ASA Annual Meeting Medically Challenging Cases Guide 2015

Transcription

Medically Challenging Cases
ANESTHESIOLOGY® 2015, the 2015 ASA annual meeting
MCC Session Number
MCC01
MCC02
MCC03
MCC04
MCC05
MCC06
MCC07
MCC08
Day
Saturday, October 24
Sunday, October 25
Sunday, October 25
Sunday, October 25
Monday, October 26
Monday, October 26
Time
10:00 a.m. – 12:00 p.m.
1:00 p.m. – 3:00 p.m.
3:15 p.m. – 5:15 p.m.
10:00 a.m. – 12:00 p.m.
1:00 p.m. – 3:00 p.m.
3:15 p.m. – 5:15 p.m.
1:00 p.m. – 3:00 p.m.
3:15 p.m. – 5:15 p.m.
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
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Copyright © 2015 American Society of Anesthesiologists
MCC Session Number – MCC01
MCC01
Saturday, October 24, 2015
10:00 AM - 10:10 AM
Ambulatory Anesthesia (AM)
Presentation Number: MC1001 - Monitor 01
A Simple and Low-Cost Nasal CPAP Mask/Circuit Assembly Maintained Spontaneous Ventilation
and Oxygenation in an Obese Patient With a History of Awareness During Colonoscopy
Erica Patel, D.O., Dennis Hall, M.D., Rose Alloteh, M.D., James Tse, M.D., Anesthesia, Rutgers
University Robert Wood Johnson Medical School, New Brunswick, NJ
A 66 year-old obese male, with a known difficult airway and intra-procedural awareness/nightmares after
EGD/colonoscopy presented for repeat colonoscopy. He received intravenous lidocaine 100 mg and
propofol (100 mg plus 150 ug/kg/min infusion). A pediatric mask was affixed over his nose, secured with
head straps and connected to the anesthesia circuit/machine with 3L/min 02/1L/min air. After a few
minutes of sedation, his airway became obstructed and 02 saturation decreased from 97% to 92%.
Adjustment of the mask with 3-5 cm H20 CPAP resulted in spontaneous ventilation and 02 saturation of
97%. He tolerated the procedure well without awareness or recall.
MCC01
10:00 AM - 10:10 AM
Fundamentals of Anesthesiology (FA)
A Simple and No-Cost Nasal CPAP Mask/Circuit Assembly Maintaining Spontaneous Respiration
and Oxygenation in a Patient With Angioedema During Emergency Awake Endotracheal Intubation
Amanda M. Doucette, M.D., Robert Jongco, M.D., Yolanda Troublefield, M.D., Nicole Grayer, M.D.,
James Tse, M.D., Anesthesiology, Rutgers Robert Wood Johnson Medical School, Surgery, Division of
Otolaryngology, Robert Wood Johnson University Hospital, New Brunswick, NJ
42 year-old female, BMI 31 kg/m, with hypertension presented with enalapril-induced angioedema
requiring emergency endotracheal intubation. Her swollen tongue was protruding through her mouth. Her
breathing/ventilation was maintained nasally via infant mask, secured with head straps, connected to
anesthesia circuit/machine delivering O2 (3 L/min) and air (1 L/min). APL was adjusted to deliver 5-6 cm
H2O CPAP. After topicalization with local anesthetics, deep sedation was titrated with propofol (total 200
mg). After two failed attempts with fiberoptic bronchoscopy with videolaryngoscopic (VL#3 blade)
guidance, intubation accomplished easily using VL (#4). She maintained spontaneous respiration and
100% O2 saturation throughout.
MCC01
10:00 AM - 10:10 AM
Innovative Approach to Delivering Nasal CPAP to a Morbidly Obese Female With Obstructive
Sleep Apnea and COPD for an Incision and Drainage of a Lower Extremity
Jessica Perez, M.D., Erica Patel, D.O., Ben Landgraf, M.D., Andrea Poon, M.D., James Tse, M.D.,Ph.D.,
Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
84 year-old female, BMI 56 kg/m2, with CAD, atrial fibrillation, COPD, OSA and recent delayed
awakening presents for IandD of lower extremity. O2 saturation increased from 94% (NC O2 4L/min) to
100% with an infant mask secured over her nose with 2 cm H2O CPAP (3L O2/1L air). She maintained
spontaneous breathing with fentanyl (4x25 mcg). She felt some pain relieved with 50% N2O. Patient was
alert and oriented immediately after procedure. Before transport, O2 sat decreased to 94% with NC O2
4L/min. It increased to 100% just adding a plastic sheet to convert NC to face tent.
MCC01
10:00 AM - 10:10 AM
Cardiac Anesthesia (CA)
Right Heart Dysfunction Following Aortic Valve Replacement Resolving With Off Pump Right
Coronary Artery Bypass Grafting
Tamar Lake, M.D., Bryant Wu, M.D., Michael Mathis, M.D., The University of Michigan, Ann Arbor, MI
An 81 year-old female with aortic stenosis and left anterior descending coronary artery stenosis
presented for aortic valve replacement with coronary artery bypass grafting. Given extensive calcification
of the aortic root, an endarterectomy of the root was performed. Following cardiopulmonary bypass, right
heart dysfunction was noted on transesophageal echocardiography. The right heart failure was poorly
responsive to inotropic support. Given concern for a calcification entering the right coronary artery
following endarterectomy, an off pump right coronary artery bypass was performed with immediate
resolution of right heart dysfunction. She was discharged on postoperative day 6 and has improved
functional capacity.
MCC01
10:00 AM - 10:10 AM
Critical Care Medicine (CC)
Persistent ICU-Acquired Weakness After Treatment with Neuromuscular Blockade for Acute
Respiratory Distress Syndrome
Catherine Kuza, M.D., Jon Dorfman, M.D., Anesthesiology, University of Massachusetts Medical School,
Worcester, MA
A 57 year-old woman with multiple comorbidities presented with septic shock from a right buttock infection
requiring surgical debridement. Postoperatively, she developed acute respiratory distress syndrome
(ARDS), required intubation and treatment with a cisatracurium infusion. Her hospital course was
complicated by ICU-acquired weakness. We present this case of persistent weakness and functional
disability 12 months after discharge and review the literature. We will discuss the risk factors,
pathophysiology, and course of ICU-acquired weakness. The functional disability experienced by patients
is significant and may persist as long as 1 to 5 years after recovery from ARDS.
MCC01
10:00 AM - 10:10 AM
Obstetric Anesthesia (OB)
Cesarean Section After Spinal Cord Injury, Neurogenic Shock Versus Autonomic Hyperreflexia
Maria R. Fuertes, M.D., Jaya Ramanathan, M.D., Anesthesiology, Regional One Health, Memphis, TN
22 year-old 19 weeks pregnant s/p MVA with cervical injury at C5 level, bilateral pulmonary contusions
and subarachnoid hemorrhage with increased intracranial pressure.She was quadriplegic and developed:
respiratory insuficiency that required mechanical ventilation and tracheostomy; urinary tract infections with
urosepsis, and base line hypotension. At week 33 Monitoring was consistent with fetal and maternal
tachycardia we proceed with Cesarean Section. Because the h/p brain injury and recurrent infections and
the fact that the patient never developed autonomic hyperreflexia we performed epidural anesthesia with
catheter placement using lidocaine 2% and subfentanyl, hypotension responded to phenyleprine.
MCC01
10:00 AM - 10:10 AM
Neuroanesthesia (NA)
Amoxapine Related Hypotension Under General Anesthesia
Timothy Howard, Mayo School of Graduate Medical Education, Jacksonville, FL
A 75 year-old man with back pain for spinal stenosis was scheduled for a revision lumbar laminectomy
and fusion. Past medical history included controlled hypertension and depression on amoxapine. History
of severe hypotesnion during prior laminectomy. After induction with propofol and remifentanil, became
severely hypotensive unresponsive to fluids, ephedrine and dopamine. Central line placed, required
infusions of vasopressin and epinephrine to maintain pressure. Case cancelled, patient awakened and
weaned off pressors within forty minutes. He had no further hypotensive episodes postoperatively.
Cardiac and other causes of hypotension ruled out.
MCC01
10:00 AM - 10:10 AM
Pediatric Anesthesia (PD)
Gastrocutaneous Fistula Closure in a 12 year-old Male With Pulmonary Hypertension
Samuel M. Barst, Nausheen Zia, M.D., Micah Burns, M.D., Whitney McBride, M.D., Anesthesiology,
Pediatric Surgery, New York Medical College - Westchester Medical Center, Valhalla, NY
A 12 year-old male who was an ex-28 week premie with pulmonary hypertension (PHT) - mean PAP 66
mmHg - and left lung hypoplasia was scheduled for closure of a gastrocutaneous fistula. The patient had
a negative response to pulmonary vasodilator testing and was managed at home on oxygen, bosentan
and sildenafil. These drugs improve the hemodynamics and exercise capacity of patients with PAH.
Anesthetic considerations included avoiding myear-oldcardial depressant agents, maintaining
normocapnia with controlled ventilation and avoiding acidosis, hypoxia, hypotension and hypothermia
which increase PVR. Other considerations included maintaining volume status and adequate preload to
the non-compliant RV.
MCC01
10:00 AM - 10:10 AM
Pain Medicine (PN)
19 year-old Female With History of Velo-cardio-facial Syndrome, Left Lower Extremity CRPS and
New Onset Psychosis
Alexandra Szabova Min, M.D., Anesthesia, Cincinnati Childrens Hospital Medical Center, Cincinnati, OH
19 year-old female with VCF syndrome, presented with left lower extremity CRPS following hamstring
release/tendon lengthening. Multidisciplinary therapy was started, with initial improvement. Then patient's
medical status worsened and she developed hallucinations consistent with psychosis related to VCF
syndrome, resistant to treatment. Her ability to cope with pain and continue PT significantly decreased.
