Congenital Long QT Syndrome:

Context: Congenital long QT syndrome (cLQTS) is the most common genetic cardiac ion channelopathy in the US. Patients with cLQTS are at risk for ventricular tachycardia (VT) in the “torsades de pointes” (TdP) pattern from physical and emotional stress, including during the perioperative period. Purpose: This narrative review outlines the history and pathophysiology of the most common types of cLQTS, describes treatments for cLQTS, discusses the experience of anesthesia providers with cLQTS, and reports recommendations for safe administration of anesthesia to these patients. Methods: Searches of MEDLINE (PubMed) and Google Scholar were conducted using the terms “congenital long QT syndrome”, “LQTS”, and “cardiac ion channelopathy” combined with “surgery” and “anesthesia”. Findings: The most common types of cLQTS (LQT1-3) are caused by loss of function mutations to potassium channels responsible for ventricular repolarization or gain of function mutations to a sodium channel responsible for depolarization. cLQTS is diagnosed using the Schwartz Criteria which considers ECG findings, clinical history, and family history. It is treated with beta blocking medication, implantable cardioverter defibrillator (ICD) insertion, or left cardiac sympathetic denervation (LCSD).  Patients with cLQTS may require anesthesia for disease-related procedures (e.g. ICD insertion or LCSD), or for treatment of issues related to cLQTS (e.g. cochlear implants for congenital sensorineural deafness). To provide a safe anesthetic, providers need to avoid medications that prolong the QTc, minimize sympathetic stimulation, assure proper function of but prevent electrical interference with ICDs, correct electrolyte imbalances, and be prepared to treat TdP.  Importance: Pre-anesthetic precautions include considering a cardiologist consultation, checking the function of the ICD, determining a baseline QTc, correcting electrolyte imbalances, premedicating to prevent anxiety, and continuing beta blocking medications on the day of surgery. Intraoperative, the anesthesia provider should apply external defibrillator pads and all monitors prior to induction, turn off ICD or adjust its settings to avoid electromagnetic interference, monitor the QT interval, have magnesium salts ready if TdP develops, consider TIVA and use sevoflurane if an inhalation agent is needed, use propofol and/or fentanyl (or an analogue) to blunt the sympathetic response of airway manipulation, and avoid ketamine, suxamethonium, and pancuronium. During emergence, the provider should consider alternatives to anticholinesterase/ anticholinergic drug combinations, avoid droperidol or ondansetron, but consider dexamethasone as prophylaxis against PONV. Limitations: Because there are no definitive guidelines for the anesthetic management of patients with cLQTS, the anesthesia provider must rely on case studies and review articles to choose a safe anesthetic for this challenging patient population

Protamine Reaction in Cardiovascular Surgery

Coronary artery bypass grafting is the most performed cardiac surgery throughout the world today. The United States alone performs over 200,00 of these procedures every year. Protamine sulfate is administered to neutralize heparin given during these cases. Known hemodynamic effects are associated with protamine and on rare occasions, true anaphylaxis. A 10.7% chance exists of a protamine reaction occurring after its administration and five different risk factors that increase that chance are an allergy to fish, use of NPH insulins, previous vasectomy, previous exposure to protamine, and rapid administration of protamine. Treatment includes fluid resuscitation, administration of vasopressors, intra-aortic balloon pump, and also methylene blue but this has not been studied. A heparin removal device as an alternative to protamine shows promise

Negative Pressure Pulmonary Edema (NPPE)

Negative pressure pulmonary edema (NPPE) is a rare but dangerous complication of general anesthesia that can lead to detrimental results, including anoxic brain injury or death, if not promptly recognized and treated. The purpose of this research is to educate professionals on the etiology, signs, symptoms, treatments, risk factors, and preventions to aid in the early recognition and treatment of NPPE. With a mortality rate up to 5%, proper provider education on NPPE is necessary to prevent its occurrence. This project followed a case report of an 18-year-old male who developed NPPE after a pilonidal cyst removal under general anesthesia

