ABSTRACT
Semaglutide is a class of long-acting glucagon-like peptide-1 receptor agonists (GLP1-RA) used for the treatment of type 2 diabetes mellitus (T2DM) and obesity. We present a 31-year-old female patient with a past medical history of T2DM without complication and no long-term or current use of insulin, class 3 obesity, hypertension, hyperlipidemia, polycystic ovary syndrome (PCOS), and anxiety, who underwent an esophagogastroduodenoscopy (EGD) in preparation for bariatric surgery while taking semaglutide. Despite appropriately following the preoperative fasting guidelines of the American Society of Anesthesiologists (ASA), endoscopy revealed food residue in the gastric body, necessitating abortion of the procedure to reduce the risk of intraoperative pulmonary aspiration. Given the lack of preoperative fasting guidelines for patients on semaglutide to date, and delayed gastric emptying being a known side effect among patients taking semaglutide, anesthesiologists should be aware of alternative methods to ensure no food is present in the stomach to mitigate the risk of pulmonary aspiration during general anesthesia.
ABSTRACT
Background: Interscalene nerve catheters have been proven to be effective in managing pain after rotator cuff repair (RCR) surgery. Liposomal bupivacaine is a newer approved therapy for use around the interscalene brachial plexus, but its analgesic efficacy has limited supporting data in various patient populations. Purpose/Hypothesis: The purpose of this study was to investigate the quality of recovery after arthroscopic RCR in patients who received either single-injection interscalene liposomal bupivacaine or an interscalene peripheral nerve catheter. It was hypothesized that interscalene peripheral nerve catheters would provide more reliable analgesia and improved patient satisfaction 48 hours after surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Enrolled were 93 consecutive patients who underwent arthroscopic rotator cuff surgery at a single ambulatory surgery center between October 2020 and June 2021. Of these patients, 13 were lost to follow-up; thus, 80 patients were included in statistical analysis. One group of patients (n = 48) received a preoperative interscalene nerve block placed with 10 mL 0.5% bupivacaine and 10 mL 1.3% liposomal bupivacaine. The second group (n = 32) received a preoperative interscalene catheter with an initial bolus of 20 mL 0.25% bupivacaine and a 0.2% ropivacaine infusion by an elastomeric pump set at 10 mL/hr for 48 hours. The primary outcome was the difference between preoperative and 48-hour postoperative quality of recovery-15 (QoR-15) scores. Secondary outcomes included visual analog pain scores, opioid use, and patient satisfaction. Complications and adverse effects were also noted. The Kruskal-Wallis test was used to analyze means and standard deviations for continuous endpoints; Fisher exact test was used to analyze counts and proportions for categorical endpoints. Results: The liposomal bupivacaine group had a mean reduction of 3.9 in their postoperative QoR-15 scores, and the catheter group had a mean reduction of 25.1 in their postoperative QoR-15 scores, indicating a significantly worse functional recovery period compared with liposomal bupivacaine within the first 48 hours (P < .001). Patients who received liposomal bupivacaine also had significantly lower pain scores on the second postoperative day, improved quality of sleep, and improved satisfaction with analgesia (P < .05 for all). Conclusion: The use of interscalene liposomal bupivacaine demonstrated significantly improved quality of recovery when compared with interscalene nerve catheter after RCR.
ABSTRACT
Pneumothorax is a known complication following breast surgery but is likely underappreciated by anesthesiologists. Iatrogenic pneumothorax can be caused by needle injury during local anesthetic injection, surgical damage to the intercostal fascia or pleura, or pulmonary injury from mechanical ventilation. We present two cases of pneumothorax following bilateral mastectomy with bilateral pectoral blocks and immediate breast reconstruction. Both cases occurred at a freestanding ambulatory surgery center in patients with no history of lung disease. One patient was found to have bilateral pneumothoraxes after complaining of shortness of breath and chest pain in the post-operative care unit. The second patient was asymptomatic but found to have a right-sided pneumothorax on a chest X-ray (CXR) that was ordered to rule-out left-sided pneumothorax due to concern of intraoperative breach of the left chest wall. Both patients were treated with chest tubes, transferred to a nearby hospital, and discharged several days later. Anesthesiologists must be aware of this potentially life-threatening complication and consider pneumothorax in the differential diagnosis of perioperative hypoxemia, shortness of breath, chest pain, and hemodynamic collapse in patients undergoing breast surgery. Though traditionally diagnosed via radiograph, pneumothorax can be rapidly diagnosed with ultrasound. Tension pneumothorax should be decompressed immediately with a needle. A clinically significant, non-tension pneumothorax is treated with chest tube placement. Equipment necessary to treat pneumothorax should be available for emergency treatment in facilities wherever breast surgery is performed.
ABSTRACT
Background The transition from internship to clinical anesthesiology (CA) training is often difficult given the differences in workflow, procedures, environment, and clinical situations. The primary aims of this study were to determine if a standardized introductory bootcamp could improve clinical knowledge and self-perceived comfort level of new anesthesiology residents in performing common operating room procedures and management of common intraoperative problems. The secondary aim of the study was to see if a standardized bootcamp could be replicated at other programs. Methods The introduction to anesthesiology resident bootcamp was developed at one institution in 2015 then expanded to a second program in 2019. The bootcamp was a one-day experience consisting of simulation and task trainers that all rising first-year CA residents (CA-1) participated in during their first month of anesthesiology training. All participating residents were given a survey immediately before and after the bootcamp. The average ratings of the questions were calculated and used as the primary measure. The Anesthesia Knowledge Test (AKT) was used as a surrogate measure of participant knowledge. Results From 2015 to 2020, a total of 105 residents completed the pre-survey and 109 completed the post-survey across the two sites. The improvement in average rating was significant (Pre: 2.04±0.46 versus Post: 3.09±0.52 p<0.0001). Individual item analysis also showed significant improvement on all of the eight items (p<0.0001). Analyses by site revealed the same results at both average score and item level. There was no significant cohort difference in either AKT-0 (Control: 57.84±26.86 versus Intervention 50.13±25.14, p=0.14) or AKT-1 (Control: 41.06±26.42 versus Intervention 41.70±26.60, p=0.90) percentile scores. Conclusions Incorporation of an introduction to anesthesia bootcamp for new residents significantly improves participant comfort level and is reproducible across institutions. However, it does not improve resident performance on standardized tests.
ABSTRACT
PURPOSE OF REVIEW: Anesthetics, such as thiopental, methohexital, propofol and ketamine have been used to induce unconsciousness for electroconvulsive therapy (ECT), each with its advantages and disadvantages. Only until recently was it discovered that ketamine may have inherent antidepressant effects. We reviewed the side effect profile of ketamine and examined the literature for whether or not ketamine augments the antidepressant effects of ECT. RECENT FINDINGS: Systematic reviews and meta-analyses of randomized controlled trials of the potential benefits of adding ketamine to ECT treatment have generated varied conclusions. Currently there is a lack of clear evidence that ketamine with ECT is more efficacious than ECT alone. SUMMARY: Large, multicenter randomized controlled trials are needed to further investigate the potential advantages of adding ketamine to ECT for patients with severe or refractory depression. The addition of ketamine to ECT treatment may have some early beneficial effect in patients with acute depressive disorders. Most likely, ECT itself is responsible for lasting remission from severe depression. Ketamine's side effect profile may be undesirable in certain patient populations, and so the risks and benefits of the addition of this drug to ECT treatment must be weighed.
