January 1997
Patient-controlled analgesia for mucositis pain in children: A three-period crossover study comparing morphine and hydromorphone.

• Recognition of sleep-disordered breathing in children.

January 1997
The Big Issue—The Digital Revolution: Where Do We Go From Here?

• With the free time afforded by the post-holiday season (no?), the philosophical mood of the new year, and the approaching new millennium, I would like to suggest a little different reading for those with an interest in the present technological revolution.

January 1997
Intercellular adhesion molecule–1 Mediates Acid Aspiration-induced Lung Injury.

• A clinical problem constantly in the minds of thoughtful anesthesia and critical care medicine practitioners is that associated with Mendelson's Syndrome, commonly known as acid aspiration-induced lung injury.

January 1997
Top 100 Hospitals—1996

• Everyone in healthcare is experiencing change—for better or worse. Those healthcare systems which will remain in the market are those which not only look within their own organization/management for specific opportunities for improvements in resource utilization and cost structure, but also simultaneously and actively engage in a "benchmarking" process—comparing one's specific management and results with those considered the "best of breed" in the industry.

January 1997
Recovery After Propofol With and Without Intraoperative Fentanyl in Patients Undergoing Ambulatory Gynecologic Laparoscopy

• This study evaluates the effect of intraoperative fentanyl supplementation on postoperative indices for ambulatory surgery patients.

January 1997
A multicenter comparison of maintenance and recovery with sevoflurane or isoflurane for adult ambulatory anesthesia. The Sevoflurane Multicenter Ambulatory Group.

• Sevoflurane is a newer inhaled anesthetic with low solubility. This study compares sevoflurane to the older inhalant, isoflurane in a 'typical' anesthetic including midazolam, fentanyl, propofol, 66% N2O, and vecuronium. This study assessed the awakening times and the quality of recovery of the two anesthetics.

January 1997
Assessment of recovery following day-case arthroscopy. A comparison between propofol and isoflurane-based anaesthesia.

• Nausea and vomiting are common but troublesome post-procedural complications for ambulatory patients. Both ondansetron and droperidol are effective antiemetics. This study compares the efficacy of ondansetron and droperidol compared to placebo, and evaluates their effects on recovery times, recovery quality, and costs of care.

January 1997
AMBULATORY NOTES

• A comparison of costs and efficacy of ondansetron and droperidol as prophylactic antiemetic therapy for elective outpatient gynecologic procedures.
  
  
• A multicenter comparison of maintenance and recovery with sevoflurane or isoflurane for adult ambulatory anesthesia. The Sevoflurane Multicenter Ambulatory Group.

January 1997
Parents and procedures: a randomized controlled trial.

• This paper examined parents' response to being present or not being present when their child was undergoing a painful procedure in the emergency room (venipuncture, intravenous cannulation, or urethral catheterization. All children were younger than 3 years. 431 parents were randomized to "intervention present" or intervention not present".

January 1997
The dos-response relation and cost-effectiveness of granisetron for the prophylaxis of pediatric postoperative emesis.

• In this placebo controlled, double blind study, 97 children were randomized to placebo, 10 or 40 mcg/kg granisetron IV during routine anesthesia. Patients were divided into nine subgroups depending on the incidence of postoperative nausea and vomiting, the need for rescue therapy, and the side effects of the antiemetics. Granisetron 40 mcg/kg was effective in reducing the incidence and frequency of emesis and also shortened time to discharge readiness.

January 1997
Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy.

• One of the most feared underlying medical conditions in the patient undergoing anesthesia is asymmetric septal hypertrophy (ASH), also referred to as subaortic stenosis or hypertrophic obstructive cardiomyopathy. Although it is a rare disorder (0.5% of patients with cardiac disease), these patients tolerate hypovolemia, hypotension and tachycardia extremely poorly.

January 1997
Perioperative respiratory complications in patients with asthma.

• The development of intraoperative bronchospasm has the potential to become an anesthetic disaster, with major morbidity and even death. Asthma occurs in more than 10 million Americans. Because general anesthesia implies airway manipulation, there is a high level of concern for perioperative complications such as laryngospasm, bronchospasm, pulmonary barotrauma and postoperative acute respiratory failure which may be very difficult to treat.

January 1997
Review of Effect of Atenolol on Mortality and Cardiovascular Morbidity After Noncardiac Surgery

• This is an extremely important study as it should directly influence the anesthesiologist's approach to the care of the patient at risk for coronary artery disease undergoing noncardiac surgery. Mangano's group had been instrumental in defining the importance of using beta blockers to reduce perioperative ischemia and associated myocardial infarctions.

February 1997
Pain and satisfaction with pain control in seriously ill hospitalized adults: Findings from the SUPPORT research investigations

• In the December 1996 issue of Critical Care Medicine, Desbiens et al. report on the incidence and severity of pain in patients enrolled in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments). Readers may recall the article published by the SUPPORT group in JAMA last Fall which suggested that the use of the pulmonary artery catheter was associated with a higher mortality in this population
  • Connors AF, Jr., Speroff T, Dawson NV, et al. — The effectiveness of right heart catheterization in the initial care of critically ill patients. JAMA 1996;276:889-97; Dr. Lubarsky reviewed this article in the December edition of AnesthesiaWeb.

February 1997
Cardiopulmonary resuscitation: What cost to cheat death?

