Anesthesia

Transient loss of power of accommodation in 1 eye following inferior alveolar nerve block: Report of 2 Cases

by Chai Wen Lin

Unintended intravascular injection from inferior alveolar nerve blocks can result in frustrating distant complications... more Unintended intravascular injection from inferior alveolar nerve blocks can result in frustrating distant complications affecting such structures as the middle ear and eyes. Possible complications affecting the eyes include blurring of vision, diplopia, mydriasis, palpebral ptosis and amaurosis (temporary or permanent). In this article, we present a complication that has been reported only rarely. Two patients developed transient loss of power of accommodation of the eye resulting in blurred vision after routine inferior alveolar nerve blocks on the ipsilateral side. Clear vision returned within 10-15 minutes after completion of the blocks. The possible explanation for this phenomenon is accidental injection into the neurovascular bundle of local anesthetic agents, which were carried via the blood to the orbital region. This resulted in paralysis of a branch of cranial nerve III, the short ciliary nerves that innervate the ciliary muscle, which controls accommodation.

The influence of simulation-based physiology labs taught by anesthesiologists on the attitudes of first-year medical students towards anesthesiology

by Ethan Bryson

DeMaria S Jr, Bryson EO, Bodian C, Khelemsky Y, Sim AJ, Schwartz AD, Katz D, Levine AI.

Middle East Journal of Anesthesiology, October 2011

BACKGROUND:

The development of medical students' perceptions of different medical specialties is based... more BACKGROUND:

The development of medical students' perceptions of different medical specialties is based on many factors and influences their career choices and appreciation of other practitioners' knowledge and skills. The goal of this study was to determine if participation in a series of anesthesiologist-run, simulation-based physiology labs changed first year medical students' perceptions of anesthesiologists.

METHODS:

One hundred first-year medical students were surveyed at random three months before completion of a simulation-based physiology lab run by anesthesiologists. All participants received the same survey instrument, which employed a 5-point Rating Scale to rate the appropriateness of several descriptive terms as they apply to a particular specialist or specialty. A post-simulation survey was performed to track changes in attitudes.

RESULTS:

Response rates to the survey before and after the simulation labs were 75% and 97% (ofthe initial cohort responding), respectively. All students who filled out the post-simulation surveys had been exposed to anesthesiologists in the prior three months whereas none had interacted with surgeons in the interim. Nearly all had interacted with internal medicine specialists in that time period. No changes in the medical students' perceptions of surgeons or internal medicine specialists were evident. Statistically significant changes were found for most descriptors of anesthesiologists, with a trend towards a more favorable perception after the simulation program.

CONCLUSIONS:

Using a survey instrument containing descriptors of different medical specialists and specialties, we found an improved attitude towards anesthesiology after medical students participated in an anesthesiologist-run simulation-based physiology lab series. Given the importance of providing high quality medical education and attracting quality applicants to the field, integrati-on of anesthesiology staff into medical student courses at the non-clinical level appears useful

Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy

by Ethan Bryson

Hamza H, Bryson EO.
Mayo Clinic Proceedings, March 2012

It remains controversial whether it is safe for recovering health care professionals to return to clinical practice... more It remains controversial whether it is safe for recovering health care professionals to return to clinical practice after treatment for drug addiction. One specific component of reentry that remains particularly contentious is the use of pharmacotherapeutics, specifically buprenorphine, as opioid substitution therapy for health care professionals who wish to return to clinical work. Because health care professionals are typically engaged in safety-sensitive work with considerable consequences when errors occur, abstinence-based recovery should be recommended until studies demonstrate that it is safe to allow this population to practice while undergoing opioid substitution therapy.

Concordance of Motor and Electroencephalograph (EEG) Tracings in an Electroconvulsive Therapy (ECT) Tracing

by Ethan Bryson

Popeo DM, Bryson EO, Kellner CH.
Journal of Electroconvulsive Therapy, March 2012

Febrile Reaction With Elevated CPK After a Single Electroconvulsive Therapy (ECT) in an Adolescent Patient With Severe Bipolar Disorder

by Ethan Bryson

Bryson EO, Pasculli RM, Briggs MC, Popeo DM, Aloysi AS, Kellner CH
Journal of Electroconvulsive Therapy, March 2012

This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder... more This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.