She was managed with oral opioids, gabapentin, and tizanidine. Peripheral nerve catheters and local
anesthetic infusion were added for 5 days to modified occupational therapy. The goal of catheters was
maintenance of ambulation and analgesics wean to minimize impact on psychotic symptoms.
MCC01
10:00 AM - 10:10 AM
Professional Issues (PI)
Having the Difficult Conversation With Patient's Family
Omonele O. Nwokolo, M.D., Glorimar Medina-Rivera, M.D., Anesthesiology, University of Texas Medical
School, Houston, TX
We present a 45 year-old man with metastatic esophageal cancer with biliary obstruction for a drain in
IR. He was DNI/DNR with AMS, hypotension, PNA, Pleural infusions and septic shock; he had a C-collar
for cancerous invasion of C1/C2 spine. The Interventionalist convinced his parents to rescind his
DNI/DNR status for the procedure. On case review, it was unclear if the drain would improve his
condition. We had a discussion with his parents regarding risks of remaining intubated; they strongly
opposed. The case was cancelled after IR agreed the drain would not improve life, it’s sometimes best to
do nothing.
MCC01
10:00 AM - 10:10 AM
Regional Anesthesia and Acute Pain (RA)
Combined Regional and Total Intravenous Anesthesia for Modified Radical Mastectomy in a
Pregnant Patient
Alexandria N. Nickless, D.O., Brian Allen, M.D., Anesthesiology, Vanderbilt Medical Center, Nashville, TN
A 32 year-old pregnant female, G1P0 at 27 weeks EGA presented with weakly estrogen- and moderately
progesterone-receptor positive left breast adenocarcinoma for modified radical mastectomy. Preoperative
single injection paravertebral blocks were placed at T1-4. The patient underwent GETA with RSI due to
risk of aspiration from physiologic changes in pregnancy. Left uterine displacement was used to prevent
aorto-caval compression. Propofol TIVA was employed. No narcotics were administered. The patient
tolerated the procedure well, had nausea or vomiting, and experienced excellent pain control.
MCC01
10:00 AM - 10:10 AM
Endovascular Approach to Alleviate Heart Failure Symptoms in Late Recurrence of Congenital
Coarctation of the Aorta
Jason M. Altman, D.O., Dhamodaran Palaniappan, M.D., Anesthesiology, University of Connecticut Hartford Hospital, Hartford, CT
We describe the anesthetic care of a 72 year-old woman with previously repaired congenital coarctation
of the aorta acutely presenting with congestive heart failure, lower extremity claudication at rest, and
hypertensive emergency. Imaging and angiography revealed an occluded aortic bypass graft, native
aortic coarctation diameter of 3.19mm, and trans-stenotic gradient over 100mmHg. Given the patient’s
severe pulmonary disease and many comorbidities, endovascular repair was attempted with stand-by
cardiopulmonary bypass present. Sedation was provided with dexmedetomidine for endovascular balloon
angiography and coarctation stenting. Post procedure the coarctation gradient was reduced to 20mmHg
and the patient’s symptoms improved over several days.
MCC01
10:00 AM - 10:10 AM
Disseminated Intravascular Coagulation With Hyperfibrinolysis During Thoracoabdominal Aortic
Aneurysm Repair
Uzondu Osuagwu, M.D., Craig Ignacio, M.D., John Zaki, M.D., Anesthesiology, University of Texas at
Houston, Houston, TX
A 41 year-old man with a pertinent history of Marfan’s Disease variant, aortic aneurysm s/p prior repair
and aortic valve replacement on coumadin presented for resection and graft replacement of his
thoracoabdominal aortic aneurysm. Repair was completed successfully with what appeared to be
adequate hemostasis. Shortly thereafter, patient had cardiac arrest ultimately requiring ECMO. TEE was
done and was remarkable for large LV thrombus with extension into the LA. He also was severely
coagulopathic, necessitating massive transfusion of red cells and other products. This case discusses
management of massive bleeding and coagulopathy in the setting of complex cardiovascular surgery.
MCC01
10:00 AM - 10:10 AM
Emergency Airway Management in Critically Ill 11-yr-old With Facial Burns
Shamsideen O. M, M.D., M.S., Brian Bravenec, M.D., Anesthesiology & Pain Management, UT
Southwestern, Dallas, TX
11 year-old overweight male with 28% TBSA burn to face and torso presents to O.R. after remaining
intubated for 5 days in ICU for dressing change. Prior to initiating dressing change, SpO2 drops to 80%
and ETCO2 is measured at 76.6mmHG. HR and BP are unchanged from baseline and patient remains
sedated with propofol.
MCC01
10:00 AM - 10:10 AM
Anesthetic Management for the OB Patient With Severe Pulmonary Hypertension and End Stage
Renal Failure
Julie A. Kado, Matthew Price, M.D., Beaumont Health System, Royal Oak, MI, Anesthesia, Beaumont
Health System, Royal Oak, MI
This is a 31 year-old pregnant patient with severe systemic lupus. Systemic manifestations included
severe mitral stenosis and regurgitation, severe pulmonary hypertension, and end stage kidney failure
requiring daily hemodialysis. The patient was managed in the ICU pre and post-operatively and was
taken to the OR for c-section under a slowly titrated lumbar epidural. The complicated medical history of
this patient brought about two specific challenges: the mode of delivery if the fetus was carried to viability,
and the anesthetic technique for delivery. This case report will cover the anesthetic implications regarding
the mode of delivery and peri-operative anesthetic considerations.
MCC01
10:10 AM - 10:20 AM
Glossopharyngeal Nerve Block for Esophagogastroduodenoscopy in Critically-Ill Patients
Medhat S. Hannallah, M.D., Andrew ElDabh, M.B., Nadim Haddad, M.D., Anesthesiology, Georgetown
University Hospital, Washington, DC, Gastroenterology, Georgetown University Hospital, Washington, DC
Deep sedation may not be well tolerated by critically ill patients undergoing
gastroesophagoduodenoscopy (EGD) because of its potential to cause cardiovascular and respiratory
depression. Glossopharyngeal nerve (GPN) block provides reliable pharyngeal anesthesia and effective
abolishing of the gag reflex. We report our experience with GPN block as the sole or main source of
anesthesia for EGD in a series of 9 critically ill, mostly ASA 4 or 4E patients who were high risk for deep
sedation.
MCC01
10:10 AM - 10:20 AM
Fast and Full: Emergent Pericardial Window for Tamponade in Patient With Severe Myasthenia
Gravis and Large Symptomatic Anterior Mediastinal Mass
Luis E. Tollinche, M.D., Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New
York, NY
39 year-old female with metastatic thymoma presented with cardiac tamponade for emergent pericardial
window. Her perioperative management was complicated by a large, symptomatic anterior mediastinal
mass and severe myasthenia gravis. Patient had recent ICU admission for respiratory failure secondary
to MG. She subsequently developed a malignant pericardial effusion and presented to urgent care with
dyspnea and chest pain. Echocardiogram was consistent with tamponade. Pt was taken to OR
emergently for pericardial window. Priorities perioperatively included perioperative access, monitoring,
and induction and maintenance of anesthesia. Additionally, the team addressed the attendant issues
related to her MG and mediastinal mass.
MCC01
10:10 AM - 10:20 AM
Intraoperative Lung Ultrasound Aids in Diagnosis of Capnothorax
Carlos A. Brun, M.D., Anesthesiology and Perioperative Care Service, Veteran's Affairs Palo Alto, Palo
Alto, CA
A 61year-old man underwent general anesthesia for elective Nissen fundoplication secondary to GERD.
Preoperatively, he had normal lung ultrasound and breath sounds. Thirty minutes after CO2 insufflation
his peak inspiratory pressure (PIP) and ETCO2 had risen despite an increase in minute ventilation with
stable vital signs and endotracheal tube position.Repeat lung ultrasound revealed lung point sign,
typically considered indicative of pneumothorax. We recommended consideration of capnothorax.
Ligation of the crus decreased PIP and ETCO2, obviating need for chest drainage or decrease of
insufflation pressure. Lung ultrasound allowed for co-management, avoidance of surgical interruption, and
serial capnothorax assessment.
MCC01
10:10 AM - 10:20 AM
Massive Pulmonary Embolism
Reddy M. Devarapalli, M.D., Munroe Regional Medical Center, Ocala, FL
37 female laparascopic gastric bypass. Factor V deficiency.15 minutes during developed VF stopped the
procedure chest compressions started, shock followed by epinephrine. VS are unobtainable. TEE
revealed a huge clot in right ventricle.10000 heparin intravenously.x2.uninterrupted chest compressions.
no vital signs. At 8:59 am, surgeon open the chest internal cardiac massage. heart started to contract
after 5 minutes with normal sinus TEE showed normal right ventricle without clot. placed on therapeutic,
hypothermic protocol for 24 hrs EEG normal pattern after 3 days. eventually with no motor, sensory or
cognitive deficits after prolonged stay in spite of prolonged resuscitation over an hour
MCC01
10:10 AM - 10:20 AM
Dexmedetomidine: Rescue Therapy for Hyperactive Emergence Delirium in the Post-Anesthesia
Care Unit: A Literature Review and Case Series
Matthew D. Read, M.D., Christopher V. Maani, M.D., Scott Blackwell, M.D., Department of
Anesthesiology, San Antonio Uniformed Services Health Education Consortium, Department of
Anesthesiology, San Antonio Military Medical Center, Fort Sam Houston, TX
Hyperactive emergence delirium in non-elderly adults is infrequently recognized and can result in serious
complications. Current practices for treatment are suboptimal and sometimes ineffective. More
appropriate strategies are necessary. With a favorable pharmacokinetic and pharmacodynamic profile,
administration of dexmedetomidine in the OR and PACU for treatment of hyperactive emergence delirium
is a reasonable option and should be considered in the clinical armamentarium. Five cases of hyperactive
emergence delirium, in non-elderly adults, were encountered and successfully treated with
dexmedetomidine. We highlight the potential utility and efficacy of dexmedetomidine as rescue therapy
for idiopathic hyperactive emergence delirium in the OR and PACU.