Comparison of Quadratus Lumborum Block and Transversus Abdominis Plane Block for Postoperative Pain Management

Enhanced recovery after surgery (ERAS) protocols have been developed to promote rapid recovery of patients who undergo certain major surgeries, throughout the perioperative continuum, with a variety of interventions. Many protocols for open abdominal cases suggest preoperative epidural, wound catheter, or transversus abdominis plane (TAP) block placement for postoperative pain management.1 This case study presents a middle-aged woman who underwent a pancreatoduodenectomy (PD) and received an alternate postoperative fascial plane block, a quadratus lumborum (QL) block, rather than the currently recommended TAP block, wound infiltration, or neuraxial anesthesia.  Considering established ERAS protocols, the purpose of this case study is to examine the use of alternative forms of regional anesthesia for open abdominal cases, specifically the quadratus lumborum (QL) block, and compare it to the currently recommended TAP block. Based on quality evidence regarding the benefits of the QL block, expanding ERAS protocols to regional anesthesia beyond wound infiltration and TAP blocks has the potential to produce increased pain management postoperatively, aiding in enhanced recovery and improved outcomes. Future, high-quality research should be initiated spanning a larger, more generalized population, including ASA III and IV, with BMIs not limited to 30 kg/m2, to confirm current study’s findings.  Further evaluation of the local anesthetic’s diffusion via the TLF and the adjacent paravertebral space should be studied, due to the inquiries of the QL block’s definite mechanism of action that remain.  Regarding the variation in fascial layers and dermatomes covered based on the type of QL block, further studies examining QL block injection sites should be considered

