Femoral neuropathy following a psoas hitch vesicopexy

A 68-year-old man classified as III on the American Society of Anaesthesiologists (ASA) physical status classification system, with a high-grade papillary urothelial cell carcinoma of the left distal ureter, underwent open retroperitoneal distal ureterectomy followed by a ureteroneocystostomy with a vesico-psoas hitch. Postoperatively, the patient complained of left proximal lower limb weakness, severe pain and hypaesthesia of the ventral left thigh suggestive of femoral neuropathy. After excluding common causes for postsurgical pain, a surgical re-exploration was eventually performed during which the sutures used in the vesicopexy were removed, resulting in almost complete resolution of the symptoms. Electromyographic analysis 4 weeks after discharge confirmed the diagnosis of femoral neuropathy, most likely caused by the sutures used in the vesicopexy. This is a rare complication with major consequences for postoperative recovery.

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Avoiding diagnostic delay for mucopolysaccharidosis IIIB: do not overlook common clues such as wheezing and otitis media

Mucopolysaccharidosis IIIB (MPS IIIB) is an autosomal recessive lysosomal storage disorder. In comparison to Hurler syndrome (MPS I) and Hunter syndrome (MPS II), characteristic facial and physical features tend to be milder and progression of neurological symptoms may initially be slower. Obvious neurological and behavioural symptoms may not appear until age 2–6 years, but once they begin, progression is relentless, leading to death by the early 20s. Although there is currently no known cure for MPS IIIB, enzyme replacement clinical trials are showing hope for delay in the progression of symptoms. Early diagnosis is therefore necessary before neurological symptoms have progressed. In our case, MPS IIIB was diagnosed at an early age because recurrent wheezing and otitis media in conjunction with hepatomegaly were recognised as more than trivial findings. A thorough examination and a definitive proactive decision to perform a liver biopsy resulted in early diagnosis of a rare disease.

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Frey syndrome following herpes zoster in an otherwise healthy girl

A 12-year-old girl presented with red spots appearing on the left side of her face. The girl was usually healthy and fully vaccinated, including varicella vaccination.

Six years prior to her presentation, she had suffered an episode of blister rash on the left side of her face, including lesions in the ear canal and buccal mucous membrane. A diagnosis of herpes zoster was made, and she was treated with acyclovir with complete skin recovery. A hearing examination demonstrated mild-to-moderate left neurosensory hearing loss.

Since then, she is having short episodes of redness on her face without pain or sweating at the exact distribution of the zoster blisters 6 years ago. The appearance of spots is related to sour foods, such as sour flavoured candies, yoghourt and green apples. The diagnosis of postherpetic Frey syndrome was made, and observational approach was adopted due to the benign character of symptoms.

https://ift.tt/2v0CBEa

Hepatitis C virus infection: 'beyond the liver

There are rare reports of association between hepatitis C virus (HCV) infection and dermatomyositis although cause and effect remains to be proven. We present a clinical case with a probable cause and effect association between these two entities. A 71-year-old woman developed an erythematous exanthem with pruritic and scaly lesions located at the torso and upper limbs associated with heliotrope and Gottron's papules. At the same time, she notice a significant loss of muscular strength. Skin and muscular biopsies made the diagnosis of dermatomyositis and the patient started with prednisolone (60 mg/day) with poor symptoms control. Paraneoplastic syndrome, HIV, hepatitis B virus and syphilis infections were excluded. HCV serology was positive, with a viral load of 58 159 IU/mL (genotype 1a). Therefore, the patient underwent a 12-week treatment with grazoprevir 100 mg and elbasvir 50 mg achieving a sustained virological response with regression of skin lesions and complete recovery of muscular strength (photodocumented before/after treatment). Additionally it was possible to reduce prednisolone dosage to 5 mg/day.

https://ift.tt/2LogO4q

Stroke-induced resolution of primary blepharospasm: evidence for the lenticular nucleus as a control candidate

Primary blepharospasm is an adult-onset focal dystonia characterised by involuntary contractions of the orbicularis oculi, leading to bilateral spasmodic closure of the eyelids. While spasms of this muscle constitute the hallmark of disease, other motor manifestations include increased spontaneous blinking and apraxia of eyelid opening. Originally misdiagnosed as a psychiatric condition, blepharospasm is now well established as being of neurological origin although questions remain as to its pathophysiological mechanisms.

We report a 66-year-old woman who had a 14-year history of primary blepharospasm which completely resolved following a left medial cerebral artery thromboembolic infarct of the lenticular nucleus. This report provides supporting evidence of the lenticular nucleus as a key structure mediating the disease which can lead to functional blindness.

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Erratum: Different transseptal puncture for different procedures: Optimization of left atrial catheterization guided by transesophageal echocardiography

Annals of Cardiac Anaesthesia 2018 21(3):346-346



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A curious case of raised gradient across mitral bioprosthetic valve

Monish S Raut, Vijay Mohan Hanjoora, Murtaza A Chishti, Akhil Govil, Rakesh Pandey, Aman Jyoti, Ravi Kumar Mahavar, Shweta Suri Kandpal, Dileep Kumar Singh Rathor

Annals of Cardiac Anaesthesia 2018 21(3):321-322

High Doppler valve gradient is generally suggestive of valve thrombosis. However, it should be corroborated with the finding of restricted leaflet movement to confirm the diagnosis. In the present case, abnormally high gradient was not associated with limited leaflet movements or any valve thrombus.

