Journal of Clinical Anesthesia

Editorial Board

2012-06-01

Intraoperative tidal volume: does it matter?

Kate Bennett, James G. Ramsay — 2012-06-01

In the last decade a true paradigm shift has occurred in the way in which patients are ventilated in intensive care units (ICUs). Large studies have shown that in patients with a diagnosis of acute lung injury, a ventilation strategy employing a lower tidal volume (VT) than traditionally used, along with the use of graded positive end-expiratory pressure (PEEP) and limited “plateau” pressure (airway pressure during an end-expiratory pause), results in better outcome. This VT is 6 mL/kg of predicted or “ideal” body weight (IBW), which takes into account height and gender only, and more closely approximates physiological VT in the spontaneously breathing mammal . Adoption of this “protective” ventilation strategy has been so widespread in critical care that many house staff rotating through our ICUs today do not remember the days when initial VT settings on a ventilator were in excess of 10 mL/kg of actual body weight.

The effect of low versus high tidal volume ventilation on inflammatory markers in healthy individuals undergoing posterior spine fusion in the prone position: a randomized controlled trial

Stavros G. Memtsoudis, Anna Maria Bombardieri, Yan Ma, Federico P. Girardi — 2011-10-17

Abstract: Study Objective: To evaluate the effect of ventilation strategy on markers of inflammation in patients undergoing spine surgery in the prone position.Design: Randomized controlled trial.Setting: University-affiliated teaching hospital.Patients: 26 ASA physical status 1 and 2 patients scheduled for elective primary lumbar decompression and fusion in the prone position.Interventions: Patients were randomized to receive mechanical ventilation with either a tidal volume (VT) of 12 mL/kg ideal body weight with zero positive end-expiratory pressure (PEEP) or VT of 6 mL/kg ideal body weight with PEEP of 8 cm H2O.Measurements: Plasma levels of interleukin (IL)-6 and IL-8 were determined at the beginning of ventilation and at 6 and 12 hours later. Urinary levels of desmosine were determined at the beginning of ventilation and on postoperative days 1 and 3.Main Results: A significant increase in IL-6, IL-8, and urine desmosine levels was noted over time compared with baseline (P < 0.01). However, no significant difference in the levels of markers was seen between the groups at any time point when controlling for demographics, ASA physical status, body mass index, duration of ventilation, or estimated blood loss.Conclusions: Although markers of inflammation are increased after posterior spine fusion surgery, ventilation strategy has minimal impact on markers of systemic inflammation.

Reliability of assessment of nasal flow rate for nostril selection during nasotracheal intubation

Hyung-Sun Lim, Deokkyu Kim, Jeongwoo Lee, Ji-Seon Son, Jun-Rae Lee, Seonghoon Ko — 2012-06-01

Abstract: Study Objective: To evaluate the reliability of assessments of nasal flow rate for improved nostril selection for nasotracheal intubation.Design: Prospective, randomized, double-blinded study.Setting: Operating room of a university-affiliated hospital.Patients: 118 ASA physical status 1 and 2 patients, aged 18-65 years, scheduled for elective maxillofacial and oral surgery requiring nasotracheal intubation.Interventions: Patients were randomized to the left or right nostril groups. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) through the mouth and each nostril were measured before anesthesia induction.Measurements: The relationship between the rate of airflow through the selected nostril and frequency of epistaxis and navigability of the nasotracheal tube were evaluated.Main Results: There were no significant differences in the frequency of epistaxis and degree of navigability of the tracheal tube between the left and right nostril groups. In both nostril groups, patients who suffered epistaxis showed significantly less FEV1 and FEV1/FVC values than did patients without epistaxis (P < 0.05). In addition, in both groups patients who passed the tube easily showed significantly higher FEV1 and FEV1/FVC values than did patients who passed the tube with resistance or failed tube passage (P < 0.05).Conclusion: Measurement of nasal flow rate is a useful clinical method for choosing a nostril for nasotracheal intubation.

