Karina Castellon-Larios

A Prospective, Comparative Study for the Evaluation of Postoperative Pain and Quality of Recovery in Patients Undergoing Robotic Versus Open Hysterectomy for Staging of Endometrial Cancer.

STUDY OBJECTIVE To measure and compare postoperative pain and patient satisfaction in patients undergoing either robotic or open laparotomy for surgical staging of endometrial cancer. DESIGN Prospective, comparative study (Canadian Task Force classification II). SETTING University hospital. PATIENTS A total of 142 patients undergoing either robotic or open laparotomy for surgical staging of endometrial cancer. INTERVENTIONS Patients scheduled for surgical staging of endometrial cancer at a single institution were identified. The patients underwent either robotic or open hysterectomy for staging of endometrial cancer. The choice of operative approach (robotic vs laparotomy) was made by the faculty physician before enrollment. Patients participated in the study for up to 48 hours for pain assessments and up to 10 ± 3 days postoperatively for quality of recovery assessments. MEASUREMENTS AND MAIN RESULTS The following measurements were performed: postoperative pain with the visual analog scale (VAS), 24-hour opioid consumption, and quality of recovery using the Quality of Recovery Questionnaire (QoR-40). The study was terminated owing to futility, given the lack of open procedures at our institution. Despite that lack of statistically significant difference between VAS scores at rest and with leg extension, there was a significant decrease in 24-hour opioid consumption in the robotic group. In addition, the QoR-40 showed an increased perception of recovery in patients within the robotic group compared with the laparotomy group. CONCLUSION Patients with endometrial cancer who underwent robotic surgery had decreased postoperative opioid consumption and improved quality of recovery compared with those who underwent surgery via laparotomy.

Desflurane Allows for a Faster Emergence When Compared to Sevoflurane without Affecting the Baseline Cognitive Recovery Time

Aims We compared the effect of desflurane and sevoflurane on anesthesia recovery time in patients undergoing urological cystoscopic surgery. The Short Orientation-Memory-Concentration Test (SOMCT) measured and compared cognitive impairment between groups and coughing was assessed throughout the anesthetic. Methods and materials This investigation included 75 ambulatory patients. Patients were randomized to receive either desflurane or sevoflurane. Inhalational anesthetics were discontinued after removal of the cystoscope and once repositioning of the patient was final. Coughing assessment and awakening time from anesthesia were assessed by a blinded observer. Statistical analysis used Statistical analysis was performed by using t-test for parametric variables and Mann–Whitney U test for non-parametric variables. Results The primary endpoint, mean time to eye-opening, was 5.0 ± 2.5 min for desflurane and 7.9 ± 4.1 min for sevoflurane (p < 0.001). There were no significant differences in time to SOMCT recovery (p = 0.109), overall time spent in the post-anesthesia care unit (PACU) (p = 0.924) or time to discharge (p = 0.363). Median time until readiness for discharge was 9 min in the desflurane group, while the sevoflurane group had a median time of 20 min (p = 0.020). The overall incidence of coughing during the perioperative period was significantly higher in the desflurane (p = 0.030). Conclusion We re-confirmed that patients receiving desflurane had a faster emergence and met the criteria to be discharged from the PACU earlier. No difference was found in time to return to baseline cognition between desflurane and sevoflurane.

Establishing an instrumented training environment for simulation-based training of health care providers: An initial proof of concept