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Neurogenic stress cardiomyopathy: What do we need to know

Ramachandran Gopinath, Syama Sundar Ayya

Annals of Cardiac Anaesthesia 2018 21(3):228-234

The interaction between the heart and brain is complex and integral to the maintenance of normal cardiovascular function. Even in the absence of coronary disease, acute neuronal injury can induce a variety of cardiac changes. Recent neuroimaging data revealed a network including the insular cortex, anterior cingulate gyrus, and amygdala playing a crucial role in the regulation of central autonomic nervous system. Damage in these areas has been associated with arrhythmia, myocardial injury, higher plasma levels of brain natriuretic peptide, catecholamines, and glucose. Some patients after brain injury may die due to occult cardiac damage and functional impairment in the acute phase. Heart failure adversely influences acute stroke mortality. Troponin and NT-proBNP are elevated in acute brain injury patients, in response to the activated renin–angiotensin–aldosterone system and other neurohumoral changes, as a protective mechanism for sympathoinhibitory activity. Such patients have been shown to be associated with higher short- and long-term mortality. While thrombolysis, neuroprotection, and other measures, alone or in combination, may limit the cerebral damage, attention should also be directed toward the myocardial protection. Early administration of cardioprotective medication aimed at reducing increased sympathetic tone may have a role in myocardial protection in stroke patients. For a full understanding of the brain–heart control, the consequences of disruption of this control, the true incidence of cardiac effects of stroke, and the evidence-based treatment options further research are needed.

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Refractory hypokalemia while weaning off bypass

Rashmi Soori, Aanchal Dixit, Prabhat Tewari

Annals of Cardiac Anaesthesia 2018 21(3):311-312

Hypokalemia is defined as serum potassium level less than 3.5 mEq/L. When the serum level of potassium is less than 3 mEq/L, intravenous potassium supplementation is warranted. A 23 yr old adult female with complaints of dyspnoea (NYHA II) since 6 yrs, dyspnoea (NYHA III) and paroxysmal nocturnal dyspnoea on and off since 2 months, diagnosed with severe mitral stenosis, was posted for mitral valve replacement. After the release of ACC, ECG revealed sine wave pattern, Transesophageal echocardiographic examination revealed global hypokinesia and ABG showed potassium of 2.3 mEq/L. Hypokalemia in cardiac patients can occur due to the effect of poor oral intake, increased renal loss by the secondary hyperaldosteronism in congestive heart failure, loss due to use of digoxin and diuretics like thiazide diuretics, loop diuretics etc. Hypokalemia should be avoided while weaning off cardiopulmonary support as it can lead to atrial and ventricular arrhythmias. Potassium ion is very important for the normal contractility of the heart. Hypokalemia if refractory to intravenous potassium supplementation, concomitant magnesium deficiency should be suspected and treated.

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Sedation effects by dexmedetomidine versus propofol in decreasing duration of mechanical ventilation after open heart surgery

Ahmed Said Elgebaly, Mohab Sabry

Annals of Cardiac Anaesthesia 2018 21(3):235-242

Objective: The objective of this study was to compare the suitability (efficacy and safety) of dexmedetomidine versus propofol for patients admitted to the intensive care unit (ICU) after the cardiovascular surgery for the postoperative sedation before weaning from mechanical ventilation. Background: Sedation is prescribed in patients admitted to the ICU after cardiovascular surgery to reduce the patient discomfort, ventilator asynchrony, to make mechanical ventilation tolerable, prevent accidental device removal, and to reduce metabolic demands during respiratory and hemodynamic instability. Careful drug selection for sedation by the ICU team, postcardiovascular surgery should be done so that patients can be easily weaned from mechanical ventilation after sedation is stopped to achieve a shorter duration of mechanical ventilation and decreased the length of stay in ICU. Methods: A total of 50 patients admitted to the ICU after cardiovascular surgery, aged from 18 to 55 years and requiring mechanical ventilation on arrival to the ICU were enrolled in a prospective and comparative study. They were randomly divided into two groups as follows: Group D patients (n = 25) received dexmedetomidine in a maintenance infusion dose of 0.8 μg/kg/h and Group P patients (n = 25) received propofol in a maintenance infusion dose of 1.5 mg/kg/h. The patients were assessed for 12 h postoperatively, and dosing of the study drug was adjusted based on sedation assessment performed with the Richmond Agitation-Sedation Scale (RASS). The patients were required to be within the RASS target range of −2 to +1 at the time of study drug initiation. At every 4 h, the following information was recorded from each patient such as heart rate (HR), mean arterial pressure (MAP), arterial blood gases (ABG), tidal volume (TV), exhaled TV, maximum inspiratory pressure, respiratory rate and the rapid shallow breathing index, duration of mechanical ventilation, midazolam and fentanyl dose requirements, and financial costs. Results: The study results showed no statistically significant difference between both groups with regard to age and body mass index. Group P patients were more associated with lower MAP and HR than Group D patients. There was no statistically significant difference between groups with regard to ABG findings, oxygenation, ventilation, and respiratory parameters. There was significant difference between both the groups in midazolam and fentanyl dose requirement and financial costs with a value of P < 0.05. Conclusion: Dexmedetomidine is safer and equally effective agent for the sedation of mechanically ventilated patients admitted to the ICU after cardiovascular surgery compared to the patients receiving propofol, with good hemodynamic stability, and equally rapid extubation time.

