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Science, Medicine, and the Anesthesiologist  |   August 2019
Science, Medicine, and the Anesthesiologist
Article Information
Science, Medicine, and the Anesthesiologist
Science, Medicine, and the Anesthesiologist   |   August 2019
Science, Medicine, and the Anesthesiologist
Anesthesiology 8 2019, Vol.131, A11-A14. doi:10.1097/ALN.0000000000002895
Anesthesiology 8 2019, Vol.131, A11-A14. doi:10.1097/ALN.0000000000002895
Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Relationship between postoperative pain and overall 30-day complications in a broad surgical population: An observational study. Ann Surg 2019; 269:856–65.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
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Little is known about associations between postoperative pain and the broad range of postoperative complications in a large heterogeneous surgical population. This prospective observational study explored the relationship between postoperative pain and postoperative complications at 30 days using patients’ perceptions and their movement-evoked pain score on the Numerical Rating Scale (NRS-MEP). The primary outcome was any surgical complication 1 month after surgery. Among the 1,014 patients, just over half (55%) had moderate-to-severe pain on postoperative day 1. At 30 days after the surgical procedure, the overall complication rate was 34%. Among patients with a postoperative day 1 NRS-MEP of 0, the proportion of patients who had complications was 0.25 (95% CI, 0.21 to 0.31). This proportion increased to 0.45 (95% CI, 0.36 to 0.55) for patients who had an NRS-MEP pain score of 10 on postoperative day 1. Patients that described their pain as unacceptable also had more postoperative complications (adjusted odds ratio 2.17; 95% CI, 1.51 to 3.10; P < 0.001). The results were similar among groups of patients that had similar surgeries and in the total surgically heterogeneous study population.
Take home message: High pain scores and unacceptable pain on postoperative day 1 may be associated with an increased risk of postoperative complications.
Restoration of brain circulation and cellular functions hours post-mortem. Nature 2019; 568:336–43.
Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
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The mammalian brain remains profoundly susceptible to hypoxia and ischemia. This study attempts to examine restoration and maintenance of microcirculation and molecular and cellular functions ex vivo at normal temperatures for up to 4 h after death in pigs. The investigators developed an extracorporeal pulsatile-perfusion system and a novel perfusate that was hemoglobin-based, acellular, noncoagulative, echogenic, and cytoprotective. The goal in using these innovations was to promote recovery from anoxia, reduce reperfusion injury, prevent edema, and provide metabolic support for the brain’s energy requirements. The authors were able to observe preservation of cells’ architecture after death and a slowing of the cell death process in the brain while restoring vascular vasodilatory responses, glial inflammatory responses, spontaneous synaptic activity, and cerebral metabolic activity in absence of global electrocorticographic activity.
Take home message: These findings suggest that intact large mammalian brains possess the capacity to restore brain microcirculation and molecular and cellular activity after a prolonged postmortem interval.
Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): A stepped-wedge cluster-randomised trial. Lancet 2019; 393:2213–21.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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The 30-day mortality rate in the 30,000 patients who undergo emergency abdominal surgery per year in the U.K. National Health Service is approximately 10%. This prospective randomized study examined the effectiveness of a national quality improvement program that tested a care pathway designed to increase postsurgical survival rates. After being grouped into geographical clusters, eligible high-volume U.K. National Health Service hospitals launched the quality improvement program in waves, with a new cluster starting each month. The patients, all adults over 40 yr of age who needed open abdominal emergency surgery, did not know whether they received usual care (n = 8,482) or the intervention (n = 7,374). The primary outcome was 90-day mortality. Sixteen percent of patients in each group died within 90 days of surgery (control group = 1,393 deaths; intervention group = 1,210 deaths; hazard ratio 1.11; 95% CI, 0.96 to 1.28).
Take home message: No survival benefit was observed from implementing this care pathway for patients undergoing emergency abdominal surgery.
An experimental randomized study on the analgesic effects of pharmaceutical-grade cannabis in chronic pain patients with fibromyalgia. Pain 2019; 160:860–9.
Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
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Patients with chronic pain desire and seek alternatives to opioids. The cannabis plant (Cannabis sativa L.), which contains more than 100 cannabinoids, is a promising alternative for the relief of chronic pain. This placebo-controlled four-way crossover trial examined the analgesia obtained by inhaling pharmaceutical-grade cannabis. Four varieties with differing Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) content were tested: Bedrocan (22.4 mg THC, less than 1 mg CBD), Bediol (13.4 mg THC, 17.8 mg CBD), Bedrolite (18.4 mg CBD, less than 1 mg THC), and placebo. Twenty chronic pain patients with fibromyalgia received a single vapor inhalation. The authors measured each patient’s THC and CBD plasma concentrations, pressure and electrical pain thresholds, spontaneous pain scores, and drug high for 3 h. They found that no variety of cannabis exceeded the placebo’s effect on spontaneous or electrical pain responses. More patients who received Bediol showed a 30% decrease in pain scores compared to placebo (90% vs. 55% of patients, P = 0.01); spontaneous pain scores correlated with the magnitude of drug high (p = 20.5, P < 0.001). Compared to placebo, cannabis varieties containing THC caused a significant increase in pressure pain threshold (P < 0.01). Interestingly, cannabidiol inhalation increased Δ9-tetrahydrocannabinol plasma concentrations but diminished the analgesic effects.
Take home message: This study demonstrates complex behaviors associated with inhaled cannabinoids in patients with chronic pain and the role of psychotropic symptoms on pain relief.
Association between gabapentinoids on the day of colorectal surgery and adverse postoperative respiratory outcomes. Ann Surg 2019 Apr 9 [Epub ahead of print].
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
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Many multimodal analgesia protocols for acute postoperative pain management after colorectal surgery include the use of gabapentin and pregabalin. Recent studies have examined their usefulness in reducing reliance on opioids during the postoperative period, but little has been published about their potential respiratory risks. This retrospective study explored the association between gabapentinoid administration on the day of surgery and adverse postoperative outcomes in colorectal surgery. In the 175,787 patients who received elective colorectal surgery during a 5-yr period, 4,677 patients (2.7%) received gabapentinoids on the day of surgery. The use of gabapentinoids doubled from 1.7% in 2009 to 4.3% in 2014. Treatment with gabapentinoids was associated with administration of lower parental morphine equivalents on surgery day compared with those who received other drugs (–2.7 mg; 95% CI, –5.2 to 0.0 mg). Patients treated with gabapentinoids were also more likely to receive noninvasive ventilation (odds ratio 1.22; 95% CI, 1.00 to 1.49) and treatment with naloxone (odds ratio 1.58; 95% CI, 1.11 to 2.26).
Take home message: While inclusion of gabapentinoids as a component of multimodal analgesia is associated with less opioid use on the day of surgery, it was also associated with higher odds of requiring noninvasive ventilation and the use of naloxone.
Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: A prospective randomised trial. Lancet 2019; 393:2201–12.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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Patients scheduled for cardiac surgery commonly have iron deficiency preoperative anemia. This prospective, double-blind, parallel-group study tested the hypothesis that treatment with 20 mg/kg ferric carboxymaltose, 40,000 units subcutaneous erythropoietin alpha, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid immediately preoperatively could reduce perioperative erythrocyte transfusions and improve outcomes in patients with iron deficiency anemia or iron deficiency without anemia when compared to placebo. The primary outcome was the number of erythrocyte transfusions during the first 7 postoperative days. In the placebo group, the median number of transfusions was 1 unit, compared to 0 units in the treatment group during the first 7 days (odds ratio 0.70; 95% CI, 0.50 to 0.98). Patients randomized to the treatment group had higher hemoglobin concentrations, reticulocyte counts, and reticulocyte hemoglobin content during the first 7 postoperative days (P ≤ 0.001). There were no differences in adverse outcomes between the groups.
Take home message: Treatment with IV iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid immediately before cardiac surgery may reduce erythrocyte and total allogeneic blood product transfusions in patients with preoperative anaemia or isolated iron deficiency.
Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: A scientific statement from the American Heart Association. Circulation 2019; 139:e891–e908.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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Among patients with acute myocardial infarction referred for coronary angiography, 5 to 6% will have myocardial infarction in the absence of obstructive coronary artery disease. Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA), a distinct clinical diagnosis with diverse pathophysiologic causes that requires appropriate evaluation to determine its underlying cause and develop treatment strategies. Accordingly, the American Heart Association recently issued a scientific statement on MINOCA that includes an updated definition, including a note that a MINOCA diagnosis should only be considered in those patients with a definite acute myocardial infarction, nonobstructive disease on coronary angiography, and no other clinical entities that would lead to myocardial injury without ischemia. The statement also provides a clinical framework and algorithms to assist in the evaluation and management of patients with this condition.
Take home message: A new statement on the diagnosis and management of myocardial infarction in the absence of obstructive coronary artery disease has been released by the American Heart Association.
Plasma transfusion products and contamination with cellular and associated pro-inflammatory debris. J Am Coll Surg 2019 Apr 25 [Epub ahead of print].
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
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Traditionally, stored plasma products have not undergone leukoreduction because of the belief that they lack cellular debris. This study tested the hypothesis that donor plasma contains sufficient leukocytes and platelets to trigger a significant proinflammatory responses in recipients. The authors analyzed samples of never-frozen liquid plasma from two level 1 trauma centers for leukocyte and platelet contamination. They then subjected known quantities of leukocytes to a freeze-thaw cycle, added them to whole blood, and then determined the extent of the inflammatory response based on induction of IL-6 production. Plasma, from two centers in two separate states, contained significant amounts of leukocyte (Site 1, n = 22, 17.3 ± 4.5 million vs. Site 2, n = 22, 11.3 ± 2.2 million) and platelet contamination (Site 1, n = 21, 0.86 ± 0.20 billion vs. Site 2, n = 22, 1.0 ± 0.3 billion). They also identified that cellular debris from as few as 1 million leukocytes induced significant increases in IL-6 levels (P < 0.0001). These contamination levels were more than 15-fold higher than needed to elicit ex vivo inflammatory responses.
Take home message: Plasma from blood banks may be contaminated with leukocytes and platelets at high enough levels to induce an inflammatory response.
2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2019; 73:2609–35.
Article Selection: Martin J. London. Image: John Fox, Brigham & Women’s Hospital.
Article Selection: Martin J. London. Image: John Fox, Brigham & Women’s Hospital.
Article Selection: Martin J. London. Image: John Fox, Brigham & Women’s Hospital.
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The American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons have issued a new expert consensus of care document on valvular heart disease. The statement’s purpose is to initiate an interdisciplinary discussion regarding the merits of creating a regionalized, tiered system of care for patients with valvular heart disease. The discussion’s focus would be to account for differences in valve center expertise, experience, and resources rather than permitting random market forces to drive care delivery. The joint proposal emphasizes performance and outcome standards for all providers and centers. Broad educational programs to introduce new interventions and incorporation of iterative changes in surgical techniques are thought to be necessary. Due to the emergence of clinical registries, it is becoming feasible to set performance standards both within and across centers, but significant work and cooperation must occur to make this proposal a reality.
Take home message: The American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons have jointly issued an expert consensus of care document on valvular heart disease.
Speech synthesis from neural decoding of spoken sentences. Nature 2019; 568:493–8.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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The lives of people who lose their ability to speak due to neurologic impairments would be transformed by technology that translates neural activity into speech. Due to the rapid and precise physical requirements associated with speech, decoding speech from neural activity is challenging. This study describes a neural decoder that synthesizes audible speech by leveraging kinematic and sound representations encoded in human cortical activity. Recurring neural networks were decoded from recorded cortical activity into representations of articulatory movement, and then transformed into speech acoustics. During test listening sessions, listeners could easily identify and transcribe synthesized speech from cortical activity. Intermediate articulatory dynamics enhanced performance. A component of the decoder was able to be transferred among participants because its decoded articulatory representations were highly conserved across different speakers. Interestingly, the decoder was able to synthesize speech based on mimed sentences performed by a silent participant.
