https://aa2day.org episodic AA2day.orgAA2day.org hosted by AA2day.org AA2day.org en-us Copyright 2018 AA2day.orgAA2day.org podcast@blubrry.com (Blubrry Podcasting) AA2day.org podcast@blubrry.com https://aa2day.org https://assets.blubrry.com/coverart/orig/22716.jpg Blubrry Podcasting: https://www.blubrry.com/ Mon, 22 Oct 2018 16:37:38 -0400 clean http://blogs.law.harvard.edu/tech/rss Thu, 26 Mar 2015 20:05:37 -0400 http://aa2day.org/2015/03/dissection/ http://www.blubrry.com/aa2day/2662900/early-diagnosis-of-retrograde-type-a-aortic-dissection-after-thoracoabdominal-aneurysm-repair/ AA2day.org Podcast Thu, 26 Mar 2015 20:05:37 -0400 Also available on YouTube (http://youtu.be/A6VPvwZK4ms). Type A aortic dissection immediately after open replacement of the thoracoabdominal aorta is a rare and potentially lethal complication that has only been reported twice previously. Dr. Abraham Sonny, Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, and colleagues describe a 74-year-old man with a history of expanding Crawford Type I thoracoabdominal aortic aneurysm who presented for open surgical repair in their article published in the March 1 issue of A&A Case Reports titled “Retrograde Type A Aortic Dissection After Thoracoabdominal Aneurysm Repair: Early Diagnosis with Intraoperative Transesophageal Echocardiography (http://journals.lww.com/aacr/Fulltext/2015/03010/Retrograde_Type_A_Aortic_Dissection_After.3.aspx).”   Routine intraoperative transesophageal echocardiography after the repair revealed a new type A aortic dissection extending up to the sinotubular junction. Subsequent emergent aortic arch repair was performed successfully under deep hypothermic circulatory arrest. Intraoperative type A aortic dissection is associated with a very high risk of early mortality and morbidity such as prolonged ventilation, renal failure, and cardiogenic shock. Routine postoperative transesophageal echocardiographic exam after aortic surgery facilitates early diagnosis and may identify associated complications such as pericardial effusion, aortic insufficiency, and coronary ischemia. Efficient surgical decision making and cerebral protection during the emergent repair are necessary for a successful outcome. 0:01:42 no AA2day.org Also available on YouTube (http://youtu.be/A6VPvwZK4ms). Type A aortic dissection immediately after open replacement of the thoracoabdominal aorta is a rare and potentially lethal complication that has only been reported twice previously. Dr. Also available on YouTube (http://youtu.be/A6VPvwZK4ms). Type A aortic dissection immediately after open replacement of the thoracoabdominal aorta is a rare and potentially lethal complication that has only been reported twice previously. Dr. Abraham Sonny, Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, and colleagues describe a 74-year-old man with a history of expanding Crawford Type I thoracoabdominal aortic aneurysm who presented for open surgical repair in their article published in the March 1 issue of A&A Case Reports titled “Retrograde Type A Aortic Dissection After Thoracoabdominal Aneurysm Repair: Early Diagnosis with Intraoperative Transesophageal Echocardiography (http://journals.lww.com/aacr/Fulltext/2015/03010/Retrograde_Type_A_Aortic_Dissection_After.3.aspx).”   Routine intraoperative transesophageal echocardiography after the repair revealed a new type A aortic dissection extending up to the sinotubular junction. Subsequent emergent aortic arch repair was performed successfully under deep hypothermic circulatory arrest. Intraoperative type A aortic dissection is associated with a very high risk of early mortality and morbidity such as prolonged ventilation, renal failure, and cardiogenic shock. Routine postoperative transesophageal echocardiographic exam after aortic surgery facilitates early diagnosis and may identify associated complications such as pericardial effusion, aortic insufficiency, and coronary ischemia. Efficient surgical decision making and cerebral protection during the emergent repair are necessary for a successful outcome. http://aa2day.org/2015/03/april2015/ http://www.blubrry.com/aa2day/2662899/april-2015-anesthesia-analgesia/ AA2day.org Podcast Wed, 25 Mar 2015 20:05:14 -0400 (http://aa2day.org/wp-content/uploads/2015/03/April-cover-infection-small-300x200.jpg) Also available on YouTube. Dr. Steven Shafer, editor-in-chief, Anesthesia & Analgesia: Recent news reports have highlighted the risks of nosocomial infection. Fourteen articles in this issue of Anesthesia & Analgesia document how anesthesiologists make a difference in perioperative infection. Research papers identify the reservoirs of bacterial contamination in the operating room, our role in hospital-acquired infections, and changes in anesthesia practice to reduce hospital-acquired infections. Hamaekers and colleagues (Rescue Ventilation Through a Small-Bore Transtracheal Cannula in Severe Hypoxic Pigs Using Expiratory Ventilation Assistance (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/Rescue_Ventilation_Through_a_Small_Bore.28.aspx)) describe the ability of a novel device incorporating active support of expiration to facilitate transtracheal ventilation and restore oxygenation in pig model of airway obstruction with severe hypoxia. Borkett and colleagues (A Phase IIa, Randomized, Double-Blind Study of Remimazolam (CNS 7056) Versus Midazolam for Sedation in Upper Gastrointestinal Endoscopy (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/A_Phase_IIa,_Randomized,_Double_Blind_Study_of.14.aspx)) from Paion UK Ltd report that a new benzodiazepine ester, remimazolam, produced rapid onset and offset of sedation for patients undergoing a diagnostic upper GI endoscopy. Banergee and colleagues (EN3427: A Novel Cationic Aminoindane with Long-Acting Local Anesthetic Properties (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/EN3427___A_Novel_Cationic_Aminoindane_with.34.aspx)) at Endo Pharmaceuticals report on a novel TRP channel-mediated local anesthetic, EN3427, that combined with lidocaine produced ~ 24 hours of analgesia in rats. As noted by