Administration Of Anesthetic Agents Research Articles

Procedural sedation and analgesia in the emergency department

Emergency medicine as a medical specialty has come a long way since its evolution from the now obsolete “Casualty Department.” A prevalent challenge in the emergency department (ED) is safe and effective administration of anesthetic agents to a patient in pain or altered mentation without compromising their airway control and hemodynamics. Fear and unfamiliarity with the use of various anesthetic agents is the major stumbling block in this regard. Procedural sedation and analgesia (PSA) in the ED improve patient satisfaction, reduces physiological stress and allows for rapid return of consciousness after traumatic procedures while providing sedation, analgesia, and amnesia. PSA is a planned service which should be provided under strict monitoring with proper preanesthetic workup and emergency measures easily available. PSA strengthens the armament of the emergency physician, allowing a better understanding of pain control and sedation without resorting to general anesthesia.

Reversal of neuromuscular blockade with sugammadex during continuous administration of anaesthetic agents: adouble-blind randomised crossover study using the bispectral index.

Sugammadex, a specific reversal agent for steroidal neuromuscular blocking drugs, has on occasion been reported to be associated with clinical signs of awakening. We performed a study to systematically search for an increase in bispectral index values and signs of awakening in patients maintained under general anaesthesia following sugammadex administration. Patients, scheduled to receive general anaesthesia with neuromuscular blockade, were included in this double-blind randomised crossover study. After surgery was completed, and while the train-of-four ratio was zero, intravenous anaesthesia was continued with the aim of maintaining the bispectral index in the range of 40-60. Patients then received either sugammadex 4mg.kg-1 or saline. In cases of incomplete reversal of neuromuscular blockade after 5min, patients received the other drug. Bispectral index and train-of-four monitoring were recorded every minute and clinical signs of awakening noted. Fifty-one patients completed the study. Median (IQR [range]) bispectral index values increased after sugammadex administration from 49 (43-53 [38-64]) to 63 (53-80 [45-97]) (p<0.01) with an increase of ≥20 in 22 patients; 14 (27%) patients had clinical signs of awakening. Saline had no effect on bispectral index values, clinical signs of awakening or degree of neuromuscular blockade. This study confirms that reversal of neuromuscular blockade with sugammadex may be associated with clinical signs of awakening despite maintenance of anaesthesia. Intravenous anaesthesia should be maintained until complete recovery of muscle function is achieved, especially when sugammadex is administered.

L-alpha-amino adipic acid provokes depression-like behaviour and a stress related increase in dendritic spine density in the pre-limbic cortex and hippocampus in rodents

Astrocyte dysfunction is implicated in clinical depression. There is a paucity of animal models to assess the role of astrocytes in depression pathogenesis. Refinement of an existing model is described here. Administration of the astrocytic toxin L-alpha aminoadipic acid (L-AAA) to the pre-limbic cortex (PLC) was assessed in rats and mice in tests of anxiety and depression related behaviours. Delivery of L-AAA to the PLC of Wistar rats produced an increase in immobility in the forced swimming test (FST) and reduced exploration in the open field. Delivery to the CA3 subfield of the hippocampus produced a deficit in the novel object relocation task. Delivery of single or two successive doses of L-AAA to the PLC of C57Bl6/J mice was sufficient to induce an increase in immobility in the mouse tail suspension (TST) and FST independently of administration of anaesthetic agent or the surgical procedure. In both mice and rats, L-AAA produced a reduction in immunoreactivity of the astrocytic marker glial fibrillary acidic protein (GFAP) for up to 72 h. L-AAA provoked an increase in the density of apical and basal dendritic spines in mice exposed to the FST when compared to non-FST controls. In summary, L-AAA provokes a region-dependent change in behaviour, a reduction in GFAP immunoreactivity and FST-provoked increased in dendritic spine density in the PLC. This model may be further employed to assess the impact of astroglial integrity on the structural plasticity of neurons and the effect of antidepressant agents on L-AAA-related changes.

Evaluation of the Protective Effect of an Ophthalmic Viscosurgical Device on the Ocular Surface in Dry Eye Patients during Cataract Surgery.

