Marissa G. Vadi

Local anesthetic systemic toxicity after combined psoas compartment-sciatic nerve block: analysis of decision factors and diagnostic delay.

987 April 2014 H IP fractures are common in elderly individuals, accounting for the majority of fracture-related medical care costs and mortality in patients over the age of 50 yr.1 In the United States, the age-standardized annual incidence of hip fractures is estimated to be 150 to 250 per 100,000 per year, with higher rates observed in women.2 Affected patients often present with multiple comorbidities, posing significant challenges to the anesthesiologist. Peripheral nerve blocks have gained popularity for anesthetic management of procedures involving the lower extremity, both as a complement to general anesthesia and as an alternative to neuraxial anesthesia. Combined psoas compartment–sciatic nerve block (CPCSNB) is a technique used to provide adequate surgical anesthesia to the ipsilateral lower extremity during operative repair of hip fracture.3,4 CPCSNB is theoretically associated with less of the sympathetic blockade and vasodilatation characteristic of neuraxial anesthesia and has successfully been performed in patients with severe aortic stenosis.5 Despite these advantages, CPCSNB is not without risk. The psoas compartment is formed by the psoas muscle, the anterior fascia of the psoas muscle, and the quadratus lumborum posteriorly; it contains the lumbar plexus (ventral rami of L1–4) and is the desired distribution of local anesthetic spread.6 Epidural spread has been reported after psoas compartment blockade, with an incidence of up to 27% in adults and 92% in children depending on the approach used.7–10 Auroy et al.,11 in a major survey of regional anesthesia complications in France, reported one case of cardiac arrest, one case of seizure, and two cases of respiratory failure associated with cephalad diffusion of local anesthetic in the epidural or intrathecal space during psoas compartment blockade. The possibility of intravascular injection or systemic absorption from the epidural venous plexus places the patients at risk for local anesthetic systemic toxicity (LAST). We report a case of LAST after CPCSNB in an elderly patient presenting for operative repair of a hip fracture. The time to onset of LAST signs and symptoms was prolonged, and patient-specific factors confounded the diagnosis. Delayed diagnosis and treatment may have contributed to the patient’s eventual adverse outcome. We discuss the cognitive factors contributing to a delay in LAST diagnosis, with an emphasis on broadly applicable principles of clinical decision making and diagnostic error. A brief review of LAST clinical presentation and treatment is also presented.

Preoperative Evaluation, Premedication, and Induction of Anesthesia

Abstract Adequate preparation of children for anesthesia allows optimization of medical conditions and leads to decreased morbidity. The medical history and laboratory testing obtained preoperatively aid the anesthesiologist in determining readiness for the planned surgery. Preparedness begins with adherence to a preoperative fasting schedule for elective surgery, selecting appropriate premedication, formulating an anesthetic plan and anticipating postoperative concerns. There are a variety of techniques for inducing general anesthesia. The technique used depends on a number of factors including the childs developmental age, understanding and ability to cooperate, previous experiences, the presence of a parent and the interaction of these factors with the childs underlying medical or surgical conditions. This chapter discusses special problems encountered in the pediatric population that require additional considerations from anesthesiologists. The preoperative period can be a stressful time for the fearful child and for those with autism spectrum disorders thus requiring the anesthesiologist to tailor the approach to meet the childs needs. Other challenges that pediatric patients present include respiratory system conditions such as obstructive sleep apnea syndrome, bronchopulmonary dysplasia, difficult airway, upper respiratory tract infections and apnea in former preterm infants. Additional conditions that are discussed include diabetes, seizure disorders, and sickle cell disease. Finally, the detection of a cardiac murmur, anemia or a fever before elective surgery will present a dilemma whether to proceed. The preoperative visit is an essential component of identifying the pediatric patients needs and devising a plan that leads to a superior patient experience, a decrease in the number of cancellations and improved outcomes.

Anaesthetic management of the child with co-existing pulmonary disease

Children with co-existing pulmonary disease have a wide range of clinical manifestations with significant implications for anaesthetists. Although there are a number of pulmonary diseases in children, this review focuses on two of the most common pulmonary disorders, asthma and bronchopulmonary dysplasia (BPD). These diseases share the physiology of bronchoconstriction and variably decreased flow in the airways, but also have unique physiological consequences. The anaesthetist can make a difference in outcomes with proper preoperative evaluation and appropriate preparation for surgery in the context of a team approach to perioperative care with implementation of a stepwise approach to disease management. An understanding of the importance of minimizing the risk for bronchoconstriction and having the tools at hand to treat it when necessary is paramount in the care of these patients. Unique challenges exist in the management of pulmonary hypertension in BPD patients. This review covers medical treatment, intraoperative management, and postoperative care for both patient populations.

