TAP Blocks and Same Day Lap Choli Surgery

Jeff Halonen, DO

The Beneficial Effects of Transverse Abdominid Plane Block After Laparoscopic Cholecystectomy in Day-Case Durgery: A Randomized Clinical Trial. Premillennialism Lykke Petersen, MD et al. Anesthesiology. September 2012- Vol 115- Number 3, p 527-533.

Summary

Patients generally have moderate pain in the early postoperative period following. There have been RCT's that suggest the use of transversal abdominis block following abdominal surgeries for analgesia. The purpose of this trial was to see of this TAP block could decrease the pain with rest and coughing, decrease opioid use and side effects after laparoscopic cholecystectomies in day-case surgery.

This trial put patients into one of two categories. One received bilateral TAP block with Ropivicaine while the other received a placebo block. Their goal was then to see if there was a difference in the above measures.

What was found was that there was a difference in the pain scores when coughing and total opioid consumption. These differences were thought to only be a small difference however.

Awake Fiberoptic vs Video Laryngoscopy

Dr. Halonen

Awake fiberoptic or awake video laryngoscopy tracheal intubation in patients with anticipated difficult airy management

Charlotte V Rosenstock et al, Anesthesiology, June 2012- Vol 116- Number 6, p 1210-1216

Summary

The gold standard for intubation in patients with anticipated difficult airways is the use of awake flexible fiberoptic intubation (FFI). The randomized clinical trial was performed to test their hypothesis that McGrath video larynscope (MVL) would be faster than FFI in these patients.

Besides time for intubation, they also compared the success of intubation in the first attempt, the ease of intubation and the patient discomfort between the two techniques. What they found is that there was no difference any of the categories that were tested between the two techniques. Because of this, maybe further studies should be performed to determine if the MVL technique should take over as the gold standard for suspected difficult intubations. Obviously, one technique should not be used if their are contraindications to that technique or if the anesthesiologists is not comfortable in performing that technique. 

Is Intra-op Hypotension Associated with a CVA? Dr. Halonen

Jeff Halonen, DO

Intraoperative Hypotension and Peripoerative Ischemic Stroke After General Surgery

This case study was performed in order to determine if there is a correlation between intraopertive hypotension and postoperative stroke as this correlation is largely unknown. The findings of this study showed that after correcting for potential confounders and with multiple testing, the duration that the mean blood pressure was decreased more than 30% from baseline remained statistically significantly associated with the occurrence of a postoperative stroke. Some of the limitations of this study that were listed would be in CEA patients, only collecting data on patie ts for 10 days postoperatively and the role of postoperative hypotension.

OSA predicts adverse outcomes, Dr. Halonen

Jeff Halonen, DO

Article

Obstructive Sleep Apnea Predicts Adverse Perioperative Outcome

Bateman, Brian MD and Eikermann, Matthias MD, PhD, Anesthesiology, April 2012- Vol 116- Number 4, p 753-755.

Summary

OSA is an important risk factor for cardiovascular disease, myocardial infarction, stroke and perhaps has an association with postoperative delirium (POD). The definition for this review of delirium is an acute, fluctuating impairment in attention and cognition. OSA, independent of obesity, has been shown by most studies to be an independent risk of Perioperative complications. These complications may be from drug side effects, inflammation and hypercoaguability.

While this study can not link OSA and PoD directly, they do make some interesting speculations. Frequent episodes of airway collapse in OSA lead to hypoxia, disrupted sleep, sleep inertia, daytime sleepiness and increased arousal threshold from sleep, all of which may be consider as potential precipitating and/or augmenting factors of delirium. These are all associated with inflammation and OSA is also, in part, an inflammatory disease.  From this, the associated observed between OSA and POd should be considered "hypothesis-generating" rather than "proven."

Amniotic Fluid Embolism, Dr. Halonen

Jeff Halonen, DO

Case Scenario: Amniotic Fluid Embolism

Bruno Riou, MD, Ph D

Anesthesiology, January 2012 issue

          Amniotic fluid embolism is a rare condition found in the time period immediately prior, during and shortly after deliver which can have catastrophic consequences. This condition is very difficult to diagnose in the early stages and we do not currently have a precise pathophysiology cause to this condition, although it is thought to be partly immune mediated or anaphylactic in nature.  The diagnosis remains a diagnosis of exclusion, but should be considered in any peripartum patient that presents with any combination of acute hemodynamic collapse, respiratory distress/hypoxia, DIC and/or mental status change without any other medical explanation.

          Some early signs and symptoms include: acute dyspnea and/or cyanosis, sudden tachycardia, hypotension, acute agitation/ALOC, seizure, coagulopathy, sudden desaturation, loss of EtCO2, ST changes and fetal distress.

          The managemnt of this condition relies on early suspicion and early aggressive hemodynamic support. The main therapies include oxygenation, circulatory support and correction of coagulopathy. Immediate Cesarian section improves neonatal neurological recovery and overall maternal outcome.