Anesthesia information management systems.

Purpose Of Review: This review will summarize and comment upon recent developments in the evolution and implementation of anesthesia information management systems (AIMS) in current practice.

Recent Findings: Availability of inexpensive hardware components has greatly reduced costs, and AIMS are now widely available as 'off-the-shelf' software systems, yet AIMS are currently in use in only a minority of institutions and anesthetic practices. AIMS have evolved rapidly from simple automated record-keeping systems to key components of modern medical information networks.

Anesthesia information management system implementation: a practical guide.

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error.

Clinical implications of mitochondrial disease.

The terms mitochondrial myopathy, mitochondrial cytopathy and inherited mitochondrial encephalomyopathy encompass a large grouping of syndromes produced either by genetically transmitted or acquired disruption of mitochondrial energy production or biosensor function. Many of these disorders are clinically apparent during infancy, but for some the metabolic signs of oxidative stress may not appear until the young or middle adult years. Initially thought to be a rare disorder, it now appears that mitochondrial dysfunction is relatively common but often unrecognized because symptoms are extremely variable and usually insidious in onset.

The elderly outpatient: current anesthetic implications.

Purpose Of Review: The present overview describes recent contributions to the literature with regard to choice of anesthetic techniques, approaches to anesthetic management of elderly outpatients undergoing arthroscopy and other procedures, reconsideration of the problem of postoperative delirium in the elderly patient, and a general summary of perioperative management and assessment of anesthetic risk in older adults.

Recent Findings: Major advances in monitoring technology, pharmacology, and comprehensive preoperative assessment have reduced the probability of major adverse outcomes for geriatric surgical patients to low levels. Therefore, it has become difficult to demonstrate clear-cut superiority for any specific anesthetic agent or approach.

Clinical implications of mitochondrial dysfunction.

Mitochondria produce metabolic energy, serve as biosensors for oxidative stress, and eventually become effector organelles for cell death through apoptosis. The extent to which these manifold mitochondrial functions are altered by previously unrecognized actions of anesthetic agents seems to explain and link a wide variety of perioperative phenomena that are currently of interest to anesthesiologists from both a clinical and a scientific perspective. In addition, many surgical patients may be at increased perioperative risk because of inherited or acquired mitochondrial dysfunction leading to increased oxidative stress.

Preoperative assessment of the elderly patient.

Organ system functional reserve variability increases progressively with age. In elderly patients, cardiopulmonary, central nervous system, and metabolic functional reserve seem to be the most important predictors of the ability to undergo surgery. Directed testing for the assessment of organ system functional reserve and identification of organs at risk, rather than the diagnosis of disease itself, is the primary goal of preoperative evaluation prior to surgery and is essential to the formulation of an effective anesthetic plan.

The aging process: anesthetic implications.

Recent improvement in our understanding of the physiology and pharmacology of aging has occurred in large part because investigators have been able to separate the effects of aging from the consequences of age-related disease. As a group, elderly patients are at increased risk of perioperative morbidity and mortality because of the high incidence of coexisting age-related disease. Even in the absence of chronic disease, organ function remains adequate to meet the basal metabolic requirements of older adults, but the functional reserve and maximal capacity of all major organ systems are significantly reduced and may not meet the increased demands associated with acute illness surgery.

The effects of aging on anesthetic pharmacology.

Aging alters both the pharmacokinetic and the pharmacodynamic aspects of anesthetic requirement. Studies of the relationship between drug concentration and effect in older adults clearly demonstrate a decline in median effective dose requirement for agents that act within the central nervous system, but there appears to be little change in the dose required for peripheral effects such as neuromuscular blockade. Most drugs also undergo somewhat slower biotransformation and demonstrate prolonged clinical effects if they require hepatic or renal degradation, although many newer agents such as remifentanil and cisatracurium have organ-independent pathways that are not affected by age.

Intraoperative air embolism with pulse irrigation device.

