MB's Articles of Interest - July 2000

ARTICLE TITLE: Postoperative pain control by epidural analgesia after transabdominal surgery. Efficacy and problems encountered in daily routine.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Mar 2000, 44(3) p296-301
AUTHOR(S): Andersen G; Rasmussen H; Rosenstock C; Blemmer T; Engbaek J; Christensen M; Ording H
AUTHOR'S ADDRESS: Department of Anaesthesiology, Herlev University Hospital, Denmark.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The efficacy of postoperative epidural pain treatment has been well documented in controlled studies. However, the literature concerning results of daily routine use of this method often only emphasises certain aspects of it. METHODS: A prospective study of 168 patients scheduled for major surgery with transabdominal access was performed in order to evaluate efficacy, side effects, complications and rate of acceptance of postoperative epidural pain treatment. The epidural catheter was placed before surgery and the patients received epidural analgesia by a bupivacaine/morphine mixture for 3 days postoperatively, continued by another 3 days with bolus injections of morphine only. RESULTS: Only few complications followed the insertion of the epidural catheter, but in about 16% of the patients the epidural catheter or the drugs administered by it made reinsertion or change in the type of analgesia necessary during the first 3 post-operative days. Despite the possibility for individualising the treatment and p.r.n. analgesics, pain relief when coughing and moving during day 1-3 was insufficient in 30-50% of the patients. Serious side effects were rare, but pruritus was frequent, as were the symptoms of nausea and vomiting. The patients were generally satisfied with the treatment; however, a small group had unacceptable pain when the epidural catheter was inserted. CONCLUSION: Analgesia was insufficient when coughing and moving in an unacceptably large number of the patients. Also the number of epidural catheter related problems was high. In order to make early intervention possible, the patients and epidural catheters should be observed daily and systematically by members of the staff competent to detect possible problems.
MB. If those who have blindly followed leaders had actually looked at the patients for whom they were prescribing post operative epidural analgesia we would not be in this mess.

ARTICLE TITLE: Auditory evoked responses and learning and awareness during general anesthesia [see comments]
COMMENTS: Comment in: Acta Anaesthesiol Scand 2000 Feb; 44(2):131-2
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Feb 2000, 44(2) p133-43
AUTHOR(S): Ghoneim MM; Block RI; Dhanaraj VJ; Todd MM; Choi WW; Brown CK
AUTHOR'S ADDRESS: Department of Anesthesia, University of Iowa, Iowa City 52242, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: There is a major distinction between conscious and unconscious learning. Monitoring the mid-latency auditory evoked responses (AER) has been proposed as a measure to ascertain the adequacy of the hypnotic state during surgery. In the present study, we investigated the presence of explicit and implicit memories after anesthesia and examined the relationships of such memories to the AER. METHODS: We studied 180 patients scheduled for elective surgical procedures. After a thiopental induction, one of four anesthetics were studied: Opioid bolus: 7.5 microg x kg(-1) fentanyl, 70% N2O, with 2.5 microg x kg(-1) supplements as needed (n=100); Opioid infusion: Alfentanil 50 microg x kg(-1) bolus, 1-1.5 microg x kg(-1) x min(-1) infusion, 70% N2O (n=40); Isoflurane 0.3%: Fentanyl 1 microg x kg(-1), 70% N2O, isoflurane 0.3% expired (n=16); Isoflurane 0.7%: Fentanyl 1 microg x kg(-1), 70% N2O, isoflurane 0.7% expired (n=23). AER were recorded before anesthesia, 5 min after surgical incision and then every 30 min until the end of surgery. A tape of either the story of the "Three Little Pigs" or the "Wizard of Oz" was played continuously between the recordings. Explicit memory was assessed postoperatively by tests of recall and recognition, and implicit memory was assessed by the frequency of story-related free associations to target words from the stories, which were solicited twice during a structured interview. RESULTS: Six patients showed explicit recall of intraoperative events: All received the opioid bolus regimen. About 7% of patients reported dreaming during anesthesia. The incidence of picking the correct story that had been presented during anesthesia averaged 49%, i.e., very close to chance level. Overall, priming occurred only at the second association tests for the opioid bolus regimen, for which the frequency of an association to the presented story among those not giving an association to the control story was 26%, which was double the frequency (13%) of an association to the control story among those not giving an association to the presented story. This was significant by McNemar's test, P=0.02. There were significant associations between awareness, priming and AER, e.g., recall was associated with higher Nb amplitudes during anesthesia and priming was associated with shorter wave latencies. CONCLUSIONS: The incidence of awareness in patients anesthetized with nitrous oxide and bolus supplementation was 6%. Thus, this anesthetic technique did not reduce the risk of awareness compared with the use of nitrous oxide alone. Implicit memory occurred during nitrous oxide and bolus supplementation. Recording AER during anesthesia may help to predict awareness and implicit memory, particularly the former. The short contents of most of the dreams which were recalled could hamper future studies in this area.

ARTICLE TITLE: Operating theatre--the patient is listening [editorial; comment]
COMMENTS: Comment on: Acta Anaesthesiol Scand 2000 Feb; 44(2):133-43
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Feb 2000, 44(2) p131-2
AUTHOR(S): Yli-Hankala A
PUBLICATION TYPE: COMMENT; EDITORIAL
MB. This editorial comment and the previous article related to awareness do not help much with the problem. The article is difficult to follow. I think the things recalled in the theatre may have been only the stories read to them rather than things about the operation itself.

