2013 Covers & Artwork

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December 2013, Volume 117, Issue 6

The dictates of chaos theory describe how the conditions of a singular event can predetermine the pathway through spacetime leading to a wide range of downstream outcomes in highly dynamic, nonlinear systems. Readers may be familiar with this as it has been referred to as the butterfly effect, wherein largescale weather patterns may result from the decision of a butterfly to flap her wings weeks earlier. This effect is all around us and can be seen in something as simple as the first pivotal move in a chess game to the critical decisions we make as anesthesiologists. Of these judgments, the choice of anesthetic induction agent comes to light in this issue. Does etomidate carve an alternate reality that is decidedly morbid? The drug we choose, the pawn we displace, is a move that is ours to make.
Naveen Nathan, MD
Cover Editor and Illustrator

November 2013, Volume 117, Issue 5

Youthful inductees into the field of anesthesiology may not appreciate the great evolution in perioperative patient safety that has occurred over decades. The beauty of our field is that we have made the provision of an anesthetic a very safe endeavor. The ironic danger of our field is that we have made the provision of anesthesia a very safe endeavor. We may veil the risk of surgery and anesthesia with the very margin of error we have created with extensive knowledge, preparation and technology. Now it is times of crisis that test our capacity to retain order amidst a clinical environment cascading into an entropic mire. Salvador Dali obsessed over the idea of permanence in his classic The Persistence of Memory and in his lesser known The Disintegration of the Persistence of Memory. We have been spoiled by the predictable and geometric state of our craft. When our intellectual architecture devolves into something organic and distorted by catastrophe, perhaps cognitive aids hold a path to resolution.

October 2013, Volume 117, Issue 4

As technological advancement outpaces our capacity to wield it, we as anesthesiologists have witnessed the evolution of increasingly high-fidelity instruments in and out of the operating room. These monitors have been engineered to communicate the well-being of disinclined patients at the utter depths of their consciousness. Though we may celebrate our own ingenuity and marvel at the latest entries into our armamentarium of surveillance, this month’s cover portrays the simplest of ideas that has given rise to our most cardinal monitors: spectrophotometry. The exploitation of a molecule’s optical signature has allowed us to scrutinize the most fundamental physiologic and pharmacologic considerations. Deep within the erythrocyte and enveloped by spiraling alpha helices the heme molecule is no exception. As delocalized electrons between pyridine and iron relax towards equilibrium at a lower thermodynamic energy state, extinction coefficients conveniently located in the red and infrared range emerge. Nature’s design of the expansive conjugated porphyrin ring system has proven fortuitous indeed.
Naveen Nathan MD
Cover Editor and Illustrator

September 2013, Volume 117, Issue 3

Depicted on this month’s cover is the endothelial glycocalyx. The illustrated perspective is unconventional and quite deliberate. It is impossible for the human eye to keep a microscopic object in focus simultaneously with its background. One either loses the forest for the trees, or fails to distinguish the trees because of the forest. Beginning in the upper right corner, red blood cells course through the all-too-familiar capillary tunnel of endothelial cells. A subtle sheen cast over these cells gradually emerges as a highly complex macromolecular surface structure known as the glycocalyx. A platelet is caught in mid-transition into the active state, no doubt interacting with inducible proteins within the protein-studded carbohydrate-based matrix. Two molecules of nitric oxide arise alluding to the powerful role the glycocalyx plays in inflammatory processes and microvascular disease. For some time now we have cast successively more powerful lenses over the role the endothelial glycocalyx plays in everything from sepsis to fluid dynamics to hemostatic competence. We understand the broader backdrop of circulatory anatomy well. It appears the time has come to appreciate the major functional microcosm hidden in plain sight along this landscape—in other words, to appreciate the trees amidst the forest. (Cover by Naveen Nathan, MD Cover Editor and Illustrator)

August 2013, Volume 117, Issue 2

How appropriate that we discuss the concept of perioperative thermoregulation in the month of August. Here in the United States we find ourselves amidst the heat of the summer season. As radiant photons bombard the metal exoskeleton of our hospital, brand new trainees thrive in the most embryonic phase of their career in the cold of the operating room. One such resident doctor holds the hose of a forced air warming device and I watch as he forcibly cork-screws it into the blanket’s receiving port. The previously dormant sheet billows forth into life embracing the patient with warmth. Still in the blissful wake of a successful tracheal intubation, this young physician likely does not yet appreciate incongruent forces that impose themselves on the less-than-glamorous task of rewarming our functionally poikilothermic patient. It would appear nothing less than logical to give back what we have taken away. The articles and editorial responses in this month’s issue cast this logic into the mire of doubt as we seek to appraise the risks and benefits of even the simplest restorative measures. (Cover by Naveen Nathan, MD, Cover Editor and Illustrator)

July 2013, Volume 117, Issue 1

"Never events" in the field of clinical anesthesiology take on almost mythological status as folktales such as "The Legend of the Lost Guidewire" pass from the accusatory lips of the storyteller to the incredulous ears of the listener. From the moment these fables begin with "Did you hear about..." to our instinctive "They did what?" reaction, maladaptive coping mechanisms are already in play. we thoughtlessly adopt and perpetuate responses focused on culpability, shame, and in the worst cases, ridicule. Gary Larson spent 15 years perfecting the art of single- paneled satire in his series The Far Side. His work, steeped in irony and suffused with a surreal interpretation of human fallibility, drew the ire of many who refused to accept our capacity for error. This month’s cover is an homage to his perspective. It is decidedly not a mockery of a very real problem in high-risk clinical medicine, rather a portal to open dialogue. The editorial discussions contained in this month’s journal advocate for a systems- based approach to medical errors in complex and dynamic environments, as opposed to reproach and remediation. The message issues forth directly from the punchline: “I can understand” supposes awareness of the context in which never- events occur, while “What do you propose” assumes a refashioned approach to patient safety, one focused on collaboration. (Cover by Naveen Nathan, MD, Cover Editor and Illustrator)

"Well what do you propose we do about this?" "I've heard of losing a guidewire, but the entire kit?"

