12-13 coverKomatsu and colleagues (Anesthetic Induction with Etomidate, Rather than Propofol, Is Associated with Increased 30-Day Mortality and Cardiovascular Morbidity After Noncardiac Surgery) identified a 2.5 fold increase in likelihood of death and a 1.5 fold increase in cardiovascular morbidity in a retrospective study of 2144 patients who received etomidate for induction of noncardiac anesthesia as compared to propensity matched subjects who received propofol. In their accompanying editorial Legrand and Plaud (Etomidate and General Anesthesia: The Butterfly Effect?) note that these findings are consistent with other retrospective findings, but cannot be considered definitive until confirmed in adequately powered prospective randomized controlled trials.

How do lipid emulsions reverse bupivacaine-induced cardiac dysrhythmias? In a study of proton channel currents in rat microglial cells Hori and colleagues (The Effect of Lipid Emulsion on Intracellular Bupivacaine as a Mechanism of Lipid Resuscitation: An Electrophysiological Study Using Voltage-Gated Proton Channels) demonstrated a three-fold reduction in intracellular bupivacaine from extracellular lipid emulsion.

The effects of anesthetics on the developing brain remain a subject of considerable interest and concern. In this issue of Anesthesia & Analgesia Kato and colleagues (Neonatal Exposure to Sevoflurane Causes Significant Suppression of Hippocampal Long-Term Potentiation in Postgrowth Rats) examined the influence of a 2-hour exposure to 2% sevoflurane in 7-day postnatal rats. Subsequent studies in postgrowth (i.e., mature) animals demonstrated reduced induction of long-term potentiation in the hippocampus, suggesting a putative mechanism for neurocognitive impairment from volatile anesthetic exposure.

There have been many studies of techniques to entertain, distract, and alleviate perioperative anxiety in children. Kerimoglu and colleagues (Anesthesia Induction Using Video Glasses as a Distraction Tool for the Management of Preoperative Anxiety in Children) compared oral midazolam to video glasses displaying cartoons and movies. The video glasses prevented the increase in anxiety during induction observed in children who received oral midazolam.

In a rat partial sciatic nerve ligation model Yang and colleagues (Intrathecal Ultra-Low Dose Naloxone Enhances the Antihyperalgesic Effects of Morphine and Attenuates Tumor Necrosis Factor-α and Tumor Necrosis Factor-α Receptor 1 Expression in the Dorsal Horn of Rats with Partial Sciatic Nerve Transection) demonstrated that the antihyperalgesic and antiallodynic effects of morphine were abolished by high doses of intrathecal naloxone, but enhanced by low doses of intrathecal naloxone.

On The Cover

The dictates of chaos theory describe how the conditions of a singular event can predetermine the pathway through space-time leading to a wide range of downstream outcomes in highly dynamic, non-linear systems. Readers may be familiar with this as it has been referred to as the butterfly effect, wherein large-scale weather patterns may result from the decision of a butterfly to flap her wings weeks earlier. This effect is all around us and can be seen in something as simple as the first pivotal move in a chess game to the critical decisions we make as anesthesiologists. Of these judgments, the choice of anesthetic induction agent comes to light in this issue. Does etomidate carve an alternate reality that is decidedly morbid? The drug we choose, the pawn we displace, is a move that is ours to make.