Anesthesiology News
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).
No difference between femoral nerve block and fascia iliaca block for analgesia following reconstructive knee surgery in adolescents
An article in the Journal of Clinical Anesthesia compared the femoral nerve block with the fascia iliaca block for postoperative analgesia in adolescents undergoing reconstructive knee surgery. Overall there was no difference between the femoral nerve block and the fascia iliaca nerve block in VAS pain scores or postoperative morphine consumption. Either the femoral nerve block or the fascia iliaca block, followed by patient-controlled analgesia with morphine, provides efficacious analgesia for adolescents undergoing ACL reconstruction.
Etomidate Decreases Cortisol Levels in Patients After Use in Intubation
An article out the Annals of Emergency Medicine the evidence on the effect of a bolus dose of etomidate on adrenal function, mortality, and health services utilization compared with other induction agents used for rapid sequence intubation. Overall it found that the mean cortisol levels were lower in elective surgical patients induced with etomidate compared with those induced with other agents between 1 and 4 hours postinduction. The differences varied from 6.1 μg/dL (95% confidence interval [CI] 2.4 to 9.9 μg/dL; P=.001) to 16.4 μg/dL (95% CI 9.7 to 23.1 μg/dL; P<.001). Two studies in critically ill patients reported significantly different cortisol levels up to 7 hours postinduction. None of the studies reviewed, nor our pooled estimate (odds ratio 1.14; 95% CI 0.81 to 1.60), showed a statistically significant effect on mortality. Only one study reported longer ventilator, ICU, and hospital lengths of stay in patients intubated with etomidate.
Improved Glottic Exposure With the Video Macintosh Laryngoscope in Adult Emergency Department Tracheal Intubations
Glottic visualization with video is superior to direct laryngoscopy in controlled operating room studies. However, glottic exposure with video laryngoscopy has not been evaluated in the emergency department (ED) setting, where blood, secretions, poor patient positioning, and physiologic derangement can complicate laryngoscopy. We measure the difference in glottic visualization with video versus direct laryngoscopy.
Comparison of ketamine and fentanyl with propofol in total intravenous anesthesia: a double blind randomized clinical trial
Propofol has emerged as a gold-standard for total inrtravenous anesthesia (TIVA) for short surgical interventions but lack of analgesia remains it’s main shortcoming therefore it is always combined with an analgesic. Ketamine and fentanyl are the popular analgesic in this context. This study was carried out to compare these drugs with propofol to assess hemodynamic and recovery profile of either combination. Time to spontaneous eye opening was similarly comparable in both the groups (8±3 min and 8±2 min) (p=0.53). Response to postoperative questionnaire at 30 minutes after anesthesia was good in both the groups. Incidence of postoperative nausea and vomiting was also insignificant statistically between both the groups. There were 5 patients in the Propofol-Fentanyl Group that developed hypotension that imporved with fluids. Overall it was shown that both ketamine and fentanyl are equally safe and efficacious with propofol for short surgical procedures.
Lung recruitment and positive airway pressure before extubation does not improve oxygenation in the post-anaesthesia care unit: a randomized clinical trial
Atelectasis is known to develop during anaesthesia and after operation atelectasis leads to impaired oxygenation. Lung recruitment manoeuvres, positive end-expiratory pressure (PEEP), and continuous positive airway pressure (CPAP) have been proposed for reduction of atelectasis but their benefits have not been shown to persist after operation. An article in this months British Journal of Anaesthesia proposed that a combination of these techniques before extubation would improve oxygenation after operation. It was found that postoperative oxygenation is not improved by a combination of a lung recruitment manoeuvre and maintenance of a positive airway pressure until extubation. Further research is needed to elucidate the mechanism of atelectasis on emergence from anaesthesia and to evaluate more invasive clinical strategies such as post-extubation CPAP.
Derivation and Validation of a Simple Perioperative Sleep Apnea Prediction Score
Obstructive sleep apnea (OSA) is a largely underdiagnosed, common condition, which is important to diagnose preoperatively because it has implications for perioperative management. Our purpose in this study was to identify independent clinical predictors of a diagnosis of OSA in a general surgical population, develop a perioperative sleep apnea prediction (P-SAP) score based on these variables, and validate the P-SAP score against standard overnight polysomnography. The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of these, 3884 patients (7.17%) had a documented diagnosis of OSA. Three demographic variables: age >43 years, male gender, and obesity; 3 history variables: history of snoring, diabetes mellitus Type 2, and hypertension; and 3 airway measures: thick neck, modified Mallampati class 3 or 4, and reduced thyromental distance were identified as independent predictors of a diagnosis of OSA. A diagnostic threshold P-SAP score ≥2 showed excellent sensitivity (0.939) but poor specificity (0.323), whereas for a P-SAP score ≥6, sensitivity was poor (0.239) with excellent specificity (0.911).
