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Trial Questions Steroids In Cardiac Surgery Drugs do not save lives, researchers find Boston—Steroids do not appear to reduce the risk for mortality, heart attack, stroke and other key outcomes in patients undergoing cardiac surgery, according to a large randomized trial of the therapy. Although some clinicians said the results offer proof that steroids should not be used in this patient population, others said subset analyses in the study and improvements in secondary end points are evidence steroids can benefit at least some see steroids page 24

Residual Paralysis: The Problem That Won’t Go Away

ixty years ago, Henry Knowles Beecher, MD, and Donald Todd, MD, published a provocative study in the Annals of Surgger e r y. T ery Th he study showed that patients given neu e ro romu omu musc scul ular ar blocking agents were six times as likelyy to di die iin n reccovvery as those who did not receive the druugs gs.. Mo Mostt Most of that excess mortality resulted from m respira r ra tory events. Six decades later, shockingly little has nts changed. As many as 100,000 patien annually in the United States suffeer respiratory complications and otheer adverse events after surgery because theey experience residual paralysis from neuroomuscular blocking agents, experts warn.. see residual page 28

INSIDE

Tissue-Engineering Anesthesiologist Redefines Stem Cells

o stem cells exist? When Charles Vacanti, MD, asks the question, one had better listen to the answer. After all, Dr. Vacanti, chair of anesthesiology, perioperative and pain medicine at Brigham and Women’s Hospital, in Boston, is a pioneer in tissue engineering and a leading expert in the field of stem cell research. But his response might come as a surprise: “I think not. I don’t think they naturally reside in tissue.” That’s not to say that stem cells cannot be generated. Indeed, Dr. Vacanti has come to believe that stem cells, which are thought to have the ability to become virtually any line of cell in the body, often are the byproduct of the methods researchers have been using to isolate them. Quite literally, they can

08 | COMMENTARY A Keynesian’s take on U.S. health care.

be shaken, stirred or chemically coaxed out of a dish. Previously, scientists have believed that stem cells either reside in the tissues or can be induced by genetic manipulation, dedifferentiating them and allowing them in effect to become blank slates. But in new, unpublished work, Dr. Vacanti’s group exposed various cell types to different forms of chemical and physical stresses—nearly killing them but performing no genetic manipulations, he said. Using a spectrographic analysis and green fluorescent imaging techniques, they observed that the stress caused

11 | PAIN MEDICINE Rise in newborn withdrawal as more pregnant women use opioids.

18 | TECHNOLOGY Robots, checklists and the future of anesthesia.

32 | CLINICAL ANESTHESIOLOGY Cutting back on unnecessary transfusions.

38 | AD LIB Sweet kisses and hammer blows—a history of self-experimentation in anesthesia (Part 1).

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Heard Here First: For an adult, the science shows there is a very narrow benefit to using one or two units of plasma, which

July 2012

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1. Ultrasound-Guided Central Venous Cannulation: Current Recommendations and Guidelines (Educational Review)

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C OR R E SP O NDENCE To the Editor: am responding on behalf of the American Board of Anesthesiology (ABA) to address information presented about the Maintenance of Certification in Anesthesiology (MOCA) program in the articles “Simulation and the MOCA (Parts 1 and 2),” published in the April and May 2012 issues of Anesthesiology News. The ABA MOCA program was developed at the request of the American Board of Medical Specialties (ABMS), of which the ABA is one of 24 member boards. The format and content of MOCA were developed to allow diplomates to demonstrate ongoing expertise in the core competencies of the practice of anesthesiology. Mandatory enrollment in MOCA was first implemented for those diplomates who received initial certification by the ABA on or after

Jan. 1, 2000. Before then, non–time-limited certificates were awarded since MOCA was not yet established. All diplomates certified before Jan. 1, 2000, are encouraged to voluntarily participate in MOCA, and many have done so. Since the program takes 10 years to complete, it is understandable that the efficacy of maintenance of certification programs with regard to improvement of patient outcomes has not yet been studied in anesthesiology or in many other specialties. However, the data that are available support the premise that “staying abreast of rapidly evolving medical and technological advances” can only enhance a physician’s practice. In her articles, Dr. [Tania] Haddad expresses concern that diplomates holding non–time-limited certificates are held to a different educational standard than those holding time-limited certificates. Our data

To the Editor: e read with interest the article by Jonathan L. Benumof, MD, and Benjamin T. Benumof, PhD, Esq, regarding the American Society of Anesthesiologists (ASA) Expert Witness Testimony Review Program. Unfortunately, it contains a host of inaccuracies and biased interpretations of case law. The authors are certainly entitled to their opinions, but we are disappointed that the description of their own experience with the ASA program includes patent falsehoods. For example, they claim the ASA “does not permit meaningful cross-examination of the investigators or the complainant. The respondent is not allowed to ask clarifying questions; false testimony and bias in the [committee], if it exists, can rule the review process completely unchallenged.” Not only does the ASA provide multiple opportunities to challenge reviewers and request recusals, cross-examination of investigators is permitted as well as dialogue with the hearing panel. In fact, both authors were permitted by ASA counsel to cross-examine an investigator despite the unorthodox nature of such “tag-team” cross-examination by both lawyer and client. The House of Delegates adopted the ASA

program after several ASA committees studied the issue. It is modeled after similar established programs of other national medical specialty societies, but includes a higher threshold for sanctioning a member. Concurrent with adoption of the program, ASA revised its Guidelines for Expert Witness Qualifications and Testimony. The preamble to those guidelines affirms support for objective, unbiased expert testimony in general, without distinguishing between plaintiff or defendant testimony: “The integrity of the litigation process in the United States depends in part on the honest, unbiased, responsible testimony of expert witnesses … The ASA supports the concept that such expert testimony by anesthesiologists should be readily available, objective, and unbiased.” We encourage readers to refer to the ASA Web site www.asahq.org for information on the Expert Witness Testimony Review Program. —Gregory K. Unruh, MD, and Jerry A. Cohen, MD

Dr. Unruh is chairman of the ASA Committee on Expert Witness Testimony Review. Dr. Cohen is ASA president. Editor’s note: Dr. and Mr. Benumof will respond to this letter in the August issue.

indicate that in the year 2015, the number of diplomates holding time-limited certificates and thus automatically enrolled in MOCA will outnumber diplomates holding non–time-limited certificates. Thereafter, a smaller minority of anesthesiology diplomates will hold a non–time-limited certificate. Some institutions already require all of their physicians to participate in maintenance of certification programs. In response to the expense of MOCA as reported in the articles, it must be noted that several of the costs cannot be solely attributed to participation in MOCA. The vast majority of diplomates must already complete continuing medical education (CME) activities to maintain their state medical licenses and/or meet their institutions’ requirements. Also, the author’s cost estimate of MOCA is inflated because the annual charge for membership in the American Society of Anesthesiologists (ASA) was included when 85% of practicing anesthesiologists are already ASA members. The ABA has elected not to develop and market its own CME products for MOCA to avoid any conflict of interest. By doing so, however, the board has no control over the cost of existing CME products which are used to fulfill MOCA requirements. The ABA understands that there is much anxiety surrounding the cognitive examination. While the examination may only be completed in years 7 through 10 of the MOCA cycle, it is important to note that diplomates are allowed to take the examination up to twice each year during that time. Results of the cognitive examination are reported only to the individual diplomate and are never published or disclosed otherwise. Of the first time-limitedd ABA diplomates—i.e., those certified in 2000 and 2001—95% have successfully completed the 10-yearr MOCA program. Simulation courses are valuable for anesthesiologists to refresh and assess their crisis management and life-savingg skills. This interactive learning method focuses on teamwork and communication in realistic patient care scenarios. The contextual learning environment targets performance improvement, and the participants are not graded. There currently are 31 ASA-endorsed simulation centers throughout the United States, making these conveniently located for most anesthesiologists. Furthermore, of the first 583 participants who completed simulation courses for MOCA, 99% reported that the course content was relevant to their practice, 94% reported that what they learned would change their practice and 97% reported that they would recommend the course to their colleagues. The ABA strives to improve MOCA for our diplomates based on feedback received. We encourage anesthesiologists to contact the ABA with any comments or questions about completing MOCA requirements. ABA staff also will be available to help our diplomates at the upcoming annual meetings of large anesthesiology organizations including those of the ASA, International Anesthesia Research Society, Society for Pediatric Anesthesia, PostGraduate Assembly of the New York State Society of Anesthesiologists and others. —J. Jeffrey Andrews, MD Dr. Andrews is acting secretary of the American Board of Anesthesiology.

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C OMM E NT A R Y

A Keynesian View of Health Care

hen people ask me my thoughts on health care, I tell them I am a Keynesian. John Maynard Keynes was the most influential economist in the United States in the early to mid-20th century—a time when, coincidentally, medicine began its ascent from the Dark Ages. Most importantly, his philosophy of economics comports

with my observations of the practice of medicine. Keynes wrote that “the theory of economics does not furnish a body of settled conclusions immediately applicable to policy. It is a method rather than a doctrine, an apparatus of the mind, a technique of thinking, which helps its possessors to draw correct conclusions.” During my 30-year career in

medicine, I have come to think about medicine in the same way. Medicine has very few settled conclusions. At its best, it is a method and a way of thinking that helps practitioners draw the right conclusions about the information at hand. Take the story of sepsis, for example. Just over a century ago, the concept of microorganisms as pathogens was first proposed and

then confirmed. Treatment started with public health measures to con-trol their spread. Laterr came the antimicrobials to eradicate the offendin ng organisms and then meaasures to treat the physioloo gic consequences of sepsis, such as fluid resuscitation and vasoactive agents. Next there were strategies aiimed at altering or neutralizing the cellular consequences of infection and, and more recently, we are taking the battle to both the molecular and genetic levels. What is the next frontier? Will it be nanotechnology or maybe something that we haven’t yet considered? A Method The overriding lesson learned by our changing approach to sepsis is that medical science is not an established and immutable collection of facts that we learn to master and continuously apply. Rather, like Keynes’ concept of economics, it is the method that we use to approach a problem. We make intelligent observations that guide our decisions. These decisions and the actions they provoke are appropriate until they are proven incorrect or something better comes along and then they should be abandoned as enthusiastically as they were initially accepted. There are certainly many more examples of the practice of medicine being an evolving science that is always changing. The only thing that stays the same is the process of making careful observations and then drawing conclusions about which treatments are likely to be effective. The practice of medicine is more than a static body of information with established solutions; it is a method.

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Health Care Delivery How about providing health care to our 300 million citizens? We can apply this same Keynesian philosophy to national health care delivery. There is no static right way to deliver care because the industry is constantly evolving and its objective, maintaining the health of our nation, is a moving target. Health care needs are determined by a set of shifting variables including an aging population; more sedentary lifestyles; increasing national obesity; the explosion of technology; and newfound interests such as patient safety, quality management and infection control. Many of these problems are being addressed by people and programs that didn’t exist 20 years ago,

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COMME N TA R Y ssocialist. Nothing could be further f from the truth. Keynes was a Cambbridge University don, married to a ballerina, and a member of the Bloomsbury Group, a collection of B eelite British writers and thinkers. He was a member of the landed gentry and w such as a true classic Adam Smith capitalist minimally who proposed his ideas to save capitalw invasive and robotic iism rather than oppose it. During the technolog y, patient ddifficult years of the U.S. depression, safety offices, quality man- w when socialism or communism were agement departments depa part rtm ment ment ntss orr infec infec- bbeing considered as viable alternatives tion control committees. Consequently, any plan to finance the health care industry that was conceived as recently as 20 years ago is no longer relevant. The initial strategies to finance this quickly evolving enterprise today seem almost quaint and the estimates of needed resources are woefully inadequate. This is a new industry that requires a new approach. The old paradigms of fee-for-service or socialized medicine have been tried and found to be inadequate. We are beyond them now and new strategies need to be designed. There are many in the planning phase, such as hybridized capitalistic/socialized systems, capitated plans with carve-outs, personal health insurance models, models employing salaried workers with incentive bonuses and so on. There are many new ideas. What seems clear is that we should never go back to the simple models of financing, such as pure fee-for-service or entirely socialized plans. They are as outdated and irrelevant today as the open wards of Florence Nightingale. The practice of medicine is changing rapidly and health care financing must continue to evolve to meet the demands of the industry. Interventionism Keynes argued that “private-sector decisions about the economy sometimes lead to bad macroeconomic outcomes for the economy.” He advocated for active policy responses by the government including monetary policy actions by a central bank and fiscal policy actions by the government. He recognized the competing needs caused by inflation on one hand and depression on the other hand. They occurred in cycles and Keynes tried to dampen the amplitude of these cycles by monetary policy. He would encourage deficit spending in a recession or depression but taxation and spending cuts during periods of inflation. Keynes’ ideas of government intervention left him open to the criticism that he was a populist or

to capitalism, interventional policies such as those proposed by Keynes saved our system. In medicine today, we are again navigating dangerous straits. We have a workforce shortage, underserved populations and problems that require more spending. At the same time, we have tremendous inflation, which suggests that we should tighten our belts. I think that if Keynes were making policy decisions today he would suggest that government intervention is

needed; I would agree with him. How can government intervention help? Here are some suggestions: Tort reform is a good place to start. I find it somewhat hypocritical that many of the physicians who think government should be out of our lives welcome its intervention with tort reform to protect us from predatory lawyers. Laws capping noneconomic or punitive damages should be adopted in all states. Eventually, I would like to see see Keynesian page 10

