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ANESTHESIA & ANALGESIA
В®
The Gold Standard in Anesthesiology
The official scientific journal of the International Anesthesia Research SocietyВ®, The Society of Cardiovascular Anesthesiologists, the Society for
Pediatric Anesthesia, the Society for Ambulatory Anesthesia, the International Society for Anaesthetic Pharmacology, the Society for Technology in
Anesthesia, the Anesthesia Patient Safety Foundation, the Society of Critical Care Anesthesiologists,
and the Society for Obstetric Anesthesia and Perinatology.
STEVEN L. SHAFER
JAMES G. BOVILL
E DITOR - IN -C HIEF
New York, New York
CHARLES W. HOGUE, JR.
A SSOCIATE E DITOR - IN -C HIEF FOR
C ARDIOVASCULAR A NESTHESIOLOGY
Society of Cardiovascular Anesthesiologists
Baltimore, Maryland
G UEST E DITOR - IN -C HIEF
International Society for Anaesthetic Pharmacology
Leiden, The Netherlands
NANCY LYNLY
S ENIOR M ANAGING E DITOR
San Francisco, California
JEANETTE ESAU
O NLINE M ANAGING E DITOR
San Francisco, California
ANA MARTINEZ
R EVIEW S YSTEMS C OORDINATOR
San Francisco, California
FRANKLIN DEXTER
S TATISTICAL E DITOR
Iowa City, Iowa
SECTION EDITORS
MARTIN ANGST
MARCEL E. DURIEUX
P AIN M ECHANISMS
Palo Alto, California
P RECLINICAL P HARMACOLOGY
International Society for Anaesthetic
Pharmacology
Charlottesville, Virginia
SORIN J. BRULL
P ATIENT S AFETY
Anesthesia Patient Safety Foundation
Jacksonville, Florida
GREGORY J. CROSBY
N EUROSCIENCE IN A NESTHESIOLOGY
AND P ERIOPERATIVE M EDICINE
P EDIATRIC N EUROSCIENCE
Boston, Massachusetts
MARIE E. CSETE
B OOK , M ULTIMEDIA , AND M EETING R EVIEWS
San Diego, California
PETER J. DAVIS
P EDIATRIC A NESTHESIOLOGY
P EDIATRIC N EUROSCIENCE
Society for Pediatric Anesthesia
Pittsburgh, Pennsylvania
TONY GIN
C LINICAL P HARMACOLOGY
International Society for
Anaesthetic Pharmacology
Shatin, Hong Kong, China
PETER S. A. GLASS
A MBULATORY A NESTHESIOLOGY
Society for Ambulatory Anesthesia
Stony Brook, New York
JEFFREY B. GROSS
C ONTINUING M EDICAL E DUCATION
Farmington, Connecticut
TERESE T. HORLOCKER
R EGIONAL A NESTHESIA
Rochester, Minnesota
FRANKLIN DEXTER
E CONOMICS , E DUCATION , AND P OLICY
Iowa City, Iowa
YUGUANG HUANG
S CIENTIFIC D IRECTOR
C HINESE L ANGUAGE E DITION
Beijing, China
JERROLD H. LEVY
H EMOSTASIS AND T RANSFUSION M EDICINE
Society of Cardiovascular Anesthesiologists
Atlanta, Georgia
SPENCER S. LIU
P AIN M EDICINE
New York, New York
MARTIN J. LONDON
P ERIOPERATIVE E CHOCARDIOGRAPHY
AND C ARDIOVASCULAR E DUCATION
Society of Cardiovascular Anesthesiologists
San Francisco, California
JIANREN MAO
P AIN M ECHANISMS
Boston, Massachusetts
GEORGE A. MASHOUR
C OVER E DITOR
Ann Arbor, Michigan
EDWARD C. NEMERGUT
G RADUATE M EDICAL E DUCATION
AND T RANSPLANTATION
A NESTHESIOLOGY
Charlottesville, Virginia
LAWRENCE J. SAIDMAN
C ORRESPONDENCE
Palo Alto, California
DWAYNE WESTENSKOW
T ECHNOLOGY , C OMPUTING ,
AND S IMULATION
Society for Technology in Anesthesia
Salt Lake City, Utah
CYNTHIA A. WONG
O BSTETRIC A NESTHESIOLOGY
Society for Obstetric Anesthesia
and Perinatology
Chicago, Illinois
MICHAEL J. MURRAY
C RITICAL C ARE , T RAUMA ,
AND R ESUSCITATION
Society of Critical Care
Anesthesiologists
Phoenix, Arizona
EDITORIAL BOARD
HONORIO T. BENZON
Chicago, Illinois
TONG J. GAN
Durham, North Carolina
ROBERT MCCARTHY
EDWARD R. SHERWOOD
VINCENT W. S. CHAN
GEORGE M. HALL
NANCY A. NUSSMEIER
NIKOLAOS J. SKUBAS
JAMES A. DINARDO
IGOR KISSIN
Boston, Massachusetts
PAUL S. PAGEL
TONY L. YAKSH
KATE LESLIE
Melbourne, Australia
CARL E. ROSOW
MARK H. ZORNOW
GREGORY LIGUORI
JOHN W. SEAR
Toronto, Ontario, Canada
Boston, Massachusetts
GETГљLIO R.
DE OLIVEIRA
FlorianoВґpolis, Brazil
KAZUHIKO FUKUDA
Kyoto, Japan
FILHO
London, United Kingdom
New York, New York
Chicago, Illinois
Syracuse, New York
Elm Grove, Wisconsin
Boston, Massachusetts
Galveston, Texas
New York, New York
La Jolla, California
Portland, Oregon
Oxford, England
Editors’ contact information, professional interests, and conflict-of-interest disclosures are available at
www.anesthesia-analgesia.org.
May 2012, Volume 114, Number 5
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ANESTHESIA & ANALGESIA
В®
The Gold Standard in Anesthesiology
ASSOCIATE EDITORIAL BOARD
SCOTT BEATTIE
Toronto, Ontario, Canada
EDMOND I EGER II
JERROLD LERMAN
JOHN C. ROWLINGSON
SIMON C. BODY
V. GRANADOS-SOTO
J. LANCE LICHTOR
Worcester, Massachusetts
PHILIP E. SCUDERI
Winston-Salem, North Carolina
RICHARD BRULL
Toronto, Ontario, Canada
EUGENE A. HESSEL, II
DAVID LUO
STANTON K. SHERNAN
JOHN F. BUTTERWORTH, IV
MARKUS HOLLMANN
CARL LYNCH, III
ROMAN SNIECINSKI
KUMAR BUVANENDRAN
KEN JOHNSON
Salt Lake City, Utah
JILL MHYRE
Ann Arbor, Michigan
THOMAS R. VETTER
WILLIAM CAMANN
GIRISH P. JOSHI
MOHAMED NAGUIB
RICHARD WEISKOPF
MARK CHANEY
LEE KOETZNER
VANCE G. NIELSEN
JOSEPH P. CRAVERO
TOM C. KREJCIE
HANS-JOACHIM PRIEBE
KENNETH DRASNER
HELEN V. LAURO
KENT H. REHFELDT
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Richmond, Virginia
Chicago, Illinois
Boston, Massachusetts
Chicago, Illinois
Lebanon, New Hampshire
San Francisco, California
San Francisco, California
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Amsterdam, The Netherlands
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Chicago, Illinois
Brooklyn, New York
Buffalo, New York
Irvine, California
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Cleveland, Ohio
Charlottesville, Virginia
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Tucson, Arizona
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GUEST EDITORS 2012
TIMOTHY ANGELOTTI
STACIE DEINER
JONAS JOHANSSON
DONALD OXORN
IOANNA APOSTOLIDOU
FRANCВёOIS DONATI
Montreal, Quebec, Canada
SANDRA KOPP
Rochester, Minnesota
EVAN PIVALIZZA
VICTOR BAUM
Charlottesville, Virginia
ANTHONY DOUFAS
HENDRIKUS LEMMENS
Palo Alto, California
RAYMOND C. ROY
Winston-Salem, North Carolina
EMINE OZGUR BAYMAN
RICHARD P. DUTTON
ADAM B. LERNER
PETER SEBEL
XAVIER CAPDEVILA
RACHEL ESHIMA MCKAY
AMAN MAHAJAN
KOH SHINGU
NEAL COHEN
San Francisco, California
THOMAS GAL
Charlottesville, Virginia
ALAN MARCO
Toledo, Ohio
PETER SLINGER
Toronto, Ontario, Canada
ANDREW DAVIDSON
ORLANDO HUNG
Halifax, Nova Scotia, Canada
TIMOTHY W. MARTIN
MARTIN STECHERT
JOSEPH MATHEW
Durham, North Carolina
OLIVER M. THEUSINGER
Palo Alto, California
Minneapolis, Minnesota
Iowa City, Iowa
Montpellier, France
Victoria, Australia
New York, New York
Palo Alto, California
Park Ridge, Illinois
San Francisco, California
Philadelphia, Pennsylvania
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Los Angeles, California
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Seattle, Washington
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Atlanta, Georgia
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ANESTHESIA & ANALGESIA
В®
The “Gold Standard” in Anesthesiology
The official scientific journal of the International Anesthesia Research Society,В® the Society of
Cardiovascular Anesthesiologists, the Society for Pediatric Anesthesia, the Society for Ambulatory
Anesthesia, the International Society for Anaesthetic Pharmacology, the Society for Technology
in Anesthesia, the Anesthesia Patient Safety Foundation, the American Society of Critical Care
Anesthesiologists, and the Society for Obstetric Anesthesia and Perinatology
Abstracts of Posters
Presented at the
International Anesthesia Research Society
IARS 2012 Annual Meeting
Boston, Massachusetts
May 18-21, 2012
Abstracts (by category):
Ambulatory Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-01 – S-14
Bleeding / Blood Product Conservation . . . . . . . . . . . . . . . . . . . . . . S-20
Cardiothoracic & Vascular - Basic Science . . . . . . . . . . . . . . S-26 – S-41
Cardiothoracic & Vascular - Clinical . . . . . . . . . . . . . . . . . . S-47 – S-77
Critical Care Medicine & Trauma . . . . . . . . . . . . . . . . . . . S-155 – S-174
Economics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-180 – S-186
Education & Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . S-192 – S-236
Equipment & Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . S-242 – S-274
Geriatric Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-280 – S-291
Liver/Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-297 – S-302
Neuroanesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-308 – S-321
Obstetric Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-327 – S-336
Pain - Basic Science . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-342 – S-350
Pain - Clinical - Acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-356 – S-366
Pain - Clinical - Chronic . . . . . . . . . . . . . . . . . . . . . . . . . . . S-372 – S-376
Pediatric Anesthesia: General Topics . . . . . . . . . . . . . . . . . S-382 – S-393
Pediatric Anesthesia: Neonatal Safety and Anesthetics . . . S-399 – S-406
Pharmacology - Basic Science . . . . . . . . . . . . . . . . . . . . . . S-412 – S-439
Pharmacology – Clinical . . . . . . . . . . . . . . . . . . . . . . . . . . S-445 – S-466
Regional Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-472 – S-493
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S-494 – S-503
Authors submitting abstracts have certified that if human research is reported, approval by an institutional human research committee has been
obtained, or if animal research is reported, the usual standards and guidelines for animal care have been followed. Material published in this
supplement has not undergone review by the Editorial Board of Anesthesia and Analgesia. Any of the abstracts in this supplement may have
been transmitted by the author to IARS in various forms of electronic medium. IARS has used its best efforts to receive and format electronic
submissions for publication in this supplement but has not reviewed each abstract for the purpose of textual error correction and is not liable
in any way for any formatting, textual or grammatical error or inaccuracy.
В©2012 by the International Anesthesia Research Society
ABSTRACTS
IARS 2012 Annual Meeting
Abstract Presentation Schedule
ANESTH ANALG
2011; 112; S-01 – S-418
Ambulatory Anesthesia – 1
S-01......Sabouri, A......................Saturday...... 4:30 PM
S-02......Rasmussen, M................ Saturday...... 4:30 PM
S-03......Rosenberg, N................. Saturday...... 4:30 PM
S-04......Silverberg, M................. Saturday...... 4:30 PM
S-05......Ootaki, C........................ Saturday...... 4:30 PM
Cardiothoracic and Vascular - Clinical – 2
S-53......Kar, S.............................Friday.......... 3:00 PM
S-54......Mikami, D...................... Friday.......... 3:00 PM
S-55......Ringenberg, K................ Friday.......... 3:00 PM
S-56......Terao, Y..........................Friday.......... 3:00 PM
S-57......Huffmyer, J.................... Friday.......... 3:00 PM
Ambulatory Anesthesia – 2
S-07......Gombar, S...................... Friday........10:00 AM
S-08......May, J............................. Friday........10:00 AM
S-09......Rosero, E........................Friday........10:00 AM
Cardiothoracic and Vascular - Clinical – 3
S-58......Voskanian, S..................Sunday........8:00 AM
S-59......Pothula, S....................... Sunday........8:00 AM
S-60......Woodford, S................... Sunday........8:00 AM
S-61......Buehler, J....................... Sunday........8:00 AM
S-62......Wijeysundera, D............Sunday........8:00 AM
S-63......Fujii, K........................... Sunday........8:00 AM
S-64......Sharma, A....................... Sunday........8:00 AM
Ambulatory Anesthesia – 3
S-10......May, J............................. Sunday........ 1:00 PM
S-11......Withdrawn
S-12......Yoshida, A......................Sunday........ 1:00 PM
S-13......Rosero, E........................ Sunday........ 1:00 PM
S-14......Srivastava, S.................. Sunday........ 1:00 PM
Bleeding / Blood Product Conservation – 1
S-20......Mudumbai, S..................Friday........10:00 AM
Cardiothoracic and Vascular - Basic Science – 1
S-26......Hare, G........................... Saturday...... 1:00 PM
S-27......Lotz, C...........................Saturday...... 1:00 PM
S-28......Hare, G...........................Saturday...... 1:00 PM
S-29......Withdrawn
Cardiothoracic and Vascular - Basic Science – 2
S-30......Steppan, J....................... Sunday........8:00 AM
S-31......Woodford, S...................Sunday........8:00 AM
S-32......Woodford, S...................Sunday........8:00 AM
S-33......Eng, R............................Sunday........8:00 AM
S-34......Wang, A..........................Sunday........8:00 AM
S-35......Tischer-Zeitz, T..............Sunday........8:00 AM
Cardiothoracic and Vascular - Basic Science – 3
S-36......Theisen, M..................... Sunday......10:00 AM
S-37......Theisen, M..................... Sunday......10:00 AM
S-38......Riess, M......................... Sunday......10:00 AM
S-39......Abaz, M......................... Sunday......10:00 AM
S-40......Theilmeier, G.................Sunday......10:00 AM
S-41......Larmann, J..................... Sunday......10:00 AM
Cardiothoracic and Vascular - Clinical – 1
S-47......Assaad, S........................ Friday.......... 1:00 PM
S-48......Bradford, W...................Friday.......... 1:00 PM
S-49......Yoshimura, T.................. Friday.......... 1:00 PM
S-50......Assaad, S........................ Friday.......... 1:00 PM
S-51......Komatsu, R.................... Friday.......... 1:00 PM
S-52......Raphael, J.......................Friday.......... 1:00 PM
Cardiothoracic and Vascular - Clinical – 4
S-65......Withdrawn
S-66......Withdrawn
S-67......Raphael, J....................... Sunday......10:00 AM
S-68......Lessa, M. A.................... Sunday......10:00 AM
S-69......Lurati Buse, G................ Sunday......10:00 AM
S-70......Farar, D.......................... Sunday......10:00 AM
Cardiothoracic and Vascular - Clinical – 5
S-71......Withdrawn
S-72......Arya, V........................... Sunday........ 3:00 PM
S-73......Raghunathan, K.............Sunday........ 3:00 PM
S-74......Yin, J..............................Sunday........ 3:00 PM
S-75......Yin, J.............................. Sunday........ 3:00 PM
S-76......Snyder, M....................... Sunday........ 3:00 PM
S-77......Avagliano, E..................Sunday........ 3:00 PM
Critical Care Medicine and Trauma – 1
S-155....Patel, S........................... Friday.......... 3:00 PM
S-156....Amhaz, H.......................Friday.......... 3:00 PM
S-157....Attaallah, A....................Friday.......... 3:00 PM
S-158....Hatakeyama, N.............. Friday.......... 3:00 PM
S-159....Kanai, R.........................Friday.......... 3:00 PM
S-160....Kumar, M.......................Friday.......... 3:00 PM
Critical Care Medicine and Trauma – 2
S-161....Withdrawn
S-162....Fuchs, R.........................Saturday....10:00 AM
S-163....Tokuda, K......................Saturday....10:00 AM
S-164....Kida, K...........................Saturday....10:00 AM
Critical Care Medicine and Trauma – 3
S-165....Kosaka, Y.......................Sunday......10:00 AM
S-166....Urner, M.........................Sunday......10:00 AM
S-167....PeГ±a, C...........................Sunday......10:00 AM
S-168....Withdrawn
S-169....Herrmann, I.................... Sunday......10:00 AM
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
IARS 2012 Annual Meeting
Abstract Presentation Schedule
Critical Care Medicine and Trauma – 4
S-170....Mascia, M...................... Sunday........ 1:00 PM
S-171....Rajaratnam, C................Sunday........ 1:00 PM
S-172....Galiatsou, E.................... Sunday........ 1:00 PM
S-173....Lehmann, C....................Sunday........ 1:00 PM
S-174....Hudcova, J..................... Sunday........ 1:00 PM
Economics – 1
S-180....Lundberg, J.................... Saturday......8:00 AM
S-181....Targ, A............................ Saturday......8:00 AM
S-182....Targ, A............................Saturday......8:00 AM
S-183....Quraishi, T.....................Saturday......8:00 AM
S-184....Lurati Buse, G................Saturday......8:00 AM
S-185....Agarwal, S.....................Saturday......8:00 AM
S-186....Withdrawn
Education and Patient Safety – 1
S-192....Fukushima, Y.................Friday........10:00 AM
S-193....Fujita, Y......................... Friday........10:00 AM
S-194....Panjwani, A.................... Friday........10:00 AM
S-195....Baker, K.........................Friday........10:00 AM
S-196....Yorozu, T.......................Friday........10:00 AM
S-197....Patel, S...........................Friday........10:00 AM
Education and Patient Safety –2
S-198....Pisklakov, S....................Friday.......... 1:00 PM
S-199....Ng, V..............................Friday.......... 1:00 PM
S-200....Stol, I..............................Friday.......... 1:00 PM
S-201....Kariya, T........................Friday.......... 1:00 PM
S-202....Rebello, E......................Friday.......... 1:00 PM
S-203....Burkle, C........................Friday.......... 1:00 PM
Education and Patient Safety – 3
S-204....Tsai, M........................... Sunday........8:00 AM
S-205....Mitchell, J...................... Sunday........8:00 AM
S-206....Lin, N............................. Sunday........8:00 AM
S-207....Molloy, B....................... Sunday........8:00 AM
S-208....Epstein, R.......................Sunday........8:00 AM
S-209....Herasevich, V.................Sunday........8:00 AM
S-210....Morrison, A.................... Sunday........8:00 AM
Education and Patient Safety – 4
S-211....Jameson, L.....................Saturday...... 1:00 PM
S-212....Kim, C............................ Saturday...... 1:00 PM
S-213....Jameson, L..................... Saturday...... 1:00 PM
S-214....SГёrensen, M...................Saturday...... 1:00 PM
S-215....Navedo, A......................Saturday...... 1:00 PM
Education and Patient Safety – 5
S-216....Grande, B.......................Saturday......8:00 AM
S-217....Levine, D.......................Saturday......8:00 AM
S-218....Bernstein, W..................Saturday......8:00 AM
S-219....Dauber, B.......................Saturday......8:00 AM
S-220....Jafari, A.......................... Saturday......8:00 AM
S-221....Saumande, B..................Saturday......8:00 AM
S-222....May, J............................. Saturday......8:00 AM
Education and Patient Safety – 6
S-223....Anderson, J....................Sunday........ 1:00 PM
S-224....Barnet, C........................Sunday........ 1:00 PM
S-225....Boone, L......................... Sunday........ 1:00 PM
S-226....Patel, H.......................... Sunday........ 1:00 PM
S-227....Yin, J.............................. Sunday........ 1:00 PM
S-228....Wagner, R......................Sunday........ 1:00 PM
S-229....Matyal, R....................... Sunday........ 1:00 PM
S-230....Muret-Wagstaff, S..........Sunday........ 1:00 PM
Education and Patient Safety – 7
S-231....Lau, J..............................Saturday...... 4:30 PM
S-232....Wanderer, J.................... Saturday...... 4:30 PM
S-233....Bause, G......................... Saturday...... 4:30 PM
S-234....Thackeray, E.................. Saturday...... 4:30 PM
S-235....Montoya, R.................... Saturday...... 4:30 PM
S-236....Chau, D..........................Saturday...... 4:30 PM
Equipment Monitoring – 1
S-242....Ali, M............................. Friday........10:00 AM
S-243....Al Rawahi, K. S.............Friday........10:00 AM
S-244....Liaw, C. M.....................Friday........10:00 AM
S-246....Peterfreund, R................Friday........10:00 AM
S-256....Stol, I..............................Friday........10:00 AM
Equipment Monitoring –2
S-247....Targ, A............................Saturday...... 3:00 PM
S-248....Kawakami, H.................Saturday...... 3:00 PM
S-249....Tampo, A........................Saturday...... 3:00 PM
S-250....El-Hadi, S...................... Saturday...... 3:00 PM
S-251....Withdrawn
S-252....Miyake, Y......................Saturday...... 3:00 PM
Equipment Monitoring –3
S-253....Kawanishi, S..................Saturday...... 1:00 PM
S-254....Rothfield, K....................Saturday...... 1:00 PM
S-255....Dimache, F.....................Saturday...... 1:00 PM
S-257....Riess, M......................... Saturday...... 1:00 PM
S-258....Yamashita, K..................Saturday...... 1:00 PM
Equipment Monitoring – 4
S-259....Dote, K...........................Saturday...... 4:30 PM
S-260....Saththasivam, P..............Saturday...... 4:30 PM
S-261....Li, Z...............................Saturday...... 4:30 PM
S-262....Yoshida, A......................Saturday...... 4:30 PM
S-263....Zheng, X........................Saturday...... 4:30 PM
Equipment Monitoring – 5
S-264....Okino, S.........................Sunday........ 1:00 PM
S-265....Terada, T........................Sunday........ 1:00 PM
S-266....Sharpe, M....................... Sunday........ 1:00 PM
S-267....Yeh, J-R.........................Sunday........ 1:00 PM
S-268....Saito, J............................ Sunday........ 1:00 PM
S-269....Emanuel, A.....................Sunday........ 1:00 PM
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
IARS 2012 Annual Meeting
Abstract Presentation Schedule
ANESTH ANALG
2011; 112; S-01 – S-418
Equipment Monitoring –6
S-270....Gebre-Amlak, K............Sunday........ 3:00 PM
S-271....Marks, R........................ Sunday........ 3:00 PM
S-272....Withdrawn
S-273....Targ, A............................Sunday........ 3:00 PM
S-274....Fortier, L. P....................Sunday........ 3:00 PM
Obstetric Anesthesia – 2
S-332....Patteson, S...................... Saturday...... 1:00 PM
S-333....Collins, B....................... Saturday...... 1:00 PM
S-334....Liu, Y.............................Saturday...... 1:00 PM
S-335....Withdrawn
S-336....Withdrawn
Geriatrics – 1
S-280....Uchida, M...................... Saturday...... 3:00 PM
S-281....Withdrawn
S-282....Withdrawn
S-283....Withdrawn
S-284....Tse, J. T. C...................... Saturday...... 3:00 PM
S-285....Mehta, T.........................Saturday...... 3:00 PM
Pain - Basic Science – 1
S-342....Nishiyama, T.................. Sunday........ 3:00 PM
S-343....Kroin, J.......................... Sunday........ 3:00 PM
S-344....Kroin, J.......................... Sunday........ 3:00 PM
Geriatrics – 2
S-286....Kendale, S...................... Friday.......... 1:00 PM
S-287....Murdoch, J..................... Friday.......... 1:00 PM
S-288....Yang, J...........................Friday.......... 1:00 PM
S-289....Shyam, V.......................Friday.......... 1:00 PM
S-290....Krenk, L.........................Friday.......... 1:00 PM
S-291....Rowan, C.......................Friday.......... 1:00 PM
Liver / Transplantation –1
S-297....Ali, M.............................Friday.......... 3:00 PM
S-298....Shah, J............................Friday.......... 3:00 PM
S-299....Kosaka, J........................Friday.......... 3:00 PM
S-300....ASHRAFI, B..................Friday.......... 3:00 PM
S-302....Yang, J...........................Friday.......... 3:00 PM
Neuroanesthesia – 1
S-308....Withdrawn
S-309....Withdrawn
S-310....Goettel, N.......................Saturday......8:00 AM
S-311....Cui, D............................. Saturday......8:00 AM
S-312....Haile, M......................... Saturday......8:00 AM
S-313....Cui, D............................. Saturday......8:00 AM
S-314....Withdrawn
Neuroanesthesia –2
S-315....Tiwari, A........................Sunday........8:00 AM
S-316....Monteiro, J..................... Sunday........8:00 AM
S-317....Naik, B........................... Sunday........8:00 AM
S-318....Withdrawn
S-319....Shilo, D.......................... Sunday........8:00 AM
S-321....Giffard, R. G. ................ Sunday........8:00 AM
Obstetric Anesthesia – 1
S-327....Stiles, K.......................... Friday........10:00 AM
S-328....Hua, F............................ Friday........10:00 AM
S-329....Patel, S........................... Friday........10:00 AM
S-330....Terkawi, A...................... Friday........10:00 AM
S-331....Li, Q............................... Friday........10:00 AM
Pain - Basic Science – 2
S-346....Takasusuki, T.................Saturday......8:00 AM
S-348....Du, J...............................Saturday......8:00 AM
S-349....Lessa, M. A....................Saturday......8:00 AM
S-350....Kroin, J.......................... Saturday......8:00 AM
Pain - Clinical – Acute – 1
S-356....Boscariol, R...................Friday.......... 3:00 PM
S-357....Buvanendran, A.............. Friday.......... 3:00 PM
S-358....Doi, K............................Friday.......... 3:00 PM
S-359....Buvanendran, A..............Friday.......... 3:00 PM
S-360....Tomar, G........................Friday.......... 3:00 PM
S-361....Sun, Y............................Friday.......... 3:00 PM
Pain – Clinical – Acute – 2
S-362....Zhao, H..........................Saturday....10:00 AM
S-363....Candiotti, K....................Saturday....10:00 AM
S-364....Cierny, G........................Saturday....10:00 AM
S-365....Sadhasivam, S................ Saturday....10:00 AM
S-366....Gan, T.J..........................Saturday....10:00 AM
Pain - Clinical – Chronic – 1
S-372....Hattori, S........................ Sunday........8:00 AM
S-373....Mamiya, K..................... Sunday........8:00 AM
S-374....Buvanendran, A..............Sunday........8:00 AM
S-375....Durkin, B....................... Sunday........8:00 AM
S-376....Withdrawn
Pediatric Anesthesia: General Topics – 1
S-382....Terkawi, A......................Friday.......... 1:00 PM
S-383....Fujii, S............................ Friday.......... 1:00 PM
S-384....Fukuhara, A....................Friday.......... 1:00 PM
S-385....Gombar, S...................... Friday.......... 1:00 PM
S-386....Maru, A..........................Friday.......... 1:00 PM
S-387....Ludwig, E...................... Friday.......... 1:00 PM
Pediatric Anesthesia: General Topics – 2
S-388....Withdrawn
S-389....Targ, A............................Saturday....10:00 AM
S-390....Bjerregaard, J.................Saturday....10:00 AM
S-392....Chrysostomou, C........... Saturday....10:00 AM
S-393....Hammer, G..................... Saturday....10:00 AM
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
IARS 2012 Annual Meeting
Abstract Presentation Schedule
Pediatric Anesthesia: Neonatal Safety and Anesthetics – 1
S-399....Zhu, R............................Saturday...... 3:00 PM
S-400....Diaz, L........................... Saturday...... 3:00 PM
S-401....Levy, R........................... Saturday...... 3:00 PM
S-402....Koo, E............................ Saturday...... 3:00 PM
Pediatric Anesthesia: Neonatal Safety and Anesthetics – 2
S-403....Bong, C..........................Sunday........ 3:00 PM
S-404....Makaryus, R................... Sunday........ 3:00 PM
S-405....Johnson-Akeju, O.......... Sunday........ 3:00 PM
S-406....Bajic, D..........................Sunday........ 3:00 PM
Pharmacology - Basic Science – 1
S-412....Perouansky, M............... Saturday......8:00 AM
S-413....Withdrawn
S-414....Withdrawn
S-415....Goodchild, C.................. Saturday......8:00 AM
S-416....Ma, H............................. Saturday......8:00 AM
S-417....Piegeler, T...................... Saturday......8:00 AM
Pharmacology - Basic Science – 2
S-418....Forman, S.......................Saturday...... 1:00 PM
S-419....Withdrawn
S-420....Sinner, B........................Saturday...... 1:00 PM
S-421....Forman, S.......................Saturday...... 1:00 PM
S-422....Dershwitz, P...................Saturday...... 1:00 PM
Pharmacology - Basic Science – 3
S-423....Withdrawn
S-424....Ishizawa, Y....................Sunday........8:00 AM
S-425....Yuki, K...........................Sunday........8:00 AM
S-426....Lessa, M.A..................... Sunday........8:00 AM
S-427....Forman, S.......................Sunday........8:00 AM
Pharmacology - Basic Science – 4
S-429....Mishima, Y....................Saturday...... 4:30 PM
S-430....LaPierre, C.....................Saturday...... 4:30 PM
S-431....Lengl, O......................... Saturday...... 4:30 PM
S-432....Theisen, M.....................Saturday...... 4:30 PM
S-433....Lin, J.............................. Saturday...... 4:30 PM
Pharmacology - Basic Science – 5
S-434....Yamaguchi, K................ Sunday......10:00 AM
S-435....Theisen, M.....................Sunday......10:00 AM
S-436....Orser, B..........................Sunday......10:00 AM
S-437....Murphy, K...................... Sunday......10:00 AM
S-438....Zhang, X........................Sunday......10:00 AM
S-439....Wu, J.............................. Sunday......10:00 AM
Pharmacology - Clinical – 1
S-445....Terasako, K.................... Saturday...... 3:00 PM
S-446....Withdrawn
S-447....Van Haelst, I.M.M......... Saturday...... 3:00 PM
S-448....Tanno, M........................Saturday...... 3:00 PM
S-449....Mirzakhani, H................ Saturday...... 3:00 PM
Pharmacology - Clinical – 2
S-450....Withdrawn
S-451....Amornyotin, S................ Saturday....10:00 AM
S-452....Iwasaki, H......................Saturday....10:00 AM
S-453....Jeleazcov, C................... Saturday....10:00 AM
S-455....Desjardins St-Jean, O..... Saturday....10:00 AM
Pharmacology - Clinical – 3
S-456....Zheng, X........................Sunday......10:00 AM
S-457....Asimolowo, O................Sunday......10:00 AM
S-458....Takahoko, K...................Sunday......10:00 AM
S-459....Kurosaki, H....................Sunday......10:00 AM
S-460....Lurati Buse, G................Sunday......10:00 AM
Pharmacology - Clinical – 4
S-461....Lurati Buse, G................Sunday........ 3:00 PM
S-462....LaPierre, C.....................Sunday........ 3:00 PM
S-463....Lurati Buse, G................ Sunday........ 3:00 PM
S-464....Morioka, N..................... Sunday........ 3:00 PM
S-465....Meissner, K.................... Sunday........ 3:00 PM
S-466....Soon Im, K.....................Sunday........ 3:00 PM
Regional Anesthesia – 1
S-472....Alrayashi, W..................Friday.......... 3:00 PM
S-473....Withdrawn
S-474....Kolodzie, K....................Friday.......... 3:00 PM
S-475....Samhan, Y......................Friday.......... 3:00 PM
S-476....Al Mahrami, M.............. Friday.......... 3:00 PM
S-477....Ogura, A.........................Friday.......... 3:00 PM
Regional Anesthesia – 2
S-478....Traiyawong, R...............Saturday....10:00 AM
S-479....Withdrawn
S-480....Withdrawn
S-481....De Oliveira, G................Saturday....10:00 AM
Regional Anesthesia – 3
S-482....Liu, J..............................Saturday...... 3:00 PM
S-483....Manis, E.........................Saturday...... 3:00 PM
S-484....Li, Z...............................Saturday...... 3:00 PM
S-485....Bae, J..............................Saturday...... 3:00 PM
S-486....Withdrawn
Regional Anesthesia – 4
S-487....McClain, R.....................Sunday........ 1:00 PM
S-488....Kaur, B...........................Sunday........ 1:00 PM
S-489....Kaur, B...........................Sunday........ 1:00 PM
S-490....Ma, H.............................Sunday........ 1:00 PM
S-491....Withdrawn
S-492....Hsu, Y............................Sunday........ 1:00 PM
S-493....Wallace, A...................... Sunday........ 1:00 PM
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Ambulatory Anesthesia
ABSTRACTS
S-01
ANESTH ANALG
2012; 114; S-01 – S-493
Table. Sensitivity and Specificity of The BIS Index in Order to
Detect The Airway Complication by Using ROC Analysis
S-01.
IS THE BIS INDEX A RELIABLE AND ACCURATE
PREDICTOR OF AIRWAY OBSTRUCTION AND SEDATION
QUALITY IN OUTPATIENT SEDATION IN DENTAL
CLINIC?
BIS
SENSITIVITY (%)
SPECIFICITY(%)
81
99
37
75
80
57
AUTHORS: A. S. Sabouri1,2, C. Heard1, P. R. Creighton1, A. N.
Shepherd1
67
62
80
60
33
90
AFFILIATION: Anesthesiology, SUNY at Buffalo, Buffalo, MA;
2
Anesthesiology, Critical Care and Pain Medicine, MGH, Boston,
MA
52
10
98
1
Introduction: During procedures performed under deep
sedation, periods of apnea, airway obstruction and hypoxia can
occur. 1 In this study we evaluated the efficacy of using the BIS
monitor to determine the depth of sedation associated with airway
obstruction also to test the efficacy of the BIS in predicting the
patient movement as reflected by the surgeon’s assessment.
Area Under The Curve 0.75
Methods: After IRB review and approval, 47 patients scheduled
for elective 3rd molar teeth extraction in the dental clinic were
recruited for this study. Written, informed consent/assent was
obtained from each patient. After establishing IV access, a BIS
monitor strip was placed. A standardized sedation regimen,
including a total of 4 mg midazolam, 100 mcg fentanyl followed
by propofol titrated in 10 mg increments to effect was used. The
appropriateness/quality of the level of sedation was evaluated by
the surgeon and the occurrence of any airway complications was
assessed by the sedation provider. All staff were blinded to the BIS
index values.
Results: Most patients were ASA class 1 or 2 (97.5%). Average
age was 17.3 (SD=1.4), BMI of 26.8 (SD= 6.5).Airway obstruction
occurred in 26 cases (65%) with desaturation in further 8 cases
(20%). During airway obstruction episodes, the mean BIS index
(In one minute period) was 64 (В±10.2), which was significantly
lower than the BIS during non obstructed sedation (77 В±11.6).
(P<0.001).By using ROC analysis, almost all airway complications
(sensitivity: 99%) occurred at a BIS level of less than 81. A BIS
of < 52 was associated with an airway complication in 98% of the
cases (specificity). A BIS of > 81 appears to be safe with respect to
airway complications. A BIS of < 52 can be considered a very high
risk for airway complication (Table).Those patients who by surgical
assessment were considered to have significant movement had a
mean BIS (В±SD) of 74.1 (В±7.9). The mean BIS score in movers
and non-movers cases were significantly higher (P< 0.01) then
obstructed cases (Figure).
Discussion: The BIS can be used to aid in sedation titration
during dental procedures. Patients with a BIS index > 80 were
moderately sedated, during which airway patency was preserved.
Airway obstruction and over-sedation is a very common
complication during office deep sedation with propofol titration
regimen. Titrating the sedation to a BIS of about 65 may reduce the
incidence of airway problems and as such may increase safety of
office sedation by non- anesthesia practitioners. The quality of block
and complexity of cases are the confounding factors that limited
usage of BIS monitor in this regard.
References:
1.Hybarger S E, Sloan T B, SNAP Index with Light Anesthesia
and MAC during Surgery. Anesthesiology 2003; 99: A330
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-02
ANESTH ANALG
2012; 114; S-01 – S-493
Table 1: OSA Risk / Modified Neck Circumference.
S-02.
EVALUATION OF DEXMEDETOMIDINE/PROFOFOL (D/P)
COMBINATION ANESTHESIA FOR PATIENTS WITH
OBSTRUCTIVE SLEEP APNEA (OSA) CHARACTERISTICS
DURING UPPER GASTROINTESTINAL (GI) ENDOSCOPY
AUTHORS: M. S. Hannallah1, M. Rasmussen1, J. Carroll2,
A. Charabaty2, C. Palese2, N. Haddad2
1) Neck circumference in cm.
2) H/O snoring: add 3 points.
3) Hypertension: add 4 points.
4) Nighttime choking: add 3 points.
Total items 1-4. A score >48 indicates high probability of OSA.
Patient Satisfication
AFFILIATION: 1Department of Anesthesia, Georgetown University
Hospital, Washington, DC; 2Department of Gastroenterology,
Georgetown University Hospital, Washington, DC
Introduction: Patients with OSA are at increased risk of
anesthesia-related morbidity and mortality.1 That risk may justify
endotracheal (ET) intubation during anesthesia for upper GI
endoscopy in OSA patients. Dexmedetomidine provides sedation
with minimal respiratory depression.2 This observational study
prospectively evaluated the efficacy and safety of D/P anesthesia
for patients with OSA characteristics without ET intubation during
upper GI endoscopy.
Methods: With IRB approval 20 consented patients undergoing
upper GI endoscopy alone or with ultrasound examination,
Barrx procedure, or colonoscopy were enrolled in the study. All
patients were considered high probability of having OSA based
on an adjusted neck circumference greater than 48 cm.3 (Table 1)
Dexmedetomidine 1 mcg/kg (maximum 100 mcg) was given over 10
min followed by propofol boluses until adequate depth of anesthesia
was achieved. Propofol infusion was used to maintain anesthesia.
BP, HR, and O2 saturation were recorded before, during, and after
the procedure. The endoscopists evaluated the anesthesia conditions
on a 10 points numerical scale (10 = perfect). PACU phase 1 time
was recorded. The following day, patients were questioned about
complications and were asked to evaluate their overall anesthesia
experience on a 10 points numerical scale (10 = perfect). Propofol
induction dose and phase 1 time were compared to data we acquired
from a different but comparable IRB approved study using only
propofol for anesthesia in patients without OSA.
Results: 15 males and 5 females aged 51В±8 years were enrolled.
Their BMI was 34.7В±8.4, and their modified neck circumference
was 53.4В±3.4 cm. 7 had positive OSA diagnoses. Propofol induction
dose was 0.8В±0.4 mg/kg; and phase 1 time was 67.5В±26.7 min. (In the
propofol only study we used for comparison, the induction dose was
2.0В±0.5 mg/kg and phase 1 time was 33.4В±5.9 min). Two patients
developed transient hypoxemic episodes during the procedure that
were easily corrected with airway maneuvers. Transient hypotension
requiring vasopressor support was experienced by 3 patients during
the procedure and 3 patients in PACU. The evaluation score was
9В±1.7 by the endoscopists, and 8В±2.3 by the patients. Post-discharge,
drowsiness was common, 2 patients reported dysphoric symptoms,
and one patient complained of dry mouth.
Discussion: P/D can provide satisfactory anesthesia for upper GI
endoscopy in OSA patients. The technique provides an alternative to
ET intubation in these high risk patients. The prolonged induction
and recovery times, however, may limit its routine use.
References:
1. Anesth Analg 2008;107(5):1543-63.
2. Anesth Analg 2010;110(1):47-56.
3. N Engl J Med 2002;347(7):498-504.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-03
S-03.
THE EFFECTS OF A CUSTOMIZABLE, OFFICE-BASED
SURGICAL SAFETY CHECKLIST ON THE RATES OF KEY
PATIENT SAFETY INDICATORS
AUTHORS: N. Rosenberg1, S. Gallagher2, J. Stenglein3,
R. Urman3, P. Hess3, F. E. Shapiro3
AFFILIATION: 1University of Massachusetts Medical School,
Worcester, MA; 2Tufts University School of Medicine, Boston, MA;
3
Harvard Medical School, Boston, MA
Introduction: Recent hospital-based studies found that a
comprehensive checklist used in an interdisciplinary, team-based
setting resulted in a reduction in surgical complications as well as
cost savings [1,2]. We developed a safety checklist template for
use in the office surgery setting to determine the feasibility of its
implementation and its effect on key patient safety indicators.
Methods: Based on the W.H.O checklist, we developed a
28-element, perioperative checklist template for use in the officebased surgical setting (Figure 1). With focus-group input from office
personnel, including surgeons, anesthesiologists, and nurses, the
checklist was customized to an office-based plastic surgery practice
and IRB approval obtained. We recorded baseline, pre-checklist
rates for each checklist item as well as post-op adverse outcomes
via a retrospective chart review of 219 cases. After an education
program and 30-day run-in period, a prospective, post-checklist
implementation chart review was initiated and is ongoing.
ANESTH ANALG
2012; 114; S-01 – S-493
Discussion: We have demonstrated the feasibility of implementВ­
ing a locally customized safety checklist in an office-based surgery
setting, and that there is a measurable rate of adverse events that
suggest potential for improvement. Use of the checklist was
associated with increases in the rates of a number of important safety
indicators and recommended practices. Improvement in practices
such as site/side marking and the increase in discussion of patient
preparation and critical events demonstrate an important change in
the operating room environment because improved communication
and teamwork are critical to any patient safety endeavor. The
90-100% increases in availability of case-specific equipment,
confirmation of EMS policy, and availability of local anesthetic
toxicity precautions demonstrate recognition by practitioners that
effective rescue is impossible without access to the necessary
materials and systems. Further work will define the impact of the
checklist on adverse outcomes and its applicability to a range of
different types of office settings.
References:
1. de Vries EN et al. N Engl J Med. 2010;363(20):1928-37.
2. Semel ME et al. Health Aff (Millwood). 2010;29(9):1593-9.
Figure 2. Percentage of Positive Responses
Pre- and Post-Checklist Implementation
Results: At baseline, 90% of charts were missing documentation
of three or more checklist elements. 15% of cases had adverse
events, of which pain (3.7%) and bleeding/bruising (3.2%) were
most common. Preliminary analysis shows that documentation of
several key safety indicators and practices increased to 90-100%
(Figure 2).
Figure 1. ISOBS Safety Checklist
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-04
S-04.
APREPITANT FOR THE PREVENTION OF
POSTOPERATIVE NAUSEA AND VOMITING: A
PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND,
PLACEBO-CONTROLLED STUDY IN PATIENTS
UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY
AUTHORS: M. B. Silverberg1,2, V. R. Pothula2, A. Schiavone2,
P. Muddasani2, A. Madupu2, S. Allanku2
affiliation: 1Anesthesiology, Toms River Surgery Center,
Toms River, NJ; 2Anesthesiology, Staten Island University Hospital,
Staten Island, NY
Introduction: Neurokinin 1 receptor antagonists like
aprepitant (AP) are anti-emetic. PONV occurs even among patients
who receive standard antiemetic prophylaxis. We studied whether
AP adds to the effects of dexamethasone (DX) and ondansetron
(ON) in preventing PONV.
Methods: One AP 40 mg or placebo tablet was randomly
given to each study patient 30 minutes prior to surgery. All
patients received a standardized anesthetic including propofol,
fentanyl, rocuronium,isoflurane, nitrous oxide, neostigmine, and
glycopyrrolate. All patients received DX 8 mg IV with induction,
and ON 4 mg IV 20 minutes prior to emergence. No other antiemetics
were used. All peri-op nausea or vomiting episodes were recorded.
Using an 11-point verbal rating score, patients rated their nausea
at pre op, PACU admission, and at 2, 24, 48 hrs, and 2 weeks after
surgery, as well as just before receiving any rescue ON for nausea.
Results: A total of 171 patients,mean age 48.4,were enrolled. 88
patients received AP; 83 received placebo. The fraction of patients
with post-operative vomiting in the placebo group was significantly
larger (13/83) than in the AP group (0/88)(P < 0.0001). The verbal
rating scores for nausea were slightly higher in the placebo group,
but the results did not achieve significance. The two groups were
similar demographically. No adverse event attributable to AP was
observed. All 13 patients in the placebo group who vomited received
rescue ON in the PACU. No patients who received AP vomited, so
none received rescue medication.
Discussion: Habib2 compared AP/DX with ON/DX and found
less post-operative vomiting with AP, but no difference in postoperative nausea. Gan1 compared rolapitant with ON or placebo
and found rolapitant to be superior to placebo at preventing PONV.
Neither of these recent studies, however, addressed whether an
NK-1 inhibitor would add to the anti-emetic efficacy of the current
standard DX/ON regimen.
This study shows that AP is superior to placebo when added
to DX/ON in preventing PONV. We deliberately enrolled only
patients undergoing a known emetogenic operation (laparoscopic
cholecystectomy),and we deliberately used a standardized, “realworld” anesthetic technique, rather than a specifically nauseapreventing technique.
References:
1.Gan TJ. Rolapitant for the prevention of post-operative nausea
and vomiting. Anesthesia and Analgesia 2011: 112:804-812
2.Habib, A.S. A comparison of aprepitant and dexamethasone
versus the combination of ondansetron and dexamethasone
for the prevention of post-operative nausea and vomiting in
patients undergoing craniotomy. Anesthesia and Analgesia 2011:
112:813-818 esthesiology 2003; 99: A330
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-05
S-05.
DOES GENERAL ANESTHESIA INCREASE THE
DIAGNOSTIC YIELD OF EUS-GUIDED FINE NEEDLE
ASPIRATION OF PANCREATIC MASSES?
AUTHORS: C. Ootaki1, T. Stevens2, J. Vargo2, Y. Jing3, A. Shiba3,
W. G. Maurer4
affiliation: 1Anesthesiology, Wake Forest University,
Winston-Salem, NC; 2Digestive Disease Institute, Wake Forest
University, Cleveland, OH; 3Outcomes Research, Cleveland Clinic,
Cleveland, OH; 4Anesthesiology, Cleveland Clinic, Cleveland, OH
Introduction: Early diagnosis may improve the outcome and
survival in patients with pancreatic cancer. Endoscopic UltrasoundGuided Fine-Needle Aspiration(EUS-FNA) has emerged as
a preferred method, combining attributes of safety, minimal
invasiveness, and good yield. Diagnostic yield for EUS-FNA is
affected by several factors, including endoscopist experience, type
of needle, and use of an in-room cytopathologist. We are unaware
of any data comparing the impact of sedation technique on the
diagnostic yield of EUS-FNA in the diagnosis of solid pancreatic
mass. Our objective was to determine the association between the
sedation method employed and the diagnostic yield of EUS-FNA.
Methods: This study was approved by the Institutional Review
Board. A retrospective cohort study was conducted involving
consecutive patients who received EUS-FNA for diagnosis of a
solid pancreatic mass at our institution’s gastrointestinal endoscopy
units from 2007 to 2009. We compared the diagnostic yield of EUSFNA between patients receiving general anesthesia (GA group) and
ANESTH ANALG
2012; 114; S-01 – S-493
conscious sedation with the combination of a benzodiazepine and
opioid provided by a qualified registered nurse (CS group). In the GA
group, a propofol (1 mg/kg) and alfentanil (5.0 Ојg/kg) loading was
administered followed by a 100 - 50 Ојg/kg/min propofol infusion
mixed with alfentanil 0.5 - 0.25 Ојg/kg/min, and a MacSafeВ® nasal
cannula was used to administer oxygen and monitor end-tidal
carbon dioxide. The EUS-FNA was defined as “successful” if it was
completed, a specimen was obtained, and if a cytological diagnosis
was obtained for the case. Secondary outcome included the rate of
complications during or after the EUS-FNA procedure.
Results: Of 371 patients, a cytological diagnosis was obtained in
73/88 patients (83%) in the GA group and 206/283 patients (73%) in
the CS group. GA was associated with an increased odds of having
a successful diagnosis as compared to CS (adjusted odds ratio, 95%
CI: 2.04, 1.06-3.9, P = 0.03). There was no difference between the
groups in rate of complications during or after the procedure (P =
0.99).
Discussion: GA was associated with a significantly higher
diagnostic yield of EUS-FNA. It is well known the EUS-FNA yield
is in part controlled by the environment. However this is the first
study that demonstrated that the sedation technique affected the
diagnostic yield of EUS-FNA in the diagnosis of solid pancreatic
lesions. Among the 77 patients who had a failed initial EUS-FNA
diagnosis under CS, twenty one patients needed surgical laparotomy
and thirty nine patients could not obtain histological diagnosis. GA
should be considered a preferred sedation method for EUS-FNA of
a solid pancreatic mass.
References: N/A
Demographics and tumor characteristics
Variables
GA group (N = 88)
CS group (N =283)
P value *
Standardized
Difference †- 0.24 ‡
Age - yr
63 В± 14 a
66 В± 12
0.045 c
Gender, Female - %
50
47
0.62 d
0.06
Body mass index - kg/m2
27 [23, 29] a
26 [22, 30] b
0.62
0.06
0.04 d
0.45 ‡
70 a
59 a
0.14 ‡
Tumor location - %
Head of pancreas
Neck of pancreas
3
2
Body of pancreas
10
26
Tail of pancreas
13
7
Uncinate of pancreas
3
6
Tumor type, Malignant (vs. Benign) - %
72
78
0.24 d
Size of tumor - cm2
12 [5, 28] a
12 [5, 28] b
0.74
0.04
Reason for biopsy, Image (vs. not) - %
80
88 a
0.05 d
0.26 ‡
Biopsy conducted by a fellow, Yes - %
28
12
< 0.001 d
0.41 ‡
Number of needles passed
3 [2, 3] a
3 [2, 4] b
0.67
0.06
Statistics were presented as mean В± SD, median [Q1, Q3], or %, as appropriate. a 1-6 patients and b 32-48 patients had a missing
value * Wilcoxon rank-sum test, unless specified; c student’s t test; and d Pearson’s chi-squared test. †Standardized differences (GACS) in means or proportions divided by the pooled standard deviation; ‡ > 0.1 in absolute value suggests imbalance.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-07
S-07.
PULMONARY MECHANICS DURING LAPAROSCOPIC
CHOLECYSTECTOMY: A COMPARISON BETWEEN
CUFFED ENDOTRACHEAL TUBE AND PROSEAL LMA
AUTHORS: S. Gombar1, N. Bajaj1, U. Dalal2
affiliation: 1Anaesthesia & Intensive Care, Government
Medical College & Hospital, Sector 32, Chandigarh, India; 2Surgery,
Government Medical College & Hospital, Sector 32, Chandigarh,
India
Introduction: Proseal LMA (PLMA) has been used for
airway maintenance during laparoscopic cholecystectomy1 however
there is limited data regarding the effects of pneumoperitoneum on
pulmonary mechanics with PLMA.2 Objective of present study was
to evaluate and compare the use of PLMA with a cuffed endotracheal
tube (ETT) with regard to changes in pulmonary function in patients
undergoing laparoscopic cholecystectomy.
Methods: After written informed consent and institutional
ethics committee approval, we studied one hundred patients (ASA
physical status1/2), 18-60 years of age who were scheduled to
undergo laparoscopic cholecystectomy under GA. Patients were
randomly allocated to one of the two groups of 50 each. Group
I: cuffed endotracheal tube and Group II ProSeal LMA. Patients
as well as the surgeons were unaware of the airway device used.
Insertion parameters, hemodynamic & ventilatory parameters
(compliance,resistance and peak/plateau airway pressure) were
measured at different time intervals before, during and after
peumoperitoneum. The statistical analysis was carried out using
ANESTH ANALG
2012; 114; S-01 – S-493
Statistical Package for Social Sciences (SPSS Inc., Chicago, IL,
version 15.0 for Windows).
Results: Statistically significant (p< 0.05) but clinically
insignificant difference was found in time taken for device insertion
in the two groups (21.8 В± 5.9 s group I & 25.4 В± 5.7 s group II).
Insertion of orogastric tube was easier and less number of attempts
were required with PLMA. Hemodynamic parameters like heart
rate, systolic, diastolic and mean blood pressures all increased
after the ETT insertion while there was a decrease/no change after
PLMA insertion. There was a significant decline in the pulmonary
compliance in group II which was more pronounced after
pneumoperitoneum. During pneumoperitoneum, higher peak and
plateau airway pressures were noted in PLMA group than in ETT
group.(TableI) After desufflation these parameters returned to near
preinsufflation levels.There was no episode of arterial desaturation
in either group.
Discussion: Our results indicate that in the PLMA group,
the degree of changes in pulmonary mechanics caused by the
pneumoperitoneum were significant however there was no incidence
of arterial desaturation, or gastric regurgitation. It may even be
better than the ETT in hypertensive/cardiac patients due to better
hemodynamic stability. Hence PLMA is a satisfactory airway device
for laparoscopic cholecystectomy under GA, but further studies are
required reagarding its safety in patients with decreased pulmonary
compliance like morbid obesity or COPD.
References:
1. Can J Anaesth 2002; 49:857-62
2. Anesth Analg 2000; 90: S1-523
Pulmonary Parameters
Parameters
Before Insufflation
Before
Insufflation
During
eumoperitoneum
During
pneumoperitoneum
After
desufflation
After
desufflation
Group I (ETT)
Group II (PLMA)
Group I (ETT)
Group II (PLMA)
Group I (ETT)
Group II
(PLMA)
35.20В±5.15
Compliance(ml/cmH2O)
48.68В±12.40
39.54В±8.68
28.36В±7.66
25.78В±5.94
40.68В±9.32
Resistance (cmH2O/L/sec)
9.14В±1.51
9.7В±2.18
11.68В±1.59
11.9В±2.29
9.02В±1.23
9.22В±1.83
Peak Pressure (cm H2O)
15.5В±2.95
17.36В±2.5
21.42В±3.32
23.1В±2.95
17.12В±2.76
18.62В±2.20
Plateau Pressure (cm H2O)
13.42В±2.87
15.6В±2.57
18.84В±3.12
21.14В±2.63
14.72В±2.43
16.82В±2.30
p<0.05 when compared with the pre-pneumoperitoneal values, Figures are MeanВ±S.D.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-08
ANESTH ANALG
2012; 114; S-01 – S-493
01-
01Table 1: Demographics
S-08.
USING A STANDARDIZED AIRWAY AND ANESTHETIC
TECHNIQUE IN MORBIDLY OBESE PATIENTS
UNDERGOING BARIATRIC SURGERY: FACILITATING
INTUBATION, AVOIDING MASK VENTILATION AND
DECREASING DESATURATION
AUTHORS: Y. Bryan1, T. Taylor1, J. May1, L. Hoke1, M. Laxton1,
A. Fernandez2
affiliation: 1Anesthesiology, Wake Forest School of Medicine,
Winston Salem, NC; 2General Surgery, Wake Forest School of
Medicine, Winston-Salem, NC
Introduction: Various airway/anesthetic techniques have
been safely used in morbidly obese (MO) patients1; however,
studies have focused on a single aspect of airway management,
e.g., intubation2. A high incidence of airway-related problems has
been found when measuring patient-centered (PC) outcomes of
intubation, ventilation, and oxygenation (IVO)3. Differences exist
regarding positioning, induction agents/doses, difficulty of bag mask
ventilation (BMV), and choices of intubating devices. We measured
the airway outcomes of IVO in MO patients undergoing bariatric
surgery using a standardized airway and anesthetic technique.
Methods: After IRB approval and informed consent, 116
patients were recruited. After premedication with midazolam
1-2 mg, patients were placed in reverse Trendelenburg and
preoxygenated for 4 min. IV induction was performed with
propofol, succinylcholine, and fentanyl using total body weight.
Patients were intubated with the StorzВ® DCI video laryngoscope
(VL) with maintenance 1-2% isoflurane, O2/air 1 L/min each, and
a dexmedetomidine infusion (0.4 mcg/kg/hr). Prior to extubation,
a lidocaine-coated 36-F nasopharyngeal airway was placed for
administration of CPAP after extubation and during transport to
PACU. Data collected included demographics, airway exam, any
problems with IVO throughout any phase of anesthetic care, and
different times during the intubation (Table 2).
Table 1: Demographics
n
Female
92
n
Male
23
Female
92
%
80.0
%
20.0
80.0
Male
23
20.0
MeanВ±SD (Range)
Age
45.2В±9.1(Range)
(23-65)
MeanВ±SD
Weight
131.8В±28.4
(89.8Age
45.2В±9.1 (23-65)
244.9)
Weight
131.8В±28.4 (89.8BMI
46.7В±7.8 (31.8-77.3)
244.9)
BMI
46.7В±7.8 (31.8-77.3)
%
n
Mallampati Class
n
%
I/II
106
92.2
Mallampati
Class
III/IV
9
7.8
I/II
106
92.2
Thyromental Distance
III/IV
9
7.8
<3 FB
26
22.6
Thyromental
Distance
≥3
FB
89
77.4
<3 FB
26
22.6
Neck
Motion
≥3
FB Range of 89
77.4
Limited
24
20.9
Neck
Range of Motion
All
91
79.1
Limited
24
20.9
All
91
79.1
Table 2: Times for intubation
Table 2: Times for intubation
Time (seconds)
Visualization
of vocal cords
Time
(seconds)
Placement ofofETT
Visualization
vocal cords
VerificationofofETT
ETCO2
Placement
Total time of ETCO
Verification
MeanВ±SD (Range)
16.5 В± 12.8
(2-93)
MeanВ±SD
(Range)
23.3
16.5В±В±21.0
12.8(5-131)
(2-93)
28.8В± В±21.0
9.1 (5-131)
(14-57)
23.3
67.5
В±
29.0
(27-185)
28.8 В± 9.1 (14-57)
Total time
67.5 В± 29.0 (27-185)
2
01-05-12
01
Table
Phases of problems with oxygenation
Results: A total of 115 patients wereTable
analyzed
(Tableof1problems
3: Phases
with3:
oxygenation
Demographics). One patient was excluded due to a protocol
Phase of Desaturation
n*
%
deviation at induction. All patients were intubated
the VL;
Phase of using
Desaturation
n*
%
however, intubation was > 2 min in 7/115 (6.1%) of patients
One Phase 26
26
57.8%
(Table 2). Two of the 115 (1.7%) patientsOne
required
BMV. FortyPhase
57.8%
five (39.1%) experienced 66 episodes of desaturation
(Tables
3
&
Intubation
5
11.1%
Intubation
5
11.1%
4). Nineteen (16.5%) patients experienced multiple desaturations
Maintenance3
3
6.7%
Maintenance
6.7%
throughout the different phases of airway management. Five (4.3%)
Extubation
18
40.0%
18
40.0%
patients experienced major desaturation (SpO2 Extubation
< 85%).
Discussion: The majority of oxygenation problems was minor
Two Phases 16
16
Two Phases
35.6%
and occurred more frequently during extubation than intubation.
Intubation
&
Maintenance
2
Intubation & Maintenance
2
4.4%
The incidence of major desaturations was low—in contrast to the
Intubation
&
Extubation
11
Extubation
11
24.4%
findings of other studies4. BMV was requiredIntubation
in a few&patients
Maintenance3 & Extubation
3
Maintenance
& Extubation
6.7%
with prolonged intubation (necessitating a change
in stylet
for
placement of the endotracheal tube) and due to desaturation.
Three Phases 3
3
Variability in intubation time may be relatedThree
to thePhases
experience level
6.7%
3
of the laryngoscopist. Further studies are required
regardingMaintenance,
patient
Intubation,
& Intubation, Maintenance,
3
6.7% &
Extubation
positioning and airway/anesthetic techniques toExtubation
optimize PC airway
*n=45 problem
patients with an oxygenation problem
outcomes of IVO.
*n=45 patients with an oxygenation
35.6%
4.4%
24.4%
6.7%
6.7%
6.7%
References:
1. Anesth Analg 2011;113:4-6.
2. Anesth Analg 2002;94:732-6.
3. Anesthesiology 2011; A548.
4. BJA 2011;106:617-31.
Table 4: of
Frequency
and magnitude of oxygen desaturations
Table 4: Frequency and magnitude
oxygen desaturations
Extubation
Total
Intubation
MaintenanceIntubation
ExtubationMaintenance
Total
%
n
%
Lowest SpO2
n Lowest
% SpOn2
% n
n %
%n
n %
% n
90-95%
12.1%
41 62.1%
90-95%
9 13.6%
8
12.1% 9 13.6%
24 36.4% 8
41 62.1% 24 36.4%
80-89%
4.5%28.8% 7 10.6%
19 28.8%
80-89%
9 13.6%
3
4.5% 9 13.6%
7 10.6% 3
19
70-79%
2
3.0%
0
0.0%
2
3.0%
4
6.1%
70-79%
2
3.0%
0
0.0%
2
3.0%
4
6.1%
69%
1.5%
0.0%
1.5%
2
3.0%
≤ 69%
1 ≤1.5%
0
0.0% 1
1
1.5% 0
2
3.0% 1
*Out
of
115
patients,
45
patients
experienced
a
total
of
66
episodes
of
oxygen
desatura
*Out of 115 patients, 45 patients experienced a total of 66 episodes of oxygen desaturation.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-09
S-09.
EFFECTS OF PREINDUCTION FENTANYL ON
DESFLURANE ANESTHESIA VIA A LARYNGEAL MASK
AIRWAY
AUTHORS: A. Kamali, J. Meng, I. Gasanova, E. Rosero, G. P. Joshi
affiliation: Anesthesiology and Pain Management, University
of Texas Southwestern Medical Center, Dallas, TX
Introduction: Desflurane is sometimes avoided with the
use of laryngeal mask airway ( LMA) due to concerns of airway
irritability. Opioids may reduce the airway responses to desflurane;
however, this has not been assessed in a double blind, randomized
manner. Therefore, we evaluated the effects of fentanyl pretreatment
on respiratory events in patients receiving desflurane via the LMA.
Methods: Outpatients randomly received either fentanyl
1 Вµg/kg (n=51) or saline (n=49) 3-5 min prior to induction with
propofol 2-2.5 mg/kg and lidocaine 20-30 mg, IV, followed by LMA
placement. Anesthesia was maintained with desflurane titrated to
BIS 50-60, and nitrous oxide in oxygen. Fentanyl 25-50 Вµg was
administered as needed to achieve a respiratory rate of 10-15/
min. In addition to occurrence of apnea and duration of manual
ventilation, incidence and severity of movement, apnea, coughing,
breath holding, and laryngospasm were recorded from the start of
induction until removal of the LMA.
Results: Two patients in each group were excluded from
analysis. There were no differences between the groups with respect
to baseline demographics and clinical characteristics as well as
intraoperative anesthetic and analgesic characteristics except higher
total opioid use in the fentanyl group. The fentanyl pretreatment
group had higher incidence of apnea (94% vs. 64%) and longer
duration of manual ventilation (3 [1.5-5] min vs. 1 [0-1.5] min) at
induction. In contrast, the fentanyl pretreatment group had lower
incidence of movements (16% vs. 51%), albeit mild. There was no
difference between the fentanyl pretreatment and placebo groups
with respect to the rates of intraoperative coughing (2.1% vs.
12.8%), breath holding (6.1% vs. 8.5%), and laryngospasm (2%
vs. 4.3%). One patient in the placebo group had severe coughing
requiring propofol administration and one patient in the fentanyl
group had laryngospasm requiring succinylcholine 20 mg. Adjusting
for smoking status did not affect the differences in apnea, need
for manual ventilation, and movement between groups; however,
occurrence of coughing statistically was higher in the placebo group
(11.8% vs 0%, respectively).
Discussion: The incidence and severity of respiratory events
with the use of desflurane via the LMA were low and similar to
previous reports1,2. Fentanyl pretreatment reduced movements at
induction of anesthesia but increased the incidence of apnea and
need for manual ventilation as well as reduced the incidence of
coughing in smokers. The remaining perioperative course was
similar.
References:
1. Anaesthesia 2003;96:701-5.
2. Anesth Analg 2006;103:1147-54.
Acknowledgment: This study was supported by funding
from Baxter Healthcare corporation.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-10
ANESTH ANALG
2012; 114; S-01 – S-493
Table 1. Demographics
S-10.
58.9В±13.5 (37-86)
AGE (yr) MeanВ±SD (Range)
AIRWAY AND ANESTHETIC MANAGEMENT IN PATIENTS
UNDERGOING THYROID SURGERY
WEIGHT (kg) MeanВ±SD (Range)
AUTHORS: S. Davis, A. Campos, N. Bhatti, J. May, L. Hoke,
Y. Bryan
ASA
BMI (kg/m2)
Introduction: Airway management in patients undergoing
thyroid and/or parathyroid surgery may be challenging. Certain
features make airways difficult to manage, e.g., small mouth
opening, Mallampati class III or IV, decreased thyromental distance,
and/or neck range of motion1. Additionally, the size of the thyroid
mass, the type of malignancy, and/or evidence of tracheal deviation
makes laryngoscopy and intubation difficult2. For intubation,
specialized airway devices (SADs) such as video laryngoscopes or
flexible fiberoptic bronchoscopes (FFBs) are used3. We present our
preliminary data comparing the effectiveness of different airway
devices and anesthetic techniques in patients undergoing thyroid/
parathyroid surgery by measuring the combined airway outcomes
of oxygenation, ventilation, and intubation (OVI).
Methods: As part of an IRB-approved, observational difficult
airway (DA) study, patients scheduled for thyroidectomy and
parathyroidectomy were enrolled between March 2010 and August
2011. DA was defined as above. Demographic data collected
included age, weight, height, BMI, ASA status, gender, and
diagnosis. Anesthetic technique, maneuvers used for bag mask
ventilation, device used for intubation, laryngoscopy attempts, and
problems with oxygenation and ventilation data were collected.
Results: A total of 26 patients were enrolled. Basic demographic
data are provided in Table 1. Seven of the 26 (27%) patients had
Mallampati class III-IV. Four of 26 (15%) patients and 1/26 (4%)
patient had <3 FB for mouth opening and TMD, respectively.
Ten of the 26 (38%) patients had limited neck range of motion.
Table 2 details the frequency of various intubating devices used
and anesthetic technique (awake /sedation vs. general). Direct
laryngoscopy (DL) was used in 4/26 (15%) patients while SADs
were used in 22/26 (85%) patients (Table 2). Table 3 provides
data regarding problems with oxygenation and ventilation. Table 4
contains detailed intubation data.
Discussion: A variety of airway devices and techniques were
safely used to intubate patients undergoing thyroidectomies. A high
incidence of desaturation occurred during airway management
related to certain patient factors. However, choice of airway device
was also dependent upon the relationship between airway exam and
extent of thyroid mass/tumor4. In addition to airway exam, the size
and location of thyroid mass/tumor was a critical factor in choosing
airway management technique.
References:
В 1 (3.8%)
7 (27%)
1 (3.8%)
17 (65.4%)
В В В В Table 2. Device and Technique
INTUBATION DEVICE
Conventional laryngoscope
Flexible fiberoptic bronchoscope
GlidescopeВ®
StorzВ® video laryngoscope
FREQUENCY (n)
%
4
11
4
7
15.4
42.3
15.4
26.9
10
16
38.5
61.5
TECHNIQUE
Awake
Asleep
В В В В Table 3. Problems with Oxygenation and Ventilation
OXYGENATION
Phases
Frequency of desaturation
Preparation
Intubation
Maintenance
Extubation
4
7
1
4
*12 patients with 16 episodes of oxygen desaturation
VENTILATION
Bag Mask Ventilation
0-2 Maneuvers
3-5 Maneuvers
RSI (No BMV)
Frequency (n)
%
5
5
16
19.2
19.2
61.5
В В В В В Table 4. Intubation
VISUALIZATION OF VOCAL CORDS
Conventional
1-2 Attempts
≥3 Attempts
Frequency (n)
%
4
1
13.8
3.4
18
6
62.1
20.7
5
0
17.2
0.0
22
2
75.9
6.9
Specialized airway device
1-2 Attempts
≥3 Attempts
*3 patients required conventional and SAD
2. Can J Anaesth 2003;50:81-5
Acknowledgment: This study was supported by funding
from Baxter Healthcare corporation.
В 8 (69%)
18 (31%)
MALE
FEMALE
PLACEMENT OF ETT
4. Laryngoscope 2009;119:S242
В GENDER
1. Anesth Analg 1997;84:611-2
3. Anaesthesia 2007;62:214-9
В 45.15В±8.04
1
2
3
4
affiliation: Anesthesiology, Wake Forest School of Medicine,
Winston-Salem, NC
В 91.2В±24.3 (51.7-167.4)
Conventional
1-2 Attempts
≥3 Attempts
Specialized airway device
1-2 Attempts
≥3 Attempts
*3 patients required conventional and SAD
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
В ABSTRACTS
S-11
S-12
ANESTH ANALG
2012; 114; S-01 – S-493
S-11.
S-12.
WITHDRAWN.
GOOD DREAMS DURING GENERAL ANESTHESIA ARE
ASSOCIATED WITH THE INCIDENCE OF PONV
AUTHORS: A. Yoshida, K. Fujii, K. Nishikawa
affiliation: Anesthesiology, Wakayama Medical University,
Wakayama, Japan
Introduction: In terms of the relationship between dreams
and awareness during general anesthesia, there have been many
studies evaluating the factors which influence the incidence of
dreams during general anesthesia. However, the association of
dreams during general anesthesia with postoperative complications
has not been clarified. This study was aimed to examine whether
dreams during general anesthesia are related to postoperative pain,
postoperative nausea and vomiting (PONV), or patient satisfaction.
Methods: Patients scheduled for elective surgery under general
anesthesia during 3 months in our hospital were included in this
study. Preoperative mental status was assessed by the Hospital
Anxiety and Depression Scale (HADS). Postoperative interview
was conducted repeatedly on leaving the operation theater and on
the next day of operation. Dreams and awareness during general
anesthesia were detected with the modified Brice interview including
the question of quality of dreams categorized as good, indifferent,
or bad. The incidence of postoperative pain and PONV were also
recorded. Data were analyzed using Mann-Whitney U test and chisquare test. P value < 0.05 was considered significant. All values are
expressed as median [interquartile ranges] or numbers [%].
Results: Six hundred and fifty-six patients were included in this
study and 171 [26.1%] patients reported having a dream. Younger
age (59 [40-70] vs. 63 [48-73]; P=0.002) and propofol maintenance
(101 [33.6%] vs. 70 [19.7%]; P<0.001) were associated with
dreams. Although having a dream could not affect the incidence
of postoperative complications, good dreams (92 [53.8%]) were
related to lower incidence of PONV (3 [3.5%] vs. 60 [11.4%];
P=0.025). Depressive patients were inclined to have bad dreams (5
[2.9%], P=0.008).
Discussion: The quality of dreams during general anesthesia
may associate with postoperative complication.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-13
S-14
ANESTH ANALG
2012; 114; S-01 – S-493
S-13.
S-14.
EFFICIENCY OF FREE-STANDING AMBULATORY
SURGERY CENTERS AND HOSPITAL-BASED
AMBULATORY SURGERY DEPARTMENTS IN THE USA: A
PROPENSITY ANALYSIS
THE MINIMUM EFFECTIVE DOSE OF DEXAMETHASONE
IN COMBINATION WITH MIDAZOLAM IN PATIENTS
UNDERGOING LAPROSCOPIC CHOLECYSTECTOMY
FOR PREVENTION OF POST OPERATIVE NAUSEA AND
VOMITING
AUTHORS: E. B. Rosero, G. P. Joshi
affiliation: Anesthesiology & Pain Management, UT
Southwestern Medical Center, Dallas, TX
AUTHORS: S. Srivastava, S. Dhiraaj, R. Gupta
affiliation: Anesthesiology, SGPGIMS, Lucknow, India
Introduction: Use of time is frequently employed as a
measure of efficiency in surgical facilities1,2. It is not clear, however,
whether free-standing ambulatory surgery centers (ASCs) are
as efficient as hospital-based ambulatory surgery departments
(HOPDs). The purpose of the study was to compare nationwide
efficiency of ASCs and HOPDs in terms of operating room (OR)
times, surgery time, postoperative time, and total time in facility for
commonly performed surgical procedures.
Introduction: Postoperative nausea and vomiting (PONV),
defined as nausea and/or vomiting occurring within 24 hours after
surgery, affects between 20% and 30% of patients.1 As many as 70%
to 80% of patients at high risk may be affected.2 The aim of the
present study is to determine the minimal dose of dexamethasone
(D) that combined with midazolam (M) would provide effective
prophylaxis of PONV after laparoscopic cholecystectomy in
patients at high risk for PONV.
Methods: Discharges with the top-ten ambulatory surgery
procedures performed in the United States in ASCs and HOPDs
were identified from the 2006 National Survey of Ambulatory
Surgery. Propensity scores (PS) derived from a logistic regression
model were used to assemble a 1:1 matched cohort of patients
undergoing the procedures in ASCs and HOPDs. Covariates in
the model for PS included type of surgical procedure, age, sex,
comorbidities, type of anesthesia, metropolitan status of facility, and
type of insurance. Differences in total OR time, surgical time, nonsurgical OR time, and time in recovery room as well as total facility
time were assessed between the matched groups.
Methods: A randomized, placebo-controlled, double blind
study of 155 females 18 to 60 years old, ASA class I and II,
nonsmokers, underwent general anesthesia for elective laparoscopic
cholecystectomy of more than one hour duration along with the use
of systemic opioids was conducted after institute ethical approval.
The study groups were divided in five groups, C (placebo-2 ml of
normal saline) ,MD1(M 0.04 mg/kg + D 1 mg), MD2(M 0.04 mg/kg
+ D 2 mg), MD4 (M 0.04 mg/kg + D 4 mg) and MD8 (M 0.04 mg/kg
+ D 8mg), drugs were given at induction of anesthesia. All episodes
of nausea and vomiting while in the hospital, during the 0 to 6 hr, 6
to 12-hr and 12 to 24 hr intervals after surgery were recorded and the
severity of nausea and pain was recorded using the VAS scale and
data were compared in the five groups.
Results: The discharges with the top-ten procedures represented
55.1% of all the ambulatory surgical procedures performed in
2006 in the United States. The PS algorithm produced a matched
cohort of 3,741 surgical visits performed in ASCs and 3,741 visits
performed in HOPDs, balanced on baseline characteristics (Table).
The OR times were significantly shorter in ASCs than in HOPDs
(median [interquartile range, IQR] = 31 [21-45] vs. 39 [27-58] min,
respectively; P<0.0001). The operative times were also significantly
shorter in ASCs than in HOPDs (15 [10-25] vs. 20 [12-31] min,
respectively; P<0.0001). Similarly, times in recovery area and total
times in facility were shorter in ASCs than in HOPDs (41 [28-65]
vs. 55 [35-83] and 76 [55-115] vs. 100 [71-145] min, respectively;
P<0.0001 for both).
Discussion: In this propensity-matched national sample, our
study reveals that for the top-ten ambulatory surgery procedures
performed in the United States, ASCs are more efficient than
HOPDs in terms of use of operative and non-operative times.
Factors associated with differences in use of time between the two
type of facilities deserve further study.
References:
1.Joshi GP. Efficiency in ambulatory surgery center. Curr Opin
Anaesthesiol. 2008 Dec;21(6):695-8.
2.Pandit JJ, Westbury S, Pandit M. The concept of surgical
operating list �efficiency’: a formula to describe the term.
Anaesthesia 2007; 62:895-903.
Results: At 0-24 hrs, There was significant difference in severity
of nausea when group C was compared with MD4 and MD8
while no difference was found with groups MD1 and MD2 .On
intergroup comparison when MD4 group was compared with MD8
then again significant difference was found (p = 0.01). Significant
difference in incidence of vomiting when group C was compared
with either group MD2, MD4 and MD8. On intergroup comparison
no significant difference was found between MD2 & MD4 group
(p=0.44). However comparisons between MD2 & MD8; and MD4
& MD8 were significant statistically (p=0.00 in both).
Discussion: According to our study,the minimum effective
dose for prevention of post operative nausea and vomiting in high
risk patients undergoing laproscopic cholecystectomy is 4 mg
of dexamethasone in combination with midazolam. There is no
difference in the severity of postoperative pain. Further reduction
in incidence and severity of PONV can be achieved with a dose
of 8 mg. Use of recue antiemetic and analgesics is even reduced
considerably with this dose.
References:
1. Drugs ; 59;213-43, 2000.
2. Eur J Anaesthesiol ; 9(Suppl 6);25-31,1992.
Groups
(n=31)
Post Operative Nausea Severity (assessed by VAS of 0-10)
0-24 hrs
Mean В±SD
�p’
C
4.04В±4.8
MD1
2.97В±4.27
0.11
MD2
2.75В±4.08
0.05
MD4
1.29В±3.37
0.00*
MD8
0.29В±1.62
0.00*
*Signifies P≤0.05
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Bleeding / Blood Product
Conservation
ABSTRACTS
S-20
S-20.
EPIDEMIOLOGY AND RISKS OF TRANSFUSION AMONG
DIFFERENT AGE STRATA IN ICU PATIENTS
AUTHORS: S. Mudumbai1,2, R. Cronkite3, E. Bertaccini1,2,
B. Cason4,5, E. Mariano1,2, T. Wagner3
affiliation: 1Anesthesia Service, VA Palo Alto, Palo Alto, CA;
2
Anesthesiology, Stanford University, Palo Alto, CA; 3Center for
Health Care Excellence, VA Palo Alto, Palo Alto, CA; 4Anesthesia
Service, VA San Francisco, San Francsico, CA; 5Anesthesiology,
University of California-San Francisco, San Francsico, CA
Introduction: While advanced age is associated with
increased mortality in intensive care unit (ICU) patients1, all
elderly ICU patients may not have a poor prognosis. Because ICUs
continue to exhibit intense utilization of packed red blood cell
(PRBC) transfusions among the elderly2, this project characterizes
for different age strata of ICU patients a) rates of transfusion and
volumes of transfusion and b) the differential risk for transfusion at
various levels of hematocrit.
Methods: We retrospectively examined data on 2,393 ICU
patients from year 2003-2009. After stratifying age, measured in
years, into intervals starting with 21 <= Age <= 50, 51 <= Age <=
60, 61 <= Age <= 70, 71 <= Age <= 80 and Age > 80,we examined
whether transfusion rates differed by age group using a multivariate
logistic regression predicting receipt of transfusion, including the
age strata as our main predictor variable with hematocrit strata,
type of admission, and Charlson co-morbidity indices as control
variables. We then calculated a series of full Cox proportional
hazard regression models to determine the adjusted hazard ratio for
1-year mortality associated with a receipt of a transfusion for each
age strata.All reported p-values are two-sided and a p-value less
than .05 is considered to be statistically significant. SAS software,
version 9.2 (SAS Institute Inc, Cary, NC) was used for the statistical
analyses.
Results: Table 1 provides a description of patient treatment
characteristics. The reference group, age>80, was transfused at
higher levels even after controlling for hematocrit levels across
almost all other age strata.The age>80 group was transfused at about
twice the rate of the 3 lowest age groups(21-50, 51-60, and 61-70).
The crude survival rates for each age group showed an increased
mortality associated with transfusions (Table 2). After adjustment,
transfusions were associated with increased mortality for all age
groups except age 21-50. However, our Cox regression interaction
model indicated that transfusions were not more or less strongly
associated with 1 year mortality for the age>80 group versus any
other age group.
Discussion: In this single-institution retrospective study,we
found that even though receiving a transfusion may confer no
greater risk on an individual basis for patients age >80, the fact that
transfusions do confer a mortality risk and that patients age>80 are
transfused in greater numbers means that this population of older
patients may still be at greater risk.
References:
1.Wood KA, Ely EW: What does it mean to be critically ill and
elderly? Curr Opin Crit Care 2003, 9:316-320
2.Corwin HL: Transfusion practice in the critically ill: can we do
better? Crit Care Med 2005; 33: 232-3
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Cardiothoracic & Vascular
Basic Science
ABSTRACTS
S-26
S-26.
HEMOGLOBIN THRESHOLDS FOR TISSUE HYPOXIA IN
ANEMIC MICE
AUTHORS: G. Hare1, K. Lee1, A. K. Tsui1, D. Mazer1,
M. Henkelman3, P. A. Marsden2
affiliation: 1Anesthesia, University of Toronto, Toronto, ON,
Canada; 2Medicine, University of Toronto, Toronto, ON, Canada;
3
Medical Biophysics, University of Toronto, Toronto, ON, Canada
Introduction: Despite the common prevalence of anemia
(~40-50% of acute care patients), treatment of anemia does not
necessarily improve survival. Therefore, a clear understanding of
the cellular and molecular response to anemia is required. Severe
anemia affects tissue hypoxia (PO2) and hypoxia inducible factor-О±
(HIF-О±) signaling1. The current study is directed at understanding
how mild or moderate anemia affects hypoxia signaling in specific
tissues within a whole animal model. We hypothesize that tissue
hypoxia occurs at different Hb thresholds throughout the body.
Methods: After obtaining institutional Animal Care Committee
approval, spontaneously breathing anesthetized HIF (ODD)luciferase mice (21% Oxygen, 2% isoflurane), were made
anemic to different Hb thresholds (90,70, 50 g/L) by stepwise
hemodilution and fluid resuscitation (pentastarch) via the tail vein
and artery. Arterial blood gases (ABG) and Hb levels (co-oximetry,
Radiometer) were measured. Realtime bioluminescent imaging was
performed, in vivo, in anesthetized mice at baseline and at 6hrs
following hemodilution. Organ specific tissue luciferase activities
were measured in vitro, at 6 hrs, relative to total protein levels in
extracted tissues (brain, liver, kidney). Plasma erythropoietin levels
were measured by ELISA. Data are presented as (mean В± SD).
Results: Target Hb thresholds near of 90 В± 2, 71 В±1 and 52 В±
1 were reached. Real-time whole body luciferase increased in a
stepwise manner to a maximum level at a Hb concentration near
50g/L in vivo (p<0.05). At the end of 6hrs, organs were extracted
for assessment of luciferase activity in vitro. The Hb threshold for
increased HIF-luciferase activity was initially reduced by ~50% at
Hb 90g/L (p<0.05), returned to baseline at Hb 70g/L and increased
by ~ 50% at Hb 50g/L (p<0.05). By contrast, kidney and liver HIF
luciferase levels remained stable until increasing at Hb thresholds
below values of 70 and 90 g/L, respectively (p,0.05 for both). The
Hb threshold for increased systemic erythropoietin (EPO) levels
was near 100 g/L.
Discussion: HIF-О± stabilization occurs at a higher Hb
threshold in the liver, and kidney relative to the brain, suggesting
that hierarchical preservation of tissue oxygen delivery during
anemia. Increased systemic EPO levels may remain a sensitive and
clinically applicable measure of anemia-induced tissue hypoxia.
This knowledge may help define the mechanism of anemia induced
organ injury and help to develop novel treatment strategies to reduce
morbidity and mortality in anemic patients. (IARS-SCA, CIHR,
HSF support)
References:
1. Proc.Natl.Acad.Sci.U.S.A. 2011; 108: 17544-9
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-27
S-27.
ISOFLURANE PROTECTS THE MURINE HEART
AGAINST ISCHEMIC INJURY VIA THE PRESERVATION
OF MITOCHONDRIAL RESPIRATION AND ITS
SUPRAMOLECULAR ORGANIZATION
AUTHORS: C. Lotz1,2, J. Zhang2, C. Fang2, P. Ping2, T. Smul1
affiliation: 1Anesthesiology, University of Wuerzburg,
Wuerzburg, Germany; 2Physiology, University of California at Los
Angeles, Los Angeles, CA
Introduction: The administration of isoflurane has been
demonstrated to elicit a protective cardiac phenotype, effectively
limiting ischemic injury1. Isoflurane is hypothesized to act on major
signaling pathways and recent evidence suggests its protective
effects are mainly executed at the level of the mitochondrion2.
We investigated the hypothesis that isoflurane mediates a
cardioprotective phenotype by preserving the in-vivo functionality
of the mitochondrial respiratory chain.
Methods: The current study was approved by the respective IRB
for animal research. Mice (9-12 wks of age, n=6 in all groups) received
isoflurane (1.0 MAC for 30 min) 36 h prior to a 30 min coronary
artery occlusion followed by 24 h of reperfusion. TTC-staining was
used to determine the myocardial infarct size. Cardiac mitochondria
were isolated after the sole administration of isoflurane with or
without 4 hrs of reperfusion or at the corresponding time-points,
respectively. Mitochondrial Ca2+-induced swelling, mitochondrial
lipid peroxidation, as well as mitochondrial respiratory chain
complex activities (I-V) were investigated. In addition, Blue NativePAGE electrophoresis followed by in-gel activity measurements
was used to monitor mitochondrial supercomplex functionality. LCMS/MS was utilized for protein identification purposes.
Results: Our data showed that isoflurane elicited a protective
cardiac phenotype after 36h, evidenced by a reduced myocardial
infarct size (p<0.05). The protective effects of the volatile anesthetic
simultaneously preserved respiratory complex III (p<0.05) activity,
as well as amended the activity of supramolecular complex
assemblies constituted by complex I-III-IV (p<0.05). The functional
benefits further were accompanied by a diminished mitochondrial
lipid peroxidation pinpointing towards reduced oxidative stress. A
decreased mitochondrial susceptibility to Ca2+-induced swelling
(p<0.05) in the isoflurane treated groups indicated circumvention of
mitochondrial permeability transition (mPT) .
Discussion: Taken together, our findings support the concept
that isoflurane protects the heart against ischemic injury in-vivo by
maintaining mitochondrial respiratory complex and supercomplex
functionality, preventing the development of an increased oxidative
stress burden and subsequent mPT.
References:
1.Raphael J. Physiology and pharmacology of myocardial preconВ­
ditioning. Semin Cardiothorac Vasc Anesth;14:54-9.
2.Muravchick S, Levy RJ. Clinical implications of mitochondrial
dysfunction. Anesthesiology 2006;105:819-37.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-28
S-29
S-28.
S-29.
HIGH DOSE BETA-BLOCKADE ACCENTUATED
CEREBRAL HYPOXIA IN ANEMIC RATS
WITHDRAWN.
AUTHORS: G. Hare1, T. Hu1, S. Beattie1, H. Leong_Poi2, D. F.
Wilson3, D. Mazer1
affiliation: 1Anesthesia, University of Toronto, Toronto, ON,
Canada; 2Medicine, University of Toronto, Toronto, ON, Canada;
3
Biochemistry and Biophysics, University of Pennsylvania,
Philadelphia, PA
Introduction: ОІ-blockade reduces the incidence of
perioperative myocardial infarction at the expense of impaired
brain perfusion. Anemia may accentuate cerebral hypoxia and
brain injury in beta blocked patients. Metoprolol impairs cerebral
perfusion during anemia by limiting the cardiac output (ОІ1-effect)
and impairing ОІ2 mediated vasodilation in isolated resistance
arteries1,2. We hypothesized that treatment with a highly ОІ1-selective
antagonist (nebivolol) will impair cerebral perfusion during
hemodilution in a dose dependent manner.
Methods: After obtaining institutional Animal Care Committee
approval, anesthetised rats were randomized to receive vehicle
(control) or nebivolol (1.25 or 2.5 mg/kg intravenously). Heart rate
(HR), cardiac output (CO, echocardiography), normalized cerebral
blood flow (nCBF, laser Doppler), and brain microvascular PO2
(G2 oxyphor) were measured before and after hemodilution to a
target hemoglobin concentration of 60 g/L. Brain hypoxia inducible
factor-О± (HIF-О±) levels were determined by Western blot. CO, and
cerebral PO2 data were collected in a blinded fashion. Data (mean В±
SD) are assessed by two-way ANOVA.
Results: A comparable hemoglobin nadir was achieved in all
groups (~60 g/L). HR decreased comparably from baseline (~300)
to ~250 bpm in both treated groups (p<0.05 for both). The CO
increased from control values (122 В± 9.5 mL) after hemodilution
(205 В± 41 mL/min, n=5, p<0.05). This effect was attenuated by both
nebivolol doses (161 В± 24 and 151 В± 13 mL/min, n=5, p<0.05). The
increase in nCBF observed after hemodilution was similar in control
and low dose nebivolol groups (90 В± 49 and 80 В± 53%, p<0.05 for
both), but attenuated in the high dose group (9 В± 12 %, p<0.05 vs.
low dose nebivolol). Similarly, brain microvascular PO2 values
were decreased to a greater degree after hemodilution with high
dose nebivolol (28.4 В± 9.6 mmHg, n=11, p<0.05), relative to both
control and low dose nebivolol groups (45.8 В± 18.7, n=5 and 36.0
В± 4.9, n=10). Increased cerebral cortical HIF-1О± levels were seen in
hemodiluted rats treated with 2.5 mg/kg of nebivolol compared to
control and low dose nebivolol groups.
Discussion: Both nebivolol doses impaired the cardiac output
response to hemodilution (ОІ1-effect). However, only the higher dose
of nebivolol attenuated cerebral perfusion and accentuated cerebral
tissue hypoxia during acute anemia. We conclude that lower dose
treatment with a highly selective ОІ1-antagonist may provide cardiac
protection with reduced risk of cerebral ischemia (Forest Research
Laboratories, IMS and IARS-SCA support).
References:
1. Anesthesiology 2009; 111:988-1000.
2. J Appl Physiol 2011; 111: 1125-1133.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-30
S-31
ANESTH ANALG
2012; 114; S-01 – S-493
S-30.
S-31.
EXERCISE AND A BREAKER OF ADVANCED GLYCATION
END PRODUCTS ATTENUATE AGE RELATED
VASCULAR STIFFNESS AND DECREASE TISSUE
TRANSGLUTAMINASE ACTIVITY AND CROSSLINKING
SYSTEMIC PERFUSION PRESSURE AND THE CLOSING
PRESSURE OF THE MICROCIRCULATION: THE
IMPORTANCE OF 30MM HG
AUTHORS: J. Steppan1, G. Sikka1, L. Santhanam1, D. Nyhan1,
D. E. Berkowitz1,2
affiliation: 1Anesthesia, Brisbane Waters Private Hospital,
Woy Woy, NSW, Australia; 2Australian School of Advanced
Medicine, Macquarie University, Sydney, NSW, Australia
affiliation: 1Anesthesiology & Critical Care Medicine, Johns
Hopkins University, Baltimore, MD; 2Biomedical Engineering,
Johns Hopkins University, Baltimore, MD
Introduction: Cardiovascular disease is the leading cause of
morbidity and mortality at an advanced age. Pathologically, aging is
associated with increased vascular stiffness, which can by measured
by pulse wave velocity (PWV) - an important an index of vascular
aging. Although both dynamic, and structural changes have been
described in aging, the underlying molecular mechanisms remain
poorly understood. Tissue transglutaminase (TG2), which forms
crosslinks between extracellular matrix proteins, may contribute to
this pathobiology. Another mechanism is the formation of advanced
glycation end product (AGE) resulting in irreversible non-enzymatic
glycosylation of proteins. We hypothesized that aging associated
changes in vascular stiffness as measured by PWV can be attenuated
by exercise and breakdown of AGE.
Methods: We determined age-dependent changes in vascular
stiffness in male Fisher rats by measuring PWV using a dual blood
pressure catheter in vivo over a wide range of blood pressures (BPs).
The animals were stratified into three groups: young, middle aged,
old. We determined the changes in vascular stiffness following
either exercise alone (4 weeks) or exercise plus ALT injection (AGE
breaker) in old animals. Furthermore we measured TG2 activity and
crosslinking.
Results: Aging lead to an incremental increase in PWV that is
more pronounced at higher BPs. According to PWV animals were
categorized into three groups: young (3-4 month), middle aged (5-9
month) and old (above 9 month of age). Baseline BPs were identical,
but PWV was significantly different at baseline and at higher BPs.
Exercise alone failed to attenuate the increased PWV in old animals,
but significantly decreased TG2 activity and crosslinking. The
combination of an AGE-breaker and exercise significantly reduced
PWV and vascular stiffness.
Discussion: We demonstrate that PWV is lowest in young
animals and then gradually increases as the vasculature stiffens.
Interestingly, PWV in the different age groups converges at
lower BPs suggesting that at lower pressure passive properties
are less important. At higher BPs, the curves diverge suggesting
that, collagen becomes the major passive contributor, leading to
stiffer vessels. A short period of exercise at an advanced age fails
to attenuate vascular stiffness, despite decreased TG2 activity
and increased TG2 crosslinking, suggesting that once vascular
remodeling has occurred exercise alone is insufficient to reverse this
process. The additional treatment with an AGE-breaker, however,
reduces vascular stiffness even in old animals. This novel finding
has potential therapeutic implications for the aging population and
further studies extending these results seem to be warranted.
AUTHOR: S. F. Woodford1,2
Introduction: Perfusion of the microcirculation requires a
minimum pressure of 30 mm Hg, the so called �closing pressure’. The
critical closing pressure has been understood primarily in relation
to dermal capillary patency, but examination of hemodynamic data
suggests that a systemic pressure gradient (MAP-CVP) of 30 mm.
Hg is a universal value below which all flow ceases in the human
adult circulation.
Methods: Continuous hemodynamic monitoring using Flotrac
in association with arterial and central venous lines was routinely
implemented over 36 months in patients presenting for elective
and urgent major surgery, and in the ICU. Hemodynamic data
was recorded at intervals between 30 minutes and 12 seconds.
Graphical analysis of hemodynamic data was performed on 419
patients over 36 months, and the clinical state of the patient was
correlated with hemodynamic variables. Hemodynamic data was
analysed in the context of proven diagnosis and clinical setting,
and included patients with anaphylaxis/cardiac arrest, lifethreatening hemorrhage, overwhelming sepsis, cardiac tamponade,
cardiopulmonary bypass,syncope and drug reactions.
Results: Ohm’s Law of the circulation (MAP-CVP=CO*SVR)
relates 3 variables, of which 2 can be measured and the third
calculated. Graphically, the relationship can be plotted in 3
configurations. If a stream of data is continuously plotted, the
patterns of response to any insult or intervention can be analysed.
Ohm’s Law can be simplified to the equation MAP-CVP=SV*SE,
where SE(systemic elastance) = MAP-CVP/SV . The systemic
perfusion pressure is the product of SV(ml/beat) and systemic
elastance (mm Hg/L). The systemic perfusion pressure never fell
below a gradient of 30 mm Hg., but a fall in systemic perfusion
pressure to 30 mm Hg was common during bypass, exsanguinating
hemorrhage preceding cardiac arrest, anaphylaxis accompanied
by cardiac arrest, fatal sepsis,syncope and induction of anesthesia.
Prior to circulatory arrest, the systemic perfusion pressure reached a
minimum at or near 30 mm Hg in every case.
Discussion: The closing pressure of the microcirculation
corresponds clinically to a systemic perfusion gradient of 30 mm
Hg. If the pressure gradient across the systemic microcirculation
falls below the capillary closing pressure, all systemic flow ceases.
References:
Bryant,R. Nix,D “Mechanical Forces: Pres­sure,shear and friction”
in Acute and Chronic Wounds: Current Management Concepts.
Third Ed: Mosby,2007, pp 205-34
Burton AC, Yamada S. Relation between blood pressure and flow in
the human forearm. J Appl. Physiol 1951; 4(5), 329-39
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-32
S-32.
GUYTON AND THE SYSTEMIC VASCULAR RESISTANCE:
THE PROBLEM OF APPLYING DC CONCEPTS TO A
PULSATILE SYSTEM
AUTHOR: S. F. Woodford1,2
affiliation: 1Anesthesia, Brisbane Waters Private Hospital,
Woy Woy, NSW, Australia; 2Australian School of Advanced
Medicine, Macquarie University, Sydney, NSW, Australia
Introduction: It has long been recognised that Ohms Law
describes a DC circuit, but the human circulation is pulsatile, and
continuous flow is only approximated in cardiopulmonary bypass
and with the artificial heart. Despite the conceptual problem
surrounding Ohm’s Law ( MAP-CVP = CO*SVR) it remains the
basis of our understanding of afterload and the treatment of heart
failure. Deconstructing the basis for variation in cardiac output
suggests that Ohm’s Law contains a systematic error.
Methods: Over 36 months, the regulation of pressure and flow
(CO) in the adult systemic circulation were analysed using data
derived from Flotrac (Edwards Lifesciences) in 370 subjects at
intervals varying from 12 seconds to 1 hour. Because the equations
for flow (CO=SV*HR) and pressure (P=CO*SVR) relate three
variables, it is possible to plot flow and pressure in a X-Y plot, and
solve for the 3rd variable (the �Z’ variable) in the graph. There are
thus 3 possible ways of representing the three variables describing
flow and pressure. Data was graphed and time dependent changes
were correlated with fluid and drug administration, arrhythmias,
haemorrhage, anaphylaxis, syncope and sepsis.
Results: A change in cardiac output may reflect a change in SV
at constant HR, a change in HR at constant SV, or changes in both;
the systemic perfusion pressure will remain constant if SV remains
unchanged at a varying heart rate, or if heart rate remains constant
and SV changes with a reciprocal change in vascular resistance.
But if SV remains constant and heart rate increases, CO will rise
and SVR decrease. Graphically, it is clear that SVR may change
with heart rate alone, without any change in SV, so the hydraulic
relationship implied in the equation is in error. This is corrected
by simplifying Ohm’s Law to the relationship MAP-CVP = SV x
Elastance, where Elastance = MAP-CVP/SV, and therefore SVR =
E/HR. Using dynes sec/cm5, this yields the relationship SVR = E
(80/HR). When HR is 160, the SVR and SVR range is halved, and
at HR 40, the SVR and SVR range are doubled.
Discussion: Ohms Law (P=CO*SVR) has led to a preoccupation
with cardiac output, but unless cardiac output is constantly corrected
for HR variation, the relationship between cardiac performance and
the vasculature is in error. The relationship described by Ohms
Law is only applicable when flow is constant (bypass, artificial
heart). Failure to apply a heart rate correction implies that much
hemodynamic literature contains a systematic error. The correct
equation is MAP-CVP = SV*Elastance where Elastance = MAPCVP/SV.
References: Guyton AC. Determination of cardiac output by
equating venous return curves with cardiac response curves. Physiol
Rev 1955; 35:123-129
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-33
S-33.
SPINAL ANESTHESIA AND CENTRAL HEMODYNAMICS:
RE-ANALYSIS OF PILOT STUDY DATA
AUTHOR: R. Eng1, G. Dobson1,2
affiliation: 1Anesthesia, University of Calgary, Calgary, AB,
Canada; 2Surgery, University of Calgary, Calgary, AB, Canada
Introduction: The role of central hemodynamics on
cardiovascular outcomes is becoming increasingly apparent and
has resulted in the development of new approaches to pressure
waveform analysis. These approaches were applied to data acquired
from a pilot study of patients undergoing spinal anesthesia for
transurethral prostate resection.
Methods: The study was approved by the Conjoint Health
Research Ethics Board of our University and all subjects provided
informed consent. Six men with no history of cardiopulmonary
disease, and not consuming any medications, were enrolled. All
subjects were monitored with continuous electrocardiogram and an
intermittent non-invasive blood pressure device. Carotid and femoral
blood pressure waveforms were recorded simultaneously using
arterial tonometers. The patients were sedated using standardized
doses of intravenous fentanyl and midazolam. Following a fluid
bolus of 15 mL/kg of normal saline, a standardized spinal anesthestic
(isobaric Bupivacaine 15 mg) was given. Twenty minutes later,
the height of the block was determined using an icepack, and the
tonometric measurements were repeated.
ANESTH ANALG
2012; 114; S-01 – S-493
Results: Mean age of subjects was 63+5 years. Baseline
mean blood pressure was unchanged between control and postspinal measurements (98+20mmHg vs. 96.5+13mmHg, p=0.7).
The reflection coefficient (О“) of the lower extremities decreased
(0.55+0.17 to 0.22+0.07, p=0.006), whereas none of the time
domain indices of the carotid pressure wave reflection changed
significantly. The effective site of reflection (ESR) changed from
44+8 cm to 36+9 cm, but this did not reach statistical significance
(p=0.11). Using changes to О“ (О”О“) and ESR (О”ESR) as the
independent variables, changes to augmentation index (О”AIx) were
modelled using multilinear regression (figure 1), О”AIx = 23+63.4 *
О”О“ + 0.96* О”ESR, R2=0.87, p <0.05.
Discussion: This pilot study demonstrates that spinal anesthesia
results in a decrease in the О“ from the lower extremities without
the expected reduction in carotid artery AI. Statistical modelling
suggests that there are two opposing factors in play, with vasodilation
of lower extremities being offset with more central vasoconstriction.
References:
1.Avolio AP. Multi-branched model of the human arterial system.
Med Biol Eng Comput. 1980; 18:709-18.
2.Mitchell GF, Wang N, Palmisano JN, Larson MG, Hamburg
NM, Vita JA, et al. Hemodynamic correlates of blood pressure
across the adult age spectrum: noninvasive evaluation in the
Framingham Heart Study. Circulation. 2010; 122:1379-86.
3.Wilkinson IB, Mohammad NH, Tyrrell S, Hall IR, Webb DJ, Paul
VE, et al. Heart rate dependency of pulse pressure amplification
and arterial stiffness. Am J Hypertens. 2002; 15:24-30.
Figure 1
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ABSTRACTS
S-34
S-34.
NEUROTRANSMITTER NPY3-36 CAN INDUCE
ANGIOGENESIS IN A HIGH CHOLESTEROL PIG MODEL
OF CHRONIC MYOCARDIAL ISCHEMIA
AUTHORS: A. Wang1, F. Mahmood1,2, K. Khabbaz1,2, P. Hess1,2,
F. W. Sellke1,2, R. Matyal1,2
affiliation: 1Anesthesia, Beth Israel Deaconess Medical
Center, Boston, MA; 2Harvard Medical School, Boston, MA
Introduction: Neuropeptide Y (NPY3-36) has potential to
cause angiogenesis. The purpose of the study is to evaluate effects
of NPY on myocardial angiogenesis in a high cholesterol swine
model with chronic myocardial ischemia.
Methods: After Institutional Review Board approval, male
Yorkshire pigs were divided into three groups (n=6 in each group).
The first group was fed a normal diet, the other two groups were fed
with high cholesterol diet, one with placebo infiltration and the other
with neurotransmitter infiltration. After 6 weeks, the animals were
anesthetized and underwent a mini-thoracotomy and an ameroid
constrictor was placed around the proximal left circumflex artery
to cause chronic ischemia. Three weeks after ameroid placement,
an angiography was preformed and microspheres were injected into
the left atrium to determine myocardial perfusion. An osmotic pump
with NPY3-36/placebo was placed for delivery at a constant rate
in the ischemic area. Five weeks after the pump placement, final
surgery was performed with coronary angiography, microspheres
injection and myocardial function assessment. Tissue was harvested
for bench analysis.
ANESTH ANALG
2012; 114; S-01 – S-493
Results: Comparisons between the groups was done using two
tailed t-test and with Newman-Keuls Multiple Comparison post-hoc
test. Probability values less than 0.05 were considered significant.
There was significant upregulation of flow in the ischemic territory
in pigs treated with NPY at rest and at paced rhythm as compared
to high cholesterol placebo group (p=<0.001 at rest and 0.03 at
paced rhythm). There was significant increase in blood vessels in
the ischemic area treated with NPY as compared to placebo group
(p=0.05). Immunoblotting showed a significant downregulation of
two angiogenesis inhibitors angiostatin (p = 0.05) and endostatin (p
= 0.004) in the NPY3-36 treated pigs.
Discussion: We have demonstrated that NPY3-36 can cause
increase in blood flow, through increased vessels formation and
inhibition of anti-angiogenic factors in the ischemic myocardium.
This is advantageous because there are 37% of patients cannot
receive any intervention because of the diffuse or severe nature of
the cardiovascular disease. This is especially significant in patients
with diabetes mellitus and hypercholesterolemia, where the process
of angiogenesis is impaired.
References:
Robich MP, Matyal R, Chu LM, et al. Effects of neuropeptide Y
on collateral development in a swine model of chronic myocardial
ischemia. J Mol Cell Cardiol 2010;49:1022-30.
Zukowska-Grojec Z, Karwatowska-Prokopczuk E, Rose W, et al.
Neuropeptide Y: a novel angiogenic factor from the sympathetic
nerves and endothelium. Circ Res 1998;83:187-95.
Blood flow in pigs with normal diet (control) compared to those with a
high cholesterol diet and placebo infiltration (HCC), and those with a high
cholesterol diet and neurotransmitter infiltration (HC NPY)
Immunoblot data showing the expression of angiostatin and endostatin
Immunohistochemistry images of the ischemic area of the pigs fed
with a high cholesterol diet. A: Exposed to placebo B: Treated with
NPY3-36
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-35
S-35.
INHIBITION OF DESFLURANE-INDUCED
POSTCONDITIONING IN A MURINE MODEL OF LONG
TERM BETA-ADRENERGIC RECEPTOR BLOCKADE
AUTHORS: T. Tischer-Zeitz1, J. Stumpner1, C. Lotz1, M. Lange1,2,
N. Roewer1, T. Smul1
affiliation: 1Department of Anaesthesia and Critical Care,
University of WГјrzburg, WГјrzburg, Germany; 2Department of
Anaesthesia and Critical Care, Mathias-Spital, Rheine, Germany
Introduction: Beta blockers are an important element of
the therapy of patients at increased cardiovascular risk1. However,
beta-1 adrenergic receptor (ADRB1) activation represents a pivotal
signalling event of anesthetic-induced postconditioning (APOST)2.
The influence of long term blockade of the ADBR1 (LTBB) on
APOST is yet unknown. We tested the hypothesis that LTBB
induces distinct changes within the receptor signalling profile and
thus inhibits APOST.
Methods: After institutional approval by the local IRB, the
ADRB1 antagonist metoprolol (Meto, 10mg/kg/d) or 0.9% NaCl
were subcutaneously administered in male BL6 mice via osmotic
pumps for a minimum of 21 days. Blood pressure and heart rate
(HR) were noninvasively monitored. Sufficient ADRB1 blockade
was defined as a continuous HR reduction of 9% or more compared
to basic value. Subsequently all animals were subjected to a 45 min
coronary artery occlusion (CAO) followed by 3 h of reperfusion. In
the respective group 1.0 MAC desflurane (Des) was administered
starting 3 min prior to the end of CAO. Myocardial infarct size (IS)
was determined by gravitoplanimetry and expressed as a percentage
of the area at risk (AAR). Changes in the expression of ADRB1,
arrestin beta 1 (Arrb1) and the alpha subunit of the Gs protein
(Gnas) were determined by RT-PCR and western immunoblotting.
Data are meanВ±SEM.
Results: Meto (n=30) significantly reduced the HR compared
to NaCl (n=21, *p<0.05) and pre-implantation measurements
(#p<0.0056) (Fig. 1, Day 0 = Day of implantation). LTBB concomВ­
itantly elicited an increase of ADRB1 mRNA (*p<0.05) whereas
ADRB1 protein concentration didn’t alter (Fig. 2). Des-induced
postconditioning caused a significant reduction of IS (32В±2%, n=7;
*p<0.05) compared to control group (CON, 48В±2, n=8). Long term
application of Meto did not affect IS (41В±3%, n=6) but inhibited
cardioprotection by Des-induced postconditioning (43В±3%, n=6)
(Fig. 3). Meto caused an increase of ADRB1, Arrb1 and Gnas
mRNA after ischemia/reperfusion that was abolished by Des.
Discussion: In the introduced murine model of controlled
LTBB Meto as well as its combination with APOST altered
ADRB1 dependent signal transduction. In this clinically relevant
constellation cardioprotection by Des-induced postconditioning was
abolished by LTBB.
References:
1.Smith SC Jr et al., Circulation 2011; 124: 2458-73.
2. Lange M et al., Anesthesiology 2009; 110: 516-28.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-36
S-36.
THE KAPPA OPIOID RECEPTOR ANTAGONIST
NOR-BINALTHORPHIMINE IMPROVES
MYOCARDIAL PERFUSION IN PIGS UNDERGOING
CARDIOPULMONARY BYPASS
AUTHORS: M. M. Theisen1,2, J. Blumenstiel1, T. P. Weber6,
H. Nagase4, J. Stypmann5, F. Ploner3
affiliation: 1Department of Anesthesiology and Intensive Care,
MГјnster University Hospital, Muenster, Germany; 2Department
of Anaesthesia and Intensive Care, Raphaelsklinik MГјnster,
Muenster, Germany; 3Department of Anesthesiology and Critical
Care Medicine, Vipiteno Hospital, Vipiteno, Italy; 4Laboratory
of Medical Chemistry, School of Pharmacy, Kitasato University,
Tokyo, Japan; 5Department of Cardiology and Angiology, MГјnster
University Hospital, MГјnster, Germany; 6Department of Anesthesia
and Intensive Care, St. Joseph Hospital Ruhr University Bochum,
Bochum, Germany
Introduction: Previous studies have demonstrated a signifiВ­
cant reduction in myocardial stunning and improved splanchnic
perfusion with the use of Оє-opioid receptor antagonists (Оє-ORA)1,2.
This study aims to further elucidate the effect of the Оє-ORA norBNI on myocardial perfusion both during and post cardiopulmonary
bypass (CPB) in pigs.
Methods: In this study 21 pigs (mean weight 35 kg) were
randomized and 24 hours prior to surgery received either nor-BNI
(3,7mg/kg) or Placebo (Plc) according to the previously established
methods used by3. The anaesthetized and intubated animals were
hemodynamically monitored using established invasive techniques.
Regional myocardial perfusion (MP) was determined using
fluorescent microspheres (FMS) infused via a fluid filled catheter,
placed in the left atrial appendage. Following induction of CPB
MAP
[mm Hg]
CO
[ml/min]
LAD
[mol/g/min]
RCX
[ml/g/min]
RCA
[ml/g/min
ANESTH ANALG
2012; 114; S-01 – S-493
and baseline measurements (compound) the pigs were exposed to
electrically induced VF and cardioplegia as well as hypothermia
(28В°C for 90 min, ischemia). Following re-establishment of normal
body temperature the animals were re-perfused for 30 minutes.
Time points used to measure MP post application of FMS were
compound, ischemia and experimental end. Mean arterial pressure
(MAP), central venous pressure and cardiac output (CO) were
maintained constant according to the established algorithms using
fluid resuscitation, norepinephrine (NE) and dobutamine (DBx).
Post mortem myocardial tissue samples were obtained from the
LAD, RCX and RCA and analyzed for retained FMS content.
Results: There was no significant difference in CO between
the two groups. The MAP was comparable in both groups during
ischemia measurement and as expected was increased at baseline
and the experimental end, although the required amount of NE
remained less compared to placebo4. Detailed data is shown in the
table.
Discussion: This study demonstrates that nor-BNI significantly
improves MP in pigs undergoing CPB. We propose that norBNI could potentially be therapeutically beneficial in patients
that are difficult to wean off CPB. Furthermore, the incidence of
cardiogenic shock and late onset ischemic complications following
cardiothoracic surgery involving CPB may be significantly reduced.
References:
1. Grosse Hartlage, Anesth Analg 2006; 103:822-32.
2. Grosse Hartlage, Anesthesiology 2003; 99:A645.
3.Endoh et al. Arch Int Pharmacodyn Ther. 1992 MarApr;316:30-42
4. Rao, Peptides. 2003; 24:745-54.
Compound
Placebo
Ischemia
End
Compound
nor-BNI
Ischemia
End
70 (64; 80)
68 (65; 88)
64 (55; 74)
98 (88; 116)#
65 (59; 69)
76 (71; 86) #
2311 (2093; 2704)
33 (15; 99)
2662 (2093; 2948)
1792 (1560; 2861)
121 ( 23; 221)
2308 (1686; 2430)
0,261 (0,206; 0,375)
0,014 (0,008; 0,036)
0,620 (0,366; 0,803)
0,544 (0,434; 0,950) #
0,014 (0,010; 0,023)
0,863 (0,683; 1,148) #
0,230 (0,173; 0,358)
0,015 (0,009; 0,046)
0,539 (0,377; 0,725)
0,533 (0,407; 0,986) # 0,035 (0,024; 0,054) # 0,818 (0,691; 1,024) #
0,252 (0,196; 0,310)
0,018 (0,011; 0,031)
0,584 (0,480; 0,833)
0,380 (0,279; 0,716) # 0,042 (0,025; 0,062) #
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
0,703 (0,462; 1,051)
ABSTRACTS
S-37
S-37.
OPIOID RECEPTOR ANTAGONISTS AFFECT THE
SUCCESS OF DEFIBRILLATION OF VENTRICULAR
FIBRILLATION (VF) IN PIGS UNDERGOING
CARDIOPULMONARY BYPASS (CPB)
AUTHORS: M. M. Theisen1,2, J. Stypmann3, H. Nagase4, T. P.
Weber5,1, T. Iden6, K. Kaerlein1
affiliation: 1Department of Anesthesiology and Intensive
Care, MГјnster University Hospital, MГјnster, Germany; 2Department
of Anaesthesia and Intensive Care, Raphaelsklinik MГјnster,
MГјnster, Germany; 3Department of Cardiology and Angiology,
MГјnster University Hospital MГјnster, Muenster, Germany;
4
Laboratory of Medical Chemistry, School of Pharmacy, Kitasato
University, Tokyo, Tokyo, Japan; 5Department of Anesthesia and
Intensive Care, St. Joseph Hospital Ruhr University Bochum,
Bochum, Germany; 6Department of Anesthesiology and Intensive
Care, Schleswig-Holstein University Hospital, Campus Kiel, Kiel,
Germany
Introduction: Previous studies demonstrated that Оє-opioid
receptor agonists show cardioprotective and anti-arrhythmic
effects1,2. Therefore we investigated the effect of four different
opioid receptor antagonists (ORA), the Оє-ORA nor-binaltorphimine
(nor-BNI), the Оґ-ORA nantrindole (NTI), the Вµ/Оє/Оґ-ORA naltrexone
(NTX, acting both peripheral and central) and the solely peripheral
acting Вµ/Оє/Оґ-ORA naltrexone methiodide (NTX-M, not able to cross
the blood-brain barrier) on the success of defibrillation of VF in pigs
which had been exposed to CPB.
Methods: Ethics approval was obtained from the
Bezirksregierung Muenster. 51 pigs (mean weight 35 kg) were
randomized and anaesthetised. Animals were monitored using
established invasive techniques and were infused with either NTX
(2,0mg/kg), NTX-M (2,56mg/kg), NTI (4,0mg/kg) or Placebo.
cumulative amount of
energy [j]
ANESTH ANALG
2012; 114; S-01 – S-493
Nor-BNI was infused at a rate of 3,7mg/kg, 24h prior to begin of
experiments as established by3. Following induction of CPB pigs
were exposed to VF, cardioplegia, cross-clamp of the aortic root as
well as hypothermia (28В°C, 90min). After normal body temperature
was obtained cross-clamping was opened and pigs were re-perfused
for 30min. Consecutive VF was defibrillated according to a
standardized protocol derived from ERC Guidelines. We measured
the cumulative amount of energy required (measured in joules) to
achieve a return of spontaneous circulation (ROSC).
Results: Pigs treated with NTX-M required significantly more
energy to achieve a ROSC (See table).
Discussion: There was no difference in the energy required
from placebo in the group of animals treated with NTX. Hence,
blockade of peripheral opiate receptors (OR) appears to have a
negative effect on the success of defibrillation. This effect can
be reversed when the centrally acting OR are blocked. The effect
caused by peripheral action is most likely mediated by Оґ-OR, as
animals treated with central and peripherally acting NTI required
substantially more energy to achieve a ROSC. While pigs treated
with nor-BNI required less energy to achieve a ROSC (p=0.052),
this result seems to indicate strongly that a centrally mediated Оє-OR
effect exists and results in a decrease in defibrillation success, which
in turn can be antagonized by the centrally acting Оє-ORA nor-BNI.
Furthermore, these results indicate that Вµ-OR mediated effects exist
and may enhance defibrillation success, and in turn can be blocked
by the “general“ peripheral acting ORA NTX-M. How this relates to
the postulated cardioprotective and anti-arrhythmic properties needs
to be further investigated.
References:
1.Chun, Korean J Anesthesiol. 2010;58:162-8.
2.Zhang, Crit Care Med. 2010;38:2365-76.
