Elizabeth Rebello

Non-invasive anesthesia for children undergoing proton radiation therapy

BACKGROUND Proton therapy is a newer modality of radiotherapy during which anesthesiologists face specific challenges related to the setup and duration of treatment sessions. PURPOSE Describe our anesthesia practice for children treated in a standalone proton therapy center, and report on complications encountered during anesthesia. MATERIALS AND METHODS A retrospective review of anesthetic records for patients ⩽18years of age treated with proton therapy at our institution between January 2006 and April 2013 was performed. RESULTS A total of 9328 anesthetics were administered to 340 children with a median age of 3.6years (range, 0.4-14.2). The median daily anesthesia time was 47min (range, 15-79). The average time between start of anesthesia to the start of radiotherapy was 7.2min (range, 1-83min). All patients received Total Intravenous Anesthesia (TIVA) with spontaneous ventilation, with 96.7% receiving supplemental oxygen by non-invasive methods. None required daily endotracheal intubation. Two episodes of bradycardia, and one episode each of; seizure, laryngospasm and bronchospasm were identified for a cumulative incidence of 0.05%. CONCLUSIONS In this large series of children undergoing proton therapy at a freestanding center, TIVA without daily endotracheal intubation provided a safe, efficient, and less invasive option of anesthetic care.

Anaesthetic techniques for unique cancer surgery procedures

Recent advances in cancer therapy have seen increased combinations of different treatment modalities as well as novel approaches that affect anaesthetic care. Increasingly, surgery is being combined with chemotherapy and radiation therapy. Moreover, minimally invasive procedures are gaining popularity and more targeted therapies are being used. These events have created a demand for new anaesthetic techniques from anaesthesiologists in order to provide safe patient care. This article will discuss anaesthetic considerations for proton therapy, hyperthermic intracavitary chemotherapy, limb perfusion, radiosurgery, robotic surgery and intra-operative radiation therapy and high-dose brachytherapy.

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.

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

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.

Peri-Operative Takotsubo Cardiomyopathy: A Case Series

Takotsubo Cardiomyopathy (TC) is a reversible, stress-induced, non-ischemic cardiomyopathy associated with temporary weakness of the myocardium and midventricular or apical ballooning [11. Emanuele Cecchi, Guido Parodi, Cristina Giglioli, Silvia Passantino, Brunella Bandinelli, et al. (2013) Stress-Induced Hyperviscosity in the Pathophysiology of Takotsubo Cardiomyopathy. The Am J Cardiol: 1523–1529.,22. Sharkey SW, Lips DL, Pink VR, Maron BJ (2013) Daughter-Mother Tako-Tsubo Cardiomyopathy. The Am J Cardiol 137–138.]. Angina, ST abnormalities, elevated troponins, ventricular asynergy, CHF, and decreased EF are all components of TC. The unique finding is that they occur on the absence of CAD [33. Bielecka-Dabrowa A, Mikhailidis DP, Hannam S, Rysz J, Michalska M, et al. Takotsubo cardiomyopathy -The current state of knowledge. Int J Cardiol:120–125.]. In this case series with IRB approval we report three cases of post-operative cardiac symptoms that all resulted in a diagnosis of TC.

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.

Investigating the association between perioperative blood transfusions and outcomes in children undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Studies indicate the perioperative transfusion of red blood cells during oncologic surgery may be associated with worse outcomes. In this study, we evaluated the impact of red blood cell transfusions on the short‐ and long‐term outcomes of children undergoing a major oncologic surgery.

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.

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

Opening and charting in the incorrect patient electronic record presents a patient safety issue. The authors investigated the prevalence of reported errors and whether efforts utilizing the anesthesia time-out and barcoding have decreased the incidence of errors in opening and charting in the patient electronic medical record in the perioperative environment. The authors queried the database for all surgeries and procedures requiring anesthesia from January 2009 to September 2012. Of the 115,760 records of anesthesia procedures identified, there were 57 instances of incorrect record opening and charting during the study period. A decreasing trend was observed for all sites combined (p < 0.0001) and at the off-site locations (p = 0.0032). All locations and the off-site locations demonstrated a statistically significant decreasing pattern of errors over time. Barcoding and the anesthesia time-out may play an important role in decreasing errors in incorrect patient record opening in the perioperative environment.