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EDITORIAL VIEWS

Anesthesiology 2009; 111:1– 4                                        Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.


Long-term Consequences of Anesthetic Management

    Editor’s Note: This is the first in a series of four Editorial Views on long-term outcomes after anesthesia and surgery. This
    series adds to other recent Editorial Views in ANESTHESIOLOGY and includes a discussion of broadening our research outside
    of the operating room to prevention of wound infections, cancer spread, cardiovascular morbidity and mortality, chronic
    postsurgical pain, and rare complications. ANESTHESIOLOGY will sponsor special sessions in 2010 on the topic of long-term
    outcomes at annual meetings of the Japanese Society of Anesthesiologists, the European Society of Anesthesiology, and the
    American Society of Anesthesiologists.

    James C. Eisenach, M.D., Editor-in-Chief




TWENTY-FIVE years ago, when I was an anesthesia res-                                     cialty a “most improved” designation from the Institute
ident, preventable anesthetic mortality occurred in per-                                 of Medicine.3 (Granted, evaluating anesthetic mortality
haps 1 of 10,000 cases1—making anesthesia the most                                       remains inexact and controversial,4,5 but the consensus
dangerous part of most operations. I refer neither to the                                is that improvement has been substantial in recent de-
patients who died of overwhelming underlying disease nor                                 cades, especially considering how much sicker patients are
to the patients who died of acute surgical misadventures; I                              now.) An unfortunate consequence of our improvement is
mean relatively healthy patients having routine operations                               that some consider anesthetic safety a more-or-less solved
who died from anesthetic causes and mistakes.                                            problem. At the very least, the number of intraoperative
  High anesthetic mortality in the early 1980s was per-                                  deaths is now so small that policymakers might reasonably
haps unsurprising considering the state of anesthesia                                    conclude that resources would be better invested else-
equipment, drugs, and training. Anesthesia machines                                      where. This thought process may contribute to the dis-
often lacked a nitrous oxide-oxygen interlock; on such                                   mally small amount of funding that the National Institutes
machines, there was little to prevent an anesthesiologist                                of Health provides for anesthesiology research.
at the end of the case from turning off the oxygen
instead of the nitrous oxide—thus delivering a hypoxic
                                                                                         Long-term Outcomes
gas mixture. And having done so, the error was often
undetected until too late because oxygen analyzers were                                    In distinct contrast to preventable anesthetic mortality,
not uniformly used.                                                                      which thankfully is now rare, all-cause postoperative mor-
  Volatile anesthetics in that era were still often deliv-                               tality is surprisingly high. About 5% of all surgical patients
ered via copper kettles, which meant that reductions in                                  die in the year after surgery; among those aged more than
fresh gas flow proportionately increased delivered anes-                                  65 yr, mortality is about 10%.6 To put this another way,
thetic concentration, sometimes to dangerous levels.                                     mortality in the year after surgery is about 10,000 times
Such episodes would rarely be detected because expired                                   more common than preventable anesthetic mortality.
gas monitoring was restricted to a limited number of                                       It is thus reasonable to ask to what extent anesthetic
academic centers that had invested in expensive and                                      management might influence long-term outcomes. The
touchy multiplexed mass spectrometry systems. Pulse                                      distinction I make here is between the classic definition
oximetry was yet to be available for some years hence.                                   of anesthetic complications, which is restricted to the
Available drugs were longer-acting and harder to use                                     immediate perioperative period extending perhaps to a
than our current ones; the less-soluble volatile anesthetic                              few days after surgery, and the potential effects of anes-
in those days was isoflurane, halothane remained in                                       thetic management on events weeks, months, or even
common use, and the shorter-acting muscle relaxant was                                   years after surgery.
curare. Furthermore, anesthesia residency was only 2 yr                                    Given that modern anesthetic drugs are uniformly
and considerably less rigorous than it is now.                                           short-acting, it is by no means obvious that conse-
  My, how it has changed! Preventable anesthetic mor-                                    quences of anesthetic management could last more than
                                                                                         hours or days after surgery. Certainly, long-term conse-
tality is now probably less than 1 case in 100,000,1,2 a
                                                                                         quences of anesthesia were not seriously considered
more than 10-fold improvement that earned our spe-
                                                                                         until relatively recently. That said, however, there is
                                                                                         increasing evidence that some intraoperative anesthetic
  Accepted for publication April 2, 2009. The author is not supported by, nor
maintains any financial interest in, any commercial activity that may be associated
                                                                                         management decisions do have long-term consequences
with the topic of this article.                                                          and that others might as well.

Anesthesiology, V 111, No 1, Jul 2009                                                1
2                                                                                                      EDITORIAL VIEWS