ARTICLE TITLE: No implicit memory for stories played during isoflurane/alfentanil/nitrous oxide anesthesia: a reading speed measurement.
ARTICLE SOURCE: Anesth Analg (United States), Mar 2000, 90(3) p733-8
AUTHOR(S): Munte S; Lullwitz E; Leuwer M; Mitzlaff B; Munte TF; Hussein S; Piepenbrock SA
AUTHOR'S ADDRESS: Departments of Anesthesiology, Neurology, Neurosurgery, Medical School of Hanover, Hanover, Germany.
PUBLICATION TYPE: JOURNAL ARTICLE
IMPLICATIONS: We showed that implicit memory during general anesthesia can be abolished by changing the hypnotic anesthetic. Increased postoperative reading speed for stories presented during propofol-alfentanil-nitrous oxide anesthesia was shown in a previous experiment, but not in our study using isoflurane for balanced anesthesia.
MB. Balanced anesthesia usually means no potent inhalational agents. The term is better not used anymore.

ARTICLE TITLE: Pain intensity and pain relief after surgery. A comparison between patients' reported assessments and nurses' and physicians' observations.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Jan 2000, 44(1) p58-62
AUTHOR(S): Klopfenstein CE; Herrmann FR; Mamie C; Van Gessel E; Forster A
AUTHOR'S ADDRESS: Department of Anaesthesiology, Pharmacology and Surgical Intensive Care, University Hospitals of Geneva, Switzerland.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: The results of this survey suggest that assessment of pain and pain relief is inadequately done by both physicians and nurses. This emphasises the importance of a better training, and a systematic assessment of pain intensity and pain relief.
MB. Maybe the problem is not a bad a implied by the pain industry.

ARTICLE TITLE: Patient-controlled versus nurse-controlled pain treatment after coronary artery bypass surgery.
ARTICLE SOURCE: Acta Anaesthesiol Scand (Denmark), Jan 2000, 44(1) p43-7
AUTHOR(S): Pettersson PH; Lindskog EA; Owall A
AUTHOR'S ADDRESS: Department of Surgical Sciences, Karolinska Institute, Karolinska Hospital, Stockholm, Sweden.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
CONCLUSION: PCA treatment after coronary artery bypass surgery resulted in better pain treatment and the use of more opioid without an increase in side effects compared with traditional NCA treatment.
MB. Previous articles have shown the opposite. 2 such could be quoted which Pattersson does as below. They are the next 2 which do not belong to this month

ARTICLE TITLE: Comparison of patient-controlled analgesia and nurse-controlled infusion analgesia after cardiac surgery.
ARTICLE SOURCE: Anaesth Intensive Care (Australia), Dec 1994, 22(6) p672-8
AUTHOR(S): Myles PS; Buckland MR; Cannon GB; Bujor MA; Langley M; Breaden A; Salamonsen RF; Davis BB

ARTICLE TITLE: Nurse-administered subcutaneous morphine is a satisfactory alternative to intravenous patient-controlled analgesia morphine after cardiac surgery.
ARTICLE SOURCE: Anesth Analg (United States), Jul 1998, 87(1) p11-5
AUTHOR(S): Munro AJ; Long GT; Sleigh JW

MB. From Pettersson et ali's article
" Two other studies have not been able to demonstrate any beneficial effect of PCA after cardiac surgery when compared to either intravenous (7) (Myles et ali) or
subcutaneous (9) (Monro et ali) morphine. In these studies, either a semi-intensive care environment with a high nurse-patient ratio or a detailed protocol for the
administration of morphine is described."
Petterssons study uses ketobenidone infusion as the control

ARTICLE TITLE: Comparison of central venous and inferior vena caval pressures.
ARTICLE SOURCE: Am J Cardiol (United States), Feb 15 2000, 85(4) p518-20, A11
AUTHOR(S): Walsh JT; Hildick-Smith DJ; Newell SA; Lowe MD; Satchithananda DK; Shapiro LM
AUTHOR'S ADDRESS: Department of Cardiology, Papworth Hospital, Papworth Everard, Cambridgeshire, United Kingdom.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Inferior vena caval pressures were measured in 60 patients undergoing cardiac catheterization and compared with central venous pressure from within the right atrium. Mean pressures within the abdominal inferior vena cava were essentially the same as mean right atrial pressure, suggesting that the inferior vena cava provides a useful safe alternative for measuring central venous pressure.
MB. You hardly need a publication to show that. I have seen saphenous vien cut downs used for CVP measurements

ARTICLE TITLE: Prophylactic antibiotics in surgery and surgical wound infections.
ARTICLE SOURCE: Am Surg (United States), Feb 2000, 66(2) p105-11
AUTHOR(S): Polk HC Jr; Christmas AB
AUTHOR'S ADDRESS: Department of Surgery, University of Louisville School of Medicine, Kentucky 40292, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (26 references); REVIEW, TUTORIAL
The debates concerning the dosage and timing of ideal prophylactic administration are likely to continue.

