You’reWrong,I’mRight
CoreyS.Scher • AnnaClebone
SanfordM.Miller • J.DavidRoccaforte
LevonM.Capan
Editors
You’reWrong,I’mRight
DuelingAuthorsReexamineClassic
TeachingsinAnesthesia
Editors
CoreyS.Scher,MD
ClinicalProfessorofAnesthesiology, DepartmentofAnesthesiology PerioperativeCareandPainMedicine, NewYorkUniversitySchoolofMedicine NewYork,NY USA
AnnaClebone,MD
AssistantProfessor,Department ofAnesthesiaandCriticalCare TheUniversityofChicago Chicago,IL USA
SanfordM.Miller,MD ClinicalProfessorofAnesthesiology (Emeritus),FormerAssistantDirectorof Anesthesiology,BellevueHospitalCenter RetiredfromDepartmentof Anesthesiology,BellevueHospitalCenter NewYorkUniversitySchoolofMedicine NewYork,NY USA
J.DavidRoccaforte,MD
ClinicalAssociateProfessorof AnesthesiologyandSurgery, DepartmentofAnesthesiology BellevueHospitalCenter,PerioperativeCare andPainMedicine,NewYorkUniversity SchoolofMedicine,SurgicalIntensive CareUnit
NewYork,NY USA
LevonM.Capan,MD DepartmentofAnesthesiology PerioperativeCareandPainMedicine, ViceChairFacultyPromotionAssociate DirectorAnesthesiaServiceBellevue HospitalCenter
NewYork,NY USA
ISBN978-3-319-43167-3ISBN978-3-319-43169-7(eBook)
DOI10.1007/978-3-319-43169-7
LibraryofCongressControlNumber:2016947744
© SpringerInternationalPublishingSwitzerland2017
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Toallofmyhearts,Lisa,Ryan,Danielle,Oliver,andDakota
CoreyS.Scher
Tomywonderfulhusband,KeithRuskin
Tomywife,Marcia,whohasstoodwithmefor61years
SanfordM.Miller
AnnaClebone
Preface
Ourjournalsaredesignedforcriticalreaderstodeterminewhetherthebestfreshlypublished paperswillbecomeessentialforpracticeornot.Asanesthesiologistsworkmorehours,with fewerresourcesandsickerpatientsthaneverbefore,itistrulyachallengetomaintain currency.Formany,readingonthesubjectofanesthesiadoesnottakeprioritywhilejuggling apersonalandprofessionallife.InvestinginprintcopiesorgainingInternetaccesstojournals inour fieldislowontheto-dolist.
Anesthesiologistslovetotalktofellowanesthesiologistsaboutcases.Eventhemostdour clinicianswillcometolifewhenanotheranesthesiologistsays, “Youwillneverbelievewhat happenedtomeintheoperatingroomlastweek.” Itisreadilytransparentthanmanyclinicians areholdingontoclinicalparadigmsthatwerelearnedinresidencythatare,ataminimum,now controversialandsometimesnolongertrue.
Therehasbeenaveritableexplosionoverthelast20yearsofhigh-qualityresearchin anesthesiology,painmedicine,andcriticalcare.Themeritofeachjournalisquantitatively determinedbyits “ImpactFactor”—thefrequencythatitsarticlesarecitedinotherpapersor reports.Theimpactofanesthesiologyanditsrelated fieldshassoaredbyover65%inthepast 5years.Fullyoverwhelmingevidencenowinfluencestheclinicalcareofpatientsinour field andisthereasonforthisgain.Despitenewstatisticalmeasures,projectdesign,andeditorial approval,manycliniciansareholdingontopracticeparametersthatareoutdatedorirrelevant. Theprocessofpracticechangeinvolves3steps.Withtheintroductionofanewpractice parameter,theprovidergoesthrough:(1)denial,(2)understandingthatthereiscontroversy, and(3)aftermoretimethanshouldbeneeded,acceptance.
Theeditorsofthisbookmadeaboldattemptatcreatingabookthatistargetedatevery clinicianinthe field,whethertheystaycurrentornot.Wepresent126cases,brokendownby subspecialty,wheretheauthorhasa “splitpersonality.” Afteracaseispresented,theauthor forcefullyrepresents2adversarialpositions:aprostanceandaconstance.Ineachcase,the authorsspeakfreely,havingcheckedtheiracademictitleatthedoor.Duringafreewheeling discussion,thecaseauthorsalternatebetweentalkingoffthecuffandpresentingcurrent evidence.Thebookismeantasaneasyreadthatcanbeopenedupatanypage.Eachcaseis onlyafewpageslongandcancapturetheattentionofthereaderforaslongasneeded.Thisis notmeanttobeareferencebook.Simplystated,thecasesaremeanttobeentertaininganda “funread.”
Inalmosteveryclinicalarena,conceptsthatwethoughtwerewritteninstoneareonthe roadtobecomingmyths.Examplesincludetheutilityofcricoidpressure,theuseofnormal saline,leftuterinedisplacement,andtheneurotoxicityofinhaledanestheticsinyoungchildren.Thesearejustthetipoftheicebergofcontroversialtopicsrecentlydebatedinour high-impactjournals.Largedatabaseanalysesonanincreasinglylargenumberoftopics demandachangeinpractice.
Anotherobjectiveofthisbookistohelpthereadertakeasmallsteptowardcurrency.The informalpresentationoftopicsiswhatwebelieveisthemostaccessiblewaytoconveynew informationtoalargenumberofreaders.Thisishowinformationismostfrequentlysharedin the “realworld” bothinsideandoutsideofmedicine.Webelievethatthisbookaccomplishes
thisgoalofinformationsharing,andthatmostofthecasesinthebookaddressthemost relevantcontroversiesinanesthesiologytoday.
Thepro–conapproachoffersadvantagesoverothermethodsofteaching.Thesecasescan bepresentedtoresidentsinamannersimilartotheSocraticmethod.Inourexperience, residentsdoprefertobetaughtusingacase-basedmethod.Longintervalsexistinthe operatingroomduringwhichminimalactivityoccurs,althoughvigilancemuststillbe maintained.Case-baseddiscussionsareaperfectwaytospendthistime.Thisbookis essentiallyalibraryforateacherwhoislookingforhigh-qualitycase-basedtopics.
Theenthusiasmoftheauthorsofeachcasewasthemostsatisfyingaspectofthisbook.The qualityofeachcasedemonstratesthatsentiment.Eachcaseauthoristobecommendedforthe wisdomandskillfulwritingcontributedtothesecases.Whilewearegratefulforeveryone involvedingettingthisworktoprint,wewillbemostgratefulifthereaderssimplyenjoythis bookanduseitasaroadtocurrencyandanimportantmodeofteachinganesthesia.
NewYork,USACoreyS.Scher Chicago,USAAnnaClebone
PartIGeneral
1ShouldRecentClinicalTrialsChangePerioperativeManagement inPatientswithCardiacRiskFactors? ...........................3 CoreyS.Scher
2ShouldReal-TimeUltrasoundGuidanceBeRoutinely UsedforCentralVenousCatheterPlacement? ......................7 JamesLeonard
3APatientwithChronicKidneyDiseaseIsComingtotheOperating RoomforanEmergentProcedure,WhichIntravenousFluidDoYou PlantoGiveHer? ...........................................11 JacobTiegsandArthurAtchabahian
4JustSayNOtoNitrous! ......................................15 CoreyS.Scher
5Closed-LoopAnesthesia:WaveoftheFutureorNoFuture? ...........19 CedarJ.FowlerandHowardChing
6ShouldAcuteRespiratoryDistressSyndrome(ARDS)Preventative VentilationBeStandardintheAdultOperatingRoom? ...............21 SamirKendale
7IGaveRocuronium3HoursAgo,DoINeedtoReverse? ..............23 DanielKohutandKevinTurezyn
8HowDoYouRecognizeandTreatPerioperativeAnaphylaxis? ..........25 AmitPrabhakar,MelvilleQ.WycheIII,PaulDelahoussaye, andAlanDavidKaye
9IsMonitoredAnesthesiaCare(MAC)SafeforAllCases? .............29 KennethM.SutinandJonathanTeets
10DoesElectrophysiologyReallyHavetoReprogramMyPatient’s PacemakerPriortoElectroconvulsiveTherapy? ....................33 EthanO.Bryson
11WhenCanTransesophagealandTrans-ThoracicEchocardiography BeUsefulinaNon-CardiacCase? ...............................35 LisaQ.Rong
12ShouldAntifi brinolyticsBeUsedinPatientsUndergoing TotalJointReplacements? ....................................39 SuzukoSuzuki
13WillOperatingRoomsRunMoreEffi cientlyWhenAnesthesiologists GetInvolvedinTheirManagement? .............................43 StevenD.Boggs,MitchellH.Tsai,andMohanTanniru
14AreOutcomesBetterforTraumaPatientsWhoAreTreated EarlywithClottingFactors? ...................................49 StevenD.BoggsandIanH.Black
15ShouldCerebralOximetryBeEmployedinMorbidlyObesePatients UndergoingBariatricSurgery? .................................53 DavidPorbunderwala
