ASA Annual Meeting Medically Challenging Cases 2014

Comments

Transcription

ASA Annual Meeting Medically Challenging Cases 2014
Medically Challenging Cases
ANESTHESIOLOGY™ 2014, the 2014 ASA annual meeting
MCC Session Number
MCC01
MCC02
MCC03
MCC04
MCC05
MCC06
MCC07
MCC08
MCC09
MCC10
MCC11
MCC12
Day
Saturday, October 11
Saturday, October 11
Saturday, October 11
Saturday, October 11
Sunday, October 12
Sunday, October 12
Sunday, October 12
Sunday, October 12
Monday, October 13
Monday, October 13
Monday, October 13
Monday, October 13
Time
8:00am – 9:30am
10:30am – 12:00pm
1:00pm - 2:30pm
3:00pm – 4:30pm
8:00am – 9:30pm
10:30am – 12:00pm
1:00pm – 2:20pm
3:00pm – 4:30pm
8:00am – 9:30am
10:30am – 12:00pm
1:00pm – 2:30pm
3:00pm – 4:30pm
Learning Track Codes
AM Ambulatory Anesthesia
OB Obstetric Anesthesia
CA Cardiac Anesthesia
PN Pain Medicine
CC Critical Care Medicine
PD Pediatric Anesthesia
FA Fundamentals of Anesthesiology
PI Professional Issues
NA Neuroanesthesia
RA Regional Anesthesia and Acute Pain
Search options:
The Medically Challenging Cases are bookmarked by day and session number.
Use Ctrl F to find an author‟s name, MCC number, or partial title.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC01
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Obstetric Anesthesia (OB) MC01
Dexmedetomidine for Surgical Treatment of Pheochromocytoma in a Pregnant Patient
Karines Rivera-Marrero, M.D., Pamela Fernandez, M.D . Anesthesiology Department, University of
Puerto Rico, San Juan, PR, USA.
Pheochromocytoma is a rare neuroendocrine tumor and surgical resection is the only curative treatment.
The anesthetic management of pheochromocytoma remains a complicated challenge requiring intensive
perioperative preparation and vigilant, because of its potentially lethal cardiovascular complications. It
becomes more complicated when the patient is pregnant. Pheochromocytoma in pregnancy is associated
with high maternal and neonatal mortality rates. Dexmedetomidine, alpha2-adrenoceptor agonist drug, in
therapeutic clinical doses has major selectivity for these receptors and promotes suitable hemodynamic
stability if used in the perioperative period. We report anesthetic management of an open resection for
pheochromocytoma in 21th week gestational woman using dexmetomidine intraoperative.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Obstetric Anesthesia (OB) MC02
Uneventful Epidural Analgesia in a Patient with Severe Thrombocytopenia
Madhumani N. Rupasinghe, M.D.,F.R.C.A, Peter Doyle, M.D., Pilar Suz, M.D., Dana Parker, M.D .
Anesthesiology, UTHSC, Houston, TX, USA.
A 39 yrs. female G6P3 presented at 37 weeks with IUFD. Co morbidities included poorly controlled
gestational diabetes, fatty liver of pregnancy and elevated blood pressure. Epidural was placed for
analgesia at a platelet count of 164. After vaginal delivery, the epidural catheter was removed, and severe
thrombocytopenia was discovered, with a platelet count of 36, the patient had no subsequent neurologic
or hematologic complications.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Obstetric Anesthesia (OB) MC03
Intrathecal Catheter Related Complications
Madhumani N. Rupasinghe, M.D.,F.R.C.A, Peter Doyle, M.D., Tina Houseworth, C.R.N.A .
Anesthesiology, UTHSC, Houston, TX, USA.
In our institution we have a skill mix of trainee residents, CRNA‟s and SRNA‟s. Our OB policy is to thread
the epidural catheter intrathecally following an accidental dural puncture. Unfortunately, in the mid night
hours a parturient with an intrathecal catheter was taken to the OR for an urgent caesarian section and
due to a breach in communication was administered a large volume of local anesthetic. The high block
was detected immediately a stat caesarian section was performed with no adverse outcome to mother or
baby. Following this incident we implemented guidelines/ picture charts, so as to avoid future errors.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Obstetric Anesthesia (OB) MC04
Congenital Heart Disease and Pregnancy, a Complex Pair: Management of a Transposition of
Great Vessels Mother and Pentalogy of Cantrell Fetus
Alecia L. Sabartinelli, M.D., Katherine Hoctor, M.D., Daria Moaveni, M.D., Amanda Saab, M.D .
Anesthesiology, University of Miami - Jackson Memorial Hospital, Miami, FL, USA.
30 year old G5 P0040 at 35 5/7 weeks was delivered urgently via cesarean due to PPROM. Maternal
history is significant for Transposition of Great Vessels s/p Mustard procedure. A modified low dose CSE
technique was used to achieve surgical anesthesia with minimal changes in hemodynamics. A live female
Copyright © 2014 American Society of Anesthesiologists
infant was delivered moving all extremities and crying. Antenatal ultrasound revealed symptoms
consistent with the diagnosis of Pentalogy of Cantrell. This diagnosis was confirmed at birth. Additional
dysmporphic features not previously recognized were also noted. She was intubated and transported to
the NICU. Determination of possible surgical intervention is pending.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Obstetric Anesthesia (OB) MC05
Chicken or the Egg? Seizure and Intraventricular Hemorrhage or Hemorrhage Followed by a
Seizure
Neeti Sadana, M.D., Suk Hong, M.D., Shannon Klucsarits, M.D. Anesthesiology, UT Southwestern
Medical Center, Dallas, TX, USA.
A 38-year-old G5P3 at forty weeks gestational age presented from triage with spontaneous rupture of
membranes. What followed was forceps delivery, a probable seizure, followed by intraventricular
hemorrhage, and emergent craniotomy for hematoma evacuation. Her intrapartum course was
complicated by suspected narcotic overdose, which led to a potential delay in her diagnosis. This case
represents the importance of neuraxial analgesia/anesthesia for seemingly uncomplicated labor in both
large academic centers and small community hospitals. This patient‟s survival highlights excellent
communication across multiple disciplines including radiology, neurosurgery, obstetrics, and
anesthesiology.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Obstetric Anesthesia (OB) MC06
Neuraxial Anesthesia For a Laboring Parturient With Evans Syndrome
Tarang Safi, M.D., Eduardo Galeano, M.D. Anesthesiology, Monetfiore Medical Center/Albert Einstein
College of Medicine, Bronx, NY, USA.
26F G4P201 with a history of SLE and Evans Syndrome s/p repeat C/S at 37 weeks under spinal
anesthesia. Patient reported a history of easy bruising and bleeding gums with a stable platelet count
>200k/uL. Neuraxial anesthesia was chosen over general anesthesia in this patient given its safety profile
in parturients. Spinal was chosen over an epidural or CSE technique because of its lower incidence of
bleeding complications. Post-operative course was complicated by uterine hemorrhage requiring
exploratory laparotomy under general anesthesia on POD2. Despite heavy bleeding requiring multiple
units of pRBC- there were no adverse outcomes from neuraxial anesthesia.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Obstetric Anesthesia (OB) MC07
Anesthetic Management for Osteogenesis Imperfecta
Omolola Salaam, M.D., Kalpana Tyagaraj, M.D. Maimonides Medical Center, Brooklyn, NY, USA.
37 years old female, G6P0, with history of Type III Osteogenesis Imperfecta (OI), presented at 35+ weeks
in preterm labor. OI complicated by short stature ( 4'3" tall), long bone and cervical spine fractures
requiring hardware placement as well as dysmorphic facies and small mouth opening . Vaginal delivery
was not an option because of significant cephalopelvic disproportion. General anesthesia with
endotracheal intubation was chosen as the safe anesthetic approach for the mother and the newborn.
Intubation was accomplished via in-line neck stabilization, video assisted laryngoscopy and extreme
flexion of endotracheal tube with an indwelling stylet and BURP maneuver.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Obstetric Anesthesia (OB) MC08
Management of the Parturient with Ludwig’s Angina
Yidy Y. Salamanca, M.D., Mala Gurbani, M.D., Abiona V. Berkeley, M.D., John Ferrari, M.D.
Anesthesiology, Temple University Hospital, Philadelphia, PA, USA.
Thirty-four year old Gravida 9, Para 4 at thirty-one weeks and two days, was scheduled for the incision
and drainage of a presumed submandibular abscess. Patient‟s vital signs were stable on room air
Copyright © 2014 American Society of Anesthesiologists
however, she had been unable to eat for at least two days, was drooling and seated upright. Patient was
intubated via awake fiberoptic with a multidisciplinary team in the operating room to facilitate emergent
tracheostomy and Caesarean section. She was taken to the Intensive Care Unit and discussions between
the teams continued in order to address sedation, pain control and airway management.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Obstetric Anesthesia (OB) MC09
New Onset Seizure in Peripartum Patient Without History of Seizure Disorder
Yidy Y. Salamanca, M.D., Diana Feinstein, D.O., Meera Gonzalez, M.D . Anesthesiology, Temple
University Hospital, Philadelphia, PA, USA.
18-year-old non-preeclamptic female with epidural analgesia for stage II labor. Patient became suddenly
unresponsive with stable vitals and spontaneous, adequate ventilation. During induction of general
anesthesia for emergency c-section, patient had tonic-clonic movements. Movement ceased once
rocuronium given. Baby delivered with Apgars 9/9. Patient transported to CT scan intubated. En route
patient developed another seziure, treated with Versed and propofol. Upon completion of CT patient had
another seizure treated with propofol. Patient began to emerge appropriately while still in CT. Transferred
to SICU and extubated an hour later, alert and appropriate, with no recollection of events.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC10
Normal (Abnormal) Radiographic Finding Following Internal Jugular Central Venous Catheter
Insertion
Arney S. Abcejo, M.D., Hugh M. Smith, M.D.,Ph.D., James R. Hebl, M.D. Anesthesia, Mayo Clinic,
Rochester, MN, USA.
A patient had a right internal jugular central venous catheter (CVC) placed during an abdominal debulking
procedure. On postoperative chest x-ray, a radiologist interpreted a 7-centimeter linear signal as being
consistent with a retained guidewire in the CVC. After removal, the anesthesia team dissected the CVC
which revealed only a polyurethane plug in the distal lumen. The manufacturer (Arrow®) states that the
synthetic plug is a standard element of CVC construction and may produce a radiopaque signal with
specific patient positioning during x-ray. This report raises awareness of this radiographic finding and
potential for unnecessary removal of clinically indicated CVCs.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Pain Medicine (PN) MC100
Opioid Detoxification Using a 10-Day Epidural Infusion With Fentanyl and Bupivicaine
Harish S. Badhey, M.D., Matthew Jaycox, M.D. Rush University Medical Center, Chicago, IL, USA.
66 y/o with spinal canal stenosis, degenerative disk disease, experiencing lumbar back pain which
progressed to a pain rating of 9/10. She was using fentanyl patch 175mcg/hr, hydrocodone/APAP
10/325mg, and tramadol. Patient endorsed sweating and generalized panic during transition between
patches without any analgesic benefit. To begin inpatient detoxification a lumbar epidural catheter was
placed under fluoroscopy to T12-L1. An infusion of bupivicaine 0.06% and fentanyl 10 mcg/cc was started
at 6cc/hour, providing neuraxial analgesia. Over 10 days the fentanyl concentration was incrementally
weaned to 0 mcg/mL while keeping the local anesthetic constant. Signs of withdrawal were minimal.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Pain Medicine (PN) MC101
Opioid-Sparing Anesthetic for a Chronic Pain Patient Undergoing Multilevel Spinal Fusion
Xiaodong Bao, M.D.,Ph.D., Thomas A. Anderson, M.D.,Ph.D., John Shin, M.D. , David A. Edwards,
M.D.,Ph.D. Massachusetts General Hospital, Boston, MA, USA.
Perioperative opioid exposure is correlated with chronic opioid use. Chronic pain patients undergoing
multilevel spinal fusion can experience severe acute pain. These patients can be comfortably taken
through the operation with little or no opioid exposure. We present the care of a 47-year-old woman with
Copyright © 2014 American Society of Anesthesiologists
chronic back pain undergoing 4-level laminectomy and fusion. Perioperative care included gabapentin
and acetaminophen with intraoperative infusions of dexmedetomidine, lidocaine, and ketamine. An
epidural was placed surgically and continued for 3 days then transitioned to oral analgesics. Superior pain
control, as measured by pain and recovery scores, can be attained with overall reduced opioid exposure.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Pain Medicine (PN) MC102
Intra-procedural Psychogenic Nonepileptic Seizure in a Chronic Pain Patient
Christine A. Beckwith, M.D., Kayode Williams, M.D., MBA. Anesthesiology and Critical Care Medicine,
Johns Hopkins, Baltimore, MD, USA.
A 30 yo male with chronic pelvic pain of unknown etiology presented to the pain clinic for a pudendal
nerve block. Patient had a history of seizure-like activity after anesthesia for procedures, so sedation was
avoided. Under fluoroscopic guidance, local anesthetic was injected, and patient simultaneously
developed generalized tonic-clonic movements and tachycardia without cyanosis or blood pressure
changes. He was unresponsive to verbal and noxious stimuli. Intravenous midazolam was administered
and symptoms resolved. Neurology was consulted and witnessed repeated episodes. Patient was
diagnosed with psychogenic nonepileptic seizure activity likely triggered by pain or anxiety.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Pain Medicine (PN) MC103
Management of 15-year-old female with Complex Regional Pain Syndrome Presenting as Left
Lower Extremity Pain and Bruising.
Daniela J. Bermudez, D.O., Jerry R. Foltz, M.D . Naval Hospital Jacksonville, Jacksonville, FL, USA.
A previously healthy fifteen-year-old girl presented toPain Management 6 months after a knee injury with
a primary complaint of largebruising of her lateral knee despite a lack of recurrent trauma. She also had
weakness, disability, andclonus. Symptoms gradually progressed toinclude allodynia, and less frequent
color changes. Unable to fully weight bear due to eight outof ten pain, she was treated with lumbar
sympathetic blocks over the course ofseven months in conjunction with CPRS specific physical therapy,
lyrica, andclonidine. Through aggressive management, she was able to return to routineactivities
including jogging.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Pain Medicine (PN) MC104
Physical Violence Against Pain Medicine Physicians: A Case Report and Discussion
Daniel J. Borman, M.D., Alexander Bowen, M.D., DeWayne Lockhart, M.D., Constantine Sarantopolous,
M.D., Melvin Gitlin, M.D. Anesthesiology, University of Miami, Miami, FL, USA.
A physician was providing care to a patient when he heard yelling outside the room. The physician
decided to look outside the office door to assess the situation and realized the risk of being attacked as
the angry patient continued to yell out obscenities and rush towards the physician. The attending tried to
close the office door to protect himself but the man slammed the door against the physician. The
physician managed to close the door before the angry patient could force his way inside. Authorities were
notified and the patient was taken away to the Emergency Room for evaluation.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Pain Medicine (PN) MC105
Spinal Cord Stimulator For Intractable Upper Abdominal Pain In The Setting of Chronic
Pancreatitis
Edward B. Braun, M.D., Stephen Campbell, D.O., Talal Khan, M.D. University of Kansas Medical Center,
Kansas City, KS, USA.
A 50 year-old male with chronic pancreatitis and history of severe right upper quadrant abdominal pain
was initially treated with medical management and celiac plexus blocks with limited benefit. Thoracic MRI
revealed an epidural hemangioma at T6. He underwent a successful spinal cord stimulator trial at T8.
Copyright © 2014 American Society of Anesthesiologists
Implantation included laminotomy and insertion of a paddle lead in the epidural space. This approach was
used in place of percutaneous lead placement to reduced the risk of lead migration, which could
potentially disrupt the hemangioma. At one year follow-up the patient showed marked improvement and
had been able to return to work.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Pain Medicine (PN) MC106
Fentanyl at 750 mcg/hr: Pain Management of a Pediatric Patient with Castleman’s Disease and
Paraneoplastic Pemphigus
Khan K. Chaichana, M.D., Anthony Anderson, M.D., Padma Gulur, M.D., David Edwards, M.D .
Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
Castleman‟s disease is a rare and usually fatal lymphoproliferative disorder of unclear etiology. It can be
associated with paraneoplastic pemphigus making palliative pain control a challenge. Our case is a 13year-old girl, with a history of asthma, who developed Castleman‟s disease with severe pemphigus.
Continual skin and mucosal sloughing caused severe chronic pain. Very high dose opioid and
benzodiazepine infusions were required for pain control. A strategy of multi-modal analgesia and opioid
rotation was used to maintain efficacy over a period of 10 months.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Pain Medicine (PN) MC107
Lumbar Epidural Blood Patch for Spontaneous Intracranial Hypotension
Tiffany C. Chen, M.D. Anesthesiology, NYU Langone Medical Center, New York, NY, USA.
The patient is a 56 year-old woman with past medical history of bipolar disorder who presented with
persistent positional headaches associated with neck stiffness, nausea, and vomiting for 1 month. The
patient denied history of surgery or trauma. Neuro exam grossly intact, no meningismus. MRI brain
demonstrated findings consistent with intracranial hypotension including subdural fluid collections, inferior
sagging of the diencephalon, cerebellar tonsillar herniation, enhancement of the dura, and pituitary
engorgement. The patient underwent lumbar epidural blood patch with improvement in symptoms. MRI 2
weeks following discharge showed decrease in size of subdural fluid collections and resolution of inferior
sagging.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Pediatric Anesthesia (PD) MC108
Laryngospasm and Post-Obstructive Pulmonary Edema During Removal of Airway Foreign Body
Under General Anesthesia
Katarzyna Luba, M.D. Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA.
Chest x-rays of a 10-month-old boy with cough and poor oral intake demonstrated a foreign body in the
hypopharynx. Emergency removal was scheduled. General anesthesia was induced and maintained with
sevoflurane by mask. A soda can tab was removed during direct laryngoscopy. The patient immediately
developed suprasternal retractions without effective ventilation and desaturation, consistent with
laryngospasm. Mask ventilation with oxygen failed to improve saturation. He was intubated. Ventilation
with oxygen improved saturation. Frothy pink secretions appeared in the endotracheal tube. Diffuse rales
appeared over both lungs. Pulmonary edema was diagnosed. Intravenous furosemide was administered.
He was transferred to the ICU.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Pediatric Anesthesia (PD) MC109
Unexpected Increase in Arterial to End-tidal CO2 Gradient in a Child Undergoing Embolization of
MAPCAs
Saifeldin A. Mahmoud, M.D.,Ph.D., Khaled A. Sedeek, M.D.,Ph.D., Patrick M. McQuillan, M.D .
Anesthesiology, Hershey Medical Center - Penn State Uinversity, Hershey, PA, USA.
Copyright © 2014 American Society of Anesthesiologists
A 17-month-old infant with multiple aorto-pulmonary collateral arteries (MAPCAs) and significant
pulmonary hypertension presented for diagnostic cardiac catheterization. On the day of the procedure,
the infant was asymptomatic with an O2 saturation in the 90‟s on 1.0 L/min O2. His parents denied any
recent illness.During the procedure, one coil was inadvertently embolized into the right lung resulting in
markedly increased PA pressures. The Pa-etCO2 gradient increased to 25 mmHg from a baseline of 2
mmHg. Therapy was initiated to reduce the PaCO2. The patient could not be weaned from mechanical
ventilation due to elevated PA pressures.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC11
Anesthetic Management of Anticipated Major Blood Loss in Radical Hemipelvectomy
Beril Abraham, M.D., Curtis Koons, M.D., Dung Nguyen, M.D . Anesthesiology, University of Kentucky,
Lexington, KY, USA.
Hemipelvectomies for malignancy can be challenging for the anesthesia provider because of major blood
loss and extensive tissue trauma. Cancer patients are at an increased risk for bleeding due to a
hypercoagulable state resulting from tumor-related fibrinolysis, effects of chemotherapy, and tumor
vascularity. Patients undergoing hemipelvectomies are commonly at risk for massive transfusion. We
present a case of a 71 year old with sacral chordoma undergoing a complex multi-team procedure with
careful preparation by our anesthesia team and execution of massive resuscitation in the setting of
anticipated major acute blood loss.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Pediatric Anesthesia (PD) MC110
Recognition of the Signs of Impending Upper Airway Obstruction and Emergent Airway
Management in Pediatric Population
Shabnam Majidian, D.O., Ranu Jain, M.D . Anesthesiology, University of Texas at Houston, Houston, TX,
USA.
This is a 7 month-old male with no significant past medical history who presented to emergency
department with one week history of persistent fever, new episode of respiratory distress, and possible
foreign body aspiration per family. Patient was found to have a bulging mass in posterior pharynx and
significant retropharyngeal soft tissue swelling on the x-ray; he was admitted with working diagnosis of
retropharyngeal abscess vs. foreign body aspiration. Upon assessment by pediatric anesthesiologist in
the emergency department patient was found somnolent with severe audible stridor. He was taken to
operating room emergently for securing the airway and hemodynamic stabilization.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Pediatric Anesthesia (PD) MC111
Airway, Bleeding and Fever: Anesthetic Challenges During Post-palatoplasty Hemorrhage
Elizabeth B. Malinzak, M.D., M. Concetta Lupa, M.D . University of North Carolina, Chapel Hill, NC, USA.
Post-tonsillectomy bleeds are challenging even in the hands of an experienced anesthesiologist. We
discuss a 9 month old female who experienced sustained post-palatoplasty hemorrhage with unstable
hemodynamics. In the operating room, airway swelling necessitated placement of an endotracheal tube
two sizes smaller than previously placed. She developed a fever during blood resuscitation, requiring a
transfusion reaction workup. Upon extubation, profuse hemorrhage was noted. She was immediately
reintubated and re-explored, revealing no bleeding source. The patient was left intubated postoperatively.
The tenuous airway, possible transfusion reaction, and undetermined cause of hemorrhage made
anesthetic management of this patient more difficult than expected.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Pediatric Anesthesia (PD) MC112
Anesthetic Management of a Patient with Sickle Cell Disease and Moya-Moya Syndrome
Copyright © 2014 American Society of Anesthesiologists
Chanchal Mangla, M.D., Michael Lyew, M.D., Shireen Pais, M.D. , Samuel Barst, M.D. Westchester
Medical Centre and New York Medical College, Valhalla, NY, USA.
A 16 year old boy with history of sickle cell disease and Moya-Moya syndrome status post
Encephaloduroarteriosynangiosis(EDAS) 4 weeks ago, on hypertransfusion protocol came in for
endoscopic retrograde cholangiopancreatography(ERCP). He was getting blood transfusion preoperatively to maintain hemoglobin above 10g. He was given general anesthesia for this procedure that
was done in prone position. Blood pressure and end tidal CO2 was maintained in high normal range to
maintain cerebral perfusion. Patient was adequately warmed up to maintain normothermia and care was
taken to avoid dehydration, acidosis, hypoxia. Procedure was completed successfully and patient
extubated at the end.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Pediatric Anesthesia (PD) MC113
Devastating Tracheal Injury after Successful Resuscitation of a Near Drowning in a 2-Year-Old
Travis H. Markham, M.D., Maria Matuszczak, M.D. University of Texas Medical School at Houston,
Houston, TX, USA.
Two year old toddler presented to the emergency department after a prolonged pool submersion and
subsequent field intubation. He was noted to have suspected tracheal rupture on imaging. Injuries were
suspected to be related to incorrect endotracheal tube size and overinflation of the cuff. In the operating
room, patient was placed on ECMO, thoracotomy performed for tracheal repair, and exchange of
endotracheal tube was done with patient in lateral position with exchange catheter and video
laryngoscope. The patient was taken to PICU where he did well and was subsequently taken off ECMO
and extubated without deficits.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Pediatric Anesthesia (PD) MC114
Thoracoschisis: The 7th Reported Case
Brooke N. Maryak, M.D., Gohalem Felema, M.D . Pediatric Anesthesiology, Mayo Clinic/Nemours
Children's Hospital, Jacksonville, FL, USA.
Thoracoschisis is a rare congenital anomaly characterized by herniation of intraabdominal organs through
a thoracic wall defect with only 6 reported cases. We present a 29 week 1.4kg preemie born with
herniated liver and intestine through a 4x3cm defect at the right 5th-8th ribs. Hypoxemia, hypercarbia,
and acidosis secondary to pulmonary hypoplasia and atelectasis from surgical compression of lungs were
challenges encountered intraoperatively making ventilation and oxygenation extremely difficult. Surgical
repair involved pulling eviscerated organs through a newly created abdominal incision into a silo.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Pediatric Anesthesia (PD) MC115
Perioperative Pulmonary Edema: A Case of POPE II Following a Tonsillectomy in a Child with
Chronic Upper Airway Obstruction
Brian S. McClure, D.O., Ashraf Farag, M.D., Cooper Phillips, M.D., Erik McClure, D.O. . Anesthesiology,
TTUHSC, Lubbock, TX, USA, Anesthesiology, Texas Tech University Health Sciences Center, Lubbock,
TX, USA, Anesthesiology, University of Kansas School of Medicine, Wichita, KS, USA.
A 5-year old male presented with a history of autism and persistent upper airway obstruction for a
tonsillectomy and adenoidectomy. After a history and physical, he was taken to the OR where a masked
induction and oral intubation. At the end of the procedure he was awakened, extubated and taken to the
PACU mildly sedated. Over the next few hours he developed dyspnea, hypoxia and labored breathing.
He was intubated and frothy sputum was suctioned. A portable chest x-ray showed pulmonary edema.
The patient was diuresed, extubated the next morning and was discharged on postoperative day 3
without further complications.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Pediatric Anesthesia (PD) MC116
A Child with Severe Neuromuscular Cervico-thoracic Kyphoscoliosis, Restrictive Lung Disease
and Uncorrected Pierre Robin Sequence Presented for Posterior Spinal Fusion
Ian W. McIntyre, M.D., Jagroop Mavi, M.D., Andrew Costandi, M.D., Mohamed Mahmoud, M.D. Cincinnati
Children's Hospital Medical Center, Cincinnati, OH, USA.
11 year old male with Pierre Robin, severe cervicothoracic kyphoscoliosis, restrictive lung disease and
severe OSA presented for spinal fusion with neuromonitoring. Spontaneous ventilation was maintained
and the patient was intubated using fiberoptic bronchoscopy. Improper patient position resulted in
abdominal compression during surgery. A transient, significant decrease in blood pressure was
remediated with repositioning. Intubation in the presence of cervical spine involvement and mandibular
hypoplasia can be difficult and may increase the risk of neurologic injury. Poor positioning with IVC
compression should be considered as a cause of sudden hypotension during this procedure.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Regional Anesthesia and Acute Pain (RA) MC117
Unilateral Lower Limb Weakness After Abdominal Hysterectomy
Christopher J. Parnell, M.D.,F.R.C.A, Srinivas Gudavalli, M.D. Anaesthesiology, Women's Hospital,
Doha, Qatar.
A forty- five year old ASA 1 lady developed unilateral lower limb weakness after combined epidural and
general anaesthesia for subtotal abdominal hysterectomy. The epidural catheter had been inserted
without pain immediately prior to the induction of general anaesthesia but was initially blamed. Sepsis and
haematoma were excluded by urgent MRI. Neurology and neurosurgery consults recommended
symptomatic treatment with simple analgesics, oral steroids and physiotherapy.EMG eight weeks later
showed normal paraspinal muscle action potentials and chronic right multi-radiculopathies from L2 to S1,
the conclusion being that the lesion was in the lumbosacral plexus and <i>not related</i> to the epidural
anaesthesia.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Regional Anesthesia and Acute Pain (RA) MC118
Regional Anesthesia for Awake EC-IC Bypass
Ankur B. Patel, D.O., Peter Vuong, M.D. Anesthesiology and Critical Care Medicine, Saint Louis
University Hospital, St. Louis, MO, USA.
This case describes the several regional anesthesia techniques applied to perform an awake EC-IC
bypass. The patient was in Mayfield pins and awakened during critical moments of the case to assess
neurocognitive functioning. Although, high flow EC-IC bypass is performed routinely, this is the first know
case of intraoperative awakening. Our patient was heavily sedated and in Mayfield pins without a secure
airway. We wish to describe the regional anesthesia techniques applied and possible emergency
situations considered.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Regional Anesthesia and Acute Pain (RA) MC119
Combined Suprascapular and Axillary (Circumflex) Block in a Patient Scheduled for I&D of
Shoulder Abscess with a Parapharyngeal Neck Mass
Bimal A. Patel, D.O., Hesham Elsharkawy, M.D. Anesthesiology, Cleveland Clinic Foundation, Cleveland,
OH, USA, Cleveland Clinic Foundation, Cleveland, OH, USA.
49 year-old male with history of Von Hippel-Lindau syndrome, pheochromocytoma, and right
parapharyngeal space mass presented for right shoulder abscess I&D. Ultrasound scanning of right neck
showed a 5.5cm tumor adjacent to brachial plexus. Decision was made to avoid the brachial plexus for
regional anesthesia and an alternative approach was used with a single shot suprascapular nerve and
posterior approach axillary (circumflex) nerve block. We will discuss the benefits of these alternative
Copyright © 2014 American Society of Anesthesiologists
shoulder blocks when there are risks associated with performing a regional block in the brachial plexus
above the clavicle.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC12
Anesthetic Management in an Adult with Rubinstein-Taybi Syndrome Using Endotracheal
Intubation
Chantal N. Afuh-LeFlore, M.D., Mohammad Shah, D.O., Juanita Villalobos, M.D . Department of
Anesthesiology, Walter-Reed National Military Medical Center, Bethesda, MD, USA.
Fifty-three year-old female with Rubinstein-Taybi Syndrome, osteoporosis, recurrent aspiration status
post left lower lobe resection presented with left femoral head fracture. Physical exam demonstrated
narrowed facies, high-arched palate, mallampati 2 airway, 2 cm mouth opening, 3-fingerbreadth
thyromental distance and short neck with limited neck extension. Due to notable anterior airway, the
patient was intubated with use of a flexible fiberoptic bronchoscope and Glidescope for visualization. The
patient underwent an uncomplicated left hip hemi-arthroplasty under GETA. After prolonged emergence
and extubation, the patient was re-intubated in the PACU due to decreased level of consciousness with
periods of obstruction and decreased SpO2.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Regional Anesthesia and Acute Pain (RA) MC120
Persistent Sciatic and Saphenous Neuropathy After a Single Shot Nerve Block
Amy Penwarden, M.D., M.S., Sally Stander, M.D., David Hardman, M.D., MBA, Harendra Arora, M.B.,B.S
. University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
A 32-year old male presented for peroneal tendon repair. The patient was otherwise healthy with no
neurologic deficits on pre-block exam. He underwent popliteal and saphenous nerve blocks, under
ultrasound guidance, with a mixture of 0.5% bupivacaine, dexamethasone and epinephrine. Block
placement was unremarkable with no evidence of nerve swelling. The patient was noted to have
prolonged sensory-motor weakness that prompted neurophysiologic testing which revealed axonal injury
to tibial, common fibular and saphenous nerves. Although the etiology of post-block nerve injuries is hard
to elucidate in most cases, the use dexamethasone in this case could have been a contributing factor.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Regional Anesthesia and Acute Pain (RA) MC121
Challenging Continuous Brachial Plexus Blockade in a Patient with Achondroplasia
Jamie R. Privratsky, M.D.,Ph.D., Claire Dakik, M.D., David S. Enterline, M.D., Jeffrey Gonzales, M.D.,
Hung-Lun Hsia, M.D . Department of Anesthesiology, Duke University, Durham, NC, USA, Department of
Radiology, Duke University, Durham, NC, USA.
A 21 year old female with achondroplasia underwent brachial plexus blockade for tenolysis of the wrist at
our institution. Inadequate supraclavicular regional blockade necessitated conversion to infraclavicular
blockade. The catheter required removal postoperatively due to suspicion of local anesthetic toxicity,
which was confirmed when pulsatile blood was obtained from the insertion site. CT-angiogram of the neck
revealed a small hematoma adjacent to the costocervical trunk. To our knowledge, this is the first report
of challenging peripheral nerve blockade in a patient with achondroplasia. Thus, caution is warranted
when performing peripheral nerve blockade in this patient population.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Regional Anesthesia and Acute Pain (RA) MC122
Chloroprocaine Use in an Interscalene Catheter in a Patient with Severe Pulmonary Disease
Brittany A. Reed, M.D., Joshua R. Dooley, M.D. Anesthesiology, Duke University Hospital, Durham, NC,
USA.
A 67-year-old-male with known severe COPD, requiring bilateral lung volume reduction nine months prior,
and evaluated for lung transplantation, presented for total shoulder arthroscopy. The risks that
Copyright © 2014 American Society of Anesthesiologists
accompany interscalene block in patients with pulmonary disease, secondary to phrenic nerve paralysis,
were discussed with the patient. The decision was made to proceed with the block using Chloroprocaine,
instead of the more commonly used Ropivacaine or Bupivacaine. This provided regional anesthesia with
the benefit of a short duration of action, which would be beneficial if the scenario of respiratory distress
arose.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Regional Anesthesia and Acute Pain (RA) MC123
A Pressure Paradox: Epidural Blood Patch for Low CSF Pressure Headache Following a Lumbar
Dural Puncture in a Patient with Idiopathic Intercranial Hypertension
Claire Rezba, M.D., Robert Rhoades, M.D . Anesthesiology, Hunter Holmes McGuire Veterans Hospital,
Richmond, VA, USA, Virginia Commonwealth University, Richmond, VA, USA.
A 35yoF with Idiopathic Intercranial Hypertension presented with headache following therapeutic dural
puncture. Although the literature is scant (given the paradox of a low pressure PDPH in the setting of a
high pressure syndrome), we performed an epidural blood patch, successfully curing her headache within
twenty-four hours. The patient returned approximately two months later with a new PDPH following
therapeutic tap. Epidural blood patch was performed again, and again proved curative. This case
provides evidence that PDPH does in fact occur in patients with IIH, and that blood patches provide a
safe, effective treatment.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Regional Anesthesia and Acute Pain (RA) MC124
To Pull or Not to Pull: Uneventful Epidural Catheter Removal Guided by P2Y12 Platelet Function
Assays and ROTEM® (Rotational Thromboelastometry) Hemostasis Analyzer in a Patient Who
Erroneously Received 4 Doses of Clopidogrel Post-Operatively
Sydney E. Rose, M.D., Roniel Weinberg, M.D . Anesthesiology, Weill Cornell Medical College, New York,
NY, USA.
79 year-old man with CAD (s/p CABG x 4, 6 DESs on Clopidogrel), DM2, and prostate cancer, presented
for prostatorectal fistula repair. He stopped clopidogrel 4 days prior, and P2Y12 assay day of surgery
confirmed platelet inhibition to be < 10%. Lumbar epidural was placed unremarkably. On POD6, it was
discovered that the patient had received 4 doses of clopidogrel, with his epidural catheter still in place.
Clopidogrel was immediately held, and daily P2Y12 assays appropriately trended decreasing platelet
inhibition, until assay day 4, when results became equivocal. ROTEM® thromboelastogram showed no
coagulopathy and the patient‟s epidural was removed unremarkably.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Regional Anesthesia and Acute Pain (RA) MC125
Challenges of Anesthetic Planning and Management for a Patient with Friedreich's Ataxia
Brian S. Rubin, M.D., Geeta Nagpal, M.D . Northwestern Memorial Hospital, Chicago, IL, USA.
A 59-year-old with Friedreich's ataxia was scheduled for an anterior hip arthroplasty, where muscle
relaxation was necessary. Diagnosed in 2008, he had a baseline neurologic status of ataxia, dysarthria,
and dysmetria. A discussion was had to determine the safest mode of anesthesia for the patient:
combined spinal-epidural verses general. Consideration of the progressive nature of the disease that
results from degeneration of the spinal cord was given for both toxicity of local anesthetics and duration of
action for neuromuscular blockade. The concerns of undue exacerbation of symptoms from neuraxial
blockade and increased sensitivity to paralytics lead the decision making process.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Neuroanesthesia (NA) MC126
Case of Severe Hypotension Associated With Vigorous Positive Pressure Ventilation
Elizabeth Mburu, M.D., Michael Misbin, M.D., David Fish, M.D . Cooper University Hospital, Camden, NJ,
USA.
Copyright © 2014 American Society of Anesthesiologists
We report the case of an 86 year old man undergoing an urgent sub-occipital craniectomy for evacuation
of left cerebellar hemorrhage and resection of mass lesion with vasogenic edema. He had a history of
long standing hypertension. This patient had a smooth induction with appropriate decrease in blood
pressure after propofol. However not long after intubation, he developed severe hypotension. The
hypotension could have been attributed to an exaggerated response to positive pressure ventilation.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Neuroanesthesia (NA) MC127
Anesthetic Management in a Patient with Anti-N-Methyl-D-Aspartate Receptor Encephalitis
Ann M. Melookaran, M.D., Trevor M. Banack, M.D . Department of Anesthesiology, Yale New Haven
Hospital, New Haven, CT, USA.
Our patient is a 33 year old female who initially presented to an outside facility with headache, fever,
aches and altered mental status. She developed neurologic symptoms including seizures and
encephalopathy. She was found to have an ovarian teratoma which was removed though her
encephalopathic symptoms continued and she was transferred to our institution. She was intubated and
on mechanical ventilation throughout her inpatient stay. She developed abdominal compartment
syndrome and underwent multiple abdominal surgeries. Anesthetic management with propofol and
volatile anesthetics were tolerated without obvious complications. Ketamine and N2O and other NMDA
antagonists were avoided.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Neuroanesthesia (NA) MC129
Anesthesia Management of a 20 Week Parturient Undergoing Spinal AVM Resection With Motor
Evoked Potential Monitoring
Anand V. Narayanappa, M.D . Valley Anesthesiology Consultants and Barrow Neurological Institute,
Phoenix, AZ, USA.
Arteriovenous malformation (AVM) is a rare condition with an incidence of 1 in 100,000. I present the
case of a 22 year old, 20 week parturient, who presented with a spinal AVM for resection. Anesthetic
management involved selecting appropriate agents for motor evoked potential (MEP) monitoring that also
limited fetal risk. Management also included selecting appropriate vasopressors to maintain blood
pressure due to the hypotension associated with the anesthesia for MEP monitoring. Given the carefully
planned perioperative care, the patient had a smooth intraoperative and postoperative course.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC13
Anesthetic Challenges and Management Associated with Protamine Reactions in the
Perioperative Period
Airat A. Agbetoba, M.D., Alice Oswald, M.D . Anesthesiology, Baylor College of Medicine, Houston, TX,
USA.
Protamine is an accepted agent used for rapid reversal ofthe anticoagulant effects of heparin. It is linked
to multiple adversereactions manifesting as transient hypotension to severe cardiovascularcollapse.
Populations most at risk for protamine reactions include having a history of NPH insulin use, true fish
allergy, and a prior vasectomy. This case report describes a 67 year old Male with several uncontrolled
systemic co-morbidities on NPH insulin undergoing a L. carotid endarterctomy. He experienced a severe
anaphylactic reaction to protamine and required prolonged intubation, fluid resuscitation, and high dose
pressor support postoperatively in the surgical intensive care unit.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Neuroanesthesia (NA) MC130
Prion Encephalopathy- Anesthetic and Infection Control Implications
Sherry Nashed, M.D., A.Elisabeth Abramowicz, M.D . Anesthesiology, Montefiore Medical Center, Bronx,
NY, USA.
Copyright © 2014 American Society of Anesthesiologists
65 year old female with suspected Creutzfeldt-Jakob disease (CJD) underwent an open brain biopsy. The
OR was emptied except for the most basic equipment. The OR table, anesthesia machine, and computer
were covered with medical sterile plastic wraps. Personnel outside the room were available to deliver
additional supplies. Due to lack of patient cooperation, general anesthesia was selected. After a
Propofol/Fentanyl induction, an LMA was placed and maintenance with inhalational anesthetic was
delivered. A partial scalp block was performed. The patient awakened in the OR and discharged the
following day. Surgical instruments were incinerated after use. Patient had confirmed CJD.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Neuroanesthesia (NA) MC131
Use of Near Infrared Spectroscopy Cerebral Oximetry Monitoring for Patient With Congenital
Absence of Internal Carotid Artery During Ipsilateral Trapezius Muscle Tumor Excision in the
Lateral Position
Sam Nia, M.D., Andrew S. Greenwald, Glen Atlas, M.D. Rutgers, New Jersey Medical School, Newark,
NJ, USA.
This is a case in which a patient with a congenitally absent internal carotid artery was scheduled for
resection of a trapezius muscle tumor from the ipsilateral side of the only remaining internal carotid. This
case demonstrates the use of near-infrared spectroscopy cerebral oximetry in successfully monitoring the
patient's already-compromised cerebral perfusion to deliver a safe and effective anesthetic for same-day
surgery.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Neuroanesthesia (NA) MC132
The Perils of an Incidental Prone Extubation: Emergent Reintubation in a Patient with Ankylosing
Spondylitis Presenting with a Difficult Airway
Karmin Nissan, M.D., Verna Baughman, M.D. Anesthesiology, University of Illinois Chicago, Chicago, IL,
USA.
A 45 year old male with ankylosing spondylitis complicated by severe cervical kyphosis underwent
emergent multi-level decompression for spinal compression fractures. Endotracheal intubation was
achieved using awake nasal fiberoptic bronchoscopy. While in the prone position he was incidentally
extubated, requiring immediate supine repositioning with emergent fiberoptic reintubation. His
perioperative course was complicated by pneumothorax from subclavian central venous catheter
placement, incidental extubation in the intensive care unit requiring reintubation, pulmonary embolism,
ventilator-associated pneumonia, and prolonged intubation with resultant tracheostomy. This case
demonstrates the requisite for close communication amongst providers and a contingency plan for
emergent reintubation during prone surgery.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Neuroanesthesia (NA) MC133
Positive Neurological Outcome After Acute Neurosurgical Hemorrhage and Sustained
Hypotension
Thaddeus J. O'Barr, M.D., Vladimir Zelman, M.D.,Ph.D., Eugenia Ayrian, M.D., Amir Shbeeb, M.D. Keck
School of Medicine of USC, Los Angeles, CA, USA, LAC and USC Medical Center, Los Angeles, CA,
USA.
•65 year-old male to undergo resection of a meningioma without prior embolization therapy.•Neurologic
exam positive for mild aphasia/memory loss.•Lasix/mannitol given upon induction.•Propofol/remifentanil
for maintenance.•Meningioma capsule incision resulted in rapid blood loss of 3300 mls. MAP‟s were 2545 mm Hg for the next 3 hours with HR > 110 and ETCO2 ranging 29-36 mm Hg•ABG‟s revealed
metabolic acidosis from hypovolemia/hypoperfusion, corrected by massive transfusion/vasopressors.
Total blood loss was 8000 mls.•By POD 1, the patient was able to open his eyes. On POD 2 was
following commands. No new cognitive/sensorimotor deficits observed at time of discharge.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Neuroanesthesia (NA) MC134
Hyperacute Thrombus During Angiography for Coiling of a Cerebral Aneurysm Necessitates
Emergent Change in Hemodynamic Goals
Jeffrey Oldham, M.D., Scott Kernan, M.D., Brett Elmore, M.D., Jeremy Dority, M.D. Department of
Anesthesiology, University of Kentucky, Lexington, KY, USA.
A forty-seven year old woman presented to the angiography suite for coil embolization of a large
intracerebral aneurysm. The anesthetic plan included a nicardipine infusion to maintain MAP between 60
- 70 mmHg along with normocapnia to prevent increases in transmural pressure and possible aneurysm
rupture. After successful coil embolization, repeat angiography revealed an acute intra-arterial thrombus.
As the aneurysm had been secured, the anesthetic management was changed to include permissive
hypertension with a phenylephrine infusion to maintain MAP > 75mmHg while thrombolytic therapy was
initiated with eptifibatide. The patient recovered uneventfully without any neurologic deficit.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Professional Issues (PI) MC135
Redefining the Physician’s Role in Capital Punishment: A Case Report
Katherine O. Heller, M.D., Joel B. Zivot, M.D. Anesthesiology, Emory University School of Medicine,
Atlanta, GA, USA.
A 46 year old man was sentenced to death by lethal injection. The inmate has a history of a congenital
cavernous hemangioma leading to airway compromise. An Emory physician was asked to comment on
whether lethal injection in this instance would violate the constitutional ban on cruel and unusual
punishment. Examination revealed extensive hemangiomas resulting in near complete occlusion of the
airway. An inmate whose medical condition will inherently risk severe suffering with any respiratory
compromise challenges the appropriateness of lethal injection as currently understood. We discuss the
various ethical implications of any physician involvement in lethal injection.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Professional Issues (PI) MC136
Should Physicians Battle with Insurance Companies to Seek Approval for Indicated Pain
Therapies?
Sahar Honari, M.D., N. Nick Knezevic, M.D.,Ph.D., Kenneth D. Candido, M.D . Anesthesiology, Advocate
Illinois Masonic Medical Center, Chicago, IL, USA.
A-39-year-old woman with CRPS Type-I of her right hand who had undergone multiple pain management
treatments, including brachial plexus blocks without benefit, was unable to get pregnant again due to the
chronic use of potent pain medications. A trial spinal cord stimulator was suggested, pending approval
from her insurance company. However, after multiple rejections, several letters from pain physicians and
numerous appeals, she received approval from her insurance company to proceed. The patient
underwent trial placement, which resulted in >80% improvement. We are expecting that with healthcare
reform, our field will face more challenges in dealing with third party payers.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Professional Issues (PI) MC137
A Case of Tracheal Resection and Reconstruction in a 29-week Pregnant Patient
Caroline Bradley Gibson Hunter, M.D., Vicki Modest, M.D . Department of Anesthesia, Critical Care, and
Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
31 year old female at 29 weeks gestation presents for tracheal resection and reconstruction for severe
tracheal stenosis. Careful planning between anesthesia, maternal-fetal medicine, and thoracic surgery
teams and good intraoperative communication was integral to the success of this case. Members of each
team were consistently present in the operating room and prepared for emergent cesaerian section,
which was ultimately not necessary. The patient did have several episodes of uterine irritability
Copyright © 2014 American Society of Anesthesiologists
intraoperatively during periods of relative hypotension and hypoxia which were managed with a
magnesium infusion.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Professional Issues (PI) MC138
Turn Right: Give a Way for Intubation
Wei Jiang, M.D . Department of Anesthesiology, Shanghai Sixth People's Hospital Affiliated with
Shanghai Jiaotong University, Shanghai, China.
A 45-year-old male with a large epiglottic cyst in the vallecula presented for excision. The patient
complainted he could not lie in supine position for long time, but a right-turn relieved the obstructing
feeling. Preoperative nasopharyngoscopy demonstrated the cyst covering any view of the glottic opening.
Awake fiberoptic bronchoscopic intubation was initially tried in supine position, but the cyst obstructed the
whole inlet of the airway. After the patient was asked turn right, the cyst was dropped due to the gravity, a
clear airway was opened and the intubation was successful with a size 7.0 ETT.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Professional Issues (PI) MC139
A Multidisciplinary Approach to Massive Transfusion
Curtis J. Koons, M.D., Robert Mclennan, M.D., Dennis Williams, M.D., Eric Ashford, M.D., Dung Nguyen,
M.D. University of Kentucky, Lexington, KY, USA.
Blood products are a scarce resource requiring judicious allocation. We present a gentleman undergoing
orthotopic liver transplantation requiring massive transfusion of blood products, exhausting the supply of
our level 1 trauma center and stressing the resources of the nearby blood center. The decision to
terminate the procedure occurred after over 300 individual blood products were administered and the
hospitals supply of albumin had been depleted. We discuss a multidisciplinary approach including the
anesthesia team, surgical team, and hospital blood bank in assessing the appropriateness of use of these
limited resources and the ethical implications of termination of transfusion.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC14
My Face Is on Fire: Airway Fire During Pacemaker Insertion
Avneep Aggarwal, M.D., Mohamed Ismaeil, M.D., Indranil Chakraborty, M.D., Priya Gupta, M.D .
Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
A 82 year-old female underwent ventricular pacemaker upgrade surgery under MAC. Patient was kept on
face mask (4 LPM) as she was a mouth breather .One hour into the procedure; patient screamed my face
is on fire .Surgeon saw a flash fire and immediately removed the drapes. We promptly removed the
oxygen face mask and placed saline soaked gauzes on patient‟s face. She sustained superficial burns on
the face around the ear and under the mandible, on the left side. Patient was admitted in the SICU for
overnight observation and was discharged next day with no further complications.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Professional Issues (PI) MC140
Digital Ischemia after Epinephrine Injection: Communication is Key
Josephine A. Kweku, M.D.,M.P.H., Laila F. Makary, M.D.,Ph.D . Anesthesiology and Pain Management,
University of Texas - Southwestern, Dallas, TX, USA.
A 66 year old right-handed male underwent excision of a right middle finger cyst by plastic surgery under
local anesthesia with sedation. The patient‟s finger was injected with 20 ml 1% lidocaine with epinephrine.
At the time of injection, the type and concentration of local anesthetic was not communicated. At the end
of the procedure, the patient‟s operative finger was noted to appear white, blanched with prolonged
capillary refill and diminished sensation. At this time it was communicated that the local anesthetic used
contained epinephrine. 1 mg of phentolamine was injected into the operative finger with immediate
resolution of symptoms.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Professional Issues (PI) MC141
An Ethical Paradigm: Patient with Inoperable Lung Mass with Mediastinal Involvement for
Palliative Craniotomy
Katherine Liu, M.D., Shawn Puri, M.D., Sergey Pisklakov, M.D . Anesthesiology, UMDNJ-New Jersey
Medical School, Newark, NJ, USA, Anesthesiology, UMDNJ - New Jersey Medical School, Newark, NJ,
USA.
Although there have been advances in the treatment of cancer, it is still a leading cause of death.
Controlling symptoms related to the cancer is of vital concern in dying patients. The patient was a 79year-old with an unresectable lung mass scheduled for palliative craniotomy. Extensive discussion took
place between patient, anesthesia and neurosurgical service. Although, the procedure was extremely
high risk a decision was made to proceed. Neurosurgeries are frequently performed with a palliative goal.
The decision to proceed involves significant ethical paradigm. The goal of palliative surgery is to improve
quality of life for patient with noncurative disease.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Professional Issues (PI) MC142
Peri-Operative Management of a Von Willebrand Disease Jehovah's Witness: Balancing Belief and
Safety
Charlie C. Lu, M.D., Gabriel Bonilla, M.D . Anesthesiology, Icahn School of Medicine at Mount Sinai, New
York, NY, USA.
Von Willebrand Disease, the most common hereditary coagulopathy, presents peri-operative challenges
to the anesthesiologist. These challenges are further compounded in a Jehovah's Witness patient
presenting for a transsphenoidal pituitary resection. Special care must be taken to respectfully and safely
resuscitate these patients. We employed a technique involving careful fluid management and facilitating
appropriate coagulation that were both deemed acceptable to the patient. This case emphasizes the
importance of autonomy versus beneficence.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Professional Issues (PI) MC143
PEA Arrest During Transport of Stroke Patient on tPA
Patrick J. Milord, M.D., MBA. NYU Langone Medical Center, New York, NY, USA.
65yo M admitted for recurrent malignant pleural effusions p/w acute aphasia and right sided weakness.
PMHx: CAD s/p CABG, ICM (EF 10%), PAD s/p bilateral CEA, NHL, SCLC, HTN, CKD, DM II. Stroke
protocol initiated, IV tPA administered, and patient transferred to Neuro IR suite. Induction and intubation
were uneventful, and cerebral angiography unremarkable. Extubation deferred, and patient transferred to
MICU. Femoral A-line revealed progressively worsening hypotension en route, and upon arrival found in
PEA arrest. ACLS activated and ROSC achieved in 8 minutes, however patient expired one hour later.
Significant R chest tube output, tPA presumed as the culprit.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC15
Emergent Hematoma Evacuation Performed on a Complex Trauma Patient Unsuitable for General
and Neuraxial Anesthesia
John M. Albert, M.D., Charles Smith, M.D . Anesthesia, Case Western Reserve University MetroHealth
Hospital, Cleveland, OH, USA.
A 63-year-old female with myasthenia gravis, super morbidobesity, atrial fibrillation on warfarin, diastolic
heart failure, and OSA presented to the ED after a wheelchair transport accident. She sustained C6
fracture, bilateral rib fractures, and a femur fracture. She had leg swelling concerning for compartment
syndrome and was taken to the OR for emergent hematoma evacuation. There were concerns with
endotracheal intubation due to her unstable neck fracture and comorbidities. Regional and neuraxial
Copyright © 2014 American Society of Anesthesiologists
anesthesia were also worrisome due to warfarin use. We felt the safest option for her procedure was
MAC, which was performed with a favorable outcome.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC16
Anesthetic Concerns in a Term Parturient diagnosed withVasovagal Syncope after Gastric Bypass
Surgery
Paul J. Alea, M.D. Naval Medical Center, Portsmouth, VA, USA.
Our patient was a 36 year old female G1P0 planning on spontaneous vaginal delivery. She was
diagnosed with vasovagal syncope which developed after she had undergone gastric bypass surgery and
lost over 180 pounds. She has had 30 syncopal episodes since 2012. She has a resting heart rate in the
40‟s-60‟s which drops into the 30‟s with painful stimuli. Pt reported “coding” during surgery for open
revision of her gastric bypass. Our concern with this patient was what precautions should be employed to
prevent excessive bradycardia leading to cardiac arrest caused by the pain of labor.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC17
Airway Management of an Acute, Unstable Cervical Spine Injury
Sandra J. Alexander, M.D., John Porter, M.D . Department of Anesthesiology, Baylor College of Medicine,
Houston, TX, USA.
This is a case report of a patient with an acute, unstable cervical spine fracture who presented to the OR
for emergent cervical spine fixation. It describes the airway management selected for the patient as well
as several other options for airway management of patients with unstable cervical spine fractures. A risk
vs. benefit discussion of the options available is presented. The case report also reviews methods for
maintaining cervical spine immobility and for decreasing cervical spine motion during airway
management.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Pediatric Anesthesia (PD) MC18
Anesthesia Management in an Infant with I-cell Disease
Claude M. Abdallah, M.D., M.S Children's National, Washington, DC, USA.
I-cell disease or mucolipidosis II, is a rare metabolic storage disorder resulting from the deficiency of a
specific lysosomal enzyme, N-acetylglucosamine-1-phosphotransferease, involved in the biosynthesis of
mannose-6-phosphate. A case report of the anesthetic management of a 9 months old infant, 5 kgs, for
laparoscopic abdominal procedure with I-cell disease, intrauterine growth retardation, Alagille syndrome,
bilateral hip dysplasia, abnormal vertebrae, elevated PT and PTT , projectile vomiting and noisy breathing
with difficult endotracheal intubation is presented. Patient‟s current status is DNR/DNI. The problems
faced and their management during anesthesia are described.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Pediatric Anesthesia (PD) MC19
Anesthesia Management of a Pediatric Patient with Costello Syndrome
Claude M. Abdallah, M.D., M.S Children's National, Washington, DC, USA.
Costello syndrome is a rare genetic disorder that affects multiple organ systems and results in significant
physiologic, metabolic, and anatomic anomalies with reports of cardiac arrest upon induction of
anesthesia. This is a challenging case of a nonverbal, nonambulatory, 7 year old male, 14 kgs, with a
complex medical history including: Costello Syndrome, cardiomyopathy, hypertension treated with
lisinopril and beta blocker, chronic lung disease, severe obstructive sleep apnea and hypotonia, history of
nasopharyngeal rhabdomyosarcoma, hydrocephalus and Chiari I malformation scheduled for upper and
lower extremities phenol, botox injections and a salivogram.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Pediatric Anesthesia (PD) MC20
Difficult Airway Management in a Child With Hurler-Scheie Syndrome
Avneep Aggarwal, M.D., Sarah Tariq, M.D . Department of Anesthesiology, University of Arkansas for
Medical Sciences, Little Rock, AR, USA, Division of Pediatric Anesthesiology and Pain Medicine,
University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, AR, USA.
A 13-year-old girl with Hurler-Scheie syndrome presented for cervical laminectomy .Review of past
anesthetic history showed that although bag and mask ventilation was easy, endotracheal intubation was
a significant challenge. ENT surgery was consulted and they decided to proceed with microlaryngoscopy
,bronchoscopy and tracheostomy. GA was induced via mask using Sevoflurane. Multiple attempts at oral
intubation by ENT surgeon with rigid bronchoscope were unsuccessful. It was decided to take a look with
Glidescope as a last-ditch option before proceeding with tracheostomy. Pediatric Glidescope enabled full
visualization of glottis opening and a size 5.5 endotracheal tube was placed without any difficulty.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Pediatric Anesthesia (PD) MC21
Challenges of Vascular Access in a Patient with CLOVES Syndrome
Titilopemi A.O. Aina, M.D., Christian Seefelder, M.D., Mary Landrigan-Ossar, M.D . Anesthesiology,
Children's Hospital Boston, Boston, MA, USA.
8 month-old male with CLOVES (congenital lipomatous overgrowth, vascular malformation, epidermal
nevi, and scoliosis/spinal deformities) syndrome involving the entire trunk and all extremities, presented
for resection of left chest wall malformation. No peripheral veins or arteries were visible or palpable and
several large vessels had been coiled and embolized. On arrival to the operating room, his vascular
access was a single-lumen tunneled central venous line (CVL) and a 24-gauge peripheral intravenous
(PIV) catheter in the left hand. Expecting large blood and volume loss, additional large-bore vascular
access was required and could only safely be established using ultrasound guidance.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Pediatric Anesthesia (PD) MC22
Repetitive Cosmetic Surgical Procedure Using Submental Intubation - A Shared Operative Field
Anita Akbar-Ali, M.D., Sarah Tariq, M.D., M-Irfan Suleman, M.D., M Saif Siddiqui, M.D., William F.
Alfonso, D.D.S. Arkansas Children's Hospital, Little Rock, AR, USA.
Submental intubation is a simple and cosmetically acceptable technique that allows unobstructed access
to the maxillofacial anatomy and avoids the need for tracheotomy. It can be performed quickly by making
an incision over lingual surface of the mandible through which oral endotracheal tube is pulled out and
secured. Given the nature of the small incision, patient can be extubated postoperatively leading to a
shorter recovery time and less health care cost. We describe this technique for intubation of a female
patient with severe maxillary and frontonasal dysplasia who was scheduled for Le Fort I maxillary
advancement and cannot intubate nasally.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Pediatric Anesthesia (PD) MC23
Life-Threatening Situation in an Infant with Congenital Lobar Emphysema
Anita Akbar-Ali, Winston Y. Ota, M.D., Jesus Apuya, M.D . Division of Pediatric Anesthesiology and Pain
Medicine, Arkansas Children's Hospital, Little Rock, AR, USA.
Congenital lobar emphysema (CLE) is a rare congenital anomaly which usually presents in neonatal
period with worsening respiratory distress and failure to thrive. Perioperative optimization and
management is challenging and may result in morbidity and mortality. Worsening emphysema with
positive pressure ventilation can cause increase in intrathoracic pressure and mediastinal shift. If
significant, these changes can result in severe hemodynamic instability and rapid deterioration of the
patient leading to cardiovascular collapse. We aim to describe the anesthetic management of an 11
Copyright © 2014 American Society of Anesthesiologists
month old infant with CLE where ventilation became impossible at induction prompting a rapid life-saving
thoracotomy.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Pediatric Anesthesia (PD) MC24
Emergent Tracheostomy in a Pediatric Patient with Short Stature
Ammar A. Alamarie, M.D., Robert Calimlim, M.D . Anesthesiology, SUNY Upstate Medical Center,
Syracuse, NY, USA.
We present a 10 year old female with a mucopolysaccharidosis disorder, short stature and kyphoscoliosis
who has had multiple spinal fusions in the past, including; occiput to C5 decompression/fusion. She
presented for posterior thoracolumbar decompression & laminectomy transpendicular distectomy T12-L1.
In the OR, after mask induction, the patient was breathing spontaneously with inhalation gas. It was
difficult to gain IV access and we were unable to ventilate her. The difficult airway algorithm was followed
and a surgical airway was placed. We aim to increase awareness of dwarfism using current literature and
will discuss the challenges providers encounter.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Pediatric Anesthesia (PD) MC25
Caudal Epidural and Dexmedetomidine Sedation: A Novel Technique for Management of the High
Risk Neonate Undergoing Hernia Repair
Liliya Aulova, D.O., Joel Waring, M.D., Evan Salant, M.D., Kalpana Tyagaraj, M.D . Anesthesiology,
Maimonides Medical Center, Brooklyn, NY, USA.
We describe a novel technique for anesthetic management of premature children undergoing lower
abdominal procedures.Former 28 weeker with history of PDA, Retinopathy of Prematurity, RDS, anemia
of prematurity and episodes of apnea, presented for bilateral inguinal hernia repair at 45 weeks. A 20
gauge caudal catheter was inserted through an 18g angiocath used as primary anesthetic. 1ml of
Bupivacaine 0.5% with 5mcg/ml of epinephrine was injected. Dexmedetomidine 1mcg and Glycopyrrolate
0.02mg were given intravenously and favorable surgical conditions were obtained. At the end of the
procedure, caudal/epidural catheter was removed and patient was transferred to NICU.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Pediatric Anesthesia (PD) MC26
Anesthetic Challenges In Managing A Blind, Deaf Down's Syndrome Adolescent With Numerous
Comorbidities During General Anesthesia
Kamyar Bahmanpour, M.D., Caroline Ryan, M.D., N. Nick Kenezevic, Ph.D . Anesthesiology, Advocate
Illinois Masonic Medical Center, Chicago, IL, USA.
A 13 year old boy with Down syndrome and a 2 year old development level, deafness, blindness, seizure
disorder, asthma, self mutilating behavior was presented for dental rehabilitation. After reviewing of his
medical history and physical examination, oral premedication was administered, the patient was
transported to OR, inhalation induction with Sevoflurane, peripheral intravenous catheter placement,
uneventful asleep fiberoptic nasal intubation while maintaining neck neutrality continued with balance
anesthesia. At conclusion, the patient was extubated deep, transported to the PACU. The patient‟s pain
was evaluated and treated based upon the revised FLACC scoring system. The patient discharged home
the same day.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Critical Care Medicine (CC) MC27
Reverse Takotsubo Cardiomyopathy in a Patient with Myasthenia Gravis- A Challenging Case
Report
Benjamin M. Aakre, M.D., Kathyrn S. Handlogten, M.D., Xun Zhu, M.D . Anesthesiology, Mayo Clinic,
Rochester, MN, USA.
Copyright © 2014 American Society of Anesthesiologists
A 26-yo female was admitted with acute myasthenic crisis secondary to CAP. The patient did well with
initial conventional treatments; however, on HD-4 became acutely hypoxic after a grand mal seizure. She
was emergently intubated and high PEEP and FIO2 were instituted to maintain O2 saturations in the 80's
..inhaled NO and ECMO were considered. A TEE was ordered which showed global LV hypokinesis
(LVEF 15-20%-previously 65%) with akinesis of the base and mid-ventricular segments. We treated
supportively with inotropes, vasopressors and diuresis as needed, transitioning to beta blocker and ACE
inhibitor for discharge (HD-17). Follow up LVEF was 45%.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Critical Care Medicine (CC) MC28
Massive Pulmonary Embolism: The Role of Extracorporeal Membrane Oxygenation
Austin J. Adams, M.D., Nancy Handler, Student, James Sullivan, M.D. University of Nebraska Medical
Center, Omaha, NE, USA.
A 45 year-old woman was admitted to the anesthesia critical care service in acute cardiogenic shock
secondary to massive PE. Chest CT showed multiple large bilateral pulmonary emboli with associated
right ventricular strain. Following cardiac arrest, ECMO cannulation was performed emergently in the ED,
and the patient was transported to the ICU for further hemodynamic stabilization. Transthoracic
echocardiography showed severe right and left ventricular dysfunction. While on ECMO and pressor
support, interventional radiology performed thrombectomy of the right pulmonary artery. Cardiac function
rapidly improved, and eight days after initial presentation, the patient was discharged from the hospital.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Critical Care Medicine (CC) MC29
Perioperative Massive Pulmonary Embolism Complicating Knee Replacement and Treated With
Percutaneous Pulmonary Artery Thrombectomy
Shvetank Agarwal, M.D., Mafdy Basta, M.D . Anesthesiology and Perioperative Medicine, Georgia
Regents University, Augusta, GA, USA.
96 y old female underwent left knee replacement for distal femur fracture under epidural anesthesia and
IV sedation. After an uneventful intraoperative course, the patient became pulseless during transfer from
OR table to the hospital bed. ROSC was achieved after about 8 minutes of CPR. Stat TTE revealed
severe RV dilation and strain concerning for pulmonary embolism. Patient deemed not a candidate for
systemic thrombolysis due to recent major surgery. Emergent percutaneous pulmonary embolectomy of a
large partially occlusive LPA thrombus was done. However, patient developed refractory lactic acidosis
and increasing ionotropic requirement and expired less than 24 h later.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Critical Care Medicine (CC) MC31
Acute Airway Obstruction Following Bronchoscopy
David J. Arcella, M.D., Venkat Mangunta, M.D., Gustavo Angaramo, M.D. University of Massachusetts
School of Medicine, Worcester, MA, USA.
65-year-old male underwent flexible bronchoscopy, endobronchial biopsy of right hilar mass cervical
node. Admitted to the ICU intubated. On arrival, airway pressures were elevated followed by a
pronounced drop in oxygen saturation. Suctioned secretions were bloody. Bedside bronchoscopy
performed where a large clot was visualized partially obstructing the right main stem bronchus and
extending into the left. Sudden desaturation and bradycardia progressed to cardiac arrest. ETT replaced
under direct laryngoscopy. During flexible bronchoscopy a large clot was suctioned by the scope, became
lodged in the tip of the ETT causing immediate obstruction of the ETT.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Critical Care Medicine (CC) MC33
Cannot Ventilate after Establishment of Cricothyrotomy
Copyright © 2014 American Society of Anesthesiologists
Teruya Asahina, D.M.D., Masao Katayama, M.D.,Ph.D., Katsuyuki Miyasaka, M.D.,Ph.D . Dept. of
Anesthesiology & ICU, Perioperative Center, St. Luke International Hospital, Chuo-ku, Tokyo, Japan.
Elective cricothyrotomy for expectoration was performed while the patient was anesthetized and apneic.
After insertion of the cricothyrotomy tube (uncuffed), the deflated tracheal tube could not be advanced
and ventilation became impossible due to massive air escape.An airway seal above the cricothyrotomy
and restoration of ventilation capability were obtained only after inflating the tracheal tube cuff and
clamping the proximal end.Cricothyrotomy is useful for emergency airway securement in patients with
spontaneous respiration. Tracheostomies for elective and long term placement have very different
indications. Elective cricothyrotomy carries significant risk when applied on apneic patients and should be
avoided.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Critical Care Medicine (CC) MC34
A Young Male Patient Presented with Fatal Right Heart Failure after Pneumonectomy
Kengo Ayabe, M.D., Tosanath Leepuengtham, M.D. Indiana University School of Medicine, Indianapolis,
IN, USA.
Pneumonectomy is associated with a significant risk for perioperative morbidity and mortality.However, it
is very rare that patients, without any previous cardiac or pulmonary morbidities, present with heart failure
after pneumonectomy.We experienced a case of 31 year old with right pneumonectomy for metastases to
the lung, who presented with severe right ventricle heart failure on post operative day 2. The patient
eventually died within 24 hours after he presented with dyspnea.We will discuss how to evaluate
pneumonectomy patients more precisely and what information we should have obtained to prevent this
young gentleman death.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Critical Care Medicine (CC) MC35
Severe Septic Shock and Resuscitative Measures: Where Do We Go From Here
Abisola Ayodeji, M.D., Eduard Logvinskiy, D.O., Kalpana Tyagaraj, M.D . Maimonides Medical Center,
Brooklyn, NY, USA.
72 year old male with past history of constipation was brought to the OR for emergent exploratory
laporatomy with severe progressive abdominal distention which had been worsening for 2 years but
associated with severe abdominal pain, rigidity for 2 days. Patient was noted to have severe tachycardia,
tachypnea and hypotension. Resuscitative measures were taken in the ER prior to patient coming to the
OR. A central line and arterial line were placed. On CT scan, patient found to have multiple free air
cavities and peritonitis. Case is being presented for discussion of severe septic shock and intraoperative
resuscitation
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC36
Injury to the Pulmonary Artery: A Shocking Experience
Erin Giles, D.O., Brian Keyes, D.O., Albert Kelly, D.O . Riverside County Regional Medical Center,
Moreno Valley, CA, USA.
Hemorrhagic shock is a potential devastating surgical complication. This is a case of injury to the
posterior descending segment of the pulmonary artery during a right sided video-assisted thorascopic
surgery that resulted in massive transfusion.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC37
Anaphylaxis Most Likely Caused By Neostigmine
Erin Giles, D.O., Alice Tsao, M.D . Riverside County Regional Medical Center, Moreno Valley, CA, USA.
A 26 year old female for a tonsillectomy had undergone an uneventful course of anesthesia. At the
conclusion of the surgery she was given Glycopyrrolate and Neostigmine to reverse the neuromuscular
Copyright © 2014 American Society of Anesthesiologists
blockade. Soon after, she suffered acute onset of hypotension and tachycardia. This was refractory to
phenylephrine. The patient was salvaged with Epinephrine. The most likely cause was an allergic reaction
to Neostigmine. The allergy test result is pending.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC38
Acute Epiglottitis and Evolving Airway Obstruction After Caustic Ingestion
Alison R. Goldberger, M.D., Paul Kelsey, M.D . Department of Anesthesiology, Mount Sinai Medical
Center, New York, NY, USA.
A 74-year-old male presented to the ED four hours after caustic ingestion with no signs of airway
compromise. Fiberoptic examination by ENT revealed an erythematous, friable epiglottis. One hour later,
the patient began to have respiratory distress with difficulty managing his saliva. The patient was brought
to the OR, the airway was topicalized with 20% benzocaine, and an awake fiberoptic intubation was
successfully performed with ENT on standby. Epiglottic swelling and airway friability was significantly
worsened from previous exam. This case highlights airway challenges present with caustic ingestion as
well as the anesthetic management of acute epiglottitis.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC39
A Simple Nasal Bi-Level PAP Mask/Circuit Improved Oxygenation and Provided Supplemental
N2O Analgesia in a Morbidly Obese Patient with OSA and Known Difficult Airway during Below
Knee Amputation under Femoral/Sciatic Block
Orlando T. Gopez, Jr., C.R.N.A., Enrique Pantin, M.D., Geza Kiss, M.D., Christine Hunter-Fratzola, M.D.,
Heather Skiff, D.O., Rose Alloteh, M.D., Andrea Poon, B.S., James T. Tse, M.D.,Ph.D . Anesthesiology,
Rutgers Medical School, New Brunswick, NJ, USA.
48 y/o male (BMI 43 kg/m2) with IDDM, spina bifida, peripheral neuropathy, difficult airway, prior difficult
endotracheal intubation required emergency tracheostomy and OSA required BiPAP presented for left
below knee amputation. He received 2 mg midazolam during femoral/sciatic blocks with ultrasound
guidance. He received additional midazolam (4 mg) and was breathing comfortably with an infant mask
secured over his nose and connected to anesthesia machine with pressure-supported ventilation
(PS/PEEP: 15/7 cm H2O; TV 500-550 cc; RR 16-18; 0.5 FiO2). He complained of pain with deep incision.
After N2O (50%) was added, he became comfortable and maintained 100% O2 saturation throughout.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC40
A Case of Malignant Hyperthermia in a Trauma Patient
Angela S. Grab, M.D., Terra Wubbenhorst, M.D . University of TX at Houston, Houston, TX, USA,
Anesthesia, University of Texas Health and Science Center, Houston, TX, USA.
Our case is a 31 year old man with no past medical or surgical history who presented for fixation of a left
femur fracture. He was induced with succinylcholine, fentanyl, lidocaine and propofol and maintained on
sevoflurane. Approximately 9 minutes after induction he was noted to have diffuse muscle tensing,
tachycardia and elevated end-tidal CO2. He was diagnosed with malignant hyperthermia and successfully
resuscitated with dantrolene and treated in the ICU. Postoperative labs confirmed his diagnosis of
malignant hyperthermia and he was discharged home after 13 days with no complication related to the
malignant hyperthermia event.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC41
Intraoperative Dexmedetomidine Induced Polyuric Syndrome
Shannon L. Granger, D.O., David Ninan, D.O . Anesthesia, Riverside County Regional Medical Center,
Moreno Valley, CA, USA, Riverside County Regional Medical Center, Moreno Valley, CA, USA.
Copyright © 2014 American Society of Anesthesiologists
A 23 year old, underwent anterior cervical and posterior spinal fusion. A fiberoptic intubation under
sedation with Dexmedetomidine was used. Once intubation was completed, Dexmedetomidine was
stopped and general anesthesia maintained with propofol and remifentanil infusions. Intraoperatively, the
patient developed polyuria reaching 700 mL/hr upon completion of the case. Dexemedetomidine was
identified as the cause by diagnosis of exclusion. Being an alpha-2 agonist Dexmedetomidine also blocks
arginine-vasopressin release and its action. The effect; polyuria, has been studied during the initial drug
trials in animal models, however only three prior cases of Dexmedetomidine induced polyuria have been
described in the literature.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC42
Undiagnosed Mast Cell Disorder Presenting as Cardiac Arrest Following Induction of General
Anesthesia
Nicholas E. Burjek, M.D., Raymond Glassenberg, M.D . Department of Anesthesiology, Northwestern
University, Chicago, IL, USA.
A 33-year-old healthy female presented for lip reconstruction following a dog bite. Immediately after
induction of general anesthesia, hypotension, bronchospasm, and rash were noted. Despite intravenous
fluids and vasopressors, she progressed to PEA arrest. Return of circulation was achieved following
chest compressions and intravenous epinephrine, but the patient required vasopressor support for
twenty-four hours. A tryptase level drawn during resuscitation returned extremely elevated at 744ng/mL
(normal <11.0). Tryptase remained abnormally elevated five months later, and skin testing to all
perioperative exposures was negative, suggesting a mast cell activation disorder rather than IgEmediated anaphylaxis as the cause of circulatory collapse.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC43
A Simple Nasal CPAP Mask/Circuit Maintained Spontaneous Respiration and Improved
Oxygenation in a High-Risk OSA Patient under Propofol Sedation during SVT Ablation
Andrew Burr, D.O., Rose Alloteh, M.D., Alexander Kahan, M.D., Bruno Beja-Umukoro, C.R.N.A., Sylviana
Barsoum, M.D., Shaul Cohen, M.D., Myroslav Figura, B.S., James Tse, M.D.,Ph.D . Anesthesiology,
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
50 y/o female (BMI 30 kg/m2) with suspected OSA presented for SVT ablation under light sedation. After
pre-oxygenation (NC O2 4 L/min and TSE “Mask”), patient couldn‟t tolerate catheter insertion with 4 mg
midazolam and 75 mcg fentanyl. With additional 75 mcg/kg/min propofol, her airway became obstructed
and required jaw-thrust. An infant mask was secured over her nose and connected to anesthesia
circuit/machine. Pressure-relief valve was adjusted to deliver 5-7 cm H2O CPAP with 4 L/min O2 and 1
L/min air (0.6-0.8 FiO2). She tolerated procedure well with propofol (75-80 mcg/kg/min) and maintained
spontaneous respiration and 99-100% O2 saturation throughout.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC44
MH Precaution and CPT Type 2 Deficiency
Ofer Burshtain, M.D., Rufino Michael, M.D . Anesthesia, Montefiore Medical Center, Bronx, NY, USA.
59 Y/O Male with pmhx significant for Malignant Hyperthermia, CPT II deficiency, HTN, and HLD
scheduled for revision of hip arthroplasty. He reported a previous episode of MH as well as multiple
episodes of rhabdomyolysis during the perioperative period with previous surgeries requiring prolonged
hospital stays. Due to the PMHx of MH, general anesthesia with inhalational agents could not be used
and neither TIVA with Propofol (due to MCT type 2 and previous rhabdomyolysis). Neuraxial epidural was
used (for intraoperative and for postoperative pain control) with 2% lidocaine and supplemented using GA
with TIVA running precedex and remifentanil.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Obstetric Anesthesia (OB) MC45
Massive Transfusion in The Obstetric Patient: Changes to Traditional Resuscitation
Wesley L. Allen, M.D., Janette McVey, M.D., Steven Fogel, M.D. University of Missouri - Columbia,
Columbia, MO, USA.
Obstetric hemorrhage is the leading cause of maternal death worldwide. Current guidelines establish a
sequential 3 drug regimen; however, when hemostasis is not attained, the guidelines falter to
suggestions. Traditional massive resuscitation follows protocols derived from research in non-obstetric
patients; yet, the physiologic differences in pregnancy necessitate a change from tradition. Fibrinolysis
from hypoperfusion and dilutional coagulopathy compound a pre-existent amplified fibrinolytic system
causing drastic unopposed coagulopathy. This case report of massive hemorrhage from unknown
placenta accreta documents how early cryoprecipitate therapy and tranexamic acid after failed primary
measures proved pivotal in hemostasis, transfusion requirements, and our obstetric patient‟s survival.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Obstetric Anesthesia (OB) MC46
Anesthetic Management for Delivery of a Parturient with T-3 Paraplegia and Autonomic
Dysreflexia
Jeremy T. Almon, M.D., Daniel Biggs, M.D., Tilak Raj, M.D., Benjamin Stam, B.S. University of
Oklahoma, Oklahoma City, OK, USA.
A 29 year old G1P0 with history of T3 paraplegia and symptoms of autonomic dysreflexia during a prior
surgery presented at 37 weeksgestation for induction of labor. A continuous labor epidural was placed in
the Obstetrical ICU. She labored for 22 hours before proceeding to C-Section that was facilitated by the
existing epidural. Patient showed signs of autonomic dysreflexia during placement of epidural and fetal
delivery. We would like to present this patient because she highlights a high risk obstetric patient with
uncommon medical problems and a unique situation that interfered with adequacy of block testing.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Obstetric Anesthesia (OB) MC47
Airway Management of Ludwig’s Angina in the Setting of Urgent Cesarean Section
Abdalhai H.m. Alshoubi, M.D., Scott Switzer, M.D . Anesthesia, Baystate Medical Center, Springfield, MA,
USA.
A 31 y/o, 36 wks gestation, presented with Ludwig‟s angina. Labor began on hospital day 4, and
evaluation revealed severe preeclampsia with breech presentation. Exam demonstrated swelling of the
right face/ neck. Airway was Mallampati 4/ limited mouth opening. Plans were made for urgent cesarean
and simultaneous I&D. GA with awake nasal Fiberoptic intubation was planned. In OR, presenting part
was 3+ station, uncomplicated vaginal delivery was performed.Following delivery, the patient was nasally
intubated via Fiberoptic. I&D of the neck was then performed. The patient was transferred to ICU for
resolution of airway edema and extubated uneventfuly on POD#1.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Obstetric Anesthesia (OB) MC48
Anesthetic Management of Third Cesarean for a Parturient with history of Hypertension,
Preeclampsia and Coarctation of Aorta
Sehar Alvi, M.D., Ranita Donald, M.D . Department of Anesthesiology & Perioperative Medicine, Georgia
Regents University, Augusta, GA, USA.
A 25- year- old G5P0311 at 28 weeks gestation with history of restenosis at the site of previously repaired
coarctation of aorta as a child, came in preterm labor and was taken for cesarean section for breech
presentation. Patient had two prior cesarean sections, one of which was classical cesarean. Patient had
history of severe preeclampsia with previous pregnancy, who presented now with history of uncontrolled
hypertension with superimposed preeclampsia. Patient underwent carefully planned spinal anesthesia.
Copyright © 2014 American Society of Anesthesiologists
Case report will describe the successful management of this complex patient with history of uncontrolled
hypertension, preeclampsia and aortic coarctation.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Obstetric Anesthesia (OB) MC49
Unusual Cause of Third Trimester Hemorrhage After Fall
Wesam F. Andraous, M.D., Joy Schabel, M.D., Ramon Abola, M.D . Anesthesiology, Stony Brook
University Hospital, Stony Brook, NY, USA.
26 year old G8P5 parturient at 31weeks gestation who presented to the emergency room with abdominal
pain and profuse vaginal bleeding after a fall,patient was brought to the operating room for a stat
cesarean section under general anesthesia for presumed placental abruption.source of the bleeding was
determined to be a penetrating periurethral injury which was then repaired.The principal causes of trauma
in pregnancy include MVA, falls, assaults, homicides, domestic violence and penetrating wounds .The
assessment and rescusitation of the injured pregnant patient must consider the needs of both the mother
and the fetus
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Obstetric Anesthesia (OB) MC50
The Challenges and Choices of Anesthetic Management for an Emergent c/s in the Parturient with
Marphan’s
Ntesi A. Asimi, M.D., Kelly Arwari, M.D., Amanpreet Kaur, M.D., Jong Lee, M.D . Anesthesiology,
University of Arizona Medical Center, Tucson, AZ, USA.
A 27 year old G2P0 at 35+1 weeks gestation with past medical history significant for Marphan‟s and
chronic lumbar CSF leak presented to our hospital complaining of a headache, visual changes, epigastric
pain and nausea for 1 week. Initial evaluation was significant for SBP >200mmHg and b/l LE weakness,
preeclampsia work up was negative. The patient was admitted for BP management and scheduled for an
elective c-section at 37 weeks. Anesthesiology team was consulted from the beginning, appropriate
testing was done, elaborative plan was set in motion and the patient underwent an uneventful c-section
under general anesthesia.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Obstetric Anesthesia (OB) MC51
Epidural vs. Spinal Anesthesia - The Multiple Sclerosis Controversy in the Obstetric Patient
Ntesi A. Asimi, M.D., Stuart Hameroff, M.D., Amanpreet Kaur, M.D., Jong Lee, M.D. Anesthesiology,
University of Arizona Medical Center, Tucson, AZ, USA.
A 31 year-old G2P0 at 37+4 weeks of gestation with PMHx significant for Multiple Sclerosis (MS)
presented with spontaneous rupture of membranes. 20 hours later fever developed, additionally an
inadequate contruction pattern was achieved with high dose pitocin. It was decided to proceed with a csection. Long discussion was held with the patient, her family and the OB team - all agreed to proceed
with general anesthesia in light of concerns for postpartum MS exacerbation. The procedure was
uneventful. At 6 months postpartum there wasn‟t any MRI evidence for MS progression; however the
patient developed lower extremities weakness and fatigue.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Obstetric Anesthesia (OB) MC52
Emergent C-Section in Patient with Space Occupying Brain Lesion
Jermaine S. Augustus, M.D., Cory Scher, M.D . Anesthesiology, NYU School of Medicine, New York, NY,
USA.
A 21 y.o. G3P0 woman at 30 weeks of pregnancy was transferred to Bellevue Hospital from an OSH with
a 5.7cm X 4.8cm right parietal mass, frontal-temporal edema, 6mm leftward midline shift and worsening
headache x1 month. She was scheduled to have a craniotomy and tumor resection by the Neurosurgery
Copyright © 2014 American Society of Anesthesiologists
service but said procedure was postponed for a STAT caesarian section, on 5/12/14, secondary to
prolonged poor fetal heart rate tracings.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Obstetric Anesthesia (OB) MC53
Anesthesiologist Prevented A Possible Maternal-Neonatal Mortality And Morbidity: A Case Of
Misdiagnosed Arnold-Chiari Malformation During Labor
Kamyar Bahmanpour, M.D., Ramsis F. Ghaly, M.D., N. Nick Kenezevic, Ph.D. Anesthesiology, Advocate
Illinois Masonic Medical Center, Chicago, IL, USA.
A 24-year-old, G1P0 full-term parturient with asymptomatic-ACM presented for delivery, anesthesia was
consulted for Epidural-placement. The patient was assured by neurologist that vaginal-delivery and
epidural-placement would be safe. Neurosurgical-consultation, requested by anesthesiologist due to
abnormal neurological-examination and advanced form of Chiari-malformation with large-syrinx in brainMRI, was strongly recommended to stop active labor and proceed with Cesarean-Section. In the OR, an
uneventful awake-fiberoptic-intubation was performed concerning herniation during laryngoscopy. After
delivery of a healthy-infant, mild-hyperventilation and Mannitol-infusion was administered to decrease
ICP. The remainder of the case was uneventful with normal Post-extubation neurological-assessment.
She was recommended to follow-up with neurosurgery later.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Regional Anesthesia and Acute Pain (RA) MC54
Paravertebral Block in a DNR/DNI Coagulopathic Patient with Multiple Rib Fractures
Sehar Alvi, Ami Karkar, M.D., Yatish Ranganath, M.D. Department of Anesthesia and Perioperative
Medicine, Georgia Regents University, Augusta, GA, USA.
84 year-old male with DNR/DNI status presented with multiple rib fractures (Right 2-7 ribs) and manubrial
fracture following MVA. Other injuries: right pulmonary contusion, right pneumothorax, mediastinal
hematoma. Co-morbidities included COPD, CHF, CAD, paroxysmal Afib on Coumadin (INR 2.7). Patient
underwent paravertebral catheter placement after reversal of anticoagulation using FFP (INR 1.4). Pain
scores, CXR, ABG showed significant improvement highlighting the effective use of a paravertebral block
in a coagulopathic elderly patient with DNR/DNI status and poor cardiopulmonary reserve. We were
successful in avoiding intubation (not an option - DNI/DNR status) by achieving adequate analgesia
thereby improving lung function.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Regional Anesthesia and Acute Pain (RA) MC55
Head and Neck Pain from Epidural Placement, Could Use of Loss of Resistance to Air Technique
Be the Culprit?
Stacy P. Baker, M.D . Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
A 24 year old obese female with no other medical history presented for labor. Epidural was placed
successfully, however with much difficulty and multiple attempts using loss of resistance to air technique.
Four hours later, patient complained of severe occipital head and neck pain. CT head without contrast
revealed occipital and posterior paravertebral soft tissue air foci. The pain impaired the patient‟s ability to
push the baby out, resulting in the decision by the OBGYN team to use vacuum assisted delivery. The
patient‟s head and neck pain was treated with IV medications and resolved spontaneously over 24 hours.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Regional Anesthesia and Acute Pain (RA) MC56
Pain a Blessing in Disguise for a Frost Bite Patient
Putta Bangalore-Annaiah, M.B.,B.S., Minal Joshi, M.D., Rajammal Jayakumar, M.D., Joel Yarmush, M.D .
New York Methodist Hospital, Brooklyn, NY, USA, Anesthesiology, New York Methodist Hospital,
Brooklyn, NY, USA.
Copyright © 2014 American Society of Anesthesiologists
A 45 year old Male with frost bite to both hands was initially managed by surgery with silvadene and
heparin. A Pain consult was called reluctantly because of unrelenting pain. The therapeutic benefit of
sympathetic block was explained. Ultrasound guided right sided stellate ganglion block with 10ml of
0.25% Bupivacaine and an ultrasound guided left axillary block with 30ml of 0.25% Bupivacaine were
performed. The patient had Immediate pain relief with improvement in the circulation in both hands.
Eventual complete recovery from stage 3 frost bite was achieved and probably should be credited to
bilateral sympathetic blocks.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Regional Anesthesia and Acute Pain (RA) MC57
Thoracic Paravertebral Block for Refractory Tietze Syndrome
Eric D. Bolin, M.D., Candra Bass, M.D . Department of Anesthesiology, University of North Carolina
Chapel Hill, Chapel Hill, NC, USA.
A 20 y.o. female patient was referred to the regional and acute pain service by cardiothoracic surgery for
evaluation of chest wall pain. The patient had been diagnosed by CT surgery with Tietze syndrome. The
pain was having a profound impact on her life and had proven refractory to conservative management.
Thoracic paravertebral block was performed successfully.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Regional Anesthesia and Acute Pain (RA) MC58
Axillary Nerve Block in a Morbidly Obese Prader-Willi Patient: A Case of Challenging Pre- and
Intra-Operative Management
Shelly S. Borden, M.D., Timothy Graham, M.D . University of Wisconsin, Madison, WI, USA.
32 year-old female with Prader-Willi Syndrome underwent creation of left forearm loop graft for ESRD.
With a BMI of 79, poor functional status, propensity for challenging airway based on pre-operative
physical examination, and diagnosis of obesity hypoventilation syndrome, we elected to perform axillary
nerve block and use dexmedetomidine, ketamine and the patient‟s home BiPAP intraoperatively. We
successfully placed an axillary block in spite of her body habitus and avoided opioids, even during the
stimulating period of graft tunneling. This approach should be considered an alternative primary surgical
anesthetic in patients with increased likelihood of difficult airway.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Regional Anesthesia and Acute Pain (RA) MC59
Ultrasound Guided Ankle Block for Transmetatarsal Amputation in a Patient with a Left Ventricular
Assist Device (LVAD)
Daniel K. Broderick, M.D., Portia I. Chipendo, B.A., Abdolnabi S. Sabouri, M.D . Anesthesia, Critical Care,
and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA, Harvard Medical School, Boston,
MA, USA.
We present a 33-year-old woman with a history of renal falilure on hemodialysis, non-ischemic
cardiomyopathy, cardiac arrest status post triscuspid valve repair, and LVAD placement requiring home
dopamine, scheduled for transmetatarsal amputation for forefoot gangrene.We used an US-guided ankle
block, injecting a half and half mixture of bupivacaine 0.5% and mepivacaine 1.5% to block the posterior
tibial, deep peroneal, superficial peroneal, sural and saphenous nerves. The presence of an LVAD and
resulting arterial nonpulsatility and peripheral edema made establishing sonographic landmarks
challenging, but the block was completely successful. She maintained stable hemodynamics and LVAD
parameters throughout the procedure.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Regional Anesthesia and Acute Pain (RA) MC60
The Complicated Uncomplicated Epidural Placed Under General Anesthesia. A Complete Spinal in
the Post Anesthesia Recovery Unit
Jason Bryant, M.D . Anesthesiology, Nationwide Childrens Hospital, Columbus, OH, USA.
Copyright © 2014 American Society of Anesthesiologists
A 5 year old male had an epidural placement with negative aspiration performed under general
endotracheal anesthesia with an episode of hypotension after dosing. The patient in PACU became
somulent with redosing and progressed to unresponsiveness and apnea requiring bag mask ventilation.
There was a fast regression of analgesic levels and the patient complained of pain after 30 minutes. As
the catheter was pulled out easy flowing clear fluid was obtained.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Regional Anesthesia and Acute Pain (RA) MC61
Regional Anesthesia as a Bridge for Acute Pain Management in Gorham-Stout Syndrome
Allison R. Castro, M.D., Patrick Boyle, M.D . Anesthesiology, University of Arizona, Tucson, AZ, USA.
Our patient is a 13 year-old female with Gorham-Stout Syndrome, and acute onset right hip pain due to
intertrochanteric cortical bone disruption from lymphatic malformation. Our acute pain service was
consulted and femoral nerve catheter was placed. With 0.2% ropivicaine infusion, her pain was zero.
When her catheter was discontinued on day four, pain was uncontrollable. A second catheter was placed
with excellent pain relief. This catheter was continued for an extended duration (twenty-two days), during
which time radiation and oral therapies were completed. At this time, the infusion rate was decreased,
and catheter removed successfully with pain at baseline.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Regional Anesthesia and Acute Pain (RA) MC62
Cauda Equina Syndrome in Low-risk Patient Following Subarachnoid Block for Total Knee
Replacement
Nicholas H. Cutchens, M.D., Eric Cox, M.D . Anesthesiology, University of Tennessee Medical Center,
Knoxville, TN, USA.
77-year-old male without history of coagulopathy or routine pharmacologic anticoagulation presented for
left total knee replacement under regional anesthesia. On post-op day #1 after uneventful first-attempt
subarachnoid block, the patient complained of numbness in a saddle-distribution, followed by overflow
incontinence and bilateral lower extremity weakness. MRI of lumbar spine showed an intraspinal
intradural hematoma. Neurologic injury resulting from hematoma associated with neuraxial anesthesia
has an estimated incidence of 1 in 220,000, with most of these featuring either hemostatic abnormality or
traumatic placement of needles. On post-operative day #2 the patient underwent emergent L4 and L5
laminectomies for hematoma evacuation.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Ambulatory Anesthesia (AM) MC63
Patient with Kennedy’s Disease: a Challenging Anesthetic in Ambulatory Surgery Setting
Jay P. Kothari, M.D., Vasanti Tilak, M.D., Sergey Pisklakov, M.D . Anesthesiology, UMDNJ - New Jersey
Medical School, Newark, NJ, USA.
Kennedy's Disease is a rare neuro-muscular disease. Bulbar neurons are affected causing muscle
weakness and body wasting. It is noticeable in the throat, causing speech and swallowing difficulties. 46‐
yr‐old man clinically diagnosed with Kennedy‟s disease was undergoing a muscle biopsy. His
examination revealed atrophy, weakness and diminished reflexes. These patients are usually
predisposed to aspiration. General anesthesia depresses the swallowing reflex and further increases the
risk of aspiration. It is not clear whether succinylcholine causes a hyperkalemic response. Decreased
levels of acetylcholine increase sensitivity to non‐depolarizing neuromuscular blockers. Due to
disadvantages of general anesthesia, we chose local anesthesia with sedation.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Ambulatory Anesthesia (AM) MC64
Patient with Diamond-Blackfan Anemia: A Challenging Case in Anesthetic Management
Jay Kothari, M.D., Rania Aziz, M.D . Dept. of Anesthesiology, Rutgers - New Jersey Medical School,
Newark, NJ, USA.
Copyright © 2014 American Society of Anesthesiologists
Diamond-Blackfan Anemia (inherited erythroblastopenia), is a rare autosomal dominant disorder from loss
of ribosome protein S19 (RPS19) function. Erythroid progenitors are affected causing low RBC counts,
while platelets and WBC are unaffected. Patients have facial, cardiac, and skeletal anomalies. An 18year-old with transfusion dependent DBA underwent dental rehabilitation under general anesthesia.
Intubation, intravenous access, and blood loss were prime concern. The patient was intubated with a
MAC 2 blade and nasal rae 6.0. Numerous attempts made for IV access were required. Packed RBCs
were available. Despite oozing, patient remained stable throughout the case.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Ambulatory Anesthesia (AM) MC65
Putting a Face to the "Difficult Airway"
Brandi N. Lewis-Polite, M.D., Sanjeev Dalela, M.B.,B.S., Shvetank Agarwal, M.B.,B.S., Manuel
Castresana, M.D . Anesthesiology and Peri-operative Medicine, Georgia Regents University, Augusta,
GA, USA.
A 45 year old patient with history of Squamous cell carcinoma of nasal cavity, upper lip, and maxilla who
had previously undergone total rhinectomy, partial maxillectomy, radiation therapy, upper lip & nasal
reconstructions with bone and split-thickness grafting and decanulated tracheostomy, presented to us for
a follow up surgery for soft tissue rearrangement and flap repair. We describe the successful airway and
anesthetic management of this patient using the gold standard awake fibreoptic intubation and discuss
the perioperative challenges pertaining to airway management in this patient who encompassed every
aspect of the "difficult airway".
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Ambulatory Anesthesia (AM) MC66
A Zebra On My Chest
Brandi N. Lewis-Polite, M.D., Henry Heyman, M.D. Georgia Regents University, Augusta, GA, USA.
A 32 yr old female with history of DM, OSA, HTN (all of which resolved after gastric bypass), migraine, &
meralgia paresthetica underwent uneventful right hammertoe repair under MAC with local per surgeon.
En route to phase II anesthesia recovery patient began complaining of progressive, constant, 10/10,
epigastric pain with associated diaphoresis. Differential diagnosis included GERD, acute cardiopulmonary
processes, & Sphincter of Oddi spasm. Patient responded immediately to naloxone with complete
resolution of her chest pain. We describe the postoperative challenges in the investigation & management
of this patient's chest pain due to opioid-induced choledochoduodenal sphincter spasm.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Ambulatory Anesthesia (AM) MC67
Intraoperative Hypotension Following Insulin Boluses in Patients with Uncontrolled Diabetes
Derek Lodico, D.O., Ashley D. Gibbs, M.D., Eric L. Kent, D.O. Naval Medical Center, Portsmouth, VA,
USA.
Insulin has multi-modal effects on hemodynamics. Measured effects are net responses of competing
vasoconstricting/vasodilatory effects of insulin.We present a case involving a 78 year old female with
uncontrolled insulin dependent diabetes mellitus, presented for elective total knee arthroplasty. She
exhibited hemodynamic instability during the case with severe hypotension following intravenous insulin
boluses requiring repeated hemodynamic support.Clinical implications of this case include careful and
selective administration of intraoperative insulin in diabetic patients. Lack of history of autonomic
neuropathy should not negate the judicious administration of insulin, as autonomic neuropathy may be
sub-clinical until the patient is stressed in surgery.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Ambulatory Anesthesia (AM) MC68
Three Cases of Lingual Nerve Neuropraxia Related to the I-gel LMA
Copyright © 2014 American Society of Anesthesiologists
Rohit Mahajan, M.D., Celia Groenhout, M.D., Srinivas Chiravuri, M.D., Baskar Rajala, M.B.,B.S .
Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
This is a case series of three patients who presented to a university-associated outpatient surgical center
for elective procedures who developed lingual nerve neuropraxia post-operatively in relation to the use of
the i-gel LMA. Lingual nerve neuropraxia in relation to the use of an LMA with an inflatable cuff is a rare
complication that has been reported about ten times in the literature. There are far fewer cases in the
literature reporting lingual nerve neuropraxia in relation to the use of an LMA without an inflatable cuff,
such as the i-gel LMA.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Ambulatory Anesthesia (AM) MC69
Anesthetic Plan Challenges in a Patient with Bronchotracheal Malacia, and Tracheal Stenosis for
Cryoablation of Renal Tumor
Shahryar Mousavi, M.D., Colleen E. O'Leary, M.D SUNY Upstate University Hospital, Syracuse, NY,
USA.
56 y/o obese female (BMI= 58) with PMHx significant for COPD, severe OSA on BIPAP, chronic
respiratory failure, tracheostomy tube,bronchotracheal malacia and tracheal stenosis (internal diameter of
4mm), HTN, GERD, anxiety, and TIA was scheduled for cryoablation of thetumor by interventional
radiology after surgeon was convinced to hold on laparoscopic nephrectomy due to very high risk of
general anesthesia for the patient because of severe respiratory failure. We were able to maintain
anesthesia safely during 3 hours of the procedure while patient was prone in CT scanner by using
combination of Ketamine, precede, versed, and fentanyl.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Ambulatory Anesthesia (AM) MC70
When Less Is More: Noninvasive Monitoring for Ambulatory Surgery in a Patient with Severe
Aortic Stenosis
Ruth Neary, M.D., Megan Anders, M.D . Anesthesiology, University of Maryland Medical Center,
Baltimore, MD, USA, Anesthesiology, University of Maryland, Baltimore, MD, USA.
Patients with varying degrees of aortic stenosis are more commonly presenting for ambulatory elective
non-cardiac surgery. Trainees should be able to develop a safe anesthetic plan for these patients. This
case will discuss newer, non-invasive technology for hemodynamic monitoring the guide the
anesthesiologist in caring for the high risk patient during low risk surgery.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Ambulatory Anesthesia (AM) MC71
A Case of Difficult IV Access During a Semi-Elective Humerus Fracture Repair
Amy M. Neely, M.D., Hanni Monroe, M.D. Anesthesiology, University of Maryland Medical System,
Baltimore, MD, USA.
A 75-year-old female presented for right humerus fracture repair. The patient had difficult IV access,
necessitating ultrasound guidance for PIV placement. She subsequently received an interscalene nerve
block. Shortly after initiation of intraoperative sedation, the PIV infiltrated. Replacement attempts were
unsuccessful. A right internal jugular central venous catheter (CVC) placed under ultrasound guidance
was found to be intra-arterial. Attempts to place an intraosseous needle failed. Finally, a 24G PIV was
secured. Surgery proceeded uneventfully. The intra-arterial CVC was removed after expert consultation.
The patient was unharmed. We will debate algorithms for procuring difficult IV access and review intraarterial CVC placement.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Pediatric Anesthesia (PD) MC72
Airway Management for a Patient with Treacher-Collin Syndrome
Copyright © 2014 American Society of Anesthesiologists
Xueqin Ding, M.D.,Ph.D . Anesthesiology and Perioperative Medicine, University Hospitals Case Medical
Center, Cleveland, OH, USA.
17 yr old with Treacher-Collins syndrome and was presented for mandibular reconstruction. The patient
has facial bones hypoplasia, micrognathia and retrognathia (Fig 1,2). Mouth opening was adequate and
he had a Mallampatti class 4 airway. After glycopyralate was given, Propofol and ketamine infusion was
started to keep pt sleep and breathing. Initial mask ventilation seemed to be difficult but improved after an
orophrayngeal airway insertion. A 7.0 ET tube connector was inserted to the nasal airway. One
performing nasal fiberoptic intubation and the other maintaining assisted ventilation through nasal airway.
Fiberoptic intubation with No 6.5 ET tube was successfully placed.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Pediatric Anesthesia (PD) MC73
Esophageal Intubation Assures Ventilation
Sonia D. Duarte, M.D., Jacinta Sá, M.D., Pedro Pina, M.D. Anaesthesiology & Intensive Care, Centro
Hospitalar do Porto, Porto, Portugal.
Esophageal atresia (EA) and tracheoesophageal fistula (TOF) occurs in 1:3000-4500 newborns. Tracheal
atresia (TA) occurs in 1:50000.
We report a case of a newborn with partial TA, EA, double TOF and
imperforate anus.
Term male newborn, no prenatal diagnosis. Apgar 4/6/7. Abundant secretions,
ineffective ventilation, intubation at 10‟. Collapsed glottic cleft. Difficult tracheal (TT) and orogastric tubes
progression.
CT scan: EA, with proximal (C7) and distal TOF (left bronchus), TT extremity in the
esophageal distal sac end. TA cranial to proximal TOF. Hemodynamic instability with inotropic support. At
22hour, uneventfully emergent gastrostomy and colostomy.
On day 6, severe desaturation, cardiorespiratory arrest.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Pediatric Anesthesia (PD) MC74
Anesthetic Dilemma: Anesthetic Management of a Floppy Infant with an Undiagnosed Disease
Sonia D. Duarte, D.O., Alexandra Saraiva, M.D., Maria João Freitas, M.D., Maria José Nunes, M.D. Dept
of Anaesthesiology & Intensive Care, Centro Hospitalar do Porto, Porto, Portugal.
Newborns with congenital hypotonic syndromes are a true anesthetic challenge. We report the anesthetic
management of a 3-month-old male with congenital hypotonia proposed for gastrostomy and muscle
biopsy.Monitored pregnancy, instrumented labor. Apgar 3/8. At birth, diagnosis of dysmorphic syndrome
(micrognathia, narrow palpebral fissures, clubfoot, laryngomalacia, “omega” epiglotis), severe global
hypotonia, poor suck with nasogastric feeding, chronic respiratory insufficiency requiring BIPAP.Standard
ASA monitoring. Induction accomplished with intravenous fentanyl and sevoflurane, followed by
intubation. Grade 2 laringoscopy with BURP. Maintenance with sevoflurane, no muscle relaxant,
adequate spontaneous ventilation with PEEP. Remaining procedure uneventfully. Successfully extubated
in the ICU 5h after.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Pediatric Anesthesia (PD) MC75
Dental Rehabilitation in a Patient with Leigh’s Syndrome under Non-Trigger Anesthesia
Management
Thejovathi Edala, M.D., M-Irfan Suleman, M.D., Edwin Abraham, M.D., Saif M. Siddiqui, M.D., Jesus
Apuya, M.D. Anesthesiology, UAMS, Little Rock, AR, USA, Pediatric Anesthesiology, Arkansas Children's
Hospital, Little Rock, AR, USA.
Leigh‟s Syndrome is a rare disorder. It was first reported in 1951 by Archibald Denis Leigh, a British
neuropathologist. It is caused by mutations in mitochondrial DNA or by deficiencies of pyruvate
dehydrogenase enzyme. We report our experience in a patient with Leigh‟s Syndrome who underwent
dental rehabilitation who also has a family history suggestive of unknown hypotonia and malignant
hyperthermia.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Pediatric Anesthesia (PD) MC76
Cystoscopic Ureterocele Puncture in an Infant Complicated by Difficulty in Ventilation,
Hypothermia and Hyponatremia
Odinakachukwu A. Ehie, M.D., Louise Furukawa, M.D . Anesthesiology, Stanford University, Palo Alto,
CA, USA.
A four-week-old infant was scheduled for cystoscopic ureterocele puncture. The anesthetic is notable for
hypothermia, hyperdynamic status requiring remifentanil infusion, and progressive difficulty with
ventilation. Upon removal of surgical drapes, the abdomen was tympanic and distended. KUB revealed
dilated loops of bowel and ABG 7.25/52/181/22 with a serum Na 117. The surgeon believed the patient
was septic with ileus but the anesthesia team thought that the bladder was perforated. After transfer to
the PICU, the anesthesia fellow communicated the unexpected PICU admission to hostile non-English
speaking parents. However, the surgeon never conveyed information regarding possible bladder
perforation to the parents.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Pediatric Anesthesia (PD) MC77
Excision of Pre-auricular Appendage in Pediatrics Patient with Cri Du Chat Syndrome
Michael Fakhry, M.D., Kogan Victoria, M.D . NYU Langone Medical Center, New York City, NY, USA.
The patient is a 6 month old male with a history of Cri du chat syndrome undergoing removal of a preauricular appendage for cosmetic reasons. His physical exam displays microcephaly and micrognathia.
We planned for general anesthesia with mask ventilation. We had readily available multiple sizes of oral
airways, nasal airways, LMA‟s, and a fiberoptic scope. He received an inhalational induction with oxygen,
nitrous oxide and sevoflurane. We inserted oral and nasal airways and mask ventilation was easy. A 24
gauge IV was inserted and the surgery proceeded for 10 minutes. Emergence was uneventful and the
patient did well post-operatively.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Pediatric Anesthesia (PD) MC78
Hurler Syndrome-- More Than a Challenging Airway?
Robert E. Freundlich, M.D., M.S., Justin Routman, M.D., Virginia Gauger, M.D . Department of
Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
A 26 year old ASA 3 patient with Hurler Syndrome, C1-C2 subluxation, valvular heart disease,
hypertension, severe restrictive pulmonary function, autoimmune hemolytic anemia and cholelithiasis
presented to our children‟s hospital for laparoscopic splenectomy and cholecystectomy. Her last
anesthetic had been 3 years prior and required fiberoptic intubation. A multispecialty team, including
anesthesia, pediatric surgery, otolaryngology, and cardiology, discussed perioperative management,
specifically airway management, hemodynamic control, and post-operative pain control. Despite airway
challenges and hemodynamic instability on induction, she was successfully extubated and transferred to
the PICU for close post-operative monitoring.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Pediatric Anesthesia (PD) MC79
Management of a Complicated Airway in a Neonate with Mobius Syndrome
Joseph A. Gallombardo, M.D . Anesthesiology, Mt. Sinai Hospital, New York, NY, USA.
Mobius Syndrome is a congenital anomaly characterized by cranial nerve palsies, orofacial
abnormalities,and often times can present unique challenges for airway management. We will discuss the
airway management of a neonate who presented with many of the features of this congenital syndrome,
as well as a tethered tongue and a cleft palate.We were able to secure the airway through fiberoptic nasal
intubation. We feel that the unique presentation of this syndrome can offer an example of the planning
and preparation involved in the management of a difficult pediatric airway.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Pediatric Anesthesia (PD) MC80
Iatrogenic IV Tylenol Overdose
Samir J. Gandhi, M.D., Ranu Jain, M.D . University of Texas Health Science Center at Houston, Houston,
TX, USA.
A 3 y/o healthy 12kg male underwent laprascopic appendectomy and was accidentally given 1000mg of
IV acetaminophen. Pediatric gastroenterology was consulted for management of potential acetaminophen
toxicity. Given the paucity of information on IV acetaminophen overdose, there were a multitude of
considerations necessary to determine the medical management, particularly from the pharmacokinetic
standpoint. This case will highlight the key points of the dialogue between the GI and anesthesia teams,
as it was a novel situation for both care teams. Subsequent to this incident, we have adopted new
guidelines for IV acetaminophen administration, with the goal of preventing future errors.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC81
Severe Respiratory Acidosis Resulting from Compromise of the Inspiratory Limb of a Coaxial
Circle Breathing Circuit During Craniotomy Utilizing Intraoperative MR Guidance
Anh Q. Dang, M.D., Nicole Cournoyer, C.R.N.A., Marc Rozner, M.D.,Ph.D., Shreyas Bhavsar, D.O .
University of Texas MD Anderson Cancer Center, Houston, TX, USA.
A 57 year-old male with oligoastrocytoma presented for craniotomy with intra-operative MR guidance.
Before imaging, a progressive increase in ETCO2 and FICO2 values was observed. Blood gas revealed
severe respiratory acidosis with pH of 7.16 and pCO2 of 79 mmHg. Disconnections in the central
inspiratory limb of the co-axial circle breathing circuit were identified. These breaks resulted in rebreathing
and consequent hypercarbia and respiratory acidosis. The faulty circuits were replaced and the acidosis
quickly resolved. The remainder of the patient‟s surgery and recovery proceeded uneventfully. In the
setting of unexplained respiratory acidosis, close inspection of the breathing circuit is indicated.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC82
Anesthetic Management in Primary Autonomic Failure
Aime Pak, M.D., Bassem Asaad, M.B.,B.Ch., Syed Azim, M.B.,B.S . Stony Brook University Medical
Center, Stony Brook, NY, USA.
A 64 year old female was scheduled for a laparoscopic rotator cuff repair. Past medical and surgical
histories include autonomic failure, lower extremity reflex sympathetic dystrophy, non-obstructive CAD,
moderate COPD requiring oxygen, neurogenic bladder status post ileal conduit, constipation and GERD.
The patient is bedridden and is transported in a horizontal position with a lift as she cannot lift her upper
body greater than 15 degrees above her lower extremities without inducing syncope. The procedure
would be in sitting position for surgical exposure. In this case, we discuss the perioperative concerns in
autonomic failure and our plan for hemodynamic control.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC83
Anesthesia for a Patient with Stiff-Person Syndrome
Hugo C. de Siqueira, Ismar de Lima Cavalcanti, M.D., Paulo Alipio Germano Filho, M.D., Alberto Esteves
Gemal, Elizabeth Vaz da Silva, Gabriel Silva Cazarim. Universidade Federal Fluminense, Niteroi, Brazil,
Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil.
Stiff-Person Syndrome is a rare condition, consisting in general stiffness, pain and bed restlesness
caused by antibodies anti-GAD (GABA's precursor). This case is about a 45 year-old woman, scheduled
for a tumorectomy in right breast under general anesthesia. It can be a challenge due to the difficulty of
handling airway due to cervical stiffness and unpredictable responses to general anesthetics caused by
possible changes in GABA‟s receptors activities. Induction: propofol 70 mg IV and introduction of
Copyright © 2014 American Society of Anesthesiologists
laryngeal mask. Maintenance: sevoflurane at 1 MAC and boluses of fentanyl, 15-20mcg (total = 70mcg),
on spontaneous ventilation. Fully wake in 15 minutes.
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC84
Use of TEE and TEG for Early Detection of Hypercoagulable States
Alexander B. Denny, D.O., Mauricio Perilla, M.D . Cleveland Clinic, Cleveland, OH, USA.
31 yo female with renal cell carcinoma with IVC involvement presented for nephrectomy. A-line, doublelumen central line catheter (CLC), and one large-bore IV were inserted. Intra-op TEE was employed to
evaluate the extent of the IVC involvement. 2 hours after the CLC was placed, The TEE examination
showed a new 4 cm elongated mobile echodensity attached to the central line. A TEG showed a
Hypercoagulable state(high G-value, Maximum amplitude and short R segment). Vascular Medicine
evaluation recommended prophylactic anticoagulation for 6 weeks after surgery. This report illustrates the
use of TEE and TEG for early hypercoagulable state diagnosis.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC85
Perioperative Management of IV Inflitration During Induction
Aladino DeRanieri, M.D.,Ph.D., Sahar Honari, M.D . Department of Anesthesiology, Advocate Illinois
Masonic, Chicago, IL, USA.
The pharmacological properties of drugs are well defined when administered intravenously or orally. The
kinetics and metabolism are less defined when IV infiltration occurs. We present the case of a patient with
multiple medical problems, limited access, and complicated by IV infiltration during induction. The case
challenges were arranging for airway management during central line placement after IV infiltration during
induction and plan and timing of extubation.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC86
Emergent Neck Exploration for a Retained Foreign Body in a Patient with Positive Toxicology
Screen: A Trauma Case Report
Aladino DeRanieri, M.D., Joseph Richards, M.D . Anesthesiology, Advocate Illinois Masonic, Chicago, IL,
USA.
Many trauma patients present acutely intoxicated and with positive toxicology screens especially cocaine.
These patients may be required to undergo general anesthesia with preparedness for elevations in blood
pressure. This case is a 44 year old male with cocaine intoxication and retained foreign body after a stab
wound to the neck was through the right ear directed in a dorsal and caudal fashion lying posterior with a
possible injury to the internal carotid artery. This case involved the emergent management of a difficult
airway, full stomach and hemodynamic management of acute cocaine intoxication.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC87
Myocardial Infarction in the Post-Anesthesia Care Unit
Garo DerParseghian, M.D., Agnes Miller, M.D., Kalpana Tyagaraj, M.D . Maimonides Medical Center,
Brooklyn, NY, USA.
86 years female with history of hypertension, hyperlipidemia, PVD, TIA, hypothyroidism, infra-renal AAA
(s/p EVAR), emphysema, and left lung lesion, had elective VATS with left upper lobe tri-segmentectomy
under general anesthesia with paravertebral block. Pre-operative dobutamine stress test was negative.
Operative course was uneventful. After arrival to PACU patient became hemodynamically unstable with
BP of 68/49 and HR in the 30s. Initial management included: ephedrine, glycopyrrolate, atropine,
epinephrine, and Calcium chloride with minimal response. ECG showed inferior wall MI. Patient was
electively intubated. Emergency cardiac catheterization revealed complete RCA occlusion.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC88
Anesthetic Management of a Patient Status Post Gender Reassignment
Sandeep T. Dhanjal, M.D., Asheesh Kumar, M.D . Anesthesiology, Walter Reed National Military Medical
Center, Bethesda, MD, USA.
64-year-old female, with history of gender reassignment, aorticstenosis, asthma, and malignant
melanoma, presented for thoracoscopy and lobectomy of the lower lobe of the right lung for known mass
that was increasing in size. General anesthesia was performed, using a double lumen endotracheal tube.
Initial gender, height, and weight were used for endotracheal tube sizing and medication dosing. Epidural
analgesia was discussed, but not performed. This case reflected the impact of gender on
pharmacodynamics and pharmacokinetics of medications used in anesthesia. This case also manifests
the complexity of anesthetic management of a patient who has undergone gender reassignment.
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC89
Paradoxical Air Embolism During Liver Transplantation
Vipul J. Dhumak, M.D.,M.P.H., Theodore Marks, M.D.,Ph.D . Cleveland Clinic Foundation, Cleveland,
OH, USA.
Air embolism is a common phenomenon during liver transplantation. It occurs during the liver reperfusion
phase or during vascular anastomosis. Mortality and morbidity is severely increased by the presence of
patent foramen ovale (PFO) or intrapulmonary shunt, leading to paradoxical air embolism. Increase in
right heart pressures due to hypoxia, acidosis, pulmonary air embolism can convert a probe patent PFO
to overt PFO. Paradoxical air embolism can result in air embolus to the coronary or the cerebral
circulation. We present a case of paradoxical air embolism leading to intraoperative cardiac events during
liver transplantation and post operative neurological complications.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Obstetric Anesthesia (OB) MC90
Reversible Cerebral Vasospasm Syndrome - A Rare Presentation of Severe Preeclampsia
Brian G. Ferguson, D.O., Kalpana Tyagara, M.D., Marzanna Vasington, M.D., David Gutman, M.D., Salim
Durrani, M.D . Anesthesia, Maimonides Medical Center, Brooklyn, NY, USA.
43 year old preterm multipara with no significant history presents to L&D triage with headache and blurry
vision. Patient appeared acutely ill with BP 190/110 mm of Hg and SpO2 70%. Fetal heart rate was in
60s. Proceeded with stat C-Section under General anesthesia. Patient was extubated in OR. In PACU,
altered mental status was detected. MRI brain showed evidence for PRES syndrome and severe
vasospasm of cerebral arteries. MRA/TCD showed Reversible Cerebral Vasospasm Syndrome (RCVS).
Patient was admitted to MICU and placed on Nicardipine infusion. Case is being presented for the
discussion of RCVS, a rare presentation severe preeclampsia.
Saturday, October 11, 2014
8:10 AM - 8:20 AM
Obstetric Anesthesia (OB) MC91
Where is the Balloon? Misadventures in Interventional Radiology For A Patient with Placenta
Accreta
Jacqueline M. Galvan, Heather Nixon, M.D . Anesthesiology, University of Illinois Hospital and Health
Sciences System, Chicago, IL, USA.
The patient, a 29 year old G2P1 at 34 weeks gestation, with a history of one prior cesarean delivery
presented with antenatal vaginal bleeding. Ultrasound revealed placenta previa with concern for placenta
increta that was confirmed with MRI. Pre-operative internal iliac balloon catheter placement in
interventional radiology followed by scheduled cesarean delivery was planned. Misunderstanding and
miscommunication regarding location of the balloons resulted in emergent cesarean delivery of a high risk
obstetric patient. We discuss potential complications and management strategies during the use of
Copyright © 2014 American Society of Anesthesiologists
arterial occlusion balloon catheters for post partum hemorrhage which can minimize maternal and fetal
risk.
