Antoinette Van Meter

A multi-institutional pilot survey of anesthesia practices during proton radiation therapy

BACKGROUND AND PURPOSE Physicians responsible for anesthesia and/or sedation (A/S) at emerging proton radiation therapy centers (PTCs) seek information about practices at established centers. We conducted a survey of A/S practices at established PTCs to provide this information for physicians at new PTCs. METHODS AND MATERIALS A web-based survey was sent to physicians responsible for A/S at 37 established PTCs. Questions were based on practice patterns and the preferred method of A/S delivery during proton-radiation therapy. One representative per institution was surveyed. RESULTS A response rate of 38%, with a combined case load of more than 15,000 anesthetics per year was obtained. Children younger than 4 years old often (72%) required A/S. The most favored A/S techniques involved total intravenous anesthesia with propofol and an unprotected airway (57%) or general anesthesia with sevoflurane and a laryngeal mask airway (36%). It was notable that 21% of facilities did not have dedicated recovery rooms. Also, anesthesia gas evacuation outlets were absent at 43% of treatment rooms. CONCLUSIONS A/S is commonly delivered to patients undergoing proton radiation therapy, most often with total intravenous anesthesia. To avert potential obstacles to the safe delivery of care, anesthesiologists at emerging centers are encouraged to participate throughout the design and planning phases of new PTCs.

Unanticipated Compression of the Trachea in a 5-Month-Old Undergoing an MRI for Evaluation of Neurofibromatosis

Neurofibromatosis type 1 is an autosomal-dominant disorder with the tendency toward the formation of tumors. Plexiform neurofibromas are the most common type of tumors seen in neurofibromatosis type 1. Approximately 50% occur in the head and neck region with a 5% incidence of airway involvement. We describe the case of a 5 month old with a plexiform neurofibroma of the neck who developed complete airway obstruction on induction of anesthesia. Magnetic resonance imaging revealed a skull base neurofibroma extending to the hypopharynx and resulting in deviation of the airway. Because of the possibility of airway involvement, a careful preanesthetic evaluation as well as a slow induction with the maintenance of spontaneous ventilation should be considered in patients presenting with facial neurofibromas.

Perioperative Severe Hypotension in a Patient with Multiple Endocrine Neoplasia Type IIb and Bilateral Adrenalectomies: Time to Review the Evidence for Stress Dose Steroids

Multiple endocrine neoplasia type IIb (MEN IIb) is an endocrine disorder which can manifest with tumors such as pheochromocytomas and neuromas. We present the case of a patient with MEN IIb, after bilateral adrenalectomies, on maintenance steroid replacement, who underwent a neuroma resection and developed severe hypotension. There is persistent controversy regarding the general administration of perioperative “stress dose” steroids for patients with adrenal insufficiency. While the most recent literature suggests that stress dose steroids are unnecessary for secondary adrenal insufficiency, the rarer form of primary adrenal insufficiency always requires supplemental steroids, specifically hydrocortisone, when undergoing surgical procedures.

Perioperative factors associated with persistent opioid use after extensive abdominal surgery in children and adolescents: A retrospective cohort study

In adults, preoperative opioid use and higher perioperative opioid consumption have been associated with higher odds of persistent opioid use after surgery. There are limited data on the prevalence and factors associated with persistent opioid use after major oncologic surgery in children.

An analysis of the survival impact of dexmedetomidine in children undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Abstract Objective: Recent evidence suggests the α2-adrenoreceptor agonist dexmedetomidine may promote metastasis of cancer cells. In this study we sought to evaluate the impact of dexmedetomidine administration on the survival of children and adolescents with cancer. Design: Retrospective chart review. Setting: Comprehensive cancer center. Patients: Children and adolescents who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis. Intervention: Intraoperative and/or early postoperative (within 24 hours of surgery) administration of dexmedetomidine. Measurements: Multivariable cox proportional hazard models were used to assess the association between dexmedetomidine administration and progression free survival (PFS) or overall survival (OS). Main results: Ninety-three patients were identified. The median age was 12 years, 42% were female, and 35% received dexmedetomidine. There were no significant differences between the baseline and perioperative characteristics of patients who received dexmedetomidine and those who did not. In the multivariable analysis, the administration of dexmedetomidine was not associated with PFS (HR = 1.20, 95% CI [0.60–2.41], p = .606) or OS (HR = 0.81, 95% CI [0.35–1.85], p = .611). Conclusion: In this retrospective study of children and adolescents who had undergone a major oncologic surgery, the intraoperative and/or early postoperative administration of dexmedetomidine was not associated with survival.

Identification of risk factors associated with postoperative acute kidney injury after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a retrospective study

Abstract Background: Acute kidney injury (AKI) is a postoperative complication associated with significant morbidity and mortality. The incidence and risks factors for AKI after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been fully studied. The purpose of this study was to identify perioperative risk factors predictive of AKI after CRS-HIPEC. Methods: This retrospective study collected demographic, tumour-related, intraoperative and postoperative data from 475 patients who underwent CRS-HIPECs. AKI was defined using the acute kidney injury network criteria and calculated on postoperative days 1, 2, 3, 7 and day of hospital discharge. We conducted univariate and multivariate analyses to assess the association between variables of interest and AKI. A p value of <0.05 was considered statistically significant. Results: The incidence of AKI was 21.3%. The multivariate analysis identified six predictor factors independently associated with the development of AKI (OR: [95%CI]); age: 1.16 (1.05–1.29, p < 0.005), BMI (overweight: 1.97 [1.00–3.88], p = 0.05) and obesity: 2.88 (1.47–5.63), p < 0.002)), preoperative pregabalin: 3.04 (1.71–5.39, p < 0.037), platinum-based infusion: 3.04 (1.71–5.39, p < 0.001) and EBL: 1.77 (1.27–2.47, p < 0.001). Splenectomy had a protective effect (OR: 0.44 (0.25–0.76, p < 0.003). Conclusions: Our study demonstrates that the incidence of AKI is high. While other studies have reported that AKI is associated with platinum-based infusion, age and obesity, we report for the first time a negative association between pregabalin use and AKI. More studies are needed to confirm our results.

Assessing the survival impact of perioperative opioid consumption in children and adolescents undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Several studies in adult patients have suggested an unfavorable association between opioid consumption and cancer progression.

Portal Catheter Fracture in a Pediatric Patient

Portal Catheter Fracture in a Pediatric Patient Antoinette Van Meter;Acsa Zavala;Uduak Williams;Pascal Owusu-Agyemang; Anesthesiology

Beat to Beat: A Measured Look at the History of Pulse Oximetry

It can be argued that pulse oximetry is the most important technological advancement ever made in monitoring the well-being and safety of patients undergoing anesthesia. Before its development, the physical appearance of the patient and blood gas analysis were the only methods of assessing hypoxemia in patients. The disadvantages of blood gas analysis are that it is not without pain, complications, and most importantly does not provide continuous, real-time data. Although it has become de rigueur to use pulse oximetry for every anesthetic, the road leading to pulse oximetry began long ago.

Opioid Use and Sleep Apnea Should Be Considered When Evaluating Postanesthesia Care Unit Desaturations Seen after Intraoperative Use of 100% Oxygen

Addressing the correspondents’ second concern, we did not assess the integrity of fracture healing in the mice exposed to anti-HMGB1; the choice of that reagent was to probe the mechanism involved in initiating the innate immune response to surgery. Were we to advocate the use of anti-HMGB1 as a treatment we agree that it would be necessary to assess fracture healing as well as other chromatin actions. We hope that our rebuttal has allayed the correspondents’ remaining concerns about our study.