Must Read/Greatest Hits Papers

[DM27]

I was curious if anyone had any journal articles from the past relating to anesthesia that they felt were must reads for people in the field.

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[deleted171991]

Why Most Published Research Findings Are False

 

[DM27]

That alone was worth this post. This is something I warn residents about frequently. One constant in medical history has been the number of beliefs and certainties that end up being false. Also, how easy it is to design and power a study to essentially "find" the desired result.

 

[Ezekiel2517]

Not specific to anesthesia but it would certainly affect your practice. If you only read one article any given year, read the Surviving Sepsis guidelines. As for others, one can easily look up past landmark studies. Most relate in some way to our specialty.

 

[vector2]

Not specific to anesthesia but it would certainly affect your practice. If you only read one article any given year, read the Surviving Sepsis guidelines. As for others, one can easily look up past landmark studies. Most relate in some way to our specialty.

Petition to retire the surviving sepsis campaign guidelines

PulmCrit- Six myths promoted by the new surviving sepsis guidelines

 

[vector2]

I was curious if anyone had any journal articles from the past relating to anesthesia that they felt were must reads for people in the field.

Collections 25 Landmark Articles Anesthesia « metajournal.com

good list of landmark CC studies, lotta overlap with anesthesia practice (fluids, pressors etc):

Top 100 Studies

 

[anbuitachi]

Totally agree. Most of the studies are small in our field consisting of often 2 to 3 digit patients. I take those studies w a huge grain of salt.

 

[ambiturner]

This is one that every resident should read, if nothing else to learn the legend of 'anesthesiologist #7': Does perioperative myocardial ischemia lead to postoperative myocardial infarction? - PubMed - NCBI

 

[dchz]

Petition to retire the surviving sepsis campaign guidelines

PulmCrit- Six myths promoted by the new surviving sepsis guidelines

YES!!

I didn't read the entire 160+ pages of surviving sepsis guideline. But i did read a lot of it on one of my researches. A lot of the "evidence" is based on very ****ty studies. It's like if you wrap **** up with many layers, it stops smelling eventually and people accept it.

Also it's not a guideline in a lot of academia. At my mid tier residency, the surviving sepsis guideline is more like dogma. The way it almost prohibitively favors norepi over all other vaso active agents is idiotic. I hate this document slightly less than Mao and Al Qaeda. You are an anesthesiologist. The problems are distributive shock and bacteremia. You don't need a dogmatic document to tell you how to treat those problems....

/end rant. I signed the petition.

 

[pgg]

This is one that every resident should read, if nothing else to learn the legend of 'anesthesiologist #7': Does perioperative myocardial ischemia lead to postoperative myocardial infarction? - PubMed - NCBI

The legend ...

 

[Ronin786]

YES!!

I didn't read the entire 160+ pages of surviving sepsis guideline. But i did read a lot of it on one of my researches. A lot of the "evidence" is based on very ****ty studies. It's like if you wrap **** up into many layers, it stops smelling and people accept it.

Also it's not a guideline in a lot of academia. At my mid tier residency, the surviving sepsis guideline is more like dogma. The way it almost prohibitively favors norepi over all other vaso active agents is idiotic. I hate this document slightly less than Mao and Al Qaeda. You are an anesthesiologist. The problems are distributive shock and bacteremia. You don't need a dogmatic document to tell you how to treat those problems....

/end rant. I signed the petition.

Not only is Surviving Sepsis a terrible document based almost entirely off Manny Rivers' terribly flawed trial, but I would also argue that it's not very useful from an anesthesia standpoint. The ED/floor/surgical team will almost certainly have already drowned the patient in fluids and chosen some cocktail of broad spectrum antibiotics. As anesthesiologists, we're in a prime position to watch the patient minute by minute and figure out how their hemodynamics and physiology react to different strategies as opposed to using an assembly line approach.

