Cognitive Aids in Obstetric Units: Design, Implementation, and Use Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field. Accepted for publication June 9, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Gillian Abir, MBChB, FRCA, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 300 Pasteur Dr, MC 5640, Stanford, CA 94305. Address e-mail to gabir@stanford.edu. © 2019 International Anesthesia Research Society

Hemodynamic Monitoring No abstract available

Anesthesiology Residents’ Documentation of Depth of Neuromuscular Blockade: A Proposed Refinement No abstract available

When Less Is More: Why Extubation With Less Than Routine 100% Oxygen May Be a Reasonable Strategy No abstract available

Anesthetic Management During Electroconvulsive Therapy in Children: A Systematic Review of the Available Literature Electroconvulsive therapy (ECT) is indicated in a myriad of pediatric psychiatric conditions in children, and its use is increasing. Literature on the clinical features salient to anesthetic care is lacking. The objective of this systematic review is to describe the available literature on the anesthetic considerations of pediatric ECT. Original publications were screened for inclusion criteria: (1) manuscript written in English; (2) persons under 18 years of age; and (3) use of ECT. Data tabulation included demographic information, details of anesthetic management and ECT procedure, and adverse events. The mean age was 15 years, 90% were 12–17 years of age, and no cases involving children <6 years of age were identified. The psychiatric diagnoses most commonly represented were major depressive disorder (n = 185) and schizophrenia/schizoaffective disorders (n = 187). ECT was also used to treat many neurological disorders. Medical comorbidities were reported in 16% of all cases. Common coexisting conditions included developmental delay (n = 21) and autism (n = 18). Primary ECT indications included severe psychosis (n = 190), symptoms refractory to pharmacotherapy (n = 154), and suicidality (n = 153). ECT courses per patient ranged from 2 to 156. Duration averaged 91.89 ± 144.3 seconds. The most commonly reported induction agents were propofol and methohexital, and the most commonly reported paralytic agent was succinylcholine. Reported adverse events included headache, nausea, sedation, and short-term amnesia, as well as rare cases of benign dysrhythmias and prolonged seizure. Negative perception and diminished access to care result in treatment delays; thus, these children present in an advanced state of disease. In examining the details of modern ECT performed in 592 children, no major anesthetic morbidity was identified. Further study should start with retrospective analysis of anesthesia data during ECT to compare various effects of anesthesia medications and technique on adverse events and outcomes. Accepted for publication May 14, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Alecia L. S. Stein, MD, Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital/Holtz Children’s Hospital, Miller School of Medicine, University of Miami Health System, 1611 NW 12th Ave, Rm SW 301, Miami, FL 33136. Address e-mail to asabartinelli@med.miami.edu. © 2019 International Anesthesia Research Society

In Response No abstract available

Analgesia in Major Abdominal Surgery No abstract available

The Clinical Use of Cricoid Pressure: First, Do No Harm Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a “standard” of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration. Accepted for publication June 27, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Sorin J. Brull, MD, FCARCSI (Hon), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 4500 San Pablo Rd, Jacksonville, FL 32224. Address e-mail to sjbrull@me.com. © 2019 International Anesthesia Research Society

To Infinity and Beyond: The Past, Present, and Future of Tele-Anesthesia Because the scope of anesthesia practice continues to expand, especially within the perioperative domain, our specialty must continually examine technological services that allow us to provide care in innovative ways. Telemedicine has facilitated the remote provision of medical services across many different specialties, but it remains somewhat unclear whether the use of telemedicine would fit within the practice of anesthesiology on a consistent basis. There have been several reports on the successful use of telemedicine within the preoperative and intraoperative realm. However, patient selection, patient and provider satisfaction, case cancellation rates, equipment reliability, and security of protected health information are just some of the issues that require further examination. This article seeks to review comprehensively the available literature related to the use of telemedicine within the preoperative, intraoperative, and postoperative phases of anesthetic care as well as analyze the major hurdles often encountered when implementing a teleconsultation service. Security of connection, data storage and encryption, federal and state medical licensure compliance, as well as overall cost/savings analysis are a few of the issues that warrant further exploration and research. As telemedicine programs develop within the perioperative arena, it is imperative for institutions to share knowledge, successes, and pitfalls to improve the delivery of care in today’s technology-driven medical landscape. Accepted for publication June 21, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Kathryn Harter Bridges, MD, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Dr, Suite 4200, MSC 240, Charleston, SC 29425. Address e-mail to bridgek@musc.edu. © 2019 International Anesthesia Research Society

Epigenetics Mechanisms in Multiorgan Dysfunction Syndrome Epigenetic mechanisms including deoxyribonucleic acid (DNA) methylation, histone modifications (eg, histone acetylation), and microribonucleic acids (miRNAs) have gained much scientific interest in the last decade as regulators of genes expression and cellular function. Epigenetic control is involved in the modulation of inflammation and immunity, and its dysregulation can contribute to cell damage and organ dysfunction. There is growing evidence that epigenetic changes can contribute to the development of multiorgan dysfunction syndrome (MODS), a leading cause of mortality in the intensive care unit (ICU). DNA hypermethylation, histone deacetylation, and miRNA dysregulation can influence cytokine and immune cell expression and promote endothelial dysfunction, apoptosis, and end-organ injury, contributing to the development of MODS after a critical injury. Epigenetics processes, particularly miRNAs, are emerging as potential biomarkers of severity of disease, organ damage, and prognostic factors in critical illness. Targeting epigenetics modifications can represent a novel therapeutic approach in critical care. Inhibitors of histone deacetylases (HDCAIs) with anti-inflammatory and antiapoptotic activities represent the first class of drugs that reverse epigenetics modifications with human application. Further studies are required to acquire a complete knowledge of epigenetics processes, full understanding of their individual variability, to expand their use as accurate and reliable biomarkers and as safe target to prevent or attenuate MODS in critical disease. Accepted for publication June 5, 2019. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Ettore Crimi, MD, Department of Anesthesiology and Critical Care Medicine, Ocala Health, 1431 SW 1st Ave, Ocala, FL 34478. Address e-mail to ettore.crimi@shcr.com. © 2019 International Anesthesia Research Society