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C OMM E NT A R Y KEYNESIAN

or retired seniors who can afford the premiums without government assiscomplete reorganization of the tort tance. Some kind of means testing system to one in which a government- seems to be in order to bend the cost run, medical/legal board would adju- curve. The American Association of dicate all claims. An unregulated legal Retired Persons and lobbies sympaindustry will not make these correc- thetic to the elderly are powerful, and tions on its own. They are far more the only entity large enough to face off powerful than we are. We need the against them is the federal government. government in our corner. The U.S. Preventive Services Task Medicare/Medicaid currently Force is an organization funded accounts for 35% of all health care by the Department of Health and spending. Much of that is for working Human Services that is tasked with CONTINUED FROM PAGE 9

determining the utility of health care measures that we are now purchasing. Their shocking finding is that 15% to 30% of Medicare expenditures are for diagnostics or treatments that are of no proven benefit or are even harmful. This situation requires some difficult decisions that, with the current absence of direction from our profession, will have to be made by the government. Approximately 30% of Medicare payments cover the cost of care for

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people in the last year of life, much in the last few months. Some of this spending is understandable because one’s terminal illness is usually the most significant (and expensive) illness of one’s life. It is still an enormous expense, and there are strategies to decrease its impact on the health care budget such as a) increased use of advance directives, b) promoting hospice care, and c) withholding futile care. It will take courage to brave the politically inspired rhetoric and the shrill claims of creating death panels, pulling the plug on Granny and so forth. The people who are best positioned to do this are physicians working closely with the government to set up some medically sound ground rules. These are only a few of the many ways the government can and should intervene in our health care system. I believe government should be kept as small as possible and that its role should be to provide services that no one else can provide, such as national defense. Regulating, not owning, the health care industry is one of those tasks. It was the government that adopted regulations from the Flexner Report that made allopathic medicine a respected profession. A governmentrun public school system started Blue Cross/Blue Shield, the first medical insurance company, which has become the engine that drives our industry. Government stepped in, in 1965, with Medicare and Medicaid to increase access to health care for our most vulnerable citizens. More recently, it has helped to both curb health care inflation (e.g., resource-based relative value scales and diagnosis-related groups) and extend coverage (e.g., Medicare parts C and D). The government has paid for resident training, built hospitals, supported health care research and provided tax incentives for purchasing health care. Government has always been an important partner to the health care industry and, like a proactive Keynesian economist, it has intervened in times of crisis. Keynes’ economic philosophy was to support capitalism not to destroy it. Medicine, these f days, seems to be on a path of selfdestruction, and I think if Keynes were still with us, he would conclude that we need a proactive government to protect us from our own folly. —Jon C. White, MD Dr. White is professor of surgery at George Washington University and chief of surgery at the VA Medical Center, in Washington, D.C.

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PA IN M E D ICIN E

As Maternal Opiate Use Rises, so Does Newborn Withdrawal

rom 2000 to 2009 in the United States, the annual rate of mothers who used opiates at the time of delivery increased nearly fivefold, and the incidence of neonatal abstinence syndrome (NAS)— a drug withdrawal syndrome in newborns— rose almost threefold, according to a new study in the Journal of the American Medical Association (2012;307:1934-1940). Mean hospital costs for discharges with NAS also grew, with the bulk attributed to state Medicaid programs (77.6% in 2009). “By 2009, there were more than 13,000 infants born, or approximately one per hour across the United States, with signs of drug withdrawal,” said lead author Stephen Patrick, MD, MPH, fellow in neonatal-perinatal medicine at C.S. Mott Children’s Hospital, and Robert Wood Johnson Foundation Clinical Scholar at the University of Michigan, Ann Arbor. NAS is characterized by increased irritability, hypertonia, tremors, feeding intolerance, emesis, watery stools, seizures and respiratory distress. The growth in NAS incidence “wasn’t known before,” Dr. Patrickk said. “Studies in the past looked at certain geographic areas. This study gives a national perspective.”

The researchers conducted a retrospective, cross-sectional analysis of a nationally representative sample of newborns with NAS. From 2000 to 2009, antepartum maternal opiate use increased from 1.19 (95% confidence interval [CI], 1.01-1.35) to 5.63 (95% CI, 4.40-6.71) per 1,000 hospital births per year (P<0.001). In the same period, the incidence of NAS increased from 1.20 (95% CI, 1.04-1.37) to 3.39 (95% CI, 3.12-3.67) per 1,000 hospital births per year (P<0.001). Mean hospital charges for discharges with NAS rose from $39,400 (95% CI, $33,400$45,400) in 2000 to $53,400 (95% CI, $49,000$57,700) in 2009 (P<0.001). During this period, total hospital charges for NAS were estimated to have grown from $190 million (95% CI, $160-$230 million) to $720 million (95% CI, $640-$800 million), adjusted for inflation (P<0.001). Length of stay for NAS remained relatively unchanged (mean approximately 16 days) during the study period. “The main limitation in our study is that we were not able to tell from the data which opiate mothers were using or to what extent they were using them appropriately,” Dr. Patrickk said. “Mothers could have been using any opiate, including heroin, methadone or prescription opiate pain relievers.”

Marie J. Hayes, PhD, professor of psychology at the University of Maine, in Orono, who co-authored an editorial ((JAMA 2012;307:1974-1975) that accompanied the study, said in an interview that the research “highlights a very significant problem in the United States. We have a new pathway to opiate dependence through prescription opiate use.” Among those affected, Dr. Hayes said, are “young women of reproductive age who are socioeconomically disadvantaged. “Greater drug availability has led to a higher incidence of [NAS] and maternal dependence during pregnancy,” Dr. Hayes wrote. “It would be interesting to have more detail on local trends—which communities are most affected.” To address the issues raised by the study, Dr. Patrick said, “There is a need for broad-based public health investment, including statewide and nationwide efforts.” Dr. Hayes said, “There is not enough research on pharmacological methods to manage newborn withdrawal [and] what to do is not known. We need clinical trials. We also need better ways to measure the severity of NAS.” —George Ochoa Dr. Patrick reported no relevant financial disclosures. Dr. Hayes reported working on a device estimating the severity of neonatal abstinence syndrome.

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P A IN M E D I C I NE

Researchers Elucidate Risk Factors For Fatal Opioid Overdose, Call for Better Screening

hysicians can reduce the number of fatal prescription opioid overdoses through simple screens for psychiatric diagnoses and a history of illicit substance use prior to prescribing these drugs, researchers have found. Investigators from the University of Utah School of Medicine, in Salt Lake

City, interviewed the friends and families of Utah residents who had died of prescription opioid overdoses; they found that more than 80% of the decedents had received an opioid prescription from a health care provider in the year prior to their death. According to study investigator

Christina Porucznik, PhD, MSPH, the findings challenge the notion that many overdoses are due to misuse of diverted prescriptions. In fact, Dr. Porucznikk said the results suggest many of these opioid-related fatalities occur while individuals are under the care of a physician.

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“The fact that most patients received a prescription from a legitimate source suggests we can be doing a better job at preventing many of these deaths,” said Dr. Porucznik, assistant professor of family and preventive medicine. “One step is to use existing and validated screening tools to look for risk factors.” Given that the epidemic of opioid overdose fatalities is a relatively recent phenomenon, researchers are only now identifying factors associated with fatal opioid overdoses. To contribute to this effort, Dr. Porucznik and her team interviewed family members or friends Table. Selected Prescription Pain Medication Use, Misuse and Abuse Indicators Among Cases of Unintentional, Opioid-Related Deaths

Took prescription medications for pain during year before death Yes No Obtained pain medications from a health care provider during the last year of lifea Yes No Took pain medications more often than prescribedb Yes No Visited more than one doctor to get more prescription pain medicationa Yes No Received prescription pain medication from a source other than a health care provider Yes No Used prescription pain medications for reasons other than to treat pain Yes No Complained that provider was not prescribing enough pain medicationa Yes No

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Health care provider raised concerns about decedent’s use of pain medicationa Yes No Others were concerned about decedent’s use of pain medicationa Yes No a

Results were restricted to decedents who reportedly used prescription medication for pain during the last year of life. b

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AnesthesiologyNews.com I 13

PA IN M E D ICIN E of the 254 Utah residents recorded in the Utah Medical Examiner Database as having died between October 2008 and October 2009 from an overdose of at least one prescription opioid. They presented the most compelling findings at the 2012 annual meeting of the American Academy of Pain Medicine (abstract 202). Dr. Porucznik’s team discovered most decedents had reportedly suffered from ongoing chronic pain. Furthermore, according to the interviewees, most of these individuals had obtained an opioid prescription during the year prior to their death (Table). Slightly more than 50% of the interviewees said their deceased friend or family member had been diagnosed with a mental illness during their lifetime, whereas approximately 60% said the decedent had a history of illicit substance use. The investigators

Opioid-Related Drug Deaths (n=254) No.

222 20

91.7 8.3

204 18

91.9 8.1

82 73

52.9 47.1

62 134

31.6 68.4

91 139

39.6 60.4

64 151

29.8 70.2

46 172

21.1 78.9

66 137

32.5 67.5

166 54

75.5 24.6

also found a majority of interviewees reported the deceased had been unemployed for two months prior to their death. “We were surprised to find the high unemployment rate among this group, but it does fit with the fact that many of the individuals we included in this study had been reportedly living with chronic pain and were possibly disabled and unable to work,” Dr. Porucznik said. “Since we don’t know what the unemployment rate is

among chronic pain patients, we cannot say whether it is different than what we found in our study population. Nevertheless, the findings do suggest that asking about employment status as part of the screening process may help identify those most at risk for fatal overdose.” Sean Mackey, MD, chief of the Pain Management Division at Stanford University School of Medicine, in California, said the findings add important information, but they are limited by

the retrospective and interview-based nature of the study. “These factors need to be prospectively validated and ultimately developed into a predictive set of tools that can be used by the prescribing physiy who was not cian,” said Dr. Mackey, involved in the study. “While prescription opioids have a clear role in the management of chronic pain, we need to better identify those individuals most likely to misuse or abuse opioids.” —David Wild

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P OLI C Y & M A NAGEMENT

Academic Centers Suffer Inadequate Staffing, Technical Support

any U.S. academic anesthesia departments are reporting inadequate levels of professional staffing, technician and transport support, according to a recent survey of the nation’s department chairs. “Unfortunately a great number of academic centers are finding shortages in infrastructural support, which are leading to inefficiencies and potential

safety issues,” said study author Steven H. Ginsberg, MD, associate professor of anesthesia at the Robert Wood Johnson Medical School, in New Brunswick, N.J. “A lot of places are finding similar things.” Dr. Ginsbergg and his colleagues found, for instance, that nearly threefourths of respondents felt the main operating room was better stocked

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complexity on sicker patients and there is less support to do them,” he said. Technician support also drops “significantly” during off hours, he added— after 3 p.m., the median number of anesthesia sites each technician covers increased from 5.46 to 15.25; at least one-third of hospitals reported having no dedicated technician on the weekend. The American Society of Anesthesiology Technologists and Technicians (ASATT) recommends that each technician cover only four rooms (http://www.asatt.org/pdf/ PositionStatement99C18.pdf ). Impact on Mission, Quality of Life The shortages are having a negative effect: More than 48% of respondents said insufficient staffing had affected resident education, and 30% said workforce problems undermined patient safety, resulting from inadequate supervision. Nearly 40% said staffing problems had “created obstacles” for the ability of faculty to take vacations (Table). “I’m hoping that this information can be used for anesthesia departments to go to their administrations and let them know some things can be improved to enhance patient care and efficiency,” Dr. Ginsburgg told Anesthesiology News. The research team sent its 63-question survey to all 133 chairs of U.S. academic anesthesia departments. More than 60 responded, for a rate of 47%—which was not unexpected, Table. Staffing Shortfalls Taking a Broad Toll on Departments Nature of the Problem

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Institutions indicating that inadequate clinical staffing affects their ability to provide adequate faculty non-clinical time Institutions indicating that inadequate clinical staffing affects their ability to provide maximal resident educational experience Institutions indicating that inadequate staffing creates situations where patient safety is compromised secondary to suboptimal supervisory ratios

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Institutions indicating that inadequate staffing creates obstacles to providing vacation time for faculty Institutions reporting that they occasionally supervise three simultaneous anesthesia sites Institutions reporting that they supervise only one clinical site at a time

AnesthesiologyNews.com I 15

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POL ICY & M A N A G E ME N T Dr. Ginsbergg said. Many of the questions require some digging to answer. “When you have busy chairpersons, we were happy with this response rate.” Dr. Ginsbergg and his team presented their analyses of questions relating to professional staffing and anesthesia technician and transport support. Had he had conducted the same survey five or 10 years ago, the responses would have been quite different. “It’s a sign of the times,” he said, noting that most facilities have had to cut back because of reductions in reimbursements to physicians and hospitals. “There is a confluence of economic events and trends that will challenge the ability of academic anesthesia departments to maintain their academic identity and provide safe clinical care for our patients. We hope that this survey will help to identify some of the specific issues that we currently face, and help us to prepare for future challenges,” Dr. Ginsbergg said. In additional findings, the median sites covered by each dedicated patient transporter increased from 7.5 to 16.5 after 3 p.m. Nearly three-fourths of the respondents said they believed inadequate transport had caused delays in the main operating room—which cost the department and hospital money, Dr. Ginsbergg said. Furthermore, 6% of institutions said they occasionally ask one faculty member to supervise three anesthesia locations at once; staffing those locations with residents would violate coverage standards from the Accreditation Council for Graduate Medical Education.

