Influence of behavioral state on the neuromodulatory effect of low-intensity transcranial ultrasound stimulation on hippocampal CA1 in mouse.

In process of brain stimulation, the influence of any external stimulus depends on the features of the stimulus and the initial state of the brain. Understanding the state-dependence of brain stimulation is very important. However, it remains unclear whether neural activity induced by ultrasound stimulation is modulated by the behavioral state. We used low-intensity focused ultrasound to stimulate the hippocampal CA1 regions of mice with different behavioral states (anesthesia, awake, and running) and recorded the neural activity in the target area before and after stimulation. We found the following: (1) there were different spike firing rates and response delays computed as the time to reach peak for all behavioral states; (2) the behavioral state significantly modulates the spike firing rate linearly increased with an increase in ultrasound intensity under different behavioral states; (3) the mean power of local field potential induced by TUS significantly increased under anesthesia and awake states; (4) ultrasound stimulation enhanced phase-locking between spike and ripple oscillation under anesthesia state. These results suggest that ultrasound stimulation-induced neural activity is modulated by the behavioral state. Our study has great potential benefits for the application of ultrasound stimulation in neuroscience.

A Survey of Current Anesthesia Trends for Electrophysiology Procedures.

BACKGROUND: There has been a dramatic shift in recent years in anesthesia coverage for electrophysiology (EP) procedures. An anesthesiologist and electrophysiologist at our institution jointly developed a survey, which was distributed to the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society. Its goal was to document current practice patterns and examine perceived variability in coverage. METHODS: On approval of the leadership from the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society, an online survey was administered to the membership. The survey included demographic data, anesthetic type, and perceptions of the respondents. RESULTS: Four hundred seventy-nine surveys were completed. Thirty-eight percent were completed by electrophysiologists and 63% by anesthesiologists, giving a response rate of 8.24% for anesthesiologists and 13.6% for electrophysiologists. Of these, 57% of respondents worked in an academic setting. Over the past 2 years, 66.5% of respondents reported anesthesia involvement in EP cases increasing. These cases are reportedly covered by all anesthesiologists in a group 55% of the time, cardiac anesthesia 32.5%, and a designated team at the remainder of the institutions. Seventy-six percent of respondents reported having designated EP block time in the schedule. Ninety-two percent of respondents reported that patient satisfaction has increased with the involvement of anesthesia services. CONCLUSIONS: Anesthesia coverage for EP procedures has continued to increase with an increase in patient satisfaction. Anesthesiologists have had to adapt and provide designated block time to accommodate this increase and also, in some instances, form teams that go beyond simply cardiac anesthesiologists to care for these patients during their procedures.

Predictors of Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in a Capitated Payment System.

BACKGROUND & AIMS: Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. METHODS: We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. RESULTS: The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. CONCLUSIONS: In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.

Codeine and opioid metabolism: implications and alternatives for pediatric pain management.

PURPOSE OF REVIEW: Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. RECENT FINDINGS: Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injuries and even death among children receiving appropriate weight-based dosages of codeine and other opioids for analgesia at home setting particularly following tonsillectomy. Several national and international organizations have issued advisories on use of codeine in pediatrics, based on cytochrome P450 family 2 subfamily D type 6 (CYP2D6) pharmacogenetics. We have discussed the pros and cons of alternatives to codeine for pain management. SUMMARY: Although routine preoperative genotyping to identify children at risk and personalized opioid use for pediatric perioperative pain management is still a distant reality, current known implications of CYP2D6 pharmacogenetics on codeine use shows that pharmacogenetics has the potential to guide anesthesia providers on perioperative opioid selection and dosing to maximize efficacy and safety.

Diversity and Similarity of Anesthesia Procedures in the United States During and Among Regular Work Hours, Evenings, and Weekends.

