anestheology latest.pdf

8/18/2019 anestheology latest.pdf

1/254

THIS MONTH IN ANESTHESIOLOGY 1A

SCIENCE, MEDICINE, AND THE ANESTHESIOLOGIST 21A

INFOGRAPHICS IN ANESTHESIOLOGY 23A

EDITORIAL VIEWS

Revealing the Real Risks of Perioperative ransfusion: Rise of the Machines! 1 J. W. Simmons and J.-F. Pittet

Perioperative Anemia and Blood ransfusions in Patients with Cancer: When the Problem, theSolution, and Teir Combination Are Each Associated with Poor Outcomes 3

J. P. Cata

Anaphylaxis to Neuromuscular-blocking Drugs: All Neuromuscular-blocking Drugs Are Not the Same 5P. M. Mertes and G. W. Volcheck

Big Brain, Small World? 8E. Olofsen and A. Dahan

◇ Refers to This Month in Anesthesiology

◆ Refers to Editorial Views

See Supplemental Digital Content CME Article

ON THE COVER:

The focus of the anesthesiologist has long been largely on determining the most appropriatethresholds for transfusion in the perioperative setting. This month’s issue of A NESTHESIOLOGY

includes a series of articles and accompanying Editorial Views that detail risks associated with

perioperative transfusion that were previously ignored, including the risk of transfusion-related

acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and the risks and

benefits of transfusion in surgical oncology patients.

● Clifford et al .: Characterizing the Epidemiology of Postoperative Transfusion-related Acute

Lung Injury, p. 12

● Clifford et al.: Characterizing the Epidemiology of Perioperative Transfusion-associated

Circulatory Overload, p. 21

● Pinheiro de Almeida et al.: Transfusion Requirements in Surgical Oncology Patients:

A Prospective, Randomized Controlled Trial, p. 29

● Simmons and Pittet: Revealing the Real Risks of Perioperative Transfusion: Rise of the

Machines!, p. 1● Cata: Perioperative Anemia and Blood Transfusions in Patients with Cancer: When the Problem,

the Solution, and Their Combination Are Each Associated with Poor Outcomes, p. 3

J n u r 1

l um 1 , u m r 1

I -


2/254

CONTENTS

PERIOPERATIVE MEDICINE

CLINICAL SCIENCE

◇ ◆ Characterizing the Epidemiology of Postoperative ransfusion-related Acute Lung Injury 12L. Clifford, Q. Jia, A. Subramanian, H. Yadav, G. A. Wilson, S. P. Murphy, J. Pathak,

D. R. Schroeder, and D. J. Kor A retrospective cohort analysis from one institution documented that perioperative transfusion-related acute lung injury occursapproximately 1.4 to 3% in surgical patients, with higher rates in patients who received larger volumes of blood component therapies.

Characterizing the Epidemiology of Perioperative ransfusion-associated CirculatoryOverload 21L. Clifford, Q. Jia, H. Yadav, A. Subramanian, G. A. Wilson, S. P. Murphy, J. Pathak,

D. R. Schroeder, M. H. Ereth, and D. J. Kor

Tis retrospective cohort study evaluated 2,162 and 1,908 patients who received intraoperative transfusions duringnoncardiac surgery in 2004 and 2011, respectively. A total of 119 patients (5.5%) in 2004 and 57 patients (3%) in2011 met criteria for transfusion-associated circulatory overload. Te incidence of transfusion-associated circulatoryoverload increased with the volume of blood product transfused, advanced age, and total intraoperative fluid balance.SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT

ransfusion Requirements in Surgical Oncology Patients: A Prospective, RandomizedControlled rial 29

J. Pinheiro de Almeida, J.-L. Vincent, F. R. B. Gomes Galas, E. Pinto Marinho de Almeida,

J. T. Fukushima, E. A. Osawa, F. Bergamin, C. Lee Park, R. Ely Nakamura, S. M. R. Fonseca,

G. Cutait, J. Inacio Alves, M. Bazan, S. Vieira, A. C. Vieira Sandrini, H. Palomba, U. Ribeiro,

Jr., A. Crippa, M. Dalloglio, M. del Pilar Estevez Diz, R. Kalil Filho, J. Otavio Costa Auler,

Jr., A. Rhodes, and L. Abrahao Hajjar

In 198 patients randomly assigned to red cell transfusions at a hemoglobin concentration of 7 or 9 g/dl. Majorcomplications were nearly twice as common in patients managed with the restrictive approach as in those managed withthe liberal approach (36% vs. 20%). Tis study supports a more liberal transfusion strategy in major cancer surgery.

Anaphylaxis Is More Common with Rocuronium and Succinylcholine than with Atracurium 39 J. I. Reddy, P. J. Cooke, J. M. van Schalkwyk, J. A. Hannam, P. Fitzharris, and S. J. Mitchell

Search of a database containing more than 400,000 anesthetic records identified 92,858 new patient exposures toneuromuscular-blocking drugs between 2006 and 2012. wenty-one of 89 patients referred to the Anesthetic AllergyClinic had anaphylaxis attributed to muscle relaxants. Use of credible numerator and denominator data found similarrates of anaphylaxis after succinylcholine and rocuronium administration, rates that were nearly an order of magnitudehigher than those for atracurium and other neuromuscular-blocking drugs. SUPPLEMENTAL DIGITAL CONTENTIS AVAILABLE IN THE TEXT

◇ Postoperative Bladder Catheterization Based on Individual Bladder Capacity: A Randomized rial 46T. A. Brouwer, P. F. W. M. Rosier, K. G. M. Moons, N. P. A. Zuithoff, E. N. van Roon, and C. J. Kalkman

In a prospective trial involving 1,840 patients, maximum bladder capacity was determined before surgery. Using predeterminedmaximum bladder capacity, the authors demonstrated that a reduction in the need for postoperative bladder catheterization could beachieved.

Accuracy of Malignant Hyperthermia Diagnoses in Hospital Discharge Records 55T. Pinyavat, H. Rosenberg, B. H. Lang, C. A. Wong, S. Riazi, J. E. Brady, L. S. Sun, and G. Li

In review by an expert panel of International Classification of Diseases coding for malignant hyperthermia over a3-yr period, approximately 70% of coded cases were considered to be malignant hyperthermia susceptible. Te mostcommon reason for inaccurate coding was high fever unrelated to anesthesia.

Relationship between Chronic Intermittent Hypoxia and Intraoperative Mean ArterialPressure in Obstructive Sleep Apnea Patients Having Laparoscopic Bariatric Surgery 64

A. Turan, J. You, C. Egan, A. Fu, I. Gazmuri, A. Khanna, Y. Eshraghi, R. Ghosh, S. Bose,

S. Qavi, L. Arora, D. I. Sessler, and A. G. DoufasRecurrent nocturnal hypoxemia in obstructive sleep apnea is not a risk marker for intraoperative hypotension in patientsundergoing laparoscopic bariatric surgery.

◇ ◆

◇ ◆


3/254

CONTENTS

BASIC SCIENCE

Propofol Attenuated Acute Kidney Injury after Orthotopic Liver ransplantation viaInhibiting Gap Junction Composed of Connexin 32 72C. Luo, D. Yuan, X. Li, W. Yao, G. Luo, X. Chi, H. Li, M. G. Irwin, Z. Xia, and Z. Hei

Anesthetized rats underwent autologous orthotopic liver transplantation in the absence or presence of treatments with aselective Cx32 inhibitor, 2-aminoethoxydiphenyl borate, or propofol. Propofol inhibited Cx32 function and attenuatedpostautologous orthotopic liver transplantation acute kidney injury. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT

Long-term Effects of Single or Multiple Neonatal Sevoflurane Exposures on RatHippocampal Ultrastructure 87L. G. Amrock, M. L. Starner, K. L. Murphy, and M. G. Baxter

Repeated exposure to sevoflurane led to a greater loss of synapses in comparison to a single exposure. Anestheticexposure led to a reduction in the number of synaptic terminals with mitochondria. Interestingly, this reduction wascorrelated to total anesthetic exposure rather than frequency of exposure. Tese data suggest that a brief anestheticexposure might sensitize the brain to subsequent anesthetic induced injury.

CRITICAL CARE MEDICINE

CLINICAL SCIENCE

Assessment of Neutrophil Gelatinase-associated Lipocalin in the Brain-dead Organ Donorto Predict Immediate Graft Function in Kidney Recipients: A Prospective, Multicenter Study 96L. Muller, A. Nicolas-Robin, S. Bastide, O. Martinez, G. Louart, J.-C. Colavolpe, F. Vachiery,

S. Alonso, J.-Y. Lefrant, and B. Riou; for AzuRea Group

Despite the ability to predict acute renal failure earlier than serum creatinine rises in critically ill patients, neutrophilgelatinase-associated lipocalin measurements in blood samples obtained from brain-dead donors before kidney graftharvesting failed to predict either delayed or normal graft function in kidney recipients.

BASIC SCIENCE

Modulation of Stress versus ime Product during Mechanical Ventilation InfluencesInflammation as Well as Alveolar Epithelial and Endothelial Response in Rats 106P. M. Spieth, P. L. Silva, C. S. N. B. Garcia, D. S. Ornellas, C. S. Samary, L. Moraes,

M. Bentes, M. M. Morales, M. Kasper, A. Güldner, R. Huhle, T. Koch, P. Pelosi,

M. Gama de Abreu, and P. R. M. Rocco

In a mild acute lung inflammation model in rats, using mechanical ventilation with an inspiratory-to-expiratory ratioof 1:1 minimized lung damage, whereas an inspiratory-to-expiratory ratio of 2:1 led to increased gene expression ofinflammatory mediators and markers of alveolar epithelial cell injury. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT

Volatile Organic Compounds during Inflammation and Sepsis in Rats: A Potential Breathest Using Ion-mobility Spectrometry 117

T. Fink, A. Wolf, F. Maurer, F. W. Albrecht, N. Heim, B. Wolf, A. C. Hauschild, B. Bödeker, J. I. Baumbach, T. Volk, D. I. Sessler, and S. Kreuer

Exhaled gas from rats given endotoxin compared with the gas from rats with bacterial sepsis was found to besignificantly different and different from rats who were in hemorrhagic shock. Breath analysis appears to be able todistinguish inflammation from infection.

