1 2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Fleischmann KE et al. J Am Coll Cardiol. 2009 Nov 24;54(22):2102-28 Circulation. 2009 Nov 24;120(21):2123-51. [Article]
In light of emerging evidence and recently published large RCTs including the POISE study (Devereaux et al, Lancet, 2008) and DECREASE-IV (Dunkelgrun et al, Ann Surg, 2009) the ACCF/AHA have published a focused update of the 2007 ACC/AHA guidelines addressing the issue of perioperative beta blockade. Sections of the 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery have been updated and other sections such as: recent data regarding perioperative beta-blocker therapy, risks and caveats and a summary have been added. An extract from the summary reads as follows:
“a class I indication for perioperative beta blocker use exists for continuation of a beta blocker in patients already taking the drug. In addition, several Class IIa recommendations exist for patients with inducible ischaemia, coronary artery disease, or multiple clinical risk factors who are undergoing vascular (ie. high-risk) surgery and for patients with coronary artery disease or multiple clinical risk factors who are undergoing intermediate-risk surgery. Initiation of therapy, particularly in lower-risk groups, requires careful consideration of the risk:benefit ratio for an individual patient. Initiation well before a planned procedure with careful titration perioperatively to achieve adequate heart rate control while avoiding frank bradycardia or hypotension is also suggested. In light of the POISE results, routine administration of perioperative beta blockers, particularly in higher fixed-dose regimens begun on the day of surgery, cannot be advocated.”
Take home message: Perioperative administration of beta-blockers seems to be beneficial for patients who are taking beta-blockers pre-operatively and those who have multiple risk factors for perioeprative coronary ischaemia and are having intermediate to high risk surgical procedures. Adequate monitoring and dose titration to predetermined haemodynamic endpoints is essential.
For related reading this month: Poldermans D et al. Perioperative strokes and beta-blockade. Anesthesiology. 2009 Nov;111(5):940-5.
See also: May Journal Watch (12); October Journal Watch (4)
2 Brain death and its implications for management of the potential organ donor. Bugge JF. Acta Anaesthesiol Scand. 2009 Nov;53(10):1239-50. [Article]
Optimal organ preservation leading up to, and during, organ procurement is important to ensure post-transplant function. Brain death is associated with a sympathetic storm that can contribute to haemodynamic instability as well as release of proinflammatory substances leading to immunologically activated organs before engraftment. Haemodynamic goals are ‘normalization’ of variables and invasive arterial monitoring as well as central venous pressure monitoring would be considered minimum monitoring standards. The myocardial injury triggered by brain death may be reversed or avoided by restoring cardiac loading conditions and the anaesthetist of the harvesting team often plays a crucial role in assessing the adequacy of actual fluid resuscitation and vasoactive medication in use. Dopamine is the preferred isotope because evidence suggests it is capable of stimulating the induction of protective enzymes and rendering the organs more resistant to the insult of ischaemia-reperfusion injury. Protective effects may also be mediated by volatile agents and other catecholamines and, if a pressor is required, favourable results have been reported using norepinephrine and vasopressin. Priorities for lung-protection include avoidance of ventilator induced lung injury via use of low pressures and tidal volumes together with moderate PEEP and avoidance of hypervolaemia. Methylprednisolone administration to brain-dead donors can reduce cytokine activation and should be given to all donors after brain death. Additional hormonal replacement may also be required.
Take home message: Donor management can be challenging and, in order to reduce negative consequences of brain death on solid organs, consideration must be given to adequate fluid resuscitation, vasoactive medication, immunosuppressive therapy and sufficient haemodynamic and other monitoring.
