Anesthesia for Patients Undergoing Peroral Endoscopic Myotomy Procedures: A Review of the Literature Idiopathic achalasia is a motility disorder of the esophagus with important implications on anesthesia and periprocedural management. As new and more complex treatment options develop, anesthesiologists are increasingly involved with these patients. The cardinal symptoms of achalasia are as follows: dysphagia, regurgitation, chest pain, and weight loss. Achalasia is also associated with an increased risk of aspiration. Patients are frequently treated by endoscopic botulinum toxin injections, pneumatic dilation of the lower esophageal sphincter, laparoscopic Heller myotomy, or peroral endoscopic myotomy (POEM). The POEM procedure is based on the concept of “natural orifice transluminal endoscopic surgery.” Because the integrity of the esophageal wall is deliberately interrupted during POEM, the mediastinum and the peritoneal cavity may be exposed. Thus, the insufflated carbon dioxide frequently causes hypercapnia, tension capnoperitoneum, capnomediastinum, or pneumothoraces. An interdisciplinary team, skilled in diagnostics and emergency measures such as therapeutic hyperventilation, percutaneous abdominal needle decompression, or pleural drainage, is essential for the successful periprocedural management of POEM. POEM is one endoscopic procedure that requires general anesthesia. But neither anesthesia-specific care algorithms nor evidence-based recommendations are currently available for these patients. Because institutional experience varies broadly across the globe, this review examines anesthesia recommendations and perioperative management of POEM procedures based on 7 retrospective case series, 1 prospective study, and our personal experience. Accepted for publication August 1, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Benjamin Löser, MD, Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock, Schillingallee 35, 18057 Rostock, Germany. Address e-mail to benjamin.loeser@med.uni-rostock.de. © 2019 International Anesthesia Research Society

Voluntary Exercise Rescues the Spatial Memory Deficit Associated With Early Life Isoflurane Exposure in Male Rats BACKGROUND: Early life anesthesia exposure results in long-term cognitive deficits in rats. Environmental enrichment consisting of social housing, a stimulating environment, and voluntary exercise can rescue this deficit. We hypothesized that exercise alone is sufficient to rescue the cognitive deficit associated with perinatal anesthesia. METHODS: Postnatal day 7 male rats (P7) underwent isoflurane (Iso) or sham exposure and were subsequently weaned at P21. They were then singly housed in a cage with a running wheel or a fixed wheel. After 3 weeks of exercise, animals underwent behavioral testing for spatial and recognition memory assessments. Animals were killed at various time points to accomplish either bromodeoxyuridine (BrdU) labeling or quantitative real-time polymerase chain reaction (qRT-PCR) to quantify brain-derived neurotrophic factor (BDNF) messenger ribonucleic acid (mRNA) levels. RESULTS: Postweaning voluntary exercise rescued the long-term spatial memory deficit associated with perinatal Iso exposure. Iso-sedentary animals did not discriminate the goal quadrant, spending no more time than chance during the Barnes maze probe trial (1-sample t test, P = .524) while all other groups did (1-sample t test, PIso-exercise = .033; Pcontrol [Con]-sedentary = .004). We did not find a deficit in recognition memory tasks after Iso exposure as we observed previously. BrdU incorporation in the adult hippocampus of Iso-sedentary animals was decreased compared to sedentary controls (Tukey P = .005). Exercise prevented this decrease, with Iso-exercise animals having more proliferation than Iso-sedentary (Tukey P < .001). There was no effect of exercise or Iso on BDNF mRNA in either the cortex or hippocampus (cortex: FExercise[1,32] = 0.236, P = .631; FIso [1,32] = 0.038, P = .847; FInteraction [1,32] = 1.543, P = .223; and hippocampus: FExercise[1,33] = 1.186, P = .284; FIso [1,33] = 1.46, P = .236; FInteraction[1,33] = 1.78, P = .191). CONCLUSIONS: Exercise restores BrdU incorporation and rescues a spatial memory deficit after early life anesthesia exposure. This demonstrates sufficiency of exercise alone in the context of environmental enrichment to recover a behavioral phenotype after a perinatal insult. Accepted for publication August 1, 2019. The authors declare no conflicts of interest. Funding: This work was funded in part by National Institutes of Health (NIH) RO1GM112831 (J.W.S.), NIH University of California, San Francisco-Clinical and Translational Science Institute (UCSF-CTSI) Grant TL1 TR001871 (J.M.S.R.), and NIH T32 GM08440 (G.A.C.). Reprints will not be available from the authors. Address correspondence to Gregory A. Chinn, MD, PhD, Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Ave, Box 0542, San Francisco, CA 94143. Address e-mail to gregory.chinn@ucsf.edu. © 2019 International Anesthesia Research Society

