A&A Practice - anesthesia-analgesia

Decreasing Frontal Electroencephalogram Alpha Power and Increasing Sensitivity to Volatile Anesthetics Over 3 Surgeries Within 7 Months: A Case Report Depth of anesthesia (DoA) monitors are widely used during general anesthesia to guide individualized dosing of hypnotics. Other than age and specific drugs, there are few reports on which comorbidities may influence the brain and the resultant electroencephalogram (EEG) of patients undergoing general anesthesia. We present a case of a patient undergoing 3 cardiac operations within 7 months with severe illness and comorbidity, leading to pronounced physical frailty and significant changes of frontal alpha power in the EEG and increased sensitivity to volatile anesthetics. These findings may have important clinical implications and should trigger further investigations on this topic. Accepted for publication May 1, 2019. Funding: This work received funding from Bangerter-Rhyner Foundation Grant and Clinical Trials Unit grant of the University Hospital of Bern, Inselspital, Bern, Switzerland. The authors declare no conflicts of interest. Clinical trial number: ClinicalTrials.gov; Identifier: NCT02976584. Address correspondence to, Heiko A. Kaiser, MD, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland., Address e-mail to heiko.kaiser@insel.ch. © 2019 International Anesthesia Research Society

Postpartum Thyroid Storm in Poorly Controlled Graves' Disease: A Case Report Hyperthyroidism during pregnancy is a relatively rare event, but poor control of hyperthyroidism during pregnancy is associated with a host of issues. These include intrauterine fetal demise, hypertensive disorders of pregnancy, preterm delivery, low birth weight, intrauterine growth restriction, and maternal congestive heart failure. One of the most feared sequelae of hyperthyroidism is thyroid storm, which has a mortality rate >10%. Patients who develop thyroid storm present several challenges to anesthesiologists including hemodynamic instability and medication management. Here, we present the anesthetic management for a parturient whose delivery was complicated by signs and symptoms consistent with thyroid storm. Accepted for publication May 23, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Jack M. Peace, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron F5-704, Chicago, IL 60611. Address e-mail to jack.peace@northwestern.edu. © 2019 International Anesthesia Research Society

Analgesic Rescue With Opioid-Only Thoracic Epidural After Surgical Infiltration of Liposomal Bupivacaine: A Case Report We present the case of a 51-year-old man with a history of recurrent lung cancer after left upper lobectomy who presented for an elective completion pneumonectomy via a bilateral anterior thoracotomy incision. At the completion of surgery, bilateral multilevel intercostal infiltration was performed with liposomal bupivacaine. Due to poorly controlled postoperative pain after extubation, a thoracic epidural was placed in the intensive care unit. An opioid-only infusion was started and transitioned to a local anesthetic–based infusion on postoperative day 2. This case report represents a novel stepwise approach of thoracic epidural management after surgical infiltration of liposomal bupivacaine. Accepted for publication May 16, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Matthew W. Swisher, MD, Department of Anesthesiology, University of California San Diego, 9500 Gilman Dr MC 0898, La Jolla, CA 92093. Address e-mail to mwswisher@ucsd.edu. © 2019 International Anesthesia Research Society

Lung Isolation for Whole Lung Lavage in a Pediatric Patient With Atypical Airway Anatomy due to Short Stature: A Case Report This case demonstrates the airway management of a pediatric patient with short stature due to STAT5b deficiency, a rare genetic immunodeficiency associated with lung disease and endocrinopathy. The patient had recurrent pulmonary infections and pulmonary alveolar proteinosis (PAP) for which whole lung lavage (WLL) was recommended. Due to short stature and overall body habitus, the patient's airway would not accommodate a traditional double-lumen tube (DLT). Therefore, we placed 2 single-lumen breathing tubes: 1 endobronchial and 1 endotracheal, to mimic a DLT and facilitate WLL, demonstrating a viable option for lung isolation in the absence of purpose-built equipment. Accepted for publication April 30, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Susan E. Eklund, MD, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Bader 3, Boston, MA 02115. Address e-mail to susan.eklund@childrens.harvard.edu. © 2019 International Anesthesia Research Society

Comparison of Twitter Use of the American Society of Anesthesiologists and the American Association of Nurse Anesthetists Twitter has become a powerful tool for dissemination of information. The objective of this study was to evaluate Twitter usage of the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA). All tweets from ASA ("@ASALifeline") and AANA ("@aanawebupdates") were collected over a 1-year time period. The content of each tweet was categorized using a rubric. ASA generated more original tweets than AANA. Twitter use was highest in October for ASA and September for AANA. Both societies are actively using Twitter. Future work should evaluate the impact of societal Twitter use. Accepted for publication May 7, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Elizabeth M. S. Lange, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron St, F5-704, Chicago, IL 60611. Address e-mail to elizabeth.lange@northwestern.edu. © 2019 International Anesthesia Research Society