Comparison of noninvasive cardiac output measurements using the Nexfin monitoring device and the esophageal Doppler

2012-06-01

Abstract: Study Objective: To evaluate the validity of cardiac output (CO) measurements obtained using the Nexfin device in comparison to those obtained with the esophageal Doppler in steady-state conditions and after phenylephrine administration.Design: Prospective observational study.Setting: Operating room of a North American academic medical center.Patients: 25 ASA physical status 1, 2, and 3 patients referred for abdominal or orthopedic surgeries.Interventions: After endotracheal intubation, patients who presented with a 20% or greater decrease in mean arterial pressure (MAP) received an intravenous (IV) bolus of 100 μg of phenylephrine. If MAP was still 20% lower than the patient's baseline level at least 10 minutes after the first vasopressor treatment, a second bolus of 100 μg of phenylephrine was given.Measurements: CO was measured simultaneously by esophageal Doppler (COED) and Nexfin (CONXF) at baseline and when blood pressure peaked after an IV 100 μg phenylephrine bolus. Comparisons were then made between the two devices to evaluate the ability of the Nexfin device to track changes in CO.Main Results: 66 pairs of data were obtained. Mean COED and CONXF were 4.7 ± 1.8 L/min and 5.6 ± 2.0 L/min, respectively. There was a significant relationship between COED and CONXF (r2 = 0.82; P < 0.001). The agreement between COED and CONXF was 0.88 ± 0.86 L/min (Bland Altman). The mean percent error (Critchley and Critchley) of CONXF versus COED was 37%. Trending analysis found a 94% concordance between changes in COED and CONXF after phenylephrine administration.Conclusions: Intraoperative CO measurement using the Nexfin device has a strong correlation with CO measured by esophageal Doppler.

Prevention of propofol-induced pain in children: pretreatment with small doses of ketamine

Guang-yi Zhao, Yao Guo, Shu-min Bao, Ling-xin Meng, Li-hong Zhang — 2012-06-01

Abstract: Study Objective: To evaluate the efficacy of ketamine in preventing propofol injection pain in children.Design: Prospective, randomized, double-blinded, placebo-controlled study.Setting: University-affiliated hospital.Patients: 192 ASA physical status 1 and 2 pediatric patients.Interventions: Patients were randomly assigned to 4 groups. Group S (control) received normal saline as a placebo; Group K1, Group K3, and Group K5 received 0.1 mg/kg, 0.3 mg/kg, and 0.5 mg/kg of ketamine, respectively. Fifteen seconds after the ketamine injection, patients were injected with propofol at a rate of 12 mL/min until loss-of-eyelash reflex.Measurement: Pain was evaluated blindly at the time of induction using a 4-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. Adverse effects were recorded. Characteristics of induction of anesthesia, such as dose of propofol and time from propofol injection to loss of consciousness (induction duration), were noted.Main Results: 39 (84.8%) Group S (control) patients had pain. Pretreatment with ketamine reduced the frequency of pain significantly to 56.5%, 17.0%, and 14.9% in Groups K1, K3, and K5, respectively. Furthermore, the frequency of moderate and severe pain in Group K1 (21.8%), Group K3 (6.4%), and Group K5 (4.3%) was significantly (P < 0.001, respectively) reduced compared with Group S (76.1%). Moreover, the dose of propofol for induction in Group K5 was smaller than in Group S, Group K1, and Group K3 (P < 0.05). One patient in Group K5 had emergence agitation.Conclusion: Pretreatment with a small dose of ketamine (0.3 mg/kg) reduced the frequency and intensity of propofol injection pain without severe adverse effects.

Use of sugammadex in patients with a history of pulmonary disease

2012-06-01

Abstract: Study Objective: To evaluate the safety and efficacy of sugammadex for reversal of rocuronium-induced neuromuscular blockade in patients with pulmonary disease.Design: Phase III, randomized, multicenter, parallel-group, comparative, safety-assessor blinded study.Setting: Nine hospital sites.Patients: 77 ASA physical status 2 and 3 patients, aged ≥ 18 years, with a history of pulmonary disease, and scheduled for surgery with general anesthesia requiring neuromuscular blockade.Interventions: Following anesthesia induction, patients received rocuronium 0.6 mg/kg with 0.15 mg/kg maintenance doses as needed. Patients were randomized to receive sugammadex 2 mg/kg or 4 mg/kg after the last rocuronium dose at reappearance of the second twitch.Measurements: Safety evaluations included adverse events, laboratory parameters, vital signs, and evidence of recurrent or residual neuromuscular blockade. Efficacy was evaluated as the time from sugammadex administration to recovery of the train-of-four (TOF) ratio to ≥ 0.9.Main Results: Safety was comparable between doses, with no evidence of residual or recurrent neuromuscular blockade. Two bronchospasm cases were reported (4 mg/kg group), both in patients with asthma who received desflurane for anesthesia maintenance. Geometric mean (95% confidence interval) times to a TOF ratio of ≥ 0.9 were 2.1 (1.7 - 3.1) min (2 mg/kg) and 1.8 (1.5 - 2.7) min (4 mg/kg).Conclusion: Sugammadex 2 mg/kg and 4 mg/kg were well tolerated and effective in patients with a history of pulmonary disease. Bronchospasm is a possibility when administering sugammadex to patients with underlying pulmonary disease.

Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia

2012-06-01

Abstract: Study Objective: To determine whether bilateral iliohypogastric and ilioinguinal (IHII) peripheral nerve blocks, given in conjunction with neuraxial morphine, reduce postcesarean analgesic requirements and side effects, resulting in improved maternal satisfaction.Design: Randomized, prospective, double-blinded, placebo-controlled study.Setting: Labor and delivery suite at Johns Hopkins Hospital.Patients: 34 women scheduled for elective cesarean delivery.Interventions: Patients were randomized to receive IHII nerve blocks bilaterally, with either total 24 mL of 0.5% bupivacaine or normal saline, following cesarean delivery via Pfannensteil incision with a standard intrathecal dose of 12 mg of 0.75% bupivacaine with 10 µg of fentanyl and 200 µg of preservative-free morphine.Measurements: Patients were assessed at 0, 6, 12, 18, and 24 hours postoperatively. Visual analog scale (VAS) pain scores at rest were recorded at each time period. Analgesic use, patients’ perception of nausea, vomiting, pruritus, and their overall satisfaction with their analgesia were recorded for the first 24 hours.Main Results: Lower VAS pain scores were seen in the bupivacaine group at 6, 12, 18, and 24 hours postoperatively (P = 0.01, P < 0.01, 0.02, and 0.04, respectively). A longer mean time to first rescue dose of ketorolac was noted in the bupivacaine group (14.3 ± 1.8 hrs) than the saline group (mean 5.6 ±1.1 hrs), (P < 0.01). Fewer patients in the bupivacaine group made requests for acetaminophen 500 mg/oxycodone 5 mg in the first 24 hours. Satisfaction was greater in the bupivacaine group. No difference in side effects was noted between groups.Conclusions: Bilateral multilevel injection IHII nerve blocks result in lower resting VAS pain scores, lower analgesic requirements, and greater satisfaction following cesarean delivery in patients who received neuraxial morphine.

Comparison of noninvasive continuous arterial waveform analysis (Nexfin) with transthoracic Doppler echocardiography for monitoring of cardiac output

2012-06-01

Abstract: Study Objectives: To compare the Nexfin cardiac output (CO) with the CO obtained from transthoracic Doppler echocardiography (TTE) during routine cardiac function screening.Design: Observational clinical study.Setting: Echocardiography laboratory.Patients: 40 ASA physical status 1 and 2 patients scheduled for routine TTE examination.Interventions: None.Measurements and Main Results: In 40 patients scheduled for routine TTE examination, we obtained simultaneous CO measurements with Doppler ultrasound and derived from Nexfin blood pressure measurements. Correlation and level of agreement between Nexfin and TTE were analyzed using Pearson correlation coefficient and Bland-Altman plots. The Pearson correlation coefficient for Nexfin versus TTE was 0.68 (CI: 0.46 - 0.82, P < 0.0001). Bland-Altman analysis showed a bias of 0.51 ± 1.1 L/min and limits of agreement of -1.6 to 2.6 L/min, with a percentage error of 39%.Conclusions: Considering limits of precision of CO measurements with Doppler echocardiography (± 30%), the agreement between noninvasive CO measurement with the Nexfin and TTE is reasonable.

A profound case of neurally mediated syncope with asystole after septoplasty

Douglas S. Ruhl, Mitchell J. Ramsey, David M. Ruffin — 2012-06-01

Abstract: Vasovagal syncope (VVS) is an alarming yet benign condition that may present postoperatively for the first time in otherwise healthy patients. Although VVS is associated anecdotally with nasal manipulation, no data have been found to quantify this incidence with otolaryngology surgeries. We present a case of profound, recurrent syncope and documented asystole with an initial diagnosis of glossopharyngeal neuralgia. We conclude with a discussion of neurally mediated syncope particular to the perioperative setting. It is essential to recognize neurocardiogenic etiology to differentiate it from other more concerning causes of syncope and asystole.

Perioperative retinoic acid syndrome in a patient with acute promyelocytic leukemia

Nikolay A. Usoltsev, M. Saeed Dhamee — 2012-06-01

Abstract: All-trans retinoic acid (ATRA), a vitamin A derivative, is prescribed for induction of chemotherapy in patients with acute promyelocytic leukemia. Like other chemotherapy agents, ATRA has an adverse effect known as retinoic acid syndrome. The case of a 22 year old woman with acute promyelocytic leukemia, who received ATRA and subsequently developed retinoic acid syndrome, is presented. The patient's symptoms resolved after administration of dexamethasone, allowing the completion of chemotherapy without further complications.