Assessment of the Effects of Desmopressin on Impaired Platelet Function Using Multiple Electrode Whole-Blood Aggregometry in Patients After Cardiac Surgery
Blood loss after cardiac surgery can be caused by acquired platelet dysfunction after cardiopulmonary bypass. Monitoring of platelet function is clinically important for the identification of patients experiencing such platelet dysfunction. 1-Deamino-8-d-arginine vasopressin (desmopressin acetate, DDAVP) has been shown to augment platelet function and to reduce blood loss in patients with platelet dysfunction. In this study, we examined the feasibility of whole blood multiple electrode aggregometry (MEA) for the detection of cardiopulmonary bypass–induced platelet dysfunction and investigated its ability to monitor DDAVP treatment. This study showed that Impaired platelet function after cardiac surgery can be assessed at the bedside using MEA. The effect of DDAVP on impaired platelet function can also be detected as significant improvement in platelet aggregation to all activators. This device might be helpful for the identification of patients who may benefit from DDAVP therapy.
Two Agents, One Syringe Provides Effective Anesthetic
A single syringe of remifentanil and propofol can deliver safe, effective IV anesthesia to patients undergoing ambulatory orthopedic surgery, a recent study has found.
The researchers, from the University of Utah, say their results may be hard for some clinicians to accept, given what they have been told to believe about total IV anesthesia (TIVA).
Plasmapheresis and Heparin Reexposure as a Management Strategy for Cardiac Surgical Patients with Heparin-Induced Thrombocytopenia
Anesthesia & Analgesia
A retrospective chart review between November 2004 and March 2008 retrieved perioperative clinical and laboratory data for 11 adult cardiac surgical patients with a preoperative history of HIT and a current positive antiheparin/platelet factor 4 (anti-HPF4) antibody titer, who were managed with plasmapheresis and heparin anticoagulation. Three of the 11 patients (27%) died of causes unrelated to HIT and 1 of these patients (9%) developed an ischemic foot, in the setting of cardiogenic shock, not thought to be HIT-related. A single plasmapheresis treatment reduced titers by 50%–84%, and 6 patients had negative titers after treatment; none of the 3 patients with reduced titers developed clinical HIT. Reducing antibody load can potentially decrease the thrombotic risk associated with high anti-HPF4 titers and decrease the urgency to initiate postoperative anticoagulation in this patient group at high risk of postoperative bleeding.
Protocol Designed for Rapid Response to Epidural Hematoma
The devastating neurologic complications that sometimes accompany epidural hematoma may be a thing of the past at Vanderbilt University Medical Center in Nashville, Tenn. Clinicians at the institution have implemented an expedited protocol for magnetic resonance imaging that involves several different medical specialties and significantly decreases the time from detection of neurologic symptoms to diagnosis.
Sugammadex reversal of rocuronium-induced NMB unaffected by volatile anesthetics
Sugammadex is equally effective for reversing rocuronium-induced neuromuscular blockade (NMB) in patients receiving maintenance anesthesia with sevoflurane or propofol, researchers report.
Analgesia for Total Hip and Knee Arthroplasty: A Review of Lumbar Plexus, Femoral, and Sciatic Nerve Blocks
Use of peripheral nerve blocks (PNBs) during lower extremity surgery has evolved. In this article, we review the pertinent anatomy and the literature concerning the advantages and disadvantages of both PNBs and traditional methods of postoperative analgesia (neuraxial and patient-controlled) for total hip arthroplasty and total knee arthroplasty.
Unilateral anesthesia possible with bupivacaine–clonidine combination
Unilateral spinal anesthesia can be achieved when bupivacaine is combined with clonidine, but clonidine does prolong the motor block and increase the need for vasopressors, researchers report. “Hyperbaric bupivacaine in small doses effectively produces unilateral spinal anesthesia for outpatient surgery,” Riika Merivirta (Turku University Hospital, Surgical Hospital, Finland) and colleagues point out.
A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study
An optimal target for glucose control in ICU patients remains unclear. This prospective randomized controlled trial compared the effects on ICU mortality of intensive insulin therapy (IIT) with an intermediate glucose control.
Continuous Renal Replacement Therapy (CRRT)
CRRT is a mode of renal replacement therapy for hemodynamically unstable, fluid overloaded patients and patients with sepsis and septic shock inmanagement of acute renal failure especially in the intensive careunit setting. The popularity of ‘slow continuous therapies’ for the treatment ofcritically ill patients with renal failure is increasing. The techniques which are most commonly used are slow continuous hemodialysis and hemodiafiltration.
