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Browsing by Author "Clark, William L."
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Item Cross Field Ventilation For Tracheal Squamous Cell Carcinoma in Patient With Prior Single Lung Transplant(2022-09-17) Garcia, Jennifer; Clark, William L.Introduction: Resection of tracheal masses can pose a significant difficulty for the management of the airway in the intraoperative period. Cross field ventilation is a technique rarely used in patients with tracheal masses and tracheobronchial injury1 where placing an endotracheal tube orally would interfere with the surgical procedures. During cross field ventilation, the surgeon will place an endobronchial tube in the bronchus and intubate the bronchus, and a sterile circuit will be passed and connected by the anesthesiology team. Throughout this time, single lung ventilation will be provided to the patient. Important considerations include maintaining the patient’s oxygenation status with adequate ventilation and maintaining the patient overall hemodynamically stable to be able to tolerate single lung ventilation. Case Description: A 71-year-old male with a past medical history of chronic obstructive pulmonary disease (COPD) post right (R) lung transplant presented for resection of squamous cell carcinoma of the trachea. His CT scan showed a posterior tracheal mass above the carina and bronchoscopy with biopsy confirmed the diagnosis. It is thought that the mass resulted from chronic immunosuppressive therapy due to his prior lung transplant. Resection of the mass under general anesthesia with cross field ventilation was planned. The patient received 100mg of propofol for induction and 100mg of rocuronium for paralysis. An oral endotracheal tube (ETT) was placed. Maintenance of anesthesia was with sevoflurane. The patient’s blood pressure was monitored continuously throughout the case with a radial arterial line, and he remained within 20% of his baseline blood pressure. His oxygen saturation remained stable throughout the case, stating between 97-98%. Before transection of the trachea for removal of the tumor, cross field ventilation was begun. The oral ETT was pulled back. Bronchoscopy was used and an endobronchial tube was placed in the R mainstem bronchus. A sterile circuit was passed through from the surgical team and connected. One lung ventilation was used for the R transplanted lung. Once the tracheal anastomosis was complete, the oral ETT was pushed back into the distal trachea and cross field ventilation was terminated. The patient was extubated at the end of the case with no difficulty and taken to the intensive care unit for recovery. Discussion: Cross field ventilation is a unique approach that can be used during surgeries involving the tracheobronchial region. It requires constant communication between the surgery team and anesthesiologist. Additionally, remembering certain considerations such as the implications of using single lung ventilation is important, especially in this patient with prior lung transplant. References: 1. Sehgal S, Chance JC, Steliga MA. Thoracic anesthesia and cross field ventilation for tracheobronchial injuries: a challenge for anesthesiologists. Case Rep Anesthesiol. 2014;2014:972762. doi: 10.1155/2014/972762. Epub 2014 Jan 12. PMID: 24527234; PMCID: PMC3913496.Item Labor Analgesia in Patient with Spinal Muscular Atrophy(2022-09-17) Boldt, Stephanie; Clark, William L.Introduction: Spinal Muscular Atrophy (SMA) is a hereditary disease caused by degeneration of anterior horn cells in the spinal cord, leading to progressive muscle weakness and atrophy. Regional anesthesia is preferred over general anesthesia in patients with SMA because of the risk of prolonged intubation and increased sensitivity to non-depolarizing muscle relaxants.1 In labor analgesia specifically, neuraxial analgesia is utilized due to the possibility of a conversion to caesarian section. Another option for labor analgesia is opioid medications. These carry an increased risk of maternal respiratory depression and may not relieve pain as effectively.2 Case Description: A 31 year-old female G1P0 with a past medical history of SMA and OSA presented for scheduled induction of labor. She utilizes a power wheelchair for mobility but can stand for transfers. She had a recent sleep study that demonstrated mild OSA and the need for CPAP at night, she was not currently using CPAP. She had a recent normal pulmonary function test. Anesthesia was consulted upon admission and patient was cleared for epidural analgesia. Labor was induced. A lumbar epidural was placed, and infusion was with bupivacaine 0.125% with 2mcg fentanyl at 10 ml/hour. On reassessment 8 hours later, epidural was not providing sufficient pain relief. Patient elected for epidural catheter removal and placement of a second catheter. A second catheter was placed and provided sufficient pain relief. Patient later met criteria for failure to progress and