Volume 3, Number 2
Fall 2013
In This Issue
In Memoriam...
Atomic View of a Ketamine...
The WAKE Score
Ten "Best Doctors"
Safar Symposium 2013
MedTass 2013
Faculty Spotlight
Dr. Manuel Vallejo Jr. New WVU Chair
Online ITE Module
In the News
Recent Awards
Recent Journal Papers
Notable Publications
Faculty on the Road
Upcoming Conferences

John P. Williams, MD Peter and Eva Safar Professor and Chair,  Department of Anesthesiology Associate Medical and Scientific Director,  UPMC International Division  
A Message from the Chair
It's unbelievable that eight months have passed since our last newsletter. Subsequently, we have many updates and much news to report! 


We have made two major changes to this newsletter. First, you will see immediately that the newsletter now uses a web-based format rather than a PDF format. We hope you agree that this new version looks better and will take up less virtual space in your inbox. Second, we are no longer calling this newsletter "Alumni Connection" in light of the fact that our audience consists of not just alumni but also current and potential department members, colleagues at the University of Pittsburgh, the academic community, department supporters and friends, and even the general public.


Also, we are expanding our social media presence. We recently created an official Facebook page and a You Tube channel. Our Facebook page is different than our alumni Facebook group. Going forward, we will post announcements on the official page rather than to the group, since the group is closed to members and doesn't have the same level of functionality as the official page. We will continue to post to the group regarding events that are only extended to alumni. In addition to these new social media pages, our residency program also maintains a Facebook page. Please, visit our pages and like us!


In a few months the 2013 American Society of Anesthesiologists (ASA) Annual Meeting will be underway. This year's meeting will be taking place October 12-16 at the Moscone Center in San Francisco, CA. The annual ASA meeting is a major event for our department, with an impressive number of medical students, residents, fellows, and faculty members presenting every year. We also host our annual alumni reception at the meeting. Our 2013 ASA Alumni Reception will be held on Sunday, October 13, 2013 from 6-9 pm. In the fall, we will distribute info on all the department presentations and ASA committee participation as well as the reception via our website, Facebook page, and an e-mail to the newsletter distribution list. Reception invitations will be mailed and e-mailed to all alumni for whom we have postal mailing and e-mail addresses on file. Please keep an eye out for info in September.  


Please consider supporting the department's academic legacy by donating to our alumni fund. Donations can be directed to specific departmental efforts such as our missionary, research, or educational missions. Information on donating to the department can be found in the Support the Department section of this newsletter.


Lastly, I wanted to thank all of our friends and readers who have provided feedback on this newsletter and who have kept us us informed, especially regarding alumni.  Please continue telling us what you are up to, what you think of our newsletter, and what kind of articles you would like to see. To submit feedback or suggestions, please contact Christine Heiner here in the department.


Thank you for your continued support and I wish you all a safe and happy fall!   

In Memory of Two Influential Alumni Department Leaders


Dr. Ephraim Siker

Dr. Stephen C. Finestone

This summer we were very sad to learn of the passing of two very prominent former department faculty members, Drs. Ephraim S. Siker and Stephen C. Finestone.


Dr. Ephraim S. Siker was Chairman of Anesthesiology Chairman at UPMC Mercy from 1960-1994. He was a visionary in the specialty, responsible for the first halothane anesthetic in the US, serving as President of the Pennsylvania Society of Anesthesiologists and the American Society of Anesthesiologists and Director of the American Board of Anesthesiology. In 1972, Dr. Siker was chosen by then President Nixon to lead a medical team during his visit to China.  Dr. Siker's receipt of the ASA's Distinguished Service Award, his training of several future academic chairs of anesthesiology departments, his service as the Rovenstine Lecturer at the ASA Annual Meeting, and at the end of his active career, his impassioned role as Executive Director of the Anesthesia Patient Safety Foundation are all testaments of Dr. Siker's influence. Our department recently established a University of Pittsburgh School of Medicine E.S. Siker Chair of Anesthesiology in recognition of Dr. Siker's many contributions.


Dr. Stephen C. Finestone served as Chief Anesthesiologist at UPMC Montefiore Hospital for 32 years as well as Vice Chairman of the University of Pittsburgh/UPMC Department of Anesthesiology. He was also a President of the Pennsylvania Society of Anesthesiology and received their Distinguished Service Award. Dr. Finestone graduated over two hundred nurse anesthetists as medical director of the University of Pittsburgh School of Anesthesia for Nurses.


More information about Dr. Siker:


Pittsburgh Post Gazette article


More information about Dr. Finestone: 


In Memory of Stephen C. Finestone, MD   

Atomic View of a Ketamine Action Site

Pei Tang, PhD 
Professor of Anesthesiology, Pharmacology & Chemical Biology, and Computational Biology  


Clinical application of general anesthetics is indispensable in modern medicine, but the molecular mechanisms of general anesthesia remain unclear. The complexity of plausible anesthetic targets and the lack of accurate structural information of these targets have hindered progress towards a mechanistic understanding. Among all the receptors involved in neuronal signal transduction, pentameric ligand-gated ion channels (pLGICs), such as the nicotinic acetylcholine receptors (nAChRs), have been identified as targets for general anesthetics.


Ketamine is widely used for the induction and maintenance of general anesthesia.  Although it is commonly known as a dissociative anesthetic acting as a noncompetitive antagonist on the N-methyl-D-aspartate (NMDA) receptor (1), ketamine is also a potent inhibitor of neuronal nAChRs (2, 3). Ketamine's action sites at these receptors, however, have not previously been identified.


Tang's group has solved the crystal structure of ketamine-bound GLIC, a bacterial homologue of pLGICs from Gloeobacter violaceus, to a resolution of 2.99 � (4). GLIC's responses to general anesthetics resemble those of nAChRs. Ketamine inhibited currents of Xenopus oocytes expressing GLIC in a concentration-dependent manner. Ketamine inhibition concentration with a half-maximal response (IC50) on GLIC is 58 μM, which is comparable to the ketamine IC50 values on the neuronal nAChRs (2, 3). The crystal structure reveals ketamine binding to a preexisting cavity in the extracellular domain of GLIC, as shown in Figure 1. The ketamine site in GLIC is near the homologous orthosteric agonist site in nAChRs, but it is 9-10 closer to the transmembrane domain. It partially overlaps with the binding interface of large antagonists in Cys-loop receptors (5, 6). Ketamine contacts mostly hydrophilic residues to form an electrostatic interaction with these residues, in addition to van der Waals interaction with some hydrophobic residues. Electrostatic interactions have contributed significantly to stabilizing ketamine binding. The functional relevance of the identified ketamine site was further validated by site-directed mutations and subsequent chemical labeling of a pocket residue to mimic anesthetic binding.



Fig. 1. The crystal structure of GLIC bound with five ketamine molecules is shown in purple. A pair of principal and complementary subunits for ketamine binding is depicted in yellow and cyan, respectively. 

The structural and functional results of ketamine binding to GLIC present a compelling case for allosteric action of anesthetics. The ketamine pocket is nearly 30 � away from the channel gate. The previously identified site for propofol or desflurane is in the upper part of the transmembrane domain within a subunit of GLIC (7), distinct from the ketamine binding site. Two factors may have contributed to different sites of allosteric action for these drugs. First, ketamine is more soluble in the aqueous phase than propofol and desflurane. It is more attractive to the solvent-exposed pocket offering electrostatic, hydrogen bonding, and van de Waals interactions. Second, ketamine has a larger molecular size than propofol and desflurane. The ketamine pocket in GLIC is comprised of flexible loops and has a volume of ~ 248 �3, compatible with a ketamine volume of 219 �3. Crystal structures of anesthetic bound GLIC reported here and previously (7) reveal at least two sets of sites for anesthetic binding. The existence of multiple anesthetic binding sites in GLIC has been suggested by several studies. Tryptophan fluorescence quenching experiments showed halothane and thiopental binding in the extracellular domain, transmembrane domain, and the extracellular-transmembrane interface of GLIC (8). Molecular dynamic simulations suggested that isoflurane could also migrate into the GLIC channel (9, 10). Multiple anesthetic sites were also identified in other pLGICs. In Torpedo nAChR, azietomidate was photolabeled not only to some pore-lining residues, but also to the agonist-binding site in the extracellular domain (11). The volatile anesthetic halothane was also found to be photolabeled to both the transmembrane and extracellular domains (12). Some halothane-labeled residues in the extracellular domain of nAChR were from the β9 and β10 strands (12), suggesting that the ketamine site in our structure represents a homologous site for anesthetic binding in other pLGICs.  


Ketamine has been traditionally classified as an NMDA receptor antagonist (1). The structural and functional data reported by Tang's group along with previous functional studies of ketamine on nAChRs may aid in a paradigm shift and call for a comprehensive examination of ketamine action on pLGICs. Ketamine inhibited the recombinant neuronal nAChRs in a subunit-dependent manner (2, 3). IC50 values of ketamine measured from the Xenopus oocyte expressing human α7 and α4β2 nAChRs (2, 3) were close to that measured with GLIC in this study. From the modeled structures of the α7 and α4β2 nAChRs (13, 14), it is notable that both proteins have a pocket similar to the ketamine pocket in GLIC, where several acidic residues are on one side of the pocket. These negatively charged residues could attract ketamine and stabilize ketamine binding. A greater number of negatively charged residues in the pocket of α7 than in α4β2 nAChRs seems to be consistent with the observation that the α7 nAChR is more sensitive to ketamine inhibition than the α4β2 nAChR (2).