3 A
closer look at organ donation after cardiocirculatory death in
Canada. Editorial: Baker A. Can J
Anaesth. 2009 Nov;56(11):789-92 [Article]
Eligibility for organ donation: a medico-legal perspective on defining and determining death. Downie J et al. Can J Anaesth. 2009 Nov;56(11):851-63
The recent introduction of donation after cardiac death (DCD) has potential to highlight medico-legal deficiencies regarding the definition and determination of death. In countries such as Canada, the use of non-heart beating donor protocols is inconsistent with Canadian law. The central issue surrounding DCD is that the determination of brain death becomes an invalid measure to determine when ‘death’ has occurred. As a result, one of the most contentious issues is the duration of the waiting period between the cessation of cardiopulmonary function and the pronouncement of death and subsequent retrieval of organs. A minimum time delay is required to limit the ‘warm ischaemic’ period. In Canada, the waiting period is 5 mins, however existing medical data do not provide empirical evidence to justify the conclusion that 5 mins is sufficient to confirm the irreversibility of cardiocirculatory arrest. Another unresolved issue is notion of irreversibility of cessation of cardiopulmonary function when advanced life support measures could conceivably reverse the cardiac arrest state. The authors suggest that the legal definition of irreversible should be defined as ‘not physically possible to reverse without violating the law on consent.’ Additionally, if it is assumed that irreversible cardiac arrest indicates brain function has irreversibly ceased, there is also potential to confuse actual death with inevitable imminent death because it may be possible for brain function to continue for some time beyond the time of arrest. It is unclear what the potential implications for healthcare workers are and whether they may be at risk of civil or criminal liability.
Take home message: Legislative reform may be required to ensure that the timing and declaration of death in non-beating heart organ donors is consistent with the law.
4 Droperidol: past, present and future. Editorial: Sneyd JR. Anaesthesia. 2009 Nov;64(11):1161-4. [Article]
This editorial reviews the current state of knowledge about droperidol for PONV prophylaxis. The author starts by exploring the background that led to serious ‘black box warnings’ for droperiodol including prolongation of the QT interval and reports of sudden death. The author concludes that ‘there are few data to support a link between low-dose droperidol and torsades de pointes’. It is interesting to note that an independent international consensus panel remarked in 2007 ‘if it were not for the black-box warning, droperidol would have been the panel’s overwhelming first choice for PONV prophylaxis’. The author then reports on the strong evidence base supporting the efficacy of droperidol including the influential IMPACT study (Apfel, NEJM, 2004) that found that ondansetron, dexamethasone and droperidol each reduced the relative risk of PONV by about 26%. The NNT for droperidol to prevent PONV has been estimated at 7-8 for doses between 1 and 1.25 mg. Unlike dexamethasone, droperidol should be administered 30 mins prior to the end of surgery. In addition, current evidence suggests that droperidol added to PCA opioid can reduce N&V by over 50% compared with placebo. Non-cardiac side effects of droperidol are rare if doses are <4 mg/day.
Take home message: Evidence supports the use of droperidol for PONV prophylaxis, either alone or in addition to other prophylactic antiemetics given on the basis of Apfel scoring
For related reading this month: - Gan TJ et al. Double-blind comparison of granisetron, promethazine, or a combination of both for the prevention of postoperative nausea and vomiting in females undergoing outpatient laparoscopies. Can J Anaesth. 2009 Nov;56(11):829-36. - Frey UH et al. Effect of P6 acustimulation on post-operative nausea and vomiting in patients undergoing a laparoscopic cholecystectomy. Acta Anaesthesiol Scand. 2009 Nov;53(10):1341-7.
See also: May Journal Watch (3);
5
Prevention of atelectasis in morbidly obese patients during general
anesthesia and paralysis: a computerized tomography study.
Reinius H et al. Anesthesiology. 2009
Nov;111(5):979-87. [Abstract]
Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Talab HF et al. Anesth Analg. 2009 Nov;109(5):1511-6.
This month two RCTs in two different journals report on optimal ventilatory strategies for prevention of pulmonary atelectasis in obese patients. Both studies used ABGs and CT scanning perioperatively to assess oxygenation and atelectasis, respectively. The first study by Talab et al. allocated 66 adult obese patients (BMI 30-50 kg/m2) scheduled to undergo laparoscopic bariatric surgery into 3 groups. The first group (n=22) received a recruitment manoeuvere (pressure of 40 cm H20 maintained for 7-8 secs) applied immediately after intubation plus ZEEP. The second group (n=22) received the same recruitment manoeuvere plus 5 cm of PEEP and the third group (n=22) received the same recruitment manoeuvere plus 10 cm of PEEP. Patients in the recruitment manoeuvere +PEEP 10 group had better oxygenation both intraoperatively and postoperatively, lower atelectasis on CT 2 hours postoperatively as well as less postoperatively pulmonary complications (desaturation, chest infection, bronchospasm) than the ZEEP and PEEP 5 groups. Adverse haemodynamics in the PEEP 10 group were not observed. The second study by Reinius et al allocated 30 adult obese patients (BMI 45 +/-4 kg/m2) scheduled to undergo gastric bypass bariatric surgery into 3 groups but only followed the patients for 40 minutes intraoperatively. The first group (n=10) received PEEP of 10 cm H20 without a recruitment manoeuvere. The second group (n=10) received a recruitment manoeuvere (pressure of 55 cm H20 maintained for 10 secs) plus ZEEP and the third group (n=10) received the same recruitment manoeuvere plus 10 cm of PEEP. In keeping with the first study, patients in the recruitment manoeuvere +PEEP 10 group had better oxygenation both intraoperatively and postoperatively and lower atelectasis on intraoperative CT than the ZEEP and PEEP 5 groups. The investigators observed a decrease in normally aerated lung tissue from 71% to 50% after anaesthesia and paralysis and end-expiratory lung volume increased 64% in the recruitment manoeuvere followed by PEEP group and 32% in the PEEP group compared to pre-intervention values. Adverse haemodynamics in the PEEP 10 group were again, not observed.
