The Role of Transcranial Doppler in Cerebral Vasospasm: A Literature Review.

Transcranial Doppler ultrasonography (TCD) is a noninvasive technique used to detect vasospasms following a subarachnoid hemorrhage. While the gold standard to evaluate vasospasms is angiography, this technique is invasive and poses additional risks as compared to TCD. TCD is performed by insonating circle of Willis arteries to measure cerebral flow velocity. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable; however, the performance of TCD is highly operator dependent and can be difficult, especially with inadequate acoustic windows. This review summarizes the use of transcranial Doppler ultrasonography (TCD) for the assessment of cerebral vasospasm.

A double-blind, randomized, multicenter, dose-ranging study to evaluate the safety and efficacy of fospropofol disodium as an intravenous sedative for colonoscopy in high-risk populations.

Fospropofol is a sedative hypnotic with a slower onset and longer duration of action. Fospropofol has demonstrated successful dose-dependent sedation at 6.5 mg/kg. This study evaluated the efficacy and safety of a lower weight-adjusted dose compared with the approved dose (4.875 or 6.5 mg/kg depending on patient subgroup) in high-risk elderly patients undergoing colonoscopy. In this study, 153 subjects were classified into 3 subgroups based on the following: age, weight, and American Society of Anesthesiologist (ASA) physical status criteria. The patients were randomized to the approved dose or weight-adjusted dose of fospropofol in a 1:1 ratio. Subgroup 1 (n = 50) consisted of patients weighing <60 kg, age 18-65 years, and ASA I or II; subgroup 2 (n = 50) consisted of patients weighing <60 kg; age 65 years and above, and ASA I-IV; and subgroup 3 (n = 53) consisted of patients weighing ≥60 kg, age 65 years and above, and ASA I-IV. Sedation, modified sedation and treatment success, and safety parameters were assessed. The approved dose had a significantly higher sedation success compared with the weight-adjusted dose: 96% versus 72% for subgroup 1; 84% versus 72% for subgroup 2; and 96% versus 67.9% for subgroup 3. There was a decreased need for alternative sedatives in subgroups 1 and 3 and fewer sedation- and treatment-emergent adverse events in all the subgroups for the approved dose. Additionally, sedation success data pooled across subgroups and examined based on age, weight, and ASA categories showed a significantly higher rate of sedation success in the approved dose arm across all the subgroups. The rate of sedation, modified sedation, and treatment success were higher in patients administered the approved dose for all the subgroups. No clinically significant advantage was demonstrated using a lower modified dose in this study population. The approved dose is recommended in the elderly, more obese, and high-risk patients when used for moderate sedation.

Retrospective Study of the Safety and Efficacy of Intraoperative Methadone for Pain Management in Patients Undergoing Elective Intracranial Surgery.

BACKGROUND: Patients undergoing intracranial surgery experience significant perioperative pain and are typically treated with short-acting opioids. Methadone, with its prolonged half-life and multimodal central nervous system effects, presents a promising option for managing postcraniotomy pain. Despite its proven efficacy in other types of surgeries, the use of methadone in patients undergoing craniotomy has not yet been explored. METHODS: A retrospective chart review was conducted for 60 adult patients ranging in age from 18 to 81 years who received methadone during intracranial surgeries. The primary outcome of interest was the total opioid consumption in oral morphine milligram equivalents (MMEs) and patient-reported pain scores within 24 hours and up to 72 hours postoperatively. RESULTS: The methadone dosage varied from 5 to 20 mg. In the infratentorial group, the median total MME on postoperative day 1, 2, and 3 was 30.5, 17, and 0.8, respectively, with mean pain scores of 3.56, 3.91, and 2.71. In the supratentorial group, the median total MME on postoperative day 1, 2, and 3 was 17.85, 15.4, and 1.2, with mean pain scores of 2.31, 1.68, and 2.21, respectively. Patients who were chronic opioid users had significantly higher pain scores and average opioid use (P < 0.05). None of the patients required administration of naloxone or airway interventions. Comparison with the historical control showed that our study patients had lower pain scores and MME. CONCLUSIONS: The single intraoperative dose of methadone is well tolerated by adult patients undergoing various types of intracranial surgeries, with minimal side effects, including elderly patients aged 65 years or older.