Saturday, October 11, 2014
8:20 AM - 8:30 AM
Obstetric Anesthesia (OB) MC92
Management of a Pregnant Patient with Hereditary Angioedema
John Gantomasso, D.O., Oksana Bogatyryova, M.D., Kalpana Tyagaraj, M.D . Maimonides Medical
Center, Brooklyn, NY, USA.
32 years parturient with history of prior C-Section, hereditary angioedema, G6PD deficiency and lumbar
surgery presents for VBAC. She was hospitalized 3 times for laryngeal edema, never intubated and
treated with IV C1 inhibitor concentrate. Upon admission, CSE was successfully placed and she delivered
a healthy girl uneventfully. C1 esterase inhibitor 500 units was administered prophylactically after
delivery. Postpartum period was uneventful. A multidisciplinary team discussion was held several weeks
prior to delivery to ensure the availability, dosing and preparation of the medication and the pharmacist
educated the whole care team regarding the mixing and use of the medication
Saturday, October 11, 2014
8:30 AM - 8:40 AM
Obstetric Anesthesia (OB) MC93
Ptosis and Unilateral Weakness: Management of Suspected Subdural Catheter Placement in the
Laboring Obstetrics Patient
Brittany E. Garel, M.D . Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital,
Baltimore, MD, USA.
A 27 year old female presented in labor. Following epidural placement, two standard test doses were
administered. Shortly after, the patient reported isolated left hand numbness. Her epidural was bolused
with 3cc of 0.125% bupivicaine and an infusion was initiated. The patient began complaining of difficulty
coughing, became hypotensive and exhibited bilateral upper and left lower extremity weakness. She also
reported patchy analgesic effect, complete loss of sensation to temperature and had right sided ptosis.
The patient was placed in the sitting position, and was administered oxygen, a fluid bolus and
phenylephrine. Following treatment the patient delivered without sequela.
Saturday, October 11, 2014
8:40 AM - 8:50 AM
Obstetric Anesthesia (OB) MC94
Thromboelastometry Guided Therapy of Refractory Bleeding in Obstetric Patient
Paulo Alipio Germano Filho, M.D., Estêvão Braga, M.D., Armin Guttman, M.D., Ana Marques, Márcio
Nagatsuka, M.D., Nubia Verçosa Figueiredo, Ph.D., Ismar Lima Cavalcanti . Hospital Federal de
Bonsucesso, Rio de Janeiro, Brazil, UFRJ, Rio de Janeiro, Brazil, UFF, Niterói, Brazil.
HELLP syndrome patient undergoes reoperation for ligation of epigastric vessels. On the 5th
postoperative day (POD) bleeding persists through the drain, refractory to transfusion of platelets and
fresh frozen plasma. Tests showed incoagulable aPTT and INR 2.27. On the 6th postoperative day
onwards employee thromboelastometry to guide therapy. In 6 POD hypofibrinogenemia diagnosed,
treated with cryoprecipitate. At 7 DPO thrombocytopenia associated with normal fibrinogen, treated with
platelet transfusion. On the 14th postoperative day again hipofibrinogenenemia treated with
cryoprecipitate. There was total control of hemorrhage and good clinical outcome. The point-of-care
coagulation monitoring viscoelastic may be useful for guiding hemostatic therapy.
Saturday, October 11, 2014
8:50 AM - 9:00 AM
Obstetric Anesthesia (OB) MC95
Emergency C-Section in a Patient with previous Fontan's Procedure
Laura E. Gilbertson, M.D., Russel E. Alexander, M.D . Anesthesiology, University of Southern California,
Los Angeles, CA, USA.
We present a case of a 23 yo F with congenital heart disease s/p Fontan‟s procedure requiring emergent
cesarean section for fetal heart tone decelerations. Fontan‟s procedure is a complex surgical procedure
Copyright © 2014 American Society of Anesthesiologists
performed in infants with hypoplastic left heart syndrome. As these patients progress into adults, they
may develop late complications such as arrhythmias, ventricular failure, protein-losing enteropathy and
thromboembolic events. Combined with the normal physiologic changes of pregnancy, patients with
congenital heart disease can have significant physiologic alterations. Careful anesthetic management is
required to avoid pulmonary edema, ventricular failure and CHF.
Saturday, October 11, 2014
9:00 AM - 9:10 AM
Obstetric Anesthesia (OB) MC96
Anesthetic Management of Pregnancy in the End Stage Liver Disease Patient
Jacob M. Gillikin, M.D.,M.P.H., Dmitri Bezinover, M.D.,Ph.D . Anesthesiology, Penn State Milton S.
Hershey Medical Center, Hershey, PA, USA.
A 40-year-old, G3P2, 40 weeks pregnant female, with end stage liver disease (ESLD) and listed for liver
transplantation, presented for delivery. ESLD was complicated by significant coagulopathy,
thrombocytopenia, and esophageal varices that required banding. A vaginal delivery was planned due to
the patient‟s stable condition, with cesarean section reserved in event of an emergency. Induction was
augmented with artificial rupture of membranes. Analgesia throughout delivery was successfully
controlled by an IV Remifentanil PCA pump. The patient gave birth to a healthy male via vaginal delivery,
with minimal postpartum bleeding controlled with uterine massage and oxytocin.
Saturday, October 11, 2014
9:10 AM - 9:20 AM
Obstetric Anesthesia (OB) MC97
Neonatal Tracheal Agenesis: An Airway Challenge for the Obstetric Anesthesiologist
Antonio Gonzalez-Fiol, M.D., Evelyn Kalyoussef, M.D., Senja Tomovic, M.D., Huma Quarashi, M.D.,
Suzanne Mankowitz, M.D. . Anesthesiology, Rutgers-New Jersey Medical School, Newark, NJ, USA,
Otolaryngology, Rutgers-New Jersey Medical School, Newark, NJ, USA, Anesthesiology, Columbia
University, New York, NY, USA.
A 1770 gram male neonate was born at 32 weeks gestation to a healthy mother. At birth, the neonate
exhibited poor respiratory effort with cyanosis and no audible cry. Despite clear visualization of the vocal
cords, resistance impeded placement of the endotracheal (ETT) through the glottis. An esophageal
intubation resulted in slight improvement in saturation. Tracheal agenesis (incidence 0.002%) was
diagnosed based on clinical findings and later confirmed by the use of radiographic evidence. Initial
stabilization requires securing an airway via esophageal intubation with positive pressure ventilation.
Overall, the prognosis is poor due to the other commonly associated anomalies (VACTERL).
Saturday, October 11, 2014
9:20 AM - 9:30 AM
Obstetric Anesthesia (OB) MC98
Labor and Delivery in a Patient with a Spinal Cord Stimulator and Fontan Physiology
David S. Greschler, M.D., Katherine G. Hoctor, M.D., Daria M. Moaveni, M.D., Amanda D. Saab, M.D .
Anesthesiology, Perioperative Medicine and Pain Management, University of Miami/Jackson Memorial
Hospital, Miami, FL, USA.
A 31 y/o G1P0 with history of tricuspid atresia s/p Fontan palliation and spinal cord stimulator for CPRS
presents in spontaneous labor at term. Due to congenital heart disease, a labor epidural was preferred to
avoid spinal or general anesthesia in an emergency. Concern was raised for a neuraxial technique in the
setting of a patient with a lumbar spinal cord stimulator and visible scars at L5-S1. Previous imaging and
bedside spine ultrasound revealed insertion of leads into the L2 epidural space traversing cephalad. A
conventional epidural was placed at the L3-L4 interspace without complication and vaginal delivery was
successful.
Saturday, October 11, 2014
8:00 AM - 8:10 AM
Pain Medicine (PN) MC99
Multimodal Analgesia in a Burn Unit: Management of Severe Pain in the Setting of Suboxone
Therapy
Copyright © 2014 American Society of Anesthesiologists
Shyamal R. Asher, M.D., Jihye Ha, M.D., Aalok Kacha, M.D., David Dickerson, M.D . University of
Chicago, Chicago, IL, USA.
42-year-old male with a history of polysubstance abuse and opioid dependence on suboxone therapy was
admitted with a 20% TBSA grease burn to the torso, neck, and arms with inhalational injury requiring
intubation. He failed the initial extubation attempt due to agitation - complaining of severe pain involving
his ear and mouth, leading to concerns for glossopharyngeal nerve injury. While intubated, his pain was
poorly controlled despite treatment with fentanyl and propofol infusions, supplemented with
hydromorphone prn. The symptoms dramatically improved after a tracheostomy, extubation, and
institution of multimodal analgesia including methadone, ketamine infusion, transdermal clonidine,
gabapentin, and hydromorphone PCA.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC02
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Obstetric Anesthesia (OB) MC144
Severe Post-Operative Bradycardia in the PACU Following Hysteroscopy
Jagroop Saran, M.D., Shuyan Huang, M.D., Suzanne Karan, M.D . University of Rochester, Rochester,
NY, USA.
We present a case of a healthy 40 year-old woman with menorrhagia for one year and uterine myoma
who underwent an uncomplicated hysteroscopy, morcellation, and endometrial ablation under general
anesthesia with a laryngeal mask airway. Immediately upon arrival to the post anesthesia care unit, she
complained of severe abdominal pain. Heart rate decreased progressively to 10 beats per minute while all
other vital signs including non invasive blood pressure and oxygen saturation were stable. The patient
was responsive throughout this episode. Glycopyrrolate, ephedrine, epinephrine were given with positive
effect. Electrolyte panel, 12 lead EKG and cardiology consult were immediately obtained.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Obstetric Anesthesia (OB) MC145
Cesarean Section of Patient with Sickle Cell Disease, HELLP Syndrome with Developing Acute
Chest Syndrome
Nicholas J. Schott, M.D., Jonathon Waters, M.D . University of Pittsburgh, Pittsburgh, PA, USA.
We described a 30 year old female with known sickle cell disease who presented with acute pain crisis at
30w5d gestation with twins. Patient had new onset pulmonary hypertension diagnosed at 28w gestation.
Patient developed HELLP syndrome, critical anemia, thrombocytopenia and was without adequate blood
product availability due to antibodies. Patient required cesarean section and prior to OR, patient
developed hypoxia and chest pain resembling clinical acute chest syndrome. We present the history,
anesthetic plan with potential use of cell salvage in sickle cell disease and management of multiple
comorbidities for surgical delivery of twins with complications including uterine atony.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Obstetric Anesthesia (OB) MC146
A Case of DIC in the Third Trimester Following Intrauterine Fetal Death: An Indwelling Neuraxial
Catheter Dilemma
Adam Schwabauer, D.O., Jesse Saliga, M.D., Stanlies D'Souza, M.D.,F.R.C.A. Anesthesiology, Baystate
Medical Center, Tufts University School of Medicine, Springfield, MA, USA.
A 35 year-old female G5P3 at 37 4/7 weeks gestation presented with a 3 day history of absent fetal
movement. Ultrasound confirmed intrauterine fetal demise. A lumbar epidural was placed for analgesia
prior to induction of labor. Two hours following successful fetal delivery, patient was noted to have
increased post-partum bleeding due to cervical laceration. The laceration was repaired using anesthesia
via the indwelling epidural catheter. Given the severity of bleeding, her epidural catheter was not
manipulated and subsequent coagulation studies revealed disseminated intravascular coagulation.
Following successful reversal of her coagulopathy, her epidural was removed 48 hours later without
incident.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Obstetric Anesthesia (OB) MC147
Presumed Venous Air Embolism During Cesarean Section
Copyright © 2014 American Society of Anesthesiologists
Adam T. Schwarz, M.D., Julia Caldwell, M.D . Penn State Milton S Hershey Medical Center, Hershey, PA,
USA.
A G3P0020 female underwent an emergent cesarean section at 24.0 weeks gestational age under
general anesthesia for moderate volume vaginal bleeding and transverse lie. Following successful
intubation and delivery of the infant, the uterus was externalized and the patient had a precipitous drop in
blood pressure, oxygen saturation, and end-tidal CO2 concerning for an embolism. The event was
successfully treated with supportive measures and she was able to be extubated upon case completion.
Postoperatively, she was monitored for subsequent complications, but she remained stable, and was later
discharged home with a diagnosis of intraoperative venous air embolism.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Obstetric Anesthesia (OB) MC148
Anesthetic Management of Acute Fatty Liver of Pregnancy
James A. Scott, D.O., Tanya Lucas, M.D . University of Massachusetts, Worcester, MA, USA.
A 25-year-old G3P1 with a twin pregnancy presented with nausea and vomiting, BP=171/89, and
AST/ALT of 158 and 154. Examination showed a jaundiced, grossly edematous patient. Labs revealed 4+
proteinuria, platelets 301, PT/PTT 25.6 and 49 seconds, and fibrinogen <50. The patient was taken for
urgent cesarean section. Two units of FFP and one unit of cryoprecipitate were administered prior to
induction of general anesthesia. After an uneventful delivery she had uterine atony requiring oxytocin,
carboprost and misoprostol. Subsequently she was diagnosed with acute fatty liver of pregnancy and is in
the SICU with multisystem organ failure.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Obstetric Anesthesia (OB) MC149
Elastic Girl and Obstetric Implications: Providing Urgent Anesthetic Care to a Parturient with
Ehlers-Danlos syndrome, Twins, and in Premature Labor
Paul R. Shekane, M.D., Mark Espina, M.D., Ghislaine Echevarria, M.D . New York University, New York,
NY, USA.
29 year old G1P0 at 26w-1d with monochorionic diamniotic twins and a history of Ehlers-Danlos
syndrome presented to the obstetrical triage unit with preterm premature rupture of membranes. A few
hours after admission the patient began complaining of worsening contractions approximately every 7-8
minutes and on exam she was now 3/60/-3 with a foot seen prolapsing into the cervical canal. Given her
changing cervical dilation and Footling breech presentation, an urgent Cesarian Section needed to be
performed. Given the known risk of neuraxial complications in the context of Ehlers-Danlos syndrome
general endotracheal anesthesia was performed with a rapid sequence induction.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Obstetric Anesthesia (OB) MC150
Labor Analgesia In a Hemophilic Parturient with Postural Orthostatic Tachycardia Syndrome
(POTS) And Epilepsy
Shashank S. Shettar, M.D., Christopher F. James, M.D . Division of Obstetric Anesthesiology, University
of Florida College of Medicine Jacksonville, Jacksonville, FL, USA, Anesthesiology, Mayo Clinic
Jacksonville, Jacksonville, FL, USA.
A 24-year old multigravida presented in preterm labor with a history of acquired hemophilia resulting in a
massive postpartum hemorrhage in a previous pregnancy, POTS (Postural Orthostatic Tachycardia
Syndrome) and a seizure disorder. Current labs revealed a Factor VIII activity of 86% with normal PTT
and PT. Hematology recommended serial Factor VIII activity monitoring and activated prothrombin
complex concentrates if indicated. Labor analgesia included a CSE with PCEA (Bupivacaine 0.1% with
2mcg/ml Fentanyl) with emphasis on limiting local anesthetic boluses to avoid any further hemodynamic
instability from POTS. Labor and postpartum period were uneventful.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Obstetric Anesthesia (OB) MC151
Pulmonary Hypertension and Pregnancy
Asha Singh, M.D., Faith Natalie Factora, M.D . Anesthesiology, Cleveland Clinic, Cleveland, OH, USA,
Cleveland Clinic, Cleveland, OH, USA.
23 yr Female with primary pulmonary hypertension on IV Prostaglandin admitted to hospital with 22 week
pregnancy and worsening shortness of breath. She refused termination of pregnancy. Her symptoms
worsened despite increasing dose of IV Prostaglandin. She developed Thrombocytopenia not responding
to treatment. Due to worsening symptoms she agreed for C-section at 24 weeks under GA. After delivery
of baby she decompensated with Suprasystolic PA pressure, Hypotension, Hypoxemia ,Hypercarbia and
Diffuse alveolar hemorrhage. TEE showed that her Foramen Ovale became patent with right to left
intracardiacshunt. She deteriorated despite NO, Milrinone. AV ECMO was started and patient shifted to
ICU.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Obstetric Anesthesia (OB) MC152
Peripartum Cardiomyopathy (Three Cases): The Role of the Anaesthetist in Diagnosing and
Managing a Serious Complication of Pregnancy
Shyrana A. Siriwardhana, M.D.,F.R.C.A, Baskaran Sabapathipillai, M.D.,F.R.C.A. Anaesthetics, North
Middlesex University Hospital, London, United Kingdom.
This presentation will describe three cases of peripartal cardiomyopathy, a life-threatening complication of
pregnancy, occurring within a three-month period in our hospital. Each presented differently and was
diagnosed respectively before, during and after labour.We have now had five cases in four months of
what is described as a rare condition in the literature, two of which were initially misdiagnosed; this may
indicate that in certain areas and populations the incidence of PPCM is higher than usually assumed. The
anaesthetist‟s essential role in history taking, early diagnosis, investigations, management and timely
referral to specialised care of this condition is described.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC153
Anesthetic Management Challenges encountered in a Patient with Advanced Amyotrophic Lateral
Sclerosis
Sehar Alvi, M.D., Evan Van Peursem, B.S., Ranita Donald, M.D . Anesthesiology & Peri-operative
Medicine, Georgia Regents University, Augusta, GA, USA.
A 74-year- old female with history of amyotrophic lateral sclerosis ( ALS ) was scheduled for therapeutic
esophagogastroduodenoscopy with percutaneous endoscopic gastrostomy tube placement under general
anesthesia. Co-morbidities included dysphagia, dysarthria, developing aphasia, dyspnea with activity,
decreased musculoskeletal strength, frequent falls, TIA , sleep apnea using BiPAP, gout, crohn‟s disease,
30 years two packs per day smoking history, PFT showed very severe restrictive airway disease. ECG
showed RBBB with LAFB. Patient underwent carefully planned general anesthesia without use of muscle
relaxants. This case will highlight the problems associated with ALS patients and the challenges
encountered with this patient's anesthetic management.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC154
Acromegaly: Airway Compromise during Emergence
Bradley B. Anderson, M.D., Mark Harbott, M.D . Anesthesiology, Baylor College of Medicine, Houston,
TX, USA.
Acromegaly is a disease of excess growth hormone resulting in a number of anatomic and
pathophysiologic changes. In particular, changes in airway anatomy result in multiple challenges for
anesthesia providers. The following case report follows a 51 year old man with acromegaly undergoing
endonasal transphenoidal pituitary resection of a growth hormone secreting tumor and his subsequent
Copyright © 2014 American Society of Anesthesiologists
post-extubation upper airway obstruction leading to emergence delirium requiring a complicated
emergent re-intubation.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC155
Recalcitrant Intraoperative Massive Subcutaneous Emphysema During Robotic Assisted
Laparoscopic Prostatectomy
Christopher M. Andrews, M.D., Jordan Yokley, M.D., Ryan Keneally, M.D . Anesthesiology, Walter Reed
National Military Medical Center, Bethesda, MD, USA.
59 year old otherwise healthy male with prostate cancer, presented for a laparoscopic robot-assisted
prostatectomy. Thirty minutes after abdominal insufflation the patient became progressively hypercarbic.
An arterial blood gas showed a pure respiratory acidosis (7.19, PaCO2 65) with normal ventilation
parameters. After sixty minutes, he was noted to have progressing massive subcutaneous emphysema
extending from the mandibular border to the knees, and was hyperventilated with marginal control of
PaCO2 levels. At the conclusion of laparoscopy the hypercarbia resolved rapidly and the patient was
extubated in the operating room after 53 minutes of continued post-operative ventilation.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC156
Peri-operative Management of Brugada Syndrome
Jaya P. Arora, M.D . Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
The patient is a 44 year old male who was diagnosed with Brugada Syndrome from a classical EKG and
lack of structural cardiac disease at his pre-op screening clinic visit for an elective procedure. The case
demonstrates his perioperative management and long term course.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC157
Necrotizing Fasciitis - Beware of Dead Ends !!
Lovkesh Arora, M.D., Bradley Grier, M.D., Marc Feldman, M.D . Anesthesiology, Cleveland Clinic
Foundation, Cleveland, OH, USA.
62-y/o male 140 kg weight w/h/o DM presented with left-sided facial swelling, initially diagnosed as
mumps, acutely worsened over 24 hours. Patient noticed a dark area along the left neck, which had
expanded rapidly 10x12 cm in size. CT scan was performed with signs concerning for necrotizing fasciitis
(subcutaneous air) and he was urgently life-flighted from outside hospital to Cleveland Clinic ED. On
evaluation had evidence of necrotic skin along the left upper neck with severe trismus. He was
emergently transferred to the operating room for superficial debridement with very challenging airway and
unfortunately succumbed intra-operatively to cardiac arrest.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC158
Proliferation of Extra-junctional Receptors in Spina Bifida. Is Succinycholine Contradicted?
Sailesh Arulkumar, M.D., Debbie Chandler, M.D . Anesthesiology, LSUHSC Shreveport, Shreveport, LA,
USA.
We report a case of a 24 year old female with a history of spina bifida with no motor strength or sensation
below the knees. Patient was brought to the operating room emergently for an exploratory laparotomy for
an incarcerated hernia. Patient was given 140mg succinylcholine for intubation. Pre-operative potassium
was 3.4. Potassium was followed post-op for 4 days and ranged from 3.5-3.9. Succinylcholine has been
contradicted in patients with major denervation injuries, spinal cord transection, and prolonged immobility
for the risk of severe hyperkalemia due via a proliferation of extra-junctional receptors.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC159
Easy Glidescope Intubation After Failed Fiberoptic Intubation in a Patient with a Tracheal
Hematoma
Zafeer Baber, M.D., Suzanne Mankowitz, M.D . Anesthesiology, Columbia University Medical Center
Center, New York, NY, USA.
93 year old woman with COPD, hypertension and heart failure was admitted for COPD exacerbation. Five
days later the patient became dyspneic, tachypneic and hypoxemic. CTA showed a rapidly expanding
retropharyngeal mass versus hematoma with marked soft tissue thickening. ENT exam revealed
significant supraglottic edema where the glottis could not be identified. The patient was taken to the OR
for an awake intubation with otolaryngology bedside in case of an emergency airway. Multiple intubation
attempts were unsuccessful using a fiberoptic bronchoscope alone and via a fastrach LMA. Prior to
tracheostomy, Glidescope attempt revealed a Grade 2 view with successful intubation.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC160
Anesthetic Management of Total Pancreatectomy with Islet Cell Autotransplantation
Zafeer Baber, M.D., HT Lee, M.D.,Ph.D . Columbia University Medical Center, New York, NY, USA.
Total pacreatectomies are performed as last line therapies for patients suffering from intractable
abdominal pain secondary to chronic pancreatitis. Aside from the normal anesthetic concerns during a
total pancreatectomy, there are additional intra-operative risks associated with an islet cell
autotransplantation including portal vein thrombosis and its associated hemodynamic effects, strict
glucose control to maximize islet cell function and management of hemorrhage and coagulopathy. We
present a 37-year-old male with a history of Type 1 diabetes and CFTR carrier suffering from idiopathic
chronic pancreatitis on a high dose regiment of home opioids is now producing C-peptide with pain relief.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC161
Severe Postoperative Hypercapnia with Sufficient Oxygenation Postoperatively
Bobby Bahadorani, D.O., Calvin Bell, D.O., Antonio Ramirez, M.D . Anesthesiology, Cleveland Clinic,
Cleveland, OH, USA.
72 year old male presented for removal of a right buccal adenocarcinoma. General anesthesia was
performed with muscle relaxant. The patient was reversed, extubated, and transferred to PACU on
6L/min nasal cannula. Upon arrival the patient had slurred speech, moved all extremities, and
hypertensive with a systolic blood pressure of 183mmHg. Within 20 minutes, the patient was
unresponsive to painful stimulus with a systolic blood pressure of 214mmHg and SpO2 100%. Stroke
protocol was initiated and an ABG was drawn revealing PCO2 170. Patient was intubated on the way to
CT and ventilated until he became responsive and ABG normalized.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Pediatric Anesthesia (PD) MC162
Management of a Pediatric Patient with Tracheomediastinal Fistula
Rita W. Banoub, M.D., Ralph Beltran, M.D., Josh Uffman, M.D., Joseph Tobias, M.D . Nationwide
Chilldren's Hospital, Anesthesiology and Pain Medicine, OH, USA.
An 11 year-old male with tracheostomy and chronic ventilator support was admitted with diagnosis of
tracheomediastinal fistula, and scheduled for placement of tracheobronchial stent. Intraoperatively, the
patient was ventilated via tracheostomy with initial parameters equivalent to his home setting. Total
intravenous anesthesia technique was adopted using propofol intermittent boluses, ketamine and
dexmedetomidine infusions. During airway manipulation, sevoflurane was added to increase the depth of
anesthesia. Ventilation via tracheostomy became inadequate while placing the stent, and required
replacement with a cuffed endotracheal tube. Stent deployment was successful. Four weeks later patient
underwent uneventful removal of the stent.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Pediatric Anesthesia (PD) MC163
The Alternative: LMAs for Tonsillectomies in Children
Alexandra E. Baracan, M.D., Richard Banchs, M.D., Katherina Lee, M.D . University of Illinois at Chicago,
Chicago, IL, USA.
A 3 yo boy underwent tonsillectomy secondary to OSA. An appropriate size reinforced LMA was used
and the case proceeded uneventfully. The child emerged from anesthesia quickly and no coughing or
gagging was observed. Tonsillectomy is a common surgical procedure in the pediatric population. The
ETT is the traditionally used airway device for tonsillectomies. Recent studies have indicated that, when
feasible to use, an LMA may be superior in safety and tolerance. Postoperative complications are also
less with the use of an LMA. The literature comparing use of LMA vs. ETT for tonsillectomies has been
reviewed and is being discussed.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Pediatric Anesthesia (PD) MC164
Anterior Mediastinal Teratoma in a 14-Year Old
Ashley D. Baracz, M.D., Michael Hosking, M.D . Anesthesiology, University of Tennessee Graduate
School of Medicine, Knoxville, TN, USA.
We describe a case of a 14-year old female who presentedwith mild dyspnea on exertion that had gotten
progressively worse. A CXR showed a large left sided mass whichwas further imaged with a CT scan and
shown to have originated in the anteriormediastinum. A biopsy showed a matureteratoma and the patient
was scheduled for surgical resection. We describe the preoperative, intraoperative,and postoperative
management of the case.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Pediatric Anesthesia (PD) MC165
17-Year-Old Honor Student with Osmotic Demyelinating Syndrome After Elective Nasal Fracture
Repair ?
Angelina D. Bhandari, M.D . Department of Anesthesia, Driscoll's Children's Hospital/ UTMB Glaveston,
Corpus Christi, TX, USA.
17 y/o honor student who was on occasional nasal vasopressin for von Willebrand disease came in for an
elective nasal septoplasty. Hematology/oncology made their recommendation for treatment
preoperatively and followed her postoperatively. 24-36 hours after successful surgery, patient had
become progressively confused and subsequently arrested on the regular floor due hyponatraemia. In the
PICU, rapid correction of the Sodium level resulted in continued confusion and deteriorating neurological
function requiring emergent MRI under anesthesia. Osmotic Demyelination Syndrome was diagnosed
and Sodium was re-lowered and slowly raised over 24 hours. The patient slowly recovered with regaining
most of her neurological function.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Pediatric Anesthesia (PD) MC166
Anesthetic Management of an Infant with a Rare Inborn Error of Metabolism (IEM)
Danielle N. Birmingham, M.D., Robert I. Richmond, M.D . University of Massachusetts Medical School,
Worcester, MA, USA.
A 3 month old female born at 41 weeks gestation via uncomplicated induced vaginal delivery presented to
the hospital with FTT, primary lactic acidosis and transaminitis of unclear etiology. History was significant
for agenesis of the corpus callosum, less than 1kg weight gain since birth and mild neurologic deficits.
She had a suspected diagnosis of pyruvate dehydrogenase deficiency. The patient was started on a
modified ketogenic diet and cofactor supplements and underwent surgical placement of a central line and
gastrostomy tube with skin and muscle biopsies. She had an uneventful perioperative course with
propofol TIVA and nitrous oxide.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Pediatric Anesthesia (PD) MC167
An Unexpected Difficult Intubation during Truncus Arteriosus Repair: Complete Tracheal Rings
Anesthetic Challenges
Kimberly R. Blasius, M.D., Peggy P. McNaull, M.D . Pediatric Anesthesiology, University of North
Carolina, Chapel Hill, NC, USA.
A 2 day old neonate presented for truncus arteriosus (TA) repair. Direct laryngoscopy revealed a grade 1
view and both a 3.0 and 2.5 cuffed-ETT were passed but both met resistance just distal the vocal cords
and were unable to be passed further. Bronchoscopy revealed significant narrowing and only a 1.8mm
scope could be passed revealing CTRs until the tracheal reopened proximal to the carina. The
multidisciplinary team discussed options for repair and a decision was made to complete a slide
tracheoplasty and the TA repair. This case of CTRs will be discussed in terms of the learning objectives.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Pediatric Anesthesia (PD) MC168
A Thoracotomy for Intralobar Sequestration: Do We Have to Do It in the OR?
Hani K. Bouchra Hanna, M.D., Joseph C. Huffman, M.D., Jesus Apuya, M.D . Department of
Anesthesiology, Arkansas Children's Hospital, University Of Arkansas for Medical Sciences UAMS, Little
Rock, AR, USA.
the golden question for sick babies undergoing emergent or elective cases , the usual question that
comes between multidisciplinary teams is the location of Operative procedure the NICU versus regular
OR , Pros and Cons which is Safer ?in this challenging case we will describe an unusual case of one
month old sick baby on inhaled nitric oxide poor oxygenation and recent diagnosis of pulmonary
sequestration where thoracotomy was done at bedside in NICU , challenges logistics as well as
perioperative anesthesia management will be described
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Pediatric Anesthesia (PD) MC169
Development of Sudden Hemodynamic Instability Following Abdominal Insufflation during a
Pediatric Abdominal Surgery
Gabrielle S. Brown, M.D., Sarah Reece Stremtan, M.D . Anesthesiology, The George Washington
University Hospital and Children's National Medical Center, Washington, DC, USA, Children's National
Medical Association, Washington, DC, USA.
A 14 year old female presented for a laparascopic heller myotomy. Two minutes following peritoneal
insufflation, the patient became profoundly bradycardic and hypotensive, with SPO2 falling into the 60‟s
and ETCO2 into the low teens. The patient was immediately given ephedrine in 5mg increments (total of
25mg), intravenous fluids bolused and switched to 100% FiO2. She was also manually bag ventilated
with normal compliance noted. Blood pressure, SPO2, and ETCO2 to the recovered within five minutes.
Given the development of sudden hemodynamic instability with temporal association to CO2 insufflation,
it was inferred that the patient had developed a CO2 embolism.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Pediatric Anesthesia (PD) MC170
Emergent Ross Procedure for MRSA Bacterial Endocarditis with Severe Aortic Regurgitation and
Pericardial Effusion with Right Atrial Collapse
Jill M. Burns, M.D., J. Michael Sroka, M.D . Wake Forest University, Winston-Salem, NC, USA.
A 3 year old female with a history of asthma presents for Emergent Ross procedure for acute bacterial
endocarditis. The patient presented from an outside hospital after three days of upper respiratory
symptoms for suspected bacterial meningitis. Subsequently, blood cultures were positive for MRSA.
Transthoracic echocardiogram showed abnormal bicommissural aortic valve with possible valvular
vegetation and possible perivalvular aneurysm versus abscess. On hospital day 11, with worsening
Copyright © 2014 American Society of Anesthesiologists
cardiopulmonary status, optiflow was initiated and repeat echo revealed extension of the perivalvular
abscess with severe aortic regurgitation and small-moderate pericardial effusion with right atrium
collapse. Patient underwent Ross Procedure.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Critical Care Medicine (CC) MC171
Repeated Cardiac Arrests Caused by an Under Sensing Epicardial Pacer Following Coronary
Artery Bypass Grafting and Maze Procedure
Sachin V. Bahadur, M.B.,B.S., Vikas Kumar, M.D., P. Benson Ham, M.D., Tao Hong, M.D . Georgia
Regents University, Augusta, GA, USA.
55 y/o male post CABG with epicardial lead placement had cardiac arrest on second postoperative day
while sitting in chair. All reversible causes were taken care of along with repeat coronary and pulmonary
angiography to rule out graft occlusion or PE. He had second cardiac arrest within 6 hours of successful
resuscitation. VF arrest was secondary to epicardial pacemaker undersensing leading to R on T
phenomenon. The epicardial leads were disconnected and patient recovered. Epicardial leads placement
is not warranted in all CABG patients and pacemaker malfunction might be difficult to diagnose in cardiac
arrest settings.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Critical Care Medicine (CC) MC172
Massive Transfusion After Liver Transplantation: Should TEG Be the New Gold Standard in
Transfusion Management?
Anila Balakrishnan, M.D., Mitchell Sally, M.D., Darren Malinoski, M.D., Eric Schnell, M.D.,Ph.D .
Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University,
Portland, OR, USA, Operative Care Division, Portland VA Medical Center, Portland, OR, USA.
A 53 year old man with end-stage liver disease secondary tohepatitis C presented for orthotopic liver
transplantation. His starting labs demonstrated an INR of 2.06, PTT 45.6, fibrinogen 112, Hct 23.2, and
platelets were 48,000. Intraoperatively, this patient had significantbleeding (EBL = 55L), requiring
continuous transfusion of pRBCs and FFP. At the end of the case, despite improving lab values, he
continued to have significant bleeding, and was transported to the ICU. Upon arrival, a
thromboelastogram (TEG) helped guide post-operative transfusion management. He was started on
tranexamic acid, and his transfusion requirements rapidly decreased.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Critical Care Medicine (CC) MC173
A Case of Acute Respiratory Distress Syndrome Complicating EBV Pneumonia
Michael J. Balderamos, M.D., James Sullivan, M.D., Angela Hewlett, M.D . Anesthesiology, University of
Nebraska Medical Center, Omaha, NE, USA, Infectious Disease, University of Nebraska Medical Center,
Omaha, NE, USA.
We present the case of a 28 year old male with no medical history who presented with a six day course of
fever, headache, and pharyngitis. He was admitted and experienced declining respiratory status. All
workup was negative except for a positive serum EBV heterophile test. Ultimately the patient required
intubation and mechanical ventilation. Chest imaging and clinical signs were consistent with ARDS. A
BAL was positive for only EBV. He was started on IV acyclovir, steroids, and ventilated in accordance
with ARDS protocol. Using this strategy the patient eventually made a full and complete recovery.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Critical Care Medicine (CC) MC174
A Case of Rocuronium Induced Anaphylaxis Reversed by Sugammadex
Rajneesh Bankenahally, M.D., Ravi Vijapurapu. Anaesthetics, Queen Elizabeth Hospital, Birmingham,
United Kingdom, Anaesthetics, City Hospital, Birmingham, United Kingdom.
Copyright © 2014 American Society of Anesthesiologists
Anaphylaxis during anaesthesia is a rare event occurring in approximately 1 in 20,000 cases and 60% of
these are secondary to the use of muscle relaxants1. We present a case of anaphylaxis to rocuronium in
a 78 year-old male patient admitted with leptospirosis to the Critical Care Unit. He developed acute
respiratory distress syndrome requiring intubation. For induction rocuronium was used and subsequent to
paralysis developed severe anaphylaxis and asystolic cardiac arrest non-responsive to conventional
treatment. The use of sugammadex led to immediate reversal of anaphylaxis, return of spontaneous
circulation and improvement in haemodynamic and respiratory state.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Critical Care Medicine (CC) MC175
Correct Placement of ICD Fails to Re-expand Lungs
Rajneesh Bankenahally, M.D., Mike McAlindon, Fliss Corcoran, Rajvinder Uppal. Anaesthetics and
Critical Care, Russells Hall Hospital, Birmingham, United Kingdom.
A 19 year old male patient admitted to the emergency department with suspected overdose needed
intubation for airway protection. There was significant desaturation post intubation and airway pressures
were very high. Chest X-Ray showed left sided pneumothorax and was treated with an intercostal chest
drain. Chest drain placement was confirmed with chest x- Ray but the pneumothorax had increased in
size with complete collapse of the left lung. Bronchoscopy was performed which revealed secretions and
mucus plugs in the left main bronchus, clearing which resulted in complete expansion of the lungs and
normal gas exchange.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Critical Care Medicine (CC) MC176
Application of Perioperative Surgical Home Model to a Patient with Renal Cell Carcinoma
Complicated by IVC Thrombus
Marisa K. Bell, Shveta Jain, M.D., Jim Nguyen, M.D., Peter Roffey, M.D., Marianna Mogos, M.D.,
Duraiyah Thangathurai, M.D. , Mark Haney, M.D . Univeristy of Southern California, Los Angeles, CA,
USA.
This case is a vehicle to discuss the philosophy of the perioperativesurgical home. A 45yo male
presented for open radical rightnephrectomy and thrombectomy. PA catheter and TEE allowed
evaluationof cardiac function, thrombus, volume status and potentialthromboembolic episodes.
Dopamine, mannitol, and nitroglycerininfusions were utilized for renal protection and manipulation of
venacava pressures during thrombectomy. Unified perioperative carepermitted early extubation,
optimization of hemodynamics, preventionof renal failure and an excellent outcome. We will also present
aretrospective chart review highlighting the role of the surgical hometo improve morbidity and mortality in
this patient population.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Critical Care Medicine (CC) MC177
Surgical Home Model for the High Risk Patient
Marisa K. Bell, Shveta Jain, M.D., Joseph Vaisman, M.D., Janak Chandrasoma, M.D., Peter Roffey, M.D.,
Marianna Mogos, M.D., Durayiah Thangathurai, M.D . University of Southern California, Los Angeles, CA,
USA.
A 21 year old female (ASA IV) presented for robotic adrenalectomy. Comorbidities included massive
obesity (BMI 60), HTN, pulmonary HTN (history of ventilator dependence), OSA, and cardiomyopathy (EF
<20%). Anesthesia was induced with low-dose propofol and sevoflurane. She was intubated via CMAC.
Arterial line, PA catheter, and TEE were placed. Pressure control ventilation was adjusted according to
her size and degree of pneumoperitoneum. Our patient was admitted postoperatively to the Anesthesia
ICU. A ketamine-fentanyl drip was utilized for pain control and sedation. She was extubated on POD #1
with aggressive ICU management involving same anesthesia team and discharged home POD#3.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Critical Care Medicine (CC) MC178
Perioperative Management of Symptomatic Ludwig's Angina
Julio Benitez-Lopez, M.D., Sean M. Quinn, M.D . University of Miami, Miami, FL, USA.
A 52 yo male, with a past medical history of substance abuse, and seizures presents to the emergency
room with a 2 day history of neck pain, and odinophagia. Patient was noted to have voice changes, and a
large submandibular mass. Otolaryngology fiberoptic examination showed oropharyngeal edema, with
obliteration of the glossoepiglottic space, consistent with ludwig's angina. Anesthesia was consulted for
emergent incision and drainage, with possible tracheostomy. Airway examination revealed limited mouth
opening, Mallampati class IV, with a tender right submandibular mass. Patient underwent successful
awake nasal fiberoptic intubation; followed by surgical drainage, and postoperative intensive care unit
monitoring.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Critical Care Medicine (CC) MC179
Serotonin Syndrome in the Intensive Care Unit Following Orthotopic Heart Transplantation.
Amar M. Bhatt, M.D., Andrew Springer, M.D., Ravi S. Tripathi, M.D . Wexner Medical Center at The Ohio
State University, Columbus, OH, USA.
BJ is a 64 yo female with non-ischemic cardiomyopathy, left-ventricular assist device, and depression
who underwent orthotopic heart transplantation. Following surgery, she was started on her home
medications including sertraline. She subsequently received methylene blue, and one dose of
ondansetron after which she developed dilated pupils, ocular clonus, diffuse muscle rigidity, bilateral
ankle clonus and severe hyperthermia. After ruling out malignant hyperthermia and neuroleptic malignant
syndrome, she was diagnosed with serotonin syndrome. All offending agents were discontinued and she
was treated with cyproheptadine, acetaminophen, lorazepam and active cooling. She had full neurologic
recovery and was discharged home in stable condition.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC180
Difficult Airway in a Patient with Recurrent Familial Giganitiform Cementoma
Brent M. Bushman, M.D., Praveen Maheshwari, M.D., Brett Hulin, D.O., Ian Bond, M.D . Anesthesiology,
University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
A 26 year old female with familial gigantiform cementoma presented to the OR for debulking of a
maxillary cementoma. The patient refused pre-oxygenation due to claustrophobia and was difficult to
bag/mask ventilate secondary to her facial deformity. The initial attempt at intubation using a GlideScope
was unsuccessful due to the protrusion of the tumor. A successful intubation was then achieved by
switching to a malleable stylet and curving it into a modified C shape. Use of a malleable stylet with a
unique C shape proved an effective method of intubation for a patient with a large oral obstruction.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC181
Severe Bronchospasm During Emergent ERCP with Air Insufflation for a Down's Syndrome
Patient with a Hiatal Hernia
Adam J. Canter, M.D., Jolie Narang, M.D., Sammy Ho, M.D . Montefiore Medical Center, Bronx, NY,
USA.
A 60y F w/ a history of Down‟s syndrome, hiatal hernia, and icterus presented for emergent ERCP for
biliary obstruction. After intubation and positioning, airway pressures rose and title volumes decreased.
Over the left lung fields, peristalsis was auscultated. Gas and irrigation were suctioned. Inadequate
minute ventilation required vent setting alterations and hand ventilation. On emergence, the patient
suddenly developed severe bronchospasm. Epinephrine, ipratropium, terbutaline, dexamethasone,
albuterol, volatile agent, and NM blocker were administered. On epinephrine drip, the bronchospasm
Copyright © 2014 American Society of Anesthesiologists
broke and the patient was kept intubated overnight. The patient was extubated within 24 hours with no
neurological deficits.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC182
Difficult Ventilation During Tracheal Resection and Sternotomy for Invasive Papillary Thyroid
Cancer
Ellise C. Cappuccio, M.D., Tracey Straker, M.D.,M.P.H . Anesthesiology, Montefiore Medical Center,
Bronx, NY, USA.
47yo F with PMH HTN and worsening “asthma” presents for total thyroidectomy and possible tracheal
resection for invasive papillary thyroid cancer. Inhalational mask induction utilized with the patient
spontaneously breathing. Suspension DL performed and the trachea was intubated with a size 6 cuffed
ETT by ENT. Later, inadequate ventilation was noted; a size 5 MLT tube was placed directly into the
trachea by ENT. Due to the extent of tumor, sternotomy was done by CT surgery. Poor ventilation again
noted and a size 6 MLT was placed by ENT. Patient remained intubated with the orotracheal tube.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC183
Post-induction Ventilator Failure in Pediatric Patient
Christine L. Carqueville, M.D., David Alspach, M.D . Department of Anesthesia & Critical Care, University
of Chicago Medical Center, Chicago, IL, USA, Anesthesiology, NorthShore University Health System,
Evanston, IL, USA.
6-month-old female, former 25 week premie, presented for bilateral myringotomy and tubes and auditory
brainstem response test under general anesthesia. The patient was mask induced, a PIV was placed, she
was intubated and manually ventilated without incident. Upon attempt to place the patient on the
ventilator, an alarm noted 'ventilator failure' despite no problems detected on the machine check earlier.
Upon inspection, the APL bypass valve connection port had broken off in the tubing (Figure). Ventilator
equipment was changed while patient was ventilated with BVM. After a machine recheck, the patient was
placed on mechanical ventilation without further incident.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC184
Should Succiny lcholine be Used for Rapid Sequence Intubation (RSI) in the Critically Ill?
Suraj M. Yalamuri, M.D., Carrie Johnson, M.D.,Ph.D., Aaron J. Sandler, M.D.,Ph.D . Duke
Anesthesiology, Durham, NC, USA.
We present a case of cardiac arrest in a 29 y/o female with a prolonged hospital course presenting for
emergent lumbar laminectomy for hematoma evacuation. Intravenous induction was accomplished with
lidocaine, propofol, and succinylcholine. Following rapid sequence intubation, ventricular fibrillation, with
features of torsades de pointes, was noted. Sinus rhythm was reestablished after two minutes of chest
compressions and administration of epinephrine, calcium chloride, andmagnesium sulfate. Surgery was
deferred and the patient was transported to the ICU. Induction of anesthesia in the critically ill presents
unique challenges.We explore the risks and benefits of succinylcholine in this patient population.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC185
Prolonged Paralysis: a Case of Pseudocholinesterase Deficiency
Jennifer Y. Wu, Dominique Schiffer, M.D . Anesthesiology, University of Colorado, Denver, CO, USA.
A 74 y/o male with obesity and hypertension presented for open cholecystectomy. He had undergone
unremarkable general anesthesia without succinylcholine one week prior and had no family history of
anesthetic complications. He received succinylcholine, propofol, and fentanyl during RSI. One hour after
induction, he was noted to have 0/4 twitches despite no further relaxant. At case end 4 hours later, patient
had 1/4 twitches. With presumed diagnosis of pseudocholinesterase deficiency, he was maintained on a
Copyright © 2014 American Society of Anesthesiologists
propofol infusion and transferred to the SICU for mechanical ventilation. Following monitored return of
twitches, patient was extubated safely and uneventfully.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC186
Severe Bronchospasm in a Patient with Dilated Cardiomyopathy and Pulmonary Emboli Resulting
in Inability to Ventilate
Vanessa Cervantes, M.D., Nicole Dobija, M.D . Anesthesiology and Pain Medicine, University of
Washington Medical Center, Seattle, WA, USA, Anesthesiology and Pain Medicine, Harborview Medical
Center, Seattle, WA, USA.
34-year-old female with history of asthma, morbid obesity, severe cardiomyopathy, and biventricular
thrombi that embolized to her lungs and lower extremities, requiring fasciotomies for compartment
syndrome, presented for debridement and skin grafting to her lower extremity wounds. After intubation,
there were elevated peak airway pressures with no breath sounds or end-tidal CO2, and oxygen
saturations to the mid-80s. Correct placement of the tube was confirmed on repeat laryngoscopy. The
patient was thought to have severe bronchospasm and this eventually broke with boluses of epinephrine.
Oxygen saturations improved and the case continued. Intraoperative TEE revealed no acute worsening of
biventricular function.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC187
Perioperative Management of a Large IGF-2 Secreting Tumor Causing Symptomatic Hypoglycemia
Vikram S. Chawa, M.D., Anjali Patel, D.O . Anesthesiology and Critical Care, St. Louis University, St.
Louis, MO, USA.
This case is about a 38 y.o. male with a history of DM I, and recently developing OSA requiring CPAP
who presented with a 8 month history of plummeting insulin requirements, increasing abdominal girth and
symptomatic hypoglycemia. He was diagnosed with an IGF-2 secreting tumor incasing the right kidney,
displacing the IVC as well as elevated urine metanepherines. He was admitted preoperatively for D10
infusion. Intraoperative management included D10 infusion and glucose testing every 15 minutes. Patient
had decreasingly labile glucose levels until 72 hours postoperatively, at which point he was started on an
insulin regimen and diet.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC188
A Simple Nasal CPAP Mask/Circuit Improved Oxygenation in an Obese Patient with Lung Cancer
Under Propofol Sedation During Radiotherapy
Antonio Chiricolo, M.D., Jacques Lorthe’, M.D., Melissa Wu, M.D., Jessica Perez, M.D., Rose Alloteh,
M.D., James T. Tse, M.D . Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
67 y/o female with obesity (BMI 39 kg/m2), asthma, OSA, NIDDM, HTN, CAD and GERD presented for
radiotherapy of the chest. After nebulized Albuterol, O2 saturation was 88-91%. It increased to 94% with
nasal cannula O2 (4 L/min) and 100% using a TSE “mask”. She desaturated to 84% with a propofol bolus
of 60mg. An infant mask was used to deliver assisted nasal ventilation (4-5 breaths), O2 saturation
increased to 100%. She resumed spontaneous respiration with nasal CPAP (12-14 cm H2O) and O2
(4L/min)/air (1L/min). She tolerated abdominal compression well with propofol infusion (50-75
mcg/kg/min) and maintained 100% SpO2 throughout.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Obstetric Anesthesia (OB) MC189
Anesthetic Considerations for the Peripartum Management of Ankylosing Spondylitis
Alexandra L. Belfar, M.D., Ashutosh Wali, M.D., Sally Raty, M.D . Baylor College of Medicine, Houston,
TX, USA.
Copyright © 2014 American Society of Anesthesiologists
The patient was a 29 y/o G1P0 female at 34 weeks gestation who had been diagnosed with ankylosing
spondylitis in Nigeria. She presented to the Pre-Anesthesia Consultation and Testing Clinic (PACT) for
evaluation for peripartum pain control/ anesthetic management in labor. All prior medical records were
unavailable due to her recent emigration to the US. Physical exam was notable for limited neck extension
due to pain, as well as limited lumbar spine extension, flexion, and lateral motion due to stiffness. Two
weeks after this visit she presented to the hospital for induction of labor due to decreased fetal
movement.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Obstetric Anesthesia (OB) MC190
Carney Complex Involving Recurrent Atrial Myxomas in a Primigravid Female with Morbid Obesity
Robert F. O'Donnell, M.D . Naval Medical Center, Portsmouth, VA, USA.
A primiparous female with history significant for Carney Complex was delivered by emergent Cesarean
section, before presenting again several months later for resection of a recurrent atrial myxoma. Carney
Complex is an autosomal dominant condition involving myxomas, hyperpigmentation, and increased
endocrine activity. The patient did not meet criteria for spinal or epidural anesthesia for her delivery, and
the emergent Cesarean section required rapid sequence induction in the setting of Cushing‟s Syndrometype physical features consistent with the endocrine effects of Carney Complex. Her rapidly enlarging
atrial myxoma was later resected to prevent ball valve-type obstruction, repeating a similar resection
during childhood.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Obstetric Anesthesia (OB) MC191
Anesthetic Challenges in the Opioid Abusing Parturient
Danielle N. Birmingham, M.D., Bronwyn Cooper, M.D . University of Massachusetts Medical School,
Worcester, MA, USA.
A 20 year old G1P0 with history of heroin abuse was admitted for IOL at 37.1 weeks due to prolonged
rupture of membranes. She had been on methadone for heroin addiction since 5 months pregnant, but
relapsed just prior to admission. Due to her history of substance abuse, there was significant difficultly
controlling labor pain. Over the course of her hospitalization, she underwent epidural catheter placement,
initiation of a remifentail PCA, and replacement of the epidural with a CSE. Labor was complicated by a
non-reassuring fetal heart rate, requiring an emergent C-section. Pain was adequately controlled with the
replacement epidural.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Obstetric Anesthesia (OB) MC192
Anesthetic Management for Labor and Delivery of a Patient with Stiff Person Syndrome
Brent T. Boettcher, D.O., Catherine Drexler, M.D . Medical College of Wisconsin, Milwaukee, WI, USA.
A woman with Stiff Person Syndrome, and associated autoimmune conditions including DM, pernicous
anemia, peripheral neuropathy was admitted to the L&D at 24w3d gestation for observation. On the 12th
day after admission the patient required Cesarean delivery due to recurrent fetal heart rate decelerations.
An epidural catheter was placed with the patient in a lateral position and continuous monitoring of fetal
heart rate. The patient was delivered of a 430g male infant with Apgar scores of 4, 5 and 6 at 1, 5, 10
minutes, respectively. The patient remained hemodynamically stable throughout the procedure and was
discharged home POD four.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Obstetric Anesthesia (OB) MC193
Acute Respiratory Distress in a Gravid Patient with Interstitial Lung Disease
Brandon J. Bortz, M.D., Sonia J. Vaida, M.D., Kunal Karamchandani, M.D . Anesthesiology, M.S. Hershey
Med Ctr, Hershey, PA, USA.
Copyright © 2014 American Society of Anesthesiologists
A twenty nine year-old female, thirty-two weeks gestation, with hereditary pulmonary fibrosis, presented to
the emergency room with dyspnea at rest and increasing oxygen requirements. On hospital day two,
patient was admitted to the ICU for worsening shortness of breath and a multidisciplinary decision was
made to try to prolong the pregnancy. However, due to worsening respiratory status refractory to
noninvasive positive pressure ventilation, it was decided that the patient required a semi-urgent cesarean
delivery. Upon transport to the operating room, the patient developed acute respiratory failure and was
emergently intubated; an emergent caesarian delivery was performed.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Obstetric Anesthesia (OB) MC194
Pneumonia With Sepsis Masquerades as Surgical Abdomen in 12 Week Parturient
Daniel E. Brezina, M.D., MBA, William Vuong, M.D . SUNY Stony Brook, Stony Brook, NY, USA.
A parturient at 12 week EGA with lower abdominal pain and vaginal bleeding underwent elap where no
pathology was discovered. In PACU her condition deteriorated with tachycardia to 150s, fever, and
tachypnea. Chest X-ray showed atelectasis and mild congestion, ABG (7.4/29/60/18) on RA. The
possibilities considered included septic abortion and pulmonary embolism. After multidisciplinary team
discussion she goes for a CAT scan to rule out PE. The scan demonstrates large multifocal pneumonia.
The patient had a full recovery with appropriate treatment; however case demonstrates the need to look
past red herrings in clinical practice.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Obstetric Anesthesia (OB) MC195
Pulmonary Embolism Presenting as Seizure in the Immediate Postpartum Period: A Case Report
Enrico M. Camporesi, M.D., Yiu-Hei Ching, M.D., Emily N. Alvey, B.S., Hesham R. Omar, M.D. , Vimal V.
Shah, M.D., Rachel A. Karlnoski, Ph.D., Catherine M. Lynch, M.D., Devanand Mangar, M.D . University of
South Florida College of Medicine, Tampa, FL, USA, Florida Gulf-to-Bay Anesthesiology Associates,
Tampa, FL, USA, Mercy Medical Center, Clinton, IA, USA.
We discuss the case of a patient with massive pulmonary embolism presenting with seizures in the
immediate postpartum period. The patient‟s course was complicated by postpartum hemorrhage and
consecutive episodes of cardiac arrest. Due to the patient‟s critical illness and hemodynamic instability,
rapid bedside transthoracic echocardiography was performed demonstrating findings consistent with
pulmonary embolism. As the patient had contraindications to systemic and directed thrombolytic therapy,
surgical embolectomy was successfully undertaken. Subsequently, the patient has been convalescing
without any further serious events.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Obstetric Anesthesia (OB) MC196
Conservative Management of Placenta Percreta in a Jehovah’s Witness Patient Complicated by
Postpartum Preeclampsia
Enrico M. Camporesi, M.D., Yiu-Hei Ching, M.D., Mary A. Cain, M.D., Emily N. Alvey, B.S., Amrat M.
Anand, M.D., Mitchel S. Hoffman, M.D., Julie U. Leffler, M.D., Devanand Mangar, M.D . University of
South Florida College of Medicine, Tampa, FL, USA, Florida Gulf-to-Bay Anesthesiology Associates,
Tampa, FL, USA.
This is a patient with placenta percreta initially managed with Cesarean delivery, uterine preservation,
and placental retention. Conservative management was pursued for extensive percreta and the patient‟s
unwillingness to accept blood products for religious beliefs. Post-delivery, she developed hypertension
and proteinuria likely due to mild preeclampsia managed with oral nifedipine. Discharge occurred on postoperative day 5. On post-operative day 12, she presented with severe hypertension and headache.
Concerning for severe preeclampsia with retained placental tissue, she underwent hysterectomy with
placenta removal. Afterwards, preeclampsia symptoms resolved and hypertension improved. Despite
definitive management, all procedures were completed without need for blood products.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Obstetric Anesthesia (OB) MC197
Combined Spinal-Epidural Anesthesia for a Severe Preeclamptic, Hemodialysis-Dependant
Woman Requiring Emergent Cesarean Section
Hector F. Casiano-Pagan, M.D., Marinell Rivera, M.D., Marcell Hernandez, M.D . Anesthesiology,
University of Puerto RIco, San Juan, PR, USA.
We describe a challenging case were the use of combined spinal and epidural anesthesia (CSEA) was
performed in a 39 year old female ASA IV, G1P0A0, at 26 weeks GWA with severe preeclampsia and
acute renal failure (ARF), requiring daily hemodialysis. Patient‟s co-morbidities included morbid obesity,
chronic hypertension, Type 1 Diabetes Mellitus, Hypothyroidism, Chronic Kidney Disease, and femoral
artery pseudoaneurysm. Emergency C-section was programmed after severity of preeclampsia ensued.
Considering patient‟s hemodynamic instability, fluid overload status, and difficult airway, adequate
anesthesia was achieved without maternal or neonatal sequela.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Regional Anesthesia and Acute Pain (RA) MC198
Difficult Complex Regional Pain Syndrome Diagnosis and Treatment in a Pediatric Patient
Alberto J. de Armendi, M.D., Daniel Corn, M.D., Christopher Godlewski, M.D., Carol Loeber, R.N., Amir
Butt, M.B.,B.S., Badie Mansour, M.D . University of Oklahoma Health Science Center, Oklahoma City,
OK, USA.
A 15 year old patient after 11 hours of anesthesia (GAwith epidural) for embryonal rhabdomyosarcoma
resection could not feel both LE.The epidural was removed after surgery. Four days later, the patient
hadburning, tingling and paresthesias, numbness, weakness and pain to the RLE. Twomonths later after
chemotherapy, the patient was treated with Morphine, Oxycontin,Amitriptyline, Zoloft, Valium, and
Gabapentin and still had symptons. Referredto PPMS and diagnosed with CRPS. Opioids were tapered,
Clonidine, Lyrica, IVLidocaine, PT, TENS unit and MRI were ordered, and epidural was placed.
Thepatient was walking three days later.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Regional Anesthesia and Acute Pain (RA) MC199
Life-Threatening, Intraoperative Hemodynamic Instability in a Quadriplegic
Peter R. DeHaai, D.O., Melanie Donnelly, M.D., Robert Jenkinson, M.D., Richard Galgon, M.D., M.S .
Anesthesiology, University of Wisconsin, Madison, WI, USA.
A 57-year-old, quadriplegic male with a remote C4-5 spinal injury presented for cystoscopy, ureteroscopy,
and laser lithotripsy for recurrent nephrolithiasis. Following administration of a spinal anesthetic and
perioperative antibiotics, the patient became hypotensive, tachycardic and unresponsive. Hemodynamic
instability improved following intubation and epinephrine/vasopressin infusions. A diffuse blanching
erythematous rash was ultimately discovered without mucosal edema or wheezing. The procedure was
canceled, and the patient was transferred to the ICU where elevated tryptase levels were detected. While
treatment was appropriate, recognition of an anaphylactic reaction was delayed in this case secondary to
the concomitant administration of a spinal anesthetic.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Regional Anesthesia and Acute Pain (RA) MC200
Supraclavicular Block for Wrist Surgery in a Patient with Meromelia of the Contralateral Forearm
Robert A. Doty, Jr., M.D., Luminita Tureanu, M.D., Edward Yaghmour, M.D., Jessica Buren, M.D., Mark
Kendall, M.D . Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
59 y/o F, ASA 2, congenitally absent LEFT forearm (Meromelia) for RIGHT arthroscopic wrist surgery
under short acting “periclavicular block” per surgeon. Patient with severe anxiety of awareness with
General Anesthesia and pain (I.V. morphine intolerance). Patient Regional Block concerns: nerve injury,
prolonged nerve blockade limiting post op self care. Patient given thorough explanation of options, risks
and benefits; chooses short acting supraclavicular block (SCB) and sedation.POSTOP: Brief anxiety from
Copyright © 2014 American Society of Anesthesiologists
right arm weakness. Pain score 0/10. No additional analgesics required. Motor block completely resolved
before discharge, with no evident neurologic deficits.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Regional Anesthesia and Acute Pain (RA) MC201
Thoracic Epidurals- To Place or Not to Place?
Kimberly B. Fischer, M.D., Karina Gritsenko, M.D . Anesthesiology, Montefiore Medical Center, the
University Hospital for Albert Einstein College of Medicine, Bronx, NY, USA.
A 72 year-old male with a history of CAD on ASA and Plavix presents to the OR for a planned VATs,
possible thoracotomy, for a pleural hematoma. Eight days prior, the patient stopped taking all
anticoagulation medications. On the day of surgery, all coagulation labs are within normal limits. He is
consented for placement of an epidural for postoperative analgesia should a thoracotomy be performed.
After extubation, a thoracic epidural is placed in a single attempt. On POD#2, the patient is unable to
move his legs. MRI documents a T1-9 epidural hematoma. He is brought emergently to the OR.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Regional Anesthesia and Acute Pain (RA) MC202
The Resilient Catheter
Michael R. Foley, M.D., Meghan Connolly, N.P., Marc Shnider, M.D., Cindy Ku, M.D . Anesthesia, Critical
Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
This is a case report of an epidural catheter that was unable to be removed by conventional means. A
thoracic epidural was placed in a 21 y/o female following a thoracotomy for an aortic aneurysm repair.
When the acute pain service team went to remove the catheter on post-operative day three the catheter
was unable to be removed despite multiple attempts, personal and techniques. Ultimately, the patient was
sent to interventional radiology where the catheter was directly visualized on CT, an introducer was
placed through the catheter, a small skin nick was made and the catheter was successfully removed.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Regional Anesthesia and Acute Pain (RA) MC203
Ropivacaine-Induced Late-Onset Systemic Toxicity after Femoral-Sciatic Peripheral Nerve Block
Under Monitored Anesthesia Care
Alexander Froyshteter, M.D., Arvind Rajagopal, M.D . Rush University Medical Center, Chicago, IL, USA.
An 80 kg 41-year-old female with past history of hypertension and lupus, presented for foot surgery under
femoral-sciatic block using 55ml of 0.5% ropivacaine with epinephrine. She was sedated lightly using a
propofol infusion. She was stable and conversant during surgery.Two hours later in the recovery room,
patient was somnolent and experienced three brief episodes of tonic-clonic seizures. Treatment included
intravenous midazolam, lorazepam, propofol, and intra-lipid followed by dilantin. CT, MRI and EEG done
were all negative. Neurology attributed the seizures to a rare case of delayed ropivacaine toxicity. She
was discharged home on day two with no sequelae.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Regional Anesthesia and Acute Pain (RA) MC204
Titrated Neural Blockade via Interscalene Catheter for Shoulder/Elbow Surgery in a Chronic Pain
Patient with Cardiopulmonary Comorbidity
Ross G. Gaudet, M.D., David M. Dickerson, M.D . Department of Anesthesiology & Critical Care,
University of Chicago Hospital, Chicago, IL, USA.
A67 year-old female with history of SLE, chronic total body pain, asthma, OSA,orthopnea, and GERD
presented for left reverse shoulder arthoplasty and ulnarnerve release. Anesthetic plan was interscalene
peripheral nerve catheter. Catheterwas tunneled and anchored through the trapezius and middle scalene
muscle tolie posterior to C5 & C6 nerve roots. Five mL 2% lidocaine was bolusedhourly after activation
with 8 mL facilitating surgical block. After an uneneventful procedure, the catheterwas infused with
0.125% bupivacaine.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Regional Anesthesia and Acute Pain (RA) MC205
TEG Platelet Mapping Guided Removal of an Epidural Catheter after Plavix and Aspirin
Administration
Carl H. Guild, III, M.D., Casey M. Windrix, M.D . Anesthesiology, University of Oklahoma College of
Medicine, Oklahoma City, OK, USA.
A 58 year old male with a past medical history of cardiac stent placement and carcinoma of the lung
presented for thoracotomy with left upper lobectomy. Aspirin and clopidogrel were discontinued for 3
weeks prior to surgery. A thoracic epidural was placed preoperatively for post-operative pain control. The
primary team prescribed aspirin and ketorolac on postoperative day 1, and resumed clopidogrel on
postoperative day 3. Adequate platelet function was confirmed on postoperative day 5 by
thromboelastography with platelet mapping. The epidural was removed with no complications.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Regional Anesthesia and Acute Pain (RA) MC206
Serratus Plane and Rectus Sheath Blocks With Liposomal Bupivacaine After Open
Cholecystectomy
Niels M. Hauff, M.D., Ross Gliniecki, M.D., Judd Whiting, M.D., Ian Fowler, M.D . Naval Medical Center
San Diego, San Diego, CA, USA.
We report two cases of ultrasound-guided rectus sheath and serratus plane blocks using liposomal
bupivacaine for pain control following open cholecystectomy with subcostal incision. A total of 266mg
liposomal bupivacaine was divided into two 133mg doses in 15cc & injected into the right serratus plane
and right rectus sheath. One patient required a morphine equivalent dose (MED) of only 21.1mg in the
first 48 hours after surgery, and he required no further opioid pain medication. A second patient required
82.5mg MED in the first 36 hours but required no additional opioids thereafter and was discharged home
on postoperative day two.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Ambulatory Anesthesia (AM) MC207
Expecting the Unexpected: Anesthetic Management of a Patient with Acute Intermittent Porphyria
Chinwe I. Nwosu, M.D . University of Maryland, Baltimore, MD, USA.
A 62-year-old woman with acute intermittent porphyria (AIP) and a post-operative lower extremity DVT,
following a knee arthroscopy months prior, presented to the hospital with a thigh hematoma in the setting
of warfarin use. Anticoagulation was discontinued and IVC filter placement was planned. AIP is a disorder
characterized by a deficiency in an enzyme necessary for the production of heme, leading to a toxic
accumulation of by-products. Acute attacks of AIP are triggered by several factors, including some
commonly used anesthetic medications. Anesthesiologists should be aware of the safety profile of
anesthetics in patients with AIP.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Ambulatory Anesthesia (AM) MC208
The Use of a Simple Nasal CPAP Mask/Circuit in the Management of a Patient with a Difficult
Airway during Upper GI Endoscopy
Arpit Patel, M.D . Anesthesia, Rutgers University, New Brunswick, NJ, USA.
69 y/o male with ESRD, paroxysmal atrial fibrillation on warfarin, GERD, difficult airway (Mallampati IV),
BMI 26.7 kg/m2, acute GI bleed and anemia presented for EGD and colonoscopy. An infant mask (#2)
was placed over his nose and connected to anesthesia breathing circuit/machine. Pressure-relief valve
was adjusted to provide 3-4 cm H2O CPAP with a mixture (0.7-0.8 FiO2) of O2 (4 L/min) and air (1
L/min). After his O2 saturation increased from 94% to 100%, he was sedated with propofol (100-150
mcg/kg/min). He tolerated procedures well and maintained spontaneous respiration (TV 250 cc, RR
20/min) and 98-100% O2 saturation throughout.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Ambulatory Anesthesia (AM) MC209
Forestalling Thyroid Storm: Perioperative Management of Uncontrolled Hyperthyroidism
Velvet M. Patterson, M.D., Mian Ahmad, M.D . Department of Anesthesiology & Perioperative Medicine,
Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA.
Thyroid storm is a metabolic and anesthetic emergency, most commonly seen in hyperthyroid females
with Graves‟ disease carrying a perioperative mortality rate of 10% to 30%. As surgery can precipitate this
condition, it is imperative that the anesthetic technique utilized avoids development of this condition.Here
we present the perioperative management of uncontrolled hyperthyroidism. All attempts by endocrinology
to control our patient‟s hyperthyroidism had failed. The benefit of thyroidectomy was deemed to outweigh
the high risk of precipitating thyroid storm. In addition her recent asthma exacerbation, secondary to beta
blockers and requiring hospitalization, necessitated our unconventional methods of sympathetic control.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Ambulatory Anesthesia (AM) MC210
Anesthetic Management in Ambulatory Setting for a Patient with MELAS Syndrome
Dritan Prifti, M.D., Hui Yang, M.D . Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
Forty-one y/o female with PMH of MELAS syndrome (Mitochondrial Encephalopathy, Lactic Acidosis, and
Stroke-like episodes), Leber Hereditary Optic Neuropathy and thyroid cancer s/p thyroidectomy
andradiation, is scheduled for dacryocystorhinostomy in an ambulatory setting. Inadequate preoperative
optimization and unreadiness for postoperative outpatient discharge make the management very
challenging in an ambulatory setting. The basics of anesthetic management of patients with MELAS
syndrome are also discussed. Patient underwent general anesthesia without major complications, and
was admitted to the hospital postoperatively for management of metabolic derangement and discharged
home the day after surgery.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Ambulatory Anesthesia (AM) MC211
Malignant Hyperthermia in the Ambulatory Surgery Setting
Paul F. Rabedeaux, M.D., Karin Zuegge, M.D., Meghan Warren, D.O., Kristopher Schroeder, M.D., Kirk
Hogan, M.D . Anesthesiology, University of Wisconsin, Madison, WI, USA.
A 21 year-old woman developed malignant hyperthermia (MH) in the post-anesthesia care unit following
general anesthesia with sevoflurane for outpatient surgery. This was aggressively managed with
dantrolene, mannitol, intravenous fluids, and re-intubation. She was extubated on post-operative day one,
but experienced two further re-triggering events requiring repeated dantrolene administration. She also
suffered a 12-second sinus pause with loss of consciousness, but achieved return of spontaneous
circulation after two chest compressions. She recovered thereafter and was discharged home on postoperative day four. Counseling patients regarding genetic testing for MH is challenging in light of current
recommendations.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Ambulatory Anesthesia (AM) MC212
Resection of IVC Tumor and Post-Op Brachial Plexus Neuropathy
Prashanth V. Reddy, M.D . New York University, New York, NY, USA.
31 yoM pmhx testicular teratoma s/p radical orchiectomy, and started on bleomycin complicated by
pulmonary fibrosis. Despite chemotherapy, pt developed retroperitoneal mass (9.6cm*5.3cm*8cm). Mass
encased and displaced the Aorta anteriorly by 4cms and compressed the IVC. Pt underwent resection by
Transplant, Vascular and GU services. Vascular ligated the IMA and Right renal artery. GU and
Transplant resected the mass. Procedure lasted 12hours with EBL500ml. Pt extubated on POD1. Pt c/o
of left arm weakness and had absent left biceps reflex. MRI showed T2 hyper intensity in superior trunk of
brachial plexus. Pt started on PT/OT for brachial plexus neuropathy.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Ambulatory Anesthesia (AM) MC213
Development of Negative-Pressure Pulmonary Edema Due to Severe Airway Obstruction
Following Electroconvulsive Therapy in A Patient Requiring Weekly Treatments
Alexandra Reynolds, B.S., Christopher Spiess, M.D . Berkeley Medical Center - an affiliation of West
Virginia University Hospitals, Martinsburg, WV, USA, Anesthesiology, Berkeley Medical Center - an
affiliation of West Virginia University Hospitals, Martinsburg, WV, USA.
SM is a 49 year old obese male with past medical history significant for HTN, BPH and schizoaffective
disorder started on ECT treatments for major depressive disorder. After his first treatment, patient
developed hypoxia and lung infiltrates on chest x-ray that required hospitalization and treatment for
pneumonia. Patient developed severe airway obstruction during recovery from anesthesia that led to
development of negative pressure pulmonary edema. His anesthetic management has been modified to
include use of an advanced airway (laryngeal mask airway) that has allowed the patient to continue
receiving ECT treatments while successfully preventing further development of NPPE.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Ambulatory Anesthesia (AM) MC214
Post-operative Delirium After Outpatient Propofol Total Intravenous Anesthesia
Christopher J. Rosicki, B.S., Sonia Kannadan, M.D., Sally Raty, M.D . Anesthesiology, Baylor College of
Medicine, Houston, TX, USA.
43 year old male with history of depression, underwent an uncomplicated diagnostic colonoscopy for GI
bleeding with only propofol titrated to comfort. Post-operatively, the patient became delirious and
combative. Haloperidol sedation was effective to control the episode and 2.5 hours later the patient had
no memory of the event. Pre and post-operative labs were unremarkable, CT abdomen was negative for
pathology. Psychiatry suggested this presentation was emergence delirium in a patient who had
underlying psychiatric issues. Delirium associated with propofol only sedation is rare with only several
descriptions in the medical literature.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Ambulatory Anesthesia (AM) MC215
Ambulatory Surgery Gone Awry: Vascular Injuries and Possible VAE in a Laparoscopic Ovarian
Cystectomy
Alpana Saini, D.O., Jaime Sanders, M.D . Hahnemann University Hospital, Philadelphia, PA, USA.
A healthy 25-year-old 157cm, 66kg PS2 female with PMH of tobacco use and an ovarian cyst presented
for a laparoscopic left ovarian cystectomy under general anesthesia in the ambulatory surgery setting.
After incision and trocar placement, there were signs of an air embolism including a drop in ETCO2
followed by hypotension and tachycardia. A significant retroperitoneal bleed was visualized. As the
surgeon converted to an open procedure, the massive transfusion protocol was initiated. General and
vascular surgeons were called. Injuries to the anterior aorta and IVC, and a mesenteric tear were
identified and repaired. Injuries were attributed to trocar placement.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Pediatric Anesthesia (PD) MC216
The Utility of the Storz Video Laryngoscope in the Management of Difficult Pediatric Airways
Boyi Gao, Suvikram Puri, M.D., Ivan Florentino, M.D., MBA. Anesthesiology, Georgia Regents University,
Augusta, GA, USA, Medical College of Georgia, Augusta, GA, USA.
A 1 day old 33 week ex-premie with Pierre-Robin Syndrome, severe micrognathia, and glossoptosis,
presented with respiratory distress. Multiple unsuccessful intubation attempts were made with direct
laryngoscopy and flexible bronchoscope. The patient was then successfully intubated with a Storz Video
Laryngoscope Miller I blade (grade II view). The Storz Video laryngoscope is well suited for the difficult
pediatric airway as it provides a more anterior exposure of the vocal cords and a better view with an
Copyright © 2014 American Society of Anesthesiologists
obstructing tongue. It may provide an important role in the management of the difficult pediatric airway
and decrease the incidence of surgical airways.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Pediatric Anesthesia (PD) MC217
Anesthetic Management Of A Newborn With A Sacrococcygeal Teratoma
Daniel J. Goldstein, M.D., Anna Clebone, M.D . Anesthesiology, University Hospitals Case Medical
Center, Cleveland, OH, USA.
A 28-week-old female fetus had an ultrasound-confirmed sacrococcygeal teratoma and was delivered via
cesarean section in the pediatric surgical suite. The fetus was previously diagnosed with intra-abdominal
ascites, hydronephrosis, hydrops fetalis, and suspected disseminated intravascular coagulation (DIC).
Upon delivery, the newborn underwent surgery to resect the tumor. The baby remained hemodynamically
stable; however, lab data confirmed the presence of DIC. Red blood cells and fresh frozen plasma were
transfused intra-operatively. Due to the rarity of AB negative CMV seronegative platelets, platelet
transfusion was delayed several hours. The infant was transferred to the NICU and remained stable
before being discharged home.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Pediatric Anesthesia (PD) MC218
Anesthetic Management of a Pediatric Patient with a Chromosome 1q44 Microdeletion Undergoing
an Orthopedic Procedure
Michelle N. Gonta, M.D., Daniel Carinci, M.D., Misuzu Kameyama, D.O . Anesthesiology, NYU Langone
Medical Center, New York, NY, USA.
10 year old male with PMH chromosome 1q44 microdeletion, microcephaly, agenesis of corpus callosum,
central sleep apnea on overnight CPAP support, seizure disorder, and developmental dysplasia of hip
presented for right femoral and acetabular osteotomy and capsuloraphy. Anesthetic plan included
inhalational induction of general endotracheal anesthesia, as well as placement of postinduction lumbar
epidural for intraoperative and postoperative pain control. Given central sleep apnea, postoperative
epidural infusion of bupivicaine without added opioid chosen. Discussion will focus on challenges of
intraoperative anesthetic management of chromosome 1q44 microdeletion, as well as options for
postoperative pain management in these patients.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Pediatric Anesthesia (PD) MC219
Pre-induction IV for RSI in Infant with Acute Increased ICP
Maria L. Grauerholz, M.D., Christian Petersen, M.D . Naval Medical Center, Portsmouth, VA, USA.
An 8 month old former 25+1 preemie status post grade I IVH presented with hydrocephalus and
increased ICP to ED. There were associated episodes of vomiting. The infant had received formula three
hours prior.The decision was made to obtain a pre-induction IV to facilitate RSI. This decision was
balanced against the concern for further increased ICP from crying that was likely. IV access was gained
and an RSI was performed without an aspiration event. Discussion: The need for a pre-induction IV in an
infant needs to be weighed against how that stressful experience that can affect the infant.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Pediatric Anesthesia (PD) MC220
A Case of Transfusion Associated Hyperkalemic Cardiac Arrest?
Jeffrey W. Hanson, M.D . Anesthesiology, Mayo Clinic/Nemours Children's Clinic, Jacksonville, FL, USA.
A 22 month old victim of non-accidental head trauma undergoing emergency decompressive left
craniectomy for a subdural hematoma experiences an intraoperative cardiac arrest during active
transfusion of packed red blood cells. Was this a transfusion associated hyperkalemic cardiac arrest
(TAHCA)? Because there is a disproportionate representation of neonates and infants in the published
Copyright © 2014 American Society of Anesthesiologists
cases of TAHCA, it is important to recognize the specific factors that place this patient population at risk.
We review the known risk factors for and measures to reduce hyperkalemia related to blood transfusions.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Pediatric Anesthesia (PD) MC221
Hemolytic Transfusion Reaction from Fresh Frozen Plasma
Dane A. Hassani, M.D . Anesthesiology, Weiss Memorial Hospital, Chicago, IL, USA.
Acute hemolytic transfusion reaction is a rare but potentially fatal complication of blood product
transfusion. While the vast majority of cases are due to ABO incompatibility of red blood cells, this
reaction can occur with fresh frozen plasma. This case describes a 16 y/o patient with scoliosis
undergoing spine surgery who developed an acute hemolytic transfusion reaction from direct donated
FFP which led to acute renal failure. Pathophysiology of the reaction as well as the dangers of direct
donated blood will be discussed.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Pediatric Anesthesia (PD) MC222
Development of Severe Peripheral Neuropathy in a Pediatric Patient With Rat Bite Fever
Jenna M. Helmer Sobey, M.D., Carrie Menser, M.D . Pediatric Anesthesiology, Vanderbilt Children's
Hospital, Nashville, TN, USA.
9 year old female presented with sepsis and multi-organ failure after suffering a bite to her right index
finger by a pet rat. Symptoms began 48 hours after the bite, including muscle aches, nausea, vomiting,
diarrhea, fever, jaundice and a petechial rash. She presented to the ED in septic shock, requiring
intubation and resuscitation. She developed renal failure requiring CVVHD. Upon clinical improvement,
the patient was extubated and immediately complained of severe pain bilaterally in her hands and feet.
The pain was predominantly neuropathic in nature. Early treatment with gabapentin led to significant
improvement in her pain.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Pediatric Anesthesia (PD) MC223
Airway Management for a Child After Decannulation of Long Term Tracheostomy
John E. Hernandez, M.D., Jinu Kim, M.D., Franco Resta-Flarer, M.D., Jonathan Lesser, M.D . St Lukes
Roosevelt Medical Center, New York, NY, USA.
A 4 yo male with long standing tracheostomy presented for sclerotherapy with bleomycin after
decannulation of long term tracheostomy. His history consisted of a large arteriovernous/lymphatic
malformation that significantly distorted his lower mandible and tongue. He received a tracheostomy at
one week of age. Multiple sclerotherapy treatments and excisions were performed. Due to anticipated
difficult airway, decision was made to intubate. Planned orotracheal intubation was difficult with
Glidescope due to thickened epiglottis and residual periglottic malformation. Successful intubation was
accomplished with a glidescope blade 2.5 and a 4.5 ett was inserted blindly through thickened glottis.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Pediatric Anesthesia (PD) MC224
Prevention of Phantom Limb Pain in a 5-Year-Old Amputation Patient Using Opioid-sparing
Systemic and Neuroaxial Analgesics
Ryan J. Horvath, M.D.,Ph.D., T. Anthony Anderson, M.D.,Ph.D . Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, MA, USA.
Here, we describe the case of a 5 year old male with past medical history significant for
Neurofibromatosis Type I, renal artery stenosis with hypertension, and congenital tibia/ fibula
pseudoarthritis with failed internal fixation requiring a below the knee amputation. We utilized combination
therapy consisting of pre- and post-operative multimodal opioid-sparing analgesia with acetaminophen
and Gabapentin and intra- and post-operative Bupivacaine/ Clonidine epidural anesthesia with the goal of
Copyright © 2014 American Society of Anesthesiologists
preventing the development of phantom limb pain. To date, the patient has not displayed any symptoms
of phantom limb pain and continues to be treated without the use of opioid analgesics.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC225
Anesthetic Management of Cadaveric Hepatic Transplant Donors. Case-Series
Erica Diaz, M.D., Salvador Castillo Baron, M.D., Marisela Correa Valdez, M.D. , Marco A. Covarrubias
Velasco, M.D. Hospital Civil de Guadalajara, Guadalajara, Mexico.
Since 1998 the Hospital Civil of Guadalajara started the Cadaveric Hepatic Transplant program where to
date we have performed 420 transplants, with an increasing success rate and an improving management.
In the beginnings of the program SHILD criteria selection was used then MELD after 2003. Invasive
monitoring with Swan Ganz catheter was substituted with CO continuous monitoring with thermodilution
and mixed venous pressure. A preliminary report o early extubation of 77% has been achieved.And a
survival rate of our last 100 patients in a month is of 92% and within 1yr of 87.2%, placing us in the
international standards.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC226
Anesthetic Management Challenges for a Patient with Duchenne Muscular Dystrophy
Ranita R. Donald, M.D., Sehar Alvi, M.D . Dept. of Anesthesiology & Perioperative Medicine, Georgia
Regents University, Augusta, GA, USA.
18-year-old male with history of Duchenne muscular dystrophy, was admitted to ICU from emergency
department with sepsis and supraventricular tachycardia. Patient was wheelchair bound, emitiated (34.6
kg), with contractures of all extrimities including neck. All necessary tests were done. Cardiology consult
was taken and patient was stabilized. Later patient was brought to operating room for laparoscopic
cholecystectomy for the diagnosis of ascending cholangitis. Patient had his surgery, and this case report
will describe the challenges we encountered with the anesthetic management of this difficult patient.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC227
Anesthetic Management Utilizing Inhaled Nitric Oxide of a Morbidly Obese, Opioid Tolerant Patient
With Severe Pulmonary Hypertension Undergoing Bariatric Surgery
Mitchell J. Donner, M.D., Farshid Firoozabadi, M.D., Abdolnabi S. Sabouri, M.D . Department of
Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA.
58-year-old female with a BMI of 42, interstitial lung disease on home oxygen, severe pulmonary
hypertension (pulmonary artery systolic/diastolic/mean pressure of 82/38/50 mmHg) and opioid tolerance
on methadone, presented for a laparoscopic partial vertical sleeve gastrectomy. The patient had an
uneventful induction and intubation with anesthetic maintenance consisting of a ketamine infusion and
inhaled sevoflurane. The breathing circuit was supplemented with nitric oxide (20 ppm). Hemodynamics
were supported with vasopressin. Intraoperatively, the patient‟s oxygenation, ventilation mechanics and
parameters were stable despite pneumoperitoneum. The patient was extubated successfully at the end of
the case with no postoperative complications.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC228
Anesthestic Management of Angioedema With Multiple Etiologies
Robert M. Doody, D.O., Jeff Halonen, D.O., Alice Tsao, M.D . Department of Anesthesiology, Riverside
County Regional Medical Center, Riverside, CA, USA.
A 64 year old obese African American female with multiple co-morbidities presented with progressive
tongue and oral mucosal swelling. She consumed walnuts earlier while currently taking an ACE inhibitor.
She states similar episode four years ago of unknown etiology. The patient was able to communicate with
Copyright © 2014 American Society of Anesthesiologists
satisfactory room-air oxygenation. Because of her stability and history of angioedema, we attempted to
preserve her airway for future possible surgical approaches. We smoothly intubated using a fiberoptic
approach under sedation with surgeons available for an emergent airway. Because of possible multiple
offending agents, she was managed for both mast cell-mediated and bradykinin-mediated angioedema.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC229
Rediscovering the Miller Blade
Caitlin M. Dore, M.D., Jyoti Dangle, M.D., Piotr AlJindi, Gennadiy Voronov. Anesthesia, John H. Stroger
Hospital, Chicago, IL, USA, John H. Stroger Hospital, Chicago, IL, USA.
50 y/o M with HTN, OSA, multinodular goiter presented for a total thyroidectomy. He had hoarseness of
voice, dysphagia to solids, occasional SOB in supine position. CT scan showed massively enlarged
thyroid (7.2 X 13 X 16 cm) .Subglottic larynx /trachea were compressed and deviated to right. Awake
glidescope view demonstrated laryngeal inlet anteriorly displaced, edematous mucosal flap seen with
phonation under the epiglottis; vocal cords not visualized, bougie attempted unsuccessful. Multiple
attempts with fibreoptic laryngoscopy were also unsuccessful. Final attempt with Miller blade and a
bougie was successful; subsequent railroading of a size 7.0 ETT
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC230
Acute Dystonic Reaction after Sevoflurane: A Rare Side Effect
Amit H. Doshi, M.D., James Ferre, M.D., Kinga Klimowicz, M.D . Anesthesiology, Allegheny Health
Network, Pittsburgh, PA, USA.
Few cases are described in the literature regarding dystonic reactions induced by anesthetic agents. We
report on a 50 year old female who had a prior history of dystonic reaction following anesthesia who was
told to avoid “triggering agents”. The patient had a knee arthroplasty and received regional anesthesia as
well as general anesthesia. Following surgery, she had a dystonic reaction similar to her previous one
with exposure to only propofol, sevoflurane, succinylcholine, and rocuronium. Subsequent nonsevoflurane anesthetics were non-triggering and it was revealed that her reaction was to sevoflurane, a
side effect not well described in the literature.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC231
Cerebral Oximetry Use in Maintaining a Safe Range of Systolic Blood Pressure in a Resistent
Hypertensive Patient
Najmeh P. Sadoughi, M.D., Duraiyah Thangathurai, M.D., Marisa Bell, M.D . LAC-USC Medical Center,
Los Angeles, CA, USA.
Perioperative management of resistant hypertensive patients may be challenging due to the high risk of
decreased cerebral perfusion while maintaining the ideal blood pressure intraoperatively for decreased
bleeding. We are reporting the use of cerebral oximetry to monitor cerebral perfusion to maintain blood
pressure 120-130/60-70 range for a major prolonged urgent cancer surgery in a patient with preoperative
systolic blood pressure above 200. The limits of BP were carefully controlled by maintaining SvO2 levels
above the baseline range in order to protect against cerebrovascular accidents.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC232
A Case Difficult Intubation Due to an Unanticipated Supraglottic Mass
Stanlies M. D'Souza, M.B.,B.S . Anesthesiology, Baystate Medical Center, Tufts University School of
Medicine, Springfield, MA, USA.
A 54 year old male with a BMI of 30, smoker with chronic back pain presented for L4-5 microdiscectomy.
His preoperative airway examination showed prominent incisors and restricted neck mobility. Following
induction with propofol and succinylcholine, mask ventilation was difficult. Direct layngoscopy showed
Copyright © 2014 American Society of Anesthesiologists
distorted glottic view and subsequent Glidescope laryngoscopy showed glottis distortion due to cystic
mass just above the vocal cords. Airway was secured with size 4 LMA and anesthesia was maintained
with intermittent propofol and sevoflurane. Patient was successfully intubated with fiberoptic
bronchoscope. Patient was extubated at the end of the case and PACU course was uneventful.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC233
Difficult Airway Management in Morbidly Obese Patient with Ankylosing Spondylitis Scheduled for
Emergent Spine Surgery
Mehran Ebadi-Tehrani, M.D., Zana Borovcanin, M.D . University of Rochester, Rochester, NY, USA.
49 year old morbidly obese male (BMI 53) was presented with a hyperextension injury at T11 with
neurologic deficit after a mechanical fall. Neuraxial imaging demonstrated features consistent with
ankylosing spondylitis in the cervical spine in addition to the acute injury. Since patient was considered
potentially having difficult ventilation and difficult intubation, decision was made to proceed with awake
fiberoptic intubation. We will discuss an approach and strategy to intubation and safe extubation of high
risk patient with morbid obesity and ankylosing spondilytis undergoing complex spine surgery in prone
position.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Obstetric Anesthesia (OB) MC234
Incapacitating Atypical Spinal Headache in an Undelivered Pre-Term Parturient: To Patch or Not to
Patch?
Tucker R. Mudrick, M.D., Michael Richardson, M.D . Anesthesiology, Vanderbilt University Medical
Center, Nashville, TN, USA.
A healthy 29-year-old G4P2012 parturient presented with preterm premature rupture of membranes
(PPROM), oligohydramnios, and breech presentation at 25.5 weeks gestational age. The patient was
emergently taken to C-section for prolonged fetal bradycardia; after undergoing epidural placement the
bradycardia resolved and the C-section was canceled. Subsequently, she developed an atypical post
dural puncture headache that presented as isolated severe neck and shoulder pain that became
incapacitating as the pain progressed. This fully resolved after the performance of an epidural blood
patch. The patient underwent labor induction 6 days later and experienced effective epidural analgesia for
the duration of her labor.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Obstetric Anesthesia (OB) MC235
Diagnosis of Amniotic Fluid Embolism Delayed by Administration of Nitroglycerin
Julius Hamilton, M.D., Jennifer Hofer, M.D., Barbara Scavone, M.D . Department of Anesthesia and
Critical Care, University of Chicago, Chicago, IL, USA.
We describe a cesarean delivery complicated by an amniotic fluid embolism (AFE). The diagnosis was
initially confounded by the administration of nitroglycerin for uterine relaxation to facilitate delivery of a
breech fetus and cessation of a phenylephrine infusion after delivery. AFE was suspected secondary to
the profound hemodynamic collapse and development of coagulopathy. . Prompt recognition of AFE, fast
resuscitation to regain hemodynamic stability, and early diagnosis and treatment of disseminated
intravascular coagulopathy were critical for the successful outcome.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Obstetric Anesthesia (OB) MC236
Intrapartum Maternal and Fetal Bradycardia - A Case of Simple Hypovolemia?
Kaitlin J. Herald, D.O., Evan Pivalizza, M.D . University of TX at Houston, Houston, TX, USA.
We report a healthy 31-year-old primigravida parturient that developed profound, cyclical bradycardia
corresponding to uterine contractions that was captured using electronic fetal monitoring (EFR). EFR was
employed due to non-reassuring fetal heart rate including late and variable decelerations. The expected
Copyright © 2014 American Society of Anesthesiologists
physiologic accelerations in maternal heart rate secondary to pain were substituted with decelerations
and hypotension. Management of hypotension and hypovolemia likely exaggerated after initiation of
epidural analgesia with colloid volume replacement resulted in complete resolution of maternal
bradycardia and fetal decelerations leading to vaginal delivery. This case illustrates the importance of
understanding complex maternal-fetal physiology in times of fetal distress.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Obstetric Anesthesia (OB) MC237
Atrial Thrombectomy Requiring Heparinization and Cardiopulmonary Bypass Post-partum Day
Two
Jennifer E. Hofer, M.D., Barbara Scavone, M.D . The University of Chicago Medicine, Chicago, IL, USA.
We describe a case of a parturient with pregnancy complicated by hyperemesis gravidarum, treated with
total parenteral nutrition via a central venous catheter (CVC). The CVC was complicated by thrombosis
extending into the right atrium, prompting urgent cesarean delivery followed by systemic heparinization
and successful thrombectomy under cardiopulmonary bypass post-partum day two.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Obstetric Anesthesia (OB) MC238
Intraoperative Hand-held Echocardiography Quickly Evaluates Preload, Systolic Function, and
Obstructive Causes of Shock During Unanticipated Obstetric Crisis
Benjamin E. Illum, M.D., Brittany Grovey, M.D., Erin Martin, M.D., Thomas Archer, M.D., MBA.
Anesthesiology, University of California San Diego, San Diego, CA, USA.
A 38-year-old female was admitted for term induction of labor. She developed tachysystole, and fetal late
decelerations prompted emergency cesarean delivery of a healthy infant. Oxytocin and methylergonivine
were administered, and adequate uterine tone was achieved. The obstetricians reported continued oozing
in the surgical field, and the patient continued to be hypotensive out of proportion to estimated blood loss
of 1500 mL despite having received 2500 mL of ringer‟s lactate, 500 mL of 5% albumin, and repeated
boluses of phenylephrine.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Obstetric Anesthesia (OB) MC239
Anesthetic Management of Flash Pulmonary Edema and Respiratory Failure in a Parturient with
Eclampsia and Peripartum Cardiomyopathy
Matthew K. Jaruwannakorn, M.D., Teri Gray, M.D., Bryan Mahoney, M.D . Anesthesiology, The Ohio
State University Wexner Medical Center, Columbus, OH, USA.
A 35-year-old G1P0 at 33+4 weeks presents for control of hypertension. History includes gestational
diabetes, hypertension, obesity, and asthma. Steroids and magnesium administered for suspected preeclampsia. Admission day, emergency cesarean delivery was performed due to hypertensive crisis,
severe respiratory distress, and fetal bradycardia. Following rapid sequence intubation, copious pink
frothy secretions filled the endotracheal tube. Following delivery, her ICU course was complicated by
tonic-clonic movements. Chest x-ray and echocardiogram revealed diffuse bilateral airspace disease and
an ejection fraction of 30% with moderate mitral stenosis (MS). Flash pulmonary edema was ruled the
result of eclampsia, MS, cardiomyopathy, and IV magnesium.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Obstetric Anesthesia (OB) MC240
Anesthetic Management of Pregnant Patient with DiGeorge Syndrome (Chromosome 22q11.2
Microdeletion)
Melissa J. Jennings, B.S., Abhinava S. Madamangalam, M.D., Bradley Kelsheimer, M.D . Department of
Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA.
Our 29 year-old G2P0 with DiGeorge Syndrome and Atrial Septal Defect (ASD) received labor epidural
analgesia at 39.1 weeks for spontaneous vaginal delivery of neonate with DiGeorge Syndrome and
Copyright © 2014 American Society of Anesthesiologists
cardiac abnormalities. Patient underwent subsequent general anesthesia for Sacrospinous Ligament
Fixation and Anal Sphincteroplasty. We describe the anesthetic considerations in a patient with DiGeorge
Syndrome and highlight significance of appropriate monitoring in such patients. Notable complications
include hypocalcemic tetanic seizures secondary to hypoparathyroidism, difficult airway when midline
neck abnormalities exist, concern for cardiovascular anomalies, and enhanced procedural infection risk
due to T-cell deficiencies secondary to thymic hypoplasia.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Obstetric Anesthesia (OB) MC241
Spinal Anesthesia in a Pregnant Patient with Spina Bifida Occulta
Melissa J. Jennings, B.S., Abhinava S. Madamangalam, M.D . Department of Anesthesiology, University
of Oklahoma College of Medicine, Oklahoma City, OK, USA.
Our 21 year-old G2P0010 with Spina Bifida Occulta received spinal analgesia at 39.3 weeks for primary
low transverse cesarean section secondary to breech presentation. We describe the anesthetic
considerations in our patient with Spina Bifida Occulta and discuss the challenges for the Anesthesia
Team. Appropriate management includes anticipating differences of the sacrolumbar anatomy as well as
anticipating unpredictable distribution of anesthetic agents due to alteration of the epidural space. The
risk of potential dural puncture or neural injury should be considered in these patients when analgesia is
performed at the level of the defect.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Obstetric Anesthesia (OB) MC242
Post Partum Cerebral Venous Thrombosis
Shivanandaswamy Kashimutt, M.D.,F.R.C.A. Anaesthesia, Huddersfield and Halifax NHS Foundation
Trust, Huddersfield, United Kingdom.
27 year old patient 10 days post-partum presented with severe headache following vaginal delivery. She
was on prophylactic Tinzaparin because of super morbid obesity . Initially it was thought to be post dural
puncture headache as epidural insertion was complicated by two difficult insertion. Even though her initial
symptoms were typical of post dural puncture headache and there was no localised neurological signs,
she underwent a CT scan of head and it showed left transverse and sigmoid sinus thrombosis. She was
started on therapeutic tinzaparin for 6 months. She made a good recovery without any neurological
complication.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Pain Medicine (PN) MC243
Ultrasound-Guided Transversus Abdominis Plane Block for Treatment of Chronic Pancreatitis
Pain: A Case Report
Lynn Correll, M.D., Daryl Smith, M.D . Anesthesiology and Pediatrics, University of Rochester, Rochester,
NY, USA, Anesthesiology, University of Rochester, Rochester, NY, USA.
The patient is a 51 year old female with chronic pancreatitis and related debilitating abdominal pain. She
was admitted for poor nutrition and severe aching and burning during her overnight g-tube feeds not
relieved by her home narcotics nor by a dilaudid PCA. We offered and performed bilateral ultrasoundguided TAP blocks using 15ml of 0.5% bupivicaine with 1:200,000 epinephrine. Shortly thereafter, she
reported significant reduction in her pain, and within hours was able to eat and tolerate full g-tube
feedings. She remained comfortable and was weaned from her PCA, became more mobile, and was
discharged home.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Pain Medicine (PN) MC244
Successful Management of Thoracic Outlet Syndrome with Anterior Scalene Muscle Botox
Injection
Copyright © 2014 American Society of Anesthesiologists
Shrif J. Costandi, M.D., Youssef Saweris, M.D., Nardine Zakhary, M.S. , Hani Yousef, M.D., Nagy
Mekhail, M.D . Pain Management, Cleveland Clinic, Cleveland, OH, USA, Evidence Based Pain Medicine
Research, Cleveland Clinic, Cleveland, OH, USA, College of Osteopathic Medicine, Pikeville, KY, USA,
Outcome Research Departement, Anesthesia Institue, Cleveland Clinic, Cleveland, OH, USA.
17 years- old female diagnosed with thoracic outlet syndrome (TOS) presenting with right arm pain worse
with abduction for 4 years. Imagining studies showed right subclavian vein compression with elevation of
the arms overhead. She failed to respond to oral medications (NSAIDs & Gabapentin), physical therapy
and manipulations. Patient was reluctant to pursue first rib resection. Anterior scalene muscle was
injected with 20 units of Botox injection under ultrasound guidance. At 3 months follow up, patient
obtained 90-100% pain relief. Botox has a potential role in conservative management of TOS. Further
studies are needed to assess its long term benefits.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Pain Medicine (PN) MC245
Successful Spinal Cord Stimulator Trial and Permanent Implant in Patient with Diabetic Peripheral
Neuropathy on Chronic Dual Antiplatelet Therapy
Bryan P. Covert, M.D., Ryan Nobles, M.D . MUSC, Charleston, SC, USA, Anesthesiology and
Perioperative Medicine, MUSC, Charleston, SC, USA.
This is a Medically Challenging Case in which a SCS trial was successful and led to permanent SCS
implantation in a patient with Diabetic Polyneuropathy taking life-long Aspirin and Clopidogrel therapy due
to cardiovascular disease. This serves as a novel case to encourage exploration into the topic of
anticoagulation therapy with indwelling SCS catheters. This case highlights a number of critical questions
that cannot clearly be ascertained through the current literature and some interesting topics for discussion
including the need for acute systemic anticoagulation in the future for vascular interventions, and risk
stratification for those patients selected for this intervention.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Pain Medicine (PN) MC246
Challenges in the Perioperative Management of the Patient Receiving Extended-Release
Naltrexone
Christopher J. Curatolo, M.D., Muoi Trinh, M.D.,M.P.H . Anesthesiology, Icahn School of Medicine at
Mount Sinai, New York, NY, USA.
Patients receiving extended release (XR) naltrexone who present for surgery present unique anesthetic
challenges including an altered response to opioids. Based on the timing of their last dose, patients may
be refractory to opioids or more sensitive to dangerous side effects due to receptor upregulation and
hypersensitivity. Additionally, re-dosing XR naltrexone soon after opioid use may precipitate withdrawal.
We present a case of a 22 year-old female receiving XR naltrexone for heroin abuse undergoing a
thyroidectomy and neck dissection. We discuss the perioperative anesthetic and analgesic planning, as
well as solutions to some of the challenges these patients pose.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Pain Medicine (PN) MC247
Success of Targeted Cervical Epidural Blood Patch in Resolving Post-Dural Puncture Headache
Michael A. DeCicca, M.D., Luciana Curia, M.D., Xi Yang, M.D . SUNY Upstate Medical University,
Syracuse, NY, USA.
We present the case of a 58 year-old former fire-fighter with a history of cervical neck pain and radicular
symptoms in the C7 distribution. While attempting an epidural steroid injection at that level, it became
apparent that the dura had been punctured. Once the epidural space was identified with loss of
resistance to air, 2 cc of contrast was injected using live fluoroscopy and intrathecal spread was apparent
(c-arm images to be incorporated). He eventually developed a postural headache with associated tinnitus
that was instantly, and completely resolved by locating the C7/T1 interspace and injecting 12 cc of
autologous blood.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Pain Medicine (PN) MC248
Post-Mastectomy Pain Syndrome; No Longer At The Periphery of Recognition
Elizabeth A. Dimmock, M.D., Kenneth Justin Naylor, M.D., David Dickerson, M.D . Department of
Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA.
A tearful, depressed, 48-year-old female presents with breast pain and severe coccydynia several months
after a mastectomy with transverse rectus abdominus myocutaneous (TRAM) flap. Her surgical history
includes lumpectomy and radiation. Ganglion impar block and RFA provide coccygeal relief; but
unfortunately, this unmasks the severity of her breast pain and heightens her anguish. Subsequent
unilateral paravertebral T4 blocks provide 75% relief, and pulsed radio frequency ablation confers 100%
relief of breast pain. This case illustrates a treatment for post-mastectomy syndrome and the associated
maladaptive pain processing of post-mastectomy breast pain, a frequently seen and often undertreated
cause of post-operative morbidity.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Pain Medicine (PN) MC249
Therapeutic/Diagnostic Block of Symptomatic Unilateral Lumbosacral Junction Pseudoarticulation (Bertolotti’s Syndrome)
Yashar Eshraghi, M.D., Brenden Astley, M.D . Anesthesiology, Case Western Reserve University, School
of Medicine, MetroHealth Medical Center, Cleveland, OH, USA.
Lumbosacral junction segmentation anomaly characterized by enlarged transverse process(es) that
articulate with the sacrum or ilium described by Bertolotti and thought to predispose to premature
degenerative changes. Two patients with right lower back and hip area for more than one year who were
diagnosed on MRI imaging with Bertolotti‟s syndrome underwent successful Lumbar Medial Branch Block
and local anesthetic injection circumferentially around the pseudarthrosis articular margin. Complete pain
relief and restoration of function were achieved for four weeks post procedure. These two cases describe
the utility of this procedure as a pre-surgical diagnostic/therapeutic tool.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Pain Medicine (PN) MC250
Management of Post-Thoracotomy Pain With Paravertebral Block Under Ultrasound Guidance
Raghuvender Ganta, M.D., Daniel Corn, M.D., Daniel Corn, M.D . Anesthesiology, OU Medical Center
and VAMC, Oklahoma City, OK, USA, Anesthesiology, OU Medical Center, Oklahoma, OK, USA.
A 72 year old man presented to the pain clinic with chronic persistent left post-thoracotomy pain for last 5
years. He had several intercostal blocks, trigger point injections with local anesthetics and steroids with
short term relief. He was also on pregabalin and other anti-depressant drugs for neuropathic pain with
minimal relief. A paravertebral block on left thoracic area performed using ultrasound guidance with
maximum relief of pain which lasted for more than 3 months.Similar blocks were performed using local
anesthetic agents and steroids under ultrasound with maximum relief for prolonged period.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Pain Medicine (PN) MC251
Treatment of Abdominal Cutaneous Nerve Entrapment Syndrome with Rectus Sheath Block
Ultrasound Guidance
Raghuvender Ganta, M.D., Robert Rowlette, M.D . Anesthesiology, OU Medical Center and VAMC,
Oklahoma City, OK, USA, Anesthesiology, OU Medical Center, Oklahoma, OK, USA.
A 56 year old woman presented to the pain clinic with chronic right upper abdominal pain for last 4 years.
She gave history of laparoscopic and abdominal surgeries 5 years ago. One year after the last abdominal
surgery, she started having abdominal pain on the right side for which she was investigated and treated
with analgesics and trigger point injections but relieved of the pain for a short period of 1-2 weeks
duration. We have performed right rectus sheath cutaneous nerve blocks with ropivacaine and
triamcinolone. The pain intensity significantly decreased and she was symptom free for 4 months.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Pediatric Anesthesia (PD) MC252
Management of a Pediatric Patient with Oral Bleeding in the Setting of ITP and Lack of IV Access
Brent S. McNew, M.D., Elisabeth Hughes, M.D . Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN, USA.
A previously healthy 21-month-old female presents urgently to the OR for profuse oral bleeding
secondary to tongue laceration after a fall. The patient is noted to have diffuse petechiae and bruising all
over her body and an isolated platelet count of less than 5 is reported. IV access was lost during transport
from the ED and the patient is actively vomiting blood. Hematology has evaluated and presumptively
diagnosed ITP and in discussion, provided perioperative hemostatic recommendations. Patient was
successfully managed by obtaining IV access under nitrous oxide sedation, then RSI followed by
intubation with awake extubation and recovery in PACU.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Pediatric Anesthesia (PD) MC253
A Pediatric Anesthetic Protocol to Expedite Biopsy of Rapidly-Enlarging Anterior Mediastinal
Masses
Sonia M. Mehta, M.D., Clifford A. Cutchins, V, M.D . Department of Anesthesiology, University of Florida,
Gainesville, FL, USA.
At our institution, seven pediatric patients were treated for rapidly-enlarging anterior mediastinal masses
in the past four years. All demonstrated anatomic effects on the tracheobronchial tree, including
compression and deviation, causing respiratory distress. Given the tenuous airway, our department, in
conjunction with interventionalists, developed a protocol to expedite the procedure and maximize patient
safety.In a formal operating room, patients are placed in the sitting position and induced with a
combination of midazolam and ketamine intravenously. They are allowed to breathe spontaneously while
the interventionalist performs a core biopsy using ultrasonographic guidance. A surgical team is available
for airway emergencies.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Pediatric Anesthesia (PD) MC254
PACU Discharge Against Medical Advice (AMA)
Petra M. Meier, M.D., Jennifer L. Dearden, M.D . Department of Anesthesiology, Perioperative and Pain
Medicine, Boston Children's Hospital, Boston, MA, USA.
A six-year-old with colonic dysmotility underwent uneventful cecostomy revision under general
anesthesia. Comorbidities included Noonan syndrome, brain malformation, sleep apnea, autonomic
dysregulation and cyanotic syncopal episodes. Postsurgical evaluation revealed an obtunded child with
intermittent airway obstruction and desaturation, prompting plans for overnight admission. The patient‟s
father refused and took his child from the Post-Anesthesia Care Unit AMA, before the risks of leaving and
benefits of hospitalization could be discussed. Our hospital‟s policy in this regard was unclear, and
collaborative recommendations for revision were made to involve personnel from hospital security, social
services and the hospital legal department.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Pediatric Anesthesia (PD) MC255
Airway Management in a Case of Acute Epiglottitis Secondary to an Infected Epiglottic Cyst
Renata M. Miketic, M.D., Terry Huang, M.D . Anesthesiology, University of Nebraska Medical Center,
Omaha, NE, USA.
Maintaining a patent airway is a core principle of anesthetic management. Without patency, a variety of
life threatening consequences can occur. The pediatric population is especially sensitive to any issues
with inadequate oxygenation and ventilation due to their unique physiological and anatomical differences
from adults. Understanding these differences can help an anesthesiologist and otolaryngologist
Copyright © 2014 American Society of Anesthesiologists
collaboratively devise a safe and effective plan in the management of an acute upper airway obstruction,
such as seen in epiglottitis. In this case, we discuss a case of acute epiglottitis secondary to an infected
epiglottic cyst in a pediatric patient.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Pediatric Anesthesia (PD) MC256
Ketamine Total Intravenous Anesthesia for Propofol Allergy in a 10-Year-Old Boy Undergoing
Selective Rhizotomy
Lauren B. Moore, M.D., Bettina Smallman, M.D . Anesthesiology, SUNY Upstate Medical Center,
Syracuse, NY, USA.
A ten year old boy with multiple severe allergies and mild cerebral palsy was scheduled to undergo a
selective rhizotomy for spasticity. The patient's family was very concerned about an allergic reaction to
propofol as the patient has severe allergies to egg yolk and egg whites. The patient required total
intravenous anesthesia as neuromonitoring would be used.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Pediatric Anesthesia (PD) MC257
Anesthetic Management of Congenital Tracheal Stenosis in a Neonate
Pablo Motta, M.D., Premal Trivedi, M.D . Texas Children's Hospital Pediatric Cardiovascular Anesthesia,
Houston, TX, USA, Pediatric Cardiovascular Anesthesia, Texas Children´s Hospital, Houston, TX, USA.
A 13-day-old, 2.75 kg neonate with respiratory failure due to segmental tracheal stenosis was scheduled
for tracheal repair on CPB. She had been intubated since birth. In the OR, ETT (3.0 cuffed) position was
confirmed above the stenotic segment with a 1.8 mm bronchoscope. Once on bypass the ETT was
withdrawn to allow the surgeon to perform a sliding tracheoplasty anastomosis (interrupted 6-0 PDS
suture with extraluminally knots). Immediately prior to completion of the anastomosis the ETT was placed
in an appropriate position with endoscopic guidance. We discuss our approach to airway management in
neonatal tracheal reconstruction.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Pediatric Anesthesia (PD) MC258
Anesthesia Management of a 9- Month-Old Baby with Cornelia de Lange Syndrome and
Diaphragmatic Hernia Presenting for Chest CT Scan
Will B. Newton, M.D., Priti Dalal, M.D.,F.R.C.A. Anesthesiology, Penn State Hershey Medical Center,
Hershey, PA, USA.
A 9-month-old female (weight 3.8kg), having a genetically confirmed diagnosis of Cornelia de Lange
syndrome, presented for CT scan of the chest for suspected diaphragmatic hernia. Physical exam
revealed microcephaly, low placed ears, short neck and bilateral upper limb amelia. She was on home
oxygen and naso-jejunal feeds for failure to thrive. The pediatric surgery and radiology teams requested
„breath holds‟ during the scan for image quality. Following inhalational induction, tracheal intubation was
achieved under deep anesthesia without paralyzing agent using a video laryngoscope. Challenges
included difficult intravenous access, difficult airway and risk of aspiration at an off-site anesthetic
location.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Pediatric Anesthesia (PD) MC259
Inadvertent Passage of Endotracheal tube through Tracheal Esophageal Fistula during
Positioning
Thanh Nguyen, M.D., Humphrey V. Lam, M.D., Thomas Austin, M.D . Vanderbilt University, Nashville,
TN, USA.
A full term Down‟s infant with transesophageal fistula (TEF) and suprasystemic pulmonary hypertension
presented for thoracoscopic repair of TEF. After general anesthesia was induced, the patient was
intubated without difficulty. A fiberoptic scope verified placement in trachea distal to the fistula. During
Copyright © 2014 American Society of Anesthesiologists
positioning for the surgery, end tidal CO2 was lost and the patient desaturated. Under fiberoptic
visualization, the endotracheal tube (ETT) was noted to be in the esophagus. The ETT was removed.
Two repeat attempts at intubation resulted in intubation of the fistula. Ultimately, fiberoptic intubation had
to be performed to guide the ETT past the fistula.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Pediatric Anesthesia (PD) MC260
Anesthetic Considerations for a Child with Anti-NMDA Encephalitis Presenting for a Right
Oopherectomy
Thanh Nguyen, M.D., Sara Walls, M.D., Humphrey V. Lam, M.D., Thomas Austin, M.D . Vanderbilt
University, Nashville, TN, USA.
A previously healthy 12-year-old female presented to the hospital with altered mental status. Initial
workup showed pleocytosis in the CSF which was suggestive of encephalitis. Further investigation found
anti-NMDA antibodies in the CSF and a MRI showed an enlarged right ovary which suggested a
paraneoplastic process caused by a teratoma. The patient was scheduled for an oophorectomy. The
challenge of the anesthetic was the patient‟s high tolerance of opioids, benzodiazepines and
dexmedetomidine, and the avoidance of anesthetic drugs that inhibit the NMDA receptor such as
ketamine, volatile anesthetics, nitrous oxide and propofol which may make the exacerbate the disease
process.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Regional Anesthesia and Acute Pain (RA) MC261
A Stuck Interscalene Catheter
Neda Sadeghi, M.D., Francesco Resta-Flarer, M.D., Jonathan Lesser, M.D., Junping Chen, M.D.,Ph.D .
Department of Anesthesiology, Mount Sinai St. Luke’s-Roosevelt Hospital, New York, NY, USA.
Following shoulder arthroplasty, a patient was discharged with an interscalene catheter coupled to an OnQ infusion system. On POD #5 and 6, the catheter wasn‟t extractable despite attempts by multiple
providers. On POD#7, patient presented to the OR for surgical removal. Ultrasound imaging
demonstrated the catheter adjacent to, but not attached to, the brachial plexus without kinking, knotting,
or looping. There was no response to catheter stimulation or instillation of local anesthetic. Catheter
traction revealed an attachment point 2cm proximal from the tip. The patient was sedated and the
catheter was extracted using steady force. There were no sequelae.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Regional Anesthesia and Acute Pain (RA) MC262
Ultrasound Guidance to Assist Difficult Lumbar Drain Placement for Endovascular Aneurysm
Repair
Jay W. Schoenherr, M.D., David Hardman, M.D . UNC Hospital, Chapel Hill, NC, USA.
A 67 year old male with severe scoliosis presented for thoracic endovascular aneurysm repair. A lumbar
drain was requested by vascular surgery to improve peri-operative spinal cord perfusion. Initial landmark
based attempts at lumbar drain placement were unsuccessful. Ultrasound was used to visualize the
lumbar spine and identify the intrathecal space. A real-time in-plane approach was used to puncture the
dura and place a lumbar drain without complication. Although ultrasound has been utilized for spinal and
epidural placement, it has not been described to facilitate lumbar drain placement, and may obviate the
use of fluoroscopy for these difficult procedures.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Regional Anesthesia and Acute Pain (RA) MC263
Single Injection of Exparel® for a Brachial Plexus Block Provides Adequate Postoperative
Analgesia Without the Need for Opioids
Rebecca L. Scholl, Vanny Le, M.D., Daniel Eloy, M.D . Anesthesiology, Rutgers New Jersey Medical
School, Newark, NY, USA, Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA.
Copyright © 2014 American Society of Anesthesiologists
Opioids are among the most common prescribed methods used to treat postsurgical pain. However, due
to patient conditions and the adverse side effects of opioids, alternative pain management modalities may
need to be considered. We present a case demonstrating the novel use of Exparel®, via a brachial plexus
block, in conjunction with a multimodal technique to provide postoperative analgesia without the use of
opioids for a patient with history of polysubstance abuse. This case may provide a model for effectively
treating postoperative acute pain while avoiding the side effects of opioids and risks and complications of
continuous peripheral nerve catheters.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Regional Anesthesia and Acute Pain (RA) MC264
Regional Anesthesia for Above Knee Amputation in an Elderly Patient with Severe Contractures
Yatish Siddapura Ranganath, M.B.,B.S., William Thomas, M.D., David Fritz, M.D., Francis Pham. Georgia
Regents University, Augusta, GA, USA, Anesthesiology & Perioperative Medicine, Georgia Regents
University, Augusta, GA, USA.
88 year-old female bedridden patient with Rheumatoid Arthritis, Alzheimer‟s dementia, HTN, DM, CAD,
Peripheral Vascular disease, severe contractures of the extremities presented for Above Knee
Amputation following dry gangrene of the left foot.The hip contracture (Angle ~ 45 degree) made it difficult
to access the groin and palpate/visualize land marks. An attempt was made (successful) in performing
ultrasound/nerve stimulator guided Femoral/Sciatic/Lateral femoral cutaneous nerve blocks. Surgery was
performed under regional anesthesia with minimal sedation.We demonstrate the successful use of
Regional anesthesia in a high risk patient with difficult anatomy/access and suboptimal positioning
utilizing the ultrasound with nerve stimulator.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Regional Anesthesia and Acute Pain (RA) MC265
Bilateral Paravertebral Blocks with Liposomal Bupivacaine: An Alternative Anesthetic Technique
for Patients with Myasthenia Gravis Undergoing Major Abdominal Surgery
Plinio P. Silva, M.D., R. Sona Bhullar, M.D., Lucien Catania, M.D., Andras L. Laufer, M.D .
Anesthesiology, Albany Medical Center, Albany, NY, USA.
A 72 year old female presented for laparotomy, repair of para-stomal hernia and re-siting of ileostomy.
Past medical history included morbid obesity, OSA on home BiPap, severe myasthenia gravis, COPD,
diverticulitis with previous colectomy and ileostomy, and history of DVTs on Revaroxaban. With the goals
of avoiding neuromuscular blocking drugs and limiting the use of perioperative opioids, bilateral T8 to T10
paravertebral blocks were performed with 5mL of liposomal bupivacaine at each level. This approach
resulted in the complete avoidance of neuromuscular blocking drugs, allowed for smooth extubation and
provided post-operative pain relief for 36 hours.
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Regional Anesthesia and Acute Pain (RA) MC266
Utilizing Regional Anesthesia and Non-sedating Multimodal Analgesia in a 9-Year-Old with
Metachromatic Leukodystrophy
Christopher M. Sobey, M.D., Elisabeth Hughes, M.D . Anesthesiology, Vanderbilt University, Nashville,
TN, USA.
