1 Perioperative blood conservation. Cardone D et al. Eur J Anaesthesiol. 2009 Sep;26(9):722-9.
This articulate review summarises the risks & benefits of blood conservation strategies in modern anaesthetic & surgical practice. In view of the fact that blood product transfusion is expensive and is associated with many potential serious adverse immunological and nonimmunological effects, blood conservation is becomingly an increasingly relevant consideration. The risk-benefit profiles of the use of lysine analogue antifibrinolytics such as tranexamic acid and aminocaproic acid appear superior to aprotinin (no longer available). A Cochrane review from 2007 found that antifibrinolytic drugs used at the time of major surgery reduced bleeding, the need for transfusion and the need for repeat surgery because of bleeding. The ‘off-label’ roles of VIIa are still evolving but a 2008 meta-analysis found that treatment with rFVIIa was effective in reducing the rate of blood transfusion, with no major safety concerns identified. Considerations relating to appropriate resource allocation and definitive indications for use of rFVIIa remain unresolved. Preoperative EPO therapy may be appropriate in certain circumstances. Preoperative autologous blood donation and acute normovolaemic haemodilution are strategies that are not without potential for harm and the evidence to support these strategies is not strong. A 2006 Cochrane review demonstrated that cell salvage reduced the need for allogeneic blood transfusions in adults undergoing surgery. Controlled hypotension and low CVP anaesthesia are practiced in certain surgeries, however evidence to support the benefit of these strategies is limited and procedure-specific. Likewise, certain surgical techniques are appropriate in specific procedures to minimize blood loss. The optimum use of blood therapies requires transfusion protocols, guidelines and clinical audit.
Take home message: The current evidence base for perioperative blood conservation strongly supports the use antifibrinolytics (tranexamic acid, aminocaproic acid) and cell salvage for procedures with anticipated high blood loss.
2 Burden of
proof. Editorial: Smiley RM Anesthesiology. 2009
Sep;111(3):470-2.
[Editorial]
Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Ngan Kee WD et al. Anesthesiology. 2009 Sep;111(3):506-12. [Article]
This article and editorial reports on a RCT (n=104) from Hong Kong that compared phenylephrine infusion to ephedrine infusion for cesarean section under spinal anaesthesia. Blood pressure was better-maintained and maternal side effects lower in the phenylephrine group and umbilical arterial pH was higher in the phenylephrine group (7.33 vs 7.25) with a lower PCO2 and less negative base excess (-1.9 vs -4.8). The authors propose that the greater propensity toward fetal acidosis in the ephedrine group was due to higher placental transfer of ephedrine and the effect of ephedrine as a metabolic stimulant. The investigators conclude that when comparing the net effect of vasopressors on fetal oxygen supply and demand balance, currently available data favor the choice of phenylephrine. The author of the accompanying editorial emphasizes that the results are consistent with every study done over the past 15 years comparing the two interventions at comparable doses. Limitations of the study include relatively frequent use of phenylephrine rescue boluses in the ephedrine group (22% vs 2%) and questionable drug potency/equivalent dosing regimes. Study was conducted in low-risk group so does not provide evidence for management of patients with compromised uteroplacental blood flow.
Take home message: Titrated phenylephrine infusions (25-100 mcg/min) for cesarean delivery under spinal anaesthesia are easy to employ and minimize maternal nausea, vomiting, and episodes of hypotension. Phenylephrine infusion is also associated with a higher neonatal pH and lower base deficits relative to ephedrine.
For related reading this month: Lee SW, Khaw KS, Ngan Kee WD, Leung TY. Management of hypotension in obstetric spinal anaesthesia. Br J Anaesth. 2009 Sep;103(3):457-8.
3 Hypertonic saline in critical care: a review of the literature and guidelines for use in hypotensive states and raised intracranial pressure. Strandvik GF. Anaesthesia. 2009 Sep;64(9):990-1003.