MCC01
10:10 AM - 10:20 AM
A Novel and Multidisciplinary Strategy for Cesarean Section With Placenta Accreta - Intraoperative
Embolization in the Hybrid Suite
Yasutaka Konishi, Jr., M.D., Satoshi Yamamoto, Kaoru Sugiki, M.D., Hidetoshi Sakamoto, M.D.,
Shigehito Sawamura, M.D.,Ph.D., Anesthesia, Teikyo University School of Medicine, Tokyo, Japan,
Anesthesiology, Perioperative and Pain Medicin, Stanford University School of Medicine, Stanford, CA
In pregnancy with placenta accrete, stepwise treatment (caesarean section without separation of the
placenta, uterine arterial embolization and hysterectomy) is often advocated to avoid lethal bleeding.
However, the embolization in the radiology department needs transfer of the postoperative patient, which
could cause massive bleeding. In a case with placental invasion to a bladder, we applied intraoperative
uterine artery embolization immediately following caesarean section in a hybrid operating suite. General
anesthesia was maintained with sevoflurane to obtain uterine atony and propofol to confirm hemostasis
before and after embolization, respectively. Total hysterectomy was performed 25 days later with the
least blood loss.
MCC01
10:10 AM - 10:20 AM
Anesthesia for Craniotomy and Meningioma Resection in the 25-Week Pregnant Patient
Morgane Giordano, B.A., Chinedum Enyinna, M.D., Ellen Steinberg, M.D., Ramon Abola, M.D.,
Anesthesiology, Stony Brook University School of Medicine, Stony Brook, NY
Although rare, a meningioma present in a pregnant female can have accelerated growth secondary to
steroid hormone receptors.Neurosurgical intervention is warranted for active hydrocephalus, signs of
imminent herniation, or progressive neurological deficits.Neurosurgical management of an intracranial
meningioma is safe. Major goals include maintaining stable maternal hemodynamics, intracranial
pressure, uterine perfusion, and fetal oxygenation. This is one of the few cases of a parturient undergoing
craniotomy for meningioma resection with continuous fetal heart monitoring and preparation for a STAT
intraoperative cesarean section.
MCC01
10:10 AM - 10:20 AM
The Anesthetic Management of a Child With IgA, IgG and Mitochondrial Deficiency Coming for
Endoscopic Sinus Surgery
Samuel M. Barst, Ivona Truszkowska, M.D., Cecelia Pena, M.D., Lianne Deserres, M.D., Anesthesiology,
Otolaryngology, New York Medical College - Westchester Medical Center, Valhalla, NY
We present a case of an 8 year-old child with combined IgA-IgG deficiency who also has a mitochondrial
complex 1,2,3 deficiency. The child was scheduled for endoscopic sinus surgery for frequent sinusitis
secondary to immunodeficiency. Anesthetic considerations for patients with mitochondrial complex
deficiency include avoidance of medications that cause oxidation stress to the mitochondria such as
propofol, aminoglycosides, and phenytoin. Patients should be maintained on glucose infusions and not
allowed to be fasted excessively. Intraoperatively, patients may display hypoventilation with spontaneous
ventilations due to muscle weakness. Over-sedation should be avoided.
MCC01
10:10 AM - 10:20 AM
Pain Medicine (PN)
Ketamine And Dexmedetomidine are a Useful Combination for Postoperative Pain Management
Control in a Major Orthopedic Surgery?
William Amaya Zuniga, Sr., M.D., Juan G. Ripoll Sanz, Sr., Student, Andrea Castro Correa, Mrs., Student,
Oscar Vasquez Gomez, Sr., M.D., Eduardo Hermida Barrera, Sr., M.D., Anesthesia, Fundación Santa Fe
de Bogotá, Bogotá, Colombia
A 74-year-old female with a history of chronic knee pain, with a previous knee replacement and a
pathological periprosthetic fracture came to the emergency room. A Femoral Osteosarcoma was
diagnosed, and the patient was scheduled for tumor resection and femoral prosthesis implantation.In the
operating room she refuses regional anesthesia/analgesia (neuraxial and femoral catheter) and inform
her NSAID allergy.The anesthesia management includes a combination of Ketamine and
Dexmedetomidine in order to improve pain control and decrease postoperative opiods consumption. The
pain management control during the postoperative period was evaluated with visual analogue scale
(VAS) with outstanding medical outcomes.
MCC01
10:10 AM - 10:20 AM
The Ethical End in Palliative Surgery
Harini Chenna, M.D., Laura Clark, M.D., Kristal Wilson, M.D., Anesthesiology, University of Louisville,
Louisville, KY
46 year-old agonal female with Stage 3b cervical adenocarcinoma, metastatic lung carcinoma, acute
renal failure (BUN 176, Cr 11.5, Hbg 4.5), bilateral hydronephrosis presented for an emergent
cystoscopy, bilateral ureteral stent placement, retrograde pyelogram, with recension of DNR.We present
the dilemma of the anesthetic options for an agonal patient as well as the ethical concerns that she may
not survive the anesthetic itself and the necessity for an interdisciplinary team approach. Due to the
precarious medical state of the patient, in light of the ethical concerns, a cooperative surgical approach
with a MAC anesthetic including ketamine was accomplished.
MCC01
10:10 AM - 10:20 AM
Pectoral Nerve Blockade for the Anesthetic Management of a Morbidly Obese Patient Undergoing
Mastectomy
Rita S. Shah, M.D., Michal Gajewski, D.O., Department of Anesthesiology, New Jersey Medical School,
Rutgers, the State University of New Jersey, Newark, NJ
Morbidly obese patients are at higher risk for respiratory failure, hypoxia, longer hospitalizations, and ICU
admissions. Such patients when undergoing breast surgery may benefit from pectoral nerve blockade
instead of general anesthesia or more time-consuming thoracic paravertebral blocks. Additionally,
pectoral nerve blocks don't carry the risk of administering a total spinal--an adverse complication of
paravertebral blocks. This case discusses the anesthetic management of a morbidly obese patient who
received medial and lateral pectoral neuraxial blockade for a mastectomy at our outpatient surgical
center. It details the efficient technique of performing the block, and the intraoperative/postoperative
analgesia with decreased narcotic consumption.
MCC01
10:10 AM - 10:20 AM
Repeated Intraoperative EKG Changes With A Negative Cardiac Work Up
Jennifer Dickerson, M.D., Lavinia Kolarczyk, M.D., Dominika James, M.D., Claude McFarlane, M.D.,
Anesthesiology, UNC Chapel Hill, Chapel Hill, NC
A 58 year-old woman with multiple cardiac risk factors presented for thyroidectomy with cardiac clearance
from her cardiologist. After induction, she developed profound hypotension, T-wave inversions and ST
depression. Intraoperative TEE demonstrated septal wall hypokinesis and LVH. The case was aborted,
and cardiology was consulted. Cardiac enzymes, TTE, and stress test were negative. She returned to the
OR three days later and again developed similar EKG changes after induction. The changes resolved
after repeated nitroglycerin administration, and the surgery proceeded without further complication.
MCC01
10:10 AM - 10:20 AM
When the Biventricular Assist Device System Loses Continuity: What to Do and Possible
Complications
Wesley A. Glick, M.D., Siang Ombaba, M.D., Janet L. Phelan, M.D., Anesthesiology, University of Illinois Chicago, Chicago, IL, Anesthesiology, Christ Advocate Hospital, Oak Lawn, IL
We present a 58 year-old female with acute, decompensating, nonischemic cardiomyear-oldpathy
maintained with combined biventricular assist devices (BiVAD). Witnessed circulatory arrest prompted
transfer to the OR for exploration and intervention. Femoral cardiac bypass was established, aggressive
resuscitation continued, and a left thoracotomy revealed the graft transporting blood from the RVAD to
the pulmonary artery trunk in discontinuity with deposition of near-complete blood volume into the left
thorax. The patient was liberated from bypass following repair, but due to TACO/TRALI, ECMO was
required for oxygenation following massive transfusion for DIC. The patient was transferred to the ICU
with open chest.
MCC01
10:10 AM - 10:20 AM
A Potential Airway Obstruction After Percutaneous Tracheostomy
Idania Mejias-Rodriguez, Hernando De Soto, M.D., Sanjiv Fitz-Morris Gray, M.D., Anesthesiology,
Surgery, UF Health, Jacksonville, FL, UF Health, Jacksonville, FL
A 57 year-old presented to the emergency department with a stab wound to the abdomen. Secondary to
prolonged intubation , the patient underwent percutaneous tracheostomy . Two days after downsizing to
an uncuffed Shiley tube, during routine maintenance of the tracheostomy site, it was found that a suction
catheter could not pass. Airway examination with a fiberoptic scope found a large piece of granulation
tissue in the trachea almost completely obstructing the lumen. After consultation with otolaryngology, the
patient was taken to the operating room and a false track or lumen was found where the granulation
tissue had been seen.
MCC01
10:10 AM - 10:20 AM
Neuraxial Anesthesia in a Patient With Pseudotumor Cerebri
Truc-Anh T. Nguyen, M.D., Marcos Izquierdo, M.D., Anesthesiology, Case Western University Metrohealth Medical Center, Cleveland, OH
A 35 year-old, Gravida 6 Para 3, female with a history of pseudotumor cerebri requested an epidural for
labor analgesia. The patient was diagnosed with the condition in 2012 and was taking Diamox regularly
with no current symptoms. The patient had an epidural placed successfully. She later underwent an
urgent Cesarean section secondary to non-reassuring fetal tracings. The patient had a successful
delivery without fetal compromise. The epidural catheter was removed after the procedure and she was
discharged on postoperative day 4. We discuss the possible anesthetic management techniques for labor
analgesia in a pseudotumor cerebri patient.
