Anesthesiology Commons^™

Epidural Anesthesia For Cesarean Section For Parturient With Recently Diagnosed Asymptomatic Chiari Malformation Type I: A Case Report, Ashie Kapoor, Jon Halling

HCA Healthcare Journal of Medicine

Chiari malformations (CMs) are congenital defects of the brain and skull that result in inferior displacement of the cerebellum. There are four types of CMs distinguished by the severity of the anatomic defects and parts of the brain that protrude beyond the foramen magnum. Of these types, CM Type I (CMI) is the least severe. It is characterized by the downward displacement of the cerebellar tonsils beyond the foramen magnum by more than 5 millimeters and goes into the cervical spinal canal. CMI is the most common type with an incidence of 0.1-0.5% in the general population and a predominance …

Endotracheal Tube Dislodgment In A High Risk Pulmonary Hypertensive Patient Due To Undiagnosed Tracheomegaly: A Case Report, Andrew Peck, Tammer N. Ghaly, Austin J. Adams, Daniel W. Johnson, Rebecca A. Aron

Graduate Medical Education Research Journal

Introduction

Airway enlargement was first described histologically in 1872, but it was not clinically reported until 1932, when Dr. Mounier-Kuhn published his seminal radiographic studies.¹ Since then, it is estimated that several hundred case reports have been published on congenital Mounier-Kuhn Syndrome (MKS), acquired tracheomegaly, and tracheobronchomegaly (TBM), yet only a few comprehensive literature reviews exist.²

Case

This case report details an elective nasal procedure for a patient with a history of significant pulmonary hypertension ad COPD on 5L home O₂ who had a symptomatic facial trauma. He was considered high risk secondary to his pulmonary disease, …

Beyond The Raskin Protocol: Ketamine, Lidocaine, And Other Therapies For Refractory Chronic Migraine., Jeffrey J. Mojica, Eric S. Schwenk, Clinton Lauritsen, Stephanie J. Nahas

Department of Anesthesiology Faculty Papers

PURPOSE OF REVIEW: The purpose of this review is to discuss the available evidence and therapeutic considerations for intravenous drug therapy for refractory chronic migraine.

RECENT FINDINGS: In carefully monitored settings, the inpatient administration of intravenous lidocaine and ketamine can be successful in treating refractory chronic migraine. Many patients with refractory chronic migraine have experienced treatment failure with the Raskin protocol. The use of aggressive inpatient infusion therapy consisting of intravenous lidocaine or ketamine, along with other adjunctive medications, has become increasingly common for these patients when all other treatments have failed. There is a clear need for prospective studies …

Barriers To Preoperative Warming: Best Practice Guideline, Tyler Comans, Zachary Hays, Caleb Leach

Doctoral Projects

The lack of preoperative warming has a direct relationship to perioperative hypothermia complications which include, but are not limited to: increased infection rate, coagulopathies, and increased myocardial oxygen consumption; all contributing to poor patient and facility outcomes. Implementation of an evidence-based educational module with visual aid can potentially increase the utilization of active warming techniques in the preoperative setting by perioperative staff. The DNP Project investigated barriers to preoperative warming by perioperative staff at a large teaching hospital in the southeastern United States. Barriers were assessed by a voluntary survey sent to 87 perioperative staff members. Twenty-two surveys were completed …

Implementation Of A Pre-Anesthesia Take-Home Evaluation (Pathe) As A Means Of Process Improvement: A Best Practice Recommendation, Russell Gray, Hunter Brown, Trey Galloway

Doctoral Projects

The pre-anesthesia evaluation (PAE) is a vital component to anesthesia providers when choosing an appropriate anesthetic plan for patients requiring surgery. The PAE, pre-anesthesia risk-factor assessment, and provision of pre-anesthesia instructions are standards of care implemented in order to assess the patient’s likely outcome of surgery and anesthesia as well as stratify any known risk factors to optimize surgical/anesthetic outcomes. Any disruption in this process could potentially lead to decreased patient/provider satisfaction, reduced patient compliance with pre-anesthetic instructions, reduced patient safety, and unnecessary financial burden.