Beyond Anesthesia Toxicity: Anesthetic Considerations to Lessen the Risk of Neonatal Neurological Injury Infants who undergo surgical procedures in the first few months of life are at a higher risk of death or subsequent neurodevelopmental abnormalities. Although the pathogenesis of these outcomes is multifactorial, an understanding of the nature and pathogenesis of brain injury in these infants may assist the anesthesiologist in consideration of their day-to-day practice to minimize such risks. This review will summarize the main types of brain injury in preterm and term infants and their key pathways. In addition, the review will address key potential pathogenic pathways that may be modifiable including intraoperative hypotension, hypocapnia, hyperoxia or hypoxia, hypoglycemia, and hyperthermia. Each of these conditions may increase the risk of perioperative neurological injury, but their long-term ramifications are unclear. Accepted for publication April 9, 2019. Funding: This work was supported by funding from the National Institutes of Health grants (grant no. 1R01HD081303-01, 1-R01 HD06 1136-01A1), Food and Drug Administration grant (grant FDA-SOL-08-SAFEKIDS-Clin 002-Project 2) and the Thrasher Foundation for M.E.M. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Mary Ellen McCann, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. Address e-mail to mary.mccann@childrens.harvard.edu. © 2019 International Anesthesia Research Society

Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study BACKGROUND: The epidemic of nonmedical use of prescription opioids (NMUPOs) has been fueled in part by the availability of leftover, legitimately prescribed opioids. In children, outpatient urological procedures are among the most common surgeries performed, but data are lacking to guide appropriate postoperative opioid prescribing. The aim of this study was to compare the amount of prescribed opioid medication to the amount taken for acute pain after minor pediatric urological surgery and to determine the disposition of excess opioid. In addition, we explored whether distinct patient characteristics and procedure type influenced opioid prescribing and consumption. METHODS: Of the 139 families of pediatric patients enrolled, 115 were interviewed within 48 hours and/or 10–14 days of discharge to determine the amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. RESULTS: The most common procedures performed were circumcision (n = 58) and orchiopexy (n = 40). Most patients (98%) were male, and 77% were <8 years of age. All opioid prescriptions were for oxycodone dosed every 4 hours as needed (PRN). Median number of doses prescribed was 30 (interquartile range [IQR], 23–31; n = 138) for both respondents who reported doses remaining (IQR, 29–31; n = 83) and those who did not (IQR, 22–32; n = 55). Among those reporting doses remaining, median number of doses consumed was 4.2 (IQR, 0–14). Multivariable linear regression showed no significant association between doses consumed and patient age, type of procedure, discharge pain score, or use of adjuvant analgesics. Median duration of opioid therapy was 2 days (IQR, 0–5; n = 83) with each additional day of opioid use corresponding to an average increase in consumption of 2.3 doses (95% confidence interval [CI], 1.8–2.8). An estimated 75% (95% CI, 69%–81%) of opioid dispensed was not consumed, and 86% (72/83) of patients took ≤18 doses. Forty-four of 65 (68%) families reported receiving no disposal instructions for leftover opioid, and only 7 families disposed of leftover medication. CONCLUSIONS: For minor pediatric urological surgeries in young boys, a 3-day supply (18 doses) of opioid was sufficient to adequately treat acute postoperative pain in most patients. Adjusting opioid dispensing to align with consumption and better educating patients and families on opioid disposal can be used to potentially decrease availability of leftover opioids in homes and communities. Accepted for publication July 17, 2019. M. Yaster is currently affiliated with the Department of Anesthesiology, University of Colorado-Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado. P. T. Vozzo is currently affiliated with the Warren Alpert Medical School of Brown University, Providence, Rhode Island. S. Gao is currently affiliated with the University of Maryland School of Medicine, Baltimore, Maryland. Funding: This work was supported by the Richard J. Traystman Endowed Chair and the Hilda and Jacob Blaustein Pain Foundation. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). J. B. Hunsberger and A. Hsu contributed equally and share first authorship. Reprints will not be available from the authors. Address correspondence to Joann B. Hunsberger, MD, MS, Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins Charlotte R. Bloomberg Children’s Center, 1800 Orleans St, Suite 6349A, Baltimore, MD 21287. Address e-mail to jhunsbe1@jhmi.edu. © 2019 International Anesthesia Research Society

