19 episodes

Depth of Anesthesia is a podcast that critically explores dogmatic clinical practices in anesthesiology.

Anesthesiology is full of claims. A claim is a practice decision that we either believe is true or is something we default to. We think that for every claim in anesthesiology, we should know what is supported or refuted by evidence and what claims have no evidence base but stand to reason.

Depth of Anesthesia David Hao, MD

    • Education
    • 5.0 • 4 Ratings

Depth of Anesthesia is a podcast that critically explores dogmatic clinical practices in anesthesiology.

Anesthesiology is full of claims. A claim is a practice decision that we either believe is true or is something we default to. We think that for every claim in anesthesiology, we should know what is supported or refuted by evidence and what claims have no evidence base but stand to reason.

    19: Is hydrocortisone, ascorbic acid (Vitamin C), and thiamine therapy effective for treatment of sepsis?

    19: Is hydrocortisone, ascorbic acid (Vitamin C), and thiamine therapy effective for treatment of sepsis?

    In this episode, we discuss the role of hydrocortisone, ascorbic acid (Vitamin C) and thiamine (HAT therapy) in the treatment of patients with septic shock. We discuss biological plausibility and comprehensively review the latest evidence.
    Our guest is Dr. Jonathan Charnin. Dr. Charnin is an assistant professor of anesthesiology in the Divisions of Multi-specialty Anesthesia and Critical Care Medicine at the Mayo Clinic
    Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com.
    Thanks for listening! If you enjoy our content, please rate us on iTunes and share our podcast with your colleagues.
    Music by Stephen Campbell, MD.
    --
    References
    Fujii T, Luethi N, Young PJ, et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA. 2020;323(5):423–431. doi:10.1001/jama.2019.22176
    Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017 Jun;151(6):1229-1238. doi: 10.1016/j.chest.2016.11.036. Epub 2016 Dec 6. PMID: 27940189.
    Englard S, Seifter S. The biochemical functions of ascorbic acid. Annu Rev Nutr. 1986;6:365-406. doi: 10.1146/annurev.nu.06.070186.002053. PMID: 3015170.
    Fowler AA 3rd, Truwit JD, Hite RD, Morris PE, DeWilde C, Priday A, Fisher B, Thacker LR 2nd, Natarajan R, Brophy DF, Sculthorpe R, Nanchal R, Syed A, Sturgill J, Martin GS, Sevransky J, Kashiouris M, Hamman S, Egan KF, Hastings A, Spencer W, Tench S, Mehkri O, Bindas J, Duggal A, Graf J, Zellner S, Yanny L, McPolin C, Hollrith T, Kramer D, Ojielo C, Damm T, Cassity E, Wieliczko A, Halquist M. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019 Oct 1;322(13):1261-1270. doi: 10.1001/jama.2019.11825. Erratum in: JAMA. 2020 Jan 28;323(4):379. PMID: 31573637; PMCID: PMC6777268.
    Donnino MW, Andersen LW, Chase M, Berg KM, Tidswell M, Giberson T, Wolfe R, Moskowitz A, Smithline H, Ngo L, Cocchi MN; Center for Resuscitation Science Research Group. Randomized, Double-Blind, Placebo-Controlled Trial of Thiamine as a Metabolic Resuscitator in Septic Shock: A Pilot Study. Crit Care Med. 2016 Feb;44(2):360-7. doi: 10.1097/CCM.0000000000001572. PMID: 26771781; PMCID: PMC4754670.
    Woolum JA, Abner EL, Kelly A, Thompson Bastin ML, Morris PE, Flannery AH. Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock. Crit Care Med. 2018 Nov;46(11):1747-1752. doi: 10.1097/CCM.0000000000003311. PMID: 30028362.

    • 25 min
    18: Is mixing in lidocaine effective for preventing burning with propofol?

    18: Is mixing in lidocaine effective for preventing burning with propofol?

