Joshua A. Bloomstone

Radial Artery Cannulation: A Review Article

Percutaneous radial artery cannulation is a well established procedure that is commonly used in the operating room and intensive care units. Relevant anatomy and attention in detail during cannulation and maintenance are important aspects of the technique that enhance patient safety. Access to the arterial circulation will remain important for hemodynamic monitoring and access to arterial blood. This article reviews the current indications, contraindications, pre-procedure assessment, technique, complications, and monitoring of the site.

Impact of Preoperative Renal Dysfunction on Outcomes of Off-Pump Coronary Artery Bypass Grafting

BACKGROUND This study assessed whether preoperative renal insufficiency predisposes patients undergoing off-pump coronary artery revascularization to postoperative dialysis. METHODS From August 2004 through June 2009, 2,275 patients undergoing off-pump coronary artery bypass were categorized into five groups (stages) by glomerular filtration rate (GFR). Of these, 1,855 patients had renal insufficiency: stage 2: 1,406; stage 3: 428; stage 4: 21, and 414 had normal renal function, stage 1. Excluded were 6 patients with end-stage renal disease (stage 5). Preoperative variables and postoperative outcomes were compared among groups. RESULTS Preoperative patient characteristics were similar; however, patients with normal renal function were younger (p = 0.001). Serum creatinine rose significantly above baseline on the first postoperative day in the renal insufficiency groups (p = 0.001). The GFR groups had similar inotrope use, reexploration rate, duration of postoperative mechanical ventilation, postoperative stroke, wound infection, and mortality rate. Stage 4 patients had a higher incidence of postoperative myocardial infarction (p = 0.002). Stage 3 and 4 patients had an increased need for postoperative dialysis vs stage 1 patients (p = 0.002). CONCLUSIONS Nonparametric contingency analysis showed patients with low preoperative GFR (stage 3 and 4, p < 0.0001) and a history of smoking (p = 0.04) were at increased risk for postoperative dialysis. Patients who required postoperative inotropic support tended toward requiring postoperative dialysis (p = 0.06). Low preoperative ejection fraction (p = 0.83), class III or IV angina (p = 0.069), and postoperative blood transfusions were not associated with the need for postoperative dialysis in patients undergoing off-pump revascularization.

A System-Wide Enhanced Recovery Program Focusing on Two Key Process Steps Reduces Complications and Readmissions in Patients Undergoing Bowel Surgery

Abstract: Enhanced recovery programs (ERPs) can improve outcomes following bowel surgery, but implementing an ERP across a large healthcare system remains challenging. In this study, a simplified ERP that focused on two process steps, early and frequent ambulation and early alimentation, was evaluated to determine its impact on outcomes. Data were collected on 5,000 adult patients undergoing elective small and large bowel operations over a 3‐year period. Complication, readmission, and mortality rates were evaluated before and after ERP implementation. A composite score was calculated based on the successful completion of the two process steps. Following implementation, there was a 35.1% increase in the composite score, which was associated with significant (p < .05) reductions in overall complications, gastrointestinal complications, pulmonary complications, and readmissions. A system‐wide ERP focusing on early and frequent ambulation and early alimentation is associated with decreased complications and readmissions in adult patients admitted for elective small or large bowel operations.

ERAS: enhancing recovery one evidence-based step at a time.

256 www.anesthesia-analgesia.org anesthesia & anaLgesia In Response We agree with Bloomstone et al.1 that early ambulation and alimentation after surgery are the pivotal changes in care that have occurred over the last 10 years. Enhanced recovery after surgery (ERAS) protocols aim to standardize perioperative care to enable early feeding and mobilization. There are a number of components to our ERAS protocol. However, we do not believe the protocol is complex. In fact, we have found that the 2 components that Bloomstone et al.1 suggest should be fundamental components of an ERAS program—early mobilization and feeding—are some of the most challenging to implement. Changing the postoperative ERAS: Enhancing Recovery One Evidence-Based Step at a Time

Why the gray zone may shift within the fog.

1. Holsträter TF, Georgieff M, Föhr KJ, Klingler W, Uhl ME, Walker T, Köster S, Grön G, Adolph O: Intranasal application of xenon reduces opioid requirement and postoperative pain in patients undergoing major abdominal surgery: A randomized controlled trial. ANESTHESIOLOGY 2011; 115:398 – 407 2. Froeba G, Georgieff M, Linder EM, Föhr KJ, Weigt HU, Holsträter TF, Kölle MA, Adolph O: Intranasal application of xenon: Describing the pharmacokinetics in experimental animals and the increased pain tolerance within a placebocontrolled experimental human study. Br J Anaesth 2010; 104:351– 8 3. Jogani V, Jinturkar K, Vyas T, Misra A: Recent patents review on intranasal administration for CNS drug delivery. Recent Pat Drug Deliv Formul 2008; 2:25– 40 4. Illum L: Is nose-to-brain transport of drugs in man a reality? J Pharm Pharmacol 2004; 56:3–17 5. Adolph O, Köster S, Georgieff M, Bäder S, Föhr KJ, Kammer T, Herrnberger B, Grön G: Xenon-induced changes in CNS sensitization to pain. Neuroimage 2010; 49:720 –30

Jury Is Still Out on Investing in Nontraditional Laparoscopic Cholecystectomy Surgical Equipment.

protein (CRP). C-reactive protein is not universally used to determine antimicrobial duration for surgical infections. Requiring surgeons to adopt a new test would have limited enrollment for the study and the generalizability of results. Despite evidence suggesting that its level correlates with the course of an infection, currently, there is still no agreed-on use of CRP levels or ratio for determining when to discontinue antimicrobial therapy in complicated intra-abdominal infection, which makes it difficult to incorporate into a trial protocol. We concur with Spartalis and colleagues that CRP appears to hold promise as a more accurate diagnostic tool than temperature or WBC count. We support the continued study of CRP in complicated intraabdominal infection and other surgical infections. We hope this allows the surgical community to develop guidelines on its use to aid its incorporation into future prospective trial protocols.