Depth of Anesthesia

Dr. Taylor Thomas, a dual fellow in obstetric and adult cardiothoracic anesthesia, and Dr. Matt Vanneman, a Clinical Associate Professor at Stanford, delve into the controversial use of pulmonary artery catheters (PACs) in cardiac surgery. They discuss the significant findings from studies showing no mortality benefit but potential harm in lower-risk patients. Intriguingly, they explore how PACs may aid management in cardiogenic shock patients. The conversation highlights the need for randomized trials to clarify their efficacy in various surgical contexts.

In this discussion, Dr. Gopika Hari, an anesthesia resident, and Dr. Lana Joudeh, a faculty member at MGH, dive into the safety of peripartum opioid use for breastfeeding mothers. They explore the transfer of opioids like morphine and fentanyl into breast milk and the implications for infant safety. The duo emphasizes the balance between effective pain management and monitoring neonatal well-being. They highlight recent studies showing minimal breastfeeding impact from fentanyl and stress the importance of ongoing research for informed clinical practices.

Dr. Mary Daniels and Dr. Scott Cao join the show to discuss the literature surrounding opioid-free versus opioid-based anesthesia and analgesia techniques. Dr. Scott Cao is currently serving as a chief resident of the MGH anesthesia residency program. He is a graduate of the University of Colorado School of Medicine. Dr. Mary Daniels is a graduate of Harvard Medical School and she is a resident in the anesthesia program. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues. — Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Shanthanna H, Beloeil H, Joshi GP. Opioid-free anesthesia in research and practice: so near yet so far! Can J Anaesth. 2024 Nov 5. English. doi: 10.1007/s12630-024-02830-1. Epub ahead of print. PMID: 39500839. Brandal D, Keller MS, Lee C, Grogan T, Fujimoto Y, Gricourt Y, Yamada T, Rahman S, Hofer I, Kazanjian K, Sack J, Mahajan A, Lin A, Cannesson M. Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg. 2017 Nov;125(5):1784-1792. doi: 10.1213/ANE.0000000000002510. PMID: 29049123; PMCID: PMC7402216. Olausson A, Svensson CJ, Andréll P, Jildenstål P, Thörn SE, Wolf A. Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis. Acta Anaesthesiol Scand. 2022 Feb;66(2):170-185. doi: 10.1111/aas.13994. Epub 2021 Nov 11. PMID: 34724195. Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S, Chen H. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine (Baltimore). 2023 Sep 22;102(38):e35126. doi: 10.1097/MD.0000000000035126. PMID: 37746991; PMCID: PMC10519493. Parra-Sanchez I, Abdallah R, You J, Fu AZ, Grady M, Cummings K 3rd, Apfel C, Sessler DI. A time-motion economic analysis of postoperative nausea and vomiting in ambulatory surgery. Can J Anaesth. 2012 Apr;59(4):366-75. doi: 10.1007/s12630-011-9660-x. Epub 2012 Jan 6. PMID: 22223185. Apfel, CC, Laara, E, Koivuranta, M, Greim, CA, Roewer, N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693-700 Camilleri M, Lembo A, Katzka DA. Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017 Sep;15(9):1338-1349. doi: 10.1016/j.cgh.2017.05.014. Epub 2017 May 19. PMID: 28529168; PMCID: PMC5565678. Jin S, Liang DD, Chen C, Zhang M, Wang J. Dexmedetomidine prevent postoperative nausea and vomiting on patients during general anesthesia: A PRISMA-compliant meta analysis of randomized controlled trials. Medicine (Baltimore). 