Anesthesiology Research and Practice The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. A Triple-Masked, Randomized Controlled Trial Comparing Ultrasound-Guided Brachial Plexus and Distal Peripheral Nerve Block Anesthesia for Outpatient Hand Surgery Tue, 15 Apr 2014 12:56:28 +0000 Background. For hand surgery, brachial plexus blocks provide effective anesthesia but produce undesirable numbness. We hypothesized that distal peripheral nerve blocks will better preserve motor function while providing effective anesthesia. Methods. Adult subjects who were scheduled for elective ambulatory hand surgery under regional anesthesia and sedation were recruited and randomly assigned to receive ultrasound-guided supraclavicular brachial plexus block or distal block of the ulnar and median nerves. Each subject received 15 mL of 1.5% mepivacaine at the assigned location with 15 mL of normal saline injected in the alternate block location. The primary outcome (change in baseline grip strength measured by a hydraulic dynamometer) was tested before the block and prior to discharge. Subject satisfaction data were collected the day after surgery. Results. Fourteen subjects were enrolled. Median (interquartile range [IQR]) strength loss in the distal group was 21.4% (14.3, 47.8%), while all subjects in the supraclavicular group lost 100% of their preoperative strength, P = 0.001. Subjects in the distal group reported greater satisfaction with their block procedures on the day after surgery, P = 0.012. Conclusion. Distal nerve blocks better preserve motor function without negatively affecting quality of anesthesia, leading to increased patient satisfaction, when compared to brachial plexus block. Nicholas C. K. Lam, Matthew Charles, Deana Mercer, Codruta Soneru, Jennifer Dillow, Francisco Jaime, Timothy R. Petersen, and Edward R. Mariano Copyright © 2014 Nicholas C. K. Lam et al. All rights reserved. Attenuation of Hemodynamic Responses to Laryngoscopy and Tracheal Intubation: Propacetamol versus Lidocaine—A Randomized Clinical Trial Sun, 13 Apr 2014 13:13:12 +0000 The purpose of this study is to assess the effects of propacetamol on attenuating hemodynamic responses subsequent laryngoscopy and tracheal intubation compared to lidocaine. In this randomized clinical trial, 62 patients with the American Anesthesiologists Society (ASA) class I/II who required laryngoscopy and tracheal intubation for elective surgery were assigned to receive propacetamol 2 g/I.V./infusion (group P) or lidocaine 1.5 mg/kg (group L) prior to laryngoscopy. Systolic and diastolic blood pressures (SBP, DBP), mean arterial pressure (MAP), and heart rate (HR) were recorded at baseline, before laryngoscopy and within nine minutes after intubation. In both groups P and L, MAP increased after laryngoscopy and the changes were statistically significant (). There were significant changes of HR in both groups after intubation (), but the trend of changes was different between two groups (). In group L, HR increased after intubation and its change was statistically significant within 9 minutes after intubation (), while in group P, HR remained stable after intubation (). Propacetamol 2 gr one hour prior intubation attenuates heart rate responses after laryngoscopy but is not effective to prevent acute alterations in blood pressure after intubation. Ali Kord Valeshabad, Omid Nabavian, Keramat Nourijelyani, Hadi Kord, Hossein Vafainejad, Reza Kord Valeshabad, Ali Reza Feili, Mehdi Rezaei, Hamed Darabi, Mohammad Koohkan, Poorya Golbinimofrad, and Samira Jafari Copyright © 2014 Ali Kord Valeshabad et al. All rights reserved. Obstetric Patients Requiring Intensive Care: A One Year Retrospective Study in a Tertiary Care Institute in India Tue, 25 Mar 2014 13:33:47 +0000 Background and Objectives. Critically ill obstetric patients are a particularly unique cohort for the intensivist. The objective of this study was to review the indications for admission, demographics, clinical characteristics, and outcomes of obstetric patients admitted to intensive care unit of a medical college hospital in southern India and to identify conditions associated with maternal mortality. Design. Retrospective analysis of pregnant/postpartum (up to 6 weeks) admissions over a 1-year result. We studied 55 patients constituting 11.6% of mixed ICU admissions during the study period. Results. The mean APACHE (acute physiology and chronic health evaluation) II score of patients at admission was 11.8. Most of the patients (76%) were admitted in the antepartum period. The commonest indications for ICU admission were obstetric haemorrhage (51%) and hypertensive disorders of pregnancy (18%). 85% of patients required mechanical ventilation and 78% required inotropic support. Conclusions. Maternal mortality was 13%, and the majority of the deaths were due to disseminated intravascular coagulation and multiorgan failure, following an obstetric haemorrhage. A dedicated obstetric ICU in tertiary hospitals can ensure that there is no delay in patient management and intensive care can be instituted at the earliest. Niyaz Ashraf, Sandeep Kumar Mishra, Pankaj Kundra, P. Veena, S. Soundaraghavan, and S. Habeebullah Copyright © 2014 Niyaz Ashraf et al. All rights reserved. Sugammadex and Ideal Body Weight in Bariatric Surgery: The Debate Continues Thu, 13 Mar 2014 12:37:00 +0000 Michele Carron Copyright © 2014 Michele Carron. All rights reserved. Controversies in the Anesthetic Management of Intraoperative Rupture of Intracranial Aneurysm