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December 2009, Volume 109, Issue 6
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It is a myth that a frog will stay in a pot of hot water until it dies if the pot is heated slowly enough. Does the rate of rewarming following hypothermic cardiopulmonary bypass affect outcome, with slower rewarming improving neurologic outcome? Or is that also a myth? We don't know, which is why the relationship between rate of rewarming following hypothermic cardiopulmonary bypass and neurological outcome is debated in this issue of Anesthesia & Analgesia. |
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November 2009, Volume 109, Issue 5
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Sellick's maneuver doesn't compress the esophagus at all, because the esophagus begins lower in the hypopharynx than the cricoid ring. As shown by Rice and Colleagues in this issue of Anesthesia & Analgesia, Sellick's maneuver compresses the hypopharynx. Compressing the hypopharynx occludes the alimentary lumen, which limits air entry into the stomach during mask ventilation, and also limits passive regurgitation. Unfortunately, most clinicians don't know how much force is required to compress the hypopharynx, and apply too little, which may do nothing at all, or too much, which may impede ventilation and intubation. Editorials in this issue of Anesthesia & Analgesia review the remarkable anatomic findings of Rice and colleagues, and reach differing conclusions on the utility of Sellick's maneuver. |
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October 2009, Volume 109, Issue 4
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Malignant Hyperthermia is the theme of this issue of Anesthesia & Analgesia. We have understood for decades that malignant hyperthermia is primarily due to genetic defects of the ryanodine receptor, pictured on the cover. One might think that identification of causative mutations and the resulting changes in amino acid sequence would bring great clarity to our understanding of MH. As shown in this issue of Anesthesia & Analgesia, that is not the case. There continues to be considerable uncertainty about the spectrum of MH, the diagnosis of MH, and the association of MH with other genetic disorders and environmental influences. |
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September 2009, Volume 109, Issue 3
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Few medical decisions are as sensitive as withdrawing life support for patients in the Intensive Care Unit. As our technology becomes more advanced, and we are able to transiently delay death in even the most hopeless of settings, physicians struggle to properly engage patients and their families with these difficult end-of-life decisions. This issue of Anesthesia & Analgesia captures how this challenge is handled in two ICUs in the Netherlands. |
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August 2009, Volume 109, Issue 2
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Mixtures of local anesthetics and opioids have become an accepted standard for continuous epidural analgesia. Several decades of basic research, animal studies, and clinical trials have established the rationale for using neostigmine, rather than opioids, to supplement local anesthetics in epidural anesthesia. One research paper and three accompanying editorials in this month's issue of Anesthesia & Analgesia contribute and provide perspective on the ongoing development of neostigmine as an alternative adjuvant to opioids for neuraxial anesthesia. |
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July 2009, Volume 109, Issue 1
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Every conceivable complication of central venous line placement has been reported in the medical literature, including unintentional catheterization of nearly every organ in the thorax. Several papers and editorials in this issue of the Journal explore whether changes in practice can reduce the occasional "oops" during central venous catheterization. |
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June 2009, Volume 108, Issue 6
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Sevoflurane is not a benign molecule. Sevoflurane can react with metallic “Lewis acids”, in particular iron, to produce hydrogen fluoride, a highly toxic gas. Water suppresses this reaction. An article in this issue of Anesthesia & Analgesia demonstrates that with certain vaporizers, in certain circumstances, “dry” sevoflurane can produce enough hydrogen sulfide to etch the glass window. An accompanying editorial highlights the importance of ensuring that sevoflurane does not come into contact with exposed metals at any time during its manufacturing, transport, storage, or administration. |
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May 2009, Volume 108, Issue 5
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It has been 50 years since cardiopulmonary bypass was introduced into clinical practice. As shown in two reviews in this month’s issue of Anesthesia & Analgesia, and well-summarized in the accompanying editorial by Drs. Oakes and Mora-Mangano, we have still not identified best practices. Fundamental questions such as pH-stat vs. alpha-stat acid-base management remain unanswered, as well as how to eliminate the risk of embolic injury. The only way to reduce the morbidity of cardiopulmonary bypass is through a combination of ongoing research and improved extracorporeal circulatory technology. |
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April 2009, Volume 108, Issue 4
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Using light to measure arterial oxygen saturation has become routine in clinical medicine. However, it is organ oxygen content, not arterial oxygen content, that is critically important. Several articles in this month’s issue of Anesthesia & Analgesia explore new tissue oximetry technologies for detecting brain and heart hypoxia–shining a light through the body to “see” the oxygen levels in tissues. The curves on the screen depict the extinction curves for oxyhemoglobin and reduced hemoglobin, which are the basis of modern oximetry. |
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March 2009, Volume 108, Issue 3
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Case durations, like ballgames, are stochastic. A single number is insufficient to describe the expected duration. Sometimes the shortest possible duration is the number you should use (for example, deciding when to arrive at the ballpark for the second game in a double header). Sometime the longest possible duration is the right number to use (for example, promising when you will be home after the first game). The average duration is only useful for deciding whether you can schedule a triple header. As explained in this issue of Anesthesia & Analgesia, simple statistical approaches provide realistic case duration numbers for the shortest, average, and longest durations, thereby improving operating room and personnel scheduling. |