Number of Responses

1.7

These findings are no surprise, said James H. Abernathy III, MD, MPH, chief of cardiothoracic anesthesiology at the Medical University of South Carolina. “I think this has been the plight of the academic anesthesia department for a long time.” y the low Still, added Dr. Abernathy, response rate means it’s possible that the remaining 53% of programs had fewer staffing issues, and thus less incentive to complete the survey. “I

would have liked to have seen the missing responses before I could draw national conclusions from these results,” he said. Yet if the results are representative, the most worrisome is the finding that nearly three-fourths of institutions said that inadequate staffing had made it difficult to provide their anesthesiologists with nonclinical time, Dr. Abernathy said. “For the specialty to continue, to evolve, to grow,

academic anesthesiologists need time to develop research careers, and education careers, to educate the next generation of anesthesiologists,” he said. “If we are not able to provide that time, I’m afraid we will lose the next generation of educators and leaders.” The survey results were presented at the 2011 PostGraduate Assembly in Anesthesiology (abstracts P-9131 and P-9132). —Alison McCook

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P OLI C Y & M A NAGEMENT

Anesthesiologists Unprepared for OR Fires, Survey Finds

nesthesiologists are woefully unprepared to carry out emergency procedures in case of fires in the operating room, a recent survey shows. According to the survey, only 10% of anesthesia providers were able to locate their OR’s fire extinguisher. Steven Barker, MD, PhD, who has served on the American Society of Anesthesiologists Task Force on Operating Room Fires, called the results “disappointing but not surprising. While the study was done in only one hospital operating suite that may not be representative of operating suites nationally, I suspect results from a multi-center study would be equally disappointing.” Dr. Barker was not involved in the survey. The results were presented at the 2012 World Congress of Anesthesiologists (abstract 466). Lead researcher Charles Cowles, MD, chief safety officer of perioperative enterprise at the University of Texas MD Anderson Cancer Center, in

Houston, said hospital staff are encouraged to remember the “RACE-PASS” mnemonic for fire safety procedure. However, he said, theoretical knowledge of fire safety procedures may not be matched by the ability to implement the RACE-PASS steps. To test his hypothesis, Dr. Cowles and a colleague asked 118 OR and procedure room staff at the University of Texas Houston Affiliated Hospitals, where Dr. Cowles was employed at the time of the study, to complete a questionnaire. Respondents were queried about their level of fire safety training and whether they could locate fire safety equipment in their work environment. Fifty-six of the survey respondents were anesthesiologists, anesthesia residents and certified registered nurse anesthetists. The rest were surgeons, surgical technologists and circulating nurses. The survey responses showed 10.7% (six of 56) of anesthesia providers could locate the nearest fire extinguisher, whereas only 5.4% (three of 56) could

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Table. Operating Room Fire Preparedness by Provider Specialty Anesthesia Providers (n=56)

Surgical Surgeons Technicians (n=17) (n=17)

Circulating Nurses (n=28)

Had formal education pertaining to OR fires

46.4% (26/56)

23.5% (4/17)

82.4% (14/17)

92.9% (26/28)

Could locate the nearest fire extinguisher

10.7% (6/56)

5.9% (1/17)

41.2% (7/17)

28.6% (8/28)

Could locate the gas cut-off

25% (14/56)

11.8% (2/17)

52.9% (9/17)

60.7% (17/28)

Could locate the nearest alarm pull station

5.4% (3/56)

11.8% (2/17)

23.5% (4/17)

10.7% (3/28)

RACE and PASS R escue anyone in immediate danger A ctivate the Alarm C onfine the fire (close the door) E xtinguish small controllable fires/or E vacuate P ull the pin A im the nozzle at the base of the fire S queeze handle S weep from side to side

identify the nearest alarm pull station. This was despite 46.4% (26 of 56) having received formal OR fire safety education, Dr. Cowles said. Only one in four (14 of 56) anesthesia providers were able to locate the gas cut-offf in their work environment (Table). Circulating nurses and surgical technicians were most prepared in case of a workplace fire, the researchers found. Dr. Cowles said one reason OR staff may not be acquainted with the location of fire safety equipment is that institutional safety departments sometimes overlook the OR when conducting inspections and performing drills. “There is a sense that it’s better not to intrude into operating rooms, which are sterile and very busy, so safety team members may choose to avoid them,” Dr. Cowles told Anesthesiology News. “However, we found that a collaboration between our environmental safety department, anesthesiologists and nurses, to coordinate a fire safety

drill, worked well. The operating room does not have to be a black box and offf limits, as safety inspectors tend to think.” Dr. Cowles agreed with Dr. Barker that although his study only included ORs at one institution, the results likely apply to other centers. He urged other institutions to conduct similar surveys at their ORs, saying the exercise in itself increased familiarity with fire safety processes and equipment. —David Wild

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TE CH N OL OG Y

Continuous Hemoglobin Monitor Accurate in Peds Surgery

non-invasive monitor provides accurate, timely and continuous measurements of total hemoglobin in pediatric patients undergoing brain surgery, investigators have found. “Non-invasive hemoglobin measurement has been evaluated in adult populations but not at all in pediatric populations,” said Lindsey LovelandBaptist, MD, assistant professor of pediatric anesthesiology at Children’s Hospital of Wisconsin, in Milwaukee. As part of a quality improvement project, the Wisconsin group evaluated the use of continuous non-invasive hemoglobin monitors in children undergoing cranial vault remodeling. These patients experience substantial blood loss and require regular transfusions and frequent laboratory hemoglobin assessment. “In general, blood loss in cranial-vault cases is difficult to estimate,” Dr. Loveland-Baptist said. “Overtransfusions and undertransfusions are [common] in this setting.” Although point-off care testing is possible, it is not always feasible. “There’s a significant lag time between drawing arterial blood gas, sending the sample to the lab and getting it back while the patient beside you might have already lost a considerable amount of blood. So an accurate, continuous readout of hemoglobin would be very useful in this patient population.” The trial included 11 patients (aged 5 to 25 months), each of whom had an arterial line. Arterial blood gases were obtained as indicated clinically throughout the procedure. Total hemoglobin readings were recorded at the same time, using the Masimo Radical-7 (Masimo) monitor. The morning after surgery, a blood sample was drawn for laboratory hemoglobin and the probe value was simultaneously measured in an awake patient. Hemoglobin values from 51 data points ranged averaged 11.6 g/dL, according to the researchers, who presented their findings at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 050). Regression analysis revealed an r2 value (for correlation) of 0.67 within subjects and 0.47 between subjects. “The device trended very well in individual patients,” Dr. Loveland-Baptist explained. “However, when we looked at the entire group, the correlation wasn’t quite as tight. Variability of one or two hematocrit points is expected on a sample sent to the laboratory, so

to have a variability of two points in a non-invasive device is not a problem.” Athough the device occasionally required repositioning, signal quality rarely was poor. “Everyone who used it said they were interested in using it for future cases,” Dr. Loveland-Baptist said. Hilary P. Grocott, MD, professor of anesthesia and surgery at the University of Manitoba, in Winnipeg,

Canada, said non-invasive hemoglobin measurement has regularly demonstrated its utility in the operating room. “One would think that with an arterial line present and the relatively rapid point-off care hematocrit testing readily available, this non-invasive technology would have limited utility,” Dr. Grocott said. “However, when things are changing rapidly, even taking a few minutes

to withdraw and process a blood sample can be difficult. Having a noninvasive, real-time measurement of hemoglobin in these clinically tenuous situations not only helps the patients, but removes one of the uncertainties of clinical practice, which can be anxietyprovokingg to the anesthesiologist.” —Michael Vlessides

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T E C H NO L O G Y

Panel Looks Forward to Role of Automation in Anesthesi Boston—Robots may not replace anesthesiologists in the near future, but improved monitoring, carefully crafted checklists and automation all promise to bring changes to the field, according to panelists at the 2012 annual meeting of the International Anesthesia Research Society. A session titled “Exploring the Future of Anesthesia Technology”

featured talks by Kirk Shelley, MD, PhD, of Yale School of Medicine, in New Haven, Conn., and Brian Rothman, MD, medical director of perioperative informatics at Vanderbilt University Medical Center, in Nashville, Tenn. Thomas M. Hemmerling, MD, of McGill University Health System in Montreal, also spoke. He and his team

recently developed a robotic intubation device called the Kepler Intubation System. He said he stocks his presentations with two slides to help answer the question about whether robots will take over anesthesia: the “politically correct” slide, in which the answer is no; “then there is my version—not for now.” Robots, he said, “should be our future in anesthesia.” Examples include “closed-loop

systems” like the CLADSS system that uses feedback control from bispectral index monitors (BISS, Covidien) to administer propofol. He also discussed his McSleepy, a cloosed-loop system that automatically controls hypnosis, analgesia and muscle relaxation. The device, which can be fully or semi-automateed, features a touch screen and voice feedback. “It ne is actutells you what the machin ally doing at each stagee of the induction, Dr. Hemmerlin ng said. Dr. Hemmerlingg and his colleagues also are developping a robotic device, called thee Mag a elllan, to perform nerve blockks. The United States lags l bbehind hi d other nations in the adoption of robotic systems to deliver anesthesia, Dr. Hemmerlingg said. That puts anesthesiologists behind other specialties, like surgery and possibly gastroenterology. Dr. Hemmerlingg predicted that the FDA soon would approve the pending reapplication for Sedasys ( Johnson & Johnson), a computerassisted system that administers propofol for use during colonoscopies and upper gastrointestinal procedures. “We really have to wake up in anesthesia and drive this development,” Dr. Hemmerlingg said. “If not, it will be driven for us. And, usually, that’s not a very good sign.” ‘Patent Everything’ Dr. Shelley, y who said his obsession is patient monitoring, talked about two other aspects of new technology— licensing and outcomes research. He said he had no conflicts of interest to report, because he does not like to sign company nondisclosure agreements. “Once I do that as an inventor, I’ve basically lost the ability to do research in that direction,” he said. At the same time, he encouraged academic inventors to “patent everything” and see the process as a “$10,000 lottery ticket,” because only one in 100 patents ever pays royalties. Dr. Shelleyy predicted future technology will be noninvasive and designed to lower costs, lower complication rates and reduce training time. He suggests inventors keep to simple ideas: “Once we understand the physiology, can we monitor it.” This part is easy, he said. “Digital signal processing has extraordinary power. We have incredible computers and we have an incredible ability to isolate, modify and amplify signals.”

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TE CH N OL OG Y ‘People throw the checklist at everything these days. You have to have a checklist that really solves problems. It’s not just technology.’ —Brian Rothman, MD The next question to ask, Dr. Shelley said sa id, is “Does id i t c ha it hange the outtcomes?” ou “Thatt turns “Th t outt to t bbe a remarkk ably complex problem,” he said. “We’re not very good at this step of it.” So far, he said, outcomes studies of pulse oximetry have been “disappointing.” In his opinion, the results from the Cochrane Review and similar studies reflect “the weakness of this concept of an outcome.” Make a List Safety is the goal of Vanderbilt’s perioperative informatics system of electronic charting. Dr. Rothman, who runs the program at Vanderbilt University Medical Center, explained how the system’s timeout checklist has been built into the center’s electronic charting system. “People throw the checklist at everything these days,” Dr. Rothman said. “You have to have a checklist that really solves problems. It’s not just technology.” It’s about educating the users and changing the culture to help technology accomplish what it should, he added. It is important to understand how to improve implementation, adoption and adherence for any checklist to be successful, Dr. Rothman said. By addressing skeptical stakeholders, end users learn how the checklist addresses problems in their environment. That way, they understand why they should perform the checklist every time. It can then become part of their daily culture, Dr. Rothman added. One key step is to customize the list, he said. For example, the model checklist from the World Health Organization has 19 items; Vanderbilt’s list has 12. Details are important. Dr. Rothman’s team brought in designers to work on fonts and graphics to improve readability.

