Evaluation of Pulmonary Artery Pressure Measurements in Severe Pulmonic Valve Insufficiency in the Absence of Tricuspid Regurgitation.

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Subcellular Energetics and Metabolism: Potential Therapeutic Applications.

Part I of this review discussed the similarities between embryogenesis, mammalian adaptions to hypoxia (primarily driven by hypoxia-inducible factor-1 [HIF-1]), ischemia-reperfusion injury (and its relationship with reactive oxygen species), hibernation, diving animals, cancer, and sepsis, and it focused on the common characteristics that allow cells and organisms to survive in these states. Part II of this review describes techniques by which researchers gain insight into subcellular energetics and identify potential future tools for clinicians. In particular, P31 nuclear magnetic resonance to measure high-energy phosphates, serum lactate measurements, the use of near-infrared spectroscopy to measure the oxidation state of cytochrome aa3, and the ability of the protoporphyrin IX-triplet state lifetime technique to measure mitochondrial oxygen tension are discussed. In addition, this review discusses novel treatment strategies such as hyperbaric oxygen, preconditioning, exercise training, therapeutic gases, as well as inhibitors of HIF-1, HIF prolyl hydroxylase, and peroxisome proliferator-activated receptors. (C) 2017 International Anesthesia Research Society

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Diversity in the American Society of Anesthesiologists Leadership.

BACKGROUND: Women and minorities are underrepresented in US academic medicine. The Sullivan Commission on Diversity in the Healthcare Workforce emphasized the importance of diverse leadership for reducing health care disparities. The objective of this study was to evaluate the demographics of the American Society of Anesthesiologists leadership. We hypothesized that the percentage of women and underrepresented minorities is less than that of their respective proportions in the general physician workforce. METHODS: An electronic survey was developed by the authors and mailed to 595 members of the American Society of Anesthesiologists leadership who had valid email addresses, including the members of the 2014 House of Delegates and state society leaders who were not the members of the House of Delegates. Univariate statistics were used to characterize survey responses and the probability distributions were estimated using the binomial distribution. A one-sample t test was used to compare the percentage of women and minorities in the survey pool to that of the corresponding percentages in the general physician workforce (38.0% women and 8.9% minorities), and the US population (51.0% women and 32.0% minorities). RESULTS: The survey response rate was 54%. A total of 21.1% (95% confidence interval: 16.4%-25.7%) of respondents were women and 6.0% (95% confidence interval: 3.3%-8.7%) were minorities. The proportion of women in the American Society of Anesthesiologist leadership was lower than the general medical workforce and the US population (P

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Utilizing Forced Vital Capacity to Predict Low Lung Compliance and Select Intraoperative Tidal Volume During Thoracic Surgery.

BACKGROUND: Tidal volume selection during mechanical ventilation utilizes dogmatic formulas that only consider a patient's predicted body weight (PBW). In this study, we investigate whether forced vital capacity (FVC) (1) correlates better to total lung capacity (TLC) than PBW, (2) predicts low pulmonary compliance, and (3) provides an alternative method for tidal volume selection. METHODS: One hundred thirty thoracic surgery patients had their preoperative TLC calculated via 2 methods: (1) pulmonary function test (PFT; TLCPFT) and (2) computed tomography 3D reconstruction (TLCCT). We compared the correlation between TLC and PBW with the correlation between TLC and FVC to determine which was stronger. Dynamic pulmonary compliance was then calculated from intraoperative ventilator data and logistic regression models constructed to determine which clinical measure best predicted low compliance. Ratios of tidal volume/FVC plotted against peak inspiratory pressure were utilized to construct a new model for tidal volume selection. Calculated tidal volumes generated by this model were then compared with those generated by the standard lung-protective formula Vt = 7cc/kg. RESULTS: The correlation between FVC and TLC (0.82 for TLCPFT and 0.76 for TLCCT) was stronger than the correlation between PBW and TLC (0.65 for TLCPFT and 0.58 for TLCCT). Patients with very low compliance had significantly smaller lung volumes (forced expiratory volume at 1 second, FVC, TLC) and lower diffusion capacity of the lungs for carbon monoxide when compared with patients with normal compliance. An FVC cutoff of 3470 cc was 100% sensitive and 51% specific for predicting low compliance. The proposed equation Vt = FVC/8 significantly reduced calculated tidal volume by a mean of 22.5% in patients with low pulmonary compliance without affecting the mean tidal volume in patients with normal compliance (mean difference 0.9%). CONCLUSIONS: FVC is more strongly correlated to TLC than PBW and a cutoff of about 3.5 L can be utilized to predict low pulmonary compliance. The equation Vt = FVC/8 reduced mean calculated tidal volume in patients with low pulmonary compliance and/or small lungs. (C) 2017 International Anesthesia Research Society

