Parmis Green

Randomized, double-blind comparison of oral aprepitant alone compared with aprepitant and transdermal scopolamine for prevention of postoperative nausea and vomiting

BACKGROUND Aprepitant blocks the emetic effects of substance P. Scopolamine antagonizes muscarinic type 1 and histamine type 1 receptors. This study compares monotherapy and multimodal therapy by looking at complete response, nausea, vomiting, and rescue medication in patients at high risk for postoperative nausea and vomiting (PONV) treated with oral aprepitant with or without scopolamine. METHODS We enrolled 120 patients in this randomized, double-blind trial. Inclusion criteria were: >18 yr old, ASA I-III, two or more Apfel four-point risk factors, undergoing an elective surgical procedure with a high risk of PONV expected to last at least 60 min. The primary outcome variable was complete response, that is, no emesis and no rescue therapy from 0 to 24 h. The outcomes measured included the incidences of nausea, vomiting, their composite, and the need for rescue medication. RESULTS The aprepitant alone and aprepitant with scopolamine did not differ in complete responses (63% vs 57%, P=0.57) or net clinical benefit (26% vs 19%, P=0.38). The number who did not experience PONV and who used rescue medication did not differ. The incidence of PONV in the post-anaesthesia care unit did not differ nor did the use of rescue medications. CONCLUSIONS This trial evaluating the effectiveness of aprepitant alone and in combination with scopolamine showed no difference between treatment groups. The primary objective, complete response, and secondary objectives, incidences of nausea, vomiting, their composite, and the need for rescue medication, all showed no statistical difference.

Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We?

There have been colossal technological advances in the use of simulation in anesthesiology in the past 2 decades. Over the years, the use of simulation has gone from low fidelity to high fidelity models that mimic human responses in a startlingly realistic manner, extremely life-like mannequin that breathes, generates E.K.G, and has pulses, heart sounds, and an airway that can be programmed for different degrees of obstruction. Simulation in anesthesiology is no longer a research fascination but an integral part of resident education and one of ACGME requirements for resident graduation. Simulation training has been objectively shown to increase the skill-set of anesthesiologists. Anesthesiology is leading the movement in patient safety. It is rational to assume a relationship between simulation training and patient safety. Nevertheless there has not been a demonstrable improvement in patient outcomes with simulation training. Larger prospective studies that evaluate the improvement in patient outcomes are needed to justify the integration of simulation training in resident education but ample number of studies in the past 5 years do show a definite benefit of using simulation in anesthesiology training. This paper gives a brief overview of the history and evolution of use of simulation in anesthesiology and highlights some of the more recent studies that have advanced simulation-based training.

Carbon monoxide-releasing molecule-2 enhances coagulation and diminishes fibrinolytic vulnerability in diluted plasma in vitro.

BACKGROUND A carbon monoxide-releasing molecule (tricarbonyldichlororuthenium (II) dimer; CORM-2) enhances coagulation and attenuates vulnerability to fibrinolysis in normal and hemophiliac human plasma. We tested the hypothesis that plasma diluted with resuscitative fluids would demonstrate improved coagulation and decreased fibrinolytic vulnerability after exposure to CORM-2. METHODS Normal, platelet-poor plasma was diluted 0%, 20%, 30%, 40%, or 50% with 0.9% NaCl (NS) or low-molecular-weight hydroxyethyl starch (VOL) and, subsequently, exposed to 0 μmol/L or 100 μmol/L CORM-2 before activation with tissue factor (n = 4 per condition). Additional plasma samples diluted with NS or VOL (0% or 30%) were exposed to 0 μmol/L or 100 μmol/L CORM-2 and 0 U/mL or 100 U/mL tissue-type plasminogen activator to assess fibrinolytic vulnerability (n = 8 per condition). Thrombelastographic data were collected until either clot strength stabilized or clot lysis occurred, as appropriate. RESULTS CORM-2 exposure maintained normal to supranormal velocity of clot formation and strength in plasma diluted up to 40% with NS. In contrast, although CORM-2 exposure improved coagulation kinetics, dilution with VOL markedly degraded thrombus formation kinetics. Similarly, fibrinolytic vulnerability to tissue-type plasminogen activator was markedly improved by CORM-2 exposure in samples diluted with NS, whereas VOL-diluted thrombi were still abnormally weak and easily lysed compared with undiluted samples despite CORM-2 exposure. CONCLUSIONS CORM-2 exposure attenuated the decrease in coagulation kinetics and enhancement of fibrinolytic vulnerability associated with hemodilution. Extensive preclinical investigation remains to be performed to determine the route of administration, safety, and efficacy of CORM-2 and other CORMs to treat trauma-associated bleeding.

