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Item 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 A Liberal Transfusion Strategy Leads to Higher Infection Rates, ORthopaedic Trauma and Anemia: Conservative vs. Liberal Transfusion Strategy (ORACL), a Prospective Randomized Study 30 Day Inpatient Complications(2022-09-17) Mullis, Leilani; Mullis, Brian; Virkus, Walter; Kempton, LaurencePurpose: There is ongoing debate what level of anemia should be used as a transfusion trigger for asymptomatic trauma patients no longer in a resuscitative phase immediately following trauma. A previous retrospective case-control study by one of the lead investigators showed there was a higher risk of complications with a more liberal strategy, and this appeared to be dose-dependent. Multiple previous studies have shown allogeneic blood transfusion is immunosuppressive and may increase infection rates in surgical patients. This study was completed to determine if a more conservative strategy was safe and might decrease the risk of infection. Methods: The ORACL pilot study randomized 100 patients ages 18-50 to a conservative transfusion strategy of 5.5 g/dL vs a liberal strategy of 7.0 g/dL in asymptomatic patients no longer being resuscitated who required inpatient admission for an associated musculoskeletal injury. Enrollment was performed at 3 level 1 trauma centers from 2014-2021. Ninety-nine patients completed 30 day follow up. Results: There was a significant association between a liberal transfusion strategy and higher rate of deep infection (defined as unplanned return to OR for debridement or admission for IV antibiotics) but superficial infection (defined as oral antibiotics alone needed without admission or debridement) did not reach statistical significance (Table 1). Multiple secondary outcomes or complications that might occur due to anemia or transfusion were not different between the two groups. Conclusion: This study shows a conservative transfusion strategy of 5.5 g/dL in an asymptomatic young Orthopaedic trauma patient leads to a lower deep infection rate without an increase in adverse outcomes.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 Accidental Central Venous Catheter Placement in the Internal Thoracic Vein: A Case Report(2020-09-12) Goodin, Patrick M.Item Airway management in a patient with Montgomery T-tube in situ(2022-09-17) Nwaneri, Francis I.; Rowe, Latoya; Suzuki, YukakoIntroduction/Background: The airway management of a patient with a Montgomery T-tube poses challenges. Unlike standard tracheostomy tubes or endotracheal tubes, t-tubes are not provided with standard connectors to fit with anesthesia breathing circuits and cause loss of inspired gases. Unfamiliarity of the tube presents challenges as well. We describe the successful anesthetic management of a case with a T- tube in situ. Case Description: 58 yo M with subglottic stenosis s/p complex airway reconstruction with placement of size 13 T-tube, DM2, NASH cirrhosis, s/p TIPS procedure for GI bleed with subsequent TIPS failure and recurrent ascites with MELD score 9. He presents for TIPS revision due to thrombosis of the stent. The airway plan was to proceed with LMA after the removal of ascites. The backup plan was a size 4 ETT through his T-tube. ENT was at bedside to remove T-tube and place tracheostomy if needed. Extratracheal limb was occluded and oxygen was given by nasal canula. Sedation was started with propofol infusion at 75mcg/kg/min for paracentesis with 2.3L fluid removal. Then the induction with propofol 100mg was performed for LMA 4 insertion. It didn't provide a good seal. Subsequently ETT 4.0 insertion through T-tube was performed. The tube position was confirmed with fiberoptic scope and taped 11cm at stoma. Good TV and end tidal CO2 achieved. Ventilation was managed with pressure support. The case was finished safely. Discussion: Many anesthesiologists may not be familiar with T-tube. T-tube's unique design presents challenges in addition to the fact that T-tube does not have standard connectors. Removal of T-tube may cause bleeding or loss of airway control. It is very important to formulate the airway plan when a patient with T-tube shows up at the hospital. Conclusion: In our case, insertion of LMA was performed, but not good seal probably due to deformed anatomy from the previous surgery. We successfully utilized a backup plan and inserted ETT 4.0 through T-tube. ENT surgeon was at patient's bedside in case if needed. The judicious anesthetic plan and airway preparation should be tailored for safe management of such patients.Item 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, AndrewIntroduction: Anesthesia for pulmonary endarterectomy (PEA) has always