Extracellular Histones Play an Inflammatory Role in Acid Aspiration-induced AcuteRespiratory Distress Syndrome 127Y. Zhang, Z. Wen, L. Guan, P. Jiang, T. Gu, J. Zhao, X. Lv, and T. Wen

Extracellular histones were significantly elevated in the bronchoalveolar lavage from mice with acid-induced lung injuryversus sham mice and in human patients who died from acute lung injury compared to survivors with acute lung injury.Extracellular histones may be causal, and targeting histones may be a reasonable therapeutic strategy. SUPPLEMENTALDIGITAL CONTENT IS AVAILABLE IN THE TEXT


4/254

CONTENTS

PAIN MEDICINE

CLINICAL SCIENCE

◇ ◆ Disruption of Cortical Connectivity during Remifentanil Administration Is Associatedwith Cognitive Impairment but Not with Analgesia 140

A. Khodayari-Rostamabad, S. S. Olesen, C. Graversen, L. P. Malver, G. P. Kurita, P. Sjøgren,L. L. Christrup, and A. M. Drewes

Remifentanil altered graph-theoretical measures of the electroencephalography, characterized by an increase inpath length in the alpha and low beta frequency ranges. Changes in path length were correlated to continuousreaction time, a measure of sedation. However, a correlation between electroencephalography measures and painperception was not apparent. Remifentanil alters functional network connectivity in the brain, and the changes in theelectroencephalography have the potential to serve as markers of remifentanil-induced sedation but not analgesia.

Immediate Rescue Designs in Pediatric Analgesic rials: A Systematic Review andMeta-analysis 150

J. Kossowsky, C. Donado, and C. B. Berde

Te investigators performed a meta-analysis of pediatric trials with four classes of analgesics, using rescue/opioid-sparingdesigns. Average pain scores were low and similar in control and experimental analgesic groups, confirming the ethicalbasis of opioid-sparing rescue designs. Opioid-sparing designs also showed good assay sensitivity. SUPPLEMENTALDIGITAL CONTENT IS AVAILABLE IN THE TEXT

◇ A Randomized Control rial of Bupivacaine and Fentanyl versus Fentanyl-only forEpidural Analgesia during the Second Stage of Labor 172M. G. Craig, E. N. Grant, W. Tao, D. D. McIntire, and K. J. Leveno

In 310 nulliparous women with epidural analgesia randomized at the onset of second stage to receive epidural fentanylalone or with bupivacaine, there was no difference in duration of second stage, degree of motor block, or instrumentaldelivery. o achieve similar degrees of analgesia, women receiving epidural fentanyl without bupivacaine required afivefold increased dose of fentanyl.

BASIC SCIENCE

Brain Serotonin Content Regulates the Manifestation of ramadol-induced Seizures inRats: Disparity between ramadol-induced Seizure and Serotonin Syndrome 178Y. Fujimoto, T. Funao, K. Suehiro, R. Takahashi, T. Mori, and K. Nishikawa

ramadol-induced seizure thresholds were reduced by serotonin depletion and increased by serotonin augmentation.Serotonin antagonists also reduced seizure threshold. Te results suggest that tramadol-induced seizures are not relatedto serotonin uptake inhibition and that these seizures are distinct from the serotonin syndrome.

EDUCATION

IMAGES IN ANESHESIOLOGY

Inversion of the Right Hemidiaphragm due to MassiveHemothorax after Central Line Placement 190

A. F. Simpao, J. A. Galvez, A. Jay Schwartz, and M. A. RehmanSUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT

CLINICAL CONCEPS AND COMMENARY

◇ Pretransfusion esting and ransfusion of Uncrossmatched Erythrocytes 191M. L. Boisen, R. A. Collins, M. H. Yazer, and J. H. Waters

Pretransfusion testing is reviewed for the anesthesiologist, with an emphasis on the electronic crossmatch and transfusionof uncrossmatched erythrocytes when testing is incomplete.

REVIEW ARICLE

◇ Regulation of Cerebral Autoregulation by Carbon Dioxide 196L. Meng and A. W. Gelb

Both perfusion pressure and nonperfusion pressure processes regulate cerebral blood flow. Te integrated effect of carbon dioxideand perfusion pressure on cerebral circulation, or the regulation of cerebral autoregulation by carbon dioxide, is discussed.


5/254

CONTENTS

MIND O MIND

Electrocardiogram 206 A. Shafer

CORRESPONDENCE

Is the Standard Supplied by the Association for the Advancement of MedicalInstrumentation the Measure of All Tings for Noninvasive ContinuousHemodynamic Devices? 208

J. Fortin, K. Lerche, D. Flotzinger, and T. O’Brien

In Reply M. Cannesson, J. Rinehart, and S.-H. Kim

Inotrope Use in Cardiac Surgery: A Cause of Worse Outcomes, or Just a Markerof Patients Who Are at Risk? 210B. G. Maxwell, J. O. Wasey, and E. S. Heitmiller

In Reply D. V. Nielsen, S. P. Johnsen, M. K. Hansen, and C.-J. Jakobsen

Lung Ultrasonography for the Detection of Anesthesia-induced Lung Atelectasis 213M. Girard, V. Généreux, and A. Monastesse

In Reply G. Tusman, C. M. Acosta, and S. H. Bohm

Early Childhood Anesthetic Neurotoxicity and Unmeasured Covariates: Tere’s the RUB 216 J. C. Drummond

In Reply C. H. Ing, C. J. DiMaggio, E. Malacova, A. J. Whitehouse, M. K. Hegarty, T. Feng,

J. E. Brady, B. S. von Ungern-Sternberg, A. J. Davidson, M. M. Wall, A. J. J. Wood, G. Li,

and L. S. Sun

Old Guidelines or Methods Cannot Insure Quality or Progress 218P. M. Kempen

In Reply J. L. Lockman and A. J. Schwartz

In Reply W. R. Hand and M. D. McEvoy

ANESTHESIOLOGY REFLECTIONS FROM

THE WOOD LIBRARY-MUSEUM

Katz Oxygen reatment for Catarrh 7George S. Bause

Laughing “Gas” from Knoxville’s Dr. H. F. Huffaker 11George S. Bause

Figuier’s Forlorn Figure: Horace Wells and the “Humbug Affair” 54George S. Bause


6/254

CONTENTS

Manuscripts submitted for consideration for publication must be submitted in electronic format. The preferred method is via the Journal’s

Web site (http://www.anesthesiology.org). Detailed directions for submissions and the most recent version of the

Instructions for Authors can be found on the Web site (http://www.anesthesiology.org). Books and educational materials

should be sent to Alan Jay Schwartz M.D., M.S.Ed., Director of Education, Department of Anesthesiology and Critical

Care Medicine, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd., Room 9327, Philadelphia,

Pennsylvania 19104-4399. Requests for permission to duplicate materials published in A NESTHESIOLOGY should be submitted

in electronic format, to the Permissions Department ([email protected]). Advertising and related correspondence shouldbe addressed to Advertising Manager, A NESTHESIOLOGY , Lippincott Williams & Wilkins, Two Commerce Square, 2001 Market Street,

Philadelphia, Pennsylvania 19103 (Web site: http://www.wkadcenter.com /). Publication of an advertisement in A NESTHESIOLOGY does

not constitute endorsement by the Society or Lippincott Williams & Wilkins, Inc. of the product or service described therein or of any

representations made by the advertiser with respect to the product or service.

INSTRUCTIONS FOR AUTHORS

Te most recently updated version of the Instructions for Authors is available at www.anesthesiology.org. Please refer to the Instructions for the preparation of any material forsubmission to A NESHESIOLOGY .

ANESTHESIOLOGY (ISSN 0003–3022) is published monthly by Lippincott Williams & Wilkins, 16522Hunters Green Parkway, Hagerstown, MD 21740-2116. Business office: Two Commerce Square,2001 Market Street, Philadelphia, PA 19103. Periodicals postage paid at Hagerstown, MD, and atadditional mailing offices. Copyright © 2014, the American Society of Anesthesiologists, Inc.

Annual Subscription Rates: United States —$799 Individual, $1566 Institution, $319In-training. Rest of World —$843 Individual, $1739 Institution, $319 In-training. Single copy rate$145. Subscriptions outside of North America must add $52 for airfreight delivery. Add statesales tax, where applicable. The GST tax of 7% must be added to all orders shipped to Canada(Lippincott Williams & Wilkins’ GST Identification #895524239, Publications Mail Agreement#1119672). Indicate in-training status and name of institution. Institution rates apply tolibraries, hospitals, corporations, and partnerships of three or more individuals. Subscriptionprices outside the United States must be prepaid. Prices subject to change without notice.Subscriptions will begin with currently available issue unless otherwise requested. Visit usonline at www.lww.com.

Individual and in-training subscription rates include print and access to the online version.Online-only subscriptions for individuals ($257) and persons in training ($257) are availableto nonmembers and may be ordered by downloading a copy of the Online SubscriptionFAXback Form from the Web site, completing the information requested, and faxing thecompleted form to 301-223-2400/44 (0) 20 7981 0535. Institutional rates are for print only;online subscriptions are available via Ovid. Institutions can choose to purchase a print andonline subscription together for a discounted rate. Institutions that wish to purchase a printsubscription, please contact Lippincott Williams & Wilkins, 16522 Hunters Green Parkway,Hagerstown, MD 21740-2116; phone: 1-800-638-3030 (outside the United States 301-223-2300/44 (0) 20 7981 0525); fax: 301-223-2400/44 (0) 20 7981 0535. Institutions thatwish to purchase an online subscription or online with print, please contact the Ovid RegionalSales Office near you or visit www.ovid.com/site/index.jsp and select Contact and Locations.

Address for non-member subscription information, orders, or change of address:Lippincott Williams & Wilkins, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116; phone: 1-800-638-3030 (outside the United States 301-223-2300/44 (0) 20 79810525); fax: 301-223-2400/44 (0) 20 7981 0535; email: [email protected] Japan, contact LWW Japan Ltd., 3-23-14 Hongo, Bunkyo-ku, Tokyo 113, Japan; phone:81-3-5689-5400; fax: 81-3-5689-5402; email: [email protected]. In Bangladesh, India, Nepal,Pakistan, and Sri Lanka, contact Globe Publications Pvt. Ltd., B-13 3rd Floor, A Block, ShoppingComplex, Naraina, Vihar, Ring Road, New Delhi 110028, India; phone: 91-11-25770411; fax:91-11-25778876; email: [email protected].

Address for member subscription information, orders, or change of address: Mem-bers of the American Society of Anesthesi ologists receive the print and online jou rnal withtheir membership. To become a member or provide a change of address, please contac t the American Socie ty of Anesthesio logi sts, 1061 Americ an Lane, Schaumburg , Illin ois60173-4973; phone: 847-825-5586; fax: 847-825-1692; email: [email protected]. For all other membership inquiries, contact Lippincott Williams & Wilkins CustomerService Department, P.O. Box 1580, Hagerstown, MD 21741-1580; phone: 1-800-638-3030(outside the United States 301-223-2300/44 (0) 20 7981 0525); fax: 301-223-2400/44(0) 20 7981 0535; email: [email protected].