ARTICLE TITLE: A review of septic shock.
ARTICLE SOURCE: Am Surg (United States), Jan 2000, 66(1) p22-9
AUTHOR(S): Hardaway RM
AUTHOR'S ADDRESS: Department of Surgery, Texas Tech University Health Sciences Center, El Paso, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (89 references); REVIEW, TUTORIAL
Data sources include research papers on the subject of septic shock from 1875 until the present. These papers numbered more than 10,000, most of which are not included in the reference list because many are duplicative. The main result of the review of literature is that all of a wide variety of treatments of septic shock have not resulted in a lowering of mortality, but in fact have increased it.

ARTICLE TITLE: Lighted stylet tracheal intubation: a review.
ARTICLE SOURCE: Anesth Analg (United States), Mar 2000, 90(3) p745-56
AUTHOR(S): Davis L; Cook-Sather SD; Schreiner MS
AUTHOR'S ADDRESS: Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (51 references); REVIEW, TUTORIAL

ARTICLE TITLE: The effects of sevoflurane on serum creatinine and blood urea nitrogen concentrations: a retrospective, twenty-two-center, comparative evaluation of renal function in adult surgical patients [see comments]
COMMENTS: Comment in: Anesth Analg 2000 Mar; 90(3):505-8
ARTICLE SOURCE: Anesth Analg (United States), Mar 2000, 90(3) p683-8
AUTHOR(S): Mazze RI; Callan CM; Galvez ST; Delgado-Herrera L; Mayer DB
AUTHOR'S ADDRESS: Department of Anesthesia, Stanford University School of Medicine, Stanford, California, USA. mazze@leland.stanford.edu.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY
IMPLICATIONS: Our data for changes in serum creatinine and blood urea nitrogen indicate that, for exposures of less than 4 minimum alveolar anesthetic concentration/h, sevoflurane is not associated with an increased risk of renal toxicity compared with other commonly used anesthetics. For clinical purposes, the pre- to postoperative changes in serum creatinine and blood urea nitrogen are appropriate measures of renal function in surgical patients.

ARTICLE TITLE: The renal safety of sevoflurane [editorial; comment]
COMMENTS: Comment on: Anesth Analg 2000 Mar; 90(3):683-8
ARTICLE SOURCE: Anesth Analg (United States), Mar 2000, 90(3) p505-8
AUTHOR(S): Bedford RF; Ives HE
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: How long should an internal jugular catheter be? [letter]
ARTICLE SOURCE: Anesth Analg (United States), Feb 2000, 90(2) p500
AUTHOR(S): Nixon C
PUBLICATION TYPE: LETTER
MB. This presents a complicated formular for working out the right length. All catheters & Seldinger wires are marked in cms. It is easy to make sure the catheter is in the right distance from the skin puncture by lining up the 20 cm mark on the wire and the catheter. Left sided catheters should not go beyond the mid-line

ARTICLE TITLE: Cannabis: time for scientific evaluation of this ancient remedy? [editorial]
ARTICLE SOURCE: Anesth Analg (United States), Feb 2000, 90(2) p237-40
AUTHOR(S): Sharpe P; Smith G
PUBLICATION TYPE: EDITORIAL; REVIEW (42 references); REVIEW, TUTORIAL

ARTICLE TITLE: Extracorporeal perfusion for the treatment of acute liver failure.
ARTICLE SOURCE: Ann Surg (United States), Apr 2000, 231(4) p460-70
AUTHOR(S): Stockmann HB; Hiemstra CA; Marquet RL; IJzermans JN
AUTHOR'S ADDRESS: Department of Surgery, University Hospital Dijkzigt and Erasmus University, Rotterdam, The Netherlands.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (90 references); REVIEW, TUTORIAL
CONCLUSIONS: Renewed interest has developed in old and new methods for an extracorporeal approach to the treatment of acute liver failure. Although temporary clinical improvement has been established, further research is needed to achieve a successful long-term clinical outcome. New developments in the field of genetic modification and tissue engineering await clinical application in the near future.

ARTICLE TITLE: Pain after laparoscopic cholecystectomy.
ARTICLE SOURCE: Br J Surg (England), Mar 2000, 87(3) p273-84
AUTHOR(S): Wills VL; Hunt DR
AUTHOR'S ADDRESS: Upper Gastrointestinal Surgical Unit, Level 5, Suite 1, St George Private Medical Centre, South Street, Kogarah, 2217 New South Wales, Australia.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (104 references); REVIEW LITERATURE
CONCLUSION: Pain after LC is multifactorial. Although many methods of analgesia produce short-term benefit, this does not equate with earlier discharge or improved postoperative function. However, single trials evaluating low-pressure insufflation, heated gas and multimodal analgesia suggest that clinically relevant benefits can be achieved.
MB. Well there you go.

ARTICLE TITLE: The new anesthesia machines [editorial]
ARTICLE SOURCE: Can J Anaesth (Canada), Mar 2000, 47(3) p201-4
AUTHOR(S): Sloan IA
INDEXING CHECK TAG(S): Human

ARTICLE TITLE: Litigation in Canada against anesthesiologists practicing regional anesthesia. A review of closed claims.
ARTICLE SOURCE: Can J Anaesth (Canada), Feb 2000, 47(2) p105-12
AUTHOR(S): Peng PW; Smedstad KG
AUTHOR'S ADDRESS: Department of Anesthesia, University of Toronto, Ontario, Canada.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: Twenty percent of all anesthesia claims in Canada are related to regional anesthesia. The legal outcome of these claims is favourable in 90%. Unfavourable clinical outcome is associated with catastrophic or major injury. There were no deaths in the regional anesthesia claims.

