regression to adjust for differences in baseline characteristics. The primary outcome was incremental cost per ICU hour avoided. RESULTS: We compared 155 patients admitted postimplementation to 133 admitted preimplementation. In the adjusted analysis, the post-HIVE implementation period avoided 27.1 hours in ICU and reduced overall health care costs by AU$2682 (US$2164) per patient, compared with preimplementation. There were no statistically significant differences in hospital length of stay (rate ratio [RR], 1.01; 95% confidence interval [CI], 0.93–1.11; P = .785), emergency readmissions (odds ratio [OR], 0.93; 95% CI, 0.44–1.99; P = .854), or hospital-acquired complications (OR, 0.68; 95% CI, 0.27–1.66; P = .393). CONCLUSIONS: In scoliosis surgery, the implementation of a remote continuous inpatient monitoring service reduced inpatient costs and hours in ICU. In this group of patients, the HIVE service provides economic evidence of the cost-effectiveness of remote monitoring.]]> Thu, 17 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01381 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/familiar_strangers.1368.aspx No abstract available]]> Tue, 15 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01368 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/acute_complications_of_rocuronium_versus.1369.aspx No abstract available]]> Tue, 15 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01369 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1370.aspx No abstract available]]> Tue, 15 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01370 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1371.aspx No abstract available]]> Tue, 15 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01371 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/absence_of_neuromuscular_monitoring_limits.1372.aspx No abstract available]]> Tue, 15 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01372 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/institutional_validation_of_quantra_guided.1373.aspx No abstract available]]> Tue, 15 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01373 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/erector_spinae_catheters_and_celiac_plexus_block.1367.aspx No abstract available]]> Fri, 11 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01367 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/how_well_do_accreditation_council_for_graduate.1359.aspx BACKGROUND: Milestones evaluation is mandated by the Accreditation Council for Graduate Medical Education (ACGME) to help training programs measure residents’ progress toward competency and identify specific areas for trainee improvement. Data from training programs raised concerns that Milestones ratings may reflect the year of training more than resident progress toward competency. We examined the relationship between residents’ Milestones ratings toward the end of residency training and their performance on the American Board of Anesthesiology (ABA) examinations, widely considered as the gold standard of competency. METHODS: We compared Milestones 2.0 ratings and board scores of all anesthesiologists who completed an ACGME-accredited residency program between July 2021 and June 2022 (AY22) and had their first-time ABA ADVANCED Examination (written), Standardized Oral Examination (SOE) and Objective Structured Clinical Examination (OSCE) performance available by 2023. We first assessed the correlation between the average rating achieved across all 23 Milestones during the last 6 months of residency training and the Z-scores of these three examinations among first-time takers. Then, we evaluated the correlations between 9 specific Milestones and their conceptually related domains tested by the ADVANCED, the SOE, and the OSCE; we calculated Pearson and polychoric correlation coefficients for continuous and ordinal data, respectively. RESULTS: All 23 Milestones 2.0 AY22 ratings were available for 1849 Post Graduate Year (PGY)-4, Clinical Anesthesia Year 3 (CA-3) residents. These were matched to 1799 first-time ADVANCED and 1383 first-time SOE and OSCE takers. The average ACGME Milestones ratings across all competencies were significantly correlated with examination Z-scores (all P < .001)—the ADVANCED (r = 0.135 [95% confidence interval {CI}, 0.089–0.180], the SOE (r = 0.117 [0.065–0.169]), and the OSCE (r = 0.112 [0.060–0.164]). For the domain-specific comparisons, scores on the ADVANCED Examination correlated modestly with the Medical Knowledge Milestone domain (r = 0.289, P < .001), but there were no statistically significant associations between SOE task ratings and their related Milestones domains (ρ = 0.027 to 0.091, P = .31 to 0.81). In comparisons of similar domains evaluated by OSCE stations and the Milestones, 2 were statistically significantly correlated with a weak magnitude (Interpretation of Monitors and Echocardiograms [ρ = 0.093, P = .031] and Ethical Issues [ρ = 0.049, P = .003]) while 2 others were not statistically significant (Application of Ultrasonography [ρ = 0.052, P = .775] and Communication with other Professionals [ρ = 0.052, P = .086]). CONCLUSIONS: There was a modest correlation between the last Medical Knowledge Milestone achieved and the ADVANCED Examination. However, the weak correlations between residency Milestones and the SOE or OSCE performance suggest that the Milestones system, as currently implemented by anesthesiology training programs, does not predict certifying examination performance.]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01359 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/ambulatory_surgery_during_intravenous_fluid.1360.aspx No abstract available]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01360 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_empty_crib__female_feticide,_abandonment,_and.1361.aspx No abstract available]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01361 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_dexamethasone_to_regulate.1362.aspx No abstract available]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01362 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_myth_of_the_phase_i_block_after.1363.aspx No abstract available]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01363 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/looking_at_history,_planning_for_the_future___an.1364.aspx No abstract available]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01364 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/age_dependent_entropic_features_during_propofol.1365.aspx BACKGROUND: Precise monitoring of anesthetic depth in children receiving propofol anesthesia is crucial. Commercial depth of anesthesia monitoring devices do not account for age-related changes in brain states and provide misleading information regarding the actual depth in young children. Entropy analysis, a typical complexity methodology, has been demonstrated to be a simple and robust tool for monitoring consciousness levels during anesthesia in adults. The validity of entropic measures for depth of anesthesia monitoring in children receiving general anesthesia remains largely unexplored. The age-related entropic feature dynamics during propofol anesthesia are still not clear. METHODS: We prospectively studied frontal electroencephalogram (EEG) recordings from subjects aged 1 to 18 years receiving propofol anesthesia. We calculated spectral power, permutation entropy (PeEn), sample entropy (SampEn), beta ratio, and bispectral index (BIS) from EEG segments obtained during wakefulness, maintenance, and recovery. PeEn quantifies the randomness of a time series and SampEn quantifies its unpredictability. Both measures convey complexity information on local connectivity within neural circuits for an EEG signal. The accuracy of these EEG measures to distinguish between propofol-induced unresponsiveness and clinical recovery was assessed. The changes in entropic feature dynamics with age during propofol anesthesia were investigated. RESULTS: Seventy-seven subjects were included for analysis. Propofol induced a significant decrease in frontal PeEn (from a median [interquartile range] of 0.75 [0.71–0.78] during wakefulness to 0.61 [0.57–0.63] during maintenance, P < .001), which returned to wakefulness levels during recovery (0.75 [0.71–0.79]), contrasting with BIS, which remained lower. A significant increase in SampEn was noted from wakefulness to maintenance (0.04 [0.04–0.06] vs 0.25 [0.20–0.28], P < .001). PeEn provided excellent performance for distinguishing between unresponsiveness and clinical recovery at an optimal classification threshold of 0.67 with the accuracy of 96.6%. The distinguishing capability of PeEn appeared superior in toddlers compared to BIS (accuracy: 94.7% vs 88.9%). SampEn also exhibited good distinguishing accuracy of 81.1% at an optimal threshold of 0.18. Frontal PeEn and SampEn, indicating information amount of intracortical neural circuits connectivity, decreased with age during propofol maintenance (P = .017 and .026, respectively). The adolescents exhibited significantly lower frontal power, PeEn, and SampEn values during propofol administration. CONCLUSIONS: The frontal PeEn served as an excellent indicator for distinguishing propofol-induced unresponsiveness from recovery in children. Frontal complexity, represented by PeEn and SampEn, decreased with age during propofol maintenance, which was hypothesized to reflect sequential neurophysiological development in frontal cortex, particularly its maturation during adolescence.]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01365 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/renal_vein_stasis_index_in_cardiac_surgery_.1366.aspx No abstract available]]> Thu, 10 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01366 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/enhancing_anesthetic_preoptimization__promising.1357.aspx The escalating costs of perioperative care are unsustainable, necessitating the identification of high-impact investment opportunities to enhance both quality and cost-effectiveness of perioperative processes. In both rural and urban areas with less access to health care resources, a sustainable health care system must focus on delivering value-based care and prioritizing population health, promoting efficiency, preventing complications, and optimizing outcomes.]]> Thu, 03 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01357 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_genifem_pilot_randomized_trial__genicular.1358.aspx No abstract available]]> Thu, 03 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01358 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_single_child_with_a_single_ventricle.1351.aspx No abstract available]]> Wed, 02 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01351 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/erector_spinae_plane_block_in_multimodal_analgesia.1352.aspx BACKGROUND: Postoperative pain after lumbar spine surgery is often severe, necessitating multimodal analgesic regimens that include opioids. Locoregional anesthesia, such as the Erector Spinae Plane Block (ESPB), may be effective in reducing postoperative pain and opioid use. This study evaluated the effect of bilateral ESPB on early postoperative pain and opioid use after lumbar spinal fusion surgery. METHODS: A single-center, randomized, blinded, placebo-controlled trial included 76 patients undergoing elective lumbar spinal fusion. Participants received either bilateral ESPB with ropivacaine or placebo (normal saline) after surgery. The primary outcome was pain intensity 1-hour postanesthesia, measured using the Numeric Rating Scale (NRS). Secondary outcomes included opioid consumption in the first 12 hours, time to first opioid use, quality of recovery, and pain intensity and opioid use at 30 days. Statistical significance was set at P < .05. RESULTS: The mean NRS 1-hour postanesthesia did not differ significantly between the ropivacaine and placebo group (3.8 ± 3 vs 4. 2 ± 2.6, P = .56). The median 12-hour opioid consumption was 11.3mg [2.5–21.5] vs 12.5 mg [5.1–22.4], median time to first opioid use 64 [22–171.5] vs 41 [21.3–89.5] minutes, and mean quality of recovery on day 1: 90. 7 ± 36 vs 102. 8 ± 20.5 and day 3: 108. 3 ± 21.2 vs 112. 5 ± 22.7, for the ropivacaine and placebo group, respectively. At 30 days, the mean NRS was 3. 4 ± 2.4 vs 3. 6 ± 2.5. Opioid use at 30 days occurred in 12 patients (16.2%) of the ropivacaine and in 15 (20.3%) of the placebo group. CONCLUSIONS: Bilateral ESPB with ropivacaine did not reduce early postoperative pain or opioid use in patients undergoing lumbar spinal fusion. Its overall benefits in a multimodal analgesic regimen appear limited and application of bilateral ESPB in all patients undergoing lumbar spine surgery is not recommended.]]> Wed, 02 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01352 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_medicine,_perioperative_surgical.1353.aspx No abstract available]]> Wed, 02 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01353 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/automated_robotic_airway_insertion_using_flexible.1354.aspx No abstract available]]> Wed, 02 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01354 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/continuous_and_noninvasive_total_blood_hemoglobin.1355.aspx BACKGROUND: Continuous measurement of total hemoglobin (tHb) can be of great clinical value during surgery, visualizing tHb trends and guiding blood transfusion practices. Devices such as those pulse oximetry-based have been available and studied over the past decade with varying results on their accuracy. We recently developed a first-of-its-kind near-infrared reflectance spectroscopy (NIRS) based algorithm to measure tHb continuously and noninvasively. This study was conducted to evaluate the performance of the NIRS based tHb algorithm using a cerebral oximetry sensor. METHODS: We performed a post hoc retrospective analysis of data collected during cardiac surgery from 3 clinical sites. Both NIRS data and blood gas tHb data were collected. Then the NIRS data was postprocessed through the NIRS based tHb algorithm to generate continuous measurement of tHb. Comparison between the 2 tHb measurements was assessed using the Bland-Altman analysis, mean absolute error (MAE), root mean square error (RMSE), 4-quadrant concordance, and error-grid analysis. RESULTS: One hundred and eighty-nine (189) patients were included in the analysis. The bias (or mean difference) and precision (or 1 standard deviation of the difference) (95% confidence interval) are 0.08 (0.02–0.19) g/dL and 1.01 (0.93–1.09) g/dL, respectively. The limits of agreement were −1.90 and 2.06 g/dL. The MAE is 0.79 (0.69–0.91) g/dL, the RMSE is 1.12 (0.94–1.30 g/dL), and the concordance is 86.1 (79.8–92.1) %. The error-grid analysis demonstrated that the majority (84%) of the measurements are in the green zone and 0% in the red zone. CONCLUSIONS: The exploratory study shows that the NIRS based tHb provided an accurate measurement of tHb in cardiac surgery patients. Further research may be needed to evaluate its accuracy and implementation in other clinical settings.]]> Wed, 02 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01355 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/awake_bronchoscopic_intubation__a_survey_of.1356.aspx No abstract available]]> Wed, 02 Jul 2025 00:00:00 GMT-05:00 00000539-990000000-01356 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/alterations_in_functional_connectivity_and_network.1349.aspx BACKGROUND: Remimazolam, an ultrashort-acting intravenous benzodiazepine, is a safe and effective sedative agent. Previous studies have established a strong correlation between cortical network alterations and general anesthesia. However, the effects of remimazolam on the cortical network remain unclear. METHODS: Twenty-two patients were administered intravenous remimazolam. Recordings were obtained using a 32-channel electroencephalography across the baseline, anesthesia, and recovery states. Brain oscillatory activity during remimazolam anesthesia was assessed through spectral power analysis. Functional connectivity was assessed using the weighted and directed phase lag indices, with the former used to construct weighted brain networks. Network characteristics were analyzed using nodal metrics (nodal clustering coefficient and efficiency) and global metrics (average clustering coefficient, average path length, modularity, and small-worldness). In addition, hub nodes were identified using the largest betweenness centrality to investigate the network’s hub structure across different states. RESULTS: Remimazolam induced significant anteriorization of alpha power and markedly decreased alpha functional connectivity in both prefrontal-frontal and anterior-posterior regions (P < .019). Remimazolam significantly affected the alpha-band functional brain network, characterized by reduced nodal clustering (P < .001) and efficiency (P < .001), but increased global clustering (P < .001), average path length (P = .022), and modularity (P < .001). The small-world property—a network structure balancing high clustering with short path lengths—was preserved under remimazolam anesthesia (slightly increased, P = .028). After remimazolam anesthesia, the hub structure of the brain was reconfigured and characterized by hub node redistribution from the posterior to anterior regions. CONCLUSIONS: Remimazolam induced reorganization of functional brain networks from highly connected, highly integrated complex networks to sparsely connected, locally modular cortical networks. These findings strengthen the notion that consciousness relies on networks capable of efficient information transmission that critically depends on the balance between global functional integration and segregation.]]> Mon, 30 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01349 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/continuous_vital_sign_monitoring_at_the_surgical.1350.aspx BACKGROUND: Complications occur in a third of patients after major noncardiac surgery and are often preceded by vital sign deviations undetected by current vital sign monitoring practice, despite major advances in surgical and perioperative care. Continuous wireless vital sign monitoring with real-time alerts may allow for a reduction of vital sign abnormalities and complications. METHODS: Adult patients undergoing major noncardiac surgery were included and randomized to either standard of care (manual intermittent vital sign monitoring) vs standard of care plus continuous wireless vital sign monitoring with real-time vital sign alerts to staff smartphones at the general postoperative ward. The primary outcome was cumulative duration of severe vital sign deviations, including desaturation, tachy- and bradycardia, tachy- and bradypnea, hypo- and hypertension. Secondary outcomes included adverse events within 30 days. Patients and outcome assessors were blinded to the randomization. RESULTS: Four hundred patients were randomized, with 200 in the intervention and 200 in the control group, respectively. Median [interquartile range (IQR)] duration of severely deviating vital signs was 60 [25–136] vs 76 [28–192] min/d in the intervention versus control group, respectively (P = .19). Duration of Spo2 <88% had a mean reduction of 47 minutes per day (95% confidence interval [CI], 18–80, P = .02). Adverse events occurred in 42.5% vs 31.5% of patients within 30 days (P = .02), and serious adverse events in 34.5% vs 29.5% (P = .39). CONCLUSIONS: Continuous vital sign monitoring with real-time staff alerts did not significantly reduce cumulative severe vital sign deviations in this setup. Significant reductions in desaturations and adverse events were found, giving evidence to future studies in the use of continuous vital sign monitoring to improve patient outcomes.]]> Mon, 30 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01350 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/multimodal_analgesia_and_enhanced_recovery.1343.aspx BACKGROUND: Multimodal analgesia, the use of more than 1 pharmacologic agent targeting different receptors, is a cornerstone of enhanced recovery after cardiac surgery (ERACS), but there are limited studies to support its efficacy. We aimed to explore associations between multimodal analgesia and enhanced recovery outcomes after cardiac surgery. METHODS: We performed a retrospective cohort study using data from the Society of Thoracic Surgeons database from 2020 to 2023. Adults undergoing elective coronary artery bypass grafting (CABG), valve, or combined CABG-valve surgery were included. Our primary hypothesis was that multimodal analgesia would be associated with a lower maximum postoperative pain score on postoperative day 3 (POD3). Secondarily, we hypothesized that multimodal analgesia would be associated with reduced mechanical ventilation hours, intensive care unit stay, delirium, pneumonia, and reintubation. Linear mixed-effects regression models and generalized linear mixed-effects regression models were used to examine the extent the use of multimodal analgesia was associated with study outcomes after controlling for confounders. RESULTS: Over the 4-year study period, there were 17,371 eligible cardiac surgical cases and 15,515 patients (89.3%) received multimodal analgesia. There was no association between multimodal analgesia use and maximum postoperative pain score on POD3 (b = −0.07, 95% confidence interval [CI], −0.32 to 0.18, P = .57), after adjusting for confounders. There was an association between multimodal analgesia use and initial mechanical ventilation hours (b = 0.45 hours, 95% CI, 0.04–0.86, P = .03). Compared to patients who received multimodal analgesia, those who did not receive multimodal analgesia had approximately 30 minutes longer of initial mechanical ventilation time on average. Initial mechanical ventilation time decreased as the number of multimodal analgesic increased (b= −0.33 hours, 95% CI, −76 to −0.10, P = .14) for 1 multimodal analgesic; Est = −1.98 hours, 95% CI, −3.79 to −0.18, P = .03 for 5 multimodal analgesics). Acetaminophen use was associated with a reduced likelihood of delirium (odds ratio [OR] = 0.75, 95% CI, 0.57–0.94, P = .02), while use of a regional nerve block was associated with increased likelihood of unplanned reintubation (OR = 1.59, 95% CI, 1.12–2.27, P = .01). CONCLUSIONS: In this retrospective study, multimodal analgesia was not associated with the primary outcome of reduction in maximum pain score but was associated with more rapid extubation. Larger prospective observational and randomized controlled trials of individual analgesic drugs are needed to optimize ERACS protocols.]]> Wed, 25 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01343 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/my_inner_picture__self_regulation_and_spiritual.1344.aspx No abstract available]]> Wed, 25 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01344 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/morphine_and_cardioprotection_in_a_failing_heart_.1345.aspx No abstract available]]> Wed, 25 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01345 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_basic_question_of_disparities_in.1346.aspx No abstract available]]> Wed, 25 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01346 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1347.aspx No abstract available]]> Wed, 25 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01347 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/gaps_in_personalizing_anesthetic_drug_delivery.1348.aspx No abstract available]]> Wed, 25 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01348 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/influence_of_vitamin_d_on_sevoflurane_induced.1338.aspx BACKGROUND: Numerous studies have demonstrated that sevoflurane might have neurotoxic effects on the developing brain. However, the underlying mechanisms and potential treatment are largely unknown. Vitamin D has immunomodulatory, anti-inflammatory, and neuroprotective effects. We aimed to investigate whether vitamin D could attenuate sevoflurane-induced neurotoxicity in the offspring of mice. METHOD: Twenty 8-week-old pregnant Swiss albino mice were randomly divided into 4 groups with 5 mice each: Control, vitamin D (Vit-D), sevoflurane (Sevo), and sevoflurane-vitamin D (Sevo-Vit-D). Throughout the pregnancy, Vit-D and Sevo-Vit-D groups were intraperitoneally administered vitamin D, while Sevo and Control groups received 1 ml of saline. On the 14th day of pregnancy, Sevo and Sevo-Vit-D were exposed to 3% sevoflurane with 100% O2 for 2 hours. Control and Vit-D were exposed to 100% O2 for 2 hours. Newborn mice from the groups were included in the study. Tissue sections of the prefrontal cortex and hippocampus were examined by immunohistochemical methods and electron microscopy (EM) on postnatal day 7 and postnatal day 45 (PN7 and PN45). The immunohistochemical methods assessed the expression levels of inflammatory cytokines, apoptotic factors, neuroprotective proteins. Open field and elevated plus maze tests were performed to assess behavioral changes at PN45. RESULTS: Vitamin D significantly attenuated the mean (95% confidence interval [CI]) sevoflurane-induced increase in the expression levels of inflammatory cytokines and apoptotic factors, such as interleukin-6 (IL-6; Sevo versus Sevo-Vit-D: 0.68 (0.66–0.7) versus 0.34 (0.32–0.35); P < .001), tumor necrosis factor alpha (TNF-α; Sevo vs Sevo-Vit-D: 0.89 (0.88–0.9) versus 0.53 (0.51–0.55); P < .001), Bax (Sevo vs Sevo-Vit-D: 0.61 (0.6–0.63) versus 0.34 (0.32–0.36); P < .001) and c-Fos (Sevo vs Sevo-Vit-D: 0.64 (0.62–0.66) vs 0.42 (0.4–0.43); P < .001) in the hippocampus at PN7. Furthermore, vitamin D improved the mean (95% CI) expression levels of antiapoptotic and neuroprotective proteins, such as Bcl-2 (Sevo vs Sevo-Vit-D: 0.46 (0.45–0.47) versus 0.56 (0.54–0.58); P < .001), BDNF (Sevo vs Sevo-Vit-D: 0.37 (0.34–0.39) vs 0.64 (0.63–0.65); P < .001), Olig2 (Sevo vs Sevo-Vit-D: 0.38 (0.36–0.39) vs 0.56 (0.54–0.58); P < .001) in the hippocampus at PN7. These changes also occurred in the prefrontal cortex at PN7 and PN45. EM images supported these data. No significant difference was found in behavioral tests between the groups. CONCLUSIONS: Our findings suggested that maternal sevoflurane exposure could cause neurotoxicity in the offspring mice. Vitamin D can protect against the negative effects of sevoflurane.]]> Mon, 23 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01338 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/anesthetic_challenges_in_hybrid_warfare__insights.1339.aspx No abstract available]]> Mon, 23 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01339 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/protective_and_immunomodulatory_functions_of.1340.aspx BACKGROUND: Acute respiratory distress syndrome (ARDS) is a result of diffuse lung injury and dysregulated inflammation. Recent studies have demonstrated that B cells can perform anti-inflammatory and tissue-protective functions. We hypothesized that systemic B-cell administration could have therapeutic effects in hyperoxic acute lung injury. METHODS: Acute lung injury was modeled in adult C57BL/6J male mice through continuous exposure to hyperoxia (FiO2 >90%). Mature B cells (CD45R+/CD19+) were purified from spleens of age- and sex-matched C57BL/6J mice. B cells (107) or saline were administered intravenously after 24 hours of hyperoxia. Hyperoxia exposure was continued for up to 96 hours. The effects of adoptive B-cell therapy were assessed using histologic, physiologic (pulse oximetry, echocardiography), and immunologic (flow cytometry) readouts. RESULTS: Hyperoxia led to a 50% depletion of endogenous pulmonary B cells by day 3, from 30% to 15% CD45+ lung immune cells (95% confidence interval [CI], 6.16–24.45; P = .0017). B-cell administration ameliorated B-cell loss, improved lung injury scores (median score in saline-treated = 3.0 vs B-cell-treated = 2.67; P = .0101) and lung cellular infiltration (F [2,34] = 11.99; P = .0001). By day 3, B cells limited the duration of oxygen desaturations (difference 0.39 seconds; median length = 1.01 seconds in saline-treated vs 0.62 seconds in B-cell-treated; 95% CI, 0.02–0.73 seconds; P = .03) and their depth (median nadir = 82.0% in saline-treated vs 85.9% in B-cell-treated, 95% CI, −6.6% to −0.84%; P = .04). B-cell-treated mice showed a median 3.82% increase in left ventricular ejection fraction by day 3, compared to 12.35% in saline-treated mice (mean difference 7.32%; 95% CI, −5.0% to 19.6%; P = .23). Exogenous B cells represented less than 1.5% of pulmonary B cells on day 3. B-cell administration had homeostatic effects on relative abundance of pulmonary immune subsets affected by hyperoxia, including endogenous B cells, CD4+ T cells, natural killer (NK) cells, monocytes/macrophages, and neutrophils. Significant immunomodulatory effects of B-cell administration were observed in myeloid cells in the lungs and included reductions in the proportion of interleukin-17 (IL-17)-expressing Ly6Clo monocytes (F [2,14] = 19.02; P = .0001), alveolar macrophages (F [2,14] = 10.32; P = .0018), and neutrophils (F [2,14] = 6.621; P = .0095) as well as interferon-gamma (IFNγ)-expressing Ly6Clo monocytes (F [2,14] = 48.83; P = .0001). CONCLUSIONS: Our data indicate that adoptive B-cell therapy ameliorates hyperoxic lung injury and may represent a novel treatment for ARDS.]]> Mon, 23 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01340 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_effect_of_hypotension_on_cerebral_metabolism.1341.aspx BACKGROUND: Current blood pressure management strategies cannot accommodate large interindividual variations in cerebral autoregulation, which may result in inadvertent cerebral ischemia. A novel optical neuromonitoring device was developed to explore the relationships between blood pressure and cerebral metabolism and hemodynamics during hypotension on cardiopulmonary bypass and the transition on bypass in cardiac surgery. METHODS: Forty-five elective adult patients were monitored by a hybrid optical device incorporating broadband near-infrared spectroscopy for monitoring changes in tissue oxygen saturation and the oxidative state of cytochrome c oxidase (oxCCO) in the brain along with diffuse correlation spectroscopy for measuring a cerebral blood flow index. Changes in the optical variables were evaluated. RESULTS: Seventy-four hypotensive events were associated with significant decreases (mean ± standard deviation) in oxCCO (−0.55 ± 0.18 μM), cerebral blood flow index (−48% ± 20%), and tissue oxygen saturation (−9% ± 5%, P < .001) when mean arterial pressure fell below 50, 35, and 25 mm Hg, respectively. Decreases in oxCCO corresponding to literature-defined cerebral blood flow lesion and functional thresholds were −1.10 and −0.87 μM. During transition on bypass, mild reductions in blood pressure and body temperature (34.9 ± 0.6°C) occurred without significant cerebral blood flow changes. Multiple linear regression demonstrated reduction in oxCCO was significantly associated with temperature and blood pressure (R2 = 0.92, P < .001), while tissue oxygen saturation and cerebral blood flow index had weaker associations (R2 = 0.75, P < .001; R2 = 0.42, P = .002, respectively). No significant changes in scalp oxCCO and tissue oxygen saturation were found during hypotensive episodes or CPB transition. Conclusions: This study identifies oxCCO as an optical variable that is highly responsive to hypotension. The work also highlights the link between blood pressure and cerebral metabolism and hemodynamics, offering potential insights into optimizing current blood pressure management.]]> Mon, 23 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01341 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/patient_perspectives_on_accessing,_understanding,.1342.aspx No abstract available]]> Mon, 23 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01342 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/balancing_reimbursement_and_safety__the_anthem.1331.aspx No abstract available]]> Thu, 12 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01331 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/right_ventricle_pulmonary_artery_coupling_and.1332.aspx BACKGROUND: The right ventricle-pulmonary artery (RV-PA) coupling ratio provides an assessment of RV function indexed to PA afterload. A low preoperative RV-PA ratio has been associated with increased mortality after transcatheter procedures. In patients undergoing cardiac surgery, we hypothesized that a lower preoperative RV-PA ratio is independently associated with a higher risk of major morbidity and operative mortality (MMOM). METHODS: We conducted a retrospective cohort study of adult patients who underwent coronary artery bypass graft and/or valve surgery (aortic, mitral, and tricuspid). The RV-PA ratio was calculated using the ratio of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP). The primary outcome was MMOM as defined by the Society of Thoracic Surgeons (STS). The Youden index was used to determine the optimal cutoff to classify into low versus high TAPSE/PASP ratio groups. Multivariable analysis was performed to test the association of TAPSE/PASP ratio with MMOM and other clinical outcomes with P- value <0.05 used for statistical significance. RESULTS: One hundred and twenty-four (14.3%) of the 868 patients who met inclusion criteria had the primary outcome of MMOM. Patients in the low TAPSE/PASP group were more likely to have MMOM (90 (22.0%) vs 34 (7.4%); P < .001) as well as longer intensive care unit length of stay (ICU-LOS), hospital LOS (H-LOS), and mechanical ventilation time (MVT). By multivariable analysis, TAPSE/PASP ratio <0.52 mm/mm Hg was associated with a significant increase in the risk of MMOM (odds ratio [OR] 1.77, 95% confidence interval [CI], 1.10–2.83, P = .018). In the analyses of secondary outcomes, for every 0.1 mm/mm Hg increase in TAPSE/PASP ratio, there was a 4% reduction in ICU-LOS and MVT, and a 3% reduction in H-LOS. CONCLUSIONS: TAPSE/PASP ratio <0.52 mm/mm Hg was associated with a significant increase in the risk of MMOM. Low preoperative TAPSE/PASP ratio was also associated with longer ICU-LOS, H-LOS, and MVT, even when adjusting for STS risk score for MMOM and cardiopulmonary bypass time.]]