“You take someone else’s tool and adapt it to your workflow, your environment, your culture,” Dr. Rothman said. “And when you adapt it, they own it.” That way, a group is more likely to use it correctly and consistently, he added. At the same time, he emphasized that information technology is not meant to replace communication: “It is meant to foster, reinforce and support communication.”

The technologies discussed by Drs. Shelleyy and Rothman have immediate application, whereas some of Dr. Hemmerling’s devices “are clearly in the future, maybe the distant future,” said John Doyle, MD, PhD, of the Cleveland Clinic, in Ohio, who moderated the panel. “You need people like [Dr.] Hemmerling to explore the fringes,” said Dr. Doyle, a member of the editorial board of Anesthesiology News. —Tinker Ready

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T E C H NO L O G Y

Video Eases Presurgery Anxiety for Peds

laying video clips during the induction of inhalational anesthesia is an effective way to reduce anxiety in children undergoing ambulatory surgery, researchers have found. The study concluded that anxiety decreased more in children who were exposed to video distraction than it did among patients provided standard distraction practices—building rapport, blowing up a balloon, joking. “We recently renovated our operating rooms, and quite a few monitors were installed for surgeons to use during endoscopic and laparoscopic procedures,” said Thomas Hackmann, MD, assistant professor of anesthesiology at Dalhousie University Medical School, in Halifax, Nova Scotia, Canada, who led the study. “And we have the opportunity to feed Internet content into these monitors, which can be moved just about anywhere in the operating room.” Dr. Hackmann and his colleagues observed that when they played YouTube videos—popular movie trailers that kids might be interested in, like “Finding Nemo” or “Ice Age”—the children responded well when given a face mask during induction of anesthesia. To quantify the observation, the researchers obtained parental consent for 89 children (ages 2-10 years). The children were randomly assigned to either the video distraction or control groups. Patients in the video distraction group watched a

video clip of the child’s preference during induction. “We asked them to lie on the table, brought the screen close to their faces and asked them to watch the video,” Dr. Hackmann said. “When we see them before the case, we ask them what they like to watch at home.” In the control group, pediatric anesthesiologists used common distraction techniques—joking around with the kids, telling a story, blowing up a balloon. The investigators used the modified Yale Perioperative Anxiety Scale to assess anxiety. The children in the two groups were similar in terms of age (4.75±2.2 years) and anxiety scores before entering the operating rooms. “The results speak for themselves,” Dr. Hackmann said. “They showed that although the groups had comparable levels of anxiety in the holding area, the children who didn’t watch the video saw their anxiety actually go up during induction, whereas it went down slightly in the children who watched the video [P<0.001].” Statistics aside, Dr. Hackmann said most children become so engrossed in what they are watching that they forget about the anesthetic. “Most of us who work with children know that we don’t just put the mask on the face right away. We hold the mask close to the face and let the child feel your fingers on their chin, or the mask close to their face and then gently bring it to their

face once they become less aware waree off it. This T s is i easier eaas asier asi sie si sieer er in children who are focusing on the vid video” vide deo eo.. Given these encouraging results results, D Dr. Ha Dr H Hack ackm ackmann nn n was quick to recommend that othe other h r institutions insti tiitut ituti it tiio ion ons ns co ns conon nsider employing this strategy in children dren dren. en n. ““If If yyou If oouu h ha hav have ave the technology, then it comes in very handy, ndy, nd dy, dy, dy y,” h y” hee sa ssai said said. aaiiiddd.. “I “I would say try it; I think you’ll be pleasantl tly tl lyy surprise surpr su urprise urpris urpri rpr rp ppri pr rris ri ise iis seeddd”.” se Peter J. Davis, MD, professor of anesthesiology i l att th tthe h Children’s Hospital of Pittsburgh, said any type of distraction is beneficial when it comes to children. But he questioned what kind of effect, if any, such measures have on postoperative behavior. “Children demonstrate ‘abnormal behavior’ for a good couple of weeks after undergoing surgery, which manifests itself in a variety of ways,” said Dr. Davis, a member of the editorial board of Anesthesiology News. “To me, that becomes one of the hallmarks for whether these practices have value. “I’m not saying they don’t inherently have value,” Dr. Davis continued. “You can argue that it’s a good thing any time we can reduce anxiety in children. But if I reduce anxiety at the time of induction, does it reduce emergence delirium in the recovery room? Does it change behavior when these kids go home?” The researchers reported their findings at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 586). —Michael Vlessides

Electronic Alerts Improve Prevention of Hypothermia

lectronic reminders can increase the number of patients with postoperative normothermia and significantly improve adherence to published hypothermia prevention guidelines, researchers have found. “Rarely does something so simple and so inexpensive result in such a significant improvement in a perioperative goal,” said lead investigator Robert Bolash, MD, a resident in the Department of Anesthesiology at St. Luke’sRoosevelt Hospital Center in New York City. “Executing any change in standard operating procedures is typically expensive, labor-intensive and difficult to implement. This reminder proved to be just the opposite.” The study found that the reminder improved clinicians’ compliance with guidelines on perioperative normothermia from the Surgical Care Improvement Project (SCIP)—a measure that hospitals and insurers are increasingly taking note of, Dr. Bolash said. The SCIP guidelines recommend that physicians use forced-air warming or circulating water garments intraoperatively or that they achieve a target temperature of 96.8 F within 30 minutes immediately before, or 15 minutes

after, the end of anesthesia (www.qualitynet.org). After noticing variable rates of guideline compliance at his institution, Dr. Bolash and senior investigator David Kramer, MD, assistant professor of anesthesiology at St. Luke’sRoosevelt, set out to investigate the effect on hypothermia rates when the perioperative hypothermia prevention reminder was used. The system was added to their anesthesia information management system (AIMS) in 2010. The researchers, who reported their findings at the 2012 annual meeting of the Society for Technology in Anesthesia (abstract 48), retrospectively compared body temperature immediately after surgery in 14,415 procedures conducted since the reminder system was put in place with 11,250 historical controls whose procedures were performed prior to the system’s implementation. The analysis included all electronically documented operating room procedures, interventional radiology procedures and cesarean deliveries performed under general and regional anesthesia. It excluded shorter procedures such as cardioversions or tracheostomies in the intensive care unit, as well as

labor analgesics for vaginal deliveries. Sex, age and physical status scores were comparable in the pre- and postintervention groups. Anesthetics were administered for an average of 138 minutes in the preintervention group and 127 minutes in the postintervention group, a statistically insignificant difference. A temperature of 96.8 F (36 C) was achieved within the SCIP-prescribed time frame in 99% of the postimplementation cases compared with 67.2% of pre-implementation cases (P<0.01), according to the researchers. Mean body temperature immediately after surgery rose from 97.2 F (36.2 C) before the intervention to 98 F (36.6 C) after it (P<0.01). Dr. Bolash and his colleagues did not compare rates of surgical wound infection, length of hospital stay, intraoperative blood loss, drug metabolism or time spent in the postanesthesia care unit, all of which are complications of perioperative hypothermia. However, he said these outcomes likely also would be improved, given the established association. David P. Martin, MD, PhD, vice chair for safety and quality, and associate

professor in the Department of Anesthesiology at Mayo Clinic in Rochester, Minn., who was not involved in the study, called the findings relevant and said interventions like this should be investigated further. “Normothermia is an increasing priority during the perioperative period, both for regulatory reasons and because normothermic patients experience fewer complications,” said Dr. Martin, chair of the American Society of Anesthesiologists’ Patient Safety Editorial Board. “Although these findings are of interest, because this study was not randomized and prospective, the authors were not able to prove causation between the reminder and lower hypothermia rates.” —David Wild

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AnesthesiologyNews.com I 23

J U LY 2 0 1 2

CL IN ICA L A N E STH E SIOL OG Y

Upright Shoulder Surgery Found Safe in Large Analysis

everal well-publicized cases of devastating neurologic injury have raised questions about the safety of the beach-chair position during shoulder surgery, but an analysis by Pittsburgh researchers of more than 13,500 patients offers reassurance about the procedure. The study found that the risk for severe neurologic injury among patients in the beach-chair position is no higher—and likely substantially lower—than one in 2,500 cases. The clinicians also noted that the position facilitates the use of regional anesthesia and sedation, thereby minimizing adverse effects from anesthesia and providing excellent postoperative pain control. Preference for the beach-chair position arose in recent decades largely out of concern that patients in the lateral position were prone to brachial plexus injury, said Max E. Rohrbaugh, MD, anesthesia resident at the University of Pittsburgh Medical Center (UPMC), who helped conduct the study. “But in 2005, there was a series of four cases in people who had shoulder surgery in the beach-chair position and didn’t wake up from their general anesthesia because of devastating neurological complications, probably related to cerebral hypoperfusion. So we all worry about this quite a lot.” However, Dr. Rohrbaugh said, despite the worrying case reports, clinical experience suggests the incidence of “devastating events” is rare. “We wanted to see if we could look back at our data to get any idea of the true frequency of these types of complications.”

Dr. Rohrbaugh and his colleagues examined the records of 13,512 patients undergoing shoulder surgery in the beach-chair position at UPMC between April 2001 and October 2010. More than 99% of these patients received a preoperative interscalene block, followed by intravenous sedation with propofol, oxygen by face mask and spontaneous respiration. Complication rates were compiled from the institution’s existing quality improvement database over the same period; the denominator of cases was confirmed by reviewing de-identified department billing records. As reported at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 235), 37 adverse events were recorded (Table). “I can comfortably say that the upper limit of the 95% confidence interval for severe neurologic complications is not more than one in 2,500 or so, and likely much less than that,” Dr. Rohrbaugh noted. “But at least that’s some kind of number that we can use.” The investigators described two cases of emergent airway compromise, both of which resulted from rapid spread of subcutaneous arthroscopic irrigation fluid. “I personally provided the nerve block for one of these patients who went in with a normal-looking head and neck and came out with tremendous swelling in the submandibular region. It had spread rapidly from her shoulder straight over,” Dr. Rohrbaugh

Table. Complications Observed in Beach-Chair Procedures Adverse Event

Number

Comments

Frequency

Emergent intubation during case

Both due to soft tissue swelling in neck

0.015

Apparent respiratory distress treated without intubation

one documented as bronchospasm, one as laryngospasm

0.015

Apnea during performance of nerve block

Perceived as excessive sedation

0.0074

Seizure or recognized local anesthetic toxicity without seizure

Persistent phrenic nerve injury

Diagnosed three months after the case

0.0074

Minor but persistent nerve injury (>3 mo)

Sensory only

0.037

CNS injury or stroke within 24 hours

CNS injury or stroke within 48 hours

Focal middle cerebral artery ischemia manifested postoperative day 1 after normal PACU course and same-day discharge

0.0074

Cognitive dysfunction in the context of dementia or persistent sedation

Gradual return to baseline

0.022

Persistent headache or tinnitus

0.015

Cardiac arrest

Myocardial infarction within 48 hours

0.0074

Dysrhythmia or hypotension

Other drug reaction

Other unexpected admission

TOTAL

0.067

one brief VT, one bigeminy, four causing delay or pressor infusion

0.044 0.0074

Dyspnea, low pulse oximetry, PONV

C S, ce CNS, central t a nervous e ous syste system; y ; PACU, CU, posta postanesthesia est es a ca caree uunit; t; PONV, O , postope p postoperative p at e nausea ausea and a d vomiting; o t g; VT,, ventricular e t cu a tac tachycardia yca y da