Surgical Site Infection                                         is surgery per se, which releases tumor cells into circu-
                                                                lation,18 depresses cell-mediated immunity including
  Arguably, the first convincing evidence for long-term          cytotoxic T-cell and natural killer cell functions,20 re-
outcomes related to anesthetic management dates to              duces circulating concentrations of tumor-related antian-
1996, which saw publication of two key articles in the          giogenic factors, increases concentrations of proangio-
New England Journal of Medicine. One, from Mangano              genic factors such as vascular endothelial growth
et al., linked perioperative -blocker administration to         factor,21 and releases growth factors that promote
myocardial infarction and mortality7 (more about this           local and distant growth of malignant tissue.19 The
topic below). The other, from Kurz et al., showed that
                                                                second factor is that volatile anesthesia per se impairs
mild hypothermia triples the risk of surgical wound
                                                                neutrophil, macrophage, dendritic-cell, T-cell, and nat-
infection8 even though surgical site infections become
                                                                ural killer-cell immune functions.22 The third factor is
clinically apparent 1– 4 weeks after surgery. The link
                                                                opioids that inhibit both cellular and humoral immune
between hypothermia and infection was subsequently
                                                                function.22 Furthermore, morphine is proangiogenic and
confirmed by an additional randomized trial.9 The risk
of surgical wound infection also appears to be mod-             promotes tumor growth.23 Consequently, nonopioid anal-
erated by supplemental oxygen, even when supple-                gesia helps preserve natural killer cell function in animals
mental oxygen is only provided during surgery and 2             and humans and reduces metastatic spread of cancer in
or 6 hr thereafter.10,11                                        rodents.24
  There is thus considerable evidence that wound infec-           Regional anesthesia and analgesia attenuate or prevent
tions, despite becoming clinically apparent weeks after         each of these adverse effects. For example, regional
surgery, are established during and immediately after sur-      anesthesia largely prevents the neuroendocrine stress
gery. All surgical wounds become contaminated; surgical         response to surgery by blocking afferent neural transmis-
sterility is only relative! Whether contamination progresses    sion from reaching the central nervous system and by
to a clinical infection is determined by the adequacy of host   blocking descending efferent activation of the sympa-
defenses during a decisive period lasting some hours after      thetic nervous system.25 Consequently, natural killer-cell
contamination. In the case of bacteria causing surgical         function is better preserved with regional anesthesia and
wound infections, the most important host defense is oxi-       metastatic load to the lungs is reduced in a rat model of
dative killing by neutrophils.12 This process requires mo-      breast cancer metastasis.20
lecular oxygen13 and is a function of tissue (as opposed to       When regional and general anesthetics are combined,
arterial) oxygen partial pressure over the entire physiologic   the amount of general anesthetic required is much re-
range. Interventions that increase tissue oxygen during the     duced, as is presumably immune suppression. Further-
decisive period, such as maintaining normothermia14 and         more, regional analgesia provides superb pain relief,
providing supplemental oxygen,10 reduce progression of          essentially obviating the need for postoperative opioids,
contamination to clinical infection.                            and the consequent adverse effects on immune function
  It is likely that infection risk is similarly diminished by   and of tumor growth.22,25 Regional analgesia also re-
other factors that support tissue oxygenation,15 including      duces release of endogenous opioids.26
adequate sympathetic block16 and good control of surgical
                                                                  Available data thus suggest that regional anesthesia and
pain.17 The potential benefit of these and other interven-
                                                                analgesia help preserve effective defenses against tumor
tions have yet to be determined in large- scale outcome
                                                                progression by attenuating the surgical stress response,
studies, but they remain under active investigation.
                                                                by reducing general anesthesia requirements, and by
                                                                sparing postoperative opioids.27 Animal studies are con-
                                                                sistent with this theory, showing that regional anesthesia
Regional Analgesia and Cancer Recurrence                        and optimum postoperative analgesia independently re-
  An additional long-term outcome to consider is cancer.        duce the metastatic burden in animals inoculated with
Although not widely appreciated, tumor surgery is usu-          breast adenocarcinoma cells.28 Available human data,
ally associated with release of tumor cells into the lym-       although extremely limited, are also consistent with this
phatic and blood streams; furthermore, a large fraction         theory. For example, paravertebral anesthesia and anal-
of patients already harbor micrometastases and scattered        gesia for breast cancer surgery is associated with an
tumor cells at the time of surgery.18 Whether this min-         approximately four-fold reduced risk of recurrence or
imal residual disease results in clinical metastases de-        metastasis.29 Similarly, epidural analgesia for radical pros-
pends largely on the balance between antimetastatic             tate surgery is associated with a 60% reduction in recur-
immune activity and the tumor’s ability to seed, prolif-        rence risk.30 Major prospective trials of paravertebral anal-
erate, and attract new blood vessels.19                         gesia for breast cancer surgery (NCT00418457)31 and
  At least three perioperative factors shift the balance        epidural analgesia for colon cancer are in progress
toward progression of minimal residual disease. The first        (NCT00684229).

Anesthesiology, V 111, No 1, Jul 2009
EDITORIAL VIEWS                                                                                                                                                       3


