Science, Medicine, and the Anesthesiologist

Key Papers from the Most Recent Literature Relevant to AnesthesiologistsBecause of a worldwide shortage of consultants who have the expertise to interpret electroencephalograms (EEGs), there is a need for a suitable artificial intelligence–based model that can provide comprehensive, reliable, and clinically oriented interpretation of routine EEGs. A convolutional neural network artificial intelligence model (SCORE-AI) was developed and validated to distinguish between normal and abnormal EEG recordings and classify abnormalities as focal or diffuse. For the development phase, SCORE-AI analyzed 30,493 EEG recordings of Scandinavian patients referred to two epilepsy centers, who were not critically ill and older than 3 months. It was then validated on a holdout test subset of 2,549 patients and three independent datasets (total N = 9,945). The SCORE-AI achieved areas under the receiver operating characteristic curves of between 0.89 and 0.96 for the various categories of EEG abnormalities. The SCORE-AI had specificity = 90%, sensitivity = 87%, negative predictive value = 95%, and positive predictive value = 75% for the detection of epileptiform abnormalities in a 100-subject, 11-center dataset.Take home message: The use of a suitably trained, artificial intelligence, expert system can detect epileptiform abnormalities in the EEG with accuracy comparable to that of human experts.This 2023 American Heart Association/American College of Cardiology Guideline (in association with several other societies) updates the previous 2012 (and 2014 update) guideline. The emphasis is on team-based, patient-centered care incorporating social determinants, costs, and shared decision-making. Nonpharmacologic therapies, particularly healthy dietary habits and exercise (including activities to reduce sitting time and to increase aerobic and resistance exercise), in patients free from contraindications, are recommended. Pharmacologic therapy updates include changes in recommendations for β-blocker use, which is no longer recommended for long-term use in the absence of myocardial infarction in the past year; left ventricular ejection fraction 50% or less; or other primary indications. For anti-anginal therapy, either a calcium channel blocker or β blocker is recommended. Updated recommendations are made for lipid targets and use of lowering therapies including first-line use of statins and newer adjunctive agents, blood pressure targets for those with or without established hypertension, and use of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists in specific patient subgroups, and for antiplatelet and anticoagulant therapy, including shorter durations of dual antiplatelet therapy in those undergoing percutaneous coronary interventions. Additional topics include use of dietary supplements, anatomic or ischemic testing, and strategies for smoking cessation.Take home message: This comprehensive clinical practice guideline by the American Heart Association and the American College of Cardiology provides up-to-date information on multiple aspects of the care of patients with chronic coronary artery disease with potential implications for the perioperative management of patients presenting for surgical procedures.A new global definition of acute respiratory distress syndrome (ARDS) was proposed by a global consensus conference as an update to the 2012 Berlin Definition, with the intent of improving diagnostic criteria for resource-limited settings and integrating new evidence and practice around oxygen measurement and delivery. Recognizing the lack of consistent chest radiography, arterial blood gas testing, and mechanical ventilation in resource-limited areas, this panel of 32 international experts, in consultation with members of 21 critical care societies, recommended adoption of the Kigali modifications to the ARDS definition. The central recommendations broaden diagnostic criteria to (1) include patients with noncardiogenic acute hypoxemic respiratory failure treated with high-flow nasal oxygen (minimum flow rate at least 30 l/min); (2) allow a Spo2:Fio2 ratio less than 315 (if Spo2 is less than or equal to 97%) to substitute for Pao2:Fio2 ratio 300 mmHg or less for hypoxemia; (3) accept lung ultrasound imaging for pulmonary edema, consolidation, or loss of aeration; and (4) selectively loosen diagnostic requirements regarding minimum positive end-expiratory pressure, oxygen flow rates, or respiratory support modalities in resource-limited settings.Take home message: This proposed global definition of ARDS adopts new evidence and practice to expand the diagnostic criteria for ARDS and improve the generalizability for resource-limited settings.The voltage-gated sodium channel subtypes NaV1.7-1.9 are primarily expressed in peripheral nociceptive neurons and are crucial for nociception. Previous efforts in drug development focused on NaV1.7, due to a strong genetic association