Marc Shnider

Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair

Importance Epidural analgesia (EA) is used as an adjunct procedure for postoperative pain control during elective abdominal aortic aneurysm (AAA) surgery. In addition to analgesia, modulatory effects of EA on spinal sympathetic outflow result in improved organ perfusion with reduced complications. Reductions in postoperative complications lead to shorter convalescence and possibly improved 30-day survival. However, the effect of EA on long-term survival when used as an adjunct to general anesthesia (GA) during elective AAA surgery is unknown. Objective To evaluate the association between combined EA-GA vs GA alone and long-term survival and postoperative complications in patients undergoing elective, open AAA repair. Design, Setting, and Participants A retrospective analysis of prospectively collected data was performed. Patients undergoing elective AAA repair between January 1, 2003, and December 31, 2011, were identified within the Vascular Society Group of New England (VSGNE) database. Kaplan-Meier curves were used to estimate survival. Cox proportional hazards regression models and multivariable logistic regression models assessed the independent association of EA-GA use with postoperative mortality and morbidity, respectively. Data analysis was conducted from March 15, 2015, to September 2, 2015. Interventions Combined EA-GA. Main Outcomes and Measures The primary outcome measure was all-cause mortality. Secondary end points included postoperative bowel ischemia, respiratory complications, myocardial infarction, dialysis requirement, wound complications, and need for surgical reintervention within 30 days of surgery. Results A total of 1540 patients underwent elective AAA repair during the study period. Of these, 410 patients (26.6%) were women and the median (interquartile range) age was 71 (64-76) years; 980 individuals (63.6%) received EA-GA. Patients in the 2 groups were comparable in terms of age, comorbidities, and suprarenal clamp location. At 5 years, the Kaplan-Meier-estimated overall survival rates were 74% (95% CI, 72%-76%) and 65% (95% CI, 62%-68%) in the EA-GA and GA-alone groups, respectively (P < .01). In adjusted analyses, EA-GA use was associated with significantly lower hazards of mortality compared with GA alone (hazard ratio, 0.73; 95% CI, 0.57-0.92; P = .01). Patients receiving EA-GA also had lower odds of 30-day surgical reintervention (odds ratio [OR], 0.65; 95% CI, 0.44-0.94; P = .02) as well as postoperative bowel ischemia (OR, 0.54; 95% CI, 0.31-0.94; P = .03), pulmonary complications (OR, 0.62; 95% CI, 0.41-0.95; P = .03), and dialysis requirements (OR, 0.44; 95% CI, 0.23-0.88; P = .02). No significant differences were noted for the odds of wound (OR, 0.88; 95% CI, 0.38-1.44; P = .51) and cardiac (OR, 1.08; 95% CI, 0.59-1.78; P = .82) complications. Conclusions and Relevance Combined EA-GA was associated with improved survival and significantly lower HRs and ORs for mortality and morbidity in patients undergoing elective AAA repair. The survival benefit may be attributable to reduced immediate postoperative adverse events. Based on these findings, EA-GA should be strongly considered in suitable patients.

CIRCULATORY EFFECTS OF PROSTAGLANDIN ENDOPEROXIDE ANALOGUES STUDIED IN THE DOG DURING LEFT VENTRICULAR BYPASS

1 Intravenous administration of both the 9α,11α‐(epoxymethano) and 11α,9α‐(epoxymethano) analogues of prostaglandin H2 (0.25 üg/kg) produced a prominent rise in pulmonary arterial pressure and a moderate increase in systemic arterial pressure. 2 Direct administration of the endoperoxide analogues (1.25 μg/kg) into the bypass reservoir produced a greater rise in systemic arterial pressure and less prominent rise in pulmonary arterial pressure. 3 An intravenous dose of prostaglandin F2α that was 20 times larger was needed to produce a comparable rise in pulmonary arterial pressure. 4 The pulmonary and systemic pressor responses produced by the endoperoxide analogues were due to a direct increase in the vascular resistance.

Assessment of Perioperative Ultrasound Workflow Understanding: A Consensus

OBJECTIVES Understanding of the workflow of perioperative ultrasound (US) examination is an integral component of proficiency. Workflow consists of the practical steps prior to executing an US examination (eg, equipment operation). Whereas other proficiency components (ie, cognitive knowledge and manual dexterity) can be tested, workflow understanding is difficult to define and assess due to its contextual and institution-specific nature. The objective was to define the workflow components of specific perioperative US applications using an iterative process to reach a consensus opinion. DESIGN Expert consensus, survey study. SETTING Tertiary university hospital. PARTICIPANTS This study sought expert consensus among a focus group of 9 members of an anesthesia department with experience in perioperative US. Afterward, 257 anesthesia faculty members from 133 academic centers across the United States were surveyed. INTERVENTIONS A preliminary list of tasks was designed to establish the expectations of workflow understanding by an anesthesiology resident prior to clinical exposure to perioperative US. This list was modified by a focus group through an iterative process. Afterwards, a survey was sent to faculty members nationwide, and Likert scale ratings for each task were obtained and reviewed during a second round. MEASUREMENTS AND MAIN RESULTS Consensus among members of the focus group was reached after 2 iterations. 72 participants responded to the nationwide survey (28%), and consensus was reached after the second round (Cronbachs α = 0.99, ICC = 0.99) on a final list of 46 workflow-related tasks. CONCLUSIONS Specific components of perioperative US workflow were identified. Evaluation of workflow understanding may be combined with cognitive knowledge and manual dexterity testing for assessing proficiency in perioperative US.