Postmaster: Send address changes to A NESTHESIOLOGY, P.O. BOX 1550, Hagerstown, MD 21740.

Advertising: Please contact Michelle Smith, Senior Account Manager, Advertising, LippincottWilliams & Wilkins, 333 Seventh Avenue, 19th Floor, New York, NY 10001; tel: (646) 674-6537,fax: (646) 607-5479, e-mail: [email protected]. For classified advertising:Keida Spurlock, Recruitment Advertising Representative, Lippincott Williams & Wilkins, TwoCommerce Square, 2001 Market Street, Philadelphia, PA 19103; tel: (215) 521-8501, fax:(215) 689-2453. e-mail: [email protected].

REVIEWS OF EDUCATIONAL MATERIAL 222

ANNOUNCEMENTS 224

CAREERS & EVENTS228

http://www.wkadcenter.com/mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.wkadcenter.com/


7/254

Mission: Promoting scientific discovery and knowledge in perioperative, critical care, and pain medicine toadvance patient care.

EDITOR-IN-CHIEF

James C. Eisenach, M.D.Editor-in-Chief, A Department of Anesthesiology

Wake Forest University School of Medicine

Medical Center Boulevard

Winston-Salem, NC 27157el: 1-800-260-5631

E-mail: [email protected]

PAST EDITORS-IN-CHIEF, A NESTHESIOLOGY

Henry S. Ruth, M.D., 1940–1955

Ralph M. ovell, M.D., 1956–1958

James E. Eckenhoff, M.D., 1959–1962

Leroy D. Vandam, M.D., 1963–1970

Arthur S. Keats, M.D., 1971–1973

Nicholas M. Greene, M.D., 1974–1976

C. Philip Larson, Jr., M.D., 1977–1979 John D. Michenfelder, M.D., 1980–1985

Lawrence J. Saidman, M.D., 1986–1996

Michael M. odd, M.D., 1997–2006

COVER ART

James P. Rathmell, M.D.Boston, Massachusetts

Annemarie B. Johnson, C.M.I.Medical Illustrator Winston-Salem, North Carolina

CME EDITORS

Leslie C. Jameson, M.D.Dan J. Kopacz, M.D.

EDITORIAL OFFICE

Vicki edeschi, Managing EditorE-mail: [email protected] Allison Akeley Vicky J. Farrington-Howrey Angel R. MarshKaren Parks A Journal

1061 American LaneSchaumburg, IL 60173-4973el: (847) 268-9296E-mail: [email protected]

LWW PUBLICATION STAFF

Druanne Martin, Publisher Joseph Albrecht, Journal Production EditorDebbie Moody, Journal Production AssociateMichelle Smith, Senior Account Manager, Advertising Keida Spurlock, Classified Advertising RepresentativeSilvia Serra, Director, Rights, Licensing & Permissions

ASA OFFICERS

John P. Abenstein, M.D., PresidentDaniel J. Cole, M.D., President-Elect Jane C. K. Fitch, M.D., Immediate Past President Jeffrey Plagenhoef, M.D., First Vice-President

Beverly K. Philip, M.D., Vice-President for Scientific Affairs

All articles accepted for publication are done so with the understanding thatthey are contributed exclusively to this Journal and become the propertyof the American Society of Anesthesiologists, Inc. Statements or opinionsexpressed in the Journal reflect the views of the author(s) and do not representofficial policy of the American Society of Anesthesiologists unless so stated.


8/254

Mission: Promoting scientific discovery and knowledge in perioperative, critical care, and pain medicine toadvance patient care.

EDITOR-IN-CHIEF

James C. Eisenach, M.D. Winston-Salem, North Carolina

EXECUTIVE EDITORS

Michael J. Avram, Ph.D., Chicago, Illinois

Charles D. Collard, M.D., Houston, exas

Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M.,Durham, North Carolina

James P. Rathmell, M.D., Boston, Massachusetts

David S. Warner, M.D., Durham, North Carolina

STATISTICAL EDITOR

imothy . Houle, Ph.D. Winston-Salem, North Carolina

EDITORS

J. David Clark, M.D., Ph.D., Palo Alto, California Hugh C. Hemmings, Jr., M.D., Ph.D., New York, New York

Shiroh Isono, M.D., Chiba, JapanBrian P. Kavanagh, M.B., B.Sc., M.R.C.P., F.C.A.R.C.S.I.,

oronto, Canada Jean Mantz, M.D., Ph.D., Clichy, FrancePiyush M. Patel, M.D., F.R.C.P.C., San Diego, California David M. Roth, M.D., Ph.D., San Diego, California Daniel I. Sessler, M.D., Cleveland, Ohio

ASSOCIATE EDITORS

Julien Amour, M.D., Ph.D., Paris, Franceakashi Asai, M.D., Ph.D., Osaka, JapanBrian Tomas Bateman, M.D., Boston, MassachusettsGeorge S. Bause, M.D., M.P.H., Cleveland, OhioBeatrice Beck-Schimmer, M.D., Zurich, SwitzerlandChad Michael Brummett, M.D., Ann Arbor, Michigan John Butterworth, M.D., Richmond, Virginia

Jaume Canet, M.D., Ph.D., Barcelona, SpainCarol Wiley Cassella, M.D., Seattle, WashingtonSteven P. Cohen, M.D., Baltimore, MarylandDeborah J. Culley, M.D., Boston, Massachusetts Albert Dahan, M.D., Ph.D., Leiden, Te Netherlands Andrew J. Davidson, M.D., M.B.B.S., F.A.N.Z.C.A., Melbourne, Australia Holger K. Eltzschig, M.D., Ph.D., Aurora, ColoradoPamela Flood, M.D., San Francisco, California Amanda A. Fox, M.D., M.P.H., Dallas, exas Admir Hadzic, M.D., Ph.D., New York, New York Quinn H. Hogan, M.D., Milwaukee, WisconsinRu-Rong Ji, Ph.D., Durham, North Carolina Yandong Jiang, M.D., Ph.D., Boston, MassachusettsSachin Kheterpal, M.D., M.B.A., Ann Arbor, Michigan

Kate Leslie, M.B.B.S., M.D., M.Epi., F.A.N.Z.C.A.,Parkville, Australia

Ronald S. Litman, D.O., F.A.A.P., Philadelphia, Pennsylvania Martin J. London, M.D., San Francisco, California Edward Mascha, Ph.D., Cleveland, OhioGeorge A. Mashour, M.D., Ph.D., Ann Arbor, MichiganPaul S. Myles, M.B., B.S., M.P.H., M.D., F.F.A.R.C.S.I.,

F.A.N.Z.C.A., Melbourne, Australia Peter Nagele, M.D., M.Sc., St. Louis, MissouriMark D. Neuman, M.D., M.Sc., Philadelphia, Pennsylvania Warren S. Sandberg, M.D., Ph.D., Nashville, ennessee Alan Jay Schwartz, M.D., M.S.Ed., Philadelphia, Pennsylvania Nikolaos J. Skubas, M.D., New York, New York Jamie W. Sleigh, M.D., Hamilton, New Zealand

Balachundhar Subramaniam, M.B.B.S., M.D., M.P.H.,Boston, MassachusettsMarcos F. Vidal Melo, M.D., Ph.D., Boston, MassachusettsHannah Wunsch, M.D., M.Sc., New York, New York

A NESTHESIOLOGY is abstracted or indexed in Index Medicus/MEDLINE, Science CitationIndex/SciSearch, Current Contents/Clinical Medicine, Current Contents/Life Sciences,Reference Update, EMBASE/Excerpta Medica, Biological Abstracts (BIOSIS), Chemical Abstracts, Hospital Literature Index, and Comprehensive Index to Nursing and AlliedHealth Literature (CINAHL).

The affiliations, areas of expertise, and conflict-of-interest disclosure statements for eachEditor and Associate Editor can be found on the Journal’s Web site (www.anesthesiology.org).

Access to articles published in A NESHESIOLOGY is available to nonsubscribersthrough pay-per-view at the journal Web site, www.anesthesiology.org. Authorsmay order quantity print or electronic reprints of their own articles using the orderform supplied with their proofs and posted to the journal Web site. For all other bulkpurchases, please contact [email protected] in North America, Car-los Moreyra ([email protected]) in Latin America, and Jean Jones([email protected]) in Europe and elsewhere.


9/254

29 Transfusion Requirements in Surgical Oncology Patients: A Prospective,Randomized Controlled Trial

The decision to transfuse patients having surgery for cancer should take into account risks of anemiaand adverse effects of blood transfusion. A composite primary outcome of death from all causes orsevere clinical complications within 30 days of randomization was compared in 198 high-risk abdominaloncological surgery patients randomly assigned to a restrictive or a liberal transfusion strategy, whoreceived an erythrocyte unit when their hemoglobin concentration decreased to less than 7 g/dl or 9 g/ dl, respectively, during their intensive care unit stay. The composite primary outcome occurred in 19.6%of the liberal strategy patients and in 35.6% of the restrictive strategy patients. See the accompanyingEditorial View on page 3 . (Summary: M.J. Avram. Image: A. Johnson/Vivo Visuals.)

21 Characterizing the Epidemiology of Perioperative Transfusion-associated

Circulatory Overload

Transfusion-associated circulatory overload (TACO) is the second leading cause of transfusion-related death, butits perioperative epidemiology is poorly understood. Perioperative TACO incidence was determined by analyzingdata abstracted from electronic medical records of 4,070 adults who underwent noncardiac surgery under generalanesthesia and received intraoperative blood product transfusions in 2004 or 2011. TACO occurred within 6 h ofthe last intraoperative blood product transfusion at rates of 5.5% in 2004 and 3.0% in 2011. Although increasedrates of TACO were associated with surgical specialty, patient age, transfusion volume, and total operative fluid bal-ance, no patient or transfusion characteristic could fully account for the decreased incidence between 2004 and2011. See the accompanying Editorial View on page 1. (Summary: M.J. Avram. Image: ©Shutterstock.)