9 y/o male with metachromatic leukodystrophy, a progressive demyelinating neurological disorder due to
arylsulphatase A deficiency, presents for intertrochanteric osteotomy for hipdysplasia. Symptomatology
includes respiratory weakness with multiplepneumonias, and bulbar weakness with swallowing difficulties
and thickened liquid diet. Concerns include weak postoperative respiratory effort, prevention of
pneumonia, and analgesia. Patient underwent the procedure with combined epidural and general
anesthesia and was successfully extubated, recovered, and directed to regular hospital floor. Pain was
well controlled postoperatively via L1-2 epidural in addition to non-sedating adjunctive analgesics, and
discharged POD 3 after an uneventful hospital stay.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Regional Anesthesia and Acute Pain (RA) MC267
Epidural Management in a Decompensating Patient with Coagulopathy
Natalie R. Strickland, M.D., Eric Briggs, M.D . Vanderbilt, Nashville, TN, USA.
67 yo cachetic male with duodenal and rectal cancer s/p exploratory laparotomy for partial small bowel
and colon resection and LOA. Pain service consulted POD#1 for uncontrolled pain, poor cough and
declining pulmonary effort. A significant coagulopathy following surgery (INR 1.9) responded to FFP with
pre-epidural INR 1.5. Challenging epidural placement with sluggish hemostasis at skin; INR had
increased to 1.6. Neuro checks ordered around the clock. Despite FFP, INR increased to 1.9 and
platelets decreased to 42. Further labs and clinical course suggested DIC, with patient expiring POD#3
following rapid clinical deterioration.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Regional Anesthesia and Acute Pain (RA) MC268
Paravertebral Blocks in a Trauma Patient taking Plavix and Utility of Thromboelastogram (TEG)
Studies
Omar Syed, M.D., Kate Hindle, M.D . Anesthesiology and Critical Care, George Washington University,
Washington, DC, USA.
In the setting of traumatic rib fractures, paravertebral nerve blocks are a valuable tool for improving pain
control and minimizing the side effects of opioid medications. We describe the case of an 82-year old
woman on plavix who suffered numerous fractures including several non-displaced rib fractures leading to
significant respiratory compromise. Given the patient‟s use of plavix, there was concern regarding
paravertebral block placement in the setting of an antiplatelet agent. Initial thromboelastogram studies
showed 100% inhibition of platelet function with subsequent improvement. With declining respiratory
function and improved platelet function, paravertebral blocks were placed with improvement in respiratory
status.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Regional Anesthesia and Acute Pain (RA) MC269
Thoracic Epidural in a Patient with Thoracic Chondrosarcoma
Mark S. Teen, M.D . Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
This is a case of a 41-year-old woman who had an anterolateral T8 corpectomy and T7-T9 anterolateral
instrumentation and interbody fusion scheduled for resection of a recurrent right paraspinal T8
chondrosarcoma. A thoracic epidural catheter was placed at the T9 level for postoperative analgesia. The
benefit of postoperative analgesia had to weighed against the increased risk of neurological deficits and
spinal hematoma in the setting of the placement of the catheter in close proximity to the lesion. Overall,
the patient did not experience any complications from the surgery or epidural, but retrospectively, we
would reconsider the placement of the epidural.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Neuroanesthesia (NA) MC270
Venous Air Embolism in an Awake Patient
Jason B. ONeal, M.D., Jeffrey K. Jankun, M.D . Department of Anesthesia, Critical Care, and Pain
Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
A 59-year-old-male with a history of Parkinson's disease presented for bilateral subthalamic deep brain
stimulators. Total scalp block was performed with lidocaine/bupivicaine. The patient's head was placed in
the Mayfield adaptor. Cefazolin was administered before initial incision. Fifteen minutes after incision, the
patient complained of a sore throat followed by non-radiating chest pain. The end tidal carbon dioxide
decreased. He became diaphoretic with hypotension and bradycardia. No source of bleeding was
appreciated, and the field was washed with normal saline. The head of the bed was lowered. The patient
received ephedrine and oxygen. Vitals improved and subjective symptoms quickly resolved.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Neuroanesthesia (NA) MC271
Generalized Tonic-Clonic Seizures in a Patient after Induction with Propofol
Stephen B. Oppenheim, M.D., Wesley Allen, M.D., Paruv Patel, M.D . University of Missouri, Columbia,
MO, USA.
53-year-old disabledwoman with diabetes, migraines, low back pain, and lower extremity
neuropathypresented for anterior/posterior lumbar spine surgery with neuromuscular monitoring.
Thepatient was induced with propofol and succinylcholine followed by an uneventfulintubation. One
minute later, thepatient began to have a generalized tonic-clonic seizure that lasted 30 secondsfollowed
by two more seizures of similar duration over the next 10 minutes. The case was aborted for a
neurologicalworkup which subsequently did not reveal an etiology of the seizures. Three months later, the
case was performedwithout propofol and no further seizures.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Neuroanesthesia (NA) MC272
Frontal Craniotomy During First Trimester: Anesthesia Considerations for Two
Helen E. Pappas, M.D., Renee Davis, M.D . Anesthesiology, University of Cincinnati Medical Center,
Cincinnati, OH, USA.
27 year old G1P0 at 7 weeks gestation presented with persistent severe headaches, nausea and
vomiting. A head CT revealed a large right frontal mass with midline shift and edema consistent with
intracranial neoplasm. She subsequently underwent tumor resection via right frontal craniotomy using
image guidance and neuromonitoring under general endotracheal anesthesia with arterial pressure
monitoring. Elevated ICP secondary to intracranial mass was managed medically with dexamethasone,
mannitol, and levetiracetam. Surgical pathology revealed grade IV glioblastoma multiforme with negative
margins. Perioperative management involved collaboration between neurosurgery, obstetrics, anesthesia,
and radiation-oncology specialists.
Saturday, October 11, 2014
11:00 AM - 11:10 AM
Neuroanesthesia (NA) MC273
Combined Dexmedetomidine and Propofol Technique for Awake Craniotomy
Purav Patel, M.D., Mike Martinez, II, D.O., Dirk Younker, M.D . Anesthesiology, University of Missouri,
Columbia, MO, USA.
Awake craniotomies pose several challenges to the anesthesiologist in the perioperative setting. The
patient has to be sedated enough to tolerate the surgery yet needs to be fully alert and cooperative during
neurocognitive testing. At our institution, 2 awake craniotomies were successfully performed under
monitored anesthesia care using a combined infusion of Dexmedetomidine and Propofol.
Dexmedetomidine provides a distinct advantage over other anesthetic techniques for this procedure in
which the ability to ensure adequate patient ventilation when a deep level of sedation is required.
Saturday, October 11, 2014
11:10 AM - 11:20 AM
Neuroanesthesia (NA) MC274
Neuronal Protection and Intraoperative Stability in Patients withMoyamoya Disease
Virag P. Patel, M.D., Eugenia Ayrian, M.D., Vladimir Zelman, M.D . Anesthesiology, University of
Southern California, Los Angeles, CA, USA.
Moyamoya disease is an idiopathic progressive vasculopathy of the intercranial arterial vasculature.
Acute neurologic symptoms often necessitate urgent vascular bypass in an effort to reverse active
symptoms and prevent further ischemic insult. While vascular bypass procedures offer macrovascular
restoration of perfusion, we contend for an equal importance of optimizing microvascular flow especially
under general anesthesia. We present five cases implementing our protocol designed to augment
microvascular perfusion and ultimately offer ideal conditions for neuronal protection. Our intraoperative
courses were uneventful and long term follow-up did not demonstrate worsening neurologic deficit.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
11:20 AM - 11:30 AM
Neuroanesthesia (NA) MC275
Anesthetic Management of a Patient with Narcolepsy
Sara Pedrosa, M.D., Pedro Amorim, M.D . Anesthesiology, Centro Hospitalar Baixo Vouga, Aveiro,
Portugal, Anesthesiology, Pain and Emergency, Centro Hospitalar do Porto, Porto, Portugal.
A 35-year-old man with a history of narcolepsy with cataplexy required general anesthesia for lumbar
herniated disk surgery. The literature is sparse regarding the safe anesthetic management of patients
with narcolepsy and we found reports of complications associated with general and regional anesthesia.
Our anesthetic management included continuation of modafinil, avoidance of sedative premedication, use
of short-acting anesthetic agents (remifentanil and propofol by TCI), hypnotic state monitorization (BIS
and Entropy) and cardiac output monitorization (LiDCO Rapid). The intraoperative period was uneventful.
Three minutes after the surgery ended the patient opened his eyes, followed orders and was extubated.
Saturday, October 11, 2014
11:30 AM - 11:40 AM
Neuroanesthesia (NA) MC276
Extensive Destruction of Cervical and Thoracic Vertebrae due to Vanishing Bone Disease
(Gorham’s Disease): Anesthetic Considerations for C1-T12 Posterior Spinal Fusion
Kevin Powell, M.D., Paul Collins, Jr., D.O., Lavinia Kolarczyk, M.D . Anesthesiology, UNC Chapel Hill,
Chapel Hill, NC, USA.
A 17 year-old male with severe neck pain was diagnosed with a rare condition called Gorham-Stout
disease (also known as vanishing bone disease). The condition is characterized by uncontrolled
proliferation of endothelial lined vessels and replacement of bone with angiomas and/or fibrosis. The
patient had extensive destruction of cervical vertebrae one through six with spinal cord impingement, and
he presented for C1-T2 posterior spinal fusion. Given his severe cervical spine instability, we performed
an awake fiberoptic intubation. We employed the use of neurologic exams during the intubation
procedure. Following intubation, cervical spine stabilization techniques were used during positioning.
Saturday, October 11, 2014
11:40 AM - 11:50 AM
Neuroanesthesia (NA) MC277
Repeated Intraoperative Seizure-like Activity during General Anesthesia
Michael P. Puglia, M.D.,Ph.D., Jingping Wang, M.D.,Ph.D . Anesthesia Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA.
A 38-year-old male without history of seizure underwent a stenting procedure of the left maxilla and
biopsy of zygomatic and mandibular masses for an odontogenic keratocyst. General anesthesia was
induced with Propofol, Lidocaine, and Fentanyl. Uneventful fiberoptic nasal intubation was facilitated with
Succinylcholine, and anesthesia was maintained with Sevoflurane. A generalized seizure-like myoclonus
affecting all muscle groups was noted approximately 20 minutes after induction and lasted approximately
30 seconds. Two additional episodes occurred at approximately 40 and 80 minutes after induction. With a
literature review, we propose an algorithm to facilitate early detection and management of intraoperative
seizure-like activity.
Saturday, October 11, 2014
11:50 AM - 12:00 PM
Neuroanesthesia (NA) MC278
Craniotomy for a Patient with Cleidocranial Dysplasia : A True Anesthetic Challenge
Shawn K. Puri, M.D., Vasanti Tilak, M.D., Anuradha Patel, M.D., Sergey Pisklakov, M.D . Anesthesiology,
UMDNJ-New Jersey Med School, Newark, NJ, USA, Anesthesiology, UMDNJ - New Jersey Medical
School, Newark, NJ, USA.
Cleidocranial dysplasia (CD) is a rare developmental disorder. CD is characterized by supernumerary
teeth, brachycephalic skull, hypoplastic clavicles, maxillary hypoplasia, high vaulted palate and palatal
clefting.Our patient presented for craniotomy and acoustic neuroma resection. A limited mouth opening,
brachycephaly and frontal bossing were noted. Videolaryngoscopy provided partial visualization of the
vocal cords allowing for intubation. The case proceeded uneventfully with successful extubation at the
Copyright © 2014 American Society of Anesthesiologists
end.Patients with CD have a variety of abnormalities interfering with their airway and requiring careful
assessment. Abnormal skull and facial structures may impede with mask ventilation and intubation.
Videolaryngoscope or fiberscope must be available.
Saturday, October 11, 2014
10:30 AM - 10:40 AM
Professional Issues (PI) MC279
Elective Total Hip Arthroplasty in a Physician with Newly Diagnosed Hepatic Failure
Conrad S. Myler, Amy C. Robertson, M.D . Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN, USA.
A 66 year old physician presented for elective total hip arthroplasty. Preoperative evaluation revealed
previously undiagnosed cirrhosis secondary to former alcohol abuse, NAFLD, and partial alpha-1
antitrypsin deficiency with a MELD score of 20, Child Class C. Hepatology consultation estimated
mortality risk with major orthopedic procedure to be 7% at one week, 27% at one month, and 40% at 3
months. Despite these risks, the patient opted to proceed. In the event of acute hepatic decompensation,
he was evaluated for liver transplantation and listed preoperatively. This case represents both clinical and
professional/ethical challenges.
Saturday, October 11, 2014
10:40 AM - 10:50 AM
Professional Issues (PI) MC280
Ethical Dilemma and Anesthetic Management in a 94-Year-Old Patient with Do Not Resuscitate
(DNR) Orders, Severe Aortic Stenosis and Femur Fracture
Ronak R. Patel, M.D., Karen Williams, M.D., Gregory Moy, M.D . George Washington University,
Washington D.C., DC, USA.
A 94 year old, 36 kg, female, presented to the hospital after a fall while walking her dog. The patient had
a past medical history of hypertension, a “heart murmur,” and prior uneventful right hip replacement done
decades ago. Further evaluation revealed that the heart murmur had been previously diagnosed as aortic
stenosis 9 years ago and the patient had refused aortic valve replacement. Imaging revealed a right
femur fracture and the patient was scheduled for an ORIF. Complicating matters the patient expressed
that she had DNR orders.
Saturday, October 11, 2014
10:50 AM - 11:00 AM
Professional Issues (PI) MC281
Radiation Exposure in the Operating Room
Panthea Taghizadeh, M.D., Thomas Dobosz, M.D., Ned Nasr, M.D., Reza Borna, M.D., Ramsis Ghaly,
M.D., David Wahba, M.D . John H Stroger Jr. Hospital of Cook County, Chicago, IL, USA.
The OR is a closed environment with potential risk for radiation induced cancer. Several factors, including
number of cases per day, configuration of X-ray equipment, and availability of protective equipment
contribute to the risk of exposure. We present two cases of thyroid cancer in the span of six months in
two anaesthetists with a combined 30 year OR exposure. Although we cannot conclude that their
occupation related exposure led to thyroid cancer, it was a likely strong contributing factor. Our goal is to
explore these factors, in order to minimize the risks at our institution, and increase awareness.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC03
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Obstetric Anesthesia (OB) MC282
Management of Sickle Cell SC Type Combined with Anti-U Antibody in a Patient Presenting for
Caesarean Section
Shyrana A. Siriwardhana, M.D.,F.R.C.A, Taskin M. Hazarika, M.B.,B.S . Anaesthetics, North Middlesex
University Hospital NHS Trust, London, United Kingdom.
This presentation will describe an unusual case of a patient who presented for CS who had both an
uncommon variant of sickle cell disease (Hb SC type) and anti-U antibody. Anti-U is associated with
hemolytic transfusion reactions and hemolytic disease of the newborn. A feature of this case was the
near-unavailability of compatible blood; options discussed included usage of non-compatible blood and of
a cell-saver machine, even though this is not recommended with sickle cells as most are hemolysed by
the machine.The patient had an uneventful CS. The importance of early planning and a multidisciplinary
approach will be discussed.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Obstetric Anesthesia (OB) MC283
Bowel Perforation During Labor
Mary So, M.D., Klaus Kjaer, M.D . Anesthesiology, NYPH Weill Cornell Medical Center, New York City,
NY, USA.
A 33-year old G1P0 woman at 37w0d with a history of ulcerative colitis and prior bowel obstructions
during this pregnancy presented with abdominal pain and no ostomy output for several hours and the
anesthesiology team was consulted for labor analgesia. An epidural was placed as the initial plan
coordinated between the obstetrical and general surgery team had been for induction of labor after
endoscopic decompression. Pain in spite of typical labor epidural dosing led to re-evaluation, revealing
bowel perforation and she was brought to the operating room for emergency cesarean section (C/S) and
exploratory laparotomy under general anesthesia.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Obstetric Anesthesia (OB) MC284
Emergent Cesarean Section in the ICU for an Intubated Patient with H1N1
Iwan P. Sofjan, M.D., Susan B. McElroy, D.O . Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA, USA.
A previously healthy pregnant G1P0 female at 34 week gestation age presented with worsening
respiratory distress. She was intubated and was positive for H1N1. Her clinical course deteriorated and
on post-intubation day 4, a decision was made to perform emergent preterm cesarean section. With
concerns of the patient not tolerating even brief period off the ICU ventilator during transport, the surgery
was performed off-site at the ICU. The delivery was successful, and the patient was then put on ECMO.
She recovered slowly and was weaned off ECMO and extubated within 2 weeks.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Obstetric Anesthesia (OB) MC285
Postpartum Seizure following Epidural Blood Patch for Post Dural Puncture Headache
Charles C. Stehman, M.D., Zoe K. Rafaat, M.D . ANESTHESIOLOGY AND PAIN MEDICINE, NAVAL
MEDICAL CENTER SAN DIEGO, San Diego, CA, USA.
Copyright © 2014 American Society of Anesthesiologists
The treatment of a post dural puncture headache with an epidural blood patch is a proven method of
alleviating what can be debilitating symptoms for the new mother. However, a thorough history and
physical exam must be obtained before proceeding with an epidural blood patch. We present a case of
postpartum eclampsia presenting shortly after an epidural blood patch on postpartum day four.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Obstetric Anesthesia (OB) MC286
Emergent Cesareansection in the Medical Intensive Care Unit
Shea L. Stoops, D.O., Brent Barta, D.O., Robert Devine, M.D., Joel Grigsby, M.D., Grace Shih, M.D .
Anesthesiology, University of Kansas Medical Center, Kansas City, KS, USA.
A 34 year old Hispanic female, Gravida 6 Para 5, with no significant past medical history presented to the
emergency room with fever and chills. An ultrasound revealed a viable fetus; a biparietal diameter
measurement corresponded to a fetal age of 29 weeks. The patient rapidly decompensated
hemodynamically, with worsening respiratory failure and required intubation. Differential diagnoses
included pneumonia, amniotic fluid embolism, and pulmonary embolism. Fetal monitoring revealed signs
of distress and an emergent cesarean section was performed in the MICU. Ultimately, a diagnosis of
H1N1 influenza was made and the patient required extra corporeal membrane oxygenation (ECMO).
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Obstetric Anesthesia (OB) MC287
Cesarean Section in a Parturient with Goldenhar Syndrome
Benjamin J. Straub, M.D . Anesthesiology, New York Medical College, Valhalla, NY, USA.
A 25 year-old woman with Goldenhar Syndrome presented at 32 weeks gestational age for scheduled
cesarean section. Manifestations of her disease include unilateral microsomia and microtia, situs
inversus, and scoliosis for which she had undergone extensive fixation of the thoraco-lumbar spine.
Spinal anesthetic placement was attempted using ultrasound to identify the interspace among
immobilized abnormal vertebrae, but multiple attempts by two anesthesiologists were unsuccessful. The
patient was induced, intubation accomplished with video laryngoscopy, and a healthy male infant
delivered under general anesthesia.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Obstetric Anesthesia (OB) MC288
Indigo Carmine-Induced Hypotension in a Parturient With Hypertrophic Cardiomyopathy,
Pulmonary Hypertension and LAD Myocardial Bridging
Evan M. Sutton, M.D., Agnes Pietrzak, D.O . Anesthesiology, Loyola University Medical Center, Chicago,
IL, USA.
Indigo carmine is a blue dye that is believed to have a safe profile without known drug or disease
interactions. We present a case of indigo carmine-induced hypotension in a parturient with hypertrophic
cardiomyopathy, pulmonary hypertension, and LAD myocardial bridging undergoing a cesarean
hysterectomy. We propose that this case of sudden hypotension is a consequence of a transient
decrease in cardiac output by means of nitric oxide inhibition and/or serotonin-mediated ventricular
inotropy.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Obstetric Anesthesia (OB) MC289
Anesthetic Management of Placenta Percreta Complicated by Loss of Urine Output. Does
Preoperative Placement of Ureteral Stents Decrease Ureteral Injury?
Rebecca A. Tisdale, M.D., Anne McConville, M.D., Richard Lancaster, M.D., John C. Bates, M.D .
Anesthesiology, Tulane University School of Medicine, New Orleans, LA, USA.
A 32 year old with placenta percreta presented at 34 weeks gestational age for a planned bilateral
internal iliac artery balloon placement, cesarean delivery, and hysterectomy. All proceeded as planned,
but prior to closure the anesthesia team noted an abrupt decrease in urine output. Flushing the foley
Copyright © 2014 American Society of Anesthesiologists
catheter, furosemide and indigo carmine administration, ABG, CBC, and invasive hemodynamic
monitoring all failed to diagnose a cause. Cystoscopy and retrograde pyelogram by urology revealed
bilateral ureteral damage. Our case will highlight the importance of a multidisciplinary approach in the
management of placenta percreta and examine the benefits of preoperative ureteral stent placement.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Obstetric Anesthesia (OB) MC290
Anesthetic Management of a Laboring Patient with Hypoplastic Left Heart Syndrome s/p Norwood
and Fontan Procedures
Erin E. Toaz, M.D., Laurie Chalifoux, M.D., Samir Patel, M.D . Anesthesiology, Northwestern Memorial
Hospital, Chicago, IL, USA.
19-year-old female with congenital hypoplastic left heart syndrome s/p Norwood and Fontan procedures
with baseline cyanosis, reduced ventricular function, and ventricular ectopy presented at 34 weeks
gestation with PPROM. Management goals included minimizing changes in PVR, SVR, and heart rate.
Left radial arterial line was placed, followed by epidural, and left IJ central line for CVP monitoring. Patient
was placed on telemetry. Fluid intake and output was strictly monitored. Titrated epidural anesthesia with
incremental doses of 2% lidocaine was administered during forceps-assisted delivery. Patient received
esmolol and one dose of lasix immediately following delivery. Intrapartum and postpartum course were
uncomplicated.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Fundamentals of Anesthesiology (FA) MC291
Monitoring the Patient Without an Non-invasive Blood Pressure Cuff or Arterial Line: When the
Standard Monitors Fail Us
Greg Balfanz, M.D . Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
A patient with an infrarenal aortic aneurysm and hypertension, ischemic cardiomyopathy status post a
heart transplant and end stage renal disease presented for endovascular repair of his aneurysm with
branch stenting of the inferior mesenteric artery. Given the surgeons needing arterial access in three of
four limbs and the patient's AV fistula in the fourth limb there was no suitable place to monitor blood
pressure for two distinct periods of the case. During this time, transesophageal echocardiography was
used to assess volume status and monitor for regional wall motion abnormalities as surrogates of
maintaining an adequate blood pressure.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Fundamentals of Anesthesiology (FA) MC293
Interesting Case of Asthma with Wheezing and Stridor
Putta S. Bangalore-Annaiah, M.B.,B.S., Sangeetha Kamath, M.D., Palagnat Radhakrishnan, M.D.,
Andrew Beyzman, M.D . New York Methodist Hospital, Brooklyn, NY, USA.
A 56 yr old female with asthma, DM and HTN Presented to ER with two recent episodes of syncope and
wheezing/stridor. Her past medical history was significant for frequent bouts of wheezing/stridor always
without syncope and usually treated with bronchodilators. She was intubated once several years ago for a
severe attack. Pulmonary embolism was suspected because of concomitant syncope. CT images showed
thyroid mass obstructing trachea resulting in slit like opening despite a barely palpable thyroid. The
Patient was immediately taken to OR and intubated awake with a fiberoptic bronchoscope for eventual
successful thyroidectomy.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Fundamentals of Anesthesiology (FA) MC294
A 74-Year-Old Patient Needs an ERCP. Oh, and By the Way, She Was Just Diagnosed With
Tetralogy of Fallot
Alexandra E. Baracan, M.D., Florin Orza, M.D . University of Illinois at Chicago, Chicago, IL, USA.
Copyright © 2014 American Society of Anesthesiologists
A 74 yo female presented for an ERCP. The patient had elevated LFTs, significant ascitis, and mildly
elevated ammonia level. We learnt that the patient was recently diagnosed with tetralogy of Fallot,
following typical findings on a transthoracic echocardiography and a cardic catherization that were
performed as part of her liver disease work up. She had lived a normal life, had had four children, and
had not known of any cardiac disease. Our case will demonstrate that one should expect the unexpected,
and that adequate preparation is the key for a successful anesthetic.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Fundamentals of Anesthesiology (FA) MC295
Difficult Induction and Anesthetic Management in a patient with Cornelia De Lange Syndrome
Jeremy R. Bates, M.D., Enas Kandil, M.D . Anesthesiology, University of Texas Southwestern Medical
Center, Dallas, TX, USA.
-A 20 year old male with a history of Cornelia de Lange Syndrome underwent general anesthesia for a
gastrostomy tube placement in the IR suite. Due to lack of IV access and noncompliance with traditional
mask induction, the patient was induced initially w
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Fundamentals of Anesthesiology (FA) MC296
Amyloidosis and Macroglossia - A Case of Difficult Airway Management
Richard E. Bazan, M.D., Monique Espinosa, M.D . Department of Anesthesiology, University of Miami /
Jackson Memorial Hospital, Miami, FL, USA.
Amyloidosis is a disorder characterized by abnormal deposition of insoluble fibrils leading to abnormal
tissue function with the potential to affect multiple organ systems. In this presentation we describe the
emergent airway management of a 74-year-old female who presented with rapidly worsening upper
airway obstruction leading to acute respiratory failure. Due to the severely obstructive macroglossia from
amyloidosis and her deteriorating clinical condition, she was taken to the operating room for awake
tracheostomy. The procedure was successful and her airway was safely secured in this manner. The pros
and cons of different airway management strategies are also discussed.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Fundamentals of Anesthesiology (FA) MC297
Atypical Bradycardia in a Patient with Chronic Atrial Fibrillation. Is it Vagal?
Marisa K. Bell, M.D., Shveta Jain, M.D., Parissa Sadoughi, M.D., Jim Nguyen, M.D. , Marianna Mogos,
M.D., Peter Roffey, M.D., Duraiyah Thangathurai, M.D., Sophie Y. Yang, B.S . Anesthesiology, University
of Southern California, Los Angeles, CA, USA, Anethesiology, University of Southern California, Los
Angeles, CA, USA, Univeristy of Southern California, Los Anglees, CA, USA, Anethesiology, University
of Southern Californa, Los Angeles, CA, USA, University of Southern California, Los Angeles, CA, USA.
Presented is an 87yo woman with multiple episodes of prolonged bradycardia that are resistant to
vagolytic therapy and epinephrine. Comorbidities include chronic atrial fibrillation. Pre-operative
EKG/ECHO reveal LBBB and EF 38%. The bradycardic episodes are related to intubation, PA catheter
placement and valsalva. One episode devolved into asystole. Heart rate is only stabilized after the
addition of isoproterenol infusion and, ultimately, pacemaker placement. We theorize that chronic atrial
fibrillation and LBB augmented her sensitivity to vagal tone. With these comorbidities, recalcitrant
bradycardia with vagal stimulation should be anticipated. Pacing (medically or electrically) should be
considered after anticholinergics and epinephrine fail.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Fundamentals of Anesthesiology (FA) MC298
Cardiac Arrest During an Orthotopic Liver Transplant due to Hypercoaguability in End Stage Liver
DIsease
Copyright © 2014 American Society of Anesthesiologists
Matthew Bell, M.D., Piotr Janicki, M.D., Dmitri Bezinover, M.D.,Ph.D . Department of Anesthesiology,
Penn State M. S. Hershey Medical Center, Hershey, PA, USA, Department of Anesthesiology, Penn
State Hershey College of Medicine, Hershey, PA, USA.
A 51 year-old female with end stage liver disease presented for liver transplant (MELD=40). During a
protracted hospitalization, she required intensive care, vassopressors and blood products. At the
beginning of the transplant surgery, her INR was 5.3; a thromboelastogram (TEG) indicated severe
coagulopathy. She received blood products and a tranexamic acid infusion; at 2 hours, her TEG had
improved without signs of hypercoagulation. Twenty minutes later, the patient had sudden pulseless
electrical activity and TEE demonstrated severe thrombosis in the pulmonary artery and all chambers of
the heart. Infusion of the fibrinolytic agent, tranexamic acid, may have exacerbated underlying
hypercoaguability.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Fundamentals of Anesthesiology (FA) MC299
Post-Anesthesia Muscular Incoordination Related to COMT Deficiency
Myriam N. Beniamin, M.D., Timothy R. Beldock, C.R.N.A . Anesthesia, Claxton-Hepburn Medical Center,
Ogdensburg, NY, USA.
A 19 year old female patient with a history of catechol-O-methyltransferase (COMT) and
methylenetetrahydrofolate reductase (MTHFR) deficiencies presented for tonsillectomy. Prior to
emergence, spontaneous ventilation with adequate tidal volumes and baseline train-of-four response was
elicited. In recovery, after following commands and verbalizing comfort, the patient experienced gross,
large motor incoordination, and inability to open her eyes or communicate. Supplemental oxygen, light
sedation and extended PACU monitoring was provided. Vital signs remained stable and spontaneous
recovery was achieved within 60 minutes. Plasma cholinesterase deficiency was retrospectively ruled out.
Which standard anesthetic agents could be responsible for this patient‟s reaction?
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Pediatric Anesthesia (PD) MC300
Anesthetic for Laparoscopic Thymectomy for Refractory Myasthenia Gravis in Pediatrics
Randall J. Campbell, Revathy Raju, M.D., Sean Clifford, M.D. . Anesthesiology, University of Louisville,
Louisville, KY, USA, Anesthesiology, Kosair Children Hospital, Louisville, KY, USA, Anesthesia and
Perioperative Medicine, University of Louisville, Louisville, KY, USA.
We present a case of anesthetic management for a 5 year old patient with refractory myasthenia gravis
that presented for thymectomy. After in-depth conversations with the surgical team an airway approach of
a single lumen tube and small doses of neuromuscular blocker with 1 minute neuromuscular monitoring
was implemented. The anesthetic provided excellent visualization for the surgical team and they were
able to successfully remove the thymus. Upon completion patient was extubated successfully.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Pediatric Anesthesia (PD) MC301
3-Day-Old Infant With Unexpected Cardiac Arrest After TEF Repair
Rose Campise-Luther, M.D., Christina Diaz, M.D . Anesthesiology, Medical College of
Wisconsin/Children's Hospital of Wisconsin, Wauwatosa, WI, USA.
A 3 day old presented to the OR for repair of a tracheoesophageal fistula. Additional preoperative findings
included an enlarged heart, secundum ASD, severe pulmonary hypertension ( improved the DOS ), right
hydronephrosis, and anal stricture. After an uneventful surgery, while waiting for a chest-X-Ray, the child
arrested and was pronounced dead after 45 minutes of CPR. After talking with the family and identifying
two unexplained infant deaths in the past, consent was obtained for an autopsy. 3 weeks later the results
showed that the child had an inherited, extremely rare conduction system abnormality that led to lethal
arrhythmias.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Pediatric Anesthesia (PD) MC302
Anesthesia for a Neonate in an Under-Resourced Setting
Beverly P. Chang, M.D., Denise Chan, M.D . Anesthesiology, Brigham and Women's Hospital, Boston,
MA, USA, Anesthesiology, Stanford University, Palo Alto, CA, USA.
A 38-week gestation, 1.43 kg infant presented at the University Teaching Hospital of Kigali, Rwanda with
bilious vomiting, failure to pass stool, and severe cachexia, suggestive of jejunal atresia. The neonate
was taken to the operating room on day of life 15 for jejunostomy and feeding tube placement. Laboratory
tests revealed a normal hemoglobin, platelet count of 64 x 109 cells/L, sodium of 124.9 mEq/L, potassium
of 5.2 mEq/L, and chloride of 99.2 mmol/L. A discussion with the surgeons revealed that there were no
ICU beds or staffing available to monitor this neonate postoperatively.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Pediatric Anesthesia (PD) MC303
Neuraxial Anesthesia in a Pediatric Patient with Recent Severe Bronchospasm under General
Anesthesia
Sundaram K. Chettiar, M.D., Anne M. Savarese, M.D . Department of Anesthesiology, University of
Maryland School of Medicine, Baltimore, MD, USA.
A 9 year old boy experienced severe bronchospasm under GETA for ORIF of a femur fracture.
Endotracheal lavage/suctioning removed a large mucus plug. He received continuous inhaled and IV
beta-agonists for persistent wheezing, and was transferred intubated to the PICU. He was extubated
shortly thereafter and weaned to 30% oxygen with continuous nebulized albuterol and IV terbutaline. That
night he required emergent fasciotomies for compartment syndrome, which were successfully performed
in the PICU under light sedation and spinal anesthesia, due to concerns about his ongoing tenuous
respiratory status. He underwent two additional uncomplicated neuraxial anesthetics for wound washouts
and closure.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Pediatric Anesthesia (PD) MC304
Ketamine Without an Intravenous Catheter During Pediatric MRI to Avoid Triggers of Malignant
Hyperthermia: A Potential Technique for Developing Nations
Franklin B. Chiao, M.D., Mohammad Piracha, M.D . Weill Cornell Medical College, New York, NY, USA.
A 3yo autistic male with a neck mass presented for MRI. The team decided to avoid inhalational agents
and any other malignant hyperthermia triggering agents. An awake intravenous (IV) catheter placement
was one option. Another option was to perform a sedated IV placement. EMLA cream was applied to the
hands and shoulder 45 minutes before potential IV placement. A ketamine intramuscular injection was
used in the shoulder. After five minutes, the patient was sedated and did not respond to stimulus from IV
placement. We believe this technique is another option for cases where avoiding inhalational gas is
desirable.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Pediatric Anesthesia (PD) MC305
Intranasal Dexmedetomidine as the Sole Agent for Emergence Delirium and Pain Management in a
1-Year Old Patient
Franklin B. Chiao, M.D., Eric Chavoustie, M.D . Department of Anesthesiology, New York Presbyterian
Medical Center- Weill Cornell Medical College, New York, NY, USA.
An infant with a history of recurrent ottitis media, adenoid hypertrophy, and emergence delirium presented
for bilateral myringotomy tube placement. No intravenous catheter was placed and the surgery was
uneventful. After completion of the procedure, intranasal dexmedetomidine was given to avoid
emergence delirium and to help with post-operative pain control. Both objectives were achieved. PACU
stay was longer than anticipated with the dose we used. We feel that this technique is a potential option
after BMT procedures.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Pediatric Anesthesia (PD) MC306
Laparoscopic Surgery for Newborns: Is It Safe?
Minji Cho, M.D., Bettina Smallman, M.D . Anesthesiology, SUNY Upstate Medical University, Syracuse,
NY, USA.
A 4-day old full-term infant with Hirschprung‟s disease underwent uneventful IV induction and intubation
for laparoscopic leveling colostomy. 2 minutes after insufflation of the abdomen, end-tidal CO2 drastically
decreased followed by loss of pulse oximetry reading, bradycardia, and cyanosis. We desufflated the
abdomen and immediately started CPR while calling for help. Airway was secure; patient was ventilated
with 100% oxygen and placed on left lateral decubitus, trendelenberg position. Transthoracic
echocardiogram showed global hypokinesis. Surgeon performed cardiocentesis and aspirated air bubbles
and soon circulation and oxygenation returned. Patient was extubated the next day to room air with no
obvious adverse outcome.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Pediatric Anesthesia (PD) MC307
Airway Management in a Twenty Two Month Old Patient with Acute Epiglottitis
Thomas J. Christianson, M.D., Carrie Menser, M.D . Anesthesiology, University of Tennessee, Knoxville,
TN, USA, Pediatric Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
A twenty-two month old male was diagnosed with acute epiglottitis and taken to the operating room for an
urgent intubation. Upon arrival in the OR the patient underwent an inhaled induction with 100% oxygen
and 8% sevoflurane while maintaining spontaneous ventilation. An IV was placed and three 1mg/kg
boluses of propofol were given over five minutes while maintaining spontaneous ventilation. A 3.5
uncuffed endotracheal tube was placed on the first attempt under suspension laryngoscopy by the
otolaryngologist. The patient was then transferred to the ICU where he received IV steroids and
antibiotics and was extubated 3 days later without complication.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Pediatric Anesthesia (PD) MC308
The Anesthetic Management of Lung Biopsy Associated Pulmonary Hemorrhage in a Child with
Suprasystemic Pulmonary Hypertension
Rachel G. Clopton, M.D., David A. Partrick, M.D., Carol Okada, M.D. , Jon Kaufman, M.D. , Neil Wilson,
M.B.,B.Ch., D. Dunbar Ivy, M.D., Robert H. Friesen, M.D., Richard J. Ing, M.B.,B.Ch . Children's Hospital
Colorado, Denver, CO, USA.
The complex anesthetic management of a 14 kg, four-year-old girl with newly diagnosed
echocardiographic RV systolic pressure of 140 mmHg is discussed. Initially she underwent PICC-line
insertion, diagnostic cardiac catheterization, atrial septostomy, bronchoscopy and left thoracoscopic lung
biopsy. Three hours post-extubation, an episode of: emesis, pallor, hypotension and hypoxemia prompted
CXR confirmation: left hemothorax. The patient was resuscitated with 1200 mls blood products, reintubated for thoracostomy tube placement, draining 700 mls of blood. The actively bleeding
suprasystemic hypertensive lung was repaired via redo-thoracoscopy under general anesthesia.
Hemodynamic stability was achieved with slow recovery and endotracheal extubation occurred on POD
6.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Critical Care Medicine (CC) MC309
A Case of Severe Immune Mediated Thrombocytopenia in the Intensive Care Unit
Somnath Bose, M.D., Ellen Wurm, M.D., Marc J. Popovich, M.D . Anesthesiology Institute, Cleveland
Clinic Foundation, Cleveland, OH, USA.
62 year old woman with prosthetic mitral valve was admitted for explant of an infected prosthetic knee.
Perioperatively, she was bridged with heparin and started on empiric Vancomycin and PiperacillinCopyright © 2014 American Society of Anesthesiologists
Tazobactum. Platelet counts dropped precipitously within 2 days reaching a nadir of 6000/mm3, without
any bleeding. Decline persisted despite substituting Heparin with Bivalirudin. Anti-PF4, anti-PLA1 antigen
were negative. Schistocytes were absent. Labs suggested a low grade DIC. Antibiotics were substituted
with Daptomycin for suspected drug-induced thrombocytopenia (DIT).Pulse dose IVIG was initiated with
rapid normalization of platelet count. She tested positive for IgG-antiplatelet antibodies to Vancomycin
and Piperacillin-Tazobactum thereby confirming the diagnosis.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Critical Care Medicine (CC) MC310
Argon Plasma Coagulation Trimming of Fractured Tracheal Bare Metal Stents
Enrico M. Camporesi, M.D., Yiu-Hei Ching, M.D., Devanand Mangar, M.D., Mark J. Rumbak, M.D.,
Robert D. Geck, M.D . Florida Gulf-to-Bay Anesthesiology Associates, Tampa, FL, USA, University of
South Florida Morsani College of Medicine, Tampa, FL, USA.
We discuss the case of a patient with tracheal obstruction secondary to tracheal stent in- and over-growth
treated with argon plasma coagulation. Previously, the patient developed tracheomalacia secondary to
inhalation injury requiring permanent tracheostomy and subsequent bare metal stent placement. In our
experience with argon plasma coagulation, we observed decreased severity and rates of tracheal
obstruction after stent trimming. While trimming exposed stent fragments may decrease granulation tissue
formation and tracheal obstruction, the potential negative effects of positive pressure ventilation and the
presence of metal vapor in the airways remain unclear.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Critical Care Medicine (CC) MC311
Intraperitoneal Insertion of Femoral Venous Catheter
Christine L. Carqueville, M.D., Mark E. Nunnally, M.D . Department of Anesthesia & Critical Care,
University of Chicago Medical Center, Chicago, IL, USA.
A 58-year-old female with acute fulminant hepatitis C presented with hemoperitoneum after a liver biopsy.
She was intubated and had an arterial line and large femoral venous catheter placed emergently in the
ICU, followed by an emergent exploratory laparotomy. In the OR, she lost several liters of blood upon
opening the abdomen and continued to bleed profusely. A rapid infuser was used to transfuse via the
femoral line, however the hemoglobin failed to improve. Insufficient response to cisatracurium led us to
suspect malposition of the femoral catheter, confirmed intra-operatively by the surgeon (Figure).
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Critical Care Medicine (CC) MC312
Perioperative Management of Fulminant Myocarditis Following Coxsackie B Virus Infection
Brian R. Gebhardt, M.D.,M.P.H., Kalhun Faris, M.D . University of Massachusetts Medical School,
Worcester, MA, USA.
A 47 year-old female with history of hypertension, hypothyroid and previous UTIs presents with fever,
abdominal pain, nausea/vomiting BP 58/32, HR 135, pH 7.18, BE -18 and CT abdomen suggestive of
right hydroureteronephrosis and possible stricture, malignancy or peristalsis. She was taken emergently
to the OR for ureteral stent placement then remained intubated post-op with worsening acidosis,
increasing vasopressor requirements, and elevated troponin of > 70 leading to cardiac catheterization.
Catheterization revealed no coronary luminal irregularities and a LVEF 25%. These findings then lead to
myocardial biopsy identifying neutrophilic myocarditis as well as Coxsackie B virus in serology.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Critical Care Medicine (CC) MC313
Management of a Difficult Airway in Patient with Cerebral Palsy
Jeremy R. Chastain, M.D., Allison Alpert, M.D . St. Louis University Hospital, St. Louis, MO, USA.
Anesthesiology was paged for intubation of a 33 year old, 22 kg patient with cerebral palsy and scoliosis
who presented with pneumonia and respiratory distress with PaCO2 95. We experienced difficulty mask
Copyright © 2014 American Society of Anesthesiologists
ventilating the patient because he produced copious secretions and his head was fixed in right lateral
position. Intubation attempts using LMA and Fiberoptic bronchoscope were unsuccessful. After placing
the patient in left lateral decubitus position, his face was up and mask ventilation was easier. Intubation
was then accomplished using CMAC and bougie. We confirmed ETT placement with ETCO2 detector
color change, auscultation and fiberoptic bronchoscopy.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Critical Care Medicine (CC) MC314
Unrecognized Airway Edema From Carotid Endarterectomy and Difficult Intubation During
Subsequent CABG Surgery
Won K. Chee, M.D., MBA. Department of Anesthesiology, The Montefiore Medical Center & Albert
Einstein College of Medicine, Bronx, NY, USA.
A 75 year old female was scheduled for carotid endarterectomy and CABG. PMH was significant for HTN,
NIDDM, hypercholesterolemia and obesity. PSH included cholecystectomy. Airway classification was
Mallampati 3. Following acute MI and emergency coronary angioplasty 3 days before, the patient
underwent right carotid endarterectomy (99.9% occluded) under general anesthesia. Postoperatively, the
patient's right side of the face drooped slightly. CT scan of the head was negative. 2 days later, general
anesthesia was induced for CABG by the same anesthesiologist. Direct laryngoscopy this time could not
visualized the vocal cords; the Glidesocpe was required for intubation.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Critical Care Medicine (CC) MC315
Management of Acute Mitral Valve Thrombosis With Venoarterial Extracorporeal Membrane
Oxygenation
Efrain I. Cubillo, IV, M.D., Hannelisa Callisen, P.A., Ayen Sen, M.D . The Mayo Clinic, Phoenix, AZ, USA.
A 30-year-old female with history of congenital mitral valve disease status post three previous mitral valve
replacements, presented in cardiogenic shock. Upon arrival, she was urgently intubated, central and
arterial lines were placed and an intra-aortic balloon pump inserted. The patient remained significantly
hypotensive for which increasing amounts of ionotropic support was required. Echocardiogram revealed a
thrombosed mechanical mitral valve. In the setting of worsening multi-organ dysfunction, the patient was
placed on VA-ECMO. After 48 hours of improved hemodynamics she was taken to the operating room for
mitral valve replacement and decannulation. The patient was discharged on postoperative day 13.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Critical Care Medicine (CC) MC316
Manegement of Pulmonary Alveolar Hemorrhage due to Stenotrophomonas Maltophilia with a
Compromised Host
Futaba Daigo, M.D., Takashi Matusaki, M.D . Tokyo Women's Medical University, Tokyo, Japan,
Okayama University Hospital, Okayama, Japan.
There are great challenges regarding ICU management of hematopoietic transplantation in terms of high
mortality. We experienced a 60-year old male patient who had hematopoietic stem cell transplantation
recipient, with sepsis, acute kidney injury, and respiratory failure due to S.maltophilia infection. Two
weeks alter after transplantation his respiratory condition deteriorated significantly due to S.maltopliliainduced acute lung injury. We managed his condition using nasal high flow support for respiratory failure
initially; however,his alveolar hemorrhage deteriorated, so we had to intubate him. The patient died of
respiratory failure within one week after intubation.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Critical Care Medicine (CC) MC317
Combination of Extracorporeal Membrane Oxygenation and High-Frequency Oscillatory
Ventilation for Severe, Refractory H1N1-Induced ARDS
Copyright © 2014 American Society of Anesthesiologists
Maurice A. Davis, M.D., Michael J. Faulkner, M.D . Anesthesiology and Perioperative Medicine, William
Beaumont Hospital, Royal Oak, MI, USA.
A 31-year-old morbidly obese male (BMI 45) presented with profound hypoxemia and suspected H1N1induced ARDS as a transfer consult for rescue therapy. Initial lung-protective strategies with APRV and
permissive hypercapnea proved insufficient. A trial of high frequency oscillatory ventilation (HFOV) was
initiated when respiratory parameters consistently revealed profound hypoxemia despite high plateau
pressures and FiO2 requirements. As hypoxemia persisted and our concern for end-organ function
increased, we instituted venovenous extracorporeal membrane oxygenation (vv-ECMO) with APRV.
Despite improvement in the oxygenation index, PaO2/FiO2, and FiO2 requirements, we were unable to
achieve adequate oxygenation until the concomitant use of HFOV and vv-ECMO.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Fundamentals of Anesthesiology (FA) MC318
The Difficult Airway Algorithm Does Not Apply Here: A 59-Year-Old Male With Stage IV
Esophageal Cancer, Tracheo-esophageal Fistula and Near Total Obstruction of Distal Trachea
Minji Cho, M.D., Colleen O'Leary, M.D . Anesthesiology, SUNY Upstate Medical University, Syracuse,
NY, USA.
A 59-year old male was newly diagnosed with esophageal cancer which had invaded the trachea causing
near obstruction of distal trachea. Rigid bronchoscopy with tracheobronchial stent placement and
debulking of tumor was scheduled. We were concerned about difficulty ventilating despite successful
intubation due to near obstruction of distal trachea and presence of tracheo-esophageal fistula.
Cardiopulmonary bypass was not available as placement of bypass access was declined due to patient‟s
poor prognosis. We proceeded with IV induction and adequate mask ventilation was confirmed.
Throughout the procedure patient could be ventilated via the bronchoscope and was extubated 3 days
later.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Fundamentals of Anesthesiology (FA) MC319
69-Year-Old Female s/p Motor Vehicle Accident for Ankle Fracture
Sonya P. Chokshi, Tony Tricinella, M.D., Michael Hofkamp, M.D . Medical Student, Texas A&M Health
Science Center, Round Rock, TX, USA, Anesthesia, Scott & White, Temple, TX, USA.
We present a 69 year old female status post motor vehicle accident for ankle ORIF accepted as a transfer
from an outside facility for escalation of care. She had a past medical history of hiatal hernia and transient
ischemic attacks. Coexisting traumatic injuries included a pelvic fracture causing a pelvic hematoma and
multiple lumbar transverse process fractures. After stabilization in the intensive care unit, she was
transported to the operating room. A rapid sequence induction was performed due to active vomiting and
history of hiatal hernia. A multimodal perioperative pain management strategy was employed including a
postoperative nerve block.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Fundamentals of Anesthesiology (FA) MC320
Management of a Difficult Airway in a Patient with Anencephaly and Facial Cleft
Telianne H. Chon, D.O., Sang Le, M.D., Joanna Green, M.D . Anesthesiology, Riverside County Regional
Medical Center, Moreno Valley, CA, USA, Anesthesiology, Children's Hospital Los Angeles, Los Angeles,
CA, USA.
An anencephalic patient with facial cleft is scheduled for a gastrostomy tube creation secondary to
feeding difficulties. There are no case reports of these patients undergoing general anesthesia. The
anesthetic plan includes an inhalational induction, obtaining peripheral intravenous access, and securing
a potentially difficult airway. At the termination of surgery, due to a combination of the anatomy and
medications used on the patient, the safest decision was to keep the patient intubated. The recovery of
the patient and time to extubation was brief. Future surgical encounters may necessitate a more
permanent airway, such as a tracheostomy.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Fundamentals of Anesthesiology (FA) MC321
A Case Report: Preoperative Thrombocytopenia in Major Abdominal Surgery
Jarva Chow, M.D.,M.P.H., Naila Mammadova, M.D.,Ph.D . Anesthesiology, SUNY Downstate Medical
Center, Brooklyn, NY, USA, Anesthesiology, Lutheran Medical Center, Brooklyn, NY, USA.
Timing of therapeutic platelet transfusion for leukemia‟s involving the spleen in the setting of major
abdominal surgery poses unique risks. The literature recommends preoperative optimization, however no
definitive studies exist to substantiate an absolute platelet transfusion trigger. We present a case
involving a 77 year old male with hairy cell leukemia presenting for elective splenectomy for symptomatic
splenomegaly (postoperative weight 3800 grams). The patient had increasing petechiae, easy bruising,
and pancytopenia with platelet count 52,000/mcL. Given the high risk of open splenectomy, as illustrated
in surgical literature, coupled with baseline clinical coagulopathy, this case represents multiple anesthetic
challenges and considerations.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Fundamentals of Anesthesiology (FA) MC322
Airway Management in a Morbidly Obese Patient with Myasthenia Gravis and Cervical Spine
Fusion
Jonathan H. Chow, M.D., Darin Zimmerman, M.D . University of Maryland, Baltimore, MD, USA.
A 50-year-old female with severe myasthenia gravis arrived to the ED with acute cholecystitis and was
taken to the OR after plasmapheresis was performed. Airway management was complicated by
myasthenia gravis, C3-T1 fusion, restricted range of motion, Mallampati IV airway, morbid obesity,
dysphagia, and active emesis. She was prepared for an awake fiberoptic nasal intubation. Topicalization
was achieved with nebulized lidocaine, sedation with a dexmedetomidine infusion, and dilatation with
nasopharyngeal airways coated with lidocaine and phenylephrine. We successfully placed a 6.0 Nasal
Rae ETT. No muscle relaxants were used, and she was extubated successfully at the conclusion of the
case.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Fundamentals of Anesthesiology (FA) MC323
Airway Considerations In A Patient With Hemangioma For Urgent Cardiac Surgery.
Ngoc Chu, D.O., Magdalena Bakowitz, M.D . Anesthesiology, Baystate Medical Center, Springfield, MA,
USA.
A 70 year-old morbidly obese female with chronic obstructive pulmonary disease, type 2 diabetes , and
long-standing hemangioma involving the anterior neck, the tongue and the supraglottic area presented for
coronary artery bypass graft surgery (CABG) after non-ST-segment elevation myocardial infarction
(NSTEMI). The extent of the hemangioma was unknown since the patient was unable to lay supine for
imaging. The patient was deemed to have a difficult airway and the risk of morbitidy from airway
management and anticoagulation during cardiopulmonary bypass were estimated to be higher than the
previously cited risk associated with cardiac surgery.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Fundamentals of Anesthesiology (FA) MC324
A Cold Leg Doesn’t Mend a Broken Heart
Michael A. Chyfetz, M.D., M.S., Sangeetha Kamath, M.D., Joel M. Yarmush, M.D., Joe Schianodicola,
M.D. Department of Anesthesiology, New York Methodist Hospital, Brooklyn, NY, USA.
We describe a case of a 74 year-old Male with history HTN and a-fib presenting with bilateral lower
extremity pain, weakness and numbness. Physical examination noted cold, molted lower extremities. In
ED, patient found in SVT (EF-10%) and cardioversion performed with adenosine, amiodarone and
lopressor. Patient brought to OR holding area for emergent axillary-bifemoral bypass. On induction
patient developed SVT and ACLS protocol successfully performed. Despite the high mortality rate surgery
continued and patient subsequently transferred to SICU in Critical Condition. Using intraoperative point of
Copyright © 2014 American Society of Anesthesiologists
care testing and bioimpedance technologies, we describe the intraoperative management of the critically
ill patient.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Fundamentals of Anesthesiology (FA) MC325
Anesthetic Management in a Patient With Fabry's Disease
Leah R. Ciaccio, D.O., Laura Cohen, D.O . Department of Anesthesia, University of Massachusetts,
Worcester, MA, USA, University of Massachusetts, Worcester, MA, USA.
A 40-year-old female with a past medical history of Fabry‟s disease and secondary posterior pontine
stroke presented for an elective laparascopic cholecystectomy. A preoperative CT angiogram showed
narrowing of her cerebral vasculature. Her risk of perioperative stroke was high and we received
recommendations for intraoperative management from a neurologist. An arterial line was placed and her
systolic blood pressure was maintained above 120mmHg with phenylephrine. She tolerated the surgery
well, without complications. We discuss Fabry‟s disease, anesthetic implications and management, and a
review of the current literature.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Obstetric Anesthesia (OB) MC326
Anesthetic Management of a Parturient with Pseudotumor Cerebri Syndrome and Bilateral
Ophthalmic Artery Aneurysms for Urgent Cesarean Delivery
Anthony Chau, M.D., FRCPC, Lawrence C. Tsen, M.D., Jie Zhou, M.D., MBA. Anesthesiology, Pain and
Perioperative Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Pseudotumor cerebri syndrome (PTCS) is a disorder of raised intracranial pressure (ICP) of unknown
etiology. Ophthalmic artery (OA) aneurysms are rare, but frequently arise from the wall of the internal
carotid artery between the OA and posterior communicating artery. We describe the successful
anesthetic management of a 26 year old G3P1 twin gestations at 36 weeks with PTCS and bilateral OA
aneurysms presenting for urgent primary cesarean delivery due to non-reassuring fetal heart rate
tracings. Careful planning, monitoring, and minimization of intra-operative large intracranial or arterial
pressure changes were essential our anesthetic management.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Obstetric Anesthesia (OB) MC327
Failed Non-Invasive BP Monitoring from Severe Shivering during Cesarean Delivery: Management
& Options
Won K. Chee, M.D., MBA. Department of Anesthesiology, The Montefiore Medical Center & Albert
Einstein College of Medicine, Bronx, NY, USA.
A 30 year old female was scheduled for primary cesarean delivery due to the non-reassuring fetal heart
rates. Her PMH was significant for gestational diabetes. Height: 5 feet 2 inches, Weight: 157 pounds, BP:
120/65, PR: 80, Hematocrit: 32. The continuous lumbar epidural catheter was placed 4 hours earlier with
a continuous infusion. In the OR an epidural bolus of lidocaine 2% with epinephrine and fentanyl were
administered. During the procedure the patient‟ shivering became intense and constant. The forced air
warmer was applied to the patient. Meanwhile, the non-invasive BP readings were ranging from 250/150
to 175/145.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Obstetric Anesthesia (OB) MC328
Anesthetic Management for Cesarean Section with Known Placental Abruption and Occult Uterine
Rupture
Daniel Chien, M.D., Scott H. Mittman, M.D.,Ph.D., Jamie D. Murphy, M.D . Anesthesiology & Critical Care
Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
A 37-year-old G4P3004 at 32-weeks gestation with chronic abruption was admitted for PPROM with
abdominal pain and vaginal bleeding. After many hours refusing any interventions, she experienced
Copyright © 2014 American Society of Anesthesiologists
worsening pain concerning for possible progressive abruption. She was eventually convinced to undergo
caesarian section with combined spinal-epidural. This was complicated by difficult surgical exposure
without signs of uterine rupture, difficult delivery thought to be due to the baby‟s head in a Bandl‟s ring,
and extensive blood loss. As the head was finally delivered, a large posterior uterine rupture was
discovered, ultimately requiring hysterectomy. She remained conscious throughout the case.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Obstetric Anesthesia (OB) MC329
Management of Postpartum Hemorrhage in a Patient with a Rare Antibody, Anti-PP1PK
Sagar Chokshi, M.D., Uma Munnur, M.D . Baylor College of Medicine, Houston, TX, USA.
A 28 y/o G4P2 female presented to BTGH at 35 weeks for IOL secondary to rare blood antibody, antiPP1PK. She was found to be antibody positive during her previous pregnancy which was complicated by
PPH of 2L. Anti-PP1PK is very rare (estimated 5.8 in 1 million). In vitro studies show that this antibody
can cause immediate hemolytic transfusion. Therefore, management of these high risk patients requires
blood conservation strategies to avoid transfusions. Because this antibody is very rare, there are very few
cases describing management of blood transfusions in patients with this antibody and even fewer in the
obstetric population.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Obstetric Anesthesia (OB) MC330
Asymptomatic Persistent Fluid Leak After Epidural for Labor Analgesia
Ngoc Chu, D.O., Cuong Vu, M.D . Anesthesiology, Baystate Medical Center, Springfield, MA, USA.
A 24 year-old G2P1, with prior caesarean section presented for vaginal delivery. Her medical history was
significant for Hodgkin‟s lymphoma under remission and asthma. Epidural was sited at L3-4 level without
clinical evidence of dural puncture. Patient underwent caesarean section for late decelerations and 20ml
of lidocaine 2% was administered through epidural. Postoperatively, patient had persistent clear fluid leak
from epidural site lasting six days although she remained asymptomatic. Patient was discharged without
further fluid leak after a single figure 8 stitch was placed to close epidural site.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Obstetric Anesthesia (OB) MC331
Size Does Matter: The Urgent C-Section in an Achondroplastic Dwarf
Michael A. Chyfetz, M.D., M.S., Jayme M. Uy, M.D., Chanchal Mangla, M.D., Joel M. Yarmush, M.D., Joe
Schianodicola, M.D . New York Methodist Hospital, BROOKLYN, NY, USA.
Achondoplasa a form of genetic dwarfism causing abnormal cartilage formation presents unique
obstacles in Anesthesia. A 35 year-old female presented at 37 weeks gestation with history significant for
Dwarfism (Height - 3‟11”; Weight - 114 lbs), Hypothyroidism (Currently on Synthroid 175 mcg daily), and
Thoracic/Lumbar Disk Hernation. Prior Anesthesia records unavailable and patient notes that she
required multiple attempts at Regional Anesthesia during previous C-Section. Physical examination noted
craniofacial and spinal abnormalities including limited neck extension suggestive of atlanto-axial instability
and severe kyphosis. In this case report, we describe the anesthetic management of an achondroplastic
dwarf using modified spinal dosing.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Obstetric Anesthesia (OB) MC332
Anesthetic Management of a Parturient with Noncompaction Cardiomyopathy
Jennifer H. Cohn, M.D., Katherine Hoctor, M.D., Oscur Aljure, M.D., J Sudharna Ranasinghe, M.D .
University of Miami Miller School of Medicine, Miami, FL, USA.
Left ventricular noncompaction cardiomyopathy (LVNC) is a rare cardiomyopathy that results from arrest
of the normal compaction process of the myocardium during embryogenesis. Also known as spongy
myocardium, it leads to extensive myocardial trabeculations and deep intra-trabecular recesses of the left
ventricular cavity. LVNC is a rare disease with a reported incidence of 0.05-0.25% per year. Patients most
Copyright © 2014 American Society of Anesthesiologists
commonly present with symptoms of heart failure and are at increased risk for arrhythmias,
thromboembolic events and sudden death.We report a favorable outcome in a parturient with LVNC who
underwent cesarean section with low dose combined spinal epidural anesthesia.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Obstetric Anesthesia (OB) MC333
The Management of Difficult Airway in an Elective Cesarean Section: A Case in a Patient With
Severe Trismus
Joe Cook, M.D.,M.P.H., Suwarna Anand, M.D., Arthur Calimaran, M.D . Anesthesiology, University Of
Mississippi Medical Center, Jackson, MS, USA.
This is a 22 year old gravida1, para 0 female with an intrauterine pregnancy at 38 weeks gestation. The
patient presented for a primary cesarean section secondary to multiple fetal anomalies. The patient had a
history of surgery to a right cheek hemangioma complicated by trismus requiring lysis of adhesions in
2009. As a result of her previous surgeries, the patient has severely restricted mouth opening measuring
approximately 3 centimeters at the interincisor. Anesthetic plan involved complete preparation for awake
fiberoptic prior to employing combined spinal and epidural anesthesia. Otolaryngology was also on
standby for the possibility of emergent tracheotomy.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Obstetric Anesthesia (OB) MC334
Epidural Intolerance
Ran Dai, M.D., David M. Dickerson, M.D., Timothy Ebbert, M.D., William McDade, M.D.,Ph.D .
Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA.
We describe a case of 34 year old G1P0 who presented at 41 weeks and 1 day for induction of labor.
Labor epidural was placed and re-placed, and during both occasions, the patient experienced sudden
onset of severe headache and bilateral neck, upper back, and shoulder pain with injection of small
volumes into the epidural space. She demonstrated no signs of neurologic dysfunction, permanent or
transient. MRI demonstrated a congenitally narrow spinal canal with minimal CSF surrounding the spinal
cord. She eventually required Caesarean section, performed with single shot subarachnoid block. She
tolerated this small volume injection without symptoms.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Regional Anesthesia and Acute Pain (RA) MC335
AV Fistula Ligation in a Patient with Orthopnea, Pulmonary Hypertension and Concurrent
Antiplatelet Therapy
Whitney D. Helgren, M.D., Harold D. Hardman, M.D . Anesthesia, University of North Carolina at Chapel
Hill, Chapel Hill, NC, USA.
A 59 year-old male status post kidney transplant was scheduled for arterio-venous fistula (AVF) ligation.
The fistula extended from his elbow well into the axilla, and was large and tortuous. His medical history
was significant for orthopnea, high output cardiac failure, severe pulmonary hypertension, and severe
coronary artery disease, with 16 previously placed coronary artery stents. At the time of surgery, he had
recently received oral antiplatelet therapy. We will discuss the anesthesia challenges, compromises, and
management plan associated with this patient, along with the outcome of our selected regional
anesthesia technique.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Regional Anesthesia and Acute Pain (RA) MC336
Interscalene Brachial Plexus Block in IVDU Patient Under GA with Thrombocytopenia and Sepsis
Darren J. Hyatt, M.D., T. Anthony Anderson, M.D.,Ph.D . Department of Anesthesia, Critical Care, and
Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
A 30 year old male with a history of intravenous drug use, presented with necrotizing fasciitis from a left
deltoid retained needle. After initial debridement, he remained intubated with sepsis requiring vasopressor
Copyright © 2014 American Society of Anesthesiologists
infusions. He re-presented to the OR for debridement on POD #1 still intubated and sedated. After a
discussion with the patient‟s family, an interscalene brachial plexus catheter was placed to facilitate
extubation and minimize the need for post-operative opioids. The patient was extubated at the completion
of surgery, and subsequently weaned off vasopressors. He required no opioids for five days postoperatively while the catheter was in place.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Regional Anesthesia and Acute Pain (RA) MC337
Combined Bilateral Rectus Sheath and TAP Blocks for Xiphoid to Pubis Incision
Ryan M.J. Ivie, M.D., Robert Maniker, M.D . Anesthesiology, Columbia University, New York, NY, USA.
A 50-year-old 48kg female with chronic pain and endovascularly repaired descending thoracic aortic
dissection presented with right common iliac artery occlusion and endoleak requiring endarterectomy with
hepatic artery and SMA bypass via midline laparotomy from xiphoid to pubis. The patient refused
neuraxial procedures but was amenable to peripheral nerve block. Combined ultrasound-guided bilateral
rectus sheath blocks and bilateral TAP blocks were performed after wound closure using a total of 48mL
ropivacaine 0.25% with 50mcg clonidine. Opioid consumption increased fourfold in the second 12 hours
postoperatively suggesting analgesic efficacy in the first 12 hours in addition to decreased opioid use.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Regional Anesthesia and Acute Pain (RA) MC338
Direct Visualization of a Lumbar Epidural Catheter in Sacral Plexus: Unilateral Threading and
Migration of the Epidural Catheter
Suneil Jolly, M.D., Aron Legler, M.D., Jinlei Li, M.D . Anesthesiology, Yale-New Haven Hospital, New
Haven, CT, USA.
69 yo M with femoral spindle cell sarcoma underwent right hindquarter amputation/hemipelvectomy. A
preoperative epidural was placed using standard landmark technique - LOR 3.5cm and secured at 8.5cm.
Midway through the 12h surgery, the surgical team visualized a catheter in the left L3-L4 nerve foramen
(pictures taken). Examination of the catheter site revealed migration to 10.5cm. Unexpectedly, good
opioid sparing effect was achieved intraoperatively through local anesthetic boluses despite catheter
migration. Postoperatively, the catheter was retracted to 6.5cm, and dilaudid/bupivicaine infusion started.
Postoperative pain remained minimal (3/10), and the catheter was removed POD #2 and discharged on
PO pain regimen.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Regional Anesthesia and Acute Pain (RA) MC339
Peripheral Nerve Catheter for Below Elbow Amputation due to Complex Regional Pain Syndrome
Type I
Charles A. Jones, M.D., Michael Bassett, M.D . Anesthesia, MetroHealth Medical Center - Case Western
Reserve University, Cleveland, OH, USA.
We are presenting a 56 year old femalescheduled for a below the elbow amputation for severe, long
standing, therapyresistant complex regional pain syndrome type I. An infraclavicular continuousperipheral
nerve catheter was placed and bolused with bupivicaine 0.5% with1:200k epinephrine for surgical
analgesia and post-operative pain. In recovery,the patient was started on her home pain medications and
an infusion ofbupivicaine 0.5% with 1:400k epinephrine was started. On post-operative day onethe
peripheral nerve catheter was attached to a home going elastometriccontinuous pump containing similar
local anesthetic and the patient wasdischarged home comfortably.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Regional Anesthesia and Acute Pain (RA) MC340
Trial Ultrasound Guided Continuous Left Stellate Ganglion Blockade Prior to Surgical Gangliolysis
in a Patient with a Left Ventricular Assist Device and Intractable Ventricular Tachycardia: A Pain
Control Application to a Complex Hemodynamic Condition
Copyright © 2014 American Society of Anesthesiologists
Sarah A. Kralovic, M.D., M.S . Department of Anesthesiology, University of Rochester, Rochester, NY,
USA.
65 year old male, admitted to the hospital with electric storm, receiving countershocks for each episode of
ventricular tachycardia (VT) via his BIV-ICD. Past medical history included non-ischemic cardiomyopathy
with a depressed ejection fraction requiring a Heartmate II implantation with development of multiple
episodes of VT. He underwent an unsuccessful VT ablation and was placed on amiodarone therapy. He
continued to suffer from episodes of VT, requiring cardioversion from his ICD. An ultrasound- guided left
stellate ganglion catheter was placed and a continuous infusion of 1% Lidocaine-MPF was started. With
no VT episodes, a left T1-T4 sympathectomy was performed (VATS).
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Regional Anesthesia and Acute Pain (RA) MC341
Utrasound-Guided Airway Blocks for Awake Intubation: A Safe and Effective Technique in
Patients with Local Head or Neck Infection
Martin Krause, M.D., Jacklynn Fanny Sztain, M.D., Erika Smith, M.D., Navparkash Sandhu, M.D., M.S .
University of San Diego, California, San Diego, CA, USA.
A 59-year-old man was admitted with dysphagia and neck swelling. CT neck revealed a right
submandibular/parapharyngeal abscess. ENT scheduled an urgent I&D of the neck. His history included
drug abuse, hypertension and c-spine fusion. Airway exam revealed limited neck extension, a swollen
tongue, trismus, a tender and indurated neck. An awake fiberoptic intubation was planned. Nostrils were
topicalized with lidocaine 4% and oxymetazoline. An eleven millimeter curvilinear ultrasound probe was
used to guide a 27-gauge needle towards both superior laryngeal nerves. The trachea was anesthetized
with lidocaine 2% injected through cricothyroid membrane using ultrasound guidance. Afterwards
nasotracheal intubation was successful.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Regional Anesthesia and Acute Pain (RA) MC342
Multimodal Pain Management with Regional Anesthesia in an Electrical Burn Patient with Brachial
Plexus Injury
Mary Margaret Lim, M.D., Kristin M. Ondecko Ligda, M.D . Anesthesiology, UPMC, Pittsburgh, PA, USA,
Department of Anesthesiology, UPMC, Pittsburgh, PA, USA.
A 49-year-old male with a past medical history of hypertension sustained six percent body surface area
third degree burns after grabbing a high voltage power line with both hands. As a result, he obtained right
brachial plexus injury and had limited motor function of his right upper extremity. During his hospital stay
he underwent right forearm, upper arm, and hand fasciotomies, multiple I&Ds, and a right below the
elbow amputation. The patient's pain was managed with multiple regional anesthetics and multimodal
analgesia.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Regional Anesthesia and Acute Pain (RA) MC343
Regional Anesthesia Facilitates the Early Detection of Compartment Syndrome in a Pediatric
Patient
Chang A. Liu, M.D., M.S., Lisa Watt, M.S.N., Jingping Wang, M.D.,Ph.D . Anesthesiology, Critical Care
and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
A 14-year-old otherwise healthy male presented with right open ankle fracture and underwent ORIF of
lower tibia and fibula. A popliteal sicatic nerve catheter with 0.1% Bupivacaine infusion at 8 ml/hr was
placed intraoperatively. He reported 0/10 pain in the PACU and minimal pain overnight. He awoke with
mild pain which later developed into severe pain the next morning. His popliteal catheter was evaluated
and 0.1% Bupivacaine was increased to 10 ml/hr. He continued to have severe pain and received
Morphine 4 mg IV with minimal relief. Acute compartment syndrome was diagnosed and he underwent
emergent decompressive fasciotomy.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Ambulatory Anesthesia (AM) MC344
Dexmedetomidine: A Great Drug for Myotonic Dystrophy Patient with Difficult Airway in
Endoscopy Suite!
Tanmay H. Shah, M.D., Anuradha Patel, M.D . Anesthesiology, RUTGERS-NJMS, Newark, NJ, USA.
Myotonic dystrophy is a chronic, slowly progressing and a serious multi-systemic autosomal dominant
disease. We performed a case of 65 year old women who presented to endoscopy suite for
esophagogastroduodenoscopy and colonoscopy. She had previous difficult intubation and tracheostomy.
Our goal was to avoid airway manipulation and to provide anesthesia with minimal respiratory depression.
We found dexmedetomidine infusion to be a highly effective approach because of its known desirable
pharmacological properties of sedation, anxiolysis, hypnosis, analgesia and anti-sialagogue effects with a
relative lack of respiratory depressant effect, which may become a problem by using higher doses of
fentanyl and midazolam.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Ambulatory Anesthesia (AM) MC345
Bronchoscopy With Stent Placement Leading to Massive Hemoptysis and Fatal Venous Air
Embolism
Benjamin M. Sherman, M.D . Anesthesiology, Legacy Good Samaritan Hospital, TeamHealth Anesthesia,
Portland, OR, USA.
The patient is a 54 year old woman with stage 4 non small cell lung cancer who presented for
bronchoscopy with stent placement for palliative treatment of pneumopericardium. During the course of
the bronchoscopy, a large mucous plug was identified in the right upper lobe and an attempt to remove it
lead to massive hemoptysis of approximately 1500ml. The patient was placed into right lateral position
but then developed massive venous air embolism leading to PEA arrest and eventual intra operative
death.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Ambulatory Anesthesia (AM) MC346
Anesthetic Considerations in a Patient with May-Hegglin Anomaly
Lee D. Stein, M.D., Levon Capan, M.D . Bellevue Hospital Center, New York, NY, USA.
A 34 year old female with a history of excessive bleeding secondary to May-Hegglin anomaly presented
for removal of foreign bodies from her left foot. She presented on the day of surgery with critically low
platelets of 13. After rescheduling and receiving two units of platelets, the patient was taken to the
operating room. Due to the high risk of bleeding we decided to avoid using a regional technique or
instrumentation of the airway. The procedure was performed under general anesthesia with a mask and
gently placed oral airway. There were no complications and the procedure was tolerated well.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Ambulatory Anesthesia (AM) MC347
Endoscopy Air Insufflation: A Mechanism for Sudden Cardiopulmonary Collapse
Paul J. Terracciano, M.D . Anesthesiology, Phelps Memorial Hospital Center, Sleepy Hollow, NY, USA.
65 year old for ambulatory colonoscopy suffered acute cardiovascular collapse from Abdominal
Compartment Syndrome secondary to air insufflation into the colon for adequate luminal distension. This
increase in intraabdominal pressure caused distension of the colon thereby affecting diaphragmatic
function. Patient exibited signs of upper airway obstruction with decrease in breathsounds. Xray
documents significant colon distension elevating the diaphragm causing atelectasis.This intraabdominal
pressure translated to increase intrathoracic pressure with a decrease in venous return. The pusle
oximeter waveform was acutely lost indicating no cardiac output and sudden cardiovascular collapse
ensued within one respiration cycle. Abdominal Compartment Syndrome mechanism for cardiovascular
collapse.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Ambulatory Anesthesia (AM) MC348
A Simple Nasal CPAP Mask/Circuit Improved Oxygenation and Prevented Severe Desaturation in a
Patient with Obstructive Sleep Apnea under Deep Propofol Sedation during Colonoscopy
James T. Tse, M.D.,Ph.D., Brian Raffel, D.O., Andrew Burr, D.O., Andrea Poon, B.S., Rose Alloteh, M.D.,
Shaul Cohen, M.D., Sylviana Barsoum, M.D . Anesthesiology, Rutgers Robert Wood Johnson Medical
School, New Brunswick, NJ, USA.
An OSA male, BMI 35 kg/m2, presented for colonoscopy without his home CPAP. He required frequent
jaw-thrust and TSE „mask” during previous EGDs. Room-air O2 saturation was 94% while lying down on
2 pillows. A nasal CPAP was assembled using infant mask, adult breathing circuit and anesthesia
machine. Pressure-relief valve was adjusted to deliver 5-7 cm H2O CPAP with 4.5 L O2/min+1.5 L air/min
(0.8 FiO2). When CPAP was 0, his airway became obstructed. He immediately resumed spontaneous
respiration with CPAP. He tolerated colonoscopy well with propofol (150 mcg/kg/min) and maintained 100
% O2 saturation throughout without airway manipulation.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Ambulatory Anesthesia (AM) MC349
Anesthetic Management of Refractory Postoperative Rigors, Fever, and Hemodynamic Instability
Following an Elective Tonsillectomy
Katherine E. Turk, M.D., Mercy Udoji, M.D . University of Alabama at Birmingham, Birmingham, AL, USA.
21 yo AAM with no PMH, NKDA S/P elective tonsillectomy developed rigors, fever(Tm101,) and
hemodynamic instability(HR>160,SBP>150) in PACU, initially concerning for MH. However, ABG, CPK,
UDS, BMP were normal. These intense rigor episodes occurred twice minutely, lasting 20 seconds.
Episodes continued 3 hours postoperatively; patient maintained appropriate mentation. Rigors refractory
to demerol, clonidine, and midazolam. Propofol administration ceased rigors; rigors returned as propofol's
effects subsided. External cooling, ice, and acetaminophen achieved temperature control. Beta Blockers
administered PRN stabilized hemodynamics. Rigors subsided. Patient remained under ICU observation
overnight without further events. Unknown medication effect suggested as causative agent.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Ambulatory Anesthesia (AM) MC350
Perioperative Management of Diabetes Mellitus
Melissa C. Villegas, D.O., Davide Cattano, M.D . University of Texas Health Science Center, Houston,
TX, USA.
Diabetes Mellitus is a chronic condition associated with microvascular and macrovascular complications
leading to increased cardiovascular morbidity and mortality postoperatively. Both hyperglycemia and
hypoglycemia pose significant risks for the patient such as osmotic diuresis leading to hypovolemia,
delayed wound healing, and electrolyte abnormalities. Interventions to improve glycemic control
perioperatively may improve outcomes. Here we present a 66 year old male with Type I insulin dependent
diabetes managed via an insulin pump. He required surgical intervention for chronic rhinosinusitis and a
sphenoid mass. We will discuss the best evidence for perioperative management of diabetes in the
ambulatory surgical setting.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Ambulatory Anesthesia (AM) MC351
The Successful Intraoperative Management of a Patient on Chronic Buprenorphine-Naloxone
Therapy
John A. Vullo, M.D., Elisha Dickstein, M.D . Anesthesiology, Icahn School of Medicine at Mount Sinai,
New York, NY, USA.
A 48 year old patient was scheduled for an outpatient laparoscopic cholecystectomy. The patient was
maintained on buprenorphine-naloxone treatment for addiction. His last dose was the evening before the
surgery. We discussed with the patient and surgeon our concerns for refractory pain. We augmented our
Copyright © 2014 American Society of Anesthesiologists
desflurane-fentanyl anesthetic with nitrous oxide 75%, a lidocaine infusion 2 mg/kg/hr, and a ketamine
infusion of 0.5 mg/kg/hr. The ketamine infusion was completed upon fascial closure. The lidocaine
infusion was continued until the patient left the OR. The patient awoke with 0/10 pain. Two hours later he
was discharged to home still with 0/10 pain.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Ambulatory Anesthesia (AM) MC352
Radial Artery Spasm During Transradial Cardiac Catherterization Requiring Brachial Plexus Block
Derrick C. Wansom, Paul E. Hilliard, M.D . University of Michigan, Ann Arbor, MI, USA.
Transradial catheterization offers advantages of lower complication rates, less patient discomfort, and
shorter hospital stays. The most frequent complication is radial artery spasm with an incidence up to 30%.
Despite the high incidence, there are few reports of vasospasm causing catheter entrapment . This case
involves a 68 year old male who experienced radial artery spasm and catheter entrapment. Conventional
techniques were unsuccessful in releasing the catheter. A supraclavicular block was placed and
subsequently the catheter was able to be withdrawn. This case suggests that upper extremity
sympathectomy procedures may be used as treatment for severe radial artery spasm.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Pediatric Anesthesia (PD) MC353
Anesthetic Management in a Pediatric Patient with Anti-GAD Antibodies
Vanessa C. Hoy, M.D., Raghava Pavoor, M.D., Venkata SK Sampathi, M.D . Anesthesiology, SUNY
Upstate Medical University, Syracuse, NY, USA.
Anti-glutamic acid decarboxylase (Anti-GABA) antibodies are often associated with autoimmune diseases
and in rare cases paraneoplastic syndromes. Due to a decreased inhibitory function of the central
nervous system, this causes an over activity of the excitatory CNS pathways. There have been several
reports of prolonged muscle weakness after use of muscle relaxants and volatile anesthetics in these
patients. We present a 3 year-old male with a history of positive anti-GABA antibodies and diagnosed
with leukemia, and was scheduled for a port placement. Anesthetic management included total
intravenous anesthetic. Post-op, extubation was uneventful and no muscle weakness was present.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Pediatric Anesthesia (PD) MC354
Foreign Body in the Airway and Tension Pneumothorax in a 700 g Premature Neonate
Johanes M. Ismawan, M.D., Claude Abdallah, M.D . Anesthesiology, Walter Reed Military Medical
Center, Bethesda, MD, USA, Anesthesiology, Children's National Medical Center, Washington, DC, USA.
A 3-day-old, 26-week premature neonate, 730 g is transferred urgently with a history of a retained foreign
body. Chest radiograph revealed a tubular structure, extending from below the vocal cords to the right
lower lobe. The patient was anesthetized in the operating room with intravenous midazolam and
ketamine, maintaining spontaneous respiration. A rigid bronchoscope was used to visualize the object,
which was removed with forceps. A tension pneumothorax was treated with urgent placement of a chest
tube and hemodynamic stabilization of the patient prior to transfer to the neonatal intensive care unit.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Pediatric Anesthesia (PD) MC355
First Exposure to Anesthesia Aids in the Diagnosis of Laryngeotracheal Stenosis
Minal Joshi, M.D., Putta Shankar Bangalore Annaiah, M.D., Stanley Santoreli , Devasena Manchikalapati,
M.D. , Joel Yarmush, M.D. . Anesthesiology, NY Methodist Hospital, Brooklyn, NY, USA.
We present a 3 month old whose first exposure to anesthesia for a hip spica facilitated the diagnosis of
laryngeotracheal stenosis.The patient was born with a large head, hypotonia, depressed nasal bridge and
bilateral hip dislocation. Workup excluded Larsen and other syndromes.On induction of anesthesia, the
vocal cords were easily viewed but seemed stenotic. A 3.5 and 3.0 ETT would not pass while a 2.5 ETT
would.Postoperatively, an otolaryngologist performed a nasal fiber optic followed by a rigid brochoscopy.
Copyright © 2014 American Society of Anesthesiologists
A Grade 3 long segment larygeotracheal steosis (90%) was diagnosed. Tracheotomy was performed
before the planned extensive reconstruction.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Pediatric Anesthesia (PD) MC356
Anesthetic Management of Patient with Prader-Willi Syndrome in the Setting of Acute Bowel
Obstruction.
Malgorzata Kasperska, D.O., Pamela Bland, M.D . Walter Reed National Military Medical Center,
Bethesda, MD, USA.
24 year old, 167 kg male with Prader-Willi Syndrome presented with an acute bowel obstruction for an
emergent sigmoidoscopy with disimpaction. The anesthetic challenges were as follows: difficult airway,
full stomach, mental retardation, morbid obesity, and obstructive sleep apnea. Monitored anesthesia care
was accomplished with midazolam and ketamine. However, the sigmoidoscopy was unsuccessful. The
surgical plan changed to laparoscopy necessitating mechanical ventilation and position change.
Intubation was challenging but successful with a combination of Glidescope and bougie. After an hour of
unsuccessful laparoscopy, asix hour open abdominal procedure was completed without any
adverseintraoperative events.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Pediatric Anesthesia (PD) MC357
Iatrogenic Pneumothorax During Attempted One Lung Isolation in an Infant
Benjay J. Kempner, M.D., Christian Petersen, M.D . Naval Medical Center, Portsmouth, VA, USA.
Case Presentation: A 4 month old was to undergo a right upper lobectomy. We attempted lung isolation
utilizing a fiberoptic scope. Oxygen was insufflated through the suction port.During our attempts, her
saturation fell precipitously. She became cyanotic and bradycardic necessitating epinephrine and chest
compressions. A CXR confirmed the diagnosis of a tension pneumothorax. She recovered uneventfully.
Discussion: Using the suction port on the fiberoptic scope to insufflate O2 caused the pneumothorax in
our patient. There are several published reports of iatrogenic pneumothorax in patients all sharing a
similar design of insufflating O2 directly through the suction side port.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Pediatric Anesthesia (PD) MC358
Ethical Issues Involving the Surgical Separation of Conjoined Twins
Shanique B. Kilgallon, M.D., Philip D. Bailey, D.O . Department of Anesthesiology and Critical Care
Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
34-week omphalo-thoraco-pagus conjoined twins who were joined at the chest and abdomen and shared
a common pericardial sac were due to be separated surgically. Twin B had non-survivable anomalies
including a nonfunctional dilated heart without normal outflow tracts, with Twin A providing all perfusion
for Twin B. The plan was to deliver the twins by cesarean section with immediate surgical separation.
There was no plan to intubate Twin B. At the time of delivery, Twin B appeared to be gasping. What
would you have done if you saw a child gasping for air and the plan was not to intervene?
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Pediatric Anesthesia (PD) MC359
Transverse Sinus Thrombosis in a Patient with Inflammatory Bowel Disease
Shanique B. Kilgallon, M.D., Laura Diaz, M.D . Department of Anesthesiology and Critical Care Medicine,
The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
A previously healthy 11y/o male was recently diagnosed with ulcerative colitis and presented to an OSH
with acute changes in mental status and bilateral lower leg weakness. In the PICU, physical exam
revealed progressive neurologic symptoms including aphasia and hemodynamic instability. Given his
rapidly deteriorating neurologic condition, the patient was emergently intubated and underwent imaging
studies. Brain MRI demonstrated acute vein of Galen, anterior straight sinus and right transverse sinus
Copyright © 2014 American Society of Anesthesiologists
thrombosis. He was brought to the interventional radiology suite for thrombolysis. Post-intervention, he
was anticoagulated and ultimately had a complete neurologic recovery and discharged to home in six
days.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Pediatric Anesthesia (PD) MC360
Congenital Hyperinsulinism in an Infant with an Anomalous Left Coronary Artery from the
Pulmonary Artery (ALCAPA)
Shanique B. Kilgallon, M.D., Gijo Alex, M.D., Aruna Nathan, M.D . Department of Anesthesiology and
Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
A 3 month old infant with ischemic heart disease, severe heart failure due to repaired ALCAPA and
myocardial infarction, severe pulmonary stenosis, and a left coronary artery stent currently maintained on
antiplatelet and anticoagulant therapy, with ongoing para-influenza pneumonitis, presented for a total
pancreatectomy for congenital hyperinsulinism (CHI). The CHI had resulted in seizures secondary to
severe hypoglycemia. The hemodynamic risk profile of a recent MI and severe CHF with ongoing
anticoagulation and the metabolic consequences of CHI escalated her risk for peri-operative
mortality/morbidity. A thorough evaluation of risk and perioperative management will be discussed.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Pediatric Anesthesia (PD) MC361
Ectopia Cordis Surgical Correction: Case Report
Daniel D. Kim, M.D., Renato S. Assad, M.D.,Ph.D., Debora O. Cumino, M.D., Vivian Cirineu, M.D.,
Virginia S. Barros, M.D . Hospital Infantil Sabara, Sao Paulo, Brazil.
A newborn, ASA Physical Status IV due to ectopia cordis presented for replacement of the heart in the
thorax. The diagnosis of ectopia cordis was made by antenatal ultrasound screening, but no omphalocele
or diaphragmatic hernia was visualized excluding Pentalogy of Cantrell. After induction of general
anesthesia and ultrasound guided central line placement, dobutamine and milrinone infusion started due
to poor peripheral perfusion. During procedure patient developed arrhythmia and sudden drops of the
cardiac output with manipulation, but the heart could be placed in the thorax. Patient was transferred to
the NICU uneventfully.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Fundamentals of Anesthesiology (FA) MC362
Anesthetic Management for a Robotic Video Assisted Thoracoscopic Ectopic Parathyroidectomy
for Persistent Hyperparathyroidism in a Patient with Difficult Intubation
Thejovathi Edala, M.D., Matthew Frank Spond, M.D . Anesthesiology, UAMS, Little Rock, AR, USA.
In up to 2 % of the cases with persistent hyperparathyroidism, an ectopic parathyroid adenoma located in
the mediastinum is the cause. This location often remains a surgical challenge for traditional open
surgery. Recently robotic video assisted thoracoscopic access associated with reduced morbidity has
increased in popularity. We report a case of a 76-year-old man with two prior parathyroid surgeries with a
parathyroid adenoma located in an aortopulmonary window that was resected by a right robotic
thoracoscopic approach and was complicated by a difficult airway.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Fundamentals of Anesthesiology (FA) MC363
My Leg Hurts More Than My Chest
Thejovathi Edala, Matthew Frank Spond, M.D., Charles A. Napolitano, M.D . Anesthesiology, UAMS,
Little Rock, AR, USA.
Systemic arterial tumor embolism is a rare complication following lung surgery. Most cases of this
complication have been reported with pneumonectomy or spontaneously with brochogenic carcinoma.
We report a case of a cold leg noted immediately after extubation following middle and lower right
bilobectomy in a 70-year-old white male presenting with spindle cell carcinoma of the right middle and
Copyright © 2014 American Society of Anesthesiologists
lower lobes. An immediate angiogram confirmed total occlusion of the right profunda femoris artery and
an emergency embolectomy and subsequent fasciotomy were done with complete return of circulation
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Fundamentals of Anesthesiology (FA) MC364
Intraoperative Fire During Ophthalmic Surgery in a Room-Air Environment
Amine El-Amraoui, M.D., Ty Bullard, M.D . Anesthesiology, University of North Carolina at Chapel Hill,
Chapel Hill, NC, USA, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
A 48-year-old male with esotropia underwent elective surgery for strabismus at our freestanding
ambulatory center. The patient expressed reservations about undergoing general anesthesia, and
therefore underwent the procedure with a combination of light IV sedation and local anesthesia. The
patient was monitored throughout the procedure with end tidal capnography. He required no
supplemental oxygen. In a room air environment, the use of electrocatuery precipitated a brief
intraoperative fire, igniting a hand-held cotton-tipped swab and immediately transferring to the patient‟s
eyebrow. As a result, the patient suffered a first degree burn to the brow area.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Fundamentals of Anesthesiology (FA) MC365
Its All in the Exchange: Emergency Cricothyrotomy After Loss of Endotracheal Airway
Alexander Escobar, M.D., Jeffrey T. Gardner, D.O., Piotr Al-Jindi, M.D., Ned Nasr, M.D . Anesthesiology,
John H. Stroger Cook County Hospital, Chicago, IL, USA.
Tube exchanging as a technique can be complicated by many factors: including obesity, airway edema,
anatomical derangement and surgical complications. Our case involved a 22 year old obese male
involved in a traumatic stabbing to the anterior chest, which during the course of his care experienced the
loss of an established endotracheal airway during double lumen tube exchange and needed an
emergency cricothyrotomy to reestablish his airway. The minimization of attempts of tube exchanges and
use of two tube exchange catheters and or using an exchange catheter with ventilating capabilities may
avoid the need for a surgical airway.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Fundamentals of Anesthesiology (FA) MC366
Post-induction Hypertensive Urgency Refractory to Treatment in a Patient Presenting for Total Hip
Arthroplasty with Undiagnosed Pheochromocytoma
Sean G. Ewing, M.D., Yijia Chu, M.D . Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
A 63-year-old male with history of well-controlled hypertension presented for hip arthroplasty. Shortly after
unremarkable induction of general anesthesia and prior to incision, he developed hypertensive urgency
with peak blood pressures of 240/140. Physical examination and standard monitors detected no other
abnormalities. Despite systematic treatment of common causes of intraoperative hypertension with
anesthetics, narcotics, and high doses of hydralazine and labetalol, systolic blood pressures remained
over 200. Normotension was ultimately achieved with nitroprusside drip. Following cancelation of surgery
and admission to the MICU, detection of elevated urine metanephrines and adrenal mass confirmed the
diagnosis of pheochromocytoma.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Fundamentals of Anesthesiology (FA) MC367
Bronchial Rupture During Robotic Left Upper Lobe Wedge Resection
Jonathan V. Feldstein, M.D . Anesthesiology, New York University Medical Center, New York, NY, USA.
An 80 year old male with type 2 diabetes, atrial fibrillation on amiodarone, and a hypermetabolic nodule in
the left upper lobe of his lung presented for a robotic wedge resection. A fiberoptic bronchoscope was
used to intubate patient with a left-sided double lumen endotracheal tube. Left upper lobe mass was
resected robotically. During mediastinal lymph node resection, surgeons visualized bronchial cuff
protruding through the proximal left mainstem bronchus. The endotracheal tube was repositioned to
Copyright © 2014 American Society of Anesthesiologists
prevent air leak and thoracotomy was performed to repair injury. After repair, testing showed no leak and
patient was extubated without issue.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Fundamentals of Anesthesiology (FA) MC368
Airway Fire: Balancing a Patient's High FiO2 Requirement and the Real Risk of a Fire
Kimberly B. Fischer, M.D., Shamantha Reddy, M.D . Anesthesiology, Montefiore Medical Center, the
University Hospital for Albert Einstein College of Medicine, Bronx, NY, USA.
A 69 year-old male was in the OR for a re-do mitral valve replacement with a room air SpO2 of 84%.
During induction, line placement, sternotomy, and mediastinal dissection, the SpO2 was maintained
between 86%-100% with a FiO2 of 1. An alarm indicated that the bellows on the ventilator ceased to fill.
The surgeon noticed a small leak in the left upper lobe and smelled isoflurane. A fire ignited in the
mediastinum - secondary to electrocautery and a high FiO2 - but was immediately extinguished. No
apparent tissue damage resulted. The surgeon suffered a third degree burn on his finger.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Fundamentals of Anesthesiology (FA) MC369
Management of a Difficult Airway in a Morbidly Obese Patient with Proteus Syndrome Prior to
Emergency Surgery for Acute Bowel Obstruction
Christopher R. Fosco, M.D., Jacqueline Galvan, M.D . Anesthesiology, The University of Illinois Medical
Center, Chicago, IL, USA, The University of Illinois Medical Center, Chicago, IL, USA.
We presenta case of a 27y/o female who presented for emergent surgical intervention of acomplete small
bowel obstruction due to incarcerated hernia. PMH includes ProteusSyndrome, morbid obesity (BMI >
55), multiple intra-abdominal surgeries,decannulated tracheostomy after suicide attempt and severe
kyphoscoliosis.After examination revealed an unfavorable airway with limited neck mobility, asleepfiberoptic tracheal intubation was attempted to secure the airway. In thischallenging case, we describe our
successful, non-invasive management of adifficult airway after initial unsuccessful attempts to intubate
and maskventilate in a patient with a rare disease at risk for aspiration.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Fundamentals of Anesthesiology (FA) MC370
Peri-Operative Anaphylaxis: Added Challenges in the Era of Drug Shortages
Elizabeth A. Fouts-Palmer, M.D., Adam B. Lerner, M.D . Anesthesia, Critical Care and Pain Medicine,
Beth Israel Deaconess Medical Center, Boston, MA, USA.
A 76 year old female with a history of anaphylaxis to penicillin presented for laparoscopic hiatal hernia
repair. After induction, she developed tachycardia and refractory hypotension. The procedure was
aborted due to suspected anaphylaxis. Post-operative testing confirmed allergies to rocuronium and
atracurium. Given its lower cross-reactivity, pancuronium was planned for the rescheduled procedure.
However, at that time, pancuronium could not be acquired by our pharmacy. Despite relatively high crossreactivity, vecuronium was felt to represent the safest available option. After a test dose, muscle
relaxation was achieved with vecuronium and the surgery was successfully completed.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Obstetric Anesthesia (OB) MC371
Black Henna and Error Reading on Pulse Oximeter
Shivanandaswamy Kashimutt, M.D.,F.R.C.A. Anaesthesia, Shivanandaswamy Kashimutt, Leeds, United
Kingdom.
A 30 year patient of Sudanese origin was scheduled for an elective caesarean section. In theatre whilst
applying the pulse oximeter it was evident that all her finger tips, toes and plantar aspects of her feet were
pigmented with black henna. We attempted to measure her haemoglobin saturation using pulse oximeter
from various digits but each time we were unable to obtain any trace (see Image). We eventually used a
paediatric ear probe on the ear lobe to measure the oxygen saturation.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Obstetric Anesthesia (OB) MC372
Peripartum Cardiomyopathy: From Cesarean Section to LVAD
Cale A. Kassel, M.D., Katie Goergen, M.D . Anesthesiology, University of Nebraska Medical Center,
Omaha, NE, USA.
Peripartum cardiomyopathy is a rare condition with significant mortality and morbidity. A 32-year-old
female admitted with dilated peripartum cardiomyopathy developed intermittent complete heart block and
required urgent cesarean section. Her most recent echocardiogram showed an EF of 10% that was stable
over the past months. A combined spinal-epidural was placed and surgical anesthesia achieved. She
remained hemodynamically stable during the procedure and delivered a healthy boy. A week after
delivery, she developed worsening heart failure and cardiogenic shock. Eventually she required
placement of a left ventricular assist device as a bridge for transplant.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Obstetric Anesthesia (OB) MC373
Arctic Sun Cooling of an Anhidrotic Parturient With Small Fiber Neuropathy During Caesarean
Delivery
Brendan S. Kelley, M.D., M.S., Michael Lee, M.D., Tiffany Orchard, D.O . Anesthesiology, Walter Reed
National Military Medical Center, Bethesda, MD, USA.
29 yo G2P1001 at 38 weeks 3 days gestational age, with a history of small fiber neuropathy (SFN)
presented for elective repeat caesarean delivery. Patient‟s autonomic dysfunction involved heat stroke 3
years prior, with progression of heat intolerance, diffuse anhidrosis, pain and redness of distal extremities.
Autonomic testing confirmed low sudomotor response, asymptomatic orthostatic hypotension, and
absence of sympathetic function in the extremities. SFN presents unique challenges for obstetric
anesthesia, notably hemodynamic instability with neuraxial analgesia and disrupted thermoregulation.
Active liquid-cooled pads were used on the patient‟s chest and flanks to maintain normothermia during
combined spinal-epidural analgesia for delivery.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Obstetric Anesthesia (OB) MC374
Bradycardic Asystolic Arrest in an Obese Parturient During Caesarian Section Under Spinal
Anesthesia
Keryong J. Koh, M.D., Stanlies D'Souza, M.D.,F.R.C.A, Mary Kraft, M.D . Anesthesiology, Baystate
Medical Center,Tuft University School of Medicine, Springfield, MA, USA.
A 26 year old obese parturient with a BMI of 41 presented for emergency caesarian section for fetal
distress under spinal anesthesia. 12 minutes post-delivery, patient presented with acute desaturation,
loss of consciousness and progressive sinus bradycardia that progressed to cardiac arrest.
Cardiopulmonary resuscitation was initiated as per ACLS protocol along with administration of
epinephrine and patient was intubated. Patient responded to resuscitative measures with the return of
spontaneous circulation. Surgery was completed uneventfully. Patient was extubated 12 hours later
without any neurological sequelae.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Obstetric Anesthesia (OB) MC375
Bleomycin Induced Pulmonary Toxicity in a Pregnant Patient
Eleni Kotsis, D.O., Kalpana Tyagaraj, M.D . Anesthesiology, Maimonides Medical Center, Brooklyn, NY,
USA.
37 year old female, pmh Hogdkin's lymphoma s/p ABVD treatment, on steroids for ITP,GDMA2 and prior
C-Section presented for Repeat C-Section. Platelet count was 33,000 with giant platelets. Hematology
recommended to continue steroids and transfuse one unit of single donor platelets prior to C-Section.
Proceeded with GA and intubation was uneventful. At the end of the procedure, patient desaturated to the
Copyright © 2014 American Society of Anesthesiologists
low 80s, which improved to low 90s prior to extubation with head up position, ETT suctioning and
repositioning. In PACU, work up ruled out PE, pulmonary edema, AFE, and pneumonia. Discharged 3
days later with saturations between 88-92%
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Obstetric Anesthesia (OB) MC376
Epidural Anesthesia for Planned Caesarean Section in a Patient with Goldenhar Syndrome
Neeraj Kumar, M.D., Joshua C. Chance, M.D., Kristen L. Lienhart, M.D . Anesthesiology, University of
Arkansas for Medical Sciences, Little Rock, AR, USA.
Goldenhar syndrome (oculo-auriculo-vertebral syndrome) is a rare congenital syndrome. These patients
present with airway involvement, cardiac and vertebral defects. We discuss the anesthetic management
of a parturient with goldenhar syndrome, presenting for a scheduled caesarean section.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Obstetric Anesthesia (OB) MC377
Comparison of Anesthetic Management of Venous Air versus Amniotic Fluid Embolism during
Cesarean Delivery
Joseph K. Kurian, M.D., Quisqueya T. Palacios, M.D . Anesthesiology, Baylor College of Medicine,
Houston, TX, USA.
Amniotic fluid embolism (AFE) and venous air embolism (VAE) are capable of producing a constellation of
severe hemodynamic derangements, coagulopathy, end organ damage, and ultimately death.
Understanding risk factors, signs and symptoms of AFE and VAE, and initiating immediate supportive
care are necessary for minimizing morbidity and improving survival. The following case report describes
evidence as to why an AFE was highly suspected in addition to the post-operative management of a 31
year old G2P1001 who required a stat cesarean delivery for fetal distress.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Obstetric Anesthesia (OB) MC378
MRSA Bacteremia in a Pregnant Patient with an Extensive IV Drug History
Matthew Kushnir, M.D., Tanya Lucas, M.D . University of Massachusetts, Worcester, MA, USA.
31 year old G2P1 female presented to the ED with acute onset back pain. The patient was found to be 24
weeks pregnant. MRI showed no osteomyelitis. On L&D the patient required excessive amounts of
opiates and during the Anesthesia pain consult she admitted to extensive IVDA. She was started on high
dose hydromorphone PCA, gabapentin, lorazepam, and acetaminophen. She went into respiratory failure
and septic shock requiring intubation. In the ICU, patient had a NSVD but the baby expired. A repeat MRI
showed sacroiliitis and an iliac intramuscular abscess. She was discharged on 6 weeks of vancomycin.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Obstetric Anesthesia (OB) MC379
Essential Thrombocytosis and Analgesic Considerations in the Obstetric Population
Jin Lee, M.D., Tiffany Angelo, D.O . Walter Reed National Military Medical Center, Bethesda, MD, USA.
Neuraxial anesthesia in the setting of essential thrombocytosis is controversial due to questionable
platelet functionality and risk of neuraxial hematoma. In this case report, the patient is a 30 year old with
prenatal course complicated by essential thrombocytosis with history of inter-uterine fetal demise at 28
weeks from umbilical thrombosis and four first trimester miscarriages. Her current pregnancy was notable
for platelet count over one million and report of minor bleeding. Decision was made to avoid neuraxial
anesthesia; she underwent uncomplicated vaginal delivery at 37+1 weeks with continuous remifentanil
infusion for analgesia.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Pain Medicine (PN) MC380
Persistent Knee Pain after TKA
Michael J. Grille, M.D., Richard Rosenquist, M.D . The Cleveland Clinic, Cleveland, OH, USA.
A 74 year old male presented to the chronic pain clinic with persistent left knee pain after total knee
arthroplasty (TKA). He underwent a left TKA for DJD and knee pain in 2011 and after the surgery
continued to suffer from the same low-anterior knee pain. Orthopedic evaluation determined the knee
replacement was stable and there was no structural cause for pain. Upon further history, he endorsed
chronic low back pain and activity-related weakness and fatigue in his legs. MRI of the spine revealed L4L5 lumbar root impingement. He underwent diagnostic and therapeutic transforaminal epidural steroid
injection with significant improvement.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Pain Medicine (PN) MC381
Transversus Abdominis Plane Blockade Supplemented With Alpha-2 and Opioid Agonism in the
Treatment of Acute Visceral Neuropathic Pain From Crohn's Disease: A Case Report
Alexander Y. Hawson, M.D., Daryl I. Smith, M.D . Department of Anesthesiology, University of Rochester,
Rochester, NY, USA.
60-year-old woman with history of Crohn‟s disease, chronic 4/10 abdominal pain on total daily oxycodone
300mg, and type 2 diabetes underwent exploratory laparotomy, lysis of adhesions, and diverting loop
ileostomy to the LLQ for perforated bowel. On POD#4, she developed acute on chronic Crohn‟s disease
abdominal pain refractory to PCA and ketorolac. The patient received left-sided continuous TAP block.
The block was bolused with 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine and 100 micrograms
of clonidine. Continuous TAP infusion of hydromorphone 12 mcg/mL and 0.1% bupivacaine was begun at
8 mL/hr. She enjoyed persistent, profound relief of abdominal pain.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Pain Medicine (PN) MC382
Lidocaine Infusion Usage for Acute Myofascial Pain Unresponsive to Conventional Therapy In the
Setting of Post Cardiac Surgery
Gurbir Johal, M.D., David Dickerson, M.D., Pavan Rao, M.D . Anesthesiology and Critical Care, University
of Chicago, Chicago, IL, USA.
We describe a case of an 82 year old female with acute lower back pain after cardiac surgery. She
underwent a seven hour, three vessel coronary artery bypass. Shortly after arriving to ICU, she not only
complained of incisional pain, but also extreme lower back pain. Attempts to manage the musculoskeletal
pain with typical multimodal analgesia were ineffective. On post-op day two, a lidocaine infusion at
1mg/kg/hr with a 0.5 mg/kg bolus was implemented. Immediate relief allowed her to sit, and participate in
physical therapy, and allow for a proper physical exam with further treatment of symptoms.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Pain Medicine (PN) MC383
A Stand-up Treatment: Implanted Spinal Cord Stimulator for Treatment of Small-Fiber Neuropathy
John Kenny, M.D., David Dickerson, M.D . Anesthesia and Critical Care, University of Chicago, Chicago,
IL, USA.
Small-fiber neuropathy (SFN) is a disorder of small afferent nerve fibers that can result in from
chemotherapeutics. We present a case of vincristine-induced SFN successfully treated with spinal cord
stimulation (SCS). A 24-year-old male with history of stage IV non-Hodgkins lymphoma presented with
progressive, burning bilateral leg pain since vincristine exposure 7 years prior. EMG and MRI were
unremarkable as was his physical exam with the exception of thigh dyesthesia. Refractory to conservative
therapy, SCS trial and implantation provided >90% relief with improved physical function. SCS may play
an important role in the treatment of SFN.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Pain Medicine (PN) MC384
Spinal Cord Stimulation for Treatment of Complex Regional Pain Syndrome of the Arm in a
Pediatric Patient
David J. Kim, M.D., M.S., Lisa Watt, PNP, Padma Gulur, M.D., David A. Edwards, M.D.,Ph.D .
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA.
In severe CRPS conservative treatments may fail. In adults, SCS has been used successfully but in
children, there are no reports of SCS treatment for upper extremity CRPS. We report treatment of a 16year-old female with a 3-year history of pain in the left wrist from an osteoma. Pain worsened after biopsy
injured the ulnar nerve and she developed allodynia, hyperhydrosis, muscle wasting, temperature
asymmetry, and increased hair growth. After failed conservative therapy, addition of cervical SCS
enabled effective OT so at 6 months she had increased ROM and strength, resolution of hyperhydrosis
and temperature asymmetry, and 1/10 pain.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Pain Medicine (PN) MC385
Should Routine MRIs of the Lumbar Spine be Required Prior to Lumbar Epidural Steroid Injections
for Sciatica?
Nebojsa Nick Knezevic, M.D.,Ph.D., Alexei Lissounov, M.D., Ramsis F. Ghaly, M.D., Kenneth D.
Candido, M.D . Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
Two young females (37 and 38 years old) received lumbar epidural steroid injections (LESI) for remotely
diagnosed disc herniations. LESI in one patient was performed due to worsening of chronic radicular
pain, and was based on a 9-year-old MRI study. At a subsequent operation, neurosurgery identified
neurilemmoma. A second patient‟s MRI was misinterpreted as being consistent with a disc extrusion, and
it was later determined by a surgical intervention as being due to post-LESI hematoma without evidence
of disc herniation.We would like to emphasize the importance of proper imaging of the lumbosacral region
prior to undertaking invasive neuroaxial procedures.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Pain Medicine (PN) MC386
Cracking Down on Complications: A Novel Case of Lead Breakage in Spinal Cord Stimulator
Sharon Lee, M.D., Intikhab Mohsin, M.D . Anesthesiology, Albany Medical Center, Albany, NY, USA.
30-year-old female with history of complex pain presented with ongoing low back, abdominal, and groin
pain. She underwent numerous abdominal and back surgeries, but to no avail. After successful trial,
decision was made to implant permanent percutaneous spinal cord stimulator using Boston Scientific
infinion 16-electrode lead and IPG programmer. Unfortunately, the patient developed C. difficile after the
permanent implant placement. After multiple episodes of unremitting, projectile vomiting, she lost her
coverage. X-ray demonstrated a gap of a few millimeters between lead and the IPG programmer.
Extraction of the device revealed a broken, fractured lead.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Pain Medicine (PN) MC387
Hulk Smash Pain! --- The Use of Radiation for Analgesia
Christopher V. Maani, M.D., Sara McAlpin, M.D., Elizabeth V. Maani, M.D., Adrienne Cummings, M.D.,
Christopher Higgins, M.D., William E. Jones, III, M.D . Anesthesiology, San Antonio Uniformed Services
Health Education Consortium (SAUSHEC), San Antonio, TX, USA, Radiation Oncology, Audie L. Murphy
VA Hospital, San Antonio, TX, USA.
Cancer pain poses significant challenges, compounded when the patient is a child. Pain from bone
metastases results from inflammation and marrow expansion. Therapeutic radiology, an under-utilized
analgesic adjunct, affords pain relief via destruction of inflammatory cells and tumor burden reduction. We
describe multi-disciplinary analgesia with strategic use of palliative radiation therapy for a female pediatric
Copyright © 2014 American Society of Anesthesiologists
patient with Ewing Sarcoma and progressive pain, refractory to both conservative pharmacological
management and aggressive management with traditional and non-traditional analgesics. We also
consider other non-conventional analgesic practices which have a role in care of cancer patients with
challenging pain management requirements.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Pediatric Anesthesia (PD) MC388
Negative Pressure Pulmonary Edema in a Pediatric Patient after Adenoidectomy
Wendy Nguyen, M.D., Shelley Ohliger, M.D . Anesthesiology, University of Maryland School of Medicine,
Baltimore, MD, USA.
A twenty-one month old 12.1 kg female toddler with recurrent acute otitis media, adenoid hypertrophy,
chronic nasal congestion, and sleep-disordered breathing presented for bilateral tympanostomy tube
insertion and adenoidectomy. On day of surgery she had increased nasal drainage, but no fever or
cough. Upon extubation following the procedure, she developed laryngospasm, which resolved with
CPAP and propofol. Shortly after arriving to the PACU, the patient became hypoxic. Bag-mask ventilation
was impossible, and so succinylcholine was given, and she was reintubated revealing pink frothy sputum
from the ETT. With aggressive ventilator management, she was extubated later that day.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Pediatric Anesthesia (PD) MC389
Compartment Syndrome Following Streptococcal Pharyngitis: Anesthetic Challenges and
Management
Evangelyn Okereke, M.D., Christina Diaz, M.D . Pediatric Anesthesiology, Children's Hospital of
Wisconsin, Milwaukee, WI, USA.
A 6-year-old previously healthy male with history of Streptococcal pharyngitis treated two weeks ago
presents with left lower extremity swelling and pain noted to have deep vein thrombosis and compartment
syndrome. The patient‟s leg remained mottled with non-dopplerable pulses after an intra-operative
fasciotomy with evidence of myonecrosis. Emergent intra-operative vascular surgery consult and resulting
angiogram demonstrated venous phlegmasia with limited blood flow and an intense inflammatory reaction
causing extensive vasospastic arterial ischemia that involved all extremities. The phlegmasia and
accompanying sepsis resulted in anesthetic challenges in obtaining arterial access, blood pressure
management, as well as an overall diminished tissue perfusion.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Pediatric Anesthesia (PD) MC390
Help Mom; I Have a Lump in my Neck: Difficult Airway in a 2-Year-Old Female Who Presented with
a Rapidly Expanding Neck Mass
Arati M. Patil, M.D . New York University Langone Medical Center, New York, NY, USA.
Previously healthy 2-year-old female presented with a temperature of 104F and right neck swelling. She
appeared somnolent with palpable tracheal deviation and rapidly expanding right neck mass. Pediatric
airway was called and she was transported to the OR spontaneously breathing, 100% on O2 facemask.
Mask induction was performed with 8% sevoflurane. DLx1 attempted with a Mac 2 blade: enlarged tonsils
and redundant soft tissue was noted with no view. Then a pediatric fiberoptic was used with a Mac 2
blade with a grade III view. Intubation was successful with a 4.5cuffed ETT. She was found to have Blineage ALL.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Pediatric Anesthesia (PD) MC391
Goldenhar Syndrome: A Rare Disease With Important Anesthetic Implications
Arati M. Patil. New York University Langone Medical Center, New York, NY, USA.
4 year old male with a history of Goldenhar syndrome presented for elective tethered cord release.
General endotracheal anesthesia was required due to the required prone positioning. The anesthesia
Copyright © 2014 American Society of Anesthesiologists
team was prepared with a pediatric fiberoptic scope, glidescope, and LMA. Smooth inhalational induction,
then placement of a 22g PIV occurred during spontaneous ventilation. 1 DL attempt was made prior to
using the FOB or glidescope. A Mac 2 blade was used with a grade 1 view and a 4.5 cuffed tube was
placed miraculously on the first attempt. Discussion will include the anesthetic difficulties typically
encountered with Goldenhar syndrome.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Pediatric Anesthesia (PD) MC392
Management of Neurogenic Pulmonary Edema Secondary to Severe Neurologic Injury Due to
Ventriculoperitoneal Shunt Malfunction and Status Epilepticus: A Case Report
Annie Lynn W. Penaco, M.D., Sudheera Kokkada Sathyanarayana, M.D., Jerry Chao, M.D .
Anesthesiology, Montefiore Medical Center, Bronx, NY, USA, Montefiore Medical Center, Bronx, NY,
USA.
Neurogenic pulmonary edema is a relatively rare and underdiagnosed clinical syndrome characterized by
acute onset of pulmonary edema following significant CNS injury. In the pediatric population, a high
percentage of NPE is caused by prolonged seizure activity. We report the case of a 5-year-old child with
status epilepticus and life-threatening NPE, detailing hospital course, medical/surgical interventions and
anesthetic challenges of perioperative care during ventriculoperitoneal shunt revision. Supporting
ventilation, oxygenation, and hemodynamics were the primary goals in perioperative management. The
case highlights how clinical suspicion and recognition is of utmost importance to institute appropriate
treatment to decrease overall morbidity and mortality.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Pediatric Anesthesia (PD) MC393
Use of a TSE Mask in a Toddler with Sickle Cell Disease under Monitored Anesthesia Care for
Insertion of an InfusaPort
Jessica Perez, M.D., Sagar Mungekar, M.D., Trishna Upadhyay, M.D., Sylviana Barsoum, M.D., Christine
Hunter Fratzola, M.D., Shaul Cohen, M.D., Andrea Poon, B.S., James T. Tse, M.D.,Ph.D .
Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
14 m/o 9.6 kg male with Sickle Cell Disease and left hip osteomyelitis presented for insertion of RIJ
InfusaPort under MAC. He was sedated with 30 mg of propofol and immediately placed on nasal cannula
O2 (1.5 L/min) and a face tent (TSE “Mask”) (0.6 FiO2) using a clear plastic shield. It was taped to his
mandible. His head was turned and stabilized with a “croissant” foam pillow. He tolerated the procedure
well with local anesthesia, propofol infusion (200-300 mcg/kg/min) and 10 mcg fentanyl. He maintained
spontaneous respiration and 100% O2 saturation throughout without any airway manipulation or
rebreathing CO2.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Pediatric Anesthesia (PD) MC394
A Difficult Airway with Cervical Instability Secondary to Ehlers-Danlos Syndrome in the Setting of
Pseudotumor Cerebri, Epilepsy, and Mitochondrial Disease: Anesthetic Management in a 13-yearold
M. Alexander Pitts-Kiefer, M.D., Sudha Ved, M.D . Department of Anesthesiology, Georgetown University
Hospital, Washington, DC, USA.
A 13-year-old, 57 Kg patient with a difficult airway secondary to cervical instability from Ehlers-Danlos
Syndrome, epilepsy with seizures triggered by neck extension, and TMJ disorder presented for C3-C5
anterior cervical discectomy and fusion with SSEP and EMG monitoring in the setting of increased
intracranial pressure from pseudotumor cerebri, chronic pain from mitochondrial disease, systemic
mastocytosis, and a history of chiari malformation. We performed an awake fiberoptic intubation under
dexmedetomidine sedation, followed by slow induction with propofol, and maintenance with sevoflurane,
dexmedetomidine, and limited use of fentanyl. Anesthetic considerations for patients with mitochondrial
disease and systemic mastocytosis will be discussed.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Pediatric Anesthesia (PD) MC395
Anesthetic Management of a 2-year-old with Muscle-eye-brain Disease and a Prior Extubation
Failure
M. Alexander Pitts-Kiefer, M.D., Kuntal Jivan, M.D., Vinh Nguyen, D.O . Department of Anesthesiology,
Georgetown University Hospital, Washington, DC, USA.
A 2-year-old girl with muscle-eye-brain disease presented for vitrectomy. The child had a prior post-op
extubation failure secondary to hypotonia and weakness resulting in an unplanned PICU admission.
Malignant hyperthermia precautions were taken. The child breathed a N2O/oxygen mixture while IV
access was obtained. Anesthesia was induced with propofol. Intubation was performed without the use of
NMBs or opioids in order to optimize conditions for a successful extubation. A retrobulbar block was
performed and anesthesia was maintained with propofol and dexmedetomidine infusion. A nasal airway
was placed at emergence and the child was extubated when awake.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Pediatric Anesthesia (PD) MC396
Management of Hutchinson-Gilford Progeria Syndrome patient for an endoscopy and
colonoscopy
Victor Polshin, M.D., Xiaoqi Liu, M.D., Kalpana Tyagaraj, M.D . Anesthesiology, Maimonides Medical
Center, Brooklyn, NY, USA.
14 year old female with history of Progeria and difficult airway presented for endoscopy due to abdominal
pain, nausea and vomiting. Difficult airway management set up included video laryngoscope, fiberoptic
bronchoscope and LMAs with ENT standby. Awake nasal fiberoptic intubation was unsuccessful under
topical airway anesthesia. Titrated dose of propofol was administered and ventilation ensured. Multiple
attempts at nasal and oral fiberoptic intubation were unsuccessful. A size 2.5 LMA was placed, and the
patient was intubated through it via a bronchoscope with a size 4.0 ETT. An orogastric tube was placed
and 500ml of coffee ground liquid was suctioned.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Regional Anesthesia and Acute Pain (RA) MC397
Safe, Simultaneous Use of Liposomal Bupivacaine in the Surgical Wound and a Bupivacaine
Epidural
Brian D. Terrien, M.D . Naval Medical Center San Diego, San Diego, CA, USA.
