Dept Of Anesthesiology & Critical Care, University Of Pennsylvania School Of Medicine

Dr Kofke Discusses Deep Circulatory Arrest and Brain Ischemia

In the Ether Way Blog Andy Kofke reviews the UPENN experience on brain preservation during circulatory arrest for aortic arch surgery and how the successes for this operation might apply to other types of surgery that produce a risk for cerebral ischemia (http://mkeamy.typepad.com/anesthesiacaucus/2007/09/deep-hypothermi.html)

Publications 2006 Department of Anesthesiology and Critical Care

Armstead W M: Association between intravascular coagulopathy and outcome after traumatic brain injury.[comment]. Neurology India 2006;54: 347-8

Armstead W M: Differential activation of ERK, p38, and JNK MAPK by nociceptin/orphanin FQ in the potentiation of prostaglandin cerebrovasoconstriction after brain injury. European Journal of Pharmacology 2006;529: 129-35

Armstead W M, Nassar T, Akkawi S, Smith D H, Chen X-H, Cines D B, Higazi A A-R: Neutralizing the neurotoxic effects of exogenous and endogenous tPA. Nature Neuroscience 2006;9: 1150-5

Atkins J H, Johansson J S: Technologies to shape the future: proteomics applications in anesthesiology and critical care medicine. Anesthesia & Analgesia 2006;102: 1207-16

Augoustides J G, Pochettino A, Ochroch E A, Cowie D, Weiner J, Gambone A J, Pinchasik D, Bavaria J E, Jobes D R, Augoustides J G T, Pochettino A, Ochroch E A, Cowie D, Weiner J, Gambone A J, Pinchasik D, Bavaria J E, Jobes D R: Renal dysfunction after thoracic aortic surgery requiring deep hypothermic circulatory arrest: definition, incidence, and clinical predictors. Journal of Cardiothoracic & Vascular Anesthesia 2006;20: 673-7

Augoustides J G T, Hosalkar H H, Milas B L, Acker M, Savino J S: Upper gastrointestinal injuries related to perioperative transesophageal echocardiography: index case, literature review, classification proposal, and call for a registry. Journal of Cardiothoracic & Vascular Anesthesia 2006;20: 379-84

Barnett R: Pro: Veno-veno bypass should routinely be used during liver transplantation.[see comment]. Journal of Cardiothoracic & Vascular Anesthesia 2006;20: 742-3

Byrem W C, Armstead S C, Kobayashi S, Eckenhoff R G, Eckmann D M: A guest molecule-host cavity fitting algorithm to mine PDB for small molecule targets. Biochimica et Biophysica Acta 2006;1764: 1320-4

Carnini A, Eckenhoff M F, Eckenhoff R G: Interactions of volatile anesthetics with neurodegenerative-disease-associated proteins. Anesthesiology Clinics 2006;24: 381-405

Churbanova I Y, Tronin A, Strzalka J, Gog T, Kuzmenko I, Johansson J S, Blasie J K: Monolayers of a model anesthetic-binding membrane protein: formation, characterization, and halothane-binding affinity. Biophysical Journal 2006;90: 3255-66

Cook-Sather S D, Litman R S: Modern fasting guidelines in children. Best Practice & Research Clinical Anaesthesiology 2006;20: 471-81

Cucchiaro G, Adzick S N, Rose J B, Maxwell L, Watcha M: A comparison of epidural bupivacaine-fentanyl and bupivacaine-clonidine in children undergoing the Nuss procedure. Anesthesia & Analgesia103: 322-7

Deutschman C S, Cereda M, Ochroch E A, Raj N R: Sepsis-induced cholestasis, steatosis, hepatocellular injury, and impaired hepatocellular regeneration are enhanced in interleukin-6 -/- mice.[see comment]. Critical Care Medicine 2006;34: 2613-20

Dominguez T E, Helfaer M A: Review of bispectral index monitoring in the emergency department and pediatric intensive care unit. Pediatric Emergency Care 2006;22: 815-21; quiz 822-4

Eckmann D M, Armstead S C: Influence of endothelial glycocalyx degradation and surfactants on air embolism adhesion. Anesthesiology 2006;105: 1220-7

Eckmann D M, Zhang J, Lampe J, Ayyaswamy P S, Eckmann D M, Zhang J, Lampe J, Ayyaswamy P S: Gas embolism and surfactant-based intervention: implications for long-duration space-based activity. Annals of the New York Academy of Sciences 2006;1077: 256-69

Frey T K E, Chopra A, Lin R J, Levy R J, Gruber P, Rheingold S R, Hoehn K S: A child with anterior mediastinal mass supported with veno-arterial extracorporeal membrane oxygenation. Pediatric Critical Care Medicine 2006;7: 479-81

Gavrin J R: The American Medical Association "Pain Management: the Online Series". Journal of Pain & Palliative Care Pharmacotherapy 2006;20: 71-7

