Anesthetic Management of an Adult With Hyperekplexia Undergoing a Laparoscopic Colectomy: A Case Report.

Hyperekplexia is a rare genetic disorder characterized by an exaggerated startle response to innocuous stimuli. There are several case reports documenting the administration of general anesthesia to infants and children with hyperekplexia and 1 case report documenting the use of a labor epidural in a parturient. These cases suggest a possible resistance to depolarizing neuromuscular blocking agents and increased risk of malignant hyperthermia. There are no case reports of adults with hyperekplexia receiving general anesthesia. We report the case of a 20-year-old woman with hyperekplexia who safely received general anesthesia without neuromuscular blockade for a laparoscopic colectomy.

Anesthesia Considerations for Pregnant People With COVID-19 Infection.

The purpose of this review is to describe updates following initial recommendations on best anesthesia practices for obstetric patients with coronavirus disease 2019. The first surge in the United States prompted anesthesiologists to adapt workflows and reconsider obstetric anesthesia care, with emphasis on avoidance of general anesthesia, the benefit of early neuraxial labor analgesia, and prevention of emergent cesarean delivery whenever possible. While workflows have changed to allow sustained safety for obstetric patients and health care workers, it is notable that obstetric anesthesia protocols for labor and delivery have not significantly evolved since the first coronavirus disease 2019 wave.

Management of maternal COVID-19: considerations for anesthesiologists.

PURPOSE OF REVIEW: To describe updates to pragmatic recommendations that were published during the first coronavirus disease 2019 (COVID-19) surge, including the current thinking about whether pregnancy worsens the severity of COVID-19. RECENT FINDINGS: Although a majority of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain asymptomatic or paucisymptomatic, pregnancy puts women at higher risk of severe COVID-19 and adverse birth outcomes. Pregnant and recently pregnant women are more likely to be admitted to intensive care units and receive mechanical ventilation than nonpregnant patients with COVID-19, although preexisting maternal comorbidities are significant risk factors.Early provision of neuraxial labor analgesia with a functional indwelling epidural catheter has been universally promoted, with the goal to reduce avoidable general anesthesia for cesarean delivery and mitigate risks for healthcare workers during airway manipulation. This recommendation, along with updated workflow models of anesthesia coverage, may contribute to a reduction in general anesthesia rates. SUMMARY: Initial recommendations to provide early neuraxial labor analgesia and avoid general anesthesia for cesarean delivery have not changed over time. Although workflows have significantly changed to allow continued patient and healthcare workers' safety, clinical anesthesia protocols for labor and delivery are essentially the same.

What obstetricians should know about obstetric anesthesia during the COVID-19 pandemic.

The COVID-19 pandemic has prompted obstetric anesthesiologists to reconsider the ways in which basic anesthesia care is provided on the Labor and Delivery Unit. Suggested modifications include an added emphasis on avoiding general anesthesia, a strong encouragement to infected individuals to opt for early neuraxial analgesia, and the prevention of emergent cesarean delivery, whenever possible. Through team efforts, adopting these measures can have real effects on reducing the transmission of the viral illness and maintaining patient and caregiver safety in the labor room.

Neuro-anesthesiology in pregnancy.

Management of the pregnant patient requiring neurosurgery poses multiple challenges, juxtaposing pregnancy-specific considerations with that accompanying the safe provision of intracranial or spine surgery. There are no specific evidence-based recommendations, and case-by-case interdisciplinary discussions will guide informed decision-making about the timing of delivery vis-à-vis neurosurgery, the performance of cesarean delivery immediately before neurosurgery, consequences of neurosurgery on subsequent delivery, or even the optimal anesthetic modality for neurosurgery and/or cesarean delivery. In general, identifying whether increased intracranial pressure poses a risk for herniation is crucial before allowing neuraxial procedures. Modified rapid sequence induction with advanced airway approaches (videolaryngoscopic or fiberoptic) allows improved airway manipulation with reduced risks associated with endotracheal intubation of the obstetric airway. Currently, very few anesthetic drugs are avoided in the neurosurgical pregnant patient; however, ensuring access to critical care units for prolonged monitoring and assistance of the respiratory-compromised patient is necessary to ensure safe outcomes.