After the completion of a literature review, the need for a best practice recommendation was …

Decreasing Pre-Procedural Fasting Times: A Benchmark Study, Sheila Gasparek

MSN Capstone Projects

On a busy Surgical Trauma unit, scheduled procedures and operations are often delayed for priority emergent cases. Patients admitted to the unit with delayed procedures often endure extended fasting times beyond the six-hour intention of standard nothing by mouth (NPO) after midnight fasting order. With prolonged fasting times, patients inquire about pending surgery times and dietary options. Some providers may allow ice chips, but most doctors prefer patients to remain NPO in case Operating Room availability opens for surgery, leaving already anxious and uncomfortable patients more frustrated as prolonged fasting affects patients’ physical and psychological well-being (Anderson & Comrie, 2009). …

Objective Structured Clinical Evaluation For Supraclavicular And Femoral Nerve Blocks Utilizing Ultrasound Guidance For Student Nurse Anesthetists, Mitchell Fowler, Christopher Bond

Doctoral Projects

The purpose of this DNP project was to create a tool to teach and evaluate student registered nurse anesthetists (SRNAs) at TheUniversity of Southern Mississippi (USM) on supraclavicular and femoral nerve blocks to promote safety in the clinical setting. An objective structured clinical evaluation (OSCE) for ultrasound-guided supraclavicular and femoral nerve blocks was created as the basis for this project. Best-practice techniques as identified by the AANA’s 14^thstandard of nurse anesthesia practice were researched and used in the development of the OSCE to promote a culture of safety for SRNAs and patients (AANA, 2019).

A culture of safety …

In Response: Neuraxial And Peripheral Misconnection Events Leading To Wrong-Route Medication Errors, Eugene R. Viscusi, Vincent Hugo, Klaus Hoerauf, Frederick S Southwick

Department of Anesthesiology Faculty Papers

No abstract provided.

The Effect Of Saline Flush After Rocuronium Bolus On Intubating Conditions In Adult Patients Undergoing Elective Surgery: A Randomized Controlled Trial, Ian Odari, Vitalis Mung’Ayi, Rajpreet Bal, David Odaba

Anaesthesiology, East Africa

Background: In emergency surgeries requiring endotracheal intubation, the time to effect of neuromuscular blocking drugs is a crucial time to avoid hypoxia and aspiration into the lungs. Various strategies have been undertaken to shorten this time. All these methods have positive results but some are associated with side effects. The effectiveness of a muscle relaxant can either be assessed using the train of four or intubating conditions on the Goldberg scale. In this study, we investigated the effects of a 20 ml saline bolus following intravenous rocuronium at 0.6 mg/kg on the proportions of patients with excellent intubating conditions …

Spinal Anesthesia Or General Anesthesia For Hip Surgery In Older Adults, Mark D. Neuman, Rui Feng, Jeffrey L. Carson, Lakisha J. Gaskins, Derek Dillane, Daniel I. Sessler, Frederick Sieber, Jay Magaziner, Edward R. Marcantonio, Samir Mehta, Diane Menio, Sabry Ayad, Trevor Stone, Steven Papp, Eric S. Schwenk, Nabil Elkassabany, Mitchell Marshall, J. Douglas Jaffe, Charles Luke, Balram Sharma, Syed Azim, Robert A. Hymes, Ki-Jinn Chin, Richard Sheppard, Barry Perlman, Joshua Sappenfield, Ellen Hauck, Mark A. Hoeft, Mark Giska, Yatish Ranganath, Tiffany Tedore, Stephen Choi, Jinlei Li, M. Kwesi Kwofie, Antoun Nader, Robert D. Sanders, Brian F. S. Allen, Kamen Vlassakov, Stephen Kates, Lee A. Fleisher, James Dattilo, Ann Tierney, Alisa J. Stephens-Shields, Susan S. Ellenberg

