Increased lung clearance of isoflurane shortens emergence in obesity: a prospective randomized-controlled trial

Accelerated ethanol elimination via the lungs

Ethanol poisoning is endemic the world over. Morbidity and mortality depend on blood ethanol levels which in turn depend on the balance between its rates of absorption and clearance. Clearance of ethanol is mostly at a constant rate via enzymatic metabolism. We hypothesized that isocapnic hyperpnea (IH), previously shown to be effective in acceleration of clearance of vapour anesthetics and carbon monoxide, would also accelerate the clearance of ethanol. In this proof-of-concept pilot study, five healthy male subjects were brought to a mildly elevated blood ethanol concentration (~ 0.1%) and ethanol clearance monitored during normal ventilation and IH on different days. IH increased elimination rate of ethanol in proportion to blood levels, increasing the elimination rate more than three-fold. Increased veno-arterial ethanol concentration differences during IH verified the efficacy of ethanol clearance via the lung. These data indicate that IH is a nonpharmacologic means to accelerate the elimination of ethanol by superimposing first order elimination kinetics on underlying zero order liver metabolism. Such kinetics may prove useful in treating acute severe ethanol intoxication.

Perioperative complications and Intensive Care Unit utilization in super-superobese patients undergoing laparoscopic bariatric surgery

Objective:

Anesthetic management for super-superobese (SSO) patients (body mass index [BMI] ≥60 kg/m²) presents a challenge for anesthesiologists. This study aimed at characterizing the early complications and Intensive Care Unit (ICU) utilization in SSO patients receiving laparoscopic bariatric surgery.

Materials and Methods:

Totally, 25 SSO patients receiving laparoscopic bariatric surgery between June 2006 and December 2011 were reviewed. The data collected included patient demographics, preoperative comorbidities, anesthetic techniques, airway management, perioperative adverse events, ICU utilization, and early complications occurring within 30 days of index surgery. Early complications were defined as the adverse events that led to permanent detrimental effects or required significant additional intervention.

Results:

A retrospective analysis was performed on data from 25 consecutive SSO patients (age: 31.2 ± 11.1 years; BMI: 64.9 ± 4.7 kg/m²). Tracheal intubation was attempted successfully in all patients but was difficult in two cases when using laryngoscopy. Bronchospasm was observed in five cases (20%) after tracheal intubation. Postoperative ICU utilization was required in five cases (20%). Early complications occurred in two cases during their stay in postanesthesia care unit (including one case of respiratory failure and one case of hyperkalemia) and in two cases during their stay in ICU (both with respiratory failure). The incidence of early complications was 16%. All patients were discharged from the hospital without sequelae.

Conclusions:

It is imperative to anticipate the potential for developing perioperative adverse events and postoperative complications in SSO patients after bariatric surgery. Appropriate utilization of ICU resources may enhance patient safety.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.