Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

What Is the Optimal Management of Postdural Puncture Headache?

INTRODUCTION Despite advances in equipment and regional anesthetic techniques, postdural puncture headache (PDPH) remains a persistent problem. In some cases, the headache is mild in intensity and brief in duration, without significant sequelae; however, this is not always the case. PDPH is occasionally severe enough to leave patients bedridden and can delay hospital discharge. PDPH can be prolonged, with reports of symptoms lasting months or even…

When Should a Combined Spinal–Epidural Be Used?

INTRODUCTION The combined spinal–epidural (CSE) technique produces reliable and rapid onset of spinal anesthesia combined with the flexibility to extend the height and duration of a block provided by continuous epidural anesthesia. CSE has become a popular technique in both obstetrics and orthopedic surgery. CSE was originally described in 1979 , as a double-segment technique with the epidural and spinal procedures performed at different interspaces of…

Anesthesia for Cesarean Delivery—Regional or General?

INTRODUCTION The 2018 cesarean delivery rate in the United States was 31.9%, down slightly from its peak in 2009 of 32.9%. The most common indications for cesarean delivery include prior cesarean delivery, labor dystocia, abnormal/indeterminate fetal heart rate tracings, fetal malpresentation, multiple gestation, and fetal macrosomia. The cesarean delivery rate is likely to increase further because women are requesting an elective cesarean delivery even for their…

Does Neurologic Electrophysiologic Monitoring Affect Outcome?

INTRODUCTION Neurologic injury from surgery results in substantial increased morbidity, mortality, and cost. More importantly, it is devastating to patients and their families. Thus techniques to lessen, reverse, and even avoid neurologic injury are very valuable. Neurologic intraoperative electrophysiologic monitoring (NIOM) can identify impending or ongoing intraoperative injury, allowing for interventions. Changes to a patient’s neurologic electrophysiologic baseline during the procedure alert the operative team that…

Which Are the Best Techniques for Reducing the Incidence of Postoperative Deep Vein Thrombosis?

INTRODUCTION Venous thromboembolism (VTE) is a major public health issue. VTE remains one of the main causes of mortality. It is also associated with considerable morbidity because nonfatal pulmonary embolism (PE) and deep vein thrombosis (DVT) induce short- and long-term complications. , In addition, anticoagulant treatment, although effective, may be a potential source of iatrogenic complications. Nevertheless, the benefit/risk ratio of widespread postoperative prophylaxis is highly…

What Actions Can Be Used to Prevent Peripheral Nerve Injury?

INTRODUCTION Perioperative peripheral nerve injury is a significant source of morbidity for patients, and the second most frequent cause of professional liability for anesthesiologists, accounting for 12% of general anesthesia malpractice claims since 1990 according to the Anesthesia Closed Claims Database, funded by the Anesthesia Quality Institute, the quality wing of the American Society of Anesthesiologists (ASA). , The incidence of postoperative peripheral nerve dysfunction is…

Optimal Intraoperative Technique to Prevent Postoperative Delirium

INTRODUCTION Delirium after surgery is an increasing concern for older adults, caregivers, and health care providers. Approximately 37% of all surgical procedures are performed on patients over the age of 65 years in Western countries. In the United States, this represented over 19 million patients in 2010. Postoperative delirium (POD) is a common adverse cognitive event, occurring in up to 65% of older patients after anesthesia…

What Works for Brain Protection?

INTRODUCTION Despite recent advances in anesthesia techniques and monitoring measures, intraoperative and postoperative neurologic events remain the most devastating complications that continue to concern anesthesia providers. Even without any significant intraoperative events, there is a considerable risk for cerebral ischemia in specific surgical populations, such as in cardiac surgeries and vascular surgeries. The neurologic sequelae range from frank stroke to cognitive dysfunction. The incidence of perioperative…

Is There a Best Technique in the Patient With Increased Intracranial Pressure?

INTRODUCTION The contents of the cranium can be divided into three major constituents. The brain or tissue compartment accounts for approximately 85% of the total intracranial volume, cerebrospinal fluid (CSF) contributes approximately 10%, and the blood in the vasculature contributes approximately 5%. Most of the cerebral blood volume (CBV) resides in the low-pressure venous system, whereas only 15% of the CBV is found in the arteries…

Is There a Best Technique to Decrease Blood Loss and Transfusion After Coronary Artery Bypass Grafting?

INTRODUCTION The importance of excessive blood loss after coronary artery bypass grafting (CABG) is related to its significant association with deleterious perioperative outcomes, including all the risks of blood transfusion. Blood transfusion after CABG significantly increases mortality risk, ischemic morbidity (e.g., stroke, myocardial infarction, and renal failure), infections (e.g., wounds, pneumonia, and sepsis), hospital stay, and overall health costs. , The techniques for reducing bleeding and…

Should Regional Anesthesia Be Used for Orthopedic Trauma Patients?

