Anesthesiology Commons^™

Cesarean Sections, Buprenorphine, Intrathecal Opioids & Pain Control – What To Do?, Madeel A. Abdullah, Md, Michelle Beam, D.O., H. Jane Huffnagle, D.O., Suzanne Huffnagle, D.O., Michelle Mele, Md, Eugene R. Viscusi, Md

Department of Anesthesiology Faculty Papers

Introduction

Suboxone^® is becoming a popular alternative to methadone maintenance in opioid abstinence. This population will likely expand in the future presenting a challenge for perioperative analgesia. Conventional pharmacology suggests that buprenorphine has a high binding affinity for the mu-opioid receptor (MOR), displacing any other opioid; and, only overcome by extremely high opioid doses. Hence recommendations are usually that buprenorphine should be discontinued before surgery so the MOR is available perioperatively. Buprenorphine is considered to have a “ceiling” analgesic effect rather than a classic opioid dose-response curve; it should not be effective for postoperative analgesia. This case supports an …

Comparing The Cumulative Pain Patients Experience Waiting For Knee Arthroplasty To Their Postoperative Pain, Eric S. Schwenk, Richard H. Epstein, Md, Cphims, Franklin Dexter

Department of Anesthesiology Faculty Papers

Introduction: Reduction of pain is a major goal of anesthesiologists treating patients undergoing knee arthroplasty. This has been achieved traditionally through the use of regional analgesia. Although these techniques decrease postoperative pain, they inherently do not affect the longstanding pain patients experience as they wait for surgery. Our objectives were to quantify: 1) the decrease in pain achieved by surgical joint replacement; and 2) the decrease in postoperative pain achievable through femoral nerve blocks versus opioids. From a systems-based perspective, we wanted to determine how much reduction in waiting time before surgery would be necessary to achieve an equal cumulative …

Evaluation Of Etoricoxib In Patients Undergoing Total Knee Replacement Surgery In A Double-Blind, Randomized Controlled Trial., Narinder Rawal, Eugene R. Viscusi, Paul M Peloso, Harold S Minkowitz, Liang Chen, Sandhya Shah, Anish Mehta, Denesh K Chitkara, Sean P Curtis, Dimitris A Papanicolaou

Department of Anesthesiology Faculty Papers

BACKGROUND: Optimal postoperative pain management is important to ensure patient comfort and early mobilization.

METHODS: In this double-blind, placebo- and active-controlled, randomized clinical trial, we evaluated postoperative pain following knee replacement in patients receiving placebo, etoricoxib (90 or 120 mg), or ibuprofen 1800 mg daily for 7 days. Patients >=18 years of age who had pain at rest >=5 (0--10 Numerical Rating Scale [NRS]) after unilateral total knee replacement were randomly assigned to placebo (N = 98), etoricoxib 90 mg (N = 224), etoricoxib 120 mg (N = 230), or ibuprofen 1800 mg (N = 224) postoperatively. Co-primary endpoints included …

Metabolic Syndrome Increases Risk For Pulmonary Embolism After Hip And Knee Arthroplasty., Boris Mraovic, Md, Brian R Hipszer, Md, Richard H. Epstein, Md, Javad Parvizi, Md, Edward C Pequignot, Md, Inna Chervoneva, Md, Jeffrey Joseph, Md

Department of Anesthesiology Faculty Papers

AIM: To investigate whether patients with metabolic syndrome (MetS) undergoing total hip or knee replacement have an increased risk for pulmonary embolism (PE).

METHODS: We studied patients undergoing total hip or total knee replacement from January 2001 to April 2006. The diagnosis of PE was based on a positive finding with a chest CT or a lung scan. Components of MetS were defined as 1) BMI≥30 kg/m(2) , 2) non-fasting preadmission glucose ≥11.1 mmol/L or diagnosis of diabetes, 3) hypertension, and 4) dyslipidemia. MetS was diagnosed if at least three of these components were present.

RESULTS: Of 7282 patients, 107 …

Perioperative Management Of Interscalene Block In Patients With Lung Disease., Eric S. Schwenk, Kishor Gandhi, Eugene R. Viscusi

Department of Anesthesiology Faculty Papers

Interscalene nerve block impairs ipsilateral lung function and is relatively contraindicated for patients with lung impairment. We present a case of an 89-year-old female smoker with prior left lung lower lobectomy and mild to moderate lung disease who presented for right shoulder arthroplasty and insisted on regional anesthesia. The patient received a multimodal perioperative regimen that consisted of a continuous interscalene block, acetaminophen, ketorolac, and opioids. Surgery proceeded uneventfully and postoperative analgesia was excellent. Pulmonary physiology and management of these patients will be discussed. A risk/benefit discussion should occur with patients having impaired lung function before performance of interscalene blocks. …

Root Causes Of Intraoperative Hypoglycemia: A Case Series., Eric S. Schwenk, Boris Mraovic, Ryan P. Maxwell, Gina S. Kim, Jesse M. Ehrenfeld, Richard H. Epstein

Department of Anesthesiology Faculty Papers

STUDY OBJECTIVE: To describe the root causes of intraoperative hypoglycemic events.

DESIGN: Retrospective analysis.

SETTING: Large academic teaching hospital.

MEASUREMENTS: Data from 80,379 ASA physical status 1, 2, 3, 4, and 5 surgical patients were reviewed. Blood glucose values, insulin, oral hypoglycemic medication doses, and doses of glucose or other medications for hypoglycemia treatment were recorded.

MAIN RESULTS: Hypoglycemia in many patients had multiple etiologies, with many cases (8 of 17) involving preventable errors. The most common root causes of hypoglycemia were ineffective communication, circulatory shock, failure to monitor, and excessive insulin administration.

CONCLUSION: Intraoperative hypoglycemia was rare, but often …

Influence Of Body Mass Index And Antibiotic Dose On The Risk Of Surgical Site Infections In Pediatric Clean Orthopedic Surgery., Jeffrey J Cies, Shannon Chan, Jobayer Hossain, B Randall Brenn, M Cecilia Di Pentima

Department of Anesthesiology Faculty Papers

OBJECTIVE: To evaluate body mass index (BMI) and antimicrobial dose as risk factors for surgical site infections in pediatric patients.

PATIENTS AND METHODS: Children between 2 and 19 years of age undergoing clean orthopedic procedures and receiving at least one dose of perioperative antibiotics (cefazolin, vancomycin, or clindamycin) were studied. The retrospective case-controlled study was conducted at the Alfred I. duPont Hospital for Children, a 180-bed tertiary-care academic pediatric hospital in Wilmington, DE. Data were collected from January 1, 2002, to December 31, 2005.

RESULTS: Underweight children had a higher risk for SSIs than overweight and normal-weight children. American Society …

Influence Of The Menstrual Cycle On The Incidence Of Nausea And Vomiting After Laparoscopic Gynecological Surgery: A Pilot Study., Tatjana Simurina, Boris Mraovic, Neven Skitarelić, Tatjana Andabaka, Zdenko Sonicki

Department of Anesthesiology Faculty Papers

STUDY OBJECTIVE: To investigate whether the phase of menstrual cycle influences the incidence of postoperative nausea and vomiting (PONV) in women undergoing general anesthesia for elective laparoscopic gynecological surgery.

DESIGN: Prospective, observational, blinded study.

SETTING: General hospital, Postanesthesia Care Unit, and gynecologic floor room.

PATIENTS: 111 ASA physical status 1 and 2 women, aged 18 to 53 years.

INTERVENTIONS: Patients were classified into three groups according to the phase of menstrual cycle at the time of anesthesia: Group F1: follicular phase (menstrual days 1-8; n = 34); Group O2: ovulatory phase (days 9-15; n = 40); and Group L3: luteal …

Ketamine As An Adjunct For The Long-Term Sedation And Analgesia Of A Patient With A Left Ventricular Assist Device (Lvad) And An Open Chest, Avni Gupta, Charles S. Kato, Eugene R. Viscusi

Department of Anesthesiology Faculty Papers

Conclusion:

A multimodal sedative and analgesic regimen that incorporates ketamine offers important therapeutic advantages in select patients who require very high doses of opioids and benzodiazepines, but warrants futher study.

Effects Of Preoperative Aspirin On Cardiocerebral And Renal Complications In Non-Emergent Cardiac Surgery Patients: A Sub-Group And Cohort Study., Longhui Cao, Scott Silvestry, Ning Zhao, James Diehl, Jianzhong Sun

Department of Anesthesiology Faculty Papers

BACKGROUND AND OBJECTIVE: Postoperative cardiocerebral and renal complications are a major threat for patients undergoing cardiac surgery. This study was aimed to examine the effect of preoperative aspirin use on patients undergoing cardiac surgery.

METHODS: An observational cohort study was performed on consecutive patients (n = 1879) receiving cardiac surgery at this institution. The patients excluded from the study were those with preoperative anticoagulants, unknown aspirin use, or underwent emergent cardiac surgery. Outcome events included were 30-day mortality, renal failure, readmission and a composite outcome - major adverse cardiocerebral events (MACE) that include permanent or transient stroke, coma, perioperative myocardial …

Acute Hypotensive Transfusion Reaction: A Case Report, Waleed Shah, Elia S. Elia

Department of Anesthesiology Faculty Papers

Introduction:

Acute hypotensive transfusion reactions are characterized by an abrupt and early onset of hypotension. This is often severe and lacks other signs of symptoms associated with more common causes of hypotension or transfusion reactions. Once the transfusion is stopped, the hypotension rapidly resolves, usually without the need for therapy.

