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2.
Anesth Analg ; 137(6): 1149-1153, 2023 12 01.
Article in English | MEDLINE | ID: mdl-37973129

ABSTRACT

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.


Subject(s)
Anesthesia , Anesthesiology , Humans , Operating Rooms , Critical Illness , Anesthesia/methods , Patient Care
4.
Anesthesiol Clin ; 41(3): 657-670, 2023 Sep.
Article in English | MEDLINE | ID: mdl-37516501

ABSTRACT

Although baby boomer generation accounts for a little more than 15% of the US population, the cohort represents a disproportionate percentage of patients undergoing surgery. As this group continues to age, a multitude of challenges have arisen in health care regarding the safest and most effective means of providing anesthesia services to these patients. Many elderly patients may be exquisitely sensitive to the effects of anesthesia and surgery and may experience cognitive and physical decline before, during, or after hospital admission. In this review article, the authors briefly examine the physiologic processes underlying aging and explore steps necessary to deliver safe, empathetic care.


Subject(s)
Anesthesia , Anesthesiology , Humans , Aged , Empathy , Aging , Delivery of Health Care
5.
J Appl Physiol (1985) ; 134(6): 1390-1402, 2023 06 01.
Article in English | MEDLINE | ID: mdl-37022962

ABSTRACT

Mechanical power can describe the complex interaction between the respiratory system and the ventilator and may predict lung injury or pulmonary complications, but the power associated with injury of healthy human lungs is unknown. Body habitus and surgical conditions may alter mechanical power but the effects have not been measured. In a secondary analysis of an observational study of obesity and lung mechanics during robotic laparoscopic surgery, we comprehensively quantified the static elastic, dynamic elastic, and resistive energies comprising mechanical power of ventilation. We stratified by body mass index (BMI) and examined power at four surgical stages: level after intubation, with pneumoperitoneum, in Trendelenburg, and level after releasing the pneumoperitoneum. Esophageal manometry was used to estimate transpulmonary pressures. Mechanical power of ventilation and its bioenergetic components increased over BMI categories. Respiratory system and lung power were nearly doubled in subjects with class 3 obesity compared with lean at all stages. Power dissipated into the respiratory system was increased with class 2 or 3 obesity compared with lean. Increased power of ventilation was associated with decreasing transpulmonary pressures. Body habitus is a prime determinant of increased intraoperative mechanical power. Obesity and surgical conditions increase the energies dissipated into the respiratory system during ventilation. The observed elevations in power may be related to tidal recruitment or atelectasis, and point to specific energetic features of mechanical ventilation of patients with obesity that may be controlled with individualized ventilator settings.NEW & NOTEWORTHY Mechanical power describes the complex interaction between a patient's lungs and the ventilator and may be useful in predicting lung injury. However, its behavior in obesity and during dynamic surgical conditions is not understood. We comprehensively quantified ventilation bioenergetics and effects of body habitus and common surgical conditions. These data show body habitus is a prime determinant of intraoperative mechanical power and provide quantitative context for future translation toward a useful perioperative prognostic measurement.


Subject(s)
Lung Injury , Pneumoperitoneum , Humans , Respiratory Mechanics , Lung , Respiration, Artificial , Obesity/surgery , Tidal Volume
6.
Anesthesiol Clin ; 41(1): 303-316, 2023 Mar.
Article in English | MEDLINE | ID: mdl-36872006

ABSTRACT

A second epidemic of burnout, fatigue, anxiety, and moral distress has emerged concurrently with the coronavirus disease 2019 (COVID-19) pandemic, and critical care physicians are especially affected. This article reviews the history of burnout in health care workers, presents the signs and symptoms, discusses the specific impact of the COVID-19 pandemic on intensive care unit caregivers, and attempts to identify potential strategies to combat the Great Resignation disproportionately affecting health care workers. The article also focuses on how the specialty can amplify the voices and highlight the leadership potential of underrepresented minorities, physicians with disabilities, and the aging physician population.


Subject(s)
COVID-19 , Physicians , Humans , Pandemics , Health Personnel , Intensive Care Units
7.
Semin Cardiothorac Vasc Anesth ; 27(1): 42-50, 2023 Mar.
Article in English | MEDLINE | ID: mdl-36473032

ABSTRACT

Preoperative cardiac evaluation is a cornerstone of the practice of anesthesiology. This consists of a thorough history and physical attempting to elucidate signs and symptoms of heart failure, angina or anginal equivalents, and valvular heart disease. Current guidelines rarely recommend preoperative echocardiography in the setting of an adequate functional capacity. Many patients may have poor functional capacity and/or have medical history such that echocardiographic data is available for review. Much focus is often placed on evaluating major valvular abnormalities and systolic function as measured by ejection fraction, but a key impactful component is often overlooked-diastolic function. A diagnosis of diastolic heart failure is an independent predictor of mortality and is not uncommon in patients with normal systolic function. This narrative review addresses the clinical relevance and management of diastolic dysfunction in the perioperative setting.


