Journal of Clinical Anesthesia

Editorial Board

2010-08-01

The impaired anesthesiologist: where do we draw the line?

Ethan O. Bryson — 2010-08-01

In this issue of the Journal of Clinical Anesthesia, the article, “The impaired anesthesiologist: not just about drugs and alcohol anymore, “ by Drs. Rose and Brown presents a thoughtful discussion of the potential for impairment of anesthesia personnel as a result of depression. This subject strikes at the very heart of our profession, for the hallmark of the anesthesiologist is vigilance, and any disease, disorder, or circumstance that reduces the capacity for vigilance deserves attention. Since depression often does not exist as an isolated entity, a more in-depth discussion of the other affective disorders alluded to in the summary statement would have broadened the applicability of this review. The authors correctly point out that it is difficult to separate substance abuse from other forms of psychiatric impairment (many patients with depression either exhibit this symptom as a result of substance abuse or they abuse substances as a form of self-medication) and they have appropriately touched on this subject as well.

Liposomal encapsulation improves the duration of soft tissue anesthesia but does not induce pulpal anesthesia

2010-06-14

Abstract: Study Objective: To compare the topical and the pulpal anesthesia efficacy of liposomal and plain benzocaine formulations.Design: Double-blinded, randomized crossover study.Setting: University ambulatory dental center.Patients: 30 ASA physical status I volunteers.Interventions: Volunteers received, in three different sessions, topical application of liposome-encapsulated 10% benzocaine (LB10), 10% benzocaine gel (B10), and 20% benzocaine gel (B20) in the right maxillary canine mucobuccal fold.Measurements: Pain associated with the needle insertion was rated by visual analog scale (VAS) and the duration of topical anesthesia was recorded. Pulpal anesthesia was evaluated using an electric pulp tester.Main Results: VAS values (median, 1st - 3rd quartiles) were 17 cm (11 - 25), 14 cm (3 - 22), and 21 cm (9 – 21) for B10, LB10, and B20, respectively. No differences were noted among the groups (Friedman test; P = 0.58). Soft tissue anesthesia was also not different. The LB10 [10 (8 - 12) min] showed longer soft tissue anesthesia (Friedman test; P < 0.01) than the other agents [B10 = 8 (5 - 10) min, and B20 = 7 (6 - 9) min]. None of the topical benzocaine formulations tested induced pulpal anesthesia.Conclusions: The encapsulation of benzocaine into liposome increased the duration of soft tissue anesthesia. However, it did not induce pulpal anesthesia.

Acceleromyographic monitoring of neuromuscular block over the orbicularis oris muscle in anesthetized patients receiving vecuronium

Yuhji Saitoh, Tsutomu Oshima, Yoshinori Nakata — 2010-08-01

Abstract: Study Objective: To evaluate the level of neuromuscular block acceleromyographically over the orbicularis oris muscle.Design: Prospective, randomized, controlled study.Setting: Operating room of a university-affiliated hospital.Patients: 36 adult, ASA physical status I and II women scheduled for mastectomy with air-oxygen-isoflurane-fentanyl anesthesia.Interventions: Patients were randomized to two groups. In the orbicularis oris group (n=18), the facial nerve was stimulated and movement of the orbicularis oris muscle was measured acceleromyographically. In the control group (n=18), adduction of the thumb was quantified mechanically.Measurements: Onset and recovery of neuromuscular block caused by vecuronium 0.1 mg/kg were compared between the groups.Main Results: Time to onset of neuromuscular block in the orbicularis oris group was significantly shorter than in the control group (176 ± 52 vs. 220 ± 34 sec, mean ± SD; P = 0.004). Times to return of the first, second, third, or fourth (T1, T2, T3, or T4) response of train-of four (TOF), and recovery of T1/control were comparable between the groups. Train-of-four ratio (T4/T1) in the orbicularis oris group was significantly higher than in the control group 50 to 120 minutes after vecuronium administration (P < 0.05).Conclusion: Depth of neuromuscular block can be assessed acceleromyographically over the orbicularis oris muscle. Onset of neuromuscular block is quicker and recovery of TOF ratio is faster over the orbicularis oris muscle than at the thumb in patients receiving vecuronium.

