The significance of widely split P waves: a case report.

BACKGROUND: P wave morphology on electrocardiogram is often overlooked but indicates abnormal cardiac conduction from various etiologies. Split P waves on electrocardiogram have been reported previously but not in a perioperative setting. CASE PRESENTATION: A 69-year-old Caucasian male patient with widely split P waves on his preoperative electrocardiogram was scheduled for a reimplantation right total hip replacement under a combined spinal-general anesthetic technique. The patient was evaluated prior to surgery by a cardiologist and the preoperative anesthesia clinic without any comment on the abnormal P wave morphology on electrocardiogram. The patient was cleared to proceed with anesthesia and surgery. Following induction of general anesthesia, his cardiac rhythm changed to a Mobitz type II pattern. The surgical procedure was cancelled, and a permanent cardiac pacemaker was inserted. CONCLUSIONS: Anesthesiologists should be aware that the presence of widely split P waves on electrocardiogram indicates the presence of atrial conduction abnormalities, likely from an ischemic or infiltrative process that can lead to more serious cardiac arrhythmias. P wave morphology should be observed and noted during the perioperative period for all patients.

Recent advances in anesthesia of the obese patient.

The anesthetic management of an obese patient can be challenging because of the altered anatomy and physiology associated with obesity. In this article, I review the recent medical literature and highlight some of the controversies in the airway management and drug dosing of morbidly obese patients.

Capnoperitoneum During Peroral Endoscopic Myotomy-Recognition and Management: A Case Report.

Peroral endoscopic myotomy (POEM) is a minimally invasive procedure for treating esophageal achalasia. During POEM, carbon dioxide is insufflated under pressure into the esophagus and stomach, which can cause clinically significant capnoperitoneum, capnomediastinum, or capnothorax. We present a case in which gas accumulation in the abdomen during POEM had adverse effects on ventilation. Once the cause was recognized, needle decompression of the abdomen led to immediate improvement in ventilation.

Tracheal Stenosis Because of Wegener Granulomatosis Misdiagnosed as Asthma.

We describe a patient with Wegener granulomatosis whose complaint of wheezing was incorrectly attributed to asthma. Anesthesiologists must recognize that tracheal stenosis is extremely common in Wegener granulomatosis and can mimic other causes of wheezing.

Caroline B. Palmer: Pioneer Physician Anesthetist and First Chair of Anesthesia at Stanford.

Caroline B. Palmer was appointed as Chief of Anesthesia at Cooper Medical College (soon renamed as Stanford Medical School) in 1909. For the next 28 years, she was an innovative leader, a clinical researcher, and a strong advocate for recognition of anesthesiology as a medical specialty. To honor her accomplishments, the operating room suite in the new Stanford Hospital will be named after this pioneering woman anesthesiologist.

Spinal Surgery and Abrupt Intrathecal Baclofen Withdrawal.

Abrupt cessation of intrathecal baclofen can lead to a serious withdrawal syndrome. The anesthesiologist must be prepared to avoid intraoperative interruption of baclofen delivery before starting spinal surgery and to recognize and treat the symptoms of baclofen withdrawal in the immediate postoperative period.

Bariatric surgery operating room time--size matters.

BACKGROUND: The goal of this study was to document the relationship between BMI and the components of bariatric surgical operating room (OR) time. METHODS: The Stanford Translational Research Integrated Database Environment identified all patients who underwent laparoscopic Roux-en-Y gastric bypass procedures at Stanford University Medical Center between May 2008 and November 2013. The 434 patients were divided into 3 groups: group 1 (n = 213) BMI ≥35 to <45 kg/m(2), group 2 (n = 188) BMI ≥45.0 to <60 kg/m(2), and group 3 (n = 33) BMI ≥60 kg/m(2). The primary variable measured was total operating room time, defined as beginning when the patient entered the OR until the moment the patient physically left the OR. Secondary variables were anesthetic induction time, nursing preparation time, operation time, time for emergence from anesthesia, and total length of hospital stay. RESULTS: Increasing BMI was associated with increased total OR time (group 1 = 202 min, group 2 = 215 min, group 3 = 235 min), mainly due to longer operation time (group 1 = 147 min, group 2 = 154 min, group 3 = 163 min). Anesthetic induction (group 1 = 17 min, group 2 = 18 min, group 3 = 23 min) and emergence times (group 1 = 12 min, group 2 = 12 min, group 3 = 22 min) were also significantly longer in the largest patients. CONCLUSIONS: Operating room schedules and plans for resource utilization should recognize that the same bariatric procedure will require more time for patients with BMI >60 kg/m(2) than for smaller bariatric patients.

