2020 Covers & Artwork

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December 2020, Volume 131, Issue 6

This month's cover art depicts the body's basic requirements to guarantee adequate organ function. To protect organs in the perioperative period, perfusion, ventilation and oxygenation, acid base regulation and blood supply has to be preserved. Perioperative organ dysfunction after surgery may affect the brain, heart, lung, kidney, liver, and intestine. Dysfunction of these organs is mainly triggered by ischemia and inflammation. An insufficient organ perfusion or a surgical insult during the perioperative period might trigger an inflammatory response. Although several experimental studies demonstrated that several drugs can be used to prevent or treat organ failure, none of the drugs have been proven effective in clinical trials yet. Therefore, current therapeutic options remain limited to organ supportive strategies. Further understanding of the molecular mechanisms of organ injury and dysfunction is important to identify novel therapeutic options in order to ameliorate perioperative care. In this issue on 'Perioperative Organ protection', articles that cover molecular mechanisms as well as clinical implications of various perioperative complications are compiled. Based on the knowledge of the molecular mechanisms of different diseases and syndromes, interventions have been developed that substantially improved patient's care. However, articles in this issue also highlight current knowledge gaps and identify future research topics.

Markus W Hollmann and Alexander Zarbock

Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

November 2020, Volume 131, Issue 5

This month's cover art depicts a tree in the shape of a human face in profile, turning in one direction to a leafy summer environment and in the other direction to a stormy winter motif, now devoid of leaves. On both sides, it is the same tree, held firm by the same trunk, in the same earth. This artwork demonstrates the need for stability and support through changing circumstances. It harkens to our ever-changing lives, and the need for grounding. In times such as these, when the only certainty is uncertainty, it is comforting to remember the continuously moving nature of life's cycle.

Amy E. Vinson, MD, FAAP
Assistant Professor of Anaesthesia, Harvard Medical School
Chair, ASA Committee on Physician Well-Being

Cover image created and copyrighted by Lightwise via 123RF.com

Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

October 2020, Volume 131, Issue 4

This month's cover art illustrates the interaction of opioids (represented by the poppy) with brain function, and downstream effects on oxygenation, hypoventilation, and patient outcomes. Respiratory depression is a common problem on the general care floor, where standard-of-care monitoring often involves intermittent spot-checks. The background image of the pulse oximeter on the finger suggests the role of continuous oxygenation monitoring and the potential protection offered by these surveillance measures. Bolden and colleagues present the OSA Death and Near Miss Registry and highlight the potentially dangerous effects of opioids and sedatives—especially when combined—when managing OSA patients postoperatively, and the importance of monitoring to prevent catastrophic outcomes. The PRODIGY trial utilized continuous capnography and pulse oximetry monitoring to determine the true incidence of respiratory depression on the general care floor and developed a novel risk prediction tool (PRODIGY risk score) to identify surgical and medical patients at high, intermediate, or low risk for respiratory depression. Khanna and colleagues found that 46% of the population enrolled in this trial had respiratory depression episodes detected by continuous monitoring. Even in the absence of a clinical respiratory event, the presence of a monitor-detected episode put these patients at a significantly increased risk of an adverse event during hospitalization.
Ashish Kumar Khanna, Karen L. Posner, Jean-Francois Payen
Naveen Nathan, MD
Cover Editor and Illustrator

September 2020, Volume 131, Issue 3

This month's cover image profiles the Josie Robertson Surgery Center (JRSC), which serves as a glimpse into the trajectory of the future. The lines are fully blurred between the characteristic risk grades of surgical procedures and the acceptability of shortened recovery stays that border on true ambulatory status. With the advancements in refined enhanced recovery approaches to perianesthetic care, centers such as the JRSC have pushed the ideas of what can be accomplished into the realm of reality.
Naveen Nathan, MD
Cover Editor and Illustrator

August 2020, Volume 131, Issue 2

The cover art for this month's issue is undoubtedly instantly recognizable as Edvard Munch's The Scream. However, it has been modified as upon closer inspection, the central character's hands no longer cradle his face. Rather, one hand braces his abdomen while the other attempts to thwart an unwelcome advance of gastrointestinal contents. Whether we consider the original work or this modification, the premise resolves to the disharmony of the human condition. It serves as the ideal imagery to portray the universal apprehension of nausea, arguably the most feared postoperative experience one may endure from the patient's perspective. With this, the reader is now directed to the most up-to-date consensus guidelines on managing this most ill-favored affair.
Naveen Nathan, MD
Cover Editor and Illustrator