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February 2009, Volume 108, Issue 2
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The October 2007 cover on physician diversion of drugs was redrawn from Despair by Edvard Munch. The Scream is Munch’s most famous work, and here highlights the deep concern within the anesthesia community for intraoperative awareness, particularly awareness of pain, a rare but potentially devastating complication. Two articles and an accompanying editorial in this issue of Anesthesia & Analgesia explore the extent of intraoperative awareness, identify risk factors, and underscore the challenges we face in understanding the true incidence of intraoperative awareness. |
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January 2009, Volume 108, Issue 1
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Two papers in this issue of Anesthesia & Analgesia observe that suppression / downregulation of the β2-adrenergic receptor may protect the brain from ischemic injury. As the editorial observes, the data on β2-adrenergic receptor activity and cerebral ischemia are conflicting. The cover denotes the possibility, and present ambiguity, of protecting the brain from ischemic injury by downregulation or inhibition of the β2-adrenergic receptor, rendered in green (courtesy of Wikipedia). |
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December 2008, Volume 107, Issue 6
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The August 27, 2006 issue of Time Magazine featured “How Veterans’ Hospitals Became the Best in Health Care.” VA research has been part of this tradition of excellence. In the 1940’s Department of Veterans Affairs research identified effective treatments for schizophrenia, diabetes, depression, heart disease, and stroke. Subsequent VA research led to the invention of the pacemaker and CT scanner. The VA Cooperative Study conclusively demonstrated that lowering blood pressure reduced the risk of stroke, congestive heart failure, and kidney failure. Started in the early 1990s, the VA’s National Surgical Quality Improvement Program has created a gold mine of information on patient risk factors and outcomes. Clinically and scientifically, the VA Health Care System is a national treasure. |
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November 2008, Volume 107, Issue 5
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Hannenberg and Sessler, “the use of infrared aural canal thermometry is incompatible with valid performance measurement under the proposed normothermia measure.” In other words, hospitals that rely on infrared aural canal thermometry may find themselves doing no better than chance at meeting the ASA’s proposed thermal management measures—an outcome with direct financial consequences if adopted by Medicare as a “pay for performance” standard. As suggested by the cover, games of chance are rarely associated with a positive financial outcome. |
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October 2008, Volume 107, Issue 4
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Memantine is an non-hallucinogenic NMDA antagonist approved for treatment of Alzheimer’s disease. As explained in this issue of Anesthesia & Analgesia, the mixed results of memantine treatment for neuropathic pain may reflect the need to start therapy immediately after injury. The data are limited, and further clinical trials are needed to characterize memantine’s role in pain management. |
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September 2008, Volume 107, Issue 3
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This issue of Anesthesia & Analgesia presents a novel hypothesis: we can study the mechanism of inhaled anesthetics through the lens of evolution. The cover depicts the logical corollary: seeing evolution through the lens of general anesthesia. If the hypothesis proves true, and insight is gained into the mechanism of inhaled anesthetic action by understanding the remarkable conservation of anesthetic sensitivity in distantly related forms of life, then the mechanism of anesthetic action in turn may reveal fundamental shared properties of all cellular organisms. |
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August 2008, Volume 107, Issue 2
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This issue of Anesthesia & Analgesia documents palonosetron’s unique interaction with the 5-HT3 receptor, an interaction that qualifies palonosetron as a new generation 5-HT3 antagonist for treatment of nausea and vomiting. Clinical trials in this issue document the potential for a single dose of palonosetron to provide prolonged prophylaxis against nausea and vomiting. In the cover graphic, palonosetron (named after Palo Alto, California) is being ushered as a new generation drug into anesthetic practice by the first generation 5-HT3 antagonists, ondansetron (pulling the wagon) and dolasetron. |
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July 2008, Volume 107, Issue 1
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While pregnancy remains at the top of the “gender specific” anesthetic considerations, men and women differ in many aspects of perioperative physiology and pharmacology. There are culturally transmitted beliefs that also influence perioperative care, such as the pervasive belief that woman are at decreased risk of coronary artery disease. This issue of Anesthesia & Analgesia explores the relationships between gender and physiology, pharmacology, anesthetic response, anesthetic risk, and academic advancement. |
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June 2008, Volume 106, Issue 6
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Do anesthetics pose a risk of neurologic injury to young children? This
issue of the Journal wrestles with this question in a series of reviews,
special articles, and a pro-con debate. Science and public policy are
major forces driving this debate. It will take many years to know the
answer, but reality always wins. |
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May 2008, Volume 106, Issue 5
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Many studies demonstrate the utility of lipid emulsions in treating the cardiovascular effects of local anesthetic overdose, including a collection of papers in this month’s issue of Anesthesia & Analgesia. On the basis of these findings, anesthesiology departments should stock lipid emulsions in all clinical settings where large doses of local anesthetics are injected. Lipids to the rescue! |
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April 2008, Volume 106, Issue 4
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How do you assess intravascular volume? New algorithms improve the utility of respiratory variation in arterial blood pressure as a measure of intravascular volume status.