BACKGROUND: Anesthesiologists providing care during off hours (ie, weekends or holidays, or cases started during the evening or late afternoon) are more likely to care for patients at greater risk of sustaining major adverse events than when they work during regular hours (eg, Monday through Friday, from 7:00 AM to 2:59 PM). We consider the logical inconsistency of using subspecialty teams during regular hours but not during weekends or evenings. METHODS: We analyzed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR). Among the hospitals in the United States, we estimated the average number of common types of anesthesia procedures (ie, diversity measured as inverse of Herfindahl index), and the average difference in the number of common procedures between 2 off-hours periods (regular hours versus weekends, and regular hours versus evenings). We also used NACOR data to estimate the average similarity in the distributions of procedures between regular hours and weekends and between regular hours and evenings in US facilities. Results are reported as mean ± standard error of the mean among 399 facilities nationwide with weekend cases. RESULTS: The distributions of common procedures were moderately similar (ie, not large, <.8) between regular hours and evenings (similarity index .59 ± .01) and between regular hours and weekends (similarity index, .55 ± .02). For most facilities, the number of common procedures differed by <5 procedures between regular hours and evenings (74.4% of facilities, P < .0001) and between regular hours and weekends (64.7% of facilities, P < .0001). The average number of common procedures was 13.59 ± .12 for regular hours, 13.12 ± .13 for evenings, and 9.43 ± .13 for weekends. The pairwise differences by facility were .13 ± .07 procedures (P = .090) between regular hours and evenings and 3.37 ± .12 procedures (P < .0001) between regular hours and weekends. In contrast, the differences were -5.18 ± .12 and 7.59 ± .13, respectively, when calculated using nationally pooled data. This was because the numbers of common procedures were 32.23 ± .05, 37.41 ± .11, and 24.64 ± .12 for regular hours, evenings, and weekends, respectively (ie, >2x the number of common procedures calculated by facility). CONCLUSIONS: The numbers of procedures commonly performed at most facilities are fewer in number than those that are commonly performed nationally. Thus, decisions on anesthesia specialization should be based on quantitative analysis of local data rather than national recommendations using pooled data. By facility, the number of different procedures that take place during regular hours and off hours (diversity) is essentially the same, but there is only moderate similarity in the procedures performed. Thus, at many facilities, anesthesiologists who work principally within a single specialty during regular work hours will likely not have substantial contemporary experience with many procedures performed during off hours.

Recent trends in the anesthetic management of craniotomy for supratentorial tumor resection.

PURPOSE OF REVIEW: The article reviews the recent evidence on the anesthetic management of patients undergoing craniotomy for supratentorial tumor resection. RECENT FINDINGS: A rapid recovery of neurological function after craniotomy for supratentorial tumor allows for the prompt diagnosis of intracranial complications and possibly an early hospital discharge. Intraoperative esmolol infusion was shown to reduce the anesthetic requirements, and may facilitate a more rapid recovery of neurological function. Outpatient craniotomy for supratentorial tumor resection has been associated with several clinical and economic benefits, but has not gained widespread use because of skepticism and medical-legal concerns. Awake craniotomy is associated with advantageous outcomes compared with surgery under general anesthesia, and is regarded as the standard of care for tumors that reside in or in close proximity to the eloquent brain. Recent studies have demonstrated that intraoperative electroacupuncture, dexmedetomidine, pregabalin, and lidocaine may facilitate postcraniotomy pain management. The use of volatile anesthetic agents in cancer surgery is associated with a worse survival compared with intravenous anesthetics, possibly by hindering immunologic defenses against cancer cells. SUMMARY: Recent evidence has yielded valuable information regarding anesthetic management of patients undergoing supratentorial tumor craniotomy. Despite a plethora of studies that compare short-term outcomes using different anesthetic and analgesic regimens, randomized controlled trials that examine the long-term outcomes (i.e., neurocognitive function, quality of life, tumor recurrence, and survival) that are of particular interest to patients are needed.

Anesthesia Practice and Perioperative Outcomes at Two Tertiary Care Hospitals in Freetown, Sierra Leone.

