Journal Club 2011-2012

Faculty: I Rampil, U Landman

When, Who, Where Topic, Papers, Comments


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.

Avoidance of nitrous oxide for patients undergoing major surgery: a randomized controlled trial. Myles PS, Leslie K, Chan MT, Forbes A, Paech MJ, Peyton P, Silbert BS, Pascoe E; ENIGMA Trial Group. Anesthesiology. 2007 Aug;107(2):221-31. [PubMed]

A Cost-Benefit Analysis of the ENIGMA Trial. Graham AM, Myles PS, Leslie K, Chan MT, Paech MJ, Peyton P, El Dawlatly AA. Anesthesiology. 2011 Aug;115(2):265-272. [PubMed]

Head and neck position for direct laryngoscopy. El-Orbany M, Woehlck H, Salem MR. Anesth Analg. 2011 Jul;113(1):103-9. Epub 2011 May 19. [PubMed]


SB Galleria

Is seeing, believing?

We had a concise review of the Herbstreit et al article. We discussed that this techniqe may have some limited use in the beginning of training before other techniques are used. It will also give the learner some confidence in getting a good larngoscopic view of the VC.

We also had a good discussion about Cousins' 1984 review article. This is a seminal paper. Cousins compiled all the case reports of the time into the paper. There is still an interest in using opiods in an efficacious way to improve patient outcomes. Interstingly, this is the most cited article in the anesthesia literature.
Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students. Herbstreit F, Fassbender P, Haberl H, Kehren C, Peters J. Anesth Analg. 2011 Sep;113(3):586-90. Epub 2011 Jun 16. [PubMed]

Intrathecal and epidural administration of opioids. Cousins MJ, Mather LE. Anesthesiology. 1984 Sep;61(3):276-310. [PubMed]

Phyathai Restaurant

Propensity Scores

Lack of effectiveness of the pulmonary artery catheter in cardiac surgery. Schwann NM, Hillel Z, Hoeft A, Barash P, Möhnle P, Miao Y, Mangano DT. Anesth Analg. 2011 Nov;113(5):994-1002. Epub 2011 Sep 14. [PubMed]

Observational studies: propensity score analysis of non-randomized data. Trojano M, Pellegrini F, Paolicelli D, Fuiani A, Di Renzo V. Int MS J. 2009 Sep;16(3):90-7.[PubMed]



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.

Limb remote postconditioning alleviates cerebral reperfusion injury through reactive oxygen species-mediated inhibition of delta protein kinase C in rats. Wang Q, Zhang X, Ding Q, Hu B, Xie Y, Li X, Yang Q, Xiong L. Anesth Analg. 2011 Nov;113(5):1180-7. Epub 2011 Aug 24. [PubMed]

A dose-ranging study of the effect of transversus abdominis block on postoperative quality of recovery and analgesia after outpatient laparoscopy. De Oliveira GS Jr, Fitzgerald PC, Marcus RJ, Ahmad S, McCarthy RJ. Anesth Analg. 2011 Nov;113(5):1218-25. Epub 2011 Sep 16. [PubMed]


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.

Anesthetic Management and Outcome in Patients during Endovascular Therapy for Acute Stroke. Davis MJ, Menon BK, Baghirzada LB, Campos-Herrera CR, Goyal M, Hill MD, Archer DP; The Calgary Stroke Program. Anesthesiology. 2012 Feb;116(2):396-405. [PubMed]

Major abdominal surgery in nursing home residents: a national study. Finlayson E, Wang L, Landefeld CS, Dudley RA. Ann Surg. 2011 Dec;254(6):921-6. [PubMed]

Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012 Feb;116(2):248-73. [PubMed]


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.

Intraoperative Hypotension and Perioperative Ischemic Stroke after General Surgery: A Nested Case-control Study. Bijker JB, Persoon S, Peelen LM, Moons KG, Kalkman CJ, Kappelle LJ, van Klei WA. Anesthesiology. 2012 Mar;116(3):658-64. [PubMed]

Partner's Presence During Initiation of Epidural Labor Analgesia Does Not Decrease Maternal Stress: A Prospective Randomized Controlled Trial. Orbach-Zinger S, Ginosar Y, Sverdlik J, Treitel C, Mackersey K, Bardin R, Peleg D, Eidelman LA. Anesth Analg. 2012 Mar;114(3):654-60. Epub 2012 Jan 16. [PubMed]

SB Galleria

Research of Dr. T. Brennan
and Cerebral Oxymetry

Dr. Shah gave us a nice introduction to Dr. Timothy Brennan (University of Iowa), keynote speaker at next week's Academic Research evening. We reviewed his article titled “Hind Paw Incision in the Rat Produces Long-lasting Colon Hypersensitivity.” It is found that surgical procedures are associated with hyperalgesia at and around the incision site, but this article was trying to establish that a long lasting visceral hypersensitivity may also accompany postsurgical hyperalgesia. Some limitations in the study were that the age of the rats were not specified. This is important since older rats have less neuroplasticity. In addition, younger rats were more resilient to pain. The number of animals per group was only 9. From our discussion, it was found that overall clinical relevance was not demonstrated.