Mon, 03 Mar 2014 11:38:14 +0000 Despite great advancements in the management of aneurysmal subarachnoid hemorrhage (SAH), outcomes following SAH rupture have remained relatively unchanged. In addition, little data exists to guide the anesthetic management of intraoperative aneurysm rupture (IAR), though intraoperative management may have a significant effect on overall neurological outcomes. This review highlights the various controversies related to different anesthetic management related to aneurysm rupture. The first controversy relates to management of preexisting factors that affect risk of IAR. The second controversy relates to diagnostic techniques, particularly neurophysiological monitoring. The third controversy pertains to hemodynamic goals. The neuroprotective effects of various factors, including hypothermia, various anesthetic/pharmacologic agents, and burst suppression, remain poorly understood and have yet to be further elucidated. Different management strategies for IAR during aneurysmal clipping versus coiling also need further attention. Tumul Chowdhury, Andrea Petropolis, Marshall Wilkinson, Bernhard Schaller, Nora Sandu, and Ronald B. Cappellani Copyright © 2014 Tumul Chowdhury et al. All rights reserved. Learning Curves of Macintosh Laryngoscope in Nurse Anesthetist Trainees Using Cumulative Sum Method Wed, 12 Feb 2014 13:02:21 +0000 Background. Tracheal intubation is a potentially life-saving procedure. This skill is taught to many anesthetic healthcare professionals, including nurse anesthetists. Our goal was to evaluate the learning ability of nurse anesthetist trainees in their performance of orotracheal intubation with the Macintosh laryngoscope. Methods. Eleven nurse anesthetist trainees were enrolled in the study during the first three months of their training. All trainees attended formal lectures and practice sessions with manikins at least one time on performing successful tracheal intubation under supervision of anesthesiology staff. Learning curves for each nurse anesthetist trainee were constructed with the standard cumulative summation (cusum) methods. Results. Tracheal intubation was attempted on 388 patients. Three hundred and six patients (78.9%) were successfully intubated on the trainees’ first attempt and 17 patients (4.4%) on the second attempt. The mean SD number of orotracheal intubations per trainee was (range 30–47). Ten (90.9%) of 11 trainees crossed the 20% acceptable failure rate line. A median of 22 procedures was required to achieve an 80% orotracheal intubations success rate. Conclusion. At least 22 procedures were required to reach an 80% success rate for orotracheal intubation using Macintosh laryngoscope in nonexperienced nurse anesthetist trainees. Panthila Rujirojindakul, Edward McNeil, Rongrong Rueangchira-urai, and Niranuch Siripunt Copyright © 2014 Panthila Rujirojindakul et al. All rights reserved. Prediction of Optimal Reversal Dose of Sugammadex after Rocuronium Administration in Adult Surgical Patients Tue, 11 Feb 2014 12:55:13 +0000 The objective of this study was to determine the point after sugammadex administration at which sufficient or insufficient dose could be determined, using first twitch height of train-of-four (T1 height) or train-of-four ratio (TOFR) as indicators. Groups A and B received 1 mg/kg and 0.5 mg/kg of sugammadex, respectively, as a first dose when the second twitch reappeared in train-of-four stimulation, and Groups C and D received 1 mg/kg and 0.5 mg/kg of sugammadex, respectively, as the first dose at posttetanic counts 1–3. Five minutes after the first dose, an additional 1 mg/kg of sugammadex was administered and changes in T1 height and TOFR were observed. Patients were divided into a recovered group and a partly recovered group, based on percentage changes in T1 height after additional dosing. T1 height and TOFR during the 5 min after first dose were then compared. In the recovered group, TOFR exceeded 90% in all patients at 3 min after sugammadex administration. In the partly recovered group, none of the patients had a TOFR above 90% at 3 min after sugammadex administration. An additional dose of sugammadex can be considered unnecessary if the train-of-four ratio is ≥90% at 3 min after sugammadex administration. This trial is registered with UMIN000007245. Shigeaki Otomo, Hajime Iwasaki, Kenichi Takahoko, Yoshiko Onodera, Tomoki Sasakawa, Takayuki Kunisawa, and Hiroshi Iwasaki Copyright © 2014 Shigeaki Otomo et al. All rights reserved. Phenoxybenzamine in Complex Regional Pain Syndrome: Potential Role and Novel Mechanisms Thu, 19 Dec 2013 09:48:29 +0000 There is a relatively long history of the use of the α-adrenergic antagonist, phenoxybenzamine, for the treatment of complex regional pain syndrome (CRPS). One form of this syndrome, CRPS I, was originally termed reflex sympathetic dystrophy (RSD) because of an apparent dysregulation of the sympathetic nervous system in the region of an extremity that had been subjected to an injury or surgical procedure. The syndrome develops in the absence of any apparent continuation of the inciting trauma. Hallmarks of the condition are allodynia (pain perceived from a nonpainful stimulus) and hyperalgesia (exaggerated pain response to a painful stimulus). In addition to severe, unremitting burning pain, the affected limb is typically warm and edematous in the early weeks after trauma but then progresses to a primarily cold, dry limb in later weeks and months. The later stages are frequently characterized