Recent and Future                        Editorials           Exploring               3. Kohn KT, Corrigan JM, Donaldson M: To err is human: Building a safer
                                                                                   health system. Washington, DC, Academy Press, 1999
Long-term Outcomes                                                                    4. Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw
                                                                                   P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on
  Additional proven or potential long-term outcomes of                             severe morbidity and mortality. ANESTHESIOLOGY 2005; 102:257–68; quiz 491–2
                                                                                      5. Lagasse RS: Innocent prattle. ANESTHESIOLOGY 2009; 110:698–9
perioperative management have already been addressed                                  6. Monk TG, Saini V, Weldon BC, Sigl JC: Anesthetic management and one-year
in recent ANESTHESIOLOGY editorials. For example, an edi-                          mortality after noncardiac surgery. Anesth Analg 2005; 100:4–10
                                                                                      7. Mangano DT, Layug EL, Wallace A, Tateo I: Effect of atenolol on mortality
torial in the December issue by Spahn et al. highlights                            and cardiovascular morbidity after noncardiac surgery. Multicenter Study of
the dangers of red cell transfusions, especially noninfec-                         Perioperative Ischemia Research Group. N Engl J Med 1996; 335:1713–20
                                                                                      8. Kurz A, Sessler DI, Lenhardt RA: Study of wound infections and temperature
tious complications, which are the major risk.32 Editori-                          group: Perioperative normothermia to reduce the incidence of surgical-wound
als in the February (Fahy et al.33 and Nunnally and                                infection and shorten hospitalization. N Engl J Med 1996; 334:1209–15
                                                                                      9. Melling AC, Ali B, Scott EM, Leaper DJ: Effects of preoperative warming on
O’Conner34) and March (Lanier and Pasternak35) issues                              the incidence of wound infection after clean surgery: A randomised controlled
discuss the risks and benefits of tight glycemic control.                           trial. Lancet 2001; 358:876–80
                                                                                      10. Greif R, Akca O, Horn E-P, Kurz A, Sessler DI: Outcomes Research™
                                                                                                        ¸
Also in March, Kehlet and Bundgaard-Nielsen discuss                                Group: Supplemental perioperative oxygen to reduce the incidence of surgical
long-term consequences of perioperative fluid manage-                               wound infection. N Engl J Med 2000; 342:161–7
                                                                                      11. Belda FJ, Aguilera L, Garcia de la Asuncion J, Alberti J, Vicente R, Ferrandiz
ment.36 An editorial by Maze focused on postoperative                              L, Rodriguez R, Company R, Sessler DI, Aguilar G, Botello SG, Orti R: Supple-
cognitive dysfunction.37 And finally, April editorials by                           mental perioperative oxygen and the risk of surgical wound infection: A random-
                                                                                   ized controlled trial. JAMA 2005; 294:2035–42
Patel and Sun38 and by Perouansky and Hemmings39                                      12. Benhaim P, Hunt TK: Natural resistance to infection: Leukocyte functions.
dealt with volatile anesthetic toxicity in newborns.                               J Burn Care Rehabil 1992; 13:287–92
                                                                                      13. Jonsson K, Hunt TK, Mathes SJ: Oxygen as an isolated variable influences
  This is the first of four editorials to address additional                        resistance to infection. Ann Surg 1988; 208:783–7
potential long-term consequences of anesthetic manage-                                14. Sheffield CW, Sessler DI, Hopf HW, Schroeder M, Moayeri A, Hunt TK,
                                                                                   West JM: Centrally and locally mediated thermoregulatory responses alter sub-
ment. The next will be by Philip Devereaux, M.D., Ph.D.,                           cutaneous oxygen tension. Wound Rep Reg 1997; 4:339–45
from the Department of Clinical Epidemiology and Bio-                                 15. Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH 3rd, Jensen JA,
                                                                                   Jonsson K, Paty PB, Rabkin JM, Upton RA, von Smitten K, Whitney JD: Wound
statistics and Medicine, McMaster University in West                               tissue oxygen tension predicts the risk of wound infection in surgical patients.
Hamilton, Ontario, Canada, who will present the evi-                               Arch Surg 1997; 132:997–1004
                                                                                      16. Kabon B, Fleischmann E, Treschan T, Taguchi A, Kapral S, Kurz A:
dence linking -blocker administration and sympatholy-                              Thoracic epidural anesthesia increases tissue oxygenation during major abdom-
sis with perioperative myocardial infarction, stroke, and                          inal surgery. Anesth Analg 2003; 97:1812–7
mortality. Devereaux was the principal investigator on                                17. Akca O, Melischek M, Scheck T, Hellwagner K, Arkilic C, Kurz A, Kapral
                                                                                             ¸                                                      ¸
                                                                                   S, Heinz T, Lackner FX, Sessler DI: Postoperative pain and subcutaneous oxygen
the recent POISE trial, which is by far the largest ran-                           tension. Lancet 1999; 354:41–2
domized trial of perioperative -blocker use.40 Marc De                                18. Denis MG, Lipart C, Leborgne J, LeHur PA, Galmiche JP, Denis M, Ruud E,
                                                                                   Truchaud A, Lustenberger P: Detection of disseminated tumor cells in peripheral
Kock, M.D., Ph.D., Department of Anesthesiology, Uni-                              blood of colorectal cancer patients. Int J Cancer 1997; 74:540–4
versite Catholique de Louvain, St. Luc Hospital, Brussels,                            19. Shakhar G, Ben-Eliyahu S: Potential prophylactic measures against postop-
                                                                                   erative immunosuppression: Could they reduce recurrence rates in oncological
Belgium, who has published extensively on the topic,                               patients? Ann Surg Oncol 2003; 10:972–92
will then discuss persistent incision pain. Finally,                                  20. Bar-Yosef S, Melamed R, Page GG, Shakhar G, Shakhar K, Ben-Eliyahu S:
                                                                                   Attenuation of the tumor-promoting effect of surgery by spinal blockade in rats.
Alexander Hannenberg, M.D., of the Department of An-                               ANESTHESIOLOGY 2001; 94:1066–73
esthesiology, Newton-Wellesley Hospital, Tufts Univer-                                21. Antoni MH, Lutgendorf SK, Cole SW, Dhabhar FS, Sephton SE, McDonald
                                                                                   PG, Stefanek M, Sood AK: The influence of bio-behavioural factors on tumour
sity School of Medicine, Newton, Massachusetts, and                                biology: Pathways and mechanisms. Nat Rev Cancer 2006; 6:240–8
Mark Warner, M.D., of the Department of Anesthesiol-                                  22. Sacerdote P, Bianchi M, Gaspani L, Manfredi B, Maucione A, Terno G, Am-
                                                                                   matuna M, Panerai AE: The effects of tramadol and morphine on immune responses
ogy, Mayo Clinic, Rochester, Minnesota, will discuss                               and pain after surgery in cancer patients. Anesth Analg 2000; 90:1411–4
how the new Anesthesia Quality Institute and Mainte-                                  23. Gupta K, Kshirsagar S, Chang L, Schwartz R, Law PY, Yee D, Hebbel RP:
                                                                                   Morphine stimulates angiogenesis by activating proangiogenic and survival-pro-
nance of Certification in Anesthesiology may improve                                moting signaling and promotes breast tumor growth. Cancer Res 2002; 62:
long-term anesthetic outcomes. As leaders of these initi-                          4491–8
                                                                                      24. Ben-Eliyahu S, Page GG, Yirmiya R, Shakhar G: Evidence that stress and
atives, they are well positioned to put them into                                  surgical interventions promote tumor development by suppressing natural killer
perspective.                                                                       cell activity. Int J Cancer 1999; 80:880–8
                                                                                      25. O’Riain SC, Buggy DJ, Kerin MJ, Watson RW, Moriarty DC: Inhibition of
  Finally, I am delighted to announce that long-terms out-                         the stress response to breast cancer surgery by regional anesthesia and analgesia
comes will be the topic of the 2010 ANESTHESIOLOGY Journal                         does not affect vascular endothelial growth factor and prostaglandin E2. Anesth
                                                                                   Analg 2005; 100:244–9
Symposium. We look forward to an in-depth exploration of                              26. Chae BK, Lee HW, Sun K, Choi YH, Kim HM: The effect of combined
this exciting new dimension of anesthesia.                                         epidural and light general anesthesia on stress hormones in open heart surgery
                                                                                   patients. Surg Today 1998; 28:727–31
Daniel I. Sessler M.D. Department of Outcomes Research, The                           27. Sessler DI: Does regional analgesia reduce the risk of cancer recurrence? A
Cleveland Clinic, Cleveland, Ohio. DS@OR.org                                       hypothesis. Eur J Cancer Prev 2008; 17:269–72
                                                                                      28. Page GG, Blakely WP, Ben-Eliyahu S: Evidence that postoperative pain is a
                                                                                   mediator of the tumor-promoting effects of surgery in rats. Pain 2001; 90:191–9
                                                                                      29. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI: Can anes-
References                                                                         thetic technique for primary breast cancer surgery affect recurrence or metasta-
                                                                                   sis? ANESTHESIOLOGY 2006; 4:660–4
   1. Lienhart A, Auroy Y, Pequignot F, Benhamou D, Warszawski J, Bovet M,            30. Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ:
Jougla E: Survey of anesthesia-related mortality in France. ANESTHESIOLOGY 2006;   Anesthetic technique for radical prostatectomy surgery affects cancer recur-
105:1087–97                                                                        rence: A retrospective analysis. ANESTHESIOLOGY 2008; 109:180–7
   2. Li G, Warner M, Lang BH, Huang L, Sun LS: Epidemiology of anesthesia-           31. Sessler DI, Ben-Eliyahu S, Mascha EJ, Parat MO, Buggy DJ: Can regional
related mortality in the United States, 1999 –2005. ANESTHESIOLOGY 2009; 110:      analgesia reduce the risk of recurrence after breast cancer? Methodology of a
759–65                                                                             multicenter randomized trial. Contemp Clin Trials 2008; 29:517–26