Dr. Helsby presented the article “Impact of Extracranial contamination on Regional Cerebral Oxygen saturation.” This article was comparing 3 cerebral oximeters in healthy volunteers. The 3 cerebral oximeters had variable sensitivity to extracranial tissue contamination. Dr. Helsby refreshed our memory on Beer’s Law. We also discussed how it is important to know how a device fails. Our discussion did admit that the cerebral oximeter does work well for a neonate.
Hind paw incision in the rat produces long-lasting colon hypersensitivity. Cameron DM, Brennan TJ, Gebhart GF. J Pain. 2008 Mar;9(3):246-53. Epub 2007 Dec 21. [PubMed]

Impact of extracranial contamination on regional cerebral oxygen saturation: a comparison of three cerebral oximetry technologies. Davie SN, Grocott HP. Anesthesiology. 2012 Apr;116(4):834-40. [PubMed]

Eastern Pavillion

Monitoring - Is the device up to the job?

Dr. Moten presented a nice review of the article by Dubost, et al. It was noted that intracranial pressures were not measured in patients. The study showed that optic nerve sheath diameter could be measured in parturients only. We could not be sure that preecclamptic patients have the same changes as someone with increased ICP. In addition optic nerve sheath diameter is affected by many factors including hypertension and renal failure. ICP is also a very dynamic number. For example measurements were not made while patients were in active labor. We discussed ways in which the study could have been strengthened. One was to make measurements during the early stages of preganancy and then again as the pregnancy progresses. The results could be compared for patients with and without preeclampsia. It was noted that this is a new technology. For us, it may more appropriate for us to continue to diagnose preeclampsia with a urine analysis.

Dr. Tam presented the article about Nexfin by Martina et al. The technology for this monitor has not changed since the 1980's. One problem is that the finger cuff does not keep up with a rapidly changing blood pressure in patients.
Noninvasive Continuous Arterial Blood Pressure Monitoring with Nexfin®. Martina JR, Westerhof BE, van Goudoever J, de Beaumont EM, Truijen J, Kim YS, Immink RV, Jöbsis DA, Hollmann MW, Lahpor JR, de Mol BA, van Lieshout JJ. Anesthesiology. 2012 May;116(5):1092-1103. [PubMed]

Optic nerve sheath diameter used as ultrasonographic assessment of the incidence of raised intracranial pressure in preeclampsia: a pilot study. Dubost C, Le Gouez A, Jouffroy V, Roger-Christoph S, Benhamou D, Mercier FJ, Geeraerts T. Anesthesiology. 2012 May;116(5):1066-71. [PubMed]

Curry Club

Publication Bias
Hemoglobin Desaturation

Dr. Chiu gave a nice review of the heoglobin desaturation article by Stefanutto, et al. We discussed the choice of medications.

Dr. Kim gave a concise review of the article publication bias paper by De Oliveira et al. The definition of bias and fact was reviewed. The authors hypothesized was that positive studies were more likely to get published than negative studies. We also reviewed impact factor which is the number of times an article gets cited elsewhere. It was discussed that Science and Nature have a large impact factor in comparison to our anesthesia journals. We also felt that journals should publish the negative findings from studies to further decrease bias. Interestingly negative papers take about 3 yrs to get published. For future journal clubs we will now have to consider publication bias. Publication bias has an impact, it can affect research, it also influences clinical guidelines, and can affect our patient care practices.
Publication bias in the anesthesiology literature. De Oliveira GS Jr, Chang R, Kendall MC, Fitzgerald PC, McCarthy RJ. Anesth Analg. 2012 May;114(5):1042-8. [PubMed]

Hemoglobin desaturation after propofol/remifentanil-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers.Stefanutto TB, Feiner J, Krombach J, Brown R, Caldwell JE. Anesth Analg. 2012 May;114(5):980-6. [PubMed]

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