As for vasopressors, norepinephrine is a good vasopressor, but particularly in the operating room, so much more can be going on with any patient and a vasopressor challenge is a much better idea. Furthermore, I feel like anesthesiologists are much more likely to reach for epinephrine when necessary, as opposed to the terrible aversion that many ICUs have for it.

As an aside, this dogmatic idea that vasopressors behave the same way in the every patient at the same dose range is quite pervasive. Particularly when it comes to norepinephrine, epinephrine or dopamine. It's asinine to think that a difference of 1 mcg/kg/min is going to magically spare certain receptors in favor of others.

With regards to the initial question, looking at the ARDSNET literature and the initial study by Amato is incredibly relevant to anesthesia. His newer work with regards to driving pressure and PEEP is also fascinating.

Amato's Initial Study: NEJM - Error
ARDSNET: NEJM - Error
Driving Pressure: NEJM - Error

 

[deleted162650]

#7: “I don’t know why all my patients are tachycardic. I keep giving esmolol. ”

#5: “That’s epinephrine.”

#7: “Oops.”

 

[Ronin786]

The legend ...

I wonder what happened to #7. Looks like they fired him halfway through.

 

[MoMoGesiologist]

YES!!

I didn't read the entire 160+ pages of surviving sepsis guideline. But i did read a lot of it on one of my researches. A lot of the "evidence" is based on very ****ty studies. It's like if you wrap **** up with many layers, it stops smelling eventually and people accept it.

Also it's not a guideline in a lot of academia. At my mid tier residency, the surviving sepsis guideline is more like dogma. The way it almost prohibitively favors norepi over all other vaso active agents is idiotic. I hate this document slightly less than Mao and Al Qaeda. You are an anesthesiologist. The problems are distributive shock and bacteremia. You don't need a dogmatic document to tell you how to treat those problems....

/end rant. I signed the petition.

Which pressor would you prefer in sepsis? Sometimes I think the afib or very tachy patients would benefit from phenylephrine gtt but then people look at me like I'm crazy...

 

[deleted875186]

Which pressor would you prefer in sepsis? Sometimes I think the afib or very tachy patients would benefit from phenylephrine gtt but then people look at me like I'm crazy...

Someone once told me they did a study on septic pts on different pressers and measured gut mucosa blood flow with some type of say probe and found norepi to give the best perfusion. I’ve never been able to find it though, anyone know of something like this?

 

[vector2]

Someone once told me they did a study on septic pts on different pressers and measured gut mucosa blood flow with some type of say probe and found norepi to give the best perfusion. I’ve never been able to find it though, anyone know of something like this?

It's probably one of the studies in the therapeutic strategies section of this article

Clinical review: Influence of vasoactive and other therapies on intestinal and hepatic circulations in patients with septic shock

 

[dchz]

Which pressor would you prefer in sepsis? Sometimes I think the afib or very tachy patients would benefit from phenylephrine gtt but then people look at me like I'm crazy...

I prefer the pressor that best treats the patient's clinical picture. In the scenario described, phenylephrine sounds like a great pressor.

 

[deleted171991]

Which pressor would you prefer in sepsis? Sometimes I think the afib or very tachy patients would benefit from phenylephrine gtt but then people look at me like I'm crazy...

That's exactly my first go to drug in tachycardia, unless the patient has a decreased EF. I watch the BP closely. If I don't see it going up as the HR is coming down, my next go-to drug is norepi.

 

[dhb]

I was curious if anyone had any journal articles from the past relating to anesthesia that they felt were must reads for people in the field.

1
2
3

 

[deleted59964]

... One constant in medical history has been the number of beliefs and certainties that end up being false.

eg - enigma 1 and enigma 2

 

[d9sccr]

Not to hijack a thread, but I know that sepsis guidelines changed during my residency and haven't gotten around to reading them. Anecdotally, I notice more and more patients in septic shock being treated with norepinephrine infusions titrated to NIBP pressures and who always appear to be under-resuscitated. These patients are just setup to crash in the OR. Is there something in the new guidelines causing this?