Deceptive level after intrathecal block for Cesarian section in a patient with prior abdomionplasty

by Ethan Bryson

Assas A, Bryson EO, Frost EAM
Middlle East Journal of Anesthesia, June 2011

Abdominoplasty is performed in an increasing number of patients, both male and female.. The removal and hence... more Abdominoplasty is performed in an increasing number of patients, both male and female.. The removal and hence rearrangement of abdominal skin may make assessment of the dermatome level of a subarachnoid block difficult. Also patients may hesitate, or even forget, to reveal cosmetic surgeries during the preanesthetic interview. Therefore it is important to maintain a high index of suspicion in patients who have had bariatric surgery. In this report we present the case of a deceptive anesthetic level in a parturient with an undisclosed history of abdominoplasty who presented for Cesarean section.

Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: use of multi-modality educational activities

by Ethan Bryson

Levine AI, Flynn BC, Bryson EO, Demaria S Jr.
Journal of Clinical Anesthesia, February 2012

In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA)... more In 2010, the American Board of Anesthesiology instituted a new Maintenance of Certification in Anesthesiology (MOCA) Part IV activity requiring diplomates to attend and self-reflect on a simulation-based course in an American Society of Anesthesiologists-endorsed program. Although there are certain course requirements, much of the curriculum and structure of these MOCA activities is left to the discretion of the participating endorsed program. The ideal course would emphasize multimodality simulation-based activities that optimize diplomate education and satisfaction, while economizing faculty requirements. We describe of our course structure and content as a potentially useful template.

Anesthesia Advances Add to Safety of ECT

by Ethan Bryson

Kellner CH, Bryson EO.
Psychiatric Times, January 2012

Modern electroconvulsive therapy (ECT) is a remarkably safe and effective antidepressant treatment. It remains a... more Modern electroconvulsive therapy (ECT) is a remarkably safe and effective antidepressant treatment. It remains a critical option for urgently ill patients, many of whom do not adequately respond to antidepressant medications.

Advances in anesthesia technique are a major part of the safety and comfort profile of ECT today. In this article, we briefly review important aspects of the anesthesia used in ECT. While we do not believe that all psychiatrists need to be expert in the details, knowledge of the basics is necessary to adequately inform patients about ECT during the referral process.

PreAnesthetic Assessment of the Patient With a Positive Antibody Screen Requiring Blood Transfusion

by Ethan Bryson

by Ethan Bryson, MD in Anesthesiology News, October 2005

Anesthesiologists are responsible for administering the majority of blood transfusions given today. While generally... more Anesthesiologists are responsible for administering the majority of blood transfusions given today. While generally safe, transfusion reactions do occur and can be fatal. Anesthesiologists need to be aware not only of the signs of a transfusion reaction and how to appropriately handle such a situation, but also of the methods used to type and cross-match blood, how the blood bank operates, facility limitations, and methods to avoid potentially fatal transfusion reactions. The presence or absence of unexpected antibodies must be confirmed and the risks and benefits of transfusion considered. Transfusion reactions have been identified by questionnaires as topics for review.

PreAnesthetic Assessment of the Patient Reporting an Allergy to Penicillin

by Ethan Bryson

by Ethan Bryson, MD in Anesthesiology News March 2007

Recent emphasis on preventing surgical wound infections has highlighted the role of the anesthesiologist as the... more Recent emphasis on preventing surgical wound infections has highlighted the role of the anesthesiologist as the physician responsible for administering appropriate antibiotic prophylaxis. Patients often report a distant or unclear history of allergy to penicillin. An antibiotic administered to a patient who has a true allergy can provoke a life-threatening reaction. The anesthesiologist should be aware of the prevalence, severity, and manifestation of allergies to antibiotics, in addition to the available alternative therapies. The unnecessary administration of powerful broad-spectrum antibiotics leads to the development of antimicrobial resistance and thus should be avoided. It is the duty of anesthesiologists to balance such concerns when selecting appropriate antibiosis.

