A&A Practice

Yin, Kai Sheng Ashton; Leong, Xin Yu Adeline

doi: 10.1213/xaa.0000000000001882pmid: 39760419

Brugada syndrome is a rare condition that increases the risk of life-threatening arrhythmias. Although there are existing anesthesia recommendations for patients with Brugada syndrome, guidance on pain management is limited. We present a novel approach to pain management in these patients, illustrated by the case of a young woman with Brugada syndrome who underwent ropivacaine peripheral nerve infusion and intravenous ketamine infusion for acute-on-chronic left upper limb pain. She received perioperative multimodal analgesia, which included neuropathic agents (pregabalin, duloxetine), and opioids (morphine, codeine). Our findings contribute to a greater understanding of safe analgesic practices for patients with Brugada syndrome.

Ranganath, Yatish S.; Chung, Eric; Carmony, Megan; Mazurek, Michael

doi: 10.1213/xaa.0000000000001888pmid: 39749959

Interscalene blocks, commonly used for shoulder surgery analgesia, often cause transient phrenic nerve palsy, leading to hemi-diaphragmatic paresis. This complication is particularly problematic in patients with pulmonary comorbidities and has been extensively investigated. However, its impact on patients with Fontan physiology remains less understood with limited representation in the literature. Hemi-diaphragmatic paresis can significantly reduce negative pressure spontaneous ventilation, leading to decreased venous return and increased pulmonary vascular resistance, which critically affects cardiac output. This case report explores regional anesthesia management in a Fontan patient undergoing shoulder surgery, emphasizing the suprascapular nerve block as an effective alternative for ambulatory patients.

Thirion, Charlotte; Abene, Salim; Van Regemorter, Victoria; Van Boven, Michel; Biermans, Alexandre; Pharaoh, Emma; Mestdagh, François

doi: 10.1213/xaa.0000000000001884pmid: 39749957

Nasotracheal intubation is a commonly used technique in elective oral and pharyngeal surgeries. This case report details an incident involving a young adult patient in which an attempt at nasotracheal intubation resulted in a life-threatening cervicofacial and thoracic emphysema. Although complications associated with nasotracheal intubation are rare, their potential severity necessitates a comprehensive preprocedural discussion and risk assessment with the surgical team to confirm its appropriate indication for each individual patient. This case underscores the need for increased awareness and readiness for managing rare but critical complications associated with airway management techniques.

Luney, Matthew S.; White, Stuart M.; Moppett, Iain K.

doi: 10.1213/xaa.0000000000001891pmid: 39760415

BACKGROUND: Hypotension during anesthesia for surgery for hip fracture is common and associated with myocardial injury, stroke, acute kidney injury, and delirium. We hypothesized that maintaining intraoperative blood pressure close to patients’ preoperative values would reduce these complications compared to usual care. METHODS: A pilot feasibility patient- and assessor-blinded parallel group randomized controlled trial. People with unilateral hip fracture aged ≥70 years with capacity to give consent before surgery were eligible. Participants were allocated at random before surgery to either tight blood pressure control (systolic blood pressure ≥80% preoperative baseline and mean arterial blood pressure ≥75 mm Hg) or usual care. Feasibility outcomes were protocol adherence, primary outcome data completeness, and recruitment rate. The composite primary outcome was myocardial injury, stroke, acute kidney injury or delirium within 7 days of surgery. RESULTS: Seventy-six participants were enrolled, and 12 withdrew before randomization. Sixty-four participants were randomized, 30 were allocated to control, and 34 to intervention. There was no crossover, all 64 participants received their allocated treatment, primary outcome was known for all participants. The composite primary outcome occurred in 14 of 30 participants in the control group compared with 23 of 34 participants in the intervention group (P = .09), relative risk 1.45 (95% confidence interval [CI], 0.93–2.27). CONCLUSIONS: A randomized controlled trial of tight intraoperative blood pressure control compared to usual care to reduce major postoperative complications after fractured neck of femur surgery is possible. However, the data would suggest a large sample size would be required for a definitive trial.

Ballacchino, Madison M.; Deiner, Stacie G.; Martinez-Camblor, Pablo; Ron, Donna

doi: 10.1213/xaa.0000000000001875pmid: 39745308

BACKGROUND: Evaluations performed before the day of surgery at perioperative clinics have been shown to reduce patient mortality and hospital lengths of stay. These clinics are becoming increasingly adopted worldwide. As the number of older patients undergoing surgery continues to increase, understanding the perspectives of this patient population regarding the preoperative evaluation process is essential to tailor care to their needs and preferences. METHODS: We administered a cross-sectional survey by email or telephone to 104 patient participants ages 75 and older who underwent preoperative assessment and surgery at a rural tertiary center in Northern New England in 2022. The survey aimed to elicit patient perspectives on whether or not they prefer to speak with an anesthesia provider before the day of surgery, and on the reasons for their preference. RESULTS: Sixty-six percent of older patients indicated they prefer to engage in conversations with their anesthesia providers before the day of surgery. The most common topics patients wanted to discuss were to address what possible side effects from anesthesia could occur, the type of anesthesia they would receive, and if other anesthesia options were available. Patients also emphasized the importance of their anesthesia provider’s awareness of their specific medical conditions, such as kidney, lung, or cervical spine conditions. CONCLUSIONS: Preanesthesia assessments allow for bidirectional communication between patients and anesthesia providers, alleviating patient anxiety and allowing for vital patient information to be collected to enhance overall patient safety. Our findings indicate that preoperative assessment by an anesthesia provider is desired and valued by the older patient population, contributing to the evidence in support of the implementation of anesthesia preoperative clinics. More research is needed to determine whether tailoring preanesthesia assessments to better align with patient preferences will translate into enhanced patient-centered outcomes.

