Minerva Medica - NWAC - Networking World Anesthesia Convention

Transcription

V O L. 1 0 7
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S U P P L. 2
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No. 3
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J U N E
ABSTRACT BOOK
7th Networking
World Anesthesia Convention
(NWAC)
New York (USA), April 20-23, 2016
2 0 1 6

7th Networking
World Anesthesia Convention
(NWAC)
New York (USA), April 20-23, 2016
NWAC ABSTRACTS
NWAC - 1
Massive pulmonary embolism during total knee
arthroplasty
S. Luis1, T. Jamroz2
1Anesthesia, Cleveland Clinic Florida, Weston, FL, United States
of America, 2Anesthesiology, Cleveland Clinic Florida, Weston, FL,
United States of America
Introduction: Cardiac arrest is a significant predictor
of PE mortality, it can occur due to many mechanisms in
massive PE. PE in intra-operative patients requires early
diagnosis and intervention by the anesthesiologist. We
present a case of Massive PE in the operative room who
was successfully treated with thrombolytics.
Case description: A 76 year old for revision of right
total knee arthroplasty surgery. During surgery patient
developed sudden decrease in SpO2 and EtCO2 and a
preliminary diagnosis of PE was made. A TEE was performed and identified a pulmonary emboli migrating to
pulmonary artery.Mild decrease in blood pressure responded to phenylephrine and fluid administration at this
time. Patient continued to decompensate with PEA and
another pulmonary emboli was identified in right ventricle. The resuscitative measures were employed and
patient stabilized with intra operative thrombolytics, advanced cardiac life support and the insertion of an IVC
filter. Surgery continued while medical stabilization was
occurring to prevent the patient from having a flail knee.
ECMO was considered however O2 saturation improved
after TPA and Nitric Oxide were administered. Patient
was weaned off the ventilator and returned to baseline
cognition.
Conclusion: Conclusion: The previous literature has
shown cases treated with ECMO for intra-operative PE.
This is a rare case being treated with thrombolytics. Early
diagnosis and aggressive treatment of intraoperative pulmonary embolism with thrombolytic can be life-saving. NWAC - 2
Hygiene practice among anesthesiologists – pilot
study results from an international focus group interview at NWAC 2015
S. Schulz-Stübner1, F. Falter2
Control, Deutsches Beratungszentrum für Hygiene,
Freiburg, Germany, 2Anesthesia and Intensive Care, Papworth
Hospital NHS Foundation Trust, Cambridge, United Kingdom
1Infection
Introduction: Despite recent progress uptake of infection control measures is slow amongst anesthesia
practitioners. With approval of the Scientific Committee
we used the Networking World Anesthesia Convention
2015 as a forum to get an overview over infection control
practices in different parts of the world.
Objectives: To perform a focus group interview about
hygiene pracice in anesthesia.
Methods: 60 congress delegates were presented with
a questionnaire and were asked to reflect on their own
practice. Results: 57 returned questionnaires were included in
the analysis and 5 distinct regions were well represented.
Nearly 100% of respondents reported that they routinely
used maximal barrier precautions for central line insertions. Needle free connectors are used increasingly, however only a small number of practitioners disinfect them
appropriately. Disinfection of regular taps of stopcocks
follows a similar pattern. Simple measures like disinfection of the outer surface of the breathing circuit or dividing the anesthesia workspace into a clean and a dirty area
are still not widely used.
Conclusion: Anesthesia practitioners are mostly
aware of infection control bundles and adhere to them
when placing central venous access. The majority of
anesthesiologists we interviewed diligently disinfected
their hands after potential contact with bodily fluids,
however only a minority does so before carrying out
aseptic tasks. There is little awareness of the anesthesia delivery unit and attached breathing circuits as a
source of contamination. Although progress has been
made in past years, more educational efforts are necessary to improve awareness of the anesthesia workplace
as a potential vector for clinically relevant infections.
NWAC - 3
Post-procedure arachnoiditis following obstetric
spinal anaesthesia: a rare case report
I. Chattopadhyay
Anaesthesiology, B R Singh Hospital and Centre for Medical
Education and Research, Kolkata, INDIA
Figure 1.
Vol. 107 - Suppl. 2 to No. 3
Introduction: Adhesive arachnoiditis is a crippling
disorder in which the pia-arachnoid undergoes an extensive inflammatory reaction to any form of injurious
stimulus. Given the evident iatrogenic etiology of ad-
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NWAC ABSTRACTS
Figure 3.
Figure 4.
hesive arachnoiditis today, prevention and caution shall
be an integral part of the health strategies to address this
condition. The prevention of post-procedure and postinjection complications are key to stop the development
of new cases or the deterioration of existing ones through
evidence-based clinical guidelines.
Case Description: A 35-year-old woman developed
adhesive arachnoiditis after spinal anaesthesia with hyperbaric bupivacaine, without any definitive precipitating cause. The patient presented eleven days postpartum
with urinary incontinence and loss of sensation over the
perineal region and buttocks. Gradually, she also developed complete loss of bowel control. Attempted treatments included conservative management with steroids,
gabapentinoids and physiotherapy, which proved partly
successful and she remains considerably better twelve
months later now. We highlight the pathophysiology of
adhesive arachnoiditis following central neuraxial blocks
and its probable causes, including contamination of the
injectate and anaesthetic drug neurotoxicity, with reference to other such published cases around the world. Conclusion: In the absence of more definitive data,
spinal and epidural anaesthesia should be done under
stringent aseptic, atraumatic techniques after discarding
all probable sources of contamination. It also seems pertinent to explain to the patient the risks of late, permanent
neurological deficit while obtaining informed consent.
Few case reports have reported the misplacement of esophageal devices into the tracheobronchial tree . We report
the misplacement of an esophageal temperature probe into
the left bronchus during left lung lobectomy surgery.
Case Description: A 66 year old man presented for left
lower lung lobectomy. General anesthesia was induced
and a 37 French left double lumen endotracheal tube was
inserted. The tracheal and bronchial cuffs were inflated
and lungs were mechanically ventilated. A 9 French temperature probe (M1024229, GE) was nasally placed and
blindly advanced for 30 cm. No cuff leakage was detected
and airway pressure remained constant. Surgery proceeded following left lung isolation and after dissection, the
left bronchus was stapled. A foreign material was transected with the bronchus that was identified as the temperature probe. Specimen was removed and the ligature was
opened to allow withdrawal of the probe and the proximal
stump was ligated. The trachea was extubated at the end of
surgery. Patient was discharged home on day 4 postoperatively with no postoperative complications.
Conclusion: Espohageal temperature monitoring
should be reconsidered in lung surgery.
NWAC - 4
Misplacement of an esophageal temperature probe
A. Dabbous1, M. Y. El Ghoul2, M. H. Ibrahim3
American University of Beirut Medical Center,
Beirut, Lebanon, 2American University of Beirut Medical Center,
Riad El Solh, Lebanon, 3Anesthesiology, American University of
Beirut Medical Center, Beirut, Lebanon
1Anesthesiology,
Introduction: Core temperature measurement during
surgery that lasts more than thirty minutes under general
anesthesia is considered standard of care .Esophageal temperature monitoring is used, because of its high accuracy,
ease of insertion and no reported significant side effects .
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NWAC - 5
Anesthetic challenges of ivc filter retrieval in the
interventional radiology suite
L. Nguyen, D.-T. Truong, A. Truong
Anesthesiology And Perioperative Medicine, MD Anderson Cancer
Center, Houston, United States of America
Introduction: Even under monitored anesthesia care
(MAC), cases involving patients with severe co-morbidities that are performed in non-operating room locations
may present formidable challenges. When an emergency
arises in remote locations, equipment for invasive monitoring and resuscitation, supply of blood products and
expert assistance may not be readily available.
Case Description: A 78 year-old male presented to the
Interventional Radiology suite for removal of a retrievable inferior vena cava filter. Past medical history included
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NWAC ABSTRACTS
Figure 5.
prostate cancer, hypertension, cardiomyopathy, implanted
cardioverter defibrillator, and right femoral vein thrombus.
He received MAC with a propofol infusion. During repeated unsuccessful removal attempts, the filter migrated
into the right atrium where its arms partially deployed.
Even though the patient remained hemodynamically stable, the decision was made to abort the procedure, obtain
vascular consultation and transfer him to a cardiac hospital. He underwent successful removal of the filter via open
heart surgery without adverse consequences.
Conclusion: IVC filter retrieval in Interventional Radiology carries the potential for catastrophic complications. Filter migration may cause caval and right atrial
injury and catastrophic hemorrhage. Life-threatening
cardiac dysrhythmias may also occur. Arterial and central venous access may be urgently needed for monitoring and management. Heightened awareness of the
potential complications, timely discontinuation of the
procedure, early expert consultation, and a multidisciplinary approach contributed to a favorable outcome.
NWAC - 6
Comparative study of the pharmacokinetics of bupivacaine after ultrasound-guided femoral nerve
block versus neurostimulation
H. Mehdi, S. Boughariou, M. Boussofara
Anesthesiology, Trauma Center, Ben Arous, Tunisia
Introduction: The femoral block with single injection
provides effective analgesia after arthroscopic knee surgery.
Objectives: The objective of this study is to compare the kinetics of bupivacaïne after ultrasound-guided
femoral nerve block performed by technical versus neurostimulation.
Methods: Carried Prospective, double-blind, included
40 patients (ps) for knee arthroscopy. The femoral block,
Then, we start an intravenous general anesthetic and we
inflate the tourniquet. Ps included were randomized into
two groups of 20 patients, gr. ultrasound (GE) where the
block is provided by ultrasound guidance and gr. neurostimulation (GN). It was administered nervous perished,
according to conventional safety rules, isobaric bupivacaïne 0.125% (0.3mg / kg). Plasma samples bupivacaïne
are made on lithium heparin tubes from the outer jugular vein before injection of bupivacaïne (T0), A5 (T5),
10 (T10), 15 (T15), 30 (T30) , 60 (T60), 90 (T90), 120
(T120) 180 (T180), 240 minutes (T240) and 24 hours
(T1440) . The pharmacokinetic assay was carried out by
chromatography (HPLC). Statistical analysis was performed using SPSS 22 software (significant if p≤0.05).
Results: There was no significant difference observed
between the two groups and neurostimulation ultrasound for
demographic characteristics (age: GE 34.2 ± 4.6 years vs GN
33,7 ± 5.4 years p: 0.87, BMI (kg / m²): GE 24,87 ± 3.6 vs
GN 2.9 ± 24,45 p: 0.62, sex ratio: GE 1,5 vs GN 1,22 p: 0.47),
The duration of the procedure of the femoral block was 3.4 ±
1.2 min in GE vs 5.2 ± 1.6 min in GN (p = 0.023).The block
installation time is 8.6 ± 2.2 min in GE vs 7.4 ± 1.8 min in
GN (p = 0.35).The injected volume of bupivacaïne was 27.4
± 4.3 ml in GE vs 26.8 ± 3.6 ml in GN. the anesthesia duration (GE 63,28 ± 24.85 vs GN 61.49 ± 26.39 p: 0.38), the
duration of arthroscopy (GE 41,28 ± 17.45 min vs GN 51,28
min± 21.13 p: 0 , 54) and the duration of tourniquet (GE 39,63
± 12.25 vs GN 40,57±5.36 min p: 0.66). The pharmacokinetics between GE and GN groups was virtually superimposed:
Cmax = 0.35 ± 0.29 mg / ml and was seen at T90 (34.7 ±
17.4 min after dropping the withers). Tmax was 33.22 ± 8.14
minutes and the T ½ is 169 ± 54 min. Cl is 0.586 ± 0.287 L
/ min or 6,83ml / kg.min-1 and Vd is 196 ± 76 2.45 ± 0.84
liters or l / kg.min-1 The AUC is 1134 ± 534 mg / l.min-1.
Analysis of the correlation between the duration of tourniquet and clearance of bupivacaïne using Pearson´s test
shows a negative correlation between these two parameters
-0.634 (p= 0,011).
Conclusion: pharmacological assay showed relatively high plasma levels of bupivacaïne in all patients
(but sufficiently below the toxic threshold) between T30
and T90. These results can be explained by the increase
in cardiac output by effect of tourniquet between T30
and T60. Postoperatively (T90), the lifting of the tourniquet will induce a mixed acidosis, responsible for the
decrease in the fraction bound to the alpha-1 acid glycoprotein bupivacaïne and therefore increase the free
fraction, and a worsening of hypothermia per -opératoire, inhibiting hepatic clearance of the local anesthetic.
NWAC - 7
Quality improvement initiative: develop a standardized hand-off protocol for utilization amongst
anesthesia providers to enhance intraoperative
communication
T. Kundu, P. Upadya
Anesthesiology, Saint Joseph’s Medical Center, Paterson, NJ, United
States of America
Introduction: The interest in handoffs in medicine
grew partly in response to The Joint Commission’s
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NWAC ABSTRACTS
Figure 7.
National Patient Safety report in 2006, which required
that institutions “implement a standardized approach to
‘handoff’ communications, including an opportunity to
ask and respond to questions.” Each anesthetic handoff
increased the risk of any major in-hospital morbidity or
mortality by 8%.
Objectives: To develop a standardized handoff protocol to be used intraoperatively for transitions of care.
Methods: Anesthesiologists were asked to rate the
importance of a subset of elements in regards to the handoff process. After reviewing other institutions’ hand-off
models and comparing them to our current practice’s
needs, we compiled and presented a prototype hand-off
tool to our department. Subsequent feedback required
reformatting for which a formal tool was constructed.
Results: The culminating hand-off tool developed
was as follows.
Conclusion: Assessing both provider and patient needs enabled the design of a concise, formatted
checklist for intraoperative use. Based on collaborative efforts, the hand-off tool has been implemented
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during this critical transition of care. With this intraoperative handoff tool, a more systematic approach to
handoffs will be used and thereby satisfaction of handoffs amongst providers is expected to increase. Consequently a decrease in mistakes that occur during the
handoff process is predicted, and compliance to the
tool will be measured across all anesthesia providers.
NWAC - 8
Cardiotocographic response to epidural analgesia
in labour : a double blinded randomised control
study
A. K. Jha1, S. Basu1, A. Basu2, B. Chatterjee2
B.R.Singh Institute for Medical Education and
Research, Kolkata, INDIA, 2Obstetrics & Gynaecology, B.R.Singh
Institute for Medical Education and Research, Kolkata, India
1Anaesthesiology,
Introduction: Neuraxial technique is the gold standard
for pain relief in labour. The widespread acceptance of epidural analgesia for labour is still lacking due to the various
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NWAC ABSTRACTS
Figure 8.
myths and controversies associated with it. It’s controversial if epidural analgesia causes changes in fetal heart rate
pattern by direct or indirect myocardial side effect.
Objectives: To study the effect of epidural analgesia
on the fetal heart rate by way of cardiotocography.
Methods: After ethical committee clearance, informed consent was taken. Study done from 1st May to
31st July. Inclusion criteria were booked singleton term
pregnancy with cephalic presentation without any obstetric complication, taking 30 subjects each as cases and
controls. Simple randomization technique of tossing a
coin was used to allocate the subjects into cases and controls. MedCalc version 11.6 [Mariakerke, Belgium: MedCalc Software 2011] was the software used for statistical
analysis and a ‘p’ value <0.005 was considered statistically significant. Limitations were a small sample size
and absence of USG guided techniques for needle placement. FHS patterns were observed by cardiotocography.
Crash tray with all the resque drugs were kept ready.
Results: No change was seen in CTG with respect to basal frequency, beat to beat variability or pattern of CTG.
Conclusion: Epidural analgesia in labour causes no
direct or indirect myocardial side effect.
NWAC - 9
Timing of administration of epidural analgesia and
risk of operative delivery in nulliparous women: a
randomised control study
I. Chattopadhyay
Anaesthesiology, B R Singh Hospital and Centre for Medical
Education and Research, Kolkata, India
Introduction: Epidural analgesia offers the most effective form of intrapartum analgesia. The timing of
initiation of epidural analgesia and its causal relationship
with mode of delivery is controversial.
Objectives: The purpose of this study was to determine whether early administration of epidural analgesia
affects obstetric outcome in nulliparous women.
Methods: A randomised study was conducted between 1st May to 31st July 2015 at a hospital in India.
The study population included term nulliparous parturients with singleton pregnancy in spontaneous labour, divided into two groups: one receiving epidural anaesthesia
with 10ml 0.125% Inj. Bupivacaine and the other as control. Cases were further divided into parturients receiving
epidural analgesia at a cervical dilatation of 3 cms or less
classified as the Early epidural group and those receiving
at 4 cms or more classified as the Late epidural group.
The modes of delivery for each group was recorded.
Sample size was 60 as calculated using power of 90%
and an a value of 0.05. P < 0.05 was considered statistically significant.
Results: 15% and 23% women in early epidural group
and 23% and 11% in late epidural group underwent cesarean section and instrumental delivery respectively as
compared to 16% and 13% of controls.
Conclusion: No statistically significant difference
was seen in operative delivery rates for women receiving
early epidural analgesia in comparison with late or no
epidural analgesia. NWAC - 10
Ultrasonic assessment of phrenic nerve paralysis
after interscalene block with ultrasound guidance
versus neurostimulation
H. Mehdi, F. Klai, S. Boughariou, M. Boussofara
Anesthesiology, Trauma Center, Ben Arous, Tunisia
Introduction: interscalene block(ISB) provides effective anesthesia and postoperative analgesia for shoulder arthroscopy.
Objectives: we compared the paralysis of the phrenic
nerve after nerve stimulation versus ISB under ultrasound by the ultrasound of the diaphragm.
Methods: we conducted a prospective randomized
study including 40 patients divided in 2 equal groups:
- Ultrasound group (GE): ISB under ultrasound guidance.
- Neurostimulation group (GN): ISB neurostimulation.
We excluded patients with a history of bronchopulmonary disease .We measured before ISB, pulsed oxygen saturation(PO2S), the peak expiratory flow(PEF),
the volume-flow of the brachial artery(VFBA) and inspiratory thickness (ET) and expiratory (EE) of the diaphragm is then calculated the thickening fraction (ET)
Tabella NWAC - 9.—Comparison of early versus late epidural analgesia and risks of operative delivery.
Epidural group
Instrumental delivery
ODDS Ratio
95% CI
1.9688
0.9545
0.3582 to 10.8215
0.1505 to 6.0558
Early epidural group
Late epidural group
Caesarean delivery
P value
0.43 (>0.05)
0.96 (>0.05)
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ODDS Ratio
1.0500
1.5273
95% CI
0.1683 to 6.5516
0.3395 to 6.8696
P value
0.95 (>0.05)
0.58 (>0.05)
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NWAC ABSTRACTS
of the diaphragm to using the following formula: ET =
(EI -EE) / EI. Measuring the thickness of the diaphragm
was performed by an ultrasound probe with a planar-type
Sonosite head, high-frequency (10 MHz) used in muscle
mode in 2D mode and at a depth of 4 to 6 cm. the probe
was placed perpendicularly in the frontal plane between
the 8th and 9th intercostal space.measurements was redone 30 min, 2 h, 6 and 24 h after the ISB. Statistical
analysis was performed using SPSS 22 software.
Results: We found no cases in the 2 groups, and in no
time, the fall of ET < 20%, PEF < 80% theoretical value
or PO2S< 95%.the VFBAwas increased by 2 times to H2
and H6 after ISB in both groups.
GE
Age(years)
BMI(kg/m2)
bupivacaine (ml)
onset time of sensory block
the axillary nerve(min)
Onset of the motor block of
the axillary nerve(min)
The duration of the act (min)
GN
p
39.7 ± 4.3 37.8 ± 6.8 0.77
26.4 ± 1.4 5.4 ± 1.7 0.36
19.6 ± 4.3 21.2 ± 3.6 0.17;
14.1 ± 2.3) 17.6 ± 3.9 0.35
14.1 ± 2.3
17.6 ± 3.9 0.35
54.6 ± 18.9 61.2 ± 19.4 0.42
Conclusion: The paralysis of the phrenic nerve is a
common complication of BIS without having a clinical
impact on breathing.
NWAC - 11
A comparative study of postoperative hypothermia
between patients receiving intraoperative IV fluid
warming devices and forced-air warming
J. Jiarpinitnun, W. Ittichaikulthol, R. Komonhirun
Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol
University, Bangkok, Thailand
Introduction: Patients undergoing surgery under
anesthesia lead to increased risk of postoperative hypothermia and complications. One of the risk factors is the
operating room temperature.
Objectives: To compare the incidence of postoperative hypothermia in obstetric and gynecologic patients
at Ramathibodi Hospital between patients receiving intraoperative IV fluid warming devices (group: S) and
forced-air warming (group: C) in operating room temperature <20°C.
Methods: A cross-sectional and randomized study
was conducted in sixty patients undergoing obstetric and
gynecologic surgery under anesthesia during April 2015
to May 2015. Outcomes were analyzed and compared between patients group S and group C in a single operating
room with the temperature <20°C. The possible factors
of postoperative hypothermia were collected body temperature in operating room (before, during and at the end
of surgery) and in PACU (when admission and before
discharge). Hypothermia is defined as a core body temperature of <36°C.
Results: Thirty patients in each group were enrolled. Of these, mean age in group S and group C
were 46.43±14.42, 51±10.85 years (p-value 0.171),
mean body weight were 59.04±15.64, 63.69±14.75
kg (p-value 0.241), mean operating room temperature
were 19.39±0.75, 19.28±1.11°C. (p-value 0.654), and
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the median of anesthetic time were 162.5, 135 min (pvalue 0.529), the body temperature when admission at
PACU were 36.19±0.54 and 36.22±0.59°C respectively (p-value 0.856). The overall incidence of postoperative hypothermia was 33.33%, group S=30% and group
C=36.67%.
Conclusion: The efficacy of intraoperative IV fluid
warming devices with forced-air warming and prewarmed fluids is comparable to forced-air warming with
pre-warmed fluids.
NWAC - 12
Ultrasound locating of the epidural space: median
versus paramedian technique
H. Mehdi, S. Zakhama, S. Boughariou, F. Klai, M. Boussofara
Anesthesiology, trauma center, ben arous, Tunisia
Introduction: epidural anesthesia is fiabe during the
prosthetic knee replacement, but it is not devoid of failure.
Objectives: we compare two of sonographic identification techniques of the yellow ligament median
transverse section versus the sagittal oblique paramedian.
Methods: 40 patients randomized into 2 equal groups:
- GM: the identification of the yellow ligament(YL) is
performed in the transverse median section.
- GP: identifying YL is made using the paramedian
sagittal section. For all patients we identified the level of
intervertebral puncture L3-L4: the low frequency ultrasound probe curved header (2 to 5 MHz) is set in abdominal mode and at a depth of 9 to 12 cm. it is placed in the
median sagittal plane. We practice a subsequent rotation
of the probe 90 ° for the middle cross section that will
allow us to locate the spinous process of L3.In the GM,
the distance between the skin and the YL is calculated,
using the cursor on the middle cross section.for GP, we
identify the YL using the oblique cutting sagittaleparamédiane then we measure by the cursor the depth of the
YL. then measures the distance between the middle of
the ultrasound probe in this view and the median sagittal
section. we calculate the distance between the sken and
YL by the theorem of Pythagoras.
Results: GM
Age (years)
64.2 ± 8.4
BMI (kg/m²)
25.8 ± 3.6
The median sagittal
0.86±0.17
identification (min)
The median transverse
0.41 ± 0.12
locating(min)
The identification of the
2.03±0.17
yellow ligament (min)
Ease of the procedure ( 0-100) 38.4±9.7
The number of attempts
27/20
The incidence of redirection of
1.25
the needle
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GP
p
63.7 ± 9.6 0.43
26.4 ± 2.9 0.36
0.84 ± 0.19 0.41
0.39 ± 0.14 0.37
1.85 ± 0.13 0.019
27.1±6.8 0.037
23/20
0.27
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Conclusion: Ultrasound locating the epidural space,
whether performed in the transverse median or paramedian sagittal cut is an easy technique to achieve with a low
incidence of complications.
NWAC - 13
A case of the anaesthetic management of a ruptured ectopic pregnancy in a 30 year old patient with
melnick needle syndrome
M. Johnson1, C. Mullins1, H. Bartels2, D. Crosby2, D. Keane2, I.
Browne1
1Anaesthesia,
National
Maternity
Hospital,
Dublin,
IRELAND, 2Obstetrics and Gynaecology, National Maternity
Hospital, Dublin, Ireland
Introduction: Melnick Needles Syndrome(MNS) is
an extremely rare genetic disorder1 (aprox. 100 reported
cases globally). It is a member of otopalatodigital spectrum disorders. MNS primarily affects bone development. It presents challenges to the anaesthetist owing to
airway and skeletal abnormalities2.
Case Description: A 30 year old primigravida with
MNS presented to the emergency room out of hours at
six weeks gestation with worsening abdominal pain. On
arrival she was unwell, tachycardic and in severe pain. A
provisional diagnosis of ruptured ectopic pregnancy was
made. Her medical history was significant for obstructive
sleep apnoea secondary to MNS. Previous surgical history
included tracheostomy, ENT and Maxillofacial procedures. No old medical records were immediately available.
Physical exam revealed features typical of MNS including micrognathia, exophthalmos, protruding cheeks, short
stature and scoliosis. Airway assessment revealed reduced
mouth opening, small airway and receding mandible. An
uncuffed 3.0 ID tracheostomy tube was insitu. A combined
spinal/epidural(CSE) provided adequate surgical anaes-
thesia for an uncomplicated open salpingectomy. The patient recovered well and was discharged on postoperative
day 3. Figure1:Facial appearance.
Conclusion: This was a challenging case of an actively bleeding MNS patient with significant airway and
skeletal abnormalities requiring emergency surgery.
Careful consideration was required as to optimal anaesthetic technique given this cases complexity. References:
1.An Undiagnosed Bone Dysplasia. Melnick, Needles.
AmJ Roentgenology 1966 2.Syndromes: Rapid Recognition and Perioperative Implications. Bissonnette. 2006.
NWAC - 14
Anaesthetic management of a child with Aicardi
Goutiere Syndrme
Venkateswaran J, P. Khanna
Anaesthesia, Aiims,Delhi, Delhi, India
Introduction: We report here a child of eleven months old with AICARDI GOUTIERE SYNDROME (AGS) with congenital cataract of both eyes,
posted for lens aspiration and PCIOL insertion of both
eyes. Anesthesia for patients with Aicardi Goutiere Syndrome, is difficult because of its rarity and lack of literature regarding it’s anesthetic concerns . The actual
frequency of the disease is unknown and only around 30
cases have been reported worldwide.
Case Description: Child is a known case of Aicardi
Goutiere Syndrome. Child has history of developmental
delay and seizure disorder. Pre operatively on examining, the child was conscious and active. Head control was
not attained, microcephaly with receding mandible was
present. In operating room, routine mnitors were attached.
Inhalation induction with 50% mixture of oxygen and air
and 8% sevoflurane was done. Intravenous access was secured with 22G venflon. Fentanyl 10 ugs (1 ug /kg ), midazolam 0.5 mg and atracurium 2.5 mg were administered.
Airway was secured with AIR Q of size 1.5. Anaesthesia
was maintained with 50% oxygen and 1 MAC isoflurane.
Intra operative vitals were stable. At the end of surgery, residual neuromuscular blockade was reversed with 0.5 mg
of neostigmine and 0.1 mg of glycopyrolate. AIR Q was
removed after fully awake and adequate respiratory effort.
Post-operative period was uneventful.
Conclusion: We are presenting this case for its rarity
and the possible anesthetic challenges one could encounter, are highlighted.
NWAC - 15
ARCTIC (acute risk change in cardio-thoracic admission to intensive care) is a new quality metric
that predicts long-term mortality in cardiac surgery
T. Coulson1, M. Bailey1, C. Reid1, D. Pilcher2
of Epidemiology And Preventive Medicine, Monash
University, Melbourne, VIC, Australia, 2Intensive Care Unit, Alfred
Hospital, Melbourne, Australia
1Department
Figure 13.
Introduction: ARCTIC is a perioperative quality
measure in cardiac surgery based on change in mortal-
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NWAC ABSTRACTS
groups (Figure 1). Cox regression showed high ARCTIC
was independently associated with non-survival (HR 1.88,
p<0.001). High ARCTIC was associated with non-survival
after propensity matching (HR 1.6, p<0.001).
Results: A high ARCTIC was strongly associated
with 1-year (OR 1.05, p<0.001) and 5-year mortality (OR
1.03, p<0.001). This persisted with multivariate analysis.