> Thu, 12 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01332 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/pharmacologic_reversal_of_xylazine_induced.1333.aspx BACKGROUND: Xylazine is an alpha-2 adrenergic agonist approved for veterinary use as a sedative and analgesic for animals. Unfortunately, xylazine has recently become a common adulterant of street drugs in the United States with xylazine-related overdoses and deaths increasing each year. Although the alpha-2 adrenergic antagonist, atipamezole, is an efficacious reversal agent for xylazine that is approved for use in animals, it is not approved for humans. In this study, we aimed to test alternative reversal agents for xylazine, and compare them with atipamezole in a rat model of xylazine-induced unconsciousness. METHODS: In adult Sprague-Dawley rats, we induced loss of righting reflex (LORR, a surrogate end point for loss of consciousness) with xylazine (5 mg/kg, intravenous [IV]) and attempted to restore consciousness by administering agents with distinct molecular mechanisms of action: atipamezole (alpha-2 adrenergic antagonist, 200 µg/kg IV); d-amphetamine (norepinephrine and dopamine reuptake inhibitor and releasing agent, 1 mg/kg); chloro-APB (dopamine D1 receptor agonist, 3 mg/kg IV); and atomoxetine (norepinephrine reuptake inhibitor, 3 mg/kg IV). Pulse oximetry and heart rate were monitored continuously. After administration of the reversal agents, time to return of righting reflex (RORR) was recorded (n = 12) and animals were assessed with a novel object recognition test (n = 17). One subset of animals underwent surgery to have electroencephalogram (EEG) leads implanted (n = 4). EEG data were recorded after xylazine injection and ensuing administration of a reversal agent and spectral analysis was performed. RESULTS: After xylazine-induced unconsciousness, the median time to RORR in atipamezole-, d-amphetamine-, and chloro-APB-treated rats was 1.5 minutes (Interquartile Range [1.0–2.0]), 2 minutes (interquartile range [IQR] [1.0–3.0]), and 2 minutes (IQR [1.0–2.0]) post drug injection, respectively, compared to 56 minutes (IQR [39.5–70.5]) after saline control (F[4,40] = 41.62, P < .0001). Atomoxetine did not significantly accelerate time to RORR. During the novel object recognition test, all animals spent the same amount of time with the familiar and novel object (range 0–143.5 sec), indicating that no reversal agents restored recognition memory. Xylazine induced an EEG pattern dominated by slow-delta oscillations. Atipamezole, d-amphetamine, and chloro-APB restored EEG oscillations similar to the awake state. CONCLUSIONS: Atipamezole, d-amphetamine, and chloro-APB accelerate emergence from xylazine-induced unconsciousness and restore EEG oscillation patterns consistent with wakefulness. However, none of these reversal agents restore recognition memory.]]> Thu, 12 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01333 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/intrathecal_morphine_and_its_impact_on_length_of.1334.aspx No abstract available]]> Thu, 12 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01334 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/xylazine_a_bane_in_need_of_an_antidote.1335.aspx No abstract available]]> Thu, 12 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01335 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_handoffs__striking_the_balance.1336.aspx No abstract available]]> Thu, 12 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01336 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/intrathecal_hydromorphone_versus_intrathecal.1327.aspx BACKGROUND: Spinal anesthesia with intrathecal morphine is often the preferred anesthetic modality for elective cesarean delivery. Side effects and drug shortages, however, prompted researchers to look into intrathecal hydromorphone as an alternative. These studies established the effective analgesic dose for 90% of patients (ED90) for both opioids for postcesarean analgesia, yet failed to demonstrate the superiority of morphine over hydromorphone. Nonetheless, the noninferiority of hydromorphone has yet to be determined. METHODS: In this noninferiority randomized blinded clinical trial, 126 patients undergoing elective cesarean delivery under spinal anesthesia received either morphine 150 µg or hydromorphone 75 µg (ED90). The primary outcome was the between-group difference of the mean Numeric Rating Scale (NRS) pain score (0–10) for the first 24 hours after cesarean delivery, with a preestablished threshold for noninferiority of 1. This 24-hour NRS pain score was defined as a single number obtained at the 24 hours postcesarean delivery interview, based on participant’s recall of their overall pain experience during this period. Secondary outcomes included differences in NRS pain scores every 6 hours, cumulative 24 hour opioid consumption, time-to-first opioid request, quality of recovery as measured by the Obstetric Quality of Recovery Score-11 (ObsQoR-11), frequency of interventions for side effects, and Apgar scores. RESULTS: The mean (standard deviation [SD]) of the 24-hour NRS pain score was 4.0 (1.7) for morphine and 3.6 (1.5) for hydromorphone (between-group difference –0.46 (95% confidence interval [CI], –1.0 to 0.1). Given that the upper limit of the 95% CI did not exceed 1, noninferiority of hydromorphone was established. No statistically significant differences were found in mean (SD) 24 hour oral morphine consumption (morphine: 4.2 mg (6.5) vs hydromorphone: 4.1 (8.0) mg; P = .98), median [interquartile range {IQR}] ObsQoR-11 score (morphine: score 87 [75–97.5] vs hydromorphone: score 90 [80–96.5]; P = .51), median [IQR] time to first opioid request (morphine: 10.2 [3.2–15.5] h versus hydromorphone: 6.2 [3.1–12.4] h; P = .35), or proportion of patients requiring interventions for opioid-related pruritus (morphine: 0.316 (variance 0.216) vs hydromorphone: 0.321 (variance 0.218) (P = .96) and opioid-related nausea and vomiting (morphine: 0.333 (variance 0.222) vs hydromorphone: 0.393 (variance 0.238) (P = .51). CONCLUSIONS: Intrathecally, hydromorphone is noninferior to morphine for analgesia after elective cesarean delivery when using the previously established ED90 for both opioids (morphine: 150 µg versus hydromorphone: 75 µg); hydromorphone provides effective analgesia and may be a suitable alternative to morphine.]]> Tue, 10 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01327 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_differential_impact_of_three_different.1328.aspx No abstract available]]> Tue, 10 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01328 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/detection_and_prevention_of_overinflation_of_the.1325.aspx No abstract available]]> Thu, 05 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01325 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_implications_of_antiretroviral.1326.aspx No abstract available]]> Thu, 05 Jun 2025 00:00:00 GMT-05:00 00000539-990000000-01326 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/walking_a_few_steps_alongside.1315.aspx No abstract available]]> Fri, 30 May 2025 00:00:00 GMT-05:00 00000539-990000000-01315 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_retrospective_study_of_ultramassive_transfusion.1316.aspx BACKGROUND: Hemorrhage is a leading cause of preventable mortality in trauma. During times of blood shortages, it may be prudent to consider a transfusion threshold during massive transfusion after which additional transfusions are futile due to nonsurvivability. The main objective of this study is to examine outcomes associated with ultramassive transfusion (UMT; defined as ≥20 units of red blood cells [RBC] within 24 hours) and determine if there is a threshold beyond which additional transfusion efforts should cease. METHODS: We performed a retrospective (2016–2022) analysis of adult trauma patients (≥ 18 years old) who underwent surgery and received blood products within 24 hours of admission at 7 US Level I trauma centers. We compared patients who received UMT and patients who received <20 units RBC and evaluated the effects of various amounts of blood products on mortality, length of stay (LOS), mechanical ventilation (MV), and complications. Segmented logistic regression analysis was performed to determine if there is a “plateau” effect of increasing RBC units on mortality. RESULTS: Of 3248 patients included, 2913 (89.7%) received <20 RBC units within 24 hours, and 333 (10.3%) received ≥20 RBC units within 24 hours. Patients receiving UMT had increased 24-hour mortality (risk ratio [RR] 6.00, 95% confidence interval [CI], 4.79–7.52, P < .001) and index hospitalization mortality (RR 3.99 [3.34–4.75], P < .001). These patients also more often developed complications (RR 1.67 [1.44–1.94], P < .001) and multiple organ failure (RR 2.78 [2.20–3.52], P < .001). Compared to those receiving 20 to 29 RBC units, those receiving 30 to 44 RBC units had statistically similar associated risk of death (RR 1.32 [0.93–1.87], P = .12); however, those receiving ≥45 RBC units had an increased associated risk of death (RR 1.59, [1.12–2.25], P = .009), and additional transfusion beyond this point did not improve the probability of survival. CONCLUSIONS: In this study, patients who received UMT had higher mortality and worse outcomes than those who received fewer units. However, this study did not identify a threshold beyond which all patients died and therefore cannot justify implementing a limit on the number of RBC units transfused based on these data alone.]]> Fri, 30 May 2025 00:00:00 GMT-05:00 00000539-990000000-01316 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/elizabeth,_a_vial_cap_mosaic.1317.aspx No abstract available]]> Fri, 30 May 2025 00:00:00 GMT-05:00 00000539-990000000-01317 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/single_syringe_total_intravenous_anesthesia_with.1320.aspx No abstract available]]> Fri, 30 May 2025 00:00:00 GMT-05:00 00000539-990000000-01320 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_effect_of_midazolam_induction_on_frontal.1313.aspx No abstract available]]> Mon, 26 May 2025 00:00:00 GMT-05:00 00000539-990000000-01313 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/building_trusting_health_care_teams.1314.aspx No abstract available]]> Mon, 26 May 2025 00:00:00 GMT-05:00 00000539-990000000-01314 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/clinical_decision_points_for_the_functional.1306.aspx No abstract available]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01306 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_effects_of_treadmill_exercise_on_the_recovery.1307.aspx BACKGROUND: Sepsis-associated encephalopathy causes irreversible cognitive dysfunction, yet no effective pharmacological treatments are available. The hippocampus is particularly vulnerable to sepsis-induced damage, and impairments in hippocampal synaptic plasticity, particularly late-phase long-term potentiation (L-LTP), are implicated in cognitive dysfunction. Brain-derived neurotrophic factor (BDNF) and its receptor, tropomyosin receptor kinase B (TrkB), play crucial roles in maintaining L-LTP. While exercise enhances cognitive function, its effects on hippocampal synaptic plasticity under conditions mimicking early rehabilitation after sepsis remain unclear. This study evaluated the impact of treadmill exercise on hippocampal L-LTP in a murine sepsis model, using a protocol resembling early clinical rehabilitation. METHODS: A total of 267 C57BL/6J mice (8–12 weeks old) underwent cecal ligation and puncture (CLP) or sham surgery, with or without treadmill exercise (30 min/d for 7 days postsurgery). Mice were divided into 4 groups: (1) sham + sedentary, (2) sham + exercise, (3) CLP + sedentary, and (4) CLP + exercise. The primary outcome was hippocampal L-LTP, assessed via electrophysiology. Secondary outcomes included hippocampal BDNF levels, locomotor activity, and survival curves. Additionally, the role of BDNF/TrkB signaling was examined using ANA-12, an antagonist of the BDNF receptor TrkB. Data are presented as mean ± standard deviation. RESULTS: L-LTP at the Schaffer collateral–CA1 synapse was significantly impaired in CLP mice 1 week after surgery (CLP + sedentary: 144% ± 15% vs sham + sedentary: 185% ± 34%; P = .008). Exercise restored L-LTP in CLP mice (CLP + exercise: 189% ± 36% vs CLP + sedentary: 144% ± 15%, P = .003), but this effect was abolished by ANA-12 (CLP + exercise + ANA-12: 155% ± 22% vs CLP + exercise + vehicle: 194% ± 37%, P < .001). Exercise also restored hippocampal BDNF levels reduced by CLP (CLP + exercise: 4190 ± 671 pg/mg protein versus CLP + sedentary: 3220 ± 647 pg/mg protein, P = .007). Locomotor activity was impaired in CLP mice but not significantly improved by exercise (P = .38). Furthermore, the survival curves differed significantly between CLP mice with and without treadmill exercise, as determined by post hoc analysis after a log-rank test (P = .003). CONCLUSIONS: Treadmill exercise therapy restored hippocampal L-LTP impaired by sepsis, at least partially mediated by activation of the BDNF/TrkB signaling pathway. Additionally, exercise altered the survival curve, though it had limited effects on locomotor activity. These findings suggest that exercise therapy may mitigate sepsis-induced synaptic dysfunction.]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01307 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/can_processed_electroencephalographic_indices_be.1308.aspx No abstract available]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01308 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/death_in_the_dentist_s_chair__the_urgent_need_for.1309.aspx No abstract available]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01309 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/sexual_orientation_and_gender_identity.1310.aspx No abstract available]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01310 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/beyond_hotspots__functional_characterization_of.1311.aspx BACKGROUND: Malignant hyperthermia (MH) is a life-threatening pharmacogenetic disorder triggered by certain anesthetics, characterized by muscle rigidity, elevated body temperature, and hypermetabolic crisis. This condition is primarily associated with genetic mutations in ryanodine receptor 1 (RYR1), which encodes the pivotal calcium release channel in the sarcoplasmic reticulum of skeletal muscle. While numerous hotspot mutations in RYR1 have been identified, the functional impact of nonhotspot mutations on channel activity related to MH remains insufficiently investigated. In this study, we identified a known pathogenic mutation (p.Arg2508His) and a novel variant (p.Asp2730Tyr), both located outside the conventional MH hotspots, in 2 patients with clinical suspicion of MH. Our objective was to investigate the functional implications of the p.Asp2730Tyr mutation in RYR1 on calcium release dynamics related to MH. METHODS: We engineered a recombinant wild-type (WT) plasmid (pcDNA3.1-3Myc-His-RYR1-WT) to express the full-length mouse skeletal muscle RYR1 using seamless multi-fragment cloning techniques. Two RYR1 mutations, p.Arg2508His (used as positive control) and p.Asp2730Tyr, were separately introduced into the WT plasmid, generating 2 mutant constructs (pcDNA3.1-3Myc-His-RYR1-p.Arg2508His and pcDNA3.1-3Myc-His-RYR1-p.Asp2730Tyr). We utilized 293T cells expression system to express either the WT or mutant forms of mouse RYR1. Fluo-4 calcium imaging was conducted to evaluate the alterations in calcium release in response to RYR1 agonists, caffeine or 4-chloro-m-cresol (4CmC), for each mutation compared to WT. RESULTS: Cells transfected with the p.Arg2508His or p.Asp2730Tyr mutation demonstrated a leftward shift in the caffeine and 4CmC concentration-response curves compared to WT, suggesting an increased channel sensitivity to caffeine and 4CmC (P < .001). The mean ± standard error of the mean (SEM) of the EC50 values for caffeine-induced calcium release was 2.56 ± 0.04 mM in WT, which significantly decreased to 1.32 ± 0.13 mM for p.Arg2508His (P < .001) and 1.12 ± 0.09 mM for p.Asp2730Tyr (P < .001). For 4CmC, the EC50 values were 43.2 ± 1.90 μM in WT, 17.2 ± 0.76 μM for p.Arg2508His (P < .001), and 21.8 ± 1.04 μM for p.Asp2730Tyr (P < .001), indicating enhanced calcium release in both mutations. CONCLUSIONS: The p.Asp2730Tyr mutation, situated beyond the established RYR1 hotspot regions, significantly alters calcium release dynamics related to MH. A comprehensive investigation into the structural conformations, functional assays, and in vivo mechanisms associated with this mutation could yield a more profound understanding of the molecular underpinnings of MH pathogenesis.]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01311 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/ultrasound_gel_versus_saline_for_acoustic_coupling.1312.aspx No abstract available]]> Fri, 23 May 2025 00:00:00 GMT-05:00 00000539-990000000-01312 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_randomized_clinical_trial_of_dexmedetomidine_on.1303.aspx BACKGROUND: Postoperative delirium (POD), emergence delirium (ED), and postoperative cognitive dysfunction (POCD) are disorders of the neuropsychiatric spectrum affecting the elderly during the postoperative period, potentially sharing a common pathophysiological pathway. Disrupted sleep postoperatively correlates with both POD and POCD, revealing overlapping risk factors. This study investigates the potential of dexmedetomidine anesthesia to reduce the incidence of POD (primary outcome), ED, POCD, impairment of sleep quality, and emergent chronic pain (secondary outcomes) in older adults undergoing major orthopedic surgery under regional anesthesia. METHODS: In this double-blind randomized control trial, patients scheduled for major lower limb orthopedic surgery under regional anesthesia were randomized to receive either dexmedetomidine or propofol for sedation at a 1:1 ratio. POD, ED, and POCD were assessed with the Confusion Assessment Method tool, the Riker Sedation-Agitation scale, and the European Battery of psychometric tests, respectively. Sleep quality was assessed using the Pittsburg Sleep Quality Index and chronic pain with the painDETECT tool. Assessments of all outcome variables were performed before surgery, and at 48 hours and 3 months postoperatively. RESULTS: A total of 80 patients (dexmedetomidine group n = 41) were enrolled in the study and completed the follow-up. POD, ED, and early POCD incidence were significantly lower in dexmedetomidine compared to propofol group (4.8% vs 38.4%, P = .001; 2.4% vs 38.4%, P < .001; 2.4% vs 56.4%, P < .001, respectively). Patients in the dexmedetomidine group reported improved sleep quality in the immediate postoperative period (lower PSQI score) and lower painDETECT scores at 3 months (4.4 ± 0.7 vs 13.4 ± 0.8, P < .001; 2.4 ± 0.9 vs 5.3 ± 0.9, P = .023, respectively). Intraoperative bradycardia and hemodynamic instability episodes were more common in the dexmedetomidine group while a single patient presented airway obstruction (2.4% vs 30.8%, P = .002) in the dexmedetomidine group. CONCLUSIONS: Sedation with dexmedetomidine resulted in a statistically and clinically important reduction in the incidence of POD, ED, and early POCD, while it improved self-reported postoperative sleep quality and reduced chronic pain scores in patients undergoing major elective lower limb surgery under regional anesthesia.]]> Thu, 22 May 2025 00:00:00 GMT-05:00 00000539-990000000-01303 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/unique_perioperative_medicine_education_programs.1291.aspx No abstract available]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01291 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/intubation_setting_and_mortality_in_trauma.1292.aspx BACKGROUND: Endotracheal intubation is essential for airway management in trauma patients but may cause hemodynamic instability and delay critical resuscitation measures. Recent studies have suggested that emergency department (ED) intubation may be linked with higher mortality compared to operating room (OR) intubation in trauma patients. However, it remains unclear if these findings apply to broader trauma populations, including both civilian and military patients. This study uses a nationwide trauma registry to test the hypothesis that ED intubation is associated with higher in-hospital mortality among major trauma patients, compared to OR intubation. METHODS: Registry-based analysis of the Israeli National Trauma Registry evaluating major trauma (Injury Severity Score [ISS] ≥16) patients requiring hemorrhage control surgery between 2016 and 2023. ED intubation was the main exposure variable with in-hospital mortality serving as the primary outcome. Multivariable logistic regression and propensity score matching were applied to adjust for confounders, including injury severity, ED vital signs, penetrating injury, and blood product administration. RESULTS: The study included 975 patients, 470 (48.2%) of whom were intubated in the ED. ED-intubated patients had significantly higher ISS and higher proportion of profound shock compared to those intubated in the OR. In-hospital mortality was more common among patients intubated in the ED (22.6%) as compared with those intubated in the OR (8.5%). In the unadjusted logistic regression, ED intubation was associated with higher odds of in-hospital mortality (OR: 3.13, 95% confidence interval [CI], 2.15–4.62). However, after adjusting for several potential confounders, the association became nonsignificant and was persistent across sensitivity subgroup analyses. Propensity score matching resulted in 1:1 matching of 271 patients in each group, balancing characteristics such as ISS, profound shock, Glasgow Coma Scale, and penetrating injury. After matching, the mortality rate was similar between groups (12.5% for ED intubation vs 12.2% for OR intubation). In the matched cohort, logistic regression demonstrated no significant association between ED intubation and in-hospital mortality (OR: 0.97, 95% CI, 0.58–1.61). ED intubation was associated with a greater than 2-fold increase in odds of ICU admission in adjusted and propensity score-matched analyses. CONCLUSIONS: ED intubation was not significantly associated with increased in-hospital mortality after controlling for injury severity and shock. These findings suggest that while ED intubation may be more frequent in severely injured patients, its independent impact on mortality in patients undergoing emergent surgery remains unclear, warranting further prospective investigation.]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01292 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_effect_of_acute_normovolemic_hemodilution_on.1293.aspx No abstract available]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01293 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/influence_of_sevoflurane_postconditioning_on.1294.aspx BACKGROUND: The mechanisms by which sevoflurane protects the brain from hypoxic-ischemic brain injury (HIBI) are unknown. Ferroptosis occurs during HIBI and is regulated by the nuclear factor erythroid 2-related factor 2 (Nrf2). This study investigated the roles of Nrf2-regulated ferroptosis in sevoflurane postconditioning (SPC)-mediated neuroprotection during HIBI. METHODS: HIBI was induced in 7-day-old rats. SPC (2.5%, 30 minutes) was performed immediately after HIBI, and some rats were injected with ML385 (an Nrf2-inhibitor) 30 minutes before HIBI. Ferroptosis was evaluated by measuring glutathione peroxidase 4 (GPx4), solute carrier family 7 member 11 (SLC7A11, also known as xCT), glutathione (GSH), cysteine, iron, malondialdehyde (MDA) levels, and mitochondrial morphology. Nrf2 and heme oxygenase-1 (HO-1) expression were determined to explore the signaling pathways involved in SPC-mediated neuroprotection. Brain morphology, left/right hemisphere weight ratios, and Nissl staining were measured to assess brain damage. The Morris water maze was conducted to assess long-term learning and memory abilities. RESULTS: SPC alleviated HIBI-induced cysteine depletion-induced (HIBI versus SPC, xCT/β-tubulin ratio: −0.435 [95% CI, −0.727 to −0.143], P = .003; Cysteine (% of Sham): −29.8 [95% CI, −39.4 to −20.2], P < .001; GSH (% of Sham): −46.5 [95% CI, −54.6 to −38.4], P < .001) and GPx4 inhibition-induced ferroptosis (HIBI versus SPC, GPx4/β-tubulin ratio: −0.287 [95% CI, −0.514 to −0.0603], P = .01). Compared with the HIBI group, the SPC group showed improved learning and memory abilities (HIBI versus SPC, platform crossings: −4 times [95% CI, −7 to −1], P = .002; escape latency: 46 seconds [95% CI, 24 to 68], P < .001), reduced brain damage (HIBI versus SPC, weight ratio of left/right cerebral hemispheres: −13.1 [95% CI, −15.7 to −10.4], P < .001; neuronal density ratio: −0.450 [−0.620 to −0.280], P < .001), and increased Nrf2 and HO-1 protein levels (HIBI versus SPC, Nrf2/β-tubulin ratio: −1.89 [95% CI, −2.82 to −0.970], P < .001; HO-1/β-tubulin ratio: −1.08 [95% CI, −1.73 to −0.442], P < .001). Inhibiting Nrf2 via ML385 partly reversed SPC-mediated neuroprotection (SPC versus SPC+ML385, weight ratio of left/right cerebral hemispheres: 12.4 [95% CI, 9.73–15.1], P < .001; neuronal density ratio: 0.412 [95% CI, 0.242–0.582], P < .001), accompanied by decreased HO-1 expression (SPC versus SPC+ML385, HO-1/β-tubulin ratio: 1.70 [95% CI, 1.05–2.34], P < .001). CONCLUSIONS: SPC inhibits both cysteine depletion- and GPx4 inhibition-induced ferroptosis by regulating Nrf2/HO-1 signaling to protect against HIBI.]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01294 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/development_of_a_standardized_perioperative.1296.aspx No abstract available]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01296 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/pharmacokinetics_and_pharmacodynamics_of_analgesic.1299.aspx Cardiopulmonary bypass (CPB) impacts pharmacokinetics and -dynamics of drugs used during cardiac surgery. These alterations can lead to changes in drug efficacy resulting in under- or overdosing. This review summarizes current knowledge on the effects of CPB on commonly used intraoperative and continuously administered anesthetics and analgesics. Out of 197 articles initially identified, 22 were included in the final review. The breakdown of studies by main topic was as follows: propofol (9 articles), sevoflurane (4), remifentanil (3), isoflurane (2), fentanyl (2), and sufentanil (2), and alfentanil (1). The initiation of CPB typically results in hemodilution and hypothermia, leading to a decrease in total plasma concentration combined with an increase in unbound plasma concentrations. This phenomenon has varying implications for different drugs: For propofol and sevoflurane, lower doses may be required during CPB to achieve the same anesthetic effect. Fentanyl and sufentanil plasma concentrations decrease by 25% on average at CPB initiation due to an increased volume of distribution, followed by an increase during CPB, with sufentanil, showing an almost 50% increase post-CPB. This implies that an additional bolus before CPB initiation should be considered, followed by a reduction of the maintenance dose to prevent prolonged sedation. Remifentanil plasma concentration decreases at CPB initiation, which implies that higher initial- or adjusted maintenance dose should be considered in normothermic patients. However, under hypothermic conditions, infusion rates should be decreased by 30% for every 5°C decrease in temperature. Alfentanils, total plasma concentration decreases during CPB, while its free fraction remains unaltered, indicating that no further adjustments are necessary. Target-controlled infusion (TCI) models for propofol (Schnider, Marsh, and PGIMER [Postgraduate Institute of Medical Education and Research]) and remifentanil (Minto) were found to be inaccurate in the context of CPB. Based on the included studies, the use of these pharmacokinetic models is not recommended. In conclusion, dosing inaccuracies resulting in adverse events in on-pump cardiac surgery underscore the importance of understanding the pharmacokinetics and -dynamics of anesthetic and analgesic drugs during CPB. The clinical implication of the altered drug responses after CPB remains challenging in this high-risk population. Key takeaways include the necessity of considering patient-specific factors, utilizing objective monitoring tools, and recognizing potential drug alterations due to CPB.]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01299 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/brain_health_screening_in_older_surgical_patients_.1300.aspx BACKGROUND: Guidelines recommend routine screening perioperatively for cognitive impairment, frailty, and delirium for patients at risk. Capturing these 3 geriatric screening variables in multicenter databases would also enable much-needed large-scale pragmatic research. Our primary hypothesis was that the well-curated Multicenter Perioperative Outcomes Group (MPOG) database would have a low rate of retrievable geriatric screening variables. Our secondary hypothesis was that multiple barriers exist that impede clinical implementation of recommended screenings as well as the digital capture of these variables into the MPOG database. METHODS: This was a 2-component study. The first component was a retrospective observational analysis using the MPOG database to identify geriatric screening variables in patients over the age of 65 undergoing nonemergent inpatient surgery. The second component was a survey sent to MPOG participant sites (49 institutions) to assess actual screening practices and perspectives. RESULTS: Of the 908,158 relevant patient records only 8054 (0.89%) were identified as having a preoperative cognitive screen, and 123,114 (13.6%) were identified as having a postoperative delirium screening. No frailty screenings were observed. Forty-3 survey responses (88% response rate) were received. Approximately half of the respondents indicated their institutions perform cognitive screening (n=22; 51.2%), frailty screening (n=17; 44.7%), or delirium screening (n = 16; 45.7%). Only 10 institutions (23.2%) reported performing all 3, and 13 (30.2%) institutions reported performing none. Multiple barriers were identified. The most common significant barrier reported was a lack of available standard screening tools for the electronic health record. CONCLUSIONS: This study identified minimal data collection related to neurocognitive disorders which appears incongruous with clinical practice guidelines. Challenges related to capturing this data locally and in multi-center datasets were identified. Overcoming those barriers may facilitate future pragmatic research studies related to this important public health priority.]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01300 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/optimizing_flow_controlled_ventilation__impact_of.1301.aspx BACKGROUND: Prehospital airway obstruction is a medical emergency requiring immediate intervention. When the insertion of a larger bore tube over an airway catheter is hindered by obstruction, flow-controlled ventilation (FCV) with expiratory ventilation assistance (EVA) may offer a solution by allowing for ventilation through the airway catheter. This method uses a continuous bidirectional flow, necessitating a high-pressure gas source, typically 100% oxygen. However, in prehospital or military settings, oxygen supplies and exact manual control may be limited. Therefore, evaluating FCV/EVA without 100% oxygen, and with variable inspiratory-to-expiratory (I:E) control is essential to ensure its feasibility in such environments. We hypothesized that arterial oxygenation with 21% oxygen would be feasible and would vary between different I:E ratios. METHODS: In this randomized crossover trial, FCV/EVA with different I:E ratios and fraction of inspired oxygen were compared in total airway obstruction. 15 crossbred male specific pathogen-free swine, mean (standard deviation [SD]) weight 56.6 (2.1) kg were divided into groups; method A (n = 9) and method B (n = 6), anesthetized, muscle relaxed and desaturated <80%. FCV/EVA was performed for 15 minutes through an airway catheter in the obstructed airway. RESULTS: In I:E 1:1 vs 1:2 with 21% oxygen, the mean difference of Sao2 was 33.8% (95% confidence interval [CI], 16.3–51.4, P =.0020) and Pao2 was 4.7 kPa (95% CI, 1.3–8.1, P =.0127). Paco2 decreased more in 1:1 than 1:1 with a pause and 1:2. Paco2 remained <5 kPa with small variability in 1:1 with 21% oxygen. CONCLUSIONS: FCV/EVA with 21% oxygen was feasible and maintained oxygenation and ventilation for 15 minutes. An I:E ratio of 1:1 was superior to 1:2. This approach may offer a viable alternative in a totally obstructed airway in resource-limited settings where higher oxygen concentrations are unavailable.]]> Fri, 16 May 2025 00:00:00 GMT-05:00 00000539-990000000-01301 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/signal,_not_noise__aperiodic_dynamics_in_the.1288.aspx No abstract available]]> Fri, 09 May 2025 00:00:00 GMT-05:00 00000539-990000000-01288 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/to_achieve_cultural_change_in_health_care_focus_on.1282.aspx No abstract available]]> Thu, 08 May 2025 00:00:00 GMT-05:00 00000539-990000000-01282 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_effects_of_dexamethasone_in_cardiac_surgery__a.1283.aspx BACKGROUND: In cardiac surgery, modulating the inflammatory response with prophylactic steroids may reduce morbidity and mortality. We aimed to evaluate the association of dexamethasone use with clinical outcomes and its variation in clinical practice in a real-world setting. METHODS: This retrospective, population-based study evaluated data of elective and urgent to on-pump cardiac surgery patients from the Netherlands Heart Registration between 2013 and 2021. Patients who received perioperative dexamethasone were compared to those who did not. The primary outcomes were 30-day mortality and a composite of 30-day mortality, in-hospital stroke, and 30-day renal or respiratory failure. Secondary outcomes included the individual components of the composite outcome, a composite of infection-related outcomes, arrhythmias, and length of hospital stay. Propensity score matching was applied to adjust for confounders. Clinical practice variation was assessed through a national survey of Dutch cardiac anesthesiologists. RESULTS: In the study, 54,694 patients were included, with 40,891 patients (74.8%) receiving dexamethasone. After propensity score matching, dexamethasone use was associated with a lower risk of the composite clinical outcome (odds ratio [OR] 0.82, 95% confidence interval [CI], 0.72–0.92, P < .001), with a significant reduction in renal failure (OR 0.57, 95% CI, 0.47–0.70, P < .001). The length of hospital stay was significantly shorter (B −0.17, 95% CI, −0.32 to −0.02, P = .025). Other individual components of the composite outcome and secondary outcomes did not show a significant association with dexamethasone use. However, in patients >80 years, dexamethasone use was associated with increased 30-day mortality (OR 1.52, 95% CI, 1.01–2.28, P = .044). The observed benefits were consistent across other demographic and clinical subgroups. The survey indicated substantial variability in dexamethasone use across centers and anesthesiologists. CONCLUSIONS: Prophylactic dexamethasone during adult cardiac surgery was associated with reduced composite clinical outcomes, renal failure, and shorter hospital stays, and seemed associated with 30-day mortality in patients >80 years old.]]