Guiding Opioid Administration by 3 Different Analgesia Nociception Monitoring Indices During General Anesthesia Alters Intraoperative Sufentanil Consumption and Stress Hormone Release: A Randomized Controlled Pilot Study BACKGROUND: This pilot study investigated the effect of sufentanil titration by 3 different analgesia monitoring devices or clinical signs during general anesthesia. METHODS: Forty-eight patients undergoing radical retropubic prostatectomy with sevoflurane/sufentanil anesthesia were randomly assigned into 4 groups and received sufentanil guided either by 1 of 3 analgesia monitoring devices (Surgical Pleth Index [SPI], Pupillary Pain Index [PPI], Nociception Level [NoL]) or by clinical judgment (control). The primary end point was intraoperative sufentanil consumption. Adrenocorticotropic hormone (ACTH) and cortisol were measured at 4 time points during the day of surgery. Data were analyzed by Kruskal–Wallis and Mann–Whitney U tests and by mixed model and area under the curve (AUC) analyses for group comparisons and time effects of stress hormones. RESULTS: The total amount of sufentanil administration (μg·kg−1·minute−1·10−3) differed between the groups (median [quartiles]: control = 5.6 [4.4–6.4], SPI = 7.2 [4.8–8.4], PPI = 2.0 [1.8–2.9], NoL = 3.8 [3.3–5.1]; PPI versus SPI, −5.1 [−6.6 to −1.3], P < .001; NoL versus SPI, −3.0 [−5.2 to 0.2], P = .024; control versus SPI, −1.6 [−3.7 to 1.7], P = .128; NoL versus PPI, 1.7 [0.6–3.4], P < .001; control versus PPI, 3.4 [2.0–4.6], P < .001; control versus NoL, 1.6 [−0.2 to 3.3], P = .017) (Hodges–Lehmann estimator [99% confidence interval {CI}], P values). The AUC analysis indicated differences among groups in cumulative ACTH levels (ng·liter−1·minute, natural logarithm (ln)-transformed data) of NoL versus PPI (−1.079 [−1.950 to −0.208], P = .001) and PPI versus SPI (1.192 [0.317–2.068], P= .001), as well as differences in cortisol levels (µg·liter−1·minute) for PPI versus SPI (46,710 [21,145–72,274], P < .001), NoL versus SPI (27,645 [3163–52,126], P = .003), and control versus SPI (31,824 [6974–56,675], P = .001) (differences in means [99% CI], P value). Secondary end points (postoperative recovery, pain level, and analgesia medication) showed no differences. CONCLUSIONS: The type of analgesia nociception monitoring affected the total amount of sufentanil administered. Lower sufentanil doses in the PPI group were associated with an increased endocrine stress response. Titration by SPI caused no opioid reduction compared to the control but was associated with a reduced endocrine stress response. Accepted for publication July 17, 2019. Funding: Institutional and/or departmental. The Nociception Level monitoring device was loaned by the company because it was not available in the department. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.anesthesia-analgesia.org). Clinical Trial Number and URL: Registration with ClinicalTrials.gov (Ref. NCT03303651): https://clinicaltrials.gov/ct2/show/NCT03303651; for access to the full trial protocol, contact the first author. Reprints will not be available from the authors. Address correspondence to Sandra Funcke, MD, Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. Address e-mail to s.funcke@uke.de. © 2019 International Anesthesia Research Society

