Management of intra-aortic balloon pumps.
Seminars in cardiothoracic and vascular anesthesia
2015; 19 (2): 106-121
Comparison of catheter tip migration using flexible and stimulating catheters inserted into the adductor canal in a cadaver model.
Journal of anesthesia
2015; 29 (3): 471-474
Intra-aortic balloon pumps (IABPs) continue to be the most widely used cardiac support devices with an annual estimate of 200 000 IABPs placed worldwide. IABPs enhance myocardial function by maximizing oxygen supply and minimizing oxygen demand. The use of IABPs is not without risk, with major vascular injury, ischemia, and infection being the most common complications, especially in high-risk patients. While recent studies have questioned the use of IABPs in patients with cardiogenic shock secondary to myocardial infarction, these studies have limitations making it difficult to formulate definitive conclusions. This review will focus on the mechanisms of counterpulsation, the management of IABPs and the evidence supporting this ventricular support therapy.
View details for DOI 10.1177/1089253214555026
View details for PubMedID 25348545
Perioperative Pain Management in a Patient with Anaphylaxis to Full Mu-agonists Presenting for Head and Neck Salvage Surgery
2015; 18 (1): E83-E85
Right Breast Mastectomy and Reconstruction with Tissue Expander under Thoracic Paravertebral Blocks in a 12-Week Parturient.
Case reports in anesthesiology
2015; 2015: 842725
Use of adductor canal blocks and catheters for perioperative pain management following total knee arthroplasty is becoming increasingly common. However, the optimal equipment, timing of catheter insertion, and catheter dislodgement rate remain unknown. A previous study has suggested, but not proven, that non-tunneled stimulating catheters may be at increased risk for catheter migration and dislodgement after knee manipulation. We designed this follow-up study to directly compare tip migration of two catheter types after knee range of motion exercises. In a male unembalmed human cadaver, 30 catheter insertion trials were randomly assigned to one of two catheter types: flexible or stimulating. All catheters were inserted using an ultrasound-guided short-axis in-plane technique. Intraoperative knee manipulation similar to that performed during surgery was simulated by five sequential range of motion exercises. A blinded regional anesthesiologist performed caliper measurements on the ultrasound images before and after exercise. Changes in catheter tip to nerve distance (p = 0.547) and catheter length within the adductor canal (p = 0.498) were not different between groups. Therefore, catheter type may not affect the risk of catheter tip migration when placed prior to knee arthroplasty.
View details for DOI 10.1007/s00540-014-1957-9
View details for PubMedID 25510467
Best multimodal analgesic protocol for total knee arthroplasty.
2015; 5 (3): 185-196
Paravertebral blocks are becoming increasingly utilized for breast surgery with studies showing improved postoperative pain control, decreased need for opioids, and less nausea and vomiting. We describe the anesthetic management of an otherwise healthy woman who was 12 weeks pregnant presenting for treatment of her breast cancer. For patients undergoing breast mastectomy and reconstruction with tissue expanders, paravertebral blocks offer an anesthetic alternative when general anesthesia is not desired.
View details for DOI 10.1155/2015/842725
View details for PubMedID 26229692
Anesthetic implications of extended right hepatectomy in a patient with fontan physiology.
A & A case reports
2014; 2 (8): 99-101
SUMMARY? Total knee arthroplasty is one of the most commonly performed operations in the USA. As with any elective joint surgery, the primary goal includes functional restoration that is not limited by pain. The use of peripheral nerve blocks for patients undergoing knee arthroplasty has resulted in decreased pain scores, improved early ambulation and decreased time to achieve hospital discharge criteria. Concern has been raised over the potential risks of femoral nerve block, and there has been growing support for the adductor canal block. It is the author's opinion that when not contraindicated, intraoperative neuraxial anesthesia combined with a continuous adductor canal block and a multimodal medication regimen for postoperative pain control is the best analgesic protocol for knee arthroplasty.