proven to be challenging. With PEA being the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) and a rising number of such surgeries performed, it is imperative that anesthesiologists are well equipped to manage patients for surgeries and their potential complications. Case Description: A 40-year-old female with group 4 pulmonary hypertension secondary to CTEPH presented for pulmonary thromboendarterectomy. She has a past medical history of multiple pulmonary embolisms (PEs) and was diagnosed with CTEPH in November of 2021, insulin-dependent diabetes mellitus, (Hemoglobin A1C 10.6), morbid obesity (Body mass index of 48.6) hypertension, gastroesophageal reflux disease, and uncontrolled obstructive sleep apnea. Computed tomography (CT) angiogram of the thorax showed a large amount of clot burden including the right distal main pulmonary artery and in all right lower lobe pulmonary arteries, chronic clots in the left lower lobe, and a dilated main pulmonary artery (figure 1). She had previously completed six months of warfarin with therapeutic international normalized ratios (INRs). Transthoracic echocardiography showed evidence of a severely dilated right ventricular (RV), and RV strain with contrast reflux into the Inferior vena cava and hepatic vein. Further workup for the surgery included Left and right heart catheterizations and Lower extremity venous and arterial doppler which yielded no coronary artery disease, elevated pulmonary artery (PA) pressures, normal perfusion, and no deep venous thrombosis respectfully. Pulmonary Angiogram (figure 2) showed evidence of patent vasculature but sequelae of CTEPH, and a nuclear medicine lung single-photon emission computerized tomography (SPECT) (figure 3) visualized areas of perfusion defects. Her pulmonary functions test (PFT) values were as follows: Forced vital capacity (FVC) 49% predicted, forced expiratory volume in the 1st second (FEV1) 46% predicted, and diffusing capacity for carbon monoxide (DLCO) 72% predicted. Intraoperatively, a left radial arterial line and left subclavian central line were performed awake. Once lines and appropriate monitors were placed, induction anesthesia and subsequent endotracheal intubation were performed. Post-induction, a pulmonary artery catheter was placed in the patient’s right internal jugular vein which yielded a PA pressure of 127/44 mmHg (figure 4). Intraoperative transesophageal echocardiography was performed during preintervention, and the results are as follows in figure 5. The patient tolerated the intraoperative course as well as multiple sessions of cardiopulmonary bypass (CBP) and deep hypothermic circulatory arrest (DHCA) as outlined in figure 6; the total bypass time being 5 hours and 4 minutes. postintervention TEE showed vast improvement in cardiovascular hemodynamics with a near normal right ventricular ejection fraction (figure 5). The patient remained intubated and was transferred safely to the surgical intensive care unit. Her postoperative course was uneventful. Discussion: The success of PEA surgery is largely contingent on a multidisciplinary team-based approach. The patient population generally has a degree of RV failure, and the goal of surgery is to ameliorate RV compromise as much as possible. CBP and DHCA have specific requirements regarding cooling and cerebral protection/oxygen monitoring. Post bypass, anesthesiologists also have to be prepared to deal with potential complications such as residual pulmonary hypertension, RV failure, reperfusion pulmonary edema, and pulmonary hemorrhage [1]. Special consideration is paid to patients with high baseline central venous pressure (CVP) or right atrial (RA) pressures for more aggressive diuresis preoperatively to lower the RA pressures in the hope of lowering the risk of subdural hemorrhages (SDH), and avoidance of all sedatives due to their potential for respiratory depression with subsequent hypercarbia and acidosis leading to increased pulmonary vascular resistance (PVR) [1]. A 7 Fr swan sheath should be placed in the right internal jugular vein if possible.; head-down position during the insertion of all lines should be avoided if possible [2]. A transesophageal echocardiography (TEE) probe should be inserted postinduction and a PA catheter can then be placed under TEE guidance, The pulmonary artery (PA) catheter is docked but not floated [1]. Continuous cardiac output (CO) monitoring should be executed. The PA catheter can be wedged at baseline to obtain the PA wedge pressure (PAWP) [1]. In addition, bispectral index (BIS) and near infra-red spectroscopy are utilized for cerebral monitoring and cerebral oximetry during periods of DHCA [4]. Esophageal and bladder temperature probes are inserted to ensure