Clin Anesth Research Articles

Effect of Subcutaneous Unfractionated Heparin Prophylaxis on Activated Partial Thromboplastin Time

(Abstracted from J Clin Anesth, 33:346–350, 2016) It has been estimated that venous thromboembolism (VTE), including pulmonary embolism and deep vein thrombosis, occurs in 17 cases per 100,000 patients in the general population every year. Age (especially age >70 years), comorbid conditions (malignancy, history of VTE, pregnancy, and congestive heart failure), reduced mobility, and recent surgery or trauma increase the risk of VTE.

Preoperative Paracetamol Improves Post-Cesarean Delivery Pain Management

(Abstracted from J Clin Anesth, 33:51–57, 2016) Pain is the most common complaint of women after a cesarean delivery. It hinders mother-child bonding, and inadequate pain management leads to postpartum depression and chronic pain development.

A Retrospective Study Showing the Extent of Compliance With Perioperative Guidelines in Patients With Coronary Stents With Regard to Double Antiplatelet Therapy

(Abstracted from J Clin Anesth, 33:179–184, 2016) In patients with obstructive coronary artery disease, therapy using percutaneous coronary intervention with bare-metal stent and drug-eluting stent placement has been found to be very effective despite challenges to the perioperative management of these patients. Dual antiplatelet therapy (DAPT), specifically a P2Y12 receptor inhibitor (clopidogrel, ticagrelor, prasugrel, orticlopidine) in addition to aspirin, is used to prevent coronary artery in-stent thrombosis, caused by complete and premature discontinuation of DAPT.

Paediatric lung isolation

### Key points Lung isolation is required for a wide variety of pathology in paediatric patients. The varying size of the paediatric airway and size limitations of each lung isolation device poses a challenge to paediatric anaesthesiologists. The need for lung isolation includes: the prevention of contamination of one lung from the other due to haemorrhage or infection, the need to control the distribution of ventilation secondary to a bronchopulmonary fistula, a lung cyst or bullae, or severe hypoxaemia from unilateral lung disease. Extensive bronchopulmonary lavage may also necessitate lung isolation. Although lung isolation can assist in surgical exposure, in the paediatric population, surgical exposure for lung resections, mediastinal exposure, and thorascopy can often be accomplished by the CO2 pneumothorax and retraction of the operative lung without the need for lung isolation. This is most common in the young patient (<2 yr of age). Slinger1 teaches that there are the ‘ABCs’ of adult lung isolation: anatomy, bronchoscopy, and chest imaging. In paediatric lung isolation, there are still all the same ‘ABC’ considerations, with the addition of ‘D’—the varying diameter of the paediatric airway with age. ### Anatomy It has been long established that there are differences between the paediatric …

Accuracy in Obtaining 100 μg from 10 mg of Morphine for Spinal Anesthesia

(J Clin Anesth. 2015;27:638–645) A 100 μg is the recommended dose of morphine for patients following a cesarean section. In France there is a variety of morphine concentrations available, including 1 mg/1 mL and 10 mg/1 mL, and 100 μg/1 mL. These different concentrations may increase the likelihood of an erroneous dosage being administered. There are also many different dilution methods that are used to prepare a dose of morphine, which can further complicate attempts to arrive at the standard postcesarean dose of 100 μg. The authors of this study attempted to evaluate the effectiveness of common dilution procedures by measuring the concentration of morphine obtained when the dilution techniques were used to obtain a dose from a 10-mg/1-mL ampule of morphine.

Chronic Headache and Backache are Long-term Sequelae of Unintentional Dural Puncture in the Obstetric Population

(J Clin Anesth. 2015;27(3):201–206) Although unintentional dural puncture (UDP) with an epidural needle and the resulting postdural puncture headache (PDPH) occur in 1% to 5% of patients who undergo neuraxial anesthesia, there are very few studies that have addressed long-term UDP and PDPH sequelae, as parturients with PDPH are not routinely followed for the development of long-term complications. The current study examined the long-term (&gt;6 wk) effects of PDPH by interviewing parturients who had UDP (recognized or unrecognized) associated with labor epidural analgesia.

