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Annual Meeting 2022, Indiana Society of Anesthesiologists
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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.Item 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/s12909-019-1700-1Item 0.25% Bupivacaine vs 0.5% Bupivacaine vs Mepivicaine/Bupivacaine: Comparisons of 3 local anesthetic regimens used in nerve blocks(2022-09-17) Lange, Michael; Yeap, Yar; Ice, KelseaBackground: Nerve blocks are a vital component of postoperative pain management. There are many local anesthetics (LA) that are utilized in providing nerve blocks. This study aims to gather information regarding the efficacy of 0.25% Bupivacaine vs 0.5% Bupivacaine vs Mepivacaine/Bupivacaine nerve blocks. Methods: Over a period of 4 months, patients who received a peripheral nerve block for postoperative pain were called within 48hrs of their surgery via telephone and asked standardized questions regarding their pain status. The data was then sorted according to what type of block was performed (Upper extremity[UE]{Supraclavicular, Interscalene, Intercostobrachial,}, Lower extremity[LE]{Femoral, Sciatic, Adductor Canal, Popliteal, Fascia Iliaca}, and other{TAP, PECs I & II, ESP, QL}) and the type of LA that was used (0.25% Bupivacaine, 0.5% Bupivacaine, Mepivacaine/Bupivacaine). Results: Overall, 35.54% of patients experienced pain in the Post Anesthesia Care Unit (PACU) with an average pain score of 6.5/10 (n=127). 47.54% of patients who received a block with 0.25% Bupivacaine experienced pain in the PACU with an average pain score of 6.8/10 (n=60). 32.14% of patients who received a block with 0.5% Bupivacaine experienced pain in the PACU with an average pain score of 5.8/10 (n=27). 0% of patients who received a block with Mepivacaine/Bupivacaine pain in the PACU experienced pain (n=10). The median pain return for 0.5% Bupivacaine, 0.25% Bupivacaine, and Mepivacaine/Bupivacaine were 23.5hrs, 9.5hrs, and 8.83hrs respectively (n=62). The median pain return for LE, UE, and Other blocks was 24.92hrs, 13.67hrs, and 11.87hrs respectively (n=74). The median motor function return for LE and UE blocks was 24.6hrs and 18.73hrs respectively (n=33). The median pain return for LE blocks which used 0.25% Bupivacaine and 0.5% Bupivacaine was 3hrs and 25.21hrs respectively (n=11). The median pain return for UE blocks that used 0.5% Bupivacaine and Mepivacaine/Bupivacaine was 19.83hrs and 8.83hrs respectively (n=13). The median pain return for Other blocks that used 0.25% Bupivacaine and 0.5% Bupivacaine was 9.5hrs and 23.5hrs respectively (n=33). The median motor function return for LE and UE blocks that used 0.5% Bupivacaine was 24.6hrs and 21.83hrs respectively (n=15). The median motor function return of UE blocks that used Mepivacaine/Bupivacaine was 15.96hrs (n=8). Conclusions: 0.5% Bupivacaine provided longer pain control in comparison to 0.25% Bupivacaine and Mepivacaine/Bupivacaine. (0.5% Bupivacaine is the superior local anesthetic for both upper and lower extremity nerve blocks). We conclude that as long as LA toxicity is not a problem, anesthesiologists should use 0.5% Bupivacaine for all nerve blocks to provide patients the maximum benefit from their regional anesthesia.Item 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.Item A Simulation Case of Cricothyrotomy in an Acute Upper GI Bleed(2022-09-17) Yu, Corinna J.; Rigueiro, Frank; Backfish-White, Kevin; Boyer, Tanna J.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 Managing ARDS in the Operating Room: A Timely Simulation for Anesthesiology Residents(2022-09-17) Daly, Christine A.; Eddy, Christopher; Boyer, Tanna J.; Mitchell, Sally A.; Sturm, Julie F.; Webb, Timothy T.Introduction: Acute respiratory distress syndrome (ARDS) is a serious medical condition with high morbidity and mortality that frequently requires management in the intensive care unit (ICU). As critical care training is a vital component of anesthesiology residency and critically ill patients often require procedures necessitating anesthesia, understanding the presentation, management, and treatment of ARDS is essential to perioperative patient care. Educational Objectives: By the end of this simulation case, learners will be able to: identify and define ARDS; describe and apply ventilator strategies for patients with ARDS; and discuss strategies to improve oxygenation in patients with ARDS in addition to adjusting ventilator settings. Methods: This simulation involved a 66-year-old man with inhalational burn injuries undergoing debridement and homografting of burns in the operating room. During