• TEE to facilitate anesthetic management during thoracotamy in a patient with severe pulmonary hypertension and pulmonary venous obstruction

      Aryal, Anuj; Mehta, Anand; Arthur, Mary E.; Castresana, Manuel R.; Medical College of Georgia; Department of Anesthesiology and Perioperative Medicine (American Society of Anesthesiologists, 2009-10)
      The lateral decubitus position, use of one-lung ventilation, and the prevention and treatment of hypoxemia continue to present challenges to the anesthesiologist, particularly in the patient with pulmonary hypertension. We describe the utility of intraoperative transesophageal echocardiography in the management of a patient with severe pulmonary hypertension and pulmonary vein stenosis undergoing thoracotomy for tissue diagnosis.
    • 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.
    • 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.
    • 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.
    • 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.
    • Use of Dexmedetomidine as Adjuvant for the Anesthetic Management of Obese Children with Obstructive Sleep Apnea Undergoing Tonsillectomy and Adenoidectomy

      Mendiola, Raul A.; Florentino-Pineda, Ivan; Department of Anesthesiology and Perioperative Medicine (Society for Pediatric Anesthesia, 2009-03)
      Obstructive sleep apnea (OSA) in children is most commonly associated with tonsillar and adenoid hypertrophy. Use of opioids and residual amounts of inhaled agents can cause severe respiratory depression and thus represent an added risk to patients with OSA in the immediate postoperative period. Dexmedetomidine, a specific alpha 2-adrenergic receptor agonist, is known for its hypnotic, sedative, analgesic and sympatholytic properties. It potentiates analgesia with the advantages of minimal respiratory compromise, rapid onset and clearance. Because dexmedetomidine has been shown to be effective as an analgesic and sedative agent while minimizing respiratory compromise, it offers a safer alternative as an adjuvant for the anesthetic management of obese pediatric patients with OSA undergoing tonsillectomy and adenoidectomy.
    • 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.