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Obstructive sleep apnea uncovered after high spinal anesthesia: a case report.

PURPOSE: To illustrate how a patient's previously undiagnosed obstructive sleep apnea was uncovered after administration of a spinal anesthetic with a high sensory blockade, and to discuss possible explanations for this occurrence and anesthetic implications. CLINICAL FEATURES: A 55-yr-old male presented for osteotomy and open reduction and internal fixation of his left femur secondary to malunion from a previous fracture. Past medical history consisted of hypertension, hypercholesterolemia, bipolar disorder, gastroesophageal reflux disease, and cluster headaches. A combined spinal-epidural technique was chosen. Isobaric bupivacaine 0.5% (15 mg), was provided for the spinal anesthetic, along with 1 mg iv midazolam for procedural sedation and 0.5 mg iv droperidol for mild nausea. Throughout the operation, many apneic events were noted, often with respiratory efforts. The patient was easily arousable during each event and would breathe normally until the next episode. Vital signs remained stable throughout. Postoperative respirology consultation was requested, and a sleep study revealed severe obstructive sleep apnea. The patient was subsequently started on continuous positive airway pressure with marked improvement in symptoms, including the cluster headaches. CONCLUSION: Recent literature suggests that high spinal blockade can result in altered levels of arousal by producing a de-afferentation of peripheral proprioceptive and sensory stimuli necessary for maintaining an awake state. In patients predisposed to upper airway obstruction, decreasing the level of consciousness can result in airway obstruction as occurs during sleep in these patients. This serves to underline the importance of considering capnography for all cases utilizing a neuraxial anesthetic technique.

Anesthesia, Epidural↗
PubMed2005

Eliminating analgesic meperidine use with a supported formulary restriction.

PURPOSE: Meperidine is a commonly used analgesic despite unique disadvantages compared with other opioid analgesics. The objective of this study was to measure the effects of a meperidine formulary restriction on the prescribing of parenteral opioid analgesics. MATERIALS AND METHODS: The study was performed at a single 750-bed tertiary care teaching hospital in Rochester, NY. The formulary restriction limited meperidine to use exclusively for rigors or procedural sedation and was supported by an educational initiative and a computerized order entry system. Independent computerized pharmacy records were used to capture all doses of parenteral morphine, meperidine, and hydromorphone administered to patients in the emergency department or on a medical or surgical inpatient floor during data-collection periods. Baseline data were collected during two 3-day periods before the formulary restriction; then comparison data were collected during three 3-day periods over 15 months after the formulary restriction. RESULTS: The number of administered doses of meperidine per day decreased from 37.5 (20.8% of parenteral opioid doses before the restriction) to 0.22 (0.1% of parenteral opioid doses, P = .001). The total number of opioid doses and morphine doses given did not change, whereas the number of hydromorphone doses increased significantly postrestriction, from 16.0 doses per day (8.9% of total) to 59.7 doses per day (29.5%) (P = .009). CONCLUSION: Meperidine formulary restriction, supported by an educational program and computerized order entry, effectively eliminated analgesic meperidine use. Hydromorphone use increased proportionately to offset the decreased use of meperidine.

Analgesics, Opioid↗
PubMed2004

Electrical cardioversion of emergency department patients with atrial fibrillation.

STUDY OBJECTIVE: Electrical cardioversion of emergency department (ED) patients with atrial fibrillation has not been well investigated. The objective of this study is to identify the outcomes and complications associated with ED electrical cardioversion of patients with atrial fibrillation. METHODS: This retrospective health records survey investigated a consecutive cohort of ED patients with atrial fibrillation who underwent electrical cardioversion in 4 EDs during a 42-month period. Trained personnel reviewed medical records for demographic characteristics, clinical descriptors, medical interventions, complications, and ED return visits within 7 days. Data were analyzed using descriptive statistics. RESULTS: The study population consisted of 388 patients (mean age 61 years; range 20 to 93 years). Duration of atrial fibrillation was less than 48 hours in 99% of the cohort. Electrical cardioversion was successful in 332 (86%) patients. Twenty-eight complications were noted in 25 electrical cardioversion encounters: 22 attributed to procedural sedation and analgesia and 6 attributed to electrical cardioversion. Three hundred thirty-three (86%) patients were discharged to home from the ED: 301 after electrical cardioversion success and 32 with electrical cardioversion failure. Thirty-nine patients (10%) returned to the ED within 7 days, 25 of these patients (6% of successful electrical cardioversion patients) returned because of relapse of atrial fibrillation. CONCLUSION: In this multicenter cohort, selected ED patients with atrial fibrillation had high rates of electrical cardioversion success, infrequent hospital admission, and few immediate and short-term complications.

Adult↗
PubMed2004

What does pain signify? A hypothesis concerning pain, the immune system and unconscious pain experience under general anesthesia.