This literature review evaluates the use of hypertonic saline (HS) in critical care. Hypertonic saline has osmotic, direct vasodilator and cardiac actions accounting for its clinical effects. Current evidence confirms that hypertonic saline is effective in raising BP in hypovolaemic shock (Grade A) and is probably of benefit in non-obstructive cardiogenic shock (Grade C). Administration in current formulations does not improve mortality in shock states (Grade A). HS is effective in reducing raised ICP (Grade A) but does not improve neurological outcomes (Grade B), nor survival in states of raised ICP (Grade A). It should be used instead of, not in conjunction with mannitol. In bolus doses, HS appears safe and does not result in major adverse effects (Grade C). Serum sodium should be measured within 6 h of administration if bolus doses are given; and re-administration of hypertonic saline should not occur until the serum sodium concentration is <155 mmol/l. Limitations of the review include difficulties evaluating the existing data due to heterogeneity between studies and solutions used. Future research should incorporate a large-scale co-ordinated investigative strategy.
Take home message: Hypertonic saline (commonly a bolus of 250 mL of 7.5% HS) can be used with good effect in certain circumstances such as hypovolaemic shock and acutely elevated ICP. However, it should only be used within a well-defined protocol.
4 The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Khan ZH et al. Anesth Analg. 2009 Sep;109(3):822-4.
This prospective observational study (n=309) explores the utility of the upper lip bite test (ULBT) compared to other recognized tools used to predict difficulty with intubation. The ULBT assesses jaw movement & presence of protruding incisors and is determined according to the following criteria: Class I-lower incisors can bite the upper lip above the vermilion line; class II-lower incisors can bite the upper lip below the vermilion line; and class III-lower incisors cannot bite the upper lip. A previous study by the same authors found that the ULBT showed greater specificity and accuracy than the mallampati classisfication. In this study the specificity and accuracy of the ULBT was 91.69% & 91.05% respectively (showing a low false positive rate relative to true negative). The specificity & accuracy was higher than the thyromental distance (82.27%, 81.8%), sternomental distance (70.64%, 71.3%) and interincisor distance (77%, 76.58%), respectively. The PPV of the ULBT was only 33.3% so, although the highest value of all airway predictors studied, shows patients with easy airways are likely to be inappropriately subjected to difficult airway protocols partly related to the challenges in predicting a rare event such as difficult intubation. The sensitivity of the ULBT alone, like all airway tests was relatively low (78.9%) showing that the test has a significant false negative rate (relative to true positive) and will fail to identify some patients in whom intubation will truly be difficult. The negative predictive value of all tests was high, indicating that all tests can predict easy intubation readily. The highest sensitivity was found with ULBT +sternomental distance ≤13.5 cm. The authors emphasize that the value of the ULBT lies in its low interobserver variability and suggest that a combination of assessment methods are used to predict the ease of intubation.
Take home message: This study that the ULBT is a favourable test for identifying easy intubations and laryngoscopy with a specificity & accuracy significantly higher than other established airway tests including interincisor distance, thyromental distance, sternomental distance.
5 Bupivacaine-induced cardiac arrest: fat is good-is epinephrine really bad? Editorial: Harvey;. Anesthesiology. 2009 Sep;111(3):467-9. [Editorial]
Epinephrine impairs lipid resuscitation from bupivacaine overdose: a threshold effect. Hiller DB et al. Anesthesiology. 2009 Sep;111(3):498-505. [Article]
This article and accompanying editorial discusses the emerging evidence that administration of high-dose adrenalin may worsen outcome in treatment of local anaesthetic toxicity with lipid emulsion. In a rodent model of bupivacaine-induced asystole followed by ventilation and CPR, 5/5 of the animals were alive at 15 minutes with if treated with lipid emulsion therapy alone, 5/5 animals survived with lipid emulsion +adrenaline 2.5 mcg/kg treatment and 5/5 animals survived with lipid emulsion+ adrenaline 5mcg/kg treatment. The survival rate for rodents given lipid emulsion + 10mcg/kg adrenalin was 3/5 and the survival rate for lipid emulsion +25 mcg/kg adrenaline was 1/5. 1/5 animals survived without adrenalin or lipid emulsion therapy. The study found that animals receiving the highest dose of adrenalin reliably had worse metabolic profiles and that a single injection of adrenalin ≥10 mcg/kg impaired lipid-based resuscitation. Treatment with adrenalin was associated with a faster return of spontaneous circulation however the authors suggest that the potential benefit arising from sooner return of spontaneous circulation is partly offset by detrimental metabolic consequences of adrenergic stimulation. Support for the hypothesis that hyperadrenergic stimulation may be detrimental can be inferred from recent studies showing little or no benefit when lipid was combined with high dose adrenalin in LA induced cardiac arrest. The authors conclude that this data suggests that haemodynamic and metabolic deterioration are interrelated and specifically implicates adrenalin-induced hyperlactataemia as a possible mechanism of delayed cardiovascular collapse associated with local anaesthetic toxicity.
