Faculty Bibliography

Although most clinicians would agree comprehensive assessment of a wound patient is important, not all know the importance of including cardiac device interrogation as part of the standard preoperative evaluation. Using clinical exemplars, the authors highlight key concepts to raise awareness among wound colleagues of this important patient safety concern.

Introduction : With the increase in anesthesia utilization in the electrophysiology laboratory, there is greater potential for arrhythmia suppression during electrophysiology study. Intravenous isoproterenol is frequently used to counteract the significant antiadrenergic impact of anesthesia, as well as induce arrhythmias and identify reconnection of pulmonary vein conduction. The effects of isoproterenol on cerebral and respiratory function during the sedated state have not been well studied. The Bispectral (BIS) Vista TM Monitor is a non-invasive device that measures electrical activity of the brain and computes a BIS value, which corresponds to a level of consciousness. The purpose of this study was to determine changes in BIS values during isoproterenol administration. Methods : Twenty consecutive patients underwent electrophysiology study under total intravenous anesthesia using propofol and remifentanil infusions. Isoproterenol was infused at a rate of 5mcg/kg/min and escalated to up to 20mcg/kg/min over 20 minutes. BIS levels were recorded before and throughout isoproterenol administration. Results : Patients demonstrated significant elevation in BIS value during isoproterenol infusion. The mean difference between pre- and post- BIS values was 21.3 [5.4, 37.2] (p = 0.00013). The isoproterenol doses which triggered a BIS spike ranged from 10.8 mcg to 90.8 mcg. The median effective isoproternol dose was 25.2 mcg. The median onset time for an isoproternol stimulated BIS spike was 6.9 minutes with rates from 2 to 20 mcg/minute. Discussion : Isoproterenol significantly increases BIS values during sedated electrophysiology study. Monitoring BIS values may be helpful in assessing the isoproterenol dosage required to overcome the suppressive effects of anesthesia on arrhythmia induction, as well as the potential need for additional anesthetics to prevent patient arousal. Conversely, decreasing BIS values are known to correlate with hypotensive episodes signaling cerebral hypoperfusion. This may be relevant in cases of hemodynamically unstable tachycardias. BIS appears to be an important tool for the optimization of anesthesia when isoproterenol is administered during electrophysiology study

Introduction : Rapid infusion devices are becoming increasingly popular for the administration of warm fluids and blood in hypovolemic patients. A recently developed system, Thermacor 1200 (Smisson-Cartledge Biomedical LLC, Macon, GA), consists of a central device to which a disposable cartridge of fluid lines attaches. Performance characteristics of this device have yet to be evaluated. We compared the Thermacor 1200 with a currently utilized infusion device, FMS 2000 (Belmont Instrument Corp., Billerica, MA), to evaluate maximum flow rates, accuracy of actual versus set flow rates, fluid warming capabilities, and air bubble elimination. Methods : A ThermaCor 1200 and an FMS 2000, owned by our institution, were evaluated in vitro after being tested for proper functioning. FMS 2000 was tested with the packaged 4.5ft patient line, and Thermacor 1200 with packaged 3ft (TC3) and 6ft (TC6) patient lines. Maximum flow rates of lactated Ringer's (LR) and expired packed red blood cells (PRBCs) were measured with 22, 20, 18, 16, 14 and 8.5F gauge catheters, using a graduated cylinder and stopwatch. Flow rate accuracy was determined by comparing the actual versus displayed flow rates, for LR and PRBCs. Temperature was measured, at various flow rates, with an electronic probe (Wavetek 23XT, San Diego, CA) positioned 3cm from the distal port of the outflow tubing, for LR and PRBCs. Air elimination capability was determined, for LR only, by infusing fluid into an inverted 20mL syringe submerged in a bucket of water, and measuring the resulting air trapped in the syringe. All measurements were repeated six times. Data were analyzed using one-factor ANOVA, and the Tukey multiple comparisons method. Statistical significance was defined as p<0.05. Results : Maximum flow rates were higher with TC3 and TC6 than with FMS 2000 in most instances, especially when using larger catheter bores (Table 1). Flow rates were more accurate with TC3 and TC6 than with FMS 2000 for LR (1.4, 1.6, and 3.5% variance from target rate, respectively; p<.001) and for PRBCs (2.1, 2.6, and 5.9% variance from target rate, respectively; p<.001). Temperatures of delivered fluid were higher with TC3 and TC6 as compared to the FMS 2000 for LR (38.0, 37.8, and 36.8degreeC. respectively; p<.001) and PRBCs (38.2, 38.1, and 37.2degreeC, respectively; p<.001). Air was not detected in fluid infused from either device. Discussion : In this experiment, the performance of the Thermacor 1200, at both lengths of patient line, was superior to that of the FMS 2000 in that it infused LR and PRBCs at higher and more accurate flow rates, at higher temperatures. (Table presented)

Wound patients commonly have multiple comorbidities, which should be optimized before anesthesia. These factors contribute not only to skin breakdown but also other causes of mortality and morbidity. Skin becomes more vulnerable to damage from pressure, friction, shear, and moisture when the skin is dry, less elastic, and less perfused. Careful assessment and implementation of an anesthetic plan using regional or general techniques can improve outcomes. The anesthesiologist plays a vital role in maintaining homeostasis during the surgically stressful perioperative period of the wound patient. Aggressive wound management in the early stages is likely to prevent wound progression to deeper levels. Policies are being implemented to decrease the risk of pressure ulcers by prevention