View details for DOI 10.2217/pmt.15.8
View details for PubMedID 25971642
Anesthetic evaluation and management of a patient with thoracic endometriosis syndrome presenting for elective surgery
JOURNAL OF CLINICAL ANESTHESIA
2013; 25 (3): 220-223
Patients who have undergone complete cavopulmonary anastomosis, the Fontan procedure, have passive venous blood flow from the superior and inferior vena cava into the pulmonary circulation without passing through the right ventricle. Although this procedure is an effective means of palliation, the resultant chronically increased central venous pressure, leads to several types of hepatic dysfunction including chronic congestion, cardiac cirrhosis, and even hepatocellular carcinoma. In this case report, we describe a patient with Fontan-associated hepatocellular carcinoma who successfully underwent a right hepatectomy.
View details for DOI 10.1213/XAA.0000000000000012
View details for PubMedID 25611770
An Overview of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion for the Anesthesiologist
ANESTHESIA AND ANALGESIA
2013; 116 (4): 924-931
Thoracic endometriosis syndrome is a relatively uncommon disorder characterized by recurrent pneumothoraces, hemothorax, chest pain, dyspnea, and hemoptysis within 48 to 72 hours of menstruation. A 34 year old, ASA physical status 2 woman with recurrent catamenial pneumothoraces due to thoracic endometriosis syndrome is presented. After treatment with video-assisted thoracoscopic surgery, she underwent successful elective diagnostic abdominal laparoscopy without incident. The presence of parenchymal injury and damage predisposes these patients to ventilator-induced lung injury. Postponement of surgery until the intermenstrual period, with lung protective ventilation, allows patients with this disease to successfully undergo general anesthesia and surgery.
View details for DOI 10.1016/j.jclinane.2012.10.011
View details for Web of Science ID 000319788900012
View details for PubMedID 23688959
Lung ischemia reperfusion injury: a bench-to-bedside review.
Seminars in cardiothoracic and vascular anesthesia
2013; 17 (1): 28-43
Anesthesiologists face several perioperative challenges when patients need cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion. To adequately care for these patients, anesthesiologists must understand the goals and objectives of the operation in addition to having a basic knowledge of the chemotherapeutic drugs that are frequently used. Optimal anesthetic management of patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion requires control of a complex interplay of physiologic mechanisms, including hyperthermia, abdominal hypertension, electrolyte abnormalities, coagulopathies, increased cardiac index, oxygen consumption, and decreased systemic vascular resistance. As this surgery continues to gain popularity among oncologic surgeons, further studies that clearly define the chemistry, pharmacokinetics, pharmacodynamics, and end points of efficacy need to be performed to elucidate optimal perioperative management.
View details for DOI 10.1213/ANE.0b013e3182860fff
View details for Web of Science ID 000316648100026
View details for PubMedID 23460568
Radiofrequency Ablation of the Supra-Orbital Nerve in the Treatment Algorithm of Hemicrania Continua
2012; 15 (5): E719-E724
Lung ischemia reperfusion injury (LIRI) is a pathologic process occurring when oxygen supply to the lung has been compromised followed by a period of reperfusion. The disruption of oxygen supply can occur either via limited blood flow or decreased ventilation termed anoxic ischemia and ventilated ischemia, respectively. When reperfusion occurs, blood flow and oxygen are reintroduced to the ischemic lung parenchyma, facilitating a toxic environment through the creation of reactive oxygen species, activation of the immune and coagulation systems, endothelial dysfunction, and apoptotic cell death. This review will focus on the mechanisms of LIRI, the current supportive treatments used, and the many therapies currently under research for prevention and treatment of LIRI.