Treatment of refractory intracranial hypertension with 23.4% saline in children with severe traumatic brain injury

2012-06-01

Abstract: The safety and efficacy of osmotic therapy with mannitol and 3% saline in the pediatric head-injured population has been widely reported; the use of 23.4% saline in children for the treatment of refractory intracranial hypertension has not. The clinical and physiologic responses of multiple 23.4% saline boluses in two children with severe traumatic brain injury (TBI) are presented. No complications were associated with the use of 23.4% saline in either patient.

The response to methylene blue in patients with severe hypotension during liver transplantation

2012-06-01

Abstract: Methylene blue is a useful therapy for catecholamine-resistant vasoplegic shock. Three cases of methylene blue administration for the treatment of catecholamine-resistant hypotension during orthotopic liver transplantation are presented.

Perioperative atrial fibrillation and epidural anesthesia: case report and review of the literature

William Kirke Rogers, Kristopher M. Schroeder — 2012-06-01

Abstract: A case of new-onset atrial fibrillation subsequent to activation of neuraxial anesthesia is presented. The development of atrial fibrillation was temporally related to placement and dosing of an epidural catheter, and may have been triggered by a vagal response to dosing of the anesthetic or the resulting treatment with fluid and an adrenergic agent. The literature on the acute preoperative management of atrial fibrillation and the implications of atrial fibrillation for the patient undergoing regional anesthesia are reviewed.

Perspectives on transdermal scopolamine for the treatment of postoperative nausea and vomiting

2012-06-01

Abstract: Transdermal scopolamine, a patch system that delivers 1.5 mg of scopolamine gradually over 72 hours following an initial bolus, was approved in the United States in 2001 for the prevention of postoperative nausea and vomiting (PONV) in adults. Scopolamine (hyoscine) is a selective competitive anatagonist of muscarinic cholinergic receptors. Low serum concentrations of scopolamine produce an antiemetic effect. Transdermal scopolamine is effective in preventing PONV versus placebo [relative risk (RR)=0.77, 95% confidence interval (CI), 0.61-0.98, P = 0.03] and a significantly reduced risk for postoperative nausea (RR=0.59, 95% CI, 0.48-0.73, P < 0.001), postoperative vomiting (RR=0.68, 95% CI, 0.61-0.76, P < 0.001), and PONV (RR 0.73, 95% CI, 0.60-0.88, P = 001) in the first 24 hours after the start of anesthesia.

Out-of-operating room anesthesia: use of the AnaConDa vaporizer with anesthesia

José Miguel Marcos-Vidal, Rafael González, Cristina García, Carlos Soria — 2012-06-01

Until recently, the use of anesthetic gases was restricted to situations where an operating room (OR) anesthesia machine with a vaporizer was available. The development of the Anesthetic Converting Device (AnaConDa; Sedana Medical, Uppsala, Sweden), which is a miniature vaporizer consisting of an antiviral and antibacterial humidifying filter, in addition to an activated charcoal membrane that allows for absorption and reuse of the anesthesia , has allowed for the use of anesthetic gases with critical care unit ventilators.

Pseudohyperkalemia in the setting of chronic lymphocytic leukemia

Vikas Shah, Jennifer W. Lee — 2012-06-01

We recently took care of an 84 year old man with chronic lymphocytic leukemia and malignant melanoma of the head and neck. He had previously undergone several unsuccessful surgical procedures, including a Mohs procedure for resection of melanoma. He came to us for definitive wide area resection as well as skin grafting and sentinel lymph node biopsy. Laboratory values during a visit to our preoperative clinic 6 days before surgery were significant for a white blood cell count of 179 × 103 cells/uL (89% lymphocytes and less than 5% prolymphocytes) and serum potassium of 6.0 mmol/L (normal: 3.5 - 5.5 mmol/L). No evidence of hyperkalemia was noted on electrocardiogram (ECG) taken during the visit.

A novel, simple method of delivering oxygen for endoscopic procedures

K. Annette Mizuguchi, Ramon F. Martin — 2012-06-01

We describe a novel, yet simple method of delivering oxygen via a simple face mask during anesthetic care for upper endoscopy or transesophageal echocardiographic procedures. Some patients do not tolerate the nasal cannula, or they require higher oxygen (O2) concentrations. Normally, one would place a simple face mask for procedures not involving the mouth. However, for procedures in which the mouth needs to be accessed, applying a simple face mask is not possible. Therefore, to deliver O2 and provide access to the mouth, we cut a hole in the middle of a simple face mask (). This modification allows an easy opening for the endoscope and simultaneous delivery of O2 to the patient (). It also permits a method for monitoring of end-tidal CO2. While waiting for the procedure to start, and at the end of the procedure, if supplemental oxygen is still needed, paper tape may be placed over the hole to prevent loss of O2 to the atmosphere ().