Berde in his editorial (Developing Better Local Anesthetics (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/Developing_Better_Local_Anesthetics.9.aspx)), better local anesthetics “could have an enormously positive impact on patient comfort, perioperative outcomes, including rehabilitation, and on the progression from acute to chronic pain.” Naveen Nathan, MD, Cover Editor and Illustrator: The most expansive gradient in the operating room is not that of end-organ perfusion pressure, core-to-ambient temperature or even the ascent to steady-state plasma drug concentration. It is that which graduates from the sanctity of the sterile environment to the hidden civilization of unicellular life that thrives amidst every groove, crevasse and ridge of the anesthetic workplace. Truly this is an inert workstation to us but a teeming metropolis to the masses hidden in plain sight. In our honorable roles as shepherds of our patients’ well-being, we unwittingly act as vessels that provide passage to every would-be symbiote, commensal and parasite to our defenseless host. A reminder of the exponent that defines their propagative potential should suffice to astound even the most dismissive mind. 0:02:41 no AA2day.org (http://aa2day.org/wp-content/uploads/2015/03/April-cover-infection-small-300x200.jpg) Also available on YouTube. Dr. Steven Shafer, editor-in-chief, Anesthesia & Analgesia: Recent news reports have highlighted the risks of nosocomial infection. (http://aa2day.org/wp-content/uploads/2015/03/April-cover-infection-small-300x200.jpg) Also available on YouTube. Dr. Steven Shafer, editor-in-chief, Anesthesia & Analgesia: Recent news reports have highlighted the risks of nosocomial infection. Fourteen articles in this issue of Anesthesia & Analgesia document how anesthesiologists make a difference in perioperative infection. Research papers identify the reservoirs of bacterial contamination in the operating room, our role in hospital-acquired infections, and changes in anesthesia practice to reduce hospital-acquired infections. Hamaekers and colleagues (Rescue Ventilation Through a Small-Bore Transtracheal Cannula in Severe Hypoxic Pigs Using Expiratory Ventilation Assistance (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/Rescue_Ventilation_Through_a_Small_Bore.28.aspx)) describe the ability of a novel device incorporating active support of expiration to facilitate transtracheal ventilation and restore oxygenation in pig model of airway obstruction with severe hypoxia. Borkett and colleagues (A Phase IIa, Randomized, Double-Blind Study of Remimazolam (CNS 7056) Versus Midazolam for Sedation in Upper Gastrointestinal Endoscopy (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/A_Phase_IIa,_Randomized,_Double_Blind_Study_of.14.aspx)) from Paion UK Ltd report that a new benzodiazepine ester, remimazolam, produced rapid onset and offset of sedation for patients undergoing a diagnostic upper GI endoscopy. Banergee and colleagues (EN3427: A Novel Cationic Aminoindane with Long-Acting Local Anesthetic Properties (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/EN3427___A_Novel_Cationic_Aminoindane_with.34.aspx)) at Endo Pharmaceuticals report on a novel TRP channel-mediated local anesthetic, EN3427, that combined with lidocaine produced ~ 24 hours of analgesia in rats. As noted by Berde in his editorial (Developing Better Local Anesthetics (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/04000/Developing_Better_Local_Anesthetics.9.aspx)), better local anesthetics “could have an enormously positive impact on patient comfort, perioperative outcomes, including rehabilitation, and on the progression from acute to chronic pain.” Naveen Nathan, MD, Cover Editor and Illustrator: The most expansive gradient in the operating room is not that of end-organ perfusion pressure, core-to-ambient temperature or even the ascent to steady-state plasma drug concentration. It is that which graduates from the sanctity of the sterile environment to the hidden civilization of unicellular life that thrives amidst every groove, crevasse and ridge of the anesthetic workplace. Truly this is an inert workstation to us but a teeming metropolis to the masses hidden in plain sight. In our honorable roles as shepherds of our patients’ well-being, we unwittingly act as vessels that provide passage to every would-be symbiote, commensal and parasite to our defenseless host. A reminder of the exponent that defines their propagative potential should suffice to astound even the most dismissive mind. http://aa2day.org/2015/03/lidocainepain/ http://www.blubrry.com/aa2day/2662898/lidocaine-purinergic-receptors-and-chronic-pain/ AA2day.org Podcast Tue, 24 Mar 2015 20:05:23 -0400 Also available on YouTube (http://youtu.be/BPuMI_yCEZA). Systemic lidocaine has several useful effects including the relief of chronic pain, and anti-inflammatory and antithrombotic actions. These diverse properties strongly suggest that mechanisms other than sodium channel blockade may be implicated in mediating the beneficial effects of lidocaine. Extracellular adenosine triphosphate (ATP) is a neurotransmitter acting through the ATP receptors P2X (ligand-gated ion channels) and P2Y (G-protein-coupled receptors). These receptors are widely distributed and are involved in many pathological conditions such as ischemia, inflammation, and pain. Dr. Takafumi Horishita, Department of Anesthesiology, School of Medicine, University of Occupational and Environmental Health, Yahatanishiku, Kitakyushu, Fukuoka, Japan, and colleagues from the Departments of Occupational Toxicology and Pharmacology, together with colleagues from the Department of Molecular Pathology and Metabolic Disease, Tokyo University of Science, Noda, Chiba, Japan, and the Cancer Pathophysiology Division, National Cancer Center Research Institute, Chuouko, Tokyo, Japan, investigated the effects of lidocaine on purinergic receptors. Their results are discussed in the article titled “Lidocaine Preferentially Inhibits the Function of Purinergic P2X7 Receptors Expressed in Xenopus Oocytes (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Lidocaine_Preferentially_Inhibits_the_Function_of.18.aspx),” which was published in this month’s issue of Anesthesia and Analgesia. In a comprehensive study, the investigators found that lidocaine inhibited ATP-induced currents in P2X7 subunits in a concentration-dependent manner. Lidocaine had no inhibitory effects on P2X3 or P2X4 subunits. Although the inhibitory concentrations were greater than those found commonly with a systemic infusion, a local effect is possible. In contrast, mepivacaine, bupivacaine and ropivacaine had no inhibitory effects on the P2X7 receptor. The researchers have shown a novel mechanism of action of lidocaine, which may in part explain its analgesic effects. It is salutary to note that one of the oldest local anesthetic drugs has important pharmacological properties that are not found with more modern agents. Lidocaine is still a key drug in modern anesthesia and pain medicine, and this study helps us to understand its mechanism of action. 0:02:04 no AA2day.org Also available on YouTube (http://youtu.be/BPuMI_yCEZA). Systemic lidocaine has several useful effects including the relief of chronic pain, and anti-inflammatory and antithrombotic actions. These diverse properties strongly suggest that mechanisms ot... Also available on YouTube (http://youtu.be/BPuMI_yCEZA). Systemic lidocaine has several useful effects including the relief of chronic pain, and anti-inflammatory and antithrombotic actions. These diverse properties strongly suggest that mechanisms other than sodium channel blockade may be implicated in mediating the beneficial effects of lidocaine. Extracellular adenosine triphosphate (ATP) is a neurotransmitter acting through the ATP receptors P2X (ligand-gated ion channels) and P2Y (G-protein-coupled receptors). These receptors are widely distributed and are involved in many pathological conditions such as ischemia, inflammation, and pain. Dr. Takafumi Horishita, Department of Anesthesiology, School of Medicine, University of Occupational and Environmental Health, Yahatanishiku, Kitakyushu, Fukuoka, Japan, and colleagues from the Departments of Occupational Toxicology and Pharmacology, together with colleagues from the Department of Molecular Pathology and Metabolic Disease, Tokyo University of Science, Noda, Chiba, Japan, and the Cancer Pathophysiology Division, National Cancer Center Research Institute, Chuouko, Tokyo, Japan, investigated the effects of lidocaine on purinergic receptors. Their results are discussed in the article titled “Lidocaine Preferentially Inhibits the Function of Purinergic P2X7 Receptors Expressed in Xenopus Oocytes (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Lidocaine_Preferentially_Inhibits_the_Function_of.18.aspx),” which was published in this month’s issue of Anesthesia and Analgesia. In a comprehensive study, the investigators found that lidocaine inhibited ATP-induced currents in P2X7 subunits in a concentration-dependent manner. Lidocaine had no inhibitory effects on P2X3 or P2X4 subunits. Although the inhibitory concentrations were greater than those found commonly with a systemic infusion, a local effect is possible. In contrast, mepivacaine, bupivacaine and ropivacaine had no inhibitory effects on the P2X7 receptor. The researchers have shown a novel mechanism of action of lidocaine, which may in part explain its analgesic effects. It is salutary to note that one of the oldest local anesthetic drugs has important pharmacological properties that are not found with more modern agents. Lidocaine is still a key drug in modern anesthesia and pain medicine, and this study helps us to understand its mechanism of action. http://aa2day.org/2015/03/blockade/ http://www.blubrry.com/aa2day/2662897/measurement-of-sensory-blockade-in-regional-anesthesia/ AA2day.org Podcast Mon, 16 Mar 2015 20:05:49 -0400  Also available on YouTube (http://youtu.be/FA5cNYA9ykg). Regional anesthesia (RA) uses contrasting technologies. The latest ultrasound technology is used to guide the correct placement of the block, but simple subjective responses to stimuli such as cold and pinprick are used to assess the effectiveness of the sensory denervation. Surely there must be a better method of measuring the adequacy of sensory blockade? Current perception threshold (CPT) is a quantitative method and is essentially a nerve stimulator with a microprocessor-controlled constant stimulus that is applied to the skin to evoke a sensory response such as itching or burning. Occasional reports suggest that it be of value in RA, but its reliability has not been determined. Dr. France Varin, Faculty of Pharmacy, Université de Montréal, Montreal, Canada and colleagues from the same faculty in addition to colleagues at the Department of Anesthesiology and the Department of Orthopedic Surgery, Maisonneuve-Rosemont Hospital, Montreal, Canada, studied current perception thresholds in volunteers and patients undergoing femoral nerve block for total knee arthroplasty. Their results are published in this month’s issue of Anesthesia and Analgesia and discussed in the article titled “The Reliability of the Current Perception Threshold in Volunteers and Its Applicability in a Clinical Setting (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/The_Reliability_of_the_Current_Perception.28.aspx).” CPT was found to be a reliable method for measuring sensory perception in healthy volunteers. It was also able to quantify the onset and progression of a femoral nerve block, with the maximal sensory response to 20 mL of ropivacaine 0.5% occurring after 22 min of dosing. The results suggest that CPT offers some progress in the quantitative measurement of sensory blockade. It may be of value in determining subtle differences in onset and intensity of block with similar concentrations of different local anesthetics. So far CPT has not found favor with anesthesiologists, but ice and a needle are so 19th century! 