• Bioactivity and Mechanism of Action of Resveratrol, A Polyhenolic Phytoalexin, in Sickle Cell Disease

      Agyekum, Davies G.; Department of Anesthesiology and Perioperative Medicine (2013-07)
      The primary goal of this research was to evaluate the fetal hemoglobin (HbF)- inducing efficacy of resveratrol (RSV), a plant polyphenol, in relevant in vitro systems, a preclinical mouse model of sickle cell disease (SCD) and to determ ine its mechanism of action. An overview of the public health impact of SCD, the molecular pathogenesis of the disease and our current understanding of the fetal-to-adult hemoglobin switch are discussed in detail below. Additionally, the roles of erythroid Kruppel-like factor 1 (KLF1) and B-cell lymphoma 11A (BCL11A) in silencing the gene responsible for fetal hemoglobin are discussed, followed by a description of experimental models used to study sickle cell disease. Lastly, the properties and applications of RSV in relevant disease models are discussed, followed by a description of the objectives and specific aims of this study.
    • Absolute cerebral oximeters for cardiovascular surgical cases

      Arthur, Mary E.; Department of Anesthesiology and Perioperative Medicine (Georgia Regents University, 2013-02)
      In the US, about 465,000 cardiopulmonary bypass grafting (CABG) procedures are performed every year. Decreases in oxygen levels occur in about 17-23% of CABG procedures which cause brain injury even in uncomplicated surgeries, and may lead to stroke, cognitive dysfunction, longer ventilation times; longer ICU and hospital stays, and higher health care costs. Because of the brain’s high metabolic rate with limited oxygen reserves, only about 10 seconds at normal body temperature makes the brain is susceptible to oxygen deprivation. A study on patients who underwent CABG surgery found that incidence of cognitive decline was 53% at discharge and 42% at 5 years (Newman, 2001). Furthermore, elderly patients are more likely to develop cerebral desaturation because of age-related reductions in physiologic reserve (Casati, 2005), and the number of surgeries involving older patients is on the rise.
    • Anterior Mediastinal Mass in a Patient Requiring Lung Isolation

      Janardhanam, Ram; Patel, Vijay; Arthur, Mary E.; Department of Anesthesiology and Perioperative Medicine; Department of Cardiothoracic Surgery (American Society of Anesthesiologists, 2010-10)
      A patient with an anterior mediastinal mass poses numerous challenges to an anesthesiologist, the major concerns being pulmonary or cardiac collapse on induction of anesthesia. Preoperative evaluation of the chest x-ray as well as the CT scan is valuable in assessing potential problems regarding management of this type of airway. An awake fiberoptic intubation is the preferred method of securing the airway.
    • Use of the Video RIFL (Rigid Flexible Laryngoscope) as an Adjunct to Direct Laryngoscopy

      Setty, Harsha; Gallen, Thomas; Dubin, Stevin; Department of Anesthesiology and Perioperative Medicine (Society for Airway Management, 2010-09)
      The ASA difficult airway algorithm incorporates different modalities in its progression. It is not uncommon for the user to fail at direct laryngoscopy, thus requiring an alternate method for securing an airway. Frequently, the alternate modalities include supraglottic airways, rigid videolaryngoscopes, or flexible fiberoptic bronchoscopes. We retrospectively reviewed charts from February 2009 to February 2010 on patients intubated in the operating room using the Video RIFL.
    • Granulomatous Conduit for Intrathecal Infusion of Morphine and Bupivacaine

      Webb, David M; Schneider, John R; Lober, Robert M.; Vender, John R.; Department of Anesthesiology and Perioperative Medicine; Department of Neurosurgery (American Society of Regional Anesthesia and Pain Medicine, 2010-11)
      Intrathecal Drug Delivery Systems (IT-DDS) have gained widespread acceptance as a therapeutic alternative to high dose parenteral opioids for unremitting chronic pain. Granuloma formation has been reported as a side effect in association with the greater use of IT-DDS. Etiological factors include infection, reaction to catheter material, and trauma at the site of implantation. The most widely accepted etiology is the use of intrathecal morphine, with granuloma formation dependent on morphine dosage. We present the case of a woman with unremitting GI pain and IT-DDS placement who developed a granuloma at the hub of the catheter which formed a sealed conduit that re-established drug flow between the pump and catheter.
    • Unanticipated Acute Adrenal Insufficiency During Emergency Thoracotomy Re-Exploration

