Jeffrey S. Berger

Anesthetic Considerations for Robot-Assisted Gynecologic and Urology Surgery

Robotic surgery was first conceived by the United States military in the 1980s. It rapidly developed in both complexity and utility and, in the early 21st century, modern robotic surgery for gynecologic and urologic surgery gained approval in the United States. Today, an ever-increasing number and variety of surgical procedures enlist robotic-assistance. Numerous anesthetic considerations for robotic surgery exist. A few of the most important aspects of conducting a safe anesthetic include: investigating the patient’s co-morbid conditions, realizing the risks associated with the robotic equipment, and positioning the patient with care. This manuscript reviews the current literature on robotic-assisted surgery for gynecologic and urologic procedures with emphasis on history, marketplace, type, variety, and expansion of surgery in these fields. The review focuses on practical considerations for the anesthesiologist caring for patients undergoing robotic surgery. Preoperative, intraoperative and postoperative issues are explored in detail. The rapid expansion of robotic surgery worldwide requires thoughtful consideration of the technique’s weaknesses and associated risks. This review provides a roadmap to adequately prepare anesthesiologists for care of gynecologic and urologic patients undergoing robot-assisted surgery.

Emotional intelligence and the relationship to resident performance: a multi-institutional study.

STUDY OBJECTIVE To test the hypothesis that emotional intelligence, as measured by a BarOn Emotional Quotient Inventory (EQ-i), the 125-item version personal inventory (EQ-i:125), correlates with resident performance. DESIGN Survey (personal inventory) instrument. SETTING Five U.S. academic anesthesiology residency programs. PARTICIPANTS Postgraduate year (PGY) 2, 3, and 4 residents enrolled in university-based anesthesiology residency programs. MEASUREMENTS Residents confidentially completed the BarOn EQ-i:125 personal inventory. The deidentified resident evaluations were sent to the principal investigator of a separate data collection study for data analysis. Data collected from the inventory were correlated with daily evaluations of the residents by residency program faculty. Results of the individual BarOn EQ-i:125 and daily faculty evaluations of the residents were compiled and analyzed. MAIN RESULTS Univariate correlation analysis and multivariate canonical analysis showed that some aspects of the BarOn EQ-i:125 were significantly correlated with, and likely to be predictors of, resident performance. CONCLUSIONS Emotional intelligence, as measured by the BarOn EQ-i personal inventory, has considerable promise as an independent indicator of performance as an anesthesiology resident.

Neurologic disease with pregnancy and considerations for the obstetric anesthesiologist.

Women with neurologic conditions present a challenge during pregnancy and in the peripartum period. Given the low prevalence of these diseases during pregnancy, most management decisions are guided by retrospective reviews and case reports. This article reviews current literature for some of the more common or complex neurologic conditions affecting pregnancy with special consideration for anesthetic management. In particular, epilepsy; multiple sclerosis; primary intracranial hypertension; secondary intracranial hypertension-Arnold-Chiari malformations and intracranial neoplasms; spinal cord injury; neuromuscular junction disorders-myasthenia gravis; and hereditary neuromuscular disorders-myotonic dystrophy and spinal muscular atrophy will be discussed. By increasing understanding of anesthetic issues for parturients with neurologic disease, providers may more effectively anticipate anesthetic considerations, thereby optimizing care plans.

Dose-response of intrathecal morphine when administered with intravenous ketorolac for post-cesarean analgesia: a two-center, prospective, randomized, blinded trial.

BACKGROUND The appropriate dose of intrathecal morphine for post-cesarean analgesia is unclear. With the inclusion of routine non-steroidal anti-inflammatory drugs, the required dose of morphine may be significantly less than the 200-300μg common a decade ago. We performed a two-center, prospective, randomized, blinded trial comparing three doses of intrathecal morphine, combined with routine intravenous ketorolac, in 144 healthy women undergoing elective cesarean delivery. METHODS Patients received an intrathecal injection of hyperbaric bupivacaine 12mg, fentanyl 15μg and a randomized dose of 50, 100, or 150μg morphine in a volume of 2.2mL. Patients received intravenous ketorolac 30mg before leaving the operating room and 15mg intravenously every 6h for the duration of the study (24h). All received postoperative patient-controlled intravenous morphine. The primary endpoint was total intravenous morphine administered postoperatively over 24h, analyzed using mixed model regression. RESULTS There were no differences between dose groups (or institutions) in intravenous morphine use over 24h. Visual analog scale scores for pain and nausea did not differ. Pruritus was greater in the 100 and 150μg groups than the 50μg group at 6h and 12h, but there was no difference between groups in nausea or pruritus treatments. Respiratory depression or significant sedation did not occur. CONCLUSION The dose-response relationship of intrathecal morphine for multimodal post-cesarean analgesia suggests that 50μg produces analgesia similar to that produced by either 100μg or 150μg.

