Anesthetic Issues Research Articles

BMI>80: a case report, looking at the obstetric, logistical and financial challenges and a review of the literature

IntroductionThis case illustrates obstetric, logistical and financial aspects of antenatal and intrapartum management of pregnant women with BMI>80.Case SummaryA 29 year-old multiparous woman with BMI of 70.2 was booked for...

A Persistant ‘Can't Intubate, Can't Oxygenate’ Crisis despite Rocuronium Reversal with Sugammadex

A 'can't intubate, can't oxygenate' airway crisis is a rare event which most anaesthetists will never experience during their career(1,2). This report highlights the outcome of time-critical decisions in a potential airway catastrophe. Rocuronium was used as an alternative muscle relaxant for rapid sequence induction. The use of sugammadex in 'can't intubate, can't oxygenate' crises is discussed and highlights how, despite adequate reversal of neuromuscular blockade, the 'can't intubate, can't oxygenate' situation failed to resolve. An asymptomatic vallecular cyst was the causal factor in this scenario. Anaesthetic issues surrounding this pathology are discussed.

Dual Bougie Technique for Nasotracheal Intubation

We read with great interest the anesthetic technique of using a gum elastic bougie (GEB) for nasal intubation in a recent issue of Anesthesia Progress. The authors recommend the use of GEB for the first attempt of nasotracheal intubation in patients with a difficult airway. We agree that this is an excellent alternative. We also have found an excellent variation of this method that utilizes a double bougie technique for insertion of a nasotracheal tube if the difficult airway can be secured initially with an orotracheal tube.

Surgery for brain abscess in children with cyanotic heart disease: An anesthetic challenge

Context:Patients with cyanotic congenital heart disease (cCHD) are prone to develop frequent brain abscesses. Surgery for these abscesses is often limited to aspiration under local anesthesia because excision under general anesthesia (GA) is considered a riskier option. Perioperative hemodynamic instability, cyanotic spells, coagulation defects, electrolyte and acid base imbalance, and sudden cardiac arrest are among the major anesthetic concerns. Most of our current knowledge in this area has been gained from a neurosurgical standpoint while there is a paucity of corresponding anesthesia literature.Aims:To highlight the anesthesia issues involved in cCHD children undergoing brain abscess excision under GA.Settings and Design:Retrospective study of our institutional experience over a 5 year period.Materials and Methods:Of all the children with cCHD who underwent brain abscess surgery from January 2005 to December 2009, only 4 were operated under GA. Surgery was done after correcting fever, dehydration, electrolyte imbalance, coagulopathy and acid-base abnormalities, and taking appropriate intraoperative steps to maintain hemodynamic stability and prevent cyanotic spells and arrhythmias. Results: All 4 patients had a successful abscess excision though with varying degrees of intraoperative problems. There was one death, on postoperative day 34, due to septicemia. Conclusions: Brain abscess excision under GA in children of cCHD can be safely carried out with proper planning and attention to detail.

Medication Shortages

Medication Shortages

SmartTots

SmartTots

Anesthetic Neurotoxicity

Anesthetic Neurotoxicity

Tripping Over Perineural Catheters

Tripping Over Perineural Catheters

The Importance of Being Negative

The Importance of Being Negative

FAER and Others

FAER and Others

Equivalence Is Victory

Equivalence Is Victory

When Duzitol Does Not Do It All

When Duzitol Does Not Do It All

Sedation and anesthesia issues in pediatric imaging

Sedation and anesthesia for pediatric imaging departments has changed dramatically for the following reasons: (1) radiologists have stopped sedating patients; (2) the majority of sedations are not for CT (because of the speed of the procedure) but for MR, which lasts 45 min or greater; (3) a cadre of services--pediatricians, emergency medicine physicians, hospitalists and intensivists, as well as anesthesiologists--can provide the services. These changes have significantly influenced the type of agents utilized for sedation and anesthesia and, most important, have created operational issues for MR departments. Nevertheless, it is important for each imaging department to create a uniform approach to sedation, taking into account patient expectations, efficiency of through-put, facilities and personnel available, and institutional costs.

Case Scenario: Metastatic Pediatric Paraganglioma Presenting during the Course of an Elective Surgery

P HEOCHROMOCYTOMA and paraganglioma are neuroendocrine tumors rarely diagnosed in pediatric patients. The incidence of malignant pheochromocytoma and paraganglioma in childhood is approximately 0.02 cases per million every year. Coincidental intraoperative diagnosis of pheochromocytoma involves very high mortality rates, reaching 50%. We present a case of coincidental diagnosis of pediatric metastatic malignant paraganglioma during an elective surgical procedure. The evaluation and management of pheochromocytoma and paraganglioma are discussed.

Controversial issues in pediatric regional anesthesia

Regional anesthesia in children has reached in the last decades a widespread approval and today is a valid and effective technique used in the daily activity in many pediatric centres. Data from surveys and studies show the very low rate of complications and suggest that the use of regional techniques in children is at least as safe as general anesthesia alone. Despite these evidences there are aspects still creating discussions on the best approach to avoid or prevent risks and on the way to make this techniques more and more reliable and safe. Compartment syndrome, test dose, loss-of-resistance technique and blocks performed under general anesthesia are examples of, sometimes, never-ending stories; this review without the presumption to solve every problem shows the more recent data to offer, if possible, the best updated-answer on these topics.