    In this episode, we discuss the mechanisms of burning with propofol infusion and explore the evidence behind strategies like mixing lidocaine with propofol. 
    Our guest today is Dr. Stu Forman, Professor of Anesthesiology at Massachusetts General Hospital. He is an investigator on several NIH-sponsored basic research grants and co-director of the Harvard Anesthesia Research Training Fellowship.
    Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com.
    Thanks for listening! Please rate us on iTunes and share with your colleagues. 
    Music by Stephen Campbell, MD. 
    --
    References
    Bengalorkar GM, Bhuvana K, Sarala N, Kumar T. Fospropofol: clinical pharmacology. J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):79-83. PMID: 21804712; PMCID: PMC3146164.
    Dajun Song, Mohamed A. Hamza, Paul F. White, Stephanie I. Byerly, Stephanie B. Jones, Amy D. Macaluso; Comparison of a Lower-lipid Propofol Emulsion with the Standard Emulsion for Sedation during Monitored Anesthesia Care. Anesthesiology 2004; 100:1072–1075 doi: https://doi.org/10.1097/00000542-200405000-00007
    Euasobhon P, Dej-Arkom S, Siriussawakul A, Muangman S, Sriraj W, Pattanittum P, Lumbiganon P. Lidocaine for reducing propofol-induced pain on induction of anaesthesia in adults. Cochrane Database Syst Rev. 2016 Feb 18;2(2):CD007874. doi: 10.1002/14651858.CD007874.pub2. PMID: 26888026; PMCID: PMC6463799.
    Fischer MJ, Leffler A, Niedermirtl F, Kistner K, Eberhardt M, Reeh PW, Nau C. The general anesthetic propofol excites nociceptors by activating TRPV1 and TRPA1 rather than GABAA receptors. J Biol Chem. 2010 Nov 5;285(45):34781-92. doi: 10.1074/jbc.M110.143958. Epub 2010 Sep 7. PMID: 20826794; PMCID: PMC2966094.
    Jalota L, Kalira V, George E, Shi YY, Hornuss C, Radke O, Pace NL, Apfel CC; Perioperative Clinical Research Core. Prevention of pain on injection of propofol: systematic review and meta-analysis. BMJ. 2011 Mar 15;342:d1110. doi: 10.1136/bmj.d1110. PMID: 21406529.
    Klement W, Arndt JO. Pain on i.v. injection of some anaesthetic agents is evoked by the unphysiological osmolality or pH of their formulations. Br J Anaesth. 1991 Feb;66(2):189-95. doi: 10.1093/bja/66.2.189. PMID: 1817619.
    Sahinovic MM, Struys MMRF, Absalom AR. Clinical Pharmacokinetics and Pharmacodynamics of Propofol. Clin Pharmacokinet. 2018;57(12):1539-1558. doi:10.1007/s40262-018-0672-3
    Scott RP, Saunders DA, Norman J. Propofol: clinical strategies for preventing the pain of injection. Anaesthesia. 1988 Jun;43(6):492-4. doi: 10.1111/j.1365-2044.1988.tb06641.x. PMID: 3261547.

    • 28 min
    17: Is it important to reverse to a train-of-four target of 90%? - Part 2 of 2