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Transesophageal echocardiography guidance for expedited pulmonary artery catheter insertion and accurate estimation of cardiac output

Monish S Raut, Vijay Mohan Hanjoora, Murtaza A Chisti

Annals of Cardiac Anaesthesia 2018 21(3):339-340



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Quest for the holy grail: Assessment of echo-derived dynamic parameters as predictors of fluid responsiveness in patients with acute aneurysmal subarachnoid hemorrhage

Ajay Prasad Hrishi, Manikandan Sethuraman, Girish Menon

Annals of Cardiac Anaesthesia 2018 21(3):243-248

Background: Acute aneurysmal subarachnoid hemorrhage (aSAH) is a potentially devastating event often presenting with a plethora of hemodynamic fluctuations requiring meticulous fluid management. The aim of this study was to assess the utility of newer dynamic predictors of fluid responsiveness such as Delta down (DD), superior vena cava collapsibility index (SVCCI), and aortic velocity time integral variability (VTIAoV) in patients with SAH undergoing neurosurgery. Materials and Methods: Fifteen individuals with SAH undergoing surgery for intracranial aneurysmal clipping were enrolled in this prospective study. Postinduction, vitals, anesthetic parameters, and the study variables were recorded as the baseline. Following this, patients received a fluid bolus of 10 ml/kg of colloid over 20 min, and measurements were repeated postfluid loading. Continuous variables were expressed as mean ± standard deviation and compared using Student's t-test, with a P < 0.05 considered statistically significant. The predictive ability of variables for fluid responsiveness was determined using Pearson's coefficient analysis (r). Results: There were 12 volume responders and 3 nonresponders (NR). DD >5 mm Hg was efficient in differentiating the responders from NR (P < 0.05) with a sensitivity and specificity of 90% and 85%, respectively, with a good predictive ability to identify fluid responders and NR; r = 0.716. SVCCI of >38% was 100% sensitive and 95% specific in detecting the volume status and in differentiating the responders from NR (P < 0.05) and is an excellent predictor of fluid responsive status; r = 0.906. VTIAoV >20% too proved to be a good predictor of fluid responsiveness, with a sensitivity and specificity of 100% and 90%, respectively, with a predictive power; r = 0.732. Conclusion: Our study showed that 80% of patients presenting with aSAH for intracranial aneurysm clipping were fluid responders with normal hemodynamic parameters such as heart rate and blood pressure. Among the variables, SVCCI >38% appears to be an excellent predictor followed by VTIAoV >20% and DD >5 mmHg in assessing the fluid status in this population.

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Concomitant diaphragmatic hernia repair with coronary artery bypass grafting surgery

Gokulakrishnan Mohan, Srinivas Kalyanaraman, Sivakumar Ramakrishnan, Sanjay Theodore

Annals of Cardiac Anaesthesia 2018 21(3):304-306

Congenital Bochdalek diaphragmatic hernia (DH) is often diagnosed incidentally in adulthood. It is recommended that all cases of DH be repaired immediately at diagnosis since acute presentation after the complications have already developed has higher morbidity and mortality. A 47-year-old male presented with Grade III angina and dyspnea. A routine chest radiograph revealed bowel shadows in the right thorax, and subsequent computerized tomography (CT) scan confirmed the same. Coronary angiogram revealed coronary artery disease which needed surgery. Off-pump coronary artery bypass grafting followed by DH repair under one-lung ventilation.

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Barriers for the referral to outpatient cardiac rehabilitation: A predictive model including actual and perceived risk factors and perceived control

Ali Soroush, Behzad Heydarpour, Saeid Komasi, Mozhgan Saeidi, Parvin Ezzati

Annals of Cardiac Anaesthesia 2018 21(3):249-254

Objective: To assess the roles of demographic factors, actual and perceived risk factors, and perceived control in the referral to cardiac rehabilitation (CR) after coronary artery bypass graft (CABG). Methods: In this cross-sectional study, data related to 312 CABG patients in a hospital of the Western part of Iran, gathered through demographics and actual risk factors' checklist, open single item of perceived heart risk factors, life stressful events scale, and perceived control questionnaire. Data analyzed by binary logistic regression. Results: The results showed that only 8.3% of CABG patients refer to CR. The facilitators of this referral included official employment (P < 0.05), coronary history (P = 0.016), and hyperlipidemia (P = 0.030) but more distance to the CR center (P = 0.042) and perceived physiological risk factor (P = 0.025) are concerned as the barriers for the referral to CR. Conclusion: Providing appropriate awareness about the benefits of CR for patients with regard to their job status, coronary history, and perception about the illness risk factors can be effective in referral to CR. In addition, the presence of CR centers in towns and facilitated achievement to these centers can play a significant role in patients' participation.