12 Characterizing the Epidemiology of Postoperative Transfusion-relatedAcute Lung Injury

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related death, but itsperioperative epidemiology is poorly understood. The combined incidence of perioperative TRALI/possi-ble TRALI was determined by analyzing data abstracted from electronic medical records of 3,379 adultswho underwent noncardiac surgery under general anesthesia and received intraoperative blood producttransfusions in 2004 or 2011, before and after introduction of TRALI mitigation strategies. TRALI/possibleTRALI occurred within 6 h of the last intraoperative blood product transfusion at rates of 1.3% in 2004

and 1.4% in 2011. Increased rates were associated with increased volumes of transfused blood product. See the accompanyingEditorial View on page 1. (Summary: M.J. Avram. Image: J.P. Rathmell.)

172 A Randomized Control Trial of Bupivacaine and Fentanyl versus Fentanyl-only for Epidural Analgesia during the Second Stage of Labor

Although epidural analgesia for pain relief during childbirth may not increase cesarean delivery rates, it can

slightly prolong first and second stages of labor. In order to determine whether eliminating local anestheticfrom epidural analgesia during the second stage would reduce its length, 310 nulliparous women with laborepidurals were randomly assigned to receive either 0.125% bupivacaine and 2 µg/ml fentanyl or 10 µg/mlfentanyl alone via the epidural catheter. The groups did not differ in duration of the second stage of labor,degree of motor blockade, mode of delivery, relief of labor pain, or maternal and neonatal outcomes. (Sum- mary: M.J. Avram. Image: J.P. Rathmell.)

THIS MONTH IN

Anesthesiology, V 122 • No 1 January 2015


10/254

46 Postoperative Bladder Catheterization Based on Individual Bladder Capac-ity: A Randomized Trial

Untreated postoperative urinary retention can lead to bladder wall overdistention and damage to thedetrusor muscle. Nonetheless, most patients prefer to avoid bladder catheterization, which has itsown risks. Eighteen hundred forty patients undergoing operations with general or spinal anesthesia

were randomly assigned to have 500 ml or their maximum bladder capacity (MBC) as the thresholdfor catheterization if the patient was unable to void spontaneously. MBC was the maximum voidedvolume at home plus the residual volume measured by ultrasound at preoperative assessment. Theincidence of catheterization was 11.8% in the control group and 8.6% in the MBC group. The average

MBC in all patients was approximately 600 ml. (Summary: M.J. Avram. Image: Hellerhoff [own work] [CC-BY-SA-3.0] [http:// creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons].)

140 Disruption of Cortical Connectivity during Remifentanil Administration IsAssociated with Cognitive Impairment but Not with Analgesia

Electroencephalographic graph theory decomposes the multiple cortical connectivity features extractedfrom multichannel electroencephalography into composite measures of the overall brain network perfor-mance and functionality: characteristic path length, measuring functional integration; mean clusteringcoefficient, measuring functional segregation; and relative small-worldness, reflecting the balance of local

segregation and global integration. These graph-theoretical measures were obtained from functional con-nectivity network measures in resting state electroencephalographic data from 21 volunteers in a dou-ble-blind, placebo-controlled, crossover study of remifentanil. Remifentanil reduced overall efficiencies of

cortical networks in α and β1 frequency ranges. Disruptions of the complex cortical networks subserving normal brain function wereassociated with loss of stability of sustained attention but not with analgesic effect. See the accompanying Editorial View on page 8 .(Summary: M.J. Avram. Image: ©Thinkstock.)

196 Regulation of Cerebral Autoregulation by Carbon Dioxide (Review Article)

Cerebral autoregulation protects the brain from ischemia and overperfusion in the face of fluctuat-ing perfusion pressure. Cerebral blood flow remains stable between the lower and the upper cere-bral perfusion pressure limits and is pressure passive at the cerebral perfusion pressures below thelower limit and above the upper limit. The integrated effect of carbon dioxide and perfusion pressureon cerebral circulation is discussed on the basis of published large animal data as well as humandata, with speculation on the aspects for which there are no supportive data. (Summary: M.J. Avram.Image: J.P. Rathmell.)

191 Pretransfusion Testing and Transfusion of Uncrossmatched Erythrocytes(Clinical Concepts and Commentary)

The level of pretransfusion testing ordered can be based on a variety of considerations, including aninstitution’s maximum surgical blood order schedule, which recommends the extent of pretransfusiontesting for common surgical procedures that will reduce unnecessary testing and costs. Pretransfu-sion testing aimed at avoiding potentially fatal hemolytic transfusion reactions is reviewed, includingcomputer or electronic crossmatching, on the basis of which any ABO and RhD type-specific unit canbe issued to a patient with a negative antibody screen and no historical antibodies. Indications for theemergency release of uncrossmatched group O erythrocytes and risks and special considerations

associated with their use are reviewed. (Summary: M.J. Avram. Image: J.P. Rathmell.)



11/254

Global, regional, and national levels and causes of maternal mortality during1990–2013: A systematic analysis for the Global Burden of Disease Study 2013.

Lancet 2014; 384:980–1004.

This worldwide survey used robust methodology to analyze trends in all-cause maternal mortality ratio(MMR) between 1990 and 2013. The total annual number of maternal deaths decreased from 376,034(95% uncertainty interval 343,483–407,574) in 1990 to 292,982 (261,017–327,792) in 2013. Between2003 and 2013, the annual rate of change in MMR was greater than –1%, reaching –3.3% for 2012–13.The most likely underlying etiologies are complications of anesthesia, embolism (air, amniotic fluid, and

blood clot). Global rates of change suggest that only 16 countries will achieve the fifth Millennium Development Goal target by

2015, which requires careful consideration for regions that are making slow progress, such as west and central Africa. (Summary:J. Mantz. Image: J.P. Rathmell.)

Effect of fenoldopam and use of renal replacement therapy among patients with

acute kidney injury after cardiac surgery: A randomized clinical trial. JAMA 2014;doi: 10.1001/jama.2014.13573 [Epub ahead of print].

Acute kidney injury is one of the most frequent complications of cardiac surgery and is associatedwith morbidity and mortali ty. In this multicenter randomized controlled trial, the effect of fenoldopam(a selective dopamine receptor D1 agonist that induces vasodilation of the renal, mesenteric, andcoronary arteries) via continuous infusion for 4 days was compared with placebo in 667 cardiacsurgical patients with early postoperative acute kidney injury admitted to the intensive care unit.

The need for renal replacement therapy was the primary outcome. Fenoldopam infusion did not reduce the need for renalreplacement therapy or 30-day mortality among patients with acute kidney injury after cardiac surgery. However, fenoldo-

pam was associated with an increased rate of hypotension. (Summary: J. Mantz. Image: J.P. Rathmell.)

Outcomes 1 year after thrombus aspiration for myocardial infarction.N Engl J Med 2014; 371:1111–20.

The use of intracoronary thrombus aspiration before primary percutaneous coronary intervention (PCI) inpatients with ST-segment elevation myocardial infarction (STEMI) remains a matter of debate. In this ran-domized, registry base trial, 7,244 patients with STEMI were allocated to undergo manual thrombus aspi-ration followed by PCI or to undergo PCI alone. It was found that a strategy of routine manual thrombusaspiration before PCI, as compared with PCI alone, did not reduce all-cause mortality or the compositeof death from any cause, rehospitalization for myocardial infarction, or stent thrombosis up to 1 yr. (Sum- mary: J. Mantz. Image: J.P. Rathmell.)

Shattuck lecture. A molecular basis for nicotine as a gateway drug. N Engl J Med 2014;

371:932–43.

Epidemiologic studies have suggested that nicotine use is a gateway to the use of marijuana and cocainein human populations, but the mechanisms of this phenomenon are unclear. In this illuminating articlewritten by prestigious authors in the domain of molecular neuroscience and medicine, the reader will finda description of how nicotine produces its effects in the brain of mice. The conclusions are applied topublic health concerns that are being raised as the popularity of electronic cigarettes rises, with empha-sis of the potential benefits to society of translating epidemiologic findings into public health policy.(Summary: J. Mantz. Image: Nicotinic channel-receptor, ©Nature Publishing Group. Used with permission.)

SCIENCE, MEDICINE, AND THE ANESTHESIOLOGIST

Key Papers from the Most Recent Literature Relevant to Anesthesiologists


Jean Mantz, M.D., Ph.D., Editor


12/254

SCIENCE, MEDICINE, AND THE ANESTHESIOLOGIST

Key Papers from the Most Recent Literature Relevant to Anesthesiologists


Sepsis Severity Score: An internationally derived scoring system from the survivingsepsis campaign database. Crit Care Med 2014; 42:1969–76.

Sepsis remains a major perioperative public health challenge. A better understanding of the risk factors pre-dicting mortality can help to improve the level of care in severe sepsis. In this study including a database of23,482 observations, a 34-item Sepsis Severity Score was generated and exhibited an excellent ability to dis-criminate between survivors and nonsurvivors. The most significant limitation is that of age and comorbidity.As with all severity scoring models, the probabilities generated in these models should be used for gainingfurther understanding of populations, not for decision making with regard to individual patients. (Summary:J. Mantz. Image: J.P. Rathmell.)

Impact of closure at the first take back: Complication burden and potentialoverutilization of damage control laparotomy. J Trauma 2011; 71:1503–11.

Damage control laparotomy (DCL) has been used as a lifesaving technique that minimizes coagulopathy,hypothermia, and acidosis. However, the morbidity carried by overutilization of this technique remainsunknown. In this retrospective cohort including 925 trauma patients who underwent immediate DCL, early

fascial closure was found to be an independent predictor of reduced complications in DCL patients. Thismay represent an overutilization of this valuable technique, exposing patients to increased complications.(Summary: J. Mantz. Image: J.P. Rathmell.)

Acupuncture for chronic knee pain: A randomized clinical trial. JAMA 2014;

312:1313–22.

Acupuncture is a popular approach to pain control. However, few studies in this area have been wellpowered, and adequate control groups have often not been included. In their recent randomized trialinvolving 282 patients, Hinman et al. evaluated acupuncture on chronic knee pain at the end of treatment(12 weeks) and at 1 yr. The study was remarkable for its use of a control (no treatment) and sham treat-ment group as well as groups receiving each of two alternative forms of acupuncture. The investigatorsfound that compared with sham treatment the traditionally and laser acupuncture–treated patients didnot achieve significant improvement in average knee pain or function, the primary outcomes in this trial.

This study does not support the use of acupuncture for knee pain, and demonstrates the need for powerful study designs to beapplied to alternative as well as allopathic pain therapies. (Summary: J.D. Clark. Image: ©Thinkstock.)

Doing today’s work superbly well—treating Ebola with current tools.

N Engl J Med 2014; 371:1565–6.