Kaplan-Meier plots showed reduced survival across all
baseline risk groups (figure 1). Cox regression showed
high ARCTIC was independently associated with nonsurvival (HR 1.88, p<0.001). High ARCTIC was associated with non-survival after propensity matching (HR
1.6, p<0.001).
Conclusion: This study demonstrates that high ARCTIC is independently associated with worse long-term
outcomes. This may represent variation in perioperative
performance and the occurrence of postoperative complications.
NWAC - 16
Satisfaction of anesthesia providers with current
practices of transitions of care
T. Kundu, P. Upadya
Anesthesiology, Saint Joseph’s Medical Center, Paterson, NJ, United
States of America
Figure 15.—Kaplan-Meier plots showing survival up to 6.6 years for patients with low ARCTIC vs. high ARCTIC at different
leverls of baseline risk.
ity risk from preoperative to postoperative phase (calculated using risk scores, AusScore and APACHEIII). High
ARCTIC denotes an increased risk of death and adverse
outcome. ARCTIC has been evaluated at patient level
and is associated with intraoperative risk factors and postoperative morbidity.
Objectives: We investigated whether ARCTIC is associated with long-term mortality.
Methods: A high ARCTIC was strongly associated with
1-year (OR 1.05, p<0.001) and 5-year mortality (OR 1.03,
p<0.001). This persisted with multivariate analysis. KaplanMeier plots showed reduced survival across all baseline risk
10
Introduction: Effective communication is essential
for safe patient care. Hand-offs between providers are
known to be critical times when errors can occur. Utilization of handoff tools in the perioperative period, entailing multiple transitions of care, plausibly correlates to
an increase in provider satisfaction and positive patient
outcomes.
Objectives: The purpose of this study was to examine
the handoff practices between anesthesia providers.
Methods: A survey was developed and distributed
to the anesthesia department. This 18-question survey
assessed aspects of the handoff process and level of
adherence. A 10 point percentage scale showed how
often elements of the hand-off process were communicated. A 12 point question was used to rank elements that were necessary to communicate during
hand-offs.
Results: Of the 42 responses, only 3 were satisfied
with current hand-off practices 100% of the time (7.14%)
and more than half (56.7%) were satisfied less than 70%
of time. Majority of the time, 33.3% of respondents felt
they received an incomplete hand-off. Over 90% of respondents thought lack of adequate hand-offs could result in morbidity and mortality. Time constraints were
believed to be the cause of inadequate hand-offs by 50%
of participants.
Conclusion: Although satisfaction with current handoff practices are adequate, there is an overwhelming
interest in improving perioperative transitions of care
thereby warranting the implementation of a formal handoff tool. Utilization of such tools in the perioperative period, entailing multiple transitions of care, plausibly correlates to an increase in provider satisfaction and positive
patient outcomes.
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NWAC ABSTRACTS
NWAC - 17
Can multidisciplinary simulation improve the care
of tracheostomy and laryngectomy patients?
E. Teh1, C. Kirby2, O. Wakelam3, A. SK Poon1
1Anaesthetic Department, Lister Hospital, Stevenage, United
Kingdom, 2Education Centre, Lister Hospital, Stevenage, United
Kingdom, 3Ent Department, Lister Hospital, Stevenage, United
Kingdom
Introduction: Following a serious incident leading
to cardiac arrest for a laryngectomy patient, it was concluded that human factors played an important contributory part. In order to address this, our simulation faculty
was approached to design training aimed at doctors and
nurses involved in the care of tracheostomy and laryngectomy patients.
Objectives: We aimed to set up high fidelity simulated scenarios for health care professionals and provide
multidisciplinary training in both technical and non-technical skills management in crises.
Methods: We organised six multidisciplinary simulation sessions using the Laerdal Essential Patient Simulator. We ran a total of 21 scenarios, involving a total of
44 participants (25 doctors and 19 nurses). Scenarios
involved acutely deteriorating laryngectomy or tracheostomy patients and were followed by a group focused
debrief. We encouraged the use of acronym Situation,
Background, Assessment and Recommendation (SBAR)
to aid concise communication between participants.
Participants completed pre-session and post-session
questionnaires and multiple choice questions in order to
evaluate the effectiveness of our training.
Results: Our data indicates that our training increases
participants’ knowledge of the differences between laryngectomy and tracheostomy patients, and improves participants’ confidence to assess and manage these patients,
including those in respiratory distress (Mann-Whitney U
test, p<0.05). Participants found the scenarios to be realistic (mean five-point Likert score 4.7/5).
Conclusion: Simulation training can improve both
the technical and non-technical skills needed to manage laryngectomy and tracheostomy patients, especially
in crisis situation. Multidisciplinary simulation training
may also make scenarios more realistic, and improve
team working skills essential for optimal patient care.
Figure 18.
the surgical field was detached and nearly injured the
Anesthesiologist.
Case Description: A young patient was posted for Tibial nail extraction under Spinal anesthesia. After checking
the level of the Spinal Anesthesia (T10) a separator screen
was fixed and the surgeon was asked to proceed. The anesthesiologist checked the vitals and started the electronic
medical documentation. The Surgeon attached the extractor zig to the Tibial implantand started the procedure
of removal with reverse hammering. 15 minutes into the
procedure the extractor zig got disengaged and flew into
the head end of the patient. The alert anesthesiologist, sidestepped the sharp flying instrument which landed on the
floor near the head end of the operating table.
Conclusion: Anesthesiologists should be aware that
such mishaps although rare may happen during the perioperative period. Such disengaged sharp instruments can
injure both the patient & anesthesiologist, if he/she is distracted during such procedures. The literature mentions
of no such event.
NWAC - 19
Surgical correction of congenital clubfoot and
pseudosyndactyly in pediatric patient with Epidermolysis Bullosa J. A. Vaz De Melo1, W. C. Rocha1, R. de Faria e Silva2, F. A. Resende1, A. Higino Gonçalves da Silva1, C. B. T. Ferreira2, M. V. Pimentel Cardoso1, M. A. Vinhal Andrade1
1Anesthesiology,
Felício Rocho Hospital, Belo Horizonte,
Brazil, 2Anesthesia, Hospital Felicio Rocho, Belo Horizonte, Brazil
Introduction: Epidermolysis bullosa (EB) is a
hereditary disease of skin and mucous membranes,
NWAC - 18
Distractions in the peri-operative period may affect both patient safety & anesthesiologist safety
R. P. Koduri, K. A. Langer
Anesthesiology & Pain Therapy, Al Mafraq Hospital, Abudhabi,
United Arab Emirates
Introduction: Music, internet and use of smart
phones (medical applications) in operating rooms have
made the job of the anesthesiologist much safer with respect to patient care. The anesthesiologist may also use
some part of this time to catch up on social media especially during procedures under regional anesthesia and
these add to the distractions in the peri-operative period.
We present a case report where a sharp instrument from
Figure 19.
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11
NWAC ABSTRACTS
which causes bubbles spontaneously or with minimal
trauma.
Case Description: Three year old male, with proposal of surgery for congenital clubfoot correction and
pseudosyndactyly, with EB and anemia, ranked ASA3.
Premedication with midazolam, inhalation anesthesia
was induced with sevoflurane under oiled facial mask,
in the mother’s presence. He was kept under spontaneous
ventilation with a face mask and complete monitorization. It was established venoclysis in the temporal region,
being fixed with bandage. As maintenance, propofol and
ketamine were used. Prophylaxis of vomiting and pain
relief postoperative with dipyrone and ondansetron. The
act was uneventful, being referred to the post-anesthetic
recovery room.
Conclusion: In patients with EB, the general principle is to avoid shear force on the skin to prevent the
formation of new lesions and not exacerbate existing limitations. Patients must be raised and never glide
on the bed during transfer, do not use adhesives directly to the skin and use adhesives based on silicone.
The lubrication of the material will reduce the aggression of the mucous membranes, and should be associated with minimal manipulation of the airway at risk of
edema. Perform prophylaxis of vomiting after surgery to
avoid esophageal injury. Maternal presence was crucial
to the child’s reassurance, allowing induction and quiet
awakening.
NWAC - 20
The use of recombinant activated factor VIIa in
refractory lower gastrointestinal hemorrhage in a
patient with recently implanted mechanical aortic
valve
S. Sudarsanan1, A. S. Omar2, H. Ewila2, A. Kindawi2
Anesthesia & Icu Division,department Of Cardiothoracic
Surgery, Heart Hospital,Hamad Medical Corporation, Doha,
2
Qatar, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
1Cardiac
Introduction: Bleeding complications are very common after cardiac surgery, however Lower gastrointestinal bleeding (LGIB) is not a usual association.
Case Description: A 50 year old male, scheduled for
elective aortic valve replacement, developed cardiac arrest after induction of anaesthesia, necessitating emergency initiation of cardiopulmonary bypass followed by
replacement with mechanical valve. He had a complicated postoperative course with renal and hepatic failure,
and supervening sepsis. He developed massive LGIB in
the form of melena, amounting to approximately 6 liters
with hemodynamic compromise, on post operative day
24, with colonoscopy revealing multiple ischemic ulcers
and hematoma in the colon. When bleeding was not controlled with transfusion of multiple blood products, and
surgical intervention was deemed too risky, 60 mcg/kg
of recombinant Factor VII A (rFVIIa), was administered,
which resulted in dramatic cessation of bleeding .A second dose was repeated 2 days later when he developed
another bout of LGIB, after which the bleeding completely stopped. Use of rFVIIa as curative therapy is well
documented, for hemostasis in LGIB, and also in post
12
cardiac surgery mediastinal bleeding. Complications of
rFVIIa are thrombosis and increased mortality associated
with thrombosis, which was higher in our patient due to
existing mechanical valve. We used the drug as a rescue
measure, when conventional blood products failed to
stop the bleeding and alternatives were limited and surgical intervention carried high mortality.
Conclusion: Favourable outcome was achieved after
giving rFVIIa, emphasizing the need to raise the awareness about using the drug as a desperate life saving measure.
NWAC - 21
Management of a severely anaemic Jehovah’s witness in a resource poor setting
I. Akhideno, B. Imadiyi
Anaesthesia, Irrua Specialist Teaching Hospital, Irrua, Nigeria
Introduction: Leviticus 17:14.”You must not eat the
blood of any sort of flesh... Anyone eating it will be cut
off” Jehovah’s Witness are guided by the above bible text
amongst others and pose clinical, ethical and medicolegal challenges to the clinician moreso in a resource poor
setting.
Case Description: A 27 year old Jehovah’s Witness
had myomectomy on account of a large uterine fibroid.
Preoperative PCV was 38%, she had a signed directive against blood transfusion. Intraoperative EBL was
4litres while 4L of Normal Saline, 1.5L of Isoplasma
and 6mg of Ephedrine were administered due to hypotension. 90minutes postoperatively,she was noticed to
be markedly pale, with 430mls of blood in abdominal
drain. PR was 111bpm, blood pressure of 80/40mmHg.
Dopamine infusion was commenced, transferred to the
ICU, postoperative PCV was 6%. IV Erythropoietin
was commenced, initially at 1500IU but increased to
20,000IU as PCV dropped to 5%.Iron Dextran 250mg
initially,also increased to 400mg.By the 9th day postop and 2nd day on high dose EPO, the PCV had appreciated to 10%, blood pressure had improved to
102/63mmHg.12th day postop, PCV had risen to 16%
with an SPO2 of 96%.. She was discharged next day
to the ward and sent home 26 days postop with a PCV
of 29%, though with some degree of bilateral hearing
loss. Only 2 doses of high dose EPO were given due to
cost and unavailability.
Conclusion: Flexibility of a clinician in managing
profound anaemia as regards use of high dose EPO in
this group of patients may be beneficial albeit with some
complications.
NWAC - 22
A case of streptococcal toxic shock syndrome
T. Sara, S. Shanbhag, M. Salim
Intensive Care, Walsall Manor Hospital, Walsall, United Kingdom
Introduction: Invasive group A streptococcal toxic
shock syndrome causes considerable mortality due to
rapid progression and misdiagnosis. The non-specific
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NWAC ABSTRACTS
clinical features and infrequent occurrence makes diagnosis extremely challenging. Successful outcome requires a high index of clinical suspicion and early aggressive treatment.
Case Description: A 63 year old man presented
to the emergency department with flu-like symptoms,
vomiting and leg pain. This developed hours after
sustaining a cutaneous injury to his thigh whilst playing football. He was admitted with severe sepsis and
multi-organ failure and immediately taken to theatre
for surgical debridement, with presumed necrotising
fasciitis. Surgical findings did not correlate with the
severity of symptoms and subsequent CT scans was
negative. After surgery he was admitted to Intensive
Care for triple antibiotic therapy and multi-organ support. He further deteriorated within hours of admission
and consequently initiated on clindamycin and immunoglobulin for assumed group A streptococcal (GAS)
infection. On day 3 of admission, blood cultures were
positive for beta-haemolytic streptococci A and subsequent histology showed fat necrosis. The patient required additional extensive debridement, after which
he gradually improved and was transferred to a tertiary
centre for plastic surgery.
Conclusion: This case highlights 3 important points
in managing GAS. Firstly, early diagnosis with prompt
and aggressive surgical debridement is imperative.
Secondly, early addition of clindamycin to beta-lactam
antibiotics reduces mortality, possibly because efficacy
is not affected by inoculum size or stage of growth.
Thirdly, immunoglobulins are suggested as adjuvant
therapy because of their ability to neutralise super antigens, facilitate opsonisation and modulate cytokine
response. NWAC - 23
Interest of tranexamic acid in the prevention of
bleeding during surgery traumatic spine
H. Mehdi, S. Boughariou, S. Zakhama, R. Massoudi, F. Klai, M.
Boussofara
Introduction: traumatic spine surgery is associated
with major blood loss for which it is often necessary to be
transfused. Many techniques blood saving are developed
in order to limit bleeding and consequently transfusion.
Objectives: We assessed whether tranexamic acid
(ATX) would reduce the accumulated blood loss over 24
hours without the occurrence of side effects.
Methods: The study was conducted between April
2013 and June 2015. 50 patients operated on for traumatic spinal arthrodesis of three to five vertebrae were
included. They were divided into two equal groups
of 25 patients each: Control (T) and Exacyl (E). The
group received Exacyl ATX intraoperatively and postoperatively until the fifth hour (10 mg / kg bolus followed by 1 mg / kg / h). We evaluated the intraoperative and postoperative blood loss until the 72th hour.
we searched the occurrence of side effects and changes
in laboratory parameters for dosing of d-dimers and I
trponine every 8 hours pending the first day.A Doppler
ultrasonography of the lower limbs was performed for
all patient with a rate of d-dimer> 10.000ng / ml. statistical analysis by SPSS 22.
Results: Age(years)
Size(cm)
sex ratio
BMI(kg/m²)
duration of the act (min)
duration of anesthesia
(min)
number of operated
vertebrae
intra-operative bleeding
(ml)
bleeding in
post-interventional
monitoring room(ml)
transfusion rate(RBC)
D-dimer(ng / ml)
TroponineI(μg / l)
T
E
p
51.4 ± 13.7
168 ± 14. 4
1.5
24.6±1.4
112.4 ± 22.8
154.7 ± 37.7
48.4 ± 16.2
167.6±17.2
2.125
23.9±1.9
128.7 ± 29.9
161.7 ± 41.2
0.23
0.19
0.11
0.27
0.09
0.17
3.92 ± 0.8
4.08 ± 0.60
0.21
782.6 ± 234.7 744.9 ± 288.7 0.22
442.7 ± 185.6 312.8 ± 88.4 0.031
0.96 ± 0.24
0.78 ± 0.31 0, 27
3968 ± 147 5847 ± 2545 0.022
0.058 ± 0.033 0.074 ± 0,027 0.12
we have noted in any patient of the 2 groups the occurrence of thromboembolic complications.
Conclusion: ATX significantly reduce blood loss in
the traumatic spinal surgery, with no impact on transfusion and no significant side effects.
NWAC - 24
Kinetics of plasma procalcitonin during the acute
phase of severe traumatic brain injury
H. Mehdi, S. Boughariou, F. Klai, S. Zakhama, M. Boussofara
Introduction: Procalcitonin is recognized as a biomarker of inflammation and sepsis. plasma levels were
found after major surgery and multiple trauma.
Objectives: evaluate the kinetics of plasma procalcitonin during the acute phase of severe trauma.
Methods: 48 Severe trauma are included in a prospective study .were excluded from the study those
who had a serious medical history that could interfere
with the assay of procalcitonémie or other acute pathologies may alter the procalcitonémie. It was noted
severity scores (IGS H0 / H48, ISS, BSC) and the kinetics of white blood cells, CRP, creatinine is and procalcitonémie (ELISA [Brahms®]). Venous samples were
taken to J1,2,3 and J7.
Results: Age (years) 35.31 ± 15.21, BMI: 24.85 ±
3.26. D. stay (days): 11.68 ± 14.23, D. mechanical ventilation (days): 7.48 ± 9,82.IGS (H0 / H48): 37.71 ± 16.38 /
34.13 ± 18.72 ISS: 38.69 ± 18.98, Glasgow: 8.65 ± 5.26.
The outcome was favorable in 62.5% of cases. The raised
mortality was 16.7%. There was no significant difference
observed between the groups regarding inflammatory
markers (GB and CRP) and serum creatinine.
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NWAC ABSTRACTS
Table I.
PCT2
PCT 7
ISS ≥ 25
ISS < 25
p
14.3±7.6
8.5±4.1
3.6±2.2
0.6±0.38
0.022
0.031
Table II.
PCT2
PCT 73
PCT 7
Dead
favorable
p
8.5 ± 5.8
9.1 ± 6.2
31.5 ± 7.5
6.7 ± 1.4
7.6 ± 1.5
19.1 ± 4.2
0.02
0.016
0.008
Conclusion: The significant increase of the kinetics
of blood Procalcitonin seems to be a predictive factor of
gravity.
NWAC - 25
High frequency percussive ventilation as rescue
therapy for severe hypoxemic respiratory failure
in a 4-month old infant with failure to thrive
Steven Dewaele1, Marie-Rose Van Hoestenberghe2, D. Schramme1,
Margot Vanderlaenen1
1Intensive Care, Zol, Genk, Belgium, 2Paediatrics, Zol, Genk,
Belgium
Introduction: Management of respiratory failure during acute respiratory infections is challenging in infants
with muscle weakness. We describe the life-saving use of
invasive High Frequency Percussive Ventilation (HFPV)
with a volumetric diffusive ventilator (VDR4) after other
methods of respiratory management failed.
Case Description: A 4 month old 5.120kg male with idiopathic failure to thrive was admitted to our pediatric ICU
with respiratory failure due to viral infection. On admission
he was treated with conventional nebulized bronchodilators (epinephrine, ipratropium bromide, salbutamol and hypertonic saline). After initial improvement of oxygenation
and acidosis, his respiratory symptoms deteriorated with
complete radiographic opacification of the right lung. Management with non-invasive positive pressure ventilation
was unsuccessful, necessitating conventional mechanical
ventilation. Several ventilator strategies failed to improve
the patient’s clinical status, chest x-ray and arterial blood
gas, making a trial with HFPV necessary. Initial VDR4 settings were: Pulsatile Flowrate 30cmH2O, Demand PEEP
0cmH2O, Oscillatory PEEP 17cmH2O, Convective Rate
32bpm, Percussive Rate 695, I:E 1:1.2, FiO2 1. Within
three hours after HFPV initiation, chest radiography re-
vealed fully expanded lungs and ventilation/perfusion relationship (P/F) further improved in accordance with the
beneficial clinical evolution (Figure 1).
Conclusion: HFPV as rescue therapy in infants not
responding to conventional ventilator strategies could
represent a viable alternative for the treatment of hypoxemic respiratory failure. Improving lung recruitment and
P/F, HFPV may avoid the need for extracorporeal membrane oxygenation.
NWAC - 26
An uncommon complication post ESWL
I. Chua
Emergency Medicine, Changi General Hospital, Singapore,
Singapore
Introduction: ESWL is a commonly performed procedure for patients with renal or proximal ureteral calculi. Major complications following ESWL are rare, with
the most frequent side effect as microscopic hematuria.
We present a case of a middle aged gentleman who presented with persistent loin to groin pain post ESWL.
Case Description: A 61 year old Malay gentleman
with a history of hypertension, hyperlipidemia, cervical
spondylosis, and left renal stone with previous ESWL
(extracorporeal shock wave lithotripsy) in 2010, 2012
and Jul 2015. He presented 10 days after the last episode
of ESWL to the Emergency Department with complaints
of fever, hematuria and left loin to groin pain and was
diagnosed as UTI with probable passed stones and discharged with analgesia and antibiotics. He reattended 3
days later because of worsening left loin to groin pain
associated with fever and gross hematuria. Clinically, his
vital signs were stable, and there was tenderness over the
left groin with negative renal punch. Bedside ultrasound
was performed which showed a left perinephric mass. He
was started on IV antibiotics and treated as for pyelonephritis with possible renal abscess and admitted to the
urology unit. A CT KUB was subsequently performed
which showed a large subcapsular perinephric haematoma with multiple small left mid-ureteric calculi.
Conclusion: ESWL is a commonly performed procedure for patients with renal calculi. Major complications
following ESWL are rare but knowledge of this potential
complication is important as imaging is an important modality for diagnosis and treatment.
NWAC - 27
Performance evaluation of two ‘point of care’ tests
monitoring heparin activity during cardiac surgery
M. John1, R. Hofmeyr2, K. Giraud3, N. Razzaq3, F. Falter1
1Anaesthesia And Intensive Care, Papworth Hospital NHS
Foundation Trust, Cambridge, United Kingdom, 2Anaesthesia
& Critical Care, Groote Schuur Hospital, Cape Town, South
Africa, 3Papworth Hospital NHS Foundation Trust, Cambridge,
United Kingdom
Figure 25.
14
Introduction: Monitoring anticoagulation with the
activated clotting time (ACT) is an integral aspect of car-
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NWAC ABSTRACTS
Table
n
TF1
TF2
TF3
TF4
TF5
TF6
TF7
Total
Device 1 (H)
Mean sd
ACT
CV
(%)
n
Device 2 (IS)
Mean sd
ACT
166 119 8.6
7.2 166 133
167 596 79.3 13.3 161 650
166 589 84.4 14.3 164 676
164 548 82.7 15.1 163 592
132 509 60.9 12.0 130 552
84
502 111.6 22.2 83
540
164 121 9.7
8.1 161 131
1043 418 68.7 16.4 1028 459
7.8
37.3
55.0
40.7
38.8
24.2
5.4
34.9
CV
(%)
5.8
5.7
8.1
6.9
7.0
4.5
4.1
7.6
diac surgery, allowing the safe conduct of cardiopulmonary bypass (CPB). Despite many different test devices
available, very few studies assessing their precision, accuracy and validity have been undertaken 1.
Objectives: Our study aimed to evaluate the performance of two commonly used ACT devices, using two
different laboratory methods: Hemochron Elite (fibrin
clot detection), i-Stat (thrombin generation).
Methods: This international multi-center study assessed device variability in ACT measurement between
Hemochron Elite [H] and i-Stat [IS]. Patients undergoing cardiac surgery were divided into elective (heparin
naïve) and urgent (heparin exposed) groups. In both
cohorts, duplicate ACT measurements were performed
at standard times using two machines of each tested
device.
Results: This data comes from 2071 measuring points
in 171 patients. The coefficients of variation (CV) are
higher when patients are heparinized. IS systematically
yields higher measurements than H. IS consistently has a
CV <10%, while H can be as high as 22%.
Conclusion: Measuring the ACT using thrombin
generation with the i-Stat is more reliable. As it generates higher readings, the safe ACT for CBP needs to be
adjusted when switching from Hemochron Elite to iStat. 1. Lasne, D., et al., Guidelines for certification of
Activated clotting time (ACT) according to the EN ISO
22870 standards. Ann Biol Clin (Paris), 2015. 73(2): p.
225-254.
NWAC - 28
Novel ultrasound processing system for real –time
automated spinal landmark identification in healthy volunteers
P. Tildsley1, M. J. Lim1, Y. Leng2, K. K. Tan2, A. T. Sia1, B. L. Sng1
1Women’s Anaesthesia, KK Women’s and Children’s Hospital,
Singapore, Singapore, 2National University of Singapore, Singapore,
Singapore
Introduction: Neuraxial procedures are abundant
worldwide for anaesthesia, pain and diagnostic testing,
with “blind” landmark palpation the standard for locating
correct needle insertion points. This is unreliable compared to ultrasound for identifying correct interspinous
levels and spinal cord injury may occur if the insertion
point is too high. Ultrasound decreases the number of
required attempts, but efficient image interpretation requires training. Our processing system aims to resolve
Figure 28.
these issues by automatically identifying relevant spinal
anatomy in real time.
Objectives: To investigate the accuracy of the processing system in identifying the L3/4 space (primary
aim) and ligamentum flavum (secondary aim) compared
to ultrasound experienced clinician identifications.
Methods: A prospective cohort study in 54 healthy
volunteers. 2 images with automated identification
markings (longitudinal view for L3/4, transverse view
for ligamentum flavum) are produced. A clinician
blinded to the ultrasound processing identification is
shown the same images, without computer markings,
and indicate their proposed L3/4 space and ligamentum flavum. Scans are considered accurate if the identified levels match.
Results: Primary aim: In 50 of 54 subjects the computer and clinician L3/4 space matched (92.6% accuracy). Secondary aim: In 53 of 54 subjects the computer
and clinician ligamentum flavum matched (98.1% accuracy).
Conclusion: Our processing system is accurate for
real-time automatic identification of the L3/4 space and
ligamentum flavum in healthy volunteers.
NWAC - 29
Surgical modification of cadaver heads to simulate
submandibular abscess for training and research
in management of difficult airways
R. Chandran1, J. B. Lai2, A. Ramadorai2, V. S. Kasireddi1
Of Anaesthesia And Intensive Care, Changi General
Hospital, Singapore, Singapore, 2Oral Maxillofacial Surgery,
Changi General Hospital, Singapore, Singapore
1Department
Introduction: Advanced airway management simulation forms an integral part of anaesthesiology training
programs. Training on manikins do not truly represent
the severity of problems faced with difficult airway management. Cadavers offer life like conditions for training.
However cadavers with difficult airway anatomy are hard
to find and simulation of difficult airway on cadavers
have rarely been attempted.
Objectives: Our objective was to simulate difficult
airway on a cadaver by surgical modification and its validation for training and research.
Methods: Bilateral condylar plating was performed
across the zygomatic arch on a normal cadaver. Prevention of condylar translation reduced the mouth opening
to 1.7 cm. Further, submandibular glands were removed
and replaced with tightly packed gauze. This simulated
submandibular abscess with tense swollen floor of the
mouth and reduced mouth opening.
Results: Airway course participants (n= 16, experience 5.7 years ± SD 5.8, trainees 11) evaluated the
specimen. MacIntosh laryngoscopy views obtained were
III(3), IV (13). Intubation using glidescope took 89 sec-
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NWAC ABSTRACTS
Figure 29.
onds ± SD 54. Simulated Model was rated as realistic
(6.6) and beneficial for skills training (6.3) on Likert
scale {1 least - 7 most ( realistic / beneficial)}.
Conclusion: Simulation of realistic difficult airways
can be achieved by surgical modification of cadavers.
These models can be used for enhanced experiential
learning and in clinical research as a surrogate to live patients with difficult airways.
NWAC - 30
Find a doctor app., an app designed to improve the
availability of anesthesiologists for the o.R. management
J. Bordones
Research & Innovation, CEIIMED, Santiago de Chile, Chile
Introduction: When scheduling surgeries, sometimes
some medical specialties, like anesthesia, might be a
scarce resource. This may present a problem for the coordination of Operating Room (O.R.), especially when
work is on-call based, or with free-lance systems. On the
other hand, some anesthesiologist may be located near a
Center in need, but not necessarily connected with it, and
eventually willing to attend the emergency.
Objectives: For this reason, we have developed an
App to be used by the staff who schedule surgeries,
this App shows on the map the anesthesiologists near a
center based on availability, location and other pertinent
criteria.
Methods: This App was created with the Appinventor.mit.edu free program. It uses the technology and functions of Tiny Data Base, Location Sensor and Google
Maps, to display the availability of anesthesiologists
nearby.
16
Figure 30.
Results: The expected results include better managing of resources by shorting the waiting period to initiate
non-programed surgeries.
Conclusion: In the near future, this App may be used
for on-call subspecialists, like pediatric anesthesia, or
other on-call specialists, for example cardiologists.