A 63 year old female with a history of substanceabuse, underwent a whipple procedure for acute
necrotizing pancreatitissecondary to a pancreatico-enteric fistula and specifically requested theavoidance
of opioids for post-operative pain control. After consultation with the surgical team andpharmacy, it was
decided to infiltrate the laparotomy incision with liposomalbupivacaine and simultaneously run a low-dose
bupivacaine epidural. There were no adverse events with this previouslyunpublished and off label use of
liposomal bupivicaine. Her pain scales were1-2 out of 10 post-operatively, she was ambulatory POD 1,
and was dischargedfrom the ICU POD 2.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Regional Anesthesia and Acute Pain (RA) MC398
Placement of Thoracic Epidural in Chronic Pain Patient with Spinal Cord Stimulator following a
Motor Vehicle Accident
James D. Turner, M.D., Amber K. Brooks, M.D . Wake Forest University Baptist Medical Center, Winston
Salem, NC, USA.
The patient is a 57 year old male with a past medical history significant for diabetes, hypertension, and
chronic pain following multiple lumbar spinal surgeries who had previously undergone placement of a
Spinal Cord Stimulator (SCS). He presented following a trauma, which resulted in left sided 1-11 rib
fractures with a flail segment along ribs 1-4, and a highly comminuted left clavicle fracture. The acute pain
service was consulted for pain management and the possibility of neuraxial analgesia to avoid intubation
Copyright © 2014 American Society of Anesthesiologists
and ventilation. A paravertebral catheter was attempted and failed, prompting the placement of a
successful thoracic epidural.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Regional Anesthesia and Acute Pain (RA) MC399
Sphenopalatine Ganglion Block for Severe, Functionally Limiting, Mucositis Pain
Dabah Wajde, M.D., David Dickerson, M.D., Nirali Doshi, M.D . Department of Anesthesia and Critical
Care, University of Chicago, Chicago, IL, USA.
We present two cases of sphenopalatine-ganglion block for severe mucositis pain.An 18-year-old male
with left-hypopharyngeal nerve sheath tumor presented with chemotherapy and radiation-induced
mucositis. He was unable to swallow or speak despite a multimodal analgesic regimen. He underwent
fluoroscopic-guided SPG block.A 53-year-old female with squamous cell carcinoma of the nasal cavity
underwent treatment with TFHX /radiation and developed left-sided throat and facial pain and underwent
SPG block.Both patients experienced >50% pain relief and were able to eat, drink and talk, however relief
differed in length of time, 10 days vs 24hrs, suggesting a neuromodulatory effect.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Regional Anesthesia and Acute Pain (RA) MC400
LA Toxicity Manifests as Stroke-like Symptoms
Ling Wang, M.D., Robert Helfand, M.D . Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
Local anesthetics toxicity can manifest as variety of symptoms. An 89 year-old female with coronary
artery disease, atrial fibrillation who underwent carpal tunnel release surgery. Axillary brachial plexus
block with injection of 35 ml of 1.5% mepivacaine with epinephrine was performed successfully with
ultrasound. Immediately after injection, patient complained of headache and dysarthria. A 250ml of 20%
intralipid bolus was given in 45 min with improvement of symptoms. Patient then underwent surgery
under light sedation uneventfully. One hour after surgery, patient developed transient SOB, and stroke
like symptoms which resolved spontaneously. Full neurological workup postoperatively revealed
stroke/TIA is unlikely.
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Regional Anesthesia and Acute Pain (RA) MC401
Acute Epidural Hematoma Presented with Foot Drop
Mi Wang, M.D., Travis Nickels, M.D., Babak Kashy, Wael Ali Sakr Esa. Anesthesiology Institue,
Cleveland Clinic, Cleveland, OH, USA, Cleveland Clinic, Cleveland, OH, USA.
A 78-year old female underwent Collis gastroplasty and Nissen fundoplicaiton. She had epidural catheter
placed at T7-8 with multiple attempts in the OR before induction. On POD 4, patient reported shooting low
back pain radiating down to right buttock and right posterior leg each time with the epidural PCA bolus.
Epidural catheter was subsequently withdrawn. Patient developed right foot drop 2-3 hours later. MRI
showed acute epidural hematoma extending from T8 to L1. Patient underwent emergent hematoma
evacuation. The dorsiflexion strength of her right foot was improved from 1/5 before laminectomies to 3/5
on POD 4.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Regional Anesthesia and Acute Pain (RA) MC402
Pain Management in Four-Limb Amputation
Nafisseh Warner, M.D., Matthew Warner, M.D., Susan Moeschler, M.D., Bryan Hoelzer, M.D . Mayo
Clinic, Rochester, MN, USA.
Acute pain following amputation can be challenging to treat given multiple underlying mechanisms and
variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor
for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade
may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity
amputation. To our knowledge, there are no reports in the literature regarding analgesic regimens in fourCopyright © 2014 American Society of Anesthesiologists
limb amputation. A case of a middle-aged female who developed gangrene of bilateral upper and lower
extremities ultimately requiring four-limb amputation in a single procedure is presented.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Regional Anesthesia and Acute Pain (RA) MC403
Successful Use of Paravertebral Blocks in a Heparinized Patient for Intraoperative Pain
Management in Ivor-Lewis Esophagectomy
Scott M. Weitzel, Derek Foerschler, D.O . Naval Medical Center, Portsmouth, VA, USA.
52 year-old ASA 3 male was admitted for heparin bridging prior to Ivor-Lewis esophagectomy.
Paravertebral blocks are not described in the literature for this surgery, but it was proposed that they
could provide perioperative pain relief and reduced risk of bleeding given his anticoagulation. Heparin
was held for four hours prior and six single shot paravertebral blocks were placed under ultrasound
guidance. We were unable to assess the efficacy of the blocks immediately postoperatively as he
remained intubated and sedated. It is notable that he was successfully extubated on postoperative day
one and had lower than expected opioid requirement intraoperatively.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Regional Anesthesia and Acute Pain (RA) MC404
Safety of Liposomal Bupivacaine Administration in the Setting of a Ropivacaine Perineural
Infusion:A Case Report
Bethany S. Williams, Jaideep Mehta, M.D . University of TX at Houston, Houston, TX, USA,
Anesthesiology, The University of Texas Medical School at Houston, Houston, TX, USA.
Shifts towards multimodal pain control have been shown to better help control post-surgical pain, reduce
opioid use, and decrease the cost of hospitalization. A novel formulation of bupivacaine in liposomal form
is a new tool that can be utilized in the setting of multimodal pain control. There is concern that using
liposomal bupivacaine along with non-bupivacaine based local anesthetics may cause an immediate
release of bupivacaine with resulting local anesthetic toxicity. In this case study we examine the safety of
using liposomal bupivacaine along with a ropivacaine continuously running perineural infusion.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Regional Anesthesia and Acute Pain (RA) MC405
Management of Thoracic Epidural Anesthesia in a Patient Placed on Emergent Cardiopulmonary
Bypass
Meredith C. Wills, D.O., Byron Edmund, M.D., Jordan Yokley, M.D . Walter Reed National Military Medical
Center, Bethesda, MD, USA.
A healthy 34 year old male was found to have an incidental left hilar mass on x-ray during evaluation for
shoulder pain. Further evaluation yielded the diagnosis of pulmonary sarcoma prompting excision.
Preoperatively, a thoracic epidural was placed for pain control. The sarcoma was found abutting the left
pulmonary artery and surrounding its first branch. The surgeon had difficulty controlling hemorrhage
during excision. Patient was placed on emergent cardiopulmonary bypass for negative margin resection
3.5 hours after epidural placement. Hemorrhage was controlled, the sarcoma excised, and the epidural
was used successfully for pain management. It was removed without complication.
Saturday, October 11, 2014
1:00 PM - 1:10 PM
Neuroanesthesia (NA) MC406
Use of Dexmedetomidine, Ketamine, and Propofol Infusions During Brainstem Cavernoma
Resection with Somatosensory and Motor-Evoked Potential Monitoring: Case Report
Alberto J. Rivera Cintron, M.D., Yasmin Maisonave, M.D., Myrna Morales-Franqui, M.D., Marinell Rivera,
M.D . Anesthesiology, University of Puerto Rico, School of Medicine, San Juan, PR, USA, University of
Puerto Rico, School of Medicine, San Juan, PR, USA.
We describe a case of 45-year-old male patient who underwent resection of a Brainstem Cavernoma.
Considering that most anesthetics affect SSEP and MEP, management of this case required continuous
Copyright © 2014 American Society of Anesthesiologists
IV infusions using Dexmedetomidine, Ketamine, and Propofol, in addition to inhaled anesthesia with
Sevoflurane. Intraoperative SSEP and MEP monitoring remained satisfactory throughout the case. We
concluded that the combination of these agents, counteract their intrinsic sympathetic effects, thereby
providing optimal surgical and monitoring conditions.
Saturday, October 11, 2014
1:10 PM - 1:20 PM
Neuroanesthesia (NA) MC407
Macklin Effect as a Serious Complication in an Acromegalic Patient
Karines Rivera-Marrero, M.D., Hector Torres, M.D . Anesthesiology Department, University of Puerto
Rico, San Juan, PR, USA.
Acromegaly is recognize as a cause of difficult airway management and tracheal intubation. Anesthetic
implication of this disorder is particularly significant in terms of changes in the upper airway and increased
chances of pulmonary and cardiovascular complications. We report the case of an acromegalic patient,
with multiple comorbidities, who was intubated after several attempts, and developed signs and
symptoms of a serious respiratory complication compatible with the Macklin effect. Macklin effect involves
a three-step pathophysiologic process: blunt traumatic alveolar rupture, air dissection along
bronchovascular sheaths, and spreading of this blunt pulmonary interstitial emphysema into the
mediastinum.
Saturday, October 11, 2014
1:20 PM - 1:30 PM
Neuroanesthesia (NA) MC408
This Is a Case of a 54-Year-Old Female With a 15-Year History of ALS that Led to Bulbar
Dysfunction and for Her to Be Bed Bound, Requiring Anesthesia With Intubation for a Radical
Nephrectomy
Daniel Robinson, D.O., Ngoc Chu, D.O., Ashish Malik, M.D . Baystate Medical Center, Springfield, MA,
USA.
This is a 52-year-old female with a history of amyotrophic lateral sclerosis requiring anesthesia for a
radical nephrectomy for a staghorn calculus causing intractable pain. She is now bed bound and has also
developed bulbar dysfunction. Induction of anesthesia was accomplished by a judicious mask induction
and once the patient reached a level of anesthesia conducive for laryngoscopy without the use of muscle
relaxants, we intubated with a Mac 3. The case proceeded without complication and muscle relaxants
were not given. She was transported to the SICU post op and was extubated the next day successfully.
Saturday, October 11, 2014
1:30 PM - 1:40 PM
Neuroanesthesia (NA) MC409
Abnormal Acute Rise in Serum Potassium Level secondary to Transfusion of 3 U of PRBCs
Najmeh P. Sadoughi, M.D., Eugenia Ayrian, M.D., Vladmir Zelman, M.D. . Anesthesiology, LAC-USC
Medical Center, Los Angeles, CA, USA, Anesthesiology, LAC-USC medical Center, Los angeles, CA,
USA, Anesthesiology, LAC-USC medical Center, Los Angeles, CA, USA.
Patient with renal cell carcinoma metastasis to spine presented for tumor debulking. Rapid blood loss led
to initiation of transfusion. After 3 Units of PRBCs, potassium level rose from 5.4 to 11.8 mEq.Discussion:
Reasons for abrupt serum potassium increase:1. PRBC Unit hemolysis2. Potassium concentration
increase during blood storage3. Potassium leakage increase from PRBCs Irradiation4.
Acidosis/hypothermiaTo avoid this situation:1. Wash PRBC2. Use blood less than 7 days old for rapid
massive transfusions3. Irradiate PRBCs immediately prior to issue4. Use in-line potassium filters5. Use
traditional treatments for hyperkalemia (insulin, calcium)
Saturday, October 11, 2014
1:40 PM - 1:50 AM
Neuroanesthesia (NA) MC410
Acute Increase of Intracranial Pressure in Post-Anesthesia Care Unit After Elective Frontal
Lobectomy
Vafi Salmasi, M.D., John Jerabek, D.O . Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
Copyright © 2014 American Society of Anesthesiologists
A 56 year old patient presented for resection of an epileptogenic focus. The procedure was eventless and
the patient‟s hemodynamics was maintained within 20% of his baseline. He was not fully responsive after
extubation and therefore had an emergent brain CT scan. Upon arrival from radiology, he started to
become bradycardic, was completely unresponsive to painful stimulus, and his pupils were dilated with
absent reflex to light. He was intubated, transported to ICU, and ICP monitoring was initiated that showed
increased ICP in the range of 60-90. Aggressive treatment of increased ICP was initiated which did not
result in improvement.
Saturday, October 11, 2014
1:50 AM - 2:00 PM
Neuroanesthesia (NA) MC411
Peri-operative Management of an Infant with Hemophilia B and Vein of Galen Malformation
Siddharth Sata, D.O., Jinu Kim, M.D., Patricia Brous, M.D., Franco Resta-Flarer, M.D . Anesthesiology, St
Lukes-Roosevelt Hospital Center - A Division of Mount Sinai Health System, New York, NY, USA.
We present a five month old male with a vein of galen posterior fossa AVM diagnosed in utero
subsequent to a RASA-1 mutation, high output heart failure, and Hemophilia B with a baseline factor 9
level <1% undergoing endovascular embolization of the AVM. The patient underwent a factor 9 assay
titration study (testing the effect of infusions on factor 9 levels) prior to the procedure and received factor
9 concentrate prior to incision and during surgery based on intraoperative factor 9 levels. The patient
underwent a series of embolization procedures using a similar protocol without incidence of hemorrhage.
Saturday, October 11, 2014
2:00 PM - 2:10 PM
Neuroanesthesia (NA) MC412
Transient Hypotension With Direct Application of Vancomycin Powder in the Operating Field
David J. Wildt, M.D., Rafi Avitsian, M.D . Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
Intravenous, impregnated bone cement, and orally administered vancomycin are known to cause allergic
reactions. Direct application of vancomycin powder before closure is part of some surgical procedures.
We are reporting a case of rapid hemodynamic change immediately after application of vancomycin
powder in a posterior cervical spine procedure.
Saturday, October 11, 2014
2:10 PM - 2:20 PM
Neuroanesthesia (NA) MC413
Anesthetic Management of Emergency Craniotomy in a Patient with Left Ventricular Assist Device
Saraswathy Shekar, M.D . Anesthesiology, University of Massachusetts - UMass Memorial Hospital,
Worcester, MA, USA.
27 year female with history of fall presented to the Operating room emergently for evacuation of intra
cerebral hematoma. She had previously received a bridge to transplantation LVAD after cardiomyopathy
developed secondary to viral myocarditis 3 years ago.She had been on Coumadin and was on the wait
list for a heart transplant. Baseline neurologic status decreased mentation and weakness in right
extremities.CT scan showed left large intra cerebral bleed with shift.The intraoperative management of
this patient is described with special focus on managing coagulopathy in patient with LVAD and
intracerebral bleed.
Saturday, October 11, 2014
2:20 PM - 2:30 PM
Neuroanesthesia (NA) MC414
Awake Craniotomy for Aneurysm Clipping for a Quadruple Amputee Patient Complicated by
Seizures and Emesis
Bryant J. Staples, M.D., Ritesh Patel, M.D . Anesthesia and Critical Care, Saint Louis University, Saint
Louis, MO, USA.
A patient with COPD and Buerger‟s vasculitis status post amputations of both his upper and lower
extremities presented with an unruptured anterior communicating aneurysm, for which he underwent an
semi-awake skull base craniotomy for aneurysm clipping. Anesthetic management complicated by lack of
peripheral vascular access requiring femoral vein and axillary artery catheterization under local
Copyright © 2014 American Society of Anesthesiologists
anesthesia. Scalp block was performed by neurosurgeons, and patient was sedated with
dexmedetomidine, remifentanil, and propofol. Surgery was complicated by emesis and multiple seizures
occurring before, during, and after aneurysm clipping.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC04
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Obstetric Anesthesia (OB) MC415
Baby in the Belly: A Case of Uterine Rupture
Stephen E. Turk, Sarah Armour, M.D . Anesthesiology, VCU, Richmond, VA, USA.
Patient is a healthy, non-English speaking 23 yo G4P1021 @ 39 weeks with prior C/S for
oligohydramnios admitted in labor, desiring TOLAC. She progressed rapidly to complete cervical dilation
and due to severe fetal bradycardia, vacuum assisted delivery was attempted but unsuccessful. FHR
improved and CSE placed. Fetal decelerations occurred again and forceps delivery attempted. C-section
called and epidural dosed. Due to language barrier and apparent distress of patient, adequacy of epidural
was questionable, so general anesthesia was induced. Fetus and placenta found in abdomen with uterine
rupture in the lower uterine segment consistent with a prior low transverse incision.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Obstetric Anesthesia (OB) MC416
Anesthetic Management of A Parurient with Multiple Sclerosis (MS) Undergoing C-Section
Kalpana C. Tyagaraj, M.D., Alexandra Mazur, M.D . Maimonides Medical Center, Brooklyn, NY, USA.
30 years female with history of Multiple Sclerosis, migraine headaches, asthma with occasional inhaler
use and one prior C-Section, presented for Repeat C-Section. Previous C-Section was under general
anesthesia. Last exacerbation was two years ago. She was off her medication during this pregnancy.
Patient recently arrived from Egypt and no records were available. A neurologist had seen her once
because of the numbness in lower extremity. Because of limited information regarding MS, decision was
made to proceed with GA. Rapid sequence induction and intubation was done with propofol and
succinylcholine. Intraoperative and postpartum course was uneventful.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Obstetric Anesthesia (OB) MC417
Pregnant Patient With Severe ITP For C-Section: Perioperative Hypoxia- Bleomycin Toxicity?
Kalpana C. Tyagaraj, M.D., ELENI KOTSIS. ANESTHESIOLOGY, MAIMONIDES MEDICAL CENTER,
BROOKLYN, NY, USA.
37 years female, with history of Hogdkin's lymphoma s/p ABVD treatment, on steroids for ITP,GDM and
prior C-Section presented for Repeat C-Section. Platelet count 33,000 with giant platelets. Hematology
recommended to continue steroids and transfuse one unit single donor platelets prior to C-Section.
Proceeded with GA. Intubation was uneventful. At the end of the procedure, patient desaturated to the
low 80s, improved to low 90s prior to extubation with head up, endotracheal suctioning and repositioning.
Work up ruled out PE, pulmonary edema, AFE, and pneumonia. Discharged 3 days later with saturations
between 88-92%.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Obstetric Anesthesia (OB) MC418
Remifentanil Labor Analgesia for a Parturient with Double Valve Replacement On Loveneox
Kalpana C. Tyagaraj, M.D., Alexandra Mazur, M.D., Liliya Aulova, D.O . Anesthesiology, Maimonides
Medical Center, Brooklyn, NY, USA.
34 years, G7P2, with rheumatic heart disease s/p AVR and MVR 2011 on lovenox, history of heart failure
during previous pregnancy, was induced for olighydramnios. Lovenox was switched to heparin infusion.
Radial A-line was placed and remifentanil PCA started to labor analgesia. Many hours later, the fetal
Copyright © 2014 American Society of Anesthesiologists
heart rate tracing worsened, found to be fully dilated. Remifentanil and heparin drips were stopped for
imminent delivery in the OR. Delivery was uncomplicated. Two hours after delivery, heparin infusion was
restarted. Case is being presented for discussion of Remifentanil PCA for labor analgesia.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Obstetric Anesthesia (OB) MC419
A Multidisciplinary Approach: Pregnant Patient With Severe Aortic Stenosis Undergoing CSection
Kalpana C. Tyagaraj, M.D., David Gutman, M.D., Liliya Aulova, D.O . Anesthesiology, Maimonides
Medical Center, Brooklyn, NY, USA.
We present the case of 27 years woman, who had C-Section because of worsening functional status.
History was significant for poorly controlled gestational diabetes and congenital bicuspid aortic valve
diagnosed after first spontaneous abortion. Valve area had worsened to 0.7cm2 at 37 weeks. A
multidisciplinary team including the cardiologist, interventional cardiologist, cardiothoracic surgeon,
maternal fetal specialist, obstetric and cardiac anesthesiologists, decided that C-Section to be done in
Hybrid OR, preinduction placement of femoral lines in case emergency valvotomy was required and
standby cardiopulmonary bypass. She delivered uneventfully under general anesthesia with
intraoperative TEE monitoring.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Obstetric Anesthesia (OB) MC420
Anesthetic Management of a Pregnant Patient with Multiple Sclerosis for C-Section
Kalpana C. Tyagaraj, M.D., Valerie Ivanova, D.O . Maimonides Medical Center, Brooklyn, NY, USA.
25 years G1P1 at 35 weeks who was diagnosed with multiple sclerosis after her previous C-Section who
completed one dose of previous steroids now on Interferon beta-1a with no current neurologic
deficit,presented to triage with possible uterine scar dehiscence. The risks of possible MS relapse were
discussed with the patient. She was taken for urgent C-Section under combined spinal epidural
anesthesia with intrathecal hyperbaric bupivacaine and fentanyl and morphine. Neurologist recommended
IVIG postpartum prior to discharge. Postoperative neurologic exam was normal and the patient was
scheduled for a follow up visit with the neurologist.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Obstetric Anesthesia (OB) MC421
Management of Parturient with HELLP Syndrome Complicated by Undiagnosed Myasthenia Gravis
Mahesh Vaidyanathan, M.D., Pankaj Jain, M.D . University of Mississippi Medical Center, Jackson, MS,
USA.
19 yo G1P0 at 30w of gestation with pre-eclampsia. Patient given magnesium and developed generalized
weakness and pulmonary edema. She developed HELLP syndrome and GA was induced for emergent csection. Sevoflurane, Rocuronium, and Fentanyl were used. The patient was reversed with Neostigmine,
but the patient did not meet extubation criteria. She did not respond to naloxone and remained apneic
until meeting extubation criteria 3 hours later. She was transferred back to the post-partum floor where
she became weak again and responded to termination of Mg infusion. Neurology was consulted. EMG
correlated with the diagnosis of Myasthenia Gravis.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Obstetric Anesthesia (OB) MC422
Combined Spinal-epidural Anesthesia for Cesarean Section in Parturient with Wolff-ParkinsonWhite (WPW) Syndrome
Ivan A. Velickovic, M.D., Borislava Pujic, M.D., Curtis Baysinger, M.D. . Anesthesiology, SUNY Downstate
Medical Center, Brooklyn, NY, USA, Anesthesiology, Klinika za Ginekologiju i Akuserstvo, Klinicki Centar
Vojvodine, Novi Sad, Serbia, Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
Copyright © 2014 American Society of Anesthesiologists
Anesthetic management of the parturient with WPW has been rarely described. A 23 year old, G1/P0,
woman was admitted at 38 weeks gestation for elective CS. An EKG showed classic delta waves of
WPW. CSE was performed at L3-L4 level and 10 mg of intrathecal bupivacaine, 20 mcg of fentanyl and
0.2 mg of morphine were given. A 2900 g female infant was delivered 2 minutes after the start of the
surgery with Apgar scores of 9/10. The rest of the case was unremarkable and patient was discharged
home on post-operative day 5.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Obstetric Anesthesia (OB) MC423
The Brugada Syndrome and Epidural Management for Labor Pain with Conversion to Cesarean
Section
Carmine M. Vincifora, Agnieszka Pietrzak, D.O . Loyola University Medical Center, Maywood, IL, USA.
The Brugada syndrome is characterized by a right bundle branch block and ST segment elevation of
leads V1-V3, an increased susceptibility to ventricular arrhythmias which may culminate in sudden death.
A 29-year-old term female with a history of Brugada syndrome presented for delivery. An epidural was
placed for labor analgesia. However, she experienced arrest of dilation, and underwent C-section with
epidural anesthesia. Due to the paucity of data in the delivering patient, the management and outcomes
of this patient‟s labor course are presented. A review of the current literature recommendations is also
completed.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Fundamentals of Anesthesiology (FA) MC424
Why Does My Breathing Sound So Strange: Anesthetic Management for Resection of an
Endoluminal Tracheal Mass Causing Stridor at Rest
Lesley A. Bennici, M.D., Jose V. Montoya, M.D., Kenneth M. Sutin, M.D . Anesthesiology, NYU Langone
Medical Center, New York, NY, USA.
84 year old female with hypertension and hyperlipidemia who presented with a right neck mass that had
been growing in size for one year. She noticed an acute episode of shortness of breath and “strange
sounding breathing” just prior to admission and chest CT showed an enlarged thyroid mass with
intrathoracic invasion and displacement of the trachea. The patient was taken to the OR for rigid
bronchoscopy and resection of the luminal tracheal mass. We will discuss considerations for anesthetic
and airway management when dealing with a patient with an endoluminal tracheal mass as well as stridor
at rest.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Fundamentals of Anesthesiology (FA) MC425
Simultaneously Managing Severe Aortic Stenosis and Moderate Pulmonary Hypertension: The
Therapy for One is Detrimental to the Other
Gabriel A. Bonilla, M.D., Brian Slater, M.D . Anesthesiology, Elmhurst Hospital Center, Elmhurst, NY,
USA, Mount Sinai Medical Center, New York, NY, USA.
A 94 year old female with severe aortic stenosis (valve area of 0.8 cm squared and gradient of 80
mmHg), moderate pulmonary hypertension (systolic 46 mmHg), hypertension, and paced at DDD 60
beats per minute secondary to sick sinus syndrome presents for a left hip open reduction, internal fixation
with cephalomedullary nail. A hemodynamically stable general anesthetic was administered. We present
an algorithm outlining anesthetic techniques, pharmacological options, and hemodynamic goals for
patients with co-existing aortic stenosis and pulmonary hypetension.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Fundamentals of Anesthesiology (FA) MC426
Emergency Surgery in Patients with Idiopathic Thrombocytopenic Purpura (ITP): Managing the
Coagulopathy
Copyright © 2014 American Society of Anesthesiologists
Gabriel A. Bonilla, M.D., Brian Slater, M.D . Anesthesia, Elmhurst Hospital Center, Elmhurst, NY, USA,
Anesthesia, Mount Sinai Medical Center, New York, NY, USA.
A 56 year old female with idiopathic thrombocytopenic purport (ITP) suffered from a spontaneous
subdural hematoma. The platelet count was 32,000 and the neurosurgery team brought the patient to the
operating room for emergent evacuation. The patient's coagulopathy led to substantial blood loss. Once
the coagulopathy was corrected with steroids and uncross-matched (because of urgency to control
bleeding) platelets, hemostasis was achieved.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Fundamentals of Anesthesiology (FA) MC427
Perioperative Anesthesia Management and Recommendations for a Patient with "StevensJohnson Syndrome"
Hani K. Bouchra Hanna, M.D., Joe R. Jansen, M.D., Terry G. Fletcher, M.D.,Ph.D. . Department of
Anesthesiology, Arkansas Children's Hospital, UAMS, Little Rock, AR, USA, Departemnt of
Anesthesiology, Arkansas Children's Hospital, UAMS, Little Rock, AR, USA, Co-Director of Burn
Anesthesia, Assistant Professor of Anesthesiology, Arkansas Children's Hospital, Little Rock, AR, USA.
Stevens-Johnson syndrome (SJS) is a rare svere blistering disorder with systemic manifestations.Patients
with SJS undergoing General anesthesia can be of great challenge to practicing anesthesiologists.We
describe the perioperative anesthetic mangement for a 46 years old female patient with microcephaly and
Developmental delay presenting to the Arkansas Childrens hospital burn center for drug induced SJS, we
will discuss the anesthetic mnagement for this patient ,the hospital course, anesthetic challenges met,
unusual findings complications encountered, difficulties met and precautions followed we will make our
recommendations for this case and of similar cases and our conclusions.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Fundamentals of Anesthesiology (FA) MC428
Laparoscopic Gastric Sleeve in a 24-year-old Female with Transverse Myelitis
Joseph Bracker, D.O., Lenore Salmon, D.O., Mari Baldwin, M.D . Anesthesia, St. Luke's-Roosevelt, New
York, NY, USA.
Transverse Myelitis, a disorder caused by inflammation of the spinal cord is characterized by symptoms
and signs of neurological dysfunction. The involvement of the motor and sensory tracts frequently
produce altered sensation, weakness or paralysis. Transverse Myelitis has been attributed to the use of
neuraxial techniques, as well as leading to an exacerbation of pre-existing CNS disorders. Additional
considerations include avoidance of depolarizing muscle relaxants for fear of severe hyperkalemia and
increased sensitivity to non-depolarizing muscle relaxants. The case presented highlights the perioperative management of a patient with Transverse Myelitis in order to achieve a positive outcome.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Fundamentals of Anesthesiology (FA) MC429
Circulatory Shock in the Post-anesthesia Recovery Room After Plastic Surgery
Guillerme D. Braga Netto, M.D . Universidade Federal Fluminense, Niteroi, Brazil.
Female, 54 yrs, 60kg, 158cm, hypertension, underwent radical right mastectomy in 2008 preceded by
quimiotherapy with adriamicine. Now undergoing mammary reconstruction. Basic standard monitoring.
General anesthesia maintained with sevoflurane. No complications. Upon arrival to the post-anesthesia
recovery room, patient referred pain. Prescribed tramadol 50mg, patient complained of nausea and was
given ondasetrone, developing bradicardia, hypertension and unresponsiveness. Week central pulse,
EKG with ST elevation?. Back in the OR: hypotension not responding to vasopressors, infused ringer
500ml, starch 6% 500ml and Gelafundin 500ml. USG at pericardial window showing both chrono and
inotropic deficiency + jugular turgency. Initiated Dobutamine with positive results.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Fundamentals of Anesthesiology (FA) MC430
Copyright © 2014 American Society of Anesthesiologists
Intraoperative Pneumopericardium During Laparoscopic Wedge Liver Biopsy
Benjamin W. Brown, M.D., Beth Ladlie, M.D . Anesthesiology, Mayo Clinic, Jacksonville, FL, USA.
A 68-year-old female with past medical history significant for pancreaticoduodenectomy for ductal
carcinoma presented for laparoscopy with liver wedge biopsy. Induction, intubation, and radial arterial line
placement were uneventful. The patient was hemodynamically stable until the surgeon perforated the
diaphragm. The blood pressure abruptly dropped to 75/38 (baseline 110s/70s), presumably due to a
tension-like pneumothorax from the abdominal insufflation. The defect was sutured closed,
hemodynamics returned to baseline, and the case was quickly completed without further complication. A
post-op chest x-ray obtained to check for residual pneumothorax was significant only for a small
pneumopericardium.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Fundamentals of Anesthesiology (FA) MC431
Awake Glidescope Intubation on an Obese and Unresponsive Patient in Respiratory Distress
Robert P. Buchmann, M.D., Michael Lasky, M.D . Saint Louis University, St. Louisi, MO, USA.
Patient in ICU with respiratory distress, despite BiPAP. PMH included: CML, DM, OSA, morbid obesity,
and hypertension; admitted for recurrent pleural effusions. Upon arrival, patient was unresponsive, but
maintaining adequate oxygen saturations on BiPAP. Due to stability and anticipated difficult airway,
patient transported to the operating room for intubation in the presence of otolaryngologist. Awake
intubation planned to preserve spontaneous ventilation, thus no sedation administered. Glidescope video
laryngoscope was inserted without difficulty or resistance, and DL was performed. Grade I view
appreciated and ETT inserted in coordination with patient‟s spontaneous ventilations. Upon intubation,
sedation administered and paralyzed for ventilator synchrony.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Fundamentals of Anesthesiology (FA) MC432
12-Year-Old Male with Acute Bilateral Vocal Cord Paralysis with Worsening Stridor after Tetralogy
of Fallot Repair
Jack C. Buckley, M.D . UCLA Medical Center, Los Angeles, CA, USA.
12 year old male developed severe stridor shortly after extubation in the ICU after a first stage repair of
Tetralogy of Fallot. The patient received a fiberoptic exam of the airway that showed vocal cord edema
and bilateral vocal cord paralysis. This case will describe the differential diagnosis of airway obstruction.
The risk factors for the development of vocal cord edema and paralysis will be discussed. Then the
management options will be outlined including both medical management and invasive management of
vocal cord edema and paralysis.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Pediatric Anesthesia (PD) MC433
Anesthetic Management of Congenital Lobar Emphysema
Andrew J. Costandi, M.D., Deborah A. Romeo, M.D., Ian McIntyre, M.D., Mohamed Mahmoud, M.D .
Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
A 6kg, 6 month old female patient presented to the ED with worsening respiratory distress. Chest CT
scan revealed congenital lobar emphysema (CLE) and, as a result, patient underwent bronchoscopy and
left upper lobectomy. Anesthesia was induced using intravenous ketamine and dexmedetomidine, and
was maintained with sevoflurane, ketamine and dexmedetomidine infusions. Intraoperative analgesia was
mainly provided with continuous caudal epidural infusion of ropivicaine and clonidine. Gentle manual
assisted spontaneous ventilation with low inflating pressure (7-20cm H2O) was utilized until the chest was
opened. The patient tolerated the procedure well and was extubated at the conclusion of the procedure.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Pediatric Anesthesia (PD) MC434
Absent Epiglottis in a 14-month-old Undergoing Airway Imaging with Dexmedetomidine Sedation
Copyright © 2014 American Society of Anesthesiologists
Elizabeth M. Cudilo, M.D., Mohamed A. Mahmoud, M.D., Anna M. Varughese, M.D.,M.P.H., Bobby Das,
M.D., Mario Patino, M.D., Robert J. Fleck, M.D., Matthew Sjoblom, M.D., Diane W. Gordon, M.D., Melissa
V. Bryant, C.R.N.A, Rajeev Subramanyam, M.D., M.S . Cincinnati Children's Hospital, Cincinnati, OH,
USA.
A 14-month-old male with past medical history significant for aspiration and thyroglossal duct cyst
excision presented for a native upper airway MRI dynamic evaluation. Previous microlaryngoscopy
bronchoscopy demonstrated only right-sided, nonfunctional epiglottic tissue scarred to the base of the
tongue. We emphasized the increased risk of aspiration and respiratory complications because of absent
normal epiglottic tissue. Sevoflurane inhalational induction was followed by glycopyrrolate administration
(0.1mg to dry secretions and prevent dexmedetomidine-[Dex]-induced-bradycardia). Dex bolus was given
(2mcg/kg over 10 minutes) prior to infusing 2mcg/kg/hr. Motion control was achieved and images
obtained. Postoperative imaging hemodynamics were stable and patient was uneventfully discharged.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Pediatric Anesthesia (PD) MC435
Intraoperative Pulmonary Edema and Postoperative Lactic Acidosis during Pediatric Spine
Surgery
Elizabeth M. Cudilo, M.D., Anna M. Varughese, M.D.,M.P.H., Mohamed A. Mahmoud, M.D., Rajeev
Subramanyam, M.D., M.S . Anesthesiology, Cincinnati Children's Hospital, Cincinnati, OH, USA.
A 16-year-old female with kyphosis presented for posterior spine fusion under general anesthesia with
propofol and remifentanil (total-intravenous-anesthesia). 320ml of PRBCs were transfused and
~15minutes later airway pressures increased slightly. Upon turning patient supine, frothy secretions
appeared endotracheally. CXR revealed bilateral parenchymal opacities. Morphine and furosemide were
administered. Patient was transferred intubated to ICU, where a severe lactic acidosis was found
requiring vasopressor support. Differential included sepsis, cardiac pathology, negative pressure
pulmonary edema, transfusion related acute lung injury (TRALI), and propofol infusion syndrome.
Evaluation revealed donor blood HLA antibodies against patient‟s blood likely causing TRALI despite
single PRBCs unit administration.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Pediatric Anesthesia (PD) MC436
Dexmedetomidine Sedation for Intracranial Pressure Monitor Placement in a Child with a
Hemorrhagic Optico-chiasmatic Hypothalamic Glioma
Elizabeth M. Cudilo, M.D., Mohamed A. Mahmoud, M.D., Sudhakar Vadivelu, D.O., Junzheng Wu, M.D .
Cincinnati Children's Hospital, Cincinnati, OH, USA.
5-yo male with extensive intratumoral hemorrhage but, without radiological evidence of increased ICP,
now altered presented for ICP monitor placement. Anesthetic goals were to avoid intubation while
providing an adequate depth of sedation that maintained hemodynamic stability, and allowed rapid
recovery for immediate neurological evaluation. Midazolam(0.02mg/kg/hr) infusion, initially started to
control tremors, was continued with an additional 2mg given in OR. Sedation was achieved with
dexmedetomidine(0.5mcg/kg) bolus, followed by titrating infusion(1-2mcg/kg/hr). Local was given prior to
incision. Procedure was tolerated well without complications. Patient breathed spontaneously on NC with
vital signs remaining at baseline. There were no immediate postoperative events.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Pediatric Anesthesia (PD) MC437
A Neonatal Face Mask Used to Improve Nasal Continuous Positive Airway Pressure for Treatment
of Laryngospasm in a Pediatric Patient After General Anesthesia Emergence
Christine M. Curcio, M.D., Viviana Freire, M.D., Christine Hunter Fratzola, M.D., Trishna Upadhyay, M.D.,
James T. Tse, M.D.,Ph.D . Anesthesiology, Rutgers Robert Wood Johnson Medical School, New
Brunswick, NJ, USA.
4 y/o 16 kg male with asthma/recurrent pneumonia presented for bronchoscopy. After smooth
sevoflurane induction, LMA was placed uneventfully. During bronchoscopy, he developed laryngospasm
Copyright © 2014 American Society of Anesthesiologists
and bronchospasm which were treated with succinylcholine and albuterol. During emergence while still in
deep plane of sevoflurane anesthesia, LMA was removed and oral airway was placed. He subsequently
developed stridor and laryngospasm. After CPAP via toddler face mask failed to improve oxygenation, a
neonatal mask with fully-inflated air cushion was quickly secured over his nose for CPAP while
simultaneously administering racemic epinephrine and albuterol via oral nebulizer mask.
Stridor/laryngospasm resolved and SpO2 improved to 96-98%.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Pediatric Anesthesia (PD) MC438
Anesthesia for a Pediatric Patient with Cardiofaciocutaneous Syndrome
Shannon B. Dare, M.D., Humphrey Lam, M.D., Thanh Nguyen, M.D., Thomas Austin, M.D . Vanderbilt
University Medical Center, Nashville, TN, USA.
Cardiofaciocutaneous (CFC) syndrome is a rare syndrome that is characterized by distinct craniofacial
features, cardiac abnormalities, andmultiple other organ system involvement. Patients may present with
pulmonary stenosis, hypertrophic cardiomyopathy, micrognathia, a short neck, laryngomalacia, and
tracheomalacia: all which may significantly impact the perioperative course of these patients. We describe
a 6 year old child with CFC syndrome presenting for an orthopedic procedure. He had an uneventful
perioperative course.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Pediatric Anesthesia (PD) MC439
Anesthetic Considerations in a Patient with Kearns-Sayre Syndrome
Francina P. Del Pino, M.D., Hyangwon Paek, M.D., Bozana Alexander, M.D., Ned F. Nasr, M.D .
Anesthesiology, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA.
A 12 year-old boy with Kearns-Sayre syndrome underwent an uneventful Nissen fundoplication and
gastrostomy tube placement for gastroesophageal reflux disease (GERD), dysphagia and poor oral
intake. The child had a pacemaker in place due to a history of complete heart block. The pacemaker was
programmed to be on DDD mode. Induction of anesthesia was performed with etomidate, remifentanyl
and a small dose of rocuronium. Sevoflurane was used for maintenance of anesthesia and surgeons
used bipolar electro cautery in order to avoid electric interference with the pacemaker. Surgery was
uneventful and patient was safely discharged from PACU with no complications.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Pediatric Anesthesia (PD) MC440
Severe Bronchospasm in 9-Month-Old with Unknown History of Tracheal Ring
Sorosch Didehvar, M.D . Anesthesiology, NYUMC, New York, NY, USA.
9 month old otherwise healthy girl with stridor was scheduled for triple endoscopy under GA for
evaluation.Mask induction was started.First a flexible bronchoscopy revealed a severe distal airway
compression on the tracheal level. During this time, the patient‟s anesthesia and airway was maintained
by intermittent masking.A direct laryngoscopy and bronchoscopy followed accompanied by episodes of
desaturations to the low 20s. Pt was immediately intubated, and help was called who assisted in giving
albuterol,epinephrine,and hydrocortisone.A ETT was placed to stent open the area of tracheomalacia and
the patient admitted to PICU in stable condition.Post-operative workup revealed a double aortic arch.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Pediatric Anesthesia (PD) MC441
Pediatric Viral Respiratory Failure Leading to ECMO
Lauren E. Dies, M.D., Ranu Jain, M.D . Univ of Texas @ Houston, Houston, TX, USA, Anesthesiology,
UT Health Science Center Houston, Houston, TX, USA.
This case involved a pediatric patient with a viral respiratory illness who rapidly deteriorated and required
ECMO for adequate ventilation.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Critical Care Medicine (CC) MC442
Management of Anticoagulation for External Ventricular Drain Placement Due to Cerebral Edema
in a Patient on Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress
Syndrome
Rasesh A. Desai, M.D., Bret Alvis, M.D . Anesthesia, Vanderbilt University Medical Center, Nashville, TN,
USA.
A 35 year-old female status-post gastric bypass complicated by unexpected intraoperative hemorrhage
became acutely altered in the intensive care unit. After intubation secondary to aspiration, the patient
developed ARDS. She was not able to tolerate APRV and ECMO was initiated. Patient‟s hypoxia and
hypercarbia improved; however, on ECMO day two she acutely developed bilateral fixed and dilated
pupils. Despite anticoagulation and no patent foramen ovale, a head CT showed infarct in left middle
cerebral artery distribution with edema and midline shift. Neurosurgery was consulted for extra-ventricular
drain placement and anticoagulation was stopped. Prior to placement she progressed to brain death.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Critical Care Medicine (CC) MC443
Heparin Induced Thrombocytopenia (HIT) and Pulmonary Embolus in a Super Morbidly Obese
Patient
Deepali Dhar, M.D., Andrew B. Leibowitz, M.D . Anesthesiology, Mount Sinai Medical Center, New York,
NY, USA.
40 year old man with obesity hypoventilation syndrome, COPD, BMI of 57.1 (227 kg) presented with SOB
to another institution. Pulmonary embolism was diagnosed and treated with heparin. His weight precluded
CT-angiography and lower extremity doppler was negative. He developed worsening hypoxia, and on day
9 of anticoagulation (AC), he tested HIT positive. Rivaroxaban was begun. On day 12, he was transferred
to our hospital in atrial fibrillation for ischemic bowel. Post-operatively he was in shock. On day 14, a TEE
revealed extensive right ventricular thrombi causing right heart failure. AC was switched to argatroban.
He died despite aggressive therapy.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Critical Care Medicine (CC) MC444
Airway Management in Traumatic Cervical Spine Injury Secondary to Stab Wound
Erica Diaz, M.D., Gloria Lares, M.D., Carla Jaramillo, M.D . Anesthesiology, Hospital Civil Fray Antonio
Alcalde, Guadalajara, Mexico.
37 yo male brought to the OR with a penetrating knife wound in C4-C5. GCS of 14, intoxicated,1 hr. since
the incident. HR:91x´ BP:137/70 SaO2:92%. We performed rapid sequence intubation with the patient in
upright position without hyperextension of the neck. Mantained him with a sufentanil infusion and
desflurane 6%. Catheterization of the right radial artery and placement of subclavian central venous
catheter. As the Thoracic surgeons extracted the knife we evaluated the airway and periferic nervous
involvement with TOF. The patient didnt suffer any nervous lesions, only a small tear of the internal
yugular vein, the trachea was intact.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Critical Care Medicine (CC) MC445
Weighing between Hypoxia and Hemodynamic Stability - PE in the Setting of Right-to-Left
Intracardiac Shunt
Juan C. Diaz-Soto, M.D., Xun Zhu, M.D . Anesthesiology, Mayo Clinic, Rochester, MN, USA.
A 91-year old female with history of DVT was admitted for acute occluding arterial thrombosis of her RLE.
She underwent thromboembolectomy and was placed on anticoagulation. TTE demonstrated elevated
RVSP, unchanged from before. On HD2 the patient developed acute desaturation to 75% in spite of
100% FiO2 support on BiPAP with surprisingly stable hemodynamics. Intracardiac right−to−left shunt at
atrial level was proved with repeat TTE with saline bubble study and was worsened by PE given her
Copyright © 2014 American Society of Anesthesiologists
history. Her cardiac output was maintained through the shunt. If shunt closure occurs, progressive
hemodynamic failure would ensue. Patient opted for comfort cares.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Critical Care Medicine (CC) MC446
Pneumomediastinum-Induced Atrial Fibrillation in the Surgical Intensive Care Unit
Jennifer Dickerson, M.D., Janakiram Ravulapati, M.B.,B.S . Anesthesiology, The University of North
Carolina Hospital, Chapel Hill, NC, USA.
A 51 year old white female was admitted to the SICU after cardiac arrest and multiple injuries secondary
to a motor vehicle collision. Bedside percutaneous tracheostomy was performed, resulting in a posterior
tracheal wall tear and pneumomediastinum. After creation of the pneumomediastinum, the patient
developed atrial fibrillation with RVR. The arrhythmia slowly improved with resolution of the
pneumomediastinum.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Critical Care Medicine (CC) MC447
Loeys-Dietz Syndrome Presenting with Acute Rectal Bleeding and Persistent Fevers
Michael H. Doan, Robert Ratzlaff, D.O . Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland,
OH, USA.
43 y/o male with a history of LDS, seizures, chronic paraparesis and incontinence from a S2 hematoma
presented to outlying hospital with rectal bleeding and bilateral leg pain. Surgical history was notable for
extensive vascular surgeries including aortic root replacement, aneurysm repair and mechanical aortic
valve for which he takes enoxaparin. On hospital day two, he was persistently febrile (39.4°C).
Neurological imaging was normal. His blood cultures were notable for Group B Streptococcus. TEE
showed echolucent spaces compressing the aortic valve graft suggesting of endocarditis. He was treated
with ceftriaxone and subsequently underwent graft replacement on his fifth hospital day.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Critical Care Medicine (CC) MC448
A Challenging Case: Serotonin Syndrome in a Young Critically Ill Patient
Arushi Kak, M.D., Caron Hong, M.D . Anesthesiology, University of Maryland, Baltimore, MD, USA.
Serotonin syndrome(SS) can be fatal and presents with hyperthermia, mental status changes, autonomic
instability, muscle rigidity, and myoclonus. Differentiation with neuroleptic malignant syndrome(NMS) is
difficult. A 30 yo female with nausea and vomiting presented to the SICU intubated with necrotizing
pancreatitis and tachycardia(160‟s), hypertension(160-200/60-100), fever(39-40°C), muscle rigidity,
rhabdomyolysis and myoclonus. Triglycerides were >3000mg/dl, the inciting factor for pancreatitis. PMH:
depression and anxiety which she took Risperidol(antipsychotic) and Fluoxetine(SSRI). Treatment:
CRRT, plasmapheresis, cooling blankets, cyproheptadine and benzodiazepine. Muscle rigidity/myoclonus
improved within 24 hours. CRRT weaned and tolerated extubation. Discharged HD#21. Successful
outcome was secondary to quick diagnosis, management and supportive care.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Critical Care Medicine (CC) MC449
Hanging in the Balance: Extracorporeal Life Support, Hemorrhage and Thrombosis
Kasey K. Fiorini, M.D., Ravi Tripathi, M.D . Department of Anesthesiology, The Ohio State University
Wexner Medical Center, Columbus, OH, USA.
64 year old female with aortic valve endocarditis underwent bioprosthetic AVR. Upon failing to wean from
bypass, she required VA ECLS. Intraabdominal bleeding occurred postoperatively requiring emergent
laparotomy and splenectomy. INR was 9.7, platelets <30,000, and fibrinogen undetectable yet heparin
was continued for ECLS. TEE showed severe global hypokinesis and, at the end of the procedure, a new
left atrial clot. Additional heparin was administered, clot excised on CPB, and heparin reversed.
Copyright © 2014 American Society of Anesthesiologists
Spontaneous echo contrast appeared in the left atrium and congealed. Flow via ECMO circuit was lost.
Further intervention was deemed futile. Examination of the circuit showed widespread thrombosis.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Critical Care Medicine (CC) MC450
Emergent Awake Nasotracheal Intubation for Angioedema in a Super Morbidly Obese Asthmatic
Patient with Von Willebrand’s Disease
Michael A. Fishman, M.D., MBA, Suneil Jolly, M.D., Lars E. Helgeson, M.D . Department of
Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
A 38-year old super morbidly obese (BMI 59) female with a history of hypertension, obstructive sleep
apnea, asthma and von Willebrand‟s disease presented with acute angioedema. Anesthesiology
responded STAT to the Emergency Department. The patient was sitting upright on a non-rebreather
mask in moderate distress with profound lingual swelling. She was unable to provide details regarding her
von Willebrand‟s disease. The multidisciplinary Threatened Adult Airway Response Team (TAART) was
activated. With ENT standing by, a smooth awake fiberoptic nasotracheal intubation was performed after
administration of DDAVP and preparation of the nose with phenylephrine 0.5% nasal spray and atomized
4% lidocaine.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Fundamentals of Anesthesiology (FA) MC451
Elective Tracheostomy in a Patient With Iatrogenic Cushing's Syndrome From Chronic Steroid
Therapy: A Case Report
Mary S. Clayton, M.D., Anupama N. Wadhwa, M.D . Anesthesiology, University of Louisville, Louisville,
KY, USA.
The anatomic and physiologic manifestations of Cushing‟s syndrome can present multiple challenges for
the anesthesiologist in the perioperative period. More specifically, the cushingoid features of the head and
neck complicate patient positioning when trying to secure the airway in the operating room. As with any
difficult airway, several plans and backup methods should be available. This is a case of a 52 year old,
morbidly obese, African-American female with Cushing‟s syndrome presenting for an elective
tracheostomy for severe obstructive sleep apnea. She was successfully intubated with a fiberoptic scope
after inhalational sevoflurane induction, maintaining spontaneous ventilation.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Fundamentals of Anesthesiology (FA) MC452
Refractory Shock in a Patient with Heparin-Induced Thrombocytopenia and an Undiagnosed Right
Atrial Thrombus
Jeffery D. Clemmons, M.D., Kimberly Nesbitt, M.D., Susan Eagle, M.D . Department of Anesthesiology,
Vanderbilt University Medical Center, Nashville, TN, USA.
Intracardiac thrombosis is a potentially deadly sequela of heparin-induced thrombocytopenia. This is a
case of a 77 year old man with ischemic cardiomyopathy, aorto-occlusive peripheral vascular disease,
and heparin-induced thrombocytopenia presenting for a level one aortoiliac thrombectomy and superior
mesenteric artery thrombectomy for cool lower extremities and ischemic bowel. Intraoperatively, patient
had refractory shock. Transesophageal echocardiogram revealed a right atrial thrombus with partial
occlusion of the tricuspid valve thought to be largely responsible for patient‟s hypoperfusion state. This
case presents an opportunity to review the pathophysiology of the heparin-induced thrombocytopenia and
the potential hemodynamic ramifications of a right atrial thrombus.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Fundamentals of Anesthesiology (FA) MC453
Hyperthermic Intraperitoneal Chemoperfusion in a Patient with Peritoneal Carcinomatosis:
Anesthetic Challenges
Copyright © 2014 American Society of Anesthesiologists
Susan C. Cosgrove, M.D., Richard K. Raker, M.D . Anesthesiology, Columbia University, New York, NY,
USA.
A thirty year old female with primary peritoneal carcinoma presented to our institution for cytoreductive
surgery and hyperthermic intraperitoneal chemotherapy in October 2013. Her diagnosis was made in
December 2011 after experiencing increasing abdominal girth. CT imaging of her abdomen and pelvis
confirmed carcinomatosis and an ovarian biopsy revealed poorly differentiated malignancy. She had
multiple cycles of chemotherapy prior to surgery and her preoperative course was notable for worsening
ascites and shortness of breath. She underwent an exploratory laparotomy, omentectomy, lysis of
adhesions, hyperthermic intraperitoneal chemotherapy, and intraperitoneal port placement with both
gynecologic oncology and general surgery teams.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Fundamentals of Anesthesiology (FA) MC454
Anesthetic Management for a Medically Challenging Post-Heart Transplant Patient
Sean G. Crane, M.D., Evan Van Peursem, Ranita Donald, M.D . Dept of Anesthesia and Perioperative
Medicine, Georgia Regents University, Augusta, GA, USA.
A 74-years-old male s/p heart transplant several years ago, with extensive past medical history significant
for multi-vessel CAD, S/P CABG, hypertrophic cardiomyopathy of the transplanted heart, ICD and
pacemaker implantation, paroxysmal atrial fibrillation/flutter, post-transplant lymphoma, dyslipidemia and
ESRD. Patient had recent episode of ventricular tachycardia and ventricular fibrillation for which
Amiodarone was started. Patient was on peritoneal dialysis since unable to tolerate the volume changes
of hemodialysis; however the peritoneal dialysis catheter stopped functioning requiring revision. This case
will high light the anesthetic concerns for this medically challenging post-heart transplant patient.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Fundamentals of Anesthesiology (FA) MC455
Bedside Gastric Sonography Helped to Define the Need for Rapid Sequence Induction
Hillenn Cruz Eng, M.D., Richelle B. Kruisselbrink, M.D.,F.R.C.A, Anahi Perlas, M.D.,F.R.C.A. Department
of Anesthesia, Toronto Western Hospital, Toronto, ON, Canada.
A 78-year-old male for emergent decompression of large bowel obstruction, CT findings revealed a
competent ileocecal valve. He had gallbladder malignancy, NIDDM with nephropathy; CAD and
exacerbated COPD. Hemodynamics were unstable, NPO status over 24 hours. A titrated induction of
general anesthesia was considered.Gastric sonography pre-induction revealed a distended antrum with
heterogeneous content of mixed echogenicity consistent with thick fluid or solids. RSI was performed with
cricoid pressure; no hemodynamic instability observed. A nasogastric tube placed post-induction obtained
400 mls of aspirate. Laparoscopy revealed a distended, incompetent ileocecal valve. The patient was
extubated awake and taken to recovery.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Fundamentals of Anesthesiology (FA) MC456
Anesthetic Management of a Gravid Patient with Subglottic Stenosis for Balloon Dilatation
Anita V. Cucchiaro, M.D., Michael J. Berrigan, M.D.,Ph.D . Anesthesiology and Critical Care Medicine,
The George Washington University Hospital, Washington, DC, USA.
Granulomatosis With Polyangitis is a progressive, devastating disease that can damage renal, upper
respiratory and vascular tissues. In pregnant patients with attendant airway changes, these
manifestations can be even more deleterious. We present a case of a gravid patient with worsening
subglottic stenosis undergoing semi-elective balloon dilatation during her second trimester. We opted for
intermittent, low-frequency jet ventilation while preventing aspiration. Risks of this technique were
weighed against the need for optimal surgical access and the expected outcome, and her surgery
proceeded without complications to the fetus or patient. Her symptoms improved, and her pregnancy
continued uneventfully.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Fundamentals of Anesthesiology (FA) MC457
Renal Injury after Combined Radical Cystoprostatectomy and Right Radical Nephroureterectomy
in Patient Anesthetized using Enhanced Recovery after Surgery (ERAS) Protocol
Tera Cushman, M.D.,M.P.H., Thomas Hopkins, M.D., MBA. Duke University Medical Center, Durham,
NC, USA.
An 82 year-old man with urothelial carcinoma and chronic kidney disease presented for combined
nephroureterectomy and cystoprostatectomy. His anesthetic plan included the Enhanced Recovery after
Surgery (ERAS) protocol for goal-directed fluid therapy. Surgical concern for pulmonary edema in the
setting of acute reduction in GFR due to nephrectomy led to preferential use of vasopressors over fluid.
Several clinical indicators suggest that he was intraoperatively under-resuscitated. Postoperatively he
required significant additional resuscitation and suffered acute kidney injury.The case highlights the
paucity of data on goal-directed fluid therapy in urologic surgery, which adds complexity to fluid
management that warrants further investigation.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Fundamentals of Anesthesiology (FA) MC458
Successful Liver Transplantation complicated by Acute Hypotensive Transfusion Reaction in a
Patient on ACE Inhibitors
Rajivan Maniam, M.D., Daniela Darrah, M.D . Columbia University College of Physicians and Surgeons,
New York, NY, USA.
Acute hypotensive transfusion reactions are related to bradykinin metabolism and present with severe
hypotension in patients taking ACE inhibitors. We present the case of a 67-year-old male with HCV
cirrhosis for emergent liver transplantation on an ACE inhibitor. Following transfusion of FFP, the patient
developed severe and sudden hypotension that resolved only with high doses of epinephrine boluses and
immediate cessation of any FFP transfusions. Transplantation was ultimately successful except for
surgical bleeding that nearly prevented abdominal closure. However, upon administration of prothrombin
complex concentrate, the coagulopathy corrected, no hypotension was observed, and the abdomen was
successfully closed.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Fundamentals of Anesthesiology (FA) MC459
Approach to General Anesthesia in the Setting of a Lower GI Bleed in a Patient with Severe
Pulmonary Hypertension and Acute Endocarditis
Jaime Daly, M.D., Jodi Sherman, M.D . Anesthesia, Yale University, New Haven, CT, USA.
63 yo woman with a repaired TVR/PVR congenital malformation, severe pulmonary HTN complicated by
chronic portal HTN on anticoagulation for A fib has recurrent hemorrhoidal bleeding. Presents with active
bleeding and worsening right heart failure. Admitted for ICU care and transfusion a TEE was done
showing endocarditis, PA pressures of 75mmHg, RA pressure of 20 and increased TV pressures. After 3
weeks of IV antibiotics her RHF had not improved. Further cardiac optimization wasn't possible. After
inhalation induction of general anesthesia, patient was hemodynamically unstable, requiring vasopressor
support and multiple transfusions of packed red blood cells.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Obstetric Anesthesia (OB) MC460
Successful Anesthetic Management of a Parturient with Complex Congenital Heart Disease and
Obstetric History
Copyright © 2014 American Society of Anesthesiologists
Sanjeev Dalela, M.B.,B.S., Shvetank Agarwal, M.B.,B.S., Manuel Castresana, M.D . Anesthesiology and
Perioperative Medicine, Georgia Regents University, Augusta, GA, USA.
A 33 year old parturient with critical congenital pulmonary valvulopathy underwent a successful cesarean
section. Her prior pregnancies were complicated with placental abruptions. Patient had received several
balloon and open valvuloplasties in her childhood followed by bioprosthetic pulmonary valve replacement
with tricuspid valve annuloplasty at 18 years of age. She had NYHA class IV dyspnea, three pillow
orthopnea, and unceasing palpitations. Anesthetic management included preinduction arterial line
placement, general anesthesia and intraoperative transesophageal echocardiography. We describe the
natural progression of pulmonary stenosis during pregnancy and the perioperative anesthetic challenges
associated with restrictive right heart congenital lesions and prior valve replacements.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Obstetric Anesthesia (OB) MC461
Anesthetic Care for Parturient with Cardiopulmonary and Neurologic Compromise and Multiple
Organ Transplants
John E. DaSilva, M.D., Kevin Finkel, M.D . University of Connecticut- Hartford Hospital, Hartford, CT,
USA.
A G1P0 39-year-old woman with a history of poorly controlled type 1 diabetes was admitted at 37 weeks
gestational age with pre-eclampsia. Complications from her diabetes included coronary artery disease,
pulmonary hypertension, prior stroke, diabetic neuropathy, foot drop, gastroparesis, and retinopathy.
Surgical history was significant for pancreas and renal transplants, and coronary artery bypass grafting.
After a multidisciplinary discussion, general anesthesia with a rapid sequence induction, central access,
and invasive arterial blood pressure monitoring was selected over a neuraxial technique as the primary
anesthetic. Anesthesia was maintained with sevoflurane, and the anesthetic, delivery, and post-operative
course were uneventful.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Obstetric Anesthesia (OB) MC462
Asymmetrical Epidural Analgesia for Induction of Labor Followed by More Asymmetrical Epidural
Anesthesia for Cesarean Delivery in a Patient with Morquio Syndrome
Carlos M. Delgado Upegui, M.D., Matt Cotton, M.D., Christopher D. Kent, M.D., Ruth Landau, M.D .
Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA.
Management of labor analgesia in women with Morquio syndrome, a congenital mucopolysaccharidosis
characterized by short stature, coarse facial features, atlanto-axial subluxation, severe thoracolumbar
kyphosis and restriction in pulmonary function has not been reported to our knowledge. For cesarean
delivery, continuous spinal anesthesia was described (1). We report the challenging management of
epidural labor analgesia followed by epidural re-dosing for cesarean delivery. Abnormal accumulation of
glycosaminoglycans in the epidural space, and/or the documented severe lumbar canal stenosis with
thecal sac compression and kyphoscoliosis, could explain the asymmetrical dermatomal extension our
patient experienced despite epidural resiting and numerous boluses. (1)SOAP 2007; A-217.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Obstetric Anesthesia (OB) MC463
A Challenging Case Of A Suspected Uterine Rupture Resulting In Post-Operative Peritonitis And
Sepsis: What Would You Have Done With The Epidural Catheter?
Carlos M. Delgado Upegui, M.D., Michael Holland, M.D., Michael Tielborg, M.D., Laurent Bollag, M.D.,
Ruth Landau, M.D . Anesthesiology and Pain Medicine, University of Washington Medical Center,
Seattle, WA, USA.
An urgent cesarean for suspected uterine rupture in a patient with 3 prior cesareans was managed with a
CSE anesthetic. Only dense adhesions and tacked loops of bowel were found. Surgical exploration 28h
later for persistent abdominal pain and 39.8ºC fever revealed a perforated small bowel loop. Sepsis was
managed in the ICU with vasopressors and antibiotics. The epidural catheter was kept 72h for postcesarean analgesia. While there is no consensus with regards to keeping an indwelling epidural catheter
Copyright © 2014 American Society of Anesthesiologists
in patients with sepsis (1), and considering the patient received antibiotics, we opted to provide neuraxial
post-operative pain management. 1.RAPM 2006.31:324-33.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Obstetric Anesthesia (OB) MC464
Quadriplegic Parturient for Repeat Cesarean Section: Challenges and Multidisciplinary Problem
Solving Approach for Successful Outcomes
Eric DeVeaux, M.D., Rishimani Adsumelli, M.D., Michelle Delemos, M.D . Stony Brook University Medical
Center, Stony Brook, NY, USA.
Management of parturients with quadriplegia is challenging. Life threatening complications such as
autonomic hyperreflexia and respiratory insufficiency can occur in the perioperative period.We recently
took care of a term parturient with T1 partial injury and who suffered from episodes of autonomic
hyperreflexia for repeat cesarean section with epidural block. Management was challenging due to
inability to assess the level of epidural block and labile hemodynamics.Multidisciplinary communication
and planning for early diagnose and treatment of autonomic hyperreflexia was critical to successful
outcome . Rationale for our management and pros and cons of available choices will be discussed.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Obstetric Anesthesia (OB) MC465
Difficult Airway: Awake Fiberoptic Intubation In a Severely Preeclamptic Patient After Failed
Spinal for Urgent Cesarean Section
Lewis P. Diamond, M.B.,B.Ch., Zana Borovcanin, M.D . Anesthesiology, Univ of Rochester, Rochester,
NY, USA, Anesthesiology, University of Rochester, Rochester, NY, USA.
We present the scenario of a failed spinal anesthetic in a 26 year old G1P0 severely preeclamptic patient
for urgent cesarean section at 26w5d with a difficult airway. The patient was developing worsening
preeclampsia and variable decelerations on a background history of hypertension, asthma, BMI 36. We
administered spinal anesthesia with subsequent motor block, but preserved sensation. She had a difficult
airway: micrognathia, Mallampati IV, thyromental distance 2 cm, with limited mouth opening and neck
extension. Due to her unfavorable airway exam a decision was made to perform an awake fiberoptic
intubation, which was successful.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Obstetric Anesthesia (OB) MC466
Anesthetic Management of a Pregnancy in a Cardiac Patient with Repaired Tetralogy of Fallot
Complicated by Severe Pulmonary Regurgitation and RV Dysfunction
Maria Florencia Eastlack, M.D., Shannon Klucsarits, M.D., Norman Huang, M.D . Anesthesiology and
Pain Management, UT Southwestern Medical Center, Dallas, TX, USA.
32 y/o female 37wks gestation with pmh of repaired TOF complicated by severe pulmonary regurgitation
and RV dysfunction, kyphoscoliosis s/p Harrington rod placement, asthma, significant restrictive lung
disease, and anorexia presents for urgent C/S.Prior to induction, arterial/central lines, inotropes, and
inhaled NO were initiated. The cardiac surgical team and pefusionist were present and ready for potential
emergent ECMO. RSI was performed with etomidate and succinylcholine. Continuous TEE was used to
monitor cardiac status. The patient remained stable and the intraoperative course was uneventful. The
patient and her neonate had an uncomplicated hospital course.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Obstetric Anesthesia (OB) MC467
Anesthetic Concerns and Management of a Parturient with Symptomatic Congenital Limb-Girdle
Myasthenia Gravis for Fetoscopic Surgery and Subsequent Cesarean Delivery
Mona Ehasz, D.O., Katherine Hoctor, M.D., Jennifer Hochman-Cohn, M.D., Sudharma Ranasinghe, M.D .
Anesthesiology, Jackson Memorial Hospital, Miami, FL, USA.
Copyright © 2014 American Society of Anesthesiologists
32 year old G1P0 with congenital limb-girdle myasthenia gravis presented at 24 weeks with PPROM and
oligohydramnios. Due to respiratory compromise she was started on prednisone, pyridostigmine, and
intermittent BiPAP. At 27 weeks she underwent fetoscopic surgery for amnioinfusion. The surgery was
successfully completed with minimal sedation and BiPAP machine on standby in the OR. Three days later
she underwent urgent cesarean delivery for fetal hydrops. Patient received a modified combined-spinal
epidural technique to reach a T6 level without changes to her respiratory status. BiPAP was again on
standby in the OR. Patient experienced an uncomplicated delivery without respiratory compromise.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Obstetric Anesthesia (OB) MC468
Persistent Unilateral Epidural Block: Resolution by Orienting the Bevel of Tuohy Needle to
Unblocked Side
Chinedum S. Enyinna, M.D . Stony Brook Hospital, Stony Brook, NY, USA.
Persistent unilateral epidural block, a rare complication, can have significant implications for parturients in
labor.Induction of epidural analgesia in a primipara was complicated by persistent unilateral block even
after easy localization of epidural space 4 times by multiple anesthesiologists. Bilateral block was
obtained by orienting Tuohy needle bevel to the unblocked side during identification of epidural space and
catheter insertion.Orienting the bevel to unblocked side might have facilitated the diffusion of the local
anesthetic by overcoming the barrier in the posteriolateral space.This simple maneuver might lead to
success in trouble shooting cases of persistent unilateral blocks.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Regional Anesthesia and Acute Pain (RA) MC469
S-Ketamine: Implications for the Military and Austere Medicine Community
Christopher V. Maani, M.D., Gregory Stevens, M.D., Katherine Slogic, M.D., Mark Liu, M.D., Leandro
Castro, M.D. , Carlo Alphonso, M.D . Anesthesiology, San Antonio Uniformed Services Health Education
Consortium (SAUSHEC), Boerne, TX, USA, Anesthesiology, San Antonio Uniformed Services Health
Education Consortium (SAUSHEC), San Antonio, TX, USA, Special Operations Unit, Tactical Rescue
Unit, Rio de Janeiro, Brazil.
Military physicians face unique challenges when treating battlefield pain. Contemporary pain
management leverages multimodal analgesic approaches, but battlefield analgesia relies on morphine
auto-injectors. This worsens cardiorespiratory depression in hemorrhaging trauma patients. Duration of
action and slow onset make it difficult to titrate IM. Battlefield analgesics should be potent, easily
transported, stable in harsh environments, with a long shelf-life and minimal cardiopulmonary effects.
With rapid onset and clearance, S-ketamine offers multiple routes of administration for easier delivery in
tactical environments. Using military medicine case studies, we will discuss the favorable profile of Sketamine for consideration as a battlefield and pre-hospital analgesic.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Regional Anesthesia and Acute Pain (RA) MC470
Parsonage-Turner Syndrome: Plexopathy & the Parturient
Christopher V. Maani, M.D., Carl Lobato, M.D., Peter Bell, M.D., Bryant Edwards, M.D., Melissa Boone,
P.A., Micah Bahr, M.D., Heather Higgins, M.D., Christopher Nagy, M.D . Anesthesiology, San Antonio
Uniformed Services Health Education Consortium (SAUSHEC), San Antonio, TX, USA.
Acute Pain Service was consulted for acute arm pain in a 33-year-old G3P0020 physician at 32 weeks
EGA with PPROM. Differential included amyotrophic brachial plexopathy or Parsonage-Turner Syndrome.
Analgesic options were limited by pregnancy, patient non-compliance with physical therapy and systemic
medications, and report of transient nerve entrapment symptoms in upper and lower extremities. We
describe diagnostic considerations like EMG and nerve blocks. This clinical scenario also allows for
discussion of multimodal and multi-disciplinary therapeutic approaches to include rest, acupressure,
TENS therapy, massage therapy, PM&R consults, topical dressings such as lidocaine or capsaicin
ointments, and peripheral nerve stimulators.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Regional Anesthesia and Acute Pain (RA) MC471
Liposomal Bupivacaine for Pectoral Nerve and Serratus Plane Blocks in Breast Surgery - A Case
Series
Paul G. Maliakel, M.D., Ross A. Gliniecki, M.D., Niels M. Hauff, M.D., Brian D. Terrien, M.D., Brandon L.
DaValle, D.O . Anesthesiology, Naval Medical Center San Diego, San Diego, CA, USA.
Liposomal bupivacaine wound infiltration by surgeons for postoperative analgesia is becoming more
prevalent, however, its use in regional blocks has not been well studied. We present a series of 15
patients undergoing breast surgery who received Pecs 1, Pecs2, and/or Serratus plane blocks for
intraoperative and postoperative analgesia. Data were collected on narcotic usage and postoperative pain
scores from arrival in the OR through 72 hours after surgery. Our results show that these blocks provide
good analgesia with low postoperative pain scores and may represent a safer and technically easier
alternative to paravertebral blocks.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Regional Anesthesia and Acute Pain (RA) MC472
Iatrogenic Methadone Toxicity: A Case Presentation
Ashish Malik, M.D., Nandakumar Ponnusamy, M.D . Anesthesiology, Baystate Medical Center,
Springfield, MA, USA.
This is a case of iatrogenic methadone toxicity leading to potential patient complications and increased
hospital length of stay. Methadone urine screening requires a different immunoassay technique than that
is used for opiate detection. The methadone metabolite, EDDP (2-ethylidene-1, 5-dimethyl-3, 3diphenylpyrrolidine) needs to be screened for versus a standard opioid urine screen. Initiation/dosing of
methadone needs to be titrated slowly given its potential for QTc prolongation. In this case, the patient
was administered additional drugs that could potentially prolong QTc.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Regional Anesthesia and Acute Pain (RA) MC474
A Novel Approach to Pain Management after Tibial Plateau Fracture
Alexandra Mazur, M.D., Kalpana Tyagaraj, M.D., Reet Lawhon, M.D . Anesthesiology, Maimonides
Medical Center, Brooklyn, NY, USA.
60 year old female with history of breast cancer and depression admitted for ORIF left tibial plateau.
Preoperative pain control with hydromorphone caused nausea responsive to aprepitant. Prior to
emergence from general, liposomal bupivicaine expanded with saline was injected into superficial and
deep tissues of the surgical field and a femoral catheter placed for postoperative pain control. Pain scores
were zero for 56 hours such that the femoral catheter was not activated. On POD#2, oxycodone ER and
oxycodone IR were started. Case presented for discussion of the use of liposomal bupivacaine for
postoperative pain management in a narcotic intolerant patient.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Regional Anesthesia and Acute Pain (RA) MC475
Placement of a Sciatic Nerve Continuous Catheter Using a Novel Lateral Approach at the Level of
the Greater Trochanter.
Conrad S. Myler, M.D., Jaime de la Fuenta, B.S., Meenal K. Patil, M.D., Jason S. Lane, M.D.,M.P.H .
Vanderbilt University School of Medicine, Nashville, TN, USA.
A 60 year-old female presented after a fall. Injuries included: right femur fracture, left tibial plateau and
fibular fractures, and L2 superior endplate fracture. A TLSO brace was placed. Operative fixation of lower
extremity fractures was performed. Postoperatively she had intractable pain in the left knee. With the
patient unable to roll laterally due to TLSO brace, a regional anesthetic to treat her left knee pain was
devised. Keeping the patient in the supine position, a left sciatic nerve continuous catheter was placed
using a novel lateral approach below the greater trochanter using nerve stimulation, yielding excellent
analgesia.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Regional Anesthesia and Acute Pain (RA) MC476
Paraspinal Abscess with Epidural Micro-hematoma
Jose M. Otero, M.D., Jean Daniel Eloy, M.D., Vanny Le, M.D . Anesthesiology, Rutgers-New Jersey Med
School, Newark, NJ, USA.
A 51 year old female developed a paraspinal abscess with associated epidural microhematoma after
placement of an epidural catheter for postoperative analgesia. The patient had a history of aortoiliac
occlusive disease and underwent aortobiiliac artery bypass surgery. The catheter was removed on
postoperative day 3. Initial symptoms were fever and severe backache at the site of catheter insertion.
The infection was diagnosed 5 days post catheter removal via a diagnostic MRI. Surgical drainage was
performed and purulent material sent for cultures revealed MRSA. The patient remained neurologically
stable and was treated with an aggressive course of IV antibiotics.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Regional Anesthesia and Acute Pain (RA) MC477
Paravertebral Nerve Blocks As A Safe and Effective Anesthesia Technique For Axillary Bi-Femoral
Profunda Artery Bypass Surgery
Raj B. Padalia, M.D., Joseph Pierson, M.D., Qing Liu, M.D.,Ph.D . Department of Anesthesiology, UPMC,
Pittsburgh, PA, USA, UPMC, Pittsburgh, PA, USA.
A 59-year-old female with autoimmune hepatitis requiring immunosuppression therapy presented for right
axillary bi-femoral profunda bypass surgery. The autoimmune hepatitis was complicated by cirrhosis and
decreased synthetic liver function, placing her at a higher risk of developing decompensated liver failure
under general endotracheal anesthesia. Therefore, an alternative strategy with regional anesthesia and
sedation was implemented. Preoperative right-sided paravertebral blocks (T2, T6 and T9) were performed
under ultrasound guidance with 10 ml of 0.5% ropivacaine at each level. Nerve blocks, together with
intraoperative sedation with propofol, ketamine, midazolam and fentanyl provided successful anesthesia
and analgesia for the surgery.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Pediatric Anesthesia (PD) MC478
Diaphragmatic Pacemaker Placement in Congenital Central Hypoventilation Syndrome: Case
Report
Daniel D. Kim, M.D., Rodrigo A. Sardenberg, M.D., Mauricio N. Nogueira, M.D., Maria F. Rua, M.D .
Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil.
A 2-year-old male, ASA Physical Status II presented for diaphragmatic pacemaker implantation. Past
medical history was significant for Congenital Central Hypoventilation Syndrome (CCHS) diagnosed after
respiratory failure and a positive testing for PHOX2B gene mutation. Due to the increased risk for apnea
the children had a tracheostomy attached to a portable ventilator. The patient underwent inhaled
induction in SIMV mode, intravenous access was obtained and balanced general anesthetic technique
was chosen. Diaphragmatic pacemaker was placed and the child was transferred to the ICU unit
uneventfully.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Pediatric Anesthesia (PD) MC479
Pediatric Difficult Airway: Retropharyngeal Abscess Causing Cervical Instability
Jinu Kim, Lucresia M. Montes, M.D., Franco Resta-Flarer, M.D., Jonathon Lesser, M.D . Mount SinaiRoosevelt, New York, NY, USA.
A 9-year-old male with an retropharyngeal abscess extending to the C1-2 vertebrae underwent a biopsy.
After unsuccessful intubation elsewhere, he was transferred to us. The CT scan was reviewed. Plan for
intubation with consideration for cervical instability was formulated in conjunction with neurosurgery and
ENT. A Glidescope, fiberoptic bronchoscope, and Lindolm laryngoscope were prepared. Patient was
Copyright © 2014 American Society of Anesthesiologists
induced with sevoflurane, propofol was titrated and initial laryngoscopy with Glidescope was performed.
Despite visualization of the cords, intubation attempts were unsuccesful with both the Glidescope and
Lindholm by ENT. Intubation was achieved on the third attempt with combination Glidescope/FOB by two
anesthesiologists.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Pediatric Anesthesia (PD) MC480
Anesthetic Management of Intracranial-Extracranial Bypass for Pediatric Moya Moya Disease
Jinu Kim, M.D., Melody Anderson, M.D., Franco Resta-Flarer, M.D., Jonathan B. Lesser, M.D . St. Luke's
- Roosevelt Mount Sinai, New York, NY, USA.
We present a 6 year old child with Moya Moya disease who underwent left and then right side
extracranial-intracranial bypass surgeries. Preoperatively the patient was maintained on aspirin, which
was continued until the day of surgery. The patient received general anesthesia after an inhalation
induction for both surgeries and after which intravenous and arterial line access was placed.
Intraoperatively, cerebral perfusion pressure was closely monitored and maintained at high normal levels.
The craniotomy and bypass were successfully completed without significant blood loss. The patient was
extubated at the end of both surgeries with no sequelae.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Pediatric Anesthesia (PD) MC481
One-Month-Old Presents for Resection of a Large Meningoencephalocele at the Skull Vertex
Anjali Koka, M.D., Mark Proctor, M.D., John Meara, M.D. , Craig McClain, M.D . Boston Children's
Hospital, Boston, MA, USA.
A one-month-old 12 kg boy was born with a large meningoencephalocele exiting the vertex of his skull.
The meningoencephalocele was diagnosed in utero, and imaging showed that it was filled predominantly
with fluid and some brain tissue. At the time of surgery, it was three times the size of his skull and
constituted half his body weight. The infant was forced to lie supine, as the weight of the
meningoencephalocele was too great for him to support. This presentation will include several
photographs and a discussion of the many anesthetic considerations, including positioning and airway
and hemodynamic management.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Pediatric Anesthesia (PD) MC482
Intractable Hypotension in a Teenager Status Post Heart Transplant with Low Ejection Fraction for
Airway Surgery Under Monitored Anesthesia Care
Neeraj Kumar, M.D., M Saif Siddiqui, M.D., Jesus Apuya, M.D., Edwin Abraham, M.D., Michael Schmitz,
M.D . Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA,
Anesthesiology, Arkansas Children's Hospital, Little Rock, AR, USA.
A 17-year-old boy s/p heart transplant with low heart ejection fraction who underwent microlaryngoscopy,
bronchoscopy and thyroplasty for recurrent laryngeal nerve paralysis under propofol-remifentanil infusion.
He developed intractable hypotension despite fluid boluses and vasopressor administration. The patient
had to be deep enough for airway procedure with intermittent emergence for vocal assessment.
Perioperative anesthetic management of a post-transplant patient will be discussed including
management of intraoperative hypotension. There will also be discussion of total Intra-venous anesthetic
(TIVA) management during monitored anesthesia care for airway surgery.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Pediatric Anesthesia (PD) MC483
Use of Nitric Oxide During Trachestomy Placement in a Preterm Infant With Severe Pulmonary
Hypertension
Cheuk Y. Lai, M.D., Jonathan Lesser, M.D., Franco Resta-Flarer, M.D . Department of Anesthesiology,
St. Luke's-Roosevelt Hospital Center, New York, NY, USA.
Copyright © 2014 American Society of Anesthesiologists
A 6-month-old infant born at 27 weeks with RDS complicated by CMV, MRSA, Grade I IVH, PDA treated
with indomethacin and persistent pulmonary hypertension was referred for microlaryngoscopy and
placement of a tracheostomy for chronic respiratory failure. The patient was brought to the OR intubated
on 0.75 FiO2 and 20 PPM nitric oxide which was continued throughout the case while general anesthesia
was maintained with sevoflurane. Percutaneous tracheostomy was attempted without success due to
anatomical difficulties and an open tracheostomy was uneventfully performed. Postoperatively, the
patient‟s respiratory status continued to decline, and he expired 3 months later.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Pediatric Anesthesia (PD) MC484
Delayed, Prolonged Pediatric Emergence Agitation: A Case Report
My Y. Liu, M.D., Bishar Haydar, M.D . University of Michigan, Ann Arbor, MI, USA.
Emergence agitation (EA) in children is a common postoperative complication typically presenting shortly
after emergence. We present an unusual case of delayed and prolonged EA presenting in a 16 month old
female with neuroblastoma after exploratory laparotomy with a well-functioning epidural catheter for
postoperative pain control. The patient was only minimally consolable with waxing and waning episodes
of agitation and was thrashing, moving purposelessly without awareness of her surroundings. Others
causes of agitation were ruled out and patient was treated successfully with ketamine. We review other
diagnostic and treatment modalities for postoperative and ICU delirium in children.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Pediatric Anesthesia (PD) MC485
Anesthetic Management for Staged Posterior Occipito-Cervical fusion and Endoscopic Endonasal
Odontoidectomy in a Child with Basilar Invagination
Yang Liu, M.D., Monte Chen, M.D . Baylor College of Medicine and Texas Children's Hospital, Houston,
TX, USA.
A 14 year old male with Klippel-Feil syndrome and basilar invagination was scheduled for staged
posterior and anterior cervical vertebrae stabilizations. Physical exam showed severe cervical flexion
deformity, limited neck mobility, short TM distance, and Mallampati class IV. Even with expected difficult
airway, initial FOB failed to identify airway structures and Glidescope failed to insert an ETT. The
combination of Glidescopy with FOB provides a better way to manage the difficult airway. This technique
was also used during subsequent procedures for persistent CSF leak and VP shunt. Surgery was also
complicated by left vertebral artery injury requiring massive blood transfusion.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Pediatric Anesthesia (PD) MC486
12-Years Old Jehovah’s Witness Undergoing Posterior Spinal Fusion for Severe Scoliosis Hemodilution Is the Only Accepted Choice for Blood Replacement
Yang Liu, M.D., Monte Liu, M.D . Baylor College of Medicine and Texas Children's Hospital, Houston, TX,
USA.
12 year old with severe scoliosis present for posterior spinal fusion. Her family is devout Jehovah's
Witness' and the parents declined to consent to blood but were amenable to hemodilution. Approximately
400 ml of autologous blood were obtained prior to incision. TIVA was used for intraoperative SSEP and
MEP monitoring. EBL was approximately 425 ml. In spite of the autologous blood, the patient‟s Hb was
5.4 once in the PACU. We decided not to transfuse due to the patient‟s stable hemodynamics and her
lack of symptoms. The patient was subsequently discharged on POD6 with a Hb of 6.1.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Fundamentals of Anesthesiology (FA) MC487
Anesthetic Management of an Adult with Edwards Syndrome/Trisomy 18: Case Report and Review
of the Literature
Vandy T. Gaffney, M.D., M.S . Department of Anesthesiology and Perioperative Medicine, Georgia
Regents University, Augusta, GA, USA.
Adult Edward's Syndrome patients require a comprehensive anesthetic plan by an experienced team of
medical professionals including an anesthesiologist, surgeon, cardiologist and otolaryngologist. All
aspects of anesthesiology should be evaluated prior entering the operating room. Comprehensive
preoperative optimization, adequate care provider communication and postoperative pain control are
critical to a successful anesthetic outcome. The anesthetic considerations in patients with Edward‟s
syndrome have been limited to pediatric anesthesiology. There is limited experience in the literature
available for the anesthetic management of adult Edward's syndrome patients. This case presentation
and discussion attempt to bridge that gap in knowledge.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Fundamentals of Anesthesiology (FA) MC488
Perioperative Anesthetic Management of a Patient with Osteogenesis Imperfecta Type III and
Chronic Pain Requiring an Intrathecal Morphine Pump
Samir J. Gandhi, M.D., Kennith N. Hiller, M.D . Anesthesiology, University of Texas at Houston, Houston,
TX, USA, Anesthesiology, University of Texas Health Science Center at Houston, Houston, TX, USA.
This is a 58 year old female with osteogensis imperfecta Type III presenting with a left hip fracture
requiring operative repair. This patient presents unique perioperative challenges given pre-existing
chronic pain treated with an intrathecal morphine dose of 12 mg per hour. The general implications of
intraoperative management of osteogenesis imperfecta including lateral positioning and regional
anesthesia will be discussed. In addition, the algorithmic care of acute on chronic pain management for
this patient will be presented.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Fundamentals of Anesthesiology (FA) MC489
Differential Diagnosis and Management of Persistent Intraoperative Hiccups: A Case Study
Marina K. Garas, Rano Faltas, M.D., Marc Fisicaro, M.D . University of New England College of
Osteopathic Medicine, Arlington, MA, USA, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
A 56 year old male with osteomyelitis of the spine presented to the operating room for an anterioposterior
L5 to S1 decompression and fusion. During the course of the surgery, the patient developed persistent
intense hiccups. Their magnitude became frequent and intense disrupting the surgical field. Differential
causes including somatosensory evoked potentials (SSEPs), hypercapnia, and electrolyte disturbance,
were explored and ruled out. This suggests a medication side effect from agents used such as Propofol
or clevidipine. Propofol has been previously implicated as a cause of intraoperative hiccups. Successful
management included administration of 100mg intravenous Lidocaine.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Fundamentals of Anesthesiology (FA) MC490
Management of the Difficult Airway Using Awake Endotracheal Intubation
Marina K. Garas, Student, Timothy Connelly, D.O . University of New England College of Osteopathic
Medicine, Biddeford, ME, USA, Roger Williams Medical Center, Providence, RI, USA.
Intubation of the bariatric patient with difficult airway and positive risk factors presents a challenge to the
anesthesiologist during the time of induction. A 38 year old female presented for laparoscopic gastric
bypass surgery after unsuccessful attempt to undergo surgery two weeks prior due to difficult airway. On
subsequent presentation, anesthesia evaluation prompted difficult airway protocol. Repeat trial of
anesthetic induction using awake intubation technique was chosen. While the awake endotracheal
Copyright © 2014 American Society of Anesthesiologists
intubation invests time and increased efforts to minimize patient discomfort, it can be utilized in situations
where routine induction of general anesthesia may propose high risk to the patient
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Fundamentals of Anesthesiology (FA) MC491
Bilateral Pneumothorax during an Awake Tracheostomy
Sebastian R. Gatica, M.D., Daniel Fernandez, M.D . Anesthesiology, University of Puerto Rico, San Juan,
PR, USA.
18-year-old male scheduled for emergent awake tracheostomy due to tracheal stenosis. PE: stridor and
dyspnea. PMH: Prolonged mechanical ventilation. SH: Tracheoplasty. CT:(fig 1). OR: ASA standard
monitors and oxygen. Stenosis was dilated using ETT #3.0, and finally ETT # 4.5. Bradycardia managed
with Atropine. Tracheal intubation was confirmed by respiratory excursion, and capnography. Left breath
sounds absent, ETT was repositioned, then replaced by tracheostomy tube. Propofol IV. Tachycardia,
worsening pulse oximetry and severe hypotension. Left breath sounds absent, pneumothorax was
diagnosed and needle was used for emergent decompression. CXR: bilateral Pneumothorax (fig 2).
Bilateral chest tube placement.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Fundamentals of Anesthesiology (FA) MC492
Intra-operative Contralateral Tension Pneumothorax in a 92-Year-Old Male during Ipsilateral VATS
Decortication
Lakshmi M. Geddam, M.D., Charles Baysinger, B.S., Tatiana N. Lutzker, M.D . George Washington
University Hospital, Washington, DC, USA.
92-year-old M with PMH significant for a left glomus jugulare tumor and neurogenic dysphagia presented
for a left VATS decortication of a left hemithorax effusion. Induction was complicated by a contralateral
pneumothorax and circulatory arrest. After aggressive resuscitation and chest tube placement, the patient
had return of circulation. Decortication was then completed, draining 2 liters of pus from the left thorax.
He was taken to the ICU, extubated POD 2, and discharged home on POD 17. This case reviews the
diagnosis of intraoperative pneumothorax and the concerns of lung decompression in a geriatric patient
with essentially one lung.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Fundamentals of Anesthesiology (FA) MC493
Neuromuscular Monitoring in Patient with Hemiplegia Secondary to Stroke
Paulo Alipio Germano Filho, M.D., Estêvão Braga, M.D., Ana Marques, Márcio Nagatsuka, M.D., Armin
Guttman, M.D., Raphael Cazagrande, M.D., Nubia Verçosa Figueiredo, Ph.D., Ismar Lima Cavalcanti,
Ph.D. . Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil, UFRJ, Rio de Janeiro, Brazil, UFF,
Niterói, Brazil.
The objective of this paper is to warn as to the neuromuscular monitoring in patients with lesions of the
central motor neurons, reporting a case of a woman aged 68, hemiplegic on the right (a result of a
stroke), who underwent a total laryngectomy and had monitoring both sides by sequence-of-four (TOF) at
the adductor muscles of the thumb. We found that after induction and complete muscle relaxation
evidenced in the healthy side, the affected side remained with TOF of 24%, and there was also wide
divergence in recovery time (TOF> 90%), 26 minutes(right) versus 64 minutes (left).
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Fundamentals of Anesthesiology (FA) MC494
Last Time They Put Me to Sleep, My Heart Stopped: The Management of Severe Pulmonary
Hypertension
Zachary S. Glicksman, M.D., Michael A. Olympio, M.D . Wake Forest Baptist Medical Center, WinstonSalem, NC, USA.
81 y/o 71 kg female ASA 4 with severe PHTN (RVSP 87 mmHg), a-fib with RVR on coumadin (INR 4.8),
diastolic CHF, COPD on home O2 and s/p aortic valve replacement presenting for percutaneous pinning
of her left hip fracture. H/o cardiac arrest during previous general anesthetic and after three days of
mechanical ventilation in the ICU sustained another arrest/resuscitation after extubation. After
optimization of arrhythmia and coagulation status, current anesthetic successfully managed with specific
attention to 1) stress-free slow onset continuous spinal; 2) preemptive arterial line monitoring; 3) BP
maintenance for coronary perfusion and 4) inspired pulmonary dilators.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Obstetric Anesthesia (OB) MC495
High Spinal after Negative Aspiration and Test Dose
Katie A. Lee, M.D., Irina Gasanova, M.D., Kimberly Yamanouchi, M.D . Anesthesiology and Pain
Management, The University of Texas at Southwestern, Dallas, TX, USA, The University of Texas at
Southwestern, Dallas, TX, USA.
A 24 year-old G2P1 presented for labor epidural, which was placed uneventfully. Catheter was
inadvertently displaced. Another epidural catheter was placed. Five minutes later with stable vital signs, 4
ml bupivacaine 0.25% and fentanyl 100 mcg were injected via the catheter. Fourteen minutes after
injection, patient developed dyspnea and "felt funny,” which was followed by apnea. High spinal was
suspected; patient was immediately intubated. Stat C/S called; baby delivered uneventfully. Thereafter,
patient went into asystole which responded immediately to epinephrine 1 mg and chest compressions.
Postoperatively, aspiration of epidural catheter returned clear fluid. Mother and baby did well.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Obstetric Anesthesia (OB) MC496
Coiling or Cesarean Section? Anesthetic Management of a 30-week Pregnant Female with Grade V
Intracerebral Hemorrhage
Rosanna Lee Nunziata, Tazeen Beg, M.D . Stony Brook University Hospital, Stony Brook, NY, USA.
The increased risk of Intracerebral Hemorrhage in a pregnant patient is controversial. It is a rare condition
that affects pregnant women at a rate of 6.1 per 100,000 deliveries and is responsible for 5-12% of all
pregnancy related deaths. Anesthetic management of such individuals can be challenging as there are
two patients involved and timely communication between all the services is important. Though maternal
hypotension is warranted, it may be injurious to the fetus. Currently, there are no definite guidelines and
management is limited to clinical judgement.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Obstetric Anesthesia (OB) MC497
Anesthetic Management of Single Ventricle Physiology in a Patient Undergoing Urgent Cesarean
Delivery
Lauren K. Licatino, M.D., William J. Mauermann, M.D., Katherine W. Arendt, M.D., David W. Barbara,
M.D . Mayo Clinic, Rochester, MN, USA.
A 30-year-old G4P3 woman presented at 25 4/7 weeks gestation for urgent Cesarean delivery for a
nonreassuring fetal heart rate tracing. Her cardiac history was notable for a Fontan procedure at age 11.
This pregnancy was complicated by atrial fibrillation, an early large placental abruption, and intrauterine
growth retardation. Following awake arterial line placement, satisfactory anesthesia was achieved using a
judiciously titrated epidural infusion of chloroprocaine and fentanyl. Delivery was uneventful. Single
Copyright © 2014 American Society of Anesthesiologists
ventricle physiology presents several challenges in the peripartum period that mandate an understanding
of the anatomy, physiology, anesthetic implications, and hemodynamic management goals.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Obstetric Anesthesia (OB) MC498
Changing Neurologic Phenomena in a Preeclamptic Patient with Recent Thromboembolic Stroke
Brandon K. Licht, M.D., Linda Polley, M.D., Baskar Rajala, M.D . Anesthesiology, University of Michigan,
Ann Arbor, MI, USA.
A 36-year-old G4P3 parturient at 29 weeks gestation required intubation for acute respiratory distress
syndrome secondary to pneumonia and diabetic ketoacidosis. A right atrial thrombus attached to a central
venous catheter was identified with transthoracic echocardiography after she developed a left-sided
hemiplegia with right frontoparietal ischemia on imaging. She subsequently developed preeclampsia with
severe features, aphasia, and focal neurological deficits. Given her increased risk of seizure with recent
cerebral ischemia, preeclampsia, and possible posterior reversible encephalopathy syndrome (PRES),
the neurology consultant recommended delivery. She underwent therapeutic cesarean delivery under
lumbar epidural anesthesia and was discharged to rehabilitation seven days later.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Obstetric Anesthesia (OB) MC499
Peripartum Decoy: Anaphylactoid Syndrome of Pregnancy Masquerading as Local Anesthetic
Toxicity
Christopher V. Maani, M.D., Daniel Raboin, M.D., Bradley Reel, M.D., Michelle Marino, M.D., Christopher
Nagy, M.D . Anesthesiology, San Antonio Uniformed Services Health Education Consortium (SAUSHEC),
San Antonio, TX, USA.
After admission for decreased fetal movement, a term 41-year-old G12P11 underwent induction of labor
and placement of labor epidural. Subsequent development of altered sensorium, hypoxia, and fetal
bradycardia were noted. With transport to OR for emergent c-section, epidural was titrated to surgical
block. The patient became stuporous, then non-responsive, with complete cardiovascular collapse and
progressive coagulopathy. Resuscitation included ACLS, massive transfusion, and damage control
surgery. The patient was transferred to ICU and eventually discharged home. This scenario fosters
discussion of the differential diagnosis for acutely decompensating parturients; LA toxicity, PE, or
Anaphylactoid Syndrome of Pregnancy which portends >80% mortality.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Obstetric Anesthesia (OB) MC500
Anesthetic Management of a Parturient with Eclampsia, HELLP Syndrome and Posterior
Reversible Encephalopathy Syndrome (PRES)
Venkat R. Mangunta, M.D., Yohel Hernandez, M.D., Tanya Lucas, M.D . Department of Anesthesiology,
Univ of Massachusetts, Worcester, MA, USA, Department of Anesthesiology, University of
Massachusetts, Worcester, MA, USA.
A 27 yo G4P0 at 26 weeks presented to the labor ward with seizures, hypertension, altered mental status,
and presumed HELLP syndrome. Initial CT scan was concerning for transverse sinus thrombosis (TST)
with follow-up MRI demonstrating significant vasogenic edema. Angiography was not immediately
available. Deterioration of mental status with worsening eclampsia led to the further work-up for TST and
possible anticoagulation. However fetal distress necessitated emergency cesarean section prior to these
interventions. Ultimately the patient was diagnosed with eclampsia/HELLP complicated by posterior
reversible encephalopathy syndrome. The patient improved after delivery. We describe PRES and a
review of current literature.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Obstetric Anesthesia (OB) MC501
Peripartum Cardiomyopathy in an Advanced Maternal Age Parturient - A Multidisciplinary
Approach
Laurie O. Mark, M.D., Aalok V. Agarwala, M.D., MBA. Anesthesia, Critical Care, and Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA.
53 year old G4PO at 38 weeks presented with a 3 day history of new onset shortness of breath,
orthopnea, PND, and swelling of her extremities. Physical exam and vitals revealed hypertension and
significant proteinuria. Transthoracic echocardiogram demonstrated a dilated left ventricle, diffuse
hypokinesis, and an EF of 32%. She was diuresed, placed on antihypertensive medications, and
scheduled for induction of labor. The management of a parturient of advanced maternal age with
peripartum cardiomyopathy requires a multidisplinary approach. The optimal mode and timing of delivery,
medical optimization, coordination of intraoperative care, and anticipation of postoperative needs must be
carefully considered.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Obstetric Anesthesia (OB) MC502
Survival of Patient with Suspected Amniotic Fluid Embolism during Urgent Cesarean Section
Travis H. Markham, Romana Baig, M.D., Karel Riha, M.D. . Anesthesiology, Univ of TX at Houston,
Bellaire, TX, USA, Anesthesiology, Univ of TX at Houston, Houston, TX, USA, Univ of TX at Houston,
Houston, TX, USA.
Patient presented for cesarean section with known uterine fibroids and practicing Jehovah's witness. Due
to patchy spinal anesthesia, patient underwent induction of general anesthesia without incident. With
extraction of the placenta and externalization of uterus, patient developed cardiopulmonary collapse with
bradycardia, desaturations, and only palpable pulses. With pharmacologic support, patient became
normotensive but on mechanical ventilation with FiO2 of 1.0 Pa02 remained in the 40s throughout the
operation. Surgery finished uneventfully and patient was extubated the following day in the ICU after
improved respiratory mechanics and determination that our patient did not develop a coagulopathy.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Obstetric Anesthesia (OB) MC503
Amniotic Fluid Embolism Resulting in Catastrophic Sympathetic Paralysis Refractory to Extreme
Measures of Shock Resuscitation
Apryl Martin, M.D., Ramsis Ghaly, M.D., Bretonya Phillips, M.D., Abed Rahman, M.D., Ned F. Nasr, M.D.,
Gennadiy Voronov, M.D . Anesthesiology and Pain Management, John H. Stroger Jr Hospital of Cook
County, Chicago, IL, USA, John H. Stroger Jr Hospital of Cook County, Chicago, IL, USA.
Amniotic Fluid embolism (AFE) is a rare but potentially life-threatening obstetric emergency. AFE is
classically thought to result from disruption of the barrier between maternal and fetal circulations during
normal labor, vaginal delivery or cesarean section, leading to embolic obstruction of pulmonary
vasculature by components of amniotic fluid. However, recent literature suggests that immunologic
activation coupled with vasoactive mediators may play a significant role in the pathophysiology of AFE.
This is the case of a 38 y.o. G4P2012 parturient with acute circulatory failure due to generalized
sympathetic paralysis that proved to be refractory to even extreme measures of resuscitation.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Pain Medicine (PN) MC504
Intraoperative and Postoperative Pain Control in a Patient on Suboxone presenting for Urgent
CABG
Ann M. Melookaran, M.D., Trevor M. Banack, M.D . Department of Anesthesiology, Yale New Haven
Hospital, New Haven, CT, USA.
57yo M with chest pain and chronic pain on suboxone presented urgently for CABG. Patient took
suboxone 24hrs prior surgery. During induction, fentanyl was administered in 100mcg increments looking
Copyright © 2014 American Society of Anesthesiologists
for medication effects. After 1,500mcg of fentanyl over 10min with no change in RR, BP, or HR, we
induced with propofol. BP was difficult to control early in the case prompting the administration of IV
tylenol, methadone, nitroglycerin, sevoflurane, and fentanyl 50mcg/kg/hr. Patient was extubated on
POD#1 with 10/10 pain. Ketamine infusion, IV tylenol, Gabapentin, Oxycodone sliding scale, and
Oxycontin were all initiated resulting in pain 3/10 after medication titration.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Pain Medicine (PN) MC505
Intrathecal Pump Overdose: Too Much Too Soon?
Cody A. Motley, M.D., Madison Russell, Student, Stephen Heimbach, M.D . Anesthesiology, University of
Oklahoma Health Sciences Center, Oklahoma City, OK, USA, Anesthesiology, University of Oklahoma
College of Medicine, Oklahoma City, OK, USA.
We present a 73 year old female with a history of chronic pain secondary to multiple lower extremity
surgeries treated with an intrathecal pain pump, who presented to her local emergency department overly
sedated. Extensive workup ruled out cerebrovascular accident and other etiologies. It was determined to
be a pain pump malfunction with subsequent overdose. Naltrexone boluses yielded dramatic resolution of
sedation prompting the need for a naltrexone infusion and transfer to our facility. Upon arrival, her pump
was accessed transdermally with the remaining morphine removed. The following day, the pump was
replaced with favorable results.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Pain Medicine (PN) MC506
Piriformis Muscle Injection for Treatment of Sciatica and Sacral pain
Eman Nada, M.D.,Ph.D., Michael Stone, M.D . Anesthesiology Department, University of Arkansas for
Medical Sciences, Little Rock, AR, USA.
A 47 year old female presented with low back pain that radiates to the right posterior hip and leg. A
Magnetic Resonance Imaging of the lumbar spine revealed an L5-S1 disc protrusion abutting the first
sacral nerve root. Medical treatment, lumber epidural steroids injections, and physical therapy failed to
give her any improvement.With the progress of time the patient started to complain of sacral pain, with
tenderness over the gluteal area. Ultrasound guided Piriformis muscle injection using bupivacaine and
methylprednisolone with stretching exercises resulted in a 70% pain relief in 3 weeks follow up that
continued to improve thereafter.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Pain Medicine (PN) MC507
58-year-old Patient with Refractory Chronic Central Neuropathic Pain With a Spinal Cord
Simulator with Intrathecal Baclofen, Ziconotide and Lamictal
Bahram Namdari, D.O., Jijun Xu, M.D.,Ph.D., Michael Stanton-Hicks, M.B.,B.S . Cleveland Clinic,
Cleveland, OH, USA.
58 year old with chronic burning bilateral lower extremity pain and spams. Patient has a history of chronic
central neuropathic pain and spasms from spinocerebellar ataxia. Patient did not respond to physical
therapy or pharmalogical treatment. An intrathecal baclofen pump was placed with improvement to
muscle spasms. Patient had a spinal cord stimulator placed with minimal pain relief. Therefore the patient
underwent a trial of intrathecal ziconotide that helped provide significant pain relief. Subsequently,
ziconotide was added to the baclofen intracthecal pump mixture. The patient reports improved pain and
spasm relief compared to before starting intrathecal baclofen and ziconotide mixture.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Pain Medicine (PN) MC508
59-Year-Old Male with Pelvic Crush Injury Requring a Third Revision of an Intrathecal Pump Due
to Pump Leakage Which Was Seen Only When a Lateral Pumpogram Was Ordered That Showed a
Creseent Moon Hypodensity Below the Pump on Imaging
Bahram Namdari, D.O., Jijun Xu, M.D.,Ph.D., Michael Stanton-Hicks, M.D . Cleveland Clinic, Cleveland,
OH, USA.
59 year old male who presents for a thrid time revision of his intrathecal pump catheter which was
replaced five times. He is being treated for chronic pelvic and lower extremity pain due to a crush injury
over twenty five years ago. After second revision, patient exerienced increased pain and discomfort. On
pumpogram, there was evidence of pump leakage due to the appearance of a cresent moon underneath
the pump when the patient was placed in the latheral position. No complications were noted during the
third revision procedure. Since the intrathecal pump catheter was revised his symptoms have improved.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Pain Medicine (PN) MC509
Leakage of Bone Cement into the Spinal Canal During Percutaneous Vertebroplasty
Junmo Park, Junggu Yi, M.D., Kwang-Uk Choi, M.D., Younghoon Jeon, M.D.,Ph.D., Dong Gun Lim,
M.D.,Ph.D . Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu, Korea,
Republic of.
A 72-year-old female with Kummell's disease at T12 and L3. During polymethyl methacrylate (PMMA)
injection under continuous fluoroscopic guidance, we recognized that the PMMA had spread out beyond
the posterior border of the T12 vertebral body, indicating PMMA leakage into the spinal canal. We
stopped injection and performed epidural catheterization immediately at the T12-L1 level to prevent
thermal injury. Through the epidural catheter, 3 ml of normal saline was injected every 3 min for 25 min
until the bone cement had fully hardened. After completing the percutaneous vertebroplasty, lower back
pain was completely resolved and she showed no neurological complications.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Pain Medicine (PN) MC510
Perioperative Pain Management of a Trauma Patient Undergoing Vivitrol® Therapy Using
Dexmedetomidine and Ketamine Infusion
Ronak D. Patel, M.D., Eugene R. Viscusi, M.D . Anesthesiology, Thomas Jefferson University Hospital,
Philadelphia, PA, USA.
A 22 year old male with a past medical history significant for previous heroin abuse, maintained on
Vivitrol® (Naltrexone XR Inj.) therapy, presented with severe pain secondary to orthopedic injuries. In
2010, the FDA approved Vivitrol (competitive opioid antagonist) for use in prevention of relapse to opioid
abuse. Once injected intramuscularly, Vivitrol maintains therapeutic levels for ~28 days. Patients on
naltrexone therapy are resistant to opioids and are challenges when in acute pain. We utilized continuous
infusions of ketamine and dexmedetomidine to achieve adequate analgesia. This case report
demonstrates a technique of providing pain management for patients on Vivitrol® therapy.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Pain Medicine (PN) MC511
Opioid Induced Hyperalgesia After Selective Neck Dissection
Matt Ploger, D.O., Anjali Patel, D.O., Hui Yuan, M.D . St. Louis University, St. Louis, MO, USA.
We describe a 66 yo male with PMH significant for CAD, HTN, GERD and recurrent tonsillar SCCa. He
presents to the OR for mandibulotomy, left SND, left radical tonsillectomy with radial free flap
reconstruction, tracheostomy, and split thickness skin graft. Intraoperatively the patient was maintained
on sevoflurane, N2O, and a low dose remifentanil infusion. Morphine was titrated in prior to emergence
and discontinuation of remifentanil. In the PACU, the patient became severely agitated, complaining of
Copyright © 2014 American Society of Anesthesiologists
extreme pain despite morphine, dilaudid, fentanyl, and Ativan. The patient then received a bolus of
dexmedetomidine, which was continued as an infusion overnight.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Pain Medicine (PN) MC512
Opioid Sparing Anesthetic for Patients at Risk for Opioid Abuse
Anne M. Que, C.R.N.A., Anthony Anderson, M.D.,Ph.D., Pascal Scemama De Gialluly, M.D . Anesthesia
and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA, Massachusetts General
Hospital, Boston, MA, USA.
AbstractA 51-year-old male with a medical history notable for bipolar disorder, hepatitis C, cirrhosis, prior
substance abuse, and squamous cell carcinoma presented for a right inguinal and pelvic lymph node
dissection. On the day of surgery, the patient requested an opioid-free anesthetic secondary to concerns
for substance abuse relapse. Epidural anesthesia was felt to be contraindicated secondary to cirrhosis.
The patient did not undergo an opioid-sparing anesthetic, had severe post-operative pain, and received a
large amount of opioids peri-operatively. We discuss an ideal anesthetic plan for this patient, the postoperative implications of different anesthetic techniques, and peri-operative opioid-sparing methods.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Pediatric Anesthesia (PD) MC513
Airway Management in a Child with Crouzon Syndrome Undergoing Monobloc Osteotomies and
Rigid External Distractor Device Placement
Monica Porter, M.D., Sumanna Sankaran, M.D . Anesthesiology, University of Michigan, Ann Arbor, MI,
USA.
8-year-old ASA 3 female undergoing midface advancement surgery. Post extubation began partially
obstructing. Placement of a nasal trumpet resulted in bleeding and near complete airway obstruction. The
child required 4 people and an oral airway to mask ventilate due to maxillary cables. A fiberoptic scope
revealed a possible sheared off nasal polyp partially obstructing the airway at the level of the vocal cords.
The patient was reintubated and taken to PICU. She was later found to have a CSF leak, a possible
complication of positive pressure mask ventilation.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Pediatric Anesthesia (PD) MC514
Spine Surgery in a Pediatric Patient With Congenital Heart Disease, Genetic Syndrome, and
Thrombophilia
Walter S. Quiroga Robles, M.D., Chandrappa Balikai, M.D., Marina Moguilevitch, M.D . Anesthesiology,
Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.
16 year old female with CHARGE syndrome presented for posterior spinal fusion, instrumentation with
intraoperative neuromonitoring. Her history was significant for coloboma, multiple cardiac defects repair,
developmental delay, hypogonadotrophic hypogonadism, deafness, Factor V Leiden, asthma, RBBB,
Mobitz II AV block with PPM, pulmonary hemosiderosis, pANCA positive, microscopic polyangiitis.
Intraoperative challenges included managing the massive blood loss in hypercoagulable patient,
neuromonitoring interaction with pacemaker function, need for possible resuscitation in prone position.
Total intravenous anesthesia was used with invasive monitoring. There were no adverse intraoperative
events despite transient dysrhythmia. Patient was transfused for significant blood loss and transferred to
PICU intubated.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Pediatric Anesthesia (PD) MC515
Anesthetic Management of a Patient with Leigh's Disease in the setting of Wolff-Parkinson-White
Syndrome: A Case Report
Benjamin C. Record, M.D., Ryan D. Burkland, M.D., Peter R. Lichtenthal, M.D . Anesthesiology,
University of Arizona, Tucson, AZ, USA.
Copyright © 2014 American Society of Anesthesiologists
Leigh‟s Disease (subacute necrotizing encephalomyelopathy) is a rare childhood mitochondrial disorder
resulting in neurodegeneration, myopathies, and potential pathology of all organ systems, which requires
careful evaluation by the anesthesiologist. We present a case of an 11 year-old female with Leigh‟s
Disease and WPW requiring general anesthesia for radiofrequency ablation. With little evidence-based
recommendations regarding anesthesia in this population, we review current literature and case reports.
We discuss the misguided concern for malignant hyperthermia, risks/benefits of intravenous and
inhalational agents in mitochondrial disorders, risk of respiratory failure, risk of prolonged neuromuscular
blockade, and danger of hyperkalemia and rhabdomyolysis with myopathies.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Pediatric Anesthesia (PD) MC516
The Use of Dexmedetomidine in a Neonate with Congenital Lobar Emphysema
Heather M. Reed, M.D., Joy Allee, M.D . Anesthesiology, University of Florida, Gainesville, FL, USA.
We describe a unique anesthetic technique for LUL resection in a neonate with congenital lobar
emphysema (CLE).The patient presented with difficulty breathing and a CT showed LUL hyperinflation.
She was induced with 5% Sevoflurane and a 1mcg/kg IV bolus of dexmedetomidine allowing for
spontaneous ventilation. A 3.5 uncuffed ETT was intentionally right main-stemmed.There are few case
reports detailing anesthetic management for CLE. We achieved spontaneous ventilation during induction
and extubated in the OR. Dexmedetomidine allowed us to decrease the risk of hyperinflation, limit use of
inhalational agent and reduce the amount of intraoperative opioid dosing.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Pediatric Anesthesia (PD) MC517
Airway Management for a Child with a Large Tonsillar Mass Prior to Sclerotherapy
Janice Riso, M.D., Franco Resta-Flarer, M.D., Jonathan Lesser, M.D., Jinu Kim, M.D., Junping Chen,
M.D.,Ph.D . Anesthesiology, St. Luke’s – Roosevelt Hospital Center, Mount Sinai Health System, New
York, NY, USA.
This is the case of a 7y/o male with a left sided tonsillar mass undergoing sclerotherapy with bleomycin.
Induction and intubation occurred in the OR with ENT prepared for emergency tracheostomy. A
peripheral IV was placed and midazolam given. Dexmedetomidine and remifentanil infusions were started
with the patients head turned to the left, maintaining spontaneous ventilation. After a propofol bolus,
visualization of the larynx was obtained with a glidescope while the endotracheal tube was advanced into
the trachea using a fiberoptic bronchoscope. Once the airway was secured, he was transported to MRI
and then to the angiography suite for sclerotherapy.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Pediatric Anesthesia (PD) MC518
Anesthetic Management of Newborn Undergoing Cloacal Exstrophy Repair
Michael K. Ritchie, M.D., Ju (Jeff) Gao, M.D., Ahmed Attaallah, M.D., Osama Al-Omar, M.D., Pavithra
Ranganathan, M.D . Anesthesiology, West Virginia University, Morgantown, WV, USA, Urology, West
Virginia University, Morgantown, WV, USA.
We describe the anesthetic management of one day old 2.18kg male born with hemivertebrae thoracic
spine, sacral agenesis, L renal agenesis, agenesis of bladder, and omphalocele consistent with cloacal
exstrophy. Fluid management, blood product management, anesthetic agent choice, temperature
maintenance, and vascular access were all considerations in this complex case. In addition, the case was
complicated by oxygen desaturation due to partial right upper lobe collapse after central line placement.
The patient underwent successful staged repair of cloacal exstrophy.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Pediatric Anesthesia (PD) MC519
Anesthetic Management for a Patient With Anti-NMDA Encephalitis and Suspected Neuroleptic
Malignant Syndrome Undergoing Malignant Ovarian Germ Cell Tumor Resection: A Case Report
Victor Rivero, M.D., Hector Casiano, M.D., Evelyn Carrero, M.D . Anesthesiology Department, University
Of Puerto Rico, San Juan, PR, USA.
Anti-NMDA encephalitis is commonly related to the presence of a tumor. Children and young adults are
equally at risk. Patient with associated tumor should be treated with surgical resection. We report a 13
year old girl with anti-NMDA encephalitis and suspicious of Neuroleptic Malignant Syndrome scheduled
for a malignant ovarian germ cell tumor resection. The anti-NMDA encephalitis has a wide range of
differential diagnosis mainly due to its constellation of symptoms. A rare association of this autoimmune
encephalitis with a malignant germ cell tumor and the presences of NMS makes our case a challenge in
terms of anesthetic management.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Pediatric Anesthesia (PD) MC520
Massive Pulmonary Embolism in a Healthy Teenager: Anesthetic Implications and Management
Sara B. Robertson, M.D., Christopher Fiedorek, M.D., Anita Akbar-Ali, M.D., Saif Siddiqui, M.D., Tariq
Parray, M.D., Jesus Apuya, M.D . Pediatric Anesthesiology, Arkansas Children's Hospital, Little Rock,
AR, USA, Anesthesiology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA.
A previously healthy 17-year-old male presented with chest pain and shortness of breath. Oxygen
saturation was 80% and ABG revealed a PaO2 of 35 mmHg. Interventional radiology, cardiology,
heme/oncology, pediatric intensive care, and anesthesiology were consulted. ECMO team was notified
and was put on standby. General anesthesia was induced with propofol and ketamine and maintained
with sevoflurane and fentanyl. IR performed pulmonary angiography and injected alteplase into both main
pulmonary arteries. At the end of the procedure, he had an episode of cardiovascular collapse requiring
brief chest compressions and a dose of epinephrine with return of spontaneous circulation.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Pediatric Anesthesia (PD) MC521
The Anesthetic Management of a Child with Ohtahara Syndrome and Severe Stridor
Usha Saldanha, M.D., Shridevi Pandya Shah, M.D., Vasanti Tilak, M.D., Ankit Jain, M.B.,B.S .
Anesthesiology, Rutgers- New Jersey Medical School, Newark, NJ, USA, Anesthesiology, UMDNJ-New
Jersey Medical School, Newark, NJ, USA.
Ohtahara syndrome is a rare pediatric condition also known as early infantile encephalopathy. The classic
EEG finding is a burst suppression pattern. We are presenting an unusual association of Ohtahara
syndrome with generalized hypotonia and severe inspiratory and expiratory stridor in an infant for
diagnostic bronchoscopy. This case involves an 11-month-old infant with an uncomplicated birth history,
and past medical history significant for failure to thrive, severe generalized hypotonia leading to motor
delay with audible stridor. Patient has a known history of laryngomalacia, arthrogryposis, and difficult
intravenous access. Bronchoscopy was performed and showed severe airway collapse.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Regional Anesthesia and Acute Pain (RA) MC522
Help! A Stuck Epidural Catheter
Jennifer Y. Wu, M.D., Gurdev Rai, M.D . Anesthesiology, University of Colorado, Denver, CO, USA.
We describe a case of a trapped Flex-tip epidural catheter in a 67 year old patient transferred from an
outside hospital. There, patient had undergone difficult thoracic epidural placement with paramedian
approach without definitive pain relief. Upon transfer, epidural removal was attempted in left and right
lateral decubitus positions, lateral flexed position. Epidural catheter stayed at 13 cm at the skin. PA and
lateral films of the catheter did not visualize epidural tract. Injection of sterile saline with patient in sitting
position finally resulted in successful removal.
Copyright © 2014 American Society of Anesthesiologists
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Regional Anesthesia and Acute Pain (RA) MC523
Novel Method of Ultrasound-Guided Supra-Inguinal Fascia Iliaca Block
Suraj M. Yalamuri, M.D., Stephen Gregory, M.D., Stuart Grant, M.B.,Ch.B . Duke Anesthesiology,
Durham, NC, USA.