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March 2008, Volume 106, Issue 3
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Medical advances take many forms: better drugs, better devices, and better delivery
of health care to patients. In Zambia some hospitals are so poor that they wash
their "disposable" latex gloves. Our enthusiasm for scientific progress must not
blind us to the need for progress in providing basic anesthesia services to the
world's poor. Photograph by Eva-Susanne Ehrenreich.
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February 2008, Volume 106, Issue 2
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Dr. Paul Janssen discovered of more than 80 pharmaceuticals, including fentanyl,
sufentanil, alfentanil, etomidate, droperidol, and haloperidol. As patients we may
have benefited from diphenoxylate (Lomotil), loperamide (Imodium),
miconazole, ketoconazole, levamisole, lorcainide, astemizole, cisapride,
and risperidone. Dr. Janssen passed away in 2003, but still contributes to the
lives of our patients.
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January 2008, Volume 106, Issue 1
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It has long been recognized that alcohol in moderate doses is
good for the heart. It is also known that volatile anesthetics
protect the heart from ischemic injury. Not only do the mechanisms
of cardioprotection for alcohol and volatile anesthetics overlap,
but volatile anesthetic further enhances the protection against
ischemic injury provided by regular alcohol consumption.
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December 2007, Volume 105, Issue 6
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Spinal surgery is frequently performed to alleviate low back pain,
but with variable success. Diagnostic spinal injections have been
used to predict the outcome of surgical intervention and decrease the
incidence of failed back surgery. Available data suggest that the
ability of diagnostic spinal injections to predict surgical outcome
is more "Wheel of Fortune" than accurate scientific forecasting.
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November 2007, Volume 105, Issue 5
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Pain is hell. The cover depicts the banishment of Pain, represented by a
well recognized figure from the triptych "The Garden of Earthly Delights"
by the Dutch painter Hieronymus Bosch. This issue of Anesthesia & Analgesia
features 7 articles describing scientific efforts to banish pain from the
lives of our patients.
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October 2007, Volume 105, Issue 4
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The cover is an adaptation of "Despair" by Edvard Munch (1893) to convey
the hopelessness of the addicted physician. Articles in this issue of Anesthesia
& Analgesia describe how physician diversion of drugs is detected through
electronic medical information systems. The electronic milieu that detected
diversion is suggested by the "Matrix" background, and contains readable messages.
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September 2007, Volume 105, Issue 3
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The melting brains in the airless environment suggest hypoxic brain injury.
This allusion to Salvador Dal's "The Persistence of Memory" suggests that
memory, a critical component of cognition, will survive, and is used to highlight
a remarkable study demonstrating protection and partial reversal of hypoxic
brain injury in this issue of Anesthesia & Analgesia.
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August 2007, Volume 105, Issue 2
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Children instinctually rely on adults to protect them, as suggested by
the tiny hand clutching the gloved fingers. This issue of Anesthesia &
Analgesia examines cardiac arrest in children, and reminds us that we
have inadequate outcome data to precisely guide our efforts
to reduce anesthesia morbidity and mortality. (The child is clutching
his father's hand).
