Ian H. Black

The Correlation Between Ketamine and Posttraumatic Stress Disorder in Burned Service Members

BACKGROUND Predisposing factors for posttraumatic stress disorder (PTSD) include experiencing a traumatic event, threat of injury or death, and untreated pain. Ketamine, an anesthetic, is used at low doses as part of a multimodal anesthetic regimen. However, since ketamine is associated with psychosomatic effects, there is a concern that ketamine may increase the risk of developing PTSD. This study investigated the prevalence of PTSD in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) service members who were treated for burns in a military treatment center. METHODS The PTSD Checklist-Military (PCL-M) is a 17-question screening tool for PTSD used by the military. A score of 44 or higher is a positive screen for PTSD. The charts of all OIF/OEF soldiers with burns who completed the PCL-M screening tool (2002-2007) were reviewed to determine the number of surgeries received, the anesthetic regime used, including amounts given, the total body surface area burned, and injury severity score. Morphine equivalent units were calculated using standard dosage conversion factors. RESULTS The prevalence of PTSD in patients receiving ketamine during their operation(s) was compared with patients not receiving ketamine. Of the 25,000 soldiers injured in OIF/OEF, United States Army Institute of Surgical Research received 603 burned casualties, of which 241 completed the PCL-M. Of those, 147 soldiers underwent at least one operation. Among 119 patients who received ketamine during surgery and 28 who did not; the prevalence of PTSD was 27% (32 of 119) versus 46% (13 of 28), respectively (p = 0.044). CONCLUSIONS Contrary to expectations, patients receiving perioperative ketamine had a lower prevalence of PTSD than soldiers receiving no ketamine during their surgeries despite having larger burns, higher injury severity score, undergoing more operations, and spending more time in the ICU.

The evolution of pain management in the critically ill trauma patient: Emerging concepts from the global war on terrorism.

Background:The evolution of military medical care to manage polytrauma, critically ill-wounded warriors from the greater war on terrorism has been accompanied by significant changes in the diagnosis, management, and modulation of acute and chronic trauma-related pain. A paradigm shift in pain management includes early treatment of pain at the point of injury and throughout the continuum of care with a combination of standard and novel therapeutic interventions. These concepts are important for all critical care providers because they translate to most critically ill patients, including those resulting from natural disasters. Previous authors have reported a high incidence of moderate to severe pain and poor analgesia in intensive care units associated with sleep disturbances, tachycardia, pulmonary complications, increased stress response with thromboembolic incidents, and immunosuppression, increased intensive care unit and hospital stays, and needless suffering. Although opioids have traditionally been the cornerstone of acute pain management, they have potential negative effects ranging from sedation, confusion, respiratory depression, nausea, ileus, constipation, tolerance, opioid-induced hyperalgesia as well as potential for immunosuppression. Alternatively, multimodal therapy is increasingly recognized as a critical pain management approach, especially when combined with early nutrition and ambulation, designed to improve functional recovery and decrease chronic pain conditions. Discussion:Multimodal therapy encompasses a wide range of procedures and medications, including regional analgesia with continuous epidural or peripheral nerve block infusions, judicious opioids, acetaminophen, anti-inflammatory agents, anticonvulsants, ketamine, clonidine, mexiletine, antidepressants, and anxiolytics as options to treat or modulate pain at various sites of action. Summary:With a more aggressive acute pain management strategy, the military has decreased acute and chronic pain conditions, which may have application in the civilian sector as well.