Anesthesiology, V 111, No 1, Jul 2009
4                                                                                                                                       EDITORIAL VIEWS


  32. Spahn DR, Moch H, Hofmann A, Isbister JP: Patient blood management:              37. Maze M, Cibelli M, Grocott HP: Taking the lead in research into postop-
The pragmatic solution for the problems with blood transfusions (editorial).         erative cognitive dysfunction. ANESTHESIOLOGY 2008; 108:1–2
ANESTHESIOLOGY 2008; 109:951–3                                                         38. Patel P, Sun L: Update on neonatal anesthetic neruotoxicity: Insight
  33. Fahy BG, Sheehy AM, Coursin DB: Perioperative glucose control: What is         into molecular mechanisms and relevance to humans. ANESTHESIOLOGY 2009;
enough? ANESTHESIOLOGY 2009; 110:204–6                                               110:703–8
  34. Nunnally ME, O’Connor MF: Glycemic control for organs: A new approach            39. Perouansky M, Hemmings HC: Between Clotho and Lachesis: How isoflu-
to a controversial topic. ANESTHESIOLOGY 2009; 110:207–8                             rane seals neuronal fate. ANESTHESIOLOGY 2009; 110:709–11
  35. Lanier WL, Pasternak JJ: Refining perioperative glucose management in             40. Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D,
patients experiencing, or at risk for, ischemic brain injury. ANESTHESIOLOGY 2009;   Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Malaga G, Avezum A,
110: 456–8                                                                           Chan M, Montori VM, Jacka M, Choi P: Effects of extended-release metoprolol
  36. Kehlet H, Bundgaard-Nielsen M: Goal-directed perioperative fluid manage-        succinate in patients undergoing non-cardiac surgery (POISE trial): A randomised
ment: Why, when, and how? ANESTHESIOLOGY 2009; 110:453–5                             controlled trial. Lancet 2008; 371:1839–47