3. Endoh, Arch Int Pharmacodyn Ther. 1992;316:30-42.
NTX
NTX-M
NTI
nor-BNI
Placebo
125
(12,5; 212,5)
362,6
(112,5; 737,5)
87,5
(62,5; 212,5)
25
(12,5; 62,5)
62,5
(43,8; 150,0)
p = 0,777
p < 0,05
p = 0,62
p = 0,052
p compound vs placebo
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-38
S-39
ANESTH ANALG
2012; 114; S-01 – S-493
S-38.
S-39.
DIFFERENTIAL CARDIOPROTECTION BY
CHROMOSOMAL SUBSTITUTION IN A CONSOMIC RAT
MODEL: ROLE OF NITRIC OXIDE IN ANESTHETIC
PRECONDITIONING
ENDOGENOUS OPIOIDS IN WOUND-SITE NEUTROPHILS
OF STERNOTOMY PATIENTS
AUTHORS: D. Nabor1, Q. Cheng1, J. R. Kersten1,3, D. F. Stowe1,2,
J. Lazar4, M. L. Riess1,5
affiliation: 1Anesthesiology, The Ohio State University
Medical Center, Columbus, OH; 2Surgery, The Ohio State University
Medical Center, Columbus, OH
affiliation: 1Anesthesiology, Medical College of Wisconsin,
Milwaukee, WI; 2Physiology, Medical College of Wisconsin,
Milwaukee, WI; 3Pharmacology & Toxicology, Medical College
of Wisconsin, Milwaukee, WI; 4Dermatology, Medical College of
Wisconsin, Milwaukee, WI; 5Anesthesiology, VA Medical Center,
Milwaukee, WI
Introduction: Dahl Salt Sensitive (SS) rat hearts are more
susceptible to ischemia/reperfusion (IR) injury than Brown Norway
(BN) or consomic SS6BN hearts.1 Moreover, IR injury can be
attenuated by anesthetic (APC) and ischemic preconditioning (IPC)
in BN, but not in SS hearts.2,3 We hypothesized that cardioprotection
is similar between APC and IPC4 and due to genetic information
on BN chromosome 6 that mediates nitric oxide (NO) generation.
Methods: Isolated hearts from BN, SS and SS6BN rats were
preconditioned with two 5-min exposures to 2 MAC sevoflurane
before 30 min global ischemia and 2 h reperfusion; controls (Con)
were not preconditioned. In some hearts, NO synthase (NOS) was
inhibited during APC by L-NAME. We monitored LV pressure
and its derivatives before, during and after ischemia and measured
infarct size (IS).
Results: Functional return on reperfusion was lower, and IS
larger in SS than in BN or SS6BN Con hearts. APC additionally
improved LV function and reduced IS in BN, but not in SS or and
SS6BN hearts. L-NAME abolished both the APC-mediated protection
in BN and the endogenous protection in BN and SS6BN hearts.
Discussion: Endogenous cardioprotection in BN and SS6BN
vs SS rats depends on NO availability as does APC-mediated
protection in BN vs SS rats. In contrast to IPC, however, APC did
not protect consomic SS6BN hearts. These novel findings suggest
that NO availability is necessary, but not always sufficient, for
APC to protect cardiac function against IR injury. In addition to
NOS, possible candidate genes for the observed genome-dependent
differences in APC-mediated cardioprotection include upstream
regulators of NOS. Supported by the Society of Cardiovascular
Anesthesiologists and the Department of Veterans Affairs.
References:
1.Kwitek AE et al. Physiol Genomics 2006;25:303-13.
2. Nabbi R et al. 2010 ASA meeting;A903.
3. Nabbi R et al. Anesth Analg 2010;110(3):SCA12.
4. Stowe DF et al. FASEB J, 2012.
AUTHORS: DH. Elsayed-Awad1, M. Abaz1, T. Theofilos1, R. S.
Tripathi1, C. B. Sai-Sudhakar2, S. Roy2
Introduction: Postoperative pain management is especially
challenging in cardiac surgery due to the nature and extent of
the procedure. The inflammatory state of the post-sternotomy
surgical wound sensitizes nerve endings, causing the transmission
of pain signals with improperly managed pain having detrimental
effects on wound healing. Animal and human models support the
involvement of peripheral opioid receptors in analgesia, particularly
under inflammatory conditions where both opioid receptor
expression and efficacy are increased. Opioid peptides expressed in
leukocytes include ОІ-endorphin (END), met-enkephalin (ENK), and
dynorphin-A (DYN), with END being predominant.
Methods: In this work, we examined the micro-environment
of sternotomy wounds of patients undergoing coronary artery
bypass grafting (CABG) to study the role of inflammatory cells
in the production of opioid peptides. Eight patients 21-80 years
of age and equally distributed between genders participated in
this study. Protocols were approved by the Institutional Review
Board. Declaration of Helsinki protocols was followed and patients
gave their written, informed consent. Wound fluid and cells were
collected from sternal wounds using a Jackson-Pratt Blake drain at
24, 48, and 72 hours post sternum closure. Venous blood was also
collected at the same time-points as well as 0 hour (pre-operative).
Wound fluid and peripheral blood samples were transported on ice
for immediate laboratory analysis after collection.
Results: Using anti-CD15 staining and flow cytometry, we show
that polymorphonuclear neutrophils (PMN) are the predominant
cells in fluid collected from sternotomy wound sites 24-72h postsurgery (n=8, p<0.05). Compared to pre-operative peripheral blood
derived PMN, significant increases in CD177+/CD66b+ PMN were
observed suggesting activation of PMN present at the wound site
(n=8, p<0.05). Increased activation state of PMN was associated
with higher levels of pro-inflammatory cytokines IL-1ОІ, TNFО±
and IL-6 in the wound fluid compared to corresponding plasma
samples (n=4, P<0.05). Strikingly higher (>500-fold) levels of
IL-1ОІ were noted. Sternal wound fluid contained high levels of
opioid peptides END and ENK 24-72h post-surgery (n=4, P<0.05).
Wound-site PMN showed significantly high levels of the mRNA of
the precursors of END and ENK suggesting that increased levels
of these peptides in the wound fluid may be in part contributed by
wound-site activated PMN (n=4, P<0.05).
Discussion: This constitutes first evidence from a patient-based
study elucidating the role of inflammatory cells in generation of
opioid peptides in the sternotomy wound environment.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-40
S-41
ANESTH ANALG
2012; 114; S-01 – S-493
S-40.
S-41.
STATINS AND IL-6-INHIBITION PREVENT
ATHEROSCLEROTIC LESION GROWTH AND
DESTABILIZATION IN A MODEL OF PERIOPERATIVE
STRESS IN ATHEROSCLEROSIS-PRONE MICE
IN VIVO FLUORESCENCE-MEDIATED TOMOGRAPHY
IMAGING DEMONSTRATES ATORVASTATIN MEDIATED
REDUCTION OF LESION MACROPHAGES IN APOEDEFICIENT MICE
AUTHORS: G. Theilmeier1, H. Janssen1, C. Wagner1, P. Demmer1,
U. Tietge , J. Larmann1
AUTHORS: J. Larmann1, T. Frenzel2,3, P. Demmer1, U. J. Tietge4,
C. Bremer5, G. Theilmeier1
affiliation: 1Anesthesiology, MHH, Hannover, Germany;
2
Pediatrics, University Hospital Groningen, Groningen, Netherlands
affiliation: 1Department of Anesthesiology and Intensive
Care Medicine, Hannover Medical School, Hannover, Germany;
2
Department of Anesthesiology and Intensive Care Medicine,
University Hospital Muenster, Muenster, Germany; 3Institute for
Anatomy, University of Muenster, Muenster, Germany; 4Department
of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases,
University Medical Center Groningen, Groningen, Netherlands;
5
Department of Clinical Radiology, University Hospital Muenster,
Muenster, Germany
Introduction: Prevention of peri-operative myocardial
infarction can be achieved using statins. Statins are known to reduce
inflammation of the plaque, plaque load and rupture of unstable
atherosclerotic lesions.1 Models for testing strategies to prevent
plaque growth and destabilization during the perioperative period
are lacking.2 We have therefore devised a model for perioperative
stress using the atherosclerosis-prone mouse apoE-/--strain
subjected to a double hit model of laparotomy and blood loss.
We tested statins and Il-6-blocking to prevent perioperative stress
induced (POS) plaque growth and destabilization.
Methods: With approval of the IRB 45 ApoE-/- mice were fed
a Western diet for 7 weeks and then subjected to a combination
of laparotomy (30’ before closure) and 20% blood loss (400 µl).
Animals were treated PO for 72 hours pre- and 72h postoperatively
with 80 mg/kg bw atorvastatin or postoperatively SC with an Il-6blocking antibody (200Вµg MP5-20S3). 72h post-POS animals were
sacrificed and plaque volume in the inomminate artery was assessed
on cryosections stained with H&E. Macrophage and VSMC content
were assessed by immunohistochemistry. Lipoprotein profiles
(baseline and 72h) as well as plasma Il-6 and TNFО± (at baseline,
4h, 6h, 12h and 24h) were assessed. Data are presented as median
(25%/75% CI) and tested by Kruskal-Wallis and Dunn’s test.
Results: Diet-induced hypercholesterolemia (total and
VLDL cholesterol, but not HDL and TG) was reduced by POS.
Plaque volume increased by POS (2.5x107 (1.0x107; 5.5x107)
vs 0.17x107(0.0x107;0.99x107) Вµm3; n=10; p<0.01). Relative
macrophage and VSMC content of the plaque remained unchanged.
POS significantly increased plasma levels of IL-6 with a peak at 6h
(758В±85 ng/mL, p<0.01, n=6) but not TNFО±. Statins reduced plaque
volume to 20%, Il-6-inhibition to 30% of POS with no change
in composition. To assess plaque vulnerability plaque rupture,
intraplaque hemorrhage and necrosis were scored and revealed a
significant destabilization of plaques by POS and a significant
reduction of vulnerability by statin or Il-6 inhibition.
Discussion: We have developed a clinically relevant model
of plaque growth and destabilization by POS. We have further
demonstrated that brief courses of high-dose statin, a known
strategy to reduce plaque vulnerability, or inhibition of Il-6, as one
cytokine endighted to cause plaque destabilization, can prevent
plaque growth and destabilization fostered by POS. Our model
will allow to screen novel and known strategies for prevention
of complication of atherosclerosis for their usefulness during the
perioperative phase.
References:
1. European Heart Journal 2009;30:2769
2. Circulation 2005;111:1422
Introduction: Perioperative statins protect patients at cardiovascular risk from adverse events and mortality. The underlying
mechanisms are unknown. Atherosclerotic lesion progression,
destabilization and rupture are driven by macrophages (M�).1 We
used non-invasive fluorescence-mediated tomography (FMT) to
image M� homing to vulnerable plaques in vivo. We assessed
whether short-term high-dose atorvastatin has plaque-stabilizing
effects in a mouse model for advanced atherosclerotic lesions.
Methods: After IRB approval 14 ApoE-/--mice were fed a highcholesterol diet to establish complex atherosclerotic plaques. After
16 wks on diet mice received 40mg/kg BW atorvastatin or vehicle
twice daily for 4 days. Thioglycollate elicited peritoneal M� from
eGFP-mice were labeled with near-infrared fluorescent dye DiR. 107
eGFP/DiR indicator M� were injected IV 2 days prior to treatment.
FMT-scans were performed on day 0, 2 and 4 to quantify M�
infiltration into aortic and brachiocephalic artery plaques. eGFP/
DiR-M� that infiltrated plaques were counted on frozen-sections
of brachiocephalic arteries by fluorescence microscopy. Lesion size
was measured on H&E stainings. Immunohistochemistry for CD68
was utilized to assess overall M� content. Plasma was collected
on day 4 for lipoprotein analysis. Data were tested for Gaussian
distribution and evaluated for significant differences (p<0.05) by
Students t-test. Results are displayed as mean or mean % of baseline
В±SEM.
Results: Longitudinal FMT scans detected an increase of
DiR-signal derived from indicator M� recruited into aortic and
brachiocephalic artery plaques. After 4 days of high-dose statin the
signal was lower than in untreated controls (75В±7 vs. 175В±35, % of
baseline, p<0.05). The reduction of recruited eGFP/DiR-M� in the
statin group was confirmed by fluorescent microscopy (50В±13 vs.
125В±23, eGFP/DiR pos. cells/lesion, p<0.02). Plaque size was not
affected (p=0.67). However, statin treatment reduced the plaque area
that stained positive for CD68 by 35% (p<0.05). Total cholesterol
was moderately reduced in statin animals (351В±21 vs. 504В±58, mg/
dl, p<0.01). Triglycerides, phospholipids, HDL, LDL and VLDL did
not differ (p=ns).
Discussion: In vivo FMT optical imaging proved its high
potential for clinical applicability to track infiltration of DiRlabeled M� into vulnerable atherosclerotic plaques. FMT-based
quantification of M� recruitment demonstrated a stabilization
of atherosclerotic lesions in ApoE-/--mice by 4-day atorvastatin
treatment. This rapid and likely lipoprotein-independent effect
could explain the reduction in cardio-vascular events in patients on
perioperative statin therapy.
References:
1. Moreno et al., Circ. 1994; 90: 775-8
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Cardiothoracic & Vascular
Clinical
ABSTRACTS
S-47
S-47.
LIBERALIZED FLUID PROTOCOL AND TISSUE
PERFUSION BIOMARKERS IN LUNG RESECTION
SURGERY
AUTHORS: S. Assaad1,2, M. Perkal1,3, T. Kyriakides1, G. Tellides1,3,
M. Ditillo1,3, A. Perrino1,2
affiliation: 1Anestehsiology and Surgery, VA Connecticut
Healthcare Systems, West Haven, CT; 2Anesthesiology, Yale
University, School of Medicine, New Haven, CT; 3Surgery, Yale
University, School of Medicine, New Haven, CT
Introduction: Perioperative fluid management for lung
resection surgery is a challenging task. Excess fluid balance has
been associated with postoperative pulmonary edema and hence
restrictive fluid management has been advised1. Concerns with
restrictive fluids include impaired tissue perfusion and acute kidney
injury (AKI) with an incidence ~25%2. Recently, protective lung
ventilation has been found to decrease the incidence of pulmonary
edema post lung resection surgery3. We hypothesize that by
employing a protective lung ventilation anesthetic, the use of a
liberalized fluid protocol targeting normovolemia would avoid
tissue hypoperfusion and AKI.
ANESTH ANALG
2012; 114; S-01 – S-493
Results: 14 pts consented and 3 surgeries were cancelled. The
11 remaining pts were males (65 В± 6.0 yrs). 8 had lobectomy, 2
wedge resection and 1 unplanned pneumonectomy. One-lung
ventilation time was 233 В± 110 min. Tidal volume was 4.5 ml/kg В±
0.2, with peak pressure of 19.9 В± 4.5 cmH2O. Intraoperative fluids
were crystalloid 2200 В± 593 ml and colloid 472 В± 403 ml. POD1-3
pts received 1260 В± 796 ml/day of crystalloids in addition to oral
intake. Central venous oxygen saturation and lactic acid were within
normal range postoperatively. Serum creatinine (p<0.05) and BNP
decreased compared to baseline and no pts met AKIN criteria (Table
1, Figure 1).
Discussion: These preliminary data did not detect AKI or
tissue hypoperfusion post lung resection surgery in patients
administered a liberalized fluid protocol in conjunction with
protective lung ventilation anesthetic. These findings suggest future
randomized controlled trials assessing liberal versus restrictive fluid
management’s impact on tissue perfusion in lung resection surgery.
References:
1. Parquin, Eur J Cardio-thorac Surg (1996) 10: 929-933
2. Kushins, Anesth Analg 2009; SCA 78
3. Licker, Crit Care 2009; 13(2)
Methods: After IRB approval, pts scheduled for lung resection
surgery excluding those for planned pneumonectomy, ejection
fraction < 40% or serum creatinine > 2 mg/dl, were asked to enroll
in this prospective observational trial. Biochemical markers of
tissue perfusion (serum creatinine, BNP, lactic acid, central venous
oxygen saturation) were measured through POD 3. Protective
lung ventilation protocol was implemented. Intraoperative fluids
consisted of crystalloid solution for maintenance (1.5 ml/kg/hr),
deficit replacement and replacement of the insensible loss (1 ml/
kg/hr). Blood loss was repleted 1:1 with colloid solution or PRBCs.
The protocol was continued postoperatively until oral intake. AKIN
criteria defined AKI. Data is presented as a mean В± SD with nonparametric analysis to compare variables.
Table 1: Perioperative Biochemical Marker Profile
Serum creatinine (mg/dl)
Preoperative
1.0 В± 0.2 (0.7-1.6)
Lactic acid (mg/dl)
Central venous saturation (%)
BNP (pg/ml)
Day of Surgery
POD 1
0.9 В± 0.2 (0.7-1.3) 0.9 В± 0.4 (0.6-1.8)
POD 2
0.9 В± 0.3 (0.6-1.5)
POD 3
0.8 В± 0.2 (0.6-1.2)
1.2 В± 0.6 (0.6-2.6) 1.3 В± 0.5 (0.7-2.1)
1.1 В± 0.5 (0.-2.1)
0.6 В± 0.2 (0.3-1.0)
71 В± 12 (51-89)
207 В± 305 (19-933)
71 В± 9.8 (52-86)
71 В± 8.6 (58-82)
p-value
0.004*
69 В± (50-87)
155 В± 70 (43-223
*Comparison between mean (DOS + POD 1-3) to baseline serum creatinine
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
NS
ABSTRACTS
S-48
S-49
ANESTH ANALG
2012; 114; S-01 – S-493
S-48.
S-49.
SURVEY OF US ACADEMIC INSTITUTIONS REGARDING
THE PRACTICE OF LUMBAR CEREBROSPINAL FLUID
DRAINS FOR AORTIC ANEURYSM REPAIRS
THE EFFICACY OF NITROUS OXIDE ON FACILITATING
LUNG COLLAPSE AT THE INITIATION OF ONE-LUNG
VENTILATION WITH BRONCHIAL BLOCKER
AUTHORS: W. Bradford, H. Arora, P. Kumar
AUTHORS: T. Yoshimura1,2, K. Ueda2, J. Sawai1, Y. Nakata3,1
affiliation: Anesthesiology, UNC Hospitals, Chapel Hill, NC
affiliation: 1Anesthesia, Teikyo University Hospital, Tokyo,
Japan; 2Anesthesia, University of Iowa Hospitals and Clinics, Iowa
City, IA; 3Graduate School of Public Health, Teikyo University,
Tokyo, Japan
Introduction: Lumbar (cerebrospinal fluid, CSF) drains are
commonly placed for spinal cord protection during thoracoabdominal
aneurysm repairs. The practice of placing the drains and their
management could vary widely from institution to institution. We
surveyed all academic institutions in the United States to get an
understanding of these practice patterns.
Methods: A web-based questionnaire was sent to all US
academic Chairs. The survey comprised of questions related to
placement, timing, monitoring and follow up of lumbar drains.
The chairs were contacted through mass email via the Society
of Academic Anesthesiologists Association as well as by postal
mailings. All chairs were requested to forward the questionnaire
to their vascular section chief so as to only have one response per
institution.
Results: The overall response rate was 34% (45/132). The
survey demonstrated wide variation in the average number of lumbar
drains performed as well as their management and follow up. Drains
were placed by anesthesiologists (84.4%), neurosurgery (13.3%)
or vascular surgery (2.2%). At institutions where neurosurgery
primarily placed lumbar drains, a majority (63.6%) were placed
after induction of anesthesia. Institutions where lumbar drains were
placed by anesthesiologists, a majority were done awake, (71.7%)
with only 29.3% being done after induction of anesthesia. Roughly
half of the respondents acknowledged placement of lumbar drains
for aortic surgery involving full cardiopulmonary bypass and
high dose heparinization, where a majority were done the day of
surgery (83.9%) as opposed to a day prior (16.1%). Over half of the
respondents affirmed that they would proceed with the scheduled
surgery even after a traumatic (bloody) placement. Post-operatively,
most drains were managed by vascular surgery (48.9%) and the
remaining by anesthesiology (33.3%), pain service (4.4%), or by
neurosurgery (13.3%). A majority of lumbar drains were pulled by
anesthesiology (66.7%) and the remaining by pain service (6.7%),
vascular surgery (13.3%), or by neurosurgery (13.3%).
Discussion: In the United States, perioperative management
of lumbar drains for aortic aneurysm repair varies widely among
academic institutions.
References:
Fedorow, C.A., et al., Lumbar Cerebrospinal Fluid Drainage
for Thoracoabdominal Aortic Surgery: Rationale and Practical
Considerations for Management. Anesthesia & Analgesia, 2010.
111(1): p. 46-58.
Estrera, A.L., et al., Cerebrospinal Fluid Drainage During Thoracic
Aortic Repair: Safety and Current Management. The Annals of
Thoracic Surgery, 2009. 88(1): p. 9-15.
Introduction: Prompt collapse of the non-ventilated lung
can facilitate thoracic surgery. However, it could be challenging
due to a small suction channel with use of bronchial blocker. We
hypothesized that the use of nitrous oxide (N2O) in the inspired
gas mixture during two-lung ventilation (TLV) leads to clinically
relevant improvement of the lung collapse during subsequent onelung ventilation (OLV) with a bronchial blocker.
Methods: After approval by the hospital’s Research Ethics
Board, written informed consent was obtained from patients
undergoing elective thoracotomy or thoracoscopic surgery. Forty
patients were randomized into two groups: N2O (n = 22) or O2
(n = 18). The N2O group received a gas mixture of oxygen and
N2O (FiO2 = 0.50) and the O2 group received 100% oxygen until
the start of OLV. Anesthesia was induced with propofol (1-2 mg/
kg) and 1 mg/kg of rocuronium and was maintained with propofol
infusion (100-150 mcg/kg/min), remifentanil (0.15-0.25 mcg/kg/
min) and intermittent boluses of rocuronium. The patients’ trachea
was intubated with an 8.0-mm internal diameter endotracheal
tube. Lung isolation was achieved with an ArndtВ® wire-guided
bronchial blocker (CookВ® Critical Care, Bloomington, IN). All
bronchial blockers were placed via the endotracheal tube using a
pediatric fiberoptic bronchoscope. After turning the patients to the
lateral position, the cuff of the bronchial blocker was inflated with
fiberoptic surveillance and patients’ lungs in both groups were then
ventilated with 100% oxygen during OLV. The surgeons, who were
blinded to the randomization, evaluated the lung deflation using
a verbal rating scale (lung collapse scale, 0= no collapse, to 10 =
complete collapse) at 1 min after opening the pleura for assessment
of initial phase of lung collapse, and also 5min and 10min for
assessment of second phase of lung collapse. Data analysis of lung
collapse scales between groups was done with Mann- Whitney tests.
Statistical significance was defined as p < 0.05.
Results: There were no significant differences in demographics
between both groups. The results of lung collapse scales were
shown in the Table. Lung collapse scales in the N2O group were
significantly improved compared with the O2 group at 5 min after
opening the pleura. However, their differences were insignificant at
1 min and 10 min.
Discussion: Animal studies have demonstrated that two phases
are primarily involved in the determination of rate of collapse of
the non-ventilated lung1,2. Our findings support that the use of N2O
clinically improves the second phase of lung collapse compared
with 100% oxygen during OLV with bronchial blockers.
References:
1. Anaesthesia 2001; 56:940-6
2. Anaesthesia 2001; 56:933-9
Lung collapse scale
1 min
N2O (n=22)
2 (1-6)
O2 (n=18)
2 (1-4)
P-value
0.7988
5 min
8 (6-10)
6 (3-7)
0.0003
10 min
10 (7-10)
9.5 (5-10)
0.1531
Data are expressed as median (range). A p-value < 0.05 is considered
statistically significant.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-50
S-50.
DOES LIBERALIZED FLUID PROTOCOL INCREASE LUNG
WATER POST LUNG RESECTION SURGERY?
AUTHORS: S. Assaad1,2, M. Perkal1,3, T. Kyriakides1, G. Tellides1,3,
A. W. Kim1,3, A. Perrino1,2
affiliation: 1Anesthesiology and Surgery, VA Connecticut
Healthcare Systems, West Haven, CT; 2Anesthesiology, Yale
University, School of Medicine, New Haven, CT; 3Surgery, Yale
University, School of Medicine, New Haven, CT
Introduction: Acute lung injury following lung resection
surgery is a rare but serious complication1,2. Although the
pathogenesis is unclear, an increase in pulmonary capillary
hydrostatic pressure has been suggested. This has led to the practice
of restrictive fluid therapy3. We hypothesized that with an anesthetic
technique employing protective lung ventilation, fluid therapy
directed at normovolemia will not result in an increase in the
extravascular lung water in the perioperative period.
Methods: After IRB approval, all patients scheduled for lung
resection surgery were asked to enroll in a prospective, observational
trial. Exclusion criteria included planned pneumonectomy, ejection
fraction < 40% or serum creatinine > 2 mg/dl. Extravascular lung
water index (EVLWI), global end diastolic index (GEDI) and
cardiac index (CI) were measured using the PiCCO monitor (Pulsion
Medical Systems, Germany). Baseline measurements were obtained
pre-incision. Following one-lung ventilation, patients were pressure
control ventilated with 100% O2 for tidal volume (Vt) of 4-6 ml/
kg, peak airway pressure (Paw)< 30 cmH2O, PEEP 5 cmH2O and
recruitment maneuver. Intraoperative fluids consisted of crystalloid
solution maintenance at 1.5 ml/kg/hr, deficit volume replacement,
and replacement of the insensible loss at 1 ml/kg/hr for open
surgeries. Blood loss was repleted 1:1 with colloid solution. The
protocol was continued postoperatively until oral intake. Diuretics
were not used routinely. PiCCO measurements were obtained for
3 days postoperatively. Data is presented as a mean В± SD. Nonparametric analysis used to compare variables.
Results: 14 patients consented to participate. Three patients’
surgeries were cancelled. The 11 remaining patients were males
age 65 В± 6.0 yrs. 8 patients had lobectomy, 2 wedge resection and
1 an unplanned pneumonectomy. Open thoracotomy was used in
8 patients and a video assisted approach in 3 patients. One-lung
ventilation time was 233 В± 110 min. Vt was 4.5 ml/kg В± 0.2, with
Paw of 19.9 В± 4.5 cmH2O. Intraoperative crystalloid fluids intake
was 2200 В± 593 ml and Hextend 472 В± 403 ml. On POD 1-3 patients
received 1260 + 796 ml/day of crystalloids in addition to oral intake.
Compared to baseline, GEDI was maintained and CI significantly
increased on POD 1-3. EVLW showed no change. (Table1).
Discussion: These preliminary results suggest that adoption of
a liberalized perioperative fluid protocol achieves normovolemia as
shown by GEDI, increased CI, without an increase in lung water.
References:
1. Ruffini E, et al, Eur J Cardiothorac Surg. 2001 Jul; 20(1):30-6
2. Licker M, et al, Crit Care 2009; 13(2):R41. Epub 2009
3. Parquin F, Eur J Cardio-thorac Surg (1996) 10: 929-933
Table 1: Values of EVLWI, GEDI and CI on POD 1-3 compared to baseline value.
Baseline
POD 1
Value p-value
POD 2
Value p-value
POD 3
Value p-value
EVLWI (ml/kg)
11.2
10.5
NS
11.5
NS
12.2
GEDI (ml/ m2)
815
856
NS
787
NS
831
NS
NS
CI (l/min/m2)
2.6
3.95
0.002
3.8
0.001
3.7
0.003
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-51
S-51.
ANESTHETIC INDUCTION WITH ETOMIDATE, RATHER
THAN PROPOFOL, IS ASSOCIATED WITH INCREASED
CARDIOVASCULR MORBIDITY AFTER NON-CARDIAC
SURGERY
AUTHORS: R. Komatsu1, J. You2, E. J. Mascha2, D. I. Sessler3,
A. Turan3
affiliation: 1Anesthesiology Institute, Cleveland Clinic,
Cleveland, OH; 2Departments of Quantitative Health Sciences and
Outcomes Research, Cleveland Clinic, Cleveland, OH; 3Department
of Outcomes Research, Cleveland Clinic, Cleveland, OH
Introduction: Etomidate is used to induce anesthesia
in critically ill patients because of its favorable hemodynamic
profile. However, the drug causes adrenal impairment which
blunts release of cortisol that accompanies surgical tissue injury1.
Cortisol augments vascular effects of endogenous epinephrine and
norepinephrine, thus maintaining blood pressure2 and etomidate
may consequently provoke postoperative hemodynamic instability.
We tested the hypothesis that etomidate is associated with postoperative cardiovascular morbidity.
Methods: We evaluated the electronic records of 31,148 ASA
physical status 3-4 patients who had non-cardiac surgery at our
institution. Among these, anesthesia was induced with etomidate in
2,616 patients whereas 28,532 were given propofol. Two thousand
one hundred forty-five patients given etomidate were propensityscore matched with 5,211 patients given propofol. The groups were
compared on post-operative cardiovascular morbidity (Table 2) and
intraoperative vasopressor requirement using logistic regression;
ANESTH ANALG
2012; 114; S-01 – S-493
the significance criterion was 0.025 (Bonferroni correction). Finally,
we summarized the differences in intraoperative hemodynamics
between the etomidate and propofol patients using the standardized
difference.
Results: Patients given etomidate had significantly greater odds
of having cardiovascular morbidity (odds ratio [OR], 1.54; 97.5%
CI, 1.22-1.94; P < 0.001). However, intraoperative vasopressor
requirement (OR, 0.98; 97.5% CI, 0.86-1.12; P = 0.72) did not
differ between the agents. The etomidate and propofol groups were
descriptively similar on systolic blood pressure during closing to
end of the case, and on diastolic blood pressure during induction
to intubation (Table 3, absolute standardized difference (STD)
<0.10; Figure). The propofol patients were more likely to have a
lower systolic blood pressure during induction to intubation and
during intubation to incision than the etomidate patients. Although
slight differences in blood pressure between etomidate and propofol
patients during other intraoperative periods were observed (Table 3,
absolute STD> 0.10; Figure), none of the differences were clinically
important.
Discussion: Etomidate was associated with increased risk
for cardiovascular morbidity. Clinicians should use etomidate
judiciously, considering improved hemodynamic stability at
induction may be accompanied by substantially worse longer-term
outcomes.
References:
1. F
ragen RJ, Weiss HW, Molteni A. The effect of propofol on
adrenocortical steroidogenesis: a comparative study with
etomidate and thiopental. Anesthesiology 1987;66:839-42
2.Grunfeld JP, Eloy L. Glucocorticoids modulate vascular
reactivity in the rat. Hypertension 1987;10:608-18
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-52
S-53
ANESTH ANALG
2012; 114; S-01 – S-493
S-52.
S-53.
HAPTOGLOBIN POLYMORPHISM AND NEW ONSET
ATRIAL FIBRILLATION FOLLOWING CORONARY
ARTERY BYPASS SURGERY
EFFECT OF INDIAN CLASSICAL MUSIC (RAGA
THERAPY) ON FENTANYL , PROPOFOL , VECURONIUM
REQUIREMENTS AND CORTISOL LEVELS IN
CARDIOPULMONARY BYPASS
AUTHORS: J. Raphael1, A. Fox3, C. D. Collard2, S. Shernan3, J. D.
Muehlschlegel3, S. Body3
affiliation: 1Anesthesiology, University of Virginia,
Charlottesville, VA; 2Anesthesiology, Texas Heart Institute,
Houston, TX; 3Anesthesiology, Perioperative and Pain Medicine,
Brigham and Women’s Hospital, Boston, MA
Introduction: Atrial fibrillation (AF) is the most common
complication after cardiac surgery (up to 40% incidence), and is
associated with increased risk of neurological, renal and infectious
complications, as well as postoperative hospital stay. Numerous
epidemiological studies have documented an association between
hemoglobin-binding protein haptoglobin (Hp) polymorphisms
(specifically the Hp 2-2 phenotype) and cardiovascular morbidity
in non-surgical patients. We sought to determine whether the Hp2-2 phenotype is independently associated with new onset AF after
coronary artery bypass graft (CABG) surgery with cardiopulmonary
bypass (CPB).
Methods: Retrospective analysis of prospectively collected data
of 775 patients undergoing primary CABG surgery with CPB at
two institutions (CABG Genomics Project; http://clinicaltrials.gov/
show/NCT00281164). Haptoglobin phenotypes were determined by
gel electrophoresis1. AF was defined as the occurrence of new onset
AF during the postoperative period of the primary hospitalization.
Univariable analysis was performed to evaluate the association
between Hp phenotypes and postoperative AF. Multivariable
adjustments were made for patient demographics and perioperative
risk factors.
Results: 267 patients (34.4%) had the Hp 2-2 phenotype, while
508 patients were either Hp 1-1 (15%) or 2-1 (50.6%). 209 patients
(27%) developed new onset AF after surgery. Within the Hp-2-2
group, 84 patients developed AF (31.5%), vs. 125 patients (24.6%)
with the non-2-2 phenotype. On univariable analysis, the Hp 2-2
phenotype was associated with increased risk of postoperative
AF (p<0.05). Other independent risk factors were patient age
(p<0.01), prior history of AF (p<0.01), and CPB time (p<0.05).
After multivariable adjustments, only age (p<0.01; OR-5.32, 95%
CI-2.32-6.03) and prior history of AF (p<0.01; OR-2.63, 95%CI1.47-5.72) were associated with postoperative AF.
Discussion: Although patients with the Hp-2-2 phenotype had
an absolute 6.9% higher risk to develop postoperative AF, this Hp
phenotype was not independently associated with postoperative AF
after CABG surgery.
References:
1.Levy AP et-al. Haptoglobin phenotype and vascular complications
in patients with diabetes. N Engl J Med. 2000;343(13):969-70.
AUTHORS: S. K. Kar, C. S. Sen
affiliation: Cardiac Anesthesia, Ipgmer, Kolkata, India
Introduction: Cardiopulmonary bypass is associated with
immense stress response and high levels of intraoperative cortisol
levels which is detrimental to the patient and involves large doses
of Fentanyl, propofol and vecuronium requirement to maintain
hemodynamic stability intraoperatively
Methods: After obtaining clearance from Institutional Ethical
Committee and written informed consent from patients, 34 patients
were assigned to either Group I Music group (n= 17) and Blank
CD Group II (n= 17). The patients awareness .level and depth of
anesthesia was monitored by BIS (Bispectral index) , Fentanyl and
propofol infusion titrated to a BIS score of 50 and neuromuscular
monitoring was done by Post tetanic count (PTC) in the Aductor
Pollicis muscle .Vecuronium was repeated whenever a PTC count
of 7 was achieved, in both the groups. Music therapy or blank CD
was played by earphone, in the patient’s ear in both the groups, from
30 mins before induction to till the patient was shifted to the ICU.
Results: We found significant decrease in the cortisol levels both
after Sternotomy and after aortic crosscalmp release. In the Music
group (Group I) which was 30 % less than the Blank CD group
(Group II). Fentanyl, propofol and vecuronium requirement in the
Music group were reduced by 30 % and 25 %and 25 % respectively,
which were statistically significant (P< 0.05)
Discussion: By unknown mechanism s Indian classical music
therapy reduced the intraoperative stress and analgesic requirement.
References:
1.References Bagchi, Kalyan. (Ed) (2003) Music, Mind and
Mental Health. New Delhi.
2.Tony Wigram, Inge Nygaard Pedersen and Lars Ole Bonde.
Jessica Kingley Publishers Philadelphia2002: A comprehensive
guide to music therapy, Theory, clinical practice Research &
Training.
3.Nisson, Rawal N, Unosson M. A comparison of intra-operative
or postoperative exposure to music--a controlled trial of the
effects on postoperative pain. Anaesthesia. 2003 Jul; 58(7):699703.
4.Yale University School of medicine 2003 Effects of music
therapy.
5.Sairam, T. V. (2004a) Medicinal Music. Chennai: Nada Centre
for Music Therapy
6.Sairam T. V. (2004b) Raga Therapy. Chennai: Nada Centre for
Music Therapy
7.Sairam, T. V. (2004c) What is Music? Chennai: Nada Centre for
Music Therapy
8. Lewis. Anesth Analg 2004; 98:533-6
9.N. Yapici, I. A. Tarhan, T. Kehlibar, T. Coruh, Y. Arslan, M.
Yilmaz, F. Yapici, A. Ozler & Z. Aykac : Blood Cortisol Levels On
Cardiopulmonary Bypass After Methylene Blue Administration
. The Internet Journal of Thoracic and Cardiovascular Surgery.
2008 Volume 11 Number 2
10.Miller 7th edition Neuro muscular monitoring chapter 47
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-54
S-54.
HIGH PRE-OPERATIVE BRAIN NATRIURETIC PEPTIDE
LEVELS PREDICT POST-OPERATIVE PROLONGED
ICU STAY AND HIGHER MORTALITY IN PATIENTS
UNDERGOING NON-EMERGENT CARDIAC SURGERY
AUTHORS: D. Mikami, H. Nakazawa, K. Moriyama, T. Yorozu
affiliation: Tokyo, Japan
Introduction: Recent evidences suggest that pre-operative
brain natriuretic peptide (BNP) levels have a high negative
predictive value of post-operative complications after cardiac and
non-cardiac surgery1. We invstigated whether pre-operative BNP
levels predict post-operative morbidity and mortality in patients
undergoing non-emergent cardiac surgery.
Methods: We retrospectively evaluated records of patients
who underwent non-emergent cardiac surgery at our institution
since April 2009 to March 2010. Patients with pre-operative renal
dysfunction (serum creatinine >1.2mg/dL), respiratory failure (P/F
ratio<300 and/or SpO2≦95% (room air), hemodynamic instability
(any vasopressor use), and patients undergoing vascular surgery
were excluded from the study. Major morbidity was defined as
one of the following: prolonged ventilation >48 hours, prolonged
ICU stay >7 days, all-cause mortality within 30 days. Estimations
of the risks were performed using logistic regression and quoted
as odds ratio (OR). Preoperative BNP value were entered into
logistic regression models along with the following parameters;
physiological findings of echocardiography, ASA physical status,
fluid administration, blood loss, transfusion required, urine output
during surgery, duration of anesthesia, and types of surgical
procedures. The cutoff value of BNP for prolonged ventilation was
defined by a receiver operating characteristic curve (ROC).Using
this cutoff value of BNP, the data were reanalyzed by entering
parameters of post-operative cardiac function, vasopressor use and
blood gas analysis.
Results: A total of 62 patients with a mean age of 68.7В±12.4
were included in this study. 42 patients underwent isolated
coronary artery bypass graft (including 23 off-pump surgery),
16 underwent valve procedure alone, and 4 underwent combined
procedures. Mean pre-operative BNP value was 391В±324 pg/mL.
Risk factors for prolonged ventilation were preoperative BNP, and
combined procedures. The risk factor for prolonged ICU stay was
preoperative BNP alone. All-cause mortality within 30 days were
associated with preoperative BNP and intraoperative urine output.
A ROC analysis demonstrated that a preoperative BNP>259pg/mL
(sensitivity:72%, specificity 57%) provided the optimal BNP cutoff
point. In the higher BNP group (>259pg/mL), postoperative CVP
and vasopressor use were significantly higher, and P/F ratio was
significantly lower (p<0.05).
Discussion: BNP is predictable of prolonged ventilation,
prolonged ICU stay and all-cause mortality within 30 days. The
cutoff value of BNP (>259pg/mL) is also predictable of postoperative hemodynamic instability .
References:
1. Anesth Analg 2011;112(5):1019-33.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-55
S-55.
POST-OPERATIVE SUPPLEMENTAL OXYGEN THERAPY
ASSOCIATED WITH INCREASED RISK FOR POSTOPERATIVE MYOCARDIAL INFARCTION IN NONCARDIAC SURGICAL PATIENTS
AUTHORS: K. J. Ringenberg, S. Shillcutt
affiliation: Anesthesiology, University of Nebraska Medical
Center, Omaha, NE
Introduction: Approximately 500,000-900,000 (0.5-0.9%)
patients experience peri-operative cardiac events annually following
non-cardiac surgery. Patients who suffer post-operative MI are
known to have an increase in morbidity and mortality.1
Methods: A retrospective evaluation was conducted of 107
medical records of patients between ages 21-93 who had elevated
serum troponin-I (>0.4 ng/mL) on post operative days zero to
five, and documentation of myocardial ischemia or MI following
non-cardiac surgery at a single academic medical center during
2004 and 2005. Seventy categorical variables were evaluated for
an association with post-operative MI. Two control patients who
did not suffer peri-operative MI were identified and appropriately
matched for each study patient.
Results: Univariate analysis of all categorical variables revealed
findings largely consistent with previously published data from
large, well designed studies.1 Multiple logistic regression revealed
other factors that correlated to peri-operative MI (Table 1).
Supplemental O2 therapy after PACU discharge had the strongest
correlation to MI.
ANESTH ANALG
2012; 114; S-01 – S-493
Discussion: Routine use of supplemental oxygen in certain
patient groups has been questioned.2,3 High flow O2 administration
may decrease cardiac output, cardiac perfusion and coronary O2
delivery in patients with and without coronary artery disease.2,3
Cabello et al examined the efficacy of O2 therapy in the setting of
acute MI, and concluded there is little evidence of benefit in nonhypoxic patients.3 In patients who have sustained a stress response
associated with surgery, it is feasible that delivery of supplemental O2
to non-hypoxic post-operative patients may have similar effects, such
as altered hemodynamics and myocardial perfusion, particularly in
the coronary microcirculation.
Our study did not establish that patients who received supplemental
O2 were hypoxic. However, only 16 of the 72 patients who received
O2 after PACU discharge and developed a MI were hypoxic in the
PACU suggesting a significant number of normoxic patients received
supplemental O2.
Additional research is needed to evaluate the association between the
delivery of supplemental O2 to post-operative patients and MI.
References:
1.Perioperative cardiac events in patients undergoing noncardiac
surgery: a review of the magnitude of the problem, the
pathophysiology of the events and methods to estimate and
communicate risk. CMAJ. 2005;173:627-34
2.Effects of oxygen inhalation on cardiac output, coronary blood
flow and oxygen delivery in healthy individuals, assessed with
MRI. Eur J Emerg Med. 2010 May 12
3.Oxygen therapy for acute myocardial infarction. Cochrane
Database of Systematic Reviews 2010, Issue 6. Art. No.:
CD007160
Table 1
VARIABLE
Odds Ratio
95% Wald
Confidence Limits
p-value of
fixed effect
HTN (intra-operative SBP>160 or DBP>110)
2.221
(1.086, 4.543)
0.0289
Poor Exercise tolerance (pre-operative)
3.203
(1.25, 8.205)
0.0153
ICU stay (post-op)
4.348
(2.142, 8.826)
<.0001
Elevated Serum Creatinine Post-operatively
(male >1.5, female >1.3)
6.711
(3.310, 13.608)
<.0001
Supplemental O2via nasal cannula or face
mask after discharge from PACU
7.033
(3.581, 13.811)
<.0001
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-56
S-57
ANESTH ANALG
2012; 114; S-01 – S-493
S-56.
S-57.
THE INTERRACTION OF LOW-DOSE
DROPERIDOL WITH PROPOFOL ON QTC INTERVAL
DURING ANESTHETIC INDUCTION
PERIOPERATIVE USE OF THE GLUCOMMANDERВ®
FOR GLUCOSE CONTROL IN PATIENTS UNDERGOING
CARDIAC SURGERY
AUTHORS: Y. Terao1, T. Toyoda1,2, M. Oji1,2, U. Higashijima1,2,
M. Fukusaki1, K. Sumikawa2
AUTHORS: J. L. Huffmyer, F. E. Blum, D. S. Groves, E. C.
Nemergut
affiliation: 1Anesthesia, Nagasaki Rosai Hospital, Sasebo,
Japan; 2Anesthesiology, Nagasaki University School of Medicine,
Nagasaki, Japan
affiliation: Anesthesiology,
Charlottesville, VA
Introduction: Although droperidol is an excellent antieВ­
metics, the use is limited to specific indication because of FDA
warning of the risk of critical arrhythmias due to the effect of QT
prolongation1. Our previous study showed that propofol shortened
QTc interval during anesthetic induction2. In this study, we
investigated the effect of low-dose droperidol and the interaction
with propofol on heart rate corrected QT (QTc) interval in surgical
patients.
Methods: Seventy-two patients undergoing upper limb surgery
were included in this study. Patients were randomly allocated to one
of 3 groups to receive 1 mL of saline (group A; n = 24), 1.25 mg of
droperidol (group B; n = 24) or 2.5 mg of droperidol (group C, n =
24) droperidol. The patients breathed 100% oxygen via a facemask
for 1 min, and received a bolus injection of saline or droperidol. One
min later, fentanyl, 3 Ојg/kg, was given and anesthesia was induced
using propofol, 1.5mg/kg, 2 min after fentanyl administration.
Immediately after loss of consciousness, a bolus of vecuronium ,0.15
mg/kg, was administered to facilitate tracheal intubation. Tracheal
intubation was performed 3 min after vecronium administration.
If bispectral index (BIS) was above 50, an additional boluse of
propofol, 0.5 mg/kg, was administered. Heart rate (HR), mean
arterial pressure (MAP), BIS, and 12-lead ECG were recorded at the
following time points: just before droperidol injection (baseline);
3 min after saline or droperidol injection (droperidol); 3 min after
propofol injection (propofol); 2 min after tracheal intubation
(intubation). The QTc interval was calculated using Fridericia
formula. A factorial ANOVA with repeated measures and post hoc
comparison, Bonferrori/Dunn procedure, were performed. A p value
< 0.05 was considered statistically significant.
Results: BIS and MAP declined after anesthetic induction in all
groups. HR declined after anesthetic induction and recovered after
tracheal intubation in all groups. As shown in table 1, QTc interval
was significantly shortened after propofol injection, compared with
baseline in group A and B, but recovered after tracheal intubation.
In group C, the QTc interval significantly prolonged after droperidol
injection, but recovered after propofol injection, and prolonged after
tracheal intubation.
University
of
Virginia,
Introduction: Hyperglycemia is a common perioperative
problem in diabetic and non-diabetic patients undergoing cardiac
surgery.1 Perioperative hyperglycemia as well as hypoglycemia
has been associated with increased morbidity and mortality.2,3
The GlucommanderВ® (Glytec Systems, Greenville, SC) is a
computerized algorithm designed to direct the administration of
intravenous insulin by continuous infusion and has been used to
control postoperative hyperglycemia in hospitalized patients. This
study evaluated use of the GlucommanderВ® versus acute care insulin
protocol during the perioperative period in cardiac surgical patients.
Methods: After IRB approval and written informed consent, 65
patients (diabetic and non-diabetic) having cardiac surgery were
prospectively randomized to the GlucommanderВ® (30 patients) or
to the standard of care group with acute care insulin protocol (35
patients). For both groups arterial blood glucose measurements were
analyzed every 30 minutes in the operating room and in the intensive
care unit for 24 hours postoperatively. The GlucommanderВ® and
acute care protocols were started once the blood glucose reached
120 mg/dl and continued 24 hours postoperatively. The goal range
for glucose was 120-150 mg/dl. Data were analyzed using mixed
effect modeling.
Results: Arterial blood glucose values were significantly
different between the groups such that the GlucommanderВ® patients
had an average mean glucose 129 В± 12.4 mg/dl versus the standard
care patients with average mean glucose 145 В± 15.8 mg/dl (p <
0.001). The GlucommanderВ® patients also spent more time in the
goal glucose range of 120-150 mg/dl as compared to the standard
of care patients.
Discussion: The GlucommanderВ® yielded lower overall average
mean glucose levels with more time spent in the target range as
compared to patients treated with a standard acute care insulin
protocol for glucose control. The GlucommanderВ® was feasible for
use in both the operating room as well as the intensive care unit.
Further studies should be conducted to determine the ideal glucose
target range for patients undergoing cardiac surgery in order to
maximize benefit and minimize hypoglycemic risk.
References:
Discussion: The results show that 1.25 mg of droperidol does
not prolong QTc interval, while 2.5 mg of droperidol prolongs QTc
interval significantly, and that QTc interval prolongation caused by
2.5 mg of droperidol is counteracted by propofol. When droperidol
is used alone in high-risk patients, the low dose of 1.25 mg would
be advisable.
1.Furnary, AP. Clinical benefits of tight glycaemic control: focus
on the perioperative setting. Best Practice & Research. Clinical
Anaesthesiology, 2009, 23(4):411-20.
References:
3.Gandhi, GY, Nuttall, GA, Abel, MD, et al. Intensive intraoperative
insulin therapy versus conventional glucose management during
cardiac surgery. Annals of Internal Medicine, 2007, 146:233-43.
1, Anesthesiology 107: 531-536; 2007.
2, Anaesthesia 65: 679-683; 2010
2.Van Den Berghe, G, Wouters, P, Weekers, F, et al. Intensive
insulin therapy in critically ill patients. The New England
Journal of Medicine, 2001, 345(19):1359-67.
Time course of QTc interval (msec)
Droperidol
Baseline
(mg)
0mg
422 (413, 434)
Droperidol
Propofol
Intubation
424 (415, 432)
417 (408, 426) *
423 (408, 433)
425 (414, 445)
418 (405, 445) *
421 (409, 454)
432 (422, 442)#
442 (428, 451) *#
1.25mg
429 (415, 448)
2.5mg
431 (419, 442) 436 (424, 446) * #
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-58
S-59
ANESTH ANALG
2012; 114; S-01 – S-493
S-58.
S-59.
INTRAVASCULAR EXPANSION WITH NITROGYCERIN
ENHANCES TISSUE OXYGENATION
CORRELATION OF EARLY HEMODYNAMIC
MEASURES IN CARDIAC SURGERY TO POSTOPERATIVE
OXYGEN UTILIZATION CAPACITY
AUTHORS: S. J. Voskanian, A. Yen, N. Samimi, M. Mogos, P.
Roffey, D. Thangathurai
affiliation: Anesthesiology, USC Keck School of Medicine,
Los Angeles, CA
Introduction: Optimal tissue perfusion is key in preserving
organ function during high-risk surgery. We hypothesize that
perioperative intravascular volume expansion with vasodilators
increases tissue perfusion via enhancement of the microcirculation.
We used central venous oxygen (ScVO2) values as surrogate
measure of the balance between total body oxygen and consumption.
Methods: Data was prospectively collected on twelve patients
undergoing laparoscopic partial nephrectomy. Patients with vital
organ dysfunction or anemia were excluded. Anesthesia was
induced with propofol and muscle relaxant and maintained with
inhalational agents supplemented by narcotics. Arterial and central
venous lines were placed and two liters intravenous fluids were
given while a low-dose (average 33mcg/min) NTG infusion was
titrated to maintain mean pressures within 10% of baseline.Central
venous samples were taken before and 30 minutes after the NTG
infusion and volume expansion.
Results: There was a statistically significant change in central
venous oxygen tension following intervention.“Pre-test” mean
central venous PO2 was 48.78mmHg, “post-test” was 55.14mmHg.
Discussion: After initiation of NTG, ScVO2 increased,
suggesting improved tissue oxygenation, likely due to improved
microcirculation. Abnormalities in microvascular function occur
during sepsis and various other inflammatory states. We hypothesize
that surgery, with its concomitant inflammatory response, is
associated with a similar disruption in the microcirculation and
can be counteracted with careful vasodilation using NTG. NTG
may reverse sympathetic tissue vasoconstriction, promote capillary
recruitment, and correct maldistributed microcirculatory blood
flow. Maintenance of tissue perfusion and oxygenation in high-risk
surgical patients may decrease the incidence of ARDS. Whether
NTG with volume loading improves global tissue oxygenation
by increasing microcirculatory flow, and whether this leads to a
reduction in morbidity and mortality in certain high-risk patients
needs further investigation.
References:
Dueck MH, Klimek M, et al. Trends but Not Individual Values
of Central Venous Oxygen Saturation Agree with Mixed Venous
Oxygen Saturation during varying Hemodynamic Conditions.
Anesthesiology 2005; 103: 249-57
Jhanji S, Lee C, et al. Microvascular flow and tissue oxygenation
after major abdominal surgery: association with post-operative
complications. Intensive Care Med 2009 35: 671-677
Spronk, et al. Nitroglycerin in septic shock after intravascular
volume resuscitation. Lancet 2002; 360: 1395-96
Thangathurai D, Charbonnet C, Wo CJ, et al. Intraoperative
Maintenance of Tissue Perfusion Prevents ARDS. New Horiz 1996
Nov; 4(4): 466-74
AUTHORS: R. J. LaFaro1, S. Pothula1, D. Maerz1, L. Montes1,
S. Oleszkiewicz1, A. Yusupov2, M. A. Inchiosa1
affiliation: 1New York Medical College, Valhalla, NY; 2New
York College of Osteopathic Medicine, Old Westbury, NY
Introduction: There has been extensive study in the attempt
to identify factors that predict the quality of postoperative outcome.
We have focused in this preliminary analysis on the relationship
of some of the earliest hemodynamic measures taken in the preincision period to the oxygen consumption index (ml/min/m2)
(VO2 index) upon arrival in the ICU.
Methods: Institutional IRB approval and patient consent were
obtained to allow sampling for blood gas measurements at intervals
that were not necessarily routine, and for the confidential use of
the entire patient record. Consents were obtained from a total of
55 patients that were scheduled for CABG or valve surgeries, or a
combination of both. All surgeries were performed in conjunction
with cardiopulmonary bypass. Complete data necessary for
calculation of VO2 index in the immediate postoperative period in
the ICU was available from 48 patients. Although we report here
on pre-incision measures that may have predictive value for certain
outcome measures, a full record of demographic characteristics,
anthropomorphic measurements, medical and surgical histories,
extracorporeal circulation and surgical times, and hemodynamic
measurements in all perioperative phases were preserved for
future analysis of possible predictive value in relation to outcome
measures.
Results: Among the measures collected, four pre-incision
values, cardiac index (CI), central venous pressure (CVP), systemic
vascular resistance (SVR) and oxygen delivery index (DO2 index)
were found to have statistically significant correlations with the ICU
VO2 index (Table 1).
Table 1: Correlations with ICU VO2 index.
Variable
DO2 index
CI
SVR
CVP
Correlation
coefficient
0 .4939
0 .4001
-0 .3938
-0 .3598
p value
0 .001
0 .012
0 .013
0 .013
Multiple linear regression analysis for the combined influence
of these four variables on ICU VO2 index yielded a correlation
coefficient of 0.548 (p <0.001). Preliminary results from a neural
network analysis of the data, which evaluates interactions among
the 4 hemodynamic variables, yielded a model for correlation with
ICU VO2 index of r = 0.885 (p <0.001). The true value of this model
can only be evaluated by its application to future patient data.
Discussion: These preliminary findings suggest that it may be
possible to utilize pre-incision hemodynamic measures to identify
patients who may pose an increased surgical or postoperative risk.
References: None
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-60
S-60.
PRESSURE AND FLOW REGULATION IN THE
AGING HUMAN CIRCULATION: FUNCTIONAL
ANALYSIS OF 370 ADULT PATIENTS PRESENTING
FOR ELECTIVE MAJOR SURGERY
AUTHOR: S. F. Woodford1,2
affiliation: 1Anesthesia, Brisbane Waters Private Hospital,
Woy Woy, NSW, Australia; 2Australian School of Advanced
Medicine, Macquarie University, Sydney, NSW, Australia
Introduction: From 1945 to 1999, at least 24 studies
examined the effect of age on SV and CO, using a range of
methodologies, in patients of both genders, aged 16-89 years.
The effect of gender on cardiovascular performance in the aging
human remains unexamined, and recommended normal values for
the human circulation do not reflect even the effect of aging. The
emergence of new measurement technologies provides anesthetists
with the opportunity to re-examine long standing recommendations.
Methods: 370 adult patients presenting for elective major
surgery over a 36 month period were monitored using arterial and
central lines and Flotrac transducers(Edwards Lifesciences). Lines
were inserted prior to induction, and baseline values recorded.
Values were recorded over 3 to 10 minutes and averaged, and the
resultant data analysed graphically. The type of surgery included
joint arthroplasty (210 subjects- 122F,88M ), coronary artery and/or
valve replacement surgery(102 subjects- 26F,76M), esophagectomy
and abdominal surgery (47 subjects-19F,28M) and 11 endovascular
procedures. There were 169 female subjects and 201 male subjects
in the cohort studied. The age range was 35-93 yrs(females) and
30-91yrs (males).
Results: At any age, there is a gender dependent difference in
resting hemodynamic parameters. At an age consistent with female
menopause, there is an overt change in the adult female circulation,
characterised by a progressive fall in SV and SV range, and a rise in
vascular resistance, independent of BSA. A similar change appears
to develop in the adult male circulation commencing a decade later.
At any age, the male circulation is characterised by a high SV and
low resistance, and the female circulation by a low SV and high
resistance. The progressive fall in SV and SV range beyond the
6th decade in both genders raises the possibility of an endocrine/
menopausal effect on the regulation of pressure and flow in the adult
circulation. The gender specific difference in the premenopausal
adult circulation is consistent with higher work capacity and superior
athletic performance in male compared with female subjects.
Discussion: the male circulation at any age differs from the
female circulation. A consistent and predictable change occurs
around the female menopause, and a decade later in males,
suggestive of an endocrine influence on blood pressure, and
arguing for a male menopause. The greater work capacity of the
male circulation prior to menopause has implications for athletic
performance and combat roles.
References:
Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS
Prospective trial of supranormal values of survivors as therapeutic
goals in high risk surgical patients. Chest 1988, 94:1176-1186
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-61
S-61.
THE EFFECT OF PREOPERATIVE ANTIHYPERTENSIVE
THERAPY ON INTRAOPERATIVE SYSTOLIC BLOOD
PRESSURE VARIABILITY
AUTHORS: R. M. Craft, J. Buehler, R. C. Carroll, C. G. Snider,
Z. Dickson
affiliation:Anesthesiology, University of Tennessee Medical
Center, Knoxville, TN
Introduction: Although perioperative blood pressure
control is often recommended, there is little data connecting these
efforts with improved outcomes. Recently, intraoperative blood
pressure variability has been shown to predict postoperative
morbidity and mortality in cardiac bypass surgery1. Risk factors
for increased variability have not been identified, but data suggests
that intraoperative instability may be the result of preoperative
antihypertensive treatment2. In this study, we have looked at the
effect of preoperative antihypertensive regimens upon intraoperative
blood pressure variability.
Methods: After IRB approval, a retrospective EMR database
search was performed. Selection criteria included hypertensive
patients on single drug therapy preoperatively who had nonemergent surgery with an arterial line. 131 patients were identified
and divided into cohorts based on preoperative antihypertensive
medication. Operative records were analyzed for the percent of
total case time that systolic blood pressure was above 135mmHg
and/or below 90mmHg. This range was derived from previously
established systolic pressure ranges that were associated with poor
outcomes in previous trials1. This data underwent statistical analysis
to compare the effect of preoperative antihypertensive medication
with intraoperative variability using χ2 and Fisher’s Exact Test,
as appropriate. Comparison of demographics, co morbidities, and
intraoperative vasopressor requirement was also completed.
Results: Refer to Figure 1 and Tables 1-4.
Discussion: Patients on beta-blockers preoperatively demonВ­
strated significantly less high-end and overall variability compared
to patients treated with ACE-Inhibitors/ARBs or diuretics. They also
had less high-end variability compared with diet controlled patients
with a trend towards less overall variability. The beta-blocker cohort
required less vasopressor support intraoperatively. An increase in
SBP variability with ACE-inhibitors/ARBs was not demonstrated.
In conclusion, antihypertensive patients treated with beta-blockers
preoperatively had less intraoperative systolic blood pressure
variability. This effect could be explained by a preponderance
of younger males in the beta blocker group. Further studies are
indicated to study the effect of gender and age upon intraoperative
hemodynamic variability
References:
1.Intraoperative systolic blood pressure variability predicts
30-day mortality in aortocoronary bypass surgery patients.
Anesthesiology, 2010 Aug;113(2):305-12.
2.Hemodynamic effects of anesthesia in patients chronically
treated with angiotensin-converting enzyme inhibitors.
ANESTH ANALG, 1992; 74:8058.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-62
ANESTH ANALG
2012; 114; S-01 – S-493
S-62.
RISK OF ELECTIVE MAJOR NON-CARDIAC SURGERY
AFTER CORONARY STENT INSERTION
AUTHORS: D. N. Wijeysundera1,2, H. C. Wijeysundera3, M.
Wasowicz2, S. Beattie2, J. Velianou4, D. Ko3,5
affiliation: 1Li Ka Shing Knowledge Institute, St. Michael’s
Hospital, Toronto, ON, Canada; 2Anesthesia and Pain Management,
Toronto General Hospital, Toronto, ON, Canada; 3Cardiology,
Sunnybrook Health Sciences Centre, Toronto, ON, Canada;
4
Cardiology, McMaster University, Hamilton, ON, Canada;
5
Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
Introduction: For patients who require non-cardiac surgery
following coronary stent insertion, current practice guidelines
recommend that surgery be delayed until 30 to 45 days after baremetal stent insertion and one-year after drug-eluting stent insertion.
However, these recommendations are largely based on single-center
studies and expert opinion. We therefore conducted a populationbased study to evaluate the outcomes of elective intermediate-tohigh risk non-cardiac surgery following stent insertion.
Methods: Following research ethics board approval, we used
linked registry data and population-based administrative databases
to conduct a cohort study of 8116 patients, aged 40 years or older,
who underwent major elective non-cardiac surgery between 2003
and 2009, and received coronary stents within 10 years before their
non-cardiac surgery. Approximately 34% (n=2725) underwent stent
insertion within two years before surgery, of whom 905 (33%)
received drug-eluting stents. For comparison, we assembled a
separate cohort of 341,350 individuals, aged 40 years or older, who
underwent major elective surgery during the time period and had
not undergone coronary revascularization. The primary outcome
was postoperative 30-day major adverse cardiac events (mortality,
hospital readmission for acute coronary syndrome or repeat
coronary revascularization).
Proportion of patients with 30-day major adverse cardiac events, based on
the interval between the most recent coronary stent insertion and subsequent
non-cardiac surgery. The red columns represent proportions for individuals
who received bare metal stents (BMS), drug eluting stents (DES), or
either type of stent (for stent insertions two to 10 years before non-cardiac
surgery). For comparison, the horizontal dashed lines represent event rates
for individuals who did not undergo coronary revascularization within 10
years before non-cardiac surgery, and had been stratified by their Revised
Cardiac Risk Index scores.
Results: The overall rate of 30-day events in patients with
coronary stents was 2.1% (n=170). As shown in the Figure, when
the interval between stent insertion and surgery was less than 30days, event rates were high for bare-metal (6.7%) and drug-eluting
(20.0%) stents. When the interval was 45 to 180 days, the event rate
for bare-metal stents was 2.6%, approaching that of intermediaterisk non-revascularized individuals. Adjusted analyses suggested
that event rates were increased if this interval exceeded 180
days (adjusted OR 1.89; 95% CI 1.08 to 3.32). For drug-eluting
stents, the event rate was 1.2% once the interval exceeded 180
days, approaching that of intermediate-risk non-revascularized
individuals.
Discussion: The earliest optimal time for elective surgery is
46 to 180 days after bare-metal stent insertion or more than 180
days after drug-eluting stent insertion. In addition to suggesting that
practice guidelines be re-evaluated, these findings will help inform
clinical decision-making when weighing the risks of operative
versus non-operative therapy in patients being considered for
major elective non-cardiac surgery following recent coronary stent
insertion.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-63
S-63.
PERIOPERATIVE REMIFENTANIL ADMINISTRATION
INHIBITS ARRHYTHMIA ATTACK INDUCED BY
NON-REENTRY MECHANISMS IN PEDIATRIC
PATIENTS UNDERGOING RADIOFREQUENCY
CATHETER ABLATION
AUTHORS: K. Fujii1,2, H. Iranami2, K. Nishikawa1
affiliation: 1Anesthesiology, Wakayama Medical University,
Wakayama, Japan; 2Anesthesiology, Japanese Red Cross Society
Wakayama Medical Center, Wakayama, Japan
Introduction: Remifentanil has been known to affect the
autonomic nervous system. Although there have been many reports
indicating the relationship between the autonomic nervous system
balance and arrhythmia, the effect of remifentanil on arrhythmia
induction has not been clarified. The aim of this prospective
observational study was to determine whether remifentanil
administration during general anesthesia can affect the arrhythmia
induction in pediatric patients undergoing radiofrequency catheter
ablation (RFCA).
Methods: After obtaining informed consent, 205 patients
undergoing elective RFCA during 22 months in our hospital were
included in this study. The anesthesia maintenance was accomplished
with propofol 6-10 mg/kg/h and remifentanil 0.05 Ојg/kg/min. If
programmed cardiac stimulation, isoproterenol infusion, or their
combination were not effective in arrhythmia induction, remifentanil
administration was discontinued. Patients whose arrhythmia could
not be induced even after remifentanil discontinuation were defined
as induction-impossible cases. Arrhythmia was classified according
to their mechanisms, Reentry or non-Reentry. The mechanisms of
Non-Reentry arrhythmia include automaticity and triggered activity.
Statistical analysis was performed using logistic regression analysis
and data were presented as number (%) or Odds ratio (OR) [95%
confidence interval (CI)].
Results: Sixty-nine patients (33.7%) were diagnosed as NonReentry arrhythmia. Remifentanil was discontinued in 6 (4.4%)
and 46 (66.7%) patients in Reentry and non-Reentry groups,
respectively (OR 43.3 [95%CI 16.6-113], P<0.001). The incidence
of induction-impossible cases in non-Reentry group was higher than
in Reentry group (13 (18.8%) vs. 4 (2.9%), OR 7.7 [95%CI 2.424.5], P=0.001).
Discussion: Remifentanil during general anesthesia was often
discontinued in patients with non-Reentry arrhythmia. We have to
pay attention to remifentanil administration during RFCA because
of its inhibitory effect on arrhythmia attack induced by non-Reentry
mechanisms.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-64
ANESTH ANALG
2012; 114; S-01 – S-493
S-64.
INVESTIGATION OF INCIDENCE, FACTORS AND
OUTCOME MEASURES ASSOCIATED WITH INCREASED
WEIGHT GAIN FOLLOWING ADULT CARDIAC SURGERY
AUTHORS: A. D. Sharma1, A. Al-Achi2, H. Trettin1, J. Seccombe1
affiliation: 1Cardiac Anesthesia/Surgery, St Vincent’s Hospital,
Green Bay, WI; 2Department of Pharmaceutical Sciences, Campbell
University, Buies Creek, NC
Introduction: Peri-operative weight gain, a marker of fluid
storage, is strongly related to patient morbidity and mortality1.
We investigated the incidence, factors, and outcome measures
associated with weight gain following cardiac surgery that have not
been extensively studied before.
Figure 1: Patient Distribution Based On Type Of Procedure.
Methods: Retrospectively, 375 records were studied (Figure1).
Admission day (AD), post-op day (POD) 1,2,3, and discharge
day (DD) weights in kilograms (kg) were recorded. Maximum
percentage patient weight gain or loss at POD1,2,3 and DD was
calculated [with respect to AD weight]. Patient’s were divided in
to two groups: High Weight Gain [HWG] group (P75 or higher)
and Lower Weight Gain [LWG] group (P25 or lower). Outcome
measures recorded were tracheal extubation time, day 4 creatinine,
total hospital LOS (length of stay), and post-surgery 30-day alive.
Results: Maximum percentage weight gain occurred at POD
2 (35.0%). Highest Weight Gain (%) [MeanВ± S.D. (n)]=6.567% В±
4.304%(375). HWG group (n=85), 75th percentile was 8.37% and
for the LWG group (n=84), 25th percentile was 4.0% (Figure2&3
and Table1). A) No difference between groups with regards to, I)
pre-operative hemoglobin, creatinine, Prothrombin time (PT),
International Normalized Ratio (INR), Partial Thromboplastin time
(PTT), Platelet counts, and II) pre-operative use of Asprin, ACE
inhibitors, Beta blockers, Amiodarone, and incidence of diabetes.
B) HWG group, older (69.84В±12.41vs63.55В±13.05yrs(p=0.001),
longer bypass times (137.05В±57.95vs117.15В±45.37 min(p=0.02),
higher blood loss post-op (24hrs) (1014.70В±630.65vs842.13В±451
.56cc(p=0.02), higher total perioperative PRBC (2.66В±2.66vs0.73
8В±1.45U(p<0.0001), platelet (0.81В±1.2vs0.16В±0.57 U(p<0.0001),
FFP
(1.53В±2.31vs0.33В±1.1U(p<0.0001),
Cryoprecipitate
(0.46В±0.91vs0.13В±0.46U(p=0.008) transfusions, and 5%Albumin
use (1882.35В±1062.47vs1461.31В±891.30cc(p=002). C) HWG group
with longer tracheal extubation times(18.92В± 34.86vs10.31В±21.41
hrs(p=0.02). No difference in Day-4 creatinine, LOS, and 30-day
alive(p>0.05). D) Multivariate analysis, HWG group: No effect of
age, bypass time, gender, blood loss post-op (24 hrs), total PRBC,
platelet, FFP, cryoprecipitate use, day 4 creatinine, and tracheal
extubation times(p>0.05). G) HWG positively associated with total
5% albumin used(p=0.002), hospital LOS(p=0.004), and negatively
associated with BSA(p=0.02). [Based on Wilcoxon/Kruskal-Wallis
Test (Rank Sums), p<0.03, considered significant].
Figure 2: Post-op Weight Gain Distribution(Patient Numbers/%Weight
Gain)
Discussion: Weight gain following adult cardiac surgery
is common, one-third of patient’s gaining 7.5% or more, and is
directly related to amount of peri-operative colloid administered
(5% Albumin), and increased hospital length of stay.
References:
1. Anesthesiology,V109,723-40,2008.
Table 1: Maximum Patient Weight Gain POD Occurrence
POD1
n=93/25%
POD2
n=131/35%
POD3
n=124/33%
DD
n=27/7%
Total
375
Figure 3: Highest Weight Gain Occurrence (POD1/2/3/DD)
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-65
S-66
S-65.
S-66.
WITHDRAWN.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-67
S-68
ANESTH ANALG
2012; 114; S-01 – S-493
S-67.
S-68.
HAPTOGLOBIN POLYMORPHISM AND PERIOPERATIVE
MYOCARDIAL INJURY FOLLOWING CORONARY
ARTERY BYPASS SURGERY
OXYHEMODYNAMIC EFFECTS OF NORMAL
VERSUS HIGH ARTERIAL BLOOD FLOW DURING
CARDIOPULMONARY BYPASS CORONARY ARTERY
BYPASS GRAFTING SURGERY
AUTHORS: J. Raphael1, A. Fox2, C. D. Collard3, S. Shernan2, J. D.
Muehlschlegel2, S. Body2
affiliation: 1Anesthesiology, University of Virginia,
Charlottesville, VA; 2В­Anesthesiology, Perioperative and Pain
Medicine, Brigham and Women’s Hospital, Boston, MA;
3
Anesthesiology, Texas Heart Institute, Houston, TX
Introduction: Perioperative myocardial injury (PMI) occurs
in 10-15% of patients after cardiac surgery and is associated with
increased short and long-term mortality, as well as, increased
utilization of healthcare resources1. Numerous epidemiological
studies have documented an association between hemoglobinbinding protein haptoglobin (Hp) polymorphisms (specifically the
Hp 2-2 phenotype) and coronary artery disease in non-surgical
patients. We sought to determine whether the Hp-2-2 phenotype
is independently associated with myocardial injury after coronary
artery bypass graft (CABG) surgery with cardiopulmonary bypass
(CPB).
Methods: Retrospective analysis of prospectively collected data
of 707 patients undergoing primary CABG surgery with CPB at
two institutions (CABG Genomics Project; http://clinicaltrials.gov/
show/NCT00281164). Haptoglobin phenotypes were determined as
previously described using gel electrophoresis . PMI was defined as
postoperative day 1 (POD-1) cardiac troponin I (cTnI) serum level
in the top 10th percentile (>10.1 Вµg/L). Continuous and categorical
variables were compared between groups using student t and chi
aquare tests respectively. A multivariable logistic model was used
to derive perioperative and demographic variables associated with
PMI.
Results: 248 patients (35.1%) had the Hp 2-2 phenotype, while
459 patients were either Hp 1-1 (15.3%) or 2-1 (49.6%). POD1 cTnI levels were higher in patients with the Hp 2-2 phenotype
compared to patients with the non-2-2 phenotype (4.4 Вµg/L vs. 3.6
Вµg/L, p<0.05). Within the patients in the top 10th percentile for
cTnI, 32 (45.7%) had the Hp 2-2 phenotype, while 38 were either
Hp 1-1(20%) or Hp 2-1 (34.3%). Other risk factors associated with
PMI were myocardial infarction within 14 days prior to surgery
(p<0.01) and CPB time (p<0.05). After multivariable adjustments,
only CPB time (p<0.05; OR-1.76, 95% CI-1.18-3.45) and
myocardial infarction within 14 days prior to surgery (p<0.01; OR2.83, 95%CI-1.85-4.32) were associated with PMI
AUTHORS: M. A. Salgado1, A. Siciliano1, M. Lessa2
affiliation: 1Surgical Division, National Institute of Cardiology,
Rio De Janeiro, Brazil; 2Laboratory of Cardiovascular Investigation,
Oswaldo Cruz Foundation, Rio De Janeiro, Brazil
Introduction: Optimal blood flow to cardiopulmonary
bypass (CPB) is a controversial matter, and so far there is no
consensus about the oxyhemodynamic variables that could reflect
the adequacy of blood flow during CPB1. Although the use of
body surface to calculate the blood flow is largely advocated, there
are no standard definitions of ideal flow to be used during CPB.
The present study investigates the changes in oxyhemodynamic
variables induced by normal versus high arterial blood flow during
CPB in patients that underwent coronary artery bypass graft surgery.
Methods: Prospective, randomized, double blind study. Sixty
six adult patients scheduled for coronary artery bypass grafting
using normothermic CBP were divided into two different group
according to blood flow parameters: Control group (2.4 В± 2 L/min/
m2) and High-flow group (3.2 В± 2 L/min/m2). Variables analyzed
were lactate, oxygen delivery, oxygen consumption, venous oxygen
saturation and venous-arterial carbon dioxide gradient, measured at
10, 20, 40 and 60 minutes.
Results: The High-flow group showed a significant improvement
of the oxygen delivery, oxygen consumption, venous oxygen
saturation, and venous-arterial carbon dioxide gradient when
compared to control group. The differences in oxyhemodynamic
variables were more significant after 40 and 60 minutes of CPB.
The systemic lactate concentration was not significantly different
when comparing High-flow group with the Control group.
Discussion: We concluded that blood flow from 3.2 В± 2 L/
min/m2 better preserves oxyhemodynamic parameters during
normothermic cardiopulmonary bypass in patients undergoing
coronary artery bypass grafting when compared to flow of 2.4 В± 2
L/min/m2. We also concluded high-flow in CPB does not change
lactate concentration, suggesting similarity in tissue perfusion in
both perfusion techniques.
References:
1.Optimal perfusion during cardiopulmonary bypass: an evidencebased approach. Anesth Analg 2009;108: 1394-417.
Discussion: Although patients with the Hp-2-2 phenotype
had higher levels of cTnI on POD-1, this Hp phenotype was not
independently associated with perioperative myocardial injury after
CABG surgery.
References:
1.Muehlschlegel JD et-al, Chromosome 9p21 variant predicts
mortalВ­В­ity after coronary artery bypass graft surgery. Circulation.
2010 Sep 14;122:S60-5.
2.Levy AP et-al. Haptoglobin phenotype and vascular complications
in patients with diabetes. N Engl J Med. 2000;343(13):969-70.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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S-69.
S-70.
VALUE OF COMBINED PRE- AND POSTOPERATIVE
NT-PROBNP MEASUREMENT TO PREDICT DEATH AND
MAJOR CARDIOVASCULAR EVENTS AT 1 YEAR AFTER
NONCARDIAC SURGERY
CARDIAC EVALUATION AND OUTCOMES IN PANCREAS
TRANSPLANTATION
AUTHORS: G. A. Lurati Buse1, E. Seeberger1, C. Werner1,
M. Filipovic2,1, D. Bolliger1, M. Seeberger1
affiliation: 1Surgery, Indiana University School of Medicine,
Indianapolis, IN; 2Anesthesia, Indiana University School of
Medicine, Indianapolis, IN
affiliation: 1Anesthesiology, University Hospital Basel,
Basel, Switzerland; 2Anesthesiology, Kantonsspital St. Gallen,
St.Gallen, Switzerland
Introduction: Several studies addressed the prognostic
value of perioperative natriuretic peptides’ measurement1,2. It is
not established if combined pre- and postoperative measurements
add to the prognostic accuracy. Our objective was to evaluate the
incremental prognostic value of combined pre- and postoperative
NT-proBNP measurement in patients undergoing noncardiac
surgery.
Methods: This is a predefined cohort analysis nested in a
randomized controlled trial. The prespecified endpoint was a
composite of all-cause mortality, acute coronary syndrome,
coronary revascularisation, and congestive heart failure requiring
hospitalization within 1 year after surgery. We measured NTproBNP prior to induction, on postoperative day 1 and 2. Patients
and outcome adjudicators were blinded. We calculated the area
under the receiver operating characteristics curve (AUC) for NTproBNP at each timepoint. We conducted a multivariate logistic
regression with the composite endpoint as dependent and NTproBNP(preoperative and day 2), postoperative troponin T elevation
and treatment allocation as independent variables.
Results: We assessed 380 patients. Information on major adverse
cardiac event at 1 year was missing in 2 (0.5%) patients; survival
data were complete. Seventy (18.4%) patients suffered an event
at 1 year. The AUC of NT-proBNP for 1-year outcome was 0.666
(95%confidence interval 0.59-0.84), 0.659 (0.59-0.73) and 0.656
(0.58-0.73) prior to induction, on day 1, and day 2, respectively.
After multivariate adjustment, preoperative NT-proBNP was no
longer significantly associated with 1-year outcome, whereas the
association for NT-proBNP on day 2 persisted (OR 1.012 per 100
pg/mL increase, 95%CI 1.001-1.023).
AUTHORS: D. Farar2, R. Mangus1, S. Kinsella2, C. Creal1, J. A.
Fridell1
Introduction: Pancreas transplantation is an effective therapy
for the treatment of diabetes. Patients with diabetes are at high risk
of developing coronary artery disease (CAD). A thorough cardiac
evaluation is required prior to pancreas transplantation. This study
reviews a large number of pancreas transplant patients to assess the
prevalence of CAD and cardiac interventions and to determine the
impact of cardiac history on post-transplant outcomes.
Methods: The records of all pancreas transplant patients from
2003 to 2010 at a single high volume center were reviewed. CAD
was assessed from a review of all available pretransplant records
for each patient. Cardiac interventions included coronary artery
bypass, stent placement or angioplasty. Post-transplant outcomes
of myocardial infarction and stroke required confirmatory testing.
Survival was assessed using Cox regression survival analysis.
Results: There were 405 transplants in 389 patients during the
study period. There were 63 patients with diagnosed CAD (16%), 19
patients with prior MI (5%), and 47 patients with previous coronary
artery intervention (12%). Median follow up was 46 months.
Posttransplant, there were 11 patients who suffered MI (3%) and 13
who suffered stroke (3%). Survival at 5-years for patients with and
without a pretransplant history of CAD was 80% and 90%, p=0.04.
Discussion: Pancreas transplant patients overall have a low
post-transplant risk of MI and stroke. Survival at 5-years posttransplant differs significantly based upon previous history of
coronary artery disease. Pancreas transplant patients should undergo
thorough pretransplant cardiac risk stratification because of their
underlying risk of CAD and their lower survival posttransplant.
References: None
Discussion: After multivariate adjustment, including by
postoperative NT-proBNP, preoperative NT-proBNP waqs no
longer associated with 1-year all-cause mortality and major
cardiovascular events after major noncardiac surgery. In contrast,
the predictive value of postoperative NT-proBNP concentrations
persisted after adjustment by the preoperative values. This findings
need confirmation in a larger cohort.
References:
1.Karthikeyan G, Moncur RA, Levine O, et al. Is a pre-operative
brain natriuretic peptide or N-terminal pro-B-type natriuretic
peptide measurement an independent predictor of adverse
cardiovascular outcomes within 30 days of noncardiac surgery?
A systematic review and meta-analysis of observational studies.
J Am Coll Cardiol. Oct 20 2009;54(17):1599-1606
2.Mahla E, Baumann A, Rehak P, et al. N-terminal pro-brain
natriuretic peptide identifies patients at high risk for adverse
cardiac outcome after vascular surgery. Anesthesiology
2007;106:1088-95.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-72
ANESTH ANALG
2012; 114; S-01 – S-493
S-72.
HIGH SPINAL ANESTHESIA IN SEVERE MITRAL
STENOSIS: COMPARISON OF HEMODYNAMICS WITH
HIGH DOSE OPIOID ANESTHESIA
AUTHORs: V. K. Arya1, L. Yaddanapuri1, P. Madhusudan1, S. K.
Thingnam2, A. Bahl3
affiliation: 1Cardiac Anaesthesia Unit, Department of
Anaesthesia & Intensive Care, Postgraduate Institute of Medical
Education And Research, Chandigarh, India; 2Department of
Cardiothoracic and vascular surgery, Postgraduate Institute of
Medical Education And Research, Chandigarh, India; 3Department
of Cardiology, Postgraduate Institute of Medical Education And
Research, Chandigarh, India
Figure 1: Heart rate at various study points
Introduction: Severe mitral stenosis (MS) has been
considered a contraindication to spinal anesthesia for fear of
unstable hemodynamics1. This prospective randomized trial
examined the effect of high spinal in combination with general
anesthesia on hemodynamics and postoperative outcome during
mitral valve replacement (MVR) surgery in patients with severe MS
and atrial fibrillation.
Methods: Fifty patients were randomized to opioid group O
(n=25) or spinal group S (n=25). Patients in group S received spinal
hyperbaric bupivacaine 40mg+1mg morphine while in group O
intravenous morphine 0.5mg/kg+4Ојg/kg fentanyl was given before
induction of general anesthesia. Phenylepherine infusion was used
to maintain mean BP > 65 mmHg in both groups. Comparisons
were made between groups for hemodynamic parameters derived by
echocardiography and pulmonary artery catheter and postoperative
profile of the patients.
Results: High spinal resulted in significant reduction of heart
rate (HR) and systemic vascular resistance index as compared to
opioids (64.6В±8.5 vs. 94.7В±18.2 beats/min and 3068.7В±726.7 vs.
3964.5В±763.6 dynes.s.cm-5.m-2 respectively, p<0.05). The mitral
diastolic velocity time integral (MVVTI) and stroke volume index
across aortic valve increased significantly after spinal as compared
to opioid (89.8В±17.7 cm/s vs 58.0В±23.3 cm/s and 39.2В±18.4 ml/
m2 vs 18.5В±12.6 ml/m2 respectively, p<0.05). Total phenylephrine
dose used, cardiac index (CI) and other hemodynamic parameters
remained comparable between the two groups. Postoperatively,
incentive spirometry volume at first hour postextubation was
significantly higher in group S than group O (320В±103.2 vs.
212В±67.5 ml/s; p< 0.05). Total morphine requirement in 24 hrs
was significantly less in spinal group. However, mean duration of
mechanical ventilation and ICU stay were comparable.
Discussion: Significant fall in HR after high spinal in this study
was similar to the earlier study in coronary artery bypass graft
patients by Kowalewsky et al2. Mean MVVTI increased as a result
of reduction in HR. This increased left ventricle filling and resulted
in maintained CI in spinal group. The lower incentive spirometry
volumes in group O may be due to effect of morphine that might
have prevented maximal patient effort. Comparable extubation
times in both groups were due to their dependence on various factors
other than early awakening of the patients. In conclusion, high
spinal anaesthesia can safely be given to patients with severe MS
undergoing MVR. It reduces the opioid consumption and provides
stable hemodynamic profile comparable to opioid anesthesia.
Figure 2: Stroke volume index at various study points
Figure 3: Systemic vascular resistance index at various study points
Figure 4: Cardiac index at various study points
References:
1.Casalino S et al. Tex Heart Inst J. 2006;33:148-53.
2.Kowalewski RJ et al. Can J Anaesth 1994;41:1189-95.randomВ­
ized study. J Cardiothorac Surg 5:17, 2010
Figure 5: Pulmonary artery wedge pressure at various study points
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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2012; 114; S-01 – S-493
S-73.
S-74.
OBSERVATIONAL STUDY OF FUNCTIONAL
HEMODYNAMICS DURING ONE LUNG VENTILATION
INCIDENCE OF ASYMPTOMATIC DVTS FOUND
IMMEDIATELY PRIOR TO ELECTIVE SURGERY
AUTHORs: K. Raghunathan1, W. T. McGee2, R. Thanawala3,
C. Gibson1, G. Hochheiser3, R. Ganim3
AUTHORs: J. Yin2, K. Clinite1, M. Ngozi2, P. O’Connor1, M. F.
O’Connor1, D. Glick1
affiliation: 1Anesthesiology, Baystate Medical Center,
Springfield, MA; 2Division of Critical Care, Baystate Medical
Center, Springfield, MA; 3Division of Thoracic Surgery, Baystate
Medical Center, Springfield, MA
affiliation: 1Anesthesia and Critical Care, University of
Chicago, Chicago, IL; 2University of Illinois at Chicago, Chicago, IL
Introduction: Intraoperative hemodynamic monitoring with
an intra-arterial catheter is common 1 during Video-Assisted
Thoracoscopic Surgeries (VATS) and Thoracotomies. The VigileoFlotrac device (Edwards LifeSciences, Irvine, CA) uses Arterial
Pulse contour based analytic methods to report Cardiac Output (CO),
Stroke Volume (SV) and Stroke Volume Variation (SVV). Dynamic
functional hemodyanmic parameters such as the SVV have been
widely studied2 and values to volume responders identified3. Cardiorespiratory interactions during procedures requiring one lung
ventilation (OLV) remain under-studied4. Our goal is to evaluate the
SVV:SV relationship during OLV.
Methods: After local IRB approval, patients scheduled to
undergo elective thoracic surgical procedures requiring OLV and
intra-arterial catheters (based on the clinical judgement of the
attending anesthesiologist) were made eligible for inclusion. After
informed consent, the Vigileo device with the Flo-Trac sensor
(software version 3.02) was attached to the intra-arterial catheter
and data (recalculated by auto-calibration every 20 seconds)
continuously displayed and captured using a computer data logger
through: transition from two lung to one lung ventilation, supine to
lateral positioning, surgical resection of lung tissue, and transition
from mechanical to spontaneous ventilation. In addition the Passive
Leg Raise (PLR) maneuver was performed in the OR.
Results: CO, SV, and SVV were tracked during routine VATS or
open thoracic surgery for our first 10 patients included in the study.
Based on all 242 paired observations collected to-date, SVV and
SV showed an inverse relationship (p<0.001). The standardized
correlation co-efficient was -0.370. Based on data from our first
8 patients, the PLR maneuver produced a predictable effect.
Compared to the baseline state, passive leg raising produced an
increase in both the CO (by 0.63 l/minute) and SV (by 9.5 cc/beat),
p<0.05. The change in CO was largely explained by the change in
SV rather than an increase in the heart rate.
Discussion: The preliminary findings in this report on functional
hemodynamics during one lung ventilation (n=10 patients, 242
paired data points) confirms that the expected inverse relationship
between SVV and SV persists during OLV despite lower tidal
volumes.
In addition, we confirmed that the positive effects of PLR on CO are
reproducible under anesthesia.
Introduction: Deep venous thrombosis (DVT) is a common
surgical complication with potentially serious consequences
including pulmonary embolism. The development of postoperative
DVTs is a great concern both clinically and administratively, and
their prevention is one of the quality standards by which hospitals
are ranked. Much of the existing literature on DVT incidences have
been on postoperative and population-based data, with a focus on
high risk groups or specific surgeries. For moderate to high risk
surgical patients, the incidence of developing DVTs postoperatively
has varied (2-20% in the thigh and 10-80% in the calf veins)1.
Meanwhile, the incidence of DVTs in the general population is
reported to be between 0.35 and 1.8 per 1,000 people per year2,3.
This study looks to determine if stress and other perioperative
considerations increase the incidence of asymptomatic DVTs in the
lower extremities immediately prior to elective surgery.
Methods: After IRB approval and informed consent 200 adult
patients scheduled for elective surgery between April and August of
2011 were enrolled in this study. Bilateral color Doppler ultrasound
examinations of the patients’ proximal and distal lower extremities
were conducted in the preoperative holding area with a portable
sonographic unit (SonoSite Micromaxx) by trained examiners.
Patients with a history of DVT within 6 months were excluded from
the study. Patient risk factors, anticoagulant medication, and ASA
classification were collected and analyzed.
Results: No DVT was found in the preoperative examinations of
the 200 patients enrolled. The mean age of the patients scanned was
58.1 years (В±14.5). Mean BMI was 28.7 (В±6.6), with 29% of patients
obese. 38.5% of the patients were taking daily aspirin or coumadin
up to one week prior to surgery. 4.5% had a history of DVT more
than 6 months prior to the study. Among other risk factors, 37%
of patients had a malignancy, 43% had hypertension, and 12%
had diabetes. 9% were taking oral contraceptives or hormone
replacement at the time of surgery. No patient was pregnant. 95% of
the patients enrolled had an ASA status of II or III.
Discussion: The incidence of asymptomatic DVTs in this
preoperative cohort was not higher than the rate of the general
population. As a result, it is unlikely that a significant proportion of
the DVTs seen after surgery are the result of previously unrecognized
clots present prior to surgery. Thus, continued efforts to limit the
risk of perioperative DVTs must concentrate on the mechanisms and
risk factors for clot formation during and after surgery.
References:
References:
1. Chest 2001;119:132S-175S
1. Cannesson et al. Crit Care 2011, 15: R197.
2. Med J Aust. 2008;189(3):144-7
2. Marik PE et al. Crit Care Med. 2009 Sep;37:2642-7.
3. J Intern Med 1992;232(2):155-60
3. Cannesson et al ANESTHESIOLOGY 2011; 115:231-41.
4. Suehiro et al. JCTVA 2010; 24 (5): 772-5.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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2012; 114; S-01 – S-493
S-75.
S-76.
INCIDENCE OF POSTOPERATIVE DVTS SHORTLY AFTER
ELECTIVE SURGERY
PAIN MANAGEMENT FOLLOWING ROBOTIC
CORONARY ARTERY BYPASS GRAFTING
AUTHORS: J. Yin2, K. Clinite1, P. Vishwanath1, M. Ngozi2, M. F.
O’Connor1, D. Glick1
AUTHORS: M. Snyder1, G. Leyvi1, M. Cecchini1, L. Boone1,
S. Nair1, J. DeRose2
affiliation: 1Anesthesia and Critical Care, University of
Chicago, Chicago, IL; 2University of Illinois at Chicago, Chicago,
IL
affiliation: 1Anesthesiology, Albert Einstein College of
Medicine & Montefiore Medical Center, Bronx, NY; 2Cardiothoracic
and Vascular Surgery, Albert Einstein College of Medicine &
Montefiore Medical Center, Bronx, NY
Introduction: The risk of developing a deep venous
thrombosis for some surgeries is highest two to five days after
surgery, with a second peak occurring around 10 days after surgery1.
For moderate to high risk surgical patients, the incidence of
developing DVTs postoperatively has varied (2-20% in the thigh
and 10-80% in the calf veins)2. This study looks to determine the
incidence of postoperative DVTs in the lower extremities following
elective surgery and to identify some of the perioperative risk
factors.
Methods: After IRB approval and informed consent 200 adult
patients scheduled for elective surgery between April and August of
2011 were enrolled in this study. Following their surgery, bilateral
color Doppler ultrasound examinations of the patient’s proximal and
distal lower extremities were conducted in the PACU for same-day
discharge patients and within 7 days for admitted patients using
a portable sonographic unit (SonoSite Micromaxx) by trained
examiners. Only the contralateral leg was scanned for patients with
casts following hip or knee surgery. Type of surgery and anesthesia,
duration under anesthesia, intraoperative DVT prophylaxis,
operative positioning, and the time interval between surgery and
post-operative scan were collected and analyzed. Patient charts
were followed for 90 days after surgery to identify the development
of postoperative DVT or PE or other complications.
Results: No DVT was found in the 166 postoperative scans
conducted an average 1.4 days following surgery. 83% of the
patients had general anesthesia for their surgery and 11% received
spinal anesthesia. The types of operations enrolled are described in
Figure 1. DVT prophylaxis was given to 50% of the patients. The
mean operative time was 173.8 minutes (В±109.0). Chart follow-up
identified the development of acute DVTs 3 and 18 days after surgery
in 2 orthopedic patients on the ipsilateral side of surgery, for a rate of
5.5% among orthopedic patients examined in this study and an overall
rate of 1.0% among all patients enrolled. Both patients received DVT
prophylaxis and were given spinal anesthesia during surgery.
Discussion: The risk of developing postoperative DVTs is low
shortly after elective surgery, but this may potentially underestimate
the actual incidence of postoperative DVTs. Risk factors that
increase the incidence of postoperative DVTs may involve longer
hospital stays or periods of immobility following surgery and
orthopedic procedures. The overall low incidence of postoperative
DVTs found may also suggest that preventative measures made
perioperatively to reduce the development of DVTs are working
effectively.
References:
1. AAHKS 2009
2. Chest 2001;119:132S-175S
Introduction: Robotic coronary artery bypass grafting
(CABG) avoids sternotomy and cardiopulmonary bypass, but
may lead to greater postoperative pain due to the need for lateral
thoracic incisions. Both continuous delivery of anesthetic through
a subpleural catheter (e.g. OnQВ® [I-Flow Corporation, Lake Forest,
CA]) and intraoperative intercostal nerve blocks effectively control
robotic CABG patients’ pain. This study seeks to determine if either
OnQ or intercostal nerve block offers an advantage in treating
postoperative pain.
Methods: A cardiothoracic surgical database was searched for
patients who received robotic CABG performed by a single surgeon
between 2007-2011. Analgesic method (OnQ or intercostal nerve
block -both using 0.25% bupivacaine) was chosen by the surgeon.
Postoperative pain was assessed using a Visual Analog Scale.
Average pain scores for the 1st - and 2nd -24 hour intervals were
compared between groups. Total amount of intraoperative and
postoperative opioids (in morphine equivalents) administered were
each compared. The Mann-Whitney test was used for data analysis.
Results: Of the 110 patients enrolled, 54 received OnQ, 54
received intercostal nerve blocks and 2 were excluded. There was no
difference between groups in the amount of intraoperative fentanyl
received (median=1250 mcg; 25th-75th percentile=825-1712
OnQ vs. 1000 mcg; 750-1500 intercostal; p=0.33). Average pain
scores for the first 24 hour interval were significantly lower in the
OnQ group (0.68; 0.29-1.34 On-Q vs. 1.21; 0.53-1.74 intercostal,
p=0.04). However, for the second 24 hour interval the average
pain scores were not statistically different (0.56; 0.00-1.28 OnQ
vs. 0.96; 0.20-1.91 intercostal, p=0.08). OnQ patients required less
postoperative IV fentanyl (100.00 mcg; 50-150 OnQ vs. 150.00
mcg; 50-250 intercostal; p=0.01) and postoperative IV opioids (10
mg; 5-15 OnQ vs. 17.5 mg; 10-30 intercostal, p=0.01). There was
no difference between the groups in the amount of postoperative
PO opioids received (15 mg; 5-25 OnQ vs. 20 mg; 5-35 intercostal,
p=0.30).
Discussion: Both pain control methods achieved satisfactory
results. Patients who received OnQ had lower pain scores during
the first 24 hours and required less postoperative IV opioids than
patients in the intercostal group despite no difference in the amount
of intraoperative fentanyl received. Although OnQ is significantly
more expensive than intercostal nerve block, it may result in more
patient satisfaction and less postoperative opioid use. However, in
an environment where reduction in health care spending is becoming
increasingly important, the benefits of using OnQ must be weighed
against its increased cost.
References: none
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-77
S-77.
KIDNEY INJURY AFTER PERCUTANEOUS AND
SURGICAL AORTIC VALVE REPLACEMENT
AUTHORS: F. Guarracino, R. Baldassarri, L. Lombardi, E.
Avagliano
affiliation: Cardiothoracic, University Hospital of Pisa,
Pisa, Italy
Introduction: Standard AVR (SAVR) is the first option
treatment for patients (pts) with severe aortic stenosis. Transcatheter
aortic valve implantation (TAVI) offers the possibility of valve
implantation in high risk pts, thus reducing complications1.
Renal failure is a frequent and severe complication of cardiac
surgery, and it is traditionally diagnosed by serum creatinine. A
novel biomarker, the neutrophil gelatinase-associated lipocalin
(NGAL), can be measured after cardiac surgery, as it has shown to
be an excellent early predictor for acute kidney injury (AKI)В­2.
In the hypothesis that the avoidance of cardiopulmonary bypass and
cardioplegic arrest could prevent renal damage, we compared the
postoperative plasmatic NGAL between patients undergoing TAVI
and those undergoing SAVR.
Methods: We collected data from 20 pts undergoing TAVI who
were case-matched with 20 control pts undergoing SAVR.
NGAL plasma test was performed at baseline and 4 hours after
cardiopulmonary bypass initiation and balloon valvuloplasty
respectively in patients undergoing surgical and percutaneous
procedure. Baseline, 4 hours and postoperative peak creatinine were
recorded. Dichotomous data were compared by using П‡2 test with
Yate’s correction or Fisher’s exact test when appropriate. Continuous
measures were compared by analysis of variance (ANOVA) or the
Mann-Whitney U test when appropriate.
Results: Baseline NGAL level was similar in the two groups,
whereas postoperative NGAL was significantly different in the two
groups (133В±76 in group TAVI vs 256В±23 in group SAVR on arrival
in ICU, p < 0.05).
Five pts in the SAVR group and two pts in the TAVI group doubled
serum creatinine levels when compared to baseline: NGAL plasma
concentration raised significantly only in these patients of the
SAVR group (p<0.05) when compared to baseline. On arrival in
ICU NGAL (p 0.015) was an independent predictor of AKI whereas
serum creatinine and serum urea were not independent predictors
of AKI.
Discussion: We suggest that cardiopulmonary bypass alone,
as required for SAVR, can lead to an increase in plasma NGAL.
In our study NGAL, compared to serum creatinine and glomerular
filtration, allowed an earlier detection of AKI thus providing the
possibility to treat kidney injury at an early stage and to prevent its
extension.
References:
1.Grube E, Laborde JC, Gerckens U, et al: Percutaneous implantВ­
ation of CoreValve self-expanding prosthesis in high-risk
patients with aortic valve disease. The Siegburg First-in-man
study. Circulation 114:1616-24, 2006.
2.Mishra J, Dent C, Tarabishi R et al. Neutrophil gelatinaseassociated lipocalin (NGAL) as a biomarker for acute renal
injury after cardiac surgery. Lancet 365:1231-1238, 2005.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
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Critical Care Medicine
& Trauma
ABSTRACTS
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Abdominal conditions causing pseudo STEMI
S-155.
ABDOMINAL ETIOLOGY FOR MIMICKED ST SEGMENT
ELEVATED MYOCARDIAL INFARCTION ON THE
ELECTROCARDIOGRAPH
Clinical Condition
Site of
Year Pseudo
STEMI
Acute pancreatitis
2008
Inf
2008
Inf
CA
2009
Inf
Thrombolytic therapy given.
CA.Cardiac enzymes and perfusion
scans normal
2009
AL
NTG infusion. CA. Normal CK-MB
and reversible changes on ECHO
2006
AS
Aspirin, NTG, thrombolytic therapy.
ECHO normal. CA
2011
IL
Aspirin, Low molecular
weight heparin, Clopidogrel,
Echocardiograpghy and troponin
level normal
2002
AS
Thrombolytic therapy, cardiac
enzymes normal
2009
Inf
Cardiac enzymes and
echocardiography normal
AUTHOR: S. Patel
affiliation: Anesthesia, The Pennine Acute NHS Trust,
Rochdale, United Kingdom
Introduction: Introduction: ST segment elevation on the
electrocardiograph (ECG) may occur in the absence of coronary
artery disease.
Methods: Medline database and Google scholar were searched
for primary non-cardiac causes of ST segment elevation on the
ECG. Search was done for �mimicked myocardial infarction (MI)’,
�simulating MI’, �pseudo MI’ for the period 2002-2011. The reports
of abdominal causes for ST segment elevation were retrieved. Initial
diagnosis and leads affected were noted. Cardiac investigations and
interventions done were noted. Proposed mechanisms and timing of
resolution of ST segment elevation were summarized.
Results: Various abdominal conditions (table) caused ST
segment elevation. Acute MI was wrongly diagnosed. Drastic
investigations and management such as coronary angiography (CA)
and thrombolytic therapy were carried out in some cases(table).
CA was performed and reported normal in 10 (out of 16) cases of
pseudo MI (table). Correct diagnosis of primary condition was by
made after investigations such as radiological (Ultrasound and CT
scan of abdomen) and biochemical in cases of acute pancreatitis,
cholecystitis, appendicitis and pheochromocytoma. Changes
reverted with correction and management of primary abdominal
condition.
Discussion: It is estimated that 500,000 STEMI events occur
every year in the US1. Confirmed STEMI requires initiation of time
bound protocol management. However, pseudo changes should
be considered in initial differential diagnosis (DD) of STEMI on
ECG. ECG changes simulating STEMI has also been reported with
intracranial haemorrhage, pneumothorax, pulmonary embolism,
pericarditis, myocarditis and hyperkalemia2. Clinical history and
examination, atypical course of ST elevation and unusual changes in
other ECG leads may help in DD. Further non-cardiac investigations
could prevent invasive cardiac procedures and management.
Acute cholecystitis
Acute appendictis
Cardiac Interventions and
Investigations Done
Aspirin, clopidogrel, Heparin
infusion. CA
Pheochromocytoma 2004
Ant
CA. Reversible changes on ECHO
2007
Ant
Aspirin, carvedilol, perindopril
given. CA. Normal ECHO.
Cancer -collecting
duct of kidney
2006
Inf and Cardiac enzymes normal, ECHO
AL
showed mass lesion in LV
Cancer - Urinary
bladder
2011
AS
CA. Mass lesion in LV on ECHO
and MRI
Distended gastric
conduit
2006
Inf
CA, Normal troponin T and LV
function on ECHO
Ruptured gastric
volvulus
2009
IL
CA, normal ventricular function on
ECHO
Intestinal
obstruction
2003
Ant
urgent cardiology consultation,
normal cardiac enzymes and normal
ventricular function
Rectus sheath
haematoma
2006
Inf
Troponin I normal
Inf=inferior; Ant=anterior; AS=anteroseptal; AL=anterolateral;
CA=coronary angiography
Mechanisms for pseudo ST segment elevation depend on primary
abdominal etiology. Acute pancreatitis related changes may occur
due to associated sepsis, cardiac effects of proteolytic enzymes
or calcium disturbances. Acute cholecystitis can cause reflex
(afferent via vagal and efferent О± receptor mediated) decrease
in coronary blood flow. Myocardial stunning due to coronary
artery spasm or neurogenic mechanism was reported as a cause
in case of pheochromocytoma. Myocardial metastasis causing
local inflammation and mass effect mimicked STEMI which was
persistent.
In conclusion, incorrect diagnosis of STEMI may lead to serious
consequences including delay in true diagnosis of acute abdominal
pathology. Physicians should be aware of rare causes of ST segment
elevation on the ECG.
References:
1. Circulation 2004; 110:588-636
2. Chest 2004; 125:1561-76
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ABSTRACTS
S-156
S-157
ANESTH ANALG
2012; 114; S-01 – S-493
S-156.
S-157.
SODIUM BICARBONATE INFUSION IN THE CARDIAC
SURGERY PATIENT: A RETROSPECTIVE STUDY
GOAL-DIRECTED THERAPY AFTER CORONARY ARTERY
BYPASS GRAFTING IMPROVES OUTCOME IN PATIENTS
WITH SEVERE LEFT VENTRICULAR DYSFUNCTION
AUTHORS: H. H. Amhaz, D. Gupta, D. Apostolou, Y. Al-Baghdadi,
L. Safadi, M. Orlewicz
affiliation: Anesthesiology, Wayne State University / Detroit
Medical Center, Detroit, MI
Introduction: There are multiple factors that contribute to
acute renal dysfunction in patients undergoing cardiac surgery.
Although some studies have shown the use of sodium bicarbonate
to be renal protective in these patients, much controversy remains.
Methods: A retrospective analysis of patients who underwent
cardiac bypass or valvular surgery over a three year period (200720010) was performed to compare biochemical and clinical
parameters in the patients who either received or did not receive
POSBI at our institution. Two groups were analyzed; 1) AfricanAmerican (AA) patients (n = 89 POSBI; n = 97 no treatment)
and 2) Non African-American (NAA) patients (n= 17 POSBI; n
= 26 no treatment). Serum creatinine and incidence of acute renal
dysfuntion as per the Acute Kidney Injury Network (AKIN) criteria
were measured within the first five post-operative days. Secondary
outcomes including ventilator time, intensive care unit length of
stay, post-operative stay and three month mortality were measured.
Results: Peri-operative sodium bicarbonate infusion (POSBI)
showed no difference between AA patients in regards to renal
dysfunction [AKIN Stage 1: 31% vs 30% (p=0.87); AKIN Stage
2: 4% vs 2% (p=0.43); or AKIN Stage 3: 9% vs 10% (p=0.81)].
Peri-operative sodium bicarbonate infusion (POSBI) also showed
no difference between NAA patients in regards to renal dysfunction
[AKIN Stage 1: 18% vs 35% (P=0.3); AKIN Stage 2: 6% vs 4%
(p=0.99); and AKIN Stage 3: 0% vs 0% (p=0.99)]. No difference
was observed in the maximal change in the serum creatinine in the
first five post-operative days following POSBI within AA patients
(p=0.91) or NAA patients (p=0.56). For other post-operative clinical
outcomes measured, the only statistically significant finding was a
decreased ventilator time in the AA patients who received POSBI
[2.0 days vs 4.8 days (p=0.0025)].
Discussion: POSBI did not result in measurable increases of
renal protection in post-cardiac surgery patients. A reduction in
ventilator time was seen in AA patients receiving POSBI.
References:
1.Chertow G et al, Independent Association between Acute Renal
Failure and Mortality following Cardiac Surgery. The American
Journal of Medicine. 1998;104(4):343-8
2.Dragun D, et al, Sodium bicarbonate to prevent increases in
serum creatinine after cardiac surgery: A pilot double-blind,
RCT. Crit Care Med. 2009;37(1):39-47
3.Meheta R, et al., Acute Kidney Injury Network: a report of an
initiative to improve outcomes in acute kidney injury. Critical
Care. 2007;11(2):1-8
4.Navaneethan S, et al, Sodium Bicarbonate Therapy for
Prevention of Contrast-Induced Nephropathy: A Systematic
Review and Meta-analysis. American Journal of Kidney
Disease, 2009;53(4):617-627
AUTHORS: A. F. Attaallah1,2, H. H. Abdelwahab2
affiliation: 1Department of Anesthesiology, West Virginia
University, Morgantown, WV; 2Department of Anesthesia and
Critical Care, Cairo University, Cairo, Egypt
Introduction: Despite the poor prognosis of advanced
ischemic cardiomyopathy, Coronary Artery Bypass Grafting (CABG)
remains an option for a selected subsets of patients. These patients
with severe left ventricular dysfunction carry a high mortality rate
(10% to 37%) and a very delicate Intesive Care Unit (ICU) course in
the early postoperative period.
We evaluated our experience with the use of a postoperative goaldirected hemodynamic management protocol, in order to identify
it’s clinical benefit on the outcome measures, for CABG patients
with severe left ventricular dysfunction.
Methods: This is a retrospective review in which we analzyed
our database of 138 consecutive patients with severe left ventricular
dysfunction (Ejection Fraction < or = 35%) who underwent isolated
coronary artery bypass grafting with cardiopulmonary bypass
during a 4-year period (2001-2005). Patients were divided into two
groups, Group A (n=74 - before 2003) where the normal routine
postoperative ICU protocol was used based on vital signs, and Group
B (n=64 - after 2003) when we started a tighter and more invasive
ICU protcol. This approach implied the insertion of a Pulmonary
Artery Catheter (PAC) and frequent echocardiography studies (on
admision and every 6 hours for the first 24 hours) to guide inotropic
support needs and fluid management therapy.
Results: The patients in both groups had similar preoperative
characteristics, were operated by the same surgical teams, and had no
significant operative differences. By using PAC measurements and
echocardiographic studies to guide inotropic support and volume
needs, a marked reduction in cardiac morbidity and mortality and a
shorter ICU stay ware observed. Third degree heart block, cardiac
related mortality, and mean ICU stay were higher in group A (5 vs 1
patients P = 0.044, 8 vs 2 patients P = 0.006, and 7.19 vs 4.98 days
P = 0.023 respectively).
Discussion: The value of PAC use, in comparison to conventional
routine ICU management, generated much controversy. Also,
the exact contribution of echocardiography in the hemodynamic
management remains undefined and the optimal exam frequency is
still debated.
Our analysis showed that PAC and echocardiographic guided
therapy following coronary artery bypass grafting in patients
with severe left ventricular dysfunction appear to be superior to
routine care. Further prospective studies are needed to draw firm
conclusions.
References:
1.Vincent JL. A reappraisal for the use of pulmonary artery
catheters. Crit Care. 2006; 10 Suppl 3: S1.
2.Oh J. Echocardiography as a non-invasive Swan-Ganz catheter.
Circulation. 2005; 111: 3192-4.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-158
S-159
ANESTH ANALG
2012; 114; S-01 – S-493
S-158.
S-159.
MECHANISM OF TACHYARRHYTHMIA IN SEPTIC
MODEL OF GUINEA PIG
RELIABILITY OF OXYGEN SATURATION BY PULSE
OXIMETER TO DETECT HYPOXEMIA OF PATIENTS IN
THE INTENSIVE CARE UNIT
AUTHORS: N. Hatakeyama1,2, Y. Aoki2, Y. Yasuda1, Y. Fujiwara1
affiliation: 1Anesthesiology, Aichi Medical University,
Nagakute, Japan; 2Anesthesiology, Toyama University Hospital,
Toyama, Japan
Introduction: In systemic inflammatory response syndrome
(SIRS) including sepsis1, tachyarrhythmia, such as atrial fibrilВ­lation,
is sometimes difficult to cure. Septic modulation of cardiac ion
channel function and expression may play a role in the formation
of tachyarrhythmia.
Methods: Septic model animal was made by intraperitoneal
lipopolysaccharide (LPS, 300 Ојg/kg) in guinea pigs. Whole cell
patch clamp was used to monitor membrane potentials and ionic
currents in atrial myocytes isolated from guinea pigs 10 h after
LPS injection. Western blot, RT-PCR, and immunohistochemical
staining were also examined.
Results: In electrophysiological monitoring, action potential
duration was significantly shortened. This was associated with the
reduction of L-type Ca2+, current and an increase of delayed rectifier
K+, current. We also observed reduced expression of Ca2+, channel
subunits and increase of K+ channel subunits. Furthermore, iNOS
synthase in atrial tissues was up regulated, and atrial nitric oxide
production evidently increased in immunohistochemical staining.
Discussion: In atrial myocytes from septic model of guinea pig,
action potential was significantly shortened. This may be the result
of the nitration of the ion channels that would alter channel functions
rather than the changes in atrial expression of the channels. The
reduction of action potential could play a role for the occurrence of
atrial tachyarrhythmia in SIRS and sepsis.
References:
1. Crit Care 2002; 6: 500-508.
AUTHORS: R. Kanai1,2, K. Moriyama1, T. Kohyama2,1, T. Yorozu1
affiliation: 1Anesthesiology, Kyorin University School of
Medicine, Tokyo, Japan; 2Intensive Care Medicine, Saiseikai
Yokohamashi Tobu Hospital, Yokohama, Japan
Introduction: Pulse oximeter is generally used as a noninvasive monitor to alert respiratory dysfunction in the intensive
care unit (ICU). SpO2 (oxygen saturation by pulse oximeter /
percutaneous oxygen saturation) are expected to be an indirect
estimation of arterial oxygen saturation (SaO2). However, there often
are gaps between SpO2 and SaO2. In this study, we investigated the
dissociation between SpO2 and SaO2 value of patients in the ICU,
and examined whether SpO2 can detect hypoxemia of patients in
the ICU.
Methods: We retrospectively evaluated 20717 arterial blood gas
samples from 3120 patients who stayed in our ICU since January
2008 to December 2010. Data were excluded when SaO2 were less
than 85% or PaO2 were higher than 100mmHg. We also excluded
data from patients under 20 years of age. First, SpO2 and SaO2
values were compared by paired t-test. Second, we calculated the
gaps between SaO2 and SpO2. SaO2 was analyzed by ABL 800
FLEX analyzer (Radiometer), and SpO2 was sampled by Masimo
SET LONPTM sensors. SpO2 value was calculated as an average
value of SpO2 0, 1 ,2 and 3 minutes before blood sampling. The gaps
between SpO2 and SaO2 were calculated as SpO2 minus SaO2[SpO2SaO2]. Third, we investigated serum lactic acid level measured
simultaneously with SaO2 level as a marker of hypoxia. Data are
expressed as means В± SD.
Results: A total of 8219 arterial blood gas samples from 1834
patients (1108 male and 726 female) were analyzed. SpO2 was
significantly higher than SaO2 (97.4В±2.4% v.s. 96.2В±2.4% , p<0.05).
The overall gaps between SpO2- SaO2 [SpO2- SaO2] were 1.2В±1.9. In
the range of 85≦SaO2<90%, 90≦SaO2<92%, and 92≦SaO2<95%,
[SpO2-SaO2] were 3.5В±4.2%, 2.7В±3.1% and 2.1В±2.1% (mean В± SD),
respectively. 31% of patients with 90≦SpO2<92% had hypoxemia
(SaO2<90%), and 5.6% of patients with 92≦SpO2<95% had
hypoxemia. Serum lactic acid levels measured simultaneously at
85≦SaO2<90%, 90≦SaO2<92%, and 92≦SaO2<95% were 2.5±3.4,
2.2В±3.3 and 1.9В±2.6 mmol/L, respectively.
Discussion: SpO2 tended to show higher value than SaO2. This
tendency was more apparent as SaO2 decreased. These results suggest
that keeping SpO2 above 90% is not enough to avoid hypoxemia. As
SpO2<90% were associated with increased morbidity and mortality
among outpatients with pneumonia compared with SpO2<92%1),
we suggest to keep SpO2 above 92% to avoid hypoxemia in the ICU.
References:
Clin Infect Dis. 2011;52(3):325-31.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-160
S-161
S-160.
S-161.
RAPID INDUCTION OF THERAPEUTIC HYPOTHERMIA
THROUGH AUGMENTED HEAT LOSS FROM THE LUNGS:
A FEASIBILITY STUDY IN SWINE
WITHDRAWN.
AUTHORS: M. M. Kumar1, B. Afessa1, J. L. Atkinson1, L. Johnson1,
V. Nayagam2
affiliation:1Mayo Clinic, Rochester, MN; 2National Center
for Space Exploration Research, NASA Glenn Research Center,
Cleveland, OH
Introduction: Hypothermia is gaining acceptance as an
adjunct therapeutic option in the management of traumatic brain
injury, strokes and cardiac arrest.1 Yet, the current methods to induce
hypothermia are slow, inefficient and cumbersome.2 The authors
report a novel technique of rapidly inducing hypothermia through
augmented heat extraction from the lungs using perfluorocarbon
(PFC) mist and cooled heliox ventilation.
Methods: Six female domestic cross-bred pigs (34-35 kg)
were used in this IACUC-approved study. Following induction
of anesthesia, a CaminoВ® 4-Fr fiber-optic pressure transducer
tipped catheter with thermistor was inserted 1.0 cm into the brain
parenchyma through a right frontal bur hole. The core temperatures
were monitored in the pulmonary artery, lower esophagus, bladder,
rectum, nasopharynx and tympanum. After stabilizing the baseline
respiratory parameters with room air ventilation for several minutes,
ventilation was switched to cooled heliox (0В±2В°C, He 70%:O2 30%)
and 0.14% (v/v) PFC mist. Heliox-PFC ventilation was continued
for 90 minutes or until the target temperature of 32В°C was reached.
All temperatures, intracranial pressure, and cerebral perfusion
pressure were recorded as a function of time using a data acquisition
system (~0.017 Hz or faster).
Results: Core temperatures declined rapidly in all animals
following the initiation of heliox-PFC mist ventilation. The brain
temperatures lagged 5-7 minutes before starting to decline. The
esophageal temperature (mean В±SD) reached target in 40В±6.8
minutes. The brain temperature declined to target in 65В±10.4
minutes (Figure 1). Cardiopulmonary functions and intracranial
(5-20 torr) and cerebral perfusion (50-70 torr) pressures remained
stable.