Currently, fascia iliaca block is performed by injecting a large volume of local anesthetic inferior to the
inguinal ligament. This technique relies on cephalad spread of the local anesthetic to block the lateral
femoral cutaneous nerve (LFCN). Anatomical dissections and high resolution ultrasound studies have
shown variability in the course and branching of the LFCN inferior to the inguinal ligament. We present a
novel, suprainguinal, ultrasound-guided technique that reliably blocks the LFCN and the femoral nerve
with a lower volume of local anesthetic. We have used this technique to successfully provide
postoperative analgesia in a patient undergoing total hip arthroplasty.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Regional Anesthesia and Acute Pain (RA) MC524
Epidural Blood Patch for Spontaneous Intracranial Hypotension and Headache in a Patient with
Neurofibromatosis
Qi Zhang, M.D., Daryl Smith, M.D . Anesthesiology, University of Rochester, Rochester, NY, USA.
The patient is a 58 year old male with a history of neurofibromatosis who presented with severe, bifrontal
headaches refractory to conservative treatment and no prior history of neuraxial trauma. Neurology was
consulted with subsequent MRI confirming diagnosis of intracranial hypotension, the incidence of which is
increased in neurofibromatosis. The Acute Pain Service was consulted for placement of an epidural blood
patch which was performed with the injection of 25ml of autologous blood under sterile conditions. The
patient reported relief of his symptoms within 10 minutes. He was discharged home with complete
headache resolution on no analgesics.
Saturday, October 11, 2014
3:00 PM - 3:10 PM
Neuroanesthesia (NA) MC525
Anesthetic Considerations and Management of Cervical Spine Fracture in a patient with KlippelFeil Syndrome
David EJ Stoike, D.O . Anesthesiology, University of Arizona, Tucson, AZ, USA.
A 53 year old male presented with a fracture through fused C3-C7 cervical vertebrae. Airway exam was
limited secondary to unstable neck and C-collar covering the mouth but revealed a short neck and chin
against chest.Awake fiber-optic nasal intubation was planned. Mask ventilation was assumed impossible.
The patient‟s airway was anesthetized. Direct airway nerve blocks could not be performed secondary to
habitus. Nasal passages were anesthetized and dilated and Fiber optic bronchoscope and ETT were
advanced through the cords easily and secured. The operative course was uneventful. Patient was
extubated fully awake in the OR.
Saturday, October 11, 2014
3:10 PM - 3:20 PM
Neuroanesthesia (NA) MC526
Successful Anesthetic Management of Electroconvulsive Therapy for a Patient With Severe
Pulmonary Hypertension Using a Continuous Infusion of Remifentanil
Mayumi Suzuki, M.D., Jiro Kurata, M.D., Koshi Makita, M.D . Anesthesiology, Japanese Red Cross
Musashino Hospital, Musashino City, Japan, Anesthesiology, Tokyo Medical and Dental University,
Tokyo, Japan.
A 23-year-old female patient was presented for electroconvulsive therapy (ECT) to treat depression and
catatonic stupor. She had severe idiopathic pulmonary hypertension requiring infusion of prostacyclin and
inhalation of oxygen. On induction with propofol we intubated her trachea to enable emergency
administration of nitric oxide, and maintained general anesthesia with sevoflurane and remifentanil to
suppress excessive stress response to an electric shock. She survived 14 sessions of ECT on separate
Copyright © 2014 American Society of Anesthesiologists
days with no signs of pulmonary hypertensive crisis. An increase of systolic blood pressure was
effectively suppressed to an average of 16%. She recovered from stupor without any complications.
Saturday, October 11, 2014
3:20 PM - 3:30 PM
Neuroanesthesia (NA) MC527
Unexpected Hypotension During Spine Surgery in a Patient with Unknown Dynamic Left
Ventricular Outflow Obstruction
Karl H. Takabayashi, M.D., Michail N. Avramov, M.D.,Ph.D . Anesthesiology, Loyola University Medical
Center, Maywood, IL, USA.
We present a case of unexpected hypotension during lumbar laminectomy and fusion in a patient with
preoperatively unknown systolic anterior motion of the mitral valve (SAM) and left ventricular outflow tract
obstruction. The sudden profound hypotension episode responded to epinephrine and intravenous fluids.
Intraoperative TEE was useful in showing not an ischemic, but a hyperdynamic left ventricle with nearobliteration of the chamber during systole. Post-operative workup confirmed LV hypertrophy, SAM,
moderate mitral regurgitation and LVOT gradient of 144mmHg.We discuss the preoperative evaluation
(unremarkable echocardiogram and angiogram, two-years prior) and the role of TEE in management of
unexpected intraoperative hypotension.
Saturday, October 11, 2014
3:30 PM - 3:40 PM
Neuroanesthesia (NA) MC528
Abrupt Onset of Diabetes Insipidus in the Setting of Spinal Fusion Surgery
Michael Tan, M.D., Peter M. Popic, M.D . Department of Anesthesiology, University of Wisconsin Madison, Madison, WI, USA.
We report a 15-year-old boy with sudden onset diabetes insipidus (DI) during spinal fusion surgery. His
intraoperative serum Na was 148 mmol/L and urine output was 3.5L over an 8-hour period. His urine
osmolality was 150 mOsm/kg. He was given IV desmopressin and his urine output and electrolytes
normalized in the next 24 hours. Abrupt onset of DI in the setting of non-pituitary related surgery is
unusual. Unrecognized DI can result in fluid and electrolyte imbalance, with potential to cause permanent
CNS damage and death. Treatment with desmopressin in central DI can halt the electrolyte imbalance
and prevent neurologic damage.
Saturday, October 11, 2014
3:40 PM - 3:50 PM
Neuroanesthesia (NA) MC529
Pulmonary Hypertension Exacerbation In a Patient with Unstable Cervical Spine Presenting For
Cervical Spine Fusion
Mohamed S. Tolba, M.D., Esam Abdelnaeem, M.D . Anesthesiology, UAMS, Little Rock, AR, USA,
UAMS, Little Rock, AR, USA.
A 32-year old, 70-kg woman presented to OR for cervical decompression. Her past history is significant
for severe idiopathic pulmonary hypertension. Preoperative right heart catheterization demonstrated an
elevated mean PAP of 50 mm Hg. Patient had unstable C1-C2 cervical spine. Anesthesia was maintained
with both Sevoflurane 0.4 MAC and TIVA, in the form of Remifentanil and Propofol infusion. At the end of
surgery, TIVA infusion was stopped and five minutes later, BP dropped from 130/70 to 50/10, SPO2
dropped from 97% to less than 60%. Hemodynamic deterioration was treated with Epinephrine and
Milrinone and patient moved intubated to ICU.
Saturday, October 11, 2014
3:50 PM - 4:00 PM
Neuroanesthesia (NA) MC530
Patient with Pseudotumor Cerebri Presenting for Possible Post-Dural Puncture Headache
Matthew W. Ufberg, M.D., Madhavi Gurram Alu, M.B.,B.S., Abiona Berkeley, M.D., Jonathan White, D.O.,
Vincent Cowell, M.D . Anesthesiology, Temple University Hospital, Philadelphia, PA, USA.
Anesthesiology consult was requested for a 21 year old Gravida 1, Para 0 at twenty five weeks gestation
with complaint of headache. Approximately two weeks prior, the patient complained of headache. She
Copyright © 2014 American Society of Anesthesiologists
was noted to have moderate papilledema and was referred to Neurology for evaluation of possible
pseudotumor cerebri. Lumbar puncture was performed by the Neurology service with opening pressures
of 42 cm H2O which were decreased by the Neurology service at that time to 18 cm H2O. Anesthesiology
consult was thereafter requested for evaluation of the patient for possible blood patch.
Saturday, October 11, 2014
4:00 PM - 4:10 PM
Neuroanesthesia (NA) MC531
Inadvertent Carotid Artery Compression Detected by Cerebral Oximetry (Fore-Sight)
Xueyuan S. Wang, M.D., Aaron J. Sandler, M.D.,Ph.D . Anesthesiology, Duke University Medical Center,
Durham, NC, USA.
A 66 year old male presented for combination carotid endarterectomy/ thyroidectomy for simultaneously
diagnosed severe right carotid artery stenosis and papillary thyroid cancer. Using cerebral oximetry
(SCO2) as an adjunctive monitor, we observed the reading on the ipsilateral side decrease significantly
during right carotid artery clamping for shunt placement and shunt removal but return to baseline while
the shunt was in place and after the endarterectomy was completed. Later in the case, another sudden
decrease in right sided SCO2 value was noted and led to the determination that a poorly positioned
retractor was impinging on the right common carotid artery.
Saturday, October 11, 2014
4:10 PM - 4:20 PM
Neuroanesthesia (NA) MC532
39-Year-Old Female at 32 Weeks Gestation for Emergency Thoracic Decompressive Laminectomy
and Tumor Resection
Patricia Frances Wawroski, M.D . Anesthesiology, Valley Baptist Medical Center, Harlingen, TX, USA.
39 year old female G6P4 at 32 weeks gestation presented withacute thoracic spinal cord compression
from metastatic breast cancer. She had recently been discharged from the hospital to outpatient
chemotherapy. The day after discharge she presented to the ER with paralysis and loss of sensation to
the lower extremities. After MRI confirmation of spinal cord compression, patient was scheduled for
emergent decompressive thoracic laminectomy. After discussion with the care team, the decision was
made to perform cesarean section followed by thoracic surgery. At the conclusion of the case, she was
extubated and transferred back to the SICU.
Saturday, October 11, 2014
4:20 PM - 4:30 PM
Neuroanesthesia (NA) MC533
Perioperative Concerns for a Patient with a Deep Brain Stimulator Presenting for Emergent
Appendectomy
Robert H. Weaver, M.D., Joshua Bigham, D.O., Jenifer Jewell, M.D., Cara Sparks, M.D., Brett Elmore,
M.D. . Anesthesiology, University of Kentucky, Lexington, KY, USA, Palmetto Health, Greenville, SC,
USA, University of Kentucky, Lexington, KY, USA.
Deep brain stimulators (DBS) are implanted electrical devices that are increasingly used to treat
movement disorders and, more recently, psychiatric disturbances. They are FDA-approved for the
treatment of tremor, both essential and that associated with Parkinson‟s disease, dystonia, and
obsessive-compulsive disorder; they also have novel uses in treating chronic pain and major depression.
As such devices become more commonplace, anesthesiologists will encounter them with greater
frequency. We present a case of a 48 year old male with a deep brain stimulator implanted for cerebral
palsy who presented for emergent laparoscopic appendectomy and its anesthetic implications every
anesthesiologist must know.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC05
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Neuroanesthesia (NA) MC534
Transient Post-Operative Visual Loss in the Supine Patient
Ammar A. Alamarie, M.D., Tracy Buckingham, M.D . Anesthesiology, SUNY Upstate Medical Center,
Syracuse, NY, USA.
We present a 66 year old male with a history of multiple cancers, hypertension, and ascending aortic
aneurysm who underwent radical cystoprostatectomy for recurrent transitional cell carcinoma of the
bladder and an ileal conduit in the supine position. The procedure was complicated by excessive blood
loss and hypotension, which was poorly responsive to resuscitation. Moreover, he had transient
postoperative visual loss which resolved five days post-op. As the baby boomers continue to grow older
with multiple medical comorbidities, we will continue encounter these patients in the OR. A current
literature review of perioperative visual loss was conducted.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Neuroanesthesia (NA) MC535
Sickle Cell Disease and Interventional Neuroradiology-Anaesthetic Challenges
Rajneesh Bankenahally, M.D., Katie Clift, Natish Bindal, Paul Dias. Anaesthetics, Queen Elizabeth
Hospital, Birmingham, United Kingdom.
Sickle cell disease is an inherited haemoglobinopathy and these patients are known to have
complications during anaesthesia and surgery. Risks associated with this disease during the
intraoperative period are well known. We describe the anaesthetic management of a 34 year old female
patient with severe sickle cell disease undergoing endovascular coiling for cavernous sinus aneurysm
and highlight the challenges particular to this type of procedure. This patient had multiple sickle cell crises
previously and was also a known difficult venous access. Patient had a successful procedure as a result
of careful planning and multidisciplinary team involvement.
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Neuroanesthesia (NA) MC536
A Challenging Triad: Moyamoya, Morbid Obesity and a Lenghty Procedure
Alexandra E. Baracan, M.D., Benjarat Changyaleket, M.D . University of Illinois at Chicago, Chicago, IL,
USA.
Moyamoya disease is a rare condition, with unknown pathophysiology, manifesting as progressive and
occlusive disease of the major cerebral vessels. Moyamoya may cause ischemic strokes or TIAs, cerebral
hemorrhages, seizures, and refractory headaches. We present the case of a 32 year old, morbidly obese
female- BMI 65, with recently diagnosed moyamoya disease, who presented for cerebral bypass surgery.
The anesthetic challenges in this case were related not only to an already impaired cerebral blood flow,
but also to the patient‟s morbid obesity and the length of the procedure. The details of the anesthetic
management are discussed.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Neuroanesthesia (NA) MC537
Intraoperative Diagnosis of Pseudocholinesterase Deficiency in an Octogenarian Undergoing
Total Intravenous Anesthesia and the Implications for Neuromonitoring
Copyright © 2014 American Society of Anesthesiologists
Demetrios A. Koutsospyros, M.D., Matthew Wecksell, M.D . Anesthesiology, New York Medical College at
Westchester Medical Center, Valhalla, NY, USA, Anesthesiology, Westchester Medical Center, Valhalla,
NY, USA.
While undergoing an L2 - S1 laminectomy and fusion, our patient was diagnosed with a previously
unknown homozygous pseudocholinesterase deficiency. This enzyme deficiency manifested itself with
prolonged motor blockade after the administration of succinylcholine, which prevented us from obtaining
intraoperative motor and electromyelography potentials. As we were utilizing a total intravenous
anesthetic with propofol and remifentanil, we had further concerns about how this patient's enzyme
deficiency would affect the metabolism of remifentanil and other esters that we might administer to her.
Eight hours after our initial dose of paralytic, the patient had good spontaneous ventilatory function and
was uneventfully extubated.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Neuroanesthesia (NA) MC538
Sitting Craniotomy, Perioperative Neuromonitoring During Neurosurgical Procedures and Related
Complications
Anna Barczewska-Hillel, M.D . Anesthesiology, Mount Sinai Roosevelt, New York, NY, USA.
29 Y.O. female with h/o von Hippel Lindau disease presented with posterior fossa hemangioblastoma.
Surgeon requested sitting position during the procedure and perioperative neurophysiologic monitoring.At
the end of the procedure surgeon concerned about brain stem injury requested postoperative mechanical
ventilation.After soft bite block was removed patient had antero-lateral tongue laceration requiring surgical
repair.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Neuroanesthesia (NA) MC539
Cardiac Rhythm Abnormalities: Challenges for Management in the Intraoperative Magnetic
Resonance Imaging Environment
Shreyas Bhavsar, D.O., Marc Rozner, M.D., Anh Dang, M.D . Anesthesiology and Perioperative
Medicine, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
Intraoperative magnetic resonance imaging (IMRI) for neurosurgical procedures allows for brain imaging
to determine anatomy and extent of tumor resection. This unique environment requires specialized
equipment, personnel, and a high level of safety awareness. We present a case of a patient scheduled for
craniotomy with IMRI who developed profound bradyarrhythmia after induction of anesthesia. Because
this arrhythmia required temporary pacing support, the IMRI was cancelled. The case was subsequently
rescheduled in a regular operating room using transesophageal atrial pacing support. The case highlights
the indications for intraoperative MRI and the limitations inherent in this environment for patient care.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Neuroanesthesia (NA) MC540
Anesthetic Management of a Jehovah’s Witness with an Ahmed Valve for Glaucoma Undergoing a
Prone Cervical Fusion
Kevin A. Blackney, M.D., Daniel Saddawi-Konefka, M.D., MBA. Department of Anesthesia, Critical Care
and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
69yo Jehovah‟s Witness female, h/o obesity, anemia, hypertension, glaucoma (Ahmed valve OD), and
macular degeneration, presented w/ urinary incontinence and BUE numbness due to severe cervical
stenosis, scheduled for urgent multilevel posterior cervical laminectomy. She was legally blind, capable of
ADLs/IADLs. She refused all blood products and believed her valve was nonfunctional; we requested
Ophthalmology consult, discussed with her and her husband the risk of POVL. We discussed blood
conservation and case duration w/surgeons. MAP was kept within 20% of baseline, head in Mayfield pins
with no pressure on eyes, reverse Trendelenberg position, performed immediate and staged follow-up
exams.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Neuroanesthesia (NA) MC541
Perioperative Management of Homicidal Patient: Cingulotomy for Obsessive-Compulsive Disorder
Cheryl E. Bline, M.D., Tao Shen, M.D., Olof Viktorsdottir, M.D . Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, MA, USA.
63 year-old man, 6‟4” and 200 pounds, non-verbal and chronically institutionalized for disabling obsessive
compulsive disorder and schizophrenia with homicidal tendencies, presented for cingulotomy after failing
medical and psychiatric treatments. Surgical consent was obtained following protracted legal
interventions given the nature of the surgery and the patient‟s lack of insight. Patient remained with
familiar institutional personnel and two security guards while admitted. Perioperative challenges included
IV insertion, monitor placement, sedation, transport, extubation and post-operative management given his
history of violence. This case demonstrates the importance of tailored anesthesia management and
multidisciplinary approach to maintain safety of patient and hospital staff.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Neuroanesthesia (NA) MC542
Awake Craniotomy with Ultrasound Guided Scalp Block for Eloquent Cortex Tumor Excision
Robert F. Bowers, M.D., Jinu Kim, M.D., Jonathan Lesser, M.D., Ali Shariat, M.D . Department of
Anesthesiology, Mount Sinai St Lukes Roosevelt Hospital Center, New York, NY, USA.
A 32 year old female with a tumor involving the eloquent cortex presented for tumor excision.
Preoperatively, an ultrasound guided scalp block with bupivacaine was performed to ensure adequate
surgical field analgesia. Intraoperatively, low dose remifentanil and dexmedetomidine was infused for
maintenance of analgesia and anxiolysis with consciousness and responsiveness. In conjunction with the
neurologist, the neurosurgeon was able to differentiate the tumor from areas of speech due to patient
cooperation. Aggressive surgical resection was possible without deleterious effects to speech centers.
The patient recovered well and was discharged from the intensive care unit on POD 2.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Cardiac Anesthesia (CA) MC543
An Abnormal Case of Presumed Malignant Hyperthermia After Cardiac Bypass
Gabriel I. Goodwin, M.D . Anesthesia, Montefiore Medical Center, Bronx, NY, USA.
59M w/unstable angina for CABG x2. PMHx HTN, CAD, R CVA, HCV, PE on A/C, w/prior emergent aortic
dissection repair. Induction and intubation were performed w/o complication. Isoflurane was used for
maintenance. Pt was noted to be rigid and hypercapnic at end CPB. Pt. hyperventilated and GA switched
to TIVA. Upon transfer to ICU, pt. became tachycardic, acidotic and febrile. MH episode resolved
w/cooling blankets & Tylenol w/o the need for Dantrolene. However, pt. had persistent fevers and
seizures until POD 3. All cultures and imaging were negative.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Cardiac Anesthesia (CA) MC544
A Case of Left Ventricular Outflow Tract Mass
Taras Grosh, M.D., Alexander Wolf, M.D., Srinivasa B. Gutta, M.D . Anesthesiology, Baystate Medical
Center, Tufts University School of Medicine, Springfield, MA, USA.
A 82 year old female otherwise asymptomatic was found to have a soft flow murmur on clinical
examination. The follow up echocardiogram revealed a mobile mass originating from the inter-ventricular
septum in the left ventricular outflow tract. Mobility of the mass was an indication for early resection to
avoid the risk of systemic embolization. Under general anesthesia, on CPB the mass was resected
completely. TEE was performed before and after removal of the mass. Post CPB, TEE revealed complete
resection of the mass. The known possible complications of myxoma resections are systemic
embolization, VSD, and recurrence.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Cardiac Anesthesia (CA) MC545
Iatrogenic Ischemic Coronary Lesion After Mitral Valve Replacement and MAZE
Barbara A. Guzman, D.O., Jayanta Mukherji, M.D., Pierre LeVan, M.D . Loyola Univ Med Ctr, Maywood,
IL, USA.
A 55 year old male with pulmonary hypertension, hyperlipidemia, chronic atrial fibrillation, severe mitral
stenosis, and aortic regurgitation underwent mitral valve/aortic valve replacement with bioprosthetic
valves, Maze procedure. Upon attempting to wean from CPB, TEE showed new severe left ventricular HK
involving the lateral, inferolateral walls. EKG showed new left bundle branch block with nonspecific ST
changes. The patient remained in cardiogenic shock with inability to separate from CPB despite maximal
inotropic support. Following lateral wall revascularization, the EKG abnormalities resolved and RWMA
partially recovered facilitating successful weaning from CPB.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Cardiac Anesthesia (CA) MC546
Anesthestic Challenges of a Patient with Ebstein’s Anomaly undergoing Significant Cardiac
Surgery
Ahmed Haque, M.D., Harold Fernandez, M.D., Igor Izrailtyan, M.D . Stony Brook University Hospital,
Stony Brook, NY, USA.
Ebstein's anomaly is a rare congenital heart defect which results in the displacement of the leaflets of the
tricuspid valve. This distortion can conclude in a morphologically abnormal RV also known as atrialization
and functional aberrations of the tricuspid valve. Our case describes 37 yo female with Ebstein's anomaly,
patent foramen ovale, severe right ventricular dysfunction, severe tricuspid regurgitation, pulmonary
hypertension, and atrial septal defect undergoing tricuspid valve replacement. Right ventricular
dysfunction, sensitivity to alterations in preload and afterload, arrythmias, and the choice of inotropes are
a few issues that require appropriate foresight in anesthestic preparation for such a patient.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Cardiac Anesthesia (CA) MC547
Subclavian Artery Occlusion Intraoperatively Manifested by Arterial Line Dissipation and
Decreased Flow Through a New LIMA-LAD
Ahmed Haque, M.D., Harold Fernandez, M.D., Igor Izrailtyan, M.D . Stony Brook Univ. Hospital, Stony
Brook, NY, USA.
Upper extremity arterial thrombosis is exceedingly rare and unexpected complication during CABG and
the consequences provide challenges for the management of the patient both intraop and postop. Our
case is 66 yo with PMH of afib, diabetes, and morbid obesity that underwent coronary artery bypass
surgery. It was noted that the radial arterial line exhibited blunted waveforms and inappropriate pressures
while concurrently the flow through the new LIMA-LAD markedly decreased. Postop, the patient had a
cold hand and dopplers done on the radial and ulnar arteries failed to register. CT angiography
demonstrated an occluded left subclavian artery as the culprit.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Cardiac Anesthesia (CA) MC548
When ACLS Fails in the Setting of Cardiovascular Collapse due to Anaphylaxis with Systolic
Anterior Motion of the Mitral Valve
Shervin R. Harandi, M.D., Maya Suresh, M.D., Sandeep Markan, M.D., Raja Palvadi, M.D . Baylor
College of Medicine, Houston, TX, USA.
The ACLS algorithm guides the conventional approach to intraoperative cardiovascular collapse, but it
may fail anesthesiologists in certain circumstances. We describe the challenging resuscitation of a 38year-old patient who developed cardiovascular collapse fifteen minutes after standard induction and
intubation for a total abdominal hysterectomy. Despite initiation of ACLS protocol with epinephrine, the
patient continued to decompensate. Intraoperative TEE revealed systolic anterior motion of the mitral
Copyright © 2014 American Society of Anesthesiologists
valve (SAM), which led us to change our therapy, as epinephrine is deleterious in the management of
SAM. After institution of specific vasopressor therapy and volume loading, the patient had a favorable
outcome.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Cardiac Anesthesia (CA) MC549
Keeping Up with the EP Lab: Anesthesia for the Placement of a Subcutaneous Internal Cardiac
Defibrillator Placement
Nazish K. Hashmi, M.B.,B.S., Avneep Aggarwal, M.D., Sushma Thapa, M.D . Anesthesiology, University
of Arkansas for Medical Sciences, Little Rock, AR, USA.
A 22 year old female presented for placement of a subcutaneous Implanted Cardiac Defibrillator. She had
a two year history of postpartum cardiomyopathy. Her most recent echocardiogram showed an ejection
fraction of 10-15% with mild mitral regurgitation. The risks of general anesthesia and pneumothorax were
explained to the patient. A pre-induction arterial line was placed and she was induced with etomidate,
lidocaine, fentanyl and rocuronium. The procedure lasted three hours. She was extubated uneventfully at
the end of the procedure and transferred to the PACU. A postoperative chest X ray did not show a
pneumothorax and she was discharged home.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Cardiac Anesthesia (CA) MC550
Intracardiac Four Chamber And Coronary Thrombosis During Orthotopic Liver Transplantation:
What Should We Do?
Alejandro Hernandez-Rodriguez, M.D., Ranjit Deshpande, M.D., Stephen Luczycki, M.D .
Anesthesiology, Yale New Haven Hospital, New Haven, CT, USA.
46-year-old male was scheduled for OLT under GETA with Isoflourane, Fentanyl and Vecuronium.
Standard ASA monitors, PAC, bilateral arterial lines and TEE were used. Patient required norepinephrine
infusion in the pre-anhepatic phase. Later, profuse bleeding required PRBC/FFP transfusions and
epinephrine support. ECHO during the anhepatic phase revealed acute thrombus in all four cardiac
chambers. Cardiac decompensation necessitated CPR and subsequently CPB. Open thoracotomy
showed no remaining thrombus, however LAD, diagonal, OM and RCA were thrombosed. Transplant was
completed while on CPB. Dilated pupils were noted and additional efforts to restore coronary circulation in
this setting were considered to be futile.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Cardiac Anesthesia (CA) MC551
Challenging Case In an Adult Patient with Dextrocardia and Hypoplastic Left Heart Syndrome for
Pacemaker Lead Implantation Via Fifth Time Sternotomy
Bryan J. Hierlmeier, M.D . Anesthesiology, University of Mississippi Medical Center, Madison, MS, USA.
21 year old female with history of dextrocardia and hypoplastic left heart syndrome status post fontan
repair as a child developed symptomatic type II degree heart block requiring pacemaker lead
implantation. Due to the patients anatomy and previous multiple sternotomies the lead insertion required
another sternotomy for cardiac exposure.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Obstetric Anesthesia (OB) MC552
Anesthetic Management for Cesarean Section in a Morbidly Obese Pre-term Parturient with
Pulmonary Edema and Anasarca Secondary to Nephrotic Syndrome Resulting from Poorly
Controlled IDDM
Melissa Masaracchia, M.D., Michelle C. Parra, M.D., Matthew J. Hoyt, M.D . Department of
Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
35-year-old morbidly obese (BMI 54) G2P1 female was admitted at 30 weeks gestation with worsening
shortness of breath, orthopnea, and anasarca in the setting of preeclampsia, poorly controlled IDDM, and
Copyright © 2014 American Society of Anesthesiologists
OSA. ABG was notable for hypoxia, and chest x-ray showed pulmonary edema. Cardiac work-up was
unremarkable; however, 24-hour urine protein was consistent with nephrotic syndrome. Worsening
respiratory status required delivery via cesarean section. All anesthetic options were considered;
however, neuraxial technique was limited by orthopnea, elevated risk for spinal hematoma due to
thromboprophylaxis, and thrombocytopenia. The patient‟s airway was non-reassuring; therefore, awake
fiberoptic intubation was utilized to secure the airway.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Obstetric Anesthesia (OB) MC553
Postpartum Preeclampsia and HELLP Syndrome Complicated by Diabetes Insipidus
Alexandra Mazur, M.D., Kalpana Tyagaraj, M.D., Agnes Miller, M.D . Maimonides Medical Center,
Brooklyn, NY, USA.
41 years G3P3 underwent C-Section under epidural and her postpartum course was complicated by
HELLP syndrome and Nephrogenic Diabetes Insipidus. Symptoms of polyuria, polydipsia with a rapidly
rising serum sodium and acute renal failure were noted in absence of neurologic symptoms and negative
MRI. In the MICU, the patient was maintained on Mg and 0.45% normal saline 300ml/hr. ADH levels were
normal, although the suspected mechanism of DI was vasopressinase enzyme from the placenta, and
vasopressin was not started due to clinical improvement. Epidural was left in situ for 2 days
postoperatively to track her coagulation profile prior to removal.
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Obstetric Anesthesia (OB) MC554
Postpartum Hemorrhage in a Patient with Abruptio Placentae and Couvelaire Uterus
Kimberly I. McClelland, M.P.H., Clairmont E. Griffith, M.D . Howard University College of Medicine,
Washington, DC, USA, Anesthesiology, Howard University Hospital, Washington, DC, USA.
The successful management of suspected abruptio placentae is dependent on myriad factors, including
the patient's co-morbidities, obstetric history and toxicology status, as well as the anesthesiologist‟s ability
to rapidly respond to unanticipated sequelae. Here, we present the case of a 37-year-old G8P2143 with a
past medical history of polysubstance abuse, PPROM, chorioamnionitis, Group B β-streptococcus (GBS)positive pregnancy/delivery and bipolar disorder who presented to L&D with chief complaints of uterine
contractions and severe abdominal pain. She had no vaginal bleeding. We will examine the
anesthesiologist‟s role in managing unexpected clinical and laboratory findings similar to those presented
in this case.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Obstetric Anesthesia (OB) MC555
Evaluation and Management of the Anesthetic Risks of the Parturient with Arnold-Chiari
Malformation and Difficult Airway
Neeraj Mehta, M.D., Cassandra Armstead-Williams, M.D., Carolina Echevarria, M.D., Jerome Lax, M.D .
Anesthesiology, New York University, New York, NY, USA.
A 34 yo G1P0 at 39 weeks with a history significant for Arnold-Chiari malformation type 1 presents with
headaches and visual floaters to L&D. She is found to be pre-eclamptic and in need of emergent
cesarean section. On physical exam, she is noted to be morbidly obese and edematous with a malampati
class IV airway, thick neck and thyromental distance less than 4 cm. Arnold-Chiari malformation is a rare,
congenital disorder involving downward displacement of the cerebellar tonsils and has numerous
important anesthetic implications that will be discussed. Furthermore, both regional and general
anesthetics pose significant risk for brain herniation.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Obstetric Anesthesia (OB) MC556
Horner’s Syndrome Is an Uncommon Complication of Lumbar Epidural Analgesia for a Woman in
Labor
Copyright © 2014 American Society of Anesthesiologists
Brian J. Melville, M.D . Anesthesiology, University of Connecticut, Farmington, CT, USA.
A healthy 27 year old primigravida with no prior medical history and uncomplicated pregnancy at 39
weeks gestation had an epidural placed at L2-L3. Approximately 1 hour after receiving a 10mL loading
dose of bupivacaine 0.1% with fentanyl 2µg/mL and starting an infusion 10mL/hr, the patient reported
right-sided facial flushing and drooping of her eyelid. She received good relief from her epidural and was
hemodynamically stable. She had a sensory level to cold at about T4. The infusion was discontinued and
the patient was reassured. Approximately 2 hours after cessation of the infusion, her symptoms resolved.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Obstetric Anesthesia (OB) MC557
PCP and Preeclampsia in the Parturient: A Recipe for Intracranial Hemorrhage and Hemodynamic
Instability
Jennifer L. Mendoza, M.D., Heather Nixon, M.D . University of Illinois at Chicago, Chicago, IL, USA.
We present a 39-year-old morbidly obese G6P2 parturient transferred to our institution with sudden-onset
left-sided weakness, headache, and diplopia. At the outside hospital, her drug screen was positive for
PCP, labs confirmed preeclampsia, and her blood pressure was 258/120. CT of the head demonstrated
acute thalamic ICH. Upon arrival, the patient was tachypneic, dyspneic, and orthopneic. Arterial line was
placed and emergent caesarean delivery was performed under general anesthesia. Although induction
and intubation were uneventful, following delivery, the patient developed hemodynamic instability with
severe hypotension and bradycardia. After a prolonged hospital stay, the patient was discharged with
improved neurologic function.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Obstetric Anesthesia (OB) MC558
Caesarean Section in a Parturient with Bivalvular Rheumatic Heart Disease and Severe Pulmonary
Hypertension
Daniela Micic, M.D., Joseph Vaisman, M.D., Shetal Patel, M.D . Department of Anesthesiology, University
of Southern California, Los Angeles, CA, USA.
32 year-old G2P0010 female presents in acute heart failure at 32+4 weeks, 10 days after aortic
valvuloplasty. TEE revealed dilated LA, mild LVH, EF 65-70%, severe MS (area 0.88cm2), moderate MR,
moderate AS (area 0.95cm2), moderate AR, and PAP 66mmHg.Patient presented to the OR for semiurgent caesarian section, with in-situ Swan-Ganz catheter. Awake arterial line was placed. Patient‟s
abdomen was prepped and draped; RSI was performed, followed by TEE placement and surgical
incision. Nitroglycerin infusion and intermittent boluses of phenylephrine were used to maintain
hemodynamic stability. The patient was extubated and transported to the cardiac ICU in stable condition.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Obstetric Anesthesia (OB) MC559
Ruptured Ectopic Pregnancy in a patient with DiGeorge Syndrome and Tetralogy of Fallot
Andrea N. Miltiades, M.D., Sarah C. Smith, M.D., Minjae Kim, M.D., M.S . Department of Anesthesiology,
Columbia University Medical Center, New York, NY, USA.
The patient is a 30 year old, G7P2 female with DiGeorge Syndrome and repaired Tetralogy of Fallot
(TOF) with severe pulmonic regurgitation and right ventricular overload. She presented to the ER in her
eighth week of pregnancy with a ruptured ectopic pregnancy with hemoperitoneum. She arrived in the OR
for exploratory laparotomy in hemorrhagic shock with a tense abdomen. Case discussion will include
anesthetic implications of DiGeorge syndrome, such as immune disorders and hypocalcemia, late
complications of TOF, and transfusion management after receiving multiple units of uncrossmatched O
negative blood.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Obstetric Anesthesia (OB) MC560
Anesthetic Considerations of Caring for a Patient With Hemoptysis Undergoing a Cesarean
Delivery
Dominique Y. Moffitt, M.D., Jeffery Swanson, M.D., Dirk J. Varelmann, M.D. . Anesthesiology, Brigham &
Women's Hospital, Boston, MA, USA, Department of Anesthesia Perioperative and Pain Medicine,
Brigham and Women's Hospital, Boston, MA, USA, Department of Anesthesia Perioperative and Pain
Medicine, Brigham & Women's Hospital, Boston, MA, USA.
31 yo primiparous woman at 27 weeks, with stage IV adenocarcinoma and brain metastases presented
with worsening hemoptysis after radiation to the chest one month prior. Repeat imaging showed
significant extension of her brain metastases requiring whole brain radiation. The initial plan for expectant
management and delay of chemotherapy until after delivery changed when bony metastases were
discovered. Given the widespread disease a multidisciplinary team (oncology, obstetric, thoracic surgery)
decided on a cesarean delivery at 28 weeks in the thoracic operating room with fiberoptic bronchoscope
and lung isolation capabilities. The case was successfully completed under a combined spinal epidural.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Pain Medicine (PN) MC561
Is There a Fungus Among Us? A Case of Fever and Headache 24 Hours After Epidural Steroid
Injection
Christiana E. Roussis, M.D., Geeta Nagpal, M.D . Anesthesiology, Northwestern University McGaw
School of Medicine, Chicago, IL, USA.
Nine months after the CDC announced the fungal meningitis outbreak, a 28 year-old healthy male
underwent right L5-S1 transforaminal epidural steroid injection with 80mg triamcinolone and 1% lidocaine.
Less than 24 hours later he presented to the Emergency Department with headache, fevers, and chills.
Vitals on admission were 98.0 F, 127/59, P 73, 98%. On examination, he was neurologically intact with no
nuchal rigidity, and he denied back pain. WBC was 18.9 K/UL. Despite discussion with the pain providers,
the ED ordered an MRI followed by lumbar puncture to rule out meningitis in the setting of the recent
outbreak.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Pain Medicine (PN) MC562
Early Pediatric Chronic Regional Pain Syndrome versus Meralgia Paresthetica: A Diagnostic
Dilemma
Kasia P. Rubin, M.D., John Grace, M.D . Anesthesiology, Rainbow Babies & Children's
Hospital/University Hospitals of Cleveland, Cleveland, OH, USA, Anesthesiology, University Hospitals of
Cleveland, Cleveland, OH, USA.
Chronic Regional Pain Syndrome (CRPS) and Meralgia Paresthetica (MP) are both uncommon, and
diagnosis is often delayed in children and adolescents. The absence of definitive pathophysiology in
CRPS, with a lack of objective diagnostic testing, has led to a descriptive diagnostic criteria, agreen upon
by expert consensus. Symptoms of MP may be similar in the early stages, but diagnosis is clearly and
definitively achieved via local anesthetic blockade of the lateral femoral cutaneous nerve. Both may
present with similar psychological overlaying features, making it difficult to initiate the invasive testing
required to rule out MP.
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Pain Medicine (PN) MC563
Myelomalacia Caused By Prior Vertebral Fusions
Adelle Safo, M.D.,M.P.H., Richard Rosenquist, M.D . Cleveland Clinic, Cleveland, OH, USA.
Myelomalacia is a condition marked by spinal cord changes evident on T1 and T2 weighted MRI studies.
This can be caused by compression of the spinal cord and trauma. The case presented describes a
woman who has had a long history of bilateral hand pain due to degenerative changes at C3-C4 caused
Copyright © 2014 American Society of Anesthesiologists
by increased stress related to previous vertebral fusions at levels below. She has had multiple cervical
spine surgeries in the past, but despite surgery and conservative treatment, the patient still continued to
have pain. MRI performed showed increased T2 and STIR intensity at C3-C4 suggestive of
myelomalacia.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Pain Medicine (PN) MC564
Intrathecal Pump Pocket CSF Seroma
Taher M. Saifullah, M.D., M.S., Jijun Xu, M.D.,Ph.D., Omar Said, M.D., Anne Sapienza-Crawford, R.N.,
Michael Stanton-Hicks, M.B.,B.S., Richard W. Rosenquist, M.D . Anesthesia, Cleveland Clinic, Cleveland,
OH, USA, Chronic Pain, Cleveland Clinic, Cleveland, OH, USA.
Intrathecal pumps are widely used to achieve continuous neuraxial analgesia in patients with chronic
pain. Common complications include epidural infections, bleeding, neurological injury, and cerebrospinal
fluid leaks. We present a unique case involving a patient with chronic pelvic pain from a motor vehicle
crush injury. He was treated with an intrathecal drug delivery system and had five intrathecal pumps
implanted since starting the therapy and was status post three revisions. He presented after a syncopal
episode and was subsequently found to have a CSF seroma located behind the pump and contained
within the subcutaneouspump pocket.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Pain Medicine (PN) MC565
Rare Presentation of Thoracic Syringomyelia with Abdominal Pain
Vafi Salmasi, M.D., Richard W. Rosenquist, M.D . Anesthesiology Institute, Cleveland Clinic, Cleveland,
OH, USA, Pain Management, Cleveland Clinic, Cleveland, OH, USA.
The patient is a 65 year old patient who presented with a chief complaint of intermittent lower abdominal
pain for four years. The pain was exacerbated by standing and alleviated by reclining or lying down.
Extensive gastrointestinal and urological work-up did not reveal any abnormalities and surgical repair of
an umbilical hernia produced no improvement. A series of transforaminal epidural injections provided only
temporary relief with local anesthetic. A thoracic spine MRI was subsequently performed and revealed the
presence of syrinx at a level consistent with his reports of pain. The patient was referred to neurosurgery
for further management.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Pain Medicine (PN) MC566
Rare Presentation of Facet Joint Disease with Upper Abdominal Pain
Vafi Salmasi, M.D., Richard W. Rosenquist, M.D . Anesthesiology Institute, Cleveland Clinic, Cleveland,
OH, USA, Pain Management, Cleveland Clinic, Cleveland, OH, USA.
The patient is a 45 year old male with a chief complaint of right upper quadrant abdominal pain for four
years. An extensive evaluation for gastrointestinal sources and MRI evaluation of the lumbar and thoracic
spine were non-diagnostic. Physical examination demonstrated thoracic paraspinal tenderness with
reproduction of his abdominal pain. The patient underwent diagnostic facet medial branch nerve block
from T7-T10 with complete pain relief on two occasions. He was subsequently treated with
radiofrequency ablation the medial branches of T7-10 with sustained pain relief for greater than 6 months
so far.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Pain Medicine (PN) MC567
Management of Intractable Chest Pain Secondary to a Pericardial Mass
Youssef Saweris, M.D., Shrif Costandi, M.D., Nardine Zakhary, M.S. , Hani Yousef, M.D.,Ph.D., Nagy
Mekhail, M.D.,Ph.D . Evidence Based Pain Medicine Research, Cleveland Clinic, Cleveland, OH, USA,
Pain Management Department, Cleveland Clinic, Cleveland, OH, USA, Kentucky College of Osteopathic
Medicine, Pikeville, KY, USA, Outcomes Reseach, Cleveland Clinic, Cleveland, OH, USA.
Copyright © 2014 American Society of Anesthesiologists
A 37 years-old-female presented with left chest pain (in T5-7 distribution) radiating to the back that is
worsened with respiration and palpitation. Chest CT scan with contrast showed a pericardial mass with fat
necrosis. Cardiologists failed to control her pain with non-steroidal anti-inflammatories and
acetaminophen. Furthermore, she developed nausea and vomiting with opioids. Tunneled thoracic
epidural catheter (TEC) with Fentanyl and Bupivacaine infusion was instigated. The patient obtained
sustained improvement for 8 weeks until her pain exacerbation resolved. Patient was able to return to her
work during that time. Painful pericardial masses are uncommon and challenging to manage.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Pain Medicine (PN) MC568
Bupivacaine Insensitivity in Thoracic Epidural and Intrathecal Catheter Placed in a Patient With
Cystic Fibrosis
Stephanie N. Schock, M.D . Anesthesiology, University of Arizona, Tucson, AZ, USA.
A 36 -year-old male with cystic fibrosis was admitted for pathologic posterior rib fractures and severe
pain. A T5-T6 thoracic epidural was placed. Anesthetic levels were achieved with the initial lidocaine
bolus but were lost after initiation of the bupivacaine infusion. Repeat lidocaine boluses were successful.
Levels were not sustained with bupivacaine infusions or boluses despite fluoroscopic intrathecal catheter
insertion.Previous studies of lidocaine and bupivacaine have demonstrated different effects on myocyte
sodium ion channels. CFTR dysfunction in cystic fibrosis is responsible for the abnormal regulation of
voltage-gated ion channels and may have resulted in this patient‟s selective bupivacaine insensitivity.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Pain Medicine (PN) MC569
Fluoroscopically Guided Epidural Blood Patches for Spontaneous Intracranial Hypotension
Manish Shah, M.D . Anesthesiology, Pennsylvania State University - Hershey Medical Center, Hershey,
PA, USA.
We present three patients diagnosed with spontaneous intracranial hypotension (SIH), based on imaging
and clinical symptoms. CSF leakage sites and dural defects were identified by MRI or CT myleography.
Fluoroscopically- or CT-guided epidural blood patch (EBP) treatment, which can be targeted using
radioimaging to achieve a precise seal at the leakage site, was used for each of these patients. Records
and radiographic images from 1-2 month follow-ups were reviewed to determine whether clinical
symptoms had resolved, and CSF leakage had improved. Each of these patients achieved significant
long term relief of headache symptoms as well as improvement of image findings.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Cardiac Anesthesia (CA) MC570
Refractory Right Ventricular Dysfunction after Radical Nephrectomy and Extensive
Thrombectomy
Yoshihisa Morita, M.D., Jerry Young, M.D . Department of Anesthesiology, Indiana University,
Indianapolis, IN, USA.
54-year-old female was scheduled for right radical nephrectomy and extensive thrombectomy for a right
renal cell carcinoma with tumor thrombi up until IVC and right atrium. Second run of cardiopulmonary
bypass was necessary due to refractive severe right ventricle dysfunction, even after which weaning was
unsuccessful. Hemodynamic monitors showed diffuse akinetic RV without any signs of pulmonary
hypertension. The patient was started on high dose of epinephrine, milrinone, norepinephrine, and
inhalational nitric oxide without success. Poor cardioprotection during cardiopulmonary bypass was
suspected. The patient got into multiorgan failure and deceased on postoperative day one.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Cardiac Anesthesia (CA) MC571
Intraoperative Pulmonary Embolus and IV tPA
Copyright © 2014 American Society of Anesthesiologists
Cody A. Motley, M.D., Ian Bond, M.D . Anesthesiology, University of Oklahoma Health Sciences Center,
Oklahoma City, OK, USA.
A 24-yr-old female with post-partum cardiomyopathy presented for an electively scheduled tracheal
dilation. Intraoperatively she suffered sudden cardiovascular collapse. Resuscitative efforts were
implemented for 80 minutes followed by cardiac evaluation with TEE. Remarkably, imaging demonstrated
a dilated and hypokinetic right ventricle secondary to a large pulmonary embolus located in the right
pulmonary artery. Intravenous tPA was subsequently administered with resolution of the embolus
followed by return of spontaneous circulation and noticeable signs of life. Despite a prolonged code, the
patient made a full recovery without any identifiable neurologic deficits.
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Cardiac Anesthesia (CA) MC572
Neonatal Heart Transplant with Aortic Arch Reconstruction for Hypoplastic Left Heart Syndrome
(Shone complex)
Pablo Motta, M.D., Monte Chin, M.D . Texas Children's Hospital Pediatric Cardiovascular Anesthesia,
Houston, TX, USA, Pediatric Anesthesia, Texas Children´s Hospital, Houston, TX, USA.
17 day old, 2.8kg, neonate with an unbalanced AV canal defect, LV and arch hypoplasia, severe AVV
regurgitation, and poor RV function. The patient was considered not a candidate for Norwood palliation
due to severity of regurgitation and function. The only therapeutic option available was an orthotropic
heart transplant with arch reconstruction. Mechanical support use was discussed but a donor heart
became available. The patient underwent surgery successfully on cardiopulmonary bypass with
anterograde cerebral perfusion tailored by NIRS and transcranial Doppler during the arch reconstruction.
We discuss our approach to neuroprotection in neonatal heart transplant associated with aortic
reconstructive surgery.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Cardiac Anesthesia (CA) MC573
Methylene Blue for the Treatment of Vasoplegia and Intraoperative Pulmonary Edema
Patrick L. Nguyen, M.D., Brett Cronin, M.D., David M. Roth, M.D . University of California, San Diego, CA,
USA.
64 year-old male with severe aortic regurgitation and mitral valve vegetations underwent aortic valve
replacement and mitral valve repair after stable induction and bypass period. Upon separation from CPB
a high cardiac output and low SVR state persisted despite vasopressors and volume resuscitation.
Additionally, copious fluid was observed from the airway following administration of platelets. Given the
likely diagnoses of post-CPB vasoplegia and TRALI, methylene blue was infused. Systemic blood
pressure returned to baseline and pulmonary edema resolved. Approximately six hours after methylene
blue administration, the patient again required increasing vasopressor doses and copious fluid was
suctioned from the airway.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Cardiac Anesthesia (CA) MC574
Intraoperative Diagnosis of Occult PDA in an Adult Endocarditis Patient w/ Suprasystemic
Pulmonary Hypertension, PFO and Severe Aortic Insufficiency
Patrick J. Milord, M.D., MBA, Ana Manrique-Espinel, M.D., Robert Nampiaparampil, M.D . NYU Langone
Medical Center, New York, NY, USA.
A 21 year old Hispanic male transferred from OSH p/w acute cardiogenic decompensation secondary to
severe AI, suspected endocarditis, and ARF. Preoperative triple-lumen CVP plus Swan-Ganz catheter
placed revealed suprasystemic pulmonary hypertension; TEE confirmed AI (bicuspid valve w/
vegetations) and dilated PA. The patient‟s ventilation was supported with inhaled NO at 20ppm given the
degree of pulmonary hypertension. Upon initiation of CPB with retrograde cardioplegia, significant
distention of the heart and further PA dilation were observed. Direct digital examination by the surgeon
demonstrated an occult PDA, which was ultimately closed under deep hypothermic circulatory arrest.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Cardiac Anesthesia (CA) MC575
Management of Acute Bleeding from Aortoesophageal Fistula During Surgical Repair
Sarah L. Nizamuddin, M.D., Atsushi Yasuda, M.D . Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA.
A 58 year old female with Marfan's syndrome status post descending aortic repair presented with
hemoptysis concerning for aortobronchial fistula and was brought to the operating room for emergent
surgical repair. Intraoperative bronchoscopy showed clean airway but endoscopy identified
aortoesophageal fistula. During thoracotomy, blood was dripping around the mouth and the patient
developed severe hypotension, which required rapid transfusion and vasopressor support. An
endotracheal tube was placed in the esophagus and cuff was inflated at the site of the fistula to stop
active bleeding until more optimal exposure could be obtained. Surgical correction was performed under
deep hypothermic circulatory arrest.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Cardiac Anesthesia (CA) MC576
Surviving a Total Clip of the Heart
Nana O. Ofosu, M.D., Wendy K. Bernstein, M.D., MBA. University of Maryland Medical Center, Baltimore,
MD, USA.
Atrial fibrillation is associated with significant morbidity and mortality from thromboembolic events. Over
90% of thromboemboli originate in the left atrial appendage. In this case, we present an 82 year old with
history of chronic atrial fibrillation, thrombocytopenia, frequent epistaxis and gastrointestinal bleed from
oral anticoagulation therapy. As a result of failed anticoagulation for atrial fibrillation and stroke
prevention, the patient was considered a candidate for video-assisted thoracoscopic left atrial appendage
clipping (AtriClip). Anesthetic management was further challenged by one lung ventilation in a patient with
a difficult airway, and maintenance of adequate oxygenation and ventilation.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Cardiac Anesthesia (CA) MC577
Development of Intraoperative von Willebrand Syndrome During Cardiac Surgery, a Cause for
Coagulopathic Concern
Brooks B. Ohlson, M.D., R Eliot Fagley, M.D . Department of Anesthesiology, Virginia Mason Medical
Center, Seattle, WA, USA.
Though von Willebrand disease is the most common hereditary bleeding diathesis, little is known about
acquired von Willebrand syndrome (vWS) and its prevalence and implications in the perioperative period.
We present a case of vWS recognized and treated intraoperatively during on-pump mitral valve repair.
Preoperative coagulation testing revealed no abnormalities but following heparin bolus the patient
developed an undetectably supratherapeutic Activated Clotting Time (ACT). The patient's measured ACT
remained undetectable despite repeated administration of protamine. Coagulation testing was otherwise
within expected limits. Suspicion was raised for undiagnosed vWS and empirically treated with
desmopressin, after which the ACT fully corrected.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Critical Care Medicine (CC) MC578
Massive Recurrent Right-sided Retroperitoneal Hemorrhage Associated with Compartment
Syndrome Causing Liver Failure
Laura E. Gilbertson, M.D., Ardeshir Jahanian, M.D., Durai Thangathurai, M.D . University of Southern
California, Los Angeles, CA, USA.
Partial nephrectomies have become an appropriate surgical technique for renal neoplasms. It is often
performed robotically, which minimizes postoperative respiratory complications. The control of bleeding
can be problematic. We report a patient presenting with a solitary kidney for a partial nephrectomy. The
dissection was complicated and the patient developed postoperative hemorrhage giving rise to recurrent
Copyright © 2014 American Society of Anesthesiologists
compartment syndromes requiring massive transfusions and total nephrectomy and resulting in liver
failure and hyperammonemia.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Critical Care Medicine (CC) MC579
Hyperammonemia in the ICU causing Central Pontine Myelinolysis
Laura E. Gilbertson, Ardeshir Jahanian, M.D., Durai Thangathurai, M.D . University of Southern
California, Los Angeles, CA, USA.
We report a patient presenting with a solitary kidney for a partial nephrectomy. The dissection was
complicated, and the patient developed postoperative hemorrhage giving rise to recurrent compartment
syndromes requiring massive transfusions and a total nephrectomy. This resulted in a prolonged ICU
course in which he developed liver failure and hyperammonemia. He was dialyzed daily and received
lactulose as treatment. He subsequently recovered from liver failure but suffered neurological dysfunction.
An MRI showed evidence of central pontine myelinolysis, most likely from the hyperammonemia.
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Critical Care Medicine (CC) MC580
Multisystem Organ Failure and Cardiac Arrest Following the Use of A popular Muscle Building
Supplement
Elisabeth R. Goldstein, M.D . Anesthesiology, NYU, New York, NY, USA.
46 year old man, with a PMH of hypertension, who presented for evaluation of hyperbilirubinemia
secondary to drug induced liver injury after “Carnage” use (beta alanine supplementation). The patient
was found to be in fulminant liver failure as well as renal failure and underwent a transjugular right renal
biopsy. This was complicated by a torn IVC as well as PEA arrest with ROSC. Following the PEA arrest,
the patient underwent massive transfusion and was cooled as per hypothermia protocol. He was taken to
the operating room for an IVC repair, during which he underwent cardiac arrest without successful
resuscitation.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Critical Care Medicine (CC) MC581
Stress Dose Steroids: One 'Size' Fits All?
Samrawit A. Goshu, M.D., Paul Barash, M.D . Anesthesiology, Yale New Haven Hospital, New Haven,
CT, USA.
The interplay of the glucocorticoid effect of stress steroids and brittle Type 1 diabetes (DM) presents
significant medical challenges. A 21 yo male type 1 DM (insulin pump); s/p liver transplant receives
prednisone 5 mg/day, presents for lumbar laminectomy. Pre-op BG was 326 mg/dL and we were
concerned that stress dose steroids exacerbate the hyperglycemia. Endocrinology consultation advised,
hydrocortisone 50 mg, rather than the 100 mg dose. He was hemodynamically stable with excellent
glycemic control in the peri-op period. This case supports the safe use of titrated stress dose steroids in
brittle diabetics who receive daily immunosuppressive doses of prednisone.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Critical Care Medicine (CC) MC582
Extensive Subcutaneous Emphysema after Cardiopulmonary Resuscitation: The Use of Positive
Pressure Ventilation in Patients at Risk for an Undiagnosed Spontaneous Pneumothorax
Ryan C. Guay, D.O., Yashar Ettekal, M.D . Anesthesiology, Albany Medical Center, Albany, NY, USA.
A 60 year-old female with medical history of oxygen-dependent COPD, hypertension, and diabetes
mellitus was admitted for symptoms related to her recent herpetic and candida esophagitis diagnosis.
Shortly after admission, the patient became tachypneic, tachycardic, hypoxic, and her mental status
changed coinciding with CPAP administration. PEA arrest was diagnosed. CPR was initiated followed by
emergent intubation. A CXR revealed a large right-sided pneumothorax and subsequent needle
decompression was performed. After resuscitation, it was proposed she had a prior spontaneous
Copyright © 2014 American Society of Anesthesiologists
pneumothorax missed on admission imaging. The patient was transferred to ICU with extensive
subcutaneous emphysema extending from head to lower extremities.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Critical Care Medicine (CC) MC583
Pulmonary Embolus after Acute Ischemic Stroke Treated with Thrombolytic
Jennette D. Hansen, M.D., Tracy McGrane, M.D . Anesthesia, Vanderbilt University, Nashville, TN, USA.
63 yo male with multiple comorbidities admitted to ICU for MCA CVA , treated with tpa and hyperosmolar
therapy. Anti-platelet therapy and DVT prophylaxis held 24 hours after tpa. Patient acutely developed
tachycardia, hypoxia and hypotension on post stroke day 7 while working with PT. Bedside echo showed
newly dilated RV with apical sharing and septal bowing compared to normal admission echo. Chest CT
confirmed saddle pulmonary embolus. The patient was evaluated by cardiac surgery for embolectomy
and by cardiology for thrombectomy but was determined not to be a candidate for either. The patient was
ultimately transitioned to comfort care.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Critical Care Medicine (CC) MC584
Use of Beta-blockade for Refractory Ventricular Fibrillation in a Patient on Extracorporeal Life
Support
Seth B. Hayes, M.D., Juan A. Crestanello, M.D., Thomas J. Papadimos, M.D., Victor R. Davila, M.D.,
Pamela K. Burcham, Pharm.D, Ravi S. Tripathi, M.D . Anesthesiology, Ohio State University Med Ctr,
Columbus, OH, USA, Surgery, Ohio State University Med Ctr, Columbus, OH, USA.
A 60 year old male status-post emergent four vessel CABG following ventricular fibrillation arrest
developed recurrent ventricular tachycardia and ventricular fibrillation refractory to pharmaceutical
management. He was cannulated for veno-arterial ECLS to support him through multiple rounds of
cardiopulmonary resuscitation and defibrillation. Despite requiring vasopressors and ECLS for
cardiogenic shock, the patient‟s arrhythmias were controlled with high-dose beta-blockade and multiple
anti-arrhythmics, all negative inotropes. The patient was ultimately liberated from ECLS and mechanical
ventilation and received a defibrillator prior to discharge.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Critical Care Medicine (CC) MC585
Perioperative Management of a Patient with Autoimmune Polyendocrine Syndrome Type 1 and
History of Critical Severe Post-Operative Hypocalcemia
Jarrett A. Heard, M.D., Gaylynn J. Speas, M.D . Department of Anesthesiology, Wexner Medical Center
at The Ohio State University, Columbus, OH, USA.
Autoimmune polyendocrine syndrome-type 1 (APS) is typically manifested by Addison's disease,
hypoparathyroidism and mucocutaneous candidiasis. There is almost no literature that addresses the
anesthetic challenges that this disease presents and as such there are almost no known anesthetic
recommendations or contraindications for managing these patients. This case report demonstrates the
challenges of managing a patient with APS type 1 who developed critical post-operative hypocalcemia
requiring ICU and how it is important to understand the clinical manifestations of APS, and create a
thorough perioperative plan as it pertains to the specifically affected organ system(s) in a patient.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Critical Care Medicine (CC) MC586
Combined Fiberoptic and GlideScope Intubation for Lost Airway During Tracheostomy
Brian P. Henk, D.O., Kalpana Tyagaraj, M.D . Anesthesiology, Maimonides Medical Center, Brooklyn, NY,
USA.
59 years female with aneurysmal subarachnoid hemorrhage S/P coiling with vasospasm, ventilator
associated pneumonia, iatrogenic pneumothorax with a chest tube in place was undergoing bedside
tracheostomy with fiberoptic bronchoscopic guidance. The fiberoptic bronchoscope (FB) became stuck
Copyright © 2014 American Society of Anesthesiologists
inside endotracheal tube (ETT) while being withdrawn and the ETT was dislodged. Attempts at intubation
via direct laryngoscopy were unsuccessful. While the view of the arytenoid was maintained under
Glidescope, a second provider advanced an ETT over the FB through the laryngeal opening to the carina.
Tip of the ETT was placed in the distal trachea. Tracheostomy was subsequently completed without
further complication.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC587
Just a Simple MAC Case
Judy G. Johnson. Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA,
USA.
A 32 y/o patient with a BMI of 46 and a Mallampati class 4 airway presented for surgical treatment of
Hidradenitis. The surgeon pushed for a simple sedation case with local anesthesia. A propofol drip was
initiated. Antibiotics were reconstituted and administered slowly by the anesthesia provider. As the initial
incision began, the patient became agitated and more propofol was given. Gradually the patient‟s oxygen
saturation began to drop, and mask ventilation was attempted. The patient became unresponsive and the
propofol drip was discontinued. The surgeon was closing the site and there was a call for additional help.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC588
Abdominal Aortic Aneurysm Repair in a Patient with a Personal History of Malignant Hyperthermia
Charles A. Jones, M.D., Matthew J. Gilbert, M.D., Karl Wagner, M.D . Anesthesia, MetroHealth Medical
Center - Case Western Reserve University, Cleveland, OH, USA.
Malignant Hyperthermia (MH) is a rare but, severecomplication seen in approximately one in 100,000
surgeries. We are presentingthe management of a 66 year old female with a personal history of MH
presentingfor an open repair of a large abdominal aortic aneurysm. After properprecautions were taken in
preparing the anesthesia machine a total intravenousanesthetic was utilized. Anesthesia was maintained
with propofol and ketamineinfusions, boluses of fentanyl, and rocuronium for muscle relaxation. The
patient was transferred intubated to the surgicalintensive care unit post-operatively, extubated on postoperative day 12, anddischarged home on post-operative day 17.
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC589
Cholinergic Crisis in a Patient with End Stage Renal Disease in the Postoperative Period
Ace Josifoski, M.D., Pavan Battu, M.B.,B.S . Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
A 55 year old female with past medical history of end stage renal disease on intermittent hemodialysis
underwent functional endoscopic sinus surgery under general anesthesia with endotrachial intubation and
muscle relaxation maintained with cisatracurium. Upon the end of the case, muscle relaxation was
reversed with neostigmine with concurrant administration of glycopyrrolate. The patient was brought to
the PACU extubated, however, soon began to exhibit signs of cholinergic crisis. This case will highlight
the diagnosis and management of a patient with cholinergic crisis as well as a discussion of the
pharmokinetics of neostigmine in a patient with end stage renal disease.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC590
Anesthetic Concerns and Management in a Patient with History of Thyroplasty and Montgomery
Vocal Cord Implant
Anne H. Kancel, D.O., Frederick Conlin, M.D . Baystate Medical Center, Springfield, MA, USA.
64 year old male with history of renal cell carcinoma, SMV thrombosis, and right sided vocal cord
paralysis after a repair of Zenkers Diverticulum and injury to right recurrent laryngeal nerve s/p vocal cord
implant presented for emergent exploratory laparotomy with small bowel resection. Patient was intubated
using a 6.5 endotracheal tube. Vocal cord implant was visualized as ETT passed through vocal cords via
Copyright © 2014 American Society of Anesthesiologists
video laryngoscope. Patient was extubated after meeting extubation criteria with ETT cuff deflated. Post
op and at two month follow up there were no signs of implant dislodgement, hoarseness, or difficulty
breathing.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC591
Airway Management for a Subglottic Foreign Body Removal with Impending Airway Compromise
Cale A. Kassel, M.D., Thomas Nicholas, M.D . Anesthesiology, University of Nebraska Medical Center,
Omaha, NE, USA.
A 56-year-old patient was admitted to the ICU with concerns for sepsis. During her ICU admission, she
was noted to have odynophagia, hoarseness, and difficulty swallowing. A consult to ENT was placed that
revealed a mass below the vocal cords obstructing over 50% of the trachea. Additionally, she had
increasing O2 requirements. She proceeded emergently to the OR for removal of the foreign body.
Anesthesia was induced with ketamine while she was hand ventilated with sevoflurane. The patient
continued spontaneous respirations while ENT retrieved the mass. Pathology revealed a mucus plug
without evidence of malignancy.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC592
Awake Parotidectomy in a Patient with Severe Carotid Disease
Marc W. Kaufmann, D.O., Jaime Baratta, M.D . Anesthesiology, Thomas Jefferson University Hospital,
Philadelphia, PA, USA.
73 yo male with h/o 100% occlusive disease of left carotid artery and an enlarging left parotid mass
presented for a parotidectomy. Pre-operatively patient was deemed to have an “extremely high risk of
stroke” with hypotension under general anesthesia or positional compromise of collateral flow. A JP bulb
attached to CVP monitor,given to patient to squeeze, was utilized to monitor left-sided motor function.
With remifentanil and dexmedetomidine infusions for sedation and local anesthetic infiltration, patient
tolerated the procedure with minimal discomfort. Hemodynamics and motor function remained stable
throughout the case. Awake parotidectomy may be considered in patients with significant comorbidities.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC593
Intraoperative Airway Evaluation Using O-Arm CT Imaging System- A Novel Tool in Improving
Patient Safety
Marta Kelava, M.D., Mauricio Perilla, M.D . Department of Anesthesiology, Cleveland Clinic Foundation,
Cleveland, OH, USA.
We present a case of a 69 years old male ex-smoker with recurrent supraglottic squamous cell carcinoma
who developed a new onset shortness of breath (SOB). A flexible laryngoscopy showed bilateral
supraglottic mass with airway narrowing to less than 5 mm, and no visualization of subglottic structures.
Pre-op CT was aborted due to the patient‟s SOB on supine position. The patient was scheduled for an
awake Tracheostomy. Intra-OR diagnostic CT scan using O-arm®system(Medtronic, Inc) was performed
before manipulating the airway. With this new information an awake fiberoptic intubation was
accomplished on first attempt. Tracheostomy was successfully performed under GA.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC594
Dysphagia, Hoarseness and a Hypopharyngeal Mass
Brian Kelly, D.O., Michael England, M.D., Marissa Schwartz, B.S., Daniel Flis, M.D., Richard Wein, M.D .
Tufts Medical Center, Boston, MA, USA, Boston University School of Medicine, Boston, MA, USA.
A 67 year old male developed a hypopharyngeal mass while taking clopidogrel for CAD. He had a history
of progressive dysphagia and hoarseness. CT scan revealed a retropharyngeal mass of unclear
etiology.His airway was determined to be stable. After admission to the ICU for a clopidogrel "washout",
Copyright © 2014 American Society of Anesthesiologists
surgical exploration proceded. His airway was safely secured and a hematoma along with a cervical
osteophyte were removed. This case report emphasizes the importance of preoperative evaluation,
specifically medication and recent symptomatology, communication with the surgical team, and airway
management.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC595
Management of Tracheostomy Tube During Esophageal Stent Placement in Patient with
Tracheoesophageal Fistula
Daanish M. Khaja, M.D., Katharina Beckmann, M.D . Anesthesiology, University of Illinois at Chicago,
Oak Park, IL, USA, Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA.
A 65 year-old female with rheumatoid arthritis complicated by pulmonary fibrosis requiring long term
tracheostomy for respiratory failure presented for esophageal stenting. Her tracheostomy cuff eroded into
the esophagus causing a large tracheoesophageal fistula. A large air leak into the esophagus prevented
adequate ventilation requiring ENT evaluation prior to proceeding. Tracheostomy was exchanged and
placed properly by ENT service with bronchoscope guidance distal to fistula with slight improvement.
During stent placement, trach cuff was deflated to avoid cuff rupture. After stenting, ventilation difficulties
resolved completely. This case highlights important anesthetic considerations for patients with
tracheoesophageal fistulas and interdisciplinary communication.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Pediatric Anesthesia (PD) MC596
IV or not IV? Inhalation Induction in a Complex Pediatric Airway
Stefan T. Samuelson, Adam I. Levine, M.D . Anesthesiology, Icahn School of Medicine at Mount Sinai,
New York, NY, USA.
An 11 year-old girl with complex lung disease required bronchoscopy. Long intubation in infancy left her
with subglottic stenosis and permanent tracheostomy. She had severe needle phobia and displayed
psychological trauma after previous attempts at inhalation induction using facial and tracheal masks were
protracted due to her complex airway.The patient was allowed to decannulate her own tracheostomy and
lidocaine was gradually trickled in. A lubricated 5.0 ETT was inserted, the cuff inflated, and a circuit
primed with sevoflurane was attached. Induction was rapid and smooth. The ETT was upsized for
bronchoscopy and the patient was extubated postoperatively without incident.
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Pediatric Anesthesia (PD) MC597
A Challenging Anesthetic Management: Endoscopic Procedures in a Child with Epidermolysis
Bullosa
Alexandra P. Saraiva, M.D., Sara Pedrosa, Fernanda Barros, M.D. . Centro Hospitalar do Porto, Porto,
Portugal, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal, Centro Hospitalar de São João, Porto,
Portugal.
We describe the anesthethic management of a 3-year-old girl with Epidermolysis bullosa, a rare genetic
mechanobullous disorder, proposed for endoscopy and broncofibroscopy.Avoiding mechanical injury to
the skin and mucosae is essential. We used gloves greased with vaseline to manipulate the child.
Electrocardiography electrodes were placed over defib-pads. The oxymeter was protected with
tegaderm®. Blood pressure monitoring was avoided. The eyes were protected with paraffin gauze, as
well as the facial mask. The patient layed in a thin gel mattress to avoid pressure injuries specially on
bony protuberances. Procedures were conducted uneventfully. No single new bulla was detected
afterwards.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Pediatric Anesthesia (PD) MC598
The Rare and Severe Hoyeraal-Hreiddarsson Syndrome, Associated With a Cyanotic Cardiopathy
and Pulmonary Fibrosis: Anesthetic Management of a Child for Dental Extrations Prior to Cardiac
Surgery
Alexandra P. Saraiva, M.D., Sónia Duarte, D.O., Rita Frada, Pedro Pina. Centro Hospitalar do Porto,
Porto, Portugal.
Hoyeraal-Hreiddarsson (HH) is a severe form of Dyskeratosis Congenita, a bone marrow failure fatal
syndrome. We describe the management of a 5-year-old girl with HH proposed for dental extractions,
diagnosed with cyanotic cardiopathy (superior vena cava thrombosis diverted all the blood to the left
atrium) and pulmonary fibrosis.Induction was accomplished with intravenous fentanyl (5 μg/Kg), propofol
(3 mg/Kg) and rocuronium (0,6 mg/Kg), followed by intubation.Sevoflurane for a BIS 40-60 was used for
maintenance. Adequate ventilation controlled by pressure was achieved.Hemodynamic and respiratory
stability at all times.ABG pre-extubation retrieved normal values. The patient was uneventfully extubated.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Pediatric Anesthesia (PD) MC599
Pop on Induction; An Unanticipated Complete Airway Obstruction In A Child for Dental Surgery
Poovendran Saththasivam, M.D . Anesthesiology, Drexel University College of Medicine, Philadelphia,
PA, USA.
Mask induction was attempted on a child for routine dental extraction but became increasingly difficult.
Upon arterial desaturation, succinylcholine was given, and after a few attempted positive pressure
ventilation, distinct „pop‟ was felt and ventilation became easy with equal bilateral chest movement, good
end tidal CO2 waveform and increasing saturation from 80‟s to 100%Direct laryngoscopy with Miller blade
size 2 revealed cloth like material wrapping around the laryngeal inlet. The foreign body was extracted
carefully using Magill forceps. Thereafter, nasal intubation was done and the case then proceeded
uneventfully with successful awake extubation at the end of the case.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Pediatric Anesthesia (PD) MC600
Perioperative Anesthetic Management for a Juvenile Patient with Angelman Syndrome
Tsuyoshi Satsumae, M.D., Makoto Tanaka, M.D . Anesthesiology, University of Tsukuba, Tsukuba-City,
Japan.
A 15-year-old girl with Angelman syndrome underwent scoliosis surgery under general anesthesia. With
the mother accompanying the patient into the operating room, and with slow induction of general
anesthesia using a mask with odor with the continued presence of her mother, we could smoothly induce
anesthesia in our patient. Ventilation was easy, and intubation was rather more straightforward than
usual. Clinically significant extension of muscle relaxant effects was not observed in our present case.
With dexmedetomidine sedation, we were able to ensure satisfactory rest both before and after
extubation. Mild bradycardia and hypotension were observed during the perioperative period.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Pediatric Anesthesia (PD) MC601
The Anesthetic Challenges in Caring for an Obese Pediatric Patient Undergoing Dental Surgery
Rebecca L. Scholl, M.D., Shridevi Pandya Shah, M.D . Anesthesiology, Rutgers - New Jersey Medical
School, Newark, NJ, USA.
Owing to the epidemic prevalence of childhood obesity in the United States, anesthesiologists are
increasingly responsible for the care of overweight or obese pediatric patients. Although the risks of
anesthetizing obese adults are clearly defined, there is a paucity of established safety guidelines to
support the specific and unique anesthetic concerns of the obese child. This is the case of a three-yearold male weighing 44 kg (BMI=32.2 kg·m-2) presenting for dental rehabilitation. The successful outcome
Copyright © 2014 American Society of Anesthesiologists
of this case serves to underscore the importance of recognizing the perioperative risks associated with
this widespread but poorly understood condition.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Pediatric Anesthesia (PD) MC602
Suspected Case of Malignant Hyperthermia During Resection of a Sacrococcygeal Teratoma
Roby Sebastian, M.D., Anita Joselyn, M.D., Rita Banoub, M.D . Anesthesiology, Nationwide Children's
Hospital, Dublin, OH, USA, Nationwide Children's Hospital, Dublin, OH, USA.
We report a suspected case of malignant hyperthermia (MH) in a neonate who underwent resection of a
large sacrococcygeal teratoma. Anesthetic management included induction and maintenance with
sevoflurane with intermittent doses of fentanyl. The first 4 hours of surgery was uneventful. Then the
heart rate gradually increased reaching 235 bpm, followed by profound hypercapnea and temperature of
38.6° C. Patient was initially treated with adenosine for supraventricular tachycardia with no effect. MH
was suspected, MH protocol was initiated, sevoflurane was discontinued and treated with dantrolene,
hyperventilation and ice packs. The patient‟s vitals returned to baseline within 20 minutes of treatment.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Pediatric Anesthesia (PD) MC603
A Case of Russell Silver Syndrome
Mehul Shah, D.O., Nikhil Thakkar, M.D . Anesthesiology, Baystate Medical Center, Springfield, MA, USA.
A 14 month old boy with a rare genetic disorder of Russell Silver syndrome associated with failure to
thrive, low birthweight, poor postnatal growth, asymmetry, micrognathia and characteristic facies
presented for hypospadias repair. Inhalation induction with jaw thrust and LMA insertion was performed in
conjunction with difficult intravenous access. Upon attempting a caudal analgesia, a sacral dimple was
noticed. A thorough ultrasound scan of the lumbosacral area was performed and subsequently used to
aid in the insertion of a caudal anesthetic. He had an uneventful general/ caudal anesthesia course with
no perioperative complications.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Pediatric Anesthesia (PD) MC604
Ventricuar Bigeminy and Hypotension on Induction During an Elective Microsurgial Varicocele
Repair in a 12-Year-Old Male
Michelle Shirak, M.D., Jung Hee Han, M.D . Anesthesiology, Weill Cornell Medical Center, New York, NY,
USA.
This is a 12 yo male with no reported past medical history undergoing an elective microsurgical
varicocelectomy under general anesthesia with an iGel. Soon after induction he was noted to be in
bradycardic bigeminy with hypotension and dynamic ST changes. He was noted to have a systolic
murmur which improved with resolution in hypotension. He was managed with fluids and intermittent
pressor boluses. Postoperatively his mother offered that he actually had been having some dizzy spells in
gym class. Cardiology was consulted and it was found that he had hypertrophic cardiomyopthy on TTE.
Sunday, October 12, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC605
Anesthetic Management of a Patient with a Giant Back Mass
Tuong Nguyen, D.O., Alison M. Alpert, M.D . Department of Anesthesiology, St. Louis University Hospital,
St. Louis, MO, USA.
This 70 year old woman presented with a large back melanoma, for which she refused treatment five
years prior to admission. The mass measured 30 x 27 cm and had become painful, making it difficult for
her to stand or sit. The patient was anemic prior to the procedure with initial hemoglobin 6.8, 8.3 g/dl after
transfusion. The patient was intubated with a CMAC while in the lateral position and was then placed
prone. She was transfused two units of PRBC‟s during the procedure. Postoperative pain was controlled
with IV methadone and patient was monitored prone in the ICU overnight.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC606
Airway Management in a Patient with a Traumatic Hyoid Bone Fracture
Dora N. Ngwang, M.D., Charles Smith, M.D., Samuel DeJoy, M.D. . Anesthesiology, Case Western/
MetroHealth, Cleveland, OH, USA, Anesthesiology, Case Westren/ MetroHealth, Cleveland, OH, USA,
Case Western/ MetroHealth, Cleveland, OH, USA.
59 year old helmeted female hit the back of a car while riding her motorcycle. Major injuries consisted of a
grossly deformed left forearm, C5 anterior edge endplate fracture, an acute fracture of the left hyoid bone
and superior horn of the left thyroid cartilage. She was scheduled for ORIF of the radius fracture. A
Glidescope was used with in-line immobilization after necessary fiberoptic imaging of the airway to
examine for occult etiologies of airway compromise. Appropriate equipment and personnel were available
in the OR to perform an emergent surgical airway on induction and intubation
Sunday, October 12, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC607
A Modified Nasal Intubation by Using a Bougie in a Patient with Facial Injury
Yuvraj S. Nijjar, M.D., Heather Gray, M.D., Hui Yuan, M.D . Anesthesiology & Critical Care Medicine, St.
Louis University, Saint Louis, MO, USA.
An 18-year-old male s/p MVC and extrication with multiple injuries, including bilateral mandibular
fractures, bilateral occipital condyle fractures with cervical coller in place for open reduction-internal
fixation and mandibulomaxillary fixation of bilateral mandibles. With cervical collar in place, a bougie was
passed via the right nare and introduced through the vocal cords using CMAC, yielding good view of
laryngeal region. Subsequently, a 7.0 Nasal RAE tube was placed over bougie. Via intubation over
bougie, the endotracheal tube passed easily with minimal trauma to soft tissue and no manipulation of the
neck or face to exacerbate any underlying injuries or fractures.
Sunday, October 12, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC608
Catastrophic Intraoperative Pulmonary Fat Embolism in Setting of Intramedullary Nailing of Right
Femur Fracture
Yuvraj S. Nijjar, M.D., Ritesh Patel, M.D . Anesthesiology & Critical Care Medicine, St. Louis University,
Saint Louis, MO, USA.
84 year-old female with HTN and CAD underwent intramedullary nailing of right femur fracture.
Intraoperatively, patient developed severe hemodynamic instability requiring line placement and
vasopressor support, and ultimately cardiac arrest necessitating cardiopulmonary resuscitation.
Procedure was aborted due to development of severe hypoxemia and shock. Post-operative
echocardiogram revealed severe right heart dilation and hypokinesis and severe tricuspid regurgitation.
Patient was transferred to the ICU where she again developed cardiac arrest requiring resuscitation. Her
condition continued to deteriorate and patient eventually died of multiorgan failure secondary to
pulmonary fat embolism.
Sunday, October 12, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC609
Emergency Intubation: When Halo Saved the Day
Irida Nikolla, M.D., Heather Nixon, M.D . Anesthesiology, University of Illinois at Chicago, Chicago, IL,
USA.
Unrecognized mediastinal mass may complicate emergent endotracheal intubation. We present the
emergent intubation of a 37yo female with PMH of breast CA (in halo vest for metastases to spine),
sepsis, respiratory distress and AMS while actively seizing. Scant information was available, but due to
halo vest, a fiberoptic intubation w/o paralysis was attempted with trouble advancing the ETT and
subsequent collapse of the ETT. After discovery of her large mediastinal mass, pt position was changed
Copyright © 2014 American Society of Anesthesiologists
with improvement in ventilation. This case highlights that difficult advancement and collapse of the ETT
may clue providers to the presence of a mediastinal mass.
Sunday, October 12, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC610
Difficult Exchange of ETT in a Transoral Robotic Resection of Supraglotic Laryngeal Tumor
Irida Nikolla, M.D., Florin Orza, M.D . Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA.
I present the case of a 55 yo male who presented for transoral robotic resection of supraglotic tumor.
Patient had RSI with propofol and succhinylcholine followed by glidescope with good view of cords but
difficulty maneuvering the ETT. 4 hours into the case was noted the the laser protective layer of the tube
had worn off; decision was made to exchange the tube through cook exchanger, with difficulty in passing
the replacement tube, and 3rd attempt being successful. We are presenting this case in demonstrating
some of the peculiar challenges of robotic ENT surgery.
Sunday, October 12, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC611
Flash Bomb: A Case of Fire and Hypoxia
Omolola Salaam, Aden Bronstein, M.D., Kalpana Tyagaraj, M.D . Maimonides Medical Center, Brooklyn,
NY, USA.
We are presenting a case of a 75 YO male with history of lung cancer and COPD.Induction and tracheal
intubation with left sided DLT size 39 was uneventful, and positioned atraumatically with fiberoptic
bronchoscopy. During case, sudden, precipitous drop in end tidal CO2 noted. Fiberoptic bronchoscopy
revealed optimal positioning. Severe hypotension followed by bradycardia in the setting of brisk bleeding
in the surgical field. Pulmonary air embolism suspected. Field was flooded with saline, bed tilted.
Abdomen noted to be markedly distended and intraoperative x-rays showed pneumoperitoneum.
Laparotomy performed and complicated by intraoperative fire upon entry into abdomen with
electrocautery.
Sunday, October 12, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC612
Urgent ORIF of Bilateral Mandibular Fractures with Possible Facial Nerve Monitoring in a 74 yearold Male with Charcot-Marie-tooth Disease
Lenore Salman, D.O., Mari Baldwin, M.D . Anesthesiology, ICAHN School of Medicine at Mount Sinai/St
Luke's-Roosevelt Hospital Center, New York, NY, USA, Anesthesiology, ICAHN School of Medicine at
Mount Sinai/St Luke's-Roosevelt Hospital Center, New York City, NY, USA.
Charcot-Marie-Tooth disease is a hereditary peripheral neuropathy that manifests as a chronic peripheral
neuromuscular denervation. Patients have muscle atrophy-which causes deformities of the limbs and
spine- as well as weakness and sensory deficiencies. General anesthesia has been described in these
patients and the major considerations include avoidance of non-depolarizing and prolonged action of nondepolarizing muscle relaxants. We present a case of a patient with Charcot-Marie Tooth disease for an
urgent ORIF of bilateral mandibular fractures with possible facial nerve monitoring. We describe how we
went about anesthetizing this patient and collaborated with the surgeons to achieve a positive outcome.
Sunday, October 12, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC613
If it Walks Like a Duck: Intra-abdominal Arterial Bleed Masquerading as Hyperthermic
Hypotension During HIPEC
Stefan T. Samuelson, M.D., Yury Khelemsky, M.D . Anesthesiology, Icahn School of Medicine at Mount
Sinai, New York, NY, USA.
A previously healthy 52 year-old male with appendiceal cancer underwent extensive open tumor
debulking followed by hyperthermic intraperitoneal chemoperfusion (HIPEC). EBL was reported as
minimal and HIPEC included firm abdominal massage by the surgeons to distribute the chemotherapeutic
Copyright © 2014 American Society of Anesthesiologists
solution. After 45 minutes the patient's MAP, already low, began dropping precipitously. The
anesthesiologist noted pink HIPEC effluent and requested prompt surgical re-exploration. Although
initially resistant, the surgeons discovered and repaired a hepatic arterial bleed. Blood loss was 1.5L and
aggressive resuscitation with fluid, blood, and pressors was required. The patient was extubated in the
OR and discharged home on POD #8.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC06
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Neuroanesthesia (NA) MC614
Neurosurgical Treatment For Epilepsy in a Patient with Right Congenital Pulmonary Hypoplasia
Guillerme D. Braga Netto, M.D., Marco Antonio Resende, M.D.,Ph.D., Ismar Cavalcanti, M.D.,Ph.D.,
Elizabeth Vaz, M.D . Anesthesiology, Universidade Federal Fluminense, Niteroi, Brazil, Universidade
Federal Fluminense, Niteroi, Brazil.
Male, 43y, 180cm, 92kg, right congenital pulmonary hypoplasia undergoing neurosurgical treatment for
temporal epilepsy and hippocampal atrophy due to inability to pharmacologically control his crises:
valproic acid 500mg, carbamazepine 200mg lamotrigine 100mg. Monitoring: SpO2, cardioscope in DII,
invasive arterial pressure, etCO2, right internal jugular vein. Anesthesia: total intravenous general
anesthesia with propofol, remifentanyl and cisatracurium. There were no complications and the patient
went to the ICU. Began showing mental confusion, desaturation and headaches during the week and was
taken back to the OR with a left temporal hemorrhagic stroke. He died 7 days later due to septic shock.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Neuroanesthesia (NA) MC615
Successful Anesthetic Management of a Patient with Adult Polyglucosan Body Disease
Nicholas J. Bremer, M.D., Kenichi Asano, M.D . Department of Anesthesiology, NYU Langone Medical
Center, New York, NY, USA.
Limited information is available on the anesthetic management of Adult Polyglucosan Body Disease
(APBD), a rare neurological disorder with multisystem involvement caused by deficiency of glycogen
branching enzyme. APBD is characterized by mixed upper and lower motor neuron signs, peripheral
neuropathy and sensory loss particularly in distal lower extremities, neurogenic bladder and subsequent
urinary incontinence, and mild cognitive difficulty. No specific treatment is available, but liver
transplantation has been performed with reduction of glycogen storage in both heart and skeletal muscle.
This case describes the anesthestic management of a patient with advanced APBD disease, with
progression to complete paralysis.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Neuroanesthesia (NA) MC616
Patient with Severe Non-Ischemic Cardiomyopathy Presenting for Emergent Decompression of
Posterior Fossa
Marion H. Bussay, M.D., Sabine Kreilinger, M.D.,Ph.D., Guy Edelman, M.D . Anesthesiology, University
of Illinois, Chicago, IL, USA.
A 37 year old morbidly obese male with history of NICM (EF < 10%), AICD and HTN was admitted with
cerebellar ischemic infarction. Acute neurologic deterioration prompted emergent surgical
decompression. After pinning and prone positioning unstable ventricular tachycardia ensued, requiring
defibrillation. Patient was returned into supine position and ACLS with chest compressions and
cardioversion resulted in ROSC. Given high risk for cerebellar herniation decision was made to proceed
with surgery. Following cardiopulmonary optimization, successful decompressive occipital craniectomy
and strokectomy was performed in the sitting position. Postoperatively the patient made a full neurologic
recovery and returned to his preoperative cardiovascular status.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Neuroanesthesia (NA) MC617
Delayed Tension Pneumothorax Following Difficult Subclavian Central Line Placement With Initial
Negative Chest Xray and Negative Intraoperative Ultrasound
Marion H. Bussay, M.D., Sabine Kreilinger, M.D.,Ph.D., Verna Baughman, M.D . Anesthesiology,
University of Illinois, Chicago, IL, USA.
A 47 y/o morbidly obese female presented for emergent craniotomy and aneurysm clipping. Several
attempts to place a central line preoperatively were unsuccessful, followed by a normal chest xray in
supine positioning. A subclavian central line was subsequently placed intraoperatively. Initially, no
changes in airway compliance were noted. During surgery intermittent desaturation and subtle increases
in peak airway pressure prompted performance of transthoracic ultrasound without evidence of
pneumothorax. Postoperatively, suctioning of mucus plug from ETT resulted in improved oxygenation.
During postoperative angiography, fluoroscopy showed a large tension pneumothorax, requiring chest
tube placement. The patient remained hemodynamically stable throughout the events.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Neuroanesthesia (NA) MC618
Simple Nasal CPAP Circuit Prevented Oxygen Desaturation in Morbidly Obese Patient During
Awake Bilateral DBS Stereotactic Lead Placement with Neurological Assessments
Gianna Casini, M.D., Christian McDonough, M.D., Stefanie Berman, M.D., Christine Hunter Fratzola,
M.D., James T. Tse, M.D.,Ph.D . Anesthesiology, Rutgers Robert Wood Johnson Medical School, New
Brunswick, NJ, USA.
59 y/o male (BMI 39 kg/m2) with Parkinson's Disease presented for Deep Brain Stimulation. Patient
deemed high risk for OSA, showing concern for obstruction with propofol boluses (20-30 mg) during head
pinning. A well-lubricated (5% lidocaine) nasal trumpet (34Fr) was inserted and connected to ETT
connector (6.0), breathing circuit and anesthesia machine delivering 4 L/min O2 and 1 L/min air.
Pressure-relief valve was adjusted to deliver 5-7 cm H2O CPAP. He tolerated procedure well under local
anesthesia and propofol sedation (100 mcg/kg/min). He maintained spontaneous respiration and 98100% O2 saturation (FiO2 0.6) throughout; he was awakened for multiple neurological assessments.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Neuroanesthesia (NA) MC619
Case Report: Anesthetic-Related Neuroprotection in a Case of Prolonged Intra-Operative Cardiac
Arrest with a Positive Neurological Outcome
Debbie Chandler, M.D., Islaam Elnagar, M.D., Chizoba Mosieri, M.D., Shilpadevi Patil, M.D. , Charles
Fox, III, M.D. LSU Shreveport, Shreveport, LA, USA.
We present the case of a 57 year old male undergoing radical nephrectomy for a primary renal
malignancy with tumor thrombus invading the inferior vena cava who experienced a prolonged cardiac
arrest secondary to massive, rapid blood loss upon dissection of the inferior vena cava. The patient was
resuscitated for over 30 minutes with standard code medications, multiple cardioversions applied directly
to exposed heart, direct cardiac massage, and massive transfusion before a stable blood pressure and
heart rate were achieved. The patient was extubated on the second post-operative day with no apparent
neurological injury
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Neuroanesthesia (NA) MC620
Excision of a Dural AV Fistula in a Parturient
Verghese T. Cherian, M.D., F.C.A.R.C.S.I., Chase Altom, M.D . Anesthesiology, Penn State Hershey
Medical Center, Hershey, PA, USA.
A 25y old, female, 33w pregnant, presented with severe headache, and was diagnosed to have a dural
AV fistula with intra-parenchymal hemorrhage.The goal was to avoid premature labor during her temporoparietal craniotomy and excision of the AV fistula. The perioperative challenges of this case included: 1)
Copyright © 2014 American Society of Anesthesiologists
monitoring the mother and fetus, during and after surgery; 2) appropriate positioning required for
adequate surgical access while avoiding aortocaval compression; and 3) conflicting requirements for
managing a gravid uterus and a brain with raised intra-cranial pressure. A good understanding of
neurological and parturient physiology and pharmacodynamics of the drugs used was crucial.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Neuroanesthesia (NA) MC621
Intraoperative PEA Cardiac Arrest in the Prone Position with Unstable Cervical Spine Fracture in
Mayfield Frame
Sean Claar, M.D., Lavinia M. Kolarczyk, M.D., Robert S. Isaak, M.D., Louie G. Jain, M.D., David
Hardman, M.D., James H. Williams, M.D . Anesthesiology, University of North Carolina, Chapel Hill, NC,
USA.
We present a case of pulseless electrical activity arrest in an 85 year old male undergoing operative
fixation of a cervical spine fracture. Two hours after induction the patient exhibited rapid onset
hypotension, unresponsive to low-dose vasopressin and epinephrine, with rapid progression to PEA
arrest. Advanced cardiac life support protocol was followed with modified prone chest compressions to
minimize cervical spine movement as the surgical team prepared for emergency supine positioning.
Spontaneous circulation was achieved prior to repositioning. Rescue TEE was utilized in an attempt to
identify the etiology of the cardiac arrest and assist the surgical decision making process.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Neuroanesthesia (NA) MC622
From Bowel to the Brain: A Diagnosis of MoyaMoya Disease Following Colonoscopy
Meghan Cohen, M.D., Anthony Silipo, M.D . University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Patient is a 51 year old female with a history of SVT, migraines and rectal neuroendocrine tumor who
underwent diagnostic colonoscopy and developed transient right sided weakness and slurred speech
post-procedure. She was diagnosed with MoyaMoya disease following angiographic evidence. Her
symptoms were attributed to intra-operative hypotension. The patient later required a second
colonoscopy, and careful steps were taken to avoid hemodynamic instability and subsequent cerebral
ischemia during MAC anesthesia. The second colonoscopy was successful and the patient did not
develop any changes in neurologic status peri-operatively.
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Cardiac Anesthesia (CA) MC623
Persistent Refractory Hypoxemia during Venovenous ECMO using a Double Lumen Avalon
Cannula in a Patient with H1N1 Influenza
Lauren G. Hinds, M.D., Mark A. Banks, M.D., Manuel R. Castresana, M.D., Shvetank Agarwal, M.D .
Anesthesiology and Perioperative Medicine, Georgia Regents University, Augusta, GA, USA.
A 41 yo female presented to our hospital with severe hypoxemia refractory to multiple modes of
mechanical ventilation. A possible diagnosis of H1N1 influenza was made and she was brought to the OR
emergently for initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) under
general anesthesia. A double lumen VV-ECMO cannula (Avalon Elite) was placed in her right internal
jugular vein under TEE guidance. Obesity and short neck created challenges in positioning the outflow
port with only mild improvement in blood oxygenation. In this case, we review the advantages of and
challenges in using DLVV-ECMO versus the more traditional two-site VV-ECMO.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Cardiac Anesthesia (CA) MC624
A Case of Fibrolamellar Hepatocellular Carcinoma Invading into the Right Heart
Jessica R. Hiruma, M.D., Zarah Antongiorgi, M.D., Komal D. Patel, M.D . Anesthesiology, Ronald Reagan
UCLA Med Ctr, Los Angeles, CA, USA.
Copyright © 2014 American Society of Anesthesiologists
An 18-year-old male with a large left hepatic lobe mass with extention into the IVC and right atrium was
admitted to UCLA with altered mental status and acute liver decompensation. A hemodialysis catheter
was placed under TEE guidance and sustained low efficiency dialysis was initiated to remove ammonia
without acute preload reduction. He was taken to the OR with plans to remove intracardiac tumor followed
by liver resection or transplant based on manual examination of tumor extension. The surgery required
extensive communication between surgical services and anesthesiologists, with many surgical decisions
made in the operating room based on TEE imaging.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Cardiac Anesthesia (CA) MC625
Brain vs. Heart: What Goes First?
Yili Huang, D.O., Trevor Banack, M.D., Ramachandran Ramani, M.D . Anesthesiology, Yale-New Haven
Hospital, New Haven, CT, USA.
56yo male presents with a pituitary adenoma with hemorrhagic components, associated with headaches.
Imaging revealed an ascending aortic aneurysm and subsequent cardiac catheterization revealed it to be
5.5cm with associated AI, but because of potential exacerbation associated with anticoagulation
necessary for cardiac repair, the decision was made to perform pituitary tumor resection first. Postinduction, pre-incision TEE demonstrated a dissection flap in the aortic root. The resection was aborted
after a discussion among anesthesia, neuro, and cardiac surgery until the ascending aorta was repaired.
Bentall procedure was scheduled and performed. The patient returned 2 months later for pituitary tumor
resection.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Cardiac Anesthesia (CA) MC626
Acute Right Ventricular Failure in a Post Cardiac Transplant Patient Presenting for Cadaveric
Kidney Transplant
Angela R. Ingram, Jonathan Gal, M.D., Meg Rosenblatt, M.D . The Mount Sinai Hospital, New York, NY,
USA.
A 48 year-old male with two prior heart transplants presented for a cadaveric kidney transplant, during
which he became increasingly hemodynamically unstable, with escalating tachycardia and refractory
hypotension. TEE was used to diagnose acute non-dilated right ventricular heart failure, likely secondary
to acute pulmonary hypertension and chronic constrictive pericarditis as a result of prior cardiac surgeries.
A multidisciplinary team approach was employed perioperatively to manage the acute right ventricular
heart failure which was unresponsive to traditional therapies, including fluids, pressors and inotropes.
Various strategies were employed to ensure patient survival throughout surgery and into the immediate
postoperative period.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Cardiac Anesthesia (CA) MC627
Massive Bilateral Pulmonary Emboli in a Patient with a Failed Fontan
Harold G. Jackson, M.D., Naila Ahmad, M.D . St. Louis University, Saint Louis, MO, USA.
This case describes a 14 year old female with failed Fontan circulation, admitted with symptoms of
worsening heart failure. During cardiac catheterization prior to heart transplant, she was incidentally found
to have massive bilateral pulmonary emboli secondary to protein losing enteropathy. PLE is described as
protein loss through the gastrointestinal tract; in this case leading to protein C deficiency. As more of
these children are aging into young adulthood we are likely to see more of the complications of Fontan
circulation in our respective patient populations. These patients challenge all medical services involved in
their care especially the anesthesiologist.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Cardiac Anesthesia (CA) MC628
Prone TEE for Intraoperative Monitoring for Urgent Thoracic Fusion in a Patient with HOCM
Suneil Jolly, M.D., Trevor Banack, M.D . Anesthesiology, Yale-New Haven Hospital, New Haven, CT,
USA.
21 yo female with PMHx of HOCM, AICD, obesity presented urgently for posterior thoracic fusion s/p
MVA. Preoperatively, cardiology suggested PA catheter for intraoperative hemodynamics. After
discussion with surgery, a TEE and a-line were placed prior to prone positioning and after head pinning.
During TEE while prone, the patient‟s BP dropped abruptly. Examination revealed new severe posterior
mitral regurgitation and nearly complete LVOT obstruction with LVOT gradient doubling. Boluses of LR
and phenylephrine were administered. The BP and TEE findings quickly returned to baseline. No further
obstructive events occurred intraoperatively. The patient was extubated and discharged POD#5 without
any complications.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Cardiac Anesthesia (CA) MC629
Transapical Transcatheter Aortic Valve Implantation in a Jehovah's Witness Patient
Mandisa-Maia Jones-Haywood, M.D . Anesthesia, Wake Forest University School of Medicine, Winston
Salem, NC, USA.
The patient is a 70 year old male Jehovah‟s Witness with severe aortic stenosis. The patient was
determined to be a high risk surgical candidate due to a history of prior sternotomy. He was referred for
transcatheter aortic valve implantation via a transapical approach. The procedure was performed
successfully under general anesthesia. Acute normovolemic hemodilution was performed within a closed
circuit. Intraoperative bleeding was controlled with prothrombin complex concentrate and desmopressin.
The patient was extubated immediately after completion of the procedure and discharged on postoperative day number four with a hemoglobin concentration of 12.3 g/dl.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Cardiac Anesthesia (CA) MC630
Transcatheter Aortic Valve Implantation in a Patient with Myasthenia Gravis
Mandisa-Maia Jones-Haywood, M.D . Anesthesia, Wake Forest University School of Medicine, Winston
Salem, NC, USA.
The patient is an 87 year old male with severe aortic stenosis and multiple comorbidities including
Myasthenia Gravis, end stage renal disease, atrial fibrillation, hypertension and diabetes who presented
for transcatheter aortic valve implantation. The procedure was performed successfully under general
anesthesia without muscle relaxant and the patient was extubated within six hours of the procedure. The
patient had an uneventful hospital course and was discharged on post-operative day number six to a
skilled nursing facility.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Cardiac Anesthesia (CA) MC631
What Would You Do? Left Ventricular Assist Devices and Chest Compressions
Dorothea Kadarian, D.O., Yilliam Rodriguez, M.D . Anesthesiology, Jackson Memorial Hospital/University
of Miami, Miami, FL, USA.
Introduction: Chest compressions are not recommended for patients with left ventricular assist devices
(LVADs) but this may warrant further questioning.Case Report: A patient with an LVAD went into cardiac
arrest requiring CPR. The LVAD was replaced four days later with another episode of cardiac arrest
occurring one month later. Both times chest compressions were performed successfully.Discussion:
Chest compressions are not recommended because of concern of damage to the outflow graft or inflow
tract. To date, there has not been documented damage to the LVAD in patients whom have received
CPR but case reports have documented successful CPR treatment.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Obstetric Anesthesia (OB) MC632
Severe Thrombotic Thrombocytopenic Purpura in Pregnancy Complicated by malpositioned
Plasma Exchange Line
Dominique Y. Moffitt, Dirk J. Varelmann, M.D . Department of Anesthesiology, Perioperative Pain
Medicine, Brigham and Women's Hospital, Boston, MA, USA.
A 31 yo G2P1 presented at 33weeks with thrombotic thrombocytopenic purpura with signs of
thrombocytopenia. Her platelet count dropped from 268G/L to 13 G/L on admission and a central venous
line (CVL) was placed for plasma exchange. The CVL placement was complicated by a carotid artery
puncture, the catheter was found to be partially extraluminal. A cesarean delivery was performed in the
cardiac OR under general anesthesia, with planned CVL removal by interventional radiology with cardiac
surgery standby. A large uterine dehiscence was noted, the baby‟s Apgars were 3 and 8. The mother was
extubated and transferred to the ICU.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Obstetric Anesthesia (OB) MC633
Anesthetic Management of a Pregnant Patient with Severe Right Heart Failure
Dominique Y. Moffitt, Jeffrey Swanson, M.D., James Hardy, M.D., Dirk J. Varelmann, M.D . Brigham and
Women's Hospital, Boston, MA, USA.
A 31 yo G3P0 at 26 weeks gestation presented with acute on chronic heart failure secondary to
eosinophilic myocarditis. Her transthoracic echo demonstrated an extremely small right ventricle, severe
tricuspid regurgitation, and a very dilated right atrium. A multidisciplinary team (obstetrics, cardiac
surgery, anesthesiology) planned for arterial and central line placements before an early epidural with
transfer to a cardiac operating room for delivery. Her labor rapidly progressed and an epidural was placed
without hemodymanic consequences and she precipitously delivered in the obstetric operating room.
Lines were placed after delivery and she was transferred to the cardiac ICU.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Obstetric Anesthesia (OB) MC634
Iatrogenic Pneumocephalus causing Severe Headache and Transient Anisocoria Following
Epidural Placement Using the Loss of Resistance to Air Technique
Michael D. Moffitt, M.D., Hariharan Sundram, M.D . Department of Anesthesiology and Pain Medicine, St.
Elizabeth's Medical Center, Brighton, MA, USA.
A 38 yo primigravida with an uncomplicated intrauterine pregnancy at 41 weeks presented for induction of
labor. Her past medical history included gastroesophageal reflux, hypothyroidism, latent tuberculosis and
chronic Hepatitis C. Following the placement of a labor epidural complicated by unintended dural
puncture, specifically using the loss- of -resistance to air technique, she immediately complained of
nausea, severe headache and had marked unilateral pupil dilation. Urgent head CT confirmed a
diagnosis of pneumocephalus. With conservative management, her symptoms resolved over the next 12
hours. She delivered uneventfully with no permanent neurological impairment. The background, workup,
treatment and recovery are discussed.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Obstetric Anesthesia (OB) MC635
Labor Epidural Analgesia for a Patient with von Willebrand Disease
Adam A. Moheban, M.D., Dmitry Portnoy, M.D . University of California, Irvine, Orange, CA, USA.
A 23 year old with a history of DDAVP responsive von Willebrand disease (vWD) was referred for
preanesthetic consultation at 38 weeks gestation. Recent lab data showed factor activity levels to be
within the physiological range. Hematology note was not available but was requested. The patient stated
she was likely diagnosed with type 1. The following night she presented in active labor and insisted on
having LEA. Despite the missing hematology note confirming type 1 vWD, an epidural catheter was
Copyright © 2014 American Society of Anesthesiologists
placed uneventfully. Her peripartum course was unremarkable. The epidural catheter was removed
without incident immediately after vaginal delivery.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Obstetric Anesthesia (OB) MC636
Case Report: An Obstetric Patient Presenting With Pulmonary Stenosis, Pulmonary
Hypertension,Obstructive Sleep Apnea & Morbid Obesity. The Anesthetic Management.
Chizoba N. Mosieri, M.D., Gurleen Sidhu, M.D . LSUHSC-Shreveport, Shreveport, LA, USA.
Morbidly obese parturient, BMI 72.5 presented to LU at 27 weeks gestation. She was transferred from OB
clinic for continuous BP monitoring and possible pre-eclampsia. Chronic hypertensive on Procardia but
noncompliant. PMH of OSA, Obesity-Hypoventilation Syndrome, non-compliant with nightly BIPAP. BP
was 160s/100s mm Hg and normalized with medication.O2 saturation was in low 80s on room air so
evaluated for hypoxia. She was subsequently discharged after few-days in-hospital treatment but
returned to ER 3-days later in respiratory distress.CXR showed worsening cardiomegaly and enlarged
central pulmonary vasculature. Multidisciplinary team management was instituted at this stage with early
anesthesiology involvement.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Obstetric Anesthesia (OB) MC637
Delivery of a Term Newborn in a Non-compliant Mother with a Congenital Bicuspid Aortic Valve
and Severe Aortic Stenosis
David Gutman, M.D . Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA.
We present the case of a 27 year old woman G2P0010 at 37 weeks gestation admitted for elective
cesarean section due to poorly controlled gestational diabetes and worsening physical tolerance. Pt had a
history of congenital bicuspid aortic valve, diagnosed after her first spontaneous abortion and diminishing
exercise tolerance with her second pregnancy. Patient‟s aortic valve area was 0.9cm2 at 28 weeks
gestation and had worsened to 0.7cm2 at 37 weeks, indicating that her stenosis was critical. She was
delivered uneventfully under general anesthesia by a large multidisciplinary team.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Obstetric Anesthesia (OB) MC638
Massive Intraoperative Pulmonary Embolism in a Postpartum Patient with Tubo-ovarian Abscess
and Septic Right Ovarian Vein Thrombophlebitis
K. Justin Naylor, M.D., Zheng Xie, M.D . Department of Anesthesiology and Critical Care, University of
Chicago, Chicago, IL, USA.
16Y G1P1 admitted with septic thrombophlebitis after uncomplicated normal spontaneous vaginal
delivery and failed medical management. CT showed right ovarian vein thrombus extending into the
inferior vena cava & air in mesenteric veins indicating transient bowel ischemia. T 40.1 C, BP 127/70 HR
180‟s, RR 20‟s, SpO2 100%, taken emergently for exploratory laparotomy & thrombectomy. Intraoperatively had sudden drop in EtCO2, severe hypoxia, and hemodynamic collapse minimally responsive
to epinephrine. CPR initiated, LIJ double lumen cordis placed, TEE consistent with PE, ECMO placed and
tPA given via PA catheter, transferred to the ICU with an open abdomen.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Obstetric Anesthesia (OB) MC639
Neuraxial Anesthesia for Cesarean Section in A Parturient with Active Herpes Zoster (Shingles)
Infection and Crohn’s Disease
Ha V. Nguyen, M.D., Marcelle Blessing, M.D . Department of Anesthesiology, Yale School of Medicine,
New Haven, CT, USA.
A 29 year-old parturient with active herpes zoster infection (shingles) involving her back and flank
presented in active labor and scheduled for cesarean section. She had a complex history of Crohn‟s
disease with numerous abdominal surgeries that suggested possibly lengthy and complicated surgery.
Copyright © 2014 American Society of Anesthesiologists
Anesthetic options were evaluated: her active shingles made neuraxial anesthesia circumspect, but her
obstetricians were concerned about prolonged fetal exposure to general anesthetics. To our knowledge,
no definitive evidence nor case reports exist of neuraxial anesthesia performed in parturients with active
zoster infections. Ultimately, we performed a combined spinal-epidural for this patient with no apparent
complications.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Obstetric Anesthesia (OB) MC640
Unique Challenges in a Parturient With C4/5 Quadriparesis, s/p Harrington Rod, and Difficult
Airway for C-section
Joel D. Nutt, M.D., Natesan Manimekalai, M.D . Department of Anesthesiology, University of Mississippi
Medical Center, Jackson, MS, USA.
31 y/o G1P0 37 week gestation scheduled for elective cesarean section.Her past medical history includes
quadriparesis at C4-C5 level, neurogenic bladder with Indiana pouch, on therapeutic heparin for LLE DVT
during this pregnancy, A1DM, scoliosis corrected with Harrington rod at T3-L5, lumbar decubitus ulcer,
and history of difficult airway from the previous surgery.Regional anesthesia is declined because of
difficult placement and variable outcome due to previous spine surgery, large decubitus ulcer, recent
anticoagulation, and the risk of autonomic dysreflexia. Cesarean section was done under GA using
Glidescope for intubation. Surgery and post-operative period were uneventful.
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Pain Medicine (PN) MC641
The Use of a Low-Dose Ketamine Infusion in the Management of an Acute Pain Crisis in a Patient
with Sickle Cell Disease
Bryan J. Simmons, M.D., Jingping Wang, M.D.,Ph.D., Mark Hoeft, M.D . Massachusetts General Hospital,
Boston, MA, USA.
Pain management of vaso-occlusive pain crises in sickle cell disease (SCD) is challenging. Most patients
require chronic opioid use, leading to opioid tolerance, further contributing to the difficulty in managing
acute pain exacerbations. We present a case of an opioid-tolerant patient with SCD admitted for an acute
pain crisis. The acute pain service was consulted for poor pain control despite escalating doses of IV
morphine. We share our experience with the use of a ketamine infusion as an opioid-sparing analgesic
and review the current literature surrounding the use of ketamine in sickle cell disease.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Pain Medicine (PN) MC642
Intrathecal Drug Delivery Device Occlusion with Persistent Seroma
Eellan Sivanesan, M.D., DeWayne Lockhart, Jr., M.D., Ramon Alegret, M.D., Dennis Patin, M.D . Jackson
Memorial Hospital/University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL, USA.
40 year old female with chronic abdominal pain alleviatedafter implantation of a Medtronic Synchromed II
device delivering intrathecal morphine. Months later, her pain returned and was refractory to increasing
dosages. Aspiration of the side port failed to return cerebrospinal fluid, fluoroscopy revealed a catheter
coiled around itself as a result of a highly mobile pump in seroma. This segment was resected and
successfully replaced. Seroma development is often treated as a minor complication with drainage and
culture, but increased pump mobility harms through multiple mechanisms. We will further discuss tools
available to evaluate function and placement.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Pain Medicine (PN) MC643
Interferential Current Therapy: An Adjunctive Treatment for Chronic Abdominal Pain
Eellan Sivanesan, M.D., Phung Pham, M.D., Maria Forrest, M.D., MBA, Asish Udeshi, M.D., Constantine
Sarantopoulos, M.D.,Ph.D . Jackson Memorial Hospital/University of Miami/Miami VA Healthcare System,
Miami, FL, USA.
Copyright © 2014 American Society of Anesthesiologists
Interferential Current Therapy (ICT) uses percutaneously appliedalternating, criss-crossing 3000-5000 Hz
electrical currents over areas ofpain, to produce analgesia and stimulate muscle function. We report three
cases of successful percutaneous ICT for the management of abdominal pain secondary to diabetic
gastroparesis, chronic pancreatitis, and gastrointestinal dysfunction. Transdermal ICT, delivered via an
RS Medical RS-4i® stimulator onto the abdomen, produced significant relief of abdominal pain in all three
patients and relieved constipation in the second patient. ICT has a potential as a simple, well-tolerated,
safe and possibly cost-effective therapy for abdominal pain and dysfunction of the GI tract.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Pain Medicine (PN) MC644
Suspected Mitral Valve Prolapse Syndrome Confounded by Multiple, Painful Comorbidities: A
Case Report
Daryl Smith, M.D., Matthew Truong. Anesthesiology, University of Rochester, Rochester, NY, USA,
University of Rochester, Rochester, NY, USA.
While the validity of mitral valve prolapse (MVP) syndrome is not proven, a small number of cases have
been reported. In this case, we describe a female with a history of anxiety who presented with severe,
intractable atypical chest pain despite 1 year of multimodal pain management. A thorough workup did not
reveal an explanation for her pain but she was found to have mitral valve abnormalities. We propose that
MVP syndrome can be a diagnosis of exclusion in a patient with mitral valve abnormalities, multiple
comorbidities, and anxiety disorders who presents with chest pain.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Pain Medicine (PN) MC645
Perioperative Management of Patient with Phantom Limb Pain
Kiwon Song, M.D . Anesthesiology, NYU Medical Center, New York, NY, USA.
24 yo M works with sheet metal, had L hand caught in machine while at work, p/w degloving and crush
injury. Taken emergently to OR for revascularization of his left 3rd finger, revision amputation of the left
1st and 2nd fingers, under GETA and infraclavicular block with flexible catheter inserted for intraop and
postop pain control. Starting postop day #1, pt complaining of severe LUE pain despite the infraclavicular
block catheter in situ, running well and physical exam showing LUE numb to any pain sensation. Pain
management consulted. Started on gabapentin, amitriptyline. Pt reported reduction of pain with the
regimen.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Pain Medicine (PN) MC646
Acute Median Nerve Injury in a Pediatric Patient: A Multidisciplinary Approach to Pain
Management
Anthony T. Tantoco, M.D., Christine Carqueville, M.D., David Dickerson, M.D . Department of Anesthesia
and Critical Care, University of Chicago Medicine, Chicago, IL, USA.
A 10 year-old-girl presented after sustaining a closed dislocation of her right elbow resulting in a median
nerve injury, neuropathy, and the development of severe pain refractory to parenteral opioids. Pain
service consultation advised a multidisciplinary approach utilizing child psychiatry, physical therapy (PT)
and multimodal analgesia via dexmedetomidine, ketamine and lidocaine, gabapentinoids, steroids, and
methadone. She was discharged on hospital day nine, comfortable, on methadone, topical lidocaine, and
gabapentin. Two weeks post-discharge, the patient reported improved functionality and pain control with
PT and her discharge medications.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Pain Medicine (PN) MC647
Neuropathic Pain and Allodynia in a Patient With Ehlers-Danlos and Short Bowel Syndrome:
Targeting the NMDA Receptor
Copyright © 2014 American Society of Anesthesiologists
Christopher J. Thacker, Michelle A. O. Kinney, M.D . Anesthesiology, The Mayo Clinic, Rochester, MN,
USA.
We present a 21 year-old female with Ehlers-Danlos, thrombophilia, and short bowel syndrome
secondary to superior mesenteric thrombotic occlusion requiring resection of all but 80 cm of small bowel.
Arterial dissections and thrombi caused severe lower extremity ischemia-induced neuropathy requiring
significant use of IV opiates and ketamine. Her short bowel syndrome (estimated PO absorption of 30%)
and significant allodynia made conversion to oral medications challenging. Frequent doses of NMDAantagonists including memantine (10 mg po QID), methadone (15 mg po QID), and ketamine (60 mg po
TID PRN) were helpful. Pregabalin (400 mg po QID) and opiates were also used.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Pain Medicine (PN) MC648
Managing Post-thoracotomy Pain After Conversion to Open for Bronchial Injury with Preceding
Exparel Use
Cesar L. Velazquez-Negron, M.D., Jordan Yokley, M.D . Walter Reed National Military Medical Center,
Bethesda, MD, USA.
65yo F w/ PMH relevant for COPD presented for robotic assisted right lung resection and mediastinal
LND. All access sites were preinjected with Exparel® (liposomal bupivacaine). During dissection the RUL
bronchial takeoff was injured and was converted to an open thoracotomy. A ketamine bolus and infusion
was started in the OR for post-op analgesia. Due to concern for an epidural in the setting of Exparel®
use, the ketamine infusion was continued for 2 days with adequate analgesia and respiratory mechanics.
A thoracic epidural was place on day 2 and used for an additional 3 days with no post-operative
complications.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Pain Medicine (PN) MC649
Pain Management with High Dose Ketamine in a Surgically Active Poly-Trauma Patient
Kevin J. Winegar, D.O., Joseph Le, D.O., Peter Willet, M.D., Anthony Scherschel, M.D., Cynthia Shields,
M.D . Walter Reed National Military Medical Center, Bethesda, MD, USA.
A twenty-nineyear-old female presented with severe orthopedic, vascular and visceralinjuries following a
parachuting accident. She had multiple surgeries andintractable pain despite the use of aggressive multimodal pain management.Simultaneous ketamine (200mg/hour), dexmedetomidine and high dose
opioidinfusions were required for suboptimal pain management (patient in ICU, over sedated and
unwilling to roll or be moved).A high-dose Ketamine infusion was initiated and continued for five dayswith
the patient intubated and ventilated.Following the high-dose ketamine infusion, the patient‟s pain
wasdramatically improved and she required 97% <i>less</i> opioid medication. <i></i>
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Cardiac Anesthesia (CA) MC650
Anesthetic Management of a Stab Wound to the Chest with a Metal Comb
Bukola Ojo, M.D., Marcos Izquierdo, M.D., Tejbir Sidhu, M.D . Anesthesiology, Case Western Reserve
University - Metrohealth Medical Center, Cleveland, OH, USA.
A 38-year-old female presented with a comb penetrating her anterior left chest, in severe chest pain and
orthopnea. Chest X-ray and echocardiogram performed in the emergency department revealed the metal
pick end entering the pericardial space and the left ventricle. The patient underwent a subxiphoid tube
pericardiostomy with removal of the cardiac foreign body under general anesthesia. The patient did well
intraoperatively, was transferred to the ICU, and discharged on postoperative day four. We discuss the
anesthetic concerns for a patient with a mediastinal stab wound with a movable object, and the
importance of intra- and peri-operative echocardiography.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Cardiac Anesthesia (CA) MC651
Persistent Ventricular Fibrillation after Aortic Valve Replacement: Intracoronary Air Embolism
Bukola Ojo, M.D., Sneha Chandra, M.D., Charles E. Smith, M.D . Anesthesiology, Case Western Reserve
University - Metrohealth Medical Center, Cleveland, OH, USA.
A 53-year-old male with severe aortic valve (AV) insufficiency, a bicuspid AV, and normal coronaries
underwent AV replacement. After cross-clamp removal and standard de-airing procedures, the rhythm
was persistent ventricular fibrillation despite multiple cardioversions. TEE revealed severely global
reduced biventricular function and an intense collection of echoes at the septal LV apex. Further de-airing
was done and inotropes, amiodarone, magnesium, and lidocaine administered. Sinus rhythm ensued,
global ventricular function gradually improved, and the hyperechoic densities were now absent. The
patient subsequently did well, and did not require CABG. The presumed diagnosis was acute myocardial
ischemia due to intracoronary air embolism.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Cardiac Anesthesia (CA) MC652
Pacemaker Pseudomalfunction
PASCAL OWUSU-AGYEMANG, M.D., Marc Rozner, M.D.,Ph.D . M.D.Anderson Cancer Center,
Houston, TX, USA.
A 75 year old male with a dual chamber pacemaker for bradycardia underwent partial nephrectomy for
renal cell cancer. Postoperative pacemaker interrogation showed normal function with no abnormalities.
Overnight, he experienced episodes of hypotension, poor urine output and mental status changes despite
adequate heart-rate. Reinterrogation revealed prolonged AV delay approaching 400 msec owing to
“ventricular intrinsic preference (VIP),” designed to reduce RV pacing. VIP was disabled and his AV delay
was set to 200 msec, resulting in the best hemodynamic response. This case demonstrates a pacemaker
pseudomalfunction in which pacemaker features designed to prevent myocardial remodeling contributed
to hemodynamic embarrassment.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Cardiac Anesthesia (CA) MC653
Cardiac Catheterization for Severe RV Hypertension in Setting of Chromosomal Anomaly and TOF
Repair
Michael D. Palmisano, M.D., Barbara Jericho, M.D . Anesthesiology, University of Illinois at Chicago,
Chicago, IL, USA.