Take home message: Animal studies suggest high-dose adrenalin may impair lipid-based resuscitation for local anaesthetic toxicity however there is currently insufficient evidence to endorse the omission of adrenalin from lipid-based resuscitative algorithms.
See also: April Journal Watch (7);
6 Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review. Macfarlane AJ et al. Br J Anaesth. 2009 Sep;103(3):335-45
This systematic review compared regional anaesthesia for total hip arthroplasty to GA as well as comparison of systemic or regional techniques for postoperative analgesia. The investigators assessed multiple outcome endpoints including: mortality, CV morbidity, DVT/PE, blood loss, duration of surgery, pain, opioid-related adverse effects, cognitive defects, length of stay and rehabilitation. Regional techniques employed included: continuous psoas block, continuous spinal, continuous lumbar plexus block, epidural, femoral nerve block(single shot and continuous) and CSE. All but one RCT found that regional analgesia reduced pain score or morphine consumption. However, compared with fascia iliaca or ‘3 in 1 block’, a femoral nerve block alone as a single shot or continuous infusion was of no benefit, presumably because it does not provide anaesthesia to the lateral cutaneous nerve of the thigh which innervates the site of skin incision in THA. Of note, only two of the 18 trials included were of Level 1 quality and the largest trial included was limited to 210 patients. Much greater numbers than those included would be required to demonstrate mortality benefit and cardiovascular morbidity and follow periods were relatively short.
Take home message: Current evidence suggests the advantages of regional anaesthesia for total hip arthoplasty are limited to reduced postoperative pain, reduced morphine consumption and reduced nausea and vomiting and possibly reduced blood loss.
7 Role of central and mixed venous oxygen saturation measurement in perioperative care. Shepherd SJ et al. Anesthesiology. 2009 Sep;111(3):649-56. [Article]
This review article attempts to evaluate central (ScvO2, SVC sample) & mixed venous oxygen (SvO2, proximal pulmonary artery sample) saturation to guide therapeutic interventions during the perioperative period. Venous oxygen saturation reflects the balance between global oxygen delivery (DO2) and global oxygen consumption (VO2) and when oxygen supply is insufficient to meet metabolic requirements, increased tissue oxygen extraction results in a decrease in the oxygen content of effluent venous blood. In turn, global oxygen delivery is determined by CO and the oxygen content of arterial blood so that adequate tissue oxygen delivery therefore depends on the adequacy of both respiratory and cardiovascular function. Likewise, considerable changes in oxygen consumption may occur during the perioperative period. Increases in VO2 resulting from pain, anxiety, or shivering may all result in a decrease in venous saturation. The main difference between ScvO2 & SvO2 is SvO2 reflects the balance between oxygen supply and demand averaged across the entire body but ScvO2 is affected disproportionately by changes in the upper body and ScvO2 measurements cannot be used to calculate VO2 or shunt fraction. Small clinical trials suggest the most appropriate target value for ScvO2 is approximately 75% and abnormalities of venous saturation are common during and after major surgery and are associated with an increased incidence of postoperative complications. Appropriate clinical interventions in response to an abnormal venous oxygen saturation may include supplemental oxygen, respiratory support, blood products, intravenous fluid, inotropic therapy, anaesthesia, analgesia, sedation and rewarming. However, there is a need for large, prospective RCTs to confirm appropriate treatment algorithms. Confounding factors relevant to venous oximetry include the increase in venous saturation that occurs with increase in fractional inspired oxygen concentration that may be misinterpreted as adequate resuscitation. As with any form of venous oximetry, interpretation errors can also arise due to intracardiac shunts, TR and catheter misplacement.
