This Month In: Anesthesiology

Use of different outcomes makes interpretation of studies of neurodevelopmental outcomes after childhood anesthesia exposure difficult. The results of three frequently used neurodevelopmental outcomes measures were assessed in 781 children, born from 1989 to 1992, from the Western Australian Pregnancy Cohort (Raine) study, 112 of whom had surgical or diagnostic procedures requiring anesthesia before 3 yr of age. Neuropsychological testing and International Classification of Diseases, 9th Revision, Clinical Modification–coded clinical outcomes identified deficits at age 10 yr in children exposed to anesthesia, whereas academic achievement scores did not, suggesting results of cognition assessment in children with early anesthesia exposure may depend on the outcome measure used. See the accompanying Editorial View on page 1303.

The incidences of serious complications related to obstetric anesthesia are uncertain. The Serious Complication Repository Project of the Society for Obstetric Anesthesia and Perinatology collected data between 2004 and 2009 from 30 institutions with quality assurance programs to determine the incidence of serious complications and risk factors for each. Of the nearly 257,000 parturients administered neuraxial or general anesthesia, 85 (1/3,000) experienced serious complications related to anesthesia. The most common of these were high neuraxial block, respiratory arrest in the labor suite, and unrecognized spinal catheter. The number of complications was too few to identify risk factors. See the accompanying Editorial View on page 1311.

A recent systematic review of the effect of checklist implementation included studies that reflect local or regional practice patterns. A meta-analysis of seven cohort studies with a varied case mix of 37,339 patients from 11 countries and published between 2009 and 2012 found use of checklists in surgery practice led to significant reductions in any major postoperative complication (a composite variable), wound infection, and blood loss, but no significant reductions in mortality, pneumonia, or unplanned return to the operating room. Given the large numbers and heterogeneity of the patients included in this meta-analysis, these results may have global applicability.

Anesthesiologists and anesthesiology residents often fail to follow the American College of Cardiology/American Heart Association (ACC/AHA) 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. The adherences of 111 anesthesiology residents from four training programs to the guidelines using memory alone and with the aid of an electronic decision support tool (DST) were evaluated and compared using multiple choice questions with clinical stems in a randomized cross-over trial. Use of an electronic DST increased adherence to the ACC/AHA guidelines and reduced management errors associated with increased costs but resulted in a longer time to complete the test. See the accompanying Editorial View on page 1309.

Dabigatran is an oral anticoagulant used to prevent strokes in patients with nonvalvular atrial fibrillation by acting as a direct thrombin inhibitor. A specific approach to reversing its anticoagulant effect is not yet available. Intravenous administration of most of the six coagulation factor concentrates (CFCs) tested reduced the prolonged bleeding time produced by orally administered dabigatran in a rat-tail incision bleeding model. None of the changes in routine coagulation assays due to addition of CFCs predicted reduced bleeding time. Most CFCs normalized in vitro thrombin generation by human plasma spiked with dabigatran at lower, but not at higher, dabigatran concentrations. See the accompanying Editorial View on page 1316.

A safe and effective means of reducing postoperative morphine requirements could decrease the risk of postoperative respiratory depression and airway obstruction after cleft palate repair. Sixty children undergoing cleft palate repair received bilateral suprazygomatic maxillary nerve blocks with either 0.2% ropivacaine or saline for postoperative pain relief in a randomized, double-blind study. Postoperative intravenous morphine administration was managed to obtain a Children and Infants Postoperative Pain Scale score of 3 or less. Morphine consumption in the 48 h after surgery was 50% less in the ropivacaine group. Nine patients in the saline group and one in the ropivacaine group required continuous morphine infusions.

Administration of 0.05 mg/kg midazolam before the end of strabismus surgery reduced the incidence of emergence agitation in children but prolonged emergence. Ninety children undergoing strabismus surgery under sevoflurane anesthesia were randomly assigned to receive intravenously administered saline, 0.03 mg/kg midazolam, or 0.05 mg/kg midazolam just before the end of surgery. Behavior on emergence was scored using a pediatric emergence delirium scale and a 4-point agitation scale. While the incidence of emergence agitation was similarly reduced by both 0.03 and 0.05 mg/kg midazolam, emergence was prolonged by 0.05 mg/kg midazolam but not by 0.03 mg/kg midazolam.

The cardiac arrhythmia encountered most frequently in adults is atrial fibrillation. Radiofrequency catheter ablation of regions of the heart that are responsible for initiating it has revolutionized the treatment of atrial fibrillation that is refractory to medical management. Preoperative evaluation of the patient undergoing an endovascular ablation procedure, the pros and cons of monitored anesthesia care and general anesthesia, and intraoperative considerations, including anticoagulation and common complications, are reviewed as are postoperative patient care and long-term outcomes.