PurposeTo evaluate the protective effect of applying an ophthalmic viscosurgical device (OVD) to the ocular surface during cataract surgery and its ability to prevent dry eye syndrome.MethodsTwenty-four patients aged 50 to 75 years who underwent cataract surgery at Seoul National University Bundang Hospital and agreed to participate in the study were included and divided into two groups: a study group who underwent cataract surgery after application of an OVD to the ocular surface, and a control group who underwent cataract surgery without application of an OVD. DisCoVisc was used as the OVD in the study group, while other factors including surgical techniques and administration of anesthetic agents were performed in both groups in the same manner. Indicators of dry eye syndrome including ocular staining score, tear break-up time, and tear osmolality were analyzed. Ocular surface disease index and a visual analog scale were analyzed for dry eye symptoms, and the amount of balanced salt solution used during surface irrigation and operation time were also analyzed.ResultsSignificant improvement in the tear break-up time, corneal ocular staining score, and ocular surface disease index score in the study group compared with the control group one week after operation (by the Mann-Whitney test). Use of OVD was associated with longer operating time.ConclusionsOVD applied to the ocular surface during cataract surgery had a protective effect on the ocular surface one week after surgery.

EVALUATION OF ACUPUNCTURE POINTS GOVERNING VESSELS 1 AND 26 ON ANESTHETIC RECOVERY OF EASTERN BOX TURTLES ( TERRAPENE CAROLINA CAROLINA).

Intramuscular administration of anesthetic agents in chelonians may result in a prolonged (≥1 hr) return of spontaneous movement and breathing, which increases the probability for peri- and postoperative complications. The acupuncture point governing vessel (GV)-26 has been demonstrated to reduce anesthetic recovery times from inhalant anesthesia in other species. In this study, 30 eastern box turtles (EBT; Terrapene carolina carolina), presented to the Turtle Rescue Team at North Carolina State University's College of Veterinary Medicine for treatment of aural abscess, were divided into four groups: control (no treatment); GV-26 acupuncture; GV-1 and GV-26 acupuncture; or GV-1 and GV-26 electroacupuncture. Turtles receiving either GV-1 and GV-26 acupuncture or GV-1 and GV-26 electroacupuncture had a significantly reduced time to return of voluntary movement ( P = 0.012 and P = 0.006, respectively), a significantly reduced time to response of limb extension ( P = 0.03 and P < 0.001, respectively), and a significantly reduced time to anesthetic recovery ( P < 0.05 and P < 0.01, respectively). Therefore, the use of either GV-1 and GV-26 acupuncture or GV-1 and GV-26 electroacupuncture produces significant reductions in anesthetic recovery time in EBTs that have received injectable anesthetics.

Pharmacokinetic of florfenicol in pulmonary epithelial lining fluid of swine and effects of anesthetic agent on drug plasma disposition kinetics

ABSTRACT The primary objective of the current study was to compare the pharmacokinetic (PK) of florfenicol (FFL) in pulmonary epithelial lining fluid and the plasma in swine. The second objectives were to evaluate the effect of anesthesia with ketamine and propofol on the PK of FFL in plasma. Bronchoaveolar lavage was utilized for quantification of PELF volume and the urea dilution method was used to determine the concentration of FFL in PELF. FFL was administered intramuscularly (IM) to swine in a single dose of 20mg/kg body weight. The main PK parameters of FFL in plasma and PELF were as follows: the area under the concentration-time curve, maximal drug concentration, elimination half-life and mean residence time were 69.45±4.36 vs 85.03±9.26μg·hr/ml, 4.65±0.34 vs 5.94±0.86μg/ml, 9.87±1.70 vs 10.69±1.60hr and 12.75±0.35 vs 14.46±1.26hr, respectively. There was no statistically significant difference between the PK profiles of FFL for the anesthetized and unanesthetized pigs. This study suggest that (i) FFL penetrated rapidly into the pulmonary and the drug concentration decay faster in plasma than in the pulmonary, (ii) the PK profile of FFL in swine was not interfered after administration of anesthetic agent.