by changes to skin texture and nail deformities, hypertrichosis, muscle atrophy, and bone demineralization. Earlier treatments of CRPS syndromes were primarily focused on blocking sympathetic outflow to an affected extremity. The use of an α-adrenergic antagonist such as phenoxybenzamine followed from this perspective. However, the current consensus on the etiology of CRPS favors an interpretation of the symptomatology as an evidence of decreased sympathetic activity to the injured limb and a resulting upregulation of adrenergic sensitivity. The clinical use of phenoxybenzamine for the treatment of CRPS is reviewed, and mechanisms of action that include potential immunomodulatory/anti-inflammatory effects are presented. Also, a recent study identified phenoxybenzamine as a potential intervention for pain mediation from its effects on gene expression in human cell lines; on this basis, it was tested and found to be capable of reducing pain behavior in a classical animal model of chronic pain. Mario A. Inchiosa Jr. Copyright © 2013 Mario A. Inchiosa Jr. All rights reserved. The Association of Postcardiac Surgery Acute Kidney Injury with Intraoperative Systolic Blood Pressure Hypotension Thu, 14 Nov 2013 10:32:05 +0000 Background. Postoperative acute kidney injury (AKI) is associated with high mortality and substantial cost after aortocoronary bypass graft (CABG) surgery. We tested the hypothesis that intraoperative systolic blood pressure variation is associated with postoperative AKI. Methods. We gathered demographic, procedural, blood pressure, and renal outcome data for 7,247 CABG surgeries at a single institution between 1996 and 2005. A development/validation cohort methodology was randomly divided (66% and 33%, resp.). Peak postoperative serum creatinine rise relative to baseline (%ΔCr) was the primary AKI outcome variable. Markers reflective of intraoperative systolic blood pressure variation were derived for each patient including (1) peak and nadir values (absolute and relative to baseline) and (2) excursion episodes beyond selected thresholds (by duration, frequency, and duration × degree). Each marker of systolic blood pressure variation was then separately evaluated for association with AKI using linear regression models with adjustment for several known risk factors (age, aprotinin use, congestive heart failure, previous myocardial infarction, baseline creatinine, bypass time, diabetes, weight, concomitant valve surgery, gender, and preoperative pulse pressure). Results. An association was identified between systolic blood pressure relative to baseline and postoperative AKI (). Conclusions. In CABG surgery patients, intraoperative systolic blood pressure decrease relative to baseline systolic blood pressure is independently associated with postoperative AKI. Solomon Aronson, Barbara Phillips-Bute, Mark Stafford-Smith, Manuel Fontes, Jeffrey Gaca, Joseph P. Mathew, and Mark F. Newman Copyright © 2013 Solomon Aronson et al. All rights reserved. Supraventricular Arrhythmias after Thoracotomy: Is There a Role for Autonomic Imbalance? Wed, 23 Oct 2013 13:53:14 +0000 Supraventricular arrhythmias are common rhythm disturbances following pulmonary surgery. The overall incidence varies between 3.2% and 30% in the literature, while atrial fibrillation is the most common form. These arrhythmias usually have an uneventful clinical course and revert to normal sinus rhythm, usually before patent’s discharge from hospital. Their importance lies in the immediate hemodynamic consequences, the potential for systemic embolization and the consequent long-term need for prophylactic drug administration, and the increased cost of hospitalization. Their incidence is probably related to the magnitude of the performed operative procedure, occurring more frequently after pneumonectomy than after lobectomy. Investigators believe that surgical factors (irritation of the atria per se or on the ground of chronic inflammation of aged atria), direct injury to the anatomic structure of the autonomic nervous system in the thoracic cavity, and postthoracotomy pain may contribute independently or in association with each other to the development of these arrhythmias. This review discusses currently available information about the potential mechanisms and risk factors for these rhythm disturbances. The discussion is in particular focused on the role of postoperative pain and its relation to the autonomic imbalance, in an attempt to avoid or minimize discomfort with proper analgesia utilization. George Vretzakis, Marina Simeoforidou, Konstantinos Stamoulis, and Metaxia Bareka Copyright © 2013 George Vretzakis et al. All rights reserved. Interaction of Local Anesthetics with Biomembranes Consisting of Phospholipids and Cholesterol: Mechanistic and Clinical Implications for Anesthetic and Cardiotoxic Effects Mon, 23 Sep 2013 11:17:57 +0000 Despite a long history in medical and dental application, the molecular mechanism and precise site of action are still arguable for local anesthetics. Their effects are considered to be induced by acting on functional proteins, on membrane lipids, or on both. Local anesthetics primarily interact with sodium channels embedded in cell membranes to reduce the excitability of nerve cells and cardiomyocytes or produce a malfunction of the cardiovascular system. However, the membrane protein-interacting theory cannot explain all of the pharmacological and toxicological features of local anesthetics. The administered drug molecules must