M.D., Mayo Clinic School of Medicine (2017)
Arthrogryposis syndromes are a heterogeneous group of disorders characterized by congenital joint contractures often requiring multiple surgeries during childhood to address skeletal and visceral abnormalities. Previous reports suggest that these children have increased perioperative risk, including hypermetabolic events discrete from malignant hyperthermia, difficult airway management, isolated hyperthermia, and difficult IV line placement. We sought to compare children with arthrogryposis multiplex congenita (AMC) versus the less severe, distal arthrogryposis syndromes (DAS) and to evaluate possible intraoperative hyperthermia of patients with AMC. We hypothesized that children with AMC had a greater incidence of intraoperative hyperthermia and more difficulty with airway management and IV access.Children aged 0 to 25 years with arthrogryposis syndromes who underwent anesthesia from 1972 to 2013 were identified. The medical records were reviewed for demographics, arthrogryposis type, and anesthetic complications. AMC subjects were compared with DAS subjects. To evaluate the probability of hyperthermia and hypermetabolic responses of patients with AMC, we performed a post hoc case-control analysis. Patients with AMC were matched in a 1:2 ratio to patients without arthrogryposis to evaluate the primary outcome of maximum intraoperative temperature.Forty-five patients with AMC and 16 patients with DAS underwent 264 and 105 unique anesthetics, respectively. There was no significant difference in intraoperative hyperthermia or hypermetabolic events (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.36-2.47; P = .90). Children with AMC were more likely to have difficult IV access (OR, 7.1; 95% CI, 1.81-27.90; P = .005). Additional evidence suggested that difficult airway management (OR, 4.06; 95% CI, 1.01-16.39; P = .049) and hemodynamic instability (OR, 4.22; 95% CI, 1.03-17.26; P = .045) were more likely in children with AMC. From post hoc case-control analysis, there was no significant difference in the mean maximum intraoperative temperature (estimated difference +0.04°C; 95% CI, -0.14 to +0.22; P = .64) or odds of intraoperative hyperthermia (OR, 1.49; 95% CI, 0.78-2.82; P = .223) for patients with AMC compared with control subjects.Children with arthrogryposis syndromes present challenges to the anesthesia and surgical teams, including greater neuromuscular disease burden and challenging peripheral IV placement, with additional evidence suggesting difficult airway management and intraoperative hemodynamic instability. Although more definitive studies are warranted, we did not find evidence of increased odds of intraoperative hyperthermia or hypermetabolic responses.
View details for DOI 10.1213/ANE.0000000000001822
View details for Web of Science ID 000394260100032
View details for PubMedID 28099287
Intrathecal (IT) morphine is considered the "gold standard" for analgesia after cesarean delivery under spinal anesthesia, most commonly administered at a dose of 100 to 200 ?g. There is less experience with IT hydromorphone for postcesarean analgesia and limited information on its optimal analgesic dose. We conducted this study to determine the effective analgesic dose for 90% patients (ED90) of IT hydromorphone that provides effective analgesia for women undergoing elective cesarean delivery and its potency ratio to IT morphine.In this dose-finding trial, 80 patients received spinal anesthesia for cesarean delivery. Participants were randomized to receive IT morphine or IT hydromorphone at a dose determined using up-down sequential allocation with a biased-coin design to determine ED90. All patients received standardized multimodal analgesia postoperatively in addition to IT opioid. An effective dose was defined as a numeric response score for pain of ?3 (scale 0-10) 12 hours after spinal injection.The ED90 was 75 ?g (95% confidence interval [CI], 46-93 ?g) for IT hydromorphone and 150 ?g (95% CI, 145-185 ?g) for IT morphine. At these doses, the 95% CI for the percentage of patients with effective analgesia (numeric rating scale ?3) was 64% to 100% for hydromorphone and 68% to 100% for morphine. Exploratory findings showed that the incidence of nausea and pruritus was not different among the most commonly used doses of IT hydromorphone (P = 0.44 and P = 0.74) or IT morphine (P = 0.67 and P = 0.38, respectively). When administering IT opioids at ED90 doses or higher, 100% (21/21) of IT hydromorphone and 95% (37/39) of IT morphine patients were satisfied with their analgesia.The ratio of IT morphine to IT hydromorphone for effective postcesarean analgesia is 2:1. Patient satisfaction was high with both medications.