News of the Ebola outbreak across West Africa is taking over the lay press and scholarly medical publica-tions. Articles describing this disease evoke fear among the public and clinicians as well as a concernthat, if there is no treatment, nothing can be done. In this superb perspective, the authors point out a mostimportant educational message for every care provider: reduction of mortality does not only rely on newhigh-tech antiviral drugs, but also on excellent routine clinical care with simple interventions (i.e., fluidloading to prevent deaths attributable to hypovolemia, rational use of basic routine biology, strict isolationmeasures of suspect cases) that will help to break transmission chains. (Summary: J. Mantz. Image: Col- orized transmission electron micrograph of the Ebola virus, Centers for Disease Control and Prevention.)


13/254

Complex Information for Anesthesiologists Presented Quickly and Clearly

INFOGRAPHICS IN ANESTHESIOLOGY

We extracted the percentage of erythrocytes transfused by service directly from the 2011 National Blood Collection and Utilization Survey Report.* The medi-

cine and pediatric (med/peds) services and hematology–oncology (hem/onc) services were grouped together in not having the potential for anesthesiologist

involvement, whereas combined surgical departments (surgery), trauma/emergency room, medical and surgical intensive care units (ICU), obstetrics/gyne-cology (OB/GYN), and other services (anesthesiology, outpatient) were deemed areas in which anesthesiologists may be involved in decisions to transfuse.

Infographic created by Jonathan P. Wanderer, Vanderbilt University School of Medicine, and James P. Rathmell, Massachusetts General Hospital/

Harvard Medical School. Illustration by Annemarie Johnson, Vivo Visuals. Address correspondence to Dr. Wanderer: [email protected].

1. Clifford L, Jia Q, Yadav H, Subramanian A, Wilson GA, Murphy SP, Pathak J, Schroeder DR, Ereth MH, Kor DJ: Characterizing the epidemiology

of perioperative transfusion-associated circulatory overload. ANESTHESIOLOGY 2015; 122:21-8

2. Clifford L, Jia Q, Subramanian A, Yadav H, Wilson GA, Murphy SP, Pathak J, Schroeder DR, Kor DJ: Characterizing the epidemiology of post-

operative transfusion-related acute lung injury. ANESTHESIOLOGY 2015; 122:12-20

3. de Almeida JP, Vincent J-L, Galas FRBG, de Almeida EPM, Fukushima JT, Osawa EA, Bergamin F, Park CL, Nakamura RE, Fonseca SMR,

Cutait G, Alves JI, Bazan M, Vieira S, Vieira Sandrini AC, Palomba H, Ribeiro U Jr, Crippa A, Dalloglio M, del Pilar Estevez Diz M, Filho

RK, Costa Auler JO Jr, Rhodes A, Haijar LA: Transfusion requirements in surgical oncology patients: A prospective, randomized controlled trial.

ANESTHESIOLOGY 2015; 122:29-38

* The 2011 National Blood Collection and Utilization Survey Report. Available at: http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf. Accessed

October 29, 2014.


mailto:[email protected]:[email protected]


14/254

A’ Journal CME is open to all readers. To take partin A Journal-based CME, complete the followingsteps:

1. Read the CME information presented on this page.2. Read this month’s article designated for CME credit (listed on

the right) in either the print or online edition.3. Register at http://education.asahq.org/2015-journal-cme.

Nonmembers will be asked to provide payment.4. Achieve a score of at least 50% correct on the six-question on-

line journal CME quiz and complete the evaluation.5. Claim credit in 15-minute increments, for a maximum of 1

AMA PRA Category 1 Credit™ per journal article.

CME Information & Disclosure

Purpose: The focus of A Journal-based CME is toeducate readers on current developments in the science and clinicalpractice of anesthesiology.

Target Audience: A Journal-based CME is intend-ed for anesthesiologists. Researchers and other health care profes-sionals with an interest in anesthesiology may also participate.

Accreditation: The American Society of Anesthesiologists is ac-credited by the Accreditation Council for Continuing MedicalEducation to provide continuing medical education for physicians.

CME Designation Statement: The American Society of Anesthe-siologists designates this Journal-based CME activity for a maxi-mum of 1 AMA PRA Category 1 Credit™ . Physicians should claimonly the credit commensurate with the extent of their participationin the activity.

Rates

Two options are available:

ASA Member Non-member

Annual Fee $0 $120Per Issue $0 $20

Payment may be made using Visa or MasterCard.

Please direct any questions about Journal-based CME to:[email protected]

Date of Release: December 2014

Termination Date: December 2017

This Month’s A NESTHESIOLOGY Journal-basedCME Article

Read the article by Pinheiro de Almeida et al . entitled “Transfusion Re-quirements in Surgical Oncology Patients: A Prospective, Randomized

Controlled Trial” on page 29 and the accompanying editorial by Cataentitled “Perioperative Anemia and Blood Transfusions in Patients with

Cancer: When the Problem, the Solution, and Their Combination AreEach Associated with Poor Outcomes” on page 3 of this issue.

Learning Objectives

After successfully completing this activity, the learner will be ableto apply the risks of anemia to perioperative cancer patients, applythe risks of blood transfusion to perioperative cancer patients, andrecognize the differences in the risk of blood transfusion between

specific patient groups.

Disclosures

Editor-in-Chief: James C. Eisenach, M.D., receives consultingfees from Aerial BioPharma LLC and Cubist Pharmaceuticals, Inc.

CME Editors: Leslie C. Jameson, M.D., receives honoraria fromGE Medical International and Masimo Corporation. Dan J.Kopacz, M.D., has an equity position in SoloDex, LLC.

Authors: Juliano Pinheiro de Almeida, M.D., Jean-Louis Vincent,M.D., Ph.D., Filomena Regina Barbosa Gomes Galas, M.D., Ph.D.,Elisangela Pinto Marinho de Almeida, M.D., Julia T. Fukushima,M.Sc., Eduardo A. Osawa, M.D., Fabricio Bergamin, M.D., Clarice

Lee Park, M.D., Rosana Ely Nakamura, M.D., Silvia M. R. Fonseca,M.D., Guilherme Cutait, M.D., Joseane Inacio Alves, R.N., Mel-lik Bazan, P.T., Silvia Vieira, R.N., Ana C. Vieira Sandrini, L.D.N.,Henrique Palomba, M.D., Ph.D., Ulysses Ribeiro, Jr., M.D., Ph.D.,

Alexandre Crippa, M.D., Marcos Dalloglio, M.D., Ph.D., Mariadel Pilar Estevez Diz, M.D., Ph.D., Roberto Kalil Filho, M.D.,Ph.D., Jose Otavio Costa Auler, Jr., M.D., Ph.D., Andrew Rhodes,M.B., B.S., and Ludhmila Abrahao Hajjar, M.D., Ph.D., have re-ported no financial relationships with commercial interests.

Author: Juan P. Cata, M.D., has reported no financial relationships with commercial interests.

ASA Staff: Kari L. Lee, Editorial Manager, and Ginger Yarger, Editor,have reported no financial relationships with commercial interests.

Resolution of Conflicts of Interest

In accordance with the ACCME Standards for Commercial Sup-port of CME, the American Society of Anesthesiologists has imple-mented mechanisms, prior to the planning and implementation ofthis Journal-based CME activity, to identify and resolve conflicts ofinterest for all individuals in a position to control content of this

Journal-based CME activity.

Disclaimer

The information provided in this CME activity is for continuingeducation purposes only and is not meant to substitute for the inde-

pendent medical judgment of a health care provider relative to diag-nostic and treatment options of a specific patient’s medical condition.

Instructions for Obtaining A NESTHESIOLOGY ContinuingMedical Education (CME) Credit

CME Editors: Leslie C. Jameson, M.D., and Dan J. Kopacz, M.D.

ANESTHESIOLOGY CME PROGRAM

http://education.asahq.org/2015-journal-cmemailto:[email protected]:[email protected]://education.asahq.org/2015-journal-cme


15/254

An, V 122 • N 1 1 January 2015

A P P R O X I M A E L Y21,000,000 blood compo-

nents were transfused in 2011 inthe United States. Almost half ofthose were transfused in the operat-ing room or perioperatively accord-ing to the 2011 National BloodCollection and Utilization SurveyReport.* Consequently, the anes-thesiologist assumes a substantialrole in mitigating adverse transfu-sion reactions. In fact, one adversereaction per 414 units transfused was reported in the above survey,accounting for 50,570 total.* Manytransfusion reactions can be iden-tified with predictable laboratorydiagnostic tests. However, whenno specific test exists or concretedefinitions are not established, thediagnosis is often missed or underappreciated. As a result,the transfusion reaction remains in obscurity; if proper safe-

guards are not implemented, the possibility of occurring againis not deterred. Tis is the case in transfusion-related acutelung injury (RALI) and transfusion-associated circulatoryoverload (ACO). In this month’s edition of A NESHESIOLOGY ,Clifford et al. have taken an enormous step in providing bet-ter detection of these common adverse reactions.1,2

Why is reporting a seemingly obvious reaction that is tem-porally related to a visible intervention so difficult? On paper,a patient without lung injury developing acute respiratorydistress within hours of receiving a blood transfusion wouldseem likely to raise red flags. Unfortunately, the clinical pic-ture is often blurred with multiple confounders. Dyspnea

is expected in patients presenting with preexisting cardiacconditions or underlying pulmonary disease. Isolating oneculprit among multiple interventions occurring in surgicalpatients is often not possible or may not have clinical rele-vance when choosing the next therapy. Indeed, the treatment

for acute respiratory failure fromadult respiratory distress syn-drome and circulatory overloadis similar regardless of etiology. Inaddition, reporting depends onthe specialty of the physicians andhow they diagnose RALI andACO.3 Personal reasons mayalso factor into reporting. Fearof reprisal, apathy, or unaware-ness of the reporting mechanismsmust be taken into account.Finally, to steal a sports phrase,the concept of “no harm, nofoul” may be a reason for under-reporting. o address these prob-lems, Clifford et al. minimizedthe human element and used therobust databases of Mayo Clinicto examine noncardiac surgical

patients over two different years. In this retrospective analysis,83,204 patients were electronically screened for signs and symp-

toms consistent with RALI or ACO. Te precision of thisstudy was augmented by natural language-processing softwaredeveloped at the Mayo Clinic. Tis electronic “data-miner”evaluates radiographic reports looking for explicit or descriptiveterms used to identify RALI and ACO. Te importance ofthis initial screening tool cannot be underestimated. Tousandsof hours would be required for detailing such records makinga study of this size implausible for many institutions. In addi-tion, the fidelity of the natural language-processing software ishigh, producing a specificity and sensitivity of 92.5 and 93.6%,respectively.1 Once limited to manageable numbers, the posi-tively screened patients were evaluated by independent physi-

cians for actual cases of RALI or ACO.Te Mayo Clinic studies focused on patients transfused in

the perioperative period in an effort to categorize this uniquepopulation. As such, postoperative incident rates of 1.4% forRALI and 4.3% for ACO may not be generalizable to the

Revealing the Real Risks of Perioperative Transfusion

Rise of the Machines!