> Thu, 08 May 2025 00:00:00 GMT-05:00 00000539-990000000-01283 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/effects_of_dexmedetomidine_combined_with_lidocaine.1284.aspx BACKGROUND: Cough reflex during extubation can lead to complications such as increased bleeding and hemodynamic instability, especially in thyroidectomy, therefore, effective suppression of cough reflex is clinically important. The aim of the study was to investigate the inhibitory effect of dexmedetomidine combined with lidocaine on the cough reflex during extubation in thyroidectomy. METHODS: A total of 180 female patients, aged 18 to 65 years, undergoing elective thyroidectomy under general anesthesia, were randomized into 3 groups: dexmedetomidine combined with lidocaine (Dex-Lido group, n = 60), lidocaine alone (Lido group, n = 60), or normal saline (Control group, n = 60). Before tracheal intubation, patients in the Dex-Lido group received dexmedetomidine combined with 2% lidocaine spray, those in the Lido group received 2% lidocaine spray, and those in the Control group received 0.9% normal saline spray, applied to the supraglottic, glottic, and subglottic areas. The primary outcome was the incidence of cough reflex at extubation. Secondary outcomes included cough severity, postoperative sore throat, hoarseness, nausea, and vomiting, as well as the need for analgesics and antiemetics, pain levels, sedation scores, and length of hospital stay. RESULTS: The incidence of cough reflex during extubation was significantly lower in both the Dex-Lido and Lido groups compared to the Control group (23% vs 70%; odds ratio [OR], 0.13; 95% confidence interval [CI], 0.06–0.29; P < .001 for Dex-Lido; 47% vs 70%; OR, 0.38; 95% CI, 0.18–0.79]; P = .010 for Lido), with a statistically significant difference between the Dex-Lido and Lido groups (23% vs 47%; OR, 0.35; 95% CI, 0.16–0.76; P = .007). Additionally, the severity of the cough reflex was markedly lower in the Dex-Lido group compared to the Control group (8/60 vs 26/60; OR, 0.20; 95% CI, 0.08–0.50; P < .001). CONCLUSIONS: The combination of dexmedetomidine and lidocaine laryngopharynx spray effectively suppresses the cough reflex during extubation, reduces postoperative sore throat, and stabilizes hemodynamics in female patients undergoing thyroid surgery.]]> Thu, 08 May 2025 00:00:00 GMT-05:00 00000539-990000000-01284 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/unplanned_intensive_care_unit_admissions_.1277.aspx No abstract available]]> Wed, 07 May 2025 00:00:00 GMT-05:00 00000539-990000000-01277 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/patient__and_institution_level_factors_associated.1278.aspx BACKGROUND: Intraoperative cardiac arrest (IOCA) is a rare but catastrophic event with significant morbidity, mortality, and health care costs. This study aimed to characterize the frequency, risk factors, and outcomes of IOCA. METHODS: Adults undergoing noncardiac surgery were identified in the 2016 to 2021 National Inpatient Sample. IOCA events were identified using the relevant International Classification of Diseases code. Multivariable regression models examined factors independently associated with IOCA and in-hospital mortality. The significance of temporal trends was calculated using Cuzick’s nonparametric test. RESULTS: Among 2671,834 noncardiac surgical admissions, 1294 (0.05%) experienced IOCA. The incidence increased from 0.05% to 0.06% during the study period, coinciding with an increase in nonelective operations during the coronavirus disease-2019 (COVID-19) pandemic. IOCA was associated with a 39.3% in-hospital mortality rate and increases in length of stay and hospitalization costs. Key risk factors for IOCA included advanced age, male sex, Black race (adjusted odds ratio [AOR] 1.40, 95% CI, 1.20–1.65), low-income status (AOR 1.21, 95% CI, 1.02–1.43), treatment at government nonfederal hospitals (AOR 1.22, 95% CI, 1.08–1.50), high-risk surgical procedures, and significant comorbidities such as congestive heart failure, cardiac arrhythmias, and valvular disease. CONCLUSIONS: Despite the initial reduction in the incidence of IOCA, this study highlights a temporal increase coinciding with the COVID-19 pandemic and an increase in nonelective surgeries. Future research should explore more granular predictors of IOCA and its outcomes to develop targeted interventions for at-risk populations and tailor guidelines to manage emerging challenges in population health.]]> Wed, 07 May 2025 00:00:00 GMT-05:00 00000539-990000000-01278 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/spectral_differences_of_anesthetic_agents_.1274.aspx BACKGROUND: Processed electroencephalography parameters are used to guide anesthesia to adequate levels for surgical procedures. Despite known spectral differences between anesthetics, studies often assume similar anesthetic states when titrating to the same target values, presupposing a reductive one-size-fits-all approach for all anesthetic agents. We hypothesize this may introduce bias and aim to characterize the differences using conventional and new approaches. METHODS: For this retrospective study, we included 108 patients undergoing surgery under general anesthesia with either fluranes or propofol. We analyzed steady-state frontal electroencephalography during surgery. Conventional approaches were compared with “fitting oscillations & one-over-f” and “variational mode decomposition” at clinically guided hypnotic and analgesic levels. After comparing the hypnotic drugs at the group level, we used 2 distinct ranges of spectral edge frequency (SEF) for further analyses (8–15 Hz vs 15–21 Hz). RESULTS: Sevoflurane and desflurane (“flurane”) demonstrated similar spectral patterns using both conventional methods and “fitting oscillations & one-over-f” and “variational mode decomposition.” “Variational mode decomposition” presented a 1.5 Hz higher central frequency (area under the receiver operating characteristic [AUC]: 0.88, 95% confidence interval [CI], 0.81–0.94, P < .001) in the propofol group (10.8 Hz [10.4–11.6]), compared to the flurane group (9.26 Hz [8.51–9.41]). “Fitting oscillations & one-over-f” produced a 2.04 Hz higher center frequency (AUC: 0.82, 95% CI, 0.72–0.91, P < .001) in the propofol group (10.6 [9.8–11.3]) compared to the flurane group (8.56 [8.02–9.69]). The exponent was 0.26 Hz−1 lower (AUC: 0.76, 95% CI, 0.67–0.85, P < .001) in the propofol group (2.45 Hz−1 [2.45–2.71]) compared to the flurane group (2.71 Hz−1 [2.50–2.93]). At the lower SEF range, “variational mode decomposition” presented a 1.5 Hz higher central frequency (AUC: 0.83, 95% CI, 0.70–0.94, P < .001) in the propofol group (10.4 Hz [9.7–10.9]), compared to the flurane group (8.92 Hz [8.03–9.45]). “Fitting oscillations & one-over-f” produced a 1.5 Hz higher center frequency (AUC: 0.83, 95% CI, 0.68–0.95, P = .002) in the propofol group (10.3 [10.0–10.8]) compared to the flurane group (8.78 [7.63–9.66]). The exponent was 0.31 Hz−1 lower (AUC: 0.79, 95% CI, 0.65–0.91, P = .002) in the propofol group (2.57 Hz−1 [2.44–2.70]) compared to the flurane group (2.88 Hz−1 [2.66–3.05]). Similar differences were found in the higher SEF group. However, no significant difference was found in the exponent between the groups. CONCLUSIONS: Differences between the electroencephalographic (EEG) spectral patterns under propofol anesthesia compared to anesthesia using fluranes were sensitively captured by 2 recent approaches to EEG analysis. This could potentially lead to establishing agent-specific anesthetic indices.]]> Tue, 06 May 2025 00:00:00 GMT-05:00 00000539-990000000-01274 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_systematic_review_of_postoperative_care.1276.aspx Perioperative care transitions or handoffs represent a high-risk period frequently compromised by communication failures and the loss of essential patient information. Handoffs play a pivotal role in mitigating these risks. A comprehensive assessment of implementation and clinical outcomes is essential to identify protocols that enhance patient safety, improve care quality, and support reproducibility. This study identifies and synthesizes existing evidence on handoff strategies, evaluating their impact on both implementation success and clinical outcomes. A systematic search of PubMed, EMBASE, and CINAHL databases was conducted to identify observational and descriptive studies addressing preoperative, intraoperative, and postoperative handoffs. Eligible studies were published in peer-reviewed, English-language journals. The selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and study quality was evaluated using the Quality Scoring System. Eleven studies evaluating the impact of handoff interventions on both implementation and clinical outcomes were included. Key implementation outcomes, including sustainability and acceptability, were commonly assessed through staff satisfaction surveys. Clinical outcomes included length of stay, duration of mechanical ventilation, and pain scores. All studies incorporated a structured preimplementation planning phase and reported significant improvements in at least 1 implementation outcome, with acceptability being the most consistently improved measure. Each study demonstrated meaningful improvements in at least 1 implementation outcome, while 7 of 11 studies reported significant enhancements in clinical outcomes. The consistent success of various methodologies—whether through expert consultation, frontline involvement, or quality improvement strategies—indicates that a tailored, site-specific approach may be more critical to success than the specific intervention strategy used.]]> Tue, 06 May 2025 00:00:00 GMT-05:00 00000539-990000000-01276 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_health_care_disparities_in_the.1273.aspx Perioperative health inequities remain a critical issue, contributing to unequal patient outcomes and financial costs despite increasing awareness and efforts to address these disparities. This systematic review evaluated anesthesiology literature from 2010 to 2023 on perioperative health care disparities related to race, ethnicity, gender, and socioeconomic status. The review aimed to identify gaps and propose research and opportunities for intervention. A comprehensive literature search was conducted using PubMed, Embase, Scopus, and Web of Science, with studies included if they focused on perioperative disparities in the United States, were published in anesthesiology journals, and met criteria for methodological rigor. The review was registered with International Prospective Register of Systematic Reviews (PROSPERO); data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and study quality was assessed with the Newcastle-Ottawa scale. Out of 1050 abstracts screened, 116 articles were reviewed for full text, with 59 studies meeting inclusion criteria. Included studies comprised retrospective cohort studies, cross-sectional analyses, a case-control study, and a randomized controlled trial, covering various surgical procedures and sample sizes from 100 to over 21 million patients. Disparities were noted in peripartum management (n = 14), mortality (n = 12), complications (n = 8), regional anesthesia use (n = 6), and pain management (n = 3), with evidence of poorer outcomes in Black and Hispanic women, older adolescents, and patients who were uninsured or on Medicaid. This review highlights the persistence of significant perioperative disparities and identifies gaps, such as limited exploration of the causes of these disparities, limited examination of disparities during the preoperative and intraoperative period, and few interventions to address these identified disparities. Reducing these disparities requires stakeholder engagement, multifaceted approaches, culturally agile training for health care teams, enhanced decision support tools, and a more diverse health care workforce. Continued research and targeted interventions at individual, community, and societal levels are essential for improving perioperative outcomes.]]> Sat, 03 May 2025 00:00:00 GMT-05:00 00000539-990000000-01273 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/risk_adjustment_of_perioperative_mortality_rate.1272.aspx BACKGROUND: The health care systems in low-income countries have extremely limited capacity to treat surgical diseases. The perioperative mortality rate has been suggested as a key quality metric to guide the expansion of care, but there is little information on how to risk-adjust this outcome measure. METHODS: We did a 42-month observational cohort study of surgical operations at a Ugandan secondary referral hospital. We examined factors associated with in-hospital 30-day perioperative mortality outcomes. The aim of the study was to suggest a suitable indicator metric for comparative health service research in low-income countries. RESULTS: The 30-day perioperative mortality rate was 5.3 % (n = 381/7170). The adjusted odds ratios (95% confidence interval) of variables associated with mortality were as follows: procedure (P < .001; laparotomy 2.6 [1.6, 4.3], P < .001; cranial surgery 2.8 [1.6, 4.9], P < .001); American Society of Anesthesiologists (ASA) rating 3.1 (2.6, 3.6), P < .001; HIV serostatus (P < .001; positive 2.7 [1.5, 4.8], P < .001); procedure urgency (urgent/emergent) 1.7 (1.2, 2.3), P = .003; home district location (P = .015; distant referral 1.4 [1.0, 1.9], P = .027); and age decile 1.1 (1.0,1.2, P = .001). Laparotomy was the commonest procedure performed (n = 2361) and was associated with 56.3% (n = 216/381) of deaths. CONCLUSIONS: Laparotomy had a strong independent association with mortality at a Ugandan secondary hospital. The laparotomy perioperative mortality rate may be a suitable outcome measure for comparative health service research in low-income countries.]]> Thu, 01 May 2025 00:00:00 GMT-05:00 00000539-990000000-01272 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/pulse_oximetry,_intraoperative_occult_hypoxemia,.1271.aspx No abstract available]]> Mon, 28 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01271 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_effect_of_electroencephalographic_trajectory.1265.aspx BACKGROUND: Postoperative neurocognitive disorders (PNDs) are frequent and serious complications that cause an enormous social and economic burden. A previous study demonstrated that certain electroencephalographic (EEG) patterns during emergence from general anesthesia are associated with a higher risk for PND. Compared to patients demonstrating the most favorable trajectory (Traj Ref: delta-dominant slow-wave anesthesia (ddSWA)→spindle-dominant SWA (sdSWA)→non-SWA (nSWA)→wake), patients presenting Traj Abrupt (ddSWA→wake) had 4-fold increased odds to develop PND and patients with Traj High (nSWA→wake) had 8-fold increased odds of developing PND. We hypothesized that commonly used neuromonitoring devices (state entropy [SE], quantium consciousness index [qCON], bispectral index [BIS], and Patient State Index [PSI]) can differentiate between the various trajectories. METHODS: From the original database of the study by Hesse et al, we analyzed 59 EEGs from patients emerging from general anesthesia. They were selected according to their trajectory. We included 19 patients who had shown the most favorable trajectory (Traj Ref), 20 who had demonstrated Traj Abrupt, and 20 who had followed Traj High. To evaluate the performance of the neuromonitoring devices, we replayed the patients’ EEGs to the monitors using an EEG player. We compared the index values for the 3 different trajectories (Traj Ref, Traj Abrupt, and Traj High) generated by the different monitoring devices, respectively. Additionally, we evaluated the correlation between the monitoring devices. RESULTS: SE and PSI were able to resolve significant differences between Traj Ref and Traj Abrupt during a major part of emergence. Traj Ref showed an almost linear increase of index values, whereas Traj Abrupt led to an episode of low index values followed by a sudden increase. However, when comparing Traj Ref vs Traj High, qCON, PSI, and BIS were the indices showing significant differences, especially at the beginning of emergence. Patients representing Traj Ref patterns had significantly lower index values than those depicting Traj High. Due to the Traj High cases starting in nSWA, their indices were already high at the start of emergence. CONCLUSIONS: Our analysis revealed that the course of the different indices reflects spectral EEG patterns during the emergence from general anesthesia. Considering certain emergence trajectories associated with a higher risk of developing PND, our approach might enable the anesthetist to identify patients particularly susceptible to PND by observing the course of index values before admission to the postanesthesia care unit.]]> Fri, 25 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01265 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/electroencephalogram_correlates_of_delayed.1266.aspx BACKGROUND: Delayed emergence from anesthesia presents clinical challenges, including prolonged stays in the postanesthesia care unit (PACU). The neurobiological mechanisms underlying delayed emergence, particularly in remimazolam-induced anesthesia, remain poorly understood. This study aimed to explore patterns of brain electrical activity of delayed emergence in remimazolam-induced anesthesia by comparing dynamic changes in electroencephalogram (EEG) activity under various anesthesia states of remimazolam and propofol, focusing on the prefrontal region. METHODS: Forty-eight patients (age >18) who underwent laparoscopic cholecystectomy randomly received remimazolam- or propofol-induced general anesthesia. Power spectrogram analysis and functional connectivity measures, phase lag entropy (PLE) and phase lag index (PLI), were used to the prefrontal EEG data collected at baseline, unconsciousness, and emergence. Correlation between EEG measures and Patient State Index (PSI) at PACU, as well as time to Aldrete 9, were compared. RESULTS: During emergence from anesthesia, EEG power revealed that the remimazolam group had higher powers than the propofol group in theta band during eyes-open (EO) (mean of 2.933 [standard deviation of 5.762] vs −2.342 [4.869]; P-value of 0.018 with independent 2-sample t test), and in the alpha band during eyes-closed (EC) (5.821 [7.35] vs −2.399 [4.53]; P < .001) and EO (4.84 [6.411] vs −3.613 [4.556]; P < .001). Conversely, the functional connectivity result showed lower PLE in the alpha band during EC (0.619 [0.0338] vs 0.684 [0.0392]; P < .0001) and EO (0.651 [0.0358] vs 0.692 [0.0428]; P = .015), and in the beta band during EC (0.682 [0.0308] vs 0.712 [0.0236]; P = .016) and EO (0.695 [0.0236] vs 0.725 [0.0195]; P < .001). In line with this, the remimazolam group had lower PSI values at PACU during EC (65.10 [14.67] vs 82.40 [6.678]; P < .0001) and EO (72.35 [12.55] vs 83.53 [6.632]; P = .006) and were slower to reach Aldrete score of 9 (median difference of 17.5; interquartile range of [0.0–21.0]; P < .001). Delayed consciousness recovery (time to Aldrete 9) under remimazolam was significantly correlated with PLE (Pearson’s correlation = −.78, P < .0001) and PLI (Pearson’s correlation =.69, P = .028) in the alpha band during deep anesthesia. CONCLUSIONS: Dynamic changes in prefrontal EEG during recovery and the correlation analyses show the potential of EEG in reflecting distinct consciousness recovery profiles between 2 drugs—slower recovery under remimazolam anesthesia. This suggests an association of EEG parameters with a unique behavioral profile of remimazolam, especially reflecting progressive changes in cerebral activity during recovery.]]> Fri, 25 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01266 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/global_access_to_clinical_office_based_surgical.1267.aspx No abstract available]]> Fri, 25 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01267 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/advancing_maternal_pain_management_after_cesarean.1268.aspx BACKGROUND: Focused anesthesia education may be beneficial for resource-constrained settings where inadequate training along with lack of infrastructure, staff, and supplies can contribute to high anesthetic morbidity and mortality rates. Some medical outreach efforts have transitioned from short-term and service-focused “missions” to education-focused global health interventions to build health care capacity. The Stanford Anesthesiology Division of Global Health Equity partnered with Foundation for African Medicine and Education (FAME), a hospital in Karatu, Tanzania, to introduce regional anesthesia through virtual workshops and in-person bidirectional exchange. This study aimed to assess the translation of hybrid global health education in regional anesthesia to improvements on maternal post-cesarean delivery pain. METHODS: From 2020 to 2023, the FAME team was trained in regional and acute pain techniques via virtual biannual 2-week workshops. The FAME head nurse anesthetist visited Stanford for a 5-week observership in October 2023, then a Stanford team traveled to Tanzania in January 2024 for 4 weeks of hands-on regional anesthesia training. The nurse anesthetists identified obstetric anesthesia as an area for application. Postsurgical pain management pathways were developed, introducing numerical pain scores and multimodal analgesia including transversus abdominis plane (TAP) blocks. Primary outcomes included maximum pain scores reported for the first 12 hours, pain scores at 12 hours and at 24 hours after C-section. Secondary outcomes included postoperative analgesic prescriptions, side effects, and hospital length of stay. RESULTS: Mean maximum pain scores after C-section were significantly decreased (preintervention: 7.6 ± 1.9 [mean ± standard deviation {SD}] versus postintervention: 4.5 ± 1.6, P < .001). Smaller decreases in pain scores were observed at 12 hours (2.5 ± 1.3 vs 2.2 ± 1.1, P < .05) and 24 hours (1.1 ± 0.9 vs 0.7 ± 0.9, P < .01). Multimodal analgesia was utilized with reduction in scheduled tramadol (97.9% vs 69.9%, P < .001) and reduced side effect profiles (dizziness [29.3% vs 16.8%, P < .05] and nausea/vomiting [24.3% vs 8.8%, P < .001]). CONCLUSIONS: This study demonstrates the impact of global health educational interventions, including virtual workshops and bidirectional exchange, on maternal pain outcomes in a Tanzanian hospital. Preintervention data collection fostered heightened awareness among the FAME nurse anesthetists of the severity of post-cesarean pain. The introduction of TAP blocks further improved their existing multimodal analgesic strategy with a clinically significant reduction in maximum pain scores. This educational strategy aims to advance global anesthesia goals, including building longitudinal partnership, thereby enhancing access to safe anesthesia education and promoting sustainable capacity building.]]> Fri, 25 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01268 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/pacu_up___feasibility_of_an_early_mobilization.1270.aspx No abstract available]]> Fri, 25 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01270 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/application_of_cisgender_anesthesia_clinical.1261.aspx No abstract available]]> Fri, 18 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01261 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/intraoperative_blood_pressure_and_hypotension_in.1263.aspx No abstract available]]> Fri, 18 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01263 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/mentor_mentee_office_based_anesthesia_experience.1264.aspx No abstract available]]> Fri, 18 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01264 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/feasibility_study_of_an_indicator_of_equivalent.1257.aspx BACKGROUND: Minimum alveolar concentration (MAC) is used as the standard measure of potency for volatile anesthetic agents. However, there is a lack of effective and quantitative indicator of the combined potency of multiple coadministered inhalation and intravenous anesthetics. We hypothesized that an indicator of equivalent potency of multiple anesthetics, normalized by MAC and derived from response surface models as a fraction (abbreviated as eMAC fraction), can reflect the total potency of multiple anesthetics. METHOD: Fifty-three patients receiving general anesthesia were enrolled. A random dose combination of propofol and remifentanil was administrated before a tetanic electric stimulus which was used to simulate incision. The vital signals and responses of patients were recorded to tetanic stimulus and in turn used to calculate the prediction probability (Pk) of the response, using the eMAC fraction and the bispectral index (BIS). After induction, the doses administered during anesthesia maintenance were entirely determined by anesthesiologists. During emergence, the anesthesiologists facilitated the awakening of patients through a combination of auditory and tactile stimuli at eMAC fraction levels of 0.8, 0.6, 0.4, and 0.2, or every 2 minutes after the certain level was reached, whichever arrived first. RESULTS: The eMAC fraction for predicting the loss of movement response to tetanic electric stimulus yielded a mean ± standard deviation (SD) Pk of 0. 80 ± 0.06, which was higher than the Pk of the BIS value for predicting the loss of movement response to tetanic electric stimulus (0.71 ± 0.07, P < .001). During maintenance of anesthesia, the eMAC fraction showed changes related to anesthetic dose and surgical phase. In all patients, approximately 71.9% of eMAC fraction values were within the range of 1.3 to 2.6. During emergence, the mean eMAC fraction values at awakening were 0. 30 ± 0.15. CONCLUSIONS: The eMAC fraction showed a superior performance in indicating the loss of response to electric stimulus compared to BIS. Anesthesiologists are familiar with the clinical use range of MAC fraction, and the distribution of eMAC fraction values during maintenance is similar to this range. This similarity allows anesthesiologists to easily use eMAC fraction in practice. These results indicate that the eMAC fraction has the potential to assist anesthesiologists in titrating multiple anesthetics to estimate the depth of anesthesia during general anesthesia, and should further be evaluated in clinical studies.]]> Thu, 17 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01257 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/publication_bias_in_leading_anesthesiology.1252.aspx No abstract available]]> Thu, 10 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01252 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/blood_health__the_ultimate_aim_of_patient_blood.1253.aspx No abstract available]]> Thu, 10 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01253 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/profiling_postpartum_recovery_after_scheduled.1245.aspx BACKGROUND: Childbirth can have a substantial impact on maternal health-related quality of life. Cesarean delivery is the most performed inpatient operation, yet little is known about normal postpartum recovery profiles. The primary aim of our study was to longitudinally evaluate global health visual analog scale (GHVAS; 0–100) scores up to 12 weeks after scheduled cesarean delivery and identify the time to plateau of scores. The secondary aims were to evaluate different domains of postpartum recovery using validated patient-reported outcome measures (Obstetric Quality of Recovery score [ObsQoR-10] and 5-level 5-dimensional EuroQol questionnaire [EQ-5D]). METHODS: After institutional review board approval, this single-center, prospective longitudinal study enrolled healthy women scheduled for cesarean delivery. Women were excluded for gestational age <32 weeks, neonatal demise, neonatal intensive care unit admission, inability to read or understand English, and if general anesthesia was used. Women completed baseline surveys before delivery and then at 24 and 48 hours after delivery. After hospital discharge, women completed surveys (including GHVAS, OBsQoR-10, EQ-5D, Edinburgh Postnatal Depression Scale, and activities of daily living) at 1 week, 3 weeks, 6 weeks, and 12 weeks postpartum. One-way repeated measures analysis of variance (ANOVA) was used to detect the difference in GHVAS and postpartum recovery outcomes with different follow-up time points. RESULTS: We enrolled 66 parturients and 3 were withdrawn. Response rates were 95%, 84%, 83%, and 76% at 1, 3, 6, and 12 weeks, respectively. Mean ± standard deviation [SD] GHVAS scores were 78 ± 16 at baseline, 64 ± 17 at 24 hours, 69 ± 15 at 48 hours, 75 ± 19 at 1 week, 88 ± 11 at 3 weeks, 88 ± 15 at 6 weeks, and 90 ± 12 at 12 weeks postpartum (P < .001). The global health VAS improved up until week 3 and then plateaued close to the maximum score between 3 weeks and 12 weeks postpartum. Mean ± SD ObsQoR-10 scores were 75 ± 15 at 24 hours, 85 ± 10 at 48 hours, and 81 ± 28 at 1 week postpartum (P = .003). The mean ± SD EQ-5D composite scores improved at 6 weeks (4.9 ± 2.9) and 3 months (4.2 ± 2.6) compared to baseline (6.5 ± 1.8) with usual activities (P = .001) and pain/discomfort (P < .001) showing significant improvement over time. ObsQoR-10 score at 24 hours correlated with ObsQoR-10 scores at 48 hours (r = 0.629, P < .001) and 1 week (r = 0.429, P < .001) but did not correlate with EQ-5D scores at 6 weeks and 12 weeks. CONCLUSIONS: Our study demonstrates that GHVAS after scheduled CD plateaus at week 3. This data can be used to inform patients about the anticipated trajectory of key postpartum recovery domains up to 12 weeks postpartum.]]> Fri, 04 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01245 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/establishing_pediatric_patient_blood_management.1248.aspx No abstract available]]> Fri, 04 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01248 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/impact_of_compound_chamomile_and_lidocaine.1249.aspx No abstract available]]> Fri, 04 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01249 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/assessing_sleep__a_new_biomarker_for_developmental.1250.aspx No abstract available]]> Fri, 04 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01250 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/regional_anesthesia_with_fascial_plane_blocks_for.1251.aspx Undertreated pain in children who undergo sternotomy for cardiac surgery can lead to cardiopulmonary complications, the development of chronic pain, and long-term maladaptive stress response. Opioids have dose-dependent side effects that may interfere with postoperative recovery. With the increasing availability of ultrasound, regional anesthesia is often included in multimodal analgesic approaches. Fascial plane blocks targeting the intercostal nerves or ventral rami are of particular interest for patients requiring full heparinization for cardiopulmonary bypass as they avoid manipulation of neuraxial and noncompressible paravertebral spaces. This narrative review summarizes the literature on fascial plane blocks for pediatric patients undergoing cardiac surgery via midline sternotomy and may serve as a guide for clinicians. Both prospective and retrospective studies are reviewed, as are prior review articles. We describe individual fascial plane block techniques including the transversus thoracic muscle plane, pectointercostal fascial plane, serratus anterior plane, and erector spinae plane blocks and provide clinical considerations for each block. Additionally, we provide an analysis of individual studies stratified by anterior or posterior approach and block type. The majority of described studies examine single-shot blocks; the existing catheter literature, which includes erector spinae plane block catheters, is also included. Our findings suggest that fascial plane blocks decrease intraoperative and postoperative opioid use, pain scores, time to extubation, and length of stay in the intensive care unit and hospital. Notably, prospective studies in this field are small, typically fewer than 100 patients, and overall include a homogenous patient population, focusing primarily on patients with acyanotic congenital heart defects. Nonetheless, despite the limitations of individual studies, there is substantial evidence to support the use of regional anesthesia, particularly for patients in whom early extubation is planned. There is a need for large, prospective multi-center studies to evaluate the effectiveness and safety of specific single-shot block types, optimal local anesthetic dosing strategies compared to active comparators, and generalizability of results across institutions. Future studies should also consider evaluating the role of regional block catheters for continuous local anesthetic infusion and the inclusion of additional surgical populations, including neonates, patients with cyanotic lesions, and those with longer postoperative mechanical ventilation courses.]]> Fri, 04 Apr 2025 00:00:00 GMT-05:00 00000539-990000000-01251 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/metabolic_flexibility_as_a_candidate_mechanism_for.1242.aspx BACKGROUND: This study investigates the role of metabolic flexibility in determining perioperative outcomes. Metabolic flexibility, a key feature of metabolic health, is the ability to efficiently switch between different fuel sources (predominantly carbohydrates and fats) depending on energy demands and availability. Given the rapidly changing physiological conditions in the perioperative period, we hypothesized that good metabolic adaptability could mitigate postoperative complications. METHODS: We conducted a retrospective observational study utilizing a prospectively collected, single-center preoperative cardiopulmonary exercise testing (CPET) database of patients undergoing a range of major surgeries between 2012 and 2022. On day 3, patients were categorized into 3 groups based on their Postoperative Morbidity Survey (POMS) scores: 0 to 1, 2, and 3 to 6. Metabolic flexibility was evaluated through measurements of fat and carbohydrate oxidation during exercise testing (CPET). Associations were explored between metabolic flexibility, cardiorespiratory fitness, and postoperative outcomes. RESULTS: Of 585 patients, those with no or low postoperative day 3 morbidity (POMS 0–1; n = 204) demonstrated significantly higher fat oxidation early in exercise before anaerobic threshold (fatty acid oxidation [FATox] area under the curve [AUC] 826 [578–1147]) compared to both POMS 2 (658 [448–922; n = 268]) and POMS 3 to 6 (608 [414–845; n = 113]); both P < .001. POMS 0 to 1 patients also had more effective carbohydrate utilization at peak exercise intensity. Higher postoperative morbidity (POMS) categories were associated with diminished metabolic flexibility characterized by a reduced ability to switch between metabolic substrates—carbohydrate oxidation (CHOox) POMS 0 to 1 group AUC 10277 (interquartile range [IQR] 7773–13358) compared to POMS 2 AUC 8356 (IQR 6548–10377) and POMS 3 to 6 AUC 6696 (IQR 473–9392); both P < .001. Reduced metabolic flexibility correlated with increased postoperative complications and an extended hospital stay. CONCLUSIONS: Metabolic flexibility may be a pivotal factor in determining postoperative outcomes. Patients with greater metabolic adaptability had fewer complications and shorter hospitalization by 4 days on average. This suggests that preoperative metabolic conditioning—something potentially achieved by targeted prehabilitation—could be linked to surgical recovery. Future research should focus on prospective studies to confirm these relationships and explore underlying mechanisms. If confirmed, metabolic flexibility assessments could be integrated into routine preoperative evaluation to better predict and improve patient outcomes.]]