Alexander Ioscovich

Images in anesthesia: transesophageal echocardiography during cesarean section in a marfan’s patient with aortic dissection

with Marfan’s syndrome presented to the emergency room with chest, back, and epigastric pain. Echocardiography three months earlier had shown mild aortic dilatation (37 mm) and mitral valve prolapse. Both transesophageal echocardiography (TEE) and computer tomography confirmed aortic dissection from the take-off of the left subclavian artery that extended past the bifurcation and to the iliac arteries. The patient was hospitalized in the intensive care unit (ICU) near the cardiothoracic surgery department for invasive monitoring that confirmed acute (Stanford) type B aortic dissection.1 Antihypertensive, sedative, and steroid therapy were administered immediately. Three days later, because of exacerbation of pain, the patient was scheduled for Cesarean section with preparation for aortic replacement in case of expansion of the dissection into the aortic arch or other unexpected and untoward complications. General anesthesia was induced with fentanyl, propofol, and rocuronium to minimize cardiovascular response to tracheal intubation, and the TEE probe was immediately positioned to monitor the condition of the dissection (video available at www.cja-jca.org). The patient remained hemodynamically stable throughout delivery and was returned to the ICU for continuous conservative treatment. Two weeks later she was discharged in good health. The baby suffered from bilateral hydronephrosis (no genetic information available to date) and mild aortic arch abnormalities compatible with Marfan’s syndrome. In the past, women with Marfan’s syndrome were counseled to avoid the risk of pregnancy and delivery. Today, with improved means of identifying patients that facilitate better care, increased longevity, and improved quality of life, more women with Marfan’s syndrome are attempting to have babies, despite the high risk of aortic dissection even in the absence of aortic root dilatation prior to pregnancy. For this reason, intraoperative TEE observation ensures an extra measure of real-time control during Cesarean section, particularly in case of acute or chronic aortic dissection, and risk factors such as aortic diameter

Epidural analgesia and severe perineal tears: a literature review and large cohort study

40 OBSTETRICAL AND PEDIATRIC ANESTHESIA 737

Congenital diaphragmatic hernia: review of the literature in reflection of unresolved dilemmas

Abstract Objective: Our objectives were to study the association between epidural analgesia and risk of severe perineal tears (SPT), and identify additional risk factors for SPT. Methods: We conducted a historical cohort study of women with term delivery between 2006 and 2011. Inclusion criteria were an uncomplicated singleton pregnancy, cephalic presentation and vaginal delivery. Multivariate logistic regression models were constructed to study the association between epidural analgesia and SPT, controlling for potential confounders. Additional models studied the association between prolonged second stage and instrumental labor and SPT. Results: During the study period, 61 308 eligible women gave birth, 31 631 (51.6%) of whom received epidural analgesia. SPT occurred in 0.3% of births. Deliveries with epidural had significantly higher rates of primiparity, induction and augmentation of labor, prolonged second stage of labor, instrumental births and midline episiotomies. The univariate analysis showed a significant association between the use of epidural and SPT (OR: 1.78, 95% CI: 1.34–2.36); however, this association disappeared when parity was introduced (OR: 0.95, 95% CI: 0.69–1.29). Instrumental deliveries and prolonged second stage of labor were both strongly associated with SPT (ORs of 1.82 and 1.77) Conclusions: Epidural analgesia was not associated with SPT once confounding factors were controlled for.

Israeli survey of anesthesia practice related to placenta previa and accreta

Background:  Congenital diaphragmatic hernia (CDH) is a rare but clinically and scientifically challenging condition. The introduction of ultrasound has enabled early prenatal detection and consequently, hope of early therapeutic intervention.

Anesthetic management of a patient with cleidocranial dysplasia undergoing various obstetric procedures

Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units.

Remifentanil-nitroglycerin combination as an anesthetic support for ex utero intrapartum treatment (EXIT) procedure

Patients with cleidocranial dysplasia, a rare autosomal dominant genetic syndrome, possess abnormal anatomical features of the head, mouth, neck and spinal column. These features may result in perioperative problems such as difficult airway and complicated regional anesthesia. We report the anesthetic management of a young woman with cleidocranial dysplasia undergoing four caesarean sections, one vaginal delivery and a dilatation and curettage, employing different modes of anesthesia. Anesthetic management in this disorder presents challenges for both general and neuraxial anesthesia.

Hip arthroplasty in patients with Gaucher disease.

