The use of bilateral transversus abdominis plane blocks with liposomal bupivacaine on postoperative cesarean delivery patients during COVID-19 pandemic is associated with reduced narcotics use and reduced length of stay.

BACKGROUND: The use of transversus abdominis plane blocks has been previously shown in both large-scale studies and our own institution to significantly reduce postoperative pain and opioid use. In addition, the use of bilateral transversus abdominis plane blocks using liposomal bupivacaine in combination with neuraxial morphine significantly reduced post-cesarean-delivery pain and opioid use. During the COVID-19 crisis, our anesthesia department in a collaborative effort with our obstetric colleagues thought that the use of bilateral transversus abdominis plane blocks with liposomal bupivacaine could reduce the use of opioids to treat postoperative pain and might result in decreased length of stay. METHODS: After institutional review board approval, a retrospective study of 288 patients who underwent cesarean delivery under spinal or epidural (neuraxial) anesthesia at Maimonides Medical Center in Brooklyn, NY was conducted. Historical controls were from 142 consecutive patients from 1 January 2012 through 12 May 2012. An additional set of controls consisted of 30 consecutive patients from 10 March 2020 through 13 April 2020. The primary outcome data analyzed were the use of opioids and length of stay. RESULTS: Post cesarean delivery, patients who received both bilateral transversus abdominis plane blocks with liposomal bupivacaine and neuraxial morphine was associated with a significant decrease in the number of patients using post operative opioids, 54%-60% decreased to 18% (p < 0.001), and a decreased length of stay; 3.1 days was reduced to 2.39 (p < 0.001). CONCLUSION: Neuraxial opioids combined with liposomal bupivacaine transversus abdominis plane blocks provided significant pain relief for patients post cesarean delivery, required less post operative opioids, and facilitated earlier discharge that may aid in reducing patient exposure and hospital burden secondary to COVID-19.

Perioperative Transfusion Associated With Increased Morbidity and Mortality in Geriatric Patients Undergoing Hip Fracture Surgery.

INTRODUCTION: Both conservative and liberal transfusion thresholds, in regard to hematocrit and hemoglobin levels, have been widely studied with varying outcomes. The aim of this study was to evaluate if transfusion administered peri- (anytime during the admission), pre-, intra-, or postoperatively an its association with morbidity and mortality in the geriatric population undergoing hip surgery. METHODS: This study was an institutional review board approved retrospective analysis of data collected from 841 patients at a single urban institution who underwent surgical repairs for hip fractures from 2008 to 2010. RESULTS: Our analysis included data from 841 surgical patients. Mean patient age was 83, 74% were female, 48% received spinal anesthesia while 52% underwent general anesthesia. Out of 841 patients, 425 were transfused during the perioperative period. Most transfusions occurred postoperatively. Perioperative, intraoperative and postoperative transfusion was associated with an increase in post-operative AKI. Intraoperative blood transfusion was associated with an increase in morbidity (11.6% increased to 22.2%) by 1.9 fold, AKI (3.9% increased to 11.1%) by 2.8 fold, as well as an increase in mortality (5.2 increased to 15.6%) within 60 days by 3 fold. CONCLUSIONS: This may suggest that patients transfused prior to surgery, despite having met a specific trigger hemoglobin level earlier, may have been treated before deteriorating to a point that would cause future systemic implications.

Assessment of Didactic Transesophageal Echocardiography Education During Anesthesia Residency.

BACKGROUND: Transesophageal echocardiography can be a useful monitor during noncardiac surgery, in patients with comorbidities and/or undergoing procedures associated with substantial hemodynamic changes. The goal of this study was to investigate if transesophageal-echocardiography-related knowledge could be acquired during anesthesia residency. METHODS: After institutional review board approval, a prospective observational study was performed in two anesthesiology residency programs. After a 41-week didactic transesophageal-echocardiography-education curriculum residents' exam scores were compared to baseline. The educators' examination was validated against the National Board of Echocardiography's Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography. RESULTS: After the 41-week course, clinical anesthesia (CA)-3 exam scores increased 12% compared to baseline (P = .03), CA-2 scores increased 29% (P = .007), and CA-1 scores increased 25% (P = .002). Pearson correlation coefficient between the educators' exam score and the special competence exam percentile rank was 0.69 (P = .006). Pearson correlation coefficient between the educators' exam score and the special competence exam scaled score was 0.71 (P = .0045). CONCLUSIONS: The 41-week course resulted in significant increases in exam scores in all 3 CA-classes. While didactic knowledge can be learned by anesthesiology residents during training, it requires significant time and effort. It is important to educate residents in echocardiography, to prepare them for board examinations and to care for the increasingly older and sicker patient population. Further work needs to be done to determine optimal methods to provide such education.

Retrospective Analysis of Geriatric Patients Undergoing Hip Fracture Surgery: Delaying Surgery Is Associated With Increased Morbidity, Mortality, and Length of Stay.