the case, the patient’s oxygenation and lung compliance demonstrated changes consistent with worsening ARDS. We conducted this simulation yearly for clinical anesthesia year 2 residents (CA2/PGY3; n=26) in 1-hour sessions with three to four learners at a time. The simulation covered five Anesthesiology Milestones related to ARDS as outlined in the Anesthesiology Milestones Project. Results: At the time of submission, 130 anesthesia residents completed the simulation. Commonly missed critical actions include failure to: recognize the need to adjust ventilator settings prior to inducing anesthesia; investigate causes of acute hypoxemia during the procedure; provide appropriate ventilator changes to improve the patient’s acute hypoxemia; and recognize the need to cancel the procedure. Most participants appropriately diagnosed and managed hypoxemia, and all agreed the simulation was a valuable learning experience. Conclusions: Simulation presents trainees with an effective opportunity to further their learning with regard to the recognition, management, and treatment of ARDS. This simulation provides an opportunity to discuss the currently evolving management of ARDS.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 Perioperative Anesthetic Considerations for Anti-NMDA Receptor Encephalitis Patients: A Case Report(2022-09-17) Chen, Andy W.; Axe, Michelle R.; Boyer, Tanna J.Introduction: Anti-NDMA receptor (anti-NMDA-R) encephalitis is a neurologic autoimmune disease that presents with characteristic psychiatric, neurological, and constitutional symptoms. It is caused by production of anti-NMDA-R antibodies, which in turn cause downregulation of NMDA receptors on central neurons. Detection of anti-NMDA-R antibodies in the serum or cerebrospinal fluid (CSF) confirms the diagnosis. The disease is often associated with an underlying tumor, most commonly an ovarian teratoma. Perioperative anesthetic management of patients with anti-NMDA-R encephalitis is a subject of interest to anesthesiologists because many anesthetic agents interact with the NMDA receptor, and therefore pose a risk of worsening the patient’s encephalitis, especially if surgical removal of the underlying teratoma is required for treatment. Case Description: A 15-year-old male diagnosed with anti-NMDA-R encephalitis in April 2022 was taken to the operating room (OR) for G-tube placement under general anesthesia in June 2022. The procedure followed a month-long hospitalization in the ICU and a month-long stay in the inpatient rehabilitation unit, all at Riley Children’s Hospital in Indianapolis, IN. The procedure was performed with total intravenous (IV) anesthesia with midazolam, dexmedetomidine, and remifentanil. Other medications the patient received during the procedure include cefazolin, dexamethasone, ondansetron, and ketorolac. Neither propofol nor volatile anesthetics were administered during the case. The patient remained hemodynamically stable intraoperatively with an uneventful postoperative course. Discussion: There is currently no definitive consensus on the optimal anesthetic regimen for patients with anti-NMDA-R encephalitis. In the available literature on this subject, both ketamine and nitrous oxide (N2O) have been routinely avoided because they are well-known for their direct NMDA-R antagonist activity. Commonly used agents include propofol, volatile anesthetics (e.g. sevoflurane), opioids, nondepolarizing paralytics, dexmedetomidine, and benzodiazepines (e.g. midazolam). Notably, volatile anesthetics (e.g. sevoflurane) and propofol are known to have some inhibitory activity on NMDA receptors, with volatile anesthetics demonstrating this moreso than propofol. Furthermore, there is some data to suggest that use of volatile anesthetics in these patients is associated with higher rates of postoperative adverse events, namely hypoventilation (potentially requiring reintubation) as well as pneumonia (e.g. aspiration pneumonia and ventilator-associated pneumonia). However, other studies and reviews have also reported no postoperative adverse events in the setting of volatile anesthetic use. A number of authors advocate for the use of midazolam, dexmedetomidine, and opioids, as these agents do not interact with NMDA receptors. Although there are no known reports of IV opioid-induced hypoventilation postoperatively in anti-NMDA-R encephalitis patients (to our knowledge), opioids still ought to be used judiciously in these patients, as they are at elevated risk of hypoventilation due to involvement of the brainstem respiratory center by the primary disease process.
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