    17: Is it important to reverse to a train-of-four target of 90%? - Part 2 of 2

    In this part II or II series on neuromuscular blockade, we investigate the claim that a train-of-four target of 90% is important to achieve prior to extubation.
    Our guest today is Dr. Daniel Saddawi-Konefka, residency program director at Mass General.
    Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com.
    Thanks for listening! Please rate us on iTunes and share with your colleagues. 
    Music by Stephen Campbell, MD. 
    --
    References
    Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111(1):110-119. doi:10.1213/ANE.0b013e3181c07428
    Ali HH, Kitz RJ. Evaluation of recovery from nondepolarizing neuromuscular block, using a digital neuromuscular transmission analyzer: preliminary report. Anesth Analg. 1973;52(5):740-745.
    Ali HH, Wilson RS, Savarese JJ, Kitz RJ. The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth. 1975;47(5):570-574. doi:10.1093/bja/47.5.570
    Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson LI. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology. 2000;92(4):977-984. doi:10.1097/00000542-200004000-00014
    Eikermann M, Groeben H, Hüsing J, Peters J. Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade. Anesthesiology. 2003;98(6):1333-1337. doi:10.1097/00000542-200306000-00006
    Gopalaiah Venkatesh Kumar, Anita Pramod Nair, Hanuman Srinivasa Murthy, Koppa Ramegowda Jalaja, Karnate Ramachandra, Gundappa Parameshwara; Residual Neuromuscular Blockade Affects Postoperative Pulmonary Function. Anesthesiology 2012; 117:1234–1244 doi: https://doi.org/10.1097/ALN.0b013e3182715b80
    Eriksson LI, Lennmarken C, Wyon N, Johnson A. Attenuated ventilatory response to hypoxaemia at vecuronium-induced partial neuromuscular block. Acta Anaesthesiol Scand. 1992;36(7):710-715. doi:10.1111/j.1399-6576.1992.tb03550.x
    Suzanne J. L. Broens, Martijn Boon, Chris H. Martini, Marieke Niesters, Monique van Velzen, Leon P. H. J. Aarts, Albert Dahan; Reversal of Partial Neuromuscular Block and the Ventilatory Response to Hypoxia: A Randomized Controlled Trial in Healthy Volunteers. Anesthesiology 2019; 131:467–476 doi: https://doi.org/10.1097/ALN.0000000000002711
    Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology. 1997;86(4):765-771. doi:10.1097/00000542-199704000-00005
    Glenn S. Murphy, Joseph W. Szokol, Jesse H. Marymont, Steven B. Greenberg, Michael J. Avram, Jeffery S. Vender, Margarita Nisman; Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Meeting Abstracts and Adverse Respiratory Events in the Postanesthesia Care Unit. Anesthesiology 2008; 109:389–398 doi: https://doi.org/10.1097/ALN.0b013e318182af3b
    Butterly A, Bittner EA, George E, et al. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. BJA: British Journal of Anaesthesia. 2010 Sep;105(3):304-309. DOI: 10.1093/bja/aeq157.
    Section Editor(s): Brull, Sorin J.Murphy, Glenn S. MD; Szokol, Joseph W. MD; Marymont, Jesse H. MD; Greenberg, Steven B. MD; Avram, Michael J. PhD; Vender, Jeffery S. MD Residual Neuromuscular Blockade and Critical Respiratory Events in the Postanesthesia Care Unit, Anesthesia & Analgesia: July 2008 - Volume 107 - Issue 1 - p 130-137 doi: 10.1213/ane.0b013e31816d1268
    Kirmeier E, Eriksson LI, Lewald H, et al. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, pro

    • 41 min
    16: Is emergence from sevoflurane substantially faster than from isoflurane?

    16: Is emergence from sevoflurane substantially faster than from isoflurane?

    We investigate the claim that emergence from sevoflurane is substantially faster than from isoflurane. We explore rationales and discuss cost. 
    Our guest today is Dr. Keith Baker, Vice Chair of Education at Massachusetts General Hospital. 
    Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com.
    Thanks for listening! Please rate us on iTunes and share with your colleagues. 
    Music by Stephen Campbell, MD. 
    --
    References
    Seitsonen ER, Yli-Hankala AM, Korttila KT. Similar recovery from bispectral index-titrated isoflurane and sevoflurane anesthesia after outpatient gynecological surgery. J Clin Anesth. 2006;18(4):272-279. doi:10.1016/j.jclinane.2005.12.005
    Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg. 2004;98(3):. doi:10.1213/01.ane.0000103187.70627.57
    Gauthier A, Girard F, Boudreault D, Ruel M, Todorov A. Sevoflurane provides faster recovery and postoperative neurological assessment than isoflurane in long-duration neurosurgical cases. Anesth Analg. 2002;95(5):. doi:10.1097/00000539-200211000-00052
    Ries CR, Azmudéh A, Franciosi LG, Schwarz SK, MacLeod BA. Cost comparison of sevoflurane with isoflurane anesthesia in arthroscopic menisectomy surgery. Can J Anaesth. 1999;46(11):1008-1013. doi:10.1007/BF03013193
    Maheshwari K, Ahuja S, Mascha EJ, et al. Effect of Sevoflurane Versus Isoflurane on Emergence Time and Postanesthesia Care Unit Length of Stay: An Alternating Intervention Trial. Anesth Analg. 2020;130(2):360-366. doi:10.1213/ANE.0000000000004093
    Yasuda N, Targ AG, Eger EI 2nd. Solubility of I-653, sevoflurane, isoflurane, and halothane in human tissues. Anesth Analg. 1989;69(3):370-373.

