Summary: M. J. Avram. Image: A. Johnson, Vivo Visuals Studio.

Summary: M. J. Avram. Image: A. Johnson, Vivo Visuals Studio.

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There are no validated neurophysiologic biomarkers that predict postoperative cognitive function, but candidate biomarkers have emerged. Posterior electroencephalographic alpha power correlates with postanesthetic functional brain network recovery, and frontal-parietal connectivity is implicated with cognitive processing and delirium risk. Perioperative cerebral oximetry may predict postoperative cognitive function because cerebrovascular disease could contribute to perioperative neurocognitive dysfunction via ischemic and hypoxic injury. This study tested the hypothesis that preoperative resting-state posterior alpha power, alpha frontal-parietal connectivity, and cerebral oximetry would correlate with postoperative neurocognitive function in a prospective cohort study of 59 adult patients requiring general anesthesia for noncardiac surgery. The primary outcome was the postoperative National Institutes of Health Cognition Toolbox score, defined as the average fully corrected (for age, sex, race, ethnicity, and level of education) T-score from tests that assess executive function, attention, working memory, and processing speed, which are cognitive domains affected by delirium. Neither preoperative posterior alpha power, frontal-parietal connectivity, nor cerebral oximetry measures were associated with postoperative cognitive function. See the accompanying Editorial on page 557.

Summary: M. J. Avram. Image: Adobe Stock.

Summary: M. J. Avram. Image: Adobe Stock.

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California’s 2017 balance billing law prohibits balance bills for patients in fully insured health plans who received nonemergency care at in-network hospitals, ambulatory surgery centers, laboratories, and imaging centers. The hypothesis that there would be no change in in-network payment amounts for anesthesia care and a decline in both out-of-network payment amounts and the portion of claims occurring out-of-network after implementation of the law was tested using average, quarterly, California county-level payment data (2013 to 2020) derived from a claims database of commercially insured patients. The association between implementation of the law and payments for anesthesia care was estimated using a difference-in-differences approach. A policy significant change was defined as a change of at least 10% in payments to practitioners or incidence of out-of-network billing. The sample consisted of 43,728 procedure code-county-quarter-network combinations aggregated from 4,599,936 claims. In the first 3 yr after its implementation, the law was associated with increases in in-network payment amounts that did not meet the policy significance threshold, declines in out-of-network payment amounts, and statistically insignificant increases in occurrence of out-of-network billing. See the accompanying Editorial on page 560.

Summary: M. J. Avram. Image: Adobe Stock.

Summary: M. J. Avram. Image: Adobe Stock.

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Single-shot suprascapular nerve block and superior trunk block are reported to provide noninferior analgesia after shoulder surgery with a lower incidence of hemidiaphragmatic paresis compared to interscalene brachial plexus block. The hypothesis that the analgesic effects of a continuous suprascapular nerve block are noninferior to those of a continuous superior trunk nerve block was tested in a double-blinded, randomized controlled study of 98 patients undergoing arthroscopic shoulder surgery under general anesthesia. The primary outcome was the worst and resting postoperative pain scores 24 h postoperatively. The extent of ipsilateral hemidiaphragmatic paresis was evaluated 24 h postoperatively to check the effect of the nerve block on the phrenic nerve. Both the worst and the resting 24-h postoperative numerical rating scale pain scores of the continuous suprascapular nerve block group were inferior to those of the continuous superior trunk block group. One continuous suprascapular nerve block patient had partial hemidiaphragmatic paresis at 24 h and nearly two-thirds of the continuous superior trunk block patients had complete or partial hemidiaphragmatic paresis.

Summary: M. J. Avram. Image: Adobe Stock.

Summary: M. J. Avram. Image: Adobe Stock.

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Postoperative atrial fibrillation is a complication occurring in 20 to 30% of cardiac surgery patients that is thought to be caused by acute surgery-related triggers acting in concert with a predisposing atrial or ventricular substrate. This secondary analysis of a randomized controlled trial evaluating the effect of posterior pericardiotomy on postoperative atrial fibrillation tested the hypothesis that baseline left atrial size and function, left ventricular diastolic function, and their intraoperative changes would be associated with postoperative atrial fibrillation independent of posterior pericardiotomy. Transesophageal echocardiography and hemodynamic measurements before sternotomy and after chest closure were used to evaluate immediate changes in left atrial size and function and left ventricular diastolic function. Intraoperative diastolic dysfunction was observed in 230 of 402 patients (57.2%), and 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Abnormal left ventricular diastolic function occurred in 75.0% of patients who developed postoperative atrial fibrillation and in 57.5% of those who did not. In multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63) and pericardiotomy (odds ratio, 0.46; 95% CI, 0.27 to 0.78) were the only covariates independently associated with postoperative atrial fibrillation.

Summary: M. J. Avram. Image: Adobe Stock.