Controversial issues: compartment syndrome, test dose, LOR‐ air/saline, etc

The article ‘Controversial issues: compartment syndrome, test dose, LOR‐ air/saline, etc.’ by Valeria Mossetti and Giorgio Ivani (doi:10.1111/j.1460‐9592.2011.03648.x), first published online on 2 July 2011 in Wiley OnlineLibrary (http://www.wileyonlinelibrary.com), has been withdrawn as it is a duplicate of the article entitled ‘Controversial issues in pediatric regional anesthesia’ by Valeria Mossetti and Giorgio Ivani (DOI: 10.1111/j.1460‐9592.2011.03655.x), first published online on 21 July 2011. The Publisher apologises for this error.

New Molecular Players in the Great Fluid Debate

Anesthesiologists, it seems, will never agree on the optimal fluid resuscitation protocols for critically ill patients. The “Great Fluid Debate” is the anesthesiology equivalent of fashion in the art world—lots of opinions, with historical cyclic swings about what is “in.” Competing fluid resuscitation strategies will always be points for discussion and disagreement, unfortunately. Getting an answer about the best resuscitation strategies is understandably difficult because of heterogeneity in outbred humans, heterogeneity of complex clinical processes such as hemorrhage, and expense of clinical studies that require long-term follow-up data. Many clinical studies on massive hemorrhage focus on survival as the major end point of analysis after fluid resuscitation; rightly so, but survival is affected by many factors in resuscitation of critically ill patients, making it difficult to gain insight into fluid administration best practices. In this issue of Anesthesia & Analgesia, Kozar et al. report their work comparing plasma versus lactated Ringer (LR) solution resuscitation in a rat hemorrhagic shock model. Resuscitation with plasma in clinical massive hemorrhage is controversial, and many trauma centers have withheld aggressive plasma resuscitation because of concerns about the risk of transmitting infection and risks of transfusion-associated lung injury. A trend toward increased early use of plasma for massive hemorrhage was prompted by recent observations in civilian and battlefield trauma settings that early use of plasma is associated with increased survival. For example, patients presenting to a Los Angeles County Hospital level I trauma center over a 6-year period were more likely to survive massive transfusion if the fresh frozen plasma/red blood cell ratio was high, up to a ratio of 1:3. Five other studies with similar conclusions are cited in the Kozar et al. report (1–5). All of these influential studies are retrospective, with all the usual caveats inherent in retrospective work, and none of the studies can address mechanism of survival because of the nature of the data. The literature dealing with massive hemorrhage has been plagued by the lack of markers (laboratory data) that reliably guide prognosis or quantify the value of resuscitation maneuvers. In particular, static clotting times are difficult to interpret in the setting of massive hemorrhage and transfusion, and likely a matrix of laboratory studies and modeling will be necessary to guide therapy. Enter potential new markers and monitors of hemorrhagic shock and resuscitation from hemorrhagic shock: the endothelial glycocalyx and syndecan-1. The endothelial glycocalyx is a complex barrier, enriched in proteoglycans of the syndecan and glypican families as well as glycosaminoglycan attachments of heparan, dermatan and chondroitin sulfates, and hyaluronan.The endothelial glycocalyx regulates movement across blood vessel walls: glycocalyx damage or shedding results in protein extravasation from the circulation, contributing to end-organ edema, and also exposes the endothelium to pathologic white cell and platelet adhesion. Glycocalyx shedding is an important acute underlying pathologic factor in reperfusion injuries, systemic inflammatory response, trauma, sepsis, and chronically in vasculopathies, but no clinical trials directed at the glycocalyx have been performed. Syndecans are ubiquitous transmembrane proteoglycans that interact with the extracellular matrix, growth factors, and chemokines to regulate adhesionand growth factor-mediated signaling pathways. Syndecans are emerging as integrators of the environments outside of the cell with signaling inside the cell. In the Kozar et al. study, the hemorrhagic shock model imposed a mean arterial blood pressure (MAP) of 30 mm Hg for 90 minutes, then rats were resuscitated to MAP 80 mm Hg with either LR solution or plasma, and normal MAP was maintained for 2 hours. Venules from the small bowel mesentery were examined for glycocalyx morphology. Ninety minutes of shock resulted in clear loss (shedding) of the glycocalyx and decreased expression of syndecan-1 message, unchanged by resuscitation with LR solution, but significantly restored by plasma. Similarly in the lung, the normally abundant syndecan protein in the alveolar wall disintegrated as a function of shock, was unchanged by LR solution, but significantly restored by plasma resuscitation. Gross lung pathology was also improved by plasma. The rapidity of restoration of endothelial and pulmonary histologic appearance is remarkable, and sets the stage for examination of the effects of timing of plasma resuscitation on end-organ recovery. This study certainly does not close the knowledge gap necessary to engender full confidence in early plasma resuscitation for hemorrhagic shock, but it does point to syndecan-1 and the glycocalyx as a whole as potential targets of therapies in shock patients. Similar to all good From Research & Development, Organovo, Inc., San Diego, California.