diffuse through the lipid barriers of nerve sheaths and penetrate into or across the lipid bilayers of cell membranes to reach the acting site on transmembrane proteins. Amphiphilic local anesthetics interact hydrophobically and electrostatically with lipid bilayers and modify their physicochemical property, with the direct inhibition of membrane functions, and with the resultant alteration of the membrane lipid environments surrounding transmembrane proteins and the subsequent protein conformational change, leading to the inhibition of channel functions. We review recent studies on the interaction of local anesthetics with biomembranes consisting of phospholipids and cholesterol. Understanding the membrane interactivity of local anesthetics would provide novel insights into their anesthetic and cardiotoxic effects. Hironori Tsuchiya and Maki Mizogami Copyright © 2013 Hironori Tsuchiya and Maki Mizogami. All rights reserved. Preoperative Screening and Case Cancellation in Cocaine-Abusing Veterans Scheduled for Elective Surgery Wed, 28 Aug 2013 13:32:42 +0000 Background. Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual anecdotes and personal experience. Methods. Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were surveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening criteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these patients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine use was also queried. Results. 172 VA anesthesia departments’ chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Results. 172 VA anesthesia departments’ chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions. There is a general consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines for managing patients screening positive for cocaine prior to elective surgery. Nabil Elkassabany, Rebecca M. Speck, David Oslin, Mary Hawn, Khan Chaichana, John Sum-Ping, Jorge Sepulveda, Mary Whitley, and Yasser Sakawi Copyright © 2013 Nabil Elkassabany et al. All rights reserved. The Effect of Prophylactic Dexmedetomidine on Hemodynamic Disturbances to Double-Lumen Endotracheal Intubation: A Prospective, Randomized, Double-Blind, and Placebo-Controlled Trial Mon, 29 Jul 2013 09:23:24 +0000 The purpose of this study was to determine the effect of dexmedetomidine on hemodynamic responses to DLT intubation compared to placebo and to assess the adverse effects related to dexmedetomidine. Sixty patients were randomly allocated to receive 0.7 μg/kg dexmedetomidine () or normal saline () 10 minutes before general anesthesia. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and rate pressure product (RPP) between groups were recorded. During intubation and 10 minutes afterward (T1-T10), the mean SBP, DBP, MAP, HR, and RPP in the control group were significantly higher than those in the dexmedetomidine group throughout the study period except at T1. The mean differences of SBP, DBP, MAP, HR, and RPP were significantly higher in the control group, with the value of 15.2 mmHg, 10.5 mmHg, 14 mmHg, 10.5 beats per minute, and 2,462.8 mmHg min−1. Four patients in the dexmedetomidine group and 1 patient in the control group developed hypotension, while 2 patients in the dexmedetomidine group had bradycardia. Prophylactic dexmedetomidine can attenuate the hemodynamic responses to laryngoscopy and DLT intubation with minimal adverse effects. This trial is registered with NCT01289769. Tanyong Pipanmekaporn, Yodying Punjasawadwong, Somrat Charuluxananan, Worawut Lapisatepun, and Pavena Bunburaphong Copyright © 2013 Tanyong Pipanmekaporn et al. All rights reserved. Does the Site of Anterior Tracheal Puncture Affect the Success Rate of Retrograde Intubation? A Prospective, Manikin-Based Study Wed, 26 Jun 2013 17:41:48 +0000 Background. Retrograde intubation is useful for obtaining endotracheal access when direct laryngoscopy proves difficult. The technique is a practical option in the “cannot intubate / can ventilate” scenario. However, it is equally useful as an elective technique in awake patients with anticipated difficult airways. Many practitioners report difficulty successfully advancing the endotracheal tube due to anatomical obstructions and the acute angle of the anterograde guide. The purpose of this study was to test whether a more caudal tracheal puncture would increase the success rate. Methods. Twenty-four anesthesiology residents were randomly assigned to either a cricothyroid or a cricotracheal puncture group. Each was instructed how to perform the technique and then attempted it on a manikin at their assigned site. Data collection included whether the trachea was intubated, the number of attempts required, and the total time. Results. Both groups displayed a high degree of success. While the group assigned to the cricotracheal site required significantly more time to perform the procedure, they accomplished it in fewer attempts than the cricothyroid group. Conclusion. Retrograde intubation performed via a cricotracheal puncture site, while more time consuming, resulted in fewer attempts to advance the endotracheal tube and may reduce in vivo laryngeal trauma. Eric A. Harris, Kristopher L. Arheart, and Kenneth E. Fischler Copyright © 2013 Eric A. Harris et al. All rights reserved. Bicarbonates for the Prevention of Postoperative Renal Failure in Endovascular Aortic Aneurysm Repair: A Randomized Pilot Trial Wed, 12 Jun 2013 11:04:34 +0000 Purpose. Contrast-induced nephropathy (CIN) can contribute to acute kidney injury (AKI) in patients