Summary: M. J. Avram. Image: Adobe Stock.

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Decisions to extubate neurosurgical patients admitted to the intensive care unit are often made subjectively due to the scarcity of evidence, frequently leading to high rates of decisions to delay extubation. Physicians were surveyed for reasons for their decision to delay extubation in a cohort of 226 prospectively enrolled spontaneous breathing trial–qualified neurosurgical patients being mechanically ventilated for more than 24 h. Using the most common reasons for extubation delay, a diagnostic scoring system for the assessment of extubation readiness was developed that combined assessment points of airway protecting function and level of consciousness. The usefulness of this Swallowing, Tongue protrusion, Airway protection reflected by spontaneous and suctioning cough, and Glasgow Coma Scale Evaluation (STAGE) score in predicting extubation success in neurosurgical patients meeting other general extubation criteria was internally validated. Delayed extubation and extubation failure occurred in 25% (57 of 226) and 19% (43 of 226) of patients, respectively. The area under the receiver operating characteristic curve for the ability of the total STAGE score to predict extubation success was 0.72 (95% CI, 0.64 to 0.79).

Summary: M. J. Avram. Image: From original article.

Summary: M. J. Avram. Image: From original article.

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Spinal cord stimulation (SCS) has been used to treat refractory neuropathic pain. High-frequency SCS (10 kHz) has been shown to provide superior analgesia and better functionality than conventional low-frequency SCS (40 to 100 Hz). Pulsed radiofrequency at approximately 500 kHz has been used for pain treatment, but how epidural pulsed radiofrequency application may affect pain is unknown. The hypothesis that a novel pulsed ultrahigh-frequency SCS (pUHF-SCS) could safely and effectively inhibit neuropathic pain was tested in a rat model of spared nerve injury–induced neuropathic pain. An epidural pUHF-SCS (± 3 V, 2-Hz pulses comprising 500 kHz biphasic sinewaves) electrode was implanted at the thoracic vertebrae (T9 to T11). Analgesia was evaluated by von Frey filament–evoked allodynia. Mechanical paw withdrawal thresholds in the ipsilateral (left) hind paw were reduced from a mean ± SD of 21.9 ± 1.7 g at baseline to 1.0 ± 0.3 g after nerve injury. Repetitive 5-, 10-, and 20-min pUHF-SCS increased the reduced ipsilateral withdrawal thresholds to 13.3 ± 6.5, 18.5 ± 3.6, and 21.0 ± 2.8 g, respectively, at 5 h post-SCS and to 6.1 ± 2.5, 8.2 ± 2.7, and 14.3 ± 5.9 g, respectively, on the second day.

Summary: M. J. Avram. Image: Adobe Stock.

Summary: M. J. Avram. Image: Adobe Stock.

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The endothelial glycocalyx is a gel-like, protective layer of proteoglycans that lines the luminal surface of vascular endothelial cells. It serves as a barrier to vascular permeability, induces endothelial initiation of nitric oxide–mediated vasorelaxation in response to shear forces, provides anticoagulant effects, and shields endothelial cells from oxidative stress. Endotheliopathy of trauma is characterized by impaired blood flow, vascular barrier integrity, and coagulation. The systemic activation of inflammatory and coagulation processes leads to endothelial barrier disruption, resulting in lung, kidney, cardiac, and multiorgan injury. The survival benefit of early plasma transfusion in trauma may be related to mitigation of endotheliopathy of trauma. Fibrinogen appears to be the key plasma component that contributes to improved mortality by stabilizing the syndecan-1 proteoglycan, rebuilding the endothelial glycocalyx, restoring microcirculatory barrier integrity, and mitigating the endotheliopathy of trauma. Retrospective and preclinical studies demonstrated improved outcomes after administration of fibrinogen concentrate, suggesting early fibrinogen concentrate administration may be advantageous in trauma patients.

Summary: M. J. Avram. Image: J. P. Rathmell.

Summary: M. J. Avram. Image: J. P. Rathmell.

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Anesthesiology departments measure individual clinical productivity to provide an objective parameter to confirm that the number of anesthesiologists and other anesthesia clinicians is correct. Another reason they measure individual productivity is the desire to use objective parameters to create an incentive system to change behavior. There are three primary ways clinical productivity can be measured: using total billed anesthesia units; using only billed time anesthesia units; and using clinical shifts worked. Before choosing a measurement, one needs to understand the limitations as well as what is valued and devalued with each category. For example, because of anesthesiologist-independent factors, measuring clinical productivity cannot be done simply by using units billed per anesthesiologist and requires in-depth understanding of how these factors affect measurements and productivity. The authors concluded that there is no best way to measure individual clinical productivity of anesthesiologists and department leadership can develop and choose the measurements that work best for their clinical situation and for the behavior they would like to modify.