Alan Jay Schwartz

Monitoring Heparin Anticoagulation and Its Neutralization

Heparin anticoagulation and its neutralization were monitored by three different techniques: a manual protamine titration, an automated activated coagulation time, and an automated protamine titration. All three techniques provided satisfactory information. The decision of which to use must be based on other considerations such as available manpower and cost of equipment. The effect of using the automated protamine titration test on heparin and protamine requirements, and on blood loss measured intraoperatively after bypass and in overnight chest bottle drainage in two groups of comparable patients undergoing coronary artery bypass operation was studied. The heparin requirements were similar (24,420 +/- 584 units, control group; 23,550 +/- 849 units, treatment group), but the protamine requirements were markedly different (429 +/- 14.7 mg, control; 258 +/- 10.4 mg, treatment; p < 0.05). There was no statistical difference in intraoperative blood loss or overnight chest bottle drainage.

Working to define professionalism in pediatric anesthesiology: a qualitative study of domains of the expert pediatric anesthesiologist as valued by interdisciplinary stakeholders.

Unprofessional behavior is a significant problem throughout graduate medical education programs and medical centers. Some authors have suggested that professionalism curricula should be focused toward faculty, not trainees, to interrupt the modeling of unprofessionalism. Developing such curricula requires a needs assessment and is challenging given data indicating that the definition of professionalism varies based on medical specialty. Thus, a specialty‐specific definition of professionalism is needed as a first step in any curriculum development.

From simulation to separation surgery: a tale of two twins.

110 January 2014 T days prior to the planned separation of 8-month-old, thoraco-omphalopagus female twins, a 2-h full-environment simulation of the separation surgery was performed. The simulation consisted of a lifelike manikin of the twins with color-coded tubing, equipment, and monitors (fig., “Simulation”), and all of the personnel who were to participate in the separation: nursing, anesthesiology, general surgery, and plastic surgery. The teams had consistently taken care of the twins during their multiple prior procedures (e.g., imaging studies and tissue expander placement). The promulgated simulation ground rules included treating the simulated patients and environment as real, maintaining professionalism, and—of considerable benefit— minimizing unnecessary conversations. Anesthetic preparation and the 8-h surgical procedure proceeded without complications, delays, or the need for additional personnel (fig., “Actual”). The entire simulation team was present and the solutions that were rehearsed during simulation were implemented. For example, the team had spent considerable time solving the challenge of maintaining sterility while transferring one twin immediately postseparation to a second table in the operating room; this task was performed smoothly on the day of surgery. Simulation had also revealed unanticipated issues, such as determining the optimal position of the twins to maintain a sufficient interface between the twins’ body surfaces and the gel grounding pad system. While conjoined twin separation surgery is both extremely complex and exceedingly rare,1 simulation offers a variety of logistics in how to prepare surgically and to accomplish the myriad steps that nursing, surgical, and anesthesia personnel must perform. Teamwork principles (e.g., leadership and communication) can be practiced and enhanced by the use of simulation to ensure the optimization of team synergy and to ensure safe, effective patient care.2,3

Stay, give me your paw. The benefits of family-centered care

The value of family-centered care in general and subspecialty pediatrics has been well documented in the literature. Translation of these principles into perioperative medicine has its logistical challenges; however, there are theoretical benefits. Specifically, pediatric patients with psychiatric diagnoses or special needs related to autism benefit from the incorporation of service animals into their daily routines. We describe the presence of one such service dog, at the request of our patient, during induction of general anesthesia. Consideration of the service dog as part of our family-centered care model improved the quality of care we provided this anxious teenager and her mother.

Rupture of pressurized plastic bags.

To the Editor: Ready’s suggestion’ that a pressure-compensating automatic tourniquet be used to aid in the rapid intravenous infusion of large volumes of intravenous fluids and blood is an excellent example of adapting a mechanical device for a different laborsaving purpose. Others2 have modified the standard wall oxygen pressure line for the same purpose. The figure which accompanies Ready’s article prompts this cautionary note. In Ready’s figure the bag of fluid is bulging out over the top of the external pressure bag. We have experienced one occasion where the bulging seam of the plastic bag containing heparin solution split, resulting in a shower of solution on the operating field, the anesthesia machine, and the adjacent personnel. of an external pressure bag designed to hold a 500-ml bag of blood or solution will invariably result in such a bulge when a 1000-ml bag of solution is placed within it. Second, even when the correct-sized bags are used, care must be taken to ensure that the top of the external pressure bag securely covers the top of the solution bag. In the accompanying figure the correct-sized bags were used. However, the bag on the right was deliberately misapplied to illustrate this possibility.

A hazard of the Intraflo continuous flush system.

Patency of pressure sensing systems can be provided by the Intraflow Continuous Flush System (Sorenson Research Company, Salt Lake City, UT 84115). This device allows continuous flow of flush solution through a regulatory valve while preventing transmission of the high pressure of the flush solution. The case presented describes the recognition of a false elevation of a monitored pressure secondary to the malfunction of the Intraflo regulatory valve. Elimination of the flush solution high pressure during monitoring prevents inappropriate data collection.

Ultrasound-guided Vascular Access: Visualizing the Tip of the Needle.