Intravenous regional anesthesia using lidocaine and neostigmine for upper limb surgery

Divya Sethi, Rama Wason — 2010-08-01

Abstract: Study Objective: To evaluate the effect of adding neostigmine to lidocaine in intravenous regional anesthesia (IVRA).Design: Randomized, double-blinded study.Setting: Tertiary-care academic medical institution.Patients: 40 ASA physical status I and II patients scheduled for elective or emergency forearm and hand surgery.Intervention: Patients were randomized to two groups of 20 patients each. In the control group, IVRA was established using 40 mL of 0.5% lidocaine with one mL of isotonic saline, while neostigmine group patients received 40 mL of 0.5% lidocaine with 0.5 mg neostigmine.Measurements: Hemodynamic parameters, onset and recovery times of sensory and motor blocks, and quality of anesthesia achieved with IVRA were recorded. After tourniquet deflation, visual analog pain scores (VAS) were noted every 30 minutes in the first two hours, as were the time to first analgesic request and total analgesic requirement in the 24-hour postoperative period.Main Results: In the first 24 hours after surgery, the neostigmine group had significantly lower VAS scores, longer time to first analgesic request, and reduced total analgesic requirement. Intraoperatively, the neostigmine group had significantly shorter sensory and motor block onset times and longer recovery times than the control group. No significant frequency of adverse effects was seen in either group. The quality of intraoperative anesthesia and frequency of tourniquet pain were similar in both groups.Conclusions: The addition of neostigmine to lidocaine shortens onset time and improves postoperative analgesia in IVRA for upper limb surgery.

Comparison of 50 μg and 25 μg doses of intrathecal morphine on postoperative analgesic requirements in patients undergoing transurethral resection of the prostate with intrathecal anesthesia

Ates Duman, Seza Apiliogullari, Mehmet Balasar, Recai Gürbüz, Murat Karcioglu — 2010-08-01

Abstract: Study Objective: To compare the efficacy of 50 μg and 25 μg doses of intrathecal morphine on postoperative pain in patients undergoing transurethral resection of the prostate (TURP) with low-dose bupivacaine.Design: Randomized, double-blinded study.Setting: Konya Hospital.Patients: 70 ASA physical status I, II, and III patients.Interventions: Patients were randomized to two groups: Group A patients received 5 mg of 0.5% hyperbaric bupivacaine (one mL) and 50 μg of morphine (0.5 mL). Group B patients received 5 mg of 0.5% hyperbaric bupivacaine (one mL) and 25 μg of morphine (0.5 mL).Measurements: Postoperative pain scores, patient and surgeon satisfaction, and side effects such as emesis, pruritus, and respiratory depression, were recorded.Main Results: Postoperative pain characteristics were similar between the two groups. Frequency of emesis was similar between the groups, while pruritus was significantly higher in Group A. No antipruritic medication was required in any patient. Patient and surgeon satisfaction was evaluated as good or excellent in both groups.Conclusions: Intrathecal morphine at a dose of 25 μg provides similar postoperative analgesia and less pruritus than the 50 μg dose in patients undergoing TURP.

Role of local anesthetic spread pattern and electrical stimulation in ultrasound-guided musculocutaneous nerve block

Bassam Al-Nasser, Christophe Hubert, Michèle Négre — 2010-08-01

Abstract: Study Objective: To evaluate local anesthetic spread on the frequency of success of musculocutaneous nerve block, and to determine needle-to-target-nerve distance by ultrasound imaging and electrical stimulation.Design: Observational study.Settings: Private hospital.Patients: 48 ASA physical status I and II adults (16 men and 32 women) scheduled for elective carpal tunnel release or wrist ganglion cyst surgery in an outpatient setting.Interventions: The musculocutaneous nerve (MCN) was identified by ultrasound. An insulated needle connected to an electrical stimulator in the “off” position was inserted in the biceps side of the probe in the plane of the ultrasound beam. The needle tip was placed in the vicinity of the MCN.Measurements: Local anesthetic spread pattern was determined by ultrasound imaging. The lowest effective current intensity was registered. The average depth of the MCN was measured by ultrasound.Main Results: In all patients, the local anesthetic solution spread was uneven. In 32% of patients (15/47), motor response was still elicited with electrical stimulation intensity lower or equal to 0.3 mA. In 26% of patients (12/47), motor response disappeared with electrical stimulation intensity higher or equal to 0.6 mA. In 42% of patients (20/47), motor response disappeared at intensities between 0.3 mA and 0.5 mA.Conclusions: A high success rate of MCN anesthesia occurred with non-circumferential spread of local anesthetic solution. Electrical current intensity was not a reliable indicator of needle-to-target-nerve distance.