Learning Disability in Children as an Outcome in Anesthesia and Analgesia Research

Learning Disability in Children as an Outcome in Anesthesia and Analgesia Research

Editor's Note

In 2009, Dr. Joachim Boldt published a manuscript in Anesthesia & Analgesia comparing albumin and hydroxyethyl starch priming cardiopulmonary bypass.1 A subsequent review by Landesärztekammer Rheinland-Pfalz (LÄ#K-RLP), the State Medical Association of Rheinland-Pfalz, determined that there was no IRB approval for the study. The article was retracted in December 2010.2 In response to the concerns regarding IRB approval LÄ#K-RLP investigated 103 additional manuscripts that included Dr. Boldt as a coauthor, including 23 manuscripts published in Anesthesia & Analgesia. Of these 23 articles, LÄ#K-RLP was able to verify IRB approval for only one.3 LÄ#K-RLP was unable to document IRB approval for the remaining 22 articles.4–25 Research without IRB approval is a violation of human rights. As described in our Guide for Authors,26 and a recent editorial,27Anesthesia & Analgesia requires IRB approval for all human research. There are no exceptions. The 22 manuscripts published by Dr. Boldt for which IRB approval has not been confirmed by LÄ#K-RLP are hereby retracted for unethical conduct of research. According to our publisher, the programs that link papers to retraction notices require a unique document identification number for each paper retracted. Therefore, this issue of Anesthesia & Analgesia contains 22 individual retraction notices representing the individual articles for which IRB approval has not been verified. Steven L. Shafer, MD Editor-in-Chief, Anesthesia & Analgesia Professor of Anesthesiology, Columbia University

Ultrasound beyond regional anesthesia: formal training?

In this issue of the Journal, Dugani et al. present a case concerning a patient undergoing a caudal block for chronic pain treatment wherein a bowel hernia, inferoposterior to the coccygeal ligament, was found incidentally using fluoroscopy and confirmed with ultrasound. The initial procedure was abandoned, and subsequently, the patient underwent coccygeal hernia repair. In this case, Dugani et al. raise two important issues in both chronic pain management and ultrasound-guided regional anesthesia, namely, ‘‘incidental detection’’ and ‘‘the capability of ultrasound to identify nonneural pathology’’, that are more notable than the authors’ ability to define the pathological condition and modify patient management using ultrasound and fluoroscopy. Undoubtedly, the continuing popularity of ultrasound techniques in regional anesthesia will result in the exposure of anesthesiologists to these issues; in fact, an increasing number of such cases are reported in many journals. However, when it comes to diagnosing pathology using ultrasound, most anesthesiologists lack training and experience. Collaboration with radiologists and formal training in ultrasound are considerations for equipping anesthesiologists to take advantage of the possibilities offered by imaging technologies. In chronic pain management, pain syndromes can be complex and difficult to diagnose. Coccydynia is no exception, presenting with symptoms from discomfort to acute and severe pain, varying between patients, and changing over time. It can occur after falls, childbirth, repetitive strain, or prior surgery. In many cases, the origin of the pain is unclear and the cause unknown. Although a diagnosis of coccydynia often is based solely on the symptoms, other organic causes (e.g., local rashes from shingles) and bone and tissue disorders (fracture) must be ruled out by performing a physical examination, diagnostic imaging, and other appropriate tests. In many cases, this ‘‘incidental detection’’ can be avoided from the outset; however, in this case, could investigations have been performed prior to the caudal injection to prevent the ‘‘on-table’’ incidental finding? Recently, the American College of Physicians and the American Pain Society proposed a joint clinical practice guideline suggesting a focused history and examination is important to identify the nature of the pain and the warning signs for underlying pathologies. Appropriate diagnostic imaging should be considered and reserved for patients with severe or progressive neurologic deficits or in cases where serious underlying conditions are suspected. In the case of Dugani et al., bowel herniation post-coccygectomy is extremely rare, and the symptoms persisting after surgery would not necessarily prompt further investigations prior to intervention, barring a change of symptoms. This case reminds clinicians to conduct appropriate investigations in patients with nonspecific pain prior to committing to an invasive intervention, especially after a surgical procedure. Nevertheless, despite the most thorough history and examination, diagnoses will occasionally be missed, thus opening the window for ‘‘incidental detection’’ in cases where extensive investigations are not indicated. Ultrasound is a challenging imaging modality because it is highly operator-dependent in terms of both acquisition and interpretation of the image. The inherent user-dependent sensitivity and specificity of ultrasound could result in either a false negative (missed diagnosis) or a false positive (misinterpretation of an insignificant lesion). Either of B. C. H. Tsui, MD (&) V. H. Y. Ip, MBChB Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, 8-120 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada e-mail: btsui@ualberta.ca