Incidence of epileptiform discharges in children during induction of anaesthesia using Propofol versus Sevoflurane

ObjectiveIn pediatric patients, anaesthesia induction is often performed with intravenous Propofol or Sevoflurane inhalation. Although epileptiform discharges have been observed during inductions with Sevoflurane, their occurrence has not been investigated for i.v. Propofol inductions. The aim of this study is to compare the incidence of epileptiform discharges in children during anaesthesia induction using Propofol versus Sevoflurane. MethodsProspective, observational cohort study in children aged 0.5–8 years undergoing elective surgery. Children were anaesthetized with either Propofol or Sevoflurane. Bi-frontal electroencephalograms electrodes were placed before start of anaesthesia. Visual electroencephalogram analysis was performed from start of anesthetic agent administration until Intubation with regard to identify epileptiform patterns, i.e. delta with spikes; rhythmic polyspikes; periodic, epileptiform discharges; or suppression with spikes. Results39 children were anaesthetized with Propofol, and 18 children with Sevoflurane. Epileptiform discharges were seen in 36% of the children in the Propofol group, versus 67% in the Sevoflurane group (p = 0.03). Incidence of the distinct types of epileptiform discharge differed for periodic, epileptiform discharges (Sevoflurane group 39% vs. Propofol group 3%; p < 0.001). Higher concentration of Remifentanil (≥0.15 µg/kg/min) was associated with less frequent epileptiform discharges (Exp 5.8; CI 95% 1.6/21.2; p = 0.008). ConclusionsPropofol i.v. induction of anaesthesia in children triggers epileptiform discharges, whereas to a lesser extent than Sevoflurane does. SignificancePresuming that epileptiform discharges have an impact on postoperative brain function, it is advisable to use Propofol rather than Sevoflurane and higher level of Remifentanil for anaesthesia induction in children.

The Determination of an Appropriate Time for Placement of the Classic Laryngeal Mask Airway in Patients Undergoing General Anesthesia.

BackgroundThe management of the airways is an essential component of anesthesia planning. Laryngeal mask airway (LMA) plays an important role in modern anesthesia, however, intubation by LMA has some complications. It may cause inadequate anesthesia depth, which can lead to adverse events. The aim of this study was to evaluate the optimal time for intubation by LMA under general anesthesia.MethodsThis study was conducted on 96 patients, who underwent operation and were appropriate candidates for intubation with appropriate LMA. The participants were divided to four groups, each with 24 cases, based on the time interval between anesthetic agent administration and intubation with LMA; 15 seconds for the first group, 16 to 30 seconds for the second group, 31 to 45 seconds for the third group, and 45 to 60 seconds for the fourth group. The patients involved in these groups were selected based on the following prerequisites, patients’ age, gender, easy intubation, need for additional drug administration, basic blood pressure before drug administration, within the time intervals one, three, and five minutes after placement of LMA, duration of LMA, SaO2 before and after placement of LMA, coughing, patient’s movement, laryngospasm, gag reflex after intubation, allowing appropriate ventilation, presence of sore throat after surgery, number of attempts, extent of mouth opening and leak in peri-LMA space.ResultsOverall, 72 males and 24 females participated in this study with a mean age of 40.64. Intubation by LMA was performed easily during the first attempt in 58% of the participants, with minimal resistance in 28.6% and with some problems during the second attempt in 10.5% of the cases. Throat pain after the operation was significantly lower. Systolic and diastolic pressure and heart rate had no statistically significant difference.ConclusionsThe results showed that in the first 15 seconds after the drug (e.g. propofol) administration, there were lower complications, rapid placement, and optimized time for the placement of LMA. The rate of success and its quality were reduced during the first attempt of insertion and termination of the effect of propofol.

