Review Course Lectures International Anesthesia Research Society IARS 2011 REVIEW COURSE LECTURES The material included in the publication has not undergone peer review or review by the Editorial Board of Anesthesia and Analgesia for this publication. Any of the material in this publication may have been transmitted by the author to IARS in various forms of electronic medium. IARS has used its best efforts to receive and format electronic submissions for this publication but has not reviewed each abstract for the purpose of textual error correction and is not liable in any way for any formatting, textual, or grammatical error or inaccuracy. 2 ©2011 International Anesthesia Research Society. Unauthorized Use Prohibited IARS 2011 REVIEW COURSE LECTURES Table of Contents Perioperative Implications of Emerging Concepts In Management of the Malignant Hyperthermia Vascular Aging, Health And Disease Patient In Ambulatory Surgery Charles W. Hogue, MD ..............................1 Denise J. Wedel, MD ...............................38 Professor of Anesthesiology and Professor of Anesthesiology, Mayo Clinic Critical Care Medicine Rochester, Minnesota Chief, Division of Adult Anesthesia The Johns Hopkins University School of Medicine, Central Venous Access Guideline The Johns Hopkins Hospital Development and Recommendations Baltimore, Maryland Stephen M. Rupp, MD ..............................41 Anesthesiologist Perioperative Management of Pain and PONV in Medical Director, Perioperative Services Ambulatory Surgery Virginia Mason Medical Center, Seattle, Washington Spencer S. Liu, MD .................................5 Clinical Professor of Anesthesiology Pediatric Anesthesia and Analgesia Outside the OR: Director of Acute Pain Service What You Need To Know Hospital for Special Surgery Pierre Fiset, MD, FRCPC............................47 New York, New York Department Head, Anesthesiology Montreal Children’s Hospital Colloid or Crystalloid: Any Differences In Outcomes? Montreal, Quebec, Canada Tong J. (TJ) Gan, MD, FRCA, MHS, Lic.Ac..............7 Professor of Anesthesiology Genomics: Why Do ‘Similar’ Patients Have Vice Chair for Clinical Research Different Outcomes? Duke University Medical Center Debra A. Schwinn, MD.............................50 Durham, North Carolina Professor and Chair, Department of Anesthesiology and Pain Medicine Critical Care Update for 2011 Adjunct Professor of Pharmacology and Robert N. Sladen, MD, FCCM .......................13 Genome Sciences, University of Washington Professor, Department of Anesthesiology Seattle, Washington Professor and Vice Chair of Anesthesiology Chief, Division of Critical Care Updates in Neuroanesthesiology Department of Anesthesiology College of George A. Mashour, MD, PhD ......................55 Physicians and Surgeons, Columbia University Director, Division of Neuroanesthesiology New York, New York Assistant Professor of Anesthesiology and Neurosurgery Faculty OB Anesteshia Update: The New Decade Neuroscience Graduate Program Cynthia A. Wong, MD ..............................24 University of Michigan Medical School Professor and Vice Chair Ann Arbor, Michigan Department of Anesthesiology Northwestern University Feinberg Multimodal Analgesia for Perioperative School of Medicine Pain Management Chicago, Illinois Asokumar Buvanendran, MD ......................58 Director, Orthopedic Anesthesia 3-Dimensional Transesophageal Echocardiography: Professor, Department of Anesthesiology Pretty Pictures or an Advance in Technology? Rush University Medical Center, Chicago, Illinois Stanton K. Shernan, MD, FAHA, FASE ...............28 Director of Cardiac Anesthesia You Can’t Put It Back: Associate Professor of Anesthesia Anesthetic Management for Lung Resection Department of Anesthesiology, Perioperative Peter Douglas Slinger, MD .........................63 and Pain Medicine Professor of Anesthesia, University of Toronto Brigham and Women’s Hospital Toronto, Ontario, Canada Harvard Medical School Boston, Massachusetts Does Blood Save Lives? Colleen G. Koch, MD, MS, FACC, MBA ...............67 Update on Thoracic Epidurals: Risks vs. Benefits? Professor of Anesthesiology Hugo Van Aken, MD, PhD, FRCA, FANZCA . .30 Cleveland Clinic Lerner College of Medicine of Case Professor, Department of Anesthesiology Western Reserve University and Intensive Care, University Hospital Müenster Vice Chair, Education and Research Münster, Germany Department of Cardiothoracic Anesthesia Cleveland Clinic, Cleveland, Ohio ©International Anesthesia Research Society. Unauthorized Use Prohibited. i Perioperative Implications of Emerging Concepts in Vascular Aging, Health, and Disease Charles W. Hogue, MD The Department of Anesthesiology & Critical Care Medicine The Johns Hopkins University School of