Category Archives: Show Notes

Episode 176: Keywords Part 11: Barbiturates and Bier Blocks

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 176: Keywords Part 11: Barbiturates and Bier Blocks
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In this 176th episode I welcome Dr. Gillian Isaac back to the show to discuss another 2 ABA key words. This time we discuss Barbiturates and Bier Blocks. I also take a moment up front to share some thoughts on the horrible tragedy of George Floyd’s death at the hands of the police and the importance of acknowledging white privilege and fighting for the fact that Black Lives Matter.

CME: https://earnc.me/ucUI9n

Reference: Clinical Anesthesia. Publication Year: 2017. Edition: 8th Ed. Authors/Editor: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.; et al.
Outline by Brian Park, MD

Awakening after a single dose of thiopental is caused by redistribution from the brain primarily to which of the following sites?
(A) Fat
(B) Heart
(C) Liver
(D) Lung

Discussion (11:00)

See full interactive episode

Episode 174: Keywords Part 10: OR Fires and Electrical Safety

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 174: Keywords Part 10: OR Fires and Electrical Safety
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In this 174th episode I welcome back Dr. Gillian Isaac to discuss another 2 highly tested ABA keywords, OR fires and electrical safety in the OR.

CME: https://earnc.me/Adkacw

OR Fires

Fire Triangle (2:52)
Most important aspect of OR fire management? (3:22)

Risk for airway fire during laser resection of tracheal tumor DECREASED in
A. CO2 rather than GAD laser
B. Helium > 60%
C. N2O > 60%
D. PVC ETT
E. Halothane in mixture

Discussion (5:24)


View full interactive post

Episode 164: Keywords part 9: Fentanyl and Breathing Circuits

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 164: Keywords part 9: Fentanyl and Breathing Circuits
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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).

CME: https://earnc.me/delVJ8

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 162: Hypertensive Disorders of Pregnancy with Juanita Henao

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 162: Hypertensive Disorders of Pregnancy with Juanita Henao
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In this 162nd episode I welcome Dr. Henao back to the show to discuss hypertensive disorders of pregnancy and how to manage them.

CME: https://earnc.me/tyN3SI

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

Episode 160: Non-OB Surgery in Pregnancy With Dave Berman

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 160: Non-OB Surgery in Pregnancy With Dave Berman
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In this 160th episode I welcome Dr. Dave Berman back to the show to discuss anesthesia for non-OB surgery during pregnancy.

CME: https://earnc.me/zVSggO

References:

1. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124(2):270–300.

2. Nonobstetric Surgery During Pregnancy – ACOG [Internet]. [cited 2019 Jul 18];Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Nonobstetric-Surgery-During-Pregnancy?IsMobileSet=false

3. Tolcher MC, Fisher WE, Clark SL. Nonobstetric Surgery During Pregnancy. ObstetGynecol 2018;132(2):395–403.

4. UpToDate [Internet]. [cited 2019 Jul 18];Available from: https://www.uptodate.com/contents/management-of-the-pregnant-patientundergoing-nonobstetric-surgery

5. Upadya M, Saneesh PJ. Anaesthesia for non-obstetric surgery during pregnancy. Indian J Anaesth 2016;60(4):234–41.

6. Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery duringpregnancy. Br J Anaesth 2011;107 Suppl 1:i72–8.

7. Nejdlova M, Johnson T. Anaesthesia for non-obstetric procedures during pregnancy. Contin Educ Anaesth Crit Care Pain 2012;12(4):203–6.

8. Mazze RI, Källén B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol 1989;161(5):1178–85.

9. Committee on Obstetric Practice and the American Society of Anesthesiologists. Committee Opinion No. 696: Nonobstetric Surgery During Pregnancy. Obstet Gynecol 2017;129(4):777–8.

10. Wilcox AJ, Weinberg CR, O’Connor JF, et al. Incidence of early loss of pregnancy. N Engl J Med 1988;319(4):189–94.

11. Davidson AJ, Disma N, de Graaff JC, et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016;387(10015):239–50.

12. Sun LS, Li G, Miller TLK, et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016;315(21):2312–20.

13. Center for Drug Evaluation, Research. FDA Drug Safety Communication [Internet]. U.S. Food and Drug Administration. 2019 [cited 2019 Jul 21];Available from: http://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communicationfda-review-results-new-warnings-about-using-general-anesthetics-and

14. Huang S-Y, Lo P-H, Liu W-M, et al. Outcomes After Nonobstetric Surgery in Pregnant Patients: A Nationwide Study. Mayo Clin Proc 2016;91(9):1166–72.

Episode 159: Postpartum hemorrhage with Juanita Henao

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 159: Postpartum hemorrhage with Juanita Henao
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In this 159th episode I welcome Dr. Juanita Henao to the show to discuss prevention and management of postpartum hemorrhage.

One CORRECTION: At about minute 4:30 Dr. Henao states that in women with PPH the mortality rate is 10% but what she meant to say is that PPH accounts for 10% of maternal deaths in the United States.

CME: https://earnc.me/n2JrEJ

References:

Thorneloe, J.C.A. Carvalho, K. Downey,M. Balki. Uterotonic drug usage in Canada: a snapshot of the practice in obstetric units of university-affiliated hospitals. Int J Obstet Anesth. 2019 Feb;37:45-51.

Hian Yan Voon , Haris Njoo Suharjono , Asrul Akmal Shafie , Mohamad Adam Bujang Carbetocin versus oxytocin for the prevention of postpartum hemorrhage: A meta-analysis of randomized controlled trials in cesarean deliveries. Taiwan J Obstet Gynecol. 2018 Jun;57(3):332-339.

