Literature Reviews: 1998

January 1998
Ondansetron vs metoclopramide in the treatment of postoperative nausea and vomiting.

• This study sought to compare the efficacy and safety of ondansetron compared with metoclopramide in the treatment of postoperative nausea and vomiting [PONV]. The authors studied 175 patients [51% of 378] who developed PONV during recovery from anesthesia for gynecologic laparoscopy. The standardized anesthetic technique consisted of intramuscular diazepam plus atropine, then thiopental, fentanyl, vecuronium, 60% nitrous oxide and isoflurane as needed.

January 1998
Midazolam premedication increases sedation but does not prolong discharge times after brief outpatient general anesthesia for laparoscopic tubal sterilization.

• It is not known whether residual midazolam effects in the immediate postoperative period may contribute to postoperative sedation and delayed discharge. These authors examined patients having laparoscopic tubal sterilization by Falope rings, because postoperative opioids are frequently needed, and this might exacerbate the possible sedation.

January 1998
Sevoflurane or halothane anesthesia: can we tell the difference?

• Bacher et al are to be congratulated for carrying out an interesting study which should give us all food for thought. Whenever new drugs are introduced we are very quick to embrace their "advantages" over old drugs and thus replace older and cheaper drugs with newer and more expensive drugs.

January 1998
Washington Report

• As you have seen from past articles on this Web site the vast majority of drugs do not have pediatric labels, i.e., there is language such as "safety and efficacy not determined for pediatric patients less than 18 years of age". This has left the practitioner in the position of prescribing drugs based on the experience of a few investigators, often without the full benefit of pharmacokinetic and pharmacodynamic data and certainly without the stamp of approval from the FDA.
  • read Dr. Coté's article on The ASA Update for Pediatrics, AnesthesiaWeb November 1997

January 1998
Recommendations for responsible monitoring and regulation of clinical software systems.

• In this position paper the authors provide important background by noting that in the 1960's, the United States FDA began new discussions on the regulation of stand-alone software programs as "medical devices". In response, a consortium of organizations has developed recommendations for public and private actions to accomplish responsible monitoring and regulation of clinical software systems.

January 1998
Trends, Guide to the Internet, 1997.

• Continually constrained in time to devote to multiple interests, I have found the Elsevier Trends Journals to be of great value in synthesizing some the fields in which I have a continued experience and interest, including life sciences, biotechnology and cardiovascular medicine. As a subscriber to some of these commercial offerings, I was interested to receive a copy of a collection, entitled "Guide to the Internet".

January 1998
Assumptions and practice in clinical medical ethics.

• One of the difficulties with discussions of medical ethics is the principles (fundamental truths) that are said to underlie all ethical reasoning. That is not to say that I believe that non-maleficence, beneficence, autonomy, justice etc. are bad ideas. However, the requirement that these beliefs be taken as truths upon which a hierarchy of reasoning is built can lead to contradictory or unnecessarily limited conclusions.

January 1998
Safety steps for epidural injection of local anesthetics: Review of the literature and recommendations.

• Few would argue with the notion that establishment of good habits based on sound science should occur during clinical training and be renewed periodically. The current issue of Anesthesia and Analgesia contains a review article from a department and an individual long renowned for an association with regional anesthesia.

Januray 1998
Dose-related biochemical markers of renal injury after sevoflurane versus desflurane anesthesia in volunteers.

• In the March 1997 issue of AnesthesiaWeb, I reported on an article by Dr Eger on volunteers exposed to 1.25 MAC sevoflurane or desflurane at 2 L/min for 8 hr . He and his colleagues demonstrated that patients receiving sevoflurane developed multiple biochemical markers of nephrotoxic injury, apparently related to the production of Compound A, formed by the interaction of a breakdown product of sevoflurane (inorganic fluoride) with sodalime at low gas flow rates.

January 1998
Light versus heavy sedation after cardiac surgery: myocardial ischemia and the stress response.

• The advent of managed care in the 1990s brought with it vigorous efforts to reduce costs by shortening postoperative intensive care unit and hospital length of stay. The established routine of postoperative overnight mechanical ventilation after uncomplicated cardiac surgery was reexamined, and gave birth to the concept of "fast tracking" - i.e. ventilatory weaning and tracheal extubation within six hours of operation.

February 1998
A Comparison of the Volume and pH of Gastric Contents of Obese and Lean Surgical Patients.