Take home message: ScvO2 & SvO2 reflect important pathophysiological changes in oxygen delivery and consumption that occur during the perioperative period.
8 Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation. Yamanaka H et al. Br J Anaesth. 2009 Sep;103(3):452-5
This article attempts to elucidate the natural history associated with post-intubation hoarseness and potential laryngeal injury. The investigators performed a 3-year prospective audit (n=3093) of patients who were extubated in the OR, and recorded postoperative hoarseness on the day of surgery and post-operative days 1, 3 and 7 via standardized interview. Hoarseness was observed in 49% of patients on the day of surgery and in 29%, 11% and 0.8% on 1, 3, and 7 postoperative days, respectively. Multiple regression analysis showed that patient age and duration of intubation, but not gender, weight, Cormack grades, or the agents used, were significant predictors of increased duration of hoarseness. 3/25 patients with persisting hoarseness were diagnosed with arytenoid cartilage dislocation and underwent surgical repair and patients suffered vocal cord paralysis.
Take home message: Approximately 50% of patients will suffer post-intubation hoarseness on the day of surgery however the incidence of hoarseness lasting for >1 week is approximately 1%. Persistent vocal cord dysfunction should be investigated to exclude arytenoid dislocation that may require surgical intervention (incidence ~0.1%).
For related reading this month:
Tan V, Seevanayagam S. Arytenoid subluxation after a difficult intubation treated successfully with voice therapy. Anaesth Intensive Care. 2009 Sep;37(5):843-6.
9 A Macintosh laryngoscope blade for videolaryngoscopy reduces stylet use in patients with normal airways. van Zundert A et al. Anesth Analg. 2009 Sep;109(3):825-31.
This RCT (n=450) allocated patients with normal airways to intubation with one of three videolaryngoscopes: the glidescope ranger, the McGrath and the Storz V-MAC. All three VLSs offered equal or better view of the glottis as assessed by the mean Cormack-Lehane grade, compared to traditional Macintosh laryngoscopy, including a larger viewing angle of the glottic entrance. Although all patients were intubated successfully with the VLSs, the investigators found that a good laryngeal view did not guarantee easy or successful tracheal tube insertion. The protocol required that a stylet was only used if intubation was not feasible after two intubation attempts (despite manufacturers recommendations for stylet use with McGrath/glidescope). The average intubation time was 34 +/- 20 secs for the glidescope, 18 +/-12 secs for the Storz V-Mac and 38 +/- 23 secs for the McGrath VLS. A stylet had to used in 7% of the patients in the Storz group compared to about 50% of the patients when the other two VLS were used. One of the main differences between direct and indirect laryngoscopy is that direct laryngoscopy relies on a line of sight and as such, via soft tissue retraction and lifting of the mandible creates a straight, unobstructed passage to the larynx. However, indirect laryngoscopy enables visualization of the larynx without creating a line of sight so that successful ETT insertion may require manipulation of the ETT to an angle that approximates that of the tracheal axis. Use of a stylet formed in the shape of a hockey stick with a 60-90 degree bend essentially compensates for the geometrical mismatch of the VLS with the laryngeal anatomy. The Storz V-MAC relies on blade design similar to the conventional Macintosh blade and so enables lateral tongue displacement and soft-tissue retraction. As such, the Storz V-MAC enables a traditional line of sight view in addition to an indirect view of the larynx. In contrast, the Glidescope and the McGrath are inserted in the mid-line and advanced over the tongue. The differences in design and technique presumably explain the greater need for a styleted ETT with the McGrath & glidescope. The authors cite evidence that use of a stylet has been implicated in rare, but potentially significant complications, including injury to the airway soft tissues and palatoglossal arch. This evidence obviously highlights the need for caution during the blind passage of an ETT (with or without a stylet) prior to the distal end coming into the view of VLS. Notable features of the study include that approximately 70% of the patients had double dentures so were unlikely to present airway challenges with direct laryngoscopy and the requirement for initial intubation to be attempted without a stylet likely biased the results in favour of a device which most closely resembles conventional direct laryngoscopy.
Take home message: The Storz VLS displaces soft tissues similar to conventional direct laryngoscopy which may limit the need for stylet use compared with the McGrath and the Glidescope VLS.
See also: June Journal Watch (3) March Journal Watch (5) April Journal Watch (1)
10 Anaerobic threshold: pitfalls and limitations. Nyasavajjala SM et al. Anaesthesia. 2009 Sep;64(9):934-6.
This editorial gives and update of the status of cardiopulmonary exercise testing (CPET). It is a low risk non-invasive investigation that measures dynamic gas exchange during graded exercise in order to calculate the anaerobic threshold (AT). AT is an estimate of the exercise capacity associated with the onset of metabolic acidosis due to an oxygen supply:demand imbalance. Numerically it is presented as the rate of oxygen consumption (VO2) at which acid starts to accumulate. A low pre-operative AT has been shown to correlate with postoperative mortality. Thresholds of peak oxygen consumption (VO2 peak) of 15 mlO2/kg/min and an oxygen consumption at the AT of 11 mlO2/kg/min have been shown to discriminate between higher and lower risk patients in non-cardiac surgery. The AT needs to be reported in the context of other results (i.e. exercise induced ischaemia), so that a more accurate assessment can be made of, not only prognosis, but also possible therapeutic interventions. Although it is a safe test, it is expensive, not widely available, lacks expert agreement about relevant endpoints and there are many areas for potential error, so it is important that clinicians know the limitations and pitfalls of CPET testing when ordering/ interpreting a test.
Take home message: CPET testing enables calculation of the anaerobic threshold and gives a dynamic assessment of cardiac and pulmonary performance during exercise.
11 Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Canty DJ et al. Br J Anaesth. 2009 Sep;103(3):352-8.
This Tasmanian audit claims to provide evidence that anaesthetist performed point-of care TTE/TOE/thoracic ultrasound, predominantly conducted in preadmission or immediately preoperatively, may have a high clinical impact in non-cardiac surgery. The investigators detail findings of 101 ultrasound studies with clinical consequences such as cancellations (n=2), change in planned surgery (n=2), and impact on haemodynamic management (n=18), conducted by a single person in a single centre. Of the positive studies performed in preadmission clinic, indications included exertional breathlessness post cardiac surgery, poor exercise tolerance prior to major joint surgery, chest pain and known significant valvular disease. Based on history and symptoms alone, AHA/ACC would suggest that most of these patients should have a formal cardiac assessment/referral/investigations, so it is difficult to determine how their management would have been different if ‘best practice’ routes of preoperative assessment had been followed. Presumably, most of the studies performed immediately prior to surgery were for non-elective procedures although this is not clearly specified in the article. Indications for these studies included known severe cardiac disease (severe IHD, HOCM) and rest angina, so it is difficult to assess whether these patients required formal cardiology review and whether their preoperative work-up was adequate. Other positive ultrasound studies were for predictable pathologies which are readily diagnosed on history/examination or other investigations or for which you would expect the treating team to have a high index of clinical suspicion as to underlying aetiology: pneumothorax associated with a fall and tender ribs, haemodynamic instability associated with an acute abdomen or after cervical spine trauma. At no point in the article is there any discussion of the diagnostic accuracy of anesthetist driven point-of-care ultrasound or reference to sensitivity/specificity/NPV/PPV that is well established with other investigative options. This becomes even more relevant as the author suggests TTE can be used a screening tool for conditions such as severe pulmonary hypertension and aortic stenosis. Another questionable observation from the author includes that TTE may be used in non-intubated patients during surgery for acute haemodynamic state diagnosis but what are the advantages of keeping a haemodynamically unstable patient non-intubated and how often is an adequate TTE obtained without interfering with the surgical field? The author also suggests that anaesthetist driven US could reduce the burden on cardiology and intensive care departments. This may be appropriate in hospitals where resources are very limited, however, you would hope this would not be a pressing issue in a tertiary referral centre where the audit was conducted. Notable features of the article are the single anaesthetist performing the studies does not specify his echocardiography training or certification, significant new findings were not verified by second observer or subsequent study and indications for echocardiography were not prospectively defined. There was also no mention in the article about the unresolved issue of training and credentialing for diagnostic US. Anaesthetists who claim competency for diagnostic US also accept the responsibility and liability for misdiagnosis and clinical consequences of such. The author’s statement that TTE is a non-invasive way of obtaining additional information without risk to the patient does not consider misdiagnosis as a potential outcome. Hopefully future studies in this area will attempt to establish the usefulness of anaesthetist-performed US compared with existing diagnostic options that have established accuracy and clinical utility.