Comparison of the Glidescope Cobalt® and Storz Dci® Video Laryngoscopes in Children Younger Than 2 Years of Age During Manual In-line Stabilization: A Randomized Trainee Evaluation Study

Objectives Video laryngoscopy facilitates tracheal intubation during manual in-line stabilization in adults, but it is not clear whether these findings translate to children. We compared trainee intubation times obtained using the GlideScope Cobalt® and Storz DCI® video laryngoscopes versus direct laryngoscopy in young children with immobilized cervical spines. Methods Ninety-three children younger than 2 years underwent laryngoscopy with manual in-line stabilization using direct laryngoscopy, GlideScope Cobalt® video laryngoscopy, or Storz DCI® video laryngoscopy. Laryngoscopists were anesthesiology trainees in postgraduate training year of 3 or more. Total time to successful intubation (TTSI), best glottic view, and maximum degrees of neck deviation were recorded. An intubation time difference longer than 10 seconds was defined as clinically significant. Results Data are reported as median; 95% confidence interval. The TTSI was similar among groups although Storz times were longer (median, 33.3 seconds; 95% confidence interval, 26.2–43.3 seconds) when compared to direct laryngoscopy (median, 23.3 seconds; 95% confidence interval, 20.7–26.5 seconds; P = 0.02). Obtaining a grade 1 Cormack-Lehane glottic view was less likely with direct laryngoscopy (P = 0.002). Maximum degrees of neck deviation were: Storz (median, 2.0; 95% confidence interval, 1.2–2.8), GlideScope (median, 2.0; 95% confidence interval, 1.4–2.6), and direct laryngoscopy (median, 1.9; 95% confidence interval, 1.2–2.1; P = 0.48). Conclusions Trainees were able to safely perform tracheal intubation in children younger than 2 years using any of the studied laryngoscopes, although Storz use resulted in a longer TTSI when compared to direct laryngoscopy. Video laryngoscopy may enhance best Cormack-Lehane glottic view during manual in-line cervical spine immobilization, but additional technical skills are needed to successfully complete tracheal intubation.

Transfusion Ethics in a Pediatric Jehovah’s Witness Trauma Patient: Simulation Case

Introduction Current ethical practice allows for adult patients with decision-making capacity to refuse blood transfusion, even at the cost of high morbidity or mortality. However, for an adult patient who is of the Jehovahs Witness faith, an unwanted blood transfusion confers a psychospiritual cost to the patient and a financial cost to health care entities. The ethical boundaries are increasingly ambiguous with minors who are members of the Jehovahs Witness faith. This simulation experience intends to identify and address knowledge gaps in the care of minors in an emergent setting using a biomedical ethics framework. Methods This scenario provides an immersive simulation experience involving a 12-year-old Jehovahs Witness patient requiring emergent laparotomy for splenic hemorrhage. Patient interview (via simulation manikin with instructor voice) and care handoff take place in an operating room setting. The learner ascertains the patients and familys refusal of blood products. Induction of general anesthesia results in profound patient hypotension secondary to acute blood-loss anemia. Pulseless electrical activity results if packed red blood cells are not administered. Ethical principles require the learner to impose an unwanted lifesaving therapy on a minor patient over the objections of family members. Secondly, the anesthesia provider must advocate for transfusion on these ethical grounds against a well-meaning but ultimately misguided surgeon who opposes transfusion. An included learner evaluation form based on ACGME core competencies facilitates postsimulation debriefing. Results Participants were primarily anesthesia residents and fellows. Anecdotally, the residents said that it “felt good to be an attending” and that the simulation helped them appreciate how important conflict resolution skills are in the OR setting. Additionally, faculty appreciated the ability to assess the development of crucial assertiveness skills, with the option of remediating incorrect behavior during the debriefing. Discussion This simulation experience provides experience in the emergent medical management of a pediatric trauma patient while also incorporating specific ethical consent issues unique to pediatric and trauma patient populations. Furthermore, this experience develops professionalism skills and practice in assertive patient advocacy.

Continuous Noninvasive Hemodynamic Monitoring in an Infant With Tetra-Amelia.

Tetra-amelia syndrome is a congenital disorder associated with near or complete absence of all 4 limbs. Noninvasive hemodynamic monitoring may be difficult or impossible in such patients. We describe the use of a finger cuff blood pressure system for continuous noninvasive blood pressure monitoring in an infant with near-complete tetra-amelia undergoing laparoscopic gastrostomy tube placement. This case suggests the potential use of such a blood pressure monitoring system for other patients with comparable deformities.