• Pulmonary aspiration of gastric contents during anesthesia occurs rarely but is feared because of the significant morbidity which can result. The mortality rate for pulmonary aspiration has been reported as 1 in 71,000 general anesthetics [1993]. The conventionally-held threshold at which an individual is considered to be at risk for pulmonary injury after aspiration is when gastric pH is less than 2.5 with gastric volume greater than 25 ml. Drugs which increase pH and decrease volume can be given, but it is important to identify those patient populations which are at increased risk and therefore will benefit from this premedication.

February 1998
A Comparison of Gasless Mechanical and Conventional Carbon Dioxide Pneumoperitoneum Methods for Laparoscopic Cholecystectomy.

• The laparoscopic approach to cholecystectomy is often chosen for patients in poorer physical condition because they may not be able to tolerate the "stresses" of cholecystectomy by laparotomy. What is generally not widely appreciated is that the conventional laparoscopic approach to cholecystectomy achieved with carbon dioxide pneumoperitoneum is associated with significant physiologic disturbances.

February 1998
Adverse events and risk factors associated with the sedation of children by nonanesthesiologists.

• The adverse events were collected with a quality assurance tool which successfully gathered information regarding the numerator and the denominator, data that has previously eluded us. Approximately 20% of children experienced an adverse event (239/1140).

February 1998
Increased risk of symptomatic hemangiomas of the airway in association with cutaneous hemangiomas in a "beard" distribution.

• Orlow et al evaluated the frequency of facial hemangiomas with asymptomatic upper airway or subglottic hemangiomas.

February 1998
Translating Good Advice Into Better Practice (editorial)

• Drs. Lee and Cooper comment on an article in the December 17, 1997 issue of JAMA — Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries (Ian G. Stiell et al. JAMA 1997;278:2075-2079). While you might not think that this article would apply to the field of anesthesiology, you would be mistaken.
  
  
• Implementation of the Ottawa Knee Rule for the Use of Radiography in Acute Knee Injuries

February 1998
Anesthesia Type Does Not Influence Early Graft Patency or Limb Salvage Rates of Lower Extremity Arterial Bypass.

• Dr. Robert H. Bode, Jr et al, in a 1996 Anesthesiology article, presented an analysis of cardiac morbidity and mortality using general vs. spinal versus epidural. Now, in the J Vasc Surg 1997, he is senior author of a paper which reanalyzes that same population looking for evidence of anesthesia choice affecting graft thrombosis.

February 1998
JAMA Review

• Peer Review of the Quality of Care: Reliability and Sources of Variability for Outcome and Process Assessments.
  
  
• Consumer Reports in Health Care: Do They Make a Difference in Patient Care?
  
  
• Health Care Quality: Incorporating Consumer Perspectives.
  
  
• Managed Care Is Not the Problem, Quality Is. (Editorial)

February 1998
Top 100 Hospitals

• This article appears in one of the widely read weekly business news journals devoted to the health care industry. It focuses on an analytical abstract of 1997´s 100 Top Hospitals: benchmark for success, prepared by the Baltimore-based HCIA. This report has become an annual tradition, and appearing on this list represents a significant achievement in the hospital industry.
  
  
  • Click here to visit the Modern Healthcare web site

Februrary 1998
The intubating laryngeal mask

• The intubating laryngeal mask. I: development of a new device for intubation of the trachea.
  
  
• The intubating laryngeal mask. II: a preliminary clinical report of a new means of intubating the trachea.
  
  
• The intubating laryngeal mask airway: an initial assessment of performance.

February 1998
Cost-benefit and efficacy of aprotonin compared with epsilon-aminocaproic acid in patients having repeated cardiac operations: a randomized, blinded clinical trial.

• Coagulopathy and bleeding continue to represent an important complication of cardiac surgery with cardiopulmonary bypass (CPB). Over the years, various theories emerged to explain the pathogenesis of CPB-induced coagulopathy. During the 1960's and 1970's it became routine in some centers to administer "prophylactic" platelets and fresh frozen plasma immediately following CPB in the belief that this would avert bleeding.

February 1998
Renal protection in patients undergoing cardiopulmonary bypass with preoperative abnormal renal function.

• In patients whose preoperative renal function is normal, acute renal failure is a rare complication of cardiac surgery with cardiopulmonary bypass (CPB). However, the risk of postoperative oliguria and renal dysfunction increases exponentially with increasing preoperative serum creatinine above 1.5 mg/dL (1). Established acute renal failure requiring dialysis after cardiac surgery has a forbiddingly high mortality - about 60% - whether or not it is of the oliguric or nonoliguric type.

