David M. Corda

A unique approach to postoperative analgesia for ambulatory surgery

Postoperative analgesia for the ambulatory surgery patient is frequently inadequate. Continuous regional analgesia improves outcome and patient satisfaction in hospitalized patients. This paper describes the successful use of continuous regional analgesia following orthopedic surgery in the ambulatory setting.

Myocardial ischemia detected by transesophageal echocardiography in a patient undergoing peripheral vascular surgery.

Prevention and early treatment of myocardial ischemia remain among the primary goals of the anesthesiologist taking care of high-risk patients, such as those undergoing vascular surgery. Guidelines have been published to assist in directing preoperative evaluation and optimization of cardiovascular status. Although perioperative monitoring allows early detection of ischemic events, all monitors have limitations that must be understood before they can be used effectively. We present a case of severe intraoperative myocardial dysfunction detected only by transesophageal echocardiography in a patient undergoing a peripheral vascular procedure. Preoperative and intraoperative management is also discussed.

A potential hazard involving the gas sampling line and the adjustable pressure limiting valve on the Drager Apollo Anesthesia Workstation.

To the Editor A 37-year-old ASA class I patient presented for an inguinal hernia repair. A Drager Fabius GS Premium anesthesia machine was used, and the machine was checked immediately before the case. No leaks were present in the circuit. After induction of anesthesia and insertion of a laryngeal mask airway, manual ventilation resulted in a tidal volume of only 100 mL because of a leak in the circuit. The patient quickly resumed spontaneous ventilation, and there was no change is Spo2 throughout the case. The circuit was changed and the CO2 canister was checked, but the leak persisted and we noticed that the capnograph sampling line had become lodged under the adjustable pressure limiting valve, preventing it from closing (Figs. 1 and 2). As soon as the sampling line was removed, the leak resolved. Because the sampling line was lodged under the part of the valve that was toward the back of the anesthesia machine, it was not immediately visualized. It appears that the sampling line became lodged under the adjustable pressure limiting valve, because it was adjusted during mask ventilation of the patient and before insertion of the laryngeal mask airway. A similar event with the Drager Fabius machine was reported in 2007. Stephen Hennenfent, MD Barry Suslowicz, MBA, BSc, CBET Palos Community Hospital Palos Heights, Illinois Scapstone@aol.com

Anesthesia in a patient with dyskeratosis congenita presenting for urgent subtotal gastrectomy

Dyskeratosis congenita is a rare and complex congenital disease that may complicate surgical treatment and impact anesthetic care. We present the perioperative management of a patient with severe pancytopenia, respiratory dysfunction, and oral leukoplakia who presented for urgent surgery for removal of a gastric hemorrhagic malignant tumor. Important issues in the management of this patient include choice of anesthetic technique, correction of pancytopenia (thrombocytopenia in particular), judicious perioperative fluid management to avoid dilutional coagulopathy, antibiotic prophylaxis, and strict aseptic technique. Careful management of a potentially difficult airway and a higher likelihood of respiratory insufficiency further complicate patient care. Knowledge of this rare disease process and its potential impact on anesthetic management is paramount for safe perioperative patient care.

Deceptive jugular manometry, blood colour and Po2 in the presence of an ipsilateral upper extremity arteriovenous fistula: a report of two cases

Manometry, blood gas analysis and colour of blood are often used as adjuncts to verify central venous access and rule out inadvertent arterial puncture. Several clinical scenarios may make these techniques unreliable. Two cases are presented involving patients with mature upper arm arteriovenous fistulas in which techniques to confirm correct central venous access contradicted ultrasound imaging findings.

Protruding coronary stent detected by transesophageal echocardiography changes surgical procedure

This case describes an unusual intraoperative transesophageal echocardiogram (TEE) finding of an unknown sinus of Valsalva mass in a patient undergoing an off‐pump coronary artery bypass procedure. The intraoperative TEE finding not only revealed a protruding right coronary ostial stent but also changed the surgical procedure to include an aortotomy that allowed successful removal of the stent. As interventional cardiologists begin exploring more techniques to manage difficult ostial lesions, this finding may be seen more commonly in the future. This case highlights how the use of routine TEE even in off‐pump coronary artery bypass procedures may be very beneficial.

Hemodynamic Changes Induced by Pneumoperitoneum and Measured With ECOM

Laparoscopic surgery presents unique hemodynamic challenges for the anesthetic management of patients. Hemodynamic changes induced by pneumoperitoneum were measured using a new noninvasive device, the Endotracheal Cardiac Output Monitor (ECOM) (ConMed Corp, Utica, NY). This monitor provides measurements—including cardiac output (CO), systemic vascular resistance (SVR), and stroke volume variation (SVV)—that were previously unavailable noninvasively. A better understanding of the applicability and reliability of this new technology in the clinical setting is important for patient safety. CONCLUSIONS