Case Report detailed in poster.

Postoperative Glycemic Variability In Diabetic And Non Diabetic Patients, Boris Mraovic, Md, Brian Hipszer, Md, Zvi Grunwald, Md, David Gratch, Do, Charles J. Yeo, Md, Jennifer Lessin, Rn, Kathleen O'Malley, Rn, Angela Gulino, Md, Peter Simpson, Meng, Jeffrey Joseph

Department of Anesthesiology Faculty Papers

Objectives: Glycemic variability increases oxidative stress and may trigger the inflammation and coagulation cascades. Variability may be associated with increase morbidity and mortality in ICU patients. We analyzed glycemic variability after major surgery in diabetic (DM) and non-diabetic (NDM) patients using an automated intravenous blood glucose monitor (IVBG).

Bapcap2-1 Does Preoperative Aspirin Improve Outcomes In Cardiac Surgery Patients?, Jian-Zhong Sun, L. Cao, H. Liu, W. Sun, S Silvestry, J. Diehl

Department of Anesthesiology Faculty Papers

Best Abstracts - Runner-up Session 2 presented at Euroanaesthesia 2011 in the Netherlands.

Background and Goal of Study: The effects of preoperative aspirin on major cardiocerebral and renal outcomes and mortality remain uncertain.

Effects Of High Intraoperative Inspired Oxygen On Postoperative Nausea And Vomiting In Gynecologic Laparoscopic Surgery, Tatjana Šimurina, Md, Msc, Boris Mraović, Md, Simon Mikulandra, Md, Msc, Zdenko Sonicki, Md, Phd, Nina Sulen, Md, Branko Dukić, Md, Tong J. Gan, M.D

Department of Anesthesiology Faculty Papers

Study objective: To assess the efficacy of intraoperative different inspired oxygen fractions (FIO2) of 0.8 and 0.5 when compared with standard FIO2 0.3 in prevention of postoperative nausea and vomiting (PONV).

Design: A prospective, controlled, randomized, double-blind study.

Setting: General hospital, postanesthesia care unit (PACU) and gynecologic floor room. Patients: 120 ASA physical status I and II women, aged 21 to 76 y, undergoing elective gynecologic laparoscopic surgery.

Interventions: Patients were randomized to receive gas mixture of 30% oxygen in air (FI O2=0.3, group G30), 50% oxygen in air (FIO2=0.5, group G50) or 80% oxygen in air (FIO2=0.8, group G80), …

High Inspired Co2 Capnograph Reading Due To Misplaced End Tidal Co2 Sampling Port, Andrew Ng, Md, Elia Elia, Md, Lisa Luyun, Md

Department of Anesthesiology Faculty Papers

In conclusion, if abnormal capnography is seen where the baseline inspiratory CO2 is higher than usual, inspect the circuit for rebreathing and consider examining the position of ETCO2 sampling port. We recommend confirming ETCO2 sampling port is connected immediately distal to Y-piece before starting a case for accurate CO2 measurement.

Electroconvulsive Therapy For A Patient With A Penetrating Ulcer In The Aortic Arch, Andrew Ng, Md, George Hsu, Md, Zvi Grunwald, Md

Department of Anesthesiology Faculty Papers

Case: An 85 year-old male presented with major depressive disorder refractory to medical therapy. A series of eight electroconvulsive therapy (ECT) was planned. Past medical history includes a small penetrating ulcer in the aortic arch, an ascending aortic aneurysm measuring 4.3 x 4.4 cm, atrial fibrillation on anticoagulation and hypertension. Medications include metoprolol, coumadin, simvastatin, alprazolam and venlafaxine.

Intraoperative Point-Of-Care Blood Glucose Values Show Poor Agreement With Central Lab Blood Values, Eric Schwenk, Md, Richard H. Epstein, Md, Cphims, Boris Mraovic, Md

Department of Anesthesiology Faculty Papers

Introduction:

Accuracy of point-of-care (POC) glucose devices compared to central lab values in critically ill patients has come into question, particularly during intensive insulin therapy.

POC devices perform particularly poorly in the hypoglycemic range.

Typically tested under ideal conditions in the lab; intraoperative, real-life data are lacking.