ARTICLE TITLE: Exercise-induced arterial hypoxemia.
ARTICLE SOURCE: J Appl Physiol (United States), Dec 1999, 87(6) p1997-2006
AUTHOR(S): Dempsey JA; Wagner PD
AUTHOR'S ADDRESS: John Rankin Laboratory of Pulmonary Medicine, Department of Preventive Medicine, University of Wisconsin-Madison, Madison, Wisconsin 53705, USA. jdempsey@facstaff.wisc.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (59 references); REVIEW, TUTORIAL
ABSTRACT: Exercise-induced arterial hypoxemia (EIAH) at or near sea level is now recognized to occur in a significant number of fit, healthy subjects of both genders and of varying ages. Our review aims to define EIAH and to critically analyze what we currently understand, and do not understand, about its underlying mechanisms and its consequences to exercise performance. Based on the effects on maximal O(2) uptake of preventing EIAH, we suggest that mild EIAH be defined as an arterial O(2) saturation of 93-95% (or 3-4% <rest), moderate EIAH as 88-93%, and severe EIAH as <88%. Both an excessive alveolar-to-arterial PO(2) difference (A-a DO(2)) (>25-30 Torr) and inadequate compensatory hyperventilation (arterial PCO(2) >35 Torr) commonly contribute to EIAH, as do acid- and temperature-induced shifts in O(2) dissociation at any given arterial PO(2). In turn, expiratory flow limitation presents a significant mechanical constraint to exercise hyperpnea, whereas ventilation-perfusion ratio maldistribution and diffusion limitation contribute about equally to the excessive A-a DO(2). Exactly how diffusion limitation is incurred or how ventilation-perfusion ratio becomes maldistributed with heavy exercise remains unknown and controversial. Hypotheses linked to extravascular lung water accumulation or inflammatory changes in the "silent" zone of the lung's peripheral airways are in the early stages of exploration. Indirect evidence suggests that an inadequate hyperventilatory response is attributable to feedback inhibition triggered by mechanical constraints and/or reduced sensitivity to existing stimuli; but these mechanisms cannot be verified without a sensitive measure of central neural respiratory motor output. Finally, EIAH has detrimental effects on maximal O(2) uptake, but we have not yet determined the cause or even precisely identified which organ system, involved directly or indirectly with O(2) transport to muscle, is responsible for this limitation.

ARTICLE TITLE: Influence of positive airway pressure on the pressure gradient for venous return in humans.
ARTICLE SOURCE: J Appl Physiol (United States), Mar 2000, 88(3) p926-32
AUTHOR(S): Jellinek H; Krenn H; Oczenski W; Veit F; Schwarz S; Fitzgerald RD
AUTHOR'S ADDRESS: Department of Anesthesiology and Intensive Care Medicine, Community Hospital of Lainz, A-1130 Vienna, Austria. jeh@ana.khl.magwien.gv.at.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: To study the effect of positive airway pressure (Paw) on the pressure gradient for venous return [the difference between mean systemic filling pressure (Pms) and right atrial pressure (Pra)], we investigated 10 patients during general anesthesia for implantation of defibrillator devices. Paw was varied under apnea from 0 to 15 cmH(2)O, which increased Pra from 7.3 +/- 3.1 to 10.0 +/- 2.3 mmHg and decreased left ventricular stroke volume by 23 +/- 22%. Episodes of ventricular fibrillation, induced for defibrillator testing, were performed during 0- and 15-cmH(2)O Paw to measure Pms (value of Pra 7.5 s after onset of circulatory arrest). Positive Paw increased Pms from 10.2 +/- 3.5 to 12.7 +/- 3.2 mmHg, and thus the pressure gradient for venous return (Pms - Pra) remained unchanged. Echocardiography did not reveal signs of vascular collapse of the inferior and superior vena cava due to lung expansion. In conclusion, we demonstrated that positive Paw equally increases Pra and Pms in humans and alters venous return without changes in the pressure gradient (Pms - Pra).
MB. These authors confuse venous return which always equals cardiac output (vol/time) with filling presuure.

ARTICLE TITLE: Clinical outcomes after carotid endarterectomy: comparison of the use of regional and general anesthetics.
ARTICLE SOURCE: J Neurosurg (United States), Feb 2000, 92(2) p291-6
AUTHOR(S): Papavasiliou AK; Magnadottir HB; Gonda T; Franz D; Harbaugh RE
AUTHOR'S ADDRESS: Department of Surgery (Neurosurgery), Dartmouth Medical School and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
MAJOR SUBJECT HEADING(S): Anesthesia, Conduction; Anesthesia, General; Carotid Stenosis [surgery]; Endarterectomy, Carotid; Postoperative Complications [etiology]
MINOR SUBJECT HEADING(S): Aged; Carotid Artery, Internal [surgery]; Carotid Stenosis [mortality]; Cerebrovascular Accident [etiology] [mortality]; Length of Stay; Myocardial Infarction [etiology] [mortality]; Postoperative Complications [mortality]; Retrospective Studies; Risk Factors; Survival Rate
INDEXING CHECK TAG(S): Comparative Study; Female; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation.
ARTICLE SOURCE: J Trauma (United States), Mar 2000, 48(3) p466-9
AUTHOR(S): Razek T; Gracias V; Sullivan D; Braxton C; Gandhi R; Gupta R; Malcynski J; Anderson HL; Reilly PM; Schwab CW
AUTHOR'S ADDRESS: Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSION: A total of 85% of patients who self-extubate during the weaning process did not require reintubation in our study. Those who have an FiO2 >50%, a lower PaO2/FiO2 ratio, had UEE occur by accident, or were not being weaned when UEE occurred required reintubation more frequently. These data suggest that some of our SICU patients are intubated longer than necessary, which may translate into more ventilator related complications, longer ICU stays and increased cost.
MB. Quite an old article (below) from Spain shows the hopelessness of the 'weaning' process. It prolongs extubation time by about 3 times.

ARTICLE TITLE: Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group.
ARTICLE SOURCE: Chest (United States), Oct 1994, 106(4) p1188-93
AUTHOR(S): Esteban A; Alia I; Ibanez J; Benito S; Tobin MJ
AUTHOR'S ADDRESS: Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain.
PUBLICATION TYPE: JOURNAL ARTICLE
Time required for weaning using a combination of synchronized intermittent mandatory ventilation (SIMV) and pressure support ventilation (PSV) was longer (17.8 days) than with other techniques (about 5 days, p < 0.01).

ARTICLE TITLE: Anatomic basis of safe percutaneous subclavian venous catheterization.
ARTICLE SOURCE: J Trauma (United States), Jan 2000, 48(1) p82-6
AUTHOR(S): Tan BK; Hong SW; Huang MH; Lee ST
AUTHOR'S ADDRESS: Department of Plastic Surgery, Singapore General Hospital, Singapore.
PUBLICATION TYPE: JOURNAL ARTICLE
RESULTS: When the shoulder was in neutral position, the subclavian vein was overlapped by the medial third or more of the clavicle and this segment of bone was able to serve as a landmark for the vein. However, shoulder elevation displaced the clavicle cephalad and reduced the degree of overlap. Mild shoulder retraction increased the area of contact between the vein and the undersurface of the clavicle, whereas protraction lifted the clavicle off the vein. CONCLUSION: Infraclavicular subclavian venipuncture should be performed with shoulders in a neutral position and also in slight retraction. An appreciation of the anatomic relationship between the clavicle and the subclavian vein is the key to successful execution of this technique.

ARTICLE TITLE: Trauma centers and trauma surgeons: have we become too specialized?
ARTICLE SOURCE: J Trauma (United States), Jan 2000, 48(1) p1-7
AUTHOR(S): Richardson JD
AUTHOR'S ADDRESS: University of Louisville School of Medicine, Department of Surgery, Kentucky 40292, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Chappel v Hart: the High Court considers causation of damage from a surgeon's negligent failure to warn.
ARTICLE SOURCE: Med J Aust (Australia), Feb 7 2000, 172(3) p134-6
AUTHOR(S): Scott RJ
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: In Chappel v Hart, the High Court upheld the decision of the Supreme Court of New South Wales that a surgeon was liable for failing to warn a patient of a previously unreported complication of a procedure. The patient, if properly warned, would have had the operation at another time, probably with a more experienced surgeon. The decision has important implications for doctors when advising patients of the risks of surgery.

ARTICLE TITLE: Relief of acute pain: a basic human right? [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Jan 3 2000, 172(1) p3-4
AUTHOR(S): Cousins MJ
PUBLICATION TYPE: EDITORIAL
MB. I don't know where this right was defined and by whom

ARTICLE TITLE: Humour in medical teaching [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Dec 6-20 1999, 171(11-12) p579-80
AUTHOR(S): Ziegler JB
PUBLICATION TYPE: EDITORIAL
MB. I use a lot of black humour.

ARTICLE TITLE: Differences between the sexes in post-surgical pain.
ARTICLE SOURCE: Pain (Netherlands), Mar 2000, 85(1-2) p79-85
AUTHOR(S): Morin C; Lund JP; Villarroel T; Clokie CM; Feine JS
AUTHOR'S ADDRESS: Faculty of Dentistry, McGill University, 3640 University Street, Montreal, Canada.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: It has been shown that women have a lower pain threshold and lower tolerance to some forms of experimental pain then men. <snip> Males and females did not differ in the total number of words chosen from the MPQ (P=0.61), or in the averaged Pain Rating Index (PRI) (P=0.53). However, women used significantly more evaluative words than men (P=0.04), suggesting that woman found the overall intensity greater. These results indicate that women find post-surgical pain more intense than males, but that men are more disturbed than women by low levels of pain that last several days.
MB. I thought males especially young ones experienced more pain than females

ARTICLE TITLE: Treatment outcome of chronic non-malignant pain patients managed in a danish multidisciplinary pain centre compared to general practice: a randomised controlled trial.
ARTICLE SOURCE: Pain (Netherlands), Feb 2000, 84(2-3) p203-11
AUTHOR(S): Becker N; Sjogren P; Bech P; Olsen AK; Eriksen J
AUTHOR'S ADDRESS: H:S Multidisciplinary Pain Centre, Danish National Hospital, Copenhagen University Hospital, Tagensvej 18B, 7122, DK-2200, Copenhagen, Denmark. nielsbecker@dadlnet.dk.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
The study showed that (i) in the multidisciplinary pain centre treatment (MPT) -group there was a significant reduction in pain intensity and improvement of, health related quality of life (HRQL) compared to the with a group of patients waiting for 6 months before treatment was initiated (WL-group), and (ii) the mere establishment of a pain diagnosis and a pain management plan by a pain specialist was not sufficient to enable the referring GP to manage severely chronic pain patients.

