Journal Club 2014-2015

Faculty: R Makaryus, U Landman
Updated: 05-08-15
Drs. Tsafos, Nunziata and Steinberg
Curry Club
6:00 PM
OB Anesthesia
Dr. Nunziata gave a concise review of the Ding, et al. and Finster & Wood articles. It was noted that there are independent predictors of ppd including epidural analgesia, increased depression 3 days postpartum, and continued breastfeeding 42 after delivery. Because the study on ppd was a cohort study, it showed only associates. The issue of C-section and ppd was not addressed. One limitation of the study was that 25% of the subject had C-sections. Interestingly, the use of the Edinburgh Postnatal Depression Scale was not validated by having patients examined by a psychiatrist.

Dr Tsafos gave a complete review of the articles relating to hypotension after spinal. The Lee, et al. article compared ephedrine and phenylephrine. This has led to the current practice of using pressors than ephedrine. The common daily practice in our obstetric unit now is to use a phenylphrine infusion prior to spinal. Our protocol was reviewed.

The classic paper of Ralston, et al. was reviewed. We discussed some issues with this study. Like other studies in that ear, the sheep model was considered to be an appropriate one for understanding humans. Even so, the protocol did not include spinals and the sheep were not in labor at the time.
The authors concluded that phedrine was superior to mephentermine as a prophylactic vasopressor.

Drs. Nunziata and Steinberg also gave us some history on the life and times of Dr. Virginia Apgar. She started out as a surgeon but Dr. Whipple recommended that she study the new field of anesthesia. She joined the first academic anesthesia program directed by Dr. Waters. She was the first female full professor at the College of Physicians and Surgeons. She is also the only anesthesiologist to be pictured on a US postage stamp. Her hobbies included fly fishing and building violins!

* Ding T, Wang DX, Qu Y, Chen Q, Zhu SN. Epidural labor analgesia is associated with a decreased risk of postpartum depression: a prospective cohort study. Anesth Analg. 2014 Aug;119(2):383-92. [PubMed]
* Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2002 Apr;94(4):920-6 [PubMed]
* Ralston DH, Shnider SM, DeLorimier AA. Effects of equipotent ephedrine, metaraminol, mephentermine, and methoxamine on uterine blood flow in the pregnant ewe. Anesthesiology. 1974 Apr;40(4):354-70. [PubMed]
* Finster M, Wood M. The Apgar score has survived the test of time. Anesthesiology. 2005 Apr;102(4):855-7. [PubMed]

Drs. DeVeaux, Park and Makaryus
Eastern Pavillion, upstairs private room
6:00 PM
"To TAP or Not To TAP Block That" - A Debate
Dr. DeVeaux gave a concise review of the Carney et al. article. Prior studies had shown that Transversus Abdominis Plane (TAP) block provided effective postop anlagesia for patients undergoing colonic resection surgery, C-section and radical prostatectomy. In this study, they found that TAP block as part of multimodal analgesia provided superior analgesia compared to a placebo block up to 48 hours postop TAH. It was easy to perform and provided reliable and effective analgesia. Limitations of the study were the difficulty in blinding these studies (there is loss of sensation associated with the block), the small study size, and the fact that there may have been variations in the technique among the 3 anesthesiologists.

The posterior or classic approach to TAP block was described. It uses landmarks such as the triangle of Petit. It is ultrasound-guided and is effective for lower abdominal surgery.

Dr. S. Park gave a complete review of the Wu et al. article. The subcostal approach is also ultrasound-guided and is effective for analgesia for the supraumbilical abdomen. They found that single injection subcostal TAP block was more effective than IV opioid analgesia. Continuous thoracic epidural analgesia was more effective than the single injection subcostal TAP block. Limitations of this study were that it was a single shot TAP block, certain patients were excluded those with BMI >30 and ASA class >3, a continuous epidural was used as a comparison and those patients did get additional local for ineffective pain relief, sensory clock plane was not tested in the patients, and also there was single blinding of the IV morphine titration in the PACU. Perhaps someone will do additional studies using the continuous TAP block catheter as a comparison since this was an area that was not looked at.

The debate ended in a tie!

Interestingly, both studies placed the blocks preop, but we place them postop. The workflow of placing the catheter was discussed. Placing it postop can add to OR time and increase time that the patient is under GA. We also discussed that this is a difficult block to place in an awake patient with a potential for complications. The safety record of our blocks was also discussed. There have been infections and peritoneal catheter puncture.

