Annual Meeting 2022, Indiana Society of Anesthesiologists

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Early Exposure to Anesthesiology: Building a Diversity Pipeline
(2022-09-17) Nwaneri, Francis I.; Rukes, Marelle M.; Adjei, Michael B.; Okano, David R.; Yu, Corinna J.
Career Mentors & 5-Year Data on the IUSM Anesthesiology Match
(2022-09-17) Yu, Corinna J.; Ye, Jian; Boyer, Tanna J.; Mitchell, Sally A.
Local Anesthetic Systemic Toxicity: A Pediatric Simulation Case for Anesthesiology Residents
(2022-09-17) Hunter, Isaac; Egan, Brian; Abbasi, Rania; Cossu, Anne; Acquaviva, Michael; Boyer, Tanna J.
INTRODUCTION: Local anesthetic systemic toxicity (LAST) is a rare but potentially lethal complication of anesthesia. It is therefore crucial for providers to be prepared when cases arise. Simulations allow providers and trainees to practice rare events with potentially severe consequences with a narrow margin for error in a controlled environment. OBJECTIVE: The objective for this article is to describe the successful implementation of a LAST simulation scenario in order to assist other institutions in organizing similar simulations, as well as to describe the importance of this particular simulation. METHODS: This simulation requires access to a simulation mannequin and OR setup. It involves a 2-year-old male undergoing a hypospadias repair who experiences LAST. Residents are expected to diagnose LAST and manage the patient using pediatric advanced life support (PALS) and intralipid. We conducted the simulation yearly for CA1 residents in 1-hour sessions with three to five learners at a time. Evaluation was done using the Anesthetists’ Non-Technical Skills (ANTS) assessment tool, as well as direct observation during the simulation and debriefing session and a follow-up survey sent to participants. RESULTS: Five cohorts of 25-28 anesthesiology residents have completed this simulation. Common areas for improvement include delayed recognition of LAST and not using the ASRA LAST checklist. Most participants were knowledgeable about the treatment of LAST and knew the pediatric dosing, but still reported finding the simulation valuable for both their skills and confidence. CONCUSIONS: Teaching about LAST is critical for all anesthesiology residents, as this is a rare but can’t-miss diagnosis. This simulation scenario is a useful and broadly applicable resource to allow residents to practice this critical learning, and residents consistently provide positive feedback about their experience.
Parental Leave During Anesthesiology Fellowship
(2022-09-17) Rigueiro, Frank; Yu, Corinna J.
Anesthetic Considerations for Cardiopulmonary Bypass and Deep Hypothermic Circulatory Arrest during Pulmonary Thromboendarterectomy in a Patient with Severe Chronic Thromboembolic Pulmonary Hypertension
(2022-09-17) Raniwsky, Alec; Kennedy, Andrew
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.
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.
Importance of Transesophageal Echocardiography for Stroke Prevention in Patients Undergoing Coronary Artery Bypass Graft Surgery - Case Report
(2022-09-17) Moseman, Anthony; Raniwsky, Alec; Carmony, Megan
Background: Transesophageal echocardiography (TEE) has become routine during cardiovascular and thoracic anesthesia. It plays a key role in surgical planning and provides vital hemodynamic information intraoperatively. Case Presentation: A 61-year-old female undergoing coronary artery bypass graft surgery, in which an intraoperative TEE was performed. Subsequently, a left atrial appendage thrombus was discovered. The case was postponed allowing for adequate anticoagulation. Successful CABG was performed after outpatient TEE determined the resolution of the left atrial appendage thrombus. Conclusions: The use of TEE intraoperatively stresses the importance of stroke prevention in patients undergoing high-risk surgeries.
Interdisciplinary Surgery-Anesthesia Education as a Valuable Component of Surgical Pre-Internship Training
(2022-09-17) Xu, Karen K.; Stanton-Maxey, Katie J.; Mitchell, Sally A.; Yu, Corinna J.; Dunlap, Julie D.; Boyer, Tanna J.
Background/Objective: Research has shown that skills-based workshops for medical students entering a surgical internship can improve learner self-confidence and provide opportunities for competency assessment.1,2 The ACS/APDS/ASE Resident Prep Curriculum is used nationally to prepare medical students for entrance into a surgical internship. This curriculum includes workshops traditionally taught by surgical faculty, teaching emergency procedures such as cricothyroidotomy without first-line airway interventions.3 We propose widespread adoption of an interdisciplinary airway and line workshop taught by anesthesia faculty as an educational intervention for pre-internship surgeons. Interdisciplinary medical education has been shown to improve perceptions of interdisciplinary collegiality and attitudes.4 This is the first known addition of anesthesiologists as teaching faculty in workshops designed to prepare medical students for a surgical internship. Methods: A half-day workshop for medical students entering surgical internships was designed as part of the MS4 preparation for internship rotation at IUSM beginning in Spring of 2017. The workshop consists of four stations and two discussions, all taught by anesthesia faculty. Prior to the workshop, learners receive access to presentations and videos for each procedure via an online learning management system (Canvas). The day begins with a discussion of difficult airway characteristics and facial morphologies that may necessitate an airway discussion prior to anesthesia. Learners then begin rotating through a total of four stations. Skills taught at these stations include IV and arterial line placement with and without ultrasound, basic airway management skills, management of difficult airways, and emergency airway access. Learners also complete a simulation exercise covering noninvasive respiratory support options in a patient with increasing respiratory distress. At the end of the workshop, learners participate in a debriefing session and discussion of how to avoid future anesthesia cancellations. They also complete a post-workshop evaluation before leaving. Results: The post-workshop evaluation was completed by 20 students in 2019 and 23 students in 2022. All learners agreed or strongly agreed that faculty from non-surgical specialties had important knowledge and wisdom for surgical trainees. Nearly all learners agreed or strongly agreed that the workshop was useful (41/43, 95%), boosted their clinical self-confidence in airway management (39/43, 91%), and that the skills and knowledge learned would be useful to them as interns and residents (42/43, 98%). Most learners (39/43, 91%) agreed or strongly agreed that this workshop should be mandatory for all students preparing for a surgical internship. Conclusions: This interdisciplinary surgery-anesthesia workshop was valuable to learners. The success of this workshop highlights the role of anesthesia providers in interdisciplinary education to prepare medical students for a surgical internship. We also highlight the worthiness of anesthesia faculty time in the education of future surgical colleagues; discussions on when to consult anesthesia for difficult airways and other issues may improve collegiality and camaraderie between disciplines and decrease same-day surgery cancellations. References: 1. Peyre SE, Peyre CG, Sullivan ME, Towfigh S. A surgical skills elective can improve student confidence prior to internship. J Surg Res. 2006;133(1):11-15. doi:10.1016/j.jss.2006.02.022 2. Brunt LM, Halpin VJ, Klingensmith ME, et al. Accelerated skills preparation and assessment for senior medical students entering surgical internship. J Am Coll Surg. 2008;206(5):897-907. doi:10.1016/j.jamcollsurg.2007.12.018 3. ACS/APDS/ASE Resident Prep Curriculum. ACS. https://www.facs.org/for-medical-professionals/education/programs/acs-apds-ase-resident-prep-curriculum/. Accessed June 13, 2022. 4. Bullard MJ, Fox SM, Wares CM, Heffner AC, Stephens C, Rossi L. Simulation-based interdisciplinary education improves intern attitudes and outlook toward colleagues in other disciplines. BMC Med Educ. 2019;19(1):276. Published 2019 Jul 24. doi:10.1186/s12909-019-1700-1
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.

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