Browsing by Author "Garcia, Jennifer"

Now showing 1 - 4 of 4
  • Thumbnail Image
    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.
  • Thumbnail Image
    Item
    Difficult Airway Algorithm in a Patient with Stridor and Significant Airway Edema Upon Extubating
    (2022-09-17) Garcia, Jennifer; Conrad, David J.
    INTRODUCTION: The difficult airway algorithm established by the American Society of Anesthesiologists (ASA) provides a set of guidelines for anesthesiologists to follow even before a patient is brought into the operating room. It begins with a physical exam evaluation of the airway in the preoperative period and the performance of a risk assessment with the available patient information. Although adequate preoperative evaluation can be presented and a difficult airway may not be expected, there are cases where an unanticipated difficult airway is encountered. Being prepared for such cases with the difficult airway algorithm in mind is crucial. The algorithm suggests beginning with bag mask ventilation and if failed, attempting placement and ventilation with a supraglottic airway. If this attempt fails, intubation can be attempted and lastly an emergency airway such as a cricothyrotomy or tracheotomy.1 CASE DESCRIPTION: A 60-year-old male ASA class 3 with a past medical history of a cerebellopontine angle (CPA) tumor, post-resection, presented for a palatoplasty for residual dysphonia and aspiration. After his initial CPA tumor resection, the patient had difficulty with airway management and a tracheotomy was performed. The tracheotomy had been removed prior to presentation for this procedure. On pre-operative assessment, the patient was a Mallampati class 2, and his airway exam was unremarkable. On induction, the patient received 200mg propofol and 100mg rocuronium for paralysis. The patient was an easy bag mask ventilation. A McGrath Mac 3 was used and with a Cormack-Lehane grade 2b view, a size 6.0 endotracheal tube (ETT) was placed. Anesthesia was maintained with sevoflurane. The patient remained hemodynamically stable throughout the case and no issues with extubation were expected; however, the patient was stridorous after extubation. Transnasal laryngoscopy revealed an edematous airway with significant supraglottic edema. The supraglottic obstruction was caused by manipulation during the surgery. The patient’s oxygen saturation began dropping. Bag mask ventilation with placement of an oral airway was unsuccessful. Laryngeal mask airway placement was attempted and unsuccessful. Video laryngoscopy was then attempted and showed edema and bleeding, leading to an unsuccessful reintubation. The decision was then made to perform an emergent tracheostomy to secure the airway. DISCUSSION: Maintaining a secure airway to assure adequate oxygenation and ventilation of a patient is of utmost importance. Anticipating difficulties with airway management is critical before bringing a patient back in to the operating room. Keeping the difficult airway algorithm in mind, even when a patient’s pre-operative airway assessment does not have features indicative of a difficult bag mask ventilation or intubation, is crucial. REFERENCES: 1. Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O’Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung; 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31–81 doi: https://doi.org/10.1097/ALN.0000000000004002 2. Rosenberg MB, Phero JC. Airway Assessment for Office Sedation/Anesthesia. Anesth Prog. 2015 Summer;62(2):74-80; quiz 80-1. doi: 10.2344/0003-3006-62.2.74. PMID: 26061578; PMCID: PMC4462705.
  • Thumbnail Image
    Item
    IU School of Medicine Correctional Medicine Student Outreach Project
    (2022-10-22) Nunge, Rebecca A; Gates, Kayla L; Fazle, Trilliah; Garcia, Jennifer; Messmore, Nicole M; Agarwal, Neeta
    Background: This project was founded on the basis that correctional medicine is an important component frequently missing from medical education. Opportunities to participate in medical care within correctional facilities, while concurrently engaging in discussions about disproportionate incarceration of certain populations and mass incarceration as a whole, will cultivate empathetic, socially-engaged, and passionate young physicians. This student organization was formed to facilitate clinical opportunities within correctional facilities and host events that focus on the broader socioeconomic and political context and forms of structural and cultural violence that have contributed to mass incarceration in the United States. Methods: In order to facilitate organizational goals, a relationship was fostered between IUSM and Dr. Kristen Dauss, the Chief Medical Officer of the IDOC. Following affiliation agreements, students may now gain clinical exposure at any facility in the state. Since its creation, IUCM has hosted virtual educational lectures, panels, and journal clubs, in collaboration with other student organizations and scholars in the field. The organization encourages engagement with original research in coordination with faculty advisors. We have also worked with administration to incorporate correctional health topics officially into the curriculum. Conclusions: As physicians who will practice medicine in the country with the highest incarceration rate in the world, having a fundamental understanding of topics related to correctional health, adverse health experiences while incarcerated, and longstanding traumatic effects of incarceration is imperative. IUCM’s goal is to create introductory materials and share resources relating to the socioeconomic and political context which has led to mass incarceration and the deficits in care for currently and formerly incarcerated people. Developing a better understanding of the justice system as well as the emotional, mental, and physical impact incarceration has on patients, and will stimulate interest in engaging with these concepts through research, volunteer work, educational events, and in patient care.
  • Thumbnail Image
    Item
    Steroids Precipitating Acute Thyrotoxic Paralysis
    (2022-03-25) Garcia, Jennifer; Pelton, Sarah; Vander Missen, Marissa; Vultorius, Daniela; Patel, Neha; Saeed, Zeb
    Case Description: A 34-year-old Black male was admitted with a new diagnosis of Graves’ disease and impending thyroid storm with a Burch-Wartofsky Score of 25. Initial labs showed undetectable TSH, total T3 of >800, free T4 of 7.21, and TrAb of 21.53. He was started on methimazole, propranolol, and hydrocortisone 100mg q8h. On day 2 of hospitalization, he presented with acute bilateral lower extremity paralysis shortly after eating lunch. His blood glucose was 231, and a stat BMP showed a potassium of 2.0. He was found to have thyrotoxic periodic paralysis (TPP). Steroids were stopped immediately, and he was given additional propranolol and potassium repletion. He received a total of 60mEq KCl and did not have recurrence after steroids were stopped. Conclusion: Steroids are very commonly used in treatment of thyroid storm but can potentially exacerbate endocrine emergencies, such as thyrotoxic periodic paralysis. Additionally, demographic factors may have also decreased the likelihood of considering the potential for TPP as the patient’s race did not correspond to the most common demographics, Asian populations. Thus, it is important to be aware of the potential effects of steroids. Clinical Significance: TPP is a rare complication of thyrotoxicosis. Excess thyroid hormones in the blood increase activity of the Na+/K+-ATPase pump, leading to intracellular shifts of potassium and consequential hypokalemia. Glucocorticoids have been shown to increase the relative amounts of Na+/K+-ATPase pumps and exacerbate hypokalemia. Steroids are one of four common treatments for thyroid storm, so their effects on transcellular ion balance must be monitored. Insulin was also found to increase Na+/K+-ATPase pump activity, explaining why episodes of TPP often correlate with carbohydrate-rich meals. Treatment of TPP, which can be done with repletion of KCl and beta blockers, must monitor for and avoid inducing a hyperkalemic state.