Michael G. Fitzsimons

Random Drug Testing to Reduce the Incidence of Addiction in Anesthesia Residents: Preliminary Results from One Program

Substance abuse occurs in approximately 1%–2% of anesthesia residents and nearly 80% of programs have had one or more resident (s) with such a problem. Education and control efforts have failed to reduce the frequency of substance abuse. Anesthesia providers have a professional obligation to be drug-free for the well being of their patients. We have instituted a program of preplacement and random urine testing of residents in anesthesiology in an attempt to decrease the incidence of substance abuse. We demonstrate that such a program is feasible, despite logistic and cultural obstacles. Larger multi-institutional studies will be required to determine whether instituting a program of random urine testing decreases the incidence of substance abuse in anesthesiology residents.

Case records of the Massachusetts General Hospital. Case 40-2012. A 43-year-old woman with cardiorespiratory arrest after a cesarean section.

From the Department of Obstetrics and Gynecology (J.L.E.), the Divisions of Obstetrical Anesthesia (K.S.) and Cardiac Anesthesia (M.G.F.), Department of Anesthesia, Critical Care, and Pain Medicine, and the Department of Surgery (T.E.M.), Massachusetts General Hospital; and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.L.E.), Anesthesia (K.S., M.G.F.), and Surgery (T.E.M.), Harvard Medical School — both in Boston.

Case 40-2012

From the Department of Obstetrics and Gynecology (J.L.E.), the Divisions of Obstetrical Anesthesia (K.S.) and Cardiac Anesthesia (M.G.F.), Department of Anesthesia, Critical Care, and Pain Medicine, and the Department of Surgery (T.E.M.), Massachusetts General Hospital; and the Departments of Obstetrics, Gynecology, and Reproductive Biology (J.L.E.), Anesthesia (K.S., M.G.F.), and Surgery (T.E.M.), Harvard Medical School — both in Boston.

Diagnosis of Congenital Unicuspid Aortic Valve in Adult Population: The Value and Limitation of Transesophageal Echocardiography

Background: This study aimed to assess the accuracy of two‐dimensional echocardiography (echo) in diagnosing unicuspid aortic valve (UAV) and to determine echo features that could improve the diagnosis. Method: We reviewed transthoracic/transesophageal echoes (TTE/TEE) from our hospital database for adult patients who had aortic valve surgery with a preoperative echo diagnosis of UAV or equivocal diagnosis of bicuspid aortic valve (BAV) BAV/UAV. Morphological characteristics of AV and ascending aortic dimensions were evaluated. Results: Nineteen patients were identified, 13 (11 Male, 2 Female, mean age 47 ± 10 years) had surgically confirmed diagnosis of UAV, six had BAV. The incidence of UAV was 2.6%. For diagnosing UAV, the sensitivity and specificity of TTE was 27% and 50% and those of TEE was 75% and 86%, respectively. For TTE, positive predictive value (PPV) was 60% and negative predictive value (NPV) was 20%. By TEE, PPV was 90% and the NPV was 67%. In UAV patients, 85% had severe aortic stenosis (mean gradient 45 ± 16 mmHg, AVA: 0.9 ± 0.2 cm2). 46% had ascending aorta aneurysm (mean aortic root, sinutubular junction, ascending aorta dimensions: 36 ± 3 mm, 31 ± 4 mm and 41 ± 8 mm). Patients with ascending aortic aneurysm were younger (41 ± 11 years vs. 52 ± 5 years, P < 0.05) All UAV were unicommissural with a posteriorly positioned commissural attachment, 69% were heavily calcified. Diagnostic accuracy was limited by quality of images, severity, and distribution of calcification. Conclusion: TEE is the diagnostic modality of choice in UAV. Identifying several echo features may improve its diagnostic accuracy. (Echocardiography 2010;27:1107‐1112)

Anesthetic Evolution in Transcatheter Aortic Valve Replacement: Expert Perspectives From High-Volume Academic Centers in Europe and the United States

Cite this article as: Prakash A. Patel, Abraham M. Ackermann, John G.T. Augoustides, Joerg Ender, Jacob T. Gutsche, Jay Giri, Prashanth Vallabhajosyula, Nimesh D. Desai, Megan Kostibas, Mary Beth Brady, Eun J. Eoh, Jeffrey G. Gaca, Annemarie Thompson and Michael G. Fitzsimons, Anesthetic Evolution In Transcatheter Aortic Valve Replacement: Expert Perspectives From High-Volume Academic Centers In Europe And The United S t a t e s , Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2017.02.051

Drug testing physicians for substances of abuse: case report of a false-positive result ☆

The risk of a false-positive urine drug screen is one of the major impediments to widespread implementation of drug testing programs in anesthesiology. A case of a false-positive urine screen for ketamine in an anesthesia provider is presented, with recommendations for methods of managing such an event.