0:03:09 no AA2day.org  Also available on YouTube (http://youtu.be/FA5cNYA9ykg). Regional anesthesia (RA) uses contrasting technologies. The latest ultrasound technology is used to guide the correct placement of the block, but simple subjective responses to stimuli such as...  Also available on YouTube (http://youtu.be/FA5cNYA9ykg). Regional anesthesia (RA) uses contrasting technologies. The latest ultrasound technology is used to guide the correct placement of the block, but simple subjective responses to stimuli such as cold and pinprick are used to assess the effectiveness of the sensory denervation. Surely there must be a better method of measuring the adequacy of sensory blockade? Current perception threshold (CPT) is a quantitative method and is essentially a nerve stimulator with a microprocessor-controlled constant stimulus that is applied to the skin to evoke a sensory response such as itching or burning. Occasional reports suggest that it be of value in RA, but its reliability has not been determined. Dr. France Varin, Faculty of Pharmacy, Université de Montréal, Montreal, Canada and colleagues from the same faculty in addition to colleagues at the Department of Anesthesiology and the Department of Orthopedic Surgery, Maisonneuve-Rosemont Hospital, Montreal, Canada, studied current perception thresholds in volunteers and patients undergoing femoral nerve block for total knee arthroplasty. Their results are published in this month’s issue of Anesthesia and Analgesia and discussed in the article titled “The Reliability of the Current Perception Threshold in Volunteers and Its Applicability in a Clinical Setting (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/The_Reliability_of_the_Current_Perception.28.aspx).” CPT was found to be a reliable method for measuring sensory perception in healthy volunteers. It was also able to quantify the onset and progression of a femoral nerve block, with the maximal sensory response to 20 mL of ropivacaine 0.5% occurring after 22 min of dosing. The results suggest that CPT offers some progress in the quantitative measurement of sensory blockade. It may be of value in determining subtle differences in onset and intensity of block with similar concentrations of different local anesthetics. So far CPT has not found favor with anesthesiologists, but ice and a needle are so 19th century! http://aa2day.org/2015/03/neurotoxicity/ http://www.blubrry.com/aa2day/2662896/a-summary-of-research-on-perioperative-neurotoxicity-in-the-elderly/ AA2day.org Podcast Thu, 12 Mar 2015 20:05:48 -0400  Also available on YouTube (http://youtu.be/TIUTBDuPp1o). Scientists and clinicians from ten countries attended the International Workshop on Perioperative Neurotoxicity in the Elderly this past May in Stockholm, Sweden. In this month’s issue of Anesthesia & Analgesia, Dr. Roderic G. Eckenhoff, Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and colleagues review the workshop proceedings in their article titled "Perioperative Neurotoxicity in the Elderly: Summary of the 4th International Workshop (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Perioperative_Neurotoxicity_in_the_Elderly__.24.aspx)." A lack of consensus about diagnostic criteria for postoperative cognitive dysfunction makes it difficult to compare studies and draw conclusions. Attendees proposed the creation of a consensus panel to draft comprehensive nomenclature to allow comparisons among studies. While epidemiologic databases being used point to a link between anesthesia, surgery and postoperative cognitive dysfunction, prospective data needs to be collected that has specific points that are quantitated. It is possible that undiagnosed preoperative cognitive dysfunction may be noticed postoperatively, skewing results. To address this a cognitive assay tool has been developed to detect a difference in cognition before and after surgery. Using cytokines, calcium dysregulation, tauopathy, and amyloidopathy as markers, researchers are finding an association between surgery, anesthesia, and cognitive dysfunction. Human biomarkers are being sought to provide quantitative measures of injury and pathology. Amyloid beta and tau proteins, markers in cerebrospinal fluid for Alzheimer's disease, are the primary biomarkers being studied. Investigators are also using brain imaging with functional MRI and PET to quantitate disease.   Carriers of genes that predispose patients to Alzheimer's disease genes show increased association between surgery and early dementia. However, this requires further study. Current preclinical research involves studying inflammation as a possible cause of postoperative cognitive decline. Clinical studies have pointed to an association between postoperative cognitive dysfunction, and increased levels of CSF IL-6 as well as several cytokines. Although inflammation has been associated with POCDS, use of steroids has not proven useful for prevention. Some investigators have hypothesized that there would be a difference in incidence of POCDS in patients who received TIVA with propofol vs. inhalational anesthetics. However, this has not been found in prospective studies. Because of the preliminary nature of data and no cohesive findings, no recommendations were made by attendees as to the type of anesthesia to use, or drugs to avoid. Attendees discussed the need to talk about postoperative cognitive decline with at-risk patients as part of informed consent. The workshop closed with a call for more research as more questions than answers remain. This is an engaging summary of what must have been a spectacular meeting. 0:03:09 no AA2day.org  Also available on YouTube (http://youtu.be/TIUTBDuPp1o). Scientists and clinicians from ten countries attended the International Workshop on Perioperative Neurotoxicity in the Elderly this past May in Stockholm, Sweden.  