> Mon, 31 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01242 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/carboxyhemoglobin_and_methemoglobin_as_biomarkers.1244.aspx BACKGROUND: Critically ill patients who receive circulatory or respiratory assist using extracorporeal membrane oxygenation (ECMO) may develop hemolysis, which can complicate the delivery of supportive care and be a potential risk factor for increased morbidity and mortality. Clinically, hemolysis is often identified using laboratory markers such as cell-free hemoglobin (CFH) and haptoglobin (Hp). However, such measurements require photometry or enzyme-linked immunosorbent assay (ELISA) and are labor intensive. In contrast, metabolic downstream products of CFH, such as carboxyhemoglobin (CO-Hb) and methemoglobin (Met-Hb), can be regularly monitored via arterial blood gas analyses in the intensive care unit (ICU). We hypothesized that CO-Hb and Met-Hb values measured during ECMO would correlate with the presence of hemolytic events as measured by CFH values exceeding 50mg/dl. We further hypothesized that CO-Hb and Met-Hb levels would correlate with peri-ECMO mortality. METHODS: Retrospective analysis of 435 patients with acute respiratory distress syndrome (ARDS) and veno-venous ECMO admitted to a tertiary ARDS referral center. Plasma concentrations of CO-Hb and Met-Hb were correlated with hemolytic events. Cutoff values of mean CO-Hb (mCO-Hb) and mean Met-Hb (mMet-Hb) associated with increased ICU mortality were calculated with recursive binary partitioning. Single and multivariable regression models for HE and ICU mortality were trained and compared. RESULTS: Simple and multivariable models including potential confounders identified associations between Met-Hb and hemolytic events (adj. odds ratio [OR] 2.99 [95% confidence interval {CI}, 2.19–4.10], P < .001). A cutoff value with 90% specificity of a hemolytic event was estimated for Met-Hb (1.55%). Both, mean CO-Hb (OR 2.03 [95% CI, 1.60–2.61], P < .001) and Met-Hb (2.78 [1.59–5.09], P < .001) were associated with ICU mortality. Cutoff values for mortality were 2% for mean CO-Hb and 1.25% for mean Met-Hb. The multivariable regression model for mortality including the continuous markers mCO-Hb and mMet-Hb produced an area under the curve (AUC) of 0.803. CONCLUSIONS: In patients with ARDS and ECMO, Met-Hb plasma concentrations were independently associated with hemolytic events. Both, mean CO-Hb and Met-Hb levels were associated with ICU mortality. These markers and their associated cutoff values might serve as a risk indicator in clinical practice.]]> Mon, 31 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01244 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/ecodesign_in_health_care__reducing_environmental,.1238.aspx No abstract available]]> Thu, 27 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01238 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/anesthesiology_resident_demographics_and_the_basic.1239.aspx BACKGROUND: The BASIC Examination was added to the US examination system for anesthesiology certification in 2014. The American Board of Anesthesiology conducted retrospective analyses to assess whether resident demographics, program characteristics, and/or prior examination performance were associated with first-time BASIC pass rates METHODS: Anesthesiology residents who took the BASIC Examination for the first time from July 2014 to November 2022 were eligible to participate, and they had at least 2 more attempts (or opportunities to attempt) through December 2023. First-time and eventual pass rates (ie, based on up to 3 attempts) were calculated for each demographic group. For those residents who had the clinical base year in-training examination (CBY ITE) scores available, demographic group performance differences on this examination were first examined. Mixed-effects logistical regression models assessed how resident demographics, program characteristics, and/or prior CBY ITE scores were associated with the odds of passing the BASIC the first time. RESULTS: The analyses included 17,286 examination attempts from 15,789 residents. The majority of residents were male (65.8%), non-Hispanic or Latino (76.2%), White (47.8%), and US medical school graduates (87.4%). Differences in the first-attempt BASIC pass rates included male (92.7%) vs female (88.1%), non-Hispanic or Latino (92.0%) vs Hispanic or Latino (85.8%), Asian (92.6%) and White (92.4%) vs Black/African American (81.9%), respectively, and US (91.5%) vs international (88.6%) medical school graduates. Females had significantly lower odds of passing the BASIC the first time than males (odds ratio [OR] = 0.53, 95% confidence interval [CI], 0.47–0.60); Black/African American residents (OR = 0.41, 95% CI, 0.33–0.51) and Middle Eastern or North African residents (OR = 0.64, 95% CI, 0.46–0.91) had lower odds of passing the BASIC on first attempt than White residents; Hispanic or Latino residents had lower odds of passing the BASIC initially than non-Hispanic or Latino residents (OR = 0.52, 95% CI, 0.42–0.64). Nevertheless, all demographic subgroups’ eventual pass rates were >99%. Male and White residents outperformed female and Black/African American residents, respectively, in CBY ITEs. The gender and race performance gaps in the first-time BASIC pass rates were attenuated but not eliminated after controlling for their CBY ITE scores—compared to male and White residents, respectively, the odds of passing the BASIC the first time changed from 46% to 56% for female residents, and from 41% to 53% for Black/African American residents. CONCLUSIONS: Female and nonwhite residents had lower first-time BASIC Examination pass rates. Almost all trainees passed by their up-to-third attempts. Future studies are needed to understand the basis of these differences and identify opportunities for improvement.]]> Thu, 27 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01239 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/phenotyping_the_transfusion_management_experience.1240.aspx BACKGROUND: Clinical experience is foundational to graduate medical education but is difficult to quantify. Self-reported case logs and scheduled rotations provide limited detail on residents’ actual experiences. The analysis of electronic health record (EHR) data may provide a more comprehensive view of residents’ actual clinical experiences. We aimed to quantify and characterize residents’ direct clinical experiences with intraoperative transfusion management as a proof of concept for the utility of EHR data in anesthesiology graduate medical education. METHODS: This retrospective observational study aimed to measure the participation of anesthesiology residency graduates with intraoperative transfusion management at a single institution. Data pertaining to the University of Michigan cases submitted to the Multicenter Perioperative Outcomes Group (MPOG) data registry from January 1, 2012, to December 31, 2022, were analyzed. The primary outcome was participation in intraoperative transfusion management defined by the transfusion of any volume of homologous packed red blood cells (pRBC) documented within the intraoperative anesthesia record. Subgroup analysis characterized resident participation in severe intraoperative hemorrhage resuscitation defined as the transfusion of ≥4 pRBCs. Additional outcomes were participation in non-pRBC blood product transfusion and transfusion of cell-salvaged blood. Surgical case and resident-specific factors were analyzed for association with resident participation in intraoperative pRBC transfusion. RESULTS: Throughout the study period, 231 residents from 8 graduating cohorts were involved in 222,006 anesthetic cases of which 8529 (4%) included intraoperative pRBC transfusion. Over the entire course of residency training, residents on average participated in 37 (standard deviation [SD] = 8) cases with intraoperative pRBC transfusion with a range of 16 to 60. The mean (SD [range]) participation with severe hemorrhage resuscitation was 10 (3 [2–22]), participation with non-pRBC transfusion was 7 (3 [1–14]), and participation with cell salvaged blood was 13 (4 [3–26]). Five of 19 surgical services (cardiac, transplant, vascular, neurosurgery, orthopedic) accounted for the majority (5668; 66%) of intraoperative transfusion management experiences. CONCLUSIONS: Variation exists in the transfusion management experience among trainees at a single academic center. This study supports the feasibility of using EHR data to quantify the clinical experiences of residents beyond the assumptions underlying self-reported case logs and time on specialty rotations. Such analyses may allow for interventions to optimize the frequency, timing, and sequencing of clinical care activities to ensure optimal clinical experience.]]> Thu, 27 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01240 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/is_there_a_better_timing_for_frontal.1230.aspx No abstract available]]> Tue, 25 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01230 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/cricothyroid_membrane_vasculature__an.1233.aspx No abstract available]]> Tue, 25 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01233 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_relationship_between_chronic_postoperative.1234.aspx BACKGROUND: After fracture-related surgery, chronic posttraumatic and/or postsurgical pain (CPSP) has a high incidence rate of up to 43% a year after surgery. Yet the underlying mechanisms are poorly understood. Murine and clinical evidence suggest immunological modulation of postsurgical pain. However, the specific cytokine profiles of patients who develop CPSP after fracture-related surgery remain to be determined. Therefore, we analyzed in an exploratory manner cytokines, chemokines and adipocytokines in patients with and without CPSP up to 1 year after fracture-related surgery. METHODS: A prospective longitudinal serum profiling of 30 patients with traumatic fractures that required osteosynthesis was conducted on the first day (D1), at 6 weeks (W6) and 1 year after surgery (Y1). Patients with CPSP at Y1 were compared to those who did not develop CPSP. A total of 22 pro- and anti-inflammatory serum cytokines, including adipocytokines, were quantified using Luminex technology. Statistical analyses included χ² test, t test, and Mann-Whitney U test, Spearman’s rank correlations, and repeated-measures mixed models with Bonferroni correction for cytokine differences between patients with and without CPSP. Receiver-operating characteristic (ROC) curves evaluated the discriminatory ability of specific cytokines regarding the development of CPSP. RESULTS: Patients with CPSP 1 year after surgery (n = 12/30, 40%) exhibited elevated resistin levels at Y1 (CPSP: 1.04 ± 1.04 vs no-CPSP: 0.41 ± 0.31 pg/mL; P < .001) as well as higher adiponectin levels at Y1 (CPSP: 9.37 ± 8.23 vs no-CPSP: 5.57 ± 2.75 μg/mL; P = .008). Patients with CPSP had higher Rantes/CCL5 (CC-chemokine ligand 5) levels immediately after surgery on D1 than patients without CPSP (mean difference [MD] = 5.5, confidence interval [CI], 1.7–9.3 ng/mL; P = .014). At W6 and Y1, adiponectin and CCL5 levels correlated with pain intensity in patients with CPSP (adiponectin: r = 0.50, P = .03; CCL5: r = −0.50, P = .03). Across the entire patient population, resistin levels were correlated with pain intensity (r = 0.34, P < .001; D1–Y1). CONCLUSIONS: Our explorative cytokine analysis uncovered an imbalance in serum cytokines and chemokines during the chronification process in patients who developed CPSP 1 year after surgically treated fractures. In particular, adiponectin and resistin were noted to be novel biomarkers for CPSP development. These data provide preliminary insight into a potential unexplored crosstalk between chronic postoperative pain and adipocytokines in the chronification of CPSP, which remains to be further analyzed.]]> Tue, 25 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01234 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/prophylactic_phenylephrine_boluses_versus_variable.1235.aspx No abstract available]]> Tue, 25 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01235 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/valar_morghulis___all_men_must_die___.1237.aspx No abstract available]]> Tue, 25 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01237 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/mapping_perioperative_care_randomized_controlled.1220.aspx The World Health Organization has recognized surgical and anesthesia care as integral components of universal health coverage. In sub-Saharan Africa (SSA), 93% of the population lacks access to essential surgical services. Postsurgery mortality in Africa is double the global average. The involvement of anesthesia providers is crucial for improved outcomes. Perioperative research can produce context-specific solutions to challenges faced in the perioperative period. SSA conducts fewer randomized controlled trials (RCTs) than high-income countries, limiting its contribution to global evidence. Our primary objectives were to document the geographical distribution of included RCTs, describe their characteristics, and evaluate the reporting quality using the Consolidated Standards of Reporting Trials (CONSORT)-2010 checklist. We followed the PRISMA Scoping Reviews (PRISMAScR) Checklist. We searched MEDLINE, the Cochrane Library, and Scopus. We identified perioperative care RCTs within SSA published from 2000 to 2022. Two independent reviewers screened potential studies and extracted data in duplicate, with disagreements resolved through consensus or a third reviewer. Quantitative analysis was done with STATA 16, and data were summarized narratively. We compared RCT quality pre-CONSORT-2010 to post-CONSORT-2010, using Pearson’s χ2 test or Fisher exact test (as applicable), considering P < .05 as statistically significant. Of 3319 records, 169 eligible RCTs were identified, randomizing 45,376 participants, with a mean sample size of 98. Between the years 2000 and 2022, there was an exponential trend towards an increasing number of RCTs in SSA (y = 1,5619e0,1051x). The RCTs were from 16 countries in SSA. Most studies were single-country, single-center, led by authors from Nigeria (63/169, 37.3 %) and South Africa (41/169, 24.3%). Most interventions were conducted intraoperatively (n = 125/169, 74%). Pharmacotherapy interventions were most investigated (n = 64/169, 37.9%), followed by analgesic interventions (n = 42/169, 24.9%). The surgical discipline most investigated was obstetrics (n = 51/169, 30.2%). The reporting quality was generally poor, with most RCTs not adhering to CONSORT guidelines and failing to register on a trial registry. This scoping review provides a comprehensive overview of perioperative care RCTs in SSA, highlighting limitations such as small sample sizes, under-representation of high surgical burden disciplines, and poor outcome reporting. Clinical trial capacity is limited to a few countries and institutions, and methodological quality remains poor despite reporting guidelines. There is an opportunity to enhance context-appropriate RCTs in SSA by prioritizing high-quality research through collaborative efforts. Our findings serve as a resource for researchers, funders, and policymakers in perioperative care research in Africa to improve future RCT designs and reporting.]]> Thu, 13 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01220 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/bridging_the_gap__the_challenge_of_conducting.1221.aspx No abstract available]]> Thu, 13 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01221 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/volatile_anesthetic_induced_skeletal_muscle.1222.aspx BACKGROUND: Volatile anesthetics are gaining attention as sedatives in intensive care units. Sedation is a significant risk factor for skeletal muscle atrophy and weakness in critically ill patients; however, volatile anesthetics’ influence on skeletal muscle atrophy remains unclear. Therefore, we investigated their effects on skeletal muscle mass using a murine-derived muscle cell line and mice. METHODS: C2C12 myotubes were exposed to isoflurane or sevoflurane. Myotube diameter was assessed using immunofluorescence. The expression levels of Atrogin-1, MuRF1, and LC3-II and phosphorylation levels of p70 S6K and Akt were analyzed to evaluate protein degradation and synthesis. To determine whether these effects were mediated through the Akt pathway, experiments with insulin-like growth factor 1 (IGF-1) were performed. Furthermore, mice skeletal muscle exposed to isoflurane or sevoflurane were compared with control mice and short-term immobility mice induced by sciatic nerve denervation (DN) or hindlimb suspension (HS). RESULTS: Exposure of C2C12 myotubes to 2.8% isoflurane or 5.0% sevoflurane reduced the myotube diameter by 14.4 µm (95% confidential interval [CI], 11.7–17.1, P < .001) and 13.2 µm (95% CI, 10.1–16.2, P < .001), respectively. Exposure to 2.8% isoflurane increased the expressions of Atrogin-1 (2.9-fold [95% CI, 2.1- to 3.8-fold], P < .001), MuRF1 (3.1-fold [95% CI, 2.4- to 3.8-fold], P < .001), and LC3-II (1.6-fold [95% CI, 1.4- to 1.8-fold], P < .001), whereas decreasing phosphorylation of p70 S6K (0.3-fold [95% CI, 0.2- to 0.4-fold], P < .001) and Akt (0.4-fold [95% CI, 0.3- to 0.5-fold], P < .001). Exposure to 5.0% sevoflurane resulted in similar effects. Additionally, IGF-1 counteracted the effects of isoflurane on myotube mass. In mice skeletal muscle, exposure to 1% isoflurane or 1.5% sevoflurane decreased Akt phosphorylation (isoflurane: 0.4-fold [95% CI, 0.1- to 0.8-fold], P = .003; sevoflurane: 0.5-fold [95% CI, 0.4- to 0.6-fold], P = .011) and increased the expression levels of Atrogin-1 (isoflurane: 4.1-fold [95% CI, 3.2- to 5.1-fold], P < .001; sevoflurane: 2.3-fold [95% CI, 1.1- to 3.5-fold], P = .026), MuRF1 (isoflurane: 2.7-fold [95% CI, 1.3- to 4.1-fold], P = .01; sevoflurane: 2.3-fold [95% CI, 1.0- to 3.7-fold], P = .022), and LC3-II (isoflurane: 1.9-fold [95% CI, 0.9- to 3.0-fold], P = .045; sevoflurane: 1.5-fold [95% CI, 1.4- to 1.6-fold], P < .001) while decreasing p70 S6K phosphorylation (isoflurane: 0.5-fold [95% CI, 0.4- to 0.6-fold], P = .013; sevoflurane: 0.7-fold [95% CI, 0.6- to 0.8-fold], P = .008) compared with DN. Similar results were observed when comparing between isoflurane or sevoflurane exposure and HS. CONCLUSIONS: Volatile anesthetics induce skeletal muscle atrophy by downregulating the Akt pathway, suggesting they may exacerbate skeletal muscle atrophy beyond immobility effects.]]> Thu, 13 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01222 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/artificial_intelligence_supporting_anesthesiology.1223.aspx No abstract available]]> Thu, 13 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01223 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/inspired_oxygen_concentration_during_the.1216.aspx BACKGROUND: A recent multicenter study suggested that the duration of single-lung ventilation, and not the intensity of the hyperoxia (ie, inspired oxygen fraction) during this period, contributes to the development of postoperative pulmonary complications. However, lung reinflation, at the cessation of single-lung ventilation, is a period of particular susceptibility to hyperoxic injury, and the impact of alveolar hyperoxia during this period on postoperative pulmonary complications has not been specifically assessed. METHODS: Clinical practice surrounding the inspired oxygen fraction at lung reinflation and potential clinical implications of alveolar hyperoxia occurring during this period were assessed in this secondary analysis of data from a multicenter retrospective cohort study. RESULTS: On multivariable logistic regression, average inspired oxygen fraction during the period of lung reinflation was independently associated with postoperative pulmonary complications (adjusted odds ratio [aOR]: 1.14, 95% confidence interval [CI], 1.01–1.29, P = .032; unit: 10% FiO2 increment). The duration of single-lung ventilation (in hours) also remained significant in this model (aOR: 1.21, 95% CI, 1.03–1.42, P = .020). CONCLUSIONS: The results of this study suggest a unique sensitivity to alveolar hyperoxia at the time of lung reinflation and raise the possibility that restricting the inspired oxygen fraction during lung reinflation could reduce injury and related sequelae. Our findings imply that a 10% increase in FiO2 during the reinflation period (eg, increasing FiO2 from 80% to 90%) would be associated with 14% greater odds of developing a postoperative pulmonary complication. However, they should be viewed as hypothesis-generating due to the retrospective nature of the study and serve as justification for prospective investigation of this association.]]> Mon, 10 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01216 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/effects_of_perioperative_exposure_on_the.1218.aspx BACKGROUND: Previous work suggests that the gut microbiome can be disrupted by antibiotics, anesthetics, opiates, supplemental oxygen, or nutritional deprivation—all of which are common and potentially modifiable perioperative interventions that nearly all patients are exposed to in the setting of surgery. Gut microbial dysbiosis has been postulated to be a risk factor for poor surgical outcomes, but how perioperative care—independent of the surgical intervention—impacts the gut microbiome, and the potential consequences of this impact have not been directly investigated. METHODS: We developed a perioperative exposure model (PEM) in C57Bl/6 mice to emulate the most common elements of perioperative medicine other than surgery, which included 12 hours of nutritional deprivation, 4 hours of volatile general anesthetic, 7 hours of supplemental oxygen, surgical antibiotics (cefazolin), and opioid pain medication (buprenorphine). Gut microbial dynamics and inferred metabolic changes were longitudinally assessed before—and at 3 time points after—PEM by 16S rRNA amplicon sequencing. We then used fecal microbial transplant in secondary abiotic mice to test if, compared to preexposure microbiota, day 3 post-PEM microbial communities affect the clinical response to immune challenge in an endotoxemia model. RESULTS: We observed transient changes in microbiota structure and function after the PEM, including reduced biodiversity, loss of diverse commensals associated with health (including Lactobacillus, Roseburia, and Ruminococcus), and changes in microbiota-mediated amino acid metabolic pathways. Mice engrafted with day 3 post-PEM microbial communities demonstrated markedly reduced survival after endotoxemia compared to those bearing preexposure communities (7-day survival of ~20% vs ~70%, P = .0002). CONCLUSIONS: These findings provide the first clear evidence that the combined effects of common perioperative factors, independent of surgery, cause gut microbial dysbiosis and alter the host response to inflammation in the postoperative period.]]> Mon, 10 Mar 2025 00:00:00 GMT-05:00 00000539-990000000-01218 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/comparison_of_the_learning_curves_of.1212.aspx BACKGROUND: The effects of different positional relationships between the probe, needle, and puncture model on in-plane puncture performance have not been fully evaluated. In this simulation study, we used a 4-period crossover design to compare the learning curves of ultrasound-guided in-plane needle placement among 4 different puncture modes by novices. METHODS: Forty residents were randomly assigned to receive training in one of 4 puncture modes according to the placement of the puncture model and the orientation of the probe to the operator: horizontal phantom-parallel probe (HP), horizontal phantom-vertical probe (HV), vertical phantom-parallel probe (VP), and vertical phantom-vertical probe (VV). They were allowed 10 trials on each mode and then received the other 3 trainings following the predefined sequences based on a Williams design. Puncture time was recorded from needle entry until successful in-plane puncture under ultrasound guidance. RESULTS: Linear and generalized linear models indicated significant effects of puncture mode and trial number on puncture time (P < .001 for all models). The mean (standard deviation [SD]) puncture times for 10 trials were 44 (44) s for HP, 37 (34) s for HV, 80 (57) s for VP, and 46 (48) s for VV. HV had the shortest puncture time, while VP had the longest. No significant difference was observed in puncture time between VV and HP modes (P = .330). Within each mode, puncture time significantly decreased from the first to the tenth trial (P = .001 for HP, P < .001 for HV, P < .001 for VP, and P = .002 for VV). VP showed the steepest learning curve; however, even after 10 trials, its puncture time remained significantly higher than that of the other 3 modes (P < .001 for all comparisons). CONCLUSIONS: Ultrasound-guided in-plane puncture difficulty follows the order VP > HP = VV > HV.]]> Thu, 06 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01212 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_preoperative_phases_of_the_perioperative.1213.aspx BACKGROUND: Individuals with neurodegenerative disorders are often provided the same perioperative care as unaffected peers, even though unidentified diminished preoperative “brain health” worsens surgical outcomes. We summarize the implementation and standardized data from a phased preoperative cognitive assessment consisting of screening tests administered by clinic staff and, on a failed screening, an immediate neuropsychological assessment from licensed neuropsychologists. METHODS: The present observational study used deidentified patient data provided via an honest broker over 2 years. The data included patients aged 65 or older at the time of treatment who were triaged for an in-person preoperative clinic visit, excluding those patients who were scheduled for orthopedic surgery. The cognitive screening assessed education, frailty, clock-drawing-test to command and copy conditions, and 3-word registration and recall. The neuropsychological evaluation involved 90-minute assessments with interviews, cognitive testing, interpretation, and recommendations to the perioperative care team. Standardized data from general cognition, attention, and memory metrics are shown for this current report. RESULTS: Of the 14,795 patients eligible for cognitive screening, 83.1% underwent screening, identifying 22.7% with atypical cognitive performance. Patients successfully screened were more often white (87.8% vs 78.4%; P < .0001), married (61.2% vs 57.9%; P < .0001), and less frail (nonfrail: 45.6% vs 20.5%; P < .0001). Of the 2790 patients referred for the comprehensive assessment, 48.9% completed the neuropsychological evaluation. Referred patients were older (74.6 ± 6.5 vs 72.9 ± 5.7 yrs; P < .0001), less educated (13.2 ± 2.9 vs 14.1 ± 2.9 yrs; P < .0001), less likely married (58.1% vs 62.8%; P < .0002), more frail (frail: 24.6% vs 16.5%; P < .0001), more likely to live in socioeconomically-deprived geographic regions (52.0% vs 47.7%; P < .0001), and had a 50% greater 1-year mortality than nonreferred patients (P < .0001). Patients who showed no impairment or had only memory impairment on the neuropsychological examination were less frail (nonfrail: 45.5% vs 30.6%; P < .0001) and only half as likely to have a canceled surgery than those who exhibited attention or combined attention and memory impairment (P = .0002). CONCLUSIONS: Findings highlight how preoperative anesthesiology and neuropsychology teams can provide cognitive screening with referrals to brain health exams, and underscore the severity of unmet cognitive health care needs in older patients electing surgery.]]> Thu, 06 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01213 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/influence_of_repeated_exposure_to_neonatal.1214.aspx BACKGROUND: Normal sleep architecture is important for brain development, and we previously demonstrated that a single exposure to isoflurane during the neonatal period did not induce changes in the sleep architecture and only minimally altered neuronal beta oscillations in adolescent rats. Here, we hypothesized that a more clinically relevant scenario of repeated shorter exposures to isoflurane during brain development may have more profound effects on sleep and wake behavior and associated delta and theta oscillations, respectively. METHODS: Male and female rat pups were exposed to sham anesthesia (30% oxygen) or repeated isoflurane delivery for 2 hours each on 3 consecutive days (total exposure of 6 hours). The rat pups were divided into 2 cohorts. In cohort 1, we evaluated the neurotoxic effects of exposure postanesthesia. In cohort 2, electroencephalogram electrodes were implanted into the rat cortex between postnatal days 21–23, and sleep architecture was classified as wake, nonrapid eye movement (NREM), and rapid-eye movement (REM) sleep. Electroencephalogram power spectra were also measured in adolescent rats over a 72-hour period. RESULTS: Isoflurane exposure (n = 11) increased neuroapoptosis to 27. 7 ± 6.5 per mm-2 when compared to the sham group (9. 6 ± 3.0 per mm-2, n = 12, P < .001) and disrupted sleep architecture in adolescent rats. Specifically, there was an increase in the total sleep time (light + dark period) from 89. 9 ± 14.2 minutes in sham group (n = 9) to 111. 2 ± 32.2 minutes in the experimental group (n = 11, P < .05). Furthermore, there were fewer transitions during the dark period from 157. 1 ± 43.3 in sham group (n = 9) to 110. 6 ± 52.5 in the experimental group (n = 11, P < .05). The absolute power of delta oscillations was significantly decreased during the light period of NREM from an average 2217 ± 2016 μV2 in the sham group (n = 8) to 791 ± 659 μV2 in the experimental group (n = 11, P < .05). Further, theta oscillations in the wake stage were significantly decreased in the light period from 1579 ± 885 μV2 in sham group (n = 8) to 690 ± 413 μV2 in the experimental group (n = 11, P < .05) and light + dark period from 1390 ± 808 μV2 in sham group (n = 8) to 691 ± 421 μV2 in the experimental group (n = 11, P < .05). CONCLUSIONS: Exposing neonatal rats to isoflurane repeatedly causes significant neurotoxicity, and alters delta and theta thalamocortical oscillations, as well as sleep architecture in adolescence. This contrasts with a single continuous exposure to isoflurane, in which we previously reported no significant effects on sleep-wake architecture and only minimal effect on beta oscillations despite similar acute neurotoxicity.]]> Thu, 06 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01214 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/electroencephalogram_correlates_of_infant_spinal.1100.aspx No abstract available]]> Tue, 04 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01100 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/sociodemographic_and_systems_risk_factors.1208.aspx BACKGROUND: Day-of-procedure cancelations are a hardship, affecting patients, families, and health care systems. One major cause of cancelations is nil by mouth (nil per os [NPO]) noncompliance. Previous single-center studies show conflicting results regarding risk factors for cancelations. The primary objective of this study was to identify demographic populations with higher-than-predicted rates of NPO noncompliance, as defined by local institutional NPO guidelines. The secondary objective was to determine whether demographic and system risk factors were associated with procedure cancelations due to NPO noncompliance. METHODS: A multicenter retrospective case-control study was conducted of children <18 years of age presenting for elective procedures requiring adherence to local institutional NPO guidelines. Data collected included sociodemographic characteristics (age, sex, race-ethnicity, language of care, and medical insurance type) and systems factors (time of day for the scheduled procedure and communication modalities used to share NPO guidelines). The primary outcome was the occurrence of noncompliance of local institutional NPO guidelines. The secondary outcome was a cancelation of the elective procedure due to NPO noncompliance. A χ2 goodness-of-fit test and multivariable logistic regression were used for statistical analyses. RESULTS: Among 164,147 pediatric patients across 10 institutions, a total of 1208 instances of NPO noncompliance were identified (0.74%). Of the patients who experienced an NPO noncompliance event, 52% had their procedure delayed to a later time of the day, and 48% had their procedure canceled. Risk factors for NPO noncompliance included being younger than <4 years old, belonging to minority race-ethnicity groups, having Spanish as the primary language of care, and having public health insurance. In the multivariable analysis, the odds of cancelation after an NPO noncompliance event were 46% higher for children whose preprocedure phone call was not answered, 62% higher for children over 4 years old, 80% higher for non-Hispanic African American/Black children, 88% higher for children with public health insurance, and twice as high for procedures scheduled in the afternoon. CONCLUSIONS: This multicenter study identified age, race-ethnicity, language of care, and health insurance type as factors associated with the occurrence of NPO noncompliance. Certain demographic and system risk factors were linked to higher rates of day-of-procedure cancelations due to NPO noncompliance. These findings raise concerns regarding disparities in access to care especially in minority populations already at an increased risk of inadequate health care access. Identifying these risk factors can help drive the development of strategies to address inequities and improve access to health care.]]