MCC01
10:10 AM - 10:20 AM
Failed Airway After Cervical Spine Surgery
Puneet Mishra, M.D., Amy Robertson, M.D., Tracy McGrane, M.D., Jonathan Niconchuk, M.D.,
Anesthesiology, Vanderbilt University, Nashville, TN
71 year-old presented with C1/C2 fracture and had occipital-C4 posterior cervical fusion. He was kept
intubated postoperatively. Seven hours later, after weaning sedation, he was awake, following
commands, and had a cuff leak. He was extubated and did well initially, but over the next 2 hours stridor
was noted. The anesthesiology team was called to re-intubate. Two attempts at indirect laryngoscopy
with McGrath were unsuccessful. LMA placement allowed for effective ventilation and oxygenation.
Fiberoptic intubation through LMA and through an ovosapien airway was attempted, but airway structures
were not identifiable. Surgeon called for surgical airway and proceeded with percutaneous tracheostomy.
MCC01
10:20 AM - 10:30 AM
Diagnosis of Prinzmetal's Angina During Preoperative Anesthesia Assessment Unit
Wissam Tobea, M.D., Gozde Demiralp, M.D., Department of Anesthesiology, University of Oklahoma
Health Sciences Center, Oklahoma City, OK
A 56 year-old African American male presented to the Preoperative Anesthesia Assessment Unit for
evaluation for robotic laparoscopic prostatectomy. During the assessment, patient complained of 5/10
chest pain with radiation to his left arm. 12-lead ECG displayed ST elevation on anterior leads and
inverted T waves on anterolateral leads. Patient was immediately sent to emergency department and
then taken to cardiac catheterization lab, urgently. Angiogram showed coronary vasospasm, which was
relieved with nitroglycerin administration indicating a vasospasm. Patient’s urine drug screen was positive
for amphetamines and cannabinoids at this time. Amlodipine and isosorbide mononitrate were initiated as
prophylaxis.
MCC01
10:20 AM - 10:30 AM
27 year-old Female in First Trimester of Gestation Who Presents for Exploratory Laparotomy Due
to Small Bowel Obstruction and Septic Shock
Alyssa E. Montana, B.S., Michael P. Hofkamp, M.D., College of Medicine, Texas A&M Health Science
Center, Temple, TX, Department of Anesthesiology, Baylor Scott & White Health, Temple, TX
We present a 27 year-old female who was nine weeks gestation and status post gastric bypass surgery
who presented from an outside facility in septic shock from a small bowel obstruction. The patient was
brought to the operating room for an exploratory laparotomy and bowel resection. Mean arterial blood
pressure was monitored with an arterial line and supported with a norepinephrine infusion. An arterial
blood gas showed a metabolic acidosis and relative hyperventilation was initiated. At the conclusion of
the procedure, the patient was brought intubated and sedated to the intensive care unit with an open
abdomen.
MCC01
10:20 AM - 10:30 AM
Dexmedetomidine Sedation for Percutaneous Endoscopic Gastric Tube Placement in the Patient
With a Difficult Airway
Katherine B. Hagan, M.D., Acsa M. Zavala, M.D., Joseph Ruiz, M.D., Anesthesiology, MD Anderson
Cancer Center, Kingwood, TX, Anesthesiology, MD Anderson Cancer Center, Houston, TX
A 51 year-old male presented for PEG 22 days post-op from a mandibulectomy with a free fibula
osteocutaneous flap. His tracheostomy was decannulated 10 days prior and had closed. His tongue was
swollen and he obstructed in any position other than 90 degrees upright. Mouth opening was severely
limited. We extensively counseled the patient and proceeded with only dexmedetomidine sedation in an
upright position. With this sedation regimen, we were prepared to fiberoptically intubate if needed.
However the PEG was successfully placed without further intervention. This represents an alternative
pathway for patients at increased risk of obstruction undergoing minor procedures.
MCC01
10:20 AM - 10:30 AM
Combined Thyroidectomy and Tracheal Resection: Airway Management Challenges
Christopher J. O'Connor, M.D., Brian McGrath, M.D., Kenneth Tuman, M.D., Anesthesiology, Rush
University Medical Center, Chicago, IL
We describe the case of a 43 y-old woman with an extensive thyroid cancer invading her trachea
producing severe tracheal stenosis that required a combined radical neck dissection, thyroidectomy and
tracheal resection. The challenge for the anesthesia team concerned the appropriate management of her
airway and the induction of anesthesia. Alternatives to airway management, including awake intubation
with a small endotracheal tube through the stenotic lesion, initial airway dilation by rigid bronchoscopy,
and the role of stand-by extracorporeal circulation, are discussed, along with a description of the
approach we employed and the team strategy used involving surgeon, nurses, and anesthesiologists.
MCC01
10:20 AM - 10:30 AM
Anesthetic Implications of a Total Body Negative Pressure Wound Dressing
Matthew D. Read, M.D., Carlo J. Alphonso, M.D., Daniel M. Bitner, M.D., Department of Anesthesiology,
San Antonio Uniformed Services Health Education Consortium, United States Army Institute of Surgical
Research Burn Center, San Antonio Military Medical Center, Fort Sam Houston, TX
A 35 year-old man with 87% total body surface area thermal injury, sustained from a motor vehicle
collision, underwent general anesthesia for excision and debridement, followed by autograft and allograft
placement and subsequent placement of a total body negative pressure wound dressing. Given anecdotal
evidence of cardiovascular collapse in prior similar situations, cardiopulmonary parameters were
monitored vigilantly while prepared to perform rescue maneuvers amidst application of negative pressure.
Ultimately, the patient survived several days in the negative pressure dressing prior to initiation of comfort
measures in the setting of invasive fungal infection.
MCC01
10:20 AM - 10:30 AM
Cesarean Delivery in a Parturient With Arrhythmogenic Right Ventricular Dysplasia
Morgane Giordano, B.A., Beata Evans, M.D., Ramon Abola, M.D., Joy Schabel, M.D., Anesthesiology,
Stony Brook University School of Medicine, Stony Brook, NY
Arrhythmogenic right ventricular dysplasia (ARVD) is a rare genetic cardiac disorder that is a rather
common cause of sudden death secondary to ventricular tachyarrhythmia in otherwise year-oldung,
healthy adults. There currently is no standard mode of delivery for pregnant women with ARVD. An
understanding of cardiac physiology can guide our anesthetic decisions in managing patients with ARVD.
The main goal involves maintaining hemodynamic stability of the parturient, especially those with signs or
symptoms of heart failure. This represents one of the few cases of the use of spinal anesthesia for a
parturient with ARVD and AICD placement for cesarean delivery.
MCC01
10:20 AM - 10:30 AM
Anesthesia Management of a Patient With Takotsubo Cardiomyopathy Undergoing Cerebral
Angiography and Treatment for Severe Cerebral Vasospasm
Anand V. Narayanappa, Christopher Morando, B.S., Valley Anesthesiology Consultants, Creighton
University School of Medicine-Phoenix Regional Campus, Phoenix, AZ
A 60 year-old female, post embolization of ruptured ACOM aneurysm, with Takotsubo cardiomyearoldpathy, presents to the angiography suite for treatment of cerebral vasospasm. Takotsubo cardiomyearoldpathy is a stress induced, non-ischemic cardiomyear-oldpathy. Treatment is supportive, and involves
avoiding inotropes. Treatment of cerebral vasospasm includes hypervolemia, hypertension, hemodilution,
and intra-arterial injection of nicardipine. The need for hypertension, often achieved with inotropes, stands
in contrast to the avoidance of inotropes for treatment of the cardiomyear-oldpathy. This presents a
challenge for anesthesia management. This case will demonstrate an effective anesthetic plan, and
management, for a patient being treated for cerebral vasospasm, with Takotsobu cardiomyear-oldpathy.
MCC01
10:20 AM - 10:30 AM
Anesthetic Management in a Patient With Complex I Mitochondrial Deficiency and Malignant
Hyperthermia Susceptibility
Lakshmi M. Geddam, M.D., Evonne Greenidge, M.D., Anesthesiology, George Washington University
School of Medicine, Washington, DC
Mitochondrial disorders are estimated to have a lifetime prevalence of 1 in 5,000 and are the most
common group of neuro-metabolic diseases (Haas). They require a different approach to the anesthetic
management, with avoidance of multiple drugs we typically use for anesthesia. We present a case of
anesthetic management in a 4 year-old male with Complex I mitochondrial disorder and possible MH
susceptibility undergoing a gastrocutaneous fistula closure.
MCC01
10:20 AM - 10:30 AM
Pain Medicine (PN)
Continuous Infraclavicular Nerve Block Catheter and Ketamine Infusion for CRPS I of Left Upper
Extremity
Ferdinand D. Iannaccone, D.O., Andrew Kaufman, M.D., Anthony Sifonios, M.D., Anesthesia, RutgersNJMS, Newark, NJ
Complex Regional Pain Syndrome I is a multifaceted condition with an imprecisely defined pathologic
pathway. Neuropathic, psychological and nociceptive derangements overlap to create an acute on
chronic decline in functionality. We present a patient who underwent placement of an infraclavicular nerve
block catheter that infused local anesthetic over the course of 2 weeks in order to give extended pain
relief enabling continued PT/OT. He also underwent intravenous ketamine infusion therapy lasting 4
hours. We objectively monitored sympathetic changes in his affected limb by monitoring temperature,
visible changes by regularly timed photography and functional changes by using a hydraulic hand
dynamometer.
MCC01
10:20 AM - 10:30 AM
Repair of Acute Type A Aortic Dissection In A Spanish-Speaking Jehovah’s Witness
Andrew M. Schroeder, M.D., Andrew J. Anderson, D.O., Richard L. Wolman, M.D., University of
Wisconsin, Madison, WI
A 36 year-old Spanish-speaking male Jehovah’s Witness presented with acute type A aortic dissection.
