General anesthesia for a patient with Brugada syndrome.

Brugada Syndrome is a genetic cardiac disease characterized by electrocardiogram changes consisting of an incomplete right bundle branch block, and ST-segment elevations in right precordial leads V1-V3. These patients are at high risk for developing spontaneous arrhythmias that can be fatal. Many factors during general anesthesia, such as medications, temperature changes, and heart rate variations, could precipitate lethal arrhythmias in this patient population. This case report describes a case of general anesthesia for a patient with known Brugada syndrome.

An unexpected needlestick injury.

Needle stick injuries occur at a significant rate. According to the National Institute for Occupational Safety and Health, there are approximately 600,000 to 800,000 needlestick and other percutaneous injuries every year among healthcare workers. Not only do the needlestick injuries put workers at risk for blood borne pathogens, but they cause a significant psychological and emotional burden for those involved. This is a report of an anesthesia resident who sustained a needlestick injury through the sterile drapes by a surgical resident.

General anesthesia complicated by perioperative iatrogenic splenic rupture.

Patients with splenomegaly often present with diverse coexisting medical disease and thus offer a variety of anesthetic considerations. The challenges that come with splenectomy have also become increasingly common to the anesthesiologist, given the growing number of indications for surgical intervention including both benign and malignant disease. Removal of the spleen is associated with numerous intraoperative and postoperative risks, including massive intraoperative hemorrhage, perioperative coagulation abnormalities, and post-splenectomy infection. When caring for the patient with an enlarged spleen scheduled for splenectomy, the anesthetic plan must address both patient and procedure specific concerns. We present a medically challenging case of a 28 year old man with splenomegaly secondary to lymphoma, who underwent elective splenectomy, which was complicated by perioperative splenic rupture and hemorrhage.

Missed steps in the preanesthetic set-up.

BACKGROUND: Anesthesiologists accomplish many tasks rapidly during induction of an anesthetic. Key preparation for induction is needed to maximize patient safety. Given the intense environment of the operating room, preparatory steps may be missed either unintentionally or possibly even intentionally to save time. We conducted this study to determine the incidence of missed steps in the operating room immediately before induction. METHODS: In this study, 200 surgical procedures were randomly checked for missed steps before induction of anesthesia using a "Revised Preanesthetic Set-Up." Additionally, multiple other operating room/case variables were recorded to determine whether there was correlation between the missed steps and certain variables such as room case load and regional versus general anesthesia. RESULTS: Twenty-three missed steps were discovered. Manual resuscitation device availability and a working suction set-up were the most frequently missed steps. A higher percentage of missed steps was found in cases in which regional was the planned anesthesia technique, in rooms with higher case loads (≥5 cases scheduled), and in rooms that attending anesthesiologists completed the set-up. CONCLUSIONS: Missed steps do occur at a significant and measurable rate. Measures need to be taken to decrease the number of missed steps to improve patient safety.

The administration of general anesthesia to a patient with croup.

Croup in a young child may lead to severe airway narrowing, and would present a severe risk for administration of anesthesia. To the best of our knowledge, there have been no previous case reports of patients undergoing general anesthesia with croup. In our report, we describe a case of a 31 month old child with croup who required anesthesia.

Extreme intraoperative hyperkalemia in a non dialysis patient undergoing kidney transplantation.

The majority of patients who present for kidney transplantation have end stage renal disease and are on dialysis. Those patients are known to be at risk for the development of hyperkalemia. A patient who has not required dialysis, and with stable potassium levels would not be expected to acutely develop intraoperative hyperkalemia. Presented here is an unusual case in which a 61-year-old man with chronic renal disease but no history of dialysis developed severe intraoperative hyperkalemia during a renal transplant.

Production pressure, medical errors, and the pre-anesthesia checkout.

Medical errors have rightly become an important societal and professional issue. While anesthesiology as a specialty has been at the forefront of the patient safety movement it is also subject to the same pressures for efficiency as any other business. Whether this pressure is at odds with the delivery of safe care is not yet clearly delineated. However, a theoretical framework of unsafe practices as well as a body of literature from other industries such as aviation suggests that production pressure may lead to unsafe practice. Also, it is unlikely that the common pressures encountered in the operating room (e.g., to reduce turnover times) have any positive financial impact for anesthesiology departments unless extra cases can be done each day. We include in this review a potential area for improvement and further research for anesthesiologists, the preanesthesia induction timeout. This crucial period of any anesthetic involves a high workload and is often the most hurried; this combination may be setting practitioners up to make errors. We suggest the use of checklists and timeouts to formalize this period and propose a useful seven-point list of crucial items and events needed before each anesthetic.

Treating stridor with opioids: a challenging case of paradoxical vocal cord movement.

A 61 year-old patient with a history of anxiety disorder presented with stridor after an uneventful laparotomy with a general anesthetic. Postoperative analgesia was withheld secondary to intermittent oxygen desaturation. She was unresponsive to standard therapies, including racemic epinephrine and albuterol nebulizers. An otolaryngology consultant performed fiberoptic laryngoscopy and paradoxical vocal cord movement was diagnosed. When fentanyl was subsequently administered to treat her pain, the stridor resolved.

Acute lung injury after thoracic surgery.

In this review, the authors discussed criteria for diagnosing ALI; incidence, etiology, preoperative risk factors, intraoperative management, risk-reduction strategies, treatment, and prognosis. The anesthesiologist needs to maintain an index of suspicion for ALI in the perioperative period of thoracic surgery, particularly after lung resection on the right side. Acute hypoxemia, imaging analysis for diffuse infiltrates, and detecting a noncardiogenic origin for pulmonary edema are important hallmarks of acute lung injury. Conservative intraoperative fluid administration of neutral to slightly negative fluid balance over the postoperative first week can reduce the number of ventilator days. Fluid management may be optimized with the assistance of new imaging techniques, and the anesthesiologist should monitor for transfusion-related lung injuries. Small tidal volumes of 6 mL/kg and low plateau pressures of < or =30 cmH2O may reduce organ and systemic failure. PEEP may improve oxygenation and increases organ failure-free days but has not shown a mortality benefit. The optimal mode of ventilation has not been shown in perioperative studies. Permissive hypercapnia may be needed in order to reduce lung injury from positive-pressure ventilation. NO is not recommended as a treatment. Strategies such as bronchodilation, smoking cessation, steroids, and recruitment maneuvers are unproven to benefit mortality although symptomatically they often have been shown to help ALI patients. Further studies to isolate biomarkers active in the acute setting of lung injury and pharmacologic agents to inhibit inflammatory intermediates may help improve management of this complex disease.

An unusual case of a patient with extreme fixed neck flexion presenting for emergency abdominal surgery.

Patients with a known difficult airway for intubation who present with intestinal obstruction are at an increased risk for receiving general anesthesia. It may be necessary to perform an awake fiberoptic intubation, or possibly a tracheostomy if an awake intubation cannot be performed. In some cases, an awake tracheostomy may not be possible due to the anatomy. We report a case in which a patient with extreme fixed neck flexion deformity in whom a tracheostomy would not have been possible, presented for emergency abdominal surgery.