Obesity increases operating room times in patients undergoing primary hip arthroplasty: a retrospective cohort analysis.

Background. Obesity impacts utilization of healthcare resources. The goal of this study was to measure the relationship between increasing body mass index (BMI) in patients undergoing total hip arthroplasty (THA) with different components of operating room (OR) time. Methods. The Stanford Translational Research Integrated Database Environment (STRIDE) was utilized to identify all ASA PS 2 or 3 patients who underwent primary THA at Stanford Medical Center from February 1, 2008 through January 1, 2013. Patients were divided into five groups based on the BMI weight classification. Regression analysis was used to quantify relationships between BMI and the different components of total OR time. Results. 1,332 patients were included in the study. There were no statistically significant differences in age, gender, height, and ASA PS classification between the BMI groups. Normal-weight patients had a total OR time of 138.9 min compared 167.9 min (P < 0.001) for morbidly obese patients. At a BMI > 35 kg/m(2) each incremental BMI unit increase was associated with greater incremental total OR time increases. Conclusion. Morbidly obese patients required significantly more total OR time than normal-weight patients undergoing a THA procedure. This increase in time is relevant when scheduling obese patients for surgery and has an important impact on health resource utilization.

Sequential bilateral lung isolation with a single bronchial blocker.

Sequential bilateral lung separation and selective lung collapse can be accomplished with either a double-lumen tube, a single bronchial blocker (BB) that must be repositioned during the operation, or by using 2 BBs, 1 placed in each main bronchus. We provided sequential bilateral lung collapse using a single BB without the need to reposition during surgery.

Comparison of procedural times for ultrasound-guided perineural catheter insertion in obese and nonobese patients.

OBJECTIVES: Perineural catheter insertion with ultrasound guidance alone has been described, but it remains unknown whether this new technique results in the same procedural time and success rate for obese and nonobese patients. We therefore tested the hypothesis that obese patients require more time for perineural catheter insertion compared to nonobese patients despite using ultrasound. METHODS: Data from 5 previously published randomized clinical trials comparing ultrasound- and stimulation-guided perineural catheter insertion techniques were reviewed, and patients who received ultrasound-guided catheters were divided into 2 groups: obese (body mass index ≥30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)). A standardized ultrasound-guided nonstimulating catheter technique was used with mepivacaine, 1.5% (40 mL), as the initial bolus via the placement needle for the primary surgical nerve block. The primary outcome was the procedural time for perineural catheter insertion. Secondary outcomes included block efficacy, procedure-related pain, fluid leakage, vascular puncture, and catheter dislodgment. RESULTS: A sample of 120 patients was identified: 51 obese and 69 nonobese. All obese patients had successful catheter placement compared to 68 of 69 (98%) nonobese patients (P = .388). The time for perineural catheter insertion [median (10th-90th percentiles)] was 7 (4-12) minutes for obese patients versus 7 (4-15) minutes for nonobese patients (P = .732). There were no statistically significant differences in other secondary outcomes. CONCLUSIONS: On the basis of this retrospective analysis, perineural catheter insertion is not prolonged in obese patients compared to nonobese patients when an ultrasound-guided technique is used. However, these results are only suggestive and require confirmation through prospective study.

Regional anaesthesia in the obese patient: lost landmarks and evolving ultrasound guidance.

Obesity is associated with a number of anaesthetic-related risks. Regional anaesthesia offers many potential advantages for the obese surgical patient. Advantages include a reduction in systemic opioid requirements and their associated side effects, and possible avoidance of general anaesthesia in select circumstances, with a lower rate of complications. Historically, performing regional anaesthesia procedures in the obese has presented challenges due to difficulty in identifying surface landmarks and availability of appropriate equipment. Ultrasound guidance may aid the regional anaesthesia practitioner with direct visualisation of underlying anatomic structures and real-time needle direction. Further research is needed to determine optimal regional anaesthesia techniques, local anaesthetic dosage and perioperative outcomes in obese patients.