Myrna C. Newland

Anesthesia-related cardiac arrest.

Background:Much is still unknown about the actual incidence of anesthesia-related cardiac arrest in the United States. Methods:The authors identified all of the cases of cardiac arrest from their quality improvement database from 1999 to 2009 and submitted them for review by an independent study commission to give them the best estimate of anesthesia-related cardiac arrest at their institution. One hundred sixty perioperative cardiac arrests within 24 h of surgery were identified from an anesthesia database of 217,365 anesthetics. An independent study commission reviewed all case abstracts to determine which cardiac arrests were anesthesia-attributable or anesthesia-contributory. Anesthesia-attributable cardiac arrests were those cases in which anesthesia was determined to be the primary cause of cardiac arrest. Anesthesia-contributory cardiac arrests were those cases where anesthesia was determined to have contributed to the cardiac arrest. Results:Fourteen cardiac arrests were anesthesia-attributable, resulting in an incidence of 0.6 per 10,000 anesthetics (95% CI, 0.4 to 1.1). Twenty-three cardiac arrests were found to be anesthesia-contributory resulting in an incidence of 1.1 per 10,000 anesthetics (95% CI, 0.7 to 1.6). Sixty-four percent of anesthesia-attributable cardiac arrests were caused by airway complications that occurred primarily with induction, emergence, or in the postanesthesia care unit, and mortality was 29%. Anesthesia-contributory cardiac arrest occurred during all phases of the anesthesia, and mortality was 70%. Conclusion:As judged by an independent study commission, anesthesia-related cardiac arrest occurred in 37 of 160 cardiac arrests within the 24-h perioperative period.

Experience with a program of faculty development.

The authors describe the faculty development program at the University of Nebraska Medical Center. Faculty needs were identified in instructional skill development, academic socialization and mentoring. Committees with campus-wide representation designed the instructional activities. Among the total 749 faculty, 59% attended at least one faculty development offering consisting of one and two-day institutes or two-hour luncheon workshops in the past five years. Evaluations ranked each event highly for quality, relevance, impact on teaching and usefulness. Experiences in creating a successful faculty development program at an academic medical center are reported. Success was measured by attendee numbers and increased participation of faculty in teaching and mentoring. Factors contributing to this success include generous financial support by leadership, broad-based planning and administrative support.

Fentanyl intermittent bolus technique for anesthesia in infants and children undergoing cardiac surgery

The use of fentanyl by an incremental intravenous (IV) bolus technique was evaluated in eight pediatric patients (ages 4 months to 5 years, ASA III-IV) undergoing corrective surgery for congenital heart defects. Anesthesia was induced with 5 to 10 micrograms/kg of fentanyl. Additional boluses of comparable size were given intermittently thereafter, in order that a total dose of 100 micrograms/kg was achieved just before instituting cardiopulmonary bypass (CPB). Heart rate, systolic blood pressure, various measures of anesthetic depth, and plasma fentanyl levels measured by radioimmunoassay were compared at various points during anesthesia, surgery, and recovery. Decreases in heart rate were observed at the time of sternal incision and at 30 minutes thereafter, when doses of fentanyl were near-maximal. No changes from baseline in systolic blood pressure or in anesthetic depth occurred at any of the intervals studied. The plasma concentration of fentanyl was 30 +/- 8 ng/mL just after completion of the fentanyl administration, immediately before CPB. With onset of CPB, the fentanyl level fell to 13 +/- 9 ng/mL, a statistically significant difference from the baseline value. No further change occurred over the additional 231 +/- 74 minutes in the operating room. The fentanyl concentration was 10 +/- 4 ng/mL upon entry into the recovery room. It is concluded that administration of fentanyl in small, intermittent IV boluses, with dosing completed before the onset of CPB, produces satisfactory plasma levels, anesthesia, and hemodynamic stability in children undergoing corrective surgery for congenital cardiac defects.

Unusual etiology of hyperkalemia in an immunocompromised patient

Hyperkalemia was found in an immunocompromised patient undergoing emergency cystoscopy. The cause of the hyperkalemia was an intraperitoneal rupture of the bladder. This case report discusses conditions that predispose patients to bladder rupture and anesthetic management of hyperkalemia.