Anesthesia and analgesia
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Anesthesia and analgesia · Feb 2015
ReviewDeliberate practice for achieving and maintaining expertise in anesthesiology.
For the dedicated anesthesiologist, a high level of expertise is needed to deliver good care to patients and to provide excellent service to surgeons, anesthesia colleagues, and others. Expertise helps the anesthesiologist recover from difficult situations and generally makes the practice run more effectively. Expertise also contributes to quality of life through higher self-esteem and long-term career satisfaction. ⋯ Anesthesiology instruction with attending supervision provides all of the necessary components for deliberate practice, and it can be effective in anesthesia. Using deliberate practice in teaching requires organization in selecting training topics, effort in challenging students to excel, and skill in providing feedback. In this article, we discuss how educational programs can implement deliberate practice in anesthesiology training, review resources for instructors, and suggest how anesthesiologists can continue the practice after residency.
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Anesthesia and analgesia · Feb 2015
What can the national quality forum tell us about performance measurement in anesthesiology?
Anesthesiologists face increasing pressure to demonstrate the value of the care they provide, whether locally or nationally through public reporting and payor requirements. In this article, we describe the current state of performance measurement in anesthesia care at the national level and highlight gaps and opportunities in performance measurement for anesthesiologists. ⋯ Few NQF performance measures are specific to anesthesia practice, and none of these appears to demonstrate the value of anesthesia care or differentiate high-quality providers. To demonstrate their role in patient-centered, outcome-driven care, anesthesiologists may consider actively partnering in jointly attributable or team-based reporting. Future measures may incorporate surgical procedures not proportionally represented, as well as procedural and sedation care provided in nonoperating room settings.
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The mechanisms of general anesthesia by volatile drugs remain largely unknown. Mitochondrial dysfunction and reduction in energy levels have been suggested to be associated with general anesthesia status. 2-Deoxy-D-glucose (2-DG), an analog of glucose, inhibits hexokinase and reduces cellular levels of adenosine triphosphate (ATP). 3-Nitropropionic acid is another compound which can deplete ATP levels. In contrast, idebenone and L-carnitine could rescue deficits of energy. We therefore sought to determine whether 2-DG and/or 3-nitropropionic acid can enhance the anesthetic effects of isoflurane, and whether idebenone and L-carnitine can reverse the actions of 2-DG. ⋯ These results from our pilot studies have established a system and generated a hypothesis that 2-DG enhances anesthetic effects via reducing energy levels. These findings should promote further studies to investigate anesthesia mechanisms.
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Anesthesia and analgesia · Feb 2015
The Antihyperalgesic Effects of Intrathecal Bupropion, a Dopamine and Noradrenaline Reuptake Inhibitor, in a Rat Model of Neuropathic Pain.
Antidepressants are often used for the treatment of neuropathic pain, and their analgesic effects rely on increased noradrenaline and serotonin levels in the spinal cord. Clinical studies have also shown that bupropion, a dopamine and noradrenaline reuptake inhibitor, has strong efficacy in neuropathic pain; however, the role of spinal cord dopamine in neuropathic pain is unknown. We hypothesized that bupropion inhibits neuropathic pain by increasing noradrenaline and dopamine in the spinal cord. In the present study, we determined the efficacy and underlying mechanisms of intrathecal administration of bupropion in a rat model of neuropathic pain. ⋯ These findings suggest that plasticity of descending inhibitory pathways such as the noradrenaline and dopamine systems contributes to the maintenance of neuropathic pain and that spinal cord noradrenaline and dopamine both play an inhibitory role in neuropathic pain.
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Anesthesia and analgesia · Feb 2015
Gas analysis using Raman spectroscopy demonstrates the presence of intraperitoneal air (nitrogen and oxygen) in a cohort of children undergoing pediatric laparoscopic surgery.
Clinically significant gas embolism during laparoscopy is a rare but potentially catastrophic event. Case reports suggest that air, in addition to the insufflation gas, may be present. We studied the effects of equipment design and flushing techniques on the composition of gas present under experimental and routine pediatric surgical conditions. ⋯ Thus, when vascular injury occurs, embolized gases will contain variable quantities of N2, O2, and CO2. As the initial insufflation volume diminishes and approaches the volume of the insufflation tubing, which occurs in infants and young pediatric patients, the concentration of N2 will approximate that of room air in an unflushed system. Small insufflation volumes containing high N2 concentrations can contribute to catastrophic air emboli in neonates and small pediatric patients.