Journal Club 2011-2012

08-25-11
Asaad
Ali
Joseph

The ENIGMA Trial
Nitrous oxide has been getting some bad press lately.

We had an interesting discussion of the ENIGMA trial. It was noted that it is very hard to categorize the actual cost of OR time. This study was not completely blinded for two reasons: they did not use a neutral third party and the surgeon could look at the anesthesia record because it was not concealed. The significance of the study was due to its large size but there are many issues that were not mentioned. Fluid treatment was not specifically mentioned; this could influence wound infection and length of hospital stay. Some other issues not touched on were use of reversal, and narcotic variability.

09-22-11
Azim
Vuong
Gruffi

SB Galleria

Is seeing, believing?

Propensity Scores

SB Galleria

Rats and Laps

We reviewed the Oliveira, et al. paper on transversus abdominis blocks. This study found that the Transervsus ABdominus Plane (TAP) block reduced postoperative pain and also enhanced quality of recovery in patients undergoing ambulatory surgery. Our group discussion noted that the study did not administer local anesthetic into the incision as part of the protocol. It might have been good to give everyone local so that a true benefit of the TAP block could be differentiated. The use of the questionnaire "Quality of Recovery 40" was also criticized.

The article by Wang, et al. is a basic science paper on the cerebral protective effects of postconditioning with an antibody that blocks PKC. This study found that limb remote ischemic postconditioning alleviated cerebral reperfusion injury through Reactive Oxygen species (ROS)-mediated inhibition of endogenous δ protein kinase C activation signaling. There was some discussion about the translational potential of this study. It is important to note that cerebral perfusion injuries do occur in clinical practice. Reperfusion injuries occur after the end of the ischemic period. In this study, focal cerebral ischemia was induced and the animals were sacrificed 120 min after reperfusion. This approach allowed sufficient time for the reperfusion injuries to occur. Ischemic postconditioning may be a way to reduce reperfusion injury in animal models.

02-16-12 
Fleischer
Dogra
Besleaga

Curry Club

Stroke, Major Adbominal Surgery, Acute Pain ... omg! (not to worry, 3 separate papers)

We reviewed the article about Endovascular Therapy for Acute stroke. This study did have limitations. They studied a small number of patients, it was retrospective, and they used a non-standard anesthetic management. There was also a great deal of bias in the study. There were 2 different groups of caregivers for the patients; not all of the caregivers were anesthesiologists. We also discussed autoregulation and ideal blood pressures for patients who may have a CVA or SAH. The importance of the type of anesthesia for these cases was also reviewed. We also reviewed the Practice Guidelines for Acute Pain Management in the Perioperative setting-the updated report by the ASA in 2012. It was noted that the ASA updates these guidelines. These guidelines are based on little evidence overall.

3-15-12 
Nguyen
Wang

Phyathai Restaurant

Intraoperative Hypotension -> Postoperative Stroke?
Partners Presence during Labor -> Less Maternal Stress? 

We reviewed the Bijker et al article. We discussed that all CVAs would not only be diagnosed by CT and that a random way to catch all the CVA patients for the study was used. Overall it was seen that blood pressure is really a vital we need to pay attention to in the OR. Interestingly there are no papers in the literature to show that blood pressure monitoring improves outcomes.

We also reviewed the Orbach-Zinger, et al article. This paper allowed partners of laboring patients to stay during the epidural placement, something that is not done at SB. We did have a discussion comparing the entrance of parents in the OR of pediatric patients vs a partner of a laboring pt during an epidural. Interestingly both had increased anxiety levels. There were some limitations to the study. This study assesed salivary amylase of both the laboring patient and the partner. We questioned whether salivary amylase is an appropriate marker for stress. It is not controlled with salivary flow rate and there was question as to whether it was equal to sympathetic nervous system activity. There was also bias since the anesthesiologist placing the epidural was not blind to a partner being in the room or being absent from the room. Overall this paper will not change our current practice.

Research of Dr. T. Brennan
and Cerebral Oxymetry

Monitoring - Is the device up to the job?

Publication Bias
Hemoglobin Desaturation