Liver Transplantation In The Face Of Severe Electrolyte Abnormalities: A Discussion Of Management Techniques, Vincent Franze, Md, Rosalba Spiritoso, Md, Elia Elia, Md, Yoogoo Kang, Md

Department of Anesthesiology Faculty Papers

Introduction:

Electrolytes disorders are a common finding in patients with End stage liver disease (ESLD). Liver transplantation (OLT) is frequently associated with massive transfusion and fluid shifts in patients with renal dysfunction, and management of hyponatremla, hyperkalemia and hypervolemia are major concerns for anesthesiologists. This case describes a multimodal approach in treatment of combined severe hyponatremla, hperkalemia and hypervolemia.

Intraoperative Insulin Administration And Hypoglycemia In Diabetic Patients, Eric Schwenk, Md, Richard H. Epstein, Md, Cphims, Boris Mraovic

Department of Anesthesiology Faculty Papers

Introduction:

Although studies are conflicting as to the benefit of intensive insulin therapy (IIT) in the critically ill, there is a 6x increase in hypoglycemia incidence in patients treated with IIT.

Anesthesia masks signs and symptoms of hypoglycemia, making intraop hypoglycemia difficult to detect clinically.

We performed this retrospective, observational analysis to:

Determine the incidence of intraoperative hypoglycemia and severe hypoglycemia

Evaluate possible causes of hypoglycemia

Determine intraop monitoring and treatment practices of diabetic patients at a large academic hospital

Clinical Accuracy Of A Hospital Point-Of-Care Glucose Meter, Brian R. Hipszer, Phd, Jennifer B. Lessin, Rn, Kathleen O'Malley, Rn, Zvi Grunwald, Md, Jeffrey I. Joseph, D.O.

Department of Anesthesiology Faculty Papers

Summary: Glucose meter performance was evaluated against the ISO 15197 guidelines in 221 time-matched venous and capillary blood samples. Accuracy decreased when the source of the reference and meter blood samples was not the same.

Inadvertent Respiratory Acidosis Due To Damaged Water Trap Of Capnograph By Isoflurane, Eileen R. Manabat, Md, Richard Berman, Md, Yoogoo Kang, Md

Department of Anesthesiology Faculty Papers

Introduction: A few reports have documented isoflurane leakage causing damage to the water trap in the Drager Apollo anesthesia machine. This case describes an abnormal capnograph tracing yielding falsely normal end-tidal carbon dioxide tension (EtCO2) after breakage of the water trap by isoflurane.

Perioperative Hyperglycemia Increases Risk For Deep Wound Infection After Major Orthopedic Surgery, Boris Mraovic, Md, Orhan Bican, Md, Javad Parvizi, Md, Jeffrey I. Joseph, D.O.

Department of Anesthesiology Faculty Papers

Total hip and knee replacement surgery are one of the most frequent major surgeries performed in the USA. In 2002, the number of primary hip and knee arthroplasty was 119,000 and 381,000, respectively. By year 2030 the number is projected to increase to 572,000 and 3,481,000 respectively.

Deep wound infection after major orthopedic surgery is one of the most serious complications causing increase in morbidity and mortality and health care costs. Various risk factors for developing infection after hip and knee replacement surgery were described including age, ASA PS status, obesity, patients' comorbidities and surgical technique factors.

Perioperative hyperglycemia may …

Somnoforme: A Century After The Introduction Of The "Ideal" Anesthetic Gas, James W. Heitz, Md

Department of Anesthesiology Faculty Papers

Since the introduction of ether as a general anesthetic, there has been a continuous quest to develop the ideal anesthetic gas. The attributes of the ideal anesthetic gas have evolved over time. At the beginning of the 20th century, the search for the ideal anesthetic was focused upon finding an anesthetic gas with rapid inhalation induction and rapid emergence that could be delivered without cumbersome apparatus and would have limited potential for toxicity. Somnoforme was a mixture of ethyl chloride, methyl chloride, and ethyl bromide designed to provide powerful efficacy with low potential for side effects by blending of several …

The Dose-Response Of Nitrous Oxide In Postoperative Nausea In Patients Undergoing Gynecologic Laparoscopic Surgery: A Preliminary Study., Boris Mraovic, Tatjana Simurina, Zdenko Sonicki, Neven Skitarelic, Tong J. Gan

Department of Anesthesiology Faculty Papers

BACKGROUND: Whether nitrous oxide (N(2)O) increases the incidence of postoperative nausea and vomiting (PONV) after laparoscopic gynecologic surgery is still controversial, which may be due to the administration of different concentrations of inspired N(2)O. We investigated whether N(2)O results in a dose-response increase in PONV. METHODS: Patients undergoing gynecologic laparoscopic surgery were randomized to receive 30% oxygen with air (G0, n = 46), 50% N(2)O with oxygen (G50, n = 46), or 70% N(2)O with oxygen (G70, n = 45). A standardized general anesthetic was used with no PONV prophylaxis. Known risk factors for PONV were controlled. Metoclopramide was used …