between SCN9A (the human gene encoding NaV1.7) and human pain. Nav1.8 was discovered as the first nociceptor-specific sodium channel and is widely used as a nociceptor marker in preclinical studies. This study identified VX-548 as a selective NaV1.8 inhibitor, which potently suppressed tetrodotoxin-resistant currents in cultured primary human dorsal root ganglion neurons with IC50 of less than 1 nM. This study reports two phase-2 trials in patients with acute postoperative pain after abdominoplasty (n = 303) or bunionectomy (n = 274). Pain was assessed on the Verbal Categorical Rating Scale and the Numeric Pain Rating Scale. VX-548 was given orally at high and low doses (100 vs. 60 mg loading doses with decreased doses every 12 h). In both trials, high but not low doses of VX-548 reduced acute pain for 48 h (least-squares mean difference vs. placebo in pain intensity difference, 37.8 (95% CI, 9.2 to 66.4) after abdominoplasty; 36.8 (95% CI, 4.6 to 69.0) after bunionectomy). Common adverse events were headache and constipation.Take home message: In a randomized trial, selective inhibition of NaV1.8 by oral VX-548 at high doses was able to reduce acute postoperative pain compared to either a low dose or placebo.Selecting the correct sized blood pressure cuff based on midarm circumference is recommended in practice guidelines. Manufacturers recommend using a small blood pressure cuff for arms of 20 to 25 cm measured at the midpoint between the acromion and the olecranon, a regular cuff for 25.1 to 32 cm, a large cuff for 32.1 to 40 cm, or an extra-large cuff for 40.1 to 55 cm circumferences. This randomized crossover trial of 195 U.S. adults with hypertension (mean age, 54 yr; 34% male; 68% Black) with a range of midarm circumferences (mean ± SD, 34 ± 7.2 cm) performed three automated oscillometric blood pressure measurements 30 s apart, using an appropriate, too-small, or too-large cuff in random order. The fourth set of measurements was done with an appropriate-sized cuff. The primary outcome was the differences in mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) measured with a regular cuff compared with an appropriate-sized cuff. Use of a regular cuff resulted in significantly lower blood pressure measurements (mean SBP difference, −3.6 [95% CI, −5.6 to −1.7] mm Hg) in individuals requiring a small cuff. Significantly higher SBP measurements (mean difference, 4.8 mmHg [95% CI, 3.0 to 6.6] and 19.5 mmHg [95% CI, 16.1 to 22.9], respectively) were obtained in individuals requiring a large or extra-large cuff if standard-sized cuffs were used. Findings were consistent but to a lesser degree for DBP.Take home message: This randomized crossover trial of hypertensive adults demonstrates that use of regular blood pressure cuff (one size too large) when a small cuff was appropriate, resulted in lower SBP, and when a large cuff was appropriate, using a regular cuff (one size too small) resulted in higher SBP.Monoclonal antibodies targeting four inhibitory immune checkpoints commonly termed immune checkpoint inhibitors (ICI) are currently used to treat approximately 50% of all cancer types. By activating the adaptive immune system, they fight cancer cells, but they may also cause immune cell infiltration to muscle tissues, including the heart and respiratory muscles. ICI myocarditis is rare but has a high mortality rate (50%). Currently available data on specific cardiac biomarkers and their use in prediction of major adverse cardiotoxic events (MACE: heart failure, ventricular arrhythmia, conduction block requiring a pacemaker, respiratory failure requiring ventilation, and sudden cardiac death) in this setting are limited. This study analyzed the diagnostic accuracy and prognostic performance of troponin-T, troponin-I, and creatine kinase in 60 patients with ICI myocarditis from two cardio-oncology units in France and Germany with 1-yr follow-up. Circulating troponin-T levels were more sensitive and provided a more accurate prognostic value with regard to MACE when compared with troponin-I and creatine kinase measurements. A troponin-T upper reference level 32× or higher within 72 h of admission was the best cutoff associated with MACE within 90 days (hazard ratio, 11.1 [95% CI, 3.2 to 38.0]; P < 0.001). This diagnostic performance was confirmed in patients from an international ICI myocarditis registry.Take home message: When diagnosing and surveilling for ICI myocarditis, troponin-T is the most sensitive biomarker. Circulating levels of troponin-I and creatine kinase tend to normalize earlier in the course of ICI myocarditis and can miss active cardiomuscular involvement.While the opioid epidemic has raised concerns over excessive intraoperative opioid administration, its association with long-term opioid utilization is unclear. This retrospective observational study analyzed 61,249 adults undergoing noncardiac surgery at an academic quaternary referral center. The exposure was the mean effect site concentration