Journal Club 2008-2009

Faculty: I Rampil, U Landman
Updated: 6-10-09

2013-2014 2012-2013 2011-2012 2010-2011 2009-2010 2008-2009 2007-2008 2006-2007 2005-2006


We begin JC anew this week, concentrating on a review of the classic papers of Anesthesiology.
The first session will examine the original paper of Barry Sellick on cricoid pressure.
I include this paper as well as a paper by Dave Schwartz (a former resident of mine) which initiated a controversy still with us (two included Letters started the controversy), and finally a pair of recent literature reviews.
JC relies on audience participation! Please review the enclosed articles and be preparted to comment on the original idea and presentation. How well has it stood the test of time? What about its efficacy? Are the reviews relevant and to the point? Where's the beef??

Sellick BA.
Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia.
Lancet. 1961 Aug 19;2(7199):404-6

Schwartz DE, Matthay MA, Cohen NH.
Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations.
Anesthesiology. 1995 Feb;82(2):367-76

Kron SS.
Questionable effectiveness of cricoid pressure in preventing aspiration.
Anesthesiology. 1995 Aug;83(2):431-2 

Jackson SH.
Efficacy and safety of cricoid pressure needs scientific validation.
Anesthesiology. 1996 Mar;84(3):751-2 

Ellis DY, Harris T, Zideman D.
Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis.
Ann Emerg Med. 2007 Dec;50(6):653-65. Epub 2007 Aug 3.

Butler J, Sen A.
Best evidence topic report. Cricoid pressure in emergency rapid sequence induction.
Emerg Med J. 2005 Nov;22(11):815-6 

In recognition of Dr. Miller's announcement of retirement this week, I have altered the schedule of classic papers to be discussed at Journal club next week. Ron authored several papers widely held as classics and the one we will discuss is his first, on the coagulopathy of massive transfusion.

1. describe the necessary blood components for clotting
2. describe the benefits of whole blood transfusion
3. provide skillful critique on classic papers discussing the early research on hemorrhage

Miller RD, Robbins TO, Tong MJ, Barton SL.
Coagulation defects associated with massive blood transfusions.
Ann Surg. 1971 Nov;174(5):794-801 

Hardy JF, De Moerloose P, Samama M; Groupe d'intérêt en Hémostase Périopératoire.
Massive transfusion and coagulopathy: pathophysiology and implications for clinical management.
Can J Anaesth. 2004 Apr;51(4):293-310 

Kozek-Langenecker S.
Management of massive operative blood loss.
Minerva Anestesiol. 2007 Jul-Aug;73(7-8):401-15 

Preoperative HypertensionStudies of anaesthesia in relation to hypertension. I. Cardiovascular responses of treated and untreated patients.
Prys-Roberts C, Meloche R, Foëx P.
Br J Anaesth. 1971 Feb;43(2):122-37 

Risks of general anesthesia and elective operation in the hypertensive patient.
Goldman L, Caldera DL.
Anesthesiology. 1979 Apr;50(4):285-92 

Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent.
Stone JG, Foëx P, Sear JW, Johnson LL, Khambatta HJ, Triner L.
Anesthesiology. 1988 Apr;68(4):495-500 
OB Anesthesia Classics
Drs. Rozbruch, S. Sharma, Zeqo, Steinberg and Rampil
Review classic OB articles related to use of vasopressors, fluid preload prior to spinal, and APGAR. 

Compare these with contemporary articles:
A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery.
Lee A, Ngan Kee WD, Gin T.
Anesth Analg. 2002 Apr;94(4):920-6 <abstract>

The Apgar score has survived the test of time.
Finster M, Wood M.
Anesthesiology. 2005 Apr;102(4):855-7 <abstract>
C. Rout's  paper was reviewed--in which a segmental analyisis was done so that less patients would be subject to risks of a fluid overload. 
Triangle test (similar to t-test)
Acute hydration for prevention of hypotension of spinal anesthesia in parturients.
Wollman SB, Marx GF.
Anesthesiology. 1968 Mar-Apr;29(2):374-80

A proposal for a new method of evaluation of the newborn infant.
Curr Res Anesth Analg. 1953 Jul-Aug;32(4):260-7 

Uterine blood flow and fetal acid-base changes after bicarbonate administration to the pregnant ewe.
Ralston DH, Shnider SM, DeLorimier AA.
Anesthesiology. 1974 Apr;40(4):348-53 
Neuromuscular Blockade Classics
Drs. Landman and Rampil
Review classical Neuromuscular blockade articles.

We had a complete review from 1942 Curare to present day classical articles related to neuromuscular blockers.
We also reviewed the monitors used then and now, and found that today there are many differences from 1954 when Beecher reported on the high mortality associated with the use of muscle relaxants.
1. Today we use much shorter acting paralytics.
2. Today we intubate and ventilate patients.
3. Today we monitor NM block.
4. Today we use reversal agents.
5. Today we use shorter acting anesthetic agents.
6. Today we monitor SpO2 and CO2.
 The 1 item that has remained the same in both times is that we still have a surgeon asking for more paralysis!