Subject(s)
Heart Failure , Ventricular Dysfunction, Left , Humans , Heart , Echocardiography , Diastole , Stroke Volume
8.
Anesth Analg ; 135(5): e39-e40, 2022 11 01.
Article in English | MEDLINE | ID: mdl-36269995

Subject(s)
Critical Care , Humans
11.
J Trauma Acute Care Surg ; 87(2): 430-439, 2019 Aug.
Article in English | MEDLINE | ID: mdl-30939572

ABSTRACT

Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.


Subject(s)
Opioid Epidemic , Pain Management , Wounds and Injuries/therapy , Acute Pain/therapy , Analgesics/therapeutic use , Chronic Pain/therapy , Humans , Opioid Epidemic/prevention & control , Pain Management/methods , Wounds and Injuries/complications
13.
Plast Reconstr Surg ; 136(4): 868-881, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26090761

ABSTRACT

BACKGROUND: Repair of hernias with loss of domain can lead to elevated intraabdominal pressure. The authors aimed to characterize the effects of elective hernia repair on intraabdominal pressure, as well as its predictors and association with negative outcomes. METHODS: Patients undergoing elective hernia repair requiring myofascial release had intraabdominal and pulmonary plateau pressures measured preoperatively, postoperatively, and on the morning of the first postoperative day. Loss of domain was measured by preoperative computed tomography. Outcome measures included predictors of an increase in plateau pressure, respiratory complications, and acute kidney injury. RESULTS: Following 50 consecutive cases, diagnoses of intraabdominal hypertension (92 percent), abdominal compartment syndrome (16 percent), and abdominal perfusion pressure less than 60 mmHg (24 percent) were determined. Changes in intraabdominal pressure (preoperative, 12.7 ± 4.0 mmHg; postoperative, 18.2 ± 5.4 mmHg; postoperative day 1, 12.9 ± 5.2 mmHg) and abdominal perfusion pressure (preoperative, 74.7 ± 15.7; postoperative, 70.0 ± 14.4; postoperative day 1, 74.9 ± 11.6 mmHg) consistently resolved by postoperative day 1, and were not associated with respiratory complications or acute kidney injury. Patients who remained intubated postoperatively for an elevation in pulmonary plateau pressure (≥6 mmHg) all demonstrated an improvement in plateau pressure by postoperative day 1 (preoperative, 18.9 ± 4.5 mmHg; postoperative, 27.4 ± 4.0 mmHg; postoperative day 1, 20.1 ± 3.7 mmHg), and could be identified preoperatively as having a hernia volume of greater than 20 percent of the abdominal cavity (p < 0.001), but were still more likely to have postoperative respiratory events (p = 0.01). CONCLUSIONS: Elevated intraabdominal pressure following elective hernia repair requiring myofascial releases is common but transient. Change in plateau pressure by 6 mmHg or more following repair can be expected with a loss of domain greater than 20 percent and is a more useful surrogate than intraabdominal pressure measurements with regard to predicting postoperative pulmonary complications. The perception and management of elevated intraabdominal pressure should be considered distinct and "permissible" in this context.


Subject(s)
Abdominal Wall/surgery , Elective Surgical Procedures , Herniorrhaphy , Intra-Abdominal Hypertension/etiology , Postoperative Complications , Adult , Aged , Elective Surgical Procedures/methods , Female , Herniorrhaphy/methods , Humans , Intra-Abdominal Hypertension/diagnosis , Intra-Abdominal Hypertension/physiopathology , Male , Middle Aged , Outcome Assessment, Health Care , Postoperative Complications/diagnosis , Postoperative Complications/physiopathology , Prospective Studies
14.
Crit Care Clin ; 30(3): 527-55, 2014 Jul.
Article in English | MEDLINE | ID: mdl-24996608

ABSTRACT

The care of the cardiac surgical patient postoperatively is fraught with several complications because of the nature of the surgical procedure itself and the common comorbidities of this patient population. Most complications occurring in the immediate postoperative period are categorized by organ system, and their pathophysiology is presented. Current diagnostic approaches and treatment options are offered. Preventive measures, where appropriate, are also included in the discussion.


Subject(s)
Cardiac Surgical Procedures/adverse effects , Heart Diseases/surgery , Postoperative Care/methods , Postoperative Complications/etiology , Postoperative Complications/therapy , Acute Kidney Injury/etiology , Acute Kidney Injury/therapy , Comorbidity , Gastrointestinal Diseases/etiology , Gastrointestinal Diseases/therapy , Heart Diseases/epidemiology , Hematologic Diseases/etiology , Hematologic Diseases/therapy , Humans , Lung Diseases/etiology , Lung Diseases/therapy , Nervous System Diseases/etiology , Nervous System Diseases/therapy , Postoperative Care/standards , Postoperative Complications/epidemiology , Practice Guidelines as Topic , Surgical Wound Infection/etiology , Surgical Wound Infection/therapy , Vasoplegia/etiology , Vasoplegia/therapy
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