Episode 172: A Pregnant Patient with Congenital Heart Disease

In this 172nd episode I welcome a panel of experts to discuss the management of a pregnant patient with congenital heart disease. Drs. Hofkamp, Vaught and Meng join me to discuss the preoperative evaluation, obstetric management, and postoperative care.

Episode 171: Anesthetic Management of Ruptured Cerebral Aneurysm with Dave Mintz

In this 171st episode, a follow up to episode 113, I welcome Dr. Mintz back to the show to discuss anesthetic management for cerebral aneurysm surgery.

References:

Chapter 13 Anesthetic management of cerebral aneurysm surgery in Cottrell and Young, Neuroanesthesia

http://www.joacp.org/article.asp?issn=0970-9185;year=2014;volume=30;issue=3;spage=328;epage=337;aulast=Kundra

The Guns of August: https://www.amazon.com/Guns-August-Pulitzer-Prize-Winning-Outbreak/dp/0345476093

Cognitive Aid website: www.rnsascar.com

Episode 169: PPE and Modified Difficult Airway Algorithm for COVID

In this episode I introduce Dr. Christina Miller’s video, linked below, that goes through PPE considerations including how to safely don and doff, and suggestions for how to handle a difficult airway in COVID patients.

Video: https://drive.google.com/file/d/1AFYIouqGVLRlstU3xXSOJTHbtorWvQ7L/view

Episode 168: COVID in Pregnancy with Dr. Nixon

In this 168th episode I welcome Dr. Heather Nixon to the show to discuss what is being done for pregnant women and women in labor who have or are suspected to have COVID-19.

The COVID book for kids by Taylor Purvis: https://playatrickonthecoronas.weebly.com/

Link for Anesthesia Toolbox daily online learning session: https://www.anesthesiatoolbox.com/docs/DOC-5178

References:

https://s3.amazonaws.com/cdn.smfm.org/media/2277/SMFM-SOAP_COVID_LD_Considerations_3-27-20_(final)_PDF.pdf

SOAP website: https://soap.org/

Episode 167: COVID Clinical Care Update

In this 167th episode I review the most recent changes that we’ve made to our protocols for caring for COVID patients and share a fantastic one page summary sheet that 3 of our ICU fellows put together. Huge thanks to Drs. Navarette, Herekar and Baronos for their work on this. It is available for download below. References are on the second page of the attachment.

Episode 166: COVID Airway Management with Aliaksei Pustavoitau

In this 166th episode I welcome Dr. Aliaksei Pustavoitau to the show to discuss management of the hypoxemia COVID-19 patient including initial triage, escalating support, endotracheal intubation, and ventilator management.

References:

Episode 165: COVID with Drs. Scott, Cereda and Nacoti

In this 165th episode I welcome Drs. Scott and Cereda from University of Pennsylvania and Dr. Nacoti from Italy to talk about COVID-19, what it is, what we know about it, what it’s like on the ground in Italy right now, and what we can learn from their experience to try to prevent it from happening here.

References:

 Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA. doi:10.1001/jama.2020.4031 

Episode 164: Keywords part 9: Fentanyl and Breathing Circuits

In this 164th episode I welcome back Dr. Gillian Isaac to do another ABA keywords episode. We discuss fentanyl and breathing systems (Mapleson and Circle systems).

Great info from Aaron Sandock:

The toxicity was reported in rats and research was published in the early-mid 90’s. 

Gonsowski, C., Laster, M., Eger, E., Ferrell, L. and Kerschmann, R. Toxicity of Compound A in Rats: Effect of a 3-Hour Administration

Anesthesiology. 1994;80(3):566-573. 

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1949689

It is actually the case that follow up studies were done in the US on volunteer patients through University of Arizona and Medical College of Wisconsin in the later 1990’s.Ebert, T., Frink, E. and Kharasch, E. Absence of Biochemical Evidence for Renal and Hepatic Dysfunction after 8 Hours of 1.25 Minimum Alveolar Concentration Sevoflurane Anesthesia in Volunteers. Anesthesiology. 1998;88(3):601-610.

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1948570

Kharasch, E. and Jubert, C. Compound A Uptake and Metabolism to Mercapturic Acids and 3,3,3-Trifluoro-2-fluoromethoxypropanoic Acid during Low-flow Sevoflurane Anesthesia. 