Discussion: A novel, minimally-invasive and effective
technique to rapidly induce hypothermia is described. The combined
influence of the thermal conductivity of helium and the vaporization
of PFC produce rapid cooling of the alveolar gases. The thin
alveolar membrane and the large surface area of contact between
the inspired gases and the pulmonary capillary blood results in a
high rate of heat transfer which rapidly cools the pulmonary blood.
The subsequent flow of the cooled arterial blood to the brain reduces
the brain temperature. The time lag between the core and the brain
temperatures depends on the blood perfusion rate to the brain
(convective flow velocity and volume). Due to the thermal mass of
the blood, the brain continues to cool for several minutes after the
cessation of heliox-PFC ventilation.
References:
1.Crit Care Med.
39(5):1113-1125,
May 2011.
2.Crit Care. 2007;
11(4): R91.
Figure 1. Supported in part by US Army CCCRP
W81XWH
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-162
S-162.
THE ROLE OF NRF2 IN INNATE IMMUNE RESPONSE
AND SURVIVAL DURING SEPTIC SHOCK IN CRITICALLY
ILL ADULTS
AUTHORS: R. Fuchs1, S. Noel2, L. Zheng2, R. Thimmulappa2,
A. Navas-Acien2, S. Biswal2
affiliation: 1Anesthesiology and Critical Care Medicine,
Johns Hopkins University, Baltimore, MD; 2Environmental Health
Science, Johns Hopkins School of Public Health, Baltimore, MD
Introduction: Sepsis is characterized by an inappropriate
host immune-inflammatory response and sustained oxidative
damage. Nrf2, a bZIP oxidant-responsive transcription factor,
regulates a battery of cytoprotective genes. Murine model studies
have demonstrated a critical role of Nrf2 in improving survival
during sepsis1. Hypothesis: We hypothesize that increased gene
expression of Nrf2 is protective and could be correlated with an
improved survival outcome.
Methods: Design: Prospective cohort study. Setting: Patients
with septic shock in the medical and surgical ICU. Sample: Adults
greater than 18 years of age were screened into study within 24 h
of diagnosis. 118 patients with septic shock were enrolled between
January 2008 and March 2010. Exposure Measure: Nrf2 gene
expression level.Outcome Measures: The primary outcome measure
for the cohort design is 60 day mortality. Nrf2 was measured in
PBMC by RT-PCR. Statistics: To assess the prospective association
of Nrf2 gene expression with mortality, we used Cox proportional
hazard models. With 60-day mortality as the outcome and hospital
days as the time metric, crude models for the outcome and log2
transformed Nrf2 gene expressions were run. Models were then
adjusted for age, gender, race, BMI and apache 2 score. Hazard
ratios are presented.
Results: At 60 days 67/118 (56.8%) patients were alive and
51/118 (43.2%) patients were dead. The hazard ratio for doubling
the Nrf2 gene expression was significant in the crude model (HR
= 1.26; C.I. 1.09, 1.47): for each doubling in Nrf2 gene expression
there is a 26% increased instant threat of dying; adjusted for age,
gender, race, and body mass index (BMI): HR = 1.25; C.I. 1.06,
1.48). Once adjusted for severity of illness (Apache 2 score) the
effect was not statistically significant anymore: HR = 1.17; C.I.
0.98, 1.41. Ventilator days and days of vasopressor support were not
statistically different between the Nrf2 mRNA levels.
Discussion: Preliminary findings suggest that higher Nrf2
mRNA expression at enrollment is associated with higher 60 day
mortality based on the crude hazard ratio for Nrf2 gene expression
level and adjusted for age, gender, race, and BMI. Since this effect
is not present once adjusted for severity of illness, we postulate that
Nrf2 gene expression level is a mediator in the pathophysiologic
cascade that leads to severity of illness in septic shock. The data do
not support the hypothesis that higher Nrf2 gene expression levels
are associated with a reduction of mortality risk. Therefore, we have
to reject our hypothesis.
References:
1.Thimmulappa et al.: Nrf2 is a critical regulator of the innate
immune response and survival during experimental sepsis, J Clin
Invest 116 (2006) 984-995
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-163
ANESTH ANALG
2012; 114; S-01 – S-493
S-163.
INHALED HYDROGEN SULFIDE PREVENTS
ENDOTOXIN-INDUCED SYSTEMIC INFLAMMATION
AND IMPROVES SURVIVAL BY ALTERING SULFIDE
METABOLISM IN MICE
AUTHORS: K. Tokuda, E. Marutani, K. Kida, F. Ichinose
affiliation: Department of Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Charlestown, MA
Introduction: Hydrogen sulfide (H2S) is a colorless gas
with a characteristic rotten-egg odor found in various natural and
industrial sources. In mammalian tissues, H2S is also produced
endogenously, acting as a gaseous-signaling molecule. Although
it has become increasingly clear that H2S can exert a host of
biological effects on various targets, the role of H2S in inflammation
remains controversial. We examined impact of H2S-breathing on
lipopolysaccharide[LPS]-induced changes in sulfide metabolism,
systemic inflammation, and survival in mice.
Methods: After obtaining IRB approval, all animal experiments
were performed. Mice were administered with LPS (10 mg/kg) or
saline intraperitoneally (IP) followed by breathing air or H2S (80
ppm) mixed in air for 6h. Tissue and blood were harvested at 6h
or 24h after LPS challenge. To examine the effects of thiosulfate, a
major metabolite of H2S, sodium thiosulfate (STS, 1 or 2 g/kg) was
administered IP immediately after LPS challenge in separate groups
of mice. Data were analyzed by one-way ANOVA. Kaplan-Meier
survival analysis was performed using Log-rank test.
Results: Mice that breathed air alone exhibited poor survival
rate and decreased plasma sulfide levels after LPS challenge.
Endotoxemia markedly increased alanine aminotransferase (ALT)
and nitrite/nitrate (NOx) levels in plasma and lung myeloperoxidase
(MPO) activity in mice that breathed air. In contrast, breathing
air supplemented with 80ppm of H2S for 6h after LPS challenge
markedly improved survival rate (Fig. 1) and attenuated LPSinduced increase of plasma ALT and NOx levels and lung MPO
activity. Inhaled H2S suppressed LPS-induced upregulation of
inflammatory cytokines in the liver and the lung. Beneficial effects
of H2S inhalation after LPS challenge were associated with restored
sulfide levels and remarkably increased thiosulfate levels in plasma
(Fig. 2). Increased thiosulfate levels in mice that breathed H2S after
LPS challenge were associated with upregulation of rhodanese,
an enzyme responsible for H2S metabolism, but not cystathionine
Оі-lyase, a H2S-producing enzyme, in the liver. Administration of
STS dose-dependently improved survival after LPS challenge in
mice (Fig. 3).
Discussion: Our results revealed that plasma sulfide levels
were decreased by LPS challenge whereas H2S breathing after
LPS challenge restored sulfide levels and remarkably increased
thiosulfate concentrations. We further demonstrated that
administration of thiosulfate per se markedly improved survival
after LPS challenge. These observations suggest that H2S breathing
attenuates inflammation and improves survival after LPS challenge
in part by altering sulfide metabolism in mice.
Figure 1. Survival rates after LPS challenge followed by 6h
inhalation of air with or without H2S (80ppm).
Figure 2. Plasma sulfide and thiosulfate levels at 6h after challenge
with saline or LPS without or with H2S breathing. *P < 0.05.
**P < 0.01.
Figure 3. Survival rates after LPS challenge with or without
administration of respective dose of sodium thiosulfate (STS).
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-164
S-164.
SODIUM SULFIDE PREVENTS WATER DIFFUSION
ABNORMALITY IN THE BRAIN AND IMPROVES LONG
TERM OUTCOME AFTER CARDIAC ARREST IN MICE
AUTHORS: K. Kida, S. Minamishima, F. Ichinose
affiliation: Department of Anaesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital and Harvard Medical
School, Boston, MA
Introduction: Sudden cardiac arrest (CA) is one of the
leading causes of death worldwide. Despite advances in cardioВ­
pulmonary resuscitation (CPR) methods, including the introduction
of the automatic electrical defibrillator (AED) and therapeutic
hypothermia (TH), fewer than 8% of adult out-of-hospital CA
victims survive to hospital discharge.1 Previously we demonstrated
that administration of sodium sulfide, a hydrogen sulfide donor,
markedly improved the neurological outcome and survival rate at
24 hours after CA and CPR in mice.2 In this study, we sought to
elucidate the mechanism responsible for the neuroprotective effects
of sodium sulfide and its impact on the long-term survival after CA/
CPR in mice.
Methods: Adult male mice were subjected to potassiuminduced CA for 7.5 minutes at 37В°C whereupon CPR was performed
with chest compression and mechanical ventilation. Mice received
sodium sulfide (0.55 mg/kg i.v.) or vehicle 1 minute before CPR. We
assessed abnormality in water diffusion in the brain caused by blood
brain barrier (BBB) leakage by diffusion-weighted imaging (DWI)
in live mice. Activity of matrix metalloproteinase 9 (MMP-9) which
disrupts the BBB was assessed with gelatin zymography.
Results: Cardiac arrest and CPR induced abnormal water diffusion
in the vulnerable regions of the brain after resuscitation, as
demonstrated by hyperintense diffusion-weighted imaging (DWI) in
the brain 24 hours after CA/CPR. Extent of hyperintense DWI was
associated with MMP-9 activation, worse neurological outcomes,
and poor survival rate at 10 days after CA/CPR. Administration
of sodium sulfide prevented the development of abnormal water
diffusion (Fig.1) and MMP-9 activation (Fig.2) and markedly
improved neurological function (Fig.3) and long-term survival after
CA/CPR (Fig.4).
Discussion: These results suggest that administration of sodium
sulfide 1 minute before CPR improves neurological function and
survival rate at 10 days after CA/CPR by preventing water diffusion
abnormality in the brain potentially via inhibiting MMP-9 activation
early after resuscitation.
References:
1. Circulation 2009; 119: 480-6
2. Circulation 2009; 120: 888-96
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-165
S-166
ANESTH ANALG
2012; 114; S-01 – S-493
S-165.
S-166.
ROLES OF BLT1 SIGNALING IN ENHANCEMENT OF
RENOPROTECTIVE AFTER CARDIAC ARREST
EFFECTS OF HEXAFLUORO-2-PROPANOL ON
INFLAMMATORY AND HEMODYNAMIC RESPONSES IN A
RAT MODEL OF ENDOTOXIC SHOCK
AUTHORS: Y. Kosaka1,2, M. Majima2, Y. Nara1, M. Toda1,
T. Yokomizo3, H. Okamoto1
affiliation: 1Anesthesiology, Kitasato University of Medicine,
Sagamihara, Japan; 2Pharmacology, Kitasato University of
Medicine, Sagamihara, Japan; 3Medical Biochemistry, Graduate
School of Medical Sciences, Kyusyu University, Fukuoka, Japan
Introduction: Leukotriene B4 (LTB4), a 5-lipoxygenase (5LOX) metabolite of arachidonic acid has been well-documented
to be a potent chemotactic factor for granulocytes. LTB4 exerts its
biological activities through two distinct LTB receptors: BLT1 and
BLT2. We have demonstrated that LTB4/BLT1 signaling enhanced
hepatic microcirculatory dysfunction during endotoxemia. The
glomerular endothelium forms an important part of the filtration
barrier in the kidney, and is damaged by ischemia-reperfusion.
Thus, we hypothesized cardiac arrest damages the glomerular
barrier through the LTB4/BLT1 signaling.
Methods: All animal experiment procedures were performed
in accordance with the guidelines for animal experimentation
of Kitasato University School of Medicine. We made 2 groups,
wild type male mice (WT, n=14), BLT1 knockout mice (BLT1-/, n=12). The mice were subjected to Cardiac arrest (CA) induced
by intravenous (IV) KCL. After 8 min of CA, we reopened their
ventilation with 100% oxygen, and the chest compressions were
started at a rate of 300bpm. Moreover, the resuscitation was initiated
with IV epinephrine (8-16Ојg in 0.5-1.0ml 0.9% saline). During
surgery, the rectal temperature was maintained at 37.0В±0.5В°C. At the
24 hours after CA, we measured their Blood Urea Nitrogen (BUN)
and serum creatinine (Cr). Statistical analysis was performed by
using one-way Mann-Whitney U-test, and statistical significance
was set at p < 0.05.
Results: There were no significant differences in time to
resuscitate, rectal temperature, and epinephrine dose between
WT and BLT1-/-. BUN was significantly higher in WT compared
with BLT1-/- (180.6В±11.2 versus 104.6В±11.0). Further, there was
significant difference between WT and BLT-/- (1.62В±0.17 versus
0.69В±0.17) in the creatinine.
Discussion: Present study showed the blockade of LTB4/BLT1
pathway prevented the ischemia-reperfusion injury in the kidney.
The results suggested that LTB4/BLT1 signaling is an attractive
therapeutic target with available specific agonists.
References:
1. Hutchens, et al, Anesthesiology 2010; 112.
2. Sohei Ito, Yoshiya Ito, et al, Shock 2008; 30(1), 87-91
AUTHORS: M. Urner, I. K. Herrmann, M. Hasler, C. Booy, B.
Roth-Z’Graggen, B. Beck-Schimmer
affiliation: Anesthesiology, University Hospital Zurich,
Zurich, Switzerland
Introduction: Sepsis with multiple organ failure remains
a leading cause of hospital morbidity and mortality on intensive
care units imparting tremendous financial costs. Recently, the
primary metabolite of sevoflurane, hexafluoro-2-propanol (HFIP),
has been found to exert immunomodulatory properties attenuating
inflammatory response to lipopolysaccharides (LPS) in vitro1.
We investigated whether HFIP attenuates plasma and tissue
inflammatory mediator expression in a rat model of endotoxic
shock.
Methods: Thirty-two male wistar rats were anesthetized,
tracheotomized, and mechanically ventilated. The animals were
randomly assigned to one of the following groups: I) LPS group
(n=8), which received intravenous Escherichia coli endotoxin (1mg/
kg); II) LPS/HFIP group (n=8), which was treated identically to the
LPS group with the additional administration of HFIP (67mcg/kg
over 30min) after LPS injection. Control groups received ringer’s
lactate instead of LPS. General anesthesia was maintained with
propofol. All animals received additional 30ml/kg of ringer’s
lactate after injection of LPS over a time period of 1 hour. Arterial
blood gases were measured every hour. Animals were euthanized
6 hours after endotoxin injection. The concentrations of monocyte
chemoattractant protein-1, key player in the recruitment of
monocytes during endotoxemia, was analyzed in bronchoalveolar
lavage fluid and in plasma. Linear regression was used to evaluate
influence of HFIP on inflammatory mediator expression.
Results: Plasma MCP-1 protein levels assessed 6 hours
after LPS injection were increased by +5192ng/ml compared to
baseline (R2=0.661, p<0.001). This increase in MCP-1 protein
was attenuated by -48% in the LPS/HFIP group (+2706ng/ml to
baseline, R2: 0.661; p=0.004). Similar results were found in BALF,
in which HFIP decreased the LPS-induced raise in MCP-1 protein
concentration by -62% (difference of 54ng/ml, p=0.034). LPSstimulated animals had a +12% higher mean arterial blood pressure
after 6 hours when treated with HFIP (78mmHg versus 67mmHg,
R2=0.684, p=0.035). No significant differences in lactate levels
were observed. HFIP attenuated base deficit in LPS-stimulated
animals by 1mmol/L (R2=0.522, p=0.034).
Discussion: Hexafluoro-2-propanol attenuated LPS-induced
inflammatory mediator secretion, the decrease in mean arterial blood
pressure, and base deficit. These results suggest that hexafluoro-2propanol may partly inhibit inflammatory response, hypotension
and the development of metabolic acidosis during endotoxic shock.
References:
1. Urner et al., Am. J. Respir. Cell Mol. Biol., 2011.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-167
S-168
S-167.
S-168.
RETROSPECTIVE ANALYSIS OF CRICOTHYROTOMIES
PERFORMED IN A LEVEL 1 TRAUMA CENTER OVER A
TEN YEAR PERIOD
WITHDRAWN.
AUTHORS: Christiane Vogt-Harenkamp1, H. Wang1, Antonio
Gonzales1, Cecilia PeГ±a1
affiliation: Anesthesiology, Texas Tech University Health
Sciences Center, Lubbock, TX
Introduction: In retrospective analyses the incidence
of cricothyrotomies (CTT) varies from 1.11 to 14.9%2 among
emergency airway procedures. Mortality related to CTTs ranges
from 40-85% and is higher in cardiac arrest3 and outside-thehospital scenarios. Data is inconclusive as to whether this high
mortality is due to the severity of the underlying condition or to
complications from CTT. The goal of this study was to identify main
factors determining outcome in these scenarios.
Methods: In compliance with our institutional IRB we evaluated
1423 de-identified medical and autopsy records with a CPT code
for invasive airway management in regard to CTTs performed in
the University Medical Center Hospital, Level 1 Trauma Center,
Lubbock, Texas between 1999 and 2010. Collected data included
patient demographics, clinical setting, CTT method, types of
providers, numbers and types of complications and patient outcome.
Descriptive statistics were used calculating means and standard
deviations for continuous variables and counts and proportions for
categorical variables. Statistical comparisons between survivors
and non-survisors were done using Student’s t-test for continuous
variables and Fisher’s exact test for categorical variables.
Results: CTTs were done in 44 (3.1%) out of 1423 patients.
Fourteen patients died during or after the procedure (31.8%). No
death was reported as being due to a failed procedure. Fourteen
(70%) of 20 CTTs (45.4%) performed in a trauma setting were
survived. All 4 (9%) coding patients deceased. EMS personnel and
trauma physicians performed the majority of CTTs, 31 (70.4%) at a
survival rate of 24 (77.4%) vs. anesthesiologists and ER physicians
with 5 CTTs each and 40% surviving. Surgical CTT (28 (63.3%)
and wire guided CTT (16, 36.4%) had similar survival rates: 18
(64.3%) versus 12 (75%). Five complications occurred (11.3%),
three (60%) related to bleeding. One of these patients died. Age,
gender or BMI were not found to influence outcome.
Discussion: Incidence, mortality and rate of complications after
CTTs in our study were similar to numbers reported in the literature.
Mortality seemed poorly related to complications. The underlying
cause and the provider’s experience seem to be of more impact on
outcome. The main shortcoming of our and any retrospective study
of cricothyrotomies is their small number throughout a wide variety
of high acuity scenarios and often insufficient documentation thus
limiting the value of statistical comparisons.
References:
1. American Surgeon1995 Jan;61(1):52-5
2. J Trauma 1997, Vol 42(5):832-38
3. Isaacs Am Surgeon 1997 Apr;63(4):343-9
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-169
S-170
ANESTH ANALG
2012; 114; S-01 – S-493
S-169.
S-170.
CF3-MEDIATED PROTECTION - SEVOFLURANE AND
ITS PRIMARY METABOLITE IMPROVE SURVIVAL IN
MURINE SEPTIC PERITONITIS
ASSESSMENT OF PERIOPERATIVE RISK: IMPACT
OF CO-MORBIDITIES & TIMING OF TREATMENT ON
PERIOPERATIVE MORBIDITY AND MORTALITY
AUTHORS: I. K. Herrmann1, M. Castellon2, D. E. Schwartz2,
G. Hu2, R. D. Minshall2, B. Beck-Schimmer1
AUTHORS: M. F. Mascia, R. Neusch, S. Stamper
affiliation: 1Anesthesiology, University and University Hospital
Zurich, Zurich, Switzerland; 2Anesthesiology and Pharmacology,
University of Illinois at Chicago, Chicago, IL
Introduction: Sepsis remains a leading cause of death in
intensive care units worldwide. There is growing evidence that
volatile anesthetics have beneficial immunomodulatory effects in
complex inflammatory conditions1-4. In this presentation, we discuss
how volatile anesthetics and their primary metabolites affect overall
survival of mice suffering from sepsis with intra-abdominal focus in
a murine cecal ligation and puncture (CLP) model.
Methods: The study protocol was approved by the Animal
Care and Use Committee. Mice were exposed to sevoflurane
(and isoflurane) either during sepsis-induction (conditioning) or
when the mice showed pronounced symptoms of inflammation
(post-conditioning), and compared to the CLP group regarding
outcome. In an additional treatment group, the primary sevoflurane
metabolite, hexafluoroisopropanol, was administered intravenously.
Results: With sevoflurane conditioning (1.2 MAC for 2 hours),
overall survival was increased to 86% compared to 17% in the CLP
group (p < 0.001, N=12). Equi-anesthetic isoflurane concentrations
did not significantly improve outcome (overall survival 44%, p
= 0.12, N=10). Application of sevoflurane 24 hours post sepsis
induction improved overall survival to 66% (p = 0.045, N=12).
Interestingly, the intravenously administered primary metabolite
of sevoflurane (hexafluoroisopropanol) was also highly effective in
improving the overall survival in CLP mice (77%, p = 0.037, N=12).
Discussion: Both sevoflurane and intravenous administration
of the primary sevoflurane CF3-metabolite reduced CLP-induced
mortality in a murine model of septic peritonitis.
References:
1. Anesthesiology, 108:1055-1062, 2008.
2. Anesthesiology,104:511-517, 2006.
3. Anesthesiology, 98:1315-1327, 2003.
4. Anesthesiology, 111, 1238-48, 2004.
affiliation: Anesthesiology, West Virginia University School
of Medicine, Morgantown, WV
Introduction: The purpose of this sudy is to examine
the relationship between comorbidities and early treatment on
perioperative outcome of critically ill and injured patients.
Methods: we examined clinical indicators likely to predict
increased risk of adverse outcomes in critically ill patients before
and after surgical interventions. By reviewing completed records
(emrs) for all patients admitted to our intensive care units we created
a database including those who had at least one operating room
encounter, and at least one night in the intensive care unit (icu) prior
to October 2011. Data including demographics, morbidity, mortality,
17 co-morbidities, use of shock drugs was statistically analyzed to
determine relationships between co-morbidities, treatment timing,
morbidity and mortality.
Results: We found that patients who spent the first night after
admission in any intensive care unit (ICU) had a better chance of
survival than those who spent their first night in non-ICU beds.
In addition, strong correlations were found between some comorВ­
bidities and adverse outcomes. The comorbidities that showed the
highest associated mortality rates were malnutrition, cancer, shock,
sepsis, dialysis, chf, pulmonary heart disease, other heart disease,
stroke and peripheral vascular disease. Adverse outcomes were not
associated with morbid obesity (bmi > 35), diabetes, hypothermia,
ischemic heart disease, copd and allied conditions, brain injury and
spinal cord injury.
Discussion: We hypothesized that, despite comorbidities, early
definitive treatment is most likely to result in the best outcome for
critically ill and injured patients, and that time and response to
definitive therapy is a measurable and significant determinant of
outcome. We found that early ICU care resulted in better survival
rates as compared to early care in stepdown and floor beds. Most
co-morbidities increased chances of death, but some, surprisingly,
had no significant adverse impact.
Most of our preliminary findings are expected, but definitive facts are
lacking for most disease states and there are no definitive outcome
prediction tools that incorporate time to treatment, or response to
definitive therapy. It is important to quantify expected outcome to
avoid arbitrary, or untimely decisions regarding end of life care, and
to enable proper allocation of limited healthcare resources. In other
words, intuition is not good enough when lives are on the line.
References:
Toshiya Shiga, Zenichiro Wajima And Yoko Ohe.
Is operative delay associated with increased mortality of hip fracture
patients? Systematic review, meta-analysis, and meta-regression.
Canadian journal of anesthesia, 2008, 55.3: 146-154
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-171
S-172
ANESTH ANALG
2012; 114; S-01 – S-493
S-171.
S-172.
THE EFFICACY OF LOW DOSE KETAMINE, FENTANYL,
AND MIDAZOLAM INFUSION FOR PREOPERATIVE
SEDATION, AND POSTOPERATIVE ANALGESIA IN
THE ICU
INTRA-ABDOMINAL PRESSURE IN ARDS: THE EFFECT
OF PRONE POSITIONING
AUTHORS: C. R. Rajaratnam, P. Roffey, M. Mogos, D. Thangathurai
affiliation: Intensive Care Unit, University Hospital of
Ioannina, Ioannina, Greece
affiliation: Anesthesiology, USC Keck Medical Center, Los
Angeles, CA
Introduction: Fears of an unknown environment coupled
with extreme anxiety and anticipation /stress are a concern for
patients undergoing a major surgical operation. These fears often
lead to undesireable physiological and psychological lability.
Standard modes of sedation which include benzodiazepines may not
be effective. Low dose ketamine with midazolam and fentanyl may
work to eliminate this sequelae associated with surgery.
Methods: Our patients were age 45-82, M=F, ASA II-IV,
undergoing urologic surgery. The patients were allocated into two
groups. The control group received standard premedication of
midazolam only. The second group received premedication which
included midazolam, fentanyl, and low dose ketamine. Following
administration of the premedication, patients were constantly
observed for changes in mood, sedation, and hemodynamic
variability in response to arrival in the OR suite. The patients were
also observed and interviewed postoperatively for evidence of
recall, or discomfort.
Results: Problems associated with preoperative sympathetic
stimulation secondary to anxiety and fear were avoided in the
patient group who received combination ketamine, fentanyl, and
midazolam. 7/10 patients in this group demonstrated a tranquil
demeanor upon entry into the OR manifested by stability in their
immediate pre-induction vital signs. This group of people described
no recall to any events that occurred after administration of the
medications. When compared to the group of patients who received
only midazolam as a preoperative sedative, 8/10 of these patients
showed no change in demeanor or level of anxiety upon entry
into the OR. These patients demonstrated sympathetic stimulation
evidenced by tachycardia and hypertension that had previously
not been present in the early preoperative period. Similarly, this
group of patients also were able to recall events leading up to the
immediate preinduction period.
Discussion: For the last 25 years at our institution, low dose
ketamine in combination with opioids and benzodiazepines has
been used as an infusion to provide excellent preoperative sedation
and postoperative analgesia when compared with the use of each
drug individually.
References:
1.Hirota K, Lambert DG. Ketamine: its mechanism(s) of action
and unusual clinical uses. Br. J. Anaesth. 1996 77: 441-4442.
2.Mao J, Price DD, Mayer DJ. Mechanisms of hyperalgesia and
morphine tolerance: a current view of their possible interactions.
Pain 1995;62: 259-74.
AUTHORS: E. Galiatsou, A. Moraiti, E. Kostanti, A. Papathanasiou,
G. Nakos
Introduction: Prone positioning improves oxygenation in
ARDS and may be an effective means of recruiting nonaerated
alveolar units and minimizing lung overinflation1. In ARDS
patients lying supine, loss of aeration predominates in the caudal
and dependent lung regions because of alveolar flooding and
compression exerted by the heart and the abdomen. Intra-abdominal
hypertension (IAH) is common in critically ill patients2. The effect
of proning on the intra-abdominal pressure (IAP) is not clear.
Previous studies have shown that IAP may remain unchanged in the
prone position and that proning improves gas exchange to a greater
degree in the presence of IAH. The purpose of this study was to look
at the effects of proning on IAP, lung mechanics and distribution of
ventilation in patients with acute respiratory failure.
Methods: The study protocoll was approved by the hospital’s
Ethics Comittee and an informed consent was taken from patients’
next of kin. All patients were sedated, paralyzed and mechanically
ventilated with a 6ml/kg tidal volume and optimum PEEP. Patients
were turned prone with the abdomen suspended by placing pillows
under the chest and the pelvis. Plateau pressure, auto-PEEP and
respiratory system compliance (CRS) were measured. Urinary
bladder pressure was used as a surrogate for IAP. A lung ultrasound
scan (LUS) was performed to assess distribution of lung aeration.
Four LUS patterns were defined and each one of the 12 lung regions
scanned was accordingly scored: normal aeration 0, interstitial
pattern 1, alveolar pattern 2, consolidation 3. All measurements
were taken in the supine position and after 60 min in the prone
position.
Results: Six patients (4 male/2 female, age 57.7В±17.0) entered
the study. Oxygenation significantly improved with proning (pO2/
fiO2 supine 112В±45.1 vs 178.2В±68.9 prone), while CRS tended to
increase (supine 32.5В±16.8 vs 41.8В±20.3 prone). The LUS score
tended to improve with proning (21.5В±9.1 supine vs 15.2В±11.4
prone). IAP in the supine position was more than 7mmHg in 4 of
the patients and tended to decrease in the prone position (11.6В±6.2
supine vs 7.6В±4.3). This was more prominent in those with a higher
IAP while supine.
Discussion: IAP may remain stable or decrease in the prone
position and this is possibly associated with improvement in lung
mechanics and distribution of aeration. Patients with IAH may
benefit more from proning.
References:
1.Am J Respir Crit Care Med 2006; 174:187-197.
2. Crit Care Med 2005; 33: 315-322. 3.
3. Aubrun F et al. Effect of a lowdose ketamine regimen on
pain, mood, cognitive function and memory after major
gynaecological surgery: a randomized, double-blind, placebo
controlled trial. Eur J Anaesthesiol 2008;25(2):97-10.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-173
S-174
ANESTH ANALG
2012; 114; S-01 – S-493
S-173.
S-174.
INHIBITION OF THE CIAP2 PATHWAY
REDUCES LEUKOCYTE RECRUITMENT IN THE
INTESTINAL MICROCIRCULATION IN MURINE
EXPERIMENTAL SEPSIS
ROLE OF SURVEILLANCE CULTURES IN IDENTIFYING
THE PATHOGENS RESPONSIBLE FOR VENTILATORASSOCIATED PNEUMONIA (VAP): ANALYSIS OF
COLONIZATION CURVES
AUTHORS: C. Lehmann1,2, L. Schuster4,1, F. Götz4,1, F. Ashour3,
D. Pavlovic4, G. Robertson2
AUTHORS: J. Hudcova1, Y. Lei2,3, A. Sarwar2, D. E. Craven3
affiliation: 1Anesthesia, Dalhousie University, Halifax,
NS, Canada; 2Pharmacology, Dalhousie University, Halifax, NS,
Canada; 3Microbiology and Immunology, Dalhousie University,
Halifax, NS, Canada; 4Anesthesiology and Intensive Care Medicine,
Ernst Moritz Arndt University, Greifswald, Germany
Introduction: Inhibition of the cellular Inhibitor of Apoptosis
Protein 2 (cIAP2) is able to render LPS-activated macrophages
highly susceptible to apoptotic triggers, thereby quickly eliminating
the resident macrophage population soon after the initiation of a
systemic inflammatory response1. Aim of our study was to evaluate
whether cIAP2 inhibition is able to reduce leukocyte recruitment
within the intestinal microcirculation, which is crucial in the
pathogenesis of septic multiple organ failure.
Methods: The study was approved by Institutional Animal Care
and Use Committee. We studied five groups of animals: wildtype
control mice, cIAP2 knockout mice, endotoxemic wildtype mice
(5 mg/kg LPS), and endotoxemic cIAP2 knockouts (5 or 50 mg/
kg LPS, respectively). Intravital microscopy of the intestinal
microcirculation was performed following 2 hours of observation
in all animals. Intestinal microvascular blood flow (IMBF) was
measured using laser Doppler flowmetry.
Results: Following two hours of endotoxemia (5 mg/kg
LPS) we observed a significant increase of leukocyte adhesion in
intestinal submucosal venules of wildtype mice in comparison to
control animals (p<.01). cIAP2 knockout mice did not show an
increased leukocyte recruitment within the intestinal submucosal
microvasculature following 5 or 50 mg/kg LPS challenge,
respectively. IMBF was not affected by cIAP2 inhibition.
Discussion: Inhibition of the cIAP2 pathway reduced leukocyte
recruitment in the intestinal microcirculation in experimental
sepsis. Pharmacological ablation of cIAP2 will potentially limit
the severity of inflammatory diseases by transiently abolishing
activated immune cells.
References:
1.Conte, Damiano, Martin Holcik, C.A. Lefebvre, E. LaCasse,
D.J. Picketts, K.E. Wright, and R.G. Korneluk. “Inhibitor of
apoptosis protein cIAP2 is essential for lipopolysaccharideinduced macrophage survival.” Mol Cell Biol 26, 2 (2006): 699.
affiliation: 1Department of Surgical Critical Care, Lahey
Clinic, Burlington, MA; 2Department of Pulmonary Medicine,
Lahey Clinic, Burlington, MA; 3Center for Infectious Diseases &
Prevention, Lahey Clinic, Burlington, MA
Introduction: Leakage of bacteria laden subglottic
secreВ­В­tions around the endotracheal tube cuff with subsequent
colonization of trachea plays an important role in the pathogenesis
of VAP. This natural history study evaluated intubated patients
for a VAP development on a daily basis. Colonization curves of
those who developed VAP were reviewed in order to determine
whether surveillance cultures are useful in identifying responsible
pathogen(s).
Methods: After IRB approval, we collected daily endotracheal
aspirate (EA) cultures and clinical data on 188 medical and surgical
patients who were intubated and ventilated >48h. Patients were
followed until extubated, had tracheostomy, died, or were comfort
measures only. Results of quantitative study surveillance cultures
(Q-EA) were not reported to treating clinicians. Growth with Q-EA
≥ 105 cfu/ml was considered significant for heavy colonization.
Infection was suspected if two of three clinical criteria (CC):
(temperature >38В°C, leukocytosis >12,000/mm3, purulent sputum)
were present. Presence of heavy colonization and CC established
diagnosis of ventilator-associated tracheobronchitis (VAT). VAP
required criteria for VAT plus a new or increasing infiltrate on the
chest radiograph. Colonization curves of patients with VAP were
constructed and analyzed. Appropriateness of antibiotic treatment
was assessed.
Challenging Case Report: N/A
Results: Out of 188 study patients, 23% (n=44) patients
developed at least one episode of VAT; VAP was diagnosed in 7%
(n=13) patients. Ten patients with VAP had one pathogen identified
and 3 patients had two different pathogens. All patients except one
with VAP were on antibiotics at time of study enrollment.
Pathogens identified were S. aureus x 4, and Gram-negative rods
(GNR) in 9 patients: Pseudomonas aeruginosa, Acinetobacter spp,
H. influenzae, Klebsiella pneumoniae, Enterobacter spp, Escherichia
coli and Stenotrophomonas maltophilia.
Five cases of VAP occurred on day 2 and were not evaluated as
no Q-EA was obtained. Q-EA identified pathogens in 62% (8/13)
of patients prior to VAP: in 4 cases by 1 day, in 3 cases by 2 days,
in one case by 4 days, and in one case by 5 days. VAT preceded
VAP in 63% (5/8) patients 1 - 6 days earlier. Out of 8 patients with
colonization curves, appropriate antibiotic coverage at time of VAP
diagnosis was present in three patients only.
Discussion: Our study surveillance cultures identified responsВ­
ible pathogen(s) for VAP ~ 2 days prior to diagnosis. VAT preceded
VAP in 63% of cases. Only three patients were treated with
appropriate antibiotics at time of VAP diagnosis. We believe that
surveillance cultures may assist in guidance of antibiotic therapy
and in identification of MDR pathogens.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Economics
ABSTRACTS
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ANESTH ANALG
2012; 114; S-01 – S-493
*USD/SEK=6.67, 11/9/11, www.ft.com
S-180.
COST-EFFECTIVENESS ANALYSIS OF ROCURONIUM
AND SUGAMMADEX VERSUS SUCCINYLCHOLINE FOR
RAPID SEQUENCE INDUCTION
AUTHORS: R. P. Insinga1, J. Lundberg2
affiliation: 1Department of Health Economic Statistics,
Merck & Co., Inc., Whitehouse Station, NJ; 2Outcomes Research,
MSD, Sollentuna, Sweden
Introduction: Sugammadex is approved by the European
Medicines Agency for reversal of neuromuscular blockade induced
by rocuronium or vecuronium. Rapid sequence induction (RSI) is
used to expedite endotracheal intubation for patients at increased risk
of getting stomach contents into the lungs and in emergency settings.
In the event of a cannot intubate cannot ventilate (CICV) situation
following anesthetic induction, neuromuscular blockade must be
reversed quickly, as patients otherwise face a high risk of morbidity
and mortality. Traditionally, a short-acting agent, succinylcholine,
has been used for RSI, which can cause hyperkalemic cardiac arrest
(HCA). This analysis investigates the cost-effectiveness of using
rocuronium and sugammadex vs. succinylcholine for RSI in the
Swedish setting.
Methods: A model of costs and clinical outcomes was developed.
Clinical outcomes of RSI were assumed similar across strategies,
except for the risk of fatal HCA. Costs were only estimated for
pharmaceuticals, as other costs would not contribute appreciably
within the model. Expected loss in quality adjusted life years
(QALYs) due to fatal HCA was calculated using Swedish life tables
and population-based utility scores. To estimate excess risk of HCA
with succinylcholine, a literature review was conducted. QALYs
were discounted at 3% annually. As the risk of a CICV event may
differ by setting, results are presented for various CICV risks.
Results: Based on data pooled from 17 published studies,
the excess risk of fatal HCA with succinylcholine was estimated
to range between 0.03-0.13%. Costs per QALY ranged between
2,524-236,062 SEK/QALY (378-35,392 USD/QALY)* when
CICV risks were varied from 1-100%, assuming the upper bound
succinylcholine risk of fatal HCA (0.13%). Costs per QALY ranged
between 12,620-1,180,308 SEK/QALY (1892-176,958 USD/
QALY)* when CICV risks were varied from 1-100%, assuming the
lower bound fatal HCA risk (0.03%). The figure shows the CICV
and fatal HCA risks for which cost/QALY thresholds of 100,000,
300,000 and 500,000 SEK/QALY are reached (constrained by the
lower/upper bounds for fatal HCA risk).
Discussion: As the risk of a CICV event using RSI is a few
percent or less in most settings, this analysis has demonstrated
that rocuronium and sugammadex can provide a cost-effective
alternative to succinylcholine for RSI in Sweden.
References:
European Medicines Agency Public Assessment Report Bridion
Statistics Sweden (life tables)
Rapport 2002:1 Folkhälsovetenskapligt Centrum
www.apoteket.se (drug prices)
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-181
ANESTH ANALG
2012; 114; S-01 – S-493
S-181.
PEDIATRIC SEDATION OUTSIDE THE
OPERATING ROOM WITH A PARAMEDIC
AUTHORS: A. Targ, A. Rogers
affiliation: Targ Mobile Anesthesia, Palo Alto, CA
Introduction: Hiring an Emergency Medical Technician
can be a valuable but often overlooked option for finding an
assistant with a skill-set uniquely matched to the needs of a mobile
pediatric dental sedation practice. The EMT scope of practice
varies by state and training level, with the continuum ranging
from EMT-B (Basic) to EMT-P (Paramedic), all of whom practice
completely independent, unsupervised airway management,
including endotracheal intubation (depending upon local laws). In
addition to assisting with medical procedures, this individual can
be trained to bill insurance, settle payments, handle scheduling and
correspondence, and transport and set up equipment.
Figure 1: Full time equivalent salary range by healthcare provider (2).
There are over 200,000 EMTs in the United States who are trained
specifically to stabilize patients and transport them to a hospital1.
An EMT can assist with pediatric sedation outside the operating
room with hourly wages as low as $8/hour and replace more
expensive Anesthesia Assistants (AAs) and RNs (Figure 1) without
compromising quality of care.
Methods: N/A
Results: An EMT hired to assist the anesthesiologist performed
the following responsibilities: equipment set up, greeting patients,
verifying NPO and medical history, assisting with sevoflurane
inhalation induction, GlideScope nasal intubation, and recovery,
disinfecting and packaging instruments for the autoclave, and
equipment troubleshooting.
The maximum full-time salary equivalent for an AA is $131,563
compared with the maximum of $52,686 for an EMT (Figure 1).
When the salaries of an RN, AA, CRNA, and EMT are compared,
the EMT is the most cost effective solution. Most states do not even
recognize the AA as a legal certificate whereas the EMT continuum
is legally recognized in every state3 (Figure 2).
33 states prohibit AA practice by statute. Only seventeen states (shown in
blue) recognize the Anesthesia Assistant (AA) as a valid certification: AL,
CO, FL, GA, KY, MI, MO, NC, NH, NM, OH, OK, SC, TX, VT, WI, and WV.
Discussion: An EMT anesthesia assistant benefits both the
medical practice and patients. An economical assistant lowers the
cost of health care and increases affordability. Although an EMT
cannot completely replace a CRNA or an AA, an EMT can provide
support to the physician in routine sedation and may have the most
experience of any available assistant when it comes to independent
decision making and properly executing cardiopulmonary resusciВ­
tation procedures.
References:
1.“Emergency Medical Technicians and Paramedics.” US
Department of Labor, Bureau of Labor Statistics. 2008
2.www.payscale.com
3. National Registry of Emergency Medical Technicians
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-182
S-182.
30 OUT OF 50 STATES NOW MANDATE PRIVATE
MEDICAL INSURERS MUST PAY CHARGES FOR
PEDIATRIC DENTAL SEDATION
AUTHOR: A. Targ
affiliation: Targ Mobile Anesthesia, Palo Alto, CA
Introduction: Introduction: Historically, private medical
insurers in the United States have refused to cover sedation and
facility charges for dental procedures by insisting that they should
be covered by dental insurance. At the same time, the private
dental insurers have been refusing to cover the sedation and facility
charges on the basis that they are for the practice of medicine and
thus not a dental benefit. To resolve the situation where a patient
has both medical and dental insurance and still has no coverage,
many states starting in the late 1990’s passed legislation requiring
medical insurers to cover sedation and facility charges for dental
procedures for children under 5 to 8 years of age and for other
people with disabilities that make them require sedation for
procedures which normally would not require sedation. Each state
has its own description of the sedation locations covered, ranging
from a “dental office” to “surgery center setting” to “hospital.” The
purpose of this study was to identify which states currently have
passed such mandates.
Methods: A search of the internet and public health organizations
and state legislature archives therein was the source of all data.
Results: The 34 states listed in the category of “Mandates” in
the table are those for which a mandate could be found. There are
16 states in the “No Mandates” category. Classification in the “No
Mandates” category does not mean that evidence was found that
there is no mandate. It means simply that no evidence of a mandate
could be located.
Discussion: Knowledge of the details of a practitioner’s partic­
uВ­lar state statutes may be helpful when submitting a claim to the
patient’s insurer since the insurer, particularly if it is based out of
state, may need to be educated about the laws governing coverage
for the sedation. In addition, the preponderance of states with
statutes may have caused national insurers for the sake of simplicity
to write guidelines applied nationally which provide a form of the
mandated benefits to insureds in states that have not in fact passed
laws mandating the benefits.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-183
S-184
ANESTH ANALG
2012; 114; S-01 – S-493
S-183.
S-184.
ECONOMIC IMPACT OF MULTI-DISCIPLINARY
PATHWAY FOR URO-ONCOLOGY SURGICAL SERVICES
IN A TERTIARY TEACHING HOSPITAL IN THE
UNITED KINGDOM
COST-CONSEQUENCE ANALYSIS OF CLONIDINE FOR
THE PREVENTION OF PERIOPERATIVE
CARDIOVASCULAR EVENTS IN NONCARDIAC
SURGERY PATIENTS
AUTHORS: T. Quraishi, U. Panchagnula, S. Bansal
AUTHORS: G. A. Lurati Buse1,2, R. Goeree3
affiliation: Department of Anaesthesia, Central Manchester
University Hospitals, Manchester, United Kingdom
affiliation: 1Anesthesiology, University Hospital, Basel,
Switzerland; 2Population Health Research Institute, McMaster
University, Hamilton, ON, Canada; 3Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton, ON, Canada
Introduction: We evaluated the impact of multi-disciplinary
perioperative pathway on patient outcomes undergoing urooncological surgical procedures at Central Manchester University
Hospitals (CMFT) in United Kingdom; namely perioperative length
of stay (LOS).
Following reconfiguration of cancer services in Northwest England,
recommendations from National Institute for Clinical Excellence
and Health (NICE)1 and National Cancer Standards in England
for Urological Cancer, CMFT is recognised as high volume and
high risk tertiary centre for uro-oncological procedures ie radical
cystectomy (RC) and radical prostatectomy (RP).
Multi-disciplinary pathway was developed in 2009 to streamline
services and improve patient outcomes.
Methods: Outcome measures (Pre and Post pathway): LOS,
perioperative morbidity/mortality and re-admissions within 30
days postoperatively were reviewed systematically by a researcher
independent from patient care. Risk assessment scores included
ASA, Lee’s cardiac index and Clavien-Dindo2. All RC patients
underwent cardiopulmonary exercise testing.
Results: 104 patients were included in the study over 18 months.
We evaluated 38 patients (10 RC and 28 RP) prior to pathway and
76 patients (24 RC and 52 RP) after implementation. Postoperative
LOS was calculated from the date of surgery to patients’ discharge
to regular residence. A 35.6% decrease in median postoperative
LOS for RC following implementation was noted. Within 30 days
postoperatively, none of the RC or RP patients were readmitted or
died. Increased use of oesophageal Doppler for goal directed therapy
and a decrease in central venous catheter use in RP patients was
noted. Increased use of rectal sheath and TAP blocks was observed
as part of multi-modal analgesia. Decreased use of epidural was
observed. Prior to the pathway, all RP were admitted 1 day prior
and admitted postoperatively to critical care; following pathway all
RP patients are admitted on the day of surgery and discharged to the
ward postoperatively.
Discussion: The results demonstrate that multi-disciplinary
pathway can improve patient outcomes resulting in economic
benefit to the hospital, primarily by reducing LOS. From average
bed costs, results can be translated to a saving of $48,000 for 30
RC & $96,000 from critical care LOS for 80 RP per annum at
CMFT. RC and RP referral rates have increased at CMFT as a
result of efficient throughput. This pathway has been integrated into
enhanced recovery (ERAS) programmes and has also been adapted
for gynae-oncology procedures at CMFT.
Introduction: Introduction: Cardiovascular events after
noncardiac surgery represent a major population health problem.
Alpha-2 agonists appear to prevent those events1. Our objective
was to compare costs and consequences of prophylactic clonidine
to prevent cardiovascular events in patients undergoing noncardiac
surgery.
Methods: We conducted a model-based cost-consequences
analysis at a program implementation level from a public payer
perspective in Canada. Primary outcomes were myocardial
infarction, stroke, and death. We set the time horizon of 30 days and
1-year given the heterogeneous long-term prognosis of noncardiac
surgery patients. We tested model assumptions by one-way
sensitivity analyses.
Results: Clonidine administration to prevent cardiovascular
complications after noncardiac surgery dominated standard care,
i.e. it saved costs and prevented adverse events. Of the 1,000
simulations, 88.3% lay in the dominant quadrant for perioperative
myocardial infarction, 68.2% for stroke, 89.1% for perioperative
death, and 92.1% for 1-year death. The impact of the program
(means over 1,000 simulations) per 100,000 patients undergoing
noncardiac surgery was 15.04 million $CAD saved and 2,397
averted perioperative myocardial infarctions, 82 averted strokes and
851 averted death at 30 day after surgery. At 1 year, the clonidine
program implementation saved 30.74 million $CAD and averted
1,134 deaths. The results were insensitive to model assumptions
with the exception of a moderate effect scenario.
Discussion: Based on current evidence, perioperative clonidine
administration to prevent cardiovascular events dominated standard
care. There are, however, methodological concerns about the current
evidence because it was generated in a limited number of patients
and because its immoderate effect size. Effectiveness data in a large
sample are required to achieve a definitive statement of the budget
impact of a program of perioperative clonidine administration.
References:
1.Wijeysundera DN, Bender JS, Beattie WS. Alpha-2 adrenergic
agonists for the prevention of cardiac complications among
patients undergoing surgery. Cochrane Database Syst Rev. 2009;
CD004126.
References:
1. Improving Outcomes in Urological Cancers. NICE,2002.
2.Short- and long-term complications of open radical prostatectomy
according to the Clavien classification system,103;336;2009.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-185
S-185.
CONTEMPORARY ANALYSIS OF THE INCIDENCE AND
ECONOMIC IMPACT OF POSTOPERATIVE PNEUMONIA
ANESTH ANALG
2012; 114; S-01 – S-493
Table 1: Post-matching outcomes of patients with and without
postoperative pneumonia (POP)*
Variable
N
No POP
Mean
N
POP
Mean
AUTHORS: S. D. Kelley1,2, S. J. Agarwal1, M. G. Erslon1, S. T. Bent3
Total cost
17177
$28,886
17177
$62,773
affiliation: Covidien, Mansfield, MA; Brigham and
Women’s Hospital, Boston, MA; 3Tulane University Department of
Anesthesiology, New Orleans, LA
LOS (days)
17177
9.2
17177
20.8
ICU time (days)
6678
6.7
12075
12.9
ICU cost
6678
$11,178
12075
$22,327
Antibiotic cost
15096
$469
16918
$1,549
Pharmacy cost
17165
$3,373
17177
$8,435
Imaging cost
15302
$1,008
17165
$1,983
Respiratory therapy cost
12173
$1,297
16290
$3,878
1
2
Introduction: Pneumonia is a serious complication after
surgery. Postoperative pneumonia (POP) is the second most
common hospital-acquired infection in the US and leads to
mortality, increased hospital length of stay (LOS) and cost(1). We
utilized a large administrative database to report the incidence,
clinical and economic outcomes of POP not present on admission
(POA) to describe the burden of POP.
*p<0.0001 for all comparisons
Methods: We studied a population of inpatient surgical adults
using the Premier Perspectiveв„ў Database (PPD) 2010. PPD is the
largest hospital resource utilization and economic database in the
US. Pneumonia was identified using ICD-9 codes 481, 482, 485
and 486. Cases with pneumonia POA and pneumonia as admitting
or primary diagnoses were excluded from the study. A 1:1 match
was performed between those with POP (cases) and those without
(controls) based on propensity scores. Patient demographics,
provider characteristics, diseases of Charlson comorbidity index,
admission status and major diagnostic categories were used to
calculate propensity scores. We used the post-matching cohort to
describe outcomes of mortality, discharge disposition, length of stay
(LOS) and hospital costs. We assessed the US-wide burden of POP
using Premier-provided projection weights.
Results: Of the 1,139,792 discharges that met the inclusion
criteria 17,177 (1.5%) developed POP. 11.8% of those with POP
died in hospital compared to 3.96% in the control group (p<0.0001).
About half the POP cases (49.34%) were discharged to a facility
other than home compared to 31.99% in the control group
(p<0.0001). Post-matching POP cases had mean total hospitalization
cost of $62,773 and LOS of 20.8 days compared to total cost of
$28,886 and 9.2 days LOS for cases without POP, respectively. POP
cases had longer postoperative stay, longer ICU stay, and higher
pharmacy, imaging and respiratory therapy costs compared to the
control group. Outcome measures post-matching are shown in Table
1. Nationally there were about 143,000 cases of POP accounting for
$8.98 billion in hospital costs and 2.98 million days of hospital stay.
Discussion: POP is associated with increased mortality and
patient discharge to facilities other than home and high economic
burden for the hospital. Better strategies for the prevention and
management of POP may lead to greatly improved patient outcomes
and substantial hospital savings.
References:
1.Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing
health-care-associated pneumonia, 2003: recommendations of
CDC and the Healthcare Infection Control Practices Advisory
Committee. MMWR Recomm Rep 2004;53:1-36.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-186
S-186.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Education & Patient Safety
ABSTRACTS
S-192
S-193
ANESTH ANALG
2012; 114; S-01 – S-493
S-192.
S-193.
REAL AMOUNT OF DRINKING INVESTIGATION WITH
THE PREOPERATION ORAL REHYDRATION THERAPY
COMPARISON OF THE REAL-TIME ULTRASOUNDGUIDED CATHETERIZATION AND THE TRAADITIONAL
PALPITATION TECHNIQUE FOR RADIAL ARTERY
CATHETERIZATION
AUTHOR: Y. Fukushima1, S. Tani1, T. Tateda2
affiliation: 1Anesthesiology, Tama South Regional Hospital,
Tama, Japan; 2Anesthesiology, St. Marianna University School of
Medicine, Kawasaki, Japan
Introduction: There are guidelines on preoperative oral
rehydration therapy in Europe and America. However, guidelines
are not yet established in Japan. We introduced preoperative oral
rehydration therapy at our hospital, but unevenness was seen in the
real amount of drinking by a patient individual.
We examined an investigation into real amount of drinking and
future measures this time.
Methods: We did 257 cases with water to drink possibility to
up to 500 ml until two hours before operating room admission from
0:00 on the operation day at the anesthesia department management
operation appointed hour of the adult in our institution and
investigated amount of drinking.
Results: The overall amount of drinking mean is 321 ml.
The average younger than 70 years is 303 ml. The average 70 years
or older is 336 ml.
The average of the case of the morning is 321 ml. The average of the
case of the afternoon is 333 ml.
These results did not have significant difference.
The average of the man is 340 ml. The average of the woman
accepted significant difference at 383 ml.
Discussion: There are the present conditions that are not still
carried out in an institution of approximately 60% in this country
after guidelines on ASA announcement. It is pointed out that the
oral rehydration therapy reduces the stress of a patient and the
healthcare worker in preoperation. However, a difference is seen in
amount of drinking by a patient. It was shown in old women in this
investigation that there was much amount of drinking.
We introduce commercial oral supplementary water liquid to
prevent unevenness of the amount of drinking or set the minimum
amount of drinking, and it is thought that it is necessary to examine
quantity and a kind of the water to drink which is not inferior to an
infusion therapy in future.
References:
1.Tanniguchi H, Sasaki T, Fujita H, et al: Preoperative fluid and
electrolyte management with oral rehydration therapy. J Anesth
2009; 23: 222-9
AUTHOR: Y. Fujita, J. Nakata, M. Nakajima, I. Sano, Y. Teramoto
affiliation: Toyohashi-city, Japan
Introduction: Radial artery catheterization is a procedure by
palpation in the operating room has been made on a daily basis.
Some patients in shock or obesity patient hardly touch the pulse, so
far, the palpation technique may take some time to catheterization.
There are reports that the initial success rate could be increased
by using the real-time ultrasound guidance for a radial artery
catheterization. (Chest.2011;139:524-529)
Methods: Thirty-eight patients requiring invasive blood
pressure who underwent surgery randomly divided into two groups;
the traditional palpation techniques of radial artery catheterization
(group P) and ultrasound guidance (group U). We measured
time from the start disinfection to catheterization and number of
punctures.
Results: Group P was significantly shorter the time to
catheterization than group U. [median seconds 84.5 vs.188.5,
P<0.05]. Group P was significantly less than the number of
punctures than group U [median number 1.0 vs.1.5, P<0.05].
Group P was significantly higher initial success rate than group U.
[mean 88.3 vs. 44.4 %, P<0.05]. Compared with the ultrasound,
the palpitation method was associated with an 87.5% improvement
in the likelihood of initial success rate [relative risk, 1.875; 95%
CI, 1.075-3.270]. Because Initial success rate was so high in the
palpation method in our facility, we couldn’t improve initial success
rate by the ultrasound guidance. Although the palpation technique
was impossible, even there were 2 cases ultrasound guidance
has been possible. The one case was in a dialysis patient with
arteriosclerosis. The other case was in a patient with a history of
ischemic heart disease
Discussion: Generally the traditional palpation techniques
of radial artery catheterization might be more certainty and more
rapid than the ultrasound guidance. If we use ultrasound guidance
after several times of punctures by the palpitation technique, the
total number of punctures may potentially reduce. We may puncture
so many times for patients with atherosclerosis and pulse less.
Ultrasound guidance is possible to catheterization even if they can’t
touch pulse. Therefore the ultrasound guidance is useful for patients
in shock and obese patients. We can observe the lumen vessel of
radial artery by ultrasound. We can insert catheters to narrow lumen
due to atherosclerosis with ultrasound guidance. Patients in shock,
obese patients, and patients with atherosclerosis may be better under
the ultrasound guidance from the first catheterization.
References:
Ultrasound-Guided Catheterization of the Radial Artery
A Systematic Review and Meta-analysis of Randomized Controlled
Trials Ariel L. Shiloh, CHEST March 2011 vol. 139 no. 3 524-529
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-194
S-195
ANESTH ANALG
2012; 114; S-01 – S-493
S-194.
S-195.
THE LEVEL OF NOISE IN THE OPERATING ROOM AT
CRITICAL TIMES
SUMMER ANESTHESIOLOGY
EXTERNSHIP:DEMONSTRATING THE ABILITY OF
EARLY CLINICAL INVOLVEMENT TO RECRUIT AND
EDUCATE MEDICAL STUDENTS
AUTHORS: S. H. Ginsberg, A. S. Panjwani, A. R. Solina, W.
Grubb, J. Kraidin
affiliation: Anesthesiology, UMDNJ-RWJ, New Brunswick,
NJ
Introduction: The level of noise in the operating room
is of importance to the anesthesiologist as it directly impacts the
ability to maintain concentration levels. Noise in the operating room
has many sources and examples include: preparation for surgery,
moving equipment, conversations among staff, telephones and
pagers, alarms and monitors. Previous studies have identified staff
related activities to be the main contributor of noise.1,2
Methods: The study was approved by the IRB. The noise level
was monitored in the operating room for 50 patients undergoing
surgery with general anesthesia (23 of which were for cardiac
surgery) during the following times: room set up, induction, skin
incision, 60 minutes into the case, drapes down and at transport. The
noise level measured during room set up was during the anesthesia
set up of the room, prior to the patient arrival.
A “Thomas scientific” sound level meter which had the ability to
record between 35- 130 decibels was used.
Noise levels were analyzed under an analysis of variance model
with random intercepts for patients. Holm’s method (Holm, 1979)
was used to adjust for multiple comparisons among the contrasts.
Results: This study consistently demonstrated that it is louder in
the operating room during the critical anesthesia components of the
case such as induction and emergence when compared to surgical
times such as skin incision or during the actual surgical procedure.
The difference in noise levels was not significant for emergence/
drapes down versus just off bypass. All other differences were
highly significant.
Discussion: The level of noise in the operating room is
important to anesthesiologists and other healthcare providers in
order to maintain concentration. However, the significance of this
increases during the more critical stages for anesthesia, such as
induction and emergence. The aim of this study was to compare
the level of noise in the operating room at times determined critical
for anesthesiologists compared with other surgical periods. This
study consistently demonstrated that it is louder in the operating
room during the critical anesthesia components of the case such as
induction and emergence than at skin incision or during the actual
surgical procedure.
References:
1.Tsiou C, Efthymiatos G, Katostaras T, Noise in the operating
rooms of Greek hospitals. J acoust Soc 2008 Feb;123(2):757-65.
2.Christensen M. Do hospital personnel influence noise levels in
an operating theatre and a postanesthesia care unit? J adv Periop
Care. 2004;2:19-26
AUTHORS: K. S. Baker, C. Daniel, P. Glass, P. A. Seidman
affiliation: Stony Brook University Hospital, Stony Brook,
NY
Introduction: Typical medical school curriculum organization
leaves students with little elective time until late in the third year, or
early in the fourth year. This causes some Anesthesiology residency
applicants to have little time to develop their interest in the field, and
some to discover their potential career too late entirely. Realizing
this,the authors describe a “Summer Anesthesiology Externship” at
their institution aimed at acquiring and developing early medical
student interest in Anesthesiology by running a 6-week program
which provides procedural, informational, and simulation education
for two medical students annually during the summer after their
first year.
Methods: The organization, timeline, and goals of the program
are outlined for review and possible implementation/adaptation
from other institutions/departments. To analyze the utility of various
aspects of the educational experience, questionnaires were sent to
externs after completion.
Results: Students unanimously (14 of 14) agreed that the
program introduced them to the true breadth of the field, and
that their practiced clinical/procedural skills improved their
confidence when performing the procedures later in medical school.
Interestingly, most (9 of 14) students applied for the externship with
some working idea of specialty choice, although the majority (10 of
14) were not explicitly interested in Anesthesiology. However, at the
end of the externship, nearly all (12 of 14) students were strongly
considering the field as a career choice.
Various aspects and importances of simulational training were
evaluated. The student simulations were shown to be adaptable to
the learning of junior level students (mean agreement rating 9.21),
and effective in developing clinical knowledge and interpersonal
skills (mean agreement ratings of 9.43 and 8.14, respectively).
Discussion: Our results show that early clinical “hands-on”
learning experience has the capacity to recruit and educate students
earlier in the medical school continuum. This has potential to inspire
more students to participate in field research, politics, conferences,
and education at a more junior level.
Numerous areas of program utility are demonstrated, including the
ability of students to identify certain niches of Anesthesia for which
they would feel most comfortable in the long-term. Importance
of simulation is shown, as above. The importance of clinical and
procedural skills learned is shown by data confirmation that the
skills are often used later in medical school, and that repeated
performance in clinical and simulational work boosted confidence
when performing these procedures.
References: NA
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-196
S-197
ANESTH ANALG
2012; 114; S-01 – S-493
S-196.
S-197.
USEFULNESS OF ULTRASOUND GUIDED CENTRAL
VENOUS INSERTION IS DEPENDENT ON THE DIFFERENT
CLINICAL EXPERIENCES
DRUG ADMINISTRATION ERRORS DURING EPIDURAL
OR SPINAL ANESTHESIA OR ANALGESIA
AUTHORS: T. Yorozu1, Y. Shiokawa2, K. Moriyama1, Y. Ohashi2
affiliation: Anesthesia, The Pennine Acute NHS Trust,
Rochdale, United Kingdom
affiliation: 1Anesthesiology, Kyorin University School of
Medicine, Mitaka, Tokyo, Japan; 2Neurosurgery, Kyorin University
School of Medicine, Mitaka, Tokyo, Japan
Introduction: Recently many reports showed that ultrasound
guided central venous catheter (CVC) insertion reduced mechanical
complications1,2. However the benefit of ultrasound devices (US)
was not shown without an adequate training of this technique2,3.
The purpose of this study is to evaluate the usefulness in reduction
of mechanical complications using US, relating to the clinical
experiences of our doctors.
Methods: Since 2008, Certifications for CVC insertions
has been given to the doctors in our hospital after they took the
educational course of CVC insertion including basic technique
using US. We divided the doctors in three groups according to the
years of their clinical experiences; group 1: junior residents less than
2 year experiences, group 2: doctors whose clinical experiences are
between 2 to 5 years, group 3: doctors whose clinical experiences
more than 5 years. The observation sheets of CVC insertion were
collected. We compared the reduction of mechanical complications
using US among the groups over 3 years (2008-2010). The data
were analyzed with Chi square tests. Research Ethics Committee of
our university approved this study.
Results: A total of 4637 observation sheets were collected. US
were used in 32.4% of all cases. Overall mechanical complication
rate was 3.5%. Reduction of the mechanical complications when
the doctors in group 2 used US was seen (Table). On the other hand,
the mechanical complications tended to increase when the doctors
in group 3 used US. Mechanical complications in group 1 varied
among years.
Discussion: The reduction of mechanical complications using
US was seen only in the insertions by the doctors of the clinical
experience between 2 and 5 years. These doctors have acquainted
this fairy new technique as well as the conventional land mark
technique in their early years of clinical experiences. They seem
to have acquired the technique successfully to reduce mechanical
complications using US after their troublesome resident years. On
the other hand most of senior doctors have already spent many years
using only land mark technique for CVC insertions. It may seem to
be difficult for them to realize that US guided CVC insertion would
not be easily successful unless they understand the differences
of these two techniques. In order to facilitate safety management
of ultrasound guided CVC insertion, enlightenment of accurate
standard technique of US guided CVC insertion for even senior
doctors is important and urgent.
AUTHOR: S. Patel
Introduction: Accidental wrong drug administration via
epidural (ED) or intrathecal (IT) route is a serious human error and
can lead to serious complications.
Methods: For the period between 2002-2011, I searched medline
database and google scholar using terms �epidural drug error’,
�accidental epidural drug injection’, �inadvertent epidural drug
injection’. Search was also done using intrathecal word in place of
epidural. Cases reported in non-english literature and non-anaesthetic
practice/procedures were excluded. Drugs administered, route and
clinical circumstances were noted. Immediate (< 1hr), short term
(< 1 day) and long term (> 1 day) consequences were summarized.
Cause of error and likely prevention strategy was noted.
Results: Mishaps took place at various stages of clinical care
including postoperative period in case of ED errors. Of 34 cases
(table 1) reported, all 9 errors of muscle relaxants were during
non-obstetric practice. In contrast, magnesium sulphate (2 cases)
and ephedrine (2 cases) errors occurred in obstetric practice (total
10 out of 34). IT errors occurred in 10 cases. ED rocuronium,
suxamethonium and remifentanyl administration required
emergency airway management and tracheal intubation. ED
glutraldehyde and IT aminophylline caused paraplegia.The later
patient died 2 years later. ED potassium chloride (KCL) resulted
in reversible cardiomyopathy post caesarean section. All 3 cases of
IT Tranexamic acid resulted in convulsions, refractory ventricular
fibrillation and death within few hours. Ampoule error was the cause
in all 4 fatal cases . In few cases systemic or ED steroids or ED
saline were administered to limit spinal cord damage.
Discussion: Common ED/IT drug administration errors differ
in obstetric and other anesthetic practice. Hew et al1 reviewed 37
cases of epidural drug administration errors covering a period of
more than 3 decades. In their report potassium chloride was the
most common drug involved followed by IV induction agents and
antibiotics. In contrast, in this study muscle relaxants followed by
MgSo4, paracetamol and tranexamic acid were frequently reported.
However, the common causes of error remain same - ampoule errors
(size, shape, label), syringe swap (size, unlabelled, wrong labelled)
and epidural/spinal catheter-IV line mixup/confusion. Preventing
ED/IT unintended drug administration should focus on multiple
strategies including high vigilance by staff involved. Use of touch
sense (by specific size, shape and surface design) to identify local
anesthetic ampoules, syringe or infusion bag might be beneficial.
Non-Luer safety connector system for neuraxial procedures has also
been recommended.
References:
1. Anaesth Intensive Care. 2003;31:44-9
References:
1.Br J Anaesth 99: 662-5, 2007, 2) N Engl J Med 348: 1123-33,
2003, 3) Anesth&Analg 110: S206, 2010
The rates of mechanical complications of each group over three years
2008
2009 2010
Group 1 ( junior residents )
13.3%* 4.2% 2 . 4 %
US used US not used
3.3%
6.5% 1.2%
Group 2 ( clinical experience
3.4%
2.3% 1 . 1 %
2 to 5 y) US used US not used 6.0%
4.1% 1.4%
Group 3 ( clinical experience
5.1% 7.0%* 2 . 7 %
>5 y) US used US not used
4.2%
3.4% 2.3%
US: ultrasound devices, y: years * p<0.05
Total
4.3% 3.2%
2.0%* 4.2%
4.4% 3.2%
Wrong drugs given via epidural (ED) or intrathecal (IT) route
Group
Drug given (number of reports)
Atracrium (2 -IT, 1-ED), Rocuronium (2),
Muscle relaxants
Cisatracrium, Vecuronium,
Pancuronium, Suxamethonium
Magnesium sulphate (2),
Electrolyte based solutions
Potassium chloride (2)
Paracetamol (3), Remifantanyl, Tramadol Analgesics
(IT), Morphine - (IT large dose)
Vasopressor/antihypertensive
Ephedrine (2), Metaraminol, Labetalol
Anticoagulants
Trenexamic acid - (3 - IT), Heparin
Antiemetics
Metochlopramide (IT), Ondansetron
Neostigmine (IT), Insulin, Gularaldehyde,
Miscellaneous
Tazobactum, Aminophylline (IT)
Where not indicated drug was given via ED route. Number indicates number
of cases reported.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-198
S-199
ANESTH ANALG
2012; 114; S-01 – S-493
S-198.
S-199.
A PILOT STUDY: TO DEVELOP A TOOL TO MEASURE
THE CLIMATE OF BULLYING AMONG ANESTHESIA
CARE PROVIDERS
THE USE OF AIRTRAQ IN AN ALTERNATE TEACHING
APPROACH TO LEARNING DIRECT LARYNGOSCOPY
AUTHORS: S. V. Pisklakov, M. Davidson, C. Schoenberg, D. Munoz
affiliation: Anesthesiology, UMDNJ-NJMS, Newark, NJ
Introduction: The primary aim of this study is to develop
a survey to aid in determining the incidence and consequences of
bullying among anesthesia providers. This will assist in ascertaining
the causes of the problem and aid in developing preventive measures
leading to a comprehensive policy to deal with bullying.
Methods: Our department has three levels of anesthesia
providers: faculty, residents and CRNAs. The view point of all
three levels was considered to assess how bullying is perceived. Our
protocol included four phases. Phase I consisted of a focus group
of three volunteers from each of the three anesthesia care provider
categories. Their input provided a definition for bullying. The focus
group was conducted using the four question sequence:
1.Main question was open ended and geared to start a discussion
about a subject.
2.Follow up questions providing details.
3. Probing questions.
4. Prompt questions
Phase II consisted of the development of the survey. Phase III
consisted of validation by seven individuals who were asked to
assess the survey for clarity and relevance. In Phase IV we will pilot
this anonymous paper and pencil survey amongst our staff.
Results: The input from the Phase I focus group provided a
definition for bullying. Phase II resulted in the developed survey.
Phase III resulted in survey validation.
Discussion: Bullying is an aggressive behavior intended to
cause distress and involves an imbalance of power between the
aggressor and the victim. Bullying causes high turnover and thwarts
productivity.2,3 The Joint Commission (TJC) requires hospitals to
create policies for dealing with this aggressive behavior.4 To mitigate
risk departments must establish comprehensive anti-bullying policy
and provide education5. One study reports that 37% of doctors in
training have been bullied1. Departments and personnel need to
develop a higher level of awareness. A mechanism for victims to
come forward should be established.6 Preventive methods might
include providing anti-bullying education and communication skill
training as a part of the curricula7.
References:
1 Paice E et al. British Medical Journal 2004; 329: 658-9.
2.Porto G, Lauve R. http://goo.gl/sYO4D accessed on February 8,
2009.
AUTHORS: V. Ng, T. Straker
affiliation: Montefiore Medical Center, Bronx, NY
Introduction: Endotracheal intubation is a fundamental
psychomotor skill essential to the field of anesthesiology. Mastering
this skill is one of the goals of all anesthesiology residencies.
Teaching intubation usually involves a laryngoscope, blades,
endotracheal tubes, and verbal instruction from a teacher. Many
factors contribute to proficiency in laryngoscopy - various teaching
styles, restricted visualization, patient anatomy, and individualized
learning curves. With these limitations we hypothesize that the initial
exposure to endotracheal intubation with the Airtraq, a rigid optical
device adapted to a camera system, may improve the technique and
speed with which direct laryngoscopy skills may be acquired.
Methods: For the first three weeks of a month long mentoring
program, the new CA-1 resident was taught to intubate using only the
Airtraq. During the first week, the Airtraq was adapted to a wireless
camera system allowing for visualization by both the resident and
the attending. Learning airway anatomy and terminology of various
structures was stressed more than the actual intubation itself. In the
second week, the Airtraq was used without the camera system. The
focus was on intubation technique utilizing the Airtraq. The third
week, the CA-1 was allowed to intubate with the Airtraq but without
instruction from the attending. During the final week of mentorship,
the CA-1 was given a laryngoscope with a MAC 3 blade and taught
the technique for direct laryngoscopy. The transition from Airtraq
to direct laryngoscopy was seamless. The resident and the attending
were able to communicate in medical language regarding the
anatomy of the airway. If the resident was experiencing difficulty,
communicating and troubleshooting the problem was accurate as
the resident knew the anatomy. Motor skills needed for the technical
aspect of laryngsocopy were not hindered by initially teaching with
the Airtraq. The resident demonstrated knowledge of the airway
anatomy and was able to utilize the anatomy to intubate correctly.
Results: N/A
Discussion: Anesthesiology requires extensive knowledge of
multiple types of equipment, pharmacology, pharmacokinetics,
and an advanced technical skill set. This skill set involves
psychomotor learning, a process applying cognitive function and
physical movement. Focus on visualization and learning anatomy
may be a suitable model for teaching laryngoscopy. In addition,
communication using appropriate medical terminology may enhance
the trust and relieve the anxiety between student and teacher. This
pilot study fulfilled the hypothesis of this investigation. This project
will be expanded to include the CA-1 class of 2012.
References: N/A
3Rosenstein AH, O’Daniel M Am J Nurs 2005;105:54-64.
4.Joint Commission - Sentinel Event Alert - Behaviors that
undermine a culture of safety. Issue 40, July 9, 2008.
5.Quine L BMJ 1999; 318:228-232
6.Bosk CL: Forgive and Remember: Managing Medical Failure.
Chicago, University of Chicago Press, 1979
7. Baldwin DC Jr et al. Western J Med 1991; 155:140-145
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-200
S-201
ANESTH ANALG
2012; 114; S-01 – S-493
S-200.
S-201.
ANESTHESIA INFORMATION MANAGEMENT SYSTEMS
(AIMS) MEDIATE IMPROVED SCIP COMPLIANCE
COMPARED TO HOSPITALS WITHOUT AN AIMS
A SIMULATION STUDY OF UNINTENTIONAL
CATECHOLAMINE FLUSH DUE TO INAPPROPRIATE
RELEASE OF AN INTRAVENOUS LINE OCCLUSION
USING SYRINGE PUMP IN INTENSIVE CARE UNIT
AUTHORS: I. S. Stol, W. S. Sandberg, J. M. Ehrenfeld
affiliation: Vanderbilt University, Nashville, TN
Introduction: The Surgical Care Improvement Program
(SCIP) is a national attempt to improve care of the patient undergoing
anesthesia and surgery by putting specific measures in place to
reduce surgical complications. Hospitals now publicly report SCIP
compliance scores to CMS in various categories based on process
measures which map to surgical outcomes. Recent studies utilizing
the Nationwide Inpatient Sample have demonstrated that SCIP1
compliance (giving prophylactic antibiotics within 1 hour of skin
incision) has been improving over the last five years ranging from
74.8% in 2005 to 88.9% in 2007,1 However, in the informatics
literature, hospitals using an AIMS have reported significantly
higher compliance rates approaching 100%2,3. This study is aimed to
assess the association between SCIP1 compliance and AIMS usage
in U.S. hospitals.
Methods: We validated and then distributed a survey to 200
U.S. hospitals to evaluate the association between AIMS use
and SCIP1 compliance. We chose a representative sample of
U.S. hospitals based on the following: Size, Geography, Urban/
Rural, and Teaching/Non-Teaching. We mailed the surveys to the
Department of Anesthesiology Chair at each hospital, followed up
with an online survey, phone calls, and ultimately, a second mailing
to those hospitals who did not return a survey. Using the Medicare
Hospital Compare database, we collected the 2005-2010 SCIP1
compliance scores from all surveyed hospitals.
Results: 106 surveys were returned. 33% of the hospitals reported
using an AIMS, and 67% did not use an AIMS. Of those hospitals
who reported using an AIMS, 67% reported installing AIMS in the
operating room within the past 5 years. Our preliminary analysis of
the 2010 data shows that the mean compliance in hospitals without
an AIMS is 94.55% and for those hospitals with an AIMS is 95.05%
(p=0.2769).
Discussion: Based on past studies such as the one done by
O’Reilly in 2006, who showed that AIMS mediated reminders
improve performance on specific elements of the SCIP measure,
one might expect hospitals with AIMS to out perform those without.
Based on our preliminary analysis, we observed a trend towards
higher compliance in the AIMS group, but the difference does not
reach statistical significance. One might conclude that either AIMS
contribute little to managing execution on SCIP measures, or that
AIMS users are not taking full advantage of the decision support
potential such systems bring. A complete analysis of the entire
2005-2010 data set will be performed.
References:
1.Roth S. Proceedings of the 2010 Annual Meeting of the ASA,
A1179.
2. O’Reilly M., et al. Anesth Analg, 2006;103:908-12.
AUTHORS: T. Kariya1, T. Miyashita1, H. Sato1, H. Kawakami1,
K. Nakamura2, T. Goto1
affiliation: 1Anesthesiology, Yokohama City University
Hospital, Yokahama, Japan; 2Emergency Medicine, Yokohama City
University Hospital, Yokohama, Japan
Introduction: Unintentional catecholamine flush due to
inappropriate release of an intravenous line occlusion using syringe
pump in intensive care unit (ICU) is dangerous for patients who
need critical care. We investigated how anesthesiology residents
handled this situation in simulated ICU setting.
Methods: Preparation and primary situation
We set up a mannequin (SimManВ®, Laerdal, Norway) that was
virtually simulated as a sedated patient under mechanical ventilation
after cardiac surgery with epinephrine and dopamine being infused
via central venous catheter by syringe pumps (TerufusionВ®, Terumo,
Japan) to maintain the blood pressure 100/50 mmHg in simulated
ICU. An operator operated the vital signs by remote control.
Scenario: A facilitator explained the primary situation to each
participant before the scenario started. Prior to a participant came
into the simulated ICU, one of the stopcocks for the catecholamine
was occluded, and the blood pressure of the mannequin dropped
to 60/30 mmHg. A few minutes after a participant came in, the
occlusion alarm of the syringe pump went off. The behavior of
the participant was observed, and if the participant inappropriately
released the occlusion and flushed catecholamine, the operator
immediately rose the blood pressure to 200/100 mmHg.
Evaluation: In the debriefing session, the facilitator evaluated
whether the participant could diagnose the intravenous line
occlusion that caused hypotension in this scenario. The participant
was asked whether he/she understood why hypertension occurred
after releasing occlusion inappropriately, and how they should have
handled.
Results: Sixteen anesthesiology residents of our hospital
consented to participate in this study. Three of them understood the
occlusion was the cause of hypotension and handled the occlusion
appropriately. Two didn’t recognize the cause of hypotension.
Eleven residents released the occlusion without relieving pressure.
One of them didn’t recognize that the cause of hypotension was
catecholamine flush.
Discussion: Anesthesiology residents might have handled the
situation of intravenous line occlusion in their clinical practice
without understanding the problem. To avoid the incident, they
may need some lessons about the intravenous line occlusion and the
properties of syringe pumps. In addition, it may be necessary for the
manufactures to improve syringe pumps, too.
References: N/A
3. Ehrenfeld JM., et al. J Clin Monit Comput, 2011;25:71-79.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-202
ANESTH ANALG
2012; 114; S-01 – S-493
S-202.
REDUCING ERRORS IN PATIENT ELECTRONIC MEDICAL
RECORDS IN THE PERIOPERATIVE ENVIRONMENT
AUTHORS: E. Rebello1, S. Kee1, J. Berger1, A. Kowalski1,
N. Harun2, F. Goravanchi1
affiliation: 1Anesthesiology and Perioperative Medicine,
MD Anderson Cancer Center, Houston, TX; 2Biostatistics, MD
Anderson Cancer Center, Houston, TX
Introduction: With the advent of anesthesia information
management systems (AIMS) in the operating room, opening
and charting in the wrong patient record presents a documentable
patient safety issue. Almost half of the 140 US academic anesthesia
departments and at least fifty percent of anesthesiologists in nonacademic settings surveyed have already implemented, are planning
to acquire, or are currently searching for an AIMS1-2. The purpose
of this study was to examine the incidence of errors in opening the
wrong patient record in the perioperative environment by location in
our practice, and to determine whether efforts to reduce such errors
have decreased the incidence over time.
Figure 1: Logarithm of percent errors in the Offisite location as a function of
time. The p-value corresponds to a test for a decreasing trend in the log of
percent errors.
Methods: We retrospectively analyzed data for all surgeries and
procedures requiring anesthesia from our Automated Anesthesia
Information System (AAIS database). Out of 73,077 total cases,
there were 45 documented errors from January 2009 - June 2011.
The anesthesia time-out was implemented in Quarter 5 (Jan 2010)
and barcoding utilizing the patient id bracelet has been ongoing.
Descriptive statistics were used in data analysis.
Results: Among the 45 errors, 9 were recorded in the operating
room, 33 were at off-site locations, and 3 did not have a case type
or location. Table 1 summarizes the case type, rate, and location
of the reported errors. There was no trend observed for all sites
combined (p value = 0.2456), or the operating room (p value =
0.4693); however, there was evidence of a significant exponentially
decreasing percent of errors observed at the off-site (Figure 1)
location (p value 0.0078).
Discussion: The off-site location was the only site that
demonstrated a statistically significant decreasing pattern over time.
Interestingly, this area had the largest number of wrong records
opened. Thus, interventions such as the anesthesia time-out and
utilizing barcodes may play an important role in decreasing errors
in wrong patient record opening in the perioperative environment.
References:
1.Egger Halbeis, C. B., R. H. Epstein, et al. (2008). “Adoption
of anesthesia information management systems by academic
departments in the United States.” Anesthesia & Analgesia
107(4): 1323-1329.
2.Trentman, T. L., J. T. Mueller, et al. (2011). “Adoption
of anesthesia information management systems by US
anesthesiologists.” Journal of Clinical Monitoring & Computing
25(2): 129-135.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-203
S-203.
PHYSICIAN ATTITUDES AND BELIEFS SURROUNDING
PERIOPERATIVE DO NOT RESUSCITATE ORDERS:
ANESTHESIOLOGISTS’ GROWING COMPLIANCE
WITH PATIENT AUTONOMY AND SELF DETERMINATION
GUIDELINES
AUTHORS: C. Burkle, M. Keegan, K. H. Berge, K. M. Swetz
affiliation: Rochester, MN
Introduction: Patients with “do not resuscitate” (DNR)
orders presenting for surgical procedures may pose ethical and
practical challenges. ASA guidelines condemn the automatic
perioperative suspension of DNR orders as a practice in conflict
with patient autonomy and self determination.1,2 We sought to
ascertain physician beliefs regarding DNR status and resuscitative
efforts (REs) during the perioperative period.
Methods: Following IRB approval, 1726 internists (IM),
surgeons (S) and anesthesiologists (A) at our tertiary referral
institution were surveyed using a web based tool. Respondents were
asked to rate their agreement with a series of statements concerning
ethical, philosophical and practical aspects of perioperative
resuscitation on a 5 point scale - (strongly) agree, (strongly) disagree,
neither agree nor disagree. Descriptive statistics, chi-square, and the
Cochrane Armitage trend test were used to analyze data.
Results: Of 388 surveys returned, 26%, 28% and 40%,
were from A, S, and IM physicians, respectively of whom 38%
were physicians in training. Overall, 30% of respondents would
automatically suspend DNR orders prior to surgery (18% of A, 38%
of S, 34% of IM, p<0.01). Fifty five percent agreed/strongly agreed
that perioperative DNR requests were “illogical”, with 71% of
surgeons expressing such an opinion (p< 0.01). Surgeons were also
more likely to agree/strongly agree that anesthesiologists should be
permitted to use all resuscitative skills independent of a patient’s
DNR status (A 64%, IM 68%, S 84%, p < 0.01). Despite these
opinions, independent of specialty, three quarters of respondents
disagreed/strongly disagreed with a statement that perioperative
DNR decisions should be made solely by physicians and 77%
believed that patients capable of consenting to surgery could
separately determine their desire for perioperative resuscitation.
Discussion: Our institution requires physician-patient
discussion of DNR orders prior to surgery. One possible outcome
includes continuation of DNR status. Yet, 30% of respondents
would automatically suspend a patient’s DNR order, possibly
resulting in conflict with patient self determination. Unlike earlier
studies, A were less likely than S or IM to assume suspension,
suggesting increased awareness of published guidelines.2,3 The
majority of respondents, however, believed patients can appreciate
the idiosyncrasies involved with OR care and make decisions
regarding REs. Our data highlight the importance of discussions to
educate patients about the spectrum and outcome of intraoperative
REs and to ensure patient autonomy.
References:
1. Crit Care 10:219, 2006
2. ASA DNR Guidelines at asahq.org
3. Anesth Analg 78:651, 1994
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-204
S-204.
A FOUR WEEK OR MANAGEMENT ROTATION
UTILIZING A CRNA-BASED EVALUTION TOOL
AUTHORS: M. Tsai1,2, Y. Patel1, C. Yen1, J. Kelbert2, J. Easdowne3,
A. Macario4
affiliation: 1Anesthesiology, University of Vermont College
of Medicine, Burlington, VT; 2Anesthesiology, Fletcher Allen Health
Care, Burlington, VT; 3Anesthesiology, Vanderbilt University,
Nashville, TN; 4Anesthsiology, Stanford University, Stanford, CA
Introduction: The traditional training model for anesthesiВ­
ology residents has been a one-on-one mentorship with an attending
physician with little opportunity for the residents to supervise
and learn to manage a team unit. However, Busso et al have
demonstrated that OR proficiency (e.g. anesthesia ready, anesthesia
prep and turnover times) and OR management skills improved for
the residents who have completed a clinical transition to practice
program1. We created a similar rotation with a focus on concepts
in leadership and management and where the actual team members
(e.g. CRNAs, AAs) of the anesthesia care team directly evaluated
the performance of the anesthesiology resident.
Methods: Prior to the OR Management Rotation commencing,
the foundation was set with various reading material including
articles on topics such as leadership skills, OR productivity and OR
throughput. The rotation progressed with increasing supervisory
duties: Week 1 involved managing two ORs staffed by CRNAs,
Week 2 increased to managing up to 3 ORs, and in Weeks 3 and 4,
the resident assumed role of Charge Attending who is responsible
for operational decisions, serves as a liaison among the surgical and
nursing services, and oversees the telephone-based preoperative
assessment center. We modified a 360-degree evaluation tool from
Vanderbilt University to fit the competencies and learning goals for
our rotation.
Figure 2. Reading Materials
Results: One resident has completed the rotation and 5/5’s
(“consistently” on a 5-point Likert scale) at the beginning and
end of the rotation. Therefore, the CRNAs and AAs felt that the
residents “consistently” performed his supervisory duties. Of
note, the resident commented that the rotation provided a venue
for administrative and management responsibilities that were not
available during residency.
Discussion: With the increasing depth and breadth of clinical
anesthesia and the large number of ACGME required rotations
and case numbers, most anesthesiologists interested in leadership
and management skills gain them with on the job training at their
first job, while others attend a business school or pursue further
training with a postgraduate fellowship. We believe that an OR
management elective coupled with a formal evaluation tool presents
an opportunity for anesthesiology residents to practice and acquire
real-world non-clinical, administrative skills.
References:
1.Busso VO et al. Implementation of a novel CA3 assistant
coordinator rotation that embraces ACGME core competencies
with focus on practice-based learning & improvement and
systems-based practice. Presented at the 2011 Annual Meeting
of the International Anesthesia Research Society. Vancouver,
British Columbia, Canada.
FIgure 3. Evaluation Tool
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-205
ANESTH ANALG
2012; 114; S-01 – S-493
S-205.
TEACHING FACULTY TO PROVIDE DIFFICULT
FEEDBACK— A FEASABILITY STUDY
AUTHORS: J. D. Mitchell1, M. Brzezinski2, E. J. Holak3, L. J.
Fisher1, Q. Cui1, S. B. Jones1
affiliation: 1Anesthesia, Critical Care, and Pain Medicine,
Beth Israel Deaconess Medical Center, Boston, MA; 2Anesthesia
and Perioperative Care, University of California San Francisco, San
Francisco, CA; 3Anesthesiology, Medical College of Wisconsin,
Wisconsin, WI
Introduction: Trainee competence is undermined if gaps
exist in interpersonal and communication skills and professionalism.
Trainees with uncorrected deficits in professionalism are more likely
to have performance issues and face disciplinary action during their
careers.1,2 Existing teaching tools are limited and not adapted to the
unique needs of anesthesia faculty and training programs.
Figure 1: Assessment of Video Tool and Discussion Format
Methods: Three videotaped resident-faculty scenarios were
created to address issues in providing difficult feedback to residents.
These scenarios were incorporated into a four-part video tool focusing
on basic elements of feedback, interpersonal communication,
professionalism, and advanced feedback and debriefing techniques.
The videos were the centerpiece of a live course for faculty (average
N = 22) featuring four interactive discussion sessions. Questions
on knowledge and perceived utility of the tools and format were
asked of attendees during and at the end of each session using an
audience response system (Turning Point Technologies). All faculty
participated in a basic feedback workshop 6 months prior to this
pilot intervention study.
Results: During each of the four sessions, an average of 15
faculty members participated in answering the questions. Learners
rated the course highly for quality and utility (Figure 1). Ratings
of video quality and utility averaged between 3 (good) and 4 (very
good) on a 5-point scale for each session. Quality and utility of
the small group discussion format similarly averaged between
good and very good. While changes in scores for the knowledge
questions were not statistically significant in this small pilot sample,
faculty reported that this course provided additional information
and techniques to help them improve their skills and comfort in
providing feedback (Figure 2).
Figure 2: Perceived Changes in Knowledge, Comfort, and Success
Discussion: This technique proved feasible and was rated
favorably by faculty for teaching a complex set of skills. The smallgroup format allowed for discussion and further modeling of the
skill sets. The audience response system enabled data collection,
immediate feedback, and group engagement. The course required 3
hours of staff time, which is shorter than comparable courses. Plans
involve testing at other centers and as part of web-based tools.
References:
1.Rhoton MF. Professionalism and clinical excellence among
anesthesiology residents. Acad Med. Apr 1994;69(4):313-315.
2.Papadakis MA, Teherani A, Banach MA, et al. Disciplinary
action by medical boards and prior behavior in medical school.
N Engl J Med. Dec 22 2005;353(25):2673-2682.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-206
S-207
ANESTH ANALG
2012; 114; S-01 – S-493
S-206.
S-207.
EVALUATION OF UPPER AIRWAY COLLAPSIBILITY
IN PATIENTS WITH OSAHS
PREVENTIVE INTERVENTIONS FOR RISING
INTRAOCULAR PRESSURE: DEVELOPMENT OF AN
OBSERVATION SCALE
AUTHORS: N. Lin1, Y. Li2, T. Li1, J. Ye2, B. Zhang1
affiliation: 1Anesthesiology, Beijing Tongren Hospital,
Capital Medical University, Beijing, China; 2Key Laboratory of
Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital,
Capital Medical University, Beijing, China
Introduction: OSAHS is a serious respiratory sleep disВ­
orders. The upper airway of those patients is prone to collapse
during sleep. Serious complications, such as airway obstruction,
ventilation failure or even death, might occurr during the induction
and recovery period of anesthesia with the action of sedative and
analgesic drugs. We try to explore the characteristics of upper
airway collapse in OSAHS in order to provide the basis for airway
management during the perioperative period.
Methods: 30 cases of patients with OSAHS, ASA 2 or 3 and
aged 20 to 59 years, were performed Uvulopalatopharyngoplasty
procedure under general anesthesia. With complete muscle
relaxation, the observation on the upper airway was conducted. At
atmospheric pressure, the collapse in the plane of palate, uvula and
the base of tongue was observed and the airway area was record
respectively. Positive airway pressure, 3 to 20 cmH2O, was given.
Each time the pressure was increased by 1 cmH2O, the changes of
the area and diameters in retropalatal airway were recorded. The
opening pressure (Popen) and the compliance of pharyngeal wall
were measured. Awaking pharyngeal diameters, area and Müller’s
respiratory collapse degree were compared with those in passive
condition. The correlations of the data between the two conditions
were analyzed.
Results: With full muscle relaxation, the plane of hard palate
full collapse in 1 case (3.3%). The uvula plane of all patients (100%)
completely collapses. The Popen ranged from 3 to 19 cmH2O. The
correlation of Popen with AHI (r = 0.377, P = 0.044) was statistically
significant, especially with supine AHI (r = 0.495, P = 0.006). With
the block length increasing, the Popen increased significantly. The
airway obstructive length, cross-sectional area and diameter were
positive correlated with BMI. Multiple regression analysis showed
that 85.2% Popen variations can be predicted based on the thickness
of lateral pharyngeal pharynx, the length of airway obstruction and
compliance of pharynx anterior and posterior wall in palate. The
process of pharyngeal opening is different in patients with different
structural loads.
Discussion: One or more plane of the pharyngeal cavity
completely collapsed in patients with OSAHS under general
anesthesia. The main parts were the soft palate and pharynx, tongue.
The cross-sectional area and anteroposterior diameter in hard palate
plane were significantly decreased. The Popen in 90% Patients with
OSAHS were not more than 15cmH2O. Popen and AHI, especially
with supine AHI, had a good correlation. In different structural load
group, the process of pharyngeal opening was different.
References: N/A
AUTHORS: B. L. Molloy, C. B. Watson
affiliation: Fairfield, CT
Introduction: Following a case of postoperative visual loss
(POVL) in the steep trendelenburg (ST) position, IOP measurements
were taken during laparoscopic surgery. IOP was observed to rise
over time with increases (4 times baseline). We observed eyelid
edema, corneal edema, ecchymosis and hypothesized that findings
were correlated to rising IOP. We trialed supine intervention
significantly impacting increase in IOP and potentially preventing
future (POVL) events since literature cites retinal cell ganglion
dysfunction following brief acute increases in IOP. Additionally,
increased venous congestion secondary to trabecular meshwork
dysregulated pressure dependent outflow may produce a low
perfusion state in the eye. Cosopt eye drops were trialed since dual
role as carbonic anhydrase inhibitor and beta adrenergic blocker is
noted. Prevention of IOP rising above 40 mmHg was the goal since
this was determined to be a critical threshold in POVL incidents.
The aim is to provide an observation scale enabling the anesthesia
caregiver to gage timing of intervention so as to prevent increases
in IOP.
Methods: The study is an instrumentation development design
comparing the Molloy/BAA observation scale with the gold
standard of IOP measurement, tonometry. An anesthesia team was
credentialed in use of a validated instrument -Reichert Tonopenxl
tonometer. Following informed consent patients undergoing ST
position procedures were enrolled. IOP was measured at start,
30 minute intervals and end of surgery. Observations were noted
at each time frame. Via multiple regression analysis a correlation
of observations were analyzed and assessed to be significantly
predictive of rising IOP levels.
Results: Analysis showed statistically significant decrease in
mean IOP of supine intervention group in comparison to ST group
with P<.001. Cosopt trial analysis showed statistical significance
in comparison to ST group. Findings of eyelid edema correlated
to a 2.5 times increase in baseline IOP. Findings of corneal edema
(chemosis) correlated to a 3.4 times increase.
Discussion: A supine intervention as well as Cosopt eye drops
can minimize the impact of lengthy ST positioning on increasing IOP.
Observed findings of eyelid edema and chemosis have significantly
correlated to increasing IOP levels. Anesthesia caregivers can assess
need for timing of interventions when observing facial changes in
lieu of performing intraocular tonometry.
References:
Bui BV, Edmunds B, Cioffi GA, Fortune B. The Gradient of Retinal
Functional Changes during Acute Intraocular Pressure Elevation.
Invest Ophthalmol Vis Sci 2005; 46(1) 202-213.
Rhee DJ, Alvarado JA, Calkins DJ, Gupta N. The Brain the Drain.
Eye Net 2011; Nov/Dec:36- 41.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-208
ANESTH ANALG
2012; 114; S-01 – S-493
S-208.
EVALUATION OF A TEXT PAGING DEVICE FOR USE
IN A CRITICAL MESSAGING ENVIRONMENT
AUTHORS: R. H. Epstein1, F. Dexter2
affiliation: 1Anesthesiology, Jefferson Medical College,
Philadelphia, PA; 2Anesthesia, University of Iowa, Iowa City, IA
Introduction: Introduction: An increasing number of
anesthesia groups are implementing decision support systems (DSSs)
that periodically query hospital databases and send real-time text
messages to mobile devices regarding clinical recommendations,
quality of care, and billing compliance. Typically, these devices
are also used for ad hoc urgent messages to medically directing
anesthesiologists.
Figure 1. Pager latencies (blue open circles) from creation time on the SQL
server to successful transmission. The one outlier page is noted in red.
Highly reliable, rapid message delivery is required. Cell phone
texting is not ideal for such use due to poor coverage in some
hospital locations, heterogeneity among mobile phone carriers
in message and phone reliability, battery issues, and occasional
prolonged latency due to high network traffic (e.g., disasters, severe
weather). We evaluated an alphanumeric pager for use in a critical
messaging environment. We subsequently implemented the tested
pager in our DSS using a web form on our anesthesia workstations
(Fig 1).
Methods: Our hospital maintains a local short-range radio
paging system covering all hospital locations for phone-based ad
hoc numeric paging and operator-initiated text paging for codes.
A dedicated interface (Zetron) was installed, allowing pages from
SQL Server (Microsoft) to Advisor II pagers (Motorola). Group
paging was configured by special codes, allowing a single page to be
transmitted to all group members (e.g., “Attendings”, “All Staff”).
Latencies of manual numeric messages were determined using
a stopwatch (phone “Send” button to pager beep). Latencies of
automated SQL pages (sent approximately every 2 min over a twomonth period) were determined from timestamps in the message
files. Computers were synchronized to network time. Percentiles
were calculated using Cleveland’s method. Confidence limits (CL)
were calculated using the method of batch means. As a control
comparison, the mean latency for phone initiated numeric pages was
7.1 В± 0.9 sec (N=100, range 5.0 to 9.0 sec).
Figure 2. Web paging form (aspx.net) for transmission of text messages from
the anesthesia information management system (AIMS) workstations to the
paging devices. Pager numbers for valid senders and recipients are stored
in the AIMS, along with common messages, selectable from the droplists.
The composed message can be manually edited, as needed. The anesthesia
tech assignments button indicates whom to page for supplies and technical
assistance.
Results: We analyzed 38,885 automated SQL pages, binned by
week. All but one page was sent within 30 sec of creation by SQL
(Fig 2). During the first two weeks, the 99.9th percentile was 24.6
sec. Following a transmitter upgrade, the 99.9th percentile was 16.1
sec (95% CL < 16.8 sec, N=6 weeks). Mean latency was 8.6 sec
(95% CL <9.3 sec). When 100 messages were sent simultaneously,
each took 1.9 В± 1.0 sec to clear the queue (i.e., total time for the
100th page was 3.3 min).
Discussion: Message delivery via the Advisor II pager was
sufficiently rapid and reliable for use in a critical messaging
environment. Determination of message latency is necessary for
devices being considered for use in an anesthesia DSS. Delivery of
multiple simultaneous pages should be avoided to mitigate queuing
delays.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-209
S-210
ANESTH ANALG
2012; 114; S-01 – S-493
S-209.
S-210.
INFORMATION SEARCH PATTERNS AMONG
PRACTICING ANESTHESIOLOGISTS: SURVEY RESULTS
AUDIT INTO EARLY POSTOPERATIVE RENAL FUNCTION
FOLLOWING HIP OR KNEE ARTHROPLASTY WITH TWO
ANTIBIOTIC REGIMES
AUTHORS: V. Herasevich, T. Weingarten, T. Long, B. Pickering
affiliation: Department of Anesthesiology, Mayo Clinic,
Rochester, MN
Introduction: The tremendous growth in electronic informaВ­
tion presents busy clinicians with the challenge of remaining
well informed while avoiding pitfalls of information overload.
Increased availability of mobile devices is changing how, where
and when information is retrieved and used. However, the access
to information source systems is often suboptimal. One strategy is
to provide clinicians with tools that optimize internet and literature
searches. To better understand how practicing anesthesiologists
access internet based information we performed a brief survey
during an anesthesiology weekly grand rounds presentation on
search strategies for research and clinical practice.
Methods: A grand rounds presentation on “Finding the
evidence. Search skills toolkit.” was made for the department of
Anesthesiology at tertiary academic medical center. Prior to the
didactic portion of the presentation, several questions were asked
of the audience using for answers recording an audience response
system - i.e. Turning PointВ© (Turning Technology, inc. Youngstown,
OH) Responses to these questions are presented as a percentage of
respondents.
Results: Forty two grand rounds participants answered
questions. Most respondents were practicing anesthesiologists
(66%) and anesthesia residents. The answers were distributed as
following:
1.What general search engine do you usually use first? Google 95%
2.Do you use Scopus on a regular basis? Yes - 5%; I don’t know
what it is - 83%
3.Do you perform searches from a mobile device? Yes - 80% (10%
of audience do not own smart phone and 75% own iPhone, 10%
Android and 5% Blackberry)
4.Do you use RSS for tracking literature updates? Yes - 7%; I don’t
know what it is - 56%
5.If you have both versions of article/document: do you prefer read
from paper or monitor screen? Prefer paper - 78%
6.Do you wish to improve search skills? 100% Yes
Discussion: The results from this survey indicate a demand
for educational activities that equip clinicians with the skills
to better utilize internet search tools for professional literature
searches and tracking. Even with increasing accessibility to mobile
devices (i.e smart phones) among practicing anesthesiologists, the
majority preferred to read printed rather than electronic versions of
documents. Additional educational endeavors aimed at informing
users regarding the various internet searching and tracking utilities
may result in increased utilization of these resources.
AUTHORS: A. Morrison, T. Tarr
affiliation: Anaesthesia, Wirral
Hospitals, Liverpool, United Kingdom
University
Teaching
Introduction: Surgical antibiotic prophylaxis with cephalosВ­
porins is associated with an increase in hospital acquired infections,
leading to increased morbidity and mortality1. This Trust, adjusted
prophylaxis for arthroplasty to teicoplanin and gentamicin. As both
drugs are associated with renal impairment in repeated doses, this
study assessed the effect of a single dose on postoperative renal
function.
Methods: This retrospective study reviewed serum urea and
creatinine of patients undergoing elective primary hip or knee
arthroplasty. The 2008 group received perioperative cefuroxime
1.5g at 0, 8 and 16hrs, the 2010 group one dose of teicoplanin
400mg and gentamicin 3.5mg/kg ideal body weight at induction.
The first 150 patients in either group were identified from the Trust’s
Theatre Register. Inclusion criteria were a preoperative serum
urea and creatinine with a subsequent measurement 18-36 hours
postoperatively.
A within-subject highly significant change in serum creatinine
was defined as a 30% increase from preoperative value and above
normal limits, in accordance with the guidelines from the Ontario
Society for Clinical Chemists2. Categorical data was analysed using
Fisher’s exact test, continuous data utilised a paired t-test.
Results: There were no significant differences with respect
to age, sex, ASA, type of operation, or mean preoperative urea
concentrations (Table 1). Mean preoperative creatinine was
lower in the 2010 group (p=0.0001). Postoperative mean urea fell
significantly in both groups. Pre- and postoperative mean creatinine
levels were similar in 2008, but 2010 postoperative creatinine
levels significantly rose. 6.4% of 2008 patients had a creatinine rise
compared to 10.4% in 2010, including 15.2% of all knee patients.
5.6% of 2010 patients had a 50% rise which was significantly higher
than 2008 (0.7%).
Discussion: Teicoplanin and gentamicin prophylaxis may
be associated with acute kidney injury in those receiving elective
arthroplasty, particularly knee surgery. A prospective study enrolling
more patients, which monitors creatinine clearance is warranted to
validate the potential adverse effects of these antibiotics.
References:
1. J Hosp Infect. 40. 1-15. 1998.
2.http://www.clinicalchemistry.on.ca/Documents/eGFR%20
CLP%20Feb%202006.pdf (this is an invalid URL)
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-211
ANESTH ANALG
2012; 114; S-01 – S-493
Average excess turnover time (min)
S-211.
GOAL DIRECTED USER TRAINING IMPROVES
EFFICIENCY OVER CENTRICITY ANESTHESIA DURING
TO EPIC ANESTHESIA AS A COMPONENT OF A SYSTEM
WIDE EMR
AUTHORS: L. C. Jameson, J. Negin, K. Bullard
Location
Centricity
Average В± SD
Epic
Average В± SD
CVC
43.7В±6.4
33.4В±17.8
GI
10.0В±0.3
31.2В±9.2*
AIP
17.1В±0.5
10.4В±0.8
AOP
5.2В±0.6
5.1В±0.6
affiliation: Department of Anesthesiology, University of
Colorado, Aurora, CO
Introduction: Medical Centers and anesthesia departments
expect a decrement in efficiency when the hospital converts from
paper or standalone electronic anesthesia record (aEMR) to an
hospital wide EMR (oEMR). This is ascribed to the complexity of
change and decreased user proficiency where proficiency is believed
dependent on user training and experience. Goal directed training
was developed by the E anesthesia MDs to assure user proficiency
and during the conversion from Centricity (C) (GE Medical
IT), an aEMR, to EPIC (E) (Epic Corp), an oEMR. The training
effectiveness was measured by comparing delay of case start time
(DOC) in C and E. DOC is the hospital metric to define efficiency.
Methods: An locally developed E training consisted of
1) interactive web activity covering all anesthesia charting and
orders functions for aEMR and oEMR 2) half day interactive
classroom activity with an E trainer 3) completion of ≥3 mock
pre, intra and post anesthesia records 4) classroom competency
certification. Competency required efficient and accurate charting of
a complex perioperative record that included all patient care skills.
Super-users conducted the classroom activities, evaluated the all
charting products and tutored as required. Some users repeated the
competency test; passing was mandatory to work after E go-live.
SQL query measured DOC, time between cases that was in excess
of turn over time goal, between for Sept 3 through Nov 30 2010,
C, and 2011, E. The dates were chosen by the “go-live” of E and
a comparable period for C. All care areas were queried: OpTime
scheduled-Inpatient (AIP), Outpatient (AOP) ORs and Cadence
scheduled--interventional procedures (CVC), GI endoscopy (GI).
The E and C chart functions were the same in all areas.
Results: DOC in the OpTime scheduled areas (AOP/AIP) was
consistent in both E and C (Figure 1, 2). E DOC was consistently
less than C for the study period (Table). GI cases done using C
were efficient. Use of Cadence caused GI DOC to increase from
10 min (C) to >30min over 3 months. CVC was inefficient and
unpredictable in both E and C.
Figure 1
Figure 2
Discussion: The training program was effective in preparing
anesthesia care team members with the skills to efficiently provide
all aspects of anesthesia care. DOC decreased with E. DOC was
stable with C and E in AOP, AIP, and CVC. DOC in GI increased
>3X. The only difference was Cadence scheduling. Hospital and
E IT were not prepared for managing anesthesia services using
Cadence. External IT decision and planning can have a major
negative impact on productivity that is independent of anesthesia
performance.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-212
ANESTH ANALG
2012; 114; S-01 – S-493
S-212.
MULTIMEDIA APP FOR ANESTHESIOLOGY:
INTERACTIVE LEARNING AND SELF ASSESSMENT
AUTHORS: C. M. Kim, N. Tahir, P. Sekhar, R. Azocar
Figure 1: Interactive
tablet for presentations
affiliation: Boston, MA
Introduction: Introduction: The implications of the geriaВ­
tric population on the practice of anesthesiology are complex
and constantly evolving. Our University’s School of Medicine,
Department of Anesthesiology obtained the American Geriatrics
Society’s Geriatrics Education for Specialty Residents (GSR) in
2008. We continue to facilitate the acquisition of the most up to
date geriatrics knowledge with development of multimedia learning
modules in our educational curriculum. Advances in technology
have allowed for innovative development and distribution of
educational materials. The concepts of self-education and selfassessment are gaining a wide popularity in medical education.
Our interactive, multimedia learning app in geriatric anesthesia will
allow students to have remote access to educational materials that not
only provide pertinent information, but also offer audio explanation
of digital graphs and texts followed by immediate evaluation of their
knowledge with oral board styled self-assessment.
Methods: Our user-friendly audio and video app allow remote
learning in an interactive manner, similar to attending a lecture. We
attempted to maximize the multimedia experience by employing
audio, video, and text to convey the key concepts that are crucial
for understanding geriatric anesthesiology. Additionally, we have
included clinical case scenarios with oral board styled questions,
combined with a video and audio commenting capabilities. Thus,
allowing the educators as well as students to watch and learn from
each other.
Figure 2: Seven different multimedia modules focusing on geriatric anesthesiВ­
ology are being developed.
Results: Under attending and faculty supervision, teams of
senior residents and medical students work together to develop
modules for their assigned topic in geriatric anesthesiology. Each
team completed a thorough literature review and summarized their
findings. Moreover, applicable clinical scenarios were created to test
learner’s knowledge with detailed explanations.
Discussion: By completing a literature review and synthesizing
learning modules together, each team members became experts in
their topics and in turn, were able to teach each other. Furthermore,
during the process of creating their own multimedia modules,
each member acquired essential skills in digital media production.
We predict continued advancement in multimedia and interactive
learning technology in all aspects of medical education and strive
to serve as an example of multifaceted medical curriculum in the
future.
References: none
Figure 3: Students can log in remotely through their digital tablets and access
each module. Each module will include an audio/visual presentation paired
with several clinical questions and scenarios.
Figure 4: Clinical questions and scenarios are presented and students’ audio/
video answers can be recorded via webcam. The recorded answers can be
viewed and critiqued by other users.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-213
ANESTH ANALG
2012; 114; S-01 – S-493
S-213.
CHARTING OF ESSENTIAL ANESTHESIA ELEMENTS IS
LESS RELIABLE IN EPIC THAN IN CENTRICITY
AUTHORS: L. C. Jameson, J. Vasquez, K. Bullard
affiliation: Department of Anesthesiology, University of
Colorado, Aurora, CO
Introduction: Centers for Medicare and Medicaid (CMS),
Institutes of Medicine and The Joint Commission have embraced
the Electronic Medical Record (EMR) as a solution for clear,
concise, consistent and auditable medical records. World Health
Organization and CMS believe best care begins with checklists,
protocols and error checking imbedded and systematically
documented in the medical record. Yet EMR functionality and user
interface requirements remain largely unregulated. The hospital
converted its anesthesia EMR (aEMR) from Centricity (C) (GE
Medical IT), a check list, protocol organized product, to Epic (E)
(Epic Corp), an activity organized product. This study compares the
impact the change from C to E had on charting compliance for 3
standard items that are required in electronic or paper anesthesia
records.
Methods: A SQL query was performed on the E and C patient
database from 9/1/11 to 11/30/11 and 9/1/10 to 11/30/10 respectively
for charting events in the outpatient (OUTpt) and inpatient (INpt)
ORs. The dates were chosen by the “go-live” of E and a comparable
period for C. The audited items were: I/O note, vital signs in the
PACU transfer note (PACU VS) and extubation note (EXTUB).
Each item required different user interaction: 1) C automatically
totaled I/O while E required user charting 2) PACU VS identical
to C process 3) EXTUB required new process in E. I/O and PACU
VS were expected in all charts. Expectation of EXTUB required OR
intubation. Patients with an ICU transfer or tracheal tube in PACU
nurse chart were removed. PACU VS process was changed for E in
Sept. Data was collected for Oct-Nov. Data is presented as % total.
Chi Square statistic was used for significance (p≥0.05).
Table 1: INpatient Charting Compliance (%)
Table 2: OUTpatient Charting Compliance (%)
Results: Comparable volume of cases was performed in INpt
and OUTpt ORs during both study periods. Charting compliance
was significantly less (p≥0.05) in E for all items in all months in
both areas (Tables). There was no improvement charting during the
study period except in OUTpt EXTUB, difference Sept to Nov. The
same staff provided care in all locations.
Discussion: Training was not a factor in charting compliance
since there was no improvement over time in E. Compliance was
high in C suggesting recognition of these items as important. PACU
VS with the same charting process had a lower compliance. This
suggests that the change from a check list, protocol organized
aEMR (C) to an activity organized word oriented (E) aEMR had a
significant persistent negative impact on basic charting compliance.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-214
S-214.
LARYNGEAL MORBIDITY AFTER INTUBATION
WITH ENDOFLEXВ® TUBE VERSUS A CONVENTIONAL
ENDOTRACHEALTUBE WITH STYLET A RANDOMIZED TRIAL
AUTHORS: M. K. SГёrensen1, N. Rasmussen2, M. S. Kristensen1,
L. S. Rasmussen1
affiliation: 1Department of Anaesthesia, Centre of Head and
Orthopaedics, Copenhagen University Hospital, Rigshospitalet,
Copenhagen, Denmark; 2Department of Otorhinolaryngology,
Centre of Head and Orthopaedics, Copenhagen University Hospital,
Rigshospitalet, Copenhagen, Denmark
Introduction: Airway injury may occur in connection with
airway management, especially tracheal intubation. This trial was
designed to assess laryngeal morbidity evaluated as hoarseness,
vocal fold injury, and abnormal voice analysis variables in a
comparison of the EndoflexВ® tube with a conventional endotracheal
tube with stylet. Our hypothesis was that use of the EndoflexВ® tube
would result in a lower incidence of hoarseness at 24 hours after
extubation.
ANESTH ANALG
2012; 114; S-01 – S-493
New videolaryngoscopic identified vocal fold injuries and
abnormal voice variables measured with Multi Dimensional Voice
Program in the total population. Patients with both preoperative
and postoperative pathology have been excluded.
EndoflexВ® tube
(n=59)
Coventional
endotracheal tube
with stylet (n=61)
Unilateralt
4
7
Bilateralt
1
2
Thickening of the vocal folds
0
2
Edema
Erythema
Hematoma
Abnormal voice variables
2
2
1
8
6
1
0
4
Methods: This prospective and patient and observer-blinded
randomized trial was approved by the regional ethics committee
and registered at ClinicalTrials.gov (ID: NCT00953433). The
study included 130 elective surgical patients scheduled for general
anesthesia with endotracheal intubation. Preoperative assessment of
hoarseness, vocal fold pathology with a flexible videolaryngoscope,
and voice analysis variables with Multi Dimensional Voice Program
(MDVP) was performed. Induction of anesthesia was done using
propofol, remifentanil and a non-depolarizing neuromuscular
blocking agent. After complete neuromuscular paralysis intubation
was performed with either an EndoflexВ® tube or a conventional
endotracheal tube with stylet by one of four consultants skilled in
airway management. Hoarseness was assessed at 24 hours after
extubation. A postoperative evaluation of vocal fold injury and of
voice analysis variables was performed 12-24 hours after extubation.
Results: Postoperative hoarseness was found in 47% after
intubation with the EndoflexВ® tube and in 57% after intubation
with a conventional tube with stylet (P=0.24). After exclusion
of patients who also had preoperative hoarseness, postoperative
hoarseness was found in 40% in the EndoflexВ® tube-group and 54%
in the conventional endotracheal tube with stylet group (P=0.14).
Abnormal voice analysis variables were present postoperatively in
38% in the EndoflexВ® tube group and in 39% in the group allocated
to endotracheal tube with stylet (P=0.96). Postoperative vocal fold
injury was present in 23% in the EndoflexВ® tube group and in 36%
in the endotracheal tube with stylet group (P=0.13). Intubation
conditions were not significantly different.
Discussion: In conclusion, no significant differences in the
frequency of hoarseness or other endpoints of laryngeal morbidity
were found after tracheal intubation using either an EndoflexВ® tube
or a conventional endotracheal tube with stylet.
References: None
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-215
S-215.
GO WITH THE FLOW: A TWO-WEEK LOW FLOW
AND CLOSED CIRCUIT ANESTHESIA ELECTIVE
FOR PEDIATRIC ANESTHESIA CLINICAL FELLOWS:
EXPERIENCE OF THE FIRST TWO YEARS
AUTHORS: A. Navedo1,2, C. D. McClain1,2, C. Sullivan1, R. S.
Holzman1,2
affiliation: 1Department of Anesthesiology, Perioperative and
Pain Medicine, Children’s Hospital Boston, Boston, MA; 2 Harvard
Medical School, Boston, MA
Introduction: The techniques of low flow and closed circuit
anesthesia (LF/CC) provide patients with the amounts of oxygen
and anesthetic gases that match the patient’s metabolic and clinical
needs. Using LF/CC, the anesthesiologist can measure and follow
the patient’s oxygen consumption and cardiac index without the
need for sophisticated or invasive techniques. Furthermore, heat loss
is minimized as is loss of airway humidification. In addition, LF/
CC allows the clinician to avoid the waste of resources, minimizing
environmental contamination by halogenated anesthetics and
greenhouse gases such as nitrous oxide.
ANESTH ANALG
2012; 114; S-01 – S-493
References: Rider EA, Keefer CH. Communication skills
competencies: definitions and a teaching toolbox. Medical
Education 2006; 40: 624-629.
Holzman RS, Lintner RN. Principles and Practices of Closed Circuit
Anesthesia, in The MGH Textbook of Anesthetic Equipment.
Sandberg W, Urman R, Ehrenfeld J (Eds) Philadelphia. Elsevier
Saunders. 2010
Fellow’s Experience
Used LF/CC
25/25 (100%)
Teaching Experience
14/25 (56%)
Injection Technique
13/25 (52%)
The authors developed this 10-day course that introduces
participants to the foundational science and clinical practice of LF/
CC anesthesia. In addition, the last two days serve to focus on the
participants’ instruction of LF/CC concepts to junior trainees while
receiving focused mentoring on teaching skills.
The purpose of this poster is to illustrate the scope of this course.
Methods: A formal program evaluation was initiated including
a review of the two-year experience of program activities. This
involved a chart review that resulted in a description of program
activities to date. An anonymous record audit will examine the
prevalence of LF/CC technique implementation by participants
subsequent to their rotation and patient outcomes with regard to
perioperative hypothermia. Finally, the cost and environmental
impact of practicing LF/CC techniques will be examined.
Challenging Case Report: N/A
Results: Twenty-five pediatric anesthesiology clinical fellows
have participated in this elective over two years and have
administered 376 anesthetics. One case had missing data and two
cases were cancelled, leaving 373 for analysis. Both vaporizer and
liquid injection techniques were utilized; injection was used in 34
cases (9.1%) by 13/25 fellows (52%). For 14/25 fellows (56%) a
teaching experience was provided.
Discussion: This elective has become the most popular for
pediatric anesthesia fellows. Feedback has been enthusiastic for
being able to estimate CO2 production, soda lime consumption, cost,
free water requirements, and a hands-on way to study Severinghaus
square root of time model and the basics of allometric scaling.
Increased oxygen consumption detected upon establishing closed circuit.
Injection technique with isoflurane: BIS correlation.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-216
S-217
ANESTH ANALG
2012; 114; S-01 – S-493
S-216.
S-217.
COMBINED TRAINING OF TECHNICAL AND
NONTECHNICAL SKILLS FOR AIRWAY MANAGEMENT
IN THE ICU
COMPARISON OF RESPONSES AT EMERGENCE TO
RESPONSES IN THE PACU IN PATIENTS WHO SPEAK
ENGLISH AS A SECOND LANGUAGE
AUTHORS: B. Grande1, M. Kolbe2, M. Weiss2, G. Grote2, D. R.
Spahn1,3, P. Steiger3
affiliation: 1Institute of Anesthesiology, University Hospital
Zurich, Zurich, Switzerland; 2Management, Technology, and
Economics, ETH Zurich, Zurich, Switzerland; 3Surgical Intensive
Care, University Hospital Zurich, Zurich, Switzerland
Introduction: Airway management is a rare but high-risk
task in Intensive Care Units. As intensive care specialists only
rarely encounter airway emergencies, acquisition and maintenance
of the respective task- and teamwork skills on the job is difficult.
Therefore, we suggest that technical as well as nontechnical aspects
(i.e., teamwork) should be integrated in simulation-based technical
mannequin training in airway management.1 This will allow for
learning, practicing, and reflecting on concrete behaviors based on
models for good taskwork and teamwork. In particular, we propose
that more emphasis should be laid on interactions between intensive
care specialists.2 As during stressful events teamwork is likely to
break down, we suggest that during airway management training,
coordination within the team should be addressed in detail.3
In doing so, airway management is likely to be more efficient,
miscommunication may be avoided and iatrogenic harm can be
prevented.
Methods: Inspired by the institutional �Difficult Intubation
Drill’, the continuous technical airway management training of the
Department of Anesthesia of the University Hospital Zurich (USZ),
Switzerland, we designed a modular airway management course
for the surgical intensive care unit (CIM). The CIM at the USZ
consists of three intensive care units with a total of 28 breathing
spaces. 37 medical staff members are trained to manage difficult
airways. This training consists of three steps: (1) technical training
of airway management on a phantom head, (2) technical training of
the difficult airway using high-fidelity simulation environment with
additional introduction of nontechnical skills (SimMan, Laerdal),
and (3) combined technical and nontechnical training of airway
management during critical situations again using high-fidelity
simulation.
Results: We will present the evaluation results of how each
step has led to improved technical as well as nontechnical airway
management results.
Discussion: Conclusions are presented referring to how the
combined training of technical and nontechnical skills has enhanced
learning of how various technical and nontechnical actions depend
on and influence each other.
References:
1.Barsuk D, Ziv A, Lin G, Blumenfeld A, Rubin O, Keidan I, Munz
Y, Berkenstadt H. Using advanced simulation for recognition
and correction of gaps in airway and breathing management
skills in prehospital trauma care. Anesth Analg 2005;100:803-9.
AUTHORS: D. Levine, R. Bhansali, B. Dauber, T. Tarsha, D. Glick
affiliation: Anesthesia and Critical Care, University of
Chicago, Chicago, IL
Introduction: Responsiveness is often used to determine
whether a patient is ready for extubation following a general
anesthetic, but little is known about the difference in English
comprehension of non-native English-speakers between conscious
states and semi-conscious states (as seen at emergence). The
purpose of this study is to determine if there is a difference in the
ability to follow commands in English in these two states.
Methods: After obtaining IRB approval and informed consent
55 adult non-native English-speaking patients and their families
were enrolled in the study. Prior to surgery, each patient was
questioned about his/her language development and proficiency
in English vs. their native language using an ascending scale
from 1 to 10. A family member recorded three commands in both
languages using a laptop computer: “open your eyes,” “squeeze my
fingers,” and “wiggle your toes.” These were then played back in
timed intervals through wireless headphones upon emergence from
general anesthesia. Data were recorded for which language a patient
responded to first in the operating room as well as their response
frequencies. The commands also were played back to the patients in
the PACU to compare conscious vs. semi-conscious understanding
of the commands.
Results: Patients’ response patterns to verbal commands in the
operating room and the recovery room are summarized in Table 1.
Strikingly, 37/55 (68%) of the patients responded better to their
native language in the OR. In contrast, only 8/55 (16%) showed
a native advantage in the PACU. Further, twenty-eight (51%) of
the 55 participants responded better to native language commands
at emergence, but equally well to both languages in the PACU.
Eight patients (15%) responded better to the native language in the
OR and in the PACU. Seventeen (31%) of the patients responded
equally well to English and the native language in both the OR and
the PACU.
Discussion: These results suggest that the majority of patients
for whom English is not the first language may respond to English
commands normally when they are fully conscious, but may not
respond as readily to English commands as to commands in their
native language when they are emerging from general anesthesia.
Further work is necessary to determine which characteristics define
the patients that will benefit from language-based modifications at
emergence and which patients do not require special arrangements
at emergence.
References: N/A
2.Reader T, Flin R, Lauche K, Cuthbertson BH. Non-technical
skills in the intensive care unit. British Journal of Anaesthesia
2006;96:551-9.
3.Driskell JE, Salas E, Johnston J. Does stress lead to a loss of
team perspective? Group Dynamics: Theory, Research, and
Practice 1999;3:291-302.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-218
S-219
ANESTH ANALG
2012; 114; S-01 – S-493
S-218.
S-219.
AN ANESTHESIA CRITERION-REFERENCED
ASSESSMENT TOOL STRATIFYING LEARNERS BY
SKILL LEVEL
THE IMPACT OF SELF-ASSESSED LANGUAGE
SKILLS AS A PREDICTOR OF LANGUAGE PREFERENCE
UPON EMERGENCE
AUTHORS: W. K. Bernstein1, D. Schreibman1, Y. Zhu3, S. Carter
Chase2, I. M. George2,3
AUTHORS: B. Dauber, J. Yin, D. Glick
affiliation: 1Anesthesiology, University of Maryland,
Baltimore, MD; 2MASTRI Center, University of Maryland,
Baltimore, MD; 3Surgery, University of Maryland, Baltimore, MD
Introduction: Anesthesiology residency is impacted by
duty hour restrictions. We have been engaged in development and
deployment of multidisciplinary simulated learning experiences
involving various learners. The decision to use ultrarealistic
events have led to insights regarding team function, coordination,
communication gaps and clinical aptitude (in a high stress, low
stakes environment). Further, recorded metrics suggest these events
can be refined and used in the training of other healthcare providers,
and the evaluation of individual or team performance. These
simulated clinical learning exercises have generated numerous
performance metrics and expert observer data. Preliminary review
suggests a relationship between performance and skill level or year
of training.
Methods:
1.Review data from past simulation events- documented expert
observer notes, feedback, and captured media. (IRB compliant
manner)
2.Apply statistical analysis
3. Refine instruments used for acquiring metrics
4.Develop and submit IRB protocol for prospective longitudinal
study of Anesthesiology resident performance
5. Deploy instrument
Results: Preliminary data appeared to NOT show correlation
between simulation performance and relative skill level. CA-3
showed highest performance rating, with CA-1s next. Further
investigation and comparison of aggregate class performance vs
aggregate class in-training exams showed average board scores as
26.3 for CA-1, 23.6 for CA-2, and 28.8 for CA-3, which strongly
correlated with our findings.
Discussion: Anesthesia residents need to master clinical
knowledge and technical skills in a limited amount of time. Use of
an advanced Simulation Center (MASTRI) comprised of reworked
former ORs, High fidelity manikins and debriefing methods creates
a realistic and believable environment, instilling similar thought
processes and emotions that residents encounter in a true operative
setting. In our scenarios, residents have the ability to interact with
the simulated patient and environment much as they would in the
real world. Further investigation is planned with psychometric
analysis to improve team dynamics and decision-making processes.
We propose to next study if the validated tool can show or predict
transfer of skills to the live OR.
affiliation: Anesthesia and Critical Care, University of
Chicago, Chicago, IL
Introduction: When emerging from anesthesia, one must
be able to judge a patient’s level of awareness by responses to
verbal commands in order to determine the timing of extubation.
However, when a patient and anesthesiologist do not speak the
same language, it may be impossible for the patient to respond to
verbal commands. In addition, many English-proficient patients
learn English as a second language and may respond more quickly
to their native language. This may be because second languages are
stored in external memory systems and pharmacologic alterations
of consciousness (i.e., anesthetics) cause a loss of the ability to use
these specialized, external memory systems [1, 2]. The goal of this
study was to determine which patients would benefit the most from
a computer assisted language intervention upon emergence.
Methods: After obtaining IRB approval and informed consent,
96 adult patients who spoke English as a second language were
enrolled. With a laptop computer, three commands were recorded
in English and in the native language from a family member of each
patient: “open your eyes”, “squeeze my fingers”, and “wiggle your
toes”. Additionally, each patient was asked to assess their English
and foreign language understanding skills on an ascending scale of
1-10. During emergence from general anesthesia, the English and
foreign language commands were played in alternation, pausing
to allow for a response. Statistical analysis was performed using a
multinomial logit (MNL) model using STATA 11 SE.
Results: There were a total of 239 responses given for the
three commands. 61.1% of the responses came only to the foreign
language, 32.6% of the responses came to both English and the
foreign language at the same time, and 6% of the responses came to
English only. The mean self-assessed English understanding skills
were rated at 7.0 (В±3.0). The mean foreign language understanding
skills were rated at 9.7 (±0.9). We defined the “fluency gap index”
as the difference between self-assessed foreign language skills and
self-assessed English skills, and it showed significant predictive
value for whether the patient responded to the foreign language
only or to both the foreign language and English upon emergence
(Table 1).
Discussion: We found a statistically significant relationship
between self-assessed language ability and patient responses to
commands upon emergence. These results emphasize the importance
of considering the special needs of those who speak English as a
second language as they emerge from anesthesia, especially when
the “fluency gap index” is large.
References:
1. Anesth Analg 2002; 95:1127.
2. Anesthesiology 2006; 104:448 -57.
References:
1.Michelson, JD, Manning L. Competency assessment in
simulation-based procedural education. Am J S. Voln196 (4).
2008. 609-615
2.Bould, MD., Crabtree NA and Naik VN. Assessment of
procedural skills in anaesthesia. BJA . Vol 103 (4). 2008. 472-483
3. Boulet, JR, Murray D, Kras, J and WOodhouse, J. Setting
Performance Standards for Mannequin-Based Acute-Care
Scenarios: An Examinee-Centered Approach. SSIH. 2008. Vol
3 (2). 72-81
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-220
S-221
ANESTH ANALG
2012; 114; S-01 – S-493
S-220.
S-221.
COMPARING OF ACROMIOAXILLOSUPRASTERNAL
NOTCH INDEX( A NEW TEST)WITH MODIFIED
MALLAMPATI TEST IN PREDICTING DIFFICULT
LARYNGOSCOPIC VIEW
CROSS-CONTAMINATION OF REUSABLE ANESTHESIA
EQUIPMENT IN THE OPERATING ROOM
AUTHORS: A. R. Jafari, M. R. Kamranmanesh,
H. Aghamohammadi, B. Gharaei, M. Poorzamani, A. H. Kashi
affiliation: Strasbourg, France
affiliation: Tehran, Islamic Republic of Iran
Introduction: We aimed to compare the efficacy of a new
bedside screening test named Acromio Axillo Suprasternal notch
index (AASI) with modified Mallampati (MMP) for predicting
difficult laryngoscopic view.
Methods: Three hundred adult patients, who were candidates
for tracheal intubation under elective surgery, were enrolled
in this prospective double blinded study. Preoperative airway
assessments were carried out with AASI and MMP. The new AASI
test is calculated as following measurement: 1) Using a ruler a
line is drawn vertically from the top of the acromion process to
the superior border of the axilla at the pectoralis major muscle,
line A; 2) A second line is drawn perpendicular to line A from the
suprasternal notch (line B); and 3) That portion of line A that lies
above where line B bisects line A is line C. AASI is calculated from
the length of line C divided by line A(AASI= C/A) After induction
of anaesthesia, laryngeal view according to the Cormack- Lehane
grading system was recorded. Receiver operating characteristic
(ROC) curve analysis was employed to compare AASI with MMP.
Results: Difficult visualization of larynx (DVL, CormackLehane III & IV) was observed in 19 (6.3% )of patients. The best cut
off point for DVL was defined at AASI≤0.49 cm. AASI had a lower
false negative and higher predictive values(sensitivity, positive
predictive value and accuracy had significant and specificity and
negative predictive value had insignificant difference) compare with
MMP
Discussion: AASI was associated with higher predictive values
than MMP and could be a useful bedside test for estimation of DVL
References:
1. Anesthesiology 1990;72:828-33.
2. Br J Anaesth 1998;80:140-6.
3. Can J Anaesth 1994;41:372-83.
4. Anesthesiology 2000;92:1229-36.
5. Br J Anaesth 1991; 66:305-9.
6. Anesthesiology 1992;77:67-73.
7. Anaesthesia 1991;46:1005-8.
8. Anaesthesia 1987;42:487-90.
9. Anesthesiology 2005;103:429-37.
10. Anesth Analg 2009; 109:822-4.
11. Anesth Analg 2009;108:544-8.
12. Anesth Analg 2006;102:818-24.
13. Anaesthesia 1984;39:1105-11.
14. Anesth Analg 2002; 94:1340-1344.
15. Acta Anaesthesiol Scand 1996; 40:421-424.
16. Acta Anaesthesiol Scand 1998; 42:136-137.(letter)
17. Br J Anaesth 1993; 71:333-334.(editorial)
18. Anaesthesia 2000; 55:274- 279.
19. Anaesth Intensive Care 1998;26:382-6.
20. Eur J Anesthesiol 2007;24:1034-40.
21. Br J Anaesth 1995;74:638-42.
22. Eur J Anesthesiol 2008;25:714-20.
23. Anesth Analg 2002;94:732-6.
AUTHORS: B. Samyn, B. Saumande, B. Lebas, V. Garcia, L.
Belotti, P. Diemunsch
Introduction: In the operating room (OR), one of the
common sources of cross-contamination between patients and
caregivers is reusable equipment such as electrocardiogram (ECG)
cables and pulse oxymeter. The aim of this observational trial was to
evaluate the microbiological contamination of ECG cables and pulse
oxymeters used in the ORs of a university hospital. Also, this study
attempted to verify the efficacy of our institutional decontamination
protocol.
Methods: A trained practitioner randomly took 96 sets of
swab samples from ECG cables, and 46 from pulse oxymeters in
15 ORs after the decontamination was performed but just before
their use for the next patient. Each set consisted of 2 swabs one
for bacteriological and one other for mycological examination. The
OR staff were not aware of the study so as not to interfere with the
routine decontamination protocol used in the OR.
Results: Table shows the results of the 142 sets of samples,
with the identified pathogenic germs. No resistant pathogen was
identified.
Discussion: The results of this study suggest that the risks
of cross-transmission of pathogens through reusable equipment
are significant. We observed microorganisms, including MSSA,
Enterococcus faecalis and Corynebacterium in 52% of the devices
examined. This suggests a need for improved decontamination
protocol particularly regular audit of the process. In addition, it
may be appropriate to use single-use equipment particularly in
contagious patients as well as in immunocompromised patients.
References:
Call, Anesth Analg. 2009 Aug;109(2):479-83.
Pulse
oxymeter
ECG cables
Number of swabs performed, n
46
96
Negative swabs culture, n [%]
15 [33]
46 [48]
Positive swabs culture, n [%]
31 [67]
50 [52]
Positive swabs finfing at least 1 non
pathogenic microorganism, witout potentially
pathogenic microorganism; n [%]
27 [58]
45 [47]
4 [9]
5 [5]
Staphylococcus aureus, n
2
1
Enterococcus faecalis, n
1
_
Aspergillus fumigatus, n
_
1
Staphylococcus aureus + Enterococcus
faecalis, n
1
1
Corynebacterium, n
_
2
Positive swabs finding at least 1 pathogenic
microorganism, with or without non
pathogenic microorganism ; n [%]
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-222
S-222.
KIDNEY INJURY AFTER PERCUTANEOUS AND
SURGICAL AORTIC VALVE REPLACEMENT
AUTHORS: E. Crawford, L. Hoke, J. May, A. Blevins, R. Calicott,
Y. F. Bryan
affiliation: Anesthesiology, Wake Forest School of Medicine,
Winston-Salem, NC
Introduction: Evaluation of new airway devices for
airway management is essential to study the effectiveness of
new products and for comparison to existing devices. The FDA’s
Center for Devices and Radiological Health is responsible for
the approval and safety of medical devices1. Upon airway device
approval, manufacturer recommendations regarding device use
may be uncertain2. After extensive testing in manikins, results may
be different than in patients3. New devices must be evaluated for
nuances, design flaws, and any unknown hidden dangers4 . We
present an alternative process in the evaluation of new airway
devices prior to use in patients.
Methods: Upon the decision to evaluate a specific airway
device, the manufacturer or distributor was contacted. Brochures,
peer-reviewed publications, and airway device samples were
requested. Permission to evaluate airway devices in patients was
sought from the Surgical Services Product Evaluation Committee
(SSPEC) ensuring that devices were FDA-approved. Prior to
committee approval, airway device evaluation began under the
directive of an anesthesiologist using manikins in the Center for
Applied Learning. The device representative inserviced anesthesia
technicians and clinicians regarding sterile processing, handling
and proper use and function. After device approval by the SSPEC,
anesthesiologists evaluated the specific devices and determined
patient selection (fig 1).
ANESTH ANALG
2012; 114; S-01 – S-493
Results: The airway device evaluation process described was
used to evaluate video laryngoscopes (Truview EvoВ©), fiberoptic
bronchoscopes (OlympusВ© Airway Mobilscope), and intubating
airways (BermanВ©, VBMВ©, WilliamsВ©). All of these devices were
deemed suitable for evaluation in patients after SSPEC approval
in summer 2011. Devices not approved for use by the SSPEC or
deemed not evaluable by the anesthesiologists were not used in
patients.
Discussion: This alternative process of evaluating new airway
devices was effective. Manikins have been used to supplement device
evaluation “on the bench” prior to pilot studies and randomized
controlled trials (4,5). A streamlined device evaluation process
assists health care providers in deciding which products to purchase,
reject, or study further. More importantly, an unbiased evaluation of
airway devices is critical to discern which patient subpopulations
benefit most from the proliferation of airway devices currently on
the market. Further research is required regarding the development
of impartial airway device evaluation processes.
References:
1. Code of Federal Regulations Title 21, Part 807.
2. N Engl J Med 365;975-7, 2011.
3. Anaesthesia 66;1-9, 2011.
4. Anaesthesia 58;107-20, 2003.
5. N Engl J Med 365;977-9, 2011.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-223
S-223.
VARIOUS OPERATING ROOM DEVICES PRODUCE
EXCESSIVE NOISE THAT MAY INCREASE STAFF STRESS
AND IMPAIR EFFECTIVE COMMUNICATION
AUTHORS: J. P. Anderson, M. J. Sharpe, S. McNulty
affiliation: Philadelphia, PA
Introduction: Noise results in stress response by the
hypothalamic-pituitary adrenal axis which contributes to sleep
deprivation, provider fatigue and impairs effective communication.
The physiological stress response is sensitive to noise levels as
low as 65 dB(A). The Environmental Protection Agency has
recommended noise not exceed 45 dB(A) in hospitals. Noise in the
intensive care, operating room and emergency department settings
has been established to be above this desired level. This study seeks
to quantify the noise levels produced by devices commonly used by
anesthesia personnel in the operating room.
Methods: A Extech Digital Datalogging Model HD600 sound
meter was placed 10 cm from noise producing equipment that was
encountered in use in different operating rooms. Noise producing
equipment evaluated was classified as either suction equipment,
patient monitoring equipment, or music radio. Acoustic data were
acquired once per second for one minute and stored in an MS-Excel
spreadsheet. Average noise level, as well minimum, maximum, and
95% confidence levels were calculated for each type of device.
Results: 72 total noise measurements were taken in 25 different
operating rooms. The average noise level for all measurements was
73.07 dB(A) (95%CI: 72.40-73.73 dB(A), average maximum: 77.83
dB(A)). 48 different suction device measurements were obtained
and the average noise produced by these devices was 71.53 dB(A)
(95%CI: 71.26-71.79 dB(A), average maximum: 74.42 dB(A)).
23 different patient monitoring device alarm measurements were
obtained and the average noise produced by these devices was
76.01 dB(A) (95%CI: 74.52-77.50 dB(A), average maximum: 84.61
dB(A)). One music radio was measured and its associated noise was
79.22 dB(A) (95%CI: 78.62-79.82 dB(A), average maximum: 85.8
dB(A)).
Discussion: Common devices used by anesthesia personnel in
operating rooms create noise that is above standard accepted levels
and may be contributing to increased patient and healthcare provider
stress and medical errors. Increased staff awareness and sensitivity
regarding the leading causes of noise in the operating room may
allow for reduced levels of noise pollution
References:
1.Effect of sound on hypothalamic-pituitary-adrenal axis.
American Journal of Physiology 1963; 204:701-4.
2.EPA Identifies Noise Levels Affecting Health and Welfare. EPA
press release - April 2, 1974
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-224
S-224.
SURGERY AT THE END OF LIFE:
A PRE-PROCEDURE PERSPECTIVE
AUTHORS: C. S. Barnet1, A. F. Arriaga2,3, D. L. Hepner1,
D. J. Correll1, A. A. Gawande3,4, A. M. Bader1,3
affiliation: 1Anesthesiology, Perioperative, and Pain
Medicine, Brigham and Women’s Hospital, Boston, MA; 2Center
for Surgery and Public Health, Brigham and Women’s Hospital,
Boston, MA; 3Health Policy and Management, Harvard School
of Public Health, Boston, MA; 4Surgery, Brigham and Women’s
Hospital, Boston, MA
Introduction: Over one quarter of medical costs for
Medicare beneficiaries are incurred during the last year of life1.
Surgical intensity during this time is also significant. The rate of
surgical intervention has been shown to vary with patient age and
geographical region2. Existing studies fail to fully characterize the
types of procedures patients undergo in the last year of life and we
know of no study that includes patients from non-Medicare payers.
This study was undertaken to better understand the types of patients
evaluated in the preoperative clinic who died within 1 year of their
procedure.
Methods: We studied 747 consecutive patients seen at the
preoperative assessment center of a tertiary care hospital during a
one month time period. All patients were scheduled for outpatient or
same day admission surgery, interventional or diagnostic procedures.
Demographic data were obtained from our patient tracking system
and the hospital’s longitudinal medical record (LMR). Surgical
indication (palliative, curative, diagnostic, elective) was assessed
based on the procedure performed and underlying diagnosis (see
Figure). Patients were assessed as alive or dead using the LMR
with confirmation via the social security national death master file.
Descriptive statistics were performed to compare the characteristics
of those that died (within one year of their procedure) to the rest of
the patient sample.
Results: Of 747 consecutive patients, there were 37 patients
confirmed dead within 365 days of surgery (5%). Average time
to death was 200+/-108 days. Twenty seven percent of these
patients had undergone palliative procedures, 30% diagnostic, 38%
curative, and 5% elective procedures (see Table). Thirty percent
had undergone low risk, 65% intermediate risk, and 5% high risk
surgical interventions. Only 54% of those who died had advanced
directives on the date of operation. When comparing decedents to
survivors, those who died within a year of surgery were older (mean
age 68.4 years vs. 59.2 years, p=0.0002) and were more likely to
have undergone a palliative (27% vs. 3%) or diagnostic (30% vs.
14%) procedure (p<0.0001).
Discussion: Nearly 1 in 20 patients seen in this tertiary care
preoperative assessment center died within one year of the date of
their procedure. Over 70% underwent non-palliative procedures.
Of those patients who died, nearly half did not have a health care
proxy or living will by the date of surgical intervention. These
data underscore the importance of pre-operative planning and
preparedness, including adequate discussions of procedure risks and
benefits at the time of surgical decision making.
References:
1. Health Serv Res. 2002 Dec;37(6):1625-42.
2. Lancet. 2011 Oct 15;378(9800):1408-13
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-225
S-226
ANESTH ANALG
2012; 114; S-01 – S-493
S-225.
S-226.
OBESITY’S EFFECT ON JOINT REPLACEMENT:
A RETROSPECTIVE REVIEW OF EARLY POSTOPERATIVE COMPLICATIONS
HANDWASHING COMPLIANCE MAY BE LOWER
THAN PREVIOUSLY REPORTED: A VIDEO
OBSERVATION STUDY
AUTHORS: W. Lee, L. Boone, J. Widyn, S. Nair, E. Delphin
AUTHORS: J. P. Rowlands, R. W. Loftus, H. M. Patel
affiliation: Anesthesiology, Albert Einstein College of
Medicine & Montefiore Medical Center, Bronx, NY
affiliation: Department of Anesthesiology, DartmouthHitchcock Medical Center, Lebanon, NH
Introduction: While obesity has been linked to diabetes,
hypertension, dyslipidemia, and longer hospital stays, its impact on
adverse outcomes after total hip replacement has been debated1,2.
A retrospective, single-center study was conducted to evaluate this
relationship.
Introduction: Health care acquired infections (HCAIs) affect
10% of hospitalized patients.1 The incidence of HCAIs is partially
explained by suboptimal hand hygiene compliance. Novel hand
hygiene systems have been shown to reduce 30-day postoperative
infections.2,3 A limitation of this prior work is reliance on hourly
hand hygiene decontamination events (HDEs) as a marker for hand
hygiene compliance as opposed to opportunity-based hand hygiene
compliance as recommended by the World Health Organization
(WHO) guidelines. The primary aim of the current study was
to ascertain intraoperative, opportunity based hand hygiene
compliance.
Methods: Clinical Looking Glass (CLG), a hospital-based
database was queried for patients with an adverse event within
30 days after total hip replacement. A chart review of identified
patients was conducted. Exclusion criteria were patients with
major or bilateral joint replacement or revision surgery, or history
of hypercoagulability. Univariate analyses were conducted for
comparison of baseline characteristics. Odds ratios were calculated
for each stratified BMI group and also calculated as obese versus
non-obese. Subsequent to data collection, patients were stratified
by BMI. Adverse events were defined as deep vein thrombosis,
pulmonary embolism, joint or surgical site infection, joint
dislocation, fracture, or death.
Results: Initial evaluation identified 308 patients, Four were
excluded for incomplete records, One for past medical history.
Twelve of the remaining 303 patients had a complication of interest
without prior history. After stratification by BMI, prevalence of
adverse outcomes was reviewed, see Table. When grouped as nonobese versus obese, there was a non-significant increase in the risk
an adverse event for a non-obese patient (OR 3.15, CI 0.99-10.10).
Discussion: From our data we observe that obesity confers
no effect on 30-day complication rates. While there are multiple
studies that link obesity to long-term complication rates, a direct
relationship between short-term and perioperative adverse outcomes
and obesity is not apparent.3 The limitations of this study may
include selection bias; subjects were identified indirectly, via ICD-9
codes using CLG software. Additionally, adverse events could have
been under reported. And finally, there is a potential for intervention
bias: obese patients may have received special care. Despite these
limitations this study is highlights the need for a larger, nationwide
cohort study to further elucidate the relationship between obesity
and joint replacement surgeries.
References:
1.Kassi, E, Chrousos, G. “Metabolic Syndromes: Definitions and
Controversies.” BMC Med, 2011, 9, 48
2.Hauck, K, Hollingsworth, B. “The Impact of Severe Obesity on
Hospital Length of Stay.” Medical Care, 2010, 48, 4,335-40
3.Davis, A, Ballantyne, J. Does body mass index affect clinical
outcome post-operatively and at five years after primary
unilateral total hip replacement performed for osteoarthritis?.
Journal of Bone & Joint Surgery, 2011, 1178-82
Characteristics
Methods: Video observation was utilized to evaluate opportunity
based hand hygiene compliance in five randomly selected operating
rooms at a large, academic medical center. Surgical cases were
videotaped using a small video camera mounted inconspicuously
on the wall behind the anesthesia work area. The videotapes were
reviewed and coded for overall hourly hand washing compliance
based on WHO criteria including before patient contact, before an
aseptic task, after body fluid exposure risk (and glove removal),
after patient contact, and after contact with the immediate patient
surroundings. In addition, hand hygiene compliance was measured
throughout 20 minute time periods in order to assess the evolution
of compliance throughout phases of the administration of general
anesthesia according to usual practice.
Results: There were 323 (В± SD 45.3) opportunities for hand
hygiene per hour of anesthesia time. Most opportunities occurred at
case start or after contact with the immediate patient surroundings.
Overall hand hygiene compliance was 2.9% (В± SD 2.7%), ranging
from 1.8% during the first 20 minutes of the case to 5% during the
subsequent 20 minutes (Table 1.) Anesthesia providers were most
likely to follow WHO guidelines pertaining to hand decontamination
following a potential body fluid exposure and least likely to follow
recommendations pertaining to hand decontamination prior to
patient contact (Table 2.)
Discussion: These findings suggest that intraoperative hand
hygiene compliance of anesthesia providers as measured by WHO
guidelines is suboptimal. These results are consistent with prior
assessments of hand hygiene compliance based on HDEs. Novel
hand hygiene systems designed to facilitate intraoperative hand
hygiene compliance are indicated in order to address the exceedingly
high number of hourly hand hygiene opportunities that occur during
the complex practice of general anesthesia.
References:
1. Am J Infect Control 2002; 30:145-52.
2. Anesthesiology 2009; 110:978-85.
3. Journal of Critical Care 2011; 26.5:489-495.
NON-Obese BMI
Obese BMI
Total
< 18.5 18.5-25 25-30 30-35 35-40 < 40
Adverse Events
1
5
2
2
2
0
12
Patients
11
65
83
94
33
17
303
Adverse Event Rate
Per 100 Patients
9.1
7.7
2.4
2.1
6.1
0
4
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-227
S-227.
FOR NON-ENGLISH SPEAKING PATIENTS IMPROVED
COMMUNICATION LEADS TO GREATER SATISFACTION
AUTHORS: J. Yin2, B. Dauber1, D. Glick1
affiliation: 1Anesthesia and Critical Care, University of
Chicago, Chicago, IL; 2University of Illinois, Chicago, Chicago, IL
Introduction: As patients awaken from general anesthetics,
they may experience periods of confusion and disorientation. This
disorientation may be particularly difficult for patients who do
not speak English or for whom English is a second language. In
general, health care organizations that provide more personal care
have been associated with higher levels of patient satisfaction1. This
study assesses the impact that the use of translated commands has
on patient satisfaction.
Methods: Patients for whom English is not their first language
were identified and enrolled for this IRB approved study after
obtaining informed consent. Each patient was asked to assess their
English and foreign language ability on an ascending scale of 1 to
10. Commands in English and in the native language were recorded
from a family member for each patient and played during emergence
from general anesthesia. After fully regaining consciousness,
patient and family satisfaction data on an ascending scale of 1 to
10 were collected in the recovery room. Patients with a previous
general anesthesia experience were asked whether their current
experience was improved, stayed the same or was worse relative
to their previous experience. The difference in self-assessed ratings
of foreign language and English speaking ability was calculated to
create a “fluency gap index.” A logit model with fluency gap as a
predictor was run on Stata 11 SE to determine the odds ratio of an
improved anesthesia experience with the translated commands.
Results: A total of 96 patients were enrolled, of which 76
patients provided a response for patient satisfaction and 68 of the
patients’ families provided a response for the family satisfaction
survey. The mean patient satisfaction score was 9.3 (range 5-10) and
the mean family satisfaction score was 9.9 (range 8-10). Of the 53
patients who compared their anesthesia experience with their prior
ones, 23 (43.4%) found it to be an improvement, while 28 (53.8%)
found no change, and 2 (3.8%) said the new experience was worse.
The logit odds ratio for the fluency gap predictor variable was found
to be 1.20 (p=0.03) for an improved experience versus a same/worse
experience.
Discussion: Patients and their family members reported very
high levels of satisfaction. Each unit difference in the self-assessed
fluency gap implies a 1.20 increase in odds that a patient for
whom English is not the first language would find their anesthesia
experience with the translated recordings an improvement over their
previous non-translated experience. Thus, the poorer a patient’s
relative English language skills the greater the benefit of the
recorded commands on patient satisfaction.
References:
1. xInquiry 1988;25(1):25-36
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
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ABSTRACTS
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ANESTH ANALG
2012; 114; S-01 – S-493
S-228.
ASSESSING THE IMPACT OF A STRUCTURED AIRWAY
SKILLS ROTATION: FROM RESIDENT CLINICAL
EXPERIENCE TO FACULTY OPINION
AUTHORS: R. G. Wagner, W. A. Weigel
affiliation: Anesthesiology, Virginia Mason Medical Center,
Seattle, WA
Introduction: In 2007, an Airway Skills Rotation (AWR)
was started at our residency program. The purpose of the AWR
is to improve residents’ airway skills, with a minimum number of
airway techniques (AWTs) required during CA1 year (Table 1). All
residents must perform the required AWTs, pass AWT OSCEs, and
pass a written exam focused on airway management. We propose
that the AWR improves residents’ skills with advanced AWTs.
Figure 1: Average number of Fiberoptic Intubations (FOBs) performed by
residents from graduating classes of 2007-2011.
Methods: Case log data was obtained and analyzed
(2007-present) for Fastrachs (FT), fiberoptic (FOB) and video
laryngoscopy (VL). To further evaluate the perceived efficacy of
the AWR, we surveyed the first two classes to complete the AWR
(2010-11). The survey was designed to obtain objective data and
opinions regarding the structure of the AWR. Additionally, we
surveyed faculty members about their perception of the AWR.
Results: Prior to the AWR, only FOBs were logged by residents.
Figure 1 shows the average number of FOBs performed by residents
between 2007-11. Classes of 2010 and 2011 were required to perform
FTs, yet there was no significant change in the average number of
FOBs between classes. To assess trends of AWTs performed, case
log data for the class of 2011 were analyzed (Figure 2). For this
class, 15 FTs and 20 FOBs were required as a CA1. The average
number of FOBs during CA1, CA2, and CA3 years was 24, 14, and
17, respectively. The average number of FTs during CA1, CA2, and
CA3 years was 17, 2, and 1, respectively. The average number of
VLs during CA2 and CA3 years were 6 and 8, respectively (VL was
unavailable prior to CA2 year). Faculty were surveyed regarding
their comfort level while supervising AWTs. For faculty who had
been at our institution before 2007, our goal was to assess changes
in comfort level since that time (Figure 3). The majority of faculty
reported an increased comfort level. The Class of 2011 was also
surveyed about comfort levels with AWTs and whether they felt the
minimum requirements were sufficient to gain proficiency. Overall,
residents felt comfortable performing FOB, VL, and FT intubations
(Figure 4). One notable finding is that most residents believed they
would have benefited from more FT experience, especially during
CA2 and CA3 years.
Discussion: Our findings suggest that residents are capable
of learning multiple AWTs simultaneously, and will seek out
techniques they find effective (exemplified by use of VL). FT use
decreases significantly after the AWR, which supports that most
residents will not independently seek training for more complicated
AWTs. The positive feedback from faculty and residents regarding
the AWR supports that it raises comfort levels and improves skills
with advanced AWTs.
Figure 2: Average number of advanced airway procedures performed by
residents of graduating class of 2011.
Figure 3: Faculty members’ survey responses regarding changes in comfort
level while performing advanced airway procedures with residents since
implementation of airway rotation in 2007.
References: None
Table 1: Airway Rotation Requirements
Class
2010
Class
2011
Class
2012
Class
2013
Class
2014
Class
Residents Year as
Video
Fiberoptics Fastrachs
in Class
CA1
Laryngoscopes
8
2007
15
5
Not Available
8
2008
20
15
Not Available
7
2009
15
20
No Requirement
8
2010
15
20
5
9
2011
15
20
5
Figure 4: Class of 2011 resident survey responses regarding comfort level with
specific airway techniques and adequacy of number of required procedures
for each advanced airway skill.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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S-229.
UTILITY OF SIMULATOR BASED TRANSESOPHAGEAL
ECHOCARDIOGRAPHY TRAINING FOR RESIDENTS
AUTHORS: R. Matyal, J. D. Mitchell, R. Bose, P. Hess, D. Nicolai,
F. Mahmood
affiliation: Anesthesia, Critical Care, and Pain Medicine,
Beth Israel Deaconess Medical Center, Boston, MA
Introduction: Performing an intraoperative TEE exam
requires cognitive and manual dexterity in the operator. Simulation
technology has been employed to reduce the initial learning curve in
procedures requiring fine motor skills and eye-hand coordination.1
Training facilitation could possibly be achieved for TEE training
utilizing a simulator. The recent development and availability of
TEE simulators provides the opportunity to test this hypothesis.2
This method of training has the potential to improve anesthesia
resident education and training.
Methods: A one-month course for anesthesia residents (n = 12)
was developed with both simulator and web-based components.
The objective was to improve cognitive understanding and image
acquisition skills. The cognitive component was achieved with
didactic lectures and web-based exercises. Pre- and post-course
exam scores were used to track cognitive improvement. Image
acquisition skills were facilitated with a hands-on simulator-based
TEE education model. A metrics software capable of recording the
simulator TEE probe manipulations made by the operator was used
ANESTH ANALG
2012; 114; S-01 – S-493
to quantify image acquisition skills. The metrics compared between
residents and experts included initial assessment plateau, variability
of the probe movement, time to achieve the final image, distance,
and accuracy.
Results: Exam scores increased significantly after the training
(p = 0.023, Figure 1). Manual skill performance improved after the
training (Figure 2). Specifically, the initial assessment plateau and
the time required to settle on a final image was reduced (Table 1).
Discussion: Both cognitive understanding and image acquisition
skills improved after the intervention. These results suggest that
a structured course utilizing a simulator accompanied by didactic
lectures and web-based exercises can be an effective training
program for residents. Data collected from this study might detail
how novice learners develop skills and how an individual performs
compared to their peers. A training program similar to the one in
this study may improve both cognitive and manual performance of
novice trainees.
References:
1.Snyder CW, Vandromme MJ, Tyra SL, Porterfield JR, Jr.,
Clements RH, Hawn MT. Effects of virtual reality simulator
training method and observational learning on surgical
performance. World J Surg. 2011;35(2):245-252.
2. Bose R, Matyal R, Panzica P, Karthik S, Subramaniam B,
Pawlowski J, Mitchell J, Mahmood F. Transesophageal
echocardiography simulator: A new learning tool. J Cardiothorac
Vasc Anesth. 2009;23(4):544-548.
Table 1. Quantitative comparison of first and final session performance in
acquiring the Trans-Gastric short axis view. Comparison was performed using
Mann-Whitney test between the first and final sessions. Data are presented
as median (25% - 75% Inter-Quartile Range). The expert performance is
included for information. *significant difference first to final.
Figure 1.Comparison of exam scores pre- and post-training (p = 0.023).
Figure 2. A: Probe manipulation in 3D space by the trainee after the first training session. B: Probe
manipulation by the trainee after the fourth training session. In B there is more contained probe motion that is
more comparable to probe motion by an expert (C)
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-230
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2012; 114; S-01 – S-493
S-230.
S-231.
IMPACT ON DEPARTMENTAL PERFORMANCE OF AN
ANESTHESIA-LED MODEL FOR INTERDISCIPLINARY
LEARNING, INNOVATION, AND IMPROVEMENT
USING HIGH-FIDELITY SIMULATION AND SKILLS
TRAINING IN-SITU TO PREPARE ANESTHESIOLOGY
RESIDENTS FOR A PEDIATRIC ANESTHESIA ROTATION
AUTHORS: S. Muret-Wagstaff, B. A. Simon
AUTHORS: J. Lau, R. Minehart, A. Derevianko, C. Mai
affiliation: Anesthesia, Critical Care and Pain Medicine, Beth
Israel Deaconess Medical Center/Harvard Medical School, Boston,
MA
affiliation: Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA
Introduction: Healthcare reform and advances in improveВ­
ment science create new opportunities for anesthesia departments
to lead perioperative efforts to learn, innovate, and improve
outcomes. However, clinical demands and production pressure limit
opportunities for caregivers from the intensive OR environment
to interact in collaborative learning and improvement efforts. Our
aim was to deploy and determine the departmental impact of a
weekly anesthesia-led, interdisciplinary learning platform providing
protected time, infrastructure, and resources for improvement in the
OR environment.
Methods: We launched Faculty Hour in 2010, uniting Anesthesia,
Surgery, Nursing and others in improvement and professional
development efforts at a large teaching hospital. OR start time is
moved 30 min. later each Tuesday to provide protected time; a
Steering Committee and Dept. Advisory Council guide efforts.
Staff participate voluntarily at 6:45 am in 90-day chartered teams,
combined anesthesia and surgery division meetings, and peer-led
faculty development sessions. We surveyed faculty anonymously
using an 11-item modification of a Baldrige assessment tool
(2009) before and one year after launch to determine progress in
organizational performance as a department in leading this effort.
Chi square test was used for analyses. IRB exempted the study.
Results: 44 of 69 faculty (63%) responded to the survey
before and after starting the intervention. Marked improvement in
organizational performance was noted overall (p<.0001) as well
as gains in each individual item ranging from 9 to 38 percentage
points. For example, faculty perceptions changed favorably in items
regarding leadership, measurement, flexibility, and innovation. In
the first 18 months, 114 anesthesiologists, surgeons, and nurses
served on 12 chartered teams; 11 cross-disciplinary divisions
met quarterly; and all anesthesia faculty participated in clinical
innovation workshops and leadership, scholarship, and education
development series. Teams achieved diverse aims such as improved
patient flow, new patient-centered trauma care pathways, and
monthly simulation-based, interdisciplinary OR team training.
Counter-intuitively, on-time OR start rates are better on Tuesdays
than any other day.
Discussion: We have deployed a replicable model for
interdisciplinary learning, innovation, and improvement in the OR
environment. Faculty Hour engages anesthesiologists, surgeons,
nurses, and others in robust collaborative efforts, with high
participation rates, striking evidence of change in organizational
performance, and better care, learning, and efficiency.
References: Baldrige Performance Excellence Program
(2009). www.nist.gov/baldrige/publications/progess.cfm (this link
is invalid. suggest using http://www.nist.gov/baldrige/)
Introduction: Studies have shown that simulation-based
training is superior to traditional teaching methods in health care
training1,2. At our institution, lecture-based curriculum is the primary
mode of orienting anesthesiology residents to specialty-specific
rotations. We describe implementation of an immersive simulationbased two-hour orientation incorporating procedural skills practice
(via task trainers) and high-fidelity mannequin simulation to teach
initial treatment of common intraoperative events.
Methods: Anesthesiology residents participate in a recurring
monthly orientation curriculum utilizing simulation on the first
day of their pediatric anesthesia rotation at our institution, in lieu
of the standard didactic lecture orientation. These sessions are
taught in-situ in the operating rooms (OR) by pediatric anesthesia
faculty. Residents are divided into two groups, and each group
participates in one hour of high-fidelity simulation and one hour
of skills training, both followed by feedback/debriefing sessions.
The cases include: 1) a parent interview for anesthesia consent
and a parent-present standard induction with a small child, and 2)
a pediatric airway emergency in the form of laryngospasm during
routine surgery, both followed by a focused debriefing. The skills
training involves intubating pediatric patients (Laerdal Sim NewB),
peripheral IV placement (NITA Newborn Modal #800 Infant
Access Simulator, VATA), and caudal anesthesia techniques (M43C
Pediatric LP Simulator, Kyoto Kagaku). Anonymous surveys were
given to residents to evaluate the orientation.
Results: The pilot orientation was initiated September 1, 2011,
with 2 to 4 residents participating each month. Seven residents have
completed the orientation to date and have all rated the course to be
very positive and helpful on anonymous surveys.
Discussion: Orientation is critical in new subspecialty rotations,
with unique and potentially challenging situations to novice learners.
Our group created a multi-modal curriculum to help familiarize and
prepare residents for challenges, without the production-pressure of
the OR or risking patient care. This model may be a useful approach
to teaching skills and how to handle emergencies within the context
of a subspecialty rotation.
References:
1.Park C, Rochlen L, Yaghmour E, Higgins N, Bauchat J,
Wojciechowski K, Sullivan J, McCarthy R. Acquisition of
Critical Intraoperative Event Management Skills in Novice
Anesthesiology Residents by Using High-fidelity Simulationbased Training. Anesthesiology 112, 202-11.
2.Fehr J, Boulet J, Waldrop W, Snider R, Brockel M, Murray D.
Simulation-based Assessment of Pediatric Anesthesia Skills.
Anesthesiology 115, 1308-15.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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2012; 114; S-01 – S-493
S-232.
S-233.
PLATFORM FOR OPERATING ROOM TEACHING AND
LEARNING (PORTAL): DEVELOPMENT OF A NEW
EDUCATIONAL PARADIGM
RECOVERING THE LONG-LOST 1937 TROPHY
AWARDED TO THE FOUNDERS MCMECHAN BY THE
INTERNATIONAL ANESTHESIA RESEARCH SOCIETY
AUTHORS: J. P. Wanderer, K. H. Baker, S. A. Forman
AUTHOR: G. S. Bause
affiliation: Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA
affiliation: 1Anesthesiology & Perioperative Medicine,
Case Western Reserve University, Cleveland, OH; 2Wood LibraryMuseum of Anesthesiology, Park Ridge, IL
Introduction: Standard AVR (SAVR) is the first option
treatment for patients (pts) with severe aortic stenosis. Transcatheter
aortic valve implantation (TAVI) offers the possibility of valve
implantation in high risk pts, thus reducing complications1.
Renal failure is a frequent and severe complication of cardiac
surgery, and it is traditionally diagnosed by serum creatinine. A
novel biomarker, the neutrophil gelatinase-associated lipocalin
(NGAL), can be measured after cardiac surgery, as it has shown to
be an excellent early predictor for acute kidney injury (AKI)В­2.
In the hypothesis that the avoidance of cardiopulmonary bypass and
cardioplegic arrest could prevent renal damage, we compared the
postoperative plasmatic NGAL between patients undergoing TAVI
and those undergoing SAVR.
Methods: We collected data from 20 pts undergoing TAVI who
were case-matched with 20 control pts undergoing SAVR.
NGAL plasma test was performed at baseline and 4 hours after
cardiopulmonary bypass initiation and balloon valvuloplasty
respectively in patients undergoing surgical and percutaneous
procedure. Baseline, 4 hours and postoperative peak creatinine were
recorded. Dichotomous data were compared by using П‡2 test with
Yate’s correction or Fisher’s exact test when appropriate. Continuous
measures were compared by analysis of variance (ANOVA) or the
Mann-Whitney U test when appropriate.
Results: Baseline NGAL level was similar in the two groups,
whereas postoperative NGAL was significantly different in the two
groups (133В±76 in group TAVI vs 256В±23 in group SAVR on arrival
in ICU, p < 0.05).
Five pts in the SAVR group and two pts in the TAVI group doubled
serum creatinine levels when compared to baseline: NGAL plasma
concentration raised significantly only in these patients of the
SAVR group (p<0.05) when compared to baseline. On arrival in
ICU NGAL (p 0.015) was an independent predictor of AKI whereas
serum creatinine and serum urea were not independent predictors
of AKI.
Discussion: We suggest that cardiopulmonary bypass alone,
as required for SAVR, can lead to an increase in plasma NGAL.
In our study NGAL, compared to serum creatinine and glomerular
filtration, allowed an earlier detection of AKI thus providing the
possibility to treat kidney injury at an early stage and to prevent its
extension.
References:
1.Grube E, Laborde JC, Gerckens U, et al: Percutaneous implantВ­
ation of CoreValve self-expanding prosthesis in high-risk
patients with aortic valve disease. The Siegburg First-in-man
study. Circulation 114:1616-24, 2006.
2.Mishra J, Dent C, Tarabishi R et al. Neutrophil gelatinaseassociated lipocalin (NGAL) as a biomarker for acute renal
injury after cardiac surgery. Lancet 365:1231-1238, 2005.
Introduction: In presenting this paper, the author’s purpose
is to illustrate techniques useful in recovering long-lost anesthesia
antiques. At the 16th Congress of Anesthetists Meeting held in
Chicago in 1937, the IARS awarded a trophy to Dr. Francis and Mrs.
Laurette McMechan.1 Sadly, Dr. McMechan was so ill at the time
that the “Founders McMechan” were honored in absentia. Widowed
by 1939, Mrs. Laurette McMechan resisted subsequent efforts to
merge the Cleveland-based International Anesthesia Research
Society with the New York-based American Society of Anesthetists
or to merge their journals. She died in California in 1970, and the
trophy disappeared.2
Methods: The author used three sets of techniques in pursuing,
validating, and recovering this trophy:
1. consulting contacts in the medical antiques world;
2.researching the trophy’s identifying characteristics, including
the inscription recorded by Omar Ranney(1); and
3. acquiring the trophy using previously successful techniques.
Results:
1.Networking Results: An overseas authority’s email alerted the
author of the trophy’s availability.
2.Results on Identifying Characteristics: From New Mexico,
the author recovered a large “loving cup” trophy. It bore the
inscription: “To F. Hoeffer McMechan, M.A., M.D., F.I.C.A.,
Editor, Secretary-General and Laurette Van Varseveld
McMechan, Associate Editor, Secretary and Hostess. In Loving
Appreciation of Devoted Services and Splendid Achievements
for the Organization, Economics, Research, Practice, Teaching,
Journalism and Fellowship of the Specialty of Anesthesia for
the World Conquest of Human Pain. In Behalf of Suffering
Humanity, Presented by the International Anesthesia Research
Society and International College of Anesthetists, Sixteenth
Annual Congress of Anesthetists, 1937.”
3.Acquisition Technique Results: The trophy was secured for
the IARS Archives by blending techniques from the worlds of
auctions and poker.
Discussion: In the mid-1990s, a furnishings vendor from
southern California spotted the McMechans’ trophy at a swap meet.
Identifying personally with the late Dr. McMechan, that terminally
ill collector kept the trophy on his mantel at home. After he died,
the trophy passed in 1996 to his brother, who, five years later, began
seeking a “more proper” owner for the “loving cup.”
This paper illustrates how a variety of acquisition techniques were
blended successfully to recover a priceless IARS treasure for a
place of honor in the Society’s archives. This 1937 “Loving Cup”
trophy was the highest award that a grateful IARS could bestow on
its Founders, Dr. Francis McMechan and Mrs. Laurette McMechan.
References:
1. Curr Res Anesth Analg 1939;18 Suppl
2. Anesth Analg 1970;49:653-654
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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2012; 114; S-01 – S-493
S-234.
S-235.
TEACHING INTRAVENOUS CATHETER PLACEMENT
TO MEDICAL STUDENTS
DEVELOPING PUBLICATIONS FOR THE MOBILE
PHYSICIAN WITH EPUB AND ADOBE INDESIGNВ©
AUTHORS: E. Thackeray, Z. Stehlikova
AUTHORS: R. Montoya, G. Sheplock
affiliation: Anesthesiology, University of Utah, Salt Lake
City, UT
affiliation: Department of Anesthesia, Indiana University
School of Medicine, Indianapolis, IN
Introduction: Intravenous (IV) catheter placement is a key
element of regional and general anesthesia, resuscitations, and
routine patient care. Medical students frequently have little or no
training in IV catheter placement prior to an anesthesiology rotation.
Production pressure in a busy academic center may preclude
adequate IV catheter teaching for medical students. We developed a
one hour class and implemented an IV practice day during the two
week anesthesiology elective to improve medical student skills in
IV catheter placement.
Introduction: Distribution of academic literature has been
dominated by Adobe’s PDF format in recent years. However
with the popularity of eReaders such as Apple’s iPhone, iPad and
Amazon’s Kindle, small and varied screen sizes call attention to the
format’s rigid structure of content display. This limitation is solved
using the ePUB format allowing creation of content that can be
distributed as a single file but optimized not only for the specific
device but also for the specific reader.
Methods: On the first day of the anesthesiology elective, medical
students are taught anatomy, theory, universal precautions, and
techniques of IV catheter placement. The one hour class includes a
video on IV cannulation produced by the New England Journal of
Medicine, discussion with a faculty anesthesiologist, demonstration
and practice on a simulated arm, and supervised IV cannulation of
participants.
Students are scheduled for one day of IV practice skills during the
first week of the two week elective. Students are assigned to an
ambulatory surgery center to place IVs under the supervision of the
preoperative nurses.
Students self-report IV attempts (total attempted, number successful,
number unsuccessful). Procedure logs are required to be completed
but do not affect the student’s grade.
Results: Students report a greater number of successful
IV cannulations after the course. In the five months prior to
implementation of the IV course, students reported an average of
6.07 successful IV placements (SD 5.0). In the first six months
after implementation of the IV course, students report an average
of 14.93 successful IV placements (SD 7.88). This represents a
significant improvement in successful IV placements(p < 0.001),
and an increase in the success rate from 61% to 75%.
Discussion: We present an effective method for teaching IV
cannulation to medical students during an anesthesiology elective.
The success rate of IV cannulation increased from 61% to 75%, a
rate comparable with that of registered nurses in practice.
Methods: Adobe InDesignВ© was utilized to adapt an existing
article for distribution using the ePUB format. First, the article was
replicated in InDesignВ© using the traditional format (1 and 2 column
format with multiple images). Then, the article was modified and
exported using the ePUB format. Finally the re-formatted article
was loaded onto various platforms for viewing.
Results: With some effort, the article was successfully ported
to multiple devices using the flexible ePUB format. This allowed
for adjustable font styles and sizes, resizable static and dynamic
media, as well as capabilities such as bookmarks, highlighting and
note taking. Limitations include single column restrictions, inability
to accommodate precise layouts, and a high learning curve to
efficiently work within Adobe InDesignВ©.
Discussion: Despite a few limitations, creation and distribution
of content utilizing InDesignВ© and the ePUB format is a viable way
to create and distribute educational materials for easy viewing on
the variety of mobile devices. These technologies serve to empower
researchers by allowing them to be their own publisher. They also
benefit physicians by giving them access to the most up to date
information in a flexible and portable format.
References:
1.Karim Mukhtar MB, MSc, FRCA. (2009) Transversus
Abdominis Plane (TAP) Block. The Journal of New York School
of Regional Anesthesia 12: 28-33.
2.Modahl M. (2011) Tablets Set to Change Medical Practice.
QuantiaMD.
IV cannulation is a relatively simple skill, but of great importance in
effectively performing general or regional anesthesia, resuscitation,
or routine clinical care. Students with strong IV skills may be more
fully incorporated into the anesthesia team and may be offered more
clinical opportunities than students without strong IV skills.
References:
Jacobsen AF, Winslow EH. Variables influencing intravenous
catheter insertion difficulty and failure: an analysis of 339 intraВ­
venous catheter insertions. Heart Lung 2005 Sep Oct;34(5)345-59.
http://goo.gl/RCdbO (accessed 1/9/2012).
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-236
S-236.
IMPLEMENTATION OF A COMPREHENSIVE BUT
SIMPLE METHOD TO MANAGE AND TRACK RESIDENT
KNOWLEDGE AND SKILL ACQUISITION DURING
PEDIATRIC ANESTHESIA TRAINING: IMPACT ON ITS
FIRST GRADUATING CLASS
AUTHORS: D. Chau, E. Bowe, R. Brown, A. DiLorenzo
affiliation:Anesthesiology, University of Kentucky, Lexington,
KY
Introduction: Pediatric anesthesiology knowledge and skills
is imparted in different ways during residency training. Ideally,
resident learners will take the initiative in determining, directing and
evaluating their learning process. Documentation of acquisition and
tracking of such knowledge has been difficult. Defining the extent
that the information is presented to each individual resident is a
complex issue and requires substantial data gathering. As a solution
we have created a program that allows a program director to
determine: 1. Whether all aspects of a curriculum are covered within
the training program, 2. The extent to which residents access the
presented information, 3. Individual learning styles and 4. Objective
and subjective progress. This comprehensive management method
was implemented 2 years ago. The first group of residents to begin
this curriculum has now graduated. The results are presented.
Methods: A master program tracks all pediatric knowledge and
skills as required by the ABA/SPA and all current methods that such
knowledge is imparted. This well-defined knowledge base is split
into 3 rotations with unique pre/post rotation self-evaluations and
surveys. The assessment results shown through a visual tracking
method, faculty feedback, perceived learning progress and future
goals are among discussed items with each resident during an end
rotation debriefing. Each individual’s progress is followed objective
and subjectively through residency.
Results: Overall CA3 performance in the ITE pediatric items in
2009, 2010 and 2011 are 6%, 2% and 9% above the national average.
Favored learning methods are textbook (41%), discussion (19%)
and lecture (18%) with podcast being only 2%. Self- perceived
knowledge level in the Likert scale showed an expected jump in
the CA3 year. The residents expressed satisfaction with current
curriculum and especially with debriefing session. Noncompliance
with taking the pre/post self- evaluations was present.
Discussion: This comprehensive program allows improved
resident knowledge management. The graduating class’s pediatric
ITE score, although now higher, cannot confirm this curriculum’s
utility yet. Learning preferences remained with textbook, discussion
and lectures despite available podcasts and online resources.
The debriefing allows for reflection on state of their knowledge
and encourages self-directed learning. This program facilitates
subspecialty knowledge and skills assessment throughout the entire
residency for both program director and resident. It allows early
identification and self -recognition in struggling residents, and
consequently it seems to encourage effort and independence for
managing their individual learning.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Equipment / Monitoring
ABSTRACTS
S-242
S-242.
ENDOTRACHEAL INTUBATION USING AIRTRAQВ®
LARYNGOSCOPE VERSUS LMA FASTRACHв„ў IN ADULT
PATIENTS: A COMPARATIVE STUDY
AUTHORS: M. Z. Ali, R. Saeed, M. Abdel-Bar, H. Helmy
affiliation: Anesthesia & S-ICU, Theodor Bilharz Research
Institute, Giza, Egypt
Introduction: AirtraqВ® (Fig.1) is a single-use direct
laryngoscope designed to provide a view of the glottis without
alignment of the oral, pharyngeal and tracheal axes.1 LMAFastrachв„ў (Fig.2) is introduced as a prototype of the laryngeal
mask airway for blind endotracheal intubation & does not require
head and neck manipulations on insertion.2 This randomized, single
blind, controlled clinical trial was designed to evaluate the usefulness
of AirtraqВ® laryngoscope for use in patients with anticipated normal
airways requiring tracheal intubation in comparison to LMA
Fastrachв„ў.
Methods: After Ethical Committee approval and patients’
written informed consents, 60 ASA I & II, middle-aged patients
of both sexes, scheduled for surgical procedures requiring tracheal
intubaВ­tion, were randomly divided into two groups; group I (n=30)
were intubated using AirtraqВ® and Group II (n=30) were intubated
using LMA Fastrachв„ў. Anesthesia was induced & maintained using
fentanyl, propofol, isoflurane & atracurium. Number of insertion
attempts, ease of insertion, overall success rate, intubation difficulty
score, duration of intubation, lowest SpO2, heart rate (HR), mean
arterial pressure (MAP) & complications were all recorded.
Results: All patients were successfully intubated. First attempt
for intubation succeeded in (80%) of group I and in (60%) of group
II. The duration of intubation was significantly shorter in group I
(p<0.001). Lowest SpO2 during intubation was significantly lower
in group II (p<0.01). Both groups showed hemodynamic stability,
despite a significant increase in the HR and MAP immediately
postintubation which continues to rise after 1- minute in comparison
to preintubation level (p<0.01). This rise was significantly higher
in group II in comparison to group I (p<0.05). Only 3 patients
(10%) of group II showed a statistically but not clinically significant
desaturation. 10% of patients in both groups had soft tissue trauma
with blood on the device and postoperative sore throat using VAS.
No recorded other complications.
Discussion: These results go in accordance with Maharaj et
al.3 in the superiority of the AirtraqВ® compared to the Macintosh
laryngoscope and with Uria A et al.4 in that the AirtraqВ® allows
glottis visualization during intubation, so damage can be minimized.
In conclusion, compared to LMA Fastrachв„ў, tracheal intubation
with the AirtraqВ® is easy and safe in patients with anticipated normal
airways showing shorter duration of intubation and maintained
hemodynamic stability.
References:
1. Anaesthesia, 2006, 61: 1093-1099.
2. Br J Anaesth 1997; 79:704 -9.
3. Anaesthesia 2008; 63: 182-188.
4. Rev Esp Anestesiol Reanim. 2009; 56:541-5.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-243
S-244
ANESTH ANALG
2012; 114; S-01 – S-493
S-243.
S-244.
PERIPHERAL NERVE SIIMULATOR INDUCED
ELECTROSTIMULATION AT P6 POINT REDUCES POST
SPINAL ANESTHESIA INDUCED HYPOTENSION
DURING SURGERY
A COMPARISON BETWEEN NOVICE AND TRAINED
PERSONNEL WHEN USING THE MACINTOSH
LARYNGOSCOPE, THE PENTAX AWSВ®, THE C-MACв„ў
AND THE BONFILS INTUBATION FIBERSCOPE:
A MANIKIN STUDY
AUTHORS: K. Al Rawahi, R. Khan, N. Kaul
affiliation: Al Harthy Complex, Oman
Introduction: Hypotension and bradycardia are a commonВ­
ly encountered undesirable effect of spinal anesthesia.1 ElectroВ­
stimulation of the P5 and P6 acupoints by TENS has been
demonstrated to augment sympathetic tone, alleviating hypotension
after spinal anesthesia in patients undergoing Cesarean section.2
that could be helped by readily available peripheral nerve stimulator
in the operation theatres.
Methods: After approval by the hospital ethical committee,
32 ASA I and II young adult patients scheduled for elective posttrauma orthopedic surgery under spinal anesthesia were randomized
into two groups. The control group (Group A, n=16) received no
P6 stimulation while the study group (Group B, n= 16) received
Train-of-four (TOF) electrical stimulation (10 mA) at the acupoint
using the PNS from just prior to spinal anesthesia till completion of
surgery. This acupoint is situated between the tendons of palmaris
longus and flexor carpi radialis,2 Chinese inches from the distal
skin crease of the wrist. One Chinese inch equals width of the
interphalyngeal joint of the thumb.3 A second electrode was placed
one inch proximal to this point.
Results: We noted that electrostimulation at P6 point in Group
B patients by a PNS decreased the fall in mean arterial pressure
(MAP) from pre-spinal level by a mean of 10.0 mmHg as compared
to 16.0 mmHg in the control group. Also, the onset of significant
fall (p<0.05) in MAP was not only delayed (20 min versus 10
min) but was also of shorter duration (10 min versus 50 min) in
group B patients as compared to non-stimulated group (group A)
patients respectively. P6 stimulation also prevented any significant
bradycardia during the study period. Number of patients needing
ephedrine or atropine to control hypotension or bradycardia
respectively was reduced by 66% in the stimulated group (Group B)
as compared to the control group patients.
Discussion: Induced TOF stimulation of P6 point successfully
attenuates the severity and duration of hypotension and bradycardia
after spinal anesthesia in patients undergoing orthopedic surgery.
References:
1.Morgan Jr GE, Mikhail MS, Murray JM. Spinal, epidural, and
caudal blocks In: Clinical Anesthesiology, 4th edition, Lange
Anesthesiology: New York, 2006.
2.Arai YCP, Kato N, Matsura M, Ito H, Kandatsu N, Kurokawa
S, Mizutani M, Shibata Y, Komatsu T. Transcutaneous electrical
nerve stimulation at the PC-5 and PC-6 acupoints reduced the
severity of hypotension after spinal anaesthesia in patients
undergoing Caesarean section. Br J Anaesth 2008; 100: 78-81.
3.Rowbothan DJ. Nausea, vomiting and their treatment. In:
Textbook of Anaesthesia (Eds: Aitkenhead AR, Rowbotham DJ,
Smith G) 4th edition, Churchill Livingstone: Edinburgh. 2001,
pp244-9.
AUTHORS: C. Liaw1, S. Lye2, E. Seet2, K. Koh2
affiliation: 1MOHH, Singapore, Singapore; 2Department of
Anaesthesia, Khoo Teck Puat Hospital, Singapore, Singapore
Introduction: Indirect laryngoscopes have been used to
improve the view of laryngeal structures, facilitate faster intubation,
and increase intubation success rate, particularly in difficult airways1.
Few studies have compared these devices, and investigated the ability
of novice compared with trained personnel to learn and successfully
use these devices. In this study, we evaluate trainee doctors versus
skilled anaesthetists when using the Macintosh laryngoscope, the
Pentax AWSВ®, the C-MACв„ў and the Bonfils intubation fiberscope
to intubate a manikin.
Methods: Thirteen trainee doctors and thirteen anaesthetists
participated in this study. A high fidelity simulation manikin was
used to simulate both normal and difficult airway scenarios. Each
participant had 8 intubation attempts on the manikin. The sequence
of device selection and airway scenarios were randomised. The time
taken for intubation, success rates of intubation, and subjective ease
of intubation were analysed, making comparisons between the 2
groups of physicians and between the 4 airway devices.
Results: There was no significant difference with regards to
the success rate of intubation between trainee doctors and skilled
anaesthetists. Intubation time with the Pentax AWSВ® was faster
for skilled anaesthetist in the difficult airway situation (22s vs 33s,
p=0.047) (Table 1). The mean time for intubation in a difficult airway
scenario for the C-MACв„ў and Pentax AWSВ® were faster than for the
Macintosh laryngoscope and Bonfils intubation fiberscope (24s, 28s
vs 80s, 61s respectively, p<0.001). The mean time for intubation in
a normal airway scenario for the C-MACв„ў and Pentax AWSВ® were
faster than for the Macintosh laryngoscope and Bonfils intubation
fiberscope (17s, 19s vs 39s, 38s respectively, p=0.002). The ease
of intubation was more favourable for all 3 indirect laryngoscopes
compared to the Macintosh laryngoscope (p<0.001).
Discussion: Both the C-MACв„ў and Pentax AWSВ® achieved
faster intubation times compared to the Macintosh laryngoscope
and Bonfils intubation fiberscope for the normal and difficult airway
scenarios. Skilled anaesthetists were 33% faster in achieving a
successful intubation compared to trainee doctors in the difficult
airway scenario with the Pentax AWSВ®. Indirect laryngoscopes were
easier to use than the Macintosh laryngoscope.
References:
Jungbauer A, Schumann A, Brunkhorst V et al. Expected
difficult tracheal intubation: a prospective comparison of direct
laryngoscopy and video laryngoscopy in 200 patients. Br J
Anaesth 2009; 102:546-50
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-246
S-246.
AN ALGORITHM FOR COMPUTER CONTROL OF DRUG
DELIVERY BY CONTINUOUS INTRAVENOUS INFUSION:
REDUCTION OF DELIVERY ONSET LAG TIME IN A
LABORATORY MODEL
AUTHORS: M. J. Parker1, M. A. Lovich2, N. M. Sims3, R. A.
Peterfreund4
affiliation: 1Division of Pulmonary, Critical Care, and Sleep
Medicine, Beth Israel Deaconess Medical Center, Boston, MA;
2
Department of Anesthesiology and Pain Medicine, St. Elizabeth’s
Medical Center, Boston, MA; 3Department of Anesthesia, Critical
Care and Pain Medicine, Massachusetts General Hospital, Boston,
MA; 4Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA
Introduction: Critically ill or anesthetized patients
commonly receive pump-driven continuous infusions of short acting
drugs in the OR or ICU. Laboratory studies show conventional drug
delivery to a patient’s circulation may substantially lag behind the
clinician’s intent, especially with restricted fluid volume delivery1.
Therapy may be suboptimal, with significant clinical impact. We
sought to enhance drug delivery onset using algorithms based on
mathematical models of infusion to control syringe pumps. We
focused on low fluid volume infusions via a central venous catheter
(CVC).
Methods: Based on Taylor dispersion2 we modeled drug
delivery by continuous infusion through a manifold/CVC system.
We assumed delivery of one drug plus carrier fluid. Model outputs
include drug concentration in the fluid path and drug delivery to the
distal end of the CVC over time. The model incorporated factors
including dead volume, flow rates and diffusion coefficient.
A hardware apparatus used computer algorithms based on the
model to drive infusion pumps to achieve desired drug delivery.
One algorithm aimed to reduce the lag time between infusion
initiation and delivery of the intended dose to the distal end of a
CVC. The algorithm was tested in a laboratory model of clinical
infusions using a tracking dye, clinical infusion components, and
quantitative spectrophotometry. Baseline flow rates reflected fluid
volume conservation practices for ICU patients. Algorithm-based
methods also conserve fluid volumes while aiming to speed drug
delivery onset. We measured the time to reach half of the predicted
steady state of drug delivery (t1/2).
Results: Delivered through an adult 16g CVC, conventional
infusions reach t1/2 at ~6 minutes. Algorithm driven infusions
reach t1/2 at ~2.5 minutes. Conventional infusions through a 9Fr
introducer reach t1/2 at ~21 minutes; algorithm driven infusions
reach t1/2 at ~4.5 minutes. With a pediatric 4Fr CVC, time to reach
t1/2 was ~16 minutes for the conventional infusion and ~3 minutes
for the algorithm driven infusion.
Discussion: We show for the first time that an algorithm
grounded on principles of fluid flow can serve as the basis of a
computer controlled drug delivery system. Laboratory data confirm
reductions of delivery lag time predicted by the mathematical
models. From the data, we predict that an algorithm system will
significantly reduce the lag time to achieve the desired steady state
of clinical drug delivery. This will impart new precision to managing
drug delivery by continuous infusion with implications for safety
and efficacy of drug therapy.
References:
1. Crit Care Med 2007, 35(12):2792-2798
2. Proc Roy Soc A 1953, 219:186-203
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-247
S-247.
AN AFFORDABLE MINIATURE MACHINE FOR PEDIATRIC
ANESTHESIA OUTSIDE THE OPERATING ROOM
AUTHOR: A. Targ
affiliation: Targ Mobile Anesthesia, Palo Alto, CA
Introduction: In running a pediatric sedation practice for
dental facilities, one of the biggest hurdles is efficiently transporting,
rapidly assembling, and putting away everything needed to create a
surgery center in as many as three different facilities in one day.
I designed and built an anesthesia machine because there was
none commercially available that transported on wheels in a fully
assembled, ready-to-use state, integrated two E-cylinders, a table,
an I.V. pole, as well as all required safety monitors, and could be
laid flat for transport.
Methods: The machine is made of FDA approved parts, DISS
O2 and N2O standard fittings, and various medical-grade one way
valves and hoses. It was welded together at a custom fabrication
shop, inspected, and certified.
-It is designed for maximum safety and portability. The core
structure is a steel, two E-cylinder transport cart welded to a
collapsible steel I.V. pole which supports an aluminum shelf
with a back on it.
-The vaporizer manifold is screwed onto the vertical back of the
shelf. The N2O/O2 mixer/flow meter assembly is bolted to the
horizontal part of the shelf next to the vaporizer. The machine is
kept upright by a collapsible tripod attached to the base of the shelf.
ANESTH ANALG
2012; 114; S-01 – S-493
-I installed a pneumatic low pressure alarm, an electronic high
pressure alarm, negative pressure alarm, sustained pressure
alarm, and dual negative pressure release valves.
-There is a N2O/O2 interlock which eliminates the possibility of
selecting a hypoxic fresh gas flow.
-There is a 12” x 12” steel table which collapses and is held down
by a powerful magnetic latch.
-The table swivels 270 degrees to different sides of the machine
for different dental setups.
-There is a refillable calcium hydroxide CO2 absorber with
popoff, two one way valves, and analog manometer.
-There is a scavenging system for N2O and a charcoal scavenger
for the sevoflurane.
- It lies flat for car transport. The Drager Vapor 2000 uniquely
does not leak any sevoflurane even when inverted.
-The unit when collapsed is the size of a golf bag and weighs
about 70 lbs. including the aluminum E-cylinders.
Results: Since 2002, the machine above has provided sedation
for 8,000 patients at more than 4,000 locations.
Discussion: The total cost of the parts for this machine was less
than $2,200. The other portable machines marketed in the United
States for mobile sedation (OBA-1, Magmedix/Magellan 2200,
Anmedic MIE Hawk, D.R.E. Integra VSO2) all are much more
expensive, cannot be tilted, need padded boxes, and require extra
trips to bring in the oxygen, table, and I.V. pole
References: The image below identifies the supplier and price
for all major components of the machine.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-248
S-249
ANESTH ANALG
2012; 114; S-01 – S-493
S-248.
S-249.
AMOUNT OF ACCIDENTAL MEDICATION FLUSH BY
SYRINGE PUMP DUE TO INAPROPRIATE RELEASE OF
OCCLUDED INTRAVENOUS LINE
COMPARISON OF AIRWAY SCOPEВ® AND
AIRTRAQВ® FOR TRACHEAL INTUBATION IN
INFANT WITH AND WITHOUT CHEST
COMPRESSIONS - A MANNEQUIN STUDY
AUTHORS: H. Kawakami, T. Miyashita, R. Yanaizumi, H. Sato,
T. Kariya, T. Goto
affiliation: Department of Anesthesiology, Yokohama City
University, Yokohama, Japan
Introduction: Unintended medication bolus is given by
a syringe pump if intravenous line occlusion is released in an
inappropriate manner after occlusion alarm of a syringe pump, and
this is a potential harm to the patient. It has been demonstrated that
the amount of bolus given in such situations is smaller with smaller
syringes1. TerufusionВ® syringe pump TE332S (Terumo, Japan) has
a special function for this particular problem. It makes the plunger
endplate withdraw after an occlusion alarm and reduces the pressure
within the syringe. It is still not well known how the amount of
accidentally injected medication is affected by different flow rate
of syringe or different type of syringe pump and we investigated
in vitro.
Methods: A syringe was inserted into a syringe pump, and
connected to a 100cm infusion tube with priming volume of 1.0ml.
A stopcock was placed to the other end of the tube. The syringe
and the tube were filled with normal saline and the stopcock was
closed. Then infusion was started at different rate (3ml/hr or 10ml/
hr), or with different syringe pump model (TerufusionВ® TE312 or
TE332S, Terumo, Japan), or different syringe size (NiproВ® 10ml or
50ml, Nipro, Japan), or at different alarm setting (High(800В±200
mmHg) or Low(300В±100 mmHg)). After occlusion alarm went off,
the occlusion was released by rotating the stopcock and the amount
of fluid coming from the stopcock was measured. Measurements
were made twice for each setting and the average was used for the
statistical analysis.
Results: Eighteen syringe pumps (9 of TE312 and 9 of TE332S)
are recruited and total 288 measurements was made. Flow rate; no
significant difference was seen between 3ml/hr and 10ml/hr.
Alarm setting; bolus was significantly lower with low alarm setting
than High. (0.132В±0.013 vs 0.268В±0.013 with TE332S, 10ml
syringe, 3ml/hr. p<0.001)
Size of syringe; bolus was significantly lower with 10ml syringe
compared with 50ml syringe (0.268В±0.013 vs 0.674В±0.116 ml with
TE332S, 3ml/hr, alarm High. P<0.001)
Syringe pump model; Significant difference was seen only when
50ml syringe was used. (TE312: 1.99В±0.16 vs TE332S: 0.674В±0.116,
alarm High. p<0.001)(Figure)
AUTHORS: A. Tampo1, A. Suzuki1, S. Sako2, T. Kunisawa2,
H. Iwasaki2, S. Fujita1
affiliation: 1Emergency, Asahikawa Medical University,
Asahikawa, Japan; 2Anesthesiology & Crical Care Medicine,
Asahikawa Medical University, Asahikawa, Japan
Introduction: Asphyxia causes cardiac arrest more
commonly in infants and children than in adults, and thus, airway
management and ventilation are very important in paediatric
resuscitation1. A Pentax-AWS Airway ScopeВ® (AWS) is a video
laryngoscope with an integrated tube guide that improves laryngeal
visualization and provides easy intubation2. We compared intubation
profiles between AWS with new neonates blade and AirtraqВ® (ATQ)
in an infant mannequin.
Methods: Following institutional approval and obtaining
written informed consent, twenty-three anesthesiologists were
percitipated. Each participant performed four different settings:
(a) intubation with AWS, (b) intubation with ATQ, (c) intubation
with AWS during chest compressions, and (d) intubation with ATQ
during chest compressions. The success rate, modified Cormack and
Lehane classification, the time to visualize the vocal cords, and the
time to place the endotracheal tube were recorded. Data are shown
as mean ± SD. Unpaired Student’s t-tests were used to analyze the
data between the devices, and P < 0.05 were considered significantly
different.
Results: Success rate and obtained laryngeal view were not
different between AWS and ATQ. The time to visualize the vocal
cords was significantly shorter with AWS compared with ATQ
without chest compressions (5.1 В± 2.5 and 7.3 В± 2.3 s, respectively).
The time to place the endotracheal tube was also significantly
shorter with AWS compared to the time with ATQ without chest
compressions (8.8 В± 3.7 and 12.1 В± 3.9 s, respectively). While
performing chest compressions, AWS allowed for a significantly
shorter time to visualize the vocal cords compared with ATQ (5.7
В± 2.6 and 9.2 В± 5.5 s, respectively). Intubation time with chest
compressions was significantly shorter with AWS compared to the
time with ATQ (9.9 В± 3.6 and 14.0 В± 6.9 s, respectively). However,
the time to visualize the vocal cords, and the time to place the
endotracheal tube with AWS and ATQ were not affected by chest
compressions.
Discussion: To minimize the amount of accidentally injected
medication when releasing occlusion, smaller size syringe pump
and low alarm setting is important. Using a syringe pump which has
a function to decrease the amount of bolus, such as TE332S, may be
helpful, but does not completely solve the problem.
Discussion: Both AWS and ATQ were effective for performing
tracheal intubations with and without chest compressions. However,
AWS provided faster tracheal intubations in infants than ATQ,
probably due to the built-in monitor that allowed operators to
continuously visualize the airway. In addition, thinner and narrower
design of the new AWS blade may provide faster access to the
larynx.
References:
References:
1. Paediatric Anaesthesia 9: 335-337, 1999
1.Biarent D. et al. European Resuscitation Council Guidelines
for Resuscitation 2010 Section 6. Paediatric life support.
Resuscitation. 2010;81:1364-88.
2.Suzuki A. et al. The Pentax-AWS((R)) rigid indirect video
laryngoscope: clinical assessment of performance in 320 cases.
Anaesthesia. 2008;63:641-47.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-250
S-251
S-250.
S-251.
TOTAL INTRAVENOUS ANESTHESIA USING
EITHER BISPECTRAL INDEX MONITORING OR
TARGET CONTROLLED INFUSION IN MAJOR
ABDOMINAL SURGERY
WITHDRAWN.
AUTHORS: S. El-Hadi1, M. M. Omran2
affiliation: 1Anesthesia, Faculty of Medicine, Alexandria,
Egypt; 2Anesthesia, Royalehayat Hospital, Kuwait, Kuwait
Introduction: The bispectral index (BIS) monitor is
advocated to prevent anesthesia awareness while allowing a
reduction in the administration of anesthetic agents. Titrating the
primary anaesthetic agent using BIS value of 40 to 60 has been
demonstrated to improve drug administration and perioperative
outcomes.1 Target controlled infusion (TCI) systems give the
potential for improving both speed and accuracy in achieving and
maintaining a desired level of anesthesia. TCI systems, enable
automatic precise and rapid control of the blood concentration and
are therefore popular with many anaesthetists.2 The aim of this work
was to determine whether a bispectral index (BIS)-based protocol is
better than a protocol based on target controlled infusion (TCI) in
total intravenous anesthesia (TIVA) on control of anesthetic depth,
consumption of anesthetics and postoperative recovery.
Methods: Thirty patients received TIVA of propofol and
remifentanil together with cisatracurium for general anaesthesia
with tracheal intubation for abdominal surgery. They were randomly
divided into two equal groups. Group I (15 patients): TIVA was
administered using TCI of propofol and remifentanil to achieve
an effect site concentration of 7.5 ng/ml. Group II (15 patients):
TIVA was maintained to keep BIS values 50 В± 10 by modifying
the infusion rates of propofol and remifentanil. Propofol and
remifentanil consumption (mg/hr), Time to achieve an Aldrete score
of ten and postoperative pain was assessed.
Results: The BIS-based protocol for administration of TIVA
decreased the consumption of anaesthetics. Propofol consumption
was 435.0 В± 125.07 mg/hr for group I and 267.13 В± 77.51mg/h for
group II (P<0.001). Remifentanil consumption was 3.34 В± 0.94
mg/h for group I and 1.87В±0.78 mg/h for group II (P<0.001). Time
to achieve an Aldrete score of ten was shorter for BIS-based TIVA
group (24.33 В± 4.88 mins) than for the TCI group (17.53 В± 2.95
mins) (P<0.001). There were no differences as regards postoperative
pain and analgesic requirement.
Discussion: Using the bispectral index as an endpoint to
maintain depth of anaesthesia resulted in lesser consumption of
intravenous propofol and remifentanil, hastened recovery with no
difference in postoperative pain.
References:
1.Liu SS. Anesthesiology. 2004; 101(2):311-5.
2.Taylor I, White M, Kenny GN. Int J Clin Monit Comput.
1993;10(3):175-80.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-252
S-252.
A NEW JACKSON TABLE AUGMENTS TISSUE
INTERFACE PRESSURE IN THE PRONE POSITION
AUTHORS: Y. Miyake1, H. Kinoshita2, H. Maeda1, M. Yamashita1,
M. Hirayama2, M. Kawakami3
affiliation: 1Nursing, Wakayama Medical University Kihoku
Hospital, Katsuragi-cho, Japan; 2Anesthesiology, Wakayama Medical
University, Wakayama, Japan; 3Orthopedic Surgery, Wakayama
Medical University Kihoku Hospital, Katsuragi-cho, Japan
Introduction: The Jackson spine table demonstrates the
least effect on hemodynamics in the prone position, indicating an
advantage in the anesthetic management1. We have recently noticed
precordial pressure ulcers after prolonged spinal surgery requiring
prone positioning on a newly developed Jackson table, Axis
JacksonTM system model 6977 (MIZUHO OSI, Union City, CA).
It is unclear whether this system is well fit for the population with
short stature. Therefore, the current study was designed to compare
the tissue-pad interface pressure at the precordial skin in Japanese
volunteers positioned in the prone fashion on conventional and new
Jackson tables.
Methods: The institutional review board approved this study and
written informed consent was obtained from each enrolled volunteer.
Eight volunteers with an average body constitution as the Japanese
population (height, weight, body mass index or chest circumference
was 169.5В±3.8 cm, 68.4В±7.8 kg, 23.8В±2.3 and 91.1В±6.9 cm,
respectively), were studied on Jackson (Jackson Spinal Surgery
and Imaging TableTM and Axis Jackson (Axis JacksonTM system
model 6977) tables. Twenty-four sensors attached to a pressure
mapping system, Force Sensitive ApplicationsTM (Vista Medical
Ltd., Winnipeg, Manitoba, Canada), were placed on the precordial
pad of each table at 2 cm intervals. The precordial pressure in each
volunteer was randomly measured 10 min after a standard prone
position using Jackson and Axis Jackson tables at 60 min intervals
with the subject’s face resting on ProneViewTM protective Helmet
System (Dupaco, Inc., Oceanside CA). Data are shown as means В±
SD. Statistical analysis was performed using repeated measures of
analysis of variance or chi-square test.
Results: The tissue-pad interface pressure at the precordial skin
in the prone position was significantly higher in the Axis Jackson
table at both maximum and mean values than the Jackson table
(Figure). Consistently with this finding, the precordial pressure was
distributed higher in the Axis Jackson compared with the Jackson
(Figure).
Discussion: The use of newly developed Axis Jackson table
demonstrated higher precordial pressure in male volunteers with
short stature, compared with the Jackson table. In contrast, the
conventional Jackson table appears more appropriate to avoid the
skin ulcer since its use showed mostly lower precordial pressure
to preserve skin perfusion2. All personnel involved in anesthetic
management for patients with prone position should acknowledge
such difference between tables although further studies are needed
to clarify the reason.
References:
1.Dharmavaram S et al., Spine 2006; 31: 1388-93
2.Herrman EC et al., J Rehabil Res Dev 1999; 36: 109-120
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-253
S-254
ANESTH ANALG
2012; 114; S-01 – S-493
S-253.
S-254.
THE EFFECT OF BEACH CHAIR POSITION ON BIS
VALUES DURING GENERAL ANESTHESIA
EVALUATION OF THE AMBU ASCOPE 2 VIDEO
BRONCHOSCOPE FOR ELECTIVE AND EMERGENCY
AWAKE INTUBATION
AUTHORS: S. Kawanishi1, M. Matsumi2, H. Morimatsu3,
T. Takahashi4, K. Morita3
affiliation: Emergency and Critical Care Center, Tsuyama
Central Hospital, Okayama, Japan; 2Department of Anesthesiology,
Ryusoh Orthopedic Hospital, Okayama, Japan; 3Department of
Anesthesiology and Resuscitology, Okayama University Graduate
School of Medicine and Dentistry, Okayama, Japan; 4Faculty of
Health and Welfare Science, Okayama Prefectural University,
Okayama, Japan
1
Introduction: The effect of postural change during surgery
under general anesthesia has not been described. The aim of this
study was to evaluate whether a beach chair position in shoulder
surgery could have some influence on the values of bispectral index
(BIS) in shoulder surgery.
Methods: We observed two groups of patients scheduled for
surgery, one was supine position group (n = 27), and the other was
beach chair position (n = 27). Anesthesia was induced with propofol
and rocuronium, and maintained with sevoflurane (end tidal
concentration 1.0 - 1.2 %). The BIS values were recorded manually
until 120 minutes after the onset of positioning and compared with
each time point at 30 min interval.
Results: There was no time-dependent difference in BIS values
during supine position. In contrast, BIS values in beach chair
position group showed a marked downward-trend through the
measurement period. End-tidal anesthetic gas concentration and
mean blood pressure did not significantly differ between the groups
consistently.
This result indicates that beach chair position causes time-dependent
decrease in BIS under general anesthesia.
Discussion: N/A
References: N/A
AUTHORS: K. P. Rothfield1,2, M. Ewing1, N. Htut1, S. Langlois1,
K. Lopez1, M. Winik1,2
affiliation: 1Anesthesiology, Saint Agnes Hospital, Baltimore,
MD; 2Nurse Anesthesia Training Program, University of Maryland,
Baltimore, MD
Introduction: Fiberoptic intubation (FOI) remains the gold
standard for securing the difficult airway. This technique, however,
requires a high degree of operator skill. FOI is complicated by
human factors, primarily the use of a monocular eyepiece to acquire
a miniaturized image. Steering the scope tip requires awkward
body twisting by the operator to maintain orientation. When a
video camera is attached to a conventional optical bronchoscope,
visualization is improved at the expense of increased device bulk,
weight and technical preparation. Recently, Ambu (Glen Burnie,
MD) introduced a second-generation, lightweight, single-use video
bronchoscope for intubation. The aScope 2 features a solid-state
imager and LED light source, and a dedicated, detached LCD
display. The aim of this study was to evaluate the efficacy of this
device in patients requiring awake intubation.
Methods: After IRB approval, 7 patients were enrolled in the
study. Informed consent was obtained from 5 patients undergoing
elective surgery. Waiver of consent was permitted by the IRB in
2 patients who required emergency intubation, including a patient
with severe angioedema, and a patient who was awakened after
failed intubation attempts with other techniques under general
anesthesia. Other indications for awake intubation included massive
goiter2, ankylosing spondylitis with morbid obesity1, severe spinal
cord compression1, and history of difficult intubation1. Measured
variables included overall and first pass success rates, complications,
time to intubation, and a visual analog intubation difficulty score.
Intubators included MDs and CRNAs with no previous experience
with the device aside from brief simulator training. Airway
topicalization was achieved with a combination of 5% lidocaine
ointment, and 4% lidocaine solution.
Results: All patients were successfully intubated with the
aScope. 5 patients were intubated on the first attempt. 1 patient
required 2 attempts, and another patient required 3 attempts.
Time from introduction of the aScope to intubation averaged
approximately 110 seconds. Average difficulty on a visual analog
scale from 0-100 (0=easy, 100=impossible) 21. The intubators in
this study agreed that the aScope was subjectively easier to use and
preferred it to a conventional bronchoscope. There were no issues
with fogging, device failure, or patient injury.
Discussion: The Ambu aScope 2 functions like an optical
bronchoscope. However, from a human factors perspective, it
simplifies the procedure by virtue of being lighter and shorter, with
LCD screen imaging rather than an eyepiece, without additional
attachments and setup time.
References:
1. Pujol E et al. Anaesthesia 2010 Oct;65(10):1037-40.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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2012; 114; S-01 – S-493
S-255.
S-256.
THE SENSASCOPE: A LEARNING CURVE
DEPENDING OF THE USERS’ EXPERIENCE
U.S. ADOPTION OF ANESTHESIA INFORMATION
MANAGEMENT SYSTEMS (AIMS): RESULTS FROM A
NATIONAL SURVEY
AUTHORS: F. Dimache, N. Stojeba, M. Baron, A. Nastasie, P.
Diemunsch
affiliation: Anesthesiology and Intensive Care, Strasbourg
University Hospital, Strasbourg, France
Introduction: The SensaScopeВ® (Swiss Acutronic, Zurich,
Switzerland) is a hybrid steerable semirigid S-shaped video stylet
that can assist in difficult airway management. It has a flexible distal
end and a LED screen. The maintenance is easier in comparison with
a fiberscope and the device is readily usable in case of emergency1.
As a follow up to a previous study2, our aim is to establish a
learning curve and assess the handling of the SensaScopeВ® on a
difficult intubation manikin (Karl Storz, Tuttlingen, Germany) by
anesthetists with various degrees of experience.
Methods: With oral informed consent, 34 anesthetists were
included in 4 groups according to their experience with fiberoptic
bronchoscopy assisted intubation (FOI): senior anesthetists having
previously performed ≥20 FOI (n=7), senior anesthetists having
performed <20 FOI (n=16), trainees in anesthesia (FOI=0, n=5) and
anesthesia nurses (FOI=0, n=6).
After detailed explanations, each operator performed six successive
SensaScope assisted intubations (SAI) on the manikin.
The time taken to complete intubation (t) was defined as the time
between picking up the device and removing it from the manikin
with the tube in place. We recorded t, the final tracheal tube position
and the degree of difficulty of the procedure. An user satisfaction
score on a 1 to 10 scale was also recorded.
The mean times for each of the six attempts were compared by the
Mann - Whitney test.
Results: The thirty four subjects performed 204 SAI. The
average intubation time diminished rapidly and the time for the 2nd
to 6th SAIs were significantly lower than the 1st SAI. From the 3rd
attempt on, the mean intubation time was constantly lower than 30
seconds. There were 5 esophageal intubations attributed to rushing.
The operators experienced in fiberoptic intubation constantly
performed better than those in other groups (p<0.035). No other
differences across groups were observed.
AUTHORS: I. S. Stol, W. S. Sandberg, J. M. Ehrenfeld
affiliation: Vanderbilt University, Nashville, TN
Introduction: AIMS are a specialized form of electronic
health record (EHR) that facilitate reliable acquisition, storage,
and display of patient data during the perioperative time frame. (1)
Widespread adoption of AIMS, which have been in existence since
the 1970s, has been hindered primarily by the financial barriers
associated with their implementation (2). As a result, only an
estimated 5% of U.S. operating rooms had an AIMS in 2006 (3).
Adoption rate of AIMS has increased recently, driven primarily
by a need to address increased regulatory reporting requirements.
Furthermore, programs such as the 2009 Federal EHR Incentive
Program, which provides a financial incentive for the “meaningful
use” of certified EHRs, are designed to speed adoption. In this study,
we determined the trends in adoption of AIMS from a nationally
representative survey of U.S. hospitals.
Methods: We compiled and distributed a nationwide survey to
200 hospitals to evaluate trends in U.S. hospitals’ adoption of AIMS.
We chose a representative sample of U.S. hospitals based on the
following variables: Size, Geography, Urban/Rural, and Teaching/
Non-Teaching. Twenty possible combinations of these variables
were identified as representative of all hospitals. Ten hospitals were
then randomly selected to be surveyed in each category, totaling 200
hospitals.
Results: 106 surveys were returned. 33% of the hospitals
reported using an AIMS, and 67% reported no AIMS use. Of those
hospitals who reported using an AIMS, 67% reported installing
AIMS within the past 5 years. Geographically, 6.1% were located
in the Southwest, 24.2% were located in the Midwest, 27.2% were
located in the Northwest, and 21.2% were located in the West
and Southeast. In terms of academic status, 81.8% were teaching
hospitals, and 21.2% were non-teaching hospitals. Additionally,
9.1% of the hospitals were small, while 90.9% were large. Only one
hospital with an AIMS was rural, while the other 96.9% were urban.
References:
Discussion: The survey identified AIMS adoption as
disproportionately high in teaching hospitals over nonteaching
hospitals, large hospitals over small hospitals, and urban hospitals
over rural hospitals. Additionally, AIMS use seems more sparse in
the Southwest region, but more evenly distributed among the other 4
geographical regions in the United States. The 67% of hospitals who
had installed an AIMS within the last 5 years are likely indicative
of the effects of the increased regulatory and reporting requirements
driving adoption of EHR technology.
1. Br J Anaesth 2006; 97: 255-61.
References:
2. ASA 2010 Anual Meeting, Abstract Number A1572.
1. Ehrenfeld, JM. Anesthesiology News. 2009: 1-8.
The average user satisfaction score was 6.67 and was not correlated
with experience or performance.
Discussion: The SensaScopeВ® is easy to handle and SAI has a
fast learning curve with good operator satisfaction.
2. Gravenstein JS. Int J Cli Monit Comput, 1986;3(2):131-134.
3. Epstein RH, et al. Anesth Analg, 2007;105(2):405-411.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-257
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2012; 114; S-01 – S-493
S-257.
S-258.
NON-INVASIVE HEMOGLOBIN MONITORING
DURING CARDIOVASCULAR SURGERY
PULSE TRANSIT TIME CAN PREDICT THE HEMODYNAMIC
EFFECTS OF POSITIVE PRESSURE VENTILATION
AUTHORS: D. Nabor1, B. Ekstrom1, P. S. Pagel1,2, M. L. Riess1,2
AUTHORS: K. Yamashita, T. Kawano, T. Yatabe, H. Abe, M.
Yokoyama
affiliation: Medical College of Wisconsin, Milwaukee, WI;
2
Anesthesiology, VA Medical Center, Milwaukee, WI
1
Introduction: Hemoglobin (Hb) is frequently monitored
intraoperatively to optimize oxygen-carrying capacity and
-delivery. A new multi-wavelength spectrophotometric method
offers continuous, non-invasive hemoglobin monitoring (SpHb). In
this observational study, we compared SpHb CO-oximetry values
with arterial hemoglobin blood samples in cardiovascular surgery
patients (n=8).
Methods: The Radical-7в„ў Pulse CO-Oximeter (Masimo,
Irvine, CA) measurements of SpHb were recorded concurrent
with Hb results from arterial blood samples at regular intervals
throughout the operation at the discretion of the anesthesiologist.
Linear regression analysis and Bland-Altman plots were used to
compare the results.
Results: In vascular patients (n=5), SpHb was highly correlated
with Hb (SpHb = 1.01В±0.10 x Hb - 0.05В±1.14, R2 = 0.91) when
the pulse oximeter was set to arterial; in contrast, venous setting
introduced a bias of +3.04 g/dl in SpHb over Hb. In addition,
preliminary results from cardiac surgery patients (n=3) suggest that
SpHb overestimates Hb by 3 to 4 g/dl, even when set to arterial.
Discussion: Continuous SpHb monitoring may offer
advantages over traditional arterial blood gas sampling by avoiding
complications from invasive catheter placement and maintenance,
frequent blood draws and by providing real-time resolution, thus
decreasing overall costs and risks and increasing patient comfort
and safety. Our data suggest a reasonable agreement between
non-invasive SpHb and Hb in major vascular surgery patients
within 1 g/dl. Its accuracy during cardiac surgery remains to be
determined. In contrast to ICU patients,1 the need for improved
accuracy and validation in different surgical patients is in line
with studies in healthy volunteers,2 emergency room patients3 and
patients undergoing Cesarean sections,4 abdominal,5 cardiac6 or
spine surgery7 where decreased peripheral perfusion was identified
as an important limitation to obtain reliable SpHb values, and
overestimation of Hb by SpHb was noted at lower Hb levels.7,8 At
this point, SpHb may serve as an useful adjunct to other clinical
monitoring, provided that its current limitations are understood and
addressed. Further studies are necessary to determine its usefulness
in different patient populations.
affiliation: Anesthesiology and Critical Care Medicine,
Kochi Medical School, Nankoku, Japan
Introduction: Application of positive end-expiratory
pressure (PEEP) was known to lead a decreasing in cardiac output
(CO). Therefore, we should pre-evaluate the hemodynamic status
before application of PEEP. For predicting CO changes, stroke
volume variation (SVV) and pulse pressure variation (PPV) has
been a useful less-invasive parameter. Pulse transit time (PTT),
measured as the interval from the ECG R wave to the pulse
plethysmograph upstroke, is recently introduced to non-invasively
assess cardiovascular response including CO. We hypothesized that
PTT variation (PTTV) might be a useful parameter to predict CO
change. The present study, therefore, examined the ability of SVV,
PPV and PWTTV for estimated CO change.
Methods: After approval of the institutional Ethics and obtaining
written informed consent, twenty-five patients who underwent
elective orthopediac surgery (ASA PS2) were enrolled in this study.
During anesthesia, ECG, the plethysmograph and the radial arterial
pressure wave were obtained from standard monitoring equipment
and FloTracTM Vigileo sensor (Edwards LifeScience). The rise
point of the pulse wave was defined as the point at which the
differentiated pulse wave reached 30% of its peak amplitude. The
measurement was made under controlled ventilation (tidal volume 8
ml/kg, respiratory rate 8/min). We changed positive end-expiratory
pressure (PEEP) from 0 to 15 cmH2O step by step by 5 cmH2O
interval and calculated PPV and PTTV every 32 beats. SVV was
obtained from FloTracTMVigilleo monitor. Receiver Operating
Characteristics curve was used to compare the predictive ability for
>15% estimated changes in CO.
Results: Area under the curve were 0.789 in SVV, 0.825 in PPV
and 0.772 in PWTTV respectively. Cut off point were 10% (74 %;
sensitivity, 85%; specificity) in SVV, 11% (73%, 85%) in PPV and
8% (73%, 67%) in PWTTV respectively.
Discussion: PTTV might be a useful parameter to estimate the
>15 % changes in CO induced by PEEP in accordance with SVV
and PPV under clinical setting.
References:
J Clin Monit Comput, 19, 313-330, 2004
References:
1. Crit Care Med 2011;39:2277-82.
2. Anesth Analg 2010;111:1424-6.
3. Ann Emerg Med 2011;57:330-3.
4. Br J Anaesth 2011 Nov 23. Epub ahead of print.
5. Anesthesiology 2012;116:65-72.
6. Anesth Analg 2011;113:1052-7.
7. Anesth Analg 2011;112:858-63.
8. Med Hypotheses 2011;77:665-7.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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2012; 114; S-01 – S-493
S-259.
S-260.
40 CASES OF TRACHEAL INTUBATION USING BOTH
STYLETSCOPE AND GLIDESCOPE (THE TAKUMI
METHOD)
COMMON INDICATIONS OF HYPERBARIC OXYGEN
(HBO2) THERAPY IN THE UNITED STATES: A SURVEY OF
HBO2 THERAPY FACILITIES
AUTHOR: K. Dote
AUTHORS: P. Saththasivam, M. Pell, K. Voralu, G. Mychaskiw
affiliation: Ehime, Japan
affiliation: Anesthesiology and Perioperative Medicine,
Hahnemann University Hospital/Drexel University College of
Medicine, Philadelphia, PA
Introduction: Even though the tracheal intubation using
Stylet scope (following SS) or Glide scope (following GS) is useful
for the case of difficult airway, it does not spread in Japan. Therefore
we attached a camera for endoscope to SS and made an image of
the SS in a monitor display. And, we also used GS at the same time.
Because we made a new method of tracheal intubation using both
images of SS and GS, we report it.
Methods: [subject] 30 cases that tracheal intubation was
urgently required for the general anesthesia and 10 cases that
tracheal intubation needed for the respiratory distress in the ward.
[method] We connected SS to a camera for endoscope and showed
8 inches of monitor. And the left of the monitor, the monitor of
GS was placed. We performed the tracheal intubation using both
SS and GS. We measured successful / failure of this intubation, the
intubation time, Cormack Grade, and the number of trial.
Results: 38 of 40 success, two failure. Two cases of the
failure was gave it up with not being obtained images by massive
bleeding. They were patients who needed intubation for respiratory
tract hemorrhage in the ward. In other 38 cases, intubation time
was required from 5 to 75 seconds (an average of 20.1 seconds).
Cormack Grade in 38 cases is C1:16, C2:16, C3:6. All 30 cases in
the operation room required only once trial, but 3 of 8 cases in the
ward required twice trial.
Discussion: (1) The Takumi Method, tracheal intubation using
both Stylet scope and Glide scope, is useful for tracheal intubation.
(2) It may be useful for tracheal intubation in the ward, especially
for the cases of difficulty airway.
References:
Efficiency of a new fiberoptic stylet scope in tracheal intubation.
Kitamura T. Anesthesiology.1999 91:1628-1632
The StyletScope facilitates tracheal intubation with the GlideScope.
Hirabayasi Y. Can J Anaesth.2006 53:1263-1264
Introduction: HBO2 therapy has been documented to be
beneficial as a primary or an adjunct treatment modality for many
medical conditions. The Food and Drug Administration (FDA) has
approved 14 indications for this treatment modality but the off label
use of HBO2 therapy has been rising in response to public demand.
Methods: Hospital affiliated and free standing clinics that offer
HBO2 therapy in the USA were searched online and contacted via
telephone. Survey questionnaires were sent through fax or email to
the HBO2 therapy facilities which were willing to participate in this
study.
Results: A total of 115 HBO2 therapy facilities agreed to
participate in this survey. The response rate was 80%, where 92
facilities completed and returned the survey questionnaires. Almost
all the facilities were staffed with physicians (98.9%) and trained
personnel (79.3%). Most of the facilities were equipped with monoplace chambers (81.5%) and also administered adjunct therapies
(91.3%) (Table 1).
Wound healing and delayed radiation tissue damage were the
most common indication for HBO2 therapy in adults. Meanwhile,
compromised skin grafts and flaps and other acute traumatic
peripheral ischemia were the most common indications for HBO2
therapy among patients aged less than 16 years old. The results
also indicated a wide range of other conditions treated with HBO2
therapy. The number of patients received HBO2 therapy for
ischemic stroke and traumatic brain injury (in adults) and cerebral
palsy, autism and Rett syndrome (in patients aged less than 16 years
old) (Table 2) were above the average range.
Discussion: HBO2 therapy is being administered for many
other medical conditions besides the currently approved indications.
Clinical research and support from the scientific community is
required to further investigate the potentials of this therapy.
References:
Gabb G, Robbin ED. Hyperbaric Oxygen. A therapy in search of
diseases. Chest 1987; 92:1074-1082.
Chan EC, Brody B. Ethical dilemmas in hyperbaric medicine.
Undersea Hyperb Med. 2001 Fall;28(3):123-30.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-261
ANESTH ANALG
2012; 114; S-01 – S-493
S-261.
INFLUENCES OF METHANE IN CONCENTRATION
DETERMINATION OF VOLATILE ANESTHETICS IN
HUMAN AND GOATS
AUTHORS: Z. Li1,2, J. Liu2,3
affiliation: 1Department of Pharmacology, West China
School of Pharmacy, Sichuan University, Chengdu, China; 2Lab of
Anesthesia and CCM, West China Hospital, Sichuan University,
Chengdu, China; 3Department of Anesthesiology, West China
Hospital, Sichuan University, Chengdu, China
Introduction: It is very important to real-timely and
accurately measure concentrations of volatile anesthetics for
properly anesthetic depth evaluation, both in operating rooms and
animal researches. In the 1970’s, Anesthetic Gas Module (AGM)
which used infrared absorption technology began being used to
measure commonly used volatile anesthetics. However, methane,
which could be produced in digestive tracts of human and ruminant
animals with a large intestinal fermentation compartment such as
goats1,2, might influence concentration determination of volatile
anesthetics. It is induced by many AGMs using 3.3Ојm infrared ray in
volatile anesthetics concentrations determination and methane also
absorbed at 3.3Ојm infrared ray3. Therefore, we design this study to
investigate if methane could affect concentrations determination of
the commonly used volatile anesthetics.
Methods: In vitro study, different concentrations isoflurane and
sevoflurane, were randomly mixed with different concentrations
methane gas (Fig.1). The concentrations of the mixed gases were
measured by Datex-ohmeda AGM-103 (10.3-13Ојm infrared ray),
Philips M1026B (3.3Ојm infrared ray) anesthetic gas module and
Aglient 4890D Gas Chromatograph, respectively4. In vivo study,
methane concentrations in end tidal gas of goats and human
were measured by the gas chromatograph to determine whether
this concentration range of methane affect the concentrations
determination of volatile anesthetics.
Results: No differences were found in the concentrations deterВ­
mination of the mixed gases measured by Datex-ohmeda AGM-103,
Philips M1026B anesthetic gas module and Aglient 4890D Gas
Chromatograph (Fig.1). The concentration measurement of volatile
anesthetics would not be affected by methane when the methane
concentration was less than 500ppm in using Datex-ohmeda AGM103, compared to 1000ppm (isoflurane) or 250ppm (sevoflurane)
for Philips M1026B (Fig.1). In goats, the methane concentration
of the end tidal gas was much higher than that of esophageal gas
(280.8В±53.8ppm vs. 2.70В±0.7ppm, Fig.2); In healthy human
volunteers, there is a very low methane concentration of the end
tidal gas. (1.06В±0.05ppm)
Figure 1 The concentrations of the mixed gases which were measured by
Datex-ohmeda AGM-103, Philips M1026B anesthetic gas module and
Aglient 4890D Gas Chromatograph. * P < 0.05 vs. 0 ppm methane.
Figure 2 Comparision of the methane concentration of the end tidal gas and
esophageal gas. * P < 0.05 vs. Air.
Discussion: When using the two Anesthetic Gas Module,
concentrations determination of isoflurane and sevoflurane were
dose-dependently influenced by methane. In general, in clinical and
experimental states, concentrations determinations of isoflurane and
sevoflurane were not affected by methane for their low concentration
range. Goats produced methane and primarily excreted via the lungs.
References:
1. Vet Anaesth Analg,32,101-6,2005.
2. Vet J,177,36-44,2008.
3. J Clin Monit Comput,14,85-8,1998.
4. J Vet Anaesth,18,4-7,1991.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-262
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2012; 114; S-01 – S-493
S-262.
S-263.
GENERAL ANESTHESIA PROLONGS MODIFIED
PULSE WAVE TRANSIT TIME
CORRELATION OF BISPECTRAL INDEX
SCORES TO MEMORY FORMATION FOLLOWING
PREMEDICATION WITH MIDAZOLAM
AUTHORS: A. Yoshida, T. Terada, S. Okino, R. Muto, N. Sato,
R. Ochiai
affiliation: Anesthesiology, Toho University Medical Center
Omori Hospital, Tokyo, Japan
Introduction: Modified pulse wave transit time (m-PWTT),
which is defined as the interval between the R wave of the
electrocardiogram and the arrival of pulse wave at the peripheral
artery, consists of the left ventricular pre-ejection period (PEP) and
the pulse wave propagation time along the large and peripheral
arteries.
m-PWTT reflects both cardiac performance and the physical
properties of blood vessels, and it is theoretically correlated with
stroke volume (SV).
In support of this theory, a novel and minimally invasive method
for continuous cardiac output (CO) monitoring has been developed,
and a good correlation between CO determined based on m-PWTT
and that determined using the thermodilution technique has already
been reported.
However, the effect of general anesthesia on PWTT is still unclear,
and thus, in the present study, we investigated the changes in
m-PWTT in patients under general anesthesia.
Methods: After obtaining approval from the institutional review
board and informed consent from the patients, 30 ASA 1-2 women
undergoing gynecological laparoscopic surgery were enrolled.
Descriptive statistics (mean +/- SD) were obtained for age (37.8 +/8.0 years), height (158.4 +/- 5.7 cm), and weight (54.8 +/- 5.7 kg).
Patients underwent propofol induction, followed by maintenance
with sevoflurane and remifentanil.
m-PWTT was recorded at the following 5 time points using
electrocardiography and fingertip pulse oximeter: 1) before
induction (control), 2) immediately after induction, 3) operative
time, 4) end of surgery, and 5) after extubation.
Data were analyzed using one-way ANOVA with Bonferroni post
hoc test. P < 0.05 was considered statistically significant.
Results: The m-PWTT (mean +/- SD) at each time point was as
follows: 1) 183.4+/- 16.8 ms, 2) 196.5 +/- 18.5 ms, 3) 209.3 +/- 16.1
ms, 4) 211.2 +/- 18.4 ms, and 5) 184.2 +/- 16.5 ms. At time points
2-4, m-PWTT was significantly prolonged more than the control.
Discussion: Our study shows that the induction of general
anesthesia prolongs m-PWTT, which persists throughout anesthesia.
The increase in PEP and delay in pulse wave propagation
are considered to be a result of the cardiodepressant and
sympathoinhibitory effects of the general anesthetics, respectively.
In addition, the dispersion of m-PWTT at each time point is within
10% of the mean value, suggesting that m-PWTT may be an
alternative parameter to estimate SV or CO, without correcting for
age or physique.
AUTHORS: X. Zheng, M. Feng, P. O’Connor, M. King, P. Lyons,
D. Glick
affiliation: Anesthesia and Critical Care, University of
Chicago, Chicago, IL
Introduction: The Bispectral Index (BIS) has been marketed
as a tool to help reduce awareness by measuring the patient’s level
of consciousness as a score from 0 (no brain activity) to 100 (full
consciousness). This study explored the correlation between BIS
scores and memory formation after preoperative sedation with
midazolam.
Methods: After IRB approval and informed consent 60
benzodiazepine naГЇve adult subjects were enrolled. A BIS Quatroв„ў
Monitor was placed on patients’ foreheads, preoperatively. BIS
scores were recorded at 5, 3, and 1 minute before administration
of midazolam, immediately after administration, and at 1 and 3
minutes after midazolam. At each recording, patients were given a
word and instructed to remember it. A total of 6 words were given, 3
before and 3 after midazolam. Patients were interviewed at 2 hours
and 24 hours postoperative to assess recall of the cued words. A
word was considered recalled if patients remembered it without
prompting at either interview.
Results: Statistically significant differences were found between
the number of recalled words before and after midazolam (2.3 and
0.9, respectively). The average BIS score for recalled words was
96.2 versus 93.7 for unrecalled words, a difference that was again
statistically significant. Focusing on consecutive words, 70% of
patients recalled word 3 (the last given pre-midazolam) whereas
only 50% recalled word 4 (the first given post-midazolam). The
corresponding BIS scores decreased an average of only 0.41 points
from word 3 to word 4. Interestingly, there was no statistically
significant difference in BIS scores between patients who recalled
both words 3 and 4 and those who only recalled word 3. There was
a 25% reduction in recall from word 4 to word 5 and a relatively
large 2.9-point drop in overall BIS scores between those two words.
A smaller proportion of patients lost recall from word 5 to word 6
(9%) with an overall BIS score reduction of 0.69 points.
Discussion: These data suggest that BIS score reductions lag
behind initial loss of recall. This may partly be explained by the
30 second running averaging technique used by the BIS monitor,
although the actual time between readings was 2 minutes. It is also
possible that the BIS score does not capture the most immediate
effects of benzodiazepines on memory, or that memory loss under
mild sedation is initiated by a route different from that which BIS
monitors. Additionally, while the decreases in recall rates were
large, the drop in BIS scores was relatively small (only 4 points,
overall) suggesting that even statistically significant changes in BIS
readings might not be clinically relevant.
References: N/A
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-264
S-264.
THE HEMODYNAMIC CHANGES DURING
PERCUTANEOUS CLOSURE OF ATRIAL SEPTAL DEFECT
USING AMPLATZER SEPTAL OCCLUDER
AUTHORS: S. Okino, T. Terada, A. Yoshida, R. Muto, N. Sato,
R. Ochiai
affiliation: Anesthesiology, Toho University, Tokyo, Japan
Introduction: Since percutaneous closure of atrial septal
defect (ASD) using Amplatzer septal occluder (ASO) is less invasive
than surgical repair, this procedure has become popular. However,
the hemodynamic change during the procedure has not been well
understood. In the present study, we examined the hemodynamic
change by using a novel monitoring system, estimated continuous
cardiac output (esCCO) which is derived from modified pulse wave
transit time (mPWTT) between R wave of electrocardiogram and
the pulse wave arrival at the finger tip by pulseoximetry.
Methods: 5 adult patients, who underwent ASD closure by
ASO under general anesthesia were studied with a written informed
consent in October and November 2011.
Mean arterial pressure (MAP), heart rate (HR), stroke volume index
(SVI) and cardiac index (CI) were continuously recorded throughout
the procedure. 5-minute-data were averaged immediately prior to
the closure of ASD as control, 5 minutes after closure (A), and
10 minutes after closure (B). SVI and CI were obtained by using
mPWTT (esCCO system, Nihon Kohden, Tokyo, Japan), which
was calibrated by cardiac output measured by transesophageal
echocardiography. % changes from control values were obtained,
and statistical analysis was done by Wilcoxon signed-rank test,
where a p value less than 0.05 was considered as statistically
significant.
Results: Demographics of the patients: 2 males and 3 females;
age 49-64 years, height 153-171 cm, weight 45-65 kg, BSA 1.411.77 m2, ASA PS 1-2, left-to-right intracardiac shunt; Qp/Qs=
1.6-3.3. The hemodynamic changes were: mBP; (A) 108В±6 %, (B)
104В±5 %, HR; (A) 97В±3 %, (B) 90В±5 %, SVI; (A) 108В±3 %, (B)
107В±6 %, CI; (A) 105В±4 %, (B) 98В±8 %. HR decreased significantly
after the procedure but MAP, SVI and CI showed no significant
change. It is suggested that ASD closure by ASO is a safe procedure
because of the minimal hemodynamic changes.
Discussion: Since less invasive procedures have become
popular in various settings, less monitoring system is required. It is
suggested that esCCO system is minimally invasive and suitable for
such procedures to monitor cardiac performance, but further study
with larger number of patients is needed to clarify its feasibility.
References:
1. Sugo Y, Ukawa T, Takeda S, et al: A novel continuous cardiac
output monitor based on pulse wave transit time. Conf Proc IEEE
Eng Med Biol Soc 2010; 2853-6.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-265
S-265.
RELATIONSHIP ACCURACY OF
ESTIMATED CONTINUOUS CARDIAC OUTPUT
AND HEMODYNAMIC PARAMETERS
AUTHORS: T. Terada, S. Okino, A. Yoshida, R. Muto, N. Sato,
R. Ochiai
affiliation: Anesthesiology, Toho University, Tokyo, Japan
Introduction: The use of a pulmonary artery catheter
(PAC) is a standard technique for measuring cardiac output in
acute-care settings. However, this technique is invasive, and the
efficacy of PACs in improving clinical outcomes is controversial.
Therefore, noninvasive cardiac output monitoring is required in the
perioperative period. Estimated continuous cardiac output (esCCO)
is based on pulse-contour and m-PWTT analyses. m-PWTT is
defined as the interval between the R wave of the electrocardiogram
and the pulse at the peripheral artery, and consists of the pre-ejection
period (PEP) and pulse wave transit time (PWTT). When PEP plays
a larger role in the m-PWTT, the accuracy of determining esCCO
might be poor because of unexpected changes in PEP, but the reason
for this is not clear. In this study, we investigated the relationship
accuracy of esCCO and the following hemodynamic parameters:
mean blood pressure (mBP), heart rate, cardiac output, and systemic
vascular resistance (SVR).
