June 2014 blood 2The June 2014 issue of Anesthesia & Analgesia has just posted.  Dr. Steven Shafer, editor-in-chief of Anesthesia & Analgesia writes:  A survey by Vetter and colleagues (Perceptions About Blood Transfusion: A Survey of Surgical Patients and Their Anesthesiologists and Surgeons) found that physicians were twice as likely as their patients to believe blood transfusions were “very often” risky, a perception not supported by data. Brown and colleagues (Odds of Transfusion for Older Adults Compared to Younger Adults Undergoing Surgery) found that advanced age was an independent risk factor for transfusion, despite a lack of evidence that elderly patients require higher hemoglobin values. In her accompanying editorial, Paloma Toledo (Shared Decision-Making and Blood Transfusions: Is It Time to Share More?) urges development of evidence-based decision aids for patients and their physicians to facilitate informed patient-centered transfusion decisions.

Murphy and colleagues (The Effect of Single Low-Dose Dexamethasone on Blood Glucose Concentrations in the Perioperative Period: A Randomized, Placebo-Controlled Investigation in Gynecologic Surgical Patients) found that perioperative dexamethasone did not elevate glucose concentrations.  De Oliveira and colleagues (Is Dexamethasone Associated with Recurrence of Ovarian Cancer?) found that perioperative dexamethasone did not increase the risk of ovarian cancer recurrence. In their accompanying editorial Colin and Gan (Cancer Recurrence and Hyperglycemia with Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis: More Moot Points?) note that these data supplement prior studies showing no adverse effects of dexamethasone on wound healing or wound infection, all supporting the safety of dexamethasone for postoperative nausea and vomiting prophylaxis.

Animal models suggest isoflurane is one of the most neurotoxic volatile anesthetics to the developing brain. Cheng and Levy (Subclinical Carbon Monoxide Limits Apoptosis in the Developing Brain After Isoflurane Exposure) demonstrate that small amounts of carbon monoxide (CO) limit isoflurane-induced apoptosis, suggesting a strategy for mitigating risks of neurologic injury in young children. In her accompanying editorial, Vesna Jevtovic-Todorovic (Good Gas, Bad Gas: Isoflurane, Carbon Monoxide, and Which Is Which?) notes that these results complement other risk-mitigating strategies. However, since CO itself causes apoptosis, our understanding of the biology is insufficient to know if CO can mitigate the risk of volatile anesthetics to the developing brain.

Based on survey and closed-claims analysis, Cote and colleagues (Death or Neurologic Injury after Tonsillectomy in Children with a Focus on Obstructive Sleep Apnea: Houston, We Have a Problem!) found that children with risk factors for obstructive sleep apnea (OSA) were at increased risk for asphyxial death after tonsillectomy. The authors recommended improved postoperative ventilatory monitoring and decreased use of opioids in children at risk for OSA. In their accompanying editorial, Brown and Brouillette (The Elephant in the Room: Lethal Apnea at Home after Adenotonsillectomy) recommend policy changes to encourage overnight observation of children who exhibit oxygen desaturation during recovery from tonsillectomy.

On the Cover

On this month’s cover the camera’s shutter has caught a glimpse of the first droplet of allogeneic blood piercing through the surface of saline within a drip chamber. In doing so, a displaced, upsurging wavefront billows forth. The juxtaposition of blood against saline could not be more ironic visually. The calm, transparent quality of routine intravenous fluid attains a sense of order bordering crystalline geometry; all of which becomes disarticulated with an opaque scarlet incursion. The journal’s cover image captures not only this physical event in a literal sense, but also that absolute, instantaneous moment when we transform into the role of a tranfusionist. That critical decision similarly sets forth a current of risks, responsibilities and expectations, all of which may be perceived variably depending on the lens used.