Impact of deep hypothermic circulatory arrest on the BIS index

2010-08-01

Abstract: Study Objective: To investigate the influence of duration of deep hypothermic circulatory arrest (DHCA) on recovery of the bispectral index (BIS).Design: Prospective cohort study.Setting: Operating room of university teaching hospital.Patients: 30 adult, ASA physical status III and IV patients scheduled for cardiac surgery with extracorporeal circulation (ECC) and DHCA.Interventions: There were no study-specific interventions undertaken with the study patients.Measurements: After induction of anesthesia, propofol and sufentanil were used for maintenance. Duration until BIS values reached indices of 10, 20, and 30 after DHCA was measured. ΔBIS was defined as the difference between BIS before the start of ECC and after DHCA at the same nasopharyngeal body temperature. Data are means ± SD (ranges).Main Results: Duration of DHCA was 24 ± 15 min (8-71 min). The deepest nasopharyngeal temperature was 20.1 ± 2.7°C at the end of DHCA. BIS reduction was 1.8/°C. At the end of DHCA, BIS was 2 ± 6 and at the end of ECC, BIS was 33 ± 11. Duration until BIS reached a value of 10 (BIS10) was 23 ± 21 min (0-83 min); until BIS reached 20 (BIS20): 36 ± 36 min (0-140 min); and until BIS reached 30 (BIS30): 43 ± 29 min (1-130 min). Regression analysis between duration of DHCA and BIS10 was R = 0.76; BIS20: R = 0.67; and BIS30: R = 0.54.Conclusion: Deep hypothermia influences BIS linearly. In addition, there appears to be a reasonable correlation between recovery of BIS values and duration of DHCA.

Have personal statements become impersonal? An evaluation of personal statements in anesthesiology residency applications

Bryan A. Max, Brian Gelfand, Meredith R. Brooks, Rena Beckerly, Scott Segal — 2010-08-01

Abstract: Study Objective: To evaluate personal statements submitted to a major academic anesthesiology program to determine the prevalence of common features and overall subjective quality, and to survey anesthesiology program directors as to how they utilized these statements during the resident selection process.Design: Structured analysis of de-identified personal statements and Internet-based survey of program directors.Setting: Large academic anesthesiology training program.Subjects: 670 applicant personal statements and academic anesthesiology program directors.Measurements: Prevalence of 13 specific essay features and 8 quality ratings were calculated for the essays and correlated with other aspects of the residency application, as abstracted from the Electronic Residency Application Service (ERAS) files. A 6-question survey regarding use of personal statements was collected from program directors.Main Results: 70 of 131 program directors queried responded to our survey. Interest in physiology and pharmacology, enjoyment of a hands-on specialty, and desire to comfort anxious patients were each mentioned in more than half of the essays. Candidates invited for an interview had essays that received higher quality ratings than essays of those not invited (P = 0.02 to P < 0.0001). Higher quality ratings were also strongly associated with graduation from a U.S. or Canadian medical school, applicant file screening score, female gender, and younger age. Interrater reliability was good (kappa 0.75-0.99 for structural features, and 0.45-0.65 for quality features). More than 90% of program directors found proper use of English to be a somewhat or very important feature of the essay. Only 41% found the personal statement to be very or somewhat important in selecting candidates for interview invitations. However, over 90% stated that they used the statements during actual interviews with invited applicants.Conclusion: The data showed a high prevalence of common features found within personal statements and a general ambivalence amongst those program directors for whom the statements were intended.

Clinical comparison of two stylet angles for orotracheal intubation with the GlideScope video laryngoscope

2010-08-01

Abstract: Study Objective: To compare the success of orotracheal intubation in 62 seconds or less using the GlideScope video laryngoscope (GVL) and a 60° or 90° angled stylet with reverse loading of the endotracheal tube (ETT).Design: Prospective, randomized study.Setting: Operating room of a university hospital.Patients: 120 ASA physical status I, II, and III adult patients undergoing elective surgery requiring general anesthesia with orotracheal intubation.Interventions: Patients were randomly allocated to two groups (n = 60 each); both groups received general anesthesia and neuromuscular relaxation. A conventional ETT was styleted and then bent from its straight configuration just above the cuff, either at 60° or 90° against its concave natural curve (reverse loading). Four attending anesthesiologists, who were blinded as to stylet assignment (the 60° or 90° group), intubated the tracheas of all patients with the GVL using either the primary or secondary stylet.Measurements: The primary outcome was success of orotracheal intubation in 62 seconds or less. The secondary outcome was actual time to intubation (TTI).Main Results: The odds ratio (OR) for intubation success was higher in the 90° group than the 60° group (OR = 10.41; P < 0.03), as evidenced by 59 of 60 patients whose tracheas were intubated successfully within 62 seconds, compared with 51 of 60 patients in the 60° group. Seven of the 9 failures were due to inability of the 60° stylet to reach the glottic opening. The three remaining failures were associated with TTI of more than 62 seconds.Conclusions: The 90° angled malleable stylet with reverse loading of the ETT provided more reliable ETT delivery to the glottic opening and had a higher success rate than the 60° stylet.