Delaying initiation of electroconvulsive treatment after administration of the anaesthetic agent and muscle relaxant reduces the necessity of re-stimulation

Objectives: To investigate the effect of delaying initiation of electroconvulsive therapy (ECT) after administration of anaesthetic agent and muscle relaxant.Methods: A retrospective cohort study utilizing a case-based analysis comparing number of re-stimulations, length of seizures, number of ECTs per series and stimulation dosage before and after introducing a new treatment regimen. In 2013, ECT was initiated approximately 60–90 seconds after administration of thiopental and succinylcholine. This interval was increased to 120 seconds in 2014. Ninety-three patients were included (40 in 2013 and 53 in 2014). Outcome measures were length of seizure, number of re-stimulations, number of ECTs per series and stimulation dosage. Regression model analyses were conducted with entering year of treatment (2013 vs. 2014), sex and age as covariates.Results: We showed that a lowered frequency of re-stimulation was independently associated with the 2014 treatment regimen. No effect of treatment regimen on duration of seizures as measured clinically or by EEG, on number of treatments per series or on stimulation dosage was observed.Conclusions: We found an association between an increased time interval from administration of thiopental and succinylcholine to ECT and a lowered risk of re-stimulations. The current study substantially strengthens the evidence on the benefits of delaying ECT after administration of anaesthetic agent and muscle relaxant.

Comparison of local anaesthesia versus spinal anaesthesia for peri anal disorders

Background: Peri anal disorders are associated with high morbidity and can be managed surgically both under spinal as well as local anaesthesia. Objectives: The study evaluates the results of anal surgery when performed under local anaesthesia as compared to spinal anaesthesia with respect to parameters like post operative pain, nausea, vomiting, analgesia requirement, voiding problem and bleeding. Material and Methods: The study included 50 patients divided in two groups (A and B) of 25 each. The patients of group A and group B were operated under local and spinal anaesthesia respectively. The patients were assessed postoperatively at 6 hrs, 8 hrs and 12 hrs on day one and then on subsequent days for different parameters like post operative pain, need and duration of analgesia required, bleeding, voiding problems and associated nausea. Result: The results of two groups were then compared and analysed. In group A 56% of patients required analgesia 8 hourly as compared to 40% in group B. No analgesics were required 3 days after the surgery in both the groups. Difficulty in voiding was seen in 12% of patients in group A as compared to 28% in group B. There was no post operative bleeding except for 4 patients in group A. Most of the patients of group A had hospital stay of 2.3±0.46 days postoperatively while those in group B stayed for 3.4±0.53 days. Conclusion: The study reveals favoured local anaesthesia over spinal anaesthesia for peri anal surgeries because of simplicity in administration of anaesthetic agent, less need of analgesia, lesser hospital stay, lesser incidence of nausea and vomiting and no need for catheterisation.

Anesthesia Issues in Central Nervous System Disorders.

Every year, millions of people affected by disorders of the central nervous system (CNS) undergo various diagnostic, therapeutic and surgical procedures requiring administration of anesthetic agents. Anesthetics exert their anesthetic, amnesic and analgesic effects by acting on multiple neuronal membrane proteins in the CNS. While some of the causal anesthetic targets have been identified, a large number of anesthetic targets remain unknown. The consequent longterm effect of anesthetic agents on expression of these various molecular targets has been implicated in mediating potentially long-lasting adverse effects. Recent work suggested that the effects of general anesthetics may not be entirely reversible, with animal studies demonstrating persistent changes in CNS protein expression post recovery from anesthesia. Age-associated or disease-induced alterations in the CNS can profoundly alter multiple aspects of brain structure, biochemistry, and function. Such maladaptive changes in the brain can render it increasingly vulnerable to the effects of various anesthetics. The selection of appropriate anesthesia drugs and protocol is mandatory, especially in individuals with pre-existing CNS disorders, so as to maximize anesthesia efficiency, avoid occurrence of adverse events, and ensure patient safety. This review aims to summarize and consider the effects and potential risks of commonly used anesthetic agents in patients with compromised CNS function. We provide a comprehensive review of the established as well as the implicated effects of anesthetic agents on the elderly as well as on the pathology and progression of common neurological conditions.