> Tue, 04 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01208 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/modeling_phase_i_postanesthesia_care_unit_patient.1210.aspx BACKGROUND: Although the importance of transporter availability to the operating room and phase I postanesthesia care unit workflow has been known since Marcon et al Anesth & Analg 2003, no detailed data have been published about patient transport times. Nearly all facilities know the times of postanesthesia care unit (PACU) discharges, but transport time through when the transporter returns consumes porter resources. METHODS: Epic’s Rover was implemented to track all PACU transports, 22,846 from July 2022 through April 2024. Destinations were grouped based on distance traveled. Transport counts and total times were calculated by 4-hour period and day of the week. χ2 and Kruskal-Wallis tests were used for inference. Number of staff starting shifts, transports per transporter per hour, and transport time per transporter per 4-hour period were determined, with χ2 and Kruskal-Wallis tests for inference. Bland-Altman plots compared (i) total transport time for each day and 4-hour period with (ii) estimates from the product of PACU discharges and the overall mean time per transport. Delayed transports were identified and evaluated for successive delays. Standardized normal probability plots and Shapiro-Wilk tests of normality were used to examine the probability distribution of total transport time among workday for 4-hour periods. RESULTS: Transports to the phase II recovery were faster than to other common transport destinations (all adjusted P ≤ .0001). Number of transports and total hours of transport time differed among 4-hour periods and destination categories (all P < .0001). Weekday was inconsequential. Approximately half of all 4-hour periods had ≥1 delay, and runs of delays were significant (P < .0001). Prediction of transport workload using the count of transports for each combination of day and 4-hour period multiplied by the overall mean time per transport proved insufficient, differing from actual time by −1.04 to +1.05 hours per 4-hour period. Total hours of transport time per 4-hour period were normally distributed for the busiest 2 periods (Shapiro-Wilk W > 0.99), allowing the mean plus the standard deviation to be used to choose the number of transporters needed for each period. CONCLUSIONS: PACU transport times differed significantly among destinations. Therefore, when >1 patient is waiting for transport, target the patient who will have the briefest transport, especially if to the phase II PACU. Approximation of transport workload based on the distribution of PACU discharges by time of day is insufficient for accurate staffing. Instead, rely on the mean and standard deviation of the workday’s total transport times during the period.]]> Tue, 04 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01210 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/early_postoperative_intravenous_iron_versus_oral.1203.aspx BACKGROUND: Postoperative anemia is a common complication after cardiac surgery, often persisting for months and substantially affecting patient recovery. Despite its prevalence, optimal treatment strategies are lacking. We aimed to evaluate whether early postoperative intravenous (IV) iron is more effective than daily oral iron in correcting anemia after cardiac surgery. METHODS: This single-center, pragmatic randomized controlled trial enrolled 110 cardiac surgery patients with moderate postoperative anemia (hemoglobin 8–11 g/dL). Participants were randomized 1:1 to receive either a single infusion of 20 mg/kg ferric derisomaltose on postoperative day 1 (IV iron group, n = 57) or 100 mg oral ferrous sulfate twice daily for 4 weeks (oral iron group, n = 53). All outcomes were assessed at 4 weeks postrandomization. The primary composite outcome aimed to measure treatment success, defined as the proportion of participants who were (a) no longer anemic (per World Health Organization criteria) and (b) neither had received allogeneic red blood cell (RBC) transfusions after randomization. Secondary end points included differences in hemoglobin levels, RBC transfusion rates, iron metrics, 6-minute walk test distances, hospital length of stay, and patient-reported outcomes. RESULTS: Primary outcome data were available for 53 participants in the IV iron group and 51 in the oral iron group. The proportion of participants who achieved the primary end point did not differ significantly between groups (28% vs 16%; risk difference 13%, 95% confidence interval [CI], −3% to 28%; P = .121). No statistically significant differences were observed in anemia prevalence (66% vs 82%; P = .058) or RBC transfusion rates (17% vs 33%; P = .054). Mean hemoglobin levels (± standard deviation) were higher in the IV iron group (12.0 ± 1.1 g/dL vs 11.4 ± 1.3 g/dL; P = .013). None of the participants in the IV iron group had ferritin levels <100 µg/L, compared to 26% in the oral iron group (P < .001, accounting for 95% CI for 0 numerators). No significant differences were observed in the 6-minute walk test, hospital length of stay, or patient-reported outcomes. Notably, no serious adverse events related to ferric derisomaltose were reported. CONCLUSIONS: Early postoperative IV iron did not demonstrate superiority over oral iron for the primary outcome. However, secondary end points suggest it may improve hemoglobin levels and reduce the prevalence of postoperative iron deficiency. These findings warrant further investigation in larger trials to confirm the clinical effectiveness of early postoperative IV iron.]]> Mon, 03 Mar 2025 00:00:00 GMT-06:00 00000539-990000000-01203 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_probability_distribution_of_times_to_awakening.1204.aspx BACKGROUND: Human studies of awakening from general anesthesia inform understanding of neural mechanisms underlying recovery of consciousness. Probability distributions of times for emergence from anesthesia provide mechanistic information on whether putative biological models are generalizable. Previously reported distributions involved nonhomogenous groups, unsuitable for scientific comparisons. We used a retrospective cohort to identify surgeon-procedure combinations of homogeneous groups of patients and anesthetics to assess the probability distribution of extubation times to inform scientific studies of awakening from anesthesia. We hypothesized an acceptable fit to a log-normal distribution. METHODS: Extubation times were recorded by anesthesia practitioners using an event button in the electronic health record. From 2011 through 2023, there were 182,374 cases with general anesthesia, not positioned prone, tracheal intubation after operating room entrance, interval from start to end of surgery ≥1 hour, and inhalational agent mean minimum alveolar concentration (MAC) fraction measured from case start through surgery end ≥0.6. We applied joint criteria of the same primary surgeon, surgical procedure, MAC fraction of each inhalational agent in 0.1 increments, and binary categories of adult, trainee finishing the anesthetic, bispectral index (BIS) monitor, N2O, sugammadex, and neostigmine. We considered all combinations of categories with ≥40 cases. We used Gas Man simulation to infer the probability distribution of volatile agent concentrations in the vessel-rich group (ie, brain). RESULTS: There were 48 cases among patients having oral surgery extractions by 1 surgeon, without anesthesia trainees, sevoflurane anesthesia with 0.3 MAC fraction at surgery end, without N2O, BIS monitor, or neuromuscular block reversal. Their extubation times followed a log-normal distribution (Shapiro-Wilk W = 0.98, P = .68). For the computer simulations, we assumed that patients differed solely in their binary threshold of vessel-rich group sevoflurane concentration at awakening (eg, patients with an awakening threshold of 0.26% would be unconscious for 0.1 to 14.8 minutes as sevoflurane is exhaled but the concentration remains ≥0.26%, and abruptly transition to consciousness at 15 minutes when the concentration reaches 0.25%). Expected awakening times would appear to be a log-normal distribution. CONCLUSIONS: A homogeneous patient population had a log-normal distribution of extubation times. Generalizable models of awakening should have that distribution. Clinicians change awakening times by their choice of agent and its MAC fraction at surgery end. Simulation suggests that the normal distribution in the log time scale for awakening, among patients with similar conditions, can represent a relatively uniform distribution among patients in the vessel-rich group (brain) partial pressure when the abrupt transition to consciousness occurs.]]> Fri, 28 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01204 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/inclusive_pathways_in_anesthesiology__addressing.1206.aspx No abstract available]]> Fri, 28 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01206 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/design_and_staged_implementation_of_a.1201.aspx BACKGROUND: Preoperative anemia is common and associated with adverse outcomes in surgical patients. There is limited information to guide the design and implementation of preoperative anemia clinics (PAC), which represents a critical barrier to entry for many practices. METHODS: This is a descriptive observational study highlighting the design and implementation of a multidisciplinary PAC, including key steps in planning, stakeholder engagement, organizational structure, identification of target populations, establishing anemia treatments, information technology and electronic health record integration, provider training, and data infrastructure. Demographic and clinical characteristics, laboratory results, and anemia treatments for individuals evaluated in the PAC from November 4, 2019 through September 15, 2023 are enumerated. Patient-reported outcomes (PROs) assessing changes in anemia symptoms and well-being after surgery are evaluated for 2 subsets of patients (one before PAC implementation [pre-PAC], another after PAC implementation [post-PAC]), without formal statistical comparison given limited sample sizes. RESULTS: The PAC was initiated as a multidisciplinary effort under support from a Mayo Clinic Practice Transformation Award in 2019, including broad representation from anesthesiology, surgery, and medical practices, along with institutional project management support (eg, project manager, information technologists, systems engineers). While initially limited to cardiac surgery patients, the PAC underwent planned incremental expansion to include other surgical services. Over the study period, 1188 PAC consultations across 1159 unique patients met eligibility criteria, with a median age of 66 (57–73) years and 58.1% women. The most common etiology of anemia was iron deficiency (69.1%) followed by anemia related to cancer (17.3%). Anemia-directed therapies were recommended in 1038 (87.4%) encounters, with 730 (70.3%) of those receiving recommended treatment preoperatively. Seven hundred nine (97.1%) treatments included intravenous iron and 146 (20.0%) included erythropoiesis-stimulating agents. Fifteen pre-PAC and 38 post-PAC implementation patients completed PROs. PAC implementation was accompanied by earlier resolution of anemia symptoms and less pronounced declines in postoperative well-being scores. CONCLUSIONS: This report highlights the key steps for successful PAC implementation. Treatment is possible for most patients and may be accompanied by improvements in patient-important outcomes.]]> Thu, 27 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01201 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_current_state_of_pediatric_cardiac.1202.aspx BACKGROUND: The population of patients with congenital heart disease has grown, but the supply of pediatric cardiac anesthesiologists has not kept pace. The Pediatric Anesthesia Leadership Council (PALC) and the Congenital Cardiac Anesthesia Society (CCAS) formed a task force to evaluate the current state of the specialty of pediatric cardiac anesthesia, including staffing, work environment, education, compensation, and career development. METHODS: Five task force working groups developed survey questions that explored 5 different aspects of a pediatric cardiac anesthesiologist’s career. Surveys were completed by CCAS member faculty volunteers, division chiefs/directors of pediatric cardiac anesthesia programs, program directors of pediatric cardiac anesthesia fellowships, and fellowship graduates from the past 10 years. RESULTS: Survey completion rates were 77% (n = 86) for CCAS faculty, 52% (n = 58) for pediatric cardiac anesthesiology directors/division chiefs, 91% (n = 21) for pediatric cardiac anesthesiology fellowship directors, and 53% (n = 65) for 2013–2022 pediatric cardiac anesthesia fellowship graduates. Of CCAS faculty respondents, 31.4% (n = 27) are considering leaving pediatric cardiac anesthesia for a less stressful field. While most respondents reported being involved in academic activities, 34% (n = 29) do not receive nonclinical time. Only 35.3% (n = 30) of respondents receive formal mentorship and 44.7% (n = 38) of participants have been sponsored for leadership positions, research opportunities, or speaking engagements. The total number of anticipated hires in the next 5 years is 129; that number goes up to 194 in 10 years. The challenge in hiring was graded as 8/10 with 10 being the most challenging. CONCLUSIONS: This survey provides important data about the current state of pediatric cardiac anesthesiology and the need to address staffing and academic support. With nearly one-third of those practicing in the field considering leaving the pediatric cardiac subspecialty and with the decreasing number of fellows per year, there is a significant cause for concern for staffing, especially when the demand for practitioners in this field is increasing. In addition, even though the majority of faculty reported being involved in academic activities, many do not receive academic time for these activities and less than half receive formal mentorship or have been sponsored for leadership positions, publications, research opportunities, or speaking engagements. Further work to recruit, retain, and develop pediatric cardiac anesthesiologists is warranted.]]> Thu, 27 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01202 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_power_of_education_to_reduce_the_carbon.1194.aspx BACKGROUND: Due to their chemical nature as fluorinated hydrocarbon compounds, volatile anesthetics are highly potent greenhouse gases, with desflurane having by far the largest CO2-equivalent (CO2e) footprint. In everyday clinical practice, the CO2e footprint can easily be reduced through the increased use of propofol or sevoflurane as well as low- and minimal-flow techniques or through the more frequent use of regional anesthesia techniques. We wanted to assess to what extent educational measures on sustainability aspects of the use of volatile anesthetics had an impact on daily practice in anesthesiology departments and to what extent this influenced the hospital’s CO2e emissions. METHODS: We conducted an observational data analysis of the consumption of anesthetics (sevoflurane, desflurane, isoflurane, and propofol) at all 3 clinical Charité campuses in the period from 2015 to 2023. The CO2e emissions were calculated for sevoflurane, desflurane, and isoflurane. External and internal (top-down or bottom-up) educational measures focusing on sustainability in anesthesia took place from September 2018 on. Shifts in CO2e emissions related to the educational measures are shown in a run chart. The number of surgeries, surgery duration, and purchasing costs were included in the analysis. RESULTS: CO2e emissions of volatile anesthetics were reduced by 90.3% from the baseline epoch (years 2015–2017) before educational interventions took place to 2023: CO2e 1470 tons (mean 2015–2017), to 191 tons (2022) to 142 tons (2023). This change was brought about by the phasing out of desflurane and the use of propofol or sevoflurane and regional anesthesia where appropriate. The fastest and most sustainable changes were seen after internal top-down measures. The total cost of anesthetics also fell over the period under review (from €541,102/$594,238 in 2015 to €281,646/$309,303 in 2023). CONCLUSIONS: Educational measures for anesthesiologists about the climate-damaging effects of volatile anesthetics—especially desflurane—can significantly reduce CO2e emissions in anesthesia clinics. On the positive side, these measures have also reduced the annual costs for anesthetics.]]> Tue, 25 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01194 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/society_of_anesthesia_and_sleep_medicine_opinion.1195.aspx No abstract available]]> Tue, 25 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01195 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_survey_of_practice_and_attitudes_toward__do_not.1196.aspx No abstract available]]> Tue, 25 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01196 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_pilot_study_of_remimazolam_during_neuraxial.1198.aspx No abstract available]]> Tue, 25 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01198 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/interpretation_of_viscoelastic_hemostatic_assays.1113.aspx BACKGROUND: Rotational thromboelastometry (ROTEM) is widely used for point-of-care coagulation testing to reduce blood transfusions. Accurate interpretation of ROTEM data is crucial and requires substantial training. This study investigates the inter- and intrarater reliability of ROTEM interpretation among experts and compares their interpretations with a ROTEM-guided algorithm. METHODS: This study was conducted at Amsterdam University Medical Center and included 90 cardiac surgery patients. ROTEM data were collected at 4 surgical stages: before induction, after aortic declamping, postcoagulation correction, and within 2 hours of intensive care unit (ICU) admission. An international panel of 7 cardiovascular anesthesiologists and one intensivist interpreted the data. Interrater reliability was assessed using Fleiss’ kappa for binary decisions and the simple matching coefficient (SMC) for multiple-choice questions. Intrarater reliability with the ROTEM-guided algorithm was also evaluated. RESULTS: Three hundred forty-three ROTEM measurements were analyzed. The interrater reliability for binary decisions was substantial to almost perfect, except after declamping (Fleiss’ kappa = 0.34). The SMC for determining type of abnormality and interventions ranged from good to excellent across all ROTEM measuring moments (SMC ≥0.75). Intrarater reliability was almost perfect for binary questions (intraclass correlation coefficient [ICC] ≥0.81) and showed excellent agreement for multiple-choice questions. Comparing expert recommendations with the algorithm resulted in an average SMC of 0.70 indicating differences in intervention recommendations, with experts frequently recommending fibrinogen and protamine over the algorithm’s suggestions of plasma and PCC. CONCLUSIONS: This study demonstrates high inter- and intrarater reliability in ROTEM interpretation among trained professionals in cardiac surgery, with almost perfect agreement on abnormalities and interventions. However, differences between expert evaluations and the ROTEM-guided algorithm underscore the need for advanced clinical decision-making tools. Future efforts should focus on developing personalized, data-driven algorithms without predefined cutoff values to improve accuracy and patient outcomes.]]> Wed, 19 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01113 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/brain_structural_and_functional_changes_associated.1186.aspx Postoperative neurocognitive disorders (PNDs) are frequent and serious perioperative complications in the elderly, and are associated with increased morbidity and mortality, length of hospital stay, and need for long-term care. At present, the pathogenesis of PND is not completely clear, and there are various risk factors including surgical trauma and stress mediating systemic inflammation towards neuroinflammation development which causes brain structural and functional changes namely PND. For elderly patients, perioperative neurological monitoring may provide insights into brain function status. Monitoring may also help clinicians identify potential risks which would ultimately allow timely and effective intervention for better perioperative safety and prognosis for elderly patients. In this review, we summarize the risk factors and potential mechanisms of PND, and discuss preliminary evidence regarding application of electroencephalography, functional near-infrared spectroscopy, functional magnetic resonance, and positron emission tomography imaging in monitoring the central nervous system during the postoperative period.]]> Wed, 19 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01186 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/noninvasive_measurement_of_lung_function_using_the.1188.aspx No abstract available]]> Wed, 19 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01188 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/effect_of_painful_stimuli_on_pvncrh_neurons_.1177.aspx BACKGROUND: Many patients undergoing surgery experience accompanying pain symptoms preoperatively. The impact of painful stimuli on general anesthesia remains largely unknown. Corticotrophin-releasing hormone neurons in the paraventricular nucleus of the hypothalamus (PVNCRH neurons) are crucial central stress hubs that respond to painful stimuli. These neurons also participate in regulating processes such as sleep and anesthesia. Natural reward can inhibit PVNCRH neurons to relieve stress-induced behavioral changes, but the effect of natural reward on the anesthesia process in patients with pain is not clear. In this study, we assessed the impact of painful stimuli on isoflurane anesthesia and its potential neural mechanism. We also investigated the potential of natural reward therapy for alleviating the impact of painful stimuli on isoflurane anesthesia. METHODS: The righting reflex test and cortical electroencephalography (EEG) were used as measures of consciousness in complete Freund’s adjuvant (CFA)-injected mice during isoflurane anesthesia. EEG and burst-suppression ratios (BSR) were used to assess the depth of anesthesia. The expression of c-Fos, fiber photometry recording, and brain slice electrophysiology were used to determine neuronal activity changes in PVNCRH neurons after CFA injection or 10% sucrose treatment. Finally, chemogenetic technology was used to specifically manipulate PVNCRH neurons. RESULTS: Compared to the saline-injected mice, the CFA-injected mice exhibited an increased the mean[SD] induction time of isoflurane anesthesia (354[48] s vs 258[30] s, P = .0001) and a reduced BSR of isoflurane anesthesia (60.1[10.3] % vs 81.5[9.76] %, P = .002). CFA injection increased PVN c-Fos expression (3667[706] vs 1735[407], P = .0002) and enhanced the population activity of PVNCRH neurons (33.4[13.6] % vs 1.23[3.57] %, P = .0009). Chemogenetic suppression of PVNCRH neurons reversed the anesthesia abnormalities in CFA-injected mice. Natural reward accelerated the induction time of isoflurane anesthesia (252[24] s vs 324[36] s, P = .003) and increased the BSR of isoflurane anesthesia (84.8[5.36] % vs 57.7[14.3] %, P = .0005). Chemogenetic activation of PVNCRH neurons reversed the effect of natural reward on isoflurane anesthesia in CFA-injected mice. CONCLUSIONS: Painful stimuli affect the process of isoflurane anesthesia by activating PVNCRH neurons, which implies that these neurons modulate isoflurane anesthesia. Additionally, natural reward alleviates the impact of painful stimuli on isoflurane anesthesia by inhibiting PVNCRH neurons.]]> Tue, 18 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01177 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_new_mouse_model_for_exploring_tranexamic.1179.aspx BACKGROUND: Tranexamic acid (TXA) plays a central role in antifibrinolytic strategies, raising intense concerns regarding TXA-associated seizures. The aim of the study was to develop an in vivo TXA-induced seizure (TIS) model and identify its features on behavior, electroencephalograph (EEG), histology, and metabolomics. METHODS: Adult healthy male C57BL/6J mice (n = 42) were randomized into 7 dosage groups to receive intracerebroventricular injection of TXA (vehicle, 1, 5, 7.5, 10, 25, 50 μg/μL, n = 6 each). The dose titration was based on behavioral observation according to the Racine scale. Further, continuous video-EEG was performed in another 8 TIS mice and 5 control mice with the stereotaxic implantation of electrodes and guide cannulas. Then hippocampus samples were obtained from an additional 10 TIS mice and 9 control mice for histological evaluation and metabolomic analysis. RESULTS: Behavioral observation revealed a dose-dependent relationship between the intensity of seizures and the intraventricular gradient of the agent. A dose of 2 μL 7.5 μg/μL TXA i.c.v. was confirmed as the target scheme to establish the model with intense behavioral seizures and typical spike epileptic EEG discharges. Histological exploration illustrated necrosis and loss of neurons as well as loss of Nissl granules in the CA3 area of the hippocampus. Additionally, metabolomic analysis revealed a variety of disturbed metabolic pathways related to seizures including amino acid, energy, antioxidant stress metabolism, and nerve signal regulation. CONCLUSIONS: The study provided an in vivo mouse TIS model with specific features on behavioral seizures, EEG discharges, histological findings, and metabolomic pathways.]]> Tue, 18 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01179 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/analgesic_efficacy_of_repeated_daily_injections.1181.aspx BACKGROUND: Total knee arthroplasty is frequently associated with postoperative pain. Continuous adductor canal blocks are widely used for postoperative analgesia. However, the high dislocation rate of nerve block catheters often leads to ineffective pain control. This study aimed to compare the analgesic effectiveness of repeated daily injections of adductor canal block up to postoperative day (POD) 2 and continuous adductor canal block in patients who underwent total knee arthroplasty. METHODS: Seventy-six patients who underwent total knee arthroplasty under spinal anesthesia were randomized to receive repeated daily adductor canal blocks at the end of surgery and in the morning of POD1 and POD2 (n = 39) or continuous adductor canal block with a patient-controlled bolus (n = 37). All patients received perioperative multimodal analgesia. The primary outcome was the time-weighted average numeric rating scale pain score at rest, measured from the end of surgery to 14:00 on POD2. Pain scores over time were also compared using generalized estimating equations. RESULTS: There was no significant difference in the time-weighted average pain score at rest (from POD0 to POD2) between the repeated injection group (2.9 ± 1.9) and the continuous group (3.1 ± 2.1; mean difference 0.09, 95% confidence interval [CI], −0.81 to 0.99; P = .842). Repeated daily injections did not reduce pain at rest or pain during movement after adjusting for time. In the continuous group, the cumulative occurrence of nerve block catheter dislocation was 48.6% (18/37) on POD1 and 62.2% (23/37) on POD2, as assessed using ultrasonography. CONCLUSIONS: This study was unable to determine whether repeated daily injections or continuous adductor canal block provided superior analgesia in terms of the average pain score during the first 2 days after total knee arthroplasty. However, considering the high dislocation rate of nerve block catheters, reducing catheter dislodgement may improve the analgesic effectiveness of continuous adductor canal blocks.]]> Tue, 18 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01181 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/data_driven_change_starts_with_data.1170.aspx No abstract available]]> Thu, 13 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01170 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/global_burden_of_complex_regional_pain_syndrome_in.1163.aspx BACKGROUND: Complex regional pain syndrome (CRPS) is a debilitating and painful condition accompanied by sensory, autonomic, trophic, and/or motor abnormalities. Although CRPS is rare in the general population, the prevalence among individuals at higher risk, particularly posttraumatic and postsurgical patients, remains unknown. This study aims to provide a benchmark that quantifies CRPS prevalence in high-risk groups, and offers insights on potential predictors of developing CRPS. METHODS: We conducted a systematic review and meta-analysis to identify studies reporting prevalence of CRPS after an inciting event (eg, fracture, surgery), specifically 12-month and 24-month prevalence (primary outcomes), as well as 3-month and 6-month prevalence (secondary outcomes). Estimates from individual studies were transformed using double-arcsine transformation, and the resulting estimates with 95% confidence interval (CI) were pooled in a meta-analysis using a random-effects model. RESULTS: We included 214 articles with data from 2491,378 participants worldwide (35 countries), of which 16,873 had CRPS. The pooled 12-month and 24-month global prevalence was 3.04% (95% CI, 2.64–3.48) and 6.46% (95% CI, 5.46–7.53), respectively. Subgroup analysis and meta-regression were performed to understand the impact of population-dependent (mechanism of injury, type of CRPS), contextual-dependent (socioeconomic status), and methodological-dependent (study design, publication year) factors. The 12-month prevalence was higher in countries with a high human development index (HDI) compared to those with a medium or very high HDI, was higher in participants with a traumatic inciting injury only versus those with surgical injury only or traumatic/surgical injury, and was higher in prospective versus retrospective studies. Meta-regression analysis showed that publication year was a significant moderator, with more recent articles reporting lower 12-month prevalence. CONCLUSIONS: This study provides a benchmark of the global prevalence of CRPS, which anesthesiologists and pain specialists can use to prioritize early diagnosis and identify those at the highest risk for CRPS.]]> Tue, 11 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01163 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/thinking_of_obstructive_sleep_apnea_in_the_causal.1157.aspx No abstract available]]> Fri, 07 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01157 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/checklists,_mnemonics,_and_the_avoidance_of.1159.aspx No abstract available]]> Fri, 07 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01159 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/requesting_a_seat_at_the_table__fibrin_stabilizing.1160.aspx No abstract available]]> Fri, 07 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01160 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_impact_of_program_and_geographic_signaling_on.1162.aspx BACKGROUND: Increased specialty competitiveness, alongside the inception of virtual interviews, has increased the number of applications submitted to the Electronic Residency Application Service (ERAS) in anesthesiology. ERAS introduced signals to provide applicants with a means to demonstrate interest in a select group of residency programs. In the 2023 to 2024 application cycle, anesthesiology applicants had the opportunity to send 5 gold and 10 silver signals in a tiered system. METHODS: This multicenter, cross-sectional (exempt) research survey was created by members of the executive council of the Association of Anesthesiology Core Program Directors (AACPD) and housed and distributed through REDCap and the University of Nebraska Medical Center. Publicly available contact information of anesthesiology core program directors was obtained from the Accreditation Council for Graduate Medical Education (ACGME) website and membership roster of the AACPD. In total, 174 anesthesiology programs were identified. A survey invitation was distributed on March 12, 2024, to all programs via e-mail with reminders. The survey closed on April 30, 2024. Survey responses were collected anonymously, with instructions to provide 1 response per program. All statistical summaries and analyses were performed using SAS 9.3 (SAS Institute). RESULTS: The survey was sent to all 174 identified programs, with a response rate of 48.9%. Small programs were defined as having <44 residents, medium 44 to 62 residents, and large >62 residents. Small programs received significantly fewer applications (median 1255) than medium (1420) and large (1558) programs (P = .0005). There was a statistically significant difference in the number of gold signals received based on program size, with large programs receiving significantly more than medium (169 vs 116, P = .0238) or small programs (168 vs 71, P < .0001). Applicants sending gold signals were more likely to receive an interview compared to those who sent silver signals (56.7% vs 31%, P ≤ .0001). Of the those interviewed, applicants who sent gold signals comprised 42% (28.7%–52.6%), whereas applicants who sent silver signals comprised 45.5% (33%–54.7%). Applicants who did not send a program signal but signaled geographically made up a smaller portion of the interview group at 3% (0%–15.4%). The percentage of matched residents sending gold signals made up 66.7% (47.1%–82.4%) of a program’s match list, whereas those sending silver signals were 25% (11.1%–33.3%) of the matched cohort. CONCLUSIONS: Anesthesiology applicants who sent program signals were selected for a large majority of available interview positions, and interviewed applicants who submitted gold and silver signals comprised the vast majority of matched resident cohorts.]]