INTRODUCTION: Hip fractures are common in elderly patients. However, this population frequently presents with significant medical comorbidities requiring extensive medical optimization. METHODS: This study sought to elucidate optimal time to surgery and evaluate its effect on postoperative morbidity, mortality, and length of stay (LOS). We performed a retrospective analysis of data collected from 2008 to 2010 on 841 patients who underwent hip fracture surgery. Patients were classified based on time to surgery and were also classified and analyzed according to the American Society of Anesthesiologists (ASA) physical classification system. RESULTS: Patients with a delay of greater than 48 hours had a significant increase in overall LOS, postoperative days, and overall postoperative complications. Patients classified as ASA 4 had an odds ratio for postoperative morbidity of 3.32 compared to the ASA 1 and 2 group (P = .0002) and 2.26 compared to the ASA 3 group (P = .0005). Delaying surgery >48 hours was also associated with increased in-hospital mortality compared to 24 to 48 hours (P = .0197). Increasing ASA classification was also associated with significantly increased mortality. Patients classified as ASA 4 had 5.52 times the odds of ASA 1 and 2 (P = .0281) of in-hospital mortality. Those classified ASA 4 had 2.97 times the odds of ASA 3 (P = .0198) of an in-house mortality. Anesthetic technique (spinal vs general) and age were not confounding variables with respect to mortality or morbidity. DISCUSSION: Surgical timing and ASA classification were evaluated with regard to LOS, number postoperative days, morbidity, and mortality. CONCLUSIONS: Delaying surgery >48 hours, especially in those with increased ASA classification, is associated with an increase in overall LOS, postoperative days, morbidity, and mortality. However, rushing patients to surgery may not be beneficial and 24 to 48 hours of preoperative optimization may be advantageous.

A Multidisciplinary Approach to Anesthetic Management of a Parturient with Severe Aortic Stenosis.

In order to optimize anesthetic management and avoid adverse maternal and fetal outcomes, a clear understanding of the changes in cardiovascular physiology that occur during pregnancy is paramount. The effects of normal gestation on the cardiovascular system are particularly significant in a parturient with cardiac valvular pathology. We present a case of a 27-year-old G2P0 at 37 weeks with a past medical history of diabetes, macrosomia, congenital bicuspid aortic valve with severe stenosis (valve area 0.7 cm(2)) who was scheduled for elective C-section. A multidisciplinary discussion involving cardiologists, cardiac surgeons, obstetric surgeons, neonatal intensivists, perfusion staff, anesthesiologists, and nursing staff was held to formulate a plan for the perioperative management of this parturient. Also, contingency plans were formulated and discussed with the care providers, in the event of acute decompensation of the mother and baby and possible need for emergency aortic valvuloplasty and/or aortic valve replacement.

Liposomal bupivacaine infiltration into the transversus abdominis plane for postsurgical analgesia in open abdominal umbilical hernia repair: results from a cohort of 13 patients.

BACKGROUND: Achieving adequate control of postsurgical pain remains a challenge in patients undergoing abdominal surgery. Transversus abdominis plane (TAP) infiltration has been shown to provide postsurgical analgesia following lower abdominal surgery. We assessed the safety and efficacy of a prolonged-release liposomal formulation of the local anesthetic bupivacaine administered via infiltration into the TAP in a cohort of patients undergoing open abdominal umbilical hernia repair. METHODS: Patients included in the study were 18-75 years of age, had American Society of Anesthesiologists physical classification status 1-3, and underwent open abdominal umbilical hernia repair with ultrasound-guided TAP infiltration immediately after surgery using an equal-volume bilateral infusion of liposomal bupivacaine 266 mg (diluted to 30 mL in normal saline). Outcome measures included patient-reported pain intensity (11-point numeric rating scale), satisfaction with postsurgical analgesia (5-point Likert scale), incidence of opioid-related adverse events, and time to first use of supplemental rescue analgesia. RESULTS: Thirteen patients underwent surgery and received bilateral TAP infiltration with liposomal bupivacaine; TAP infiltration failed in the first patient. Mean numeric rating scale pain scores were 0.6 immediately before TAP infiltration and remained ≤2.3 through 120 hours after infiltration; mean scores at 120 hours and 10 days were 0.9 and 0.4, respectively. Ten patients (77%) required supplemental analgesia; median time to first use was 11 hours. At discharge and day 10, 54% and 62% of patients, respectively, were "extremely satisfied" with postsurgical analgesia (Likert score 5). There were no opioid-related or other adverse events. CONCLUSION: Although the current study was limited by both its lack of a control group and its small size, to our knowledge, it is the first published report on use of liposomal bupivacaine for TAP infiltration. In this cohort, liposomal bupivacaine was observed to be well tolerated with encouraging analgesic efficacy.

Management of a cadaveric orthotopic liver transplantation in a pediatric patient with complex congenital heart disease.

