To explore mechanisms of restrictive respiratory physiology and high pleural pressure (P_Pl) in severe obesity, we studied 51 obese subjects (body mass index = 38–80.7 kg/m²) and 10 nonobese subjects, both groups without lung disease, anesthetized, and paralyzed for surgery. We measured esophageal and gastric pressures (P_Es, P_Ga) using a balloon-catheter, airway pressure (P_AO), flow, and volume. We compared P_Es to another estimate of P_Pl based on P_AO and flow. Reasoning that the lungs would not inflate until P_AO exceeded alveolar and pleural pressures (P_AO > P_Alv > P_Pl), we disconnected subjects from the ventilator for 10–15 s to allow them to reach relaxation volume (V_Rel) and then slowly raised P_AO until lung volume increased by 10 ml, indicating the “threshold P_AO” (P_AO-Thr) for inflation, which we took to be an estimate of the lowest P_Alv or P_Pl to be found in the chest at V_Rel. P_AO-Thr ranged from 0.6 to 14.0 cmH₂O in obese and 0.2 to 0.9 cmH₂O in control subjects. P_Es at V_Rel was higher in obese than control subjects (12.5 ± 3.9 vs. 6.9 ± 3.1 cmH₂O, means ± SD; P = 0.0002) and correlated with P_AO-Thr ( R² = 0.16, P = 0.0015). Respiratory system compliance (C_RS) was lower in obese than control (0.032 ± 0.008 vs. 0.053 ± 0.007 l/cmH₂O) due principally to lower lung compliance (0.043 ± 0.016 vs. 0.084 ± 0.029 l/cmH₂O) rather than chest wall compliance (obese 0.195 ± 0.109, control 0.223 ± 0.132 l/cmH₂O). We conclude that many severely obese supine subjects at relaxation volume have positive P_pl throughout the chest. High P_Es suggests high P_Pl in such individuals. Lung and respiratory system compliances are low because of breathing at abnormally low lung volumes.

The clinical practice of anesthesia has undergone many advances in the past few years, making this the perfect time for a new state-of-the-art anesthesia textbook for practitioners and trainees. The goal of this book is to provide a modern, clinically focused textbook giving rapid access to comprehensive, succinct knowledge from experts in the field. All clinical topics of relevance to anesthesiology are organized into 29 sections consisting of more than 180 chapters. The print version contains 166 chapters that cover all of the essential clinical topics, while an additional 17 chapters on subjects of interest to the more advanced practitioner can be freely accessed at www.cambridge.org/vacanti. Newer techniques such as ultrasound nerve blocks, robotic surgery and transesophageal echocardiography are included, and numerous illustrations and tables assist the reader in rapidly assimilating key information. This authoritative text is edited by distinguished Harvard Medical School faculty, with contributors from many of the leading academic anesthesiology departments in the United States and an introduction from Dr S. R. Mallampati. This book is your essential companion when preparing for board review and recertification exams and in your daily clinical practice.

Rapid shifts in the demographics and techniques of weight loss surgery (WLS) have led to new issues, new data, new concerns, and new challenges. In 2004, this journal published comprehensive evidence‐based guidelines on WLS. In this issue, we've updated those guidelines to assure patient safety in this fast‐changing field. WLS involves a uniquely vulnerable population in need of specialized resources and ongoing multidisciplinary care. Timely best‐practice updates are required to identify new risks, develop strategies to address them, and optimize treatment. Findings in these reports are based on a comprehensive review of the most current literature on WLS; they directly link patient safety to methods for setting evidence‐based guidelines developed from peer‐reviewed scientific publications. Among other outcomes, these reports show that WLS reduces chronic disease risk factors, improves health, and confers a survival benefit on those who undergo it. The literature also shows that laparoscopy has displaced open surgery as the predominant approach; that government agencies and insurers only reimburse procedures performed at accredited WLS centers; that best practice care requires close collaboration between members of a multidisciplinary team; and that new and existing facilities require wide‐ranging changes to accommodate growing numbers of severely obese patients. More than 100 specialists from across the state of Massachusetts and across the many disciplines involved in WLS came together to develop these new standards. We expect them to have far‐reaching effects of the development of health care policy and the practice of WLS.