We also discussed additional articles. One was Long, et al. "Transversus abdominis plane block in children: a multicenter safety analysis of 1994 cases from the PRAN (Pediatric Regional Anesthesia Network) database, (Anesth Analg. 2014 Aug;119(2):395-9). At SB we do some pediatric TAP blocks but it depends on the surgeon.

It was suggested that perhaps TAP blocks should be used for services such as urology and bariatric surgery. It was also noted that the opiate consumption was a primary outcome in the studies and that when new drugs are tested the pain score is often an endpoint. Opiate consumption tends to have less variability so that fewer subjects are needed.

* Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Anesth Analg. 2008 Dec;107(6):2056-60. [PubMed]
* Wu Y, Liu F, Tang H, Wang Q, Chen L, Wu H, Zhang X, Miao J, Zhu M, Hu C, Goldsworthy M, You J, Xu X. The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and intravenous opioid analgesia after radical gastrectomy. Anesth Analg. 2013 Aug;117(2):507-13. [PubMed]

Drs. Sverdlova, Pak, Moller and Makaryus
Phyathai Restaurant 6:00 PM
Vascular/General - ERAS patients' hospital stay
Dr. Pak gave an excellent concise review of the Miller et al. article. ERAS (Enhanced Recovery After Surgery) is a multimodal approach to perioperative care that combines a range of interventions to enable early mobilization and feeding after surgery. This study from Duke gathered data from open or laparoscopic colorectal surgery before and after implementing the ERAS protocol. Before ERAS, there was rare standardization of care; all patients fasted from midnight and had a bowel prep. After ERAS initiation, patients were educated about the ERAS pathway in the preop clinic. Bowel prep was not done for colonic procedures and clear liquids were allowed 3 hrs prior to OR. Patients were also given a preoperative drink. As long as there was no conta-indication, a thoracic epidural was placed. All patients received goal directed fluid therapy (GDFT). Postop analgesia was via epidural infusion of opiod and local anesthetic. Immediately after surgery, liquids were encouraged. Early mobilization was done; patients were out of bed for 6 hrs on the day of surgery. The ERAS protocol showed reduced Length of Stay (LOS) and reduced incidence of UTI. Our discussion tried to elucidate which component decreased LOS. The entire team played a role, the anesthesiologist and surgeon, but also the RNs and the preop education that the patient received. The RN was found to be very important in the preop education and postoperative course (getting the patient out of bed, and encouraging an oral diet). We also discussed the complications that anesthesia can cause and how these can be avoided or minimized. Successful aspects of our own Ambulatory Center were discussed. RNs are a factor and so is reduced used of narcotic. These changes in practice can allow a better flow of patients through the OR, through the postop period and the return to home. The study demonstrated that the combined effort of everyone contributed to the decreased LOS. Each element can contribute a small amount to decrease the LOS and then overall recovery was optimized. Nursing is the key.

Dr. Sverdlova reviewed the article by Lidder et al. They found that carbohydrate drinks taken preop along with postop polymeric supplements are beneficial in comparison to no placebo drinks. Some limitations of the study were the size, the difference in texture of the supplement vs the placebo. (e.g. yogurt might be more pleasing to have than flavored water.) Also, the diabetic population was excluded; it might be beneficial to include diabetics in a future study. Also, the optimal volume of drink was not determined. It was noted that in Europe that amino acids are given to prevent infection. There was also discussion as to what our ideal supplement is.

* Miller TE, Thacker JK, White WD, Mantyh C, Migaly J, Jin J, Roche AM, Eisenstein EL, Edwards R, Anstrom KJ, Moon RE, Gan TJ; Enhanced Recovery Study Group. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014 May;118(5):1052-61. [PubMed]
* Lidder P, Thomas S, Fleming S, Hosie K, Shaw S, Lewis S. A randomized placebo controlled trial of preoperative carbohydrate drinks and early postoperative nutritional supplement drinks in colorectal surgery. Colorectal Dis. 2013 Jun;15(6):737-45. [PubMed]

