2021 Covers & Artwork

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December 2021, Vol. 133, Issue 6

This month’s cover art depicts the rapid patient throughput from arrival to the ambulatory facility to discharge home after day case or same-day surgery. Ambulatory surgical care continues to expand and has become the fastest growing segment of the health care industry. Ambulatory surgery is associated with improved postoperative outcomes and lower health care costs. It allows patient-centered care with enhanced recovery in the comfort of the patient’s home. Overall, outpatient surgery, particularly in an ambulatory surgery center, helps meet the triple aim of health care: patient satisfaction, population health, and value. This ambulatory anesthesia¬–themed issue of Anesthesia & Analgesia presents topics such as patient selection, anesthetic management, post-discharge care, and expansion of ambulatory surgery and anesthesia in low- and middle-income countries. It emphasizes the critical role anesthesiologists can play in improving perioperative care and the safety of patients undergoing ambulatory surgery.
Girish P. Joshi

Cover art composed by
Naveen Nathan, MD

November 2021, Vol. 133, Issue 5

Management of the pediatric cardiac surgical patient is complex. Much like the cover art this month inspires the notion that anesthesia is both art and science, there are many practices in pediatric cardiac anesthesiology that are well accepted but are more influenced by the art of anesthetic management than by direct scientific evidence. Multi-institutional databases, such as the Society of Thoracic Surgeons Congenital Heart Surgery Database, allow centers all over the world to collaborate and share information about quality, common practice, and outcomes that can help reveal associations between management and risk of certain outcomes. The pediatric cardiac surgical population has benefitted greatly from multi-institutional collaboration, since the volume at any one given center would make such outcomes research difficult, and prospective trials are impeded by the ability to control the multitude of factors that may be related to outcomes. In a field so focused on technical surgical outcomes, it can be easily lost that there is a great deal related to the final outcome that begins with intraoperative management. While the threshold for transfusion often receives the most attention, the target for transfusion is an important consideration for the anesthesiologist, and this article reveals how the post-operative hematocrit is associated with morbidity and mortality.

Justin B. Long, Branden M. Engorn, Kevin D. Hill, Liqi Feng, Karen Chiswell, Marshall L. Jacobs, Jeffrey P. Jacobs, and Dheeraj Goswami

Justin Bradley Long
Cover art composed by
Naveen Nathan, MD
Cover Editor and Illustrator

October 2021, Vol. 133, Issue 4

This month's cover depicts the most commonly used halogenated anesthetics and nitrous oxide as contributors to greenhouse gas (GHG) emissions to the atmosphere. Due to minimal metabolism in vivo, all of these agents, to quite varying degrees, have been shown to be GHGs due to their ability to reduce outgoing thermal radiation from leaving the Earth's atmosphere into space. In addition, some of the agents used today, such as isoflurane, nitrous oxide, and halothane, have been shown to be ozone depleting by catalytic reactions in the atmosphere due to the elements present in them. Interestingly, over the past decade or so, due to a decrease in use of chlorofluorocarbons in aerosols, nitrous oxide has become the leading cause of ozone depletion as a substance emitted by humans. Although the most significant GHG remains carbon dioxide, anesthetic agents contribute to the GHG effect. This issue of Anesthesia & Analgesia highlights the impact of the use of both inhaled and intravenous anesthetics on the environment.

Shane Varughese, MD, and Raza Ahmed, MD

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

September 2021, Vol. 133, Issue 3

This month's cover art appropriately sets a disquieting tone, picturing a vaping device with a warning label: May cause acute lung injury. A pulmonary syndrome entitled e-cigarette, or vaping, product use–associated lung injury (EVALI), related to vaping devices such as e-cigarette and marijuana product use has surfaced in the past several years, presenting with respiratory, gastrointestinal, and constitutional symptoms. Respiratory symptoms may progress to acute respiratory distress syndrome and even death in some cases. Marketing of vaping products has consisted of the use of sweet and fruity flavors and flashy names and packaging, specifically targeting children and adolescents. The result has been a significant increased use in this population. With unregulated ingredients and additives, and uncertainty as to which are most highly associated with worse pulmonary effects, the risks to children are high. In addition, a recent study showed that 13- to 24-year-olds who vaped were at 5 to 7 times higher risk of a COVID-19 diagnosis than naïve cohorts. Unique risks to adolescents and young adults include effects on brain development related to nicotine and marijuana, commonly used in vaping products. Finally, another perioperative consideration relates to surgical wound healing, which has been shown to be compromised in individuals who use vaping products. The concept that replacing traditional tobacco products with vaping devices is risk free is clearly erroneous. The frank targeting of children, who could develop life-long tobacco and cannabis use disorders when exposed early in life, is highly concerning.