> Fri, 07 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01162 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/epidemiological_investigation_of_unplanned.1148.aspx BACKGROUND: Over 75% of surgeries worldwide are elective and unplanned ICU admissions after these surgeries pose a major—albeit rare—challenge. However, few epidemiological studies have focused on patients requiring unplanned ICU admission directly from the operating room after elective surgeries are lacking. This study uses the Japanese Intensive Care Patient Database (JIPAD) to describe unplanned ICU admissions after elective surgeries. METHODS: We conducted a multicenter retrospective cohort study using data from the JIPAD from April 2015 to March 2022, focusing on patients with unplanned ICU admissions after elective surgery. Collected variables included patient characteristics, treatments, outcomes, reasons for ICU admission, and type of surgery. We categorized the reasons for ICU admission into 9 types: anaphylaxis, hemorrhage, anesthesia-related complications, respiratory-related complications, cardiovascular-related complications, neurological-related complications, surgical-related complications, electrolyte/acid-base abnormalities, and unknown causes. The type of surgery was classified using JIPAD definitions. RESULTS: Among 141,969 patients in the JIPAD who underwent elective surgery, 2666 patients (1.9%) required an unplanned ICU admission. Cardiac arrest before ICU admission occurred in 52 patients (2.0%), the median APACHE III score was 51, and 1218 patients (45.7%) required postoperative mechanical ventilation. The median hospital stay for patients with unplanned ICU admission was 21 days and in-hospital mortality was 3.3% (88/2666). The most common reason for ICU admission was respiratory complications (n = 440, 16.5%), followed by hemorrhage (n = 377, 14.1%). Cardiovascular-related complications had the highest in-hospital mortality at 6.8% (20/294). Hospital mortality exceeded ICU mortality, suggesting that patients expected to derive limited benefit from intensive care may have been transitioned out of the ICU to accommodate other patients with greater need. The most frequent surgeries requiring unplanned ICU admission were for gastrointestinal neoplasms (n = 464, 17.4%), followed by orthopedic surgeries (n = 303, 11.4%). Anaphylaxis occurred across a broad spectrum of surgeries. Respiratory-related complications were common in patients with other respiratory diseases and accounted for over half of the total number of cases according to surgery type. Neurological-related complications were most frequent in craniotomies for neoplasms. CONCLUSIONS: In our review of a nationwide ICU database from 2015 to 2022 we identified a 1.9% rate of unplanned ICU admission and found that mortality varied according to the reasons for ICU admission. Respiratory-related complications were most common, and cardiovascular complications were most associated with in-hospital mortality. Further research may help us to better understand the epidemiology of unplanned ICU admission after surgery.]]> Wed, 05 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01148 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/effect_of_low_dose_ketamine_infusion_in_the.1149.aspx BACKGROUND: Low-dose ketamine may have an opioid-sparing effect in critically ill patients but may also predispose them to traumatic memories. We evaluated the effects of low-dose ketamine infusion in the intensive care unit (ICU) on fentanyl consumption and traumatic memories after hospital discharge. METHODS: This randomized, double-blind, controlled trial was conducted at a university-based surgical ICU. 118 adult patients who were admitted to the ICU after noncardiac, nonneuro, nontrauma surgery between March 2019 and May 2021 were randomized to receive ketamine 1.5 µg/kg/min (n = 60) or placebo (n = 58). Fentanyl was given to achieve pain control (10-point numerical rating scale pain score [NRS] < 4) and sedation control (Richmond Agitation and Sedation Scale [RASS] level between −2 and 0). A secondary study was conducted by a telephone interview after ICU discharge using the Thai version of the posttraumatic stress disorder (PTSD) questionnaire to evaluate signs and symptoms of PTSD and traumatic memories to the time spent in the ICU. RESULTS: 24-hour fentanyl consumption was lower in patients who received ketamine compared with placebo (399 µg [95% confidence interval {CI}, 345–454] vs 468 µg [95% CI, 412–523], difference −68 µg; 95% CI, −67 to −69; P = .041); RASS and NRS scores did not differ between the 2 groups. Exploratory effect modification analysis suggested that the opioid-sparing effect of ketamine may be more relevant in patients with intraabdominal surgery (P-for-interaction = 0.012, difference, −177 µg; 95% CI, −204 to −149 µg; P = .001). No acute adverse effects of ketamine were observed. The secondary study included the information from 91 patients from the primary study. Long-term follow-up data was available for 45 patients (23 in the control group, 22 in the ketamine group), and the evaluations were taken 43 ± 8 months after ICU discharge. In this secondary study, ketamine use was associated with a higher incidence of frightening and delusional memories of critical illness and ICU treatment (65% vs 41%, P = .035). CONCLUSIONS: Low-dose ketamine is associated with a small but statistically significant reduction (15%) of postoperative opioid consumption in the ICU. Our secondary study revealed that patients who received low-dose ketamine during fentanyl-based postoperative pain therapy in the ICU recalled more frightening and delusional memories after ICU discharge.]]> Wed, 05 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01149 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/opioid_preconditioning_in_heart_failure__new.1152.aspx No abstract available]]> Wed, 05 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01152 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/association_of_intraoperative_occult_hypoxemia.1143.aspx BACKGROUND: Despite the widespread use of pulse oximetry for intraoperative estimation of arterial oxygen saturation, there is growing evidence that certain patient populations may be vulnerable to inaccurate pulse oximetry measurements and that unrecognized hypoxemia is associated with end-organ damage and adverse outcomes. In this single-center retrospective cohort study, we sought to better elucidate the relationship between intraoperative occult hypoxemia and postoperative mortality among patients undergoing anesthesia and surgery. METHODS: Data were collected from our departmental data warehouse for adult patients (≥18 years) undergoing anesthesia between 2008 and 2019 with at least 1 intraoperative arterial blood gas recorded. The number of occult hypoxemic events, defined as arterial oxygen saturation (Sao2) of <88% despite oxygen saturation measured by pulse oximetry (Spo2) >92%, were determined. Mortality data were obtained from the Social Security Death Master File and used to determine 30-day and 1-year postoperative mortality. Propensity score overlap-weighted Firth logistic regression and Cox proportional-hazard modeling were performed to analyze whether at least 1 occult hypoxemic event was predictive of 30-day and 1-year mortality. RESULTS: There were 25,234 patients and 62,707 paired readings included in the final analysis. There were 351 patients (1.4%) with at least 1 occult hypoxemic reading. The overall 30-day mortality rate was 3.3% and 1-year mortality rate was 10.2%. In the overlap-weighted models, patients who experienced at least 1 occult hypoxemic event had significantly higher odds of both 30-day mortality (odds ratio [OR] = 2.89, 95% confidence interval [CI], 1.46–5.72, P = .002) and 1-year mortality (hazard ratio [HR] = 1.90, CI, 1.48–2.43, P < .001). There was no significant interaction between occult hypoxemia and self-reported race/ethnicity for predicting mortality. CONCLUSIONS: Intraoperative occult hypoxemic events are associated with significantly higher odds of 30-day and 1-year mortality, independent of self-reported race/ethnicity.]]> Tue, 04 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01143 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/anesthetic_management_of_parturients_with.1144.aspx Achondroplasia accounts for approximately 70% of all forms of dwarfism. Cesarean delivery is often required in parturients with achondroplasia due to cephalopelvic disproportion. There is no consensus on the optimal management for cesarean delivery considering the difficulties in both general and regional anesthesia in patients with achondroplasia. The aim of this study was to explore the literature for prior case reports and series to determine the optimum anesthetic management for cesarean delivery in achondroplastic patients. We conducted a review of the literature using Embase, Medline, Scopus, and Web of Science database searches for case series and case reports on achondroplasia and pregnancy through January 2024. Conference abstracts >3 years old were excluded, as well as data on forms of dwarfism other than achondroplasia, patients taller than 147 cm, and non-English language papers. Extracted data included demographic information, anesthetic management, and reported complications. The literature review resulted in 57 manuscripts with a total of 80 anesthetics. Anesthetic management consisted of planned general anesthesia (n = 16), single injection spinal (n = 28), epidural (n = 17), combined spinal-epidural (n = 12), and intrathecal catheter (n = 1). Six patients required conversion from neuraxial anesthesia to general anesthesia due to failed neuraxial placement (n = 3), inadequate blockade (n = 2), and high neuraxial block (n = 1). Reduced dose of intrathecal bupivacaine was common in this population. Complications such as hypotension (4 in 64), inadvertent dural puncture (1 in 64), and transient paresthesia (3 in 64) during neuraxial technique were reported but were infrequent. Neuraxial anesthesia is more common and a viable option in carefully selected parturients with achondroplasia. We recommend reduction of intrathecal local anesthetic as part of a titratable neuraxial technique (ie, combined spinal-epidural) that minimizes the risk of hypotension, high spinal, and emergent intubation.]]> Tue, 04 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01144 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/fibrinogen_replacement_in_neonatal_cardiac.1145.aspx No abstract available]]> Tue, 04 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01145 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/fibrinogen_dose_variability_in_cardiac_surgery.1141.aspx No abstract available]]> Mon, 03 Feb 2025 00:00:00 GMT-06:00 00000539-990000000-01141 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/preoperative_psychological_factors,_postoperative.1139.aspx BACKGROUND: Acute orthopedic injuries and subsequent surgical repair can be challenging for children and adolescents and result in posttraumatic stress reactions that can be problematic after the acute perioperative period. In a cohort of patients undergoing anterior cruciate ligament reconstruction (ACLR), we investigated the incidence and explored risk factors associated with the development of posttraumatic stress disorder (PTSD) symptoms after surgery. METHODS: We analyzed data from a multicenter, prospective, observational registry of pediatric patients undergoing ACLR. Patient data included demographic, psychological assessments, postoperative pain measures, and a posttraumatic stress disorder assessment (Child PTSD Symptom Scale [CPSS]) collected after the operation. An analysis of patients who provided survey data at 6 months was used to determine the incidence of posttraumatic stress reactions and to explore associated risk factors. RESULTS: A total of 519 patients were enrolled in a prospective observational study of outcomes after ACLR. A cohort of 226 patients (44%) provided completed data collection and CPSS follow-up surveys at 6 months. We found that 17 of the patients (7.5%) met the criteria for PTSD at 6 months which represents 3.3% of our total study population (17/519). A univariate analysis suggested that a negative (P = .017), excitable (P = .039), or inhibitory (P = .043) temperament compared to a positive temperament, high preoperative scores for anxiety (P = .001) or depression (P = .019) and high pain scores on postoperative day (POD)1 (P = .02) increased the odds of PTSD at 6 months. A multivariable model revealed that patients self-reporting symptoms consistent with clinical anxiety/depression preoperatively and patients with a max pain score ≥7 on POD1 were 29 times (P = .018) and 9.8 times (P = .018) more likely to develop PTSD at 6 months. CONCLUSIONS: A portion of patients undergoing ACLR are at risk for the development of symptoms consistent with PTSD. Risk factors include preoperative anxiety or depression and high postoperative pain scores. Interventions designed to address preoperative risk factors and optimization of postoperative pain may represent opportunities to improve outcomes in this patient population.]]> Fri, 31 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01139 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/regional_anesthesia_and_pain_outcomes_after.1133.aspx BACKGROUND: Optimal perioperative pain management is unknown for adolescent patients undergoing anterior cruciate ligament reconstruction (ACLR). The study aimed to determine the association of nerve blocks with short- and long-term pain outcomes and factors influencing self-reported neurological symptoms. METHODS: We performed a multisite, prospective observational study of adolescent patients undergoing ACLR. Perioperative data included demographics, block details, anesthetic, and surgical techniques. Self-reported surveys documented pain scores, medication use, and neurological symptoms at various time points after the surgery (postoperative day [POD] 1, POD 3, week 6, and month 6). Associations between different groups of peripheral nerve blocks (PNBs) and the absence of a block were analyzed for their effects on acute postoperative pain outcomes. In addition, factors influencing self-reported neurological outcomes were determined using both univariate and multivariate regression. RESULTS: Data from 519 subjects (aged 15 years, 55.7% female) showed that 23.9% of patients with anterior plus posterior nerve blocks (A+P PNB) reported severe postanesthesia care unit (PACU) pain scores, compared to 40% with no PNB and 38.3% with anterior PNB (A-PNB). Patients receiving A-PNB or A+P PNB had significantly lower intraoperative morphine equivalents (MEs) (0.49 mg/kg and 0.46 mg/kg, respectively) vs no block patients (0.61 mg/kg). Total PACU MEs were lower for any patient who received a PNB. Multivariable logistic regression analysis showed that patients who received A+P PNB or a hamstring autograft had lower POD 1 severe pain scores (odds ratio [OR] = 0.35; 95% confidence interval [CI], 0.15–0.84 and OR = 0.35; 95% CI, 0.15–0.83, respectively). Patients with PNBs with local anesthesia concentration (LAC) greater than 0.25% reported higher POD1 pain scores (OR = 2.14; 95% CI, 1.1–4.16) compared to those with lower LAC. Patients with PNB catheters had reduced POD 1 pain. Multivariable logistic regression analysis for numbness at week 6 revealed a greater odds of numbness for A-PNB with LAC >0.25% (OR = 5.13; 95% CI, 1.27–20.8). At month 6, patients receiving PNB with perineural steroid adjuvant were more likely to report numbness (dexamethasone OR = 5.93; 95% CI, 1.61–21.9, methylprednisolone OR = 11.3; 95% CI, 2.16–58.6). CONCLUSIONS: Patients who received A+P PNB had lower postoperative pain scores than those who received no block. Additional studies are necessary to discern how PNB type, graft harvest site, LAC, and adjuvants influence pain control, persistent numbness, and weakness.]]> Wed, 29 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01133 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/patients__experiences_with_opioid_tapering_in.1129.aspx Tapering opioids is an effective strategy to reduce the risks associated with long-term opioid therapy. However, patients’ experience with tapering can influence the success of this treatment. Understanding patients’ experiences with opioid tapering will allow for patient-centered approaches to be adopted to tailor interventions to achieve safe and successful taper outcomes. This paper aims to synthesize qualitative data capturing patients’ experiences with opioid tapering for noncancer pain. Qualitative studies in English that explored patients’ experiences with opioid tapering in noncancer pain were included. MEDLINE, Embase, Scopus, and PsycINFO were searched from inception to March 2023. Two authors independently selected the studies, extracted data, and assessed the quality of included studies using the Critical Appraisal Skills Programme. A meta-synthesis allowed for overarching themes to be identified to form a new interpretation of the data in the context of past literature. From 5714 articles identified, 10 studies were included that met the inclusion criteria after title/abstract screening and full-text review. These studies involved 218 patients with experience tapering opioids. Three key themes guiding the new meta-synthesis were identified: (1) patient-provider interactions, (2) individualized care, and (3) tactics to manage the opioid tapering process. This review demonstrated the role that patient-provider interactions, tailored care, and effective tapering strategies play in facilitating a favorable patient experience during the opioid tapering process. Future research should incorporate the themes identified in this review to optimize the patient’s taper experience.]]> Tue, 28 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01129 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/whispers_in_the_operating_room__anesthesia_and.1131.aspx No abstract available]]> Tue, 28 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01131 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/patient_blood_management_program_implementation.1132.aspx No abstract available]]> Tue, 28 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01132 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/in_response.1121.aspx No abstract available]]> Mon, 27 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01121 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/anesthesia_trauma_guidelines__a_systematic_review.1116.aspx This systematic review describes the available clinical practice guidelines (CPGs) for the anesthetic management of trauma and appraises the accessibility and quality of these resources. This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted across 8 databases (MEDLINE, Embase, Web of Science, CABI Digital Library, Global Index Medicus, SciELO, Google Scholar, and National Institute for Health and Care Excellence) for guidelines from 2010 to 2023. Two independent reviewers assessed guideline eligibility and extracted data, which were audited by a third reviewer. Data regarding author demographics, accessibility, clinical topics, and quality were collected. The quality of guidelines was evaluated according to the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) Instrument. A total of 2426 articles were identified, of which 165 met eligibility criteria and were included. Guidelines were developed by 122 professional societies and authors from 51 countries. By region, Europe contributed with the most authors (61%), while Africa had the fewest (4%). Most CPGs were developed by authors from high-income countries (HIC) and only 12% had a first or last author from low- and middle-income countries (LMIC). The United States was the country with the most guideline authors. While 70% were open access, the average cost for paid access was US$36.61. Among the 8 languages identified, English was the most common. The most common topics were blood and fluid management, shock, and airway management. The overall quality of included guidelines was considered moderately high, with an average NEATS score of 3.13 of 5. Quality scores were lowest for involvement of patient perspectives, plans for updating, and presence of a methodologist. On logistic regression analysis, the involvement of a methodological expert was the only predictor of having a high-quality NEATS score, with no association observed with open accessibility, English language, society endorsement, first author from a HIC, or a multidisciplinary group composition. Though many countries and societies have contributed to the development of anesthesia CPGs for trauma, there has been a disproportionate lack of representation from LMICs, where the burden of trauma mortality is highest. In this study, we identify barriers to accessibility and areas for improving future guideline quality. We recommend ongoing efforts to incorporate perspectives from diverse settings and to increase the availability of high-quality, open-access guidelines to improve worldwide health outcomes in trauma.]]> Fri, 24 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01116 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/effects_of_variable_ventilation_on_gas_exchange_in.1110.aspx BACKGROUND: The rapid advancement of minimally invasive surgical techniques has made laparoscopy a preferred alternative because it reduces postoperative complications. However, inflating the peritoneum with CO2 causes a cranial shift of the diaphragm decreasing lung volume and impairing gas exchange. Additionally, CO2 absorption increases blood CO2 levels, further complicating mechanical ventilation when the lung function is already compromised. Standard interventions such as lung recruitment maneuvers or increasing positive end-expiratory pressures can counteract these effects but also increase lung parenchymal strain and intrathoracic pressure, negatively impacting cardiac output. The application of variability in tidal volume and respiratory rate during mechanical ventilation to mimic natural breathing has shown benefits in various respiratory conditions. Therefore, we aimed to evaluate the short-term benefits of variable ventilation (VV) on gas exchange, respiratory mechanics, and hemodynamics during and after capnoperitoneum, compared to conventional pressure-controlled ventilation (PCV). METHODS: Eleven anaesthetized rabbits were randomly assigned to PCV or VV. Oxygenation index (Pao2/FiO2), arterial partial pressure of carbon dioxide (Paco2), and respiratory mechanical parameters were assessed after a 15-minute-long ventilation period before, during, and after capnoperitoneum. According to a crossover design, after measurements at the 3 different stages, the ventilation mode was changed, and the entire sequence was repeated. RESULTS: Capnoperitoneum compromised respiratory mechanics, decreased oxygenation, and caused CO2-retention compared to baseline measurements under both ventilation modalities (P < .05, for all). Application of VV resulted in lower Pao2/FiO2 (405. 5 ± 34.1 (mean ± standard deviation [SD]) vs 370. 5 ± 44.9, P < .001) and higher Paco2 (48. 4 ± 5.1 vs 52. 8 ± 6.0 mm Hg, P = .009) values during capnoperitoneum compared to PCV. After abdominal deflation and a lung recruitment maneuver, VV proved more beneficial for CO2 removal than PCV (41. 0 ± 2.3 vs 44. 6 ± 4.3mmHg, P = .027). No significant difference was observed in the respiratory mechanical or hemodynamic parameters between the ventilation modalities under the same conditions. CONCLUSIONS: The detrimental effects of capnoperitoneum on gas exchange were more pronounced with VV. However, after the release of capnoperitoneum, VV significantly improved CO2 clearance. Therefore, VV could possibly be considered as an alternative ventilation modality to restore physiological gas exchange after, but not during, capnoperitoneum.]]> Wed, 22 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01110 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/comparing_general_anesthesia_based_regimens_for.1104.aspx BACKGROUND: Total intravenous anesthesia (TIVA)-based and volatile-based general anesthesia have different effects on cerebral hemodynamics. The current work compares these 2 regimens in acute ischemic stroke patients undergoing endovascular therapy. METHODS: We conducted a systematic literature search across MEDLINE, Embase, Cochrane, CINAHL, Web of Science, and Scopus. We identified English language studies including adult acute ischemic stroke patients managed with endovascular therapy under general anesthesia delineable into TIVA only and/or volatile only, and obtained categorical data for favorable functional outcomes using the modified Rankin scale (mRS ≤2), at 90 days after endovascular therapy. Odds ratios (OR) and standardized mean differences were calculated to inform a network meta-analysis approach, which permitted the inclusion of studies comparing a form of general anesthesia (ie, TIVA only or volatile only) to conscious sedation. RESULTS: The search rendered 6235 articles, of which 15 met inclusion criteria. Three studies directly investigated TIVA versus volatile, whereas 12 studies compared general anesthesia to conscious sedation. The total number of subjects was 3015 (conscious sedation: n = 1067; general anesthesia: n = 1948 [TIVA: n = 1212, volatile: n = 736]). No significant differences were identified between TIVA and volatile groups in 90-day neurological outcome (OR = 1.25, 95% confidence interval [CI], 0.81–1.91; P = .31), 90-day mortality (OR = 0.72, 95% CI, 0.42–1.24; P = .24), successful recanalization (OR = 1.33, 95% CI, 0.70–2.52; P = .39), or recanalization time (standardized mean difference = 0.03, 95% CI, –0.35 to 0.41; P = .88). Additionally, no significant differences were identified between the conscious sedation group and the TIVA group in 90-day neurological outcome (OR = 1.14, 95% CI, 0.84–1.53; P = .40), 90-day mortality (OR = 0.87, 95% CI, 0.62–1.23; P = .43), successful recanalization (OR = 0.76, 95% CI, 0.52–1.10; P = .15), or recanalization time (standardized mean difference = –0.18, 95% CI, –0.47 to 0.11; P = .23), and between the conscious sedation group and the volatile group in 90-day neurological outcome (OR = 1.42, 95% CI, 0.92–2.17; P = .11), 90-day mortality (OR = 0.63, 95% CI, 0.36–1.12; P = .11), successful recanalization (OR = 1.01, 95% CI, 0.52–1.94; P = .98), or recanalization time (standardized mean difference = –0.15, 95% CI, –0.52 to 0.23; P = .44). CONCLUSIONS: This network meta-analysis showed that the perioperative use of either general anesthesia-based regimen, or sedation, did not significantly impact various endovascular therapy-related outcomes. However, the current work was underpowered to detect differences in anesthetic agents, clinico-demographic characteristics, or procedural factors.]]> Mon, 20 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01104 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_culture_of_anesthesiologists.1107.aspx No abstract available]]> Mon, 20 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01107 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/what_came_first_the_pathology_or_the_pain_.1101.aspx No abstract available]]> Tue, 14 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01101 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/what_lay_beneath.1103.aspx No abstract available]]> Tue, 14 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01103 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/sexual_harassment_in_academic_anesthesiology__a.1091.aspx BACKGROUND: A report by the American Association of Medical Colleges (AAMC) showed that academic anesthesiology has the highest prevalence of sexual harassment among specialties for both men and women. We aimed to explore the prevalence, sources, and impact of sexual harassment on anesthesiologists in academic centers in the United States and Canada. We also sought recommendations for its mitigation. METHODS: An anonymous online survey instrument was designed based on a previously published report, yielding 39 questions, including demographics and 4 open-ended questions. The survey was sent via email to Association of University Anesthesiologists (AUA) members, who were encouraged to share across academic anesthesiology departments in the United States and Canada. RESULTS: A total of 626 responses were received; after exclusion of incomplete and nonfaculty responses, 484 complete survey responses were analyzed. 52.9% of respondents identified as men and 45.9% as women; 3 respondents (0.6%) identified as nonbinary, and 3 respondents (0.6%) preferred not to answer. 43.6% of respondents perceived there is sexual harassment in academic anesthesiology. Significantly more women than men reported presence of sexual harassment in academic medicine (65.3% vs 38.3%, P < .001), in academic anesthesiology (59.5% vs 30.1%, P < .001), and in their place of work (37.8% vs 18.3%, P < .001). 14.5% of men and 43.2% of women had experienced sexual harassment at least once in the past 12 months (P < .001). 43.7% of women reported ever experiencing unwanted physical contact in the workplace compared to 16.8% of men; 74.3% of women reported ever experiencing verbal or nonverbal conduct in the workplace related to gender that caused embarrassment, distress, or offense compared to 24.6% of men (P < .001). 8.2% of men reported feeling their clinical ability doubted, compared to 87.8% of women (P < .001). Experiences of sexual harassment were most consistent with verbal and nonverbal behaviors that convey hostility, objectification, or exclusion of members of one gender. Colleagues from anesthesiology were most likely to be reported as the source of sexual harassment (44.6% of unwanted physical contact, 59% of verbal or nonverbal conduct). The impact was described along 4 themes: emotional, cognitive, behavioral, and professional. Participants made recommendations for eliminating sexual harassment by raising awareness, providing education, establishing reporting, offering support, and ensuring accountability. CONCLUSIONS: This survey confirms the high prevalence of sexual harassment in academic anesthesiology. The most common sources are anesthesiology colleagues. The recommendations for leaders and institutions include creating a professional environment free from harassment with support for targets and accountability for instigators.]]> Thu, 02 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01091 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/multi_institutional_study_of_multimodal_analgesia.1093.aspx BACKGROUND: Posterior spinal fusion (PSF) surgery for correction of idiopathic scoliosis is associated with chronic postsurgical pain (CPSP). In this multicenter study, we describe perioperative multimodal analgesic (MMA) management and characterize postoperative pain, disability, and quality of life over 12 months after PSF in adolescents and young adults. METHODS: Subjects (8–25 years) undergoing PSF were recruited at 6 sites in the United States between 2016 and 2023. Data were collected on pain, opioid consumption (intravenous morphine milligram equivalents (MME)/kg), and use of nonopioid analgesics through postoperative days (POD) 0 and 1. Pain descriptors, functional disability, and quality of life were assessed preoperatively, 2 to 6 and 10 to 12 months after surgery using questionnaires (PainDETECT, Functional Disability Inventory [FDI], and Pediatric Quality of Life Inventory [PedsQL]). Descriptive analyses of analgesic use across and within sites (by preoperative pain and psychological diagnoses), acute postoperative pain and yearly in-hospital analgesic trends are reported. Pain trajectories over 12 months were analyzed using group-based discrete mixture. CPSP (defined as pain score >3/10 beyond 2 months postsurgery), and associated FDI and PedsQL were analyzed. RESULTS: In this cohort (343 patients, median [interquartile range {IQR}] 15.2 (13.7–16.6) years, 71.1% female), perioperative use of opioids and nonopioid analgesics significantly varied across sites (P < .001). Preoperatively, gabapentinoids were administered to 48.2% (157/343). Intraoperatively, opioid use included remifentanil (264/337 [78.3%]) and fentanyl (73/337 [21.7%]) infusions, and methadone boluses (159/338 [47%]). Postoperatively, patient-controlled analgesia was commonly used (342/343 [99.9%]). Within sites MMA use did not appear to differ by preoperative pain or psychological comorbidities. Median in-hospital opioid use declined over time (−0.08 [standard error {SE} 0.02] MME/kg/POD 0 to 1 per year, P < .001) while increased use of ketamine (P < .001), methadone (P < .001), dexmedetomidine (P < .001), and regional analgesia (P = .015) was observed. Time spent in moderate-to-severe pain on POD 0 to 1 was ≈33%. CPSP was reported by 24.2% (64/264) with ~17% reporting ongoing neuropathic/likely neuropathic pain. Four postsurgical pain trajectories were identified; 2 (71%) showed resolving pain and 2 (29%) showed persistent mild and moderate-to-severe pain. Although FDI and PedsQL improved over time in both CPSP and non-CPSP groups (P < .001), FDI was higher (P < .001) and PedsQL lower (P = .001) at each time point in the CPSP versus the non-CPSP group. CONCLUSIONS: MMA strategies showed site-specific variability and decreasing yearly trends of in-hospital opioid use without changes in acute or chronic pain after PSF. There was a high incidence of persistent pain associated with disability and poor quality of life warrants postoperative surveillance to enable functional recovery.]]> Thu, 02 Jan 2025 00:00:00 GMT-06:00 00000539-990000000-01093 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/associations_between_social_determinants_of_health.1088.aspx BACKGROUND: This study examined the association between opioid-use disorder (OUD)-related diagnoses (eg, opioid dependence) and social determinants of health (SDoH) among patients with chronic pain. METHODS: A cross-sectional study was performed using the All of Us dataset (including >70,000 patients) to measure associations between SDoH and OUD using population- and individual-level surveys. Mixed-effects multivariable regression models (random effect being zip code) were conducted for each of the key SDoH domains. The odds ratio (OR) and 95% confidence interval (CI) were reported. RESULTS: There were 71,727 participants identified to have chronic pain, of which 7272 (10.1%) had OUD. Using data from all participants with population-level survey data available (n = 71,684), the Area Deprivation Index was associated with increased odds of OUD (OR, 5.70, 95% CI, 2.34–13.83, P < .001). Being unemployed (OR, 1.91, 95% CI, 1.59–2.31, P < .001) was associated with OUD. Chronic pain patients with a college degree or greater had lower odds of having OUD (OR, 0.48, 95% CI, 0.39–0.59, P < .001). Responses to questions related to delayed medical care (OR, 1.42, 95% CI, 1.20–1.69, P < .001) and inability to afford medical care (OR, 1.37, 95% CI, 1.16–1.63, P < .001) were associated with an increased odds of OUD. Chronic pain patients who were never married or without a partner (OR, 1.49, 95% CI, 1.28–1.73, P < .001) had higher odds of OUD. CONCLUSIONS: The study revealed a significantly greater social disadvantage metric in chronic pain individuals with OUD.]]