In this paper, I present a case-study that initiates a discussion about the meaning of pain. The case-study concerns a person who was under deep sedation during colonoscopy. The person did not experience pain from a first-person perspective, although pain was evident to the medical team from a second-person perspective. The divergence of pain perspectives raises an interesting quandary. If the body communicates pain while pain consciousness is blocked by the sedation procedure, our conclusion should be that the intersubjective aspect of pain precedes the "subjective," first-person experience of pain. This conclusion is not consistent with the common representational conception of pain that places the intrasubjective point of view prior to the intersubjective point of view. The solution I offer to this quandary is the quasi-paradoxical idea that pain can be experienced unconsciously through the immune system. Following this suggestion, I hypothesize that post-traumatic stress disorders following general anesthesia may result from this unconscious pain experience. If this idea is scientifically grounded, then physicians should: (1) consider ways of blocking the unconscious pain experience produced by the immune system without interfering with the immune response, and (2) study pain as a complex cognitive and unconscious system by drawing an analogy with the immune system, which follows similar logic.

Anesthesia, General↗
PubMed2000

Acute pain and pain control: state of the art.

Recognition and treatment of pain in the emergency department has undergone an evolution in the past decade. Emergency clinicians, educators, and researchers have begun to address the undertreatment of pain as well as challenge the long-standing dogmas concerning pain treatment. Well-described barriers, both psychological and educational, contribute to our providing inadequate pain relief. This state-of-the-art update describes the current perception of our practice with regard to pain relief and how it can be modified. Pain and pain control is such a broad and complex topic that only new advances and important principles relevant to the practice of emergency medicine are presented. Headache, pediatric pain, and procedural sedation and analgesia are not covered in this article as they will be addressed in future state-of-the-art articles.

Analgesics↗
PubMed2001

Chemical immobilization of felids, ursids, and small ungulates.

Private ownership of wild animals is on the rise. With the advent of potent new sedative agents, many practitioners now receiving these cases have the means to increase the safety and effectiveness of chemical immobilization in many wildlife species. Chemical immobilization is actually the induction of anesthesia. In many cases, induction alone suffices to achieve some management or medical goal, whereas in other cases, maintenance anesthesia is required. One quickly realizes that once these species are induced, maintenance anesthesia is often familiar, based on experiences with domestic animals that bear close similarity to the species discussed in this chapter. Induction and recovery of wild animals requires special attention to details to prevent "fight or flight" responses from marring the success of a sedation procedure. Although potent novel drugs allow veterinarians to expand their practice horizons, it is vital to evaluate legal and safety issues thoroughly before engaging in the care of wildlife species on a regular basis.

Anesthesia↗
PubMed2003

Microsystems in health care: Part 6. Designing patient safety into the microsystem.

BACKGROUND: This article explores patient safety from a microsystems perspective and from an injury epidemiological perspective and shows how to embed safety into a microsystem's operations. MICROSYSTEMS PATIENT SAFETY SCENARIO: Allison, a 5-year-old preschooler with a history of "wheezy colds," and her mother interacted with several microsystems as they navigated the health care system. At various points, the system failed to address Allison's needs. The Haddon matrix provides a useful framework for analyzing medical failures in patient safety, setting the stage for developing countermeasures. CASE STUDY: The case study shows the types of failures that can occur in complex medical care settings such as those associated with pediatric procedural sedation. Six patient safety principles, such as "design systems to identify, prevent, absorb, and mitigate errors," can be applied in a clinical setting. In response to this particular case, its subsequent analysis, and the application of microsystems thinking, the anesthesiology department of the Children's Hospital at Dartmouth developed the PainFree Program to provide optimal safety for sedated patients. CONCLUSION: Safety is a property of a microsystem and it can be achieved only through thoughtful and systematic application of a broad array of process, equipment, organization, supervision, training, simulation, and team-work changes.

Academic Medical Centers↗
PubMed2002

The use of methohexital during neonatal cardioversion.

We report on the use of methohexital during elective neonatal direct current cardioversion. In contrast with the available data on cardiac management in neonates with supraventricular tachycardia and the guidelines on anaesthetic management during cardioversion in adults, data on anaesthetic management in neonates are still lacking. Methohexital might be an option for procedural sedation and anaesthesia during elective cardioversion in neonates.

Anesthetics, Intravenous↗
PubMed2004

The pediatric airway.

Good airway management technique is an essential skill for physicians in most specialties. This article begins with a review of basic airway anatomy and the physiology of the uninstrumented airway. This subject is of particular importance given the increasing use of procedural sedation and the increased recognition of sleep-disordered breathing in infants and children. A discussion of the various artificial airways and their advantages and disadvantages follows. The difficult airway is an important contributor to both patient morbidity and mortality. It is important to have a planned management approach available for the anticipated and, more importantly, the unanticipated difficult airway. The recommendations of the American Society of Anesthesiologists Taskforce on the Management of the Difficult Airway have good application for this important problem. The fetus with the prenatal diagnosis of a lesion that predicts a difficult airway presents a particular challenge. The utilization of an ex-utero intrapartum treatment method is presented as an important approach for the delivery and airway management of these infants. This section closes with a discussion of the prehospital airway management of the pediatric patient.