Deborah Rusy, MD, Anita Honkanen MD, et al.

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

August 2021, Vol. 133, Issue 2

The implementation of supportive measures, consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia, in high risk patients undergoing cardiac surgery significantly reduces the occurrence of moderate/severe AKI. This issue of Anesthesia & Analgesia explores how well clinicians can maintain compliance with renoprotective bundles aimed at optimizing outcomes.

Alexander Zarbock, MD, Mira Kullmar, MD, Marlies Ostermann, MD, Gianluca Lucchese, MD, Kamran Baig, MD, Armando Cennamo, MD, Ronak Rajani, MD, Stuart McCorkell, MD, Christian Arndt, MD, Hinnerk Wulf, MD, Marc Irqsusi, MD, Fabrizio Monaco, MD, Ambra Licia Di Prima, MD, Mercedes Garcia Alvarez, MD, Stefano Italiano, MD, Jordi Miralles Bagan, MD, Gudrun Kunst, MD, Shrijit Nair, MD, Camilla L'Acqua, MD, Eric Hoste, MD, Wim Vandenberghe, MD, Patrick M. Honore, MD, John A. Kellum, MD, Lui G. Forni, MD, Philippe Grieshaber, MD, Christina Massoth, MD, Raphael Weiss, MD, Joachim Gerss, PhD, Carola Wempe, PhD, and Melanie Meersch, MD

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

July 2021, Volume 132, Issue 1

The cover image for this month's issue of Anesthesia & Analgesia convenes on the critical inflection point of perfusion pressure beyond which significant myocardial ischemia results. Truthfully, our desire for such an objective line in the sand cannot be known since every patient is unique and represents their own host of variables. Hallqvist and co-workers have investigated these individual thresholds in a nested case-control study of patients undergoing noncardiac surgery. Individually defined intraoperative hypotension was associated with a high risk of myocardial infarction, suggesting that increased vigilance of blood pressure control may be beneficial.

Naveen Nathan, MD

Linn Hallqvist, MD, Fredrik Granath, PhD, Michael Fored, MD, PhD, and Max Bell, MD, PhD

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

June 2021, Volume 132, Issue 6

Within the field of anesthesiology, studies on cognitive dysfunction during the past 3 decades have largely centered upon the role of anesthetics. It might be surprising then that, outside the surgical arena, acute and chronic cerebral hypoxia as a result of comorbidities such as obstructive sleep apnea, chronic obstructive pulmonary disease, heart failure, cerebrovascular disease, and anemia have been well validated as major contributors to cognitive impairment, especially in the elderly. Surgery then superimposes additional hypoxic threats such as acute anemia, respiratory depression, pulmonary edema, and hypotension, predisposing these same individuals to worsening hypoxia-related cognitive outcomes. Finally, it should be appreciated that with aging, on a physiologic and cellular level, the ability to manage hypoxia is also impaired. This intersection of increasing chronic and acute hypoxic exposure with aging and the diminished capability to manage hypoxia, appears to place the aged at high risk for hypoxia-related postoperative cognitive failure.

Brina Snyder, PhD, Stephanie M. Simone, BS, Tania Giovannetti, PhD, and Thomas F. Floyd, MD

Cover art composed by
Naveen Nathan MD
Cover Editor and Illustrator

May 2021, Volume 132, Issue 5

Fans of Pablo Picasso may recognize this month's cover image as an adaptation of his work for the theme of postoperative respiratory depression. The Old Guitarist was produced as an expressionistic work during the artist's 'blue period' in which monochromatic hues were employed and largely took on somber tones. But of course, to anesthesia care providers, the color blue connotes an entirely different theme. Recognition and avoidance of the cyanotic endpoint of respiratory depression has long been a cardinal goal of postoperative management. In this issue, several articles aim to further characterize post-anesthetic respiratory depression and enhance our knowledge base to improve patient outcomes.