A complication of an epidural blood patch

C. Subdural hematoma. Epidural blood patch (EBP) is generally accepted as an effective and relatively low risk therapeutic option for post dural puncture headache, as well spontaneous spinal cerebrospinal fluid (CSF) leak in patients not responding to conservative management [[1]Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks.Headache. 2013; 53: 1034-1053Crossref PubMed Scopus (196) Google Scholar]. Subdural hematoma (SDH) after EBP is a very rare complication. As in the case described by Verduzco et al., our patients also demonstrated an eight segment spread of the hematoma [[2]Verduzco L.A. Atlas S.W. Riley E.T. Subdural hematoma after an epidural blood patch.Int J Obstet Anesth. 2012; 21: 189-192Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. There are generally three predominant theories for development of SDH after EBP [3Riley C.A. Spiegel J.E. Complications following large–volume epidural blood patches for postdural puncture headache.J Clin Anesth. 2009; 21: 355-359Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 4Devroe S. Van de Velde M. Demaerel P. et al.Spinal subdural hematoma after an epidural blood patch.Int J Obstet Anesth. 2015; 24: 288-289Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. One is that the initial dural puncture with the Tuohy needle created a means of communication between the epidural and subdural spaces. The other is that the Tuohy needle was in the subdural space during the EBP with the blood injected into the subdural space. A third possibility is that both events occurred simultaneously. Intrathecal injection of an EBP has also been reported following accidental dural puncture with MRI demonstrating the intrathecal hematoma [[5]Kalina P. Craigo P. Weingarten T. Intrathecal injection of epidural blood patch.Emerg Radiol. 2004; 11: 56-59Crossref PubMed Scopus (38) Google Scholar]. A complication of an epidural blood patchJournal of Clinical NeuroscienceVol. 31PreviewA 58-year-old woman presented 1 week following an epidural blood patch (EBP) performed due to spontaneous cerebrospinal fluid (CSF) leak (diagnosed by intracranial MRI findings of CSF hypotension obtained for headaches). A spine MRI was performed as part of the continuing work-up to identify the source of the CSF leak (Fig. 1). She was otherwise asymptomatic. Full-Text PDF

The Case Files

The Case Files

SAMBA Consensus Guidelines for the Management of Postoperative Nausea and Vomiting: An Executive Summary for Perianesthesia Nurses

POSTOPERATIVE NAUSEA AND VOMITING (PONV) remains one of the most common, and most distressing postoperative complications. Despite advances in pharmacological and nonpharmacological prophylactic and rescue interventions, postoperative vomiting (POV) occurs in approximately 30% of surgical patients, while the incidence of nausea is around 50%. The incidence of PONV in high risk patients may run as high as 80%. 1 Gan T.J. Diemunsch P. Habib A.S. et al. Consensus guidelines for the management of postoperative nausea and vomiting. [Erratum appears in Anesth Analg. 2014 Mar;118(3):689]. Anesth Analg. 2014; 118: 85-113 Crossref PubMed Scopus (920) Google Scholar , 2 Kapur P.A. Editorial: The Big “Little Problem”. Anesth Analg. 1991; 73: 243-245 Crossref PubMed Google Scholar , 3 Odom-Forren J. Hooper V. Moser D.K. et al. Postdischarge Nausea and Vomiting: Management Strategies and Outcomes Over 7 Days. J Perianesth Nurs. 2013; 29: 275-284 Abstract Full Text Full Text PDF Scopus (22) Google Scholar , 4 Odom-Forren J. Jalota L. Moser D.K. et al. Incidence and predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth. 2013; 25: 551-559 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar , 5 Samuels J.D. Perioperative nausea and vomiting: much ado about nothing?. Aesthetic Plast Surg. 2013; 37: 634-635 Crossref PubMed Scopus (3) Google Scholar , 6 Sussanne B. Arwestrom C. Baker A. Bertero C. Nurses’ experiences in the relief of postoperative nausea and vomiting. J Clin Nurs. 2010; 19: 1865-1872 Crossref PubMed Scopus (8) Google Scholar Although relatively short-lived in nature, patients identify PONV as one of the most dreaded postoperative complications, many fearing PONV more than postoperative pain. 1 Gan T.J. Diemunsch P. Habib A.S. et al. Consensus guidelines for the management of postoperative nausea and vomiting. [Erratum appears in Anesth Analg. 2014 Mar;118(3):689]. Anesth Analg. 2014; 118: 85-113 Crossref PubMed Scopus (920) Google Scholar , 2 Kapur P.A. Editorial: The Big “Little Problem”. Anesth Analg. 1991; 73: 243-245 Crossref PubMed Google Scholar , 5 Samuels J.D. Perioperative nausea and vomiting: much ado about nothing?. Aesthetic Plast Surg. 2013; 37: 634-635 Crossref PubMed Scopus (3) Google Scholar Protracted PONV is associated with increased cost of care, most commonly related to extended PACU length of stay (LOS) and increased unplanned hospital admissions. Unrelieved postdischarge nausea and vomiting (PDNV) has been associated with delayed return to work/normal activities of daily living, and often contributes to emergency department visits and associated hospital readmission. 1 Gan T.J. Diemunsch P. Habib A.S. et al. Consensus guidelines for the management of postoperative nausea and vomiting. [Erratum appears in Anesth Analg. 2014 Mar;118(3):689]. Anesth Analg. 2014; 118: 85-113 Crossref PubMed Scopus (920) Google Scholar , 3 Odom-Forren J. Hooper V. Moser D.K. et al. Postdischarge Nausea and Vomiting: Management Strategies and Outcomes Over 7 Days. J Perianesth Nurs. 2013; 29: 275-284 Abstract Full Text Full Text PDF Scopus (22) Google Scholar , 4 Odom-Forren J. Jalota L. Moser D.K. et al. Incidence and predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth. 2013; 25: 551-559 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Vallire D. Hooper, PhD, RN, CPAN, FAAN, is a Manager, Nursing Research, Mission Hospital, Asheville, NC