Take home message: A recruitment manoeuvere + PEEP 10 cm is a successful strategy to improve oxygenation and reduce atelectasis in morbidly obese patients during anaesthesia.
6 Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Giglio MT et al. Br J Anaesth. 2009 Nov;103(5):637-46. [Article]
This metanalysis aimed to define the effects of goal directed therapy (GDT) on postoperative GI and liver complications. Sixteen RCTs (3410 participants) were identified as eligible. Goal directed therapy aims to increase oxygen delivery and avoid gut hypoperfusion by monitoring and manipulating haemodynamic variables within predefined endpoints. This is based on the knowledge that splanchnic perfusion is compromised after 10-15% reduction in intravascular volume. The majority of included studies (8) used PACs to achieve their aims, 5 studies used oesophageal Doppler, and LidCO, pulse pressure variation and CVP was each used in 1 study. GI complications were ranked as major (radiological or surgical intervention required) or minor (no or only pharmacological therapy required). Major GI complications were significantly reduced by GDT compared to the control group (OR 0.42, CI 0.27-0.65) and minor complications were also significantly decreased in the GDT (OR 0.54, CI 0.17-0.5). Treatment did not reduce hepatic injury rate. The author concludes that GDT, by the maintenance of adequate systemic oxygenation, can protect organs particularly at risk of perioperative hypoperfusion. The main limitations of the study include reporting bias and methodological heterogeneity of the included studies.
Take home message: This meta-analysis support the ability of GDT to reduce major and minor GI complications in the perioperative period.
7 Emerging trends in minimally invasive haemodynamic monitoring and optimization of fluid therapy. Benington S et al. Eur J Anaesthesiol. 2009 Nov;26(11):893-905.
This review explores two methods of haemodynamic monitoring: the volumetric approach based on transpulmonary dilution techniques and arterial pressure waveform analysis (APWA) otherwise known as pulse contour analysis. All commercially available monitors that use pulmonary indicator dilution techniques apply the Stewart-Hamilton equation to calculate CO. Transpulmonary dilution techniques (PiCCO-thermal, LiDCO-lithium) are also used to obtain static estimates of cardiac preload responsiveness via calculation of volumetric parameters such as intrathoracic blood volume (ITTV) and global end-diastolic volume (GEDV). In addition, these systems enable the calculation of extravascular lung water (EVLW) that aim to estimate the degree of pulmonary oedema. A value of more than 10 ml/kg is considered abnormally high. Pulse contour analysis offers the promise of real-time/continuous dynamic CO measurement. APWA is utilized in the PiCCO, LiDCO/PulseCO and FloTrac/Vigileo systems. All forms of APWA require some degree invasive vascular access. The LiDCO system requires only standard arterial and peripheral venous cannulae. The PiCCO system requires a specialized femoral arterial cannula as well as a CVP. Both PiCCO and LiDCO employ transpulmonary technique for system calibration of APWA CO monitoring. FLoTrac/Vigileo system does not need external calibration and requires only a specialized transducer and cable spliced into the patient’s existing arterial pressure monitoring set-up. Multiple studies have raised concerns about the accuracy of FloTrac/Vigileo and have found poor limits of agreement with reference methods of CO measurement.
