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Anesthesiology:
doi: 10.1097/ALN.0b013e318288bb6c
Education: Anesthesia Literature Review

Anesthesia Literature Review

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Perioperative Medicine

Intraoperative high-dose dexamethasone for cardiac surgery: A randomized controlled trial. JAMA 2012; 308:1761–7
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This robust prospective multicenter randomized controlled trial of 4,494 patients undergoing cardiac surgery with cardiopulmonary bypass did not show any difference in the primary outcome (composite of death, myocardial infarction, stroke, renal or respiratory failure at day 30) between those allocated to receive a unique 1 mg/kg intraoperative dose of dexamethasone versus placebo (fig. 1). Noteworthy, postoperative blood glucose levels were higher in the dexamethasone group compared with placebo. The routine use of a unique intraoperative high dose of corticosteroids in adult cardiac surgical patients for anti-inflammatory purposes should be reconsidered in light of these findings.
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Association between aldosterone antagonist therapy and risks of mortality and readmission among patients with heart failure and reduced ejection fraction. JAMA 2012; 308:2097–107
The clinical effectiveness and safety of newly introduced antialdosterone therapy was examined in older patients admitted with heart failure and reduced ventricular ejection fraction. All-cause mortality, cardiovascular readmission, and hyperkalemia at 30 days and 1 yr were examined in a cohort of 5,887 patients (mean age: 77.6 yr) obtained from the clinical registry data linked to the Medicare claims between 2005 and 2010. Initiation of aldosterone antagonist therapy was not found to be independently associated with improved mortality and cardiovascular remission but was associated with fewer heart failure readmissions in older patients with reduced ventricular ejection fraction, and an increased risk of hyperkalemia on readmission within 30 days after discharge. These results interestingly point out the gap between large randomized trials showing major improvement in major outcome endpoints (mortality) by antialdosterone drugs and their tempered effectiveness and safety in clinical practice.
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Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med 2012; 367:1979–87
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Risk of recurrence of thromboembolic events after a first episode is high after a patient discontinues anticoagulants. This randomized, blinded, placebo-controlled trial enrolled 822 patients who had completed initial anticoagulant therapy after a first episode of venous thromboembolism and were allocated either to 100 mg aspirin daily or placebo for up to 4 yr. Aspirin did not significantly improve the rate of recurrence of thromboembolism (primary endpoint, 6.5% per year in the aspirin arm vs. 4.8% per year in placebo-treated patients, P = 0.09), but it reduced the occurrence of major vascular events. This study suggests that there may be some benefit to daily aspirin after completion of anticoagulant therapy for a first episode of venous thromboembolism (fig. 2).
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Gabapentin for refractory chronic cough: A randomized, double-blind, placebo-controlled trial. Lancet 2012; 380:1583–9
Airway irritation is a serious issue in anesthesiological practice. Gabapentin is used for treating neuropathic pain. Because chronic cough may be favored by central reflex sensitization, this offers a rationale for a possible efficacy of gabapentin. This randomized, double-blind, placebo-controlled trial found that gabapentin significantly improved chronic cough-specific quality of life, pending an increased rate of nausea and fatigue compared with placebo-treated patients.
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Critical Care Medicine

Hyperoxia is associated with increased mortality in patients treated with mild hypothermia after sudden cardiac arrest. Crit Care Med 2012; 40:3135–9
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In this retrospective cohort study performed on 170 consecutive patients with sudden cardiac arrest who underwent therapeutic mild hypothermia, multivariable analysis showed that lower PaO2 was a predictor of improved in-hospital survival and better neurologic outcome at discharge (fig. 3). Given the evidence of the potentially detrimental effects of hyperoxia in the context of cardiopulmonary resuscitation, specific oxygenation goals should be defined in the context of cardiac arrest and resuscitation.
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Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. A randomized controlled trial. JAMA 2012; 308:1985–92
Alleviation of sedation by either daily sedation interruption or protocolized sedation has been shown to reduce duration of mechanical ventilation, length of stay, and morbidity. Whether the combination of these strategies would further augment benefits remains unknown. This randomized controlled trial examined the impact of protocolized sedation (n = 209) versus protocolized sedation plus daily interruption of sedatives (n = 209) on time to successful intubation as a primary outcome. No difference was observed between protocols for primary or secondary outcomes. However, daily sedation interruption increased workload for nurses. Keeping in mind the article by Kress showing the huge benefits of daily interruption alone published in 2000, it is worthy to note that protocolized sedation developed during the last decade has improved patient outcome by itself.
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Pain Medicine

Central projection of pain arising from delayed onset muscle soreness in human subjects. PLoS One 2012; 7:e47230
Functional magnetic resonance imaging is used to improve our understanding of the activation of the central nervous system in human subjects. This technique has been used extensively to understand mechanisms of acute and chronic pain. Many studies have focused on the influence of supraspinal structures on pain. Most pain studies using functional magnetic resonance imaging have tested cutaneous stimuli to understand acute and chronic pain mechanisms. This study examined muscle soreness and its activation of the central nervous system by muscle contraction. Widespread supraspinal structures, including motor areas, insular cortex, and a variety of thalamic nuclei, were activated by the painful muscle, including areas traditionally not thought of as pain-transmitting regions, like the anterior cerebellum. This study highlights the effects of muscle pain in human volunteers.
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Education

The nature of excellent clinicians at an academic health science center: A qualitative study. Acad Med 2012; 87:1715–21
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This goal of the study was to gain an understanding of the characteristics of high-performing clinicians. Peer nomination was used to identify a group of physicians who were then interviewed to ferret out their conceptualization and personal implementation of the traits of excellent clinicians. The authors’ premise is that being able to characterize the traits defining excellent clinicians will offer insight to guide medical education and facilitate faculty development. The semistructured interviews of the excellent clinicians shed insight on three dominate themes that characterized the behavior of excellent clinicians (table 1). These themes define how individuals achieve clinical excellence through their understanding of the necessary attitudes and behaviors that result in a high level of professionalism, an engaging personal style, and a self-assured humility. Academic anesthesiologists can positively impact patient care by role modeling the themes that define clinical excellence, expecting that faculty colleagues will learn and teach them to others and insisting that they be taught to graduate trainees.

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