The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019.

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Ketamine-A Narrative Review of Its Uses in Medicine.

One of the most fascinating drugs in the anesthesiologist's armament is ketamine, an N-methyl-D-aspartate receptor antagonist with a myriad of uses. The drug is a dissociative anesthetic and has been used more often as an analgesic in numerous hospital units, outpatient pain clinics, and in the prehospital realm. It has been used to treat postoperative pain, chronic pain, complex regional pain syndrome, phantom limb pain, and other neuropathic conditions requiring analgesia. Research has also demonstrated its efficacy as an adjunct in psychotherapy, as a treatment for both depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and neurologic conditions. Ketamine is not without its adverse effects, some of which can be mitigated with certain efforts. Such effects make it necessary for the clinician to use the drug only in situations where it will provide the greatest benefit with the fewest adverse effects. To the best of our knowledge, none of the reviews regarding ketamine have taken a comprehensive look at the drug's uses in all territories of medicine. This review will serve to touch on its chemical data, pharmacokinetics and pharmacodynamics, medical uses, and adverse effects while focusing specifically on the drugs usage in anesthesia and analgesia.

A comparison of plaintiff and defense expert witness qualifications in malpractice litigation in anesthesiology.

BACKGROUND: Expert witnesses serve a crucial role in the medicolegal system, interpreting evidence so that it can be understood by jurors. Guidelines have been established by both the legal community and professional medical societies detailing the expectations of expert witnesses. The primary objective of this analysis was to evaluate the expertise of anesthesiologists testifying as expert witnesses in malpractice litigation. METHODS: The WestlawNext legal database was searched for cases over the last 5 years in which anesthesiologists served as expert witnesses. Internet searches were used to identify how long each witness had been in practice. Departmental websites, the Scopus database, and state medical licensing boards were used to measure scholarly impact (via the h-index) and determine whether the witness was a full-time faculty member in academia. RESULTS: Anesthesiologists testifying in 295 cases since 2008 averaged over 30 years of experience per person (mean ± SEM, defense, 33.4 ± 0.7, plaintiff, 33.1 ± 0.6, P = 0.76). Individual scholarly impact, as measured by h-index, was found to be lower among plaintiff experts (mean ± SEM, 4.8 ± 0.5) than their defendant counterparts (mean ± SEM, 8.1 ± 0.8; P = 0.02). A greater proportion of defense witnesses were involved in academic practice (65.7% vs 54.8%, P = 0.04). CONCLUSIONS: Anesthesiologists testifying for both sides are very experienced. Defense expert witnesses are more likely to have a higher scholarly impact and to practice in an academic setting. This indicates that defense expert witnesses may have greater expertise than plaintiff expert witnesses.

Structural basis for suppression of a host antiviral response by influenza A virus.

Influenza A viruses are responsible for seasonal epidemics and high mortality pandemics. A major function of the viral NS1A protein, a virulence factor, is the inhibition of the production of IFN-beta mRNA and other antiviral mRNAs. The NS1A protein of the human influenza A/Udorn/72 (Ud) virus inhibits the production of these antiviral mRNAs by binding the cellular 30-kDa subunit of the cleavage and polyadenylation specificity factor (CPSF30), which is required for the 3' end processing of all cellular pre-mRNAs. Here we report the 1.95-A resolution X-ray crystal structure of the complex formed between the second and third zinc finger domain (F2F3) of CPSF30 and the C-terminal domain of the Ud NS1A protein. The complex is a tetramer, in which each of two F2F3 molecules wraps around two NS1A effector domains that interact with each other head-to-head. This structure identifies a CPSF30 binding pocket on NS1A comprised of amino acid residues that are highly conserved among human influenza A viruses. Single amino acid changes within this binding pocket eliminate CPSF30 binding, and a recombinant Ud virus expressing an NS1A protein with such a substitution is attenuated and does not inhibit IFN-beta pre-mRNA processing. This binding pocket is a potential target for antiviral drug development. The crystal structure also reveals that two amino acids outside of this pocket, F103 and M106, which are highly conserved (>99%) among influenza A viruses isolated from humans, participate in key hydrophobic interactions with F2F3 that stabilize the complex.

