Normal Saline and Dextrose 5% in Water Do Not Support Bacterial Growth 24 Hours After Being Spiked in the Perioperative Environment.

BACKGROUND: The Joint Commission requirement is that the US Pharmacopeia Chapter <797> is followed, which recommends that administration of compounded sterile preparations should begin no later than 1 hour after their preparation. We hypothesized that simply spiking the IV fluid in a nonsterile environment does not pose an increased risk of infection to the patient. METHODS: Two 1000-mL bags of IV fluid (normal saline and dextrose 5% in water) were spiked and hung in 5 busy perioperative locations, once a week for a 13-week period. A 10-mL sample was drawn from each bag of IV fluid at time zero and 24 hours resulting in 260 samples in total. All samples were inoculated in 2 separate growth media (sheep's blood agar and thioglycollate broth). The primary outcome was growth versus no growth in any of the specimens. If any growth was noted, the sample was marked as positive and further testing to identify the organism was undertaken. RESULTS: A total of 257 samples (normal saline = 127, dextrose 5% in water = 129) were collected over a period of 13 weeks, yielding 514 specimens. Three samples were excluded from the study secondary to the IV bags being discarded accidentally. No growth was identified in any of the specimens. The 97.5% CIs were as follows: normal saline = 127 (0-0.034) and dextrose 5% in water = 129 (0-0.033), correcting for multiple tests. CONCLUSIONS: No bacterial growth was noted in any of the 257 samples collected. Normal saline and dextrose 5% in water do not support bacterial growth 24 hours after their preparation using standard sterile techniques in the perioperative space.

How Long Is Too Long? The Prespiked Intravenous Debate.

BACKGROUND: As the number of operative cases increases, there is a greater emphasis on reducing inefficiency while maintaining patient safety. Recently, the issue of prespiking intravenous (IV) bags was raised. No study has assessed whether the risk of infection is related to the length of time a sterile (IV) fluid bag has been spiked. After completion of a pilot study revealed no microbial growth within 24 hours of an IV spike, a larger formal study was undertaken to determine whether there was an increased infection risk within 4 hours of spiking an intravenous fluid bag. METHODS: Five IV administration sets were spiked and hung in busy perioperative areas once a week for a 5-week period. Five samples were drawn from each IV set. Approximately 10 mL was collected per sample. All samples were inoculated in 2 separate growth media. If any growth was noted, the sample was marked as positive. RESULTS: A total of 125 samples were collected over a period of 5 weeks, yielding 250 specimens. No samples were excluded from the study. No growth was identified in any of the specimens. The 95% confidence interval was estimated to be 0, 0.063. DISCUSSION: There was no bacterial growth in prespiked normal saline IV bags in a perioperative environment. Thus, prespiking of normal saline IV bags in advance should pose no risk of infection to a patient if prepared within 4 hours.

Premedication with Intravenous Ibuprofen Improves Recovery Characteristics and Stress Response in Adults Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

OBJECTIVES: Examine the effect of preoperative dose of IV ibuprofen on stress response and postoperative recovery in laparoscopic cholecystectomy patients. DESIGN: Prospective, randomized, controlled, double-blind, multicenter trial. SETTING: Three university-based, tertiary care hospitals. SUBJECTS: Fifty-five adults, ASA 1, 2, or 3 scheduled for laparoscopic cholecystectomy were given a single preoperative dose of placebo or IV ibuprofen 800 mg. METHODS: Neurobehavioral assessments were evaluated preoperatively, in PACU, POD 1, and POD 3, using the 40-item Quality of Recovery questionnaire (QoR40), 9-item Modified Fatigue Severity Scale (MFSS), and 15-item Geriatric Depression scale (GDS). Blood samples were taken for cytokines (TNF-alpha, IL-1ß, IL-2, IL-6, IL-10, IFNγ), cortisol, CRP, epinephrine, and norepinephrine prior to the administration of study drug/placebo, intraoperatively, and after surgery. RESULTS: Global QoR40 scores remained at baseline for ibuprofen patients but significantly decreased in the placebo group. Severity of fatigue increased in patients receiving placebo but had no change with ibuprofen. The placebo group had lower GDS scores on POD 3. Epinephrine and norepinephrine were significantly lower intraoperatively for the ibuprofen group. Cortisol decreased postoperatively in the ibuprofen group. There was an impact of drug treatment on the immune response, as seen by an increase in TNFα and an increase in IL-10 when compared with placebo. CONCLUSIONS: Our results suggest the addition of NSAIDs may improve the overall quality of recovery, postsurgical fatigue, and early postoperative outcomes. Preoperative administration of IV ibuprofen modulates the stress and inflammatory response, as demonstrated by a decrease in the level of catecholamines, cortisol, and cytokines. TRIAL REGISTRATION: Clinicaltrials.gov identifier: 01938040.

