Physicians, including anesthesiologists, are working later in life. This issue contains an original investigation and editorial regarding assessment of competency and educational needs of the older anesthesiologist.

  • Warner: More Than Just Taking the Keys Away …, p. 501

  • Tessler et al. : Association between Anesthesiologist Age and Litigation, p. 574

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More Than Just Taking the Keys Away … 501

Mark A. Warner 

Getting Oil and Water to Mix 504

Evan D. Kharasch 

Neurotoxicity and the Need for Anesthesia in the Newborn: Does the Emperor Have No Clothes? 507

Andrew J. Davidson 

Surgery and the Plastic Brain 510

Michael S. Avidan and Tammie L. Benzinger 

Preoperative Transfusions to Limit the Deleterious Effects of Blood Transfusions 513

Jean-Louis Vincent and Christophe Lelubre 

Videolaryngoscopes: Do They Truly Have Roles in Difficult Airways? 515

Takashi Asai 

Reconstructing Deconstructed Blood for Trauma 518

Richard B. Weiskopf 

Practice Advisory for Preanesthesia Evaluation: An Updated Report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation 522

The American Society of Anesthesiologists Committee on Standards and Practice Parameters presents an updated report of the Practice Advisory for Preanesthesia Evaluation. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT 

Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access 539

The American Society of Anesthesiologists Committee on Standards and Practice Parameters presents a report of the Practice Guidelines for Central Venous Access. The Guidelines focus on the prevention of infectious complications and prevention and treatment of major vascular injury. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT 

Association between Anesthesiologist Age and Litigation 574

Michael J. Tessler, Ian Shrier, and Russell J. Steele 

Three age groups of Canadian anesthesiologists, from postresidency to retirement, were examined for frequency of litigation. The oldest group had the highest frequency of litigation and greatest severity of injury in the litigations pursued.

Exceptionally Stable Fluorous Emulsions for the Intravenous Delivery of Volatile General Anesthetics 580

Jun-Pil Jee, Maria C. Parlato, Mark G. Perkins, Sandro Mecozzi, and Robert A. Pearce 

A new dibranched fluorinated polymer allows the formation of exceptionally stable emulsions for the intravenous delivery of sevoflurane.

Delayed Environmental Enrichment Reverses Sevoflurane-induced Memory Impairment in Rats 586

Jennifer Shih, Laura D. V. May, Heidi E. Gonzalez, Elaine W. Lee, Rehan S. Alvi, Jeffrey W. Sall, Vinuta Rau, Philip E. Bickler, Gopal R. Lalchandani, Marianna Yusupova, Elliott Woodward, Heejae Kang, Alan J. Wilk, Colleen M. Carlston, Mortay V. Mendoza, Jeremy N. Guggenheim, Maximilian Schaefer, Allison M. Rowe, and Greg Stratmann 

Behavioral consequences of anesthesia-induced developmental neurotoxicity are treatable. Sevoflurane, but not tissue injury, caused a short-term memory deficit that was reversed by delayed environmental enrichment.

Surgery and Brain Atrophy in Cognitively Normal Elderly Subjects and Subjects Diagnosed with Mild Cognitive Impairment 603

Richard P. Kline, Elizabeth Pirraglia, Hao Cheng, Susan De Santi, Yi Li, Michael Haile, Mony J. de Leon, and Alex Bekker; for the Alzheimer's Disease Neuroimaging Initiative 

The authors explored postoperative changes in brain volume (total gray matter and hippocampus) and cognition using the Alzheimer's Disease Neuroimaging Initiative database. Analyzed regions showed increased rates of atrophy in surgical versus  nonsurgical subjects.

Advance Targeted Transfusion in Anemic Cardiac Surgical Patients for Kidney Protection: An Unblinded Randomized Pilot Clinical Trial 613

Keyvan Karkouti, Duminda N. Wijeysundera, Terrence M. Yau, Stuart A. McCluskey, Christopher T. Chan, Pui-Yuen Wong, Mark A. Crowther, Siroos Hozhabri, and W. Scott Beattie 

In 60 anemic cardiac surgical patients, prophylactic transfusion of 2 erythrocyte units 1 to 2 days before surgery reduced perioperative anemia and erythrocyte transfusions. Studies assessing the renal protective effects of this intervention are warranted.