THU0335 Identification of the Optimum Puncture Level by A Lumbar Spine Ultrasonography Decreases the Pain during the Epidural Injection Procedure in Patients with A Presumed Difficult Puncture

BackgroundUltrasound (US) is widely used in rheumatology to study and guide infiltration of peripheral joints. This imaging modality can also provide useful information about the anatomy of the lumbar spine....

Opioid-Induced Pruritus

Opioid-Induced Pruritus

In-hospital Management of Diabetes

In-hospital Management of Diabetes

Novel Splint Allowing Concurrent Midface and Occlusal Control During Orotracheal Intubation

Occlusal splints are used in craniomaxillofacial surgery to control the dental-bearing bony structures of the midface and mandible. They are created to guide the mobile bone segments into position based on the ideal or planned dental and facial relationships. For conventional orthognathic cases and maxillofacial trauma scenarios involving the dentition, a nasal endotracheal tube is required, allowing the teeth to be closed into intermaxillary fixation. However, in situations where access to the nasal cavity is required, such as concurrent rhinoplasty, or when higher osteotomies involving the midface are performed requiring advancement or manipulation of the nasal region, the nasal tube needs to be converted into an oral tube (J Clin Anesth 2011;23:342). This requires time and inconvenience and is a potentially dangerous maneuver in the setting of existing surgical edema, fluids, and manipulation. We report on a novel oral splint design allowing for both intermaxillary fixation to be established using an oral endotracheal tube while allowing for manipulation of the midface via the nasal cavity and not requiring a tube change intraoperatively.

A01 Effect of Dexmedetomidine on Hemodynamic Responses during Induction Period, Skull-Pin Application and Skin Incision in Patients undergoing Craniotomy