Relationship Express: A Pilot Program to Teach Anesthesiology Residents Communication Skills

BACKGROUND The Accreditation Council for Graduate Medical Education requires residency programs to teach 6 core competencies and to provide evidence of effective standardized training through objective measures. George Washington Universitys Department of Anesthesiology and Critical Care Medicine implemented a pilot program to address the interpersonal and communication skill competency. In this program, we aimed to pilot the Relationship Express model, a series of exercises in experiential learning to teach anesthesiology residents to build effective relationships with patients in time-limited circumstances. The purpose of this paper is to describe the application of this model for anesthesiology training. METHODS A total of 7 first-year clinical anesthesiology residents participated in this pilot study, and 4 residents completed the entire program for analysis purposes. Relationship Express was presented in three 1.5-hour sessions: (1) introduction followed by 2-case, standardized patient pretest with feedback to residents from faculty observers; (2) interpersonal and communication skills didactic workshop with video behavior modeling; and (3) review discussion followed by 2-case, standardized patient posttest and evaluation. RESULTS MODIFIED BROOKFIELD COMMENTS REVEALED THE FOLLOWING THEMES: (1) time constraints were realistic compared with clinical practice; (2) admitting errors with patients was difficult; (3) patients were more aware of body language than anticipated; (4) residents liked the group discussions and the video interview; (5) standardized patients were convincing; and (6) residents found the feedback from faculty and standardized patients helpful. CONCLUSIONS Resident retrospective self-assessment and learning comments confirm the potential value of the Relationship Express model. This program will require further assessment and refinement with a larger number of residents.

Postoperative chest pain: accidental discovery of a hiatal hernia while using transthoracic echocardiography to detect myocardial ischemia.

Written, informed patient consent for publication was obtained to report this case. An 82-year-old man with osteoarthritis presented for elective right knee arthroplasty. The patient had a history of sick sinus syndrome with a permanent pacemaker. An electrocardiogram (ECG) taken preoperatively showed a paced rhythm at 70 beats per minute. Shortly after an uneventful operation under spinal anesthesia, while under the care of an anesthesiologist covering the postanesthesia care unit, the patient developed severe, intermittent chest pain. The rest of the examination remained unchanged with stable hemodynamics and a paced heart rhythm. An ECG and chest radiograph revealed no changes from baseline. Because the paced-ECG was not useful in diagnosing an acute coronary syndrome, a cardiologist was consulted to perform an emergent transthoracic echocardiogram (TTE). The patient was positioned left lateral decubitus for examination. Absent chest pain, the TTE was normal; during chest pain, left ventricular function remained normal without regional wall motion abnormalities. However, a 3 3.5 cm hyperechoic mass was seen posterior to the left atrium in both the parasternal, long-axis view, with the probe along the left sternal border in the third–fifth intercostal space, and the apical, 5-chamber view, with the probe over the apical impulse (Figs. 1 and 2). Further examination with color flow Doppler failed to demonstrate vascular flow within the mass (Video 1; see Supplemental Digital Content 1, http://links.lww.com/AA/A246; see Appendix for video legend). Additionally, although the mass appeared to compress the left atrium, there was no flow acceleration across the mitral valve suggesting no obstruction or functional stenosis attributable to the mass. IV perflutren contrast given during the echocardiogram demonstrated complete left atrial opacification without opacification of the mass and without filling defect within the left atrium, further suggesting an extracardiac and avascular mass (Video 2; see Supplemental Digital Content 2, http://links.lww.com/AA/A247; see Appendix for video legend). Because hiatal hernia was suspected, the patient was instructed to ingest a carbonated beverage. TTE visualization of microbubbles in the cavity of the mass strongly suggested the diagnosis of hiatal hernia, although this clip was unavailable for publication because of poor image quality. A computed tomographic scan was performed that confirmed the presence of a hiatal hernia (Fig. 3). Appropriate management of the hiatal hernia was pursued with successful resolution of the patient’s symptoms.

Cervical Varices Presenting as Vaginal Bleeding: A Description of Two Cases and A Management Plan

C l i n M e d International Library Citation: Chyjek K, Hutz C, Macri C, Berger J, Venbrux A, et al. (2015) Cervical Varices Presenting as Vaginal Bleeding: A Description of Two Cases and A Management Plan. Obstet Gynecol Cases Rev 2:053 Received: April 20, 2015: Accepted: July 28, 2015: Published: August 01, 2015 Copyright:

Confessions of Physicians: What Systemic Reporting Does Not Uncover.

I t’s ?1 July, and the newest group of anesthesiology residents is sitting around the conference table. With clear memories of previous failed efforts to get them to ‘‘open up,’’ the program director is trying something new. Sixteen pieces of folded paper are arranged in a pile, one for each resident in the room. Each paper contains a typed statement, and there are no names attached to these ‘‘confessions.’’ The papers are shuffled and dealt, poker-style, to the group. Participants are reminded, ‘‘Even if you get your own statement, do not reveal the authorship, as anonymity is critical to the session.’’ The first statement is read: