Anesthesiology News
Towards early individual goal-directed coagulation management in trauma patients
Major trauma is associated with significant blood loss due to both the severity of injuries and trauma-related coagulopathy. Acute coagulopathy in trauma patients is frequent and has been associated with a worse clinical outcome. In this issue of the British Journal of Anaesthesia, Fries and Martini review the mechanisms of trauma-related coagulopathy and the central role of fibrinogen in its treatment.
Validity of the 6 min walk test in prediction of the anaerobic
threshold before major non-cardiac surgery
The assessment of exercise capacity before major non-cardiac surgery is recommended to help improve risk prediction perioperatively at the individual patient level.1 2 There are two principal methods utilized in clinical practice in the UK: acardiopulmonary exercise test (CPET) and patient-reported metabolic equivalent (MET) scores. A CPET is generally regarded as the ‘gold standard’ assessment, providing objective rather than subjective analysis of exercise capacity. Specific measurements obtained during testing have been
validated in the prediction of perioperative risk for major noncardiac surgery.
The effect of intravenous tranexamic acid on blood loss and surgical field quality during endoscopic sinus surgery: a placebo-controlled clinical trial
Measurements: Amount of blood loss and bleeding and satisfaction scores were obtained from the surgeon. Main Results: Blood loss in the TA group was 184 ± 64 mL and in the placebo group, 312 ± 75 mL on average (P < 0.01). The median (range) bleeding score in the TA group was significantly lower than the placebo group [2 (1-3) vs 2.5 (2-4); P < 0.0001]. The surgeon was more satisfied with the surgical field in the TA group than the placebo group [median score: 4 (3-5) vs 3 (1-5), P < 0.001].
Direct effect of morphine on breast cancer cell function in vitro: role of the NET1 gene
Experimental data suggest that postoperative analgesia in general and opioids in particular may affect the risk of metastases after primary cancer surgery. Perioperative single-gene activation may also spark metastatic disease. The NET1 gene promotes migration in adenocarcinoma cells. The authors investigated opioid receptor expression in both breast cancer cell lines and the direct effect of morphine and NET-1 on breast cancer cell migration in vitro and found that the NET1 gene, but not opioid receptors, is expressed in breast adenocarcinoma cells and may facilitate their migration. Morphine increased both expression of NET1 and cell migration but not when NET1 was silenced, implying that NET1 contributes to mediating the direct effect of morphine on breast cancer cell migration.
Protective and Detrimental Effects of Sodium Sulfide and Hydrogen Sulfide in Murine Ventilator-induced Lung Injury
The antiinflammatory effects of hydrogen sulfide (H2S) and sodium sulfide (Na2S) treatment may prevent acute lung injury induced by high tidal volume (HVT) ventilation. However, lung protection may be limited by direct pulmonary toxicity associated with H2S inhalation. Therefore, the authors tested whether the inhalation of H2S or intravascular Na2S treatment can protect against ventilator-induced lung injury in mice.
The Etomidate Requirement Is Decreased in Patients with Obstructive Jaundice
Patients with obstructive jaundice have increased sensitivity to inhaled anesthetics. In rodent brain, bilirubin can enhance γ-aminobutyric acid A/glycinergic synaptic transmission. Etomidate is a nonbarbiturate hypnotic that induces sedation through γ-aminobutyric acid A receptors in the central nervous system. We tested the hypothesis that patients with obstructive jaundice have an altered sensitivity to etomidate.
Mixed venous oxygen saturation predicts short- and long-term outcome after coronary artery bypass grafting surgery
Complications of an inadequate haemodynamic state are a leading cause of morbidity and mortality after cardiac surgery. Unfortunately, commonly used methods to assess haemodynamic status are not well documented with respect to outcome. The aim of this study was to investigate 
as a prognostic marker for short- and long-term outcome in a large unselected coronary artery bypass grafting (CABG) cohort and in subgroups with or without treatment for intraoperative heart failure.
Two thousand seven hundred and fifty-five consecutive CABG patients and subgroups comprising 344 patients with and 2411 patients without intraoperative heart failure, respectively, were investigated. 
was routinely measured on admission to the intensive care unit (ICU). The mean (SD) follow-up was 10.2 (1.5) yr. Overall it was found that 
<60% on admission to ICU was related to worse short- and long-term outcome after CABG, regardless of whether the patients were admitted to ICU with or without treatment for intraoperative heart failure.
Emerging modes of ventilation in the intensive care unit
Potentially harmful effects of positive pressure mechanical ventilation have been recognized since its inception in the 1950s. Since then, the risk factors for and mechanisms of ventilator-induced lung injury (VILI) have been further characterized. Publication of the ARDSnet tidal volume trial in 2000 demonstrated that a ventilator strategy limiting tidal volumes and plateau pressure in patients with acute respiratory distress syndrome was associated with a 22% reduction in mortality. Since then, a variety of ventilator modes have emerged seeking to improve gas exchange, reduce injurious effects of ventilation, and improve weaning from the ventilator. We review here emerging ventilator modes in the intensive care unit (ICU).
Pain on injection of propofol: a comparison of methylene blue and lidocaine
The authors sought to investigate whether methylene blue, given before injection of propofol, was effective in reducing the frequency and severity of pain associated with propofol injection. Patients were randomly allocated to one of three groups of 30 patients each. Group I received 50 mg of methylene blue, Group II received 40 mg of lidocaine, and Group III, the control group, was given normal saline. All drugs were given as a 2.0 mL bolus 45 seconds before propofol administration. Pain frequency was 90% in the saline group, whereas the frequencies were significantly lower in the lidocaine and methylene blue groups (26.7% and 40%, respectively). Overall it was found that Intravenous pretreatment with methylene blue appears to be effective in reducing the pain during propofol injection.
A comparison of low vs conventional-dose heparin for minimal cardiopulmonary bypass in coronary artery bypass grafting surgery
The biocompatibility of minimal extracorporeal circuits has improved; however, anticoagulation is still required. We compared standard high-dose anticoagulation with a low-dose heparin regimen in a retrospective study of patients who underwent coronary bypass surgery using minimal cardiopulmonary bypass. One hundred patients who received 300 IU.kg−1 heparin were compared with 68 patients who received heparin according to an individually adjusted activated coagulation time target of 300 s, resulting in a mean (SD) heparin dose of 145 (30) IU.kg−1. There were no thromboembolic events in either group; however, patients in the low-dose group had lower 24-hour mean (SD) postoperative blood loss than the conventional group (545 (61) vs 680 (88) ml, p = 0.001) and a reduced rate of transfusion of allogeneic blood (15% patients transfused vs 32%, p = 0.01). An individually tailored low-dose heparin regimen for minimal cardiopulmonary bypass is safe and may be associated with reduced bleeding and lower transfusion requirements
Remifentanil as single agent to facilitate awake fibreoptic intubation in the absence of premedication
Remifentanil is increasingly being used as the primary agent to provide sedation during awake fibreoptic nasal intubation. In this observational study, we aimed to determine the optimal effect site concentration of remifentanil, using a target controlled infusion based on the Minto pharmacological model, to provide optimal safe intubation conditions without the use of other sedatives/premedication and/or spray-as-you-go local anaesthesia. Twenty patients with anticipated difficult airway participated in the study. Good intubating conditions were achieved in all patients with mean (SD) effect site concentration of 6.3 (3.87) ng.ml−1 of remifentanil recorded at nasal endoscopy and 8.06 (3.52) ng.ml−1 during tracheal intubation. No serious adverse event occurred during any of these procedures. These preliminary findings suggest that this is a feasible and safe technique for awake fibreoptic nasal intubation.
Efficacy of pregabalin in acute postoperative pain: a meta-analysis
Multimodal treatment of postoperative pain using adjuncts such as gabapentin is becoming more common. Pregabalin has anti-hyperalgesic properties similar to gabapentin. In this systematic review, we evaluated randomized, controlled trials (RCTs) for the analgesic efficacy and opioid-sparing effect of pregabalin in acute postoperative pain. A systematic search of Medline (1966–2010), the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar was performed. We identified 11 valid RCTs that used pregabalin for acute postoperative pain. Postoperative pain intensity was not reduced by pregabalin. Cumulative opioid consumption at 24 h was significantly decreased with pregabalin. At pregabalin doses of <300 mg, there was a reduction of 8.8 mg [weighted mean difference (WMD)]. At pregabalin doses ≥300 mg, cumulative opioid consumption was even lower (WMD, −13.4 mg). Pregabalin reduced opioid-related adverse effects such as vomiting [risk ratio (RR) 0.73; 95% confidence interval (CI) 0.56–0.95]. However, the risk of visual disturbance was greater (RR 3.29; 95% CI 1.95–5.57). Perioperative pregabalin administration reduced opioid consumption and opioid-related adverse effects after surgery.
New Twist in Colloids-Crystalloids Tussle
The long-standing debate over whether colloid or crystalloid solutions make better volume-expanders for surgical and trauma patients has taken a surprising turn, with allegations of research fraud engulfing a well-known proponent of certain colloids.
Joachim Boldt, MD, PhD, until recently of the Klinikum der Stadt Ludwigshafen in Germany, has been accused of having fabricated entire studies, failing to obtain IRB approval for studies that were conducted, and forging names of co-authors on manuscript submissions.
Is replacement of albumin in major abdominal surgery useful?
The authors evaluated retrospectively serum albumin concentrations as well as morbidity and mortalitiy of abdominal surgical patients who –if hypoalbuminemic– did not receive human albumin solutions versus those who did receive such solutions. The records of 76 consecutive patients who had undergone elective abdominal surgery were reviewed. Preoperative and postoperative serum albumin concentrations up to the seventh day after surgery were recorded. Morbidity and mortality were followed until the time of discharge from the hospital. After analysis it was found that postoperative serum albumin concentration had no correlation with postoperative morbidity. There is no justification for perioperative albumin replacement in abdominal cancer surgical patients.
Continuous S-(+)-ketamine administration during elective coronary artery bypass graft surgery attenuates pro-inflammatory cytokine response during and after cardiopulmonary bypass
Coronary artery bypass surgery (CABG) with cardiopulmonary bypass (CPB) leads to elevated circulating plasma cytokines. In this prospective randomized study, the effect of an S-(+)-ketamine-based anaesthetic protocol on perioperative plasma cytokine levels was compared with standard anaesthesia with propofol and sufentanil during CPB. The data in this study demonstrates that S-(+)-ketamine possesses anti-inflammatory potential. Anaesthesia with S-(+)-ketamine may have beneficial effects in attenuating the CPB-induced systemic inflammatory response.
Can plasma B-type natriuretic peptide levels predict need for mechanical ventilation after injury?
B-type natriuretic peptide (BNP) is a neurohormone released from cardiomyocytes in response to volume expansion and increased ventricular wall distension. Increased plasma BNP levels are associated with mortality in critically ill patients cared for in medical intensive care units (ICUs). Additionally, plasma BNP levels may serve as a biomarker for excessive fluid resuscitation after injury. The utility of plasma BNP levels as a prognosticator of outcomes after injury has not been previously described. The purpose of this study was to describe the change in plasma BNP levels over the first 48 hours after injury and determine if there was a correlation between plasma BNP levels and clinical outcomes. Overall the changes in plasma BNP levels over the first 24 hours after ICU admission may have prognostic value in determining the need for mechanical ventilation in patients admitted to ICUs after injury. Additionally, the correlation between plasma BNP levels at 24 hours and mechanical ventilation requirements is not due solely to resuscitation volume. Further studies examining the prognostic value of plasma BNP levels after injury are warranted.
Childbirth deaths from spinal anesthesia rising
The number of U.S. women who die from anesthesia complications during childbirth has fallen sharply in recent decades. But deaths specifically related to so-called regional anesthesia, which includes epidurals and spinal blocks, have crept upward since the mid-1990s, a new study finds.
Sonographic diagnosis of pneumothorax
Over the last decade, the use of ultrasound as a technique to look for pneumothorax has rapidly evolved. This review aims to analyze and synthesize current knowledge on lung ultrasound targeted at the diagnosis of pneumothorax. The technique and its usefulness in different scenarios are explained, and its merits over conventional radiology are highlighted.
Hemodynamic changes in children with Down syndrome during and following inhalation induction of anesthesia with sevoflurane
This article evaluated whether children with Down Syndrome are at increased risk of bradycardia and hypotension during and following sevoflurane induction. The Down syndrome group was more likely to experience bradycardia and had greater decreases in HR from baseline. These findings were similar for children with or without congenital heart defects. There were no differences between groups in the number who were treated with a pharmacologic agent.
Effects of high intraoperative inspired oxygen on postoperative nausea and vomiting in gynecologic laparoscopic surgery
This article sought to assess the efficacy of intraoperative inspired oxygen fractions (FIO2) of 0.8 and 0.5 when compared with standard FIO2 of 0.3 in the prevention of postoperative nausea and vomiting (PONV). Patients were randomized to receive a gas mixture of 30% oxygen in air (FIO2 = 0.3, Group G30), 50% oxygen in air (FIO2 = 0.5, Group G50), or 80% oxygen in air (FIO2 = 0.8, Group G80); there were 36 patients in each group. A standardized sevoflurane general anesthesia, postoperative pain management, and antiemetic regimen were used. High intraoperative FIO2 of 0.8 and FIO2 of 0.5 do not prevent PONV in patients without antiemetic prophylaxis. An intraoperative FIO2 of 0.8 has a beneficial effect on early vomiting only.