Methods: After obtaining approval from the institutional
review board and informed consent from the patients, PAC therapy
was used during the perioperative period. The patients underwent
propofol induction, followed by maintenance therapy with
sevoflurane and remifentanil. After induction, a PAC was placed
for measuring injection cardiac output (ICO). ICO and esCCO
were simultaneously measured at 1-hour intervals during the
operation. The relationship between the differences in the ICO and
esCCO, which were simultaneously measured, and hemodynamic
parameters was analyzed.
Results: Descriptive statistics (mean В± SD) were calculated for
age (38.4 В± 13.5 years), height (158.4 В± 5.7 cm), weight (54.8 В±
5.7 kg), and gender (men, 12; women, 5). The differences in the
simultaneous measurements of ICO and esCCO increased with
increase in the ICO and decrease in the SVR.
Discussion: When PEP plays a larger role in the m-PWTT, the
accuracy of estimating esCCO might be poor. esCCO is noninvasive
and can be useful if we understand the properties of this device.
References:
1.Sugo Y, Ukawa T, Takeda S, et al: A novel continuous cardiac
output monitor based on pulse wave transit time. Conf Proc
IEEE Eng Med Biol Soc 2010; 2853-6.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-266
S-267
ANESTH ANALG
2012; 114; S-01 – S-493
S-266.
S-267.
SUCTION DEVICE UTILIZATION STRATEGIES TO
REDUCE OPERATING ROOM NOISE
SCALING EXPONENT OF DFA FOR HRV
AS AN ASSESSMENT OF ACTIVITY OF ANS
DURING SURGICAL OPERATION
AUTHORS: M. J. Sharpe, J. P. Anderson, S. McNulty
affiliation: Anesthesiology, Thomas Jefferson University
Hospital, Philadelphia, PA
Introduction: The World Health Organization recommends
noise levels in operating rooms do not surpass 35 dB. The
Environmental Protection Agency recommends noise not exceed
45 dB in hospitals. Anesthesia providers routinely use suction
intraoperatively. There are a variety of permutations of suction
device utilization which may produce varying degrees of noise.
The extent of noise produced by this equipment, as well as the least
noisy means of operating suction devices is unknown. This study
seeks to describe the noise produced by various permutations of
suction device apparatuses.
Methods: A Extech Digital Datalogging Model HD600 sound
meter was placed 10cm from suction devices in operating rooms.
It was noted whether device was a portable suction unit or one
connected to institution’s “wall” suction, and whether the suction
unit was connected to a bronchoscope, a Yankaeur tip or left open
to the environment. Acoustic data were acquired once per second
for one minute and stored in an MS-Excel spreadsheet. Average
noise level, minimum, maximum, and 95% confidence levels were
calculated.
Results: 48 total noise measurements from 25 different operating
rooms revealed average noise for all suction devices measured was
71.53 dB(A) (95%CI: 71.26-71.79 dB(A), avg max: 74.42 dB(A)).
45 wall suction devices produced average noise of 71.17 dB(A)
(95%CI: 70.91-71.44 dB(A), avg max: 74.10 dB(A)). Of the
devices connected to wall suction, 21 were attached to a Yankaeur
and measured 67.82 dB(A) (95%CI: 67.71-67.92 dB(A), avg
max: 69.32 dB(A)). 11 wall suction devices were connected to
bronchoscopes and measured 73.07 dB(A) (95%CI: 73.00-73.13
dB(A), avg max: 73.71 dB(A)). 13 wall suction canisters were left
open to the environment and measured 75.00 dB(A) (95%CI: 74.2975.70 dB(A), avg max: 82.16 dB(A)).
3 portable suction devices connected to a Yankaeur tip produced
average noise 76.81 dB(A) (95%CI: 76.54-77.07 dB(A), avg max:
79.10 dB(A)).
Discussion: All measured suction devices produced levels of
noise above accepted thresholds. Portable suction devices produced
statistically significantly more noise than wall suction devices and
should be avoided wherever possible. Wall suction units produce
the least amount of noise when connected to a Yankauer tip, and
more noise when connected to a bronchoscope. Wall suction devices
produce the most noise when connected to an open canister. When
not actively suctioning patients, wall unit suction devices should
either be turned off or remain attached to Yankaeur tip to produce
the least amount of noise.
References:
1. WHO Guidelines for Community Noise. 1999
2.EPA Identifies Noise Levels Affecting Health and Welfare. EPA
press release - April 2, 1974.
AUTHORS: J. Yeh1, S. Fan2
affiliation: 1Research Center for Adaptive Data Analysis,
National Central University, Taoyuan, Taiwan; 2Anesthesiology,
National Taiwan University Hospital, Taipei, Taiwan
Introduction: The present studies showed the scaling expoВ­
nent (О±1), scales of 4-11, of detrended fluctuation analysis (DFA)
reflects the short-term fractal organization in heart rate variability
(HRV) as an assessment for sympathovagal modulation of
cardiac systems. Furthermore, activity of autonomic nerve system
(ANS) acts differently form consciousness in anesthesia. In this
investigation, DFA О±1 was used as an assessment for the activity of
ANS during surgical operations.
Methods: Heartbeat time series of 10 patients who accepted
surgical operations were analyzed using DFA to evaluated the
activities of ANS during surgical operations. The events of
induction, intubation, drugs injections, and the actions of operations
were marked for the purpose to address the probable changes of
ANS activity. Values of DFA О±1 varying with time were used to
be compared with the probably event-driven changes of ANS
activity for the purpose of evaluating the performance of О±1.
During the surgical operations, state entropy and response entropy
were maintained at stable states with values from 30 to 50 on the
maintenance stage of anesthesia.
Results: Average of the corresponding short-term scaling
exponent of DFA is 0.97 В± 0.07. Referring the correlated studies
about of DFA О±1 for different stages during sleep: value of DFA О±1
is 0.9-1.0 for stages 1 & 2; 0.8-0.9 for stage 3; and 1.1-1.2 for REM
stage. The average of DFA О±1 for patients under anesthesia is similar
to that of subjects during light sleep stage. Moreover, DFA О±1 also
signifficiently responded to the effects of stimuli, such as intubation,
surgical stresses, and the drugs.
Discussion: The activities of ANS are signifficiently
independent from the consciousness. Even under anesthesia, ANS
still works to take responses to surgical stresses and the effects of
drugs. To maintain ANS activity within an appropriate dynaimc
range is an important part of anesthesia. So far, the short-term scaling
exponent of DFA to human heartbeat time series is considered as a
good assessment of ANS activity. More details of the connections
between DFA О±1 and ANS activity should be investigated in the
following works.
References:
Mourot L., Bouhaddi M., Gandelin E., Cappelle S., Nguyen N.U.,
Wolf J.P., Roullon J.D., Hughson R., and Regnard J., Conditions
of autonomic reciprocal interplay versus autonomic co-activation:
Effects on non-linear heart rate dynamics, Autonomic Neuroscience:
Basic and Clinical, 137:27-36, 2007.
Penzel T, Kantelhardt J.W., Grote L., Peter J.H. and Bunde A.,
Comparison of detrended Fluctuation Analysis and Spectral
Analysis for Heart Rate Variability in Sleep and Sleep Apnea, IEEE
Transactions on Biomedical Engineering, 50(10):1143-1151, 2003.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-268
ANESTH ANALG
2012; 114; S-01 – S-493
S-268.
THE ACCURACY OF NONINVASIVE AND CONTINUOUS
TOTAL HEMOGLOBIN MEASUREMENT BY PULSE
CO-OXYMETRY UNDERGOING HEMODILUTIONAL
AUTOLOGOUS TRANSFUSION
AUTHORS: J. Saito1, M. Kitayama1, T. Kudo1, H. Hashimoto2,
K. Hirota1
affiliation: 1Anesthesiology, Hirosaki University Graduate
School of Medicine, Hirosaki, Japan; 2Surgical Center, Hirosaki
University Graduate School of Medicine, Hirosaki, Japan
Introduction: Monitoring of total hemoglobin levels is one
of the most essential indicator of the need for blood management
during surgery. Recently new technology, pulse CO-Oxymetry with
SpHbTM (SpHb) provides noninvasive and continuous hemoglobin
measurement. The SpHb may enable a more rapid detection of
clinically significant blood loss. However few studies showed
accuracy of the SpHb during acute Hb change, normovolemic
hemodilution or rapid blood transfusion1,2. We then evaluated
the accuracy of SpHb compared with invasive laboratory COOxymetry (tHb) undergoing acute normovolemic hemodilution and
the following autologous blood transfusion
Methods: After receiving IRB approval and written informed
consent, twenty four patients were enrolled in this study. They were
scheduled to undergo urological or gynecological surgery, in which
a blood loss of about 500 ml or more was anticipated. After induction
of general anesthesia, two units of blood, approximately 800 ml were
drawn and stocked in pair of blood correction bags through a central
venous catheter. Replacement of the corrected blood was done with
1,000 ml of lactate Ringer solution included 3% dextrane40 taking
care that normovolemic state was maintained all the time. Blood
samples were obtained from a radial artery catheter three times,
pre-, during and post- of each phase, hemodilution and autologous
transfusion, in which acute tHb level changed dramatically. During
surgery blood samples were obtained every 30 min. In the same
point, SpHb, Perfusion index and Pulse variability index were
continuously monitored and manually recorded.
Figure 1. A scatterplot of 228 hemoglobin values
as determined by SpHb and tHb collected from 24
patients (r2=0.56, n=228, p<0.0001).
Figure 2. A Bland-Altman plot of 228 hemoglobin
values as determined by SpHb and tHb collected from
24 patients (Bias=1.12 g/dl, Precision=1.25 g/dl).
Results: Two hundred twenty eight bloods samples for tHb
measurement were corrected with equal number of paired SpHb
measurements. Liner regression analysis of all SpHb and tHb values
is shown in Figure 1. A Bland-Altman plot is shown in Figure 2.
Mean bias and precision of 228 SpHb and tHb values were 1.12 g/
dl and 1.25 g/dl, respectively. There was no significant difference in
SpHb accuracy parameter between acute hemodilutional phase and
autologous transfusion phase.
Discussion: Compared to previous studies in healthy subjects,
this study revealed the tendency of SpHb values higher than tHb
values. This discrepancy in SpHb may be affected by several
factors, peripheral digital perfusion, intravascular volume and acute
changes in tHb3). Furthermore this study indicates that general
anesthesia may also affect accuracy of SpHb measurement. In
future investigations, we could use this new noninvasive monitor
as clinical decision making to guide transfusion therapy with to gain
better insights into these limitations.
References:
1. Anesth Analg 2010;111:1424-6
2. Crit Care Med 2011;39:2277-82
3. Anesth Analg 2011;112:858-63
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-269
S-269.
USE OF FIBER OPTIC SPECTROSCOPIC TECHNOLOGIES
TO MONITOR SPINAL CORD ISCHEMIA IN REAL TIME
AUTHORS: A. Emanuel1, R. Galler3, A. D’Souza4, R. Mesquita5,
A. Yodh5, T. Floyd1,5
affiliation: 1Dept. of Anesthesiology, Stony Brook University
Medical Center, Stony Brook, NY; 2Dept. of Surgery, Stony
Brook University Medical Center, Stony Brook, NY; 3Dept. of
Neurosurgery, Stony Brook University Medical Center, Stony
Brook, NY; 4Dept. of Biomedical Engineering, Stony Brook
University, Stony Brook, NY; 5Dept. of Physics and Astronomy,
University of Pennsylvania, Philadelphia, PA
Introduction: Spinal cord injury remains a devastating
complication of aortic surgery. Spinal cord ischemia may be
amenable to treatment if detected early. Failure to rapidly detect
spinal cord ischemia can result in permanent paresis and paraplegia,
depending on the severity of the loss of perfusion. Current methods
employed to detect spinal cord ischemia are indirect, temporally
insensitive, and nonspecific. Our objective was to develop a device
to monitor changes in spinal cord blood flow and oxygenation, in
real-time.
Methods: A thin fiber optic probe, implementing Diffuse
Optical Spectroscopy (DOS) to measure tissue oxygenation and
Diffuse Correlation Spectroscopy (DCS) to measure blood flow,
was designed and tested in adult Dahl sheep. The device was
tested after placement in the mid-thoracic spinal cord region,
after both open (laminectomy) and percutaneous approaches were
employed. The device was further tested in intrathecal and epidural
locations. Spinal blood flow and oxygenation, along with mean
arterial pressure (femoral & carotid) were measured during blood
pressure manipulations via sodium nitroprusside, neosynephrine or
vasopressin administration, and after intra-aortic balloon inflation in
the superior descending thoracic aorta.
Results: Changes in spinal cord blood flow tracked closely
changes in MAP elicited by all interventions. Patterns of changes
in blood flow after interventions were consistent with rapid
autoregulation. Significant changes in tissue oxygenation were not
elicited. Results were not impacted by positioning in either epidural
or subdural space, nor by manner of placement.
Discussion: Our data confirms the novel application of DCS
and DOS technologies to appropriately and in real-time monitor
changes in blood flow and oxygenation that occur in the spinal cord
during various hemodynamic perturbations.
References:
Estrera AL, Sheinbaum R, Miller CC, Azizzadeh A, Walkes JC, Lee
TY, Kaiser L, Safi HJ: Cerebrospinal fluid drainage during thoracic
aortic repair: safety and current management. Ann Thorac Surg
2009; 88: 9-15
Wynn MM, Mell MW, Tefera G, Hoch JR, Acher CW: Complications
of spinal fluid drainage in thoracoabdominal aortic aneurysm repair:
a report of 486 patients treated from 1987 to 2008. J Vasc Surg 2009;
49: 29-34
Mesquita RC, Durduran T, Yu G, Buckley EM, Kim MN, Zhou C,
Choe R, Sunar U, Yodh AG. Direct measurement of tissue blood
flow and metabolism with diffuse optics. Philos Transact A Math
Phys Eng Sci. 2011 Nov 28;369(1955):4390-406.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-270
S-271
ANESTH ANALG
2012; 114; S-01 – S-493
S-270.
S-271.
DETERMINATION OF POSTOPERATIVE AND
INTRAOPERATIVE PREDICTORS OF POST-OPERATIVE
DETERIORATION
HOW FAST DOES THE CUFF PRESSURE RISE WHEN
USING NITROUS OXIDE?
AUTHORS: K. Gebre-Amlak1, L. M. Weavind2, J. M. Ehrenfeld2
affiliation: Miami, FL
affiliation: 1Vanderbilt University School of Medicine,
Nashville, TN; 2Vanderbilt University Medical Center, Nashville,
TN
Introduction: While the morbidity and mortality attributed
to anesthesia is low, there continues to be a high post-operative
complication rate (23.5-27.6% all complications; 14.9-18.4%
major complications)(1). Failure to rescue was associated with a
higher mortality rate (12.5-21.4% death after major complication)1.
These findings suggest that early identification and management
of patients who have post-surgical complications can significantly
affect morbidity and mortality. We set out to identify pre- and intraoperative characteristics that may be predictive of an adverse event
in the immediate post-operative setting (ie within 48 hours post
surgery).
In order to address this, we previously reported a pilot study of
post surgical patients comparing those who had an unanticipated
transfer to the ICU from a surgical ward within 48 hours (n=422)
with a second cohort who weren’t transferred to an ICU within
48 hours (n=389)2. Having found that preop beta blocker usage,
intraop vasopressin usage, maximal intraop heart rate, and PRBC
transfusion predicted both increased ICU transfer and a two-fold
increase in mortality at 30 days (8% vs 4%; p=0.04), we now report
our subsequent efforts to extend our predictive modeling.
Methods: Our work expands upon our original effort to include
(1) a larger cohort of patients from 12/04 to 8/11, (2) additional
predictor variables (including patient characteristics - PMH, home
meds, preop labs, etc.; and a series of intraop physiologic markers
- vital sign variability, intraop drug admin patterns, etc.), and (3)
a set of secondary outcomes including post-surgical acute kidney
injury and cardiac ischemia. We are in the process of utilizing
both traditional statistical analysis and advanced machine learning
algorithms to model our dataset.
Results: We identified a cohort of 62,830 adult patients who
had a surgical procedure and were admitted to a surgical ward postop; of these, 735 had an unanticipated transfer to the ICU within
48 hrs in comparison to 57,543 who did not have a post-surgical
ICU stay. This is summarized in Table 1. We are now in the process
of modeling the differences with regards to preoperative patient
characteristics and intraoperative conditions between these patient
populations.
Discussion: We have developed an approach to provide a novel
multivariate analysis of risk for post-operative adverse events and
in the process of building a predictive model for risk assessment
for operative patients. We will ultimately integrate our model into
an AIMS for prospective testing and validation of the risk score to
provide real-time post-operative deterioration predictions.
AUTHOR: R. Marks
Introduction: It is well know that administering general
endotracheal tube anesthesia (GETA) with nitrous oxide may cause
the endotracheal tube (ETT) cuff pressures to increase.1. However,
it is not clear how rapidly this takes place and how high the pressures
will increase, especially with the common use of high volume -low
pressure endotracheal tubes. The purpose of this study will be to
measure these values in a laboratory model of GETA.
Methods: We placed a 7.0 I.D. Mallinckrodt Hi-lo ETT
(Coviden LLC, Mansfield, MA) in a simulated trachea and inflated
the cuff with 9 ml of air to achieve an initial cuff pressure of 20
cm water. When then connected the ETT to a patient ventilator and
the trachea to an artificial lung. We instituted CMV at a rate of 10
and tidal volume of 700 ml with a 50% mixture of nitrous/oxygen.
We measured the cuff pressure every 5 minutes until reaching a
steady plateau. We then measured the amount of volume required to
remove from the cuff in order to return to the starting cuff pressure.
We then repeated the experiment with a starting pressure of 30 and
40 cm water. We also measured the incremental increase in cuff
pressure from injecting air in increments of 0.1 ml from a starting
pressure of 20 cm water to a final pressure of 100 cm water. The cuff
pressures were all measured using a standard cuff pressure gauge
(King System Corp, Germany).
Results: The cuff pressures all reached an equilibrium plateau
in about 45-60 minutes with cuff pressures of 60, 64 and 70 from a
starting pressure of 20,30 and 40 cm water respectively, The amount
of gas removed from the cuff in order to return to the baseline cuff
pressures was 0.95, 0.7 and 0.65 respectively. The measurement
of cuff pressure as a function of cuff volume exhibited a linear
relationship and was found to be approximately 5 cm of water for
every 0.1 ml increase in volume between the ranges of 20 - 100 cm
water.
Discussion: The experiment showed that the high volume low pressure cuffs behave quite differently in vivo than expected.
Once the cuff has been inflated to the point where the compliance
is reduced by contact with the tracheal lumen, the cuff no longer
behaves as expected, but rather exhibits linear behavior. In addition,
the study shows how rapidly nitrous oxide can elevate the cuff
pressure, and we therefore recommend that cuff pressure should
always be continuously monitored in patients undergoing GETA
with nitrous oxide.
References:
Stanly TH, Kwawamura R, Graves C. Effects of nitrous oxide on
volume and pressure of endotracheal tube cuffs. Anesthesiology
1974;41:256-62.
References:
1. NEJM 2009, 361;14 pg 1368-1375
2. ASA Annual Meeting 2011, Chicago IL A1525
Table 1
Surgical
Ward
Number of pts (%)
62830
Average Age (SD) 52.7 (16.4)
Length of Stay
5.2 (7.2)
(SD)
% Male
55.1
% Female
44.9
Floor deterioration
with ICU transfer
in 48 hours
No post-op ICU
stay during
hospitalization
735 (1.17)
57543 (91.59)
58.4 (15.1)
52.1 (16.4)
14.0 (13.4)
4.7 (6.4)
55.1
44.9
54.4
45.6
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-272
S-272.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-273
ANESTH ANALG
2012; 114; S-01 – S-493
S-273.
A RADIO SYSTEM FOR RELAYING THE PATIENT
MONITOR AUDIO OUTPUT TO THE ANESTHESIOLOGIST
DURING PEDIATRIC SEDATION
AUTHOR: A. Targ
affiliation: Targ Mobile Anesthesia, Palo Alto, CA
Introduction: The anesthesiology motto of “vigilance”
reflects the need to be aware of a problem in order to correct it
timely. The need for vigilance is particularly acute in the care of
children in dental facilities where staff may have no experience
with sedation. Pediatric dental facilities usually have distractions
not seen in the typical sedation location such as crying children in
neighboring operatories, questions from worried parents observing
the procedure on their child, the whine of the 500,000 RPM dental
drill, helicopter landings, running water, cell phone calls, and the
need to leave the area for numerous x-rays to name a few.
The transmitter has a long wire attached to its microphone, and, after locating
the speaker on my monitor, I permanently mounted the microphone on the
stand such that it is as close as possible the speaker. I adjust the monitor
volume to control the intensity of the sound I hear with my earpiece. A low
monitor volume setting works fine which keeps the beeping and alarms
inaudible to the dental staff to not distract them. This should work with any
monitor.
To make sure that I hear my monitor’s audio output, I built a
transmitter into the monitor stand and a receiver into my stethoscope.
The system has worked well and comfortably for over 8,000 cases
with only rare instances of radio interference.
Methods: The monitor is a 900 MHz Wireless Camcorder
Transmitter/Receiver1. The transmitter requires a 1.5V input from an
AA battery and has a 150 foot range. It is integrated into the monitor
stand, so I installed a 1.5V DC transformer and ran the wires into
the battery case of the transmitter and attached each lead to a screw
inserted in the appropriate end of a ½” dowel cut to the proper size
to act as a permanent “dummy” AA battery. Both transmitter and
receiver are 2.0”x2.5”x0.5” and 1.5 ounces without the battery.
Results: N/A
Discussion: N/A
References:
1.Sony Model WCS-999 Camera Mountable 900 MHz Lavalier
Microphone System, $99.99
The receiver is powered by a single AA battery and can be set to one of three
channels which needs to match that of the transmitter. To hear the sounds, I
use a custom molded earpiece with a tiny powered speaker built into it (2).
This connects to the audio out 1/8” jack of the receiver. If I do not want to
wear the earpiece, I use a AAA battery powered speaker (designed for an iPod
Nano) (3) that plugs into the audio jack.
2.EmTech Laboratories, Inc., 7745 Garland Circle, Roanoke, VI
24019, $70.00
3.Merk Mini Nano Speakers, Merkury Innovations, 2006 Model:
MI-SPNN, $19.99
The receiver sits in a BBC brand “belt pager pouch” with a Velcro closure that
is attached to my stethoscope.
The earpiece needs to have a handle built into it to prevent the power wires from being used as a handle and
eventually failing. To manufacture the earpiece, an audiologist needs to make an ear impression (EmTech will want
you to send them the 1/8” mono jack and some cable. This can be cut from the bottom of the receiver since it is
provided to interface with recording equipment which will never be used in this application).
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-274
S-274.
PERIPHERAL NERVE STIMULATION AND RESIDUAL
NEUROMUSCULAR BLOCKADE: INTERIM ANALYSIS
OF THE RECITE STUDY
AUTHORS: L. Fortier1, D. M. McKeen2, K. Turner3, B. Warriner4,
A. J. Chaput5, A. Galarneau6
affiliation: 1HГґpital Maisonneuve-Rosemont, MontrГ©al,
QC, Canada; 2IWK Health Centre, Halifax, NS, Canada; 3Queen’s
University, Kingston, ON, Canada; 4Vancouver General Hospital,
Vancouver, BC, Canada; 5The Ottawa Hospital, Ottawa, ON,
Canada; 6Merck Canada, Kirkland, QC, Canada
Introduction: Residual neuromuscular blockade (rNMB) is
common at tracheal extubation (TE) and in the post-anesthesia care
unit (PACU). Residual blockade at the time of TE may be associated
with an increased risk of hypoxemia, impaired pharyngeal function
and risk of aspiration, and airway obstruction.1 Full recovery
of neuromuscular function (TOF ratio ≥0.9) at the time of TE is
strongly recommended.2,3 Use of peripheral nerve stimulation (PNS)
and reversal of neuromuscular blocking agents (NMBA) with
acetylcholinesterase inhibitors may help to prevent rNMB, but the
extent and impact of their use has not been documented in Canadian
clinical practice. The RECITE (REsidual Curarization and its
Incidence at Tracheal Extubation) study prospectively examined the
incidence of rNMB during routine anesthesia practice.
Methods: RECITE is an ongoing prospective, multicenter
trial assessing the incidence of rNMB in ASA class 1-3 adults
undergoing elective open abdominal or laparoscopic surgery.
All subjects provided written informed consent. Neuromuscular
function was assessed using acceleromyography (TOF-WatchВ® SX).
The attending anesthesiologist and PACU nurses were blinded to
the TOF-Watch monitoring. NMBA dosing, administration of NMB
reversal and the decision to extubate were at the discretion of the
anesthesiologist in accordance with local practices. The impact of
PNS monitoring on the incidence rNMB at TE and at arrival at the
PACU were assessed.
Results: The interim analysis was performed on a total of 141
evaluable subjects recruited at 8 centers between June 2011 and
December 2011. The study population was mainly female (74%)
and median age 45 years old. Procedures included laparoscopic
(54%) and open abdominal (46%) surgeries. Rocuronium was
used in 99% of cases. PNS was used in 94% of cases. Overall,
the incidence of rNMB at TE and at arrival in the PACU was 57%
and 45%, respectively. These findings are independent of PNS
monitoring (Table 1).
Discussion: These interim data suggest that despite extensive
subjective PNS monitoring in Canadian clinical practice, rNMB
was identified in a majority of patients at the time of TE and in
a high proportion of patients at arrival in the PACU. Additional
intervention(s) other than PNS monitoring are warranted to predict
or diagnose rNMB.
References:
1. Anesth Analg 2010;111:120
2. Anesthesiology 2003;98:1042
3. Anesth Analg 2004;98:854
Table 1: Incidence and Relative Risk of rNMB
PNS (TE - N=132)
(PACU - N=117)
No PNS
(N=9)
Relative Risk
p
[95% CI]*
Value**
0.9778 [0.535 TE
1.000
75 (57%)
5 (56%)
1.787]
(N=141)
1.2500 [0.673 PACU
0.730
52 (44%)
5 (56%)
2.320]
(N=126)
* using SAS Proc FREQ ** using Fisher’s exact test (two-sided test)
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ANESTH ANALG
2012; 114; S-01 – S-493
Geriatric Anesthesia
ABSTRACTS
S-280
S-280.
PARADOXICAL FEATURES OF NITROUS OXIDEOXYGEN-REMIFENTANIL ANESTHESIA
AUTHORs: M. Uchida, N. Fukuhara, A. Maruyama, K. Ishii, M.
Tamura, T. Jinma
affiliation: Anesthesiology, Social Insurance Chuo General
Hospital, Shinjyuku, Japan
Introduction: Fentanyl (Fen) alone provides sufficient
anesthesia without sevoflurane (SeV), when used with 66% N2O
in O21. This study aimed to investigate the features of N2O-O2remifentanil (Rf) anesthesia, which is largely unknown.
Methods: Eighteen patients (49В±18 years old) with ASA I-II
who underwent general anesthesia were included in this study.
Anesthesia was induced by a bolus of 1.0 mg/kg propofol and 0.6
mg/kg rocuronium. Rf infusion at 0.3 or 0.4 Ојg/kg/min was started
5 min before induction. Before starting operation, pure O2 was
changed to 50% O2 in air and 1.2 vol% SeV was started. Fifteen
min after SeV in expired gas reached 1.2 vol% (same MAC as 66%
N2O), we measured heart rate viability for 5 min and calculated the
ratio of low-frequency to high-frequency component (LF/HF) of the
power spectra using CheckMy HeartВ® (DailyCare BioMedical Inc.,
Chungli, Taiwan) (control). Then SeV was stopped and 66% N2O in
O2 was started. Fifteen min after SeV concentration in expired gas
declined to 0.1 vol%, we measured LF/HF again. Then Rf infusion
rate was increased to 0.7 Ојg/kg/min at increments of 0.1 Ојg/kg/min,
and we measured LF/HF at every increment 15 min after the Rf
infusion rate was changed. Rocuronium was infused at 20 mg/h
during anesthesia. Non-invasive systolic (SBP) and diastolic (DBP)
blood pressure, and heart rate (HR) were measured every 2.5 min.
BIS and EEG were monitored using a BIS apparatus.
Results: LF/HF, sympathetic nerve activity decreased as Rf
infusion rate increased to 0.5 Ојg/kg/min and then made a plateau as
Rf infusion rate was over 0.6 Ојg/kg/min. SBP increased depending
on Rf concentration. DBP increased as Rf infusion rate increased
to 0.5Ојg/kg/min and then decreased as Rf infusion rate was over
0.6 Ојg/kg/min. HR decreased depending on Rf concentration. After
the beginning of N2O, EEG became sign wave-like, BIS decreased
to nearly 30 and the suppression ratio number began to appear on
the BIS apparatus in most cases. There was no awakening during
anesthesia.
Discussion: Akata et al2 reported that SeV induced inhibition of
norepinephrine-induced contractions probably caused by reduction
of [Ca2+]i and suppression of myofilament Ca2+ sensitivity of
vascular smooth muscle cells. The blood/gas partition coefficient
of N2O is similar to that of desfulurane, so theoretically there is no
delay of awakening using N2O-O2-Rf anesthesia. Our study showed
that the optimal Rf infusion rate is 0.5 Ојg/kg/min with respect to
stable circulation dynamics. Overall N2O-O2-Rf anesthesia is very
safe and is particularly suitable for older patients.
References:
1.Anesthesiology 1999;90:398-405
2. Anesthesiology 2000;92:1441-53
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-281
S-282
S-281.
S-282.
WITHDRAWN.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-283
S-283.
WITHDRAWN.
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ANESTH ANALG
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ABSTRACTS
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ANESTH ANALG
2012; 114; S-01 – S-493
min pre-oxygenation (NC:99В±1%; TM:100В±1%5), lowest O2
Sat (NC:92В±8%; TM:97В±4%) (Fig 1), severe desaturation (O2
Sat <85%) (NC:4/13; TM:1/51) (Fig 2) and bag-mask ventilation
(NC:1/13; TM: 0/51) (Fig 3). In 3 NC patients, NC was converted to
TSE “Mask” due to severe desaturation (O2 Sat:81±3%). Their O2
Sat was increased to 86В±5%, 93В±3% and 97В±2% at 5 min intervals.
S-284.
PRE-OXYGENATION WITH A NO-COST TSE “MASK”
PREVENTS SEVERE DESATURATION AND REDUCES
THE NEED FOR BAG-MASK VENTILATION IN ELDERLY
PATIENTS UNDER DEEP PROPOFOL SEDATION DURING
UPPER GI ENDOSCOPY
AUTHORS: J. Tse, K. Dauphinee, T. Mehta, C. W. Hunter, L.
Spina, S. Cohen
affiliation: Dept. of Anesthesia, UMDNJ-Robert Wood
Johnson Medical School, New Brunswick, NJ
Introduction: Patients undergoing upper GI endoscopy
(EGD) routinely receive nasal cannula (NC) O2 and sedation. NC
delivers minimal O2 when the mouth is kept open by a bite-block.
Sedation may cause respiratory depression, especially in elderly
patients. A plastic sheet was shown to improve oxygenation by
transforming NC to a face tent (TSE “Mask”) in patients during
EGD(1). We examined its effectiveness in preventing severe
desaturation in elderly patients during EGD.
Methods: Review of patients who underwent EGD, EUS, PEG
or ERCP identified 2 groups. Group 1 (NC, n=43) received only NC
O2. Group 2 (TM, n=168) received NC O2 and a TSE “Mask” using
a clean specimen bag (Photos)(1-3). Patients received NC O2 (3-6
l/min) and only propofol. Student t-test and Chi Square test were
used for analysis. A p value <0.05 was considered as significant.
(MeanВ±S.D.)
Results: Among elderly (>70 y/o) patients, there were no
differences in age, BMI, ASA Status (NC:2.6В±0.7; TM:2.7В±0.7),
room air (RA) O2 Sat, propofol dose, duration and highest NC O2
flow (Table). There were significant differences in O2 Sat after 5
Among younger patients (<70 y/o), there were no differences in
age, BMI, ASA (NC:2.0В±0.7; TM:2.1В±0.7), RA O2 Sat, propofol
dose, duration, highest NC O2 flow and O2 Sat after 5 min preoxygenation (Table). There were significant differences in lowest
O2 Sat (NC:89В±10%; TM:97В±4%)(Fig 1), severe desaturation (O2
Sat <85%) (NC:13/40; TM:2/117)(Fig 2) and bag-mask ventilation
(NC: 4/40; TM:1/117)(Fig 3). In 13 NC patients, NC was converted
to TSE “Mask” due to severe desaturation (O2 Sat:84±6%). Their
O2 Sat was improved to 97В±4%, 98В±3% and 100В±0% at 5 min
intervals.
Among 9 NC and 102 TM patients, there were significant
differences in FiO2 (NC: 0.36В±0.18; TM: 0.49В±0.12), and FeO2
(NC: 0.46В±0.17; TM: 0.72В±0.16).
Discussion: Data show that pre-oxygenation with TSE “Mask”
prior to deep propofol sedation for EGD prevents severe desaturation
and reduces the need for assisted bag-mask ventilation in elderly as
well as younger patients. It increases O2 delivery without raising
NC O2 flow. It can also be used as a rescue technique when patient’s
oxygenation deteriorates. However, it appears that oxygenation of
elderly patients would not recover as quickly as that of younger
patients.
References:
1. Anesth 107:A922, 2007
2. Anesth 102:484, 2005; 3. www.TSEMask.com
Effects of TSE “Mask” on Oxygenation during Upper GI Endoscopy
Elderly (>70
Age (years)
y/o)
BMI (kg/
m2)
Duration
(min)
RA O2 Sat
Highest NC O2
Flow (l/min)
O2 Sat
5-min O2
Lowest O2
Sat
Sev Desat
(<85%)
Bag-Mask
Vent
Propofol
dosage ug/
kg/min
NC Group
(n=13)
81±6 ‑
26В±6
43В±22
97В±3%;
5.6В±2.7
99В±1%
92В±8%
4/13
1/13
147В±65
TM Group
(n=51)
79В±6 n.s.
26В±5 n.s
41В±21 n.s.
97В±2% n.s.
4.9В±1.2 n.s.
100В±1%
*p<0.05
97В±4%
*p<0.001
1/51
*p<0.001
0/51
*p<0.05
160В±61 n.s.
NC Group
(n=40)
53В±13
28В±4
34В±14
98В±2%
5.0В±1.2
99В±1%
89В±10%
13/40
4/40
216В±74
TM Group
(n=117)
53В±12 n.s.
28В±7 n.s.
39В±15 n.s.
98В±2% n.s.
4.8В±1.2 n.s.
100В±1% n.s.
97В±4%*
p<0.0001
2/117 *
p<0.001
1/117
*p<0.01
192В±62 n.s.
Younger
(<70 y/o)
Mean±S.D.; NC: Nasal Cannula; TM: TSE “Mask”; RA: room air; Sev Desat: severe desaturation; Vent: assisted ventilation; n.s. Not significant different;
*Significantly different from NC group
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-285
S-285.
PRE-OXYGENATION WITH A NO-COST TSE “MASK”
PREVENTS SEVERE DESATURATION AND REDUCES
THE NEED FOR ASSISTED BAG-MASK VENTILATION
IN PROPOFOL-SEDATED ELDERLY PATIENTS DURING
CARDIOVERSION/AICD TESTING
AUTHORS: T. Mehta, P. Patel, G. George, S. Cohen, S. Barsoum,
J. Tse
affiliation: Dept. of Anesthesia, UMDNJ-Robert Wood
Johnson Medical School, New Brunswick, NJ
Introduction: Patients undergoing cardioversion or AICD
testing routinely receive IV sedation and O2 via nasal cannula
(NC). Deep sedation or airway obstruction may cause severe
desaturation, especially in elderly patients (> 70 y/o) with multiple
cardiopulmonary diseases. A simple plastic sheet has been shown
to improve oxygenation by transforming NC to a face tent (TSE
“Mask”) in propofol-sedated patients during EGD in a prospective
study(1). This technique has been used in the Cardiac Cath Lab. We
examined its effectiveness in improving oxygenation and preventing
severe desaturation in elderly patients during cardioversion or AICD
testing.
Methods: Retrospective review of patients who underwent
cardioversion or AICD testing identified 2 groups. Group 1 (NC,
n=47) received only NC O2. Group 2 (TM, n=121) received NC
O2 and a TSE “Mask” using a clean clear plastic specimen bag to
cover patient’s nose and mouth as described (Photos)(1-3). Patients
received NC O2 (3-5 l/min or higher as needed) and only IV
propofol. Student t-test and Chi Square test were used for analysis.
A p value <0.05 was considered as significant. (MeanВ±S.D.)
ANESTH ANALG
2012; 114; S-01 – S-493
Results: Among the elderly patients (>70 y/o) (NC: n=24; TM:
n=47), there were no differences in age, BMI, ASA Physical Status
(III), room air (RA) O2 Sat and propofol dose (Table). There were
significant differences in O2 Sat after 5 min pre-oxygenation (NC:
99В±1%; TM: 100В±1%), the highest NC O2 flow (NC: 7.3В±2.8 l/min;
TM: 4.7В±1.5), the lowest O2 Sat (NC: 84В±13%; TM: 97В±4%)(Fig
1), severe desaturation (O2 Sat <85%) (NC: 10/24; TM: 1/47)(Fig
2) and bag-mask ventilation (NC: 9/24; TM: 0/47)(Fig 3).
Among the younger patients (<70 y/o) (NC: n=23; TM: n=74), there
were no differences in age, BMI, ASA Status (III), room air (RA)
O2 Sat and propofol dose (Table). There were significant differences
in O2 Sat after 5 min pre-oxygenation (NC: 99В±1%; TM: 100В±0%),
the highest NC O2 flow (NC: 7.3В±3.0 l/min; TM: 5.0В±.7), the lowest
O2 Sat (NC: 87В±9%; TM: 95В±6%)(Fig 1), severe desaturation (O2
Sat<85%) (NC: 9/23; TM: 4/74)(Fig 2) and bag-mask ventilation
(NC: 9/23; TM: 2/74)(Fig 3).
Discussion: These data show that pre-oxygenation with TSE
“Mask” prior to propofol sedation for cardioversion/AICD testing
prevents severe desaturation and reduces the need for assisted bagmask ventilation in both elderly and younger patients. It improves
oxygenation without raising NC O2 flow rate. This face tent
takes only a few seconds to prepare at no cost and may improve
patient safety. It also reduces procedure interruptions and should
be routinely used for pre-oxygenation prior to sedation during
cardioversion/AICD testing.
References:
1. Anesth 107:A922, 2007
2. Anesth 102:484, 2005
3. www.TSEMask.com
Effects of TSE “Mask” on Oxygenation during Cardioversion/AICD Testing
Elderly (>70
y/o)
Age (years)
BMI (kg/m2)
RA O2 Sat
NC Group
(n=24)
80В±6
27В±6
99В±2%
7.3В±2.8
99В±1%
84В±13%
100В±1%*
p<0.05
97В±4%*
p<0.0001
Highest NC O2
Flow (l/min)
O2 Sat 5-min Lowest O2
O2
Sat
TM Group
(n=47)
78В±5 n.s.
28В±8 n.s.
98В±2% n.s.
4.7В±1.5*
p<0.0001
Younger (<70
y/o)
NC Group
(n=23)
TM Group
(n=74)
60В±8
30В±7
99В±2%
7.3В±3.0
99В±1%
87В±9%
5.0В±.7* p<0.0001
100В±0%*
p<0.0005
95В±6%*
p<0.0001
58В±10 n.s.
31В±8 n.s.
98В±3% n.s.
Sev Desat
(<85%)
Bag-Mask
Vent
Propofol Dose
(mg/kg)
10/24
9/24
0.97В±0.23
1/47* p<0.001
0/47*
p<0.001
0.94В±0.29 n.s.
9/23
9/23
0.98В±0.41
4/74* p<0.001
2/74*
p<0.001
0.96В±0.35 n.s.
Mean±S.D.; NC: Nasal Cannula; TM: TSE “Mask”; RA: room air; Sev Desat: severe desaturation; Vent: assisted ventilation; n.s. Not significant different; *
Significantly different from NC group
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
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S-287
ANESTH ANALG
2012; 114; S-01 – S-493
S-286.
S-287.
AN INCREASING INTEREST IN ANESTHESIA AND
ALZHEIMER’S DISEASE: PAST, PRESENT, AND FUTURE
WAIT TIMES TO SURGERY, POST-FRACTURE
AUTONOMY & IN-HOSPITAL MORTALITY IN A SUBSET
OF HIP FRACTURE PATIENTS
AUTHORS: S. Kendale, C. Scher
affiliation: Anesthesiology, New York University, New York,
NY
Introduction: Alzheimer’s disease (AD) is a neurodegenera­
tive disorder that causes dementia, with a relatively high postdiagnosis mortality. It is pathologically characterized by deposits
of beta-amyloid protein plaques and tangled Tau protein. There is a
potentially congruous link between anesthesia and AD, which may
allow research in anesthesia to further elucidate mechanisms of
AD, and vice versa. We hypothesize that that there is an increasing
interest in anesthesia and Alzheimer’s disease.
Methods: Literature search was performed using Web of
Science query [Topic=(Alzheimers) AND Topic=(anesthesia),
sorted by �Times Cited -- highest to lowest’, limited to Subject Area
of Anesthesiology] to obtain the most cited articles, and sorted by
�Publication Date’ to obtain a measure of how many articles on the
subject have been published per year. A literature review revealed
aspects that are most often investigated and have garnered the most
interest. Citation information was used to trend the overall academic
interest in AD and anesthesia. Comparison was performed using
unpaired t-test.
Results: Using the aforementioned methods, a total of 110
articles on anesthesia and AD were found. The number of unique
articles published in the last decade is statistically significantly
greater than in the previous decade (p<0.05). The topics most
often cited include relation of anesthetics to AD pathophysiology,
involvement of neurotransmitters or receptors, postoperative
cognitive dysfunction, genetic predisposition, and relation of AD to
anesthesia exposure.
Discussion: Our results suggest that there has been an
increasing interest in the relationship between anesthesia and
Alzheimer’s disease within the last decade, as there has been a
significantly greater number of publications on the topic. Most
studies focus on the effect of anesthetics on the proliferation of betaamyloid plaques, phosphorylation of Tau protein to form tangles,
and neurotransmitter pathways, in addition to memory impairment
and postoperative cognitive dysfunction.
Current recommendations on perioperative care are limited much
of the study on the subject having been conducted in vitro or in
vivo rodent models precludes generalization to a human population.
Given the increased interest in anesthesia and Alzheimer’s disease,
it may be prudent, when reasonable, to direct further research with
a focus on obtaining human data that can be applied in clinical
practice.
References:
J Alz Dis.22 Suppl 3:121-7, 2010
Anes&Analg. 108(5):1627-30, 2009 May.
J Amer Geri Soc. 42(2):198-201, 1994 Feb.
Anesthesiology 2004; 101: 703-9
J Neurosci 2007; 27: 3090-7
Acta Anaesth Scand 2003; 47: 260-6.
AUTHORS: M. Kaspervacius1, M. McMullen2, J. Murdoch2,
J. Rudan3, R. Allard2, V. Shyam2
affiliation: 1School of Medicine, Queen’s University,
Kingston, ON, Canada; 2Anesthesiology & Perioperative Medicine,
Kingston General Hospital/ Queen’s University, Kingston, ON,
Canada; 3Surgery, Division of Orthopedic Surgery, Kingston
General Hospital/ Queen’s University, Kingston, ON, Canada
Introduction: More than 264,000 elderly people suffered hip
fractures in the U.S during 2007 alone.1 Morbidity and mortality
rates are high in these patients, particularly when the wait times
to surgery exceed 48 hours.2 Reducing wait time is important
for improvement in patient care and reducing healthcare costs.
The current investigation examined wait times from emergency
presentation to surgical fixation and alterations in level of autonomy
following hip fracture in 207 patients.
Methods: Following IRB approval, data was gathered
retrospectively on all hip fracture admissions to a mid-sized teaching
center in 2010. Demographic information, time from emergency
presentation to surgery/discharge, pre-and post-fracture functional
level (as defined by level of living independence), and in-hospital
mortality rates were recorded.
Results: Of the 220 hip fracture patients admitted, charts of 13
were excluded due to missing data for precise presentation time.
Of the 207 remaining, the average age was 81 В± 9 years and 70%
were women. 79% underwent surgery within 48 hours and the
average time to discharge was 15 days. 61% of all patients lived at
home independently prior to fracture, while only 18% returned to
this functional level upon discharge. 29% lived in a long-term care
(LTC) facility prior to the fall while 44% were discharged to LTCs;
7% died in-hospital.
Discussion: Consistent with other centers, the majority of
patients at our center underwent surgery within 48 hours.3 Our
in-hospital mortality rate was also comparable to that of other
centers.4 Further prospective investigations may be warranted to
comprehensively determine the impact of time to fixation on longterm autonomy, morbidity, mortality and cost-efficacy of healthcare
delivery. Our preliminary study suggests a need to focus resources
on regaining pre-operative autonomy and living status. This would
not only greatly improve the quality of life for these patients but also
reduce healthcare costs.
References:
1.National Hospital Discharge Survey; 2007 Summary, National
Health Statistics repors. No. 29, Hyattsville, MD: National
Center for Health Statistics. 2010
2.Effect of early surgery after hip fracture on mortality and
complications: systematic review and meta-analysis. Can Med
Assoc J; 182:1609-16. 2010
3.Is operative delay associated with increased mortality of hip
fracture patients? Systematic review, meta-analysis, and metaregression. Can J Anesth; 55:135-9. 2008
4.The relationahsip between short-term mortality and quality of
care for hip fracture: A meta-analysis of clinical pathways for hip
fracture. JAGS;57(11) 2046-2054. 2009
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-288
S-288.
INFECTION PROMOTION THE DEVELOPMENT
OF POSTOPERATIVE COGNITIVE DYSFUNCTION
IN ELDERLY RATS
AUTHORS: J. Yang, L. Chen, H. Zhang, Z. Li, X. Wang, H. Wang
affiliation: Chengdu, China
Introduction: Although postoperative cognitive dysfunction
(POCD) is being increasingly studied as an important postoperative
complication of the elderly, the pathogenesis of POCD still remains
unknown. Anesthesia or operation themselves has been thought to
closely relate to POCD. This study was designed to investigate the
association between POCD and anesthesia or/and nephrectomy.
Methods: 96 aged male SD rats were randomly assigned to
four independent experimental proceedings. 50% oxygen inhalation
(group C), 1.7% isoflurane anesthesia (group I), left nephrectomy
under 1.7% isoflurane anesthesia (group S), and left nephrectomy
and LPS injection (250ug/Kg) after surgery (group L). Y maze was
applied to assess cognitive function, while locomotor activity was
tested daily in an open filed. A MILLIPLEX MAP Rat Cytokine
Panel was used to quantify levels of TNFa and IL-6 in hippocampus
and plasma on 0.25, 1, 3, 7 days post-intervention.
Results: Cognitive function of group L was severely impaired
on postoperative 3 and 4 day, locomotor activity was also depressed
of group L on postoperative 0.25 day, while no significant
differences have been found in other three groups (Fig.1). On
postoperative 0.25 day in group L, there were significant increases
in plasma concentrations of TNF-О±and IL-6 compared to those
in control group, isoflurane group and surgery group (P < 0.05),
especially plasma concentration of IL-6 which was about 56 times
higher than that of control group, and recovered to the normal on
postoperative 1 day (Fig.2,3). No significant difference in cytokines
was found in other groups. Though no statistical significance of
cytokines in hippocampus was found, increased levels of cytokines
in hippocampus of group L on postoperative 0.25 day were detected.
Discussion: LPS leads to a significant increase of plasma IL-6
on postoperative 0.25 day and an impaired cognition function on
postoperative 3, 4 day, suggesting the close relation between proinflammatory cytokines and impaired cognitive function. Isoflurane
inhalation or left nephrectomy may be not enough to impair
cognition function.
References:
Cao XZ, Ma H, Wang JK et al. Postoperative cognitive deficits and
neuroinflammation in the hippocampus triggered by surgical trauma
are exacerbated in aged rats. Prog Neuropsychopharmacol Biol
Psychiatry 2010;34:1426-32.
Bryson GL, Wyand A. Evidence-based clinical update: General
anesthesia and the risk of delirium and postoperative cognitive
dysfunction. Canadian Journal of Anaesthesia-Journal Canadien D
Anesthesie 2006;53:669-77.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
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ABSTRACTS
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S-290
ANESTH ANALG
2012; 114; S-01 – S-493
S-289.
S-290.
PERIOPERATIVE MANAGEMENT OF ELDERLY
HIP FRACTURE PATIENTS WITH CONCOMITANT
AORTIC STENOSIS
POSTOPERATIVE COGNITIVE DYSFUNCTION AFTER
FAST-TRACK HIP AND KNEE ARTHROPLASTY
AUTHORS: S. Tierney , M. McMullen , J. Murdoch , J. Rudan ,
R. Allard2, V. Shyam2
1,2
2
2
3
affiliation: 1School of Medicine, Queen’s University,
Kingston, ON, Canada; 2Anesthesiology & Perioperative Medicine,
Kingston General Hospital/Queen’s University, Kingston, ON,
Canada; 3Department of Surgery, Division of Orthopedic Surgery,
Kingston General Hospital/Queen’s University, Kingston, ON,
Canada
Introduction: Hip fractures in the elderly are common and
associated with increased morbidity and mortality, particularly
when surgery is not achieved within 48 hours.1,2 As a result,
guidelines have been set to ensure surgical repair in 48 hours or less.
Addressing co-morbidities in this population has been shown to be
equally important. Thus a balance is required to identify patients
who will benefit most from efficient preoperative optimization
practices.3 The purpose of the current investigation was to identify
those hip fracture patients with aortic stenosis (AS), and examine
the practices surrounding their perioperative care
Methods: Following IRB approval, we reviewed charts of
all patients who underwent surgical hip repair at a mid-sized
academic center during 2010. We documented the time from
admission to surgery, the clinical description of any murmur, the
echocardiographic results and/or prior diagnosis of AS, anesthetic
technique, and postoperative complications.
Results: Charts of 220 patients were reviewed. In total,
63 patients (29%) had a documented murmur. Of these, 29
(46%) received an echocardiogram on current admission. The
echocardiogram was associated with a delay to surgery (2.6 days
versus 1.5 days; p =0.05) but served to diagnose new moderate to
severe AS in 6 cases (21%). In total, AS was identified in 26 patients
(12%). Of those with AS, 69% (n=18/26) were given general
anesthesia compared to 38% of non-AS patients (n=74/194). 8%
of patients with AS (n=2) were postoperatively admitted to the ICU
compared to 5% of patients without AS (n=9). In-hospital mortality
was elevated in AS patients (15%, n=4)) compared to (5%, n=10)
those without AS.
Discussion: Our study describes the prevalence of AS in elderly
hip fracture patients. These findings may have important implications
for perioperative management of this patient population. Further
prospective investigations may be warranted to determine the costs
& benefits of instituting standardized perioperative guidelines
incorporating both early anesthesia assessment and focused
echocardiographic studies to facilitate the timely management in
this complex patient population.
References:
1.Is operative delay associated with increased mortality of hip
fracture patients? Systematic review, meta-analysis, and metaregression. Can J Anaesth; 55:135-9. 2008
2.Effect of early surgery after hip fracture on mortality
and complications: systematic review and meta-analysis.
CMAJ;182:1609-16. 2010
3.Does delay to theatre for medical reasons affect the perioperative
mortality in patients with a fracture of the hip? J Bone Joint Surg
Br; 92(6):835-84. 2010
AUTHORS: L. Krenk2,3, L. S. Rasmussen1, H. Kehlet2,3
affiliation: 1Department of Anaesthesia, Centre of Head
and Orthopaedics, Rigshospitalet, University of Copenhagen,
Copenhagen, Denmark; 2Section of Surgical Pathophysiology,
Rigshospitalet, University of Copenhagen, Copenhagen, Denmark;
3
The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty,
Copenhagen, Denmark
Introduction: Postoperative cognitive dysfunction (POCD)
is a significant problem after major surgery and associated with
increased mortality. Increasing age, low level of education, and
preoperative cognitive deficits may predispose to the development
of POCD but otherwise the pathophysiology is not clear.1
We hypothesized that a fast-track approach with reduced surgical
stress, use of opioid-sparing multimodal analgesia and a quick return
to patients’ own home may reduce incidence of early POCD. The
primary aim of this study was to evaluate the incidence of POCD
one week after fast-track hip or knee arthroplasty (THA or TKA) and
compare this to the previous found incidence in the ISPOCD study
of 25% after 1 week.2 The possible role of inflammatory reponse
(CRP), pain, opioid use, and sleep quality was also evaluated.
Methods: In a prospective multicenter study we included 225
non-demented patients > 60 years undergoing fast-track THA or
TKA. Anesthesia and postoperative analgesia were standardized
with limited opioid use. All patients underwent neuropsychological
testing preoperatively, 1 week and 3 months postoperatively with a
well-established test battery.
CRP was determined preoperatively, on postoperative day (POD)
1, 2 and at the postoperative test session. Visual Analogue Score
(VAS) for pain and the Pittsburg Sleep Questionnaire (PSQI) were
administered at the preoperative and postoperative test sessions.
Opioid use during hospitalisation was recorded.
A z-score was calculated for each test, and POCD was defined as
the presence of 2 z-scores of more than 1.96 or a cumulated z-score
of more than 1.96.3
Results: At 1 week POCD was found in 20/220 patients (9.1%
[CI 95%: 5.6-13.7%]). Mean length of stay was 2.6 days (range
1-8). Patients with POCD tended to be older with a mean age of
71.4(range 60-85) versus non-POCD patients 68.9(range 60-86)
years, (p=0.07). POCD patients showed a tendency to have a higher
MMSE score (p=0.06) and less education compared to non-POCD
patients (p=0.09). CRP, PSQI, VAS score, opioid use, duration of
anesthesia and surgery were not significantly different (p > 0.2). The
risk of developing POCD at 3 months was significantly increased
in patients with POCD at 1 week (23.6% versus 6.7%), (p=0.02).
Discussion: A marked reduction of POCD 1 week compared
to previous findings from the ISPOCD group after major surgery
was seen after fast-track THA and TKA. No significant role of
inflammation, pain response, sleep quality or opioid use was found.
References:
1. Acta Anaesthesiol.Scand. 2010;54;951-956
2. Lancet 1998;351;857-861
3. Acta Anaesthesiol.Scand. 2001;45;275-289
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ABSTRACTS
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ANESTH ANALG
2012; 114; S-01 – S-493
S-291.
EXPOSURE OF TG2576 MICE TO ISOFLURANE RESULTS
IN NO DETECTABLE INCREASE IN AОІ AMYLOID LOAD
VIA [18F]AV45 PET IMAGING CONFIRMED WITH
AUTORADIOGRAPHIC INVESTIGATION
AUTHORS: C. Rowan1, S. Kennel2, R. M. Craft1, J. Wall2,
E. Martin2
affiliation: 1Department of Anesthesiology, University of
Tennessee Graduate School of Medicine, Knoxville, TN; 2Preclinical
and Diagnostic Molecular Imaging Laboratory, Department of
Medicine, University of Tennessee Graduate School of Medicine,
Knoxville, TN
Introduction: Isoflurane may increase deposition of AОІ
amyloid, and thus may accentuate diseases such as Alzheimer’s1-3.
Tg2576 mice have a genetic predisposition to amyloid deposition,
which may increase with isoflurane exposure3. The specific aim
of this study was to examine the longitudinal effect of isoflurane
via a novel PET tracer for amyloid, [18F] AV45 (florbetapir), as
compared to histological methods. The hypothesis was that exposed
mice would demonstrate an increased plaque burden over time.
Figure 1. Mean number of plaques (standard deviation).
Methods: This protocol was approved by the Institutional
Animal Care and Use Committee at our University in Knoxville.
Twenty Tg2576 mice were aged 8 months, then randomly selected
to receive exposure (E) to 2% isoflurane for 2 hours or air only (C).
One exposed mouse died, and was replaced with a control, for a
total of 10 exposed mice.
After 24 hours, mice (5 E, 4 C) were injected with 200-300 ОјCi
(dosimeter corrected) of [18F] AV45 and sacrificed 20 minutes later
by isoflurane overdose for PET/CT scans. After scanning, half of the
brain was fixed in formalin. After 3 months, the remaining 10 mice
(5 E, 5 C) were processed as before. One paraffin slide from each
brain was exposed to I-125 labeled amyloid reactive peptide p5 for
autoradiography.
Results: Plaque number increased in both groups, but only the
increase in the control group was significant (p < 0.05). The groups
(E,C) were not statistically different from each other at either the 24
hour or 3 month time points (Fig. 1). The radiologic images at 24
hours and 3 months are shown in Figures 2 and 3. There were no
statistically significant differences in the T:M ratio of AV45 uptake
at any time point (Fig. 4).
Discussion: Our results show no difference in amyloid
deposition in isoflurane-exposed versus control Tg2576 mice
using the tracer AV45 and confirmed with autoradiography. This
result is in contrast to previous work3. The number of plaques was
small, though it did increase over time. If this represents early
neurodegeneration, isoflurane may have little effect on amyloid
deposition. Longitudinal studies using [18F] AV45 may be useful in
elucidating the effect of isoflurane on AОІ amyloid deposition.
Figure 2. PET scan using AV45
at 24 hours post-exposure to
isoflurane, vs. control.
Figure 3. PET scan using AV45
at three months post-exposure vs.
control.
References:
1.Culley DJ, et al.: Nitrous oxide decreases cortical methionine
synthase transiently but produces lasting memory impairment in
aged rats. Anesth Analg 2007: 105:83-8.
2.Xie Z, et al.: The common inhalation anesthetic isoflurane
induces caspase activation and increases amyloid beta-protein
level in vivo. Ann Neurol 2008; 64:618-27.
3.Bianchi SL, et al.: Brain and behavior changes in 12-monthold Tg2576 and nontransgenic mice exposed to anesthetics.
Neurobiol Aging 2008; 29:1002-10.
Figure 4. Mean T:M at 20 minutes post-injection of [18F]AV45 (standard
deviation).
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Liver / Transplantation
ABSTRACTS
S-297
S-297.
CISATRACURIUM DOSE-RESPONSE RELATIONSHIP IN
PATIENTS WITH LIVER DISEASE
AUTHORs: M. Z. Ali, R. Saeed, M. Abo Sedera
affiliation: Anesthesia & S-ICU, Theodor Bilharz Research
Institute, Giza, Egypt
Introduction: Cisatracurium is approximately 3 times
more potent than atracurium, devoid of histamine release and
cardiovascular side effects1 Hofmann degradation plays an important
role in cisatracurium elimination than that of atracurium.2 Patients
with liver disease exhibit abnormal response to most of muscle
relaxants. This study was designed to evaluate the dose-response
of cisatracurium in patients with mild-moderate liver impairment in
comparison to healthy subjects.
Methods: After Ethical Committee approval and patients’ written
informed consents, 80 ASA I & II patients of both sexes, scheduled
for surgical procedures requiring general anesthesia, were divided
into two groups; Group I (control group, n=40) and Group II (Liver
dysfunction group, Child’s classification A or B, n=40). Anesthesia
was induced & maintained using fentanyl, thiopentone, isoflurane
& a small initial dose (10Ојg.kg-1) of cisatracurium, the 1st doseresponse point was recorded to estimate ED80. Supplemental dose
was administered and the neuromuscular response was observed
until achievement of maximum block (2nd dose-response point).
The dose-response curve was constructed, ED50 & ED95 were
estimated. Preoperative laboratory parameters, 1st dose-response,
estimated ED80, calculated 2nd dose, 2nd dose-response, measured
ED50 & measured ED95 were recorded.
Results: The preoperative laboratory parameters (Table 1)
showed statistical significant differences (p=0.001) between the
two groups regarding serum albumin, total bilirubin, ALT, AST,
PT, PC & INR. The operative data (Table 2) showed statistically
insignificant difference between the two groups regarding the 1st
dose response (p=0.152), the estimated ED80 (p=0.886) & the
calculated 2nd dose (p=0.886) & statistically significant differences
between the two groups regarding the 2nd dose response (p=0.006),
the measured ED50 (p=0.010) & the measured ED95 (p=0.001).
Figure 1 &2 show the dose-response curves.
Discussion: These results meet those of Dahaba et al.3 in the
measured ED95 of the control group and do not go in accordance
with Cammu et al.4 who found that cisatracurium requirement
during liver transplantation was higher than in healthy patients &
recovery appeared prolonged. In conclusion, the measured ED50
& ED95 through two-doses dose-response curve technique were
clinically insignificant from using the single-dose technique. The
dose-response curve of cisatracurium in patients with liver disease
was clinically insignificant in comparison to healthy subjects.
References:
1. Anaesthesiology 1994;8:A1075.
2. Clin Pharmacol Ther. 1995;58:132-42.
3. Br. J. Anaesth. 2007;98:342-6.
4. J Clin Anesth. 2002 Mar;14:135-9.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-298
S-298.
OPTIMISING THE POST OPERATIVE PAIN CONTROL
FOR LIVER DONORS - A COMPARATIVE ANALYSIS
AUTHORS: J. Shah, J. Pasnak, J. Butterworth
affiliation: Anesthesiology, Virgnia Commonwealth University
Medical Center, Richmond, VA
Introduction: Liver transplant remains the only curative
treatment for end-stage liver diseases. Among other concerns in the
early post-operative period after a living liver donation are pain,
pain induced stress. There are limited options for post operative
pain control in these patients with impaired heaptic function and
coagulopathy. This retrospective study compares the quality of pain
management, when local anesthetic blocking the pain pathway in
the wound (OQP) or in EPI with PCA in both groups.
Methods: After approval from IRB we reviewed the charts
of patients( 1998 - 2007). From a total of 76 charts with needed
data points for review, the two groups were identified: EPI n =42
and OQP n= 34. These groups were in chronology. We created a
comprehensive tracking tool (TT) to document the PS, SS at each
12 hours and narcotic/ non-narcotic rescue medications with amount
and time administered for the first 48 hours postoperatively. Overall
post operative management was standard per institutional protocol.
Results: PS was significantly higher first 12 hours in OQP group.
Nevertheless total narcotic consumption for 48 hours was no
difference. SS was significantly higher EPI group as the were
sedated.
Discussion: The drawbacks of epidural technique in this subset
of patients include: delay of retrieval of the epidural catheter, delay
of ambulation,delay for prophylaxis for DVT, a risk of peri- spinal
hematoma ( all due to coagulopathy of partial neo liver), hypotension
(overzealous fluid resuscitation). Thus we regard the epidural
technique to have relative drawbacks in this population. Relative
to EPI the OQP with I/V PCA provided adequate pain relief(except
for for first 12 hours) and permitted early ambulation and initiation
for DVT prophylaxis. A functionally compromised lobe of liver
can metabolize small dose of narcotic with LA but we avoided
acetaminophen and NSAIDs. A compromised (function,enzymatic,
metabolic) liver may have unpredictable metabolism and clearance
of these drugs. The study recommends, a simple.safe, effective
alternative with OQP with I/V PCA for upper abdominal post
operative pain relief. Avoiding central axis catheter is feasible for
these patients.
References:
1.Anesthesia and outcome after partial hepatectomy for adult to
adult donor transplantation. Hwang GS, McCluskey SA. Current
Opin Organ Transplant 2010:15:377-382
Comparison For The Two Groups : Z Test And Standard Deviation
Categories compared EPI
vs. OQP
P = < 0.05 is
Consider significant*.
Standard
Deviation SD
The narcotic requirement (total
in mg.) post op. 48 hours
P = 0.053
SD =0.035
Average Progressive Pain
Score( PS) @ each 12 hours
period for 48 hours
P= 0.039*
SD =0.035
Average Progressive Sedation
score (SS) @ each12 hours
period for 48 hours
P= 0.02*
SD= 0.56
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-299
S-299.
THE PERIOPERATIVE CHANGES OF OXIDATIVE
STRESS AND ANTIOXIDANT CAPACITY IN
PATIENTS UNDERGOING LIVING DONOR LIVER
TRANSPLANTATION
AUTHORS: J. Kosaka, H. Morimatsu, N. Obata, T. Matsusaki, R.
Kaku, K. Morita
affiliation: Anesthesiology and Resuscitology, Okayama
University Hospital, Okayama, Japan
Introduction: Oxidative stress defined as imbalance between
oxidants and antioxidants. The involvement of oxidative stress
in the pathogenesis of several liver diseases has been extensively
investigated.
We previously demonstrated that the antioxidant capacity of
patients underwent living donor liver transplantation (LDLT) was
higher than the value of donors after induction of general anesthesia.
Simultaneously, we also showed that serum total bilirubin level had
a negative correlation with oxidative stress level and a positive
correlation with antioxidant capacity in LDLT recipients.
In addition to these results, we measured the perioperative oxidative
stress level and biological antioxidant potential in LDLT recipients.
Methods: We identified 7 adult patients underwent elective
LDLT at our University Hospital between June and November 2011.
ANESTH ANALG
2012; 114; S-01 – S-493
The d-ROMs test provides a measure of the whole oxidant capacity
of plasma against the N,N-diethylparaphenylendiamine in acidic
buffer. Such oxidant capacity is mainly due to hydroperoxides
with the contribution of other minor oxidant factors. The BAP test
allows evaluating the plasma antioxidant biological potential as the
capacity of the plasma sample to reduce ferric ions to ferrous ions.
Simultaneously, serum total bilirubin level was measured in the
central laboratory.
Results: The perioperative changes of the d-ROMs value, the
BAP value, and serum total bilirubin level were shown in Figure.
The d-ROMs value at 1 hour after I/R obviously decreased compared
to the value at start of operation and remained the same level. On the
other hand, the BAP value at 1 hour after I/R obviously increased
and after that the value decreased slowly. Serum total bilirubin level
had no significant correlation with the d-ROMs value and the BAP
value.
Discussion: As a result, oxidative stress level significantly
decreased and biological antioxidant potential significantly
increased after I/R in LDLT recipients. Serum total bilirubin level
had no correlation with the perioperative changes of oxidative stress
and antioxidant capacity. These results suggested that oxidative
stress level and antioxidant capacity after ischemia/reperfusion
might compose of several factors rather than bilirubin.
References: N/A
The metabolites by reactive oxygen species (d-ROMs) and the
plasma biological antioxidant potential (BAP) were measured at
4 points, start of operation, 1 hour after ischemia/reperfusion(I/R),
end of operation, postoperative day 1. We measured these factors
using the free radical specific evaluator FREEВ®.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-300
S-300.
INTRACTABLE SEVERE PULMONARY EDEMA DURING
ORTHOTOPIC LIVER TRANSPLANT (OLT)
AUTHORS: Y. Morita, K. Fukazawa, B. Ashrafi, E. A. Pretto
affiliation: Department of Anesthesiology, University of
Miami, Miller School of Medicine, Miami, FL
Introduction: Intractable severe pulmonary edema during
OLT can be a fatal complication. Massive production of secretions
can rapidly fill the lungs and endo-tracheal tube leading to
hypoventilation and hypoxia. We sought to characterize the
incidence, timing, and related risk factors of intractable severe
pulmonary edema during OLT.
Methods: After IRB approval, we performed a retrospective
observational survey of OLT cases performed between 2007 and
2011 at Miami Transplant Institute. Demographics of recipient
and donor, as well as intraoperative and postoperative data were
collected from patient records. We defined intractable severe
pulmonary edema as any sudden clinically significant decrease in
oxygen saturation (SpO2<90%) with or without visible pink, frothy
secretions in the endotracheal tube requiring immediate treatment,
without any radiographic evidence of pulmonary edema prior to
OLT.
Results: Of all 632 OLT patients identified, a total of 9
patients (1.4%) had severe PE during OLT. (Table) All patients
received blood transfusions before and after reperfusion (pRBC
8.9 В± 2.6 units, FFP 12 В± 3.7 units, Platelets 5.4 В± 8.6 units). Eight
cases occurred in the neo-hepatic phase (89%) and 1 case before
reperfusion (11%). Median time interval from last blood transfusion
to PE was 79 min (25-257 min). In the 8 cases that developed PE
post reperfusion, median time interval from reperfusion to PE was
34 min (15-85 min). Perioperative mortality among PE cases was
11% (1 in 9), from refractory hypoxia.
Discussion: We found that severe PE during OLT is rare
(1.4%) albeit a life threatening complication (11% mortality) and
temporally related to reperfusion. Despite a large dose of steroids
given as immunosuppressant at reperfusion, 89% of PE cases in
our study occurred within 2.5 hours of reperfusion. These results
suggest an association between PE and reperfusion but warrant
further investigation into other contributing factors such as TRALI.
References:
1. Snowden CP et al. Liver Transpl. 2000 Jul;6(4):466-70.
2. Aduen JF et al. Liver Transpl. 2003 Jul;9(7):764-71.
3. Yost CS et al. Chest 2001;119;219-223
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ANESTH ANALG
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ABSTRACTS
S-302
S-302.
WITHDRAWN.
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ANESTH ANALG
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Neuroanesthesia
ABSTRACTS
S-308
S-309
S-308.
S-309.
WITHDRAWN.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-310
S-310.
CEREBRAL ANEURYSM SURGERY AS
AMBULATORY DAY SURGERY
AUTHORS: N. Goettel, L. Venkatraghavan, P. Manninen
affiliation: Anesthesia, UHN Toronto Western Hospital,
Toronto, ON, Canada
Introduction: In the neurosurgical treatment of patients with
intracranial lesions, such as unruptured cerebral aneurysm, a need
for postoperative hospital admission has generally been assumed.
Ambulatory day surgery is an evolving specialty in line with
demands of modern medicine and economics. When hospital
stays are shortened, there less chances of complications such
as nosocomial infections, medical errors and thromboembolic
events1,2,3.
From the anesthetic point of view, the important areas of
consideration for day surgery include the choice of an suitable
anesthetic technique, assuring maximum standards of anesthetic
security, quality of care, and patient safety4,5.
The purpose of this study is to review the anesthetic management of
the patients who underwent a craniotomy for clipping of a cerebral
aneurysm on the basis of day surgery in our institution.
Methods: In this retrospective, observational study, the medical
records of all patients who were scheduled for craniotomy for
clipping of a cerebral aneurysm on the basis of day surgery were
analyzed. The data included the preoperative assessment of the
patient, the intraoperative anesthetic management, postoperative
care, and the presence of perioperative complications.
Results: In this initial report, 20 patient scheduled for day
surgery aneurysm repair were reviewed. Basic patient demographics
were similar among study groups (fig. 1).
Distribution of patients is demonstrated in Figure 2.
Reasons for unplanned postoperative hospital admission varied,
ranging from changes in level of consciousness in PACU,
bradycardia, postoperative fever, severe PONV, and generalized
motor weakness.
Discussion: Our data demonstrates that surgical repair of
unruptured cerebral aneurysms can be safely performed in an
ambulatory day surgery setting. However, the presence of an
adequate infrastructure and a backup strategy for unplanned
admission are required, since complications occur and remain
highly unpredictable.
Anesthetic care for these patients should be individually orientated,
including a thorough preoperative assessment and screening for
eligibility of day surgery, personalized intraoperative anesthetic
management, and a close collaboration of involved medical
teams into the postoperative period in order to identify and treat
complications, that may lead to unplanned hospital admission.
References:
1. Boulton M et al. J Neurosurg 2008; 108:649.
2. Grundy PL et al. Br J Neurosurg; 2008 22:360.
3. Carrabba G et al. Minim Invas Neurosurg 2008; 51:1
4. Blanschard HJ et al. Anesth Analg 2001; 92:89.
5. Gupta A. Curr Opin Anaesthesiol 2007; 20:520.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-311
ANESTH ANALG
2012; 114; S-01 – S-493
S-311.
INHIBITION OF BECLIN-1/CLASS III PI3K DEPENDENT
AUTOPHAGY BY PROPOFOL PREVENTS NEURONAL
PC12 CELLS DEATH DURING GLUCOSE AND OXYGEN
DEPRIVATION IN VITRO
AUTHORS: D. Cui1, L. Wang1, A. Qi2, Q. Zhou1, X. Zhang1,
W. Jiang1
affiliation: 1Anesthesiology, Shanghai Sixth People’s Hospital
Affiliated with Shanghai Jiaotong University, Shanghai, China;
2
Postgraduate School, Soochow University, Suzhou, China
Introduction: Autophagic cell death is a type of programmed
cell death that plays elusive roles in controlling neuronal damage
and metabolic homeostasis1. The present study was to investigate
the effects of propofol on autophagic neuronal cell death after
OGD in vitro, and to explore the molecular mechanisms by which
propofol affect autophagy processes.
Methods: Hypoxia in cultured neuronal PC12 cells was
induced by the oxygen-glucose deprivation (OGD) in vitro. The
ultrastructural changes in neuronal PC12 cells were examined
with transmission electron microscopy (TEM). The expression of
autophagy-related proteins were examined with immunoblotting.
The role of autophagy in OGD induced death of neurons was assessed
by propofol(10, 20 or 50 ВµM) and pharmacological inhibition of
autophagy with 3-methyladenine (3-MA, 20 mM), LY294002(50
ВµM) or Bafilomycin A1 (Baf, 4 ОјM) using cytotoxicity assay and
cell viability assay. To further confirm the influence of propofol
on the response of the class III PI3K-Beclin-1-Bcl-2 interaction
to OGD-induced autophagy in the presence of propofol, the cells
were transiently transfected with small interference RNA (siRNA)
against Beclin1 for 48h before OGD.
Figure 1. Ultrastructural changes in PC12 cells after OGD injury.
Results: OGD induced activation of autophagy in PC12 cells
as evidenced by the increased formation of autophagosomes and
autolysosomes; the increased production of microtubule-associated
protein 1 light chain 3; the upregulation of Beclin 1, class III PI3K
expression; and the decreased levels of cytoprotective Bcl-2 protein
in PC12 cells. Furthermore, propofol slightly but significantly
attenuated OGD-induced death of PC12 cells in a dose-dependent
manner . We also observed a significantly increased interaction
between Beclin-1 and class III PI3K, leading to Beclin-1-dependent
autophagic cell death, while the administration of propofol promoted
Bcl-2 protein expression and significantly decreased Beclin 1, class
III PI3K, LC3- II protein expression in the OGD-injured PC12 cells.
Discussion: Our data suggest that autophagy might represent a
novel mechanism by which OGD damage induces cell death, and the
inhibition of the autophagy activation and maturation by propofol
might reduce OGD injury. These results suggest that propofol
prevent autophagic neuronal cell death via down-regulation of class
III PI3K, Beclin-1, LC3- II and up-regulation of Bcl-2 signal in
vitro .Our findings suggest a novel strategy for the development of a
novel therapy for hypoxia damage.
References: 1. Am J Pathol 2008, 172:454-469.
Figure 2. Increased class III PI3K (A and C), Beclin-1 (B and D), Bcl-2 (E and
G) and LC3-II (F and H) expression in PC12 cells after OGD injury.
s-311 • continued on next page
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continued
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S-311 • continued
Figure 3. Inhibition of autophagy by propofol reduced OGD-induced PC12
cell injury.
Figure 5. The expression of autophagy-related proteins during 6 h of OGD
after transfection with Beclin-1 siRNA at specific concentration (100 nM)
for 48 h.
Figure 4. The effect of propofol on the expression of autophagy-related
proteins in PC12 cells following OGD.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-312
S-312.
INTRAOPERATIVE DEXMEDETOMINE INFUSION
ENHANCES QUALITY OF RECOVERY AND MODULATES
CYTOKINE LEVELS AFTER MAJOR SPINE SURGERY
AUTHORS: A. Y. Bekker1, S. Didehvar1, M. Urban2, R. P. Kline1,
M. M. Haile1
affiliation: 1Anesthesiology, New York University School
of Medicine, New York, NY; 2Anesthesiology, Hospital for Special
Surgery, New York, NY
Introduction: Surgery induces a variety of endocrine and
immune changes collectively known as the “stress response“
which, in turn, results in post-operative sickness behavior1.
Anesthetic management may modulate this physiological response
thus affecting the postoperative course. We hypothesized that
intra-operative administration of dexmedetomidine (DEX), a
symphatolytic agent, would reduce the stress response and improve
the quality of recovery in patients undergoing major surgery.
Methods: We conducted a prospective randomized study on
54 patients undergoing multilevel spinal fusion. Anesthesia was
maintained with either propofol/fentanyl/DEX (PFD) or propofol/
fentanyl/placebo-saline (PFS). The quality of recovery was assessed
using a 40-item questionnaire (QoR40) and a 9 question fatigue
scale (FFS) administered preoperatively, in the PACU and on
postoperative days (POD) 1, 2 and 30. Blood samples were collected
ANESTH ANALG
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at baseline, in the PACU and POD 1 and analyzed for levels of
cytokines IL-6, IL-8 and IL-10,. Data was analyzed with SPSS 19
software using mixed model analysis of variance or rank analysis.
Results: QoR40 Scores were significantly lower compared to
baseline (BSL) on POD1 and POD 2 for both groups combined
(-18.78, p<0.001; -9.61, p<0.001). QoR-40 values returned toward
BSL on POD3 (-4.389, p=0.229). Although patients in PFD group
reported superior recovery at all time points, these scores were
significantly lower in the PFS group by pairwise comparison only
on POD3 (-13.74, p=0.005). No behavioral assessments were
significantly different on POD 30. All patients reported significantly
higher level of fatigue postoperatively, but intergroup difference
in FSS was detected on POD2 only (50.0(PFS) vs 36.3(PFD),
p=0.035). Levels of cytokines Il-6, Il-8, and Il-10 levels were
significantly higher immediately after surgery and at POD 1. DEX
significantly reduced postoperative rise in IL-10, but not in IL-6 or
IL-8.
Discussion: DEX infusion during multilevel spinal fusions
improved the quality of recovery and reduced fatigue in the early
postoperative period. Moreover, it reduced plasma levels of IL-10 in
comparison to the control group. Our sample size was not sufficient
to detect differences in either the incidence of complications or
clinically relevant outcomes (e.g. hospital length of stay).
References:
1.Kelley et al. Cytokine-induced sickness behavior. Brain Behav
Immun. 2003 Feb;17 Suppl 1:S112-8.
Peri-Operative Cytokine Levels
Variable
Group
Cytokine
Baseline (pg/ml)
PACU (pg/ml)
POD1 (pg/ml)
Median (25-75%), N
Median (25-75%), N
Median (25-75%), N
IL-6
PFS (28)
PFD (26)
L (L - L), 6 L (L - 3.93), 8
3.71 (1.21-19.90), 17 9.36 49.95 (11.2-82.10), 27
(1.44-22.13), 21
60.80 (27.33-122.75), 24
Il-8
PFS (28)
PFD (26)
4.07 (1.12-6.28), 20 6.89
(4.01-14.03), 23
11.27 (2.10-23.05), 23
11.85 (7.55-23.78), 25
16.40 (6.23-24.60), 27
20.85 (12.60-31.20), 23
IL-10
PFS (28)
PFD (26)
L (L - 3.62), 8 L (L - L ), 5
19.8 (5.58-55.48), 23 L (L
-9.00), 12
9.27 (1.81-28.93), 23
13.30 (1.11-17.10), 17
“L” indicates values below the resolution of the cytokine measurement.
Peri-Operative Quality of Recovery Scores
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ABSTRACTS
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ANESTH ANALG
2012; 114; S-01 – S-493
S-313.
INHIBITION OF AUTOPHAGY BY PROPOFOL INCREASES
NEURONAL CELL SURVIVAL FOLLOWING CEREBRAL
ISCHEMIA-REPERFUSION INJURY IN RATS
AUTHORS: D. Cui1, L. Wang1, A. Qi2, Q. Zhou1, X. Zhang1,
W. Jiang1
affiliation: 1Anesthesiology, Shanghai Sixth People’s Hospital
Affiliated with Shanghai Jiaotong University, Shanghai, China;
2
Postgraduate School, Soochow University, Suzhou, China
Introduction: Propofol exerts protective effects on neuronal
cells, in part through the inhibition of programmed cell death.
Autophagic cell death is a type of programmed cell death that
plays elusive roles in controlling neuronal damage and metabolic
homeostasis1. We therefore studied whether propofol could
attenuate the formation of autophagosomes, and if so, whether the
inhibition of autophagic cell death mediates the neuroprotective
effects observed with propofol.
Methods: The rat cerebral ischemia model was induced by both
clamping the common carotid arteries and inducing hypotension for
10min. The ultrastructural changes in rat hippocampal pyramidal
neurons were observed by transmission electron microscopy (TEM)
at 1-24 h after ischemia/reperfusion (I/R). we measured the number
of pyramidal neurons in the CA1 region of the hippocampus
following severe ischemic insults at various time points using
histochemical techniques. The expression of autophagy-related
proteins were examined with immunoblotting. We also examined
the effects of propofol on the pyramidal neurons of the hippocampus
using TEM, histochemical and immunohistochemical techniques at
12 h after I/R.
Figure 1. Ultrastructural changes in rat hippocampal pyramidal neurons at 1
(AB), 3 (AC), 6 (AD), 12 (AE) and 24 h (AF) after I/R.
Figure 2. LC3-II
was detected with a
monoclonal anti-LC3-IIFITC antibody (green).
Results: TEM revealed that the formation of autophagosomes
and autolysosomes in pyramidal rat hippocampal neurons after
ischemia/reperfusion insults. The number of hippocampal
pyramidal neurons was reduced in the ischemic CA1 hippocampus
at 3 h and was further decreased at 6-24 h after ischemia. There was
a significant increase in the number of LC3 II-labeled vesicles at 1
h, which peaked at 3-6 h after I/R treatment. A western blot analysis
revealed that the autophagy-related proteins, such as microtubuleassociated protein 1 light chain 3 (LC3-II), Beclin-1 and class III
PI3K, were also increased accordingly, but cytoprotective Bcl-2
protein was decreased. The negative effects of I/R, including the
formation of autophagosomes and autolysosomes, the increase in
LC3-II, Beclin-1 and class III PI3K expression and the decline in
Bcl-2 production were all inhibited by propofol as well as these
specific inhibitors of autophagy, such as 3-methyladenine (3-MA)
at 12 h after I/R.
Discussion: Our data suggest that propofol can markedly
attenuate autophagic processes via the decreased expression of
autophagy-related proteins. This inhibition improves cell viability,
which provides a novel explanation for the pleiotropic effects of
propofol that benefit the nervous system. Our results are the first to
show propofol-attenuated autophagic cell death in hypoxic neuronal
PC12 cells and the rat hippocampus after I/R insult.
References:
1. Am J Pathol 2008, 172:454-469.
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Figure 3. The neuronal damage and histological characteristics of necrotic
neurons were assessed by a histological examination.
Figure 5. Effect of propofol on the expression of autophagy-related proteins
during I/R.
Figure 4. Propofol increased the number of the hippocampal pyramidal
neurons and decreased the expression of the LC3-II protein and the number
of lysosomes and autophagosomes in the ischemic hippocampus after I/R in
the rats.
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ABSTRACTS
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S-314.
S-315.
WITHDRAWN.
A COMPARATIVE STUDY BETWEEN
DEXMEDETOMIDINE AND CLONIDINE ON
HEMODYNAMIC RESPONSES DURING INTUBATION AND
EXTUBATION FOR INTRACRANIAL SURGERY
AUTHORs: G. S. Tomar, A. K. Tiwari, S. Ganguly
affiliation: Dept. of Anaesthesiology & Critical Care, St.
Stephen’s Hospital, New Delhi, India
Introduction: Evaluation and comparison between the
efficacy of clonidine and dexmedetomidine on hemodynamics and
stress responses during intubation and extubation in intracranial
surgery in humans.
Methods: 60 ASA (I) and (II) patients of age group 20-60 of
either sex, presenting for intracranial surgeries with Glasgow coma
scale score 14 or 15 divided in three groups of 20 each.
Group (1) – (Dexmedetomidine group): Two doses each of 0.5 mcg/
kg dexmedetomidine iv over 60 seconds; the first one immediately
just before induction of anaesthesia and other at the end of the
surgery with the last skin suture.
Group (2) – (Clonidine group): Two doses each of 3-5 mcg/kg
clonidine iv over 60 seconds the first one immediately just before
induction of anaesthesia and other at the end of surgery with the
last skin suture.
Group (3) – (Control group): Only 1-2 mcg/kg fentanyl as an
induction agent.
Observations: Systolic, diastolic and mean arterial pressure
(MAP), heart rate (HR),02 saturation (SpO2) and end-tidal CO2
concentration will be recorded 1min before intubation/extubation,
at intubation/extubation and at 1, 3, 5, 10, 20 and 30 min after
intubation/extubation; recovery time after anaesthesia.
Results: Hemodynamic stability was better seen in both group 1
and group 2 during intubation/extubation as compared with control
group 3 (p<0.05). Although fall in blood pressure (systolic, diastolic,
mean) and heart rate were maximum in group 2 after intubation/
extubation after 10 min (p<0.05) as compared with other groups 1
& 3. Recovery time was shorter with Group 1(p<0.05). SP02 and
ETC02 values were remain invariable among all groups.
Discussion: Patients in group 1(dexmedetomidine) were
subjected to more hemodynamic stability in terms of lesser fall in
BP & heart rate at and after intubation/extubation along with faster
recovery than Group 2(clonidine) and control group 3.
References:
1.Safety and efficacy of dexmedetomidine in neurosurgerical
patients. Aryan HE, Box KW, Ibrahim D, Desiraju U, Ames CP.
Brain Injury, 2006;20(8):791-798.
2.Effects of a2- adrenoceptor agonists on perinatal excitotoxic
brain injury: comparison of clonidine and dexmedetomidine.
Vincent L, Jean M, Hugo L, Marie DJ, Philippe E, Pierre G.
Anesthesiology, 2002;96(1):134-141.
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ABSTRACTS
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S-317
S-316.
ANESTH ANALG
2012; 114; S-01 – S-493
S-317.
ANESTHESIA FOR DEEP BRAIN STIMULATION
AUTHORS: J. N. Monteiro , M. Sankhe
1
2
affiliation: 1Anesthesiology, PD Hinduja National Hospital
& Medical Research Centre, Mumbai, India; Neurosurgery, PD
Hinduja National hospital & Medical Research Centre, Mumbai,
India
Introduction: The aim of this study was to evaluate the
safety, efficacy and patient acceptance of the technique conscious
sedation and the scalp nerve block in our patient population
undergoing “Deep brain stimulation” surgery.
Methods: After hospital ethics committee approval was
obtained written informed consent was obtained from the patients
undergoing an elective “Deep Brain Stimulation” surgery. 70
consenting patients were enrolled in our prospective observational
study that commenced in 2001 and continues through to date.
Anesthetic Considerations: The challenge for the
anesthesiologist is to provide adequate analgesia, sedation,
hemodynamic stability in an “awake”, cooperative patient for
neurological testing.The essential components of success outlined
are establishing rapport with the patient, careful patient positioning
and coordinated teamwork. Attention directed toward maintenance
of peri-operative drug therapy, associated physiological disturbances
and potential adverse drug interactions.
Anesthetic technique: General anesthesia is administered
in uncooperative patients; while local anesthesia as a scalp nerve
block with conscious sedation is an option in adults. After surgery,
patients spend the first postoperative night in the ICU (intensive
care unit) for precautionary purposes. This is followed by the
programming of the stimulators.
Results: The indications, contraindications, patient selection
criteria, demographic profiles, patient preparation and intraoperative
complications encountered are described. 70 patients underwent
the procedure since 2001 when the first case was performed in our
institution the data was collected till date.
Discussion: Conscious sedation combined with a scalp block
is an extremely effective, safe anesthetic technique with a low
complication rate, uniform patient tolerance and it facilitates awake
neurological testing. It carries low morbidity and mortality rates and
minimizes ICU and total hospital stay. Safe anesthesia depends on
team work, well designed protocols and systems not just individual
competence and care.
References:
Anesthesia for Deep Brain stimulation and in patients with
implanted neurostimulator devices BJA 2009 Poon 152-165
Clinical experience with Dexmedetomidine for implantation of
Deep Brain stimulators Anesthesia Analgesia 2006 Rozet I 1224-
INCIDENCE AND RISK FACTORS FOR ACUTE KIDNEY
INJURY AFTER MULTILEVEL SPINE SURGERY
AUTHORS: D. Colquhoun, W. McKinney, A. Smith, M. Durieux,
J. Raphael, B. Naik
affiliation: Charlottesville, VA
Introduction: Acute kidney injury (AKI) is a risk factor for
perioperative morbidity and mortality.1 Risk factors for developing
AKI are varied and include the presence of pre-existing kidney
disease and the nature of the surgery. The identification of even
mild degrees of postoperative renal dysfunction is important, as it is
associated with both short and long term morbidity and mortality.2
Complex spine surgery is associated with significant perioperative
hemodynamic and hemostatic perturbation. These changes can
compromise renal perfusion and increase the risk of developing
AKI. We conducted a retrospective study to determine the incidence
of and risk factors for AKI in multilevel spine surgery
Methods: After IRB approval, Current Procedural Terminology
(CPT) codes were used to identify subjects undergoing two or more
levels of spine surgery with or without instrumentation between
June 2008 and July 2011. Demographic data included age, gender
and race. Subjects with pre-existing chronic kidney disease (CKD)
requiring renal replacement therapy were excluded. The presence
of preoperative CKD, hypertension, diabetes and amount of intraoperative blood loss were recorded. Operative extent was defined
as < 4, 4-8 and > 8 surgical levels. AKI was defined by the RIFLE
classification using the glomerular filtration rate (GFR). The GFR
was calculated using the Modified Diet In Renal Disease formula.
A baseline preoperative and the lowest postoperative GFR in the
first seven days were recorded. The risk of AKI was analyzed by
a Fisher exact test where appropriate. Statistical significance was
defined as P<0.05.
Results: Six hundred and fifty four patients, with 63%, 17%
and 20% having <4, 4-8 and > 8 levels of surgery respectively
were identified. Out of the 654 patients, 27 (4.1%) developed AKI
as defined by the RIFLE classification. Of these, 23 (3.5%) fell in
the RIFLE-risk category while 4 (0.6%) developed RIFLE-injury
(Graph 1). No patient developed RIFLE-failure or required renal
replacement therapy. Preoperative hypertension was associated
with an increased risk of developing postoperative AKI (p=0.029).
Gender, CKD and diabetes were not associated with postoperative
AKI (Table1). No association was found between age, surgical
levels and intraoperative blood loss and the risk of developing AKI.
Discussion: This study demonstrates a low incidence of AKI
in complex spine surgery. The majority decrease in GFR fell into
the RIFLE-risk category with only a small percent of patients in
the RIFLE-injury group. Hypertension was the only risk factor
associated with postoperative AKI. Complex spine surgery carries
a low risk of postoperative AKI.
References:
1. Am J Kidney Dis 2009; 53: 961
2. Ann Surg 2009; 249: 851
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ABSTRACTS
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S-318.
WITHDRAWN.
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ANESTH ANALG
2012; 114; S-01 – S-493
S-319.
POST-SPLENECTOMY SHORT-TERM MEMORY
DYSFUNCTION IN MICE IS ATTENUATED BY DELAYED
TREATMENT WITH SLK, A NOVEL ANTI-PLATELET
ANTIBODY
AUTHORs: D. Shilo1, Y. Li2, A. Y. Bekker1, T. M. Wisniewski2,
M. M. Haile1
affiliation: 1Anesthesiology, NYU Langone Medical Center,
New York, NY; 2Neurology, NYU Langone Medical Center, New
York, NY
Introduction: Post-splenectomy mice demonstrate a delayed
loss of short-term memory (STM) possibly associated with neuroinflammation1. The anti-GPIIIa49-66 antibody, SLK (derived from
patients with HIV immune-related thrombocytopenia), induces
the fragmentation of activated platelets2 which play a role in the
inflammatory response. We hypothesized that post-splenectomy
SLK would attenuate CNS dysfunction.
Methods: After IACUC approval, 60 Swiss-Webster mice (3035gms, 6-8wks) were randomized into 2 groups that underwent
splenectomy and IV injections 3h post-op: (1) Control Group
received Saline & (2) Experimental Group received 400ug SLK.
Splenectomy was performed under 2.5% Isoflurane with a 1 cm
incision, ligation with 6-0 silk, and closure with 4-0 silk. Controls
had Object Recognition Testing (ORT) once on either day 1, 5, 9,
or 14.Experimental mice had ORT once on either Day 5 or 9. ORT
measures STM by exploiting the tendency of mice to explore novel
objects in the presence of a familiar object. During learning, mice
are placed in an arena with two identical objects for 15m. 1h later a
familiar object is replaced with a novel object for a 3m testing trial.
When STM is impaired, equal time is devoted to both objects. When
STM is intact, more time is spent exploring the novel object. The
Recognition Index (RI) is the ratio of time spent exploring the novel
object to the total time spent exploring both objects.
Figure 3. Effects of the central (intracisternal) administration of propofol
(PROP - 100 Вµg; solid arrows, first and second injection) or intralipid (LIPID;
solid arrows, first and second injection) on the mean arterial pressure before
and after central (intracisternal) opioid receptor blockade with naloxone
(NAL - 100 Вµg; dashed arrow) in pentobarbital-anesthetized Wistar rats. *P <
Results: Saline mice demonstrated impaired STM on Day 5
and normal STM at other time points. Using ANOVA, we rejected
the null hypothesis that the distribution of STM values for all
control were equal (F=6.195, p=0.002). In pairwise comparisons of
controls, day 5 was different than all other days (d1,d9, d14; p<0.05)
after Tukey’s correction for multiple comparisons. Examining both
groups (SLK, con) on days 5 & 9, we found SLK different than
control on day 5 (p=0.006, Tukey’s correction; Anova, F = 4.4;
p=0.01). Thus, SLK mice showed intact STM on Days 5 & 9.
Discussion: Post-operative CNS dysfunction may be secondary
to platelet-mediated neuro-inflammation. Post-splenectomy treatВ­
ment with SLK, which inhibits activated platelets, prevented
short term memory loss. SLK warrants further investigation in the
treatment of inflammation-associated cognitive dysfunction.
References:
1.Haile et al. The COX-2 Inhibitor Meloxicam Ameliorates Short
Term Memory Dysfunction and Modulates Microglia Activation
after Splenectomy in Adult Mice. ASA Abstract, Oct 2011.
2.Wisniewski et al. Dissolution of arterial platelet thrombi in
vivo with a bifunctional platelet GPIIIa49-66 ligand which
specifically targets the platelet thrombus. Blood: 2010 Jun 4.
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ABSTRACTS
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S-321.
MICRORNA-181 REGULATES BOTH CHAPERONE
GRP78 AND BCL-2 FAMILY PROTEINS CHANGING
OUTCOME FROM ISCHEMIC BRAIN INJURY IN
VITRO AND IN VIVO IN MICE
AUTHORS: R. Giffard1, Y. Lu1,2, L. Xu1, L. A. Voloboueva1,
Y. Ouyang1
affiliation: 1Department of Anesthesia, Stanford University
School of Medicine, Stanford, CA; 2Department of Anesthesia,
Beijing Tiantan Hospital, Capital Medical University, Beijing,
China
Introduction: The discovery of microRNAs (miRNAs) has
added a new level of posttranscriptional regulatory control to our
understanding of the regulation of gene expression. Previous studies
indicate that members of the HSP70 family of molecular chaperones
and pro-survival members of the Bcl-2 apoptosis regulatory family
are major cellular protective mechanisms that can prevent stress
induced cell death. Chaperones function in all cellular compartments
and reduce oxidative stress and maintain correct folding of proteins.
When stress is more severe cells decide whether to undergo
apoptotic cell death or not, with the balance between pro-death and
pro-survival members playing a critical role in determining cell fate.
Using computational miRNA target prediction algorithms, we found
that miR-181 could potentially target the 3’UTRs of both HSP70
and Bcl-2 family members.
Methods: The luciferase assay used renilla luciferase reporter
vector phRL-TK1. Primary astrocytes were prepared from mouse
brain, injury was induced by glucose deprivation (GD). One day
after intracerebroventricular injection of plasmid or antagomir adult
male mice were subjected to transient suture occlusion of the middle
cerebral artery, infarct volume assessed by cresyl violet staining and
protein levels by western1.
Results: We cloned miR-181 and its mutant into a miRNA
vector and the 3’UTRs of HSP70 and Bcl-2 family members into
the reporter vector. Targets GRP78, Bcl-2, Mcl-1, and Bim showed
reduced luciferase activity with wild type but not with mutated
miRNA sequence. While Bcl-2 and Mcl-1 are anti-apoptotic, Bim
is a BH3 only proapoptotic protein. We altered endogenous miR181 levels in primary astrocyte cultures and found reduction of
miR-181 provides protection against GD-induced brain cell death,
accompanied by an increase in GRP78, Bcl-2, and Mcl-1 proteins.
mir-181a thus suppressed 3 well known protective proteins,
consistent with overall worsened survival. We did not detect Bim
protein in our cells. When we modulated miR-181 levels in mice
prior to transient cerebral ischemia, we observed decreased infarct
volumes when we reduced levels of miR-181a.
Discussion: Our results show that miR-181 can target both a
member of the HSP70 family, the endoplasmic reticulum molecular
chaperone GRP78, and 3 members of the Bcl-2 apoptotic regulatory
family and thereby contribute to the regulation of ischemic brain cell
injury. Overall increased miR-181 increases injury, while reduction
leads to reduced injury. Manipulating levels of miRNAs provides a
novel approach to neuroprotection.
References:
1.Ouyang YB et al. Neurobiology of Disease, 45, 555-563, 2012.
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Obstetric Anesthesia
ABSTRACTS
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S-327.
EXIT PROCEDURE ON-CALL: A CASE OF SUCCESSFUL
INTERDISCIPLINARY COMMUNICATION
AUTHORs: K. Stiles, G. Shih
affiliation: Anesthesiology, University of Kansas Medical
Center, Kansas City, KS
Introduction: The ex utero intrapartum treatment (EXIT)
procedure is performed in cases of life threatening fetal airway
anomalies. It allows for airway management of the fetus prior to
separation from maternal circulation. It is an uncommon procedure
that demands coordination between multiple specialties.
Many challenges to effective communication exist in medicine.
Health care teams are dynamic in nature with membership often
changing on a daily basis. Failures in communication are often the
root cause in sentinel events. Lack of communication increases the
risk of surgical errors. Coordination of an EXIT procedure requires
communication not only between specialties, but also among
colleagues on each team.
Methods: n/a
Results: Our patient was a 35 yo G2P0100. She presented to MFM
with history of a cesarean delivery at 31 weeks in Indonesia and
neonatal death within hours after delivery due to a presumed airway
anomaly. The current pregnancy was complicated by AMA, GDM,
polyhydramnios and fetal retrognathia. She was admitted for an
amnioreduction at 33 6/7 weeks.
Consultations were made to ENT, plastic surgery, pediatrics and
anesthesiology. Along with MFM, ENT and nursing, the obstetrical
anesthesiologist was present for discussion and planning of the
EXIT procedure. Cesarean delivery at 36 2/7 weeks was scheduled
as a first case on a weekday. All other anesthesia staff were informed
of this patient and the upcoming procedure.
The patient presented with PROM at 35 4/7 weeks on a weekend
morning. The primary MFM and OB anesthesiologist were out of
town. On-call staff from each of the specialties were aware of this
case because of prior communication. Although this particular team
had never met, they were able to formulate a plan the morning of
the procedure. The patient underwent c/s under general anesthesia.
The infant was unable to be intubated by direct laryngoscopy and
tracheostomy was successfully performed. The baby girl was
delivered 26 minutes after incision, with APGARS 5 & 8. She was
transported to the NICU in stable condition.
Discussion: This case illustrates successful interdisciplinary
communication. Deliberate attempts at communication among
specialties turned a potentially emergent situation into a controlled
procedure with a positive outcome for both patients. This case also
demonstrates how communication within our specialty allowed for
delivery of a successful anesthetic for both mother and infant.
References:
Teamwork and patient safety in dynamic domains of healthcare: a
review of literature. Acta Anaesthesiol Scand 2009; (53): 143-151
Interdisciplinary teamwork in hospitals: A review and practical
recommendations for improvement. Journal of Hospital Medicine.
doi: 10.1002/jhm.970
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ABSTRACTS
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S-328.
THE EFFECT OF PROPHYLACTIC ADMINISTRATION
OF DEXAMETHASONE FOR NAUSEA OR VOMITING
IN GYNECOLOGICAL OR OBESTETRIC SURGERY:A
SYSTEM REVIEW AND META-ANALYSIS IN
RANDOMIZED CONTROLLED TRIALS
AUTHORs: F. Z. Hua
affiliation: Nanchang, China
Introduction: Dexamethasone has been commonly used
in gynecological and obstetric surgery to prevent postoperative
nausea or vomiting (PONV). However, the optimal dose and
time of administration has not been comprehensively quantitative
analysis yet. To assess the influence of prophylactic administration
of dexamethasone on PONV for patients undergoing gynecological
or obstetric surgery
Methods: We searched the databases of MEDLINE (from
January 1966 to November 2011), EMBASE (from January 1985 to
November 2011), and the Cochrane Central Register of Controlled
Trials (up to November 2011). Selection criteria: Randomized
controlled trials (RCTs), which compared the influences between
the single dose dexamethasone group and placebo group on PONV,
were included in this study. Data collection and analysis: the primary
data of the incidence of postoperative nausea (PON), postoperative
vomiting (POV), PONV, rescue antiemetic and adverse events was
extracted. Three authors independently extracted the data, and
evaluated the quality of studies by Jadad scale.
ANESTH ANALG
2012; 114; S-01 – S-493
Results: Twenty-four RCTs with 2,246 patients met the
eligibility criteria, and were included in this meta-analysis
eventually. The results of the system review suggested that: (1)
less than 4.0 mg dose of dexamethasone did not have substantial
effects on preventative PONV; (2) the dose-range of 5-10 mg had
effects on preventative PONV; (3) the 8-10mg dose dexamethasone
preoperatively administrated in patients who had history of PONV or
motion sickness, and underwent general anesthesia or laparoscopic
surgery had better effect on PONV than postoperatively, but the
effects of 5mg dose dexamethason in post-operation was better than
in the period of pre-operation; (4) The risk of adverse events was not
significantly different between dexamethasone groups and control
group.
Discussion: The 5mg dose of prophylactic dexamethasone
administration was the minimal effective dose for preventing
PONV for gynecological and obstetric surgery; the 8-10mg dose of
dexamethaosne for patients who were high risk, general anesthesia,
or laparoscopic surgery was optimal and recommended.
References:
1McCracken G, Houston P,and Lefebvre G (2008)J Obstet
Gynaecol Can 30: 600-607, 608-616
2 Fujii Y, Tanaka H,and Toyooka H (1995) Can J Anaesth 42: 387390
3 Yuksek MS, Alici HA, Erdem AF, et al (2003) J Int Med Res 31:
481-488
The forest plot showed the effect of prophylactic administration of different doses of dexamethasone on the postoperative nausea or
vomiting (PONV). It indicated that less equal 4mg dose did not have any effects on PONV; 5mg and 8-10mg dose had significantly effect
on PONV. Fixed effect model was used. The squares and horizontal lines corresponded to the study-specific RR and 95% CI. The area of
the squares reflected the study-specific weight. The diamond represented the pooled RR and 95% CI.
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PONV at different dose funnel plot examining the publication bias. Each point represented a trial.
SE=Standard Error, RR=Relative Risk. The funnel plots were relatively symmetrical, suggesting the
absence publication bias.
The forest plot showed the effect of prophylactic administration of different doses of dexamethasone on PONV between Laparoscopic
surgery and traditionally open surgery. It indicated that less equal 4mg dose did not have substantially effect on PONV; the single 5mg
dose had effect by traditionally open surgery on PONV; and 8-10mg dose had significantly effect on PONV. Fixed effect model was used.
The squares and horizontal lines corresponded to the study-specific RR and 95% CI. The area of the squares reflected the study-specific
weight. The diamond represented the pooled RR and 95% CI.
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ABSTRACTS
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ANESTH ANALG
2012; 114; S-01 – S-493
S-329.
EPIDURAL AND INTRATHECAL DRUG INJECTION
ERRORS IN OBSTETRIC ANESTHESIA AND ANALGESIA
(1981-2011)
AUTHORS: S. Patel , S. Patel
1
2
affiliation: 1Anesthesia, The Pennine Acute Trust, Rochdale,
United Kingdom; 2Obstetrics and Gynaecology, The Royal Bolton
Hospital, Bolton, United Kingdom
Introduction: Drug admnistration errors can lead to
devastating consequences. Our aim was to review reported cases of
wrong drug given into epidural (ED) or intrathecal (IT) route during
pregnancy or immediate postpartum period.
Methods: We searched medline database and google scholar
using the search terms �epidural drug error’, �accidental epidural
drug injection’, �inadvertent epidural drug injection’ for the period
of 1981-2011. Search was also done using intrathecal word. Drugs
involved, clinical settings and possible reasons for error were
recorded. Maternal immediate, short (< 24 hrs) and longterm (post
postpartum period) consequences were noted. Where applicable,
labour and neonatal outcome were noted.
Results: 13 case reports met the criteria (table 1). No direct
effects on the course of labour, mode of delivery or neonatal
outcome were reported. In two cases spinal failed and GA was
needed. On three occasions, ED �failed’ to work and was recited in
2 cases before realizing the error. Epidural infusions of magnesium
sulphate (MgSO4) (3 cases) and paracetamol were given for few
hours (table 1). Flaccid paraplegia and autonomic disturbances
(1 case) and severe cardiomyopathy requiring IPPV and IABP (1
case) occurred after potassium chloride (KCL) was injected into ED
space. In a case of Tranexamic acid woman developed convulsions,
refractory VF and died in few hours. There were no long term
residual neurologic or systemic consequences in any other case.
Drugs involved in mishap
Drug (reference)
Clinical setting
2ml 50% MgSO4 bolus
(1)
spinal for cervical
suturing
3 g MgSO4 over 2 hrs (2)
ED for LP
10 ml 15% KCL (3)
end of elective LSCS
50 mg Ephedrine in 10 ml soon after ED test dose
bolus (4)
for LP
50 mg Ephedrine in 10 ml
bolus (5)
Unspecified amount of 0.5
ml Metchlopramide (6)
14.5 mg of Labetalol (7)
1 ml Ondansetron (8)
8.7 g and 9.6 g MgSO4
over few hrs - 2 different
patients (9)
Unspecified amount
of15% KCL (10)
Unspecified amount of
Tranexamic acid (11)
400 mg of paracetamol
over 3 hrs (12)
during top up 11 hrs
after ED for LP
spinal for elective
LSCS
immediate postpartum
tubal ligation via
spinal catheter
ED for emergency
LSCS
Drug supposed to
be given/used
heavy xylocaine
2% 2ml
infusion was piggy
backed with LA
infusion
NS
LA with fentanyl
Ropivacaine with
fentanyl
Fentanyl. (LA was
injected separately)
IV labetalol to
treat intraoperative
high BP
Fentanyl (with LA)
soon after ED test
dose for LP
LA with Fentanyl
ED for elective LSCS
NS
spinal for emergency
LSCS
soon after test dose ED
infusion started for LP
LA
Levobupivacaine
LP- labor pain, ED=epidural, LA=Bupivacaine, NS=normal saline
Discussion: Ampoule error1,3,6,10,11, failure to check drug8,9,
syringe swap4,5, infusion bags confusion9,12 and catheter mistaken
for IV line2,7 were the main causes for the mistake. In addition,
other factors such as lack of education, junior staff, fatigue, poor
lighting, hospital supply and storage were reported as contributory
factors. Distraction during the procedure (e.g. during labour) and
urgent and unpredictable nature of work might have played the role.
When epidural is not working, wrong drug administration should
be included in differential diagnosis. High vigilance could have
prevented errors. Some other measures advocated for prevention
include use of coloured labels for drugs and infusion bags, separate
drug trays, prefilled syringes labelled with electronic barcodes,
different connectors for epidural and intravenous injections, policies
or protocols for checking anaesthetic and other drugs.
References:
1. S Afr Med J 1985;68:367
2. Anesth Analg 1987;66:1020
3. Can J Anes 1988;35:361
4. IJOA 2004;13:58
5. J Cli Anesth 2004;16:74
6. Rev Bras Anestesiol 2004; 54:663
7. IJOA 2005;14:340
8. J Cli Anesth 2006;18:216
9. IJOA 2006;15:63
10.Int J Cardi 2008;124:e14
11.APSF newsletter, 2010 spring
12. IJOA 2011;20:192
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-330
S-330.
BETA-2 ADRENERGIC RECEPTOR POLYMORPHISMS
AFFECT LABOR PAIN IN NULLIPAROUS WOMEN
AUTHORS: A. S. Terkawi1, W. M. Jackson2, S. Hansoti1,
R. Tabassum1, P. Flood3
affiliation: 1Department of Anesthesiology, King Farad
Medical City, Riyadh, Saudi Arabia; 2Department of AnesthesiВ­
ology, Columbia University, New York, NY; 3Department of
Anesthesiology, University of California, San Francisco, San
Francisco, CA
Introduction: Labor pain differs substantially among
parturients. It varies secondary to demographic, clinical, and
psychological factors. Genetics may play an important role in
baseline sensitivity to pain1. ОІ-2-adrenergic receptor genotype is
a risk factor for chronic pain and influences sensitivity in human
experimental pain testing2. We hypothesized that polymorphisms in
this gene may influence the development and intensity of labor pain.
Methods: 250 parturients were prospectively enrolled with
written informed consent and IRB approval. Obstetrical and
anesthesia treatment data were recorded with respect to time. DNA
was prepared from blood samples and genotyped at two common
non-synonymous SNPs in the ОІ-2AR gene (Sequenom; Danvers,
MA). Labor pain was recorded as an NRS score and modeled as
a sigmoidal function with respect to cervical dilation. The effect
of demographic, genetic, and clinical covariates on labor pain was
assessed with NONMEM using PLTTools with previously described
methods3.
Results: Parturients who carry G at the 27th amino acid ОІ2AR
developed labor pain more rapidly that parturients with the common
allele (Fig. 1). Induction was associated with more pain in early
labor. Artificial rupture of membranes, augmentation with oxytocin
and younger age were associated with more rapid development of
labor pain (Fig. 2). Patients treated with meperidine had a more
rapid development of pain than patients who received no analgesic
(Table 1).
Discussion: Parturients who express at least one minor allele
at ОІ2AR-27 develop pain more rapidly than other parturients. This
polymorphism is associated with lower levels of receptor expression
and greater sensitivity to pain in quantitative sensory testing. These
factors can be separated from expected effects of labor induction,
augmentation, membrane rupture and analgesic treatment using
mixed effects models. These finding suggest that autonomic tone
may play a role in labor pain.
References:
1.J Lotsch and Geisslinger. Current evidence for a modulation of
nociception by human genetic polymorphisms Pain 132 (2007)
18-22
2.L Diatchenko, AD Anderson, GD Slade, RB Fillingim, SA
Shabalina, Tomas J. Higgins, S Sama, I Belfer,D Goldman,
MB Max, BS Weir and W Maixner. Three Major Haplotypes
of the ОІ-2 Adrenergic Receptor Define Psychological Profile,
Blood Pressure, and the Risk for Development of a Common
Musculoskeletal Pain Disorder. American Journal of Medical
Genetics 141B (2006) 449-462
3.Debiec J, Conell-Price J, Evansmith J, Shafer SL, Flood P.
Mathematical modeling of the pain and progress of the first stage
of nulliparous labor. Anesthesiology 2009;111:1093-110.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-331
S-331.
EPHEDRINE VS PHENYLEPHRINE FOR THE
MANAGEMENT OF HYPOTENSION DURING SPINAL
ANESTHESIA FOR CESAREAN SECTION: AN UPDATED
META-ANALYSIS
AUTHORS: F. Lin1, M. Qiu2,1, X. Ding2, Q. Li1
affiliation: 1Department of Anesthesiology, Shanghai Tenth
People’s Hospital of TongJi University, Shanghai, China; 2First
Clinical College, Nanjing Medical University, Nanjing, China
Introduction: Anna Lee1 performed a systematic review
comparing the efficacy of ephedrine and phenylephrine for
management of hypotension in 2002, and there a lot of well-designed
trials with controversial results have been published. Therefore, an
updated meta-analysis is necessary.
Methods: Databases of MEDLINE, EMBASE and the Cochrane
Central Register of Controlled Clinical Trials were searched (updated
on September 26th 2011). Pooled risk ratio (RR) or standard mean
difference (SMD) and their 95% confidence intervals (95% CI)
were calculated for the incidence of intra-operative hypotension or
umbilical blood pH values. And, a RR<1 or an SMD>0 represents
that ephedrine is associated with less hypotension or higher
umbilical blood pH values compared with phenylephrine.
Results: A number of 15 trials and 742 parturients under elective
caesarean section were analyzed. With prophylactic intravenous
use, ephedrine and phenylephrine did not differ significantly in
the incidence of hypotension (RR = 1.08, 95% CI: 0.66, 1.75),
umbilical arterial pH values (SMD = -0.38, 95% CI: -1.67, 0.92)
or venous pH values (SMD = -0.14, 95% CI: -0.50, 0.21). The
same results were achieved when given intramuscularly. When
used to treat hypotension, ephedrine and phenylephrine did not
differ significantly in hypotension (RR = 0.79, 95% CI: 0.40, 1.56),
while parturients received phenylephrine had neonates with higher
ANESTH ANALG
2012; 114; S-01 – S-493
umbilical arterial pH values (SMD = -1.32, 95% CI: -2.33, -0.31)
(Figure 1) and venous pH values (SMD = -0.79, 95% CI: -1.09,
-0.49) (Figure 2) than those given ephedrine.
Discussion: Prophylactic use of ephedrine and phenylephrine
were equally effective for the prevention of maternal hypotension
in cesarean section under spinal anesthesia; when used to treat
hypotension, phenylephrine was superior to ephedrine with higher
umbilical blood pH values.
References:
1.Anna Lee, Warwick D. Ngan Kee, Tony Gin. A Quantitative,
Systematic Review of Randomized Controlled Trials of
Ephedrine Versus Phenylephrine for the Management of
Hypotension During Spinal Anesthesia for Cesarean Delivery.
Anesth Analg 2002; 94: 920-6.
Meta-analysis Results Summary
Prevention
Intravenous Intramuscular
Hypotension
Umbilical
Arterial pH
Umbilical
Venous pH
RR (95% CI)
1.08 (0.66,
1.75)
1.24 (0.71,
2.18)
Heterogeneity
<0.01
Treatment
0.79 (0.40,
1.56)
0.39
0.7
-0.38 (-1.67,
SMD (95% CI)
0.92)
N/A
-1.32 (-2.33,
-0.31)
Heterogeneity
N/A
<0.01
<0.01
-0.14 (-0.50, -0.23 (-0.59, -0.79 (-1.09,
SMD (95% CI)
0.21)
0.14)
-0.49)
Heterogeneity
0.79
0.79
0.48
RR: risk ratio; SMD: standard mean difference; a RR<1 or an SMD>0
represents that ephedrine is associated with less hypotension or higher
umbilical blood pH values compared with phenylephrine.
Figure 1 Comparison of Umbilical Arterial pH Values
Figure 2 Comparison of Umbilical Venous pH Values
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-332
S-333
ANESTH ANALG
2012; 114; S-01 – S-493
S-332.
S-333.
INTRAUTERINE FETAL KETAMINE FOR IMMOBILITY
DURING CORDOCENTESIS AND FETAL TRANSFUSION
DOES THE ADDITION OF ONDANSETRON TO IV-PATIENT
CONTROLLED NALOXONE FURTHER IMPROVES
POST C/S EPIDURAL -FENTANYL INDUCED PRURITUS
TREATMENT?
AUTHORS: S. K. Patteson, M. Graham
affiliation: Anesthesiology, University of Tennessee Medical
Center, Knoxville, TN
Introduction: N/A
AUTHORS: Shruti Shah1, Shaul Cohen1, Salvatore Zisa1, Branson
Collins1, Purvi Patel1, Sylvia Barsoum1
affiliation:Anesthesiology, RWJMS-UMDNJ, New Brunswick,
NJ
Methods: N/A
Challenging Case Report: A 21 yo G4P2 at 31 weeks
gestation presented for percutaneous umbilical cord sampling
and transfusion secondary to fetal anemia. The patient was
taken to the operating room and placed supine with left lateral
uterine displacement. Standard ADA monitors were applied and
fetal monitoring utilized throughout the procedure. Ultrasound
identified fetal position, umbilical cord, and a posterior placenta.