Mistaken Endobronchial Placement of a Nasogastric Tube During Mandibular Fracture Surgery.

A 64-year-old male had an awake right nasal fiber-optic intubation with an endotracheal tube for open reduction and internal fixation of bilateral displaced mandibular fractures. After induction of anesthesia, an 18 Fr nasogastric tube (NGT) was inserted through the left nostril and was secured. The patient required high flow rates to deliver adequate tidal volumes with the ventilator. A chest x-ray done in the postanesthesia care unit revealed a malpositioned NGT in the left lower lobe bronchus, which was immediately removed. The patient was extubated on postoperative day 2. Various traditional methods, such as aspiration of gastric contents, auscultation of gastric insufflations, and chest x-ray are in use to detect or prevent the misplacement of an NGT. These methods can be unreliable or impractical. Use of capnography to detect an improperly placed NGT should be considered in the operating room as a simple, cost-effective method with high sensitivity to prevent possibly serious sequelae of an NGT placed within the bronchial tree.

Impact of regional versus general anesthesia on the clinical outcomes of patients undergoing major lower extremity amputation.

BACKGROUND: Patients undergoing major lower extremity amputation (MLEA) for peripheral arterial disease are often elderly, debilitated, and fraught with medical comorbid conditions that place them at high risk for surgical intervention. Data from lower extremity revascularization surgeries are often extrapolated to determine which anesthetic modality to use for amputations, with preference given to regional anesthesia. However, there is little evidence to support the use of one mode of anesthesia over another. We conducted this study to determine the effect of anesthetic modality on the clinical outcomes of patients undergoing above- or below-knee amputations. METHODS: This study is a retrospective review of consecutive patients who underwent MLEA at a single center between 2002-2011. The study population was divided into 2 groups based on anesthetic modality (i.e., regional vs. general anesthesia). These groups were compared based on demographics and comorbidities. Major outcomes analyzed included death, myocardial infarction (MI), and pulmonary complications. Secondary outcome measures included cardiac arrhythmias, venous thromboembolism (VTE), and duration of stay in the intensive care unit and hospital. RESULTS: Four hundred sixty-three patients were identified; 56 patients were excluded for incomplete data, leaving 407 patients in the 2 groups combined. Of these, 259 patients underwent amputation under regional anesthesia; 148 underwent amputation under general anesthesia. Patients in the regional anesthesia group were older (76.6 vs. 71.6 years; P=0.001) and had a lower body mass index (25.2 vs. 26.9 kg/m2; P=0.013). They were also less likely to be on preoperative antiplatelet therapy (aspirin or clopidogrel) or anticoagulation (27% vs. 45%; P<0.001). Regional anesthesia was associated with a lower incidence of overall postoperative pulmonary complications (15% vs. 24%; P=0.02) and postoperative arrhythmia (14% vs. 25%; P=0.001). Duration of stay in the intensive care unit (1.92 vs. 3.85 days; P=0.001) and hospital (19.4 vs 23.1 days; P=0.037) were significantly longer in the group receiving general anesthesia. No significant differences in postoperative MI (12% vs. 9%; P=not significant [NS]), VTE (5% vs. 7%; P=NS) or mortality (10% vs. 13%; P=NS) was seen between groups. Controlling for procedure, above- versus below-knee amputation did not significantly alter these results. CONCLUSIONS: Regional anesthesia for patients undergoing MLEA is associated with a lower incidence of postoperative pulmonary complications and cardiac arrhythmias. It is also associated with lower resource use. As such, regional anesthesia should likely be the favored anesthetic modality for patients undergoing MLEA.

A Novel Makeshift Method to Collect Leaking Epidural Fluid: A Case Report.

A healthy 34-year-old full-term parturient was admitted to the labor suite where a combined spinal-epidural (CSE) was easily placed on the first attempt for labor analgesia. After an uneventful delivery, the epidural catheter was removed. Two days later, the patient experienced a fluid leak from the puncture site. The fluid was analyzed to determine whether it was an interstitial or a cerebrospinal fluid (CSF). We describe a novel technique to collect the leaking fluid without admixing fluid from the surrounding area. No previous reports describe a similar technique to diagnose the source of this questionable fluid leak.

Pulseless electrical activity during electroconvulsive therapy: a case report.

BACKGROUND: Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy. CASE PRESENTATION: We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre. CONCLUSION: We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.

Ultrasensitive detection of low-abundance surface-marker protein using isothermal rolling circle amplification in a microfluidic nanoliter platform.