NWAC - 31
Comparison of Remifentanil versus Dexmedetomidine in sedation for fibreoptic intubation
Introduction: intubation vigil fiberoptic requires adequate sedation for the procedure without inducing the
patient’s apnea.
Objectives: The aim of our study was to compare two
ways of sedation for tracheal intubation under fibreoptic
(ITF).
Methods: A prospective study including 40 adult patients admitted for scheduled reconstructive surgery of
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NWAC ABSTRACTS
the face burns requiring ITF. They were randomized into
2 groups:
- GR: under sedation remifentanil
- GD: dexmedetomidine sedation All patients underwent a gargle by the lidocaïne 5%, and then practice a
bilateral laryngeal nerve block according to the technique
of Vannier. Then three lidocaïne sprays are made at each
nostril. Finally, the endoscope is lubricated by the lidocaïne gel.
Oxygenation was maintained through a nasal tube
(6l / min). Then, patients GR received sedation with a
remifentanil bolus 0.75 µgkg-1 followed by an infusion
at a rate of 0.075 µgkg-1 min-1. In GD, intravenous sedation with a dexmedetomidine bolus of 0.4 µgkg-1 followed by an infusion at a rate of 0.7 µgkg-1 hr-1. Then
we proceeds to ITF. Statistical analyze is ensured by
SPSS 22 (p < 0.05).
Results: no difference between the 2 groups for
age (GR: 44.7 ± 11,9years vs GD: 41.6 ± 15.3; p =
0.39) and BMI (kg / m²): 23.9 ± 1,3 in GRvs24,8
±1,7dans GD, p = 0.33. The ease of intubation (0à10):
4.3 /10 in GR vs 3.4/10 in GD, p = 0.11. Successful
ITF from the 1st attempt: 75% (GR) vs85% (GD); p
= 0, 21.Sédation deep (RAMSAY>3) : 5% (GR) vs
0% (GD); p = 0.09; bronchospasm: 30% GR vs 10%
GD(p = 0,11. respiratory distress (bradypnea, SpO2 <
90%): 10% GR vs. 5% GD(p = 0, 22. cough: 20% GR
vs 15% GD p = 0.45.
Conclusion: dexmedetomidine or Remifentanil associated to local anesthesia; allow ITF in good conditions.
NWAC - 32
Intraoperative severe hypoxemia in a patient undergoing bronchoscopic excision of tracheal tumor
under vv-ecmo support
J. Chiehmin Hsu1, K.-B. Chen1, K.-S. Poon1, C.-F. Wu2, K. Hsiurong
Liao1
1Department Of Anesthesiology, China Medical University Hospital,
Taichung, Taiwan, 2Department Of Cardiac Surgery, China Medical
University Hospital, Taichung, Taiwan
Introduction: Anesthetic management of critical
tracheal obstruction is very challenging. When it‘s
impossible to establish secure airway with conventional technique of anesthetic induction, VV-ECMO
will be the optimal choice to provide gas exchange
and systemic oxygenation. Despite well-functioning
of VV-ECMO, recirculation phenomenon can impede
the efficiency of VV-ECMO and cause intraoperative
hypoxemia.
Case Description: A 33 year-old man was arranged
to undergo bronchoscopic excision of tracheal tumor due
to near-total tracheal obstruction induced hypoxemia
(Sat.=86%). Followed by induction of total intravenous
general anesthesia, VV-ECMO was set with drainage
cannula in femoral vein and reinfusion cannula in SVC.
Unexpected severe hypoxemia (Sat.=78%) occurred
even though the extracorporeal blood flow achieved the
maximal rate as 900ml/min. High oxygen tension of
blood sampled from outflow was detected and recirculation phenomenon was suspected. Repositioning the rein-
Figure 32.
fusion cannula would be the most immediate strategy to
reduce recirculation. TEE was planning to guide the cardiac surgeon to manipulate the reinfusion cannula. The
pulmonarist completed tumor excision simultaneously
and the patient restored 100% saturation then weaned
VV-ECMO at the end of the surgery.
Conclusion: When VV-ECMO is necessary in critical airway obstruction, recirculation can decrease VVECMO efficiency and lead to hypoxemia. Differential
diagnosis of this phenomenon is crucial and TEE will be
very helpful in reduction of recirculation by assistance of
creating better cannula configuration and positioning in
emergent condition.
NWAC - 33
Retromolar intubation as an alternative intubation
method to prevent dental injury
L. Nguyen1, D.-T. Truong2, A. Truong2
1Anesthesiology And Perioperative Medicine, MD Anderson Cancer
Center, Houston, United States of America, 2Anesthesiology And
Perioperative Medicine, MD Anderson Cancer Center, Houston, TX,
Introduction: Despite advances in airway management, perianesthetic dental injury remains one of the
most common anesthesia related claims. Risk factors
include poor dentition and difficult intubation. The retromolar space, located behind the last molar and the ascending ramus of the mandible, can be used to fiberoptically intubate patients at risk for dental injuries.
Case Description: A 51 year-old male with squamous
carcinoma of the neck was scheduled for direct laryngoscopy under general anesthesia. Examination revealed poor
oral hygiene, periododontal disease, dental abscesses, and
multiple broken teeth. After induction with propofol, fentanyl, and rocuronium, ventilation was easy with bag and
mask. A flexible fiberoptic scope armed with a 6.5 mm
tracheal tube was inserted in the left retromolar space and
guided through the vocal cords to the trachea. The tube was
then advanced over the scope to achieve retromolar intubation. Post intubation, the teeth were intact. He was extubated uneventfully and discharged home.
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NWAC - 35
Ultrasound-guided percutaneous tracheostomy in
incisive care
Figure 33.
Conclusion: Use of a dental guard with a rigid blade
or flexible fiberoptic oral midline intubation with an intubating airway are not reliable means to prevent dental
damage. Nasal fiberoptic intubation may risk epistaxis
and airway trauma. Using the retromolar space as an entry point far away from vulnerable teeth allows minimal
intraoral manipulation. Flexible retromolar intubation
offers an effective and safe option to prevent anesthesiarelated dental injuries.
NWAC - 34
Helium-oxygen mixture for the rescue treatment in
upper airway obstruction; evidence vs. beliefs
A. B. Hemph, J. Jakobsson
Anaesthesia & Intensive Care, Institution for Clinical Science,
Karolinska Institutet, Danderyd, Sweden
Alan Barach introduced in 1930-ties helium/oxygen
mixture to the medical world. He found that helium’s physical properties reduce airway resistance, especially in the
obstructed airway and help reduce the work of breathing
and improve gas exchange. Helium oxygen mixture has
since then been used sporadically as rescue treatment in
patients with severe upper airway obstruction. The aim of
the present review was to search and review the available
evidence for its safe and effective clinical use in adults with
compromised upper air way. In all 32 publications including 45 patients administered helium containing gas mixture for the treatment of upper airway obstruction in adults
were found in Public domain literature. Most case reports
describe short-term beneficial effects; temporarily improving breathing and oxygenation. Authors of the case reports
suggest helium-oxygen mixture as an optional bridge, while
more definite treatment takes action. There are however no
prospective randomized controlled studies, thus there is lack
of proof supporting its safe and efficacious use. Clinical trials with helium-oxygen mixtures conducted in moderate to
severe asthma have provided non-conclusive results while
its use as the driving gas for nebulization of broncho-dilating agents seems to have clear benefits improving peripheral drug deposit and effect. The sparse but seemingly positive clinical experiences favour the use of helium-oxygen
mixture as a symptomatic rescue therapy. The risk for side
effects seems minor. There is however still lack of evidence
to support general use of oxygen-helium mixture for upper
airway compromise. Further studies are warranted. 18
Introduction: The percutaneous tracheostomy (PCT)
is commonly used in the ICU as relay orotracheal intubation (OTI).
Objectives: The aim of our study was to evaluate the
PCT with ultrasound guidance in intensive care.
Methods: Patients in moderate extension of the neck.
The thyroid and cricoïd cartilages and tracheal rings were
located by ultrasound. The probe of tracheal intubation
was removed under ultrasound guidance above the first
tracheal ring. The space between the first and the second tracheal ring was spotted in longitudinal section by a
horizontal line. The skin-tracheal distance was measured.
Neck vessels were visualized cross-sectional color Doppler. The middle of the trachea was marked by a vertical
line, avoiding to pass through the vessels. The puncture
point was at the intersection between the two lines.
Results: The study included 80 patients. The duration
of ultrasound guidance was 7.81 ± 2.24 min with an average length of the proceeding after registration of 5.74 ±
1.47 min. The success rate at the first attempt was 91.25
% and the procedure was easy in 91.75 % of the cases.
For minor early complications, the incidence rate for antegrade passage of TPC guide 6.25 %, 3.75 % for the
minor bleeding, 2.5 % for the transient hypotension and
1.25% for the transitional Oxygen desaturation. The only
major early complication was subcutaneous emphysema
For late complications, 2.5 % for the swallowing disorder, 3.75% for decanulation failure, 2.5 % for dysphonia
and 5 % for unsightly scar.
Conclusion: TPC with ultrasound guidance allows
better feasibility and shorter procedure duration.
NWAC - 36
Anesthetic management of an achondroplastic
dwarf with difficult airway and spine for total hip
replacement
D. Jain1, P. Khanna2, N. Neiseville3
1Department of Anesthesiology, Pain Medcine & Critical
Care, All India Institute of Medical Sceinces, New Delhi,
INDIA, 2Anesthsiology, Pain Medicine and Critical Care, all India
Institute of Medical Sciences, New Delhi, INDIA, 3Anaesthesiology,
Pain Medicine And Critical Care, All India Institute of Medical
Sciences, New Delhi, India
Introduction: Achondroplasia is the commonest
skeletal dysplasia and possesses multiple anesthetic challenge involving airway, spine, obesity and cardiopulmonary system. We describe the anesthetic management and
importance of awake fiber-optic intubation in an achondroplastic dwarf with difficult airway with severe pulmonary disease for total hip replacement (THR).
Case Description: A 59 year old female achondroplastic dwarf with avascular necrosis of femur was posted for
bilateral THR. She was 121 cm tall (BMI = 32.83) and a
known case of bronchial asthma for past 20 years. She had
flexion deformity of hips and knees with thoracolumbar ky-
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NWAC ABSTRACTS
patient physiology might be suboptimal and manual ventilation may not be ideal due to increased risk of regurgitation in the presence of a full stomach.
Objectives: We performed a randomized controlled
trial to compare preoxygenation with OptifloTM and facemask for patients requiring rapid sequence induction for
surgery. Primary end point was PaO2 post intubation and
secondary outcome was time for desaturations.
Methods: 40 patients were consented and randomly
assigned to THRIVE or Face mask group. They were
pre oxygenated for 3 minutes with THRIVE or facemask
before the induction of anaesthesia. Intubation was then
attempted. A blood gas sample was obtained and PaO2
levels and time to intubate were documented.
Results: Average PaO2 in THRIVE group was
43.67kPa and 41.88 kPa in the FM group, the difference
not statistically significant. The average apnoea time in
the THRIVE group was 247.5 sec and 123 sec in the face
mask group (p value of <0.001) (figure 1). This was attributed to continued oxygenation possible with THRIVE
contributing to reducing stress of a time pressured situation. The BMI of patients ranged from 24.5 to 50.
Conclusion: The results suggest that continuous oxygenation with THRIVE increase the safety margin of airway
management in RSI by prolonging the apnoea time. This
has significant impact on training and patient safety as time
pressure has been shown to affect decision making being
less objective and more likely to be influenced by intuition.1
Figure 36.
phoscoliosis with fusions of multiple vertebral bodies along
with narrowed foramen magnum. Pulmonary function test
revealed severe restrictive and obstructive lung disease. Airway examination showed depressed nose, large tongue with
receding mandible, short and thick neck with marked limitation on extension, decrease thyromental distance. Airway
topicalisation was done with lignocaine nebulization and
spray. Fiberoptic was introduced through nose and trachea
was intubated via ‘spray as you go’ technique. General anesthesia was given and arterial line secured. Patient was shifted
to ICU for monitoring and extubated the next day with uneventful post op recovery.
Conclusion: We emphasize the importance of a detail
pre-anesthetic evaluation and planning for the most appropriate anesthetic technique in such patients. Decision
has to be individualized based on the patients anatomical
characteristics and associated co-morbidities.
NWAC - 37
Use of transnasal humidified rapid insufflation
ventilatory exchange (thrive) for rapid sequence induction
F. Mir1, R. Nouraei2, R. Iqbal1, M. Cecconi1, A. Patel2
St
Georges
Hospital,
London,
United
Kingdom, 2Anaesthesia, Royal National Throat, Nose and Ear
Hospital, London, United Kingdom
1Anaesthesia,
Introduction: Maintenenace of oxygenation during
intubation is a fundamental principle of airway management. This is important in emergency situations where
NWAC - 38
Reduction of postoperative ileus time after gastrointestinal resection and anastomosis surgeries
with combination of crystalloid and colloid fluids
M. Ghodraty1, F. Rokhtabnak1, H. Dehghan1, A. Reza Kholdebarin1,
A. Reza Pournajafian1, M. Baghaee Vajie2
1Anesthesiology, Iran University of Medical Sciences, Firoozghar
Hospital, Tehran, Iran, 2Surgery, Iran University of Medical
Sciences, Firoozghar Hospital, Tehran, Iran
Introduction: Ileus is a prevalent complication of
abdominal surgeries. Which cause various complications
also mortality of these patients. The results of some recent studies show the improvement of intestinal microcirculation with the use of colloid fluids.
Objectives: The aim of this study is evaluation of the
effect of two intravenous fluid therapy regimens on the
speed of intestinal motility return after gastro-intestinal
resection and anastomosis surgeries.
Methods: In a randomized clinical trial, 100 patients
with ASA physical class I-III candidate for GI tract resection & anastomosis was enrolled to the study and during
the operation, two different fluid therapy i.e. crystalloids
in group (A) and crystalloids + colloids in group (B) was
used. In the postoperative period the speed of returning the
normal intestinal function, ileus time, urinary output, water & electrolytes status, were compared between groups.
Results: Mean length of ileus in group (A) was 5199
± 1416 min and in group (B) 4403 ± 1249 min. (P =
0.006) There wasn’t any correlation between ileus time
and the length of surgery, age and sex of the patients. The
variation of serum potassium concentration in group B
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NWAC ABSTRACTS
( - 0.22 ± 0.53 meq/l) was lower than group A ( – 0.48 ±
0.56 meq/l) (P = 0.027).
Conclusion: This study showed that, colloid fluids (Voluven) usage in the composition of patient’s intra-operative
fluid therapy in GI tract resection & anastomosis cause faster
return of intestinal motility and reduction of ileus time.
NWAC - 39
Relationship between the control of blood pressure and cerebral oximerty values in carotid surgery
D. Milosevic1, D. Golic1, V. Vujanovic1, P. Beric1, N. Raseta2, B.
Tomanic1, V. Milosevic3, N. Keleman1, S. Keleman3
1Clinic For Anesthesia And Intensive Care, University Clinical
Center Banjaluka, Banjaluka, Bosnia ad Herzegovina, 2Faculty
of Medicine, University Clinical Center Banjaluka, Banjaluka,
Bosnia and Herzegovina, 3Pediatric Intensive Care Unit, University
Clinical Center Banjaluka, Banjaluka, Bosnia and Herzegovina
Introduction: The brain uses ~20% of аvailable oxygen
for normal function. In a normal physiological state normal
blood flow is remarkably consistant. Autoregulation of cerebral blood flow is ability of the brain to maintain constant
blood flow despite changes in perfusion pressure. Normal
range of cerebral perfusion pressure is 60-150mmHg. Outside this range autoregulaton is damaged, and CBF becomes
linearly dependent of perfusion pressure.
Objectives: The objectives of our work is to find correlation between arterial blood pressure and cerebral oxymetry values, with hypothesis that controlled hypertension give more value of cerebral oximetry.
Methods: Fifty patients were subjected to CEA. Type
of anesthesia in 27 cases - GA and in 23 cases - cervical
plexus block. Monitoring we used was invasive arterial
pressure measurement and cerebral oximetry monitoring - INVOS. Recorded data preoperative, clump on, and
correction BP/INVOS by vasoactive drugs.
Results: In 36 cases blood pressure oscilation was up
to 15% of baseline values. In 14 cases blood pressure
oscilation was over 15% of baseline values (unstabile).
For all patients we recorded: Preoperative -baseline average MAP 106.7 mmHg St Dev 9.82, CI ±2.72 “Clump
on” average MAP 105.9 mmHf St Dev 15.85, CI ± 4.39
Baseline INVOS average 70,91 St Dev 4,81, CI± 1.33
“Clump on” INVOS 64,38 St Dev 6,54, CI± 1.81 For
whole group Pearson positive correlation of BP/INVOS
r=0,70 (moderate positive) For hemodynamic unstabile
BP/INVOS r= 0,86 (strong positive).
Conclusion: Controled hypertension may improve
cerebral oxygenation, reduce risk of ischemic brain injury and use of shunt.
NWAC - 40
A case of functional weakness after general anaesthesia
E. Low, C. X
Anaesthesiology, Singapore General Hospital, Singapore, Singapore
Introduction: Functional weakness is weakness of a
limb inconsistent with a neurological disease. We describe
a case of a patient with left hemiparesis post-anaesthesia.
Case Description: An ASA 1 female, age 37, was list-
20
Figure 40.—Anaesthetic events perioperatively..
ed for bilateral Coronoidectomy for trismus. Her mouth
opening was 4 centimetres, the rest of her airway assessment was otherwise unremarkable. She was counselled
for awake fiberoptic intubation (FOB).
In recovery, there was weak eye opening on the left and
a left hemiparesis. An urgent MRI/MRA brain returned
negative for a stroke. Further workup ruled out organic
causes of the left hemiparesis. Neurology’s impression
was possible functional weakness. Further conversation
with the patient did not suggest awareness intraoperatively, however she additionally mentioned discomfort
during the awake FOB, and a low pain threshold.
Conclusion: Functional weakness is the weakness of
a limb inconsistent with a neurological disease, not intentionally produced, and unexplained medically. Diagnosis
can be challenging, and requires detailed history including onset and course of symptoms, symptoms of dissociation, and social background. Hoover’s sign-the intrinsic
tendency to extend the hip when flexing the contralateral
hip against resistance-has demonstrated good sensitivity
and specificity. Development of functional weakness has
been loosely associated with factors including pain. Associated risk factors and etiology for functional weakness
are unknown and are certainly worth exploring.
NWAC - 41
Supra-orbital pressure test to assess the depth of
anesthesia for laryngeal mask airway insertion in
children
K. Pokharel, B. Bhattarai, A. Subedi, S. Khatiwada, A. Koirala
Anesthesiology And Critical Care, B P Koirala Institute of Health
Sciences, Dharan, Nepal
Introduction: Supra-orbital pressure (SOP), a potent
stimulus used to assess unconscious patients, has not yet
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NWAC ABSTRACTS
been used to evaluate anesthetic depth for laryngeal mask
airway (LMA) insertion.
Objectives: We aimed to assess if response to supraorbital pressure can predict success of LMA insertion in
children.
Methods: Fifty children (ASA I-II), aged 2-10 years,
randomly received either supra-orbital pressure or jaw
thrust (JT) after a standard anesthetic. LMA was inserted
when the motor response to the study intervention was
absent. Outcome parameters were the number of successful insertions at the first attempt, and the LMA insertion
conditions which included the ease of mouth opening
and LMA insertion, occurrence of upper airway reflexes
and motor response to insertion. Each of these insertion
conditions were graded using a three-point scale and the
summed score was calculated.
Results: Success rate of LMA insertion at first attempt
was 84% in SOP group and was comparable to JT group
(p>0.05). The summed score of LMA insetion conditions
was favourable (<5) in both groups (p>0.05) and was as
low as zero in 18 patients in each group.
Table I.—Successful insertions and insertion conditions of
LMA at the first attempt. Values are expressed as number or
median (interquartile range).
Supraorbital Jaw P value
pressure
thrust
(n=25)
(n=25)
Successful insertion
21
Mouth opening (full/partial/nil)
25/0/0
Coughing (nil/slight/gross)
22/3/0
Swallowing (nil/slight/gross)
24/1/0
Laryngospasm (nil/partial/total)
25/0/0
Movement (nil/slight/gross)
18/5/2
Ease of insertion
23/2/0
(easy/dificult/impossible)
Insertion condition summed score 0 (0-1)
20
25/0/0
23/2/0
23/1/0
24/1/0
20/4/1
24/1/0
0.59
1.0
1.0
1.0
1.0
0.49
1.0
0 (0-1)
0.97
Conclusion: Supra-orbital pressure test is equally effective as jaw thrust maneuver to indicate optimal conditions for
LMA insertion during general anesthesia in children.
NWAC - 42
Kennedy’s disease: dodging the pitfalls
R. Leong, R. Chandran
Anaesthesia and Surgical Intensive Care, Changi General Hospital,
Singapore, Singapore
Introduction: Kennedy’s disease is a rare neurodegenerative disorder of the lower motor neurons characterized by progressive spinal and bulbar muscular atrophy. Concerns of general anaesthesia include the risk
of aspiration in patients with bulbar involvement and
increased sensitivity to muscle relaxants leading to respiratory compromise. Selection of appropriate technique
is of utmost importance to prevent perioperative complications. We report a safe and effective anaesthetic technique for cholecystectomy in patients with kennedy’s
disease, which has not been reported before.
Case Description: A patient with Kennedy’s disease
was posted for elective laparoscopic cholecystectomy.
Symptoms included bulbar weakness manifesting as dysar-
thria, tongue atrophy and proximal myopathy. Patient was
intubated using target controlled infusion of propofol and
remifentanil. Satisfactory anaesthetic plane and abdominal
wall relaxation was achieved without the use of muscle relaxants. The procedure was converted to open cholecystectomy due to dense inflammatory adhesions in the Calot’s
triangle. Ultrasound guided right T7/8 paravertebral block
catheter was performed post extubation. Well titrated continous paravertebral block facilitated effective pain management, early mobilization and physiotherapy with no
respiratory compromise. Recovery was smooth with no
respiratory complications or exacerbation of neurological
symptoms. Patient was discharged after seven days.
Conclusion: Total intravenous anaesthesia without
muscle relaxants can provide adequate abdominal wall
relaxation for laparoscopic and open cholecystecomy in
patients with Kennedy’s Disease. Paravertebral block
provides adequate analgesia, reduces opiod consumption
and helps in early mobilization and physiotherapy. Total
intravenous anaesthesia with paravertebral block is a safe
and effective anaesthetic technique for cholecystectomy
in patients with Kennedy’s disease.
NWAC - 43
A case report on baclofen induced tourette like
syndrome with tics and echolalia
E-L. Ooi1, X. J. Yu2
1Anaesthesia And Surgical Intensive Care, Changi General Hospital,
Singapore, Singapore, 2Anaesthesia And Surgical Intensive Care,
CGH, Singapore, Singapore
Introduction: Baclofen, a lipophilic analogue of
gamma – aminobutyric acid, is a muscle relaxant commonly used to treat spasticity. Spasticity could be associated with fracture or other injury to muscles, tendons
or bone below the level of spinal cord injury. Baclofen’s
use has been associated with depression, coma, seizurelike activities, respiratory depression and cardiovascular
effects1. Tourette syndrome, presents in childhood, with
motor and vocal tics.
Case Description: Madam X, a 78 year old Chinese
lady with history of hypertension, iron deficiency anemia
and atrial fibrillation, was admitted for left hip pain after
a fall. Investigations – MRI showed bilateral coxa Magna with acetabular remodeling, secondary degenerative
changes related to childhood Perthe’s disease, with no
hip fracture. Acute pain service prescribed Paracetamol
1gram 6hrly, Tramadol 50milligrams tds and Oxynorm
5milligrams tds/prn for breakthrough pain. Primary team
added baclofen 10mg tds 0745H - After 4 doses of baclofen, she was found unresponsive (GCS E1V1M5)
with facial tics. Urgent CT and MRI brain were normal.
0930H - She opened her eyes to pain stimuli and made
incomprehensive verbal sounds. 1100H - She developed
complex echolalia. Baclofen was discontinued with a
complete recovery within 24 hours. EEG showed diffuse encephalopathy with no epileptiform activity. Neurologist’s impression was Baclofen induced Tourette like
syndrome with tics and echolalia. She was discharged
ambulating well, remaining well at outpatient followups.
Conclusion: Baclofen is a widely used muscle relax-
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NWAC ABSTRACTS
ant with relatively safe profile, but for those patients with
high risk for adverse effects, it should be avoided or used
with extreme caution.
NWAC - 44
Effect of bevel direction on the success rate of ultrasound-guided radial arterial catheterization
S. Lee, C. B. In, Y. T. Jeon
Anesthesiology And Pain Medicine, Seoul National University
Bundang Hospital, Seongnam, Korea, Republic of
Introduction: Numerous studies have demonstrated
that ultrasound (US)-guided radial artery catheterization
improves the success rate of cannula insertion compared
to the traditional palpation method. However, the effect
of bevel direction on the success rate of US-guided radial
artery catheterization has not been known.
Objectives: This study assessed the effect of bevel
direction on the success rate of US-guided radial artery
catheterization.
Methods: A total of 204 patients requiring radial artery catheterization were randomly divided into bevel-up
(n=102) and bevel-down (n=102) groups. After identifying the radial artery with US imaging, its diameter and
depth (from the skin) were measured; success rate, cannulation time, and number of attempts were compared
among groups. Complications such as hematoma, edema,
and vasospasm were also recorded.
Results: The success rate for the first cannulation attempt was higher for the bevel-down versus bevel-up
group (86 of 102 [84%] vs. 73 of 102 [72%]; p=0.028).
Mean cannulation time (sec) was significantly lower
in the bevel-down versus bevel-up group (33 vs. 36,
p=0.011). The incidence of posterior wall haematoma
was lower in the bevel-down versus bevel-up group (11
of 102 [11%] vs. 22 of 102 [22%]; p=0.024). There were
no complications such as edema, vasospasm, or thrombosis.
Conclusion: The bevel-down approach during USguided radial artery catheterization exhibited a higher
success, and lower complication rate compared to the
bevel-up approach.
NWAC - 45
Undiagnosed tof with fluctuation of oxygen saturation during emergency operation
K.-C. Shih1, J.-H. Chang2, K.-S. Poon2
1Department Of Anesthesiology, China Medical University Hospital
(CMUH),Taichung, Taichung, Taiwan, 2China Medical University
Hospital (CMUH),Taichung, Taichung, Taiwan
Introduction: We reported a case of undiagnosed tetralogy of Fallot(TOF) with unusual initial presentation
of periodic desaturation during brain tumor surgery.
Case Description: A 63-year-old housewife with
history of hypertension received steroid and emergent
craniotomy due to consciousness disturbance and Brain
CT scan revealed multiple brain tumors. The initial vital
22
signs were all within normal limits when patient arrived
in operation room. The laboratory data were within normal limit except anemia( Hb gm/dl). The chest roentgenography revealed cardiomegaly and auscultation revealed pan-systolic murmur over lower sternal area with
clear breathing sound. The course of induction of general
anesthesia was smooth. EndtidalCO2 suddenly dropped
and followed by prompt hypotension and desaturation of
pulse oximetry from 100% to 32% within minutes during the neurosurgeon removed tumors. Intra-operative
transesophageal echocardiography was performed immediately and demonstrated typical characteristics of TOF.
Before the end of operation, there were several fluctuated
cycles of desaturation. The patient could dramatically
regain oxygen saturation and arterial blood pressure by
herself. We infused nor-epinephrine to increase systemic
vascular resistance could decrease the frequency of this
disaster.
Conclusion: TOF can exit in elderly with specific
preconditions, like patent ductus arteriosus or large bidirectional VSD, as our patient. There was no report of
accidental finding of adult TOF during general anesthesia
in before. The presentation of fluctuation of oxygen saturation was quite confusing for diagnosis and treatment
during emergency major brain operation. Emergency
transesophageal echocardiography can give us help in
diagnosis and management.
NWAC - 46
Bronchoscopy under general anaesthesia (ga): a
study to show patient tolerance and viewing conditions with bronchoscopy under general anaesthetic
in lung transplant patients
S. Kapoor1, D. Sarridou1, N. Lees1, J. Woolley2, M. Carby3, J.
Mitchell1
1Anaesthetics, Royal Brompton and Harefield NHS Trust, London,
United Kingdom, 2Psychiatry, Royal Brompton and Harefield NHS
Trust, London, United Kingdom, 3Transplant, Royal Brompton and
Harefield NHS Trust, London, United Kingdom
Introduction: Adequate airway views, good patient
tolerance and patient’s satisfaction are vital components
in assessment of successful bronchoscopy procedures,
particularly with respects to the use of GA in lung transplant patients.