View details for DOI 10.1177/1089253212458329
View details for PubMedID 23042205
Unintentional Dural Puncture with a Tuohy Needle Increases Risk of Chronic Headache
ANESTHESIA AND ANALGESIA
2012; 115 (1): 124-132
Hemicrania continua (HC) is an uncommon primary headache disorder in which the diagnosis centers on unilaterality and its absolute responsiveness to indomethacin. We describe 3 patients with a long standing history of headache diagnosed as hemicrania continua. There was profound response to indomethacin which was limited by side effects. In one patient the therapy with indomethacin was limited secondary to co-morbidities. Initial diagnostic blockade provided significant relief of symptoms based on which radio-frequency ablation of the supraorbital nerve was performed with substantial improvement in symptoms. Traditionally, hemicrania continua has been managed exclusively with oral analgesics and is defined by its singular response to indomethacin. Radio-frequency ablation (RFA) has been reported in the literature for multiple indications. This case series is unique in that it describes 3 patients diagnosed with hemicrania continua with pain referred in the supraorbital nerve distribution, who underwent radiofrequency ablation of the supraorbital nerve with resultant resolution of headaches. Traditionally, hemicrania continua has been managed exclusively with oral analgesics and is defined by its singular response to indomethacin. This report is unique in that it describes three patients diagnosed with hemicrania continua with pain referred in the supraorbital nerve distribution who underwent radiofrequency ablation of the supraorbital nerve with resultant resolution of headaches. After the RFA medical management was minimal to none in both patients. Though the utility and cost efficacy of RFA of peripheral nerves needs to be confirmed in well-designed trials we present these cases as an example of how this minimally invasive technique can safely provide analgesia in a difficult to treat cephalgia. Moreover if precise anatomical localization of the headache is possible then diagnostic blockade of the appropriate peripheral nerve may be performed followed by radiofrequency ablation to provide potentially more sustained analgesia in patients where medical management is ineffective or poorly tolerated.
View details for Web of Science ID 000312498100011
View details for PubMedID 22996866
Asystole after orthotopic lung transplantation: examining the interaction of cardiac denervation and dexmedetomidine.
Case reports in anesthesiology
2012; 2012: 203240-?
Neuraxial analgesia is chosen by almost half of women who give birth in the United States. Unintentional dural puncture is the most common complication of this pain management technique, occurring in 0.4% to 6% of parturients. Severe positional headaches develop acutely in 70% to 80% of these parturients. Acute postdural puncture headaches are well known, but few studies have investigated long-term sequelae. We investigated the incidence of and risk factors for chronic headache and chronic back pain in parturients who experienced unintentional dural puncture with a 17-gauge Tuohy needle compared with matched controls.In a case control design, 40 parturients who sustained unintentional dural puncture with a 17-gauge Tuohy needle over an 18-month period and 40 controls matched for age, weight, and time of delivery were recruited by telephone and 2 validated questionnaires were administered assessing headache and back pain symptoms 12 to 24 months after delivery.The incidence of chronic headaches in the study group (28%) was significantly higher than in the matched controls (5%) (OR = 7, P = 0.0129). Subjects who experienced dural punctures were more likely than controls to report chronic back pain (OR = 4, P = 0.0250), but treatment with an epidural blood patch was not a risk factor for chronic back pain.Patients who incur unintentional dural punctures with large-gauge needles are surprisingly likely to continue to suffer chronic headaches. Treatment with an epidural blood patch does not enhance the risk of chronic back pain. The pathophysiology underlying these symptoms and the best treatment for this syndrome are not known.
View details for DOI 10.1213/ANE.0b013e3182501c06
View details for Web of Science ID 000305600800022
View details for PubMedID 22467897
Anesthetic evaluation and perioperative management in a patient with new onset mediastinal mass syndrome presenting for emergency surgery.
Case reports in anesthesiology
2011; 2011: 782391-?
Dexmedetomidine is an ?(2)-receptor agonist commonly used for sedation and analgesia in ICU patients. Dexmedetomidine is known to provide sympatholysis and also to have direct atrioventricular and sinoatrial node inhibitory effects. In rare instances, orthotopic lung transplantation has been associated with disruption of autonomic innervation of the heart. The combination of this autonomic disruption and dexmedetomidine may be associated with severe bradycardia and/or asystole. Since orthotopic lung transplant patients with parasympathetic denervation will not respond with increased heart rate to anticholinergic therapy, bradyarrhythmias must be recognized and promptly treated with direct acting beta agonists to avoid asystolic cardiac events.
View details for DOI 10.1155/2012/203240
View details for PubMedID 23091739
Mediastinal mass syndrome (MMS) is a complex case that poses many challenges to the anesthesiologist. The cornerstone of management focuses on the potential hemodynamic changes associated with this syndrome. We describe the anesthetic management of a patient with a previously undiagnosed mediastinal mass presenting for emergency neurosurgical surgery.
View details for DOI 10.1155/2011/782391
View details for PubMedID 22606395