Kay B. Leissner

Strategies in postoperative analgesia in the obese obstructive sleep apnea patient.

Objective:Obstructive sleep apnea (OSA) has become an epidemic worldwide, and OSA patients frequently present for surgery. Comorbidities such as cardiovascular disease, diabetes, hypertension, stroke, gastrointestinal disorder, metabolic syndrome, chronic pain, delirium, and pulmonary disorder increase the perioperative risk for OSA patients. Methods:This is a narrative review of the impact of sedative and analgesic therapy on the intraoperative and postoperative course of an obese OSA patient. Results:An understanding of postoperative complications related to OSA and drug interactions in the context of opioid and nonopioid selection may benefit pain practitioner and patients equally. Conclusions:Management of acute postoperative pain in OSA patient remains complex. A comprehensive strategy is needed to reduce the complications and adverse events related to administration of analgesics and anesthetics.

Physiology and pathophysiology at high altitude: considerations for the anesthesiologist

Millions of people live in, work in, and travel to areas of high altitude (HA). Skiers, trekkers, and mountaineers reach altitudes of 2500 m to more than 8000 m for recreation, and sudden ascents to high altitude without the benefits of acclimatization are increasingly common. HA significantly affects the human body, especially the cardiovascular and pulmonary systems, because of oxygen deprivation due to decreased ambient barometric pressure. Rapid ascents may lead to high-altitude diseases that sometimes have fatal consequences. Other factors, such as severe cold, dehydration, high winds, and intense solar radiation, increase the morbidity of patients at HA. Anesthesiologists working in or visiting areas of higher elevations should become familiar with the human physiology, altered pharmacology, and disease pattern of HA.

Deep Hypothermic Circulatory Arrest and Bivalirudin Use in a Patient With Heparin-Induced Thrombocytopenia and Antiphospholipid Syndrome

Abstract  Background: Patients with heparin‐induced thrombocytopenia II (HIT II) need an alternative nonheparin‐based method of anticoagulation for cardiopulmonary bypass (CPB) to prevent thrombosis and thrombosis related complications. Methods: Bivalirudin was used during CPB and deep hypothermic circulatory arrest (DHCA) for resection of multiple right atrial masses in a patient with HIT II and antiphospholipid antibodies syndrome (APS). Anticoagulation was monitored with the activated clotting time (ACT) and a target ACT of 450 seconds or greater was maintained. Results: Surgical removal of multiple right atrial masses was successful and there was no evidence of thromboembolic events. Clot was noticed in the cardiotomy and venous reservoir after CPB was discontinued and the system flushed. The postoperative course was uneventful. Conclusions: Anticoagulation was successfully managed with bivalirudin, a new short‐acting, and direct thrombin inhibitor. Further studies are necessary to evaluate the safety of bivalirudin during DHCA.

Respiratory Perioperative Management of Patients With Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) has become a major public health problem in the United State and Europe. However, perioperative strategies regarding diagnostic options and management of untreated OSA remain inadequate. Preoperative screening and identification of patients with undiagnosed OSA may lead to early perioperative interventions that may alter cardiopulmonary events associated with surgery and anesthesia.1 Hence, clinicians need to become familiar with the preoperative screening and diagnosis of OSA. Perioperative management of a patient with OSA should be modified and may include regional anesthesia and alternative analgesic techniques such as nonsteroidal anti-inflammatory drugs that may reduce the need for systemic opioids. Additionally, supplemental oxygen and continuous pulse oximetry monitoring should be utilized to maintain baseline oxygen saturation. Postoperatively patients should remain in a semi-upright position and positive pressure therapy should be used in patients with high-risk OSA.

Left Atrial Dissection and Intramural Hematoma After Aortic Valve Replacement

Fig 1. LA dissection, left ventricle (LV), LVOT, and aorta (Ao) are visualized in the midesophageal long-axis view after the first AVR. The LA is compressed by the intramural hematoma (white arrows) leading to hypotension. The image is recorded in the process of re-establishing cardiopulmonary bypass. (Color version of figure is available online.)

A prospective, blinded evaluation of a video-assisted '4-stage approach' during undergraduate student practical skills training.

BackgroundThe 4-stage approach (4-SA) is used as a didactic method for teaching practical skills in international courses on resuscitation and the structured care of trauma patients. The aim of this study was to evaluate objective and subjective learning success of a video-assisted 4-SA in teaching undergraduate medical students.MethodsThe participants were medical students learning the principles of the acute treatment of trauma patients in their multidiscipline course on emergency and intensive care medicine. The participants were quasi- randomly divided into two groups. The 4-SA was used in both groups. In the control group, all four steps were presented by an instructor. In the study group, the first two steps were presented as a video. At the end of the course a 5-minute objective, structured clinical examination (OSCE) of a simulated trauma patient was conducted. The test results were divided into objective results obtained through a checklist with 9 dichotomous items and the assessment of the global performance rated subjectively by the examiner on a Likert scale from 1 to 6.Results313 students were recruited; the results of 256 were suitable for analysis. The OSCE results were excellent in both groups and did not differ significantly (control group: median 9, interquantil range (IQR) 8–9, study group: median 9, IQR 8–9; p = 0.29). The global performance was rated significantly better for the study group (median 1, IQR 1–2 vs. median 2, IQR 1–3; p < 0.01). The relative knowledge increase, stated by the students in their evaluation after the course, was greater in the study group (85% vs. 80%).ConclusionIt is possible to employ video assistance in the classical 4-SA with comparable objective test results in an OSCE. The global performance was significantly improved with use of video assistance.