March 1998
In rats breathing from a nonrebreathing system, substitution of desflurane for isoflurane toward the end of anesthesia incompletely restores the time of recovery toward that of desflurane.

• Less soluble inhaled agents such as desflurane leave the body more rapidly and allow a more rapid emergence than more soluble anesthetics such as isoflurane. However, desflurane is more expensive to administer than isoflurane.

March 1998
Tracheal intubation in ambulatory patients: Using remifentanil and propofol without muscle relaxants.

• Tracheal intubation is usually facilitated by administering a muscle relaxant. However, for ambulatory surgery patients, it is important to avoid the side effects of our anesthetic interventions. Specifically, the use of succinylcholine as muscle relaxant is associated postanesthetic myalgias, as well as less common but more serious complications.

March 1998
Drugs for Pediatric Emergencies (Electronic Article)

• The Committee on Drugs of the American Academy of Pediatrics published the revision of the statement on Drugs for Pediatric Emergencies. This statement is meant as a supplement to and not a replacement for more advanced sources of information such as the Advanced Pediatric Life Supports (APLS) and Pediatric Advanced Life Support (PALS). When possible the drug doses presented in this document are consistent with those contained in APLS or PALS.
  • Click here for full article on the Pediatrics web site

March 1998
Factors that influence parents' decisions to consent to their child's participation in clinical anesthesia research.

• Tait et al have performed a valuable service to those of us who carry out clinical research in pediatric patients. Although in the past there has been minimal pharmaceutical support for pediatric studies the upcoming FDA reform legislation will likely, we hope, result in an increase in industry supported pediatric studies.

March 1998
Perioperative Blood Transfusion and Postoperative Mortality.

• Human Cardiovascular and Metabolic Response to Acute, Severe Isovolemic Anemia

March 1998
Evaluating Transfusion Triggers (Editorial)

• Dr. Thurer, in his editorial focusing on both of the peer-reviewed original articles provided some historical background which comprised the basis for the conventional wisdom that perioperative patients should receive red blood cell transfusion with hemoglobin concentrations of less than 100 grams per liter (hematocrit less than 0.30).

March 1998
Accupressure Treatment for Prevention of Postoperative Nausea and Vomiting

• Nausea and vomiting provide substantial contributions to patients' suffering in a variety of circumstances: the postoperative period, cancer chemotherapy, opioid-related side effects to name but a few. Rational administration of anti-emetics to target each of the physiologic systems involved in nausea and vomiting (dopaminergic, cholinergic, histamine and serotonin) can help a great deal, however, some of these medications are very costly and have side effects of their own.

March 1998
Social Support in Families of Children with Chronic Conditions: Suppotive and Nonsupportive Behaviors.

• Social support is an important factor protective of physical and mental health. This is particularly the case when a patient lives with a chronic illness or a disability and becomes even more complex when this patient is a child. Social support is defined as the subjective sense of receiving something (emotional support, tangible help, and/or information) from family members, persons in the community, and professional service providers.

March 1998
Use of a vital capacity maneuver to prevent atelectasis after cardiopulmonary bypass: an experimental study.

• Cardiopulmonary bypass (CPB) may have adverse effects on postoperative pulmonary function via two mechanisms: inflammatory lung injury, caused by contact activation of mediators by perfusion of blood through the extracorporeal circuit, and atelectasis, caused by allowing the lungs to collapse during CPB. It is not uncommon to observe an increase in intrapulmonary shunt (Qs/Qt) to 20-25% in the postoperative period.

March 1998
Prophylactic atenolol reduces postoperative myocardial ischemia.

• Beta-adrenergic blocking drugs - incredibly useful, incredibly under-utilized. (Editorial)

April 1998
A Randomized Controlled Trial of Prophylactic Chest Physiotherapy in Major Abdominal Surgery

• This British study suggests that preoperative instruction combined with postoperative administration of chest physiotherapy reduces postoperative pulmonary complications (6% vs. 27%), and increases postoperative oxygen saturation in patients having open abdominal surgery.

April 1998
Use of Outpatient Preoperative Evaluation to Decrease Length of Stay for Vascular Surgery

• It's hard to believe that we're reporting same day admission effects in 1997. But we are. I travel all over the country, and I don't know of virtually anyone in any major center still admitting carotids and fem pops the day before scheduled elective surgery, but, in case anyone is still wasting money out there, we present the following.

