RESIDENT IMPLEMENTATION OF THE 2007 ACC/AHA GUIDELINES ON PREOPERATIVE CARDIAC EVALUATION IN NON-CARDIAC SURGERY PATIENTS: IS CLINICAL EXPERIENCE ENOUGH?

BACKGROUND: Preoperative evaluation of surgical patients is important, as perioperative complications are associated with increased mortality. Specialties including anesthesiology, internal medicine, cardiology, and surgery are involved in the evaluation and management of these patients. This institutional study investigated the residents' knowledge of the 2007 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on perioperative evaluation of patients undergoing non-cardiac surgery. METHODS: This pilot study used a web-based survey questionnaire to assess resident's knowledge of the 2007 ACC/AHA guidelines through individual steps and corresponding branch point(s) in twelve clinical scenarios. Additionally, residents were asked if they were aware of, or if they had received lectures on ACC/AHA guidelines. Staff anesthesiologists with training in cardiac and intensive care medicine validated the scenarios. RESULTS: A total of 104 resident participants were surveyed including 35 anesthesiology residents, 41 internal medicine residents, 20 surgery residents, and 8 cardiology fellows. Awareness of the 2007 ACC/AHA guidelines by specialty was: anesthesiology (85%), internal medicine (97.6%), cardiology (100%), and surgery (70%). Only 54.3% of anesthesiology, 31.7% of internal medicine, 100% of cardiology, and 10% of surgery residents stated they received lectures. The overall mean score achieved on the eleven scenarios was 50.4% for anesthesiology, 47.0% for internal medicine, 55.7% for cardiology, and 42.3% for surgery. CONCLUSIONS: Although the majority of residents were aware of the 2007 ACC/AHA guidelines, fewer received lectures and regardless of specialty, implementation of these guidelines was poor. There exists significant room for improvement in the understanding of preoperative assessment of non-cardiac surgery patients.

Breast lesions with intractable pain in end-stage renal disease: calciphylaxis with chronic hypotensive dermatopathy related watershed breast lesions.

BACKGROUND: There are very few reports about end-stage renal disease (ESRD) patients with breast pains in the medical literature, posing a difficulty to understand their pathophysiology. CASE PRESENTATION: A 47-year-old African American female patient with ESRD on hemodialysis presented to the pain clinic with new-onset black maculopapular skin lesions on her breasts. These lesions started out as dark spots and then became necrosed, exposing the underlying tissue. The painful and tender lesions were located in a circumferential pattern around the bases of both breasts. She had stopped using breast supporting undergarments secondary to allodynia-hyperalgesia eliciting from necrotizing skin tissues. Her recent skin biopsy was inconclusive about ruling in or out the possibility of calciphylaxis. However, her past mammograms had showed calcium deposits in her breasts. Her other past medical history was significant for chronic hypotension with recently diagnosed legal blindness bilaterally. Her home medications included midodrine. The systolic blood pressures in either arm were consistently recorded in high 60s to low 70s during the interdialytic periods. She had multiple emergency room admissions secondary to persistent chronic hypotension; however the underlying pathophysiology for intractable but asymptomatic hypotension remained obscure. Over the course of the next 11 months her nonhealing breast lesions progressed and became infected. She developed septic shock due to infected lesions. Per her do-not-resuscitate requests, she died peacefully while under inhospital hospice care. CONCLUSION: Morbidity-mortality with calciphylaxis and chronic hypotension related tissue changes is high, and the breast lesions in ESRD patients require aggressive treatment for underlying inadequate oxygen delivery to these peripheral tissues.

Post-operative alopecia after robotic surgery in steep Trendelenburg position: a restated observation of pressure alopecia.

Postoperative alopecia is an uncommon complication and its outcome is aesthetically drastic. Although its mechanism has not been clearly elucidated, a proposed risk factor is steep Trendelenburg positioning (30-40 degrees) that is frequently used during robotic gynecologic surgeries. We report a case of postoperative alopecia in 53-year-old female patient who had undergone robotic-assisted laparoscopic hysterectomy and bilateral salpingoophorectomy with sacrocolpopexy and cystoscopy. Prevention of alopecia with proper head positioning, avoidance of mechanical compression by rigid objects and maintenance of intraoperative hemodynamics is of utmost importance for anesthesiologists.

Special article: mandragora: anesthetic of the ancients.

Initial attempts at surgical anesthesia began many centuries ago, with the plants of antiquity. The mandragora, or mandrake, was used as a sedative and to induce pain relief for surgical procedures. It has been depicted in tablets and friezes since the 16th century before the common era (BCE) and used for its sedative effects by Hannibal (second century BCE) against his enemies. The Romans used the mandrake for surgery. The Arabs translated the scientific work of the Ancients and expanded on their knowledge. They developed the Spongia Somnifera, which contained the juice of the mandrake plant. After the fall of the Islamic cities of Europe to the Christians, scientific work was translated into Latin and the Spongia Somnifera was used in Europe until the discovery of the use of ether for surgical anesthesia.