A 21 year old healthy parturient was diagnosed as having a fetus with micrognathia. She was scheduled for an ex-utero intrapartum treatment (EXIT) procedure. General anesthesia consisted of remifentanil, nitrous oxide, and midazolam. Intravenous nitroglycerin was used for uterine relaxation. This technique offered hemodynamic stability and provided uterine relaxation that may be rapidly terminated. For the fetus, it provided excellent transplacental anesthesia. Supplemental direct fetal anesthesia is recommended to prevent the rapid decline of analgesia/anesthesia that occurs after placental separation.

Downgrading of high-grade vesicoureteral reflux is a reliable option in the treatment of children with grade IV‒V reflux accompanied by breakthrough infections

Patients with Gaucher disease suffering from the consequences of femoral head osteonecrosis deserve a treatment modality that will eliminate pain, preserve ambulation and hopefully will endure long enough to allow satisfactory daily life. Total hip arthroplasty fulfills these 3 objectives. The rate of complications during anesthesia and during surgical procedure is comparable to otherwise healthy population if the Gaucher patients are carefully evaluated pre-surgery and prepared by a medical team familiar with all aspects of the disease. With prompt preparation, meticulous procedure, and careful post-operative care, patients with Gaucher disease may benefit from long-lasting hip prostheses. It is to be hoped that newer types of implants would allow longer revision-free periods even in this young patient population who have developed avascular necrosis, and a greater hope for patients with Gaucher disease would be that early administration of bone-specific therapies may prevent osteonecrosis.

Thromboelastography as a Surrogate Marker of Perisurgical Hemostasis in Gaucher Disease.

PURPOSE To evaluate incidence of urinary tract infection (UTI) and natural history of downgraded vesicoureteral reflux (VUR) in children with high-grade VUR following endoscopic correction. MATERIALS AND METHODS We retrospectively studied 54 children (13 males and 41 females) with a mean age of 1.8 years who underwent endoscopic correction of Grade IV‒V VUR due to breakthrough infections while on antibiotic prophylaxis. Reflux was Grade IV in 40 (74%) and V in 14 (26%) patients comprising 95 renal refluxing units (RRU). Reflux was corrected in 72 (76%) RRU. 18 (34%) patients/23 (24%) RRU demonstrated downgrading of VUR. 21 of the 23 RRU showed Grade II and 2 Grade III VUR, and were taken off antibiotic prophylaxis and allocated to observation. Patients were followed for 2-22 years (median 14 years). RESULTS Technetium 99m dimercaptosuccinic acid renal scan demonstrated preoperative renal scarring in 21 (78%) of the 23 RRU with downgraded VUR. None of the children developed febrile UTI after surgery. 1 RRU showed renal function deterioration. 8 (44%) of the 18 patients underwent follow-up voiding cystourethrogram, and in 7 (88%) there was either spontaneous resolution of VUR or downgrade to Grade I VUR. CONCLUSIONS Downgrading of VUR is a reasonable option in patients with high-grade VUR suffering from breakthrough infections while on antibiotic prophylaxis. It leads to the cessation of febrile UTIs, further spontaneous resolution of VUR and may potentially avoid renal damage.

Prolonged propriospinal myoclonus following spinal anesthesia for cesarean section: case report and literature review.

Thromboelastography (TEG) has long been available for routine monitoring of perisurgical and postpartum hemostasis, especially at point of care. The purpose of this study is to retrospectively compare TEG parameters to concomitant standard clotting test results in an unselected cohort of patients with Gaucher disease to ascertain whether TEG values are specific and sensitive enough to substitute for classic coagulation tests for decision making. This remains a cogent concern because of high incidence of thrombocytopenia in patients with Gaucher disease. Thromboelastography values were compared to concomitant platelet counts, partial thromboplastin time, international normalization ratio, and plasma fibrinogen. Demographic characteristics were collected from patients’ files. There were 22 patients with Gaucher disease (2 children; 12.5%) for whom there were 24 TEG results at the same time as classic coagulation test results and 30% performed platelet function tests. The current study shows linear and/or monotonic relationships between platelet counts and several TEG values that were significant over a range of platelet counts including severe thrombocytopenia. The fibrinogen component, correlating only with the rate of clot lysis, played a lesser role. Based on these preliminary results albeit in a small cohort with only 1 case of hemorrhage, there is putative support for the intention to treat patients with Gaucher disease based on TEG results using the same TEG protocol as for other patients undergoing comparable procedures in our institution.