       ANESTHESIOLOGY REFLECTIONS

                                                              Hingson’s Peace Gun




                        Familiar with jet-injection injuries from his military background, Anesthesiologist Robert A.
                        Hingson, M.D. (1913–1996) published about needle-free injection as early as 1947. By the
                        following year, Hingson had penned papers about his “Hypospray” device, nearly 20 years
                        before Hyposprays were featured on television’s Star Trek and then in more than a dozen
                        unrelated science fiction movies. Surprisingly, this handheld version of a Hingson “Peace
                        Gun” pictured above—with its luger-like metal silhouette and sharp bottle piercer— went unchal-
                        lenged through airport security x-ray machines as it was curatorially hand-carried to the gallery
                        of the Wood Library-Museum. Facilitated by patent innovations in the 1960s by Aaron Ismach and
                        others, Hingson and his Cleveland and Pittsburgh colleagues popularized jet injection technolo-
                        gies which have immunized more than a billion people and eradicated smallpox worldwide.
                        (Copyright © the American Society of Anesthesiologists, Inc. This image appears in color in the
                        Anesthesiology Reflections online collection available at www.anesthesiology.org.)
                            George S. Bause, M.D., M.P.H., Honorary Curator, ASA’s Wood Library-Museum of Anes-
                        thesiology, Park Ridge, Illinois, and Clinical Associate Professor, Case Western Reserve
                        University, Cleveland, Ohio. UJYC@aol.com.


Anesthesiology, V 111, No 1, Jul 2009

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Long-term Consequences of Anesthetic Management