Drs. Brezina, I. Wu
HSC Galleria at 6 pm
Post Operative Cognitive Dysfunction - Preclinical Studies
Dr. Wu gave an excellent concise review of the article by Chi et al. POCD (PostOperative Cognitive Dysfunction) can be associated with pain. POCD can be a problem in elderly patients. It is the temporary decline in cognitive functioning in the weeks or months after a surgical procedure. It can have long-term disability and increased mortality. A relationship between postoperative pain and long-term memory impairment may exist. This study examined the impact of postoperative pain on cognitive functions in aged rats (24-25 months old). The study hypothesized that postoperative pain mediates the long lasting memory deficits in elderly patients. N-methyl -D-aspartate (NMDA) receptor (NR) plays a role in learning, memory and processing pain. The authors further hypothesized that postoperative pain cause POCD by increasing NR expression. They also examined whether memantine (a non -competitive NR antagonist) prevented the development of memory deficits after anesthesia and surgery. Results from the study showed that effective postoperative analgesia can prevent development of spatial memory decline. Limitations of the study were that it only replicated minimally invasive surgery, and measured only NR2 subunits (N-methyl-D-aspartate receptor 2) which vary according the developmental stage vs NR1 subunits which distribute in the brain. The authors felt that postoperative pain management may be important in the prevention of POCD in elderly patients. We discussed that in human studies, opiates are discontinues about one week after surgery. This basic science article helped us understand mechanisms, but it does not translate clinically. It is not clear how these results relate to POCD in humans.

Dr. Brezina presented a good review of the Zhang et al paper. He mentioned that POCD is detected in 10-15% of patients older than age 60. It can be seen in neurocognitive testing three months after surgery. This study found that amantadine attenuated surgery-induced learning and memory impairment. This effect was mediated by GDNF (Glial cell-Derived Neurotrophic Factor) via inhibition of neuroinflammation. The main limitation of the study was that only minor surgery was performed on the rats; it is not known whether amantadine would be effective in reducing neuroinflammation and cognitive impairment after major surgery. Only male rats were used since estrogen can fluctuate and influence learning and memory in female rats. Another limitation was that the rats were not evaluated before the surgery to ensure that they learned equally and had equal cognitive abilities. Our discussion noted that POCD is rare in humans but measured in small rats. We discussed how POCD is more common after longer surgeries in humans. POCD in humans is tested as verbal abilities, thus it relates to the left side of the brain. The rats received spatial memory tests; these emphasize the left side of the brain. POCD in humans is found equally for regional and general anesthetics. POCD in humans is probably mulitfactorial. It may be related not just to anesthesia but also to the surgery, stress from the surgery, educational level of the patient, etc. We had a very good discussion about hypothetical scenarios. The next time we get that family member telling us that their parent has never been the same after their last surgery, we can all think back to this journal club on POCD.

* Zhang J, Tan H, Jiang W, Zuo Z. Amantadine alleviates postoperative cognitive dysfunction possibly by increasing glial cell line-derivedneurotrophic facto in rats. Anesthesiology. 2014 Oct;121(4):773-85. [PubMed]
* Chi H, Kawano T, Tamura T, Iwata H, Takahashi Y, Eguchi S, Yamazaki F, Kumagai N, Yokoyama M. Postoperative pain impairs subsequent performance on a spatial memory task via effects on N-methyl-D-aspartate receptor in aged rats. Life Sci. 2013 Dec 18;93(25-26):986-93. [PubMed]

Drs. Dave, Pollack, Probst and Makaryus
Curry Club 6 pm
Neuro/ENT - Relax the Brain; Ease the Pain
Dr. Dave gave an excellent review of the article by Quentin et al. There were 80 patients enrolled In this prospective randomized double blind study. Patients received either 0.7 g/kg or 1.4 g/kg of 20% mannitol at surgical incision. Brain relaxation was categorized on opening of the dura using a 1 to 4 scale. 1 indicated the best relaxation and 4 referred to a bulging brain. The dose of mannitol had no effect on relaxation score unless the midline shift was accounted for. Once midline shift was corrected then the high dose mannitol had a better chance of an improved relaxation score in comparison to low dose mannitol. It was discussed that the scoring could be affected by having multiple surgeons assessing the brain relaxation. We also discussed the study in comparison to clinical practice at SB. It was discussed that in our OR low dose mannitol is fine. We also use additional maneuvers to get better relaxation. The study kept etco2 in the mid 30’s. Also with the high dose mannitol there can be metabolic abnormalities such as hyponatremia, but in this study they did not get the metabolic abnormality, In the study the patients had need for a rescue dose of mannitol , but at Stony brook we do not see that as much. It was also discussed that mannitol as an osmotic diuretic. It extracts water from intracellular compartments, reducing total body water. Following IV administration, intracranial pressure falls within 60-90 minutes.