Jeffrey W. Simmons, M.D., Jean-Francois Pittet, M.D.

Copyright © 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2015; 122:1-2

“The potential for this type of

technology is extraordinary.”

Image: ©Shutterstock.

Corresponding articles on page 12 and page 21.

Accepted for publication September 3, 2014. From the Department of Anesthesiology (J.W.S.) and Departments of Anesthesiology, Sur-gery, and Cell and Developmental and Integrative Biology ( J.-F.P.), University of Alabama at Birmingham, Birmingham, Alabama.

* The 2011 National Blood Collection and Utilization Survey Report. Available at: http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf . Accessed October 29, 2014.

EDITORIAL VIEWS

http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdfhttp://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf


16/254

Anesthesiology 2015; 122:1-2 2 J. W. Simmons and J.-F. Pittet

Editorial Views

entire transfused population. Te incidence rate of RALI inthe critically ill population, as might be common at the MayoClinic, has been estimated to be between 5.1 and 15%.4,5 Also, by combining highly probable cases with actual cases,the incident rates that were calculated have the potential to be

artificially high. However, requiring imputability or identifica-tion of transfusion as the sole causal factor in acute respiratoryfailure from adult respiratory distress syndrome and circulatoryoverload results in underappreciation of the disease. Coincid-ing with underrecognition, the Mayo Clinic researchers limitedtheir results to 6 h posttransfusion. Tis was intentionally done;however, expanding their definition of the perioperative periodmay have identified an even greater incidence. Te postoperativeperiod can range from 6 to 24 h depending on the disease stud-ied. In an effort to generalize these results, multicenter effortsusing the Mayo Clinic natural language-processing softwarecould be used, and the definition of the postoperative period

standardized. Highlighted in this study is the use of computerautomation to examine thousands of records in an electronicdatabase. In this study, language-processing software retrospec-tively identified low-incident, high-morbidity processes withastounding fidelity. Will it be possible for this same softwareto perform concurrent searches during a patient’s hospital stayto detect disease patterns and assist in decision making? Tepotential for this type of technology is extraordinary.

ransfusion-related acute lung injury and ACO are thenumber one and two causes of transfusion-related deaths inthe United States. In 2013, the Federal Drug Administrationreported that 38 and 24% of the deaths after transfusion wereattributable to RALI and ACO. ransfusion could not beruled out as the cause in an additional 32% of deaths (approxi-mately 21 of 71 cases in FY2013).6 Tus, recognition of theadverse reaction and accurate reporting are crucial in mitigat-ing risk to patients. Trough identification of patients withRALI and ACO, risk stratification regimens can be betterconstructed. Epidemiological studies such as these studies pavethe way for tailored transfusion practices for patients at high riskfor RALI or ACO. Importantly, recognition of blood com-ponents that have caused RALI will allow for future exclusionof those donors. As well, blood component traits can be identi-fied that put patients at higher risk for these disease processes.

Whether transfusion-related adverse reactions are notreported due to human error or underrecognition, the risk topatients remains high. Trough use of intelligent automation,Clifford et al. have identified the overall risk of RALI at 1.4%and ACO at 4.3% in the perioperative patient. For RALI,dramatic underrecognition of the disease was identified. Inaddition, increasing volume transfused and increasing age wasclinically predictive of developing RALI. Te Mayo Clinicstudy identified increased risk of ACO with certain surgicalprocedures, increased transfusion volume, and total operativefluid balance. Tis coincides with know risk factors publishedby the RALI Study Group.7 When transfusion-related adversereactions occurred, hospital stay was prolonged and mortality

was augmented (odds ratio, 15.6 for RALI).

Te landscape of hemotherapy is ever-changing. Cliniciansshould seek to better recognize adverse transfusion reactions.Te goal of minimizing transfusions to limit patient exposureto adverse reactions is reasonable and practical. o accomplishthis, patient blood management strategies are being widely

implemented and have been successful in reducing blood trans-fusions in tertiary care centers.8 Te principles of patient bloodmanagement are based on the three pillars concept: optimiz-ing preoperative erythropoiesis, reducing operative blood loss,and harnessing the patient’s physiological tolerance of anemia.9 Anesthesiologists should recognize this changing landscape as we are often on the front lines of blood transfusion.

Acknowledgments

Supported by the National Institutes of Health, Bethesda,Maryland (grant no. RO1 GM086416, to Dr. Pittet).

Competing InterestsThe authors are not supported by, nor maintain any finan-cial interest in, any commercial activity that may be associ-ated with the topic of this article.

Correspondence

Address correspondence to Dr. Pittet: [email protected]

References

1. Clifford L, Jia Q, Subramanian A, Yadav H, Wilson GA,Murphy SP, Pathak J, Schroeder DR, Kor DJ: Characterizingthe epidemiology of postoperative transfusion-related acutelung injury. A Nesthesiology 2015; 122:12–20

2. Clifford L, Jia Q, Yadav H, Subramanian A, Wilson GA, MurphySP, Pathak J, Schroeder DR, Ereth MH, Kor DJ: Characterizingthe epidemiology of perioperative transfusion-associated cir-culatory overload. A Nesthesiology 2015; 122:21–8

3. Vaar AP, Wr K, Bnnkad JM, van or Mh, Bckr e,gajc o, scuz MJ, Juffrman NP: t pracc f rprntransfusion-related acute lung injury: A national survey amongcnca and prcnca dcpn. tranfun 2010; 50:443–51

4. Bnn AB, Aun gl, Br M, McFann KK, tma s,Ramrz g, Rn h, sman CC, M M: tranfun-rad acu un njur n iCU pan admd w a -rnna bdn. innv Car Md 2010; 36:1710–7

5. Vaar AP, Juffrman NP: tranfun-rad acu unnjur: A cnca rvw. lanc 2013; 382:984–94

6. Rarc CfBea: Faa Rprd FDA Fwn Bd

Ccn and tranfun: Annua summar fr Fca yar2013. Admnran UsFaD, d2013

7. Murp el, Kwaan N, ln MR, gajc o, hubmar RD,Gropper MA, Koenigsberg M, Wilson G, Matthay M, BacchettiP, t P; tRAli sud grup: Rk facr and ucm ntransfusion-associated circulatory overload. Am J Med 2013;126:357.29–38

8. la MF, Rbr h, Mukar sA, Farmr s, tv J, Jwacw V, Dxn t, lau P, Ward M, Vdanvc M, trnn K, KrurPC, gaar t, Ka A, hfmann A, smmn JB, twrS; Western Australian Patient Blood Management Program: Apragmatic approach to embedding patient blood managementn a rar pa. tranfun 2014; 54:1133–45

10. Leahy MF, Mukhtar SA: From blood transfusion to patient blood management: A new paradigm for patient care andc amn f bd ranfun pracc. inrn Md J2012; 42:332–8

mailto:[email protected]:[email protected]


17/254

Aneteolo, V 122 • No 1 3 January 2015

IN this month’s issue of ANESHESIOLOGY , de Almeida

et al.1 elegantly investigatedpostoperative administration ofpacked erythrocytes in patients who were admitted to the surgicalintensive care unit after abdomi-nal cancer surgery. Te study

was a controlled, parallel-group,double-blind superiority trial in which patients were randomizedto receive blood transfusions usingrestrictive (hemoglobin


18/254

Anesthesiology 2015; 122:3-4 4 Juan P. Cata

Editorial Views

Other important points to consider in terms of thepotential impact of anemia on postoperative outcomes arethe patient’s age, rapidity of anemia onset, and the hemo-globin-duration deficit product (or duration below a criticalhemoglobin value).6 Very low hemoglobin concentrations

are generally well tolerated in young individuals, but olderpatients appear to be at a high risk for anemia-related mor-tality, possibly owing to age-associated limited organ reserve.Te duration below a critical hemoglobin value also deservesattention because a delay in administering erythrocytes toimprove oxygen delivery is directly related to mortality inpatients whose hemoglobin concentrations are below 8 g/dl.7

Blood transfusion is the mainstay therapy for moderate-to-severe perioperative anemia; however, administration of bloodproducts is associated with poor outcomes in patients withand without cancer. In those with cancer, blood transfusionscan directly (via soluble factors) and indirectly (via transfusion

related immune modulation) induce proliferation and spreadcancer cells present at sites of minimal residual disease (tumormargins and dormant tumors).8 After transfusions, there is anincrease in the concentrations of local (tumor microenviron-ment) and circulating proinflammatory cytokines and prosta-glandin E, which tilt the balance toward immune suppression. At the cellular level, there is a reduction in the function of nat-ural killer cells; a decrease in the proliferation of CD4+, CD8+ cells, and B lymphocytes; induction of regulatory cells;and a decrease in maturation and antigen-presenting activ-ity of dendritic cells, which also contributes to a diminishedimmune function.9 Furthermore, administration of bloodproducts may facilitate proliferative and metastatic propertiesof cancer cells via angiogenic and oncogenic factors leakedfrom stored erythrocytes, a phenomenon associated with theso called storage lesion.10 Hence, patients with cancer are at ahigher risk of tumor recurrence after receiving blood transfu-sions, which constitutes the “second evil.”

Last, the combination of intraoperative or postopera-tive anemia and blood transfusion, the “third evil,” maycause the most harm.3 In the context of an ongoing insultas occurs during surgery, the summation of the responseto moderate-to-severe anemia (“first hit”) followed by theresponse to the blood transfusion (“second hit”) may causean exaggerated systemic inflammatory and immune sup-pressive response, and endothelial dysfunction.11 In thegeneral surgical population, this can translate into a higherrisk for early postoperative morbidity and mortality. Inpatients with cancer, the consequences of inflammationand “immune paralysis” can be seen as an increased risk forrecurrence or cancer-specific mortality.