even cooling and warming [5]. Controlled ventilation is maintained with care to avoid hypoxia, hypercarbia, and acidosis which will further increase PVR [1]. Dopamine is started at 5 mcg/kg/min, titrated, and continued for the duration of the surgery till transfer to the Intensive Care Unit (ICU). Maintenance of adequate systemic vascular resistance (SVR) is important as it determines the RV perfusion pressures. Boluses of phenylephrine can be administered for rapid titration of SVR [3]. CO measurements are taken before the initiation of CBP. These measurements are repeated after patients are weaned off CBP. Heparin of 4 IU/kg is given to the patient to achieve an activated clotting time (ACT) of >400 s. The bypass pump is primed as per normal to other procedures with the only change being that the priming solution is replaced by albumin 5% instead of crystalloids or gelafundin [1]. Propofol is infused for maintenance of anesthesia at the start of CBP, titrated as per BIS monitoring [1]. Patients with CTEPH and chronic hypoxemia are usually polycythemic. At the initiation of CBP, one to two autologous units of blood is obtained depending on the starting hemoglobin (Hb) concentration and size of the patient, targeting a Hemoglobin of 7–9 g/dL during bypass. The hemodilution of blood with autologous donation leads to decreased blood viscosity which aids with tissue oxygen delivery and promotes uniform cooling in preparation for DHCA [4]. Carbon dioxide is also given at low flow during bypass to promote cerebral vasodilatation and increase cerebral oxygenation before DHCA [5]. Patients are cooled gradually to a core temperature of 20°C or 18° C before circulatory arrest is initiated. DHCA is continued for a maximum of 20 min if cooled to 20°C, 25 min if cooled to 18°C, or when cerebral oximetry drops below 40%. Bypass is then resumed for 10 min before another round of DCHA is performed as required [4]. Rewarming is achieved gradually to ensure uniformity. Esophageal temperatures should not exceed 37°C and the gradient between esophageal and bladder temperatures should not exceed 5° at any point. Atrial-ventricular pacing is usually commenced at a rate of 80–90 beats/min if required to maintain CO. The aim is to wean off bypass with the patient relatively underfilled: CVP half of pre-bypass values [5]. Additional inotropic support may be started if required. The post-bypass CO measurements are recorded again. Should the MAP be borderline when coming off bypass, CO should be guided by cerebral oximetry as a surrogate marker instead of MAP, aiming for levels obtained when on full flow on bypass [3]. Once the patient is hemodynamically stable, protamine is administered to achieve pre-bypass values. A target Hb of 10 g/dL is desired, and respiratory rate is adjusted to achieve normocapnia [2]. Patients are transferred to the intensive care unit (ICU) with the ICU ventilator. Care is taken to avoid disconnecting the endotracheal tube from the ventilator to maintain PEEP as these patients are prone to reperfusion lung injury. Dopamine infusion is typically continued overnight to maintain CO and perfusion pressures at appropriate levels [3]. Pacing is continued from OR if needed. Patients are kept intubated overnight for lung protection with the aim of extubating after 24 hours. Fluids are kept at a minimum to maintain “dry lungs”, with the aim of a negative 1–1.5 L fluid balance by the first postoperative day [1]. References: 1) Chen Y, Tan Z, Shah SS, T Loh KW. Perioperative anesthesia management for pulmonary endarterectomy: Adopting an established European Protocol for the Asian Population. Ann Card Anaesth. 2019;22(2):169-176. 2) Madani MM, Jamieson SW. Technical advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Semin Thorac Cardiovasc Surg 2006; 18:243. 3) Ng O, Giménez-Milà M, Jenkins DP, Vuylsteke A. Perioperative Management of Pulmonary Endarterectomy-Perspective from the UK National Health Service. J Cardiothorac Vasc Anesth 2019; 33:3101. 4) Poullis M. Thromboendarterectomy and circulatory arrest. Interact Cardiovasc Thorac Surg 2012; 14:375. 5) Vuylsteke A, Sharples L, Charman G, et al. Circulatory arrest versus cerebral perfusion during pulmonary endarterectomy surgery (PEACOG): a randomised controlled trial. Lancet 2011; 378:1379.Item Anterior Cricoid Shelf: Subglottic Stenosis or Normal Anatomy?(2021-09-18) Brown, Kayla; Cochran, Sean; Backfish-White, Kevin; Yu, Corinna J.Item Artificial CO₂ Pneumothorax for Diaphragmatic Plication(2020-09-12) McGrath, Mackenzie; Neuman, Nicholas; Soi, Tejinder; Yu, CorinnaItem Cardiac Tamponade: An Adult Simulation for CA1 Residents(2020-09-12) Tenbarge, Madison; Boles, Brady; Geiser, Matthew; Mercho, Raphael; Boyer, Tanna