Objective: Several decades of armed conflict at a time of incredible advances in medicine have led to an acknowledgment of the importance of cognitive workload and environmental stress in both war and the health care sector. Recent advances in portable neurophysiological monitoring technologies allow for the continuous real-time measurement and acquisition of key neurophysiological signals that can be leveraged to provide high-resolution temporal data indicative of rapid changes in functional state, (i.e., cognitive workload, stress, and fatigue). Here, we present recent coordinated proof of concept pilot project between private industry, the health sciences, and the USA government where a paper-based self-reporting of workload National Aeronautics and Space Administration Task Load Index Scale (NASA TLX) was successfully converted to a real-time objective measure through an automated cognitive load assessment for medical staff training and evaluation (ACLAMATE). Methods: These real-time objective measures were derived exclusively through the processing and modeling of neurophysiological data. This endeavor involved health care education and training with real-time feedback during high fidelity simulations through the use of this artificial modeling and measurement approach supported by Aptima Corporations FuSE2, SPOTLITE, and PM Engine technologies. Results: Self-reported NASA TLX workload indicators were converted to measurable outputs through the development of a machine learning-based modeling approach. Workload measurements generated by this modeling approach were represented as a NASA TLX anchored scale of 0–100 and were displayed on a computer screen numerically and visually as individual outputs and as a consolidated team output. Conclusions: Cognitive workloads for individuals and teams can be modeled through use of feed forward back-propagating neural networks thereby allowing healthcare systems to measure performance, stress, and cognitive workload in order to enhance patient safety, staff education, and overall quality of patient care. The following core competencies are addressed in this article: Medical Knowledge, Interpersonal Skills, Patient Care, and Professionalism.

The effectiveness of a single dose of oral ibuprofen plus caffeine in acute postoperative pain in adults

Commentary on : Derry S, Wiffen PJ, Moore RA. Single dose oral ibuprofen plus caffeine for acute postoperative pain in adults. Cochrane Database Syst Rev 2015;7:CD011509. A number of studies have been performed regarding non-steroidal anti-inflammatory drugs (NSAIDs) and the combination with caffeine for the control of postoperative pain; most of them involving molar surgeries and tension headaches; none of them have been developed in the past 10 years. This study presented by Derry and colleagues assessed the analgesic efficacy of a single dose of ibuprofen plus caffeine when compared to placebo for moderate to severe postoperative pain. Up to February 2015, the authors searched the Cochrane Central Register of Control Trials, MEDLINE, EMBASE and the Oxford Pain Relief Database. Two independent authors assessed the search results and agreed which …

Elevated Transaortic Valvular Gradients After Combined Aortic Valve and Mitral Valve Replacement An Intraoperative Dilemma

High transaortic valvular gradients, after combined aortic valve and mitral valve replacement, require prompt intraoperative diagnosis and appropriate management. The presence of high transaortic valvular gradients after cardiopulmonary bypass, in this setting, can be secondary to the following conditions: prosthesis dysfunction, left ventricular outflow tract obstruction, supravalvular obstruction, prosthesis–patient mismatch, hyperkinetic left ventricle from administration of inotropes, left ventricular intracavitary gradients, pressure recovery phenomenon, and increased transvalvular blood flow resulting from hyperdynamic circulation or anemia. Transesophageal echocardiography is an extremely useful tool for timely diagnosis and treatment of this complication. We describe a case of a critically ill patient with endocarditis and acute lung injury, who presented for combined aortic valve and mitral valve replacement. Transesophageal echocardiographic assessment, post–cardiopulmonary bypass, revealed high transaortic valvular gradients due to encroachment of the mitral prosthesis strut on the left ventricular outflow tract, which was compounded by a small, hypertrophied, and hyperkinetic left ventricle. Discontinuation of inotropic support, administration of fluids, phenylephrine, and esmolol led to resolution of the high gradients and prevented further surgery.

Mitral Valve Annuloplasty Ring Dehiscence Diagnosed Intraoperative With Real-Time 3D Transesophageal Echocardiogram

Mitral annular calcification (MAC) is often a result of the accumulation of lipids around the annulus, which can lead to degeneration and calcification of the valve. Multiple risk factors have been associated with the progression of MAC and life-threatening complications such as the early mitral valve annuloplasty dehiscence. Our case describes the different risk factors for annuloplasty dehiscence in a patient with severe MAC, as well as the importance of its early recognition intraoperatively with 3D transesophageal echocardiography.