Take home message: There is a need for good evidence to support the indications for and diagnostic utility of anaesthetist-performed point-of-care ultrasound (TTE/TOE/thoracic) in the non-cardiac setting.
See also: June Journal Watch (6)
Other articles of potential specific interest:
CARDIAC
Younker D et al. Cardiac arrest upon induction of general anesthesia: transesophageal echocardiography-assisted diagnosis of impending paradoxical embolus. Anesthesiology. 2009 Sep;111(3):67
Klein AA et al. The impact of intra-operative transoesophageal echocardiography on cardiac surgical practice. Anaesthesia. 2009 Sep;64(9):947-52.
De Hert S et al. A comparison of volatile and non volatile agents for cardioprotection during on-pump coronary surgery. Anaesthesia. 2009 Sep;64(9):953-60.
Liskaser FJ et al. Role of pump prime in the etiology and pathogenesis of cardiopulmonary bypass-associated acidosis. Anesthesiology. 2000 Nov;93(5):1170-3.
REGIONAL ANAESTHESIA
Malinzak EB et al. Regional anesthesia for vascular access surgery. Anesth Analg. 2009 Sep;109(3):976-80. Review.
Scott M et al. Antiseptic solutions for central neuraxial blockade: which concentration of chlorhexidine in alcohol should we use? Br J Anaesth. 2009 Sep;103(3):456; author reply 456-7
Robards C et al. Sciatic nerve catheter placement: success with using the Raj approach. Anesth Analg. 2009 Sep;109(3):972-5.
Erdil F et al. The effects of intrathecal levobupivacaine and bupivacaine in the elderly. Anaesthesia. 2009 Sep;64(9):942-6.
Shibata Y et al. Ultrasound-guided intercostal approach to thoracic paravertebral block. Anesth Analg. 2009 Sep;109(3):996-7.
Jankovic ZB et al. An anatomical study of the transversus abdominis plane block: location of the lumbar triangle of Petit and adjacent nerves. Anesth Analg. 2009 Sep;109(3):981-5.
Ultrasound-guided femoral catheter placement. Anaesth Intensive Care. 2009 Sep;37(5):758-66.
GENERAL TOPICS Apfel CC et al. Droperidol has comparable clinical efficacy against both nausea and vomiting. Br J Anaesth. 2009 Sep;103(3):359-63.
Appukutty J et al. Nasogastric tube insertion using different techniques in anesthetized patients: a prospective, randomized study. Anesth Analg. 2009 Sep;109(3):832-5.
McGain E et al. An audit of potentially recyclable waste from anaesthetic practice. Anaesth Intensive Care. 2009 Sep;37(5):820-3.
Leslie K et al. Dreaming and electroencephalographic changes during anesthesia maintained with propofol or desflurane. Anesthesiology. 2009 Sep;111(3):547-55.
Kasuya Y et al. Accuracy of postoperative end-tidal Pco2 measurements with mainstream and sidestream capnography in non-obese patients and in obese patients with and without obstructive sleep apnea. Anesthesiology. 2009 Sep;111(3):609-15.
Kortelainen J et al. Effects of remifentanil on the spectrum and quantitative parameters of electroencephalogram in propofol anesthesia. Anesthesiology. 2009 Sep;111(3):574-83.
Welch MB et al. Perioperative peripheral nerve injuries: a retrospective study of 380,680 cases during a 10-year period at a single institution. Anesthesiology. 2009 Sep;111(3):490-7.
Prielipp RC et al. Perioperative nerve injury: a silent scream? Anesthesiology. 2009 Sep;111(3):464-6
Meyhoff CS et al. Should dosing of rocuronium in obese patients be based on ideal or corrected body weight? Anesth Analg. 2009 Sep;109(3):787-92.
Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Johnson RK et al. American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention. Circulation. 2009 Sep 15;120(11):1011-20.
RESEARCH Sanders RD et al. Does correcting the numbers improve long-term outcome? Anesthesiology. 2009 Sep;111(3):475-7.
PAIN Leung JM et al. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009 Sep;111(3):625-31. - De Kock M. Expanding our horizons: transition of acute postoperative pain to persistent pain and establishment of chronic postsurgical pain services. Anesthesiology. 2009 Sep;111(3):461-3
AIRWAY Greenland KB et al. Difficult airway management--a glass half empty. Anaesthesia. 2009 Sep;64(9):1024-5.
Drolet P. Management of the anticipated difficult airway--a systematic approach: continuing Professional Development. Can J Anaesth. 2009 Sep;56(9):683-701.
Walker L et al. Randomized controlled trial of intubation with the McGrath Series 5 videolaryngoscope by inexperienced anaesthetists. Br J Anaesth. 2009 Sep;103(3):440-5
Siddiqui N et al. Heart rate/blood pressure response and airway morbidity following tracheal intubation with direct laryngoscopy, GlideScope and Trachlight: a randomized control trial. Eur J Anaesthesiol. 2009 Sep;26(9):740-5.
Hirabayashi Y et al. Apparent blind spot with the GlideScope video laryngoscope. Br J Anaesth. 2009 Sep;103(3):461-2.
Hackell RS et al. Management of the difficult infant airway with the Storz Video Laryngoscope: a case series. Anesth Analg. 2009 Sep;109(3):763-6.
Liu EH et al. Tracheal intubation with videolaryngoscopes in patients with cervical spine immobilization: a randomized trial of the Airway Scope and the GlideScope. Br J Anaesth. 2009 Sep;103(3):446-51
PAEDIATRICS Cox RG et al. Supraglottic airways in children: past lessons, future directions. Can J Anaesth. 2009 Sep;56(9):636-42
PERIOPERATIVE MEDICINE Webster NR et al. Does strict glucose control improve outcome? Br J Anaesth. 2009 Sep;103(3):331-4.
Loadsman JA. Preoperative screening for obstructive sleep apnoea--are we losing sleep over nothing? Anaesth Intensive Care. 2009 Sep;37(5):697-9.
Blake DW et al. Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesth Intensive Care. 2009 Sep;37(5):720-5.
OBSTETRIC ANAESTHESIA Robins K et al. Intraoperative awareness during general anesthesia for cesarean delivery. Anesth Analg. 2009 Sep;109(3):886-90
NEUROANAESTHESIA
Anastasian ZH et al. Evoked potential monitoring identifies possible neurological injury during positioning for craniotomy. Anesth Analg. 2009 Sep;109(3):817-21.
TRAUMA ANAESTHESIA von Elm E et al. Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence. Br J Anaesth. 2009 Sep;103(3):371-86.
Stephens CT, Kahntroff S, Dutton RP. The success of emergency endotracheal intubation in trauma patients: a 10-year experience at a major adult trauma referral center. Anesth Analg. 2009 Sep;109(3):866-72.
“?GENDER ISSUES”
Waddington MS et al. The influence of gender and experience on intubation ability and technique: a manikin study. Anaesth Intensive Care. 2009 Sep;37(5):791-801.
Written by Maryanne Balkin, September 2009
Feedback welcome: M.Balkin@alfred.org.au
Disclaimers:
1 Best attempts are made to include articles representative of recent publications but no attempt is made to include every important article.
2 Commentary & take home message is only one of many possible opinions/interpretations of the literature.
For other 2009 editions of journal watch: http://www.anaesthesiacases.com.au/cpd