BACKGROUND: Anesthesia in West Africa is associated with high mortality rates. Critical shortages of adequately trained personnel, unreliable electrical supply, and lack of basic monitoring equipment are a few of the unique challenges to surgical care in this region. This study aims to describe the anesthesia practice at 2 tertiary care hospitals in Sierra Leone. METHODS: We conducted an observational study of anesthesia care at Connaught Hospital and Princess Christian Maternity Hospital in Freetown, Sierra Leone. Twenty-five percent of the anesthesia workforce in Sierra Leone, resident at both hospitals, was observed from June 2012 to February 2013. Perioperative assessments, anesthetic techniques, and intraoperative clinical and environmental irregularities were noted and analyzed. The postoperative status of observed cases was ascertained for morbidity and mortality. RESULTS: Between the 2 hospitals, 754 anesthesia cases and 373 general anesthetics were observed. Ketamine was the predominant IV anesthetic used. Both hospitals experienced infrastructural and environmental constraints to the delivery of anesthesia care during the observation period. Vital sign monitoring was irregular and dependent on age and availability of monitors. Perioperative mortality during the course of the study was 11.9 deaths/1000 anesthetics. CONCLUSIONS: We identified gaps in the application of internationally recommended anesthesia practices at both hospitals, likely caused by lack of available resources. Mortality rates were similar to those in other resource-limited countries.

Encuesta sobre la situación actual de la evaluación preoperatoria en los hospitales de España / A national survey on current practice of preanaesthetic assessment in elective surgery patients in Spain

Objetivo. Analizar la práctica común en las consultas externas preanestésicas de los pacientes sometidos a cirugía electiva en los hospitales públicos españoles. Material y métodos. Estudio observacional descriptivo transversal. Las variables principales de estudio fueron: características de los pacientes, tipo de evaluación preanestésica realizada, profesional evaluador y tipo de apoyo durante el proceso de evaluación. Como secundarias se contemplaron: número de quirófanos de cirugía programada y número de consultas preanestésicas. Se realizó análisis descriptivo uni y bivariante. Resultados. Fueron invitados a participar 214 hospitales del Sistema Nacional de Salud. Los 203 que finalmente participaron en la encuesta, disponían de consultas externas preanestésicas. En 183 de ellos (90%) pasan por dicha consulta todos los pacientes candidatos a intervención quirúrgica programada y en 202 (99,5%) la valoración preanestésica es realizada por un anestesiólogo del equipo. Reciben apoyo de una enfermera en 128 hospitales (63%), sola (49%) o junto a un auxiliar de enfermería (14%). En 68 de ellos (33%) es un auxiliar de enfermería el que ayuda en la consulta preoperatoria, mientras que en 7 centros (3%) no cuentan con ningún apoyo. En 14 de los centros (7%) las enfermeras realizan en la consulta valoraciones preanestésicas de forma autónoma tuteladas por un anestesiólogo. Centros con un mayor número de pacientes disponen de mayor número de consultas preanestésicas. Hospitales con un mayor número de quirófanos funcionantes reciben en mayor proporción el apoyo de una enfermera en la consulta preoperatoria. Conclusiones. La instauración de algún tipo de consulta externa preanestésica está asumida por la totalidad de los Servicios de Anestesiología de los hospitales públicos españoles. Aunque hay diferencias en el diseño y la organización(AU)

Objective. To analyse the preanaesthetic assessment prior to elective surgery in hospitals of the Spanish National Health Care System. Methods. A prospective cross-sectional descriptive observational survey was performed. Primary variables were patient characteristics, type of preanaesthetic evaluation and the evaluator, as well as type of support the evaluator received during patient assessment. Secondary variables included the number of operating rooms available for elective surgery, as well as preanaesthesia clinic facilities. Data were analysed by univariate and bivariate descriptive analysis. Results. A total of 214 hospitals of the Spanish Health Care System were invited to participate, and 203 centres responded, with all of them having a preanaesthesia assessment clinic. In 183 of them (90%), elective surgerypatients were interviewed prior to their surgical intervention, and in 202 hospitals (99.5%) a anaesthesiologist physician performed the interview. In 128 hospitals (63%), anaesthesiologists were helped during preoperative assessment by nurses alone (49%) or together with auxillary nurses (14%). In 68 of hospitals (33%) they were supported only by auxillary nurses and in 7 hospitals (3%) they obtained no help at all. In 14 centres (7%) anaesthesia nurses assessed patients directly (under supervision of an anaesthesiologist physician). Hospitals with a higher volume of patients performed more preanaesthesia interviews. Hospitals with more running operating rooms received more nurse support in the preanaesthesia assessment clinic. Conclusions. Some kind of preanaesthesia assessment clinic exists in all Anaesthesia Departments of public Spanish hospitals, although there are differences in design and organisation(AU)

Translational advances in pain and anesthesia for cancer patients.