undergoing endovascular aortic aneurysm surgery. We evaluated the incidence of AKI together with the evolution of early biomarkers of renal injury in patients receiving bicarbonates or NaCl 0.9%. Methods. This study involved endovascular aortic aneurysm surgery patients. Group A () received bicarbonates 3 mL/kg/h for 1 h before the procedure and then 1 mL/kg/h until 6 h after surgery, whereas group B () received NaCl 0.9% using the same protocol. Biomarkers of renal injury from urine (interleukin-18 (IL-18), neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl--D-glucosaminidase (NAG), and kidney injury molecule 1 (KIM-1)) and blood (NGAL, cystatin C) were measured at baseline and 3, 24, and 48 h postoperatively. Results. AKI occurred in 1 patient (2.9%), in the bicarbonates group. IL-18, NAG, NGAL, and KIM-1 significantly rose in both groups after the surgery. There was a greater rise in NGAL and IL-18 after 3 h in the bicarbonates versus NaCl 0.9% group: 1115% versus 240% increase () and 338% increase versus 1.4% decrease (). Conclusions. Despite significant elevation in biomarkers of renal injury, we demonstrated a low rate of AKI following endovascular aortic surgery. Véronique Brulotte, François A. Leblond, Stéphane Elkouri, Éric Thérasse, Vincent Pichette, and Pierre Beaulieu Copyright © 2013 Véronique Brulotte et al. All rights reserved. Sugammadex and Ideal Body Weight in Bariatric Surgery Thu, 06 Jun 2013 09:38:28 +0000 Background. The obese patients have differences in body composition, drug distribution, and metabolism. Sugammadex at recovery in a dose of 2 mg kg−1 of real body weight (RBW) can completely reverse the NMB block; in our study we investigated the safety and efficacy of Sugammadex dose based on their ideal body weight (IBW). Methods. 40 patients of both sexes undergoing laparoscopic bariatric surgery were enrolled divided into 2 groups according to the dose of Sugammadex: the first received a dose of 2 mg kg−1 of IBW and the second received a dose of 2 mg kg−1 of RBW. Both were anesthetized with doses calculated according to the IBW: fentanyl 2 μg kg−1, propofol 3 mg kg−1, rocuronium 0,6 mg kg−1, oxygen, air, and desflurane (6–8%). Maintenance doses of rocuronium were 1/4 of the intubation dose. Sugammadex was administrated at recovery. Results. The durations of intubation and maintenance doses of rocuronium were similar in both groups. In IBW group, the / value of 0.9 was reached in 151 ± 44 seconds and in 121 ± 55 seconds in RBW group (). Discussion. Recovery times to / of 0.9 are surprisingly similar in both groups without observing any postoperative residual curarization. Conclusion. Sugammadex doses calculated according to the IBW are certainly safe for a rapid recovery and absence of PORC. Maria Sanfilippo, Francesco Alessandri, Ahmed Abdelgawwad Wefki Abdelgawwad Shousha, Antonio Sabba, and Alessandra Cutolo Copyright © 2013 Maria Sanfilippo et al. All rights reserved. Anesthesia for ERCP: Impact of Anesthesiologist's Experience on Outcome and Cost Tue, 28 May 2013 18:47:14 +0000 The present study evaluates the effect of anesthesiologist's experience in providing deep sedation for endoscopic retrograde cholangiopancreatography (ERCP) on cost and safety. Methodology. Perioperative records of 1167 patients who underwent ERCP were divided on the basis of anesthesiologist assisting these procedures either on regular basis (Group R) or on ad hoc basis (Group N). Comparisons were made for anesthesia times, complication rates, and airway interventions. Results. Across all American Society of Anesthesiologists (ASA) Classes, regular anesthesiologists were more efficient (overall mean anesthesia time in Group R was versus minutes in Group N). Within Group R, anesthesia times across all ASA classes were comparable. In Group N, anesthesia times for higher ASA status patients were significantly longer (ASA IV, versus ASA I, minutes). Intubation rates (0.76% versus 12.8%) and median minimal oxygen saturation (100% versus 97.01%) were significantly higher in Group R. Had Group R anesthesiologists performed all procedures, the hospital could have saved US $ 758536 (based upon operating room time costs). Conclusion. Experience in providing deep sedation improved patient safety and decreased the operating room turnaround time, thereby lowering operating room costs associated with these procedures. Basavana G. Goudra, Preet Mohinder Singh, and Ashish C. Sinha Copyright © 2013 Basavana G. Goudra et al. All rights reserved. A Study to Compare the Analgesic Efficacy of Intrathecal Bupivacaine Alone with Intrathecal Bupivacaine Midazolam Combination in Patients Undergoing Elective Infraumbilical Surgery Wed, 15 May 2013 09:38:16 +0000 Spinal anaesthesia, which is one of the techniques for infraumbilical surgeries, is most commonly criticized for limited duration of postoperative analgesia. Several adjuvants have been tried along with local anesthetic for prolonging the duration of analgesia. In this study, we have observed the effect of midazolam as an adjuvant in patients undergoing infraumbilical surgery. In this prospective, randomized, double blinded, and parallel group and open label study of 90 adult patients aged 18–60 years, of American Society of Anaesthesiologists (ASA) status I and II, scheduled for elective infraumbilical surgery, were randomly allocated in two groups. Each patient in group “B” received hyperbaric bupivacaine 12.5 mg along with 0.4 mL of normal saline in the subarachnoid block, and patients of