Kevin W. Hatton

Vagal nerve stimulation: overview and implications for anesthesiologists.

Vagal nerve stimulation is an important adjunctive therapy for medically refractory epilepsy and major depression. Additionally, it may prove effective in treating obesity, Alzheimers disease, and some neuropsychiatic disorders. As the number of approved indications increases, more patients are becoming eligible for surgical placement of a commercial vagal nerve stimulator (VNS). Initial VNS placement typically requires general anesthesia, and patients with previously implanted devices may present for other surgical procedures requiring anesthetic management. In this review, we will focus on the indications for vagal nerve stimulation (both approved and experimental), proposed therapeutic mechanisms for vagal nerve stimulation, and potential perioperative complications during initial VNS placement. Anesthetic considerations during initial device placement, as well as anesthetic management issues for patients with a preexisting VNS, are reviewed.

Methylene blue for the treatment of septic shock.

Septic shock is a major cause of morbidity and mortality in the intensive care unit, and effective therapies are limited. Methylene blue is a selective inhibitor of guanylate cyclase, a second messenger involved in nitric oxide‐mediated vasodilation. The use of methylene blue in the treatment of septic shock has been repeatedly evaluated over the past 20 years, but data remain scarce. To evaluate the safety and efficacy of methylene blue for the treatment of septic shock, we conducted a literature search of the EMBASE (1974‐June 2009), MEDLINE (1966‐June 2009), and International Pharmaceutical Abstracts (1970‐June 2009) databases. All available studies published in English were reviewed. Observational studies with methylene blue have demonstrated beneficial effects on hemodynamic parameters and oxygen delivery, but use of methylene blue may be limited by adverse pulmonary effects. Methylene blue administration is associated with increases in mean arterial pressure while reducing catecholamine requirements in patients experiencing septic shock; however, its effects on morbidity and mortality remain unknown. Well‐designed, prospective evaluations are needed to define the role of methylene blue as treatment of septic shock.

Utilization of Pharmacist Responders as a Component of a Multidisciplinary Sepsis Bundle

Background: Sepsis and septic shock remain a significant burden on the US health care system. A multidisciplinary response system (Coordinated Response to Sepsis, CaRTS) that included a pharmacist responder was implemented for patients with newly suspected sepsis. Objective: To evaluate the time to appropriate antibiotic administration among patients with the CaRTS intervention compared with historical controls. Method: The CaRTS intervention included an electronic order set as well as activation of a multidisciplinary team of pharmacy and nursing personnel to coordinate resuscitation and medication administration. The CaRTS group was compared to historical controls. The primary outcome of the study was the proportion of patients with appropriate antibiotic administration within 1 hour of recognition of sepsis. Secondary outcomes included achievement of mean arterial pressure (MAP) ≥65 mm Hg and central venous pressure (CVP) of 8 to 12 mm Hg within 6 hours. Result: The CaRTS intervention was used for 49 patients and 59 historical controls were included for analysis. Patients with the CaRTS intervention had a greater than 20 times higher odds of antibiotic administration within 1 hour compared with controls (odds ratio [OR] 22.4, 95% confidence interval [CI] 7.5-69) and were more likely to have a CVP ≥8 mm Hg at 6 hours (OR 2.4, 95% CI 1.0-5.6) compared with controls. CaRTS patients achieved statistically nonsignificant increases in MAP ≥65 mm Hg (OR 2.2, 95% CI 0.7-7.7). Conclusion: Utilization of a multidisciplinary sepsis bundle that included a pharmacist responder improved the proportion of patients receiving appropriate antibiotics within 1 hour of recognition of sepsis compared to historical controls.

Malignant Hyperthermia: A Pharmacogenetic Disorder

Given the rarity and lethality of malignant hyperthermia, it is critical that all health care providers practicing in the perioperative setting have the ability to identify and institute timely life-saving therapy for this disorder.

Integrating evidence-based medicine into the perioperative care of cardiac surgery patients.

a r t m p d w c v p THE BEST PRACTICE PATTERNS in modern medical care aim to integrate the evidence from the medical literature with the clinician’s personal and institutional expertise (including cumulative clinical experience, education, and skills) and the individual patient’s preferences and values. The integration of evidence-based medicine (EBM) into perioperative care is an important component of modern anesthesiology, surgery, pharmacy, and nursing practice, particularly in the arena of cardiac surgery (CS). Because the evidence in this area continually is evolving, the landscape of EBM for the perioperative care of CS patients is ever-changing, with optimized, patient-centered care as the impetus for progress. Additionally, various external funding and oversight organizations as well as accreditation agencies, including the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, have begun to affect physician and hospital reimbursement and accreditation by tracking hospital and physician performance on certain “core measures” and their reported incidence of so-called “never-events” (conditions or complications that should occur with a very low incidence) when providing ideal or perfect clinical care. In this review, the authors describe the application of the most current literature to 4 important perioperative problems including glycemic control, hospital-associated infections, coagulopathies, and postoperative delirium and cognitive decline. Each of these topics relates to the perioperative care of patients undergoing CS, and each of these topics already is or eventually may be integrated into a public reporting scorecard and individual practitioners and hospitals may, therefore, have a vested interest in improving the care of patients with regard to each of these issues. Although a complete review of the literature for each of these problems is far beyond the scope of this review, the authors attempt to draw a few conclusions from the best available information in each section, recognizing that there may be significant limitations to the integration of these recommendations within some health care systems.

Development of a translational model to screen medications for cocaine use disorder II: Choice between intravenous cocaine and money in humans

BACKGROUND A medication for treating cocaine use disorder has yet to be approved. Laboratory-based evaluation of candidate medications in animals and humans is a valuable means to demonstrate safety, tolerability and initial efficacy of potential medications. However, animal-to-human translation has been hampered by a lack of coordination. Therefore, we designed homologous cocaine self-administration studies in rhesus monkeys (see companion article) and human subjects in an attempt to develop linked, functionally equivalent procedures for research on candidate medications for cocaine use disorder. METHODS Eight (N=8) subjects with cocaine use disorder completed 12 experimental sessions in which they responded to receive money (

Continuous wound catheters: practical considerations for use.

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Neurophysiological monitoring simulation using flash animation for anesthesia resident training.

1.00 and

Do hemodynamic measures accurately predict volume responsiveness when lung compliance is severely reduced by acute lung injury/acute respiratory distress syndrome?

3.00) or intravenous cocaine (0, 3, 10 and 30mg/70kg) under independent, concurrent progressive-ratio schedules. Prior to the completion of 9 choice trials, subjects sampled the cocaine dose available during that session and were informed of the monetary alternative value. RESULTS The allocation of behavior varied systematically as a function of cocaine dose and money value. Moreover, a similar pattern of cocaine choice was demonstrated in rhesus monkeys and humans across different cocaine doses and magnitudes of the species-specific alternative reinforcers. The subjective and cardiovascular responses to IV cocaine were an orderly function of dose, although heart rate and blood pressure remained within safe limits. CONCLUSIONS These coordinated studies successfully established drug versus non-drug choice procedures in humans and rhesus monkeys that yielded similar cocaine choice behavior across species. This translational research platform will be used in future research to enhance the efficiency of developing interventions to reduce cocaine use.

The Use of Fospropofol During Bronchoscopy

Several studies have shown both bupivacaine and ropivacaine to be safe during continuous wound infiltration.