Misdiagnosis of anterior cutaneous nerve entrapment syndrome as a somatization disorder

IntroductionAnterior cutaneous nerve entrapment syndrome (ACNES) is a frequently overlooked disease, causing chronic abdominal wall pain due to entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves. It is often misdiagnosed as a psychiatric condition, particularly under the heading of a somatization disorder.ObjectivesWe describe the case of a patient who developed depressive symptoms after months of suffering from chronic abdominal wall pain.AimsTo report a case-study, describing ACNES as a cause of persistent depressive symptoms.MethodsA case-study is presented and discussed, followed by a literature review.ResultsA 35-year-female was referred to a psychiatrist for her depressive symptoms and persistent cutaneous abdominal pain for months. There she was diagnosed with a depression and possible somatization disorder and she received psychotherapy. Through Internet search, the patient found ACNES as a possible cause for her persistent abdominal pain. Since administration of anesthetic agents only shortly relieved her symptoms, a surgeon decided to remove the nerve end twigs. After surgery, her somatic problems and depressive mood disappeared.ConclusionThe awareness of ACNES is still very limited in medicine. This may lead to incorrect diagnoses, including psychiatric disorders such as somatization disorder.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Lactic acidosis treatment by nanomole level of spermidine in an animal model

Lactic acidosis occurs in a number of clinical conditions, e.g. in surgeries, orthotopic liver transplant, and anesthetic agent administration, which has deleterious effects on the patient’s survival. The most rational therapy for these patients, the sodium bicarbonate administration, cannot prevent those accompanying deficiencies and may actually be harmful. In addition, tromethamine adjusts the blood pH, it does not affect the lactate accumulation. Therefore, discovery of a therapeutic agent is still a major unsolved problem. In this study, the rats were divided into different groups and lactic acidosis type B was induced in them. Then, the effect of different injection doses of spermidine (0–20nmol) on lactic acidosis was analyzed by measuring the lactate level and pH in the rat blood samples. The results showed that spermidine effectively and simultaneously inhibited the lactate and pyruvate accumulations, and also adjusted the pH of bloodstream. On the other hand, it has been shown (Damuni et al., 1984; Rahmatullah and Roche, 1988) that spermidine increases the activity of phosphatase, leading to prevention of lactate accumulation. The results indicate that administration of only nanomole level of spermidine may be the best treatment in the liver transplant and other patients suffering from lactic acidosis type B.

An enriched simulation environment for evaluation of closed-loop anesthesia

To simulate and evaluate the administration of anesthetic agents in the clinical setting, many pharmacology models have been proposed and validated, which play important roles for in silico testing of closed-loop control methods. However, to the authors' best knowledge, there is no anesthesia simulator incorporating closed-loop feedback control of anesthetic agent administration freely available and accessible to the public. Consequently, many necessary but time consuming procedures, such as selecting models from the available literatures and establishing new simulator algorithms, will be repeated by different researchers who intend to explore a novel control algorithm for closed-loop anesthesia. To address this issue, an enriched anesthesia simulator was devised in our laboratory and made freely available to the anesthesia community. This simulator was built by using MATLAB(®) (The MathWorks, Natick, MA). The GUI technology embedded in MATLAB was chosen as the tool to develop a human-machine interface. This simulator includes four types of anesthetic models, and all have been wildly used in closed-loop anesthesia studies. For each type of model, 24 virtual patients were created with significant diversity. In addition, the platform also provides a model identification module and a control method library. For the model identification module, the least square method and particle swarm optimization were presented. In the control method library, a proportional-integral-derivative control and a model predictive control were provided. Both the model identification module and the control method library are extensive and readily accessible for users to add user-defined functions. This simulator could be a benchmark-testing platform for closed-loop control of anesthesia, which is of great value and has significant development potential. For convenience, this simulator is termed as Wang's Simulator, which can be downloaded from http://www.AutomMed.org .

Residual anaesthesia drugs in intravenous lines – a silent threat?

Residual anaesthesia drugs in intravenous lines – a silent threat?