PreAnesthetic Assessment of the Emergency Obese Patient Requesting a Peripheral Nerve Block

by Ethan Bryson

by Ethan Bryson, MD in Anesthesiology News, January 2005

Many procedures may be performed using regional anesthetic techniques. When faced with the patient who has multiple... more Many procedures may be performed using regional anesthetic techniques. When faced with the patient who has multiple medical problems, in addition to a potentially difficult airway, the anesthesiologist must decide whether to secure the airway under controlled conditions and proceed with general anesthesia, or go forward with a regional technique. In the latter case, the  nesthesiologist must proceed with the understanding that, should the airway be lost at some point, a life-threatening situation may result. The prevention of complications requires careful planning on the part of the anesthesiologist. The preference of the patient regarding anesthesia technique must be sought and considered. The experience and comfort level of the anesthesiologist for various  echniques is also an important determinant in decision making.

PreAnesthetic Assessment of the Patient With a History Of Prolonged Postoperative Nausea and Vomiting

by Ethan Bryson

by Ethan Bryson, MD in Anesthesiology News, March 2006

Postoperative nausea and vomiting continue to be problematic areas in anesthesia, as evidenced by frequent reports of... more Postoperative nausea and vomiting continue to be problematic areas in anesthesia, as evidenced by frequent reports of therapies in the literature. A periodic in-depth review of the treatment strategies has been identified by committee as required knowledge for clinical anesthesiologists.

Anesthesia and Addiction, International Anesthesiology Clinics 49 (1), Winter 2011

by Ethan Bryson

By Ethan O. Bryson, M.D., and Elizabeth A. M. Frost, M.D.
Philadelphia, Lippincott Williams & Wilkins, 2011.
Pages: 176. Price: $176.00.

This is a review of the special issue of the International Anesthesiology Clinics book on Anesthesia and Addiction... more This is a review of the special issue of the International Anesthesiology Clinics book on Anesthesia and Addiction that Dr. Frost and I put together that was published in the January 2012 issue of Anesthesiology.

Rocuronium as muscle relaxant for electroconvulsive therapy in a patient with adult-onset muscular dystrophy

by Ethan Bryson

Bryson EO, Aloysi AS, Katz M, Popeo D, Kellner CH.
Journal of Electroconvulsive Therapy, December 2011

Adult-onset muscular dystrophy is an inherited myopathy characterized by a variable degree of progressive muscle... more Adult-onset muscular dystrophy is an inherited myopathy characterized by a variable degree of progressive muscle weakness and degeneration. Although not usually fatal, significant muscle weakness results in an up-regulation of acetylcholine receptors on the less responsive postjunctional muscles. The resulting profound potassium release when these receptors are stimulated by the depolarizing muscle relaxant succinylcholine can result in potentially fatal cardiac arrhythmias. We report a case of electroconvulsive therapy safely administered in a 61-year-old man with adult-onset muscular dystrophy requiring muscle relaxation with rocuronium.

Exposure of anesthesia providers in recovery from substance abuse to potential triggering agents

by Ethan Bryson

Hamza H, Bryson EO.
Journal of Clinical Anesthesia, November 2011

Study Objective: To determine the experience, attitudes, and opinions of anesthesia providers in recovery from... more Study Objective: To determine the experience, attitudes, and opinions of anesthesia providers in recovery from addiction to anesthetic agents, who subsequently undergo surgery or who require opioid analgesics for injuries or other conditions.

Design: Survey instrument.

Setting: Academic medical center.

Subjects: Physicians and nurse-anesthetists in recovery in the United States.

Measurements: A link to a survey was posted on the Anesthetists in Recovery website on January 17, 2010 and allowed to remain active for a period of one week. The survey also was distributed via email to recovering anesthesiologists in a “snowball sampling” method. Completed surveys were reviewed, and data were compiled using Survey Monkey, with categorical variables described as frequencies and percentages.

Main Results: A total of 30 surveys were returned, with 27 (90%) reporting a history of abusing anesthetics or drugs commonly found in the work environment, and 19 (65.5%) reporting abuse of recreational drugs and drugs used during the administration of anesthesia. Twenty-eight (93%) respondents reported finding themselves in a situation that necessitated they receive their former drug of choice for legitimate medical reasons while in recovery.

Conclusions: Anesthesia care providers in recovery from addiction to anesthetic agents may undergo subsequent exposure to these agents due to medical necessity. Participation in a program of recovery with support from family members may decrease the risk of relapse but does not eliminate it.