Background: The cerebral blood flow should be preserved by controlling the mean arterial pressure in acceptable cerebral perfusion pressure ranges during craniotomy. The author hypothesized that dexmedetomidine would attenuate hemodynamic changes during propofol induction, skull-pin application and skin incision in neurosurgical patients undergoing a craniotomy, compared with fentanyl. Methods: Thirty patients (18–65 years), scheduled for elective intracranial surgery, received dexmedetomidine 1 μg/kg or fentanyl 2 μg/kg infusions before propofol based anesthesia. Propofol was started at 3.0 μg/ml on a target control syringe pump and titrated to maintain a similar level of sedation by using Bispectral index in both groups. The hemodynamic variables were continuously recorded and analyzed for the results. Results: Five minutes after induction with propofol, systolic pressure (Ps), diastolic pressure (Pd) and mean arterial pressure (MAP) were significantly higher in dexmedetomidine group. After that, MAP and HR in both groups increased after skull-pin fixation, but were not statistically significant. Ps, Pd and MAP in both groups increased slightly after the skin incision but all were not significantly different. The induction and total dose of propofol were not lower than those of fentanyl group, even though the dexmedetomidine group required less fentanyl intraoperatively, but there was no statistical difference. Conclusion: Dexmedetomidine 1 μg/kg does not seem more effective than using fentanyl 2 μg/kg on blunting hemodynamic changes to propofol induction, tracheal intubation, skull-pin fixation, and skin incision in craniotomy patients. References Pasternak JJ, Lanier WL. Neuroanesthesiology Update 2010. Neurosurg Anesthesiol 2011; 23: 67–99. Bekker A, Sturaitis M, Bloom M, Moric M, Golfinos J, Parker E, et al. The effect of dexmedetomidine on perioperative hemodynamics in patients undergoing craniotomy. Anesth Analg 2008; 107: 1340–7. Bilotta F, Lam AM, Doronzio A, Cuzzone V, Delfini R, Rosa G. Esmolol blunts postoperative hemodynamic changes after propofol-remifentanil total intravenous fast-track neuroanesthesia for intracranial surgery. J Clin Anesth 2008; 20: 426–30.

Invited Commentary

Invited Commentary

Dexmedetomidine can stabilize hemodynamics and spare anesthetics before cardiopulmonary bypass

We previously confirmed the effectiveness of dexmedetomidine (DEX) for stabilizing hemodynamics as well as sparing anesthetics during anesthetic induction in patients undergoing cardiac surgery (Kunisawa et al. in J Clin Anesth 21:194-199, 1). In this study, we investigated whether these effects of DEX continue until the start of cardiopulmonary bypass (CPB). Twenty-two patients with mild to moderate cardiovascular disease were randomized into two groups [DF2 group: DEX dose of 0.7 μg/kg/h after initial dose and effect-site concentration (ESC) of fentanyl of 2 ng/ml; PF4 group: saline and ESC of fentanyl of 4 ng/ml]. Propofol was administered for anesthetic induction and maintenance. Hemodynamics, cardiovascular drugs, ESC of propofol, and cardiovascular responses to skin incision (SI) and sternotomy (St) were measured or calculated. Blood pressure (BP) at the pre-/post-SI periods was higher in the DEX group (137 ± 17/140 ± 16 mmHg) than in the placebo group (85 ± 9/109 ± 24 mmHg). Percent increases in cardiovascular response to SI or St were lower in the DEX group than in the placebo group (for example, 1.9 ± 2.2 vs. 27.4 ± 19.9% in systolic BP due to SI). ESCs of propofol at SI and St in the DEX group were lower than those in the placebo group. DEX combined with 2 ng/ml fentanyl before CPB can suppress the decrease in blood pressure at the pre- and post-SI periods, can blunt the cardiovascular responses to SI and St, and can spare the required ESC of propofol despite fentanyl concentration, which was half of that in the placebo group.

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Fibrinogen concentrate for management of bleeding

Fibrinogen concentrate for management of bleeding

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Morphology Identification Using Transesophageal Echocardiography in Migratory Renal Cell Carcinoma Surgery

RENAL CELL CARCINOMA WITH INFERIOR VENA CAVAL (IVC) extension presents many difficulties for intraoperative management. Transesophageal echocardiography (TEE) has been recognized as a valuable intraoperative tool to monitor the tumor during surgical resection. 1 Chan F. Ngan Kee W.D. Low J.M. Anesthetic management of renal cell carcinoma with inferior vena caval extension. J Clin Anesth. 2001; 13: 585-587 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar , 2 Koide Y. Mizoguchi T. Ishii K. et al. Intraoperative management for removal of tumor thrombus in the inferior vena cava or the right atrium with multiplane transesophageal echocardiography. J Cardiovasc Surg. 1998; 39: 641-647 PubMed Google Scholar Real-time monitoring of the tumor during surgery allows rapid diagnosis of tumor embolization. This is a relatively rare complication, occurring in less than 0.4% of all renal cell carcinomas and less than 5% of renal cell carcinomas involving the IVC, 3 Chen H. Ng V. Kane C.J. et al. The role of transesophageal echocardiography in rapid diagnosis and treatment of migratory tumor embolus. Anesth Analg. 2004; 99: 357-359 Crossref PubMed Scopus (27) Google Scholar but is feared because of its disastrous complications.