The discovery of the ketamine-binding pocket expands the scope of the drug-binding mode and is particularly valuable for the understanding of functional data related to drug action in the extracellular domain of pLGICs. For a long time, the search for targets of soluble drugs, such as benzodiazepine and its derivatives, was focused on sites equivalent to but not the orthosteric ligand site in GABAA receptors (15-17). Residue selection for mutagenesis and subsequent functional studies has relied heavily on structures of ligand-bound acetylcholine binding proteins (6, 18), due to the limited number of high-resolution structures with ligand binding to pLGICs (19-21) and the lack of experimental structures for GABAA receptors. The atomic binding mode of ketamine in GLIC provides an additional structural template, which is invaluable for the design of novel modulators or the search for optimal binding modes of benzodiazepine derivatives at the interfaces of various subtype subunits (22).  




1. Harrison, N.L., and Simmonds, M.A. (1985). Quantitative studies on some antagonists of N-methyl D-aspartate in slices of rat cerebral cortex. Br. J. Pharmacol. 84, 381-391.


2. Coates, K.M., and Flood, P. (2001). Ketamine and its preservative, benzethonium chloride, both inhibit human recombinant alpha7 and alpha4beta2 neuronal nicotinic acetylcholine receptors in Xenopus oocytes. Br. J. Pharmacol. 134, 871-879.


3. Yamakura, T., Chavez-Noriega, L.E., and Harris, R.A. (2000). Subunit-dependent inhibition of human neuronal nicotinic acetylcholine receptors and other ligand-gated ion channels by dissociative anesthetics ketamine and dizocilpine. Anesthesiology 92, 1144-1153.


4. Pan, J., Chen, Q., Willenbring, D., Mowrey, D., Kong, X.P., Cohen, A., Divito, C.B., Xu, Y., and Tang, P. (2012a). Structure of the pentameric ligand-gated ion channel GLIC bound with anesthetic ketamine. Structure 20, 1463-1469.


5. Bourne, Y., Radic, Z., Araoz, R., Talley, T.T., Benoit, E., Servent, D., Taylor, P., Molgo, J., and Marchot, P. (2010). Structural determinants in phycotoxins and AChBP conferring high affinity binding and nicotinic AChR antagonism. Proc. Natl. Acad. Sci. USA 107, 6076-6081.


6. Hansen, S.B., Sulzenbacher, G., Huxford, T., Marchot, P., Taylor, P., and Bourne, Y. (2005). Structures of Aplysia AChBP complexes with nicotinic agonists and antagonists reveal distinctive binding interfaces and conformations. EMBO J. 24, 3635-3646.


7. Nury, H., Van Renterghem, C., Weng, Y., Tran, A., Baaden, M., Dufresne, V., Changeux, J.P., Sonner, J.M., Delarue, M., and Corringer, P.J. (2011). X-ray structures of general anaesthetics bound to a pentameric ligand-gated ion channel. Nature 469, 428-431.


8. Chen, Q., Cheng, M.H., Xu, Y., and Tang, P. (2010). Anesthetic binding in a pentameric ligand-gated ion channel: GLIC. Biophys. J. 99, 1801-1809.


9. Brannigan, G., LeBard, D.N., Henin, J., Eckenhoff, R.G., and Klein, M.L. (2010). Multiple binding sites for the general anesthetic isoflurane identified in the nicotinic acetylcholine receptor transmembrane domain. Proc. Natl. Acad. Sci. USA 107, 14122-14127.


10. Willenbring, D., Tian Liu, L., Xu, Y., and Tang, P. (2011). Binding of Isoflurane to Glic Alters the Structure and Dynamics of the Protein. Biophys. J. 100, 273a.


11. Ziebell, M.R., Nirthanan, S., Husain, S.S., Miller, K.W., and Cohen, J.B. (2004). Identification of binding sites in the nicotinic acetylcholine receptor for [3H]azietomidate, a photoactivatable general anesthetic. J. Biol. Chem. 279, 17640-17649.


12. Chiara, D.C., Dangott, L.J., Eckenhoff, R.G., and Cohen, J.B. (2003). Identification of nicotinic acetylcholine receptor amino acids photolabeled by the volatile anesthetic halothane. Biochemistry 42, 13457-13467.


13. Haddadian, E.J., Cheng, M.H., Coalson, R.D., Xu, Y., and Tang, P. (2008). In silico models for the human alpha4beta2 nicotinic acetylcholine receptor. J. Phys. Chem. B 112, 13981-13990.


14. Mowrey, D., Haddadian, E.J., Liu, L.T., Willenbring, D., Xu, Y., and Tang, P. (2010). Unresponsive correlated motion in alpha7 nAChR to halothane binding explains its functional insensitivity to volatile anesthetics. J. Phys. Chem. B 114, 7649-7655.


15. Boileau, A.J., Kucken, A.M., Evers, A.R., and Czajkowski, C. (1998). Molecular dissection of benzodiazepine binding and allosteric coupling using chimeric gamma-aminobutyric acidA receptor subunits. Mol. Pharmacol. 53, 295-303.


16. Morlock, E.V., and Czajkowski, C. (2011). Different residues in the GABAA receptor benzodiazepine binding pocket mediate benzodiazepine efficacy and binding. Mol. Pharmacol. 80, 14-22.


17. Sigel, E., and Buhr, A. (1997). The benzodiazepine binding site of GABAA receptors. Trends Pharmacol. Sci. 18, 425-429. 


18. Celie, P.H., van Rossum-Fikkert, S.E., van Dijk, W.J., Brejc, K., Smit, A.B., and Sixma, T.K. (2004). Nicotine and carbamylcholine binding to nicotinic acetylcholine receptors as studied in AChBP crystal structures. Neuron 41, 907-914.


19. Dellisanti, C.D., Yao, Y., Stroud, J.C., Wang, Z.Z., and Chen, L. (2007). Crystal structure of the extracellular domain of nAChR alpha1 bound to alpha-bungarotoxin at 1.94 A resolution. Nat. Neurosci. 10, 953-962.


20. Li, S.X., Huang, S., Bren, N., Noridomi, K., Dellisanti, C.D., Sine, S.M., and Chen, L. (2011). Ligand-binding domain of an alpha(7)-nicotinic receptor chimera and its complex with agonist. Nat. Neurosci. 14, 1253-1259.


21. Pan, J., Chen, Q., Willenbring, D., Yoshida, K., Tillman, T., Kashlan, O.B., Cohen, A., Kong, X.P., Xu, Y., and Tang, P. (2012b). Structure of the pentameric ligand-gated ion channel ELIC cocrystallized with its competitive antagonist acetylcholine. Nat. Commun. 3, 714.


22. Richter, L., de Graaf, C., Sieghart, W., Varagic, Z., Morzinger, M., de Esch, I.J., Ecker, G.F., and Ernst, M. (2012). Diazepam-bound GABA(A) receptor models identify new benzodiazepine binding-site ligands. Nat. Chem. Biol. 8, 455-464.

The WAKE Score and Routine Perphenazine Use: Striving for "Zero Tolerance" of Post-Operative Nausea and Vomiting 


Brian A. Williams, MD, MBA

Professor and Director of Ambulatory Anesthesia
Director, VA Pittsburgh Healthcare System (VAPHS) Ambulatory Anesthesia, Regional Anesthesia/Acute Pain Medicine Service, and Perioperative Evaluation

Michael L. Kentor, MD Associate Professor and Chief Anesthesiologist, UPMC Mercy South Side Outpatient Center and UPMC East


Christine Heiner, BA

Scientific Writer


The "WAKE Score," created in 1997 by Drs. Brian A. Williams and Michael L. Kentor (currently Chief Anesthesiologist at UPMC East and UPMC Mercy South Side Outpatient Center), outlines recovery parameters after anesthesia and/or moderate sedation. The WAKE score allows for safe bypass of the Post-Anesthesia Care Unit (PACU) after most every type of ambulatory anesthetic that is designed with WAKE criteria in mind, including after general and spinal/regional anesthesia. In August 2010, the WAKE score was rolled out for daily clinical use, becoming the official anesthesia/sedation recovery criteria for all of UPMC. This important initiative for standardizing recovery criteria is a Joint Commission-driven patient care directive, and WAKE has replaced the traditional Aldrete score at both UPMC and at VAPHS. WAKE predicts successful same-day discharge when its PACU bypass criteria are met, and similarly predicts hospital cost savings after PACU bypass. In the year 2000, PACU bypass with WAKE was associated with a per-patient hospital cost savings of $400 (1-3); this hospital cost savings value has likely significantly increased since then, based on inflation. 