Perioperative acute kidney injury: risk factors, recognition, management, and outcomes

by Andrew Ferguson

Borthwick E, Ferguson A

Published 5 July 2010, doi:10.1136/bmj.c3365
Cite this as: BMJ 2010;341:c3365
Clinical Reviewmore

Published 5 July 2010, doi:10.1136/bmj.c3365
Cite this as: BMJ 2010;341:c3365
Clinical Review
Perioperative acute kidney injury: risk factors, recognition, management, and outcomes

Emma Borthwick, specialist registrar1, Andrew Ferguson, consultant in intensive care medicine and anaesthesia2

1 Nephrology and Intensive Care Medicine, Belfast City Hospital, Belfast BT12 7BA, 2 Craigavon Area Hospital, Portadown BT63 5QQ

Correspondence to: A Ferguson fergua@yahoo.ca
doi:10.1136/bmj.b2370


Summary points

Perioperative acute kidney injury (AKI) is common but poorly recognised and managed

Perioperative AKI increases surgical mortality and morbidity and increases cost

An apparently successful surgical outcome may not mean a successful renal outcome

Careful and thoughtful preoperative assessment, including identifying patients with existing chronic kidney disease and stopping and avoiding nephrotoxic drugs, will reduce the incidence of perioperative AKI.

Management of AKI centres on optimising fluid status and blood pressure, treating sepsis, and removing nephrotoxic agents where possible

Patients with AKI are often complex to treat, and senior help should be sought at an early stage


Acute kidney injury (AKI), formerly known as "acute renal failure," is associated with increased morbidity, mortality, duration of hospital stay, and healthcare cost.w1 Despite this, published data on perioperative acute kidney injury, occurring between the time of admission for surgery and the time of discharge, are scarce outside the cardiovascular surgery setting. Regardless of the clinical setting, the diagnosis of AKI is often delayed, and treatment is suboptimal in a large proportion of cases.1 To improve diagnosis and treatment, clinicians need to understand the risks and triggers for perioperative AKI, the association of even small transient rises in creatinine concentration with risk of death,2 and what actions they need to take promptly on diagnosis. The term acute kidney injury reflects the importance of thinking of the condition as a spectrum or continuum of disease that may be recognised at an early stage, rather than as an "all or nothing" phenomenon as implied by the term acute renal failure. Recognising earlier stages of renal impairment allows for early appropriate action that may interrupt a process of functional decline.

In this article we recommend the introduction of systems to ensure that changes in creatinine concentration from baseline are urgently highlighted to the clinical team. We outline the risk factors for perioperative AKI and discuss how to recognise the condition, manage it, and improve outcomes, focusing on the non-specialist surgery setting and using evidence from randomised trials, retrospective studies, meta-analyses, and expert reviews, as well as the recommendations of recent guidelines.

Perioperative Management of the Hemodialysis Patient

by Andrew Ferguson

Trainor D, Borthwick E, Ferguson A. Perioperative Management of the Hemodialysis Patient. Seminars in Dialysis 2011; 24: no. doi: 10.1111/j.1525-139X.2011.00856.x.

Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems worldwide. The... more Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems worldwide. The prevalence of end-stage renal disease (ESRD) has increased by 20% since 2000 and stands at 1699 per million people in the USA. ESRD is associated with an increased risk of cardiovascular comorbidity, increased severity of cardiovascular disease, and an adjusted all-cause mortality rate that is 6.4–7.8-fold higher than the general population. These patients may present electively or emergently for surgery related to, or remote from, the CKD. In any perioperative setting, the patient with hemodialysis-dependent CKD represents a significant clinical challenge, and successful management of these patients requires effective cooperation and communication between nephrology, anesthesia, and surgical staff. The ESRD patient’s nephrologist will have the best knowledge of their medical history, comorbidities, and future management goals and may have been the clinician who instigated the referral for the surgery, e.g., for parathyroidectomy, vascular access surgery, nephrectomy or renal transplantation. As such, they are in an ideal position to contribute to, or coordinate, early preoperative medical optimization of the patient and also to provide advice during postoperative recovery and rehabilitation. In this article, we provide an overview of some of the key aspects of managing these patients successfully during the perioperative period. We propose the integration of cardiopulmonary exercise testing and cardiovascular optimization into the care of these high-risk patients and provide an overview of the importance of maintaining microvascular perfusion and the role of viscosity in preserving the capillary perfusion network.