Also available on YouTube (http://youtu.be/TIUTBDuPp1o). Scientists and clinicians from ten countries attended the International Workshop on Perioperative Neurotoxicity in the Elderly this past May in Stockholm, Sweden. In this month’s issue of Anesthesia & Analgesia, Dr. Roderic G. Eckenhoff, Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and colleagues review the workshop proceedings in their article titled "Perioperative Neurotoxicity in the Elderly: Summary of the 4th International Workshop (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Perioperative_Neurotoxicity_in_the_Elderly__.24.aspx)." A lack of consensus about diagnostic criteria for postoperative cognitive dysfunction makes it difficult to compare studies and draw conclusions. Attendees proposed the creation of a consensus panel to draft comprehensive nomenclature to allow comparisons among studies. While epidemiologic databases being used point to a link between anesthesia, surgery and postoperative cognitive dysfunction, prospective data needs to be collected that has specific points that are quantitated. It is possible that undiagnosed preoperative cognitive dysfunction may be noticed postoperatively, skewing results. To address this a cognitive assay tool has been developed to detect a difference in cognition before and after surgery. Using cytokines, calcium dysregulation, tauopathy, and amyloidopathy as markers, researchers are finding an association between surgery, anesthesia, and cognitive dysfunction. Human biomarkers are being sought to provide quantitative measures of injury and pathology. Amyloid beta and tau proteins, markers in cerebrospinal fluid for Alzheimer's disease, are the primary biomarkers being studied. Investigators are also using brain imaging with functional MRI and PET to quantitate disease.   Carriers of genes that predispose patients to Alzheimer's disease genes show increased association between surgery and early dementia. However, this requires further study. Current preclinical research involves studying inflammation as a possible cause of postoperative cognitive decline. Clinical studies have pointed to an association between postoperative cognitive dysfunction, and increased levels of CSF IL-6 as well as several cytokines. Although inflammation has been associated with POCDS, use of steroids has not proven useful for prevention. Some investigators have hypothesized that there would be a difference in incidence of POCDS in patients who received TIVA with propofol vs. inhalational anesthetics. However, this has not been found in prospective studies. Because of the preliminary nature of data and no cohesive findings, no recommendations were made by attendees as to the type of anesthesia to use, or drugs to avoid. Attendees discussed the need to talk about postoperative cognitive decline with at-risk patients as part of informed consent. The workshop closed with a call for more research as more questions than answers remain. This is an engaging summary of what must have been a spectacular meeting. http://aa2day.org/2015/03/cabgoutcome/ http://www.blubrry.com/aa2day/2662895/can-the-anesthesiologist-affect-outcome-after-cabg-surgery-a-study-from-new-york/ AA2day.org Podcast Wed, 11 Mar 2015 20:05:09 -0400  Also available on YouTube (http://youtu.be/A4bLCv15f8w). Back in the mid-1980s, there was a study (PMID 3970360) showing that postoperative myocardial infarction after coronary artery bypass graft (CABG) surgery was more likely in patients who had ... 0:03:58 no AA2day.org  Also available on YouTube (http://youtu.be/A4bLCv15f8w). Back in the mid-1980s, there was a study (PMID 3970360) showing that postoperative myocardial infarction after coronary artery bypass graft (CABG) surgery was more likely in patients who had ...  Also available on YouTube (http://youtu.be/A4bLCv15f8w). Back in the mid-1980s, there was a study (PMID 3970360) showing that postoperative myocardial infarction after coronary artery bypass graft (CABG) surgery was more likely in patients who had ... http://aa2day.org/2015/03/headache/ http://www.blubrry.com/aa2day/2662894/headache-isnt-the-only-complication-of-dural-puncture/ AA2day.org Podcast Tue, 10 Mar 2015 20:05:14 -0400 Also available on YouTube (http://youtu.be/JPVi691XVJ0). Headache is what we commonly think of as a sequela of dural puncture. Other adverse consequences of dural puncture include ocular and auditory disturbance. Ocular abnormalities are due to cranial nerve palsy, typically involving the sixth nerve cranial (abducens nerve), and uncommonly involving the third and fourth cranial nerves. Dr. Jennifer E. Hofer, Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, and Dr. Barbara M. Scavone, also from the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, summarize the incidence, time course, presentation, pathophysiology, risk factors, prevention, and treatment of cranial nerve six palsy after dural puncture. Their review is contained in the article titled “Cranial Nerve VI Palsy After Dural-Arachnoid Puncture (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Cranial_Nerve_VI_Palsy_After_Dural_Arachnoid.23.aspx),” published in this month’s issue of Anesthesia & Analgesia. Headache usually precedes ocular involvement. Though other neurologic and ophthalmic abnormalities should be considered, if an isolated ocular deficit preceded by headache is seen within 3 weeks of dural puncture, the abnormality is likely a consequence of dural puncture. Patient complaints include blurred or double vision, sensitivity to light, and trouble focusing or reading. On physical exam, there is impaired ocular abduction, though findings may be subtle. In most cases the palsy is unilateral. Diplopia may persist for months. However, by 8 months the majority of patients (89%) have recovered. The basis for palsy is presumed to be due to loss of CSF that results in intracranial hypotension, with caudal displacement of the brainstem causing cranial nerve traction. The position of cranial nerve VI in the brain makes it susceptible to preferential damage. Neural ischemia may result in focal segmental demyelination (neuropraxia) and/or axonal interruption. The length of time for recovery is a function of the time needed for myelin regeneration. Since headache precedes cranial nerve VI palsy, and both are related to intracranial hypotension, they may share similar risk factors. Postdural puncture headache is most likely in younger individuals, and in women, after vaginal as opposed to cesarean section. Use of small-gauge and non-cutting needles decreases the incidence of headache. Though epidural blood patch usually provides relief of headache, it does not reliably reverse cranial nerve VI palsy, particularly if neural demyelination has already occurred. This is a nice review of an important topic. Clinicians should be aware that headache is not the only potential complication of dural puncture. 