Faculty Bibliography

INTRODUCTION: Serum troponin levels are employed as sensitive markers of perioperative ischemia and/or infarction and result in elevated levels 2-4 hours after myocyte damage, and peak at approximately 12 hours. This measurement is insightful, as ischemia may be subclinical in the perioperative period. Reportedly, infarcts occur 24-48 hours postoperatively. However, we sought to examine this and determine the specific incidence and time period when troponin elevations occurred in our patient population. This data is useful to direct our perioperative specialists when and where to focus increased scrutiny. METHODS: With IRB approval, a retrospective analysis of 44,800 cases during 2013 and the first quarter of 2014 were reviewed to determine if and when troponins were elevated during the perioperative period. All cases were performed at NYU Langone Medical Center with cardiac surgical cases excluded. Surgical services which did not send any troponin values during the course of the study were also excluded. Specifically, time to peak troponin and which surgical service was performing the operation was evaluated. RESULTS: A total of 44,800 non cardiac cases were performed over 2013 and the first quarter of 2014. Troponins were drawn on 3736 patients with 633 cases having a positive troponin. Vascular surgery was the surgical department with the highest percentage of cases having a positive troponin (15%). 13% of troponins peaked immediately post op while 47% of peak troponins occurred greater than 24 hours after departing the operating room. The distribution of positive troponins by service is shown in the pie chart. Ortho Spine & Joints are over-weighted because of the high volume of cases (> 15% of all cases). CONCLUSIONS: Our results confirm a significant intra-operative risk with a majority of peak troponins in the first 24 hours (peak time 12-16 hours after surgery), and an elevated incidence out to 48 hours. There may be an artifact in clustering of times due to fixed collection times for blood samples. As perioperative specialists, knowing when ischemia occurs and which patients are at high risk for having positive troponins will allow us to conduct future studies aimed at preventing and limiting the morbidity and mortality from myocardial ischemia. This study provides quantitative measures of the relative risk of various types of surgery and the timing of myocardial damage in the perioperative period

OBJECTIVES: : To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. DESIGN: : Institutional Review Board approved prospective randomized study. SETTING: : Metropolitan tertiary-care referral center. PATIENTS: : All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. INTERVENTIONS: : Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. MAIN OUTCOME MEASURES: : Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. RESULTS: : Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. CONCLUSIONS: : Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control. LEVEL OF EVIDENCE: : Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE: Ultrasound technology has been applied to increase both efficacy and safety of certain peripheral nerve blocks. This case report describes the first successful ultrasound-guided lumber plexus block. CLINICAL FEATURES: We describe a 91-year-old woman with aortic stenosis who successfully underwent open reduction and internal fixation of a fractured right hip with a lumbar plexus block. Ultrasound provided direct visualization to help identify the anatomical structures and guide the block needle during performance of the block. Complete block of the lumbar plexus was attained within 15 min, and the surgical procedure was performed uneventfully. CONCLUSION: The use of ultrasound has gained popularity to perform peripheral nerve blocks. In this case report, a successful lumbar plexus block was performed with ultrasound guidance. By direct visualization, using this technology may potentially reduce complications associated with lumbar plexus blocks