Evaluation of psychological impact of COVID-19 on anesthesiology residents in the United States.

The aim of our study was to evaluate the impact of COVID-19 on the mental health of in-training anesthesiology residents in the United States. A link containing validated survey tools including the Depression-Anxiety-Stress-Scale (DASS-21), the Abbreviated Maslach Burnout Inventory (aMBI), and the Brief Resilient Coping Scale (BRCS) along with questions related to work environment, and additional personal factors were emailed to 159 Anesthesiology residency programs across the US. 143 responses were received of which 111 were complete. The prevalence of depression, anxiety, stress and burnout was 42%, 24%, 31% and 71% respectively. Emotional exhaustion, depersonalization, and reduced feelings of personal accomplishment were experienced by 80%, 53%, and 65% of respondents, respectively. The BRCS scale showed 33% of respondents with low, 44% with moderate and 22% with high coping scales. Logistic regression analyses indicated those with a prior mental health diagnosis were 3 times more likely to have a non-normal DASS depression score, 4 times more likely to have a non-normal DASS anxiety score, and 11.74 times more prone to emotional exhaustion. Increased work hours and higher training levels were associated with increased levels of stress. In our survey, prior mental health illness, gender and increased work hours were the main drivers of increased risk.

Anesthetic Management of a Patient With a Ruptured Heterotopic Pregnancy for Emergency Exploratory Laparotomy.

Heterotopic pregnancy (HP) is an uncommon clinical condition characterized by the coexistence of intrauterine and extra-uterine pregnancies. HP is a diagnostic challenge as the typical methods for the early diagnosis of ectopic pregnancy are confounded by the simultaneous presence of intrauterine pregnancy (IUP). Ruptured HP is a potentially life-threatening obstetric emergency and can result in significant morbidity and mortality. Early diagnosis is the key to a favorable outcome. With the increasing number of patients undergoing artificial reproductive technology (ART), which is an important risk factor for HP, the odds of encountering HP patients are also growing. Anesthesiologists are challenged by the need to manage a bleeding obstetric patient while simultaneously ensuring the safety of the IUP. We present perioperative management of a patient with bleeding ruptured HP for emergency laparotomy who went on to have a successful twin delivery 37w3d via cesarean section.

Anesthetic Management of a Super Morbidly Obese Obstetric Patient With a Body Mass Index of 109 kg/m2 Presenting for Her Fourth Caesarean Delivery.

Morbidly obese obstetric patients undergoing anesthesia present many unique challenges. Previous caesarean sections (CSs) further complicate their management. We present the successful anesthetic management of a super morbidly obese obstetric patient with body mass index (BMI) of 109 kg/m2 who underwent her fourth CS. As per our review, this patient has the highest recorded BMI in the obstetric anesthesia literature. A 27-year-old female, G4P3003, presented for fourth repeat CS at 38 weeks' gestation. She had obstructive sleep apnea, hypertension, atrial fibrillation, and type 2 diabetes. Her first CS was emergent under general anesthesia (GA), and the other two were performed under neuraxial anesthesia, with the most recent one complicated by intraoperative cardiac arrest requiring cardiopulmonary resuscitation. Preoperative preparation involved multidisciplinary preparation, planning, and risk stratification. Although neuraxial anesthesia is preferred over GA for CS, she refused neuraxial anesthesia due to her prior traumatic experience and the potential that it caused her prior cardiac arrest. In addition, her inability to position for a block or lay flat, poor anatomical landmarks, unknown length of surgery, plan for periumbilical incision, uncertain placental status, and risk of massive hemorrhage convinced us to consider GA. Surprisingly, her airway examination was reassuring. Two 18G peripheral intravenous lines and an arterial line were obtained prior to induction. With optimum patient positioning and preoxygenation, modified rapid sequence induction with mask ventilation and endotracheal intubation with direct laryngoscopy were performed. A healthy baby was delivered without significant intraoperative complications. Intraoperative lung-protective strategy with recruitment maneuvers, multimodal analgesia, and elective postoperative continuous positive airway pressure aided in successful extubation. Postoperatively, pulmonary toilet, early mobilization, physical therapy, and venous thromboembolism prophylaxis were employed. Her postoperative course was complicated by severe preeclampsia and pulmonary embolism, which were managed successfully in the intensive care unit. She was discharged initially to outpatient rehabilitation followed by home. This case highlights the complexities and significance of an individualized approach in managing super morbidly obese obstetric patients.

Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations.

BACKGROUND: Although the safety and feasibility of awake craniotomy are well established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol. METHODS: A retrospective case series was performed on 7 patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection. RESULTS: Six patients had intracranial AVMs, and 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway. CONCLUSIONS: Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.

Mechanisms of valve competency after mitral valve annuloplasty for ischaemic mitral regurgitation using the Geoform ring: insights from three-dimensional echocardiography.

AIMS: Left ventricular remodelling leads to functional mitral regurgitation resulting from annular dilatation, leaflet tethering, tenting, and decreased leaflet coaptation. Mitral valve annuloplasty restores valve competency, improving the patient's functional status and ventricular function. This study was designed to evaluate the mechanisms underlying mitral valve competency after the implantation of a Geoform annuloplasty ring using three-dimensional (3D) echocardiography. METHODS AND RESULTS: Seven patients (mean age of 65 years) with ischaemic mitral regurgitation underwent mitral valve annuloplasty with the Geoform ring and coronary artery bypass surgery. Pre- and post-operative 3D echocardiograms were performed. Following mitral annuloplasty, mitral regurgitation decreased from 3.4+/-0.2 to 0.9+/-0.3 (P-value<0.0001), mitral valve tenting volume from 13+/-1.7 to 3.2+/-0.3 mL (P-value<0.001), annulus area from 12.6+/-1.0 to 3.3+/-0.2 cm2 (P-value<0.0001), valve circumference from 13+/-0.5 to 7.3+/-0.3 cm (P-value<0.0001), septolateral distance from 2.1+/-0.1 to 1.4+/-0.06 cm (P-value<0.01) and intercommissural distance from 3.4+/-0.1 to 2.7+/-0.03 cm (P-value<0.03). There was significant decrease in the septolateral distance at the level of A2-P2 with respect to other regions. These geometric changes were associated with the improvement in the NYHA class from 3.1+/-0.3 to 1.3+/-0.3 (P-value<0.002). CONCLUSION: The mitral valve annuloplasty with the Geoform ring restores leaflet coaptation and eliminates mitral regurgitation by effectively modifying the mitral annular geometry.

Three-dimensional echocardiographic evaluation of an incidental quadricuspid aortic valve.

BACKGROUND: Quadricuspid aortic valve is one of the rare forms of congenital cardiac valvular disease. Its diagnosis is often missed, even with the transthoracic echocardiogram. Many of these patients progress to aortic incompetence later in life requiring surgical intervention. In addition, quadricuspid aortic valve can be associated with other congenital cardiac deformities. Hence early recognition and follow-up is critical in these patients. CASE PRESENTATION: We report a patient with quadricuspid aortic valve identified on intraoperative transesophageal 3-D echocardiography. This 66-year-old male presented with the features of congestive heart failure. The preoperative transthoracic echocardiogram (TTE) disclosed, moderately severe aortic valve insufficiency along with severe mitral and tricuspid regurgitation, but failed to reveal the quadricuspid anomaly of the aortic valve. Interestingly, this patient had undergone transthoracic echocardiography on two previous occasions during the past seven years for the evaluation of his valvular heart disease, which all failed to document this anomaly. Intraoperatively, transesophageal echocardiography (TEE) displayed an aortic valve composed of three medium and one small cusps. CONCLUSION: Our patient's case demonstrates the usefulness of transesophageal echocardiography in detection of this uncommon congenital malformation.

Epidural Labor Analgesia for a Patient with Neuromyelitis Optica: A Case Report and Review of the Literature.