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Individualized Anesthetic Management for Patients Undergoing Electroconvulsive Therapy: A Review of Current Practice.

Electroconvulsive therapy (ECT) remains an indispensable treatment for severe psychiatric illness. It is practiced extensively in the United States and around the world, yet there is little guidance for anesthesiologists involved with this common practice. Communication between the anesthesiologist and the proceduralist is particularly important for ECT, because the choice of anesthetic and management of physiologic sequelae of the therapeutic seizure can directly impact both the efficacy and safety of the treatment. In this review, we examine the literature on anesthetic management for ECT. A casual or "one-size-fits-all" approach may lead to less-than-optimal outcomes; customizing the anesthetic management for each patient is essential and can significantly increase treatment success rate and patient satisfaction. (C) 2017 International Anesthesia Research Society

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Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies.

BACKGROUND: Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype. METHODS: To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss >=1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models. RESULTS: For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI] = 4.9-99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI = 4.2-15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI = 3.4-11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI = 1.7-17.1), multiple pregnancies (aOR = 3.2; 95% CI = 1.7-6.3), and a predelivery hemoglobin = 11 g/dL). CONCLUSIONS: Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD. (C) 2017 International Anesthesia Research Society

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The Pathway of Injectate Spread With the Transmuscular Quadratus Lumborum Block: A Cadaver Study.

BACKGROUND: The spread of injectate resulting from a transmuscular quadratus lumborum (TQL) block and a transverse oblique paramedian (TOP) TQL block has never been examined. The aim of this cadaveric study was to investigate by which pathway the injectate spreads cephalad into the thoracic paravertebral space and which nerves were dyed by the injectate cephalad and caudad to the diaphragm when performing a TQL and a TOP TQL block. We also aimed to investigate whether the thoracic and lumbar sympathetic trunks as well as the lumbar plexus were covered by the injectate. METHODS: Ultrasound-guided bilateral TQL and TOP TQL injections were administered in 8 cadavers. A total of 16 injections were performed. With the TQL injection, the curvilinear transducer was oriented in the transverse plane above the iliac crest at the posterior axillary line to identify the Shamrock sign. With the TOP TQL injection, the same transducer was placed with a TOP orientation 3 cm lateral to the L2 spinous process to identify the L2 transverse process and the adjoining quadratus lumborum muscle. For both techniques, the needle was advanced in-plane to the transducer, with the end point in the interfascial plane between the quadratus lumborum and psoas major muscles. Thirty milliliters of dye solution was injected bilaterally for each technique. The spread of the dye was evaluated by subsequent dissection. RESULTS: In all successful injections, the dye was seen to spread into the thoracic paravertebral space and the intercostal spaces to surround the somatic nerves and the thoracic sympathetic trunk. The main pathway of spread of injectate was posterior to the medial and lateral arcuate ligaments. Caudad to the diaphragm, the injected dye surrounded the subcostal, iliohypogastric, and ilioinguinal nerves in all cases, whereas the genitofemoral and lateral femoral cutaneous nerves were dyed in a varying degree. No dye was seen to surround the lumbar plexus, femoral nerve, or lumbar sympathetic trunk. The pattern of spread was similar with the TQL and TOP TQL injections. CONCLUSIONS: The spread of injectate with the TQL and TOP TQL approaches is cephalad from the lumbar point of administration between the quadratus lumborum and psoas major muscles, predominantly via a pathway posterior to the arcuate ligaments and into the thoracic paravertebral space to reach the somatic nerves and the thoracic sympathetic trunk in the intercostal and paravertebral spaces. The lumbar plexus and lumbar sympathetic trunk are not affected. (C) 2017 International Anesthesia Research Society

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