Anesthesia Journal Retracts Fluid Paper Over Ethics Concerns, Possible Fraud
Joachim Boldt, MD, PhD, a leading German anesthesiologist with more than 200 papers to his name, has been accused of “very serious misrepresentations” in a paper he published late last year in the journal Anesthesia & Analgesia.
In a retraction notice published online Oct. 28, Steven L. Shafer, editor-in-chief of the journal, wrote that Dr. Boldt and his co-authors did not obtain approval from an institutional review board or informed consent from patients in their December 2009 article, “Cardiopulmonary bypass priming using a high dose of a balanced hydroxyethyl starch versus an albumin-based priming system.”
Legal, Clinical Data Paint Conflicting Picture of Cricoid Pressure
Lawsuits on behalf of patients who aspirate their stomach contents during or shortly after surgery are nearly twice as likely to involve the death of the patient as other malpractice claims related to anesthesia, Washington researchers have found. What’s more, although cases in which clinicians applied cricoid pressure along with rapid sequence induction tended to result in smaller damage awards, the procedure was used in roughly half of aspiration claims—“raising the question of its effectiveness,” the researchers said.
Postoperative Activity, but Not Preoperative Activity, of Antithrombin Is Associated with Major Adverse Cardiac Events After Coronary Artery Bypass Graft Surgery
Low levels of antithrombin (AT) have been independently associated with prolonged intensive care unit stay and an increased incidence of neurologic and thromboembolic events after cardiac surgery. This article hypothesized that perioperative AT activity is independently associated with postoperative major adverse cardiac events (MACEs) in patients undergoing coronary artery bypass graft (CABG) surgery. It found that preoperative AT activity is not associated with MACE after CABG surgery. MACE is independently associated with postoperative AT activity but only at time points occurring predominantly after the MACE.
Propofol Headed for Controlled Substance Schedule
The Drug Enforcement Administration plans to add the sedative propofol to its roster of scheduled drugs. The agency is circulating a proposed rule that would classify propofol as a Schedule IV substance, putting it in the same category as midazolam, diazepam, lorazepam and the sleeping aid zolpidem, according to a DEA official familiar with the decision. Schedule IV drugs “are known to produce euphoric moods as adverse events and have histories of abuse” in the United States and abroad.
Duloxetine reduces morphine requirements after knee replacement surgery
Multimodal analgesia is advocated for perioperative pain management to reduce opioid use and its associated adverse effects. Serotonin and norepinephrine are involved in the modulation of endogenous analgesic mechanisms via descending inhibitory pain pathways in the brain and spinal cord. An increase in serotonin and norepinephrine may increase inhibition of nociceptive input and improve pain relief. Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor, has demonstrated efficacy in chronic pain conditions such as painful diabetic neuropathy and post-herpetic neuralgia. The objective of the study was to evaluate the efficacy of duloxetine in reducing morphine requirements in patients after knee replacement surgery. Overall perioperative administration of duloxetine reduced postoperative morphine requirements during the first 48 h after knee replacement surgery, without significant adverse effects.
Preoperative Statin Therapy Is Not Associated with a Reduced Incidence of Postoperative Acute Kidney Injury After Cardiac Surgery
The objective of this study was to examine the association between preoperative statin therapy and the prevalence of postoperative acute kidney injury (AKI) in patients undergoing cardiac surgery with the use of cardiopulmonary bypass. In 2646 propensity-matched pairs, the incidence of AKI was 12.0% in the statin group versus 12.8% in the no statin group (P = 0.38). The statin group had a 1.63% incidence of postoperative dialysis versus 2.08% in the no statin group (P = 0.22). In the same propensity-matched population, hospital mortality occurred in 1.63% of patients in the statin group compared with 2.1% in the no statin group (P = 0.19). These results suggest that previously reported reductions in perioperative mortality for patients taking preoperative statins and undergoing cardiac surgery is likely not mediated through a reduction in postoperative AKI.
Activation of Central Opioid Receptors Induces Cardioprotection Against Ischemia-Reperfusion Injury
Small doses of intrathecal morphine provide cardioprotection similar to that conferred by IV morphine and ischemic preconditioning (IPC). This article investigated the relative role of central versus peripheral opioid receptors in intrathecal morphine preconditioning (ITMPC). The infarct size/area-at-risk were significantly reduced in the IPC (22% ± 3%) and ITMPC (26% ± 5%) groups compared with the control group (48% ± 9%) (P < 0.01). The addition of ITNM reversed the cardioprotective effects of ITMPC (45% ± 4%), whereas IV administration of the drug did not have any effect on ITMPC (28% ± 9%, P < 0.01).
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