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Abnormal mitral valve apparatus in a case of hypertrophic obstructive cardiomyopathy: Intraoperative transesophageal echocardiography

Neelam Aggarwal, Jasbir Singh Khanuja, Sameer Saurabh Arora, Rahul Maria

Annals of Cardiac Anaesthesia 2018 21(3):315-318

Hypertrophic obstructive cardiomyopathy is a relatively common disorder that signifies asymmetric hypertrophy of interventricular septum causing obstruction of the left ventricular outflow tract (LVOT). However, more recent studies have shown that during ventricular systole, flow against an abnormal mitral valve apparatus results in drag forces on the part of the leaflets. The mitral leaflet is pushed into the LVOT to obstruct it. We present a case where intraoperative transesophageal echocardiography played a crucial role in defining the etiology of LVOT obstruction that subsequently helped in deciding the surgical plan.

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Prospective, randomized clinical trial comparing use of intraoperative transesophageal echocardiography to standard care during radical cystectomy

Richa Dhawan, Sajid Shahul, Joseph Devin Roberts, Norm D Smith, Gary D Steinberg, Mark A Chaney

Annals of Cardiac Anaesthesia 2018 21(3):255-261

Purpose: Our prospective, randomized clinical study aims to evaluate the utility of intraoperative transesophageal echocardiography (TEE) in patients undergoing radical cystectomy. Materials and Methods: Eighty patients were randomized to a standard of care group or the intervention group that received continuous intraoperative TEE. Data are presented as means ± standard deviations, median (25th percentile, 75th percentile), or numbers and percentages. Characteristics were compared between groups using independent sample t-tests, Wilcoxon–Mann–Whitney tests or Chi-square tests, as appropriate. All tests were two-sided and P < 0.05 was considered to indicate statistical significance. Results: Both groups had similar preoperative demographic characteristics. There was a significant difference between central line insertion with all insertions in the control group (15%, 6 vs. 0%, 0; P < 0.003). Of all the perioperative complications, 80% occurred in the control group versus 20% in the TEE group, with 21% of controls experiencing a cardiac or pulmonary complication compared to 5% in the TEE group (8 vs. 2, P < 0.04). The control group patients were more likely to have adverse cardiac complications than the TEE group (15%, 6 vs. 3%, 1; P < 0.040). Postoperative cardiac arrhythmia was observed only in the control group (13%, 5 vs. 0%, 0; P <.007). Prolonged intubation was only observed in the control group (10%, 4 vs. 0%, 0; P < 0.017). Conclusion: TEE can be a useful monitoring tool in patients undergoing radical cystectomy, limiting the use of central line insertion and potentially translating into earlier extubation and decreased postoperative cardiac morbidities.

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Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement

Tanveer Singh Kundra, PS Nagaraja, KS Bharathi, Parminder Kaur, N Manjunatha

Annals of Cardiac Anaesthesia 2018 21(3):328-332

Context: Inhaled levosimendan may act as selective pulmonary vasodilator and avoid systemic side effects of intravenous levosimendan, which include decrease in systemic vascular resistance (SVR) and systemic hypotension, but with same beneficial effect on pulmonary artery pressure (PAP) and right ventricular (RV) function. Aim: The aim of this study was to compare the effect of inhaled levosimendan with intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Settings and Design: The present prospective randomized comparative study was conducted in a tertiary care hospital. Subjects and Methods: Fifty patients were randomized into two groups (n = 25). Group A: Levosimendan infusion was started immediately after coming-off of cardiopulmonary bypass and continued for 24 h at 0.1 mcg/kg/min. Group B: Total dose of levosimendan which would be given through intravenous route over 24 h was calculated and then divided into four equal parts and administered through inhalational route 6th hourly over 24 h. Hemodynamic profile (pulse rate, mean arterial pressure, pulmonary artery systolic pressure [PASP], SVR) and RV function were assessed immediately after shifting, at 1, 8, 24, and 36 h after shifting to recovery. Statistical Analysis Used: Intragroup analysis was done using paired student t-test, and unpaired student t-test was used for analysis between two groups. Results: PASP and RV-fractional area change (RV-FAC) were comparable in the two groups at different time intervals. There was a significant reduction in PASP and significant improvement in RV-FAC with both intravenous and inhalational levosimendan. SVR was significantly decreased with intravenous levosimendan, but no significant decrease in SVR was observed with inhalational levosimendan. Conclusions: Inhaled levosimendan is a selective pulmonary vasodilator. It causes decrease in PAP and improvement in RV function, without having a significant effect on SVR.

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A Low-dose human fibrinogen is not effective in decreasing postoperative bleeding and transfusion requirements during cardiac surgery in case of concomitant clinical bleeding and low FIBTEM values: A retrospective matched study

Iuliana-Marinela Lupu, Zineb Rebaine, Laurence Lhotel, Christine Watremez, Stéphane Eeckhoudt, Michel Van Dyck, Mona Momeni