0:02:39 no AA2day.org Also available on YouTube (http://youtu.be/JPVi691XVJ0). Headache is what we commonly think of as a sequela of dural puncture. Other adverse consequences of dural puncture include ocular and auditory disturbance. Also available on YouTube (http://youtu.be/JPVi691XVJ0). Headache is what we commonly think of as a sequela of dural puncture. Other adverse consequences of dural puncture include ocular and auditory disturbance. Ocular abnormalities are due to cranial nerve palsy, typically involving the sixth nerve cranial (abducens nerve), and uncommonly involving the third and fourth cranial nerves. Dr. Jennifer E. Hofer, Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, and Dr. Barbara M. Scavone, also from the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, summarize the incidence, time course, presentation, pathophysiology, risk factors, prevention, and treatment of cranial nerve six palsy after dural puncture. Their review is contained in the article titled “Cranial Nerve VI Palsy After Dural-Arachnoid Puncture (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Cranial_Nerve_VI_Palsy_After_Dural_Arachnoid.23.aspx),” published in this month’s issue of Anesthesia & Analgesia. Headache usually precedes ocular involvement. Though other neurologic and ophthalmic abnormalities should be considered, if an isolated ocular deficit preceded by headache is seen within 3 weeks of dural puncture, the abnormality is likely a consequence of dural puncture. Patient complaints include blurred or double vision, sensitivity to light, and trouble focusing or reading. On physical exam, there is impaired ocular abduction, though findings may be subtle. In most cases the palsy is unilateral. Diplopia may persist for months. However, by 8 months the majority of patients (89%) have recovered. The basis for palsy is presumed to be due to loss of CSF that results in intracranial hypotension, with caudal displacement of the brainstem causing cranial nerve traction. The position of cranial nerve VI in the brain makes it susceptible to preferential damage. Neural ischemia may result in focal segmental demyelination (neuropraxia) and/or axonal interruption. The length of time for recovery is a function of the time needed for myelin regeneration. Since headache precedes cranial nerve VI palsy, and both are related to intracranial hypotension, they may share similar risk factors. Postdural puncture headache is most likely in younger individuals, and in women, after vaginal as opposed to cesarean section. Use of small-gauge and non-cutting needles decreases the incidence of headache. Though epidural blood patch usually provides relief of headache, it does not reliably reverse cranial nerve VI palsy, particularly if neural demyelination has already occurred. This is a nice review of an important topic. Clinicians should be aware that headache is not the only potential complication of dural puncture. http://aa2day.org/2015/03/runners-up/ http://www.blubrry.com/aa2day/2662893/runners-up-for-the-most-important-publications-judged-to-be-significant-game-changers-for-the-field-of-anesthesiology/ AA2day.org Podcast Mon, 09 Mar 2015 20:05:20 -0400 Also available on Youtube (http://youtu.be/woSbqJ_uNRY). All lists have runner-ups. And for the article,  Game Changers: The 20 Most Important Anesthesia Articles Ever Published 0:06:09 no AA2day.org Also available on Youtube (http://youtu.be/woSbqJ_uNRY). All lists have runner-ups. And for the article,  Game Changers: The 20 Most Important Anesthesia Articles Ever Published Also available on Youtube (http://youtu.be/woSbqJ_uNRY). All lists have runner-ups. And for the article,  Game Changers: The 20 Most Important Anesthesia Articles Ever Published http://aa2day.org/2015/03/peripartum/ http://www.blubrry.com/aa2day/2662892/peripartum-cardiomyopathy-a-review/ AA2day.org Podcast Tue, 03 Mar 2015 19:05:10 -0500 Also available on YouTube (http://youtu.be/0qtuWRj8Kt8) A recent aa2day summary (http://aa2day.org/2015/02/maternalcpa/) described a case of a pregnant patient who suffered a cardiac arrest. The authors noted that the patient had a hyperdynamic left ventricle with concentric remodeling, signs of heart failure. It’s important that anesthesiologists caring for parturients understand the physiology and clinical presentation of heart disease, as well as the management of these patients. Associate Professor Alicia Therese Dennis, Department of Anaesthesia, The Royal Women’s Hospital, Parkville, Australia, reviews peripartum cardiomyopathy in this month’s issue of Anesthesia & Analgesia in the article titled “Heart Failure in Pregnant Women: Is It Peripartum Cardiomyopathy? (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Heart_Failure_in_Pregnant_Women___Is_It_Peripartum.22.aspx)” Peripartum cardiomyopathy (PPCM) is defined as heart failure with left ventricular systolic dysfunction quantified by echocardiography. It occurs in about 1:2000 patients, either in the third trimester or in the first months after delivery. Left untreated, mortality can be as high as 50%. Many patients with peripartum cardiomyopathy experience a long-term reduction in cardiac function, particularly if left ventricular end-diastolic diameter is > 60 mm and there is a fractional shortening < 21%. The etiology of this disease is not clear. To make the diagnosis one must exclude other causes such as fluid overload, tachyarrhythmias, hypertensive heart disease, severe anemia, thyrotoxicosis, sepsis, drug toxicity (including cocaine use), valvular heart disease, congenital heart disease, and prior cardiomyopathy (idiopathic, chemotherapy-associated, and