Dexmedetomidine sedation for awake tracheotomy: case report and literature review

Marianne D. David, Lorenzo De Marchi — 2010-08-01

Abstract: The safe administration of conscious sedation in a patient with a critical airway who underwent awake tracheotomy using dexmedetomidine, a selective alpha2-agonist with sympatholytic, anxiolytic, analgesic, and sedative properties, is presented. Unlike other commonly used sedative agents, dexmedetomidine provided adequate sedation with minimal respiratory depression.

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy

2010-08-01

Abstract: A case series of patients with diabetic nephropathy, who underwent lower limb debridement or amputation below the knee during successful combined sciatic and femoral nerve block with bupivacaine 0.25%, is presented. Because impaired nerve conduction in diabetes mellitus results in lower local anesthetic agent requirement, a dose-sparing, minimal effective concentration for surgical anesthesia for peripheral nerve blockade may be more favorable for patients with diabetes and chronic renal disease.

Acute pulmonary embolism and a patent foramen ovale: analysis of atrial right-to-left shunting by biphasic transcardiopulmonary thermodilution curves

2010-08-01

Abstract: A 69-year-old woman with an acute pulmonary embolism developed an intracardiac right-to-left shunt, which was diagnosed early on and quantified via biphasic transcardiopulmonary thermodilution curves. With transesophageal echocardiography, a patent foramen ovale and an impressive atrial right-to-left shunt were visualized.

Pulmonary edema after da Vinci-assisted laparoscopic radical prostatectomy: a case report

2010-08-01

Abstract: A 63 year-old man developed sudden pulmonary edema after uneventful robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer despite normal preoperative laboratory findings and appropriate anesthetic management. The pulmonary edema was attributed to prolonged (4 hrs) pneumoperitoneum with concomitant high intraabdominal pressure (15-20 mmHg).

Percutaneous aortic valve replacement: overview and suggestions for anesthestic management

Hermann Heinze, Holger Sier, Ulrich Schäfer, Matthias Heringlake — 2010-08-01

Abstract: Transcutaneous aortic valve replacement (AVR) is increasingly used for high-risk patients with severe aortic stenosis, who have high operative mortality for surgical placement during cardiopulmonary bypass (CPB). Retrograde transfemoral AVR is usually performed during sedation, whereas antegrade transapical AVR is done with general anesthesia. Both procedures can be carried out without CPB. Extended hemodynamic monitoring, including pulmonary artery catheterization and transesophageal echocardiography, may be useful. Transfemoral AVR requires placement of a transvenous right ventricular pacing lead. Typical complications include local bleeding, obstruction of the coronary ostia, and neurological insult due to embolization of sclerotic material. Aortic regurgitation due to paravalvular leakage or inadequate device expansion also may occur. Renal function may deteriorate on excessive application of contrast medium. Atrioventricular blocks may occur later rather than after conventional AVR which tend to occur immediately.

The impaired anesthesiologist: not just about drugs and alcohol anymore

Gregory L. Rose, Raeford E. Brown — 2010-08-01

Abstract: The safety of patients and the health of clinicians are affected by drug and alcohol abuse. Affective disorders such as depression are also common in medical professionals, including anesthesiologists. The suicide rate among anesthesiologists is high. Since depression is the most common psychological characteristic associated with suicide, it may be a marker for risk of suicide.

Subcutaneous emphysema of the eyelid on emergence from general anesthesia after a craniotomy

Andrea K. Girnius, Rafael Ortega, Lawrence S. Chin — 2010-08-01

A 64-year-old woman presented for elective left pterional craniotomy and left middle cerebral artery aneurysm clipping. After induction of general anesthesia, the trachea was intubated with a 7.0 mm endotracheal tube (ETT). Anesthesia was maintained with isoflurane in oxygen. Nitrous oxide was not used. The lungs were mechanically ventilated using positive pressure.