2017 Jan;96(1):e5770. doi: 10.1097/MD.0000000000005770. PMID: 28072722; PMCID: PMC5228682. Qi Y, Zhou M, Zheng W, Dong Y, Li W, Wang L, Xu H, Zhang M, Yang D, Wang L, Zhou H. Effect of S-Ketamine on Postoperative Nausea and Vomiting in Patients Undergoing Video-Assisted Thoracic Surgery: A Randomized Controlled Trial. Drug Des Devel Ther. 2024 Apr 16;18:1189-1198. doi: 10.2147/DDDT.S449705. PMID: 38645990; PMCID: PMC11032156. Wang Q, Ding X, Huai D, Zhao W, Wang J, Xie C. Effect of Intravenous Lidocaine Infusion on Postoperative Early Recovery Quality in Upper Airway Surgery. Laryngoscope. 2021 Jan;131(1):E63-E69. doi: 10.1002/lary.28594. Epub 2020 Mar 2. PMID: 32119135. Bakan M, Umutoglu T, Topuz U, Uysal H, Bayram M, Kadioglu H, Salihoglu Z. Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study. Braz J Anesthesiol. 2015 May-Jun;65(3):191-9. doi: 10.1016/j.bjane.2014.05.001. Epub 2014 Jun 3. PMID: 25925031. Beloeil H, Garot M, Lebuffe G, Gerbaud A, Bila J, Cuvillon P, Dubout E, Oger S, Nadaud J, Becret A, Coullier N, Lecoeur S, Fayon J, Godet T, Mazerolles M, Atallah F, Sigaut S, Choinier PM, Asehnoune K, Roquilly A, Chanques G, Esvan M, Futier E, Laviolle B; POFA Study Group; SFAR Research Network. Balanced Opioid-free Anesthesia with Dexmedetomidine versus Balanced Anesthesia with Remifentanil for Major or Intermediate Noncardiac Surgery. Anesthesiology. 2021 Apr 1;134(4):541-551. doi: 10.1097/ALN.0000000000003725. PMID: 33630043. Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, Jin Z, Kovac AL, Meyer TA, Urman RD, Apfel CC, Ayad S, Beagley L, Candiotti K, Englesakis M, Hedrick TL, Kranke P, Lee S, Lipman D, Minkowitz HS, Morton J, Philip BK. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020 Aug;131(2):411-448. doi: 10.1213/ANE.0000000000004833. Erratum in: Anesth Analg. 2020 Nov;131(5):e241. doi: 10.1213/ANE.0000000000005245. PMID: 32467512. Egan TD. Are opioids indispensable for general anaesthesia? Br J Anaesth. 2019 Jun;122(6):e127-e135. doi: 10.1016/j.bja.2019.02.018. Epub 2019 Mar 28. PMID: 31104756. Shanthanna H, Ladha KS, Kehlet H, Joshi GP. Perioperative Opioid Administration. Anesthesiology. 2021 Apr 1;134(4):645-659. doi: 10.1097/ALN.0000000000003572. PMID: 32991672. Myles PS, Wengritzky R. Simplified postoperative nausea and vomiting impact scale for audit and post-discharge review. Br J Anaesth. 2012 Mar;108(3):423-9. doi: 10.1093/bja/aer505. Epub 2012 Jan 29. PMID: 22290456. Dinges HC, Otto S, Stay DK, Bäumlein S, Waldmann S, Kranke P, Wulf HF, Eberhart LH. Side Effect Rates of Opioids in Equianalgesic Doses via Intravenous Patient-Controlled Analgesia: A Systematic Review and Network Meta-analysis. Anesth Analg. 2019 Oct;129(4):1153-1162. doi: 10.1213/ANE.0000000000003887. PMID: 30418234. Feng CD, Xu Y, Chen S, Song N, Meng XW, Liu H, Ji FH, Peng K. Opioid-free anaesthesia reduces postoperative nausea and vomiting after thoracoscopic lung resection: a randomised controlled trial. Br J Anaesth. 2024 Feb;132(2):267-276. doi: 10.1016/j.bja.2023.11.008. Epub 2023 Dec 1. PMID: 38042725. Zhang Y, Ma D, Lang B, Zang C, Sun Z, Ren S, Chen H. Effect of opioid-free anesthesia on the incidence of postoperative nausea and vomiting: A meta-analysis of randomized controlled studies. Medicine (Baltimore). 2023 Sep 22;102(38):e35126. doi: 10.1097/MD.0000000000035126. PMID: 37746991; PMCID: PMC10519493. Zhou F, Cui Y, Cao L; Opioid-Free Anesthesia Working Group. The effect of opioid-free anaesthesia on the quality of recovery after endoscopic sinus surgery: A multicentre randomised controlled trial. Eur J Anaesthesiol. 2023 Aug 1;40(8):542-551. doi: 10.1097/EJA.0000000000001784. Epub 2023 Jun 29. PMID: 37377372.