0.022 0.27

said. “This is a key complication to be aware of if you’re going to use this position for shoulder arthroscopy with a natural airway.” The investigators were quick to point out

that other clinicians may hesitate before extrapolating the UPMC data to their own institutions. First, the overwhelming majority of cases were performed under regional anesthesia with preserved spontaneous ventilation. In addition, clinicians at UPMC agree on routine treatment thresholds for hypotension at systolic blood pressure below 90 mm Hg or mean arterial pressure below 60 mm Hg, and for bradycardia below 40 beats per minute. “Many people use this position with general anesthesia with a volatile anesthetic, an endotracheal tube and positive pressure ventilation,” Dr. Rohrbaugh said. “In those instances, the combination of upright position, volatile anesthetic–induced vasodilatation and cardiosuppression, and increased intrathoracic pressure could lead to decreased cerebral blood flow, thereby causing more central nervous system morbidity than occurred in the series.” Robert M. Raw, MD, clinical associate professor of anesthesiology at the University of Iowa, in Iowa City, said the UPMC study was limited by both its long duration—over which time providers and practices can change—and its retrospective nature. Associations revealed in the study do not guarantee that the beach-chair position or any other aspect of anesthesia management had any direct influence on outcomes. “However, in the dearth of multiple good series data, this study acquires importance and is well w said. worth a look at and contemplating,” Dr. Raw “It invites other centers to similarly review their own data. Nobody would dispute that a sitting position challenges maintenance of adequate blood pressure for patient safety during anesthesia.” Dr. Raw w said he was particularly interested to see the airway complications related to escaped arthroscopic fluid. “We don’t recall an airway concern at our institution despite seeing some amazingly swollen forequarters after arthroscopic surgery,” he said. “We will, however, draw added caution about airway care in our practice from this study.” —Michael Vlessides

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CLI NI CA L A NESTH E SIOL OG Y STEROIDS

CONTINUED FROM PAGE 1

patients undergoing cardiac surgery. “We did not find an effect on the primary end point, although you might say there is a clear trend toward benefit,” said Stefan Dieleman, MD, anesthesiology resident at the University Medical Center Utrecht, in The Netherlands, who helped conduct the study. Dr. Dieleman presented his group’s findings at the 2012 annual meeting of the Society of Cardiovascular Anesthesiologists (SCA). David Mazer, MD, professor and vice-chair for research in the Department of Anesthesia at the University of Toronto, Ontario, Canada, said the Dutch findings are not the last word on the matter. “This study provides intriguing, provocative information, but it doesn’t definitively answer the question yet about whether steroids should be used in this population,” said Dr. Mazer, r an investigator in the ongoing SIRS (Steroids in Cardiac Surgery Trial) study. “Because of the directionality of the results and the subset analyses, I think the question is still not settled.” Further clarity will come from SIRS, he said. Common Practice, But Evidence Lacking During heart surgery, many clinicians administer high doses of corticosteroids to reduce the systemic inflammatory response that can occur during the procedure and potentially decrease multiorgan system dysfunction. This practice is controversial as the benefit is unclear and the drugs carry potential side effects such as hyperglycemia, gastrointestinal bleeding, increased risk for infections, impaired wound healing, increased serum lactate and prolonged extubation time.

Since 2008, no fewer than four meta-analyses have concluded that only a sufficiently powered randomized trial could illuminate the effects of prophylactic steroids in adult patients undergoing cardiac surgery and cardiopulmonary bypass (Eur Heart J 2008;29:2592-2600; Circulation 2009; 119:1853-1866; J Cardiothorac Vasc Anesth 2010;25:156-165; Cochrane Database Syst Rev 2011;5:CD005566). The DECS (Dexamethasone for Cardiac Surgery) trial presented at SCA was launched in 2006 and involved eight Dutch medical centers. The multicenter trial enrolled nearly 4,500 patients undergoing elective or semi-elective on-pump cardiac surgery. Half received 1 mg/kg of dexamethasone after induction of anesthesia, and the other half received placebo. In each arm of the study, roughly 40% of patients underwent coronary artery bypass graft surgery (CABG), 20% underwent CABG plus another procedure and 40% underwent a cardiac procedure other than CABG. The researchers hypothesized that dexamethasone could provide a 2% absolute risk reduction in the primary end point, defined as a 30-dayy composite of mortality, myocardial infarction, stroke, acute renal failure and ventilation lasting more than 48 hours. Upon analysis, the researchers found a 1.5% difference in the composite end point favoring dexamethasone, but the effect was not statistically significant (P=0.065). Mortality was similar in both arms (1.4% vs. 1.5%). In the prespecified subgroups, however, the researchers identified a statistically significant benefit in the composite primary end point for patients with a EuroScore of 5 or higher, and for those younger than age 65 years. Surprisingly, the investigators said, they found a trend toward

‘The results of the DECS trial will significantly influence which patient groups should receive steroids during heart surgery with cardiopulmonary bypass.’ — John Augoustides, MD

AnesthesiologyNews.com I 25

J U LY 2 0 1 2

CL IN ICA L A N E STH E SIOL OG Y a harmful effect in patients older than age 80 years. EuroScore is a method of calculating predicted operative mortality for patients undergoing cardiac surgery. Patients receiving dexamethasone spent less time on mechanical ventilation, had shorter stays in the intensive care unit and hospital and exhibited less evidence of delirium after surgery. Another surprise was that patients who received dexamethasone were less, not more, likely to develop infections. Dr. Dieleman said that he was disappointed that the study failed to reach the primary end point, but that he considered the benefits in the secondary end points relevant. He is now using steroids in his patients who are younger than age 75 years, regardless of their EuroScore. Mark Chaney, MD, director of cardiac anesthesia at the University of Chicago Medical Center, said the evidence for steroid use in cardiac patients simply was not there. “Certainly, most people believe that attenuating the systemic inflammatory response will likely be beneficial, but the studies have not clearly shown that it is truly clinically beneficial,” he said. John Augoustides, MD, associate professor of anesthesiology and critical care at the University of Pennsylvania, in Philadelphia, said clinicians in the United States likely will pay attention to the Dutch findings. “The results of the DECS trial will significantly influence which patient groups should receive steroids during heart surgery with cardiopulmonary bypass,” Dr. Augoustides said. “The preliminary data from the DECS trial suggest that the benefits of steroids in cardiac surgery with cardiopulmonary bypass may be maximized in high-risk patients.” Dr. Augoustides said he would use corticosteroids in certain patients, such as those who undergo aortic arch reconstruction under deep hypothermic circulatory arrest. Waiting for SIRS Dr. Mazer noted that including prolonged ventilation in the composite end point with other more clinically relevant outcomes such as mortality and stroke might contribute to the controversy about whether steroids are beneficial. Currently, he said, he uses steroids only in patients with deep hypothermic circulatory arrest and cardiac surgery patients who already are receiving the drugs for other indications. He said the DECS findings would not change his practice.

Dr. Mazer added that he was “intrigued” by the lower incidence of delirium and infection in patients who received dexamethasone, but also pointed out there seemed to be a paradox in the study, given that age is an important factor in the EuroScore. “The paradox in the DECS study is that elderly patients had a higher mortality, but yet higher EuroScore patients had a better outcome,” he said. “But the SIRS study should definitely answer the question of whether

or not higher-risk patients should get steroids, because SIRS is only enrolling patients with a EuroScore greater than 5.” The SIRS trial is an international, randomized, double-blind, placebocontrolled trial of adult patients undergoing cardiopulmonary bypass surgery led by Richard Whitlock, MD, assistant professor of cardiac surgery at McMaster University, in Hamilton, Ontario, Canada. Patients in the study receive a placebo or 500 mg

of IV methylprednisolone divided into two 250 mg doses, one during induction of anesthesia and the other at the beginning of cardiopulmonary bypass. The trial aims to enroll 7,500 patients at approximately 75 centers and is expected to report its preliminary findings in fall 2013, Dr. Whitlock said. —Kate O’Rourke Drs. Augoustides, Chaney, Dieleman, Whitlock and Mazer have no relevant disclosures.

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CLI NI CA L A NESTH E SIOL OG Y

Paralysis More Common After Facial Muscle Monitoring

atients whose neuromuscular function during surgery is monitored at the face are much more likely to experience residual paralysis after the procedure than those monitored at the wrist, researchers have found. The study, by researchers in Washington, underscores the lack of a standard in the monitoring of patients who receive neuromuscular blocking drugs (NMBDs). “Anesthesiologists need to consider the limitations of neuromuscular monitoring on the face,” study author Dr. Stephan Thilen, MD, MS, assistant professor in the Department of Anesthesiology & Pain Medicine at University of Washington, in Seattle, told Anesthesiology News. “Our study suggests that monitoring on the face could misguide management of muscle relaxation.” A miscalculation can have clinically relevant consequences, Dr. Thilen said. Even if paralysis persists only 10 to 20 minutes into the recovery period, airway problems, including breathing and swallowing, can result (see article, page 1). “Many people underestimate the importance of residual paralysis as a risk factor for immediate postoperative complications in the recovery room,” Dr. Thilen said. “Upper airway patency is best when people are awake, alert and have fully functioning muscles.” To monitor the effects of NMBDs, anesthesiologists perform train-off four (TOF) measurements, ments, typically at the wrist (adductor pollicis) or face (oorbicularis oculi or corrugaator supercilii muscles). However, Dr. Thilen saidd, experts define recovery ffrom muscle relaxation as a robust response in the hand—and different muscles likely respond diifferently to musccle relaxants. Inde ed, multiple studdies consistently s how that the muscles of the face are more resiistant to relaxants than muuscles in the hand. “When you see an adequate

response at the face, it does not mean you will see a comparable response at the hand,” he said. So if anesthesiologists record strong activity in the muscles in the face, they may believe an NMBD is having little effect— and thus may be tempted to administer more drugs, further increasing the patient’s risk for residual paralysis. To test whether monitoring at different locations is associated with the risk for residual paralysis, Dr. Thilen and his colleagues tested muscle functioning in 150 patients immediately following surgery that included use of NMBDs. To do so, they performed quantitative TOF-ratio measurements at the ulnar nerve. The researchers then reviewed patients’ records to note variables—including the type, dose and timing of muscle relaxants given—and asked providers for additional information, such as where they monitored muscle activity. Patients whose muscle activity was monitored at the face were about 3.5 times as likely to experience residual paralysis (P<0.01) as those who were monitored at the wrist (unadjusted odds ratio, 3.9; adjusted odds ratio, 3.4; 95% confidence interval, 1.26-9.13). “Nobody has ever done an outcome study of patients that were monitored at the hand versus patients that were monitored at the face,” said Aaron F. Kopman, MD, retired professor of anesthesiology at New York Medical College, in Valhalla. “I think this is a potentially pot important study.”” How wever, Dr. Kopman said, the data are missing a key element: dosing information for NMBDs. If researchers could show that facial monitoring uuses higher doses of NMBDs, that would N exxplain why patients arre more likely to waake up with paralysis,, Dr. Kopman said. Witthout that information,, the findings lack the foorce they might otherwise have. Still, he added, “my prejudice is to completely

AnesthesiologyNews.com I 27

J U LY 2 0 1 2

CL IN ICA L A N E STH E SIOL OG Y

SSIs After Joint Surgery Cost Hospitals Millions

significant percentage of patients who develop surgical site infections after undergoing hip or knee replacement surgery, will be readmitted to the hospital for further complications related to wound infections, new research shows. Preventing such readmissions could save the U.S. health care system as much as $65 million a year, according to research led by Keith Kaye, MD, of Detroit Medical Center/Wayne State University. Dr. Kaye’s group presented its findings at the 2012 annual meeting of the Association of Professionals in Infection Control and Epidemiology (APIC). The research team analyzed data from health insurance claims for about 40 million insured individuals covered by employer-based health plans. Their goal was to uncover the rate of readmission and the financial effects of surgical site infections (SSIs) beyond the initial treatment of the complications. “The prosthetic joint population was important to study because these patients are particularly vulnerable to adverse events following [SSIs], leading to unnecessary pain, suffering and medical costs,” Dr. Kaye said in a statement. “Given the government’s

agree with these conclusions.” The literature shows that muscles in the face are harder to paralyze than those in the hand. “So if you are monitoring the face, patients are going to become more deeply paralyzed, and thus harder to reverse,” he said. Despite the difference between monitoring at the face and the wrist, anesthesiologists often choose the face simply because it is often easier to access during surgery, Dr. Thilen said. “We look at what is accessible to us, so we look at the face; however, we need to be aware of the limitations of this monitoring modality.” Consequently, Dr. Kopman said, anesthesiologists would benefit from a way of monitoring neuromuscular function at the hand when the arms are not accessible during surgery. Dr. Thilen’s group presented its findings at the 2011 annual meeting of the PostGraduate Assembly in Anesthesiology (abstract P-9212).

focus on reducing readmission rates, such complications could likely be a future target for decreased reimbursement.” Of the 174,425 patients in the database who underwent hip or knee replacement in 2007, 1.2% were hospitalized for an SSI within one year of their procedure. Of those, more than 12% were readmitted in the following

year due to SSI-related issues. The average hospital stay for the readmission was 8.6 days, at a cost of approximately $7,000 per patient. The data also showed that more than 40% of patients with SSIs were hospitalized for other reasons in the year following their diagnosis. For these patients, the average hospital stay was 6.2 days, at a cost of $31,000.