 

[deleted171991]

Not to hijack a thread, but I know that sepsis guidelines changed during my residency and haven't gotten around to reading them. Anecdotally, I notice more and more patients in septic shock being treated with norepinephrine infusions titrated to NIBP pressures and who always appear to be under-resuscitated. These patients are just setup to crash in the OR. Is there something in the new guidelines causing this?

What do you mean by under-resuscitated?

If you mean that they are not pumped full of saltwater anymore, that's good. Btw, any patient with sepsis (hence decreased SVR and possibly distributive shock) will have a risk of crashing after more vasodilators (e.g. general anesthesia) are applied. The solution is giving more vasoconstrictors first (e.g. boluses of norepi before induction etc.), not fluids (unless you can prove that the patient is both hypovolemic and fluid-responsive, which is complicated).

I haven't read this yet (it's on my list), but, based on its authors, I would be surprised if it's not a great paper, even for anesthesiologists: Intravenous fluid therapy in critically ill adults | Nature Reviews Nephrology (it takes OpenAthens, which many of you should have at work).

The main problem with anesthesiologists and intensivists nowadays is not that we haven't read the "great" papers; it's that we don't know modern physiology and pathophysiology because we don't keep current with the literature, and especially the great blogs and minds of our fields. It requires time and dedication, but it's always heartbreaking to see an anesthesiologist or intensivist who still treats her patients as if it's still 2008. E.g. one who recommends the Surviving Sepsis Campaign guidelines or the famously unethical (and repeatedly disproven) Emanuel Rivers study.

I personally find that being up-to-date with the critical care literature also makes me a better anesthesiologist for my sicker patients. Good starting points for that would be www.emcrit.org, www.lifeinthefastlane.com and http://maryland.ccproject.com. Don't hesitate to learn resus or airway management from EM docs/blogs; they deal with some of the same problems as anesthesiologists and intensivists.

I strongly suggest spending time on review articles, even on blogs, versus individual papers. Breadth and perspective should come before depth, or you'll end up wasting time on stuff that has been proven irrelevant. Read the papers whose abstracts or summaries (on good blogs) suggest that they apply to your patient population, not just the "great" papers, and take everything with a grain of salt. E.g., the famous ARDSNet paper only proved that 6 ml/kg is better than 12 ml/kg of tidal volume. Who the heck uses 12 ml/kg? Know the big picture of as many good papers as possible, not the details of a few "great" ones. Breadth first.

Also, remember @BLADEMDA. Such an inspiration for anybody who wants to become more knowledgeable about anesthesia. Just look up his posts, many of which point to relevant papers.

 

[deleted171991]

Data fabrication and other reasons for non‐random sampling in 5087 randomised, controlled trials in anaesthetic and general medical journals

 

[nimbus]

Data fabrication and other reasons for non‐random sampling in 5087 randomised, controlled trials in anaesthetic and general medical journals

It begins in middle school science fairs where lots of data is made up BS. As a species we are not suited to perform good science which is often laborious and tedious and unrewarding.

 

[vector2]

It begins in middle school science fairs where lots of data is made up BS. As a species we are not suited to perform good science which is often laborious and tedious and unrewarding.

That, plus the fact that we are simply unable to grasp the value of studies that show a non-effect of an intervention. Drug and device development is so costly that there will never be a paradigm where researchers who find a drug or device ineffective in a large phase 3 trial will be rewarded for the service they performed.

Just look at angiotensin II. I can guarantee you it has no beneficial effect on 30 day survival for a pt who's already on 60 mcg/min of norepi and 6 units/hr of vasopressin, but all one has to do is massage a result where hypotension resolves a bit earlier and boom, approved.

 

[dhb]

That, plus the fact that we are simply unable to grasp the value of studies that show a non-effect of an intervention. Drug and device development is so costly that there will never be a paradigm where researchers who find a drug or device ineffective in a large phase 3 trial will be rewarded for the service they performed.