Anesthesia↗
PubMed1996

The acute and residual effects of subanesthetic concentrations of isoflurane/nitrous oxide combinations on cognitive and psychomotor performance in healthy volunteers.

A blind, randomized, cross-over trial was conducted to determine the degree of psychomotor/cognitive impairment and the recovery profile produced by combinations of subanesthetic concentrations of isoflurane and nitrous oxide in healthy volunteers. In the experiment, subjects (n = 10) inhaled 100% oxygen-placebo, 30% nitrous oxide in oxygen, and 0.2% and 0.4% isoflurane in oxygen, alone, and in combination with 30% nitrous oxide, in different sessions. Dependent measures included psychomotor and cognitive performance. Impairment was profound with the combination of inhaled anesthetics, and from an analysis of control conditions (the anesthetics alone), it appeared that isoflurane produced more impairment than did nitrous oxide. The time course of recovery was extremely rapid, with subjects returning to control-level functioning 5 min after cessation of the drug inhalation. The drug combination of isoflurane and nitrous oxide appears to be a promising candidate for conscious sedation procedures, although its analgesic and mood-altering effects need to be studied more systematically.

Adult↗
PubMed2000

Validation of a blind transpyloric feeding tube placement technique in pediatric intensive care: rapid, simple, and highly successful.

OBJECTIVE: Nasogastric feeding in intensive care is poorly tolerated as a result of gastroparesis. Transpyloric (TP) feeding has been limited by difficulty in tube placement. This study was to independently validate the success rate of a previously published bedside TP feeding tube (FT) placement technique. DESIGN: Prospective interventional study. SETTING: Tertiary pediatric intensive care unit (PICU) in a university hospital. PATIENTS: Children whose intensivist requested TP feeding, and who were without known fundoplication, pharyngeal trauma, or gastric ulceration. INTERVENTIONS: After informed consent, an unweighted polyurethane feeding tube with a flexible wire stylet was inserted using a standard technique with metoclopramide, right lateral position, and air insufflation during advancement until <2 mL air could be aspirated after insufflation of 5-10 mL air. The tubes were inserted by one of the authors, whose training was only to observe one insertion, then perform one insertion with supervision. MEASUREMENTS AND MAIN RESULTS: Patient demographics, procedural data, and success rate based on radiography were prospectively recorded. There were 71 insertions on 38 patients from February 1999 to October 1999. Patients were aged 56 +/- 69.8 months, weighed 17.8 +/- 18 kg, 69% were ventilated, and 56% received procedural sedation. Success rate for TP-FT placement was 63/71 insertions (88.7%) in an average of 7.43 +/- 6.85 mins (median, 5 mins; range, <1-45 mins); of 38 patients, 36 had a successful TP- FT (95%). Insertion was well tolerated. Of the successful TP-FTs, on day 1 (n = 63) the FT was in distal duodenum or jejunum in 51% and by days 3-5 (n = 51), this increased to 75%. CONCLUSIONS: Bedside placement of a TP-FT with this technique is simple, rapid, well tolerated, and highly successful with little training. Immediate radiograph to confirm TP placement may not always be necessary. In our experience, this technique has obviated the need to search for another method to achieve a transpyloric feeding tube.

Journal Article↗
PubMed2005

Jaw thrust can deteriorate upper airway patency.

Upper airway obstruction is a frequent problem in spontaneously breathing children undergoing anesthesia or sedation procedures. Failure to maintain a patent airway can rapidly result in severe hypoxemia, bradycardia, or asystole, as the oxygen demand of children is high and oxygen reserve is low. We present two children with cervical masses in whom upper airway obstruction exaggerated while the jaw thrust maneuver was applied during induction of anesthesia. This deterioration in airway patency was probably caused by medial displacement of the lateral tumorous tissues which narrowed the pharyngeal airway.

Adolescent↗
PubMed2006

Ketamine increases opening cerebrospinal pressure in children undergoing lumbar puncture.

Intravenous ketamine, often administered concomitantly with midazolam, is one of the most commonly used drugs for procedural sedation in children. Although it is considered safe for use in children, ketamine can increase intracranial pressure. Hence, this study was carried out to determine whether adding ketamine to midazolam prior to performing lumbar puncture would be associated with a higher cerebrospinal fluid opening pressure in children with suspected aseptic meningitis. Thirty-nine children aged 6 months to 14 years were included: 26 in group A (intravenous midazolam plus ketamine) and 13 in group B (intravenous midazolam only). Mean cerebrospinal fluid opening pressure in group A was 24.4 cm H2O (median 23 cm H2O) compared with 20 cm H2O (median 19.8 cm H2O) in group B (P = .011). Intravenous ketamine prior to performing lumbar puncture is associated with a significantly higher lumbar cerebrospinal fluid opening pressure in children with aseptic meningitis. However, no outcome differences have been found between the two groups.

Adolescent↗