> Mon, 23 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01088 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/comparative_effectiveness_of_analgesia_for_early.1085.aspx BACKGROUND: Timely and effective analgesia after tonsillectomy in children is crucial, but there is currently no consensus on the optimal analgesics. This analysis aimed to identify the most effective for this surgery. METHODS: We conducted a systematic review and network meta-analysis (random-effects model) of randomized controlled trials comparing analgesics for pediatric tonsillectomy. We searched relevant studies in PubMed, Embase, Cochrane Library, and Web of Science databases from database inception until June 30, 2023. Children (≤18 years old) who underwent tonsillectomy with or without adenoidectomy were eligible for inclusion. Primary outcomes encompassed pain score and postoperative complications; secondary outcomes included postoperative supplementary analgesia, functional evaluation, and sedation score. RESULTS: In total 82 randomized controlled trials involving 6110 patients were included, forming the primary network that comprised comparative data for 16 different interventions (including placebo) across 6 types of analgesics. The integrated analysis revealed that nonsteroidal anti-inflammatory drugs except ketoprofen had no significant effects in relieving postoperative pain (mean difference [MD], −2.96; 95% confidence interval [CI], −5.59 to −0.32; P = .10). Local anesthetic infiltration (bupivacaine: MD, −2.76; 95% CI, −3.88 to −1.64, P = .01; ropivacaine: MD, −2.49; 95% CI, −4.25 to −0.73, P = .02; lidocaine: MD, −1.86; 95% CI,-3.52 to −0.2, P = .02; levobupivacaine: MD, −1.06; 95% CI, −2.00 to −0.12, P = .01), analgesics (morphine: MD, −2.07; 95% CI, −3.14 to −1.00; P = .02), and glucocorticoids (dexamethasone: MD, −0.45; 95% CI, −0.73 to −0.16; P = .01) were effective in relieving pain after pediatric tonsillectomy. In reducing incidence of postoperative complications, dexamethasone was superior to bupivacaine (relative risk [RR], 0.60; 95% CI, 0.43–0.83; P = .02). Regarding the number of patients needing rescue analgesic, levobupivacaine was superior to lidocaine (RR, 0.51; 95% CI, 0.32–0.81; P = .01). In rescue analgesia requirement, morphine outperformed lidocaine (RR, 0.44; 95% CI, 0.25–0.75; P = .01) and ropivacaine (RR, 0.54; 95% CI, 0.32–0.91; P = .01) in efficacy but not different from bupivacaine (P = .10) and levobupivacaine (P = .12). CONCLUSIONS: Based on these results, we would recommend local bupivacaine infiltration or local levobupivacaine infiltration for older children and dexamethasone injection for younger children for early analgesia after tonsillectomy. However, clinicians should choose the optimal analgesic based on the individual child’s condition and clinical situation.]]> Fri, 20 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01085 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/preoperative_blood_brain_barrier_integrity.1077.aspx BACKGROUND: Brain homeostasis imbalance, characterized by cognitive dysfunction and delirium, frequently occurs in the elderly after surgery. Investigating why this complication only affects part of patients undergoing the same surgery, and anesthesia remains intriguing. This study tested the role of preoperative blood-brain barrier (BBB) integrity in the occurrence of postoperative brain homeostasis imbalance using mice with conditional BBB damage. METHODS: Preoperative BBB breakdown was induced in End-SCL-Cre-ctnnb1fl//fl (iCKO) mice by administering tamoxifen (intraperitoneal [i.p.]). This breakdown was assessed using Evans Blue (EB) leakage and immunoglobulin G (IgG) staining. Postoperative brain homeostasis imbalance was evaluated through the Novel Object Recognition test, the Barnes Maze, and neuroinflammation tests. Synapse loss was detected by colabeling synaptophysin and PSD-95, followed by Western blotting. The role of astrocytes in this pathogenesis was evaluated by comparing cognitive behaviors, hippocampal gene expression, and astrocytic phagocytosis of synaptophysin in iCKO mice with and without genetic inhibition of perioperative astrocyte activity. RESULTS: Tamoxifen treatment (30 mg/kg/d) induced BBB breakdown of iCKO mice in a time-dependent manner (analysis of variance [ANOVA] for time, P = .0006), but not in their littermate control mice (nCKO, P > .999). A 3-day tamoxifen treatment induced slight BBB breakdown (EB leakage: 95% confidence interval [CI], 13.9–204.8, P = .013; IgG level: 95% CI, 12.6–51.4: P = .001), but did not cause significant cognitive impairment in the Novel Object Recognition test in iCKO mice (95% CI, −7.99 to 6.12; P > .999). Anesthesia and surgery-induced significant cognitive impairment (all P < .0001 for the Novel Object Recognition test, Barnes Maze test), neuroinflammation, and synaptic loss in iCKO mice with 3-day tamoxifen treatment, but not in nCKO mice with the same treatment. Inhibiting astrocyte activity alleviated the impact of anesthesia and surgery on cognitive function (all P < .0001 for the Novel Object Recognition test, Barnes Maze test), gene expression, and synapse pruning in iCKO mice with 3-day tamoxifen treatment. CONCLUSIONS: Preoperative BBB integrity influences the impact of anesthesia and surgery on the brain, with astrocytes modulating this effect. These findings partly explain the heterogeneity in the occurrence of postoperative brain homeostasis imbalance.]]> Tue, 17 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01077 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/obstetric_hemorrhage_in_low__and_middle_income.1079.aspx No abstract available]]> Tue, 17 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01079 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/postoperative_ataxic_breathing__a_new_tool_for.1069.aspx No abstract available]]> Fri, 06 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01069 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_influence_of_pharmacogenetic_factors_on_the.1071.aspx Morphine is a potent analgesic used for treating surgical and cancer pain. Despite being the drug of choice for the management of severe pain in children, the high interindividual variability in morphine pharmacokinetics limits its clinical utility to effectively relieve pain without adverse effects. This review was conducted to identify and describe all studies that have assessed the effect of genetic factors on the pharmacokinetics of morphine and its main metabolites in children. Embase and Medline databases were used to conduct the literature search, and the systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Of the 188 articles screened and after the application of specific inclusion and exclusion criteria, the review identified 8 studies. These studies suggest that genetic variants of selected metabolic enzymes and transporters may play a role in the observed interindividual variability in morphine plasma concentrations. Variants of the genes SLC22A1 and ABCC3 had the most supporting evidence for genetic variants that influence morphine and morphine metabolites pharmacokinetics. Although the available evidence suggests a potential genetic contribution to the variability in morphine concentration, the heterogeneity of the included studies in terms of experimental design and small sample sizes in some studies makes it challenging to propose the use of genetic biomarkers to personalize morphine dosing. This underscores the need to conduct more comprehensive and large-scale pharmacokinetic-pharmacogenetic studies to determine how or if genetic testing can optimize morphine safety and effectiveness in children.]]> Fri, 06 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01071 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/association_of_general_anesthesia_for_cesarean.1065.aspx BACKGROUND: Compared to neuraxial anesthesia, general anesthesia (GA) for cesarean delivery is associated with an increased risk of postpartum depression (PPD) requiring hospitalization. However, obstetric complications occurring during childbirth (eg, stillbirth) are associated with both increased use of GA and increased risk of PPD, and may account for the reported association between GA and PPD. This study assessed the association of GA for cesarean delivery with PPD requiring hospitalization, outpatient visit, or emergency department (ED) visit, accounting for obstetric complications. METHODS: This retrospective cohort study included women who underwent a cesarean delivery in New York State between January 2009 and December 2017. Women were followed for 1 year after discharge for readmission, outpatient visit, or ED visit. The primary outcome was PPD requiring readmission, outpatient visit, or ED visit. The 2 secondary outcomes were (1) PPD requiring readmission, and (2) suicidality. Obstetric complications included severe maternal morbidity, blood transfusion, postpartum hemorrhage, preterm birth, and stillbirth. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of PPD, PPD requiring readmission, and suicidality associated with GA were estimated using the propensity score matching and the overlap propensity score weighting methods. RESULTS: Of the 325,840 women included, 19,513 received GA (6.0%; 95% CI, 5.9–6.1). Complications occurred in 43,432 women (13.3%) and the GA rate for these women was 9.7% (95% CI, 9.4–10.0). The incidence rate of PPD was 12.8 per 1000 person-years, with 24.5% requiring hospital readmission, and was higher when an obstetric complication occurred (17.1 per 1000 person-years). After matching, the incidence rate of PPD was 15.5 per 1000 person-years for women who received neuraxial anesthesia and 17.5 per 1000 person-years for women who received GA, yielding an aHR of 1.12 (95% CI, 0.97–1.30). Use of GA was associated with a 38% increased risk of PPD requiring hospitalization (aHR: 1.38; 95% CI, 1.07–1.77) and with a 45% increased risk of suicidality (aHR 1.45; 95% CI, 1.02–2.05). Results were consistent when using the overlap propensity score weighting. CONCLUSIONS: Use of GA for cesarean delivery is independently associated with a significantly increased risk of PPD requiring hospitalization and suicidality. It underscores the need to avoid using GA whenever appropriate and to address the potential mental health issues of patients after GA use, specifically by screening for PPD and providing referrals to accessible mental health providers as needed.]]> Wed, 04 Dec 2024 00:00:00 GMT-06:00 00000539-990000000-01065 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/handoff_mnemonics_used_in_perioperative_handoff.1061.aspx BACKGROUND: Perioperative handoffs are known to present unique challenges to safe and effective patient care. Numerous national accrediting bodies have called for standardized, structured handoff processes. Handoff mnemonics provide a memory aid and standardized structure, as well as promote a shared mental model. We set out to identify perioperative handoff intervention studies that included a handoff mnemonic; critically assess process and patient outcome improvements that support specific mnemonics; and propose future recommendations. METHODS: We conducted a systematic review of the English language perioperative handoff intervention literature designed to identify handoff mnemonic interventions. A comprehensive protocol was developed and registered (CRD42022363615). Searches were conducted using PubMed, Scopus, ERIC (EBSCO), Education Full Text (EBSCO), EMBASE (Elsevier), and Cochrane (January 1, 2010 to May 31, 2022). Pairs of trained reviewers were involved in all phases of the search and extraction process. RESULTS: Thirty-seven articles with 23 unique mnemonics met the inclusion criteria. Most articles were published after 2015 (29/37; 78%). Situation, Background, Assessment, Recommendation (SBAR), and SBAR variants were used in over half of all studies (22/37; 59%), with 45% (10/22) reporting at least 1 statistically significant process improvement. Seventy percent of handoff mnemonics (26/37) were expanded into lists or checklists. Fifty-seven percent of studies (21/37) reported using an interdisciplinary/interprofessional team to develop the intervention. In 49% of all studies (18/37) at least 1 measurement tool was either previously published or the authors conducting some form of measurement tool validation. Forty-one percent of process measurement tools (11/27) had some form of validation. Although most studies used training/education as an implementation strategy (36/37; 97%), descriptions tended to be brief with few details and no study used interprofessional education. Twenty-seven percent of the identified studies (10/37) measured perception alone and 11% (4/37) measured patient outcomes. CONCLUSIONS: While the evidence supporting one handoff mnemonic over others is weak, SBAR/SBAR variants have been studied more often in the perioperative environment demonstrating some process improvements. A key finding is that 70% of included studies converted their handoff mnemonic to a list or checklist. Finally, given the essential nature of effective handoffs to perioperative patient safety, it is crucial that handoff interventions are well developed, implemented, and evaluated. We propose 8 recommendations for future perioperative handoff mnemonic clinical interventions and research.]]> Tue, 26 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01061 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/practice_advisory_on_the_implementation_of.1055.aspx Preoperative anemia is common and associated with worse outcomes in cardiac surgery including acute kidney injury, red blood cell transfusion, cardiovascular complications, stroke, infection, and death. Patient blood management programs, which include dedicated clinical programs to diagnose and treat anemia in advance of surgery (ie, preoperative anemia programs), have been highlighted as a means to optimize the blood health of each patient, thereby decreasing risk for allogeneic transfusion and improving clinical outcomes. However, there remain implementation challenges for preoperative anemia programs, including difficulties with education of patients and staff, short lead times to address anemia, infrastructure and staffing limitations, lack of clear leadership or ownership of preoperative anemia, the need to develop treatment algorithms and ensure appropriate infusion therapy support, lack of capital support, and insurance/reimbursement concerns, amongst others. The purpose of this advisory from the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee and the Subcommittee on Patient Blood Management with endorsement from the Society for the Advancement of Patient Blood Management (SABM) is to provide guidance on the development and implementation of a preoperative anemia clinic or service line, including identification and navigation through potential logistical barriers. A detailed analysis of financial incentives is highlighted in our companion article in this edition focuses on the return on investment of anemia management. Although originating with a focus on anemia before cardiac surgery, this advisory is broadly applicable to all perioperative patients.]]> Fri, 22 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01055 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/for_the_love_of_clove.1058.aspx No abstract available]]> Fri, 22 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01058 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/glabridin_hypnosis_in_zebrafish_larvae_is.1048.aspx BACKGROUND: R-Glabridin is a major flavonoid of licorice (Glycyrrhiza glabra) root and known to modulate GABAA receptors, which are targets of many clinical hypnotics. However, R-glabridin hypnotic activity has not been reported in animals. METHODS: Inverted photomotor responses (IPMRs) were used to assess the hypnotic effects of natural R-glabridin and synthetic R/S-glabridin in wild-type zebrafish larvae and transgenic larvae lacking functional GABAA receptor β3 subunits (β30/0). Two-electrode voltage-clamp electrophysiology in Xenopus oocytes heterologously expressing ion channels quantified the effects of R-glabridin on wild-type and mutated human α1β3γ2L GABAA receptors, NR1B/NR2A N-methyl-D-aspatate (NMDA) receptors, and α4β2 neuronal nicotinic (nnACh) receptors. RESULTS: IPMRs in wild-type zebrafish larvae identified R/S-glabridin as an inhibitor (IC50 = 7.5 µM; 95% confidence interval [CI], 5.9–9.3 µM) that was about half as potent as R-glabridin (IC50 = 4.4. µM; 95% CI, 3.6–5.4 µM). In β30/0 zebrafish larvae, R-glabridin inhibited IPMRs with IC50 = 7.5 µM (95% CI, 5.6–10.0 µM). Electrophysiologic studies revealed that R-glabridin directly activated and positively modulated α1β3γ2L GABAA receptors. Modulation was significantly reduced by α1L232W and β3N265M mutations in the β+/α- transmembrane intersubunit sites where etomidate binds, but not by 5 other point mutations in 4 other transmembrane modulator binding sites. NMDA and nnACh receptors were inhibited by R-glabridin. DISCUSSION/CONCLUSIONS: Our findings in zebrafish larvae indicate that IPMR inhibition by R-glabridin is more potent than S-glabridin and that β3-containing GABAA receptors contribute significantly to this behavioral effect. Molecular studies show that R-glabridin modulates at least 3 known anesthetic-sensitive ion channels, suggesting that it is a multimodal hypnotic.]]> Thu, 21 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01048 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/outcomes_associated_with_a_patient_blood.1052.aspx BACKGROUND: Obstetric patient blood management (PBM) strategies were used at Corniche Hospital in 2018, initially focusing on minimizing bleeding, with other clinical strategies implemented incrementally. This study assesses program outcomes in patients with major obstetric hemorrhage of 2000 mL or greater. METHODS: A retrospective study of 353 women admitted to The Corniche Hospital between 2018 and 2023 who experienced major obstetric hemorrhage of 2000 mL or greater. The primary outcome measure was units of red blood cell (RBC), fresh-frozen plasma (FFP), and platelet units transfused. Secondary outcomes included pretransfusion hemoglobin in patients with no active bleeding, hemoglobin levels 3 weeks postdischarge, anemia predelivery, blood product-acquisition cost savings, mortality, composite morbidity (transfusion reaction, acute lung injury, thrombosis, sepsis, postpartum hysterectomy), hospital and high-dependency unit length of stay, and all-cause emergency readmissions within 28 days. RESULTS: Comparing baseline (2018) with the final year (2023), the mean units of RBCs, FFP, and platelets transfused per admission decreased from 4.18 to 0.67 (P-trend <.001), resulting in blood acquisition savings of US$ 175,705. Over the same period the percentage of women anemic predelivery decreased from 40.3% to 23.8% (P-trend = 0.015) and the mean pretransfusion hemoglobin level in nonactively bleeding patients decreased from 7.54 g/dL to 6.35 g/dL (P-trend < .001). The mean hemoglobin rise 3 weeks postdischarge increased from 2.41 g/dL in 2018 to 4.26 g/dL in 2023. There were no changes in adjusted composite morbidity, hospital, or high-dependency unit length of stay. CONCLUSIONS: In women with a major obstetric hemorrhage of 2000 mL or greater, the implementation of an obstetric PBM program was associated with reduced blood product utilization, reduced costs, reduced anemia, and increased hemoglobin rise postdischarge.]]> Thu, 21 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01052 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/preoperative_biofluid_biomarkers_for_predicting.1054.aspx Preoperative biofluid biomarkers reflecting pathophysiological, neuronal injury, and inflammation as well as those for Alzheimer’s disease (AD) may be valuable tools for the risk stratification of perioperative neurocognitive disorders (PNDs) in older adults. We summarized current evidence relating these preoperative biomarkers to PND beyond 7 days, in older surgical participants aged ≥60 years. Studies that evaluated the association of preoperative biomarkers with cognitive decline as an outcome, beyond 7 days, were identified through searches of 6 databases and 3 trial registries to 17 January 2024. Preclinical studies, intracranial surgical, or studies with participants aged <60 years were excluded. Studies varied widely in the assessment of PND, so a wide range of cognitive outcomes was accepted, including those using the term postoperative cognitive dysfunction (POCD) to define cognitive decline. The pooled incidence of POCD utilizing a binary cognitive outcome was summarized. Fifteen studies involving 2103 participants were included. Marked heterogeneity was evident in the cognitive outcome metrics, assessment timeframes, limiting a quantitative synthesis. Of the 9 studies using binarized cognitive outcomes, the incidence of POCD was 23.4% (95% confidence interval [CI], 6.6–46.2) at <3 months, 11.4% (95% CI, 8.1–15.0) at 3 to <12 months, and 6.9% (95% CI, 1.9–14.5) at ≥12 months postoperatively. Of the 15 studies, 9 described blood-based biomarkers, 4 described cerebrospinal fluid (CSF) biomarkers, and 2 measured both blood and CSF markers. The biomarkers evaluated reflected the pathogenic indicators neuronal injury (9 studies), inflammation (5 studies) and of amyloid (5 studies), and Tau (1 study). The studies included were of medium to high quality. Evidence was the most promising for amyloid biomarkers, with 4 of 5 included studies demonstrating associations of lower preoperative biofluid amyloid biomarker levels with increased risk of POCD. In conclusion, preoperative biofluid amyloid biomarkers may hold potential utility for the prediction of POCD, although current evidence remains limited. Other potential preoperative biomarkers for POCD included p-Tau181 and Neurofilament Light, however small sample sizes, study heterogeneity, and conflicting results limited conclusions drawn. Standardized cognitive outcome metrics and common assessment timeframes are additionally required in future studies to ascertain the prognostic utility of these biomarkers for POCD.]]> Thu, 21 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01054 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_role_of_delta_opioid_receptor_in_mediating_the.1041.aspx BACKGROUND: Failing heart is more likely to suffer from myocardial ischemia/reperfusion (I/R) injury. This poses a great challenge for anesthesiologists in managing patients with heart failure during major surgery. Evidence from animal studies suggests that the delta-opioid receptor (DOR) contributes to alleviating acute myocardial injuries. However, little is known regarding the cardioprotective effects of cardiac DOR in patients with chronic heart failure. This study aimed to examine DOR expression in failing hearts and explore how DOR regulates the Janus kinase signal transducer and activator of the transcription-3 (JAK/STAT3) pathway to mediate morphine-induced cardio protection in heart failure. METHODS: We measured the DOR protein levels in human and rat heart tissues with chronic heart failure. To investigate the cardioprotective role of DOR, we administered the DOR-specific antagonist, naltrindole (NTD), and JAK2 inhibitor, AG490, before morphine preconditioning (MPC) in an isolated perfusion model of myocardial I/R injury in postinfarcted failing rat heart. We examined the infarct size, cardiac enzymes, cardiac function, cardiomyocyte apoptosis, apoptosis-related proteins, and STAT3 phosphorylation in the heart. RESULTS: The protein levels of DOR were significantly elevated in the myocardial tissues of humans and rats with chronic heart failure, by 1.4-fold (mean difference 0.41; 95% confidence interval [CI], 0.04–0.78; P = .032) and 2.3-fold (mean difference 1.26; 95% CI, 0.25–2.28; P = .009), respectively, compared to control tissues. Disease severity positively correlated with DOR expression (human: R2 = 0.316, P = .004; rat: R2 = 0.871, P = .021). Blocking DOR substantially reversed the cardioprotective effects of MPC in postinfarcted rat hearts, increasing the mean (standard deviation) percentage of infarct size from 15.0 (3.9)% to 30.8 (7.7)% (P < .001). Similarly, AG490 inhibited MPC restoration of cardiomyocyte apoptosis (33.3 [4.2]% vs 16.6 [3.4]%; P < .001). Both NTD and AG490 markedly suppressed STAT3 phosphorylation by 60.1% (mean difference 0.60; 95% CI, 0.27–0.93; P = .002) and 44.1% (mean difference 0.44; 95% CI, 0.06–0.83; P = .027), respectively, and also lowered the Bcl-2/Bax ratio by 85.5% (mean difference 0.86; 95% CI, 0.28–1.43; P = .006) and 68.2% (mean difference 0.68; 95% CI, 0.51–0.85; P < .001) respectively in heart tissues at the end of reperfusion. CONCLUSIONS: DOR protein levels increased in failing hearts of both humans and rats. Blocking cardiac DOR selectively reduced morphine-induced cardio protection by inhibiting the JAK2/STAT3 pathway. These findings indicate that cardiac DOR is a potential therapeutic target for protecting against heart failure due to I/R injury.]]> Wed, 13 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01041 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/return_on_investment_of_preoperative_anemia.1037.aspx Despite multiple recent guidelines recommending the diagnosis and treatment of anemia before elective cardiac surgery, few institutions have formal programs or methods in place to accomplish this. A major limitation is the perceived financial shortfall and the leadership buy-in required to undertake such an initiative. The purpose of this advisory from the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee with endorsement by the Society for the Advancement of Patient Blood Management (SABM) is to provide an overview of preoperative anemia management programs with an emphasis on the associated financial implications. This advisory reviews the evidence for preoperative anemia management programs in both cardiac and noncardiac surgery, discusses options for managing preoperative anemia, provides novel financial modeling regarding the implementation of preoperative anemia management programs, and describes implementation challenges, potential solutions, and opportunities for improvement.]]> Thu, 07 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01037 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/cross_sectional_survey_to_assess_hospital_system.1032.aspx BACKGROUND: Mothers in Africa are 50 times more likely to die after cesarean delivery (CD) than in high-income countries, largely due to hemorrhage. It is unclear whether countries across Africa are adequately equipped to prevent and treat postpartum hemorrhage (PPH) during and after CD. METHODS: This was a cross-sectional survey of anesthesiologists and obstetricians across the African Perioperative Research Group (APORG). The primary objective was to determine readiness of the hospital system to implement the World Health Organization (WHO) recommendations for prevention and treatment of PPH during and after CD. The secondary objectives were to evaluate the availability of blood products, skilled human resources and establish available postoperative care after CD. Survey question format was close-ended or Likert scale, with options “always,” “sometimes,” or “never.” RESULTS: Responses were analyzed from 1 respondent from each of 140 hospitals from 29 low- and middle-income countries across Africa. Most respondents completed every data field on the case report form. Regarding WHO recommendations on prevention of PPH, oxytocin and misoprostol were available in 130/139 (93.5%) and 101/138 (73.2%) hospitals, respectively. There was limited access to heat-stable carbetocin (12/138 [8.7%]) and ergometrine (35/135, [25.9%]). Controlled cord traction for removal of placenta was always performed in 133/135 (98.5%) hospitals. Delayed cord clamping when neonatal resuscitation was not indicated, was not performed universally (86/134 [64.2%]). Regarding the treatment of PPH, crystalloids were always available in 133/139 (95.7%) hospitals, and the preferred initial resuscitation fluid (125/138 [90.6%]). Uterine massage was always performed in 117/139 (84.2%) hospitals. Tranexamic acid was always available in 97/139 (69.8%) hospitals. The availability of intrauterine balloon tamponade devices was limited. Most had immediate access to theater (126/139 [90.6%]). Responses concerning organizational recommendations showed that 113/136 (83.1%) hospitals had written protocols for the treatment of PPH. Protocols for patient referral and simulation training were limited. Most hospitals had access to emergency blood (102/139 [73.4%]). There was limited access to blood component therapy, with platelets available at 32/138 (23.2%), cryoprecipitate at 21/138 (15.2%) and fibrinogen at 11/139 (7.9%) hospitals. In-person specialist cover was reduced after-hours. CONCLUSIONS: Important WHO-recommended measures to reduce hemorrhage during and after CD, are not currently available in many hospitals across Africa. It is likely that the lack of a combination of factors leads to failure to rescue mothers in Africa from postoperative complications. These findings should facilitate codesign of quality improvement initiatives to reduce hemorrhage related to CD.]]> Wed, 06 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01032 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/a_little_blue_butterfly.1034.aspx No abstract available]]> Wed, 06 Nov 2024 00:00:00 GMT-06:00 00000539-990000000-01034 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_utility_of_electroencephalograhy_in_guiding.1019.aspx Traditional pediatric anesthetic dosing using pharmacokinetic estimates based on age and weight is often imprecise, frequently leading to oversedation. Intraoperative electroencephalography (EEG) allows visualization of the brain’s response to anesthetic agents in real time, facilitating precise titration of anesthetic drug doses optimized for the individual child. The goal of EEG-guided anesthesia management is to maintain an optimal state of hypnosis during various stages of the procedure while minimizing hemodynamic instability and other adverse effects of anesthesia. This is especially important in children with less predictable anesthetic requirements, such as children with atypical neurodevelopment, altered levels of consciousness before anesthesia, or those receiving total intravenous anesthesia, neuromuscular blockers, or a combination of anesthetic agents with different mechanisms of actions. Children with limited cardiorespiratory reserves and those undergoing high-risk procedures such as cardiopulmonary bypass also benefit from EEG guidance as they have a narrower therapeutic window for optimal anesthetic dosing. Various processed EEG (pEEG) monitors are available for intraoperative monitoring in children. These monitors display a pEEG index based on the manufacturer’s algorithm, purportedly indicating the patient’s hypnotic state. Due to differences in developmental neurophysiology and EEG dynamics in children, pEEG indices may not always reliably indicate the hypnotic state, especially in neonates and infants. Learning to interpret nonproprietary EEG parameters including the raw EEG, spectral-edge frequency 95% (SEF95), and density spectral array can prevent overreliance on pEEG indices. This review provides an overview of the advantages of EEG guidance during clinical anesthesia, including potential reduction in anesthetic dosage, prevention of EEG suppression, and reduction in peri-operative adverse events. We describe the use of nonproprietary EEG parameters in guiding anesthesia in children for various clinical end points including laryngoscopy, surgical incision, and maintenance of anesthesia, as well as sedation. We illustrate these principles with various case examples commonly encountered during pediatric anesthesia. Lastly, we discuss strategies to expand intraoperative EEG monitoring in children through education and training programs, as well as advocate for further research to assess clinical outcomes associated with EEG guidance to support its routine use in clinical care.]]> Wed, 30 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-01019 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/variations_in_current_practice_and_protocols_of.1011.aspx BACKGROUND: Multimodal analgesia (MMA) aims to reduce surgery-related opioid needs by adding nonopioid pain medications in postoperative pain management. In light of the opioid epidemic, MMA use has increased rapidly over the past decade. We hypothesize that the rapid adoption of MMA has resulted in variation in practice. This cross-sectional study aimed to determine how MMA practices have changed over the past 6 years and whether there is variation in use by patient, provider, and facility characteristics. METHODS: Our study population includes all patients undergoing surgery with general anesthesia at 1 of 6 geographically similar hospitals in the United States between January 1, 2017 and December 31, 2022. Intraoperative pain medications were obtained from the hospital’s perioperative information management system. MMA was defined as an opioid plus at least 2 other nonopioid analgesics. Frequencies, χ2 tests (χ2), range, and interquartile range (IQR) were used to describe variation in MMA practice over time, by patient and procedure characteristics, across hospitals, and across anesthesiologists. Multivariable logistic regression was conducted to understand the independent contributions of patient and procedural factors to MMA use. RESULTS: We identified 25,386 procedures among 21,227 patients. Overall, 46.9% of cases met our definition of MMA. Patients who received MMA were more likely to be younger females with a lower comorbidity burden undergoing longer and more complex procedures that included an inpatient admission. MMA use has increased steadily by an average of 3.0% each year since 2017 (95% confidence interval =2.6%–3.3%). There was significant variation in use across hospitals (n = 6, range =25.9%–68.6%, χ2 = 3774.9, P < .001) and anesthesiologists (n = 190, IQR =29.8%–65.8%, χ2 = 1938.5, P < .001), as well as by procedure characteristics. The most common MMA protocols contained acetaminophen plus regional anesthesia (13.0% of protocols) or acetaminophen plus dexamethasone (12.2% of protocols). During the study period, the use of opioids during the preoperative or intraoperative period decreased from 91.4% to 86.0% of cases; acetaminophen use increased (41.9%–70.5%, P < .001); dexamethasone use increased (24.0%–36.1%, P < .001) and nonsteroidal anti-inflammatory drugs (NSAIDs) increased (6.9%–17.3%, P < .001). Gabapentinoids and IV lidocaine were less frequently used but also increased (0.8%–1.6% and 3.4%–5.3%, respectively, P < .001). CONCLUSIONS: In a large integrated US health care system, approximately 50% of noncardiac surgery patients received MMA. Still, there was wide variation in MMA use by patient and procedure characteristics and across hospitals and anesthesiologists. Our findings highlight a need for further research to understand the reasons for these variations and guide the safe and effective adoption of MMA into routine practice.]]