The abdomen was prepped and draped in sterile fashion and the
skin and subcutaneous tissue infiltrated with local anesthetic. The
obstetrician attempted cordocentesis. Despite local anesthetic the
patient expressed extreme discomfort and intense cramping at
the insertion site. Patient received fentanyl 100 mcg IV without
relief, promethazine 12.5 mg IV for nausea, and an additional
200mcg fentanyl IV incrementally. Maternal movement and
discomfort became more pronounced. In total, 500 mcg fentanyl
was incrementally administered without effect on the patient’s pain
or discomfort. In addition, fetal movement impaired proper needle
placement. The obstetrician requested fetal immobility to facilitate
fetal transfusion. After considering options, a decision was made for
the obstetrician to administer IM ketamine to the fetus at 7.5 mg/
kg estimated weight via cordocentesis needle. Maternal anxiety and
pain prevented completion of the procedure and general anesthesia
was induced. Blood sample was not obtained as the obstetrician
elected to proceed with fetal transfusion by transperitoneal
approach. Mother and fetus tolerated the procedure well after
general anesthesia.
Multiple large cordocentesis studies have been conducted evaluating
technique, insertion site, gestational age, and complications1,2.
Although some mention fetal movement, none address intervention
for it. Fetal analgesia with IV fentanyl has been implicated in use for
intrauterine procedures.3 FDA package insert labeling of vecuronium
and rocuronium approve IV use only. In our case, an active fetus
prevented safe access to placental vessels and fetal intraabdominal
cavity. Ketamine’s excellent safety profile and rapid onset may
provide a viable option in a similar clinical situation.
Results: n/a
Discussion: n/a
Introduction: Patient-administered IV naloxone has been
applied routinely for the treatment of epidural-fentanyl-induced
pruritus after C/S. Ondansetron is effective to treat epidural opioidinduced pruritus1.
Methods: OBJECTIVE: We determine whether the addition
of ondansetron to our IV-patient controlled naloxone solution can
further improve the treatment of post C/S pruritus. METHODS:
Fifty women scheduled for elective C/S under epidural lidocaine
2%, fentanyl 5 mcg/ml and epinephrine 5 mcg/ml without parentral
opioids were studied. Upon arrival at PACU, patients received
epidural-PCA fental-ropivacaine-epinephrine and were randomized
to one of two groups. Group I: (n=25) received patient-administered
IV naloxone via PCA device (Abbott Life-Care, Abbott Laboratories,
Chicago IL). Each patient could receive naloxone IV-patient
controlled dose of 0.04 mg ( in 5 ml) and a lockout time interval of
5 min. Group II: (n=25) received patient-administered IV naloxone
mixed with ondansetron via PCA device (Abbott Life-Care, Abbott
Laboratories, Chicago IL). Each patient could receive naloxone IVpatient controlled dose of 0.04 mg mixed with 0.5 mg ondansetron (
in 5 ml) and a lockout time interval of 5 min. Patients were evaluated
at 1, 2, and 4 hrs, then every 4 hrs or sooner, if needed, for a total
of 48 hrs for the following: fentanyl, naloxone total doses, fentanyl
side effects, VAS pain scores, itching scores, overall satisfaction and
satisfaction from the pruritus treatment. Pain intensity at rest and the
incidence and type of side effects were assessed by using a 10-point
scale (0 = none, 10 = worst ever experience). Overall satisfaction
with the infusion was assessed by using a 10-point scale (0 = no
satisfaction, 10 = best satisfaction). Data is expressed as mean + SD
or % incidence. P< 0.05 was considered significant.
Results: There were no differences among the groups with
respect to age, height, parity, pain scores, incidence of sedation,
nausea, or vomiting, and satisfaction from itching treatments.
conclusion: The addition of ondansetron to our IV-patient
controlled naloxone solution for the treatment of post C/S pruritus,
reduced the maximum pruritus scores and increased the overall
satisfaction from this pruritus treatment.
References:
References:
Int J Obstet Gynec 2006; 93: 13-17
1. Borgeat et al. Anesthesiology 1999; 90: 432-6
Table 1
Prenat Diagn 2000; 20: 224-228
I-Naloxone
II-Naloxone/
Odensetron
Sedation
5(20%)
2(8%)
20(80%)
Anesthesiology 2001; 95: 828-835
Itching
21(84%)
Vomiting
3(12%)
0(0%)
Max Itching Score
4.2В±3.3*
5.9В±2.5
Max Pain
3.9В±2.6
3.5В±2.6
Total Naloxone dose
9.1В±11.1*
6.5В±7.5
Max Sedation Score
0.9В±1.7
0.9В±2.1
Max Nausea Score
0.9В±2.5
0.2В±1.2
Overall Satisfaction
8.7В±1.2**
9.7В±0.5
Overall Narccan Satisfaction
9.5В±1.0
9.6В±0.6
* p<0.05; ** p<0.003
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-334
ANESTH ANALG
2012; 114; S-01 – S-493
S-334.
HEMODYNAMIC PROFILE OF PATIENTS HAVING
CESAREAN DELIVERY UNDER SPINAL ANESTHESIA
OBTAINED BY CONTINUOUS MEASUREMENT OF
CARDIAC OUTPUT AND STROKE VOLUME
AUTHORS: Y. Liu, M. M. Pian-Smith, L. R. Leffert, R. Minehart,
R. M. Kacmarek, Y. Jiang
affiliation: Massachusetts General Hospital, Boston, MA
Introduction: There are 1.5 million Cesarean deliveries
(CD) annually in the United States. Most are performed under
spinal or epidural anesthesia. Dramatic hemodynamic instability
occurs frequently with SA which may be associated with adverse
effects on the mother and baby. Hemodynamic control has been
traditionally guided by blood pressure. However, this approach has
been questioned since vasoactive agents may keep blood pressure in
the target range, while cardiac output (CO), which is a determinant
of O2 delivery, can be markedly reduced. The aims of this study
were to 1) continuously measure CO and stroke volume (SV) and
establish the hemodynamic profile of patients having CD under
spinal anesthesia, and 2) determine if real-time awareness of the CO
and SV by the care-team translates into an improved hemodynamic
profile.
Figure 1. Cardiac output and mean arterial blood pressure plot at the nadir of
mean arterial blood pressure after spinal anesthesia.
Methods: Thirty elective CD patients receiving spinals were
randomized into 2 groups (A and B). CO and SV were measured
in all patents with a non-invasive monitor (ICON, Cardiotronic). In
Group A (n=15), the anesthesia care providers were unaware of the
CO and SV measurement and standard of care was given to patients.
In Group B (n=15), the anesthesia care providers were aware of
real-time CO and SV measurements.
Results: There was no significant difference in demographics
between groups. Even though we hypothesized that the care team
would treat patients based on changes in their CO and SV, there was
no difference in the total dosage of phenylepherine (A: 2.36В±1.88mg
vs. B: 1.89В±1.61mg, P=0.51) and ephedrine (A; 8.5В±11.6mg vs. B:
20.6В±33.9mg, P=0.3). Hemodynamic stability evaluated by the
maximum, minimum and mean value of MAP, CO, SV, and HR
were not significantly different between groups. The incidence of
intra-operative nausea and vomiting was the same in both groups
(46.7%). Hypotension developed in 80% and MAP decreased by
29.9В±13.2% from baseline at 8.5В±5.2 min after spinal anesthesia.
However, CO changes did not correlate to MAP and varied from
-35% to 67% of baseline (3.53 to 12.57 L/min) at the nadir of MAP.
With treatment of hypotension, 61% had CO reduction of more
than 20% from baseline within 3 min of phenylephrine bolus (80160mcg).
Discussion: In this sample, real-time awareness of CO and
SV did not affect the treatment of CD patients by the care team.
Importantly, there was poor correlation between CO and MAP
in patients having CD under spinal anesthesia. Thus, treating
hypotension per se, as opposed to diminished CO and SV, may
represent a missed opportunity to optimize O2 delivery.
References:
1. BJOG 2006; 113:657-663
2. Anesthesiol Clin 2008; 26:75-88
3. Anesth Analg 2009; 108: 887-97
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-335
S-335.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-336
S-336.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Pain – Basic Science
ABSTRACTS
S-342
S-342.
ANTINOCICEPTIVE INTERACTION BETWEEN
INTRATHECALLY ADMINISTERED BUPIVACAINE AND
EPIBATIDINE IN RATS
AUTHOR: T. Nishiyama
affiliation: Anesthesiology and Critical care, Higashi Omiya
General Hospital, Saitama, Japan
Introduction: A nicotinic acetylcholine receptor agonist,
epibatidine has strong antinociceptive effects, but also toxic. To
have effective antinociception with decreasing toxicity, synergistic
effects might be useful. The interaction between intrathecal
epibatidine and midazolam or clonidine showed some antagonistic
effects, while morphine had synergistic antinociception with
epibatidine. The present study investigated the interaction between
intrathecally administered bupivacaine and epibatidine in two
different nociceptive models in rats expecting synergistic effects.
Methods: Sprague-Dawley rats with lumbar intrathecal catheters
were tested for their thermal tail withdrawal response using the
tail flick test and for their paw flinches by formalin injection after
intrathecal drug administration. The combination of each 1/2, 1/4,
1/8, or 1/16 50 % effective dose (ED50) was administered. The
ED50s of epibatidine1and bupivacaine2 were derived from our
previous studies. The interaction was tested by an isobolographic
analysis. Eight rats were used in each dose group. Behavioral side
effects were also investigated.
Challenging Case Report: N/A
Results: The ED50 of the combination could not be obtained
in the tail flick test even when each dose was increased to 2ED50.
In both phase 1 and 2 of the formalin test, the combination had a
tendency of synergistic effect, while not statistically significant
due to big variations. The combination of 2ED50 induced motor
disturbance.
Discussion: Intrathecal bupivacaine and epibatidine might
be antagonistic for thermal nociception, while they might be
synergistically antinociceptive for formalin induced acute and
chronic inflammatory nociception.
References:
1. Nishiyama T. J Anesth 2009; 23: 370-7.
2. Nishiyama T. Anesth Analg 2004; 98: 1056-61.
ED50
Bupivacaine (Вµg)
Epibatidine (ng)
Bupivacaine in
combination (Вµg)
Epibatidine in
combination (ng)
Tail flick
Formalin
phase 1
Formalin
phase 2
7.1 (3.5-13.8)
5.7 (3.5-8.8)
3.2 (1.7-6.3)
32.0 (22.0-46.5) 38.0 (21.5-65.1)
N/A
N/A
1.2 (0.0014x106)
9.8 (8.8x10-71.1x108)
27.1 (10.4-43.5)
0.3 (0.02-5.81)
2.6 (0.15-45.8)
ED50 values are shown as mean and 95% confidence interval (in parenthesis).
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-343
S-343.
LUMBAR FACET JOINT OSTEOARTHRITIS
AND PAIN IN THE RAT
AUTHOR: J. Kroin, J. Kim, H. Im, J. Li, K. J. Tuman, A. Buvanendran
affiliation: Rush Medical College, Chicago, IL
Introduction: The etiology of lower back pain in patients
is often complex. Osteoarthritis of the lumbar facet joints have
been implicated as a potential causative factor, but that is still
controversial.1-3 The present study examines pain-related behaviors
in a facet joint osteoarthritis animal model.
Methods: With IACUC approval, facet joint osteoarthritis
was produced in male Sprague-Dawley rats (325-350g; n=6) by
percutaneous puncture of the right lumbar facet joints at L3/L4,
L4/L5, and L5/L6 levels. Facet joints were located and punctured
by two-needle protocol, beginning with a 21G hypodermic needle
inserted through the skin of the right lower back until the sacrum
and L6/S1 joint were located. The needle was then removed and
reinserted 7 mm more rostral until the tip lodged firmly into the L5/
L6 facet joint. A 26G Hamilton needle was inserted into the 21G
needle and lowered until it could be felt puncturing the facet joint
capsular tissue. This procedure was then repeated for the L4/L5, and
L3/L4 facet joints. For sham surgery animals (n=6), the 21G needle
was inserted through the skin, and advanced in succession to the L5/
L6, L4/L5, and L3/L4 facet joints, but without lodging firmly in the
facet joint (and no 26G needle inserted). Pressure hyperalgesia in the
lower back was measured using an applied force gauge (algometer).
With the animal gently held, the applied force was slowly increased
at 100 g per sec until an audible vocalization was heard. Movementrelated pain was evaluated by the number of vocalizations in 5 trials
to twisting or arching of the back. Osteoarthritis in the lumbar facet
joints was assessed with Safranin-O staining, and foraminal changes
by micro-CT scanning. Behavioral pain measures over the 12 weeks
after facet joint or sham surgery were compared with repeated
measures general linear model.
Results: Facet joint puncture produced primary pressure
hyperalgesia and movement-related pain in the lower back, and
this was maintained for at least 12 weeks (figures). Histological
examination showed loss of facet joint proteoglycan in cartilage
ground substance in facet joint puncture rats, but no intervertebral
foraminal stenosis.
Discussion: Lumbar facet joint puncture causes pressure
hyperalgesia and movement-related pain in the lower back of rats,
and cartilage degeneration in the facet joint. In this model, there was
no foraminal stenosis suggestive of nerve root involvement. These
observations suggest this model may have utility in evaluating
interventions used to treat facet joint osteoarthritis.
References:
1. Clin Orthop Relat Res 1997,335:166-80
2. Curr Pain Headache Rep 2004,8:512-7
3. Anesthesiology 2007, 106:591-614
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-344
S-344.
REPEATABILITY OF PERCUTANEOUS INTRATHECAL
INJECTIONS IN MICE
AUTHORS: J. Kroin, J. Li, M. Moric, A. Buvanendran
affiliation: Rush Medical College, Chicago, IL
Introduction: Weekly intrathecal injections of methylpredniВ­
solone have been reported to reduce pain from postherpetic
neuralgia,1 and intrathecal injections of insulin-like growth factor
(IGF)-1every 2 weeks have had a modest but significant beneficial
effect in ALS patients.2 To study these and similar therapeutic
protocols it would be desirable to test these concepts in mice. While
there have been studies with repeated intrathecal injections of
drugs in mice over a few days,3 the feasibility of performing these
injections over long periods of time has not been examined.
Methods: After IACUC approval, C57BL/6 mice of both
genders (9 male, 13 female) were briefly anesthetized with 1.5%
isoflurane in oxygen. The skin around the lower back was shaved,
wiped with alcohol and prepped with chlorhexidine. The hip bones
were lifted slightly, and a 30-G needle attached to a 50 ВµL syringe
inserted through intact skin into the spinal subarachnoid space
at approximately the level or the 5th or 6th lumbar vertebrae.4
Puncture of the dura was indicated reliably by a flick of the tail.
Then, 5 ВµL of 0.75% bupivacaine was injected over 2 sec. Prior
to each injection, the animal’s gait was observed visually while
walking on a metal grid on the table. Immediately after injection the
mice were removed from the anesthesia nose cone, and placed on a
horizontal wire grid on the table. Their gait was then re-evaluated
at 2 min intervals. A spinal block is indicated by the animal moving
with the front limbs only, while dragging the hind limbs. This gait
inhibition has been demonstrated by other investigator’s using 5
ВµL of 0.75% bupivacaine.5,6 Animals were injected weekly for 20
weeks. Duration of motor block over the 20 weeks was analyzed
with repeated measures mixed procedure (SAS software).
Results: 96% (22/23) of the mice completed the 20-week
protocol without any morbidity or long-term gait abnormality. One
animal was sacrificed at week 14 due to skin erosion at the injection
site. While there were some fluctuation in the motor block duration
over time (figure), there was no difference between the first injection
and the 20th injection (P=0.9739).
Discussion: Weekly percutaneous intrathecal injections of local
anesthetics are feasible in the mouse over months without loss of
potency or long-term motor dysfunction. This suggests that research
studies with long-term therapeutic intrathecal injections (e.g. growth
factors) can be tested in this model.
References:
1. N Engl J Med 2000;3431514-9
2. Neurol Res 2005;27:768-72
3. Neuroscience 2009; 161:381-91
4. JPET 1987;242:90-5
5. Acta Pharm Tox 1984;54:253-7; 6. Br J Anaesth 1985;57:329-32
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-346
S-348
ANESTH ANALG
2012; 114; S-01 – S-493
S-346.
S-348.
ROLE OF SPINAL VOLTAGE SENSITIVE CALCIUM
CHANNELS ON NOCICEPTIVE BEHAVIOR AND
EXCITATORY NEUROTRANSMISSION
HYPERBARIC OXYGENATION ALLEVIATES CCIINDUCED NEUROPATHIC PAIN THROUGH INHIBITING
PRO-APOPTOSIS GENES OVER-EXPRESSION IN THE
SPINAL CORD
AUTHORS: T. Takasusuki1, K. Nemoto1, S. Yamaguchi1, T. Yaksh2
affiliation: 1Anesthesiology, Dokkyo Medical University,
Mibu, Japan; 2Anesthesiology, University of California, San Diego,
La Jolla, CA
AUTHORS: J. Du, R. Yousif, D. Foster, F. Li, Z. Yang
Introduction: The release of substance P, an excitatory
neurotransmitter from small primary afferents is mediated by
voltage sensitive calcium channels (VSCCs) that are expressed at
presynaptic nerve terminals. The auxiliary О±2Оґ1 subunit of VSCCs
regulates both excitatory and inhibitory spinal neurotransmission
via a presynaptic mechanism. The role of VSCCs and О±2Оґ1
subunit to the nociceptive transmission remains uncertain. In the
present study, we determined the effects of intrathecal (IT) N-type
(ziconotide), T-type (mibefradil), L-type (diltiazem and verapamil)
VSCCs blockers and О±2Оґ1 subunit binding agent (gabapentin)
on nociceptive behaviors and small primary afferent substance P
release evoked by intraplantar injection of formalin.
Introduction: Increased apoptotic changes in the spinal
cord may be responsible for chronic constriction injury (CCI)
induced neuropathic pain. We previously reported that hyperbaric
oxygen (HBO) alleviated CCI-induced neuropathic pain by
reducing endoneuronal TNF-О± production. In the present study, we
investigated apoptosis-relative genes expression in the spinal cord
3 days after CCI.
Methods: Formalin-induced flinching behavior was measured
using an automated detection system. Rats with chronic intrathecal
catheters received IT pretreatment with saline, ziconotide (0.3, 0.6 or
1Вµg), mibefradil (50 or 100Вµg), diltiazem (300 or 500Вµg), verapamil
(50, 100 or 200Вµg) or gabapentin (100 or 200Вµg) 10min before i.p.l.
injection of formalin (5%, 50Вµl) into the left hindpaw. Immediately
after the formalin injection, nociceptive flinching was quantified. In
separate rats, to assess the release of substance P, animals underwent
transcardial perfusion with 4% paraformaldehyde 10 min after
the formalin injection and the incidence of neurokinin 1 receptor
(NK1r) internalization in the ipsilateral superficial dorsal horn was
determined in immunofluorescent stained tissues.
Results: IT ziconotide (0.3, 0.6 and 1Вµg), mibefradil (100Вµg),
diltiazem (500Вµg), verapamil (200Вµg) and gabapentin (100 and
200Вµg) significantly reduced formalin-induced paw-flinching in
phase II (P < 0.05), but not phase I. Ziconotide (0.3, 0.6 and 1Вµg) and
gabapentin (200Вµg, but not 100Вµg) significantly inhibited evoked
NK1r internalization (P < 0.05). In addition, NK1r internalization
induced by exogenous substance P (IT) was not blocked by IT
ziconotide (0.6Вµg) and gabapentin (200Вµg).
Discussion: IT ziconotide and gabapentin attenuated formalininduced paw flinching behavior and, at corresponding doses,
substance P release in lamina I. N-type VSCCs and VSCCs О±2Оґ1
subunit presynaptically mediate nociceptive transmission in the
spinal cord dorsal horn. Supported by NIH-DA02110
References: N/A
affiliation: Anesthesiology, Upstate Medical University,
Syracuse, NY
Methods: The proposed study was approved by the Institutional
Committee for the Humane Use of Animals.Rats were randomized
into: CCI (n=16), CCI + HBO (n=16) and Sham (n=16) groups.
Mechanical allodynia was tested daily following surgery. CCI+HBO
rats were treated with HBO for 1 hr once a day. 3 days post-CCI,
8 rats in each group were sacrificed and the spinal cords harvested.
The another 8 rats in each group were observed for 7 days. The
expression of TNF-О±, Caspase-3 and SOD and NF-ОєB genes was
detected by RT-PCR.
Results: 7 days post-CCI, mechanical allodynia had developed
compared to sham animals (4.31 В± 0.10 vs. 5.17 В± 0.08, p <0.05).
HBO significantly alleviated mechanical allodynia (4.69 В±
0.11 vs.4.31В± 0.11, p<0.05). Compared to Sham, CCI-induced
neuropathic pain was associated with higher mRNA levels of TNF-О±
(16.92В±0.87 vs.11.96В±1.50, p<0.05), Caspase-3 (17.74В±3.45 vs.
12.75В±3.01, p<0.05) and SOD (3.32В±0.54 vs. 1.43В±0.37, p<0.05),
and lower mRNA levels of NF-ОєB (2.56В±0.33 vs. 4.16В±0.27,
p<0.05) 3 days post-CCI. HBO significantly decreased CCI-induced
mRNA levels of TNF-О± (11.67В±1.89, p<0.05 vs. CCI), Caspase-3
(11В±1.02, P<0.05 VS. CCI), and SOD (1.21В±0.147, P<0.05 VS.
CCI). CCI-induced neuropathic pain is also associated with more
apoptotic cells in the spinal cord, being 19.25 В± 2.44 vs. 10В± 0.45,
p<0.05. HBO significantly reduced CCI-induced apoptosis to the
level of sham animals, being 8.25 В± 0.90 vs. 10В± 0.45, p=ns. The
apoptotic cells were neurons verified by Nissl stain.
Discussion: The present study suggests that the overly expressed
pro-apoptosis genes and the subsequent spinal apoptotic changes
may contribute to the development of CCI-induced neuropathic
pain. The inhibitory role of HBO on spinal pro-apoptosis genes may
be responsible for it’s beneficial effect on CCI-induced neuropathic
pain.
References:
Li F, Fang L, Huang S, Yang Z, Nandi J, Thomas S, Chen C,
Camporesi E. Hyperbaric oxygenation therapy alleviates chronic
constrictive injury-Induced neuropathic pain and reduces tumor
necrosis factor-alpha production. Anesth Analg 2011 113:626-633
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-349
S-350
ANESTH ANALG
2012; 114; S-01 – S-493
S-349.
S-350.
THE INVOLVEMENT OF OPIOID RECEPTORS IN THE
EXERCISE-INDUCED CARDIOPROTECTION AGAINST
ISCHEMIA-REPERFUSION INJURY IN VIVO
GLYCEMIC CONTROL AND SCIATIC NERVE BLOCK
DURATION IN DIABETIC RATS
AUTHORS: J. Borges, L. Paes, E. Tibirica, M. Lessa
affiliation: Rush Medical College, Chicago, IL
affiliation: Laboratory of Cardiovascular Investigation,
Oswaldo Cruz Foundation, Rio De Janeiro, Brazil
Introduction: In vitro studies of the myocardial tolerance
against ischemia-reperfusion (I-R) injury induced by exercise has
suggested the involvement of the Opioid system1. However, the link
between exercise-induced cardioprotection and the opioid system
remains an area where further clarification of the mechanisms
involved is needed2. This first phase of the study aims to verify a
vivo model of exercise-induced cardioprotection against I/R injury
in rats.
Methods: Male Wister rats (250-300g) were first divided into
2 groups: trained and sedentary. The trained group underwent 4
consecutive days of treadmill training (60 min at 70% of maximal
velocity obtained in a graded exercise test). In the sedentary group
the rats were placed on a non-moving treadmill 60 min during 4
consecutive days. The trained rat group were then divided into 2
groups: an Exercise I-R group (Exe I-R; n = 7) and a Naloxone
(a non-selective opioid receptor antagonist) + Exercise I-R group
(Nal + Exe I-R; n = 7). Non-trained animal were also divided into
2 groups: Sedentary I-R (Sed I-R; n = 10) and Sedentary Sham I-R
(S-Sed I-R; n = 9). To induce the I-R injury, anesthetized animals
were submitted to a left thoracotomy and a 30 min interventricular
coronary occlusion followed by 60 min of reperfusion. The
hemodynamic parameters were recorded and the infarct size was
determined by double staining using triphenyltetrazolium/Evans
blue and expressed as a percentage of the area at risk (AAR).
Results: The Sed I-R group had a 43.5% larger infarct area
when compared to the Exe I-R group (38.6 В± 5.0 and 21.8 В± 4.5%
of the AAR respectively, p<0.05, Fig. 1). Naloxone pretreatment
completely blocked the exercise-induced cardioprotection (37.6 В±
3.1% of the AAR, Fig 1). Hypotension elicited by the I-R injury
was not seen in the Exe I-R group. The S-Sed I-R group showed
no infarct.
Discussion: Our results indicate that opioid system is involved
in cardioprotective effects of the aerobic exercise in the anesthetized
rat. New protocols are ongoing to determine the role of the opioid
receptors subtypes in this exercise-induced cardioprotection.
References:
Opioids and cardioprotection. Pharmacol Ther 2001;89: 123-37.
Attenuation of heat shock-induced cardioprotection by treatment
with the opiate receptor antagonist naloxone. Am J Physiol Heart
Circ Physiol 2002;282: H2011-7
AUTHORS: J. Kroin, K. J. Tuman, A. Buvanendran
Introduction: Short-term (perioperative) glycemic control
is currently practiced in diabetic patients to prevent poor wound
healing, and to reduce incidence of infection.1 In diabetic rats, the
duration of local anesthetic sciatic nerve block is prolonged.2 This
study investigates if blood glucose control affects duration of sciatic
nerve block arising from local anesthetic injection in diabetic rats.
Methods: With IACUC approval, rats were injected with 50
mg/kg streptozotocin (STZ) to destroy pancreatic beta cells, and
induce diabetes.3 At 28 days after STZ injection, diabetic rats were
randomly divided into 3 treatment groups: tight long-term glucose
control (s.c. insulin implant 3U/day for 14 days), tight short-term
glucose control (2 inj/day of 6U NPH insulin for 3 days); moderate
long-term glucose control (s.c. insulin implant 1.5U/day for 14
days). Diabetic control rats received placebo implants or injections.
After the end of the of the insulin treatment, sensory and motor
responses in leg were recorded, and then 0.1 mL of 1% lidocaine
hydrochloride with 5 Вµg/mL epinephrine hydrochloride was
percutaneously injected onto the sciatic nerve. Animals were then
evaluated for the duration of nerve block.
Results: With tight long-term glucose control, tail blood glucose
levels were 62В±14 mg/dL in insulin-treated diabetic rats vs. 480В±17
mg/dL in untreated diabetic rats (P<0.001). The local anesthetic
solution produced a longer mean duration of sensory nerve block
in untreated diabetic rats (148В±16 min) vs insulin-treated diabetic
rats (84В±4 min) (P=0.005). Similarly, motor block was 148В±16 min
vs 86В±2 min (P=0.005). With moderate long-term glucose control,
levels were 120В±7 mg/dL in insulin-treated diabetic rats versus
386В±12 mg/dL in untreated diabetic rats (P<0.001). Sensory nerve
block duration was 135В±2 min vs 85В±3 min (P=0.001); and motor
block was 138В±4 min vs 85В±3 min (P=0.001).With tight short-term
glucose control, levels were 70В±8 mg/dL in insulin-treated diabetic
rats versus 408В±12 mg/dL in untreated diabetic rats (P<0.001),
but there was no reduction in nerve block duration with insulin
treatment.
Discussion: With long-term glucose control in diabetic rats,
the duration of nerve block was about 60 min shorter than in the
untreated diabetic rats, and similar to that of normal rats.2 However,
tight short-term glucose control did not affect nerve block duration,
suggesting that this neuropathy cannot be rapidly reversed.
References:
1. Anesthesiology 2009;110:408-21;
2.Reg Anesth Pain Man 2010;35:343-350;
3. Anesthesiology 1992;77:941-947
Figure 1. Trained or sedentary anesthetized Wistar rats submitted to ischemiareperfusion (I-R) injury with or without pretreatment with naloxone. Sed
I-R, Sedentary I-R; Exe I-R, Exercise I-R; Nal + Exe I-R, Naloxone (a nonselective opioid receptor antagonist) pretreatment + Exercise I-R; S-Sed I-R,
Sedentary Sham I-R; % AAR, percentage of the area at risk. # p < 0.01 vs Sed
I-R * p< 0.05 vs Exe I-R
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Pain – Clinical – Acute
ABSTRACTS
S-356
S-357
ANESTH ANALG
2012; 114; S-01 – S-493
S-356.
S-357.
MULTIMODAL ANALGESIA IMPROVES THE
MANAGEMENT OF BRACHYTHERAPY
POSTOPERATIVE PAIN EXPERIENCE:
RESULTS FROM A HOSPITAL ACUTE PAIN SERVICE
AUTHORS: N. Eipe1, R. Boscariol1, J. Penning1, R. Samant2, C. Ee2
AUTHORS: A. Buvanendran, C. M. Zook, S. C. Toleikis, J. Kroin
affiliation: Anesthesiology, The Ottawa Hospital, Ottawa,
ON, Canada; 2Radiation Oncology, The Ottawa Hospital, Ottawa,
ON, Canada
affiliation: Rush Medical College, Chicago, IL
1
Introduction: High-dose-rate (HDR) brachytherapy is
a radiation treatment technique that involves the application
of localized internal radiation to the cervix. Outpatient HDR
brachytherapy performed with sedation administered by registered
nurses under the supervision of a radiation oncologist is becoming
increasingly popular. We report the first study comparing the effect
of premedication with multimodal analgesia on the treatment of
carcinoma cervix with brachytherapy done under sedation.
Methods: The present retrospective study included 15
consecutive patients who underwent a total of 39 HDR brachyВ­
therapy treatments. 22 treatments were done with oral multimodal
analgesia (study group) consisting of acetaminophen, tramadol and
pregabalin. These were compared to the preceding 17 treatments
(control group) from the same center where no premedication
was given. The outcome measures studied were- total midazolam
dose, total opioid dose, pain scores, recovery scores, duration of
procedure and of stay.
Results: The results show a statistically significant decrease in
the amount of sedation required by those patients who had received
multimodal analgesia. Decreases were also seen in analgesic
requirements, pain scores and duration of procedure were also
seen in the study group, though these differences did not achieve
statistical significance. No operative or treatment complications
occurred in either group.
Discussion: The need for Anesthesiology presence during HDR
brachytherapy of the cervix has been previously studied. With the
rational use of different analgesic medications, these procedures
requiring sedation may be safely performed with increased patient
comfort and satisfaction.
HDR brachytherapy for carcinoma cervix may be a pain model
where radiation induced hyperalgesia and other pro-nociceptive
mechanisms may play an important role. Pregabalin may be useful
adjunct to treat these patients and together with tramadol and
acetaminophen may provide adequate foundational analgesia for
sedation. We will discuss the possible mechanisms by which these
drugs are effective in this pain model.
This quality assurance study demonstrates that pre-emptive
multimodal analgesia improves the management of HDR
brachytherapy for carcinoma cervix in a statistically significant and
clinically relevant manner.
References:
1. Anaesthesia.2000; 55:899-904.
2. Br J Anaesth. 2006; 96:195-200.
Introduction: Pain control is considered a mandated part
of the comprehensive surgical postoperative experience. The acute
pain service comprises a multidisciplinary group of clinicians
specialized in pain management and who apply an ever-increasing
array of modalities to attenuate postoperative pain. In a survey based
on telephone questionnaire data from 1998-2002, 73% of patients
that had surgery as inpatients experienced pain before discharge,
with almost half of those pain patients reporting severe to extreme
pain.1 These patient outcomes are not that different from an earlier
1995 study,2 indicating that postoperative pain management had
not improved from 1995 to 2002. In this study, we evaluate a more
recent experience to assess the effectiveness of a hospital acute pain
service in managing postoperative pain.
Methods: With IRB approval, postoperative inpatient pain
records for 3552 patients were obtained from the Acute Pain Service
at our Medical Center for the years 2008-2009. Pain Intensity on
a 11-point Numerical Rating Scale (NRS) (0=No Pain,10=Worst
Imaginable Pain) were recorded until discharge from the Acute Pain
Service. These data were analyzed for the maximum pain, minimum
pain, and pain at discharge. Adverse events such as nausea,
vomiting, and itching were also analyzed.
Results: Epidural analgesia was used at some time in 72.9% of
the patients, and 32.4% had IV PCA. At discharge from the Acute
Pain Service the NRS score was 3.47 В± 0.04 (mean В± SE). Over the
postoperative period the maximum NRS was 5.52 В± 0.05, and the
minimum NRS was 2.11 В± 0.04. 80.2 % of patients had pain (NRS
≥ 1), which is close to the 73% with pain (using verbal categories)
before discharge in the telephone questionnaire data.1 However in
that 1998-2002 study, 48% of the inpatients with pain had severe
to extreme pain before discharge from the hospital,1 while only
16.8% of the patients with pain in our Acute Pain Service records
had severe to extreme pain (NRS ≥7) at discharge from the Acute
Pain Service. The incidences of nausea and vomiting were less in
the Acute Pain Service records than in the 1998-2002 study: nausea
(5.8% vs. 28%), vomiting (1.2% vs. 21%); but itching was similar
(7.4% vs. 10%).
Discussion: While we cannot precisely compare verbal pain
category data from telephone questionnaires to NRS scores obtained
at the patient bedside, our analysis suggests that the incidence of
severe to extreme pain at discharge from the Acute Pain Service has
been greatly reduced over the last 10 years. In addition, postoperative
nausea and vomiting have also been considerably reduced.
References:
1. Anesth Analg 2003;97:534-40.
2. Anesthesiology 1995;83:1090-4.
3. Curr Opin Anaesthesiol. 2008; 21:514-8.
4. Oncol Nurs Forum. 2001; 28:743-51.
5. Support Care Cancer.1995; 3:205-7.
6. Am J Clin Oncol. 2004; 27:449-51.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-358
S-358.
SUPERFICIAL CERVICAL PLEXUS BLOCKS IMPROVE
ANALGESIC OUTCOMES FOLLOWING THYROID
SURGERY: A META-ANALYSIS OF RANDOMIZED
CONTROLLED TRIALS
AUTHORS: K. Doi1, H. Hoshijima1, N. Kuratani2, R. Takeuchi1,
N. Matsumoto1
affiliation: 1Anesthesiology, Saitama Medical University
Hospital, Moroyama/Saitama, Japan; 2Anesthesiology, International
University of Health and Welfare Hospital, Nasushiobara, Japan
Introduction: Thyroid surgery can cause mild to moderate
postoperative pain. Recently, the use of superficial cervical plexus
blocks (SCPBs) as an analgesic technique for thyroid surgery has
been reported1,2. There has, however, been little information about
the efficacy of SCPBs in terms of postoperative analgesia following
thyroid surgery. In this study, we performed a meta-analysis of
randomized controlled trials to assess the analgesic efficacy of
SCPBs combined with general anesthesia (GA).
Methods: A comprehensive search of the literature was
conducted to identify clinical trials comparing a placebo with SCPBs
following thyroid surgery. Two reviewers independently assessed
each report to confirm that all reports met our inclusion criteria.
The primary outcomes were determined to be acute postoperative
pain scores. Visual analogue pain scores and numerical rating scales
were converted to a standardized 0-10 scale.
The data from each trial were combined using the randomizedeffects model to calculate the weight mean difference (WMD) and
their corresponding 95% confidence intervals (CIs). Funnel plots
were used to assess publication bias.
Results: Eight randomized controlled trials met our inclusion
criteria. Overall, 350 patients received SCPBs and 344 received
placebos. The use of SCPBs reduced pain scores at 0 hrs (WMD
-0.94, 95% CI -1.81 to -0.07; P=0.03), at 2 hrs (WMD -1.04, 95% CI
-2.01 to -0.07; P=0.04), and at 6 hrs (WMD -0.45, 95% CI, -0.88 to
-0.03; P=0.04), but did not reduce pain scores at 12 hrs (WMD 0.05,
95% CI, -0.38 to 0.49; P=0.81), postoperatively. The heterogeneity
of the data was not statistically refuted. Publication bias was evident
in a funnel plot.
Discussion: Our analysis revealed that the use of SCPBs
in addition to GA provides a better postoperative pain control
compared with the use of GA alone during the acute postoperative
period.
References:
1. Anesth Analg 2001; 92: 1538-42
2. Reg Anesth Pain Med 2006; 31: 34-39
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-359
S-359.
IS POSTOPERATIVE PAIN UNDERMANAGED AFTER
INPATIENT SURGERY?
AUTHORS: A. Buvanendran, S. Rybak, C. M. Zook, S. Jha, M.
Moric, J. Kroin
affiliation: Rush Medical College, Chicago, IL
Introduction: In the United States, 45 million inpatient
surgeries are performed annually.1 However, pain after surgery
remains an under-recognized clinical problem. In a survey based on
data from 1998-2002, 66% of patients had moderate-to-extreme pain
in the first few days after surgery.2 These patient outcomes are not
that different from a previous study,3 indicating that postoperative
pain management had not improved from 1995 to 2002. However, in
recent years there has been increased attention to pain management
in the hospital setting, and so the patient outcomes in recent years
may be more encouraging.
Methods: With IRB approval, written informed consent was
obtained in the patient’s room before hospital discharge. The patient
was then asked questions about their postoperative pain experience:2,3
(1) Pain intensity on verbal categorical scale; (2) Patient satisfaction
with pain medication. Sample size was based on power estimates
using 1998-2002 data,2 on incidence of severe-to-extreme pain after
surgery (35%). Our hypothesis is based on demonstrating a 20%
reduction in that incidence (to 28%) with 2011 practice protocols.
For О±=0.05, Power =0.8, we estimate sample size to be 365 patients.
ANESTH ANALG
2012; 114; S-01 – S-493
Results: Data from our 428 inpatients were compared with
the 129 inpatient surgeries in the 2003 paper.2 Overall the two
ordinal trends were significantly different (P=0.0004), with the
earlier data displaying larger proportions of “Extreme pain” (18%
v 2%, p<0.0001) and “Severe Pain” (17% v 10%, p=0.0380) but
correspondingly lower proportions of “Moderate Pain” (30% v 41%,
p=0.0184), “Slight Pain” (9% v 30%, p<0.0001), with more patients
reporting “No Pain” (27% v 16%, p=0.0064). The histograms of
the pain categories for our study are approximately normal (Figure).
Patient satisfaction with pain medication was not significant overall
between the 2 studies (p=0.1154), as most categories were similar:
Very dissatisfied (1% v 1% p=0.7033), Dissatisfied (3% v 2%,
p=0.5134), Slightly dissatisfied (3% v 3%, p=0.9204), slightly
satisfied (10% v 6%, p=0.1204), Satisfied (40% v 33%, p=0.1704),
but current satisfaction data reflected a higher rate of Very Satisfied
(43% v 54%, p=0.0289).
Discussion: Although we cannot exactly compare data from
telephone questionnaires to interviews at patient bedside, the results
suggest that the incidence of severe-to-extreme pain after inpatient
surgery has been greatly reduced in the last 10 years, perhaps due to
more consistently applied pain management protocols.
References:
1.National Ctr. Health Statistics http://goo.gl/A8hdG.
2.Anesth Analg 2003;97:534-40.
3. Anesthesiology 1995;83:1090-4.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-360
S-360.
PROSPECTIVE COMPARATIVE STUDY OF ANALGESIC
EFFICIENCY OF PARAVERTEBRAL BLOCK WITH
ROPIVACAINE (0.2%) AND DEXMEDETOMIDINE +
ROPIVACAINE (0.2%) IN RENAL SURGERIES
AUTHORS: G. S. Tomar, A. K. Tiwari, S. Ganguly
affiliation: Dept. of Anaesthesiology & Critical Care, St.
Stephen’s Hospital, New Delhi, India
Introduction: We aim to compare the efficacy of the
paravertebral block with 0.2% ropivacaine and 0.2% ropivacaine
with dexmedetomidine. We also compare hemodynamic changes
in both the groups and total requirement of ropivacaine in first 24
hours in the two groups.
Methods: 60 adults patients of ASA physical status I and
II, scheduled for unilateral renal surgeries were included in this
prospective randomized open label parallel group double blind study.
After placing 18G epidural catheter through 18G tuohy needle 3cm
inside T12-L1 paravertebral block was activated in group I patients
by 18ml of ropivacaine(0.2%) + 1mcg/kg dexmedetomidine. Next
in both the groups general anaesthesia with endotracheal intubation
and controlled ventilation was instituted with injection propofol,
lignocaine 2% (preservative free), rocuronium intravenously.
Anaesthesia was maintained with isoflurane 0.5-1% in N20 and
02. Hemodynamic parameters were noted down at the time skin
incision and if pulse rate and blood pressure exceeded 20% of
the baseline value in any patient, he/she was excluded from the
study as block failure and was offered systemic opioid analgesia.
At the end of surgery anaesthetic agents were discontinued and
neuromuscular blockade was reversed with 50mcg/kg neostigmine
along with 10mcg/kg glycopyrrolate. When patients were able to
communicate properly their pain was assessed by the VAS score
and hemodynamic parameters. The patients were administerd the
first top up dose (12 ml of ropivacaine 0.2%) in group I and (12
ml of ropivacaine 0.2%+0.5mcg/kg of dexmedetomidine) in group
II for the paravertebral blockade for continuation of postoperative
analgesia as soon as VAS exceeds 3 and the time was noted down.
This was the primary end point of our study. Subsequently top ups
will be given according to vas score and the total requirement of
ropivacaine in first 24 hour will be noted down in both the groups.
Total requirement of ropivacaine in 24 hours is our second end point
of our study.
Results: Group II patients experienced significantly greater pain
free hours than group I(p<0.05). Also total ropivacaine consumption
in much lower in group II (p<0.05).
Discussion: Paravertebral ropivacaine along with dexmedetoВ­
midine prolongs the duration of analgesia in unilateral renal
surgeries than ropivacaine alone. Also, the total requirement of
ropivacaine is less in dexmedetomidine group.
References:
Paleczny J, Zipser P, Pysz M. Paravertebral block for open
cholecystectomy
Anaesthesiology Intensive Therapy, 2009,XLI,2; 76-79.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-361
ANESTH ANALG
2012; 114; S-01 – S-493
affiliation: 1Anesthesiology, Beijing TongRen Hospital,
Capital Medical University, Beijing, China; 2Anesthesiology, Duke
Medical Center, Durham, NC; 3Pediatrics, Stanford University
School of Medicine, San Francesco, CA; 4Anesthesiology, Beijing
ChaoYang Hospital, Capital Medical University, Beijing, China
Results: Twenty one trials comparing systemic lidocaine with
placebo or blank control for postoperative analgesia and recovery
after abdominal surgery were included in this review. Weighted
mean difference for cumulative opioid analgesic consumption after
surgery was -6.48 mg (95% confidence interval, CI: -9.66,-3.31).
Postoperative pain intensity at rest (visual analogue scale, 0-100
mm) was significantly decreased in the lidocaine group at 6 and 24
h compared with the control group. Postoperative pain score during
activity was also significantly decreased in the lidocaine group 6h
after surgery. Moreover, the mean time to first flatus and bowel
movement was significantly shortened by 6.65 hours (95%CI:
-10.51,-2.78) and 11.74 hours (95%CI:-16.97, -6.51), respectively,
with lidocaine intervention compared with control.
Introduction: Postoperative pain management remains a
significant challenge after abdominal surgery. Opioid, as a mainstay
for postoperative analgesia, can exacerbate postoperative ileus
and further delay patient recovery.1 Systemically administrated
lidocaine has analgesic, anti-inflammatory and anti-hyperalgesic
effects.2-3 The aim of this meta-analysis was to evaluate the efficacy
of systemic lidocaine for postoperative pain management and
recovery after abdominal surgery.
Discussion: In this meta-analysis, we demonstrated that
perioperative systemic lidocaine was an effective adjunct for
postoperative pain management and improves postoperative
recovery profile after abdominal surgery. Most widely used regimen
consists of a bolus of lidocaine 1.5 mg/kg followed by an infusion
of 2 mg/kg/hr.Further large, well-designed studies are required
to confirm these findings and to determine the most efficacious
regimen.
Methods: We searched the databases of Medline (1966 -2010),
CINAHL, The Cochrane Central Register of Controlled Trials, and
Scopus for randomized controlled trials investigating the use of
systemic lidocaine for postoperative pain management and recovery
after abdominal surgery. We extracted data about postoperative
opioid consumption, postoperative pain intensity, opioid-related
side-effects, time to first flatus and length of hospital stay.
References:
S-361.
PERIOPERATIVE SYSTEMIC LIDOCAINE FOR
POSTOPERATIVE ANALGESIA AND RECOVERY
AFTER ABDOMINAL SURGERY A META-ANALYSIS OF
RANDOMIZED CONTROLLED TRIALS
AUTHORS: Y. Sun1, T. Li1, T. Gan2, N. Wang3, Y. Yue4
1. Acta Anaesthesiol Scand 2004; 48: 1194-1207.
2. Anesthesiology 2000; 93: 858-875.
3. Pain 2000; 85: 217-224.
Postoperative pain intensity
VAS pain score
No of trials
Lidocaine Group (n)
Control Group (n)
WMD (95%CI)
6h
11
335
345
-7.65 (-13.56, -1.74)
24 h
13
390
400
-4.29 (-7.58, -1.00)
72 h
8
206
206
-2.52 (-6.91, 1.87)
pain Postoperative score at rest
Postoperative pain score during activity
6h
7
210
210
24 h
9
254
254
-10.36 (-16.45, -4.27)
-3.77 (-7.55, 0.00)
72 h
8
206
206
-1.72 (-7.55, 1.35)
WMD: weighted mean differences CI: confidence interval
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-362
S-362.
APPLICATION OF TRAMADOL ANALGESIA AFTER OFFPUMP CORONARY ARTERY BYPASS GRAFT SURGERY
AUTHORS: H. Zhao, Y. Feng, Y. Jiang
affiliation: Anesthesiology, Peking University People’s
Hosptial, Beijing, China
Introduction: The analgesic action of tramadol is based
on a multimodal mechanism of action. Potential advantages
of administering tramadol for postoperative pain relief include
earlier recovery and less sedation than opiates. This prospective
randomized controlled study aimed to investigate the analgesic
efficacy and safety of tramadol used after off-pump coronary bypass
graft surgery (OPCAB).
Methods: Sixty-two consecutive patients undergoing OPCAB
under standard sufentanil-based general anesthesia in Peking
University People’s Hospital were randomly allocated to receive
tramadol 1 mg/kg or sufentanil 0.1 ug/kg at the end of sternal
closure, followed by patient-controlled analgesia (bolus tramadol
0.2mg/kg, or sufentanil 0.02ug/kg, lockout time being 10min) with
background infusions (tramadol 0.15mg/kg/h or sufentanil 0.015ug/
kg/h). Patients were transferred to cardiac surgery intensive care
unit (CSICU) directly after surgery. Pain intensity was rated by the
patients with visual analogue scale (VAS) at 12, 24 and 48 hours
after surgery. The level of sedation was assessed by using a 5-point
score (1=fully awake, 5 =asleep, not arousable) at the same time
interval.
Results: Demographic and surgical data were comparable
between two groups. Patients in Tramadol group were less painful
and sedated compared with patients in Sufentanil group. Patients
in Tramadol group tended to have an earlier awakening from
general anesthesia and an earlier tracheal extubation than patients in
Sufentanil group, but the difference was not statistically significant.
Patients were more satisfied with pain management in Tramadol
group.
Discussion: Postoperative cardiac surgical patients need good
pain relief for hemodynamic stability, early extubation, cooperation
for chest physiotherapy and prevention of pulmonary dysfunction.
Patients in Tramadol group were less painful and sedated compared
with patients in Sufentanil group. Patients in Tramadol group
tended to have an earlier awakening from general anesthesia and
an earlier tracheal extubation than patients in Sufentanil group. This
could be explained by discontinuing use of sufentanil after large
amount of sufentanil during surgery and providing equally effective
analgesics. In summary, tramadol could attenuate postoperative pain
after OPCAB effectively and has a tendency to accelerate patients
awakening and weaning from mechanical ventilation.
References:
1. J Cardiothorac Vasc Anesth. 2007;21(1):35-40.
2. Anesth Analg 1979;58:390-5
3. Drugs 1997;53 Suppl 2:18 -24.
4. Ann Card Anaesth. 2001 Jan;4(1):13-6.
5. Anesth Analg 2006;102:1668-73
6. Anesth Analg. 2001;93(4):859-64.
7. J Cardiothorac Vasc Anesth. 2004;18(6):755-8.
8. Acta Anaesthesiol Scand. 2007;51(5):601-6.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-363
S-364
ANESTH ANALG
2012; 114; S-01 – S-493
S-363.
S-364.
THE ASSOCIATION OF ATP-BINDING CASSETTE B1
(ABCB1) SINGLE-NUCLEOTIDE POLYMORPHISM TO
MORPHINE CONSUMPTION IN POSTOPERATIVE PAIN
PREOPERATIVE GABAPENTIN IS ASSOCIATED WITH
REDUCED OPIOID CONSUMPTION IN LAPAROSCOPIC
DONOR NEPHRECTOMY: A PILOT STUDY
AUTHORS: Y. Rodriguez, Z. Yang, Y. Zhang, O. Rodriguez, K.
Candiotti
AUTHORS: G. B. Cierny1, B. J. Wolf2, W. D. Stoll1, W. Hand1,
M. D. McEvoy1
affiliation: Anesthesiology, University of Miami School of
Medicine, Miami, FL
affiliation: 1Anesthesia and Perioperative Medicine, Medical
University of South Carolina, Charleston, SC; 2Biostatistics and
Epidemiology, Medical University of South Carolina, Charleston, SC
Introduction: ABCB1 gene, the single-nucleotide polyВ­
morphВ­ism (SNP) C3435T, has been frequently associated with
different P-gp expression and activities1.This altered activity may
result in increased absorption from the intestine, a reduced renal
clearance, and an increased brain concentration, leading to a decrease
in dosage requirements or a possible increase in clinical effects for
some opiates that are P-gp substrates , especially morphine2,3. No
previous studies have clear evidence that an association between
SNPs of ABCB1 (C3435T) and morphine consumption in acute
pain treatment. The aim of this study was to test the association
of the common SNP of ABCB1 and morphine consumption in
postoperative pain in patients undergoing nephrectomies.
Methods: IRB approval and signed informed consent were
obtained. DNA was extracted from blood of 138 patients undergoing
a nephrectomy. The C3435T SNP of ABCB1 was analyzed. Opioid
consumption and pain scores were evaluated in these patients
postoperatively.
Results: We found statistically significant differences in
cumulative morphine consumption among the various genotypes in
the 6 hrs (p=0.009), 12hrs (P=0.004), and 24 hrs (P=0.008) postoperative period. The TT genotype (n=25) had significant lower
morphine consumption compared with CT (n=63) and CC (n=50)
genotypes. No statistically significant differences among the three
genotype groups were noted for postoperative pain scores.
Discussion: Our results clearly demonstrated an association
of the ABCB1 polymorphism to inter-individual variations in
morphine consumption in the acute postoperative period after
patients underwent nephrectomies. The ABCB1 polymorphism
may be served as an important factor to predict acute morphine
consumption in postoperative patients.
References:
1.Hoffmeyer S, Burk O, von Richter O, Arnold HP, Brockmoller
J, Johne A, Cascorbi I, Gerloff T, Roots I, Eichelbaum M,
Brinkmann U. Functional polymorphisms of the human
multidrug-resistance gene: multiple sequence variations and
correlation of one allele with P-glycoprotein expression and
activity in vivo. Proc Natl Acad Sci U S A 2000; 97: 3473-8.
2.Lotsch J, Geisslinger G, Tegeder I. Genetic modulation of the
pharmacological treatment of pain. Pharmacol Ther 2009; 124:
168-84.
3.Kharasch ED, Hoffer C, Whittington D, Sheffels P. Role of
P-glycoprotein in the intestinal absorption and clinical effects of
morphine. Clin Pharmacol Ther 2003; 74: 543-54.
Introduction: Preoperative gabapentin has been shown
to decrease post-operative opioid consumption in a number of
laparoscopic surgical procedures. However, this has not been
investigated in laparoscopic living donor nephrectomy (LDN).
Accordingly, we sought to test the hypothesis that a single
preoperative dose of gabapentin 1200mg (GABA) is associated with
reduced opioid consumption in the postoperative period.
Methods: A retrospective chart review examined patients who
received GABA compared to age, sex, and BMI-matched controls
and followed them throughout their hospitalization. Patients
were excluded from the analysis if they had any pain syndromes
for which they were on chronic analgesics. The primary outcome
was cumulative opioid consumption (morphine equivalents) in
PACU and at 6, 12, 24, and 36 hours after surgery. A mixed linear
regression model was used to assess differences in cumulative
opioid use. The model included a random subject effect with a firstorder autoregressive covariance structure to account for correlation
among individual subjects’ five repeated measurements. P <0.05
was considered significant.
Results: There was no difference between groups in age, sex,
BMI, or ASA class (N=9 in each group). There was a significant
reduction in cumulative morphine equivalents through PACU (0.496
vs 0.725 mg/kg, p=0.019), 6 hours (0.563 vs 0.853 mg/kg, p=0.003),
12 hours (0.629 vs 0.949 mg/kg, p=0.001), 24 hours (0.755 vs 1.13
mg/kg, p<0.001), and 36 hours (0.897 vs 1.32 mg/kg, p<0.001) (see
Figure 1).
Discussion: Excellent pain control for any surgical patient is
of paramount concern. However, pain control for LDN patients
is a double-concern because making the process as pain-free as
possible can affect the experience of the donor and the likelihood
of recipients to receive a kidney transplant in this manner. For this
patient population, our findings suggest that the use of a single,
preoperative dose of gabapentin (1200mg PO) may be a associated
with a 30% reduction in opioid consumption for up to 36 hours
postoperatively. Future research will need to address this issue in a
prospective, randomized controlled trial.
References:
Kong VKF, Irwin MG. Gabapentin: A Multimodal Perioperative
Drug. Br J of Anaesth, 2007; 99: 775-786
Turan A, Karamanlioglu B, Memis D, Usar P, Pamukcu Z, Ture
M. The Analgesic Effects of Gabapentin After Total Abdominal
Hysterectomy. Anesth & Analg, 2004; 98: 1370-1373.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-365
ANESTH ANALG
2012; 114; S-01 – S-493
S-365.
PERIOPERATIVE PAIN AND MORPHINE CLEARANCE
IN CHILDREN: DOES RACE MATTER?
AUTHORS: S. Sadhasivam1, E. Krekels2, P. Ngamprasertwong1,
V. Chidambaran1, A. A. Vinks2,1
affiliation: 1Anesthesiology, Cincinnati Children’s Hospital
Medical Center, Cincinnatti, OH; 2Clinical Pharmacology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH
Introduction: Inter-individual variability in analgesic
response and adverse effects and narrow therapeutic indices of
opioids is a major problem in perioperative practice. Morphine is a
commonly used perioperative opioid in children. We observed high
between subjects variability in the analgesic response to morphine;
African-American children experienced more postoperative
pain and Caucasian children had more morphine related adverse
effects1. In this prospective study, we aimed to address underlying
pharmacokinetic and pharmacogenetic mechanistic factors
contributing to the racial differences in perioperative pain and
morphine related adverse effects.
Methods: Prospective genotype-blinded observational clinical
study evaluating pharmacokinetics, pharmacogenetics and
pharmacodynamics of intravenous morphine during tonsillectomy
and adenoidectomy (T&A), among 150 Caucasian and AfricanAmerican children aged 6 to 18 years. All participants received
standard perioperative care with an intraoperative dose of 0.2 mg/kg
morphine (children with obstructive sleep apnea received 0.1 mg/
kg of morphine). Serial blood samples (3 or 4 blood samples per
patient) were obtained for morphine, morphine-3-glucuronide and
morphine-6-glucuronide levels and for pharmacogenetic testing.
UGT2B7, the major Uridine Glucuronyl Transferase isoform
responsible for 3- and 6-glucoronidation of morphine was tested for
genotype.
Individual morphine clearance values (symbols) and the covariate relationship
describing the change in population morphine clearance (lines) versus
bodyweight, the most predictive covariate. Green symbols and line represent
the African-Americans, blue symbols and line represent the Caucasians and
other races (with children from other races represented by open symbols).
Results: Of the 146 children evaluable for analysis, 29 were
African-American and 113 were Caucasian. African-American
children have significantly higher morphine clearance (23%)
than Caucasian patients (Figure 1). Although the wild type of the
UGT2B7 isozyme is more prevalent in the AA patients, common
UGT2B7 genetic variations (-161C>T and 802C>T) were not
associated with observed racial differences in morphine clearance.
Discussion: Race of the child is an importance factor in
perioperative intravenous morphine clearance, which can partly
explain an unequal burden of increased perioperative pain in
Caucasian and increased opioid adverse effects in African-American
children. Its role in personalizing analgesia with morphine needs
further investigation.
References:
1. Sadhasivam, et al. Pediatrics 2012 (In Press)
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-366
S-366.
KIDNEY INJURY AFTER PERCUTANEOUS AND OPIOIDRELATED ADVERSE EVENTS INCREASE LENGTH
OF STAY AND DRIVE UP TOTAL COST OF CARE IN A
NATIONAL DATABASE OF POSTSURGICAL PATIENTS
AUTHORS: T. Gan1, G. Oderda2, S. Robinson3
affiliation: 1Anesthesiology, Duke University Health System,
Durham, NC; 2Pharmacotherapy, University of Utah, Salt Lake City,
UT; 3Premier Research Services, Charlotte, NC
Introduction: The primary objective of this retrospective
study was to identify the relationship between opioid use and related
adverse drug events (ADEs) with increased length of stay (LOS)
and total cost in patients undergoing some of the more common
surgeries in hospitals in the United States.
Methods: The de-identified Premier database was queried for this
study. Selection criteria included the following inpatient surgeries:
open colectomy, laparoscopic colectomy and cholecystectomy, total
abdominal hysterectomy and hip replacement surgery in patients 18
years of age and older between 2008 and 2010. ADEs were defined
using ICD-9 diagnosis codes. LOS and total cost outliers were
defined as ≥1 standard deviation above the mean values. Patients
with ADEs in the population were matched (1:3) to patients without
ADEs on age, severity of illness (SOI) and gender. Descriptive
statistics and regression were used to analyze the outcomes of
LOS and total cost. A p-value of <0.05 was considered statistically
significant.
Challenging Case Report: N/A
Results: Prior to matching, the incidence of opioid-related ADE
was 19.4%. There were 45,342 patients with an opioid-related
ADE matched to 135,941 without an opioid-related ADE. The
mean unadjusted LOS for patients with an opioid-related ADE was
statistically significantly longer than for patients without an opioidrelated ADE; 5.2 days (SD 3.5) versus 4.1 days (2.8) (p<0.0001).
The mean unadjusted total cost that included an opioid-related
ADE compared to the total cost without an opioid-related ADE
was $18,309 (SD 11,267) and $17,281 (SD 10,209), respectively.
Patients who experienced an opioid-related ADE had a larger
percentage of LOS and total cost outliers compared to patients who
did not experience an opioid-related ADE; 8.3% versus 5.3% and
13.0% vs. 5.3%, respectively. The adjusted cost variation from the
baseline cost was $1,614 comparing opioid-related ADE to nonADE and an adjusted LOS variation from baseline LOS of 0.70
days.
Discussion: From this large national database, postsurgical
patients who experienced an opioid-related ADE had a statistically
significantly longer LOS and a higher total cost than those without
an opioid-related ADE. Reducing the incidence of opioid-related
ADEs by reducing opioid dosages and overall consumption may
in turn reduce LOS and total hospital costs. Further investigations
regarding the impact of opioid dosage on the incidence of related
ADEs would shed additional light on how to reduce LOS and
hospitalization costs.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Pain – Clinical – Chronic
ABSTRACTS
S-372
S-372.
SPINAL CORD STIMULATION FOR INTRACTABLE
METASTATIC SPINAL TUMOR RELATED PAIN
AUTHOR: S. Hattori, T. Igarashi, J. Takarada, H. Sano, M. Yokota
affiliation: Anesthesiology and Pain Service, The Cancer
Institute Hospital of JFCR, Tokyo, Japan
Introduction: Roughly 10 to 20% of cancer pain patients fail
to achieve satisfactory pain relief with conventional management.
Spinal cord stimulation(SCS) has been widely used in non-malignant
chronic pain but seldom in cancer pain. Author will present two
cases of intraspinal metastases with severe pain successfully treated
by SCS that relieved intermittent pain attacks and improved activity
of living and QOL.
Methods: Case 1: 60-year-old male who underwent cyberknife
treatement to intraspinal metastases of lung cancer. He was
experiencing intractable, raging, and seizure-like pain attacks
striking his lower back and lower extremity intermittently(15min
interval). All conventional pain medication and interventions failed
to relieve his pain. SCS was scheduled.
Case 2: 50-year-old female with intraspinal metastases of thyroid
cancer. She was experiencing continuous and intermittently raging
back and thigh pain. All convetional pain medication had failed to
relieve her pain and suffering with side-effects. SCS was considered
and performed.
Results: In Case 1, intrathecal adminsitration of morphine and
bupivacaine gave somewhat satisfactory pain relief but for only
two weeks. SCS was then considered due to the recurrence of pain
attacks that resembled the symptom of spinal injury and made him
paralyzed supine on bed. SCS successfully relieved his pain and
enabled to sit up, eat and reduce systemic dose of opioids.
In Case 2, spinal attack and intractable continuous pain forced her
to hospitalize. Life expectancy was estimated 3 to 5 years. Test
injection of spinal morphine did not give any pain relief. Trial
stimulation gave sufficient pain relief, diminished pain attacks, and
reduced opioid dose down to 20%.
Discussion: Spinal cord stimulation is the most commonly used
implantable neurostimulation modality for management of nonmalignant pain syndromes. There are only few reports in cancer
pain management.As SCS blocks afferent fibers by inhibiting
transmission through spinothlamic tract, we speculate that our two
cases was successfully relieved from pain by this theory. SCS was
the only option in case 1, and SCS was preferred because of long life
expectancy in case 2. In conlusion, although further accumulation of
case reports and investigation is necessary, SCS may be a therapeutic
alternatives for intractable pain in spinal related metastases.
References:
Yakovlev AE, Spinal cord stimulation for cancer related low back
pain. Am J Hosp Palliat Care, 2011
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-373
S-373.
CHANGES IN SALIVARY AMYLASE ACTIVITY BEFORE
AND AFTER TRANSCUTANEOUS XENON LIGHT
IRRADIATION AROUND THE STELLATE GANGLION
AUTHOR: K. Mamiya, N. Abe, Y. Onodera, A. Sugawara, M.
Kanao, H. Iwasaki
affiliation: Anesthesiology and Critical Care Medicine,
Asahikawa Medical University, Asahikawa, Japan
Introduction: Stellate ganglion block (SGB), using local
anesthetics, inhibits cervical sympathetic innervation, temporarily.
Some studies have shown that SGB inhibits secretion of stress
hormones in humans.On the other hand, transcutaneous Xenon light
(Xe-light) irradiation around the SG has been utilized instead of
SGB because it sometimes causes serious adverse effects.Besides,
a Daeki Amylase MonitorВ® (DAM) (NIPRO, Osaka, JAPAN)
measures salivary amylase activity and displays it numerically.We
previously proved that salivary amylase activity drops minimum 5
minutes after SGB and this results indicate that SGB has a relieving
effect on patients’ stress. (Fig 1) In this study, we assessed salivary
amylase activity in patients underwent the Xe-light irradiation
around the SG.
Methods: With IRB approval and informed consented, 14
healthy volunteers participate in this study. After the stabilization
period, 10 minutes of the Xe-light irradiation was performed with a
Xe-light treatment device (Excel-Xe, Nihon Ito, Tokyo, Japan). We
measured the salivary amylase activity in four conditions: (1) after
lying on a bed for 5 minutes before the irradiation (control value),
(2) immediately, (3) 5, and (4) 15 minutes after the irradiation.
Additionally, we measured the patient’s stress before and after the
irradiation using visual analogue scale (VAS). Data are expressed as
means В± SD. ANOVA followed by Mann-Whitney U test was used
and P values of less than 0.05 were considered to be statistically
significant.
Results: Salivary amylase activity in each condition were
(1) 11.8В±5.8, (2) 11.1В±5.5, (3) 11.6В±5.9 and (4)11.1В±5.9IU/L.
There were no difference in amylase activity before and after the
irradiation (P=0.2191). But VAS value was significantly decreased
after the irradiation.(24В±18.3 v.s.13.8В±10.6mm,P=0.04). (Fig.2)
Discussion: In SAM system, there exists two regulatory
mechanism, hormonal regulation and direct innervations. The
change of the serum norepinephrine level by hormonal regulation
is delayed by 20-30 min in response to loading stress. In contrast,
when secretion of Salivary alpha amylase is stimulated by direct
innervation, its response is within one to a few minutes. Our data
showed that there were no difference in amylase activity before and
after the irradiation, although VAS value was significantly decreased.
Therefore, Xe-light irradiation might have a relieving effect on
patient’s stress, although it have not blocked the sympathetic
nerve system and anti-stress effect of Xe-light irradiation might be
different from SGB.
References:
1. Yamaguchi M, Kanemori T, Kanemaru M et al. Performance
evaluation of salivary amylase activity monitor. Biosense
Bioelectron 2004; 20 : 491-7
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-374
S-374.
PERSISTENT POSTSURGICAL PAIN AFTER T
OTAL KNEE REPLACEMENT: PREOPERATIVE
HEALTH STATUS AS A RISK FACTOR?
AUTHORS: A. Buvanendran, M. Moric, J. Kroin, K. J. Tuman
affiliation: Rush Medical College, Chicago, IL
Introduction: Total knee replacement (TKR) is regarded as a
safe, cost-effective treatment for osteoarthritis providing substantial
improvements in functional status and quality of life. However, for
the 15% of patients dissatisfied after TKR, persistent postsurgical
pain (PPP) of the operated knee is their most frequent complaint.1
Methods: With IRB approval, we assessed PPP at 6 months after
surgery in 38 patients undergoing primary TKR performed using
standard techniques.2 PPP was defined as “pain in the operated knee
at six months after TKR, with other causes of pain excluded and
reported intensity on 0-10 NRS scale of ≥4”. Pre- surgical SF-36
measures of health status were also evaluated. The SF-36 consists
of 36 questions relating to the patient’s physical and mental health.
The possible risk factors were evaluated using a stepwise logistic
regression (entry p-value of 0.30 and retention p-value of 0.10). The
clinicians recording and assessing PPP at 6 months were blinded to
pre and intraop information for that subject, in particular they were
blinded to presence or level of risk factors for the respondents.
Results: At 6 months after TKR surgery, 9/38 (24%) patients
had PPP. Lower preoperative total SF-36 score is an independent
risk factor for the development of PPP. The preoperative SF-36 total
score was predictive of PPP at 6-months (P=0.0142) with an odds
ratio of 0.866 (95% confidence interval: 0.772, 0.971), indicating
that a lower SF-36 total score (indicating poorer functional and
psychosocial state) is associated with PPP. The SF-36 subscale of
mental health was also predictive of PPP at 6-months (P=0.0396).
In particular, the role-emotional component was individually
significant (P=0.0312). Finally, the preop SF-36 subscale of physical
health was predictive of PPP at 6-months (P=0.0449). In addition,
higher acute postoperative NRS pain intensity independently
predicts increased incidence of PPP. The acute postoperative NRS
pain intensity is significantly higher, by 1.3 NRS, for the PPP than
the non-PPP group (repeated measures test, P=0.0358) and the
predictive model trended towards significance (logistic regression,
P=0.064) with an odds ratio of 1.86 (95% CI: 0.97, 3.58).
Discussion: The results indicate that broadly defined mental
and physical functioning at preop (SF-36 scores) independently
predict the development of persistent knee pain at 6 months post
TKR surgery. A larger prospective study is needed to explore all
of the risk factors and mechanisms, including relative importance
(weighting) and interactions.
References:
1.Clin Orthop Relat Res 2003;416:27-36;
2. Anesth Analg 2010;110:199-207
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-375
S-375.
PAIN, FUNCTIONAL AND MOOD STATUS IN
PATIENTS WITH NEUROGENIC CLAUDICATION
BEFORE AND AFTER MINIMALLY INVASIVE
LUMBAR DECOMPRESSION
AUTHORS: B. Durkin1, J. Romeiser1, R. Peyster4, A. W. Shroyer2,
R. Davis3, H. Benveniste1,4
affiliation: 1Anesthesiology, Stony Brook University, Stony
Brook, NY; 2Surgery, Stony Brook University, Stony Brook, NY;
3
Neurosurgery, Stony Brook University, Stony Brook, NY;
4
Radiology, Stony Brook University, Stony Brook, NY
Introduction: Chronic low back pain from lumbar spinal
stenosis (LSS) is a common cause of pain and impaired mobility.
A new quality assurance program (Q/A) was designed and
implemented to assess the safety of the “Minimally Invasive Lumbar
Decompression” (MILD®) procedure and the impact on changes in
LSS patient’s pain, functional and mood status over time. Here we
report the QA safety and outcomes data from 32 MILD patients.
Methods: QA Project Quality Plan was approved by the
Anesthesia and Surgery QA committees and the Hospital’s Chief
Quality Officer; and the IRB notified as per standard operating
procedures. The LSS patients were evaluated after careful
determination of eligibility for the MILD Procedure via interview
and MRI evaluation. For this QA program, patient demographic,
social, medical, surgical, functional (Oswestry Disability Index
(ODI), pain (11-point numerical rating scale and self-reported
sketches of radiculopathy patterns) information were collected
as well as mood status evaluated by the NIH Patient-Reported
Outcomes Measurement Information System (PROMIS).
ANESTH ANALG
2012; 114; S-01 – S-493
Results: The patients were elderly (72.6В±9.9) with baseline pain
scores of 7.0В±2.0 and all had neurogenic claudication. Functional
status evaluated by the ODI scores at baseline was 43.1В±18.0
indicating moderate disability in daily living. In regards to mood
status, the NIH PROMIS Depression Item Bank score was 48
indicating slightly better than average mood status in comparison
to the norm prior to surgery. All patients underwent the MILD
procedure without complications. When comparing baseline pain
scores to 1, 3 and 6-months follow-up values the patients showed
at least 30% improvement (Table 1). At 3 and 6-months the ODI
was improved by 26% and 45%, respectively, suggesting that the
patients did better over time. Interestingly, the frequency of selfreported lower extremity �radiculopathy’ was still present in 73%
of the patients (N=15) at 3-months but its overall distribution was
decreased.
Discussion: Based on our preliminary QA program findings,
we conclude that functional improvements and pain reduction were
demonstrated for the majority of the MILD patients up to 6 months
following the procedure. However, the patient’s self-reported lower
extremity radiculopathy after the procedure revealed remaining
areas of radiculopathy in spite of improvement in overall pain and
functional scores.
References:
1.Markman JD, Gaud KG: Clin Geriatr Med. 2008;24:369-388,
viii.
2.Taylor VM, Deyo RA, Cherkin DC, Kreuter W: Spine (Phila Pa
1976). 1994;19:1207-1212; discussion 1213.
3.Deer TR, Kapural L: Pain Physician. 2010;13:35-41.
Example of a patient’s self-reported
lower extremity radiculopathy
patterns before and after the MILD
procedure. It is clear that the
radiculopathy disappeared at 1 and
3 month after the procedure but
partially returned at 6-month.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-376
S-376.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Pediatric Anesthesia
General Topics
ABSTRACTS
S-382
S-383
ANESTH ANALG
2012; 114; S-01 – S-493
S-382.
S-383.
ANESTHETIC CONSIDERATIONS IN LEIGH
DISEASE;CASE REPORTS AND LITERATURE REVIEW
THE EEFFECT OF DEXMEDETOMIDINE ON
HEMODYNAMICS AND ELECTROCARDIOGRAPHY OF
DEXMEDETOMIDINE IN CHILDREN WITH CONGENITAL
HEART DISEASE
AUTHOR: A. S. Terkawi1, T. M. Wani1, K. M. Al-Shuaibi1, J. D.
Tobias2
affiliation: 1Department of Anesthesiology, King Farad
Medical City, Riyadh, Saudi Arabia; 2Department of Anesthesiology,
Nationwide Children’s Hospital, Columbus, OH
Introduction: N/A
Methods: N/A
Challenging Case Report: Leigh disease is an extremely
rare disorder, characterized by a progressive neurodegenerative
course with a sub-acute necrotizing encephalomylopathy. It usually
present in infancy with developmental delay, seizures, dysarthria
and ataxia. These patients may also develop episodes of lactic
acidosis that usually lead to deterioration of the disease, respiratory
failure and death. The prognosis is usually generally poor as
there is no definitive therapy. Due to rarity of the condition, the
most appropriate anesthetic plan remains unclear. Understanding
of the pathophysiology of the disease combined with a careful
preoperative assessment are keys in ensuring a safe and effective
perioperative course which may significantly improve the quality of
care for these patients. We present two patients with Leigh disease
who required anesthetic care. The perioperative course of both
patients was uneventful with the first patient being discharged home
after two days without complications. The second patient remains
hospitalized because of his co-morbid condition and its sequelae
including respiratory failure and an altered level of consciousness.
The important points regarding the perioperative care of such
patients are presented, the pathophysiology of the disorder is
discussed, and previous reports regarding the anesthetic care of such
patients are reviewed.
Results: N/A
Discussion: N/A
References: N/A
AUTHOR: S. Fujii1, M. Nagashima2, S. Kitamura1, S. Fujioka1,
S. Kawasaki1, T. Nagaro1
affiliation: 1Anesthesiology and Resuscitation, Ehime
University Hospital, Toon City, Japan; 2Pediatric Cardiovascular
Surgery, Ehime University Hospital, Toon City, Japan
Introduction: Dexmedetomidine (DEX), a highly selective
О±2 agonist, is used for sedation in the intensive care unit (ICU)1.
Although DEX has a wide safety margin in the respiratory system,
there have been concerns related to hypertension, hypotension, and
bradycardia. The aim of this study is to determine the hemodynamic,
sedative, respiratory, and electrocardiographic (ECG) effects of
DEX in children with congenital heart disease (CHD) and who have
undergone cardiac surgery.
Methods: This study was a prospective, observational, and
institutional study. DEX (0.5 Ојg/kg/h) was continuously administered
in the ICU for postoperative sedation in 34 children (age range, 0-14
years; median age, 10 months) who underwent cardiac surgery with
cardiopulmonary bypass. Hemodynamic, sedative, and respiratory
variables were measured at pre-administration, 10 min, 1 h, and 3 h
after DEX administration. Two ECGs per children were obtained at
pre-administration (T1) and 6 h after the administration (T2).
Results: Heart rate (HR) significantly decreased from 139 В± 24
bpm at pre-administration to 132 В± 23 bpm after 1 h (p < 0.01)
and to 125 В± 22 bpm after 3 h (p < 0.01) of DEX administration.
Arterial systolic and diastolic pressure significantly decreased after
only 1 h from 96 В± 14 mmHg to 90 В±13 mmHg (p < 0.05) and 56
В± 9 mmHg to 52 В± 9 mmHg (p < 0.01). Sedative status (Richmond
Agitation Sedation Scale) was well maintained, and we observed
no respiratory depression. ECGs showed that the HR significantly
decreased from 131 В± 26 bpm at T1 to 113 В± 24 bpm at T2 (p <
0.01). In accordance, QT duration was significantly prolonged from
337 В± 55 msec to 356 В± 57 msec (p < 0.05). However, PR, corrected
PR, corrected QT, and QRS duration did not differ between T1
and T2. Atrioventricular block occurred in 2 children after DEX
administration. One of these children already had prolonged PR
duration at T1; however, the other had normal PR duration at T1.
In both the children, the atrioventricular block was recovered by
reducing or discontinuing the DEX infusion rate.
Discussion: Postoperative continuous low-dose administration
of DEX did not suppress respiration and maintained good sedative
status. Administration of DEX in children with CHD was not
associated with any significant ECG interval abnormalities other
than a trend of bradycardia and a temporary reduction in blood
pressure in the early stages. DEX can be used safely for postoperative
sedation in children who have undergone cardiac surgery; however,
the ECG should be closely monitored during DEX administration.
References:
1.Electrocardiographic Effects of dexmedetomidine in Patients
with Congenital Heart Disease. Intensive Care Med 2010;36:836842
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-384
S-385
ANESTH ANALG
2012; 114; S-01 – S-493
S-384.
S-385.
A RANDOMIZED COMPARISON OF THE I-GEL
WITH THE PROSEAL LARYNGEAL MASK AIRWAY IN
PEDIATRIC PATIENTS
SAFETY AND EFFICACY OF PROSEAL LMA
VERSUS CLASSIC LMA IN CHILDREN - A
RANDOMIZED CONTROLLED TRIAL
AUTHORS: A. Fukuhara, R. Okutani, Y. Oda
AUTHORS: S. Gombar, A. Jafra, D. Kapoor
affiliation: Department of Anesthesiology, Osaka City
General Hospital and Children’s Hospital, Osaka, Japan
affiliation: Department of Anesthesia & Intensive Care,
Government Medical College & Hospital, Chandigarh, India
Introduction: The i-gel is a supraglottic airway device with
a noninflatable cuff. Despite numerous studies comparing the i-gel
with laryngeal mask airways, there are few reports comparing these
devices in children (1,2). This prospective, randomized, controlled
trial compares the performance of the pediatric i-gel with the Proseal
laryngeal mask airway (PLMA) in anesthetized and ventilated
children.
Introduction: There are well known limitations of the
CLMA in paediatric patients, in particular size 1 and 2.(1) Its low
pressure seal might be inadequate for positive pressure ventilation
(PPV). Its modification, Proseal LMA has higher oropharyngeal
leak pressures with feasibility of PPV.(2) This study was designed
to compare the safety and efficacy of the PLMA versus the CLMA
in children undergoing elective ambulatory procedures.
Methods: The authors included 128 children, aged 3 month
to 15 yr, scheduled for elective surgery under general anesthesia.
Anesthesia was induced with propofol or sevolflurane, muscle
relaxants were not used before insertion of the devices. The primary
outcome variable was the ease of insertion. Other outcome variables
were time for insertion, oropharyngeal leak pressure, first-attempt
and overall success rates and fiberoptic findings.
Methods: Following Institutionall ethics committee approval,
one hundred children aged 6m to 10 years were randomly allocated
to either PLMA or CLMA groups.After induction of general
anaesthesia, atracurium besylate 0.5 mg.kg-1 was used to facilitate
muscle relaxation with fentanyl 2 Вµg kg-1 for analgesia. A size 1.5,
2, or 2.5 (depending on the weight), PLMA/ CLMA was chosen
as per group allocation of the patient.The primary outcome was
the oropharyngeal leak pressure (OLP). Secondary outcomes were
the time and number of attempts for insertion, quality of airway, &
fibreoptic placement.The quality of the initial airway was assessed
during manual ventilation, as: excellent, good, or poor. The OLP
was determined by closing the expiratory valve of the circle system
at a fixed gas flow of 3 liters.min-1. A flexible fibreoptic scope
was introduced into the airway tube for viewing and scoring the
laryngeal structures as 1,2,3 & 4.(3)
Results: Demographic data did not differ between the groups
except the size 2.5 i-gel and PLMA. Insertion of the i-gel was
significantly more difficult than PLMA (P = 0.046). Fiberoptic score
was significantly better in the i-gel group than in the PLMA group (P
< 0.01), although there were no differences in leak pressure between
the groups. First attempt success rate was 96% and 95% in the i-gel
and PLMA groups, respectively; overall success rate was 100% in
both groups. There were no major side effects with either device.
Discussion: Insertion of the i-gel was more difficult than PLMA,
whereas the fiberoptic view was better through the i-gel than PLMA.
Both the i-gel and PLMA were successfully used in children.
References:
1. Theiler LG, et al. Anesthesiology 2011;115:102-10.
2. Beringer RM, et al. Anaesthesia 2011;66:1121-6.
Results: The primary variable tested was OLP. The baseline
demographic data were comparable. The mean OLP in PLMA
(30.02 В± 3.21 cmH2O) was significantly higher than CLMA 21.62
В± 2.49 cmH2O. (p < 0.001). There was significant difference in
the time taken for insertion of PLMA versus CLMA 21.90 В± 4.93
seconds vs 19.46 В± 5.99 seconds (p<0.05) In group I, all patients
had an excellent quality of airway, while in group II, 30(60%)
patients had an excellent quality of airway. (p<0.001). There was no
statistically significant difference in the fibreoptic grading between
the two groups (31,14,5 vs 31,15,4) (p>0.05) (Table 1).
Discussion: The PLMA has higher oropharyngeal leak pressures
compared to the CLMA. The success of the 1st attempt insertion
was higher for the PLMA. Hence PLMA is a safe, efficacious,
and easy-to-use supraglottic airway device in children undergoing
elective ambulatory procedures providing a better quality of
airway as compared to CLMA during controlled ventilation. Also,
the results show that correct fibreoptic anatomic placement of the
LMA cannot be considered as a valid end point for assessing the
satisfactory placement of the device.
References:
1. Paed Anaesth 2002; 12: 420-3
2. Br J Anaesth 2005; 95: 827-30
3.Anaesthesiol Intensivmed Notfallmed Schmerzther 2000; 35:
692-4
Results
PLMA (n=50)
CLMA (n=50)
Time taken for insertion(sec)
21.90 В± 4.93
19.46 В± 5.99
1st attempt success rate (%)
92%
90%
50 (100%),0
30(60%),
20 (40%)
P<0.001
30.02 В± 3.21
21.62 В± 2.49
P<0.001
100%
-
31,14,5,0
31,15,4,0
4%
6%
Quality of initial airway:
Excellent/good, n(%)
Oropharyngeal leak pressure
(cmH2O)
Ease of OGT insertion
Fibreoptic scoring
Grade 4,3,2,1
Blood on LMA (%)
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
P<0.05
ABSTRACTS
S-386
S-387
ANESTH ANALG
2012; 114; S-01 – S-493
S-386.
S-387.
KIDNEY INJURY AFTER PERCUTANEOUS AND
A RANDOMIZED TRIAL OF INTRA-NASAL
DEXMEDETOMIDINE AND SUFENTANIL COMPARED TO
ORAL MIDAZOLAM FOR PEDIATRIC DENTAL SEDATION
KIDNEY INJURY AFTER PERCUTANEOUS
AND POPULATION PHARMACOKINETICS (PK)
OF DEXMEDETOMIDINE (DEX) IN PEDIATRIC
INTENSIVE CARE
AUTHORS: A. Maru1, C. Heard2,3, R. Mireles2, M. Yarussi2,
P. Creighton1
AUTHORS: J. Fiedler-Kelly1,3, E. Ludwig1, D. Stalker2
affiliation: 1Pediatric Dentistry, Women & Children’s Hospital
of Buffalo, Buffalo, NY; 2Pediatric Anesthesiology, Women &
Children’s Hospital of Buffalo, Buffalo, NY; 3Pediatric Critical
Care, Women & Children’s Hospital of Buffalo, Buffalo, NY
Introduction: Conscious or moderate sedation is routinely
used to facilitate the dental care of an uncooperative child. There
are many different drugs and routes of administration available
for sedation. IN Dexmedetomidine has previously been used as a
premed to general anesthesia, but not as a sedative for a surgical
treatment. The aim of this study is to assess the effectiveness in
our dental clinic of two drug regimens, oral Midazolam (POM),
our routine sedative, and intranasal Dexmedetomidine/Sufentanil
(INDS). We will compare the two regimens for efficacy, duration
of affect and incidence of any complications such as respiratory
events, nausea or excess sedation.
Methods: After FDA approval (IND# 112699) for the use of
IN Dexmedetomidine in children and IRB approval, patients were
recruited and randomized to receive either POM (1 mg/kg, max
20mg) or INDS (DEX 2mcg/kg, max 40mcg & SUF 1 mcg/kg, max
20mcg). The quality of sedation was assessed by a blinded observer
using the RASS, UMSS, and OSBRS, as well as an assessment by
the attending and resident dentist (also blinded) on a score of 1-10
(poor - excellent sedation).
Results: We have recruited 15 subjects so far. Average age and
weight and number of procedures per case was 4.9 years, 19.9kg
and 4.13 respectively. Sedation used: 6 children received POM and
9 received INDS with average doses of 19mg POM, 34 mcg IN
DEX and 17mcg IN SUF. The mean procedural time was 38 minutes
and time to discharge 57 minutes (no difference between groups).
The mean sedation rating by dental resident and attending was 3.3
& 3.6 for the POM sedation and 8.3 & 7.6 for the INDS sedation
respectively (p < 0.05). The mean RASS for the procedure was 1.00
for POM & 1.44 for INDS (p value 0.07) and for the end was 0.50
for POM & -1.78 for INDS (p value 0.02). OSBRS average for the
procedure was 3.33 for POM & 2.00 for INDS (p value 0.01) and
for the end was 2.83 for POM & 2.00 for INDS (p value 0.01).
UMSS average for the start was 1.17 for POM & 1.89 for INDS (p
value 0.06) and for the end was 0.83 for POM & 1.67 for INDS (p
value 0.02). There was 1 episode of nausea in the INDS group and
2 INDS patients required supplemental nasal cannula oxygen at 2L/
min. Both techniques were rated highly (> 9/10) by the parents on a
follow-up phone call and the IN administration was well tolerated.
Discussion: Data collection is ongoing. Preliminary data
obtained thus far shows INDS appears to be a better regiment for
dental sedation procedures by providing significantly effective
dental sedations at the start, during the procedure, and end as shown
by the assessment scores. The incidence of airway complications
and nausea was not different (underpowered at present).
References: N/A
affiliation: 1Pharmacometric Services, Cognigen Corporation,
Buffalo, NY; 2Global Medical Affairs, Hospira, Inc., Lake Forest, IL;
3
Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
Introduction: Although the pharmacokinetics (PK) of
dexmedetomidine (DEX) in children have been described, published
reports include limited subjects without consideration of neonates.1
A population PK analysis of DEX was performed using pooled data
from 4 studies of pediatrics aged > 28 weeks to 17 years.
Methods: Pediatric subjects were mechanically ventilated,
requiring sedation in an intensive care setting. DEX loading doses
ranging from 0.05 - 1.00 Ојg/kg were administered over 10-20
minutes, followed by maintenance infusions of 0.05 - 2.00 Ојg/kg/h
for 2 - 24 hours. Blood samples for PK analysis were obtained during
and post-DEX infusion (up to 13) in patients other than neonates (up
to 8). A population nonlinear mixed effects modeling approach was
used to characterize DEX PK. Other factors potentially contributing
to inter-subject PK variability were evaluated using forward
selection/backward elimination (О±=0.05/0.001). The PK model
was evaluated using a simulation based prediction corrected visual
predictive check (VPC).
Challenging Case Report: N/A
Results: DEX PK parameters were estimated using a 2
compartment disposition model with CL, Q, Vc, and Vp parameters,
fixed allometric exponents on clearance (CL), intercompartmental
CL (Q) (0.75 for CL and Q) and distribution volumes for the central
(Vc) and peripheral (Vp) compartments (1.0 for Vc and Vp), an
additional shift on the CL exponent for neonates most likely related
to lack of maturation of drug metabolizing enzymes, and age effects
on Q and Vp (both decrease with increasing age). Population
mean (%SEM) values for CL, Vc, Q, and Vp were 10.7(3.4) L/h,
8.49(10.5) L, 63.5(23.8) L/h, and 14.7(7.2) L, respectively. Modelbased simulated concentrations were in close agreement with the
observed data. Weight-adjusted CL and Vc estimates decrease with
increasing age, and approach values expected in adults.2 The 95%
confidence intervals for the geometric mean DEX CL were within
the targeted bounds of 60% to 140% of the point estimates for all
age groups. All intervals for Vc were within the targeted bounds,
except for the 6 to 17 year age group (0.70, 1.43).
Discussion: The PK of DEX were characterized using the largest
patient population with the broadest age range, DEX maintenance
doses and infusion durations reported to date. The model evaluation
results indicate that PK are predicted well over the range of DEX
concentrations occurring during and immediately after maintenance
infusion. Overall, these results will support improved DEX dosing
recommendations in this critically ill population of children.
References:
1. Anesthesia Analg; 110:1383, 2010.
2. Precedex product information, Hospira Inc., 2008.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-388
S-388.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-389
S-389.
GLIDESCOPE REDUCES LARYNGOSCOPY ASSOCIATED
LARYNGOSPASM IN 1,200 CONSECUTIVE PEDIATRIC
NASAL INTUBATIONS WITHOUT MUSCLE RELAXANT
AUTHORS: T. West, A. Targ, N. Noone
affiliation: Targ Mobile Anesthesia, Palo Alto, CA
Introduction: Children experience perioperative laryngoВ­
spasm at twice the adult rate1. Laryngospasm (LS), defined in
this study as partial or complete vocal cord closure preventing the
passage of an appropriately sized* endotracheal tube (ETT), risks
oxygen desaturation, pulmonary edema, aspiration, bradycardia,
and cardiac arrest1. Many studies have shown the GlideScope video
laryngoscope (GVL) equal or superior to direct laryngoscopy (DL)
for glottic visualization and ETT insertion2, yet none have examined
GVL assisted pediatric nasal intubation.
Methods: Records of 1,290 consecutive ASA I elective dental
procedure patients under 12 years of age (all anesthetized by one
anesthesiologist experienced with 5,000 pediatric nasal intubations)
were retrospectively surveyed. In each case, a standardized
induction had been performed. Sevoflurane (8%) was administered
followed by placement of supraglottic airway device(s) as needed
(Guedel oral airway and/or laryngeal mask airway). At an end
tidal sevoflurane concentration of 3.0%, a mean of 6.1 В± 1.9 mg/
kg propofol was given to induce apnea, thus avoiding anesthetic
exhalation and undesired reduction of anesthetic depth during nasal
intubation. An 18 F red rubber catheter guided the Nasal RAE
ETT through the nasopharynx to decrease trauma3, and tracheal
intubation was completed with a tube bender. The first 637 cases
were performed by Miller laryngoscope and the second 653 by
GVL. In every case of LS during laryngoscopy, succinylcholine was
administered and resulted in immediate resolution and ETT passage.
Ninety cases were excluded due to deviation from protocol (42 no
propofol given, 37 no intubation desired, 8 LS prior to laryngoscope
insertion, 3 other), leaving 1,200 cases for analysis (600 DL, 600
GVL).
Results: LS during laryngoscopy occurred in 16 of 600 DL
patients and 4 of 600 GVL patients. The log odds of LS increases
by 1.45 with DL (95% C.I. 0.43-2.7) and is significant at О±=0.01
(see table 1). Propofol was significantly lower in the GVL group
(p ≤ .01).
Discussion: This previously unreported finding supports routine
use of GVL for children undergoing nasal intubation when muscle
relaxation is not desired. It is unlikely the GVL group’s lower
propofol dose would reduce LS, as propofol has been reported to
resolve LS4. The significant reduction in LS with GVL may result
from reduced stimulation with video laryngoscopy (less force
applied and improved laryngeal view).
* ETT size (mm i.d.) = 4 + patient age/4 (В±0.5 mm based on patient
size)
References:
1. Olsson GL. Acta Anaesthesiol Scand 1984; 28(5):567
2. Jones PM. Anesth. Analg. 2008; 107(1):144
3. Watt S. Anesthesiology 2007; 106(2):238
4. Alalami AA. Pediatr Anesth 2008; 18:281
Table 1: A logistic regression was used to assess the effects of demographics,
preoperative medication, and DL vs GVL on laryngoscopy associated LS. DL
was found to be associated with an increase in LS.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-390
ANESTH ANALG
2012; 114; S-01 – S-493
S-390.
CAUDAL ANESTHESIA FOR PEDIATRIC
CARDIAC CATHETERIZATION
AUTHORS: J. Bjerregaard, R. Williams
affiliation: Department of Anesthesiology, Fletcher-Allen
Healthcare, University of Vermont, Burlington, VT
Introduction: A wide variety of anesthetic techniques have
been utilized over the years for cardiac catheterization in children.
The diagnostic success of the procedure relies on obtaining stable
hemodynamics with as little perturbation from the patient’s baseline
as possible. We review our experience over the last 15 years using
caudal anesthesia in combination with either light propofol sedation
or light planes of sevoflurane anesthesia in children undergoing
cardiac catheterization. We believe this technique provides the
cardiologist with an immobile and insensate patient while causing
limited negative physiological impact.
Methods: A retrospective descriptive case series of
patients receiving caudal anesthesia for cardiac catheterization.
Demographics, anesthetic use, and hemodynamic data were
retrospectively assessed for the efficacy and hemodynamic stability
of the technique.
Figure 1. Hemodynamic profile of patients during procedure with a caudal
anesthetic block at 30, 60, and 90 minute intervals. Presented as mean arterial
pressure variability.
Results: Fifty-four records were reviewed, consisting of patients
ages 2 months to 10 years old, who had caudal anesthesia attempted.
In the 50 patients successfully blocked, 39 patients received
propofol at an average infusion rate of 128 mcg/kg/min. Eleven
intubated patients received sevoflurane at an average minimum
alveolar concentration (MAC) depth of 0.6. All patients maintained
systolic blood pressures within 20% of the mean at selected time
points. All patients were at some point maintained on FiO2 less than
or equal to 30%.
Discussion: The use of caudal anesthesia as an integral part of
the anesthetic plan for pediatric cardiac catheterization appears to
be a practical technique with a high success rate. Caudal anesthesia
may offer a number of potential benefits to patients undergoing
cardiac catheterization including minimal alterations in the patient’s
native physiology and the ability to extend analgesia and motor
blockade into the post catheterization period.
References:
1. Proceedings of the 7th Congress of the Pan American Medical
Association, Havana, Cuba, 1939, pp 75-82, 109-113.
2. Anesth Analg. 1961 Sep-Oct;40:483-90.
3. Anesth Analg. 1992 Apr;74(4):490-4.
4. Anesth Analg.1999 Dec;89(6):1411-6.
5. J Cardiothorac Vasc Anesth. 2003 Dec;17(6):686-90.
6. Paediatr Anaesth. 2005 Jan;15(1):50-3.
7. Anesth Analg. 2000 May;90(5):1014-9.
8. Anesth Analg. 2000 May;90(5):1020-4.
9. Anesthesiology. 1979 Apr;50(4):319-23.
10.Paediatr Anaesth. 1997;7(3):205-9.
11. Anesth Analg. 2002 May;94(5):1165-8.
12. Anesthesiology. 1987 Nov;67(5):681-5.
13. Paediatr Anaesth. 2009 Sep;19(9):829-36.
14. Anaesthesia. 2006 Mar;61(3):277-81.
15. Paediatr Anaesth. 2005 Jan;15(1):23-8.8:281
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-392
S-393
ANESTH ANALG
2012; 114; S-01 – S-493
S-392.
S-393.
A PHASE II/III, OPEN-LABEL, MULTICENTER, SAFETY,
EFFICACY AND PHARMACOKINETIC STUDY OF
DEXMEDETOMIDINE IN NEONATES AGES ≥ 28 WEEKS
TO ≤ 44 WEEKS GESTATIONAL AGE
A PHASE III, RANDOMIZED, DOUBLE-BLIND, DOSECONTROLLED, MULTICENTER STUDY OF THE
SAFETY AND EFFICACY OF DEXMEDETOMIDINE IN
MECHANICALLY VENTILATED CHILDREN
AUTHORS: C. Chrysostomou1, S. Schulman2, M. Polak3, M. Herrera4,
B. Cofer5, L. Gramlich6
AUTHORS: G. B. Hammer1, D. E. Soliman2, C. Newth3,
J. Boriosi4, S. Schulman5
affiliation: 1Children’s Hospital of Pittsburgh, Pittsburgh,
PA; 2Duke University Medical Center, Durham, NC; 3West Virginia
University, Morgantown, WV; 4Roosevelt Hospital, Guatemala
City, Guatemala; 5Greenville Hospital System, Greensville, SC;
6Loyola University Medical Center, Maywood, IL
affiliation: 1Stanford University, Stanford, CA; 2Children’s
Hospital of Pittsburgh, Pittsburgh, PA; 3Children’s Hospital Los
Angeles, Los Angeles, CA; 4University of Wisconsin, Madison, WI;
5
Duke University Medical Center, Durham, NC
Introduction: Dexmedetomidine (DEX), a highly selective
alpha-2 adrenergic agonist with sedative, analgesic and anxiolytic
effects, has been used successfully in pediatric patients during
and after mechanical ventilation. To date, the pharmacokinetics
(PK) of DEX has only been characterized across limited
pediatric populations. The present study investigated the PK,
pharmacodynamic, safety and efficacy profile of DEX in premature
and full-term neonates ages ≥28 wks to ≤44 wks gestational age
admitted to an intensive care unit.
Methods: 36 initially intubated and mechanically ventilated
patients were grouped by age: group I patients (N=12) were premature
neonates ≥28 wks to <36 wks, and group II patients (N=24) were term
neonates ≥36 wks to ≤44 wks gestational age. Within each age group,
there were 3 escalating DEX dose levels that included a loading dose
(LD, mcg/kg) over 10 mins followed by a maintenance dose (MD,
mcg/kg/hr) for 6-24 hrs duration: level 1: 0.05 LD/0.05 MD; level 2:
0.1 LD/0.1 MD; and level 3: 0.2 LD/0.2 MD.
Results: All patients who enrolled to receive DEX completed
the treatment. The mean gestational age for group I-level 1 and
2 was 30.3 and 32.5 wks, and 38.7 wks for group II levels 1-3.
Adequate sedation was seen in most patients and rescue sedation
with midazolam (0.22 В± 0.26 mg/kg) was given in 4 patients (17%)
in group II. Rescue analgesia with fentanyl was given in 2 (17%)
patients in group I and 11 (46%) patients in group II. 5 (21%)
patients in group II received rescue morphine. In group I, level 1
and 2, DEX weight adjusted clearance (CLw) was 0.41 and 0.29
L/hr/kg, maximum plasma concentration (Cmax) was 102 and 107
pg/mL, volume of distribution (Vssw) was 2.7 and 3.8 L/kg, and
elimination tВЅ was 3 and 8 hrs respectively. In group 2, level 1,
2 and 3 CLw was 0.61, 0.64 and 0.73 L/hr/kg, Cmax was 78, 122
and 326 pg/mL, Vssw was 1.4, 2.8 and 2.1 L/kg, and tВЅ was 3, 5
and 3 hrs respectively. A lower CLw was observed in group I and
total exposure (AUC) was 4.5 times larger than group II. The safety
profile observed was typical of the critically ill, high risk pediatric
population and post-operative surgical patients. Adverse events
(AEs) were reported in 8 (67%) patients in group I and 15 (62%)
patients in group II; only 3 (8.3%) patients reported AEs related to
DEX. In group I bradycardia and diastolic hypotension were each
reported by 1 (8.3%) patient and hypertension was reported by 1
(4.2%) patient in group II. None had serious AEs related to DEX or
AEs needing DEX discontinuation.
Introduction: Sedation and analgesia are important therapies
in the pediatric intensive care unit (PICU). Prolonged administration
of benzodiazepines and opioids may result in delirium, physical
dependence, tolerance and withdrawal upon discontinuation.
Dexmedetomidine (DEX), a highly selective alpha-2 adrenergic
agonist, is used in pediatric patients for sedation during and after
mechanical ventilation. The safety and efficacy of DEX for sedation
in intubated, mechanically ventilated children in the PICU was
investigated.
Methods: 175 PICU patients were randomized to receive either
low-dose (LD) DEX (n=89) or high-dose (HD) DEX (n=86). In
the LD group, cardiopulmonary bypass (CPB) patients received
0.2 mcg/kg followed by 0.025-0.5 mcg/kg/hr; non-CPB patients
received 0.3 mcg/kg followed by 0.05-0.5 mcg/kg/hr. In the HD
group, post-CPB patients received 0.5 mcg/kg followed by 0.10.7 mcg/kg/hr; non-CPB patients received 0.6 mcg/kg followed
by 0.2-1.4 mcg/kg/hr. Patients were also grouped by age: group 1
was ≥1 to <24 months; group 2 was ≥24 months to <17 years. The
primary endpoint was the percent of patients that did not require
rescue midazolam (MDZ) to achieve adequate sedation, measured
by a University of Michigan Sedation Scale (UMSS) score of 1-3
while intubated. Total amount of rescue MDZ was summarized by
descriptive statistics and difference between groups was assessed by
PROC NPAR1WAY.
Results: 77 patients in the LD group and 76 patients in the
HD group completed treatment. The LD group had a mean age of
10.7 months versus 14.7 months in the HD group. A nonsignificant
(p=0.28) dose response effect was observed with more patients
in the HD group (54.3%) not requiring rescue MDZ to maintain
the target sedation than in the LD group (44.6%), irrespective of
age. The difference in the median amount of rescue MDZ between
LD and HD groups was not statistically significant. There was a
nonsignificant trend toward increased efficacy in HD, post-CPB
patients, wherein more patients did not require supplemental MDZ
rescue compared to patients in the LD group (27.3% vs 50.0%;
p=0.10). No clinical difference in safety profile of LD and HD was
found. There did not appear to be an increased incidence of DEXrelated adverse events in this pediatric population.
Discussion: DEX is effective at sedating premature and term
neonates and is well tolerated without significant AEs. Premature
neonates appear to have lower CLw and longer elimination tВЅ.
Discussion: DEX was effective at sedating critically ill infants
and children following major cardiac surgery with CPB as well as
non-cardiac surgery. DEX was well-tolerated in children at all doses
studied in both groups. A limitation of this study was the overlap in
DEX dosing in the HD and LD groups. Future studies are needed
to determine if DEX administration reduces the amount of MDZ
needed for sedation in children following major surgery.
References: N/A
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Pediatric Anesthesia
Neonatal Safety & Anesthetics
ABSTRACTS
S-399
ANESTH ANALG
2012; 114; S-01 – S-493
S-399.
ISOFLURANE EXPOSURE IS ASSOCIATED WITH
DECREASED MIGRATION AND ALTERED ACTIVATION
MORPHOLOGY IN CULTURED RODENT MICROGLIA
AUTHORS: R. Zhu, C. D. Bub, J. M. O’Donnell, V. L. Jacobs, S.
C. Hillier, E. A. Romero-Sandoval
affiliation: Anesthesiology, Dartmouth-Hitchcock Medical
Center, Lebanon, NH
Introduction: Neurotoxicity is associated with anesthetic
exposure during critical phases of brain development in animals,
resulting in persistent adverse neurobehavioural effects. However,
the mechanisms underlying the long-term neurocognitive deficit
occuring after a discrete anesthetic exposure remain uncertain.
Because microglia serve important neuromodulatory, neurotrophic,
and neurodevelopmental roles, the effects of anesthetic exposure
on microglial survival and function may be significant and
relevant. Thus, we evaluated survival, migration, morphology, and
inflammatory mediator release in immortalized microglial cultures
after exposure to isoflurane.
Microglial Migration. 3 h exposure to isoflurane inhibited migration in BV-2
cells. 1 h and 3 h exposed BV-2 cells migrated towards 0.1 uM ADP for 2 h.
Results are shown as mean cell counts per 20x field as percentage of control
+/- SEM for all treatment groups. *p<0.01
Methods: Murine-derived BV-2 immortalized microglia were
cultured as described previously1. Viability was confirmed by trypan
blue staining prior to exposure to 3% isoflurane in 21% O2 / 5%CO2
/ 74%N2 for 0, 1, or 3 hours. The following elements of microglial
function were evaluated. ADP-stimulated microglial migration
using Boyden Chambers, microglial death and early apoptosis were
quantified using Flourescence Activated Cell Sorting (FACS) with
Propidium Iodide and Annexin V labeling respectively. Microglial
morphology was graded by a blinded observer using medium
power microscopy and a 4-point glial activation scale (1 = reactive,
condensed and elongated cytoplasm with processes, to 4 = quiescent,
speading cytoplasm with few processes), as described previously2.
Finally, LPS-stimulated release of inflammatory mediators IL-6 and
TNF-О± were measured using ELISA of cell culture supernatant.
Results: Microglial exposure to either 1 or 3 hours of isoflurane
had no effect on LPS-stimulated IL-6 or TNF-О± release. Similarly,
microglial apoptosis and/or cell death were not significantly
increased by isoflurane exposure. However, a 3 hour exposure to
isoflurane was associated with a significant decrease in microglial
migration. Isoflurane exposure was also associated with significantly
altered microglial morphology, reflecting increased glial activation.
Activation Morphology. 3 h exposure to isoflurane alters migrated microglial
morphology. Multiple 20x field images were scored on a scale of 1-4. Results
displayed as mean score with 95% C.I., p<0.01.
Discussion: Microglia are abundant, highly motile, non-neuronal
cells with important roles in synaptic maintenance, maturation,
and elimination3,4. Alterations in microglial function, particularly
motility, may adversely affect neurodevelopment. Further work is
ongoing to characterize the mechanisms underlying these isofluraneinduced alterations in microglial motility and morphology.
However, it remains to be determined if there are neuro-maturational
consequences associated with these phenomena.
References:
1. J. Neurochem 2008;107:557-69
2. J. Neuroinflammation 2011;8:121
3. Nature Neuroscience 2007;10:1387-94
4. Science 2011;333:1456-8
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-400
S-401
ANESTH ANALG
2012; 114; S-01 – S-493
S-400.
S-401.
INCREASING CUMULATIVE EXPOSURE TO
VOLATILE ANESTHETIC AGENTS AND NARCOTICS IS
ASSOCIATED WITH POORER NEURODEVELOPMENTAL
OUTCOMES IN PATIENTS WITH HYPOPLASTIC LEFT
HEART SYNDROME
CARBON MONOXIDE PREVENTS ANESTHESIA-INDUCED
NEUROAPOPTOSIS IN NEWBORN MICE
AUTHORS: L. K. Diaz1, S. Koh2, M. Gerdes3, X. Luan3,
M. Rehman1, J. W. Gaynor2
Introduction: Volatile anesthetics cause wide-spread neuroВ­
apoptosis in the developing brain1. Carbon monoxide (CO) has
ant-apoptotic properties and exhaled endogenous CO is commonly
re-breathed during low-flow anesthesia in infants and children
resulting in sub-clinical CO exposure2,3. We hypothesized that low
concentrations of CO inspired during volatile anesthetic exposure
would prevent anesthesia-induced neuroapoptosis. We aimed to
quantify the number of activated caspase-3 cells and TUNEL
positive nuclei in the developing brain following concomitant
exposure to CO and isoflurane.
affiliation: 1Anesthesiology and Critical Care Medicine,
The Children’s Hospital of Philadelphia, Philadelphia, PA;
2
Cardiothoracic Surgery, The Children’s Hospital of Philadelphia,
Philadelphia, PA; 3Pediatrics, The Children’s Hospital of
Philadelphia, Philadelphia, PA
Introduction: Despite improved survival with staged
reconstruction neurodevelopmental (ND) dysfunction is common
in patients with hypoplastic left heart syndrome (HLHS)1,2. Animal
and human studies suggest that repeated exposures to anesthetic
agents may be toxic to the immature brain3,4. The role of cumulative
exposure to volatile anesthetic agents (VAA), and fentanyl in ND
disability in patients with HLHS is not known.
Methods: In a study of genetic polymorphisms and ND outcome
after cardiac surgery, 96 children with HLHS underwent assessment
of ND status at 4 years of age including cognition, processing speed,
language, attention, impulsivity, memory, executive function,
social competence, academic achievement, visual-motor and finemotor skills. Total exposure to VAA and fentanyl for cardiac and
noncardiac surgeries from birth to 4 year testing was derived from
an anesthetic database and intensive care unit (ICU) flowsheets.
Exposure to halothane, isoflurane, sevoflurane and/or desflurane
was converted to age-adjusted minimum alveolar concentrationhours (MAC-hrs) and summed to yield total VAA exposure. Total
intravenous fentanyl dosage (bolus and continuous infusion) was
calculated in micrograms/kg (Ојg/kg). The effect of exposure to VAA
and fentanyl on ND outcomes was evaluated using multivariate
logistic regression.
Results: All patients had intraoperative fentanyl and VAA
exposure, and all received fentanyl in the ICU. 537 anesthetic
exposures were evaluated; 478 had VAA, with total VAA exposure
ranging from 0.9-35.3 MAC-hrs (median 7.54). There were 337
intraoperative fentanyl exposures. Cumulative intraoperative and
ICU fentanyl dosage ranged from 118.59 to 3998.28 Ојg/kg (median
309.87). After adjustment for patient and operative confounders
(including stage 1 length of stay and number of cardiac operations),
increasing VAA exposure was associated with worse full-scale
IQ, total language, executive function, memory, reading and math
skills (all p< 0.05). Increasing fentanyl exposure predicted worse
full scale IQ, total language, processing speed, memory, fine motor
skills and math skills (all p< 0.05). (See supp data)
Discussion: These findings support the hypothesis that in HLHS
patients increased cumulative exposure to both VAA and fentanyl
results in worse ND outcomes. Anesthetic and postoperative sedative
management are modifiable. Clinical trials are indicated to confirm
these findings and to determine if other anesthetic and analgesic/
sedative strategies are associated with less impaired outcomes.
AUTHORS: R. Levy, Y. Cheng
affiliation: Washington, DC
Methods: 7 day old male CD-1 mice underwent 1-hour exposure
to 0 ppm (air), 5 ppm, or 100 ppm CO in air with or without isoflurane
(2%). Thus, six different cohorts were evaluated. Five hours after
exposure, brains were harvested and immunohistochemistry for
activated caspase-3 and TUNEL assays were performed. Three
to four slices per animal were assessed and three mice per cohort
were evaluated. In a separate cohort, carboxyhemoglobin levels
(COHb%) were measured immediately after exposure. Change in
COHb% was assessed with T-test and significance set at P<.05. The
number of caspase-3 positive cells and TUNEL positive nuclei were
determined in primary somatosensory neurocortex, hippocampus,
and hypothalamus/thalamus. Significance was assessed with
ANOVA and post hoc Tukey’s test.
Results: COHb% increased significantly following exposure
to 5 ppm and 100 ppm CO in a concentration-dependent manner
compared to air exposed controls. Isoflurane significantly increased
the number of activated caspase-3 positive cells and TUNEL
positive nuclei in all regions of the brain examined in air-exposed
mice. CO exposure abrogated isoflurane-induced increases in
activated caspase-3 and TUNEL positive nuclei in each brain region
in a dose-dependent manner.
Discussion: Consistent with prior reports, 1-hour isoflurane
exposure increased neuroapoptosis in several regions of the
developing brain4. Exposure to 5 ppm and 100 ppm CO increased
COHb% confirming time-weighted exposure. Both concentrations
of CO prevented isoflurane-induced neuroapoptosis in each brain
region in a dose-dependent manner. Thus, low-flow anesthesia
designed to result in re-breathing of specific concentrations of
CO may be a desired strategy to prevent anesthesia-induced
neurotoxicity in infants and children.
References:
1.Istaphanous GK, Loepke AW. Curr Opin Anaesthesiol. 22:36873, 2009.
2. Zhou H, et.al. Exp Biol Med. 235:1236-43, 2010.
3. Nasr V, et.al. Br J Anaesth. 105:836-41, 2010.
4.Johnson SA, Young C, Olney JW. J Neurosurg Anesthesiol.
20:21-8, 2008.
References:
1. Int J Pediatr 2010; 2010: 1-13.
2. Paediatr Anaesth 2011; 21: 554-559.
3. Anesth Analg 2011;113:1170-9.
4. Pediatrics 2011; 128: 5 e1053-e1061.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-402
S-403
ANESTH ANALG
2012; 114; S-01 – S-493
S-402.
S-403.
COMPARATIVE NEUROTOXIC EFFECTS OF
DEXMEDETOMIDINE AND KETAMINE IN PRENATAL
MONKEY BRAINS
EFFECTS OF EXPOSURE TO GENERAL ANAESTHESIA IN
INFANCY ON ACADEMIC PERFORMANCE AT AGE 12
AUTHORS: E. Koo , T. Oshodi
affiliation: 1Department of Paediatric Anaesthesia, KK
Women’s and Children’s Hospital, Singapore, Singapore; 2Singapore
Polytechnic, Singapore, Singapore; 3National University of
Singapore High School of Mathematics and Science, Singapore,
Singapore
1
2
affiliation: 1Research and Development - Preclinical, Hospira,
Inc., Lake Forest, IL; 2Maccine Pte Ltd, Singapore, Singapore
Introduction: Previous studies have demonstrated that ketaВ­
mine induced apoptosis and degeneration in developing monkey
brains (Slikker 2007, Zou 2009). Dexmedetomidine (Dex) is a
general anesthetic with a different mechanism of action from
ketamine. The present study compared the neurotoxic effects of the
two drugs in prenatal Cynomolgus monkeys.
Methods: Twenty pregnant monkeys at approximate gestation
day 120 (В±7days) were divided into 4 groups. Group 1 animals were
cage controls and did not receive any treatment. Group 2 animals
were dosed with Ketamine at 20mg/kg IM followed by a 12-hour
infusion at 20-50mg/kg/hr. Group 3 animals received Dex at 3Вµg/
kg IV over 10 minutes followed by a 12-hour infusion at 3Вµg/kg/
hr (HED). Group 4 animals received Dex at 30Вµg/kg IV over 10
minutes followed by a 12-hour infusion at 30Вµg/kg/hr (10X HED).
Six hours following end of infusion, all animals were anesthetized
with Ketamine (20mg/kg IM) and each fetus was removed by
C-section. The entire duration of the C-section was no longer than 1
hour to minimize the exposure of ketamine to the fetus (especially
the control and Dex-treated animals). Blood samples from both the
dams and fetuses were measured for the concentration of Dex. Each
fetus was perfusion-fixed with 10% NBF and the brains were then
removed from all fetuses, stored in 10% NBF and processed for
paraffin sections. Serial sections were cut through the frontal cortex
and were stained to detect for apoptosis (Caspase 3 and TUNEL)
and neurodegeneration (silver stain). The slides were evaluated
by a board-certified veterinary pathologist and the incidences of
neuroapoptotic and neurodegenerative cells were quantified.
Challenging Case Report: N/A
Results: There were no significant neuroapoptotic lesions
present in untreated fetal brains. In-Utero treatment with Ketamine
resulted in marked apoptosis and degeneration primarily in Layers
I and II of the frontal cortex, thus reproducing previous findings
reported by Slikker and Zou. In contrast, fetal brains from animals
treated with Dex showed none to minimal neuroapoptotic or
neurodegenerative lesions at both the low- and high-dose levels;
lesion incidence for both groups were similar to untreated controls.
PK samples confirmed systemic exposure of Dex in both dams and
fetuses.
Discussion: The current study showed that unlike ketamine,
Dexmedetomidine at both the low-dose (HED) and at 10X HED;
did not induce apoptosis in the developing brain of Cynomolgus
monkeys.
References:
Slikker, W., et. al. “Ketamine-induced neuronal cell death in the
perinatal rhesus Monkey.” Tox Sci 98:145-158, 2007.
Zou, X, et. al.“ Prolonged exposure to ketamine increases neurode­
gen­er­ation in the developing monkey brain.” Int J Devl Neuroscience
27:727-731, 2009.
AUTHORS: C. L. Bong1, J. Tan1, I. W. Koh2, J. Soo3, S. Lum3
Introduction: Studies in animal models have shown that
exposure to general anaesthetic (GA) agents in neonatal life cause
irreversible damage to the developing brain.1,2 Human cohort studies
also suggest that children exposed to GA in early childhood were
more likely to have behavioral problems3 and learning disabilities4.
We aimed to determine if exposure to GA during infancy for minor
surgery in otherwise healthy children would predispose them to
poorer academic achievement at age 12, based on aggregate scores
achieved in the Primary School Leaving Examination (PSLE), when
compared to children with no previous exposure to GA.
Methods: From our hospital database, children born in 19981999 with no pre-existing medical conditions, who were exposed
to general inhalational anaesthesia for minor surgical procedures
(herniotomies, circumcision, pyloric stenosis) before age 1 were
compared to age-matched controls with no previous exposure to GA.
Exclusion criteria: prematurity, genetic disorders, central nervous
system disorders, major congenital cardiac defects, severe renal
disorders and family history of developmental delay, intellectual
disability and psychological disorders. Parents of participants
completed a 20-minute telephone interview with questions on their
medical history, school and home environment. Primary outcome
measure was the aggregate score achieved in the standardized PSLE
exam taken at age 12, a surrogate measure of functional outcome.
