Perioperative management of obstructive sleep apnea: a survey of Puerto Rico anesthesia providers.

BACKGROUND: Obstructive sleep apnea (OSA) prevalence has been increasing in the past years adding significant morbidity. Perioperative management is controversial and few studies have addressed this matter. The American Society of Anesthesiology (ASA) and the American Academy of Sleep Medicine (AASM) have developed clinical practice guidelines for the perioperative management of patients with OSA. Existing evidence suggest an increase in early postoperative complications in patients with OSA. Nevertheless, data about perioperative management of OSA is limited. To our knowledge, only two studies that address this matter, none in Puerto Rico. METHODS: A questionnaire was given to participants at the annual meeting of anesthesiology in Puerto Rico. The document was then anonymously deposited into sealed box. RESULTS: The response rate was 80 %. The awareness about written postoperative policy in patients with diagnosed (23 %) and suspected (11 %) OSA was low. If a written policy were available, 46 % of patients would have gone to ICU. The most important factor for final disposition was the degree of OSA, which was decided by surgery and anesthesia (69 %). In the last year, at least one complication related to OSA was observed in 20 % of respondents. The most common preoperative screening tool was the ASA guidelines. Seventy-two percent of respondents suggested a lack of institutional policies as the main reason for disparity. CONCLUSION: There is a significant heterogeneity in the current clinical practice. The main barriers identified to achieve current recommendations were lack of institutional policies, awareness of current guideline, formal training in management of OSA, and access to a sleep specialist.

Evaluation of a vancomycin dosing regimen for patients on high flux hemodialysis: an observational study.

UNLABELLED: Vancomycin is the mainstay antibiotic used in hemodialysis group due to high prevalence of methicillin resistant Staphylococcus Aureus. For years regimens of vancomycin in high flux hemodialysis (HFHD) patients were designed to achieve a pre-dialysis vancomycin concentration between 5-20 ug/mL. Recent guidelines increased the recommended pre-dialysis level to 15-20 ug/ml for health care associated infections, bacteremia and osteomyelitis. The purpose of this study was to determine if the loading dose (LD) before HFHD and the maintenance dose (MD) of vancomycin achieved a pre-dialysis concentration between 15-20 ug/ml on HFHD in-patients with a suspected infection. The second purpose was to predict an adequate vancomycin dosage to achieve the new recommended levels. MATERIAL AND METHODS: An observational prospective study on hospitalized adult patients on HFHD with evidence of infection treated with 1 gm LD of vancomycin and 500 mg MD. Plasma levels of vancomycin were measured before each HFHD for three consecutive times. Age, gender, weight at admission, blood flow rate, dialyzer flow rate, type of filter and HFHD length were evaluated. RESULTS: Twenty-one patients met the inclusion criteria. All of them were treated with 1 gm LD of vancomycin and 500 mg MD protocol. The mean pre-dialysis concentration #1 was 10.8 ug/mL. The mean pre-dialysis concentration #2 was 13 ug/mL, and the mean pre-dialysis concentration #3 was 12 ug/mL. Only 36% of HFHD sessions achieved an adequate vancomycin level. A liner regression analysis predicted that a loading dose of 23 mg/kg LD and 8 mg/kg MD achieved the recommended pre-dialysis vancomycin concentration. CONCLUSIONS: Current dose regimen of 1 gm LD and 500 mg MD of Vancomycin are not adequate to achieve recommended pre-dialysis level of 15-20 ug/mL for health care associated infections, bacteremia and osteomyelitis in most patients on HFHD. Based on our statistical analysis, we recommended that 23 mg/kg of LD and 8 mg/kg of MD would achieve an adequate vancomycin level.

Life-threatening hemoptysis: case of Osler-Weber-Rendu Syndrome.

Hereditary haemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is a rare autosomal dominant vascular disorder. Patients with HHT may present with a wide spectrum of clinical manifestations, some considered to be life-threatening. We present the case of a 53-year-old male who presented with massive haemoptysis. Chest computed tomography scan was remarkable for a large anterior, left lower lobe arteriovenous malformation. The patient underwent a pulmonary angiogram with embolization of a large left lung arteriovenous malformation, which proved to be successful in controlling the bleeding.