In a statement, APIC president Michelle Farber, RN, said, “Infection preventionists need to be familiar with health care quality incentive programs to demonstrate the value of the infection prevention program to the financial health of their organizations and patient experience.” —Maureen Sullivan

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28 I AnesthesiologyNews.com

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C LIN I C A L A N ES THES IO LO G Y RESIDUAL

CONTINUED FROM PAGE 1

The lack of clinical standards for monitoring postsurgeryy weakness means the situation is unlikely to improve anytime soon, said Sorin Brull, MD, professor of anesthesiology at Mayo Clinic, in Jacksonville, Fla. “I feel very strongly that the American Society of Anesthesiologists should come up with some standards for perioperative monitoring,” Dr. Brulll said. Although there are no firm data on the scope of the problem, Dr. Brull backed out an estimate of the potential scope of residual paralysis at the 2012 annual meeting of the International Anesthesia Research Society, in Boston. Of the roughly 40 million surgeries performed in the United States each year, about 60%, or 24 million, involve general anesthesia. If residual paralysis occurs in as much as 40% of patients who receive general anesthesia—admittedly near the top end of the range—he said, that’s 10 million patients. Critical respiratory events will affect 0.8% of those patients, and another 0.1% will require emergent reintubation in the postanesthesia care unit (PACU). The total: approximately 100,000 cases per year of potential harm “directly related” to residual paralysis. “I know it doesn’t happen here,” Dr. Brull said facetiously, referring to the anesthesiologists in the audience and their institutions. “But it does happen.” Part of the problem is that the clinical tests for residual paralysis are not especially accurate. That goes for f fourr monitoring, feeling for the consubjective train-oftraction of the affected muscles or evaluating patients by their clinical correlates—how firmly they can bite a tongue depressor, squeeze a hand or hold up their heads. “All of the clinical tests, all of them, have a very low predictive value,” Dr. Brulll said. “Even though 100% of clinicians use them, 99.9% of us are wrong half the time.” That might be an overstatement, but the condition does seem to have a way of eluding anesthesiologists, said Glenn Murphy, MD, director of cardiac anesthesia and clinical research at NorthShore University HealthSystem, in Chicago. Dr. Murphyy said that the vast majority of clinicians report never having seen a case of the complication, which seems unlikely, he said, given that “I see it a couple of times a month. If quantitative neuromuscular monitors are used in the PACU, most clinicians would discover that adverse respiratory events related to residual neuromuscular block are not rare events.”

Residual block: just ask the patient.

The available reversal agents are at least partly to blame, he said. Neostigmine in particular does not work very well. “In the best of circumstances, it takes an average of 10 to 15 minutes to achieve complete neuromuscular recovery,” Dr. Murphyy said. “The problem is we are pulling the endotracheal tube out without demonstrating that full recovery of muscle activity has occurred.” As it happens, the muscles that maintain airway Unambiguous Safety Issue tone are exquisitely sensitive to blocking agents. When Nor is it a trivial complication safely ignored. weak, they can obstruct and collapse. Small degrees “There’s clearly a patient safety issue involved here,” of residual block appear to be more threatening for Dr. Murphyy said. Adverse events can range from mild patients who are predisposed to airway difficulties— airway obstruction to life-threateningg hypoxemic epi- those with sleep apnea and chronic obstructive pulmosodes. Residual paralysis also affects the quality of nary disease, for example. y who has studied the issue. recovery, said Dr. Murphy, High-Risk Populations “When we leave patients with residual block, they “The majority of patients with a little bit of residual experience a variety of unpleasant symptoms of muscle block in the PACU will feel weak, but won’t develop weakness during the PACU admission.” In one such trial, Dr. Murphy’s group randomized life-threateningg problems,” he said. “But if a patient patients to quantitative neuromuscular monitoring with minimal pulmonary or cardiac reserve is left (TOF-Watch SX, Bluestar Enterprises) or no moni- with incomplete neuromuscular recovery, significant toring in the operating room. “When we evaluated adverse respiratory events may occur following trathem for symptoms and signs of muscle weakness, they cheal extubation.” clearly felt a lot worse” when experiencing residual As same-dayy surgeries become more common block, he said. and the use of short-actingg anesthetics like propofol

and desflurane broadens, residual paralysis is likely to become a common postoperative occurrence, Dr. Murphyy added. Aaron Kopman, MD, a retired professor of anesthesiology at New York Medical College, in Valhalla, has been working with Dr. Brulll on a journal article about residual paralysis. “While there’s a general consensus as to what should be done in terms of monitoring, there is a huge disconnect between what neuromuscular aficionados suggest and what is done in the real world,” Dr. Kopman said. “Probably 50% of anesthesiologists don’t use proper monitoring even though it’s available.” Why the practice gap? Although Dr. Kopman said the answer is complicated, part of the problem is that most nerve stimulators do not provide quantitative data. “They don’t give you a number you can deal with. Without that, I think people tend not to use the devices.” The lack of official guidelines doesn’t help, he added, as does what he said was the fate of articles and editorials on the subject: “They fall into a black hole.” To be fair, Dr. Kopman said, the problem is not isolated to the United States. In 2007, the Association of Anaesthetists of Great Britain and Ireland recommended that nerve stimulators “must be available whenever a muscle relaxant is used during induction and maintenance of anesthesia and must also be immediately available in recovery.” But two years later, Richard Birks, MD, chairman of the group that created the guidelines, published a letter to the editor of Anaesthesia, the association’s official journal, which hedged that position somewhat. Dr. Birks stated that “neuromuscular monitors should be available rather than attached routinely”—a position with which Dr. Kopman said he “could not disagree more,” Dr. Kopman said. “Our professional societies are not providing leadership.” Jeffrey L. Apfelbaum, MD, chair of the ASA’s Committee on Standards and Practice Parameters (CSPP), said the panel will not be reviewing issues related to residual paralysis this year. “We recognize that it’s an area of interest and it is in the queue for consideration.” Dr. Apfelbaum, chair of the Department of Anesthesia and Critical Care at the University of Chicago, noted that the CSPP receives many such requests on important areas of interest from ASA members annually and prioritizes them for consideration, review and possible publication. Publications in 2012 include statements on central venous access, preanesthetic evaluation, postoperative vision loss and acute pain management in the perioperative setting. Several other practice parameters are in various stages of production. Each of these documents typically involves hundreds of hours of work by physician volunteers and costs the ASA approximately $250,000 to produce—an outlay that covers expenses including travel, production costs and the consultant fees of two independent experts tasked with validating the analyses of the clinician volunteers. As a result, Dr. Apfelbaum said, the CSPP can do only so much in a given year. Dr. Brull “is right,” Dr. Apfelbaum said. “It’s certainly a topic of interest, but when we have prioritized it, it hasn’t yet risen to the top of the list.” —Adam Marcus

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Propofol TIVA Not a Blood-sparing Technique for Sinus Surgery

pilot study by a research team has concluded that there is no significant correlation between total intravenous anesthesia (TIVA) with propofol and platelet inhibition in patients undergoing endoscopic sinus surgery. The study also revealed that TIVA with propofol does not improve postoperative recovery compared with inhalational anesthesia.

“The primary goal of the study was to compare TIVA and inhalational anesthesia for blood loss,” said study leader Davide Cattano, MD, associate professor of anesthesia and medical director of the Preoperative Anesthesia Clinic at the University of Texas Health Science Center, in Houston. “So we started with a literature review, which showed a 50-50 split in terms of what people

feel. Half say propofol reduces blood loss and the other half says it doesn’t do anything.” Endoscopic sinus surgery (ESS) under general anesthesia has become the predominant approach to such procedures. Because surgical site bleeding is a critical factor during ESS, anesthesiologists often look for techniques to minimize the potential problem. Although

propofol is known to dilate blood vessels, few studies have attempted to demonstrate the benefit of TIVA as the sole technique to reduce bleeding. Dr. Cattano and colleagues randomized 23 ESS patients to receive either TIVA, using propofol and remifentanil, or inhalational anesthesia with a combination of sevoflurane and remifentanil. Blood samples were collected before and after surgery; platelet mapping (Haemonetics) was used as point-off care bedside testing. The MA (maximum amplitude, signifying clot strength) and the percentage platelet inhibition (defined by the extent of non-response of the platelet ADP or TXA2 receptor to the exogenous ADP and arachidonic acid [AA]) were analyzed. As Dr. Cattano reported at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 247), 12 patients (eight sevoflurane, four propofol) had subtle preoperative MAADP alterations, but only two of these had significant inhibition of ADP or AA combined. Six patients who had a significant change in either their preoperative or postoperative MA-ADP exhibited significant blood loss, compared with eight patients with significant change who did not have significant blood loss. “Originally, we were asking how propofol reduces blood loss,” Dr. Cattano told Anesthesiology News. “Some people claim it increases venous capacitance; others say it decreases vascular resistance. But by utilizing a promising device that measures mucosal nose blood flow [Rhinolux; Rhios GmbH], we actually found that blood flow is increased with propofol. We know from neurosurgery that propofol affords better maintenance of vascular resistance. So if propofol does, indeed, reduce blood loss, it’s likely through a mechanism of vasoregulation. This is a novel finding that we are seeking to better investigate.” The researchers also examined postoperative recovery and found no significant differences between the TIVA with propofol and the inhalational anesthesia groups with regard to duration of anesthesia, time to discharge from the postanesthesia care unit (PACU), incidence of postoperative nausea and vomiting (PONV), rescue analgesia or adverse events. The two groups also were comparable on recovery time and recovery quality. “The results show that see TIVA page 33

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Study Provides Fodder for Use of Statins in Critically Ill

tatins can reduce the risk for proximal-legg deep vein thrombosis in critically ill patients, researchers have found. The findings, from a substudy of a large, multicenter clinical trial, showed that use of statins was associated with as much as a 50% lower risk for DVT, although the researchers stopped short of advocating the administration of statins in the intensive care unit. The study was presented at the annual meeting of the Society of Critical Care Medicine (SCCM; abstract 112). “This study suggests that statins could be helpful in further lowering the risk for deep vein thrombosis in critically ill patients; however, further research is needed in the form of a randomized trial to see if this holds up when tested very carefully,” said Deborah Cook, MD, professor of medicine at McMaster University in Hamilton, Ontario, Canada. Dr. Cook was principal investigator of the PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial) study from which the substudy was drawn. PROTECT was a governmentfunded, randomized Phase III trial that compared dalteparin (Fragmin, Pfizer) with unfractionated heparin in 3,764 medical-surgical patients. The study, which involved 67 ICUs in six countries, identified no significant differences in rates of proximal-legg DVT between patients receiving dalteparin and those receiving heparin. However, dalteparin significantly reduced the risk for pulmonary embolism without causing an increase in major bleeding (N Engl J Med 2011;364:1305-1314). Several large observational studies have suggested that patients taking statins have a lower risk for developing DVTs (Thromb Res 2011;12:422-430), as has a large randomized trial of more than 17,000 healthy people (N Engl J Med 2009;360:1851-1861). The PROTECT researchers sought to examine whether the cholesterol-loweringg drugs would have a similar effect in critically ill hospitalized patients. Use of a statin in the previous week reduced the risk for DVT by almost 50% (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.27-0.77; P=0.003). DVT was diagnosed by twice-weekly compression leg ultrasound. The overall DVT rate in the study was 5.4%. Roughly 20% of patients were taking statins. “We considered statins that patients were receiving in the ICU,

which were principally the drugs they would have been receiving before they became critically ill,” Dr. Cookk said. Critically ill patients have so many risk factors for blood clots, such as surgery, the severity of their illness and catheterization of large veins, that researchers had not expected to find an association between statins and DVT. “After adjusting for those risk factors,

statins still turned out to be important,” Dr. Cookk said. “This was a somewhat surprising finding.” She added that the study “is the largest study to date evaluating the possible impact of statins on blood clots in the ICU setting.” Michael Woo, MD, assistant professor of anesthesia and critical care at the University of Chicago Medical Center, said the role of statins in critical

illness “may be more intellectually exciting than clinically relevant. The research points to associations of variable strength. That there is a causative connection is less solid.” —Kate O’Rourke Drs. Cook and Woo reported no relevant disclosures.

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New Zealand Program Cuts Unnecessary Transfusions

s efforts to reduce unnecessary transfusions grow, one initiative at New Zealand’s largest hospital system trimmed the number of red blood cell units transfused over a 10-month period by 11%. The reduction saved the institution more than $1.3 million in related costs over the same period. The project focused on promoting

single-unit transfusions at higher hemoglobin thresholds and emphasized the added safety of conducting fewer transfusions. “These researchers should be applauded for significantly reducing red cell transfusions through instituting this program,” Aryeh Shander, MD, president of the Society for the Advancement of Blood Management, said in an

interview. “We know patients do just as well when clinicians use restrictive transfusion practices than when they transfuse liberally.” Dr. Shander, r who also is chief of the Department of Anesthesiology, Critical Care and Hyperbaric Medicine at Englewood Hospital and Medical Center in Englewood, N.J., was not involved in the latest study.

