Brian Kaufman

The Use of Dexmedetomidine Infusion for Awake Craniotomy

Anesthesia for intracranial procedures requiring patient cooperation presents a challenge to the anesthesiologist. Drugs administered during the procedure should provide an adequate level of sedation and analgesia for bone flap removal, but must not interfere with functional testing and electrocorticography. In this case report, we describe the use of dexmedetomidine in combination with nitrous oxide and sevoflurane for bone flap removal and dexmedetomidine alone for brain mapping of the cortical speech area. Dexmedetomidine is a highly specific a2adrenoreceptor agonist with sedative, analgesic, and anesthetic-sparing effects (1,2). It does not suppress ventilation. Small-dose infusion of this drug in healthy volunteers provided sedation that could be easily reversed with verbal stimuli (3). We anticipated that the patient treated with dexmedetomidine would be sedated and comfortable but easily arousable to tolerate a prolonged awake craniotomy.

Dexmedetomidine facilitates the withdrawal of ventilatory support in palliative care

WITHDRAWAL of ventilatory support in the setting of a terminal illness presents the challenge to the physician of maintaining the comfort of the patient and optimizing sedation and analgesia for the time that the patient has remaining to be with his or her family and friends. Opiates and benzodiazepines are most commonly used for terminal palliation, but this combination of medications has the disadvantage of depressing ventilatory drive and airway reflexes to the degree that it may hasten the patients death. This problem has been discussed in medical and legal literature invoking the medieval theological concept of the rule of double effect to assist physicians who are faced with the need to make the distinction between euthanasia and appropriate symptom relief in the terminally ill. 1,2 Dexmedetomidine (Abbott Laboratories, Abbott Park, IL), with its highly selective α 2 agonism, provides physicians with another pharmacologic treatment option that addresses many of the possible sources of end-of life distress, 3 with less of a problem with the double effect. We report on the care of a patient where provision of palliative care and withdrawal of ventilatory support was optimized by the use of a dexmedetomidine infusion.

Goal-directed transthoracic echocardiography during advanced cardiac life support: A pilot study using simulation to assess ability

Introduction Goal-directed echocardiography (GDE) is used to answer specific clinical questions that provide invaluable information to physicians managing a hemodynamically unstable patient. We studied perception and ability of house staff previously trained in GDE to accurately diagnose common causes of cardiac arrest during simulated advanced cardiac life support (ACLS); we compared their results with those of expert echocardiographers. Methods Eleven pulmonary and critical care medicine fellows, 7 emergency medicine residents, and 5 cardiologists board certified in echocardiography were enrolled. Baseline ability to acquire 4 transthoracic echocardiography views was assessed, and participants were exposed to 6 simulated cardiac arrests and were asked to perform a GDE during ACLS. House staff performance was compared with the performance of 5 expert echocardiographers. Results Average baseline and scenario views by house staff were of good or excellent quality 89% and 83% of the time, respectively. Expert average baseline and scenario views were always of good or excellent quality. House staff and experts made the correct diagnosis in 68% and 77% of cases, respectively. On average, participants required 1.5 pulse checks to make the correct diagnosis. Of house staff, 94% perceived this study as an accurate assessment of ability. Conclusions In an ACLS-compliant manner, house staff are capable of diagnosing management-altering pathologies the majority of the time, and they reach similar diagnostic conclusions in the same amount of time as expert echocardiographers in a simulated cardiac arrest scenario.

Blood Lactate Measurement in the ICU: Is It Still Useful After All These Years?

Address correspondence to Dr Kaufman, New York University Medical Center, Department of Anesthesiology, 550 First Ave., New York. h?’ 10016. Determination of blood lactate levels became useful as a clinical tool to assist in the evaluation and management of the critically ill patient when rapid, easy, accurate, and inexpensive analytic techniques were developed that allowed for its measurement. Subsequent studies demonstrated the prognostic capabilities of initial, peak, and serial blood lactate determinations in critically ill patients with and without clinical signs of acute circulatory failure

Anesthetic care of a patient with an intracranial hemorrhage after thrombolytic therapy

Thrombolytic therapy is being used with increasing frequency to treat acute myocardial infarction (MI). It is important for both the general and cardiac anesthesiologist to understand the effects of thrombolysis on hemostasis and myocardial function, since these patients can present for emergent surgery in the cardiac or general operating theater. The authors report a case of a patient who developed an intracranial hemorrhage following thrombolytic therapy that required emergency surgical intervention.

Acute Respiratory Distress Syndrome: Potential Pharmacologic Interventions

The mortality of the acute respiratory distress syndrome (ARDS) remains high despite advances in supportive care of ARDS and in the understanding of the pathogenesis. Numerous inflammatory mediators including reactive oxygen species, arachidonic acid metabolites, and growth factors, are present in the circulation of patients with or at risk for developing this syndrome and play a key pathophysiologic role in the development of lung injury. Pharmacologic therapy is being evaluated to: 1) support the failing lung by improving gas exchange; 2) interrupt the mediator-induced mechanisms of inflammation and injury. Although none of these experimental therapies has yet been proven to improve survival in well conducted prospective, randomized, double-blind, controlled clinical trials, many have demonstrated improvement in physiologic function. These results have helped lay the groundwork for future advances in this field.

PACU AND ICU CARE: Evaluation and Management of Postoperative Cardiovascular Complications

The dynamic physiologic changes that occur in the early postoperative period place the cardiac patient at increased risk for a variety of cardiovascular complications. The limitations in cardiac reserve in patients with cardiac disease also increase the clinical significance of any postoperative problems. For example, the development of hypertension is usually well tolerated in healthy patients, but may precipitate congestive heart failure (CHF), myocardial ischemia, or arrhythmias in the patient with underlying cardiac pathology. The anesthesiologists responsibility to the patient with heart disease extends to the post-anesthesia care unit (PACU) and intensive care unit (ICU). Appropriate perioperative management can lower the incidence of potentially life-threatening postoperative problems. This article discusses three common postoperative complications (myocardial ischemia/infarction, hypertension, arrhythmias) that occur with increased frequency in patients with cardiac disease. Understanding the mechanisms of their development, their physiologic impact, and available treatment options should lead to optimal postoperative care of the cardiac patient undergoing noncardiac surgery.