In conclusion, moderate-to-severe anemia and blood trans-fusions induce marked changes in the homeostasis of severalphysiological processes, including endothelial function, com-plement activation, the inflammatory response, and immunefunction, all of which have been linked to the pathogenesis ofend-organ ischemia (particularly in older patients and those

with advanced atherosclerotic disease). Tey have also been

linked to cancer recurrence. Until oxygen delivery can bemonitored precisely, perioperative physicians must rely on ahemoglobin value to “safely” transfuse or not patients duringand after surgery. Te work by de Almeida et al.1 supportsprevious studies, indicating that perioperative anemia is the

predictor of mortality in patients with cancer. Teir workindicates that maintaining a hemoglobin concentration above9 g/dl is prudent in cancer surgery patients. In those patients who are at risk of developing significant anemia during or aftersurgery (hemoglobin


19/254

An, V 122 • N 1 5 January 2015

IN the current issue of A NESHESIOLOGY , Reddy et al.1 report a

two-hospital, retrospective, obser-vational, cohort study confirmingthat anaphylaxis is more common with rocuronium and succinylcho-line than with atracurium, a topicthat is difficult to assess and was firsthighlighted in this journal in 2003.2 Although any medication can poten-tially cause perioperative anaphy-laxis, neuromuscular-blocking drugs(NMBDs), antibiotics, latex, andchlorhexidine are the most likely todo so. Regional differences regardingthe relative risk of allergic reactionsto NMBDs do exist. NMBDs repre-sent the dominant causes of anaphy-laxis in several countries and regionssuch as France,2–4 Norway,5 Spain,6 and Australasia,7 whereas otheragents may be primarily involved inother countries.8 Nevertheless, aller-gic reactions to NMBDs remain aserious concern for anesthesiologistsbecause death may occur even when

reactions are rapidly and adequatelytreated.9 Te reported incidence ofperioperative anaphylaxis is quitevarying, ranging between 1:3,500and 1:20,000. Part of the variabilityis likely due to difficulty in deter-mining the exact exposures to the numerous drugs, bloodproducts, and agents used in the operative setting. Te num-ber of documented cases of intraoperative anaphylaxis istypically reported in aggregate for a large population, leavingthe specifics of the total amount and type of medications thepopulation was exposed to in question.

In the study by Reddy et al., the authors take the advan-tage of their ability to retrieve detailed information concern-ing new patient exposure to each NMBD from electronicanesthetic records available in the two participating centersover 7 yr. Tis allowed a more precise estimate of the num-ber of patients exposed as the denominator when calculat-ing the relative risk of allergic reactions associated with the

use of each NMBD. Tis methodhelps eliminate the primary concern with data based on drug sales, whichhave the potential to overestimatethe exposure resulting in a poten-tial underestimation of anaphylaxisrate. Interestingly, the authors’ find-ings are similar to the estimates ofallergic reactions to NMBDs basedon drug sales. Tis study confirmsthe increased relative risk of aller-gic reaction to succinylcholine androcuronium in countries where ahigh rate of reaction to NMBDs isreported.

Te surveillance of intraoperativeadverse drug reactions still repre-sents a clinical and statistical chal-lenge10 because these reactions arerare, random, and mostly indepen-dent from the repeated exposure ofpatients to anesthesia. In addition,possible biases and underreportingmake comparison between drugsrelatively difficult. Another weak-ness of any reporting system is that

responsible physicians seem to havelittle understanding of which drugis actually causing the anaphylac-tic reaction when several drugs aresimultaneously administered dur-ing anesthesia induction due to a

lack of a single confirmatory test.11 With thorough reviewin this study, it was noted that 9 of the 21 cases of identi-fied NMBD anaphylaxis did not meet the standard skin testcriteria for positivity but correctly warranted inclusion basedon clinical picture and adjunct testing.

Because identification of the anaphylactic mechanism,

of the responsible drug, and of the alternative safe agentsis not always straightforward, a standard use of tryptasemeasurements in case of suspected allergic reactions andinvestigation of these reactions in compliance with estab-lished guidelines12 by allergists trained in the field of drugallergy working in close collaboration with anesthesiolo-gists should be promoted.13,14 Reddy et al. confirm that

Anaphylaxis to Neuromuscular-blocking Drugs

All Neuromuscular-blocking Drugs Are Not the Same

Paul Michel Mertes, M.D., Ph.D., Gerald W. Volcheck, M.D.

Copyright © 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2015; 122:5-7

Image: ©Thinkstock.

Corresponding article on page 39.

Accepted for publication September 15, 2014. From the Strasbourg Medical School, Hôpitaux Universitaires de Strasbourg, Nouvel HôpitalCivil, Strasbourg, Cedex, France (P.M.M.); and Mayo Medical School, Rochester, Minnesota (G.W.V.).

“There are many factors

that will influence the

choice of a specific NMBD,

depending on the clini-

cal situation, [includ-

ing] the likely increased

allergic risk associatedwith succinylcholine and

rocuronium....”


20/254

Anesthesiology 2015; 122:5-7 6 P. M. Mertes and G. W. Volcheck

Editorial Views

allergic reactions are associated with greater tryptase andgreater severity than nonallergic cases. Because no predic-tive test can help us to identify patients at risk before anyreaction, reduction of the risk of perioperative anaphylaxiscan only be based on secondary prevention.12 Tis report

provides a strong motivation for a thorough and systematicinvestigation of any hypersensitivity reactions occurringduring the perioperative period15 to avoid any undesirablesubsequent exposure to an offending agent toward whichone is already sensitized. Tis necessity is further supportedby the small number of minor reactions diagnosed in thisstudy, probably related to under-referral of mild reactionsto all agents, a reality clearly demonstrated in the litera-ture.4,15 Te authors were not able to determine the num-ber of reactors who were receiving anesthesia for the firsttime, had a history of multiple anesthetic exposure or evenhistory of previous reaction. Tis information would be

helpful in future studies in determining sensitization pat-terns. Going forward, studies of intraoperative anaphylaxisshould include a standard definition of anaphylaxis, uni-form skin testing, specific immunoglobulin E drug testing,tryptase measurements, and review by an allergist in con- junction with an anesthesiologist.

Te risk of allergic reactions is not the only drug char-acteristic that anesthesiologists must take into account when making their cl inical choice. In view of the numberof side effects associated with the use of succinylcholine,a controversy exists concerning replacing this old drug byrocuronium for rapid sequence induction.16 Neverthe-less, because of their rapid onset of effect, both drugs willremain essential in the anesthesiologists’ armamentarium. Another interesting point that must be considered is thatrocuronium can be rapidly reversed by sugammadex, apossibility that can make rocuronium a drug of choicein countries where sugammadex is available.17 Sugam-madex has also recently been proposed to improve recov-ery in case of anaphylaxis to rocuronium18; however, itsability to play a role in reaction reversal remains contro-versial.19,20 Moreover, hypersensitivity reactions, eitherallergic or not, have been reported with sugammadex,21 and this drug has not been approved in the United Statesat present.

Due to the amount of vecuronium exposures, Reddy etal. were not able to provide specific information concern-ing the risk associated with its use. Tis drug has beenshown to have a lower risk of anaphylaxis than rocuroniumin large epidemiologic studies22 and its effect can also beeffectively reversed by sugammadex.23 Tey consideredatracurium to be a safe alternative but were not able tocomment on the relative risk associated with cisatracuriumbecause this drug is not in use in Australasia. Cisatracu-rium has been shown to have the lowest risk of hyper-sensitivity reactions, either allergic or not, in large cohortstudies,3,22 and has also been shown to have the lowest

rate of cross-sensitization with other NMBDs in allergic

patients.7,22 Tere are many factors that will influence thechoice of a specific NMBD, depending on the clinicalsituation, but the likely increased allergic risk associated with succinylcholine and rocuronium, and the relativelylow risk associated with atracurium and even more so with

cisatracurium must be part of the clinical reasoning whenconsidering the use of a NMBD.

Competing Interests

The authors are not supported by, nor maintain any finan-cial interest in, any commercial activity that may be associ-ated with the topic of this article.

Correspondence

Address correspondence to Dr. Mertes: [email protected]

References

1. Reddy JI, Cooke PJ, van Schalkwyk JM, Hannam JA, FitzharrisP, Mitchell SJ: Anaphylaxis is more common with rocuroniumand succinylcholine than with atracurium. A NESTHESIOLOGY 2015; 122:39–45

2. Mertes PM, Laxenaire MC, Alla F: Anaphylactic and anaphy-lactoid reactions occurring during anesthesia in France in1999–2000. A Nesthesiology 2003; 99:536–45

3. Dn sW, Mr PM, Ppan N, hadnuf F, Manvk JM; GERAP: Hypersensitivity reactions during anesthesia.Ru frm nn Frnc urv (2005–2007). Mnrva

Anestesiol 2012; 78:868–78

4. Mr PM, Aa F, tréc P, Aur y, Jua e; grupd’eud d Réacn Anapacïd Pranéqu:

Anaphylaxis during anesthesia in France: An 8-year nationalsurvey. J Allergy Clin Immunol 2011; 128:366–73

5. harb t, gurmn AB, irn A, Dbnda t, Frvaa e: Anapax durn ana n Nrwa: A 6-ar n-cnr fw-up ud. A Nesthesiology 2005; 102:897–903

6. lbra t, Audcana Mt, Pz MD, Bac A, Frnándz e,Cañada P, gaamnza g, Marnz-Abda i, gnzáz-Maav i, Muñz D: sud f prnv racn andanaphylaxis during anesthesia in Spain. J Investig AllergolClin Immunol 2008; 18:350–6

7. sadr Ph, Cark RC, Bunnn Dl, Pa PR: Anapaxto neuromuscular blocking drugs: Incidence and cross-reac-v n Wrn Auraa frm 2002 2011. Br J Ana2013; 110:981–7

8. gurrr C, Wnarn tN, Marn DP, Babvc N, Narr BJ,Sprung J, Volcheck GW: Allergic reactions during anesthesiaa a ar Und sa rfrra cnr. An Ana 2011;

113:1202–12 9. Rr M, Ppan N, laarc C, Cn J, Ma N,

Dm P, g P, Mr PM; Frnc Nwrk f RnaPharmacovigilance Centres: Fatal anaphylaxis with neuro-mucuar bckn an: A rk facr and manamnanalysis. Allergy 2014; 69:954–9

10. Laake JH, Røttingen JA: Rocuronium and anaphylaxis—A sta-tistical challenge. Acta Anaesthesiol Scand 2001; 45:1196–203

11. Krøaard M, garv lh, Mnné t, huum B: Arc rac-tions in anaesthesia: Are suspected causes confirmed on sub-qun n? Br J Ana 2005; 95:468–71