April 1998
The Myth of the Top Management Team

• Unprecedented changes in all industry, particularly the healthcare industry, have called for increasing use of "teams" in an effort to effect rational analysis and behavior. For better or worse, those who have entered the practice of medicine primarily for the opportunities to engage in direct patient care have been pressed into more and more participation in "teams" (e.g., self-directed work teams, service design teams, sales teams, cross-functional teams, process redesign teams, etc, etc.). Not surprisingly, the top executives of any organization profess to belong to a top-level "executive team."

April 1998
Chemokines— Chemotactic Cytokines That Mediate Inflammation

• Inflammation is central to many diseases and conditions related directly to anesthesiology, critical care medicine, and perioperative care. Research in this field has made great strides in helping to dissect the general process of inflammation into increasingly detailed components and regulatory processes, each potentially offering specific avenues for prevention and intervention in various disease states. Even definitions of conditions associated with inflammation have undergone considerable evolution. Further, the array of endogenous substances associated with the inflammatory process has grown significantly in number and complexity.

April 1998
Acute respiratory depression as a complication of nebulised morphine

• One way that we have been able to expand our pharmacologic armamentarium is by exploration of new routes of administration of old drugs. The last 10 years has seen an explosion of interest in techniques and technology for administering drugs across skin (creams, patches, electrotransport systems) and mucosa (nose, mouth, rectum). The lung provides an amazing surface area for drug absorption. However it is somewhat difficult to quantitate dosing of inhaled drugs in that characteristics of the delivery system can substantially affect the amount of drug absorbed.

April 1998
Conscious awareness during general anaesthesia: Patients'perceptions, emotions, cognition and reactions.

• Despite multiple reports in the professional literature (40 in the bibliography of this paper) and the lay press, patients continue to suffer from the sequelae of awareness during general anesthesia. The most disturbing aspect of the current paper is not that awareness occurs (although it certainly would reassure all of us if there were a sure way to prevent it), but that, despite widespread knowledge that awareness is possible, damaging disparaging comments continue to be made.

April 1998
A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy.

• Over the last decade the advent of managed care has created enormous pressure to discharge patients from hospital earlier, thereby saving thousands of dollars in medical costs. One approach to this issue is the use of epidural catheters to create "preemptive analgesia" – i.e. prevention of transmission of nociceptive impulses at the spinal levels involved in the generation of the pain response.

April 1998
Catecholamine activation in the vasomotor center on emergence form anesthesia: the effects of alpha-2 agonists.

• Through the development of anesthesiology as a specialty an enormous amount of attention has been given to techniques of anesthetic induction and maintenance, and much less to the emergence and recovery phase. Yet this may be the most critical period of the entire anesthetic, as patients go from a controlled, protected, tightly monitored situation, to a situation where their airway is no longer protected, pain control is mitigated by the fear of causing respiratory depression, and monitoring is progressively less intense.

April 1998
High concentration versus incremental induction of anesthesia with sevoflurane in children: a comparison of induction times, vital signs, and complications.

• Epstein et al., compared two techniques for the gaseous induction of anesthesia in children. They clearly demonstrated a more rapid induction in the 8% sevoflurane group when compared with the incremental sevoflurane concentration induction technique. Although this difference was statistically different at the 0.01 level, the actual time difference was only a mean of 24 seconds.

May 1998
Absence of Biochemical Evidence for Renal and Hepatic Dysfunction after 8 Hours of 1.25 Minimum Alveolar Concentration Sevoflurane Anesthesia in Volunteers.

• The anesthetic sevoflurane undergoes degradation by carbon dioxide absorbents to compound A. Administration of compound A to rats produces renal injury characterized by proximal tubular necrosis, that results in increased urinary excretion of glucose, protein and the proximal tubular enzymes known as NAG and alpha-GST.

May 1998
Transient Neurologic Symptoms after Spinal Anesthesia. A Lower Incidence with Prilocaine and Bupivacaine than with Lidocaine.

• Despite its long record of safety, there have recently been reports that transient neurologic symptoms (TNS) occur after lidocaine spinal anesthesia. Clinicians are seeking alternative agents. For long surgical procedures, bupivacaine is a good alternative, but for brief procedures a short acting alternative local anesthetic needs to be identified.

May 1998
Ropivacaine in paediatric surgery: preliminary results.