16IsNormalSalineSolutiontheBestCrystalloidforIntravascular VolumeResuscitation? .......................................55 SaadRasheed
PartIICardiac
17ShouldLocalAnesthesiawithConsciousSedationBeConsidered theStandardofCareOverGeneralAnesthesiaforTranscatheter AorticValveReplacementviatheTransfemoralApproach? ............59 GlenD.QuigleyandJennieY.Ngai
18ShouldAntiplateletTherapyBeStoppedPreoperativelyinaPatient withCoronaryArteryStents? ..................................63 CaitlinJ.GuoandKatherineChuy
19IsExtubatingMyCardiacSurgeryPatientPostoperativelyinthe OperatingRoomaGoodIdea? .................................67 JosephKimmelandPeterJ.Neuburger
20IsaPulmonaryArteryCatheterNeededIfYouHaveTransesophageal EchocardiographyinaRoutineCoronaryArteryBypassGrafting? ......71 ChristopherY.TanakaandJohnHui
21WhenShouldYouTransfuseaPatientWhoIsBleedingAfter CardiopulmonaryBypass? ....................................75 CindyJ.Wang
22NeuraxialVersusGeneralAnesthesiainaPatientwithAsymptomatic SevereAorticStenosis ........................................79 PatrickB.SmollenandArthurAtchabahian
23ShouldHigh-RiskCardiacPatientsReceivePerioperativeStatins? .......81 HimaniV.Bhatt
24CardiopulmonaryBypassCases:ToHemodiluteorNot? ..............83 NicoleR.Guinn
25AreSeizuresReallyaProblemAftertheUseofAntifibrinolytics? ........85 DmitryRozinandMadelynKahana
26IsRegionalAnesthesiaforCardiacSurgeryaGoodIdea? .............87 M.MeganChacon
27AreSurgicalandAnesthesiaMedicalMissionsin Low-andMiddle-IncomeCountriesHelpingorHurting?TheEvolving FieldsofGlobalAnesthesiaandGlobalSurgery .....................89 JameyJermaineSnell
PartIIIThoracic
28CanOxygenationinSingle-LungThoracicSurgeryBeAffected byInhibitionofHypoxicPulmonaryVasoconstriction? ................95 RebekahNam
29IsaBronchialBlockerJustasGoodasaDouble-Lumen TubeforAchievingAdequateLungIsolation? ......................97 AlexandraLewisandDavidAmar
30YourThoracicEpiduralisNotWorking:HowDoYouProvide AnalgesiaPost-thoracotomy? ...................................101 AngelaReneeIngramandAnujMalhotra
PartIVPediatric
31PediatricUpperRespiratoryInfection:YouCancelledtheCase andToldtheParentstoReschedule,Right? ........................105 BrianBlasiole
32DoesaLowMeanBloodPressureintheNeonateUnderAnesthesia LeadtoCognitiveDe ficits? ....................................109 AnnaCleboneandCoreyS.Scher
33DoesRapidSequenceInductionHaveaRoleinPediatricAnesthesia? ....111 MichaleSofer
34AnestheticNeurotoxicity:IsAnesthesiaToxictotheDeveloping Brain?ShouldICancelMyBaby’sSurgery? .......................115 MisuzuKameyamaandCoreyS.Scher
35ShouldanAnxiousParentBeAllowedtoBePresentfortheInduction ofAnesthesiainHerChild? ...................................117 PaulA.TripiandMarkM.Goldfinger
36WhatIstheRoleofPremedicationinthePediatricPatient? ............121 ElliotS.SchwartzandAnnaClebone
37PresenceofFamilyMembersintheOperatingRoom:IsThis ReallyHelpful? .............................................125 MichelleN.GontaandMisuzuKameyama
38IsItAppropriateforComplicatedPediatricSurgicalPatients toReceiveCareOutsideofSpecializedPediatricCenters?
MarkM.GoldfingerandPaulTripi
39AretheTransfusionGoalsforaPrematureInfanttheSame Asfora7-Year-Old? ........................................131 OlgaN.Albert
40HowShouldYouGettheAutisticChildintotheOperating RoomWhentheMotherObjectstoIntramuscularKetamine? ..........133 GlennE.MannandJerryY.Chao
41Is “Deep” ExtubationPreferableinPatientsatRisk forBronchospasm? ..........................................135 ManojDalmia
42WhatIstheBestApproachtoaPediatricPatient withanUnexplainedIntraoperativeCardiacArrest? .................139 SherrylAdamicandAnnaClebone
43MalignantHyperthermia: “ItCertainlyIs” Versus “ItCertainlyIsNot!” ........................................143 CoreyS.Scher
44IsTherea “Right” DrugtoChooseWhentheBloodPressureIsLowand MoreVolumeIsnottheAnswerinaPediatricPatient? ...............147 JenniferL.LiedelandMadelynKahana
PartVObstetric
45WhichIsSafer:ATraditionalEpiduraloraCombined SpinalEpidural? ............................................153 JuanDavila-VelazquezandJeffreyBernstein
46WhenShouldaPatientUndergoingDilationandEvacuation ofProductsofGestationBeIntubated? ...........................155 BarbaraOrlando,AgnesMcNamaraLamon,andMigdaliaSaloum
47TwoBloodPatchesHaveFailed.NowWhat? .......................157 AlexanderSinofskyandArthurAtchabahian
48ShouldaSpinalBeUsedforSurgicalAnesthesiaAfteraFailedLabor Epidural? .................................................161 AntonioGonzalezFiolandSuzanneK.W.Mankowitz
49AccidentalDuralPuncture:ShouldanIntrathecalCatheter BeThreaded? ..............................................165 KatherineChuyandShruthimaThangada
50ShouldIntraoperativeCellSalvageBeUsedDuring CesareanDelivery? ..........................................169 AlaeldinA.DarwichandSharonE.Abramovitz
51ShouldDamageControlorTraditionalResuscitation BeUsedforAbnormalPlacentationCases? ........................173 AnnaKorban,AntonioGonzalezFiol,andStephanieR.Goodman
52ManagingtheNoncompliantHIV-PositiveMother: APRO/CONDebate .........................................177 SimonKimandCoreyS.Scher
PartVINeuroanesthesia
53AtWhatHematocritShouldaPatientWhoisUndergoing CraniotomyforTumorbeTransfused? ...........................183 MarkBurbridge
54TraumaticBrainInjury:WhereDoWeStandwithKetamine andHyperventilation? ........................................185 CoreyS.Scher
55IsGeneralAnesthesiaorConsciousSedationMoreAppropriate forPatientsUndergoingEndovascularClotRetrievalforAcute IschemicStroke? ...........................................189 ElinaAbramchayevaandJinuKim
56TranexamicAcidforMajorSpineSurgery ........................193 SergeyPisklakov
57ShouldMajorSpineSurgeryPatientsBeExtubatedintheOperating Room? ...................................................197 A.ElisabethAbramowicz
58GeneralAnesthesiaforIntra-arterialStrokeTreatment(Endovascular MechanicalThrombectomy):StillNeededoraThingofthePast? .......201 A.ElisabethAbramowicz
59IsItBettertoPerformaCraniotomyforBrainTumor ResectionAwake? ...........................................205 JohnL.ArdJr.andIreneKim
60NitrousOxideinNeuroanesthesia:DoesItHaveaPlace? ..............207 ElizabethA.M.Frost
61ShouldWeTreatHypertensionImmediatelyBeforeElectroconvulsive Therapy? .................................................209 ElanaB.Lubit
PartVIITransplant
62ViscoelasticTestinginLiverTransplantation .......................215 CynthiaWang
63Antifi brinolyticsinLiverTransplantation .........................219 CynthiaWang
64WouldYouRecommendAcceptinga “DonationAfterCardiac Death” Liver? .............................................221 CoreyS.Scher
65ShouldOnlyPatientsWhoAreMedicallyOptimizedReceive aLiverTransplant? .........................................225 CoreyS.Scher
66IstheModelforEnd-StageLiverDisease(MELD)ScoretheBest WaytoEvaluateLiverTransplantPatientsPreoperatively? ............229 BenjaminHellerandJeronZerillo
67ASmallBowelTransplantforaPatientwithScleroderma:OnceAgain ontheSlipperySlopeBothClinicallyandEthically ..................233 CoreyS.Scher
PartVIIICriticalCare
68ShouldSteroidsBeUsedinSepticShock? .........................239 SamionShabashev
69ShouldExtracorporealMembraneOxygenationBeUsedfortheEarly TreatmentofAcuteRespiratoryDistressSyndrome? .................241 MelissaM.AnastacioandScottA.Falk