Effective cancer pain management requires multidisciplinary approaches for multimodal analgesia. Although opioids have been the cornerstone, developments such as regional anesthesia and interventional pain techniques, complementary and alternative medicine, and new pharmaceuticals also have shown promise to relieve cancer pain. This overview of relevant clinical efforts and the modern day state of the science will afford a better understanding of pain mechanisms and multimodal approaches beneficial in optimizing analgesia for cancer patients.

Anestesia subaracnoidea selectiva: Soluciones diluidas a bajas dosis / No disponible

No disponible

[Descriptive analysis of work and trends in anaesthesiology from 2005 to 2006: quantitative and qualitative aspects of effects and evaluation of anaesthesia].

INTRODUCTION: In anaesthesiology, economic aspects have been insufficiently studied. OBJECTIVE: The aim of this paper was the assessment of rational choice of the anaesthesiological services based on the analysis of the scope, distribution, trend and cost. METHODS: The costs of anaesthesiological services were counted based on "unit" prices from the Republic Health Insurance Fund. Data were analysed by methods of descriptive statistics and statistical significance was tested by Student's t-test and chi2-test. RESULTS: The number of general anaesthesia was higher and average time of general anaesthesia was shorter, without statistical significance (t-test, p = 0.436) during 2006 compared to the previous year. Local anaesthesia was significantly higher (chi2-test, p = 0.001) in relation to planned operation in emergency surgery. The analysis of total anaesthesiological procedures revealed that a number of procedures significantly increased in ENT and MFH surgery, and ophthalmology, while some reduction was observed in general surgery, orthopaedics and trauma surgery and cardiovascular surgery (chi2-test, p = 0.000). The number of analgesia was higher than other procedures (chi2-test, p = 0.000). The structure of the cost was 24% in neurosurgery, 16% in digestive (general) surgery,14% in gynaecology and obstetrics, 13% in cardiovascular surgery and 9% in emergency room. Anaesthesiological services costs were the highest in neurosurgery, due to the length anaesthesia, and digestive surgery due to the total number of general anaesthesia performed. CONCLUSION: It is important to implement pharmacoeconomic studies in all departments, and to separate the anaesthesia services for emergency and planned operations. Disproportions between the number of anaesthesia, surgery interventions and the number of patients in surgical departments gives reason to design relation database.

Hypnosis as sole anesthesia for major surgeries: historical & contemporary perspectives.

Hypnosis is a well validated treatment for acute and chronic pain (Montgomery, DuHamel, & Redd, 2000). It has been found capable of reducing inflammation, altering blood flow, and producing beneficial effects when hypnotic suggestions are provided during and prior to surgery (Frederick, 2001) and other painful medical procedures. This paper quotes extensively from historical examples of the use of hypnosis (mesmerism) as the sole anesthesia for major surgeries in the 1800's. These historic examples by themselves provide powerful documentation of the ability of the mind to influence the body, but they are then followed by a review of contemporary literature and controlled research on the use in hypnosis in relation to surgery and prior to medical procedures.

Avances sobre el conocimiento y monitorización de la anestesia adecuada / Advances in knowledge and monitoring of adequate anaesthesia

