Issues

In a review of the past 2 decades of closed anesthesia malpractice claims, two areas (obstetrics and spinal surgery) were overrepresented. Common to many cases were lack of timely diagnosis, timely transfusion, and reoperation, often reflecting poor team communication.

In a double-blind, randomized, placebo-controlled crossover study, GAL021 stimulated ventilation in male volunteers with alfentanil-induced respiratory depression at a clamped and elevated end-tidal carbon dioxide partial pressure, increasing both tidal volume and respiratory rate. GAL021 also stimulated poikilocapnic ventilation during alfentanil administration, without affecting sedation, antinociception, hemodynamics, or safety parameters.

Tidal volumes of 6 versus 10 ml/kg of ideal body weight in patients with normal lungs were prospectively and randomly compared in terms of markers of lung injury. A significant increase in plasma levels of neutrophil elastase in the V_T6 group and Clara cell protein 16 in the V_T10 group was observed, which may represent the effect of atelectrauma and increased alveolar distention, respectively.

The main causes of survived intraoperative arrest were preoperative complications (33%), anesthetic complications (28%), and surgical complications (26%). The initial recorded rhythms were asystole (57%), pulseless electrical activity (31%), and ventricular fibrillation (16%). By day 90, 44% of the survivors had a good functional outcome.

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In a preplanned secondary analysis of 291 cardiac surgical patients randomized to receive perioperative dexamethasone or placebo, the treatment groups did not differ in the incidence of postoperative cognitive decline 1 or 12 months after surgery. These results fail to support the use of dexamethasone to prevent postoperative cognitive decline in heart surgery patients.

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Use of a Maximum Surgical Blood Order Schedule in a tertiary hospital reduced blood over-ordering from 40 to 25% of patients. Emergency release of uncrossmatched blood increased from 0.22 to 0.31%. Combining the Maximum Surgical Blood Order Schedule with electronic crossmatching reduced costs by $6 per patient.

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Sevoflurane induced Tau phosphorylation and GSK3β activation and led to cognitive impairment 3 weeks after exposure in 6-day-old mice. The simultaneous administration of the GSK3β inhibitor lithium prevented the cognitive impairment. Increased Tau phosphorylation may contribute to the anesthesia-induced cognitive impairment in neonatal animals and GSK3β may serve as a therapeutic target for the prevention of this impairment.

At a dose of 1 minimum alveolar concentration, isoflurane activated InsP3R and this activation was accompanied by an increase in intracellular calcium. Moreover, cell death was increased by isoflurane. The data support the premise that isoflurane modulates InsP3R calcium-release channel and this activity may underlie a variety of effects of isoflurane, including neurotoxicity.

In mice, cardiac preconditioning from isoflurane involved increased caveolin levels in mitochondria and their associated improved respiratory function. These effects were blocked by pretreatment with Gi inhibitors, suggesting that agents that target Gi and caveolin trafficking may serve as cardioprotective agents.

Using in vivo and in vitro models of ischemia, sevoflurane preconditioning reduced astrocytic NRDG2 expression and neuronal apoptosis, which was counteracted by NDRG2 overexpression. Reduction of astrocytic NDRG2 expression by sevoflurane preconditioning is a novel astrocyte-mediated mechanism for anesthetic neuroprotection.

In 10 patients with auto-positive end-expiratory pressure (PEEP), neurally adjusted ventilator assist (NAVA) ventilation and pressure support ventilation (PSV) were compared during PEEP trials. The pressures required to overcome auto-PEEP were significantly less with NAVA than with PSV and could be reliably assessed by diaprhagmatic electrical activity (EAdi) monitoring in comparison with esophageal pressure.

Lung recruitability and computed tomography scan–derived positive end-expiratory pressure are unrelated. The positive end-expiratory pressure required in patients who had more recruitment and less recruitment were similar.

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In a double-blind, randomized, placebo-controlled study of patients with preexisting impaired renal function undergoing coronary artery bypass grafting, preoperative administration of a high dose of recombinant human erythropoietin had no renal protective effects.

In a systematic review of 15 studies including approximately 1,000 patients, heterogeneity in drug, dose, timing, and outcome measure as well as general low quality precludes definitive conclusions although a majority of studies reported positive outcomes. There is insufficient evidence to support the routine use of antidepressants for analgesia in the perioperative period.

Knockdown of the GluR1-interacting protein stargazin by intrathecal small interfering RNA reduced both postoperative pain and membrane GluR1 levels in a rat plantar incision model. Targeting the stargazin–GluR1 subunit interaction could provide a novel analgesic approach for postoperative pain.

The neurosteroids tested produced voltage and use-dependent block of all the subtypes tested, with more potent effects on Na_v1.2. Inhibition of Na_v1.2 in the spinal cord by allopregnanolone is a plausible mechanism for its analgesic effects if confirmed in neuronal preparations and pain models.

In rats, a mixed gluco- and mineralocorticoid agonist (6-α methylprednisolone) was less effective than a glucocorticoid-selective agonist in reducing behavioral sensory afferent hypersensitivity, and combination of 6-α methylprednisolone with a mineralocorticoid antagonist improved its efficacy.

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Simulation-based training courses for maintenance of certification in anesthesiology have been very well received and have led to widespread reports of meaningful practice improvement.