• "CPR: What cost to cheat death?" This timely and apposite question is posed by Lee et al. in the December issue of Critical Care Medicine. They attempt to answer it not by metanalysis but by evaluation of outcome data on CPR from contemporary studies. In this they distinguished the resources required for in-hospital arrest ("Code Team") from out-of-hospital arrest (EMS, physician "on-line", ER).

Febuary 1997
Sevoflurane depresses myocardial contractility less than halothane during induction of anesthesia in children.

• The purpose of this study was to compare the echocardiographic derived indices of cardiac contractility during induction with 1.0 and 1.5 MAC sevoflurane and halothane. Twenty unpremedicated children ages 8.9 � 2.9 vs 8.1 � 3.2 yr. were randomized to halothane or sevoflurane. The authors found that blood pressure and heart rate were stable with both agents.

February 1997
Are chest radiographs and electrocardiograms still valuable in evaluating new pediatric patients with heart murmurs or chest pain?

• The purpose of this study was to determine the usefulness of electrocardiography and chest radiography in evaluation of patients referred to pediatric cardiologists for evaluation of a heart murmur or chest pain.

February 1997
Cardiovascular effects of desflurane and isoflurane in patients with coronary artery disease

• This study compares the cardiovascular effects of equipotent concentrations of desflurane and isoflurane in ASA 3 patients undergoing elective CABG surgery. Both groups had a standardized induction with etomidate and 3-5 mcg/kg fentanyl and pancuronium. The inhaled agent was administered in slowly increasing concentrations after intubation.

February 1997
Prevalence and source of pain in pediatric inpatients

• Systematic attention to the provision of appropriate analgesia for infants and children has been a relatively recent phenomenon. Over the last 20 years, epidemiological studies of pain and analgesic use have focused on specific patient groups such as postoperative patients or those with cancer.

February 1997
Gabapentin adjunctive therapy in neuropathic pain states

• Gabapentin (Neurontin) is a water-soluble GABA analog that was recently approved for the treatment of seizures. This report of 4 cases by Rosener et al from the Pain Management Service at Cornell Medical Center is one of the first papers describing its use for the management of neuropathic pain.

February 1997
Outlook 1997: Batten Down the Hatches.

• While ushering in 1997, it is interesting to consider the predictions and projections offered by observers of the healthcare system in which we work. Mr. McLaughlin, a senior editor for Modern Healthcare, compiled predictions for the upcoming year from experienced writers related to a dozen major segments of the healthcare field. The 12 segments reviewed and the major points from each contributor are presented below. Each has significant bearing on the anesthesiology practitioner.

February 1997
JAMA Netsight: A Guide to Interactive Medicine; Internet Anatomy 101; Accessing Information on the World Wide Web.

• This short article in the January 8, 1997 edition of JAMA has information for the novice computer user as well as the seasoned "cyberwarrior". The authors summarize their goal nicely: "....we will try to demystify the technology and illustrate exactly what occurs when a user clicks the computer mouse and ventures out to visit a Web site.

February 1997
Selective use of the intensive care unit after nonaortic arterial surgery.

• In medicine, clinical practice is quite often nothing more than following an old routine. Why do something a particular way? Frequently the answer is nothing more than "Because that's the way we do it." The reasons for instituting a particular practice may have been sound in the past, but as technology and skill progress, we must not fail to question whether the old way of doing things is still the right way.

February 1997
Statistical Modeling to Predict Elective Surgery Time

• Applications of Information Systems to Operating Room Scheduling.

March 1997
Patient-controlled sedation for cataract surgery using peribulbar block.

• Typically, sedation to supplement cataract surgery under peribulbar block is given intravenously by a health care professional. This study investigates patient-controlled sedation in a group of patients with median ages 67-70. Patients were able to administer increments of either midazolam 0.1 mg, propofol 3.3 mg or saline.

March 1997
Comparison of propofol and a propofol-methohexitone mixture for induction of day-case anaesthesia

• Two short acting intravenous agents are currently available for the induction of anesthesia in ambulatory surgery. Propofol is highly popular because of its short recovery time and low incidence of postoperative sequelae. However, methohexital produces less cardiovascular and respiratory depression and is less expensive. This Scottish study investigates the properties of a mixture of propofol and methohexital with those of propofol alone.

March 1997
Propofol or halothane for children with asthma: effects on respiratory mechanics.

• This study examined respiratory mechanics in 60 children ages 2-12 years. Half the children had a history of reactive airway disease and half were considered normal. Anesthesia was induced with propofol (3mg/kg), fentanyl (1 ug/kg), and the trachea intubated following neuromuscular blockade with atracurium (0.5 mg/kg).

March 1997
Parental desire for perioperative information and informed consent: A two-phase study.

• The purpose of this study was to identify the perioperative information that parents desire from the anesthesiologist and to determine whether the provision of detailed anesthetic information is associated with increased parental anxiety.

March 1997
Endoluminal Stent Grafts for Infrarenal Abdominal Aortic Aneurysms

• It was only a matter of time before stenting followed the course of blood flow out from the heart to the periphery. Exciting new applications of stents are beginning to transform the field of vascular surgery. Experimental applications are beginning for carotid stenoses, and a significant number of patients have now been stented for aortic aneurysm repair.