In brief, WAKE is a slight modification of the 10-point modified Aldrete scoring system with additional "zero tolerance" criteria: "no pain," no shivering, no pruritus, no lightheadedness/hypotension/orthostasis, and no post-operative nausea and vomiting (PONV) (Tables 1-3) (3).  PONV can occur with general (most commonly), regional, or local anesthesia and can result in physical damage (ruptured sutures, stitches, or esophageal tissue), metabolic problems (electrolyte imbalance, dehydration), patient dissatisfaction, loss of work, and delayed hospital discharge, all of which can increase health care costs (4-6). Severe PONV, although rare, can result in aspiration of gastric contents and subsequent pulmonary sequelae such as pneumonia or pneumothorax (6-8).


Considering the dangers and costs of PONV and the WAKE zero tolerance criteria for PONV, what strategies can help prevent PONV? Studies have identified factors that increase a patient's baseline PONV risk: female gender, nonsmoking status, history of PONV or motion sickness, postoperative opioid use, and duration of surgery greater than 60 minutes (6, 9, 10). Additionally, use of volatile anesthetics, opioids, nitrous oxide, and large-dose neostigmine (greater than 2.5 mg IV) has also been shown to increase PONV risk (6, 11-13).  


Although current guidelines from the Society for Ambulatory Anesthesia denote that patients with 0-1 of these risk factors have a 10-20% risk of encountering PONV, they do not recommend routine prophylaxis for such patients. Based on our clinical experience, however, we consider less than 10% an "acceptable threshold" for PONV incidence, and aim for less than 5% in daily practice (6) by recommending routine multimodal PONV prophylaxis irrespective of risk factors.


Our long-recommended "zero tolerance" antiemetic algorithm for outpatients is to: avoid volatile anesthetics and use propofol as the "induction" and "maintenance" anesthetic of choice; avoid opioids and maximize the use of nonemetogenic multimodal analgesics; use local, regional, and multimodal analgesia to the fullest extent possible; and use routine, low-dose administration of selected, off-patent antiemetics in patients for whom there are no contraindications (6). Figure 1 summarizes our prophylactic strategy.


Figure 1: The WAKE "zero tolerance" antiemetic algorithm (click to enlarge)

Our published experience at UPMC Montefiore using routine multimodal prophylaxis for regional anesthesia patients yielded PONV rates below 10%. In a study published in 2005 (14), we analyzed same-day outcomes of 1,907 orthopedic patients treated from 1995 to 1999. At the time, risk-scoring strategies had not yet been widely published or endorsed, so a "pan-prophylaxis" technique was commonly used. We retrospectively compared patients receiving this pan-prophylaxis" with patients given less-systematic (if any) prophylaxis. When volatile agents were avoided and when regional anesthesia techniques were combined with two or more antiemetics (commonly perphenazine 1.25 mg i.v. and dexamethasone 4 mg i.v.), the PONV incidence was only 9% (95% confidence interval: 7-11%).  This same study also showed an associated benefit of preventing post-discharge nausea and vomiting when perphenazine-dexamethasone were used in combination.  We now routinely use 8 mg per-oral perphenazine, since intravenous perphenazine has been unavailable since 2002.


The routine use of perphenazine in our antiemetic algorithm for most every patient has been significant to the success of our PONV prophylaxis initiative, as well as PACU bypass and/or fast-tracked PACU discharge using the WAKE Score system. We have used perphenazine for over 15 years (15), now in almost 50,000 patients with no clinically significant patient complications when dosing thresholds were not exceeded. Although ondansetron, dexamethasone, and droperidol (when used for prophylaxis in the past) were each estimated to reduce PONV risk by approximately 25% (6), none of these medications are optimal when used alone. We began using perphenazine in 1997 after reviewing a publication reporting equal-to-greater efficacy and fewer side effects with perphenazine alone than with droperidol, metoclopramide, or ondansetron alone (16). In 2006, we reported our success with using a perphenazine-dexamethasone-ondansetron combination for a prospective spinal/regional anesthesia patient cohort (17). In this study, the PONV rate was even lower at 4% (95% confidence interval: 2- 7).   Finally, based on the cytochrome P450 enzyme system, perphenazine likely increases the bioavailability of ondansetron in patients where CYP2D6 is a "rapid metabolizer," since perphenazine is a CYP2D6 inhibitor.


In a recent study, we found that single-dose perphenazine is not only effective at reducing PONV, but also creates "almost zero" extrapyramidal symptoms (EPS) (18). Throughout UPMC, 45,766 patients received either 4 mg or 8 mg of perphenazine before same-day surgery from 2001 through mid-2012. Only six patients "likely" or "possibly" encountered EPS. All had near-immediate resolution of symptoms, with five receiving intravenous diphenhydramine for treatment. Phrased differently, only 1.3 EPS events (95% CI: 0.4, 3.0) per 10,000 patients occurred following single-dose perphenazine of 4-8 mg. All patients who experienced preoperative reactions were able to proceed to surgery without complications or delay. Only one patient required unplanned three-hour observation due to sedation from diphenhydramine. Given the extremely infrequent side-effect profile with this low, single, perphenazine dose, we believe perphenazine use should be encouraged (if not considered an institutional standard of care) as an essentially risk-free adjunct to any multimodal PONV prophylactic regimen, assuming the patient meets our recommended criteria. 


We do not recommend perphenazine PONV prophylaxis for patients greater than 70 years old, less than 12 years old, less than 45 kg, with a history of cerebral palsy or Parkinson's disease, with any history of extrapyramidal reactions to phenothiazines, and/or are taking any Class III antidysrhythmic medication. Based on theoretical drug interaction concerns, patients prescribed aripiprazole or paroxetine may sufficiently benefit from 4 mg instead of 8 mg perphenazine, and patients prescribed both aripiprazole and paroxetine may be candidates for no preoperative perphenazine.  These factors are important to consider when interpreting the infrequency of perphenazine-associated side effects. 


It is uncommon when a drug costing one dollar can be integral to saving the hospital $400 or more per case.  Perphenazine has a remarkable track record of patient-centered safety and efficacy at UPMC and VAPHS, entailing over 50,000 patients.  There seem to be only positive attributes of the routine use of perphenazine 4-8 mg for all patients before surgery, acknowledging the qualifiers above. Its non-sedating properties, along with its own antiemetic benefits, and finally its enzymatic influences on the efficacy of ondansetron (also less than a dollar), appear to be compelling patient-centered reasons to routinely trust a single-dose of an FDA-approved drug that has been marketed for over 50 years.



Table 1: Differences between the WAKE and Modified Aldrete Scoring Criteria and how the WAKE Score System is calculated. Phase 1, 2, and 3 recovery are defined as the patient conditions of ''emergence", ''preparation for going home,'' and ''resuming normal activities after discharge home,'' respectively. Phase 1 recovery bypass should only be considered when no interventions are needed for the "zero tolerance criteria." Patient pain scores should not exceed 3-4 units above "baseline pain score with movement" at the time of Phase 1 bypass or discharge (10 point scale) for regional, general, or monitored anesthesia. The patient must have a minimum WAKE score of 8 and meet the zero tolerance criteria for Phase 1 bypass or discharge.


Modified Aldrete Scoring System Criteria (19)

WAKE Scoring Criteria (1, 2, 20)




WAKE score


can move all 4 extremities   

can move at least 1 upper extremity & at least 1 lower extremity


can move 2 extremities

can move 1 upper extremity


no movement

no movement




cough on command



involuntary cough





Blood Pressure (BP)


BP 20% of baseline

BP 20% of baseline



20-40%, no orthostasis



40+%, or orthostasis


Level of Consciousness







not responding



Oxygen Saturation (SaO2)


SaO2 > 92% on room air  

SaO2 > 95% RA or preop reading minus 2



SaO2 > *90% with O2

SaO2 > *95% with O2 or preop reading minus 2



SaO2 < *90% with O2

SaO2 < *95% or preop reading minus 2


Additional "Zero Tolerance" criteria



  •  "No Pain"
  • No PONV
  • No Shivering
  •  No Pruritus
  • No Lightheadedness/ Hypotension / Orthostasis



Table 2: Parameter-scored WAKE Criteria for PACU Bypass (outpatient surgery) or PACU Discharge (inpatient or outpatient surgery), and the likely effects of anesthetic technique/drug selection on meeting the described criteria for fast-tracking purposes. Table (courtesy Jeffrey Moore, DO) submitted as part of an invited article by Current Opinion in Anesthesiology, 2013. A score of 8 or higher, along with meeting all the Zero Tolerance Criteria (Table 3), are sufficient to qualify for PACU Bypass after outpatient surgery, or Fast-track PACU discharge when transfer to an inpatient non-monitored bed is planned after surgery.  For patients with diagnosed obstructive sleep apnea (OSA), a score of 9 is recommended, along with the same Zero Tolerance Criteria (Table 3), and after 30-60 minutes of no episodes of witnessed apnea in an otherwise non-stimulating PACU environment.  The authors will send OSA patients to a postoperative monitored bed (e.g., coninuous pulse-oximetry with or without capnography) if these OSA-specifc WAKE Criteria are not met.


Movement (LE: lower extremity; UE: upper extremity)


Purposeful movement of (at least) 1 LE and 1 UE


Purposeful movement of at least 1 UE (and neither LE)


No purposeful movement


Clinical correlations:

  • An isobaric spinal would decrease the likelihood of achieving a score of  "2" compared to an ipsilateral hyperbaric spinal
  • Prolonged emergence time from general anesthesia with volatile anethetic (+/- neuromuscular blocking drugs) would increase the likelihood of achieving a score of "0" as opposed to a "1" or "2"
  • Interscalene block patients with blocks designed to provide overnight anesthesia-analgesia would not achieve an Aldrete parameter score of 2, since only 3 of 4 extremities would achieve purposeful movement.