Department of Anesthesiology Faculty Papers

Background: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

Methods: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 …

Ketamine For Refractory Chronic Migraine: An Observational Pilot Study And Metabolite Analysis., Eric S. Schwenk, Marc C. Torjman, Ruin Moaddel, Jacqueline Lovett, Daniel Katz, William Denk, Clinton Lauritsen, Stephen D. Silberstein, Irving W. Wainer

Department of Anesthesiology Faculty Papers

Patients with refractory chronic migraine have substantial disability and have failed many acute and preventive medications. When aggressive intravenous therapy is indicated, both lidocaine and (R,S)-ketamine infusions have been used successfully to provide relief. Retrospective studies have shown that both agents may be associated with short-term analgesia. In this prospective, observational pilot study of 6 patients, we compared the effects of lidocaine and (R,S)-ketamine infusions and performed metabolite analyses of (R,S)-ketamine to determine its metabolic profile in this population. One of (R,S)-ketamine's metabolites, (2R,6R)-hydroxynorketamine, has been shown in animal studies to reduce pain, but human studies in patients undergoing continuous …

Pharmacologic And Clinical Considerations Of Nalmefene, A Long Duration Opioid Antagonist, In Opioid Overdose., Amber N. Edinoff, Catherine A. Nix, Tanner D. Reed, Elizabeth M. Bozner, Mark R. Alvarez, Mitchell C. Fuller, Fatimah Anwar, Elyse M. Cornett, Adam M. Kaye, Alan D. Kaye

School of Medicine Faculty Publications

No abstract provided.

Anticoagulation With Argatroban In A Patient With Heparin-Induced Thrombocytopenia And Renal Insufficiency Undergoing Orthotopic Heart Transplantation, Michael Stuart Green, Johann Mathew, Christopher R Hoffman, Henry Liu

Department of Anesthesiology Faculty Papers

Unfractionated heparin is the anticoagulant of choice for cardiac surgery that requires cardiopulmonary bypass. However, it can cause serious side effects like heparin-induced thrombocytopenia (HIT), an immune-mediated process where antibodies are directed against heparin and platelet 4 complexes. In such cases, alternative pharmacologic strategies are implemented to facilitate safe bypass conditions. A woman with severe decompensated heart failure was heparinized for intra-aortic balloon pump and subsequent LVAD placement. On day 6, a fall in platelets from 113,000 to 26,000 was noted. She was diagnosed with HIT. Heparin was discontinued and replaced with an argatroban infusion for the duration of her …

Awake Craniotomy For Resection Of Intracranial Meningioma: First Case Series From A Low- And Middle-Income Country, Saqib Kamran Bakhshi, Noyan Jawed, Faraz Shafiq, Ather Enam

Section of Neurosurgery

Introduction: Awake craniotomy (AC) has emerged as a better modality for resection of intra-axial brain tumors. The advantages are not just related to the preservation of neurological function, but also include early recovery, short hospital stay and possibly lower costs. However, data on AC for meningioma resection is deficient, likely because of concerns related to intra-operative pain and blood loss.
Methods: All patients who underwent AC, using awake through-out technique for resection of meningioma, during the last five years, were included in the study. Non-probability consecutive sampling technique was employed. Variables for demographics, and details of diagnosis and surgical procedure …

Thoracoscopic Left Atrial Appendage Ligation Complicated By Persistent Left Superior Vena Cava, Rebecca A. Aron, Maria Decastro, Kristina L. Koch, Kenneth Neff, Tyler Gouvea

Graduate Medical Education Research Journal

We herein report a 64 year-old male who had an incidental finding of a persistent left superior vena cava (SVC) revealed by intraoperative transesophageal echocardiography (TEE) during a Maze procedure with left atrial appendage ligation. During the intraoperative TEE, an incidental dilated coronary sinus > 1.1 cm was noted which prompted further evaluation and aided in our ultimate diagnosis. Consequently, significant additional surgical dissection and manipulation were required to isolate the left upper pulmonary vein. This case report reviews the anatomy and embryology of a persistent left SVC, discusses its clinical implications, and identifies surgical considerations for treatment.

