Kenneth Keown (1917-1985): Innovator in Early Cardiac Anesthesiology.

Kenneth Keown, MD, was a forward-thinking anesthesiologist who developed techniques to allow the safe practice of cardiac anesthesia and opened the door for the future development of more complex intracardiac surgical procedures. His early successful protocols for cardiac anesthesiology and his wide-reaching education of others on these methods earned him the designation of "the grand old man of anesthesia for inside-the-heart surgery" at a young age. His contributions also extended to groundbreaking research in hypothermia, lidocaine uses as an antiarrhythmic, and advocacy for anesthesiology as a specialty. We highlight the accomplishments of Dr. Keown that may be unrecognized by those outside the field of cardiac anesthesiology, as they paved the way for the success of modern cardiac surgery.

Isomeric Carborane Neuromuscular Blocking Agents.

We synthesized a family of neuromuscular blocking agents (NMB) based on decamethonium, but containing a carborane cluster in the methylene chain between the two quaternary ammonium groups. The carborane cluster isomers o-NMB, m-NMB, and p-NMB were tested in animals for neuromuscular block and compared with agents used clinically: rocuronium and decamethonium. All three isomers caused reversible muscle weakness in mice as determined by grip strength and inverted screen tests, with a potency rank of p-NMB > rocuronium > decamethonium > m-NMB > o-NMB. The mechanism of action of the compounds was determined by using the in vitro rat phrenic nerve hemi-diaphragm preparation and electrophysiologic measurements in cells. Neostigmine reversed hemi-diaphragm weakness caused by the three isomers and rocuronium, but not succinylcholine. In electrophysiologic recordings of currents through acetylcholine receptor channels, the carborane compounds did not activate channel activity but did inhibit channel activation by acetylcholine. These results demonstrate that the carborane neuromuscular blocking agents are non-depolarizers in contrast to the depolarizing action of the parent compound.

Opiate Analgesics and the Perioperative Management of Patients with Obstructive Sleep Apnea.

As the rate of obesity and subsequently obstructive sleep apnea (OSA) continue to rise in North America and prescriptions for narcotic analgesics number in the tens of millions, it has become increasingly important to understand the interaction between OSA and opiate analgesics. Understanding the mechanism of action of opiate analgesics and the pathophysiology of OSA can help medical professionals understand the unique risks associated with pain management in this population of patients.

Pain management in the geriatric population.

Pain is a highly prevalent and clinically important problem in the elderly. Unfortunately, due to difficulties in assessing pain in geriatric patients, the complexities of multiple comorbidities, and the high prevalence of polypharmacy, many practitioners are reluctant to treat pain aggressively in this unique patient population. Safe and effective treatment therefore, requires a working knowledge of the physiologic changes associated with aging, the challenges of accurately assessing pain, the unique effects of common therapeutic agents upon the elderly as well as the importance of adjunctive therapies. The following review is intended to provide the practitioner with practical knowledge for safer and more effective treatment of pain.

Pain management mini-series part III. Procedural sedation for the non-anesthesia provider.

Diagnostic and therapeutic procedures performed outside of the operating room can necessitate the administration of sedation by non-anesthesia trained personnel. Risks associated with procedural sedation can be decreased through proper patient evaluation and selection. Understanding sedative pharmacology, dosing and delivery, monitoring and airway rescue techniques are essential to safely provide sedation. Supervision of sedation policies should occur via a carefully constructed sedation policy and ongoing sedation committee evaluation and review to ensure adequate patient care.

Pain management mini-series. Part II. Chronic opioid drug therapy: implications for perioperative anesthesia and pain management.

In the U.S., there is a growing percentage of chronic pain patients requiring surgery. Chronic pain patients require careful evaluation and planning to achieve appropriate acute pain management. Peri-surgical pain management often requires continuation of previously prescribed chronic pain modalities and careful selection of multimodal acute pain interventions. This article will provide a broad overview of chronic pain, definitions, and current recommendations for the treatment of perioperative pain in patients maintained on opioid therapy.