July 2020, Volume 131, Issue 1

This month's cover art transitions an image of planet earth into arguably the most infamous virus to enter the collective mind of the world's population. It is meant to convey the global spread of the ultimate agent of chaos. Consider a molecular machine devoid of consciousness bent on a singular goal: self-replication at the cost of all host cells left in its wake. It has challenged our resilience, our coping mechanisms, and our very belief systems. It has not, however, penetrated the advance of science. Indeed, it has amplified it.
Naveen Nathan, MD
Cover Editor and Illustrator

June 2020, Volume 130, Issue 6

I usually do not author the cover narrative in the first person. I try to create space for the message to come from the collective consciousness of our colleagues worldwide with the assumption that we all subscribe to similar persuasions. I spent some length of time concerning myself with how best to portray the idea of frailty for this issue. We equate frailty with the elderly but, truthfully, the concept is more aligned with any one individual's index of resilience. Understand that I constructed this image during a time in which a worldwide pandemic shifted into a full-on assault on humanity. Frailty began to take on a new meaning. Recent times have mandatorily compelled us to consider our vulnerability. Our physical and, more importantly, psychological constitution has been challenged. Of all things, I had to convey impermanence. Bleak as it may seem to think we are no longer the apex predator, there is yet one force of nature that can temper a molecular machine that rages through our populace, and that is time; time to reflect, time to be introspective of the things that really matter, and time to heal the frail.
Naveen Nathan, MD
Cover Editor and Illustrator

May 2020, Volume 130, Issue 5

In creating the cover image for an artificial intelligence themed issue of Anesthesia & Analgesia, the idea of transforming organic and cellular thought into a geometric, starkly mathematical stream of intelligence was pursued. Much of this can be seen as the topographical anatomy of the neuron shifts into wireframe models of Schwann cells, which themselves transmute into digital data streams. Articles in this issue entertain how the age of data will bring forth machine learning and robotic technology into the practice of anesthesiology. Acknowledgment is offered to Colin Behrens, whose original image of a neuron was used as the substrate for this final image (found at pixabay.com).
Naveen Nathan, MD
Cover Editor and Illustrator

April 2020, Volume 130, Issue 4

This month's cover artwork reflects the reality espoused by the attendant articles contained in this issue. As anesthesiologists, we strive to create a harmonious arc of care for our patients that finds us ever more frequently in the preoperative realm of their management. Unfortunately, the feather-weight mass of our aspirational goals for patient care are often no match for the density of production pressures, billable actions, and timeliness of surgical intervention. Achieving balance between these two worlds seems almost impossible. The referenced articles thoughtfully underscore the need for focus on preoperative optimization; that our current, mere 'assessment' should evolve to comprehensively and deliberately improve the physical status of patients in preparation for surgery.
Naveen Nathan, MD
Cover Editor and Illustrator

March 2020, Volume 130, Issue 3

The cover artwork this month juxtaposes the anguish of pain with the visual analog scale that is too often misinterpreted in our assessment of patients. Attaching a number to an emotional state is by all estimates contrived and far too often is why this scale is not utilized the way it was intended. Herein lies the theme of this issue, a sharp focus on 'prehabilitating' patients through psychological education in their understanding and expectations of pain and, ultimately, to empower them.
Naveen Nathan, MD
Cover Editor and Illustrator

February 2020, Volume 130, Issue 2

The image on this month's cover uses a translucency effect for icons related to perioperative care as they hover about a tablet-based app. This reflects just how early the stages are for the development of meaningful remote technologies in anesthetic practice. The ideas of teleconferencing for preoperative consultation, intraoperative remote monitoring, and postoperative surveillance are just the beginning motivations for a rapidly evolving technology. Articles in this issue provide a comprehensive description of available use functions of remote technologies in anesthetic practice and their potential to transform our practice.
Naveen Nathan, MD
Cover Editor and Illustrator

January 2020, Volume 130, Issue 1

Although we focus our attention intensely on the heart's pump function, we often succumb to the mystique of its ability to generate electrical activity. Perhaps this is because the electroconductive cells of the heart do not so easily fit the mold of direct or alternating current power sources. Biologic systems which evolved in a water-based environment decidedly have to be more complex than the simple electron flow through copper wiring. This, of course, makes them just as complicated when it comes to all the environmental (physiological) forces that create aberrations of rhythm. As our patient population ages, so too will the integrity of their internal circuit boards.
Naveen Nathan, MD
Cover Editor and Illustrator