Dr. Jess Hawkins, an anesthesia resident at Massachusetts General Hospital, delves into the intricate world of remifentanil and opioid-induced hyperalgesia. She discusses its complexities and challenges, highlighting how remifentanil can influence pain sensitivity and opioid usage in postoperative patients. The conversation covers significant studies on the effects of different dosages and withdrawal implications, sparking important conversations about improving pain management strategies. This session is a must-listen for those interested in anesthesia and pain management.

Dr. Caroline Andrew, an anesthesia resident at Massachusetts General Hospital, and Dr. David Nathan, Director of its Diabetes Center and Harvard Medical School Professor, delve into the complex relationship between intraoperative dexamethasone and diabetes. They discuss a case study highlighting elevated blood sugar risks, scrutinize a randomized control trial revealing dexamethasone’s significant impact on post-surgical glucose levels, and emphasize the importance of careful insulin management for diabetic patients, addressing the broader implications for patient outcomes.

Dr. Zach Cost, an anesthesia resident at Massachusetts General Hospital, and Dr. Pavan Bendapudi, assistant professor at Harvard Medical School, delve into tranexamic acid (TXA) and its relationship with thromboembolic risk. They dissect the clash between TXA's hemostatic benefits and potential dangers, referencing pivotal studies like CRASH-2. Their conversation also covers differentiating TXA from Amicar regarding efficacy and risks, while exploring its effectiveness in surgery and the complexities surrounding antifibrinolytic therapy.

Dr. Mark Neuman and Dr. Sam Falkson join the show to discuss the literature around risks of regional versus general anesthesia for postoperative delirium. Dr. Neuman is the founding Director of the Center for Perioperative Outcomes Research and Transformation and Professor of Anesthesiology at Penn Medicine. Dr. Sam Falkson is an anesthesia resident at the Massachusetts General Hospital. This podcast was recorded as part of the Depth of Anesthesia podcast elective. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues. — Follow us on Instagram @DepthofAnesthesia and on Twitter (X) @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016;2(2):CD000521. Ravi B, Pincus D, Choi S, Jenkinson R, Wasserstein DN, Redelmeier DA. Association of duration of surgery with postoperative delirium among patients receiving hip fracture repair. JAMA Netw Open. 2019;2(2):e190111. Patel V, Champaneria R, Dretzke J, Yeung J. Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review. BMJ Open. 2018;8(12):e020757. Zheng X, Tan Y, Gao Y, Liu Z. Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials. BMC Anesthesiol. 2020 Jun 30;20(1):162. Neuman MD, Feng R, Carson JL, et al. Spinal anesthesia or general anesthesia for hip surgery in older adults. N Engl J Med. 2021;385(22):2025-2035. Rathmell JP, Avidan MS. Patient-centered outcomes after general and spinal anesthesia. N Engl J Med. 2021 Nov 25;385(22):2088–9. Stone AB, Poeran J, Memtsoudis SG. There remains a role for neuraxial anesthesia for hip fracture surgery in the post-REGAIN era. Reg Anesth Pain Med. 2023 Aug;48(8):430-432. doi: 10.1136/rapm-2022-104071. Epub 2023 Mar 28. PMID: 36977527. Li T, Li J, Yuan L, et al. Effect of regional vs general anesthesia on incidence of postoperative delirium in older patients undergoing hip fracture surgery: the raga randomized trial. JAMA. 2022;327(1):50-58.