Annals of Cardiac Anaesthesia 2018 21(3):262-269

Background: Studies evaluating the hemostatic effects of fibrinogen administration in cardiac surgery are not conclusive. Aims: We investigated whether the use of a low-dose human fibrinogen in case of clinical bleeding after protamine administration and concomitant low FIBTEM values is effective in reducing postoperative bleeding. Secondary end-point was to investigate the consumption of allogeneic blood products. Setting and Design: This was a retrospective matched study conducted at university hospital. Materials and Methods: Among 2257 patients undergoing surgery with cardiopulmonary (CPB) bypass, 73 patients received a median dose of 1 g human fibrinogen (ROTEM-Fibri group). This group was matched with 73 patients who had not received human fibrinogen (control group) among 390 patients having undergone surgery at the moment FIBTEM analysis was unavailable. Statistical Analysis: Matching was performed for the type and the presence of redo surgery. McNemar and Wilcoxon paired tests were used to respectively compare the categorical and quantitative variables. Results: The CPB bypass time was significantly higher in the ROTEM-Fibri group (P = 0.006). This group showed significantly higher bleeding in the first 12 and 24 h postoperatively (P < 0.001) and required significantly more transfusion of blood products (P < 0.001) and surgical revision (P = 0.007) when compared with the control group. There was no significant difference in the number of thromboembolic complications. Conclusions: These results show that the administration of 1 g of fibrinogen based on low-FIBTEM values and clinical bleeding after protamine administration does not stop bleeding and the need for transfusion of allogeneic blood products.

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Sustained ventricular arrhythmias in an asymptomatic child posted for laparoscopic rectopexy: An anesthetist's dilemma?

Kavya R Upadhya, Chandrika Y Ramavakoda, Madhavi Ravindra, Anuradha Ganigara

Annals of Cardiac Anaesthesia 2018 21(3):343-344



https://ift.tt/2mHjrPP

Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study

Kunal Sarin, Sandeep Chauhan, Akshay Kumar Bisoi, Anjali Hazarika, Neena Malhotra, Pratik Manek

Annals of Cardiac Anaesthesia 2018 21(3):270-274

Background: Blood transfusion requirement during neonatal open heart surgeries is universal. Homologous blood transfusion (HBT) in pediatric cardiac surgery is used most commonly for priming of cardiopulmonary bypass (CPB) system and for postoperative transfusion. To avoid the risks associated with HBT in neonates undergoing cardiac surgery, use of autologous umbilical cord blood (AUCB) transfusion has been described. We present our experience with the use of AUCB for neonatal cardiac surgery. Designs and Methods: Consecutive neonates scheduled to undergo cardiac surgery for various cardiac diseases who had a prenatal diagnosis made on the basis of a fetal echocardiography were included in this prospective observational study. After a vaginal delivery or a cesarean section, UCB was collected from the placenta in a 150-mL bag containing 5 mL of citrate–phosphate–dextrose–adenine-1 solution. The collected bag with 70–75 mL cord blood was stored at 2°C–6°C and tested for blood grouping and infections after proper labeling. The neonate's autologous cord blood was used for postcardiac surgery blood transfusion to replace postoperative blood loss. Results: AUCB has been used so far at our institute in 10 neonates undergoing cardiac surgery. The donor exposure in age and type of cardiac surgery-matched controls showed that the neonates not receiving autologous cord blood had a donor exposure to 5 donors (2 packed red blood cells [PRBCs], including 1 for CPB prime and 1 for postoperative loss, 1 fresh frozen plasma, 1 cryoprecipitate, and 1 platelet concentrate) compared to 1 donor for the AUCB neonate (1 PRBC for the CPB prime). Postoperative blood loss was similar in both the groups of matched controls and study group. Values of hemoglobin, total leukocyte count, platelet counts, and blood gas parameters were also similar. Conclusions: Use of AUCB for replacement of postoperative blood loss after neonatal cardiac surgery is feasible and reduces donor exposure to the neonate. Its use, however, requires a prenatal diagnosis of a cardiac defect by fetal echo and adequate logistic and psychological support from involved clinicians and the blood bank.

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Regional analgesia in cardiothoracic surgery: A changing paradigm toward opioid-free anesthesia?

Murali Chakravarthy

Annals of Cardiac Anaesthesia 2018 21(3):225-227



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In Response to “Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study”

Praveen Kumar Neema

Annals of Cardiac Anaesthesia 2018 21(3):275-276



https://ift.tt/2AbUyp2

The unexpected diagnosis of phaeochromocytoma in the anaesthetic room

Louise Kenny, Victoria Rizzo, Jason Trevis, Elena Assimakopoulou, Dierdre Timon

Annals of Cardiac Anaesthesia 2018 21(3):307-310

A 77-year-old man was admitted for aortic valve replacement and combined coronary bypass grafting. Grossly, labile arterial pressures were demonstrated on anesthetic induction prompting cancellation and Intensive Care Unit transfer. Urine analysis identified high normetadrenaline/creatinine ratio, plasma metanephrine, and plasma normetanephrine. A left adrenal lesion on computed tomography scan collectively indicated pheochromocytoma. Laparoscopic adrenalectomy was prioritized at multidisciplinary team before cardiac surgery. Vague symptoms of pheochromocytoma pose a diagnostic problem, being often attributed to common/co-existing pathology. The blood pressure instability on anesthetic required precise control, multidisciplinary input, and awareness of possible diagnosis as a routine intervention for hypotension may have been fatal in view of underlying cardiac pathology.

https://ift.tt/2mKnvz4

Transcatheter aortic valve implantation: General anesthesia using transesophageal echocardiography does not decrease the incidence of paravalvular leaks compared to sedation alone

Cédrick Zaouter, Sara Smaili, Lionel Leroux, Guillaume Bonnet, Sébastien Leuillet, Alexandre Ouattara