It has long been recognized that the magnitude of stroke volume variation (SVV) broadly correlates to the degree of preload responsiveness. Mechanical ventilation induces cyclical changes in systolic and pulse pressures referred to as systolic pressure variation (SPV) and pulse pressure variation (PPV) and these parameters have been used as surrogates for SVV. The advent of APWA has also allowed the study of real-time stroke volume monitoring (PiCCO) and in some studies has been shown to correlate well with SPV and predict fluid responsiveness more accurately than CVP and PAOP. Limitations of these systems include intrathoracic haemorrhage, or intracardiac shunts (transpulmonary thermodilution), variable SVR (APWA) and abnormal perfusion values (EVLW).
Take home message: Transpulmonary dilution techniques correlate well with PAC derived measurement of CO. Emerging evidence suggests volumetric measures of preload (GEDV, ITBV) appear to be superior to CVP and POAP. The value of APWA lies in its ability to provide continuous CO measurements rather than the snapshots provided by dilution techniques. In mechanically ventilated patients dynamic indices such as stroke volume variation are useful in assessing preload responsiveness.
See also: March Journal Watch (1); August Journal Watch (4)
8 Rare complications and national databases. Editorial: Lee LA et al. Anesth Analg. 2009 Nov;109(5):1357-9
The prevalence of perioperative visual loss in the United States: a 10-year study from 1996 to 2005 of spinal, orthopedic, cardiac, and general surgery. Shen Y et al. Anesth Analg. 2009 Nov;109(5):1534-45 [Article]
This study aimed to determine the prevalence and associated risk factors for postoperative visual loss (POVL) using a large US database (Nationwide Inpatient Sample-NIS). The NIS collects data from more than 1000 randomly selected, nonfederal hospitals and currently comprises approximately 90% of all US hospital discharges. The authors analysed data from the eight most common nonocular surgeries (except O&G surgery to prevent gender bias). Cardiac (8.64/10,000) and spinal fusion surgery (3.09/10000) had the highest rates of POVL. By contrast, POVL after appendicetomy was 0.12/10,000. For the first time, this study demonstrated patients undergoing common nonspinal orthopaedic surgery, specifically hip and femur surgery and knee arthoplasty, had an increased risk of POVL (1.08-1.86/10000) compared with patient undergoing abdominal surgery. Surprisingly, patients younger than 18 yrs were the age group with the highest risk for POVL (4.37/10,000), specifically cortical blindness predominantly associated with scoliosis surgery. Older patients tended to suffer ischaemic optic neuropathy and retinal vascular occlusion. Other significant positive predictors for POVL were male gender, Charslon comorbidity index, anaemia and blood transfusion. The prevalence of POVL decreased between 1996-2005.The accompanying editorial feels that Shen et al were very selective and cautious in their use of the NIS database and made a point that the major results confirm previous smaller studies. Regardless, significant limitations encountered by this study design include incomplete data entry, lack of any intraoperative data, inability to verify POVL diagnosis or other data and inability to determine whether a condition is preexisting.
Take home message: Practioners should carefully weigh the risk and benefits of using anaesthetic techniques that may cause extreme physiologic derangement in those procedures that are considered high risk for POVL-a rare but potentially devastating complication.
9 Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Liao P et al. Can J Anaesth. 2009 Nov;56(11):819-28.
This retrospective matched cohort study (n=240 pairs) tested the hypothesis that OSA is a risk factor for the development of postoperative complications. Matching criteria included gender, age difference <5 yrs, type of surgery and <5 year difference between two surgery dates. There was a significantly greater overall incidence of postoperative complication in the OSA group compared with the non-OSA group (44% vs 28%, respectively). The major contributor to the higher occurrence of complications was the increased incidence of respiratory complications (33% OSA group vs 22% non-OSA group). Desaturation with SaO2 <90% was the most common complication and the group with the highest rate of complications were observed in OSA patients not using CPAP preoperatively. The majority of complications occurred after ward transfer. Similarly, OSA patients required increased interventions including oxygen therapy, additional monitoring, CPAP and ICU admission. Of note, the OSA patients had a higher prevalence of pre-existing co-morbidities, including obesity, hypertension, GORD, DM, hypothyroidism, asthma and COAD compared to the non-OSA controls that may represent unmeasured confounders. Other limitations include retrospective study design with presumed missing data and reliance on discharge coding to identify eligible patients as well as likely under-reporting of complications due to lack of standardized monitoring or surveillance. It is worth noting that the departmental policy that existed during the study period did not require OSA patients to be monitored more intensively or to be admitted to ICU. Another interesting observation from this study is the increased incidence of intubation/ventilation difficulties in the OSA group including two cardiac arrests, increased attempts at intubation and a greater incidence of grade III/IV Cormack-Lehane views.