Blood Pressure (sitting and supine)


Within 20% of preoperative baseline, not orthostatic


Within 20-40% of preoperative baseline, not orthostatic


Less than 40% of preoperative baseline, and/or orthostatic


Clinical correlations:

  • Isobaric bilateral spinal would likely cause a greater sympathectomy and hypotension than would an ipsilateral hyperbaric spinal
  • Vasodilatory effects of propofol sedation would likely dissipate 
    equal to or faster than the vasodilatory effects of volatile anesthetics
  • Low-dose detamine sedation will not cause vasodilation and subsequent hypotension

Level of Consciousness


Awake, follows commands; easily aroused when called


Arouse to stimuli, protective reflexes, follows commands


Obtunded or persistently somnolent; � protective reflexes


Clinical correlations:

  • Avoidance of airway instrumentation, mechanical ventilation, volatile agents, and systemic opioids allows faster emergence from anesthesia and return of a level of consciousness consistent with a score of "2"
  • Perphenazine, ondansetron, and dexamethasone are all off-patent non-sedating antiemetics

Respiratory Effort


Coughs and deep-breathes freely, and/or on command


Involuntarily cough only; unsupported airway


Tachypnea, dyspnea or apnea, and/or requiring airway support


Clinical correlations:

  • Avoidance of airway instrumentation, mechanical ventilation, irritating volatile agents, and neuromuscular blocking drugs all favor a more timely score of "2"

Oxygen Saturation


≥95% or (preoperative reading minus 2) without supplemental O2


≥95% or (preoperative reading minus 2) with supplemental O2


<95% or (preoperative reading minus 2) � supplemental O2


Clinical correlations:


  • Systemic opioids and neuromuscular blocking drugs can cause hypoventilation-induced desaturation; ipsilateral hyperbaric spinal anesthesia and/or peripheral nerve blocks would be very unlikely to do so


Table 3: "Zero Tolerance Criteria" for WAKE Score PACU Bypass (outpatient surgery) or Fast-track PACU Discharge (inpatient or outpatient surgery). Table (courtesy Jeffrey Moore, DO) submitted as part of an invited article by Current Opinion in Anesthesiology, 2013. 


(1) Pain as appropriately adjusted to patients' baseline pain scores (with movement) at the surgical site

Clinical correlations:

  • Preoperative peripheral nerve blocks render patients more likely to meet this criterion 
    than would postoperative systemic opioids for rescue analgesia. 
  • Buprenorphine added to peripheral nerve blocks will carry likely much greater analgesic duration 
    than would an opioid-equivalent dose of systemic morphine or other systemic opioid.
  • Maintenance anesthesia with propofol avoids the hyperalgesic effects of volatile anesthetics.
  • Spinal / regional anesthesia is less hyperalgesic than is anesthesia with volatile anesthetics and short-acting opioids.

(2) PONV as a "yes-no" assessment

Clinical correlations:

  • Preoperative oral perphenazine is less sedating than intraoperative prochlorperazine, and is similarly non-sedating as ondansetron and dexamethasone
  • Systemic clonidine (e.g., as a nerve block adjuvant) may have antiemetic benefits
  • Volatile anesthetics and systemic opioids are emetogenic

(3) Shivering, pruritus, and/or orthostatic symptoms (lightheadedness and/or hypotension in the sitting position)

Clinical correlations:

  • Ipsilateral hyperbaric spinal (comprised of a lower overall total intrathecal dose than would an isobaric bilateral spinal) may be less likely to create lightheadedness in the sitting position when compared with isobaric spinal anesthesia, by the time surgery is finished
  • Systemic clonidine (e.g., added to peripheral nerve blocks) 
    and phenylephrine infusions (commonly co-administered during spinal anesthesia)
    have favorable anti-shivering and/or thermoregulatory benefits
  • Volatile anesthetics disrupt thermoregulation more so than does regional anesthesia
  • Systemic opioids commonly cause pruritus




  1. Williams BA, Kentor ML, Williams JP, Vogt MT, DaPos SV, Harner CD, Fu FH. (2002) PACU bypass after outpatient knee surgery is associated with fewer unplanned hospital admissions but more phase II nursing interventions. Anesthesiology 97:981-8.
  2. Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, Roberts MS, Chelly JE, Harner CD, Fu FH (2004) The economics of nerve block pain management after anterior cruciate ligament reconstruction: Significant hospital cost savings via associated PACU bypass and same-day discharge. Anesthesiology 100:697-706.
  3. Williams BA, Kentor ML. (2011) The WAKE Score: Patient-Centered Ambulatory Anesthesia and Fast-Tracking Outcomes Criteria. International Anesthesiology Clinics Volume 49, Number 3, 33-43.
  4. Golembiewski J, Chernin E, and Chopra T. (2005) Prevention and treatment of postoperative nausea and vomiting. Am. J. Health-Syst. Pharm. 62, 1247-1262.
  5. Gan TJ. (2006) Risk factors for postoperative nausea and vomiting. Anesth. Analg. 102, 1884-1898.
  6. Skledar SJ, Williams BA, Vallejo MC, et al. (2007) Eliminating postoperative nausea and vomiting in outpatient surgery with multimodal strategies including low doses of nonsedating, off-patent antiemetics: is ''zero tolerance'' achievable? ScientificWorld-Journal. 7:959-977.
  7. Scuderi PE and Conlay LA. (2003) Postoperative nausea and vomiting outcome. Int. Anesthesiol. Clin. 41, 165-174.
  8. Bremner WG and Kumar CM (1993) Delayed surgical emphysema, pneumomediastinum and bilateral pneumothoraces after postoperative vomiting. Br. J. Anaesth. 71, 296-297.
  9. Apfel CC, Greim CA, Koivuranta M, et al. (1999) A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 91, 693-700.
  10. Koivuranta M, Laara E, Snare L, et al. (1997) A survey of post-operative nausea and vomiting. Anaesthesia 52, 443-449.
  11. Zhao SZ, Chung F, Hanna DB, et al. (2004) Dose-response relationship between opioid use and adverse effects after ambulatory surgery. J. Pain Symptom Manage. 28, 35-46.
  12. Apfel CC, Kranke P, Katz MH, et al. (2002) Volatile anaesthetics may be the main cause of early but not delayed postoperative vomiting: a randomized controlled trial of factorial design [see comment]. Br. J. Anaesth. 88, 659-668.
  13. Gan TJ, Meyer R, Apfel CC, et al. (2003) Consensus guidelines for managing postoperative nausea and vomiting. Anesth. Analg. 97, 62-71.
  14. Kentor ML and Williams BA. (2005) Antiemetics in outpatient regional anesthesia for invasive orthopedic surgery. Int. Anesthesiol. Clin. 43, 197-205.
  15. Williams BA, Kentor ML, Vogt MT, et al. (2006) Reduction of verbal pain scores after anterior cruciate ligament reconstruction with two-day continuous femoral nerve block: a randomized clinical trial. Anesthesiology 104, 315-327.
  16. Desilva PH, Darvish AH, McDonald SM, Cronin MK, and Clark K. (1995) The efficacy of prophylactic ondansetron, droperidol, perphenazine, and metoclopramide in the prevention of nausea and vomiting after major gynecologic surgery. Anesth. Analg. 81139-143.
  17. Williams BA, Kentor ML, Skledar SJ, Orebaugh SL, Vallejo MC. (2007) Routine Multimodal Antiemesis Including Low-Dose Perphenazine in an Ambulatory Surgery Unit of a University Hospital: A 10-Year History. Scientific World-Journal. 7: 978-986.
  18. Henao JP, Peperzak KA, Lichvar AB, Orebaugh SL, Skledar SJ, Williams BA. Incidence of Extrapyramidal Symptoms Following Administration of Oral Perphenazine 4 or 8 mg: An 11-Year Retrospective Analysis. Anesthesia and Analgesia, in press.
  19. Aldrete JA. (1995) The post-anesthesia recovery score revisited. J Clin Anesth 7:89-91.
  20. Williams BA, Kentor ML, Williams JP, Figallo CM, Sigl JC, Anders JW, Bear TC, Tullock WC, Bennett CH, Harner CD, Fu FH. (2000) Process analysis in outpatient knee surgery: Effects of regional and general anesthesia on anesthesia-controlled time. Anesthesiology. 93:529-38.