of fentanyl and hydromorphone, derived from intraoperative opioid administration data. The primary outcomes were maximum pain score and total opioid administration (measured in morphine milligram equivalents) in the postanesthesia care unit (PACU). Secondary outcomes included longer-term opioid outcomes such as opioid prescribing at 30, 90, and 180 postoperative days. After using propensity score matching to adjust for confounders such as patient demographics and comorbidities, increased intraoperative fentanyl and hydromorphone administration was associated with lower maximum PACU pain scores (adjusted odds ratio, 0.82; 95% CI, 0.80 to 0.83 fentanyl; adjusted odds ratio, 0.94; 95% CI, 0.92 to 0.96 hydromorphone) and decreased opioid administration in the PACU (adjusted odds ratio, 0.94; 95% CI, 0.91 to 0.96 fentanyl; adjusted odds ratio, 0.81; 95% CI, 0.78 to 0.84 hydromorphone). These results imply that a 100-µg increase in fentanyl administration and a 0.5-mg increase in hydromorphone administration would be associated with, respectively, a 0.49-point and 0.08-point reduction in maximal PACU pain score. Increased fentanyl administration was associated with decreased long-term opioid prescribing while increased hydromorphone administration was associated with increased long-term opioid prescribing.Take home message: The single-center retrospective observational study suggests that increased intraoperative opioid administration is associated with lower postoperative pain scores and postoperative opioid utilization, with mixed results on longer-term opioid prescribing.There is a clear association of high surgeon-volume and hospital-volume and patients’ outcome leading to improved morbidity and mortality. However, it is unclear whether high-volume anesthesiology care has a similar positive impact. This population-based retrospective cohort study was performed to examine the association of hospital-level adjusted rate of high-volume anesthesiology care and hospital-level adjusted rate of 90-day major morbidity according to Clavien-Dindo grade 3–5 in complex gastrointestinal cancer surgery with focus on adult patients undergoing esophagectomy, pancreatectomy, and hepatectomy. Between 2007 and 2018, 7,893 patients from 17 Ontario hospitals, defined as centers of excellence because of standardized processes, were included. High-volume anesthesiology care was defined as a volume of 6 or more procedures per year performed by an anesthesiologist. Six (interquartile range, 3.5 to 10.5) procedures per year were found as median anesthesiologist volume, 189 (72 to 358) procedures for the annual median hospital volume. A range of 0 to 88% was reported as high-volume anesthesiology care over the study period; major morbidity varied from 38 to 45%. The unadjusted rate ratio between high-volume anesthesiology care and postoperative major morbidity was 0.97 (95% CI, 0.95 to 0.98; P = 0.002). After adjustment for several factors such as age, sex, hospital teaching status, and so forth, the association was still significant (P < 0.001).Take home message: This retrospective study reports that high-volume anesthesiology care is associated with lower rates of 90-day major morbidity. For each 10% increase in patients receiving high-volume anesthesiology care, the hospital rate of postoperative major morbidity decreases by 4%.Pre-eclampsia is a leading cause of maternal and perinatal mortality, and interventions in low-income or middle-income settings are uncertain. This parallel-group, multicenter, randomized controlled trial compared planned delivery versus expectant management in women with pre-eclampsia from 34 to 36 weeks’ gestation at nine centers (India and Zambia; December 2019 to March 2022), randomly assigning subjects to planned delivery or expectant management (284 vs. 281 women) stratified by multiple key risk factors. The primary maternal outcome was a composite of maternal mortality or morbidity (superiority hypothesis). The primary perinatal outcome was a composite of one or more of the following: stillbirth, neonatal death, or neonatal unit admission of more than 48 h (noninferiority hypothesis; 10% difference). No significant difference was noted in the primary maternal outcome (60% vs. 55%, adjusted risk ratio, 0.91; 95% CI, 0.79 to 1.05). Noninferiority was established in the primary perinatal outcome by intent to treat (19% vs. 22%; adjusted risk difference, –3%; 90% CI, –8.67 to 1.90; noninferiority P < 0.0001). Also, severe maternal hypertension and stillbirth were reduced with planned delivery (adjusted risk ratio, 0.83; 95% CI, 0.70 to 0.99; and 0.25; 0.07 to 0.87, respectively) as well as other serious adverse events.Take home message: This low- and middle-income country randomized trial suggests that planned delivery can be safely offered with late preterm pre-eclampsia and reduces the risk of neonatal morbidity and severe maternal hypertension.

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