Take home message: This study found that patients with diagnosed OSA have an increased incidence of postoperative complications, the most frequent being oxygen desaturation <90% providing further evidence that this patient group requires higher levels of monitoring and interventions perioperatively.
See also: April Journal Watch (11); October Journal Watch (6)
10 Sellick's maneuver: to do or not do. Editorial: Ovassapian A et al Anesth Analg. 2009 Nov;109(5):1360
On cricoid pressure: "may the force be with you". Editorial: Lerman J. Anesth Analg. 2009 Nov;109(5):1363-6.
Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Rice MJ et al. Anesth Analg. 2009 Nov;109(5):1546-52.
An observational study and 2 editorials explore some of the contentious issues associated with cricoid pressure. The study reports the neck MRI results of 24 non-sedaated adults with and without cricoid pressure (CP). Measurements were made of the postcricoid hypopharynx, airway compression, and lateral displacement of the cricoid ring during application of CP. The study found that the area behind the cricoid ring is the hypopharynx (not oesophagus) and the cricoid ring and hypopharynx move together as an anatomic unit, making the actual position of the oesophagus irrelevant. With CP, the mean anterioposterior diameter of the hypopharynx was reduced by 35% and the lumen likely obliterated. However, because the study only shows compression of the conduit between the stomach and the pharynx with CP, not prevention of regurgitation, the study results only enable the efficacy of CP to be inferred, not proven. Lerman’s editorial states that despite an almost 5 decade history, the level of evidence to support the effectiveness of cricoid is a paltry 4 or 5 resulting in a Grade D recommendation for its use. He also cites two systematic reviews that concluded there was no evidence for or against the application of cricoid pressure. He discusses disadvantages of CP including airway obstruction and interference with ventilation, intubation as well as other complications such as vomiting, aspiration and oesophageal rupture that have been reported with its use. He feels that the study by Rice supports an anatomical link between the cricoid and the hypopharynx but he is less enthusiastic about equating these measures to physiological metrics. In contrast, the editorial by Ovassapian et al states that Rice’s study clearly demonstrates the efficacy of CP. In addition, he advocates the use of gentle mask ventilation during RSI.
Take home message: This study provides radiological evidence that CP effectively compresses the conduit between the stomach and pharynx and it may prevent laryngeal soiling if regurgitation occurs.
11 Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression. Kotzé A et al. Br J Anaesth. 2009 Nov;103(5):626-36. [Article]
This systematic review and metaregression aimed to determine whether local anaesthetic dose influences the quality of analgesia from paravertebral block (PVB). Secondary aims were to determine whether choice of LA, continuous infusion, adjuvants, pre-emptive PVB, or addition of PCA opioids improve analgesia. Twenty-five trials suitable for metaregression were identified (n=763). The use of higher doses of bupivacaine (890-990 mg/24 hrs compared with 325-472.5 mg/24 hrs) was found to predict lower pain scores at all time points up to 48 hours postoperatively. Interestingly, no difference was detected between groups in potential occurrence of LA toxicity. Continuous infusions of LA predicted lower pain scores compared with intermittent boluses. The use of adjuvant clonidine or fentanyl, pre-emptive PVB, and the addition of patient-controlled opioids to PVB did not improve analgesia. This study relied on indirect comparisons between the non-randomised treatment arms of different trials that are vulnerable to confounding factors and other sources of bias.
Take home message: This indirect comparison of data found that higher dose LA regimens for PVB and the use of continuous infusions for maintenance are predictive of lower VAS scores up to 48 h after thoractomy; decreasing postoperative pain by around 50% in each case.
12 Early cognitive impairment after sedation for colonoscopy: the effect of adding midazolam and/or fentanyl to propofol. Padmanabhan U et al. Anesth Analg. 2009 Nov;109(5):1448-55. [Abstract]
This Melbourne RCT (n=200) compared cognitive recovery after sedation for outpatient colonoscopy with propofol alone compared with midazolam and/or fentanyl. Baseline cognitive function was assessed using CogState before and after sedation. In the propofol plus adjuvants group, 84 patients received fentanyl and 57 patients received midazolam and, unsurprisingly, total propofol doses were lower in this group. There were no significant differences detected between groups with respect to cognitive function at discharge, although overall cognitive function was impaired at discharge compared to baseline. When considered for individual patients, 37 patients (18.5%) were classified as showing clinically significant cognitive decline and multivariate analysis revealed administration of >2 mg of midazolam to be a predictor of impaired cognitive function at discharge. Procedure times were shorter and operating conditions were superior with propofol +/- adjuvants compared to propofol alone. Recovery times, recall, dreaming, quality of recovery and patients’ satisfaction with care were similar between groups. A limitation of this study is that the timing of cognitive testing was determined by the patient’s readiness for discharge rather than a predetermined set time. There was also no distinction made between potential differing cognitive impact of fentanyl vs midazolam and the choice and of one or both adjuvants, as well as dosage, was determined solely by the treating anaesthetist.