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The project coordinator, Ian Olan, MBA, CPA, program manager for the Auckland District Health Board in New Zealand, outlined the initiative at the 2012 World Congress of Anaesthesiologists (abstract 448). Ingrained Waste In October 2010, prior to implementation of the program, clinicians at 1,200-bed Auckland Hospital routinely used two or more units of blood per transfusion—despite evidence that each additional transfused unit increases the risk for mortality and morbidity (Crit Care Med 2008;36:2667-2674), Mr. Olan said. Many clinicians at the hospital used generous hemoglobin transfusion thresholds of 100 to 130 g/L. Furthermore, because clinicians anticipated delays in deliveries from the blood bank, they often ordered excess amounts of red blood cells as a backstop, leading to significant wastage. On average, for every transfused unit of blood, nearly five units were ordered. To tackle the problem of unnecessary transfusions and blood product waste, the Auckland Health Board formed a multidisciplinary Blood Transfusion Committee, including anesthesiologists, transfusion nurses and hematologists. The committee developed posters encouraging clinicians to administer one, rather than two, units of packed red blood cells and other printed material emphasizing the benefits to patient safety of reducing transfusions. The team also developed and disseminated procedure-specific transfusion protocols and algorithms incorporating lower hemoglobin thresholds of 80 to 100 g/L. Mr. Olan and his colleagues hastened the delivery of blood from the bank to the operating room (OR) by cross-matchingg and preparing blood products the night before elective surgeries and, for acute patients, by sending generic product to the OR while cross-matchingg their blood. These steps encouraged clinicians to minimize precautionary orders, Mr. Olan said. The program also targeted waste of fresh frozen plasma (FFP) by centralizing the thawing process in the blood bank, Mr. Olan said. Whereas FFP was thawed in ORs under the previous system and unused thawed plasma frequently went to waste, under the new system thawed plasma not used by the ordering clinician is made available to other clinicians in the hospital. Mr. Olan and his team found that

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be some, albeit questionable, effects of propofol on platelet function, they endoscopic sinus surgery does not nec- are not clinically significant,” Dr. Joshi essarily increase PONV,” Dr. Cattano said. “Thus, effects on platelet function added. should not be a determinant in choice One patient in each group had nau- of anesthetic technique, at least until we sea, but without vomiting. Eight have good evidence. patients in the propofol group and 10 “With respect to recovery from anesin the sevoflurane group reported pain thesia, there are numerous studies on arriving in the PACU, but only five comparing TIVA and inhalational anesin each group received rescue morphine thesia,” Dr. Joshi continued. “Review of literature suggests that induc(median dose, 4 mg). Dr. Cattano noted that although no tion of anesthesia with propofol and differences were found between inhalational anesthesia and TIVA with regard to the quality of immediate postoperative recovery, other considerations when choosing between the two forms of general anesthesia should include cost, history of PONV and the likelihood of bleeding Girish P. Joshi, MBBS, MD, professor of anesthesiology and pain management at the University of Texas Southwestern Medical School, in Dallas, called the study too small to provide meaningful guidance for clinical practice. “Even if we assume that there may CONTINUED FROM PAGE 30

maintenance with newer shorter-acting inhaled anesthetics allows for an early emergence, but there is no difference in the late recovery. Furthermore, propofol TIVA may be beneficial in patients at very high risk for PONV. Finally, because the benefits of propofol with respect to its recovery characteristics are significant, it will remain the drug of choice for TIVA.” In a related study (abstract 738), Dr. Cattano’s group compared the costs associated with TIVA and inhalational

anesthesia for ESS. Using the same patients as in the previous study, they found that the two anesthetic methods cost roughly the same—$530 for three hours of the TIVA combination and $550 for the inhalational mix of similar duration. However, the researchers noted, remifentanil, at $400, makes up the bulk of the TIVA expense. As a result, the cost of TIVA for ESS might well be driven down substantially. —Michael Vlessides

NYSORA 2012

NEW YORK SCHOOL OF REGIONAL ANESTHESIA

10 months after they implemented the program, the number of red blood cell units transfused per patient had fallen to 0.45 from 0.51 prior to the intervention, a drop of about 11%. The reduction totaled a savings of 2,080 units over the study period. The number of FFP units used per patient also decreased, from an average of 0.12 units before the intervention to 0.09 units after the program was introduced. This amounted to a savings of 1,121 FFP units during the 10-month period. The cost savings from the reduced use of blood product–related nursing hours over the study period was about $1.3 million, Mr. Olan reported. “Although we haven’t looked at changes in patient outcomes, we are assuming there have also been fewer transfusionrelatedd adverse events,” he said. Although the campaign’s success in reducing red blood cell unit transfusions is praiseworthy, Dr. Shanderr said units of transfused FFP remained excessively high after the intervention. “For an adult, the science shows there is a very narrow benefit to using one or two units of plasma, which clinicians often do,” Dr. Shanderr noted. “If an order for one or two units of plasma is placed, I can almost guarantee you that there is no need for the product at all.” —David Wild

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Volatile Anesthesia Found Safe in Aging Brains Study of isoflurane points to role of pre-op cognition over agents Chicago—Recent studies in animals and in the laboratory have demonstrated that isoflurane appears to promote the generation and aggregation of amyloid β protein in the brain, two markers of Alzheimer’s disease. The findings have prompted researchers to wonder whether these isoflurane-induced neuronal changes may predispose elderly individuals to postoperative cognitive problems. The answer appears to be no. In a new study, Terri Monk, MD, of Duke University Medical Center, in Durham, N.C., and colleagues found that rates of postoperative delirium were comparable between patients receiving isoflurane and those receiving total intravenous anesthesia (TIVA) with propofol. “Since there have been no human studies looking at this problem, I was trying to determine if inhaled anesthetics were worse for elderly people undergoing general anesthesia,” said

Dr. Monk, professor of anesthesiology at Duke and an expert in postoperative delirium. “And I wanted to compare isoflurane with propofol, because propofol has not been associated with the same types of changes in animals and cellular models.” Dr. Monk and her colleagues enrolled 200 adults, aged 65 years and older, into the trial. All patients were undergoing major orthopedic surgery. Prior to the procedure, patients underwent an evaluation that examined memory, executive function and depression. Intraoperatively, all participants were premedicated with midazolam; propofol was used for induction of anesthesia. Patients were randomized to receive either isoflurane or TIVA for maintenance of anesthesia at the recommended depth of anesthesia. The researchers followed the

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patients for three days after surgery and assessed them using the Confusion Assessment Method to determine the presence of postoperative delirium. Postoperative delirium occurred in 13 patients (13.5%) who received isoflurane and 14 (13.6%) given propofol TIVA (P=0.99). The adverse event was more common among those with lower scores on preoperative cognitive testing, specifically the executive and memory components of the test (P<0.05 for both). No associations were found between delirium and age (P=0.33), educational level (P=0.29) or depression (P=0.14), according to the researchers. Cognition was the only factor that independently predicted delirium when the variables were considered together, Dr. Monk said. Both executive function and memory were associated with delirium when considered independently in separate models. Patients who experienced delirium after surgery had poorer orthopedic outcomes three months after surgery. “Our primary finding—and it is really consistent with other studies we have done—is that it is the preoperative status of the brain that predisposes a patient to delirium,” Dr. Monk told Anesthesiology News. “The type of general anesthesia does not appear to influence cognitive outcomes in the early postoperative period.” The only caveat, she added, is that the study looked only at delirium. The researchers plan to follow the patients for a year or more and test them for signs of cognitive decline. “It may be that changes will occur later after surgery and we’ll find a difference a year or three years out,” Dr. Monk said. “But at least for the period immediately following surgery, we know that the

type of anesthesia does not affect their recovery and we don’t have to change our anesthetic practice at this time. There no evidence yet that we should all run out and stop using the inhalational agents on older patients.” Kathryn E. McGoldrick, MD, professor and chair of anesthesiology at New York Medical College, in Valhalla, said that given the graying of the nation—Americans over age 65 will account for 19% of the population in 2030, up from 12.4% in 2000, government statistics show—the potential roles of anesthesia and surgery in postoperative cognitive dysfunction in elderly individuals are extremely important issues. “Dr. Monkk and her colleagues have made notable contributions to advancing our understanding of postoperative cognitive dysfunction in the elderly, and it is gratifying to note that these researchers are investigating postoperative delirium as well,” Dr. McGoldrick said. “There seems to be a growing perception that postoperative cognitive changes may say more about our patients than about our anesthetic techniques or agents.” Dr. McGoldrickk noted that a study by Evered and colleagues (Anesthesiol( ogy 2011;114:1297-1304) found that 20% of elderly patients having total hip replacement had pre-existingg cognitive impairment and 22% had amnestic mild cognitive impairment. Those results suggest that the aging nervous system has less reserve, she said, and that perhaps hospitalization and surgery unmask marginal cognitive function. Gregory J. Crosby, MD, of Brigham and Women’s Hospital, in Boston, has emphasized the need for a robust, reproducible and practical tool to assess preoperative cognitive function in elderly surgical patients, Dr. McGoldrick added. “One would hope that such an instrument would assist in risk stratification, and contribute to a more comprehensive risk– benefit analysis for elective surgery in potentially vulnerable patients,” she said. Dr. Monk’s group reported its findings at the 2011 annual meeting of the American Society of Anesthesiologists (abstract 613). —Michael Vlessides

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Anesthesiology, Second Edition

David Longnecker; David L. Brown; Mark F. Newman; Warren Zapol McGraw-Hill, May 2, 2012 Much more than a how-to manual of anesthetic techniques, this book presents an up-to-the-minute, accessible compilation of crucial concepts and principles—one that affirms the book’s status as the gold-standard reference in the field.

Atlas of Ultrasound-Guided Regional Anesthesia: Expert Consult—Online and Print: Second Edition

Andrew T. Gray Elsevier/Saunders, October 15, 2012 Dr. Gray, a pioneer of ultrasound guidance in regional anesthesia, demonstrates step-by-step a full range of nerve block techniques designed to help you improve the quality and success rate of regional blocks. A companion Expert Consult site features videos of regional blocks perr formed under ultrasound guidance.

Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia

Admir Hadzic McGraw-Hill, December 7, 2011 Featuring sections that progress from the foundations of regional anesthesia to the clinical applications of nerve blocks, this book includes tips and insider perspectives from the leadership of The New York School of Regional Anesthesia and its academic affiliates. The book includes an at as of atlas o ultrasound u t asou d anatomy a ato y for o regional eg o a anesthesia a est es a and a d pain pa medicine. ed c e

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Atilio Barbeito; Andres D. Shaw; Katherine Grichnik McGraw-Hill, May 24, 2012 Thoracic Anesthesia a offers a current, detailed review of the basic, needto-know concepts of thoracic anesthesia, along with clear, practical suggestions for handling commonly encountered scenarios. The book is filled with high-yield insights into such pivotal topics as respiratory physiology, imaging, one-lung ventilation and postoperative care.

