Literature Reviews: 1999

• Kanaya et al, using cultured neonatal rat heart myocytes, compared the myocardial depression of sevoflurane, isoflurane, and halothane. This type of research is important because the major continuing source of morbidity and mortality in children, particularly infants, occurs during anesthetic induction. It is at this point in time that the infant is most vulnerable because of the rapidly changing concentration of inhalation agent, relative dehydration, and other factors such as hypoventilation or relative anesthetic overpressure resulting in a very rapid depression of myocardial function.

• Seri et al examined the regional hemodynamic responses of sick preterm infants to dopamine infusions. Since the vast majority of medications (approximately 80 percent) are not approved in some age population of children (meaning no pharmaceutical industry-sponsored study was performed with sufficient supporting data submitted to the FDA to allow labeling), this paper represents an important contribution to our knowledge.

• I picked this editorial because I know Lee and Paul, and they're smarter than your average bear. When Fleisher and Barash talk, people listen (they're like Merrill Lynch). They review a mediocre article by Gottlieb et al., which looks at the Cleveland Clinic's database on people who got angioplastied before their vascular surgery.

• Whether we like it or not, we will be judged by those who pay for the care we provide. That judgment used to come in the form of whether the patient said thank you when we made our postoperative visit. If they were really happy, a tin of cookies showed up in the department a few days after discharge

• Epidural catheters have either a single opening at the patient end of the catheter (uniport) or multiple lateral holes near a fused catheter tip (multiport). When selecting an epidural catheter, we must weigh the benefits of rate of successful block and ease of confirming the epidural placement against the risk of adverse outcomes: inadequate block and intravascular or subarachnoid placement, or multicompartment placement in the case of the multiport catheter

• The most common life threatening problems with epidurals occur as a result of where malpositioned epidural catheters come to rest: most commonly, intravascularly (IV), to a lesser extent, intrathecally (IT), and, rarely, in the subdural space. We employ many different safety steps to define these inadvertent misplacements. These tests are chosen to cause the least physiological impairment of the parturient, and to ensure the clearest endpoint.

• Last year, the American Society of Anesthesiology published Standards and Guidelines for the perioperative care of patients undergoing anesthesia. As a supplement to the ASA standard, the Quality Assurance Committee of the American Academy of Pediatrics Section on Anesthesiology has developed recommendations for the facility-based components of programs which provide perioperative care for infants and children

• "Fast-tracking" (FT) and "early extubation" (EE) for cardiac surgery patients are concepts whose implementation is becoming standard in hospitals around the country. This brief review will cover the following topics about FT: 1) introduction, 2) length of stay (LOS) and what patient factors affect it, 3) coronary artery bypass graft (CABG) in the elderly, and 4) the role of minimally invasive cardiac surgery.

• Patients with persistent postoperative nausea and vomiting (PONV) in the ambulatory surgical unit have an increased risk of symptoms 24 hours after surgery as well as an approximately 3-to 4-fold increased likelihood of unanticipated admission. However, the routine administration of antiemetics to all patients would result in unnecessary added costs and side-effects.

• Holzki and Kretz are to be congratulated for reviewing the literature and comparing the gold standard halothane with the newer agent sevoflurane. The authors raise several interesting questions: Are anesthesiologists who care for children changing to sevoflurane because it is a new drug, because of excellent marketing, or because it is superior to halothane?

• Since the Acute Respiratory Distress Syndrome (ARDS) was first described over 30 years ago, tremendous clinical and basic research investigations have been undertaken to define the process and its natural history. Continuing efforts are directed towards determining the incidence of ARDS (estimated to be 3-8 cases per 100,000/year worldwide); identifying those at greatest risk for developing ARDS; and applying standardized and innovative therapies to improve survival of patients with ARDS.

• Dr. Bennett-Guerrero has done an excellent job in prospectively evaluating those "general" cases we usually assign to our most talented anesthesiologists and/or CRNA's-the AAA, big long liver whack, etc. It was always our opinion that putting our best people on these cases made sense, and now we know why. Fully 27% have a prolonged hospitalization due to some major organ problem. What most of us would not have readily agreed to before this paper was that it was our "fault."

• This is a very timely and important article on how to make the transesophageal echocardiographic (TEE) examination of the mitral valve a more standardized and useful exam. TEE is extremely useful for cardiac surgery involving valvular structures, especially the mitral valve (MV)

• Because adenotonsillectomy is one of the most commonly performed pediatric surgical procedures and is typically accompanied by considerable postoperative pain that may either delay discharge from the ambulatory unit or necessitate unanticipated overnight admission, improved methods to provide postoperative analgesia are advantageous

• JA Thorpe, in an article in 1993, highlighted the association between labor epidurals and the incidence of cesarean section for dystocia. However, he erroneously went further and stated that epidurals were the cause of increased of cesarean section rate, even thought the study design could not support this conclusion. His article is responsible for a mass of research that has begun to show the same association without the cause and effect relationship

• The 1999 annual meeting of the American Society of Anesthesiologists (ASA) was filled with important information for anesthesiologists with a particular interest in critical care. This started with the day-long satellite meeting of the American Society of Critical Care Anesthesiologists (ASCCA) on Friday, October 8th, and continued through refresher course lectures, abstract and poster presentations, the Rovenstine lecture, and various plenary sessions and committee meetings at the ASA meeting.

• The Society for Ambulatory Anesthesia (SAMBA) held its 3^rd Mid-Year Meeting on October 8, 1999, in Dallas. The meeting focused on optimizing practice patterns in ambulatory anesthesia. It began with a presentation by Beverly Philip, MD, about benefits of preoperative education and evaluation. She described patient evaluation in terms of medical and psychosocial criteria. Medical evaluation criteria are based on health status and physiologic age, not chronologic age. She described in more detail the evaluation of patients with cardiovascular disease.

• I just finished a busy call night in the ICU and am riding to and from Chicago for an afternoon meeting so I can be in the operating room tomorrow morning. Fortunately, somebody else is driving while I dictate this commentary. Who says we have stress in our lives? Who says we excessively multi-task? As Alfred E. Newman reminds me, "What, me worry?"

• This is an article describing an attempt by the authors to control the inevitable hyperglycemia that occurs during hypothermic cardiopulmonary bypass with an insulin infusion protocol in previously normoglycemic patients

• This is a succinct, readable article, which reviews the current knowledge about assessing patients with cardiac disease for non-cardiac surgery and offers a paradigm to guide the anesthesiologist as the primary physician responsible for preoperative evaluation of patients presenting for surgery

• At the Ambulatory Anesthesia Poster Discussion Session on the morning of Monday, October 11th, all the presentations focused on the very important issue of postoperative nausea and vomiting (PONV).

• Given the nation's ever-expanding proportion of senior citizens, it is no doubt with gusto that bureaucrats seek possible ways to limit Medicare spending. Representing the number one Medicare expenditure, cataract surgery is an enticing and highly visible target. With more than 1.3 million cataract operations performed annually in the United States, the economic impact of each aspect of cataract surgery,