Take home message: Adjuvants such as fentanyl and midazolam can be used in addition to propofol for outpatient sedation, possibly improving quality of sedation and ease of procedure, without increasing duration of admission or incidence cognitive impairment at discharge.
13 Some unanswered questions about temperature management. Roth JV. Anesth Analg. 2009 Nov;109(5):1695-9.
This review article explores some of the issues pertaining to perioperative temperature management. Section 1 of this article discusses the unresolved issue of temperature management in the infected, febrile patient. Experts remain divided as whether fever is a harmful byproduct of infection or an adaptive host-defence response that is a beneficial part of a co-ordinated physiological response. In order to prevent reflex shivering, the author feels there are strong arguments to maintain a febrile patient at his or her elevated temperature with some exceptions such as CEA, neurosurgery & cardiac surgery. Section II discusses the relative importance of intraoperative versus postoperative hypothermia. Hypothermia induced complications include morbid myocardial outcomes, surgical wound infection, coagulopathy, increased allogenic transfusions, negative nitrogen balance, delayed wound healing, delayed postanaesthetic recovery, prolonged hospitalization, shivering and patient discomfort. Many patients who are normothermic at the end of a case are hypothermic during part of the surgery because of heat redistribution from the core to periphery at start of an anesthetic. Prewarming significantly attenuates the initial decrease in core temperature but it requires additional resource utilization and is currently not standard of care. Section III provides arguments as to why aggressive warming techniques may be important in short duration cases. The author feel that, even in the absence of a demonstrable intraoperative increase in core temperature, a warmer periphery resulting from active warming may allow a patient to normalize his or her temperature more quickly postoperatively.
Take home message: Aspects of perioperative temperature management that lack consensus opinion includes management of the febrile patient, intraoperative versus postoperative hypothermia and active warming for short duration cases.
Other articles of potential specific interest:
AIRWAY
Malik MA et al. A comparison of the Glidescope, Pentax AWS, and Macintosh laryngoscopes when used by novice personnel: a manikin study. Can J Anaesth. 2009 Nov;56(11):802-11.
Mannion S et al. Turning the corner on intubation: fibrescope-assisted videolaryngoscopy. Can J Anaesth. 2009 Nov;56(11):878-9
Teoh WH et al. A prospective, randomised, cross-over trial comparing the EndoFlex and standard tracheal tubes in patients with predicted easy intubation. Anaesthesia. 2009 Nov;64(11):1172-7. -
Ray DC et al. A comparison of McGrath and Macintosh laryngoscopes in novice users: a manikin study. Anaesthesia. 2009 Nov;64(11):1207-10.
Riad W et al. Effect of cricoid pressure on the laryngoscopic view by Airtraq in elective caesarean section: a pilot study. Eur J Anaesthesiol. 2009 Nov;26(11):981-2.
Powell L et al. Comparison of the performance of four laryngoscopes in a high-fidelity simulator using normal and difficult airway. Br J Anaesth. 2009 Nov;103(5):755-60.
Nakstad AR et al. The GlideScope Ranger video laryngoscope can be useful in airway management of entrapped patients. Acta Anaesthesiol Scand. 2009 Nov;53(10):1257-61.
Maassen R et al. A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesth Analg. 2009 Nov;109(5):1560-5.
Malik MA et al. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth. 2009 Nov;103(5):761-8.
CARDIAC - Shehabi Y et al. Prevalence of delirium with dexmedetomidine compared with morphine based therapy after cardiac surgery: a randomized controlled trial (DEXmedetomidine COmpared to Morphine-DEXCOM Study). Anesthesiology. 2009 Nov;111(5):1075-84.
CRITICAL
CARE
Grände PO et al. Active cooling in traumatic brain-injured patients: a questionable therapy? Acta Anaesthesiol Scand. 2009 Nov;53(10):1233-8.