Ten Department Physicians Make Pittsburgh Magazine's 2013 "Best Doctors" List

L to R, Top to Bottom: Shushma Aggarwal, MD; Cheryl Bernstein, MD; Barbara W. Brandom, MD; Jacques E. Chelly, MD, PhD, MBA; ZongFu Chen, MD; Franklyn P. Cladis, MD; Peter J. Davis, MD; Andrew Herlich, DMD, MD, FAAP; Jerome Parness MD, PhD;  and Erin A. Sullivan, MD

Ten department physicians made Pittsburgh Magazine's 2013 "Best Doctors" listMore than 450 UPMC physicians were named in 76 areas of expertise. The list was compiled by Best Doctors� and derived from the Best Doctors in America� database, which includes the names and profiles of more than 45,000 of the best doctors in the United States. Physicians are included in the database after an exhaustive peer review. Shushma Aggarwal, MD, Jacques E. Chelly, MD, PhD, MBA, ZongFu Chen, MD, Andrew Herlich, DMD, MD, FAAP, Jerome Parness MD, PhD, and Erin A. Sullivan, MD were named Best Doctors in the specialty of anesthesiology. Dr. Sullivan was also named in the specialty of pediatric cardiovascular anesthesiology. Barbara W. Brandom, MD, Franklyn P. Cladis, MD, Peter J. Davis, MD, and Dr. Herlich were named Best Doctors in the specialty of pediatric anesthesiology. Cheryl Bernstein, MD was named in the specialty of neurology. 

2013 Safar Symposium and Multi-Departmental Trainees' Research Day 

The eleventh annual Safar Symposium and third annual Multi-Departmental Trainees' Research Day was held on May 16-17, 2013.  This yearly event honors the late Dr. Peter Safar and his wife Eva for their contributions to the scientific community and highlights current research in areas spanning Dr. Safar's interests. Read more on our website.


MedTass 2013 


The Department of Anesthesiology, in conjunction with the Peter M. Winter Institute for Simulation, Education, and Research (WISER), UPMC, the Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), and the Renato Fiandaca Simulation Center, held the 3rd Mediterranean Transplantation Anesthesiology and Simulation Symposium (MedTASS) at the Grand Hotel Villa Igiea in Palermo, Italy on April 12-13, 2013. Read more on our website.


Faculty Spotlight: Erin A. Sullivan, MD


Erin A. Sullivan, MD

Associate Professor Dr. Erin Sullivan joined the University of Pittsburgh Department of Anesthesiology faculty in 1998. Upon her arrival, she was appointed Director of Thoracic Anesthesiology. She was named Director of Cardiac Anesthesiology at UPMC Presbyterian Hospital in 2002 and Chief of the Division of Adult Cardiothoracic Anesthesiology for the Department of Anesthesiology in 2007. She is also currently Associate Chief Anesthesiologist at UPMC Presbyterian Hospital and a faculty member of the McGowan Institute for Regenerative Medicine. Additionally, Dr. Sullivan directs our ACGME-accredited Adult Cardiothoracic Anesthesiology Fellowship Program.


Dr. Sullivan earned both her BS (Biochemistry) and MD from Louisiana State University. She completed her internship and residency (serving as Chief Resident in '89-'90) at the University of Texas in Houston, where she continued to complete fellowships in cardiothoracic anesthesiology, critical care medicine, and pharmacology research.


She stayed at the University of Texas to launch her academic and clinical career, joining the anesthesiology faculty and serving as Assistant Residency Program Director there in 1990. The following year, she moved to the UCLA Department of Anesthesiology, where she directed both the residency and the Cardiothoracic Anesthesiology Fellowship programs. She left UCLA in 1998 to come to Pittsburgh.


Dr. Sullivan's current research interests include management and treatment of cardiac failure; inhalation therapy for treatment of pulmonary hypertension; and regional anesthesia and pain management for patients undergoing cardiothoracic surgery. Dr. Sullivan has been a principle investigator on several industry-sponsored clinical trials. In 2010, the Agency for Healthcare Research and Quality awarded a three year research grant of $4 million to the Society of Cardiovascular Anesthesiologists FOCUS initiative to improve teamwork to prevent infections in cardiac operations.  UPMC Presbyterian was chosen as one of seventeen sites throughout the US to participate in the study, with Dr. Sullivan serving as the principal investigator.


Dr. Sullivan has achieved national recognition within her specialty through her appointment to several professional societies' committees at the local, state, and national level. She has served on numerous American Society of Anesthesiologists (ASA) committees over the course of her career. Currently, she is a member of the following ASA groups: House of Delegates (Delegate from PA); Committee on Surgical Anesthesia; Board of Directors (Alternate District Director from PA); Strategic Planning Committee; House of Delegates Credentials Committee; Advisory Group on Health Policy; and the Committee on Governance Effectiveness and Efficiencies. Most recently, Dr. Sullivan was appointed Chair of the ASA Committee on Governmental Affairs and Chair of the 2012 ASA House of Delegates Reference Committee on Administrative Affairs.


Dr. Sullivan has served as a question writer for the ASA's Self-Education and Evaluation Program and the American Board of Anesthesiology (ABA)-ASA Joint Council on In-Training Examinations. She serves as an Associate Examiner for the ABA Part 2 Examination. Dr. Sullivan was nominated as a candidate for the ABA Board of Directors in 2012 and was invited to assist the ABA with the development of subspecialty certification in Adult Cardiothoracic Anesthesiology in 2013.


She is also a member of the International Anesthesia Research Society, Society of Cardiovascular Anesthesiologists, American Society of Echocardiography, American Heart Association, Society for Education in Anesthesia, American College of Physician Executives, Pennsylvania Medical Society (Political Advocacy Executive Council), and the Allegheny County Medical Society. Notably, she is a Past President and a current member of the Board of Directors and the Executive, Judicial, and Insurance and Legislation Committees of the Pennsylvania Society of Anesthesiologists and served as the President of the Western Pennsylvania Society of Anesthesiologists from 2001-2002.


Dr. Sullivan has written several book chapters for major cardiothoracic anesthesiology textbooks, peer reviewed journal articles, and numerous abstracts. She is a reviewer and Editorial Board member of the Journal of Cardiothoracic and Vascular Anesthesia.


Throughout her career, Dr. Sullivan has received many honors and awards. Most recently, she was nominated for the American Board of Anesthesiology Board of Directors and in 2012 and was selected as one of the "Best Doctors" by Pittsburgh Magazine and included in the Best Doctors in America database in 2010, 2011, 2012, and 2013 ("Best Doctors" is an expert medical consultation service that offers advice to patients with serious medical conditions and injuries).

Dr. Manuel C. Vallejo Jr. Named Chair of the WVU Department of Anesthesiology

Manuel C. Vallejo, Jr., DMD, MD

Congratulations to Manuel C. Vallejo, Jr., DMD, MD, who has been named Chair of the Department of Anesthesiology at West Virginia University (WVU). Dr. Vallejo was selected after a comprehensive national search and will assume his new position on September 9, 2013. A press release announcing his new appointment is published on the WVU Healthcare website.


Dr. Vallejo, a department faculty member since 1997, is currently Professor of Anesthesiology with appointments in the University of Pittsburgh School of Medicine, School of Nursing, and School of Dental Medicine. He also is Director of Obstetric Anesthesia, Director of the Obstetric Anesthesia Fellowship Program, Obstetric Anesthesia Clinical Coordinator for the University of Pittsburgh Nurse Anesthesia Program, and Medical Director of the University of Pittsburgh Dental Anesthesia Program.


Dr. Vallejo earned his BS in chemistry and his DMD at the University of Pittsburgh School of Dental Medicine in Pittsburgh, and his MD at WVU School of Medicine in Morgantown. After graduating, he completed his dental residency at the Veterans Affairs Medical Center in Martinsburg, West Virginia, and his internship in medicine and pediatrics at the WVU School of Medicine. His anesthesiology residency was conducted at Mercy Hospital in Pittsburgh.


Dr. Vallejo is a member of the American Society of Anesthesiologists (ASA), the Pennsylvania Society of Anesthesiologists (PSA), and the Society for Obstetric Anesthesia and Perinatology (SOAP) where he is currently Chair of the SOAP Education Committee. He was Editor-in-Chief of Obstetric Anesthesia Digest from 2005 through 2012 and is on The Scientific World Journal editorial board. Dr. Vallejo is a contributing member of the University of Pittsburgh School of Medicine Admissions Committee and is the recipient of several honors and awards, including the excellence in clinical instruction teaching award presented by the University of Pittsburgh Department of Anesthesiology and the Stephen C. Finestone clinical instructor of the year teaching award presented by the University of Pittsburgh School of Nursing Nurse Anesthesia Program. Dr. Vallejo received the University of Pittsburgh 2012 Chancellor's Distinguished Teaching Award presented by Mark A. Nordenberg, Chancellor of the University of Pittsburgh and was appointed to the University of Pittsburgh School of Medicine Academy of Master Educators. Dr. Vallejo was elected 2nd Vice President of SOAP in 2012 and will become President of SOAP in 2015. In 2013, he was elected to active membership in the Association of University Anesthesiologist (AUA).

Online ITE Study Module Created by Department Members Available to Residents and Faculty to Prepare for Exams

An online in training examination (ITE) study module is available for University of Pittsburgh/UPMC residents to prepare for the ITE and board exams and for faculty to prepare for re-certification exams. This study module, created by resident Joseph P. Resti, MD (Class of 2013) under the guidance of Tetsuro Sakai, MD, PhD (faculty mentor), was initiated by the introduction of Knowledge Gap Reports from the American Board of Anesthesiology by John P. Williams, MD. All items in this module are from the Knowledge Gap Reports, a list of the most commonly missed questions on previous board examinations. The module can be accessed online.