Objectives: To evaluate the use of GA in lung transplant patients undergoing bronchoscopy both from patient and bronchoscopist point of view.
Methods: A proforma was completed by patients and
bronchoscopists before and after bronchoscopy. Quantitative scoring scales were used to assess patient’s choice
of future anaesthetic and evaluate patient tolerance and
viewing conditions from the bronchoscopists.
Results: Fifty patients underwent bronchoscopies with GA [46/50 (92%)] or awake sedation [4/50
(8%)]. TABLE 1 shows the overwhelmingly positive bronchoscopists’ assessment of the procedure. Assessment of choice of anaesthesia for future bronchoscopies in these patients highlighted overwhelmingly that
86% [43/50] chose GA, 14% [7/50] chose awake sedation or had no preference and 100% [50/50] agreed to
undergo the procedure again under GA if required.
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NWAC - 48
Assessment of frailty in a university teaching hospital: a service improvement project
V. Wroe, M. Stott
Anaesthesia, University Hospital Aintree, Liverpool, United
Kingdom
Conclusion: Extreme satisfaction from bronchoscopists can be seen in terms of airways viewing
and good patient tolerance with the use of GA in the
lung transplant patients undergoing bronchoscopy. One
patient undergoing awake sedation had the procedure
abandoned in view of terrible tolerance. These results
highlight the satisfactory conditions at Harefield Hospital with use of GA during bronchoscopy and how the
majority of patients continue to prefer GA for future
procedures.
NWAC - 47
Unintended hypothermia: a multi modal approach
M. Tandon, C. K. Pandey
Anaestheia, ILBS, New Delhi, India
Introduction: Unintended hypothermia (UIH) during surgery under general anaesthesia (GA) has adverse implications. Prewarming is advocated to prevent
UIH but is time consuming and can be uncomfortable
for patient. There is no universally agreed protocol for
prewarming and the claims to efficacy are debatable
and varied.
Objectives: To Study the efficacy of multimodal approach as protocol for temperature management.
Methods: For surgeries under combined general
and epidural anaesthesia of duration > 2 hours, ambient
temperature was maintained 24-27oC before induction
of GA and during insertion of epidural catheter. Active
warming was done using warming mattress set to temperature 38o C, hot air blanket with temperature set to
38oC and fluid warming device (Hotline™) with preset temperature of 41oC. Nasopharyngeal temperature
was continuously monitored. After induction of GA and
draping of patient, ambient temperature was decreased
and maintained at 21-24o C and was increased to 2427o C at end of surgery. During surgery, for every 0.1oC
above 37 oC one heating device was switched off such
that at 37.3o Celsius all the 3 devices were switched off.
Irrigation Fluid was warmed to 39oC.
Results: Baseline temperature was 35.9±0.4oC. Minimum
temperature recorded was 35.7±0.4oC. Mean decrease in temperature below the baseline temperature was 0.2±0.2o Celsius. Temperature at end of surgery was 37.4±0.5oC.
Conclusion: Mulitmodal approach that includes ambient temperature management is an effective way to
minimize redistributive heat loss and UIH. The efficacy
of the approach is similar to those published for prewarming and can be considered as an alternative.
Introduction: Frailty is an independent risk factor for
adverse outcomes in surgical patients. Identifying frailty
in elderly patients pre-operatively and implementing a
focussed action plan may positively impact outcomes.
The British Geriatrics Society (BGS) recommends
screening for frailty in all outpatient encounters using the
easily utilisable PRISMA-7 questionnaire.
Objectives: To calculate the prevalence of frailty in
the pre-operative population over 60 years of age at our
University Teaching Hospital using the PRISMA-7 questionnaire. This data will be used to establish a frailty preoperative review clinic.
Methods: After local audit committee approval, all
patients over 60 attending pre-operative assessment
clinic over two weeks in November 2015 were assessed
for frailty using the PRISMA-7 questionnaire. Patients
scoring greater than 3/7 points were classified as ‘frail’.
Results: A total of 112 questionnaires were completed.
48/112 (43%) patients scored >3, consistent with frailty.
Conclusion: A significant proportion of the patients
questioned fulfilled the criteria for frailty. This initial survey will enable us to plan service improvement for frailty,
focussing on comprehensive geriatric assessment with targeted interventions to minimise length of stay, morbidity
and mortality. References Partridge, J. S. L. et al Frailty in
the older surgical patient: A review. Age and Ageing 2012;
41: 142-147. Fit for Frailty - consensus best practice guidance for the care of older people living in community and
outpatient settings - a report from the British Geriatrics Society 2014. http://www.bgs.org.uk/campaigns/fff/fff_full.
pdf (11 January 2016, date last accessed).
NWAC - 49
Risk factors of reintubation in post anesthetic care
unit after general anesthesia in ramathibodi hospital
P. Duangngoen1, W. Ittichaikulthol2, T. Thamjamrassri1, J. Jiarpinitnun1
1Anesthesiology, Faculty of Medicine Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand, 2Anesthesiology, Faculty of
Medicine Ramathibodi Hospital, Bangkok, Thailand
Introduction: Postoperative reintubation is a major
respiratory complication and a significant indicator for
anesthetic services. Minimizing the incidence of reintubation in post anesthetic care unit (PACU) is the goal for
quality improvement in anesthetic care.
Objectives: To study the incidence of reintubation in
PACU and risk factors of reintubation.
Methods: The retrospective study was conducted in
35,216 patients underwent surgery under general anesthesia with endotracheal tube in Ramathibodi Hospital
during January 2010 to December 2013.
Results: The incidence of reintubation in PACU after
general anesthesia (n=35) was 9.9: 10,000 patients. The
incidences of factors associated with patients, surgery and
anesthesia were 37.1%, 20% and 42.9%, respectively. There
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NWAC ABSTRACTS
was 71.4% of patients with ASA 3-4. The factors of anesthetic care that led to reintubation was 42.9%. These factors
include the effect of remaining muscle relaxant, anesthetic
drugs or opioid received during perioperative period. The
incidence of reintubation was found mainly beyond the office hours (16.00-18.00 pm). The highest incidence was 1.1
patients: 10,000 working hours. The risk of reintubation in
patients aged ≥65 years was 2.7 times (OR= 2.7, p=0.005)
higher as compared to the risk of age of 15-65 years. Patients with ASA 3-4 had higher risk of reintubation (OR=
2.8, p=0.006) as compared with ASA 1-2.
Conclusion: The risk factors of reintubation in PACU
for patients underwent surgery and received general
anesthesia with endotracheal tube were age ≥65 years,
ASA 3-4, remaining effect of anesthetic drug and service
beyond the office hours. These results could be used to
improve the anesthetic care services.
NWAC - 50
The effects of sugammadex usage on postoperative
stress hormones
I. Ozdemirkan1, B.B. Guven2, K.H. Cansiz2, H. Sen2, S. Ozkan2, G.
Dagli3
1Department of Anesthesiology And Reanimation, Gulhane Military
Medical Academy, Ankara, Turkey, 2Department of Anesthesiology
And Reanimation, Gulhane Military Medical Academy Haydarpasa
Training Hospital, Istanbul, Turkey, 3Department of Anesthesiology
And Reanimation, Sanko University Medicine Faculty, Gaziantep,
Turkey
Introduction: Sugammadex is a kind of drug that
binds with high-affinity to non-depolarizing muscle relaxants with steroidal structure and antagonizes the neuromuscular blockade with an entirely different mechanism of cholinesterase inhibition (encapsulation).
Objectives: We aimed to find out the effects of sugammadex on stress hormones in postoperative period.
Methods: 60 patients, undergoing elective lumbar disc
herniation (LDH) or laparoscopic cholecystectomy under
general anesthesia were enrolled in this study. Patients were
assigned randomly into sugammadex group (Group-S) or
control group (Group-C) before the surgery. In addition to
the standard monitorization neuromuscular blockade was
monitored with train-of-four. The induction and maintenance of anesthesia were applied through standard way.
At the end of the surgery, with the re-emergence of T2 in
group-C and S, neostigmine and sugammadex was used respectively for reversal. In order to determine serum cortisol,
insulin, aldosterone and glucose levels, blood samples were
obtained from the patients preoperatively, 30th minutes of
the surrgery, 5-minutes after the reversal and in the 2nd hour
of postoperative period.
Results: Patient demographics, total surgery time and
rocuronium requirements and perioperative hemodynamic
measurements were similar between the groups. The difference of serum glucose, insulin, cortisol and aldosterone levels were not statistically significant at both groups for each
sample. In both groups, following surgery samples of serum
glucose, insulin, cortisol and aldosterone levels significantly
increased as compared with preoperative values.
Conclusion: In conclusion, stress response to surgery
emerged in both groups of our study and we believe that
sugammadex usage does not affect the levels of stress
hormones in postoperative period.
24
NWAC - 51
Propofol sedation for endovascular thrombectomy
for acute ischemic stroke: hemodynamic and neurological impact
B. Schockaert1, M. Desmet1, C. Missant2
AZ Groeninge, Kortrijk, Belgium, 2Anesthesiology,
University Leuven, Biomedical Sciences Group, campus Kulak
Kortrijk, Kortrijk, Belgium
1Anesthesiology,
Introduction: Monitored anesthesia care with spontaneous breathing is preferred during endovascular
thrombectomy in selected patients. Propofol sedation
and hypercapnia may however cause hypotension and
cerebral vasodilation impairing neurological outcome.
Objectives: To investigate the effect of propofol on
hemodynamics and neurological outcome in patients undergoing endovascular thrombectomy.
Methods: A one year, single center, retrospective
analysis was performed. Seven patients were excluded
due to use of general anesthesia, aborted procedure or
incomplete data. 48 patients were included. Invasive
blood pressures, heart rate and Glasgow coma scale
(GCS) were recorded. GCS was additionally recorded
3 months after the procedure. Standard descriptive statistics were used to evaluate hemodynamic and neurological data.
Results: During thrombectomy and propofol sedation, systolic blood pressure increased from 156±28 to
169±31mmHg (p=0.0019). Diastolic blood pressure decreased from 79±21 to 56±14 mmHg (p<0.001). Heart
rate decreased from 80±19 to 75±15 bpm(p=0.025).
The GCS remained unchanged after the endovascular
procedure (12±3 pre-procedure and 12±4 immediately
post-procedure). 15 patients died within 3 months, including 12 after hospital discharge, decreasing the GCS
to 10±6 at three months (p=0.04 vs. post-procedure).
In survivors, the GCS increased to 14±2 (p=0.009 vs.
post-procedure).
Conclusion: Propofol sedation during endovascular cerebral thrombectomy did not suppress systemic
hemodynamics. The protective Cushing reflex increased systolic blood pressure, decreased heart rate
and maintained GCS. Although the GCS was significantly lower after 3 months due to a high mortality
rate, propofol sedation didn’t impair the GCS in those
who survived.
NWAC - 52
Myocardial ischemia in noncardiac surgery: a
challenge for the anesthesiologist
R. Faria-Silva, C. Ferreira, W. Rocha, J. Melo
Anesthesia, Hospital Felicio Rocho, Belo Horizonte, Brazil
Introduction: Life expectancy increased over the last
years in a significant way. The amount of patients with
multiple comorbidities that undergo noncardiac surgeries is significant. Peri and postoperative cardiovascular
complications are frequent. It is an economic burden that
reduces life expectancy.
Case Description: male, 69 years-old, hypertensive,
former tobacco user, victim of a ischemic stroke and also
a deep venous thrombosis. Uses regularly sinvastatine,
aspirin, lysinopril and indapamide. Admitted to hyatal
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hernia correction laparoscopically, under balanced general anesthesia. After induction he developed hypotension
associated with a new left bundle branch block, which
promptly disappeared after 10mg of ephedrine. During
the perioperative setting, continuous phenylephrine was
used to maintain mean arterial pressure at 70mmHg.
Surgery underwent just fine until the extubation period,
when he developed again a left bundle branch block, this
time associated with hypertension (mean arterial pressure at 100mmHg). Patient was taken to the intensive
care unit, where a transthoracic echocardiogram and troponin measurements were normal.
Conclusion: myocardial infarction diagnosis in
the perioperative setting is difficult and may postpone
adequate treatment. We need at least two markers:
enzyme increase, symptoms of chest pain, dynamic
changes in EKG or deficits of contractility. Chest pain
can be absent or attributed to other causes. ST segment changes can occur due to ion imbalance, hypothermia, hyperventilation, anesthetic drugs or patient
positioning. Increases in troponin indicate myocardial
damage, but can be attributed to pulmonary thromboembolism, acute heart failure, sepsis, myocarditis,
acute kidney injury or shock.
NWAC - 53
Liver transplantation in patient with Type 1 glycogenosis: the importance of macrohemodynamics
R. Faria-Silva, C. Ferreira, W. Rocha, J. Melo
Anesthesia, Hospital Felicio Rocho, Belo Horizonte, Brazil
Introduction: Glucose-6-phosphatase deficiency
(von Gierke disease) is a glycogen storage disease.
Hypoglycemia is the hallmark finding, but patients may
be asymptomatic. Most adults develop liver adenomas in
the second to third decade of life, which may lead to malignant transformation.
Case Description: Male, 30 years-old, submitted to
liver transplantation due to hepatocarcinoma. Invasive
monitoring included arterial pressure, pulmonary artery
catheter, urinary output and blood gas analysis. Since the
beginning of the intervention, arterial blood pH was maintained close to 7.2, serum bicarbonate around 15mEq/L
(range values 22 – 26mEq/L), and lactate levels around
160mEq/L (range values 5 – 20mEq/L). Hemoglobin levels were 9.0mg/dL. Glucose, sodium and potassium levels
were normal. To our surprise, despite this lactic acidosis,
all macrohemodynamic parameters were normal without
the use of vasoactive drugs. After liver reperfusion, the
macroscopic aspect was good. The patient was extubated
at the operating room and taken to the intensive care unit
in stable conditions, slightly hypertensive.
Conclusion: The use of perfusion markers such as
lactate levels and arterial blood pH are considered gold
standard to evaluate global tissue perfusion. Intraoperatively we guided our decisions by the macrohemodynamic parameters. When seen retrospectively, the congenital
disease that caused the intervention could explain changes in these markers. This case was a tough challenge
for the anesthesiologist who nowadays is more and more
concerned about tissue perfusion and microhemodynamics. It would be even more challenging if the patient presented hemodynamic instability.
NWAC - 54
Cardiac anaesthesia and intensive care management in a non-cardiac centre - a report of two cases
M.M. Salawu1, A. Akinmola2, A.V. Elumelu2, B. Ode2
1Anaesthesia And Intensive Care, National Hospital Abuja, Abuja,
Nigeria, 2Anaesthesia And Intensive Care, National Hospital Abuja,
Abuja FCT, Nigeria
Introduction: Cardiac Surgery is not commonly performed in sub Saharan Africa except in a few specialist
cardiac centers.In Nigeria, there is hardly any government referral center that carries out routine cardiac surgery. As a result a lot of cardiac surgeries are done abroad
at a great cost.Recently, however a few cardiac outreach
surgeries have been performed in a few Government referral centers using expertise and techniques from some
foreigners and Nigerians in diaspora.
Case Description: Case1.—A 5month old male infant
diagnosed of Tetralogy of Fallot(TOF) at 5days of age. He
had repair of TOF with prolonged surgery time, and was
haemodynamically unstable and was nursed in cardiac ICU.
He was taken back to the thearter because of coagulopathy
and was managed in the ICU for 7days before discharge to
a step-down ward. Case 2.—A 3year old male child with
double outlet right ventricle and pulmonary stenosis with
tetralogy of fallot, which was diagnosed at 2 weeks of life.
He had complex cyanotic heart disease with operative diagnosis of TOF with severe pulmonary artery hyperplasia and
almost atretic pulmonary valve and long operative course.
He was admitted in cardiac ICU in shock and with significant pressor support. He had multiple electrolyte and acidbase corrections with blood transfusions.He deteriorated
and had cardiac arrest and died 4 hours post surgery.
Conclusion: Cardiac anaesthesia is a challenging and
novel practice in our environment and continuous outreach programme such as this will reduce cost of cardiac
surgery, makes it readily available in our country and
thus building local expertise. NWAC - 55
Adult dental extraction under general anaesthesia
B. Hong
Oral And Maxillofacial Surgery, Northern Deanery, Middlesbrough,
United Kingdom
Introduction: Many adults in the United Kingdom
(UK) appear to undergo simple dental extractions under
general anaesthesia (GA) on the National Health Service
(NHS), a healthcare system funded by taxation. This can
impact on patients as well as the limited resources of the
NHS.
Objectives: This study explored hospital-based clinicians’ perceptions of the current situation and their
views on the need for guidelines.
Methods: An electronic survey was distributed to
the membership of the British Association of Oral and
Maxillofacial Surgeons. Dental core trainees were also
invited to participate via deaneries. The survey was carried out over two-month period.
Results: Two-hundred-and-forty clinicians from 107
out of 159 (67.3%) oral and maxillofacial surgery units
in the UK completed the survey. The participants perceived that patient demand-driven GA for dental extrac-
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tion was prescribed in their unit always (2.1%), most of
the time (41.9%), sometimes (43.6%). The participants
chose dental anxiety (27.7%) and availability on the NHS
(21.2%) as the most fundamental factor that drives the
patient demand for GA extractions in the UK. While the
majority of participants (81.7%) felt that GA dental extraction should not be available on the NHS, some clinicians (18.3%) disagreed for reasons such as respect for
patient choice and difficulty in absolutely defining ‘clinical need’. Some participants (58.3%) felt that specific
guidelines with case selection criteria would be helpful,
but others (41.7%) disagreed.
Conclusion: While many clinicians agree on the high
number of demand-driven GA prescriptions and its negative implications, measures to improve the situation remain debatable.
NWAC - 56
External recycling unit for xenon recovery from
anesthetic circuit and reuse for multiple patient on
purification
V. Sheth1, A. Ritter2
of Chemistry, Chemical Biology And Biomedical
Engineering, Stevens Institute of Technology, Hoboken, NJ, United
States of America, 2Department of Chemistry, Chemical Biology And
Biomedical Engineering, Stevens Institute of Technology, Hoboken,
1Department
Introduction: Xenon, being a potent inhalation anesthetic with many salubrious qualities, except that expense
has mitigated the development of its use for anesthesia.
Many researchers have suggested a niche for xenon as
anesthetic based on its pharmacokinetic, cardiac stability,
neuroprotective and analgesic properties.
Objectives: Being scarce and expensive, a closed
rebreathing circuit offers the optimum delivery method.
Reducing waste through on-line recycling after regeneration and purification will help xenon to find its place
among anesthetic substances.
Methods: To eliminate waste, we have designed a system that will recover Xenon from exhaled gas. The Xenon
is recovered using Silver Nanoparticle (Ag‐ETS‐10)
adsorption bed to provide interaction between xenon and
silver at low pressure. During Adsorption, the high selectivity of silver exchange zeolite for Oxygen and Xenon is observed. This Selectivity allows on-line recycling of xenon
in an anesthetic closed loop system. Regeneration of xenon
occurs offline by thermal heating the adsorption unit, then
separating and purifying xenon for future uses.
Results: Anesthetic xenon can be recovered and reused from patient to patient to make it economically
competitive with current gold standard methods for inhaled anesthetics.
Conclusion: This low-cost xenon anesthetic gas will
be attractive for two broad applications: (1) Xenon will be
the anesthetic agent of choice for large fraction of millions
of surgical procedures that are performed each year in the
United States on patients with cardiovascular conditions
(2) because of fewer complications with rapid induction
and emergence, xenon anesthesia can reduce patient time
in hospitals, with large benefits to healthcare costs.
26
NWAC - 57
Generation of human alveolar type ii epithelial
cells from the differentiation of human induced
pluripotent stem cells derived from urine samples
C. Wang1, F. Hei2, Z. Ju2, J. Yu2
Department, State Key Laboratory of Cardiovascular
Disease, Fuwai Hospital, National Center for Cardiovascular
Disease, Chinese Academy of Medical Sciences and Peking
Union Medical College, Beijing, China, 2State Key Laboratory
of Cardiovascular Disease, Fuwai Hospital, National Center for
Cardiovascular Disease, Chinese Academy of Medical Sciences and
Peking Union Medical College, Beijing, China
1Anesthesia
Introduction: Human alveolar type II (AT II) epithelial cells play a key role in the cell therapy of lung disease.
Many lung diseases such as acute lung injury and acute
respiratory distress syndrome are associated with impaired function of AT II epithelial cells. Human induced
pluripotent stem cells (HiPSCs) derive from patients’ autologous cells and can differentiate into certain kind of
cells in endoderm, mesoderm and ectoderm, so they can
also differentiate into AT II epithelial cells.
Objectives: This study explored whether urine-derived human induced pluripotent stem cells (UiPSCs)
had the ability to differentiate into human alveolar type II
(AT II) epithelial cells.
Methods: In this study, we present a simple, effective and noninvasive way of getting human induced pluripotent stem cells (HiPSCs) from exfoliated renal epithelial cells which exist in urine. Immunofluorescence
staining, karyotyping and teratoma experiments have
proved that these cells are HiPSCs and their pluripotency.
Our four-step induction protocol was conducted to generate AT II cells from UiPSCs.
Results: UiPSCs can differentiate into AT II cells and
these cells have phenotypic properties similar to mature
human AT II cells, such as outstretched and epitheliumlike morphology and the specific expression markers of
AT II cells (Surfactant Protein A, Surfactant Protein B
and Surfactant Protein C).
Conclusion: As this study indicates that AT II cells
can be generated from UiPSCs, it may be useful for modeling and treatment of lung disease caused by dysfunction of AT II cells and make a contribution to the studies
of human lung development and regenerative medicine.
NWAC - 58
An observational study to compare the effect of
pregabalin with pregabalin and dexamethasone
for post operative analgesia in orthopedic surgeries under spinal anesthesia
R. Agrawal, M. Mehta, J. Patel
Anaesthesia, SBKS MIRC, Piparia, Vadodara, Vadodara, India
Introduction: Postoperative pain is a major problem
after orthopedic surgeries. Appropriate management of
postoperative pain is known to reduce the length of the
hospital stay and to make patients more comfortable by
reducing pain-associated complications.
Objectives: Aim of the present study is to evaluate post
operative analgesic benefit of Pregabalin and a combination
of Pregabalin and Dexamethasone & To compare, 1) The
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NWAC ABSTRACTS
efficacy 2) Duration of action 3) Intra-operative and postoperative complications and 4) Side effects, if any.
Methods: It is an observational study wherein 60
patients scheduled for orthopedic surgeries under spinal
anesthesia ranging from 20-50 years in ASA grade I and
II were allocated into two groups P and D. Patients in
group P were given tab Pregabalin 300mg whereas patients in group D were given tab Pregabalin 300mg + inj
Dexamethasone 16mg iv . Pregabalin was given orally
1 hour prior to administration of the spinal anesthesia.
I.V. dexamethasone 16 mg was given in group D before
the induction of anaesthesia .Routine monitoring was
done,intraoperatively.Pain intensity, analgesic requirements, and side effects were assessed in the postoperative period till 24 hrs. Patient with Visual analogue scale
more than 3 was given Inj diclofenec 1mg/kg iv.
Results: Compared with group P, pain scores were
lower in group D at 24 hours after surgery. Frequency
of additional rescue analgesic administration was significantly lower in group D.
Conclusion: Combined administration of pregabalin
and dexamethasone conferred analgesic benefits superior
to those of pregabalin alone. Side effects were recorded
less in the group using Pregabalin and Dexamethasone.
NWAC - 59
Spontaneous neutrophil extracellular traps (NETosis)
and cell free DNA as features associated with cryptogenic liver disease and stress response to anaesthesia
C.K. Pandey1, K. Prakash1, S. Bhardwaj1, G. Ramakrishna2, M. Tandon1
1Anaesthesiology And Critical Care Medicine, Institute of Liver and
Biliary Sciences, New Delhi, New Delhi, India, 2Clinical Research,
Institute of Liver and Biliary Sciences, New Delhi, New Delhi, India
Introduction: Neutrophils use a death program
termed NETosis, in which nuclear DNA, histones, and
serine proteases are released as extracellular traps as an
antimicrobial strategy. We report spontaneous NETosis
as a probable cause of cryptogenic liver disease and its
probable role in the stress response to anaesthesia.
Case Description: In the setting of living donor liver
transplantation, we report a case of cryptogenic liver disease with low neutrophil count 1792 (Recipient) vs 4897
(Donor) and low neutrophil to lymphocyte ratio as compared to donor (1.6 vs 2.18). Neutrophils were isolated
from both recipient and donor preoperatively (baseline),
post-induction 2hrs following anaesthesia and at 24hrs
post-surgery. Donor neutrophils at baseline showed intact nuclear morphology, while that of recipient showed
distorted morphology with extracellular DNA with typical NETosis feature. Post-induction neutrophil showed
NETosis, which was more pronounced in the recipient
than donor. Notably, at 24hrs post-surgery both recipient and donor showed absence of NETosis suggestive
of a neutrophil recovery, which was evident by the total
counts (7900 vs 8160). Evaluating NETosis requires sophisticated imaging setup, hence we tested cell free DNA
in the plasma samples as a simple marker of NETosis
which showed elevated levels of 18S DNA.
Conclusion: Activated neutrophils leading to NETosis may be implicated in the pathogenesis of cryptogenic
chronic liver disease. Neutrophils of healthy individuals
can show transient activation leading to NETosis as a
consequence of stress following anaesthesia induction.
NWAC - 60
Intraarticular infiltration of Liposome Bupivacaine for analgesia after trapeziectomy and ligament
reconstruction with tendon interposition for basal
joint osteoarthritis of the thumb
J. Boons1, J. Duerinckx2, E. Peeters1, V.B. Sam1, C. Vandepitte1, N.
Knezevic1
1Anesthesiology - Icu - Emergency, NYSORA-Europe’s CREER (Center
for Research, Education & Enhanced Recovery after Orthopedic Surgery)
Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, Ziekenhuis Oost-Limburg Genk, Belgium, Genk,
Belgium, 2Orthopedic Surgery, NYSORA-Europe’s CREER (Center for
Research, Education & Enhanced Recovery after Orthopedic Surgery)
Ziekenhuis Oost-Limburg Genk, Belgium, Genk, Belgium
Introduction: We report a novel approach to postoperative pain management with liposome bupivacaine
(Exparel®) in patients having trapeziectomy and LRTI.
Objectives: The objective was to investigate the adequacy of intraarticular infiltration of liposome bupivacaine for analgesia after LTRI.
Methods: Two patients underwent trapeziectomy and
LRTI, consisting of resection of the trapezium bone, followed by harvesting of half of the flexor carpi radialis
tendon, to reconstruct the volar beak ligament and for
interposition arthroplasty. Both patients received GA for
surgery and an infiltration with Exparel® into the joint
space postoperatively (Figure).
Results: Both patients had excellent postoperative
analgesia throughout 48h postoperatively to allow discharge home short after the surgery. Neither patient required opioid rescue analgesia or showed evidence of
local inflammatory reaction.
Conclusion: Local anaesthetic infiltration is commonly used after trapeziectomy and LRTI. However,
the short duration of currently available local anaesthet-
Figure 60.—Intraarticular infiltration of liposome bupivacaine.
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NWAC ABSTRACTS
ics often requires hospitalization for pain management.
We report our preliminary experience with intra-articular
injection mixtures of Exparel®. Randomized controlled
trials are indicated to more objectively determine the analgesic benefit of Exparel® in trapeziectomy and LRTI
which we observed in our patients.
NWAC - 61
Utility of nerve stimulator guided peripheral nerve
blocks for limb surgery in patients with leprosy in
a developing country
M. Traore1, J. Boons2, C. Bouts2, S. Baete2, M. Golebiewski2, C.
Kinkpe1, M. Beye1
1Anesthesiology, Centre Hospitalier de l’Ordre de Malte, Dakar,
Senegal, 2Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Belgium
Introduction: Leprosy is a chronic infectious disease
which causes peripheral neuropathy with severe deformities of the extremities.
Objectives: We describe the utility of nerve stimulation (NS) guided peripheral nerve blocks (PNB) in leprosy patients undergoing limb surgery.
Methods: We reviewed our institutional use of regional anesthesia in leprosy patients between 2011 and 2015.
Patients received baseline clinical neurological evaluation before and after PNB. All PNB’s were performed
guidance using either Ropivacaine 0.75% or
with NS
Bupivacaine 0.5%.