> Fri, 25 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-01011 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_empty_space.1001.aspx No abstract available]]> Mon, 21 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-01001 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/perioperative_analgesic_interventions_for.994.aspx BACKGROUND: High pain levels immediately after surgery have been associated with persistent postsurgical pain. Still, it is uncertain if analgesic treatment of immediate postsurgical pain prevents the development of persistent postsurgical pain. METHODS: We searched MEDLINE, CENTRAL, and Embase up to September 12, 2023, for randomized controlled trials investigating perioperative analgesic interventions and with reported pain levels 3 to 24 months after total hip or knee arthroplasty in patients with osteoarthritis. The primary outcome was pain score 3 to 24 months after surgery, assessed at rest and during movement separately. Two authors independently screened, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 tool. We conducted meta-analyses and tested their robustness with trial sequential analyses and worst-best and best-worst case analyses. RESULTS: We included 49 trials with 68 intervention arms. All but 4 trials were at high risk of bias for the primary outcome. Moreover, the included trials were heterogeneous in terms of exclusion criteria, baseline pain severity, and which cointerventions the participants were offered. For pain at rest, no interventions demonstrated a statistically significant difference between intervention and control. For pain during movement, perioperative treatment with duloxetine (7 trials with 641 participants) reduced pain scores at 3 to 24 months after surgery (mean difference −4.9 mm [95% confidence interval {CI}, −6.5 to −3.4] on the 0–100 visual analog scale) compared to placebo. This difference was lower than our predefined threshold for clinical importance of 10 mm. CONCLUSIONS: We found no perioperative analgesic interventions that reduced pain 3 to 24 months after total hip or knee arthroplasty for osteoarthritis. The literature on perioperative analgesia focused little on potential long-term effects. We encourage the assessment of long-term pain outcomes.]]> Thu, 17 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-00994 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/impact_of_chronic_hepatitis_c_virus_on_acute.987.aspx BACKGROUND: Acute kidney injury (AKI) is one of the most common complications after liver transplantation (LT) and can significantly impact outcomes. The presence of hepatitis C virus (HCV) infection increases the risk of AKI development. However, the impact of HCV on AKI after LT has not been evaluated. The aim of this study was to assess the effect of HCV on AKI development in patients who underwent LT. METHODS: Between January 2008 and April 2023, 2183 patients who underwent living donor LT (LDLT) were included. Patients were divided into 2 groups based on the presence of chronic HCV infection. We compared LT recipients using the propensity score matching (PSM) method. Factors associated with AKI development were evaluated using multiple logistic regression analysis. In addition, 1-year mortality and graft failure were assessed using a Cox proportional regression model. RESULTS: Among 2183 patients, the incidence of AKI was 59.2%. After PSM, the patients with HCV showed a more frequent development of AKI (71.9% vs 63.9%, P = .026). In multivariate analysis after PSM, HCV was associated with AKI development (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.06–2.20, P = .022), 1-year mortality (Hazard ratio [HR], 1.98; 95% CI, 1.12–3.52, P = .019), and graft failure (HR, 2.12; 95% CI, 1.22–3.69, P = .008). CONCLUSIONS: The presence of HCV was associated with increased risk for the development of AKI, 1-year mortality, and graft failure after LT.]]> Wed, 16 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-00987 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/association_of_short_term_pain_and_chronic_pain.973.aspx BACKGROUND: The impact of pain intensity on the progression trajectories of cardiometabolic multimorbidity (CMM) is not well understood. We attempted to dissect the relationship of short-term pain (STP) and chronic pain intensity with the temporal progression of CMM. METHODS: We conducted a prospective cohort study based on the UK Biobank participants. Incident cases of cardiometabolic diseases (CMDs) were identified based on self-reported information and multiple health-related records in the UK Biobank. CMM was defined as the occurrence of at least 2 CMDs, including heart failure (HF), ischemic heart disease (IHD), stroke, and type 2 diabetes (T2D). The pain intensity was categorized into 5 levels based on pain duration and the number of sites involved, including chronic widespread pain (CWSP), chronic multilocation pain (CMLP), chronic single-location pain (CSLP), STP, and free-of-pain (FOP). Multistate models were used to assess the impact of pain intensity on the CMM trajectories from enrollment to initial cardiometabolic disease (ICMD), subsequently to CMM, and ultimately to death. RESULTS: A total of 429,145 participants were included. Over the course of a 12.8-year median follow-up, 13.1% (56,137/429,145) developed ICMD, 19.6% (10,979/56,137) further progressed to CMM, and a total of 5.3% (22,775/429,145) died. Compared with FOP, CMLP (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.06–1.17) and CWSP (HR, 1.26; 95% CI, 1.13–1.42) elevated the risk of transitioning from ICMD to CMM. STP (HR, 0.89; 95% CI, 0.82–0.96), CSLP (HR, 0.88; 95% CI, 0.82–0.95), and CMLP (HR, 0.87; 95% CI, 0.81–0.93) lowered the risk of transition from ICMD to mortality, and STP also reduced the risk of transition from enrollment to mortality (HR, 0.94; 95% CI, 0.89–0.98). The results of disease-specific transitions revealed that the influence of pain intensity varied across transitional stages. Specifically, CMLP and CWSP heightened the risk of conversion from T2D or IHD to CMM, whereas only CWSP substantially elevated the transition risk from HF to CMM. CONCLUSIONS: Our results highlighted reductions in chronic pain may mitigate both the onset and progression of CMM, potentially having an important impact on future revisions of cardiometabolic and pain-related guidelines.]]> Wed, 09 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-00973 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/anesthesia_for_posterior_tracheopexy_in_pediatric.965.aspx Tracheobronchomalacia refers to an abnormally excessive collapse of the trachea and/or bronchi during exhalation. In the pediatric population, tracheobronchomalacia is increasingly recognized as a cause of morbidity and mortality. Historically, options for medical management and surgical intervention were limited, and patient outcomes were poor.]]> Fri, 04 Oct 2024 00:00:00 GMT-05:00 00000539-990000000-00965 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/risk_of_venous_thromboembolism_after_total_knee.941.aspx BACKGROUND: Obstructive sleep apnea (OSA) is a prevalent condition associated with many comorbidities. However, establishing the independent impact of OSA on specific health outcomes can be challenging without access to a substantial patient cohort. This study aimed to investigate whether a diagnosis of OSA was independently associated with venous thromboembolism (VTE) after total knee arthroplasty (TKA). METHODS: In this retrospective cohort study, we interrogated the TriNetX Analytics Research Network, a large database comprising the billing claims and electronic health record-derived data of >117 million patients. Using Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, we identified US adult patients who underwent TKA between January 1, 2013 and January 1, 2023, with and without preexisting OSA (and ≥2 OSA occurrences overall). We then analyzed the 1-month postoperative incidence of VTE as a composite outcome of deep vein thrombosis (DVT) and pulmonary embolism (PE) incidence, as well as cerebrovascular accident (CVA), myocardial infarction (MI), and DVT and PE individually. Baseline demographic and comorbidity covariates were incorporated into a 1:1 propensity score-matched analysis to clarify the independent effect of OSA. RESULTS: During the 10-year study period, a total of 197,460 patients underwent TKA. Of these, 27,976 met the criteria for inclusion in the OSA cohort, while 150,830 had no documented history of OSA. In the initial analysis, OSA was significantly associated with the primary outcome (DVT/PE) as well as all secondary outcomes (CVA, MI, and individually with DVT and PE) at 1 month postsurgery. After generating propensity score matched cohorts, DVT/PE remained significantly associated with OSA, with an absolute risk difference of 0.7% (odds ratio [OR], 1.19, confidence interval [CI], 1.1–1.3, P < .001), as were the secondary outcomes of DVT (OR, 1.11, CI, 1.0–1.2, P = .030) and PE (OR, 1.41, CI, 1.2–1.6, P < .001). CONCLUSIONS: In this study encompassing a nationally representative sample of TKA patients, OSA was associated with increased incidence of VTE at 1 month postoperatively, an association that persisted after the generation of matched cohorts. While limitations related to the lack of patient-level data, disease severity, and therapy adherence should be acknowledged, our large sample size enabled us to factor many baseline characteristics into our analysis, reinforcing the association of these findings. Prospective work is needed on the impact of modulating factors such as anticoagulation regimen and positive airway pressure therapy on these outcomes.]]> Mon, 16 Sep 2024 00:00:00 GMT-05:00 00000539-990000000-00941 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/developments_in_transfusion_medicine__pulmonary.947.aspx Staying updated on advancements in transfusion medicine is crucial, especially in critical care and perioperative setting, where timely and accurate transfusions can be lifesaving therapeutic interventions. This narrative review explores the landscape of transfusion-related adverse events, focusing on pulmonary transfusion reactions such as transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI). TACO and TRALI are the leading causes of transfusion-related morbidity and mortality; however, specific treatments are lacking. Understanding the current incidence, diagnostic criteria, pathogenesis, treatment, and prevention strategies can equip clinicians to help reduce the incidence of these life-threatening complications. The review discusses emerging pathogenic mechanisms, including the possible role of inflammation in TACO and the mechanisms of reverse TRALI and therapeutic targets for TACO and TRALI, emphasizing the need for further research to uncover preventive and treatment modalities. Despite advancements, significant gaps remain in our understanding of what occurs during transfusions, highlighting the necessity for improved monitoring methods. To address this, the review also presents novel blood cell labeling techniques in transfusion medicine used for improving monitoring, quality assessment, and as a consequence, potentially reducing transfusion-related complications. This article aims to provide an update for anesthesiologists, critical care specialists, and transfusion medicine professionals regarding recent advancements and developments in the field of transfusion medicine.]]> Fri, 13 Sep 2024 00:00:00 GMT-05:00 00000539-990000000-00947 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/pro_con_debate__anesthesiologists_should_be.934.aspx In this Pro-Con commentary article, we discuss whether anesthesiologists should be responsible for treating preoperative anemia. This debate was proposed based on the article published in this issue of Anesthesia & Analgesia by Warner et al, which is an advisory on managing preoperative anemia endorsed by both the Society of Cardiovascular Anesthesiologists and the Society for Advancement of Patient Blood Management. All evidence suggests that anemia is not just an innocent “bystander” which can be solved by transfusion. In fact, both anemia and transfusion are independently associated with adverse outcomes, so why not avoid both? It just makes sense that patients show up for surgery with enough red blood cells to avoid needing transfusion with someone else’s. Even if we agree that preoperative anemia is worth treating before surgery, the question remains who should be responsible for doing so, and therein lies the reason for this Pro-Con debate. Should it be the responsibility of the anesthesiologist, or not? Let the readers decide.]]> Mon, 09 Sep 2024 00:00:00 GMT-05:00 00000539-990000000-00934 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/the_case_for_the_role_of_primary_care_in_patient.932.aspx Patient blood management (PBM) is a patient-centered evidence-based strategy designed to preserve a patient’s own blood and improve health outcomes. The effectiveness of PBM programs is now well-established globally within tertiary and secondary sectors, with demonstrable outcome benefits and cost savings. However, the role of primary care and the general practitioner in PBM is poorly understood. Yet the essential attributes of primary care, including access, continuity, coordination, and comprehensiveness, align well with PBM principles, enabling general practitioners to provide personalized holistic management of anemia for the community. The skill set of general practitioners in integrating and continuing care through the transition period after hospitalization is especially important. General practitioners are well-suited to the roles of health promotion and prevention, and have the potential to deliver substantial population health benefits. Given the public health imperative of this condition, it is vital that policy-makers appropriately support the role of general practitioners with financing, education, and resources for PBM in primary care.]]> Thu, 05 Sep 2024 00:00:00 GMT-05:00 00000539-990000000-00932 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/evaluation_of_the_noninvasive_estimated_continuous.931.aspx BACKGROUND: The estimated continuous cardiac output (esCCO) system is a hemodynamic monitor that uses electrocardiograms and pulse oximeter waves to noninvasively estimate cardiac output. The coefficients for esCCO measurement have been established for adult patients, but the appropriate coefficients for pediatric patients are unclear. Therefore, this study determined esCCO coefficients for pediatric patients and validated the accuracy and tracking ability of a modified esCCO system. METHODS: An initial study compared cardiac output measurements using transthoracic echocardiography and esCCO in 60 pediatric patients aged <15 years who underwent elective noncardiac surgery. Consequently, the coefficients for the esCCO measurements were redefined for pediatric patients. The main study compared cardiac output measurements between transthoracic echocardiography and modified esCCO in 80 pediatric patients. Measurements were performed pre- and postoperatively, and the accuracy and trending ability of the cardiac output measurements were evaluated using Bland-Altman analysis and a polar plot. RESULTS: The correlation coefficients between the modified esCCO and transthoracic echocardiography were 0.96 and 0.98 in the pre- and postoperative measurements, respectively. In Bland-Altman analysis, the bias (standard deviation [SD]), 95% limits of agreement, and percentage error were 0.03 (0.28), −0.53 to 0.60, and 18% in the preoperative measurement, and −0.04 (0.19), –0.42 to 0.35, and 15% in the postoperative measurement, respectively. The polar plot showed that the cardiac output changes were well tracked, with an angular bias (SD) of 2.9° (6.0°) and radial 95% limits of agreement ranging from −9.2° to 14.9°. CONCLUSIONS: Cardiac output measurement by esCCO with modified coefficients for pediatric patients showed high accuracy and tracking ability compared with cardiac output measurement by transthoracic echocardiography. This noninvasive cardiac output measurement could benefit perioperative hemodynamic monitoring in children.]]> Wed, 04 Sep 2024 00:00:00 GMT-05:00 00000539-990000000-00931 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/3_dimensional_virtual_reality_versus_2_dimensional.917.aspx BACKGROUND: Preoperative anxiety is common in children. It can contribute to negative experiences with anesthetic induction and may cause adverse physiological and psychological effects. Virtual reality (VR) and electronic tablet devices are 2 audiovisual distraction tools that may help to reduce anxiety and enhance the preoperative experience. This study aimed to compare the use of an immersive 3-dimensional (3D) VR to 2-dimensional (2D) video on anxiety in children during induction of general anesthesia. METHODS: Two hundred children (4–13 years) undergoing elective or emergency surgery under general anesthesia were enrolled in this randomized, controlled trial. Participants were randomized to use either the 3D VR goggles (intervention) or 2D video tablet (control) during anesthetic induction. Anxiety, the primary outcome, was measured using the modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF) at 2 time points: in the preoperative holding area before randomization (T1) and during induction of general anesthesia (T2). The primary outcome was analyzed using a linear regression model, including demographic and other covariates, to investigate any differences in anxiety scores. Secondary outcomes included evaluating compliance during the anesthetic induction (Induction Compliance Checklist), emergence of delirium (Cornell Assessment of Pediatric Delirium), perceived usefulness of the device, and child satisfaction. RESULTS: Participant characteristics were similar between the 3D VR (n = 98) and 2D video (n = 90) groups, with a mean (±standard deviation) age 8. 8 ± 2.8 years. The median (lower quartile, upper quartile) mYPAS-SF scores for the 3D VR group at the preoperative holding area were 22.9 (22.9, 35.4), then 29.2 (24.0, 41.7) during induction. For the 2D Video group, the scores were 27.1 (22.9, 35.4) and then 30.2 (22.9, 41.1). No significant difference was observed in the increase in mYPAS-SF scores between groups (P = .672). Children in the 3D VR group were less likely to be rated as having a perfect induction (P = .039). There was no evidence of a difference between the groups in emergence delirium. Both devices were rated highly for usefulness and patient satisfaction. Children preferred VR, while anesthesiologists and parents felt the 2D was more useful. CONCLUSIONS: This randomized controlled trial demonstrated that preoperative anxiety was equally low and induction compliance high with both 3D VR and 2D video distraction in children with parental presence during anesthetic induction.]]> Fri, 23 Aug 2024 00:00:00 GMT-05:00 00000539-990000000-00917 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/quantified_ataxic_breathing_can_detect.922.aspx BACKGROUND: Ataxic breathing (AB) is a well-known manifestation of opioid effects in animals and humans, but is not routinely included in monitoring for opioid-induced respiratory depression (OIRD). We quantified AB in normal volunteers receiving increasing doses of remifentanil. We used a support vector machine (SVM) learning approach with features derived from a modified Poincaré plot. We tested the hypothesis that AB may be found when bradypnea and reduced mental status are not present. METHODS: Twenty-six healthy volunteers (13 female) received escalating target effect-site concentrations of remifentanil with a low baseline dose of propofol to simulate typical breathing patterns in drowsy patients who had received parenteral opioids. We derived respiratory rate (RR) from respiratory inductance plethysmography, mental alertness from the Modified Observer’s Assessment of Alertness/Sedation Scale (MOAA/S), and AB severity on a 0 to 4 scale (categories ranging from none to severe) from the SVM. The primary outcome measure was sensitivity and specificity for AB to detect OIRD. RESULTS: All respiratory measurements were obtained from unperturbed subjects during steady state in 121 assessments with complete data. The sensitivity of AB for detecting OIRD by the conventional method was 92% and specificity was 28%. As expected, 69 (72%) of the instances not diagnosed as OIRD using conventional measures were observed to have at least moderate AB. CONCLUSIONS: AB was frequently present in the absence of traditionally detected OIRD as defined by reduced mental alertness (MOAA/S score of <4) and bradypnea (RR <8 breaths/min). These results justify the need for future trials to explore replicability with other opioids and clinical utility of AB as an add-on measure in recognizing OIRD.]]> Fri, 23 Aug 2024 00:00:00 GMT-05:00 00000539-990000000-00922 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/subphenotypes_in_acute_respiratory_distress.908.aspx Patients with acute respiratory distress syndrome (ARDS) have severe respiratory impairment requiring mechanical ventilation resulting in high mortality. Despite extensive research, no effective pharmacological interventions have been identified in unselected ARDS, which has been attributed to the considerable heterogeneity. The identification of more homogeneous subgroups through phenotyping has provided a novel method to improve our pathophysiological understanding, trial design, and, most importantly, patient care through targeted interventions. The objective of this article is to outline a structured, stepwise approach toward identifying and classifying heterogeneity within ARDS and subsequently derive, validate, and integrate targeted treatment options. We present a 6-step roadmap toward the identification of effective phenotype-targeted treatments: development of distinct and reproducible subphenotypes, derivation of a possible parsimonious bedside classification method, identification of possible interventions, prospective validation of subphenotype classification, testing of subphenotype-targeted intervention prospectively in randomized clinical trial (RCT), and finally implementation of subphenotype classification and intervention in guidelines and clinical practice. Based on this framework, the current literature was reviewed. Respiratory physiology, lung morphology, and systemic inflammatory biology subphenotypes were identified. Currently, lung morphology and systemic inflammatory biology subphenotypes are being tested prospectively in RCTs.]]> Mon, 19 Aug 2024 00:00:00 GMT-05:00 00000539-990000000-00908 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/methylphenidate_reversal_of.894.aspx BACKGROUND: Dexmedetomidine and ketamine have long elimination half-lives in humans and have no clinically approved reversal agents. Methylphenidate enhances dopaminergic and noradrenergic neurotransmission by inhibiting reuptake transporters for these arousal-promoting neurotransmitters. Previous studies in rats demonstrated that intravenous methylphenidate induces emergence from isoflurane and propofol general anesthesia. These 2 anesthetics are thought to act primarily through enhancement of inhibitory Gamma-aminobutyric acid type A (GABAA) receptors. In this study, we tested the behavioral and neurophysiological effects of methylphenidate in rats after low and high doses of dexmedetomidine (an alpha-2 adrenergic receptor agonist) and ketamine (an N-methyl-D-aspartate [NMDA] receptor antagonist) that induce sedation and unconsciousness, respectively. METHODS: All experiments used adult male and female Sprague-Dawley rats (n = 32 total) and all drugs were administered intravenously in a crossover, blinded experimental design. Locomotion after sedating doses of dexmedetomidine (10 µg/kg) or ketamine (10 mg/kg) with and without methylphenidate (5 mg/kg) was tested using the open field test (n = 16). Recovery of righting reflex after either high-dose dexmedetomidine (50 µg/kg) or high-dose ketamine (50 mg/kg) with and without methylphenidate (1–5 mg/kg) was assessed in a second cohort of rats (n = 8). Finally, in a third cohort of rats (n = 8), frontal electroencephalography (EEG) was recorded for spectral analysis under both low and high doses of dexmedetomidine and ketamine with and without methylphenidate. RESULTS: Low-dose dexmedetomidine reduced locomotion by 94% in rats. Methylphenidate restored locomotion after low-dose dexmedetomidine (rank difference = 88.5, 95% confidence interval [CI], 70.8–106) and the effect was blocked by coadministration with a dopamine D1 receptor antagonist (rank difference = 86.2, 95% CI, 68.6–104). Low-dose ketamine transiently attenuated mobility by 58% and was not improved with methylphenidate. Methylphenidate did not affect the return of righting reflex latency in rats after high-dose dexmedetomidine nor ketamine. Frontal EEG analysis revealed that methylphenidate reversed spectral changes induced by low-dose dexmedetomidine (F [8,87] = 3.27, P = .003) but produced only transient changes after high-dose dexmedetomidine. Methylphenidate did not induce spectral changes in the EEG after low- or high-dose ketamine. CONCLUSIONS: Methylphenidate reversed behavioral and neurophysiological correlates of sedation, but not unconsciousness, induced by dexmedetomidine. In contrast, methylphenidate did not affect sedation, unconsciousness, nor EEG signatures in rats after ketamine. These findings suggest that methylphenidate may be efficacious to reverse dexmedetomidine sedation in humans.]]> Wed, 07 Aug 2024 00:00:00 GMT-05:00 00000539-990000000-00894 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/running_late.842.aspx No abstract available]]> Thu, 13 Jun 2024 00:00:00 GMT-05:00 00000539-990000000-00842 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/implementation_of_a_multidisciplinary_team_to.841.aspx For the first time in history, people age older than 65 years make up >20% of the non-metro population, compared with 16% of the metro population. From 2010 to 2020 the nonmetro population age older than 65 years grew by 22%, while the working-age population declined by 4.9%, and the population aged under 18 years declined by 5.7%.1,2 Multidisciplinary geriatric surgical programs are an increasingly recognized approach to the care of older surgical patients and preliminary data suggest they can reduce length of stay. Although rural areas have the greatest proportion of patients age older than 65 years, implementation of such programs faces special challenges in rural settings with limited resources. Dartmouth-Hitchcock Medical Center is one of the most rural academic centers in the United States. Challenges include a shortage of geriatric-trained providers, long distances to access primary care and subspecialists, and extremely limited postacute care options and skilled nursing facility beds. To address the unique needs of our provider and patient population we began with a development period where we conducted stakeholder interviews. Using these data, we mapped out a workflow and developed pilot projects to address different portions of the workflow, such as preoperative screening for frailty and cognitive impairment, interdisciplinary weekly case conferences, proactive case management, delirium and geriatric surgery postoperative pathway order sets, and a variety of tools for reorientation and delirium management. Herein we describe the process of development and pragmatic clinical implementation of geriatric-focused care for older surgical patients in our rural tertiary center, including some of the main challenges we faced and the strategies we undertook to overcome them, and some of our early patient centered and clinical outcomes. This information may assist other institutions as they design geriatric-focused surgical programs to address the growing population of older adults and the need for compliance with state legislation. The clinical program described is not a research study, and the outcome data we report is for the purpose of description, and should not be interpreted as a rigorous research investigation of the effect of our intervention.]]> Wed, 12 Jun 2024 00:00:00 GMT-05:00 00000539-990000000-00841 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/women_in_anesthesiology_and_the_mid_career_stall_.716.aspx Women anesthesiologists face many challenges when trying to advance their careers and find balance in personal and professional endeavors. In this article, we introduce the reader to several concepts central to understanding the challenges faced by mid-career women anesthesiologists and highlight why these challenges become particularly pronounced when women enter the mid-career stage. We describe how lack of constructive actionable feedback combined with lack of mentorship and sponsorship negatively affects women in the workplace. We also outline barriers and bias that mid-career women anesthesiologists face in high-level leadership roles along with the disproportionally high burden of nonpromotable work. We present a discussion of mistreatment and burnout, which are compounded by concurrent demands of parenthood and a professional career. We conclude with the impact that these barriers have on mid-career women anesthesiologists and recommendations for mitigating these challenges. They include a systematic increase in mentorship and sponsorship, an individualized professional development strategy, and an improved and comprehensive approach to promotion.]]> Tue, 30 Jan 2024 00:00:00 GMT-06:00 00000539-990000000-00716 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/data_and_metrics_for_patient_blood_management__a.615.aspx Data collection, analysis, and reporting are fundamental for a successful hospital-based patient blood management program; however, very little has been published on the topic. Our aim was to synthesize evidence from a literature review to provide a detailed, practical list of outcome metrics, and the required data collection(s) to inform implementation. Ovid MEDLINE and PubMed were searched for any full-text original research articles published from inception to the year 2020. We included any studies reporting the implementation of interventions or programs study authors defined as “patient blood management” and extracted information on data collected and metrics reported. We included 45 studies describing the implementation of a patient blood management program and/or strategies. The outcomes reported by these studies were grouped into 1 of 36 metrics. We compiled a list of 65 relevant data elements to collect, and their potential source hospital information systems: patient administration, laboratory, transfusion/blood bank, operating room, pharmacy, emergency department, and intensive care unit. We further categorized patient blood management data systems into basic, intermediate, and advanced based on the combination of different information systems sourced. The results of this review can be used to inform patient blood management programs in planning what data collection(s) are needed, where these data can be sourced from, and how they can be analyzed.]]> Tue, 08 Aug 2023 00:00:00 GMT-05:00 00000539-990000000-00615 https://journals.lww.com/anesthesia-analgesia/fulltext/9900/assessments_of_onset_and_duration_of_drug_effects.51.aspx No abstract available]]> Fri, 15 Jan 2021 00:00:00 GMT-06:00 00000539-990000000-00051 https://journals.lww.com/anesthesia-analgesia/fulltext/9000/research_productivity_and_rankings_of.97189.aspx BACKGROUND: To evaluate the relative research productivity and ranking of anesthesiology departments in Canada and the United States, using the Hirsch index (h-index) and 4 other previously validated metrics. METHODS: We identified 150 anesthesiology departments in Canada and the United States with an accredited residency program. Publications for each of the 150 departments were identified using Thomson’s Institute for Scientific Information Web of Science, and the citation report for each department was exported. The bibliometric data were used to calculate publication metrics for 3 time periods: cumulative (1945–2014), 10 years (2005–2014), and 5 years (2010–2014). The following group metrics were then used to determine the publication impact and relative ranking of all 150 departments: h-index, m-index, total number of publications, sum of citations, and average number of citations per article. Ranking for each metric were also stratified by using a proxy for departmental size. The most common journals in which US and Canadian anesthesiology departments publish their work were identified. RESULTS: The majority (23 of the top 25) of top-ranked anesthesiology departments are in the United States, and 2 of the top 25 departments (University of Toronto; McGill University) are in Canada. There was a strong positive relationship between each of h-index, total number of publications, and the sum of citations (0.91–0.97; P < .0001). Departmental size correlates with increased academic productivity on most metrics. The most frequent journals in which US and Canadian anesthesiology departments publish are Anesthesiology, Anesthesia and Analgesia, and the Canadian Journal of Anesthesia. CONCLUSIONS: Our study ranked the Canadian and US anesthesiology departmental research productivity using the h-index applied to each department, total number of publications, total number of citations, and average number of citations. The strong relationship between the h-index and both the number of publications and number of citations of anesthesiology departments shows that the departments with the highest number of publications are also producing research with the most highly cited articles (ie, most impact), as demonstrated by the h-index. Accepted for publication August 17, 2017. Funding: This study has been partially funded by the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa. S.B. was supported by The Ottawa Hospital Anesthesia Alternate Funds Association. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Sylvain Boet is the archival author. Reprints will not be available from the authors. Address correspondence to Sylvain Boet, MD, PhD, Anesthesiology and Pain Medicine & Department of Innovation in Medical Education, the Ottawa Hospital, University of Ottawa, and the Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada. Address e-mail to sboet@toh.ca. © 2020 International Anesthesia Research Society]]> Mon, 05 Mar 2018 00:00:00 GMT-06:00 00000539-900000000-97189 https://journals.lww.com/anesthesia-analgesia/fulltext/9000/expression_of_concern.97166.aspx No abstract available]]> Thu, 12 Oct 2017 00:00:00 GMT-05:00 00000539-900000000-97166