T. Anthony Anderson, PhD, MD

Anesthesiologist, Lucile Packard Children’s Hospital, Stanford University School of Medicine. All Tweets represent my opinion only.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

We are really excited about the potential of focused ultrasound as a non-invasive, non-pharmacological periperal nerve blockade tool for improving acute pain management. However, there is still a lot of work to do. Please let us know what you think. https://t.co/GbeqzTW7J9

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Without a more judicious approach to study design, results of such trials, such as this one, are not only erroneous but also misleading.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Opioids cause respiratory depression, while heavy sedation with non-opioids (here dexmedetomidine) results in airway obstruction.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Lastly, one of the primary outcomes of the study was postoperative hypoxemia, yet there was no distinction made about whether the hypoxemia was due to airway obstruction or respiratory depression.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia It appears that heart rate was the main determinant in treatment intervention, but a low heart rate is really only important if perfusion pressure decreases. Yet, it appears that treatment occurred for bradycardia, independent of the blood pressure.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia It is further unclear how dexmedetomidine would be readily titrated to heart rate when the mean surgery length was less than three hours. Also, a protocol for heart rate management is not defined.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia 0.05 mg/kg of morphine is a low dose for patients who have undergone ‘major’ or ‘intermediate’ surgery. Prior studies typically use a morphine dose ranging from 0.1-0.25 mg/kg (but usually at the start of surgery), even for ambulatory surgeries.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia The late discontinuation of dexmedetomidine certainly accounts for the increased time for anesthesia, extubation, and PACU stay in the dexmedetomidine group despite having a similar duration of surgery.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Remifentanil and dexmedetomidine were stopped at the end of surgery. Given the differences in elimination time, dexmedetomidine should have been stopped at least 30 minutes prior to the end of surgery.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Or, as the context sensitive and terminal elimination half-lives of fentanyl best mimic those of dexmedetomidine after a three-hour infusion, it would have been more rational to compare study arms with fentanyl and dexmedetomidine infusions.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Given the context sensitive and terminal elimination half-lives remifentanil should be compared to esmolol, not dexmedetomidine.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia Practitioners must be aware of the pharmacokinetics of intraoperative agents, cognizant of whether they are being used as analgesics, anesthetics, or both, and then tailor their delivery for both intraoperative and postoperative goals.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@_Anesthesiology @Duke_Anesthesia The study design is perplexing. How were the drugs and doses chosen for comparison? Do the authors use opioid-free analgesic plans? If they did, they would understand why these study arms are so dissimilar.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@emilysharpe @_Anesthesiology Do any of those who designed the study actually utilize opioid-free anesthetics in their practice?

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@emilysharpe @_Anesthesiology Given differences in sedation level after use, analgesic efficacy, and pharmacokinetics, any opioid-free anesthetic should not be compared to any opioid-inclusive anesthetic.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@emilysharpe @_Anesthesiology The study design did not account for a number of critical subtleties that must be considered to effectively utilize opioid-free intraoperative analgesic and anesthetic techniques.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@emilysharpe @_Anesthesiology I am surprised that no one is commenting about the many major issues with this study's methodology. How many people actually use significant intraoperative opioid-sparing or opioid-free analgesic plans? The 2 study arms are comparing apples to oranges.

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@G_DsouzaMD #SPPM2019 #PedsPain #PedsAnes The evidence is strong for which outcome(s) if remifentanil is used intraop? What is its benefit? There are many alternatives. Intraoperative remifentanil use makes for any ‘easy’ anesthetic but we are supposed to be perioperative physicians

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@G_DsouzaMD #SPPMchat #SPPM2019 The thought of remifentanil as standard for painful surgeries literally makes me shudder. Intraoperative remifentanil is associated with hyperalgesia and chronic pain. A better question is to ask yourself why your anesthetic requires remifentanil

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

@DeepaKattail #SPPMchat #SPPM2019 My baseline analgesic plan for almost any length pediatric surgery includes acetaminophen, dexamethasone, dexmedetomidine +/- ketorolac

[T. Anthony Anderson, PhD, MD @TAnthonyAnders1]

Every (almost) patient of mine receives acetaminopen and dexamethasone as baseline intraop analgesics, then some intraop combination of ketorolac, dexmedetomidine, ketamine, lidocaine infusion, magnesium, esmolol infusion (preop pregabalin in some patients). #SPPMchat