He initially refused surgical intervention secondary to his religious beliefs regarding blood transfusion. The
use of our institution’s unique standardized questionnaire identified the patient’s specific restrictions and
facilitated informed consent. Communication with the surgeon led to a modified staged surgical technique
with successful emergency hemiarch at 25°C and planned future TEVAR. Our blood conservation
technique included acute normovolemic hemodilution and cell salvage in continuity with the patient’s
circulation, albumin, cryear-oldprecipitate, PCC, rFVIIa, desmopressin, vitamin K, and other hemostatic
products with the patient’s consent.
MCC01
10:20 AM - 10:30 AM
Paravertebral Catheter Placement for Perioperative Pain Control in a Patient With Metastatic
Prostate Cancer
Jenna L. Falcinelli, M.D., Nicole R. Guinn, M.D., Brandi A. Bottiger, M.D., Richard E. Moon, M.D., Duke
University, Durham, NC
We present a challenge in postoperative pain control for a patient with metastatic prostate cancer with
vertebral metastasis. Debulking of his large retroperitoneal tumor with an extensive abdominal incision
was planned. Neuraxial anesthesia is frequently used for prostate cancer resection; however, since 90%
of all prostatic metastases involve vertebrae, and frequently bleed, epidural catheter placement could
precipitate neuraxial hematoma or edema with subsequent catastrophic spinal cord impingement. To
achieve effective analgesia, we chose bilateral paravertebral catheters with continuous 0.2% ropivicaine
infusion. In this case, we describe successful paravertebral catheter placement in lieu of neuraxial
analgesia for postoperative pain control.
MCC01
10:20 AM - 10:30 AM
Anesthetic Management of a Severely Symptomatic Patient Scheduled for Mediastinoscopy and
Biopsy of Anterior Mediastinal Mass
Bimal A. Patel, D.O., Marius Gota, M.D., Anesthesiology, Cardiac, Cleveland Clinic Foundation,
Cleveland, OH
41 year-old female with a history of hypothyroidism, congenital lymphedema, presenting with acute on
chronic dyspnea was found to have an anterior mediastinal mass and right lower lobe pulmonary
embolism. The patient was scheduled for mediastinoscopy with biopsy of mass under general anesthesia.
Due to the severity of symptoms and close proximity of the mass to the heart and trachea, a plan for
awake fiberoptic intubation and pre-induction femoral arterial/venous lines for cardiopulmonary bypass
was made. We will discuss the preoperative, intraoperative, and postoperative management strategies
necessary for patients presenting with an anterior mediastinal mass.
MCC01
10:20 AM - 10:30 AM
Anesthetic Management of a Patient With Highly Symptomatic Hypertrophic Obstructive
Cardiomyopathy (HOCM) With Recent ICD Placement for Recurrent Non-Sustained Ventricular
Tachycardia (NSVT) Undergoing Robotic Prostatectomy
Gabriel A. Pollock, M.D., Heike Knorpp, M.D., Anesthesiology, University of Illinois at Chicago, Chicago,
IL
This is the case of a 59 year-old male with highly symptomatic HOCM and recent ICD placement for
recurrent NSVT who underwent a robotic prostatectomy. HOCM is a rare condition which carries
significant perioperative risk for refractory shock, cardiac arrest, and other adverse outcomes. These risks
were considered particularly high for this patient with severe symptoms with 2 metabolic equivalents and
recent hemodynamically significant arrhythmias. Through development of an anesthetic plan that
accounted for this patient’s unique physiology and use of transesophageal echocardiography to manage
beta blockade and fluid status the procedure was completed without significant morbidity or mortality.
MCC01
10:20 AM - 10:30 AM
Life-threatening Recurrent Flash Alveolar Hemorrhage and Pulmonary Edema: When is it Time to
Extubate?
aisan raisdana, M.D., Katharina Beckmann, M.D., Anesthesiology, University of Illinois at Chicago,
Chicago, IL
A 25 year-old female with PMH of SLE complicated by CKD, PRES and CHF presented to our ICU
intubated for hemorrhagic flash pulmonary edema. Her hospital course was notable for three extubations
complicated by immediate recurrent hemorrhagic flash pulmonary edema necessitating re-intubation. The
third extubation was remarkable for difficulty ventilating and intubating due to significant airway trauma
and emergence of copious frothy secretion followed by PEA arrest. Patient was eventually re-intubated
and resuscitated, and then underwent extensive renal and cardiac workup leading to aggressive diuresis
and adjustment of immune-modulating therapy. She was ultimately extubated over tube exchanger and
discharged home.
MCC01
10:20 AM - 10:30 AM
Optimal Positioning for Difficult Epidural Removal
Lisa Marie Chargualaf, M.D., Ramesh M. Singa, M.D., Peter Scala, M.D., Robert Ciolino, M.D.,
Anesthesiology & Perioperative Medicine, Saint Barnabas Medical Center, Livingston, NJ,
Anesthesiology and Perioperative Medicine, Saint Barnabas Medical Center, Livingston, NJ
A 34 year-old G2P1 parturient presented to the hospital in active labor after spontaneous rupture of
membranes with a 50% effacement, cervical dilation of 7cm, and 0 station. Her labor progressed and she
underwent an uneventful epidural catheter placement and normal spontaneous vaginal delivery. Epidural
catheter removal after delivery was found to be difficult. Patient was positioned in a variety of ways with
multiple attempts to remove said catheter, with much difficulty. Optimal positioning was identified and
catheter was removed with tip intact, though markedly stretched Beyond its normal length.
MCC01
10:20 AM - 10:30 AM
A Case of Grade 3 Bone-Cement Implantation Syndrome (BCIS) in an Elderly Patient Undergoing
Total Hip Arthroplasty
David Vahedi, M.D., Dennis Dimaculangan, M.D., Michael Pedro, M.D., Steve Minear, M.D.,
Anesthesiology, SUNY Downstate Medical Center, Brooklyn, NY
BCIS is characterized by hypoxia, sudden loss of arterial pressure, pulmonary hypertension, arrhythmias,
loss of consciousness and cardiac arrest. Our patient was a 79 year-old male with history of
hypertension, hyperlipidemia, CKD, anemia, dementia, schizophrenia and multiple myeloma, who
presented with a pathologic fracture of the proximal femur requiring total hip replacement. The patient
was hemodynamically stable until shortly after bone-cement application, went into cardiac arrest. TEE
was immediately performed, which revealed an empty left ventricle,elevated PA pressures with RV failure
characteristic of BCIS. Resuscitation was initiated while the patient was in the left lateral decubitus
position.
MCC01
10:30 AM - 10:40 AM
Fatal Cerebral Air Embolism Complicating Endoscopic Retrograde Cholangio-pancreatography
(ERCP)
Abdalhai H.M. Alshoubi, M.D., Rosner, Rosner, Derek, D.O., Sergey Moldavskiy, D.O., Curtis Thacker,
D.O., Department of Anesthesiology and Pain Medicine, Baystate Medical Center, Springfield MA, Tufts
University Medical Center, Springfield, MA
61 year-old Female ASA-III underwent ERCP for cholelithiasis. Noting patient co-morbidities and A.M.
nausea and vomiting, the decision was made to proceed with RSI/general anesthetic. Upon emergence,
the patient experienced an episode of bronchospasm with hypoxemia to 70% that was treated and
resolved quickly with bronchodilators. Subsequently, the patient failed to emerge from anesthesia with
suboptimal cerebration. The initial work up of delayed emergence was unremarkable. An hour later, the
patient showed a Glasgow Coma Scale score of 4/15. An urgent head CT was normal. An MRI, 24-hours
later, revealed diffuse anoxic brain injury. The patient died 14 days later.
MCC01
10:30 AM - 10:40 AM
Unilateral Angioedema Following Routine Sinus Surgery
Phillip L. Telefus, Jeremy Goldfarb, M.D., Anesthesia, Boston Medical Center, Boston, MA, Anesthesia,
Massachusetts Eye and Ear, Boston, MA
A 60y male with chronic rhinosinusitis underwent uncomplicated sinus surgery. His PMHx is significant for
CAD, HTN, GERD. ACE-inhibitors caused hyperkalemia, but not swelling. He denied a personal or family
history of angioedema. Approximately two hours following surgery, he developed isolated left-sided
tongue swelling, initially felt to be mechanical injury, but quickly recognized as angioedema. Pruritis,
bronchospasm, or other signs of anaphylaxis were absent. He endorsed moderate dyspnea without
stridor and remained able to both protect his airway and manage secretions. He was treated with
corticosteroids and H1/H2 blockers with slow resolution. Testing, including complement, tryptase, and
RAST, was unremarkable.
MCC01
10:30 AM - 10:40 AM
Anesthetic Management of a Patient With Stiff-person Syndrome
Cassidy Schwab, M.D., Antolin S. Flores, M.D., The Ohio State University, Columbus, OH
A 48 year-old woman with Stiff-person syndrome (SPS) presented for pacemaker lead extraction due to
bacteremia. SPS is characterized by rigidity and spasm involving axial and limb musculature. Muscle
paralytics and volatile anesthetics have been associated with delayed awakening and post-operative
hypotonia in reported cases. She was unable lay flat secondary to pain and spasticity and used 3L
oxygen via nasal cannula; thus, general anesthesia was warranted. Pre-anesthetic management included
arterial line placement and preoxygenation. Following induction with propofol, anesthesia was maintained
with propofol and remifentanyl infusions with spontaneous ventilation. Post-operative extubation and
clinical course were uncomplicated without respiratory compromise.