Results: Seventy-three patients received a total of
102 PNB’s, with a mean age of 28 years [14-80] and a
sex ratio of 0.25 (M:F). Forty-four axillary blocks were
performed for ulnar, median and cubital-median neurolysis (Figure). Twentynine combined sciatic and femoral
nerve blocks were performed for posterior tibial neuroly-
Figure 61.—Hypertrophic leprous neuritis of the ulnar nerve.
28
sis and leg amputations. Median current intensity to elicit
electromotor response was 0.4 mA. The average block
onset time was 20 minutes with a 94% successrate and
average duration of sensory block was 18 hours. After
6 months, 84.5% of all patients were reassessed without
evidence of neurologic deficit. Conclusion: Leprosy continues to be rampant in
developing countries. Patients whose peripheral nerves
are affected often require limb surgery. Our data suggests that NS guided PNB provides adequate anesthesia
without neurologic deterioration in patients with leprosy.
NWAC - 62
Effect of epinephrine mixture for brachial plexus
block on vital sign change during shoulder arthroscopic surgery under beach chair position: retrospective study
B.J. Kim, C.S. Lim, S.Y. Lee, H.S. Yoon, J.Y. Lee, S.I. Park, J.U.
Lee, Y.S. Shin
Department of Anesthesiology And Pain Medicine, School of
Medicine, Chungnam National University, DaeJeon, Korea
Introduction: Beach chair position (BCP) can cause
significant hypotension, which could lead to severe cerebral hypo-perfusion and neurologic complications.
Brachial plexus block (BPB) is effective method for
postoperative pain control which induced by shoulder
arthroscopic surgery. Epinephrine can be used for prolongation of local anesthetics duration, and it could be
absorbed into blood so that result in systemic effect.
Objectives: To compare vital sign changes of patient
who are performed BPB with epinephrine mix or not during shoulder arthroscopic surgery.
Methods: Patient data was collected from March-2013
to August-2014 retrospectively. We divided data to 3
groups – General: BPB without epinephrine mixture
under general anesthesia (GA), Epinephrine: BPB with
epinephrine mixture under GA, and Regional: only BPB.
0.75% ropivacaine 20cc was used for BPB. Mean arterial
Figure 62.—Heart rate change. Values are means. *: P<0.05 and
**: P<0.01 in Kruskal Wallis test.
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NWAC ABSTRACTS
pressure (MAP) and heart rate (HR) were measured for
30 minutes, 5-minute interval. BPB was done before GA
induction.
Results: 432 patient data was used. Regional group
shows less change in MBP compared with other groups.
There is no significant change in MBP between General
and Epinephrine group. HR was significantly increased
in Epinephrine compared with other groups.
Conclusion: BPB with epinephrine mixture cannot
prevent hypotension caused by BCP during shoulder
arthroscopic surgery. Only, HR can be increased with
epinephrine mixture. Hypotension during shoulder arthroscopic surgery can be prevented when only regional
anesthesia was done without general anesthesia.
NWAC - 63
Red herring: septicaemia following bilateral facet
joint radiofrequency denervation
Y.C. Tay, M. Abrahams
Anaesthesia, Addenbrookes Hospital, QQ, United Kingdom
Introduction: Lumbar facet joint radiofrequency denervation is a common treatment for chronic low back pain.
Safety assessments reveal procedural complications to be
rare. However, causation is often assumed should patients
turn septic after a procedure. Although there have been
reports of spontaneous or iatrogenic septic arthritis with
facet joint injections, we could not find reports of systemic
infection following lumbar facet denervation.
Case Description: We present a patient who underwent bilateral lumbar facet joint radiofrequency denervations complicated by multi-sensitive staphylococcus
aureus septicaemia requiring intensive care, albeit without injection site infection.Imaging revealed multiple
collections within the left pelvic sidewall, distal psoas,
left gluteus and pelvic floor muscles adjacent to an old
fractured pubic rami.
Conclusion: This report illustrates the role of a pain
physician in managing post-procedural infection and
serves as a reminder that chronological association of an
infection to a procedure does not always reflect causality. A multidisciplinary approach to management is vital
especially when the purported causative procedure is not
widely understood across medical disciplines. Immunosuppressed patients undergoing pain procedures have a
higher risk of complications and preventive or mitigative
measures are suggested.
NWAC - 64
The analgesic effectiveness of ipsilateral transversus abdominis plane block in adult patients undergoing appendectomy: a prospective randomized
controlled trial
A. Ghimire1, B. Bhattarai2
And Critical Care, B.P.Koirala Institute of Health
Sciences, Dharan, NEPAL, 2Anesthesiology And Critical Care, B P
Koirala Institute of Health Sciences, Dharan, Nepal
1Anaesthesiology
Introduction: Transversus abdominis plane block
(TAP) produces effective pain relief following lower ab-
dominal surgeries but is yet to be routinized in different
type of surgeries including appendectomy. The main risk
of visceral injury can be logically avoided if the block is
performed using landmark technique in the absence of
USG guidance.
Objectives: We aimed to assess the effectiveness of
TAP block with bupivacaine for postoperative analgesia
using landmark technique (performed with the abdomen
open) in adult patients undergoing appendectomy.
Methods: Forty patients undergoing appendectomy
were randomized to undergo ipsilateral TAP block with
bupivacaine (n=20) versus control (n=20) in addition to
standard postoperative analgesia. All patients received
standard general anaesthesia. The block was performed
using the landmark technique with 20 ml of 0.5% bupivacaine or saline on ipsilateral side just before abdominal
closure. Pain severity was measured using Visual Analogue Scale (VAS). Tramadol 50 mg was administered as
rescue analgesic intravenously when VAS was 4 or more
postoperatively. The duration of analgesia and the requirement of tramadol in 24 hours postoperatively were
recorded.
Results: Mean duration of analgesia in the TAP block
with bupivacaine was longer as compared with placebo
(724.00±299.07 min vs 168.25±55.18 min; P< 0.01).The
TAP block with bupivacaine compared with placebo significantly reduced postoperative VAS pain scores. Mean
tramadol requirement in the first 24 hours was also reduced (42.50±37.25 mg vs 120.00±55.18 mg; P<0.01).
No TAP block related complications noted.
Conclusion: Ipsilateral TAP block with bupivacaine
using landmark technique with the abdomen open in appendectomy provides effective postoperative analgesia
and opioids sparing effect.
NWAC - 65
Quadraus lumborum block (QL) is more effective
than transversus abdominal plane (TAP) block as
part of multimodal analgesia for total abdominal
hysterectomy
K. Yelamati1, T. Bhatti2, L. Baxendale3
1Burton Hospitals.NHS Foundation Trust, Burton on Trent, United
Kingdom, 2Anaesthetics, Burton Hospitals NHS Foundation Trust,
Burton on Tret, United Kingdom, 3Burton Hospitals NHS Foundation
Trust, Burton on Trent, United Kingdom
Introduction: Regional anaesthesia is an imortant
component of multimodal analgesia. Quadratus lumborum (QL) block is a relatively new technique for perioperative analgesia in abdominal surgeries.Its effectiveness is due to the spread of local anaesthesia resulting in
paravertebral block.
Objectives: In this observational,non-randomised
study we compared the effectiveness and efficacy of QL
block with TAP block for peri-operative pain relief in
patients undergoing total abdominal hysterectomy,both
laparascopic assisted and open.
Methods: 10 consective ASA 1-2 patients were included in this study. Their mean age was 53 years (44-62).
All patients received Gabapentine 300 mg & Oxycodone
10 mg as premedication. They all receieved standard gen-
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NWAC ABSTRACTS
eral anaesthesia. Bilateral ultrasound guided QL block was
performed by a single operator using 25 mls of Levobupicaine on each side. All patients recieved i.v Paracetamol,
Morphine and ketorolac as additional analgesia during
the surgery.No ptient was given nitrous oxide intra operatively. Post operatively, all patients received regular Paracetamol, Naproxen and two further doses of Oxycodone.
Patients also receieved Morphine and/or Tramadol for
breakthrough pain as required. Pain scores and Morphine
consumption in the first 24 hours post operative period
was compared with the patients who received TAP block
by the same operator in his previous study.
Results: Average pain score in QL group was 1 (0-3)
as compared to 2 in TAP group. Mean perioperative Morphine consumption in QL group was 18 mgs as compared
to 39 mgs in TAP block group.
Conclusion: Quadratus lumborum block provides
more effective peri operative analgesia than TAP block
in patients undergoing total abdominal hysterectomy.
NWAC - 66
Ultrasound guided adductor canal block and ring
block of knee provides prolonged and superior analgesia in enhanced recovery total knee arthroplasty
as compared to local infiltration analgesia alone
V. Mandava1, T. Bhatti2, L. Baxendale1
1Burton Hospitals NHS Foundation Trust, burton on Trent, United
Kingdom, 2Anaesthetics, Burton Hospitals NHS Foundation Trust,
Burton on Trent, United Kingdom
Introduction: Local Infitration Analgesia (LIA) provided by the surgeion intraoperatively is the essential
component of total knee arthroplasty done as enhanced
recovery surgery. Traditionally the nerve blocks are
avoided which can impact on early mobilisation of patients after the surgery.
Objectives: The aim of this study was to evaluate the
feasibility, safety and effectiveness of regiional anaesthesia techniques in enhanced revovery knee arthroplasty.
Methods: 22 ASA 1-3 patients, mean age of 72
years undergoing unilateral total knee arthroplast were
included in this non-randomised campative study. All
patients received same premedication and post operative analgesia. All patient received low dose spinal with
levobupicaine 0.25% for surgery. In group A, 12 patients
received LIA intraoperatively by the surgeon. In group
B 10 patients received ultrasound guided adductor canal
block and ring block of the knee using Levobupivacaine
0.125%, 15 mls and 100 mls respectively. Post operative
analgesia, physiotherapy and mobilization protocol was
similar in both groups. Pain scores, 1st requirement of
post operative analgesia, total morphine consumption in
first 24 hours after operation and mobilsation were compared in both groups.
Results: Mean pain scores, first requirement of analgesia and 24 hours morphine consumption in Group A
versus B were 2 &1, 158 & 390 minutes and 25 & 10
mgs. No patient in Group B, compared to 2 in group A,
failed mobilization after 4 hours.
Conclusion: Ultrasound guided adductor canal block
and ring block of knee result in better and prolonged post
30
operative analgesia without affecting mobilization in patients undergoing enhanced recovery unilateral total knee
arthroplasty.
NWAC - 67
A novel approach to ilioinguinal (IIN) and iliohypogastric (ih) nerve block using peripheral nerve stimulator (pns) for hernia surgery: a prospective
observational study in 100 patients
S. Giri1, S.K. Singh2
1Anaesthesia,
Pragati Hospital And Research Centre,
Sivasagar,Assam, India, 2Anaesthesia, Royal Liverpool University
Hospitals, Liverpool, United Kingdom
Introduction: It is a misconception amongst anaesthetist that Ilioinguinal (IIN) and Iliohypogastric (IH) are
purely sensory nerves. For the first time in literature we
describe a technique for blocking IIN and IH nerves using peripheral nerve stimulator (PNS) in day case inguinal hernia surgeries.
Objectives: To evaluate the efficacy and safety of
PNS guided IIN and IH block in the Transversus Abdominis Plane (TAP), supplemented with Genitofemoral
nerve (GFN) block, for day cases inguinal hernia surgeries.
Methods: One hundred ASA-I & II adult patients
listed for elective inguinal hernia repair were prospectively recruited for the study. IIN and IH nerve block was
performed using PNS at a point 5cm cranial and 5 cm
posterior to the anterior superior iliac spine (ASIS). We
observed for the twitches in the lower abdominal wall
and the inguinal region (T10-L1 territory). Data was collected for intraoperative pain, discomfort and conversion
to GA. Post operative pain scores and post-op complications were also recorded.
Results: In 92%(92 out of 100) of the patients, block
was deemed to be successful . Conversion to GA was required in 8%(8 out of 100) of the cases. In the “successful
nerve block” patients, none (0%) complained of pain or
discomfort during the surgical procedure.
Conclusion: PNS guided IIN/IH Nerve block in the
TAP plane with GFN supplementation is an excellent
anaesthesia technique for adult inguinal hernia surgery.
Use of PNS increases the success rate, safety and helps in
locating the nerves in the transversus abdominis plane.
NWAC - 68
Intraoperative anaesthetic complications following
spinal anaesthesia for caesarean section: a prospective study in a tertiary setting
C. Ochukpue1, N. Edomwonyi2, N. Okojie2, C. Imarengiaye2
Of Anaesthesia, Ubth, University of Benin Teaching
Hospital, Benin City, Nigeria, 2University of Benin Teaching
Hospital, Benin City, Nigeria
1Department
Introduction: A reduction in anaesthesia related
complications has been observed following the introduction of regional techniques. The use of subarachnoid
block has become an established and reliable method of
providing anaesthesia for lower abdominal, obstetric and
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NWAC ABSTRACTS
lower limb surgeries due to its ease of performance, rapid
onset of action and cost effectiveness.
Objectives: This study aimed to determine the intraoperative complications associated with subarachnoid
block, its management and outcome in parturients undergoing caesarean section.
Methods: 125 consecutive parturients scheduled for
caesarean section under spinal anaesthesia were recruited. Approval was obtained from the Institution’s Ethics
Committee. History, demographic characteristics, indications for caesarean section and intraoperative events were
documented. Data was analysed using SPSS version 20.
Results: The commonest complication observed was
hypotension with an incidence of 36.3%. Severe hypotension was managed with ephedrine and rapid fluid boluses. Other complications were shivering, tachycardia,
bradycardia, nausea and vomiting.
Conclusion: Subarachnoid block is safe for caesarean
section if the anaesthetist is aware of the complications
associated with its use. Early recognition and prompt
management of complications by the anaesthetist is paramount. Precautions to prevent complications where possible, by carefully monitoring of the patient and management of the complications appropriately and as soon as
possible will ensure good outcome.
NWAC - 69
Ultrasound b lines in patients undergoing transurethral resection of the prostate (TURP): early feature of TURP Syndrome?
E. Marini1, M. Giraudini1, F. Forfori1, L. Gargani2
1Anaesthesia, Cisanello Hospital- University of Pisa, Pisa,
Italy, 2Cardiology, National Research Council, Pisa, Italy
Introduction: The infusion of irrigation fluid during the
transurethral resection of the prostate (TURP) can cause
volume overload and dilution hyponatremia, defining the
so-called TURP syndrome. Pulmonary edema is one of the
most life-threatening conditions of TURP syndrome.
Objectives: Recently lung ultrasound (LUS) has been
progressively more utilized in emergency department and
theatres. Purpose of our study was to assess whether there
was a change in the number of B-lines before and after
TURP.
Methods: Ten patients undergoing TURP were enrolled. Each patient was scanned immediately before and
after surgery to determine the number of B-lines pre and
postoperatively. None of the patients had significant lung
or cardiac disease that could explain the presence of Blines beforehand.
Results: None of the patients developed TURP syndrome. B-lines were significantly increased at the end of
surgery (p<0.001) and the delta B-lines between pre-and
post-surgery was related to the length of the procedure (Rsquared=0.45; p<0.05). B-lines were significantly more
represented in the lung inferior zones compared to the
apical zones (p<0.003), however, some B-lines appeared
postoperatively also in the antero-superior area of the lung.
Conclusion: Lung ultrasound can easily assess dynamic
variations of pulmonary aeration after TURP, through evaluation of B-lines. B-lines changes are related to the length
of surgery. Whereas inferior B-lines likely represent the sonographic correspondence of lung deaeration of dependent
zones, antero-superior B-lines may depict fluid accumulation in the lungs. This ultrasound tool seems promising as
an early feature of TURP syndrome.
NWAC - 70
Core temperature monitoring during obstetric
spinal anaesthesia using an ingestible telemetric
sensor
L. Du Toit1, D. Van Dyk1, R. Hofmeyr1, C. Lombard2, R. Dyer1
1Department Of Anaesthesia And Perioperative Medicine, University
of Cape Town, Cape Town, South Africa, 2Biostatistics Unit, Medical
Research Council of South Africa, Tygerberg, South Africa
Introduction: Spinal anaesthesia may decrease core
body temperature. The extent of hypothermia is not well
described in obstetric spinal anaesthesia. Core temperature monitoring is often performed inaccurately, or omitted in awake patients undergoing regional anaesthesia.
Objectives: This study aimed to record the intestinal
temperature changes associated with obstetric spinal anaesthesia using an ingestible telemetric sensor.
Methods: 31 women presenting for elective cesarean
section were consented for this observational study. The
CorTemp system (HQ Inc., Florida) was used to measure
and record intestinal temperature changes on the day of
surgery.
Results: Results are reported as mean (±standard
deviation; interquartile range). After spinal anaesthetic
injection, intestinal temperature decreased 1.3°C (±0.31;
1.12-1.48) to reach a temperature nadir after 1:02:20
hours (±0:23:03; 0:43:32-1:18:42). 60% of participants
reached their temperature nadir after leaving the operating theatre. 46% of participants only reached their temperature nadir after leaving the post-anaesthetic recovery area. Participants required 3:38:07 hours (±2:00:59;
2:15:15-4:54:45) to recover to 37.0°C.
Conclusion: In our setting, obstetric spinal anaesthesia is associated with a decrease in core temperature of
more than 1ºC. The core temperature commonly continues to decrease after the patient leaves the operating theatre, and may continue to decrease after discharge from
the post-anaesthetic recovery area. Various temperature
recovery patterns were seen; these were easily charted
with the CorTemp system. The system provides core
temperature monitoring that is acceptable to awake patients. It further allows continuous temperature monitoring into the post-anaesthetic period.
NWAC - 71
Brachial plexus blocks in palliative surgery: necessity rather than a choice
R. Chandran, K. Desouza, X. Panganiban David, M. Nithiyananthan
Department Of Anaesthesia And Intensive Care, Changi General
Hospital, Singapore, Singapore
Introduction: Patients with advanced lung cancer
are at high risk of respiratory compromise with general anesthesia. Careful consideration is needed on the
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NWAC ABSTRACTS
reiterates that nurturing skills in regional anaesthesia is
more of a necessity rather than choice in integrating a
palliative care approach.
NWAC - 72
Anaesthetic management of a parturient with pulmonary oedema for emergency caesarean section:
a case report
C. Ochukpue1, N. Edomwonyi2, C. Imarengiaye2
Of Anaesthesia, University of Benin Teaching Hospital,
Benin City, Nigeria, 2University of Benin Teaching Hospital, Benin
City, Nigeria
1Department
Figure 71.
choice of anaesthesia for palliative care procedures in
these terminally ill patients with limited pulmonary
reserve.
Case Description: We present a 69 year male for
palliative fracture fixation of a painful pathological
fracture of left humerus. Concerns included stage 4
adenocarcinoma of left lung with total collapse, increasing oxygen requirements (fiO2 = 0.4), severe
cachexia and non-suitability for ICU admission. . ORIF of proximal left humerus was completed with
ultrasound guided supraclavicular block (20 mls 0.5%
L- Bupivacaine) and supplemental ultra low volume interscalene block (4 mls 0.5% L-Bupivacaine). No analgesics or sedatives were used. Patient was comfortable
throughout the procedure with verbal analogue pain score
of 0. The immediate postoperative period was pain free
and uneventful. Patient developed right basal pneumonia
and succumbed to his illness two weeks after surgery.
Conclusion: Regional anaesthesia is a safer alternative to general anaesthesia in patients with advanced lung
cancer. The use of ultra low volume interscalene block
to potentiate the effects of supraclavicular block is of utmost importance in fixation of fracture humerus, when
sedatives need to be avoided. Further, this case report
32
Introduction: The patients with pre-eclampsia usually have impaired renal function, reduced serum albumin
and increased capillary permeability due to endothelial
damage. These changes predispose to an increased risk
of pulmonary oedema.
Case Description: Mrs R.O, a 27 year old para 2+0
parturient at 35+3weeks gestational age presented with a
history of difficulty in breathing and cough. On examination, she was in respiratory distress, tachycardic, blood
pressure 180/80mmHg and SpO2 was 57% in room air.
Auscultation of the chest revealed bilateral basal crepitations. A diagnosis of pulmonary oedema secondary to
severe preeclampsia was made. She was treated with labetalol and magnesium sulphate and was scheduled for
emergency caesarean section. General anaesthesia was
the technique of choice. About 500mls of frothy sputum was suctioned from the endotracheal tube and 20mg
of frusemide was given intravenously. A live female
neonate weighing 2.02kg was delivered. Analgesia was
achieved with 4mg of morphine. Estimated blood loss
was about 400mls with a urine output of 800mls. At the
end of surgery she was transferred to the intensive care
unit for elective mechanical ventilation where she was
ventilated for 48hrs and discharged home on the 10th
postoperative day in a satisfactory condition.
Conclusion: Early recognition and appropriate management of pulmonary oedema will result in a favourable
outcome.
NWAC - 73
Interscalene brachial plexus block for clavicle surgery in a patient with bilateral pneumothorax
S. Tuijp1, S. Dewaele1, P. Vanelderen1, S. Van Boxstael1, C. Vandepitte1, S. Van Poucke1, M. Beran1, R. Witvrouw2
1Anesthesiology-icu-emergency, NYSORA-Europe’s CREER (Center
for Research, Education & Enhanced Recovery after Orthopedic
Surgery) Department of Anesthesiology, Intensive Care, Emergency
Medicine and Pain Therapy, Ziekenhuis Oost-Limburg Genk,
Belgium, Genk, Belgium, 2Orthopaedic Surgery, NYSORA-Europe’s
CREER (Center for Research, Education & Enhanced Recovery
after Orthopedic Surgery) Department of Anesthesiology, Intensive
Care, Emergency Medicine and Pain Therapy, Ziekenhuis OostLimburg Genk, Belgium, Genk, Belgium
Introduction: Non-ventilatory anesthesia strategies,
including regional anesthesia may decrease the risk of
postoperative complications in respiratory compromised
patients. We describe a successful use of interscalene brachial plexus block (ISB) to avoid mechanical ventilation
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NWAC ABSTRACTS
and risk of tension pneumothorax in a pediatric patient with
displaced clavicle fracture and bilateral pneumothorax.
Case Description: A 14 year old patient with posttraumatic brain contusion, left lung contusion, bilateral
pneumothorax and multifragment fracture of the left
clavicle was scheduled for clavicle surgery. Since the
patient was respiratory and hemodynamically stable,
no chest tubes were placed. An ultrasound-guided ISB
was performed with 14 ml lidocaine 2%. The surgery
proceeded uneventfully with intraoperative sedation
consisting of midazolam 2 mg, ketamine 15 mg, targetcontrolled infusion of propofol at 1 mcg/ml and spontaneous ventilation. Postoperative analgesia consisted of
acetaminophen 1g QID and ketorolac 30 mg TID.
Conclusion: In patients with bilateral pneumothorax
where intubation and mechanical ventilation can be hazardous, nonventilatory anesthetic strategies may offer a
solution. Based on our case experience, ISB is a viable
alternative for anesthetic management in a patient with
multifragmentary clavicular fracture.
NWAC - 74
A survey of education and training programmes in
ultrasound-guided regional anaesthesia
Y.C. Lim, M. Ng, C.L. Mah, E. Ooi
Anaesthesia And Surgical Intensive Care, Changi General Hospital,
Singapore, Singapore
Introduction: The practice of Ultrasound-Guided
Regional Anaesthesia (UGRA) has increased in recent
years. There are no national guidelines for education of
UGRA for anaesthesia trainees in Singapore.
Objectives: We aim to study current teaching methods of regional anaesthesia, their perceived effectiveness
and our trainees’ comfort level with regards to the performance of specific blocks.
Methods: This anonymous survey was sent to anaesthesia trainees in all training institutions in Singapore and
data was collected over 1 month.
Results: 139 trainees from 6 institutions completed the survey. 91% did not have a formal training program for UGRA in their institution. Only a third had
attended lectures on physics and sonoanatomy and
half had attended live model workshops. For practice
of needling techniques, 17% had used gelatin models,
25% used partial task model and 8% attended cadaveric workshops. The most effective training methods
as perceived by trainees were live model workshops,
formal training blocks and cadaveric workshops. 61%
of trainees felt they had inadequate opportunities
and resources to support their training. Majority of
trainees felt confident in performing brachial plexus
and femoral nerve blocks after 20 blocks while the
learning curve for popliteal and sciatic blocks appear
steeper where trainees only felt confidant after performing more than 30 blocks.
Conclusion: Trainees perceive they will benefit from
more formalised training programs, in particular, workshops and designated training blocks. The learning curve
for sciatic nerve block appears to be steeper than brachial
plexus and femoral nerve blocks.
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NWAC ABSTRACTS
NWAC 2016
NWAC2016 - 1
Long term glycemic control as a predictor for postoperative length of stay in diabetic patients undergoing total knee replacement surgery
G.Y. Lin1, G.H.C. Liew1, W.Y. Ng2, H. R Abdullah1
1Anesthesiology,
Singapore General Hospital, Singapore,
Singapore, 2Singapore General Hospital, Singapore, Singapore
Introduction: 52% of diabetics are estimated to suffer from arthritis and may require total knee replacement
(TKR) [1]. Hence, it is important to investigate the impact of preoperative glycemic control for this common
but invasive surgery. Previous studies suggested poor
glycemic control does not increase the risk of surgical
complications [2]; however, its relationship with length of
stay (LOS) is not clear.
Objectives: We aim to determine if poor glycemic
control in diabetic patients undergoing TKR is associated
with prolonged LOS.
Methods: Upon IRB approval, the records of 2676
patients who underwent TKR from January 2013 to
June 2014 in Singapore General Hospital were retrospectively studied. A total of 504 diabetic patients were
included in the final analyses. Poorly controlled diabetes was defined as HbA1c ≥ 7% and prolonged LOS defined as ≥ 5 days. Other variables included were patient
demographics, type of diabetic therapy, co-morbidities
and intra-operative factors. Univariate analyses were
performed to determine significant clinical factors, and
multivariate analysis was done to determine independent predictors.
Results: We found no significant link between HbA1c
and LOS. Additional results are presented in Table I.
Table I.—Risk factors for prolonged post-operative LOS
in diabetic patients undergoing total knee replacement
from multiple logistic regression analysis, adjusted for
covariates.
P-Value Odds Ratio
HbA1c ≥ 7%
0.927
Anemia
0.005
History of Chronic Kidney 0.001
Disease
History of Cerebrovascular 0.024
Accident
Duration of Operation
<0.001
(minutes)
95%
Confidence
Interval
0.98
1.85
3.84
0.66 to 1.46
1.20 to 2.84
1.70 to 8.67
3.06
1.16 to 8.01
1.02
1.01 to 1.02
Conclusion: We found that among diabetics undergoing TKR, poor long term glycemic control does not
increase the risk of prolonged hospital stay. However,
anemia, history of chronic kidney disease, cerebrovascular accident and duration of operation were noted to be
independent predictors.
34
NWAC2016 - 2
Advantages of epidural anesthesia vs. general anesthesia for lumbar microdisc surgery
Q. Morina1, D. Bunjaku2, A. Morina2, F. Kelmendi3
1Clinic Of Anesthesia And Intensive Care, University Clinival
Center of Kosova, Prishtina, Kosovo, 2Clinic Of Anesthesia And
Intensive Care, University Clinical Center of Kosova, Prishtina,
KOSOVO, 3Clinic Of Neurosurgery, University Clinical Center of
Kosova, Prishtina, Kosovo
Introduction: The use of epidural anesthesia(EA) for
patients undergoing lumbar microdisc surgery (LMS) remains controversial.
Objectives: The aim of this study is to evaluate and
compare the relative morbidities associated with EA and
general anesthesia(GA) for LMS with respect to intraoperative and early pos-operative side -effects.
Methods: After institutional approval n=43 ASA I-II
patients undergoing elective LMS were randomized in two
groups. Groups were similar in age weight and type of operation. Group of the patients receiving EA -19 were given
a single injection of 18 ml bupivacaine 0.25% plus100
μg of fentanyl.Patients receiving GA n=24 were induced
with Propofol, fentanyl, midazolam, and atracurium. The
recorded data during surgery were: the heart rate (HR),
systolic, diastolic, mean arterial blood pressure (MABP),
oxygen saturation, blood loss measured in routine manner . Post operatively : occurrence of nausea,vomiting and
pain intensity was evaluated by using VAS.