Imho the problem is that MDs are too emotionally and financially invested to apply the 13th law of the House of God.
Everybody wants to be a gd hero.

 

[d9sccr]

What do you mean by under-resuscitated?

If you mean that they are not pumped full of saltwater anymore, that's good. Btw, any patient with sepsis (hence decreased SVR and possibly distributive shock) will have a risk of crashing after more vasodilators (e.g. general anesthesia) are applied. The solution is giving more vasoconstrictors first (e.g. boluses of norepi before induction etc.), not fluids (unless you can prove that the patient is both hypovolemic and fluid-responsive, which is complicated).

I haven't read this yet (it's on my list), but, based on its authors, I would be surprised if it's not a great paper, even for anesthesiologists: Intravenous fluid therapy in critically ill adults | Nature Reviews Nephrology (it takes OpenAthens, which many of you should have at work).

The main problem with anesthesiologists and intensivists nowadays is not that we haven't read the "great" papers; it's that we don't know modern physiology and pathophysiology because we don't keep current with the literature, and especially the great blogs and minds of our fields. It requires time and dedication, but it's always heartbreaking to see an anesthesiologist or intensivist who still treats her patients as if it's still 2008. E.g. one who recommends the Surviving Sepsis Campaign guidelines or the famously unethical (and repeatedly disproven) Emanuel Rivers study.

I personally find that being up-to-date with the critical care literature also makes me a better anesthesiologist for my sicker patients. Good starting points for that would be www.emcrit.org, www.lifeinthefastlane.com and http://maryland.ccproject.com. Don't hesitate to learn resus or airway management from EM docs/blogs; they deal with some of the same problems as anesthesiologists and intensivists.

I strongly suggest spending time on review articles, even on blogs, versus individual papers. Breadth and perspective should come before depth, or you'll end up wasting time on stuff that has been proven irrelevant. Read the papers whose abstracts or summaries (on good blogs) suggest that they apply to your patient population, not just the "great" papers, and take everything with a grain of salt. E.g., the famous ARDSNet paper only proved that 6 ml/kg is better than 12 ml/kg of tidal volume. Who the heck uses 12 ml/kg? Know the big picture of as many good papers as possible, not the details of a few "great" ones. Breadth first.

Also, remember @BLADEMDA. Such an inspiration for anybody who wants to become more knowledgeable about anesthesia. Just look up his posts, many of which point to relevant papers.

I have every intention to start reading this stuff now that I finished residency and have a bit more free time

To illustrate what I mean by under-resuscitated this is the most recent case I had:

60ish y/o male with PMH of HTN and HLD only presented to OSH with C.diff and treated OP. Patient developed toxic mega colon and was transferred to our hospital. He spent a day in the ICU to be "resuscitated". He receiving 7 or 8 liters of crystalloid in total during that time and was started on antibiotics. That seems reasonable to me. They started norepinephrine a few liters in and titrated it to a cuff pressure (drives me nuts that this is so so commonplace for surgical patients). Clearly the inciting pathology was worsening as the patient became increasingly acidotic (lactate was above 4 when he came to the OR) and went into AKI. Instead of intubating the patient early, adding pressors, and potentially starting HD, he was started on a bicarb drip and maxed on a single pressor. When I saw the guy, he was on the verge of also going into respiratory failure. Preinduction arterial line and gas right after intubation showed a pH of 7.22. I treated him as a cardiac-RSI induction and he still predictably tanked right after.

This pseudo-resuscitated surgical patient seems almost commonplace at both my training program and new hospital. Obviously he wasn't getting better w/o surgery but there's a lot that could've been done to prepare him better for surgery. Where I trained, it was typical to get patients in septic shock d/t gangrene in similar conditions. Just wondering if something in there literature has lead to this.