Pediatric orthotopic liver transplantations (OLT) are commonly performed nowadays. Two primary reasons for OLT in children are complications from either extrahepatic biliary atresia (EHBA) or inborn errors of metabolism. However, congenital liver disease may be associated with significant other congenital abnormalities. We present a case of a successful OLT in a pediatric patient with a history of EHBA, situs inversus, and complex congenital heart disease. The cardiac anomalies include dextrocardia, absence of the atrial septum (single atrium), single atrioventricular valve (a-v canal), and an incomplete ventricular septum. Prior surgery include a Kasai procedure for EHBA, banding of the proximal main pulmonary artery, and Broviac catheter placement. We present the anesthesia concerns and management for this complicated case.

Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.

BACKGROUND: The influence of labor epidural fentanyl on the neonate is controversial. The purpose of this study was to determine whether epidural fentanyl has an impact on breast-feeding. METHODS: Women who previously breast-fed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: (1) no fentanyl group, (2) intermediate-dose fentanyl group (intent to administer between 1 and 150 microg epidural fentanyl), or (3) high-dose epidural fentanyl group (intent to administer > 150 microg epidural fentanyl). On postpartum day 1, the mother and a lactation consultant separately assessed whether the infant was experiencing difficulty breast-feeding, and a pediatrician assessed infant neurobehavior. All women were contacted 6 weeks postpartum to determine whether they were still breast-feeding. RESULTS: Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose, and 58 were randomly assigned to receive high-dose fentanyl. On postpartum day 1, women who were randomly assigned to receive high-dose fentanyl reported difficulty breast-feeding (n = 12, 21%) more often than women who were randomly assigned to receive an intermediate fentanyl dose (n = 6, 10%), or no fentanyl (n = 6, 10%), although this did not reach statistical significance (P = 0.09). There was also no significant difference among groups in breast-feeding difficulty based on the lactation consultant's evaluation (40% difficulty in each group; P = 1.0). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 microg fentanyl (P = 0.03). At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n = 1, 2%) (P = 0.005). CONCLUSIONS: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than woman who were randomly assigned to receive less fentanyl or no fentanyl.

Characterization of the acetaminophen-induced degradation of cytochrome P450-3A4 and the proteolytic pathway.

It has been shown that large doses of acetaminophen can result in increased degradation of the hepatic cytochrome P450 (CYP) enzymes in vivo; however, the proteolytic pathways have not been identified. We found that incubating transfected HepG2 cells that express CYP3A4 or a reconstituted microsomal model containing human liver microsomes and cytosol, high concentrations of acetaminophen could induce a dose- and time-dependent degradation of CYP3A4. In the microsomal model the degradation could be blocked and augmented by the presence of catalase and superoxide dismutase, respectively. Tocopherol could also protect against the acetaminophen-induced degradation. However, lipid peroxidation assays showed no significant increases in lipid peroxidation products nor was there any protection by propyl gallate. Protease and proteasome inhibitors showed that the proteolytic process was mainly (85%) mediated by the lysosomal pathway, whereas a minor portion (15%) of the degradation was mediated by the proteasomal pathway. Both pepstatin A and anti-cathepsin D neutralizing antibody decreased acetaminophen-induced degradation of CYP3A4 in microsomal model systems. Pepstatin A also blocked the acetaminophen-induced degradation of the CYP3A4 in a transfected HepG2 cell line. Incubating the 3A4 cells in the presence of acetaminophen also increased cathepsin D content and activity. The lysosomal pathway, mainly mediated by cathepsin D, appears to be the major proteolytic pathway involved in the degradation of the P450 enzymes induced by toxic doses of acetaminophen.

Induction of CYP3A by ethanol in multiple in vitro and in vivo models.

BACKGROUND: Cytochrome P-450 3A (CYP3A) is responsible for the metabolism of numerous therapeutic agents. The content of CYP3A seems to be affected by ethanol ingestion. Because ethanol is used widely, its potential interaction with CYP3A is of great interest. The effects of ethanol on CYP3A content and activity were assessed in different in vivo and in vitro models. METHODS: Rats fed either the Lieber-DeCarli ethanol-containing diet or an ethanol and liquid diet via the intragastric tube feeding method were used. Additionally, HepG2 cell lines that constitutively and stably express human CYP3A4 were constructed to study ethanol interactions with CYP3A4. RESULTS: In all models tested, ethanol induced CYP3A activity and content, as assessed by the metabolism of fentanyl, a sensitive and specific CYP3A substrate, and Western blot analysis, respectively. In the CYP3A4-expressing HepG2 cell line, incubation with ethanol caused a dose-dependent increase in CYP3A4 activity. Ethanol also increased messenger RNA levels of CYP3A4. In the HepG2-CYP3A4 line, incubation with cycloheximide caused a decrease in fentanyl metabolism secondary to a decrease in CYP3A4 levels; this decrease was prevented by coincubation of cycloheximide with ethanol. CONCLUSIONS: Ethanol induced CYP3A activity and content both in vitro and in vivo. There may be multiple mechanisms of induction of CYP3A4 by ethanol, including stabilization of messenger RNA and protein. Ethanol-induced increases in both the protein level and activity of CYP3A4 may play a role that might be of pathophysiological or clinical significance.