Thursday, June 12, 2014



Extracorporeal cardiopulmonary resuscitation.(ECPR)

Curr Opin Crit Care. 2014 Jun;20(3):259-65

This review highlights that ECPR is feasible for both In Hospital Cardiac Arrest  and Out of Hospital Cardiac Arrest . In the recent series, the outcome of ECPR in In Hospital Cardiac Arrest  is satisfactory, with survival rates good with neurologic outcome reaching the 40-50% range. All series converge in highlighting that time from cardiac arrest to ECMO flow is a critical determinant of outcome, with survival rates of 50% when initiated within 30min of In Hospital Cardiac Arrest, 30% between 30 and 60min, and 18% after 60min. Results of ECPR in Out  of Hospital Cardiac Arrest  are more challenging. Recent series suggest that good outcome can be obtained in 15-20% of the patients, provided that time from arrest to ECMO is shorter than 60min. Duration of cardiac arrest seems to be more important than location of cardiac arrest. ECPR thus seems to be a valuable option in selected cases


Asleep Versus Awake: Does It Matter?: Pediatric Regional Block Complications by Patient State: A Report From the Pediatric Regional Anesthesia Network.

Reg Anesth Pain Med. 2014 Jun 10.



The investigators analized  more than 50,000 pediatric regional anesthesia blocks from an observational prospective database, and determined  the rate of adverse events in relation to the patient's state at the time of block placement. Primary outcomes considered were postoperative neurologic symptoms (PONSs) and local anesthetic systemic  toxicity (LAST). Secondary outcome was extended hospital stay due to a block complication.


Postoperative neurological symptoms occurred at a rate of 0.93/1000 (confidence interval [CI], 0.7-1.2) under GA and 6.82/1000 (CI, 4.2-10.5) in sedated and awake patients.
The only occurrence of PONSs lasting longer than 6 months (PONSs-L) was a small sensory deficit in a sedated patient (0.019/1000 [CI, 0-0.1] for all, 0.48/1000 [CI, 0.1-2.7] for sedated patients).
 There were no cases of paralysis.
There were 5 cases of LAST or 0.09/1000 (CI, 0.03-0.21). The incidence of LAST in patients under GA (both with and without NMB) was 0.08/1000 (CI, 0.02-0.2) and 0.34/1000 (CI, 0-1.9) in awake/sedated patients.
Extended hospital stays were described 18 times (0.33/1000 [CI, 0.2-0.53]). The rate for patients under GA without NMB was 0.29/1000 (CI, 0.13-0.48); GA with NMB, 0.29/1000 (CI, 0.06-0.84); sedated, 1.47/1000 (CI, 0.3-4.3); and awake, 1.15/1000 (CI, 0.02-6.4).

They conclude that  the placement of regional anesthetic blocks in pediatric patients under GA is as safe as placement in sedated and awake children.

Tuesday, June 10, 2014

Effect of General Anesthesia in Infancy on Long-Term Recognition Memory in Humans and Rats.



The authors compared twenty eight children ages 6-11 who had undergone a procedure requiring general anesthesia before age 1 to twenty eight age- and gender-matched children who had not undergone anesthesia.
 Recollection and familiarity were assessed in an object recognition memory test using receiver operator characteristic analysis. In addition, IQ and Child Behavior Checklist scores were assessed.
 In parallel, thirty three 7-day old rats were randomized to receive anesthesia or sham anesthesia. Over ten months, recollection and familiarity were assessed using an odor recognition test.
They found that anesthetized children had significantly lower recollection scores and were impaired at recollecting associative information compared to controls. Familiarity, IQ, and Child Behavior Checklist scores were not different between groups.
In rats, anesthetized subjects had significantly lower recollection scores than controls while familiarity was unaffected. Rats that had undergone tissue injury during anesthesia had similar recollection indices as rats that had been anesthetized without tissue injury.
These findings suggest that general anesthesia in infancy impairs recollection later in life in humans and rats. In rats, this effect is independent of underlying disease or tissue injury.

Sunday, June 8, 2014



Clevidipine compared with nitroglycerin for blood pressure control in coronary artery bypass grafting: a randomized double-blind study.



Can J Anaesth. 2014 May;61(5):398-406


The investigators tested the hypothesis that clevidipine, a rapidly acting dihydropyridine calcium channel blocker, is not inferior to nitroglycerin (NTG) in controlling blood pressure before cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG).


100 patients undergoing CABG with CPB were randomized at four centres to receive intravenous infusions of clevidipine (0.2-8 μg·kg(-1)·min(-1)) or NTG (0.4 μg·kg(-1)·min(-1) to a clinician-determined maximum dose rate) from induction of anesthesia through 12 hr postoperatively. 

The study drug was titrated in the pre-CPB period with the aim of maintaining mean arterial pressure (MAP) within ± 5 mmHg of a clinician-predetermined target.

Total mean [standard deviation (SD)] dose pre-bypass was 4.5 (4.7) mg for clevidipine and 6.9 (5.4) mg for NTG (P < 0.05).

CONCLUSION:

During CABG, clevidipine was not inferior to NTG for blood pressure control pre-bypass.



Anesthetic considerations in pregnant women at advanced maternal age.





Anesthesia management of parturients aged 45 years and above is comparable to the management of women aged 40-44 years. However, parturients ≥45 are more susceptible to
bleeding complications. 
Of note, parturients aged ≥45 years had an approximately eight-fold risk for postpartum hemorrhage.