Perioperative management of a pediatric patient with short-chain acyl-CoA dehydrogenase deficiency

Warwick A. Ames, Kevin J. de la Roza, Neil A. Hanson — 2012-06-01

We report the anesthetic management of a 12 year old boy undergoing a posterior spinal fusion. In addition to a past medical history significant for palliated congenital heart disease (fenestrated lateral tunnel Fontan), the patient had a rare metabolic disorder, short-chain acyl-CoA dehydrogenase (SCAD) deficiency.

Falsely low pulse oximetry values caused by aortocaval fistula

David C. Martin, Cynthia Chui — 2012-06-01

We report an unusual case of aortocaval fistula causing falsely low pulse oximetry values due to high-pressure, partial arterialization of the venous system. An 84 year old man presented via Emergency Services with a massive, infrarenal abdominal aortic aneurysm. The patient was taken rapidly to an operating room and prepared for aortovascular surgery. Initial vital signs included blood pressure of 148/78 mmHg, pulse of 88 bpm, and oxygen saturation of 39%. Pulse by plethysmography correlated with heart rate by electrocardiogram. An arterial blood gas was obtained, showing PaO2 to be 350 mmHg. Large-bore central venous access was obtained shortly after induction of anesthesia, and initial central venous pressure (CVP) was recorded at 45 mmHg. Central venous waveform was atypically bifid in nature.

Noninvasive removal of an entrapped supraclavicular catheter

Michael V. Presta, Scott W. Byram, Christopher L. Reis, Michael Sniderman — 2012-06-01

With the increase in orthopedic outpatient surgeries being performed today, there is a growing need for pain management techniques that are safe and that will provide prolonged postoperative pain relief . Regional anesthesia techniques, including continuous peripheral nerve blockade, provide superior analgesia when compared with general anesthesia alone. However, these procedures are not without risk .

Failure of the Easy Cap II CO2 detector to indicate esophageal intubation

Sheldon B. Gomes, George Mychaskiw — 2012-06-01

Urgent and emergent endotracheal intubation is an often challenging procedure, frequently performed during suboptimal conditions. Colorimetric CO2 detectors such as the Easy Cap II (Nellcor Healthcare Group LP, Pleasanton, CA, USA) are sometimes used in lieu of capnography because of their portability, ease of use, and low cost. We report a case wherein an Easy Cap II CO2 detector falsely indicated endotracheal tube (ETT) placement, leading to severe morbidity and ultimately death.

Journal of Clinical Anesthesia

Editorial Board

Table of Contents

Intraoperative tidal volume: does it matter?

The effect of low versus high tidal volume ventilation on inflammatory markers in healthy individuals undergoing posterior spine fusion in the prone position: a randomized controlled trial

Reliability of assessment of nasal flow rate for nostril selection during nasotracheal intubation

Comparison of noninvasive cardiac output measurements using the Nexfin monitoring device and the esophageal Doppler

Prevention of propofol-induced pain in children: pretreatment with small doses of ketamine

Use of sugammadex in patients with a history of pulmonary disease

Bilateral multi-injection iliohypogastric-ilioinguinal nerve block in conjunction with neuraxial morphine is superior to neuraxial morphine alone for postcesarean analgesia

Comparison of noninvasive continuous arterial waveform analysis (Nexfin) with transthoracic Doppler echocardiography for monitoring of cardiac output

A profound case of neurally mediated syncope with asystole after septoplasty

Perioperative retinoic acid syndrome in a patient with acute promyelocytic leukemia

Treatment of refractory intracranial hypertension with 23.4% saline in children with severe traumatic brain injury

The response to methylene blue in patients with severe hypotension during liver transplantation

Perioperative atrial fibrillation and epidural anesthesia: case report and review of the literature

Perspectives on transdermal scopolamine for the treatment of postoperative nausea and vomiting

Out-of-operating room anesthesia: use of the AnaConDa vaporizer with anesthesia

Pseudohyperkalemia in the setting of chronic lymphocytic leukemia

A novel, simple method of delivering oxygen for endoscopic procedures

Perioperative management of a pediatric patient with short-chain acyl-CoA dehydrogenase deficiency

Falsely low pulse oximetry values caused by aortocaval fistula

Noninvasive removal of an entrapped supraclavicular catheter

Failure of the Easy Cap II CO2 detector to indicate esophageal intubation