group “BM” received 12.5 mg hyperbaric bupivacaine along with preservative free midazolam 0.4 mL (2 mg). We found that use of midazolam as adjuvant with the local anesthetic in spinal anaesthesia significantly increases the duration of analgesia (median 320 min versus 220 min) and motor block (median 255 min versus 195 min) but decreases the incidence of postoperative nausea-vomiting (PONV). Anirban Chattopadhyay, Souvik Maitra, Suvadeep Sen, Sulagna Bhattacharjee, Amitava Layek, Sugata Pal, and Kakali Ghosh Copyright © 2013 Anirban Chattopadhyay et al. All rights reserved. Copper and Anesthesia: Clinical Relevance and Management of Copper Related Disorders Mon, 13 May 2013 15:24:47 +0000 Recent research has implicated abnormal copper homeostasis in the underlying pathophysiology of several clinically important disorders, some of which may be encountered by the anesthetist in daily clinical practice. The purpose of this narrative review is to summarize the physiology and pharmacology of copper, the clinical implications of abnormal copper metabolism, and the subsequent influence of altered copper homeostasis on anesthetic management. Adrian Langley and Charles T. Dameron Copyright © 2013 Adrian Langley and Charles T. Dameron. All rights reserved. Anesthesia with Propofol versus Sevoflurane: Does the Longer Neuromuscular Block under Sevoflurane Anesthesia Reduce Laryngeal Injuries? Wed, 27 Feb 2013 14:03:57 +0000 Anesthesia can be maintained with propofol or sevoflurane. Volatile anesthetics increase neuromuscular block of muscle relaxants. We tested the hypothesis, that sevoflurane would cause less vocal cord injuries than an intravenous anesthesia with propofol. In this prospective trial, 65 patients were randomized in 2 groups: SEVO group, anesthesia with sevoflurane, and TIVA group, total intravenous anesthesia with propofol. Intubating and extubating conditions were evaluated. Vocal cord injuries were examined by stroboscopy before and 24 and 72 h after surgery; hoarseness and sore throat were assessed up to 72 h after surgery. Hoarseness and sore throat were comparable between both groups (not significant). Similar findings were observed for vocal cord injuries: 9 (SEVO) versus 5 (TIVA) patients; ; the overall incidence was 24%. Type of vocal cord injuries: 9 erythema and 5 edema of the vocal folds. Neuromuscular block was significantly longer in the SEVO group compared with the TIVA group: 71 (range: 38–148) min versus 52 (range: 21–74) min; . Five patients (TIVA group) versus 11 patients (SEVO group) needed neostigmine to achieve a TOF ratio of 1.0 . Under anesthesia with propofol laryngeal injuries were not increased; the risk for residual curarization, however, was lower compared with sevoflurane. Thomas Mencke, Amelie Zitzmann, Susann Machmueller, Arne Boettcher, Martin Sauer, Hans-Wilhelm Pau, Gabriele Noeldge-Schomburg, and Steffen Dommerich Copyright © 2013 Thomas Mencke et al. All rights reserved. Real-Time Ultrasound-Guided Spinal Anaesthesia: A Prospective Observational Study of a New Approach Thu, 10 Jan 2013 11:09:40 +0000 Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1–6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83–4.1) demonstrating the feasibility of this technique in routine clinical practice. P. H. Conroy, C. Luyet, C. J. McCartney, and P. G. McHardy Copyright © 2013 P. H. Conroy et al. All rights reserved. Brain Temperature: Physiology and Pathophysiology after Brain Injury Wed, 26 Dec 2012 17:43:27 +0000 The regulation of brain temperature is largely dependent on the metabolic activity of brain tissue and remains complex. In intensive care clinical practice, the continuous monitoring of core temperature in patients with brain injury is currently highly recommended. After major brain injury, brain temperature is often higher than and can vary independently of systemic temperature. It has been shown that in cases of brain injury, the brain is extremely sensitive and vulnerable to small variations in temperature. The prevention of fever has been proposed as a therapeutic tool to limit neuronal injury. However, temperature control after traumatic brain injury, subarachnoid hemorrhage, or stroke can be challenging. Furthermore, fever may also have beneficial effects, especially in cases involving infections. While therapeutic hypothermia has shown beneficial effects in animal models, its use is still debated in clinical practice. This paper aims to describe the physiology and pathophysiology of changes in brain temperature after brain injury and to study the effects of controlling brain temperature after such injury. Ségolène Mrozek, Fanny Vardon, and Thomas Geeraerts Copyright © 2012 Ségolène Mrozek et al. All rights reserved. Perioperative Anesthesiological Management of Patients with Pulmonary Hypertension Fri, 12 Oct 2012 17:04:44 +0000 Pulmonary hypertension is a major reason for elevated perioperative morbidity and mortality, even in noncardiac surgical procedures. Patients should be thoroughly prepared for the intervention and allowed plenty of time for consideration. All specialty units involved in treatment should play a role in these preparations. After selecting each of the suitable individual anesthetic and surgical procedures, intraoperative management should focus on avoiding all circumstances that could contribute to exacerbating pulmonary hypertension (hypoxemia, hypercapnia, acidosis, hypothermia, hypervolemia, and insufficient anesthesia and analgesia). Due to possible induction of