We present a 20 year old female with partial trisomy of chromosome 1q who had Tetralogy of Fallot repair
at age 11 years who presented for cardiac catheterization to evaluate her severe right ventricular
hypertension. Her chromosomal anomaly, significant for micrognathia, small mouth, growth retardation,
and mental retardation had potential for difficult intubation. Severe tricuspid regurgitation, right ventricular
hypertension and post TOF repair physiology necessitated careful hemodynamic management. After
grade IV view with standard direct laryngoscopy, successful endotracheal intubation with Glidescope was
achieved. Although the procedure was otherwise uncomplicated, her complex cardiac and airway
anatomy required vigilant planning and care.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Cardiac Anesthesia (CA) MC654
Catecholamine-Induced Myocardial Stunning secondary to Bilateral Pheochromocytoma
Sunhee Park, M.D., Jessica Morgan Cronin, M.D., Gao Wei Dong, M.D., Candice Morrissey, M.D.,
Laeben Lester. Johns Hopkins Hospital, Baltimore, MD, USA.
36 year old woman with a history of neurofibromatosis type 1 presented with acute shortness of breath
and hypertensive crisis. She was found to have bilateral pheochromocytoma and developed stress
cardiomyopathy (EF 5-10%) with signs of multi-organ hypoperfusion. She was placed on extracorporeal
membrane oxygenation (ECMO) preoperatively. The patient then underwent a bilateral adrenalectomy on
Copyright © 2014 American Society of Anesthesiologists
cardiopulmonary bypass with a successful general anesthetic focused on maintenance of intraoperative
hemodynamic stability. Her severe cardiac dysfunction improved post-operatively with ECMO
decannulation on POD#3 and significant clinical recovery (EF 55-60%) by POD#4.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Cardiac Anesthesia (CA) MC655
Managing Anti-coagulation in Heparin-induced Thrombocytopenia/Thrombosis Patient During
Artificial Heart Transplant
Hiral R. Patel, M.D., Timothy R. Pawelek, M.D . Department of Anesthesiology, University of Texas
Health Science Center at Houston, Houston, TX, USA.
65-year-old male with history of CAD s/p stent presented with infero-lateral STEMI s/p PCI. Hospital
course was complicated by post-infarct VSD requiring IABP and Tandem Heart, and Heparin Induced
Thrombocytopenia/Thrombosis (HIT/T) requiring Bivalirudin. Subsequently, patient underwent total
artificial heart transplant. The bleeding risk with other anticoagulants was high due to non-reversibility.
Heparin was reused in spite the history of HIT/T, and was later reversed by protamine. Therapeutic
plasma exchange (TPE) was also performed pre/post surgery with goal to keep HIT antibody titers to
minimal. Peri-operative course was uneventful with no significant thrombosis, bleeding, or coagulopathy;
Bivalirudin was restarted after surgery.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Cardiac Anesthesia (CA) MC656
Fixing the Pipes of a Faulty Plumbing System: Anesthetic Management of Adults with Congenital
Heart Defects
Roshan S. Patel, M.D., Wendy K. Bernstein, M.D . Department of Anesthesiology, University of Maryland,
Baltimore, MD, USA.
Medical advances have resulted in an increasing number of adults living with congenital heart disease.
We present the case of a 50 year-old female with history of surgically corrected anomalous left coronary
artery off the pulmonary artery (ALCAPA) who presented for revision and coronary artery bypass grafting.
The complex physiology of this patient required a perioperative strategy to minimize coronary steal and
myocardial ischemia while maintaining stable hemodynamics and preventing arrhythmias. The successful
anesthetic management of this high-risk patient facilitated an uneventful perioperative course and
enabled her to be discharged on POD4 without sequelae.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Cardiac Anesthesia (CA) MC657
Rare Iatrogenic Internal Iliac Artery Injury During Lumbar Microdiscectomy
Shachi C. Patel, M.D., John Mitchell, M.D., Autumn Brockman, M.D., Selina Long, M.D., Robina Matyal,
M.D . Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Brookline,
MA, USA.
A 41-year-old female underwent elective right-sided L4-L5 microdiscectomy for lumbar disk herniation.
Intraoperatively, the patient developed refractory hypotension without tachycardia, despite immediate
volume resuscitation and vasopressor support. Bedside TTE was vital in ruling out pericardial effusion,
RV strain, and regional wall motion abnormalities, and proved successful for showing for poor ventricular
filling. A retroperitoneal bleed was highly suspected due to patient‟s abdominal pain, hemodynamic
instability, and TTE findings. Due to rapid mobilization of hospital resources, CTA was used as a
diagnostic tool to identify right internal iliac artery perforation with subsequent minimally invasive
endovascular repair of arterial injury.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Cardiac Anesthesia (CA) MC658
Systolic Anterior Motion of Mitral Valve Detected by Paradoxical Response to Epinephrine
Adrian B. Pichurko, M.D., Heike Knorpp, M.D . Department of Anesthesiology, University of Illinois,
Chicago, IL, USA.
A 51 year-old ASA III male underwent an orthotopic liver transplant. He required two attempts clamping
the IVC, but otherwise initial hemodynamics were unremarkable. Initial transesophageal echocardiogram
(TEE) revealed an ejection fraction of 65-70% and an elongated anterior mitral leaflet, but otherwise
unremarkable anatomy. Following reperfusion, epinephrine was administered to treat hypotension;
however, hypotension worsened despite an increase in heart rate. Outflow tract obstruction was
suspected and prompted re-examination with TEE, which revealed systolic anterior motion (SAM) causing
dynamic outflow tract obstruction. Epinephrine was discontinued in favor of phenylephrine with
improvement in hemodynamics. The patient completed the anesthetic without complication.
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Critical Care Medicine (CC) MC659
Anesthesia for Electroconvulsive Therapies in a Catatonic Patient with Neuroleptic Malignant
Syndrome
Ryan E. Hofer, M.D., David W. Barbara, M.D . Anesthesiology, Mayo Clinic, Rochester, MN, USA.
A 48-year-old male with schizophrenia treated with asenapine presented with altered mental status,
fevers, cogwheel rigidity, and elevated creatine kinase. Neuroleptic malignant syndrome (NMS) was
diagnosed and treatment with dantrolene initiated. Endotracheal intubation and intensive care unit
admission were eventually required for hypoxemia secondary to inability to clear secretions. Serial
electroconvulsive therapies under anesthesia were performed for approximately two weeks.
Controversies exist regarding optimal anesthetic management for electroconvulsive therapy and the
safety of succinylcholine in these patients with coexisting NMS. In this case we present the varying
anesthetics that our patient safely underwent during his prolonged hospital course.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Critical Care Medicine (CC) MC660
Spontaneous Tension Pneumoperitoneum: An Uncommon Etiology of Asystole Code
Patricia Hooper, M.D., Tomasina Q. Parker-Actlis, M.D., Beth Townsend, M.D. , Billy Branch, M.D., Raj
Makadia, M.D., Scott J. Howard, D.O.. Anesthesiology, LSU Health Sciences Ctr, Shreveport, LA, USA,
Anesthesiology, LSU Health Science Center, Shreveport, LA, USA, Surgery, LSU Health Science
Center, Shreveport, LA, USA, Internal Medicine, LSU Health Science Center, Shreveport, LA, USA,
Family Medicine, LSU Health Science Center, Shreveport, LA, USA, Critical Care, LSU Health Science
Center, Shreveport, LA, USA.
Patient is a 69 year-old female who presented to the emergency department complaining of abdominal
pain, nausea and shortness of breath. Patient had undergone left femur pinning for a fracture six days
prior to presentation. In the emergency department she went into asystole. She was resuscitated and
intubated. Imaging demonstrated pneumoperitoneum. She was taken to the operating room and found to
have gastric perforation secondary to necrotic gastric volvulus as well as a large paraesophageal hernia.
The necrotic portion of the stomach was resected. Within one week she extubated and transferred to the
floor in stable condition.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Critical Care Medicine (CC) MC661
Spontaneous Intra-operative Pneumothorax Diagnosed with Ultrasound
Shuyan Huang, M.D., Jacek Wojtczak, M.D . Department of Anesthesiology, University of Rochester
Medical Center, Rochester, NY, USA.
A 61 year-old woman recovering from a motor vehicle accident one-month prior, underwent right
calcaneus ORIF with general anesthesia and an ETT. Past medical history is remarkable for hypertension
Copyright © 2014 American Society of Anesthesiologists
and left pneumothorax, with subsequent removal of the left chest tube. At the completion of the surgery,
the patient was noted to be tachypneic with decreased tidal volumes, tachycardic and hypotensive.
Decision for extubation was deferred. Intra-operative right lung ultrasound revealed the presence of Alines and absence of comet tailing and the sliding sign, confirming the diagnosis of pneumothorax. A
right-sided chest tube was placed by trauma surgery.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Critical Care Medicine (CC) MC662
Right Aortic Arch and Kommerell’s Diverticulum Causing Increased Peak Airway Pressures in an
Intubated Patient
Jai Sailesh Jani, M.D., Mirza Mahdi, M.D., N. Nick Knezevic, M.D.,Ph.D . Anesthesiology, Advocate
Illinois Masonic Medical Center, Chicago, IL, USA.
A 75-year-old gentleman who underwent operative fixation of multiple fractures required intubation and
mechanical ventilation post-operatively for respiratory distress. A CT-scan done on admission had
revealed a right sided aortic arch with an aberrant left subclavian artery and Kommerell‟s diverticulum. A
follow-up chest X-ray revealed that his endotracheal tube (ETT) was high, and was advanced two
centimeters and the patient suddenly developed very high peak inspiratory pressures. Fiberoptic
bronchoscopy was performed and a pulsatile mass was seen just distal to the ETT. The ETT was
withdrawn two centimeters and his peak airway pressures normalized.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Critical Care Medicine (CC) MC663
Hemicorporectomy: The Anesthetic Management
Jenifer MN Jewell, M.D., Zach Kimball, M.D., Eric Ashford, M.D., Daniel Kenady, M.D., Annette Rebel,
M.D. University of Kentucky, Lexington, KY, USA.
Hemicorporectomy, or translumbar amputation, is a complex, last-resort procedure involving removal of
the lower portion of the body due to benign and malignant disorders. Statistically, long term survival
following hemicorporectomy is not favorable; likely due to the procedure complexity, postoperative
complications, and/or the underlying disease process. The procedure is inundated with significant
physiologic implications and complications, including death from pulmonary edema even years following
the procedure. We present a quadriplegic male who underwent hemicorporectomy for chronic
osteomyelitis secondary to sacral decubitus ulcers. This case highlights the perioperative challenges
associated with: body weight/blood volume reductions, pain control and massive fluid shifts.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Critical Care Medicine (CC) MC664
Liver Transplantation in a Patient with Moderate Portopulmonary Hypertension: When to Proceed
Versus Cancel
Benjamin J. Judd, M.D., Muhammad Y. Qadri, M.D.,Ph.D., Robert S. Isaak, D.O., Harendra J. Arora, M.D
. University of North Carolina-Chapel Hill, Chapel Hill, NC, USA.
A 56 year-old man with a history of hepatocellular carcinoma and mild portopulmonary hypertension
(POPH) presented to the operating room for orthotopic liver transplantation. Prior to incision, a
transesophageal echocardiogram was performed and a pulmonary artery catheter was placed. The mean
PA pressures were measured in the low 40‟s, which is moderate to severe. The patient‟s PA pressures
were successfully lowered using inhaled nitric oxide and intravenous epoprostenol. Postoperatively, the
medications were continued and he had no major complications. The dilemma of proceeding versus
cancelling an orthotopic liver transplant prior to incision in the setting of POPH will be discussed.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Critical Care Medicine (CC) MC665
Mechanical Circulatory Support with Impella Device in the Perioperative Period
Lilibeth Fermin, M.D . Anesthesiology, University of Miami, Miami, FL, USA.
A 41 year-old-male with history of cocaine abuse had a cardiac arrest at work. On arrival to hospital, a
transthoracic echo showed ruptured papillary muscle and flail anterior leaflet. Cardiac catheterization did
not reveal coronary artery disease. Impella device was placed secondary to cardiogenic shock. Patient
underwent emergency mitral valve replacement. Post-operative period complicated by cardiogenic shock,
respiratory failure, renal failure, and right parietal infarct. On postoperative day five, the Impella device
was removed. The pharmarcologic inotropic support was weaned off in the following days. This case
illustrates the safe use of Impella for a period over six hours.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Critical Care Medicine (CC) MC666
Management of Post Operative Hemorrhage in a Patient with Acquired Von Willebrand Disease
Secondary to Aortic Stenosis
Malgorzata Kasperska, D.O., Cesar Velazquez-Negron, M.D., Je H. Park, B.S., Ryan Keneally, M.D .
Walter Reed National Military Medical Center, Bethesda, MD, USA, Uniformed Services University of the
Health Sciences, Bethesda, MD, USA.
A 69-year-old Caucasian male with a medical historysignificant for bicuspid aortic valve with severe
stenosis presented to thehospital for aortic valve replacement. Intraoperatively, he
demonstratedworsening coagulopathy and received: pRBCs, Platelets and DDAVP with no improvement.
With the concern for continued postoperative hemorrhage due to acquired von Willebrand disease his
further management included: pRBC, Cryoprecipitate and recombinant Factor VIII/von Willebrand factor.
Over the next 24 hours patient continued to improve and his coagulopathy resolved within 48 hours postoperatively.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Critical Care Medicine (CC) MC667
A Case Report of Suspected Perioperative Anaphylaxis Associated With Sugamadex
Obata Katsuyoshi, M.D.,Ph.D., Ozaki Minobu, M.D., Matsuyama Hiroyuki, M.D.,Ph.D., Matsuyama
Hiroyuki, M.D.,Ph.D . Anesthesiology, Lizuka Hospital, Iizuka, Japan, Lizuka Hospital, Iizuka, Japan.
(Case presentation)Patient was a 39-year old male who was scheduled for ileocecal resection.He had
past medical history of allergy for anti-hemorrhoidal medication. After epidural catheterization,anesthetic
induction was performed(propofol,rocuronium) and general anesthesia was maintained(sevoflurane,
remifentanil and epidural analgesia).Sugamadex was administered for reversal of rocuronium.We
extubated him five minutes later.Nine minutes after sugamadex iv, systemic flush appeared,SpO2 fell and
shock state developed(BP:58/33).We diagnosed anaphylaxis and administerd vesopressors with
Histamine-1 antagonist.28minutes later, he returned to normal hemodynamic state.(Conclusion)We
experienced perioperative sugamadex anaphylaxis. If your patient goes into shock status shortly after you
use sugamadex,notice that it is a possibility of developing anaphylaxis.
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC668
Pulmonary Hypertensive Crisis Resulting in Intraoperative Cardiopulmonary Arrest
Ali B. Khalifa, M.D., Mark Harbott, M.D . Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
The patient is a 69 y/o male with a history of hypertension, ischemic cardiomyopathy with an EF of 15 20%, severe pulmonary hypertension, an AICD placed for primary prevention, CKD, and metastatic
prostate cancer s/p bladder radiation. The patient underwent General Anethesia for a cystoscopy. During
emergence of anesthesia, the patient had PEA arrest. The patient was resuscitated with pressors and
sodium bicarbonate. We postulate that during emergence, the patient experienced mild hypercarbia that
Copyright © 2014 American Society of Anesthesiologists
was enough to cause a pulmonary hypertensive crisis and subsequent right sided heart failure. This, in
turn, caused left sided heart failure and cardiopulmonary arrest.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC669
Anesthetic and Perioperative Management for the Removal of an Aortic Paraganglioma
Ali B. Khalifa, M.D., Sandeep Markan, M.D., Bina Dara, M.D . Anesthesiology, Baylor College of
Medicine, Houston, TX, USA, Anesthesiology, VA Medical Center/Baylor College of Medicine, Houston,
TX, USA.
Paragangliomas are rare neuroendocrine tumors from chromaffin cells of the adrenal medulla and
sympathetic ganglia. A 73 y/o male with HTN and CKD developed paroxysmal atrial fibrillation, dizziness,
and abdominal pain. He was later diagnosed with a para-aortic paraganglioma. The patient was started
on alpha blockade with phenoxybenzamine despite being on beta blockade already. He experienced
episodes of severe hypertension and episodes of severe bradycardia during manipulation of the periaortic mass. He was successfully extubated. This case study reviews the hallmarks of the preoperative
work up, intraoperative events, and potential post operative complications associated with a
paraganglioma.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC670
To Clot or Not: Concurrent Hypercoagulopathy and Hypocoagulopathy in a Patient with Splenic
Marginal Zone Lymphoma
Firdous A. Khan, M.D., Lee C. Chang, M.D . Department of Anesthesiology, Baylor College of Medicine,
Houston, TX, USA.
A 70 year old female with history of splenic lymphoma presented for open splenectomy. Preoperative
laboratories showed a prolonged partial thromboplastin time (PTT) greater than 100 seconds ,
prothrombin time (PT) greater than 49 seconds, and international standardized ratio (INR) greater than
6.0. Further workup revealed presence of a lupus anticoagulant, which actually made her thrombophilic.
However, her INR and PT were prolonged secondary to presence of inhibitors to both factors II and VII,
making her at risk for intraoperative bleeding. Even with her factor derangements, blood component
therapy was judiciously held due to concern for risk of thrombotic complications.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC671
Respiratory Failure in a Renal Transplant Recipient Post-alemtuzumab Immunosuppression
Induction
Namrata Khimani, M.D., Victor Lan, M.D., Steven Miller, M.D . Anesthesiology, Columbia University
Medical Center, New York, NY, USA.
We present a case of respiratory failure associated with intra-operative administration of alemtuzumab, a
T-cell and B-cell depleting antibody that is increasingly being used for immunosuppression in renal
transplantation. A 60-year-old male with no significant cardiac or pulmonary history, who was dialyzed
one day prior, underwent uneventful renal transplantation with intra-operative alemtuzumab induction
over six hours. While preparing for extubation on pressure support ventilation, he was noted to be
hypercarbic with high minute ventilation and significant lactic acidosis. He was extubated six hours later to
CPAP in the intensive care unit and had an unremarkable post-operative.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC672
Bronchial Blocker Use for Single Lung Ventilation in a Patient with Cervical Spinal Stenosis
Jesse J. Kiefer, M.D . Department of Anesthesiology, University of Maryland Medical Center, Baltimore,
MD, USA.
64-year-old male with cervical spinal stenosis was scheduled for left thoracotomy with lower lobe
resection for non-small cell lung cancer. Cervical MRI demonstrated degenerative changes, severe spinal
canal stenosis at C3-4 level with cord flattening, and multilevel foraminal narrowing. To maintain cervical
neutrality, a fiber optic intubation with a single lumen tube during manual inline stabilization was
performed then a cervical collar was placed and maintained for the case duration. To provide single lung
ventilation and facilitate surgical exposure, a bronchial blocker was placed following intubation. At case
completion, the patient was extubated and neurological exam demonstrated no deficits.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC673
New Intra-Operative Left Bundle Branch Block during EVAR; To Reverse Heparinization or Not?
Alexander J. Kim, M.D., James Kim, M.D . Anesthesiology, Yale New Haven Hospital, New Haven, CT,
USA, West Haven VA Medical Center, West Haven, CT, USA.
71 year old male with Past Medical History of 5 centimeter abdominal aortic aneurysm, bladder cancer,
Barrett‟s Esophagus, pulmonary embolism 6 months prior, with pre-operative MUGA showing apical
hypokinesis, who underwent inferior vena cava filter placement and endovascular aorta repair. Intraoperatively, the patient spontaneously developed a new wide complex QRS, consistent with Left Bundle
Branch Block. He had already been heparinized for preparation for the EVAR. Differential diagnosis
included myocardial ischemia, and was treated as such. However, a major decision point was whether or
not to reverse heparinization with protamine, as typically done at the end of an EVAR.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC674
Anesthetic Management Using Nasal Airway for Patients With Submandibular Abscess Expected
Difficult Airway
Yeojung Kim, M.D., Jun Lee, D.D.S., Eui-Mook Lee, D.D.S . Wonkwang University Daejeon Dental
Hospital, Daejeon, Korea, Republic of.
We report several cases in which the use of nasal airway for airway management of submandibular
abscess.Asleep nasal fiberoptic intubation using nasal airway was performed for submandibular abscess
required general anesthesia. After sedation with propofol and remifentanil, a nasal airway combined with
endotracheal tube adaptor was inserted into the patient‟s one nostril, and connected anesthetic circuit for
direct oxygen supply and assisted ventilation. BIS was maintained between 75 and 85. Fiberoptic
intubation was performed into the other nostril.Monitored anesthesia care using nasal airway was
performed for brief incision and drainage for submandibular abscess. The above method was performed.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC675
Prolonged Nondepolarizing Relaxation in a Patient with Hypokalemic Periodic Paralysis
Joseph A. Kimmel, M.D., Laurence Susser, M.D . Bellevue Hospital Center, New York, NY, USA.
53 year old male with past medical history of hypokalemic periodic paralysis presented with acute
abdominal pain. X-ray revealed free air under the diaphragm and the patient was scheduled for emergent
exploratory laparotomy. Patient was brought to the OR and a rapid sequence induction was performed
with double dose rocuronium, propofol, and fentanyl. Case proceeded uneventfully but at the end of the
case almost 2 hours after induction the patient remained fully relaxed with zero tetanic response.
Potassium levels never decreased below 3.1 but patient did not regain suitable strength for extubation
until the following morning, 10 hours post-induction.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC676
Alcohol intoxication and Anesthesia: When To Go
Chase Kissling, M.D., Matthew Pena, M.D . Naval Hospital Pensacola, Pensacola, FL, USA.
This is the case of a 51 year old female ASA III who presented as an add-on for right shoulder
hemiarthroplasty. An odor of alcohol was detected during preoperative evaluation by the anesthesiologist.
The patient admitted to drinking a pint of hard alcohol daily. Record review revealed a history of
alcoholism, renal failure, cirrhosis, and alcohol withdrawal seizures. Vital signs were significant for
hypertension, tachycardia, and pain 10/10. Surgery was delayed to admit for pain control, blood pressure
control, and observation for alcohol withdrawal. Blood alcohol level was 272.2 mg/dL on admission.
Alcohol withdrawals began within hours of admission.
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Pediatric Anesthesia (PD) MC677
Anesthetic Challenges in the Management of a Patient with Congenital Phocomelia
Andrew R. Sim, M.D., Jerry Chao, M.D., Chandrappa Balikai, M.D., Marina Moguilevitch, M.D . Montefiore
Medical Center the University Hospital for Albert Einstein College of Medicine, New York, NY, USA.
We present a 16-year-old female born with congenital phocomelia with severe thoracolumbar
dextroscoliosis scheduled for extensive anterior and posterior spinal fusion in a two-staged procedure.
Pre-operative exam revealed severe scoliosis, rudimentary upper limbs with bifid digits, a micrognathic
jaw, small mouth, short thyromental distance and limited neck mobility. Phocomelia is a rare birth defect
associated with maternal thalidomide exposure. It is characterized by severe limb deformities and is
sometimes associated with skeletal and craniofacial abnormalities. We discuss the challenges and
perioperative considerations for this case, including airway management, one-lung ventilation, difficulty in
monitoring and vascular access, and post-operative pain control.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Pediatric Anesthesia (PD) MC678
A Compromised Airway in the Setting of Postpneumonectomy Syndrome
Mark J. Smeltzer, M.D . Medical College of Wisconsin, Milwaukee, WI, USA.
Postpneumonectomy syndrome is a condition in which the airway andesophagus become obstructed by
extreme rotation of the mediastinum. 9yo female, with history of pneumonectomy, presented for injection
of tissue expander. Near the end of the procedure, the patient began to react. Simultaneously, her
ETCO2 became zero, hand ventilation was unsuccessful, and she desaturated. Following development of
bradycardia, CPR was initiated. Epinephrine, atropine, and removal of injected fluid resulted in a
perfusing blood pressure and normocapnia. Following pneumonectomy, scars and adhesions can lead to
compression of the remaining lung and cardiac structures during surgery, creating a dangerous clinical
presentation.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Pediatric Anesthesia (PD) MC679
Grade I View, but No Place for the Tube to Go: An Unanticipated Difficult Airway in a Neonate
Carrie B. Sparkman, Arundathi Reddy, M.B.,B.S., Randall Schell, M.D . University of Kentucky, Lexington,
KY, USA.
We describe recognitionand management an unanticipated difficult airway in a two-week-old 3.5 kg
termneonate scheduled for cystoscopy and resection of PUV. Following IV induction,in spite of a grade
one view on DL, a 2.5 endotracheal tube could not bepassed. 1.5 LMA was placed and a 2.2mm FOB
passed through the LMA, vocal cordswere visualized but unable to pass beyond the glottic opening. Rigid
bronchoscopy performed by ENT showed grade3 subglotticstenosis involving the anterior aspect of
subglottic area with a smallposterior opening. Tracheostomyperformed, airway photos obtained, patient
transferred to NICU.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Pediatric Anesthesia (PD) MC680
Stridor in the Preterm Neonate: Presentation, Management, and Outcomes of a Complete Vascular
Ring
Joe Strosin, M.D., Susan Staudt, M.D . Department of Anesthesia, Medical College of Wisconsin,
Milwaukee, WI, USA, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI,
USA.
This case describes a 15 day old female with a past medical history of stridor who was brought to the
operating suite for otolaryngolocial evaluation via direct laryngoscopy and rigid bronchoscopy and found
to have an extrinsic compression of the trachea. The patient remained relatively hypoxemic despite
adequate mask technique which included application of CPAP, which aided in the diagnosis of an
extrinsic tracheal compression. This patient was subsequently intubated past the tracheal compression
and taken immediately for a CT angiography for confirmation of a complete vascular repair, and the
patient underwent surgical repair the following day.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Pediatric Anesthesia (PD) MC681
Anesthetic Management for a Patient with Lissencephaly: 5 Case Reports
Kei Suzuki, M.D., Tsuyoshi Satsumae, M.D., Makoto Tanaka, M.D . Anesthesiology, University of
Tsukuba, Tsukuba-city, Japan.
Case 1: A 5-month-old girl underwent ventriculopeitoneostomy. Tracheal intubation was difficult and
completed with an aid of cricoid pressure in the third trial. Case 2: A 1-year-old girl underwent
gastrostomy due to recurrent aspiration pneumonia. She had severe epilepsy. Case 3: A 4-year-old boy
underwent gastrostomy. His background was similar to Case 2. In order to prevent aspiration or apneic
episode, he returned to the ward without being extubated. Case 4: A 2-year-old boy underwent
orchiopexy. He had muscle hypotonia. Case 5: A 13-year-old boy underwent plastic surgery of hip
dislocation. He was complicated with severe epilepsy.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Pediatric Anesthesia (PD) MC682
Complete Traumatic Tracheal Transection and Cervical Spine Fracture from Clothesline Injury to
the Neck
Sarena N. Teng, M.D., Rita Agarwal, M.D., Jeremy D. Prager, M.D. , Debnath Chatterjee, M.D . Pediatric
Anesthesiology, Ochsner Medical Center, New Orleans, LA, USA, Pediatric Anesthesiology, Children's
Hospital Colorado, Aurora, CO, USA, Pediatric Otolaryngology, Children's Hospital Colorado, Aurora,
CO, USA.
A 12-year-old boy sustained a clothesline injury to his neck from a steel cable while riding a dirt bike. He
had difficulty phonating and was intubated at the scene. On arrival at the hospital, he was found to have
bilateral pneumothoraces. Suspecting a tracheal injury, an emergent tracheostomy was performed and
bilateral chest tubes were placed. CT neck revealed an unstable fracture of C2/3 vertebrae with spinal
cord impingement.Closed reduction of the C2/3 fracture and halo placement was performed under
neurophysiologic monitoring. Flexible tracheoscopy and subsequent neck exploration revealed a
complete disruption of the trachea below the cricoid cartilage.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Pediatric Anesthesia (PD) MC683
Intraoperative Discovery of Laryngotracheal Cleft During Tracheo-Esophogeal Fistula Repair
Eric Tesoriero, D.O., Martina G. Downard, M.D . Department of Anesthesiology, Wake Forest Baptist
Health, Winston Salem, NC, USA.
A term male was scheduled for TEF Repair on day-of-life 2. Pre-operative examination and imaging were
consistent with Type C TEF. Workup was negative for associated syndromes. Intraoperatively there were
several periods of difficulty ventilating which improved with repositioning of the endotracheal tube,
Copyright © 2014 American Society of Anesthesiologists
recruitment maneuvers, and administration of albuterol. After ligation of TEF there was a persistent air
leak which prompted otolaryngology consultation for direct laryngoscopy and bronchoscopy and a Grade
IV Laryngotracheal Cleft was identified. The patient was transferred to the Neonatal ICU for further
management and on day-of-life 47 underwent open trans-tracheal repair of Laryngotracheal Cleft.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Pediatric Anesthesia (PD) MC684
Intracardiac Rhabdomyoma Causing Right Ventricular Outflow Tract Obstruction in a Newborn
Sheel P. Todd, M.D., J Michael Sroka, M.D . Wake Forest School of Medicine, Winston-Salem, NC, USA.
A newborn male born at 37 3/7 weeks gestation presented for resection of intra-cardiac mass with right
ventricular outflow tract obstruction. He was diagnosed prenatally with suspected intracardiac
rhabdomyoma given family history of tuberous sclerosis. A postnatal echocardiogram was significant for
multiple presumed tumors, the largest being adherent to the pulmonary valve, severely dilated and
dysfunctional right ventricle with supra-systemic pressure, compression of the left ventricle, and
diminished left to right flow across a patent ductus arteriosus. The patient had a valve-sparing resection
of the rhabdomyoma with subannular patch and patch plasty of main pulmonary artery on
cardiopulmonary bypass.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Pediatric Anesthesia (PD) MC685
Tummy Time! Airway Collapse in an 11-Year-Old With Large Anterior Mediastinal Mass Relieved
Only With Prone/Lateral Position
Luis E. Tollinche, M.D . Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Large anterior mediastinal masses can lead to acute airway collapse after induction of general
anesthesia. This is a case of an 11 year old male with Non Hodgkin's Lymphoma who presented in
respiratory distress for urgent tissue diagnosis and central line placement to emergently initiate
chemotherapy. After spontaneous breathing induction and intubation of trachea, patient developed airway
collapse. All maneuvers described in algorithm for airway collapse failed (including bronchoscopy, single
lung ventilation, etc) Positioning our patient in left lateral decubitus was the only successful maneuver that
relieved airway obstruction.
Sunday, October 12, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC686
Anesthesia Management for Debridement of a MALT Lymphoma Mass Occluding the Trachea
Jagroop Saran, M.D., Anna Kaminski, D.O . University of Rochester, Rochester, NY, USA.
We report a case of a rare tracheal MALT lymphoma in a 79-year-old male with progressively worsening
shortness of breath for 3 months prior to presenting at an outside facility with acute worsening of
dyspnea. CT revealed a tracheal mass located distal to the vocal cords occluding 95% of the trachea.
Past medical history significant for CAD s/p CABG, Aortic Stenosis s/p AVR, Atrial fibrillation on Warfarin,
combined systolic and diastolic heart failure, OSA on CPAP. We discuss the challenges faced in
providing adequate sedation for bronchoscopy and debridement while maintaining spontaneous
ventilation in a patient with multiple medical comorbidities.
Sunday, October 12, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC687
Ace-Inhibitor induced Acute Hypotension following an Intra-operative Blood Transfusion
Rahul Sarna, M.D., Yasser Al-Baghdadi, M.D . Anesthesiology, University of Connecticut, Hartford, CT,
USA.
A 60 y.o. female required an intraoperative blood transfusion during an elective exploratory laparotomy.
Within seconds of starting the blood transfusion the blood pressure dropped from 100/60mmHg to
40/26mmHg. The blood transfusion was immediately stopped and the patient was resuscitated and
stabilized using IVF and vasopressors. Several repeated transfusion attempts produced identical drops in
Copyright © 2014 American Society of Anesthesiologists
blood pressure, even after the patient was re-typed and cross-matched. The patient was left intubated
and transferred to the ICU for close monitoring. Further work-up implicated a bradykinin mediated
reaction with leukoreduction filters due to an ace-inhibitor induced alteration in bradykinin kinetics.
Sunday, October 12, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC688
Anesthesia for the Oldest Survivor Affected with Mulibrey Nanism
Jaskaran Sawhney, M.D., Manmeet Bedi, M.D., Wing Tai Kong, M.D. , Robert R. Calimlim, M.D..
Anesthesia, State University of New York Upstate Medical University, Syracuse, NY, USA, Anesthesia,
State University of New York Upstate Medical Center, Syracuse, NY, USA, Internal Medicine, Danbury
Hospital, Danbury, CT, USA, Anesthesiology, SUNY Upstate University Hospital Medical Center,
Syracuse, NY, USA.
Mulibrey Nanism is a rare autosmoal recessive disorder characterized by prenatal onset progressive
growth failure and multiple organ manifestations including cardiovascular, hepatic, cerebral,
musculoskeletal, ophthalmologic, and endocrine involvement. Common findings characterizes the
syndrome include constrictive pericarditis, myocardial hypertrophy, muscular hypotonia, hepatomegaly,
characteristic facial features, ophthalmologic pigment dispositing, and progressive growth failure of
prenatal onset. The case presented is of the oldest surviving member of Mulibrey Nanism. The surgery
was for a resection of an Ampullary Adenoma, for which the patient underwent a Whipple procedure. The
case involved a careful anesthetic plan to ensure optimal safety for the unique patient.
Sunday, October 12, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC689
Anesthetic Management of a Patient with Ankylosing Spondylitis
Andrew J. Schulz, M.D., Richard Galgon, M.D., M.S . Department of Anesthesiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA.
A 52 year-old male with severe ankylosing spondylitis presented for ureteroscopy and laser lithotripsy
with stent placement. Anesthetic management was challenged by a history of difficult intubation from
cervicothoracic spine fixation and hyperkyphosis. Co-morbidities included morbid obesity (BMI 42),
obstructive sleep apnea, and diabetes mellitus. Successful anesthetic management included use of an
air-Q for coaxial tracheal intubation and airway maintenance during emergence, avoidance of long acting
neuromuscular blocking drugs, minimization of opioid analgesia, and careful intra-operative positioning.
Safe home discharge occurred on the procedure day.
Sunday, October 12, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC690
Esophageal Perforation Secondary to Oral Gastric Tube Placement
Kara G. Segna, M.D., Matthew Hirshfeld, M.D . Thomas Jefferson University Hospital, Philadelphia, PA,
USA.
Oro and nasogastric tube placement for gastric decompression is a procedure commonly performed by
anesthesiologists. Gastric tubes are normally placed blindly in anesthetized, intubated patients.
Complications are rare. We present a case of esophageal perforation in a 75 year old female with history
of asthma, bronchiectasis, WPW, pericarditis with effusion, and incarcerated type 3 paraesophageal
hernia status post nasogastric tube decompression presenting for laproscopic paraesophageal hernia
repair.
Sunday, October 12, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC691
Transfemoral Aortic Valve Replacement Complicated by Postoperative Autonomic Instability and
Respiratory Failure; A New Presentation of Neuroleptic Malignant Syndrome
Ashley N. Sharma, M.D., Roy Sheinbaum, M.D . Anesthesia, University of Texas at Houston, Chicago, IL,
USA, Cardiac Anesthesiology, University of Texas at Houston, Houston, TX, USA.
Copyright © 2014 American Society of Anesthesiologists
A 92 year-old male with a history of untreated parkinson's disease presented for elective TAVR for severe
aortic stenosis. Thirty minutes following successful extubation and transfer to the CCU, the patient
developed respiratory failure and bradycardia. He required reintubation and received Dantrolene over
concern for NMS. The patient improved over several days, only significant findings being leukocytosis
and mildly elevated Creatinine kinase. This case discusses Donepezil as a newly recognized cause for
NMS and new diagnostic criteria for at risk patients.
Sunday, October 12, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC692
Methemoglobinemia in a Patient with Multiple Co-morbidities Taking Rasburicase
Beamy S. Sharma, M.D . Anesthesiology, NYU Lagone Medical Center, New York, NY, USA.
A 57 year old male recently diagnosed with stage IIIb large B-cell lymphoma was admitted for
hypotension. His past medical history was also significant for DVT and PE requiring life-long
anticoagulation and gastric ulcers. During his hospital stay he developed AKI secondary to both tumor
lysis syndrome and an obstructive mass. He was urgently scheduled for ureteral stent placement where
his oxygen saturation was seen to be 78%, improving minimally with supplemental oxygen. With a blood
gas with co-oximeter panel, he was diagnosed with methemoglobinemia secondary to use of a tumor lysis
drug, rasburicase.
Sunday, October 12, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC693
Total Intravenous Anesthesia for Patients with Myotonic Dystrophy
Deepak R. Sharma, M.D., MBA, Mari Baldwin, M.D., Antonia Francis, M.D . Anesthesiology, Mount Sinai
St. Luke's Roosevelt, New York, NY, USA, Obstetrics & Gynecology, Mount Sinai St. Luke's Roosevelt,
New York, NY, USA.
We describe the anesthetic management of a 30 year old female with a history of myotonic dystrophy
manifesting as progressive daytime fatigue and hand muscle rigidity presenting for abdominal
myomectomy. She had no previous personal or familial anesthetic history. We performed a general
anesthetic with a rapid-sequence induction. Total intravenous anesthesia was maintained with
remifentanil and propofol with minimal muscle relaxation to avoid post operative weakness and
respiratory depression. There was extensive collaboration with the surgeons and the patient to plan for a
successful outcome. The surgery was performed uneventfully. The patient was discharged on
postoperative day 3 without complications.
Sunday, October 12, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC694
GlideScope™ Guided Fiberoptic Intubation in an Adult with Acute Epiglottitis
Deepak R. Sharma, M.D., MBA, Franco Resta-Flarer, M.D., Jinu Kim, M.D., Jonathan Lesser, M.D .
Anesthesiology, Mount Sinai St. Luke's Roosevelt, New York, NY, USA.
A 28 year old healthy female presented to the ED with 4 days pharyngitis and 6 hours dysphagia, profuse
oral secretions, and submandibular lymphadenitis. Imaging revealed severe epiglottic thickening and she
was transferred to the OR for emergent intubation. Following intravenous induction, her oropharynx was
visualized with a GlideScope™. She was successfully intubated with a 6.0 endotracheal tube using a
preloaded fiberoptic bronchoscope as a flexible light wand. She was monitored in the ICU and treated
with intravenous antibiotics and steroids. She was safely extubated 2 days later after appreciating
significantly decreased epiglottic inflammation on a GlideScope™ view.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Neuroanesthesia (NA) MC695
Management of Posterior Cervical Fusion in Patient with Severe Aortic Stenosis and Mitral
Regurgitation
Sonya Delwadia, M.D., Laura Gilbertson, M.D., Chelsia Varner, M.D., Vladimir Zelman, M.D., Eugenia
Aryian, M.D . Anesthesiology, University of Southern California, Los Angeles, CA, USA.
A 68 yo M with aortic stenosis and mitral regurgitation presented for C4-C7 laminectomy and posterior
spinal fusion.A Swan Ganz catheter was placed and a dobutamine infusion was started. The PA
pressures elevated and the blood pressure trended down. The dobutamine drip was increased and a
neosynephrine drip started. In the ICU, the patient was continued on a neosynephrine drip to maintain the
MAP for spinal perfusion and was weaned off by POD #1.Conclusion: Cardiac condition should be
optimized preoperatively, SG catheter and careful fluid management should be considered for severe
aortic stenosis in the prone position
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Neuroanesthesia (NA) MC696
Emergency Circulatory Arrest for Intraoperative Intracranial Aneurysm Rupture During Open
Aneurysm Clipping
Patrick B. Forrest, M.D., Magnus Teig, M.B.,Ch.B . Anesthesiology, University of Michigan, Ann Arbor, MI,
USA.
A 43 year old woman with a history of APCKD and five known cerebral aneurysms underwent open
aneurysm clipping. Two separate episodes of aneurysm rupture occurred intra-operatively, necessitating
three distinct periods of pharmacological cardiac arrest using Adenosine to facilitate surgical control of
bleeding. Anesthetic management also included prolonged periods of burst suppression for neuroprotection. At the end of the procedure the patient was neurologically intact and successfully extubated.
She was discharged home from the hospital three days after surgery. This case demonstrates the
importance of clear interdisciplinary OR communication, focused anesthetic management and teamwork
during cranial aneurysmal rupture.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Neuroanesthesia (NA) MC697
Anesthetic Management of a ruptured Grade 5 Martin-Spetzler AVM
Sarah Ann Gerken, M.D., Joseph Sisk, M.D., Ali Hassan, M.D . Univeristy of Toledo Medical Center,
Toledo, OH, USA.
A previously healthy 23 year old male was transferred from an outlying hospital after new onset seizures
and a fall from standing height, found to be due to a large intracranial hemorrhage. He was taken
emergently to the O.R. and utilizing intra-operative cerebral angiography and surgical resection, a grade 5
Martin-Spetzler AVM, with principal supply from the right MCA and its branches, was identified and
resected. Angiography at the conclusion of the case demonstrated that the R MCA and its branches no
longer filled. The patient survived and is showing a successful recovery.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC07
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Neuroanesthesia (NA) MC698
Alternative Positioning of BIS Electrodes in Resection of Brain Tumor Frontal Lobe
Paulo Alipio Germano Filho, M.D., Estêvão Braga, M.D., Armin Guttman, M.D., Márcio Nagatsuka,
Lidiane Vasconcelos, Ana Marques, Ismar Lima Cavalcanti, Ph.D., Nubia Verçosa Figueiredo, Ph.D. .
Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil, UFF, Niterói, Brazil, UFRJ, Rio de Janeiro,
Brazil.
The bispectral index (BIS) is a parameter that allows monitoring of cerebral cortical activity and therefore
correlates with anesthetic depth and is useful prevention of intraoperative awareness and diagnosis of
cerebral suffering through suppression rate. Classically cortical electrical activity is captured using
electrodes placed on the fronto-temporal region. This case report aims to demonstrate the use of BIS
electrodes in an alternative position (right parietal-occipital) in a male patient, 53 years old, during
resection of a frontal cerebral tumor.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Neuroanesthesia (NA) MC699
Preventing Hemorrhage During a Craniotomy in a Patient with Hemophilia A
Samit P. Ghia, M.D., Jinu Kim, M.D., Jonathan Lesser, M.D., Franco Resta-Flarer, M.D . St. Luke's
Roosevelt Hospital Center, New York, NY, USA.
We present a 17-year-old obese male with Hemophilia A and a past cerebro-vascular accident resulting
in seizure disorder undergoing a craniotomy, hemispherectomy and EVD placement for chronic seizures.
The patient received general inhalational anesthesia. After intubation and before surgical incision,
Recombinant Factor VIII and Tranexamic Acid boluses were administered and a Tranexamic Acid
infusion was initiated. Prior to completion of surgery, Recombinant Factor VIII was administered while
checking a Factor VIII level. The craniotomy and hemispherectomy were successfully completed without
significant blood loss and other sequelae.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Neuroanesthesia (NA) MC700
Cerebral Oximetry and Balloon Test Occlusion
Ryan W. Gordon, M.D., James R. Langdon, M.D . Anesthesiology, University of Tennessee Graduate
School of Medicine Knoxville, Knoxville, TN, USA.
A 19 year old male with a history significant for craniopharyngioma with prior resection presented for
balloon test occlusion for evaluation of a known dissecting fusiform pseudoaneurysm. The patient was
given light sedation throughout the case, allowing for intermittent neuro evaluations to be performed
during the occlusion portion of the study. In addition to EEG and intermittent neuro evaluations, cerebral
oximetry was utilized as an additional modality throughout the case, including the occlusion of the right
internal carotid artery. Given the many options available for neuromonitoring during balloon occlusion,
such as EEG and SPECT, we decided to utilize cerebral oximetry.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Neuroanesthesia (NA) MC701
A Case of Anesthesia Mumps: Acute Sialadenitis Necessitating Tracheal Reintubation Following
Right Frontal Craniotomy
Copyright © 2014 American Society of Anesthesiologists
Malani M. Gupta, M.D., Brian P. Ferla, M.D . Department of Anesthesia, Critical Care and Pain Medicine,
Beth Israel Deaconess Medical Center, Boston, MA, USA.
A 56 year-old male underwent uncomplicated right craniotomy for sphenoid wing meningioma resection.
Patient was intubated easily and atraumatically, and positioned supine with left-turned head for five hours
prior to uneventful extubation. Two hours postoperatively, patient developed painless left neck swelling
that increased dramatically over the next hour and necessitated reintubation--the glottis was noted to be
partially obscured by tissue edema. Subsequent imaging revealed left parotid and submandibular
periglandular edema, supporting a diagnosis of acute sialadenitis. Swelling improved with
dexamethasone, and patient was extubated on POD#4 and discharged on POD#7. At two-week followup, neck swelling was completely resolved.
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Neuroanesthesia (NA) MC702
Unanticipated Intraoperative Mycotic Aneurysm Rupture
Patricia M. Habimana, M.D., Brett Elmore, M.D., Jeremy Dority, M.D . Anesthesiology, University of
Kentucky, Lexington, KY, USA, University of Kentucky, Lexington, KY, USA.
22 year-old IVDA with IE, presented with SDH. Taken to OR for evacuation. Noted intraparenchymal and
subarachnoid hemorrhage, then a MCA aneurysm was discovered. Upon defining its borders, there was
rupture and massive unanticipated hemorrhaging ensued.Our management aimed for neuroprotection to
limit further focal cerebral ischemia . However keeping CPP adequate in face of uncontrolled hemorrhage
was challenging. Induced hypotension would assist in reducing hemorrhage although it would likely
exacerbate already ischemic penumbra by reducing CBF.Although rare, presence and potential rupture of
mycotic aneurysm should be considered and anticipated in patients with intracranial hemorrhage and
history of IE.
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Neuroanesthesia (NA) MC703
Management of Anticoagulation in a Patient with Left Ventricular Assist Device and Subdural
Hematoma
Brian P. Henk, D.O., David Gutman, M.D., Emil Malamud, M.D . Anesthesiology, Maimonides Medical
Center, Brooklyn, NY, USA.
64 year old female with PMHx of CHF, s/p placement of Heartmate II LVAD 2 month previously, GERD,
HTN, PPM coming to OR for emergent evacuation of acute expansion of subdural hematoma with 1cm
midline shift and brain herniation, which developed after restarting anticoagulation. Pt had 8/10 headache
but was neurologically intact. Craniotomy was peformed under GA with ETT. Pre-operative INR was 2.2.
andwas reversed with FFP. Evacuation was completed without complication and pt was extubated at end
of procedure and transfered to CTICU. Cardiac surgeon and Neurosurgeon discussed post-operaitve safe
anticoagulation.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Cardiac Anesthesia (CA) MC704
Cardiac Myxoma Resection: Intraoperative Management and Acute Complications
Jeffrey Kallas, Student, Pierce Johnson, Student. Drexel College of Medicine, Philadelphia, PA, USA.
We present the case of a 57 year old male with a 6x5 cm left atrial myxoma who underwent emergent
resection following presentation with clinical signs of heart failure. Anesthetic management included,
general anesthesia, double lumen ETT, invasive lines, CPB and TEE. Intraoperative period was
characterized by hemodynamic fluctuations, SBP ranged from 66-170mm Hg. Following unremarkable
separation from CPB the patient was transferred to the ICU where he developed an acute reentry
arrhythmia with marked hemodynamic instability. The patient was resuscitated and treated. We will review
the operative management of myxoma resection, highlighting acute post-op complications and commonly
encountered arrhythmias.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Cardiac Anesthesia (CA) MC705
Isolated Mitral Valvulopathy - A Rare Presentation of Radiation-Induced Cardiac Injury
Ami M. Karkar, M.D., M.S., Manuel Castresana, M.D., Vinayak Kamath, M.D. , Shvetank Agarwal, M.D .
Anesthesiology and Perioperative Medicine, Georgia Regents University, Augusta, GA, USA,
Anesthesiology and Perioperative Medicine, Georgia Regents University, Augusta, GA, GA, USA,
Cardiothoracic Surgery, Georgia Regents University, August, GA, USA.
35-year-old female with multiple comorbidities including myelomatous malignancy for which she received
chemotherapy and mediastinal irradiation 13 years back underwent mitral valve replacement with a
25mm On-X valve. Intraoperative TEE showed diffuse thickening and sclerosis of leaflets with shortening
of cordae causing severe mitral regurgitation, severe left atrial dilatation and mildly reduced EF. Other
than isolated mitral valvulopathy, no other cardiovascular stigmata of past mediastinal irradiation including
pericardial disease, CAD or conduction defects were seen. Also interestingly, no other valve was
affected. We discuss the clinical manifestations, radiobiological mechanisms, pathophysiology,
chronology and anesthetic management of late radiation-induced cardiac injury.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Cardiac Anesthesia (CA) MC706
Congenital Gerbode Malformation (Left Ventricle to Right Atrial Fistula) Masquerading as an Acute
Infarct Ventricular Septal Defect: Caveat Interpretor
Jonathan Kay, M.D . Cardiovascular Anesthesia, St. Lukes Hospital, Milwaukee, WI, USA.
A 75 y.o. woman presented to an outlying hospital with sepsis, acute right coronary occlusion ,
cardiogenic shock, and a new murmur. Initial echocardiograms were read as an infarct induced
ventricular septal defect. Because of continued instability, an intra-aortic balloon was placed and surgery
scheduled for coronary bypass grafting and VSD closure. At time of surgery, echocardiography revealed
a congenital Gerbode Defect (ventricular septal defect causing vsd to right atrial fistula) not an infarct
induced vsd.The important physiologic, echocardiographic, and treatment differences between the rare
Gerbode Defect and the more common acute infarct related ventricular septal defect are reviewed.
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Cardiac Anesthesia (CA) MC707
Anesthesia Management of Aortic Valve Replacement in Myasthenia Gravis Patient, the Era of
New Reversal
Ahamd Abou Leila, M.D., Aliyya Dabbous, M.D., Patricia Nehme, M.D . Anesthesiology, John H. Stroger
Jr. Hospital of Cook County, Chicago, IL, USA, Anesthesiology, American University of Beirut, Beirut,
Lebanon.
The anesthesia management of Myasthenia gravis usually includes substitution of muscle relaxants by
administration of high doses of inhalational agent or the use of TIVA with epidural anesthesia.Cardiac
patients are intolerant to high doses of inhalation agents. TIVA and epidural anesthesia are associated
with risk of awareness and epidural hematoma respectively. The use of muscle relaxants is essential to
prevent hazardous movements.Our case is about novel approach in the management of MG in cardiac
patient presenting for AVR. We used Rocuronium for intubation then continuous infusion 0.1mg/kg/hr.
Paralysis reversed by Sugammadex 4mg/kg with adequate recovery of Neuromuscular function.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Cardiac Anesthesia (CA) MC708
Management of a Patient with a Renal Tumor and IVC Thrombus Extension into the Right Atrium
Wesley L. Allen, M.D., Joseph L. Reeves-Viets, M.D., MBA. University of Missouri - Columbia, Columbia,
MO, USA.
72-year-old active gentleman with hypertension and prior DVT presented with acute bilateral lower
extremity edema, abdominal distention, shortness of breath and loss of appetite. A right renal cell tumor
with thrombus extension into the atrium and occlusion of the hepatic veins was diagnosed. Key
Copyright © 2014 American Society of Anesthesiologists
multidisciplinary preparation and collaboration with Urology and Cardiothoracic Surgery for radical right
nephrectomy with IVC thrombectomy via abdominal approach with retrohepatic IVC mobilization without
extracorporeal circulation was accomplished. Anesthetic management included pre-operative arterial line
placement, CVP and TEE guided resuscitation. EBL >20L. The patient remained intubated, following
verbal commands with GCS 11T 48 hours post-operatively.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Cardiac Anesthesia (CA) MC709
Perioperatory Complications in Aortitis due to Salmonella: Could the Endovascular Aortic Repair
Be the Treatment of Choice?
William Amaya Zuniga, Sr., M.D., Michelle Catherinne Salazar-Marulanda, M.D., Karina Ortega, M.D .
Anestesiology, Fundacion Santa Fe De Bogota, Bogota, Colombia.
A 67-year-old female presented with abdominal pain, distention, fever and emesis. The tomography found
an ulcerated plaque in the descending aorta without a dissection flap or an aneurysmatic dilatation. The
blood cultures were positive for salmonella and confirmed bacteremia. The symptoms persisted, therefore
a second tomography was made, showing an increase in the aortic ulcer and evidencing a
pseudoaneurysm. An emergency procedure was considered. The endovascular aortic repair was chosen
as the best option to reduce the mortality and morbility. General anesthesia with invasive monitoring was
used. The technique was realized to have a hemodynamic stability with attenuated sympathetic response.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Cardiac Anesthesia (CA) MC710
Management of Acute Hypovolemia in a Patient with a Total Artificial Heart
Shyamal R. Asher, M.D., Mark Nunnally, M.D . University of Chicago, Chicago, IL, USA.
A 59 year-old male with a history of ischemic cardiomyopathy with acute decompensated heart failure
required implantation of a total artificial heart device (Syncardia®; Tucson, AZ). On postoperative day 23,
he developed large melenic stools with associated acute hypotension requiring massive transfusions. At
the time, his MAPs were in the 50s with his device at a set heart rate of 135. An EGD revealed red blood
in duodenum and proximal jejunum with no active bleeding. Administration of 13 units of packed red cells
and 5 units of FFP improved his MAPs to 70s at rate of 139.
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Cardiac Anesthesia (CA) MC711
Post Robotic Transmyocardial Revascularization Cardiac Arrest Secondary to Ventricular Rupture
- How Do We Access the Chest?
Ntesi A. Asimi, M.D., Samata Paidy, M.D., Robert Poston, M.D . University of Arizona Medical Center,
Tucson, AZ, USA.
A 60 year-old male with PMHx significant for multiple congenital cardiac repairs, ischemic
cardiomyopathy, and CHF was found to have significant diffuse high grade occlusive disease. The patient
was advised and agreed to proceed with robotic off-pump transmyocardial revascularization (TMR).
Secondary to distorted anatomy and possible pericardial inflammation the TMR was aborted, the patient
underwent uneventful emergence from general anesthesia and was successfully extubated. Upon
transport to CTICU the patient develop cardiovascular collapse. An emergency sternotomy was
performed, right ventricular perforation was quickly recognized, and CPB was initiated. Hemodynamic
stabilization was established and the ventricle repaired. The patient recovered completely
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Cardiac Anesthesia (CA) MC712
Myocardial Bridging: Perioperative Management of a Rare Coronary Syndrome
Deepa Asokan, M.D., Jyotsna Rimal, M.D., Sergey Pisklakov, M.D., Vasanti Tilak, M.D . Anesthesiology,
UMDNJ - New Jersey Medical School, Newark, NJ, USA.
Copyright © 2014 American Society of Anesthesiologists
This case report is an example of the perioperative implications of a myocardial bridging, a rare anomaly
that is often overlooked. It is characterized by an intramyocardial route of a segment of one of the major
coronary arteries.A patient with previously diagnosed myocardial bridging and chronic chest pain
presented for a removal of a hip implant. Maintaining optimal heart rate, oxygenation and blood oxygencarrying capacity are crucial. Beta-blockers and calcium channel blockers are the recommended
treatments. Metoprolol was used perioperatively reducing heart rate and increasing the diastolic time, with
a decrease in compression of the tunneled artery.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Obstetric Anesthesia (OB) MC713
Neuraxial Anesthesia for Cesarean Delivery in a Patient with an Intrathecal Hydromorphone Pump
and Spinal Cord Stimulator for Complex Regional Pain Syndrome
Frederick T. O'Donnell, M.D., Ezekiel P. Tarrant, B.S . Anesthesiology, University of Missouri Hospitals
and Clinics, Columbia, MO, USA, University of Missouri School of Medicine, Columbia, MO, USA.
We describe the case of a 40 year old G8P1 parturient with complex regional pain syndrome and history
of recurrent pregnancy losses. An elective repeat Cesarean delivery was planned due to abruptio
placenta with a previous pregnancy. The patient expressed a strong desire to be awake for the delivery of
her baby. Our plan for neuraxial anesthesia was complicated by an intrathecal hydromorphone pump and
a spinal cord stimulator, as well as anticoagulation therapy. We elected to perform a spinal anesthetic
with radiologic guidance to minimize the risk of damage to the indwelling devices.
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Obstetric Anesthesia (OB) MC714
Anesthetic Management of Central Core Disease for Instrumented Vaginal Delivery
Douglas S. Bentley, M.D., Andrew Herlich, M.D., Kristin Ondecko Ligda, M.D . Anesthesiology, University
of Pittsburgh, Pittsburgh, PA, USA.
Core myopathies are the most common congenital myopathies in the United States, with a high
prevalence of Malignant Hyperthermia (MH), even in the absence of triggering anesthetic agents. We
describe the case of a 25 year old primiparous female with confirmed Central Core Disease, personal
history of Harrington rod placement, and significant family history of MH presenting for preanesthetic
evaluation in her first trimester of pregnancy. She eventually underwent a successful instrumented
vaginal delivery using a spinal anesthetic despite to the patient‟s initial desire for a “natural” delivery
without general or regional anesthesia.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Obstetric Anesthesia (OB) MC715
Pregnant Patient with No CSF!
Barbara S. Orlando, M.D., Deborah Stein, M.D., Jacqueline Geier, M.D., Dimitri Kassapidis, D.O., Alan
Santos, M.D . Mount-Sinai Roosevelt Hospital, New-York, NY, USA.
In parturients combined spinal-epidural (CSE) used more because lower incidence of failure compared to
lumbar epidural.Cerebrospinal fluid(CSF) confirms correct placement in the epidural space and midline.
Healthy patient requests CSE.2 attempts by senior resident:failure to find epidural space.OB anesthesia
fellow gets LOR(L4-5).Spinal needle threaded with "dural pop",but no CSF.Second attempt same
level,LOR no CSF. Epidural catheter placed,incomplete relief, even with Lidocaine 2%.CSE is replaced
by attending with ultrasound. 5th and 6th attempts (L3-4) with no CSF. Catheter provides incomplete
relief. 7th and 8th attempts by different attending, (L3-4/L2-3).No CSF, catheter inefficient.Patient refuses
further attempts, opts for general anesthesia if cesarean.
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Obstetric Anesthesia (OB) MC716
Anesthesia Management of a Pregnant Patient with HCOM
Copyright © 2014 American Society of Anesthesiologists
Barbara S. Orlando, M.D., Deborah Stein, M.D., Jonathan Epstein, M.D., Wojciech Reiss, M.D., Leroy
Phillips, M.D., Alan Santos, M.D . Mount-Sinai Roosevelt Hospital, New-York, NY, USA.
During pregnancy,hypertrophic cardiomyopathy(HCOM)patients risk hemodynamic deterioration:aortocaval compression,blood loss,major sympathetic stimulation.33 y/o at 38 weeks with recent incidental
diagnosis of massive HCOM:septal anterior wall thickness 29-30mm on echo,admitted in
labor.Anesthesia consulted:early epidural to avoid sympathetic stimulation recommended,but pt waits 4
hours.CSE with spinal dose:20mcg Fentanyl(partial relief),epidural dose:Bupivacaine 0.25%
2+3cc(complete relief,good hemodynamic stability),epidural infusion:Bupivacaine 0.0625%+Fentanyl
12cc/h.Later patient taken for cesarean delivery (CD) for face presentation.Epidural loaded with 5+5cc
Lidocaine 2% with epinephrine but block inadequate.Spinal done:Bupivacaine 0.75% 1.4cc,200mcg of
Morphine.Uneventful CS, BP,HR stable with Phenylephrine.Both general and regional
anesthesia(CSE,epidural/spinal catheter)used for CD.Spinal is not the preferred choice:risk of poorly
tolerated sympathetic blockade
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Obstetric Anesthesia (OB) MC717
Anesthetic Management for VATS for Mediastinal Abscess During the Second Trimester or
Pregnancy
Jeffrey C. Ottmar, M.D., Ellen K. Roberts, M.D., Nicholas W. Markin, M.D . Anesthesiology, University of
Nebraska Medical Center, Omaha, NE, USA, University of Nebraska Medical Center, Omaha, NE, USA.
A 33 year-old pregnant female at 18 weeks gestation with a mediastinal mass presented for a Videoassisted Thoracoscopic Surgery for diagnosis and treatment. Prior to the operation, the patient appeared
septic with tachycardia, a fever, and labile blood pressure related to the Group F Streptococcus abscess
that had developed. A rapid sequence induction was performed and a double lumen tube was used to
allow one-lung ventilation during the procedure. An arterial line was placed after induction to help monitor
hemodynamics. The patient had an episode of desaturation while on single-lung ventilation that was likely
related to her pregnancy.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Obstetric Anesthesia (OB) MC718
Use of Thromboelastography in an Obstetric Patient with Glanzmann’s Thrombasthenia
Pooja Pandya, M.D., Jamie Murphy, M.D., Lori Suffredini, M.D . Anesthesiology and Critical Care
Medicine, Johns Hopkins University Hospital, Baltimore, MD, USA.
A 33 yo G1P0 with Glanzmann‟s Thrombasthenia was admitted for IOL. Her platelet count was normal,
but based on abnormal TEG, the patient was counseled against neuraxial labor analgesia. A CS was
ordered for failure to progress. Aminocaproic acid and platelets were administered prior to incision.
During intubation, dark fluid was noted originating from the esophagus. An OGT was placed, yielding one
liter of coffee ground emesis. Pantoprazole infusion and additional platelets were administered. EGD
revealed two esophageal erosions with visibly bleeding vessels; these were clipped. She had no further
episodes of bleeding and was discharged on hospital day nine.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Obstetric Anesthesia (OB) MC719
Labor Analgesia for Cesarian Section in an Achondroplastic Dwarf
Taral Patel, D.O., Dhiren Soni, D.O., Kathleen Kwiatt, D.O . Anesthesia, Cooper University Hospital,
Camden, NJ, USA.
S.M was a 21 year old g1p0 achondroplastic dwarf presenting for elective cesarian section. Her
confounding medical problems included asthma, sleep apnea, spinal stenosis, history of a VP shunt
placed at birth for hydrocephalus, cervical spine surgery as an infant for unknown reasons, and history of
a tracheostomy as an infant also for unknown reasons. This case demonstrates the dilemma in choosing
the safest yet most effective means of labor analgesia for this particular patient.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Obstetric Anesthesia (OB) MC720
Why is the Baby Backwards and Why is the Uterus Falling Apart? The Perfect Storm
Tiffany D. Perry, M.D., Elizabeth Lange, M.D., Heather Nixon, M.D . University of Illinois at Chicago,
Chicago, IL, USA.
Our medically challenging case is a 42 yo G3P1 at 38.5 wks GA admitted for IOL for diabetes. Although
the vertex presentation was confirmed, at full dilation the fetus was noted to be in breech position with a
malpositioned FSE. Neuraxial anesthesia was attempted but NRFHTs necessitated GA. Immediately after
delivery, the patient sustained uterine dehiscence/disintegration with involvement of the uterine artery,
posterior uterine wall, cervix and vagina. Resuscitation of PPH required transfusion and vasopressors.
This case highlights that fetal malposition at advanced dilation may serve as a warning of uterine injury
during labor.
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Obstetric Anesthesia (OB) MC721
A Multidisciplinary Approach to the Management of a Parturient with a Rare NUT Midline
Carcinoma (NMC): A Case Report
Thao T. Pham, M.D., Michele Mele, M.D . Thomas Jefferson University, Philadelphia, PA, USA.
A 33-year-old female at 27-wks IUP with NUT midline carcinoma, a rare and extremely aggressive form of
SCC, presented for extensive orbital exenteration, resection of anterior craniofossa, right neck dissection
and anterolateral thigh free flap. Intra-operative management of this complex 13-hr procedure required
the involvement of multiple surgical teams including MFM and neonatology. Anesthetic management
proved challenging with goals to safely obtain ETT intubation in light of an extensive tumor involving
aeorodigestive tract, optimize and maintain normal uteroplacental blood flow and maternal physiology in
the face of surgeon‟s request for fluid restriction and limited vasopressor use to prevent flap
complications.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Pain Medicine (PN) MC722
Spinal Cord Stimulator Implant For Patient With Chronic Bilateral Lower Extremity Pain Secondary
to Exertional Compartment Syndrome
Qi Zhang, M.D., Joel Kent, M.D . Anesthesiology, University of Rochester, Rochester, NY, USA.
28 y.o. male presented with bilateral lower extremity pain secondary to manometrically diagnosed
exertional anterior and posterior compartment syndrome. Patient failed previous conservative
management with opioids, neuromodulators, NSAIDS, mixed reuptake inhibitors, TCAs and physical
therapy. Invasive surgery (one anterior and two anterior/posterior fasciotomies) provided minimal
sustained pain relief. His severe restrictive functional capacity was limited to five minutes of standing or
walking. Dual lead eight contact spinal cord stimulator trial followed by permanent implant over T11 and
T12 spinal levels alleviated greater than 95% of the patient‟s pain symptoms. He returned to work and
regular activities on OTC ibuprofen prn.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Cardiac Anesthesia (CA) MC723
Desaturation After Cesarean Delivery of a Parturient with a Single Left Ventricle
Sravankumar R. Polu, M.D., Daria M. Moaveni, M.D., Amanda D. Saab, M.D., Katherine G. Hoctor, M.D .
Jackson Memorial Hospital-University of Miami, Miami, FL, USA.
A 23 year old G2P0010 with single ventricle physiology due to tricuspid atresia s/p fenestrated Fontan
palliation was scheduled for cesarean delivery at term. ASA standard monitors were used and a
transesophageal echocardiogram was available. A combined-spinal epidural anesthesia technique was
used to build the anesthetic level; she remained hemodynamically stable throughout epidural dosing and
delivery. During closure, she complained about nasal congestion, started sneezing, and desaturated to
the low 90s. Differential diagnosis included congestion of her Glenn, shunting through the fenestration,
Copyright © 2014 American Society of Anesthesiologists
and fluid overload. Her symptoms resolved with supplemental oxygen, furosemide, and head elevation.
Her postoperative course was uncomplicated.
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Cardiac Anesthesia (CA) MC724
Cardiac Arrest during Total Intravenous Anesthesia in an Undiagnosed Brugada Patient
Shawn K. Puri, M.D., Ming Xiong, M.D., Yurii Gubenko, M.D., Sergey Pisklakov, M.D . UMDNJ - New
Jersey Medical School, Newark, NJ, USA.
Brugada Syndrome (BrS) is a rare disease leading to fatal arrhythmias. BrS is identified by ST-segment
elevation of a saddleback-type. This is a case of ventricular fibrillation (VF) during total intravenous
anesthesia (TIVA) in a patient presented for cervical spine fusion. Induction and intubation were
uneventful. Patient developed sustained ventricular tachycardia which degenerated to VF prior to incision.
Cardioversion was immediately applied and sinus rhythm recovered. Electrophysiologic study revealed
BrS.TIVA may create autonomic imbalance and carries arrhythmogenic risk. ECG of BrS is dynamic and
sometimes normal. Anesthesiologists should be aware of a patient's BrS history and changes in ECGs.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Cardiac Anesthesia (CA) MC725
Anesthetic Management for Pericardiectomy in a Patient with Constrictive Pericarditis and Right
Heart Failure
Suvikram Puri, M.D., Sanjay Dwarakanath, M.D., Nadine Odo, Vinayak Kamath, M.B.,B.S., Mary Arthur,
M.D . Anesthesiology and Perioperative Medicine, Medical College of Georgia At Georgia Regents
University, Augusta, GA, USA, Cardiothoracic and Vascular Surgery, Medical College of Georgia At
Georgia Regents University, Augusta, GA, USA.
A white male with right heart failure, COPD, diabetes, hyperlipidemia, and hypertension, presented with
worsening SOB and edema. TEE and cardiac MRI were suggestive of constrictive pericarditis with
thickening of the anterior pericardium. Cardiac catheterization revealed normal coronaries. CT chest
showed large right pleural effusion. Patient underwent median sternotomy and extended pericardiectomy
for constrictive pericarditis. Patient was found to have thickened pericardium, extensively compressing
the RV, superior and inferior vena cava along with much of the anterior aspect of the left ventricle.
Surgery was successfully performed off-pump with TEE monitoring and preparedness for
cardiopulmonary bypass.
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Cardiac Anesthesia (CA) MC726
Hypertrophic Cardiomyopathy with Systolic Anterior Motion Diagnosed During Presentation for
Mitral Valve Repair
Sirisha A. Rao, M.D., Trevor Banack, M.D . Anesthesiology, Yale University School of Medicine, New
Haven, CT, USA.
A 75 year old female with progressive shortness of breath and a PMH of CVA and right hemiplegia
presents for minimally invasive mitral valve repair via thoracotomy. Pre-hospital TTE reported severe
mitral regurgitation. Pre-incision TEE revealed severe posteriorly directed mitral regurgitation from systolic
anterior motion of the mitral valve from asymmetric septal hypertrophy creating left ventricle outflow tract
obstruction. We immediately showed and discussed these findings with the surgeon, which changed the
surgery to a median sternotomy, myomectomy and left atrial appendage ligation. Post bypass echo
revealed mitral regurgitation and decreased LVOT gradient. The patient was discharged on POD #7.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Cardiac Anesthesia (CA) MC727
Pre-Induction STEMI On a Patient Scheduled for CABG: Proceed or Delay the Case?
Tiffany M. Richburg, M.D., Eric Wang, Student, Vinayak Kamath, M.B.,B.S. , Mary E. Arthur, M.D .
Anesthesiology and Perioperative Medicine, Medical College of Georgia at Georgia Regents University,
Copyright © 2014 American Society of Anesthesiologists
Augusta, GA, USA, Medical College of Georgia at Georgia Regents University, Augusta, GA, USA,
Cardiothoracic Surgery, Medical College of Georgia at Georgia Regents University, Augusta, GA, USA.
This case involved a 64 year old male with a past medical history of hypertension, DM II and MVCAD
scheduled for a 2- vessel CABG. Preoperative cardiac evaluation revealed 80% stenosis of the left main
and left anterior descending arteries, and preserved EF. Prior to induction, the patient complained of
chest pain, became diaphoretic, hypertensive and went into SVT. The EKG tracing revealed ST elevation
in multiple leads followed by atrial fibrillation. The patient was immediately given supplemental oxygen,
morphine, metoprolol, and nitroglycerin. His chest pain resolved and EKG subsequently converted to
sinus rhythm before proceeding with the CABG.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Cardiac Anesthesia (CA) MC728
Thoracotomy for ICD Upgrade Secondary to Coronary Sinus Anomaly
Tiffany M. Richburg, M.D., Eric Wang, Student, William Maddox, M.D. , Mary E. Arthur, M.D .
Anesthesiology and Perioperative Medicine, Medical College of Georgia at Georgia Regents University,
Augusta, GA, USA, Medical College of Georgia at Georgia Regents University, Augusta, GA, USA,
Cardiology, Electrophysiology, Medical College of Georgia at Georgia Regents University, Augusta, GA,
USA.
A 65 y/o male with hypertension, OSA, DMII, ventricular tachycardia, atrial fibrillation, LBBB, and
nonischemic CM, NYHA class 3 CHF, EF 15% with an ICD in place presented with persistent intermittent
episodes of decompensated CHF. We decided to upgrade to a bi-ventricular ICD, however the initial
upgrade attempt in the electrophysiology lab was unsuccessful. The patient was found to have an
anomalous venous drainage system which prevented placement of the LV lead via the coronary sinus,
therefore a left thoracotomy for LV epicardial lead placement was performed in the OR. Maintaining
adequate hemodynamics was key to a successful procedure.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Cardiac Anesthesia (CA) MC729
Management and Outcome of Catastrophic Bypass Failure during On-Pump Aortic Valve
Replacement
AmyCecilia E. Sanders, M.D.,Ph.D., Elizabeth Thomas, D.O., Arjang Khorasani, M.D . Anesthesiology,
Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
A 57 year-old man presented for Aortic Valve Replacement (AVR), which was uneventful until midway
through the pump run when the perfusionist noted failure of forward flow with continued filling of the
venous reservoir, possibly due to a clot in the circuit. The machine was immediately changed out, while
the anesthesia team rapidly cooled the patient with ice to minimize cerebral oxygen consumption.
Unfortunately, the venous reservoir was not clamped early, and a significant amount of the patient's blood
volume was lost. We will discuss the management of this rare event and its similarities to deep
hypothermic circulatory arrest.
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Cardiac Anesthesia (CA) MC730
Anesthetic Vigilance in Caring for a Parturient with Undiagnosed Cardiac Murmur
AmyCecilia E. Sanders, M.D.,Ph.D., Sheri Zimmerman, D.O., Simin Saatee, M.D . Anesthesiology,
Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
We were confronted with a 26-year-old parturient in active labor requesting an epidural who on physical
exam had a very loud systolic heart murmur which had not been noted or evaluated during her
pregnancy. This was associated with hoarseness and a history of self-limited hemoptysis in her 6th
month. While providing labor analgesia, we also initiated a workup of the murmur, which was found to be
due to severe rheumatic heart disease causing critical mitral stenosis (valve area 0.6cm2), severe
pulmonary hypertension, and aortic regurgitation. This diagnosis may have proved life-saving, and would
not have been possible without anesthetic vigilance.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Cardiac Anesthesia (CA) MC731
Alternative Anesthesia Induction in Patients with Anterior Mediastinal Mass Undergoing
Therapeutic Rigid Bronchoscopy
Mona G. Sarkiss, M.D.,Ph.D., Carlos A. Jimenez, M.D., Rodolfo C. Morice, M.D., David Ost, M.D. ,
Georgie A. Eapen, M.D . UTMD Anderson Cancer Center, Houston, TX, USA, Department of Pulmonary
Medicine, The University of Texas MD Anderson Cancer Center., Houston, TX, USA, Department of
Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Two case reports of patients with large anterior mediastinal mass causing more than 80% obstruction of
the trachea scheduled for rigid bronchoscopy and tracheal stents placement. Anesthesia is induced with
propofol infusion while the patient is in a sitting position. Once the patient is sedated positive pressure
ventilation tailored to the patient‟s altered respiratory pathophysiology with increased I:E ratio is instituted.
The adequacy of the positive pressure ventilation and stable hemodynamics are established before the
patient is gradually lowered to supine position and muscle relaxant is administered. Consequently, the
rigid bronchoscope is administered safely and jet ventilation is initiated.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Critical Care Medicine (CC) MC732
Hypotension and Cardiac Arrest After Temporary Pacing Wire Removal
Catriona Kelly, M.B.,Ch.B., Thomas Price, M.B.,B.Ch., Paula Pyper, M.B.,B.Ch . Critical Care Unit,
Altnagelvin Area Hospital, Derry, United Kingdom.
A 70 year old female was admitted to Critical Care following a PEA arrest on the ward. She was
diagnosed with Complete Heart Block and a transvenous temporary pacing wire was inserted. After the
wire was removed she developed profound hypotension and cardiac arrest. ECHO showed a cardiac
tamponade and pericardial aspiration was performed as part of the reususcitation, but was unfortunately
unsuccessful. This case highlights the usefulness of bedside ECHO in diagnosis and treatment of cardiac
complications.
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Critical Care Medicine (CC) MC733
Canines in Critical Care - A Patient's Tail
Catriona Kelly, M.B.,Ch.B., Michaeline Kelly, M.B.,B.Ch., Niamh Sweeney, M.B.,Ch.B . Altnagelvin Area
Hospital, Critical Care Unit, Derry, United Kingdom.
A 60 year old lady, with the background history of depression was admitted for the management of acute
severe pancreatitis.Her mood was noted to be low and she was prescribed her SSRI. Her SSRI was
stopped because of high temperatures attributed to the interaction of Linezolid and Sertraline. Her affect
was blunted and after a suitable washout period the SSRI was restarted. One of this lady's greatest
interests at home was her pet dog, the Infection Control team granted permission for visits. This pet
therapy, coupled with SSRI therapy brought about an appreciable improvement in her mood and
motivation.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Critical Care Medicine (CC) MC734
Extubation in the Operating Room for an Orthotopic Hepato-Kidney Transplant Recipient
Yoshie Kikuchi, Takashi Matsusaki, Mari Shibata, Ryuji Kaku, Hiroshi Morimatsu. Okayama University
Hospital, Okayama, Japan.
We experienced a re-intubated recipient due to recurarization of rocurnium in ICU. A 58-year-old female
had an orthotopic hepato-kidney transplantation for NASH and renal failure for diabetes. We managed
using CHDF in order to manage potassium and acidosis intraoperatively. Surgical Time was 9 hour 44
minutes and RCC 18 units, 14 units FFP and 10 units platelet were required. We tried to extubate her in
the operating room and take her to ICU; however, she had to be re-intubated in the ICU due to hypoxia
one hour after transplantation due to the delayed effects of rocuronium reversed by sugammadex.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Critical Care Medicine (CC) MC735
ECMO for Cardiac Rescue in the Operating Room after Postpartum Spontaneous Coronary Artery
Dissection
Kathleen E. Knapp, M.D., Efrain I. Cubillo, IV, M.D., Alyssa B. Chapital, M.D.,Ph.D., Ricardo A. Weis, M.D
. Anesthesiology, Mayo Clinic, Phoenix, AZ, USA, Mayo Clinic, Phoenix, AZ, USA.
Spontaneous coronary artery dissection is an infrequent cause of acute coronary syndrome in the general
population. There is however, an increased incidence of SCAD in young women, especially in the
peripartum period. The majority of cases have favorable outcomes with medical management or PCI
however CABG and transplantation are utilized in severe cases. This case is that of a 30 yo post-partum
female with multivessel SCAD requiring CABG with subsequent biventricular failure and inability to wean
from bypass. We believe ours is the first case reported in which ECMO was used in the management of a
post-partum patient with SCAD.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Critical Care Medicine (CC) MC736
Use Of Methylene Blue In Refractory Distributive Shock
Curtis J. Koons, M.D., Adam Mason, D.O., Kevin Hatton, M.D., Jeremy Dority, M.D . Department of
Anesthesiology, University of Kentucky, Lexington, KY, USA.
The use of methylene blue in septic and vasoplegic shock has been well described. However, its use in
distributive shock in the setting of cerebral vasospasm is not well described. The pathogenesis of
vasodilatory shock is multifactorial, but it appears to involve increased nitric oxide production leading to
activation of guanylate cyclase. Methylene blue is known to inhibit guanylate cyclase, and may be useful
for the treatment of distributive shock. We describe a case of distributive shock with cerebral vasospasm
due to subarachnoid hemorrhage. Initiation of therapy with methylene blue led to reduced vasopressor
requirements and improved cerebral perfusion pressure.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Critical Care Medicine (CC) MC737
Use of Combination Therapy with Steroid, Pulmonary Vasodilator and ECMO in Refractory
Hypoxemia Associated with ARDS Triggered by Viral Pneumonia
Vikas Kumar, M.D., Mafdy Basta, M.D., Sehar Alvi, M.D., Manuel Castresana, M.D . Anesthesiology,
Georgia Regents University, Augusta, GA, USA.
41 y-o female with PMH of mastectomy and chemotherapy for breast cancer, presented to ER with
shortness of breath of three weeks duration. She was severely hypoxemic despite treatment with 100%
oxygen, high levels of PEEP, inverse ratio, airway pressure release ventilation, HFOV and prone position.
Venovenous ECMO and ventilation with APRV showed little improvement and infusion of
methylprednisolone in addition to inhaled epoprostenol was then started with significant improvement in
oxygenation over the next few days. On day 14th the ECMO was discontinued and later she was
extubated successfully and discharged home on hospital day thirty.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Critical Care Medicine (CC) MC738
Ethical Dilemma Regarding Blood Transfusion in a Patient with Critically Low Hemoglobin
Vikas Kumar, M.D., David Fritz, M.D., Sachin Bahadur, M.B.,B.S., Sehar Alvi, M.D., Manuel Castresana,
M.D . Anesthesiology, Georgia Regents University, Augusta, GA, USA.
56 y/o male admitted to ICU after Whipple procedure and re-explored for bleeding. Preoperatively he
refused blood transfusion influenced by his wife who was Jehowah‟s witness. She rejected blood
transfusion despite his critical condition. He was on mechanical ventilator, vasopressors, developed acute
renal failure requiring hemodialysis and his hemoglobin dropped to 2.8 gm/dl. The hospital legal
counselor was consulted and patient was awakened after turning off sedation. After assessment of his
Copyright © 2014 American Society of Anesthesiologists
decision making capacity, he was asked to make decision regarding blood transfusion, which he agreed
and his life was saved. He was later discharged from ICU in stable condition.
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Critical Care Medicine (CC) MC739
Airway Pressure Release Ventilation Induced Pneumomediastinum in a Patient with Acute Chest
Syndrome from Sickle Cell Disease
Vikas Kumar, M.B.,B.S., Jawad Salim, M.D., Tyler L. Evans, M.D., Manuel Castresana, M.D . Georgia
Regents University, Augusta, GA, USA.
30 y/o old male with past medical history of sickle cell disease and kidney transplant underwent resection
of abdominal wall tumor. On POD 1, he developed acute chest syndrome, pulmonary embolism, was
intubated and had an exchange transfusion for HbS of 52%. Airway pressure release ventilation mode
was initiated with phigh of 30 cmH20 because of worsening oxygenation. He was sedated mean airway
pressure ranging from 25 - 30 cm H2O. The next day he developed acute onset right-sided swelling of
face and subcutaneous emphysema from a large left pneumothorax and pneumomediastinum, which
resolved with chest tube placement.
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Critical Care Medicine (CC) MC740
Pontine Infarction Secondary to Basilar Artery Thrombosis Masked by Delirium Tremens After
Coronary Artery Bypass Graft Surgery
Vikas Kumar, M.D., Mafdy Basta, M.D., Sehar Alvi, M.D., Manuel Castresana, M.D . Anesthesiology,
Georgia Regents University, Augusta, GA, USA.
62 y/o male with PMH of ethanol abuse underwent 3-vessel CABG and extubated next day. On POD 2,
he got agitated and started on alcohol withdrawal protocol including multiple doses of haloperidol and
lorazepam. On POD # 4, he became febrile along with progressive mental obtundation; showed no
improvement after withholding all sedatives and administering flumazenil. CT scan head showed
extensive subacute infarct in posterior circulation involving pons and midbrain with basilar artery
thrombosis. His heparin induced thrombocytopenia antibody initially came back positive with negative
serotonin release assay. Patient remained comatose and died from cardiac arrest after prolonged
hospitalization.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Fundamentals of Anesthesiology (FA) MC741
Submental Intubation vs Tracheostomy in Maxillofacial Trauma
Anna J. Klausner, M.D., Meg A. Rosenblatt, M.D . Mount Sinai Medical Center, New York, NY, USA.
A 26-year-old male was transferred to our ER with multiple facial injuries. CT revealed panfacial fractures
requiring open reduction and internal fixation of multiple fractures including LeFort I. We chose to perform
an awake intubation due to anticipated limitations with mouth opening and mask ventilation. After
discussion with the surgeons, we chose to perform a submental orotracheal intubation, as a nasal
approach was contraindicated. After intubation with a reinforced endotracheal tube, the surgeons created
a submental incision and the proximal end of the tube was passed through the incision and secured.
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Fundamentals of Anesthesiology (FA) MC742
The Use of Awake Fiberoptic Intubation and Extubation with Cook Catheter in Management of
Difficult Airway in a Morbidly Obese Patient
Nebojsa Nick Knezevic, M.D.,Ph.D., Raheleh Rahimi-Darabad, M.D., Gilka Lara, M.D . Anesthesiology,
Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
A-42-year-old morbidly obese man with extremely short neck with high circumference, Mallampathy class
III presented for C6-C7 fusion. The patient received nebulized and gargling lidocaine, midazolam, oral
benzocaine and transtracheal lidocaine. Awake fiberoptic intubation with oral endotracheal tube (ETT)
Copyright © 2014 American Society of Anesthesiologists
was performed. After surgery the patient was awake, breathing spontaneously and following commands.
Atomized endotracheal and IV lidocaine were given, and Cook catheter size-11 was placed and ETT was
removed. In PACU respiration remained normal, and Cook catheter was removed. Awake fiberoptic
intubation and extubation with Cook catheter are probably the safest technique in management of difficult
airway in these patients.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Fundamentals of Anesthesiology (FA) MC743
Peritoneal-lung Fistula: An Unusual Presentation
Shweta Koirala, M.D., Sivan Wexler, M.D . Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
64 year old obese female underwent sleeve gastrectomy complicated by peritoneal lung fistula. The
thoracic portion was surgically corrected, and she presented to surgery several months later for
laparoscopic conversion to roux-en-y gastric bypass for definitive control of the abdominal component.
Throughout peritoneal insufflation sharp spikes in end-tidal carbon dioxide (ETCO2) were noted with
levels reaching 200 mmHg. Arterial carbon dioxide and pH remained normal. ETCO2 normalized with
desufflation. The presumed diagnosis of a persistent peritoneal lung fistula was made despite surgical
correction. Our case is the first report on use of capnography to identify a peritoneal lung fistula.
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Fundamentals of Anesthesiology (FA) MC744
An Unanticipated Difficult Airway with No Glidescope or Fiberoptic Scope Immediately Available
Edward Kosik, D.O., Jeffrey Krause, M.D., Benjamin Stam, B.S . University of Oklahoma Health Science
Center, Oklahoma City, OK, USA.
Our case involved an adult male scheduled for an ablation procedure for atrial fibrillation with an
unanticipated difficult airway in a remote location. The Glidescope or fiberoptic scope was not
immediately available secondary to the remote location. We describe a novel technique using a
disposable Airtraq device, an endotracheal tube introducer and endotracheal tube.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Fundamentals of Anesthesiology (FA) MC745
GlideScope Direct-Intubation-Trainer™ Facilitated Rigid Bronchoscopy and Excision of an
Obstructing Endobronchial Mass
Cheuk Y. Lai, M.D., Franco Resta-Flarer, M.D., Jonathan Lesser, M.D., Jonathan Epstein, M.D .
Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, New York, NY, USA.
A 66-year-old chronic smoker with critical airway obstruction and worsening dyspnea was urgently taken
to the OR after imaging revealed a large RML lung mass. General endotracheal anesthesia was induced
and flexible bronchoscopy revealed a friable right distal tracheal mass causing 90% occlusion of the right
mainstem bronchus. At this point, the ETT was removed and DL was performed using the Glidescope
Direct Intubation Trainer™ to facilitate uneventful insertion of a rigid ventilating bronchoscope while
maintaining visualization of a compromised airway. Intrathoracic tumor excision and balloon
bronchoplasty proceeded uneventfully. 3 days later, the patient returned for additional tumor debulking.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Fundamentals of Anesthesiology (FA) MC746
Anesthetic Management of Binder Syndrome
Seth E. Landa, M.D., Kar-Mei Chan, M.D., Stephen P. Winikoff, M.D., Eliyahu N. Cooper, M.D., Justin
Carbonello, M.D., Nadine Mirzayan, M.D . Anesthesia, St. Joseph's Regional Medical Center, Paterson,
NJ, USA, Anesthesiology, St. Joseph's Regional Medical Center, Paterson, NJ, USA.
Binder Syndrome, or maxillonasal dysplasia, is a congenital disorder that is characterized by
malformation of the nose and/or maxilla. Common features include hypoplasia of the maxilla and nasal
septum, absence of the anterior nasal spine, a flattened nose with acute nasolabial angle, and associated
abnormalities of the upper teeth, palate, and cervical vertebrae. Surgical correction may include bone
Copyright © 2014 American Society of Anesthesiologists
grafts, implants and soft tissue advancement.We describe the anesthetic management of a 50 year-old
man with Binder Syndrome who presented for debridement of an infected forehead-to-nose flap.
Challenges included difficult mask ventilation and intubation requiring a novel approach to anesthetic
induction.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Fundamentals of Anesthesiology (FA) MC747
Emergency Adult Foreign Airway Aspiration
Bahram Namdari, D.O., Stephen Detzel, D.O., Marco Martua, M.D . Cleveland Clinic, Cleveland, OH,
USA.
71 year old male patient arrives to emergency department following a choking episode while eating
chicken wings. The patient has a history of paroxysmal atrial fibrillation, multiple transient ischemic
attacks, and congestive heart failure. He was recently discharged from the hospital following a
cerebrovascular accident in the setting of discontinued anticoagulation. This resulted in dysphagia and
left sided weakness. A neck CT reported a 2.7cm tubular structure with calcified rim within the superior
esophagus at or just above the level of the thoracic inlet with no overt signs of esophageal perforations.
The plan was to perform an awake fiberoptic intubation
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Fundamentals of Anesthesiology (FA) MC748
Regional Anesthesia for Total Hip Replacement in a Super, Super Morbidly Obese Woman
Philip W. Lebowitz, M.D . Anesthesiology, Montefiore Medical Center, Bronx, NY, USA.
A 5'3", 346-lb (BMI 61.3) woman with GERD, hypertension, COPD, asthma, OSA, and pulmonary
hypertension, as well as TIAs treated with clopidogrel (discontinued), undergoing total hip replacement
was given spinal anesthesia that stopped working midway through the procedure with the patient in the
left lateral decubitus position. The patient refused general anesthesia. Breathing N2O did not provide
suitable analgesia, and a propofol infusion irritated the patient‟s arm beyond her tolerance. Eventually, the
patient accepted sevoflurane and N2O via an anesthesia facemask, though the patient required a
nasopharyngeal airway to relieve upper airway obstruction while breathing spontaneously through the
surgery.
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Fundamentals of Anesthesiology (FA) MC749
Bilateral Superficial Cervical Plexus Block With Dexmedetomidine Sedation in a Patient With
Severe Tracheal Stenosis : Case Report
Donghun Lee, M.D., HaeKyu Kim, M.D.,Ph.D., AhReum Cho, M.D.,Ph.D., Euna Lee, M.D . Anesthesia
and Pain Medicine, Pusan National University Hospital, Busan, Korea, Republic of.
When general anesthesia using endotracheal intubation is not possible, other anesthetic strategies are
suggested, such as cervical epidural anesthesia (CEA), local anesthesia, cardiopulmonary bypass (CPB),
and extracorporeal membrane oxygenation (ECMO). However, these strategies have potential problems.
We report a case of severe tracheal stenosis that received a bilateral superficial cervical plexus block
under dexmedetomidine sedation through tracheal dissection until endotracheal tube (ETT) insertion,
which allowed the airway to be secured before surgery under general anesthesia.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Pediatric Anesthesia (PD) MC750
Epidermolysis Bullosa: Anesthetic Concerns and Considerations
Maisie M. Tsang, M.D., Stephen Winikoff, M.D., Padmaja Upadya, M.D . Anesthesiology, St. Joseph's
Regional Medical Center, Paterson, NJ, USA, St. Joseph's Regional Medical Center, Paterson, NJ, USA.
An interesting pediatric case of Epidermolysis Bullosa in dental surgery - our rationale behind, and
approach to safe patient care.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Pediatric Anesthesia (PD) MC751
Anesthetic Plan for the Undiagnosed Hypotonic Child
Cesar L. Velazquez-Negron, M.D., Pamela Bland, M.D . Walter Reed National Military Medical Center,
Bethesda, MD, USA.
A twelve year old female with a history of progressive scoliosis and undiagnosed congenital hypothonia
presented for a multilevel spinal fusion. She has no past surgical or anesthetic history. Her parents noted
vague generalized weakness since the age of 2. However, over the last two years, this weakness had
progressed to the point of having difficulty walking up stairs and performing other activities.The differential
diagnoses include a wide variety of muscular dystrophies, mitochondrial diseases, and central core
disease all of which have unique and varying implications on anesthetic management.
Sunday, October 12, 2014
1:20 PM - 1:30 PM
Pediatric Anesthesia (PD) MC752
The Liver Without Its Ducts: A Case Presentation of Biliary Atresia & The Anesthetic Management
For A Kasai Procedure
Christina X. Wang, M.D., Carlos Campos, M.D . Anesthesiology, Baylor College of Medicine, Houston,
TX, USA.
A 2 month old former 39 week male diagnosed with a hepatic cyst in utero was born with jaundiced skin,
acholic stools, and failure to thrive. Given his liver cyst history and initial imaging studies, his
hyperbilirubinemia was presumed to be secondary to a choledochal cyst. Biliary atresia was also a part of
the differential as were other causes of hyperbilirubinemia. Our patient was scheduled for an open biopsy
with intraoperative cholangiogram and cystectomy with possible reconstruction. In this case, we outline
the presentation, diagnosis, and treatment of biliary atresia and the anesthetic management of a Kasai
procedure.
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Pediatric Anesthesia (PD) MC753
One Hot Mess: Challenges of Early Diagnosis of Malignant Hyperthermia in a Pediatric Patient
Lindy Watanaskul, M.D., Emily Joe, M.D., Hanni Monroe, M.D . University of Maryland Medical School,
Baltimore, MD, USA.
A healthy 15-year-old male presented for elective patellar repair. He received a femoral nerve block and
general anesthesia with an LMA. Intraoperatively, the patient developed significant tachycardia and
hypercarbia. His temperature increased rapidly, with a peak of 38.5 C. Malignant hyperthermia (MH) was
suspected and dantrolene was administered with quick resolution of symptoms. Diagnosis of MH was
equivocal based on post-crisis labs results, including mild respiratory acidosis and mild elevations in CPK,
myoglobin, and potassium. A positive ryanodine mutation was later found. We will discuss the challenges
in early recognition, treatment, and airway management of malignant hyperthermia.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Pediatric Anesthesia (PD) MC754
Low Pressure Oxygenation During Dilation of Subglottic Stenosis
Andrew Weiss, M.D., M.S., Diana Khalil, M.D., Adrian Gooi, M.D., Harley Wong, M.D., Heinz Reimer, M.D
. University of Manitoba, Winnipeg, MB, Canada.
We describe the management of a patient with congenital heart defects during tracheal dilation of severe
subglottic stenosis. Using an endovascular dilation catheter with a luer-lock side port allows for the
assembly of a syringe and stop-cock apparatus. This apparatus allows for the delivery of oxygen at the
patient‟s rate of consumption during the period of total tracheal occlusion. The infant was administered
total intravenous anaesthesia with maintenance of spontaneous ventilation throughout the case. He had a
pair of sequential subglottic dilations, each dilation for a full two minutes, and maintained 100% saturation
throughout.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Pediatric Anesthesia (PD) MC755
Ipsilateral Tension Pneumothorax after Thorascopic Left Congenital Diaphragmatic Hernia Repair
Tracy E. Wester, M.D., Eric Stickles, M.D . Vanderbilt, Nashville, TN, USA, Department of Pediatric
Anesthesiology, Vanderbilt, Nashville, TN, USA.
Our patient, a 3.6 kg four day-old male with a congenital diaphragmatic hernia underwent thorascopic
repair. Upon closure and return to supine position, the patient's oxygen saturation fell. Auscultation
revealed coarse breath sounds on the right and expected decreased breath sounds on the left. Further
deterioration occurred despite 100% FiO2 and manual ventilation, with prolonged desaturation and
bradycardia. Oxygen saturations and heart rate improved somewhat after interventions including
epinephrine, paralysis, and ETT exchange to a cuffed tube, but the patient remained unstable. Emergent
CXR demonstrated significant left pneumothorax. Needle decompression of the left chest provided
immediate improvement in physiologic status.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Pediatric Anesthesia (PD) MC756
Perioperative Care of an Adolescent with Congenital Adrenal Hyperplasia Related to 11βhydroxylase Deficiency
Emmett E. Whitaker, M.D., Graciela Argote-Romero, M.D., Enrique Tome, M.D., Venkata R. Jayanthi,
M.D. , Joseph D. Tobias, M.D . Department of Anesthesiology and Pain Medicine, Nationwide Children's
Hospital/The Ohio State University Wexner Medical Center, Columbus, OH, USA, Pediatric Surgery,
Hospital Escuela Universidad Nacional Autonoma De Honduras Unah, San Pedro Sula, Honduras,
Pediatric Urology, Nationwide Children's Hospital/The Ohio State University Wexner Medical Center,
Columbus, OH, USA.
We present a case of a 14 year old female with previously untreated congenital adrenal hyperplasia
related to 11-B hydroxylase deficiency. The patient had suffered near complete virilization of secondary
sex characteristics. Anesthetic and surgical management of the patient will be reviewed. This patient was
cared for during a surgical mission trip to San Pedro Sula, Honduras sponsored by International
Volunteers in Urology (Salt Lake City, Utah) and the Ruth Paz Foundation (San Pedro Sula, Honduras).
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Pediatric Anesthesia (PD) MC757
Dancing the Fine Line Between Life and Death: How to Recognize ROHHAD Syndrome and
Manage its Unique Challenges
James E. Wolf, M.D., Nicole Collins, D.O., Ann Lawrence, M.D . Anesthesiology, Fletcher Allen Health
Care, Burlington, VT, USA.
Four year-old female with a past medical history of unexplained, rapid and excessive weight gain and
severe BiPAP-dependent sleep apnea requiring several admissions for diagnostic and therapeutic
procedures under anesthesia. She was eventually admitted to the PICU with a heart rate of 50 and a
temperature of 28.5 degrees Celsius. Presumptive diagnosis of ROHHAD Syndrome was made and
further supported by a large retroperitoneal mass found on MRI. She had an extensive hospital course
requiring multiple anesthetics with varying degrees of hemodynamic instability compounded by a disease
which is poorly understood and minimally documented in the academic literature.
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Pediatric Anesthesia (PD) MC758
Management of Difficult Airway in a Pediatric Patient with Achondroplasia
Heng Wu, M.D., Stephan Klumpp, M.D . Jackson Memorial Hospital, Miami, FL, USA.
A 5-month-old boy born at 27-week with achondroplasia was scheduled for gastrostomy. After induction,
patient was successfully ventilated. Initial attempts to intubate using Miller-0 and Parson blades by
anesthesia resident and attending were unsuccessful. The vocal-cords and epiglottis couldn't be
visualized. Pediatric ENT surgeon was consulted. After 2 more failed attempts, the ENT surgeon
Copyright © 2014 American Society of Anesthesiologists
successfully placed the endotracheal tube. The landmarks for intubation were abnormal: absent epiglottis,
presence of false vocal-cords, extreme anterior larynx deviated to the left. After intubation the
gastrostomy-tube was placed uneventfully. After discussion with parents, tracheostomy was performed for
the further management of this patient.
Sunday, October 12, 2014
1:00 PM - 1:10 PM
Fundamentals of Anesthesiology (FA) MC759
Pseudocholinesterase Deficiency: Not Just Genetics
Nathaniel J. Sharp, M.D., Thomas Tinker, M.D . Anesthesiology, University of Oklahoma, Oklahoma City,
OK, USA.
A 50-year-old male underwent an anorectal procedure in our surgery center. He had had multiple similar,
short procedures; most recently five months prior. The patient received standard induction medications,
including succinylcholine. At the conclusion of this procedure, the patient did not regain TOF twitches or
display spontaneous respiratory effort. This surgical procedure and anesthetic plan mirrored prior
surgeries. After EMS transfer to the hospital, the patient‟s CT head was unchanged & dibucaine number
was normal. Notable physical findings were cachexia and significant weight loss. The etiology of this
patient‟s prolonged paralysis, its pathogenesis and differential diagnosis will be revealed.
Sunday, October 12, 2014
1:10 PM - 1:20 PM
Fundamentals of Anesthesiology (FA) MC760
Brain Oximetry and Mixed Venous Gas Guiding Resuscitation to Reduce Ischemic Injury with
Aortic Cross Clamp
Amir Shbeeb, M.D., Susan J. Alvarez, M.D., Mariana Mogos, M.D., Peter Roffey, M.D., Duraiyah
Thangathurai, M.D . Anesthesiology, University of Southern California, Los Angeles, CA, USA.
We present a 52 year-old male ASA 5E patient with severe vascular disease undergoing emergent aortic
aneurysm stenting, superior mesenteric and celiac artery grafting, aortic cross clamp, and left
nephrectomy. The surgery limited perfusion to vital organs secondary to aortic cross clamp and severe
bleeding. We describe the anesthetic management using cerebral oximetry and mixed venous analysis to
guide intraoperative fluid resuscitation to decrease hypoxic tissue injury. This discussion summarizes the
utility of these measurements along with the value and importance of monitoring resuscitation end points
in critically-ill patients.
Sunday, October 12, 2014
1:30 PM - 1:40 PM
Fundamentals of Anesthesiology (FA) MC761
Brain Oximetry Guiding Massive Transfusion Resuscitation in Acute Hemorrhagic Shock
Amir Shbeeb, M.D., Sarah Moore, M.D., Rahul Modi, M.D., Duraiyah Thangathurai, M.D . Anesthesiology,
University of Southern California, Los Angeles, CA, USA.
Brain oximetry is a non-invasive device used to monitor oxygenation of cerebral tissue. In this case, we
used brain oximetry to guide our resuscitation with a patient hemorrhagic shock. In emergent anesthesia,
resuscitation and end-organ tissue perfusion are of the essence. This case posed several changes as
she presented coagulopathic, hypothermic, acidotic, edematous, on vasopressors, and in hemorrhagic
shock on the brink of cardiopulmonary arrest. With aggressive management of the above challenges, we
were able to provide adequate resuscitation and maintain tissue and vital organ perfusion with the use of
brain oximetry as a surrogate for mixed venous oxygen saturation.
Sunday, October 12, 2014
1:40 PM - 1:50 PM
Fundamentals of Anesthesiology (FA) MC762
Difficult Airway Management in Airway Surgery Involving the High Risk Patient
Mariam W. Sheikh, D.O., Franco Resta-Flarer, M.D., Jonathan Lesser, M.D., Junping Chen, M.D .
Anesthesiology, St. Lukes Roosevelt Hospital Center, New York, NY, USA.
69 year old male with a long standing tracheostomy presented for a cordotomy, and removal of tracheal
and stomal granulation tissue using laser. His history consisted of myelodysplastic syndrome, previous
Copyright © 2014 American Society of Anesthesiologists
craniotomy for an epidural and subdural hematoma, and bilateral carotid stents following a CVA with left
sided hemiparesis. Orotracheal intubation was difficult using direct and video laryngoscopy secondary to
abundant granulation tissue, limited neck mobility and bleeding from hematologic dysfunction. Successful
orotracheal intubation with a reinforced endotracheal tube was accomplished using a zero degree scope.
A dual-cuffed tube was later inserted from the tracheal stoma and removed during lasering.
Sunday, October 12, 2014
1:50 PM - 2:00 PM
Fundamentals of Anesthesiology (FA) MC763
Isorhythmic Atrioventricular Dissociation with Hemodynamic Instability during Craniotomy for
Tumor
Tao Shen, M.B.,B.S., Robert Peterfreund, M.D.,Ph.D., Jonathan Charnin, M.D . Anesthesia, Critical Care
and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
We describe a case of isorhythmic A-V dissociation with accelerated junctional rhythm causing significant
hypotension in a 94 year-old man with dual-chamber pacemaker and LVH undergoing left frontal
craniotomy for meningioma. Poorly responsive to β-blockade and escalating doses of
neosynephrine/norepinephrine, hypotension and dysrhythmia were successfully treated with diltiazem
and induction of A-V pacing by placing a magnet over the pacemaker. Isorhythmic A-V dissociation is a
common cardiac dysrhythmia during volatile anaesthesia. While generally well tolerated, this case
demonstrates its significant hemodynamic effects in a patient with compromised cardiac reserve reliant on
normal atrial contribution to LV filling and cardiac output.
Sunday, October 12, 2014
2:00 PM - 2:10 PM
Fundamentals of Anesthesiology (FA) MC764
Perioperative Injuries Related to Intravenous Catheters
Nidhi Sheokand, M.B.,B.S., Ramprasad Sripada, M.D . Anesthesiology, University of Iowa Hospitals and
Clinics, Iowa City, IA, USA.
A patient presented for right hip arthroplasty under general anesthesia. Better intravenous access was
lost with concomitant hypotension during left lateral positioning. Ultrasound guided right EJV catheter
placed due to unsuccessful attempts at peripheral access. This was used to transfuse blood products and
crystalloids without overt signs of obstruction. At emergence, after resuming supine position, right lower
facial swelling, ecchymosis and swelling in the neck extending to upper chest was noted, raising concerns
for infiltration of the intravenous catheter. This necessitated continued postoperative endotracheal
intubation and unplanned intensive care unit admission due to concerns of potential airway compromise.
Sunday, October 12, 2014
2:10 PM - 2:20 PM
Fundamentals of Anesthesiology (FA) MC765
Airway Management in the Presence of Bronchoeoesophageal Fistula Involving the Left Mainstem
Bronchus
Josh M. Shepherd, D.O., Anjali Patel, D.O . Anesthesiology, Saint Louis University, Saint Louis, MO,
USA.
A 75 year old female with a benign left mainstembronchoesophageal fistula presented to the OR for
repair via right thoracotomy. The patient‟s airway was managed with a right 35 French double lumen tube
along with a 14 French airway exchange catheter placed through the tracheal lumen. During repair of the
airway, the left lung was ventilated with a hand operated jet ventilator via the exchange catheter. Once
repair of the left mainstem bronchus was completed the exchange catheter was removed and one lung
bellows driven ventilation was resumed without complication.
Sunday, October 12, 2014
2:20 PM - 2:30 PM
Fundamentals of Anesthesiology (FA) MC766
A Case of Emergent Airway Management of an Obstructing Anterior Mediastinal Mass
Kara K. Siegrist, M.D., Jonathan Wanderer, M.D . Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN, USA.
Copyright © 2014 American Society of Anesthesiologists
27 year old female with transverse myelitis who presented with progressive dyspnea, cough, and several
months of night sweats and weight loss secondary to a newly diagnosed, large obstructing anterior
mediastinal mass. Anesthesia was consulted emergently overnight for airway management of worsening
respiratory distress. Upon arrival to the ICU, the patient was hypoxic, speaking in 2 word phrases,
dyspneic on non-rebreather facemask, positioning herself in a tripod configuration with significant
accessory muscle utilization. An awake fiberoptic endotracheal intubation was performed utilizing airway
topicalization with viscous and nebulized lidocaine and systemic anxiolysis with dexmetetomidine.
Spontaneous respiration was maintained throughout the procedure.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC08
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Neuroanesthesia (NA) MC767
There's No Blood in the Field! Occult Catastrophic Vascular Injury During Lumbar Spine Surgery
Corey R. Herman, M.D., Tara L. Kennedy, M.D., Colleen A. Vernick, D.O., Megan J. Sharpe, M.D .
Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA, Anesthesiology, UMass
Memorial Medical Center, Worcester, MA, USA.
Vascular injury during posterior lumbar spine surgery can have catastrophic consequences if not
identified rapidly. We present a case report of a 60 year old female who underwent a posterior lumbar
decompression for degenerative spondylolisthesis. During discectomy, there was a sudden drop in end
tidal carbon dioxide and a marked dampening of EEG followed by profound hypotension and tachycardia.
A lack of sustained bleeding in the operative field led to a delayed diagnosis of a near-transection of the
abdominal aorta. Resuscitation measures were initiated and stat intraoperative trauma surgery and
vascular surgery intervention were able to stabilize the patient.
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Neuroanesthesia (NA) MC768
Neurosurgery for a Patient With a Left Ventricular Assist Device (LVAD) in the Prone Position
Jesse T. Hochkeppel, M.D., Stacie Deiner, M.D . Anesthesiology, Icahn School of Medicine at Mount
Sinai Hospital, New York, NY, USA.
A 61 year old male with a history of ischemic and valvular cardiomyopathy requiring LVAD placement
presented for anesthetic evaluation secondary to a ventral epidural collection at the L3-L4 interspace
requiring urgent decompressive laminotomy in the prone position. Management was further complicated
by the need for cessation of anticoagulation. The case proceeded uneventfully through utilization of an
interdisciplinary team. Given the paucity of available literature on this subject, we are presenting a review
of our management of this patient to serve as an overview of the perioperative considerations for patients
with LVAD‟s and the specific concerns related to prone positioning.
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Neuroanesthesia (NA) MC769
Anesthetic Management of a High Risk Cardiac Patient Undergoing an Awake Craniotomy for
Intracranial Bypass of a Recurrent Complex Aneurysm with a Radial Artery Graft
Harold G. Jackson, M.D., Peter Vuong, M.D., Ethan Reynolds, M.D . Anesthesiology & Critical Care, St.
Louis Univ, Saint Louis, MO, USA.
A 65 year old male with significant cardiac history including: myocardial infarct, CHF with an estimated
ejection fraction of 10%, and ICD dependence underwent awake stereotactic craniotomy for intracranial
bypass of a recurrent giant MCA aneurysm. This approach was decided upon after this patient was
turned down for interventional coiling given his cardiac comorbidities. Performing the procedure awake
affords the advantage of neurological testing before any vessels are permanently clipped or sacrificed.
Also, avoidance of general anesthesia and the increased risk of postoperative morbidity and mortality in
this patient was paramount to a successful outcome.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Neuroanesthesia (NA) MC770
Multiple System Atrophy: Anesthetic Implications
Jenifer MN Jewell, M.D., Robert Weaver, M.D., Jeremy Dority, M.D., Pieter Steyn, M.D . University of
Kentucky, Lexington, KY, USA.
Copyright © 2014 American Society of Anesthesiologists
Multiple System Atrophy or Shy Drager Syndrome is a rare, progressive neurological disorder of the
central and autonomic nervous system causing significant orthostatic hypotension as well as other
autonomic dysfunctions. Autonomic dysfunction presents a challenge to perioperative anesthetic
management. We present a case of a patient with Multiple System Atrophy, Parkinsonian type, who
underwent implantation of a deep brain stimulator in two stages. This case highlights the challenge of
blood pressure control in a patient with significant orthostatic hypotension.
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Neuroanesthesia (NA) MC771
One Patient, Four Cases, 24 Hours: Unusual Complications After Carotid Body Tumor Resection
Versan S. Johnson, M.D., Hokuto Nishioka, M.D . University of Illinois at Chicago, Chicago, IL, USA.
Thirty-three-year-old female with inherited paraganglioma who presented for elective resection of a right
carotid body tumor. Her pre-operative workup, including plasma catecholamine levels, was negative and
intra-operative course was uneventful. Around midnight in the ICU she was found down after attempting
to get out of bed independently. At thattime she was noted to have left- sided hemiplegia and facial palsy.
Head CT revealed a thrombosed right carotid graft and new right-sided MCA infarct. She subsequently
underwent three emergency procedures including open thrombectomy of the vein graft, angiogram and
thrombectomy of the right MCA occlusion, and right decompressive craniectomy.
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Neuroanesthesia (NA) MC772
Perioperative Management of Acute Baclofen Withdrawal
Daniel T. Judkins, M.D., Priya Gupta, M.D., Indranil Chakraborty, M.D., Mohamed Ismaeil, M.D .
Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
A 27-year-old female with cerebral palsy was admitted to the ICU for acute baclofen withdrawal. She
presented with a low-grade fever, tachycardia, labile blood pressure, and tachypnea. The neurosurgery
team decided to perform an emergent baclofen pump exchange after failure of medical therapy in the
ICU. Her anesthesia plan included a bolus of midazolam prior to transfer to the OR, intravenous induction
with midazolom, fentanyl, propofol, and rocuronium, and maintenance with sevoflurane. She had
significant improvement in her symptoms after an intrathecal baclofen dose was given. After completion
of the procedure, she returned to the ICU in stable condition.
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Neuroanesthesia (NA) MC773
Takotsubo Cardiomyopathy With Induction of General Anesthesia in a Polymorbid Patient
Undergoing Elective Surgery
Eduardo J. Jusino, M.D., Rafi Avitsian, M.D., Hesham Elsharkawy, M.D . Anesthesiology, Cleveland
Clinic Foundation, Cleveland, OH, USA.
A 70 year old male with history of coronary artery disease, congestive heart failure, atrial fibrillation,
rheumatoid arthritis, hypertension, hyperlipidemia, chronic kidney disease and chronic obstructive
pulmonary disease presented for lumbar decompression laminectomy. Preoperative echocardiogram
demonstrated an ejection fraction of 58%. Induction of anesthesia produced a refractory hypotensive
state with response to only large doses of epinephrine. Echocardiogram during the episode and repeated
within 24 hours showed extensive wall motion abnormalities consistent with either ischemia/infarction or
Takotsubo cardiomyopathy, with ejection fraction of 30%. Cardiac catheterization revealed 95% right
coronary artery stenosis which could not explain the diffuse left ventricular dysfunction.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Neuroanesthesia (NA) MC774
Management of Intraoperative Cerebral Edema in a Patient with Sickle Cell Disease - How to
Decompress the Brain Without Precipitating Crisis?
Copyright © 2014 American Society of Anesthesiologists
Emily B. Kahn, M.D., Ryan M. Chadha, M.D . Anesthesiology, Yale-New Haven Hospital, New Haven,
CT, USA.
A patient with sickle cell disease and history of acute chest syndrome presented for emergency
craniotomy with dural venous sinus thrombosis and hemorrhage. CT showed midline shift and the patient
had altered mental status. Before surgery, the patient received an exchange transfusion. During surgery,
there was significant cerebral edema and 23.4% sodium chloride was given to decompress the brain.
Mannitol was not given because it could cause dehydration and precipitate a sickle crisis. Recovery was
uneventful. This case discusses the competing goals of treating cerebral edema while avoiding a sickle
crisis in a patient at risk.
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Neuroanesthesia (NA) MC775
Spontaneous Resolution of Paraplegia Upon Placement of Lumbar Cerebrospinal Fluid Drain
Status- Post Endovascular Repair of a Thoracic Aortic Aneurysm
Sang J. Kim, M.D., Edward Mathney, M.D . Anesthesiology, Icahn School of Medicine at Mount Sinai,
New York, NY, USA.
74 year-old male with history of coronary artery disease status-post CABG, COPD, chronic kidney
disease, peripheral vascular disease and thoracic aortic aneurysm (TAA) initially admitted for systemic
inflammatory response syndrome (SIRS) and respiratory failure secondary to right hemothorax was
incidentally found to have enlarging TAA from 2.6cm to 7.1cm within a 19-day period. Patient underwent
emergent surgery for thoracic endovascular aortic repair (TEVAR) under general anesthesia and became
paraplegic post-operatively. Emergent lumbar cerebrospinal drainage was placed with subsequent
resolution of neurologic deficit.The history of the use of lumbar cerebrospinal drainage in TEVAR surgery
will be explored in this presentation.
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Cardiac Anesthesia (CA) MC776
Aortic Valve Replacement for Severe Aortic Stenosis in Patient with Mucopolysaccaridosis Type II
Nicholas J. Bremer, M.D., Peter Neuburger, M.D . Department of Anesthesiology, NYU Langone Medical
Center, New York, NY, USA.
43-year-old male with Hunter Syndrome” (Mucopolysaccaridosis 2, MPS2) for minimally invasive Aortic
Valve Replacement. Patient has had known severe aortic stenosis since childhood, as part of MPS2,
followed by annual transthoracic echocardiograms, recently more symptomatic with increasing dyspnea
on exertion. Also as part of MPS2, patient also with severe intrathoracic tracheomalacia, severe
bronchomalacia, severe cervical spinal stenosis, limited mobility of all joints including limited extension of
cervical spine, pulmonary granulomatous disease, and gastroesophageal reflux disease. Discussion of
this case to focus on airway, cardiac, pulmonary, orthopedic, and neurologic implications of MPS2 in
patients undergoing cardiac and routine surgery.
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Cardiac Anesthesia (CA) MC777
Intraoperative Reprogramming of Biventricular Pacemaker to Biventricular Asynchronous Mode
David J. Brenneman, M.D., F. Luke Aldo, D.O., Dhamodaran Palaniappan, M.D . Anesthesiology,
University of Connecticut, Farmington, CT, USA, Anesthesiology, Hartford Hospital, Hartford, CT, USA.
A 70 year-old man with biventricular pacemaker/automated implantable defibrillator (BiVVIR mode) for
ischemic cardiomyopathy (ejection fraction 10%) presented for a Whipple procedure. During preoperative
CIED interrogation, anti-tachyarrhythmia/defibrillation function was suspended. Intraoperatively, there was
significant hemodynamic instability associated with tachycardia in the context of unipolar electro-cautery
interference. As hemostasis was unsatisfactory with bipolar cautery, intraoperative electrophysiology (EP)
consultation was obtained. Reprogramming to BiVOO mode after confirmation with manufacturer resulted
in recovery of hemodynamic stability and good outcome. This case highlights the preservation of
biventricular pacing in patients with low ejection fraction and raise awareness of biventricular
asynchronous settings in newer CIEDs.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Cardiac Anesthesia (CA) MC778
Pulmonary Arterial Pressures Exceed Systemic in Patient with PHTN Secondary to CTEPH
Undergoing Navigational Bronch for RLL Biopsy
Bryant Bunting, D.O., Dennis Phillips, D.O . University of Pittsburgh, Pittsburgh, PA, USA.
Patient with known Chronic Thromboembolic Pulmonary Hypertension (CTEPH) with PA pressures of
79/31 (50) on dual Tadalafil and Ambrisentan therapy underwent navigational biopsy for suspicious RLL
nodule. Early anesthetic course was complicated by profound increase in pulmonary artery pressures
(peak of 150mmHg systolic) and drop in oxygen saturation. Management required vasoactives, inotropes,
and iNO and prompted TEE evaluation to assess LV function and possible right to left shunt.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Cardiac Anesthesia (CA) MC779
Right Sided Aortic Arch, Aberrant Left Subclavian Artery, and Kommerell's Diverticulum
Alyssa M.U. Burgart, M.D., Jayanta Mukherji, M.D . Loyola University Chicago, Maywood, IL, USA.