Results: The mean intraoperative blood pressure and HR
was significantly higher in the GA group as compared with
the EA group.In the EA group at the beginning of surgery,
there were hypotension and bradycardia in 23% of patients,
which needed atropine or ephedrine injection. The mean
pain scores in EA group was significantly lower in comparison with that of GA group (P < 0.01). Patients with epidural
anesthesia had significantly less nausea and vomiting.
Conclusion: This study revealed that EA have some
advantages over GA regarding intraoperativ hemodynamic stability,prolonged postoperative analgesia and
significant less postoperative side-effects.
NWAC2016 - 3
The effects of tibial intraosseous versus intravenous administration of vasopressin in a porcine
model of ventricular fibrillation
A. Johnson1, J. Burgert1, J. Garcia-Blanco2
Army Graduate Program In Nurse Anesthesia, US Army
Medical Department and School, Fort Sam Houston, TX, United
States of America, 2Department Of Clinical Research, The Geneva
Foundation, Tacoma, WA, United States of America
1Us
Introduction: The intraosseous (IO) route may be
used when intravenous (IV) access cannot be rapidly
obtained. Vasopressin may be used as an alternative to
epinephrine to treat ventricular fibrillation (VF).
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NWAC ABSTRACTS
Objectives: Compare the effects of vasopressin via
tibial intraosseous (TIO) and intravenous (IV) routes
on return of spontaneous circulation (ROSC), time to
ROSC, odds of ROSC, maximum plasma concentration
(Cmax) and time to maximum concentration (Tmax) in a
swine model of VF.
Methods: This prospective, experimental study randomly assigned Yorkshire swine to one of three groups:
TIO (n=7), IV (n=7), and the control group (n=7). VF was
induced and sustained and CPR initiated 2 minutes postarrest. Vasopressin (40u) was administered via the TIO or
IV routes and blood specimens collected for 4 minutes.
Specimens were analyzed using liquid chromatography.
Resuscitation continued for 20 minutes or until ROSC.
Results: There was no significant difference in ROSC,
time to ROSC, or Tmax between the TIO and IV groups;
(p > 0.05) in all outcome measures. All subjects had
ROSC in the TIO and IV groups. No control group swine
had ROSC. Odds ratio analysis indicated there was 225
times greater chance of survival in both the TIO and IV
groups compared to the control. The Cmax of vasopressin was significantly higher in the IV group compared to
the TIO group (p=0.02).
Conclusion: The TIO route was an effective route for
vasopressin administration in a swine model of VF. Although there was higher Cmax in the IV group versus the
TIO group, there was no difference in survival.
NWAC2016 - 4
Organization of high efficiency regional anesthesia
service in a high-volume orthopedic surgery service
A. Visan1, D. Xu2, I. Leunen2, C. Vandepitte2, K. Corten2, J. Bellemans2, C. Desticker2, D. Baens2
1Healthcare Consulting, Executive Cortex Consulting, Miami,
Fl, United States of America, 2Anesthesiology, Intensive Care,
Emergency Medicine And Pain Therapy, NYSORA-Europe’s
CREER(Center for Research, Education&Enhanced Recovery after
Orthopedic Surgery), Genk, Belgium
Introduction: Perioperative service lines strive for
efficiency, effectiveness, value and overall cost reduction. The 4 ORs that comprise the orthopedic anesthe-
sia service line at NYSORA-Europe’s CREER Center,
ZOL Genk, Belgium, have an unique design whose
cost:benefit ratio is closely monitored.
Objectives: We critically examined these OR’s current workflows to evaluate and optimize efficiency.
Methods: This observational study had 3 phases: (1)
on-site assessment, (2) process analysis and (3) metrics
development. The on-site assessment focused on the current workflow patterns for patients, anesthesia services,
surgery services, and nursing staff. The flowchart illustrates the importance of consistent application of standardized protocols and optimal patient management pathways. An analysis of the operating room flows highlights
the importance of parallel processing and specific role
designation for all staff members.
Results: Several essential operating room metrics of
importance for process improvement were selected as
high impact in determining the efficiency of the orthopedic service line.
Table I.—Areas of utilization among 4 ORs at ZOL Genk,
Belgium.
Variable
N
Median
Mean±SD
Turn-Over Time (min)
Utility Rate (%) min pts in or/min
between 8am-4.30pm
Anesthesia OR Time (min)
Surgical Procedure Time (min)
Time between Surgery Finish and
Patient Leaving OR (min)
Total OR Time (min)
93
20
7.0
94.2
6.6±2.8
94.3±2.0
114
114
105
7.5
45.0
5.0
8.9±5.7
50.2±32.5
6.4±5.5
105
68.0
76.4±37.4
Conclusion: Maximal utilization of an induction
room, optimal multidisciplinary team coordination in the
perioperative environment, consistent use of protocols
for regional anesthesia techniques, time-efficient and
procedure-specific patient draping, and implementation
of modern surgical techniques can serve as a model of the
high-efficiency orthopedic service line.
NWAC2016 - 5
A survey of the current practise of regional anaesthesia for ophthalmic surgery in hospitals in
South-East London
S. Esprit, C. Oti
Anaesthesia, King’s College Hospital London, London, United Kingdom
Figure 4.
Introduction: There have been many advances in the
peri-operative management Ophthalmic surgery patients.
Most undergo surgery under local anaesthesia in Day surgery environments.
Objectives: The goal of this study was to survey current practise of regional anaesthesia provided for Ophthalmic surgery, investigating adherence to guidelines for
practise in the United Kingdom, produced by the joint
working party of the Royal College of Anaesthetists and
the Royal College of Ophthalmologists.
Methods: A link to an electronic survey was sent
to approximately 380 anaesthetists in nine hospitals in
south-east London. Surveys were completed and submitted on-line. Data was collected over a four week period.
A reminder email sent after two weeks.
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NWAC ABSTRACTS
Results: 114 responses were received, (approximate
31% response rate), 74% of responses were from Consultants. 88% of respondents felt competent performing
sub-Tenon blocks, 63% performing peri-bulbar blocks
and only 6% felt competent performing retro-bulbar
blocks. Approximately 50% insert intravenous access for
retro-bulbar blocks and only 20% for peri-bulbar blocks.
70% of respondents put saturation probes on patients
whilst performing any block, and over 90% have saturation probes intra-operatively.
Conclusion: The majority of respondents feel competent performing sub-Tenon or peri-bulbar blocks,
only 6% feel competent with retro-bulbar blocks. It is
recommended that intravenous access is essential with
peri-bulbar or retro-bulbar blocks, a standard currently not practised by majority of our respondents. This
needs improvement, so this summary and the guidelines were emailed to recipients of the questionnaire.
The aim is for an increased awareness of the guidelines and a copy should be available in all Ophthalmic
theatres.
NWAC2016 - 6
Addition of Exparel® to Bupivacaine Hydrochloride results in similar early block characteristics
but significantly longer analgesia in patients with
rotator cuff repair
C. Vandepitte1, I. Leunen1, J. Boons1, M. Golebiewski1, M. Heylen1,
C. Bouts1, L. Anne2, R. Witvrouw2, A. Hadzic1, P. Vanelderen1
1Anesthesiology, Intensive Care, Emergency Medicine And Pain
Therapy, NYSORA-Europe’s CREER (Center for Research, Education
& Enhanced Recovery after Orthopedic Surgery), Ziekenhuis OostLimburg Genk, Belgium, Genk, Belgium, 2Orthopedic Surgery,
NYSORA-Europe’s CREER (Center for Research, Education &
Enhanced Recovery after Orthopedic Surgery), Ziekenhuis OostLimburg Genk, Belgium, Genk, Belgium
Introduction: Liposomal bupivacaine (Exparel®)
was recently introduced in USA. Exparel® promises a
longer duration of analgesia in PNBs.
Objectives: We tested the hypothesis that addition of
Exparel® to Bupi HCl results in similar early block characteristics, but longer duration of analgesia than Bupi
HCl alone.
Methods: After IRB and NID approval
(NCT02554357), 40 subjects were randomized to interscalene brachial plexus block (ISB) with either 15 ml
Bupi HCl 0.25% or 5 ml Bupi HCl 0.25% followed by 10
ml Exparel® under ultrasound guidance. All patients received general anesthesia for surgery and were assessed
by a blinded observer.
Results: A total of 39 patients successfully completed the study. There was no difference in demographics between these two groups or baseline pain
scores. The difference in the worst pain scores was
significantly lower (p<0.04) in the Exparel® at 48, 76
and 96 hours (6.1±3.3 vs 3.3±2.9, 6.2±2.7 vs 3.6±2.3,
and 4.8±3.2 vs 2.4±3.3, respectively). The duration
of sensory blockade was 26.5±17.8 hrs in control vs
79.3±19.2 hrs in Exparel®. No patient developed respiratory symptoms suggestive of phrenic nerve paresis
or LAST. Patient satisfaction with pain control was
higher in the Exparel®.
36
Conclusion: Preliminary analysis of our study suggests that addition of Exparel® to Bupi HCl results in
similar early block characteristics, significantly longer
duration of sensory blockade and much better analgesia
and patient satisfaction than Bupi HCl alone.
NWAC2016 - 7
Ultrasound-guided specific blocks of the distal tibial and deep peroneal nerves for hallux valgus
surgery
S. Van Boxstael1, I. Leunen1, C. Bouts1, J. Wierinckx2, D. Dylst1, J.
Van Melkebeek1, S. Dewaele1, C. Vandepitte1
Belgium, Genk, Belgium, 2Orthopaedic Surgery, NYSORA-Europe’s
CREER (Center for Research, Education & Enhanced Recovery
after Orthopedic Surgery) Department of Anesthesiology, Intensive
Care, Emergency Medicine and Pain Therapy, Ziekenhuis OostLimburg Genk, Belgium, Genk, Belgium
Introduction: Hallux valgus surgery (Scarf osteotomy) is
a painful procedure mostly done on an outpatient basis. Popliteal block is commonly used for postoperative analgesia but
the resultant foot-drop prevents early ambulation.
Objectives: We examined the feasibility of US-guided distal tibial and deep peroneal nerve blocks (DT+DP)
for hallux valgus surgey.
Methods: After informed consent 9 patients scheduled
for Scarf osteotomy received DT+DP using 3-5ml 0.5%
ropivacaine 0.5 to 1% for each nerve and subcutaneous infiltration of 4-10ml ropivacaine 0.5% to 1% at mid-tarsal level
to block the saphenous nerve. All patients received standardized intraoperative sedation protocol titrated to patient comfort. A successful block was defined as the ability to perform
the surgery with DT+DP as a sole anesthetic without supplemental opioids or conversion to GA.
Results: All included patients had an adequate surgical anesthesia and analgesia. No patient developed a foot
drop. The mean duration of analgesia was 15h30min. The
patient and block durations characteristics are shown in
Table I.
Case Age Sex
(y)
Local
Volume Succes Foot
anesthetic
(ml)
drop
First
pain
(h after
block)
Worst
VAS
D0-7
23h
23h
15h
30 min
12h
12h
8h
15h
30 min
15h
15h
30 min
4(D4)
1(D3)
6(D2)
1
2
3
69
45
53
F
F
F
Ropi 1%
Ropi 1%
Ropi 1%
15
15
10
+
+
+
-
4
5
6
7
48
55
47
25
M
F
F
M
Ropi 0.5%
Ropi 0.5%
Ropi 0.5%
Ropi 0.5%
15
20
20
20
+
+
+
+
-
8
9
25
19
M Ropi 0.5%
F Ropi 0.5%
10
20
+
+
-
2(D2)
7(D0)
9(D0)
8(D0)
5(D1)
5(D2)
Conclusion: Ultrasound-guided specific blocks of the
distal tibial and deep peroneal nerves for hallux valgus
surgery is a well suited technique for perioperative anesthesia and analgesia in hallux valgus surgery. Encouraged
MINERVA MEDICA
June 2016

NWAC ABSTRACTS
by our preliminary findings, we are currently conducting
a randomized, controlled trial comparing DT+DP to popliteal block.
NWAC2016 - 8
The influence of multimodal thoracic epidural or
thoracic paravertebral analgesia on the postoperative pain after lung surgery
V. Novak -Jankovic, V. Paver-Erzen, M. Voje
Clinical Department Of Anesthesiology And Intensive Therapy,
University MedicalCentre Ljubljana, Ljubljana, Slovenia
Introduction: Lung surgery can induce severe postoperative pain.
Objectives: The influence of two different analgesic
techniques on the postoperative pain after lung surgery
were studied.
Methods: 40 patients (ASA II-III) were randomly
allocated to two groups. In thoracic epidural analgesia
(TEA- 20 pts) cathether was placed between T6-T7
epidurally; in the paravertebral analgesia (TPA- 20
pts) cathether was placed at T6-T7 in the paravertebral space. In both groups preoperatively, 4 mg of
morphine and 15 mL of 0.5% bupivacaine were injected through the catheter. Infusion of analgesic mixture (10 mg of morphine, 50 mg of bupivacaine and
0.15 mg of clonidine in 100 mL of saline) was given
3 days postoperatively for PCA at the rate of 1 mL/h,
bolus dose 3 mL and lock out period of 30 min. The
data were analysed by the ANOVA test; p<0.05 was
considered significant.
Results: There were no significant differences in static VAS between 2 groups 3 days postoperatively.On the
first postoperative day dynamic VAS was significantly
higher in the TPA group compared to the TEA group
(Table I). There were no differences in the use of rescue
analgesic diclofenac between 2 groups . Table I.—Analgesic characteristics Postoperative
day
TEA
TEA
TEA
TPA
TPA
TPA
1
2
3
1
2
3
S-VAS 2,21±1,1 1,71±1,2 2,0±1,0 3,72±1,1 2,18±1,4 2,45±2,0
D-VAS 2,5±1,3 2.42±1,1 2,85±1,4 4,3*±1,5 3,5±1,6 3,09±1,4
Static VAS (S-VAS), dynamic VAS(D-VAS) *p<0,05 values are means ±SD.
Conclusion: Multimodal TEA and TPA showed
comparable pain relief after lung surgery. NWAC2016 - 9
International cardiopulmonary bypass practice:
how much variation exists between regions?
T. Coulson, L. Miles, F. Falter
Anesthesia And Intensive Care, Papworth Hospital NHS Foundation
Trust, Cambridge, United Kingdom
Introduction: Cardiopulmonary bypass practice varies between institutions. We undertook an international
survey of cardiac anesthesiologists so as to better define
regional variations in conduct of cardiopulmonary bypass (CPB).
Objectives: To describe and compare cardiopulmonary bypass practice between global regions.
Methods: We distributed a survey to national and
international specialist cardiac anesthesia societies
using an online tool. Nations were grouped into geographical regions. North comprised Europe, Canada
and the USA, while South comprised Australia, New
Zealand and South Africa. Activated clotting time
(ACT) targets, arrest techniques, cardioplegia compositions and prime compositions were compared
between the two groups. Differences between groups
were evaluated using the chi-squared test or Fisher’s
exact test where appropriate.
Results: 586 responses were received from North,
and 185 from South. There were significant differences between the groups. South were more likely to
aim for a higher ACT (500-549) than North (28% vs
5.8%, p<0.001). There were no differences in pump
prime fluid type (crystalloid vs colloid) or crystalloid composition. Albumin was more commonly used
in the South (p<0.001). Prime additive differences
for South vs North included: heparin (56% vs. 49%),
bicarbonate (27% vs. 20%,) and mannitol (32% vs
41%)(p<0.001). Cardioplegia additives also differed
(p<0.001).
Conclusion: This novel, global survey showed
marked differences in CPB practice between North and
South. The reasons for these differences are poorly understood. As much as this survey demonstrates that there
are numerous ways of safely conducting CPB it should
serve as a base for correlating morbidity and mortality in
further studies.
NWAC2016 - 10
Comparison of effects of ozone therapy and hyperbaric oxygen therapy added added to antibiotherapy on cytokine levels in experimental sepsis model among rats
E. Bicerer1, H. Tufekci1, K. Dere1, O.M. Ipcioglu2, S. Ozkan1, G.
Dagli1
1Anesthesiology And Reanimation, GATA Haydarpasa Training
Hospital, Istanbul, Turkey, 2Biochemistry, Gata Haydarpasa
Training Hospital, Istanbul, Turkey
Introduction: Sepsis is a systemic inflammatory reaction mediated by endogenous mediators which affects all
organs and systems. Tissue damage mostly occurs during
the process triggered by cytokines. Hyperbaric oxygen
therapy (HBOT) might be beneficial in sepsis treatment
due to its antimicrobial effects. Ozone is gas with a high
potential for oxydation. With the oxydation of bacterial
cell membrane it has a bactericidal effect. In this study, we
aimed to analyze the changes imposed by ozone therapy
and HBOT added to antibiotherapy in experimental sepsis.
Objectives: We formed 5 experiment groups, each
consisting of 10 rats.
Methods: In group 1 , we have adde ozone therapy
at dose of 0.9 mg/kg to the antibiotherapy, in group 2 we
MINERVA MEDICA
37
NWAC ABSTRACTS
have added HBOT to the antibiotherapy. While we only
applied antibiotherapy in group 3 , in group 4 we only
induced sepsis. Group5 silmutaneously recieved only
physiological saline. All therapies were continued for 5
days. On day 6 we studied the IL1, IL10 and TNFalpha
levels in the serums of rats.
Results: we identified that inflammatory cytokine
levels in all groups which recieved ozone therapy were
significantly lower compared to other groups (p=0.001).
we identified a significant increase in the serum levels
of IL10 as antiinflamatuar cytokine in the group that recieved ozone therapy compared to other groups.
Conclusion: In conclusion, considering significant
differences in proinflammatory cytokine levels, we believe that ozone added to antibiotherapy in sepsis could
have positive effect on survival ratios by supressing
inflammatory processand that is more effective than
HBOT.
NWAC2016 - 11
A randomized controlled study of the pharmacokinetics and resuscitative effects of humeral intraosseous vasopressin in an adult swine model of ventricular fibrillation
J. Burgert1, A. Johnson1, J. Garcia-Blanco2
1Us Army Graduate Program In Nurse Anesthesia, US Army
Introduction: The intraosseous (IO) route may be
used when intravenous (IV) access cannot be rapidly
obtained. Vasopressin may be used as an alternative to
epinephrine to treat ventricular fibrillation (VF).
Objectives: The purpose of this study was to compare the effects of humeral IO (HIO) and IV vasopressin,
on the rate of return of spontaneous circulation (ROSC),
odds of ROSC, time to ROSC and pharmacokinetic
measures in an adult swine model of VF.
Methods: This prospective, experimental study randomly assigned 27 Yorkshire swine to three groups; HIO
(n = 9), IV (n = 9), and a no drug control group (n = 9).
VF was induced and chest compressions began at 2 minutes post-arrest. Vasopressin (40 U) was administered at
4 minutes post-arrest. Blood specimens were collected
for 4 minutes and analyzed. Swine were resuscitated until
ROSC or 29 post-arrest minutes elapsed.
Results: ROSC was significantly higher in the HIO
and IV groups compared to control (p = 0.001). Odds ratios of ROSC indicated no significant difference between
the HIO and IV groups (p=0.47) but significant differences between the treatment groups and control (p=0.01
and 0.02). Time to ROSC for HIO and IV was 621.20
seconds and 554.50 seconds, (p=0.22). Maximum plasma concentration and time to maximum concentration in
the HIO and IV groups was 71753.9 pg/mL and 61853.7
pg/mL, 111.42 seconds and 114.55 seconds respectively.
Conclusion: The HIO route delivers vasopressin effectively in an adult swine model of VF. Plasma concentrations of HIO vasopressin were comparable to IV
vasopressin.
38
NWAC2016 - 12
Effects of tibial intraosseous versus intravenous
administration of vasopressin in a porcine model
of hypovolemic cardiac arrest
A. Johnson1, J. Burgert1, J. Garcia-Blanco2
Army Graduate Program In Nurse Anesthesia, US Army
1Us
Introduction: Hypovolemic cardiac arrest is the leading cause of preventable traumatic death in the US. Vascular collapse makes vascular access procedures difficult
and delays the administration of life-saving drugs. The
intraosseous (IO) infusion route may be used when IV
access is delayed or unobtainable.
Objectives: To compare the effects of vasopressin via
tibial intraosseous (TIO) and intravenous (IV) routes on
maximum drug concentration (Cmax), the time to maximum concentration (Tmax), return of spontaneous circulation (ROSC), and time to ROSC in a hypovolemic
cardiac arrest model.
Methods: This prospective, experimental study randomly assigned Yorkshire swine to one of four groups:
TIO (n=7), IV (n=7), CPR with defibrillation, no drug
(n=7), and the control group receiving CPR only (n=7).
After exsanguinating 31% of total blood volume, ventricular fibrillation was induced and CPR initiated 2 minutes
post-arrest. At 4 minutes post-arrest, 40 units of vasopressin were administered via the TIO or IV routes and blood
samples collected over 4 minutes. Vasopressin concentrations were analyzed using liquid chromatography. Resuscitation continued for 20 minutes or until ROSC.
Results: There was no difference in Cmax (p =.079),
Tmax (p =.084) between the TIO and IV groups or time
to ROSC between the TIO, IV, and CPR with defibrillation groups (p > 0.05). There was no significant difference between the TIO and IV groups relative to occurrence of ROSC (p = 1.0).
Conclusion: The TIO route was effective for the treatment of hypovolemic cardiac arrest in a porcine model.
NWAC2016 - 13
Neurotoxic effects of intraneurally or perineurally
injected solutions of saline and increasing concentrations of ropivacaine in the sciatic nerve of Wistar rats
S. Van Boxstael1, I. Leunen1, C. Vandepitte1, N. Knezevic1, I. Hasanbegovic2, A. Hadzic1
Belgium, Genk, BELGIUM, 2Anatomy, University of Sarajevo
Medical School, Sarajevo, Bosnia and Herzegovina
Introduction: Using a rat model, this study examined
the neurotoxic effects of varying concentrations of ropivacaine when injected perineurally.
Objectives: We hypothesized that neurologic injury
after intrafascicular application of ropivacaine will be
greater with increasing concentration of ropivacaine.
MINERVA MEDICA
June 2016

NWAC ABSTRACTS
Methods: After IRB, 100 sciatic nerves in rats were
randomized to receive one of four concentrations either of ropivacaine(0.2%-0.5%-0.75%-1%) or saline
intraneurally or perineurally. Needles were placed
under optic microscopy guidance and opening injection pressure data were recorded. Neurologic examinations were performed at baseline,1,2,3,4,5,6,24,48
and 72 h by blinded investigators. After 3 days the
sciatic nerves were histologically examined for qualitative and quantitative evidence of nerve damage.
Results: The degree of histologic nerve injury increased with higher concentrations of ropivacaine. As
opposed to perineural, intrafascicular injections resulted in motor and sensory neurologic deficit and microscopic nerve damage. Injury occurred only with injections that resulted in high opening injection pressures.
Conclusion: When injections occurred intrafascicularly, intraneural injection of ropivacaine exhibited
concentration dependent neurotoxic effects with histologic evidence of nerve damage; the magnitude of
this effect was concentration dependent. Perineurally
injected ropivacaine resulted in concentration dependent duration of blockade without evidence of neurologic injury. Injury always occurred when needle
placement was intrafascicular. Intrafascicular needle
placement and injection resulted in histologic evidence
of nerve damage at all concentrations of ropivacaine.
Dupuytren’s cord; 48 hours later (2nd phase) the fingers
are manipulated to disrupt the cords. Both phases are
painful, with the 2nd phase necessitating GA or LA infiltration for manipulation.
Objectives: We examined the utility bupivacaineliposomal bupivacaine (Exparel®) mixture as single anesthetic modality for both phases.
Methods: After informed consent and IRB, 7 patients
received US-guided distal median and ulnar nerve blocks
(PNBs) with 4 ml of the mixture 0,5% Bupivacaine and
Exparel® in 50:50 ratio. Quality of anesthesia, sensory
and motor block of the hand were assessed through 72
hours after PNBs.
Results: Bupivacaine-Exparel® mixture provided
complete anesthesia-analgesia for both phases of the
procedure in all but one patient. The motor and sensory
block lasted 24 and 72 hours, respectively (Figure). The
sensory block in the single patient with anesthetic failure
for 2nd Phase returned a few hours and lasted an additional 24 hours.
Conclusion: Median and ulnar blocks with Bupivacaine-Exparel® mixture provided complete anesthesia
for both phases of the treatment in all but one patient,
with sensory block lasting up to 72 hours. Dose-ranging
studies are indicated to determine the optimal dose of
Bupivacaine-Exparel® for more consistent PNBs over
the desired therapeutic range.
NWAC2016 - 14
The utility of Liposomal Bupivacaine for anesthesia and analgesia in patients having collagenase
injection and fingers manipulation for treatment
of Dupuytren contractures
NWAC2016 - 15
Pharmacodynamics response surface model applied in sedation for gastrointestinal endoscopiesmidazolam and opioids interactions
S. Van Boxstael1, I. Leunen1, D. Dylst1, C. Vandepitte1, P. Vanelderen1, J. Duerinckx2
1Anesthesiology, Intensive Care, Emergency Medicine And Pain
Therapy, NYSORA-Europe’s CREER (Center for Research, Education
& Enhanced Recovery after Orthopedic Surgery), Ziekenhuis OostLimburg Genk, Belgium, Genk, Belgium, 2Orthopedic Surgery,
NYSORA-Europe’s CREER (Center for Research, Education &
Enhanced Recovery after Orthopedic Surgery) Ziekenhuis OostLimburg Genk, Belgium, Genk, Belgium
Introduction: Injection of collagenase clostridium
histolyticum (Xiapex®) is used to treat Dupuytren’s contractures. In the 1st phase, Xiapex® is injected into the
Figure 14.
M. Tsou, C. Ting, J. Liou
Department Of Anesthesiology, Taipei Veterans General Hospital,
Taipei, Taiwan
Introduction: Classical midazolam-opioid combination for gastrointestinal endoscopy sedation has been
adopted for decades. Dosing regimens have been studied
but mainly involves initial boluses only.
Objectives: We intend to use a sophisticated pharmacodynamic tool, response surface model (RSM), to simulate sedation using different regimens. RSM can predict
patient’s response during different phases of examination
and predict patient’s wake-up time with precision, which
will aid physicians in guiding their dosing strategy and
timing.
Methods: A full Greco RSMs of midazolam and alfentanil were constructed using 33 patients who received
esophagogastroduodenoscopy (EGD) and colonoscopy
The procedure was divided into 3 phases: EGD, colonoscopy and intersession. OAA/S is used to assess patient
response. Step two involves simulating of six different
regimens with midazolam and opioids. Loss of response
at 95% probability for adequate anesthesia and return of
consciousness at 50% probability was selected for simulation purposes.
Results: The full Greco RSMs for each of the phases
showed significant synergy between midazolam and alfentanil. The balanced midazolam and opioid combination provided adequate anesthesia and most rapid return
MINERVA MEDICA
39
NWAC ABSTRACTS
of consciousness. The awakening time from the final
bolus of medication was 7.4 min during EGD and colonoscopy stimulation, and 9.1 min during EGD simulation.
Only one patient (3%) developed temporary hypoxemia
which was promptly managed with simple measures.
Conclusion: Simulation of regimens with different characteristics gives insights on dosing
strategies. We believe with the aid of our response surface model, we can demonstrate that with the correct
dosing strategies, midazolam and opioids can achieve
adequate sedation and rapid recovery.
NWAC2016 - 16
A review of mechanical ventilation in the intensive
care unit of National Hospital Abuja
A.V. Elumelu, O. Ekumankama, S.S. Jamgbadi
Anaesthesia And Intensive Care, National Hospital Abuja, Abuja,
Nigeria
Introduction: Ventilatory support by means of mechanically generated positive pressure ventilation is a
therapeutic intervention which is not widely available in
most Nigerian hospitals. The Intensive care unit (ICU) of
National Hospital Abuja is a 10 bedded unit which caters
40
for a wide variety of ill patients from within the hospital
and other surrounding hospitals. An audit of ventilated
patients was carried out.
Objectives: To determine the indications for the commencement of mechanical ventilation in the Intensive
Care unit of National Hospital Abuja. To determine the
socio-demographic variables of patients ventilated in
the Intensive Care Unit of National Hospital Abuja. To
review the source of referral for patients who were ventilated in the Intensive Care Unit of National Hospital
Abuja. To review the outcomes of ventilated patients.
Methods: A review of the ICU records as well as the
case records of all ventilated patients over a 24 month
period from November 2011 and October 2013. Information was gathered using a structured questionnaire.