WOMAN trial collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27;389(10084):2105-2116.

Main EKGoffman DScavone BMLow LKBingham DFontaine PLGorlin JBLagrew DCLevy BSNational Partnership for Maternal SafetyCouncil on Patient Safety in Women’s Health Care.National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. Obstet Gynecol. 2015 Jul;126(1):155-62.

Duffield A1McKenzie CCarvalho BRamachandran BYin VEl-Sayed YYRiley ETButwick AJ. Effect of a High-Rate Versus a Low-Rate Oxytocin Infusion for Maintaining Uterine Contractility During Elective Cesarean Delivery: A Prospective Randomized Clinical Trial. Anesth Analg. 2017 Mar;124(3):857-862

David H. Chestnut, Cynthia A Wong, Lawrence C Tsen, Warwick D Ngan Kee, Yaakov Beilin, Jill Mhyre. Chestnut’s Obstetric Anesthesia: Principles and Practice. Fifth edition. Chapter 38, Anterpartum and Postpartum, Hemorrhage. 

Episode 158: Keywords part 8-hepatic disease for the advanced exam and PACU for the basic exam with Gillian Isaac

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 158: Keywords part 8-hepatic disease for the advanced exam and PACU for the basic exam with Gillian Isaac
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In this 158th episode we return with another keywords episode with Dr. Gillian Isaac. We discuss hepatic disease for the advanced exam and PACU care for the basic exam.

CME: https://earnc.me/rEmBIA

Show Notes by Dr. Brian Park

Random recs:

Cloud Atlas: https://www.amazon.com/Cloud-Atlas-Novel-Liam-Callanan/dp/0385336950

Wolf Hall: https://www.amazon.com/s?k=wolf+hall+by+hilary+mantel&i=stripbooks&crid=2F978D2O2UCW&sprefix=wolf+hall%2Cstripbooks%2C135&ref=nb_sb_ss_i_1_9

Bottle of Lies: https://www.amazon.com/Bottle-Lies-Inside-Story-Generic-ebook/dp/B07JG49BQW/ref=sr_1_1?keywords=bottle+of+lies&qid=1581089047&s=books&sr=1-1

Thanks to Brian Robinson for pointing out: reversal of  rocuronium with Sugammadex can occasionally cause severe bronchospasm, especially in higher doses, and this was one of the reasons its release was delayed in the U.S.

Although most sugammadex hypersensitivity reactions cause mild symptoms such as sneezing, nausea, rash, and urticaria, there is a small but finite risk of anaphylaxis with potentially life-threatening symptoms such as airway edema, bronchospasm, and cardiovascular collapse.
www.apsf.org › article › sugammadex-the-anaphylactic-risk

Episode 154: EEG monitoring with Dr. Emery Brown

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 154: EEG monitoring with Dr. Emery Brown
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In this 154th episode I welcome Dr. Emery Brown to the show to discuss how we monitor the depth of anesthesia. We discuss the drawbacks to BIS and why Dr. Brown thinks the EEG itself is the best way to go.

CME: https://earnc.me/fbGYsk

References:

EEG reading tutorials: https://eegforanesthesia.iars.org/

Purdon et al: The Ageing Brain: Age-dependent changes in the electroencephalogram during propofol and sevoflurane general anaesthesia

Brown et al: General Anesthesia and Altered States of Arousal: A Systems Neuroscience Analysis. Annu. Rev. Neurosci. 2011.

Brown et al: General Anesthesia, Sleep, and Coma. NEJM. 2010.

Brown et al: Multimodal General Anesthesia: Theory and Practice. A&A 2018.

Purdon et al: Clinical Electroencephalography for Anesthesiologists. Part I: Background and Basic Signatures. Anesthesiology 2015.

Dental Anesthesia info:

Contacts:

Thomas Whitmer: thomas.whitmer.tw@gmail.com

Mana saraghi: msaraghi@gmail.com

References:

https://www.ada.org/en/ncrdscb/dental-specialties/specialty-definitions

http://www.ada.org/~/media/CODA/Files/anes.ashx

American Society of Dentist Anesthesiologists website: https://www.asdahq.org

Virtual tour https://www.youtube.com/watch?v=ZJ1Mo65ah4w&feature=youtu.be



Episode 152: Keywords Part 7: MH and Hepatic Disease for the Basic Exam

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 152: Keywords Part 7: MH and Hepatic Disease for the Basic Exam
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In this 152nd episode I welcome Dr. Gillian Isaac back for another 2 ABA keywords. We discuss malignant hyperthermia and the portion of hepatic disease that is covered by the Basic Exam. We’ll do the portion covered by the Advanced Exam on the next keywords episode.

CME: https://earnc.me/NU3JPS

Malignant Hyperthermia Website: www.mhaus.org

Great review website where Dr. Isaac gets her questions: http://www.anesthesiahub.com

Atlantic Article: https://www.theatlantic.com/entertainment/archive/2012/03/what-do-fact-checkers-and-anesthesiologists-have-in-common/253838/#note

Episode 150: Keywords Part 6: Supraclavicular, Axillary and Benzos

Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast
Episode 150: Keywords Part 6: Supraclavicular, Axillary and Benzos
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In this 150th episode I welcome back Dr. Gillian Isaac to do another round of ABA keywords. We discuss 2 additional upper extremity blocks (supraclavicular and axillary) and then benzodiazepines.

CME: https://earnc.me/4aBzu8