Transesophageal Echocardiography Use for Orthotopic Liver Transplant

Impact Statement: Transesophageal echocardiography (TEE) is an invaluable tool used in cardiac surgery. So why is it not consistently used in other high-risk surgeries, such as orthotopic liver transplantation (OLT)? Key Words: Transesophageal echocardiography, Liver graft, Liver transplantation Introduction: This scholarly project observes a high-risk patient undergoing an OLT. Hemorrhage, acute cardiac dysfunction, fluid shifts, and other intraoperative pathologies associated with OLT present many challenges for the anesthesia provider. Therefore, timely identification, evaluation, and intervention of intraoperative pathology are necessary to maintain hemodynamic stability. Traditionally, intra-arterial and pulmonary artery catheters (PACs) were used as hemodynamic monitors. Recently, however, transesophageal echocardiography (TEE) has been used for noncardiac surgery to assess hemodynamic status. The objective of this project is to identify the benefits gained from using TEE during OLT in addition to traditional hemodynamic monitoring techniques (CVP/PAOP) and how these findings affect fluid and medication management. Case Presentation: A 50-year-old female underwent general anesthesia for OLT. The patient’s medical history included cirrhosis, ascites, portal hypertension, portal vein thrombosis, thrombocytopenia, anemia, obesity, and coronary artery disease. Surgical history included splenic embolization and coronary artery bypass graft. The patient was transported to the OR, and standard monitors were applied. Initial VS were as follows: BP 148/75, HR 89, SpO2 92%, RR 24. The patient underwent an uneventful anesthetic induction and intubation. Sevoflurane was used to maintain anesthesia. A radial arterial line and an internal jugular introducer with a PAC were placed. Epinephrine and norepinephrine infusions were used to treat intraoperative hypotension. 1.5 L of 5% albumin, 6 U of packed red blood cells (PRBCs), 5 U of fresh frozen plasma (FFP), and 1 U of platelets were administered. Along with intraarterial blood pressure monitoring, CVP and PA pressure monitoring was used to estimate volume status and treat hypotension. Profound hypotension was treated frequently with vasopressors, fluids, and blood products throughout the case. The patient remained intubated and was transported to the intensive care unit (ICU) postoperatively. Forty-eight hours postoperatively, the patient remained intubated. Due to acute kidney injury, a continuous furosemide infusion and subsequent dialysis were required. Discussion: The reviewed literature provided ample evidence that TEE for OLT can be used to make new intraoperative diagnoses, many of these being difficult to identify by other means. Common findings included intracardiac thrombus (ICT), ventricular dysfunction, and multiple embolic pathologies. Shillcutt et al found that 88% of participants in their study had some form of abnormal TEE finding during OLT. TEE findings were also found to impact fluid and medication administration. Hofer et al found that vasopressor (56%), vasodilator (63%), and fluid management (50%) were all impacted by TEE findings in OLT patients. While evidence was provided to exhibit the efficacy of TEE as an intraoperative monitor, sufficient evidence was not provided to support better patient outcomes based on TEE assessments. This is largely due to a lack of quality observations and controlled research during OLT. The most significant evidence supporting better outcomes was from a retrospective observational cohort study that compared TEE, PAC, and a combined therapy group. The authors found that the patients undergoing OLT with both TEE and PAC had the lowest hospital length of stay (LOS), 30-day mortality, and infusion of fluids. This suggests that the addition of TEE with traditional monitors may be the safest method of hemodynamic monitoring. In the presented case study, the addition of TEE monitoring may have helped diagnose the causes of hemodynamic instability more rapidly and potentially altered medication and fluid administration. While the assumption that timely diagnosis of intraoperative findings leads to better outcomes may be reasonable, higher-powered studies are necessary to verify this assumption. Until beneficial outcomes have been validated, the use of TEE cannot be recommended as a comprehensive intervention for every OLT. However, it should be used based on the anesthesia provider’s judgment along with other monitoring tools. Conflict of Interest: I have no conflict of interest to disclose. References: De Marchi L, Wang CJ, Skubas NJ, et al. Safety and benefit of transesophageal echocardiography in liver transplant surgery: a position paper from the society for the advancement of transplant anesthesia (SATA). Liver transplant. 2020;26:1019-1029. doi: 10.1002/lt.25800 Hofer RE, Vogt MNP, Taner T, Findlay JY. Influence of intraoperative transesophageal echocardiography and pulmonary artery catheter monitoring on outcomes in liver transplantation. Transplant. Direct. 2020;6:e525-e525. doi: 10.1097/TXD.0000000000000972 Shillcutt, Sasha K., MD, FASE, Ringenberg KJ, MD, Chacon MM, MD, et al. Liver transplantation: intraoperative transesophageal echocardiography findings and relationship to major postoperative adverse cardiac events. J.Cardiothorac. Vasc. Anesth. 2016;30:107-114. https://doi-org.ezproxy.tcu.edu/10.1053/j.jvca.2015.09.009. Fayad A, Shillcutt S, Meineri M, Ruddy TD, Ansari MT. Comparative effectiveness and harms of intraoperative transesophageal echocardiography in noncardiac surgery: a systematic review. Semin Cardiothorac Vasc Anesth.2018;22:122-136. doi: 10.1177/1089253218756756 Hofer CK, Zollinger A, Rak M, et al. Therapeutic impact of intra-operative transoesophageal echocardiography during noncardiac surgery. Anaesthesia. 2004;59:3-9. https://doi-org.ezproxy.tcu.edu/10.1111/j.1365-2044.2004.03459.x

A Review Evaluating Intravascular Access for High Volume Resuscitation: Can You Keep Up?