Refractory status epilepticus: new insights in presentation, treatment, and outcome

Refractory status epilepticus (RSE), defined as status epilepticus that fails to respond to the acute administration of two antiepileptic medications, occurs in approximately a third of patients with status epilepticus, and is associated with increased hospital length of stay, mortality, and functional disability. Common presentations include: (1) generalized convulsive status epilepticus or complex partial status epilepticus that continue despite initial therapies; (2) stupor or coma following a generalized convulsive or complex partial seizure; or (3) stupor or coma following brain surgery or acute brain injury. When status epilepticus continues or recurs 24 hours or more after the initiation of anesthetic therapy, or recurs on the reduction or withdrawal of anesthesia, it is termed super RSE. Published evidence on optimal management of RSE consists largely of case reports or small series. The mainstay of treatment is the administration of anesthetic agents titrated to electrographic seizure control. Adjunctive therapies include hypothermia and immunosuppression and less commonly, surgery, electrical stimulation therapies, and induction of ketosis. Patients with cardiopulmonary complications and prolonged duration of drug-induced coma tend to have worse post-treatment functional outcomes. However, significant improvement over time can occur in survivors, and thus treatment is justified even in patients who require prolonged anesthetic coma. The strongest predictors of outcome are duration of anesthetic coma, etiology, and development of cardiopulmonary complications.

Anesthetic complications due to extremely low ankle blood pressure caused by peripheral arterial disease

Anesthetic complications due to extremely low ankle blood pressure caused by peripheral arterial disease

Prone insertion of a size 0.5 intubating laryngeal airway overcomes severe upper airway obstruction in an awake neonate with Pierre Robin syndrome

To the Editor, We present a case of a one-day-old 3-kg neonate who was scheduled to undergo a computed tomography (CT) scan to examine a severe upper airway obstruction secondary to Pierre Robin syndrome. The patient had remained in a prone position in the neonatal intensive care unit since birth, as transition to the supine position resulted in severe upper airway obstruction, sternal retractions, and oxygen desaturations despite the use of a nasopharyngeal airway. Commonly described goals to manage the airway in this context include using an oral/nasal airway to alleviate the airway obstruction prior to induction of anesthesia, using a supraglottic airway device, 1 and possibly securing the airway with a tracheal tube using a fibreoptic bronchoscope through a supraglottic device. We have experienced favourable results using the intubating laryngeal airway (ILA TM ) (Cookgas LLC; St Louis, MO, USA) as a conduit for tracheal intubation in neonates and infants with a difficult airway. 2,3 As the patient was unable to tolerate the supine position, airway management was performed in the CT suite with the patient awake in the prone position without administration of anesthetic agents. The anesthetic considerations for this patient included obtaining intravenous access, administration of an antisialagogue and chronotropic agent, and management of the airway with the patient in the awake state. Our primary plan was to place the ILA to manage the airway with the patient in the awake state, and our back-up plan was to intubate the trachea through the ILA using a fibreoptic bronchoscope. We applied standard American Society of Anesthesiologists’ monitors, and the anesthesia machine was then checked. Next, intravenous access was established in the patient’s left foot with the child awake prior to any airway intervention. Atropine 0.1 mg was subsequently administered as an antisialagogue. An assistant extended and stabilized the neonate’s head over the edge of the bed, and a size 0.5 ILA was placed with minimal gagging. The patient was then turned to the supine position with resultant improvement in airway

Subarachnoid anaesthetic blockade for sacral nerve stimulator insertion

Colorectal DiseaseVolume 14, Issue 8 p. 1028-1028 Correspondence Subarachnoid anaesthetic blockade for sacral nerve stimulator insertion A. M. Jadav, A. M. Jadav Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: alkajadav@hotmail.comSearch for more papers by this authorP. Dobbs, P. Dobbs Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: alkajadav@hotmail.comSearch for more papers by this authorS. R. Brown, S. R. Brown Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: alkajadav@hotmail.comSearch for more papers by this author A. M. Jadav, A. M. Jadav Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: alkajadav@hotmail.comSearch for more papers by this authorP. Dobbs, P. Dobbs Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: alkajadav@hotmail.comSearch for more papers by this authorS. R. Brown, S. R. Brown Northern General Hospital, Herries Road, Sheffield S5 7AU, UK E-mail: alkajadav@hotmail.comSearch for more papers by this author First published: 25 May 2012 https://doi.org/10.1111/j.1463-1318.2012.03106.xRead the full textAboutRelatedInformationPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume14, Issue8August 2012Pages 1028-1028 RelatedInformation RecommendedEffective local anaesthetic volumes for sciatic nerve blockade: a clinical evaluation of the ED99M. Keplinger, P. Marhofer, D. Marhofer, K. Schroegendorfer, W. Haslik, M. Zeitlinger, C. V. Mayer, S. C. Kettner, AnaesthesiaReversal of neuromuscular blockade with sugammadex during continuous administration of anaesthetic agents: a double‐blind randomised crossover study using the bispectral indexM. Le Guen, C. Roussel, T. Chazot, G. A. Dumont, N. Liu, M. Fischler, AnaesthesiaMexiletine has a local anesthetic effect on sciatic nerve blockade in ratsKuang-I Cheng, Ja-Ping Shieh, Ching-Nan Lin, Koung-Shing Chu, Aij-Lie Kwan, Chia-Hui Hou, Jhi-Joung Wang, Drug Development ResearchAnesthetic quality during cesarean section following subarachnoid or epidural administration of bupivacaine with or without fentanylCh. OLOFSSON, A. EKBLOM, E. SKÖLDEFORS, B. WÅGLUND, L. IRESTEDT, Acta Anaesthesiologica ScandinavicaAbdominal Nerve Blockade for Postoperative Analgesia after Caesarean SectionP. Kuppuvelumani, Hema Jaradi, Alex Delilkan, Asia-Oceania Journal of Obstetrics and Gynaecology