Experience Treating Electrical Storm Using An Ultrasound Guided Stellate Ganglion Blockade, Thomas A. Nicholas Iv, Levi Zehr, Han-Jun Wang, Daniel R. Anderson, Steven J. Lisco

Graduate Medical Education Research Journal

Introduction: Electrical storm is a life-threatening condition in an often medically complex patient population. Pharmacologic ultrasound-guided stellate ganglion blockade is a treatment option in combination with maximized systemic antiarrhythmic medications. There is an emerging body of case reports supporting stellate ganglion block efficacy and safety for this condition.

Methods: Retrospective study on ultrasound-guided stellate ganglion blocks for electrical storm investigating patient clinical characteristics, immediate and long-term outcomes, and procedure related complications.

Results: Four (75% men) critically ill patients maximized on standard antiarrhythmic therapy underwent six bedside ultrasound-guided stellate ganglion block procedures. All blocks were unilateral left-sided, two patients underwent repeat …

Clinical Use Of Lactate Measurements: Reply, Richard M. Pino, Jaskaran Singh

School of Medicine Faculty Publications

No abstract provided.

What Factors Predict An Anesthesiologist’S Willingness To Proceed With An Anesthetic?, Nadine K. Ragbir

Doctoral Dissertations and Master's Theses

Anesthesiologists are exposed to higher stress levels than many other physician specialties. They are also at an increased risk for developing mental disorders, alcohol and drug dependencies, sleep disturbances, and suicidal ideations. Therefore, the purpose of this dissertation was to explore the factors that predict an anesthesiologist’s willingness to proceed with an anesthetic. The current study consisted of two stages. The first stage was developing a regression equation that was used to predict anesthesiologists’ willingness to proceed with an anesthetic. During the second stage, additional data was collected to test the model that was developed in the first stage. Six …

Percutaneous Coronary Intervention Of Totally Occluded Coronary Venous Bypass Grafts: An Exercise In Futility?, Evan Nardone, Brandon M Madsen, Melissa Mccarey, D L Fischman, Nicholas Ruggiero, Paul Walinsky, Alec Vishnevsky, Michael P. Savage

Department of Medicine Faculty Papers

Background: Percutaneous coronary intervention (PCI) of diseased saphenous vein grafts (SVG) continues to pose a clinical challenge. Current PCI guidelines give a class III recommendation against performing PCI on chronically occluded SVG. However, contemporary outcomes after SVG intervention have incrementally improved with distal protection devices, intracoronary vasodilators, drug-eluting stents, and prolonged dual antiplatelet therapy.

Aim: To reassess the procedural and long-term outcomes of PCI for totally occluded SVG with contemporary techniques.

Methods: This was a retrospective observational study conducted at a single university hospital. The study population consisted of 35 consecutive patients undergoing PCI of totally occluded SVG. Post-procedure dual …

Interventional Spine And Pain Procedure Credentialing: Guidelines From The American Society Of Pain & Neuroscience, Ramana K. Naidu, Rahul Chaturvedi, Alyson M. Engle, Pankaj Mehta, Brian Su, Krishnan Chakravarthy, Kasra Amirdelfan, Jeffrey Henn, Dawood Sayed, Jay S. Grider, Timothy Deer

Anesthesiology Faculty Publications

Background: The discipline of interventional pain management has changed significantly over the past decade with an expected greater evolution in the next decade. Not only have the number of procedures increased, some of the procedures that were created for spine surgeons are becoming more facile in the hands of the interventional pain physician. Such change has outpaced academic institutions, societies, and boards. When a pain physician is in the credentialing process for novel procedure privileges, it can leave the healthcare system in a challenging situation with little to base their decision upon.