• Ivani et al conducted a double blind study of bupivacaine (0.25%, 2 mg/kg) vs. ropivacaine (0.2%, 2 mg/kg) for caudal anesthesia and postoperative pain management in children. They found that ropivacaine was an effective local anesthetic in children and even suggested that, because of its apparent better cardiotoxic profile, it may offer a wider margin of safety for children.

May 1998
Choral Hydrate Sedation: The Additive Sedative and Respiratory Depressant Effects of Nitrous Oxide

• One of the important issues faced by departments of anesthesiology is to assist hospitals in developing institution guidelines for monitoring pediatric and adult patients who undergo procedures which require sedation. Dentists in particular, although active in developing monitoring guidelines within their specialties, have been less than specific in defining levels of sedation in practice when compared with the written description.

May 1998
Method of Medicare Reimbursement and the Rate of Potentially Ineffective Care of Critically Ill Patients.

• Anesthesiologists are often involved in ICU care. Our technical expertise is often sought for cardiopulmonary management, pain relief, and/or intraoperative care of these very sick individuals. Are we actually helping our patients?

May 1998
Rapid and Ultrarapid Opioid Detoxification Techniques

• Opioid addiction and dependence is characterized by a withdrawal syndrome that is so unpleasant that many addicted individuals avoid detoxifying their bodies, even though they desperately want to do so. Traditional management utilizes a methadone taper to ease the withdrawal from drugs such as heroin. In point of fact, due to the unpleasant effects of withdrawing methadone support, many people stay on methadone for extended periods of time, never truly losing their opioid dependence.

May 1998
Preemptive Epidural Analgesia and Recovery from Radical Prostatectomy: A randomized controlled trial.

• Preempting the memory of pain. (Editorial)

May 1998
Ischemic preconditioning in the intact rat heart is mediated by delta1- but not mu- or kappa-opioid receptors

• While anesthesiology practitioners are comparative experts on the concepts of opioid receptor agonists and antagonists in analgesia, it may not be fully appreciated how much laboratory and clinical research is in process regarding the "other" possible roles of various opioid receptors in health and disease.

May 1998
Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards.

• Widespread use of epidural analgesia with opioids and/or local anesthetics and patient-controlled analgesia using intravenous opioids have substantially improved postoperative analgesia in the last twenty years. A technique which combines both of these, patient-controlled epidural analgesia (PCEA), was first reported in obstetric patients in 1990 and has been further studied in relatively small numbers of obstetric and postoperative patients.

May 1998
Sedative/analgesic regimen in postoperative cardiac patients: An influence on hospital length of stay.

• There are many pressures on contemporary physicians to reduce hospital length of stay as well as other easily measurable parameters. The creative tension between market forces and concerns for patient care has led to innovative approaches to a wide range of issues. Of concern is the fact that frequently focus is on a single aspect, such as drug costs, rather than on the entire picture.

May 1998
Factors that predict the use of positive inotropic drug support after cardiac valve surgery.

• Factors predictive of the requirement for positive inotropic agents after cardiopulmonary bypass (CPB) for coronary artery bypass grafting (CABG) have been previously defined as advanced age, female gender, decreased left ventricular ejection fraction and prolonged CPB or aortic cross clamp time.

May 1998
Gastric mucosal oxygen delivery decreases during cardiopulmonary bypass despite constant systemic oxygen delivery.

• In the March 1998 issue of Anesthesia and Analgesia, Sicsic et al. describe the use of a new method of assessing gastric mucosal perfusion, laser Doppler (LD) flowmetry. The LD probe is fixed to a suction catheter placed via a gastric tube; aspiration of the suction catheter holds it and the LD probe against the gastric wall. The signal Doppler shift is directly proportional to the number and mean velocity of red blood cells in the tissue volume studied

June 1998
Fast-Track Eligibility After Ambulatory Anesthesia: A Comparison of Desflurane, Sevoflurane, and Propofol.

• Most studies comparing newer anesthetic agents with older ones in outpatient settings have attributed improved earlier awakening times, but not reductions in postanesthesia care unit (PACU) or facility discharge times, to the newer agents. We have come to understand that in order to truly reap the benefits of the newer agents, we need to change how we care for patients during the recovery process. Fast-tracking represents one such change, and one step toward the goal of improved ambulatory anesthesia.

June 1998
The Effect of Timing of Ondansetron Administration on Its Efficacy, Cost-Effectiveness, and Cost-Benefit as a Prophylactic Antiemetic in the Ambulatory Setting.