View details for DOI 10.1213/ANE.0000000000001229
View details for Web of Science ID 000381838800020
View details for PubMedID 26974022
There are few data regarding postoperative hyperglycaemia in non-diabetic compared with diabetic patients following postoperative nausea and vomiting prophylaxis with dexamethasone. Eighty-five non-diabetic patients and patients with type-2 diabetes were randomly allocated to receive intravenous dexamethasone (8 mg) or ondansetron (4 mg). Blood glucose levels were measured at baseline and then 2, 4 and 24 h following induction of anaesthesia. In non-diabetic patients, the mean (SD) maximum blood glucose was higher in those who received dexamethasone compared with ondansetron (9.1 (2.2) mmol.l(-1) vs. 7.8 (1.4) mmol.l(-1) , p = 0.04). In diabetic patients, the mean (SD) maximum blood glucose was also higher in those who received dexamethasone compared with ondansetron (14.0 (2.5) mmol.l(-1) vs. 10.7 (2.4) mmol.l(-1) , p < 0.01). Multivariate analysis demonstrated that dexamethasone administration was a significant predictor of maximum postoperative blood glucose increase (p < 0.01) after adjusting for potential confounders. There was no interaction between baseline blood glucose level, or presence or absence of diabetes, and dexamethasone administration. We conclude that dexamethasone increases postoperative blood glucose levels in both non-diabetics and diabetics.
View details for DOI 10.1111/anae.13544
View details for PubMedID 27523051
The objective of this study was to design and implement a preclinical elective (termed selective) in anesthesiology, critical care, and perioperative medicine and to report survey results assessing the impact of the selective on first- and second-year medical students' understanding of basic concepts, comfort with procedural skills, and interest in the specialty.Preinvention and postintervention survey evaluation was used as the design of this study.The study was conducted at Mayo Medical School and Mayo Clinic.The participants in this study are first- and second-year medical students.A 1-week introductory anesthesiology curriculum was developed to include didactic sessions, shadowing experiences, lunch and dinner panels, mentorship and networking opportunities, and procedural workshops in airway management, ultrasound, and vascular access techniques.Preselective and postselective surveys using a 10-point scale (1, strongly disagree; 10, strongly agree) were administered 1 week before and after the selective.A total of 8 students participated in the selective, with a 100% survey response rate. Students reported significant increases for all survey questions regarding basic concepts and skills. The largest increases were reported in comfort with airway management skills, understanding of the perioperative surgical home model, and vascular access skills. All participants indicated a higher likelihood of pursuing anesthesiology as a career and attributed their increased interest in anesthesiology to the selective.This new selective was successful in giving first- and second-year medical students a comprehensive overview of anesthesiology and increasing medical student interest in the specialty. The success of this selective leads to promising belief that similar peer-designed educational experiences can be developed at other medical schools to improve education and interest in this area of medicine.
View details for DOI 10.1016/j.jclinane.2016.02.006
View details for Web of Science ID 000376811600039
View details for PubMedID 27185704
Objective To report on the failure rate of spinal catheters placed following inadvertent dural puncture (IDP) compared with re-sited epidural catheters in the obstetric population. Research design and methods Patients who experienced IDP during epidural or combined spinal epidural placement with 17 or 18 gauge Tuohy needles for labor analgesia between 2003 and 2014 were identified using our post-dural puncture headache (PDPH) database. Patients were categorized into two groups: those who had spinal catheters inserted and those who had epidural catheters re-sited. Main outcome measure Failure rate associated with spinal or re-sited epidural catheters (defined as need for repeat block or alternative analgesic modality). Secondary outcomes were incidence of PDPH, need for epidural blood patch (EBP), and adverse events. Results A total of 109 patients were included in the final analysis; 79 ultimately had spinal catheters and 30 ultimately had re-sited epidural catheters. There were no differences between spinal catheters and re-sited epidural catheters in failure rate (22% vs. 13%, P?=?0.33), incidence of PDPH (73% vs. 60%, P?=?0.24), need for EBP (42% vs. 30%, P?=?0.28), number of headache days, or maximum headache scores. There was also no difference in the rate of adverse events including high block levels, hypotension, and fetal bradycardia (9% vs. 7%, P?=?1.0) between the two groups. Conclusions There were no differences in failure rates, PDPH outcomes, or adverse events between spinal catheters and re-sited epidural catheters following IDP in parturients receiving labor analgesia. Limitations of the study include its single-center retrospective non-randomized design, and the uneven number of patients in the two groups with a relatively small number in the re-sited epidural catheter group.