March 1997
What Happens After Discharge? Return Hospital Visits After Ambulatory Surgery

• Dr. Twersky notes that less serious postoperative events after ambulatory surgery do not receive much physician or analytic attention. This study retrospectively examined a database of ambulatory patients to see whether there were any trends for patients who returned to the hospital within 30 days after surgery. All visits were coded as to whether they were related to the patient's ambulatory surgery or not.

March 1997
Procurement and allocation of Solid Organs for Transplantation

• The demand for more solid organ donors is increasing beyond the supply. The process of organ transplantation has direct meaning to the providers of perioperative services, including anesthesia and critical care. This article reviews the current state of procurement and allocation of organs, beginning with the evolving sources of organs, trends in the characteristics of cadaveric donors, the organ allocation process and an evaluation of the performance of the present procurement and allocation process.

March 1997
The Work of Leadership

• Regardless of title or position, few practitioners are without leadership responsibilities in some form. The environment of major change in today's world raises the question in even the most seasoned leaders minds of how best to guide their endeavor forward in the most constructive manner.

March 1997
Primary bronchomalacia in infants and children.

• In pediatric anesthesia one is from time to time presented with an infant with wheezing that persists despite what appears to be adequate medical therapy. We are all used to thinking of tracheomalacia as a cause of persistent upper airway sounds (stridor) in infants, but the etiology of persistent lower airway sounds (wheezing) has been less well defined.

March 1997
A systematic review of antidepressants in neuropathic pain.

• Much of the use of antidepressants for the treatment of neuropathic pain has been the result of anecdotal reports and personal experience rather than of systematic study. McQuay and colleagues from the University of Oxford have performed a systematic review and meta-analysis of the available studies to address current clinical debates.

March 1997
Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers.

• In the early 1970s the volatile anesthetic agent, methoxyflurane - which had been very popular because of its analgesic properties and smooth emergence – gained notoriety through its association with postoperative polyuric acute renal failure. Elegant detective work in the laboratory and clinic by Michael Cousins and Richard Mazze elucidated that the culprit was the fluoride molecule, a product of extensive hepatic biotransformation of methoxyflurane.

March 1997
Outcome assessment and pulmonary artery catheterization: why does the debate continue?

• Readers will doubtless recall the disturbing report on the SUPPORT study in JAMA last fall which found that the use of the pulmonary artery catheter is associated with increased mortality (1), and the controversial editorial (2) that accompanied it in which suggested that the FDA apply a moratorium on its use.
  
  
  • Dr. Lubarsky reviewed this article
    
    
    • Abstract available in the December 1996 edition of AnesthesiaWeb.)

April 1997
Effect of ketorolac tromethamine on hemostasis.

• Ketorolac is known to have antiplatelet properties. This study assessed the effect of ketorolac on hemostasis compared with low-dose heparin, ketorolac-heparin combination and placebo.

April 1997
Evaluation of morphine versus fentanyl for postoperative analgesia after ambulatory surgical procedures.

• Claxton et al examined the postoperative side effects and adequacy of pain management in adult patients undergoing outpatient surgical procedures. Fifty-eight adults were randomly assigned to receive either morphine or fentanyl in equipotent doses in a double-blind, randomized fashion. Opioid doses were titrated in the postanesthesia care unit (PACU) to visual analog scores of < 40mm and patient satisfaction.

April 1997
Nitrous oxide does not increase vomiting after dental restorations in children.

• Splinter et al, examine the effect of nitrous oxide on the incidence of postoperative vomiting in children. 330 pediatric patients, 2 - 12 years of age scheduled for dental procedures were entered into the study. Some children were premedicated with oral midazolam (0.5 mg/kg up to 15 mg). Some children then underwent a gaseous induction of anesthesia with halothane while others were induced with intravenous propofol.

April 1997
JCAHO Tries Again

• Following almost 11 years of confusion, the Joint Commission on Accreditation of Health Care Organization (JCAHO) just unveiled its latest plan to base accreditation, in part, on provider performance. Since its inception in 1951, the JCAHO used capacity for provision of high quality care as the basis for judging hospitals and other health care providers.

April 1997
Inhaled Nitric Oxide in Full-Term and Nearly Full-Term Infants with Hypoxic Respiratory Failure.

• Two original articles appeared back-to-back in the New England Journal, both dealing with clinical applications of nitric oxide in the treatment of newborn infants with pulmonary hypertension related to respiratory failure. These articles are remarkably parallel in nature and arrive at similar conclusions and recommendations related to the evolving practice of administering inhaled nitric oxide therapeutically to infant patients. It is now recognized that inhaled nitric oxide is a selective pulmonary vasodilator.

April 1997
the Use of Alpha2-Adrenoceptor Agonists in Anesthesiology

• Epidural clonidine used as the sole anesthetic agent during and after abdominal surgery: a dose-response study.
  
  
• Dexmedetomidine as an anesthetic adjunct in coronary artery bypass grafting.
  
  
• Perioperative sympatholysis: beneficial effects of the alpha2-adrenoceptor agonist mivazerol on hemodynamic stability and myocardial ischemia.

April 1997
Plasma concentrations of bupivacaine in neonates after continuous epidural infusion.

• Five years ago, there were several reports of bupivacaine toxicity in infants and children. As a result dosage recommendations for continuous infusion of bupivacaine in infants were reduced from a maximum of 0.45 mg/kg/hr to 0.2 mg/kg/hr. Larsson and colleagues at the Karolinska Hospital in Sweden now report their evaluation of the safety and efficacy of the new bupivacaine doses.