The Effect of Propranolol on Posttraumatic Stress Disorder in Burned Service Members

Posttraumatic stress disorder (PTSD) is reported to affect almost one third of the civilian burn patient population. Predisposing factors for PTSD include experiencing a traumatic event. Of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) soldiers returning home after deployment without injury, 17% reported cognitive symptoms of PTSD. The authors recent study of soldiers burned in OIF/OEF showed a PTSD prevalence of ∼30%, which is similar to civilian studies. Burns are characterized by hypermetabolism and increased catecholamine levels. &bgr;-Adrenergic receptor blocking agents, like propranolol, decrease catecholamine levels. Propranolol may reduce consolidation of memory and a prophylaxis for PTSD. This retrospective study examines the relationship between PTSD prevalence and propranolol administration. After institutional review board approval, propranolol received, number of surgeries, anesthetic/analgesic regimen, TBSA burned, and injury severity score were collected from patients charts. The military burn center received 603 soldiers injured in OIF/OEF, of which 226 completed the PTSD Checklist-Military. Thirty-one soldiers received propranolol and 34 matched soldiers did not. In propranolol patients, the prevalence of PTSD was 32.3% vs 26.5% in those not receiving propranolol (P = .785). These data suggest propranolol does not decrease PTSD development in burned soldiers. The prevalence of PTSD in patients receiving propranolol is the same as those not receiving propranolol. More research is needed to determine the relationship between PTSD and propranolol.

Total Intravenous Anesthesia Including Ketamine versus Volatile Gas Anesthesia for Combat-related Operative Traumatic Brain Injury

Background:Traumatic brain injury is a leading cause of death and severe neurologic disability. The effect of anesthesia techniques on neurologic outcomes in traumatic brain injury and potential benefits of total intravenous anesthesia (TIVA) compared with volatile gas anesthesia (VGA), although proposed, has not been well evaluated. The purpose of this study was to compare TIVA versus VGA in patients with combat-related traumatic brain injury. Methods:The authors retrospectively reviewed 252 patients who had traumatic brain injury and underwent operative neurosurgical intervention. Statistical analyses, including propensity score and matched analyses, were performed to assess differences between treatment groups (TIVA vs. VGA) and good neurologic outcome. Results:Two hundred fourteen patients met inclusion criteria and were analyzed; 120 received VGA and 94 received TIVA. Good neurologic outcome (Glasgow Outcome Score 4–5) and decreased mortality were associated with TIVA compared with VGA (75% vs. 54%; P = 0.002 and 5% vs. 16%; P = 0.02, respectively). Multivariate logistic regression found admission Glasgow Coma Scale score of 8 or greater (odds ratio, 13.3; P < 0.001) and TIVA use (odds ratio, 2.3; P = 0.05) to be associated with good neurologic outcomes. After controlling for confounding factors using propensity analysis and repeated one-to-one matching of patients receiving TIVA with those receiving VGA with regard to Injury Severity Score, Glasgow Coma Scale score, base deficit, Head Abbreviated Injury Score, and craniectomy or craniotomy, the authors could not find an association between treatment and neurologic outcome. Conclusion:Total intravenous anesthesia often including ketamine was not associated with improved neurologic outcome compared with VGA. Multiple confounders limit conclusions that can be drawn from this retrospective study.

Cognitive outcome after spinal anesthesia and surgery during infancy.

BACKGROUND:Observational studies on pediatric anesthesia neurotoxicity have been unable to distinguish long-term effects of general anesthesia (GA) from factors associated with the need for surgery. A recent study on elementary school children who had received a single GA during the first year of life demonstrated an association in otherwise healthy children between the duration of anesthesia and diminished test scores and also revealed a subgroup of children with “very poor academic achievement” (VPAA), scoring below the fifth percentile on standardized testing. Analysis of postoperative cognitive function in a similar cohort of children anesthetized with an alternative to GA may help to begin to separate the effects of anesthesia from other confounders. METHODS:We used a novel methodology to construct a combined medical and educational database to search for these effects in a similar cohort of children receiving spinal anesthesia (SA) for the same procedures. We compared former patients with a control population of students matched by grade, gender, year of testing, and socioeconomic status. RESULTS:Vermont Department of Education records were analyzed for 265 students who had a single exposure to SA during infancy for circumcision, pyloromyotomy, or inguinal hernia repair. Exposure to SA and surgery had no significant effect on the odds of children having VPAA. (mathematics: P = 0.18; odds ratio 1.50, confidence interval (CI), 0.83–2.68; reading: P = 0.55; odds ratio = 1.19, CI, 0.67–2.1). There was no relationship between duration of exposure to SA and surgery and performance on mathematics (P = 0.73) or reading (P = 0.57) standardized testing. There was a small but statistically significant decrease in reading and math scores in the exposed group (mathematics: P = 0.03; reading: P = 0.02). CONCLUSIONS:We found no link between duration of surgery with infant SA and scores on academic achievement testing in elementary school. We also found no relationship between infant SA and surgery with VPAA on elementary school testing, although the CIs were wide.

