This Month in Anesthesiology

Abstract

The authors examined the epidemiology of perioperative AIS in three common surgeries in adult patients: hemicolectomy, total hip replacement, and lobectomy/segmental lung resection. Data were extracted from a national database in the United States for the years 2000 to 2004. Patients with perioperative AIS were identified as were comorbid conditions that may be risk factors for perioperative AIS. Those who developed perioperative AIS were as follows: 0.7% of hemicolectomy patients, 0.2% of total hip replacement patients, and 0.6% of lobectomy/segmental lung resection patients. For patients older than 65, AIS rose to 1.0% for hemicolectomy, 0.3% for hip replacement, and 0.8% for pulmonary resection. Perioperative AIS is an important source of morbidity and mortality associated with noncardiac, nonvascular surgery particularly in elderly patients. See the accompanying Editorial View on page 209 Anesthetic requirements of the fruit fly mutant minisleeper and other Drosophila mutants were determined based on the response of the flies at different concentrations of isoflurane and sevoflurane. The average amount of daily sleep in wild-type Drosophila was 965 minutes but only 584 minutes in minisleeper mutant flies. The EC50values in wild-type Drosophila were 0.706 for isoflurane and 1.298 for sevoflurane; however, EC50values in the minisleeper mutant flies for isoflurane and sevoflurane were 1.306 and 2.013, respectively. A single-gene mutation in Drosophila that causes an extreme reduction in daily sleep is responsible for a significant increase in the requirement of volatile anesthetics. This study has implications for sleep and mechanisms of anesthesia and sedation.Hyperglycemia in perioperative patients has been identified as a risk factor for morbidity and mortality. Intensive insulin therapy (IIT) has been shown to reduce morbidity and mortality among the critically ill, decrease infection rates and improve survival after cardiac surgery, and improve outcomes in acute neurological injury and acute myocardial infarction. However, severe hypoglycemia and adverse events associated with IIT are a concern. The authors summarize the mechanisms and rationale of hyperglycemia and IIT, and review the evidence behind the use of IIT in the perioperative period. While avoidance of hyperglycemia is clearly beneficial, the appropriate glucose target and specific subpopulations that might benefit from IIT have yet to be identified. See the accompanying Editorial View on page 204 The authors hypothesized that the use of factor XIII would delay the decrease in clot firmness in high-risk patients with high fibrin monomer levels. This concept was tested in a prospective, randomized, double-blind, placebo-controlled trial in elective cancer surgery. Patients were randomized to receive factor XIII (30 U/kg) or placebo and standard therapy. During the interim analysis, clot firmness was evaluated. Patients receiving placebo lost 38% firmness whereas those receiving factor XIII did not. This proof of concept study confirmed that patients at high risk for intraoperative blood loss showed reduced loss of clot firmness when factor XIII was administered. Further clinical trials are needed to assess this treatment on blood loss and use of blood products. See the accompanying Editorial View on page 212 An updated report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids.In multivariate models, body mass index is a weak but significant predictor of difficult and failed intubation.Tighter glucose control may improve renal function in potential organ donors. See the accompanying Editorial View on page 207 Early transfusion is an independent predictor of adult respiratory distress syndrome in adult trauma. See the accompanying Editorial View on page 216