  • 1. EDITORIAL VIEWS Anesthesiology 2009; 111:1– 4 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Long-term Consequences of Anesthetic Management Editor’s Note: This is the first in a series of four Editorial Views on long-term outcomes after anesthesia and surgery. This series adds to other recent Editorial Views in ANESTHESIOLOGY and includes a discussion of broadening our research outside of the operating room to prevention of wound infections, cancer spread, cardiovascular morbidity and mortality, chronic postsurgical pain, and rare complications. ANESTHESIOLOGY will sponsor special sessions in 2010 on the topic of long-term outcomes at annual meetings of the Japanese Society of Anesthesiologists, the European Society of Anesthesiology, and the American Society of Anesthesiologists. James C. Eisenach, M.D., Editor-in-Chief TWENTY-FIVE years ago, when I was an anesthesia res- cialty a “most improved” designation from the Institute ident, preventable anesthetic mortality occurred in per- of Medicine.3 (Granted, evaluating anesthetic mortality haps 1 of 10,000 cases1—making anesthesia the most remains inexact and controversial,4,5 but the consensus dangerous part of most operations. I refer neither to the is that improvement has been substantial in recent de- patients who died of overwhelming underlying disease nor cades, especially considering how much sicker patients are to the patients who died of acute surgical misadventures; I now.) An unfortunate consequence of our improvement is mean relatively healthy patients having routine operations that some consider anesthetic safety a more-or-less solved who died from anesthetic causes and mistakes. problem. At the very least, the number of intraoperative High anesthetic mortality in the early 1980s was per- deaths is now so small that policymakers might reasonably haps unsurprising considering the state of anesthesia conclude that resources would be better invested else- equipment, drugs, and training. Anesthesia machines where. This thought process may contribute to the dis- often lacked a nitrous oxide-oxygen interlock; on such mally small amount of funding that the National Institutes machines, there was little to prevent an anesthesiologist of Health provides for anesthesiology research. at the end of the case from turning off the oxygen instead of the nitrous oxide—thus delivering a hypoxic Long-term Outcomes gas mixture. And having done so, the error was often undetected until too late because oxygen analyzers were In distinct contrast to preventable anesthetic mortality, not uniformly used. which thankfully is now rare, all-cause postoperative mor- Volatile anesthetics in that era were still often deliv- tality is surprisingly high. About 5% of all surgical patients ered via copper kettles, which meant that reductions in die in the year after surgery; among those aged more than fresh gas flow proportionately increased delivered anes- 65 yr, mortality is about 10%.6 To put this another way, thetic concentration, sometimes to dangerous levels. mortality in the year after surgery is about 10,000 times Such episodes would rarely be detected because expired more common than preventable anesthetic mortality. gas monitoring was restricted to a limited number of It is thus reasonable to ask to what extent anesthetic academic centers that had invested in expensive and management might influence long-term outcomes. The touchy multiplexed mass spectrometry systems. Pulse distinction I make here is between the classic definition oximetry was yet to be available for some years hence. of anesthetic complications, which is restricted to the Available drugs were longer-acting and harder to use immediate perioperative period extending perhaps to a than our current ones; the less-soluble volatile anesthetic few days after surgery, and the potential effects of anes- in those days was isoflurane, halothane remained in thetic management on events weeks, months, or even common use, and the shorter-acting muscle relaxant was years after surgery. curare. Furthermore, anesthesia residency was only 2 yr Given that modern anesthetic drugs are uniformly and considerably less rigorous than it is now. short-acting, it is by no means obvious that conse- My, how it has changed! Preventable anesthetic mor- quences of anesthetic management could last more than hours or days after surgery. Certainly, long-term conse- tality is now probably less than 1 case in 100,000,1,2 a quences of anesthesia were not seriously considered more than 10-fold improvement that earned our spe- until relatively recently. That said, however, there is increasing evidence that some intraoperative anesthetic Accepted for publication April 2, 2009. The author is not supported by, nor maintains any financial interest in, any commercial activity that may be associated management decisions do have long-term consequences with the topic of this article. and that others might as well. Anesthesiology, V 111, No 1, Jul 2009 1
  • 2. 2 EDITORIAL VIEWS Surgical Site Infection is surgery per se, which releases tumor cells into circu- lation,18 depresses cell-mediated immunity including Arguably, the first convincing evidence for long-term cytotoxic T-cell and natural killer cell functions,20 re- outcomes related to anesthetic management dates to duces circulating concentrations of tumor-related antian- 1996, which saw publication of two key articles in the giogenic factors, increases concentrations of proangio- New England Journal of Medicine. One, from Mangano genic factors such as vascular endothelial growth et al., linked perioperative -blocker administration to factor,21 and releases growth factors that promote myocardial infarction and mortality7 (more about this local and distant growth of malignant tissue.19 The topic below). The other, from Kurz et al., showed that second factor is that volatile anesthesia per se impairs mild hypothermia triples the risk of surgical wound neutrophil, macrophage, dendritic-cell, T-cell, and nat- infection8 even though surgical site infections become ural killer-cell immune functions.22 The third factor is clinically apparent 1– 4 weeks after surgery. The link opioids that inhibit both cellular and humoral immune between hypothermia and infection was subsequently function.22 Furthermore, morphine is proangiogenic and confirmed by an additional randomized trial.9 The risk of surgical wound infection also appears to be mod- promotes tumor growth.23 Consequently, nonopioid anal- erated by supplemental oxygen, even when supple- gesia helps preserve natural killer cell function in animals mental oxygen is only provided during surgery and 2 and humans and reduces metastatic spread of cancer in or 6 hr thereafter.10,11 rodents.24 There is thus considerable evidence that wound infec- Regional anesthesia and analgesia attenuate or prevent tions, despite becoming clinically apparent weeks after each of these adverse effects. For example, regional surgery, are established during and immediately after sur- anesthesia largely prevents the neuroendocrine stress gery. All surgical wounds become contaminated; surgical response to surgery by blocking afferent neural transmis- sterility is only relative! Whether contamination progresses sion from reaching the central nervous