GENERAL TOPICS - Silverman TA et al; Planning Committee and the Speakers. Hemoglobin-based oxygen carriers: current status and future directions. Anesthesiology. 2009 Nov;111(5):946-63. Review
Editorial: Cross MH. MRSA, screening and implications for the anaesthetist. Anaesthesia. 2009 Nov;64(11):1164-7.
Eipe N et al. Bowel surgery and multimodal analgesia: same game, new team? Anesth Analg. 2009 Nov;109(5):1703-4; author reply 1704.
Editorial: Leung JM et al. Long-term cognitive decline: is there a link to surgery and anesthesia? Anesthesiology. 2009 Nov;111(5):931-2
Avidan MS et al. Long-term cognitive decline in older subjects was not attributable to noncardiac surgery or major illness. Anesthesiology. 2009 Nov;111(5):964-70.
Dewachter P et al. Anaphylaxis and anesthesia: controversies and new insights. Anesthesiology. 2009 Nov;111(5):1141-50
NEUROANAESTHESIA
Bonhomme V et al. Awake craniotomy. Eur J Anaesthesiol. 2009 Nov;26(11):906-12.
OBSTETRICS
Tamdee D et al. A randomized controlled trial of pentazocine versus ondansetron for the treatment of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. Anesth Analg. 2009 Nov;109(5):1606-11
Editorial: Benhamou D et al. Neuraxial anesthesia for cesarean delivery: what criteria define the "optimal" technique? Anesth Analg. 2009 Nov;109(5):1370-3.
Leo S et al. A randomized comparison of low doses of hyperbaric bupivacaine in combined spinal-epidural anesthesia for cesarean delivery. Anesth Analg. 2009 Nov;109(5):1600-5
Djabatey EA et al. Difficult and failed intubation in 3430 obstetric general anaesthetics. Anaesthesia. 2009 Nov;64(11):1168-71.
PAEDIATRICS
Malviya S et al. The incidence of intraoperative awareness in children: childhood awareness and recall evaluation. Anesth Analg. 2009 Nov;109(5):1421-7.
PAIN
Sen H et al. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50.
Yardeni IZ et al. The effect of perioperative intravenous lidocaine on postoperative pain and immune function. Anesth Analg. 2009 Nov;109(5):1464-9
PERIOPERATIVE MEDICINE
Goei D et al. The interrelationship between preoperative anemia and N-terminal pro-B-type natriuretic peptide: the effect on predicting postoperative cardiac outcome in vascular surgery patients. Anesth Analg. 2009 Nov;109(5):1403-8.
Grek S et al. A cost-effective screening method for preoperative hyperglycemia. Anesth Analg. 2009 Nov;109(5):1622-4
Editorial: Elkassabany N et al. Thinking clearly about postoperative delirium and perioperative medications: how concerned should we be? Can J Anaesth. 2009 Nov;56(11):785-8.
Katznelson R et al. Delirium following vascular surgery: increased incidence with preoperative beta-blocker administration. Can J Anaesth. 2009 Nov;56(11):793-801.
REGIONAL
ANAESTHESIA
Brull R et al. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth. 2009 Nov;56(11):812-8.
Belavy D et al. Ultrasound-guided transversus abdominis plane block for analgesia after Caesarean delivery. Br J Anaesth. 2009 Nov;103(5):726-30.
Jochum D et al. One size does not fit all: proposed algorithm for ultrasonography in combination with nerve stimulation for peripheral nerve blockade. Br J Anaesth. 2009 Nov;103(5):771-3; author reply 773-4.
Akyildiz E et al. Single vs. double stimulation during a lateral sagittal infraclavicular block. Acta Anaesthesiol Scand. 2009 Nov;53(10):1262-7.
Orebaugh SL et al. Interscalene block using ultrasound guidance: impact of experience on resident performance. Acta Anaesthesiol Scand. 2009 Nov;53(10):1268-74.
Yun MJ et al. Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block. Acta Anaesthesiol Scand. 2009 Nov;53(10):1282-7
TRAUMA ANAESTHESIA
Maguire M, Hurn C, Cook S, Pollard C. Transfusion for trauma in Australia. Anaesthesia. 2009 Nov;64(11):1263-4
Written by Maryanne Balkin, November 2009
Feedback welcome: M.Balkin@alfred.org.au