Take home message: These findings suggest that eventually speech may be restored using some type of neuroprosthetic technology.
Trends in sedentary behavior among the U.S. population, 2001-2016. JAMA 2019; 321:1587–97.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
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Engaging in sedentary pastimes like watching television has been associated with poorer health outcomes, it is unclear whether this has resulted in changes in sedentary behaviors over time. This study examined trends and patterns in sedentary behaviors and sociodemographic correlates. Data from the National Health and Nutrition Examination Survey (NHANES) formed the basis of this serial, cross-sectional analysis. The authors examined the prevalence of watching television for 2 h/day or more and comparable pastimes among nearly 52,000 people during a 15-yr period, including 32,000 adults and 10,000 each of children and adolescents. The authors found that the prevalence of 2-h blocks of time devoted to sitting while watching television was high among all ages (children, 62%; adolescents, 59%; adults, 65%; adults aged 20 to 64 yr, 62%; and 65 yr or older, 84%). From 2001 through 2016, the trends decreased among children over time (difference, −3.4% [95% CI, −11% to 4.5%]; P for trend = 0.004), driven by non-Hispanic white children. These trends were stable among adolescents (−4.8% [95% CI, −12% to 2.3%]; P for trend = 0.60) and among adults aged 20 through 64 yr (−0.7% [95% CI, −5.6% to 4.1%]; P for trend = 0.82). However, sedentary watch time increased among adults aged 65 yr or older (difference, 3.5% [95% CI, −1.2% to 8.1%]; P for trend = 0.03). Additionally, the estimated prevalence of computer use outside school or work for 1 h or more per day increased in all ages.
Take home message: The estimated prevalence of participating in sedentary activity like watching television or videos for at least 2 h per day has decreased slightly over the past 15 for all age groups with the exception of individuals 65 yr of age and older.
Association of domestic responsibilities with career satisfaction for physician mothers in procedural vs nonprocedural fields. JAMA Surg 2019 Apr 10 [Epub ahead of print].
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
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Female physicians who have children may face challenges in balancing domestic obligations with their career leading to fewer opportunities for advancement and job satisfaction. This study explored the association between increased domestic workload and career dissatisfaction in proceduralists and nonproceduralist physicians. Attending physician mothers completed an online survey; the authors performed univariate analysis on responses that claimed sole responsibility for 5 or more when compared to less than 5 main domestic responsibilities. Nearly all of the 1,712 respondents had a partner or spouse (n = 1,698, 99.2%). Among these, 458 (27.0%) worked in a procedure-oriented specialty. Most respondents reported being solely responsible for most domestic tasks with no differences between the procedural and nonprocedural groups. Those in procedural specialties who were responsible for five or more domestic tasks were more interested in career changes than those with fewer household responsibilities (105 of 191 [55.0%] vs. 114 of 271 [42.1%]; P = 0.008). Multivariate analysis of the proceduralist cohort demonstrated that primary responsibility for five or more domestic tasks was independently associated with the desire to change careers (odds ratio 1.5; 95% CI, 1.0 to 2.2; P = 0.05).
Take home message: Women with higher levels of domestic responsibility are more likely to be dissatisfied with their careers.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
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Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
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Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
Article Selection: J. David Clark. Image: J. P. Rathmell.
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Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
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Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
Article Selection: Deborah J. Culley. Image: ©gettyimages.
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Article Selection: Martin J. London. Image: John Fox, Brigham & Women’s Hospital.
Article Selection: Martin J. London. Image: John Fox, Brigham & Women’s Hospital.
Article Selection: Martin J. London. Image: John Fox, Brigham & Women’s Hospital.
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Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
Article Selection: Martin J. London. Image: J. P. Rathmell.
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Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
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Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
Article Selection: Deborah J. Culley. Image: J. P. Rathmell.
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