system and by to a clinical infection is determined by the adequacy of host blocking descending efferent activation of the sympa- defenses during a decisive period lasting some hours after thetic nervous system.25 Consequently, natural killer-cell contamination. In the case of bacteria causing surgical function is better preserved with regional anesthesia and wound infections, the most important host defense is oxi- metastatic load to the lungs is reduced in a rat model of dative killing by neutrophils.12 This process requires mo- breast cancer metastasis.20 lecular oxygen13 and is a function of tissue (as opposed to When regional and general anesthetics are combined, arterial) oxygen partial pressure over the entire physiologic the amount of general anesthetic required is much re- range. Interventions that increase tissue oxygen during the duced, as is presumably immune suppression. Further- decisive period, such as maintaining normothermia14 and more, regional analgesia provides superb pain relief, providing supplemental oxygen,10 reduce progression of essentially obviating the need for postoperative opioids, contamination to clinical infection. and the consequent adverse effects on immune function It is likely that infection risk is similarly diminished by and of tumor growth.22,25 Regional analgesia also re- other factors that support tissue oxygenation,15 including duces release of endogenous opioids.26 adequate sympathetic block16 and good control of surgical Available data thus suggest that regional anesthesia and pain.17 The potential benefit of these and other interven- analgesia help preserve effective defenses against tumor tions have yet to be determined in large- scale outcome progression by attenuating the surgical stress response, studies, but they remain under active investigation. by reducing general anesthesia requirements, and by sparing postoperative opioids.27 Animal studies are con- sistent with this theory, showing that regional anesthesia Regional Analgesia and Cancer Recurrence and optimum postoperative analgesia independently re- An additional long-term outcome to consider is cancer. duce the metastatic burden in animals inoculated with Although not widely appreciated, tumor surgery is usu- breast adenocarcinoma cells.28 Available human data, ally associated with release of tumor cells into the lym- although extremely limited, are also consistent with this phatic and blood streams; furthermore, a large fraction theory. For example, paravertebral anesthesia and anal- of patients already harbor micrometastases and scattered gesia for breast cancer surgery is associated with an tumor cells at the time of surgery.18 Whether this min- approximately four-fold reduced risk of recurrence or imal residual disease results in clinical metastases de- metastasis.29 Similarly, epidural analgesia for radical pros- pends largely on the balance between antimetastatic tate surgery is associated with a 60% reduction in recur- immune activity and the tumor’s ability to seed, prolif- rence risk.30 Major prospective trials of paravertebral anal- erate, and attract new blood vessels.19 gesia for breast cancer surgery (NCT00418457)31 and At least three perioperative factors shift the balance epidural analgesia for colon cancer are in progress toward progression of minimal residual disease. The first (NCT00684229). Anesthesiology, V 111, No 1, Jul 2009
  • 3. EDITORIAL VIEWS 3 Recent and Future Editorials Exploring 3. Kohn KT, Corrigan JM, Donaldson M: To err is human: Building a safer health system. Washington, DC, Academy Press, 1999 Long-term Outcomes 4. Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on Additional proven or potential long-term outcomes of severe morbidity and mortality. ANESTHESIOLOGY 2005; 102:257–68; quiz 491–2 5. Lagasse RS: Innocent prattle. ANESTHESIOLOGY 2009; 110:698–9 perioperative management have already been addressed 6. Monk TG, Saini V, Weldon BC, Sigl JC: Anesthetic management and one-year in recent ANESTHESIOLOGY editorials. For example, an edi- mortality after noncardiac surgery. Anesth Analg 2005; 100:4–10 7. Mangano DT, Layug EL, Wallace A, Tateo I: Effect of atenolol on mortality torial in the December issue by Spahn et al. highlights and cardiovascular morbidity after noncardiac surgery. Multicenter Study of the dangers of red cell transfusions, especially noninfec- Perioperative Ischemia Research Group. N Engl J Med 1996; 335:1713–20 8. Kurz A, Sessler DI, Lenhardt RA: Study of wound infections and temperature tious complications, which are the major risk.32 Editori- group: Perioperative normothermia to reduce the incidence of surgical-wound als in the February (Fahy et al.33 and Nunnally and infection and shorten hospitalization. N Engl J Med 1996; 334:1209–15 9. Melling AC, Ali B, Scott EM, Leaper DJ: Effects of preoperative warming on O’Conner34) and March (Lanier and Pasternak35) issues the incidence of wound infection after clean surgery: A randomised controlled discuss the risks and benefits of tight glycemic control. trial. Lancet 2001; 358:876–80 10. Greif R, Akca O, Horn E-P, Kurz A, Sessler DI: Outcomes Research™ ¸ Also in March, Kehlet and Bundgaard-Nielsen discuss Group: Supplemental perioperative oxygen to reduce the incidence of surgical long-term consequences of perioperative fluid manage- wound infection. N Engl J Med 2000; 342:161–7 11. Belda FJ, Aguilera L, Garcia de la Asuncion J, Alberti J, Vicente R, Ferrandiz ment.36 An editorial by Maze focused on postoperative L, Rodriguez R, Company R, Sessler DI, Aguilar G, Botello SG, Orti R: Supple- cognitive dysfunction.37 And finally, April editorials by mental perioperative oxygen and the risk of surgical wound infection: A random- ized controlled trial. JAMA 2005; 294:2035–42 Patel and Sun38 and by Perouansky and Hemmings39 12. Benhaim P, Hunt TK: Natural resistance to infection: Leukocyte functions. dealt with volatile anesthetic toxicity in newborns. J Burn Care Rehabil 1992; 13:287–92 13. Jonsson K, Hunt TK, Mathes SJ: Oxygen as an isolated variable influences This is the first of four editorials to address additional resistance to infection. Ann Surg 1988; 208:783–7 potential long-term consequences of anesthetic manage- 14. Sheffield CW, Sessler DI, Hopf HW, Schroeder M, Moayeri A, Hunt TK, West JM: Centrally and locally mediated thermoregulatory responses alter sub- ment. The next will be by Philip Devereaux, M.D., Ph.D., cutaneous oxygen tension. Wound Rep Reg 1997; 4:339–45 from the Department of Clinical Epidemiology and Bio- 15. Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH 3rd, Jensen JA, Jonsson K, Paty PB, Rabkin JM, Upton RA, von Smitten K, Whitney JD: Wound statistics and Medicine, McMaster University in West tissue oxygen tension predicts the risk of wound infection in surgical patients. Hamilton, Ontario, Canada, who will present the evi- Arch Surg 1997; 132:997–1004 16. Kabon B, Fleischmann E, Treschan T, Taguchi A, Kapral S, Kurz A: dence linking -blocker administration and sympatholy- Thoracic epidural anesthesia increases tissue oxygenation during major abdom- sis with perioperative myocardial infarction, stroke, and inal surgery. Anesth Analg 2003; 97:1812–7 mortality. Devereaux was the principal investigator on 17. Akca O, Melischek M, Scheck T, Hellwagner K, Arkilic C, Kurz A, Kapral ¸ ¸ S, Heinz T, Lackner FX, Sessler DI: Postoperative pain and subcutaneous oxygen the recent POISE trial, which is by far the largest ran- tension. Lancet 1999; 354:41–2 domized trial of perioperative -blocker use.40 Marc De 18. Denis MG, Lipart C, Leborgne J, LeHur PA, Galmiche JP, Denis M, Ruud E, Truchaud A, Lustenberger P: Detection of disseminated tumor cells in peripheral Kock, M.D., Ph.D., Department of Anesthesiology, Uni- blood of colorectal cancer patients. Int J Cancer 1997; 74:540–4 versite Catholique de Louvain, St. Luc Hospital, Brussels, 19. Shakhar G, Ben-Eliyahu S: Potential prophylactic measures against postop- erative immunosuppression: Could they reduce recurrence rates in oncological Belgium, who has published extensively on the topic, patients? Ann Surg Oncol 2003; 10:972–92 will then discuss persistent incision pain. Finally, 20. Bar-Yosef S, Melamed R, Page GG, Shakhar G, Shakhar K, Ben-Eliyahu S: Attenuation of the tumor-promoting effect of surgery by spinal blockade in rats. Alexander Hannenberg, M.D., of the Department of An- ANESTHESIOLOGY 2001; 94:1066–73 esthesiology, Newton-Wellesley Hospital, Tufts Univer- 21. Antoni MH, Lutgendorf SK, Cole SW, Dhabhar FS, Sephton SE, McDonald PG, Stefanek M, Sood AK: The influence of bio-behavioural factors on tumour sity School of Medicine, Newton, Massachusetts, and biology: Pathways and mechanisms. Nat Rev Cancer 2006; 6:240–8 Mark Warner, M.D., of the Department of Anesthesiol- 22. Sacerdote P, Bianchi M, Gaspani L, Manfredi B, Maucione A, Terno G, Am- matuna M, Panerai AE: The effects of tramadol and morphine on immune responses ogy, Mayo Clinic, Rochester, Minnesota, will discuss and pain after surgery in cancer patients. Anesth Analg 2000; 90:1411–4 how the new Anesthesia Quality Institute and Mainte- 23. Gupta K, Kshirsagar S, Chang L, Schwartz R, Law PY, Yee D, Hebbel RP: Morphine stimulates angiogenesis by activating proangiogenic and survival-pro- nance of Certification in Anesthesiology may improve moting signaling and promotes breast tumor growth. Cancer Res 2002; 62: long-term anesthetic outcomes. As leaders of these initi- 4491–8 24. Ben-Eliyahu S, Page GG, Yirmiya R, Shakhar G: Evidence that stress and atives, they are well positioned to put them into surgical interventions promote tumor development by suppressing natural killer perspective. cell activity. Int J Cancer 1999; 80:880–8 25. O’Riain SC, Buggy DJ, Kerin MJ, Watson RW, Moriarty DC: Inhibition of Finally, I am delighted to announce that long-terms out- the stress response to breast cancer surgery by regional anesthesia and analgesia comes will be the topic of the 2010 ANESTHESIOLOGY Journal does not affect vascular endothelial growth factor and prostaglandin E2. Anesth Analg 2005; 100:244–9 Symposium. We look forward to an in-depth exploration of 26. Chae BK, Lee HW, Sun K, Choi YH, Kim HM: The effect of combined this exciting new dimension of anesthesia. epidural and light general anesthesia on stress hormones in open heart surgery patients. Surg Today 1998; 28:727–31 Daniel I. Sessler M.D. Department of Outcomes Research, The 27. Sessler DI: Does regional analgesia reduce the risk of cancer recurrence? A Cleveland Clinic, Cleveland, Ohio. DS@OR.org hypothesis. Eur J Cancer Prev 2008; 17:269–72 28. Page GG, Blakely WP, Ben-Eliyahu S: Evidence that postoperative pain is a mediator of the tumor-promoting effects of surgery in rats. Pain 2001; 90:191–9 29. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI: Can anes- References thetic technique for primary breast cancer surgery affect recurrence or metasta- sis? ANESTHESIOLOGY 2006; 4:660–4 1. Lienhart A, Auroy Y, Pequignot F, Benhamou D, Warszawski J, Bovet M, 30. Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ: Jougla E: Survey of anesthesia-related mortality in France. ANESTHESIOLOGY 2006; Anesthetic technique for radical prostatectomy surgery affects cancer recur- 105:1087–97 rence: A retrospective analysis. ANESTHESIOLOGY 2008; 109:180–7 2. Li G, Warner M, Lang BH, Huang L, Sun LS: Epidemiology of anesthesia- 31. Sessler DI, Ben-Eliyahu S, Mascha EJ, Parat MO, Buggy DJ: Can regional related mortality in the United States, 1999 –2005. ANESTHESIOLOGY 2009; 110: analgesia reduce the risk of recurrence after breast cancer? Methodology of a 759–65 multicenter randomized trial. Contemp Clin Trials 2008; 29:517–26 Anesthesiology, V 111, No 1, Jul 2009
  • 4. 4 EDITORIAL VIEWS 32. Spahn DR, Moch H, Hofmann A, Isbister JP: Patient blood management: 37. Maze M, Cibelli M, Grocott HP: Taking the lead in research into postop- The pragmatic solution for the problems with blood transfusions (editorial). erative cognitive dysfunction. ANESTHESIOLOGY 2008; 108:1–2 ANESTHESIOLOGY 2008; 109:951–3 38. Patel P, Sun L: Update on neonatal anesthetic neruotoxicity: Insight 33. Fahy BG, Sheehy AM, Coursin DB: Perioperative glucose control: What is into molecular mechanisms and relevance to humans. ANESTHESIOLOGY 2009; enough? ANESTHESIOLOGY 2009; 110:204–6 110:703–8 34. Nunnally ME, O’Connor MF: Glycemic control for organs: A new approach 39. Perouansky M, Hemmings HC: Between Clotho and Lachesis: How isoflu- to a controversial topic. ANESTHESIOLOGY 2009; 110:207–8 rane seals neuronal fate. ANESTHESIOLOGY 2009; 110:709–11 35. Lanier WL, Pasternak JJ: Refining perioperative glucose management in 40. Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, patients experiencing, or at risk for, ischemic brain injury. ANESTHESIOLOGY 2009; Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Malaga G, Avezum A, 110: 456–8 Chan M, Montori VM, Jacka M, Choi P: Effects of extended-release metoprolol 36. Kehlet H, Bundgaard-Nielsen M: Goal-directed perioperative fluid manage- succinate in patients undergoing non-cardiac surgery (POISE trial): A randomised ment: Why, when, and how? ANESTHESIOLOGY 2009; 110:453–5 controlled trial. Lancet 2008; 371:1839–47 ANESTHESIOLOGY REFLECTIONS Hingson’s Peace Gun Familiar with jet-injection injuries from his military background, Anesthesiologist Robert A. Hingson, M.D. (1913–1996) published about needle-free injection as early as 1947. By the following year, Hingson had penned papers about his “Hypospray” device, nearly 20 years before Hyposprays were featured on television’s Star Trek and then in more than a dozen unrelated science fiction movies. Surprisingly, this handheld version of a Hingson “Peace Gun” pictured above—with its luger-like metal silhouette and sharp bottle piercer— went unchal- lenged through airport security x-ray machines as it was curatorially hand-carried to the gallery of the Wood Library-Museum. Facilitated by patent innovations in the 1960s by Aaron Ismach and others, Hingson and his Cleveland and Pittsburgh colleagues popularized jet injection technolo- gies which have immunized more than a billion people and eradicated smallpox worldwide. (Copyright © the American Society of Anesthesiologists, Inc. This image appears in color in the Anesthesiology Reflections online collection available at www.anesthesiology.org.) George S. Bause, M.D., M.P.H., Honorary Curator, ASA’s Wood Library-Museum of Anes- thesiology, Park Ridge, Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland, Ohio. UJYC@aol.com. Anesthesiology, V 111, No 1, Jul 2009