Annals of Cardiac Anaesthesia 2018 21(3):277-284

Background: Transcatheter aortic valve implantation (TAVI) is a valid option for patients with severe aortic stenosis judged to be at high surgical risk. For this procedure, there is no agreement on the appropriate type of anesthesia. Sedation offers several advantages, but general anesthesia (GA) leads to less paravalvular leaks (PVLs) probably because of the transesophageal echocardiography (TEE) guidance. The objective was to compare the incidence of PVL among patients receiving conscious sedation (TAVI-S) and patients receiving GA (TAVI-GA). We made the hypothesis that a referral center does not necessitate TAVI-GA to reduce the incidence of moderate-to-severe PVL. Aim: The primary outcome was the incidence of moderate-to-severe PVL at 30 days after the implantation. Design and Setting: This study design was a retrospective observational trial in a university hospital. Methods: The TAVI-S group underwent the procedure under conscious sedation. In the TAVI-GA group, an endotracheal tube and a TEE probe were inserted. After the valve deployment, PVL was assessed by hemodynamic and fluoroscopic measurements in the TAVI-S group. TEE was also used in the TAVI-GA group to evaluate the presence of PVL. When PVL was moderate or severe according to the Valve Academic Research Consortium criteria. Results: TAVI-S and TAVI-GA were accomplished in 168 (67.5%) and 81 (32.5%) patients, respectively. Our results show no difference between the two groups regarding the incidence and grade of PVL. Conclusion: Performing TAVI under GA with TEE guidance is not associated with a lower incidence of moderate and severe PVL.

https://ift.tt/2A79C7o

Echocardiographic evaluation of aorta to right atrial fistula secondary to ruptured sinus of valsalva aneurysm

Ashley V Fritz, Kathryn S Boles, Archer Kilbourne Martin

Annals of Cardiac Anaesthesia 2018 21(3):313-314

We present the case of a 37 year old male who presented with new onset dyspnea, tachycardia, palpitations, and chest tightness. His initial work up demonstrated a dilated pulmonary artery with reflux of contrast dye in to the IVC. Transthoracic echocardiogram identified a "windsock" appearance indicating Sinus of Valsalva aneurysm (SVA) and severe aortic regurgitation. As a result, the patient was taken for emergent surgery where the windsock tissue was surgically repaired with bovine pericardial patch. This case illuminates the uncommon occurrence of SVA and the ability to recognize these findings on multiple imaging modalities including transthoracic, transesophageal two and three dimensional echocardiography as well as direct surgical field visualization.

https://ift.tt/2mHj9sd

Ocriplasmin in the Treatment of Vitreomacular Traction in a Patient with Central Retinal Vein Occlusion: A Case Report

Aim: To investigate the efficacy of intravitreal injection of ocriplasmin (JETREA®) in the treatment of vitreomacular traction (VMT). Materials and Methods: An 81-year-old man with VMT associated with central retinal vein occlusion in his left eye, was treated with a single intravitreal injection of ocriplasmin (25 μg). Best corrected visual acuity (BCVA), ocular fundus, and optical coherence tomography were examined before and after treatment. Results: Complete release of VMT produced a reduction of central macular thickness, ranging from 459 to 141 μm. BCVA remained stable. Discussion and Conclusions: The use of ocriplasmin was effective in the treatment of VMT. Ocriplasmin represents a valid alternative to conventional pars plana vitrectomy.
Case Rep Ophthalmol 2018;9:357–364

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Repeated Testing With the Hypertonic Saline Assay in Mice for Screening of Analgesic Activity

BACKGROUND: In vivo animal assays are a cornerstone of preclinical pain research. An optimal stimulus for determining the activity of potential analgesics would produce responses of a consistent magnitude on repeated testing. Intraplantar (i.pl.) injection of hypertonic saline (HS) in mice produces robust nociceptive responses to different analgesics, without evidence of tissue damage. Here, we investigated whether the nociceptive response is changed by repeating the injection at different times and sites in a mouse and whether it is attenuated by morphine. METHODS: We conducted randomized and blinded experiments to assess responses to repeated i.pl. 10% HS in female CD-1 mice. An injection of HS was followed by a second injection into the same hind paw at 4 hours, 24 hours, or 7 days. A separate group of mice each received i.pl. injections at 5, 10, and 15 days. In 2 independent experiments, 30 minutes after initial HS injections in the ipsilateral hind paw, mice received HS injection into the contralateral hind paw or ipsilateral forepaw. The ability of morphine to block the nociceptive responses was examined by injecting morphine at 5-day intervals. RESULTS: Repeated injection of HS did not alter the responses at 4 hours (84 vs 75 seconds; mean difference [95% CI], −9 [−40 to 23]; P = .6), 24 hours (122 vs 113 seconds; −6 [−24 to 12]; P = .5), or 7 days (112 vs 113 seconds; −0.3 [−12 to 11]; P = .95) or at multiple injections (day 0, 122 seconds vs day 5, 121 seconds; −0.3 [−28 to 27], P > .99; day 10, 118 seconds; 2.5 [−36 to 41], P = .99; day 15, 119 seconds; 2 [−36 to 38], P = .99). A previous hind paw injection did not change the responses of the contralateral hind paw (right, 93 seconds versus left, 96 seconds; −3 [−20 to 13], P = .7) or of the ipsilateral forepaw (forepaw after HS, 146 seconds versus forepaw after 0.9% saline, 149 seconds; −3 [−28 to 22], P = .8). Morphine dose-dependently attenuated HS responses (control, 94 seconds versus 4 mg/kg, 66 seconds; 29 [−7 to 64], P = .12; versus 10 mg/kg, 27 seconds; 67 [44–90], P