BACKGROUND:The ACGME has proposed changes to the curriculum for anesthesia residents. These changes include increasing critical care from 2 to 4 months, pain from 1 to 3 months, and obstetrics, pediatric, neuroanesthesia, and cardio thoracic anesthesia from 1 to 2 months. In addition, they have included a preoperative clinic for 1 month. METHODS:With IRB approval, a survey of the anesthesia residents at New York University was distributed. The residents questioned ranged from the CA-1 to the Ca-3 class. The survey questioned the residents on their current curriculum and the proposed changes. RESULTS:22 Residents completed the questionnaire. Seventy-seven percent of the residents polled felt they had enough experience in critical care with the current requirements and 82% did not want the increase to 4 months (p=0.007). Seventy-three percent of the residents responded that their pain management exposure was sufficient and 82% did not want it increased (p=0.011). Overwhelmingly, 82% of those polled felt an entire month of preoperative clinic was not necessary. Seventy-three percent of those residents polled would not be comfortable on subspecialty rotations as early as August of their CA-1 year. 82% felt that too much of their training would be spent outside of the operating room, and the majority (59%) thought more residents would be on each rotation. Moreover, 55% think that the proposed changes will adversely affect residents in training. DISCUSSION/CONCLUSIONS:The results of this survey demonstrate that most residents at New York University do not think the current curriculum should change. The majority opinion is that it will negative impact their education.

OBJECTIVE: To assess the skills of anesthesiologists in the interpretation of chest radiographs. DESIGN: Randomized evaluation conducted among anesthesiologists and radiologists. SETTING: Postgraduate Assembly of the New York State Society of Anesthesiologists in 1999, and the Department of Radiology, New York University Medical Center. PARTICIPANTS: A total of 61 anesthesiologists (48 attending physicians; 13 residents); control group of 8 radiology residents (all participants volunteered). INTERVENTIONS: After completing a demographic survey, participants were asked to review a series of 10 chest radiographs. A brief clinical scenario accompanied each radiograph. No time limit was set for these interpretations. Measurements and Main Results: The demographic characteristics of the anesthesiology participants included university faculty (46%), private group practitioners (41%), independent practitioners (11%), and 1 participant with an unspecified type of practice. Additional training among the participants included internal medicine (31%), surgery (19%), and pediatrics (3%); 34% did not specify any additional training. Of the participants, 92% were involved in cases requiring general anesthesia; 96% managed patients in the recovery room; and 34% managed patients in the intensive care unit. Of participants, 80% usually order chest radiographs, but only 42% interpret the films themselves. Misdiagnosed radiographs included pneumothorax by 11% of participants, free air under the diaphragm by 41%, bronchial perforation from a nasogastric tube by 28%, right mainstem intubation by 20%, superior vena cava perforation from a central venous catheter by 31%, normal film by 75%, negative pressure pulmonary edema by 16%, left lower lobe collapse by 80%, pulmonary infarction from a pulmonary artery catheter by 29%, and tension pneumothorax by 41%. Overall scores of the attending physicians were not significantly different from that of residents (p > 0.05). The control group of radiology residents scored significantly better (mean, 83.7; p = 0.009) than the anesthesia residents (mean, 62.8) and anesthesia attending physicians (mean, 62.5). CONCLUSION: Anesthesiologists are deficient in skills for the interpretation of chest radiographs. The skill level of university-based physicians is not greater than physicians in private practice, and skill level does not improve with level of training or experience. Most anesthesiologists rely on radiologists for interpretative results. Further training during the residency years may help improve diagnostic skills

Objective. Postoperative intravenous (IV) versus epidural morphine patient-controlled analgesia (PCA) were compared regarding maintenance of initial PCA route, pain levels, side effects, and levels of satisfaction. Additionally, the role of preoperative attitudinal expectations in predicting postoperative levels of satisfaction with pain management as well as maintenance of initial PCA route was evaluated. Design. After either abdominal or thoracic surgery, 70 eligible patients were randomized to receive morphine either through an epidural route (n = 37) or an intravenous PCA pump (n = 33). Setting. A large tertiary university teaching hospital in a major northeastern city. Outcome measures. Patients completed visual analogue rating scales 1 week before surgery regarding attitudes such as expectations of satisfaction with pain management after surgery and expectations of medication efficacy postsurgically. Postoperatively, beginning the day after surgery, patients were asked to complete visual analogue rating scales every 12 hours until they were discharged, for a maximum of 3 postoperative days. The scales evaluated included pain, ability to think, and satisfaction with pain control. Results. There were no significant between-group differences on the postoperative visual analogue scales. Although the overall rate of changing the initial PCA route to which the patients were randomized was identical for both groups (30%), those patients who had thoracic surgery changed their route of PCA administration significantly less when their initial PCA route was epidural (20%) than when their initial PCA route was IV (46%) (P <.05). Patients who were satisfied with pain control postoperatively were more likely to have been started on IV PCA (P =.001), have lower preoperative expectations of postoperative satisfaction with pain (P <.001), and have higher preoperative expectations of medication effects on postoperative pain (P <.001). Additionally, older patients (P =.007) and patients with lower preoperative expectations of postoperative satisfaction with pain (P =.003) were more likely to adhere to their initial treatment protocol. Conclusions. Both techniques, IV and epidural PCA, result in high levels of satisfaction. Satisfaction with PCA can be accurately predicted in nearly three of four patients based on initial PCA route and preoperative attitudes. Additionally, maintaining the initial treatment plan can be accurately predicted based on age and preoperative attitudes. Patient expectations about pain relief should be addressed preoperatively, particularly with younger patients, for optimal results