Dr. Nick Kumar and Dr. Andy Siemens from the Massachusetts General Hospital anesthesia residency join the show to discuss the literature comparing double lumen endotracheal tubes and bronchial blockers. Dr. Dan Saddawi-Konefka joins as our faculty expert - special thanks to Dan for supporting the ongoing Depth of Anesthesia podcast elective. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Clayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, Hu M, Sinclair A, Tan J. A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth. 2015 Aug;29(4):955-66. doi: 10.1053/j.jvca.2014.11.017. Epub 2014 Dec 2. PMID: 25753765. Uwe Klein, Waheedullah Karzai, Frank Bloos, Mathias Wohlfarth, Reiner Gottschall, Harald Fritz, Michael Gugel, Albrecht Seifert; Role of Fiberoptic Bronchoscopy in Conjunction with the Use of Double-lumen Tubes for Thoracic Anesthesia : A Prospective Study. Anesthesiology 1998; 88:346–350 doi: https://doi.org/10.1097/00000542-199802000-00012 Risse J, Szeder K, Schubert AK, Wiesmann T, Dinges HC, Feldmann C, Wulf H, Meggiolaro KM. Comparison of left double lumen tube and y-shaped and double-ended bronchial blocker for one lung ventilation in thoracic surgery-a randomised controlled clinical trial. BMC Anesthesiol. 2022 Apr 2;22(1):92. doi: 10.1186/s12871-022-01637-1. PMID: 35366801; PMCID: PMC8976407. Morris BN, Fernando RJ, Garner CR, Johnson SD, Gardner JC, Marchant BE, Johnson KN, Harris HM, Russell GB, Wudel LJ Jr, Templeton TW. A Randomized Comparison of Positional Stability: The EZ-Blocker Versus Left-Sided Double-Lumen Endobronchial Tubes in Adult Patients Undergoing Thoracic Surgery. J Cardiothorac Vasc Anesth. 2021 Aug;35(8):2319-2325. doi: 10.1053/j.jvca.2020.11.056. Epub 2020 Nov 28. PMID: 33419686. Jo Mourisse, Jordi Liesveld, Ad Verhagen, Garance van Rooij, Stefan van der Heide, Olga Schuurbiers-Siebers, Erik Van der Heijden; Efficiency, Efficacy, and Safety of EZ-Blocker Compared with Left-sided Double-lumen Tube for One-lung Ventilation. Anesthesiology 2013; 118:550–561 doi: https://doi.org/10.1097/ALN.0b013e3182834f2d

It's our first solo episode! We review the evidence around perioperative use of gabapentinoids (gabapentin and pregabalin) and discuss interesting concepts including trial sequential analysis and minimally important difference. If you enjoy our content, leave a 5-star review on Apple Podcasts and share our content with your colleagues. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Dirks J, Fredensborg BB, Christensen D, Fomsgaard JS, Flyger H, Dahl JB. A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mastectomy. Anesthesiology. 2002 Sep;97(3):560-4. doi: 10.1097/00000542-200209000-00007. PMID: 12218520. Ian Gilron; Is Gabapentin a "Broad-spectrum" Analgesic?. Anesthesiology 2002; 97:537–539 doi: https://doi.org/10.1097/00000542-200209000-00004 Mishriky BM, Waldron NH, Habib AS. Impact of pregabalin on acute and persistent postoperative pain: a systematic review and meta-analysis. Br J Anaesth. 2015 Jan;114(1):10-31. doi: 10.1093/bja/aeu293. Epub 2014 Sep 10. PMID: 25209095.Fabritius ML, Geisler A, Petersen PL, Nikolajsen L, Hansen MS, Kontinen V, Hamunen K, Dahl JB, Wetterslev J, Mathiesen O. Gabapentin for post-operative pain management - a systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand. 2016 Oct;60(9):1188-208. doi: 10.1111/aas.12766. Epub 2016 Jul 18. Erratum in: Acta Anaesthesiol Scand. 2017 Mar;61(3):357-359. PMID: 27426431. Chan JSK, Harky A. Trial sequential analysis in meta-analyses: A clinically oriented approach with real-world example. J Thorac Cardiovasc Surg. 2021 Jul;162(1):167-173. doi: 10.1016/j.jtcvs.2020.06.063. Epub 2020 Jun 27. PMID: 32868066. Clephas PRD, Kranke P, Heesen M. How to perform and write a trial sequential analysis. Anaesthesia. 2022 Jul 13. doi: 10.1111/anae.15811. Epub ahead of print. PMID: 35831946. Michael Verret, François Lauzier, Ryan Zarychanski, Caroline Perron, Xavier Savard, Anne-Marie Pinard, Guillaume Leblanc, Marie-Joëlle Cossi, Xavier Neveu, Alexis F. Turgeon, the Canadian Perioperative Anesthesia Clinical Trials (PACT) Group; Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology 2020; 133:265–279 doi: https://doi.org/10.1097/ALN.0000000000003428 Deljou A, Hedrick SJ, Portner ER, Schroeder DR, Hooten WM, Sprung J, Weingarten TN. Pattern of perioperative gabapentinoid use and risk for postoperative naloxone administration. Br J Anaesth. 2018 Apr;120(4):798-806. doi: 10.1016/j.bja.2017.11.113. Epub 2018 Feb 10. PMID: 29576120. Kharasch ED, Clark JD, Kheterpal S. Perioperative Gabapentinoids: Deflating the Bubble. Anesthesiology. 2020 Aug;133(2):251-254. doi: 10.1097/ALN.0000000000003394. PMID: 32667153; PMCID: PMC7367437.