Results: A total of 191 patients, 46.02%, were ventilated. The male female ratio was 2.13:1. Ages ranged
from 8 months to 88 years, with a mode of 35 years and
a mean of 38.9 years. Coma from medical and traumatic
causes, accounted for the ventilation of 126 (65.97%)
patients. Over half of the ventilated patients, (56.02%)
originated from the Accident and Emergency unit. Others were from the operating theatres and other hospitals.
Outcomes ranged from complete recovery to death.
Conclusion: Mechanical ventilation, if made more
widely available, will help save more productive lives. MINERVA MEDICA
June 2016

NYSORA
14th Annual Symposium
New York (USA), September 19-20, 2015
NYSORA ABSTRACTS
How effective is the interventional pain procedure
in the diagnosis of spinal pain?
D. Maheshwari, G. Afshan, A. Sarfraz
Aga Khan University Hospital, Karachi – Pakistan
Background: Interventional pain management
(IPM) is a rapidly growing and evolving specialty
of medicine devoted to the diagnosis and treatment
of chronic pain. Despite of modern technology like
magnetic resonance imaging (MRI), computed axial
tomographic scanning (CAT scan), neurophysiological
testing physician are unable to diagnose the cause of
low back pain in only 15% of patients in the absence
of disc herniation and neurological deficit while diagnostic IPM procedures can reveal its source in 90%
of patients. The objective of this audit is to observe
how effective the interventional pain procedure in the
diagnosis of spinal pain is.
Methods: After approval by Ethical Review Committee and departmental Anaesthesia Research Committee, all adult patients with a history of spinal pain
≥ 6 weeks and refractory to conservative treatment
scheduled for diagnostic IPM procedure for spinal
pain between January to December 2013 were enrolled in this audit. Patients with a history of spinal
surgery were excluded from the audit. Common IPM
procedures included in this audit were, epidural injection (cervical, thoracic, lumbar and caudal), facet
joint block and sacroiliac joint block. Pain score was
monitored by numerical rating pain scale (NRS) 0 to
10 scale. Efficacy of diagnostic block was considered
positive in case of ≥50% pain relief.
Results: Diagnostic intervention for spinal pain was
performed in 102 patients (Average age 54.83±16.45),
among them 60% (n=61) were females and 40%
(n=41) were males. Duration of spinal pain was found
to be more than a year in 56% patients. As for as pattern of pain distribution concerns, 87% patients had
radicular pain compare to 13% patients were suffering
from axial pain.
Discussion: From this study it is evident that most
common patient population who received IPM is of
spinal pain with radicular distribution. However patient with axial spinal pain also received IPM. For
best of our knowledge this is the first report sharing
ratio of radicular versus axial pain requiring IPM in
a tertiary care pain setup. We also found excellent
pain relief (according to operational definition of
Pain relief for this audit) following IPM in our patient sample compare to reported pain relief in recent
literature.
Conclusions: Efficacy of positive diagnostic block
was found in 83.33%(n=85). With this audit it was
proved that diagnostic interventions for spinal pain not
only help in tt1e diagnosis but they may also lead to
significant pain relief.
References
1. Manchikanti L, Falco FJE, Singh V, Pampati V, Parr AT,
Benyamin RM, Fellows B, Hirsch JA. Utliization of
interventional techniques in managing chronic pain in the
Medicare population: Analysis of growth patterns from
2000 to 2011. Pain Physician 2012;15:E969-E982.
2. Manchikanti L, Boswell MV, Sing V, Derby R, Fellows
B, Falco FJ et al.. Comprehensive Review of Neurophysiologic Basis and Diagnostic Interventions in Managing
Chronic Spinal Pain. Pain Physician 2009;12:71 121.
Patient refusal for regional anesthesia in Elderly
Orthopedic Population; A Cross Sectional Survey
at a tertiary care hospital
A. Abdul Salam; G. Afshan
Aga Khan University Hospital, Karachi- Pakistan
Background: Orthopedic surgery challenges the anesthesiologist with its diversity in procedures and age
groups. Improvements in pain management techniques in
the last decade have had a major impact on the practice
of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established.
In our institution, both general and regional anesthesia,
are being offered to the elderly orthopedic population
but regional anesthesia is not frequently been accepted
by elderly population. The objective of this study was to
determine the frequency of various reasons for refusal of
regional anesthesia in elderly patients undergoing orthopedic surgeries
Methods: It was a Cross Sectional Survey. Total of
182 elderly patients who have refused regional anesthesia were included in the survey and interviewed according to the structured questionnaire. The questionnaire
was designed to assess the reasons why elderly patients
refuse regional anesthesia
Results: 63.7% of the elderly population in our study
was female. 51% had a past history of surgery, with
70.2% of these have had general anesthesia. Most common reason for the refusal of regional anesthesia was surgeon’s choice (38.5%), whereas 20.3% of the respondents knew nothing about regional anesthesia. There was a
significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake
during operation (24.1%) respectively.
Discussion: It has been observed earlier that the elderly patients coming in our institution prefer GA over
RA. We actually wanted to see the factors responsible for
this & found that refusal in most of the cases is based on
many misconception about the safety & conduct of RA
e.g. backache & fear of being awake during surgery. In
addition we found that our surgeons have a major impact
on patient’s preference and it does influence patient’s
choice regarding anesthesia technique. This trend has
also been reported in many other countries of Asia.
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NYSORA ABSTRACTS
Conclusions: This survey showed that anesthesiologists were the main source of information. Main reasons
among elderly female population are the fear of remaining awake and backache however overall it was the surgeons choice which made patients refuse RA.
References
1. Zimmermann M, Jansen V, Rittmeister M. The use of
regional anesthesia in orthopedics. Orthopade. 2004
Jul;33(7):784-95.
2 Rhee WJ, Chung CJ, Lim YH, Lee KH, Lee SC. Factors
in patient dissatisfaction and refusal regarding spinal anesthesia. Korean J Anesthesiol. 2010 Oct;59(4):260-4.
3. Ahmed l, Afshan G. Knowledge and attitudes of pakistani
women towards anesthesia techniques for Caesarean Section. J Pak Med Assoc. 2011 Apr;61(4):359-62.
Ultrasound-guided continuous ilioinguinal-iliohypogastric nerve block for pelvic pain in a patient
after cesarean delivery
Figure 1.—·Nerves of the female perineum.
J. S. Baik, E. S. Kim, H. K. Kim
Department of Anesthesia and Pain Medicine, School of Medicine,
Pusan National University, Busan, Korea
Introduction: Ilioinguinalii liohypogastric (II/IH)
nerve neuropathy is the second most common neuropathy after major pelvic surgery, with a reported incidence
up to 3.7% after Pfannenstiel incision.
These complications are often reversible but may be
debilitating and result in permanent disability.
We present a case of intractable groin pain after cesarean delivery successfully treated with ultrasound-guided
continuous Il/lH nerve block in patients with breast-feeding.
Case report: A 33-year-old female underwent emergency cesarean resection 5 days ago presented to emergency department with severe pelvic pain. The patient
had burning, lancinating, and intermittent pain on left
groin region, especially area of superomedial thigh and
the mons pubis and labia majora (Fig. 1). She sometimes
felt numbness on inguinal region. The pain was developed second postoperative day (POD) when she walked
for exercise. And, it was getting worse over time. Symptoms were aggravated by standing, raising leg, bending
over, and walking. The pain did not occur when she lay
on her back. She continued to stay in the bed due to intractable pain, despite urination or defecation. There was
no sensory loss or muscle paralysis on left lower extremity. There were also no sympathetic mediated symptoms,
such as edema or sweating changes. The visual analogue
scale (VAS) was over 7.
On emergency department, diagnostic workup including computed tomography (CT) of pelvis was performed
to rule out inguinal hernia. There were no abnormal findings, such as bulging on groin or silk glove sign in physical examination. No abnormal finding was observed in
CT of pelvis except enlarged uterus. In presumed diagnosis of ilioinguinal/iliohypogastric (II/IH) or genitofemoral neuralgia, diagnostic block of II/IH nerve was first
performed because the patient declined to take medicine
due to breast-feeding. Using an aseptic technique, II/IH
nerve block was performed with 6-13MHz linear probe
44
Figure 2.—Ultrasound image (A) showing local anesthetic pocket between internal oblique (IOM) and transversus abdominis (TAM). Ultrasound image (B) showing
catheter in the pocket.
(HFL 38x 13-6 MHz transducer, Sonosite Inc, Bothell,
WA, USA) connected to ultrasound (S-nerve, Sonosite
lnc, Bothell, WA, USA). After negative aspiration, 0.2%
ropivacaine 7 ml with dexamethasone 5 mg was injected
in the TA plane on left side. The VAS was immediately
decreased from 7 to 2 after infiltration. The patient could
stand or move freely, though the pain sometimes occurred. On POD 8, ultrasound-guided perineural catheter
insertion was performed with set for continuous epidural
anesthesia (Fig.2). A patient controlled analgesia (PCA)
pump delivered local anesthetics to the patient through
a catheter for 3 days (continuous basal infusion rate 5
ml/h, demand dose 5 ml, and lockout time 30 min). The
patient had complete resolution of symptoms with continuous catheter.
Discussion: The most common causes of neuropathy
after pelvic surgery are transection from incision, entrapment, compression or stretching of the nerve.
— Occult inguinal hernia can represent similar symptom but not palpable on physical examination. Ultrasound and CT cannot reliably exclude occult groin abnormalities.
— Genitofemoral neuropathy is associated with nulliparity and prolonged second stage of labor. And the
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NYSORA ABSTRACTS
dermatome of genital branch is overlap with ilioinguinal
nerve.
— There are no studies demonstrating the safety of
ropivacainc for breast-feeding, but it is highly protein
bound; therefore, the ropivacainc exposure of the nursing
infant is likely to be significantly lower than anticonvulsant and antidepressant exposure.
Conclusions: While II/IL neuropathy after pelvic
surgery often resolves spontaneously, continuous nerve
block using ultrasound might be a good option for intractable pain in patient with breast-feeding.
References
1. Cardosi RJ, Cox CS, Hoffman MS. Postoperative neuropathies after major pelvic surgery. Obstet Gynecol.
2002; 100:240-2.
2. Luijendijk RW, Jeekel RJ, Storm RK, Schutte PJ, Hop
WC, Drogendijk AC, Huikeshoven FJ. The
low
transverse Pfannenstiel incision and the prevalence
of incisional hernia and nerve entrapment. Ann Surg
1997;225:365-9.
Figure 2.
Continuous Femoral Nerve treatments for 20 days
might avoid phantom limb pain
V. Bansal
St.Louis University, St Louis, MO
Background: Ultrasound-guided femoral CPNB can
possibly significantly reduce neuropathic pain in a small
child following a traumatic lawnmower accident. In contrast to an epidural, the CPNB allowed him to be independently mobile and avoid urinary catherization during
his perioperative stay of 1 month. More significantly, the
patient required minimal medications postoperatively,
and has not experienced phantom pain even 2 months
after discharge.
Methods: Following a traumatic injury to the distal leg by a lawnmower, the patient was brought in the
OR initially for extensive debridement of dirt and torn
tissue. After the third debridement, he received three
femoral SSNB injections for the next three debridements. After two weeks of aggressive antibiotics treatment, the patient underwent amputation of distal limb.
Figure 1.
He received a femoral CPNB which stayed in-situ for 2
weeks. The infusion rate was 5cc initially and weaned
gradually to 2cc/hr at the end of his stay. The patient’s
pain score were plotted daily with the procedures performed listed below.
Results: The patient was extensively traumatized and
complained of significant pain after his first three l&D,
with postop pain 10/10. Subsequent I&Ds were treated
with femoral SSNB that reduced the patient’s pain levels
to VAS 0/10.Afler the R.lower leg amputation we performed the R.femoral CPNB and found that our patient
was comfortable throughout his stay afterwards. The patient had intermittent pain on the L. leg from the skin
graft harvest site, but well controlled with IV narcotics.
In followup with the family the patient has had no pain
even discharge from the hospital. More surprisingly, he
has not complained any signs of phantom pain (see picture on right).
Conclusions: The incidence of phantom pain after
traumatic injury is somewhere between 50% and 95%,
depending on the study and the population. Preliminary
studies at UCSD have treated phantom pain with CPNB
x 6 days with good success.
In our case, we were able to treat our patient’s pain
from the beginning and possibly avoided neuropathic
pain by blocking the disturbance to the somatosensory
nervous system.
References
1. The prevalence of phantom sensation and pain in pediatric amputees. Krane EJ. J Pain Symptom Manage. 1995
Jan;10(1)21-9.
2. Phantom limb pain in young cancer related amputees:
recent experience at St Jude children’s research hospital.
Burgoyne LL, Clin J Pain 2012 Mar-Apr;28(3):222-5.
3. Treating intractable phantom limb pain with ambulatory
continuous peripheral nerve blocks: a pilot study. Ilfeld
BM, Moeller-Bertram T, Hanling SR, Tokarz K, Mariano
ER, Loland VJ, Madison SJ, Ferguson EJ, Morgan AC,
Wallace MS. Pain Med. 2013 Jun;14(6):935-42.
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Comparing Intrathecal Buprenorphine with Intrathecal Diamorphine in addition to Bupovacaine for
Caesarean Section under Spinal Anaesthesia
M. Ghani, T. Anyaegbuna, L. Ali
Ealing Hospital, London, UK
The co-administration of small doses of opiates to
Bupivacaine for spinal anaesthesia has been recommended to improve intraoperative comfort, and to reduce the
requirements for post-operative analgesia. We compared
Buprenorphine to Diamorphine and looked at the post
operative side effects, namely; nausea, vomiting and pruritus, as well as post operative Morphine requirements, in
women undergoing elective caesarean section.
Methods: To allow for standardization, all mothers
undergoing elective caesarean section under spinal anaesthesia were given 2.2mls of 0.5% heavy Bupivacaine,
with the addition of either 300mcg Diamorphine or 60mg
Buprenorphine. All mothers also received 100mg Diclofenac rectally at the end of their operations.
Results: Of the 105 mothers who received Buprenorphine, two complained of nausea and eleven complained
of pruritus. Forty-six mothers required one postoperative
intramuscular injection of Morphine, and two mothers
required intramuscular injections of Morphine.
In the Diamorphine group of 102 mothers, fourteen
complained of nausea, thirteen experienced vomiting
episodes and thirty-five complained of pruritus. Interestingly, twenty-four mothers required one postoperative
intramuscular injection of Morphine and ten mothers
required two postoperative intramuscular injections of
Morphine.
Results:
Conclusions: The addition of intrathecal Buprenorphine to Bupivacaine in spinal anaesthesia in place of
Diamorphine demonstrated less side effects, in particular
relating to nausea, vomiting and pruritus. Buprenorphine
also provided a comparable duration of action and analgesic affect to Diamorphine. In addition, Buprenorphine
comes in a single, preservative free preparation with no
dilution required, unlike Dlamorphine. As such, there is
less margin for error during drug preparation for inthethecal injections.
References
1. Brill S, Gurman GM and Fisher A. A history of neuraxial
administration of local analgetics and opioids. Eur J Anaesthesiol. 2003;20:682-9.
46
2. Ipe, S., Korula, S., Varma, S., George, G. M., Abraham,
S. P., & Koshy, L. R. A comparative study of Intrathecal
and epidural buprenorphine using combined spinal-epidural technique for caesarean section. Indian Journal of
Anaesthesia, 2010;54(3), 205-209.
3. Kelly MC, Carabine UA, Mirakhur RK. Intrathecal diamorphine for analgesia after Caesarian section; A dose
finding study and assessment of side effects. Anaesthesia.
1998; 53:231-237.
A Comparison of recovery time when using 2-Chloroprocaine or Bupivacaine for Spinal anesthesia
for surgeries of short duration
F. Haddad, P. Fanapour, N. Ahmed, S. Shah
Introduction: 2-Chloroprocaine is becoming a popular alternative for spinal anesthesia in the setting of outpatient surgery1. We initiated an IRB approved, subject
blinded, randomized control trial comparing 2-chloroprocaine to bupivacaine for saddle block spinal anesthesia in anorectal procedures of short duration. Outcomes
were focused on the recovery phase with emphasis on
time to ambulation, time to first micturition, and time to
discharge.
Methods: Patients were enrolled and randomized to
receive either 1.0-1.3 ml of 3% 2-chloroprocaine MPF
or 1.0-1.2 ml of 0.75% bupivacaine at the anesthesia
provider’s discretion, without the addition of spinal
adjuncts. Exclusion criteria were contraindications to
spinal anesthesia, such as patient refusal, sepsis at the
site of injection, hypovolemia, coagulopathy, indeterminate neurologic disease and increased intracranial
pressure. A saddle anesthesia block was produced in
the seated position, then patients underwent an anorectal procedure of expected short duration (less than one
hour) in the jackknife position. Intraoperative sedation
and additional IV analgesia was supplemented at the
anesthesia provider’s discretion. Multiple data points
were collected during the intraoperative period including administration of sedatives, analgesics, vasoactive
medications, and fluids. The estimated blood loss and
adequacy of the spinal anesthetic were also noted.
PACU data points collected include time to ambulation and first micturition, and presence and treatment
of nausea, pain, and hemodynamic instability. Patients
were contacted the following day to report on any anesthesia related complications including symptoms of
Transient Neurologic Syndrome (TNS) or other neurologic sequelae, spinal headache, nausea/vomiting,
backache, and other adverse side affects or symptoms.
Patients also to reported a satisfaction score on a ten
point scale (1-10).
Results: After reviewing preliminary results on
16 patients, 8 who received bupivacaine, and 8who
received 2-chloroprocaine, time of admission to discharge from the PACU was entirely determined by
time to ambulation or time to first micturition. All
patients were required to ambulate prior to discharge,
however, not all patients were required to urinate (determined by case per case basis by surgeon). There
were no apparent differences in PACU data points
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NYSORA ABSTRACTS
collected between the two groups except for time to
ambulation and time to first micturition. For these reasons, a preliminary analysis of these two data points
were performed by the biostatistics department at our
institution (Table I).
Table I.
Drug
Average Time
Average Time
to Ambulation
to First Void
(min)
(min)
Bupivacaine
2-Chloroprocaine p-value
179.88±63.3
67.75±33.18
p=0.0011
196.6±93.6
136.75±90.7
p=0.22
Discussion: Our preliminary results show a significant reduction with 2-chloroprocaine in average time to
ambulation (difference of 112.87 minutes). There is also
a trend to a reduction with 2-chloroprocainein average
time to first micturition (average difference of 59.85 minutes). However statistical significance was not achieved
in this category because of the large variability in the
means (~90 minutes in each group). The study is likely
underpowered at this point to show a significant difference. Thus far, there has been one reported incidence of
TNS by a patient in the bupivacaine group, none in the
2-chloroprocaine group.
Conclusions: Multiple studies have shown the safety
and efficacy of 2-chloroprocaine for spinal anesthesia2.
Our data supplements these finding by demonstrating its
effectiveness in shortening PACU stay time as compared
to bupivacaine in anorectal procedures of short duration.
This decreases valuable PACU nursing requirements and
bed occupancy, patient and hospital cost requirements,
and patient inconvenience.
References
1. Yoos JR, Kopacz DJ. Spinal 2-chloroprocaine for surgery: an initial 10-month experience. Anesth Analg.
2005; 100: 553-8.
2. E. Goldblum and A. Atchabahlan. The use of 2-chloroprocaine for spinal anaesthesia. Acta Anaesthesiol Scand
2013; 57:545-552.
3. Casati A, Fanelli G, Danelli G, Berti M, Ghisi D, Brivio
M, Putzu M, Barbagallo A. Spinal anesthesia with lidocaine or preservative-free-2-chlorprocaine for outpatient
knee arthroscopy: a prospective, randomized, doubleblind comparison. Anesth Analg 2007; 104:959-64.
Dexmedetomidine improves supraclavicular brachial plexus block quality and duration of analgesia when used together with 0.5% ropivacaine:
single center randomized control trial
T. Halaszynski, J. Li
Yale University School of Medicine, Department of Anesthesiology,
USA
Introduction: Brachial plexus nerve blockade
has opioid sparing and analgesic benefits for upper extremity surgery (1). However, single injection
techniques are limited by pharmacological profile of
current long-acting local anesthetics (LA). Efforts
to prolong block duration (increase anesthetic dose,
continuous catheters) are limited by medication ther-
apeutic window and can present management challenges. Co-administration of adjuvants (epinephrine,
α2-agonists, steroids) as strategies to extend analgesia have been trialed. This study investigated value
of adding dexmedetomidine to ropivacaine during
placement of supraclavicular brachial plexus blockade (SCB) during upper extremity surgery.
Methods: Institutional review board approval/patient informed consent obtained. Study had no financial
conflict of interest. Sixty patients for upper extremity
surgery received a SCB block and randomly assigned
into 2 groups; Group I received 30 ml 0.5% ropivacaine and Group II received 75ug of dexmedetomedine mixed with 30 ml 0.5% ropivacaine. Sample size
was calculated to achieve a P value of 0.05. Following end points were measured: onset of sensory/motor blockade, duration of sensory/motor block, visual
analogue scale (VAS) pain scores, time to first request/
amount of rescue opioids, assessment of transition to
pre-block status, and side-effect profile (bradycardia,
hypotension nausea/vomiting).
Results: Table I shows Group II patients revealed
longer duration of sensory/motor blockade (shorter time
to sensory/motor block onset; not shown), prolonged
analgesia, lower opioid rescue requirements, and lower
VAS pain scores (Figure 1). Patients receiving dexmedetomidine during SCB expressed a slower, less abrupt
and gradual return to pre-block sensory level(s) compared to the more intense and moderate-to-severe painful return of pre-block sensory levels for patients from
Group I. All patients showed complete return to preblock sensory/motor levels and none revealed sensory/
motor dysfunction/deficit(s). No statistical difference in
side-effects observed (i.e. bradycardia, hypotension, nausea, vomiting).
Discussion: Mixing α2 agonists with LA could
have benefits during perineural administration (2,3)
and this study demonstrated efficacious SCB parameters without evidence of adverse events. Lack of Food
and Drug Administration approval of adjuvants for
perineural application may explain the few published
trials on this topic, however, improved understanding
of basic physiology and roles of targeted drug delivery has lead to re-evaluation of α2-agonists in pain
management.(4) Additional animal and clinical trials
are warranted to establish safety profiles and potential
side effects before widespread clinical use of perineural dexmedetomidine.
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NYSORA ABSTRACTS
References
1. Fredrickson M, et al.. Postoperative analgesia for shoulder surgery: a critical appraisal and review of current
techniques. Anaesthesia 2010;65:608-24.
2. McCartney C, et al.. Should we add clonidine to local
anesthetic for peripheral nerve blockade? A qualitative
systematic review of the literature. Reg Anesth Pain Med.
2007; 32:330-8.
3. Popping D, et al.. Clonidine as an adjuvant to local
anesthetics for peripheral nerve and plexus blocks: a
meta-analysis of randomized trials. Anesthesiology.
2009;111:406-15.
4. Abdallah F, et al.. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block:
a systematic review and meta-analysis. Br J Anaesth
2013;110:915-25.
Implantable drug delivery systems with morphine
in fibromyalgia: a case report
Y. M. Ju, H. S. Moon
Department of Anesthesiology and Pain Medicine, College of
Medicine, The Catholic University of Korea, Seoul, Korea
There is no gold standard treatment for fibromyalgia
syndrome (FMS).If other treatments fail, opioids including morphine should be considered.
Our case demonstrates that an implantable drug delivery system (IDDS) with morphine is a potential treatment
option for refractory fibromyalgia patients.
Case report: A 44-year-old woman was diagnosed
with FMS 3 years ago. She had been treated with pregabalin and milnacipran. However, side effects had forced
her to abandon these treatments. She had a score of 8 out
of 10 on the numeric rating scale (NRS) for widespread
pain. The fibromyalgia impact questionnaire (FIQ) score
was 79 points. Moreover, the patient complained of sleep
disturbance; fatigue; and anxiety. Only opioids were
able to reduce her pain. However, the effectiveness of
opioids gradually decreased because of opioid tolerance.
Although the opioid dose was increased to an equivalent
morphine dose of 305 mg/day orally, the pain relief was
insufficient, and side effects such as constipation and
nausea were aggravated. An epidural morphine infusion
was carried out to test the intrathecal morphine pump
implant. At morphine dose was 20 mg/day, the pain intensity decreased from 8 to 4 out of 10 on the NRS, and
side effects were not seen during the trial period. We
implanted an intrathecal drug delivery system with the
catheter tip positioned at the T10 level. Over 3months,the
dosage of morphine sulfate infusion was increased, till it
reached 2.7 mg/day and the patient’s NRS score became
3 or 4. Sleep disturbance also decreased. The FIQ score
decreased from 79 to 47. Breakthrough pain, which occurred on average twice a day, was controlled with 600
µg transmucosal fentanyl. Medication for background
pain was unnecessary.
Discussion: The FMS is a chronic pain disease characterized by widespread pain, fatigue, sleep disturbance,
depressive moods, and cognitive impairment. The goal
of FMS treatment is usually symptom improvement and
functional maintenance. It is well known that there is
a three-fold elevation of substance P (SP), which is an
excitatory neurotransmitter in the cerebrospinal fluid of
FMS patients. An experimental animal study showed that
an intrathecal opioid infusion was more effective for suppressing the release of SP than a subcutaneous opioid injection. We expected that an IDDS in FMS would inhibit
the central sensitization of pain and would have fewer
side effects than systemic opioid treatment.
Conclusions: Fibromyalgia patients have chronic
pain, which is difficult to treat. lf other treatments fail or
are not tolerated, an IDDS with morphine sulfate should
be considered for those who had a successful intrathecal
or epidural opioid trial.
References
1. An update on pharmacotherapy for the treatment of fibromyalgia. Calandre EP, Rico-Vilademoros F, Slim M.
Expert Opinion Pharmacother. 2015.
2. Inhibition by spinal mu- and delta-opioid agonists of
afferentevoked substance P reelase. Kondo l, Marvizon
JC, Song B, Salgado F, Codeluppi S, Hua XY, Yaksh TL.
J Neurosci. 2005.
Safe and effective analgesia via continuous proximal intercostalblock (picb) for trans apical
tavr
S. Kapoor, K. Viassakov
Dept. Of Anesthesiology, Brigham and Womens Hospital, Boston, MA,
USA
Figure 1.—The position of the intrathecal catheter tip (at
T10 level).
48
Objective: Continuous proximal intercostal nerve
block (PICB) should be an effective and low risk approach to analgesia in anticoagulated patients, with the
potential to aid in fast-tracking, decrease mechanical
ventilation duration and afford the advantages of analgesia provided by epidural and traditional paravertebral
blocks.
Methods: Two patients undergoing Transapical
TAVR received continuous analgesia via proximal intercostal blockade.
A linear high-frequency ultrasound probe (Sonosite
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NYSORA ABSTRACTS
Fentanyl on POD#2. Patient had a VAS score of 0-2 on
POD# 1,2 and 3.Dermatomal spread was difficult to assess in this patient. Both patients had an uncomplicated
recovery. There were no complications from the proximal intercostal nerve catheters.
Conclusions: TA-TAVR is perfarmed on the sickest
patients who do not qualify for traditional AVR. Both our
patients remained hemodynamically stable with boluses
of Ropivacaine, had 3 to 4 levels of dermatomal spread,
and required minimal narcotics. Our case study demonstrates that PICB may be a feasible technique for pair
management in such patients. The more medial approach
to the intercostal space may cause spread of the local anesthetic to the paravertebral space and it may be safer as
only intercostal muscles are pierced. A formal prospective investigation of PICB in thoracotomy/patients is
warranted.
References
Figure 1.
M-Turbo, 8-12 MHZ) was placed parasagittally, parallel to the Spine. After identifying the correct intercostal
space, the US probe was moved medially to identify
the transverse processes. The probe was then translated
laterally,1 cm or more from the transverse process’s lateral edges, till the best view of the ribs, the pleura and
the internal intercostal membrane was obtained. A 18 G
Tuohy needle, 10 cm (Pajunk) was inserted in-plane to
approximately 2 mm superficial to the internal intercostal
membrane/parietal pleura (hyperechoic line) and injection of local anesthetic could produce depression of that
structure.
Case 1.—85 yrs/F with severe aortic stenosis, a porcelain ascending aorta and multiple co morbidities, presented
for a TA-TAVR. After informed consent, using the PICB
technique, a left intercostal catheter was placed at the T5
intercostal space and advanced 8 cms beyond the needle
lip. 20 ml of 0.5% Ropivacaine was injected as a bolus. 2
hours after block placement, patient received 12,000 units
of i.v. Heparin followed by Protamine reversal. The patient
was extubated in the OR. After repeating another bolus,
the catheter was removed on POD#0, 2 hours before the
scheduled loading dose of 300 mg Plavix.