 

[nimbus]

I have every intention to start reading this stuff now that I finished residency and have a bit more free time

To illustrate what I mean by under-resuscitated this is the most recent case I had:

60ish y/o male with PMH of HTN and HLD only presented to OSH with C.diff and treated OP. Patient developed toxic mega colon and was transferred to our hospital. He spent a day in the ICU to be "resuscitated". He receiving 7 or 8 liters of crystalloid in total during that time and was started on antibiotics. That seems reasonable to me. They started norepinephrine a few liters in and titrated it to a cuff pressure (drives me nuts that this is so so commonplace for surgical patients). Clearly the inciting pathology was worsening as the patient became increasingly acidotic (lactate was above 4 when he came to the OR) and went into AKI. Instead of intubating the patient early, adding pressors, and potentially starting HD, he was started on a bicarb drip and maxed on a single pressor. When I saw the guy, he was on the verge of also going into respiratory failure. Preinduction arterial line and gas right after intubation showed a pH of 7.22. I treated him as a cardiac-RSI induction and he still predictably tanked right after.

This pseudo-resuscitated surgical patient seems almost commonplace at both my training program and new hospital. Obviously he wasn't getting better w/o surgery but there's a lot that could've been done to prepare him better for surgery. Where I trained, it was typical to get patients in septic shock d/t gangrene in similar conditions. Just wondering if something in there literature has lead to this.

Sounds familiar. At my place the levophed would be running through a shady 22g IV too.

 

[MoMoGesiologist]

I have every intention to start reading this stuff now that I finished residency and have a bit more free time

To illustrate what I mean by under-resuscitated this is the most recent case I had:

60ish y/o male with PMH of HTN and HLD only presented to OSH with C.diff and treated OP. Patient developed toxic mega colon and was transferred to our hospital. He spent a day in the ICU to be "resuscitated". He receiving 7 or 8 liters of crystalloid in total during that time and was started on antibiotics. That seems reasonable to me. They started norepinephrine a few liters in and titrated it to a cuff pressure (drives me nuts that this is so so commonplace for surgical patients). Clearly the inciting pathology was worsening as the patient became increasingly acidotic (lactate was above 4 when he came to the OR) and went into AKI. Instead of intubating the patient early, adding pressors, and potentially starting HD, he was started on a bicarb drip and maxed on a single pressor. When I saw the guy, he was on the verge of also going into respiratory failure. Preinduction arterial line and gas right after intubation showed a pH of 7.22. I treated him as a cardiac-RSI induction and he still predictably tanked right after.

This pseudo-resuscitated surgical patient seems almost commonplace at both my training program and new hospital. Obviously he wasn't getting better w/o surgery but there's a lot that could've been done to prepare him better for surgery. Where I trained, it was typical to get patients in septic shock d/t gangrene in similar conditions. Just wondering if something in there literature has lead to this.

Without source control, I don't know how much it matters whether you intubate early, place an aline, start vaso/AT2/steroids/HD; patient is gonna do poorly. Sounds like maybe patient perfed? Not that I'm not saying it's strange to be maxed out on one pressor with a bicarb gtt, but getting patient to the OR when it became clear medical management was failing, before the respiratory failure and AKI, maybe would've prevented those complications.

 

[deleted171991]

I have every intention to start reading this stuff now that I finished residency and have a bit more free time

To illustrate what I mean by under-resuscitated this is the most recent case I had:

60ish y/o male with PMH of HTN and HLD only presented to OSH with C.diff and treated OP. Patient developed toxic mega colon and was transferred to our hospital. He spent a day in the ICU to be "resuscitated". He receiving 7 or 8 liters of crystalloid in total during that time and was started on antibiotics. That seems reasonable to me. They started norepinephrine a few liters in and titrated it to a cuff pressure (drives me nuts that this is so so commonplace for surgical patients). Clearly the inciting pathology was worsening as the patient became increasingly acidotic (lactate was above 4 when he came to the OR) and went into AKI. Instead of intubating the patient early, adding pressors, and potentially starting HD, he was started on a bicarb drip and maxed on a single pressor. When I saw the guy, he was on the verge of also going into respiratory failure. Preinduction arterial line and gas right after intubation showed a pH of 7.22. I treated him as a cardiac-RSI induction and he still predictably tanked right after.