Effect of Remote Ischemic Preconditioning in Patients Undergoing Hepatectomy With Portal Triad Clamping: A Randomized Controlled Trial BACKGROUND: Remote ischemic preconditioning (RIPC) is reported to reduce liver injury in patients undergoing hepatectomy for colorectal liver metastasis, but its role is unclear in hepatocellular carcinoma patients with portal triad clamping during hepatectomy. METHODS: In this prospective, randomized trial, 140 patients with hepatocellular carcinoma undergoing liver resection requiring portal triad clamping were randomized to a RIPC group or a control group. Patients in the RIPC group received RIPC (3 cycles of 5-minute ischemia and 5-minute reperfusion in right upper limb with cuff pressure at 30 kPa [225 mm Hg]) approximately 10 minutes after induction of anesthesia. In the control group, patients received sham RIPC (the cuff was not inflated). The primary outcome was the postoperative peak level of total bilirubin (TBIL) and was analyzed with the independent t test. Secondary outcomes were liver function test at postoperative days 1, 3, and 5; postoperative morbidity and mortality during the first month; and the length of postoperative hospital stay. RESULTS: Data from 136 patients (69 in the RIPC group and 67 in the control group) were analyzed. The RIPC group had on average a 5.9 μmol lower peak level of TBIL than the control group; the mean difference is −5.9, and the 95% confidence interval (CI) reverses to −17.9 to 6.1. There were no significant differences between the 2 groups in liver function test at postoperative days 1, 3, and 5; postoperative morbidity and mortality during the first month; and the length of postoperative hospital stay. CONCLUSIONS: We found no evidence that RIPC can reduce postoperative liver injury after hepatectomy. Accepted for publication August 6, 2019. Funding: This work was supported by B. Bruan anesthesia science funding (grant 2015-13 to W.L.). The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Wenqian Lin, MD, SunYat-Sen University Cancer Center, State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Guangzhou 510120, China. Address e-mail to linwq@sysucc.org.cn. © 2019 International Anesthesia Research Society

Special Report From the Society for the Advancement of Blood Management: The Choosing Wisely Campaign Over 7 years ago, the American Board of Internal Medicine Foundation (ABIM) created the national Choosing Wisely campaign with the purpose of encouraging active dialogue between health care providers and patients, focusing on appropriateness, quality care, and resource management. This special communication from the Society for the Advancement of Blood Management (SABM) serves to highlight the society’s recent participation in the Choosing Wisely campaign, encouraging sensible dialogue between clinicians and our patients with the intent to promote patient-centered, evidence-based care. The article addresses the rationale and supportive data for the 5 SABM Choosing Wisely recommendations. Accepted for publication August 1, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Carolyn D. Burns, MD, Independent Patient Blood Management (PBM) Physician Consultant, 301 Pepperbush Rd, Louisville, KY 40207. Address e-mail to cburnspbm@gmail.com. © 2019 International Anesthesia Research Society

Revisiting the Classification of Neuromuscular Blockade, Aligning Clinical Practice and Research No abstract available

Scholarly Activity of Anesthesiology Residents No abstract available

In Response No abstract available