​The prospective randomized trial (Malcharek et al) of evoked potentials was reviewed by Dr. Pollack. Twenty-one patients with no preexisting motor deficits were undergoing carotid endareterectomy (CEA) with either propofol or desflurane anesthesia. Remifentanil was given to both groups. Desflurane was more effective than propofol in reducing the tcMEP amplitude. Intraindividual differences in tcMEP amplitudes for the desflurane propofol regimen were smaller. Each patient serves as his/her own control. Studies prior to this one involved younger patients and this study used an older population. We discussed that this study would not change our clinical practice because TIVA is used when tcMEP is taken.

* Quentin C, Charbonneau S, Moumdjian R, Lallo A, Bouthilier A, Fournier-Gosselin MP, Bojanowski M, Ruel M, Sylvestre MP, Girard F. A comparison of two doses of mannitol on brain relaxation during supratentorial brain tumor craniotomy: a randomized trial. Anesth Analg. 2013 Apr;116(4):862-8. [PubMed]
* Misra S, Parthasarathi G, Vilanilam GC. The effect of gabapentin premedication on postoperative nausea, vomiting, and pain in patients on preoperative dexamethasone undergoing craniotomy for intracranial tumors. J Neurosurg Anesthesiol. 2013 Oct;25(4):386-91 [PubMed]
* Malcharek MJ, Loeffler S, Schiefer D, Manceur MA, Sablotzki A, Gille J, Pilge S, Schneider G. Transcranial motor evoked potentials during anesthesia with desflurane versus propofol - A prospective randomized trial. Clin Neurophysiol. 2014 Dec 8. pii: S1388-2457 [PubMed]

Drs. Cho, Moon and Adsumelli
HSC Galleria 6 pm
Uro/Gyn: Some issues in Renal Transplantation and Prostatectomy
Dr. Cho gave an excellent review of the Potura et al article. There were 150 patients enrolled in the study. Patients received either normal saline or an acetate-buffered balanced crystalloid during and after cadaveric renal transplant. Venous blood gases were obtained at the start and then every 30 min until discharge from the postop unit. Serum creatinine and 24 hour urine output were followed on postop day 1, 3 and 7. Hyperkalemia (k>5.9 mmol/l) was seen in 13 of the saline group and 15 of the balanced group. Minimum base excess was lower in the saline group. Maximum chloride was higher in the saline group. There was no difference in the creatinine and urine output. More patients in the saline group required catecholamines. We discussed that saline may not be the ideal choice of IV fluid. Current evidence implies that hyperchloremic solutions can cause renal vasoconstriction and a decrease in gfr. Use of balanced crystalloid resulted in less hyperchloremia and metabolic acidosis. In spite of much evidence to the contrary, the "myth" of using NS in these patients is still going strong and being passed on to residents. There were some limitations to the study. One was that that the lack of financial support resulted in sporadic enrollment. It was an open label study which means that the researcher was aware of the solution used. Additionally, the follow up period was limited to 7 days postop.

Dr. Moon presented a concise review of the Min-Soo Kim, et al. paper. This study assessed increased ICP from CO2 pneumoperitoneum with steep Trendelenburg using ultrasound measurement of ONSD (optic nerve sheath diameter) for patients undergoing robot assisted laparoscopic radical prostatectomy (RALRP). There has been a large increase in robotic surgeries in the past few years. Stony Brook has 3 robots. ICP can be measured by shunt placement, fundoscopic exam (cup of optic nerve or u/s measurement of the optic disc), and CT/MRI. ONSD measurements were first done in cadaveric studies. In this study ONSD was measured before induction, 10 and 30 minutes after CO2 and positioning and then after the patient was returned to the supine position. The CO2 pneumoperitoneum and 30° Trendelenburg caused a 12.5% increase in ONSD. Some limitations of the study were that: it was not blinded, the patient population had a relatively small body habitus, small n, and a lack of information about past medical history (other than just excluding patients who had neurologic history). The relevance of elevated ICP during RALRP still needs further evaluation. ONSD is an interesting application of ultrasound in the OR. it is a less invasive method than other assessments of ICP.

* Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E. An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial. Anesth Analg. 2015 Jan;120(1):123-9. [PubMed]
* Kim MS, Bai SJ, Lee JR, Choi YD, Kim YJ, Choi SH. Increase in intracranial pressure during carbon dioxide pneumoperitoneum with steep trendelenburg positioning proven by ultrasonographic measurement of optic nerve sheath diameter. J Endourol. 2014 Jul;28(7):801-6. doi: 10.1089/end.2014.0019. Epub 2014 Mar 5. [PubMed]

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