human immunodeficiency virus-associated cardiomyopathy). Risk factors include advanced maternal age or teenage pregnancy, African ethnicity, pregnancy with multiple fetuses, family history, and multiparity (although PPCM occurs for most women with the first or second pregnancy). However, some patients have no risk factors. Early intervention can lessen the chance of developing overt heart failure. Standard management around the time of delivery, including IV fluid therapy and use of oxytocin, can put patients with this disease at increased risk of developing heart failure. Patients with PPCM can present with orthopnea, dyspnea, cough, swelling, excessive weight gain, and palpitations. It’s important to use echocardiography to differentiate this disease from respiratory disease, particularly asthma. Echocardiographic findings include ventricular dilatation and hypokinesia. If echocardiographic findings include preserved ejection fraction, the patient most likely has another cause of heart failure which may include hypertensive heart failure, or valvular heart disease, not peripartum cardiomyopathy. There is no specific treatment for the disease. Management is symptomatic and needs to be multidisciplinary including cardiologists. Beta-adrenergic blockade with metoprolol should be considered when the patient is stabilized.   Database development might help us better understand the epidemiology of the disease. This is an excellent review of an important topic. It is increasingly clear that cardiovascular disease, especially cardiomyopathy and hypertensive disorders, is a major cause of maternal morbidity and mortality. While peripartum cardiomyopathy is rare, delays in diagnosis are common and contribute to adverse maternal outcomes. With improved recognition the obstetric and anesthesia teams have the potential to improve maternal outcomes. 60 mm and there is a fractional shortening < 21%. The etiology of this disease is not clear. To make the diagnosis one must exclude other causes such as fluid overload, tachyarrhythmias, hypertensive heart disease, severe anemia, thyrotoxicosis, sepsis, drug toxicity (including cocaine use), valvular heart disease, congenital heart disease, and prior cardiomyopathy (idiopathic, chemotherapy-associated, and human immunodeficiency virus-associated cardiomyopathy). Risk factors include advanced maternal age or teenage pregnancy, African ethnicity, pregnancy with multiple fetuses, family history, and multiparity (although PPCM occurs for most women with the first or second pregnancy). However, some patients have no risk factors. Early intervention can lessen the chance of developing overt heart failure. Standard management around the time of delivery, including IV fluid therapy and use of oxytocin, can put patients with this disease at increased risk of developing heart failure. Patients with PPCM can present with orthopnea, dyspnea, cough, swelling, excessive weight gain, and palpitations. It’s important to use echocardiography to differentiate this disease from respiratory disease, particularly asthma. Echocardiographic findings include ventricular dilatation and hypokinesia. If echocardiographic findings include preserved ejection fraction, the patient most likely has another cause of heart failure which may include hypertensive heart failure, or valvular heart disease, not peripartum cardiomyopathy. There is no specific treatment for the disease. Management is symptomatic and needs to be multidisciplinary including cardiologists. Beta-adrenergic blockade with metoprolol should be considered when the patient is stabilized.   Database development might help us better understand the epidemiology of the disease. This is an excellent review of an important topic. It is increasingly clear that cardiovascular disease, especially cardiomyopathy and hypertensive disorders, is a major cause of maternal morbidity and mortality. While peripartum cardiomyopathy is rare, delays in diagnosis are common and contribute to adverse maternal outcomes. With improved recognition the obstetric and anesthesia teams have the potential to improve maternal outcomes.]]> 0:03:40 no AA2day.org Also available on YouTube (http://youtu.be/0qtuWRj8Kt8) A recent aa2day summary (http://aa2day.org/2015/02/maternalcpa/) described a case of a pregnant patient who suffered a cardiac arrest. The authors noted that the patient had a hyperdynamic left v... Also available on YouTube (http://youtu.be/0qtuWRj8Kt8) A recent aa2day summary (http://aa2day.org/2015/02/maternalcpa/) described a case of a pregnant patient who suffered a cardiac arrest. The authors noted that the patient had a hyperdynamic left ventricle with concentric remodeling, signs of heart failure. It’s important that anesthesiologists caring for parturients understand the physiology and clinical presentation of heart disease, as well as the management of these patients. Associate Professor Alicia Therese Dennis, Department of Anaesthesia, The Royal Women’s Hospital, Parkville, Australia, reviews peripartum cardiomyopathy in this month’s issue of Anesthesia & Analgesia in the article titled “Heart Failure in Pregnant Women: Is It Peripartum Cardiomyopathy? (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Heart_Failure_in_Pregnant_Women___Is_It_Peripartum.22.aspx)” Peripartum cardiomyopathy (PPCM) is defined as heart failure with left ventricular systolic dysfunction quantified by echocardiography. It occurs in about 1:2000 patients, either in the third trimester or in the first months after delivery. Left untreated, mortality can be as high as 50%. Many patients with peripartum cardiomyopathy experience a long-term reduction in cardiac function, particularly if left ventricular end-diastolic diameter is > 60 mm and there is a fractional shortening < 21%. The etiology of this disease is not clear. To make the diagnosis one must exclude other causes such as fluid overload, tachyarrhythmias, hypertensive heart disease, severe anemia, thyrotoxicosis, sepsis, drug toxicity (including cocaine use), valvular heart disease, congenital heart disease, and