• Postoperative nausea and vomiting (PONV) remains a persistent cause of morbidity after ambulatory anesthesia and surgery. There are several antiemetics which can be used to reduce the incidence of PONV, but they all have a price - whether side effects, dollar cost, or both. Ondansetron, a 5-HT3 receptor antagonist, is a highly effective antiemetic with few side effects, but a considerably high cost. It is therefore important to identify the optimum dose and timing of dosing in order to achieve the highest degree of benefit for the money spent. This study evaluated 164 women, ASA status 1 or 2, who were scheduled for outpatient laparoscopic procedures.

June 1998
A comparison of awake versus paralyzed tracheal intubation for infants with pyloric stenosis.

• Cook-Sather et al have prospectively compared two approaches to tracheal intubation in infants with pyloric stenosis. Traditional teaching when I trained at that very same institution was that awake intubation would reduce the potential for pulmonary aspiration of gastric contents. As the years have gone by and having observed many residents and fellows struggle with the "awake" intubation of a healthy robust infant, a number of surgeons commented "why not use succinylcholine, as one would in other "full stomach" patients?

June 1998
Sevoflurane compared with halothane for tracheal intubation in children.

• O'Brien et al studied 40 infants undergoing tracheal intubation following administration of either halothane or sevoflurane. The clinical endpoint used to begin laryngoscopy was small pupils with central pupil position. Nineteen of 20 patients in each group were judged to have acceptable intubating conditions, although the vocal cords were more likely to be moving or closing with sevoflurane than with halothane. In addition, the time to reach conditions for intubation was more rapid with halothane.

June 1998
Notes from the SCA

• The annual meeting of the Society of Cardiovascular Anesthesiologists (SCA) is one of the best attended anesthesia conferences in the world. Held during the last week of April in beautiful Seattle, it was my pleasure to attend. Not only did I get to see the city, eat at great restaurants, and hit the Nike Town store for the best (and most expensive) athletic wear selection I've ever seen, but the conference was actually downright interesting.

June 1998
Prospective study of calcium channel blocker use, cardiovascular disease, and total mortality among hypertensive women.

• What have we learned from the calcium channel blocker controversy? (Editorial)

June 1998
Induction of neoangiogenesis in ischemic myocardium by human growth factors: first clinical results of a new treatment of coronary heart disease.

• The authors of this article remind us of the limitations of current revascularization of the heart: "For the cardiac surgeon who is attempting to treat CHD, the use of sections of autologous blood vessels as bypass material is subject to severe limitations. Autologous arterial conduits are in short supply, and segments of the saphenous vein do not remain patent for very long. Furthermore, 'complete' revascularization is limited if diffuse coronary arteriosclerosis is present and extensive, especially if there are additional peripheral stenoses."

June 1998
Clearance of morphine in postoperative infants during intravenous infusion: The influence of age and surgery.

• In April 1997, I reviewed two articles on the pharmacology of drugs commonly used in neonates, fentanyl and bupivacaine. Additional information regarding morphine pharmacokinetics was recently published by Dr. Anne Lynn and her colleagues at the University of Washington.
  
  
  • Wilson AS, et al. Anesth Analg 1997;84:315-8
  • Larsson BA, et al. Anesth Analg 1997;84:501-5

June 1998
Mood during epidural patient-controlled analgesia with morphine or fentanyl.

• It is always a pleasant surprise to come across systematic documentation and explanation of one's long-held clinical biases! Our usual practice for postoperative pain management in infants and children who have had lumbar or caudal epidural catheters placed in the operating room is to run infusions of bupivacaine and either morphine or fentanyl.

June 1998
Exposure to environmental tobacco smoke and the risk of adverse respiratory events in children receiving general anesthesia.

• Few topics have received more publicity in the general media than the putatively harmful effects of exposure to "second-hand smoke". On the grounds of this issue, an increasingly powerful anti-smoking lobby is waging a fight to the finish against a retreating tobacco lobby. Meanwhile, we watch with bated breath.....

July 1998
Myocardial Infarction after Non-Cardiac Surgery.

• The most interesting aspect of this study is its finding that postoperative MIs occur early in the postoperative course. This is in sharp contrast to traditional teachings that most such MI's occur 2-3 days postoperatively.

July 1998
Adverse Drug Reactions: A Review.

• Given the recent emphasis in the medical and lay press regarding the seriousness and extent of adverse drug reactions within health-care systems, it is useful for practitioners in anesthesiology to review some of the current thinking expressed in the literature about this subject. The Drug Information Journalis an ongoing source of new information regarding drug design and development, and the authors of the present article from that journal provide a nice update on the definitions, epidemiology, demographics, and economics of adverse drug reactions.
  
  
  • The Drug Information Journal

July 1998
Off-Label Use of Drugs: A Sticky Situation

• A shift in the regulatory approach.
  
  
• The effect of Pharmacy Benefit Manager Clinical Programs and Services on access to prescription drug benefit coverage.
  
  
• Implications of regulatory policies on off-label uses for industry competitiveness.
  
  
• Questions to ponder concerning off-label uses.

July 1998
Update From the 13th Annual Meeting of the Society of Ambulatory Anesthesia

• The 13th Annual Meeting of the Society of Ambulatory Anesthesia was held in Scottsdale, Arizona on April 23-26, 1998. The general sessions of the meeting began with a Point-Counterpoint program, in which presenters compared and contrasted new or controversial issues. Other didactic sessions covered the topics of Fast-Tracking in Ambulatory Surgery, Office Based Anesthesia, New Innovations, Medical Malpractice Issues and Clinical Updates.

July 1998
Pediatric cardiac surgery: The effect of hospital and surgeon volume on in-hospital mortality.

• Hannan et al analyzed the relationship between "annual provider (hospital and surgeon) volume of pediatric cardiac surgery and in-hospital mortality". They examined 16 different centers within New York state from 1992 to 1995 for a total of 7,169 cases. The authors found a significant increase in mortality in those centers which performed fewer than 100 cardiac surgical cases per year when compared with centers performing a greater number of cases annually (8.26 versus 5.59 percent).

July 1998
Lidocaine iontophoresis for topical anesthesia before intravenous line placement in children.

• Zempsky et al performed a double-blind randomized study of the use of lidocaine iontophoresis as a means for reducing the pain of intravenous catheter insertion in children. It is always a major issue to insert an intravenous catheter in children of just about any age. This is because fear of the needle, even a 30 gauge for injection of local anesthetic, often supersedes any logic in terms of pain being related to the diameter of the needle. Having spent many a day "negotiating" with a fearful child, the availability of alternate methods for pain relief is quite desirable.

August 1998
Automated Electrocardiograph ST Segment Trending Monitors: Accuracy in Detecting Myocardial Ischemia.

• Anyone who's bought EKG monitors in the last few years probably has some version of automated ST segment analysis available on their new monitors. Many of us make management decisions with this "on-line, real time" information. But how good is that information? Dr. Leung and colleagues, well known in the cardiac ischemia research world, attempt to answer part of that question in this study.

August 1998
Health-care Report Cards and Implications for Anesthesia.

• Swamidoss et al start out their paper with a quote from TS Eliot: "Where is the knowledge we have lost in information?" I liked it immediately.

August 1998
Plasma levels of clonidine following epidural bolus injection in children. CO₂ tension effects of clonidine in paediatric caudal analgesia.

• Transcutaneous CO₂ tension effects of clonidine in paediatric caudal analgesia

August 1998
Upper airway reflexes during a combination of propofol and fentanyl anesthesia.

• Laryngeal reflexes: Exploring terra incognita.

August 1998
A comparison of the laryngeal mask airway and cuffed oropharyngeal airway in anesthetized adult patients.

• This study also sought to compare the cuffed oropharyngeal airway (COPA) with the laryngeal mask airway (LMA) in anesthetized adult patients. They compared the devices with respect to (1) placement success rate, (2) airway interventional requirements, (3) airway stability in different head/neck positions, (4) cardiorespiratory tolerance, and (5) intraoperative and postoperative clinical problems.

August 1998
The placement of the cuffed oropharyngeal airway with sevoflurane in adults: A comparison with the laryngeal mask airway.

• The cuffed oropharyngeal airway (COPA) is a new airway device that has recently been introduced into clinical practice. It is an oropharyngeal airway with a cuff to seal the pharynx and lift the tongue. Because the COPA rests in the oropharynx, the depth of anesthesia required to successfully place this device maybe different from the laryngeal mask airway (LMA), which sits in the hypopharynx. These authors sought to determine the anesthetic duration required to achieve good conditions for COPA or LMA insertion while administering sevoflurane alone by face mask. Twenty patients each were assigned to the COPA or LMA groups.

August 1998
The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy.

• Pappas et al examined the effectiveness of dexamethasone in the prevention of nausea and vomiting in children undergoing tonsillectomy. Despite the development of new antiemetic medications, this particular operation is still associated with a relatively high incidence of vomiting. Their study focused just on dexamethasone and its effects and then the need for rescue antiemetic therapy, return to hospital, or phone calls to the hospital or physicians regarding continued nausea or vomiting at home.

August 1998
Prolongation of the QT interval and the sudden infant death syndrome.

• Prolongation of the QT interval and the sudden infant death syndrome (Editorial).

September 1998
A Comparison of Nebulized Budesonide, Intramuscular Dexamethasone, and Placebo for Moderately Severe Croup.

• Before the advent of a vaccine for the prevention of Haemophilus influenza type B infections, there was a fairly high seasonal incidence of acute epiglottitis which required emergent endotracheal intubation. The differential diagnosis always included acute laryngotracheobronchitis. Anesthesiologists were frequently called upon to assist with the diagnosis and airway management of children who presented with stridor.

September 1998
A Comparison of the Efficacy, Safety, and Patient Satisfaction of Ondansetron Versus Droperidol as Antiemetics for Elective Outpatient Surgical Procedures.

• It doesn't matter what this paper says, or what my opinion is of this research. YOU are still going to give ondansetron. It's better. Right? As a matter of fact, why don't we just burn all of these rubbish scientific journals anyway before they pollute our opinions with factual knowledge.

October 1998
Should adult patients drink fluids before discharge from ambulatory surgery?

• Postoperative nausea and vomiting (PONV) is a common problem in ambulatory surgical patients, causing delayed discharge as well as unanticipated admission and readmission after discharge. The causes of PONV are multifactorial and include stimuli from the gastrointestinal tract. It has been demonstrated in pediatric patients that restricting oral fluids before discharge may reduce PONV.

October 1998
Cannabis for migraine treatment: the once and future prescription? An historical and scientific review.

• There are few aspects of applied pharmacology that evoke as much emotional response in society at large as the use of cannabis drugs. Attempts to find common ground between strongly-held positions on both sides still are limited by the presence of persistent 'marijuana myths'. As a result, many patients who could benefit from its therapeutic effects are faced with a choice between tolerating unpleasant symptoms or treating those symptoms in a manner that puts them outside the law.

November 1998
Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies.

• This paper compared the safety and efficacy of two methods of sedation for orthopedic emergency room procedures. A total of 260 patients were studied. Children in both groups received substantial doses of midazolam (up to 2.5 mg bolus with a total of 7.5 mg for first reduction dose) combined with fentanyl (up to 100 �g) or ketamine (up to 2 mg/kg). Additional doses of all drugs were allowed if the "sedation" was judged to be inadequate.

November 1998
The Pediatric Sedation Unit: A mechanism for pediatric sedation

• Lowrie et al describe their experience with a sedation unit. The facility is run and supervised by pediatric critical care nurses and fellows. This unit was developed in an attempt to provide safe sedation for children in a variety of venues. Although the intentions are good when one carefully reads between the lines, in essence these practitioners are allowing nurses, not CRNAs, but critical care nurses, to practice anesthesiology. Children were sedated with fentanyl, ketamine, and infusions of propofol.

November 1998
Update from the American Society of Anesthesiologists Annual Meeting

• Well... nothing really. Anesthesia is still safe. The job market is opening up. Surgical volume is up. The roof has still not caved in. Anesthesia residency slots are being filled more easily. So I'll content myself with discussing the cutting edge developments in information systems (which took up a whole lot of the exhibitor's floor space this year) and the lecture given by Uwe Reinhardt, Ph.D. at the annual Aspect function (makers of the BIS monitor).

December 1998
Friendliness of OR Staff is Top Determinant of Patient Satisfaction With Outpatient Surgery.

• Numerous studies have attested to high patient satisfaction with ambulatory surgery, but few have indicated which factors determine patient satisfaction. This study identified 12 factors that potentially affect patient satisfaction and asked each patient to rank the five factors that were most important in determining their satisfaction.

December 1998
A clinical evaluation of transdermal therapeutic system fentanyl for the treatment of cancer pain.

• Patients' fears of drug tolerance and addiction are well known (and recently objectively demonstrated¹) barriers to obtaining pain relief. Physicians' knowledge of the specific risks, particularly of tolerance, also continues to evolve.