MCC01
10:30 AM - 10:40 AM
Fatal Massive Intracardiac Thrombosis: Unexpected Complication During Repair of Complex
Aortic Dissection With Pseudoaneurysm
Jayakar G. Guruswamy, Cory Koenig, D.O., Raymond L. Cooper, M.D., Anesthesiology, Henry Ford
Hospital, Detroit, MI
Fatal intracardiac thrombosis is a rare event during cardiac surgery following CPB. 53 year-old male
underwent repair of complex aortic pseudoaneurysm under CPB. After administration of protamine for
reversal of heparin patient developed severe hypotension and thrombosis in all cardiac chambers. ACLS
was initiated and CPB resumed. All efforts to rescue proved unsuccessful. The cause of this dreadful
complication,which are unclear and the various treatment options available to manage this complication
will be discussed in the presentation.
MCC01
10:30 AM - 10:40 AM
Bronchial Laceration Requiring Extracorporeal Membrane Oxygenation After Intubation With an
Eschmann Stylet
Stephen L. Freiberg, M.D., Scott H. Mittman, M.D.,Ph.D., Anesthesiology and Critical Care Medicine,
Johns Hopkins Hospital, Baltimore, MD
A 31 year-old woman underwent rigid bronchoscopy and suspension microlaryngoscopy for dilatation of
multilevel tracheal and glottic stenosis. She developed hypoxemia and stridor in the PACU so was
emergently reintubated using an Eschmann stylet. She developed massive subcutaneous edema and
was found to have bilateral pneumothoraces and pneumoperitoneum as a result of a 3cm tear extending
from the carina to the left bronchus. The location of the tear required V-V ECMO for oxygenation and
ventilation, and a laparotomy to relieve the abdominal compartment syndrome. The lesion was repaired
via thoracotomy and the patient was decannulated from ECMO 3 days later.
MCC01
10:30 AM - 10:40 AM
Significant Diffuse Dermal Reaction of Unknown Origin After Epidural Placement for Labor
Analgesia
Ramesh M. Singa, M.D., Richard Pitera, Jr., M.D., Anesthesiology and Perioperative Medicine, Saint
Barnabas Medical Center, Livingston, NJ
An epidural was placed in a 34-year-old woman for pain control during labor. After delivery, our patient
experienced pruritis at her back, followed hours later by a diffuse maculopapular rash covering the back
and shoulders. Her symptoms were refractory to topical and oral anti-inflammatory drugs. She was
subsequently discharged to home three days later with no improvement. Complete resolution took one
month. She had patch testing three months after epidural placement -- none of the allergens
demonstrated on testing had been administered during placement of the epidural.
MCC01
10:30 AM - 10:40 AM
Unrecognized Thyroid Storm in Patient With Subarachnoid Hemorrhage
Jun-Young Chung, M.D., Sang-Il Yoon, M.D., Department of Anesthesiology and Pain Medicine, Kyung
Hee University Hospital at Gangdong, Seoul, Korea, Republic of
53 year-old-man with history of hyperthyroidism visited emergency department for severe bursting
headache. He appeared anxious, but had alert mentality. Cranial CT showed SAH with right MCA
aneurysm. Emergency operation was performed, because his mental status was suddenly changed. After
induction, heart rate and fever was gradually increased. So, we suspected thyroid storm and injected
esmolol and cortisol. After operation, patient was transferred to ICU. Thyroid function test revealed
increased T3 and free T4 level, so methimazole administration was started. At 4 day after operation,
thyroid hormone level was normalized and patient recover to alert mentality.
MCC01
10:30 AM - 10:40 AM
Arthrogryposis Child for Cleft Palate Surgery
Navjot Panesar, M.B.,B.S., Bejal Patel, M.B.,B.S., Tahzeeb Bhagat, M.B.,Ch.B., The Evelina Children's
Hospital, London, United Kingdom
We present a 15 month male with arthrogryposis for hard and soft palate surgery. These cases present
us with several challenges. They can be a difficult intubation as micrognathia and trismus are prevalent.
There can be problems with hypoventilation and aspiration of gastric content into the lungs due to
scoliosis, thoracic deformity and myear-oldpathy. Venous access can be difficult due to contractures.
Positioning and regional techniques can also be extremely challenging. Patients also exhibit increased
sensitivity to agents used in general anaesthesia (opiods, intravenous and inhalational agents), hence
they can manifest malignant hyperpyrexia or hypermetabolic reaction.
MCC01
10:30 AM - 10:40 AM
Pain Medicine (PN)
Bilateral Thoracic Paravertebral Catheter Placement for Mediastinal Chest Tube Pain: Case Report
Stephanie J. Pan, Zachary Fisk, M.D., University of Washington, VA Puget Sound Health System,
Seattle, WA
A 66 year-old male with chronic pain underwent CABG and aortic valve repair with 3 mediastinal chest
tubes (CTs). Post-extubation, he reported unbearable pain at the mediastinal CT insertion sites despite
appropriate interventions. Bilateral paravertebral catheters were placed at T7 under ultrasound guidance.
Immediately, his pain diminished substantially and incentive spirometry efforts improved. With continuous
infusions, patient’s pain scores remained between 0 and 4. PCA usage was minimal. No opioid related
side effects were noted. He remained hemodynamically stable without vasopressors. To our knowledge,
use of paravertebral blocks for pain associated with mediastinal CTs after cardiac surgery has not been
described.
MCC01
10:30 AM - 10:40 AM
Capacity and Competence in Medical Consent With an Adolescent Minor Refusing Urgent Surgery
Meera K. Kirpekar, M.D., Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
The notion of informed consent originates from the bioethical principle of autonomy, the patient’s right to
make their own decision, free from coercion from others. By law, minors lack the competence to make
their own medical decisions. However, medical, legal, and ethical challenges arise when the minor is a
developmentally appropriate and competent adolescent, whose voice must be taken seriously, and
dissent exists between the decision of the legal guardian and the patient’s wishes - such as in our case of
an adolescent refusing urgent surgery whose parents consented to surgery.
MCC01
10:30 AM - 10:40 AM
Regional Anesthesia in the Treatment of Sickle Cell Crisis
Kristina M. Coger, M.D., Melanie Donnelly, M.D., Anesthesiology, University of Colorado, Denver, CO
26 year-old male presents in a sickle cell crisis experiencing severe right knee/thigh pain. His history
includes sickle cell anemia, ESRD, and chronic pain. He was admitted for sickle cell crisis after
hemodialysis, and had a negative infectious and orthopedic workup. Home oral pain regimen is dilaudid 8
mg Q4H, lyrica 75 mg BID, acetaminophen 1 g Q6H, and methadone 10 mg Q6H. Patient was managed
with a dilaudid PCA without adequate pain control and he complained of 10/10 pain. APS was consulted
and placed a femoral nerve catheter. His dilaudid went from 106 to 9 mg/day and 2/10 pain.
MCC01
10:30 AM - 10:40 AM
Vector Flow Mapping Shows Mid-systolic Vortex Cause SAM After Ross Procedure of Congenital
AS
Koichi Aliyama, M.D., Chie Uenaka, M.D., Rie Soeda, M.D., Shihoko Okabayashi, M.D., Yoshifumi Naito,
M.D., Fumimasa Amaya, M.D.,Ph.D., Toshiki Mizobe, M.D.,Ph.D., Teiji Sawa, M.D.,Ph.D.,
Anesthesiology, Kyoto Prefectural University of medicine, Kyoto City, Japan
We report the SAM case after Ross procedure which was performed for valvular AS in a 5 years old boy.
On coming off CPB, TEE image showed MR and SAM. Therefore inotropic agents administration were
stopped, and hemodynamic condition was stabilized. Vector flow mapping showed mid systolic vortex
caused SAM and the LV energyloss was high.
MCC01
10:30 AM - 10:40 AM
A Case of Intraoperative Cardiac Arrest Secondary to Pneumopericardium During a POEM
Procedure
Jesse L. Saliga, M.D., John Stenglein, M.D., Randahl Cooley, M.D., Baystate Medical Center, Springfield,
MA
A 63 year-old male underwent an elective perioral endoscopic myear-oldtomy for symptomatic achalasia.
During the procedure pericardium was unknowingly punctured and the patient quickly developed severe
hypotension before losing pulses. CPR was initiated immediately. After ten minutes of adequate chest
compressions, vasopressor and inotropic support patient regained pulses and blood pressure. An
intraoperative chest X-ray showed large amount of gas in the pericardial cavity. Marked
pneumopericardium is a serious and potentially fatal complication of endoscopic procedures in the chest,
and should be considered in the differential diagnosis for sudden instability.
MCC01
10:30 AM - 10:40 AM
Takotsubo Cardiomyopathy Under Anesthesia
William D. Deskins, M.D., Rana Latif, M.D., Anesthesia, University of Louisville, Louisville, KY
This report describes a case of takotsubo cardiomyear-oldpathy (TCM) that occurred in a year-oldung
female patient undergoing direct laryngoscopy and possible bronchoscopy under anesthesia. TCM is a
transient syndrome of acute, reversible heart failure. Although clinically it mimics acute coronary
syndrome, it is not secondary to obstructive coronary artery disease. On echocardiography, the left
ventricle during systole demonstrates the shape of a pot with a narrow neck and a round bottom. The
etiology of TCM is unknown but hypotheses include elevated catecholamines from stress leading to
coronary artery vasospasm, microvascular dysfunction and impaired fatty acid metabolism causing
transient ventricular hypokinesis.
MCC01
10:30 AM - 10:40 AM
A Case of Severe Pulmonary Hypertension and Pregnancy
Helen Harvey, M.D., Martin Slodzinski, M.D., Ph.D., Anesthesiology and Critical Care Medicine, Johns
Hopkins, Baltimore, MD
Mrs. M is a 29 year-old woman with morbid obesity, hypertension, systemic lupus erythematosus (SLE)
and severe pulmonary hypertension who is 18 weeks pregnant and scheduled for termination of
pregnancy due to maternal risk factors via dilation and evacuation. Her mean pulmonary artery pressure
on right heart catheterization prior to starting therapy was 62 mmHg. Her pulmonary hypertension therapy
includes sildenafil and treprostinil infusion. Anesthetic plan involved an awake arterial line and a slowly
titrated lumbar epidural with avoidance of hypercarbia, hypoxia, acidosis and hypotension. She tolerated
the procedure without complications.