Dr. Chris Di Capua and Dr. Bryan Glezerson (@BryanGlezerson) join the show to discuss the literature around the risk of aspiration with LMAs compared to ETTs. This is an episode produced from the Depth of Anesthesia Podcast Elective that's available to MGH anesthesia residents. Special thanks to Dr. Saddawi-Konefka for supporting the initiative. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anaesth. 1998 Jun;45(6):564-7. doi: 10.1007/BF03012709. PMID: 9669012. Bernardini A, Natalini G. Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube: analysis on 65 712 procedures with positive pressure ventilation. Anaesthesia. 2009 Dec;64(12):1289-94. doi: 10.1111/j.1365-2044.2009.06140.x. Epub 2009 Oct 23. PMID: 19860753. Qamarul Hoda M, Samad K, Ullah H. ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery. Cochrane Database Syst Rev. 2017;7(7):CD009026. Published 2017 Jul 20. doi:10.1002/14651858.CD009026.pub2 Maltby JR, Beriault MT, Watson NC, Fick GH. Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-Classic vs. tracheal intubation. Can J Anaesth. 2000 Jul;47(7):622-6. doi: 10.1007/BF03018993. PMID: 10930200. Kim D, Park S, Kim JM, Choi GS, Kim GS. Second generation laryngeal mask airway during laparoscopic living liver donor hepatectomy: a randomized controlled trial. Nature. 2021 Feb 11;11(1):3532. doi: 10.1038/s41598-021-83173-5. PMID: 33574495; PMCID: PMC7878811. Parikh SS, Parekh SB, Doshi C, Vyas V. ProSeal Laryngeal Mask Airway versus Cuffed Endotracheal Tube for Laparoscopic Surgical Procedures under General Anesthesia: A Random Comparative Study. Anesth Essays Res. 2017;11(4):958-963. doi:10.4103/aer.AER_97_17 Park SK, Ko G, Choi GJ, Ahn EJ, Kang H. Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis. Medicine (Baltimore). 2016 Aug;95(33):e4598. doi: 10.1097/MD.0000000000004598. PMID: 27537593; PMCID: PMC5370819. White LD, Thang C, Hodsdon A, Melhuish TM, Barron FA, Godsall MG, Vlok R. Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis. Anesth Analg. 2020 Oct;131(4):1092-1101. doi: 10.1213/ANE.0000000000004618. PMID: 32925330. Halaseh BK, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H. The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases. Anaesth Intensive Care. 2010 Nov;38(6):1023-8. doi: 10.1177/0310057X1003800610. PMID: 21226432. Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. doi: 10.1002/14651858.CD010105.pub2. PMID: 24014230.