Methods: This paper was developed by a consensus …

A Call To Action Toward Optimizing The Electrical Dose Received By Neural Targets In Spinal Cord Stimulation Therapy For Neuropathic Pain, Krishnan Chakravarthy, Rajiv Reddy, Adnan Al-Kaisy, Thomas Yearwood, Jay S. Grider

Anesthesiology Faculty Publications

Spinal cord stimulation has seen unprecedented growth in new technology in the 50 years since the first subdural implant. As we continue to grow our understanding of spinal cord stimulation and relevant mechanisms of action, novel questions arise as to electrical dosing optimization. Programming adjustment — dose titration — is often a process of trial and error that can be time-consuming and frustrating for both patient and clinician. In this report, we review the current preclinical and clinical knowledge base in order to provide insights that may be helpful in developing more rational approaches to spinal cord stimulation dosing. We …

Breaking The Pain Cycle Successfully In A Child With Severe Pain Due To Recurrent Pancreatitis: A Case Report, Ali Sarfraz Siddiqui, Mansoor Chandio

Department of Anaesthesia

Abdominal pain, due to pancreatic diseases like idiopathic recurrent pancreatitis and chronic pancreatitis, is difficult to manage with medications alone in some patients. The Coeliac plexus innervates abdominal organs including the liver, gallbladder, pancreas, etc. We are presenting a case of the successful pain man-agement of a 13-year-old boy with recurrent pancreatitis, by the application of coeliac plexus block. The patient was admitted to the hospital with severe abdominal pain in August 2019. Multimodal analgesia was provided to manage his pain, but he continued to have moderate to severe pain in the abdomen. So, he was scheduled for coeliac plexus …

Duration Of Cessation Of Smoking Before Elective Surgery: Impact On Intraoperative Hemodynamics And Early Postoperative Pain In Developing Country, Mohsin Nazir, Gauhar Afshan, Muslima Ejaz, Amir Raza

Department of Anaesthesia

Aim and Background: It is estimated that up to 20% of patients coming for elective surgery are smokers and carry a risk of perioperative complications. Though smoking cessation and its impact on perioperative outcome are widely investigated worldwide we were unable to find any data in Pakistan. The objective of the study is to determine the impact of the duration of smoking cessation before elective surgery on intraoperative hemodynamics and postoperative pain in Pakistani population.
Methods: It was a prospective cohort study conducted at the Aga Khan University Hospital Karachi, Pakistan, for one-year duration. A total of 260 patients scheduled …

Creation And Implementation Of An Intraoperative Lidocaine Infusion Protocol For Gastric Surgery, Kayla Donnay, Eric Howard, Lindsey Krueger, Linda Mcdonald, Kyle Nelson

Conference Presentation Abstracts

Background: The recent opioid epidemic in the United States has damaged the country’s public health system and led to devastating patient outcomes. Healthcare providers are responsible to do their part in reducing these negative consequences. The purpose of this quality improvement project was to develop and implement an evidence-based protocol for an intraoperative lidocaine infusion during gastric surgery. The project consisted of five parts: (1) development of an evidenced-based Intraoperative Lidocaine Infusion Protocol, (2) education of the anesthesia team, (3) collection of baseline data, (4) implementation of the Intraoperative Lidocaine Infusion Protocol and (5) evaluation of the results. Method: Baseline …

Examining Enhanced Recovery After Surgery (Eras) Protocol Compliance, Joseph Vecore, Jonathon Baich, Linda Mcdonald

Conference Presentation Abstracts

Background: The development of enhanced recovery after surgery (ERAS) protocols have allowed for improved patient outcomes by utilizing a multimodal approach. The use of ERAS for surgical procedures reduces perioperative complications that could lead to increased morbidity, mortality, and length of stay. Additionally, by utilizing a multimodal approach, ERAS protocols help limit opioid use during the perioperative period. The purpose of this quality improvement project was to examine the rate of compliance to the ERAS protocol during colorectal surgery at Beaumont Hospital- Royal Oak. The different levels of compliance were evaluated for their effects on the following patient outcomes: opioid …

Comparison Of Perioperative Analgesia Between Intravenous Paracetamol And Fentanyl For Rigid Hysteroscopy: A Randomised Control Trial, Dileep Kumar, Kamal Kumar, Mohammad Hamid