This pseudo-resuscitated surgical patient seems almost commonplace at both my training program and new hospital. Obviously he wasn't getting better w/o surgery but there's a lot that could've been done to prepare him better for surgery. Where I trained, it was typical to get patients in septic shock d/t gangrene in similar conditions. Just wondering if something in there literature has lead to this.

Now if I say that the 7-8L of crystalloid in a day may have caused his AKI... you'll say I am nuts. But it's very possible (hypotension combined with renal venous congestion/intra-abdominal hypertension, especially in the context of an already distended bowel), unless there was a lot of fluid loss through diarrhea (which may also explain the bicarb drip - since the patient's acidosis would have been also due to loss of bicarbonate).

That patient obviously needed an a-line (after it was clear that a few drops of low-dose pressor won't do it), and probably intubation. I usually find pressors on small peripheral IVs and cuffs in community MICUs (and SICUs, if run by the same medical intensivists).

Very good example for what I was saying about critical care being applied physiology and pathophysiology. This patient would have probably benefited from much higher MAPs than the 65 he was probably kept on, to maintain renal and bowel perfusion pressure.

 

[midazzoler]

All this sepsis talk reminds me of this case: Pt comes back into the OR tachy to 130s with mental status changes for re op to drain another abdominal abscess. She is on one drip: Cardizem. I turned it off and got the case started then started looking though the notes to find out why she was on cardizem. This was the cardiologist last note before pt went to the OR....

 

[psychbender]

All this sepsis talk reminds me of this case: Pt comes back into the OR tachy to 130s with mental status changes for re op to drain another abdominal abscess. She is on one drip: Cardizem. I turned it off and got the case started then started looking though the notes to find out why she was on cardizem. This was the cardiologist last note before pt went to the OR....


View attachment 240348

Sent from my SM-G930V using SDN mobile

 

[vector2]

I doubt that cardiologist was aware of the literature, but there has been a reemergence of interest in using beta blockers in sepsis. There appears to be at least some data showing that blunting the maladaptive sympathetic overstimulation is beneficial. Obviously the pt should be adequately fluid resuscitated first to ensure that the tachycardia isn't simply due to hypovolemia...

Beta-blockers in sepsis: time to reconsider current constraints? | BJA: British Journal of Anaesthesia | Oxford Academic

 

[nimbus]

Not a clinical article but still worth reading. An example of a real scientist doing useful work.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3850914/pdf/2046-7648-2-29.pdf

 

[fakin' the funk]

All this sepsis talk reminds me of this case: Pt comes back into the OR tachy to 130s with mental status changes for re op to drain another abdominal abscess. She is on one drip: Cardizem. I turned it off and got the case started then started looking though the notes to find out why she was on cardizem. This was the cardiologist last note before pt went to the OR....

Dunno about where you work, but if I took a picture of a patient's chart and posted it on an internet forum I just might get fired.

 

[pgg]

Dunno about where you work, but if I took a picture of a patient's chart and posted it on an internet forum I just might get fired.

He didn't post anything different than the case vignettes we all post here all the time. Nothing there that's even close to being identifying information. We don't even know what country he's in.

 

[fakin' the funk]

He didn't post anything different than the case vignettes we all post here all the time. Nothing there that's even close to being identifying information. We don't even know what country he's in.

I can read, thank you though.

If it's a fireable offense for me, it might be for the poster too. Heck, it might even be for you too. Check in with your local med legal / risk / compliance people and get back to me on your policy.

 

[epidural man]

These are two MUST READS!

Let me know what you think if you haven't read them before.

 

[nimbus]

These are two MUST READS!

Let me know what you think if you haven't read them before.

Grip strength? I thought ortho was all about 1x max bench. The differences would be even greater if they measured bench press.

 

[deleted162650]

Ortho requires bench press + IQ to be greater than 250.