Neuromyelitis optica (NMO) is a rare demyelinating disorder affecting the spinal cord and optic nerves. Like multiple sclerosis (MS), it predominantly affects women during childbearing years. The impact of neuraxial anesthesia on the course of NMO is uncertain. There are no large studies available to draw definitive conclusions regarding the safety of neuraxial anesthesia in this population. A review of the current literature suggests that neuraxial anesthesia is unlikely to exacerbate neurologic symptoms in pregnant patients with NMO. However, given the rarity of this disease entity among patients requesting epidural labor analgesia, we recommend taking a cautious approach.

Case Report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery.

Trauma is estimated to complicate approximately one in twelve pregnancies, and is currently a leading non-obstetric cause of maternal death. Pregnant trauma patients requiring non-obstetric surgery pose a number of challenges for anesthesiologists. Here we present the successful perioperative management of a pregnant trauma patient with multiple injuries including occult pneumothorax who underwent T9 to L1 fusion in prone position, and address the pertinent perioperative anesthetic considerations and management.

Successful perioperative management of a patient with the left ventricular assist device for brain tumor resection: case report and review of the literature.

Heart failure is the leading cause of death in the United States. Our increasingly aged population will contribute to an increased incidence and prevalence of heart failure, thereby augmenting the need for mechanical circulatory devices. Here we present the first successful resection of a brain tumor in a left ventricular device- (LVAD-) dependent patient with increased intracranial pressure and address pertinent perioperative anesthetic considerations and management.

Negative pressure pulmonary edema with laryngeal mask airway use: Recognition, pathophysiology and treatment modalities.

Negative pressure pulmonary edema (NPPE) following the use of the laryngeal mask airway (LMA) is an uncommon and under-reported event. We present a case of a 58-year-old male, who developed NPPE following LMA use. After biting vigorously on his LMA, the patient developed stridor upon emergence, with concurrent appearance of blood-tinged, frothy sputum and pulmonary edema. He subsequently required three days of mechanical ventilation. After discontinuation of mechanical ventilation the patient continued to require additional pulmonary support using continuous positive airway pressure, with a full facemask, to correct the persistent hypoxemia. His roentgenographic findings demonstrated an accelerated improvement with judicious administration of intravenous furosemide.

Efficacy of chordal cutting in alleviating ischemic mitral regurgitation: insights from 3-dimensional echocardiography.

BACKGROUND: Ischemic mitral regurgitation often complicates severe ischemic heart disease and adversely affects the prognosis in these patients. There is wide variation in the clinical spectrum of ischemic mitral regurgitation due to varying location and chronicity of ischemia and anomalies in annular and ventricular remodeling. As a result, there is lack of consensus in treating these patients. Treatment has to be individualized for each patient. Most of the available surgical options do not consistently correct this condition in all the patients. Chordal cutting is one of the newer surgical approaches in which cutting a limited number of critically positioned basal chordae have found success by relieving the leaflet tethering and thereby improving the coaptation of leaflets. Three-dimensional echocardiography is a potentially valuable tool in identifying the specific pattern of tethering and thus the suitability of this procedure in a given clinical scenario. CASE PRESENTATION: A 66-year-old man with cardiomyopathy and ischemic mitral regurgitation presented to us with the features of congestive heart failure. The three-dimensional echocardiography revealed severe mitral regurgitation associated with the tethering of the lateral (P1) and medial (P3) scallops of the posterior leaflet of the mitral valve due to secondary chordal attachments. The ejection fraction was only 15% with severe global systolic and diastolic dysfunction. Mitral regurgitation was successfully corrected with mitral annuloplasty and resection of the secondary chordae tethering the medial and lateral scallops of the posterior leaflet of the mitral valve. CONCLUSION: Cutting the second order chordae along with mitral annuloplasty could be a novel method to remedy Ischemic mitral regurgitation by relieving the tethering of the valve leaflets. The preoperative three-dimensional echocardiography should be considered in all patients with Ischemic mitral regurgitation to assess the complex three-dimensional interactions between the mitral valve apparatus and the left ventricle. This aids in timely surgical planning.