Con la aparición de la Teoría de la cascada anestésica en el año 2005 y el conocimiento de los circuitos de reverberación sostenida, el concepto de la anestesia y de cómo se producen los distintos eventos relacionados en su proceso ha despertado a un sinfín de consideraciones directamente relacionadas con estructuras anatómicas encadenadas del sistema nervioso central y, aún más, de estructuras moleculares –situs y locus- que intervienen definitivamente en la producción de un fenómeno hasta ahora tan ambiguo como este. El, cada día, más creciente conocimiento de los receptores GABAA, NMDA, glutamato, glicina, de sus subunidades o de los canales iónicos transmembrana; de su ubicación y actuación por acción de los fármacos anestésicos; pone de relieve que las teorías hasta ahora conocidas mantenían una importante laguna que no explicaba el efecto anestésico ni sus parcelas. La hipótesis de que los anestésicos generales producen hipnosis, amnesia e inmovilidad por actuación en diversas partes del sistema nervioso central y por distintos mecanismos moleculares, arrancó hace tan solo diez años. Desde entonces, hemos aprendido la teoría unitaria de la narcosis se ha modificado desarrollando numerosos componentes, cada uno de los cuales interviene en microcircuitos neuronales discretos. Estas redes se caracterizan por células específicas, interconexiones y sistemas de neurotransmisión determinados, lo que expresa objetivos moleculares –locus- diferentes para los anestésicos generales y ello abre nuevas expectativas al desarrollo de fármacos específicos, desprovistos de efectos secundarios (AU)

UIT the onset of the Anesthetic Cascade Theory in 2005 and the knowledge of sustained reverberation circuits, the events related with the anesthetic process and the anesthesia concept have woke up a lot of considerations about the connections of anatomic structures of central nervous system and, even more, about molecular structures –situs and locus- definitively implicated in the production of such ambiguous phenomenon like this. The growing knowledge about GABAA, NMDA, glutamate and glycine receptors, their subunits and their ionic channels; the knowledge about the location and their activation mediated by anesthetic drugs remarks that actual theories had an important defect because they didn´t explain the anesthetic effect or its components. The hypothesis that explains the effect of general anesthetics as producers of amnesia, hypnosis and immobility operating on different structures of central nervous system and by different molecular mechanisms started just ten years ago. Since then, we have learnt that narcosis unitary theory ha been modified developing new components, each one of them works are characterized by specific cell types, interconnections and specific neurotransmitter system that reveal different molecular targets –locus- of general anesthetic agents, so the knowledge of this new locus opens a new era in the development of new specific anesthetic drugs without unwanted side-effects (AU)

Past accomplishments and future directions: risk prevention in anesthesia and surgery.

Anesthesiology has served as a model for patient safety in health care and was the first medical profession to treat patient safety as an independent problem. Anesthesiology has implemented widely accepted guidelines on basic monitoring, conducted long-term analyses of closed malpractice claims, developed patient simulators as meaningful training tools, and addressed problems of human error. The National Surgical Quality Improvement Program is the first national, validated, and peer-controlled program that uses risk-adjusted outcomes for the comparative assessment and improvement of the quality of surgical care. The program has reduced postoperative complications in the Veterans Administration, at both national and local levels. It is becoming more evident that processes and events during surgery can be important determinants of long-term outcomes after anesthesia and surgery.

Ureteroscopy: anesthetic considerations.

Ureterorenoscopy (URS) is a vital procedure in the armamentarium of the modern-day urologist for the management of ureteral and renal pathology. With advances in ureteroscopic design and the introduction of short-acting anesthetics, URS can now be performed efficiently with high patient satisfaction and minimal posteroperative recovery time. Recently, URS under local anesthesia, with or without sedation, has become a viable option for a high percentage of correctly selected patients. For those patients who then require deeper sedation or general anesthesia, anesthesia can be induced quickly with the new agents such as remifentanil, propofol, and desflurane, without a prolonged postoperative recovery period.

Herbal medicine and anaesthesia.

Herbal medicines are increasingly used in both western and Chinese societies. This is partly attributed to the alleged limitations of scientific medicine in the cure and control of chronic diseases. Many patients do not disclose that they have used herbs before surgery and hence their physicians remain unaware of the potential herb-drug interactions. With respect to anaesthesia, herbs can cause coagulation disorders, cardiovascular side-effects, water and electrolyte disturbances, endocrine effects, hepatotoxicity, and prolongation of the effects of anaesthetic agents. Anaesthesiologists should obtain a history of herbal medicine use from patients and work out the adverse perioperative herb-drug interactions in advance of the actual operation. If in doubt, the herbal medicine should be stopped for 2 weeks prior to anaesthesia and surgery.