Randomized Double Blind Control Study Comparing the Efficacy of Intracuff Alkalinized Lidocaine to Low Dose Remifentanil Infusion in Attenuating the Endotracheal Tube Induced Emergence Phenomena

Emergence from general anesthesia is often complicated by the endotracheal tube (ETT) induced airway and circulatory reflexes which can lead to potentially dangerous complications. Considerable research has been focused on prevention of these emergence phenomena (EP). Nevertheless, the problem is still far from its final solution. Objective: To compare the efficacy of intracuff alkalinized lidocaine (ICL) vs low dose remifentanil infusion in attenuating the ETT-induced EP. Methods: 120 ASA I-III patients, aged 18-65 years, were randomly assigned to receive intracuff alkalinized lidocaine (2% lidocaine mixed 1:1 with 1.4% NaHCO 3 ) or an intravenous (IV) remifentanil infusion (0.05-0.5 mcg/ kg/min) combined with intracuff saline during desflurane-based general anesthesia. At the end of surgery, after desflurane was turned off in the assigned group, low dose remifentanil, or its equivalent placebo was decreased to one-tenth of the mean dose but not less than 0.01 mcg/kg/min and it was continued until extubation. A blinded researcher observed each patient from the time desflurane was discontinued until at least five minutes after extubation. Coughing was evaluated as either present or not, and graded on a point scale based on severity. The patients were also observed for development of any adverse events along with the vital signs during this emergence phase. Results: The incidence (44% vs 67%, p=0.02) and severity of coughing, overall, was significantly less in the lidocaine group compared to remifentanil group). The lidocaine group also had a lower incidence of significant coughing (2-3 on point scale) (25% vs 49%, p=0.009). The mean arterial pressure (MAP) in the lidocaine group was lower than the remifentanil group at extubation and 5 minutes after extubation.

Transesophageal Echocardiographic Diagnosis of Severe Functional Tricuspid Stenosis During Infected Implantable Cardioverter-Defibrillator Lead Extraction

raphy (TEE) is a safe and highly sensitive technique in the diagnosis of CDIE. Coupling TEE with transthoracic echocardiography (TTE) can further provide clinically useful information in determining whether patients require surgical or transvenous lead extraction. The utilization of TEE in high-risk patients provides valuable and real-time information for hemodynamic status, cardiac anatomy, and cardiac function. There are many complications related to implantable cardioverter-defibrillator (ICD) lead extraction, including, but not limited to, septic pulmonary and systemic emboli, tricuspid valvular apparatus injury, right ventricular (RV) dysfunction secondary to myocardial distortion or inversion, cardiac perforation, and cardiac tamponade. 3,4 The authors present a case report highlighting the value of TEE for early recognition and management of hemodynamic complications associated with transvenous lead extraction.

Prosthetic Mitral Perivalvular Defect Occlusion With Multiple Amplatzer Devices Using 3D Transesophageal Echocardiography and Fluoroscopic Guidance

ERIVALVULAR MITRAL REGURGITATION IS a serious complication associated with mitral valve replacement surgery. The presence of moderate-to-severe perivalvular leak (PVL) should prompt urgent repair to reduce the risk of associated complications, such as hemolytic anemia and left ventricular remodeling. Historically, PVLs have been corrected with redo mitral valve replacement, which can be associated with a 6% to 22% mortality rate, especially in high-risk patients. 1,2 Minimally invasive approaches to perivalvular defect occlusion should, therefore, be considered in high-risk patients to improve survival outcomes. The authors present a case highlighting the value of 3D transesophageal echocardiography (TEE) during minimally invasive PVL repair with Amplatzer II devices.

Airway Management in a Patient with Metatropic Dysplasia: Grossly Abnormal Anatomy Combined with a Low Functional Residual Capacity

C l i n M e d International Library Citation: Werner JG, Uribe AA, Larios KC, Bergese SD, McKiernan MP (2014) Airway Management in a Patient with Metatropic Dysplasia: Grossly Abnormal Anatomy Combined with a Low Functional Residual Capacity. Int J Anesthetic Anesthesiol 1:007 Received: August 20, 2014: Accepted: September 22, 2014: Published: September 29, 2014 Copyright: