• 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.
    • 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.
    • Dexmedetomidine as an Adjuvant for MRI Sedation in a Neurologically Impaired Child

      Qadeer, Ahsan; Yates, Laurie J.; Florentino-Pineda, Ivan; Department of Anesthesiology and Perioperative Medicine (Society for Pediatric Anesthesia, 2009-03)
      Emergence from anesthesia may be delayed in neurologically impaired children. The higher incidence of respiratory complications in these patients is due to the associated comorbidities such as gastroesophageal reflux and poor function of laryngeal and pharyngeal reflexes. Use of dexmedetomidine (DEX), a highly selective alpha-2 adrenergic receptor agonist, is becoming popular, as practitioners continue to discover its safety and efficacy as a sedative and anesthetic adjunct. The primary advantage DEX may have over other agents commonly used for pediatric sedation is a lack of significant respiratory events, such as changes in respiratory rate, end-tidal CO2 and oxyhemoglobin saturation. In this case report, DEX was effectively used to provide sedation for MRI in a child with severe neurological impairment.
    • Does CVP Correlate with Transesophageal Echocardiographic Evaluation of Right Heart Function?

      Arthur, Mary E.; Reddy, Satish V.; Mehta, Anand R.; Castresana, Manuel R.; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2009-10)
      Important goals in the management of cardiac patients under general anesthesia include accurate evaluation of right heart function, preload status, and assessment of fluid responsiveness. Central venous pressure (CVP) recorded from the right atrium or superior vena cava is said to reflect intravascular volume. The ability of the CVP to predict fluid responsiveness, i.e., an increase in stroke index/cardiac index following a fluid challenge, has indirectly advanced the idea that CVP is a measure of right heart function and that patients with right ventricular failure may exhibit elevated CVP. Several echocardiographic parameters including right ventricular ejection fraction, amplitude of the tricuspid annular plane systolic excursion (TAPSE) assessed by M-mode, and tricuspid annular systolic velocity recorded by Doppler tissue imaging have been used to evaluate right ventricular function.
    • Drug-eluting Stent Thrombosis and Acute Myocardial Infarction in PACU

      Donald, Ranita R.; Issah, Seidu; Chaknis, Caren; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2009-10)
      Lately, more patients have been presenting for noncardiac surgery after recent placement of cardiac stents, either bare-metal stents or drug-eluting stents. Noncardiac surgery performed following recent stent placement poses risk of acute stent thrombosis due to inherent hypercoagulable state of surgery as well as the common practice of perioperatively discontinuing antiplatelet therapy, which may result in major adverse cardiac events such as stent thrombosis, myocardial infarction and death. Acute stent thrombosis accounts for up to a 60% acute myocardial infarction rate and up to a 45% mortality rate. The risk of perioperative bleeding associated with continued antiplatelet therapy must be weighed against the catastrophic event of stent thrombosis. We report a challenging case involving DES thrombosis and acute myocardial infarction in the immediate postoperative period. This case highlights the importance of the scientific advisory recently released by the American Heart Association and American College of Cardiology against the premature discontinuation of antiplatelet therapy in patients with coronary stents.
    • Emergent Airway Management in an Infant with Congenital Laryngeal Cyst Causing Airway Obstruction

      Downard, Martina; Florentino-Pineda, Ivan; Department of Anesthesiology and Perioperative Medicine (Society for Pediatric Anesthesia, 2009-03)
      Congenital Laryngeal Cysts (CLC) is a rare but often life-threatening condition that affects approximately one in 150,000 live births. Clinical presentation of CLC includes respiratory distress, stridor, feeding intolerance, and failure to thrive. If the cyst is large enough to cause complete obstruction of the airway, asphyxia may rapidly cause death if left untreated in a neonate. Therefore, CLC must be included in the differential in an infant or newborn with stridor and respiratory distress refractory to medical treatment. This case report describes an infant with a history of worsening stridor who was found to have a large cystic mass obstructing the airway.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • 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.
    • Severe Compartment Syndrome Following Extravasation of Fluids in a Critically Ill Neonate

      Martinez-Lu, Kianfa; Weatherred, Ted; Florentino-Pineda, Ivan; Department of Anesthesiology and Perioperative Medicine (Society for Pediatric Anesthesia, 2009-03)
      Intravenous therapy is generally a safe and effective way to administer different therapies to patients of all ages. Despite its ubiquitous use in modern medicine, it is not devoid of complications. Hematoma formation, phlebitis, infection, and tissue infiltration are some common complications of the use of peripheral IV catheters. Here we report a case in which peripheral IV fluid extravasation caused severe compartment syndrome in a critically ill preterm neonate undergoing exploratory laparotomy in the NICU.
    • Single-Stranded Oligonucleotide Aptamer Binding to P-Selectin Inhibits Adhesion of Sickle Red Blood Cells and Leukocytes to Endothelial Cells in Sickle Cell Disease Model Mice: Novel Therapeutics for Vaso-occlusive Episodes

      Gutsaeva, Diana R.; Parkerson, James B.; Schaub, Robert G.; Kurz, Jeffrey C.; Head, C. Alvin; Medical College of Georgia; Department of Anesthesiology and Perioperative Medicine (American Society of Hematology, 2009-12)
      Adhesive interactions between circulating red blood cells (RBC), leukocytes, and endothelial cells in post capillary venules have been implicated as a contributing factor to the pathogenesis of vaso-occlusion, the major cause of morbidity and mortality associated with sickle cell disease (SCD). Endothelial cell P-selectin, a member of the selectin family of cell adhesion molecules, plays a key role in leukocyte recruitment as well as in the adhesion of sickle RBC (sRBC) to the endothelium. The expression of P-selectin is elevated in SCD and the interaction of P-selectin and its ligands is likely to contribute to impairment of the microvascular flow and thereby to the development of painful vaso-occlusive episodes. Aptamers, short single-stranded oligonucleotides that fold into complex 3-D structures and bind to ligands, have been developed for a wide range of therapeutic targets. Although anti-P-selectin aptamers have been shown to inhibit leukocyte rolling in vitro and to display efficacy in mouse models for inflammation, anti-adhesion activity of anti-P-selectin aptamers has never been evaluated in SCD.
    • 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.
    • 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.