Adam D. Niesen

Perioperative seizures in patients with a history of a seizure disorder.

BACKGROUND: The occurrence of perioperative seizures in patients with a preexisting seizure disorder is unclear. There are several factors unique to the perioperative period that may increase a patients risk of perioperative seizures, including medications administered, timing of medication administration, missed doses of antiepileptic medications, and sleep deprivation. We designed this retrospective chart review to evaluate the frequency of perioperative seizures in patients with a preexisting seizure disorder. METHODS: We retrospectively reviewed the medical records of all patients with a documented history of a seizure disorder who received an anesthetic between January 1, 2002 and December 31, 2007. Patients excluded from this study include those who had an outpatient procedure or intracranial procedure, ASA classification of V, pregnant women, and patients younger than 2 years of age. The first hospital admission of at least 24 hours during which an anesthetic was provided was identified for each patient. Patient demographics, character of the seizure disorder, details of the surgical procedure, and clinically apparent seizure activity in the perioperative period (within 3 days after the anesthetic) were recorded. RESULTS: During the 6-year study period, 641 patients with a documented seizure disorder were admitted for at least 24 hours after an anesthetic. Twenty-two patients experienced perioperative seizure activity for an overall frequency of 3.4%(95% confidence interval, 2.2%–5.2%). The frequency of preoperative seizures (P < 0.001) and the timing of the most recent seizure (P < 0.001) were both found to be significantly related to the likelihood of experiencing a perioperative seizure. As the number of antiepileptic medications increased, so did the frequency of perioperative seizures (P < 0.001). Neither the type of surgery nor the type of anesthetic (general anesthesia, regional anesthesia, or monitored anesthesia care) affected the frequency of perioperative seizures in this patient population. CONCLUSIONS: We conclude that the majority of perioperative seizures in patients with a preexisting seizure disorder are likely related to the patients underlying condition. The frequency of seizures is not influenced by the type of anesthesia or procedure. Because patients with frequent seizures at baseline are likely to experience a seizure in the perioperative period, it is essential to be prepared to treat seizure activity regardless of the surgical procedure or anesthetic technique.

Analgesia after Cesarean delivery: a retrospective comparison of intrathecal hydromorphone and morphine ☆

STUDY OBJECTIVE To compare analgesia and opioid-related side effects of intrathecal morphine and intrathecal hydromorphone after elective Cesarean delivery. DESIGN Retrospective, comparative study. SETTING Labor and delivery unit of an academic hospital. PATIENTS 114 parturients age ≥ 18 years, presenting for elective Cesarean delivery. INTERVENTIONS Patients who received 0.04 mg intrathecal hydromorphone were compared to a random sample of patients who received 0.1 mg intrathecal morphine for postoperative analgesia. MEASUREMENTS The primary outcome was the presence of any opioid-related complication (pruritus, nausea or vomiting, respiratory depression) requiring treatment within 24 hours of intrathecal opioid administration. Secondary outcomes included total opioid consumption (in oral morphine equivalents) within 24 hours of intrathecal opioid administration and verbal pain score (0 = none, 10 = worst) at 4, 8, 12, 18, and 24 hours after intrathecal opioid administration. MAIN RESULTS 38 patients who received intrathecal hydromorphone 0.04 mg were compared with 76 patients given 0.1 mg of intrathecal morphine for elective Cesarean delivery. No significant differences in demographics were noted between groups. There were no statistically significant differences between the intrathecal hydromorphone and intrathecal morphine groups in overall frequency of opioid-related complications (50% vs. 34.2%; P = 0.11), 24-hour opioid consumption (33 mg oral morphine equivalent [OME] vs. 8 mg OME; P = 0.27), or pain scores at any time point up to 24 hours. CONCLUSIONS Overall, analgesia and incidence of opioid-related side effects after 0.04 mg of intrathecal hydromorphone did not differ statistically from 0.1 mg of intrathecal morphine.

Combined spinal-epidural versus epidural analgesia for labor and delivery.

The rapid onset of analgesia and improved mobility with combined spinal-epidural (CSE) techniques has been associated with a higher degree of maternal satisfaction compared with conventional epidural analgesia. However, controversy exists in that initiation of labor analgesia with a CSE may be associated with an increased risk for nonreassuring fetal status (ie, fetal bradycardia) and a subsequent need for emergent cesarean delivery. Overall, both epidural and CSE techniques possess unique risk/benefit profiles, and the decision to use one technique rather than the other should be determined based on individual patient and clinical circumstances.

Clinical application of a novel video camera laryngoscope: a case series venturing beyond the normal airway ☆

The McGRATH Video Laryngoscope Series 5 is an example of indirect laryngoscopic equipment. Experience using this device to safely intubate the trachea of awake and asleep patients with known or anticipated difficult airways is presented.