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Minimum Alveolar Concentration-Awake of Sevoflurane Is Decreased in Patients With End-Stage Renal Disease

BACKGROUND: End-stage renal disease (ESRD) has been shown to be associated with abnormal neural function. Clinically used inhaled anesthetic agents typically exert their effect through multiple target receptors in the central nervous system. Pathological changes in the brain may alter sensitivity to inhaled anesthetic agents. This study aimed to determine the minimum alveolar concentration-awake (MACawake) of sevoflurane in patients with ESRD compared to patients with normal renal function. METHODS: Patients underwent inhalational induction of anesthesia and received sevoflurane at a preselected concentration according to a modified Dixon "up-and-down" method starting at 1.0% with a step size of 0.2%. The concentration of sevoflurane used for each consecutive patient was increased or decreased based on a positive or negative response to verbal command in the previous patient. Serum neuron-specific enolase, a biomarker of impaired neurons, was also measured. RESULTS: Forty-one patients were enrolled: 20 with ESRD and 21 as controls. The MACawake of sevoflurane in patients with ESRD was significantly lower than that observed in the control group (0.56% [standard deviation {SD} = 0.10%] vs 0.67% [SD = 0.08%]; P = .031). Patients with ESRD exhibited higher serum neuron-specific enolase levels compared to the control group (16.4 ng/mL [SD = 5.0] vs 8.7 ng/mL [SD = 2.9]; P

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Perceptions of Perioperative Stroke Among Chinese Anesthesiologists: Starting a Long March to Eliminate This Underappreciated Complication

No abstract available

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Preoperative Continuation Versus Interruption of Oral Hypoglycemics in Type 2 Diabetic Patients Undergoing Ambulatory Surgery: A Randomized Controlled Trial

Patients with type 2 diabetes mellitus receiving oral hypoglycemic drugs (OHDs) are usually instructed to stop them before surgery. We hypothesize that continuing OHD preoperatively should result in lower perioperative blood glucose (BG) levels. Ambulatory surgery patients with type 2 diabetes mellitus on OHDs were randomized to continue (n = 69) or withhold (n = 73) OHDs preoperatively. Log-transformed BG levels at pre-, intra-, and postoperative periods were analyzed. Perioperative BG levels were significantly lower (mean, 138 mg/dL; 95% confidence interval, 130–146 mg/dL) in the group that continued versus the group that discontinued OHDs (mean, 156 mg/dL; 95% confidence interval, 146–167 mg/dL; P

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Capnography, Esophageal Intubation, and Capnomanaging Cardiac Arrests in the Operating Room

No abstract available

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Influence of Nasal Tip Lifting on the Incidence of the Tracheal Tube Pathway Passing Through the Nostril During Nasotracheal Intubation: A Randomized Controlled Trial

BACKGROUND: For safe nasotracheal intubation without middle turbinate injury, the tracheal tube should pass through the lower pathway, which is beneath the inferior turbinate and immediately above the nasal floor of the nostril. The purpose of this study was to assess the influence of nasal tip lifting on the incidence of passing preformed nasal Ring-Adair-Elwyn (RAE) tubes through the lower pathway during nasotracheal intubation. METHODS: Patients were randomly assigned to a "nasal tip lifting group" or a "neutral group." For patients in the nasal tip lifting group, an investigator pulled the nasal tip in a cephalad direction when inserting a preformed nasal RAE tube into the nostril after induction of anesthesia. For patients in the neutral group, a tube was inserted with the nasal tip in a neutral position. The pathway by which the tube passed in each patient was identified using a fiberscope. The incidence of the tube passing through the lower pathway was compared between the 2 groups. The incidence of epistaxis was also evaluated. RESULTS: Eighty-six patients were enrolled and completed the study protocol. The incidence of the tracheal tube passing through the lower pathway was significantly higher in the nasal tip lifting group (79.1%) than in the neutral group (51.2%) (relative risk, 1.55; 95% confidence interval, 1.11–2.15; P = .007). Although the incidence of epistaxis was not different between the groups (18.6% vs 32.6%; P = .138), it was lower when the tracheal tube passed nasal cavity through the lower pathway (14.3%) than the upper pathway (46.7%), regardless of the randomized group with adjustment for potentially confounding variables (odds ratio, 0.19; 95% confidence interval, 0.07–0.54; P = .002). CONCLUSIONS: The nasal tip lifting maneuver helped to guide preformed nasal RAE tubes into the lower pathway during nasotracheal intubation. Accepted for publication June 18, 2018. Funding: None. The authors declare no conflicts of interest. Clinical trial number and registry URL: ClinicalTrials.gov (NCT03102255) (https://ift.tt/2v6X4Ya). Reprints will not be available from the authors. Address correspondence to Jung-Man Lee, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Republic of Korea. Address e-mail to jungman007@gmail.com. © 2018 International Anesthesia Research Society

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A Survey of Charge Sensitivity and Charge Awareness Among Intensive Care Unit Providers in a Large Academic Medical Center