prior cardiomyopathy (idiopathic, chemotherapy-associated, and human immunodeficiency virus-associated cardiomyopathy). Risk factors include advanced maternal age or teenage pregnancy, African ethnicity, pregnancy with multiple fetuses, family history, and multiparity (although PPCM occurs for most women with the first or second pregnancy). However, some patients have no risk factors. Early intervention can lessen the chance of developing overt heart failure. Standard management around the time of delivery, including IV fluid therapy and use of oxytocin, can put patients with this disease at increased risk of developing heart failure. Patients with PPCM can present with orthopnea, dyspnea, cough, swelling, excessive weight gain, and palpitations. It’s important to use echocardiography to differentiate this disease from respiratory disease, particularly asthma. Echocardiographic findings include ventricular dilatation and hypokinesia. If echocardiographic findings include preserved ejection fraction, the patient most likely has another cause of heart failure which may include hypertensive heart failure, or valvular heart disease, not peripartum cardiomyopathy. There is no specific treatment for the disease. Management is symptomatic and needs to be multidisciplinary including cardiologists. Beta-adrenergic blockade with metoprolol should be considered when the patient is stabilized.   Database development might help us better understand the epidemiology of the disease. This is an excellent review of an important topic. It is increasingly clear that cardiovascular disease, especially cardiomyopathy and hypertensive disorders, is a major cause of maternal morbidity and mortality. While peripartum cardiomyopathy is rare, delays in diagnosis are common and contribute to adverse maternal outcomes. With improved recognition the obstetric and anesthesia teams have the potential to improve maternal outcomes. http://aa2day.org/2015/03/aspirin/ http://www.blubrry.com/aa2day/2662891/perioperative-management-of-aspirin-therapy/ AA2day.org Podcast Mon, 02 Mar 2015 19:05:34 -0500 Also available on YouTube (http://youtu.be/KRNk1KlgdVs). Aspirin constitutes important lifelong therapy for many patients with cardiovascular (CV) disease or significant CV risk factors. However, perioperative aspirin management (continuation versus temporary cessation) in patients undergoing noncardiac surgery is a common clinical conundrum that balances aspirin’s potential for decreasing thrombotic risk against possible increased perioperative blood loss. Dr. Neal Stuart Gerstein, Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, and colleagues conducted a focused review of aspirin’s role in CV disease and examined the pertinent literature related to perioperative aspirin management, including an appraisal of the POISE-2 trial results. Their review is published in this month’s issue of Anesthesia & Analgesia in the article titled “Perioperative Aspirin Management After POISE-2: Some Answers, but Questions Remain (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Perioperative_Aspirin_Management_After_POISE_2__.14.aspx).” POISE-2 suggests that aspirin administration during the perioperative period does not change the risk of a CV event and may result in increased bleeding. However, these findings are tempered by a number of POISE-2 methodological issues. Based on the currently available literature including POISE-2, the authors recommend that aspirin should not be administered to patients undergoing surgery unless there is a definitive guideline-based primary or secondary prevention indication. However, for patients taking lifelong aspirin for a definitive guideline-based primary or secondary indication, aspirin should likely be continued throughout the perioperative period unless the patient is undergoing a closed-space procedure (i.e., intracranial or middle ear), intramedullary spine surgery, or possibly prostate surgery. 0:01:51 no AA2day.org Also available on YouTube (http://youtu.be/KRNk1KlgdVs). Aspirin constitutes important lifelong therapy for many patients with cardiovascular (CV) disease or significant CV risk factors. However, perioperative aspirin management (continuation versus t... Also available on YouTube (http://youtu.be/KRNk1KlgdVs). Aspirin constitutes important lifelong therapy for many patients with cardiovascular (CV) disease or significant CV risk factors. However, perioperative aspirin management (continuation versus temporary cessation) in patients undergoing noncardiac surgery is a common clinical conundrum that balances aspirin’s potential for decreasing thrombotic risk against possible increased perioperative blood loss. Dr. Neal Stuart Gerstein, Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, and colleagues conducted a focused review of aspirin’s role in CV disease and examined the pertinent literature related to perioperative aspirin management, including an appraisal of the POISE-2 trial results. Their review is published in this month’s issue of Anesthesia & Analgesia in the article titled “Perioperative Aspirin Management After POISE-2: Some Answers, but Questions Remain (http://journals.lww.com/anesthesia-analgesia/Fulltext/2015/03000/Perioperative_Aspirin_Management_After_POISE_2__.14.aspx).” POISE-2 suggests that aspirin administration during the perioperative period does not change the risk of a CV event and may result in increased bleeding. However, these findings are tempered by a number of POISE-2 methodological issues. Based on the currently available literature including POISE-2, the authors recommend that aspirin should not be administered to patients undergoing surgery unless there is a definitive guideline-based primary or secondary prevention indication. However, for patients taking lifelong aspirin for a definitive guideline-based primary or secondary indication, aspirin should likely be continued throughout the perioperative period unless the patient is undergoing a closed-space procedure (i.e., intracranial or middle ear), intramedullary spine surgery, or possibly prostate surgery.