The safety and efficacy of ECT and anesthesia in the setting of multiple sclerosis.

Multiple sclerosis (MS), a demyelinating disorder characterized by relapsing and remitting symptoms of weakness and paresthesias, often worsens after surgery and the administration of anesthesia; whether recurrence is due to the surgery, to the use of anesthetics, or to hyperpyrexia remains unclear.1 Therefore, referring psychiatrists and anesthesiologists should understand the potential complications when patients with MS are referred for treatment. We present the case of a young woman with MS and unstable bipolar disorder who received numerous treatments with electroconvulsive therapy (ECT) that involved use of brief general anesthesia and discuss the relationship between ECT, anesthetics, and recurrence of MS. No exacerbation of MS arose despite repeated anesthetic challenges associated with ECT.

Attention-Deficit/Hyperactivity Disorder and Successful Completion of Anesthesia Residency: A Case Report.

Cognitive and physical disabilities among anesthesia residents are not well studied. Cognitive disabilities may often go undiagnosed among trainees, and these trainees may struggle during their graduate medical education. Attention-deficit/hyperactivity disorder (ADHD) is an executive function disorder that may manifest as lack of vigilance, an inability to adapt to the rapid changes associated with anesthesia cases, distractibility, an inability to prioritize activities, and even periods of hyperfocusing, among other signs. Programs are encouraged to work closely with residents with such disabilities to develop an educational plan that includes accommodations for their unique learning practices while maintaining the critical aspects of the program. The authors present the management of a case of an anesthesia resident with a diagnosis of ADHD, the perspectives of the trainee, program director, clinical competency director, and the office of general counsel. This article also provides follow-up in the five years since completion of residency.

Anesthesia services during operation unified assistance, aboard the USNS mercy, after the tsunami in southeast asia

The tsunami that struck Southeast Asia on December 26, 2004, resulted in the deaths of >300,000 individuals. The U.S. response included the formation of the first combined civilian/ military peacetime humanitarian effort, directed by the National Command Authority as Operation Unified Assistance. This effort included military personnel from the U.S. Navy and civilians assembled by Project HOPE. Anesthesiologists and certified nurse anesthetists provided care in >150 cases. We discuss the initial response, medical and cultural planning, logistical support, procedures, and lessons learned in this unique opportunity.

Successful Right Ventricular Mechanical Support After Combined Heart-Liver Transplantation

A 45-year-old male with a history of right-sided congestive heart failure associated with cirrhosis presented for combined heart-liver transplantation. At age 28 he was diagnosed with a right-sided cardiac mass. At that time he underwent a massive debulking of the mass associated with excision of the tricuspid valve. Pathology showed thrombus and a benign fibroproliferative process. After his operation he lived with severe tricuspid regurgitation, eventually leading to cardiac cirrhosis associated with recurrent ascites, pleural effusions, a chronic cough, and decreased exercise tolerance. He presented for consideration for combined heart and liver transplantation. Echocardiography performed during his transplant evaluation revealed normal left ventricular size and function, an ejection fraction of 64%, trace mitral regurgitation, and a small and hypokinetic right ventricle with only a small remnant of the tricuspid valve. There was dilation of the right ventricle and inferior vena cava with associated hepatic vein dilation. The interatrial septum was shifted toward the left, consistent with right atrial volume overload. There was evidence of a patent foramen ovale. Right and left cardiac catheterization at the time of initial evaluation demonstrated no evidence of coronary artery disease. Superior vena cava pressure was 24 mmHg, mean right atrial pressure was 26 mmHg, mean pulmonary artery pressure (PA) was 26 mmHg, and pulmonary capillary wedge pressure was 15 mmHg with spontaneous ventilation. Cardiac output was 2.45 L/min and cardiac index 1.3 L/min/m 2 by thermodilution. Pulmonary vascular resistance (PVR) was reported as 359.2 dynes·sec·cm -5 (4.49 Woods units). Liver biopsy was consistent with cirrhosis. Several attempts at radiofrequency ablation for atrial fibrillation were unsuccessful. His condition progressed such that he required intensive care management with sildenafil, intravenous milrinone (0.1 µg/kg/min), dobutamine (70 µg/min), and phenylephrine (10 µg/min) before surgery and was thus admitted to the intensive care unit and listed as status 1A for combined heart-liver transplantation. Sixty-three days after his admission, a suitable 25-year-old brain