June 2013, Volume 116, Issue 6

As anesthesiologists we find ourselves enduring the unfortunate and unpredictable state of drug shortages as well as the restrictions imposed by the fractured economy of medicine. These current struggles have left us with a seemingly limited palette of methodologies. We can take the cynical and utterly myopic view that individualized therapy in anesthetic practice is but a ruse, that we have only to choose between general versus regional anesthesia, intravenous versus inhalational induction, and pain control by way of opiates or nonsteroidal antiinflammatory drugs. It is our responsibility though to remain engaged with the idea that anesthetic care begins far in advance of rendering our patients into a state of cerebro- electrical quiescence. As we willfully take our apprehensive (though consenting) patients safely along the shores of the river Styx, what of our most vulnerable patient populations: those at extremes of age and limited by a reduced capacity for comprehension? How fear must be redefined and hyperbolic in their minds! In this issue we offer an opportunity to employ the sensibilities of the consummate caregiver. A case report herein profiles the use of a trained service dog in the anesthetic induction of an autistic patient. What otherwise might have been a turbulent and scarring process was characterized instead by a measured and dignified descent into the embrace of the patient’s care team, aided by no less than man’s best friend. The cover photograph reflects the control that our patients surrender to us, and that at times we may want to give it back. Individualized care in anesthesiology is hardly a lost art form; indeed it is alive and well.

May 2013, Volume 116, Issue 5

This month’s cover aims to extol the legacy of nitrous oxide. It like no other drug has endured an utterly dichotomous perception among anesthesiologists. We either embrace its pharmacologic virtues unconditionally or despise its shortcomings. Whatever one may opine about its utility, it would be difficult to argue the singularity of nitrous oxide among medical gases and anesthetics. It is not often we administer a non-carbon-based drug with such distinctive physicochemical characteristics as a matter of routine. The duality of its role throughout history is portrayed in this Victorian-era style etching which conceptually spans everything from basic chemical synthesis to the meta-consciousness of euphoria. On the left is displayed the classic method for synthesis described by English chemist Joseph Priestley in 1775. Nitrous oxide is produced by heating iron shavings in nitric acid.An oiled-silk bag collects the gas along with other impure oxides of nitrogen. The figures on the right offer an account of the primary use of nitrous oxide during the early nineteenth century: recreational intoxication. Nitrous oxide would not enjoy a role as an anesthetic until the mid-1800s.The reader is invited to search for other fanciful allegories within the illustration, not the least of which includes a cloud formation in the molecular arrangement of our beloved nitrous oxide. (Cover illustration by Naveen Nathan, MD, Cover Editor)

April 2013, Volume 116, Issue 4

In the year 1490, Leonardo Da Vinci rendered the Vitruvian Man, a pen and ink drawing aimed at characterizing the ideal proportions of the human figure. The construct of anatomical perfection derived from the treatises of the ancient Roman architect Vitruvius who held the human figure to be the fundamental source of proportion. On the cover image, Da Vinci’s classic figure takes on the role of the anesthesiologist: the fundamental source of proportion and balance in perioperative medicine. In this illustration, no less than 6 outstretched arms tether the figure to the cardinal domains of the clinical perianesthetic sphere.The anesthesiologist bound to these elements through data streams casts forth the metaphor of a communication “web.” As advances in communication technology have allowed for expansive latitudes of data exchange from the preoperative arena to the postanesthesia recovery unit, so too have risen the expectations and accessibility of the omnipresent anesthesiologist.The question remains, is the anesthesiologist in control at the center of the web, or trapped among its tendrils? (Cover illustration by Naveen Nathan, MD, Cover Editor)

March 2013, Volume 116, Issue 3

We have exciting news! The International Anesthesia Research Society is launching a new journal, Anesthesia & Analgesia Case Reports. Case reports have a distinguished role in the history of our specialty. Our discipline traces to the first public demonstration of anesthesia by Dr. William Morton in the Ether Dome (it wasn’t called that when Morton did his demonstration). The resulting case report by Bigelow is considered among the most important publications in the history of medicine. Today many journals, including Anesthesia & Analgesia, have such demanding criteria for acceptance of case reports that clinically useful case reports are almost impossible to publish in high quality journals.That has changed with the introduction of Anesthesia & Analgesia Case Reports, a new home for high quality case reports to guide clinical practice.The cover is a tribute to the seminal contributions of case reports to our specialty. It is also an unabashed promotion of our new sister journal, Anesthesia & Analgesia Case Reports.

February 2013, Volume 116, Issue 2

Perioperative stroke is a devastating outcome. Because perioperative stroke is uncommon, a “retrospectoscope” based on large patient databases is required to analyze the incidence of stroke and associated risk factors. In this issue of Anesthesia & Analgesia, an analysis of the ACS-NSQIP database by investigators at the University of Michigan found a 0.6% incidence of stroke in patients undergoing noncarotid vascular surgery. The analysis also characterized demographic data associated with increased risk of stroke. While the identified associations are not necessarily causal, understanding the characteristics of patients at increased risk may permit targeted interventions.

January 2013, Volume 116, Issue 1

Anesthesiology trainees represent the future of our field, but how well are we engaging them in the scientific pursuits that are critical to a vibrant specialty? In this issue of Anesthesia & Analgesia, Dr. Shireen Ahmad and colleagues analyze the factors associated with resident research success. An accompanying editorial by Dr. Margaret Wood highlights the important role of the chair and anesthesiology leadership in that success.