Department of Anaesthesia

Objective: To compare efficacy of intravenous paracetamol and fentanyl for intra-operative and post-operative analgesia in patients undergoing rigid hysteroscopy.
Method: The prospective randomised control trial was conducted at Aga Khan University Hospital, Karachi, from October 2016 to June 2017, and comprised patients aged 18-65 years with American Society of Anesthesiologists grade I or II undergoing hysteroscopy who were randomised into paracetamol group P and fentanyl group F. Anaesthesia induction technique was standardised and analgesia in group P was paracetamol 15mg/Kg administered 15-30 minutes pre-surgery, and in group F, it was fentanyl 2mcg/kg administered at induction of anaesthesia. Intra-operative pain was …

Anaesthetic Management Of Tracheal Injury Following Blunt Neck Trauma: An Unusual Late Presentation, Muhammad Saad Yousuf, Mohammad Bin Pervez, Saulat Fatimi, Khalid Samad

Department of Anaesthesia

Tracheal injuries, following blunt neck trauma, are life-threatening surgical emergencies with high risk of mortality. A high index of suspicion is necessary to avoid missing an occult injury because delays in diagnosis and definitive treatment are associated with poorer outcomes. We, herein, report a case of a 28-year man who presented in Emergency Department 15 days after blunt neck trauma from an accident involving electric cable. Anaesthetic challenges, airway management and importance of effective close loop communication, during repair of complex tracheal reconstruction, will be discussed in this case report.

Peripheral Nerve Stimulation: A Review Of Techniques And Clinical Efficacy, Alan D. Kaye, Sasha Ridgell, Edward S. Alpaugh, Aya Mouhaffel, Aaron J. Kaye, Elyse M. Cornett, Azam A. Chami, Rutvij Shah, Bruce M. Dixon, Omar Viswanath, Ivan Urits, Amber N. Edinoff, Richard D. Urman

School of Medicine Faculty Publications

Chronic pain is a common source of morbidity in many patient populations worldwide. There are growing concerns about the potential side effects of currently prescribed medications and a continued need for effective treatment. Related to these concerns, peripheral nerve stimulation has been regaining popularity as a potential treatment modality. Peripheral nerve stimulation components include helically coiled electrical leads, which direct an applied current to afferent neurons providing sensory innervation to the painful area. In theory, the applied current to the peripheral nerve will alter the large-diameter myelinated afferent nerve fibers, which interfere with the central processing of pain signals through …

Comprehensive Review And Update Of Burning Eye Syndrome, Stephen Giacomazzi, Ivan Urits, Briggs Hoyt, Ashley Hubble, Elyse M. Cornett, Kyle Gress, Karina Charipova, Amnon A. Berger, Hisham Kassem, Alan D. Kaye, Omar Viswanath

Journal of Patient-Centered Research and Reviews

Keratoconjunctivitis sicca (“dry eye”) is a common (14%–30% of adults over age 48) though difficult to treat condition that causes both discomfort and disability with associated dryness, pain, and visual disturbances. Etiology is not clearly understood but is likely varied, with a subset of patients suffering from chronic neuropathic pain referred to as “burning eye syndrome.” This review of existing literature summarizes the clinical presentation, natural history, pathophysiology, and treatment modalities of burning eye syndrome.

Chronicity of burning eye syndrome is likely secondary to increased nociception from the cornea, decrease in inhibitory signals, and nerve growth factor expression alterations. Treatment …

Ketamine In The Past, Present, And Future: Mechanisms, Metabolites, And Toxicity., Eric S. Schwenk, Basant Pradhan, Rohit Nalamasu, Lucas Stolle, Irving W. Wainer, Michael Cirullo, Alexander Olsen, Joseph V. Pergolizzi, Marc C. Torjman, Eugene R. Viscusi

Department of Anesthesiology Faculty Papers

PURPOSE OF REVIEW: While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented.

RECENT FINDINGS: Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being …