ARTICLE TITLE: Involvement of presurgical pain in preemptive analgesia for orthopedic surgery: a randomized double blind study.
ARTICLE SOURCE: Pain (Netherlands), Feb 2000, 84(2-3) p169-73
AUTHOR(S): Aida S; Fujihara H; Taga K; Fukuda S; Shimoji K
AUTHOR'S ADDRESS: Department of Anesthesiology, Niigata University School of Medicine, Niigata, Japan. aae62360@pop21.odn.ne.jp.
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: Preemptive analgesia (PA) was significantly effective for removal surgery, but ineffective for fracture or arthritic surgery. For the fracture and arthritic surgery PA treatment groups, there was a significant correlation between pre- and postsurgical (6h) spontaneous pain, while the corresponding control groups showed no significant correlation. Postsurgical visual analogue score VAS values in the fracture and arthritic surgery control groups increased significantly compared with presurgical VAS values. PA was effective when presurgical pain was absent, but ineffective when presurgical pain was present. We propose that central sensitization is already established by presurgical pain, and preserved until the termination of surgery. The ineffectiveness of PA did not depend on whether the pain was acute (fracture surgery) or chronic (arthritic surgery).

ARTICLE TITLE: Liver transplantation [editorial]
ARTICLE SOURCE: QJM (England), Oct 1999, 92(10) p547-50
AUTHOR(S): Neuberger J
PUBLICATION TYPE: EDITORIAL; REVIEW (14 references); REVIEW, TUTORIAL

ARTICLE TITLE: Brain death diagnosis in misleading conditions.
ARTICLE SOURCE: QJM (England), Jul 1999, 92(7) p407-14
AUTHOR(S): de Tourtchaninoff M; Hantson P; Mahieu P; Guerit JM
AUTHOR'S ADDRESS: Clinical Neurophysiology Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium. detourtchaninoff@nchm.ucl.ac.be.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (33 references); REVIEW, TUTORIAL
ABSTRACT: The necessity of defining brain death (BD) arose from technological development in medical science. The definition of this concept had practical consequences and opened the way to organ donation from BD patients. Nowadays, the imbalance between the number of organs available for transplantation and the size of the demand is becoming critical. In most laboratories, a BD diagnosis is made according to precise criteria and in a well-defined process. BD diagnosis should be improved, not only to assure the safety and to preserve the human dignity of the patient, but also in order to increase the rate of organ donation. By analysing some epidemiological parameters in BD diagnosis and organ donation, it appears that BD diagnoses can be made more often and more rapidly if one has a reliable, accurate, and safe confirmatory test, especially under misleading conditions (hypothermia, drugs, metabolic disturbances). In our experience, the use of multimodality evoked potentials (MEPs) to confirm a BD diagnosis has many advantages: MEPs can be rapidly performed at the patient's bedside, assess the brain stem as well as the cerebral cortex, and are innocuous for the patient. Moreover, their insensitivity to the aforementioned misleading factors is sufficient to distinguish BD from clinical and EEG states that mimic BD. They give an immediate diagnosis, and no delay is required in BD confirmation if there is sufficient cause to account for BD. MEPs are a safe, accurate, and reliable tool for confirming a BD diagnosis, and their use can improve the organ donation rate while preserving the safety of the patient.
MB. There seems to be some circularity in their defintions

ARTICLE TITLE: In what way may race, ethnicity or culture influence asthma outcomes? [editorial; comment]
COMMENTS: Comment on: Thorax 2000 Mar; 55(3):177-83
ARTICLE SOURCE: Thorax (England), Mar 2000, 55(3) p175-6
AUTHOR(S): Partridge MR
MAJOR SUBJECT HEADING(S): Asthma [ethnology]
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Assisted ventilation for chronic neuromuscular disorders [editorial; comment]
COMMENTS: Comment on: Thorax 2000 Jan; 55(1):4-11
ARTICLE SOURCE: Thorax (England), Jan 2000, 55(1) p1-2
AUTHOR(S): Road JD
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: The problems with punitive damages in lawsuits against managed-care organizations.
ARTICLE SOURCE: N Engl J Med (United States), Jan 27 2000, 342(4) p280-4
AUTHOR(S): Studdert DM; Brennan TA
AUTHOR'S ADDRESS: RAND, Santa Monica, CA 90407, USA.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Legalized physician-assisted suicide in Oregon--the second year.
ARTICLE SOURCE: N Engl J Med (United States), Feb 24 2000, 342(8) p598-604
AUTHOR(S): Sullivan AD; Hedberg K; Fleming DW
AUTHOR'S ADDRESS: Oregon Health Division, Portland 97232, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: In the second as compared with the first year of legalized physician-assisted suicide in Oregon, the number of patients who died after ingesting lethal medications increased, but it remained small in relation to the total number of persons in Oregon who died. Patients who request assistance with suicide appear to be motivated by several factors, including loss of autonomy and a determination to control the way in which they die.