Background: Antiemetic drugs are costly, are associated with variable efficacy, and can produce unwanted side effects when used for prophylaxis against postoperative nausea and vomiting. This clinical study was designed to compare the efficacy of transcutaneous electrical acupoint stimulation using a ReliefBand to ondansetron (Zofran) when utilized alone or in combination for preventing postoperative nausea and vomiting after plastic surgery. Methods: A single-center, randomized, double-blind, placebo- and sham-controlled study design was conducted to compare three prophylactic antiemetic treatment regimens in 120 outpatients undergoing plastic surgery procedures with routine low-dose droperidol prophylaxis: (1) ondansetron (n = 40), 4 mg intravenous ondansetron and a sham ReliefBand; (2) acustimulation (n = 40), 2 ml intravenous saline and an active ReliefBand; and (3) combination (n = 40), 4 mg intravenous ondansetron and an active ReliefBand. The incidences of postoperative nausea and vomiting, as well as the need for "rescue" antiemetics, were determined at specific time intervals for up to 72 h after surgery. The outcome variables assessed included recovery times, quality of recovery score, time to resumption of normal diet, and patient satisfaction with the prophylactic antiemetic therapy. Results: Use of the ReliefBand in combination with ondansetron significantly reduced nausea (20 vs. 50%), vomiting (0 vs. 20%), and the need for rescue antiemetics (10 vs. 37%) compared with ondansetron alone at 24 h after surgery. Furthermore, the ability to resume a normal diet (74 vs. 35%) within 24 h after surgery was significantly improved when the ReliefBand was used to supplement ondansetron (vs. ondansetron alone). Finally, the quality of recovery (90 +/- 10 vs.70 +/- 20) and patient satisfaction (94 +/- 10 vs. 75 +/- 22) scores were significantly higher in the combination group the ondansetron group. There were no significant differences between the ReliefBand and ondansetron when administered as adjuvants to droperidol for antiemetic prophylaxis. Conclusions: The ReliefBand compared favorably to ondansetron (4 mg intravenously) when used for prophylaxis against postoperative nausea and vomiting. Furthermore, the acustimulation device enhanced the antiemetic efficacy of ondansetron after plastic surgery.

Non-opioid analgesics are often used to supplement opioids for the management of perioperative pain. In this randomized, double-blinded, placebo-controlled study, we examined the effects of acetaminophen and a cyclooxygenase type-2 inhibitor, celecoxib, when administered alone or in combination, before elective otolaryngologic surgery in 112 healthy outpatients. Subjects were assigned to 1 of 4 study groups: Group 1, placebo (vitamin C, 500 mg per os [PO]); Group 2, acetaminophen 2000 mg PO; Group 3, celecoxib 200 mg PO; or Group 4, acetaminophen 2000 mg and celecoxib 200 mg PO. All patients received a standardized anesthetic technique. During the postoperative period, pain was assessed using a 10-point verbal rating scale. Recovery times, the need for rescue analgesics, side effects, and patient satisfaction scores were also recorded. The combination of acetaminophen and celecoxib was significantly more effective than placebo in reducing postoperative pain. Celecoxib, when administered alone or in combination with acetaminophen, improved patients’ satisfaction with their postoperative analgesia. With the combination of acetaminophen and celecoxib, an additional expenditure of $6.16 would be required to obtain complete satisfaction with postoperative pain management in one additional patient who would not have been completely satisfied if he/she had received the placebo. However, oral celecoxib or acetaminophen alone was not significantly more effective than placebo in reducing postoperative pain when administered before surgery. We conclude that oral premedication with a combination of acetaminophen (2000 mg) and celecoxib (200 mg) was highly effective in decreasing pain and improving patient satisfaction after outpatient surgery.