Anesthetists and anesthesiologists are frequently in the unique position of administering high-volume resuscitation in the setting of hemorrhage, hypovolemia, or vasodilatory shock.  The ability to rapidly infuse intravenous (IV) fluid solutions differs vastly for different types and sizes of IV access. In patients that may require rapid large volume resuscitation, it is critical to understand the capacity of existing IV devices.  Selecting the most appropriate IV access for patients can be paramount in preventing hypotension, end organ dysfunction, and even death. This article objectively reviews and compares the flow rates of commonly used central and peripheral intravenous devices to demonstrate the influence of catheter length and radius.   &nbsp

Effect of Dexmedetomidine on Incidence of Emergence Delirium in Adult Nasal Surgery

Background/Purpose/Question.  Emergence delirium (ED) is an acute phenomenon that develops in the early phase of recovery from general anesthesia, and characterized by confusion, disorientation, & possible violent behavior, and is a common occurrence particularly with nasal surgery. Dexmedetomidine is a highly selective alpha-2 adrenergic agonist that results in anxiolysis, sedation, analgesia, and sympatholysis without depressing ventilation. This educational scholarly project aimed to review the literature and investigate the effect of intraoperative dexmedetomidine on the incidence of ED in adults recovering from general anesthesia after nasal surgery. Methods/Evidence Search.  PubMed and EMBASE were structurally searched from 2011 to 2021. Five randomized controlled studies (RCT) were selected that compared intraoperative dexmedetomidine to a placebo and how the recovery profile was affected in adults after nasal surgery. Key search terms included “anesthesia”, “dexmedetomidine”, “emergence”, “nasal surgery”. Synthesis of Literature/Results/Discussion.  There were collectively 392 participants across these five studies, and the incidence of ED in dexmedetomidine groups was significantly lower than control groups (respectively 21% vs. 50%). The mean arterial pressure (MAP) and heart rate (HR) among dexmedetomidine groups exhibited less variability during emergence without hypotension, which indicates a more stable hemodynamic profile. Analgesic and antiemetic requirements in the post-anesthesia care unit (PACU) were decreased in dexmedetomidine groups, however these results were not statistically significant. Conclusion/Recommendations for Practice.  Intraoperative dexmedetomidine significantly decreases the incidence of ED. Secondary effects, like hemodynamic stability and analgesia, were observed, but these qualities need to be further studied before they can be generalized. Overall, dexmedetomidine is a safe and effective anesthetic adjunct that facilitates a smoother emergence after nasal surgery without any complications. Keywords: Anesthesia, dexmedetomidine, emergence, nasal surger

Prevention of Opioid Induced Hyperalgesia Following Remifentanil Infusion: A Case Report

Remifentanil, a potent µ-opioid agonist, is useful in anesthesia because of its rapid onset and short duration of action. However, the same traits that make remifentanil useful can also lead to increased pain sensation when it is discontinued. Nociceptive sensitization following opioids is termed opioid-induced hyperalgesia (OIH). Proposed preventative treatments for remifentanil-induced OIH run the spectrum of cost and feasibility. This case report will discuss the use of and rationale for readily available techniques aimed at preventing OIH. These techniques include intravenous ketamine, inhaled nitrous oxide, oral pregabalin, and gradual cessation of remifentanil infusion