Case series: anesthetic management of patients with spinal and bulbar muscular atrophy (Kennedy’s disease)

PurposeKennedy’s disease (KD) is a rare, X-linked recessive, neurodegenerative disorder of lower motor neurons characterized by progressive proximal limb and bulbar muscular atrophy with spontaneous laryngospasm, which may present an anesthetic risk. We undertook a computerized search of the Mayo Clinic medical records database between January 1996 and May 2008 for patients with KD undergoing general anesthesia. Medical records were reviewed for anesthetic techniques and perioperative complications.Clinical featuresWe identified six patients with KD, confirmed by DNA testing, who underwent 13 general anesthetics. Succinylcholine was used in two patients, and non-depolarizing neuromuscular blockers in seven cases, all without adverse effects. Although laryngospasm was not identified in any patient, one patient with advanced disease experienced postoperative glottic edema, worsening respiratory distress, bulbar dysfunction, requiring tracheostomy and prolonged ventilatory support. One patient experienced a pneumothorax.ConclusionThe potential for bulbar dysfunction and muscle weakness in patients with KD places them at risk for perioperative complications from anesthesia. Anesthesia providers should be cognizant of the different potential anesthetic risk factors in these patients.RésuméObjectifLa maladie de Kennedy est un trouble rare récessif lié au genre et neurodégénératif des neurones moteurs inférieurs caractérisé par l’atrophie musculaire progressive des membres proximaux et des bulbes, provoquant des laryngospasmes spontanés, ce qui peut engendrer un risque lors de l’induction de l’anesthésie. Nous avons entrepris une recherche électronique de la base de données des dossiers médicaux de la clinique Mayo entre janvier 1996 et mai 2008 pour les patients souffrant de la maladie de Kennedy et subissant une anesthésie générale. Les dossiers médicaux ont été passés en revue afin d’identifier les techniques anesthésiques utilisées et les complications périopératoires.Éléments cliniquesNous avons identifié six patients souffrant de la maladie de Kennedy, confirmée par un test ADN, qui ont subi 13 anesthésies générales. La succinylcholine a été utilisée chez deux patients, et les bloqueurs neuromusculaires non dépolarisants dans sept cas; aucun effet secondaire n’a été observé. Bien que le laryngospasme n’ait été identifié chez aucun patient, un patient souffrant d’un stade avancé de la maladie a manifesté un œdème glottique, une détresse respiratoire se détériorant, un dysfonctionnement bulbaire, et a nécessité une trachéotomie et un soutien respiratoire prolongé. Un patient a manifesté un pneumothorax.ConclusionLa possibilité de survenue d’un dysfonctionnement bulbaire et de faiblesse musculaire chez les patients souffrant de la maladie de Kennedy constitue un risque pour ces patients de subir des complications périopératoires liées à l’anesthésie. Les prestataires d’anesthésie devraient être au fait quant aux différents facteurs de risque anesthésique potentiels pour ces patients.

Ultrasound‐Guided Posterior Femoral Cutaneous Nerve Block: A Cadaveric Study

To identify any anatomic barriers to local anesthetic spread between the sciatic nerve (SN) and the posterior femoral cutaneous nerve (PFCN) at the level of the infragluteal crease and to describe a potential technique for an ultrasound (US)‐guided subgluteal PFCN block in a cadaveric model.

Interspace between Popliteal Artery and posterior Capsule of the Knee (IPACK) Injectate Spread: A Cadaver Study

Local anesthetic injection into the interspace between the popliteal artery and the posterior capsule of the knee (IPACK) has the potential to provide motor‐sparing analgesia to the posterior knee after total knee arthroplasty. The primary objective of this cadaveric study was to evaluate injectate spread to relevant anatomic structures with IPACK injection.

Infraclavicular versus axillary nerve catheters: A retrospective comparison of early catheter failure rate

STUDY OBJECTIVES Continuous brachial plexus catheters are often used to decrease pain following elbow surgery. This investigation aimed to assess the rate of early failure of infraclavicular (IC) and axillary (AX) nerve catheters following elbow surgery. DESIGN Retrospective study. SETTING Postoperative recovery unit and inpatient hospital floor. PATIENTS 328 patients who received IC or AX nerve catheters and underwent elbow surgery were identified by retrospective query of our institutions database. MEASUREMENTS Data collected included unplanned catheter dislodgement, catheter replacement rate, postoperative pain scores, and opioid administration on postoperative day 1. Catheter failure was defined as unplanned dislodging within 24 h of placement or requirement for catheter replacement and evaluated using a covariate adjusted model. MAIN RESULTS 119 IC catheters and 209 AX catheters were evaluated. There were 8 (6.7%) failed IC catheters versus 13 (6.2%) failed AX catheters. After adjusting for age, BMI, and gender there was no difference in catheter failure rate between IC and AX nerve catheters (p = 0.449). CONCLUSIONS These results suggest that IC and AX nerve catheters do not differ in the rate of early catheter failure, despite differences in anatomic location and catheter placement techniques. Both techniques provided effective postoperative analgesia with median pain scores < 3/10 for patients following elbow surgery. Reasons other than rate of early catheter failure should dictate which approach is performed.

Intrathecal Hydromorphone and Morphine for Postcesarean Delivery Analgesia: Determination of the ED90 Using a Sequential Allocation Biased-Coin Method

690 www.anesthesia-analgesia.org September 2016 • Volume 123 • Number 3 Copyright

Infection in Association with Local and Regional Anesthesia

Infections associated with regional anesthesia may be more prevalent than previously thought and are associated with various risk factors. In general, central neuraxial block should not be performed in patients with untreated systemic infection except in the most extraordinary circumstances. Strict adherence to aseptic technique, including masks and gloves, skin disinfection, and maintaining sterility of equipment, is critical to avoid infection and colonization of potentially harmful bacteria. Epidural abscess is most likely to occur in immunocompromised patients with prolonged durations of epidural catheterization, with the most common causative organism being S. aureus. In contrast, meningitis following neuraxial blockade occurs more frequently in healthy individuals who have undergone uneventful spinal anesthesia. In general, neuraxial blocks in patients with preexisting viral disease (herpes, HIV) or who are immunocompromised are safe; however, the usual precautions and safety measures are still recommended. The patient care team must be vigilant of any signs or symptoms of infection so that the source can be identified and treatment be initiated as early as possible.