INTRODUCTION Trauma is a major cause of morbidity and mortality worldwide and is the leading cause of death for individuals younger than 30 years of age in the United States. Perioperative and acute pain management for trauma victims can be challenging. Inadequate treatment of acute pain can potentiate the stress response associated with trauma, which may lead to the development of chronic pain syndromes. One study…

Is There a Best Analgesic Technique for Hip Surgery?

INTRODUCTION Anesthesia and analgesia for hip surgery present a great challenge, especially considering the patient demographic, namely the elderly with significant comorbidities such as cardiac disease, pulmonary disease, and renal insufficiency. All of these conditions can adversely affect surgical outcome. Therefore effective perioperative anesthesia and analgesia management is essential to decreasing morbidity and mortality and improving function recovery and long-term surgical outcome. Hip surgery is traditionally…

Deep Vein Thrombosis Prophylaxis With Heparin and Heparin-Like Drugs Used in Combination With Neuraxial Anesthesia and Deep Plexus Blocks

INTRODUCTION Early recovery after surgery (ERAS) and the current opioid pandemic have made health care providers and patients consider regional anesthesia (RA) options, including neuraxial anesthesia and nerve/nerve plexus blocks, as alternatives to traditional opioids. RA has been shown to be associated with additional benefits of lower volume of blood loss and transfusion rate, decreased perioperative infections such as pneumonia, and decreased length of stay. In…

Nonsteroidal Antiinflammatory Drugs, Antiplatelet Medications, and Spinal Axis Anesthesia

INTRODUCTION Many people use cyclooxygenase (COX)-1 and cyclooxygenase-2 (COX-2) inhibitors (nonsteroidal antiinflammatory drugs [NSAIDs]) on a regular basis. This is particularly true of the elderly, who are more prone to having osteoarthritis and rheumatoid diseases. The elderly are also more likely to have had cardiac stent placements or coronary angioplasties performed and to have vascular disease in general and so may take antiplatelet medications, such as…

Can We Prevent Recall During Anesthesia?

INTRODUCTION Three large prospective studies of the incidence of intraoperative awareness from Australia, Europe, and North America suggest that the overall rate is in the range of 0.1% to 0.2% or 1 to 2 per 1000 patients. Intraoperative awareness can be a minor or a major complication depending on the severity and the response of the individual patient; in severe cases posttraumatic stress disorder may occur.…

Fast-Track Cardiac Anesthesia: A Vital Core of Perioperative Cardiac Surgery Programs

INTRODUCTION Opioid-based anesthesia emerged as a safe and effective way to maintain hemodynamic stability in patients undergoing cardiac surgery in the early 1970s and used large doses (typically 0.5 mg/kg to 1.0 mg/kg) of long-acting opioids such as morphine. , The limitations of morphine-based cardiac anesthesia included delayed anesthetic emergence, prolonged postoperative mechanical ventilation, and histamine-induced hypotension. In response to these limitations, fentanyl-based anesthesia (typical doses…

Should Targeted Temperature Management Be Used Routinely After Intraoperative Cardiac Arrest?

INTRODUCTION More than 500,000 people experience cardiac arrest in the United States each year, and approximately half of these occur in the hospital environment. Resuscitation attempts are unsuccessful in the majority of cardiac arrest victims, although as many as 30% to 45% of patients achieve the restoration of circulatory function (return of spontaneous circulation [ROSC]). Even among those who are successfully resuscitated, many have a guarded…

Is Nitrous Oxide Associated With Outcome?

INTRODUCTION Nitrous oxide is the venerable elder statesman of anesthesia. Its use has been characterized by peaks and troughs of enthusiasm and controversy from its first use to the present day. The first documented synthesis of nitrous oxide is generally attributed to the clergyman scientist Joseph Priestly in 1772, although some have attributed its first isolation to a physician, Joseph Black, in 1767. Humphry Davy, a…

What Is the Best Means of Preventing Perioperative Renal Injury?

INTRODUCTION Perioperative acute kidney injury (AKI) is defined as a new onset of AKI within 7 days after surgery according to the Kidney Diseases: Improving Global Outcomes (KDIGO) criteria. It is associated with substantial short- and long-term complications, including, but not limited to, an increased risk for dying, a longer hospital stay, progression to chronic kidney disease (CKD), and considerably increased health care costs. Like all…

Does Perioperative Hyperglycemia Increase Risk? Should We Have Aggressive Glucose Control Perioperatively?

INTRODUCTION The prevalence of diabetes mellitus in the United States is such that in 2020, the Centers for Disease Control and Prevention (CDC) estimated that 26.9 million individuals, or 8.2% of the US population, carried a formal diagnosis of the condition. In the context of glycemic control in the perioperative period, our clinical bias is toward heightened awareness in this particular patient population where perturbations in…