ARTICLE TITLE: Physicians' experiences with the Oregon Death with Dignity Act [see comments]
COMMENTS: Comment in: N Engl J Med 2000 Feb 24; 342(8):583-4
ARTICLE SOURCE: N Engl J Med (United States), Feb 24 2000, 342(8) p557-63
AUTHOR(S): Ganzini L; Nelson HD; Schmidt TA; Kraemer DF; Delorit MA; Lee MA
AUTHOR'S ADDRESS: Department of Veterans Affairs, and Center for Ethics in Health Care, Oregon Health Sciences University, Portland, USA. ganzinil@ohsu.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Our data indicate that in Oregon, physicians grant about 1 in 6 requests for a prescription for a lethal medication and that 1 in 10 requests actually result in suicide. Substantive palliative interventions lead some--but not all--patients to change their minds about assisted suicide.

ARTICLE TITLE: Physician-assisted suicide and euthanasia in practice [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Feb 24; 342(8):551-6; Comment on: N Engl J Med 2000 Feb 24; 342(8):557-63; Comment on: N Engl J Med 2000 Feb 24; 342(8):593-4
ARTICLE SOURCE: N Engl J Med (United States), Feb 24 2000, 342(8) p583-4
AUTHOR(S): Nuland SB
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Pharmacologic paralysis and withdrawal of mechanical ventilation at the end of life.
ARTICLE SOURCE: N Engl J Med (United States), Feb 17 2000, 342(7) p508-11
AUTHOR(S): Truog RD; Burns JP; Mitchell C; Johnson J; Robinson W
AUTHOR'S ADDRESS: Children's Hospital, Boston, MA 02115, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
MB. The ethics of this sounds a bit dodgy to me.

ARTICLE TITLE: Women physicians in academic medicine: new insights from cohort studies [see comments]
COMMENTS: Comment in: N Engl J Med 2000 Feb 10; 342(6):426-7
ARTICLE SOURCE: N Engl J Med (United States), Feb 10 2000, 342(6) p399-405
AUTHOR(S): Nonnemaker L
AUTHOR'S ADDRESS: Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, DC 20037, USA. lnonnemaker@aamc.org.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Disparities persist in the advancement of men and women on medical school faculties. However, the numbers of women physicians at all levels of academic medicine are increasing.

ARTICLE TITLE: Women in academic medicine: new insights, same sad news [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Feb 10; 342(6):399-405
ARTICLE SOURCE: N Engl J Med (United States), Feb 10 2000, 342(6) p426-7
AUTHOR(S): De Angelis CD
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: The search for a better oral rehydration solution for cholera [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Feb 3; 342(5):308-13
ARTICLE SOURCE: N Engl J Med (United States), Feb 3 2000, 342(5) p345-7
AUTHOR(S): Rabbani GH
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Diet, colorectal adenomas, and colorectal cancer [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Apr 20; 342(16):1149-55; Comment on: N Engl J Med 2000 Apr 20; 342(16):1156-62
ARTICLE SOURCE: N Engl J Med (United States), Apr 20 2000, 342(16) p1206-7
AUTHOR(S): Byers T
INDEXING CHECK TAG(S): Human
MB. Diet did not have any effect.

ARTICLE TITLE: Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury [see comments]
COMMENTS: Comment in: N Engl J Med 2000 Apr 20; 342(16):1211-3
ARTICLE SOURCE: N Engl J Med (United States), Apr 20 2000, 342(16) p1179-86
AUTHOR(S): Cassidy JD; Carroll LJ; Cote P; Lemstra M; Berglund A; Nygren A
AUTHOR'S ADDRESS: Alberta Centre for Injury Control and Research, Department of Public Health Sciences, University of Alberta, Edmonton, Canada. dcassidy@ualberta.ca.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: The elimination of compensation for pain and suffering is associated with a decreased incidence and improved prognosis of whiplash injury.

ARTICLE TITLE: Pain and public policy [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Apr 20; 342(16):1179-86
ARTICLE SOURCE: N Engl J Med (United States), Apr 20 2000, 342(16) p1211-3
AUTHOR(S): Deyo RA
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: The Institute of Medicine report on medical errors--could it do harm?
ARTICLE SOURCE: N Engl J Med (United States), Apr 13 2000, 342(15) p1123-5
AUTHOR(S): Brennan TA
AUTHOR'S ADDRESS: Brigham and Women's Hospital, Boston, MA 02115, USA. tabrennan@partners.org.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Underlying causes and survival in patients with heart failure [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Apr 13; 342(15):1077-84
ARTICLE SOURCE: N Engl J Med (United States), Apr 13 2000, 342(15) p1120-2
AUTHOR(S): Givertz MM
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy [see comments]
COMMENTS: Comment in: N Engl J Med 2000 Apr 13; 342(15):1120-2
ARTICLE SOURCE: N Engl J Med (United States), Apr 13 2000, 342(15) p1077-84
AUTHOR(S): Felker GM; Thompson RE; Hare JM; Hruban RH; Clemetson DE; Howard DL; Baughman KL; Kasper EK
AUTHOR'S ADDRESS: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Previous studies of the prognosis of patients with heart failure due to cardiomyopathy categorized patients according to whether they had ischemic or nonischemic disease. The prognostic value of identifying more specific underlying causes of cardiomyopathy is unknown. CONCLUSIONS: The underlying cause of heart failure has prognostic value in patients with unexplained cardiomyopathy. Patients with peripartum cardiomyopathy appear to have a better prognosis than those with other forms of cardiomyopathy. Patients with cardiomyopathy due to infiltrative myocardial diseases, HIV infection, or doxorubicin therapy have an especially poor prognosis.