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Peter Marhofer Oxford University Press, November 19, 2010 Ultrasonographic guidance for regional anesthetic blocks is an innovative technique that allows for the direct visualization of nerves, adjacent structures and the position of the needle, as well as for the precise observation of the spread p of local anesthetic. AN0712

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Little Used in OR, Clonidine Shows Promise as Epidural Agent San Diego—Although not commonly used in the perioperative setting, epidural clonidine works well as the sole analgesic agent for abdominal surgery, a recent study found. The researchers said patients who received the anesthetic reported significantly lower pain scores than their counterparts who received epidural bupivacaine. “Clonidine is a very interesting drug that has been studied for many years,” said Alaa Abd-Elsayed, MD, a resident at the University of Cincinnati Academic Health Center, in Ohio, who led the study. “Many studies have demonstrated its potent analgesic effects. In this trial, we wanted to compare clonidine with bupivacaine in patients undergoing lower abdominal surgery.” Dr. Abd-Elsayed and colleagues studied 40 ASA status I-II patients (aged 18-50 years), all of whom were scheduled for elective lower abdominal surgery. The patients were randomized to receive intraoperative epidural analgesia with either clonidine or

bupivacaine (n=20 in each group). Clonidine patients received an initial dose of 10 mcg/kg (maximum dose, 600 mcg) in 7 mL of saline over 15 minutes, followed immediately by a 6 mcg/kg per hour infusion for 12 hours. Bupivacaine patients received 7 mL of 0.5% bupivacaine over 15 minutes as an initial dose, followed immediately by a 0.2% infusion (7 mL per hour) for 12 hours. Dr. Abd-Elsayed, who reported his group’s findings at the 2012 annual spring meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract P4), said pain scores were found to be significantly lower in patients given clonidine than in those who received bupivacaine (1.5±0.5 vs. 3.4±1.0). Intraoperative and postoperative opioid requirements also were significantly lower in patients who received clonidine. Although respiratory rate and oxygen saturation were similar between patients in each group, patients who received bupivacaine experienced a

greater reduction in their heart rate than those given clonidine (22%±5.1% vs. 10%±3.3%). Systolic blood pressure fell in both groups, by 21.2%±3.9% in clonidine patients and 17.1%±3.6% in bupivacaine patients. Diastolic blood pressure also fell in both groups, by 13.3%±2.8% in clonidine patients and 8.8%±3.1% in bupivacaine patients. The side-effect profile tended to favor patients receiving clonidine. Postoperative nausea and vomiting were significantly less frequent in the clonidine group, as was urinary retention. Although the occurrence of pruritus and shivering was significantly more common in the bupivacaine group, sedation scores were significantly higher in patients receiving clonidine. “But the sedation was not to a point that we had to do anything special for it,” Dr. Abd-Elsayed said. “Clonidine was very effective at controlling pain and hemodynamic parameters in our patients,” Dr. Abd-Elsayed said. “It reduced the need for rescue intravenous pain medications, and had

a prolonged action after discontinuation of epidural infusion compared to bupivacaine.” Kenneth Drasner, MD, professor of clinical anesthesia and perioperative care at the University of California, San Francisco School of Medicine, wondered why clonidine has failed to gain more widespread acceptance in the anesthesia community, despite consistently positive results. “Clonidine has been around a long time, and these data have been around a long time. So why isn’t anybody using it?” “I remember if you go back to interpleural catheters, every published study I saw concluded that they were fantastic,” Dr. Drasner added. “But you look around, and nobody’s using them. Why is that? And I think if clonidine has been around so long and we’re still not using it, there’s a reason why.” “I really don’t know” why the drug is not more widely used, Dr. Abd-Elsayed said. “But I think we should use it more.” —Michael Vlessides

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A D L IB STEM CELLS

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the cells to exhibit genetic activity normally associated with embryonic stem cells. “None of the [cells] before treatment expressed these embryonic stem cell markers,” said Dr. Vacanti, who presented some of the new findings at the 2012 annual meeting of the Society of Cardiovascular Anesthesiologists (SCA). “After treatment, they all did. After we injure any mature cell, it can be altered to become virtually identical” to the embryonic state in terms of gene expression (Figure 1). The researchers then showed that, through stressinduced injuries, they could cause lymphocytes to become all three major cell lines: endoderm, mesoderm and ectoderm. “Mature cells reverted back to stem cells and expressed all three germ layers,” Dr. Vacanti said. Dr. Vacanti’s group has submitted their results for publication, and their manuscript is currently under review. But they have not discussed their findings publicly—indeed, Dr. Vacanti nearly had to scuttle his talk at SCA because his institution’s lawyers were filing patents on some aspects of the work up until the last minute. As a result, Anesthesiology News could not speak with independent experts about the new research. Dr. Vacanti is no stranger to controversy. In 1995, he helped create what came to be known as the “ear mouse,” a lab rodent that served as a four-legged platform for growing human cartilage in the shape of an ear (Figure 2). Photos of the distorted animal sparked outrage in the animal rights community. Although the notion that stem cells might be created without gene tinkering doubtless will come as a shock to many researchers, Dr. Vacanti said the cells are no less useful. “They have virtually unlimited potential for tissue repair,” he said. In other work, Dr. Vacanti’s lab has demonstrated that the injury-induced stem cells can be used to regenerate everything from new tracheas to nerves in the spinal cord. With the trachea, for example, the researchers procure normal mature adult cells, injure with chemicals the adult cells to generate stem cells that are

grown in an incubator and then transfer to a scaffold. Once the scaffold is sufficiently populated with the correct cells, the researchers implant it into the affected area.

grown it, they would not have operated and found it to be correctable,” he said. Dr. Vacanti is submitting a proposal to the FDA to perform 10 such tracheal transplants in humans. His group has conducted experiments Lifesaving Gamble using a similar procedure to repair the damaged spinal cords of animals. To date, In a test of the procedure that—for reasons that had nothing to do with they have performed the procedure on six the transplant itself—did not succeed, monkeys, including two control animals Dr. Vacanti’s group grew a trachea in the Charles Vacanti, MD and four that received stem cell injections. Of the four animals given the cells, abdomen of a 14-year-old girl with a benign but aggressive airway tumor. Even two have experienced “virtually perfect” after several surgeries and consultations at five insti- recoveries, Dr. Vacanti said, including the ability to tutions, he said, the mass kept returning, each time run normally on a treadmill. The other two are still weak but have regained what he called “pretty good claiming more tracheal tissue. “It looked like it was so large that when you took function.” it out you could not pull the two ends of the trachea The studies so far have been conducted outside together and she would die,” he said. “She was told the United States, although Dr. Vacanti said he tried it was inoperable. Take her home, take her to Disney for several years to find a U.S. institution that would World, she’ll be dead in one year.” house the work. “No one was comfortable with With nothing to lose, Dr. Vacanti’s group sug- resecting spinal cords because they felt that it burned gested growing a tissue-engineered tracheal auto- a bridge irreversibly,” he said in an interview with graft using their technique. “We started to grow it Anesthesiology News. “Ultimately, you may not need in the incubator on cartilage to resect the cord. You need only resect the scar tisfrom a rib biopsy. We seeded it sue” that forms at the site of the injury. onto a scaffold, and, after time, In fact, that seems to be the reason that stem cells transplanted the scaffold into therapies have failed to repair damage to the spiher abdomen, wrapped in her nal cord. The new cells grow new spinal cord tissue, own omentum to have a vas- but not as fast as the fibrous tissue and scarring that cularized pedicle,” Dr. Vacanti forms at the site of the injury. explained. Dr. Vacanti said he hoped to be able to launch Once the new trachea was human trials of acute spinal cord injury, possibly ready, the girl was prepped for as early as late 2015. He also would like to use the the procedure. But after excis- untreated control animals as a model for chronic ing the tumor, the girl’s sur- spinal cord injury to see if the technique can rescue geons realized that she in fact long-damaged nerves. As for adverse effects, he said, “We have done had enough viable trachea left to remove the mass and repair thousands of these procedures and have not seen the trachea without requiring any evidence of malignancies.” Dr. Vacanti’s brother, Figure 1. Left: Normal, untreated, mature lymphocyte taken from the new organ. Martin Vacanti, MD, a pathologist, has been analyzthe blood of an OCT4/GFP mouse. While it expresses the mature cell surface In a sense, Dr. Vacanti said, ing the tissues for signs of abnormal cell growth. “He marker CD45 (red), there is no evidence of green fluorescence that would although the graft was not has been looking for chromosomal anomalies, among indicate embryonic stem cell markers in this special breed of mice. the fact that it existed needed, other things, and has found none.” Right: Stress-treated lymphocytes express green fluorescent protein that enabled the sucas an option is associated with the embryonic cell marker OCT4, in this mouse, while it does not express the mature surface marker CD45. —Adam Marcus cessful surgery. “If we had not

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‘A Few Sweet Kisses’: A History of Self-Experimentation In Anesthesia (Part 1)

edical history is filled with examples of researchers who have used themselves as experimental subjects. One of the most famous of these is Werner Forssmann. In 1929, Forssmann began a surgical residency at a Red Cross Hospital outside Berlin. He was fascinated by an experiment French doctors had conducted on a horse, which he read about in medical school and decided to replicate it on himself. Despite the opposition of his superior, Forssmann enlisted the help of a nurse, Gerda Ditzen, and catheterized his own heart with a ureteral tube almost 30 inches long. An xx rayy technician was persuaded to snap proof of the procedure. His superior, Richard Schneider, accepted the experiment when x ray, y and that night the two celebrated he saw the xin a local tavern. Forssmann repeated the procedure on himself five more times over the next month. In 1956, Forssmann shared the Nobel Prize in Physiology or Medicine with two American physicians, Dickinson Richards and Andre Cournand, whose further work on heart catheterization before World War II made it a staple of cardiac medicine. In 1974, Forssmann published a memoir, Experiments on Myself. Some selff experimenters in the history of anesthesia also are well known. Thomas Beddoes and Humphry Davy tested the physical and psychological effects of nitrous oxide inhalation on themselves at Beddoes’ Pneumatic Institute outside Bristol, England, in 1799 and 1800. Their efforts were repeated by William Allen, Astley Cooper and others in London in early 1800. William Barton and his fellow chemistry classmates in Philadelphia also were experimenting on themselves during that period. Barton wrote his medical school dissertation on nitrous oxide and served many years as a progressive naval surgeon. Experimentation with nitrous oxide quickly became a classroom and public lecture favorite in the years before Morton’s 1846 ether demonstration in Boston. Itinerant showmen often calling themselves “professor” traveled a circuit of the larger cities in both America and Britain offering lectures and demonstrations of nitrous oxide inhalation for the paying customers. Male volunteers from the audience would take the stage and, with the professor’s assistance, breathe nitrous oxide and usually amuse the audience with their bizarre behavior and speech. Such a demonstration in Hartford, Conn., in December 1844, led to the development of anesthesia. Dentist Horace Wells attended a program by Gardner Quincy Colton, who became one of the best-known showmen and later brought nitrous oxide into dentistry. Wells noticed that a young man injured his leg during the demonstration but seemed to feel no pain. The next day, Wells persuaded his colleague John Riggs to pull one of his teeth after Colton administered the gas. The pain-free success of this event led Wells to Massachusetts General Hospital the following month in an attempt to

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use for surgery. The patient, probably not fully anesthetized, reacted in such a way that the attempt was considered a failure. But Wells’ effort sent another colleague, William Morton, on a search for a better agent; and in October 1846 he would use ether successfully in the same operating theater. Almost two years before Wells, physician Crawford Long also tried ether in successful surgery on James Venable in Jefferson, Ga. Unfortunately, Long did not publish an account of his achievement until after Morton’s. Long conceived the idea in much the same way as Wells; ether “frolics” were a common private entertainment of the time, even in a small town in the South. Long had experienced them during his medical student days in Philadelphia. In a letter he wrote to a druggist in Athens, Long made clear his reasons for participating. “We have some girls in Jefferson who are anxious to see it taken, and you know nothing would afford me more pleasure than to take it in their presence and to get a few sweet kisses.” Long later married one of those ladies, Caroline Swain.

experiments designed to solve several problems faced by RAF pilots downed at sea. This research involved life jacket design, temperature maintenance in ocean water and the best method of artificial respiration to be used on rescued pilots in need of resuscitation. Pask was anesthetized numerous times and set adrift in the research pool as various jacket designs and other aspects were tested. These experiments were filmed and shown to RAF pilots to boost their morale. Pask, a heavy smoker, was admitted to a nearby hospital for recovery after each experiment. As might be expected, he was not in the best of shape. In 1946, Pask wrote his medical school thesis at Cambridge on this work; its title was as unrevealing as the experiments were exciting: “Anaesthetic Techniques in Research.” He and Macintosh published a few articles on the experiments between 1948 and 1961. Pask became the second professor of anesthesia in Britain and held that post until his death in 1966 at age 53. A smoker to the end, he expected his residents to always carry cigarettes and matches in case he needed them.

—A.J. Wright, MLS The War Effort Such can be the stimulus for scientific advances. Mr. Wright is an historian in the anesthesiology department at the Yet a much more serious purpose drove British anes- University of Alabama School of Medicine, at Birmingham. thetist Edgar A. Pask. Born in 1912, he trained as a physician and spent two years at London HospiSuggested Reading tal. In 1939 he joined Professor Robert Macintosh’s Altman LK. Who Goes First? The Story of Self-Experimentation in Medicine. Anesthesia Department at Oxford—the only such New York, NY: Random House;1987. academic unit in Britain at the time. Conacher ID. The big ideas of Edgar Alexander Pask (1912-66). After the outbreak of World War II, the depart- J Med Biogr.r 2010;18:44-48. ment offered short courses in anesthesia in sup- Enever G. Edgar Pask and his physiological research—an unsung hero of port of the war effort. Soon Pask was sent to the World War Two. J R Army Med Corps. 2011;157:8-11. Physiological Laboratory at the Royal Air Force Fiks AP. Self-Experimenters: Sources for Study. Westport, CT: Praeger; 2003. (RAF) Research Station in Farnborough. Pask and Franklin J, Sutherland J. Guinea Pig Doctors: The Drama of Medical his colleagues there began a remarkable series of Research through Self-Experimentation. New York, NY: Morrow; 1984.

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