Cardiac resuscitation in the operating room: Reflections on how we can do better

‘‘The man who comes to the hospital carrying his valise should walk out of the hospital carrying his valise.’’ These wise words were told to me long ago by a mentor who was advising me that our first obligation is to heal our patients and, in the course of that healing, to keep our patients safe from harm. That advice applies to all of medicine. Since their initial use, the administration of anesthetic agents has been accompanied with tremendous benefit and considerable risk. Not long after ether was introduced, the deaths of patients were reported, many young and undergoing minor procedures. As medical knowledge has developed, anesthesia has become safer, but risk remains. Cardiac arrest in the operating room, the most severe expression of that risk, remains an infrequent but catastrophic event, and many factors can contribute when it occurs. There are many causes of cardiac arrest in the operating room; nevertheless, reversible causes are of primary concern here, particularly those that may be related to the anesthetic. Cardiac arrest in the operating room is different from cardiac arrest occurring elsewhere in the hospital or outside the hospital environment. In the operating room, arrests are generally recognized quickly, mainly because of sophisticated physiologic monitoring, with pulse oximetry, capnography, and end-tidal CO2 complementing routine blood pressure and electrocardiogram measurements. Patients are in an ideal setting for the rapid administration of oxygen, often with secure controlled airways and immediate intravenous access. Defibrillators and resuscitation drugs are usually readily available along with personnel who are familiar with their use, and chest compressions can be initiated immediately. The foregoing factors taken together facilitate generally higher survival rates from operating room cardiac arrests, particularly if the arrest is related to anesthesia. Thus, general guidelines for treating cardiac arrest in general hospital wards or outside the hospital do not necessarily translate well to the operating room setting. In this issue of the Journal, two articles deal with an aspect of this problem. In their article, Moitra et al. focus on the treatment of cardiac arrest in the operating room. They specifically address how such events differ from their occurrence in other locations, and they provide an in-depth discussion of the special characteristics. They propose a set of algorithms designed to guide anesthetic care, first to avoid cardiac arrest and second to treat it if it should occur. Moitra et al. make a significant contribution to the management of this problem, but there is still a significant step to accomplish. Even armed with these modified algorithms, we still face a considerable challenge to make the algorithms easily usable in the clinical setting. In a recent editorial, de Caen and Bhanji extend the discussion on resuscitation to include children and infants, and they provide a practical update on pediatric resuscitation for the anesthesiologist. They concisely summarize the most current scientific evidence and expert opinion, and they encourage anesthesiologists to adopt the new rearrangement of the classic airway-breathing-circulation (ABC) approach to cardiopulmonary resuscitation (CPR) to a compression first approach, i.e., compressions-airwaybreathing, making CPR more consistent across age groups. Also in the current issue of the Journal, an article by Charapov and Naveen presents a case of prolonged and successful resuscitation of a patient undergoing an urgent abdominal procedure. The case report joins others in the W. R. Berry, MD (&) Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA e-mail: wberry@hsph.harvard.edu