Anesthetic Management for Combined Anterior Cervical Spinal Decompression and Fusion and Cesarean Delivery: A Case Report.

A 31-year-old G2P1 (gravida 2 para 1) woman at 34 weeks of gestation presented after a motor vehicle collision with an incomplete cervical spinal cord injury. The patient underwent emergent anterior cervical decompression and fusion (ACDF), immediately followed by cesarean delivery. We discuss the clinical decision making to perform ACDF first, weighing risks and benefits to both mother and baby. We also address important anesthetic considerations for this pregnant patient having emergent spine surgery, including positioning with left uterine displacement, rapid sequence intubation to minimize aspiration risk, choice of vasopressor, implications of total intravenous maintenance anesthetic, and the medical teams involved in this care.

Improved Intraoperative Hemodynamics in Burn Surgery: An Institutional Change to Pediatric-Specific Hemostasis Solutions.

A cornerstone of burn surgery hemostasis is infiltration of tumescent vasopressor solutions and topical vasoconstrictor-soaked compresses. Studies detailing pediatric-specific concentrations of these solutions are lacking. Our aim was to assess hemodynamic changes after an institutional change in tumescent vasopressor solution and vasopressor-soaked topical compresses for hemostasis management during pediatric burn surgery. Once the institutional change was implemented, cases performed before and after the intervention were reviewed; inclusion criteria included age 0 to 18 years, burn TBSA ≥ 10%, and surgery length > 50 minutes. Primary outcomes included changes in intraoperative mean arterial pressure, maximum inhaled anesthetic concentration, need for direct-acting vasodilators, estimated blood loss, and need for blood transfusions. Thirty patients were included in the intervention group, and 31 in the control group. There was a significant difference in peak intraoperative blood pressure in the intervention group (21.4%) compared with the control group (48.0%, P = .005). Maximum inhaled anesthetic concentrations were lower in the intervention group (2.5% vs 2.8%, P = .02). Estimated blood loss per TBSA decreased significantly (8.2 ml/1% TBSA vs 1.7, P = .008), as well as blood transfusion rates, with a transfusion rate of 16.7% in the intervention group vs 45.2% in the control group (P = .03). The changes instituted in type and concentration of tumescent solution and vasopressor-soaked topical compresses were associated with improved hemodynamic changes and decreased transfusion rates intraoperatively.

Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway. METHODS: This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway. RESULTS: There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36-7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02-5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02-1.50; P = .04). CONCLUSIONS: We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.

Mortality After High-Energy Pelvic Fractures in Patients of Age 65 Years or Older.

OBJECTIVES: To document in-hospital and 1-year mortality rates after high-energy pelvic fracture in patients 65 years of age or older as compared to a younger cohort. DESIGN: Retrospective review. SETTING: Urban Level 1 academic trauma center. PATIENTS: Seventy consecutive patients 65 years of age and older treated for pelvic fracture resulting from high-energy mechanism from 2008 to 2011. A total of 140 patients 18-64 years of age were matched to the study population based on mechanism of injury and OTA Code 61 subtype for comparison. INTERVENTION: Review of demographics, injury characteristics, hospital management, and mortality. MAIN OUTCOME MEASUREMENTS: Mortality. RESULTS: The overall inpatient mortality rate was 10%. The older cohort exhibited an inpatient mortality rate 3 times higher than the younger cohort (18.6% vs. 5.7%, P = 0.003). There was no difference in mortality 1 year post discharge (5.3% vs. 3.8%, P = 0.699). No significant differences in initial Glasgow Coma Scale or Injury Severity Score were identified (GCS 12.9 vs. 12.4, P = 0.363; ISS 24.7 vs. 23.4, P = 0.479). Multivariate analysis identified the Charlson Comorbidity Index (CCI) (P = 0.012) and Abbreviated Injury Scale (AIS)-chest (P = 0.005) as independent predictors of in-hospital mortality, and CCI (0.005) and AIS-abdomen (0.012) for 1-year mortality. CONCLUSIONS: After controlling for mechanism of injury and pelvic fracture classification, we found that adults ≥65 and those with multiple comorbidities were more likely to die in the hospital than younger adults. However, mortality within 1-year postdischarge was low and did not differ between groups. This is in sharp contrast to the high rates of postdischarge mortality observed in elderly patients with a hip fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Observation of enhanced heat dissipation in columns packed with superficially porous particles.

At high flow rates and pressures, columns packed with sub-2 µm particles suffer from efficiency losses due to frictional heating. The thermal environment of the column (insulated or isothermal) can decrease or magnify these losses. While a number of studies have been conducted demonstrating the improved performance (partially due to the benefits of enhanced thermal conductivity) of columns packed with superficially porous particles, none have made a comparison between sub-2 µm fully and superficially porous particles in an isothermal environment where radial thermal gradients are maximized and thermal broadening is amplified. Here we show that when such columns are characterized in a recirculating water jacket (providing an isothermal environment), efficiency loss and changes in retention and mobile phase temperature are reduced for sub-2 µm superficially porous particles compared to sub-2 µm fully porous particles.