Jouryyeh, Basil; Beshara, Michael

doi: 10.1213/xaa.0000000000001890pmid: 39745277

Transcatheter aortic valve replacement (TAVR) is a common treatment for severe aortic stenosis (AS), but it carries the risk of severe complications, including device embolization. We present a case of a TAVR valve embolization into the left ventricular outflow tract (LVOT), diagnosed with transesophageal echocardiography (TEE) shortly after device deployment. The dislodged valve was successfully retrieved from the LVOT into the aorta, flattened, and stabilized with a thoracic endovascular aneurysm repair (TEVAR) stent, enabling the successful implantation of a new TAVR valve.

Cormier, Nicholas R.; Kinney, Daniel A.; Gaiser, Robert R.

doi: 10.1213/xaa.0000000000001885pmid: 39745283

BACKGROUND: The Accreditation Council for Graduate Medical Education defines “nonphysician obligations” as “duties performed by nursing and allied health professionals, transport services, or clerical staff.” How anesthesiology trainees understand the concept of “nonphysician obligations” and are impacted by these obligations is incompletely understood. The objective of the study was to identify how anesthesiology trainees define “nonphysician obligations,” which obligations impact trainee education, and what attitudes trainees hold. METHODS: A survey was administered to Anesthesiology residents (N = 86) at a large academic hospital in 2023. Respondents defined “nonphysician obligations,” listed obligations that impacted their education, and indicated the frequency of these obligations. Respondents scored their agreement with statements appraising attitudes toward the clarity and consistency of the term and classified anesthesiology tasks as physician/nonphysician. The authors developed a conceptual framework defining “nonphysician obligations” using grounded theory and categorized the participants’ responses based on this framework. Tallies assessed which obligations and attitudes were most prominent. RESULTS: The response rate was 82.6% (n = 71). Respondents defined nonphysician obligations with either a patient-centered or physician-centered framework. Tasks spanning nursing, patient transport, anesthesia technicians, certified registered nurse anesthetists, and care coordinators impacted education most. Outlier definitions and obligations emerged, including personal and household obligations. Fifty-seven percent of trainees disagreed that the definition of nonphysician obligations was clear. Forty-seven percent agreed definitions held by anesthesiology trainees were aligned. Sixty-two percent felt that different medical specialties did not share a common definition. Classification of typical anesthesiology tasks as physician/ nonphysician was heterogenous. CONCLUSIONS: “Nonphysician obligations” are defined by a new, nuanced, specialty-specific explanatory framework, and those that impact education are summarized in distinct classes. Trainee definitions and attitudes expose possible faults in how nonphysician obligations are currently evaluated.

McWhirter, Ryan; Holly, Tsione; Ayad, Ihab A.; Moore, Jeremy P.; Biniwale, Reshma; Rahman, Siamak

doi: 10.1213/xaa.0000000000001906pmid: 39831719

Management of refractory ventricular fibrillation (VF) in patients with implantable implantable cardioverter defibrillator (ICD) presents a therapeutic challenge. We present a case of pediatric refractory ventricular tachycardia (VT)/Torsade de Pointe managed effectively with bilateral stellate ganglion block (SGB) with a long-acting local anesthetic for 18 days as a bridge to more definitive surgical management.

Casey, Ryan T.; Like, Brian J.

doi: 10.1213/xaa.0000000000001907pmid: 39791590

After vascular puncture and catheterization, arteries can have many complications that impede blood flow such as vasospasm, thrombosis, and emboli generation, among other complications. Treatment depends on severity of ischemic symptoms and can range from as mild as applying local heat packs to surgical thrombectomy. We present a case of digital ischemia secondary to vascular puncture that was successfully treated with a supraclavicular nerve block, resulting in the vascular surgery team canceling an emergent surgery.

Glebov, Maxim; Portnoy, Yotam; Patapanyan, Estela; Drori, Elad; Katsin, Maksim; Berkenstadt, Haim; Orkin, Dina

doi: 10.1213/xaa.0000000000001899pmid: 39791605

This case series reviews surgeries involving elderly patients with femoral neck fractures on apixaban who underwent spinal anesthesia (SA) within 72 hours of their last dose. Despite patients being on anticoagulation, no neurological complications occurred, suggesting SA may be practical in cases where the benefits of timely surgery outweigh the potential risks, including apixaban discontinuation for a period of less than the recommended 72 hours with detectable levels of the drug remaining in the plasma. Quantitative apixaban measurements offered useful anticoagulation status insights, though safe thresholds remain undefined.