Medicine, Baltimore, MD Despite a decline in mortality rates over the past and their implications for the care of elderly patients four decades, cardiovascular disease remains the undergoing surgery will be provided. leading cause of morbidity and mortality in the US, affecting 80 million adults.1,2 The prevalence and public AGERELATED VASCULAR CHANGES health impact of cardiovascular disease is projected Chronological age is an established risk factor to steadily increase due to the general aging of the for vascular disease, yet age-associated changes in population and the rising incidence of obesity and the vasculature vary greatly between individuals.16 hypertension.2 The implications of an aging population Although there has been much focus on pathological with cardiovascular disease are important for the more abnormalities involving the intima (justifiably since than 20 million individuals who undergo surgery this is the site of atherosclerosis and endothelial annually in the US, of whom, 10% will have a major dysfunction), aging is associated with changes to all complication within 30 days of surgery.3,4 Adverse layers of the vasculature that lead to a generalized complications that affect the brain, such as delirium “stiffening” of central arteries. These changes can and postoperative cognitive dysfunction (POCD), occur in the absence of atherosclerosis and form the are even more common. These conditions are distinct basis of the growing concept of “vascular age” as a phenomena that disproportionately affect the elderly. determinant of risk for adverse outcomes independent Delirium is defined as an acute fluctuating disorder of chronological age.16-18 In addition to providing of consciousness, attention, cognition, and perception prognostic information for ambulatory populations, that cannot be explained by preexisting or evolving it is now appreciated that arterial stiffness identifies dementia (DSM-IV). Postoperative delirium occurs in risk for myocardial infarction, stroke, renal failure, 5% to 15% of patients but in as many as 16% to 62% and mortality after cardiac surgery.19-22 Consequently, of high-risk patients undergoing hip fracture surgery.5,6 manifestations of vascular aging might provide the Postoperative delirium is independently associated basis for more refined risk stratifications in balancing with risk for prolonged hospitalization, medical the risks and benefits of surgery. complications, loss of independence, admission to Multiple mechanisms for age-related arterial a nursing home, reduced functional capacity, and stiffening have been identified, including increased mortality.7-9 Delirium typically occurs ~24 hrs after deposition of collagen and increased fragmentation of surgery and resolves within 48 hrs, but it may persist elastin in the proximal aorta.23,24 Media accumulation until hospital discharge in 39% of patients and for 1 of matrix metalloproteinases and fibronectin may month after surgery in 33%.10,11 POCD is a decrement promote aortic wall thickening by promoting matrix from baseline in higher order thought processes protein degradation.25,26 Furthermore, vascular smooth involving learning, memory, attention, visual-spatial muscle cells have been found to increase in size in processing, abstract thinking, and executive function. the media and migrate to the endothelium, an effect The diagnosis of POCD requires psychometric testing, that might result from the binding of elastin-laminin and thus, unlike delirium, deficits may not always fragments to specific smooth muscle and endothelial be clinically manifested. Defining the frequency of receptors.27-29 Inflammatory processes also have been POCD is problematic because the literature contains implicated in the pathophysiology of central artery many methodological inconsistencies, including wall and intimal thickening,29 and the cross-linking of characteristics of the patients tested, psychometric extracellular matrix proteins has been linked to arterial battery used, timing of testing, definitions of decline, wall thickening.30,31 A genetic predisposition to vascular and other factors.6 Regardless, POCD has been stiffening has also been suggested, with polymorphisms suggested to occur in 12% to 30% of patients 3 months of the angiotensin receptor, metalloproteinases, after cardiac surgery and in 10% to 13% of elderly fibrillin-1, endothelin, and others implicated.32-36 patients after non-cardiac surgery.12-14 The development of POCD is associated with longer hospitalization, MANIFESTATIONS OF CENTRAL VASCULAR STIFFNESS altered quality of life, and early and late mortality.6,14,15 The ejection of blood from the left ventricle generates a series of waves that are initially propagated antegrade, A further understanding of the effects of aging on