We present a 63-year-old male with a chief complaint of paroxysmal dyspnea, severe reactive airway
disease, and esophageal stricture. After thorough workup, he was found to have a right-sided aortic arch,
aberrant left subclavian artery, and Kommerell‟s diverticulum. His disease was surgically treated via a left
thoracotomy approach. In this case, we review the embryologic origin of the disease, the relevant adult
anatomy, and the unique anesthetic considerations, especially those pertaining to the airway.
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Cardiac Anesthesia (CA) MC780
Extracavitary Cardiac Carcinoid Presenting with Right Ventricular Outflow Tract Obstruction
Enrico M. Camporesi, M.D., Yiu-Hei Ching, M.D., Veronica L. Massey, M.D., Christiano C. Caldeira, M.D.,
Hesham R. Omar, M.D. , Devanand Mangar, M.D . Florida Gulf-to-Bay Anesthesiology Associates,
Tampa, FL, USA, Florida Advanced Cardiothoracic Surgery, Tampa, FL, USA, Mercy Medical Center,
Clinton, IA, USA.
We discuss the case of a patient with metastatic cardiac carcinoid from a gastrointestinal primary site.
Initially, the patient had developed obstructive cardiac symptoms secondary to a mass in the right
ventricular outflow tract and initiated on external beam radiation therapy. As the tumor did not respond
with symptom progression, the patient was referred for surgical excision under cardiopulmonary bypass.
Intraoperative transesophageal echocardiogram demonstrated an extra-cavitary lesion with endocardial
sparing which was confirmed on surgical exploration. Resection was completed with patch repair of the
right ventriculotomy site. Surgical pathology revealed synaptophysin and chromogranin positivity
confirming the diagnosis of metastatic carcinoid.
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Cardiac Anesthesia (CA) MC781
Hypotension POD#1 after AICD Placement: A Case of Undiagnosed IVC Perforation
Ryan M. Chadha, Trevor Banack, M.D . Yale New Haven Hospital, New Haven, CT, USA.
84 year old male post AICD placement 24 hours prior presented for emergent pericardial window. Awake
arterial line was placed, type and cross sent, uneventful inhalation induction was performed, and the
pericardium was accessed draining 800ml of effusion. The effusion returned on TEE. Median sternotomy
was performed with two liters of blood drained with hemodynamic compromise, necessitating crash
cardiopulmonary bypass and transfusion of uncrossmatched blood. Examination revealed IVC laceration
caused by AICD lead placement. During the case, the blood bank reported the patient‟s blood had
antibodies, hydrocortisone and diphenhydramine were administered. After surgical repair and
resuscitation, the patient recovered uneventfully.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Cardiac Anesthesia (CA) MC782
Intraoperative Evaluation of Right Ventricular Outflow Tract Myxoma by Real Time ThreeDimensional Transesophageal Echocardiography
Chan Chen, M.D.,Ph.D., Jun Gu, M.D., Wei Meng, M.D.,Ph.D., Haibo Song, M.D., Da Zhu, M.D.,Ph.D.,
Eryong Zhang, M.D.,Ph.D . Department of Anesthesiology and Translational Neuroscience Center, West
China Hospital, Chengdu, China, Department of Thoracic and Cardiovascular Surgery, West China
Hospital, Chengdu, China.
Primary cardiac tumors are rare, of which, the most common benign tumors are myxomas. Cardiac
myxoma arising form right ventricular outflow tract (RVOT) is extremely rare, but could cause major
clinical sequelae and pose considerable diagnostic and therapeutic challenges. Here, we report the
intraoperative application of real-time three-dimensional transesophageal echocardiography (RT3DTEE)
in the assessment of a patient with a RVOT myxoma. RT3DTEE clearly assess the characteristics of the
mass, such as the size, shape, attachment points, and composition. With the intraoperative guidance of
RT3DTEE, the patient underwent successful removal of the mass.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Cardiac Anesthesia (CA) MC783
Infective Endocarditis Complicated by Intra-operative Desaturation and Post-op Pacemaker Lead
Dislodgement
Jennifer M. Chesnut, D.O., Nathan Smith, M.D., Lyle Stefanich, M.D . University of Oklahoma Medical
Center, Oklahoma City, OK, USA.
An 81-year-old male with multiple comorbidities, presented for lead extraction and temporary pacer
placement. He had been treated by another facility for bacteremia 2 months prior to admission. An
echocardiogram performed the day before surgery demonstrated expected cardiac dysfunction, with a
"1.8x1.3cm hypoechoic mass on right ventricular lead". The patient refused further aggressive surgical
intervention. During the lead extraction, he had an episode of desaturation which was evaluated using
intraoperative CT angiography. After a successful operative course, patient was recovering with a
sandbag placed on chest to minimize hematoma formation. This resulted in dislodgement of temporary
pacemaker.
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Cardiac Anesthesia (CA) MC784
Heparin Neutralization in a Patient with Protamine Anaphylaxis
Atif N. Chowdhury, M.D., Mark Chaney, M.D., Joseph Devin Roberts, M.D . Anesthesiology and Critical
Care, University of Chicago, Chicago, IL, USA.
A 66 year old morbidly obese male with ischemic cardiomyopathy status post AICD placement, CAD
status post four vessel CABG, and critical aortic stenosis underwent aortic valve replacement. The patient
had a documented anaphylactic reaction to protamine manifested by hypotension and bronchospasm
during prior cardiac surgery at an outside hospital. After joint consultation between the cardiac surgery
and cardiac anesthesia teams we decided to proceed with full heparinization and subsequent
neutralization with protamine injected directly into the ascending aorta. Here we describe the approach
and anesthetic management of cardiac surgery in a patient with protamine anaphylaxis.
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Obstetric Anesthesia (OB) MC785
Hypoxia and Hypotension During General Anesthesia for Caesarean in the Setting of a Failed
Spinal in a Medically Complex Patient
Emily M. Pollard, B.S., Bradley Kelsheimer, M.D., Betty J. Haywood, M.D., Casey Windrix, M.D .
University of Oklahoma, Oklahoma City, OK, USA.
A 36 year-old female with pre-gestational diabetes, hypertension, severe asthma, morbid obesity, and
schizophrenia presented at 36 weeks gestation for delivery by urgent cesarean section secondary to
Copyright © 2014 American Society of Anesthesiologists
indeterminate fetal heart rate tracing and maternal noncompliance with monitoring. The patient had a
flattened affect and disorganized speech but assented to and cooperated with spinal anesthesia. Despite
an apparently successful spinal, the patient expressed pain upon incision, and was rapidly intubated and
converted to general anesthesia without incident. Shortly after hysterotomy, the patient became acutely
hypotensive and hypoxic. We will detail our differential diagnosis and anesthetic management of this
challenging patient.
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Obstetric Anesthesia (OB) MC786
Abrupting Parturient with Unknown Severe Mitral Valve Stenosis
Victor Polshin, M.D., Meyer Halpern, M.D., Kalpana Tyagaraj, M.D . Anesthesiology, Maimonides Medical
Center, Brooklyn, NY, USA.
A 40 year old G4 P1112, 27-week pregnant Pakistani female presented to L&D with vaginal bleeding
secondary to abruption and was rushed to OR for emergency Cesarean Section. Patient was known to
obstetrician to have a vague history of cardiac disease, with both obstetrician and patient stating that
cardiologist said she was “fine”. GA was administered via rapid-sequence induction and intubation, and
Cesarean Section was started. Patient immediately developed severe hypotension and bradycardia,
treated with fluids, pressors and anti-arrhythmics, followed by post-op pulmonary edema. Severe mitral
stenosis due to rheumatic heart disease diagnosed by Echo.
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Obstetric Anesthesia (OB) MC787
Avoiding a Spike in Intracranial Pressure for Cesarean Delivery at 33 weeks in a Primagravida with
Intracranial Tumor and Midline Shift
Christopher P. Potestio, M.D., Nicole Devenish, B.S., Joseph Myers, M.D . Georgetown Univ Hospital,
Washington, DC, USA, Georgetown University School of Medicine, Washington, DC, USA.
A 30 year-old G1P0 at 32 weeks gestation presented with tonic-clinic seizure and was found to have an
intracranial tumor with midline shift on magnetic resonance imaging (MRI). Considering the risk of
craniotomy in a parturient, we planned cesarean delivery prior to tumor resection with emphasis on
minimizing elevation of intracranial pressure (ICP). We avoided neuraxial technique due to risk of dural
puncture. The intraoperative analgesia plan focused on decreasing risk of postoperative nausea and
vomiting while minimizing respiratory depression during recovery. It included intraoperative ketorolac,
wound infiltration with bupivacaine, and careful titration of hydromorphone in the postoperative setting.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Obstetric Anesthesia (OB) MC788
Combined Emergency Cesarean Section and Bentall Procedure for Type A Aortic Dissection in a
Pregnant Patient
Suryanarayana M. Pothula, M.D., Sangeeta Kumaraswami, M.D., Saurabh Dang, M.D . New York
Medical College, Valhalla, NY, USA.
A 34-year-old patient, 37 weeks pregnant, presented to a neighboring hospital complaining of chest
discomfort. The pregnancy had been uneventful. She was stable hemodynamically and there was no
neurodeficit. Doppler of lower extremities excluded deep vein thrombosis. She was sent home but
returned to the emergency room within a few hours. CT scan with pulmonary embolism protocol revealed
Type A aortic dissection and cardiac tamponade. At our institution, intraoperative TEE confirmed
ascending aortic intimal tear, severe aortic regurgitation and cardiac tamponade. The dilemma involved
timing of cesarean section and aortic repair, modification of anesthetic technique and considering fetal
monitoring.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Obstetric Anesthesia (OB) MC789
Peripartum Decoy: Anaphylactoid Syndrome of Pregnancy Masquerading as Local Anesthetic
Toxicity
Daniel P. Raboin, M.D., Bradley Reel, M.D., Michelle Marino, M.D., Christopher Nagy, M.D., Christopher
V. Maani, M.D . Department of Anesthesiology, San Antonio Uniformed Services Health Education
Consortium, San Antonio, TX, USA.
A41-year-old G12P11 @38 weeks underwent induction of labor for pre-eclampsia.She subsequently
developed altered sensorium and fetal bradycardia. The patientwas transported to the OR for emergent csection with aggressive titration ofher in-situ epidural. Within minutes, the patient became nonresponsive, withensuing cardiovascular collapse and clinical coagulopathy. Following ACLS and massive
transfusion, thepatient was transferred to the ICU, eventually making a full recovery. This scenario fosters
discussion of thedifferential diagnosis for acutely decompensating parturients with an emphasison
Anaphylactoid Syndrome of Pregnancy. This syndrome portends 80-90% mortalityand remains difficult to
diagnose and manage.
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Obstetric Anesthesia (OB) MC790
Splenectomy for Idiopathic Thrombocytopenic Purpura in Pregnancy
Alena S. Rady, D.O . Anesthesiology, University of Connecticut, Avon, CT, USA.
26-year-old G1P0 female without significant past medical and obstetric history developed significant
thrombocytopenia and subsequently diagnosed with Idiopathic Thrombocytopenic Purpura at 7 weeks
gestation. Despite ongoing treatment with high dose steroids and intermittent IVIG patient‟s platelets
continued to drop with nadir of 10000. In light of failure of conservative treatment, splenectomy was
scheduled at 22 weeks of gestation. Procedure began laparoscopically, however converted to open due
to difficult access. After speciment removal patient received platelets transfusion with appropriate
response. Patient tolerated procedure well. Fetal heart rate monitored by Doppler before and after the
procedure.
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Obstetric Anesthesia (OB) MC791
Non-obstetric Surgery in a Pregnant Patient with Sickle Cell Disease
Selina N. Read, M.D . Penn State Hershey Medical Center, Hershey, PA, USA.
We present a 20 year old African American female with homozygous sickle cell disease at 12 weeks
gestation who sustained a left humerus fracture and underwent open reduction internal fixation of the
distal humerus without major complications.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Obstetric Anesthesia (OB) MC792
Obstetric patient with Large Parotid Tumor
Prashanth V. Reddy. New York University, New York, NY, USA.
27 G1P0 at 36wks EGA with pmhx right parotid tumor presented for r/o labor. CT showed 6.9*7.4*9.1cm
parotid mass. Pt had 2cm mouth opening. After discussion with OB and ENT, decision made for C-section
with tumor resection 1 week later. ENT present during C-section in case surgical airway required. Pt
underwent C-section under spinal anesthesia. PostOp course complicated by multiple episodes of
vomiting and pt sent to IR for PEG placement under local. Upon insufflation pt started vomiting and
became hypoxic. STAT Airway called and pt was intubated via nasal fiberoptic on 5th attempt. Pt
underwent tracheostomy the next day.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Obstetric Anesthesia (OB) MC793
Anesthetic Management of Parturient with Surgically Corrected Subaortic Stenosis and
Symptomatic Ventricular Tachycardia
Michael K. Ritchie, M.D., Matthew Jordan, M.D., Pavithra Ranganathan, M.D., Ahmed Attaallah, M.D. ,
Manuel Vallejo, M.D. . Anesthesiology, WVUH, Morgantown, WV, USA, Department of Anesthesiology,
West Virginia University, Morgantown, WV, USA, Anesthesiology, West Virginia University, Morgantown,
WV, USA.
We present a case of a 21-year-old G2P0100 parturient at 38w5d gestation with a past history of
surgically corrected hypertrophic subaortic stenosis who presented for repeat low transverse cesarean
section. The patient was found to be symptomatic at home with dyspnea on minimal exertion and multiple
episodes of palpitations consistent with NYHA class II heart failure. The anesthetic plan included
preoperative fluid loading to maintain adequate preload, a combined spinal epidural anesthetic and
phenylephrine infusion for hemodynamic support and afterload maintenance. The patient delivered
without complication. Her postoperative course was complicated only be mild pulmonary edema corrected
with furosemide administration.
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Cardiac Anesthesia (CA) MC794
Intraoperative Pulmonary Embolism during Mediastinoscopy: Medical and Ethical Decision
Making in the Midst of Catastrophe
Goonjan Sunil Shah, M.D., Lavinia M. Kolarczyk, M.D . Anesthesiology, University of North Carolina,
Chapel Hill, NC, USA.
A 63 year old female was admitted for superior vena cava syndrome secondary to a large invasive
anterior mediastinal mass. She was brought to the operating room for mediastinoscopy for tissue
diagnosis and staging. The patient was intubated via awake fiberoptic approach. Thirty minutes into
surgical dissection, a sudden 50% decrease in end tidal carbon dioxide occurred. Refractory hypotension
and hypoxia ensued. Rapid diagnostic evaluation included fiberoptic bronchoscopy and TEE, both of
which were largely unremarkable. Therapeutic interventions included bilateral needle decompression and
right thoracotomy without improvement. Etiology was presumed tumor embolism. ECMO was briefly
discussed, but then reconsidered.
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Cardiac Anesthesia (CA) MC795
Emergent Thromboembolectomy of Near Occlusive Right Atrioventricular Thrombus
Kara K. Siegrist, M.D., Julian Bick, M.D . Anesthesiology, Vanderbilt University Medical Center, Nashville,
TN, USA.
70yo male with history of alcoholism and syncope who initially presented with 8% body surface area
burns secondary to thermal injury sustained during a syncopal episode. Echocardiography and
angiography both confirmed a thrombus spanning from right atrium to right ventricle with bilateral upper
and lower pulmonary artery thrombus. Emergent thromboembolectomy was undertaken with
cardiovascular arrest prior to anesthesia induction and emergent institution of cardiopulmonary bypass
undertaken. Intraoperative course complicated by poor venous drainage and high central venous
pressures discovered to be secondary to clot obstruction of the venous cannula. Post-procedure
transthoracic echo demonstrated dilated, severely hypokinetic right ventricle.
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Cardiac Anesthesia (CA) MC796
Cardiovascular Collapse Associated with IVC Filter Migration and Saddle Embolization
Mark M. Smith, M.D., C. Thomas Wass, M.D., Norman E. Torres, M.D., Juan N. Pulido, M.D., Kent H.
Rehfeldt, M.D . Anesthesiology, Mayo Clinic, Rochester, MN, USA.
Copyright © 2014 American Society of Anesthesiologists
Inferior vena cava (IVC) filter migration to the cavo-atrial junction with strut extension through the caval
wall was identified, and percutaneous removal was planned. Following anesthetic induction, the patient
suffered cardiopulmonary collapse. Transesophageal echocardiography revealed ongoing pulmonary
thromboembolization. Following emergent sternotomy, the IVC filter was removed utilizing
cardiopulmonary bypass (CPB). Separation from CPB was unsuccessful due to severe right ventricular
dysfunction and near-systemic pulmonary artery pressures. Re-exploration revealed saddle embolus
requiring embolectomy. Subsequent separation from CPB was uneventful. Retrieval of migrated IVC
filters and the attendant risk of thromboembolism create unique challenges for anesthesiologists.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Cardiac Anesthesia (CA) MC797
Emergent Ascending Aorta Replacement from Iatrogenic Intramural Hematoma and Contained
Rupture Causing Right Pulmonary Artery Compression and New Right Heart Strain
Nader M. Soliman, M.D., Robert Nampiaparampil, M.D . Anesthesiology, NYUMC, New York, NY, USA.
65 yo female smoker with anticardiolipin antibody underwent coil embolization for a right vertebral artery
complex aneurysm. POD#1 she developed syncope and a burning sensation in her chest in the setting of
hypotension and bradycardia. CTA revealed a new ascending aortic intramural hematoma with a
contained rupture and dissection. She was emergently taken to the OR and intra-op TEE revealed an
ascending aortic intramural hematoma extending to the proximal arch compressing the right PA resulting
in RVOFT obstruction with severe RV dilation. She underwent replacement of ascending aorta with
Gelweave graft using profound hypothermic circulatory arrest and retrograde cardioplegia.
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Cardiac Anesthesia (CA) MC798
Acute Coronary Thrombosis During IR Guided Perivalvular Repair
Kiwon Song, M.D . Anesthesiology, NYU Medical Center, New York, NY, USA.
63 year old male with Hypothyroidism, gout, HTN, Rhematic heart disease, chronic AF with VVI PPM,
mechanical AVR and MVR p/w mechanical valve related hemolytic anemia and worsening LE edema and
dyspnea. TEE shown to have paravalvular MR. IR guided paravalvular MR repair attempted. Intraop, pt
developed mechanical MVR thrombus and embolization to LMCA and LAD. TEE showing hypokinetic LV
and asynchronous MV leaflet opening. Chest compression initiated with administration of heparin, epi,
vasopressin, 2units of PRBC, tPA. IABP place. Pt successfully resuscitated with vital signs back to
baseline. Case aborted due to the critical condition of the pt.
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Cardiac Anesthesia (CA) MC799
Perioperative Management of the Patient with Thyroid Storm Accompanied with Severe Cardiac
Dysfunction
Bryant J. Staples, M.D., Hui Yuan, M.D . Anesthesia & Critical Care, Saint Louis University, Saint Louis,
MO, USA.
A 28-year-old male with Graves‟s disease in thyroid storm presented for total surgical thyroidectomy
following failure of medical treatment because of adverse effects (rash, hepatitis, coagulopathy). He
developed severe cardiac dysfunction ranging from A-flutter with 2:1 block to clinical significant dilated
cardiomyopathy with EF 20% before the surgery. Perioperative course was complicated by intraoperative
exacerbation of acute CHF and beta-blocker resistant tachycardia, followed by severe postoperative
hypoparathyroidism leading to carpopedal spasms requiring constant calcium infusion. A thorough
perioperative management was carried out to reduce the risk of complications associated with thyroid
storm, cardiac dysfunction and surgical procedure.
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Cardiac Anesthesia (CA) MC800
Concern for Malignant Hyperthermia in a Patient Undergoing Bilateral Lung Transplantation
Copyright © 2014 American Society of Anesthesiologists
Jessica B. Sulser, M.D . Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
This is a case of a 33-year-old female with a history of severe pulmonary hypertension, mild AI, moderate
TR, severe RAE, and a home O2 requirement, who presented for double lung transplantation. Her
intraoperative course was complicated by increased vasopressor requirements, as well as concern for
malignant hyperthermia due to rising body temperature, unexplained acidosis, and ventricular arrhythmias
requiring cardioversion. The decision was made by the anesthesia team to proceed with dantrolene
administration while on cardiopulmonary bypass. The patient was successfully weaned off of
cardiopulmonary bypass and had an otherwise uneventful postoperative course.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Cardiac Anesthesia (CA) MC801
A Case Report of Emergent Resection of Massive Pulmonary Artery Intimal Sarcoma
Nobue Tahira, M.D., Hiroyuki Matsuyama, M.D.,Ph.D., Katsuyoshi Obata, M.D.,Ph.D. . Anesthesiology,
Iizuka Hospital, Fukuoka, Japan, Iizuka Hospital, Fukuoka, Japan, Iizuka Hispital, Fukuoka, Japan.
Intimal sarcoma of the pulmonary artery is extremely rare and seldom undergose emergency surgical
resection. We present the case of a 73 year-old man who underwent emergency massive pulmonary
intimal sarcoma resection due to severe dyspnea. Soon after transfer to the operation room ( just before
induction of anesthesia) , cardio-pulmonary arrest occurred because of a massive tumor embolism. We
started CPR immediately and surgeons cannulated & started PCPS. The sarcoma was resected as
completely as possible. Although the patient needed cardiorespiratory support for several days, he was
discharged on foot without neurological deficit.
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Cardiac Anesthesia (CA) MC802
Successful Treatment of Unexpected Intraoperative Cardiac Arrest Caused by Coronary
Vasospasm
Hitomi Takemura, M.D., Yoshinobu Nakayama, M.D., Yasufumi Nakajima, M.D.,Ph.D., Shusuke
Takeshita, M.D., Teiji Sawa, M.D.,Ph.D . Department of Anesthesiology, Kyoto Prefectural University of
Medicine, Kyoto, Japan.
We present the case of a 60-year-old Japanese man with an unremarkable history of disease who
underwent laparoscopic ileocecal resection. Anesthesia induction and start of surgery were uneventful.
However, 1 h after pneumoperitoneum, the blood pressure suddenly decreased with a significant ST
elevation, and he subsequently developed V-Fib cardiac arrest, which interrupted mesenterial resection.
After prompt resuscitation, cardiac collapse recovered. Intraoperative transesophageal echocardiography
revealed hypokinesis of the right coronary artery perfusion territories. Postoperative coronary
arteriography and myocardial scintigraphy findings showed a coronary vasospasm that had developed
during the intraoperative cardiac arrest. We review this case and consider more appropriate actions.
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Critical Care Medicine (CC) MC803
Colonic Mucormycosis in a Critically Ill Patient with Pancytopenia and Systemic Lupus
Erythematosis
Dinesh J. Kurian, M.D., MBA, Matthew Mauck, M.D.,Ph.D., Timmothy E. Miller, M.D . Anesthesiology,
Duke University Medical Center, Durham, NC, USA.
Mucormycosis is a rare fungal infection, and the gastrointestinal tract is a very rare site for this type of
infection. We present a case of a patient with systemic lupus erythematosus who was treated for sepsis
secondary to a colonic mucormycosis infection. His course in the Intensive Care Unit was characterized
by myocardial infarction, renal failure, and pulmonary edema. He required mechanical ventilation,
continuous veno-venous hemodialysis, and emergent laparotomy for bowel perforation. His status
declined, leading to his eventual demise. In this case, we present the risk factors, diagnosis, and
treatment of invasive colonic mucormycosis in a critically ill patient.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Critical Care Medicine (CC) MC804
Undiagnosed Adrenal Insufficiency in the ICU after a Partial Nephrectomy
Jarrett M. Leathem, D.O., Kunal Karamchandani, M.D., Lisa Sinz, M.D . M.S. Hershey Med Ctr, Hershey,
PA, USA, M.S. Hershey Med. Ctr., Hershey, PA, USA.
A 65 year-old male, with history of right-radical nephrectomy and bilateral renal cancer, was admitted to
the ICU after a left-partial nephrectomy. The patient‟s surgery was complicated by massive blood loss
with intermittent periods of hypotension. In the ICU, the patient remained stable for two days before
developing tachycardia with stable blood pressure over the subsequent two days. On day-5 post-op, the
patient had a pulseless electrical activity arrest and was resuscitated. When other possible causes had
been ruled out, stress-dose steroids were initiated and he rapidly improved, indicating acute adrenal
insufficiency, despite imaging showing bilateral adrenal glands.
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Critical Care Medicine (CC) MC805
Status Asthmaticus Patient Successfully Treated With Volatile Agent in MICU
Jiwon Lee, M.D., Amy Dorwart, M.D., John Hasewinkel, M.D . IU School of Medicine, Indianapolis, IN,
USA.
A 35 year old poorly controlled asthmatic presented to ED with severe dyspnea and hypoxemia. Patient
was intubated for worsening acute hypoxemic and hypercarbic respiratory failure. He was sedated with
propofol and ketamine and admitted to the MICU for ventilatory support. Standard attempts to correct his
severe respiratory acidosis and reduce persistently elevated peak airway pressures proved unsuccessful.
As a last resort, prior to initiating ECMO, anesthesia was consulted to provide volatile anesthetics. An
anesthesia machine was taken to the MICU to provide 2% sevoflurane for 14 hours. He showed nearly
immediate improvement on ventilation with marked improvement in ABGs.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Critical Care Medicine (CC) MC806
Management of Meningitis-Induced Rhabdomyolysis Following Blunt Traumatic Injury
James A. Leonard, M.D., J. David Roccaforte, M.D . New York University, New York, NY, USA.
67 year old male pedestrian struck presented with multiple traumatic injuries including
subarachnoid/subdural hemorrhage requiring temporary ICP monitor placement. He was intubated by
EMS and transported to our ICU off sedation with brainstem reflexes intact. He developed increasing
fevers and acute kidney injury on hospital day 15 and was diagnosed with concurrent E. coli meningitis
and rhabdomyolysis (CK and creatinine levels were normal on initial hospital presentation). He required
two weeks of antibiotics and four weeks of CVVH/hemodialysis prior to resolution of both processes.
Pathogenesis and treatment of meningitis-induced rhabdomyolysis in the acute trauma setting will be
discussed.
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Critical Care Medicine (CC) MC807
Acute Management of Elevated Peak Airway Pressures and PEA Arrest in the IR Suite
Raymond Lew, M.D., Ranjit Deshpande, M.D . Anesthesiology, Yale, New Haven, CT, USA.
49 year old female with history of cirrhosis presented with abdominal pain. Workup showed a pancreatic
mass and marked bile duct dilatation. A biliary drain and paracentesis were performed and shortly after,
the patient developed respiratory distress. After intubation, imaging showed hemoperitoneum from inferior
epigastric vessels injured during the paracentesis. The patient was rushed to the IR suite for embolization
where she decompensated into PEA arrest with elevated peak airway pressures, necessitating the
anesthesia team to take over the acute management of the patient. An uncommon cause of PEA arrest
was diagnosed and acutely treated, leading to successful resuscitation.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Critical Care Medicine (CC) MC808
An Unusual Cause of Post-Operative Delirium
Raymond Lew, M.D., Shamsuddin Akhtar, M.D . Anesthesiology, Yale, New Haven, CT, USA.
21 year old male presented after a MVC with open left femur and tibia fractures. Patient reported no loss
of consciousness. Emergent surgical stabilization under general anesthesia was uneventful.
Postoperatively, patient was anemic and received a blood transfusion, during which he became
tachycardic and febrile. Transfusion was stopped but the patient became acutely agitated, combative, and
hypoxic, requiring intubation. Labs showed no evidence of hemolytic transfusion reaction but workup of
cognitive dysfunction revealed multiple small strokes in both cerebral hemispheres. Echocardiogram
showed a right to left intracardiac shunt. A diagnosis of fat embolism syndrome was entertained.
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Critical Care Medicine (CC) MC809
Use of Transesophageal Echocardiogram to Diagnose Etiology of Intraoperative Hypoxia During
Liver Transplantation.
Megan C. Lofton, M.D . Anesthesiology, University of Maryland Medical Center, Baltimore, MD, USA.
The value of perioperative cardiac assessment with transesophageal echocardiogram (TEE) has been
well established in cardiac operations. TEE is a vital tool to diagnose and treat the dynamic changes in
ventricular function, volume status and other parameters pertinent to maintaining optimal hemodynamics.
Recently, the use of TEE has become more prevalent in non-cardiac operations and has even shown
value in assessing intraoperative pulmonary conditions. This use was demonstrated in a case in which
intraoperative hypoxia was diagnosed and treated in a 41 year old woman with end stage liver disease
undergoing liver transplantation on the basis of the TEE evaluation.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Critical Care Medicine (CC) MC810
Successful Use of Steroids for Rescue of Late ARDS during Extra-Corporeal-MembraneOxygenation Circulation
Nadia Lunardi, M.D.,Ph.D., Paolo Diana, M.D., Dustin T. Money, R.R.T. , Michael Gelvin. Anesthesiology,
University of Virginia Health System, Charlottesville, VA, USA, Anesthesiology, University of Padova,
Padova, Italy, Division of Cardiovascular Perfusion, University of Virginia Health System, Charlottesville,
VA, USA, Director of Perfusion, Division of Cardiovascular Perfusion, University of Virginia Health
System, Charlottesville, VA, USA.
C.A. was a previously healthy young female who developed ARDS and required maximal veno-venous
ECMO support for a total duration of 23 days. While on ECMO, she failed a trial of inhaled nitric oxide due
to increased lactates and carboxyhemoglobin, and was excluded from a bilateral lung transplant
secondary to disseminated intravascular coagulation, a small intracranial hemorrhage and pancreatitis.
On ARDS day 21 a trial of moderate-dose intravenous methylprednisolone was started, followed by a
dramatic improvement in the PaO2/FiO2 ratio and lung compliance, allowing for separation from ECMO
within 1 week. C.A. now lives at home on minimal supplemental oxygen.
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Critical Care Medicine (CC) MC811
Progressive Hypoxemia During Preanhepatic Phase in Liver Transplantation: A Case Report
Weike Mao, M.D., Qian Xu, M.D., Quanjun Zhou. Anesthesia, Union Hospital, Tongji Medical College,
Huazhong University of Science and Technology, Wuhan, China, Anesthesiology, Union Hospital,
Huazhong University of Science and Technology, Wuhan, China.
A case of an episode of progressive hypoxia occurring during preanhepatic Phase is presented. A 41
years old male patient suffering from primary hepatic carcinoma, was scheduled for liver
transplantation.SpO2 100% and PaO2 19.6 kPa were found at beginning of mechanical ventilation with
100%O2. During preanhepatic Phase SpO2 gradually decreased to 88% with PaO2 8.2 kPa and PaCO2
Copyright © 2014 American Society of Anesthesiologists
4.2 KPa within one and half hours. By dilating pulmonary vessels, sevoflurane inhalation and dopamine
continuously perfusion the SpO2 and PaO2 began to back to normal range. The potential causes and
pathological changes in this patient were discussed.
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Fundamentals of Anesthesiology (FA) MC812
Intraoperative Pulseless Electrical Activity during Open Repair of a Type IV Thoracoabdominal
Aneurysm
Steve M. Leung, M.D., Maged Argalious, M.D . Department of Anesthesiology, Cleveland Clinic
Foundation, Cleveland, OH, USA.
52-year-old male presented for open repair of a 9.5 cm type-IV thoraco-abdominal aortic aneurysm. His
PMHx were mild diffuse CAD, A-fib with dual-chamber PPM, DMII, OSA, and morbid obesity.
Intraoperative course was complicated by prolonged supraceliac aortic crossclamp, large EBL,
coagulopathy requiring massive transfusion. At the end of surgery, he developed A-fib with RVR
progressing to PEA arrest requiring CPR, inotrope and vasopressor support. TEE showed biventricular
dilation, severe RV systolic dysfunction and reduced LV function secondary to myocardial stunning
(hypotension, reperfusion, and PEA). He was extubated several days later without neurological sequelae
and return of biventricular function to baseline.
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Fundamentals of Anesthesiology (FA) MC813
Intraoperative Management of Resistant Hypotension; A New Form of Distributive Shock?
Sam Li, M.D . John H. Stroger Hospital, Chicago, IL, USA.
74 y.o. AAM with PMH of prostate cancer s/p XRT in 2001, HTN, CKD, and anemia presented for a
proctectomy, cystoprostectomy, colostomy and urostomy for rectal adenocarcinoma with invasion to
prostate. He failed to follow our pre-op recommendations regarding his antihypertensive drug regimen of:
Minoxidil, Carvediolol, Enalapril, Doxazosin, and Hydralazine. With a preoperative H&H 9.0/27.8 & BP
113/63; intraoperatively, he suffered from refractory hypotension that had a limited response with three
concurrent pressors. In conclusion, it would have been best to postpone this elective case. However, if
emergent, it would necessitate the use of combinatory pressor therapy with CVP monitoring.
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Fundamentals of Anesthesiology (FA) MC814
A Case of Difficult Ventilation After Successful Intubation in the Emergency Setting Due to a Ball
Valve Clot
Justin S. Liberman, M.D., Wade Weigel, M.D., Joseph M. Neal, M.D . Anesthesiology, Virginia Mason
Medical Center, Seattle, WA, USA.
A difficult airway is not always strictly dictated by patient anatomy, nor does airway management
necessarily end with successful placement of an endotracheal tube. We present a case of difficult
laryngoscopy in an elderly patient who developed oropharyngeal bleeding after otolaryngologic surgery.
Despite successful intubation of the trachea, the patient‟s oxygenation and ventilation continued to
deteriorate which ultimately resulted in pulseless electrical activity. Using physical examination and
observation of airway pressures, we systematically arrived at a diagnosis of a ball-valve clot at the
endotracheal tube tip.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Fundamentals of Anesthesiology (FA) MC815
Perioperative New Onset ST Segment Changes during Neurosurgical Procedure: What to do next?
Matthew A. Lilien, M.D . Anesthesiology, SUNY Upstate Medical University, Syracuse, NY, USA.
We present a case of cerebral meningioma excision with negative cardiac history with new onset of
intraoperative ST depression after induction of anesthesia but prior to surgical incision. There was no
hemodynamic instability. TEE showed no segmental wall motion abnormality; a diagnosis (by exclusion)
Copyright © 2014 American Society of Anesthesiologists
of coronary microvascular disease (cardiac syndrome X) was made, which helped the decision making
process towards continuation of surgery. Post op clinical data showed no evidence myocardial infarction
or ischemia. The clinical information obtained with intraoperative TEE in certain cases may have a direct
impact on surgical decision making and therefore may positively influence patient outcome.
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Fundamentals of Anesthesiology (FA) MC816
Anesthetic Considerations and Management of an Adolescent with Mitochondrial Myopathy and
Cystic Fibrosis
Joseph C. Liljenquist, M.D., Joao P. A. Reinhard, M.D., Kerry Kreidel, M.D . University of Arizona,
Tucson, AZ, USA.
Mitochondrial myopathy (MM) is a multi-organ system disease caused by defects in the electron transport
chain and oxidative phosphorylation of mitochondrial metabolism. The disease may present specific
difficulties with regard to anesthesia and the evidence base for anesthetic recommendations is limited.
We report the anesthetic management of a 15 year-old male with MM and cystic fibrosis who presented
for exploratory laparotomy indicated for small bowel obstruction. The patient‟s manifestations of MM
included progressive weakness, significant developmental delay, and previous episodes of lactic acidosis
requiring hospitalization. The case highlights important anesthetic considerations and outlines the
successful anesthetic management of this patient.
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Fundamentals of Anesthesiology (FA) MC817
Direct Laryngoscopy Can Still Work
Jia Liu, M.D., Judith Marie Gron, C.R.N.A., Ehab Farag, M.D . Anesthesiology, Cleveland Clinic
Foundation, Cleveland, OH, USA.
An 80-year-old female with history of a massive thyroid goiter and CAD post operative date (POD) one for
CABG presented to our operating room (OR) for emergent cerebral angiogram for acute cerebral vascular
accident from left ICA occlusion. When she was brought to the OR, she was unresponsive and
hypertensive with SBP in 200‟s. She was also in pulmonary edema, which caused failure of fiberoptic
intubation. We quickly placed an LMA, and established good ventilation. We then took out the LMA and
used laryngoscope to successfully intubated the patient with the help from another assistant manually
lifted the goiter.
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Fundamentals of Anesthesiology (FA) MC818
Unilateral Tension Pneumothorax Following Attempted Double-Lumen Endotracheal Tube
Placement
Melanie M. Liu, M.D., Leroi Stephenson, M.D . Anesthesiology, Yale-New Haven Hospital, New Haven,
CT, USA.
A 68 yo F with hypoxemic respiratory failure presented for right VATS lung biopsy. Two attempts at
double-lumen ETT placement were unsuccessful, with bag-mask ventilation between attempts. The
patient became progressively hypoxic and hypotensive, requiring vasopressin and epinephrine. Following
intubation with a single-lumen ETT, left-sided breath sounds and chest rise were absent. Fiberoptic
bronchoscopy revealed no mucous plugging or airway injury. CXR showed left tension pneumothorax
with mediastinal shift. Left thoracostomy was performed with subsequent resolution of hypotension and
improved oxygenation. A bronchial blocker was placed, and the planned procedure was performed. The
patient did not meet extubation criteria.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Fundamentals of Anesthesiology (FA) MC819
Laparoscopic Cholecystectomy in a Patient with End Stage Amyotrophic Lateral Sclerosis
Copyright © 2014 American Society of Anesthesiologists
Brandon M. Lopez, M.D., Jason Lane, M.D . Anesthesiology, Vanderbilt Medical Center, Nashville, TN,
USA.
Amyotrophic Lateral Sclerosis (ALS) is a rare, fatal neurological condition that destroys motor neurons.
Patients present with worsening skeletal muscle weakness, atrophy, spasticity and profound respiratory
muscle weakness. When ALS patients need surgical procedures, the anesthesiologist must take into
account a multitude of factors to ensure a safe anesthetic. We present the case of a 38 year old female
with end stage ALS for laparoscopic cholecystectomy. An inhalational anesthetic was delivered by preexisting tracheostomy. To maximize the chances of the patient being able to be weaned from the
ventilator, the anesthetic did not utilize any neuromuscular blocking drugs.
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Fundamentals of Anesthesiology (FA) MC820
The Importance of Serial Tryptase Levels in Intraoperative Allergic Reactions
Cornel Mihalache, M.D., Barbara G. Jericho, M.D . Anesthesiology, University of Illinois at Chicago,
Chicago, IL, USA.
A 60 year old female presents for an axillary lymph node biopsy. A previous anesthesia record indicated
shortly after induction, the patient became persistently hypotensive, requiring transient hemodynamic
support with epinephrine and vasopressin. Presumptive anaphylactic reaction was no longer considered
since a one-time tryptase level was normal. For the lymph node biopsy, after a rapid sequence induction,
the patient again became persistently hypotensive and developed wheezing. Diphenhydramine,
famotidine, hydrocortisone, and albuterol were promptly administered with swift resolution of wheezing
and hypotension. Initial tryptase level was normal, yet a tryptase level one hour later was elevated.
Sunday, October 12, 2014
3:00 PM - 3:10 PM
Fundamentals of Anesthesiology (FA) MC821
Klippel-Trenaunay Syndrome With Airway Vascular Malformations- A Series of 3 Anesthetics and
Their Challenges
Germana L.m. Silva, M.D., Herodotos Ellinas, M.D . Anesthesiology, Medical College of Wisconsin,
Milwaukee, WI, USA.
We present a series of 3 anesthetics (1 out of the OR) in a 41 y/o womanwith a history of KlippelTrenaunay Syndrome, seizure disorder, developmentaldelay, OSA, and inability to lay supine due to
airway venous malformations. Wediscuss the challenging airway with multiple malformations and
concerns forboth accessing the airway and avoiding bleeding in a developmentallyhandicapped and
extremely anxious patient. We define Klippel-Trenaunay Syndromeand its associated comorbidities,
describe the key elements in pre-operativeevaluation and perioperative management of these patients;
and demonstrate thechallenging anesthetics administered for our patient.
Sunday, October 12, 2014
3:10 PM - 3:20 PM
Fundamentals of Anesthesiology (FA) MC822
Intraoperative Hyperkalemia of Unknown Etiology in a Young Patient with Wolff-Parkinson-White
Syndrome
Andrew R. Sim, M.D., Sudheera Kokkada Sathyanarayana, M.D., Michael Rufino, M.D . Montefiore
Medical Center Albert Einstein College of Medicine, New York, NY, USA.
A 21-year-old male with Wolf-Parkinson-White Syndrome, s/p unsuccessful ablation, presented for
mandibular and maxillary osteotomy. Anesthesia was induced with propofol, rocuronium, and nasal
intubation, and maintained using sevoflurane with oxygen. Fentanyl and hydromorphone were given for
analgesia. 3 hours into surgery, EKG showed ST elevation and peaked T waves. Arterial blood gas
showed serum potassium 6.3 mEq/L and lactate 2.5 mmol/L. EKG changes promptly returned to baseline
after administering calcium chloride, sodium bicarbonate, glucose-insulin. Postoperative CPK level was
found to be 2834 U/L. Undiagnosed muscular dystrophy as a cause for hyperkalemia and elevated CPK
was suspected, pending further diagnosis.
Copyright © 2014 American Society of Anesthesiologists
Sunday, October 12, 2014
3:20 PM - 3:30 PM
Fundamentals of Anesthesiology (FA) MC823
Failed Cricothyrotomy, What Is the Next Step in the Difficult Airway Algorithm?
Jonathan B. Siskind, D.O., Zana Borovcanin, M.D . Anesthesiology, University of Rochester Medical
Center, Rochester, NY, USA.
23 year old male presented with a gunshot wound to the head. Emergency medical technicians were
unable to intubate the patient and proceeded with an emergency cricothyrotomy. The first attempt failed,
but the second attempt, was successful. A 6.0 cuffed endotracheal tube (ETT) was placed through the
cricothyrotomy into the trachea. Upon arrival to Emergency Department, the patient desaturated with
SPO2 levels in the 70-80s. Anesthesiology was consulted to manage the airway. A Glide Scope was
used to visualize the glottic opening. After air bubbles were seen exiting beneath the epiglottis, a 7.0 ETT
was successfully inserted into the trachea.
Sunday, October 12, 2014
3:30 PM - 3:40 PM
Fundamentals of Anesthesiology (FA) MC824
Emergent Difficult Airway After-hours: Awake Fiberoptic Intubation in a Non-English Speaking
Patient?
Jose R. Soberon, M.D., Noah Emerson, D.O., Christian P. Hasney, M.D. . Anesthesiology, Ochsner Clinic
Foundation, New Orleans, LA, USA, Ochner Clinic Foundation, New Orleans, LA, USA, Department of
Otolaryngology, Ochsner Clinic Foundation, New Orleans, LA, USA.
A previously healthy Latino male presented to the Emergency Department complaining of facial pain,
swelling, and shortness of breath. Physical examination revealed significant facial edema, trismus, and a
Mallampati IV airway. He did not speak or understand the English language.An urgent CT scan showed a
right facial abscess extending into the masticator space, with diffuse edema resulting in critical
compression of the airway at the level of the oropharynx.He was transported emergently to the operating
room at 5:30AM for a controlled intubation and incision and drainage of the aforementioned abscess.
Sunday, October 12, 2014
3:40 PM - 3:50 PM
Fundamentals of Anesthesiology (FA) MC825
Acute Dystonic Reaction to General Anesthesia with Propofol: A Case Report
Rachel C. Steckelberg, M.D.,M.P.H., David Tsiang, M.D., Nir Hoftman, M.D . Anesthesiology and
Perioperative Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA, USA.
A 67-year old male underwent uneventful robotic-assisted thorascopic resection of a solitary pulmonary
fibrous tumor. Immediately following extubation, the patient developed respiratory distress that did not
resolve with treatment. Benadryl provided only temporary relief. Muscle relaxation reversal was confirmed
with nerve stimultator. Bronchoscopic visualization of vocal cords showed minimal to absent opening with
inspiration. The patient was given diazepam and reintubated. Given the patient‟s history of difficulty
breathing after previous surgery and the lack of vocal cord movement, dystonic reaction to propofol was
suspected. The patient remained intubated for 2 hours in the PACU before being extubated uneventfully.
Sunday, October 12, 2014
3:50 PM - 4:00 PM
Fundamentals of Anesthesiology (FA) MC826
Modified Seldinger Technique for Insertion of a Difficult Tracheotomy Tube
LaDouglas J. Suber, M.D., Gregory K. Kim, M.D., Naomi Smukler, M.D., Amanda Hu, M.D., Ashish Sinha,
M.D.,Ph.D . Anesthesiology, Drexel University College of Medicine, Philadelphia, PA, USA,
Otolaryngology, Drexel University College of Medicine, Philadelphia, PA, USA.
A 35 year old female with neck scarring and limited range of motion from severe burns and radiation,
coded after developing respiratory distress. A flexible fiberoptic nasotracheal intubation was performed
after failed intubation attempts and failed emergent cricothyrotomy. In the OR for a formal tracheotomy,
the tracheotomy tube continually entered a false lumen. A ureteral guidewire was threaded through the
nasotracheal tube with the proximal end being pulled through the stoma, leaving the guidewire‟s distal
Copyright © 2014 American Society of Anesthesiologists
end in the trachea‟s lumen. A Cook exchange catheter was placed over the wire and the tracheotomy
tube was placed using a modified Seldinger technique.
Sunday, October 12, 2014
4:00 PM - 4:10 PM
Fundamentals of Anesthesiology (FA) MC827
Increased Arterial-ETCO2 Gradient: Apneic Oxygenation to the Rescue?
David K. Sum, M.D., Paul G. Barash, M.D . Anesthesiology, Yale University School of Medicine, New
Haven, CT, USA.
The ETCO2-PaCO2 gradient is an important indicator of equipment malfunction or severe patient core
organ dysfunction. A 29 yo male undergoes renal transplant. Following an uneventful anesthetic, on
emergence he exhibits movements consistent with inadequate reversal of neuromuscular blockade,
despite appropriate reversal and normal TOF. Although ETCO2 was 40mmHg, ABGs showed pH 6.92,
PaCO2 110 and PaO2 423, which were consistent with apneic oxygenation. The arterial-ETCO2 gradient
(70 mmHg) normalized only with controlled ventilation. This case illustrates, regardless of normal ETCO2,
in the presence of adequate PaO2, the ETCO2-PaCO2 gradient yields clinically important but subtle
diagnostic information.
Sunday, October 12, 2014
4:10 PM - 4:20 PM
Fundamentals of Anesthesiology (FA) MC828
Anesthetic Management for Renal Allotransplantation in a Patient With Prior Liver Transplant,
Severe Pulmonary Hypertension, and Inclusion Body Myositis
Jinglu Sun, M.D., Hesham Elsharkawy, M.D . Cleveland Clinic Foundation, Cleveland, OH, USA.
A 61 year old male with history of liver transplant (hepatitis C), inclusion body myositis, severe pulmonary
hypertension, and proliferative glomerulonephritis on hemodialysis presented for a kidney transplant.
Induction with propofol and cisatracurium was uneventful. Central venous access was complicated by the
presence of bilateral thrombi in the left and right IJ, so access was obtained in the right subclavian vein.
Neuromuscular blockade was maintained with cisatracurium boluses. Patient was transported intubated
to SICU postoperatively. Although our case did not have any major complications, we would like to
discuss the implications of the patient‟s numerous comorbidies on anesthetic management.
Sunday, October 12, 2014
4:20 PM - 4:30 PM
Fundamentals of Anesthesiology (FA) MC829
Anesthetic Management of Myasthenia Gravis Patient Requiring Neuromuscular Blockade After
Thymectomy
Peter Sykora, D.O., James W. Heitz, M.D . Anesthesiology, Thomas Jefferson University Hospital,
Philadelphia, PA, USA.
A 67-year-old man with history of myasthenia gravis presented for exploratory laparoscopy and lysis of
adhesions for recurrent small bowel obstruction with general anesthesia. The patient previously
underwent thymectomy but still experienced residual weakness. The surgery required the use of
neuromuscular blockade which presented a challenge to provide adequate yet reversible muscle
relaxation in this patient with potentially abnormal pharmacodynamics. An accelerometer was utilized for
determination of adequate recovery from neuromuscular blockade. We evaluated its applicability as a
quick and reliable adjunct in the assessment of myasthenia gravis patients. The potential clinical benefits
of this technology are discussed.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC09
Monday, October 13, 2014
8:00 AM - 8:10 AM
Cardiac Anesthesia (CA) MC830
Hemodynamic Management of Moderate Aortic Stenosis during Orthotopic Liver Transplantation
Devin T. Kearns, D.O., Corey Zetterman, M.D . University of Nebraska, Omaha, NE, USA.
67 year old female with ESLD secondary to NASH, T2DM, HLD and aortic stenosis presents for liver
transplantation. After induction and satisfactory vascular access was obtained, TEE examination
confirmed moderate AS, 1.3 cm². ESLD is a hyperdynamic cardiovascular state with decreased SVR,
central hypovolemia and increased CO (2). These hemodynamics are more challenging in the presence
of AS due to profound fluid shifts, sudden decrease in preload during liver resection and impaired
myocardial contractility during the post-reperfusion syndrome (1). Resuscitation was guided by
intraoperative TEE and CVP monitoring (3). The patient tolerated the procedure well and transported to
the SICU.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Cardiac Anesthesia (CA) MC831
The Anesthetic Management of a Patient with Situs Inversus Totalis with an Atrial Septal Defect: A
Case Report
Yenabi J. Keflemariam, M.D., Charles Fox, III, M.D . Anesthesiology, LSUHSC-Shreveport, Shreveport,
LA, USA.
Situs Inversus is thought to occur in roughly 0.01% (1 in 10,000) people in the general population with a
5-10% prevalence of concurrent congenital heart disease. In the following case report, we discuss the
anesthetic management of an African-American female with situs inversus totalis and an atrial septal
defect which presented clinically with symptoms consistent with congestive heart failure exacerbations
resistant to medical management. The following case report reviews the pre-, intra-, and post-operative
management of patient with an ostium secundum atrial septal defect with fenestrations that was surgically
corrected by primary repair.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Cardiac Anesthesia (CA) MC832
Perioperative Management of a Pediatric Patient with a Thrombosing LVAD in an Emergent
Hemicraniectomy
James D. Kelleher, M.D., Meg Rosenblatt, M.D., Alexander Mittnacht, M.D . Anesthesiology, Mount Sinai
Medical Center, Icahn School of Medicine, New York, NY, USA.
A 7 year old female with dilated cardiomyopathy, post LVAD placement, presented for an emergent
hemicraniectomy for elevated ICP following RMCA stroke. Initial LVAD placement was complicated by
fibrin stranding in the device requiring a tubing exchange, HIT leading to anticoagulation with bivalirudin,
and multiple thrombotic strokes necessitating the hemicraniectomy. Intraoperatively, with the patient off
anticoagulation, LVAD function was impaired by thrombosis, so the patient was prepared for emergent
LVAD discontinuation by initiating epinephrine and milrinone infusions. The device function persisted until
the completion of surgery when a low dose bivalirudin infusion was restarted to prevent further
thrombosis.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Cardiac Anesthesia (CA) MC833
Giant Thebesian Valve Appearing as a Right Atrial Mass
Firdous A. Khan, M.D., Suman Rajagopalan, M.D., Raja Rama Palvadi, M.D . Anesthesiology, Baylor
College of Medicine, Houston, TX, USA.
Copyright © 2014 American Society of Anesthesiologists
A 60 year old man presented with a history of chest pain with dyspnea. He had a medical history
significant for hypertension, diabetes , and cirrhosis. The patient was found to have severe three vessel
coronary artery disease. Transthoracic echocardiogram revealed a mobile mass in the right atrium. He
was scheduled for coronary artery bypass grafting and excision of right atrial mass. After induction of
anesthesia, transesophageal echocardiography was performed, which showed instead a Thebesian
valve. The mass was excised and pathology confirmed tissue consistent with an enlarged Thebesian
valve .
Monday, October 13, 2014
8:40 AM - 8:50 AM
Cardiac Anesthesia (CA) MC834
Heparin Resistance in the Setting of Mitral Valve Endocarditis
Nicole M. King, M.D., Nicholas C. Connolly, M.D., Alfredo R. Ramirez, M.D., Amy A. Hernandez, M.D. .
Naval Medical Center San Diego, San Diego, CA, USA.
A 20 year old male with a known history of Strep Mitis mitral valve endocarditis required valve
replacement due to diffuse embolic events, including left hepatic artery thrombosis and associated
hepatic infarct. Prior to initiating cardiopulmonary bypass, patient displayed evidence of heparin
resistance requiring FFP transfusion and additional heparin dosing. Initial review of the literature shows
risk of heparin resistance in the setting of endocarditis is both synthetic and consumptive in etiology.
Endocarditis is considered a risk factor for heparin resistance, though there are few case reports and little
guidance as to how to approach this clinical scenario.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Cardiac Anesthesia (CA) MC835
Anesthetic Management for Resection of an Inferior Vena Cava Leiomyosarcoma with
Venovenous Bypass
Francis L. Kirk, M.D., Nadia Hensley, M.D . Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Baltimore, MD, USA.
A 31 year-old male with a 15cm retroperitoneal tumor adherent to his inferior vena cava presented for
resection. General endotracheal anesthesia was induced. An arterial line andthree venous introducer
sheaths (2 IJ, 1 AC) were placed. After the exploratory laparotomy and initial dissection, venovenous
bypass was instituted via cannula placed in the femoral vein with return flow to the internal jugular. The
tumor was resected en block, the aorta was reconstructed with an aortobiiliac graft, and the IVC was
reconstructed with a tube graft. A massive transfusion was required. The patient was taken to the ICU
postoperatively.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Cardiac Anesthesia (CA) MC836
Aortic Stenosis and Dementia: An Anesthesia Challenge
Shweta Koirala, M.D., John Jerabek, D.O . Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
92 year old male presented for bilateral femoral rod insertion after sustaining a femur fracture. His
medical history includes, severe Dementia, Progressive Critical Aortic Stenosis (AS) with an AV valve
area of 0.43 cm2. After a cardiology consult he was scheduled for emergency surgery. His anesthetic
management included invasive monitoring, bilateral femoral nerve blocks and Trans- esophageal
echocardiography. Intra-operatively he required pressor support. Extubation in the Intensive Care Unit
was delayed because of his baseline neurological status. He was subsequently extubated and discharged
on the eighth postoperative day.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Cardiac Anesthesia (CA) MC837
Profound, Refractory Intraoperative Hypotension- Differential Diagnosis and Management
Eleni Kotsis, D.O., Lynn Belliveau, D.O . Anesthesiology, Maimonides Medical Center, Brooklyn, NY,
USA.
Copyright © 2014 American Society of Anesthesiologists
72 year old male with history of HTN, atrial fibrillation, nonischemic cardiomyopathy (EF 15%) and RV
dysfunction with a wearable automatic defibrillator, presented for <i>elective</i> open suprapubic
prostatectomy for BPH. Patient was on pradaxa, stopped 11 days prior, finasteride, tamsulosin,
carvedilol, and furosemide. Preoperative labs were normal and EKG showed afib, LVH, and prolonged
QT. Since patient refused neuraxial anesthesia, the case was done under GA. Induction and intubation
was uneventful; monitors included arterial line, pulmonary artery catheter and TEE. Persistent
hypotension ensued, requiring multiple vasopressors and inotropes to maintain hemodynamic stability.
The patient was successfully discharged 3 days later.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Cardiac Anesthesia (CA) MC838
Providing Anesthesia to a Patient on ECMO: A Case Report
Molly B. Kraus, M.D., Ricardo Weis, M.D., Harish Ramakrishna, M.D . Mayo Clinic Hospital, Phoenix, AZ,
USA.
Thirty-eight year-old male on full ventilatory support for ARDS secondary to H1N1 influenza was
transferred to a tertiary care center. Due to a worsening clinical picture, he was started on venovenous
ECMO. Five days later, a massive right frontal intraparenchymal hemorrhage with midline shift and
downward uncal herniation was found on CT. The heparin drip was stopped, reversed with fresh frozen
plasma and ECMO continued. He was taken to the OR for right frontal craniotomy and clot evacuation
under general anesthesia. This poster will discuss ECMO complications and the anesthetic management
of patients on ECMO.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Critical Care Medicine (CC) MC839
Massive Bilateral Pleural Effusions and Generalized Edema Following Major Urologic Surgery with
Recent Chemotherapy
Jim Nguyen, M.D., Shveta Jain, M.D., Marisa Bell, M.D., Peter Roffey, M.D., Mariana Mogos, M.D.,
Duraiyah Thangathurai, M.D . Anesthesiology, Keck Medicine of USC, Los Angeles, CA, USA, Keck
Medicine of USC, Los Angeles, CA, USA.
Development of bilateral pleural effusions is a rare postoperative complication in patients with healthy
lungs. Massive capillary leak can occur due to administration of large amounts of IV fluids, low albumin,
severe blood loss, massive transfusions, and prolonged extensive surgeries. We are reporting a patient
with bladder cancer on chemotherapy who underwent anterior exenteration and developed massive
bilateral pleural effusions and generalized edema that occurred 48 hours postoperatively. Chemotherapy
may result in release of cytokines and other vasoactive substances, resulting in capillary and endothelial
injury. Awareness and aggressive treatment are key to avoiding a potentially fatal outcome in these
situations.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Critical Care Medicine (CC) MC840
Disseminated Strongyloidiasis: The Cause of Acute Respiratory Distress Syndrome
Hiroyuki Nishi, M.D., Taichi Hina, M.D., Koji Teruya, M.D., Tatsuya Fuchigami, M.D.,Ph.D., Manabu
Kakinohana, M.D.,Ph.D., Kazuhiro Sugahara, M.D.,Ph.D., Kazuhiro Sugahara, M.D.,Ph.D . Faculty of
Medicine, University of the Ryukyus, Nishihara, Japan, University of the Ryukyus, Nishihara, Japan.
Strongyloidiasis is commonly unapparent, chronic infection, but immune suppressed subjects can
develop fatal disease. In this case, it caused ARDS, which was rare in Japan. We report challenging
aspects of severe strongyloidiasis.A 62-year old female born in southern island of Japan was admitted to
undergo chemoradiotherapy and steroid therapy for cervical cancer. She suddenly developed severe
respiratory failure and was transferred to ICU. A few days later, we found lots of worms by Bronchoalveolar lavage and diagnosed disseminated strongyloidiasis. By administration of Ivermectin, the patient
recovered. Immunosuppression by chemoradiotherapy and steroid are a higher risk of complications of
strongyloidiasis.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:20 AM - 8:30 AM
Critical Care Medicine (CC) MC841
Severe Complications of Intra-aortic Balloon Pump Use
Jeffrey Oldham, M.D., Deborah Rohner, M.D . Department of Anesthesiology, University of Kentucky,
Lexington, KY, USA.
A 50 year old male presented with acute myocardial infarction, severe mitral regurgitation and cardiogenic
shock requiring IABP, valve replacement and revascularization. Veno-venous ECMO was needed to
wean from bypass due to hypoxia. He required postoperative pressors and IABP. Pules in his right leg
were lost, likely caused by ischemia from the IABP. He developed rhabdomyolysis requiring fasciotomy.
He ultimately weaned from IABP and ECMO but required dialysis. He experienced ventricular tachycardia
due to hyperkalemia from rhabdomyolysis. He had continued episodes of arrhythmias despite normal
electrolytes and amiodarone. An amputation was performed but continued arrhythmias resulted in his
death.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Critical Care Medicine (CC) MC842
How Sigmoid Interventricular Septum Affects Hemodynamics During Reperfusion of Liver
Transplantation
Ji Hyun Park, M.D., Gyu-Sam Hwang, M.D.,Ph.D . Department of Anesthesiology and Pain Medicine,
University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea, Republic of.
Age of liver transplantation recipients isincreasing. A 70 year-old male diagnosed with liver cirrhosis
revealed normal preoperativeechocardiography with “sigmoid” interventricular septum without LVOTO.
Inductionof anesthesia was uneventful. Shortly after reperfusion, post-reperfusionsyndrome developed
with compromised hemodynamic instability. Epinephrine 20 mcgwas given, but blood pressure decreased
instead. TEE revealed hypovolemia ofthe heart chambers along with SAM that led to LVOTO. Blood
pressure increasedto a normal range after injection of phenylephrine 100 mcg and intravenousvolume.
We emphasize the importance of age-related changes of the heart thataffects hemodynamics during
surgery.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Critical Care Medicine (CC) MC843
Perioperative Management of Patients Following Bleomycin Therapy
Roshni Patel, M.D., Neil Bailard, M.D . Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
The anesthesiologist should be aware of the implications of bleomycin therapy and its potential for
pulmonary toxicity. The following case describes unique management concerns including oxygen use and
fluid management. A 37 year old with recurrent testicular cancer s/p bleomycin chemotherapy underwent
a retroperitoneal lymph node dissection. In an effort to avoid pulmonary morbidity, the patient was fluid
restricted and maintain on a Fi02 of 25%. The patient became hypotensive, tachycardic, and acidotic.
Patient remained intubated postoperatively and was adequately fluid resuscitated. This case brought up
interesting issues about balancing risks vs benefits of resuscitation given potential for pulmonary toxicity.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Critical Care Medicine (CC) MC844
Massive Pulmonary Hemorrhage after Massive Pulmonary Embolism
Amy C.S. Pearson, M.D., Megan N. Manento, M.D., Francis X. Whalen, M.D . Anesthesiology, Mayo
Clinic, Rochester, MN, USA.
A 34-year-old previously-healthy Caucasian female presented to the bronchoscopy suite for evaluation of
a one-week history of hemoptysis. Sixteen days prior to presentation, she suffered an in-hospital PEA
cardiac arrest secondary to unprovoked bilateral pulmonary emboli. She was subsequently maintained on
home oxygen and warfarin anticoagulation without embolectomy. In the bronchoscopy suite, she was
intubated fiberoptically, where a copious amount of fresh blood was noted originating from the right lower
lobe, causing significant desaturations. In this case, we discuss immediate management options for
Copyright © 2014 American Society of Anesthesiologists
pulmonary hemorrhage as well as possible mechanisms and treatment options for coexisting pulmonary
hemorrhage and embolism.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Critical Care Medicine (CC) MC845
Sepsis vs. Adrenocortical Insufficiency: Newly Diagnosed Addison's Disease in a Healthy Teen
Cecilia Pena, M.D., Amy Henry, M.D . Pediatric Anesthesiology, Medical College of Wisconsin, Children's
Hospital of Wisconsin, Milwaukee, WI, USA.
Healthy 16yo female presented with emesis and abdominal pain. She was admitted to OSH and
subsequently transferred to CHW for worsening condition; presumed a ruptured appendix. She received
inotropes and blood products, but continued to decline despite her appendectomy. On postop day 1, she
continued to require inotropes and ventilatory support. Bedside TTE demonstrated dilated
cardiomyopathy and 20% EF. Random cortisol was low at that time, 0.2, thus steroid therapy started.
Endocrine workup confirmed Addison‟s disease and hypothyroidism. On hospital day 7 she was
extubated and on day 8, weaned from inotropes. Pre-discharge echo on hospital day 13 was normal.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Critical Care Medicine (CC) MC846
Air Embolism after Endobronchial Biopsy
Julia C. Peters, M.D., Jeana E. Havidich, M.D., Peter A. DeLong, M.D., Christopher S. Manfred, M.D.,
Maura J. Adams, M.D., David M. Whittaker, C.R.N.A . Dartmouth Hitchcock Medical Center, Lebanon,
NH, USA.
64 y.o. male presented for endobronchial biopsy of an obstructing left upper lobe mass. PMH significant
for smoking, palpitations, arthritis. GETA was induced. Shortly after the start of the procedure, the patient
experienced bronchial hemorrhage, PEA arrest, and a 800ml blood loss. A bronchial blocker was placed,
code called, and emergent TEE performed. TEE demonstrated intracardiac air, with continuous bubble
entrainment through the left pulmonary vein. Evolving WMA‟s noted, likely due to coronary air embolism.
ROSC was achieved in 10 minutes after standard ACLS and 2u PRBC. The ETT was replaced with a
right sided DLT after hemostasis was achieved.
Monday, October 6, 2014
9:20 AM - 9:30 AM
Critical Care Medicine (CC) MC847
Severe Septic Shock Immediately After VATS and Pleurodesis in the PACU
Matt Ploger, D.O., Hui Yuan, D.O . Anesthesiology, St. Louis University, Saint Louis, MO, USA.
We describe a 55yo female admitted for progressive SOB secondary to advanced metastasis from
ovarian cancer. A VATS with pleurodesis was performed. During the procedure, the surgeon dissected
adhesive tissue in left chest, draining 100cc of white cloudy fluid. The patient tolerated one-lung
ventilation well. After chest tube placement, she was extubated without obvious difficulty. However, upon
entering PACU, she became hemodynamically unstable with hypotension, tachycardia and increased RR
with hypoxia. After recognizing the patient was in septic shock from infected chest fluid or necrosis of
tumor tissue, intubation with ventilator support followed by medical management of sepsis was initiated.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Ambulatory Anesthesia (AM) MC848
Postoperative Angioedema in Ambulatory Surgery
Abdenour Abib, M.D . Department of Veterans Affairs, Central Arkansas Veterans Healthcare System,
Little Rock, AR, USA.
64 year old man with a history of hypertension, GERD, and DJD who underwent a knee arthroscopy. Past
history of multiple surgeries with no reported complications. His procedure was short and uneventful.
Initially, ready for discharge to home, when he started complaining of a swollen lip that progressed to a
swollen tongue despite treatment, and ultimately to difficulty breathing. An awake fiber optic intubation
Copyright © 2014 American Society of Anesthesiologists
was performed and the patient was transfered to MICU for further treatment, where he remained
intubated for two days. He was successfully extubated on day three, and discharged home on day four.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Ambulatory Anesthesia (AM) MC849
Uvular Hydrops .Another Opioids Adversity on the Respiratory System
Ahamd Abou Leila, M.D., Piotr Aljindi, M.D., Joyti Dangle, M.D . John H. Stroger Jr. Hospital of Cook
County, Chicago, IL, USA.
Opioids are well known for their side effects on respiratory system.The most common adversity is central
respiratory depression ,however a rare side effect may involve the airway known as Uvular hydrops.Our
case highlights this rare side effect that occurred in 75 yo male patient during cystoscopy under MAC
without any airway instrumentation.Intraoperativly patient received sufentanil 25 mcg. Postoperativly
physical exam showed uvular swelling.Since no uvular swelling triggers identified ,uvular hydrops linked
to opioids was the most likely cause.Patient admitted to hospital , received supportive therapy,after
improvement he was discharged home.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Ambulatory Anesthesia (AM) MC850
Hypermetabolism and Increased MAC Requirements for Exam Under Anesthesia at Ambulatory
Surgery Center
Bettina Barr, Jin Meng, M.D . Anesthesia, UT Southwestern Dallas, Cedar Hill, TX, USA, UT
Southwestern Dallas, Dallas, TX, USA.
56 year old male with HTN,DM2, GERD presents with anal fissure for exam under anesthesia. Patient
describes history of difficult intubation and postop sore throat. Smooth induction and easy LMA
placement. On Sevoflurane 1.7 and 50% N2O he starts moving and kicking after lithotomy position
placement. Succinylcholine and proposal were given due to biting on LMA vs laryngospasm and patient
intubated via Glidescope and bougie. Exam proceeded and the patient requires a total of 1000mg and
MAC of sevoflurane at >\=3 throughout the 45 min case. Patient denies drug use and none of the home
medications are known P450 inducers.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Ambulatory Anesthesia (AM) MC851
Postoperative Care of Retroperitoneal CO2 and CO2 narcosis after Inguinal Hernia Repair at
Ambulatory Surgery Center
Bettina Barr, Jin Meng, M.D., Quincia C. Wilkins, M.D. Anesthesia, UT Southwestern Dallas, Cedar Hill,
TX, USA, UT Southwestern Dallas, Dallas, TX, USA, UT Southwestern Medical Center, Dallas, TX, USA.
55 year old female with history of hypothyroidism, anxiety presents for inguinal hernia repair at the
ambulatory care center. Intraoperative course was uneventful. She received 250mcg fentanyl and 0.4mg
dilaudid. On emergence patient reports inadequate pain control after surgery. Repeated sedationawakening cycle limited our ability to give opioids postoperatively. She also complained of nausea and
vomiting. A balanced risk-benefit treatment plan was applied for treatment of pain and nausea while
avoiding sedation. This prompted our discussion of retroperitoneal CO2 as a cause for her prolonged
recovery.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Ambulatory Anesthesia (AM) MC852
Anesthetic Management of Patient with Massive Thyroid Goiter and Medical Complexity
Scheduled as Ambulatory Surgery
Charles D. Barry, M.D., Ranita Donald, M.D . Anesthesiolgy and Periopertive Medicine, Georgia Regents
University, Augusta, GA, USA.
A 74 - year -old male with massive nontoxic multinodular goiter with tracheal deviation and sub-sternal
extension, scheduled for total sub-sternal thyroidectomy. Co-morbidities included hypertension,
Copyright © 2014 American Society of Anesthesiologists
hyperlipidemia, uncontrolled diabetes, former smoker, obesity, OSA, difficult airway, CAD, MI twice, s/p
angioplasties and stent, with history of cardiac arrest during previous surgery. Patient underwent carefully
planned general anesthesia with balanced technique using remifentanil, propofol, and sevoflurane for
maintenance, and laryngeal nerve monitoring endotracheal tube for laryngeal nerve monitoring. This case
report will highlight the management of airway and other problems associated with this complex patient
who had cardiac arrest during previous surgery.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Ambulatory Anesthesia (AM) MC853
Post-operative Stroke Following Colonoscopy With Subsequent Angioedema Secondary to TPA
Requiring Emergent Re-intubation
Raymond Pla, M.D., Rohini Battu, M.D . Anesthesiology and Critical Care Medicine, The George
Washington University, Washington, DC, USA.
54 AAM w/ HTN on lisinopril, OSA, morbid obesity, TIA, hypothyroidism, HIV scheduled for screening
colonoscopy requiring GETA. Extubated and taken to PACU. 30 min after arrival pt started having
aphasia and R sided weakness in PACU. Stat head CT showed an ischemic stroke. Pt immediatly started
on TPA with subsequent angioedema of tongue and lips requiring emergent intubation. Admitted to ICU
where patient self extubated on POD 4 with no new deficits.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Ambulatory Anesthesia (AM) MC854
Irreversible Electroporation for Metastatic Adrenocortical Carcinoma
Matthew G. Bean, D.O., Edward Kruse, D.O., Sanjay Dwarakanath, M.B.,B.S . Anesthesiology, Medical
College of Georgia at Georgia Regents University, Augusta, GA, USA, Surgical Oncology, Medical
College of Georgia at Georgia Regents University, Augusta, GA, USA.
A 46-year-old male with recurrent adrenocortical carcinoma underwent an exploratory laparotomy, tumor
debulking, and irreversible electroporation of multiple liver metastases. Monitoring with 5-lead EKG and
synchronization of irreversible electroporation was done to avoid causing an R-on-T phenomenon. An
external defibrillator was immediately available. During irreversible electroporation, muscle relaxation with
the abolishment of twitches was required. Blunting of sympathetic response and pain control were
achieved with intermittent lidocaine boluses through a lumbar epidural and an intravenous sufentanil
infusion. The patient remained hemodynamically stable and had no episodes of arrhythmia.
Postoperatively, pain was controlled with bupivacaine epidural infusion and a hydromorphone PCA.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Ambulatory Anesthesia (AM) MC855
Prolonged Emergence After Orchiopexy: A Possible Psychiatric Complication
Brett A. Blakeway, M.D., Casey Windrix, M.D . Anesthesiology, University of Oklahoma Health Sciences
Center, Oklahoma City, OK, USA.
A healthy 23 year old male underwent general anesthesia for orchiopexy for an undescended testes.
Preoperatively, the patient was visibly anxious and expressed concerned over the possibility of an
orchiectomy. An uneventful balanced general anesthetic was administered. Postoperatively, the patient
remained delirious with reduced consciousness and disorientation; this state persisted for several hours
despite stable vital signs, normal laboratory studies, and a negative urine drug screen. This state ended
abruptly with no residual sequela. With no physiological or pharmacological explanation we suggest that
the patient suffered from an acute conversion reaction due to the stress of possible orchiectomy.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Ambulatory Anesthesia (AM) MC856
Diphenhydramine Abuse and Effects on Anesthesia
Joann E. Bolton, M.D., Sher-Lu Pai, M.D . Mayo Clinic Florida, Jacksonville, FL, USA.
Copyright © 2014 American Society of Anesthesiologists
This is a case presentation of a 57-year-old male with severe atypical acid reflux symptoms who was
scheduled for laparoscopic sphincter augmentation with linx device. He had a history of polysubstance
abuse, sober for 12 years. At the pre-operative evaluation, he reported significant oral diphenhydramine
use; up to 740mg per day. A review of the uses of diphenhydramine is presented along with the effects of
chronic high dose consumption. Chronic and Acute toxicity may cause challenges with managing a
patient under anesthesia including neurologic and cardiac changes. Patients may require inpatient
rehabilitation prior to surgery.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC857
Hemodynamically Unstable Urosepsis: How Do I Manage Atrial Fibrillation with RVR?
Martha E. Oelschlaeger, M.D., Roy Soto, M.D., Steven Gill, M.D . Beaumont Health System, Royal Oak,
MI, USA.
AF, an 80yo male with history of atrial fibrillation with RVR, rate controlled with 80mg sotalol daily,
presented with sepsis and obstructing renal calculi. On presentation he was hypotensive and in atrial
fibrillation. He missed two doses of sotalol before presentation, but the decision not to treat
prophylactically for RVR was made due to the patient's hemodynamic instability. Following stent
placement, in the recovery room he developed RVR with HR 170s, became unresponsive, and rapidly
desaturated. The episode resolved with 3 doses of diltiazem 5mg IV and supplemental oxygen. He was
admitted to the ICU for observation.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC858
Autonomic Dysfunction in a T9 Paraplegic Undergoing AKA with General Anesthesia
Brian K. O'Hara, M.D., Amy Robertson, M.D . Department of Anesthesiology, Vanderbilt University
Medical Center, Nashville, TN, USA.
A 62 year old WF with ESRD on HD, atrial fibrillation (no B-blockade), remote CVA, prior PE, obesity,
autonomic dysfunction and T9 paraplegia (s/p remote T6-L1 PSF) presents for left AKA due to
osteomyelitis. Preoperatively she is hypotensive at baseline requiring fludrocortisone and midodrine daily,
with preoperative systolic blood pressure of 80 mm Hg. Her last HD was 3 days prior to the procedure,
limiting her fluid allowances. She also has a history of autonomic dysreflexic responses with certain
stimulation, and refuses regional anesthesia due to both a needle phobia and previous spinal fusion.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC859
Simultaneous Orthotopic Liver and Kidney Transplant in Polycystic Disease
Brian K. O'Hara, Roy Kiberenge, M.D., Ram Pai, M.B.,B.S . Vanderbilt University Medical Center,
Nashville, TN, USA.
43 year old female with paroxysmal atrial fibrillation, periventricular cavernous malformation and
polycystic liver and kidney disease with significant organomegaly presented for orthotopic liver and kidney
transplant. Her native liver weight was approximately 30 pounds, with her right kidney over 15
centimeters in length. Her intraoperative course was complicated by severe shifts in hemodynamics
secondary to unavoidable hepatic compression of vasculature during the dissection phase with concern
of overtreatment and hypertension in the setting of her intracranial pathology and documentation of likely
previous cerebral bleeding. The patient also suffered from massive ascites loss and extensive fibrinolysis
on thromboelastography.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC860
Unconventional Anesthetic Management of Broncho-pleural-cutaneous Fistula
Jeffrey Oldham, M.D., Cara Sparks, M.D., Zaki Hassan, M.D . Department of Anesthesiology, University
of Kentucky, Lexington, KY, USA.
Copyright © 2014 American Society of Anesthesiologists
A twenty-three year old female status post traumatic pneumonectomy with large broncho-pleuralcutaneous fistula presented for operative repair. Lung isolation was planned but left double lumen tube
placement and intentional left mainstem placement of a single lumen tube under fiberoptic visualization
were not possible due to small airway diameter and extreme angulation of the bronchus. A single lumen
tube was placed under direct laryngoscopy but a large air leak prevented adequate ventilation. A foley
catheter was passed externally through the fistula into the bronchial stump under fiberoptic visualization
to occlude the leak and facilitate ventilation.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC861
Difficult Airway in a Patient with a Large Thyroid, Arytenoid Prolapse and Anterior Larynx
Siang King Ombaba, Ulana Leskiw, M.D., Bernard Pygon, M.D. University of Illinois at Chicago, Chicago,
IL, USA.
A 61 year-old female presented for thyroidectomy and microdirect laryngoscopy with laser after previous
unsuccessful fiberoptic intubation. Review of patient records and discussion with otolaryngologist and
former anesthesia team indicated the challenge resulted from rightward tracheal deviation by large
thyroid, complicated by significantly prolapsing arytenoids. Awake oral intubation was attempted with #3
Miller blade after intravenous sedation and airway topicalization. Vocal cords were visualized, but the
angle created by prolapsing arytenoids and anterior larynx did not permit endotracheal tube passage.
Glidescope-assisted fiberoptic bronchoscopy did facilitate successful intubation. After general anesthetic
induction, thyroidectomy and excision of bilateral corniculate cartilages were performed.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC862
Bilateral Pneumothorax and Pneumomediastinum After Airway Catheter Exchanger (ACE) Use
Alicja Orkiszewski, M.D.,Ph.D., Shienna Sharma, M.D., Daniel Gregory, P.A., Gregory Victorino, M.D .
Anesthesiology, ACMC, Highland Hospital, Oakland, CA, USA, Surgery - Trauma, ACMC, Highland
Hospital, Oakland, CA, USA.
24 y/o F with GSW to the face was brought to ER where she was orally intubated despite of extensive
face/neck injury. 2 days later she came to OR for jaw reconstruction and ETT exchange for a nasal.
Multiple attempts with ACE and fiberoptic were unsuccessful and patient remained orally intubated.Due to
neck swelling surgical airwy was not established. After the procedure increased subcutaneous
emphysema was noticed. CXR revealed bilateral pneumothorax ( R>L) and pneumomediastinum. R chest
tube was placed.Later ETT was exchange and reconstruction surgery was performed. Patient was
discharge home on POD# 13 in stable condition.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC863
Anesthetic Approach to a Biologically Active Carcinoid Tumor of the Lung in a Patient with a
Difficult Airway
Jamel P. Ortoleva, Yili Haung, M.D., Viji Kurup, M.D . Anesthesiology, Yale New Haven Hospital, New
Haven, CT, USA.
Carcinoid tumor of the lung is a rare yet known malignancy that can cause serious intra-operative
complications via secretion of biologically active molecules. Associated complications can be very difficult
to manage especially if unanticipated. Our patient is a classic presentation of active carcinoid scheduled
for VATS lobectomy and illustrates the importance of early planning to prevent crisis. Her medical history
is significant for DM2, asthma, OSA and obesity (BMI 54.4), which also contributed to difficult double
lumen ETT intubation managed via tube exchanger to a single lumen ETT and bronchial blocker leading
to successful lung isolation with lobectomy tumor excision.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC864
Anesthetic Approach to Excision of an Obstructive Mass Stemming from the Epiglottis in a Poorly
Controlled Hypertensive with a Retropharyngeal Carotid Artery
Jamel P. Ortoleva, William Rosenblatt, M.D . Anesthesiology, Yale New Haven Hospital, New Haven, CT,
USA, Anesthesiology, Yale University School of Medicine, New Haven, CT, USA.
Masses obstructing the airway can present a challenge to the anesthesiologist. Even in patients with
otherwise straightforward anatomy, safely securing the airway can be a great challenge and
complications can be disastrous. Our patient is an example of a mobile, pedunculated , epiglottic mass
that presents for robotic assisted excision. Her medical history is significant for poorly controlled
hypertension on 5 medications, Hiatal hernia, morbid obesity (BMI: 43), retropharyngeal carotid artery,
OSA on CPAP, and Hepatitis C. Awake nasal intubation technique was utilized given the potential for
obstruction, aspiration, and to best achieve surgical access.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC865
Dentures on the Larynx: The Story of a Challenging Airway and a Review of Foreign Bodies in the
Upper Airway
Tyler W. Pagel, M.D., Christopher Canlas, M.D . Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN, USA.
A morbidly obese 66 year-old male who was failing extubation in the Trauma ICU required intubation. He
suffered significant facial trauma and multiple cervical fractures from a motor vehicle collision. Oral
fiberoptic intubation via LMA was performed unsuccessfully. Ventilation became progressively more
difficult between attempts. Subsequently, a McGrath video laryngoscope was utilized, which produced a
view of a flesh colored object overlying the larynx. After successful intubation, the foreign body was
retrieved, found to be the man's upper partial denture plate. This case expands the differential diagnosis
of hypoxemia in a trauma patient.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Cardiac Anesthesia (CA) MC866
One Heck of a Catheter! VP Shunt Migration into Pulmonary Artery
Farhan Farooqui, M.D., Cathy Bachman, M.D . Anesthesia and Critical Care, University of Chicago,
Chicago, IL, USA.
A 17 yo had a VP shunt placed at age 7. He presented with SOB and had a CT which documented the
catheter in the PA. TEE was used to guide catheter removal which required CPB. His PA pressures were
50% systemic indicated pulmonary hypertension. Additionally, his RV was dilated. There have been few
cases of this in the literature. The theory is that the operator goes through the jugular vein allowing
communication with the vascular system. This case highlights a complication of vp shunts and the use of
TEE. It also highlights the delay in patient presentation.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Cardiac Anesthesia (CA) MC867
Papillary Muscle Rupture Following Inferior Myocardial Infarction: An Uncommon but
Catastrophic Complication
Jennifer Fraser, M.D., Joshua Zimmerman, M.D., Natalie Silverton, M.D., Elizabeth Thackeray,
M.D.,M.P.H . Anesthesiology, Stanford University, Stanford, CA, USA, Anesthesiology, University of Utah,
Salt Lake City, UT, USA.
A 63 year-old man suffered an inferior STEMI with subsequent drug-eluting stent placement. Five days
later he developed progressive dyspnea and chest pain. Though his EKG showed only sinus tachycardia
he was taken for urgent coronary evaluation. He immediately suffered PEA arrest, requiring intubation,
ACLS and placement of an intra-aortic balloon pump. Coronary angiography revealed RCA in-stent
thrombosis but attempts at revascularization were unsuccessful and the patient remained profoundly
Copyright © 2014 American Society of Anesthesiologists
unstable. The anesthesiology team performed rescue TEE, establishing the diagnosis papillary muscle
rupture with acute severe mitral regurgitation. The patient‟s condition was deemed unsurvivable and he
expired in the cardiothoracic ICU.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Cardiac Anesthesia (CA) MC868
Acute Mitral Regurgitation Due to Technical Complication During Transcatheter Aortic Valve
Replacement (TAVR)
Brad A. Fremming, M.D., Katie J. Goergen, M.D . Anesthesiology, University of Nebraska Medical Center,
Omaha, NE, USA.
We describe theanesthetic management of an 85 year-old female with aortic stenosis whopresented for
TAVR. This case highlightsthe value of using intraoperative TEE during procedures employing
newertechnologies. During deployment of thedelivery system, a guide wire was inadvertently placed in
the mitralsub-valvular apparatus resulting in acute mitral regurgitation. This complicationwas first detected
using TEE, prior to evidence of hemodynamic instability.Communication between the Anesthesiology
team and the operating team, guided bythe use of intraoperative TEE, proved effective in reversing the
complicationand hemodynamic instability, allowing the procedure to be completed withoutfurther
complication.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Cardiac Anesthesia (CA) MC869
The Spine vs. the Heart: An Emergent CABG in a Patient with Cervical Spine Injury Also Requiring
Emergent Stabilization
Ilana R. Fromer, M.D., Benjamin Salter, D.O., Cindy Wang, M.D . Anesthesiology, Icahn School of
Medicine, New York, NY, USA.
66 year-old male hospitalized after unstable cervical spine injury requiring surgical treatment presented
with STEMI during hospital stay requiring urgent CABG. Patient was intubated using awake fiberoptic
technique while in cervical collar. After airway was secured, the neurosurgical team completed a
neurological assessment, anesthesia was induced, and the patient was placed in traction to avoiding
cervical injury. Lines placed femorally and TEE not performed due to nature of spinal injury. An off-pump
CABG was completed , patient was placed back in cervical collar, and transported to ICU. Patient was
extubated with no further neurologic sequalae and spine intervention was planned.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Cardiac Anesthesia (CA) MC870
Fire in the Operating Room
Satoru Fujii, M.D., Mika Mori, M.D . Kanazawa University Hospital, Kanazawa City, Japan.
A 72 year-old man was scheduled for aortic valve replacement surgery. General anesthesia was
administered uneventfully and his aortic valve was implanted as planned. However, after weaning off
cardiopulmonary bypass, suddenly, the surgeon‟s gown caught fire, which spread to sterile sheet,
respiratory circuits and the pulmonary artery catheter. Subsequently. we extinguished the fire using
normal saline. The cause of the fire was determined to be electrocautery equipment. We could have
prevented the fire if we had put aside the equipment properly and could have well prepared for the fire if
we had installed carbon dioxide fire extinguisher.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Cardiac Anesthesia (CA) MC871
Migration and Fracture of SVC Stent: A Unique Complication During SVC Stenting
Clinton L. Fuller, M.D., Suman Rajagopalan, M.D . Anesthesiology, Baylor College of Medicine, Houston,
TX, USA.
Superior vena cava stenting has become accepted primary treatment for symptoms related to superior
vena cava syndrome, of either a malignant or benign etiology. Stenting provides rapid relief of symptoms
Copyright © 2014 American Society of Anesthesiologists
with minimal invasiveness, but is not without complications, including migration, fracture, reocclusion, vein
damage, infection, and bleeding. In our case, a 55 year-old female with stage 4 lung adenocarcinoma
presented for SVC stenting and during the procedure, the stent migrated into the right atrium, and
fractured upon retrieval, leaving the stent lodged partially within the right internal jugular vein. We discuss
the important anesthetic considerations during stent retrieval.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Cardiac Anesthesia (CA) MC872
Dilemma of the Echodensity: Re-explore or Anticoagulate?
Arun Ganesh, M.D., Brian Barrick, M.D., Priya Kumar, M.D . Dept. of Anesthesiology, University of North
Carolina, Chapel Hill, NC, USA.
Cardiac transplantation in a 67 year old male was complicated by an inadvertent tear in the pulmonary
artery, resulting in additional cross clamping and a prolonged CPB run. An extracorporeal non-pulsatile
LVAD was placed for failure to wean. Echocardiographic examination the following day revealed a large
echodensity on the aortic valve that was suspicious for thrombus. Surgical re-exploration would require a
bypass run and additional cross clamp time, adding more insult to a compromised ventricle.
Anticoagulation alone would not provide adequate protection from a major embolic event. A
multidisciplinary risk benefit assessment led to the successful resolution of this dilemma.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Cardiac Anesthesia (CA) MC873
Transcatheter Aortic Valve Replacement Prior to Left Ventricular Assist Device Placement
Chandrika R. Garner, M.D., Mark Stafford Smith, M.D . Anesthesiology, Duke University Medical Center,
Durham, NC, USA.
Left ventricular assist device (LVAD) placement is an option for patients with left heart failure, but such
devices require aortic valve competency. In patients with aortic insufficiency, options include oversewing
the aortic valve and aortic valve replacement.Our patient had severe left ventricular systolic dysfunction,
severe aortic stenosis, and moderate aortic insufficiency. She underwent mini-sternotomy and
thoracotomy for combined transapical Sapien aortic valve and Heartware LVAD placement. Anesthetic
considerations included induction and pre-bypass management of a patient with her comorbidities as well
as transesophageal echocardiography to assess valve placement post-deployment, LVAD cannula
positioning, and right heart function.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Cardiac Anesthesia (CA) MC874
Refractory V-fib and Pulmonary Artery Thrombosis in a Patient Presenting for ECMO
Decannulation and BiVAD Placement
Andrew J. Gentilin, M.D., Theresa Gelzinis, M.D . Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA, USA.
A 63 y.o. male with recent CABG complicated by post-op Ventricular Fib arrest from graft kinking
presented in acute cardiac decompensation and recurrent ventricular fibrillation. After initial repair of graft
failure, patient remained on ECMO for 4 days then presented for ECMO decanulation and BiVAD
placement. Upon TEE examination, there was prominent echogenicity in the main and right pulmonary
arteries consistent with thrombus. Patient remained in ventricular fibrillation resistant to amiodarone,
lidocaine, >20 defibrillations, and attempts at overdrive ventricular pacing throughout the operation.
Despite hemodynamic instability throughout, pulmonary thrombus was removed and the patient
transferred from ECMO to BiVAD support.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:00 AM - 8:10 AM
Critical Care Medicine (CC) MC875
Conservative Management for an Emergent Ileus Case Due to Heat Disorder
Takashi Matsusaki, Kazumasa Hiroi, Tetsufumi Sato. Okayama University Hospital, Okayama, Japan,
National Cancer Center, Tokyo, Japan.
A 75-year-old male patient (postoperative colon cancer resection) visited our hospital due to abdominal
pain and nausea. His abdominal CT scan showed ileus due to hernia of abdominal wall scarring. He also
had acute renal failure (serum creatinine: 17 mg/dL, potassium: 8.2 mEq/L) because of severe
dehydration due to heat disorder. He received life-saving, emergent dialysis. We requested a surgical
consult regarding laparotomy; however, his general condition worsened. We decided on conservative
management including dialysis, hydration, respiratory and hemodynamic support. His general condition
improved and he was withdrawn from mechanical support within two weeks.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Critical Care Medicine (CC) MC876
Airway Development Status-Post Gunshot Wound (GSW) to the Shoulder with Expanding Neck
Hematoma and Cartilage Disruption
Kimberly I. McClelland, M.P.H., Clairmont E. Griffith, M.D., Girum D. Hailedingle, M.D . Howard University
Hospital, Washington, DC, USA.
A 60-year-old driver arrived to the ED after being shot twice in the upper back. Despite tracheal deviation
observed on X-ray, the patient lacked signs and symptoms of mass effect or pneumothorax and was
considered hemodynamically stable. However, after CT, he complained of cervical collar tightness; and,
with the results of the CT available, was promptly identified as a dynamically difficult airway patient. The
fact that he remained talkative proved misleading with respect to anticipating airway patency. The rapid
deterioration of his airway was an unexpected consequence of his injuries and provides a valuable clinical
lesson regarding emergency airway management.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Critical Care Medicine (CC) MC877
Anti-coagulation Management for a Critical Care Patient with History of HIT with Recurrent
Thrombi and Bleeding Episodes
Patrick J. McConville, M.D., Lisa Weavind, M.D., Christopher Hughes, M.D . Vanderbilt University Medical
Center, Nashville, TN, USA.
We describe the critical care management of a 23 year old female with diagnosis of heparin-induced
thrombocytopenia who presented with abdominal pain. The initial CT demonstrated extensive DVT/PE
including mesenteric, splenic and portal thrombi. Patient underwent small bowel resection for mesenteric
venous ischemia. Post-operatively, patient‟s anti-coagulation management was difficult as she continued
to develop thrombi on anti-coagulation as well as hemorrhagic episodes eventually requiring splenic
artery embolization. Over her hospitalization, she had a prolonged treatment with various anti-coagulants
argatroban, fondaparinux, and bivalirudin before a confirmatory Serotonin Release Assay for HIT was
negative and she was transitioned to unfractionated heparin.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Critical Care Medicine (CC) MC878
Management of Accidental Hypothermia
Sanjay S. Mehta, Joseph Reeves-Viets, M.D . University of Missouri Columbia Health System, Columbia,
MO, USA.
Accidental hypothermia has low incidence and has limited evidence to guide clinical decision-making. We
were called to ED for consultation of a 23 y/o female polysubstance abuser that presented with severe
hypothermia after 12hr exposure to < 150 C with core temp of <250 C. On arrival, she arrested and
received CPR for 3 hrs prior to placement on CPB. She was cardioverted at 350 C, and weaned from
Copyright © 2014 American Society of Anesthesiologists
CPB on vasopressin. She was transferred to MICU with GCS 3T at 8 hrs. Family decided to withdraw
care at 25 hrs.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Critical Care Medicine (CC) MC879
Neurally Adjusted Ventilatory Assist Mechanical Ventilation Applied Pre and Post Operatively in
Congenital Diaphragmatic Hernia
Tiffany Minehart, M.D., Rachel Bozeman, M.D., Christy Dixon, R.T. , William Patten, M.D.. Transitional
Medicine, Georgetown University Hospital, Washington, DC, USA, Emergency Medicine, West Virginia
University, Morgantown, WV, USA, West Virginia University, Morgantown, WV, USA, Pediatrics, West
Virginia University, Morgantown, WV, USA.
A 14 month old female presented to the emergency department in acute respiratory distress, requiring
immediate intubation with mechanical ventilation. Chest x-ray demonstrated an Anderson Catheter tip
projecting over the left upper quadrant of the abdomen. During the first 24 hours, the patient experienced
discomfort and asynchrony with multiple modes of mechanical ventilation and required increased
amounts of sedative medications. NAVA mechanical ventilation was initiated with positive results. NAVA
was continued until the patient underwent surgical closure of the left anterior Bochdalek diaphragmatic
hernia. NAVA ventilation was resumed until post-operative day one when the patient was successfully
extubated.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Critical Care Medicine (CC) MC880
Liver Transplant in Patient with ARDS and Sepsis
Prabhat Mishra, M.D., Anand Lakshminarasimhachar, M.D . Anesthesiology, Washington University in St.
Louis, Saint Louis, MO, USA, Washington University in St. Louis, Saint Louis, MO, USA.
L.K. is a 33-year old woman transferred to BJH for sepsis and multi-organ system failure. Along with liver
failure needing transplant, AKI, and cerebral edema, the patient‟s ARDS required high PEEP to maintain
oxygenation in SICU. Intraoperatively, patient given prostacyclin and chest tubes were placed in right
chest to prevent lung collapse. Patient‟s head was angled 30-45 degrees for oxygenation and to decrease
ICP. A 9-french cordis with PA catheter was placed and norepinephrine, vasopressin, epinephrine
administered. Patient received 10 pRBCs, 6 FFP, 3 platelets, and 40 units cryoprecipitate. Closure
compromised oxygenation so patient was packed and transported to SICU.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Critical Care Medicine (CC) MC881
Does Massive Transfusion Always Result in Multiple Organ Dysfunction Syndrome?
Meghan C. Whitley, D.O., Venugopal S. Reddy, M.D., F.C.A.R.C.S.I., Mary E. McAlevy, M.D . Penn State
Milton S. Hershey Medical Center, Hershey, PA, USA.
A patient with an ampullary adenoma who had undergone a Whipple procedure, presented to our ICU
with bleeding from his gastrojejunal anastomosis. On arrival, he was hypotensive, with abdominal
distention and gross upper and lower GI bleeding. He received a total of 138 units of packed cells, 103
units of plasma, 16 units of platelets and 7 units of cryoprecipitate during a 48 hour period. Despite
receiving this massive amount of blood products, he did not have any of the sequelae of massive
transfusion complications that can affect the brain, lung, heart, liver or kidney.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Critical Care Medicine (CC) MC882
Multiple Failed Extubations Leading to Diagnosis of Autoimmune Disease
Kristal L. Wilson, M.D., Joshua Graham, M.D., Anu Wadhwa, M.D . Anesthesiology and Perioperative
Medicine, University of Louisville, Louisville, KY, USA.
We present a case of a 57 year old male with a six week history of increasing dysphagia, dysarthria,
diplopia, orthopnea and 20 pound weight loss. Neurologic workup included a head and neck MRI that
Copyright © 2014 American Society of Anesthesiologists
required general anesthesia and endotracheal intubation. After meeting extubation criteria the patient was
extubated and emergently needed reintubation due to respiratory distress. Unsuccessful extubation was
performed multiple times before a diagnosis of myasthenia gravis was made. Patient was started on
pyridostigmine, along with received multiple treatments of plasmapheresis, and was successfully
extubated in the operating room, on treatment day five.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Critical Care Medicine (CC) MC883
Serotonin Release Assay Negative in a Post-Whipple Patient With New Onset Thrombocytopenia
and Thrombosis: Is It Heparin-Induced Thrombocytopenia?
Edward C. Yang, M.D., Nadia Haider, M.D . Anesthesiology, Advocate Illinois Masonic Med Ctr, Chicago,
IL, USA, Edward J Hines, VA Medical Center, Chicago, IL, USA.
Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication of heparin therapy. A
commonly used algorithm for scoring the likelihood of HIT is the “4 Ts” test in conjunction with heparininduced platelet antibody / platelet factor 4 and serotonin release assay. However, false-positive and
false-negative laboratory tests remain a concern. We present a case of a post-Whipple patient suspected
to have HIT with conflicting laboratory tests, but who clinically improved off heparin. Our case illustrates
an example of a classic “false negative”, where a supposed test (e.g. serotonin release assay) with
greater than 98% sensitivity and specificity failed to predict a diagnosis.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Obstetric Anesthesia (OB) MC884
Simultaneous Positive Intravascular Test Dose and High Spinal in a Parturient
Katrina M. Von Kriegenbergh, M.D., Bettina U. Schmitz, M.D . Anesthesiology, Texas Tech University
Health Sciences Center, Lubbock, TX, USA.
27 year old female with suspected subdural catheter placement during a labor epidural. A test dose of 3
mL 1.5% lidocaine with 1:200,000 epinephrine increased maternal HR to 150 bpm and the catheter was
removed. One space cephalad, repeat test dose increased maternal HR to 170 bpm, decreased SBP
from 120 to 77 mm Hg, and the patient complained of weakness indicating a high spinal. The catheter
was removed, she was closely monitored, and her hemodynamics stabilized after fluid bolus and
phenylephrine. Her numbness resolved completely in an hour and she was discharged home 48 hours
after spontaneous vaginal delivery.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Obstetric Anesthesia (OB) MC885
Obstetric and Anesthetic Management of a Parturient with Extensive Lower Extremity DVT
Meng Wang, M.D.,Ph.D., Joy Schabel, M.D . Anesthesiology, Stony Brook University Hospital, Stony
Brook, NY, USA.
This case report describes the obstetric and anesthetic management of a 31 year-old G1P0 parturient
with Factor V Leiden deficiency on anticoagulation therapy for an extensive deep venous thrombus in the
left lower extremity since 33 weeks gestation. Therapeutic anticoagulation was maintained with
enoxaparin and switched to heparin infusion. Pt underwent an uneventful stat cesarean section for nonreassuring fetal heart tracing with successful epidural anesthesia. Our case report describes the
peripartum management of extensive lower extremity DVT and reviews the etiology, risk factors, current
management guidelines and considerations for surgical (IVC filter placement) versus medical (anticoagulation only) approaches.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:20 AM - 8:30 AM
Obstetric Anesthesia (OB) MC886
Anesthetic Management of a Parturient with a History of Pneumonectomy for a Normal Vaginal
Delivery
John J. Weir, M.D., Katherine Hoctor, M.D., Jayanthie Ranasinghe, M.D . Anesthesiology, University of
Miami, Miami, FL, USA.
A 29-year-old G1P0 at 39 weeks gestation presented for normal vaginal delivery. She had a history of a
left mainstem bronchus carcinoid tumor for which she underwent left pneumonectomy five years prior.
After consultation with her obstetrician and anesthesia, it was decided to proceed with a normal vaginal
delivery with scheduled induction of labor and early implementation of combined spinal-epidural
analgesia. Pulse oximetry was utilized for close monitoring of her oxygen saturation during labor. Early
placement of an epidural catheter was utilized to preclude the onset of labor pain that could deteriorate
her already compromised respiratory function.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Obstetric Anesthesia (OB) MC887
HELLP Syndrome and Neuraxial Anesthesia: Thromboelastography to Assess Adequacy of
Coagulation Status
Garrett K. Wright, M.D., Tilak Raj, M.D . Anesthesiology, OU Medical Center, Oklahoma City, OK, USA.
A 28-year-old G2P0 patient presented with severe pre-eclampsia at our facility and requested neuraxial
anesthesia after induction of labor. Admission labs revealed a platelet count of 110,000 and repeat
platelet count showed a decrease to 84,000. A thromboelestogram was obtained which showed the
patient to have a normal coagulation status and an epidural catheter was subsequently placed. Serial
follow-up labs revealed a plummetting platelet count and picture of HELLP syndrome with the platelet
count dropping to a nadir of <15,000. The catheter was left in place until the platelet count normalized.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Obstetric Anesthesia (OB) MC888
Anesthetic Management for Cesarean Section in a Patient with Tuberous Sclerosis
Benjamin R. Yost, M.D., Chizoba Mosieri, M.D . Anesthesiology, LSUHSC Shreveport, Shreveport, LA,
USA.
A 32 year-old female G8P4124 at 33w5d with PMH of MI, CVA x 2, hypertension, Tuberous Sclerosis,
polycystic kidney disease and previous C/S x4 presented to the labor-unit complaining of contractions.
Upon arrival, patient was hypertensive (190s/110s) with concomitant severe orthostatic hypotension. Due
to non-reassuring fetal monitoring, patient was taken for repeat C/S. Standard ASA monitoring was used
with a radial arterial line placed in the OR. Epidural was placed for management of anesthesia. Infant was
delivered with APGAR scores of 7 and 8 at one and five minutes. Mother was transferred to MICU for
further observation
Monday, October 13, 2014
8:50 AM - 9:00 AM
Obstetric Anesthesia (OB) MC889
Anesthetic Management of Colloid Cyst Removal of the Third Ventricle in a Pregnant Patient: A
Case Report
Linda Walker Young, M.D., M.S., Thirupatthi Kumar, M.D., Matthew Mello, M.D., Izabela Wasiluk, M.D .
Anesthesiology, University of Florida College of Medicine, Jacksonville, FL, USA.
Colloid cysts occur in three per million per year. Intracranial lesions rarely present during pregnancy.
Symptomatology are common in both brain tumors and pregnancy. The parturient with an intracranial
lesion poses a unique anesthetic challenge.A 21year old G1P0 presented with severe papilledema. A
MRI revealed a cyst in the third ventricle, obstructive hydrocephalus and Arnold Chiari malformation Type
1.A right frontal craniotomy was performed, followed by a VP shunt. The patient subsequently delivered
via cesarean section at 36 weeks.Our case emphasizes the importance of a well organized anesthetic
plan to include a multidisciplinary approach.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
9:00 AM - 9:10 AM
Obstetric Anesthesia (OB) MC890
Blood Conservation Techniques in Jehovah's Witness Parturients
Anthony Zapata, M.D., Christopher J. Rosicki, Crystal C. Wright, M.D . Baylor College of Medicine,
Houston, TX, USA.
22 year old G4P3 Jehovah's Witness female with morbid obesity, three prior cesarean sections and
chronic anemia presents for elective cesarean section under neuraxial anesthesia. The patient agreed to
normovolemic hemodilution, cell salvage, tranexamic acid, factor VIIa and prothrombin complex
concentrate use perioperatively. Preoperatively 750 ml of autologous blood was collected and 2.5 liters of
LR were infused. Cesarean section under spinal anesthesia was performed with an EBL of 1350ml. Near
completion of the procedure the patient was given 750ml of autologous blood and 150ml of cell salvage
blood. There were no perioperative maternal or fetal complications.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Obstetric Anesthesia (OB) MC891
Dialysis in HELLP Syndrome Parturient
Reine A. Zbeidy, M.D . Anesthesiology, University of Miami, Miami, FL, USA.
A 34 y.o, 27-week gestation woman presented following three tonic-clonic convulsions. Her blood
pressure was 200/110 and she had severe proteinuria, bilirubinuria, and oliguria with scant dark urine.
FHR was reassuring. She received magnesium sulfate and nicardipine. Her creatinine was 327mmol/l,
AST 1869U/L, ALT 466UI/L, bilirubin 18mg/dl ,Ht32 and Hb 11, platelet count 90.000. She underwent
cesarean delivery under general anesthesia with propofol and suxamethonuim. She was transfused with
PRBC, platelets and FFP. She was transferred to ICU still intubated.She had multiple sessions of
CVVHD. She was extubated after 6-days. She was discharged home after 20 days in satisfactory
condition.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Obstetric Anesthesia (OB) MC892
A Parturient with Von Willebrand IIB Disease and Chronic Thrombocytopenia for Cesarean
Delivery
Reine A. Zbeidy, M.D., Ara Samra, M.D . Anesthesiology, University of Miami, Miami, FL, USA,
Anesthesiology, Jackson Memorial Hospital, Miami, FL, USA.
33 y/o G2P0010 at 37 weeks of gestation,diagnosed with VWD IIb,chronic thrombocytopenia.Admitted for
pre-delivery workup.The patient was seen by Hematology and was given intermediate purity
FactorVIII/Von Willibrand Factor concentrates every 12 hours.During workup platelet levels were found to
be 13,000.The next day the patient had to undergo an emergent cesarean delivery due to fetal
tachycardia.General anesthesia was performed.PRBC,FFP‟s,cryoprecipitate,and platelet were made
available,along with a cell saver machine. The patient received four units of platelets in transit to the
OR,four on incision,and four units during closure.Her surgery was uncomplicated, with an estimated blood
loss of 1000 ml.Her postoperative course was uneventful
Monday, October 13, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC893
Emergent Management of the Catastrophic Airway
Christopher V. Maani, M.D., Matthew Turek, M.D., Betsy Murray, M.D., Mark Cheney, M.D., Daniel
Raboin, M.D., Stephen C. Bird, M.D., David Layer, M.D . Anesthesiology, San Antonio Uniformed
Services Health Education Consortium (SAUSHEC), San Antonio, TX, USA.
Knowing the ASA Difficult Airway Algorithm is required for management of difficult airways, both
anticipated and unanticipated. However, knowing is only half the battle. Timely decision making, efficient
resource utilization and coordinated multi-disciplinary efforts promote optimal clinical outcomes for
patients. We discuss 2 emergent cases of catastrophic airway management in the ICU. The first is an
Copyright © 2014 American Society of Anesthesiologists
anticipated difficult airway which required emergent intubation for progressive respiratory failure. The
second highlights management of the unanticipated difficult airway with hypoxia, obtundation, and airway
compression following CEA. We review current concepts in airway management as well as novel
strategies and pitfalls encountered.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC894
Emergent Airway Management: Less is More vs More is More
Christopher V. Maani, M.D., Dannielle Hutsler, M.D., Garrett Jackson, M.D., Kevin Brady, M.D., Jett
Mercer, M.D., Daniel Bitner, M.D., Carlo Alphonso, M.D . Anesthesiology, San Antonio Uniformed
Services Health Education Consortium (SAUSHEC), San Antonio, TX, USA.
In emergent airway management, airway optimization competes with responsibilities to first do no harm the key is recognizing when less is more. We describe two antithetical situations where the anesthesia
team was consulted for emergent airways. Intubation was avoided when a 36-year-old Crouzon
syndrome patient with known difficult airway and acute onset dyspnea improved after a lidocaine
nebulizer treatment. In contrast, proposed ER intubation of an obese 70-year-old with recurrent
angioedema required escalation to the OR for awake intubation. Both instances illustrate our role as team
leaders and patient advocates maximize patient safety and promote optimal patient outcomes.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC895
Perioperative Management of a Patient with Systemic Mastocytosis
Brittany D. Maggard, M.D . Department of Anesthesiology and Perioperative Medicine, University of
Louisville, Louisville, KY, USA.
We are presenting the case of a 50 year old female scheduled for the removal of a pelvic mass. The
patient‟s history was complicated by two recent surgeries aborted following cardiovascular collapse upon
induction of anesthesia. Following these incidents, extensive workup revealed a diagnosis of systemic
mastocytosis. Systemic mastocytosis is a rare disorder of mast cell proliferation with clinical symptoms
related to the overwhelming release of histamine from mast cell degranulation. Disease exacerbation can
be triggered by medications, temperature changes, anxiety, and pain. Patients with this disorder require
careful perioperative management to avoid potentially severe consequences of excessive histamine
release.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC896
Successful Perioperative Management of Mast Cell Activation Syndrome
Keila Maher, M.D., Aaron Sandler, M.D.,Ph.D . Anesthesiology, Duke University, Durham, NC, USA.
A 25 yo female with Ehlers-Danlos Syndrome, ankylosing spondylitis, prior CVA and Mast Cell Activation
Syndrome (MCAS) presented for ankle ligament repair. She reported prior anaphylaxis during anesthesia
attributable to her MCAS. MCAS is an idiopathic condition characterized by episodic mast cell mediator
release causing an anaphylactic response. We avoided all known patient‟s known triggers, agents known
to cause histamine release and utilized regional techniques with a successful outcome. The patient
reported high satisfaction with experience. The issues related to the management of this condition will be
discussed.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC897
Airway Management of Patients With Squamous Cell Carcinoma of the Oropharynx
Shabnam Majidian, D.O., Vadim Ioselevich, M.D . Anesthesiology, University of Texas at Houston
Medical Center, Houston, TX, USA.
This is a 53 year-old male with T3N0M0 squamous cell carcinoma of the oropharynx. He presented to the
operating room for full mouth teeth extraction. On the imaging, patient noted to have a soft palate mass,
Copyright © 2014 American Society of Anesthesiologists
left greater than right extending along the left lateral pharyngeal wall at the nasal and oropharynx into the
left glossotonsillar sulcus and left base of the tongue. A combination of nasal fiber optic intubation with
assistance of a video laryngoscope for obtaining grade I view Cormack-Lehane classification was
performed for a successful intubation.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC898
Intracranial Dural Arteriovenous Fistula (DAVF) Identified After Robotic Assisted Hysterectomy
Michelle E. DaCosta, M.D., Helene Finegold, M.D . Anesthesiology, Allegheny West Penn Residency
Program, Allegheny Health Network, Pittsburgh, PA, USA.
A 35 year old G7P5 with history of morbid obesity (104 kg, ¬¬BMI 39) and menometrorrhagia presents for
a robotic assisted total hysterectomy. The operating time was 134min and there were no surgical or
anesthesia complications. The patient reported right ear fullness immediately after waking up from
surgery. Over the next couple of days she had intermittent right ear pulsatile sensations, which were
increasing in intensity. The patient continued to have symptoms and after three weeks further evaluation
included MRA/MRV of the Head and Neck, which showed an intracranial DAVF. The patient underwent
endovascular embolization for definitive treatment.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC899
Delayed Symptoms From Tracheal Tear After Uneventful Tracheal Intubation Confounded by
Possible Esophageal Tear During ERCP
Amy K. Marino, M.D., Brian Ferrell, C.R.N.A., Irina Gasanova, M.D.,Ph.D., Girish Joshi, M.D.,
F.C.A.R.C.S.I . Department of Anesthesiology, University of Texas Southwestern, Dallas, TX, USA,
Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA.
A 44 year-old, 4‟11” tall, 61kg, female with unremarkable preoperative examination underwent ERCP in
prone position under general anesthesia. The ERCP was complicated with concerns of esophageal tear
based upon dye extravasation seen on fluoroscopy, but it was determined that no specific intervention
was necessary. After the procedure, she experienced vomiting and shortness of breath. Neck and facial
swelling with crepitus was noted, which was followed by emergent re-intubation. Bronchoscopy and CT
confirmed a 3.5cm posterior tracheal defect requiring primary surgical repair with stent placement.
Postoperative course was complicated by difficulty weaning the ventilator. She was discharged on POD
28.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC900
An Emergency Airway: From the Floor to the OR
William E. Marion, M.D., William B. Somerset, D.O . Anesthesiology, Temple University Hospital,
Philadelphia, PA, USA.
The airway team was called to the floor by the surgical team for emergent intubation of a patient with
tracheal stenosis. Although the patient was in obvious severe distress, she was saturating well on a face
mask at 6 lpm O2. The airway team evaluated available films and disagreed with that diagnosis. The
patient was taken to the OR for bronchoscopy through an LMA. A vascular supraglottic mass was
discovered without subglottic stenosis. The surgeon inadvertently lacerated the mass causing bleeding
and requiring removal of the LMA followed by tracheal intubation.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC901
Perioperative Negative Pressure Pulmonary Edema (NPPE) in ENT Surgery
Zwade J. Marshall, M.D., MBA, Linda S. Aglio, M.D., M.S . Department of Anesthesiology, Perioperative
and Pain Medicine, Brigham & Women's Hospital, Boston, MA, USA, Department of Anesthesiology,
Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
Copyright © 2014 American Society of Anesthesiologists
A 62 year-old obese (115-kg) female with hoarseness presented for laryngeal mass biopsy. Induction was
uncomplicated with a Sheridan 5.0 cuffed endotracheal tube to facilitate surgical manipulation. At
emergence, she was agitated, tachycardic and spontaneously ventilating with low tidal volumes (2cc/kg).
Frothy, pink discharge was suctioned from her endotracheal tube prior to extubation. She became acutely
distressed and progressively hypoxic requiring reintubation. A portable chest x-ray revealed diffuse
interstitial infiltrates and arterial blood gas showed pO2 of 93 on 100% oxygen. NPPE resulting from low
internal diameter endotracheal tubes may cause significant patient morbidity without prompt recognition
and appropriate intervention.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Cardiac Anesthesia (CA) MC902
Intramural Hematoma of the Posterior Wall of the Left Atrium After Cardiopulmonary Bypass:
Should Cardiopulmonary Bypass Be Repeated?
Shusuke Takeshita, Yoshinobu Nakayama, M.D., Hitomi Takemura, M.D., Teiji Sawa, M.D.,Ph.D.,
Yasufumi Nakajima, M.D.,Ph.D . Department of Anesthesiology, Kyoto Prefectural University of Medicine,
Kyoto, Japan.
Here we present the case of an 82-year-old woman with hypertension who presented with symptoms of
left ventricular failure and findings of a left atrial myxoma protruding through the mitral valve orifice.
Intraoperative transesophageal echocardiography after cardiopulmonary bypass (CPB) revealed a small
intramural hematoma in the posterior wall of the left atrium that was not visible on preoperative screening.
Despite the reversal of heparin and hemostatic agents, the hematoma gradually enlarged as the left atrial
chamber collapsed and the patient‟s hemodynamic parameters worsened. The patient underwent
hematoma extraction during a repeat CPB and successfully recovered after surgery.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Cardiac Anesthesia (CA) MC903
Percutaneous Right Atrial Thrombus Removal via Angiovac- A Review and Discussion of the Role
of intraoperative TEE in this case.
Christopher Tam, M.D., Brian Cho, M.D., Thomas Bilfinger, M.D., Igor Izrailtyan, M.D . Anesthesiology,
Stony Brook University Hospital, Stony Brook, NY, USA, Cardiothoracic Surgery, Stony Brook University
Hospital, Stony Brook, NY, USA.
A 28 year old male with HIV, Stage IV B-cell Lymphoma on chemotherapy developed a TIA with left sided
weakness. Patient was subsequently transferred to our hospital for further work up and management. He
was found on TTE to have a large right atrial thrombus measuring at 2.2 cm x 1.5 cm. Patient was at risk
of a fatal thrombotic embolism into the pulmonary artery. Decision was made to remove the thrombus via
a percutaneous Angiovac technique. We will discuss the percutaneous Angiovac procedure and the
importance of intraoperative TEE to control and guide removal of cardiac thrombi.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Cardiac Anesthesia (CA) MC904
Percutaneous Left Atrial Appendage Occlusion in Patients with Atrial Fibrillation- A Review and
Discussion of the LARIAT Procedure and the Utility of Intraoperative TEE
Christopher Tam, M.D., Brian Cho, M.D., Roger Fan, M.D., Igor Izrailtyan, M.D . Stony Brook University
Hospital, Stony Brook, NY, USA.
A 72 year old female with atrial fibrillation on Rivaroxaban, s/p CVA, presented to our hospital with an
upper GI bleed secondary to a duodenal arteriovenous malformation. Patient was at high risk for
thromboembolic event given CHADS2 score and at high risk for repeat bleeding if anticoagulation
continued. Decision was made to perform a LARIAT procedure to decrease risk of left atrial appendage
thrombus and an embolic event from occurring. The patient tolerated the procedure well and was
discharged with no significant sequelae. We will discuss the LARIAT procedure as well as the utility of
TEE during these procedures.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:30 AM - 8:40 AM
Cardiac Anesthesia (CA) MC905
Devastating Paralysis After Thoracoabdominal Aortic Aneurysm Repair Using a Spinal Drain
Stephanie F. Tran, M.D., Saleem Zaidi, M.D . Anesthesiology, University of Texas Health Science Center
- Houston, Houston, TX, USA, Critical Care, Houston Methodist Hospital, Houston, TX, USA.
An active male undergoes elective repair of his thoracoabdominal aortic aneurysm and immediately after
surgery experiences profound sensory and motor defictis along with kidney injury. A spinal drain was
placed preoperatively and although management of the drain in the post-operative course was not idea;
his profound paralysis was more likely due to intraoperative insults.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Cardiac Anesthesia (CA) MC906
Tako-Tsubo Cardiomyopathy In A Middle Aged Woman After Orthotopic Liver Transplantation
Paula Trigo Blanco, M.D., Daniel Kinney, M.D., Ranjit Deshpande, M.D . Yale New Haven Hospital, New
Haven, CT, USA.