    • 23 min
    15: Is dural puncture epidural (DPE) the optimal labor analgesia technique?

    15: Is dural puncture epidural (DPE) the optimal labor analgesia technique?

    In this episode, we investigate the following claims related to DPE:
    1. Dural puncture epidural (DPE) technique improves analgesic quality versus traditional epidural
    2. DPE technique has faster onset of analgesia versus traditional epidural
    3. DPE has less adverse effects compared with combined spinal-epidural (CSE)
    Our guest today is Dr. Ronald George (@Ron_George), Professor and Chief of Obstetric Anesthesia at UCSF.
    Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com
    Thanks for listening! Please rate us on iTunes and share with your colleagues. 
    Music by Stephen Campbell, MD. 
    --
    References
    Heesen M, Rijs K, Rossaint R, Klimek M. Dural puncture epidural versus conventional epidural block for labor analgesia: a systematic review of randomized controlled trials. Int J Obstet Anesth. 2019;40:24-31. doi:10.1016/j.ijoa.2019.05.007
    Thomas JA, Pan PH, Harris LC, Owen MD, D'Angelo R. Dural puncture with a 27-gauge Whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology. 2005;103(5):1046-1051. doi:10.1097/00000542-200511000-00019
    Wilson SH, Wolf BJ, Bingham K, et al. Labor Analgesia Onset With Dural Puncture Epidural Versus Traditional Epidural Using a 26-Gauge Whitacre Needle and 0.125% Bupivacaine Bolus: A Randomized Clinical Trial. Anesth Analg. 2018;126(2):545-551. doi:10.1213/ANE.0000000000002129
    Cappiello E, O'Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg. 2008;107(5):1646-1651. doi:10.1213/ane.0b013e318184ec14
    Chau A, Bibbo C, Huang CC, et al. Dural Puncture Epidural Technique Improves Labor Analgesia Quality With Fewer Side Effects Compared With Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial. Anesth Analg. 2017;124(2):560-569. doi:10.1213/ANE.0000000000001798

    • 26 min
    14: What is the approach to post-extubation stridor in COVID-19?

    14: What is the approach to post-extubation stridor in COVID-19?

    In this episode, we explore the evidence for various strategies to manage post-extubation stridor and the applications to COVID-19 patients.
    Our guest today is Dr. Tiara Calhoun (@tiaraforsyth), an internal medicine resident at the Massachusetts General Hospital. 
    She is an active contributor to FLARE (Fast Literature Assessment and Review), a newsletter that appraises the rapidly evolving literature on SARS-CoV-2. 
    Check FLARE out here: https://www.massgeneral.org/news/coronavirus/treatment-guidance/fast-literature-updates
    An additional question for our listeners to dive into is the optimal timing of steroid administration. Let us know what you find! 
    Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com
    Thanks for listening! Please rate us on iTunes and share with your colleagues. 
    Music by Stephen Campbell, MD. 
    --
    Full references on Episode Webpage. 
    https://us19.campaign-archive.com/?u=ef98149bee3f299584374540a&id=fe09c50f3a

    • 25 min

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