MCC01
10:30 AM - 10:40 AM
A Uniquely Challenging Airway: Prone Awake Nasal Fiberoptic Intubation
Markand Patel, M.D.., Shaun Patel, D.O..,Henry Kroll, M.D., Anesthesiology and Pain Medicine, Henry
Ford Hospital, Detroit, MI
40 year-old/m with PMHx of morbid obesity 800 lbs (BMI 114), hypertension, fractured ankle and confined
to bed , extreme weight gain, inability to lie supine due to SOB, in prone position for 2 years, developed
severe panniculitis and decubitus ulcers on chest/abdomen. Surgical debridement was deemed
necessary in the operating room. Anticipating a difficult airway and potentially difficult ventilation following
intubation, the decision was made to perform prone nasal awake fiberoptic intubation with ENT at
bedside. Patient was pre-oxygenated with the help of CPAP on ICU ventilator and with liberal use of local
anesthetic, airway was successfully secured.
MCC01
10:40 AM - 10:50 AM
Anesthetic Management of Patient With Large Obstructing Vallecular Mass
Luis L. Llamas, M.D., Gregory S. Milios, D.O., Hunter R. Graver, B.S., Department of Anesthesiology,
University of Texas Health Science Center at San Antonio, San Antonio, TX
The case is a 61 year-old male ASA 3 initially evaluated in clinic for dyspnea and dysphagia who comes
to the operating room for excision of a large obstructing vallecular mass. Prior to the case, the ENT
surgeon declares that the patient cannot be safely intubated via direct laryngoscopy and requests an
awake fiperoptic intubation. Intrapoeratively, the case was complicated by near-extubation, difficult
surgical removal, and post operative laryngospasm. The purpose of this presentation is to educate and
remind anesthesiologists that proper history and physical examination together with good preparation and
communication with surgeons prevents bad outcomes
MCC01
10:40 AM - 10:50 AM
Intra-abdominal Sepsis From Perforated Diverticulum in a Patient With Left Ventricular Assist
Device
Sarah J. Hemauer, M.D.,Ph.D., Brian Allen, M.D., Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN
64 year-old female with history of CAD, cardiomyear-oldpathy, s/p CABG with redo x2, ICD, LVAD placed
in 2013, on chronic anticoagulation, listed for heart transplant was admitted with pneumoperitoneum and
sepsis from perforated diverticular abscess. She underwent exploratory laparotomy, ileocecectomy and
drainage of large intra-abdominal abscess. Intraop, she experienced diffuse intra-abdominal bleeding and
was packed and transported to the ICU with open abdomen. LVAD use is increasing and infections with
LVAD patients are not uncommon, thus it is important that we are familiar with managing intraabdominal
comorbidities in LVAD patients, including interplay between sepsis and LVAD physiology.
MCC01
10:40 AM - 10:50 AM
To Transfuse Or Not: A Dilemma in Anesthetic Management of Intra-Operative Acute Hypotensive
Transfusion Reaction (AHTR)
Thao T. Alite, M.D., Nicole Renaldi, D.O., Anesthesiology, Thomas Jefferson University Hospitals,
Philadelphia, PA, Anesthesiology, Thomas Jefferson University, Philadelphia, PA
AHTR is a rare and self-limiting adverse reaction to blood product transfusion in subsets of patients
receiving Angiotensin Converting Enzyme Inhibitors (ACEI). With increased utilization of ACEI for multiple
medical conditions, the need to recognize and implement appropriate treatments for AHTR has become
increasingly important. We will discuss the intra-operative management of 2 cases of near death
episodes of hypotension secondary to blood transfusion. A 64 year-old male with HTN and pancreatic
adenocarcinoma who presented for Whipple procedure and a 73 year-old male on enalapril for HTN
undergoing left VATS for left lung carcinomatosis secondary to SCC of the neck.
MCC01
10:40 AM - 10:50 AM
Aortic Valve Replacement Complicated by Aortic Dissection Requiring Repair via Hypothermic
Circulatory Arrest
Michael R. Mathis, M.D., Sean Neill, M.D., University of Michigan, Ann Arbor, MI, Anesthesiology,
University of Michigan, Ann Arbor, MI
We describe a 37 year-old ASA 4 female with a history of bicuspid aortic valve, status-post aortic
valvuloplasty, complicated by aortic valve restenosis. For severe aortic stenosis, the patient underwent a
bioprosthetic aortic valve replacement. During aortic cannulation, an expanding hematoma within the
ascending aorta was visualized via transesophageal echocardiography. After a discussion with the
surgeon, the decision was made to cannulate the femoral artery for cardiopulmonary bypass, followed by
hypothermic circulatory arrest to facilitate ascending and hemiarch aortic repair. The aortic valve
replacement then proceeded uneventfully, highlighting the critical role of a vigilant cardiothoracic
anesthesiologist in guiding cardiac surgical interventions.
MCC01
10:40 AM - 10:50 AM
Persistent Reversible Cerebral Vasoconstriction Syndrome (RCVS) Despite Intra-arterial
Verapamil
Melissa Z. Murphy, M.D., Adam B. King, M.D., Department of Anesthesiology, Vanderbilt University
Medical Center, Nashville, TN
51 YF presented with a severe headache was found to have a left PICA aneurysm and underwent
subsequent coil embolization. Intraoperatively, the patient was noted to have RCVS and was treated with
intra-arterial verapamil. Post-operatively, she began experiencing right-sided weakness. CT showed
global vasospasm. Patient was emergently taken to the OR for repeat intra-arterial verapamil. Although
patient was neurologically stable throughout the ICU stay, PO verapamil, nimodipine, MgS and
vasopressors did not reverse the ongoing RCVS initially. Patient spontaneously recovered three weeks
later and was discharged home without neurological complications. Medical intervention and close ICU
monitoring resulted in good outcome.
MCC01
10:40 AM - 10:50 AM
Severe Post-Partum Hemorrhage Secondary to Uterine Inversion Complicated by Cardiovascular
Collapse and Suspected Amniotic Fluid Embolism
Anne H. Kancel, D.O., John Stenglein, M.D., Anesthesiology, Baystate Medical Center, Springfield, MA
A 29 year-old G1P1 female with PMHx of fetal alcohol syndrome was admitted at 41 weeks gestation for
induction of labor. Following a successful epidural, the patient underwent an unremarkable vaginal
delivery. After the subsequent delivery of the placenta, the patient began to hemorrhage. Manual exam
revealed a boggy uterus, unresponsive to uterotonics. STAT evaluation with ultrasound demonstrated
uterine inversion and the patient was taken immediately to the OR. Post induction, the uterus was quickly
reverted. Almost immediately, the patient experienced complete cardiovascular collapse and the
appearance of copious pulmonary edema, raising suspicion for an amniotic fluid embolism.
MCC01
10:40 AM - 10:50 AM
Left Temporal Craniotomy With Awake Speech Mapping
Sanaz Ghaffari, M.D., Ayrian Ayrian, M.D., Anesthesia, University of Southern California, Woodland Hls,
CA, Anesthesia, University of Southern California, Los Angeles, CA
Certain craniotomies are performed with lesions encroaching regions of the cortex responsible for
speech, motor, sensory, or vision. These surgeries usually involve intraoperative cortical mapping,
requiring the patient to be awake. In this case study, a 47 year-old woman was to undergo a left temporal
craniotomy with awake speech mapping. The anesthetic plan for the patient included the asleep-awakeasleep technique.
MCC01
10:40 AM - 10:50 AM
Cervical and Mediastinal Mass With Near Complete Tracheal Compression in a 3 Month Old
Lauren Licina, M.D., Albert Yeung, M.D., Weill Cornell Medical College, Department of Anesthesiology,
New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY
A 3 month old with progressive stridor presented with respiratory distress. Computed tomography
revealed a large cervical and mediastinal mass with encasement of the right carotid artery and near
complete tracheal compression. Respiratory distress persisted despite initiation of heliox. Due to concern
for complete airway collapse, a multidisciplinary team decided to urgently intubate in the operating room.
The patient was kept spontaneously ventilating and received atropine, topical lidocaine and ketamine for
rigid bronchoscopy, with advancement of an endotracheal tube Beyond the tracheal compression.
Additional sedation with maintenance of spontaneous ventilation was initiated for biopsy of the mass.
MCC01
10:40 AM - 10:50 AM
Pain Medicine (PN)
Continuous Peripheral Nerve Block for Treatment of Complex Regional Pain Syndrome I in
Children
Rishi Raj Agarwal, M.D., Patrick Tighe, M.D., Galaxy Li, M.D., Anesthesia, University of Florida,
Gainesville, FL
Treatment of complex regional pain syndrome I (CRPS-I) in children remains challenging due to the lack
of established treatment modalities. However, continuous peripheral nerve blocks (CPNB) may offer both
acute and chronic pain relief for this condition. We report on the treatment of lower extremity CRPS-I,
refractory to management with physical therapy, cognitive behavioral therapy, antiepileptics, ketamine,
and lumbar sympathetic block, in a 12 year-old male and a 17 year-old female using popliteal CPNB.
MCC01
10:40 AM - 10:50 AM
Supraglottic Jet Oxygenation and Ventilation Via Nasal Approach During Microlaryngeal Surgery
for Vocal Polyps Resection
Huafeng Wei, Hui Qiao, M.D., Wenxian Li, University of Pennsylvania, Philadelphia, PA, Department of
Anesthesiology, The Eye Ear Nose and Throat Hospital, Fudan University, Shanghai, China.
