Annual Meeting 2022, Indiana Society of Anesthesiologists

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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, Kelsea
Background: 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.
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.
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.
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.
Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents
(2022-09-17) Chen, Andy W.; Okano, David R.; Mitchell, Sally A.; Cartwright, Johnny F.; Moore, Christopher; Boyer, Tanna J.
Introduction: Anesthesiologists may encounter multiple obstacles in communication when attempting to collect information for emergency surgeries. Occult tension pneumothorax that was asymptomatic in the Emergency Department (ED) could become apparent upon positive pressure ventilation and pose a critical threat to the patient intraoperatively. Methods: This simulation is primarily designed to train first-year of clinical anesthesia (CA-1) residents. It is designed as a 50-minute encounter consisting of 2 scenes. The first scene focuses on information collection and communication with a non-cooperative patient with multiple distractors. The second scene focuses on the early diagnosis of tension pneumothorax and the treatment. Results: This scenario has been developed as one of the regular simulation trainings at our facility. We tried to keep the simulation environment as realistic as possible. We did not grade the learners based on their performance, although most of the residents met the educational objectives. Commonly missed critical actions included misdiagnosing the tension pneumothorax as mainstem intubation, bronchospasm, pulmonary thromboembolism, or anaphylaxis. All residents learned from this scenario, as they rated the feedback and debriefing as “extremely useful” or “very useful.” Discussion: Our simulation program helps anesthesia residents develop crisis management skills for perioperative incidents in a safe environment, as well as to foster excellent communication skills. Time constraints limit the number of the residents who can sit in the “hot seat.” The structure of the mannequin often limits the ability to diagnose pneumothorax by auscultation. The scenarios can be also employed to educate student anesthesia assistants in the future.
Airway management in a patient with Montgomery T-tube in situ
(2022-09-17) Nwaneri, Francis I.; Rowe, Latoya; Suzuki, Yukako
Introduction/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.
Lumbar Fusion in A Patient With Achondroplasia
(2022-09-17) Sheel, Vasu; Clark, William L.; Mohiuddin, Amer; Ravindranath, Sapna
Introduction: 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.
Erector Spinae Plane Blocks vs No Blocks for Laparoscopic Hysterectomy
(2022-09-17) Blais, Austin; Yeap, Yar; Warner, Matthew
Background: Erector spinae plane blocks have recently gained traction in modern literature as a simple and effective alternative to Transverse Abdominis Plane (TAP) blocks for decreasing post-operative abdominal pain. Post-operative pain causes a significant burden to patients receiving laparoscopic hysterectomy, which can be ameliorated with effective anesthetic care promoting faster recovery. Objective: Our study aims to test the hypothesis that ESP block patients will have better pain scores and less opioid usage compared to patients who only receive IV pain meds. Methods: We performed a retrospective chart review on patients at University Hospital who underwent laparoscopic hysterectomy between May 2019-August 2021. 64 patients met criteria for inclusion. Those who received ESP block were compared with controls who received no block. Results: Our review found a significant reduction in both the patient reported max pain (4.0 vs 7.0, P=0.005) and average pain scores (2.2 vs 3.5, P=0.029) as measured by the Visual Analogue Scale. Conclusion: The erector spinae plane block shows potential for being an effective and simple alternative to TAP blocks or to IV opioids for the control of post-operative pain in laparoscopic hysterectomy.
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, Laurence
Purpose: 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.
Medical Student Concerns For Respiratory Protection on Anesthesiology Electives
(2022-09-17) Yu, Corinna J.; Webb, Timothy T.; Guillaud, Daniel; Mitchell, Sally A.

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