In the News


Journey to Medicine 
Several media outlets have spotlighted the department-supported "Journey to Medicine" (JTM), a precollege academic mentorship program for African American males in grades six and up that aims to increase the number of minority males on the path toward careers in medicine by reaching students early in their schooling. New Pittsburgh Courier published an article featuring JTM in February 2013. Also, WQED aired a segment featuring JTM in their television series Portrayal & Perception: African American Men and Boys on Monday, March 18.


On Thursday, May 16th, 2013, KDKA-TV Pittsburgh aired a story on how using simulation at WISER prepares first responders and medical professionals for disaster situations. 


Andrew Herlich, DMD, MD, FAAP
Andrew Herlich, DMD, MD, FAAP served as an expert witness in the murder trial of Dr. Kermit Gosnell, a doctor arrested in 2011 for eight counts of murder at his abortion clinic in Philadephia, PA. Dr. Herlich testified regarding the clinic's allegedly incompetent and dangerous anesthesiology practices and that resulted in the death of one of Dr. Gosnell's patients. He was quoted in an Associated Press articlethat was picked up by media sources across the country, including The Washington PostCBS NewsABC NewsThe Miami HeraldThe Pittsburgh Post-Gazette, and The Denver Post. Gosnell was convicted on three of the murder charges and sentenced to life in prison without the possibility of parole in May 2013.


The NBC News article "Why woodchucks don't upchuck" covered nausea and vomiting research from University of Pittsburgh Cancer Institute neuroscientist and Department of Anesthesiology faculty member Charles C. Horn, PhD. 

William R. Lariviere, PhD


William R. Lariviere, PhD addressed research on pain genetics in an expert testimony video entitled "Target Identification Strategies in the Genomic Era" posted on the Pain Clinician website. 



Dawn A. Marcus, MD was interviewed for a segment on therapy dogs on Pet World Insider Radio, a syndicated network with shows on more than 100 AM/FM stations. Listen to the interview online 

Recent Honors and Awards

Jacques E. Chelly, MD, PhD, MBA

Jacques E. Chelly, MD, PhD, MBA was given the Adriana M. Selvaggio, MD Dedication to Commitment and Quality Award in recognition of his dedication to the UPMC Shadyside Medical Staff at UPMC Shadyside Day on Monday, June 17, 2013.Dr. Chelly was also appointed Officier of the Ordre des Palmes Academiques (Order of Academic Palms), an Order of Chivalry of France for academics and cultural and educational figures. Decisions on nominations and promotions are made by the French Minister of Education.



Dr. Bairbre Golden, an anesthesiologist at UPMC Beacon Hospital in Dublin, Ireland was elected to the Irish Medical Council (Comhairle na nDocht�ir� Leighis) for the 2013-2018 term.



Graduate student Carroline Lobo's poster "Perceptions of People with Chronic Pain about their Personal, Professional, and Social Environments: Survey Results of an Outpatient Clinic Population" (Lobo CP, Marcus DA, Bernstein CD) won first place in health policy and management at the University of Pittsburgh Graduate School of Public Health Dean's Day Graduate Student Research Competition on Monday, April 15, 2013. The poster reports data from a study Carroline is conducting with department faculty members Dawn A. Marcus, MD and Cheryl Bernstein, MD.



Dawn A. Marcus, MD
Dawn A. Marcus, MD was nominated for a WEGO Health Activist Silver Stethoscope Award, which is given "to a healthcare professional who utilizes social media, online community, and technology to make the world a better place." The website www.sharecare.com  also named Dawn A. Marcus, MD among the top 10 social healthmakers "driving the conversation" for migraine & headaches.



Tetsuro Sakai, MD, PhD and Manuel C. Vallejo Jr., MD, DMD were elected to the Association of University Anesthesiologist (AUA) as members during the annual AUA meeting in Miami, FL on April 4-6, 2013.



Helen Shnol, a research scholar working with Inna Belfer, MD, PhD, won the 1st place Director's Award in Clinical Sciences at the 25th Annual University of Pittsburgh Cancer Institute Scientific Retreat on June 14, 2013 for her poster "Pain Phenotypes in Pregnancy: Analysis of Clinical, Demographic, Psychosocial, and Psychophysical Correlates" (Shnol H, Dionise Z, Vallejo MC, Dalby P, Landsittel D, Belfer I).


Helen Shnol and Inna Belfer, MD, PhD with their winning poster.


William Simmons MD was selected to receive the 2013 UPMC Physician Inclusion Champion award at the July 30 UPMC Partnership Appreciation Event. 

William Simmons, MD


 Linda Szymanski received the Mary DePaolis-Lutzo CRNA Instructor of the Year Award and Cynthia Wells, MD received the Stephen Finestone Anesthesiologist Instructor of the Year Award at the University of Pittsburgh School of Nursing Nurse Anesthesia Program graduation ceremony on April 27, 2013. This year 22 students graduated, and 10 took employment with our department.



An abstract/poster by Kevin Taylor (Med 2) and mentor Jim Ibinson, MD, PhD won awards for Best of Meeting in Patient-Oriented Research and Best of Category in Pain Mechanisms, and was also a finalist for the Best of Meeting Award at the 2013 International Anesthesia Research Society (IARS) Annual Meeting. Their abstract, "A Study of the Functional Connectivity of the Insula and the Anterior Cingulate Gyrus During Pain Processing," was chosen by the 2013 meeting judges for these distinctions from over 400 submissions.  Kevin has been working on this project as part of his Pitt Med Scholarly project. 



Kevin Taylor and Jim Ibinson, MD, PhD at IARS


Cynthia Wells, MD received the University of Pittsburgh School of Medicine Clerkship Preceptor of the Year Award at the 2012 Curriculum Colloquium.



Northeast Ohio Medical University (NEOMED) honored Brian Williams, MD, MBA during its recent commencement ceremony on May 18 at The University of Akron's E.J. Thomas Performing Arts Center in Akron, Ohio. Dr. Williams is a NEOMED class of 1991 alumnus.
Brian Williams, MD, MBA (center) at the NEOMED commencement ceremony

Recent Journal Papers


Adams PS, Shapiro R, Hilmi IA. Postoperative Cardiac Tamponade after Kidney Transplantation: A Possible Consequence of Alemtuzumab-Induced Cytokine Release Syndrome [Letter to the Editor]. Transplantation. 95(3):e18-e9, February 2013. 


Alhazzani W, Jacobi J, Sindi A, Hartog C, Reinhart K, Kokkoris S, Gerlach H, Andrews P, Drabek T, Manzanares W, Cook DJ, Jaeschke RZ. The Effect of Selenium Therapy on Mortality in Patients with Sepsis Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Critical Care Medicine. Publish Ahead of Print, 2013.


An J-x, Fang Q-w, Sullivan EA, Williams JP. Spine Surgery May Cause More Spinal Epidural Hematomas than Spinal Puncture. Chinese Medical Journal. 126(2):286-9. 2013.


Backeris ME, Patel RM, Metro DG, Sakai T. Impact of a Productivity-Based Compensation System on Faculty Clinical Teaching Scores, as Evaluated by Anesthesiology Residents. Journal of Clinical Anesthesia. 25(3):209-13, May 2013.


Ball RD, Henao JP, Ibinson JW, Metro DG. Peripheral Intravenous Catheter Infiltration: Anesthesia Providers Do Not Adhere to Their Own Ideas of Best Practice. Journal of Clinical Anesthesia. 25(2):115-20, March 2013.


Belfer I, Schreiber KL, Shaffer JR, Shnol H, Blaney K, Morando A, Englert D, Greco C, Brufsky A, Ahrendt G, Kehlet H, Edwards RR, Bovbjerg DH. Persistent Postmastectomy Pain in Breast Cancer Survivors: Analysis of Clinical, Demographic, and Psychosocial Factors. Journal of Pain. Epub ahead of print, Jul 23, 2013.


Belfer I, Segall SK, Lariviere WR, Smith SB, Dai F, Slade GD, Rashid NU, Mogil JS, Campbell CM, Edwards RR, Liu Q, Bair E, Maixner W, Diatchenko L. Pain Modality- and Sex-Specific Effects of COMT Genetic Functional Variants. Pain. 154(8):1368-76, August 2013.


Belfer I. Nature and Nurture of Human Pain. Scientifica. vol. 2013, Article ID 415279, 19 pages, 2013.


Bernstein CD, Albrecht KL, Marcus DA. Milnacipran for Fibromyalgia: a Useful Addition to the Treatment Armamentarium. Expert Opin Pharmacother. 14(7):905-16, May 2013.


Blasiole B, Bayr H, Vagni VA, Janesko-Feldman K, Cheikhi A, Wisniewski SR, Long JB, Atkins J, Kagan V, Kochanek PM. Effect of Hyperoxia on Resuscitation of Experimental Combined Traumatic Brain Injury and Hemorrhagic Shock in Mice. Anesthesiology. 118(3):649-63, 2013.


Brandom BW, Muldoon SM. Unexpected MH Deaths without Exposure to Inhalation Anesthetics in Pediatric Patients. Paediatr Anaesth. 23(9):851-4, September 2013.


Brandom BW, Veyckemans F. Neuromuscular Diseases in Children: a Practical Approach. [Editorial]. Paediatr Anaesth. 23(9):765-9, September 2013.