Case 2.—68yr/F with severe aortic stenosis, multiple
co morbidities including severe COPD, right vocal cord
paresis and subglottic stenosis presented for TA-TAVR.
Using the PICB technique, a left sided intercostal was
inserted to a depth of 4 cms beyond the needle tip and
bloused with 20cc of 0.5% Ropivacaine. 4 hours later,
6000 units IV Heparin was injected and reversed with
Protamine. The patient was extubated the next morning due to concern for her difficulty airway. Plavix
was started on POD#0. The Blupivacaine infusion was
maintained for 3 days and the intercostal catheter was
removed on POD#3.
Results:
Case 1.—The patient received 150 mcg of Fentanyl
intraoperatively. VAS scores varied between 0 to 3 on
POD#0. Dermatomal spread was assessed in the ICU
from T4 to T7.She needed additional 0.4 mg iv Dilaudid
on POD #0.
Case 2.—The patient received 200 mcg IV Fertanyl
intraoperatively, 50 mcg Fentanyl on POD#1 and 75 mcg
1. Ultrasound guided intercostal approach to thoracic PVB.
Shibata, Yasuyuki; Anesthesia & Analgesia. 109(3) 996997, Sept 2009
2. In-Plane Ultrasound-Guided Thoracic Paravertebral
Block: A Preliminary Report of 36 Cases With Radiologic Confirmation of Catheter Position. Renes, Steven;
RAPM. 35(2):212-216, March/April 2010.
3. Epidural analgesia for cardiac surgery. Cochrane Database Syst Rev.2013.Svircevic V, Passier MM.
Transient Cortical Blindness and Posterior Reversible Encephalopathy Syndrome (PRES) due to
Preeclampsia in the Antepartum in a Parturient
who underwent Cesarean-Section with Combined
Spinal-Epidural
P. Patel, M. Johnson, S. Mellender, S. Cohen
Department of Anesthesiology, Robert Wood Johnson Medical
School – Rutgers, The State University of New Jersey, New
Brunswick, New Jersey, USA
Introduction: Posterior Reversible Encephalopathy
Syndrome (PRES) typically presents w/ nonspecific clinical manifestations including headaches, seizures, vomiting, mental status changes, loss of consciousness and
visual abnormalities.1
Methods: While visual abnormalities commonly include
blurred vision, hemianopia and visual neglect reversible cortical blindness is very rare in PRES.2, 3 The most common
cause of PRES is pre-eclampsia or eclampsia 3 On neuroimaging, PRES is characterized by bilateral posterior cerebral vasogenic edema, especially in the parietal and occipital
lobes.4-5
Results: A 33 y/o F (G2P0) at 32 weeks gestation
presents at RWJUH ED d/t bilateral vision loss for
12 hours and headache associated w/ nausea, but not
vomiting. The patient is alert, awake and in severe distress as she is only able to see “light and movements”.
At presentation in ED, vital signs are VVNL except
BP:167/108. The patient was evaluated on the previous
day by her OB/GYN where she was found to be hypertensive and treated w/ labetalol. She has since taken 1
dose, and feels that her present symptoms are secondary to medication. Fetal movements were last felt 24
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NYSORA ABSTRACTS
3.
4.
5.
Axial view - MRI w/o contrast
Sagittal view - MRI w/o contrast
Figure 1.—Post-operative brain MRI w/o contrast shows
extensive posterior circulation-predominant bilateral supratentorial and infratentorial signal abnormalities including marked involvement of the brainstem as well as
acute scattered small biparietal and bioccipital infarcts,
most compatible with posterior reversible encephalopathy syndrome (PRES).
hours ago. Pt receives labetalol 10 mg and magnesium
sulfate 2 g IV in the ED upon arrival. Following admission to L&D, a biophysical profile is performed (2/10)
w/ a max. vertical pocket of 2.1 cm and BP 1s remeasured at 190/112.Patient is taken to OR for immediate
C-section d/t NRFHR and severe preeclampsia. Spinal
anesthesia is administered during the peri-operative
period. Following delivery of a healthy fetus, the patient notes marked visual improvement and reports
being able to see shapes. Continuous Mg infusion is
administered for seizure prophylaxis. Post-operatively,
patient shows rapid 24-hour improvement in vision and
cognition with complete resolution of all symptoms at
discharge 4 days post-op.
Discussion: Primary antepartum goals in the anesthetic management of severely preeclamptic patients
exhibiting signs of PRES includes achieving hemodynamic stability (optimization of maternal blood
pressure, cardiac output and uteroplacental perfusion), prevention of seizure and stroke and facilitating
prompt fetal delivery. Historically, there has been a
pervasive belief that spinal anesthesia in patients with
severe preeclampsia causes severe hypotension and
decreased uteroplacental perfusion, therefore avoiding its use.6 However, studies have concluded that although severely preeclamptic patients did experience
more severe hypotension after spinal anesthesia than
after epidural anesthesia, that difference was unlikely
to be clinically significant.7 No studies have demonstrated clinically significant differences in outcomes
when spinal anesthesia is compared with epidural or
general anesthesia. In fact, riskbenefit considerations
strongly favor neuraxial techniques over general anesthesia for cesarean delivery in the setting of severe
preeclampsia as long as neuraxial anesthesia is not
contraindicated.6
References
1. Hinchey J, Chaves C, Appignani B, Breen J, Pao L,
Wang A, et al.. A reversible posterior leukoencephatolopathy syndrome. New England Journal of Medicine.
1996;334(8):494-500.
2. Llovera L, Roit Z, Johnson A, Sherman L. Cortical blind-
50
6.
7.
ness, a rare complication of pre-eclampsia. The Journal
of Emergency Medicine. 2005;29(3):295-297.
Cunningham FG, Fernandez CO, Hernandez C. Blindness associated with preeclampsia and eclampsia. Arn J
Obstet Gynecol 1995;172-1291.
Lirnan TG, Bohner G, Hauschmann PU, Endres M, Siebert E. The clinical and radiological spectrum of posterior
reversible encephalopathy syndrome: The retrospective
Berlin PRES Study. Journal Neurology. 2012;259(1):155164.
Hugonnet E, Da ID, Boby H, Claise B, Petitcolin V, Lannareix V, et al.. Posterior reversible encephalopathy syndrome (PRES): Features on CT and MR imaging. Diagnostic and Interventional Imaging. 2013;94:45-52.
Henke V.G., Baleman B.T., Leffert L.R. Spinal anesthesia in severe preeclampsia. Anesthesia and Analgesia.
2013;117(3):686-693.
Visalyaputra S, Rodanant O, Somboonviboon W, Tantivitayatan K, Thienthong S, Saengchote W. Spinal versus
epidural anesthesia for cesarean delivery in severe preeclampsia: a prospective randomized, multicenter study.
Anesth Analg. 2005; 101:862-8.
Safely Administering Neuraxial Anesthesia in a
Patient with Phosphorylase B Kinase (PBK) and
Mitochondrial Complex I (MCI) deficiencies
P. Patel, B. Raffel, S. Mellender, S. Cohen
School - Rutgers, The State University of New Jersey, New
Brunswick, New Jersey, USA
Introduction: Phosphorylase b kinase (PBK) is required for the activation of phosphorylase by converting the less enzymatically-active phosphorylase b to the
more active phosphorylase with a resulting increase in
glycogenolysis. PBK deficiency is genetically heterogeneous; both autosomal recessive and x-linked forms
exist.1 While most forms of PBK deficiency are mild
(asymptomatic), clinical signs can include myopathy,
hepatomegaly and cirrhosis.1 Mitochondrial Complex I
Deficiency (NADH-Quinone oxidoreductase deficiency), is a disorder of Complex I in the electron transport
chain affecting oxidative phosphorylation. The majority of MCI deficiencies are autosomal recessive but instances of maternal inheritance exist. It is a progressive
neuro-degenerative disorder that can involve multiple
organ systems with varying symptoms.2 Two forms of
MCI deficiency include fatal infantile multi-system
disorder and mitochondrial encephalmyopathy, both of
which are highly progressive. A 3rd form is myopathic
and is characterized by muscle weakness and intolerance.2
Case description: 27 y/o F (G2P1) at 35 weeks
gestation presents in preterm labor w/ previous history of uncomplicated C-section. PMH is significant
for PBK and MCI deficiencies. PSH includes multiple endoscopies, JTube/G-Tube placement and Nissen
fundoplication. Patient has previously experienced
adverse effects to metoclopramide (neurologic regression and tardive dyskinesia). The patient cannot recall whether she had an epidural or spinal anesthesia
during previous C-section, however she states that she
has had trouble awakening and prolonged sedation
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NYSORA ABSTRACTS
from general anesthesia during surgical procedures.
Patient’s FH is significant for maternal PBK and MCI
deficiencies. A combined spinal epidural (CSE) was
used during C-section. Patient was hydrated with an
IV solution including dextrose. 1.6 cc of 0.75% Marcaine (12 mg), 15 mcg fentanyl with epinephrine was
injected intrathecally without complication. A T-6
level was achieved with spinal anesthesia. Safe anesthetic care without complication was provided to the
patient using CSE while being able to avoid administering any drugs that may have interacted with her
biochemical deficiencies.
Discussion: Patients with PBK deficiency are at
risk for hypoglycemia and should be treated perioperatively with glucose. Patient s who are hypotonic should have neuromuscular blocking agents
titrated to desired muscle paralysis and may require
postoperative mechanical ventilation. The effect of
MCI deficiency varies based on the class of anesthetic. Patients with mitochondrial disease are not at
increased risk of malignant hyperthermia but volatile gases do inhibit mitochondrial complex I. Increased sensitivity to volatile anesthetics should be
anticipated, including both a reduction of MAC and
also enhanced vasodilation and myocardial depression.3, 4 Propofol inhibits mitochondrial acylcarnitine
transferase and complex III. Single induction dose of
propofol is safe (except for those on ketogenic diets) but propofol infusions are not tolerated, leading
to propofol infusion syndrome.3, 4 Dexmedetomidine
and remifentanil have been used as TIVA for patients
with mitochondrial disease. Ketamine, Etomidate,
and Barbiturates should all be avoided because they
all inhibit complex I and mitochondrial respiration.5
Amongst opioids, Remifentanil has no effect on the
mitochondria and is preferred over fentanyl [3, 4].
Morphine affects mitochondrial membrane potential
and should be avoided.6 Local anesthetics all inhibit
acylcarnitine transferase and mildly inhibit complex
I. Lidocaine is the preferred local anesthetic over
ropivacaine and bupivacaine, though all three mildly
inhibit ATP synthesis.7
References
1. Goldstein, J., et al. Phosphorylase Kinase Deficiency,
in GeneReviews(R), R.A. Pagon, et al., Editors . 1993,
University of Washington, Seattle: Seattle WA.
2. Fassone E and S. Rahman. Complex I deficiency: clinical features, biochemistry and molecular genetics. J
Med Genet, 2012. 49(9): 578-90.
3. Ellinas H. and E.A. Frost, Mitochondrial disorders-a
review of anesthetic considerations. Middle East J Anaesthesiol, 2011. 21(2):235-42.
4. Haas R.H. et al., Mitochondrial disease: a practical approach for primary care physicians. Pediatrics, 2007.
120(6): 1326-33.
5. Anderson C.M., et al. Barbiturates induce mitochondrial depolarization and potentiate excitotoxic neuronal death. J Neurosurg, 2002. 22(21):9203-9.
6. Mastronicola D, et al. Morphine but not fentanyl and
methadone affects mitochondrial membrane potential by inducing nitric oxide release in glioma cells.
Cell Moll Life Sci, 2004. 61(23):2991-7.
7. Weinberg G.L., et al. Bupivacaine inhibits acylcamitine exchange in cardiac mitochondria. Anesthesiology, 2000. 92(2):523-8.
Treatment of Post-Dural Puncture Headache
(PDPH) with Sphenopalatine Ganglion Block
(SPGB) in a Pediatric Patient w/ Cervical Syringohydromyelia Presenting with Acute Altered
Mental Status (AMS) s/p Vaccination Series vs Tic
Bourne Infection
P. Patel, S. Shah, R. Jongco, S. Mellender, S. Cohen
School-Rutgers, The State University of New Jersey, New Brunswick,
New Jersey. USA
Introduction: PDPH is a debilitating complication of
lumbar puncture (LP) characterized by a vicious cycle of
immobility, weakness and depression.1 Numerous treatments have been applied for the proper management of
PDPH but their safety and efficacy still need improvement.
Case description: A 17 y/o F w/ PMHx/o PCOD &
IBS was admitted to PICU w/ AMS and h/o of clonic
movements in UE/LE’s. Two days prior to presentation,
the patient complained of B/L extremity weakness while
at work. Later that day, symptoms progressed as she developed confusion and began experiencing spontaneous,
clonic movements in all extremities. Patient denied incontinence or post-ictal period. Patient’s father took her
to an ED where they suspected dystonic reaction and administered diphenhydramine and then lorazepam (1mg)
which broke the movements. Labs were normal and urine
toxicology was negative. The next day, patient was seen
by pediatric neurology and had normal EEG. They determined that the etiology was unlikely to be neurological in
origin and recommended f/u w/ ID. The evening prior to
admission, the patient’s clonic movements persisted and
she began experiencing new onset visual hallucinations.
In addition, the patient’s mother also found two ticks
(embedded, not engorged) on the patient’s posterior knee
and abdomen just prior to presentation in our ED. The
patient had been hiking earlier in the week. On PE, no
fever or rashes were noted. No recent travel history. The
patient received Yellow Fever vaccine (4 weeks prior),
meningococcal conjugate booster (Menactra) and hepatitis A booster (10 days prior) and typhoid vaccine (PO
5 and 3 days prior). Patient reported feeling feverish for
3 days following her booster vaccines. LP, head CT w/o
contrast, brain MRI w/ & w/o contrast and lumbar spine
Axial view
Sagittal view
Figure 1.—Cervical and thoracic spine MRI w/ & w/o
contrast revealed syringohydromella of the cervical and
upper thoracic spinal cord w/o associated enhancement
or intraspinal lesion.
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NYSORA ABSTRACTS
MRI w/ & w/o contrast were negative. During her stay in
the PICU, patient developed a postural frontal headache
suspected to be PDPH secondary to LP. Headache was
effectively treated w/ SPGB. Cervical and thoracic spine
MRI w/ & w/o contrast revealed syringohydromyeila of
the cervical and upper thoracic spinal cord w/o associated enhancement or intraspinal lesion.
Discussion: Therapeutic epidural blood patch
(EBP) is currently the standard of care for post-LP
cephalagia with a success rate ranging from 68% 90%.2 Epidural blood patches are known to be associated with negative sequelae, including subdural and
epidural hematoma, needle trauma, back pain, meningitis, and a possible second dural puncture.3, 4 Thus,
we are advocating the use of sphenopalatine ganglion
block (SPGB) as a first-line treatment for PDPHs.
SPGB is a noninvasive anesthetic intervention with
minimal adverse effects and high efficacy.5, 6 lt can
be performed by inserting a cottontipped applicator
saturated with 5% water-soluble lidocaine ointment
through each nares bilaterally and positioning the end
of the applicator tip just superior to the middle turbinate and anterior to the pterygopalatine fossa and
sphenopalatine ganglion for 1O minutes with the patient in supine position. Acute stimulation of the SPG
with good anatomical and physiological placement
leads to rapid termination of severe headache.7, 8
References
1. Loesar E.A., Hill G.E., Bennett G.M., Saderbarg J.H.,
Time vs. success rate for epidural blood patch. Anesthesiology, 1978;49(2):147-8.
2. Heyman H.J., Salem, M.R., Early blood patch recommended. Anesth Analg. 1987;66(3):284.
3. Takkok, I.H., Carter D.A., Brinker R. Spinal subdural
haematoma as a complication of immediate epidural
patch. Can J Anaesth. 1996;43(3):306-9.
4. Davies J.M., et al.. Subdural haematoma after dural
puncture headache treated by epidural blood patch. Br J
Anaesth. 2001;86(5):720-3.
5. Cohen S., et al.. Sphenopalatine ganglion block for postdural puncture headache. Anaesthesia. 2009. 64(5):5745.
6. Cohen S, et al.. Sphenopalatine ganglion block: a safer
alternative to epidural blood patch for postdural puncture
headache. Reg Anaesth Pain Med. 2014;39(6):563.
7. Ansarinia M., Rezai A., Tepper S.J., Steiner C.P., Stump
J.,Stanton-Hicks M., Machado A., Narouze S. Electrical
stimulation of sphenopalatine ganglion for acute treatment of cluster headaches. Headache 2010;50(7):116474.
8. Tepper S.J., Rezai A., Narouze S., Steiner C., Mohajer
P., Ansarinia M. Acute treatment of intractable migraine
with sphenopalatine ganglion electrical stimulation.
Headache. 2009;49(7):983-9.
Conventional vs Endoscopic Radiofrequency Ablation for Treatment of Lumbar Facet Syndrome
N. Prabhu, U. Parvez
St. Joseph’s Regional Medical Center, Department of Anesthesiology
Introduction: Chronic back pain is a common health
issue and has a negative impact on the quality of life.
The lower back is a common site of back pain. Causes
52
Figure 1.—Spinal Facet Joint (3) (http://www.joint-pain
solutions.com/facet-jointpain.html).
of lower back pain include sprains, herniated discs, facet
joint arthritis, intervertebral disc degeneration, spinal stenosis, and trauma (1). Lower back pain persisting for >12
weeks is defined as chronic (2). Many structures in the
lower back contribute to the generation of pain including
facet joints. Inflammation/injury to lumbar facet joints
can lead to development of lumbar facet syndrome.
Objective: To present a case of lumbar facet syndrome that was treated with percutaneous radiofrequency
ablation (RFA) and endoscopic RFA and to compare effectiveness of both techniques on long-term pain relief.
Case report: 69 year old female with history of lower
back pain since 2007. History and physical examination
revealed bilateral lumbar facet joints as the source of
pain. The patient tried several therapeutic interventions
including medical management, physical therapy, medial
branch blocks, previous RFA treatment, lumbar epidural
and sacroiliac joint steroid injections all resulting with
recurrence of pain. Currently her back pain has resolved
for >21 months, after undergoing medial branch conventional percutaneous RFA at L3, L4, and L5 levels on the
left side and endoscopic RFA at L3, L4, and L5 levels on
the right side in 2013.
Results: There was insignificant difference in pain relief between conventional and endoscopic RFA. The patient had complete pain relief wiht conventional RFA for
15 months after which she experienced occasional mild
spasms on left lumbar side, that was relieved with low
dose cyclobenzaprine. Patient has been symptom free for
>21 months on the right lumbar side. Her pain scores on
the Visual Analog Scale have been ‘0’ at all follow-up
visits for this duration.
Discussion: After experiencing relief with two consecutive medial branch blocks, facet pain can be better
relieved with radiofrequency ablation (RFA), which
involves delivering heat to create lesions along medial
branch nerves. Traditionally, RFA has been performed
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NYSORA ABSTRACTS
solely under fluoroscopic guidance. Endoscopic guided RFA is a newer method of RFA. It possesses the
advantage of direct visualization of affected nerves
in comparison to the fluoroscopic guided technique.
Disadvantages of endoscopic guidance include longer
duration of procedure, lengthened recovery time, prolonged anesthesia, increased cost, and potential cosmetic scarring.
Conclusions: Both conventional and endoscopic
RFA have similar effects in long-term pain relief. The
patient has had pain relief for >21 months. Comparing
the advantages and disadvantages of endoscopic versus
conventional percutaneous fluoroscopic guided RFA and
based on the comparable outcomes, conventional fluoroscopic medial branch RFA is a preferable technique.
References
1. NINDS Back Pain Information Page. (n d.). Retrieved
August 2, 2015.
2. Chronic Pain: Symptoms, Diagnosis, & Treatment | NIH
MedlinePlus the Magazine.(Spring 2011 Issue: Volume 6
Number 1 Page5-6). Retrieved August 2, 2015.
3. Facet Joint Pain, Symptoms and treatment options for
facet pain.(n.d.). Retrieved August 2,2015.
MINERVA MEDICA
53
Author’s Index
A
Abdul Salam A., 43.
Abdullah H. R., 33.
Abrahams M., 29.
Afshan G., 43.
Agrawal R., 27.
Ahmed N., 46.
Akhideno I., 12.
Akinmola A., 25.
Ali L., 46.
Anne L., 35.
Anyaegbuna T., 46.
B
Baens D., 34.
Baete S., 28.
Baghaee Vajie M., 20.
Baik J. S., 44.
Bailey M., 10.
Bansal V., 45.
Bartels H., 9.
Basu A., 6.
Basu S., 6.
Baxendale L., 30.
Bellemans J., 34.
Beran M., 33.
Beric P., 20.
Beye M., 28.
Bhardwaj S., 27.
Bhattarai B., 21, 29.
Bhatti T., 30.
Bicerer E., 37.
Boons J., 27, 28, 35.
Bordones J., 16.
Borglund Hemph A., 18.
Boughariou S., 5, 8, 13, 14, 17,
18.
Boussofara M., 5, 8, 13, 14, 17,
18.
Bouts C., 28, 35, 36.
Browne I., 9.
Bunjaku D., 34.
Burgert J., 34, 37, 38.
Dehghan H., 20.
Dere K., 37.
Desmet M., 24.
Desouza K., 32.
Desticker C., 34.
Dewaele S., 14, 33, 36.
Du Toit L., 31.
Duangngoen P., 24.
Duerinckx J., 27, 38.
Dyer R., 31.
Dylst D., 36, 38.
Imarengiaye C., 31, 32.
In C. B., 22.
Ipcioglu O. M., 37.
Iqbal R., 19.
Ittichaikulthol W., 8, 24.
J
J V., 9.
Jain D., 19.
Jakobsson J., 18.
Jamgbadi S. S., 39.
Jamroz T., 3.
Jeon Y. T., 22.
Jha A. K., 6.
Jiarpinitnun J., 8, 24.
John M., 15.
Johnson A., 34, 37, 38.
Johnson M., 9, 49.
Jongco R., 51.
Ju Y. M., 48.
Ju Z., 26.
E
Edomwonyi N., 31, 32.
Ekumankama O., 39.
El Ghoul M., 4.
Elumelu A. V., 25, 39.
Esprit S., 35.
Ewila H., 12.
F
K
Falter F., 3, 15, 36.
Fanapour P., 46.
Faria-Silva R., 12, 25.
Ferreira C., 12, 25.
Forfori F., 31.
Kapoor S., 23, 48.
Kasireddi V. S., 16.
Keane D., 9.
Keleman N., 20.
Keleman S., 20.
Kelmendi F., 34.
Khanna P., 9, 19.
Khatiwada S., 21.
Kholdebarin A., 20.
Kim B. J., 28.
Kim E. S., 44.
Kim H. K., 44.
Kindawi A., 12.
Kinkpe C., 28.
Kirby C., 11.
Klai F., 8, 13, 14, 17, 18.
Knezevic N., 27, 38.
Koduri R. P., 11.
Koirala A., 21.
Komonhirun R., 8.
Kundu T., 5, 10.
G
Garcia-Blanco J., 34, 37, 38.
Gargani L., 31.
Ghani M., 46.
Ghimire A., 29.
Ghodraty M., 20.
Giraud K., 15.
Giraudini M., 31.
Giri S., 30.
Golebiewski M., 28, 35.
Golic D., 20.
Guven B. B., 24.
C
Cansiz K. H., 24.
Carby M., 23.
Cecconi M., 19.
Chandran R., 16, 21, 32.
Chang J., 22.
Chatterjee B., 6.
Chattopadhyay I., 3, 7.
Chen K., 17.
Chua I., 14.
Cohen S., 49, 50, 51.
Corten K., 34.
Coulson T., 10, 36.
Crosby D., 9.
H
L
Haddad F., 46.
Hadzic A., 35, 38.
Halaszynski T., 47.
Hasanbegovic I., 38.
Hei F., 26.
Heylen M., 35.
Higino A., 12.
Hofmeyr R., 15, 31.
Hong B., 26.
Hsu C., 17.
D
I
Dabbous A., 4.
Dagli G., 24, 37.
Ibrahim M., 4.
Imadiyi B., 12.
Lai J. B., 16.
Langer K. A., 11.
Lee J. U., 28.
Lee J. Y., 28.
Lee S. Y., 28.
Lee S., 22.
Lees N., 23.
Leng Y., 15.
Leong R., 21.
Leunen I., 34, 35, 36, 38.
Li J., 47.
Liao K. H., 17.
Liew G. H. C., 33.
Lim C. S., 28.
Lim M. J., 15.
Lim Y. C., 33.
Lin G. Y., 33.
MINERVA MEDICA
Liou J., 39.
Lombard C., 31.
Low E., 20.
Luis S., 3.
M
Mah C. L., 33.
Maheshwari D., 43.
Mandava V., 30.
Marini E., 31.
Massoudi R., 13.
Mehdi H., 5, 8, 13, 14, 17, 18.
Mehta M., 27.
Mellender S., 49, 50, 51.
Melo J., 25.
Miles L., 36.
Milosevic D., 20.
Milosevic V., 20.
Mir F., 19.
Missant C., 24.
Mitchell J., 23.
Moon H. S., 48.
Morina A., 34.
Morina Q., 34.
Mullins C., 9.
N
Neiseville N., 19.
Ng M., 33.
Ng W. Y., 33.
Nguyen L., 4, 18.
Nithiyananthan M., 32.
Nouraie R., 19.
Novak –Jankovic V., 36.
O
Ochukpue C., 31, 32.
Ode B., 25.
Okojie N., 31.
Omar A. S., 12.
Ooi E., 22, 33.
Oti C., 35.
Ozdemirkan I., 24.
Ozkan S., 24, 37.
P
Pan K., 22.
Pandey C. K., 23, 27.
Panganiban David X., 32.
Park S. I., 28.
Parvez U., 52.
Patel A., 19.
Patel J., 27.
Patel P., 49, 50, 51.
Paver-Erzen V., 36.
Peeters E., 27.
Pilcher D., 10.
Pimentel M., 12.
Pokharel K., 21.
Poon A., 11.
Poon K., 17.
55
AUTHOR’S INDEX
Pournajafian A., 20.
Prabhu N., 52.
Prakash K., 27.
R
Raffel B., 50.
Ramadorai A., 16.
Ramakrishna G., 27.
Raseta N., 20.
Razzaq N., 15.
Reid C., 10.
Resende F., 12.
Ritter A., 26.
Rocha W., 12, 25.
Rokhtabnak F., 20.
S
Salawu M. M., 25.
Salim M., 13.
Sam V. B., 27.
Sara T., 13.
Sarfraz A., 43.
Sarridou D., 23.
Schockaert B., 24.
56
Schramme D., 14.
Schulz-Stübner S., 3.
Sen H., 24.
Shah S., 46, 51.
Shanbhag S., 13.
Sheth V., 26.
Shih K. C., 22.
Shin Y. S., 28.
Sia A. T., 15.
Singh S. K., 30.
Sng B. L., 15.
Stott M., 23.
Subedi A., 21.
Sudarsanan S., 12.
T
Tan K. K., 15.
Tandon M., 23, 27.
Tay Y. C., 29.
Teh E., 11.
Thamjamrassri T., 24.
Tildsley P., 15.
Ting C., 39.
Tomanic B., 20.
Traore M., 28.
Truong A., 4, 18.
Truong D., 4, 18.
Tsou M., 39.
Tufekci H., 37.
Tuijp S., 33.
W
Upadya P., 5, 10.
Wakelam O., 11.
Wang C., 26.
Wierinckx J., 36.
Witvrouw R., 33, 35.
Woolley J., 23.
Wroe V., 23.
Wu C., 17.
V
X
Van Boxstael S., 33, 36, 38.
Van Dyk D., 31.
Van Hoestenberghe M., 14.
Van Melkebeek J., 36.
Van Poucke S., 33.
Vandepitte C., 27, 33, 34, 35,
36, 38.
Vanderlaenen M., 14.
Vanelderen P., 33, 35, 38.
Vaz De Melo J. A., 12.
Viassakov K., 48.
Vinhal M., 12.
Visan A., 34.
Voje M., 36.
Vujanovic V., 20.
X C., 20.
Xu D., 34.
U
MINERVA MEDICA
Y
Yelamati K., 30.
Yoon H. S., 28.
Yu J., 26.
Yu X. J., 22.
Z
Zakhama S., 8, 13, 14, 17, 18.
Vol. 107 - 2016