The Relationship of Intravenous Midazolam and Posttraumatic Stress Disorder Development in Burned Soldiers

BACKGROUND Midazolam, a short-acting benzodiazepine, is administered preoperatively and intraoperatively for amnesia and anxiolysis. Subsequently, patients often do not recall events which occurred while they were sedated. Recent studies have also reported retrograde facilitation after midazolam exposure. Posttraumatic stress disorder PTSD is based on memory of a traumatic event. Because of the concern that midazolam may enhance memory of the traumatic event in which soldiers were injured, we investigated the prevalence of PTSD in those burned soldiers who received perioperative midazolam and those who did not. We also investigated the intensity of the memories related to the traumatic event. METHODS After institutional review board approval, all charts of US soldiers who completed the PTSD Checklist-Military (PCL-M) screening tool (2004-2008) after admission to US Army Institute of Surgical Research were reviewed to determine the number of operations, the anesthetic regime, total body surface area (TBSA) burned, and Injury Severity Score (ISS). RESULTS The PCL-M was completed by 370 burned soldiers from Operation Iraqi Freedom/Operation Enduring Freedom. During surgery, 142 received midazolam, whereas 69 did not. The prevalence of PTSD was higher in soldiers receiving midazolam as compared with those who did not (29% vs. 25%) (p = 0.481). Both groups had similar injuries based on TBSA and ISS. Patients who received midazolam also had similar scores on PCL-M questions related to memory of the event. CONCLUSIONS Rates of PTSD are not statistically different in combat casualties receiving midazolam during intraoperative procedures. Intraoperative midazolam is not associated with increased PTSD development or with increased intensity of memory of the traumatic event. Patients receiving midazolam had similar injuries (TBSA and ISS) and underwent a similar number of operations as those not receiving midazolam.

Observations: clinical revenue directly attributable to anesthesiology residents.

During the graduate medical education reform of the 1990s, anesthesiology programs across the country downsized to accommodate a perceived oversupply of anesthesiologists in the marketplace and to make room for an additional number of training positions in the primary care residencies.1 As academic programs struggled to work more efficiently either with replacement of clinical staff members or with different staffing models, many programs experienced an increase in their operational costs because of a reduction of their labor force and a discrepancy in anesthesiology billing practices.2,3 Prior to 2011, the Centers for Medicare and Medicaid Services (CMS) and many private insurance companies reimbursed anesthesiology programs at a 50% discount. Today, academic anesthesiology programs have been able to bill for 100% of the services provided, regardless of staffing ratios.4 We examined the revenue stream directly generated by the clinical activities of anesthesiology residents at our program during the time period July 1, 2011, through June 30, 2012, and demonstrated that our entire residency program delivered 4664 billable anesthetics, billed for

Novel use of a portable ventilation device with low-flow tracheal insufflation of oxygen in a Swine model.

7,892,558, and collected

A boring Thanksgiving.

2,802,969 in total payments. We determined that direct costs for an anesthesiology resident by clinical training year, including salary and fringe benefits for Clinical Anesthesia year 1 (CA-1), CA-2, and CA-3, were

Low-flow transtracheal rescue insufflation of oxygen after profound desaturation.

65,951,