With advances in immunology and cancer biology, there is an unmet need for increasingly sensitive systems to monitor the expression of specific cell markers for the development of new diagnostic and therapeutic tools. To address this challenge, a highly sensitive labeling method that translates antigen-antibody recognition processes into DNA detection events that can be greatly amplified via isothermal rolling circle amplification (RCA) is applied. By merging the single-molecule detection power of RCA reactions with microfluidic technology, it is demonstrated that the identification of specific protein markers can be achieved on tumor-cell surfaces in miniaturized nanoliter reaction droplets. Furthermore, this combined approach of signal amplification in a microfluidic format could extend the utility of existing methods by reducing sample and reagent consumption and enhancing the sensitivities and specificities for various applications, including early diagnosis of cancer.

Labor Epidural in a Patient Who is Allergic to Lidocaine: A Case Series.

Continuous epidural anesthesia is considered the best modality for pain relief during labor, local anesthetic allergy is an uncommon occurrence but if a patient has an allergy to bupivacaine or lidocaine owing to its cross-reactivity with bupivacaine then it becomes very challenging to manage labor analgesia. A direct challenge test to rule out actual hypersensitivity was not considered a viable option given the risks involved if a severe allergic reaction occurred with the test dose. Using IV opioid-based analgesia has harmful effects for both mother and the baby in addition to decreasing participation of mothers in the birthing process owing to its sedative properties. We report two cases where the mother had a history of lidocaine allergy, so labor analgesia was managed using chloroprocaine patient-controlled epidural analgesia (PCEA).

Left Lower Lung Collapse in a Patient Undergoing Endoscopic Procedure.

ASA closed claims from 2000 to 2009 have shown that adverse respiratory events are more common in nonoperating room locations like endoscopy suite than in the operating room (44% v/s 20%). Here, we report a case of lung atelectasis which resulted in hypoxemia in a malnourished patient undergoing endoscopic procedure. It is crucial to identify the high-risk patients and monitor them appropriately in the postoperative phase. Continuous capnometry may offer additional benefit by identifying hypercapnia, hypoventilation at the earliest in the recovery area, thus preventing serious complications.

Perioperative Automated Noninvasive Blood Pressure- (NIBP-) Related Peripheral Nerve Injuries: An Anesthetist's Dilemma-A Case Report and Review of the Literature.

Peripheral nerve injury following regional or general anesthesia is a relatively uncommon entity but, potentially, a serious complication of anesthesia. Most nerve injuries are related to either regional anesthesia or position-related complications, and they are rarely seen in association with the use of automated blood pressure monitoring. We describe a patient who developed neurological dysfunction of all the three major nerves, median, ulnar, and radial, after general anesthesia. The distribution of sensory motor deficit along with the nerve conduction study demonstrated the location of the anatomical nerve lesions coinciding with the automatic noninvasive blood pressure (NIBP) cuff. No other cause of nerve injury was identified except for the use of the NIBP cuff. In the absence of another identifiable cause, we strongly suspected the NIBP cuff compression as a possible cause for the nerve injuries. In this article, we will discuss the possible risk factors, mechanisms, diagnosis, and prevention of perioperative nerve injury.

Successful Regional Anesthetic for a Parturient with Moyamoya Syndrome.

Anesthesia for Cesarean section could be challenging due to the physiological changes during pregnancy, but it can be more complicated if associated with sickle cell disease and moyamoya disease. The moyamoya syndrome is nothing but sickle cell disease complicated by cerebral vasculopathy. Incidence of moyamoya disease in the USA is 0.086/100,000 people. We report a case of a pregnant woman with sickle cell disease and moyamoya syndrome, who underwent a successful spinal epidural for primary cesarean section, with careful monitoring of blood pressure.

Anesthetic Management of Laparoscopic Pyloromyotomy for Pyloric Stenosis in a Neonate with Hereditary Spherocytosis.

We describe a case of hereditary spherocytosis in a neonate with pyloric stenosis requiring laparoscopic pyloromyotomy. Hereditary spherocytosis is the most commonly inherited hemolytic anemia causing hyperbilirubinemia and mild anemia. Anesthetic management for laparoscopic pyloromyotomy is challenging. Multiple factors involved, such as anemia, hyperbilirubinemia, and the effect of drugs, play an important role in anesthetic management.

A controlled release bupivacaine-alginate construct: Effect on chondrocyte hypertrophy conversion.