View details for DOI 10.1185/03007995.2016.1146665
View details for Web of Science ID 000374970900006
View details for PubMedID 26818623
To assess whether maintenance of labor epidural analgesia using programmed intermittent epidural bolus (PIEB) is associated with reduced local anesthetic (LA) consumption, patient-controlled epidural analgesia (PCEA) use, and rescue analgesia requirements compared to continuous epidural infusion (CEI).This is a retrospective study at an academic university medical center. Women receiving epidural labor analgesia from March to July of 2015 were identified and categorized into three groups: 1) CEI 5?mL/hr, 2) PIEB 5?mL/60?minutes, 3) PIEB 3?mL/30?minutes. The LA consisted of bupivacaine 0.125?mg/mL and fentanyl 2??g/mL. All patients had similar PCEA settings. Data were collected on pattern of LA usage, obstetric outcomes and Bromage scores.The primary endpoint was total volume of LA consumed per hour. Secondary outcomes included need for clinician boluses, pattern of PCEA use, degree of motor blockade and delivery mode.We included 528 patients (262 had CEI, 162 had PIEB 5?mL/60?minutes, and 104 had PIEB 3?mL/30?minutes). Median LA consumed was 10.3, 9.5, and 9.7?mL/hr, respectively (p?=?0.10). There were no differences in PCEA attempts or rescue clinician boluses, but PCEA volume (p?=?0.03) and ratio of PCEA attempts/given (p?0.01) were significantly different among the groups. Patients receiving PIEB 3?mL/30?minutes used lower PCEA volume than patients receiving CEI (p?=?0.04). Patients with PIEB 5?mL/60?minutes and PIEB 3?mL/30?minutes had a higher ratio of PCEA attempts/given than CEI patients (p?=?0.01 and p?0.01, respectively). There were no differences in Bromage scores (p?=?0.14) or delivery mode (p?=?0.55) among the groups.The epidural maintenance regimen used (CEI vs. PIEB) was not associated with differences in LA consumption, motor blockade or delivery mode. Main limitations of the study include its single center retrospective design and the fact that patients were not randomized to treatment groups.
View details for DOI 10.1080/03007995.2016.1181619
View details for Web of Science ID 000381016100015
View details for PubMedID 27100210
View details for PubMedCentralID PMC5319872
With increasing numbers of hospitals adopting electronic medical records, electronic search algorithms for identifying postoperative complications can be invaluable tools to expedite data abstraction and clinical research to improve patient outcomes.To derive and validate an electronic search algorithm to identify postoperative thromboembolic and cardiovascular complications such as deep venous thrombosis, pulmonary embolism, or myocardial infarction within 30 days of total hip or knee arthroplasty.A total of 34 517 patients undergoing total hip or knee arthroplasty between January 1, 1996 and December 31, 2013 were identified. Using a derivation cohort of 418 patients, several iterations of a free-text electronic search were developed and refined for each complication. Subsequently, the automated search algorithm was validated on an independent cohort of 2 857 patients, and the sensitivity and specificities were compared to the results of manual chart review.In the final derivation subset, the automated search algorithm achieved a sensitivity of 91% and specificity of 85% for deep vein thrombosis, a sensitivity of 96% and specificity of 100% for pulmonary embolism, and a sensitivity of 100% and specificity of 95% for myocardial infarction. When applied to the validation cohort, the search algorithm achieved a sensitivity of 97% and specificity of 99% for deep vein thrombosis, a sensitivity of 97% and specificity of 100% for pulmonary embolism, and a sensitivity of 100% and specificity of 99% for myocardial infarction.The derivation and validation of an electronic search strategy can accelerate the data abstraction process for research, quality improvement, and enhancement of patient care, while maintaining superb reliability compared to manual review.
View details for DOI 10.4338/ACI-2015-03-RA-0026
View details for Web of Science ID 000362263300011
View details for PubMedID 26448798
View details for PubMedCentralID PMC4586343