12. Mr PM, Manvk JM, Juffr l, Abrr W, trrri, Brckw K, Dm P; Wrkn grup f sFAR andsFA; eNDA; eAACi inr grup n Dru Ar: Rducn rk f anapax durn ana: 2011 updadudn fr cnca pracc. J inv Ar CnImmunol 2011; 21:442–53

mailto:[email protected]:[email protected]:[email protected]:[email protected]


21/254


EDITORIAL VIEWS

13. Mertes PM, Demoly P, Malinovsky JM: Hypersensitivity reac-tions in the anesthesia setting/allergic reactions to anesthet-c. Curr opn Ar Cn immun 2012; 12:361–8

14. Volcheck GW, Mertes PM: Local and general anestheticsimmediate hypersensitivity reactions. Immunol Allergy ClinNr Am 2014; 34:525–46, v

15. Malinovsky JM, Decagny S, Wessel F, Guilloux L, Mertes

PM: smac fw-up ncra ncdnc f anap -laxis during adverse reactions in anesthetized patients. Acta

Anaesthesiol Scand 2008; 52:175–81

16. Perry JJ, Lee JS, Sillberg VA, Wells GA: Rocuronium versus uccncn fr rapd qunc nducn nuban.Cochrane Database Syst Rev 2008: CD002788

17. Aceto P, Perilli V, Modesti C, Ciocchetti P, Vitale F, Sollazzi L: Arwa manamn n b pan. sur ob Ra D2013; 9:809–15

18. McDnn NJ, Pav tJ, grn lK, Pa PR: suammadx n manamn f rcurnum-nducd anapax. Br J

Anaesth 2011; 106:199–201

19. Cark RC, sadr Ph, Pa PR: t r f uammadx n dvpmn and mdcan f an arc rpn rcurnum: evdnc frm a cuanu md. Anaa2012; 67:266–73

20. ln J, Brd Ch, D Crck ls, eb Dg: Rcurnum-induced anaphylaxis is probably not mitigated by sugamma-dx: evdnc frm an in vitro experiment. Anaesthesia 2011;

66:526–7 21. tur A, Kaank A: hprnv acad w uam-

madex administration: A systematic review. Anaesthesia2014; 69:1251–7

22. Mr PM, Amn-gan i, guéan-Rdruz RM,Mun-Favr C, Audbr g, o’Brn J, Frnd D, BrzanuM, Buazz h, guéan Jl: hprnv racn neuromuscular blocking agents. Curr Pharm Des 2008;14:2809–25

23. Manvk JM, Paud B, Dban B, Mr PM: [D wknw a ndcan and d ffc f uammadx?]. AnnFr Anesth Reanim 2011; 30:709–10

ANESTHESIOLOGY REFLECTIONS FROM THE WOOD LIBRARY-MUSEUM

Katz Oxygen Treatment for Catarrh

Just before World War I, the company of Chicago’s Samuel Katz peddled his “Oxygen Treatment forCatarrh” as an oxygenating panacea. He advertised that his cure-all contained “as much Oxygen as 86times its weight in food and drink” ( left ). Katz reminded his readers that if they placed “any living thing in avacuum, without oxygen … it will die” ( right ). In 1917 another Chicago-based organization, the AmericanMedical Association (AMA) published analyses of Katz Oxygen Treatment revealing it to consist of fourdiscrete boxes, consisting chiefly of (1) “aloes,” (2) “magnesium dioxide, magnesium carbonate and …calcium salts, with acacia,” (3) “sodium perborate and tartaric acid,” and (4) “cotton soaked in menthol.”So ironically, Chicago provided a home to promoters (Katz and Company) and discreditors (the AMA) ofthe Katz Oxygen Treatment. (Copyright © the American Society of Anesthesiologists, Inc.)

George S. Bause, M.D., M.P.H., Honorary Curator, ASA’s Wood Library-Museum of Anesthesiology,Schaumburg, Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland,Ohio. [email protected]


22/254


EDITORIAL VIEWS

13. Mertes PM, Demoly P, Malinovsky JM: Hypersensitivity reac-tions in the anesthesia setting/allergic reactions to anesthet-c. Curr opn Ary Cn immun 2012; 12:361–8

14. Volcheck GW, Mertes PM: Local and general anestheticsimmediate hypersensitivity reactions. Immunol Allergy ClinNr Am 2014; 34:525–46, v

15. Malinovsky JM, Decagny S, Wessel F, Guilloux L, Mertes

PM: symac fw-up ncra ncdnc f anapy -laxis during adverse reactions in anesthetized patients. Acta

Anaesthesiol Scand 2008; 52:175–81

16. Perry JJ, Lee JS, Sillberg VA, Wells GA: Rocuronium versus uccnycn fr rapd qunc nducn nuban.Cochrane Database Syst Rev 2008: CD002788

17. Aceto P, Perilli V, Modesti C, Ciocchetti P, Vitale F, Sollazzi L: Arway manamn n b pan. sur ob Ra D2013; 9:809–15

18. McDnn NJ, Pavy tJ, grn lK, Pa PR: suammadx n manamn f rcurnum-nducd anapyax. Br J

Anaesth 2011; 106:199–201

19. Cark RC, sadr Ph, Pa PR: t r f uammadx n dvpmn and mdcan f an arc rpn rcurnum: evdnc frm a cuanu md. Anaa2012; 67:266–73

20. lyn J, Brd Ch, D Crck ls, eb Dg: Rcurnum-induced anaphylaxis is probably not mitigated by sugamma-dx: evdnc frm an in vitro experiment. Anaesthesia 2011;

66:526–7 21. tur A, Kaanky A: hyprnvy acad w uam-

madex administration: A systematic review. Anaesthesia2014; 69:1251–7

22. Mr PM, Amn-gan i, guéan-Rdruz RM,Mun-Favr C, Audbr g, o’Brn J, Frnd D, BrzanuM, Buazz h, guéan Jl: hyprnvy racn neuromuscular blocking agents. Curr Pharm Des 2008;14:2809–25

23. Manvky JM, Paud B, Dban B, Mr PM: [D wknw a ndcan and d ffc f uammadx?]. AnnFr Anesth Reanim 2011; 30:709–10

ANESTHESIOLOGY REFLECTIONS FROM THE WOOD LIBRARY-MUSEUM

Katz Oxygen Treatment for Catarrh

Just before World War I, the company of Chicago’s Samuel Katz peddled his “Oxygen Treatment forCatarrh” as an oxygenating panacea. He advertised that his cure-all contained “as much Oxygen as 86times its weight in food and drink” ( left ). Katz reminded his readers that if they placed “any living thing in avacuum, without oxygen … it will die” ( right ). In 1917 another Chicago-based organization, the AmericanMedical Association (AMA) published analyses of Katz Oxygen Treatment revealing it to consist of fourdiscrete boxes, consisting chiefly of (1) “aloes,” (2) “magnesium dioxide, magnesium carbonate and …calcium salts, with acacia,” (3) “sodium perborate and tartaric acid,” and (4) “cotton soaked in menthol.”So ironically, Chicago provided a home to promoters (Katz and Company) and discreditors (the AMA) ofthe Katz Oxygen Treatment. (Copyright © the American Society of Anesthesiologists, Inc.)

George S. Bause, M.D., M.P.H., Honorary Curator, ASA’s Wood Library-Museum of Anesthesiology,Schaumburg, Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland,Ohio. [email protected]


23/254

An, V 122 • N 1 8 January 2015

T HE electroencephalogramis the scalp recording of the

electrical activity of the brain andreflects the activity of millions of

neurons on and just below the sur-face of the brain.

Te electroencephalogramis used extensively as surrogatemarker of anesthetic effect. Terhythmic pattern of the electroen-cephalogram is complex and whilesome patterns are easily recognizedby the eye, such as sleep spindlesduring stage 2 sleep, sophisti-cated analyses techniques havebeen developed to disentangle the

complexities of electroencephalo-graphic behavior. In this issue of A NESHESIOLOGY , Khodayari-Ros-tamabad et al.1 present data on theeffect of the opioid remifentanil onthe electroencephalogram. Teyfirst performed a functional con-nectivity analysis to establish thecharacteristics of the cortical network and subsequently analyzedthe network with a techniquebased on graph theory. Functional

connectivity represents statisticalcovariation between brain regions(i.e., brain regions with similarrhythmic activity), however, with-out any implications regarding causality or mechanism. oconstruct the network, Khodayari-Rostamabad et al.1 cal-culated the coherence matrix of the electroencephalogramin the standard bands, assuming that the electrodes serve asnodes to the network. Apart from the electroencephalogram,other techniques, such as functional magnetic imaging, maybe used to define functional brain connectivity.2

Graph Theory

Graph theory can be described as the mathematical analy-sis of networks in which the graph represents a set of network nodes.3 A well-known example of a graph theoreticalproblem was published by Stanley Milgram in 19674 in hisfamous paper entitled “Te small-world problem.” He stud-ied the number of intermediate sequential acquaintances(nodes) that are required to connect two random individuals

in the United States. In one of hisstudies, the Nebraska study, thenumber of connections rangedfrom 2 to 10 with a median of

6, very close to an earlier predic-tion by Frigyes Karinthy in 1929,5 who predicted that a network of just five acquaintances of 1.5 bil-lion people suffices to connect twoinhabitants of our planet. We areall aware of the complex networksin our lives. Another intuitiveexample of a small-world networkis the existing network of airports.o get around the world, we fly toa highly connected “hub” airport

that creates a shortcut throughoutthe network and allows us to travelmost efficiently to our destination.

A major step forward to fur-ther understanding small-worldnetworks was made by Watts andStrogatz.6 Tey explored networksthat varied in complexity froma regular network to a network with an increased amount of dis-order to a randomly connectednetwork (fig. 1).6 Te networks

are described in terms of nodes(vertices) and connecting paths(edges) with characteristic pathlength L (fig. 2). Tree connected

vertices (e.g., positioned in a triangle) make up a cluster withclustering coefficient C (note that clusters may be definedin alternative ways). Clustering coefficient C is defined asthe average across vertices of the ratio of existing trianglesand possible triangles; the characteristic path length L as theaverage shortest distance between vertices (one step betweenvertices equals a path length of 1).6,7 As recently explained,for brain networks, the characteristic path length represents

the global efficiency in information transmission in the brainnetwork; the clustering coefficient represents a measure oflocal functional segregation of brain activities.8,9 Te highlyregular network of Watts and Strogatz6 has high values forC and L, indicative of a network in which the vertices arehighly connected but the flow of information between verti-ces is slow. Te total random network of Watts and Strogatz6 has low values for C and L, which indicates that the vertices

Big Brain, Small World?

anestheology latest.pdf

Documents