      Rawlings, J Lee; Spivey, Jerry A; Castresana, Manuel R.; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2010-10)
      For the last 50 years there has been a debate over the management of corticosteroid supplementation in the context of surgical or critically ill patients. At a minimum, clinicians agree that chronic corticosteroids should be continued in the perioperative or ICU setting, however in patients without a history of steroid use, acute adrenal insufficiency as the cause of hemodynamic compromise can be an elusive diagnosis. We present a case report.
    • Thrombolytic Therapy in a Patient with an Epidural Catheter

      Janardhanam, Ram; Mellinger, John D.; Hammonds, William D; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2010-10)
      The ability to provide comfort and relieve pain during the postoperative period is a priority in the care of the surgical patient. Epidural anesthesia is widely used to manage postoperative pain. The epidural infusion of local anesthetics combined with opioids provides excellent pain relief. It also reduces intra- and postoperative narcotic requirements, leading to earlier mobilization and faster discharge. However, epidural analgesia carries risks for the patient. This presentation reports on the risk of treating a patient with thrombolytics while receiving epidural analgesia.
    • General Anesthesia in an Ex-Utero Intrapartum Treatment (EXIT) Procedure for a Neonate with NAGER Syndrome

      Grinage, Brandon C; O'Bannon, Robert Toney; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2010-10)
      In the ex-utero intrapartum treatment (EXIT) procedure, an incision is made similar to that for a cesarean section. Following uterine incision, the baby is partially delivered by the obstetrician but remains attached to the maternal-fetal unit, allowing the pediatric surgeon to establish or secure an airway while the baby maintains oxygen saturation on utero-placental support. Once the airway has been secured, the obstetric team resumes control of the procedure, the umbilical cord is cut and clamped, and the delivery of the baby is completed. We report on an EXIT procedure performed for fetal craniofacial abnormalities secondary to Nager Syndrome.
    • Challenge of a Difficult Airway and Anesthetic Management in a Patient with Still's Disease

      Donald, Ranita R.; Taylor, Emi; Gallen, Thomas; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2010-10)
      Adult-onset Still’s disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology with articular and extra-articular (systemic) manifestations. The disorder owes its name to Sir George Frederick Still, who in 1897 described 22 children with symptoms consistent with what is currently known as systemic onset juvenile idiopathic arthritis. AOSD was established almost a century later in 1971, when Eric Bywaters encountered and described adult patients presenting with pediatric Still’s disease symptoms. Compared to rheumatoid arthritis in adults, AOSD runs a much more acute course, quite often affecting many parts of the body before settling in the various joints. Diagnosis of AOSD is difficult to establish due to the nonspecific clinical and laboratory findings. Tracheal intubation may become difficult due to impairment of cervical spine, temporomandibular joint and laryngeal involvement (crico-arytenoid arthritis). Patients with chronic articular disease have more disability and worse prognosis than patients with only systemic symptoms.
    • Strategies for a Successful Anesthesiology Clerkship and Rewarding Experience for Medical Students

      Donald, Ranita R.; Odo, Nadine; Dawkins, Susan; Mason, Nikova; Gilbertson, Laura; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2010-10)
      The anesthesiology clerkship is a senior year selective in our institution which fulfills the critical care rotation requirement. Our clerkship has been such a popular rotation that enrollment can be quite competitive. Thanks to the dedication of our faculty and residents, students consistently report positive experiences about this rotation. Many of the medical students are not aware of the anesthesiologist’s multi- faceted role as a perioperative physician until their clerkship rotation in anesthesiology. Choosing a specialty is a difficult and stressful process. Anesthesiology continues to be a highly desirable specialty among U.S. medical students.
    • Morbidly Obese Complex Obstetrical Patient with Undiagnosed Peripartum Cardiomyopathy and Development of Flash Pulmonary Edema in PACU

      Donald, Ranita R.; Crews, Lindsay K; Department of Anesthesiology and Perioperative Medicine (International Anesthesia Research Society, 2010-05)
      Peripartum cardiomyopathy (PPCM) is a rare disorder of uncertain etiology. Virchow and Porack first recognized the relationship between heart failure and pregnancy in the 1870s when they noted myocardial degeneration in patients who died in the postpartum period. PPCM was first described as a distinctive cardiomyopathy in 1937 by Gouley et al. Since then, much has been learned about this disease process, and better treatment options now exist. Incidence varies greatly worldwide. Reports suggest an incidence of 1 case per 299 live births in Haiti, 1 per 1000 in South Africa, and 1 per 3000-4000 in the United States. Reported mortality rates are between 18% and 56%. A latent form of PPCM has also been described. Here we describe a case of latent PPCM in a morbidly obese patient who developed dramatic flash pulmonary edema in the postanesthesia care unit.
    • Neurologic Deficit Following Ultrasound Guided Femoral Nerve Block

      Aryal, Anuj; Mayfield, James; Hammonds, William D; Department of Anesthesiology and Perioperative Medicine (Society for Ambulatory Anesthesia, 2010-05)
      Ultrasound provides real time visualization of peripheral nerves while performing a peripheral nerve block. We present a case of post operative neural dysfunction following ultrasound guided femoral nerve block on a patient undergoing left knee arthroscopy.
    • Intranasal Septal Perforation in a 4-Year-Old by an Impacted Button Battery: A Case Report and Review of the Literature

      Mattingly, Diana; Crews, Lindsay K; Florentino-Pineda, Ivan; Department of Anesthesiology and Perioperative Medicine (Society for Pediatric Anesthesia, 2010-03)
      While intranasal foreign bodies account for less than 1% of pediatric emergency room visits, proper diagnosis and management is critical to minimize significant morbidity and mortality. Intranasal button batteries in particular pose a significant threat to the pediatric population as nasal mucosal necrosis, septal perforation, facial cellulitis, and lateral nasal wall necrosis can occur within hours of insertion. The incidence of impacted button batteries has risen with the increased prevalence in common electronics like hearing aids, watches, and musical greeting cards. One study estimated that button batteries comprised 7% of intranasal foreign bodies removed from pediatric patients in a 6-month period. We report a case of intranasal button battery impaction in a 4-year-old male that resulted in significant tissue injury and required general anesthesia for extraction.
    • Prevention of Progressive Deterioration of Motor Evoked Potentials During General Anesthesia

      O'Bannon, Robert Toney; Dubin, Stevin; Department of Anesthesiology and Perioperative Medicine (Society for Neuroscience in Anesthesiology and Critical Care, 2010-10)
      The increasing frequency and complexity of spinal column corrective procedures have aided the advancement of evoked potential monitoring. The effectiveness of somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) to detect iatrogenic cord ischemia during surgical manipulation has been well established. Detection followed by corrective measures can limit and/or prevent iatrogenic injuries associated with instrumentation during these corrective surgical procedures.
    • The Influence of Ethnicity on Visual Analog Scale Pain Ratings: Pre- and Post-Radiofrequency Application for Pain of Zygapophyseal Joint Origin

      Rogg, Schuyler A; Martinez-Lu, Kianfa; Martin, Dan C; Williams, Gwendolyn O; Hammonds, William D; Department of Anesthesiology and Perioperative Medicine (American Society of Interventional Pain Physicians, 2010-02)
      Increased scrutiny of the allocation of health care dollars makes the identification of factors influencing treatment outcomes important. Few studies have examined the relationship between ethnicity and the efficacy of chronic pain management interventions (as opposed to acute pain syndromes). Radiofrequency application (RFA) is a common treatment modality for pain due to zygapophyseal joint (z joint) disease. This survey reviewed the efficacy of RFA in African American (AA) and non-Hispanic Caucasian patients. This study is a retrospective chart review of patients who underwent RFA to the L3, L4 medial branch nerves, dorsal ramus of L4, and the accessory nerve from the S1 dorsal ramus to the L5-S1 z joint.
    • Transcranial Doppler measures in patients with sickle cell disease at high risk for stroke and receiving hydroxyurea: the HyRetro ancillary study

      Adamkiewicz, Thomas; Odo, Nadine; Kutlar, Abdullah; Kwiatkowski, Janet L; Adams, Robert J; School of Medicine; Morehouse College; Department of Anesthesiology and Perioperative Medicine (American Society of Hematology, 2010-12)
      Children with sickle cell disease (SCD) and increased transcranial Doppler sonography velocity measures are at increased risk for stroke. Although chronic transfusion decreases risk tenfold, this form of therapy is burdensome and includes risk of iron overload. Hydroxyurea therapy is effective in preventing SCD complications, although its effect in preventing SCD central nervous system complications is less clear and a matter of current investigation.
    • Hydroxyurea induces fetal hemoglobin expression by activating cAMP signaling pathways in a cAMP- and cGMP-dependent manner

      Ikuta, Tohru; Gutsaeva, Diana R.; Parkerson, James B.; Yerigenahally, Shobha D; Head, C. Alvin; Department of Anesthesiology and Perioperative Medicine (American Society of Hematology, 2010-12)
      Here we show that hydroxyurea (HU) induces fetal hemoglobin (HbF) expression by activating the cAMP pathway through two independent mechanisms. Although HU increased both cAMP and cGMP levels in CD34+-derived erythroblasts, only the cAMP pathway was found to be activated. However, HU-induced HbF expression was affected by the activities of both adenylate cyclase (AC) and soluble guanylate cyclase (sGC). HU decreased the expression of cGMP-inhibitable phosphodiesterase (PDE) 3B in a sGC-dependent manner, resulting in activation of the cAMP pathway. Second, HU induced the expression of cyclooxygenase-1 (COX-1) and increased the production of prostaglandin E2 (PGE2), which resulted in activation of the cAMP signaling pathway through AC. HU therapy elevated plasma PGE2 levels in sickle cell patients. These results demonstrate that HU induces HbF expression by activating the cAMP pathway via dual signaling mechanisms.
    • The Use of Dexmedetomidine During Nasotracheal Intubation in a Patient with CHARGE Syndrome

      Crews, Lindsay K; Mattingly, Diana; Florentino-Pineda, Ivan; Department of Anesthesiology and Perioperative Medicine (Society for Pediatric Anesthesia, 2010-03)
      CHARGE Syndrome (CS), also known as Hall-Hittner syndrome, is a congenital disorder comprised of multiple anomalies (coloboma, heart defect, atresia choanal, retarded growth and development, genital hypoplasia, ear anomalies/deafness). First described in 1979 by Hall and Hittner, it is caused by a mutation in the gene CHD7 on chromosome 8.1 Facial and upper airway features of CS, including midface hypoplasia, micrognathia, cleft lip, and palate, anterior larynx, and subglottic stenosis, make the airway management of these patients a challenge for the anesthesiologist. Because difficult airway management is a concern, spontaneous ventilation is recommended until the airway is secured. We report the use of dexmedetomidine (DEX) for deep sedation in a CS patient who required nasotracheal intubation using a fiberoptic bronchoscope (FB) while breathing spontaneously.
    • Synergistic Enhancement of Sickle Red Blood Cell Adhesion to Endothelium by Hypoxia and Low Nitric Oxide Bioavailability

      Gutsaeva, Diana R.; Parkerson, James B.; Yerigenahally, Shobha D; Ikuta, Tohru; Head, C. Alvin; Department of Anesthesiology and Perioperative Medicine (American Society of Hematology, 2010-12)
      The mechanisms underlying sickle red blood cell (RBC) adhesion to the endothelium, which constitutes a major pathologic event in sickle cell disease (SCD), are not fully understood. Adhesion of sickle RBCs to endothelial cells is believed to be regulated by multiple hematologic and physiologic factors including fetal hemoglobin levels, leukocyte count, oxygen tension, inflammatory cytokines, and nitric oxide (NO) bioavailability, but the extent to which each parameter contributes to sickle RBC adhesion remains unclear. Our objective was to examine how the adhesion of sickle RBCs to endothelium is affected by hypoxia and NO bioavailability using an in vivo system.
    • Improving cultural competency among anesthesiology residents via virtual interactions with Hispanic standardized patients

      Arthur, Mary E.; Albritton, Josephine; Florentino-Pineda, Ivan; Odo, Nadine; Head, C. Alvin; Palladino, Christie; Department of Anesthesiology and Perioperative Medicine (Association of American Medical Colleges, 2010-11)
      Hispanics/Latinos comprise about 15% of the US population and are the fastest growing minority in America. In Georgia, however, Hispanics represent only about 3% of the population, and health professionals training in the state may have few opportunities to interact with Hispanic patients. Language and cultural barriers, lack of health insurance, and so on, can lead to health disparities. Improved cultural competence among health care professionals can help to reverse such disparities. As such, the Medical College of Georgia at Georgia Health Sciences University (MCG) has made it a priority to improve the cultural competency of its allied health, dental, medical and nursing students through its Quality Enhancement Plan. Similarly, the anesthesiology department is planning a project in which residents will interview the standardized patient remotely via Skype and webcams, in a manner similar to the telemedicine model, then receive immediate feedback from the SP and faculty member.