Venous air embolism is a potentially fatal complication. In a patient undergoing extensive debridement of an open perineal wound, hemodynamically significant air embolization occurred during use of a pulsatile saline irrigation device. We describe another intraoperative setting in which venous air embolism is a risk.

Localized hypothermia influences assessment of recovery from vecuronium neuromuscular blockade.

The purpose of this study was to determine the extent to which localized hypothermia of a monitored extremity alters the assessment of recovery from vecuronium-induced neuromuscular blockade. Bilateral integrated evoked electromyographic (IEMG) responses were measured in the ulner distribution of 14 anaesthetized patients who had differing upper extremity temperatures as measured at the adductor pollicis to determine whether localized hypothermia alters the clinical assessment of spontaneous recovery from vecuronium-induced neuromuscular blockade. All patients received general anaesthesia with thiopentone, N2O/O2 and opioid; 11/14 patients received isoflurane for blood pressure control.

Monitoring technique affects measurement of recovery from succinylcholine.

To compare recovery time from neuromuscular blockade after the administration of a single intravenous bolus of succinylcholine (1 mg/kg), we measured, both mechanically and electromyographically, the evoked twitch responses in the hand muscles of 10 patients. Electromyographic data were obtained, electronically integrated, and recorded by a newly available clinical monitoring device. Using both the mechanical and the electromyographic devices, we recorded the times for first return of twitch, as well as for 25% and 75% recovery of twitch height compared with prerelaxant twitch baseline values and compared the values by calculating least-squares regression lines.

A departmental policy addressing chemical substance abuse.

Substance abuse is a major socioeconomic problem. However, the ready availability of potent narcotic and sedative drugs probably constitutes a unique risk for anesthesiologists. Until recently, few anesthesia departments were prepared to recognize or safely manage afflicted colleagues.

Electrical and mechanical train-of-four responses during depolarizing and nondepolarizing neuromuscular blockade.

Simultaneous measurements of train-of-four (TOF) responses by integrated electromyography (IEMG) and twitch force were compared for atracurium, vecuronium, and succinylcholine in 30 subjects during nitrous oxide-fentanyl anesthesia. Determinations of TOF were made during neuromuscular blockade (NMB) onset and recovery. Scattergrams and least squares regression lines were plotted, and z-tests for parallel slope and common intercept were used to compare lines.

Density of normal human cerebrospinal fluid and tetracaine solutions.

Density and specific gravity (SG) were determined at two or more temperatures between 23 and 37 C for 15 samples of normal human cerebrospinal fluid (CSF) and CSF mixed with tetracaine, and for tetracaine solutions commonly used for spinal anesthesia. Density was determined from measured weight and volume, and SG was calculated using the density of water at the same temperature. With 95% confidence limits, SG of normal human CSF at 37 C ranges from 1.

Isobaric tetracaine spinal anesthesia and the lithotomy position.

The extent and pattern of anesthesia produced by hyperbaric and by isobaric 0.5% tetracaine spinal anesthesia were compared in this blind-observer, randomized study of 103 spinal anesthetics performed in 98 patients having genitourinary surgery in the lithotomy position. Pinprick stimulation showed no significant differences in maximum segmental sensory levels, times to maximum level, or duration of anesthesia for isobaric as compared to hyperbaric tetracaine.

Temperature correction of arterial blood-gas parameters: A comparative review of methodology.

The need for accurate clinical diagnosis and appropriate intervention requires that a modern blood-gas laboratory have the means to correct for significant discrepancies between patient temperature and the temperature at which in vitro blood samples are analyzed. Recent advances in mini- and microcomputer technology permit application of any or all of the correction formulas above at modest cost and minimal inconvenience (See the Appendix). An expanded program for a TI-59 desk-top calculator and P-100C printer which gives labeled hard-copy readout of temperature-corrected pH, PCO2, PO2, and hemoglobin saturation values, as well as bicarbonate concentration and in vivo base excess is in daily clinical use in our operating room and is available from the authors upon request.