Little is known about charge sensitivity or charge awareness among intensive care unit (ICU) providers in the United States. In a survey of 295 ICU providers at a large, academic medical center, 92.5% of respondents agreed that controlling health care expenses is partly their responsibility. However, 87.4% of respondents reported that they did not know the charges for most of the tests and medications they prescribe. Among surveyed participants, the correct charge for a medical procedure or test was selected only 35% of the time. While ICU providers overwhelmingly agree that controlling expenses is their responsibility, charge awareness is low and likely limits their ability to make value-based decisions. Accepted for publication June 19, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Adam J. Kingeter, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Ave S MAB 422, Nashville, TN 37232. Address e-mail to Adam.Kingeter@vanderbilt.edu. © 2018 International Anesthesia Research Society

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Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1

No abstract available

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Dynamic Indices: Use With Caution in Spontaneously Breathing Patients

No abstract available

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Pharmacological Characters of Oliceridine, a μ-Opioid Receptor G-Protein[FIGURE DASH]Biased Ligand in Mice

BACKGROUND: A major advancement in the field of analgesic pharmacology has been the development of G-protein[FIGURE DASH]biased opioid agonists that display less respiratory depression than conventional drugs. It is uncertain, however, whether these new drugs cause less tolerance, hyperalgesia, and other maladaptations when administered repeatedly. METHODS: The archetypical µ-opioid receptor agonist morphine and, separately, the G-protein[FIGURE DASH]biased µ-opioid receptor agonist oliceridine were administered to mice. These drugs were used in models of acute analgesia, analgesic tolerance, opioid-induced hyperalgesia, reward, and physical dependence. In addition, morphine and oliceridine were administered for 7 days after tibia fracture and pinning; mechanical allodynia and gait were followed for 3 weeks. Finally, the expression of toll-like receptor-4 and nacht domain-, leucine-rich repeat-, and pyrin domain-containing protein 3 (NALP3) and interleukin-1β mRNA were quantified in spinal tissue to measure surgical and drug effects on glia-related gene expression. RESULTS: We observed using the tail flick assay that oliceridine was a 4-fold more potent analgesic than morphine, but that oliceridine treatment caused less tolerance and opioid-induced hyperalgesia than morphine after 4 days of ascending-dose administration. Using similar analgesic doses, morphine caused reward behavior in the conditioned place preference assay while oliceridine did not. Physical dependence was, however, similar for the 2 drugs. Likewise, morphine appeared to more significantly impair the recovery of nociceptive sensitization and gait after tibial fracture and pinning than oliceridine. Furthermore, spinal cord toll-like receptor-4 levels 3 weeks after fracture were higher in fracture mice given morphine than those given oliceridine. CONCLUSIONS: Aside from reduced respiratory depression, G-protein[FIGURE DASH]biased agonists such as oliceridine may reduce opioid maladaptations and enhance the quality of surgical recovery. Accepted for publication June 12, 2018. Funding: This study was supported by VA Merit Review Grant I01BX000881 to J.D.C. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to De-Yong Liang, PhD, and J. David Clark, MD, PhD, Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA. Address e-mail to dyliang@stanford.edu and djclark@stanford.edu. © 2018 International Anesthesia Research Society

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Do Epidural Catheter Size and Flow Rate Affect Bolus Injection Pressure in Different Programmed Intermittent Epidural Bolus Regimens? An In Vitro Study

BACKGROUND: The optimal programmed intermittent epidural bolus regimen for labor analgesia remains unknown. Some studies indicate that better drug spread in the epidural space results from greater injection pressure; however, there is a lack of data regarding the maximum pressure generated by epidural bolus injection using different catheters and flow rates. METHODS: We evaluated the flow and pressure characteristics of 11 commonly used epidural catheters combined with 3 different infusion pumps that deliver epidural infusions according to the programmed intermittent epidural bolus regimen. Pressure changes were measured over time at flow rates of 100, 250, and 400 mL·hour−1 and with a bolus volume of 10 mL. To account for repeated measures, linear mixed models were used. Features were selected with a backward stepwise procedure continued until only statistically significant variables were left in the model. RESULTS: We performed 660 measurements. The mean maximal pressure generated during bolus injection ranged from 86 to 863 mm Hg for different flow rates and catheter designs. The interaction between flow rate and catheter gauge resulted in 1.31, 1.65, and 2.00 mm Hg of pressure increase for 18G, 19G, and 20G catheters, respectively, per 1 mL·hour−1 of increased flow rate (P

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Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Total Hip Arthroplasty

Successes using enhanced recovery after surgery (ERAS) protocols for total hip arthroplasty (THA) are increasingly being reported. As in other surgical subspecialties, ERAS for THA has been associated with superior outcomes, improved patient satisfaction, reduced length of hospital stay, and cost savings. Nonetheless, the adoption of ERAS to THA has not been universal. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after THA. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, ventilation, tranexamic acid, fluid minimization, glycemic control), and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for THA. There is evidence in the literature and from society guidelines to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for THA. Accepted for publication June 12, 2018. Funding: This project was funded under contract number HHSP233201500020I from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services. Conflicts of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Christopher L. Wu, MD, Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021. Address e-mail to chwu@jhmi.edu. © 2018 International Anesthesia Research Society

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