Secondary outcome measure was the diagnosis of learning disability
at age 12.
Results: 103 subjects and 119 controls completed the study.
(Subjects: 257 identified, 182 contactable, 24 declined, 46 excluded
per exclusion criteria, 103 recruited. Controls: 322 identified, 197
contactable, 49 declined, 19 excluded, 119 recruited.) The incidence
of learning disability was 16.8% higher in subjects relative to the
controls(21.9% vs 5.1% P<0.001). After correcting for number
of previous GAs, race, gender, maternal education, housing and
learning disability, there was a mean reduction of 4.4 points in PSLE
aggregate scores in the subjects relative to the controls (P=0.414;
effect size = 0.11 SD; P=0.414).
Discussion: Exposure to GA in otherwise healthy children
for minor surgery before their first birthday was associated with
a significantly higher incidence of learning disability at age 12.
However, in the absence of any learning disability, there was no
significant difference in the academic achievements of these
children at age 12 relative to children who had never been exposed
to anaesthesia.
References:
1. J Neurosci 2003; 23:876-82
2. Br J Pharmacol 2005; 146:189-197
3. Anesthesiology 2009; 110:805-12
4. Anesthesiology 2009; 110:796-804
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-404
S-405
ANESTH ANALG
2012; 114; S-01 – S-493
S-404.
S-405.
METABOLIC STATUS IN NEONATAL RAT BRAIN IN
RESPONSE TO GENERAL ANESTHESIA DIFFERS FROM
THE YOUNG RAT BRAIN: THE ROLE OF GLUTAMATE
EMBRYONIC STEM CELL BASED INSIGHTS
INTO ANESTHESIA INDUCED COGNITIVE DEFICIT:
A ROLE FOR ALTERED NEUROGENESIS
AUTHORS: R. Makaryus, H. Lee, Z. Jacob, M. Yu, T. Feng,
H. Benveniste
AUTHORS: O. Johnson-Akeju1, K. Eggan2
affiliation: Anesthesiology, Stony Brook University Medical
Center, Stony Brook, NY
Introduction: Proton magnetic resonance spectroscopy
(1HMRS) can be used to detect abnormalities in the brain, which
may reveal neuronal injuries, ischemia, inflammation, and even
possibly neurogenesis and apoptosis. We previously showed that
cerebral metabolomic patterns depend on anesthetic regimen used.1
The main differences seen in adult animals are an increase in the
levels of glutamate and lactate in response to inhalational agents as
compared to intravenous agents.1 We sought to determine if these
differences would also be seen in younger animals, particularly
those undergoing synaptogenesis (PND 6 - 11) and slightly older
animals (PND 21 - 36).
Methods: Following approval by the local IACUC, rats were
divided into four groups based on age and anesthesia exposure:
Neonatal Sevoflurane (n=11), Neonatal Propofol (n=10), Weaned
Sevoflurane (n=8), and Weaned Propofol (n=9). All animals were
monitored for respiratory rate, heart rate, temperature, and O2 sats
while breathing 60% O2. The sevoflurane groups received 1 MAC
Sevoflurane, while the propofol groups received 1 MAC equivalent
doses. Total anesthesia duration for all animals was 6 hours;
1HMRS was performed in the hippocampus and thalamic regions
using a 9.4T MRI.
Results: Age and body weights were matched across groups.
Metabolite milli-molar values attained via LCModel were compared
across all four groups using two-way ANOVA analysis. Multiple
metabolites differed by animal age; however, glutamate [glu] was
the only one that differed by type of anesthesia with p < 0.0001 for
both brain regions. Post-hoc analysis revealed that glutamate was
significantly higher in the weaned group; however, for the neonatal
animals, there was no significant difference in glutamate between
the two anesthetics. PLS-DA analysis showed a clear separation
between the four groups with a significant Q2 value of >0.3 for both
regions, and confirmed our ANOVA results.
Discussion: Although [Glu] trended to increase in the neonatal
brain with sevoflurane, the baseline [glu] was lower compared to
the young animals, which is probably related to brain maturity.
Glutamate is the primary excitatory neurotransmitter in the brain
and is also an essential intermediary in energy metabolism. Clearly
from the point of view that [Glu] is representing metabolism, lower
[Glu] in neonatal brain signifies lower metabolism and/or neuronal
activity in agreement with neurophysiological data. The significance
of the metabolic profiles in relation to potential neurotoxicity is
currently being investigated
References:
1.Makaryus R, Lee H, et al. The metabolomic profile during
isoflurane anesthesia differs from propofol anesthesia in the live
rodent brain. J Cereb Blood Flow Metab. Jan 26 2011
affiliation: 1Department of Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, MA; 2Stem
Cell and Regenerative Biology, Harvard Stem Cell Institute,
Cambridge, MA
Introduction: Evidence from animal studies suggesting that
anesthetic agents induce neuronal degeneration has prompted the
proposal of a direct causal link between anesthesia induced neuronal
degeneration and cognitive decline. However, anesthetic related
cognitive decline has a delayed onset and is progressive in nature
suggesting that alteration of hippocampal-dependent neurogenesis
is a likely contributing factor1. Since most agents implicated
in cognitive decline are ubiquitous in their receptor targets, a
precise understanding of the alterations induced by these agents is
challenging. In this study, we describe the use of a mouse embryonic
stem cell (MESC) approach to study this problem.
Methods: An in vitro motor neuron differentiation model was
used to circumvent the lack of robust and sub-type specific generation
of cortical neuronal generation from stem cell models.The effects
of candidate receptor modulators were systematically screened
via immunofluorescence microscopy during HB9::GFP transgenic
MESC directed neuronal differentiation. Quantification was
performed by flow cytometry (BD LSRFortessa). Immunostaining
for pan-neuronal markers was also performed. Forced expression
of defined transcription factors in HB9::GFP embryonic mousefibroblasts generated functional induced motor neurons (iMN’s) that
do not traverse through a progenitor intermediate. We then tested
the promising result from our initial screen in this model. Finally, a
micro-array analysis (illumina MouseRef-8 v2) to elicit a candidate
gene list was performed.
Results: Ketamine had a significant time and concentration
dependent detrimental effect on neurogenesis (p<0.05, Tukey’s
HSD), distinct from the direct toxic effect of the various drug/
drug combinations screened. MK-801 also had a similar effect on
neurogenesis, implicating the NMDA receptor (p<0.05, Tukey’s
HSD). Immunostaining for neuronal markers confirmed that the
effect we observed was not specific to motor neuron generation. We
found that ketamine had non-significant effects on iMN generation
even at toxic doses, likely because iMN’s do not transition through
a neural progenitor state. Finally, transcriptional profiling helped
characterize candidate genes for further analyses.
Discussion: In summary, through a systematic approach, we
provide evidence that prolonged NMDA receptor antagonism of a
progenitor pool is sufficient to impair neurogenesis. Furthermore, to
propose a principled mechanistic account of this phenomenon, we
have elicited candidate downstream targets for functional studies.
Further studies are underway to assess whether these observations
can be recapitulated in a human in vitro model.
References:
1. Stratmann. Anesth Analg. 2011;113(5):1170
Animal Groups – Age and Weight
Average Age (days)
Average Weight (grams)
Neonatal Sevoflurane
8.3
20.6
Neonatal Propofol
8.7
24.9
Weaned Sevoflurane
28.0
87.6
Weaned Propofol
27.2
92.7
Temperatures were kept strictly at 36.9В±0.29В°C
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-406
S-406.
CHRONIC MORPHINE ADMINISTRATION LEADS TO
INCREASED NEUROAPOPTOSIS IN NEWBORN RATS
AUTHORS: D. Bajic, K. G. Commons, S. G. Soriano
affiliation: Department of Anesthesiology, Perioperative and
Pain Medicine, Children’s Hospital Boston, Boston, MA
Introduction: Prolonged neonatal opioid exposure has been
associated with faster onset of opioid analgesic tolerance1, and a longterm neurodevelopmental delay, cognitive and motor impairment2.
We hypothesized that neurotoxicity in the form of apoptotic cell
death would be increased in association with development of
antinociceptive tolerance to morphine in developing rat.
Methods: The Institutional Animal Care and Use Committee at
our institution approved the experimental protocol for the use of
animals in this study. Three groups of newborn rats were analyzed:
(1) naГЇve group (n=6) that did not receive any treatment; (2) control
group (n=5) that received only normal saline (NS); and (3) chronic
morphine group (n=8) that received only morphine. Morphine
sulfate or equal volume of NS was injected subcutaneously twice
daily for 6.5 days starting on the postnatal day 1 (PD1). Apoptotic
neurons were labeled using immunohistochemical technique against
caspase-3. Apoptotic cells were counted in different anatomical
regions: somatosensory cortex, amygdala, hippocampus, and
periaqueductal gray of the midbrain. The mean density (#Caspase-3
immunolabeled cells/section/brain В± SD) was counted for each
anatomical region. We have used ANOVA to determine statistical
difference between treatment groups. Behavioral study using Hot
Plate Test confirmed development of antinociceptive tolerance to
chronic morphine in separate groups of animals (n=6/group).
Results: Chronic morphine administration was associated with
(1) analgesic tolerance, and (2) statistically significant increase in
density of apoptotic cells in somatosensory cortex and amygdala,
but not in hippocampus or periaqueductal gray. Caspase-3
immunoreactive cells exhibited morphology analogue to different
types of neurons.
Discussion: Although several reports have demonstrated
neuroapoptosis following opioid administration in vitro3 and in
vivo at the spinal cord level in adult rats4, our study demonstrates
increased supraspinal apoptosis in developing brain (PD7).
Increased apoptosis is selectively found in distinct anatomical
regions important for sensory processing (somatosensory cortex)
and memory of emotional processing (amygdala), and did not affect
brain areas important for learning (hippocampus) or nociceptive
processing (periaqueductal gray). Future studies should examine
apoptosis following chronic opioid administration in the context of
pain.
References:
1.Anand, K.J., et al. Arch Pediatr Adolesc Med, 1999. 153(4): p.
331-8.
2.McGlone, L., H. Mactier, and L.T. Weaver. Arch Dis Child,
2009. 94(9): p. 708-12.
3.Singhal, P.C., et al. J Immunol, 1998. 160(4): p. 1886-93.
4.Mao, J., et al. J Neurosci, 2002. 22(17): p. 7650-61.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
Pharmacology – Basic Science
ABSTRACTS
S-412
S-413
S-412.
S-413.
A CENTURY IN PURSUIT OF THE UNITARY IDEAL:
CAUSES AND CONSEQUENCES
WITHDRAWN.
AUTHOR: M. Perouansky
affiliation: Anesthesiology, University of Wisconsin SMPH,
Madison, WI
Introduction: Why scientists sought for so long a single
universal mechanism to explain how a diverse group of agents
caused a behavioral state as complex as anesthesia is far from
obvious. An accepted truism among clinicians and researchers
attributes this perseverance in the search for a unitary mechanism
in general and the long-standing domination of lipoid theories in
particular to the influence of Hans Meyer and Ernest Overton. Their
independent work, published at the turn of the 19th to the 20th
century, is typically presented as being at the root of the quest for
the holy grail of a unitary mechanism of anesthetic action.
Methods: A thorough review of the original literature published
in that period was conducted and the results challenge this view.
Results: Meyer and Overton inherited the paradigm of a
�unitary’ explanation of anesthetic action from earlier work where
both the likely target (lipids) and the underlying mechanism
(universal) are concerned. Their work was targeted at systematizing
existing knowledge, not at the discovery of novelty.The paradigm
was formulated by Claude Bernard, arguably the greatest scientific
authorities in the life sciences of the 19th century. Bernard firmly
believed that the sensitivity to anesthesia was fundamental criterion
that separated true �life’ from mere �chemistry’. If true, this would
have been an invaluable argument in the then raging debate between
physicalists and vitalists about the nature of life. His belief paired
with his scientific authority are largely responsible for establishing
universality as the overarching paradigm of anesthetic mechanisms.
Discussion: Bernard’s paradigm determined for over a century
both the nature and, more importantly, the interpretation of
experiments that addressed mechanisms of anesthetic action.
The experiments that led to the Meyer-Overton rule were a
consequence of the unitary paradigm, not its source. Lipids, in turn,
rose to prominence against the likes of protagon and colloids only
decades later - much like mammals succeeded the dinosaurs: not
by virtue of inherent strength but as a result of their competitors’
weakness.
Time has shown that it has been easier to shed an individual target
(lipids) than to abandon the paradigm (universality).
References:
Ernst v. Bibra, Emil Harless, Erlangen, 1847
Claude Bernard: Leçons sur ., Paris 1875
Claude Bernard: Leçons sur ., Paris 1878
Hans Meyer: Welche Eigenschaft., 1899
Ernest Overton: Studien uber die Narkose, Jena, 1901
J. T. Gwathmey: Anesthesia, New York, 1918
Hans Winterstein: Die Narkose ..., Berlin, 1919
J.H. Burn, H.G. Epstein, Brit.Med.J. 1946;533-535
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-414
S-414.
withdrawn.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-415
S-415.
PHAXANCDв„ў, A CAPTISOLВ®-ENABLED WATER SOLUBLE
PREPARATION OF ALPHAXALONE FOR INTRAVENOUS
ANESTHESIA AND SEDATION: COMPARISON OF
TOXICITY WITH PROPOFOL AND ALTHESINВ® IN RATS
AUTHORS: C. S. Goodchild , A. Kolosov1, B. Boyd , J. M. Serrao
1,3
2
3
affiliation: 1Monash Institute of Medical Research, Monash
University, Clayton, VIC, Australia; 2Faculty of Pharmacy and
Pharmaceutical Sciences, Monash University, Parkville, VIC,
Australia; 3Drawbridge Pharmaceuticals Pty Ltd, Malvern, VIC,
Australia
Introduction: Alphaxalone is a neuroactive steroid anesthetic.
This water-insoluble drug, initially formulated using CremophorEL
(AlthesinВ®)(1), was found to be a versatile and safe intravenous
anesthetic that was used in clinical practice in many countries from
1972-1984. Its therapeutic index (LD50 Г· AD50) was 15-20(2).
By comparison the therapeutic index of propofol is reported to be
в€ј 6(3). AlthesinВ® was withdrawn from clinical practice because
of hypersensitivity to the CremophorEL. Subsequent attempts to
make an aqueous formulation of alphaxalone suitable for human
use have failed. PhaxanCDв„ў is a solution of alphaxalone 10mg/
ml dissolved in 0.9% saline and 13% CaptisolВ® (7-sulfobutylether
ОІ-cyclodextrin; a molecule with a lipophilic cavity that enables drug
dispersal in water for human use).
ANESTH ANALG
2012; 114; S-01 – S-493
Therapeutic Index of Anesthetic formulations
of alphaxalone and propofol
Anesthetic formulation
AD50
LD50
Therapeutic
(mg.kg-1) (mg.kg-1)
Index
PHAX (alphaxalone in CaptisolВ®)
2.79
>84
>30
ALTH (alphaxalone in
CremophorEL)
2.95
43.6
14.8
PROP (propofol in lipid emulsion)
4.63
27.7
5.98
The alphaxaolone preparations are equipotent as anesthetics and less
toxic than the lipid formulation of propofol. The CaptisolВ® preparation of
alphaxalone is also less toxic than the Cremophor preparation of the same
compound
Objectives:
1. measure the doses of PhaxanCDв„ў that cause anesthesia and
lethality in rats and
2. compare the therapeutic index of PhaxanCDв„ў with propofol and
AlthesinВ®
Methods: The studies below were approved by our University IRB.
Alphaxalone (10mg.ml-1) was prepared using 13% CaptisolВ®
and saline (PhaxanCD® - PHAX). An “Althesin®-like” solution
of alphaxalone was prepared in 20% CremophorEL (ALTH)
as described previously(2). Jugular intravenous catheters were
implanted in male Wistar rats (150-200g). Separate groups of
ten rats each were given intravenous injections of PHAX, ALTH
or propofol emulsion [10mg.ml-1; PROP] from 1.25 mg.kg-1 to
lethal doses. Doses of each agent that caused anaesthesia (loss of
righting reflex) and lethality in 50% of rats (AD50 and LD50) were
calculated by probit analysis.
Results: Intravenous PHAX, ALTH and PROP caused doserelated sedation and anesthesia, AD50 values being 2.79, 2.95 and
4.63 mg.kg -1 respectively. Propofol was 100% lethal at doses
greater than 30 mg.kg-1 (LD50 = 27.7 mg.kg-1). At doses of
alphaxalone between 50 and 60 mg.kg-1 all rats given AlthesinВ®
died (LD50 = 43.6 mg.kg-1) whereas none died when given the
same doses of alphaxalone as PhaxanCDв„ў which caused no more
than 20% lethality even at the maximum dose tested of 84 mg.kg-1.
Control experiments with the vehicles of the three preparations
given alone showed no toxicity but the presence of CaptisolВ®
increased the therapeutic index of alphaxalone in PHAX compared
with ALTH.
Discussion: The alphaxalone formulations (PhaxanCDв„ў and
AlthesinВ®) are equipotent anesthetics, causing fast onset anesthesia
with 1.6 times the potency of propofol. PhaxanCDв„ў is less toxic
than the propofol lipid formulation and also the alphaxalone
formulation in CremophorEL (AlthesinВ®).
References:
1. Br J Anaesth 1980 52(4):363-5.
2. Postgrad Med J 1972 48:Suppl-7.
Probit regression on PhaxanCDв„ў lethality data could not be completed
because increasing dose of PhaxanCDв„ў caused a maximum death rate of
20%; further increase in dose led to no further increase in lethality - there was
a ceiling effect for lethality
3 . Anaesthesia 1987 42(10):1045-50.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-416
S-416.
EFFECT OF BRAIN LIDOCAINE CONCENTRATION
ON PROPOFOL SEDATION IN RATS
AUTHORS: H. Ma1,2, J. Mao1, J. Meng1, X. Chen1, N. Zhang1,
Y. Saito2
affiliation: 1Anesthesiology Department, General Hospital
of Ningxia Medical University, Yinchuan, China; 2Anesthesiology
Department, Shimane University Faculty of Medicine, Izumo, Japan
Introduction: It is reported that spinal anesthesia and
epidural anesthesia has sedative effect. However, the underlying
mechanism of sedative effect is not clear. Several studies supported
that deafferentation is the main possible mechanism, but Pollock
reported that possibly favouring direct action on the brain by the
spread of cerebrospinal fluid. This study was to investigate the effect
of brain lidocaine concentration on propofol sedation in rats.
Methods: With our institutional approval, Sprague-Dawley
male rats were used in this study. After intrathecal catheterization,
40 Sprague-Dawley rats were randomly assigned to one of four
groups and ten rats in each group: intrathecal lidocaine group (IT-L
group), intravenous lidocaine group (IV-L group), intrathecal normal
saline group (IT-NS group) and controls which were respectively
received lidocaine (2%, 15 microliter) intrathecal injection,
lidocaine (2%, 15 microliter) intravenous injection, normal saline
15 microliter intrathecal injection and without any injection. And
then intravenously infused propofol and the dosage of propofol
required to ablate the eyelid reflex were recorded and compared
among four groups. After propofol requirements measurement, the
rats were sacrificed with an overdose of propofol in IT-L group and
IV-L group for determination of brain lidocaine concentrations by
RP-HPLC and compared between two groups. Propofol dose was
compared using ANOVA followed by Scheffe’s tests, and brain
lidocaine concentrations was compared by paired t-test, and p<0.05
was considered statistically significant.
Results: The dose of propofol required to ablate the eyelid
reflex were significantly decreased in IT-L group (8.20В±0.95 mg/
kg) compared with that in IV-L group (10.61В±0.92 mg/kg), ITNS group(11.65В±0.91 mg/kg) and controls (11.26В±1.23 mg/
kg) (P<0.001) (Fig.1). No significant difference was found in
the propofol requirement between IV-L group, IT-NS group and
controls (P>0.05). The brain lidocaine concentration was not
significantly different between IT-L group(1.83В±0.50 Вµg/g) and
IV-L group(1.68В±0.46 Вµg/g) (P>0.05)(Fig.2).
Discussion: The results showed that brain lidocaine concentraВ­
tion was not significantly different between IT-L group and IV-L
group , however lidocaine subarachnoid block can reduce propofol
requirement for sedation in rats. So the mechanism for sedation
during subarachnoid block would be not the direct effect of
local anesthetic to the brain by the spread of cerebrospinal fluid.
Deafferentation would be a reasonable mechanism.
References:
1. Pollock JE, et al. Anesthesiology 2000; 93: 728-34.
2. SentГјrk M, et al. Br J Anaesth 2008; 101: 255 60.
3. Hanxiang Ma, et al. ASA Annual meeting 2010; A1613.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-417
S-418
ANESTH ANALG
2012; 114; S-01 – S-493
S-417.
S-418.
LIDOCAINE AND ROPIVACAINE, BUT NOT
CHLOROPROCAINE, ATTENUATE TNF-ALPHA INDUCED
SRC ACTIVATION, ICAM-1 PHOSPHORYLATION
AND MIGRATION OF HUMAN LUNG CANCER CELLS
INDEPENDENTLY FROM SODIUM CHANNEL INHIBITION
CARBOETOMIDATE INHIBITS О±4ОІ2 NEURONAL
NICOTINIC ACETYLCHOLINE RECEPTORS AT
CLINICALLY RELEVANT CONCENTRATIONS
AUTHORS: T. Piegeler1,2, E. Votta-Velis2, B. Beck-Schimmer1,
D. E. Schwartz2, R. D. Minshall2,3, A. Borgeat4
affiliation: 1Institute of Anesthesiology, University Hospital
Zurich, Zurich, Switzerland; 2Department of Anesthesiology,
University of Illinois Hospital & Health Sciences System, Chicago,
IL; 3Department of Pharmacology, University of Illinois Hospital &
Health Sciences System, Chicago, IL; 4Division of Anesthesiology,
Balgrist University Hospital Zurich, Zurich, Switzerland
Introduction: Retrospective analysis of patients undergoing
cancer surgery suggests the use of regional anesthesia may reduce
cancer recurrence and improve survival1. Amide-linked local
anesthetics (LA) were demonstrated to have anti-inflammatory
properties2, e.g. in experimental lung inflammation or in patients
undergoing colorectal surgery3. There is increasing evidence that
similar inflammatory processes involving Src tyrosine protein
kinase (Src) and intercellular adhesion molecule-1 (ICAM-1) are
important in tumor growth and metastasis4,5. We hypothesized that
amide-, but not ester-linked LA may inhibit inflammatory cytokinesignaling and migration of a human lung cancer cell line.
Methods: NCI-H838 lung cancer cells were incubated
with Tumor Necrosis Factor-О± (TNF-О±) in absence/presence of
ropivacaine, lidocaine or chloroprocaine (1nm - 100ОјM). Cell
lysates were analyzed for Src-activation (pY419 Src) and ICAM1-phosphorylation (pY512 ICAM-1) via Western blot. Experiments
using the agonist veratridine and the antagonist tetrodotoxin
evaluated the role of the voltage-gated sodium channel (VGSC).
Additionally, cell migration through a polycarbonate membrane at 4
hours in presence of the LA was assessed.
Results: Basal Src-activity was decreased by 48% (p=0.022)
by ropivacaine treatment (10ОјM) of H838 cells for 20 minutes.
Ropivacaine and lidocaine co-administered with TNF-О± decreased
Src-activation (52% by 1ОјM ropivacaine, p=0.022; 73% by 10ОјM
lidocaine, p=0.016) and ICAM-1-phosphorylation (32% by 1ОјM
ropivacaine, p=0.031; 50% by 1ОјM lidocaine, p=0.016) compared
to TNF-О± alone, whereas chloroprocaine had no such effect. The
inhibitory effects on Src- and ICAM-1-phosphorylation were
independent from the VGSC. Migration at 4 hours was inhibited
by 28% (p=0.046) in presence of 1ОјM ropivacaine and by 24% by
1nM lidocaine (p=0.01). Chloroprocaine and a shorter exposure (15
minutes) of ropivacaine did not alter cancer cell migration.
Discussion: Inhibition of Src-activity, ICAM-1-phosphorylВ­
ation, and migration of NCI-H838 lung adenocarcinoma cells by
amide - but not ester - local anesthetics provide a molecular mechanВ­
ism by which local anesthetics could exhibit a beneficial effect in
cancer progression and metastasis.
AUTHORS: D. W. Pierce, E. Pejo, M. Haburcak, D. E. Raines, S.
A. Forman
affiliation: Anesthesia Critical Care & Pain Medicine,
Massachusetts General Hospital, Boston, MA
Introduction: Carboetomidate is an etomidate-like sedative/
hypnotic drug that replaces the imidazole ring of etomidate with
a pyrrole, greatly reducing inhibition of adrenal corticosteroid
synthesis (Ref 1). Like etomidate, carboetomidate modulates
GABAA receptors to produce hypnosis. However, carboetomidate
effects on other ion channels that mediate general anesthetic actions
are unknown. Here, we compare the effects of etomidate and
carboetomidate on human N-methyl-D-aspartate receptors (NR1B/
NR2A) or neuronal nicotinic receptors (alpha4/beta2), which are
cationic ligand gated ion channels that are thought to mediate effects
of some sedative/hypnotic drugs.
Methods: Animals were used with approval of the institutional
IACUC. Receptors were recombinantly expressed in Xenopus
oocytes, and sensitivity to drugs was measured using two microelectrode voltage clamp electrophysiology. Concentrationdependent inhibition was analyzed by fitting combined data from
multiple oocytes (normalized to each oocyte’s response) to logistic
(Hill) equations, providing best-fit estimates for IC50 and Hill slope.
We also measured the olive oil: water partition coefficients for
etomidate and carboetomidate, using calibrated high performance
liquid chromatography to measure compounds in different phases.
Results: Etomidate did not significantly inhibit either type of
receptor at concentrations up to 100 ОјM, whereas carboetomidate
inhibited neuronal nicotinic receptors with an IC50 of 13 ОјM (95%
CI: 9.9 to 18 ОјM). The oil:water partition coefficients for etomidate
and carboetomidate were 2200 and 7700, respectively.
Discussion: Carboetomidate at concentrations near its EC50
for loss of righting reflexes in tadpoles (5 ОјM) significantly
inhibits alpha4/beta2 neuronal nicotinic receptors. Compared with
etomidate, carboetomidate’s higher hydrophobicity is associated
with inhibition of neuronal nicotinic receptors, consistent with other
studies of general anesthetics that inhibit these channels (Ref 2).
Carboetomidate may affect more ion channel targets associated with
general anesthesia than etomidate.
References:
1. Cotten, J et al; Anesthesiology 2010;112:637-44.
2. Solt, K et al. Anesth & Analg 2002; 110:455-60.
Supported by grants from NIH to SAF (R01GM89745) and DER
(R01GM87316)
References:
1. Exadaktylos AK et al: Anesthesiology 2006;105:660-4
2. Blumenthal S et al: Anesthesiology 2006;104:961-9
3. Herroeder S: Ann Surg 2007;246:192-200
4. Guarino M: J Cell Physiol 2010;223:14-26
5. Roland CL: Surgery 2007;141:705-7
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-419
S-419.
withdrawn.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-420
S-420.
THE APPLICATION OF MIDAZOLAM ON DEVELOPING
NEURONS INDUCES PROFOUND CHANGES IN GABAA
RECEPTOR EXPRESSION
AUTHORS: B. Sinner1, O. Friedrich2, B. M. Graf1
affiliation: 1Department of Anesthesiology, University of
Regensburg, Regensburg, Germany; 2Medical Biotechnology,
University of Erlangen-Nueremberg, Erlangen, Germany
Introduction: In the immature brain, the NMDA- and
GABAA receptors play an important role in neuronal development
and differentiation. The application of NMDA receptor antagonists
led to an increase in NMDA receptor expression1 By activating
important transcription factors like cAMP element binding protein,
GABA promotes synaptogenesis2. Here we investigated the effects
of the GABAA receptor agonists muscimol or midazolam on
GABAA receptor expression, CREB-phosphorylation and NFkB
expression in developing neurons.
Methods: After approval of the IRB for animal research,
hippocampal cell cultures from embryonic Wistarrats were incubated
on day 15 in culture either with muscimol (50ВµM) or midazolam
(100 or 300nM) for 15 min or 4h, respectively. In our culture the
GABAA receptor is inhibitory at this time point but the neurons
are still developing3. Western blots were performed immediately
and 24h after washout of the drug to determine the expression of
GABAA receptors, CREB, p-CREB and NFkB. Statistical analysis
was performed using one-way ANOVA. * p < 0.05 was regarded as
statistically significant.
Challenging Case Report: N/A
Results: The application of muscimol (50ВµM) or midazolam (100
or 300nM) for 15min or 4h resulted in a significant, concentrationand time-dependent decrease in the GABAA receptor expression
[Fig.]. After incubating the developing neurons for 15min a dosedependent decrease of CREB phosphorylation and a reduction of
the NFkB expression could be detected. 24h after washout of the
drug, the GABAA receptor expression was restored back to baseline
levels in the neurons that were exposed to midazolam or muscimol
for only 15min. In contrast, in the 4h group, the GABAA receptor
expression was still reduced 24h after washout. 24h after washout
of the respective drug, NFkB and CREB phosphorylation was
increased in both groups. This increase was more pronounced in the
neurons with the shorter exposure time.
Discussion: The application of midazolam or muscimol had a
significant concentration- and time-dependent impact on GABAA
receptor expression. The long-term incubation for 4h does not restore
GABAA receptor expression back to baseline levels and influences
gene transcription factors. The reduction of the inhibitory receptor
might increase the excitability and therewith the vulnerability of the
developing neurons. This could explain the neurotoxic effects of
midazolam on the developing brain.
References:
1. Slikker W et al. Toxicol Sci. 2007; 98:145-58.
2. Mantelas A. et al. Brain Res Dev Brain Res. 2003;145:185-95
3. Sinner B. et al. .Anesth Analg 2011, 113:1161-9.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-421
S-422
ANESTH ANALG
2012; 114; S-01 – S-493
S-421.
S-422.
ANESTHETIC EFFECTS ON SYNAPTIC GABAA
RECEPTORS CONTAINING ОІ3 SUBUNITS ARE
QUANTITATIVELY SIMILAR TO RECEPTORS
CONTAINING ОІ2
ALPHA-E432: A NOVEL TORPEDO NICOTINIC
ACETYLCHOLINE RECEPTOR AZI OCTANOL
PHOTOLABEL SITE
AUTHORS: M. Haburcak, D. Stewart, Y. Jounaidi, S. A. Forman
affiliation: Anesthesia Critical Care & Pain Medicine,
Massachusetts General Hospital, Boston, MA
Introduction: Both etomidate and propofol act via
GABAA receptors containing ОІ2 or ОІ3 subunits. Molecular
studies of etomidate and propofol have mostly been performed on
recombinant О±1ОІ2Оі2 receptors, the most abundant GABAA subtype in mammals. However, knock-in animal studies have shown
that the major actions of etomidate and propofol are mediated by
receptors containing ОІ3 subunits. Here we quantitatively compare
the interactions of GABA, etomidate, and propofol at human
О±1ОІ3Оі2L versus О±1ОІ2Оі2L GABAA receptors, using the framework
of allosteric co-agonism.
Methods: Animals were used with approval of the institutional
IACUC. Recombinant О±1ОІ3Оі2L human GABAA receptors were
expressed in Xenopus laevis oocytes and currents evoked with
GABA, anesthetics, or combinations of the two were measured
using two electrode voltage clamp electrophysiology. We measured
GABA concentration responses with and without etomidate or
propofol, maximal GABA efficacy, spontaneous activation, and
direct receptor activation by the two anesthetics. Results were
compared to our published results with О±1ОІ2Оі2L receptors, and
analyzed by global fitting with an established co-agonist model1.
Results: GABA EC50 in О±1ОІ3Оі2L receptors was 14 ОјM and,
while GABA-evoked currents were sensitive to picrotoxin, there
was no evidence of spontaneous receptor activity in the absence
of GABA. Maximal GABA (3 mM) responses of the О±1ОІ3Оі2L
receptors are enhanced 10-15% by propofol, indicating GABA
efficacy similar to О±1ОІ2Оі2L receptors. Both etomidate and propofol
produced leftward shifts of the GABA concentration-response
curve, similar to those observed in О±1ОІ2Оі2L receptors. Direct
activation of О±1ОІ3Оі2L receptors by propofol or etomidate is also
equivalent to results known for О±1ОІ2Оі2L receptors. Overall, the
effects of GABA, etomidate, and propofol in О±1ОІ3Оі2L receptors
were similar to those previously reported in О±1ОІ2Оі2L receptors. A
co-agonist model fitted to О±1ОІ3Оі2L data for GABA and etomidate
also resulted in parameters similar to those for О±1ОІ2Оі2L1.
Discussion: The interactions of GABA, etomidate, and
propofol with О±1ОІ3Оі2L GABAA receptors are remarkably similar
to О±1ОІ2Оі2L. These data suggest that additional molecular studies
of the anesthetic sites in these two receptors are likely to show
congruency. The differential impact of ОІ2 and ОІ3 mutations
on anesthetic sensitivity in animals is likely due to differential
localization within critical neural circuits.
References:
1. Rusch et al., J Biol Chem 2004;279:20982-92.
Supported by grants from NIH (R01GM89745 and P01GM58448)
AUTHORS: P. Dershwitz1, Z. Dostalova1, K. Parker2, D. Stewart1,
K. W. Miller1, S. A. Forman1
affiliation: 1Anesthesia Critical Care & Pain Medicine,
Massachusetts General Hospital, Boston, MA; 2Virgin Instruments
Corp., Sudbury, MA
Introduction: Azi-octanol is a photo-activatable anesthetic
alcohol similar to octanol. Torpedo nicotinic acetylcholine receptors
(TnAChRs) are an abundant natural ligand-gated ion channel model
for anesthetic target channels in the mammalian nervous system.
Several TnAChR residues interacting with azi-octanol have been
identified using radio-photo-labeling, proteolysis, and Edman
degradation. Mass spectroscopy is another approach to identifying
photo-labeled residues that requires less protein and no radioactivity.
Methods: Animals were used with institutional IACUC approval.
TnAChRs in native membranes were photolabeled with azi-octanol.
Subunits were purified by SDS gel electrophoresis, digested
with chymotrypsin, and analyzed with high performance liquid
chromatography-mass spectroscopy (HPLC-MS). The functional
role of the О±E432 residue was investigated by incorporating mutations
that altered sidechain size, hydrophobicity, and charge. Wild-type
and mutant receptors were heterologously expressed in Xenopus
oocytes. Two-microelectrode voltage clamp electrophysiology
was used to assess both acetylcholine concentration-responses and
octanol-dependent inhibition. Normalized concentration-response
data sets for each type of channel were analyzed by non-linear least
squares fits to logistic (Hill) equations to determine acetylcholine
EC50s and octanol IC50s.
Results: HPLC-MS identified an 11-residue peptide with
molecular weight 1172.63 Da, corresponding to the О± subunit
sequence A427-GRLIELSQEG. About 10% of this peptide was
photolabeled, with a mass (1300.75 Da) corresponding to addition
of one azi-octanol. MS-MS sequencing identified О±E432 as the
photo-incorporation site. Octanol inhibition studies in wild-type
and О±E432 mutant (C, L, Q, and K) channels showed no significant
difference between the fitted global IC50 (23 ОјM; 95% CI 12 - 42
ОјM) and individual channel IC50s. Acetylcholine EC50s were:
WT: 105 ОјM; О±E432Q: 15ОјM; О±E432K: 51 ОјM; О±E432L: 123 ОјM;
and О±E432 C: 152 ОјM. EC50s for О±E432Q and О±E432K mutants
significantly differed from wild-type (p < 0.0001).
Discussion: Large hydrophobic peptide fragments of membrane
proteins are difficult to analyze with mass spectroscopy. Here, MS
was used to identify a novel azi-octanol labeling site, О±E432, at the
extracellular end of the TnAChR О±-M4 domain that was inaccessible
to Edman sequencing. Mutating О±E432 alters ACh sensitivity,
indicating allosteric linkage to channel gating1. The О±E432 residue
does not contribute to the octanol inhibitory site in the ion pore, but
could play a role in anesthetic-induced desensitization.
References:
1. Xiu X et al. J. Biol Chem 2005;280:41655-66.
Supported by NIH grants P01-GM58448 and R01-GM89745
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
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S-423.
WITHDRAWN.
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-424
ANESTH ANALG
2012; 114; S-01 – S-493
S-424.
SELECTIVE INHIBITION OF PROPOFOL IN CORTICAL
SINGLE NEURONS IN THE MACAQUE BRAIN
AUTHORS: Y. Ishizawa1, A. Uchida1, J. T. Gale2, E. N. Brown1,
E. N. Eskandar2
affiliation: 1Anesthesia, Critical Care & Pain Medicine,
Massachusetts General Hospital, Boston, MA; 2Neurosurgery,
Massachusetts General Hospital, Boston, MA
Introduction: The mechanisms underlying general
anesthetic-induced unconsciousness remain poorly understood.
Here we propose a non-human primate model to determine
anesthetic effects at the single neuronal level and at the higher level
of behavior simultaneously.
Methods: Two adult macaque monkeys were trained to perform
a multisensory task in which the animal was required to press
a button to participate each trial and received a combination of
tactile and auditory stimuli (airpuff to face, sound, simultaneous
airpuff+sound, or no stim). Propofol infusion (200mcg/kg/min,
60min) was performed in an alert behaving condition and single
neuron activities and local field potentials (LFPs) were acquired
from the primary somatosensory cortex (S1) and a frontal
association cortex (ventral premotor area, PMv) through surgically
implanted arrays. The animal’s trial-by-trial behavioral response
was recorded. All experiments were performed in compliance with
the APS/NIH guidelines.
Results: Baseline neural firing rates were significantly decreased
under propofol anesthesia in all cortical areas. In S1, 44 neurons
(61%) were responsive only to airpuff and the response remained
throughout anesthesia (Fig.A). The response to airpuff (green traces)
and the response to airpuff and sound (dark blue traces) were almost
identical, indicating unimodal function of these neurons. In the S1
bimodal neurons (n=28, 39%), the response to sound stimulus (red
traces) appeared to be smaller than the response to airpuff (Fig.B).
At 60 min of anesthesia (center column) the sound response was
completely inhibited while the response to airpuff remained. The
recovery of these bimodal neurons appeared to be slow. At the
animal’s loss of response (11.7±0.7 min of the propofol infusion),
the baseline firing rates were significantly decreased and the
response to sound appeared to diminish. In PMv, the majority of the
airpuff-responsive neurons showed bimodal response (n=27, 60%,
Fig.C). In these neurons the sound response was nearly completely
inhibited during propofol anesthesia. At 60 min of recovery, the
response to both puff and sound were still significantly smaller than
the awake level.
Figure 1. Population response of cortical single neurons during awake,
anesthesia (at 60min of propofol infusion) and recovery. The sensory
stimulation was presented at time 0 for 250 msec. A. S1 puff-responsive
(unimodal) neurons. B. S1 bimodal neurons. C. PMv bimodal neurons. Error
bar = s.e.m.
Discussion: Cortical neurons in S1 and PMv were well
characterized depending on their response to multisensory stimuli.
A general anesthetic propofol predominantly inhibited auditory
response in bimodal neurons in S1 and PMv and the recovery of these
bimodal neurons appeared to be prolonged. The air-puff response
remained at a deep anesthetic level producing burst suppression in
most of the S1 neurons. Advanced analysis on neural connectivty
will further elucidate the neural mechanisms of anesthetic-induced
loss of responsiveness.
References: None
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ABSTRACTS
S-425
S-425.
VOLATILE ANESTHETIC ISOFLURANE INHIBITS
INTEGRIN LEUKOCYTE FUNCTION-ASSOCIATED
ANTIGEN-1(LFA-1)
AUTHORS: K. Yuki1, M. Shimaoka1, R. Eckenhoff2, T. Springer1
affiliation: 1Department of Anesthesiology, Perioperative
and Pain Medicine, Children’s Hospital Boston, Boston, MA;
2
Department of Anesthesiology, University of Pennsylvania,
Philadelphia, PA
Introduction: In ex vivo leukocytes treated with isoflurane
exhibited decreased cell adhesion to endothelium. LFA-1 is an
important adhesion molecule in the process of leukocyte arrest. We
hypothesized that isoflurane would show functional interaction with
LFA-1.
Methods: In vitro binding assay The binding of ICAM-1 to
LFA-1 was tested in the cell-based and cell-free assays. For the
cell-based assay, flow cytometry was used to detect the binding of
soluble ICAM-1-IgA/ IgA-FITC multimers to LFA-1 on LFA-1
expressing cells with or without isoflurane. For the cell-free assay,
soluble LFA-1 was immobilized indirectly on ELISA plates with its
capturing antibody. ICAM-1-IgA fusion protein was added with or
without isoflurane, and then bound ICAM-1 was detected by HRP
anti IgA and substrate.
Binding sites analysis Azi-isoflurane is photo-activating isoflurane
to examine the binding sites of isoflurane on proteins. After the
incubation of LFA-1 protein with azi-isoflurane and exposure to
300 nm illumination, SDS-PGE purification, band excision, and
trypsinization was followed by nano-LC/MS to identify peptides
and residues that had been modified.
Functionality of azi-isoflurane binding site(s) Various sites on a1
helix of b2 subunit were mutated into alanine . Wild-type aL plasmid
and wild-type or mutant b2 plasmid were co-transfected into
293T cells. The binding of soluble ICAM-1 to LFA-1 and LFA-1
expression on the cell surface were examined using flow cytometry.
Results:
In vitro binding assay
In K562 cells transfected with LFA-1, PBMCs and Jurkat cells,
isoflurane inhibited LFA-1/ICAM-1 binding. Also in the cell-free
system, isoflurane inhibited LFA-1/ICAM-1 interaction in a dosedependent fashion.
Binding sites analysis
The binding site analysis of azi-isoflurane on LFA-1 demonstrated
that this compound binds to aL and b2 subunits. The binding site(s)
of azi-isoflurane on aL subunit correlated with the binding site(s)
demonstrated by I domain crystal. This binding site(s) on b2 subunit
was on a1 helix.
Functionality of a1 helix of b2 subunit
Since the function of a1 helix on b2 subunit was not determined yet,
we performed alanine-scanning mutagenesis on this region. Some
of alanine scanning mutants on the helix were constitutive active
mutants, and some was constitutive deactivating mutant, suggesting
that this helix is functionally important for LFA-1/ICAM-1 binding.
Discussion: LFA-1 was inhibited by isoflurane at cell and
cell-free levels. The binding site analysis suggested that isoflurane
binds both a and b subunits, which could be part of mechanism for
isoflurane induced suppression of neutrophils extravasation.
References: none
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-426
ANESTH ANALG
2012; 114; S-01 – S-493
S-426.
PHARMACOLOGICAL MECHANISMS INVOLVED IN
THE ANTINOCICEPTIVE EFFECTS OF INTRAVENOUS
DEXMEDETOMIDINE IN MICE
AUTHORS: R. S. Rangel2, B. Marinho3, R. Soares de Moura3,
M. Lessa1
affiliation: 1Laboratory of Cardiovascular Investigation,
Oswaldo Cruz Foundation, Rio de Janeiro, Brazil; 2Pharmacology,
State University of Rio de Janeiro, Rio de Janeiro, Brazil;
3
Pharmacology, Federal University of Rio de Janeiro, Rio de
Janeiro, Brazil
Introduction: Dexmedetomidine (DEX) is a О±2-adrenergic
receptor (О±2-AR) agonist mainly used as an anesthetic adjuvant and
as a sedative in critical care settings1,2. Typically, О±2-AR agonists
release NO and subsequent activate NO-GMPc pathway3,4 and have
been implicated with antinociception. In this study, we investigate
the pharmacological mechanisms involved in the antinociceptive
effects of DEX, using an acetic acid-induced writhing assay in mice.
Methods: Saline or DEX (1, 2, 5 or 10 Ојg/kg) was intravenous
injected 5 min before ip administration of acetic acid and the resulting
abdominal constrictions (writhes) were then counted for 10 min.
To investigate the possible mechanisms related to antinociceptive
effect of DEX (10 Ојg/kg), the animals were also pretreated with one
of the following drugs: 7-nitroindazole (7-NI; 30 mg/kg i.p.); 1H[1,2,4] oxadiazole [4,3-a] quinoxalin-1-one (ODQ; 2.5 mg/kg, i.p.);
yohimbine (1 mg/kg, i.p.); atropine (2 mg/kg, i.p.); and naloxone
(0.2 mg/kg, i.p.). A rota-rods and open field performance test were
performed with DEX at 10 Ојg/kg dose.
Figure 1. The antinociceptive effect of dexmedetomidine, assessed by the
writhing test in mice. Mean В± S.E.M.; n = 6 *P < 0.05 vs. saline #P < 0.05 vs.
DEX 0, 1, 2 and 5 Ојg/kg.
Results: DEX demonstrated its potent antinociceptive effect in a
dose-dependent manner (Fig. 1). The pretreatment with 7-NI, ODQ,
atropine and glibenclamide significantly reduced the antinociceptive
affects of DEX (Fig. 2 and 3 A and B). However, naloxone showed
no effecting DEX-induced antinociceptive (Fig. 3 C) . The rota-rod
and open field tests confirmed there is no detectable sedation or even
significant motor impairment with DEX at 10 Ојg/kg dose (Fig. 4
and 5).
Discussion: Our results suggest that the О±2-AR and NO-GMPc
pathways play important roles in the systemic antinociceptive effect
of DEX in a murine model of inflammatory pain. Furthermore, the
antinociceptive effect exerted by DEX appears to be dependent on
KATP channels, independent of opioid receptor activity.
References:
1.Dexmedetomidine: a review of clinical applications. Curr Opin
Anaesthesiol 2008;21: 457-61.
2.The changing role of non-opioid analgesic techniques in the
manageВ­ment of postoperative pain. Anesth Analg 2005;101:
S5-22.
3.Alpha-2 adrenoceptor agonists: defining the role in clinical
anesthesia. Anesthesiology 1991;74: 581-605.
4.Role of signal transduction in anesthetic action. Alpha 2
adrenergic agonists. Ann N Y Acad Sci 1991;625: 409-22.
Figure 2. The effect of
pretreatment with 7-NI (A),
ODQ (B) and glibenclamide (C)
on dexmedetomidine-induced
antinociception in mice, as assessed
by the writhing test. Mean В±
S.E.M.; n = 6 *P < 0.05 compared
to vehicle П†P < 0.05 compared to
dexmedetomidine.
Figure 3. The effect of
pretreatment with atropine (A),
yohimbine (B) and naloxone (C)
on dexmedetomidine-induced
antinociception in mice, as
assessed by the writhing test.
Mean В± S.E.M.; n = 6. *P < 0.05
compared to vehicle П†P < 0.05
compared to dexmedetomidine.
s-426 • continued on next page
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continued
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2012; 114; S-01 – S-493
S-427.
MODULATION OF Оґ SUBUNIT-CONTAINING GABAA
RECEPTORS BY ETOMIDATE DEPENDS ON SUBUNIT
ARRANGEMENT
AUTHORS: H. Feng, Y. Jounaidi, S. A. Forman
affiliation: Anesthesia Critical Care & Pain Medicine,
Massachusetts General Hospital, Boston, MA
Introduction: GABAA receptors are allosterically modulated
by a variety of compounds including neurosteroids and the general
anesthetic etomidate. GABAA receptors containing О±, ОІ, and Оґ
subunits are localized extrasynaptically and mediate GABAergic
tonic inhibition. Evidence from studies of neurosteroid modulation
of concatenated subunit assemblies suggests that the subunit
arrangement of О±ОІОґ may vary1. Here, we compare the modulation by
etomidate and tetrahydrodeoxycorticosterone (THDOC) on О±1ОІ3Оґ
receptors with different subunit arrangements.
Figure 4. The effect of dexmedetomidine (DEX - 10 Вµg/kg), diazepam (DZP
- 1 mg/kg) and the vehicle on the mice in the rota-rod test. Mean В± S.E.M.; n
= 6 *P < 0.05 vs. diazepam
Methods: Plasmids encoding concatenated GABAA receptor
subunit assemblies for ОІ3-О±1-Оґ, ОІ3-О±1, and О±1-ОІ3, along with free
subunits, were obtained from Prof. Erwin Sigel (Bern, Switzerland).
We injected messenger RNAs encoding concatenated ОІ3-О±1-Оґ
trimer with either ОІ3-О±1 or О±1-ОІ3 dimer into Xenopus oocytes to
express ОІ3-О±1-Оґ/ОІ3-О±1 and ОІ3-О±1-Оґ/О±1-ОІ3 receptors. The effects of
etomidate (3 ОјM) or THDOC (1 ОјM) on maximal (1 mM) GABAactivated receptor currents was measured using two-microelectrode
voltage-clamp electrophysiology. Enhancement was compared
using one-way ANOVA.
Results: Both dimer/trimer combinations produced small oocyte
currents after 24-48 hours of incubation. THDOC produced similar
large enhancements of currents from ОІ3-О±1-Оґ/ОІ3-О±1 and ОІ3-О±1-Оґ/
О±1-ОІ3 receptors. However, etomidate produced a greater maximal
current enhancement in ОІ3-О±1-Оґ/О±1-ОІ3 receptors than in ОІ3-О±1-Оґ/
ОІ3-О±1 receptors. GABA currents from oocytes injected with
mRNAs encoding free О±1, ОІ3, and Оґ subunits were larger, showed
less THDOC and etomidate enhancement, and did not differ from
currents elicited with only О±1 and ОІ3.
Discussion: There is uncertainty in the subunit arrangement
of О±ОІОґ GABAA receptors, in part due to difficulty in assuring
incorporation of Оґ when free subunits are expressed in Xenopus
oocytes. Using concatenated receptor constructs helps assure Оґ
subunit incorporation. Our data confirm that GABA behaves like
a weak partial agonist in Оґ-containing GABAA receptors, and that
etomidate and THDOC modulate GABAA receptors via different
mechanisms. The greater enhancement in ОІ3-О±1-Оґ/О±1-ОІ3 receptors
vs. ОІ3-О±1-Оґ/ОІ3-О±1 suggests that etomidate interactions at ОІ3/ОІ3
interfaces may be more efficacious than those at ОІ3/О±1 interfaces.
References:
1. Kaur KH et al, J. Biol Chem 2009;284:7889-96
Supported by grants from NIH (R01GM89745 and P01GM58448)
Figure 5. The effect of dexmedetomidine (DEX), diazepam (DZP) and the
vehicle on the mice in the open field test. The mice received DEX (closed
square,10 Вµg/kg), DZP (closed triangle, 1 mg/kg) or the vehicle (open cicle).
In A, the graph represents the number of walked squares against time. In B,
the graph represents the area under the curve (AUC) calculated for each timeeffect curve. Mean В± S.E.M.; n = 6. *P < 0.05 vs. vehicle.
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ABSTRACTS
S-429
S-429.
THE EFFECT OF PROPOFOL ON
ANANDAMIDE-INDUCED INJURY IN HUMAN
UMBILICAL VEIN ENDOTHELIAL CELLS
AUTHORS: Y. Mishima, A. Ito, T. Ito, N. Kameyama, K. Ushijima
affiliation: Anesthesioloy, Kurume University, Kurume, Japan
Introduction: Anandamide (AEA) is present at low levels
and is quickly degraded by fatty acid amide hydrolase (FAAH).
However, serum AEA levels are highly elevated during endotoxic
shock1, thereby inducing cell death. Propofol, a short-acting
intravenous hypnotic and general anesthetic agent, has several
unique properties such as inhibiting FAAH, reducing cytokineinduced apoptosis, and scavenging free radicals. This study aimed
to examine whether propofol inhibits FAAH against AEA-induced
cell injury.
Methods: Human umbilical vein endothelial cells (HUVECs)
were treated with propofol or URB597, a potent FAAH inhibitor,
and incubated for 30 min prior to AEA administration. After 24 h
incubation with AEA, the survival and viability of HUVECs were
determined by the trypan blue exclusion test and cell proliferation
assay (MTT assay). Residual AEA concentration in the propofolor URB597-treated culture media was measured by liquid
chromatography/mass spectrometry (LC/MS). The magnitude of
FAAH inhibition by propofol and URB597 was evaluated using an
FAAH inhibitor screening assay.
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2012; 114; S-01 – S-493
Results: Evaluation of cell viability by the MTT assay 24 h after
AEA administration showed that propofol significantly inhibited,
whereas URB597 significantly deteriorated, AEA-induced cell
death in a dose-dependent manner (Fig 1A, B).
AEA did not affect cell viability at 1-5 ВµM. Importantly, pretreatment
with 10 ВµM URB597 significantly deteriorated the viability of cells
exposed to 1-5 ВµM AEA. In contrast, 50 ВµM propofol had no effect
on the viability of cells exposed to 1-5 ВµM AEA (Fig 2A, B).
AEA concentration in the culture media 24 h after exposure to 10
ВµM AEA co-incubated with 50 ВµM propofol was 7.9 ВµM, whereas
that in the culture media 24 h after exposure to 10 ВµM AEA coincubated with 10 ВµM URB597 was 1.6 ВµM.
The FAAH inhibitor screening assay showed that both propofol
and URB597 inhibited FAAH activity in a dose-dependent manner.
However, propofol did not inhibit FAAH activity at clinical
concentrations (Fig 3).
Discussion: FAAH inhibition caused cell death even at low
AEA concentrations; however, propofol did not cause a significant
deterioration of AEA-induced cell death. In addition, the residual
concentration of AEA co-incubated with propofol was much
higher than that of AEA co-incubated with URB597. Although the
protective mechanism of propofol against AEA-induced cell death
is unclear, these findings suggest that propofol does not act as an
FAAH inhibitor in clinical situations and may prevent AEA uptake
by cells.
References:
1.Varga K, Wagner JA, Bridgen DT, Kunos G. Platelet- and
macrophage-derived endogenous cannabinoids are involved in
endotoxin-induced hypotension. FASEB J 1998;12:1035-44.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-430
S-430.
EVALUATION OF A PROPOFOL-REMIFENTANIL
RESPONSE SURFACE MODEL IN PATIENTS
UNDERGOING ULTRASONIC ENDOSCOPY
AUTHORS: T. Evans1, C. LaPierre1, P. Gambus2, K. B. Johnson1,
T. Egan1, D. Westenskow1
affiliation: 1Department of Anesthesiology and Biomedical
Engineering, University of Utah, Salt Lake City, UT; 2Anesthesiology
Department, Universidad de Barcelona, Barcelona, Spain
Introduction: Prior work in our laboratory characterized
the interaction between propofol and remifentanil for two effect
measures in healthy volunteers: loss of responsiveness (LOR) and
loss of response to esophageal instrumentation (LREI). This data
was used to build response surface models for both effects. The aim
of this study was to compare model predictions of LOR and LORI
with observed responses in 110 patients undergoing a propofolremifentanil anesthetic for upper endoscopy. Our hypothesis was
that model predictions would be consistent with observations.
Methods: Patients received target controlled infusions of propoВ­
fol and remifentanil. Predicted propofol and remifentanil effect
site concentrations were used to predict the probability of LOR
and LREI. The Ramsay Sedation Scale (RSS) was measured in
all patients before during and after the procedure at random times
to ensure factors correlated with time would not confound the
assessment. Model predictions of LOR were compared to observed
instances of RSS > 4. Model predictions of LREI were compared to
(i) observed assessments of a gag response and (ii) insertion of an
endoscope. Model predictions were compared to observations using
a Kolmogorov -Smirnov test. A p-value less than 0.05 indicated that
predictions and observations were not from the same population.
Results: Model predictions of LOR and RSS>4 are presented
in Figure 1. Predictions of LOR were not consistent with observed
instances of RSS>4 (p =0.002). Patients’ level of sedation was
less than predicted by the model. Model predictions of LREI
without gag are presented in Figure 2 with endoscope insertion
independent of gag in Figure 3. Predictions of LREI were consistent
with observed gag responses (p = 0.059) but not with observed
endoscope insertions (p = 0.014). The LREI model predicted that
patients would respond when the endoscope was placed.
Discussion: Our results in part confirmed our hypothesis.
The LOR model under predicted unresponsiveness compared to
observations. The poor performance of the LOR model may be due
to the presence of a stimulus when patient responses were recorded,
which was present in volunteers when building the LOR model.
The LREI model predicted gag responses well but performed
poorly by over predicting a response to esophageal instrumentation
when endoscopes were successfully placed. This may be a function
of endoscopist willingness to tolerate some gag response when
inserting an endoscope.
References:
Anesth Analg. 2011 Feb;112(2):331-9
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-431
S-431.
SYSTEMIC ENDOTOXINAEMIA-INDUCED
ALTERATIONS OF SUBSTANCE P-LIKE
IMMUNOREACTIVITY IN DIFFERENT ORGANS OF MICE
AUTHORS: O. Lengl1, E. PintГ©r2, Z. Helyes2, T. Bagoly2, J. Quinn3,
K. SГЎndor2
affiliation: 1Departments of Anaesthesiology and Intensive
Care, University of PГ©cs, PГ©cs, Hungary; 2Pharmacology and
Pharmacotherapy, University of PГ©cs, PГ©cs, Hungary; 3School of
Biomedical Sciences, Liverpool University, Liverpool, United
Kingdom
Introduction: Substance P (SP) encoded by the preprotaВ­
chykinin A (TAC1) gene predominantly in sensory neurons evokes
neurogenic inflammatory responses via neurokinin 1 (NK1)
receptors localized on vascular endothelial, immune and smooth
muscle cells. Hemokinin-1 (HK-1) derived from the TAC4 gene in
non-neural, inflammatory cells is structurally and functionally very
similar. SP and HK-1 are immunologically identical, they are both
detected with radioimmunoassay. Therefore, we aimed to investigate
systemic endotoxin-evoked alterations of SP and HK-1 in different
mouse organs, and to differentiate between the expression of these
two peptides using TAC1 gene-deficient (TAC1-/-) animals.
Methods: Lipopolysaccharide (LPS, 400 ug) was injected i.p.
to male TAC1-/- mice and their C57Bl/6 counterparts (n=9-10/
group) to induce a systemic inflammatory response characteristic
of early human sepsis. Saline-treated mice of the same age served
as intact controls. The lung, heart, liver and kidney were excised
4 h after the treatment following exsanguination in deep sodiumthiopenthal anaesthesia. SP-like immunoreactivity (SP-LI) of
these organ homogenates was measured with sensitive and specific
radioimmunoassay.
Results: In intact mice the highest SP-LI, 113.3+28.2 fmol/, was
measured in the kidney. 61.5+4.7 fmol/mg was detected in the liver,
12.3+2.2 fmol/mg in the myocardium and 4.04+0.45 fmol/mg in
the lung. SP-LI in the kidney and the liver of non-inflamed TAC1/-mice lacking SP was approximately half of what was measured
in wildtypes, but in the heart and the lung the concentrations were
almost the same. Four hours following the systemic LPS challenge
a 4-fold increase was observed in the myocardium in wildtype mice,
but only a 2-fold elevation occurred in the TAC1-/- group compared
to the respective intact controls. There was no significant change
in the lung in either group. In contrast, SP-LI markedly decreased
in the liver and the kidney by about 40% and 70%, respectively, in
wildtypes. In TAC1-/- mice there was no change in the liver and
about 40% decrease occurred in the kidneys.
Discussion: The highest SP-LI is measured in the kidney and
liver, the half of which is SP predominantly of sensory neural
origin and the other half is HK-1 derived from non-neural cells.
However, the small concentration in the heart and the lung is HK1, since the same level is measured in TAC1-/- animals. Systemic
endotoxinaemia significantly increases SP concentration in the heart,
which is likely to be due to its release from peripheral peptidergic
sensory nerve terminals. SP levels markedly decrease in the liver
and the kidney presumably due to its depletion by the 4-h timepoint.
References: N/A
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-432
S-432.
THE DELTA OPIOID RECEPTOR ANTAGONIST
NALTRINDOLE IMPROVES SPLANCHNIC PERFUSION IN
PIGS DURING CARDIOPULMONARY BYPASS
AUTHORS: M. M. Theisen1,2, T. Iden5, T. P. Weber3, H. Nagase4,
M. Maas1, K. Kaerlein1
affiliation: 1Department of Anesthesiology and Intensive
Care, MГјnster University Hospital, MГјnster, Germany; 2Department
of Anaesthesia and Intensive Care, Raphaelsklinik MГјnster,
MГјnster, Germany; 3Department of Anesthesia and Intensive Care,
St. Joseph Hospital Ruhr University Bochum, Bochum, Germany;
4
Laboratory of Medical Chemistry, School of Pharmacy, Kitasato
University, Tokyo, Japan; 5Department of Anesthesiology and
Intensive Care, Schleswig-Holstein University Hospital, Campus
Kiel, Kiel, Germany
Introduction: The use of cardiopulmonary bypass (CPB) is
increasingly common in modern cardiothoracic surgeryВ­1. However,
one of the major postoperative complications and leading causes of
mortality is visceral hypoperfusion. Studies performed in conscious
dogs have demonstrated that NTI significantly improves splanchnic
perfusion (SP)2. The aim of this study was to investigate if NTI also
improves SP in pigs undergoing CPB and thus might reduce the rate
of gastrointintestinal complications.
Methods: Ethics approval for this study was obtained from
the Bezirksregierung Muenster. In this study 21 pigs (mean 35 kg)
were anaesthetized and intubated and received a CVC and arterial
catheter. Cardiac output was measured using a transit time flowprobe
# = p<0.05 Placebo versus NTI
Baseline
ANESTH ANALG
2012; 114; S-01 – S-493
positioned around the pulmonary trunk. A fluid filled catheter in
the left atrium was used to infuse fluorescent microspheres. After
establishing baseline measurements either placebo or 4mg/kg NTI
were infused and measurements were repeated (compound). The
pigs were then exposed to electrically induced VF and cardioplegia
as well as hypothermia (28В°C for 90 min, ischemia). Following
re-establishment of normal body temperature the animals were
re-perfused for 30 minutes. The last measurements were taken
30 minutes after successful weaning from ECC. Any care given
to the pigs during CPB followed a standardized protocol. After
euthanasia tissue specimens were taken for analysis of fluorescent
microspheres.
Results: Hemodynamic parameters such as mean arterial
pressure [MAP] and cardiac output [CO] were comparable at all
data acquisition points. We have successfully demonstrated that
splanchnic perfusion is clearly reduced by CPB. NTI improves rates
of perfusion before, during and after cross-clamp time (Ischemia).
More detailed data are presented in the table.
Discussion: This study clearly demonstrates that NTI increases
SP before, during and post CPB. This effect is also independent of
the hemodynamics. We propose that visceral hypoperfusion and the
resultant gastrointestinal morbidity and mortality resulting from
CPB could be significantly improved with the use of NTI. Further
investigations are needed to elucidate this topic of high importance.
References:
1.Hanssen: Ann Surg. 2008; 248:117-25.
2. Grosse Hartlage: Eur J Anaesthesiol. 2004; 21: p 54.
Compound
Ischemia
End
Placebo
NTI
Placebo
NTI
Placebo
NTI
Placebo
NTI
MAP [mm Hg]
80,3
[73,6;94,4]
88,4
[82,0;93,6]
70,4
[63,5;79,8]
67,3
[64,6;74,5]
68,4
[64,7;87,7]
76,4
[68,2;85,6]
63,7
[54,7;73,6]
72,2
[67,2;79,0]
CO [ml/min]
2467
[2220;3031]
2533
[2007;2897]
2311
[2093;2704]
1792
[1560;2861]
10
[-49;36]
79
[23;126]
2662
[2093;2948]
1928
[1535;3015]
0,20
[0,16;0,27]
0,24
[0,15;0,33]
0,11
[0,06;0,19]
0,26 #
[0,16;0,45]
0,24
[0,18;0,37]
0,46#
[0,31;0,69]
0,12
[0,08;0,17]
0,15 #
[0,11;0,23]
0,30
[0,16;0,43]
0,26
[0,19;0,41]
0,13
[0,08;0,24]
0,29 #
[0,19;0,38]
0,29
[0,16;0,67]
0,49 #
[0,39;0,77]
0,16
[0,10;0,18]
0,21 #
[0,17;0,34]
0,24
[0,18;0,38]
0,34
[0,27;0,39]
0,12
[0,09;0,22]
0,34 #
[0,24;0,50]
0,19
[0,12;0,56]
0,51 #
[0,29;0,69]
0,18
[0,11;0,22]
0,29 #
[0,21;0,37]
0,13
[0,12;0,19]
0,23 #
[0,18;0,39]
0,06
[0,04;0,09]
0,20 #
[0,16;0,34]
0,08
[0,05;0,14]
0,15 #
[0,11;0,23]
0,10
[0,07;0,12]
0,15 #
[0,10;0,19]
0,21
[0,16;0,25]
0,22
[0,18;0,38]
0,07
[0,04;0,09]
0,25 #
[0,18;0,38]
0,09
[0,06;0,14]
0,19 #
[0,13;0,30]
0,10
[0,09;0,12]
0,17 #
[0,13;0,20]
0,20
[0,16;0,28]
0,22
[0,18;0,27]
0,05
[0,04;0,08]
0,26 #
[0,19;0,34]
0,08
[0,06;0,10]
0,25 #
[0,13;0,29]
0,10
[0,09;0,11]
0,16 #
[0,10;0,18]
0,22
[0,18;0,29]
0,25
[0,18;0,32]
0,10
[0,06;0,14]
0,29 #
[0,21;0,34]
0,06
[0,05;0,13]
0,14 #
[0,12;0,16]
0,12
[0,08;0,16]
0,17 #
[0,14;0,25]
0,15
[0,11;0,22]
0,22 #
[0,17;0,29]
0,08
[0,05;0,12]
0,27 #
[0,18;0,29]
0,06
[0,05;0,11]
0,16 #
[0,11;0,20]
0,11
[0,07;0,13]
0,19 #
[0,11;0,23]
Duodenum p
[ml/g/min]
Duodenum d
[ml/g/min]
Jejunum p
[ml/g/min]
Jejunum d
[ml/g/min]
Ileum p
[ml/g/min]
Ileum d
[ml/g/min]
Colon p
[ml/g/min]
Colon d
[ml/g/min]
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-433
S-433.
ACID SENSING ION CHANNEL CURRENTS
REGULATED BY TETRACAINE
AUTHORS: J. Lin1, T. Leng2, Z. Xiong2
affiliation: 1Anesthesiology, SUNY Downstate Medical
Center, Brooklyn, NY; 2Neuroscience, Morehouse School of
Medicine, Atlanta, GA
Introduction: Acid-sensing ion channels (ASICs) are
proton-gated cation channels activated by protons. They conduct
sodium and calcium influx resulting in membrane depolarization
and neuronal excitation. ASIC1a channels are expressed in central
nervous system and involved in various physiological processes,
such as synaptic plasticity, learning and memory1, and acidosis
mediated induced injury2. Our recent observation that ОІ-amyloid,
an important player in the pathology of Alzhermer’s disease,
significantly inhibits the ASIC currents in CNS neurons, suggests
that inhibition of the function of ASIC1a channels contributes to
the impairment of cognitive functions3. The primary action of
local anesthetics is to block sodium channel. However, it has been
shown that they have multiple pharmacological effects on other ion
channels in central nerve system. Here we show that local anesthetic
tetracaine significantly suppress the ASIC1a currents in a usedependent manner.
Methods: The experiment protocol was approved by Animal Use
and Care Committee at our institution. CHO cells were transfected
with ASIC1a channels as described2. Whole-cell patchclamp
and fast perfusion techniques were employed to record the ASIC
currents induced by pH drops from 7.4 to 6.0. Fast perfusion was
achieved with a multibarrel perfusion system. ASIC currents were
recorded with Axopatch-200B amplifier and pClamp 8.2 software.
Results: Lowering the extracellular pH to 6.0 results in an
inward ASIC1a current in transfected CHO cells. Co-application of
tetracaine (1-3 mM) with acid pulse (4 sec duration, every 2 min)
progressively inhibited the amplitude of the ASIC currents (Figure
1, n=3-5). The degree of inhibition is more pronounced with higher
frequency of ASIC activation.
Discussion: It has been shown that ASICs can be modulated
by various endogenous and pharmacological agents4. ASICs may
represent a mechanism for anesthetics mediated pharmacological
effects. Our result shows that tetracaine inhibits the ASIC1a currents,
which represents a new pharmacological effect of tetracaine in the
central nerve system.
References:
1. Neuron. 34, 463-477
2. Cell 118, 687-698
3. Society for Neuroscience Annual Meeting, Abstract 237.8. 2009
4. Curr.Med.Chem. 2007; 14: 1753-63
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-434
S-434.
THE INHIBITORY EFFECTS OF KETAMINE ON
SUBSTANCE P RECEPTOR IN U373 MG HUMAN
ASTROCYTOMA CELLS
AUTHOR: K. Yamaguchi
affiliation: Tokyo, Japan
Introduction: The neuropeptide substance P (SP) is an
important mediator of neurogenic inflammation within the central
and peripheral nervous system, but the effects of ketamine on SP
receptor (SPR) are not clear. The mitogen-activated protein kinase
(MAPK) family of proteins are involved in many cellular signaling
functions. Extracellular signal-regulated kinase 1/2 (ERK1/2),
a member of the family, is involved signaling through epidermal
growth factor (EGF) receptor. In this study, we investigated the
effects of IV anesthetics on SPR function in the human astrocytoma
cell line U373 MG cells which express high levels of SPR and
chosen as an astrocytoma in vitro model to investigate. We examined
the effects of ketamine on SP-induced ERK1/2 activation in U373
MG cells.
Methods: U373 MG human astrocytoma cells were stimulated
with substance P (100nM) for 10 min at 37C. Prior to stimulation,
cells were treated with ketamine (1ОјM to 1mM) for 30 min. ERK
activity was assessed by immunoblotting with phosphorylated
ERK antibody followed by enhance chemifluorescent detection.
Immunoreactive bands were quantified using computer assisted
densitometry. All data are expressed as mean В± SD. Statistical
analysis was performed using ANOVA.
Results: Ketamine caused a dose dependent inhibitory effect
of SP-induced ERK1/2 phosphorylation (p < 0.01 for ketamine
concentrations 10 ОјM to 1 mM). Ketamine did not reduce EGFmediated ERK1/2 activation.
Discussion: Our results suggested that ketamine inhibits SP
induced ERK1/2 activation. This finding suggests that the inhibition
of SPR function by these compounds may be important in the
analgesic effects of ketamine.
References:
1.Yamaguchi K, Richardson MD, Bigner DD, Kwatra MM. Signal
transduction through substance P receptor in human glioblastoma
cells: roles for Src and PKCdelta. Cancer Chemother Pharmacol.
2005 56:585-93.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-435
S-435.
ANESTH ANALG
2012; 114; S-01 – S-493
induction of ECC and baseline measurements (compound) pigs
were exposed to VF and cardioplegia as well as hypothermia (28В°C
for 90min, ischemia). After normal body temperature was obtained
pigs were re-perfused for 30min and weaned off ECC strictly
according to a weaning protocol. 30min after completed weaning
process (End) animals were euthanized and tissue specimens were
taken from the whole splanchnic bed for analysis of retained FMS
content, results of all specimen were averaged. Time points used to
determine SP post application of FMS were after instrumentation
(compound), ischemia and experimental end. Mean arterial pressure
(MAP), and cardiac output (CO) were kept constant initially by fluid
replacement, followed by infusion of norepinephrine (NE).
THE KAPPA OPIOID RECEPTOR ANTAGONIST NORBINALTORPHIMINE INCREASES SPLANCHNIC
PERFUSION WHILE DECREASING VASOPRESSOR
REQUIREMENTS BOTH DURING AND POST
EXTRACORPOREAL CIRCULATION IN SWINE
AUTHORS: M. M. Theisen1,2, J. Blumenstiel1, J. Stypmann3, T. P.
Weber4, M. Fobker6, F. Ploner5
affiliation: 1Department of Anesthesiology and Intensive Care,
MГјnster University Hospital, Muenster, Germany; 2Department of
Anaesthesia and Intensive Care, Raphaelsklinik MГјnster, Muenster,
Germany; 3Department of Cardiology and Angiology, MГјnster
University Hospital, MГјnster, Germany; 4Department of Anesthesia
and Intensive Care, St. Joseph Hospital Ruhr University Bochum,
Bochum, Germany; 5Department of Anesthesiology and Critical
Care Medicine, Vipiteno Hospital, Vipiteno, Italy; 6Department
of Laboratory Medicine, MГјnster University Hospital, MГјnster,
Germany
Results: Cardiac output was comparable at all data points.
Nor-BNI significantly increases mean arterial pressure (MAP) at
the experimental end when compared to placebo study group but
interestingly without altering CO at all time points measured.
Nor-BNI improved SP significantly at any data point. Surprisingly
this effect was combined with a significant decrease of vasopressor
requirements (see table).
Introduction: The use of extracorporeal circulation
(ECC) is increasingly common in modern cardiothoracic surgery.
Although rare, one of the major postoperative complications and
leading causes of mortality is splanchnic hypoperfusion1. Studies
performed in conscious dogs have demonstrated that opioid receptor
antagonists (ORA) significantly improve splanchnic perfusion
(SP)2,3. This study aims to investigate if the Оє-ORA nor-BNI is able
to improve SP in pigs undergoing ECC.
Discussion: SP was significantly improved in the nor-BNI
study group with significantly reduced NE requirements in pigs.
The negative side effects associated with vasopressors were thus
also reduced. However, if nor-BNI also reduces the rate of both
gastrointestinal complications and deaths in patients undergoing
ECC needs to be further investigated. Again, the increase of MAP
by administration of nor-BNI was demonstrated again5.
References:
1. Geissler, Interact Cardiovasc Thorac Surg 2006; 5:239-42.
2. Weber, Anesthesio-logy 2002; 96:438-41.
3. Grosse Hartlage, Eur J Anesthesiol 2005; 22:A-204.
4. Theisen, Anesth Analg. 2010; 110:1243-4.
5. Rao, Peptides. 2003; 24:745-54.
Methods: In this study 21 pigs (weight 35 В± 2.5 kg) were
randomized and 24 hours prior to surgery received either norBNI (3,7mg/kg) or placebo according to3. The anaesthetized and
intubated pigs were hemodynamically monitored using approved
invasive techniques including cardiac output (CO). Regional SP
was determined using fluorescent microspheres (FMS) infused via
a fluid filled catheter, placed in the left atrial appendage. Following
Placebo
MAP
[mm Hg]
CO
[ml/min]
SP
[ml/g/min]
NE
[Ојg]
nor-BNI
Compound
Ischemia
End
Compound
Ischemia
End
70
(64; 80)
68
(64; 87)
64
(55; 74)
98 #
(88,116)
65
(59; 69)
76 #
(71; 86)
2311
(2093; 2704)
10
(-49; 36)
2662
(2093; 2948)
2429
( 2135; 2801)
-30
(-77; -6)
2308
(1686; 2430)
0,077
(0,038; 0,163)
0,129
(0,057; 0,274)
0,104
(0,053; 0,166)
0,254 #
(0,134; 0,473)
0,214 #
(0,114; 0,450)
0,174 #
(0,098; 0,308)
0
(0; 0)
281
(168; 778)
130
(13; 222)
00
(0; 0)
253
(101; 417)
0#
(0; 3)
# p < 0.05; Placebo versus nor-BNI. NE displayed in cumulative doses up to the next data point.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-436
S-437
ANESTH ANALG
2012; 114; S-01 – S-493
S-436.
S-437.
MEMORY IMPAIRMENT AND REDUCED SYNAPTIC
PLASTICITY AFTER ISOFLURANE ANESTHESIA IS
MEDIATED BY О±5GABA-A RECEPTORS IN MICE
TWO HOURS OF ANESTHESIA DOES NOT
IMPAIR SUSTAINED ATTENTION IN RATS TESTED
24 HOURS LATER
AUTHORS: A. Zurek2, E. M. Bridgwater2, B. A. Orser1,2
AUTHORS: K. Murphy1, T. Veuthey1, A. Bates2, J. McGaughy2,
M. Baxter1
affiliation: Anesthesia, Sunnybrook Health Sciences, Toronto,
ON, Canada; 2Physiology, University of Toronto, Toronto, ON,
Canada
1
Introduction: General anesthetics cause cognitive deficits
that persist much longer than would be expected on the basis of their
pharmacokinetics. Оі-Aminobutyric acid type A receptors containing
the О±5 subunit (О±5GABAAR) are targets for most anesthetics and
have been implicated in memory deficits in the early postoperative
period. We sought to determine whether working memory and
short-term memory are impaired 24 h after isoflurane anesthesia and
whether memory deficits can be reversed by reducing the function
or expression of О±5GABAARs. Also, to identify the network
substrates that underlie memory deficits, synaptic plasticity was
studied in the CA1 region of the hippocampus 24 h after isoflurane.
Methods: The study was approved by the institutional Animal
Care Committee. Wild-type (WT) and О±5GABAAR null-mutant
(Gabra5-/-) mice were treated with isoflurane (1.3%; 1 MAC) or
vehicle for 1 h. Memory was assessed with an object recognition
task 24 h after isoflurane. Working memory and short-term memory
were tested 1 min and 1 h after training, respectively. To determine
whether inhibition of О±5GABAARs reverses memory deficits, mice
were treated with L-655,708 (0.35 mg/kg) 23.5 h after isoflurane
and 30 min before behavioral training. For electrophysiological
recordings, hippocampi were harvested 24 h after exposure to
vehicle or isoflurane. Long-term potentiation (LTP) and longterm depression (LTD) of synaptic transmission were studied by
measuring the percent change from baseline in field postsynaptic
potentials (fPSPs) after stimulation. Brain slices were stimulated
with high theta frequency (TBS) and 20 Hz protocols.
Results: Short-term memory was impaired in WT mice after
isoflurane (Iso) as evidenced by a decrease in the discrimination
ratio (Control 0.66 В± 0.03 vs. Iso 0.51 В± 0.03, P = 0.0005). In
contrast, working memory was intact (Control 0.68 В± 0.05 vs. Iso
0.67 В± 0.04, P = 0.979). Short-term memory loss was reversed by
L-655,708 (effect of Iso Г— L-655,708, F2,102 = 3.59, P = 0.032;
Iso 0.51 В± 0.03, vs. Iso + L-655,708 0.67 В± 0.03, P < 0.05) and
Gabra5-/- mice showed no memory deficits (effect of Iso F1,47 =
0.375, P = 0.544). LTP induced by TBS was reduced in isofluranetreated mice (Control 53.90 В± 16.38% vs. Iso 29.36 В± 12.65%, P =
0.006). Stimulation at 20 Hz caused LTP in controls and LTD in
isoflurane-treated mice (14.20 В± 16.22% vs. -17.33 В± 9.12%, P <
0.0001).
Discussion: A brief exposure to isoflurane impairs short-term
but not working memory for 24 hours. These deficits are reversed by
inhibiting О±5GABAARs. Plasticity in the hippocampus is impaired
after isoflurane suggesting a possible network substrate for the
memory deficit.
References: N/A
affiliation: 1Friedman Brain Institute, Mount Sinai School of
Medicine, New York, NY; 2Department of Psychology, University
of New Hampshire, Durham, NH
Introduction: Cognitive impairments may occur after
general anesthesia including post-operative cognitive dysfunction.
Rats given two hours of isoflurane-nitrous oxide anesthesia are
impaired in the acquisition of a radial arm maze task when training
is begun 48 hours after anesthesia1. To extend the characterization
of cognitive deficits after general anesthesia, we trained rats on the
5-choice serial reaction time task (5CSRTT)2 and an operant test of
sustained attention (SAT)3.
Methods: In the 5CSRTT task, one of five operant box response
ports is illuminated briefly. If the rat makes a nose-poke to the port
that was illuminated, a reward is delivered. Rats were trained on
a version of the task, which included a variable ITI to increase
attentional demands. In the SAT, rats were trained to distinguish
between signal (presence of visual stimulus) and non-signal
(absence of visual stimulus) trials by pressing the appropriate one
of two levers extended 2s after presentation of the stimulus. Rats
were tested on a version of the task, which included distractors.
Signal duration varied and all trials were presented in a temporally
unpredictable fashion to heighten attentional demands. Rats trained
in the 5CSRTT received either 2 hours of 1.2% isoflurane anesthesia
in 70% nitrous oxide/30% oxygen (N=9) or 2 hours of medical air
(FiO2 0.3) (N=8). Following post anesthetic behavioral testing for
1 week the control group (N=8) then received 2 hours of propofol
(0.6 mg/kg/min) and fentanyl (15 Ојg/kg/hr) anesthesia, followed by
a second period of post anesthesia testing. Rats trained in the SAT
received either 2 hours of 1.2% isoflurane anesthesia in 70% nitrous
oxide/30% oxygen (N=11), 2 hours of propofol (0.6 mg/kg/min) and
fentanyl (15 Ојg/kg/hr) anesthesia (N=12) or 2 hours of medical air
(FiO2 0.3) (N=12).
Results: No performance parameters in either task were affected
by anesthesia treatment in the first test session 24 hours after
anesthesia, or in the subsequent week post-exposure. This indicates
that 2 hours of isoflurane/nitrous oxide or propofol/fentanyl
anesthesia is insufficient to produce attentional impairments in adult
rats, as assessed by performance in the 5CSRTT and SAT.
Discussion: Thus, previously reported impairments in spatial
learning following anesthesia treatment probably cannot be ascribed
to generalized attentional or motivational deficits, but likely reflect
specific hippocampal system dysfunction.
References:
1. Culley et al (2004) Anesthesiology, 100, 309-314.
2. Robbins, T. W. (2002) Psychopharmacology, 163, 362-380.
3.McGaughy, J. & Sarter, M. (1995) Psychopharmacology, 117(3),
340-357.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-438
S-439
ANESTH ANALG
2012; 114; S-01 – S-493
S-438.
S-439.
ALLYL TFD-MEPHOBARBITAL : POTENT
ENANTIOSELECTIVE PHOTOREACTIVE BARBITURATE
GENERAL ANESTHETICS THAT INTERACT WITH
HUMAN GABA(A) RECEPTORS
ACTIVATION OF THE CB2 RECEPTOR SYSTEM
ALLEVIATES AMYLOID-INDUCED MEMORY
DEFICIENCY
AUTHORS: P. Y. Savechenkov2, D. Stewart1, X. Zhang1,3, R. Ge1,
K. S. Bruzik2, K. W. Miller1,3
affiliation: Cleveland, OH
affiliation: 1Department of Anesthesia, Critical Care & Pain
Medicine, Massachusetts General Hospital, Boston, MA; 2College
of Pharmacy, University of Illinois at Chicago, Chicago, IL;
3
Department of Biological Chemistry and Molecular Pharmacology,
Harvard Medical School, Boston, MA
Introduction: Barbiturates exert many actions and likely
have many sites of action. In addition to their well-known anesthetic
action, they act as sedative hypnotics, anticonvulsants, anxiolytics,
respiratory and cardiorespiratory depressants, and muscle relaxants.
Paradoxically, some agents can cause excitation and convulsions
and this property is very sensitive to small changes in structure.
For example, one enantiomer may be an anesthetic and the other
a convulsant.
Methods: We have synthesized allyl mTFD-mephobarbital
(1-methyl, 5-allyl, 5-m-trifluoromethyldiazirinyl barbituric acid)
and separated its enantiomers. With institutional approval, anesthetic
potency was determined as loss of righting reflexes in tadpoles.
With prior institutional approval, oocytes were obtained from adult,
female Xenopus laevis and studied by two-electrode voltage clamp
experiments. Human GABA(A)Rs containing О±1ОІ2Оі2L subunits
were expressed in oocytes. Human О±1ОІ3Оі2L GABA(A)Rs were
expressed in HEK293 cells, and [3H]ligand binding to membrane
preparations determined by filtration assay.
Challenging Case Report: N/A
Results: R(-)allyl mTFD-mephobarbital is one of the most potent
barbiturates ever synthesized with an EC50 of 4 uM, comparable
to R(+)etomidate. However, S(+)allyl mTFD-mephobarbital is
ten-fold less potent as a general anesthetic. In human GABA(A)
Rs containing О±1ОІ2Оі2L subunits expressed in oocytes, the R-, but
not the S-enantiomer enhanced currents elicited by low GABA
concentrations and robustly shifted the GABA concentrationresponse curve to the left. The underlying mechanisms were
characterized using ligands that bind to three different sites on
the GABA(A)R: the agonist site, the benzodiazepine site and the
cage convulsant site. In human О±1ОІ3Оі2L GABA(A)Rs expressed
in HEK293 cells, the enantiomers exhibited distinct patterns
in modulating each of these sites. Both enantiomers enhanced
agonist ([3H]muscimol) binding by 2 to 3-fold with half-effect
concentrations differing by ten-fold and being close to their
anesthetic EC50s. At the benzodiazepine site [3H]flunitrazepam
binding was weakly enhanced with the R(-) enantiomer again being
more potent than the S(+). However, the two enantiomers differed
strikingly in their ability to modulate [3H]EBOB binding at the
cage convulsant sites. Whereas S(+) caused only slight variations
in [3H]EBOB binding at concentrations up to 150 uM, the R(-)
enantiomer almost completely inhibited binding in the physiological
concentration range.
AUTHORS: J. Wu, B. Bie, H. Yang, J. Xu, D. Brown, M. Naguib
Introduction: Amyloid fibrils induce significant neuroinВ­
flamВ­mation, characterized by the activated microglia and astrocytes,
in the brains of patients with Alzheimer’s disease. Emerging studies
suggested the roles of cannabinoid receptor 2 (CB2) in the pathogenesis
of Alzheimer’s disease. Our previous work established MDA7,
1-((3-benzyl-3-methyl-2,3-dihydro-1-benzofuran-6-yl)carbonyl)
piperidine, as a novel potent selective CB2 agonist . In this study, we
demonstrate that MDA7 blunts neuroinflammation and ameliorates
the memory deficiency in the rat model of Alzheimer’s disease.
Methods: Adult male Sprague-Dawley rats (200-250 g) were
applied and all animal procedures were approved by the Institutional
Animal Care and use Committee. Abeta1-40 fibrils (10 microg/side)
was microinjected into the hippocampal CA1 area to establish the
rat model of Alzheimer’s disease. Same volume of saline was used
in the control group. MDA7 (15 mg/kg) was intraperitoneally (i.p.)
administered daily for 14 days in both modeled and control groups.
Immunostaining and immunoblotting were performed to exam the
expression of CB2, CD11b, glial fibrillary acidic protein (GFAP),
and IL-1beta. Whole-cell recordings in hippocampal slices and
Morris water maze were performed to test the effect of MDA7 on
amyloid fibrils-impaired synaptic plasticity and memory function.
Results: Significant increases of CD11b and GFAP immuВ­
noreactivity, enlarged cell mass, and increased cell complexity were
noted in the microglia and astrocytes respectively in the hippocampal
CA1 of the modeled rats (Figs. 1 & 2). Immunoblotting study revealed
an increased IL-1beta level in the hippocampal CA1 tissue in the
modeled rats. The expression of CB2 receptor was also increased
in the hippocampal CA1 tissue in the modeled rats. Meanwhile,
systemic administration of MDA7 significantly attenuated amyloid
fibrils-induced upsurge of CB2, CD11b and GFAP expression and
IL-1beta synthesis in hippocampal CA1. Furthermore, MDA7
significantly recovered amyloid fibrils-impaired electric stimuliinduced long term potentiation, and improved the performance in
the water maze test in the modeled rats.
Discussion: Activation of central microglial CB2 receptor by
MDA7 significantly attenuated the glia activation, improved the
impaired synaptic plasticity in hippocampus as well as memory
deficiency induced by Abeta1-40 fibrils. The CB2 receptors
in microglia may serve as a novel target for the treatment of
Alzheimer’s disease.
References:
Nature 346(6284), 561-4.
Discussion: Thus R(-) and S(+) allyl mTFD-mephobarbital
are effective general anesthetic photolabels that modulate human
GABA(A)R function enantioselectively and may be useful for
identifying binding sites on the GABA(A)R and other targets.
References: Funded by GM 58448
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Pharmacology – Clinical
ABSTRACTS
S-445
S-446
S-445.
S-446.
THE INCIDENCE OF THE PROPOFOL-INDUCED
YAWNING RESPONSE IS HIGHER IN
POSTMENOPAUSAL WOMEN
WITHDRAWN.
AUTHOR: K. Terasako
affiliation: Shobara Red Cross Hospital, Shobara-City, Japan
Introduction: I have experienced two cases of the temporoВ­
mandibular joint dislocation due to forceful yawning during
induction with propofol.
Although yawning occurs frequently during the intravenous (IV)
induction of general anesthesia, the significance of this response
remains unknown.
I reported that the incidence of the propofol-induced yawning
response is higher in male than in female and that the falls in arterial
blood pressure seen following IV-administrated propofol have
nothing to do with the occurrence rate of yawning1.
The increased probability of the yawning response in male patients
in the past study is consistent with the finding that yawning was
found to be an androgen-dependent sexually dimorphic behavior,
occurring in males more frequently than in females in adult rhesus
monkeys2,3.
The purpose of the present study is to examine whether
postmenopausal women yawn more often than young women.
Methods: Ninety female patients [ each of the American Society
of Anesthesiologists physical status 1-2 and scheduled for elective
surgery under general anesthesia] over 13 years old participated
in this study. There were seventy women aged over fifty years old
and they were allocated to postmenopausal female group. After
obtaining baseline values and oxygenation through the mask, IV
injection of 1.5mg/kg propofol was administered by the investigator
over a 5-s period. As the only clinical end point, the occurrence
of the yawning response (characterized by mouth opening) was
observed continuously after the start of the anesthetic infusion.
The end of the 1-min observation period represented termination of
this study. Then, rocuronium (0.6mg/kg) was administered IV, and
mask-assisted ventilation with 97% oxygen and 3% sevoflurane was
applied until tracheal intubation.
Results: The incidence of the propofol-induced yawning
response was higher in postmenopausal female group (27%) than in
younger female group (5%) (P<0.05).
There were no significant differences among the postmenopausal
female-yawning(+), postmenopausal female-yawning(-), younger
female-yawning(+) and younger female-yawning(-) groups in
baseline MAP, baseline HR ,MAPGAP, MAP after induction, HR
after induction and body weight.
Discussion: The incidence of the propofol-induced yawning
response is higher in postmenopausal women than in younger
women. Estrogen may prevent yawning response in younger women.
The falls in arterial blood pressure seen following IV-administrated
propofol have nothing to do with the occurrence rate of yawning.
References:
1. Terasako K. Anesth analg 2011;112:S384
2.Serra G, Collu M, Serra A, Gessa GL. Eur J Pharmacol
1984;104:383-6
3. Graves FC, Wallen K. Horm Behav 2006;49:333-6
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-447
S-448
ANESTH ANALG
2012; 114; S-01 – S-493
S-447.
S-448.
MONOAMINE OXIDASE INHIBITORS
AND THE OCCURRENCE OF INTRAOPERATIVE
HEMODYNAMIC EVENTS
INFLUENCES ON GLUCOSE METABOLISM OF PRIOR
AMINO ACID ADMINISTRATION AFTER STARTING
PREOPERATIVE FASTING AND THE USEFULNESS
OF AMINO ACID INTAKE COMBINED WITH
CARBOHYDRATE LOAD
AUTHORS: I. Van Haelst1,2, T. Egberts2,3, H. Doodeman1,
C. Kalkman4, W. van Klei4
affiliation: 1Clinical Pharmacy, Medical Center Alkmaar,
Alkmaar, Netherlands; 2Clinical Pharmacy, University Medical
Center Utrecht, Utrecht, Netherlands; 3Pharmacoepidemiology and
Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences,
Utrecht, Netherlands; 4Perioperative Care and Emergency Medicine,
University Medical Center Utrecht, Utrecht, Netherlands
Introduction: Although Monoamine Oxidase Inhibitors
(MAOIs) have been available for more than 50 years, the
perioperative management of patients treated with MAOIs is still
under discussion. From the point of view of appropriately treating
the psychiatric illness, perioperative continuation is recommended.
However, potentially fatal drug interactions have been reported in
patients where (ir)reversible MAOIs were used concurrently with
opioids or sympaticomimetic agents during anesthesia. There are no
evidence-based guidelines and experts disagree whether to continue
the use of MAOIs before surgery or not1-3. The aim of this study was
to investigate the occurrence of intraoperative hemodynamic events,
such as hypertension and tachycardia, when MAOIs were continued
during anesthesia.
Methods: A retrospective observational cohort study was
conducted among patients who were admitted for elective surgery
requiring anesthesia in eight Dutch hospitals (2004-2010). The
index group included current users of MAOIs. The reference group
included a sample of nonusers matched to the index group on
hospital, type of surgery and anesthesia (ratio 1:3). The outcome
was the occurrence of the following intraoperative hemodynamic
events: hypo- or hypertension and tachy- or bradycardia. The
incidence of the serotonergic syndrome was also registered.
Results: Approximately 280,000 surgical procedures were
performed in the participating hospitals in the observed 33 years.
The index group included 51 current users of a MAOI. The reference
group included 149 nonusers. Intraoperative hypotension occurred
less frequently in users of a MAOI (49%) than in nonusers (69%)
(p = 0.01). The occurrence of hypertension, brady- and tachycardia
during anesthesia was not different between users of a MAOI (28%,
57% and 20%, respectively) and those of the reference group (26%,
56% and 26%, respectively). In none of the study patients the
serotonergic syndrome was diagnosed.
Discussion: Severe adverse hemodynamic events, such as
hypertension and tachycardia, did not occur more frequently in
users of MAOIs – who continued their use during anesthesia –
compared to nonusers. Intraoperative hypotension occurred even
less frequently in users of a MAOI than in nonusers. These findings
suggest that there is no longer much justification to discontinue (ir)
reversible MAOIs before surgery, with the attendant considerable
risk of compromising their psychiatric status.
References:
1. Eur J Anaesth 2011; 28:684-722;
2. Psychosomatics 2006; 47:8-22
3. Drugs 1996;51: 238-259
AUTHORS: M. Tanno, H. Fukushima, S. Ohara, Y. Tanaka
affiliation: Mito Medica center National Hospital OrganizaВ­
tion, Ibaraki-machi Iaraki-ken, Japan
Introduction: Intraoperative amino acid administration
beneficially elevates intraoperative temperature, shortesns intensive
care hospitalization, inhibits postoperative protein catabolism, etc.
Influences on glucose metabolism of prior amino acid administration
after starting preoperative fasting and the usefulness of amino acid
intake combined with glycemic load were examined in healthy
volunteers.
Methods: Two experiments were conducted in the same
volunteers using a randomized sequential crossover design. Both
groups started fasting at 21:00. The amino acid group received an
amino acid supplement (Amino VitalВ®) 3.6 g with 250 mL water at
22:00 and 7:00. Then, a 250 mL carbohydrate solution (Arginade
WaterВ®) was consumed at 8:00. The carbohydrate group drank 250
mL of water at 22:00 and 7:00 without receiving the amino acid
supplement. Then, the same carbohydrate solution amount was
consumed at 8:00. Blood tests were conducted at 8:00 and 10:00 to
measure blood sugar (BS), insulin (IRI), free fatty acid (FFA), total
ketone body concentration (ketone), glucagon (GU) and growth
hormone (GH).
Amino VitalВ® contains 18 kcal, leucine 0.54g, isoleucine 0.43g,
valine 0.36g, glutamine 0.65g, and others 1.72g (Ajinomoto CO.,
INC., Tokyo).
Arginade WaterВ® contains 200 kcal, with 45g carbohydrate per 200
mL (Nestle Nutrition Institute, Tokyo).
Challenging Case Report: N/A
Results: Results of 10 volunteers. Blood test results at 8:00
(amino acid vs carbohydrate group): BS, 83 В± 19 vs 89 В± 23 mg/
dL; IRI, 5.1 В± 2.3 vs 5.0 В± 2.3 IU/mL; FFA, 444 В± 143 vs 550 В±
143 ОјEq/L; ketone, 57 В± 52 vs 91 В± 64 Ојmol/L. Blood test results
at 10:00: BS, 89 В± 19 vs 83 В± 18 mg/dL; IRI, 11.6 В± 12.9 vs 6.0 В±
4.0 IU/mL; FFA, 215 В± 117 vs 163 В± 87 ОјEq/L; ketone, 18 В± 8 vs
17 В± 8 Ојmol/L. In intra-group comparisons, FFA, Ketone and GH
levels were significantly reduced due to carbohydrate load (p<0.05),
whereas BS, IRI and GU levels did not change significantly. There
was no significant difference in any other data between the 2 groups.
Discussion: Administration of amino acid supplements during
the early period after initiation of fasting was expected to inhibit
protein catabolism via the following process: branched-chain amino
acids activate pyruvate dehydrogenase complexes, and arginine
enhances secretion of GH and GU. This would lead to rapid
glycogenolysis and then rapid gluconeogenesis, thereby stabilizing
BS. However, we found that amino acid intake after initiation of
fasting does not affect glucose metabolism. Moreover, it was
suggested that intake of amino acid supplements combined with a
carbohydrate load as preoperative rehydration therapy may not exert
intraoperative nutritional efficacy.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-449
ANESTH ANALG
2012; 114; S-01 – S-493
S-449.
OPTIMAL CONTROL OF MUSCLE RELAXATION FOR
ELECTROCONVULSIVE THERAPY: A COMPARISON OF
SUCCINYLCHOLINE VERSUS ROCURONIUM-INDUCED
NEUROMUSCULAR BLOCKADE
AUTHORS: H. Mirzakhani1,3, C. A. Welch2,3, E. George1,3, T. O.
MacDonald1,3, A. Nozari1,3, M. Eikermann1,3
affiliation: 1Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA; 2Psychiatry,
Massachusetts General Hospital, Boston, MA; 3Harvard Medical
School, Boston, MA
Introduction: Muscle relaxation is required to avoid
excessive muscle contractions during electroconvulsive therapy
(ECT). Succinylcholine (Sux) is most commonly used. The optimal
dose of neuromuscular blocking agent (NMBA) for ECT minimizes
evoked muscle contractions without undue prolongation of recovery
from NMBA effects. In a cross-over, assessor-blinded, prospective,
randomized study, we evaluated the optimal dose of rocuronium
(Roc) and succinylcholine (Sux) for ECT.
Figure 1. A & B: Time course of action of twitch height (1 Hz stimulation
frequency) following succinylcholine and rocuronium injection. Twitch
height is given in per cent of post-calibration baseline. A: Onset of action.
B: Recovery of twitch height. Means and standard deviations of values
taken from patients who received a neuromuscular blocking agent dose that
optimized ECT-induced motor activity. *p<0.05
Methods: We included 20 patients, aged 24-80 years (ASA:
I-III), scheduled for a series of ECT. Patients received in a random
order either Sux or Roc by utilizing the staircase technique1. Doses
were incrementally increased or decreased by 10% based on the
assessment of a psychiatrist blinded to dose. Following induction
of general anesthesia, the TOF-Watch SX was calibrated (mode 1,
50 mA), and 1 Hz single twitch was initiated. Blood pressure, heart
rate, SpO2, and time to recovery of spontaneous breathing were
measured throughout. Data are reported as MeanВ±SD.
Results: 84 treatments were conducted in 20 patients. ECT
was initiated at nadir T1, 1.5В±0.4% and 4В±0.9% for Sux and Roc,
respectively, p<0.05. The optimal doses of Sux and Roc for ECT, as
defined by smallest dose of NMBA that provides acceptable ECT
condition, were 0.8В±0.2 mg/kg, and 0.4В±0.08 mg/kg respectively. In
patients receiving the optimal NMBA dose, onset of action (figure
1A) and time to T1 recovery to 100% (figure 1B) were significantly
shorter following Sux compared with Roc, p<0.05. Similarly, time
to return of spontaneous breathing was significantly shorter for Sux
4.6В±1 min compared with Roc 6.5В±1 min, p<0.05.
The mean difference in recovery time from adequately attenuated
muscle strength for ECT using Roc compared with Sux was
1.9В±1.2 minutes (endpoint: spontaneous breathing) and 4.2В±3.5 min
(endpoint: T1 recovery).
There was no significant difference in patients’ anesthesia regimen
(compounds and dose), and ECT parameters. Of note, duration
of motor seizure activity was significantly longer following Roc
compared with Sux (30В±12 vs. 22В±8s, respectively, p<0.05.
Discussion: Almost complete T1 suppression is required
to optimize muscle relaxation for ECT. Both rocuronium (with
neostigmine reversal) and succinylcholine can be safely used. The
optimal doses of succinylcholine and rocuronium for ECT were
0.8В±0.2 and 0.4В±0.08 mg.kg-1 for rocuronium respectively. The
mean increase in time required for recovery using rocuronium
compared with succinylcholine was 2-4 minutes, depending on the
criteria used to define adequate recovery from NMDAs.
References:
1. Reynolds LM et al. Anesthesiology 1996
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-450
S-451
ANESTH ANALG
2012; 114; S-01 – S-493
S-450.
S-451.
WITHDRAWN.
DEEP SEDATION FOR COLONOSCOPY IN OVERWEIGHT
PATIENTS: A COMPARISON BETWEEN PROPOFOL
ALONE VERSUS PROPOFOL AND KETAMINE
AUTHORS: S. Amornyotin, S. Kongphlay
affiliation: Bangkoknoi, Thailand
Introduction: The aim of this study was to evaluate and
compare the clinical efficacy of propofol alone and propofol and
ketamine for deep sedation (DS) for colonoscopy in overweight
(BMI>25) patients in a teaching hospital in Thailand.
Methods: We undertook a retrospective review of the sedation
service records of overweight patients who underwent colonoscopic
procedures from December 2007 and May 2009. All patients were
premedicated with intravenous midazolam before the procedure.
The primary outcome variable was the successful completion of
the endoscopy. The secondary outcome variables were sedation and
procedure-related complications during and immediately after the
procedure, and mortality rate.
Results: There were 98 overweight patients who underwent
colonoscopic procedure by using deep sedation technique during
the study period. After matching age, gender, ASA physical status
and indications of procedure, 38 patients were sedated by using
propofol alone (group P) and 42 patients were sedated with propofol
and ketamine (group PK). All sedation was given by residents or
anesthetic nurses directly supervised by staff anesthesiologist in the
endoscopy room. There were no significant differences in patients’
characteristics, sedation time, indication, anesthetic personnel,
mortality rate, success rate and sedative agents used between the
two groups. Sedation-related complication including hypotension in
group P was significantly higher than in group PK. However, all
complications were easily treated, with no adverse sequelae.
Discussion: Deep sedation in both regimens for colonoscopy in
overweight patients provided effective and safe. No serious adverse
events were observed. However, the combination of propofol and
ketamine used for DS had significantly lower complication than the
propofol alone.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-452
S-453
ANESTH ANALG
2012; 114; S-01 – S-493
S-452.
S-453.
PREDICTION OF ADDITIONAL SUGAMMADEX IN A
SHORT RECOVERY PHASE IN PEDIATRIC PATIENTS
THE IMPACT OF PROTEIN BINDING AND HEPATIC
BLOOD FLOW ON SUFENTANIL PHARMACOKINETICS
DURING CARDIAC SURGERY WITH
CARDIOPULMONARY BYPASS
AUTHORS: H. Iwasaki1, K. Takahoko1, S. Otomo1, T. Sasakawa2,
T. Kunisawa1, H. Iwasaki1
affiliation: 1Department of Anesthesiology and Critical
Care Medicine, Asahikawa Medical University, Asahikawa, Japan;
2
Department of Anesthesiology, Shriners Burns Institute Shriners
Hospital for Children, Massachusetts General Hospital, Harvard
Medical School, Boston, MA
Introduction: Sugammadex (Sug) can reverse successfully
even a profound rocuronium-induced neuromuscular block (NMB).
It is reported that muscle relaxation rebound can occur for doses of
Sug in a limited critical range1. The aim of this study is to determine
the necessity of additional Sug administration in a short period by
observing the recovery in the twitch height and TOF ratio.
Methods: Twenty-three scheduled pediatric surgical patients
(ASA class 1-2, age 1-10yr, BW 7.6-27kg) undergoing general
anesthesia were randomly divided into four groups at the end of
surgery ; (T2-1.0) group (n=7) : received Sug 1.0 mg/kg, (T2-0.5)
group (n=6) : received 0.5 mg/kg for reversal of NMB at the level
of T2. (PTC-1.0) group (n=4): received Sug 1.0 mg/kg, (PTC-0.5)
group (n=6): received 0.5mg/kg for reversal of NMB at the level
of PTC1~4. All patients received additional Sug (0.5~1mg/kg),
five minutes after first administration of Sug and then evaluated
the change of T1 height and train-of -four (TOF) ratio. Total
recommended dose of Sug were administered before extubation.
Neuromuscular monitoring was performed using the TOF Watch
SXВ® accelermyograph and stimulated the ulnar nerve.
Results: After the second administration of Sug, the patient was
classified into (insufficient) group if T1 height had increased more
than 10% of control. And if no change in T1 height was observed,
the patients were classified into (sufficient) group.
All patients in the (T2-1.0) group and one patient in the (T2-0.5)
group were classified into (sufficient) group. All patients in the
(PTC-1.0) group and (PTC-0.5) group, and five patients in the (T20.5) group were classified into (insufficient) group.
Recoveries of T1 height at 1-3min and TOF ratio at 1-5min were
significantly faster in (sufficient) group compared to sufficiency
group after initial dose of Sug administration.
However, it has been demonstrated that TOF ratio only in the
(sufficient) group recovers over 90% within 3 minutes after initial
Sug administration. (Figure1,2)
Discussion: TOF ratio >0.9 measured at the adductor pollicis
muscle had been accepted to be an index showing sufficient
recovery from neuromuscular block.2
It is demonstrated that the necessity of Sug administration can be
decided to observe the TOF ratio after Sug injection. It should be
administered an additional Sug for adequate NMB recovery when
TOF ratio 3 min after initial Sug is shown under 0.9.
References:
1. Anesth Analg 2007;104:582-4
2. Anesthesiology 1997 Nov;87(5):1035-43
AUTHORS: C. Jeleazcov, T. Saari, H. Ihmsen, J. Schuettler, J.
Fechner
affiliation: Anesthesiology, University Hospital Erlangen,
Erlangen, Germany
Introduction: It has been shown that the pharmacokinetics
of sufentanil are changed during cardiopulmonary bypass (CPB)1,
but little is known about the unbound sufentanil concentrations.
Therefore, we investigated the pharmacokinetics of total and
unbound sufentanil during CPB.
Methods: After IRB approval and written informed consent,
13 male patients (53-71 yr, 70-96 kg) undergoing coronary artery
bypass surgery received total intravenous anesthesia with propofol
and target controlled infusion (TCI) of sufentanil using Gepts model2
and targeting plasma concentrations of 0.4 ng/ml (n=6) or 0.8 ng/
ml (n=7). Arterial blood samples were taken at skin incision, 5 min
before start of CPB, 15 min and 45 min after start of CPB, 15 min
after stop of CPB and at last suture. Total and unbound sufentanil
concentrations were measured by ultra HPLC with tandem mass
spectrometry. Pharmacokinetics were determined by population
analysis (NONMEM) using linear multicompartment models. The
goodness of fit of the model was assessed by both median prediction
error (MDPE) and median absolute prediction error (MDAPE).
Results: Sufentanil was administered over 221В±57 min with
a mean dosis of 0.56В±0.05 and 1.03В±0.06 Вµg/kg/h for the target
concentrations of 0.4 and 0.8 ng/ml, respectively (meanВ±SD).
The total sufentanil concentrations were consistently higher than
targeted (Ctotal/Ctarget > 1), particularly in the pre-bypass phase,
and decreased subsequently (table), whereas the unbound sufentanil
concentrations remained fairly constant. Free fraction of sufentanil
increased significantly during CPB. Pharmacokinetics were
adequately described by a two-compartment model (MDPE=-2.2%,
MDAPE=21.2%). The elimination clearance CL1 was significantly
higher during and after CPB when compared to the pre-bypass
phase. Volumes of distribution increased slightly during and after
CPB. CL1 could be modeled as a function of hepatic blood flow and
free fraction (“well-stirred” model). V1 and V2 could be modeled as
a function of free fraction.
Discussion: TCI of sufentanil with the Gepts model led to a
distinct overdosing in the pre CPB phase. Protein binding and hepatic
blood flow showed a clear effect on sufentanil pharmacokinetics.
References:
1.Effects of cardiopulmonary bypass on sufentanil pharmacoВ­
kinetics in patients undergoing coronary artery bypass surgery.
Anesthesiology 2004;101:862-71.
2.Linearity of pharmacokinetics and model estimation of
sufentanil. Anesthesiology 1995;83:1194-204.
[Funding] This study was partly supported by a grant of the
German Federal Ministry of Education and Research (BMBF, FKZ
01EX1015B)
Pre-CPB
CPB
Post-CPB
1.35 В± 0.41 *
Ctotal/target
2.45 В± 0.90
1.36 В± 0.47 *
Free fraction (%)
8.6 В± 3.3
13.2 В± 4.7 *
11.8 В± 4.8 *
CL (L/min)
0.60 В± 0.20
1.33 В± 0.44 *
1.04 В± 0.34 *
V1 (L)
9.0 В± 0.7
9.8 В± 1.0 *
9.6 В± 0.7 *
V2 (L)
57.7 В± 8.8
68.4 В± 7.7 *
67.5 В± 8.8 *
Pharmacokinetics in the three periods (meanВ±SD), * p<0.05 compared to
Pre-CPB (RM ANOVA, Tukey test).
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-455
S-456
ANESTH ANALG
2012; 114; S-01 – S-493
S-455.
S-456.
ROCURONIUM NEUROMUSCULAR BLOCKADE IS
POTENTIATED BY ONDANSETRON
DEXMEDETOMIDINE INFUSION TIME CONSIDERATIONS
FOR AWAKE FIBEROPTIC INTUBATION
AUTHORS: O. Desjardins St-Jean, L. Fortier, F. Donati
AUTHORS: X. Zheng, J. Swaniker, D. Glick
affiliation: Anesthesia, University of Montreal, Montreal,
QC, Canada
affiliation: Anesthesia and Critical Care, University of
Chicago, Chicago, IL
Introduction: Ondansetron, a 5-HT3 receptor antagonist,
is used commonly at the end of anesthesia and surgery to prevent
postoperative nausea and vomiting (PONV). The 5-HT3 receptors
belong to the same superfamily as the nicotinic receptors at the
neuromuscular junction. Therefore, ondansetron could have an
effect at the neuromuscular junction. The purpose of this study was
to determine the effect of ondansetron on an already established
rocuronium-induced neuromuscular block.
Introduction: Sedation regimens for awake fiberoptic
intubation (AFOI) typically include a benzodiazepine and an
opioid, a combination that can result in hypoventilation and
hypoxia. Dexmedetomidine is a sedative with few cardiovascular
and ventilatory effects. Previous studies have elucidated the benefits
of dexmedetomidine in reducing opioid requirements for intubation
when added to the conventional sedation regimen. In this study, the
effect of preoperative dexmedetomidine infusion time on opioid
requirements for AFOI was explored.
Methods: This randomized double blind study involved 30
patients between the ages of 18 to 75 years undergoing elective
surgical procedures under total intravenous anesthesia and tracheal
intubation were recruited. Train-of-four (TOF) stimulation was
applied at the ulnar nerve at the wrist and the response of the adductor
pollicis muscle was recorded with a GE NMT MechanoSensor
(GE Healthcare, Helsinki, Finland) device. After the beginning of
recovery from a 0.6 mg/kg bolus, a rocuronium infusion was started
at a rate adjusted to keep the value of the first twitch (T1) constant,
between 20 and 30% of the control value. With the infusion rate
unchanged, patients were randomized to receive ondansetron 4 mg,
followed by saline 15 min later (O-S Group), or saline, followed
by ondansetron 15 min later (S-O Group). The primary outcome
measurement was T1 15 min after the first injection. Results are
expressed as mean (SD).
Results: The baseline T1 value was the same in both groups
[23.7 (2.6) % in the S-O and 24.2 (2.3) % in the O-S Groups]. In
the S-O Group (15 patients), T1 increased slightly to 27.1 (7.7 %)
15 min after saline and in the O-S Group (15 patients), there was a
decrease to 20.5 (4.2) % 15 min after ondansetron, for a difference
of 6.6 % (95 % CI 2.0 to 11.2 %) (P = 0.007 between groups). In the
S-O group, injecting ondansetron at 15 min was followed by a 4.8
(3.4) % decrease during the next 15 min, and in the O-S Group, T1
continued to decrease during the same time period (Figure).
Discussion: This study shows that ondansetron has a mild
potentiating effect on rocuronium-induced neuromuscular blockade.
Giving ondansetron 4 mg at the end of surgery could increase the
degree of residual paralysis, especially in patients with borderline
recovery.
References: N/A
Methods: After IRB approval and informed consent 26 adult
narcotic naГЇve patients undergoing elective surgical procedures
with AFOI were enrolled. Patients were administered intravenous
midazolam and a continuous infusion of dexmedetomidine.
Hemodynamic markers were recorded at one-minute intervals
until the completion of intubation. Fentanyl (1 mcg/kg, rounded to
the nearest 25 mcg) was titrated as needed to achieve a Ramsay
Sedation Score ≥ 2. Within 24 hours of surgery, patient satisfaction
with the intubation procedure and any post-operative complications
were assessed.
Results: No overall correlation was found between dexmedetoВ­
midine infusion time and the amount of fentanyl needed, but there
was a significant reduction in the amount of fentanyl required for
patients infused with dexmedetomidine for 22 minutes or more
(P<0.05). Patients receiving the infusion for at least 22 minutes
required an average of 1.08 mcg/kg fentanyl compared to 1.76 mcg/
kg for patients infused for less time, representing a 39% decrease
in the opioid requirement. No correlation was found between the
amount of dexmedetomidine administered per kilogram body weight
and fentanyl given per kilogram of body weight. No significant
difference between subjects receiving 22 minute or longer infusions
compared to subjects receiving shorter infusions was found in terms
of hemodynamic markers including systolic blood pressure and
heart rate; in oxygen saturation; in post-operative complications; or
in satisfaction.
Discussion: Dexmedetomidine may be a useful adjunct sedative
for decreasing the amount of opioid required during fiberoptic
intubation, thus lowering the risk of hypoventilation. However,
its usefulness may be limited by an infusion length requirement.
Time must be given for the preoperative infusion to maximize the
benefits of dexmedetomidine with regards to opioid requirements.
Thus dexmedetomidine use for AFOI is ideally suited for elective
procedures that allow sufficient infusion time, and use in emergent
procedures may provide lesser benefits.
References:
1. J Clin Anesth. 2009;21(3):194-9.
2. Am J Ther. 2010;17(6):586-95.
Figure: First twitch height (T1) against time with a constant background
infusion of rocuronium. Injection of ondansetron or saline at 0 min and saline
or ondansetron at 15 min.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-457
S-458
ANESTH ANALG
2012; 114; S-01 – S-493
S-457.
S-458.
THE EFFECT OF DIFFUSION OF 4% LIDOCAINE
THROUGH THE MEDTRONIC EMG ENDOTRACHEAL
TUBE CUFF ON NIM-RESPONSEВ®
USEFULNESS OF ESTIMATED PLASMA
CONCENTRATION (CP) FOR DECIDING THE TIMING OF
REPEATED BOLUS ROCURONIUM ADMINISTRATION
UNDER DESFLURANE ANESTHESIA
AUTHORS: O. Asimolowo, A. Apostol, S. Jalou, K. Sundaram,
M. Dela pena
affiliation: Brooklyn, NY
Introduction: Thyroid and parathyroid surgery pose chalВ­
lenges to anesthesiologists. Lidocaine is injected into the cuff
for smooth emergence.1 It diffuses across endotracheal tube
cuff and assist in the prevention of ETT-induced cough during
emergence from general anesthesia.2 The most common and
serious complication after thyroid and parathyroid surgery is the
risk of recurrent laryngeal nerve injury.3 Several techniques of
intraoperative neurophysiology testing (INT) have been developed.
The Medtronic Xomed Nerve Integrity Monitor EMG Endotracheal
tube is a flexible silicone endotracheal tube with electrodes on the
main shaft, which makes contact with the patient’s vocal cords to
facilitate electromyographic (EMG) monitoring during surgery.4
The objective of the study is to determine if lidocaine 4% placed
in the Medtronic EMG ET tube cuff has an effect on the EMG
monitoring of vocal cords
Methods: Medtronic EMG ET tubes were used in 40 patients
undergoing thyroid or parathyroid surgery; all received the same
anesthetic management. As a control for each patient, the EMG
recording with air was used. After obtaining consent, patients were
randomized to have either lidocaine or saline injected into the cuff.