70WhatIstheMostEffectiveInitialResuscitationfortheSeptic ShockPatient? .............................................245 HowardNearman
71ShouldPatientswithAcuteRespiratoryDistressSyndrome BePlacedinthePronePositiontoImproveVentilation? ..............249 AratiPatil
72WhatIstheBestStrategyforVentilationinAcuteRespiratory DistressSyndrome? .........................................251 LeeStein
73IsaSingleDoseofEtomidateforRapidSequenceIntubation(RSI) SafeintheCriticallyIllPatient? ................................255 MattBilbily
74ShouldIntensiveCareUnitPatientsBeDeeplySedated? ..............257 CaitlinJ.Guo
75IsThereAnyAdvantagetoAlbuminOverCrystalloid forVolumeResuscitation? .....................................261 MichaelJ.Naso
76ThereIsNothingDexmedetomidineDoesthatCannotBeDone OldSchool ................................................265 HershPatel
77DoesTreatingSystemicInflammatoryResponseSyndromeLead toBetterOutcomesinSurgicalPatients? ..........................269 NaderSoliman
78ShouldMechanicallyVentilatedIntensiveCareUnitPatients ReceivePhysicalTherapy? ....................................271 JonathanV.Feldstein
PartIXAmbulatory
79ShouldPersistentPostoperativeNauseaandVomitingDelayDischarge ofanAmbulatorySurgeryPatientfromthePost-anesthesiaCareUnit? ...275 DavidShapiroandAndrewGoldberg
80ShouldWePostponeSurgeryinPatientswithUncontrolled PreoperativeHypertension? ....................................279 KristinaNatanandArthurAtchabahian
81ShouldtheMorbidlyObesePatientBeAllowedtoLeave theDayofSurgery? .........................................281 ChristopherJ.CuratoloandAndrewGoldberg
82ShouldComplementaryandAlternativeMedicine(CAM)BeUsedfor theTreatmentofPostoperativePainFollowingAmbulatorySurgery? .....285 DennisGrech,DavidKam,andPreetPatel
83ProsandConsofaFreestandingAmbulatorySurgeryCenter(ASC) VersusaHospital-BasedOperatingRoom .........................289 DennisGrech,PreetPatel,andDavidKam
PartXAcutePain
84CanaRegionalAnestheticAffecttheDevelopmentofPhantom LimbPain? ...............................................295 ChristopherDeNatale
85Charcot–Marie–ToothDiseaseandRegionalAnesthesia:IsPerioperative NeuraxialAnalgesiaReallyContraindicated? .......................297 MagdalenaAnitescu
86PositionalHeadacheWithoutaPreviousLumbarPuncture: WouldaBloodPatchBeUseful? ................................299 MagdalenaAnitescu
87Single-DoseEpiduralMorphineorPatient-ControlledEpidural Analgesia(PCEA)forPost-CesareanPainControl? ..................301 LuciaDaianaVoiculescu,OlgaEydlin,andJosephThomasLargi
88IsOpioidAvoidanceWarrantedforaPatientwithObstructiveSleep ApneainthePostoperativePeriod? ..............................305 LuciaDaianaVoiculescuandOlgaEydlin
PartXIRegional
89IsSpinalorEpiduralAnesthesiaContraindicatedinaPatient withMultipleSclerosis? ......................................311 UchennaO.Umeh
90TheScanner,theTwitcher,orBoth:HowBesttoPerform PeripheralNerveBlocks? .....................................313 JunpingChen
91DoWeKnowtheMechanismofIntravenousLipidEmulsion(ILE) TherapyforHighBloodLevelsofLocalAnesthetics? .................317 OlgaFerreiraMartins
92SecretsBehindKeepingYourBlockCatheterWorking ...............319 MindaL.Patt
93IsanIndwellingNeuraxialorPeripheralNerveCatheterSafeinaTrauma PatientWhoNeedsTwice-DailyLowMolecularWeightHeparin? .......323 BrookeAlbright-TrainerandRobertTrainer
94AwakeorAsleep:CanRegionalNerveBlocksBeSafelyPerformed intheHeavilySedatedorAsleepPatient? .........................327 ShawnaDorman
95IntraneuralInjection:AGoodIdeaornot? ........................331 JanBoublik
96IsaTransversusAbdominisPlane(TAP)BlockBetterThan SurgicalFieldInfiltration? ....................................333 BeamySharma,UchennaO.Umeh,andShruthimaThangada
97IsPoint-of-Care(POC)CoagulationTestingWorthwhileBefore RegionalorNeuraxialAnesthesia? ..............................337 PaulShekane
98ShouldaPeripheralNerveBlockBePlacedinanAnticoagulated Patient? ..................................................339 KiwonSongandKatherineChuy
99AretheBenefi tsofStimulatingPeripheralNerveBlockCatheters WorththeRisks? ...........................................343 AgatheStreiffandJunpingChen
PartXIIChronicPain
100EpiduralSteroidInjectionorPhysicalTherapyforLumbosacral RadiculopathyDuetoDiscHerniation? ...........................349 RyanT.Gualtier
101ShouldaTrialofEpiduralSteroidInjectionsBeDoneBefore ConsideringSpineSurgery? ...................................353 LoriRusso
102EpiduralSteroidInjectionforUnilateralRadicularPain:Isthe TransforaminalApproachSuperiortoInterlaminarInjection? ..........357 LuciaDaianaVoiculescu,TomasJ.Kucera,andAngelaZangara
103IsaTricyclicAntidepressanttheBestFirst-LineAgentinTreating NeuropathicPain? ..........................................361 DaliaH.Elmofty
104WhataretheRisksandBenefi tsofSpinalCordStimulators andIntrathecalPumps? ......................................363 MagdalenaAnitescuandNiraliShah-Doshi
105HowDoYouDetermineIfaPatienthasOpioid-InducedHyperalgesia? ...367 DaliaH.Elmofty
106CanAcuteandChronicPostsurgicalPainBeDecreasedwith PerioperativeNeuropathicAgents? ..............................369 OmarRashidQureshiandSheetalPatil
107IsUrineDrugTestingaGoodIdeaforPatientsonChronic OpioidTherapy? ...........................................373 ChiragD.Shah,M.FahadKhan,andDavidS.Cheng
108Dexamethasone:ToUseorNotToUse ThatistheQuestion ..........377 LuciaDaianaVoiculescuandRahulPathak
109ShouldOpioidAnalgesicsBeUsedforManagingPaininaPatient withaDrugAddiction?.......................................381 TiffanySou
110IsSympatheticBlockadeUsefulinComplexRegionalPain Syndrome(CRPS)? ..........................................383 TomasKuceraandFloriaChae
PartXIIITrauma
111IsPulsePressureVariationMoreAccurateThanCentralVenousPressure (CVP)orPulmonaryArteryPressure(PAP)forVolumeResuscitation? ...389 CoreyS.Scher
112WhatIstheBestManagementStrategyforVenousAirEmbolism? ......393 AmitPrabhakarandJamesRiopelle
113DoesCerebralOximetryHaveanImportantRoleinTrauma? ..........397 CoreyS.Scher
114ShouldNewTraumaParadigmsBeUsedintheCare oftheSevereTraumaPatient? .................................401 CoreyS.Scher
PartXIVPerioperative
115DoHerbalSupplementsCreateUnnecessaryRiskforPatients? .........407 MarkR.Jones,FranciscoCalixto,andAlanDavidKaye
116HowMuchEvaluationoftheAirwayIsEssentialPriortoAnesthesia? ....411 LevonM.Capan,SanfordM.Miller,andCoreyS.Scher
117AreThereConcernswithUsingDroperidolforSedation foranAwakeFiberopticIntubation? .............................415 CoreyS.Scher
118DoSpecialMeasures SuchasPostoperativeCPAP,aProlongedPACU Stay,andPACUEtCO2Monitoring ImprovetheOutcomeinaPatient withObstructiveSleepApnea? .................................419 BrentJ.Luria
PartXVProfessionalism
119DonotResuscitate:WhatDoesthatMeanPerioperatively?
ElizabethA.M.Frost
120ShouldaTraineeBeAllowedtoReturntoAnesthesiology AfterNarcoticDiversionandPresumedAddiction? ..................429 CoreyS.Scher
121ShouldAnesthesiaPersonnelBeSubjecttoMandatoryDrugTesting? ....431 ThorLidasanandJudyChang
122DoesReturningaRecoveredAddictedPhysiciantoActive AnesthesiologyPracticeDoMoreHarmThanGood?
JudyChangandThorLidasan
123DoesDisruptiveBehaviorAmongAnesthesiaCareProviders DecreasePatientSafety? ......................................439 SergeyPisklakov
124IsBurnoutAmongAnesthesiologistsaHumbugoraRealEntity?
SergeyPisklakov
125TheTumorIsInoperable:TellthePatientorPunttotheSurgeon? ......447 ElizabethA.M.Frost
126WhatIstheRoleofPainPhysiciansintheOpioidEpidemic?