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July 2007, Volume 105, Issue 1
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Millions have a drug problem: they can't get any. In Uganda, non-governmental
organizations and the government cooperated to make morphine available in
palliative care. Photo: WHO, Marko Kokic. A landmark treatise in this issue
of Anesthesia & Analgesia explores pain management as a universal human right.
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June 2007, Volume 104, Issue 6
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"In one ear and out the other" is the title of an editorial in this issue of
Anesthesia & Analgesia. The associated case report describes how physicians
failed to pass along information that a patient's glucose could not be monitored
at the bedside. Their insulin titration, based on falsely elevated readings,
killed the patient. Failure to listen can be deadly.
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May 2007, Volume 104, Issue 5
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Is ultrasound imaging the "holy grail" (see screen) for providing fast and
reliable nerve blocks? Or is it just another fad, like 3D glasses 50 years ago?
This question is explored in this issue of Anesthesia & Analgesia.
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April 2007, Volume 104, Issue 4
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According to church elders, scripture is unclear about whether Jehovah's Witnesses
can receive "fractions of fractions" derived from blood. Patient must decide
for themselves. Three editorials, from individuals with divergent views
on transfusion in Jehovah's Witnesses, all reach the same conclusion: the decision
of the patient must be respected.
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March 2007, Volume 104, Issue 3
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Sugammadex permanently binds rocuronium and vecuronium, like a black hole that
irreversibly draws in light and matter. The cover shows a black hole, ringed by
a molecule of sugammadex. The molecules on the cover are rocuronium (purple) and
a single molecule of vecuronium (blue). The molecular coordinates of sugammadex,
rocuronium, and vecuronium are based on x-ray crystallography, and were
supplied by Organon Pharmaceuticals.
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February 2007, Volume 104, Issue 2
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This issue of Anesthesia & Analgesia explores two forms of alternative
medicine: acustimulation and magnetic therapy. There are data suggesting
efficacy of acustimulation (acupuncture and acupressure) in several
clinical settings. There is no setting in which static
magnets have reproducibly demonstrated efficacy.
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January 2007, Volume 104, Issue 1
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The stress of anesthesia and surgery has been compared to a marathon. Do beta blockers
help patients cross the finish line? Maybe, but some patients on placebo do well,
while others (check out the background) fall short. This issue of Anesthesia & Analgesia explores
the data around perioperative beta-blockade. Northern California residents will
recognize the allusion to the "Bay to Breakers" race held yearly in San Francisco.
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December 2006, Volume 103, Issue 6
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The operating schedule is like a large elephant that must be moved through
the constraints imposed by the available resources. This issue of Anesthesia
& Analgesia explores the importance of matching operating room resources to
clinical needs, which can often be done through rational rearrangement of
existing resources.
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November 2006, Volume 103, Issue 5
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Recent data, and an FDA advisory meeting, have left clinicians with a difficult
choice regarding aprotinin. If they give aprotinin, they may damage organs. If
they don't, patients may require extensive transfusion. This issue of Anesthesia
& Analgesia explores the controversy surrounding aprotinin.
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October 2006, Volume 103, Issue 4
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Our colleagues occasionally complain about the
amount of time required for resident teaching. How much time is typically added to a
case when it involves teaching? As explained in a series of papers
in this issue of Anesthesia & Analgesia, just 4.5 minutes. The cover is not
posed, but shows our Correspondence Editor, Dr. Lawrence Saidman, teaching
a Stanford resident.
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September 2006, Volume 103, Issue 3
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Dolphins require regular sleep, just like all mammals. They also need to
continually swim, be on the lookout for predators, and surface for air. As discussed
in this issue of Anesthesia & Analgesia, half of the dolphin brain sleeps at a time,
as shown by the two BIS monitors, one monitoring the awake side in the water, and one
monitoring the sleeping side in the stars.
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August 2006, Volume 103, Issue 2
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As suggested by the "isoflurane purple" umbrella, inhaled anesthetics provide protection
to both the heart and the brain from adverse conditions. This issue of Anesthesia & Analgesia offers
recent research results on the mechanism of cardioprotection and neuroprotection.
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July 2006, Volume 103, Issue 1
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The children playing on the dexmedetomidine molecule appear to be enjoying
themselves, but they are precariously placed. The "not approved in children"
appears like a warning sign in a park: all too readily ignored.
This issue of Anesthesia & Analgesia
explores the safety of dexmedetomidine in children, and the complex issues
involved in studying drugs in vulnerable patients.
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Covers and Artwork copyright 2006 International Anesthesia Research Society
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