decision was made for primary low transverse caesarian section. Neuraxial analgesia was used for the case instead of general anesthesia because of the risk for prolonged intubation. The bupivacaine/fentanyl epidural infusion was continued. For additional pain control, 100mcg epidural fentanyl, 100mcg IV fentanyl and 30mg IV ketorolac were given throughout the procedure. A supernova nasal cannula was at 2-3L/min to provide positive pressure. Postoperatively, the patient was transferred to the post-anesthesia care unit, the epidural was removed, and pain was adequately controlled with oral medications. Discussion: Epidural labor analgesia can be given as a continuous epidural infusion (CEI) or as a programmed intermittent epidural bolus (PIEB). CEI was chosen for this patient because of a lower risk of sympathectomy and respiratory compromise. However, PIEB has been shown to decrease breakthrough pain better than CEI, which may have contributed to the failed first epidural. This case demonstrates that early communication between the obstetric and anesthesia teams is important. Because of the advanced knowledge of the patient, she was able to receive a working epidural well before the decision was made to go to caesarian section. This prevented possible prolonged intubation and allowed the mother to safely experience the birth of her baby. References: 1. Abati E, Corti S. Pregnancy outcomes in women with spinal muscular atrophy: A review. Journal of the Neurological Sciences 2018 May 15; 388: 50-60. doi: 10.1016/j.jns.2018.03.001. 2. Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018 May 21;5(5):CD000331. doi: 10.1002/14651858.CD000331.pub4. PMID: 29781504; PMCID: PMC6494646. 3. Fidkowski CW, Shah S, Alsaden MR. Programmed intermittent epidural bolus as compared to continuous epidural infusion for the maintenance of labor analgesia: a prospective randomized single-blinded controlled trial. Korean J Anesthesiol. 2019 Oct;72(5):472-478. doi: 10.4097/kja.19156. Epub 2019 Jun 20. PMID: 31216846; PMCID: PMC6781207.Item Lumbar Fusion in A Patient With Achondroplasia(2022-09-17) Sheel, Vasu; Clark, William L.; Mohiuddin, Amer; Ravindranath, SapnaIntroduction: Achondroplasia is the most common cause of short-limbed, disproportionate dwarfism. It is an autosomal dominant condition that is caused by variations in the FGFR3 gene, a fibroblast growth factor receptor. Approximately eighty percent of achondroplastic cases are de novo. The remaining are inherited. If both parents have achondroplasia, there is a twenty-five percent chance of offspring suffering from homozygous achondroplasia, which is a lethal condition. There is also a fifty percent chance of offspring having achondroplasia. This gene mutation inhibits proliferation of the chondrocytes, which ultimately causes impaired endochondral bone formation. The disease process is characterized by clinical features such as shortening of the arms and legs, macrocephaly, kyphoscoliosis, and accentuated lumbar lordosis. These features of patients with achondroplasia are known to make spinal surgery and anesthesia especially difficult. Anesthetic complications and difficult airway intubations are due to many different factors that often require the anesthesiologist to take extra consideration into their anesthetic plan. Many times, the use of devices to better help with viewing the airway are essential. Case Description: A 63-year-old female with a history of achondroplasia, osteopenia, lumbar-adjacent segment disease with spondylolisthesis, and previous L4-5 spinal decompression and fusion surgery presented for an extended bilateral L3-4 lumbar fusion due to lumbar stenosis. Pre-operatively, the patient was determined to be an ASA class III and a Mallampati class I. Vascular access with a peripheral IV was obtained, and an arterial line was placed for intra-operative blood pressure monitoring. 100 mg of propofol and 50 mCg of fentanyl were used for induction. 30 mg of rocuronium was used for paralysis. Intubation was achieved with the use of a video laryngoscope. A fiberoptic bronchoscope was immediately available as well. A grade I view with full visualization of the glottis was obtained for successful intubation. The operative period was uneventful. The patient was re-admitted to the hospital one week later for a fluid collection at the surgical site. Discussion: Patients with achondroplasia pose many potential risks when undergoing anesthesia and surgery. For example, obtaining vascular access can be difficult because of lax skin and excess subcutaneous tissue. Ultrasound should be utilized for easier placement when possible. Achondroplastic patients also have more difficult airways than the typical patient. This is due to the many anatomical variations they may have, especially in the face and spine. Commonly, macroglossia, limited neck mobility, and potential atlanto-axial instability are factors that must be taken into consideration. Taking measures such as utilizing video