Objective: Osteoarthritis is a degenerative disease of the joint, affecting over 30 million people in the US1. A key characteristic of OA is chondrocyte hypertrophy, characterized by chondrocyte changes to a more rounded and osteoblastic phenotype, characterized by increased IL-6 and IL-8 secretion2. While there are no cures for OA, treatments focus on mitigating pain and inflammation, the two main symptoms of OA. However, the analgesics, NSAIDS and corticosteroids commonly used, do not target regeneration and have negative side effects. Local anesthetics (LA) can be used as a pain management alternative but are usually short lasting and therefore, not suited for chronic conditions such as OA. Our engineered sustained release local anesthetic construct successfully delivers bupivacaine for an extended period of time3-5. This study is designed to evaluate the effect of the LA system on chondrocytes in an inflammatory OA-like environment. Design: Chondrocytes were cultured with bolus, liposomal, or construct LA and either untreated or treated with TNF-α and IL-1α for 24 hrs, 48 hrs, or 96 hrs. Chondrocyte viability, interleukin-8 (IL-8), interleukin-6 (IL-6), collagenase activity and proteoglycan deposition were assessed. Results: In the presence of the engineered construct, the chondrocytes retained viability and regenerative function. Moreover, the construct allowed for higher initial doses to be used, which promoted more regeneration and decreased inflammation without compromising cellular viability. Conclusions: The construct promotes a less hypertrophic chondrocyte environment while promoting a more anti-inflammatory environment. These two factors are consistent with a less OA progressive environment when using the engineered construct, compared to bolus LA.

Comparison of the potency of lidocaine and chloroprocaine in sciatic nerve block in Sprague-Dawley rats.

AIM: This study investigates the relative potencies and ED(50) of the local anesthetics lidocaine and chloroprocaine in a sciatic block in Sprague-Dawley rats. METHODS: The study involved 80 rats (chloroprocaine n = 40, lidocaine n = 40). Each rat was injected close to the sciatic nerve with 0.1 ml of the concentration of local anesthetic being tested. Using the up-and-down allocation technique, the next concentration was determined by the response of the previous subject to a higher or lower concentration. A successful block was assessed by pinching the fifth metatarsal. Absent vocalization and a very weak withdrawal response were defined as the onset of block. RESULTS: Using the up-and-down methodology, the estimates of ED(50) for chloroprocaine was 0.1 ml of 1.2% (with 95% CI of 1.1-1.6), and that for lidocaine was 0.1 ml of 0.65% (with 95% CI of 0.65-0.88), giving a lidocaine/chloroprocaine potency ratio of 1.85 (with 95% CI of 1.66-2.61). DISCUSSION: Using the results of this study, the effects of the two drugs can be compared using the commercially available concentrations of chloroprocaine and lidocaine in a peripheral nerve block.

Myotonic Dystrophy and Anesthetic Challenges: A Case Report and Review.

Providing anesthesia to patients with myotonic dystrophy (DM) can be very challenging due to the multisystemic effects of the disease and extreme sensitivity of these patients to sedatives, opioids, and anesthetic agents. Other factors such as hypothermia, shivering, or mechanical or electric stimulation during surgery can precipitate myotonia which is difficult to abolish and can lead to further complications. Generally, local or regional anesthesia is preferred to avoid the complications associated with general anesthesia in this group. However there are several case reports of successful use of general anesthesia (with or without volatile agents and with or without opioids). These general anesthetic cases led to postoperative admission to the regular floor or ICU. We present a case of a woman with a history of DM who underwent robotic assisted laparoscopic hysterectomy under general anesthesia and was discharged home on the same day.

Bilateral Brachial Plexus Block Using Chloroprocaine For Surgery Of Bilateral Radial Fractures.

We report a case of a 41-year-old male with anticipated difficult airway undergoing a repair of a bilateral radial fracture under bilateral sequential brachial plexus block. Anesthesiologists are reluctant to perform bilateral blocks because of the fear of complications like diaphragmatic paralysis, local anesthetic (LA) toxicity, and pneumothorax. We advise that with the correct application of LA pharmacokinetics, careful patient selection and usage of ultrasound, bilateral blocks can be done safely. We used chloroprocaine as an LA in one of the blocks to reduce the dose required for the more toxic LAs. chloroprocaine's fast metabolism also helped us to prevent the overlapping of peak plasma concentration of different LAs. To our knowledge, this is the first reported case in the literature where chloroprocaine was used for bilateral brachial plexus block.

Celiac plexus block as a diagnostic tool in suspected pediatric median arcuate ligament syndrome.

We report the use of celiac plexus block (CPB) as a diagnostic aid in the evaluation of median arcuate ligament syndrome (MALS) in a pediatric patient. MALS is a rare cause of severe, debilitating, abdominal postprandial pain associated with nausea, vomiting, occasional diarrhea, unintentional weight loss, and abdominal bruit. MALS is a diagnosis of exclusion, after multiple investigations. This is the first case report where CPB was used to confirm candidacy for corrective surgery in the pediatric population and has served as the cornerstone in diagnosis of MALS.