Preoperative Optimization of the Asthmatic Patient

Introduction.              Asthma is a common upper respiratory condition among patients across the developmental spectrum. The condition is estimated to affect over 300 million people worldwide with prevalence rate and condition severity continually increasing.1 With such a high prevalence rate worldwide, it is common to encounter asthmatic patients in need of elective surgery.1 Bronchospasm is a common pathophysiologic feature of asthma. During a bronchospasm, the smooth muscle of the airway contracts and narrows the diameter of the airway.1 As a result, a significant impedance to airflow can result. The obstruction to airflow makes ventilation difficult if not impossible. Patients who experience intraoperative bronchospasm are at increased risk for postoperative morbidity and mortality.1 Given the severe implications of intraoperative bronchospasm, the anesthetic care of the asthmatic patient should focus on preoperative assessment and optimization in order to mitigate the risk of intraoperative bronchospasm and postoperative pulmonary complications. The purpose of pursuing this topic is to educate anesthesia providers about the complications resulting from intraoperative bronchospasm and to provide guidelines for preventing bronchospasm during the surgical period. Case presentation.              A recent case of intraoperative bronchospasm involved a 77-year-old, female, ASA 4 inpatient. The patient had significant medical history including asthma and COPD. The scheduled procedure was a closed reduction of the left hip with percutaneous pinning. During the preoperative assessment the patient was identified, the planned procedure and surgeon were confirmed, all allergies and medications were reviewed, medical and anesthetic history were reviewed, and a physical exam was conducted. During the preoperative interview the patient confirmed a history of reactive airway disease, but reported that her asthma was well-controlled with current medications and denied any recent exacerbations. The patient did not receive any preoperative medications other than analgesics for pain control. The patient was taken to the operating room for surgery and was preoxygenated prior to anesthetic induction. The patient was induced with IV propofol, fentanyl, and lidocaine. Succinylcholine was subsequently administered to achieve optimal conditions for intubation. The patient was successfully endotracheally intubated and sevoflurane administered for anesthetic maintenance. Prior to incision, the ventilator alarms were triggered by high peak pressures and low tidal volumes. Manual ventilation was initiated, but was found to be difficult, leading to a progressive oxygen desaturation. As bronchospasm was suspected, albuterol was administered endotracheally. The patient responded well to the bronchodilator, ventilation became easier, and the oxygen saturation improved. Once the patient was stabilized, the hip surgery continued without further incident. However, at the conclusion of the surgery and just prior to emergence, the patient experienced another severe bronchospasm. Again, albuterol and epinephrine treatment were initiated until the patient respiratory status stabilized again. The patient remained intubated and was transferred to ICU to allow for further pulmonary stabilization prior to extubating. Discussion.              A literature review was conducted on the anesthetic management of the asthmatic patient undergoing surgery. The current literature emphasizes the importance of comprehensive assessment and pharmacologic optimization of the asthmatic patient during the preoperative period as the most efficacious method for reducing poor post-operative pulmonary outcomes. Bronchodilatory beta 2 adrenergic agents such as albuterol or salbutamol effectively reduce the incidence of intraoperative bronchospasm. The findings suggest that the intraoperative problems related to bronchospasm encountered in the presented case may have been avoidable.             As discussed, the prevalence of asthma is significant among surgical patients. With a high number of asthmatic patients receiving general anesthesia for surgery, prevention of intraoperative bronchospasm is important for improving outcomes among this patient population. Based on the current literature, the recommendation for practice would be to preoperatively treat all asthmatic patients, regardless of the perceived severity of their asthma, with a bronchodilatory agent prior to surgery in an effort to reduce the incidence of intraoperative bronchospasm.             Future research on the topic should consider the costs associated with added length of hospital stay and additional treatment following an intraoperative bronchospasm. Prevention of an asthma exacerbation during the preoperative period is likely the most cost-effective approach to managing a patient with reactive airway disease.   Keywords Bronchodilators, bronchospasm, asthma, optimizatio

Barriers and Determinants that Influence Membership in the American Association of Nurse Anesthetists

The American Association of Nurse Anesthetists (AANA) have a significant role in providing various benefits to their members and advancing the profession. However, membership percentages have decreased within the last 10 years. A review of the literature was conducted to identify the determinants that influence decision-making regarding professional association membership. It was discovered that Florida was among the states with the highest percentages of nonmembers. For that reason, a scholarly project was developed and implemented to examine the factors that influence decision-making regarding professional association membership among Florida’s licensed nurse anesthetists. An online survey was developed and sent to all Florida Certified Registered Nurse Anesthetists (CRNAs) with the help of the Florida Association of Nurse Anesthetists (FANA). The results of the survey revealed barriers to membership included dissatisfaction with the new National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) Continued Professional Certification (CPC) requirements, cost of membership, and a lack of education about the AANA. Determinants to membership identified included the benefit of CEUs and tracking, professional promotion, and the AANA’s political advocacy. There was insufficient power to compare FANA members’ and nonmembers’ responses due to a low nonmember response rate. However, sufficient information was derived to suggest implications and recommendations to help improve future research efforts and better understand the issue