A Prospective Randomized Equivalence Trial of the GlideScope Cobalt® Video Laryngoscope to Traditional Direct Laryngoscopy in Neonates and Infants 622

John E. Fiadjoe, Harshad Gurnaney, Nicholas Dalesio, Emily Sussman, Huaqing Zhao, Xuemei Zhang, and Paul A. Stricker 

In a population of healthy infants with normal airway anatomy, tracheal intubation was performed with similar times and success rates using the GlideScope Cobalt® video laryngoscope (Verathon Medical, Bothell, WA) as compared with direct laryngoscopy with a Miller 1 blade.

Comparative Effectiveness of the C-MAC Video Laryngoscope versus  Direct Laryngoscopy in the Setting of the Predicted Difficult Airway 629

Michael F. Aziz, Dawn Dillman, Rongwei Fu, and Ansgar M. Brambrink 

A randomized controlled trial that compared conventional Macintosh blade laryngoscopy with the C-MAC® video laryngoscope (Karl Storz, Tuttlingen, Germany) in patients presenting with a predicted difficult airway found that using the C-MAC video laryngoscope improves intubation success at first attempt.

Pulmonary Hypertension in Lambs Transfused with Stored Blood Is Prevented by Breathing Nitric Oxide 637

David M. Baron, Binglan Yu, Chong Lei, Aranya Bagchi, Arkadi Beloiartsev, Christopher P. Stowell, Andrea U. Steinbicker, Rajeev Malhotra, Kenneth D. Bloch, and Warren M. Zapol 

In this study, an ovine model of autologous blood storage and transfusion was developed. The model was utilized to examine the hemodynamic effects of blood transfusion after storage of erythrocytes for prolonged periods. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT 

Choice of Anesthetic Combination Determines Ca2+Leak after Ischemia-Reperfusion Injury in the Working Rat Heart: Favorable versus  Adverse Combinations 648

Michael Zaugg, Lianguo Wang, Liyan Zhang, Phing-How Lou, Eliana Lucchinetti, and Alexander S. Clanachan 

The choice of anesthetic combination determines the postischemic sarcoplasmic Ca2+leak and intracellular Ca2+overload after ischemia-reperfusion injury in the working rat heart. Propofol antagonizes sevoflurane protection but does not block remifentanil protection. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT 

Intraoperative Hypotension and Perioperative Ischemic Stroke after General Surgery: A Nested Case-control Study 658

Jilles B. Bijker, Suzanne Persoon, Linda M. Peelen, Karel G. M. Moons, Cor J. Kalkman, L. Jaap Kappelle, and Wilton A. van Klei 

This study supports the hypothesis that intraoperative hypotension, especially when defined as a decrease in mean blood pressure relative to baseline, can influence the evolution of postoperative strokes by compromising blood flow to ischemic areas.

Continuous Femoral Nerve Blocks: Decreasing Local Anesthetic Concentration to Minimize Quadriceps Femoris Weakness 665

Maria Bauer, Lu Wang, Olusegun K. Onibonoje, Chad Parrett, Daniel I. Sessler, Loran Mounir-Soliman, Sherif Zaky, Viktor Krebs, Leonard T. Buller, Michael C. Donohue, Jennifer E. Stevens-Lapsley, and Brian M. Ilfeld 

For continuous femoral nerve blocks, the authors found no evidence that local anesthetic concentration and volume influence block characteristics, specifically quadriceps weakness, suggesting that local anesthetic dose (mass) is the primary determinant of perineural infusion effects.

Xenon Attenuates Hippocampal Long-term Potentiation by Diminishing Synaptic and Extrasynaptic N -methyl-D-aspartate Receptor Currents 673

Stephan Kratzer, Corinna Mattusch, Eberhard Kochs, Matthias Eder, Rainer Haseneder, and Gerhard Rammes 

In acute murine hippocampal brain slices, the inhalational anesthetic xenon impaired long-term potentiation and N -methyl-D-aspartate receptor-mediated neurotransmission.

Influence of Supervision Ratios by Anesthesiologists on First-case Starts and Critical Portions of Anesthetics 683

Richard H. Epstein and Franklin Dexter 

The number of operating rooms that an anesthesiologist can supervise concurrently is determined by the probability of multiple simultaneous critical portions of cases (i.e. , requiring presence) and the availability of cross-coverage. The timing and duration of critical portions of cases was determined from 1 yr of data at a tertiary care hospital and the percentages of days with at least one supervision lapse occurring at supervision ratios between 1:1 and 1:3 were determined. Even at a supervision ratio of 1:2, lapses occurred on 35% of days. Decreasing the supervision ratio from 1:2 to 1:3 has a large impact on supervision lapses during first case starts. These lapses occur even after excluding case starts, lunch relief, and breaks. To mitigate morning lapses, either staggered starts or additional anesthesiologists working at the start of the day would be required.