Recovery Following Desflurane Versus Sevoflurane Anesthesia for Outpatient Urologic Surgery in Elderly Females

Background: An unresolved question is the time required for the ability to return to complex tasks following anesthesia. Objectives: This study aims to characterize the severity and duration of cognitive impairment following sevoflurane or desfluane anesthesia after brief surgery using tests of cognitive ability to objectively testing performance. Patients and Methods: This study is a double blinded randomized controlled trial. Patients were randomized to receive either a desflurane or sevoflurane-based anesthetic. On the morning of the surgery the subjects performed baseline cognitive task tests (Mini Mental Status exam, Trail Making Test Part A and B, Digit Symbol Coding, Hopkins Verbal Learning Test, Stroop Color and Word Test to determine baseline cognitive function. Cognitive testing was repeated 30 minutes and 1 hour after surgery whereas Modified Telephone Interview for Cognitive Status (TICS-M) and Memory Aging Telephone Screen (MATS) was used on the following day of surgery. Results: Trail Making Test Part B cognitive test showed statistically significant in comparison for pre and post exposure of anesthetics. This difference was seen in the desflurane group. Other cognitive tests did not show differences on exposure to the anesthetic gases. Conclusions: This study questioned the difference between volatile anesthetic agent’s effects on patients completing a battery of neurocognitive tests attempting to answer if one agent has a more profound effect. Our study shows no statistically significant cognitive decline except for those in the Trail Making Part B in the Desflurane group. This conclusion is limited by the inherent limitations of the study, but does reinforce that the systemic inflammatory response from the surgery contributes cognitive impairment.

Subdural hematoma following labor analgesia utilizing an intrathecal catheter.

To the Editor: We report a subdural hematoma following repeated neuraxial analgesia during labor. A healthy parturient presented with an unremarkable preanesthetic examination. At L3–L4, an 18-gauge Tuohy was advanced until a depth of 4 cm. Free-flowing cerebral spinal fluid (CSF) confirmed accidental dural puncture. A 20-gauge catheter was advanced 4 cm into the intrathecal space (IT) and secured at 8 cm at the skin. One milliliter bupivacaine 0.25 % with sufentanil 5 lg preceded infusion of bupivacaine 0.0625 % with fentanyl 1.5 lg/ml and epinephrine 1:700,000 at 2 ml/ h. Four hours later, analgesia became less potent. On inspection the catheter unintentionally came out to 4 cm, thus exiting the IT. Aspiration no longer produced freeflowing CSF. Vaginal exam revealed advancement of labor. Repeat epidural catheterization at L2–L3 followed. Ten milliliters bupivacaine 0.25 % and the same infusion solution yielded analgesia. On postpartum day (PPD) 1, bilateral headache without photophobia appeared. By PPD 3 pain was nonradiating, worsened with standing, and not improved with fluid or caffeine. Examination yielded no focal neurological deficits. Magnetic resonance imaging on PPD 3 demonstrated hyperintensity along the left frontoparietal convexity and left tentorium consistent with subdural hematoma (Fig. 1). Medical management included oxycodone/acetaminophen, tramadol, ibuprofen, and morphine until PPD 9. Computed tomography on PPD 7 revealed stability. Dural puncture is a common complication of epidural placement, with incidence of 0.3 % [1]. Pressure decrease results in traction on the meninges and vascular structures, yielding headache [2]. Infrequently, subdural hematoma occurs following low CSF pressure, causing vein dilatation and traction on bridging veins, resulting in tearing [2]. Prompt epidural blood patching may influence subdural hematoma formation by sealing the dural leak. Recently, advancing a catheter into the IT following dural puncture has been advocated [3]. Kuczkowski and Benumof recommended five steps: (1) injection of CSF into the IT through the needle; (2) insertion of an IT catheter; (3) continuous intrathecal labor analgesia; (4) leaving the catheter in situ for 12–20 h; and (5) injection of 3–5 ml preservative-free saline into the IT before removal [4]. Intrathecal catheter placement does not negate all risk. The anesthesiologist must frequently check for accidental catheter removal. Unrecognized displacement increases the risk of subdural hematoma [5]. Following intrathecal catheter analgesia, patients need frequent monitoring for early recognition of complications. Anticoagulation, cerebral atrophy, dehydration, arteriovenous malformations, and excessive CSF leakage [5] are M. S. Green S. George P. Green Department of Anesthesia, Hahnemann University Hospital, Drexel University College of Medicine, Philadelphia, PA, USA

Utilization of Smartphone Applications by Anesthesia Providers

Health care-related apps provide valuable facts and have added a new dimension to knowledge sharing. The purpose of this study is to understand the pattern of utilization of mobile apps specifically created for anesthesia providers. Smartphone app stores were searched, and a survey was sent to 416 anesthesia providers at 136 anesthesiology residency programs querying specific facets of application use. Among respondents, 11.4% never used, 12.4% used less than once per month, 6.0% used once per month, 12.1% used 2-3 times per month, 13.6% used once per week, 21% used 2-3 times per week, and 23.5% used daily. Dosage/pharmaceutical apps were rated the highest as most useful. 24.6% of the participants would pay less than

Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients

2.00, 25.1% would pay

Atraumatic intubation: experience using a 5.0 endotracheal tube without a stylet for laryngeal surgery.

5.00, 30.3% would pay

Endotracheal Cardiac Output Monitor in a Patient With Severe Tricuspid Regurgitation

5–

A case of postpartum coronary artery dissection managed surgically.

10.00, 9.6% would pay