Catecholamine-induced Cardiomyopathy and Pheochromocytoma

A previously asymptomatic 37-yr-old man presented to the hospital with acute hypertension of 220/120 mm Hg and unstable ventricular tachycardia requiring cardioversion. A transthoracic echocardiogram (TTE) 1 yr earlier had shown mitral valve prolapse with moderate mitral regurgitation (MR), normal left ventricular (LV) size and function and mild right ventricular (RV) dilation. His TTE after admission revealed dilated, hypokinetic RV with mild tricuspid regurgitation and flattening of the interventricular septum (IVS) (Video Clip 1; please see video clip available at www.anesthesia-analgesia.org). The estimated LV ejection fraction (EF) was 55% with moderate MR. The rest of the TTE was unremarkable. Further workup revealed elevated urine catecholamine levels and a 5 6 cm right adrenal mass. The patient was started on phenoxybenzamine and labetalol and was scheduled for adrenalectomy. A repeat, preoperative TTE 1 wk after admission demonstrated a deteriorated LVEF of 30% and an otherwise unchanged examination. Consequently, the diagnosis of pheochromocytoma and catecholamine-induced cardiomyopathy was made. A biventricular assist device was on standby in anticipation of intraoperative cardiac deterioration. Intraoperative transesophageal echocardiography (TEE) demonstrated a massively dilated and severely hypokinetic RV distorting the normal cardiac anatomy. Systolic and diastolic IVS flattening was present (Fig. 1, Video Clip 2; please see video clip available at www.anesthesia-analgesia.org). The right atrium was enlarged and tricuspid regurgitation remained mild. The LV was also significantly dilated with an estimated EF of 25%–30% (Video 1). The mitral valve annulus was widened at 5.1 cm. Mitral valve prolapse with severe, eccentric MR (vena contracta width 1 cm) was visualized (Video Clip 3; please see video clip available at www.anesthesiaanalgesia.org). The intraoperative anesthetic management was based on the stage of surgery, hemodynamic changes and TEE findings. His measured pulmonary artery pressures were mildly elevated with episodic increases to 80/40 mm Hg. The cardiac index was 2.6 L/m and the systemic vascular resistance was 1500 dynes s cm . Sodium nitroprusside, esmolol, and phentolamine were titrated to effect for intermittent hypertension of up to 240/130 mm Hg. Severe hypotension to 60/30mm Hg (cardiac index 3.2 L/m, systemic vascular resistance 500 dynes s cm ) followed adrenalectomy requiring treatment with epinephrine, norepinephrine, arginine vasopressin, and volume expansion. His arterial blood pressure slowly improved to 90/60 mm Hg. The estimated LVEF improved to 35% and ventricular assist device placement was deemed unnecessary. The patient had an uncomplicated postoperative course. TTE 1 mo later showed normalization of LV size and function. The mitral valve annulus was less dilated (4.2 cm) and the MR was moderate (vena contracta width of 0.55 cm). RV function improved slightly with less dilation and minimal IVS flattening (Video 1). This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Bioterrorism and children: unique concerns with infection control and vaccination.

Treatment of child victims of a bioterrorism attack is complicated because they may be more vulnerable to the agents used and may suffer more complications from the treatment strategies. Isolation and other infection control measures can be psychologically harmful to young children and may require that they undergo sedation. Most of the recommended antibiotics and antiviral treatments for bioterror agents have not been approved for use in children, and children undergoing smallpox vaccination have a higher incidence of complications than adults. Pediatric anesthesiologists should expect to be part of the pediatric care team and must be careful to observe infection control procedures to limit the spread of disease caused by bioterror attack.

Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery.

Author Affiliations: Illinois Surgical Quality Improvement Collaborative, Chicago (Wandling, Minami, Johnson, O’Leary, Yang, Holl, Bilimoria); Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Wandling, Minami, Johnson, O’Leary, Yang, Holl, Bilimoria); Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (Wandling, Minami, Johnson, O’Leary, Yang, Holl, Bilimoria); Department of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (O’Leary).

Persistent Atrial Septum Defect Despite Placement of Two Amplatzer Septal Occluders

Herein, we are presenting a case of persistent interatrial septal defect diagnosed during coronary artery bypass grafting (CABG). Twice, attempts had been made to close this shunt using amplatzer septal occlude. However, percutaneous technique had failed in both occasions. The patient presented with chest pain 4 years after the second attempt and required urgent CABG. Persistent shunt was repaired during surgery.