May 1997
What happens after discharge? Return hospital visits after ambulatory surgery.

• These authors performed a retrospective review of hospital records to identify the frequency of return hospital visits after ambulatory surgery in this teaching hospital-integrated ASU. 6243 patients over 12 consecutive months were reviewed. 187 returned to the same hospital within 30 days. 54% returned to the emergency room and 46% were rehospitalized. 1.3% of the total returns were for complications.

May 1997
The direction of the Whitacre needle aperture affects the extent and duration of isobaric spinal anesthesia.

• Isobaric spinals are commonly used for ambulatory anesthesia, and the Whitacre needle has become popular since it is associated with a lower incidence of postdural puncture headache. One concern, however, is the in-facility recovery time needed. This study assessed the effect of cephalad versus caudad direction of the 27 ga Whitacre needle aperture on the extent and duration of spinal anesthesia.

May 1997
Follow-up of school-age children with bronchopulmonary dysplasia.

• Giacola et al performed a follow-up examination of 12 neonatal intensive care graduates who had bronchopulmonary dysplasia (BPD) and two control groups of 12 children (12 preterm and 12 term age-matched normal children with uncomplicated perinatal course). The height, but not the weight, of both preterm groups was less than the full term group. More important for the anesthesiologist was the fact that children with BPD had a higher incidence of pneumonia at all ages than either the preterm or term control groups.

May 1997
Comparison of cuffed and uncuffed endotracheal tubes in young children during anesthesia.

• Khine et al compared the safety and complications of using cuffed vs. uncuffed endotracheal tubes in 488 children ranging in age from the neonate to 8 years. The groups appeared to be evenly matched regarding weight, duration of intubation, and type of procedure but the patients in the uncuffed group tended to be slightly younger (p = 0.05).

May 1997
Benchmarking the perioperative process.

• This paper presents the development of a patient routing system that tracks patients as they move through the perioperative experience.

May 1997
Costs of care and administration at for-profit hospitals and other hospitals in the United States

• I love research that defies conventional wisdom, as this paper does. We are all led to believe how mean and lean for-profit hospitals are, and so would expect less money wasted on administration versus the amount being spent on the necessary medical care of our patients.

May 1997
Focus on Zafirlukast: a leukotriene receptor antagonist for the prophylaxis and chronic treatment of asthma.

• This article reviews the pharmacology and clinical trials of the first agent of a new therapeutic class of drugs approved by the FDA to treat asthma by antagonism of the cysteinyl leukotriene receptor. Approximately 10 million individuals in the United States are known to have asthma, a disease which has only relatively recently been recognized to be comprised in part of a significant inflammatory component.

May 1997
Concomitant Endothelin Receptor Subtype-A Blockade During the Progression of Pacing-Induced Congestive Heart Failure in Rabbits.

• A primary goal in anesthesiology/critical care medicine is control of cardiopulmonary function. Many of the drugs currently deployed by practitioners in this regard are related to knowledge acquired over several decades about "Classic" physiological mediators.

May 1997
Occupational exposure to sevoflurane, halothane and nitrous oxide during paediatric anaesthesia: waste gas exposure during paediatric anaesthesia.

• In the course of taking care of our patients, we must remember also to care for ourselves. One potential source of injury to anesthesiologists and other operating room personnel is exposure to anesthetic gases. While no clear dose-effect relationships between chronic exposure to anesthetic gases and damage to neurological, psychomotor, reproductive or bone marrow function have been demonstrated, it seems prudent to know the extent of this exposure in order to minimize it.

May 1997
Efficacy and safety of intravenous midazolam and ketamine as sedation for a therapeutic and diagnostic procedures in children.

• Clinicians in many specialties are faced with the challenges of providing safe and cost-effective sedation for children undergoing painful and non-painful diagnostic and therapeutic procedures. The JCAHO has charged anesthesiologists with the responsibility of setting uniform standards of care for sedation performed throughout a given institution.

May 1997
Laryngeal mask airway in severe cervical stenosis.

• In the March issue of the Canadian Journal of Anaesthesiology, Defalque and Hyder (1) report on the use of a laryngeal mask airway (LMA) to facilitate ventilation of a 61 year-old man with severe ankylosing spondylitis requiring intense muscle relaxation for a closed reduction of a dislocated femoral head.

May 1997
Navigation in uncharted waters: is anesthesiology on course for the 21st century?

• In the March 1997 issue of Anesthesiology, the text of the Rovenstine Lecture delivered by Dr. David Longnecker, Professor and Chairman of the Department of Anesthesiology at the University of Philadelphia, is published in full. Whether one attended the lecture at the 1996 American Society of Anesthesiologists meeting or not, it will be salutory to read this article. It is at once thoughtful and thought-provoking.

June 1997
Evaluation of morphine vs. fentanyl for postoperative analgesia after ambulatory surgery procedures

• Adequate control of postoperative pain is critical to the success of ambulatory surgical procedures. However, opioids, which are effective in controlling postoperative pain, are also associated with significant side effects. Fentanyl is currently the drug of choice because of fast onset time and reasonable duration of action, but morphine may provide more prolonged pain relief. This study compares morphine with fentanyl for postoperative analgesia after painful ambulatory surgical procedures.

June 1997
Late intraoperative clonidine administration prevents postanesthetic shivering after total intravenous or volatile anesthesia.