hypotonic blood circulation, intravenous vasodilators (milrinone, dobutamine, prostacyclin, Na-nitroprusside, and nitroglycerine) should be administered with the greatest care. A method of treating elevations in pulmonary pressure with selective pulmonary vasodilation by inhalation should be available intraoperatively (iloprost, nitrogen monoxide, prostacyclin, and milrinone) in addition to invasive hemodynamic monitoring. During the postoperative phase, patients must be monitored continuously and receive sufficient analgesic therapy over an adequate period of time. All in all, perioperative management of patients with pulmonary hypertension presents an interdisciplinary challenge that requires the adequate involvement of anesthetists, surgeons, pulmonologists, and cardiologists alike. Jochen Gille, Hans-Jürgen Seyfarth, Stefan Gerlach, Michael Malcharek, Elke Czeslick, and Armin Sablotzki Copyright © 2012 Jochen Gille et al. All rights reserved. Pain Management Techniques and Practice: New Approaches, Modifications of Techniques, and Future Directions Sun, 16 Sep 2012 13:49:59 +0000 Andrea Trescot, Hans Hansen, Standiford Helm, Giustino Varrassi, and Magdi Iskander Copyright © 2012 Andrea Trescot et al. All rights reserved. Effect of Head Rotation on Cerebral Blood Velocity in the Prone Position Wed, 05 Sep 2012 10:53:57 +0000 Background. The prone position is applied to facilitate surgery of the back and to improve oxygenation in the respirator-treated patient. In particular, with positive pressure ventilation the prone position reduces venous return to the heart and in turn cardiac output (CO) with consequences for cerebral blood flow. We tested in healthy subjects the hypothesis that rotating the head in the prone position reduces cerebral blood flow. Methods. Mean arterial blood pressure (MAP), stroke volume (SV), and CO were determined, together with the middle cerebral artery mean blood velocity (MCA 𝑉mean) and jugular vein diameters bilaterally in 22 healthy subjects in the prone position with the head centered, respectively, rotated sideways, with and without positive pressure breathing (10 cmH2O). Results. The prone position reduced SV (by 5.4±1.5%; 𝑃<0.05) and CO (by 2.3±1.9 %), and slightly increased MAP (from 78±3 to 80±2 mmHg) as well as bilateral jugular vein diameters, leaving MCA 𝑉mean unchanged. Positive pressure breathing in the prone position increased MAP (by 3.6±0.8 mmHg) but further reduced SV and CO (by 9.3±1.3 % and 7.2±2.4 % below baseline) while MCA 𝑉mean was maintained. The head-rotated prone position with positive pressure breathing augmented MAP further (87±2 mmHg) but not CO, narrowed both jugular vein diameters, and reduced MCA 𝑉mean (by 8.6±3.2 %). Conclusion. During positive pressure breathing the prone position with sideways rotated head reduces MCA 𝑉mean ~10% in spite of an elevated MAP. Prone positioning with rotated head affects both CBF and cerebrovenous drainage indicating that optimal brain perfusion requires head centering. Jakob Højlund, Marie Sandmand, Morten Sonne, Teit Mantoni, Henrik L. Jørgensen, Bo Belhage, Johannes J. van Lieshout, and Frank C. Pott Copyright © 2012 Jakob Højlund et al. All rights reserved. The Influence of Pharmacological Preconditioning with Sevoflurane on Incidence of Early Allograft Dysfunction in Liver Transplant Recipients Thu, 09 Aug 2012 08:56:27 +0000 Background. Pharmacological preconditioning is one of the tools used to diminish preservation injury. We investigated the influence of sevoflurane preconditioning of liver grafts on postoperative graft function. Methods. Consecutive 60 deceased brain donors were randomized into sevoflurane group or control group. In sevoflurane group donors were treated with endexpiratory 2,0 volume% of sevoflurane during procurement. Primary endpoint was postoperative liver injury. Secondary endpoint was incidence of early allograft dysfunction (EAD). Results. The groups were not different in median DRI, donor age, graft steatosis, and MELD score. Peak AST and ALT levels were lower in sevoflurane group than in control group: 792 and 1861 (𝑃=0,038) for AST and 606 and 1191 for ALT (𝑃=0,117). Incidence of EAD was 16,7% in sevoflurane group and 50% in control group (Fisher test, 𝑃=0,013). In subgroups without steatosis preconditioning with sevoflurane did not have influence on incidence of EAD. In subgroups with mild and moderate steatosis incidence of EAD was lower in recipients of liver grafts treated with sevoflurane. Conclusions. Preconditioning with sevoflurane during organ procurement improves graft function by lowering incidence of early allograft dysfunction, particularly in recipients of steatotic liver grafts. Andrei F. Minou, Alexander M. Dzyadzko, Aliaksei E. Shcherba, and Oleg O. Rummo Copyright © 2012 Andrei F. Minou et al. All rights reserved. Anesthesia for Pars Plana Vitrectomy with Insulin Needle, Is It Possible? Wed, 08 Aug 2012 09:38:23 +0000 Peribulbar block is commonly used for ocular posterior segment surgery. This work aimed to compare the efficacy of using 12.5 mm to 25 mm standard needle length in performing single injection peribulbar block for retinal surgery. Peribulbar block was performed in 120 patients using either standard 25 mm or 12.5 mm 30 G needle (insulin needle). While applying digital pressure around the needle hub, 8–10 mL of local anesthetic are injected. Ocular movement was assessed at 5 and 10 min using simple akinesia score (0–8). If after 10 min score was >1, supplementary injection was given. Visual