Anesthesiology. 1999;91(5):1267-1278.

https://www.ncbi.nlm.nih.gov/pubmed/10551576

The key point of the final article concludes that humans are nearly devoid of renal beta lyase, the key enzyme in directing biodegradation of compound A to the toxic renal thiol. Essentially, this research was done in the late 90’s but the original possibility of renal toxicity in humans from just a few years prior has stuck in peoples’ minds (and therefore textbooks). 

More recent studies agree:

Ong Sio LDela Cruz R,  and Bautista A. Sevoflurane and renal function: a meta-analysis of randomized trials.

Med Gas Res. 2017 Oct 17;7(3):186-193.

https://www.ncbi.nlm.nih.gov/pubmed/29152212

Gillian’s random recommendation: Born a Crime by Trevor Noah

Circle C Farm: https://www.circlecfarmfl.com

Episode 163: Thoracic Wall Blocks with Barbara Versyck

In this 163rd episode I welcome Dr. Barbara Versyck to the show to discuss thoracic wall blocks. We discuss the types of blocks, what they are used for, and what the evidence is for their efficacy.

References:

Videos: 

Pecs II: https://www.youtube.com/watch?v=YFWneF4pwOA

Serratus Anterior block: https://www.youtube.com/watch?v=K2w46jjMgfMErector

Spinae plane block: https://www.youtube.com/watch?v=EVowRjEFUfk

Literature: 

Chin, Ki Jinn. “Thoracic wall blocks: from paravertebral to retrolaminar to serratus to erector spinae and back again–a review of the evidence.” Best Practice & Research Clinical Anaesthesiology (2019).

Versyck, B., G‐J. van Geffen, and K‐J. Chin. “Analgesic efficacy of the Pecs II block: a systematic review and meta‐analysis.” Anaesthesia 74.5 (2019): 663-673.

Poster: 

https://www.bbraun.com/content/dam/catalog/bbraun/bbraunProductCatalog/S/AEM2015/en-01/b9/thoracic-wall-blocks-forbreastcancersurgery.pdf.bb-.98924081/thoracic-wall-blocks-forbreastcancersurgery.pdf

Episode 162: Hypertensive Disorders of Pregnancy with Juanita Henao

In this 162nd episode I welcome Dr. Henao back to the show to discuss hypertensive disorders of pregnancy and how to manage them.

CLARIFICATIONS:

  1. During our discussion of treatment of eclamptic seizures Dr. Henao said benzos were first line treatment. This is assuming the patient is already getting magnesium. For test questions, the answer for first line treatment should be Mg. In reality, patients will likely get both at the same time.
  2. Serum Mg concentrations can be reported as mmol/L, meq/L or mg/dL. The important ranges to know for testing (though in reality different people may get symptoms at different times) are a therapeutic range of 2-3.5 mmol/L or 4-7 mEq/L or 5-9 mg/dL; A loss of patellar reflexes at >3.5, >7, >9; Respiratory paralysis at >5, >10, >12 and cardiac arrest at >12.5, >25, >30. EKG changes including prolonged PR and widened QRS happen in much the same range as loss of patellar reflexes, maybe a bit before but there is a lot of overlap.

References:

  1. Hofmeyr R, Matjila M, Dyer R. Preeclampsia in 2017: Obstetric and Anaesthesia Management. Best Pract Res Clin Anaesthesiol. 2017 Mar;31(1):125-138.
  2. Dhariwal NK, Lynde GC. Update in the Management of Patients with Preeclampsia. Anesthesiol Clin. 2017 Mar;35(1):95-106.
  3. Aya AG, Mangin R, Vialles N, Ferrer JM, Robert C, Ripart J, de La Coussaye JE. Patients with severe preeclampsia experience less hypotension during spinal anesthesia for elective cesarean delivery than healthy parturients: a prospective cohort comparison. Anesth Analg. 2003 Sep;97(3):867-72.
  4. Roberge S, Nicolaides K, Demers S, Hyett J, Chaillet N, Bujold E. The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: systematic review and meta-analysis. Am J Obstet Gynecol. 2017 Feb;216(2):110-120.
  5. David Chestnut Cynthia Wong Lawrence Tsen Warwick D Ngan Kee Yaakov BeilinJill Mhyre Brian T. Bateman Naveen Nathan. Chestnut’s Obstetric Anesthesia: Principles and Practice. 5th edition. Chapter 36: Hypertensive Disorders. Pg 825-859

Killers of the Flower Moon (Dr. Henao’s random recommendation): https://www.amazon.com/Killers-Flower-Moon-Osage-Murders/dp/0385534248