The use of curare in general anesthesia
Griffith HR, Johnson GE

The lack of cerebral effects of d-tubocurarine
Smith SM, Brown HO, Toman JEP, Goodman LS
Anesthesiology 1947 8(1):1-14 

A study of the deaths associated with anesthesia and surgery: based on a study of 599,548 anesthesias in ten institutions 1948-1952, inclusive.
Beecher HK, Todd DP.
Ann Surg. 1954 Jul;140(1):2-35 

Neuromuscular effects of d-tubocurarine, edrophonium and neostigmine in man.
Katz RL.
Anesthesiology. 1967 Mar-Apr;28(2):327-36 <pdf>

The relation between the response to "train-of-four" stimulation and receptor occlusion during competitive neuromuscular block.
Waud BE, Waud DR.
Anesthesiology. 1972 Oct;37(4):413-6 

Monitoring of neuromuscular function in the clinical setting.
Kelly D, Brull SJ.
Yale J Biol Med. 1993 Sep-Oct;66(5):473-89. 
Tachycardia Classics
Drs. Landman and RampilReview classical Tachycardia articles.
Thank you to all the speakers tonight (Drs. Rampil, Cohanim, Kogan, Wurstle, Dubrow and Montgomery) who gave clear, succinct reviews of the articles. We had a great review of 5 classical articles. We had a refresher on the necessary items for efficient review of articles: Hypothesis (is there a reasonable question to be answered?), Methods (Is the question answered and is bias eliminated?), Statistics (was there an approriate answer which was powered to the study?), Results (Are the results expected or unexpected?) and Conclusion (Is the conclusion supported by the results?) from the articles.

Just a few interesting points:

The Bennett/Stanley Study actually had multiple questions (hypotheses). It id not have a power analysis-as many older papers in that era. The conclusion reached was fentanyl is a local anesthetic-as we all know this is not the reality for 2009.

The Martin study from 1982 statistic test was not clarified if it was tailed or not. The student t test was done-but was not elaborated on.

The Slogoff study is a classic that all must read. The infamous anesthesiologist #7 comes from this study.  It helps usher in use of beta blockade, Tachycardia is seen as a predictor of ischemia and the the large n in the study was all by 1 surgeon Debakey.  This paper was the first link showing EKG changes perioperatively and intraop can lead to morbidity postoperatively.

The Helfman study involved a very large dosage of esmolol in bolus to patients-something that no one in attendance tonight felt was a normal bolus given.  It was not clear how the doseage numbers for the lidocaine, fentanyl and esmolol were chosen. A better study would involve using multiple doseages and then seeing what was best for each medication.  We had lots and lots of statistics review as seen and the final study by Ko had ANOVA analysis done.  
Human cardiovascular responses to endotracheal intubation during morphine--N2O and fentanyl--N2O anesthesia.
Bennett GM, Stanley TH.
Anesthesiology. 1980 Jun;52(6):520-2 

Does perioperative myocardial ischemia lead to postoperative myocardial infarction?
Slogoff S, Keats AS.
Anesthesiology. 1985 Feb;62(2):107-14. 

Small-dose fentanyl: optimal time of injection for blunting the circulatory responses to tracheal intubation.
Ko SH, Kim DC, Han YJ, Song HS.
Anesth Analg. 1998 Mar;86(3):658-61 

Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol?
Helfman SM, Gold MI, DeLisser EA, Herrington CA.
Anesth Analg. 1991 Apr;72(4):482-6. 

Low-dose fentanyl blunts circulatory responses to tracheal intubation.
Martin DE, Rosenberg H, Aukburg SJ, Bartkowski RR, Edwards MW Jr, Greenhow DE, Klineberg PL.
Anesth Analg. 1982 Aug;61(8):680-4 

ICP control Classics
Drs. Landman and Rampil

Review classical ICP control articles.

Thanks to Dr. Rampil and Dr. Diguglielmo for reviewing the 3 classic neuro articles.  

We had a chance to hear how neuroanesthesia was given in  the 60s, 70s and 80s. 
We had a chance to review some neuro basics such as  CPP=MAP-ICP as well as review on thiopentone. 
Today we found in our group- thiopental is still given-there was consensus to that in the restaurant. 
It was interesting to see how thinking has changed over the years with regard to halothane.
Hyperventilation in craniotomy for brain tumor.
Schettini A, Cook AW, Owre ES.
Anesthesiology. 1967 Mar-Apr;28(2):363-71 

Rapid intraoperative reduction of intracranial pressure with thiopentone.
Shapiro HM, Galindo A, Wyte SR, Harris AB.
Br J Anaesth. 1973 Oct;45(10):1057-62. 

Brain surface protrusion during enflurane, halothane, and isoflurane anesthesia in cats.
Drummond JC, Todd MM, Toutant SM, Shapiro HM.
Anesthesiology. 1983 Oct;59(4):288-93 

Pediatric Anesthesia Classics
Drs. Seidman, Nguyen, Husain

Review classical pediatric anesthesia articles. "Give that baby latte"

The 2 older papers by Welborn are the classic papers we will be basing our discussion on, ANY resident CA2 or above should have already read these as they are in your pediatric readings. The last is a recent review recommitting to caffeine for neonates. We will be running this journal club slightly differently. As ALWAYS we expect you to have read the papers and be prepared to discuss them. We will NOT be going over the papers and reading them for you as part of journal club. We plan quizzes, games and prizes. We need to show your commitment to lifelong learning and professionalism by having you be prepared. Just do it, or you will be out of luck to play games and will not win prizes. Clear?
The use of caffeine in the control of post-anesthetic apnea in former premature infants.
Welborn LG, de Soto H, Hannallah RS, Fink R, Ruttimann UE, Boeckx R.
Anesthesiology. 1988 May;68(5):796 

Postanesthetic apnea and periodic breathing in infants.
Welborn LG, Ramirez N, Oh TH, Ruttimann UE, Fink R, Guzzetta P, Epstein BS.
Anesthesiology. 1986 Dec;65(6):658 

The former preterm infant and risk of post-operative apnoea: recommendations for management.
Walther-Larsen S, Rasmussen LS.
Acta Anaesthesiol Scand. 2006 Aug;50(7):888