After this, lidocaine 4% or saline (5mL) was injected into the EMG
ET tube cuff. Blinding was done by giving the anesthesiologist
either saline or lidocaine in a syringe, both colorless liquids. The
stimulation of the recurrent laryngeal nerve produced amplitude
and latency of the EMG curves tracing recorded on Medtronic
NIM (Nerve Integrity Monitoring System). Lidocaine or normal
saline (NS) was infused when the surgeon stimulates the recurrent
laryngeal nerve for the first time at 1A, then 2 more times during
the case at 0.8 A.
Results: N/A
Discussion: There was no statistically difference on the effect on
the EMG monitoring of vocal cords between the two groups. Even
though there was no statistical difference, there was a difference
in the amplitude and latency of the EMG curves between the two
groups at 5 minutes.
References:
1.Soltani, H. and Aghadavoudi, O. The Effect of Different
Lidocaine Application Methods on Postoperative Cough and
Sore Throat. Journal of Clinical Anesthesia. 2002. 14:15-18.
2.Huang, Chun-Jen, et al. In vitro diffusion of lidocaine across
endotracheal tube cuffs. Canadian Journal of Anesthesia. 1999.
Vol 46, 82-86.
3.Chiang F. et al. The mechanism of recurrent laryngeal nerve
injury during thyroid surgery - The application of intraoperative
monitoring.
AUTHORS: K. Takahoko1, H. Iwasaki1, S. Otomo1, T. Sasakawa2,
H. Iwasaki1
affiliation: 1Anesthesiology, Asahikawa medical college,
Asahikawa, Japan; 2Anesthesiology, Shriners Burns Institute
Shriners Hospital for Children Massachusetts General Hospital
Harvard Medical School, Cambridge, MA
Introduction: It has been suggested to administer
sufficient doses of neuromuscular blocking drugs (NMBD) using
a neuromuscular-blocking monitor during the surgery needed
an absolute immobilization. However, it is difficult to find an
optimal timing of relaxant injection in a clinical practice because
the neuromuscular monitor sometimes shows inaccurate degree of
neuromuscular blockade. In previous studies, we demonstrated that
the Cp (estimated plasma concentration) of rocuronium was a useful
parameter to administer an additional relaxant under sevoflurane
anesthesia1. It has been reported that desflurane tend to have a
greater potentiation effect of non-depolarizing relaxants than that of
the other volatile anesthetics. Therefore, the aim of this study was
to evaluate a clinical usefulness of Cp for deciding the timing of
additional rocuronium administration during desflurane anesthesia.
Methods: After obtaining IRB approval and informed consent,
we recruited 10 patients who had received elective ophthalmic
surgery. Anesthesia was maintained with 0.7 MAC of desflurane and
remifentanil. The ulnar nerve was stimulated using TOF WatchR SX
with supramaximal train-of-four stimulations. Tracheal intubation
was performed after administration of 0.6 mg/kg of rocuronium.
When the T1 height recovered to 25% of the maximum height, Cp
was calculated (1stcalculation: Cp1) and recorded; the Cp values
was calculated using Szenohradszky’s parameter. Then, 0.15 mg/kg
of rocuronium was administered to the patient. When the T1 height
recovered to 25% again, the same calculation was performed (2nd
calculation: Cp2), and the values from the 1st and 2nd calculations
were compared. Data were analyzed by a paired t test. P values less
than 0.05 were considered to be statistically significant.
Results: Data were presented as mean В± SD. [figure1] Among
the groups absolute Cp values varied widely, but it was demonstrated
that inter-individual variability of the 1st and 2nd Cp values were
not significantly different.
Discussion: During repeated bolus administration of rocuronium
under desflurane anesthesia, the Cp of rocuronium was a good
predictor of recovery. Using both conventional neuromuscularblocking monitor and Cp enables us a safer anesthetic management
during desflurane anesthesia.
References:
1.Comparison of the validitity of the Cp and Ce during repeated
bolus administration of rocuronium. Sasakawa T et al: ASA
2010
4.Dollo, G. et al. Endotracheal tube cuffs filled with lidocaine
as a drug delivery system: in vitro and in vivo investigations.
European Journal of Pharmaceutical Sciences 13 (2001) 319323
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-459
S-460
ANESTH ANALG
2012; 114; S-01 – S-493
S-459.
S-460.
DOES REMIFENTANIL AFFECT THE INCIDENCE OF
COLON CANCER RECURRENCE?
IMPACT OF SEVOFLURANE VS. PROPOFOL ON
INCIDENT DELIRIUM AFTER NONCARDIAC SURGERY- A
RANDOMIZED CONTROLLED TRIAL
AUTHORS: H. Kurosaki, K. Fujii, K. Nishikawa
affiliation: Anesthesiology, Wakayama Medical University,
Wakayama, Japan
Introduction: Anesthetic technique during cancer surgery
has been reported to have the potential to affect long term outcome.
Although it is well known that morphine suppresses human Natural
Killer cell cytotoxicity leading to harmful potential to cancer
recurrence, the effect of synthetic opioids, such as fentanyl or
remifentanil, on cancer recurrence has not been clarified. This study
was aimed to evaluate the inhibitory effect of remifentanil on cancer
recurrence in patients undergoing colon cancer surgery.
Methods: We retrospectively reviewed the records of 157
patients undergoing radical colon cancer (stage IIIa/ IIIb) surgery
performed in our hospital from January 2005 to December 2009.
The follow-up period ended on October 2011. Prospective factors
for cancer recurrence included preoperative complications, location
of tumor, tumor stage, perioperative remifentanil use, and blood
transfusion. Primary outcomes were the presence or absence of
cancer recurrence and disease free interval. Kaplan-Meier method
and Cox proportional hazards model were used. Data were
represented as number (%) or Mean [95% confidence interval] and
P < 0.05 was considered as significant.
Results: Cancer recurrences were detected in 28 patients
(17.8%) and remifentanil was used perioperatively in 77 patients
(49.0%). Remifentanil could neither inhibit the incidence of cancer
recurrence (13 (16.9%) vs. 15 (18.8%), P=0.84) nor prolong mean
disease free interval (1238 [1159-1316] days vs. 1841 [1697-1985]
days, P=0.70). Cox hazard analysis demonstrated that Stage IIIb
was the only predictor of cancer recurrence (Odds ratio 2.2 [95%
confidence interval 1.0-4.8], P=0.041) and remifentanil usage
was not associated with cancer recurrence (Odds ratio 0.7 [95%
confidence interval 0.2-2.1], P=0.52).
AUTHORS: G. A. Lurati Buse1, E. Seeberger1, M. Filipovic2,1,
D. Bolliger1, M. Seeberger1
affiliation: 1Anesthesiology, University Hospital Basel,
Basel, Switzerland; 2Anesthesiology, Kantonsspital St. Gallen, St.
Gallen, Switzerland
Introduction: Animal studies suggest neuroprotection by
sevoflurane. There is some evidence supporting this neuroprotective
effect in patients undergoing cardiac surgery1. Our objective was to
evaluate if sevoflurane compared to propofol reduced the incidence
of postoperative delirium in patients undergoing major noncardiac
surgery.
Methods: This is a secondary analysis of a randomized
controlled trial of sevoflurane vs. propofol to reduce perioperative
ischemia. The occurrence of delirium was a prespecified secondary
endpoint. We enrolled patients at cardiovascular risk in 3 centres
between February 2006 and October 2010. Patients were
randomized to maintenance of anesthesia with sevoflurane or
propofol. Research staff previously trained by a neuropsychologist
assessed the occurrence of delirium by the Confusion Assessment
Method (CAM) at baseline, on postoperative day 1, 2 and day 7 or
discharge day whatever occurred first. Postoperative delirium was
defined as a CAM suggestive of delirium on postoperative day 1
or 2 or 7.
Results: We enrolled 385 patients. Five patients dropped out
(3 patients in the sevoflurane group); as such 181 patients received
sevoflurane and 199 patients propofol. The CAM was missing in 1
patient (0.3%) on postoperative day 1, in 5 (1.3%) on day 2, and in
42 (11.1%) on postoperative day 7. Delirium was diagnosed in 50
(13.2%) patients, 21 (11.6%) after sevoflurane and 29 (14.6%) after
propofol (p=0.392). Delirium decreased over time: 8.4% on day 1,
6.6% on day 2, and 2.1% on day 7.
Discussion: We found that intraoperative remifentanil usage
during colon cancer surgery was not associated with cancer
recurrence.
Discussion: Compared to propofol, sevoflurane did not reduce
the occurrence of postoperative delirium in patients undergoing
major noncardiac surgery.
References: N/A
References:
1.Schoen J, Husemann L, Tiemeyer C, Lueloh A, Sedemund-Adib
B, Berger KU, Hueppe M, Heringlake M.. Cognitive function
after sevoflurane- vs propofol-based anaesthesia for on-pump
cardiac surgery: a randomized controlled trial. Br J Anaesth.
2011 Jun;106(6):840-50
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-461
S-461.
RANDOMIZED CONTROLLED TRIAL OF SEVOFLURANE
VS. PROPOFOL TO PREVENT MYOCARDIAL ISCHEMIA
IN NONCARDIAC SURGERY PATIENTS
AUTHORS: G. A. Lurati Buse1, P. Schumacher2, W. Studer3,
E. Seeberger1, D. Bolliger1, M. Seeberger1
affiliation: 1Anesthesiology, University Hospital Basel,
Basel, Switzerland; 2Anesthesiology, BГјrgerspital Solothurn,
Solothurn, Switzerland; 3Anesthesiology, Kantonsspital Liestal,
Liestal, Switzerland
Introduction: Animal studies suggest cardioprotection by
sevoflurane. There is evidence supporting this cardioprotective
effect in patients undergoing cardiac surgery1,2. Our objective was
to evaluate if sevoflurane compared to propofol reduces myocardial
ischemia in patients undergoing major noncardiac surgery.
Methods: We enrolled patients at cardiovascular risk in 3
centers between February 2006 and October 2010. Patients were
randomized to maintenance of anesthesia with sevoflurane or
propofol. We recorded continuous ECG (cECG) for 48 hours
perioperatively and measured troponin T on postoperative day 1
and 2, and 12-lead ECG at 7 days. The predefined primary endpoint
was a composite of myocardial ischemia in cECG and troponin
elevation. Secondary endpoints were the single items of the primary
endpoint and a composite of cECG ischemia, troponin elevation and
Q-wave development. Patients and outcome assessors were blinded.
We tested dichotomous endpoints by chi-squared on intention-totreat basis.
Results: We enrolled 385 patients. Five patients dropped out
(3 patients in the sevoflurane group); as such 181 patients received
sevoflurane and 199 patients propofol. cECG was missing in 2
(1.1%) patients in the sevoflurane and 6 (3%) in the propofol group.
Troponin data on both postoperative day 1 and 2 were missing in
3 (1.7%) patients after sevoflurane and 3 (1.5%) after propofol.
Simultaneous missing of troponin and cECG did not occur. The
primary composite endpoint occurred in 75 (41.4%) patients
after sevoflurane and 81 (40.7%) after propofol (relative risk
0.98, 95%confidence interval 0.76-1.27). None of the secondary
endpoints differed between treatments.
Discussion: Compared to propofol, sevoflurane did not reduce
the occurrence of perioperative ischemia in patients undergoing
major noncardiac surgery.
References:
1.Yu CH, Beattie WS. The effects of volatile anesthetics on cardiac
ischemic complications and mortality in CABG: a meta-analysis.
Can J Anaesth. 2006 Sep;53(9):906-18
2.Yao YT, Li LH. Sevoflurane versus propofol for myocardial
protection in patients undergoing coronary artery bypass grafting
surgery: a meta-analysis of randomized controlled trials. Chin
Med Sci J. 2009 Sep;24(3):133-41
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-462
ANESTH ANALG
2012; 114; S-01 – S-493
Optimization targets and priorities
S-462.
DEVELOPMENT OF PROPOFOL-REMIFENTANIL DOSING
MULTIOBJECTIVE OPTIMIZATION ALGORITHM FOR
MODERATELY PAINFUL PROCEDURES REQUIRING
ESOPHAGEAL INSTRUMENTATION
AUTHORS: C. LaPierre, K. B. Johnson, D. Westenskow, T. Egan
affiliation: Bioengineering and Anesthesiology, University of
Utah, Salt Lake City, UT
Introduction: Anesthesia for upper endoscopy balances
drug requirements with patient safety. The ideal dosing scheme
provides adequate analgesia and sedation while avoiding loss of
responsiveness (LOR), respiratory depression (RD), and airway
obstruction (AO). Clinicians often accept some RD, LOR, and/or
AO to achieve their overall therapeutic goals. We hypothesized that
optimization techniques applied to response surface drug interaction
models can identify dosing regimens that minimize RD, AO, and
LOR yet provides satisfactory conditions for upper endoscopy.
Ideal
Min
Max
Priority
1) Time to Ready for EI
4
3
5
3
2) Placing Endoscope
2.25
2
4
5
3) Maintenance
6
5
10
6
4) Respiratory Depression
1.75
0
2
1
5) Airway Obstruction
1
0
2.5
2
6) Return of Responsiveness
2
0
4.5
4
Ideal = ideal objective time. Min = minimum allowable time. Max =
maximum allowable time. Priority = relative importance of the objective.
Methods: Six experts in procedural sedation were asked to
achieve a consensus on the allowable duration of LOR, AO, and
RD during a 10 minute upper endoscopy procedure using propofol
and remifentanil. Objective functions were developed that used this
expert opinion to identify an optimal dosing regimen for propofol
and remifentanil. Using previously developed propofol-remifentanil
interaction models of LOR, RD, RC and loss of response to
esophageal instrumentation (LREI), the objective functions were
evaluated using 3840 different propofol-remifentanil dosing
regimens. Each dosing regimen varied in terms of the propofol and
remifentanil bolus sizes and infusion rates.
Results: The expert consensus is presented in Table 1. The
objective functions are presented below. Time to Ready for EI is
the time from the beginning of the remifentanil infusion until a 70%
probability of LREI. Placing Endoscope is the time from Objective
1 until the probability of LREI drops below 58%. Maintenance is
the total time the probability of LREI is between 26% and 58%.
Respiratory Depression is the time to reach either a 5% probability
of RD or LOR, whichever is quicker, once the procedure ends.
Airway Obstruction is the time to reach either a 5% probability
of AO or LOR, whichever is quicker, once the procedure ends.
Return of Responsiveness is the time to reach a 5% probability of
LOR once the procedure ends. The optimal dosing regimen was a
propofol bolus of 0.8 mg/kg and infusion rate of 40 mcg/kg/min
and a remifentanil bolus of 0.2 mcg/kg and an infusion rate of 0.05
mcg/kg/min. Model predictions of probability of LOR, RD, RC and
LREI are presented as isoboles in Figure 1. The resulting propofolremifentanil effect-site concentrations are overlaid.
P(NR to EI) = probability of no response to esophageal instrumentation.
P(RD) = probability of respiratory depression. P(RC) = probability of
respiratory compromise. P(LOR) = probability of loss of responsiveness.
Discussion: Our results confirmed our hypothesis. A
remifentanil propofol dosing regimen exists that minimizes the
duration of LOR, AO, and RD that, according to expert opinion,
is acceptable AND provides conditions that will accommodate
upper endoscopy procedures. This dosing regimen merits clinical
validation in patients undergoing brief endoscopic procedures.
References: none
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-463
S-464
ANESTH ANALG
2012; 114; S-01 – S-493
S-463.
S-464.
IMPACT OF SEVOFLURANE VS. PROPOFOL ON NTPROBNP RELEASE AFTER NONCARDIAC SURGERY- A
RANDOMIZED CONTROLLED TRIAL
PREOPERATIVE CARBONHYDRATE ADMINISTRATION
PREVENTS CATABOLISM OF FAT
AUTHORS: G. A. Lurati Buse1, P. Schumacher2, R. Schumann1,
J. Fassl1, D. Bolliger1, M. Seeberger1
affiliation: 1Anesthesiology, University Hospital, Basel,
Switzerland; 2Anesthesiology, BГјrgerspital Soothurn, Solothurn,
Switzerland
Introduction: Animal studies suggest cardioprotection by
sevoflurane. There is evidence supporting this cardioprotective
effect in patients undergoing cardiac surgery1,2. Our objective was to
evaluate if sevoflurane compared to propofol reduces postoperative
NT-proBNP release in patients undergoing noncardiac surgery.
Methods: This is a secondary analysis of a randomized controlled
trial of sevoflurane vs. propofol to reduce perioperative ischemia.
Postoperative NT-proBNP concentrations were prespecified
secondary endpoints. We enrolled patients at cardiovascular risk
in 3 centres between February 2006 and October 2010. Patients
were randomized to maintenance with sevoflurane or propofol.
We measured NT-proBNP on postoperative day 1 and 2. Patients
and laboratory staff were blinded. The distributions of NT-proBNP
concentration on both postoperative days were skewed; as such,
we tested for differences in the distribution of postoperative NTproBNP concentrations (day 1 and day 2) of patients allocated to
sevoflurane and to propofol by Mann-Whitney-test.
Results: We enrolled 385 patients. Five patients dropped
out (3 patients in the sevoflurane group); as such 181 patients
received sevoflurane and 199 patients propofol. The NT-proBNP
concentration was missing in 5.8% (22/380) on day 1 and in 4.2%
(16/380) on day 2. The median NT-proBNP concentration on
postoperative day 1 was 545.5 pg/mL (interquartile range [IQR]
260-545.5) after sevoflurane and 558.5 pg/mL (IQR 238.251,247.25) after propofol (p=0.844). On postoperative day 2, the
median NT-proBNP concentrations was 937.0 pg/mL (IQR 483.0937.0) and 931 pg/mL (IQR 422.5-2074.0) after sevoflurane and
after propofol (p=0.858), respectively.
Discussion: Compared to propofol, sevoflurane did not affect
postoperative NT-proBNP release in patients undergoing major
noncardiac surgery.
References:
1.Yu CH, Beattie WS. The effects of volatile anesthetics on cardiac
ischemic complications and mortality in CABG: a meta-analysis.
Can J Anaesth. 2006 Sep;53(9):906-18
2.Yao YT, Li LH. Sevoflurane versus propofol for myocardial
protection in patients undergoing coronary artery bypass grafting
surgery: a meta-analysis of randomized controlled trials. Chin
Med Sci J. 2009 Sep;24(3):133-41
AUTHORS: N. Morioka, R. Kanamori, K. Shimizu, T. Uno, M.
Ozaki
affiliation: Tokyo Women’s Medical University, Yokohama,
Japan
Introduction: Conventionally, before surgery, an intravenous
solution not containing carbohydrates has been administered
in patients. Recently, however, preoperative administration of
carbohydrates such as glucose has been reported to prevent such
clinical changes. Besides, the effects of preoperative fasting on
patients, including an improvement of insulin resistance and effects
of other nutrients on fat metabolism, have not been studied in detail.
In the present study, we investigated the effects of preoperative
carbohydrate administration (glucose load) on intraoperative and
postoperative clinical conditions of patients undergoing elective
laparoscopic colectomy.
Methods: 35 patients aged 20 years or older who were scheduled
to undergo elective laparoscopic colectomy. ASA Physical Status
classification of 1 or 2 with no history of abnormal glucose tolerance
or abnormal electrolyte metabolism the glucose administration group
(G group, 10 patients) and the control group (GF group, 10 patients).
In the G group, 1500 mL of a maintenance solution containing 10%
glucose (glucose load: 150 g) was administered from the day before
surgery, and in the GF group 1500 mL of a glucose-free extracellular
fluid replacement solution was administered in a similar manner.
Results: figure1
Discussion: Changes in blood glucose and HOMA-IR, an
indicator of insulin resistance, were within normal range because
patients with diabetes were excluded from the study, and preoperative
glucose administration in patients with normal glucose metabolism
did not affect insulin resistance. In addition, glucose administration
that started before surgery suppressed the excess of fat catabolism.
In contrast, administration of the solution not containing glucose
during surgery enhanced fat catabolism. These findings indicate
that glucose loading, even a small amount, may be necessary before
and during surgery. Furthermore, administration of a glucose-free
solution significantly affects fat metabolism before and during
surgery. Glucose administration did not affect protein catabolism.
Changes in blood glucose due to stress hormone were negligible.
Although further studies on protein and fat administration and
administration in patients suspected of abnormal glucose tolerance
are necessary in the future, the results suggest the administration of
carbohydrates such as glucose before and during surgery may be
essential to maintain perioperative metabolism.
References:
Wallace TM, Levy JC, atthews DR. Use and abuse of HOMA
modeling. Diabetes Care. 2004 Jun;27(6):1487-95
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-465
S-466
ANESTH ANALG
2012; 114; S-01 – S-493
S-465.
S-466.
UDP GLUCURONOSYLTRANSFERASE 2B7*2 (802C>T,
RS7439366) INFLUENCES SERUM LEVELS OF MORPHINE
AND MORPHINE GLUCURONIDES INVERSELY TO PUPIL
EFFECTS AFTER I.V. CYCLOSPORINE IN A CROSSOVER
VOLUNTEER STUDY
THE EFFECT OF APREPITANT FOR THE PREVENTION OF
POSTOPERATIVE NAUSEA AND VOMITING IN PATIENTS
UNDERGOING GYNECOLOGIC SURGERY WITH
INTRAVENOUS PATIENT-CONTROLLED ANALGESIA
USING FENTANYL
AUTHORS: K. Meissner1,3, H. E. Meyer zu Schwabedissen2, C. E.
Göpfert3, J. Blood3, T. Kim3, E. Kharasch3
AUTHORS: K. Soon Im, L. Se Jin
affiliation: 1Klinik für Anästhesiologie und Intensivmedizin,
Universitätsmedizin Greifswald, Greifswald, Germany; 2Dept.
of Pharmacology/Center for Drug Absorption and Transport,
Universitätsmedizin Greifswald, Greifswald, Germany; 3Dept. of
Anesthesiology, Washington University in St. Louis, St. Louis, MO
Introduction: Morphine remains the most widely used
intravenous opioid in the perioperative setting worldwide.
Maintaining therapeutic CNS concentrations of many opioids is
confounded by considerable variability in disposition. Several
findings indicate a role for the UDP glucuronosyltransferase 2B7
for variability of substrate effects, attributed to genetic factors and
changes in glucuronization. However, evidence for effect variation
due to genetically determined UGT 2B7 activity and thus variable
glucuronization of morphine in humans is lacking. In the context of
drug transport inhibition by cyclosporine, serum levels as well as
effect should be more predictable.
Methods: We tested the hypothesis that variations of morphine
levels and effects could be explained in part by genetic variation
in the UGT2B7*2 locus (H268Y) by pupil diameter change in 12
healthy volunteers, who were given 0.1 mg/kg morphine i.v. for one
hour with and without the infusion of 0.25 mg/kg/h cyclosporine
for two hours (preceedeing and during the morphine infusion) in
a crossover fashion. Here we report the results for the UGT2B7
(rs7439366) SNP on chromosome 4, coding for a histidine or a
tyrosine at position 268, resulting in decreased enzyme activity.
Results: Five subjects exhibited the wildtype (CC), and seven
were heterozygous (CT) carriers of the mutant allele. Peak clinical
effects, indicated by miosis, were measured between 1 and 3 hours
after the start of injection. No major differences could be detected for
the mutated variants after morphine only (CC vs. CT: peak 1.9/2.1
mm, 10 h AUC 11.1/11.3), but after cyclosporine intervention
by means of an extended plateau phase (peak 2.8/2.8 mm, AUC
16.7/19.5). Surprisingly, these findings were accompanied by
attenuated serum levels in CT carriers for morphine (CC vs. CT:
control: 55.3 В± 8.3 vs. 36.5 В± 8.8 ng/ml; CsA: 55.8 В± 12.7 vs. 43.9 В±
9.5 ng/ml) as well as for morphine-3- (136.5 В± 20.6 vs. 106.5 В± 33.6
and 135.6 В± 21.5 vs. 107.9 В± 26.5) but not 6-(25.3 В± 6.2 vs. 22.3 В±
4.3 and 23.7 В± 5.6 vs. 22.0 В± 5.8) glucuronide.
affiliation:Anesthesiolsy, Soonchunhyang University Hospital,
Seoul, Republic of Korea
Introduction: The aim of this study was to evaluate the effect
of an NK1 receptor antagonist (aprepitant) for reducing postoperative
nausea and vomiting (PONV) for up to 24 h in patients undergoing
gynecological surgery with iv patient-controlled analgesia (PCA)
using fentanyl for postoperative pain control.
Methods: In this prospective, randomized, double blinded
study, a healthy 84 gynecological surgical patients receiving a
standardized general inhalation anesthesia were investigated.
Patients were randomly allocated to receive aprepitant 80 mg orally
before 3 h operation (aprepitant group) or not to receive it (control
group). All patients received ramosetron 0.3mg iv after induction of
anesthesia. We assessed incidence of PONV, severity of nausea, use
of rescue antiemetics and incidence of adverse events for up to 24
hours postoperatively.
Results: During the first 24 h after operation, the incidence of
nausea was lower in aprepitant group (50%) compared to the control
group (81%), and the incidence of vomiting was lower in aprepitant
group (5%) compared to the control group (43%) (P < 0.05). In
addition, severity of nausea was lower in aprepitant group than in
control group over 24 h postop (P < 0.05). Use of rescue antiemetics
were lower in aprepitant group than control group over 24 h postop.
(p < 0.05).
Discussion: In patients regarded as high risk for PONV
undergoing gynecological surgery with iv-PCA using fentanyl,
the addition of aprepitant to ramosetron significantly decreases the
incidence of PONV, use of rescue antiemetics and nausea severity
for up to 24 hours postoperatively.
References:
1. Diemunsch P, et al. Br J Anaesth 2009; 103: 7-13.
2. Gan TJ. Anesthesia & Analgesia 2006; 102: 1884.
Discussion: We conclude that while morphine effects might
be influenced in part by UGT2B7 genotype, there is no readily
explainable increase in morphine or morphine-glucuronide serum
levels in 2B7*2 subjects. As described before, drug transport
inhibition seems to have far more influence on morphine effect
- but without influencing serum levels, which warrants further
investigation.
References: n/a
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
Regional Anethesia
ABSTRACTS
S-472
S-473
S-472.
S-473.
CAN THE USE OF HIGH DOSE DEXMEDETOMIDINE
WITH BUPIVACAINE ELIMINATE THE NEED FOR A
PERIPHERAL NERVE CATHETER?
WITHDRAWN.
AUTHORS: W. Alrayashi, C. Scher, L. Capan
affiliation: Anesthesiology, New York University Medical
Center, New York, NY
Introduction: Dexmedetomidine (Dex) is gaining traction as
an effective adjunct in regional and neuraxial analgesia.1-3 Our aim
was to determine the duration of motor and sensory blockade using
bupivicaine (Bupiv) with high dose Dex in a popliteal nerve block
(Dex-PB). We also compared that to Bupiv with epinephrine (Epi)
in a saphenous nerve block (Epi-SB) on the same patient.
Methods: A 29 year old male, NK, with a right bimalleolar
ankle fracture presented for ORIF. A Dex-PB was done under
ultrasound guidance and 20 cc of 0.5% Bupiv with 100mcg of Dex
was injected. The Epi-SB was completed with 10cc of 0.5% Bupiv
with 1:200,000 of Epi. After induction and LMA placement, he
remained hemodynamically stable. NK was discharged the same
day with follow up phone calls on post-op days 1, 2, 3, 7, and 14.
Sensation, motor function, pain score, medication intake, and side
effects were assessed.
Results: The patient had 22.5 hrs of motor and 44.2 hrs of
sensory blockade after the Dex-P block. In contrast, the Epi-S lasted
9 hrs and 13 hours, respectively. In the recovery room, there were no
significant alterations in blood pressure (defined as a ≥20% change
from baseline) or heart rate (≥10% change). One tablet of Norco
5mg-325mg was taken 8 hrs post-injection and then every 8 hrs
the following day for a pain score of 3/10 along the medial side
of his ankle. He had no pain along the lateral aspect of his ankle
until 44.2 hrs later, subsequently increasing his narcotic intake. He
noted tingling along the medial and then lateral side of his leg, 12hrs
and 40hrs post-injection; both of which resolved within 2-3 hrs. NK
denied lightheadedness, sedation, syncope, nausea, vomiting, and
blurry vision.
Discussion: Prior studies have demonstrated that the use of
Dex is a safe and valuable adjunct in regional analgesia. A proposed
mechanism is that it blocks a hyperpolarization-activated cation
current, not by О±2 receptor agonism.3 Brummet et al. showed that
the nerve axon and myelin of rats were not adversely affected
after a Dex + Bupiv sciatic block.1 Esmaoglu et al. confirmed that
adding 100mcg of Dex to levobupivicaine extended the duration of
an axillary block.2 Our case differed in that we compared Dex +
Bupiv versus Epi + Bupiv using two different blocks in one patient.
We found an unexpected duration of sensory (>40 hrs) and motor
blockade (>20 hrs) when Dex was used. This encourages the idea
that peripheral nerve catheters may not be needed for select cases,
which would presumably decrease the risk of infections, cut costs,
and expedite discharge.
References:
1. Anesthesiology 2008;109:502-11
2. Anesth Analg 2010;111:1548-51
3. Anesthesiology 2011;115:836-43
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-474
S-474.
THE EFFECT OF A PREOPERATIVE SCIATIC NERVE
BLOCK IN ADDITION TO A FEMORAL NERVE BLOCK
FOR AMBULATORY ACL RECONSTRUCTION: A
RETROSPECTIVE ANALYSIS
AUTHORS: K. Kolodzie1, J. M. Cohen1, S. Shah2, P. Aleshi1
affiliation: 1Department of Anesthesia & Perioperative
Care, University of California, San Francisco, San Francisco, CA;
2
College of Medicine, University of Illinois at Chicago, Chicago, IL
Introduction: For patients undergoing ambulatory arthroВ­
scopic reconstruction of the anterior cruciate ligament (ACL)
excellent postoperative analgesia with minimal systemic side effects
is of critical importance for early recovery and discharge as well as
patients’ satisfaction. Regional anesthesia techniques might be able
to contribute to these goals. The knee is innervated by the femoral
nerve anteriorly and the sciatic nerve posteriorly; both of which
could be potential targets for peripheral nerve blocks. Femoral nerve
block (FNB) alone has not consistently been shown to improve
postoperative analgesia1,2 and data on the efficacy of combined
nerve blocks are sparse. The aim of this study was to retrospectively
compare patients receiving FNB to those undergoing femoral and
sciatic nerve blocks (FSNB) preoperatively. We hypothesized that
a combined FSNB would result in lower postoperative pain scores,
decreased opioid consumption, and a shorter PACU duration.
Methods: Upon IRB approval a retrospective chart review of
patients undergoing arthroscopic ACL reconstruction at a single
ambulatory center between 10/09 and 05/11 was performed. Patients
receiving either FNB or FSNB preoperatively were included.
Primary outcome variables were highest PACU pain score, total
morphine equivalents (ME) and PACU time.
Relevant demographic and perioperative data were extracted and
univariate group comparison between patients receiving FNB only
versus patients receiving FSNB was performed. П‡2 test and MannWhitney U-test were applied as appropriate. Due to an uneven
distribution of baseline characteristics we developed multivariate
linear regression models for each primary outcome.
Results: A total of 191 patients were included. All patients
received a FNB preoperatively. 93 patients additionally received a
posterior sciatic nerve block (SNB). All patients underwent general
anesthesia with placement of a laryngeal mask.
In multivariate linear regression higher PACU pain scores were
found in patients receiving FNB vs FSNB and in patients receiving
autograft vs allograft. Higher total ME were found in patients
receiving FNB only and in patients with higher BMI scores. The
need for a rescue block and the presence of PONV in PACU were
identified as predictors for increased PACU time.
Discussion: The addition of a preoperative SNB to a FNB was
associated with lower postoperative pain scores and decreased
opioid requirements. Further prospective studies are needed to
confirm these positive results and to investigate additional important
outcomes such as patients’ satisfaction, time- and cost-effectiveness,
and adverse event rates.
References:
1. Acta Anaesthesiol Scand. 2010 Apr;54(4):414-20
2. Am J Sports Med 2009;37:78-86
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-475
S-475.
A PILOT STUDY TO COMPARE EPIDURAL
IDENTIFICATION AND CATHETERIZATION USING
A SALINE FILLED SYRINGE VERSUS A NOVEL
CONTINUOUS HYDROSTATIC PRESSURE SYSTEM
AUTHORS: Y. M. Samhan, H. H. El Sabae, H. F. Khafagy, M.
Mahert
affiliation: Giza, Egypt
Introduction: We are introducing a novel continuous hydroВ­
static pressure system for identification and catheterization of
epidural space and minimizing associated complications. Thus, we
designed this prospective randomized study to compare the salinefilled syringe with the continuous hydrostatic system as regards the
ease of epidural performance.
Methods: Laboratory model: When various anesthetists
introduced 18 G epidural needle through thick, closed-cell foam,
the exerted pressure ranged between 250-300 mmHg. We started by
a pressure of 20 mmHg then increased incrementally. The flowing
saline at 40-60 mmHg was about 2-3 ml; the same volume while
using saline-filled syringe so we settled this pressure as a standard
during the procedure.
Clinical study: After obtaining institutional ethical commitВ­
tee approval and informed written consents, 108 patients aged 2565 years ASA I-II scheduled for elective endoscopic urological
procedures were enrolled in the study. They were randomly assigned
to perform loss of resistance epidural technique by either: the
conventional method with saline-filled syringe (group C) or using
the novel continuous hydrostatic pressure system (group P). The later
technique depends on observing passage of free flow of pressurized
normal saline connected by infusion set to epidural needle via the
side channel of a three way stopcock during its advancement. Once
the needle reached the epidural space, the epidural catheter was
inserted from the back of stopcock and advanced in the epidural
space to “float” easily while saline was flowing. In both groups, 10
ml of bupivacaine 0.5% with 50 ug fentanyl were injected. Time
to identify epidural space, number of attempts and ease of epidural
catheterization were assessed. Sensory and motor block after 20
min, surgical conditions and any side effects were recorded.
Results: There were no significant differences in demographic
data. In group P, time to identify epidural space is significantly
shorter, number of attempts is significantly less and the motor block
at 20 min is significantly lower compared with group C (P value
0.001, 0.023, 0.018 respectively). No significant difference in the
catheterization, sensory block, surgical conditions and incidence of
side effects.
Discussion: Our results are similar to the Episure AutoDetect
syringe1 and Epidrum2 concerning time to identify epidural space
and number of attempts in the former. We concluded that this
hydrostatic pressure technique is an easy way to identify epidural
space using available tools in the operating room without recorded
complications.
References:
1. Anesth Analg 2008;106:541-3.
2. J Anesth 2011 Nov [Epub ahead of print].
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-476
S-477
ANESTH ANALG
2012; 114; S-01 – S-493
S-476.
S-477.
EVALUATION OF PREDICTIVE POWER OF DIFFICULT
SPINAL SCORE TO ACTUAL DIFFICULTY DURING
SPINAL ANESTHESIA AND ITS COMPLICATIONS
CHARACTERISTICS OF TRANSIENT PARESTHESIA
DURING EPIDURAL CATHETER PLACEMENT: THE
INCIDENCE AND LOCATION OF PARESTHESIA
ACCORDING TO THE VERTEBRAL LEVEL OF THE
PUNCTURE
AUTHORS: M. Al-Mahrami1,2, M. J. Albahrani2,1, S. Trehun1,2,
R. Khan1,2, N. Kaul1,2
affiliation: 1Anaesthesia & ICU, Khoula Hospital, Al Harthy
Complex, Oman; 2Anaesthesia & ICU, Royal Hospital, Muscat,
Oman
Introduction: Score for predicting difficult spinal anesthesia
administration has been suggested by Atallah, Demian and Shorrab,
2004. However they made no attempt to correlate the difficulty
in spinal anesthesia administration and complications associated
during or after the procedure.
Methods: After Hospital Ethical Committee approval, 64 ASA
I & II patients of either sex undergoing surgical procedures under
spinal anesthesia were randomly selected. The patients were graded
into 4 grades of PDSS according to 4 different variables suggested
by Atallah, Demian and Shorrab1.
Standard technique of spinal was used. Number of attempts and
duration in minutes required for successful intra-thecal spinal
needle placement, discomfort during the procedure, was successful
or failed, and development of post spinal complications like
backache, post spinal headache, or persistent neurological injury
were recorded.
Results: The results of this study demonstrate that as we progress
from grade I to grade IV of PDSS the number of spinal needle
pricks needed to perform successful spinal anesthesia increased
from a mean of 1.0 to 2.2 and time to administer spinal anesthesia
increased for a mean of 5.0 to 8.1 minutes. However we did not note
any correlation between increasing grades of PDSS and post-spinal
complications, possibly due to small sample size.
Discussion: This clinical trial has demonstrated that an increase
in grade of PDSS is directly correlated with an increase in number
of spinal needle pricks and time to successfully perform spinal
anesthesia. This may have clinical significance as these issues can
be discussed with the patient and the surgeon prior to initiating
spinal anesthesia. In addition, a quick assessment of PDSS can
forewarn the attending anesthesiologist of the probable difficulty he/
she may encounter in terms of needle pricks and time for successful
spinal anesthesia with increasing grade of PDSS. This may be of
great significance in situations where urgency is paramount as
during LSCS.
References:
Atallah MM, Demian AD, Shorrab AA. Development of a difficulty
score for spinal anaesthesia. Br J Anaesth 2004; 92: 354-60.
AUTHORS: A. Ogura1,2, M. Zenfuku2, Y. Nakajima2, T. Inoue3
affiliation: 1Anesthesiology, Mizonokuchi Hospital, Teikyo
University School of Medicine, Kawasaki, Japan; 2Anesthesiology,
Shizuoka Red Cross Hospital, Shizuoka, Japan; 3Anesthesiology,
Chiba-Hokusoh Hospital, Nippon Medical School, Chiba, Japan
Introduction: Several studies have reported the incidence
of transient paresthesia during epidural catheter placement, but
none have analyzed the characteristics including the location of
paresthesia. We hypothesized that the characteristic of paresthesia
including the location might be related to the vertebral level of
epidural puncture.
Methods: After obtaining IRB approval and informed consent,
adult patients were divided into four groups according to the epidural
puncture site: UT (upper thoracic, T3-4), MT (middle thoracic,
T8-9), LT (lower thoracic, T11-12), and LB (lumbar, L3-4). The
patient was positioned in right lateral decubitus position. Epidural
puncture was performed via paramedian approach. After choosing
the interspace, a skin wheel of local anesthetic was applied at a point
1 cm lateral to the edge of the spinous process. The Tuohy needle
was inserted until the vertebral lamina was encountered. After
advancing the needle to the ligamentum flavum, the epidural space
was identified by the loss-of-resistance technique to normal saline.
A closed-tip side-hole nylon catheter was inserted 5 cm cephalad
in the epidural space. Transient paresthesia, technical difficulties
and the occurrence of complications during the catheter placement
were recorded. Data were analyzed by ANOVA test followed by
Scheffe’s post-test or Chi-square analysis as appropriate. P < 0.05
was considered significant.
Results: There were no major complications noted in all groups.
The incidences of paresthesia in the UT (n = 240), MT (n = 301),
LT (n =302) and LB (n = 339) groups were 4 (1.7%), 13 (4.3%), 22
(7.3%) and 0 (0%), respectively, with significant differences among
the groups (P < 0.0001). Paresthesia disappeared in all patients after
epidural catheter placement. There were no permanent neurologic
complications in all cases. The table shows locations of paresthesia
according to the puncture level.
Discussion: Paresthesia occurred unilaterally or bilaterally and
the location of parethesia was also characteristic depending on the
puncture level. Paresthesia is more frequently observed in the lower
thoracic region than in the other regions. The lumbar enlargement
of the spinal cord extends in the region. The cause of paresthesia
might be due to the catheter-induced compression of the nerve root
or the spinal cord. In the present study, we employed the original
paramedian technique described by Bonica1. No cases in the lumber
group observed paresthesia during the procedure. This might be
attributable to straight advancement of the catheter having been
easier in the epidural space, such that nerve root compression at the
intervertebral foramen may be avoided.
References:
1. Anesthesiology; 18: 723-783, 1956
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-478
S-479
S-478.
S-479.
THE EFFECT OF MUSIC ON PATIENTS’ INTRAOPERATIVE ANXIETY IN ORTHOPEDIC SURGERY
UNDER SPINAL ANESTHESIA
WITHDRAWN.
AUTHORS: R. Traiyawong
affiliation: Anesthetic Nursing Department,
Nakhornratchasima Hospital, Muang, Thailand
Maharat
Introduction: The purpose of this quasi-experimental
research was to study effects of music on intraoperative anxiety and
physiologic response of orthopedics’ patient under spinal anesthesia
Methods: Purposive sampling was used. Sixty-six patients
scheduled for elective orthopedics surgery at our hospital during
June to December 2009 were enrolled. The subjects were divided
into two groups. The experimental group received conventional
care plus the Thai light music while the control group received
conventional care. The State Anxiety of Spielberger and physiologic
response were assessed and analyzed as the study outcomes. Data
were analyzed by means of percentage, means, standard deviation,
t-test, and covariance.
Results: The study revealed the level of anxiety was significantly
lower than the control group (P<0.05 ) .No significant differences in
blood pressure, heart rate, and respiratory rate were found between
groups.
Discussion: The results indicated that music can be used to
decrease intraoperative anxiety and to promote relaxation in patients
underwent surgery which is relevant to the strategy of the hospital
for increasing patients’ satisfaction.
References:
1.Khan F, Nazir S . Assessment of pre operative anxiety in patients
for elective surgery. J Anesth Clin Pharmacology 2007; 23(3):
259-62.
2.Nilsson U, Unosson M, Rawal N. Stress reduction and analgesia
in patients exposed to calming music postoperatively: a
randomized controlled trial. Eur J Anaesthesiol 2005; 22 (2): 96102.
3.Leardi S, Pietroletti R, Angeloni G, Necozione S, Ranalletta, G,
Del Gusto B. Randomised clinical trial examining the effect of
music therapy in stress response to day surgery. British Journal
of Surgery 2007; 94(8): 943 47.
4.Bally K, Campbell D, Chesnick K, Tranmer J. Effects of patient
controlled music therapy during coronary angiography on
procedural pain and anxiety distress syndrome. Critical Care
Nurse 2003; 23(2): 50 8.
5.Hong JY, Kang IS, Koong MK, Yoon HJ, Jee YS, Park JW,
Park ,et al. Preoperative anxiety and propofol requirement in
conscious sedation for ovum retrieval. J Korean Med Sc 2003;
18: 863-68.
6.Agarwal A, Ranjan, R, Dhiraaj S, Lakra A, Kumar M, Singh,
U. Acupressure for prevention of preoperative anxiety: a
prospective, randomised, placebo controlled study. Anaesthesia
2005; 60(10): 978-81.
7.Lepage C, Drolet P, Girard M, Grenier Y, DeGagne R. Music
decreases sedative requirements during spinal anaesthesia.
Anaesthesia and Analgesia 2001; 93(4): 912 16.
8.Mok E, Wong K. Effects of music on patient anxiety. AORN.
2003; 77(2): 396 - 410.
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-480
S-480.
WITHDRAWN.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-481
ANESTH ANALG
2012; 114; S-01 – S-493
S-481.
KIDNEY INJURY AFTER PERCUTANEOUS AND DOSE
RANGING EFFECTS OF INTRATHECAL EPINEPHRINE
ON ANESTHESIA/ANALGESIA: A META-ANALYSIS
AND META-REGRESSION OF RANDOMIZED
CONTROLLED TRIALS
AUTHORS: G. S. De Oliveira, R. J. McCarthy
affiliation: Chicago, IL
Introduction: Several opioids and non-opioids drugs have
been used intrathecally in conjunction with local anesthetics in
order to improve analgesia and anesthesia outcomes. Intrathecal
epinephrine has been examined by clinical studies but its effects on
analgesia/anesthesia outcomes as well as on undesirable side effects
is not clearly defined. The objective of this study was to examine
the effects of intrathecal epinephrine on intrathecal anesthesia/
analgesia.
Methods: We performed a Meta-analysis using a random-effect
model. Effects of intrathecal epinephrine dose were evaluated by
pooling studies into 3 dosage groups: low (1-100 mcg), intermediate
(101-200mcg) and high (≥200mcg). Meta-regression analysis was
also performed to examine the presence of a linear association
between intrathecal epinephrine dose and effect size on evaluated
outcomes.
Results: Twenty-four randomized clinical trials with 1271
subjects were included. The mean (95% CI) combined effects favored
intrathecal epinephrine over placebo for duration of analgesia, 27.0
(20.8 to 33.3) , sensory , 24.3( 18.7 to 29.9) and motor block, 32.2
(26.2 to 38.2 ) minutes. The incidence of hypotension was greater
in the epinephrine group compared to placebo, odds ratio (95%
CI) of 1.5 (1.1 to 2.3). The increase incidence of hypotension
was not detected for the intermediate dose group, 0.9 (0.5 to 1.7).
The incidence of instrumental delivery/c-section was lower in the
epinephrine group compared to saline, 0.63(0.41 to 0.95).
Discussion: Intrathecal epinephrine has dose dependent clinical
and adverse effects. Doses>100 mcg can reduce the incidence of
hypotension while proving significant clinical benefits on sensory
and motor block duration.
References:
1.Salinas FV, Liu SS. Spinal anaesthesia: local anaesthetics
and adjuncts in the ambulatory setting. Best Pract Res Clin
Anaesthesiol. 2002 ;16:195-210.
s-481 • continued on next page
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ABSTRACTS
S-481
continued
S-481 • continued
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-482
S-482.
TROUBLE-SHOOT CONTINUOUS PERIPHERAL NERVE
CATHETER, HOW MUCH SHOULD WE WITHDRAW?
AUTHOR: J. Liu
affiliation: Department of Anesthesiology and Critical Care,
University of Pennsylvania, Philadelphia, PA
Introduction: Continuous peripheral nerve catheter (CPNC)
is a common practice to provide regional anesthesia. It provides
great benefits of regional anesthesia, such as extending the duration
of analgesia that could not be achieved by single shot nerve block,
titrating effects with various concentrations and volumes, and etc.
However, CPNC is more complicated to place and maintain than
single shot nerve block. One frequent question is how to troubleshoot peripheral nerve catheter. The practice is largely based on
personal clinical experience.
We conducted this study to test the hypothesis that the position
of the tip of the CPNC is not correlated with the bevel direction
of the needle when the catheter is over-threaded. Our secondary
hypothesis is that when withdrawing the over-threaded catheter, the
tip does not start to move until it is only a few centimeters beyond
the original position of needle tip.
Methods: We used store bought pig hind leg as our model.
Ultrasound-guided in plane sciatic nerve block was performed
with 18G Contiplex Tuohy needle, 30 mL local anesthetics was
injected after satisfactory needle placement. This procedure reflects
our usual clinical practice when placing CPNC. Non-stimulating
20G CPNC was then threaded beyond the tip of the needle. The
needle was subsequently removed from the hind leg with the CPNC
remaining in place. The movement of the tip of CPNC was observed
under fluoroscopy while CPNC was withdrawn one centimeter at a
time. There were two groups in the study, catheter was threaded 5
centimeters beyond the tip of the needle in group one, and at least 10
centimeters beyond the tip of the needle in group two.
Results: Our preliminary observation indicated that the position
of the tip of the CPNC is less likely correlated with the bevel
direction of the needle when the catheter is over-threaded. The tip
of CPNC was not adjusting immediately when CPNC was overthreaded and then withdrawn. The tip only started to adjust after the
CPNC is only a few centimeters beyond the original position of the
tip of the needle.
Discussion: In conclusion, we would recommend the following.
First, we recommend against over-thread catheter. Second, in
case of necessity of adjusting over-threaded catheter, we would
recommend withdrawing catheter based on the original depth of
needle so that the tip of the catheter will only be several centimeters
beyond the original depth of needle. Currently, we are replicating
our preliminary findings.
References: None in the literature.
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-483
S-483.
A TIME STUDY OF NEURAXIAL REGIONAL
ANESTHESIA TECHNIQUE FROM PATIENT
POSITIONING TO NEEDLE INSERTION: IMPLICATIONS
FOR CHLORHEXIDINE SKIN ANTISEPSIS
AUTHORS: E. Manis1, P. Nystrom2
affiliation: 1Wright State University Boonshoft School of
Medicine, Dayton, OH; 2Anesthesiology, Pulmonary and Critical
Care Medicine, Department of Veterans Affairs Medical Center,
Dayton, OH
Introduction: When performing neuraxial regional
anesthesia techniques, antiseptic skin preparation is necessary to
minimize infectious complications. Although there is insufficient
clinical data to support FDA approval of chlorhexidine use prior to
lumbar puncture, chlorhexidine is recommended for skin preparation
prior to spinal or epidural anesthesia1,2. To date, chlorhexidine skin
antisepsis has not been associated with neurologic complications3.
The manufacturer recommends up to three minutes of drying time
after chlorhexidine prep. Most anesthesia providers apply skin
antisepsis just prior to placing a sterile field drape and beginning
the procedure. This practice limits the amount of time for antiseptic
solution skin contact and drying. We propose that application of
skin antiseptic solution immediately after patient positioning and
identification of anatomical landmarks provides at least 3 minutes
for solution contact and drying prior to needle insertion.
Methods: The study is an observational, blinded operator, time
study of neuraxial technique from patient positioning and anatomical
landmark identification to needle insertion. All anesthesia staff and
trainees were unaware of the time study while observed performing
spinal and epidural anesthesia in routine practice. A hidden
stopwatch recorded time from the moment the provider turned away
from the patient after patient positioning and marking anatomical
landmarks, i.e. start time. The time of skin antisepsis was noted
(Tprep), and timing was stopped when the spinal or epidural needle
contacted skin. Total time from start to stop was documented
(Ttot) as well as skin prep to needle insertion (Tdiff=Ttot-Tprep).
Descriptive statistical analysis was performed on the time results
with SPSS 19.0.
Results: See Table 1
Discussion: Approximately 5 minutes elapse from the time a patient
is positioned to the time a spinal or epidural needle contacts skin.
A substantial number of neuraxial procedures are performed in
much less time by anesthesia providers highly skilled in neuraxial
techniques. In this study, 20/45 (44%) neuraxial procedures had less
than 3 minutes of skin antisepsis contact and drying time. To allow
the most time for antiseptic solution skin contact and drying during
neuraxial procedures, a single application of skin antisepsis should
occur immediately after positioning the patient and identifying the
relevant procedural anatomy.
References:
1. Reg Anes Pain Med 2006;31:311-23
2. Anesthesiology 2010;112:1-16
3. Reg Anes Pain Med 2011;36:A28, pg. 510
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ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-484
ANESTH ANALG
2012; 114; S-01 – S-493
S-484.
A MODEL OF TAIL NERVE BLOCK IN CONSCIOUS RATS
AUTHORS: Z. Li1,2, J. Liu2,3
affiliation: 1Department of Pharmacology, West China School
of Pharmacy, Sichuan University, Chengdu, China; 2Laboratory
of Anaesthesia and Critical Care Medicine, West China Hospital,
Sichuan University, Chengdu, China; 3Department of Anesthesiology,
West China Hospital, Sichuan University, Chengdu, China
Introduction: In resent years, interests in use of new local
anesthetics and additives designed to enhance block duration
and quality, have been developed. One of important works was
preclinical testing in animals to determine safety, efficacy, and
pharmacokinetics of those drugs. This study was designed to
develop a simple and effective model of tail nerve block without
general anesthesia and surgical incision assist for exploring and
studying new local anesthetics.
Methods: All the animal experiments in this study were
approved by the Institutional Animal Care and Use Committee
of our University. Tail nerves of adult male SD rats were blocked
by respectively injecting 1% lidocaine (Lido group) and 0.5%
bupivacaine (Bupi group) around tail nerves. The blocking
procedures were performed as follows: two elastic rubber tourniquets
were prior applied on the base of the tail and 4 cm distally to the
base of tail respectively until 2 minutes after drugs injection. After
local skin disinfection, tail nerve block was performed on the two
sides of tail between two tourniquets, and the sites of injection were
near the base of the tail (about Co5-8, Fig. 11. With a 26 G needle
connected to a microsyringe, 100 ОјL drugs were infiltrated near to
the dorsal and lateral surface of the caudal transverse process in
each injection, and each side of the tail received two blocks with an
interval of about 1cm along the axis of the tail. For assessing the tail
nerve block model, effects of tail nerves block induced by the two
classical local anesthetics were assessed and compared by recording
disappear and recovery time of thermal and mechanical nociception,
which were measured by recording the latency in tail flick test
and monitoring the response in tail clamp test with an alligator2.
Pathological study of the rat-tail nerves was used to evaluate the
potential influence of drugs.
Results: The results showed that after drugs were administered
around rat-tail nerves, thermal and mechanical nociception of rat-tail
disappeared, while unchanged by normal saline. There was a faster
disappearance and a shorter recovery of thermal and mechanical
nociception in Lido group than Bupi group (Tab.1 and Fig.2). No
abnormal results were found in both the 3-day observation and the
pathological study (Fig.3), and pain threshold of all rats were fully
recovered.
Discussion: An easily operated, reliable and reversible model
of tail nerve block was developed in conscious rats and could be
used to evaluate efficacy, safety and pharmacokinetics of new local
anesthetics and additives.
References:
1. Laboratory animals,37,121-5,2003.
2. Anesth Analg,110,1227-32,2010.
Figure 1. Schematic diagram summarizing the anatomy of the nerve, blood
vessel and ossature in the rat tail. A: Diagram showing coronal plane of the
rat tail (dorsal aspect); B, C and D: Diagrams orderly showing transverse
plane of 3rd, 6th and 11th sections of coccygeal vertebra(Co3, Co6, Co11).
1, sacral vertebra (S1-S4); 2, coccygeal vertebra (Co1, Co2, Co3, etc.); 3,
tail nerve cord; 4, drugs administered site (Co5-8); 5, spinous process;
6, prezygapophysis; 7, tail lateral artery; 8, tail lateral vein; 9, transverse
process; 10, middle sacral artery; 11, haemal arch; 12, middle caudal artery;
13, haemal process.
Figure 2. Comparison of pain threshold changes of rat-tails (presented by
%MPE of tail flick latency) and pain threshold changes of rat paws (presented
by %MPE of tail flick latency) among Lido, Bupi and NS group. (Mean В± SD,
n = 10) *P < 0.05 vs. NS group; # P < 0.05 vs. baseline. Lido, Bupi and NS
Group: 1% lidocaine, 0.5% bupivacaine or normal saline were administered
around tail nerves of rats in these group, respectively.
Figure 3. Typical
histological
cross-sections and
coronal-sections
of rat-tail nerves in
Lido, Bupi, and NS
groups. (Original
magnification Г— 400)
Lido, Bupi and NS
Group: 1% lidocaine,
0.5% bupivacaine
or normal saline
were administered
around tail nerves of
rats in these group,
respectively.
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ABSTRACTS
S-485
S-485.
ASSOCIATION OF BMI WITH POSTOPERATIVE PAIN
AND QUALITY OF RECOVERY AFTER TOTAL HIP
REPLACEMENT: ROLE OF INSULIN RESISTANCE
AUTHORS: R. Motaghedi2, J. J. Bae1, P. M. Shaw1, S. G.
Memtsoudis1, S. S. Liu1
affiliation: 1Anesthesiology, Hospital for Special Surgery,
New York, NY; 2Pediatrics, NewYork-Presbyterian Hospital/Weill
Cornell Medical Center, New York, NY
Introduction: In the United States, approximately 436,000
total hip replacements (THR) are performed with an expected 673%
increase by 2030 due in part to increasing rates of obesity1. It is
controversial whether severity of postoperative pain2 is associated
with obesity, and potential underlying mechanisms are unknown.
A common complication of obesity is insulin resistance3 which can
lead to an inflammatory response amplified by the perioperative
stress response. The severity of this underlying inflammatory
response in the obese may play a mechanistic role in modulation
of pain during the post operative period, as opposed to effect of
weight per se. Thus we performed this prospective observational
study to determine association of BMI and insulin resistance with
postoperative pain and quality of recovery after THR.
Methods: IRB approval and written consent were obtained from
60 patients undergoing unilateral THR. The intent was to enroll
20 normal weight, 20 overweight, and 20 obese subjects. Patients
undergoing insulin, oral hypoglycemic, or systemic steroid treatment
were excluded due to exogenous effects on glucose and insulin.
Anesthesia and postoperative analgesia were standardized and
consisted of spinal anesthesia followed by PCEA until 1200 POD1.
Measurements included QoR40 questionnaire preoperative and on
POD 1 and 2, verbal pain scores (0-10), and PCEA consumption.
Insulin resistance was measured by Homeostatic Model Assessment
of Insulin Resistance (HOMA-IR)4. Other measurements of interest
included C reactive protein as a general marker of stress response,
glucose-insulin ratio as a secondary measure of insulin resistance,
and hemoglobin A1c.
Results: Patients with increased BMI were more insulin resistant
but had similar C reactive protein levels preoperatively (Table). On
POD1, C reactive protein levels increased to a similar degree in all
patients but again patients with increased BMI became more insulin
resistant. Neither BMI nor markers of insulin resistance correlated
with postoperative pain, PCEA consumption, or quality of recovery
(Table, Figures)
Discussion: Our findings suggest that obesity (BMI) is not
associated with worse postoperative pain or quality of recovery after
total hip replacement. Obesity is associated with increased severity
of perioperative insulin resistance but not generalized surgical
stress response; however insulin resistance does not appear to have
a mechanistic role in postoperative pain or recovery.
References:
1. JBJS Am. 2007 Apr;89(4):780-5.
2. Eur J Pain. 2010 Feb;14(2):149.e1-7.
3. Diabetes. 2002 Jan;51(1):204-9.
4. Diabetologia. 1985 Jul;28(7):412-9.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-486
S-487
ANESTH ANALG
2012; 114; S-01 – S-493
S-486.
S-487.
WITHDRAWN.
THE ADDITION OF NERVE STIMULATION TO
ULTRASOUND GUIDANCE DOES NOT IMPROVE
SUCCESS DURING PLACEMENT OF THE ARROW
STIMUCATH AT THE POPLITEAL SCIATIC NERVE: A
PROSPECTIVE RANDOMIZED TRIAL
AUTHORS: S. Porter1, R. McClain1, D. Wax2, C. Robards1
affiliation: 1Anesthesiology, Mayo Clinic, Jacksonville, FL;
2
Anesthesiology, Mt Sinai Medical Center, New York, NY
Introduction: There is debate as to whether or not nerve
stimulation (NS) is required to place peripheral nerve catheters
when using ultrasound (US) guidance. There are data that indicate
intraneural needle placement can fail to elicit an appropriate
motor response1. There is also conflicting evidence as to whether
stimulating catheters improve postoperative analgesia compared
to non-stimulating catheters2,3. There has been evidence that US
in combination with NS is superior to nerve stimulation alone in
terms of popliteal nerve blockade4,5. Given the previously published
reports, we hypothesized that there is improvement in sensory and
motor blockade for stimulating popliteal perineural catheters placed
under US guidance when NS is used.
Methods: After IRB approval, 21 patients undergoing elective
foot and ankle surgery were randomly assigned to either an US or
US+NS guided continuous popliteal sciatic nerve block using a
lateral approach. In both groups, the catheter was advanced 5 cm
past the needle tip at which point, 30 milliliters of mepivacaine
1.5% was injected.
The primary end-point of the study was successful nerve blockade
at 20 minutes. Secondary end-points included: block performance
time, minimum stimulating current, pain scores on post-operative
day 1 and day 2, and patient satisfaction.
Results: There was no significant difference in successful nerve
blockade at 20 minutes in the US versus US+NS groups (73 vs
80%, p=1). Procedure time was significantly shorter in the US only
group (median 62 seconds vs 130.5 seconds , p<0.01). Postoperative
pain scores and overall patient satisfaction were not significantly
different between the two groups.
Discussion: In this small, randomized, blinded trial, we have
found that the addition of NS provides no benefit over the use of
US alone. US alone was associated with a significantly shorter
block performance time. US+NS showed no significant difference
in pain control, patient satisfaction, or block success. There were
no apparent block-related complications. Of note, a minimum
stimulating current as high as 3.77 milliAmperes in the US alone
group yielded a successful nerve block. The study was terminated
at 21 patients after we experienced complications with the Arrow
Stimucath in patients undergoing brachial plexus blockade6,7.
References:
1. Reg Anesth Pain Med, 2008;33:207-10.
2. Anesth Analg, 2008;106:1316-21.
3. J Clin Anesth, 2007;19:434-9.
4. Reg Anesth Pain Med, 2008;33:259-65.
5. Anesth Analg, 2008;106:1553-8.
6. Can J Anaesth, 2011;58:482-3.
7. Can J Anaesth, 2011;58:62-7.
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-488
S-488.
AN ULTRASOUND GUIDED TECHNIQUE FOR
PERFORMING THE SUPERIOR LARYNGEAL NERVE
BLOCK
AUTHORS: B. Kaur, R. Tang, A. Sawka, H. Vaghadia
affiliation: Department of Anaesthesia, University of British
Columbia, Vancouver General Hospital, Vancouver, BC, Canada
Introduction: We investigated the feasibility of performing
an ultrasound guided superior laryngeal nerve (SLN) block using
a novel ultrasound technique. To date, only a single case report
performed this block under ultrasound guidance, but the SLN
was not visualized and surrogate landmarks were utilized.1,2 We
hypothesized that with the improvements in ultrasonographic
technology, the SLN could be visualized to enable accurate
placement of the needle.
Pre Injection (SLN indicated by arrow)
Methods: After ethics and institutional approval, a 8-15 MHz
transducer (HST15-8/20 linear probe (Ultrasonix, Richmond, BC,
Canada) was used on 2 fresh unembalmed cadavers to identify the
SLN nerve bilaterally. With cadavers in the supine position and neck
in the extended position, we performed initial scans of the neck using
the transducer placed in the transverse position relative to the skin,
to identify the greater cornu of hyoid bone and the superior lateral
aspect of the thyrohyoid membrane. By rotating the medial aspect
of the probe cephalad, the SLN was identified. A needle was inserted
in-plane to the ultrasound beam, advanced to the SLN and 1ml of
green dye was injected. Correct dye placement was confirmed by a
blinded anatomist and the dye spread was noted and photographed.
Results: In both cadavers, we confirmed successful bilateral dye
placement on the SLN by anatomical dissections.
Discussion: Visualization of the SLN has not been consistently
successful leading some authors to advocate use of the hyoid image
or superior laryngeal artery as surrogate ultrasound landmarks for
blockade of the nerve.1,2 This may in part be due to technological
limitations with previous generations of ultrasound systems.4 Current
ultrasound technology, which has improved image processing and
resolution has now made it possible to identify and target the SLN
under ultrasound guidance. We propose that this method may be
used in humans to perform the block safely and successfully.
Post Injection (SLN indicated by arrow)
References:
1.Manikandan S, Neema PK, Rathod RC. Ultrasound guided
bilateral superior laryngeal nerve block to aid awake endotracheal
intubation in a patient with cervical spine disease for emergency
surgery. Anaesthesia Intensive Care 2010; (28): 946-948
2.Green J.S., Tsui B.C.H. Applications of ultrasonography in ENT:
Airway Assessment and Nerve Blockade. Anesthesiology Clin
2010; (28): 541-553.
3.Vaghadia H, Lawson R, Tang R, et al. Failure to visualize the
superior laryngeal nerve using ultrasound imaging. Anaesth
Intensive Care 2010; 39(3): 503.
4.Chin K.J., Chan V. Ultrasound - guided peripheral nerve
blockade. Curr Opinion in Anaesthesiology 2008; (21): 624-63
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
ABSTRACTS
S-489
ANESTH ANALG
2012; 114; S-01 – S-493
S-489.
REAL TIME PARAVERTEBRAL BLOCKADE USING
A GPS GUIDED ULTRASOUND SYSTEM
AUTHORS: B. Kaur, R. Tang, A. Sawka, H. Vaghadia
affiliation: Department of Anaesthesia, University of British
Columbia, Vancouver General Hospital, Vancouver, BC, Canada
Introduction: We report the successful use of a novel Sonix
GPS system to accurately place a needle tip in the paravertebral
space of 2 cadavers using both, an in-plane and out-of-plane
approach. Needle tip placement was confirmed by methylene dye
injection into the space and dissection.
Methods: After instituitional and ethics approval, 3 unembalmed cadavers were used to perform in- plane thoracic
paravertebral (TPVB) injections on one side of the cadaver and out
of plane paravertebral injections on the other side at 4 levels: T5,
T7, T9, T11. The C5-2/60 GPS convex probe on the Sonix Touch
(Ultrasonix, Richmond, BC) was used to identify the TPVB space
in the transverse plane. A Sonix GPS 19G 80mm needle (Ultrasonix,
Richmond, BC) was advanced in an in- plane or out of plane fashion
into the paravertebral space using the needle guidance system. 1 ml
of methylene blue dye was injected, a guide wire left in situ, and
blind dissections were performed to confirm dye placement. The
study was repeated in 10 adults, with local anaesthetic. Block was
assessed by sensory loss to temperature post procedure.
In plane paravertebral injection with needle in TPVB space
Results: 8 in-plane and 12 out-of plane paravertebral injections
were performed using this technique in cadavers. 5 in-plane and 9
out-of-plane injections were successful. Dissection into the thoracic
cavity revealed no pleural punctures with either technique. In 10
patients 3 unilateral TPVB injections were placed at 3 levels for post
operative analgesia. Successful block to ice was demonstrated in all.
Discussion: TPVB block is a well described technique for
unilateral analgesia of contiguous dermatomes after thoracic
surgery.1,2 Locating the paravertebral space using an ultrasound
guided approach is challenging due to the acute insertion of
the needle and poor visualization of needle tip. We used a novel
approach with the Sonix GPS System (Ultrasonix, Richmond, BC)
and demonstrated successful placement of TPVB block in cadavers
and humans. We propose that this technology may be used to
perform the TPVB block safely and successfully in patients.
Out of plane injection with `x’ in TPVB space
References:
1.C.O. Riain S, O. Donnell B, Guffe T, C. Harman D, P. Fraher
J, Shorten G. Thoracic paravertebral block using real time
ultrasound guidance. Anesthesia and Analgesia Jan 2010; 110
(1): 248-51.
2.Karmakar MK. Thoracic paravertebral block. Anesthesiology
2001;(95): 771- 80
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-490
ANESTH ANALG
2012; 114; S-01 – S-493
S-490.
and HR were recorded at diferent time. Data were analyzed by using
independent-Sample T test and one-way ANOVA between groups.
KIDNEY INJURY AFTER PERCUTANEOUS AND EFFECTS
OF NERVE BLOCK COMBINED GENERAL ANESTHESIA
ON STRESS RESPONSE IN ELDER PATIENTS WITH
LOWER LIMB SURGERY
Results: There was no significant differences in characteristics
between 2 groups (Table 1). increased IL-6 was significantly
increased at T4 in group C and at T2~T4 in group G compared to T0
(P<0.05). Cor was significantly increased at T2~T4 compared to T0.
(P<0.05). E and NE was significantly increased at T1~T4 compared
to T0 in group G (P<0.05). The levels of IL-6, Cor, E and NE were
significantly increased at T2~T4 in group G than those in group C
(P<0.05) (Fig.1). MAP and HR were significantly higher at T2 in
group G than those in group C (P<0.05).
AUTHORS: H. Ma, J. Yu, X. Chen, F. Ma, L. Deng, J. Meng
affiliation: Anesthesiology Department, General Hospital of
Ningxia Medical University, Yinchuan, China
Introduction: Neuraxial anesthetic blockade has a definite
advantage in elderly patients over general anesthesia, as it reduces
surgical stress by decreasing sympathetic efferent nerve activity and
blocking nociceptive impulses from the operative site. In this study,
we investigate the effects of combined lumbar plexus sciatic never
block and general anesthesia on stress hormone in elder patients
with lower limb surgery.
Methods: With our institutional approval, 50 patients subject
to unilateral lower limb operation were randomly assigned to 2
groups: combined lumbar plexus sciatic never block and general
anesthesia (group C, n=25), general anesthesia (group G, n=25). All
patients received midazolam 0.03 mg/kg after entering the operating
room. Group C: Lumbar plexus block and sciatic never block was
performed by ultrasound-guided, and then anesthesia was induced
with 2-4 ug/kg fentanyl, 0.15~0.20 mg/kg cisatracurium besylate
and 0.5~1.5 mg/kg propofol, and then the laryngeal mask airway
(LMA) was inserted. Group G: Anesthesia induction was simmilar to
Group C. Anesthesia was maintained with propofol and remifentanil
infusion. Blood samples were taken before anesthesia (T0), at the
beginning of the surgery (T1), 30 min after the beginning of surgery
(T2), at the end of the surgery (T3), 1 h after the end of surgery
(T4) for determination of IL-6, Cortisol (Cor), epinephrine (E) and
norepinephrine (NE) and the mean arterial blood pressure (MAP)
Discussion: Never block combined general anesthesia can attenuate
the stress hormone responses in elder patients with lower limb
surgery by blocking nociceptive afferent input signals from the
traumatised site and prevents sympathetic as well as segmental
efferent nerve activity.
References:
1. KyungYeon Yoo, et al. Anesth analg, 2006;102:1223-8.
2. Yuhong Li, et al. Anesth analg, 2008; 106: 1559-61.
3. Lena B , et al. Brain Behav Immun, 2009; 23: 217-24.
Table 1: Demographic Data
Characteristics
Group C,
(n=25)
Group G,
(n=25)
P-value
Age (year)
69.5В±8.7
70.4В±10.3
0.465
Male/Female
9/16
10/15
0.50
Weight (Kg)
59.4В±11.6
63.3В±9.3
0.364
OR time (min)
61.8В±13.4
52.4В±14.2
0.119
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-491
S-492
ANESTH ANALG
2012; 114; S-01 – S-493
S-491.
S-492.
WITHDRAWN.
INTERPATIENT VARIABILITY IN INTRATHECAL DRUG
DISTRIBUTION: CEREBROSPINAL FLUID PULSATILE
MAGNITUDE, FREQUENCY, SOLUTION BARICITY, AND
TOXICITY RISKS
AUTHORS: Y. Hsu, A. Linninger
affiliation: Department of Bioengineering, University of
Illinois at Chicago, Chicago, IL
Introduction: Intrathecal drug delivery is frequently used
to administer anesthetics to the central nervous system (CNS).
However, even with identical dosage and administration mode,
drug distribution in the spine is highly variable in different patients,
leading to unpredicatble clinical outcomes. Drug biotransport
in the spinal canal is strongly influenced by the pulsations of the
cerebrospinal fluid (CSF), induced by cerebrovasculature expansions
in the cranium. The frequency (heart rate) and magnitude of CSF
pulsations vary greatly between subjects, which could influence
drug transport speed in vivo. We hypothesize that the CSF pulsatility
is a key factor for interpatient variability observed clinically. We
also investigate the toxicity risks associated with solution baricity
for different postures.
Methods: We tested the hypothesis using medical imagebased computational fluid dynamics. Magnetic resonance imaging
(MRI) and CINE-MRI were performed to capture the subject’s
CNS anatomy and CSF pulsatile velocities. Drug biodistribution
was computed using an anatomically consistent spine model
reconstructed from MR images. The effects of CSF pulse frequency
and magnitude on drug distribution were quantified for a simulated
bolus injection at the second lumbar vertebra. Then, the variability
in drug distribution after identical injections for three subjects with
different physiological parameters was quantified. In addition,
spatiotemporal drug distribution was computed for isobaric and
hyperbaric solutions. Risk assessment was performed for different
heart rates, CSF pulse magnitudes, and solution baricities.
Challenging Case Report: N/A
Results: Results show that CSF pulse frequency, magnitude,
and solution baricity strongly influence drug distribution. Peak
concentration in CSF after injection for a heart rate of 120bpm is
26.4% lower than that for a heart rate of 60bpm. Doubling the CSF
stroke volume per pulse lowered the peak concentration by 38.1%.
The computed profiles of hyperbaric solution are a function of
patient posture, and undesired high concentrations may result due
to gravity.
Discussion: Our computations identify key parameters -CSF
pulse frequency and magnitude- for interpatient variability in drug
distribution observed clinically. In addition, computations confirm
the effect of solution baricity on drug distribution observed clinically.
This study also has great potential for personalized medicine. The
results show that the same infusion may cause different toxicity risks
for different subjects. Personalizing infusion therapies according to
the subject’s physiological parameters is crucial for increasing the
safety and efficiency of intrathecal infusions.
References: N/A
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ABSTRACTS
S-493
S-493.
THREE TIMES DAILY SUBCUTANEOUS
UNFRACTIONATED HEPARIN AND THORACIC
EPIDURAL ANALGESIA: A RETROSPECTIVE REVIEW
OF 928 CASES
AUTHORS: J. Davis, B. Bankhead, A. F. Wallace, E. Eckman,
J. Strunk
affiliation: Anesthesiology, University of Utah, Salt Lake
City, UT
Introduction: Subcutaneous unfractionated heparin (SC
UFH) given every eight hours (TID) is widely used for perioperative
thromboprophylaxis. Limited data exist regarding the safety
of epidural catheters in the presence of TID SC UFH. The 2010
American Society of Regional Anesthesia guidelines caution
against using TID SC UFH in patients with indwelling epidural
catheters. The aim of this retrospective study was to identify a
diagnosis of epidural hematoma, deep vein thrombosis (DVT), or
pulmonary embolism (PE) in patients who had a thoracic epidural
catheter while receiving TID SC UFH. We hypothesized that none
of the patients would have an epidural hematoma, the incidence of
DVT/PE would be comparable to both national DVT/PE rates and
our institution’s overall DVT/PE rate, and the partial thromboplastin
time (PTT) would be elevated in a subgroup of study patients.
Methods: We queried our University’s Hospital database to
identify patients who had received TID SC UFH in the presence
of an indwelling thoracic epidural from 7/1/2008 to 10/31/2010.
Patients in this group who were diagnosed with an epidural
hematoma, DVT, or PE were recorded. We also identified patients
whose PTT measured greater than 40 seconds while receiving TID
SC UFH.
Results: During the 28 month period, 928 patients (study group)
had an indwelling epidural catheter and received TID SC UFH. We
found no epidural hematomas. 7 patients (0.75%) were diagnosed
with a DVT/PE. There were 113 patients (12%) who had a measured
PTT greater than 40 seconds at one point during therapy with TID
SC UFH.
Discussion: Given that epidural hematomas are so rare,
our sample size was inadequate to make definitive conclusions
regarding the safety of TID SC UFH in the presence of an indwelling
thoracic epidural. However, the absence of epidural hematomas
in our cohort is reassuring. We found that 12% of the patients in
our study group had a PTT >40 seconds while on TID SC UFH.
This demonstrates the importance of measuring the PTT during SC
UFH thromboprophylaxis, particularly prior to epidural catheter
removal. This also suggests that TID SC UFH could in fact be a safe
thromboprophylactic regimen used in conjunction with thoracic
epidural analgesia, assuming that PTT values are closely followed.
Finally, our study group had a 0.75% incidence of DVT/PE, which
is consistent with rates reported by the National Surgical Quality
Improvement Program (0.73% in 2008) and is also consistent with
our institution’s overall DVT rate of 0.8%. In conclusion, no patient
developed an adverse event while receiving TID SC UFH along
with an indwelling epidural catheter, and the thromboprophylaxis
appeared to be effective.
References: None
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
ANESTH ANALG
2012; 114; S-01 – S-493
S-494
ABSTRACTS
A
Abadir, Adel,
S-376 - Withdrawn
Abaz, Motaz, S-39
Abdel-Bar, Maha, S-242
Abdelwahab, Hisham H.,
S-157
Abe, Hidehiro, S-258
Abe, Nobuko, S-373
Abo Sedera, Mounis, S-297
Afessa, Bekele, S-160
Agarwal, Santosh J., S-185
Aghamohammadi,
Homayoun, S-220
Ahmad, Nauman,
S-486 - Withdrawn
Al Rawahi, Khalid Salim, S-243
Al-Achi, Antoine, S-64
Al-Baghdadi, Yaseer, S-156
Al-Mahrami, Maya Salim
Abdullah, S-476
Al-Shuaibi, Khalid M., S-382
Albahrani, Maher J., S-476
Aleshi, Pedram, S-474
Ali, Mohamed Z., S-242, S-297
Allanku, Sharat, S-04
Allard, Rene, S-287, S-289
Alrayashi, Walid, S-472
Amhaz, Hassan H., S-156
Amirthalingam, Uma,
S-335 - Withdrawn
Amornyotin, Somchai,
S-281 - Withdrawn,
S-282 - Withdrawn,
S-283 - Withdrawn, S-450,
S-451
Anderson, James P., S-223,
S-266, S-272
Aoki, Yuta, S-158
Apostol, Alexandru, S-457
Apostolou, Dimitrios, S-156
Arora, Harendra, S-48
Arriaga, Alexander F., S-224
Arya, Virendra K., S-72
Ashour, Fatma, S-173
Ashrafi, Behrouz, S-300
Asimolowo, Olabisi, S-457
Assaad, Sherif, S-47, S-50
Atkinson, John L., S-160
Attaallah, Ahmed F., S-157
Avagliano, Ester, S-77
Azocar, Ruben, S-212
B
Bader, Angela M., S-224
Bae, James J., S-485
Bagoly, TerГ©z, S-431
Bahl, Ajay, S-72
Bajaj, Nidhi, S-07
Bajic, Dusica, S-406
Baker, Keith H., S-232
Baker, Kevin S., S-195
Baldassarri, Rubia, S-77
Bankhead, Byron, S-493
Bansal, Sujesh, S-183
Barnet, Caryn S., S-224
Baron, Mathilde, S-255
Barsoum, Sylviana, S-285,
S-333
Bates, Andy, S-437
Bause, George S., S-233
Baxter, Mark, S-437
Beattie, Scott, S-28, S-62
Beck-Schimmer, Beatrice,
S-166, S-169, S-417
Bekker, Alex Y., S-312, S-319
Belotti, Laure, S-221
Bent, Sabrina,
S-29 - Withdrawn
Bent, Sabrina T., S-185
Benveniste, Helene, S-375,
S-404
Berge, Keith H., S-203
Berger, Joel, S-202
Berkowitz, Dan E., S-30
Bernstein, Wendy K., S-218
Bertaccini, Edward, S-20
Bhalla, Anil, S-66 - Withdrawn
Bhansali, Rahul, S-217
Bhatt, Harshad,
S-376 - Withdrawn
Bhatti, Naeem, S-10
Bie, Bihua, S-439
Biswal, Shyam, S-162
Bjerregaard, Jens, S-390
ANESTH ANALG
2012; 114; S-01 – S-493
Blevins, Ashley, S-222
Blood, Jane, S-465
Blum, Franziska E., S-57
Blumenstiel, Jonas, S-36, S-435
Body, Simon, S-52, S-67
Bolliger, Daniel, S-69, S-460,
S-461, S-463
Bong, Choon L., S-403
Boone, Louvonia, S-76, S-225
Booy, Christa, S-166
Borgeat, Alain, S-417
Borges, Juliana, S-349
Boriosi, Juan, S-393
Boscariol, Rya, S-356
Bose, Ruma, S-229
Bowe, Edwin, S-236
Boyd, Ben, S-415
Bradford, William, S-48
Bremer, Christoph, S-41
Bridgwater, Erica M., S-436
Brown, David, S-439
Brown, Emery N., S-424
Brown, Raeford, S-236
Bruzik, Karol S., S-438
Bryan, Yvon, S-08, S-10
Bryan, Yvon F., S-222
Brzezinski, Marek, S-205
Bub, Christine D., S-399
Buehler, Jason, S-61
Bullard, Kenneth, S-211, S-213
Burkhardt, Kevin,
S-473 - Withdrawn
Burkle, Christopher, S-203
Butterworth, John, S-298
Buvanendran, Asokumar,
S-343, S-344, S-350, S-357,
S-359, S-374
C
Calicott, Randy, S-222
Camporesi, Enrico M.,
S-491 - Withdrawn
Campos, Amy, S-10
Candiotti, Keith, S-363
Capan, Levon, S-472
Carroll, John, S-02
Carroll, Roger C., S-61
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-495
ABSTRACTS
Carter Chase, Sheree, S-218
Cason, Brian, S-20
Castellon, Maricela, S-169
Cecchini, Michael, S-76
Chalayonnawin, Wiyada,
S-283 - Withdrawn,
S-450 - Withdrawn
Chaput, Alan J., S-274
Charabaty, Aline, S-02
Chau, Destiny, S-236
Chaudhari, Anushree A.,
S-66 - Withdrawn
Chen, Li, S-288
Chen, Xuexin, S-416, S-490
Cheng, Qunli, S-38
Cheng, Ying, S-401
Chidambaran, Vidya, S-365
Chrysostomou, Constantinos,
S-392
Cierny, George B., S-364
Clinite, Kimberly, S-74, S-75
Cofer, Benton, S-392
Cohen, Joshua M., S-474
Cohen, Shaul, S-284, S-285,
S-333
Collard, Charles D., S-52, S-67
Colquhoun, Douglas, S-317
Commons, Kathryn G., S-406
Correll, Darin J., S-224
Craft, Robert M., S-61, S-291
Craven, Donald E., S-174
Crawford, Emily, S-222
Creal, Cristina, S-70
Creighton, Paul R., S-01
Creighton, Paul, S-386
Cronkite, Ruth, S-20
Cui, Derong, S-311, S-313
Cui, Qi, S-205
Davis, Raphael, S-375
Davis, Stephanie, S-10
De Oliveira, Gildasio S., S-481
Dela pena, Margarita, S-457
Delphin, Ellise, S-225
Demmer, Philipp, S-40, S-41
Deng, Liqin, S-490
Derevianko, Alexandre, S-231
DeRose, Joseph, S-76
Dershwitz, Philip, S-422
Desjardins St-Jean, Olivier,
S-455
Dexter, Franklin, S-208
Dhiraaj, Sanjay, S-14
Diaz, Laura K., S-400
Dickson, Zackary, S-61
Didehvar, Sorosch, S-312
Diemunsch, Pierre, S-221,
S-255
DiLorenzo, Amy, S-236
Dimache, Florin, S-255
Ding, Xiangxiang, S-331
Ditillo, Michael, S-47
Dobson, Gary, S-33
Doi, Katsushi, S-358
Donati, Francois, S-455
Dong, Changsheng, S-302
Dong, Hai-long,
S-413 - Withdrawn
Doodeman, Hieronymus J.,
S-447
Dostalova, Zuzana, S-422
Dote, Kentaro, S-259
Downes, Katheryne L.,
S-491 - Withdrawn
Du, Jin, S-348
Durieux, Marcel, S-317
Durkin, Brian, S-375
D’Souza, Angela, S-269
D
Dalal, Usha, S-07
Daniel, Cormican, S-195
Dauber, Benjamin, S-217,
S-219, S-227
Dauphinee, Kristen, S-284
Davidson, Melissa, S-198
Davis, Jennifer, S-493
E
Easdowne, Jane, S-204
Eckenhoff, Roderic, S-425
Eckman, Erik, S-493
Ee, Choan, S-356
Egan, Talmage, S-430, S-462
ANESTH ANALG
2012; 114; S-01 – S-493
Egberts, Toine C.G., S-447
Eggan, Kevin, S-405
Ehrenfeld, Jesse M., S-200,
S-256, S-270
Eikermann, Matthias, S-449
Eipe, Naveen, S-356
Ekstrom, Ben, S-257
El Sabae, Hossam H., S-475
El-Hadi, Sherif, S-250
elgebaly, Ahmed S., S-71
Elsayed-Awad, Hamdy, S-39
Emanuel, Asher, S-269
Eng, Reuben, S-33
Epstein, Richard H., S-208
Erslon, Mary G., S-185
Eskandar, Emad N., S-424
Evans, Tyler, S-430
Ewing, Mary, S-254
F
Fan, Shou-Zen, S-267
Fang, Caiyun, S-27
Farar, Damond, S-70
Fassl, Jens, S-463
Fechner, Joerg, S-453
Feng, Hua-Jun, S-427
Feng, Mallory, S-263
Feng, Tian, S-404
Feng, Yi, S-362
Fernandez, Adolfo, S-08
Fiedler-Kelly, Jill, S-387
Filipovic, Miodrag, S-69, S-460
Fisher, Lauren J., S-205
Flood, Pamela, S-330
Florez, Carlos,
S-414 - Withdrawn
Floyd, Thomas, S-269
Fobker, Manfred, S-435
Forman, Stuart A., S-232,
S-418, S-421, S-422, S-427
Fortier, Louis Philippe, S-274
Fortier, Louis-Philippe, S-455
Foster, Dalton, S-348
Fox, Amanda, S-52, S-67
Fox, Charles J.,
S-29 - Withdrawn
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-496
ABSTRACTS
Frenzel, Tim, S-41
Fridell, Jonathan A., S-70
Friedrich, Oliver, S-420
Fuchs, Ralph, S-162
Fujii, Keisuke, S-12, S-63, S-459
Fujii, Sonoko, S-383
Fujioka, Shiho, S-383
Fujita, Satoshi, S-249
Fujita, Yasuaki, S-193
Fujiwara, Yoshihiro, S-158
Fukazawa, Kyota, S-300
Fukuhara, Aya, S-384
Fukuhara, Naoki, S-280
Fukusaki, Makoto, S-56
Fukushima, Hisahi, S-448
Fukushima, Yuji, S-192
G
Galarneau, Andre, S-274
Gale, John T., S-424
Galiatsou, Efie, S-172
Gallagher, Sean, S-03
Galler, Robert, S-269
Gambus, Pedro, S-430
Gan, Tong J, S-361, S-366
Ganguly, S., S-315, S-360
Ganim, Rose, S-73
Garcia, Vincent, S-221
Gasanova, Irina, S-09
Gawande, Atul A., S-224
Gaynor, J. W., S-400
Ge, Rile, S-438
Gebre-Amlak, Kassatihun,
S-270
George, Edward, S-449
George, Gina, S-285
George, Ivan M., S-218
Gerdes, Marsha, S-400
Gharaei, Babak, S-220
Gibson, Charles, S-73
Giffard, Rona Greenberg, S-321
Ginsberg, Steven H., S-194
Glass, Peter, S-195
Glick, David, S-74, S-75, S-217,
S-219, S-227, S-263, S-456
Goeree, Ron, S-184
Goettel, Nicolai, S-310
Gombar, Satinder, S-07, S-385
Gomez, Santiago,
S-29 - Withdrawn
Gong, Jie, S-161 - Withdrawn,
S-168 - Withdrawn
Gonzales, Antonio, S-167
Goodchild, Colin S., S-415
Goravanchi, Farzin, S-202
Goto, Takahisa, S-201, S-248
Graf, Bernhard M., S-420
Graham, Mary Ellen, S-332
Gramlich, Lisa, S-392
Grande, Bastian, S-216
Grote, Gudela, S-216
Groves, Danja S., S-57
Grubb, William, S-194
Guarracino, Fabio, S-77
Guo, Si, S-161 - Withdrawn,
S-168 - Withdrawn
Gupta, Deepak, S-156
Gupta, Rakhi, S-14
Göpfert, Christine E., S-465
Götz, Friederike, S-173
H
Habeebulah, Syed,
S-335 - Withdrawn
Haburcak, Marian, S-418, S-421
Haddad, Nadim, S-02
Haile, Michael M., S-312, S-319
Hammer, Gregory B., S-393
Hand, William, S-364
Hannallah, Medhat S., S-02
Hansoti, Shehnaz, S-330
Hare, Gregory, S-26, S-28
Harun, Nusrat, S-202
Hashimoto, Hiroshi, S-268
Hasler, Melanie, S-166
Hatakeyama, Noboru, S-158
Hattori, Seiji, S-372
Heard, Christopher, S-386, S-01
Helmy, Hosam, S-242
Helyes, Zsuzsanna, S-431
Henkelman, Mark, S-26
ANESTH ANALG
2012; 114; S-01 – S-493
Hepner, David L., S-224
Herasevich, Vitaly, S-209
Herrera, Mario, S-392
Herrmann, Inge K., S-166,
S-169
Hess, Philip, S-03, S-34, S-229
Hickey, Anita,
S-473 - Withdrawn
Higashijima, Ushio, S-56
Hillier, Simon C., S-399
Hirayama, Michiko, S-252
Hirota, Kazuyoshi, S-268
Hochheiser, Gary, S-73
Hoke, Lauren, S-08, S-10, S-222
Holak, Elena J., S-205
Holzman, Robert S., S-215
Hoshijima, Hiroshi, S-358
Hsu, Ying, S-492
Htut, Nyan, S-254
Hu, Guochang, S-169
Hu, Tina, S-28
Hua, Fu Z., S-328
Huang, Yuguang, S-479
Hudcova, Jana, S-174
Huffmyer, Julie L., S-57
Hunter, Christine W., S-284
I
Ichinose, Fumito, S-164, S-163
Iden, Timo, S-37, S-432
Igarashi, Tae, S-372
Ihmsen, Harald, S-453
Im, Hee-Jeong, S-343
Inchiosa, Mario A., S-59
Inoue, Tetsuo, S-477
Insinga, Ralph P., S-180
Iranami, Hiroshi, S-63
Ishii, Kouta, S-280
Ishizawa, Yumiko, S-424
Ito, Asuka, S-429
Ito, Takahiko, S-429
Iwasaki, Hajime, S-452, S-458
Iwasaki, Hiroshi, S-249, S-373,
S-452, S-458
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-497
ABSTRACTS
J
Jackson, William M., S-330
Jacob, Zvi, S-404
Jacobs, Valerie L., S-399
Jafari, Ali R., S-220
Jafra, Anudeep, S-385
Jalou, Sanaa, S-457
Jameson, Leslie C., S-211, S-213
Janssen, Henrike, S-40
Jeleazcov, Christian, S-453
Jha, Sachin, S-359
Jiang, Wei, S-311, S-313
Jiang, Yan, S-362
Jiang, Yan-hua,
S-308 - Withdrawn
jiang, yandong, S-334
Jing, You, S-05
Jinma, Takehiro, S-280
Johnson, Ken B., S-430, S-462
Johnson, Larry, S-160
Johnson-Akeju, Oluwaseun,
S-405
Jones, Stephanie B., S-205
Jones, William,
S-376 - Withdrawn
Joshi, Girish P., S-09, S-13
Jounaidi, Youssef, S-421, S-427
K
Kacmarek, Robert M., S-334
Kadoi, Yuji,
S-314 - Withdrawn
Kaerlein, Kristoffer Tim, S-37,
S-432
Kaku, Ryuji, S-299
Kalarickal, Philip, S-29
Kalkman, Cor J., S-447
Kamali, Amin, S-09
Kameyama, Naomitsu, S-429
Kamranmanesh, Mohammad
R., S-220
Kanai, Riichiro, S-159
Kanamori, Rie, S-464
Kanao, Megumi, S-373
Kapoor, Dheeraj, S-385
Kar, Sandeep K., S-53
Kariya, Takayuki, S-248, S-201
Karlnoski, Rachel,
S-491 - Withdrawn
Kashi, Amir H., S-220
Kaspervacius, Mykolas, S-287
Kaul, Naresh, S-243, S-476
Kaur, Balvindar, S-488, S-489
Kawakami, Hiromasa, S-201,
S-248
Kawakami, Mamoru, S-252
Kawanishi, Susumu, S-253
Kawano, Takashi, S-258
Kawasaki, Syun, S-383
Kee, Spencer, S-202
Keegan, Mark, S-203
Kehlet, Henrik, S-290
Kelbert, Julie, S-204
Kelley, Scott D., S-185
Kendale, Samir, S-286
Kennel, Stephen, S-291
Kersten, Judy R., S-38
Khabbaz, Kamal, S-34
Khafagy, Hanan F., S-475
Khan, Rashid, S-243, S-476
Kharasch, Evan, S-465
Kida, Kotaro, S-163, S-164
Kim, Anthony W., S-50
Kim, Cindy M., S-212
Kim, Jaesung, S-343
Kim, Thomas, S-465
King, Michael, S-263
Kinoshita, Hiroyuki, S-252
Kinsella, Sandra, S-70
Kitamura, Sakiko, S-383
Kitayama, Masato, S-268
Kline, Richard P., S-312
Ko, Dennis, S-62
Koh, Ivy W., S-403
Koh, Kwong Fah, S-244
Koh, Shannon, S-400
Kohyama, Tomoki, S-159
Kolbe, Michaela, S-216
Kolodzie, Kerstin, S-474
Kolosov, Anton, S-415
Komatsu, Ryu, S-51
ANESTH ANALG
2012; 114; S-01 – S-493
Kongphlay, Siriporn,
S-281 - Withdrawn,
S-282 - Withdrawn,
S-283 - Withdrawn,
S-450 - Withdrawn, S-451
Koo, Edward, S-402
Kosaka, Junko, S-299
KOSAKA, YASUHARU, S-165
Kostanti, Eleonora, S-172
Kowalski, Alicia, S-202
Kraidin, Jonathan, S-194
Krekels, Elke, S-365
Krenk, Lene, S-290
Kristensen, Michael S., S-214
Kroin, Jeffrey, S-343, S-344,
S-350, S-357, S-359, S-374
Kryuchkova, Anna,
S-376 - Withdrawn
Kudo, Tomoyuki, S-268
Kumar, Bhupesh,
S-66 - Withdrawn
Kumar, Matthew M., S-160
Kumar, Priya, S-48
Kundra, Pankaj,
S-335 - Withdrawn,
S-388 - Withdrawn
Kunisawa, Takayuki, S-249,
S-452
Kuratani, Norifumi, S-358
Kurosaki, Hiromichi, S-459
Kyriakides, Tassos, S-47, S-50
L
LaFaro, Rocco J., S-59
Lange, Markus, S-35
Langlois, Scott, S-254
LaPierre, Cristen, S-430, S-462
Larmann, Jan, S-40, S-41
Lau, Jennifer, S-231
Laxton, Melissa, S-08
Lazar, Jozef, S-38
Lebas, Benjamin, S-221
Lee, Hedok, S-404
Lee, Keith, S-26
Lee, Wilson, S-225
Leffert, Lisa R., S-334
Lehmann, Christian, S-173
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-498
ABSTRACTS
Lei, Yuxiu, S-174
Leng, Tiandong, S-433
Lengl, Orsolya, S-431
Leong_Poi, Howard, S-28
Lessa, Marcos Adriano, S-68,
S-349, S-426
Levine, Daniel, S-217
Levy, Richard, S-401
Leyvi, Galina, S-76
Li, Fenghua, S-348
Li, Guohua, S-186 - Withdrawn
Li, Hong-Bin,
S-161 - Withdrawn,
S-168 - Withdrawn
Li, Jinyuan, S-343, S-344
Li, Quan, S-331
Li, Tianzuo, S-206, S-361
Li, Yanru, S-206
Li, Yong-Sheng, S-319
Li, Zhuo, S-261, S-288, S-484
Liaw, Chen Mei, S-244
Lin, Fuqing, S-331
Lin, Jun, S-433
LIN, Na, S-206
Linninger, Andreas, S-492
Lipov, Eugene G.,
S-473 - Withdrawn
Liu, Henry, S-29 - Withdrawn
Liu, Jiabin, S-482
Liu, Jin, S-261, S-484
liu, jing shi, S-302
Liu, Spencer S., S-485
Liu, Yanhong, S-334
Loftus, Randy W., S-226
Lombardi, Linda, S-77
Long, Timothy, S-209
Lopez, Kevin, S-254
Lotz, Christopher, S-27, S-35
Lovich, Mark A., S-246
Lu, Yu, S-321
Luan, Xianqun, S-400
Ludwig, Elizabeth, S-387
Lum, Stacey, S-403
Lundberg, Johan, S-180
Lurati Buse, Giovanna A., S-69,
S-184, S-460, S-461, S-463
Lye, Soh Teng, S-244
Lyons, Patrick, S-263
M
Ma, Fuqiang, S-490
Ma, Hanxiang, S-416, S-490
Ma, Hong, S-308 - Withdrawn
Maas, Matthias, S-432
Macario, Alex, S-204
MacDonald, Teresa O., S-449
Madhusudan, Poorna, S-72
Madupu, Ashwin, S-04
Maeda, Hiromi, S-252
Maerz, David, S-59
Mahert, Mohamed, S-475
Mahmood, Feroze, S-34, S-229
Mai, Christine, S-231
Majima, Masataka, S-165
Makaryus, Rany, S-404
Mamiya, Keiko, S-373
Mangar, Devanand,
S-491 - Withdrawn
Mangus, Richard, S-70
Manis, Erika, S-483
Manninen, Pirjo, S-310
Mao, Jingjing, S-416
Mariano, Edward, S-20
Marinho, Bruno, S-426
Marks, Roger, S-271
Marsden, Philip A., S-26
Martin, Emily, S-291
Maru, Ami, S-386
Marutani, Eizo, S-163
Maruyama, Atsushi, S-280
Mascha, Edward J., S-51
Mascia, Michael F., S-170
Matsumi, Masaki, S-253
Matsumoto, Nobuyuki, S-358
Matsusaki, Takashi, S-299
Matyal, Robina, S-34, S-229
Maurer, Walter G., S-05
May, Joseph, S-08, S-10, S-222
Mazer, David, S-26, S-28
McCarthy, Robert J., S-481
McClain, Craig D., S-215
ANESTH ANALG
2012; 114; S-01 – S-493
McClain, Robert, S-487
McEvoy, Matthew D., S-364
McGaughy, Jill, S-437
McGee, William T., S-73
McKeen, Dolores M., S-274
McKinney, William, S-317
McMullen, Michael, S-287,
S-289
McNulty, Stephen, S-223,
S-266, S-272
Mehta, Tejal, S-284, S-285
Meissner, Konrad, S-465
Memtsoudis, Stavros G., S-485
Meng, Jin, S-09
Meng, Jinhai, S-416, S-490
Mesquita, Rickson, S-269
Meyer zu Schwabedissen,
Henriette E., S-465
Michael, Rafik,
S-376 - Withdrawn
Michaels, Joseph,
S-376 - Withdrawn
Mikami, Daisuke, S-54
Miller, Keith W., S-422, S-438
Minamishima, Shizuka, S-164
Minehart, Rebecca, S-231,
S-334
Minshall, Richard D., S-169,
S-417
Mireles, Ramiro, S-386
Mirzakhani, Hooman, S-449
Mishima, Yasunori, S-429
Mitchell, John D., S-205, S-229
Miyake, Yuko, S-252
Miyashita, Tetsuya, S-201,
S-248
Mogos, Mariana, S-58, S-171
Mohammed, Adil, S-333
Molloy, Bonnie L., S-207
Monteiro, Joseph N., S-316
Montes, Lucresia, S-59
Montoya, Ruben, S-235
Moraiti, Anastasia, S-172
Moric, Mario, S-344, S-359,
S-374
Morimatsu, Hiroshi, S-253,
S-299
Morioka, Nobutada, S-464
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-499
ABSTRACTS
Morita, Kiyoshi, S-253, S-299
Morita, Yoshihisa, S-300
Moriyama, Kiyoshi, S-196,
S-54, S-159
Morrison, Adrian, S-210
Motaghedi, Roja, S-485
Muddasani, Pallavi, S-04
Mudumbai, Seshadri, S-20
Muehlschlegel, Jochen D., S-52,
S-67
Munoz, Daisy, S-198
Murdoch, John, S-287, S-289
Muret-Wagstaff, Sharon, S-230
Murphy, Kathy, S-437
Muto, Rika, S-262, S-264, S-265
Mychaskiw, George, S-260
N
Nabor, Darren, S-38, S-257
Nagaro, Takumi, S-383
Nagase, Hiroshi, S-36, S-37,
S-432
Nagashima, Mitsugi, S-383
Naguib, Mohamed, S-439
Naik, Bhiken, S-317
Nair, Singh, S-76, S-225
Nakajima, Motoaki, S-193
Nakajima, Yoshiki, S-477
Nakamura, Kyota, S-201
Nakata, Jun, S-193
Nakata, Yoshinori, S-49
Nakazawa, Harumasa, S-54
Nakos, George, S-172
Nara, Yoshihiro, S-165
Nastasie, Adriana, S-255
Navaie, Maryam,
S-473 - Withdrawn
Navas-Acien, Ana, S-162
Navedo, Andres, S-215
Nayagam, Vedha, S-160
Negin, Julie, S-211
Nemergut, Edward C., S-57
Nemoto, Kohei, S-346
Neusch, Rebecca, S-170
Newth, Christopher, S-393
Ng, Vanessa, S-199
Ngamprasertwong, Pornswan,
S-365
Ngozi, Mary Ann, S-74, S-75
Nicolai, David, S-229
Nishikawa, Kohichi, S-12, S-63,
S-459
Nishiyama, Tomoki, S-342
Noel, Sanjeev, S-162
Noone, Nick, S-389
Nozari, Ala, S-449
Nyhan, Daniel, S-30
Nystrom, Perry, S-483
O
O’Connor, Michael F., S-74,
S-75
O’Connor, Patrick, S-74, S-263
O’Donnell, Jennifer M., S-399
Obata, Norihiko, S-299
Ochiai, Ryoichi, S-262, S-264,
S-265
Oda, Yutaka, S-384
Oderda, Gary, S-366
Ogura, Akira, S-477
Ohara, Sayaka, S-448
Ohashi, Yuuki, S-196
Oji, Makito, S-56
Okamoto, Hirotsugu, S-165
Okino, Sayaka, S-262, S-264,
S-265
Okutani, Ryu, S-384
Oleszkiewicz, Stephen, S-59
Omran, Mohammed M., S-250
Onodera, Yoshiko, S-373
Ootaki, Chiyo, S-05
Orlewicz, Marc, S-156
Orser, Beverley A., S-436
Oshodi, Timi, S-402
Otomo, Shigeaki, S-452, S-458
Ouyang, Yi-Bing, S-321
Ozaki, Makoto, S-464
P
Paes, Lorena, S-349
Pagel, Paul S., S-257
Palese, Caren, S-02
ANESTH ANALG
2012; 114; S-01 – S-493
Panchagnula, Umakanth, S-183
Panjwani, Anjana S., S-194
Papathanasiou, Athanasios,
S-172
Parker, Kenneth, S-422
Parker, Michael J., S-246
Pasnak, Jan, S-298
Patel, Hetal M., S-226
Patel, Purvi, S-285, S-333
Patel, Santosh, S-155, S-197,
S-329
Patel, Swarup, S-329
Patel, Yash, S-204
Patteson, Stephen K., S-332
Pavlovic, Dragan, S-173
Pejo, Ervin, S-418
Pell, Max, S-260
Penning, John, S-356
Perkal, Melissa, S-47, S-50
Perouansky, Misha, S-412
Perrino, Albert, S-47, S-50
Peterfreund, Robert A., S-246
Peyster, Robert, S-375
Pian-Smith, May C. M., S-334
Pickering, Brian, S-209
Piegeler, Tobias, S-417
Pierce, David W., S-418
Ping, Peipei, S-27
PintГ©r, Erika, S-431
Pisklakov, Sergey V., S-198
Ploner, Franz, S-36, S-435
Polak, Mark, S-392
Poorzamani, Mahtab, S-220
Porter, Steven, S-487
Pothula, Suryanarayana, S-59
Pothula, Vijayasimha R., S-04
Pretto, Ernesto A., S-300
Puri, Goverdhan D.,
S-66 - Withdrawn
Q
Qi, Aihua, S-311, S-313
Qiu, Mantang, S-331
Quinn, John P, S-431
Quraishi, Tanviha, S-183
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-500
ABSTRACTS
R
Raghunathan, Karthik, S-73
Raines, Douglas E., S-418
Rajaratnam, Crisanjali R., S-171
Rangel, Rafael S., S-426
Raphael, Jacob, S-52, S-67,
S-317
Rasmussen, Lars S., S-214,
S-290
Rasmussen, Michael, S-02
Rasmussen, Niels, S-214
Rebello, Elizabeth, S-202
Rehman, Mohamed, S-400
Rice, Mark J.,
S-251 - Withdrawn
Riess, Matthias L., S-38, S-257
Ringenberg, Kyle J., S-55
Robards, Christopher, S-487
Robertson, George, S-173
Robinson, Scott, S-366
Rodriguez, Odalys, S-363
Rodriguez, Yiliam, S-363
Roewer, Norbert, S-35
Roffey, Peter, S-58, S-171
Rogers, Althea, S-181
Romeiser, Jamie, S-375
Romero-Sandoval, Edgar A.,
S-399
Rosenberg, Noah, S-03
Rosero, Eric, S-09
Rosero, Eric B., S-13
Rosinia, Francis A.,
S-29 - Withdrawn
Roth-Z’Graggen, Birgit, S-166
Rothfield, Kenneth P., S-254
Rowan, Cody, S-291
Rowlands, John P., S-226
Roy, Sashwati, S-39
Rudan, John, S-287, S-289
Rybak, Sabina, S-359
S
Saari, Teijo, S-453
Sabouri, Abdolnabi S., S-01
Sadhasivam, Senthilkumar,
S-365
Saeed, Reham, S-242, S-297
Safadi, Lawrence, S-156
Sai-Sudhakar, Chittoor B., S-39
Saito, Junichi, S-268
Saito, Yoji, S-416
Sako, Sumiko, S-249
Salgado, Maria A., S-68
Samant, Rajiv, S-356
Samhan, Yasser M., S-475
Samimi, Nadiv, S-58
Samyn, Brice, S-221
Sandberg, Warren S., S-200,
S-256
Sankhe, Milind, S-316
Sano, Hiromi, S-372
Sano, Itsuro, S-193
Santhanam1, Lakshmi, S-30
Sarwar, Akmal, S-174
Sasakawa, Tomoki, S-452,
S-458
Saththasivam, Poovendran,
S-260
Sato, Hitoshi, S-201, S-248
Sato, Nobukazu, S-262, S-264,
S-265
Saumande, Bruno, S-221
Savechenkov, Pavel Y., S-438
Sawai, Jun, S-49
Sawka, Andrew, S-488, S-489
Scher, Corey, S-286, S-472
Schiavone, Angela, S-04
Schoenberg, Catherine, S-198
Schreibman, David, S-218
Schuettler, Juergen, S-453
Schulman, Scott, S-392, S-393
Schumacher, Philip, S-461,
S-463
Schumann, Regina, S-463
Schuster, Lea, S-173
Schwartz, David E., S-169,
S-417
Se Jin, Lee, S-466
Seccombe, John, S-64
Seeberger, Esther, S-69, S-460,
S-461
Seeberger, Manfred, S-69,
S-460, S-461, S-463
ANESTH ANALG
2012; 114; S-01 – S-493
Seet, Edwin, S-244
Seidman, Peggy A., S-195
Sekhar, Pavan, S-212
Sellke, Frank W., S-34
Sen, Chaitali S., S-53
Serrao, Juliet M., S-415
Sessler, Daniel I., S-51
Shah, Jagdip, S-298
Shah, Shruti, S-333
Shah, Sujay, S-474
Shang, You,
S-161 - Withdrawn,
S-168 - Withdrawn
Shapiro, Fred E., S-03
Sharma, Ajeet D., S-64
Sharpe, Megan J., S-223, S-266,
S-272
Shaw, Pamela M., S-485
Shepherd, Adam N., S-01
Sheplock, George, S-235
Shernan, Stanton, S-52, S-67
Shiba, Ayako, S-05
Shih, Grace, S-327
Shillcutt, Sasha, S-55
Shilo, Dan, S-319
Shimaoka, Motomu, S-425
Shimizu, Keisuke, S-464
Shiokawa, Yoshiaki, S-196
Shroyer, Annie Laurie W., S-375
Shyam, Vidur, S-287, S-289
Siciliano, Alexandre, S-68
Sikka, Gautam, S-30
Silverberg, Michael B., S-04
Simon, Brett A., S-230
Sims, Nathaniel M., S-246
Sinner, Barbara, S-420
Smith, Andrew, S-317
Smith, Jessica C.,
S-473 - Withdrawn
Smul, Thorsten, S-27, S-35
Snider, Carolyn G., S-61
Snyder, Max, S-76
Soares de Moura, Roberto,
S-426
Soliman, Doreen E., S-393
Solina, Alann R., S-194
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-501
ABSTRACTS
Sonoda, Seijiro,
S-423 - Withdrawn
Soo, Janice, S-403
Soon Im, Kim, S-466
Soriano, Sulpicio G., S-406
Spahn, Donat R., S-216
Spina, Laurie, S-284
Springer, Timothy, S-425
Srivastava, Shashi, S-14
Stalker, Dennis, S-387
Stamper, Samantha, S-170
Stedje-Larsen, Eric T., S-473
Stehlikova, Zuzana, S-234
Steiger, Peter, S-216
Stenglein, John, S-03
Steppan, Jochen, S-30
Stevens, Tyler, S-05
Stewart, Deirdre, S-421, S-422,
S-438
Stiles, Katherine, S-327
Stojeba, Nathalie, S-255
Stol, Ilana S., S-200, S-256
Stoll, William D., S-364
Stowe, David F., S-38
Straker, Tracey, S-199
Strunk, Joseph, S-493
Studer, Wolfgang, S-461
Stumpner, Jan, S-35
Stypmann, Jörg, S-36, S-37,
S-435
Sugawara, Ami, S-373
Sullivan, Cornelius, S-215
Sumikawa, Koji, S-56
sun, huiping, S-302
Sun, Yanxia, S-361
Sundaram, Krishnamurthi,
S-457
Suzuki, Akihiro, S-249
Swaniker, Jasmine, S-456
Swetz, Keith M., S-203
SГЎndor, Katalin, S-431
SГёrensen, Martin K., S-214
T
Tabassum, Rabeena, S-330
Tahir, Naveed, S-212
Takahashi, Toru, S-253
Takahoko, Kenichi, S-452,
S-458
Takarada, Junko, S-372
Takasusuki, Toshifumi, S-346
Takeuchi, Risa, S-358
Tampo, Akihito, S-249
Tamura, Mariko, S-280
Tan, Josephine, S-403
Tan, Wen-fei,
S-308 - Withdrawn
Tanaka, Yoshiaki, S-448
Tang, Raymond, S-488, S-489
Tani, Shosei, S-192
Tanno, Masaru, S-448
Targ, Alex, S-181, S-182, S-247,
S-273, S-389
Tarr, Terence, S-210
Tarsha, Taj, S-217
Tateda, Takeshi, S-192
Taylor, Trevor, S-08
Tellides, George, S-47, S-50
Terada, Takashi, S-262, S-264,
S-265
Teramoto, Yuzo, S-193
Terao, Yoshiaki, S-56
Terasako, Kiyoshi, S-445
Terkawi, Abdullah S., S-330,
S-382
Thackeray, Elizabeth, S-234
Thanawala, Ruchi, S-73
Thangathurai, Duraiyah, S-58,
S-171
Theilmeier, Gregor, S-40, S-41
Theisen, Marc M., S-36, S-37,
S-432, S-435
Theofilos, Tykie, S-39
Thimmulappa, Rajesh, S-162
Thingnam, Shyam K., S-72
Tibirica, Eduardo, S-349
Tierney, Sarah, S-289
Tietge, Uwe, S-40
Tietge, Uwe J., S-41
Tischer-Zeitz, Tobias, S-35
Tiwari, Akhilesh K., S-315,
S-360
Tobias, Joseph D., S-382
ANESTH ANALG
2012; 114; S-01 – S-493
Toda, Masaya, S-165
Tokuda, Kentaro, S-163
Toleikis, Sandra C., S-357
Tomar, Gaurav S., S-315, S-360
Toyoda, Tomomi, S-56
traiyawong, ratchanee, S-478
Trehun, Swarn, S-476
Trettin, Hope, S-64
Tripathi, Ravi S., S-39
Tsai, Mitchell, S-204
Tse, James T.C., S-284, S-285
Tsui, Albert K., S-26
Tuman, Kenneth J., S-343,
S-350, S-374
Turan, Alparslan, S-51
Turner, Kim, S-274
U
Uchida, Ayako, S-424
Uchida, Masashi, S-280
Ueda, Kenichi, S-49
Uno, Toshihiro, S-464
Urban, Michael, S-312
Urman, Richard, S-03
Urner, Martin, S-166
Ushijima, Kazuo, S-429
V
Vaghadia, Himat, S-488, S-489
Van Haelst, Ingrid M.M., S-447
van Klei, Wilton A., S-447
Vargo, John, S-05
Vasquez, Jacqueline, S-213
Vasudevan, Armugam,
S-388 - Withdrawn
Velianou, James, S-62
Velraj, Jaya, S-335 - Withdrawn
Venkatraghavan, Lashmi,
S-310
Veuthey, Tess, S-437
Vinks, Alexander A., S-365
Vishwanath, Pallavi, S-75
Vogt-Harenkamp, Christiane,
S-167
Voloboueva, Ludmila A., S-321
Voralu, Kirtanaa, S-260
В©International Anesthesia Research Society. Unauthorized Use Prohibited.
S-502
ABSTRACTS
Voskanian, Steven J., S-58
Votta-Velis, E. Gina, S-417
W
Wagner, Christian, S-40
Wagner, Ross G., S-228
Wagner, Todd, S-20
Wall, Jonathan, S-291
Wallace, Austin F., S-493
Wanderer, Jonathan P., S-232
Wang, Angela, S-34
Wang, Guang-Zhi,
S-168 - Withdrawn
Wang, Helen, S-167
Wang, Huaiming, S-288
Wang, Li, S-311, S-313
wang, ming de, S-302
Wang, Nan, S-361
Wang, Xiao, S-288
Wani, Tariq M., S-382
Warriner, Brian, S-274
Wasowicz, Marcin, S-62
Watson, Charles B., S-207
Wax, David, S-487
Weavind, Liza M., S-270
Weber, Thomas P., S-36, S-37,
S-432, S-435
Weigel, Wade A., S-228
Weingarten, Toby, S-209
Weiss, Mona, S-216
Welch, Charles A., S-449
Werner, Claudia, S-69
West, Tenaya, S-389
Westenskow, Dwayne, S-430,
S-462
Widyn, James, S-225
Wijeysundera, Duminda N.,
S-62
Wijeysundera, Harindra C.,
S-62
Williams, Robert, S-390
Wilson, David F., S-28
Winik, Mark, S-254
Wisniewski, Thomas M., S-319
Wold, Courtney C.,
S-251 - Withdrawn
Wolf, Bethany J., S-364
Woodford, Stephen F., S-31,
S-32, S-60
Wu, Jiang, S-439
X
Xiong, Juyang,
S-186 - Withdrawn
Xiong, Zhigang, S-433
Xu, Jijun, S-439
Xu, Lijun, S-321
Xu, Zhonghuang, S-479
Y
Yaddanapuri, Laxminarayan,
S-72
Yaksh, Tony, S-346
Yamaguchi, Keisuke, S-434
Yamaguchi, Shigeki, S-346
Yamashita, Koichi, S-258
Yamashita, Miyoko, S-252
Yanaizumi, Ryota, S-248
Yang, Hui, S-439
Yang, Jinfeng, S-302
yang, jing, S-288
Yang, Zhe, S-363
Yang, Zhongjin, S-348
Yao, Shang-Long,
S-161 - Withdrawn,
S-168 - Withdrawn
Yarussi, Michelle, S-386
Yasuda, Yoshitaka, S-158
Yatabe, Tomoaki, S-258
Ye, JIngying, S-206
Yeh, Jia-Rong, S-267
Yen, Audrey, S-58
Yen, Christopher, S-204
Yin, Jonathan, S-74, S-75, S-219,
S-227
Yodh, Arjun, S-269
Yokomizo, Takehiko, S-165
Yokota, Miyuki, S-372
Yokoyama, Masataka, S-258
Yorozu, Tomoko, S-54, S-159,
S-196
Yoshida, Akari, S-12
Yoshida, Akiko, S-262, S-264,
S-265
ANESTH ANALG
2012; 114; S-01 – S-493
Yoshimura, Tatsuya, S-49
You, Jing, S-51
Yousif, Remone, S-348
Yu, Jingfang, S-490
Yu, Mei, S-404
Yue, Yun, S-361
Yuki, Koichi, S-425
Yusupov, Albert, S-59
Z
Zahoor, Abdul,
S-486 - Withdrawn
Zenfuku, Misako, S-477
Zhang, Bingxi, S-206
Zhang, Huiwei, S-288
Zhang, Jun, S-27
Zhang, Ning, S-416
Zhang, Xi, S-438
Zhang, Xiaoli, S-311, S-313
Zhang, Yanping, S-363
Zhao, Hong, S-362
Zheng, Laura, S-162
Zheng, Xiwen, S-263, S-456
Zhou, Quanhong, S-311, S-313
Zhu, Rebecca, S-399
Zhu, Yue, S-218
Zisa, Salvatore, S-333
Zook, Christopher M., S-357,
S-359
Zurek, Agnieszka, S-436
В©International Anesthesia Research Society. Unauthorized Use Prohibited.