Role of ketamine in acute postoperative pain management: a narrative review.

OBJECTIVES: The objective of this narrative review was to examine the usage of ketamine as a postoperative analgesic agent across a wide variety of surgeries. DESIGN: A literature search was performed using the phrases "ketamine" and "postoperative pain." The authors analyzed the studies that involved testing ketamine's effectiveness at controlling postoperative pain. Effectiveness was assessed through various outcomes such as the amount of opiate consumption, visual analog scale (VAS) pain scores, and persistent postoperative pain at long-term follow-up. RESULTS: While many different administration protocols were evaluated, delivering ketamine both as a pre- or perioperative bolus and postoperative infusion for up to 48 hours appeared to be the most effective. These effects are dose-dependent. However, a number of studies analyzed showed no benefit in using ketamine versus placebo for controlling postoperative pain. While ketamine is a safe and well-tolerated drug, it does have adverse effects, and there are concerns for possible neurotoxicity and effects on memory. CONCLUSIONS: In a number of limited situations, ketamine has shown some efficacy in controlling postoperative pain and decreasing opioid consumption. More randomized controlled trials are necessary to determine the surgical procedures and administrations (i.e., intravenous, epidural) that ketamine is best suited for.

In-office vasovagal response after rhinologic manipulation.

BACKGROUND: Advances in endoscopic sinus surgery have led to a greater number of in-office procedures away from the traditional operating room setting. Rhinologists acting independently of anesthesiologists must be prepared for potential complications, such as vasovagal response (VVR), that may arise during in-office rhinologic manipulations. In this study, we review our experience with this condition and discuss risk factors and a management algorithm for in-office VVR. METHODS: A retrospective analysis at a large tertiary referral center was performed on all patients undergoing in-office endoscopic procedures with rhinologic manipulation between July 2008 and June 2012. A total of 4973 patients underwent in-office endoscopic procedures and 8 patients with VVR were identified. Demographic data, diagnosis, procedure performed, and outcomes were reviewed. RESULTS: Eight patients out of 4973 (0.16%) experienced VVR during in-office endoscopic procedures. Seven (87.5%) of these 8 patients recovered from the VVR within 30 minutes and subsequently completed their scheduled procedure. One (12.5%) of the 8 patients did not fully recover after 30 minutes and was sent to the Emergency Department, where he was stabilized and subsequently discharged. The most common comorbidities in these 8 patients with VVR were hypercholesterolemia in 3 patients (37.5%), and hypertension and benign prostatic hyperplasia, each found in 2 patients (25.0%). CONCLUSION: Although the incidence of VVR during rhinologic procedures is low, rhinologists should be familiar with this condition and be prepared for its management.

Sinonasal adenoid cystic carcinoma: systematic review of survival and treatment strategies.

OBJECTIVE: This study reviews the published outcomes related to sinonasal adenoid cystic carcinoma (SNACC). Clinical presentation, radiographic diagnosis, pathology, treatment, and management outcomes of this uncommon disease are reported. Data Sources PubMed database. METHODS: A systematic review of studies for SNACC from 1960 to 2012 was conducted. A PubMed search for articles related to SNACC, along with bibliographies of those articles, was performed. Articles were examined for both individual patient data (IPD) and aggregate patient data (APD) that reported survivability. Demographics, disease site and spread, treatment strategies, follow-up, outcome, and survival were described for IPD, and a meta-analysis for survival rates was performed for APD. RESULTS: A total of 55 journal articles were included. Individual patient data were reported in 39 journal articles, comprising a total of 88 cases of SNACC. Sixteen articles, totaling 366 patients that reported aggregate 5-year survivorship pertaining to SNACC, were also included. Average follow-up in the IPD was 51.2 months (range, 1-198 months), and 5-year survivorship was 63.5%. In the studies reviewed, surgery followed by postoperative radiotherapy was the most common therapy used and resulted in the highest percentage of survivors. Aggregate patient data meta-analysis revealed a 5-year survival rate of 62.5%. CONCLUSION: This study contains the largest pool of SNACC patients to date. The data suggest that SNACC has a poor overall prognosis. It also suggests that surgery with postoperative radiotherapy is the most commonly used and may possibly be the most effective therapy.