Having a Conscious Patient During Cardiopulmonary Resuscitation: Is It Not Time to Consider Sedation Protocol?: A Case Report A middle-aged man with acute inferior wall myocardial infarction was admitted in cardiac arrest and in an unresponsive state to the hospital. Cardiopulmonary resuscitation (CPR) was initiated. Patient showed signs of consciousness throughout the CPR. The impact of awareness during CPR on the neuropsychological status of a patient with a favorable neurological outcome is yet to be studied on a large scale. Sedation protocol without compromising hemodynamic status may prove a fair choice in such cases. Accepted for publication April 9, 2019. Funding: None. The author declares no conflicts of interest. Address correspondence to Vasanth Sukumar, DA, DNB, Royal Care Super Specialty Hospitals, Neelambur, Coimbatore 641062, Tamil Nadu, India. Address e-mail to vasnt.dr@gmail.com. © 2019 International Anesthesia Research Society

Bilateral Sciatic Neuropathies as a Complication of Positioning During Neuraxial Anesthesia for Cesarean Delivery: A Case Report Neurologic complications following neuraxial anesthesia for cesarean delivery are rare. We present a 33-year-old parturient who developed prolonged lower extremity weakness following a single-shot subarachnoid block for cesarean delivery. After neurologic evaluation, she was diagnosed with bilateral sciatic neuropathies due to prolonged positioning for the anesthetic. We review the incidence of nerve injury associated with neuraxial anesthesia and risk factors for developing peripheral nerve injury in this context. We offer a solution to prevent this complication from occurring. Accepted for publication March 18, 2019. Funding: None. The authors declare no conflicts of interest. The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components. Address correspondence to Bradley A. Reel, MD, Department of Anesthesia, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX 78234. Address e-mail to bradley.a.reel2.mil@mail.mil. © 2019 International Anesthesia Research Society

Andexanet Alfa for Urgent Reversal of Apixaban Before Aortic Surgery Requiring Cardiopulmonary Bypass: A Case Report Andexanet alfa is a recombinant factor Xa decoy molecule capable of reversing direct and indirect factor Xa–inhibiting anticoagulants. We present an adult patient on apixaban for nonvalvular atrial fibrillation who required urgent reoperative aortic surgery for an aortic root pseudoaneurysm. Apixaban was reversed with andexanet alfa. A second dose of andexanet alfa was required before surgical incision for persistently elevated antifactor Xa levels. Intraoperative management required use of cardiopulmonary bypass (CPB). No major adverse cardiovascular, cerebrovascular, hemorrhagic, or thromboembolic events were observed. Accepted for publication May 13, 2019. The authors declare no conflicts of interest. Funding: None. Address correspondence to Devon Flaherty, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to flaherdc@gmail.com. © 2019 International Anesthesia Research Society

Large Iatrogenic Tracheal Injury From Attempted Endotracheal Cuff Leak Remedy: A Case Report Continuous insufflation of oxygen into the pilot balloon of an endotracheal tube has been documented as a viable method to fix an incompetent endotracheal tube cuff. We present a case of a large iatrogenic tracheal injury resulting from an improvised cuff leak management device. Valuable lessons are discussed to prevent similar incidents. Accepted for publication April 10, 2019. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal's website (www.cases-anesthesia-analgesia.org). Address correspondence to Ron E. Samet, MD, Division of Trauma Anesthesiology, University of Maryland Medical Center, 22 S Greene St, Room T1R77, Baltimore, MD 21201. Address e-mail to rsamet@som.umaryland.edu. © 2019 International Anesthesia Research Society

Electroencephalogram Suppression Despite Extremely Low–Dose Anesthetic During Cardiac Surgery: A Case Report A prominent feature of electroencephalogram (EEG) under general anesthesia is anteriorization of α waves. We report the case of a 63-year-old man anesthetized for coronary artery bypass grafting in whom the NeuroSENSE-processed EEG monitor recorded only δ waves in the absence of α frequencies, along with high EEG suppression despite extremely low doses of anesthetics during the whole procedure. The patient fully recovered from anesthesia 2 hours after the procedure and showed neither awareness nor neurological complications. This atypical EEG pattern under low concentration of anesthetics may be an intraoperative marker of a specific brain phenotype. Accepted for publication April 15, 2019. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. Address correspondence to Victoria Van Regemorter, MD, Anesthesiology, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Ave Hippocrate 10, 1200 Bruxelles, Belgium. Address e-mail to victoria.vanregemorter@uclouvain.be. © 2019 International Anesthesia Research Society

Alexandros Sfakianakis
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