Neuraxial Morphine-Induced Hypothermia After Cesarean Delivery Managed With Nalbuphine: A Case Report.

Neuraxial morphine-induced hypothermia has been reported as a relatively rare complication, with the successful use of naloxone and lorazepam to reverse symptoms. We report a case of intrathecal morphine-induced hypothermia with profuse sweating, intractable nausea, and vomiting in a primigravid woman undergoing cesarean delivery in the setting of preeclampsia. All symptoms rapidly resolved after a single dose of intravenous nalbuphine. Because nalbuphine has a long track record of safe use on labor and delivery units, it is an attractive and novel choice for treatment of neuraxial morphine-induced hypothermia.

Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals.

Novel coronavirus disease 2019 is rapidly spreading throughout the New York metropolitan area since its first reported case on March 1, 2020. The state is now the epicenter of coronavirus disease 2019 outbreak in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early case series with 7 coronavirus disease 2019-positive pregnant patients, 2 of whom were diagnosed with coronavirus disease 2019 after an initial asymptomatic presentation. We now describe a series of 43 test-positive cases of coronavirus disease 2019 presenting to an affiliated pair of New York City hospitals for more than 2 weeks, from March 13, 2020, to March 27, 2020. A total of 14 patients (32.6%) presented without any coronavirus disease 2019-associated viral symptoms and were identified after they developed symptoms during admission or after the implementation of universal testing for all obstetric admissions on March 22. Among them, 10 patients (71.4%) developed symptoms of coronavirus disease 2019 over the course of their delivery admission or early after postpartum discharge. Of the other 29 patients (67.4%) who presented with symptomatic coronavirus disease 2019, 3 women ultimately required antenatal admission for viral symptoms, and another patient re-presented with worsening respiratory status requiring oxygen supplementation 6 days postpartum after a successful labor induction. There were no confirmed cases of coronavirus disease 2019 detected in neonates upon initial testing on the first day of life. Based on coronavirus disease 2019 disease severity characteristics by Wu and McGoogan, 37 women (86%) exhibited mild disease, 4 (9.3%) severe disease, and 2 (4.7%) critical disease; these percentages are similar to those described in nonpregnant adults with coronavirus disease 2019 (about 80% mild, 15% severe, and 5% critical disease).

Obstetric Anesthesia During the COVID-19 Pandemic.

With increasing numbers of coronavirus disease 2019 (COVID-19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States, preparation for the unpredictable setting of labor and delivery is paramount. The priorities are 2-fold in the management of obstetric patients with COVID-19 infection or persons under investigation (PUI): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). The goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the COVID-19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice.

Adding to the Denominator: A Case Report of Neuraxial Anesthesia for Cesarean Delivery in the Setting of Hemolysis, Elevated Liver Enzyme, Low Platelet, Thrombocytopenia, and Pulmonary Hypertension.

The acceptable platelet count for the safe provision of neuraxial anesthesia in obstetric patients is unknown. Comorbidities may sway a provider to perform neuraxial anesthesia, despite thrombocytopenia, as the putative risk of spinal-epidural hematoma may not outweigh the risks associated with general anesthesia. The case of a 22-year-old nulliparous woman undergoing a cesarean delivery with a new diagnosis of pulmonary hypertension and right heart failure, compounded with thrombocytopenia and possible Hemolysis, Elevated Liver Enzyme, and Low Platelet (HELLP) syndrome, is presented. Risks and benefits of general versus neuraxial anesthesia in this specific setting are reviewed.

Antagonists of the TMEM16A calcium-activated chloride channel modulate airway smooth muscle tone and intracellular calcium.