analogue scale (0–10) was used at the end of the procedure to assess surgeons’ satisfaction and patients’ intraoperative pain. No differences in akinesia score at 5 & 10 min ( and 0.36, resp.). Initial volume injected was comparable between groups (), however total volume of local anesthesia and supplementary injections were significantly higher in 12.5 mm group ( and 0.01, resp.). No difference as regard surgeons’ satisfaction and patients’ intraoperative pain ( and 0.18, resp.). Peribulbar block with 12.5 mm needle together with digital compression is a suitable alternative to the standard block with 25 mm needle length for retinal surgery. Waleed Riad, Nauman Ahmed, Emad Abboud, Essam Al-Harthi, and Eman Kahtani Copyright © 2012 Waleed Riad et al. All rights reserved. Autologous Blood Transfusion after Local Infiltration Analgesia with Ropivacaine in Total Knee and Hip Arthroplasty Sun, 05 Aug 2012 13:23:20 +0000 Aims. To study the safety of autotransfusion following local infiltration analgesia (LIA) with ropivacaine. Background. Knowledge of blood concentrations of ropivacaine after LIA and autotransfusion is crucial. However, very limited data are available for toxicological risk assessment. Methods. Autotransfusion was studied in patients after total knee arthroplasty (TKA: 𝑛=25) and total hip arthroplasty (THA: 𝑛=27) with LIA using 200 mg ropivacaine, supplemented with two postoperative bolus injections (150 mg ropivacaine). Drainage blood was reinfused within 6 h postoperatively. Results. Reinfusion caused a significant increase in the serum concentration of total ropivacaine for TKA from 0.54±0.17 (mean ± SD) to 0.79±0.20 μg/mL (𝑃<0.001) and a nonsignificant increase for THA from 0.62±0.17 to 0.63±0.18 μg/mL. The maximum free (unbound) concentration after reinfusion was 0.038 μg/mL. Peak total and free venous ropivacaine concentrations after 8 h and 16 h postoperative bolus injections were 2.6 μg/mL and 0.11 μg/mL, respectively. All concentrations observed were below the threshold for toxicity and no side effects were observed. Conclusion. Autotransfusion of patients undergoing knee or hip arthroplasty after local infiltration analgesia with 200 mg ropivacaine can be performed safely, even supplemented with 8 h and 16 h postoperative bolus injections. Torben Breindahl, Ole Simonsen, Peter Hindersson, Bjarne Brødsgaard Dencker, Mogens Brouw Jørgensen, and Sten Rasmussen Copyright © 2012 Torben Breindahl et al. All rights reserved. Procedural Complications of Spinal Anaesthesia in the Obese Patient Mon, 30 Jul 2012 12:00:11 +0000 Background. Complications of spinal anaesthesia (SpA) range between 1 and 17%. Habitus and operator experience may play a pivotal role, but only sparse data is available to substantiate this claim. Methods. 161 patients were prospectively enrolled. Data such as spread of block, duration of puncture, number of trials, any complication, operator experience, haemodynamic parameters, was recorded and anatomical patient habitus assessed. Results. Data from 154 patients were analyzed. Success rate of SpA in the group of young trainees was 72% versus 100% in the group of consultants. Trainees succeeded in patients with a normal habitus in 83.3% of cases versus 41.3% when patients had a difficult anatomy (𝑃=0.02). SpA in obese patients (BMI ≥ 32) was associated with a significantly longer duration of puncture, an increased failure ratio when performed by trainees (almost 50%), and an increased number of bloody punctures. Discussion. Habitus plays a pivotal role for SpA efficiency. In patients with obscured landmarks, failure ratio in unexperienced operators is high. Hence, patient prescreening as well as adequate choice of operators may be beneficial for the success rate of SpA and contribute to less complications and better patient and trainee satisfaction. Manuel Wenk, Christian Weiss, Michael Möllmann, and Daniel Matthias Pöpping Copyright © 2012 Manuel Wenk et al. All rights reserved. The Role of Thoracic Medial Branch Blocks in Managing Chronic Mid and Upper Back Pain: A Randomized, Double-Blind, Active-Control Trial with a 2-Year Followup Thu, 19 Jul 2012 08:37:53 +0000 Study Design. A randomized, double-blind, active-control trial. Objective. To determine the clinical effectiveness of therapeutic thoracic facet joint nerve blocks with or without steroids in managing chronic mid back and upper back pain. Summary of Background Data. The prevalence of thoracic facet joint pain has been established as 34% to 42%. Multiple therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include medial branch blocks, radiofrequency neurotomy, and intraarticular injections. Methods. This randomized double-blind active controlled trial was performed in 100 patients with 50 patients in each group who received medial branch blocks with local anesthetic alone or local anesthetic and steroids. Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months. Results. Significant improvement with significant pain relief and functional status improvement of 50% or more were observed in 80% of the patients in Group I and 84% of the patients in Group II at 2-year followup. Conclusions. Therapeutic medial branch blocks of thoracic facets with or without steroids may provide a management option for chronic function-limiting thoracic pain of facet joint origin. Laxmaiah Manchikanti, Vijay Singh, Frank J. E. Falco, Kimberly A. Cash, Vidyasagar Pampati, and Bert Fellows Copyright © 2012 Laxmaiah Manchikanti et al. All rights reserved.