Robert H. Bode

practice Guidelines for Management of the Difficult airway An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway

RACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for Management of the Difficult Airway: An Updated Report by

Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia

Background Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia, most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences. This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease. Methods Four hundred twenty‐three patients, between 1988 and 1991, were randomly assigned to receive general (n = 138), epidural (n = 149), or spinal anesthesia (n = 136) for femoral to distal artery bypass surgery. All patients were monitored with radial artery and pulmonary artery catheters. Postoperatively, patients were in a monitored setting for 48–72 h and had daily electrocardiograms for 4–5 days and creatine phosphokinase/isoenzymes every 8 h x 3, then daily for 4 days. Cardiac outcomes recorded were myocardial infarction, angina, and congestive heart failure. Results Baseline clinical characteristics were not different between anesthetic groups. Overall, the patient population included 86% who were diabetic, 69% with hypertension, 36% with a history of a prior myocardial infarction, and 41% with a history of smoking. Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received. In the intention to treat analysis, incidences of cardiac event or death for general, spinal, and epidural groups were 16.7%, 21.3%, and 15.4%, respectively. The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was ‐1.6% (95% confidence interval ‐9.2%, 6.1%) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia. Conclusions The choice of anesthesia, when delivered as described, does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery.

Anesthesia type does not influence early graft patency or limb salvage rates of lower extremity arterial bypass

PURPOSE The effect of anesthesia type on 30-day graft patency and limb salvage rates was evaluated in patients who underwent femoral to distal artery bypass. METHODS Of 423 patients randomly assigned to receive general, spinal, or epidural anesthetic, 76 did not meet protocol standards and 32 had inadequate anesthesia. A chart review of the remaining 315 patients was undertaken to obtain surgical information not recorded in the original study. All patients were monitored with radial and pulmonary artery catheters. After surgery, patients were in a monitored setting for 48 to 72 hours and had graft function assessments hourly during the first 24 hours and then every 8 hours until discharge. RESULTS Fifty-one patients were lost to follow-up (15 general, 22 spinal, 14 epidural). Baseline clinical characteristics were similar for the three groups except prior carotid artery surgery, which was more common in the spinal group. Indications for surgery were also similar except for a higher incidence of nonhealing ulcer in the epidural group. There were no differences among groups for 30-day graft patency with or without reoperation, 30-day graft occlusion, death, amputation, or length of hospital stay. CONCLUSION These results suggest that the type of anesthetic given for femoral to distal artery bypass does not significantly affect 30-day occlusion rate, limb salvage rate, or hospital length of stay.

Spinal anesthesia reduces oxygen consumption in diabetic patients prior to peripheral vascular surgery

Background and Objectives. The purpose of this study was to evaluate the effect of spinal anesthesia in &OV0312;2 in a uniform high‐risk patient population and also the relationship between dermatomal level of block and &OV0312;O2, neither of which has been investigated previously. Methods. The effect of spinal anesthesia on &OV0312;2 was studied in 17 diabetic patients undergoing lower limb peripheral vascular surgery. Measurements were made before and 15 minutes after administration of a tetracaine spinal anesthetic. Values for &OV0312;2 and oxygen delivery (&OV0312;O2) were derived from cardiac output as measured by thermodilution, hemoglobin concentration, and arterial and mixed venous blood gas analysis. The dermatomal level of the sensory block was determined by use of a hand‐held nerve stimulator. Results. Mean &OV0312;2 decreased by 27.7% (P = .001) (95% confidence limits, decrease of 22.4‐90.4%). Mean &U1E0A;O2 and arterial blood gases were unchanged, and the mean postspinal oxygen extraction ratio (&OV0312;O2/&U1E0A;O2) decreased by 20.5% (P = .002) (95% confidence limits, decrease of 9.1‐32.3%). There was a relationship between changes in &OV0312;O2 and sensory block height (P = .029). Conclusions. Spinal anesthesia in diabetic patients is associated with a reduction in &OV0312;O2, the extent of which appears to be, at least in part, a function of the level of spinal sensory block.

Age and History of Cardiac Disease as Risk Factors for Cardiac Complications After Peripheral Vascular Surgery in Diabetic Patients

OBJECTIVE To examine the relationship of age and clinical factors to postoperative cardiovascular events in a cohort of diabetic patients undergoing peripheral vascular surgery. PATIENTS AND METHODS In this cohort study, 316 diabetic patients were followed up prospectively after femoral-to-distal artery bypass surgery. The major end points of the study were all-cause mortality and cardiac morbidity (cardiac events defined as nonfatal myocardial infarction, unstable angina, and congestive heart failure). RESULTS The overall postoperative cardiac event rate was 17.1% (54/316), with a 7.6% (24/316) rate of postoperative death or nonfatal myocardial infarction. Older diabetic patients (> or = 65 years) had a complication rate of 19.9% (43/216) compared with an 11.0% (11/100) complication rate in younger diabetic patients (< 65 years) (P = .02). Younger diabetic patients with a clinical history of coronary artery disease had an event rate of 18.2% (39/216) compared with an event rate of 2.4% (1/42) in younger diabetic patients without known cardiac disease (P = .02). In contrast, event rates were similar (20.7% [150/208] vs 18.2% [66/108]) in older diabetic patients with or without prior evidence of cardiac disease. CONCLUSION Advanced age and clinical evidence of coronary artery disease are important determinants of postoperative outcome in diabetic patients undergoing peripheral vascular surgery.