<zdoi;10.1097/ALN.0000000000001049> Anesthesiology, V 125 • No 2 396 August 2016 U ltrasound (us) devices are widely used to visualize the anatomy for peripheral venous, central venous, and arterial vascular access procedures.1–3 optimizing the ultrasound image of the needle and its relation to the targeted vascular structure is critical to improve chances of success. It is important to identify the tip of the needle and distinguish it from the bevel. The images demonstrate crosssectional or transverse ultrasound visualization of the needle tip (fig. E) and bevel (fig. F) located within the vein of a child (fig. d). It is possible to differentiate the tip of the needle (white dot in red circle; fig. B and E) from the bevel or needle shaft (larger, irregular white structure; fig. C and F). When the ultrasound beam intersects the tip of the needle, only a small fraction of the beam reflects back to the probe (fig. G). The tip of the needle can be identified as a small, mildly hyperechoic structure (fig. E). In contrast, the bevel has a concave surface, and it reflects a larger portion of the ultrasound beam, resulting in scatter and increased ultrasound signal received by the transducer (fig. H).2,4 The bevel appears as a bright, irregular hyperechoic structure (fig. F). When the bevel or shaft is identified, scanning proximally in small increments will allow visualization of the actual needle tip (fig. E). Confirmation of tip visualization can be accomplished by scanning beyond the tip until it disappears (fig. a and d).2 The ultrasound-guided needle tip visualization technique can be replicated in most accessible vascular structures.4

Transient and reproducible loss of motor-evoked potential signals after intravenous levetiracetam in a child undergoing craniotomy for resection of astrocytoma

Transcranial electrical motor-evoked potential (tceMEP) monitoring is used in complex intracranial and spinal surgeries to detect and prevent neurological injury. We present a case of transient, reproducible loss of tceMEPs after an infusion of levetiracetam during craniotomy and tumor resection in a child. Cessation of the infusion resulted in restoration of baseline tceMEPs. When the infusion was resumed at the end of the procedure, a similar decrease in tceMEPs was seen as before, after the infusion was stopped. The surgery and postoperative course proceeded without incident, and the patient experienced a full recovery.

Cephalad migration of pediatric caudal epidural catheters associated with change from prone to supine position.

1353 December 2012 R ADIOPAQUE epidural catheters are inserted at a caudal location and threaded cephalad with the patient in the lateral decubitus or prone position. Each catheter tip location is confirmed via fluoroscopy or epidurogram1 and then the catheter is secured with sterile dressing and Dermabond® (Ethicon Inc., Somerville, NJ).2 We recently found radiographic evidence of cephalad migration of a caudal epidural catheter tip in a pediatric patient after a position change, despite unchanged catheter skin depth. The figure shows the catheter tip in a patient in the prone (fig. A, T6 level, at insertion in the operating room) and supine (fig. B, T2/T3 level, 60 min postinsertion in the neonatal intensive care unit) positions. Proper catheter tip position had been confirmed in the prone position using fluoroscopy. Although the catheter remained secured at its initial skin depth in the caudal region, postoperative supine radiographs showed the catheter tip had migrated cephalad to the T2/T3 level. Cephalad migration not only resulted in the catheter providing inadequate analgesia, but also increased the risk of undesirable side effects (e.g., cardiac accelerator fiber blockade). The catheter was withdrawn and provided good postoperative analgesia after its tip was reconfirmed at the desired level in the supine position. Based on this finding, we now confirm the locations of caudally threaded epidural catheters with the patient in the supine position.

The fetus as patient.

A 19-WEEK PARTURIENT presented with a fetus with a lung mass. Magnetic resonance imaging (panel A) demonstrated a congenital cystic adenomatous malformation (CCAM) occupying the right chest causing mediastinal shift, cardiac compression (H heart), and displacement of the hemidiaphragm (arrow). Both lungs were compressed. Hydrops fetalis was present (A fetal ascites; B bowel; L liver). Echocardiography revealed a compressed but structurally normal heart. The hydrops improved after aspiration, but the macrocyst recurred and the solid component continued to enlarge. A thoracoamniotic shunt was placed for continuous drainage. Imaging at 36 weeks (panel B) demonstrates the right hemidiaphragm in the correct position and resolution of the fetal ascites. Lung hypoplasia and mediastinal shift necessitated mass resection during ex utero intrapartum therapy. A maternal laparotomy was performed, followed by hysterotomy allowing delivery of the fetal head, chest, and arm. High-dose volatile anesthetic (2 minimum alveolar concentration of desflurane) provided uterine relaxation and fetal anesthesia. Maternal blood pressure was maintained with phenylephrine. Intramuscular fetal injections included fentanyl (20 g/kg), vecuronium (200 g/kg), and atropine (20 g/kg). The fetus was intubated (not ventilated), and pulse oximeter and peripheral venous access were established. After pulmonary lobectomy, the fetus was ventilated and delivery and newborn resuscitation were completed. Congenital cystic adenomatous malformation results from overgrowth of terminal bronchial epithelium. Mass effect results in pulmonary hypoplasia. Cardiac compression with impaired venous return leads to lethal cardiac failure (hydrops). Maternal health is threatened, asa state similar topreeclampsia (maternalmirror syndrome)mayensue. Exutero intrapartumtherapyprocedure isa feasibleandpotentially a life-saving treatment for congenital cystic adenomatous malformation. It provides time on uteroplacental gas exchange for controlled resection of the large fetal lung mass. The anesthetic goals for ex utero intrapartum therapy procedure include achieving uterine hypotonia, usingdeepgeneralanesthesiaornitroglycerin, tomaintainuteroplacentalcirculation;avoidingpostpartumhemorrhage;maintainingnormal maternal blood pressure often requiring -adrenergic agonist support; and achieving surgical anesthesia for the fetus to avoid first breathing while avoiding fetal cardiac depression.