Brumovsky PR, Seal RP, Lundgren KH, Seroogy KB, Watanabe M, Gebhart GF. Expression of Vesicular Glutamate Transporters in Sensory and Autonomic Neurons Innervating the Mouse Bladder. J Urol. 189(6):2342-9, June 2013.


Campbell NF, Davis PJ. All Boats Rise with the Tide. [Editorial]. Anesthesia & Analgesia. 116(6):1193-4, June 1, 2013.


Cantu-Medellin N, Kelley EE. Xanthine Oxidoreductase-Catalyzed Reduction of Nitrite to Nitric Oxide: Insights Regarding Where, When and How. Nitric Oxide. Epub ahead of print, February 27, 2013.


Chelly JE, Singla SK, Melson TI, Lacouture PG, Paadre S, Carr DB. Safety of a Novel Parenteral Formulation of Diclofenac after Major Orthopedic or Abdominal/Pelvic Surgery in a Population Including Anticoagulated, Elderly Orrenally Insufficient Patients: An Open-Label, Multiday, Repeated Dose Clinical Trial. Pain Med. 14(5):749-61, May 2013.


Cohen SP, Galvagno SM, Plunkett A, Harris D, Kurihara C, Turabi A, Rehrig S, Buckenmaier CC, Chelly JE. A Multicenter, Randomized, Controlled Study Evaluating Preventive Etanercept on Postoperative Pain after Inguinal Hernia Repair. Anesthesia & Analgesia. 116(2):455-62, February 1, 2013.


Cormican D, Subramaniam K. Con: Simulators for Transesophageal Echocardiography Training. Society of Cardiovascular Anesthesiologists Newsletter. 12(1):8-10, February 2013.


Dilla AJ, Waters JH, Yazer MH. Clinical Validation of Risk Stratification Criteria for Peripartum Hemorrhage. Obstet Gynecol. 122(1):120-6, July 2013.


Drabek T, Boucek CD, Buffington CW. Wearing Ambidextrous Vinyl Gloves Does Not Impair Manual Dexterity. J Occup Environ Hyg. 10(6):307-11, June 2013.


Emerick T, Metro D, Patel R, Sakai T. Scholarly Activity Points: a New Tool to Evaluate Resident Scholarly Productivity. British Journal of Anaesthesia. Epub ahead of print, April 16, 2013.


Feng B, Kiyatkin ME, La JH, Ge P, Solinga R, Silos-Santiago I, Gebhart GF. Activation of Guanylate Cyclase-C Attenuates Stretch Responses and Sensitization of Mouse Colorectal Afferents. J Neurosci. 33(23):9831-9, June 5, 2013.


Furman JM, Marcus DA, Balaban CD. Vestibular migraine: clinical aspects and pathophysiology. The Lancet Neurology. 12(7):706-15, 2013.


Golfeiz C, Best MW, Vallejo MC. Space Occupying Epidural Air Necessitating Emergent Caesarean Delivery [Letter to the Editor]. British Journal of Anesthesia, August 2013.


He J, Hu B, Shi X, Weidert ER, Lu P, Xu M, Huang M, Kelley EE, Xie W. Activation of the Aryl Hydrocarbon Receptor Sensitizes Mice to Non-Alcoholic Steatohepatitis by Deactivating the Mitochondrial Sirtuin Deacetylase Sirt3. Mol Cell Biol. Epub ahead of print, March 18, 2013.


Herlich A. Anesthetic Emergencies in Oral Surgery: Malignant Hyperthermia, Endocrinopathy, and Neurologic Events. Oral Maxillofac Surg Clin North Am. 25(3):507-14, August 2013.


Herlich A. Perioperative Temperature Elevation: Not All Hyperthermia is Malignant Hyperthermia. Paediatr Anaesth. 23(9): 842-50, September 2013.


Janata A, Magnet IAM, Drabek T, Stezoski JP, Janesko-Feldman K, Erik Popp M, Garman RH, Tisherman SA, Kochanek PM. Extracorporeal Versus Conventional Cardiopulmonary Resuscitation After Ventricular Fibrillation Cardiac Arrest in Rats: A Feasibility Trial. Critical Care Medicine. Epub ahead of print, May 9, 2013.


Konig G, Hamlin BR, Waters JH. Topical Tranexamic Acid Reduces Blood Loss and Transfusion Rates in Total Hip and Total Knee Arthroplasty. J Arthroplasty. Epub ahead of print, July 22, 2013.


Konig G, Yazer MH, Waters JH. Stored Platelet Functionality Is Not Decreased After Warming with a Fluid Warmer. Anesth Analg. Epub ahead of print, Aug 6, 2013.


Marcus DA, Bhowmick A. Fibromyalgia Comorbidity in a Community Sample of Adults with Migraine. Clin Rheumatol. Epub ahead of print, June 7, 2013.


Marcus DA, Blazek-O'Neill B, Kopar JL. Symptom Reduction Identified After Offering Animal-Assisted Activity at a Cancer Infusion Center. Am J Hosp Palliat Care. Epub ahead of print, May 31, 2013.


Marcus DA. The Science behind Animal-Assisted Therapy. Curr Pain Headache Rep. 17(4): 32, April 2013.


Mowrey D, Cheng MH, Liu LT, Willenbring D, Lu X, Wymore T, Xu Y, Tang P. Asymmetric Ligand Binding Facilitates Conformational Transitions in Pentameric Ligand-Gated Ion Channels. J Am Chem Soc. 135(6):2172-80, February 13, 2013.


Pizzi LJ, Chelly JE, Marlin V. Nursing Time Study for the Administration of a PRN Oral Analgesic on an Orthopedic Postoperative Unit. Pain Manag Nurs. Epub ahead of print, June 5, 2013.


Reder LM, Victoria LW, Manelis A, Oates JM, Dutcher JM, Bates JT, Cook S, Aizenstein HJ, Quinlan J, Gyulai F. Why it's Easier to Remember Seeing a Face We Already Know Than One We Don't: Preexisting Memory Representations Facilitate Memory Formation. Psychological Science. 24(3):363-72, Mar 1, 2013.


Sakai T, Hudson M, Davis P, Williams J. Integration of Academic and Clinical Performance-Based Faculty Compensation Plans: a System and its Impact on an Anaesthesiology Department. Br J Anaesth. Epub ahead of print, May 19, 2013.


Schreiber KL, Martel MO, Shnol H, Shaffer JR, Greco C, Viray N, Taylor LN, McLaughlin M, Brufsky A, Ahrendt G, Bovbjerg D, Edwards RR, Belfer I. Persistent Pain in Postmastectomy Patients: Comparison of Psychophysical, Medical, Surgical, and Psychosocial Characteristics Between Patients With and Without Pain. Pain. 154(5):660-8, May 2013.


Singh S, Wirth KM, Phelps AL, Badve MH, Shah TH, Sah N, Vallejo MC. Epidural Catheter Placement in Morbidly Obese Parturients with the Use of an Epidural Depth Equation prior to Ultrasound Visualization. The Scientific World Journal. Article ID 695209, 6 pages, 2013.


Talarico JF, Varon AJ, Banks SE, Berger JS, Pivalizza EG, Medina-Rivera G, Medina-Rivera G, Rimal J, Davidson M, Dai F, Qin L, Ball RD, Loudd C, Schoenberg C, Wetmore AL, Metro DG. Emotional Intelligence and the Relationship to Resident Performance: a Multi-Institutional Study. Journal of Clinical Anesthesia. 25(3):181-7, 2013.


Tanaka KA, Bader SO, Sturgil EL. Diagnosis of Perioperative Coagulopathy-Plasma versus Whole Blood Testing. J Cardiothorac Vasc Anesth. 27(4 Suppl):S9-S15, August 2013.


Tanaka KA, Bolliger D. On the Reversal of New Oral Anti-Coagulants: Can We Simply Extrapolate Data from the Animal Models to Humans? [Editorial]. British Journal of Anaesthesia. 110(3):329-32, March 1, 2013.


Tanaka KA, Egan K, Szlam F, Ogawa S, Roback JD, Sreeram G, Guyton RA, Chen EP. Transfusion and Hematologic Variables after Fibrinogen or Platelet Transfusion in Valve Replacement Surgery: Preliminary Data of Purified Lyophilized Human Fibrinogen Concentrate versus Conventional Transfusion. Transfusion. Epub ahead of print, May 30, 2013.


Tanaka KA, Kor DJ. Emerging Haemostatic Agents and Patient Blood Management.  Best Pract Res Clin Anaesthesiol. 27(1):141-60, March 2013.


Tanaka KA, Mazzeffi MA, Grube M, Ogawa S, Chen EP. 3-factor Prothrombin Complex Concentrate and Hemostasis after High-Risk Cardiovascular Surgery. Transfusion. 53(4):920-1, April 2013.


Turan A, Waters JH, Sessler DI. A Novel Approach to Preoperative Blood Orders. [Editorial]. Anesthesiology. 118(6):1250-1, 2013.


Vallejo MC, Cobb BT, Steen TL, Singh S, Phelps AL. Maternal Outcomes in Women Supplemented With a High-Protein Drink in Labour. Australian and New Zealand Journal of Obstetrics and Gynaecology. 53(4):369-74, 2013.