laryngoscope or fiberoptic bronchoscope are beneficial when intubating the patient. In addition, awake intubation with appropriate topical anesthetic and airway blocks can be considered. This provides the physician with real time feedback of any complications that may take place. Shoulder rolls can be used to help provide the patient’s neck with more extension and better open their airway. As was the case with this patient, a secondary method of intubation should be at hand for potentially difficult airways. Cardiorespiratory function may also be impaired. Therefore, patients should be monitored with pressure-controlled ventilation. Ideally, a high respiratory rate and lower tidal volume should be used both intra-operatively and post-operatively. Ventilation post-operatively can be utilized to avoid potential airway edema and pooling of secretions. Finally, patients with achondroplasia may have more anxiety about undergoing anesthesia than other patients. Proper counseling of intra-operative risks and management should be utilized to help reassure the patient.Item Neuraxial Anesthesia for a Lower Extremity Biopsy on a Patient Younger Than 55 Weeks Post-Conceptual Age(2022-09-17) Mercho, Raffi; Khan, Ayesha; Clark, William L.Introduction: Postoperative apnea is a major concern with surgery in neonates. Postoperative apnea can be defined as respiratory pauses of more than 15 seconds that can be associated with bradycardia, desaturation, cyanosis or hypotonia. Risk factors for postoperative apnea in neonates include prematurity, congenital anomalies, history of apnea and bradycardia, anemia, and lung disease. Another significant risk factor is post-conceptual age less than 46-60 weeks at time of surgery. Postoperative apnea affects 10% of infants under 60 weeks of post-conceptual age. The younger the patient’s gestational and post-conceptual ages, the greater the risk for postoperative apnea. (1) Some studies suggest that neonates that receive general anesthetics experience more respiratory complications as opposed to those who do not. Immature liver elimination and harsh adverse reactions of general anesthetics likely play a large role in postoperative apnea. As a result, infants at high risk for development of postoperative apnea may benefit from a regional anesthetic instead. (2) Case Description: A 42-week post-conceptual age female who was born at term without complications presented to orthopedics for a right foot mass. An MRI revealed a large, vascularized subcutaneous mass located on the dorsum of the right foot. The differential diagnosis included vascular malformation and infantile fibrosarcoma. The patient was referred to plastic surgery and interventional radiology for a biopsy of the mass two weeks later. Neuraxial anesthesia was preferred for this operation to reduce the risk of postoperative apnea that could arise from general anesthesia. The procedure was discussed with the patient’s family and their consent was obtained for both general and regional anesthesia. A 25-gauge spinal needle was used to inject 4mg of bupivacaine via a midline approach in the L4-L5 interspace. The patient was then supervised using standard ASA monitors. Her vital signs remained stable throughout the biopsy. The patient was then transferred to the post-anesthesia care unit where she was able to move all extremities and produce urine. She was discharged from the hospital later that day. Pathology later identified the mass as a rapidly involuting congenital hemangioma. Discussion: Postoperative apnea poses a significant risk to the neonate after a general anesthetic. Specific ages regarding postoperative apnea monitoring vary by institution. At our institution, neonates up to fifty-five weeks of post conceptual age are monitored for at least eight hours after a general anesthetic. A spinal block was performed on a 44-week post-conceptual age female prior to a foot mass biopsy. The patient was comfortable after the operation and avoided an inpatient stay that would have been required had she undergone general anesthesia. Measures to avoid an overnight hospital stay should be considered as they can reduce the cost of care for families and improve resource management for hospitals. This is especially pressing for healthcare institutions during the COVID-19 pandemic when resources are inherently limited. Conclusion: A neuraxial approach versus general anesthesia is a viable option for a patient receiving a lower extremity biopsy procedure at <55 weeks post-conceptual age. References: 1. Jean-Philippe Salaün, Mathilde de Queiroz, Gilles Orliaguet. Development: Epidemiology and management of postoperative apnea in premature and term newborns. Anesthesia Critical Care & Pain Medicine, 39(6), 2020. 871-875. 2. Özdemir, T., & Arıkan, A. Postoperative apnea after inguinal hernia repair in formerly premature infants: Impacts of gestational age, postconceptional age and Comorbidities. Pediatric Surgery International, 29(8), 2013. 801–804.