ARTICLE TITLE: Benefits of cardiac rehabilitation and exercise training [editorial; comment]
COMMENTS: Comment on: Chest 2000 Jan; 117(1):47-51
ARTICLE SOURCE: Chest (United States), Jan 2000, 117(1) p5-7
AUTHOR(S): Lavie CJ; Milani RV
PUBLICATION TYPE: COMMENT; EDITORIAL; REVIEW (25 references); REVIEW, TUTORIAL

ARTICLE TITLE: Beta-blockade for patients undergoing vascular surgery [letter]
ARTICLE SOURCE: N Engl J Med (United States), Apr 6 2000, 342(14) p1052; discussion 1052-3
AUTHOR(S): Litwack RS; Gilligan DM; De Gruttola V
PUBLICATION TYPE: LETTER
MB There were several letters on this topic.

ARTICLE TITLE: Sedation and analgesia for procedures in children.
ARTICLE SOURCE: N Engl J Med (United States), Mar 30 2000, 342(13) p938-45
AUTHOR(S): Krauss B; Green SM
AUTHOR'S ADDRESS: Division of Emergency Medicine, Children's Hospital and Harvard Medical School, Boston, MA 02115, USA. krauss@a1.tch.harvard.edu.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (67 references); REVIEW, TUTORIAL

ARTICLE TITLE: Improving the success of organ transplantation [editorial; comment]
COMMENTS: Comment on: N Engl J Med 2000 Mar 2; 342(9):613-9
ARTICLE SOURCE: N Engl J Med (United States), Mar 2 2000, 342(9) p647-8
AUTHOR(S): Carpenter CB
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Improved graft survival after renal transplantation in the United States, 1988 to 1996.
ARTICLE SOURCE: N Engl J Med (United States), Mar 2 2000, 342(9) p605-12
AUTHOR(S): Hariharan S; Johnson CP; Bresnahan BA; Taranto SE; McIntosh MJ; Stablein D
AUTHOR'S ADDRESS: Division of Nephrology, Medical College of Wisconsin, Milwaukee 53226, USA. hari@mcw.edu.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Since 1988, there has been a substantial increase in short-term and long-term survival of kidney grafts from both living and cadaveric donors.

ARTICLE TITLE: Uncontrolled oxygen administration and respiratory failure in acute asthma.
ARTICLE SOURCE: Chest (United States), Mar 2000, 117(3) p728-33
AUTHOR(S): Chien JW; Ciufo R; Novak R; Skowronski M; Nelson J; Coreno A; McFadden ER Jr
AUTHOR'S ADDRESS: Division of Pulmonary and Critical Care Medicine of University Hospitals of Cleveland, and the Department of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH 44106-5067, USA.
PUBLICATION TYPE: JOURNAL ARTICLE
CONCLUSIONS: Our data demonstrate that the administration of 100% oxygen to acutely ill asthmatics may adversely influence carbon dioxide elimination.

ARTICLE TITLE: Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred [see comments]
COMMENTS: Comment in: Chest 2000 Feb; 117(2):305-7
ARTICLE SOURCE: Chest (United States), Feb 2000, 117(2) p551-5
AUTHOR(S): Ho AM; Chung DC; Joynt GM
AUTHOR'S ADDRESS: Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong. hoamh@hotmail.com.
PUBLICATION TYPE: JOURNAL ARTICLE

ARTICLE TITLE: Epidural analgesia and cardiac surgery: worth the risk? [editorial; comment]
COMMENTS: Comment on: Chest 2000 Feb; 117(2):551-5
ARTICLE SOURCE: Chest (United States), Feb 2000, 117(2) p305-7
AUTHOR(S): Castellano JM; Durbin CG Jr
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Sodium bicarbonate for the treatment of lactic acidosis.
ARTICLE SOURCE: Chest (United States), Jan 2000, 117(1) p260-7
AUTHOR(S): Forsythe SM; Schmidt GA
AUTHOR'S ADDRESS: Department of Medicine, University of Chicago School of Medicine, Chicago, IL, USA.
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (91 references); REVIEW, TUTORIAL
ABSTRACT: Lactic acidosis often challenges the intensivist and is associated with a strikingly high mortality. Treatment involves discerning and correcting its underlying cause, ensuring adequate oxygen delivery to tissues, reducing oxygen demand through sedation and mechanical ventilation, and (most controversially) attempting to alkalinize the blood with IV sodium bicarbonate. Here we review the literature to answer the following questions: Is a low pH bad? Can sodium bicarbonate raise the pH in vivo? Does increasing the blood pH with sodium bicarbonate have any salutary effects? Does sodium bicarbonate have negative side effects? We find that the oft-cited rationale for bicarbonate use, that it might ameliorate the hemodynamic depression of metabolic acidemia, has been disproved convincingly. Further, given the lack of evidence supporting its use, we cannot condone bicarbonate administration for patients with lactic acidosis, regardless of the degree of acidemia.
MB. It is interesting that the inferences in my acid base account are gradually becoming established.
http://www.usyd.edu.au/su/anaes/lectures/acidbase_mjb/acidbase.html