Vallejo MC, Sturgill E, Natbony L, Golfeiz C. Postpartum Peroneal Nerve Injury following Caesarean Delivery [Letter to the Editor]. British Journal of Anesthesia, June 2013.


Victoria L, Manelis A, Oates J, Dutcher JM, Aizenstein HJ, Gyulai F, Quinlan JJ, Reder LM. Why it's Easier to Remember Seeing a Face We Already Know than One We Don't: Pre-Existing Memory Representations Facilitate Memory Formation. Psychological Science. 24(3):363-72, March 1, 2013.


Visoiu M, Yakovleva N. Continuous Postoperative Analgesia via Quadratus Lumborum Block - An Alternative to Transversus Abdominis Plane Block. Paediatr Anaesth. Epub ahead of print, August 9, 2013.


Waleed AW, Jacobi J, Sindi A, Hartog C, Reinhart K, Kokkoris S, Gerlach H, Andrews P, Drabek T, Manzanares W, Cook DJ, Jaeschke RZ. The Effect of Selenium Therapy on Mortality in Patients with Sepsis Syndrome: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Crit Care Med. 41(6):1555-1564, June 2013.


Waters JH, Yazer MH. Bleeding Causes Harm ... Really?! Transfusion. 53(1):2-4, 2013.


Wilson SH, Rest C, Pearce-Smith B, Hudson ME, Chelly JE. Regional Anesthesia for Ambulatory Surgery: The Ideal Technique for a Growing Practice. Anesthesiology News. 39(4), April 2013.


Yanovski B, Gat M, Gaitini L, Ben-David B. Pediatric Thoracic Paravertebral Block: Roentgenologic Evidence for Extensive Dermatomal Coverage. J Clinical Anesth. 25(3):214-6, May 2013.

Notable Publications







The Journal of Perioperative Echocardiography, edited by Kathirvel Subramaniam, MD and Bala Subramaniam, MD (Harvard University), was launched with the publication of the first issue this March. The journal contained three contributions from department authors:


  • Cho S, Bader S, Heitz J. Venous Air Embolism during Anterior Lumbar Surgery. J Perioper Echocardiogr. 2013;1(1):30-2.
  • McHugh S, Bader S. Intraoperative Transesophageal Echocardiography in the Management of a Right Coronary Artery to Coronary Sinus Fistula. J Perioper Echocardiogr. 2013;1(1):21-3.
  • Subramaniam K, Subramaniam B, Puri G. Perioperative Transesophageal Echocardiography: Advances and Challenges. J Perioper Echocardiogr 2013;1(1):1-3.



The letter to the editor "Pregabalin Effective for the Prevention of Chronic Postsurgical Pain: Really?" by Jacques E. Chelly, MD, PhD, MBA  published in Anesthesia and Analgesia (2013 Feb;116(2):507-8) was selected among thousands to be included in the American Academy of Pain Management (AAPM) February 13, 2013 E-newsletter Currents: Pain Management News and Research


Three papers by Department of Anesthesiology faculty authors Inna Belfer, MD, PhD, Dawn A. Marcus, MD, and Cheryl Bernstein, MD were featured on www.MDLinx.com:  


  • Kolesnikov Y, Gabovits B, Levin A, Veske A, Qin L, Dai F, Belfer I. Chronic pain after lower abdominal surgery: do catechol-O-methyl transferase/opioid receptor μ-1 polymorphisms contribute? Molecular Pain. 2013; 9(19). MDLinx.com link
  • Marcus DA, Bernstein C, Albrecht KL. Brief, Self-Report Fibromyalgia Screener Evaluated in a Sample of Chronic Pain Patients. Pain Medicine. 2013 May; 14(5):730-5. MDLinx.com link
  • Marcus DA, Bernstein CD, Haq A, Breuer P. Including a Range of Outcome Targets Offers a Broader View of Fibromyalgia Treatment Outcome: Results from a Retrospective Review of Multidisciplinary Treatment. Musculoskeletal Care. Epub ahead of print, July 23, 2013. MDLinx.com link


"TRPV1 and TRPA1 Antagonists Prevent the Transition of Acute to Chronic Inflammation and Pain in Chronic Pancreatitis," by Pittsburgh Center for Pain Research Investigators Erica Schwartz, PhD, Jun-Ho La, PhD, Nicole Scheff, PhD, Brian M Davis, PhD (Department of Medicine), Kathryn M. Albers, PhD (Department of Medicine), and Gerald F. Gebhart, PhD published in The Journal of Neuroscience (2013 March 27, 2013; 33(13):5603-11) was highlighted on Pain Research Forum, an interactive web community dedicated to finding treatments for untreatable pain conditions.



The textbook ICU Care of Abdominal Organ Transplant Patients included three chapters authored by Department of Anesthesiology resident Ali Abdullah, MBChB and faculty members Charles David Boucek, MD; Ibtesam A. Hilmi, MB, CHB, FRCA; and Raymond M. Planinsic, MD:


  • Chapter 13: An Approach to Anesthesia for Liver Transplant, Charles Boucek
  • Chapter 17: Anesthesia Care for Kidney Transplant Recipients, Ibtesam A. Hilmi, Ali R. Abdullah, Raymond M. Planinsic
  • Chapter 20: Anesthetic Management for Pancreatic Transplant Recipients, Ibtesam A. Hilmi, Ali R. Abdullah, Raymond M. Planinsic




"Ryanodine Receptor Type 1 Gene Variants in the Malignant Hyperthermia-Susceptible Population of the United States" by department faculty authors Barbara W. Brandom, MD and Mihaela Visoiu, MD with colleagues from Uniformed Services University of the Health Sciences, Northwestern University, and State University of New York at Buffalo, which was published in the May 2013 issue of Anesthesia and Analgesia (A&A) (116(5):1078-86), was featured by the journal's Editor-in-Chief in the May News from the International Anesthesia Research Society. The paper is also a current "featured A&A article" on the IARS website.




Dawn A. Marcus, MD appeared on the cover of the summer 2013 issue of the magazine Fibromyalgia and Chronic Pain Life. Her article, "Call in the Dogs," appeared on pages 10-11. Read the issue online


Faculty on the Road


Barbara W. Brandom, MD


Barbara W. Brandom, MD will participate in a Malignant Hyperthermia (MH) meeting sponsored by MHAUS at the University of Toronto on November 1-2, 2013. At the meeting, David MacLennan, the scientist who identified the RYR1 MH mutation in pigs, will be honored for his continued studies in the molecular biology of MH.Dr. MacLennan has also been selected for induction into the Canadian Medical Hall of Fame.


Michael S. Gold, PhD

Michael S. Gold, PhD will serve as a panelist in the Pain Research Forum Webinar: Toward a Cell Biology of Pain on September 12, 2013, 12-1:00PM EDT. Register online to view the webinar.



Eric E. Kelley, PhD will present "Diminution of Hyperglycemia and Cardiopulmonary Dysfunction in Obesity: Protective Roles for Xanthine Oxidase and Nitrite" at the VIII Meeting of the Society for Free Radical Biology and Medicine-South American Group (VIII SFRBM-SAG), 14-17, October 2013, School of Law, University of Buenos Aires, Buenos Aires, Argentina.


Steven L. Orebaugh, MD

Steven L. Orebaugh, MD will lecture at the New York School of Regional Anesthesia (NYSORA) September 21-22, 2013 in Times Square, NYC at the annual NYSORA scientific meeting.



Raymond M. Planinsic, MD
Raymond M. Planinsic, MD 
will speak at the Anesthesia Symposium for Hepatic and Pancreatic Surgery at the Hospital da Luz in Lisbon, Portugal on October 5, 2013.  His lectures are entitled "Point of Care Testing in the OR" and "Anesthesia for End Stage Liver Disease and Liver Transplantation."



Jonathan H. Waters, MD 
Jonathan H. Waters, MD will speak at the Society for the Advancement of Blood Management (SABM) meeting in Los Angeles, CA on September 20, 2013. His talk is entitled, "
Patient Blood Management - Going Beyond the Pre-Operative Clinic."


Upcoming Conferences


The "Biology and Control of Nausea and Vomiting 2013" conference, organized by Charles Horn, PhD, Associate Professor of Medicine and Anesthesiology and Bill Yates, PhD, Professor of Otolaryngology and Neuroscience will be held at the University of Pittsburgh on October 3-4, 2013. Attendees can earn a maximum of 8.5 AMA PRA Category 1 Credits™ or 0.8 CEUs. Register



The 10th Annual Pre-ASA Meeting of Orthopedic Anesthesia Pain & Rehabilitation Society OAPRS/ Society of Geriatric Anesthesia SAGA /Society for the Advancement of Geriatric Anesthesia will be held on Friday, October 11th, 2013 in San Francisco, CA. Department faculty members Bruce Ben-David, MD and Jacques E. Chelly, MD, PhD, MBA will present. Attendees can earn a maximum of 8.0 AMA PRA Category 1  Credits™ or 0.8 CEUs. Dr. Chelly is President of the OAPRS. Register


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The University of Pittsburgh Department of Anesthesiology gratefully acknowledges the individuals online who have contributed to the Alumni Fund. Thank you for your generous donations.