Naveen Nathan MD
Cover Editor and Illustrator

April 2021, Volume 132, Issue 4

Readers may recognize the cover artwork for this month as an adaptation of Japanese artist Katsushika Hokusai's The Great Wave off Kanagawa, a woodblock print from the early 19th century. The color palette has been modified as this image has been used for a unique context: to reflect the fundamental importance of blood pressure to cellular viability. If one were to put their imagination to use and trace the outline of the great wave, a loose waveform of an arterial line tracing emerges. It would be hard to consider many other aspects of care that are so elemental as the maintenance of perfusion pressure. The article featured in this month's issue attempts to broaden our understanding of how we assess variation in this focused area of practice.

Naveen Nathan MD
Cover Editor and Illustrator

March 2021, Volume 132, Issue 3

Surgery remains the mainstream of cancer therapy despite the potential risks of micrometastasis and the formation of new metastatic foci. Different anesthetic techniques, propofol-based total intravenous anesthesia and volatile anesthesia, may be associated with different oncological outcomes due to their distinct impacts on cancer cell biology and host immunity. Chang and colleagues present a systematic review and meta-analysis and highlight the potentially beneficial effects of propofol over volatile anesthetics on long-term overall survival. This finding is supported by several in vitro and in vivo studies which consistently demonstrate the anti-metastatic and anti-tumorigenic property of propofol. In contrast, contradictory results are observed with regard to the influences of volatile anesthetics on cancer cell biology, with most of the studies indicating pro-metastatic and pro-tumorigenic effects. Inspiring as they may be, the results presented in this study is limited by the nature of the retrospective design of the included studies. Several large-scaled randomized control trials are being conducted worldwide, including the CAN Study, the VAPOR-C Trial, and the GA-CARES Trial. The results from these trials are required to answer definitively whether propofol should be routinely used in cancer surgery.

Chun-Yu Chang, MD and Ming-Chang Kao, MD, PhD

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

February 2021, Volume 132, Issue 2

This month's cover art depicts central musculature, as loss of central muscle mass is now recognized as a biomarker of frailty, and as a risk factor for poor outcomes after surgery. Loss of muscle mass and function—sarcopenia—is a common degenerative disease of the elderly. Its causes are complex, multifactorial, and inter-connected. At the systems level, hormonal changes, inflammation, oxidant stress, and lifestyle contribute to sarcopenia. Cellular senescence and a toxic senescence associated secreted phenotype affects many cells, including skeletal muscle stem cells (satellite cells) which become dysfunctional with aging, limiting muscle repair and regeneration. At the subcellular level, mitochondrial dysfunction is a major contributor to sarcopenia and lysosome dysfunction also plays a role. Molecular mechanisms underlying all these contributing pathologic processes have been identified, but effective pharmacologic treatment of sarcopenia is not yet available. The most effective way to prevent and treat sarcopenia remains exercise.

Marie Csete MD, PhD

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

January 2021, Volume 130, Issue 1

This month's cover art shows the evolution of humans that includes the acquisition of tools during this continuum that culminates in an individual with severe obesity as a possibility when the prevalence of this disease is rising worldwide. The medical profession faces unresolved questions and opportunities to better understand the disease and care for these patients. Schumann and colleagues focus on 4 topics in their narrative review that are of interest to practitioners caring routinely for patients with obesity. Ultrasound can help us "see" gastric content and plan accordingly. Blood pressure monitoring accuracy is more complex and a challenge in patients with obesity, but solutions may soon be emerging. The appropriate dosing of antibiotics, heparins and vasoactive drugs has unique considerations and a dosing scalar where one size fits all remains elusive. The review concludes with the issue of preoxygenation and airway management at in- and extubation of the trachea. These are core concerns for the anesthesiologist, and informed optimization of management strategies for these patients will improve safety and outcomes.

Roman Schumann, MD, FASA

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