NicholasJ.Bremer
Contributors
ElinaAbramchayeva,DO DepartmentofAnesthesiology,MountSinaiWestSt.Luke’s Hospital,NewYork,NY,USA
SharonE.Abramovitz,MD DepartmentofAnesthesiology,NewYorkPresbyterian Hospital WeillCornellMedicine,NewYork,NY,USA
A.ElisabethAbramowicz,MD DepartmentofAnesthesiology,NewYorkMedicalCollege, WestchesterMedicalCenter,Valhalla,NY,USA
SherrylAdamic,BA,MSA DepartmentofAnesthesiology,UniversityHospitalsofCleveland,Cleveland,OH,USA;Mentor,OH,USA
OlgaN.Albert,MD DepartmentofAnesthesiology,PerioperativeandPainMedicine, StanfordUniversityMedicalCenter,Stanford,CA,USA
BrookeAlbright-Trainer,MD DepartmentofAnesthesiology,HunterHolmesMcGuireVA MedicalCenter,Richmond,VA,USA
DavidAmar,MD DepartmentofAnesthesiologyandCriticalCareMedicine,Memorial SloanKetteringCancerCenter,NewYork,NY,USA
MelissaM.Anastacio,MD DepartmentofSurgery,MedstarWashingtonHospitalCenter, Washington,DC,USA
MagdalenaAnitescu,MD,Ph.D DepartmentofAnesthesiaandCriticalCare,Universityof ChicagoMedicine,Chicago,IL,USA
JohnL.Ard,JrMD DepartmentofAnesthesiology,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
ArthurAtchabahian,MD DepartmentofAnesthesiology,NewYorkUniversitySchoolof Medicine,NewYork,NY,USA
JeffreyBernstein,MD DepartmentofAnesthesiology,MontefioreMedicalCenter Weiler Division,Bronx,NY,USA
HimaniV.Bhatt,DO,MPA CardiothoracicDivision,DepartmentofAnesthesiology, MountSinaiMedicalCenter,NewYork,NY,USA
MattBilbily,MD DepartmentofAnesthesiology,KingstonGeneralHospital,Kingston,ON, Canada
IanH.Black,MD DepartmentofSurgery,CheyenneVAMedicalCenter,Cheyenne,WY, USA
BrianBlasiole,MD,Ph.D DepartmentofAnesthesiology,Children’sHospitalofPittsburgh ofUPMC,Pittsburgh,PA,USA
StevenD.Boggs,MD,MBA DepartmentofAnesthesiology,JamesJ.PetersVAMedical CenterandtheMountSinaiHospital,Bronx,NY,USA;DepartmentofAnesthesiology,Icahn SchoolofMedicineatMountSinai,Manhattan,NY,USA
JanBoublik,MD,Ph.D DepartmentofAnesthesiology,PerioperativeandPainMedicine, StanfordSchoolofMedicine,StanfordUniversity,Stanford,CA,USA;Somers,NY,USA
NicholasJ.Bremer,MD DivisionofPainMedicine,DepartmentofAnesthesiology, ColumbiaUniversityMedicalCenter,NewYork,NY,USA
EthanO.Bryson,MD DepartmentsofAnesthesiologyandPsychiatry,IcahnSchoolof MedicineatMountSinai,NewYork,NY,USA
MarkBurbridge,MD DepartmentofAnesthesia,StanfordUniversityMedicalCenter, Stanford,CA,USA
FranciscoCalixto,MD DepartmentofAnesthesiology,TulaneMedicalCenter,New Orleans,LA,USA
LevonM.Capan,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine,NewYorkUniversitySchoolofMedicine,NewYork,NY,USA
M.MeganChacon,MD DepartmentofAnesthesiology,UniversityofNebraskaMedical Center,Omaha,NE,USA
FloriaChae,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
JudyChang,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
JerryY.Chao,MD DepartmentofAnesthesiology,MontefioreMedicalCenter,The UniversityHospitalforAlbertEinsteinCollegeofMedicine,Bronx,NY,USA
JunpingChen,MD,Ph.D DepartmentofAnesthesiology,MountSinaiSt.Luke’sand MountSinaiWestHospital,NewYork,NY,USA
DavidS.Cheng,MD DepartmentofOrthopedicSurgery/PhysicalMedicineandRehabilitation,RushUniversity,Chicago,IL,USA
HowardChing,MD DepartmentofAnesthesiology,NYULangoneMedicalCenter,New York,NY,USA
KatherineChuy,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA;EnglewoodCliffs,NJ, USA
AnnaClebone,MD DepartmentofAnesthesiaandCriticalCare,TheUniversityofChicago, Chicago,IL,USA
ChristopherJ.Curatolo,MD,MEM DepartmentofAnesthesiology,IcahnSchoolof MedicineatMountSinai,NewYork,NY,USA
ManojDalmia,MD DepartmentofAnesthesiology,PerioperativeCareandPainManagement,NewYorkLangoneMedicalCenter,NewYork,NY,USA
AlaeldinA.Darwich,MD DepartmentofAnesthesiology,NewYorkPresbyterianHospital WeillCornellMedicine,NewYork,NY,USA
JuanDavila-Velazquez,MD DepartmentofAnesthesiology,MontefioreMedicalCenter WeilerDivision,Bronx,NY,USA
PaulDelahoussaye,MD DepartmentofAnesthesiology,LouisianaStateUniversityHealth SciencesCenter,NewOrleans,LA,USA
ChristopherDeNatale,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
ShawnaDorman,MD DepartmentofAnesthesia,NewYorkUniversityLangoneMedical Center-HospitalforJointDiseases,NewYork,NY,USA
DaliaH.Elmofty,MD DepartmentofAnesthesiaandCriticalCare,UniversityofChicago, Chicago,IL,USA
OlgaEydlin,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversitySchoolofMedicine,NewYork,NY,USA
ScottA.Falk,MD DepartmentofAnesthesiologyandCriticalCare,Hospitalofthe UniversityofPennsylvania,Philadelphia,PA,USA;Voorhees,NJ,USA
JonathanV.Feldstein,MD DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA
AntonioGonzalezFiol,MD DepartmentofAnesthesiology,Rutgers,NewJerseyMedical School,Newark,NJ,USA;Secaucus,NJ,USA
CedarJ.Fowler,MD,Ph.D,MPH DepartmentofAnesthesiology,PerioperativeandPain Medicine,StanfordUniversity,Stanford,CA,USA
ElizabethA.M.Frost,MBChB,DRCOG IcahnMedicalCenteratMountSinai,NewYork, NY,USA;Purchase,NY,USA
AndrewGoldberg,MD DepartmentofAnesthesiology,IcahnSchoolofMedicineatMount Sinai,NewYork,NY,USA
MarkM.Goldfinger,MD,FAAP DepartmentofAnesthesiologyandPerioperativeMedicine,UniversityHospitalsCaseMedicalCenter,RainbowBabiesandChildren’sHospital, Cleveland,OH,USA
MichelleN.Gonta,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
StephanieR.Goodman,MD DepartmentofAnesthesiology,ColumbiaUniversityMedical Center,NewYorkPresbyterian – Columbia,NewYork,NY,USA
DennisGrech,MD DepartmentofAnasthesiology,RutgersNewJerseyMedicalSchool, Newark,NJ,USA
RyanT.Gualtier,MD DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA
NicoleR.Guinn,MD DepartmentofAnesthesiology,DukeUniversityMedicalCenter, DUMC,Durham,NC,USA
CaitlinJ.Guo,MD,MBA DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
BenjaminHeller,MD DepartmentofAnesthesiology,IcahnSchoolofMedicineatMount Sinai,NewYork,NY,USA
JohnHui,MD DepartmentofAnesthesiology,MontefioreMedicalCenter,AlbertEinstein CollegeofMedicine,Bronx,NY,USA;DepartmentofAnesthesiology,MayoClinic, Rochester,MN,USA
AngelaReneeIngram,MD DepartmentofAnesthesiology,Children’sHospitalofPittsburghofUPMC,Pittsburgh,PA,USA
MarkR.Jones,BA DepartmentofSurgery,HarvardMedicalSchool,Brighamand Women’sHospital,Boston,MA,USA
MadelynKahana,MD DepartmentofAnesthesiology,MontefioreMedicalCenter,Bronx, NY,USA
DavidKam,MD DepartmentofAnasthesiology,PerioperativeMedicine,andPainManagement,UniversityofMiami,Miami,Fl,USA
MisuzuKameyama,DO DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
AlanDavidKaye,MD,Ph.D DepartmentofAnesthesiology,LouisianaStateUniversity HealthSciencesCenter,UniversityMedicalCenter,NewOrleans,LA,USA
SamirKendale,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
M.FahadKhan,MD,MSc,MSPH DepartmentofAnesthesiology,PerioperativeCareand PainMedicine,NewYorkUniversitySchoolofMedicine,NewYork,NY,USA
IreneKim,MD DepartmentofNeurosurgery,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
JinuKim,MD DepartmentofAnesthesiology,MountSinaiWestSt.Luke’sHospital,New York,NY,USA
SimonKim,BA,MD DepartmentofAnesthesiology,BellevueHospital,NewYork,NY, USA;DepartmentofAnesthesiologyandPerioperativeCare,UniversityofCaliforniaIrvine, Orange,CA,USA
JosephKimmel,BSE,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
DanielKohut,MD DepartmentofAnesthesiology,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
AnnaKorban,MD DepartmentofAnesthesiology,Rutgers,NewJerseyMedicalSchool, SouthRiver,NJ,USA
TomasJ.Kucera,MD,MS AttendingPhysician,AdvancedPainManagement,Madison, WI,USA
AgnesMcNamaraLamon,MD DepartmentofAnesthesiology,Mt.SinaiRoosevelt Hospital,NewYork,NY,USA;Durham,NC,USA
JosephThomasLargi,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversitySchoolofMedicine,NewYork,NY,USA
JamesLeonard,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
AlexandraLewis,MD DepartmentofAnesthesiologyandCriticalCareMedicine,Memorial SloanKetteringCancerCenter,NewYork,NY,USA
ThorLidasan,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, BellevueHospitalCenter,NewYork,NY,USA
JenniferL.Liedel,MD DivisionofPediatricCriticalCare,DepartmentofPediatrics,Albert EinsteinCollegeofMedicine,Children’sHospitalatMontefiore,Bronx,NY,USA
ElanaB.Lubit,Ph.D,MD DepartmentofAnesthesiology,NewYorkUniversitySchoolof Medicine/BellevueHospitalCenter,NewYork,NY,USA
BrentJ.Luria,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
AnujMalhotra,MD DepartmentofAnesthesiology,PainManagement,IcahnSchoolof MedicineatMountSinai,NewYork,NY,USA
SuzanneK.W.Mankowitz,MD DepartmentofAnesthesiology,ColumbiaUniversity MedicalCenter,NewYork,NY,USA;Teaneck,NJ,USA
GlennE.Mann,MD DepartmentofAnesthesiology,MontefioreMedicalCenter,The UniversityHospitalforAlbertEinsteinCollegeofMedicine,Bronx,NY,USA
OlgaFerreiraMartins,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
SanfordM.Miller,MD NewYorkUniversitySchoolofMedicine,NewYork,NY,USA; DepartmentofAnesthesiology,BellevueHospitalCenter,NewYork,NY,USA
RebekahNam DepartmentofAnesthesiology,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
MichaelJ.Naso,MD Philadelphia,PA,USA
KristinaNatan,MD NorthernValleyAnesthesiology,Shirley,NY,USA
HowardNearman,MD,MBA DepartmentofAnesthesiologyandCriticalCare,Hospital oftheUniversityofPennsylvania,Philadelphia,PA,USA;DepartmentofAnesthesiologyand PerioperativeMedicine,UniversityHospitalsCaseMedicalCenter,Cleveland,OH,USA
PeterJ.Neuburger,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversitySchoolofMedicine,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
JennieY.Ngai,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversitySchoolofMedicine,NYUAnesthesiaAssociates,NewYork,NY,USA
BarbaraOrlando,MD DepartmentofAnesthesiology,Mount-SinaiWestHospital,New York,NY,USA;Scarsdale,NY,USA
HershPatel,MD,MBA DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA;MonmouthJunction,NJ,USA
PreetPatel,MD DepartmentofAnesthesiologyandPainManagement,RutgersRobert WoodJohnsonMedicalSchool,NewBrunswick,NJ,USA
RahulPathak,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversitySchoolofMedicine,NewYork,NY,USA
AratiPatil,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine,New YorkUniversityLangoneMedicalCenter,NewYork,NY,USA
SheetalPatil,MD DepartmentofAnesthesiaandPainManagement,UniversityofChicago, Chicago,IL,USA
MindaL.Patt,MD DepartmentofAnesthesiology,NewYorkPresbyterianHospital,Weill CornellMedicine,NewYork,NY,USA
SergeyPisklakov,MD DepartmentofAnesthesiology,MontefioreMedicalCenter,Albert EinsteinCollegeofMedicine,Bronx,NY,USA
DavidPorbunderwala,MD DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA
AmitPrabhakar,MD,MS DepartmentofAnesthesiology,LouisianaStateUniversity HealthSciencesCenter,NewOrleans,LA,USA
GlenD.Quigley,MD,MBA DepartmentofAnesthesiology,LankenauMedicalCenter, Wynnewood,PA,USA
OmarRashidQureshi,DO DepartmentofAnesthesiaandCriticalCare,Universityof ChicagoMedicalCenter,Chicago,IL,USA
SaadRasheed,MD DepartmentofAnesthesiology,NewYorkUniversity,NewYork,NY, USA
JamesRiopelle,MD DepartmentofClinicalAnesthesiology,LouisianaStateUniversity HealthSciencesCenter,NewOrleans,LA,USA
LisaQ.Rong,MD DepartmentofAnesthesiology,WeillCornellMedicalCenter,NYP, NewYork,NY,USA
DmitryRozin,MD DepartmentofAnesthesiology,MontefioreMedicalCenter,Bronx,NY, USA
LoriRusso,MD DepartmentofAnesthesiology,NYULangoneMedicalCenter,NewYork, NY,USA
MigdaliaSaloum,MD DepartmentofAnesthesiology,Mt.SinaiWest/Mt.SinaiSt.Luke’s, NewYork,NY,USA;Brooklyn,NY,USA
CoreyS.Scher,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversitySchoolofMedicine/LangoneMedicalCenter,NewYork,NY,USA
ElliotS.Schwartz,BA,MD DepartmentofAnesthesiologyandPerioperativeMedicine, UniversityHospital,CaseWesternReserveUniversity,Cleveland,OH,USA
SamionShabashev,MD DepartmentofAnesthesia,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
NiraliShah-Doshi,MD DepartmentofAnesthesiaandCriticalCare,TheUniversityof ChicagoMedicalCenter,Chicago,IL,USA
ChiragD.Shah,MD,JD DepartmentofPhysicalMedicineandRehabilitation,Rush UniversityMedicalCenter,Chicago,IL,USA
DavidShapiro,MD DepartmentofAnesthesiology,IcahnSchoolofMedicineatMount Sinai,NewYork,NY,USA
BeamySharma,MBA,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
PaulShekane,MD DepartmentofAnesthesiology,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
AlexanderSinofsky,MD DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA;Louisville,KY,UnitedStates
PatrickB.Smollen,MD DepartmentofAnesthesiology,PerioperativeCare,andPain Medicine,NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
JameyJermaineSnell,MD DepartmentofAnesthesiology,PerioperativeandPainMedicine,BostonChildren’sHospital/HarvardMedicalSchool,Boston,MA,USA
MichaleSofer,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
NaderSoliman,MD DepartmentofAnesthesiology,NewYorkUniversity,NewYork,NY, USA;LosAngeles,CA,USA
KiwonSong,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine, NewYorkUniversityLangoneMedicalCenter,NewYork,NY,USA
TiffanySou,MD DepartmentofAnesthesiology,NewYorkUniversityLangoneMedical Center,NewYork,NY,USA
LeeStein,MD DepartmentofAnesthesiology,NewYorkUniversity/Bellevue,NewYork, NY,USA
AgatheStreiff,MD DepartmentofAnesthesiology,MountSinaiSt.Luke’sandMountSinai WestHospital,NewYork,NY,USA
KennethM.Sutin,MD DepartmentofAnesthesiology,PerioperativeCareandPainMedicine,NYUSchoolofMedicine,NewYork,NY,USA
SuzukoSuzuki,MD DepartmentofAnesthesiology,NewYorkUniversityLangoneMedical Center/HospitalforJointDiseases,NewYork,NY,USA
ChristopherY.Tanaka,MD DepartmentofAnesthesiology,MontefioreMedicalCenter, AlbertEinsteinCollegeofMedicine,Bronx,NY,USA
MohanTanniru,MD MIS,SchoolofBusinessAdministrationOaklandUniversity, Rochester,MI,USA
JonathanTeets DepartmentofAnesthesiology,PerioperativeCareandPainMedicine,NYU SchoolofMedicine,NewYork,NY,USA
ShruthimaThangada,MD DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA
JacobTiegs,MD DepartmentofAnesthesiology,PerioperativeCare&PainMedicine,New YorkUniversitySchoolofMedicine,NewYork,NY,USA
RobertTrainer,DO,MBA DepartmentofAnesthesiology,HunterHolmesMcGuireVA MedicalCenter,Richmond,VA,USA
PaulA.Tripi,MD,FAAP DepartmentofAnesthesiologyandPerioperativeMedicine, UniversityHospitalsCaseMedicalCenter,RainbowBabiesandChildren’sHospital,Cleveland,OH,USA
MitchellH.Tsai,MD,MMM DepartmentofAnesthesiology,UniversityofVermont MedicalCenter,Burlington,VT,USA
KevinTurezyn,BA,MD DepartmentofAnesthesiology,NewYorkUniversityLangone MedicalCenter,NewYork,NY,USA;LongIslandCity,NY,USA
UchennaO.Umeh,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversityLangoneMedicalCenter/HospitalforJointDisease,New York,NY,USA;QueensVillage,NY,USA
LuciaDaianaVoiculescu,MD DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversitySchoolofMedicine,NewYork,NY,USA
CindyJ.Wang,MD DepartmentofAnesthesiology,NewYork-PresbyterianHospital/Weill CornellMedicine,NewYork,NY,USA
CynthiaWang,MD DepartmentofAnesthesiologyandPainManagement,Universityof TexasSouthwesternMedicalCenter,Dallas,TX,USA
MelvilleQ.WycheIII,MD DepartmentofAnesthesiology,LouisianaStateUniversity HealthSciencesCenterSchoolofMedicine,NewOrleans,LA,USA
AngelaZangara,BSNRN,MSNFNP DepartmentofAnesthesia,NewYorkUniversity SchoolofMedicine,NewYork,NY,USA;Brooklyn,NY,USA
JeronZerillo,MD DepartmentofAnesthesiology,DivisionofLiverTransplantation,Icahn SchoolofMedicineatMountSinai,NewYork,NY,USA
ShouldRecentClinicalTrialsChange PerioperativeManagementinPatients withCardiacRiskFactors?
CoreyS.Scher
Case
A75-year-oldmanwithaknownhistoryofanischemic cardiomyopathypresentsforresectionofapresumed malignantlivertumor.Hehad2cardiacstentsplacedinthe lastyearandahalf.Hismedicationsincludespironolactone, lisinopril,pioglitazone,andatorvastatin.Healsotakes 81mgaspirinperday.Arecentcardiaccatheterization showedthathisstentswerewideopenandtherewasevidenceofdiffuse,cardiacarterialdiseasenotamenableto stentingorsurgery.Hisejectionfractionis32%,andthere isdiastolicdysfunctiononhisechocardiogram.
Question
Whatisthebestplanforanestheticmanagementinapatient withmultiplecardiacriskfactors?
CON: IthinkIhavealloftheinformationIneedtogoahead withageneralanesthetic,apreoperativethoracicepidural andanawakearteriallinebeforeinduction.Iwillusepulse pressurevariation(PPV)todetermine fluidstatusanduse eitherhetastarchoralbuminifheendsuponthesteep portionoftheStarlingcurvewhereitisessentialtogive fluids.APPV>13%meansthatstrokevolumeischanging withinspirationandexpiration;theseoscillationsimplya decreaseinpreload.ItfollowsthatapatientwithPPV of>13%willbe fluidresponsive[1].Iwouldnothydrateto aPPVlessthan13%asthereisariskof fluidoverloadand congestiveheartfailure.Iwouldgolightlyonthecrystalloidsandbeabitheavy-handedonbloodproductsorcolloid toimprovestrokevolume.Inaddition,Iwillgetacolleague tohelpmeoutwithatrans-esophagealechocardiogram (TEE).
C.S.Scher(&)
DepartmentofAnesthesiology,PerioperativeCareandPain Medicine,NewYorkUniversitySchoolofMedicine,NewYork, NY10016,USA
e-mail:coreyscher@gmail.com
PRO: Ithinkthatyourplanismorethanreasonable;Iam curioushowthisplanevolved.Ithinkthereismorethatyou canofferthepatienttoimprovehiscarebasedonessential clinicaltrials.Tobeginwith,Ithinkthepatientwouldhave benefitedifhehadbeenonastatin.TheCAREtrial (CholesterolAndRecurrentEvents)clearlyshowedthat loweringlow-densitylipoproteins(LDL)withastatinloweredtheriskofacardiaceventinpatientswithdocumented cardiacdisease[2].Itisessentialtonotethatthiswasnotan anesthesiastudybutsimplyastudyonthevalueofstatinson bothlipidsandheartdisease.Therewerefewermyocardial infarctionsinthestatingroupcomparedtoplacebo.Statin useledtoalowerincidenceofinfarctionandstrokewhen interventionssuchasstentsorsurgerywerechosen.More andmoreproofexistsovertimethattakingperioperative statinsisprotectiveagainstcomplications[2].Whilethe relativesuccessoftheCAREtrialwasattributedtolowering LDLanditsassociatedplaqueformation,itispossiblethat thestatinmighthaveimpactedtheamountofinflammation inthecoronaryarteries.
CON: Everypatientshouldbemanagedonacase-by-case approach.AlthoughtheCAREtrialisinteresting,Iwould notdelaythecaseforpreoperativemanagementofhis lipoproteins.Ifhereportedgoodexercisetoleranceand generalfunction,Iwouldgoaheadtoday.Thecancersurgerywillcertainlybemorebeneficialtothispatient’ssurvival.Theevidenceforgivingstatinsatthetimeofsurgery ismuddled,asthestudyisoldandcardiacstentsareaclearer prophylacticparadigmthanstatins.
PRO: Ithinkyoushouldalsoaddabeta-blockertoyour patient’sregimen.ThePOISEtrial(PerioperativeIschemic Evaluation)[3]wasarandomizedcontrolledtrialexploring theimpactofperioperativebeta-blockersoncardiacdeath, non-fatalmyocardialinfarctions,andnon-fatalcardiacarrest. Inthetrial,metoprololwasfoundtodecreasetheriskof non-fatalmyocardialinfarction,whilemakingtheriskof strokeandmortalityhigher[3].Ihavebeenusing
© SpringerInternationalPublishingSwitzerland2017 C.S.Scheretal.(eds.), You’reWrong,I’mRight,DOI10.1007/978-3-319-43169-7_1
beta-blockersforyearsandhaveneverseenacaseofstroke duetohypoperfusion,butIonlyusebeta-blockersinpatients withpersistenthypertensionandnotincasesofhypovolemia. Ititratemydosecarefully.Anindividualevaluationshouldbe performedforeachpatienttodeterminetherisk–benefi tratio ofusingbeta-blockade.Iwouldclearlyuseitinthiscase.
PRO: Idolikethatthepatientisonspironolactone.
CON: Whyisthatafactor?Youwouldhavetomakeupa reasontoconvinceme.
PRO: Thereisgoodevidenceforaldosteroneinhibitorsin patientswithsystolicheartfailure[4].
CON: However,theevidencefrompatientswith heartfailure andapreservedejection fraction(HFpEF),suchasyours,is limited.InpatientswithHFpEF,thefunctionofspironolactonewasconsidered[5].TheoutcomesofpatientshospitalizedforHFpEFwhoreceivedspironolactonewerecompared tothosewhodidnot.Thepost-hospitalmortalityrateand readmissionsat1yearwereanalyzed.Withamultivariate survivalanalysis,1212patientswithHFpEFwithameanage of79yearswerestudied.Themajorityhadhypertensiveheart disease(50.7%).ForpatientswithHFpEF,theadministration ofspironolactonewasassociatedwithanincreaseinall-cause readmission,perhapsduetothehigherrateofhyperkalemia.
PRO: TheAldo-DHFrandomizedcontrolledtrial,the TreatmentofPreservedCardiacFunctionHeartFailurewith anAldosteroneAntagonisttrial[4]anditsechocardiography sub-studyshowedimprovementsinechocardiographic measuresofdiastolicfunctioninpatientsonspironolactone. Inthe firstofthesetrials,hospitalizationforheartfailurewas signifi cantlyreducedwithspironolactonetherapy;therewas nodifferenceintheprimaryoutcomeofcardiovascular death.Inpatientswhoareathighrisk,theremaybea reductionincardiovascularmortality.The finalwordisnot yetin,buttheevidenceisincreasinginfavorofusing spironolactoneforstableheartfailurepatients.
CON: Soundslikethecost–benefitisevolvinginfavorof blockingaldosterone,evenwiththeriskofhyperkalemia.
HowdoIavoid fluidoverload,though?Idonotwantto overloadthispatient.Iwilltitratenormalsalineboluses basedonpulsepressurevariation.
PRO: Fluidadministrationisaloadedtopic.Itmakesnosense togivenormalsaline(NS)becausethesepatientsinvariably endupwithahyperchloremicmetabolicacidosis,whichis associatedwithincreasedmorbidityandmortality[6].
Iwillalsosay,fromallthatIhavereadinthelast2years, colloidsaren’tgreateither.
CON: Sowhathaveyoubeenreadingthatmadeyoucometo thatconclusion?Inmymind,itisclearthatlessvolumeis neededandthepatientslookbetteraftercolloidresuscitation.
PRO: Letusnotconfuseopinionswithfacts.Finallythere aresomestrongdatathatthereisverylittleplaceforcolloid resuscitation.Inafairlyrecentmeta-analysisbyPereletal. [7],theauthorstates, “Thereisnoevidencefromrandomized controlledtrialsthatresuscitationwithcolloidsreducesthe riskofdeath,comparedtoresuscitationwithcrystalloids,in patientswithtrauma,burnsorfollowingsurgery.Furthermore,theuseofhydroxyethylstarchmightincreasemortality.Ascolloidsarenotassociatedwithanimprovementin survivalandareconsiderablymoreexpensivethancrystalloids,itishardtoseehowtheircontinueduseinclinical practicecanbejusti fied” [7].Enoughsaidonthisissue,as thousandsofpatientswereincludedinthe78trialsanalyzed.
CON: Iamstartingtoagree,asIhavenotseenanyrandomizedcontrolledtrialswithstrongdataforcolloids.Iam nowsecond-guessingmyclinicalpractice.
Thereissomethingelsethatisbuggingme.Whilecolloidsappeartonotbeuseful,isthereadifferencebetween crystalloids?
PRO: Actuallythatisanessentialquestion.Balancedsalt solutionssuchasplasmalyte,lactatedRingers,and Normosol-Raresuperiortonormalsalineforresuscitation. Iamgoingtogoonrecorddeclaringthatnormalsalineno longerhasaplaceinmodernmedicine.Simplystated,the titleofapaperinAnesthesiaandAnalgesiain2013by McCluskeyetal.[6]saysitall, “Hyperchloremiaafter noncardiacsurgeryisindependentlyassociatedwith increasedmorbidityandmortality:apropensity-matched cohortstudy.” Thestuffisoutrighttoxic.Afteraliter,you starttogodownthewrongpath.Icannotthinkofacase whereitwouldbeadvantageous.Somearescaredtogive balancedsaltsolutions,withtheirsmallamountsofpotassium,torenalfailurepatients;Ihavefoundthatinclinical practicethisisanonissue.Forresuscitation,hypertonic saline,5–7%,isincreasinglyused,becauseitishyperoncoticandcanbeusedasavolumeexpander.Hypertonic salinedraws fluidintotheintravascularspace,andverylittle isneededtogetthejobdone.Althoughaconcern,hypernatremiaisonlyrarelyseenaftera100ccinfusion.Asingle 100ccbagof5%salinecanbridgeapatienttotransfusion whenbloodisnotavailableorisnotready.Still,caution mustbeexercised,ashypernatremiacanbeassociatedwith signifi cantmorbidityorevenmortality.
CON: Ihaveresuscitatedhundredsofpatientsover30years withnormalsalineandhaveneverhadaproblem.
PRO: Maybeyoujustdon’tfollowupwellwithhowyour patientsdopostoperatively.
CON: I’llmeetyouinthealleyafterI finishthisliversegmentresection.Doyouhaveanymorepearlsofwisdomfor thatcase,SirProfessor?
PRO: Inliverloberesections,withtheexcellentsurgical teamthatwehave,weplace1large-boreIVandablood pressurecuff.Athoracicepiduralisplacedunder fluoroscopicguidance.
CON: Noarterialline?!Andwithnocentralline,howdo youmeasurecentralvenouspressure(CVP)?Thesurgeons alwayswanttheCVPonthelowsidetopreventengorgementoftheliverwhiletheyarecuttingit.Thearteriallineis alsoessentialinapotentialhemorrhage.
PRO: Simplystated,theCVPdoesnotcorrelatewith filling oftheheartasdeterminedbyTEE.Ifyougiveasmalldose ofphenylephrinetoanypatient,theCVPwillincreasewith nochangein fillingpressures[8].
Massicotteetal.publishedapaperthatisconclusivefor mypractice[8].Init,theyask, “dorightventricular end-diastolicvolume(RVEDV)andintrathoracicblood volume(ITBV)byTEErepresentcardiacpreloadbetterthan centralvenouspressure(CVP)andpulmonarycapillary wedgepressure(PCWP)?” Leftventricularend-diastolic volume(LVEDV)istherealmeasureofcardiacpreload,and LVEDVwascomparedtotheseothermeasures.
Itwasdemonstratedthatavarietyoffactors,liketheuse ofpositiveend-expiratorypressure(PEEP)andvasopressors,hadasigni ficantimpactonCVPbutasmalleffecton LVEDV(truecardiacpreload).WhentheCVPishigh,itis inconceivablethatyoucouldloweritwithanytechnique otherthanphlebotomy whichyouwouldneverwanttodo inaliverresection[8].Simplystated,maybe,andI emphasizemaybe,CVPcouldbevaluableintrending.Ifa centralveinisverydistensible,addingvolumemaynot increaseCVPandiftheveinused,bynature,isnotdistensible,smallchangesinvolumemayincreasetheCVP signifi cantlywithoutanyimpactonpreload.
Andhowwouldyoumanagethispatient’sdiabetes?
PRO: Therearemanyofuswhopracticeanesthesiaanddo notknowwhattolookforinpostoperativevisits.Ifitisnot inouranesthesiologyjournals,itdoesnotmeanitdoesnot exist.
Thepatientisonpioglitazone,anoralagentfordiabetes. “OptimalGlucoseManagementinthePerioperativePeriod” isanexcellentpaper[9]fromthesurgicalliteratureona topicthatIwas “soft” on.InthepastIwouldnotcancela caseforabloodsugarof200.Infact,theseborderline glucoselevelsonlyclimbasthecaseproceeds.Hyperglycemiaisdefinedasglucosegreaterthan189mg/dl. Factorscontributingtopoorcontrolinclude “counterregulatoryhormones,hepaticinsulinresistance,decreased insulin-stimulatedglucoseuptake,useof dextrose-containingintravenous fluids,andenteralandparenteralnutrition” [9].Hyperglycemiaintheperioperative periodisassociatedwithincreasedmorbidityanddecreased survival.Bothmorbidityandmortalityaroundthetimeof surgeryaredecreasedbyidealglucosemanagement.Inow measureglucosewithavenoussampleandsenditofftothe laboratorywitharequestforimmediateresultsorobtainan arterialorvenousbloodgas,whichgivesyouaresponse withinminutes.Iwouldnowcharacterizemybehaviorsurroundinghyperglycemiaas “intense.”
CON: Wouldyougothroughthis “intense” therapyfora glucoseof200?
PRO: Withsurgicalstimulationandtheaccompanying cortisolrelease,theglucoseonlygoesup,andyes,anything above180receivesintenseinsulintherapy.Therehastobea linesomewhere,thatisthetriggerpoint.Therearesomany prosandconsinwhatappearstobearoutinecase.Letus lookatsomeofthemafterconsultingourcolleaguesinour department.
CON: Weneedtochatmore.Iamreadytogointothe operatingroom.Despitetheimpressivedatabaseyouhavein yourmind,IwilldothiscasejustlikeIalwayshave.
Summary
Thesepapersmightchangethewayyoupractice.Staying currentisessentialassomuchoftheliteraturefromthetime thatIwasaresidentissimplynottrueanymore.Although noteverystudywillstandthetestoftime,itisworth
examininganddiscussingthelatestliteraturewithyour colleagues,fortheultimatebenefi tofthepatientsyoucare foreveryday.
References
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Peter always took note of everything new and important that he saw. Vitsen had to take him everywhere—to the hospitals, the foundling asylums, and the prayer meetings of different religious sects. He found great pleasure in the anatomical cabinet of the celebrated Ruisch, who had greatly advanced the art of preserving corpses from decomposition by injections. It was with difficulty that the czar could be got out of the room. He stood there transfixed and as it were unconscious, and he could not pass before the body of a child, that seemed to smile as if it were alive, without kissing it. His taste for being present at surgical operations went so far that at his request a special door was made in the wall of the St. Peter Hospital, by which he could enter it with Ruisch from the embassy, unobserved and unmolested by the curious. It was this doctor who recommended to him the surgeons for the new Russian naval and military troops.
After a stay of two months the Russian embassy went to the Hague, where it had long been expected. The entry was even more magnificent than at Amsterdam. Peter wished to attend the formal audience of his embassy in strict incognito. Vitsen, accompanied by two gentlemen, fetched him in his carriage. The czar wished to take along his dwarf, and when told that space was lacking, he replied: “Very well, then, he will sit on my lap.” At his command a drive was taken outside the town. At every one of the many mills that he passed, he asked what it was for; and on being told that one before which there were no stores was a grinding-mill, he jumped out of the carriage, but it was locked. On the road to Haarlem he observed a small water-mill for irrigating the land. It was in vain that they told him it was encompassed by water. “I must see it,” was the reply. The czar satisfied his curiosity and returned with wet feet. Twilight was already setting in, and the Dutch escort of the czar were rejoicing that the sight-seeing was at an end. But alas! before entering the Hague, Peter felt the carriage give a sharp jolt. “What is it?” he inquired. He was told that the carriage had driven on to a ferry-boat. “I must see it,” said he, and by lantern light the width, length, and depth of the ferry-boat had to be taken. Finally, at eleven at night, one of the best hotels in the Hague was reached. The czar was given a beautiful bedroom with a four-post bed. He preferred a garret. After midnight it
occurred to him to spend the night at the hotel where his ambassadors were. Looking there for a place to sleep in, he found a Russian servant snoring on a bear skin. With a few kicks he awakened him. “Go away, go away, I am going to sleep here.” At last he found a comfortable resting place.
On the day of the audience, Peter dressed himself as an ordinary nobleman in a blue garment not overladen with gold lace, a large blond wig, and a hat with white feathers. Vitsen led him to the anteroom of a hall where soon the members of the states general and many distinguished spectators assembled. As some time passed before the retinue of his embassy arrived, and meanwhile all eyes in the hall were turned towards the ante-chamber where the czar was, he became extremely restless. “It takes too long,” he said and wanted to depart. But Vitsen represented to him that he would have to pass through the hall where the states general were already assembled. Thereupon he demanded that the lords should turn their backs to him as he passed through the room. Vitsen replied that he could command the lords nothing, as they were the representatives of the sovereignty of the land, but that he would ask them. The reply brought back was that the lords would stand up as the czar passed through the room, but would not turn their backs. Peter then drew his great wig before his face and ran at full speed through the assembly room and down the porch.
In the Hague also Peter had several informal meetings with the stadholder, King William; he became personally acquainted with the eminent statesmen Heinsius, Van Slingerland, Van Welde, Van Haven, and with the recorder of the states general, Franz Flagel. He besought the latter to find him someone who would know how to organise the Russian chancellery on the Dutch model. He also entered into connection with the celebrated engineer, General Coehorn, and on his recommendation took many Dutch engineering officers into the Russian service.
As Peter next undertook a journey to Leyden, the great scientist Leeuwenhoek had to come on board his yacht. He brought some of his most beautiful apparatus and a microscope with him. Peter conversed with him for two hours, and manifested much pleasure in
the observation of the circulation of the blood in fishes. Boerhaave took him to the Botanical Gardens and to the anatomical lectureroom. On observing that one of his suite could not hide his aversion for a body which seemed to him particularly worthy of observation on account of its exposed sinews, he ordered him to tear out one of these sinews with his teeth.
From Leyden, Peter returned to Amsterdam. Here he often joined in the work on the galley which had been commenced at his request. In the name of the town Vitsen requested the czar to accept this ship as a present. Peter gave it the name Amsterdam, and in the following year, laden with wares bought by Peter himself, it started on its first journey to Archangel. From Amsterdam Peter often made excursions to Zaandam, ever keen and confident, although his Russian attendants trembled and quaked at the threatening dangers. On market days he was greatly entertained by the quacks and tooth drawers. He had one of the latter brought to him, and with great dexterity soon acquired the knack necessary for this profession. His servants had to provide him with opportunities for practising the newly acquired art.
Through Vitsen the Dutch Jews petitioned the czar to permit their nation, which had been banished by Ivan IV from Russia, to re-enter it, and they offered to prove their gratitude by a present of 100,000 gulden. “My good Vitsen,” replied Peter, “you know my nation and that it is not yet the time to grant the Jews this request. Tell them in my name that I thank them for their offer, but that their condition would become pitiable if they settled in Russia, for although they have the reputation of swindling all the world in buying and selling, I am afraid they would be greatly the losers by my Russians.”
During his sojourn in Amsterdam Peter received the joyful news of two successful engagements against the Tatars in July and August. To celebrate this victory he gave a brilliant fête to the authorities and merchants of the town. The brilliant victory of Prince Eugene at Zenta was yet more decisive for the issue of the war against the Turks.
On the 9th of November Peter, accompanied only by Lefort, returned to the Hague, where he informed King William III of his desire to see England. The king preceded him, and sent three men of war and a yacht under the command of Admiral Mitchel to conduct the czar. On the 18th of January, 1698, accompanied by Menshikov and fifteen other Russians of his suite, he set sail at Hellevoetsluis. Soon after the first days of his arrival in England, he exchanged the dwelling assigned to him in the royal castle of Somerset for the house of Mr. Evelyn at Deptford in the neighbourhood of the admiralty works, whence he could enter the royal construction yards unseen. There he learned from the master builders how to draw up the plan according to which a ship must be built. He found extreme pleasure in observing the cannon at the Tower, and also the mint, which then excelled all others in the art of stamping.
In his honour Admiral Carmarthen instituted a sham sea fight at Spithead on the 3rd of April which was conducted on a greater scale than a similar spectacle given for him in Holland. He often visited the great cathedrals and churches. He paid great attention to the ceremonial of English church worship; he also visited the meetinghouses of the Quakers and other sects. At Oxford he had the organisation and institutions of the university shown him. As in Holland, he preferred to pass most of his time with handicraftsmen and artists of every kind; from the watchmaker to the coffin maker, all had to show him their work, and he took models with him to Russia of all the best and newest. During his stay he always dressed either as an English gentleman or in a naval uniform.
In Holland the English merchants had presented the czar with a memorial through Count Pembroke on the 3rd of November, 1697, in which they had petitioned for permission to import tobacco (which had been so strongly forbidden under the czars Michael and Alexis), and offered to pay a considerable sum of money for the privilege. The marquis of Carmarthen now again broached the subject, and on the 16th of April a treaty was signed with the Russian ambassador Golovin for three years, which authorised Carmarthen’s agents to import into the Russian Empire in the first year three thousand hogsheads (of five hundred English pounds each), and in each of the
following two years four thousand hogsheads, against a tax of 4 kopecks in the pound. Twelve thousand pounds were paid down in advance. This money placed the czar in a position to make still greater purchases, as well as to engage a greater number of foreigners in his service; amongst them the astronomer and professor of mathematics Ferguson of Scotland, the engineer Captain Perry, and the shipbuilders John Dean and Joseph Ney.f
King William made Peter a present of the Royal Transport, a very beautiful yacht, which he generally used for his passage over to Holland. Peter went on board this vessel, and got back to Holland in the end of May, 1698. He took with him three captains of men-of-war, five-and-twenty captains of merchant ships, forty lieutenants, thirty pilots, thirty surgeons, two hundred and fifty gunners, and upwards of three hundred artificers. This colony of ingenious men in the several arts and professions sailed from Holland to Archangel on board the Royal Transport; and were sent thence to the different places where their service was necessary. Those whom he engaged at Amsterdam took the route of Narva, at that time subject to Sweden.
[1698 ]
While the czar was thus transporting the arts and manufactures from England and Holland to his own dominions, the officers whom he had sent to Rome and Italy succeeded so far as also to engage some artists in his service. General Sheremetrev, who was at the head of his embassy to Italy, made the tour of Rome, Naples, Venice, and Malta; while the czar proceeded to Vienna with the other ambassadors. All he had to do now was to observe the military discipline of the Germans, after seeing the English fleet and the dockyards in Holland. But it was not the desire of improvement alone that induced him to make this tour to Vienna, he had likewise a political view; for the emperor of Germany was the natural ally of the Russians against the Turks. Peter had a private audience of Leopold, and the two monarchs stood the whole time of the interview, to avoid the trouble of ceremony.
EXECUTION OF THE STRELITZ BY COMMAND OF PETER THE GREAT
(Painted for T H ’ H W by Thure de Thulstrup)
During his stay at Vienna, there happened nothing remarkable, except the celebration of the ancient feast of “landlord and landlady,” which Leopold thought proper to revive upon the czar’s account,
after it had been disused during his whole reign. The manner of making this entertainment, to which the Germans gave the name of Wirthschaft, was as follows: The emperor was landlord, and the empress landlady; the king of the Romans, the archdukes, and the archduchesses were generally their assistants; they entertained people of all nations, dressed after the most ancient fashion of their respective countries. Those who were invited as guests drew lots for tickets; on each of which was written the name of the nation, and the character to be represented. One had a ticket for a Chinese mandarin, another for a Tatar mirza, another for a Persian satrap, or a Roman senator; a princess might happen to be allotted the part of a gardener’s wife, or a milkwoman; and a prince might act the peasant or soldier. They had dances suited to these different characters; and the landlord and landlady with their family waited at table. On this occasion Peter assumed the habit of a Friesland boor, and in this character was addressed by everybody, at the same time that they talked to him of the great czar of Muscovy. “These indeed are trifles,” says Voltaire, from whom the account is taken, “but whatever revives the memory of ancient customs is, in some measure, worthy of being recorded.”
THE INSURRECTION OF THE STRELITZ
Peter was preparing to continue his journey from Vienna to Venice and Rome when he was recalled to his own dominions by news of a general insurrection of the strelitz, who had quitted their posts on the frontiers, and marched on Moscow. Peter immediately left Vienna in secret, passed through Poland, where he had an interview with King Augustus, and arrived at Moscow in September, 1698, before anyone there knew of his having left Germany.e
When Peter I arrived from Vienna he found that his generals and the douma had acted with too great leniency. He cherished an old grudge against the strelitz; they had formed the army of Sophia which had been arrayed against that of the czar, and in his mind was still alive the memory of the invasion of the Kremlin, the murder of his maternal relatives, the terrors undergone by his mother in Troitsa,
the plots that had well-nigh prevented his departure for the west, and the check placed by the mutineers on the plans he had matured for the good of his country during his journey through Europe. He resolved to seize the opportunity thus placed in his hands to crush all his enemies at one blow, and to inaugurate in old Russia a reign of terror that should recall the days of Ivan IV. The particular point of attack had been his taste for foreign fashions, for shaven chins, and abbreviated garments. These therefore should be the rallying-sign of the Russia of the future. Long beards had been the standard of revolt; long beards must fall. He ordered all the gentlemen of his realm to shave, and even performed that office with his own hand for some of the highest nobles of his court. On the same day the Red Square was covered with gibbets. The patriarch Adrian tried in vain to divert the anger of the czar. “My duty is to protect the people and to punish rebels,” was the only answer he received.
On the 10th of October a first consignment of two hundred prisoners arrived in the Red Square, followed by their wives and children, who ran behind the carts chanting funeral dirges. The czar ordered several officers to assist the headsman in his work. Johann Korb, an Austrian who was an eye-witness of the scene, relates that the heads of “five rebels were struck off by the noblest hand in Russia.” Seven more days were devoted to the executions, and in all about a thousand victims perished. Many were previously broken on the wheel or given up to other frightful tortures. The czar forbade the removal of any of the bodies, and for five months Moscow was given the spectacle of corpses hanging from the turrets of the Kremlin, or exposed in the public squares. Two of Sophia’s female confidantes were buried alive, and Sophia herself and the repudiated czarina, Eudoxia Lapukhin, noted for her attachment to old customs, were confined in monasteries. After the revolt of the inhabitants of Astrakhan, who murdered their voyevod (1705), the militia was abolished and the way was clear for the establishment of a new army.g
WAR WITH SWEDEN
[1699 ]
The external relations as well as the domestic circumstances of the empire were at this juncture peculiarly favourable to the czar’s grand design of opening a communication with the Baltic. He had just concluded a treaty of peace for thirty years with the Turks, and he found himself at the head of a numerous army, a portion, at least, of which was well disciplined, and eager for employment. The death of General Lefort, in 1699, at the early age of forty-six, slightly retarded the progress of his movements; but in the following year he prepared to avail himself of events that called other powers into action and afforded him a feasible excuse for taking the field.
Charles XII, then only eighteen years of age, had recently succeeded to the throne of Sweden. The occasion seemed to yield an auspicious opportunity to Poland and Denmark for the recovery of certain provinces that in the course of former wars had either been wrested from them by Sweden, or ceded by capitulation. Augustus, the elector of Saxony, called by choice to the throne of Poland, was the first to assert this doctrine of restitution, in which he was quickly followed by the Danish king. Livonia and Esthonia had been ceded by Poland to Charles XI, and the provinces of Holstein and Schleswig had been conquered from Denmark in the same reign, and annexed to the Swedish territories. The object of the allies was to recover those places. Sweden, thus assailed in two quarters, presented an apparently easy victory to the czar, whose purpose it was to possess himself of Ingria and Karelia, that lay between him and the sea. A confederacy was, therefore, entered into by the three powers for the specific view of recovering by war those provinces that had previously been lost by war. But Peter miscalculated his means. The arms of Sweden were crowned with triumphs, and her soldiery were experienced in the field. The Russian troops, on the contrary, were for the greater part but raw recruits, and, except against the Turks and Tatars, had as yet but little practice in military operations. The genius of Peter alone could have vanquished the difficulties of so unequal a contest.
The preparations that were thus in course of organisation awakened the energies of Charles. Without waiting for the signal of
attack from the enemy, he sent a force of eight thousand men into Pomerania, and, embarking with a fleet of forty sail, he suddenly appeared before Copenhagen, compelled the king of Denmark within six weeks to sign a peace by which the possession of Holstein was confirmed to the reigning duke, and a full indemnity obtained for all the expenses of the war. He had no sooner overthrown the designs of the Danish monarch than he turned his arms against Poland. Augustus had laid siege to Riga, the capital of Livonia; but that city was defended with such obstinacy by Count Dalberg that the Polish general was glad to abandon the enterprise, upon the shallow pretext that he wished to spare the Dutch merchandise which was at that time stored in the port. Thus the confederation was dissolved, and the struggle was left single-handed between the Russians and the Swedes.
Peter, undismayed by the reverses of his allies, poured into Ingria an army of sixty thousand men. Of these troops there were but twelve thousand disciplined soldiers; the remainder consisted of serfs and fresh levies, gathered from all quarters, rudely clad, armed only with clubs and pikes, and unacquainted with the use of firearms. The Swedish army, on the other hand, was only eight thousand strong; but it was composed of experienced battalions, flushed by recent successes, and commanded by able generals. The advanced guards of the Russians were dispersed on their progress, in some skirmishes with the Swedes; but the main body penetrated to the interior, and intrenched itself before the walls of Narva, a fortified place on the banks of the Narova, a river that flowed from Lake Peipus into the Baltic Sea. For two months they lay before the town, when Peter, finding it necessary to hasten the movements of some regiments that were on their march from Novgorod, as well as to confer with the king of Poland in consequence of his abandonment of the siege of Riga, left the camp, delegating the command to the duke of Croy, a Flemish officer, and prince Dolgoruki, the commissary-general.
[1701 ]
His absence was fatal to this undertaking. Charles, during a violent snow-storm, that blew directly in the face of the Russians, attacked the
enemy in their intrenchments. The besiegers were filled with consternation. The duke of Croy issued orders which the prince Dolgoruki refused to execute, and the utmost confusion prevailed amongst the troops. The Russian officers rose against the Germans and massacred the duke’s secretary, Colonel Lyons, and several others. The presence of the sovereign was necessary to restore confidence and order, and, in the absence of a controlling mind the soldiers, flying from their posts and impeding each other in their attempts to escape, were slaughtered in detail by the Swedes. In this exigency, the duke of Croy, as much alarmed by the temper of the Russians as by the superiority of the enemy, together with almost all the German officers in the service, surrendered to the victorious Charles, who, affecting to despise his antagonist, contented himself with retaining a few general officers and some of the Saxon auxiliaries, as prisoners to grace his ovation at Stockholm, and suffered the vanquished troops to return home. Thus failed the first descent upon Ingria, which cost Russia, even on the statement of the czar himself, between five thousand and six thousand men. The loss of the Swedes is estimated by Peter at three thousand, but Voltaire reduces the number to twelve hundred, which, considering the relative positions of both armies, and the disadvantages of other kinds under which the Russians were placed, is more likely to be accurate.
This unpropitious event did not discourage Peter. “The Swedes,” he observed, “will have the advantage of us for some time, but they will teach us, at last, how to beat them.” If Charles, however, had followed up his success, and pushed his fortunes into the heart of Russia immediately after this victory, he might have decided the fate of the empire at the gates of Moscow. But, elated with his triumphs in Denmark, and tempted by the weakness of the Poles, he embraced the more facile and dazzling project of concentrating his whole power against Augustus, declaring that he would never withdraw his army from Poland until he had deprived the elector of his throne. The opportunity he thus afforded Peter of recruiting his shattered forces, and organising fresh means of aggression, was the most remarkable mistake in the whole career of that vain but heroic monarch.