Gavrin J R: Palliative care. Anesthesiology Clinics 2006;24: xv-xvi

Gavrin J R: A prototypical gateway to the World Wide Web: Making sense of pain relief. Journal of Pain & Palliative Care Pharmacotherapy 2006;20: 29-31

Hecker J G, Laslett L, Campbell E, Nunnally M, O'Connor A, Ellis J E, Frogel J K, Fleisher L A: Case 2-2006: Catastrophic cardiovascular collapse during carotid endarterectomy. Journal of Cardiothoracic & Vascular Anesthesia 2006;20: 259-68

Huh J W, Franklin M A, Widing A G, Raghupathi R: Regionally distinct patterns of calpain activation and traumatic axonal injury following contusive brain injury in immature rats. Developmental Neuroscience 2006;28: 466-76

Johansson J S: Central nervous system electrical synapses as likely targets for intravenous general anesthetics.[comment]. Anesthesia & Analgesia 2006;102: 1689-91

Kohl B A: Con: Should aspirin be continued after cardiac surgery in the setting of thrombocytopenia?[comment]. Journal of Cardiothoracic & Vascular Anesthesia 2006;20: 114-6

Levine G K, Deutschman C S, Helfaer M A, Margulies S S: Sepsis-induced lung injury in rats increases alveolar epithelial vulnerability to stretch.[see comment]. Critical Care Medicine 2006;34: 1746-51

Li M, Ratcliffe S J, Knoll F, Wu J, Ances B, Mardini W, Floyd T F: Aging: impact upon local cerebral oxygenation and blood flow with acute isovolemic hemodilution. Journal of Neurosurgical Anesthesiology 2006;18: 125-31

Longnecker D E: Resident duty hours reform: are we there yet?[comment]. Academic Medicine 2006;81: 1017-20

Miksa D, Irish E R, Chen D, Composto R J, Eckmann D M: Dextran functionalized surfaces via reductive amination: morphology, wetting, and adhesion. Biomacromolecules 2006;7: 557-64

Muravchick S, Levy R J: Clinical implications of mitochondrial dysfunction. Anesthesiology 2006;105: 819-37

Ochroch E A, Gottschalk A, Troxel A B, Farrar J T: Women suffer more short and long-term pain than men after major thoracotomy. Clinical Journal of Pain 2006;22: 491-8

Pan J Z, Wei H, Hecker J G, Tobias J W, Eckenhoff R G, Eckenhoff M F: Rat brain DNA transcript profile of halothane and isoflurane exposure. Pharmacogenetics & Genomics 2006;16: 171-82

Sadhasivam S, Ganesh A, Robison A, Kaye R, Watcha M F: Validation of the bispectral index monitor for measuring the depth of sedation in children.[see comment]. Anesthesia & Analgesia 2006;102: 383-8

Xi J, Liu R, Rossi M J, Yang J, Loll P J, Dailey W P, Eckenhoff R G: Photoactive analogues of the haloether anesthetics provide high-resolution features from low-affinity interactions. ACS Chemical Biology [Electronic Resource] 2006;1: 377-84

The conflict of organizational ethics and societal rule of law

Nontherapeutic quality improvement: The conflict of organizational ethics and societal rule of law

Michael A. Rie, MD; W. Andrew Kofke, MD, MBA, FCCM

Objective: Critical care ethics focuses largely on patient autonomy. Cost containment is necessary but requires rationing and limitations on a patient’s right to consume beneficial services. No laws address a process of autonomy rights limitation to consume resources in the intensive care unit. We analyzed the frictional interface between necessary cost containment as a quality improvement activity contrasted with individual autonomy in the context of the evolution of research ethics.

Data Sources and Synthesis: Scholarly books, peer-reviewed articles, congressional record, legal sources, the World Wide Web, and the National Archives and Records Administration were evaluated in the context of current cost-containment– driven nontherapeutic quality improvement activities.

Principal Findings: Three generations in the evolution of human research ethics are identified: 1) Hippocrates to Nuremberg Code, 2) Nuremberg to Belmont, and 3) Belmont to present.  Similar ethical lapses, which place the individual at risk without disclosure for the good of future patients, have arisen recurrently in the course of history and continue presently when nontherapeutic quality improvement activities are framed as a human research activity with essentially no ethical oversight. Consequently, the fiduciary obligations of professionals and their employer institutions to their mutual patients may be at odds, creating complex layers of conflicted decision making. Nonetheless, professional Hippocratic duty to “the patient” must be congruent with the organizational ethos of limited funding “stewardship” to produce meaningful patient care. Medicine’s integrity is legally protected and mandated under the state interests (parens patria doctrine) of the common law.

Conclusion: When hospitals (society and its health insurance methods) fail to ration transparently under “cost-containment ethics,” they threaten the ethical integrity of the medical profession.  (Crit Care Med 2007; 35[Suppl.]:S66–S84)