Patient is a 47 yo woman with past medical history of HTN and cirrhosis (MELD score 30), thought to be
secondary to EtOH abuse and possible autoimmune etiology. Patient underwent ortothopic liver
transplantation, transferred to SICU postoperatively. On POD#1 patient was uneventfully extubated.
Overnight she became hemodynamically unstable, tachycardic and hypotensive. ECG showed T wave
inversions diffusely. Troponin T was elevated. Transthoracic echocardiogram revealed moderately
decreased left ventricle systolic function (estimated EF 32%) with akinesis of the apex and hypokinesis of
the septum, mid-distal lateral, anterior and inferior walls. Patient briefly required vasopressors but
recovered completely within a week
Monday, October 13, 2014
8:50 AM - 9:00 AM
Cardiac Anesthesia (CA) MC907
Tracheo-esophageal-aortic Fistula on EGD s/p Intra-aortic Stent
Tyson Vandagriff, M.D., JL Reeves-Viets, M.D., MBA. Anesthesiology, University of Missouri, Columbia,
MO, USA.
42 y/o female presented for EGD for toxemia and cough with swallowing and air in the mediastinum three
months after urgent intra-aortic stent, which revealed tracheo-esophageal-aortic fistula with stent visible
and bronchial fistula above the carina. She was converted to emergent left thoracotomy with fem-fem
bypass/profound hypothermia and 40 minute‟s circulatory arrest for replacement of aortic stent with a
Dacron conduit, esophagectomy, and closure of left mainstem bronchial fistula. Amiodorone,
norepinephrine, and epinephrine were used to wean from CPB. POD 3 pt no longer required
hemodynamic support. Pt extubated POD 12, discharged to rehab POD 18 and sustained complete
recovery.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Cardiac Anesthesia (CA) MC908
Ruptured Distal Aortic Arch Aneurysm With Prolonged Circulatory Arrest
Tyson Vandagriff, M.D., JL Reeves-Viets, M.D., MBA. University of Missouri, Columbia, MO, USA.
62 yo male with 6.1x4.5 cm distal arch aneurysm with contained rupture for aortic arch repair with
circulatory arrest and profound hypothermia. Patient underwent 55 minutes circulatory arrest due to
difficult surgical exposure. Post-bypass, he required amiodorone, dobutamine and nicardipine and his
coagulopathy failed standard transfusion therapy requiring factor seven to correct.The patient moved his
upper extremities but not lower extremities on POD3. MRI exhibited innumerable ischemic foci throughout
cerebral hemisphere, cerebellum, and pons suggestive of embolism. By post-op day 8 he demonstrated
marked improvement with GCS 11T, which abruptly deteriorated on POD 13 and care was withdrawn.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
9:10 AM - 9:20 AM
Cardiac Anesthesia (CA) MC909
Pseudoaneurysm of Ascending Aorta with Rupture on Re-do Sternotomy
Tyson Vandagriff, M.D., JL Reeves-Viets, M.D., MBA. Anesthesiology, Univ of Missouri, Columbia, MO,
USA, Anesthesiology, University of Missouri, Columbia, MO, USA.
Patient was 50 y/o male with a history of continued poly-substance abuse presenting s/p CAB with large
pseudoaneurysm of ascending aorta. Planned fem-fem bypass was instituted prior to sternal re-entry,
during which time the pseudoaneurysm ruptured, requiring profound hypothermia while access was
completed and manual control of bleeding achieved. Aortic aneurysm was then repaired directly, along
with oversewing an area near the proximal innominate artery. Post-repair the patient showed continued
signs of bi-ventricular failure, requiring vasopressors and IABP to support weaning. Coagulopathy was
managed with plasma, platelets, cryoprecipitate, and finally factor VII. Recovery was slow but complete.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Cardiac Anesthesia (CA) MC910
Are Two Better Than One? A Case of Bilateral Selective Cerebral Perfusion during Thoracic Aortic
Surgery
Ammar Wahood, M.D., Chiranjeev Saha, M.D . Rush University, Chicago, IL, USA.
59 year old male with history of newly diagnosed chronic lymphocytic leukemia was found to have a 6 cm
ascending aortic aneurysm. The patient underwent repair of the aneurysm and hemi-arch proximal to the
take off of the innominate artery. The brain was perfused with ante grade cerebral perfusion via right
axillary artery. Soon after deep hypothermic cardiac arrest was instituted the cerebral oximetry displayed
significant difference between cerebral hemispheres, this was quickly corrected by a left carotid artery
catheter for bilateral antegrade cerebral perfusion.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC911
Resection of Multiple Large Desmoid Tumors From the Chest Wall, Scapula, and Thoracic
Paravertebral Area in a Patient with Gardner's Syndrome Status Post Small Bowel Transplant
Daniel T. Tamez, M.D., Tony Silipo, D.O . Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA.
Resection of large recurrent desmoid tumor of the scapula, thoracic paravertebral area and chest wall in a
patient with Gardner's syndrome status post small bowel transplant. Additional challenges include
intraoperative orthopedic consult, multiple position changes, management of significant blood loss,
consideration for brachial plexus nerve injury, and one lung ventilation strategies.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC912
Malignant Hyperthermia with Superimposed Hyperbaric Oxygenation
Paul J. Terracciano, M.D . Anesthesiology, Phelps Memorial Hospital Center, Sleepy Hollow, NY, USA.
Malignant Hyperthermia episode occurred under general anesthesia which was masked by prior
hyperbaric oxygen treatment. The patient developed increasing ventilatory pressures. Dantrolene and
malignant hyperthermia hotline called while the protocol 1 thru 7 was instituted. Arterial blood gas after 30
minutes of dantrolene showed pH= 7.05,pCO2=101,paO2=157, Base Excess =4.8. After hyperbaric
oxygen treatment the tissue oxygen/blood tension is 1500mmHg. Urine myoglobin measured 3x normal
amount. Medical record information from family revealed that the maternal grandfather had a problem
with surgery /anesthesia in 1999. New information was analyzed and reflected why this episode
occurred.Patient 100% survived with no abnormalities.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC913
Airway Management for a Cricotracheal Resection in an Adult
Brian D. Terrien, M.D . Anesthesia, Naval Medical Center San Diego, San Diego, CA, USA.
45 y/ofemale with a long history of idiopathic subglottic stenosis (SGS) who had been treated with
multiple endoscopic balloon dilations, steroid injections and topical application of Mitomycin-C. The
patient underwent a cricotracheal resection (CTR) for definitive treatment of her SGS which was
complicated by tracheal dehiscence requiring a tracheostomy and subsequent Montgomery T-Tube
placement, still in place four months postoperatively. This case highlights anesthetic challenges of airway
management of open surgical airway cases. While there is ample surgical literature describing CTR‟s,
scant anesthetic literature exists describing techniques for airway management of this uncommon
surgical procedure.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC914
Airway Management of Levamisole Induced Vasculitis and Necrosis of the Face
Elizabeth Tetteh, M.D., Serge Tyler, M.D . Anesthesia, John H Stroger Cook County Hospital, Chicago,
IL, USA.
We present a case of a 36 year old female with sarcoidosis and long history of cocaine abuse, who was
admitted to the hospital for levamisole induced severe vasculitis of her face, hands, and legs. During her
admission the vasculitis worsened and the affected areas became necrotic. The necrosis severely limited
her mouth opening and prevented access to the nares for intubation. In this medically challenging case
we present successful inhalational induction with subsequent successful oral intubation using direct
laryngoscopy.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC915
Airway Management and Double Lumen Tube Placement in Acute Pulmonary Hemorrhage from a
Tumor Involving Pulmonary Artery
Jacob I. Tiegs, M.D., Laurence Susser, M.D . Anesthesiology, New York University Langone Medical
Center, New York, NY, USA.
52 year old female with stage IV lung cancer and known right hilar lung mass involving pulmonary artery
in hemorrhagic shock due to hemoptysis. Patient intubated in ED and brought to IR for embolization of
offending vessels. Blood was present in airway making visualization difficult. Single lumen ETT
exchanged over tube exchanger for double lumen tube with Glidescope guidance. Fiberoptic scope used
to confirm placement of bronchial lumen in left bronchus. Hemorrhage continued with elevated airway
pressures and intermittent hypoxia with isolated left lung ventilation. Right pulmonary artery cause of
hemorrhage. Patient taken to MICU and expired within 24 hours.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC916
Intraoperative Management of Hyperkalemia in a Patient Undergoing Combined Liver-Kidney
Transplant
Jerry Tee Todd, M.D., Gaurav P. Patel, M.D . Department of Anesthesiology, Emory University, Atlanta,
GA, USA.
A 66-year-old man with end-stage liver disease secondary to hepatitis C and end-stage renal disease
secondary to diabetes presented for a combined liver-kidney transplant. Metabolic panel on the day
before surgery revealed a potassium level of 4.6 mmol/L. A baseline arterial blood gas obtained
immediately after induction showed a potassium level of 6.3 mmol/L. In anticipation of reperfusion, serum
potassium was lowered aggressively with a total of 82 units of insulin and 75 mEq of sodium bicarbonate,
resulting in a level of 4.1 mmol/L just prior to reperfusion. There were no significant cardiac dysrhythmias
during reperfusion.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC917
Goal-directed Fluid Management Based on The Pulse Oximeter-Derived Plethysmograph
Variability (ΔPOP) in Posterior Spine Fusion Surgeries in Children With Scoliosis
Mohamed S. Tolba, M.D., M.Saif Siddiqui, M.D., Anita Akbar, M.D., Edwin Abraham, M.D., Jesus Apuya,
M.D., Muhammad Jaffar, M.D . Anesthesiology, UAMS, Little Rock, AR, USA, ACH, Little Rock, AR, USA.
15-year-old child 50 kg scheduled for posterior spinal fixation secondary to idiopathic thoracolumbar
scoliosis. Anesthesia was maintained with remifentanil and propofol infusion.Ringer‟s lactate (LR) was
infused at 10 ml/kg/hr. We used hemoglobin 7gm/dl as our cut off threshold for blood transfusion. 250 ml
Ringer‟s Lactate or 100 ml albumin was given as a bolus in 10 minutes if Pulse Oximeter-Derived
Plethysmograph Variability (ΔPOP) was higher than 15%. ABG checked hourly to assess the PH and
Lactate level to confirm the tissue perfusion status. At the end of procedure, we stopped TIVA and patient
was extubated completely awake.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC918
Cardiac Arrest after Starting Manual Jet Ventilation In a Patient With Metastatic Lung Cancer
Presented for Endobronchial Ablation
Mohamed S. Tolba, Esam Abdelnaeem, M.D . UAMS, Little Rock, AR, USA.
A 71 y/o WM presented to OR for Bronchoscopic right lower lobe bronchus ablation secondary to
complete occlusion secondary to metastatic lung cancer. Rigid bronchoscope was used for ablation and
ventilation was maintained using manual jet ventilation. Anesthesia was maintained using Propofol and
Fentanyl increments.Few minutes after starting manual jet ventilation, pulse oximeter plethysmograph
waveform became a flat line. Pulse was found to be impalpable. EKG initially did not show any change
but rapidly evolved into VT/VF.Code blue was activated and patient was intubated and CPR started.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC919
Treatment of Post-Operative Pulmonary Edema in a Patient with Undiagnosed Hypertrophic
Obstructive Cardiomyopathy
Mohamed S. Tolba, Esam Abdelnaeem, M.D . UAMS, Little Rock, AR, USA.
A 44-yr-old man was admitted with a stab wound to right thigh. His history was significant for asthma
controlled by albuterol inhaler prn. Anesthesia was maintained using sevoflurane and Fentanyl. In PACU
the patient started to complain of difficulty of breathing, Sao2 dropped to 90% . Patient reported wound
pain of 9/10. Albuterol inhaler and Furosemide 40 mg were given without any improvement. Transthoracic
Echocardiography (TTE) was done and showed septal hypertrophy and mitral regurge. Esmolol infusion
was started and Morphine was given for analgesia, and after 15 min patient started to feel better.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC920
GI Tract and Airway Foreign Objects in the Non-OR Anesthesia (NORA) Setting
Alexander S. Greene, M.D., Patrick McConnville, M.D., Michael Pilla, M.D., Jason Lane, M.D .
Anesthesiology, Vanderbilt University, Nashville, TN, USA.
We describe the perioperative management of a 19 year old developmentally delayed patient who
presented to the Endoscopy Lap for endoscopic removal of gastrointestinal foreign objects (construction
nails) under general anesthesia. Physical exam revealed the patient to have stridor and suspicion for
foreign objects in his airway in addition to his gastrointestinal tract. At time of removal, the patient was
found to have three child toy blocks in/around his glottic opening. This case demonstrates the value of a
detailed anesthesia history and physical exam in the management of foreign body ingestion in the nonOR anesthesia (NORA) setting.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC921
Perioperative Management of Hereditary Angioedema in a Patient Presenting for Emergency
Surgery
Stephen H. Gregory, M.D., Aaron J. Sandler, M.D.,Ph.D . Duke University Medical Center, Durham, NC,
USA.
Hereditary angioedema is a rare disorder characterized by significanttissue edema following minor
trauma, occasionally resulting inlife-threatening airway compromise. We report a case of a 22 yearoldmale with a past medical history of hereditary angioedema presentingvia transfer from an outside
hospital for emergent hand reimplantationafter an industrial accident. The patient reported a history
ofextremity swelling but denied any history of airway symptoms. Hereported several family members with
similar symptoms of varyingseverity. We discuss the preoperative preparation and
perioperativemanagement of a patient with known hereditary angioedema presentingfor an emergent
procedure.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Fundamentals of Anesthesiology (FA) MC922
Intractable Bronchospasm in a Patient with Known Autonomic Dysreflexia Related to
Quadriplegia: Can Epinephrine Be Used Safely?
Ryan C. Guay, D.O., Branko Furst, M.D . Anesthesiology, Albany Medical Center, Albany, NY, USA.
We present a case of management of severe bronchospasm triggered by surgical manipulation of the
airway in a quadriplegic patient with a known history of autonomic dysreflexia. A 55-year-old male with a
medical history of spinal cord transection at T4 level presented to the ED for bleeding from tracheostomy.
The anesthetic management was tailored to the patient‟s history with importance placed on maintaining
spontaneous ventilation and managing changes in hemodynamics. Soon after the case began the patient
developed severe bronchospasm. Multiple therapeutic steps were performed, including the eventual use
of an epinephrine infusion with consideration of its potential hemodynamic consequences.
Monday, October 13, 2014
8:30 AM - 8:40 AM
Fundamentals of Anesthesiology (FA) MC923
Robotic Uvulopalatopharyngoplasty: A Novel Approach for Treatment of Obstructive Sleep Apnea
Joseph R. Guenzer, M.D., Dalia Elmofty, M.D . Anesthesia and Critical Care, University of Chicago
Medicine, Chicago, IL, USA.
A 39 year-old male with severe obstructive sleep apnea (OSA) presented for robotic-assisted lingual
tonsillectomy and uvulopalatophrayngoplasty (UPPP). Robotic surgery is becoming more recognized as
an approach for pharyngeal surgery. A robotic approach for UPPP specifically is novel and entails several
considerations, such as acute worsening of airway obstruction post-operatively, that are of importance for
the anesthesia provider. The patient has a body mass index (BMI) of 25 and uses an oral appliance. The
patient was intubated nasally, the table turned 180 degrees, neuromuscular blockade maintained, and the
patient was successfully extubated over a Bougie.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Fundamentals of Anesthesiology (FA) MC924
Unplanned Liver Auto Transplant During Removal of a Retroperitoneal Mass
Cosmin Guta, M.D., Wagih Gobrial, M.D . Anesthesiology Institute, Cleveland Clinic, Weston, FL, USA.
A 76 yo male with significant PMHx was scheduled for removal of a retroperitoneal tumor.
Intraoperatively, the patient was placed on veno-venous bypass in order to decompress the liver
congestion. The case evolved to an unplanned liver autotransplant. We describe the anesthetic
implications, management and outcome of the unexpected procedure.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:50 AM - 9:00 AM
Fundamentals of Anesthesiology (FA) MC925
Tension Pneumothorax on the Dependent Lung During Video Assisted Thoracoscopy
Cosmin Guta, M.D., George Develasco, M.D., Cherie Fisher, M.D., Anthony Han, M.D. , Wagih Gobrial,
M.D . Anesthesiology Institute, Cleveland Clinic, Weston, FL, USA, Cleveland Clinic, Weston, FL, USA,
Texas Tech University, El Paso, TX, USA.
A 47 yo female without significant PMHx underwent left thoracoscopy for lung biopsy followed by possible
wedge resection. Intraoperatively, after an uneventful DLT placement and patient positioning, she
developed progressive severe hypoxia, unresponsive to standard management. The patient become
hemodynamically unstable, the procedure was stopped and a STAT CXR confirmed a tension
pneumothorax on the dependent lung. After the CT placement, the procedure was resumed and finalized
without further complication. The patient underwent a full recovery postoperatively.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Fundamentals of Anesthesiology (FA) MC926
Anesthetic Management of a Patient With Massive Bilateral Ovarian Cystadenomas
Sara Guzman-Reyes, M.D., Aanchal Sharma, M.D., Glorimar Medina- Rivera, M.D., Erikka Washington,
M.D., Sonya A. Johnson, M.D . Anesthesiology, UTHHSC, Houston, TX, USA, Anesthesiology, UTHSC,
Houston, TX, USA.
Among the ovarian neoplasms, serous cystadenomas being the benign tumor can present with abdominal
distension as an only symptom. If no secondary symptoms occur, patient might delay the consultation of
physicians. However, these massively enlarged ovarian cysts can present with a complex set of
physiologic and surgical challenges. We present the successful anesthetic and surgical management of
45 year old woman who presented with massive bilateral ovarian cystadenomas (107kg). She was not
able to either lie supine or lift herself despite assistance. We focus on use of stepwise planning and
multidisciplinary approach to safe and successful recovery of the patient.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Fundamentals of Anesthesiology (FA) MC927
Anesthetic Management of Right Hemi-Hepatectomy in a Jehovah’s Witness Patient With Lynch
Syndrome
Sara Guzman-Reyes, M.D., Myron H. Arnaud, C.R.N.A., Aanchal Sharma, M.D. , Timothy C. Hollenbeck,
M.D. , Peter Doyle, M.D.. Anesthrsiology, UTHHSC, Houston, TX, USA, Anesthesiology, UTHHSC,
Houston, TX, USA, UTHHSC, Houston, TX, USA, UTHSC, Houston, TX, USA.
The anesthetic management for hepatic resection is a challenging, associated with the potential for major
surgical blood loss and accompanied with the proposition for hemodynamic instability. A 39-year-old male
a devout Jehovah‟s Witness member presented for right hepatectomy for metastatic colon cancer with
genetically confirmed Lynch syndrome. The patient indicated that he accepted death should indicated
blood transfusions be withheld in accordance with his wishes/directives. The risks associated with cell
salvage, with regard to metastatic dissemination, were discussed with the patient. We describe the
management that complicated and challenged conventional approaches of anesthetic management for a
hepatic resection patient.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Fundamentals of Anesthesiology (FA) MC928
Complex Airway Management: The Use of Tracheostomy for the Management of Severe
Obstructive Sleep Apnea
Sara Guzman-Reyes, M.D., Clendeninn J. Dallis, M.D., Timothy C. Hollenbeck, M.D., Yitzchak E.
Weinstock, M.D. . Department of Anesthesiology, UTHHSC, Houston, TX, USA, Anesthesiology,
UTHHSC, Houston, TX, USA, Department of Otorhinolaryngology, UTHHSC, Houston, TX, USA.
We present the case of a 54-year-old, morbidly obese (BMI 42) man requiring surgical tracheostomy for
the management of severe obstructive sleep apnea (OSA) refractory to non-invasive positive airway
Copyright © 2014 American Society of Anesthesiologists
pressure (PAP) therapies.This presented several challenges: oropharyngeal and laryngeal
thrush,patient's refusal to an awake intubation,inability to tolerate the supine position, and extensive
scarring and flap across the anterior neck and thorax from surgical repair of prior burn injuries altering
surface anatomy. We discuss the combined operative and anesthetic strategy for this case given the
patient‟s comorbidities and the sheer complexity of the airway management, post-operative outcomes,
and strategies for improvement.
Monday, October 13, 2014
8:00 AM - 8:10 AM
Fundamentals of Anesthesiology (FA) MC929
Intraoperative ST Elevations in a Healthy Patient Who Underwent a Low-risk Procedure Under
Sedation
Xun Zhu, M.D . Mayo Clinic, Rochester, MN, USA.
A 62 year old construction worker without significant PMHX received supraclavicular block as primary
anesthetic for right wrist arthrodesis. After two hours of tourniquet application, ST segment elevations
were noted. Patient was asymptomatic and hemodynamically stable. Tourniquet was deflated and ST
changes were resolved. Post-Operative Troponins returned negative but echocardiogram showed
significant reduced function of EF 30% with commensurate left ventricular dilatation. The patient admitted
heavy Alcohol drinking history. The patient likely presented with compensated alcohol cardiomyopathy
rather than coronary artery disease. He was started on lisinopril and metoprolol and will be followed up in
heart failure clinic.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Neuroanesthesia (NA) MC930
Normal Motor Evoked Potentials and Somato-Sensoryevoked Potentials in a Patient with Acute
Intramedullary Hematoma
Cristina Barboi, M.D., Richard J. Toleikis, Ph.D., Raquel Hernandez, D.O . Anesthesiology, Rush
University, Chicago, IL, USA.
IOM is effective in predicting an increased risk of adverse outcomes during spinal surgery. We describe a
case where SSEPs and MEPs remained present in a patient with a cervical intramedullary hematoma. A
48 year old woman presented for cervical facet steroid injection. Postprocedure she reported numbness,
pain and weakness in the right upper extremity. A CT showed a cervical intramedullary hyperdensity, an
MRI of the cervical spine demonstrated an intramedullary hematoma. Emergency cervical decompression
was performed under general anesthesia. Post induction SSEPs and MEP remained normal. In this case
IOM failed to detect long tract sensory and motor dysfunction.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Neuroanesthesia (NA) MC931
Acute Severe Hypokalemia During Emergency Craniotomy for Subarachnoid Hemorrhage
Vibhuti Kowluru, M.D., Gebhard Wagener, M.D . Columbia University Medical Center, New York, NY,
USA.
Two patients (27 and 50-years) presented with new-onset seizures due extensive subarachnoid
hemorrhages. Both patients received one to three doses of mannitol 1g/kg and two to five doses of
hypertonic saline prior to emergent craniotomy. Initial potassium levels were 3.2 and 2.8 mmol/L but
intraoperatively they decreased to 1.9 and 1.7 mmol/L despite aggressive potassium replacement therapy
and severe metabolic acidosis. No arrhythmias ensued but both patients never regained mental function
and subsequently died.Acute hypokalemia after subarachnoid hemorrhage is poorly understood and
probably mutlfactorial. In this case presentation, we will review existing data and explore possible
physiologic explanations.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
8:30 AM - 8:40 AM
Neuroanesthesia (NA) MC932
Urgent Thoracic Laminectomy for Suspected Epidural Hematoma in a Patient With a History of
Diabetes Mellitus Type I, Chronic Regional Pain Syndrome and Myelopathy
John Kroger, B.S., Michael P. Hofkamp, M.D . Texas A&M Health Science Center College of Medicine,
Round Rock, TX, USA, Anesthesiology, Baylor Scott & White Health, Temple, TX, USA.
We present a 40 year old female with a history of chronic regional pain syndrome (type 1) and deep
venous thrombosis of the right upper extremity, diabetes mellitus type 1 and progressive myelopathy with
a suspected epidural hematoma who was scheduled for urgent thoracic laminectomy. Complicating
factors included difficult vascular access, the prone position and a questionable arteriovenous
malformation discovered intraoperatively. The surgeon requested monitoring of motor evoked potentials;
a balanced anesthetic technique consisting of inhaled sevoflurane and continuous intravenous infusions
of propofol and remifentanil was employed. After extubation, there was a small delay in obtaining a
reassuring neurological exam.
Monday, October 13, 2014
8:40 AM - 8:50 AM
Neuroanesthesia (NA) MC933
Resection of Acromegalic Patient's Growth Hormone Secreting Pituitary Macroadenoma in
Intraoperative MRI Suite
Andrew Weiss, M.D., M.S., Roshan Raban, M.D., FRCPC, Ryan Amadeo, M.D., FRCPC. University of
Manitoba, Winnipeg, MB, Canada.
A 60 year old female presented with a short history of headache and vision changes and was noted to
have pronounced cheekbones, an enlarged jaw, macroglossia, a deepened voice and enlarged digits.
These features had, in retrospect, developed over the previous two years. She was found to have a
pituitary macroadenoma and was booked for surgical resection of the tumour in an intraoperative MRI
suite with intraoperative neurophysiological monitoring. Her airway exam suggested a likely difficult
intubation, but MRI safety protocols mandate minimizing (and counting) all magnetic objects that enter the
suite. We describe our strategy for maximizing safety.
Monday, October 13, 2014
8:50 AM - 9:00 AM
Neuroanesthesia (NA) MC934
Indications, Anesthetic Protocol, and Outcomes for Patients Undergoing Deep Brain Stimulation:
Tourette Syndrome Case Study
Mourad M. Shehebar, M.D., Irene P. Osborn, M.D . Mount Sinai Medical Center, New York, NY, USA.
Deep Brain Stimulation (DBS) is a staged surgical treatment for certain disease processes, including most
notably Parkinson‟s but has been used for Tourette‟s, refractory depression, dystonia, and essential
tremors. Equivalent to a brain pacemaker, DBS electrodes send impulses to specific regions of the brain
while being calibrated and optimized by neurologists. During stage one, or the awake stage, scalp blocks
are performed, head-clamp is applied, intra-operative imaging is completed and subsequently dura is
exposed via burr holes. We present a case study of a patient with severe Tourette Syndrome successfully
undergoing three stages of DBS utilizing our unique anesthetic protocol.
Monday, October 13, 2014
9:00 AM - 9:10 AM
Neuroanesthesia (NA) MC935
Anesthetic Management of Patient with Asphyxiating Thoracic Dystrophy (Jeune Syndrome)
Heng Wu, M.D., Daniel Medel, M.D., Ronald Samson, M.D . Jackson Memorial Hospital, Miami, FL, USA.
The patient is a 55 year old male with Asphyxiating Thoracic Dystrophy (Jeune Syndrome) who presented
to the Neurosurgical operating roomfor anterior cervical corpectomy and fusion. Due to his rare condition,
thepatient‟s thoracic cavity was severely reduced in size, and his lungvolumes and pulmonary excursion
were extremely poor. The syndrome also impairs his renal function, his surgical history includes kidney
transplants on two separate occasions. Preoperatively, the patient notified us that a prior surgery required
Copyright © 2014 American Society of Anesthesiologists
a postoperative re-intubation for respiratory failure. The patient tolerated the surgery and prone
positioning well and was extubated without incident.
Monday, October 13, 2014
9:10 AM - 9:20 AM
Neuroanesthesia (NA) MC936
Anesthetic Management of an Emergency Cesarean Section and Craniectomy in a Parturient with
Glioblastoma Multiforme
Peter D. Yim, Zafeer Baber, M.D., Suzanne Mankowitz, M.D . Columbia University, New York, NY, USA.
A 28-year-old G2P1 presented at 34 4/7 weeks with multiple syncopal episodes and seizures. MRI
showed large left parieto-occipital mass concerning for Glioblastoma Multiforme . The patient was taken
emergently to the OR for Cesarean Delivery following an ictal episodes with fetal asystole. Surgery was
performed under general anesthesia with a rapid sequence intubation. Following the surgery the patient
remained non-responsive with a dilated pupil and was emergently taken back for a craniectomy and
partial tumor debulking. The patient‟s post-operative course was complicated by autonomic storm,
streptococcus bacteremia, and a DVT leading to death.
Monday, October 13, 2014
9:20 AM - 9:30 AM
Neuroanesthesia (NA) MC937
Anesthetic Management of Ovariectomy in 3 Patients with Anti-N-methyl-D-aspartate Receptor
Encephalitis
Kaoru Yoshimatsu, M.D., Takashi Hakusui, Jiro Kurata, M.D.,Ph.D., Koshi Makita, M.D.,Ph.D .
Anesthesiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan, Department of Anesthesiology,
Tokyo Medical and Dental University, Tokyo, Japan.
Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an auto-immune disease that presents
variety of neurological disorders such as seizure, coma, and respiratory depression. While resection of an
associated ovarian tumor is often indicated, there remains much uncertainty regarding safety of general
anesthetics because they might modify the function of the affected NMDAR. Here we describe anesthetic
management of ovariectomy in 3 women with anti-NMDAR encephalitis. Sevoflurane, propofol,
remifentanil, and fentanyl were all tolerated without any major adverse events. We will discuss current
rationales for drug selection in those patients in light of pharmacological interaction with NMDAR.
Copyright © 2014 American Society of Anesthesiologists
MCC Session Number – MCC10
Monday, October 13, 2014
11:30 AM - 11:40 AM
Obstetric Anesthesia (OB) MC1000
Klippel-Trenaunay Syndrome: A Danger Foreseen Is a Danger Avoided
Avneep Aggarwal, M.D., Danny Wilkerson, M.D . Department of Anesthesiology, University of Arkansas
for Medical Sciences, Little Rock, AR, USA.
A 25-year-old G1P0 at 39 weeks with a history of Klippel-Trenaunay Syndrome presented for induction of
labor for preeclampsia. She was diagnosed at age of 16. She had a port wine stain on her back and
hypertrophy of her right thigh. She never had any thrombosis. She never had any imaging of her spine
done. After discussion with obstetrician and patient, it was decided to get magnetic resonance imaging of
her spine done so that she can have epidural or spinal analgesia, if possible. MRI showed an ill-defined
lesion from T10 to L2 suggestive of vascular malformation.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Obstetric Anesthesia (OB) MC1001
IVUS and TEE- Guided Endovascular Repair of Descending Aortic Aneurysm in a Pregnant Patient
Oscar D. Aljure, M.D., Katherine Hoctor, M.D., Edward Gologorsky, M.D., Daria Moaveni, M.D . University
of Miami / Jackson Memorial Hospital, Miami, FL, USA.
37 year old G3P2002 at 22 weeks with a thoracic aortic peudoaneurysm at the subclavian artery (5.1 cm)
and an additional aneurysm of the ascending aorta. Connective tissue workup was negative.
Intraoperatively flow through left hypogastric artery was maintained to sustain uterine perfusion. IVUS
utilized to guide graft deployment and to allow measurement of appropriate sizing of endograft . IVUS,
TEE, and spot fluroscopy were utilized to confirm deployment. No contrast was used, with limited
radiation exposure. An interdisciplinary approach for DAA repair in pregnancy is paramount. Utilization of
intraoperative TEE and IVUS allowed avoidance of contrast and minimization radiation.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC1002
Continuous Stroke Volume and Pulse Pressure Variation Analysis in a Surgical Patient with
Diastolic Heart Dysfunction
Benjamin S. Maslin, M.D., Aymen Alian, M.D . Anesthesiology, Yale University School of Medicine, New
Haven, CT, USA.
An 84-year-old male with moderate-to-severe diastolic heart dysfunction presented for
cystoprostatectomy. Stroke volume variation (SVV) with esophageal Doppler and arterial waveform pulse
pressure variation (PPV) were continuously monitored. Episodes of hypotension (MAP<60) with fluid
responsiveness (> 13% SVV and PPV) were stabilized after periodic 200 cc crystalloid and 100 cc 5%
albumin boluses. After a cumulative 600 cc blood loss, parameters suggested continued fluid
responsiveness. A unit of PRBCs was administered, after which SVV and PPV suggested decreased fluid
responsiveness. Subsequently, the patient maintained hemodynamic stability and a negligible base
deficit. He was extubated and had an uneventful post-operative course.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC1003
Emergent Laparotomy in a Patient Treated With Apixaban for Atrial Fibrillation
Luke B. McBride, M.D., Garry A. Johnson, M.D., Douglas C. Bankhead, M.D . Anesthesiology and
Perioperative Medicine, University of Missouri, Columbia, MO, USA.
Copyright © 2014 American Society of Anesthesiologists
An 80 year old female treated with apixaban for atrial fibrillation presented with peritonitis. She was taken
to the operating room for emergent laparotomy. After induction of general anesthesia, a central line was
placed causing excessive bleeding. There is no approved reversal agent for apixaban. 53 units per
kilogram of Feiba was administered through the central line. Surgical incision was made and the
abdomen entered without excessive bleeding. Thirty minutes into surgery, the patient began to bleed near
and remote from surgical dissection and became hypotensive. Supportive care with vasoactive drugs,
fluid resuscitation and massive transfusion protocol was initiated.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC1004
Delayed Emergence Status-Post Total Hip Arthroplasty in a Patient with Severe Asthma, COPD,
Hepatitis and Suspected Parkinson’s Disease
Kimberly I. McClelland, M.P.H., Clairmont E. Griffith, M.D . Howard University Hospital, Washington, DC,
USA.
A 59-year-old man with a history of asthma, COPD, Hepatitis C, and alcohol abuse underwent a total hip
arthroplasty due to osteonecrosis. Months prior to surgery, the patient endorsed orthostatic hypertension
and gait disturbance. Despite having ASA and Mallampati scores of III, the patient‟s pre- and intraoperative courses were uneventful and he was placed under general anesthesia with propofol,
desflurane, fentanyl and rocuronium. The patient was difficult to arouse 90 minutes post-operatively and
was sent to the PACU, where he was extubated approximately 30 minutes later, for a total of two hours of
delayed awakening from anesthesia.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC1005
Efficient Vascular Access in a Hypovolemic Trauma Patient
Kimberly I. McClelland, M.P.H., Clairmont E. Griffith, M.D., Besrat Mesfin, M.D., Darren R. Heath, C.S.A. ,
David A. Rose, M.D. Howard University Hospital, Washington, DC, USA.
A 25-year-old man status-post multiple GSWs to the abdomen, scrotum and lower extremities was
brought into the ED and noted to be combative, agitated, diaphoretic, intoxicated and hypotensive.
Bilateral dorsalis pedis pulse signals were not appreciated via Doppler ultrasound, and previously failed
attempts at arterial access resulted in bilateral upper extremity hematomas, necessitating the
identification of alternate vascular access points using sonographic guidance. Additionally, omental
evisceration was observed upon admission, and the patient underwent an emergent exploratory
celiotomy, with the primary intraoperative concern being the repeated failure of the patient‟s A-line during
the extensive procedure.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC1006
Placement and Confirmation of Central Line in a Patient with VACTERL Association with
Abnormal Cardiovascular Anatomy
Brian S. McClure, D.O., Ashraf Farag, M.D., Cooper Phillips, M.D . Anesthesiology, TTUHSC, Lubbock,
TX, USA.
A twelve year old female with VACTERL association with known cardiovascular abnormalities presented
for a large pelvic reconstruction surgery. Central venous access was determined to be necessary due to
the length and extent of the surgical plan and difficult peripheral access. An IJ was placed after induction
of general anesthesia. This case demonstrates the placement and confirmation of a CVL including
identification of left sided vena cava using bedside ultrasound, blood gas, chest x-ray and transthoracic
echocardiography.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC1007
Rapid Atrial Fibrillation during Induction
Copyright © 2014 American Society of Anesthesiologists
Joseph T. McRuiz, M.D . University of Connecticut Health Center, Farmington, CT, USA.
68 year old man presenting for low anterior resection for colon cancer. He has a history of chronic atrial
fibrillation on coumadin which was stopped five days ago and atenolol which he did not take the morning
of surgery. He also had a history of two beers a day. Induction was carried out with propofol, fentanyl and
followed by rocuronium. Before laryngoscopy, the patient went into rapid atrial fibrillation to 170s, which
was unresponsive to esmolol, and eventually lowered to the 110s through metoprolol and dilaudid. The
case was cancelled and the patient placed on a cardizem drip.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC1008
Airway Emergency After Tracheal Resection
Maria L. Mendoza, M.D., John Doyle, M.D.,Ph.D . Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.
40 year old male scheduled for total thyroidectomy and tracheal resection with primary anastomosis.
Medical history was significant for Grave‟s disease and severe asthma. Ten months before surgery he
had an episode of thyrotoxicosis requiring intubation; complicated by tracheal injury and subsequent
subglottic stenosis. Patient was intubated by ENT surgeons with rigid bronchoscope. Anesthesia was
maintained with isoflurane, propofol and remifentanil. Intraoperative course was uneventful. Immediately
post-extubation he developed a neck hematoma, incision was opened and airway was secured with
supraglottic airway rather than a tracheal tube, avoiding harm to the fresh tracheal anastomosis. The
hematoma was evacuated without reintubation.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC1009
Unexplained Shock In A Patient Undergoing Posterior Spinal Fusion After Ondansetron
Administration
Jessika D. Michael, Itay Bentov, M.D.,Ph.D . Anesthesiology and Pain Medicine, University of
Washington, Seattle, WA, USA.
A 69-year-old female with history of HTN, Smoking, Asthma, Anxiety, and Lumbar Stenosis underwent
Lumbar 4-5 Discetomy/PSIF/PLIF. Preoperative ECG and functional status were normal. The
intraoperative course was uneventful except for hypotension and bradycardia after turning prone.
Immediately following ondansetron administration (during skin closure), the patient developed prolonged
QT, junctional bradycardia and hypotension that were hypothesized to be 5-HT3 receptor agonist induced
Bezold Jarisch reflex but were inexplicably resistant to glycopyrolate, atropine, vasopressin, ephedrine,
phenylpehrine, and fluid resuscitation. She was effectively treated with glucagon and later disclosed selfprescribing an overdose of Propranolol to relieve her anxiety preoperatively.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC1010
Metastatic Pheochromocytoma Requiring Internal Hemipelvectomy: A Case Report of Intraoperative Management
Daniela Micic, M.D., Mona Kulkarni, M.D . Department of Anesthesiology, University of Southern
California, Los Angeles, CA, USA.
A 55 year-old female with history of left adrenalectomy for pheochromocytoma presents with metastatic
disease requiring internal hemipelvectomy. Pre-operatively, phenoxybenzamine therapy was initiated and
echocardiogram showed moderate diastolic dysfunction.Pre-induction vital signs were BP 142/98 and HR
67. An awake arterial line was placed, followed by smooth induction and intubation. Central access was
obtained. Blood pressure was labile (90-140s/40-70s), unresponsive to phenylephrine. Norepinephrine
infusion, and intermittent vasopressin were used for refractory hypotension. Intra-operatively, patient
received 4L crystalloid, 500mL 5% albumin, 2 PRBC. Urine output was 75mL, blood loss 350mL. On
POD1, pressors were weaned and the patient was successfully extubated.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
10:30 AM - 10:40 AM
Cardiac Anesthesia (CA) MC1011
Line-associated DVT Removal with Novel AngioVac Aspiration Device via Fontan and Glenn
Shunts
Chonghua Wang, M.D., Steven Tham, M.D., John Moriarty, M.D., Komal Patel, M.D . University of
California at Los Angeles, Los Angeles, CA, USA.
Patient with fenestrated Fontan repair developed PICC-line associated venous thrombus warranting
removal to prevent paradoxical embolus. Patient underwent DVT removal in IR suite with novel AngioVac
aspiration system which uses 22F percutaneous venous cannula with suction tip and veno-venous
bypass. Due to the location of the thrombus, removing it required passing a large cannula through her
cardiac shunts, which interfered with venous return and cardiac output. Her chronic renal insufficiency,
recent treatment for CHF exacerbation, pacemaker dependency with temper-perm wires in right IJ and
heparin allergy made the management more challenging. Thrombus removal was successful with no
residual thrombi.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Cardiac Anesthesia (CA) MC1012
Anesthesia Management for Minimal Incision Mitral Valve Replacement
Meng Wang, M.D.,Ph.D., Harold A. Fernandez, M.D., Igor Izrailtyan, M.D.,Ph.D . Stony Brook University
Hospital, Stony Brook, NY, USA.
This case report describes anesthetic management of a 61 year-old female undergoing a minimal incision
mitral valve replacement (MI MVR). Left and right arm arterial pressure monitors, endoballoon for aortic
clamping, percutaneous coronary sinus catheter for retrograde cardioplegia, PA catheter for heartdecompression, and cerebral oximeter were all utilized to ensure cardiac and cerebral protection against
ischemia. Patient underwent an uneventful surgery and recovery and was discharged in 6 days. Our case
report describes the intra-operative management of MI MVR and reviews the evolution, various options
for cannulation/aortic clamping and the crucial role of TEE and fluoroscopy for this particular approach.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Cardiac Anesthesia (CA) MC1013
Embolization of a Primary Cardiac Synovial Sarcoma Leading to Emergent Vascular Intervention
for Acute Limb Ischemia in an 18-year-old
Lisa Weaver, M.D., Amar Bhatt, M.D., Hamdy Awad, M.D . Wexner Medical Center at The Ohio State
University, Columbus, OH, USA.
An 18-year-old male with no PMH presented to an outsidehospital for a cold, painful right leg.He
underwent thrombectomy and right lower extremity fasciotomy for abilateral iliac artery saddle
embolus.Postoperative TTE revealed a left ventricular mass and he presented toour facility for emergent
resection via aortotomy, on cardiopulmonarybypass. Intraoperative TEE revealed alarge pericardial
effusion and a 6x4cm mass originating from the papillarymuscle. The mass obstructed the leftventricular
outflow tract, causing a ball-valve effect through the aorticvalve. The patient tolerated the operation well,
and the final histopathologyshowed a poorly-differentiated synovial sarcoma.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Cardiac Anesthesia (CA) MC1014
Liver and Kidney Transplant in Patient with Incidental Finding of Severe Aortic and Mitral Stenosis
and Severe Mitral Regurgitation on Intraoperative Transesophageal Echocardiogram
Brittany L. Willer, M.D., Neil Matthey, M.D., Sheila Ellis, M.D . Anesthesiology, University of Nebraska
Medical Center, Omaha, NE, USA.
Liver transplantation is a unique surgery fraught with hemodynamic, electrolyte, and coagulation profile
fluctuations that provide a challenge to even the most experienced anesthesiologists. To reduce
perioperative cardiac-related morbidity, most patients undergo extensive preoperative workup to exclude
severe ischemic or valvular disease. Here we describe the incidental finding of severe aortic stenosis and
Copyright © 2014 American Society of Anesthesiologists
severe mitral regurgitation and stenosis on intraoperative transesophageal echocardiogram during a liver
transplant (with a normal pre-transplant cardiac workup just 4 months prior), recount the patient‟s
anesthetic management, and discuss the potential hemodynamic consequences of such lesions during
the three phases of the surgery.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Cardiac Anesthesia (CA) MC1015
Upper Extremity Neuropathies Post Cardiac Surgery
Emily M. Williams, M.D., Krithika Anand, M.D., Chen Thay Chau, M.D., Ioanna Apostolidou, M.D .
University of Minnesota, Minneapolis, MN, USA.
Upper extremity neuropathy that leads to permanent disability is a serious threat after cardiac surgery. It
has been reported to occur in up to 24% of cardiac cases. It is frequently under diagnosed, unreported
and ignored after cardiac surgery. We would like to report 4 recent cases of upper extremity peripheral
neuropathy that were diagnosed by physical therapy, imaging, or neurologic examination and describe
the process of diagnosis, management, and outcome. We could like to increase awareness of upper
extremity neuropathies after cardiac surgery and identify opportunities that might help to prevent or
decrease their incidence.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Cardiac Anesthesia (CA) MC1016
Transesophageal Echocardiographic Diagnosis of Right Ventricular Inflow Obstruction by Multiple
Right Atrial Vegetations During ICD Lead Extraction
Colleen E. Wirtz, D.O., Michael Essandoh, M.D . The Ohio State University Wexner Medical Center,
Columbus, OH, USA.
The use of Implantable Cardioverter Defibrillators (ICDs) has increased during the last decade.
Approximately 0.06-0.6% of these devices will present with infective endocarditis, and 37% will have
coexisting tricuspid valve involvement. This report illustrates a case of infective endocarditis that involved
not only the ICD lead, but also the tricuspid and eustachian valves. The large vegetations caused
functional inflow obstruction and hemodynamic instability during attempted lead extraction. We highlight
the importance of the use of not only transthoracic, but also transesophageal echocardiography for the
confirmation of vegetation size, location, and its intraoperative importance to avoid serious complications.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Cardiac Anesthesia (CA) MC1017
Anesthetic Management of a Hybrid Approach to Trans-catheter Pulmonary Valve Replacement in
a Previously Repaired Tetralogy of Fallot Patient
Robert W. Wong, M.D., Lorraine Lubin, M.D . Anesthesia, Cedars Sinai Medical Center, Los Angeles, CA,
USA.
15 year old male born with tetralogy of Fallot s/p transannular patch repair as an infant. Although the
patient was asymptomatic, a cardiac MRI showed severe pulmonary valve regurgitation with right
ventricular dilatation. Initial evaluation for percutaneous Melody valve placement was deferred given the
enlarged size and tortuosity of the pulmonary artery. A hybrid approach was then planned with placement
of a Melody valve within a stent combination. A subxiphoid, per-ventricular approach was used to access
the right ventricle, a stent was placed within the tortuous pulmonary artery to provide a secure landing
strip for the melody valve.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Cardiac Anesthesia (CA) MC1018
Massive Fatal Intraoperative Pulmonary Embolism with Paradoxical Embolism
Na Yang, M.D., Luiz F. Maracaja, M.D., Helen V. Lauro, M.D . Anesthesia, SUNY Downstate Medical
Center, Brooklyn, NY, USA.
Copyright © 2014 American Society of Anesthesiologists
A 60 years old woman presented for elective hysterectomy. General Anesthesia induction, intubation and
maintenance were uneventful until the uterus was lifted from the abdominal cavity. Patient developed
sudden onset of bradycardia, hypotension, severe hypoxemia and cyanosis with EtCO2 below 10 mmHg.
Intraoperative TEE revealed massive intracardiac embolism involving the all 4 cardiac chambers,
pulmonary artery and multiple mobile emboli in the LV, LVOT across the aortic valve, hypokinetic RV and
akinetic LV. Despite performing ACLS protocol, multiple high dose vasopressors drip and tPA bolus
infusion, patient remained in pulseless electric activity and pounced dead after 40 min CPR.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Cardiac Anesthesia (CA) MC1019
Aortic Valve Replacement in an Fetal Alcohol Syndrome Patient with Prior Ventricular Septal
Defect Repair
Na Yang, M.D., Helen Logginidou, M.D . Anesthesia, SUNY Downstate Medical Center, Brooklyn, NY,
USA.
A 35 year old woman, severely disabled from inborn Fetal Alcohol Syndrome, history of childhood VSD
repair, presents for Redo-Sternotomy Aortic Valve Replacement. Patient weight 38 kg with classic
dysmorphic facial features which awake fibroptic intubation was performed for difficult airway. TEE
revealed severe AS with PDA. Aortic valve was replaced under total 105 min of cardiopulmonary bypass
time. Patient was disconnected from CBP with minimal vasopressors support, but developed TRALI
during second unit of PRBC transfusion which progress to severe ARDS in the postoperative period.
Patient had very complicated ICU course, and expired in 2 weeks despite aggressive treatment.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC1020
A Supraglottic Lesion Causing "Ball-valve" Respiratory Mechanics in a Patient Needing Emergent
Laparotomy
Luis E. Tollinche, M.D . Department of Anesthesiology and Critical Care, Memorial Sloan Kettering
Cancer Center, New York, NY, USA.
58 year old male with history of squamous cell cancer of pyriform sinus who previously received radiation
and adjuvant chemotherapy; now presents with recurrence of disease in hypopharynx. History of difficult
intubation secondary to radiation and surgery of his oropharynx and now demonstrates ball-valve
respiratory mechanics as a result of his supraglottic lesion. He requires emergent laparotomy for repair of
dislodged gastrostomy tube. Given the competing interests and risks of induction of general anesthesia,
the patient would require awake fiberoptic intubation. No sedation could be given. Pt was successfully
intubated fiberoptically with assistance of head and neck surgery.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC1021
Large Anterior Mediastinal Mass and Positive Pemberton's Sign in a Patient Undergoing
Thyroidectomy
Paula Trigo Blanco, M.D., Christopher Szabo, M.D., Hossam Tantawy, M.D . Yale New Haven Hospital,
New Haven, CT, USA.
A 64-year-old man presented for total thyroidectomy for a symptomatic multinodular goiter with positive
Pemberton‟s sign. Patient reported voice changes and neck pressure when lying down, with no real
difficulty breathing or swallowing. Workup revealed multiple large thyroid nodules with no apparent airway
compression. Equipment (fiberoptic and rigid bronchoscopes, tracheal tubes of various sizes) was ready
for immediate use. Anesthesia was induced with sevoflurane with preservation of spontaneous
respiration. A size 7 tracheal tube was inserted easily. Bilateral breath sounds were confirmed, and
mechanical ventilation started without issues. Surgery was uncomplicated and patient was uneventfully
extubated at the end.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC1022
Perioperative Considerations for Resection of a Large Carotid Body Tumor Invading the Right
Internal Carotid Artery
Dam-Thuy Truong, M.D., Dilip Thakar, M.D., Stephen Lai, M.D. , Angela Truong, M.D . University of
Texas MD Anderson Cancer Center, Houston, TX, USA.
A 65-year-old female presented for resection of a large carotid body tumor causing 70% obstruction of the
right internal carotid artery. Medical history included a previous subarachnoid hemorrhage. Preoperative
investigation for pheochromocytoma was negative. There was no cranial nerve involvement. Preoperative
tumor embolization was done to minimize blood loss. Intraoperative EEG was used for brain function
monitoring. Blood products were available for potential massive blood loss. A shunt was placed during
tumor resection and vascular reconstruction. Surgery was uneventful. Postoperatively, the patient was
closely monitored for hypoxia and hypercarbia due to potential intraoperative injuries to carotid
baroreceptor and chemoreceptors.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC1023
Right Atrial Herniation Following Right Extrapleural Pneumonectomy: Risk Factors, Diagnosis and
Management
Dam-Thuy Truong, Dilip Thakar, M.D., Angela Truong, M.D . Anesthesiology & Perioperative Medicine,
University of Texas MD Anderson Cancer Center, Houston, TX, USA.
A 63-year-old man with mesothelioma underwent right extrapleural pneumonectomy and pericardiectomy.
The pericardial defect was repaired with a Dexon mesh pericardial patch. The patient was transferred to
the ICU. On the first postoperative day he developed tachycardia and hypotension. Chest radiograph
showed a mass in the right hemithorax. Cardiac herniation was confirmed by echocardiography. On
exploratory thoracotomy, the right atrium was found to be herniated superiorly through the pericardial
opening. The heart was repositioned inside the pericardial cavity. Hemodynamic parameters rapidly
improved. Dacron patch was used to close the pericardial defect. The patient was returned to ICU in good
condition.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC1024
Securing Airway in a Patient With Large Retropharyngeal/Prevertebral Abscess
Alice Tsao, M.D., Vyacheslav Belous, D.O . Anesthesiology, Riverside County Regional Medical Center,
Moreno Valley, CA, USA.
57 YO male coming for incision and drainage of large retropharygeal/prevertebral abscess. Patient was
obese, had recent onset pneumonia, but was awake with stable vital signs. MRI showed 10x3 cm
abscess located from C1 to C6 prevertebrally, with possible communication to spinal canal and a C5-6
disc collapsed. Our anesthetic goals were to minimize the chance of abscess rupture and maintain
spontaneous respiration. We chose Dexmedetomidine sedation, balanced with Sevoflurane, then
intermittent bolused Ketamine/Propofol to achieve smooth airway inspection and intubation with
Glidescope.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC1025
A Simple and No-Cost TSE-Alloteh Nasal CPAP/CF Mask/Circuit Improved Oxygenation in a HighRisk OSA Patient with Coagulopathy under Propofol Sedation during Upper GI Endoscopy
James T. Tse, M.D.,Ph.D., Amanda Doucette, M.D., Andrew Burr, D.O., Tanya Milask, C.R.N.A., Dennis
B. Hall, M.D., Rose Alloteh, M.D., Alexandra Nicholas, B.S., Christine Hunter Fratzola, M.D .
Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
71 y/o man with dyspnea, ascites, cirrhosis, esophageal varices, thrombocytopenia, coagulopathy, BMI
30 kg/m2 and OSA presented for urgent EGD. After pre-oxygenation (NC O2 4 L/min+TSE “Mask”), he
Copyright © 2014 American Society of Anesthesiologists
was sedated with propofol (75-150 mcg/kg/min). His airway was obstructed during difficult endoscope
insertion. O2 saturation dropped from 99% to 85%. An infant mask was placed over his nose and
connected to anesthesia breathing circuit/machine. O2 saturation increased to 96% with assisted nasal
ventilation (4 breaths). He resumed spontaneous respiration with 3-5 cm H2O CPAP with 100% O2
saturation (0.8 FiO2) and tolerated well despite difficult EGD and capsule insertion.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC1026
An Infant Face Mask Improved Nasal Ventilation in an Obese Adult Patient by a Petite Anesthesia
Resident during General Anesthesia Induction
James T. Tse, M.D.,Ph.D., Viviana Freire, M.D., Christine Curcio, M.D., Sylviana Barsoum, M.D.,
Christine Hunter Fratzola, M.D., Rose Alloteh, M.D., Myroslav Figura, B.S., Shaul Cohen, M.D .
Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
40 y/o female (BMI 35 kg/m2) with Class IV airway presented for laparoscopy. She was pre-oxygenated
lying on 20 degree incline. After GA induction, anesthesia resident couldn't obtain adequate face-mask
seal with both small hands for anesthesia attending to ventilate patient without or with oral airway. With
oral airway, attending could easily ventilate her alone. An infant mask with well-inflated air cushion was
quickly placed over patient‟s nose, resident closed her mouth and obtained tight nose-mask seal with left
hand and easily ventilated her with right hand. She was intubated using video-laryngoscopy and
maintained 99-100% O2 saturation throughout.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC1027
Marfan's Patient going for Nasal Reconstruction
David W. Tunick, M.D., Adam Levine, M.D . Anesthesiology, MSSM, New York, NY, USA, MSSM, New
York, NY, USA.
55 year old with Marfan‟s and a history of multiple brain and aortic aneurysms status post repair going for
nasal reconstruction. Review of the literature found nothing regarding risks of arterial cannulation in
patients with Marfan's. However, given the fragility of their arteries, we thought the risk of placing an
arterial line and potentially damaging the artery outweighed the benefits in this patient who has been
stable status post aneurysm repairs. This strategy made it vital to maintain stable hemodynamics
throughout the case. To accomplish this, we used a remifentanil infusion and asked the surgeons not to
inject any epinephrine.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC1028
Perioperative Considerations For Alternating Left and Right Bundle Branch Blocks
Channing C. Twyner, M.D., Arun Subramanian, Sonia Jain. Mayo Clinic, Rochester, MN, USA, Mayo
Clinic, Rochester, MN, MN, USA.
An 88-year-old male with dilated cardiomyopathy (EF 36%) and cerebrovascular disease presented for
surgical management of fractured femoral neck. Baseline ECG demonstrated left bundle branch block
(BBB) and PR prolongation of 240 milliseconds. Subsequent ECG showed right BBB and left axis
deviation. Alternating BBB is a marker of significant conduction system disease and portends a high risk
of progression to complete atrioventricular block. An A-V pace-port pulmonary artery catheter was
electively placed and good ventricular lead capture ensured before induction of anesthesia. Surgical and
postoperative course was uneventful. Permanent pacemaker was recommended. Anesthetic implications
of perioperative alternating BBB are reviewed.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC1029
This Sux: Dastardly PChE Deficiency, Infiltrated IVs, and Troublesome Tourniquets
Copyright © 2014 American Society of Anesthesiologists
Gregory M. Halenda, M.D., Emily L. Sturgill, M.D., Colleen M. Moran, M.D . Anesthesiology, University of
Pittsburgh Medical Center, Pittsburgh, PA, USA.
We present a unique case of pseudocholinesterase deficiency. A 21 year old man with history of IV drug
abuse and poor venous access presented for urgent drainage of a hand abscess under general
anesthesia. On induction an IV infiltration led to an unknown amount of succinylcholine being deposited in
the operative arm. A tourniquet was placed proximal to the infiltration. At the conclusion of surgery, the
patient experienced delayed awakening. Diagnosis and management of pseudocholinesterase deficiency
was more difficult in the context of the IV infiltration and tourniquet use.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC1030
Patient with Conn’s Syndrome- Intraoperative Management of Resistant Hypertension and
Hypokalemia
Michelle Han, M.D., Jennifer White, M.D., Marisa Bell, M.D., Duraiyah Thangathurai. LAC+USC, Los
Angeles, CA, USA.
Our patient is a 53 year old female who underwent a robotic left adrenelectomy for Conn‟s syndrome that
was resistant to medical management. Our patient had poorly controlled hypertension and electrolyte
derangements including hypokalemia and hypernatremia due to a single aldosterone secreting adrenal
adenoma. General anesthesia was induced with fentanyl, propofol, and maintained with isoflurane.
Intraoperative control of blood pressure was achieved with nitroglycerin and nicardipine infusions and
normokalemia with aggressive intravenous repletion of potassium. The patient tolerated the case well,
was titrated off both infusions and was extubated at the end of the case.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC1031
Prolonged Paralysis After Succinylcholine- Oral Contraceptive may be the Culprit
Michelle Han, Clara Espi, M.D., Shveta Jain, M.D . LAC+USC, Los Angeles, CA, USA.
We present a case of prolonged paralysis after succinylcholine administration. Our patient is a 38 year old
female with neurofibromatosis II who underwent facial reanimation under general anesthesia. TOF
twitches returned without fade at 60 minutes post succinycholine administration. Patient‟s dibucaine
number resulted at 84.7% inhibition (normal: 81.6-88.3% inhibition). However, our patient had decreased
serum cholinesterase levels at 1934 IU/L (normal: 2673-6592 IU/L). We hypothesize that our patient‟s
serum cholinesterase level was decreased due to oral contraceptives which are known to have a
quantitative effect on serum cholinesterase levels.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC1032
Parotidectomy in a Patient with Arnold-Chiari Syndrome
Sarah E. Hartlage, M.D., M.S., Marina Varbanova, M.D . University of Louisville, Louisville, KY, USA.
Arnold-Chiari malformation Type I is a congenital or acquired anomaly of downward displacement of the
lowermost portion of the cerebellum. It commonly presents in adults with symptoms related to
hydrocephalus or syringomyelia. Other features may include scoliosis, oculomotor disturbances, syncope,
spasticity, paraparesis, or respiratory failure. Patients may have difficult airway and are at risk of
neurologic deterioration during anesthesia. We present a case of a 79 year old gentleman with ArnoldChiari malformation and syringomyelia who required parotidectomy and neck dissection for suspected
metastatic melanoma. We systematically review risks associated with the syndrome and include
discussion about monitoring and management strategies.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC1033
Successful Crisis Resource Management, Cognitive Aid, and “Reader” Utilization in Malignant
Hyperthermia
Copyright © 2014 American Society of Anesthesiologists
Whitney D. Helgren, Marjorie Stiegler, M.D., Robert Isaak, D.O . Anesthesia, University of North Carolina
at Chapel Hill, Chapel Hill, NC, USA.
We present a 47-year-old Lumbee Indian male who developed tachycardia, extreme hypercarbia, and
severe muscle rigidity during emergence from a volatile general anesthetic for a 1% burn. Using the
clinical grading scale recommended by MHAUS1, we had an “almost certain” case of malignant
hyperthermia. As a result of the early recognition and deliberate utilization of crisis resource management
techniques2, cognitive aids3, and a “reader,”4 he had an excellent outcome, with complete resolution of
acidosis (peak 7.14/84/140/27.3) within 6 hours, and downtrending creatinine kinase within 18 hours.
Interestingly, there may be a familial predisposition amongst Lumbee Indians, a locally concentrated
heritage.5,6
Monday, October 13, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC1034
Emergent Anesthesia In an LVAD Patient
Mada F. Helou, M.D., Ehab S. Farag, M.D., John Kanaan, M.D . Anesthesiology, Cleveland Clinic
Foundation, South Euclid, OH, USA, Cleveland Clinic, Cleveland, OH, USA.
Fifty two year old male with history of non-ischemic cardiomyopathy (EF 15%), destination Heartmate II
LVAD, atrial fibrillation, hypertension, hyperlipidemia, obesity, restrictive lung disease, obstructive sleep
apnea, and GI bleed who presents for repair of incarcerated hernia. Standard ASA monitors, arterial line,
central line. Induction with versed, fentanyl, lidocaine, etomidate & rocuronium. Maintenance with
Sevoflurane. Patient was taken intubated to the Cardiovascular ICU, sedated on low dose propofol.
Challenges included true understanding of LVAD physiology, maintenance of normovolemia without
inducing fluid overload, and avoidance of an increase in SVR to ensure proper LVAD function.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC1035
VATS Procedure Complicated by Acute Heart Failure and Flash Pulmonary Edema
Yohel Hernandez Jimenez, M.D., Venkat R. Mangunta, M.D., Tanya Lucas, M.D . Anesthesiology, Umass
Medical School, Worcester, MA, USA.
A 61 year-old male with a Hx of PVD, Hypertension and COPD with poor medical care underwent a right
upper lobe wedge resection for a pulmonary nodule. Surgery was uneventful until emergence, when the
patient developed severe hypertension. He was extubated with adequate tidal volumes and oxygen
saturation. The hypertension was treated with multiple medications. Patient was stable with adequate
oxygen saturation however he suddenly desaturated, requiring reintubation. Oxygen saturation low
despite reintubation and 100% FiO2. We present a case of flash pulmonary edema, management,
outcomes, and a review of the current literature.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC1036
The Art of Improvisation: Difficult Airway Management With Limited Resources Outside of the
Operating Room
Blair H. Herndon, M.D., Priya A. Kumar, M.D., Earl W. Weyers, M.D., Harendra Arora, M.D .
Anesthesiology, University of North Carolina Health Care, Chapel Hill, NC, USA.
We describe the case of an unanticipated difficult airway in an emergency intubation in the Surgical ICU.
The patient‟s neck was restrained in a c-collar following a motor vehicle accident. Intubation attempts with
direct laryngoscopy and video laryngoscopy, holding in-line stabilization, were unsuccessful. Fiberoptic
intubation of the trachea was eventually achieved with a 6.0 ETT through a size 3 LMA. A 5.0 ETT was
then used as a “pusher” to remove the LMA. We will discuss the challenges of difficult airway
management in remote locations outside of the operating room and describe some unconventional
techniques which may be helpful.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC1037
Evidence Based Prehospital Management of Chest Trauma
Kenneth N. Hiller, Ashley Upton, M.D . Anesthesiology, The University of Texas at Houston Medical
School, Houston, TX, USA, Anesthesiology, University of Texas at Houston Medical School, Houston, TX,
USA.
21-year-old ejected from motor vehicle experienced head and chest injuries. Unrecognized esophageal
intubation led to subsequent bradycardic arrest that progressed to pulseless electrical activity. CPR and
bilateral chest decompression led to return of spontaneous circulation. Prehospital pericardiocentesis
performed by flight team. On hospital arrival, penetrating object in right upper quadrant visible and moving
with each heartbeat. Chest tomography revealed penetrating cardiac object with pneumoperitoneum.
Massive transfusion protocol initated. In operating room, surgical dissection showed needle traversed left
lobe of the liver, diaphragm, right ventricle, and terminated in the interventricular septum. Large bore
needle removed under direct vision contained dried blood.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Cardiac Anesthesia (CA) MC938
The Use of Transesophageal Echocardiography in Type B Aortic Dissection with Rupture into the
Right Hemithorax
Catherine Kuza, M.D., Elifce Cosar, M.D . Anesthesiology, University of Massachusetts Medical School,
Worcester, MA, USA.
We present a 72-year-old man with uncontrolled hypertension who presented with back pain.
Computerized tomography angiogram demonstrated an acute type B aortic dissection with fusiform
enlargement at the distal arch and right mediastinal hematoma, compatible with aortic rupture.
Transesophageal echocardiography (TEE) was used throughout the procedure, to ensure the wire was in
the true lumen, and guided endograft deployment into the thoracic aorta. We discuss the patient‟s
presentation, intraoperative anesthetic management, and postoperative course. We will review current
literature on the benefits and limitations of TEE use during endovascular repair of a type B aortic
dissection.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Cardiac Anesthesia (CA) MC939
Right Ventricular Failure from Plaque Rupture in Off-Pump Coronary Artery Bypass Graft Surgery
Catherine Kuza, M.D., Elifce Cosar, M.D . Anesthesiology, University of Massachusetts Medical School,
Worcester, MA, USA.
We present a 60-year-old male with an inferior ST elevation myocardial infarction who underwent left
internal mammary artery to left anterior descending artery off-pump coronary artery bypass graft surgery
(CABG). The procedure was complicated by a severe intraoperative right ventricular infarction and
dysfunction. He was taken for emergent cardiac catheterization and found to have plaque rupture distal to
the mammary anastomosis. He was then returned to the operating room for on-pump bypass lesion
repair. We describe the presentation, diagnosis, intraoperative management, postoperative outcome, and
literature review of off-pump CABG complications.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Cardiac Anesthesia (CA) MC940
Sinus Venosus Atrial Septal Defect with Partial Anomalous Pulmonary Venous Connection in an
Adult: A Case Report of Intraoperative Management
John J. Lee, M.D., Mona Kulkarni, M.D., Jayesh Patel, M.B.,B.S . USC, Los Angeles, CA, USA.
24-year-old woman with pulmonary hypertension, chronic dyspnea presents for atrial septal defect
closure. Pre-operative echocardiogram showed pulmonary artery pressure 70/19, mild tricuspid and mitral
regurgitation, sinus venosus atrial septal defect, normal ejection fraction.Pre-induction BP 124/68, HR 54.
Awake arterial line, followed by smooth induction, mild hyperventilation, intubation. Central access, PAC,
Copyright © 2014 American Society of Anesthesiologists
TEE were placed. Blood pressure was low (MAP 50) after bypass, with suprasystemic pulmonary artery
pressures (120). Epinephrine, milrinone infusions, inhaled nitric oxide were used for refractory pulmonary
hypertension and right heart strain. Intra-operatively, patient received 1000mL 5% albumin, 4 PRBC,
plasmalyte 2000mL. Urine output 700mL. Stable to ICU.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Cardiac Anesthesia (CA) MC941
A Severe Acute Intracardiac and Pulmonary Artery Thrombosis During Post-cardiopulmonary
Bypass Period
Hongyi Lei, Ph.D., Zhiqiang Chen, Xiaoping Ye, M.D., Hongfei Zhang, Ph.D., Shiyuan Xu, M.D., Jingping
Wang, M.D . Department of Anesthesiology, Zhujiang Hospital, Southern Medical University, Guangzhou,
China, Massachusetts General Hospital. Harvard Medical School, Boston, MA, USA.
A 53-years-old woman with a history of tricuspid valve incompetence underwent tricuspid valvuloplasty.
After the artificial tricuspid implanted and cardiopulmonary bypass (CPB) on, protamine was used to
neutralize heparin. The right ventricle and atrium were found swallow and blood pressure down to
40mmHg without pulse, no response to epinephrine. Reheparinization was immediately performed and
return to CPB. Massive thrombosis in the right atrium, right ventricle and pulmonary artery were detected.
After removal of the thrombosis, and separation from CPB, epinephrine and noradrenaline were used to
maintain the blood pressure. We discuss the early detection and management for acute intracardiac
thrombosis.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Cardiac Anesthesia (CA) MC942
Saccular Thoracoabdominal Aortic Aneurysm: An Extremely Rare Complication of Systemic BCG
Infection
Jingyi Li, M.D., Shreyajit Kumar, M.D . Anesthesiology, New York Presbyterian Weill Cornell, New York,
NY, USA.
A 70 year old male received Bacillus Calmette-Guerin (BCG) immunotherapy for bladder cancer. Over the
following months, he developed weight loss, malaise, and thunderclap chest pain. Workup revealed
systemic BCG infection with a saccular (likely mycotic) thoracic aortic aneurysm concerning for rupture.
Tuberculosis treatment was initiated and urgent thoracoabdominal aneurysm repair undertaken.
Anesthetic management involved one lung ventilation, ICP monitoring, and continuous cardiac output
monitoring. In the OR, the patient had severe ST depressions and vasoplegia refractory to high
vasopressors. He required postoperative ionotropic support but recovered with full neurologic function.
Nucleic acid testing of aneurysm tissue confirmed tuberculosis.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Cardiac Anesthesia (CA) MC943
Post Induction STEMI in a Patient with Drug Eluting Stent Thrombosis after Clopidogrel
Withdrawal Due to Cervical Spine Trauma
Lei Li, M.D., Abdel Ragab, M.D., Mark Poler, M.D., Michael Entrup, M.D., Xianren Wu, M.D . Geisinger
Medical Center, Danville, PA, USA.
A 56-year-old male with HTN, CAD s/p DES stent (LAD, 7/2012), IDDM, morbid obesity, CRI, prior ACDF
C4-C7 (2003) was scheduled for ACDF C2-C4 secondary to trauma-induced central cord syndrome.
Clopidogrel was withheld 7-days. He had an episode of nonsustained VT 20-minutes post induction with
dropping of BP, Sat and ETCO2. EKG revealed STEMI across the precordial leads with inferior ST
depression; TEE revealed akinesis in anterior-anteroseptal wall. Angiogram showed occlusion of the midLAD artery. 2 BMS were emergently placed in mid-and-distal LAD. Patient had a complicated recovery
including tracheostomy and PEG tube placed day 17.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
11:30 AM - 11:40 AM
Cardiac Anesthesia (CA) MC944
Bronchoscopy for Biopsy of Large Hilar Mass Compressing Corina and Superior Vena Cava
James F. Lincoln, M.D., Velvet Patterson, D.O., Mario Gonzalez, D.O . Anesthesiology, Hahnemann
University Hospital, Philadelphia, PA, USA.
65 year old African-American female with history of heart failure ejection fraction 5-10%, severe COPD,
diabetes, hypertension, OSA admitted for COPD exacerbation. CT chest shows right hilar soft tissue
mass 10 x 7 x 6cm markedly compressing SVC, carina, and right mainstem bronchus. Patient unable to
lie supine secondary to dyspnea. Patient scheduled for bronchoscopy by pulmonology with cardiothoracic
surgery standby. Patient airway anesthetized with nedublized 4% lidocaine and viscous lidocaine. Pt
sedated with midazolam and ketamine, titrated for spontaneous respirations. Bronchoscopy performed in
sitting position. Patient tolerated procedure well, breathing spontaneously throughout and following
commands.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Cardiac Anesthesia (CA) MC945
Careful With Those Leads: Sternotomy Leading to Cardiac Arrest in a Pacemaker-Dependent
Patient
Melanie M. Liu, M.D., Terence Rafferty, M.D . Anesthesiology, Yale-New Haven Hospital, New Haven,
CT, USA.
A 55 yo M with complete heart block presented for redo sternotomy and mitral valve replacement.
Preoperatively, his pacemaker was reprogrammed to asynchronous mode. Sheath introducer and PA
catheter placement were unsuccessful due to SVC stenosis. During median sternotomy, the patient
experienced sudden asystolic cardiac arrest. Chest compressions were immediately begun. Pacemaker
interrogation showed no change from preoperative settings. Femoro-femoral cardiopulmonary bypass
was emergently initiated. Examination of the sternotomy site revealed transection of all pacing wires. The
remainder of the procedure was uneventful, and the patient was admitted to ICU hemodynamically stable
and with new epicardial pacing wires in place.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Cardiac Anesthesia (CA) MC946
Cardiac Arrest During Balloon Aortic Valvuloplasty
Melanie M. Liu, M.D., Trevor Banack, M.D . Anesthesiology, Yale-New Haven Hospital, New Haven, CT,
USA.
An 87 yo F with severe aortic stenosis presented for TAVR. During balloon valvuloplasty, ST segment
elevations developed followed by cardiac arrest. Chest compressions were begun, epinephrine was
given, and femoro-femoral cardiopulmonary bypass (CPB) was initiated. Initial weaning from CPB was
successful on epinephrine infusion. During PA catheter placement, the patient went into v-fib arrest
resistant to defibrillation. Subsequent chest compressions resulted in deformation of the prosthetic valve
and RV rupture. CPB was restarted with epinephrine, milrinone, dobutamine, and vasopressin infusions
required for separation from CPB due to RV hypokinesis. She was admitted to the ICU and expired hours
later.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Critical Care Medicine (CC) MC947
The Great Awakening. Unexpected and Sudden Recovery From Toxic Metabolic Encephalopathy
in a 61-Year-Old Status Post Ivor Lewis Esophagectomy and Wedge Resection, Subsequently
Found to Have a 10cm Esophagopleural Fistula
Melissa Potisek, M.D., Janakiram Ravulapati, M.D . Anesthesiology, University of North Carolina at
Chapel Hill, Chapel Hill, NC, USA.
A 61 year old female with severe achalasia presented for Ivor Lewis Esophagectomy and RLL wedge
resection. On POD 2, patient developed hypoxic respiratory failure, was intubated, and was found to have
Copyright © 2014 American Society of Anesthesiologists
a large right pulmonary artery embolism. On POD 3, her neurologic exam was significant for inability to
follow commands or move extremities, which persisted when sedation was held. Her course was
subsequently complicated by feculent drainage from her right thoracostomy tube, persistent fever despite
broad spectrum antibiotics, hypotension requiring vasoactive infusions, and acute respiratory distress
syndrome. On POD 18, patient suddenly opened her eyes and began following commands.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Critical Care Medicine (CC) MC948
Emergency Intubation in Patient with Endobronchial Stent
Sajith K. Rai, M.D., Matthew Draughon, M.D., Prasad Atluri, M.D . Department of Anesthesiology, Michael
E. Debakey V A Medical Center; Baylor College of Medicine, Houston, TX, USA, Department of
Anesthesiology, Michael E. Debakey V A Medical Center; Baylor College of Medicine, Houston, UT, USA.
The use of endobronchial stents are becomingincreasingly more common in the management of patients
with both benign and malignant airway diseases.In our case, a lung cancer patient with an in situ
endobronchialsilicone Y-stent had a code blue event and required emergent intubation. . We learned that
effective communication, understanding the stent types and their complications, and bronchoscopic
visualization of the trachea and stent and careful guidance of the ETT into position are all important in
securing the airway in these patients
Monday, October 13, 2014
10:50 AM - 11:00 AM
Critical Care Medicine (CC) MC949
The Unusual Case of A Broken-Hearted Patient
Vaidy S. Rao, M.D., Amanda R. Gomes, M.D., Nathan J. Smith, M.D . Anesthesiology, Oklahoma
University Health Sciences Center, Oklahoma City, OK, USA.
A 66 year old female undergoing elective umbilical hernia repair experienced rapid deleterious
cardiovascular collapse requiring intraoperative epinephrine and dobutamine infusions with eventual
discontinuation of the procedure. Immediate perioperative TTE performed by anesthesia was suggestive
of RV dilation. After a seven day stay in the MICU, an extensive cardiology workup suggested stressinduced cardiomyopathy. Also known as Takotsubo cardiomyopathy or broken-heart syndrome,
perioperative reporting has become more prevalent since the mid 2000s. We propose a review over the
collective diagnostic, therapeutic, and epidemiological literature may prove highly valuable for
anesthesiologists and intensive care physicians managing these complex and unusual cases.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Critical Care Medicine (CC) MC950
Sevoflurane in the Treatment of Refractory Status Asthmaticus in the Adult Population
Rahul Sarna, M.D . Anesthesiology, University of Connecticut, Hartford, CT, USA.
A 42 y.o. female with history of severe persistent asthma and multiple intubations was admitted for acute
respiratory failure due to status asthmaticus. She was intubated in the ER and treated aggressively with
nebulizers, IV steroids and Heliox. The patient‟s respiratory status deteriorated and blood gases depicted
worsening Pa02 despite 100% Fi02. Patient received trial of general anesthesia with sevoflurane at 1
MAC for 4 hours. Serial blood gases showed improvement in Pa02 along with decreases in peak airway
pressure. Physical exam revealed resolution of wheezing. The Fi02 was weaned and the patient was
successfully extubated a few days later.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Critical Care Medicine (CC) MC951
Management of Refractory Psychosis in a Young, Postoperative ICU Patient
Leslie A. Schornack, M.D., Bret Alvis, M.D . Department of Anesthesiology, Vanderbilt University,
Nashville, TN, USA.
A 35 year old female presented for a laparoscopic gastric bypass. Her intraoperative course was
complicated by a right renal vein injury, resulting in unexpected massive blood loss requiring a massive
Copyright © 2014 American Society of Anesthesiologists
transfusion and an emergent exploratory laparotomy with a repair of the renal vein. She was extubated
POD #1; however, within 5 hours she became acutely agitated and disoriented. Despite numerous antipsychotic and sedation medication regimens attempted, the patient continued to have refractory agitation
and psychosis. On post-operative day 3, her psychotic episode resulted in a massive aspiration event of
gastric content that, ultimately, led to her demise.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Critical Care Medicine (CC) MC952
Anesthetic Management of a Giant Hepatic Hemangioma Associated with Pulmonary and Cardiac
Compromise.
Gretchen A. Schultz, M.D., Courtney Jones, M.D . Anesthesiology, University of Cincinnati, Cincinnati,
OH, USA.
47 yo woman with a 24cm, symptomatic right lobe hepatic hemangioma presented for right hepatectomy
after an aborted attempt eight years prior. The hemangioma had increased in size and was causing right
atrial compression, displacement of the IVC and portal vein, and near total compression of the right lung.
Right atrial compromise was confirmed by intraoperative TEE. Anesthetic course was complicated by a
23L blood loss and severe coagulopathy. This case illustrates intraoperative management of a patient
with extrathoracic cardiac and pulmonary compression in the setting of massive intraoperative blood loss.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Critical Care Medicine (CC) MC953
Anesthetic Management of a Case of Multi-Visceral Transplantation
Mohamed A. Shaaban, M.D . General Anesthesiology - Fellow of Liver Transplantation Anesthesiology,
Cleveland Clinic Foundation, Cleveland, OH, USA.
I wish to present a case of multi-visceral transplantation in a 37 years old patient, patient received the
following organs: Stomach, duodenum, pancreas, intestine, liver, right kidney. Patient's history is
remarkable for HIV, HCV, ESLD,esophageal varices with TIPS, ESRD, Short Bowel syndrome after
Bowel Ischemia. The presentation will include pre-operative evaluation, intraoperative management and
post-operative course and complications.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Critical Care Medicine (CC) MC954
Rhabdomyolysis in the Presence of Massive Acute Pulmonary Embolism
Pradeep S. Singanallur, M.D., Venugopal Reddy, M.D . Pennsylvania State University Hershey Medical
Center, Hershey, PA, USA.
A 30 year-old former drug addict with multiple abdominal surgeries, prior pulmonary embolism (PE), and
poor compliance with anti-coagulation underwent prophylactic placement of an IVC filter before
abdominal wall reconstruction for enterocutaneous fistula. Post-operatively, the patient had acute onset of
obtundation and severe hypotension and needed resuscitation. Imaging indicated massive PE. Venous
duplex ultrasound was performed and indicated multiple large thrombi bilaterally in deep veins of the
lower extremities. Presence of myoglobin in the patient‟s urine prompted a serum check of myoglobin and
CPK, which were grossly elevated. A diagnosis of rhabdomyolsis was made, and the patient received
appropriate treatment.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Critical Care Medicine (CC) MC955
Paradoxical Fat Embolism Causing Delayed Awakening and Encephalopathy During Isolated
Femur Fracture Nailing
Arian A. Smalley, M.D., David E. Dahl, M.D., Patrick McConville, M.D., Allen Sirizi, M.D . UTMCK,
Knoxville, TN, USA, Anesthesiology, UTMCK, Knoxville, TN, USA.
21M ASA 1 with no prior medical history underwent uneventful left proximal IM nail following traumatic
isolated femur fracture. Following a trial of extubation, he suffered delayed awakening and required
Copyright © 2014 American Society of Anesthesiologists
reintubation and workup. The only positive finding after head CT and chest x-ray was mild pulmonary
edema. Repeat imaging studies the following weeks revealed multiple tiny infarcts globally on head MRI
consistent with fat embolism syndrome. The patient continued to be encephalopathic with mild cognitive
improvement throughout his three week hospitalization. Therapy was mainly supportive. He had full
cognitive return at discharge from a skilled nursing facility five weeks later.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Ambulatory Anesthesia (AM) MC956
Suspected Carbon Dioxide Embolism During Pneumoperitoneum for Outpatient Laparoscopic
Cholecystectomy
Melissa L. Byrne, D.O . Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
We present the case of an obese 38 year-old female with symptomatic cholelithiasis scheduled for
laparascopic cholecystectomy in the ambulatory surgical setting. Following uneventful rapid-sequence
induction, the Veress needle was inserted and low-flow insufflation of carbon dioxide initiated.
Approximately one minute after insufflation, the patient‟s end-tidal carbon dioxide fell precipitously from
32 to 4 mmHg and subsequently, the patient became hypotensive, cyanotic and pulseless consistent with
inadvertent venous carbon dioxide embolus. ACLS was initiated and the patient was successfully
resuscitated. Using this case, we will discuss the detection and management of clinically significant gas
embolism during laparoscopic surgery.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Ambulatory Anesthesia (AM) MC957
Can Intraoperative Hypertensive Emergency Always Be Avoided During Resection of Aggressive
Pheochromocytoma: A Case Report
Praveen Chahar, M.D., F.C.A.R.C.S.I., John Jerabek, D.O . Cleveland Clinic, Cleveland Clinic, OH, USA.
We present a case of a 55 year old Male with past medical history of Hypertension, Hyperlipidemia,
Depression, Neurofibromatosis, Diabetes and Pheochromocytoma scheduled for laparoscopic resection
of Pheochromocytoma. Preoperatively he had extremely high levels of catecholamines (> 1000 times
normal).The patient was adequately prepared with alpha and beta blockade with phenoxybenzamine and
atenolol. Intraoperative course during handling of tumor was marked by hypertensive emergency with
extremely high levels of blood pressure (Systolic blood pressure >300mmhg) leading to extensive use of
vasodilators and labile blood pressure.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Ambulatory Anesthesia (AM) MC958
MAC Sedation for a Patient with Challenging Airway
Kailian chen. Maimonides medical center, Brooklyn, NY, USA.
27 years male with history of osteogenesis imperfecta, short stature, wheelchair bound, hypertension,
moderate obstructive sleep apnea and multiple spinal surgeries, was scheduled dental restoration and
extraction. Airway exam showed: Mallampati III, short thyromental distance, limited range of motion of
neck and barrel shaped rib cage. The procedure was performed under MAC with moderate sedation with
2mgs midazolam and 50mcg of fentanyl. Patient responded to verbal commands during the procedure.
Intermittently small boluses of propofol was administered for deep sedation as required. However, patient
was easily arousable and responded purposefully, following commands
Monday, October 13, 2014
11:00 AM - 11:10 AM
Ambulatory Anesthesia (AM) MC959
Dexmedetomidine for Ambulatory Center Breast Procedures in the Obese Patient
Franklin B. Chiao, M.D . Department of Anesthesiology, New York Presbyterian Medical Center-Weill
Cornell Medical College, New York, NY, USA.
An elderly obese female with anxiety presented for excision of a breast lesion. Given the patients
concerning airway exam and weight, there was risk for obstruction. With the patient's high level of anxiety,
Copyright © 2014 American Society of Anesthesiologists
the perioperative team wanted to keep patient sedated deeply enough to avoid patient movement or
recall. A combined propofol and dexmedetomidine technique was used successfully for the case.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Ambulatory Anesthesia (AM) MC960
Trocar Insufflation of the Bladder in a 50-year-old Patient Having Laparoscopic Surgery
Franklin B. Chiao, M.D., Kristen Fardelmann, M.D . Department of Anesthesiology, New York
Presbyterian Medical Center-Weill Cornell Medical College, New York, NY, USA.
A 50 year old female with migraines presented for laparoscopic removal of an adnexal cyst. Thirty
minutes after starting the surgery, the foley was expanded greatly in a balloon-like fashion. Urine also
became tinted with a red color. After notifying the surgeon and performing diagnostic work, urology was
called to repair trocar induced bladder perforation. There have been only a small amount of cases
reported in the literature.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Ambulatory Anesthesia (AM) MC961
Diagnosis and Management of Intrathecal Injection Following Retrobulbar Block
Alexander D. Cohen, M.D., Gustavo Lozada, M.D . Anesthesiology, Tufts Medical Center, Boston, MA,
USA.
57F with hypertension and OSA presented to a tertiary care center for pars plana vitrectomy under
retrobulbar block with MAC. Approximately 5 minutes after retrobulbar block with 50% lidocaine-50%
bupivicaine patient became acutely anxious, then unresponsive with a HR in the 40s. The patient was
ultimately diagnosed with intrathecal local anesthetic injection resulting in brainstem anesthesia. This is a
complication for this procedure, occurring with frequency as high as 1 in 350 injections. Given the rarity of
the event, and the increasing frequency that anesthesiologists are asked to take part in these cases the
diagnosis and management are increasingly relevant.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Ambulatory Anesthesia (AM) MC962
Acute Epistaxis in a Patient with Hereditary Hemorrhagic Telangiectasia in the Prone Position in
the Endoscopy Suite
Meghan Cook, M.D., Uma Sasso, M.D . Anesthesiology, The Ohio State University Wexner Medical
Center, Columbus, OH, USA.
Hereditary hemorrhagic telangiectasia (HHT) is an inherited disorder with incomplete capillary
development resulting in significant bleeding complications. This case describes a 78-year-old man with
HHT presenting for removal of an infected biliary stent in the endoscopy suite. After induction he was
intubated orally and turned prone. Almost immediately, the patient suffered acute epistaxis thought to be
provoked by prone positioning despite adequate padding. He was quickly placed supine and managed
with emergent otolaryngology assistance. Given the high incidence of epistaxis in this patient population,
it is reasonable to attempt endoscopy procedures supine.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Ambulatory Anesthesia (AM) MC963
Stiletto Challenges in Anesthesia!
Sanjeev Dalela, M.B.,B.S., Zalak Patel, M.D., Shvetank Agarwal, M.D., Manuel Castresana, M.D., Anshu
Dalela, M.D. . Anesthesiology and Perioperative Medicine, Georgia Regents University, Martinez, GA,
USA, Georgia Regents University, Augusta, GA, USA, Brookdale University Medical Center, Brooklyn,
NY, USA.
22 yr female was emergently brought to the OR for removal of a stiletto from the patient‟s left eye.The
patient was hit with a stiletto shoe and the heel remained inserted in the patient‟s left eye with its sole
covering most of the facial structures. Patient also had a full stomach with alcohol intoxication.After
airway topicalization,she was successfully intubated with a fiberoptic scope. We present the challenges
Copyright © 2014 American Society of Anesthesiologists
encountered in securing an airway with very limited access to the face and airway due to iatrogenic
foreign body in a patient with a full stomach, and an intraocular injury.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Ambulatory Anesthesia (AM) MC964
A Case Report: Mitochondrial Disorders and General Anesthesia
William D. Deskins, M.D., Daisy Sangroula, M.D . Anesthesia, University of Louisville, Louisville, KY,
USA.
Patients with mitochondrial disease frequently require GA throughout their workup, however, data is
limited on the safety of anesthetics in these patients. Because these patients are at risk of metabolic
decompensation, delivery of anesthesia safely can be challenging. This case report presents a 35 year
old Caucasian female with a known mitochondrial DNA mutation having a thyroid lobectomy. After
thorough evaluation of the patient‟s comorbidities and literature review, a ketamine, dexmedetomidine,
sufentanil, and remifentanil induction was used followed by remifentanil and nitrous oxide for
maintenance. The patient tolerated GA well and experienced no complications.
Monday, October 13, 2014
8:10 AM - 8:20 AM
Fundamentals of Anesthesiology (FA) MC965
ST Elevation MI in a Patient During Noncardiac Surgery
Ari S. Balofsky, M.D., Sonia Pyne, M.D . Anesthesiology, University of Rochester Medical Center,
Rochester, NY, USA.
We present the case of a patient who experienced an intraoperative ST elevation myocardial infarction
(STEMI) complicated by profound bradycardia and hypotension during elective noncardiac surgery. Rapid
evaluation by assessment of the clinical situation and 12 lead electrocardiogram allowed for prompt
treatment with immediate cardiac catheterization and stenting of the occluded artery. The anesthesia care
team provided continuous care from the onset of the elective surgery through the completion of the
cardiac intervention in the cardiac catheterization lab. Despite his challenging intraoperative course, the
patient was discharged home two days later in good condition.
Monday, October 13, 2014
8:20 AM - 8:30 AM
Regional Anesthesia and Acute Pain (RA) MC966
Cement Syndrome & Hip Hemiarthroplasty: Intraoperative Management of patient with Severe
Pulmonary Hypertension
Ilan Margulis, M.D., Minda Patt, M.D., Tiffany Tedore, M.D., Angela Selzer, M.D., Caroline Buhay, M.D .
Weill Cornell Medical College, New York, NY, USA.
90 yo female presenting for hip hemiarthroplasty with PMH significant for severe pulmonary hypertension
(PA sys>95mmHg), Atrial Fibrillation, NSTEMI , Pacemaker and kyphoscoliosis. Cement syndrome is a
known complication associated with hemiarthroplasty which can result in morbidity and mortality
associated with increased pulmonary pressures. Given baseline severe pulmonary hypertension and
tenuous right heart function, there was significant concern for the potential of cement syndrome
intraoperatively. Monitoring included a preinduction arterial line and initiation of Milrinone. Central venous
access obtained, an epidural catheter placed for analgesia and the patient received a general anesthetic
for controlled ventilation. Inhaled nitric oxide was available.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Fundamentals of Anesthesiology (FA) MC967
Laryngeal Mask Airway for Balloon Dilation and Resection of High‐grade Proximal Tracheal
Stenosis via Laryngeal Mask Airway
Susan C. Darrah, M.D., Jay Roby, M.D . Anesthesiology, USC, Los Angeles, CA, USA.
Patients with severe tracheal stenosis can be challenging to the anesthesiologist. Historically, a distal
intubation technique has been the gold standard for airway management. In cases of severe stenosis
where passage of even the smallest endotracheal tube is unfeasible one must resort to alternative airway
Copyright © 2014 American Society of Anesthesiologists
management techniques. Here we describe a novel approach by the use of a laryngeal mask airway for
bronchoscopic balloon dilation to improve respiratory physiology prior to tracheal resection and
anastomosis. The LMA was then also used to facilitate transillumination of the trachea via fiberoptic
bronchoscope to locate the precise location for incision.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Fundamentals of Anesthesiology (FA) MC968
Intravenous Lidocaine as a Potential Treatment for Cholestatis-Induced Pruritus
Aileen L. Pan, M.D . Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD,
USA.
24-year-old female (68kg) with chronic cholestasis presents for a percutaneous biliary tube replacement
due to malposition. Previously, she had a congenital choledochal cyst removed, and her course has been
complicated by recurrent biliary strictures and cholangitis. Consequentially, she suffers from pruritus that
is marginally managed with hydroxyzine. Given her significant complaints of pruritus with vigorous
scratching preoperatively, she was bolused with IV Lidocaine 2% 100mg and noticed immediate relief. A
Lidocaine 2% infusion 2mg/kg/h was started. After 1.5 hours, her pruritus was mild with no signs of
itching. The Lidocaine 2% infusion was thus continued until arrival to the PACU.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Fundamentals of Anesthesiology (FA) MC969
Intra-operative Basilar Artery Aneurysm Thrombus in a Patient with Sickle Cell and Moya Moya
Syndrome
Vijay Parekh, M.D., Maninder Singh, M.D . Anesthesiology, Case Western Reserve University
Metrohealth Medical Center, Cleveland, OH, USA.
A 14-year-old female with HbSS, Moya Moya syndrome, and previous silent CVA presented to the IR
suite for endovascular coiling of a non-ruptured basilar aneurysm. The airway was secured with an OETT
and an arterial line was placed. Thirty minutes into the procedure, a basilar thrombus was discovered and
tPA was started. The patient remained hemodynamically stable and she demonstrated no neurological
deficits after extubation. Head CT post-incidence showed subacute cerebellar infarcts. This case
exemplifies the difficult peri-operative management of HbSS, CVA, and Moya Moya that required a multidisciplined approach due to limited standard of care guidelines.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Fundamentals of Anesthesiology (FA) MC970
TEE Guided Congestive Heart Failure Management during Total Nephrectomy
Cooper W. Phillips, Dennis Ho, D.O., Brian McClure, D.O . Texas Tech Health Science Center, Lubbock,
TX, USA.
A CHF patient was diagnosed with renal cancer and suffered a cardiac arrest managed with hypothermic
therapy, CABG, and IABP. Three months later, the patient was scheduled for total nephrectomy despite
poor EF and significant pulmonary hypertension. Induction and placement of CVL, PAC, and arterial line
with ultrasound was uneventful. TEE showed dilated RA, global hypokinesis, and moderate pulmonary
hypertension. Cardiac function and hemodynamics improved with epinephrine infusion. Diminishing
pressures suggested hypovolemia but TEE found normovolemia and large pulmonary effusion. Chest
tube was placed postoperatively and the patient was stable for planned ICU stay. He was discharged 5
days later.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Fundamentals of Anesthesiology (FA) MC971
Second Attempt at Embolization of an Arteriovenous Malformation Following Previous
Intraoperative Cardiac Arrest
Jeffrey A. Planchard, M.D., MBA, Kenneth Cummings, M.D . Anesthesiology Institute, Cleveland Clinic
Foundation, Cleveland, OH, USA.
Copyright © 2014 American Society of Anesthesiologists
A 24 year-old female presents for preoperative assessment. She has been referred by an outside hospital
(OSH). Since childhood, the patient has had a large arteriovenous malformation (AVM) occupying her
right quadriceps. After many surgeries to coil the AVM, ethanol embolization was attempted at the OSH.
Intra-operatively, the patient experienced cardiac arrest requiring chest compressions. While anaphylaxis
was considered (known allergy to contrast dye), her team discovered a vein had carried ethanol to her
heart causing direct cardiac toxicity. The surgery is to be attempted again, with the surgical team
choosing n-butyl cyanoacralate as the means of embolization.
Monday, October 13, 2014
11:20 AM - 11:30 AM
Fundamentals of Anesthesiology (FA) MC972
Massive Intracardiac Thrombus During Liver Transplantation
Laura K. Porter, M.D., Satya Krishna Ramachandran, M.D . University of Michigan, Ann Arbor, MI, USA.
A 58-year old man with Hepatitis C cirrhosis and hepatocellular carcinoma presented for orthotopic liver
transplant. Pre-operative TTE demonstrated systolic anterior motion of the mitral valve and patent
foramen ovale. Due to the position of the tumor in the caudate lobe, bicaval clamps were necessary for
explant of the native liver. Shortly after reperfusion, the patient had severe hypotension, and intra-cardiac
thrombus was noted throughout all four cardiac chambers, extending across the PFO. Median sternotomy
and embolectomy was attempted without improvement in hemodynamics. The patient was poorly
responsive to chest compressions, vasopressors, or inotropes. He expired intra-operatively.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Fundamentals of Anesthesiology (FA) MC973
Controlled Hypotension for Orthognathic Surgery in a Patient with a Vulnerable Cervical Spine
Due to Disc Herniation at C6
Christopher P. Potestio, M.D., Sudha Ved, M.D., Christina Bence, B.S. Georgetown University School of
Medicine, Washington, DC, USA.
An otherwise healthy 38 year old, 89 kilogram man with OSA and jaw deformity was scheduled for
orthognathic surgery. Prior to surgery, he developed herniated nucleus pulposus at C6 causing dull pain,
paresthesia, and weakness in the left arm. Symptoms were relieved by epidural steroid injection but his
spinal cord remained vulnerable to ischemia. Anesthetic management included controlled hypotension to
minimize bleeding while monitoring for spinal cord ischemia with sensory evoked potentials and EMG.
Unfortunately, the patient experienced postoperative pain and paresthesia in the right radial nerve
distribution- a neurapraxia from peripheral nerve compression caused by patient positioning.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Fundamentals of Anesthesiology (FA) MC974
XYY, MH Reaction, Positive CHCT and a RYR1 Mutation
Lauren E. Potts, M.D., Erin Tracy, M.D., Peter Bedocs, M.D. , Nyamkhishig Sambuughin, Ph.D., John
Capacchione, M.D. Anesthesia, Walter Reed National Military Medical Center, Bethesda, MD, USA,
Walter Reed National Military Medical Center, Bethesda, MD, USA, Uniformed Services University of the
Health Sciences, Bethesda, MD, USA, Uniformed Services University of Health Sciences, Bethesda, MD,
USA.
A20-year-old 6‟4” 136kg muscular XYY male underwent general anesthesia fortesticular torsion.
Following induction, he developed tachycardia, hyperthermiaand hypercarbia. Laboratory analyses
showed acidosis, hyperkalemia andhyperCKemia. The patient was admitted to the SICU and treated for
suspectedmalignant hyperthermia (MH). Subsequent muscle biopsy with caffeine halothanecontracture
testing was positive for MH. Genetic analysis revealed a Val2627LeuRyR1 MH-causative mutation. This
is the first reported case of XYY incombination with an RyR1 MH-causative mutation, and raises the
question of howXYY might exacerbate MH susceptibility.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
11:50 AM - 12:00 PM
Fundamentals of Anesthesiology (FA) MC975
Refractory Postoperative Vasoplegia after Low Dose Hydralazine Administration: Is the
Perioperative Use of Angiotensin Converting Enzyme Inhibitor to Blame?
Kevin Powell, M.D., Lavinia M. Kolarczyk, M.D . Anesthesiology, UNC-Chapel Hill, Chapel Hill, NC, USA.
80 year-old female with peripheral vascular disease and hypertension presented for cervical
lymphadenectomy and neck dissection. She took her Lisinopril 14 hours prior to surgery. She was
hypertensive upon emergence and in the PACU. Blood pressure was treated with two doses of
hydralazine 5 mg, given 10 minutes apart. Refractory hypotension (SBP <70 mmHg) ensued, which was
unresponsive to fluids, phenylephrine and vasopressin. During this time, she had significant ST
depression. She was stabilized with small epinephrine boluses and norepinephrine infusion. She was
transferred to SICU for vasopressor support. Cardiac evaluation was negative. She remained
vasopressor dependent for 5 hours.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Cardiac Anesthesia (CA) MC976
Open Gastric Tumor Resection in a Patient with Left Ventricular Assist Device (LVAD)
Armin F. Deroee, M.D., Alparslan Turan, M.D . Anesthesiology, Cleveland Clinic Foundation, Cleveland,
OH, USA, Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
A 75 year old man presented with recurrent upper gasterointestinal bleeding because of gastric
gasterointestinal stromal tumor. He was scheduled for open gastrotomy. Cardiac history was significant
for EF of 10% ± 5% , left ventricular assistance device (LVAD) HeartMate2 because of ischemic
cardiomyopathy and ICD. The ICD was turned off. A preinduction A-line was placed via ultrasound.
Cardiac output was constantly monitored via VAD control console. The patient was induced and
intubated. General anesthesia was maintained by sevoflurane. Hypotension was treated with IV fluids and
phenylephrine. The surgery was successfully done and the patient was extubated with no complications.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Cardiac Anesthesia (CA) MC977
Hole in the Heart: A Mysterious Case of RV Rupture During Outpatient Surgery
Prianka Desai, M.D., Michael Ancuta, M.D., Mandeep Kalsi, M.D . Yale New Haven Hospital, New Haven,
CT, USA.
DS is a 53 year old who presented for removal of an IVC filter. It was accessed via right IJ and after
removal the patient developed hypotension unresponsive to phenylephrine and ephedrine. After IVFs,
vasopressin and epinephrine, the patient‟s blood pressure stabilized and she was extubated and brought
to PACU. She developed dyspnea and progressively worsening mental status. She became hypotensive
again and was then reintubated emergently. Bedside TTE revealed large pericardial effusion and
moderate to severely decreased LV and RV systolic function. Given tamponade physiology, she was
taken emergently to the OR for mediastinal exploration, which revealed RV rupture.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Cardiac Anesthesia (CA) MC978
Mitral Valve Replacement with Preoperative Exchange Transfusions in a Patient with Sickle Cell
Disease
Todd Dodick, M.D., Farhan Farooqui, M.D., J. Devin Roberts, M.D., Mark Chaney, M.D . University of
Chicago, Chicago, IL, USA.
A 48 year old HbS/β+thallasemia female with history of many sickle crises and a prior episode of acute
chest syndrome was diagnosed with mitral valve endocarditis and severe MR. After a course of antibiotics
and negative repeat blood cultures she was scheduled for MV replacement. She had received monthly
exchange transfusions for several months for a non-healing leg ulcer, and was again exchange
transfused the day prior to surgery. Another exchange transfusion was performed before initiation of CPB
Copyright © 2014 American Society of Anesthesiologists
in the OR, to a final Hb S concentration of <5%. She underwent MVR and tricuspid DeVega with an
uncomplicated perioperative course.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Cardiac Anesthesia (CA) MC979
Conflicting Hemodynamic Goals in an Adult Patient with Fontan Physiology Presenting for
Resection of a Hepatocellular Carcinoma
David P. Dorsey, M.D., Steve Kwon, M.D.,M.P.H., Eric Krieger , Raymond Yeung, M.D., Krishna Natrajan,
M.D., Gregory Dembo, M.D . Anesthesiology, University of Washington, Seattle, WA, USA, Surgery,
University of Washington, Seattle, WA, USA, Cardiology, University of Washington, Seattle, WA, USA.
After undergoing a Fontan procedure at age 9 for single-ventricle physiology, a 32 year-old man was
diagnosed with hepatocellular carcinoma, a disease increasingly recognized in the post-Fontan
population. Typically, surgical resection of liver tumors relies on low central venous pressure to minimize
blood loss; however, the post-Fontan circulation‟s dependence on passive caval blood flow through the
pulmonary vascular bed to maintain cardiac output potentially limits this strategy. We describe the use of
pre-operative cardiac catheterization to simulate and test tolerance of decreased central venous
pressures in a patient with Fontan physiology who subsequently underwent successful resection of his
hepatocellular carcinoma.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Cardiac Anesthesia (CA) MC980
The Anesthetic Management of Abdominal Aortic Perforation Post Aortic Balloon Pump Insertion
Avichai Dukshtein, Lynn Belliveau, D.O., Stanislav Sidash. Anesthesiology, Maimonides Medical Center,
Brooklyn, NY, USA, Maimonides Medical Center, Brooklyn, NY, USA.
A 74 years male with a history of CHF (EF30%), CAD s/p PCI, severe AR, MR, TR, Atrial fibrillation, HTN,
Pulmonary hypertension and Chronic renal failure who was admitted to the CTICU for preoperative
optimization with IABP for scheduled AVR and MVR. IABP position was not optimal. Aortic rupture was
suspected. Patient was rushed to the OR with transfusion en route. A preinduction arterial line was
placed. Rapid sequence induction was done with 1000mcg of fentanyl and succinylcholine. A PA catheter
placed. PRBCs and products were transfused with a rapid infuser. Injury to the right iliac artery was
successfully stented
Monday, October 13, 2014
11:20 AM - 11:30 AM
Cardiac Anesthesia (CA) MC981
The Anesthetic Management of TVR and PVR in a Patient With Carcinoid Syndrome
Avichai Dukshtein, Lynn Belliveau, D.O., Garo DerParseghian. Maimonides Medical Center, Brooklyn,
NY, USA, Anesthesiology, Maimonides Medical Center, Brooklyn, NY, USA.
A 58 yo M with PMH of metastatic neuroendocrine ca of the pancreas, carcinoid syndrome, HCV, NIDDM
and smoker was admitted for worsening SOB and decreased exercise tolerance. Patient was also had
episodic wheezing and dyspepsia. Catheterization revealed normal LV function and absence of CAD.
TTE showed RV dilatation secondary to severe TR and PVR. Perioperative optimization with octreotide
and everolimus was initiated. Upon OR entry, hydocortisone, pepcid, benadryl and an octreotide bolus
were given prior to induction. Intra-op intermittent boluses of octreotide were administered for
unexplained hypotensive episodes with TEE monitoring of RV function. Insulin infusion strict glucose
control.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Cardiac Anesthesia (CA) MC982
Anesthetic Management of a Patient with Pheochromocytoma and Mitral Stenosis undergoing
reoperation for Mitral Valve Replacement: A Case Report
Thejovathi Edala, Alla Klimova, M.D., Esamelden Abdelnaem, M.D., Mohammed Ismaeil, M.D., Charles
A. Napolitano, M.D . Anesthesiology, UAMS, Little Rock, AR, USA.
Copyright © 2014 American Society of Anesthesiologists
Concomitant mitral valve stenosis and pheochromocytoma are rare occurrences.The patient with severe
mitral valve stenosis alone poses intraoperative issues, but the influence of an active pheochromocytoma
presents additional challenges to cardiac anesthesiologist in the patient requiring redo cardiac surgery.
We describe the anesthetic management in a 50 year old African American female patient presenting with
pheochromocytoma for redo mitral valve surgery
Monday, October 13, 2014
11:40 AM - 11:50 AM
Cardiac Anesthesia (CA) MC983
Anesthetic Management of an Adult Patient with Severe Pulmonic Stenosis, Secundum Atrial
Septal Defect and End Stage Renal Disease for Pulmonic Valvuloplasty and Atrial Septal Defect
Closure in the Cardiac Catheterization Suite
Ahmad Elsharydah, M.D., MBA, Star L. Rogers, M.D . Anesthesiology and Pain Management, UT
Southwestern Medical Center, Dallas, TX, USA.
A 53 year-old female with a history of moderate to severe pulmonic valve stenosis, secundum atrial septal
defect (ASD), stroke, hypertension and end stage renal disease presented to our institution with chest
pain and increasing dyspnea. Patient underwent a balloon valvuloplasty and percutaneous ASD closure
in the cardiac catheterization suite. Anesthetic management included general endotracheal anesthesia,
transesophageal echocardiography (TEE). Close hemodynamic monitoring and coordination with the
cardiologist were essential to minimize the post ASD closure and valuvloplasty physiological changes in
the pulmonary and circulatory systems. The anesthetic was uneventful and the patient was discharged
home the next day.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Cardiac Anesthesia (CA) MC984
Acute Intraoperative Pulmonary Embolus: Strategies to Improve Detection
Stephen R. Estime, M.D., Frank Dupont, M.D . Anesthesia & Critical Care, University of Chicago,
Chicago, IL, USA.
A 36 year old otherwise healthy male with history of GERD complicated by Barrett's Esophagus
presented for an Ivor-Lewis esophagectomy. After preoperatively placement of a thoracic epidural, a DBL
ETT was inserted after RSI & GA was maintained. 30 minutes into the laparoscopic portion, the patient
was noted to be hypoxic on 50% Fi02 with hypotension. After ruling out other causes, a PE was
suspected after ABG and intraoperative TEE findings & the procedure was aborted. Spiral CT chest
imaging confirmed the PE and the patient was transferred to the SICU for further management.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Critical Care Medicine (CC) MC985
Emergent Management of PEA Arrest Following Rapid-sequence Induction of Anesthesia
LaTasha Moore, M.D., Chasen Croft, M.D . University of Florida, Gainesville, FL, USA.
A 44-year-old morbidly obese male with necrotizing pancreatitis and paralytic ileus who was being
managed in the SICU developed sudden respiratory distress requiring intubation. Rapid-sequence
induction with succinylcholine and propofol was administered which led to immediate PEA arrest requiring
5 minutes of CPR and epinephrine. Complete workup of underlying cause was negative; attributed to
excessive vagal response from increased intra-abdominal pressure. The patient developed ARDS and
had a prolonged stay in the SICU.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Critical Care Medicine (CC) MC986
Management of Refractory Status Epilepticus in a Patient Ultimately Diagnosed with CreutzfeldtJakob Disease
Cody D. Murphy, M.D., Ozan Acka, M.D., Michael Heine, M.D., Jenna Dismore, M.D., Trinoh Rojas, M.D .
University of Louisville, Louisville, KY, USA.
Copyright © 2014 American Society of Anesthesiologists
Status epilepticus is a life-threatening condition in which one in five patients die within thirty days of an
initial seizure. Several novel approaches have been described to deal with status epilepticus refractory to
traditional therapy. Our case involves a previously healthy female presenting with involuntary arm
movements persisting for months, followed by rapid progression to status epilepticus. Over several
weeks, her condition was refractory to conventional therapy and novel treatments including
plasmapheresis and ketamine burst suppression. The patient only responded to high dose pentobarbital
suppression. Ultimately, seizure activity resumed upon weaning of pentobarbital and Creutzfeldt-Jakob
disease was confirmed.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Critical Care Medicine (CC) MC987
Succinylcholine in the ICU Patient: Can We Avoid Cardiac Arrests?
Kerra K. Murray, M.D., Marcos Gomes, M.D., Jessica Enix, M.D . OUMC, Oklahoma City, OK, USA.
This is a 33 year old male patient status post gunshot wound to the abdomen, POD 6 from intestinal
anastomosis and left nephrectomy, with improving creatinine from 2.6 to 1.9 and brisk urine output. He
was extubated in the morning but evolved to respiratory distress, worsen abdominal exam, and altered
mental status in the afternoon. Pain and agitation were treated. Blood gas at bedside was
7.03/112/106/29 after attempting pharmacologic reversal of narcosis. Rapid sequence intubation with
Sellick maneuver was performed using versed, fentanyl, and succinylcholine. The patient progressed with
bradycardia followed by asystole shortly after induction.
Monday, October 13, 2014
11:00 AM - 11:10 AM
Critical Care Medicine (CC) MC988
A Post Operative Diagnostic Dilemma
Asha A. Naik, Sr . Anaesthesiology, Wrexham Maelor Hopsital, Wrexham, United Kingdom.
A 58 year old obese female undergoing elective parathyroidectomy had 500mg of methylene blue preoperatively. Her background included hypertension,depression which was treated with Ramipril ,
venlafaxine and Nitrazepam. She received benzodiazepine premedicationInduction and intraoperative
period was uneventful .Post-extubation she remained rousable with fluctuant GCS, agitated, dystonic,
pyrexial with abnormal eye movements , limb rigidity .Due to persistent hypercapnea she was reintubated and ventilated.Extubated 10 hours later, she exhibited signs that fit into the Hunter Serotonin
Toxicity CriteriaAdmitted to ICU overnight she made a complete neurological recovery, being discharged
to the ward later in the day.
Monday, October 13, 2014
11:10 AM - 11:20 AM
Critical Care Medicine (CC) MC989
Perioperative Management of an Elderly Patient with a History of Tetralogy of Fallot Repair
Presenting for Resection of a Pheochromocytoma
Michael Nayshtut, M.D., Joseph W. Dooley, M.D . Anesthesiology, University of Rochester, Rochester,
NY, USA.
We present a medically complex 76-year-old woman with a repaired Tetralogy of Fallot, scheduled for a
laparoscopic pheochromocytoma resection that required conversion to an open procedure. Necessary
pre-operative preparation for pheochromocytoma resection resulted in medical decompensation of the
patient medically managed for decades for her TOF repair. Intra-operative monitoring and management
had to be tailored to the patient‟s physiology. Post-operative ICU management and complications, in
particular the need for prolonged mechanical ventilation, was greatly influenced by her cardiac anatomy.
Other medical problems include CHF, pulmonic valve stenosis, aortic aneurysm, atrial fibrillation (on
warfarin), HCV, CKD 3, and type II DM.
Copyright © 2014 American Society of Anesthesiologists
Monday, October 13, 2014
11:20 AM - 11:30 AM
Critical Care Medicine (CC) MC990
Emergency Completion Pneumonectomy Complicated by Intraoperative Acute Myocardial
Infarction
Edward D. Foley, M.D., F.C.A.R.C.S.I., Christina Riccio, M.D . Anesthesiology and Pain Medicine,
University of Texas Southwestern Medical Center, Dallas, TX, USA.
70F DM/ hypertension/hyperlipidemia underwent VATS for pumonary adenocarcinoma. Anesthesia
inductionwas uneventful and a 37F DLT, aline and 2 large IVs were placed easily. Surgery
wascomplicated by pulmonary artery laceration with hemorrhagic shock. VATSwas converted to a
thoractomy with completion pneumonectomy. STsegment elevation was noted during inital resuscitation
but normalized with transfusion/vasoactive medications.En-route to ICU, ST elevations returned and stat
echo revealed new anterolateral/ septal akineis with areduced EF. Angio showed 3V disease with acute
occlusion of the midLAD. A bare metalstent was placed. Patient weaned off pressors and was extubated
POD 1.
Monday, October 13, 2014
11:30 AM - 11:40 AM
Critical Care Medicine (CC) MC991
Massive Intra-Operative Pulmonary Embolism During Ankle Surgery
Christopher N. Franco, D.O., Raymond Graber, M.D . Anesthesiology and Perioperative Medicine,
University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA.
A forty-one year old morbidly obese female with a previous history of hypertension and cocaine abuse
had a fall while intoxicated, and she suffered an ankle fracture and hemorrhagic stroke. Six weeks
following rehabilitation, she underwent an ankle fracture repair. During the operation, she developed a
massive saddle pulmonary embolism, which was confirmed by echocardiography. Following an emergent
thrombectomy, her right ventricle did not completely recover. A right ventricular assist device was placed.
Her post-operative course was complicated by arrhythmias, renal failure, respiratory failure, and
gastrointestinal bleeding. Ultimately, she developed multisystem organ failure and expired.
Monday, October 13, 2014
11:40 AM - 11:50 AM
Critical Care Medicine (CC) MC992
Peripartum Cardiomyopathy: Using the TandemHeart and Heartware LVAD to Bridge to Transplant
Michael Fujinaka, M.D., Kimberly Robbins, M.D., Albert P. Nguyen, M.D. U.C. San Diego, San DIego, CA,
USA.
We present a medically challenging case of a previously healthy 28 year old woman who presented in
florid cardiogenic shock due to delayed diagnosis of peripartum cardiomyopathy. Her condition was
stabilized by the emergent placement of a TandemHeart left ventricular assist device (LVAD). One day
later she was transitioned to a Heartware LVAD as a bridge to transplant. She has since recovered from
her near death experience and is currently awaiting a new heart. We will discuss the intraoperative
management of switching from a TandemHeart to Heartware, as well as postoperative management.
Monday, October 13, 2014
11:50 AM - 12:00 PM
Critical Care Medicine (CC) MC993
Anesthetic Management of a Patient who Developed Acute Right Ventricular Failure Secondary to
Auto-PEEP
Ashley E. Gabrielsen, D.O., Elifce Cosar, M.D . Department of Anesthesiology, University of
Massachusetts Medical Center, Worcester, MA, USA.
A 48 yo male presented with atrial fibrillation and subsequent pneumatosis intestinalis secondary to
intestinal perforation. After initial bowel resection, the patient returned to the operating room for
abdominal wall closure. Immediately after abdominal wall closure, the patient became hypotensive and
difficult to ventilate. The patient then went into PEA arrest. He was successfully resuscitated with the
ACLS protocol. Arrest was thought to be due to acute right ventricular failure secondary to hypercarbia
Copyright © 2014 American Society of Anesthesiologists
and auto-PEEP phenomenon. The patient was taken to the ICU with vasopressor support. After a
complicated course that included another PEA arrest, he was discharged home.
Monday, October 13, 2014
10:30 AM - 10:40 AM
Obstetric Anesthesia (OB) MC994
Anesthesia for Cesarean Section in a Morbidly Obese Patient with OSA
Lihua Zhang, M.D., Chi Dola, M.D., Sabrina Zhang, M.D. . Anesthesiology, Tulane, New Orleans, LA,
USA, Obstetric and Gynecology, Tulane University Hospital and Clinic, New Orleans, LA, USA,
Anesthesiology, Tulane University Hospital and Clinic, New Orleans, LA, USA.
We present successful epidural anesthesia and assisted mechanical ventilation by continuous positive
airway pressure (CPAP) in a parturient woman with obstructive sleep apnea (OSA), morbid obesity,
chronic hypertension, and gestational diabetes. A 39-year-old woman at 36 weeks' of gestation was
admitted for induction. We administered continuous epidural analgesia for cesarean section after failure
of vaginal induction. During the procedure, the patient was not able to maintain her oxygen saturation with
nasal cannula 2L O2 in supine position, her ventilation was continuously assisted by CPAP. The maternal
and fetal outcomes were successful.
Monday, October 13, 2014
10:40 AM - 10:50 AM
Obstetric Anesthesia (OB) MC995
Anesthetic Management of Achondroplastic Dwarf for Cesarean Section
Abdullah N. Abdullah, M.D., Jaya Ramanathan, M.D . Anesthesiology, University of Tennessee College of
Memphis, Memphis, TN, USA, Anesthesiology, University of Tennessee College of Medicine, Memphis,
TN, USA.
We present a case of a 17-year-old G1P0 achondroplastic dwarf presenting for elective cesarean section.
The patient was 44 inches tall and weighed 90 pounds with a MP Class 3 airway and limited neck
movements. A preoperative ENT consultation was sought for bronchoscopic evaluation of upper airway
before surgery. A single-shot spinal with hyperbaric bupivacaine 3.75 mg and 15 mcg of fentanyl was
administered at L3-4 interspace. A T4 level of anesthesia was obtained. Caesarian section was
uneventful. The patient was carefully monitored postpartum for complications. Post-operative course was
uneventful and she was discharged home on POD #3.
Monday, October 13, 2014
10:50 AM - 11:00 AM
Obstetric Anesthesia (OB) MC996
Perioperative Management of a 14-Week Pregnant Female with Severe Grave’s Thyrotoxicosis
(Thyroid Storm)
Phillip S. Adams, D.O., Richard Zhang, B.S., Anthony Silipo, D.O . Anesthesiology, University of
Pittsburgh Medical C