Molecular Changes Induced in Rat Liver by Hemorrhage and Effects of Melanocortin Treatment 692

Caterina Lonati, Andrea Sordi, Daniela Giuliani, Luca Spaccapelo, Patrizia Leonardi, Andrea Carlin, Alessandra Ottani, Maria Galantucci, Paolo Grieco, Anna Catania, and Salvatore Guarini 

Melanocortins restore blood pressure, reverse metabolic acidosis, and prevent hemorrhage-induced alterations in liver gene expression. Melanocortins could be an effective adjunctive therapy in hemorrhagic shock. SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE IN THE TEXT 

Adventures in Anesthetic Mechanisms 701

Joseph F. Antognini 

This article is a revisiting of original material published as: Antognini JF, Schwartz K: Exaggerated anesthetic requirements in the preferentially anesthetized brain. ANESTHESIOLOGY 1993; 79:1244–9.

Case Scenario

Postoperative Liver Failure after Liver Resection in a Cirrhotic Patient 705

Catherine Paugam-Burtz, Julia Wendon, Jacques Belghiti, and Jean Mantz 

Management of postoperative liver failure after liver resection for hepatocellular carcinoma in a cirrhotic patient is highlighted.

Images in Anesthesiology

A Proposal to Minimize Work Area Contamination during Induction 712

Elise M. Mecham and Harriet W. Hopf 

Anesthesia Literature Review 713

Review Article

Prevalence of Survivor Bias in Observational Studies on Fresh Frozen Plasma:Erythrocyte Ratios in Trauma Requiring Massive Transfusion 716

Anthony M.-H. Ho, Peter W. Dion, Janice H. H. Yeung, John B. Holcomb, Lester A. H. Critchley, Calvin S. H. Ng, Manoj K. Karmakar, Chi W. Cheung, and Timothy H. Rainer 

Uncontrolled observational studies comparing high versus  low plasma with packed erythrocyte ratio in trauma resuscitation requiring massive transfusion were reviewed. Ten of the 26 studies reviewed probably contain survivor bias favoring increased use of plasma.

Mind to Mind

Close Quarters: An Introspective 729

Richard L. Saupé 

If It Was … 732

Antonia Micalizzi 

Reducing Blood Losses and Transfusion Requirements in Craniosynostosis Surgery: An Endless Quest? 733

Estelle Vergnaud, Antonio Vecchione, Stéphane Blanot, Federicco di Rocco, Eric Arnaud, Dominique Renier, Philippe Meyer; and the Pediatric Craniofacial Group 

In Reply

Christophe Dadure and Xavier Capdevila 

In Reply

Susan M. Goobie, Petra M. Meier, David Zurakowski, and Navil F. Sethna 

Puzzling ENIGMA: Cost-Benefit Analysis of Nitrous Oxide 735

Girish P. Joshi 

In Reply

Paul S. Myles and the ENIGMA Trial Investigators 

Intranasal Application of Xenon: A Shortcut to the Brain or Just a Longer Way to It through the Lungs? 736

Andrey B. Petrenko and Hiroshi Baba 

In Reply

Oliver Adolph, Thorsten Frederik Holsträter, Gebhard Froeba, and Michael Georgieff 

Why the Gray Zone May Shift within the Fog 739

Joshua A. Bloomstone, Karthik Raghunathan, and William T. McGee 

How Accurate Is Pulse Pressure Variation as a Predictor of Fluid Responsiveness?

Andrew Verniquet and Rafid Kakel 

The “Gray Zone Approach”: Assessing the Accuracy of Pulse Pressure Variation without Considering the Prevalence?

Piet A. H. Wyffels and Patrick F. Wouters 

In Reply

Maxime Cannesson, Yannick Le Manach, Benoit Vallet, and Benoit Tavernier 

The Rohrig Dropper Device for Ether or Chloroform 509

George S. Bause 

Bateman's Drops of Tinctured Opium 579

George S. Bause 

MBC Stovaine Pastilles 664

George S. Bause 

25 Years of Curating for the Wood Library-Museum 704

George S. Bause 


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