• Post anesthetic shivering develops in up to 60% of patients recovering from general anesthesia. Central adrenergic receptors appear to modulate postanesthetic shivering. Previous studies utilizing clonidine suggest that its effect is related to the time, dose, and duration of its administration.

June 1997
Antagonism of suxamethonium-induced jaw muscle contraction in rats.

• Shi et al, in an animal model have demonstrated that a low dose of vecuronium or dantrolene will decrease the masseter muscle rigidity induced by succinylcholine. They performed the experiment with an elevated jaw muscle temperature to exaggerate the normal response to succinylcholine. They speculate that pretreatment with small doses of vecuronium might decrease succinylcholine induced masseter muscle rigidity in the clinical situation as well.

June 1997
Airway muscle in preterm infants: Changes during development.

• Sward-Comunelli et al have documented with their pathology study of 55 lungs from preterm infants with what we have observed clinically for many years— even preterm infants can develop bronchospasm. This is the best study to date documenting the presence of bronchial muscle at all levels of the airway, even in infants as young as 23 weeks gestational age.

June 1997
Perioperative Maintenance of Normothermia Reduces the Incidence of Morbid Cardiac Events: A Randomized Clinical Trial.

• In this article Steve Frank and colleagues serve up some chilling information about the risk of mild hypothermia. The effect of hypothermia on the incidence of perioperative cardiac morbidity is examined. Kurz et al¹ recently published a much discussed article demonstrating that postoperative infections and length of stay were affected by mild hypothermia in patients at high risk for postoperative infections.

June 1997
Institutional Review Board Approval and Publication of Human Research Results

• The Declaration of Helsinki is the standard reference for the rules of ethical conduct of studies involving human beings. It is based on the premise that any patient has the right to make an un-coerced, reasoned decision on whether or not to participate in a study, all of which is encompassed in the practice of "informed consent."

June 1997
Biological markers of acute lung injury: prognostic and pathogenetic significance.

• The pathogenetic mechanisms of acute lung injury have focused most recently on the cellular and biochemical mediators of the acute respiratory distress syndrome (ARDS). Searching for sensitive and specific biologic markers of ARDS has become an increasingly compelling matter for three primary reasons.

June 1997
Pain Management in the Emergency Department: Patterns of analgesic utilization.

• The Emergency Department (ED) is another place where analgesic requirements can be substantial and practitioners training and experience in prescribing analgesics to pediatric patients can be highly variable. This study is the work of physicians at an academic medical center (Rainbow Babies and Children's Hospital, Case Western Reserve University) and a community academic medical center (MetroHealth Medical Center, Case Western Reserve University).

June 1997
Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision.

• Any study of medication use must address the issues of the safety and efficacy of the drug. In the past, discussions of appropriate analgesia for infants sometimes were simply terminated by assertions that infants do not feel pain. This argument is clearly inappropriate and now rarely used.

June 1997
Prolonged sedation of critically ill patients with midazolam or propofol: impact on weaning and costs.

• Propofol has enjoyed widespread acceptance as a sedative-hypnotic given by continuous infusion in the intensive care unit (ICU). Although it lacks analgesic and amnestic effects, and is usually given in combination with an opioid such as fentanyl or morphine, its rapid titrateability, lack of accumulation, and reliably fast emergence have made propofol a desirable addition to our sedative regimens.

June 1997
Experience with end-of-life practice at a university hospital.

• One of the most neglected areas of medicine is decision-making for and care of the terminally ill. Appropriate and humane withdrawal of aggressive and invasive medical support technologies allows patients with irreversible fatal disease to spend their final days in dignity, close to their loved ones, with all medical measures geared toward their comfort. In addition, cessation of futile care in a high intensity unit saves a large amount of unnecessary cost.

July 1997
A randomized multicenter study of remifentanil compared with alfentanil, isoflurane, or propofol in anesthetized pediatric patients undergoing elective strabismus surgery.

• Davis et al performed the first multicenter trial of remifentanil in a pediatric population using propofol, alfentanil, and isoflurane as comparators. It was of interest that there was no difference in time to extubation, time to purposeful movement, time to hospital discharg or incidence of vomiting; the incidence of postoperative hypoxemia and need for naloxone was higher in the alfentanil group.

July 1997
Hyperbaric dye solution distribution characteristics at the pencil-point needle injection in the spinal cord model.

• Neurologic injury has been reported after continuous spinal anesthesia with hyperbaric local anesthetics, usually 5% lidocaine in 7.5% dextrose. The flow-rate limiting and directional characteristics of caudally directed microcatheters may lead to an intrathecal maldistribution of local anesthetic, which may be responsible for the findings. Similar transient ridicular irritation has been reported after the use of pencil-point needles.

July 1997
A retrospective review of 4,767 consecutive spinal anesthetics: Central nervous system complications.

• Spinal anesthesia has been long used, and has been associated with a low rate of neurological complications. In several large studies prior to 1970 totaling over 50,000 anesthetics, the reported incidence of minor sensory neurological deficits range from 0-0.7%, and minor motor deficits from 0.005-0.02%. The practice of spinal anesthesia has changed since those studies, with differences in spinal needles and spinal anesthetic agents.

July 1997
Pulse oximetry as a fifth pediatric vital sign.

• Mower and colleagues examined the utility of pulse oximetry for triage of pediatric patients presenting to a University based emergency room practice. Patients who bypassed triage or who were in need of immediate attention were excluded. This study was cleverly designed because prior to discharge from the facility, the physicians had to fill in a questionnaire in order to receive the proper discharge forms.

July 1997
Making It Pay!

• The Role of Cost-effectiveness Analysis in Health and Medicine.

July 1997
Making It Pay! Part 2 of a 3-article series reviewed by Dr. Lubarsky.

• Recommendations of the Panel on Cost-Effectiveness in Health and Medicine.

July 1997
Pretreatment with inhaled nitric oxide inhibits neutrophil migration and oxidative activity resulting in attenuated sepsis-induced acute lung injury.

• In this paper by Bloomfield, et al., the authors emphasize that gram negative sepsis in adult respiratory distress syndrome are majors causes of morbidity and mortality in hospitalized patients—up to 500,000 patients per year are affected with a mortality rate of about 50%. Adult respiratory distress syndrome (ARDS) affects about 43% of patients with sepsis and is associated with mortality rates approaching 80%-90% when associated with other organ failure.

July 1997
HMO Makeover: Are Managed Care Efforts to Overhaul Its Image too Little, too Late?

• Everyone is aware that the managed-care industry has an image problem, but this article helps to shed light on the specific details. For example, in a survey released by a public relations firm in 1996, only 10% of a cross-section of consumers thought the managed-care industry was "believable."

July 1997
Intravenous methadone for cancer pain unrelieved by morphine and hydromorphone: clinical observations.

• An update on the clinical use of methadone for cancer pain.

December 1997
Comparison of end-tidal and arterial carbon dioxide in infants using laryngeal mask airway and endotracheal intubation.

• This is an interesting study because it systematically compared the end-expired carbon dioxide values obtained at the 15 mm connector in infants anesthetized with a non-rebreathing system with controlled ventilation, with both a laryngeal mask airway and an endotracheal tube.

July 1997
The rational use of intravenous amiodarone in the perioperative period.

• Amiodarone, a potent antiarrhythmic agent used for intractable ventricular arrhythmias, has been available in oral form for many years. It gained considerable notoriety among anesthesiologists because of its extraordinarily long half-life (29 days), and disconcerting hemodynamic and pulmonary side-effects. These include intractable bradyarrhythmias and heart block, polymorphic ventricular arrhythmias, markedly impaired response to beta-adrenergic inotropic agents, and postoperative ARDS (possibly related to oxygen toxicity).

July 1997
Intrathecal morphine for coronary artery bypass grafting and early extubation.

• There has been considerable interest recently in the use of regional analgesic techniques in cardiac surgery, including intrathecal and epidural opioids. These have been promoted both in an effort to facilitate early tracheal extubation and "fast tracking" as well as improve postoperative pain control.

August 1997
Nicardipine versus nitroprusside for controlled hypotension during spinal surgery in adolescents.

• This is an interesting paper because it examines this group's experience with two techniques for induced hypotensive anesthesia. The authors prospectively compared sodium nitroprusside versus the calcium channel blocker nicardipine. Both groups were evenly matched for age, weight, and operative time.

August 1997
The Ouchless Place: No pain, Children's Gain

• Schechter et al described their experience in attempting to minimize the painful experiences children often have during hospitalization. The authors described the creation of a multidisciplinary committee that specifically addressed the issue of barriers to adequate pain control in children. This group systematically reduced the pain associated with hospitalization by adopting a uniformity of approaches to post operative pain management.

August 1997
My mother caused my illness: The story of a survivor of Munchausen by proxy syndrome

• All of us shrink from the idea that an adult, particularly a parent, would deliberately harm a child; we would very much prefer to believe that that does not happen. Many kinds of abuse occur within the home and as such are difficult for medical personnel to detect, but Munchausen by proxy syndrome (MBPS) intimately involves the health care system.

August 1997
Neurologic evaluation of infant and adult rats before and after sciatic nerve blockade.

• I have reviewed several articles in this forum which have included issues related to the difficulties in assessing pain in infants and young children. Others have addressed the pharmacodynamic and pharmacokinetic differences between them and adult patients.

September 1997
The Effect of Isoflurane, Halothane, Sevoflurane, and Thiopental/Nitrous Oxide on Respiratory System Resistance after Tracheal Intubation.

• Potent inhaled agents are frequently used to prevent and manage brochospasm. Although halothane is often recommended as the agent of choice in such situations, the relative efficacy of the volatile anesthetics in humans has not been well studied.

September 1997
Acute Pain and Central Nervous System Arousal Do Not Restore Impaired Hypoxic Ventilatory Response during Sevoflurane Sedation.

• These authors sought to identify the influence of acute pain on resting minute ventilation and on the ventilatory control, measured by the ventilatory response to isocapnic hypoxia during wakefulness and sedation.

September 1997
Management of Anticoagulation Before and After Elective Surgery.

• This is a topic of great interest to anesthesiologists, intensivists, and all other perioperative personnel. The authors, Drs. Kearon and Hirsh, have written a clear, easy to understand guide of how to optimally treat patients who are taking warfarin preoperatively. The analysis is organized by the type of embolic risk (venous thromboembolism, arterial thromboembolism, from a fib/mechanical heart valves) and the time interval from the last episode (<1 month carrying the highest risk).

September 1997
Hemodynamic Response and Change in Organ Blood Volume During Spinal Anesthesia in Elderly Men with Cardiac Disease.

• For years, we have all had drummed into our heads that volume is the remedy for spinal hypotension. The reason for this review is to tell you, "Hey, it's probably OK to give some neo to your elderly patient with a drop in BP after his spinal." This study demonstrates that although volume does drop (left ventricular volume decreased almost 20%), afterload decreases even more (systemic vascular resistance - SVR - decreased 26%).

September 1997
Probucol and multivitamins in the prevention of restenosis after coronary angioplasty.

• Although positive immediate results may accrue with the treatment of narrowed coronary arteries with balloon angioplasty, Tardif et al note that a reliable approach to the prevention of restenosis is still very much needed. This is a well-designed study, which examines the use of Probucol, a potent antioxidant used initially to lower serum cholesterol concentrations and which significantly reduces luminal narrowing after balloon coronary angioplasty.

September 1997
Associated malformations in infants with cleft lip and palate: A prospective, population-based study.

• Essentially all patients with cleft lips, and most of those with true cleft palates, come to the operating room for repair within the first few months of life. Many also are anesthetized for procedures to repair associated anomalies. In this paper, a multidisciplinary team of investigators at the Karolinska Hospital in Stockholm, Sweden reports the results of the prospective collection of data on the prevalence and characteristics of congenital defects associated with cleft lip and palate.

September 1997
Alternative Routes of Drug Administration - Advantages and Disadvantages

• This subject review was developed by the Committee on Drugs of the American Academy of Pediatrics. The purpose of this document was to point out the pitfalls that might occur when administering drugs to children when such use have really only been systematically investigated in adults, or not investigated at all.

September 1997
Comparison of end-tidal and arterial carbon dioxide in infants using laryngeal mask airway and endotracheal intubation.

• This is an interesting study because it systematically compared the end-expired carbon dioxide values obtained at the 15 mm connector in infants anesthetized with a non-rebreathing system with controlled ventilation, with both a laryngeal mask airway and an endotracheal tube.

September 1997
Rocuronium versus succinylcholine for rapid sequence induction using a variation of the timing principle.

• This study compared the efficacy of low dose rocuronium vs succinylcholine to gain rapid control of the airway. Unfortunately the situation studied is not the same as one would encounter in clinical practice.

September 1997
Intramuscular atropine sulfate in children: comparison of injection sites.

• This is a very interesting paper because it clearly demonstrates that the absorption of a drug is markedly dependent upon the site of administration. This has been an issue of debate for succinylcholine for many years. The authors are to be commended for using a relatively innocuous drug with an easy endpoint to study, i.e. a change in heart rate following atropine.

October 1997
Dysregulation of calcium homeostasis after severe burn injury in children: Possible role of magnesium depletion.

• Klein et al examined calcium homeostasis in 10 children with extensive thermal injuries. Their observation is not new; Martyn et al reported a number of years ago that children with extensive thermal injury have persistent ionized hypocalcemia.¹  Klein et al found a blunted response to parathormone, low levels of parathormone, and an association with hypomagnesemia.

October 1997
The effects of midazolam on propofol-induced anesthesia.

• Midazolam is frequently used to achieve several goals: for preoperative sedation and amnesia, as well as with an intravenous induction agent to accelerate the onset of hypnosis and to reduce the dose requirements of other drugs.

October 1997
The Impact of Choice of Muscle Relaxant on Postoperative Recovery Time: A Retrospective Study.

• It is a truly great opportunity to debunk junk science. With that introduction, one must assume I did not agree with the conclusions of this paper. And that is correct. A flawed methodology and conclusions unsupported by the data are the hallmarks of this study.

October 1997
The Problem with Long Acting Muscle Relaxants? They Cost More!

• Dr. Caldwell uses his editorial soapbox to promote the related article I reviewed this month (The Impact of Choice of Muscle Relaxant on Postoperative Recovery Time: A Retrospective Study. Ballantyne et al.). It is hard to understand how a "scientist" can so blindly accept flawed data and conclusions in a prominent journal and ignore the real science driving these issues.

October 1997
Controversies in Pulmonary Artery Catheterization.

• An entire edition of this Journal, which is an official publication of the Society of Critical Care Medicine, is devoted to the process of arriving at consensus with regard to the procedure of pulmonary artery catheterization.

October 1997
Twenty-four-hour pharmacokinetics of rectal acetaminophen in children.

• Patrick Birmingham enlisted excellent clinical and laboratory support from his colleagues at Northwestern University as well as sophisticated pharmacokinetic modeling from Dennis Fisher at the University of California San Francisco to provide a more complete picture of the uptake and distribution of a single dose of rectal acetaminophen.

October 1997
Management of patient-controlled analgesia: A comparison of primary surgeons and a dedicated pain service.

• Those of us who manage or participate in dedicated acute pain services (APS), know that we provide better care for patients whose postoperative pain is managed by APS-directed patient controlled analgesia (PCA) than is given when primary care surgeons (PS) supervise PCA.

October 1997
Intranasal ketamine preinduction of paediatric outpatients.

• In the late 1970s, a survey of inpatients at a large pediatric hospital revealed that the thing the children remembered as being most unpleasant about their stay was the intramuscular (IM) injection of preoperative sedatives. Anesthesiologists there and elsewhere began to consider acceptance of medication administration to be important and to evaluate their previous practice of IM premedication of infants and children.

October 1997
Radial artery diameter decreases with increased femoral to radial arterial pressure gradient during cardiopulmonary bypass.

• Most cardiac anesthesiologists are familiar with a fairly common phenomenon that is observed toward the end of cardiopulmonary bypass (CPB) and for about an hour thereafter: the arterial pressure reflected by the radial catheter is considerably lower than the true central arterial pressure.

October 1997
The effect of dopamine on hepatic blood flow in patients undergoing epidural anesthesia.

• Over the past two decades there has been considerable controversy over the beneficial effect of low-dose dopamine on renal function and the prevention of renal failure. The mechanisms by which dopamine may benefit renal function include an increase in renal blood flow and its specific diuretic action on dopaminergic receptors in the renal tubule.

October 1997
Improvement in oxygenation by phenylephrine and nitric oxide in patients with severe acute respiratory distress syndrome.

• Phenylephrine and inhaled nitric oxide in adult respiratory distress syndrome: when are two better than one? (Accompanying Editorial)
  
  
• Permissive hypercapnia with and without expiratory washout in patients with adult respiratory distress syndrome.

November 1997
The 1997 ASA Round-Up

• What I Did on My Fall Vacation in San Diego

• Perioperative Information Management: A Panel Report

November 1997
The 1997 ASA Round-Up

• Perioperative Information Management: A Panel Report

November 1997
The 1997 ASA Round-Up

• The Prone Position in Acute Respiratory Distress Syndrome(ARDS)

November 1997
The end of life sequence.

• The nature of suffering and the nature of opportunity at the end of life.

November 1997
The 1997 ASA Round-Up

• The ASA update for pediatrics

November 1997
Clinical Management of Latex-Allergic Children.

• Holzman reviews an experience of caring for pediatric patients with known latex allergy while avoiding pretreatment with histamine 1 and 2 blockers or steroids. Holzman's study had only one reaction in 162 patients who underwent 267 surgical procedures.

November 1997
The 1997 ASA Round-Up

• Research in Ambulatory Anesthesia.

December 1997
Rocuronium versus succinylcholine for rapid sequence induction using a variation of the timing principle.

• This study compared the efficacy of low dose rocuronium vs succinylcholine to gain rapid control of the airway. Unfortunately the situation studied is not the same as one would encounter in clinical practice.

December 1997
Comparison of light want and suspension laryngoscopic intubation techniques in outpatients.

• Light wand endotracheal intubation by transillumination of the neck is a technique now used in patients with anticipated or unanticipated difficult airways.

December 1997
Use of the laryngeal mask airway as an alternative to tracheal tube during ambulatory anesthesia.

• It is commonly believed the laryngeal mask (LMA) offers advantages over the tracheal tube (TT) for ambulatory surgical procedures. This prospective randomized multicenter trial was designed to test the hypothesis that use of the LMA was associated with reduced anesthetic and analgesical requirements,

December 1997
A Comparison of the Prophylactic Antiemetic Effect of Ondansetron and Droperidol on Patients Undergoing Gynecologic Laparoscopy

• A prospective randomized double-blind comparison was made of the prophylactic administration of ondansetron versus droperidol. The study population was a high risk group for PONV (postoperative nausea and vomiting)--160 females undergoing gynecologic laparoscopic procedures.

December 1997
Unindicated Preoperative Testing: ASA Physical Status and Financial Implications

• The Journal of Clinical Anesthesia often has the most readable and approachable articles, especially on economic issues. This one is no exception. The authors undertook this study to determine the cost to the hospital of unnecessary preoperative testing. They compared current ordering patterns of preoperative tests for ambulatory ASA 1 and 2 (healthy) patients versus ASA 3 (sicker) patients.

December 1997
A comparative study of the vasodilator effects of prostaglandin E₁ in patients with pulmonary hypertension after mitral valve replacement and with adult respiratory distress syndrome.

• About ten years ago there was a flurry of interest in the use of intravenous infusion of prostaglandin E₁ for the treatment of pulmonary hypertension in patients following mitral valve replacement. It quickly became evident that its potent and effective pulmonary vasodilator effects were offset by unacceptable systemic vasodilation and hypotension.

December 1997
Preoperative therapy with amiodarone and the incidence of acute organ dysfunction after cardiac surgery.

• The potent antiarrhythmic agent, amiodarone, is increasingly being used to manage refractory ventricular and supraventricular arrhythmias.
  • Also see: The rational use of intravenous amiodarone in the perioperative period. Balser JR. Anesthesiology 1997; 86:974-87 - reviewed in the July 1997 issue of AnesthesiaWeb.

December 1997
Opioid-sparing effects of a low-dose infusion of naloxone in patient-administered morphine sulfate.

• Patients' comfort in the post-operative period is frequently limited by the presence of opioid-associated side effects, particularly nausea and vomiting, pruritus, urinary retention and respiratory depression. These side effects can prolong hospitalization and administration of other medications to treat opioid-related side effects can themselves have side effects.

December 1997
The Yale preoperative anxiety scale: How does it compare with a "gold standard"?

• Optimal pre-anesthetic medication has been an ongoing issue in pediatric anesthesia. If one reads more than one paper on the effects of preoperative anxiolytic drugs in children, a major difficulty is immediately apparent: each has used a different measure of anxiety. Most of these scales consist of single word global assessments, and distinctions between measures of anxiety and measures of cooperation are usually absent.