Passing a reinforced gastric tube behind a non-ProSeal Laryngeal Mask Airway

Rajesh Mahajan, Amit Manhas, Rahul Gupta — 2010-08-01

Various instruments have been passed into the gastrointestinal tract behind the classic Laryngeal Mask Airway (LMA Classic; Intavent Direct, Maidenhead, UK). Although more difficult than the ProSeal LMA, the potential space behind the cuff allows insertion of larger instruments. Four studies in adults involving the LMA Classic showed a low success rate for passage of a gastric tube behind the LMA Classic cuff (40-55%) . This finding was attributed to the soft and flexible nature of the gastric tube . Amitabh and colleagues reported nasal passage of a cuffed red rubber tracheal tube (ETT) behind the LMA cuff into the upper esophagus, followed by railroading of the gastric tube through it to achieve nasogastric intubation . The use of a reinforced gastric tube to assist insertion of a nasogastric tube behind a properly positioned LMA is presented.

Reproducible peaked T wave due to transfusion via central venous catheter in an infant

Satoki Inoue, Yuki Terada, Hitoshi Furuya — 2010-08-01

Cardiac arrest associated with hyperkalemia during transfusion has been reported . Transfusion-related hyperkalemia depends not only on the potassium concentration in the blood product, but also on volume and rate of transfusion . It has also been suggested that transfusion via the central venous catheter contributes to a more concentrated potassium load to the heart, especially in pediatric patients . Compared with stored blood units, fresh blood units, which have a lower potassium concentration, seem to be rarely related to hyperkalemia during transfusion . However, we report a reproducible peaked T wave that was probably due to transfusion of fresh umbilical cord blood.

Gastroesophageal reflux disease causing a difficult airway

Viviane G. Nasr, Claude Abdallah — 2010-08-01

Gastroesophageal reflux disease (GERD) is a physiological condition in newborns and infants that usually disappears spontaneously around the age of 12 or 18 months . GERD is generally a benign medical condition and it is manifested commonly by digestive signs. It has been associated with otolaryngologic manifestations mainly in children, including hoarseness, subglottic stenosis, and laryngomalacia. In contrast, only 4% to 10% of adults complaining of GERD have otolaryngologic symptoms. Routinely, when dealing with a patient diagnosed with GERD, attention is focused on preventing aspiration, while the possibility of a difficult airway in association with GERD may be overlooked. We describe GERD as a cause of laryngomalacia in a patient leading to supraglottic collapse and difficult tracheal intubation.

Abstract highlights presented at the 13th Annual Society of Airway Management (SAM) Scientific Meeting, Las Vegas, Sept. 25-27, 2009

Thomas Mort — 2010-08-01

re: The role of surgery in postoperative nerve injuries following total hip replacement (J Clin Anesth 2010;22:285-293)

2010-08-01

The order of authorship should be: Anna Uskova MD, Anton Plakseychuk MD, PhD, Jacques E. Chelly MD, PhD, MBA.

Journal of Clinical Anesthesia

Editorial Board

Table of Contents

The impaired anesthesiologist: where do we draw the line?

Liposomal encapsulation improves the duration of soft tissue anesthesia but does not induce pulpal anesthesia

Acceleromyographic monitoring of neuromuscular block over the orbicularis oris muscle in anesthetized patients receiving vecuronium

Intravenous regional anesthesia using lidocaine and neostigmine for upper limb surgery

Comparison of 50 μg and 25 μg doses of intrathecal morphine on postoperative analgesic requirements in patients undergoing transurethral resection of the prostate with intrathecal anesthesia

Role of local anesthetic spread pattern and electrical stimulation in ultrasound-guided musculocutaneous nerve block

Impact of deep hypothermic circulatory arrest on the BIS index

Have personal statements become impersonal? An evaluation of personal statements in anesthesiology residency applications

Clinical comparison of two stylet angles for orotracheal intubation with the GlideScope video laryngoscope

Dexmedetomidine sedation for awake tracheotomy: case report and literature review

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy

Acute pulmonary embolism and a patent foramen ovale: analysis of atrial right-to-left shunting by biphasic transcardiopulmonary thermodilution curves

Pulmonary edema after da Vinci-assisted laparoscopic radical prostatectomy: a case report

Percutaneous aortic valve replacement: overview and suggestions for anesthestic management

The impaired anesthesiologist: not just about drugs and alcohol anymore

Subcutaneous emphysema of the eyelid on emergence from general anesthesia after a craniotomy

Passing a reinforced gastric tube behind a non-ProSeal Laryngeal Mask Airway

Reproducible peaked T wave due to transfusion via central venous catheter in an infant

Gastroesophageal reflux disease causing a difficult airway

Abstract highlights presented at the 13th Annual Society of Airway Management (SAM) Scientific Meeting, Las Vegas, Sept. 25-27, 2009

re: The role of surgery in postoperative nerve injuries following total hip replacement (J Clin Anesth 2010;22:285-293)