BACKGROUND: Perioperative bronchospasm refractory to ß agonists continues to challenge anesthesiologists and intensivists. The TMEM16A calcium-activated chloride channel modulates airway smooth muscle (ASM) contraction. The authors hypothesized that TMEM16A antagonists would relax ASM contraction by modulating membrane potential and calcium flux. METHODS: Human ASM, guinea pig tracheal rings, or mouse peripheral airways were contracted with acetylcholine or leukotriene D4 and then treated with the TMEM16A antagonists: benzbromarone, T16Ainh-A01, N-((4-methoxy)-2-naphthyl)-5-nitroanthranilic acid, or B25. In separate studies, guinea pig tracheal rings were contracted with acetylcholine and then exposed to increasing concentrations of isoproterenol (0.01 nM to 10 µM) ± benzbromarone. Plasma membrane potential and intracellular calcium concentrations were measured in human ASM cells. RESULTS: Benzbromarone was the most potent TMEM16A antagonist tested for relaxing an acetylcholine -induced contraction in guinea pig tracheal rings (n = 6). Further studies were carried out to investigate the clinical utility of benzbromarone. In human ASM, benzbromarone relaxed either an acetylcholine- or a leukotriene D4-induced contraction (n = 8). Benzbromarone was also effective in relaxing peripheral airways (n = 9) and potentiating relaxation by ß agonists (n = 5 to 10). In cellular mechanistic studies, benzbromarone hyperpolarized human ASM cells (n = 9 to 12) and attenuated intracellular calcium flux from both the plasma membrane and the sarcoplasmic reticulum (n = 6 to 12). CONCLUSION: TMEM16A antagonists work synergistically with ß agonists and through a novel pathway of interrupting ion flux at both the plasma membrane and sarcoplasmic reticulum to acutely relax human ASM.

Calcium-activated chloride channels anoctamin 1 and 2 promote murine uterine smooth muscle contractility.

OBJECTIVE: To determine the presence of calcium activated chloride channels anoctamin 1 (ANO1) and 2 (ANO2) in human and murine uterine smooth muscle (MUSM) and evaluate the physiologic role for these ion channels in murine myometrial contractility. STUDY DESIGN: We performed reverse transcription polymerase chain reaction to determine whether ANO1 and 2 are expressed in human and murine uterine tissue to validate the study of this protein in mouse models. Immunohistochemical staining of ANO1 and 2 was then performed to determine protein expression in murine myometrial tissue. The function of ANO1 and 2 in murine uterine tissue was evaluated using electrophysiologic studies, organ bath, and calcium flux experiments. RESULTS: ANO1 and 2 are expressed in human and MUSM cells. Functional studies show that selective antagonism of these channels promotes relaxation of spontaneous MUSM contractions. Blockade of ANO1 and 2 inhibits both agonist-induced and spontaneous transient inward currents and abolishes G-protein coupled receptor (oxytocin) mediated elevations in intracellular calcium. CONCLUSION: The calcium activated chloride channels ANO1 and 2 are present in human and murine myometrial tissue and may provide novel potential therapeutic targets to achieve effective tocolysis.

Retrospective audit of outcome of regional anesthesia for delivery in women with thrombocytopenia.

Regional anesthesia for pain at delivery in the presence of maternal thrombocytopenia is a clinical dilemma. We reviewed 10,369 obstetric cases (12 months) from our tertiary center. Generally, hemodilution of pregnancy does not result in thrombocyte counts of <150,000/mm(3) at delivery. A total of 166 births (1.6%) were recorded in women with thrombocytes <150,000/mm(3) at delivery. Parturients with >150,000/mm(3) at week 36 were separated post hoc (n=35; 21%) and the remaining parturients were divided as having <100,000/mm(3) (n=30; 18%) or 101,000-150,000/mm(3) (n=101; 60.5%). Epidural or spinal anesthesia was administered to 30% women with <100,000/mm(3) whereas 56% women with >101,000/mm(3) received these options (P=0.003). A total of 13.9% of parturients with trimester-long thrombocytopenia required blood products; 10/23 (43.5%) parturients undergoing cesarean section also required blood products (P=0.000). Four of six babies with Apgar scores of