A 44 year-old female with bilateral vocal polyps scheduled for microlaryngeal surgery was anesthetized
and paralyzed. ‘No-tube’ was proposed instead of tracheal intubation to prevent obstruction of the
surgical field. Supraglottic jet oxygenation and ventilation (SJOV) vial nasal approach was performed
using WEI Nasal Jet Tube (WEI NASAL JET or WNJ, Figure 1) and provided an optimal, motionless view
of the surgical field. SaO2 was maintained above 98% throughout the surgery for 11 minutes, and the
PetCO2 was increased slightly to about 50 mmHg. The patient recovered well and no adverse events
were reported 24h postoperatively.
MCC01
10:40 AM - 10:50 AM
An Imperfect Paramedian Attempt: Incidental Discovery of an Intrapleural Catheter After
Paramedian Approach for Placement of aThoracic Epidural Catheter
Nathaniel J. Brown, M.D.,Ph.D., Matthew Fiegel, M.D., Anesthesiology, University of Colorado, Aurora,
CO
We present a case of a moderately difficult preoperative thoracic epidural placement attempt that resulted
in inadvertently introducing the catheter into the intrapleural space without puncture of lung parenchyma.
The approach to epidural catheter placement was right paramedian and standard confirmatory techniques
seemed to indicate successful placement. The catheter was later observed in the left thoracic cavity by
the operating surgeon. The patient suffered no neurological or pulmonary damage, had no shortness of
breath, coughing, or other symptoms; no adverse sequelae developed. The patient’s pain was managed
with low dose ketamine infusion and hydromorphone PCA.
MCC01
10:40 AM - 10:50 AM
Emergent Spine Surgery in a Trauma Patient: The Critical Importance of Obtaining Available
History
Christopher J. Hancock, M.D., Lavinia Kolarczyk, M.D., Kevin Powell, M.D., Department of
Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
54 year-old male trauma patient with multiple injuries presented emergently for management of T8
Chance fracture. Cardiopulmonary arrest occurred on scene, and had multiple injuries including bilateral
hemothoraces. He received multiple units of PRBC and vasopressors for hemodynamic support. History
obtained from family included "difficulty getting blood out of his heart,” but unknown diagnosis. Post
induction TEE revealed profound hypovolemia, severe mitral regurgitation with LVOT obstruction from a
redundant anterior leaflet (SAM physiology). Patient was resuscitated prior to surgical start and
vasoactive medications were weaned. This case stresses the importance of a thorough history and
management of SAM physiology.
MCC01
10:40 AM - 10:50 AM
Using Transesophageal Echocardiogram (TEE) to Identify Hepatic Outflow Obstruction Caused by
Cannulation of Inferior Vena Cava (IVC) for Extracorpeal Membrane Oxygenation (ECMO)
Mun Wong, M.D., Emil Malamud, M.D., Kalpana Tygaraj, M.D., Anesthesiology, Maimonides Medical
Center, Brooklyn, NY
A 58 year-old female developed acute respiratory failure from worsening interstitial lung disease caused
by dermatomyear-oldsitis requiring venovenous ECMO (VV-ECMO) support. On POD#2, patient
developed abnormally elevated hepatic enzymes (ALT 851 IU/L, AST 2194IU/L) and increased right lower
extremity edema. Decision was made to switch to smaller and shorter IVC drainage cannula via left groin.
Procedure was uneventful. Upon transferring patient from operating table to hospital bed, flow decreased
50 percent. TEE in long axis view of IVC showed distal tip of cannula migrated into the hepatic vein. The
cannula was repositioned and the ECMO outflow improved.
MCC01
10:40 AM - 10:50 AM
Citrullinemia: How The Uric Acid Cycle Can Still Haunt Anesthesiologists
Daniel Roshan, M.D., Barbara Jericho, M.D., Anesthesiology, University of Illinois at Chicago, Chicago, IL
Our patient is a 25 year-old woman with a history of Type 1 Citrullinemia who was scheduled for a
portacath placement. The patient initially presented to the ICU with one day of severe vomiting and
altered mental status and found to have hyperammonemia. The patient was treated appropriately and
fortunately had an uneventful operative course. Citrullinemia is a disorder of the Uric Acid cycle which
results in the accumulation of ammonium, manifesting as lethargy, seizures, hepatic dysfunction, coma
and death if not treated. This rare disorder presents unique challenges to the anesthesia provider which
requires a tailored plan.
MCC01
10:40 AM - 10:50 AM
Atrial Flutter During Elective Caesarean Section
William Cronin, Jin Lee, M.D., Tiffany Angelo, M.D., John Benjamin, M.D., Anesthesia, Walter Reed
National Military Medical Center, Bethesda, MD
A 29 year-old active duty multigravida woman with no prior cardiac history presented at 39 weeks
gestation for scheduled repeat elective cesarean delivery with a spinal anesthetic. Shortly after incision
the ECG demonstrated saw toothed p-waves at a rate of 100 to 200 beats per minute with varying A-V
conduction of 2:1-4:1. Patient endorsed sensation of heart palpitations but was otherwise asymptomatic.
Surgery proceeded without complication with return of normal sinus rhythm and 1:1 A-V conduction
immediately after delivery. Cardiology evaluated patient in PACU and deemed no further work-up
necessary. Patient recovered without issue and was discharged POD#2.
MCC01
10:40 AM - 10:50 AM
Successful Treatment of Acute Allergic Reaction to Tranexamic Acid During Total Knee
Arthroplasty
Adil Mohiuddin, M.D., shruti Shah, M.D., Shaul Cohen, M.D., Renu Chhokra, M.D., Christine W. HunterFratzzola, M.D., Anesthesiology, Rutgers-RobertWood Johnson Medical School, New Brunswick, NJ
A 64 year-oldF with PMH of peptic ulcer disease, osteoarthritis of both knees, no known allergies
presented for right total knee arthroplasty. Intraoperative tranexamic acid resulted in an acute allergic
reaction; hypotension, airway edema and obstruction requiring intubation and hemodynamic support. The
causes of hypersensitivity reactions can come from a variety of unexpected sources. It is important for the
anesthesiologist to remain vigilant to quickly identify and treat aggressively allergic reactions with
appropriate resuscitative measures.
MCC01
10:50 AM - 11:00 AM
Dealing With Known But Unanticipated Complications of Nasotracheal Intubation - The Clinical,
Social and Administrative Issues
Ahsan S. Syed, M.D., Senthil Gopalakrishnan, M.D., Giorgio Veneziano, M.D., Richard Cartabuke, M.D.,
Joseph Tobias, M.D., Anesthesiology and Pain Management, Nationwide Children's Hospital, Columbus,
OH
Recently we witnessed a nasally inserted endotracheal tube (ETT) perforating the retropharyngeal
submucosal space in 2 pediatric patients. This is a known, but unanticipated complication of nasotracheal
intubation. Both patients were scheduled for dental rehabilitation in ambulatory surgery centers. Both
patients required ENT consultation, prolonged antibiotic coverage, and an over-night hospital stay.
Families were informed about the need for nasal intubation at the time of the informed consent.
Anticipated complications of general anesthesia were discussed at length. However, these potential
complications of nasotracheal intubation were not addressed in detail preoperatively.
MCC01
10:50 AM - 11:00 AM
Perioperative Management of Systemic Mastocytosis
Kimberly M. Yongren, M.D., Adam Fischler, M.D., Scott Pompa, M.D., University of Connecticut,
Farmington, CT
Mastocytosis is a group of uncommon disorders associated with episodic mast cell mediator release and
accumulation of mast cells. Mastocytosis can be associated with perioperative immediate hypersensitivity
reaction that can be clinically indistinguishable from anaphylaxis. Mast cell degranulation can be triggered
by many factors commonly found in the perioperative period. We present a 51 year-old male with a
history of Indolent Systemic Mastocytosis admitted for gallstone pancreatitis and scheduled for
cholecystectomy. The patient was treated throughout the perioperative period with Diphenhydramine,
Ranitidine, Prednisone and Montelukast. The patient underwent an uneventful general anesthetic and
postoperatively course.
MCC01
10:50 AM - 11:00 AM
Management of an Emergent Nephrectomy in an Jehovah’s Witness With Severe Anemia and
Ongoing Blood Loss
Aladino DeRanieri, M.D., Pezhman Mehrabian, M.D., Hamid Vahabzadehmonshie, Anesthesiology,
Advocate Illinois Masonic, Chicago, IL
PREOP 50 year-oldM Jehovah’s witness with a seizure disorder, severe developmental delay POD 3 s/p
partial nephrectomy for renal mass. Pt with ongoing blood loss (hgb 11 to 3.8). Pt scheduled for emergent
ex lap and possible nephrectomy. OR Proceeded with GETA once ASA standard monitors and
defibrillator applied. Due to the tenuous hemodynamics minimal agents to avoid cardiovascular collapse.
Clot evacuation and nephrectomy proceeded uneventfully. Pt transferred intubated and sedated to SICU
due to severe anemia and reflexive tachycardia. POSTOP Patient mental state returned to his base line,
iron and erythropoietin were given to induce erythropoiesis.
MCC01
10:50 AM - 11:00 AM
Unexpected ECMO After Minimally Invasive Mitral Valve Repair
Nichole L. Townsend, M.D., Ricardo A. Weis, M.D., Mayo Clinic, Phoenix, AZ
A 56 year-old otherwise healthy male presented for minimally invasive mitral valve repair. Coming off
bypass dobutamine was started with good cardiac function; however oxygenation was inadequate despite
ventilation with 100% oxygen. Pulmonary edema fluid began rushing from the endotracheal tube,
occluding the circuit. Hemodynamics began to decline requiring epinephrine, norepinephrine and
vasopressin drips. Several minutes after a protamine test dose, the RV became increasingly hypokinetic,
then akinetic. CPR was started followed by reinitiation of bypass. After improvement of oxygenation and
hypercarbia, RV function improved. Given the continued pulmonary edema and concern for recurrent
cardiac failure, VA ECMO was instituted.
MCC01
10:50 AM - 11:00 AM
Liver Transplant Failure Secondary to Hepatic Artery Thrombosis in a Patient With Budd-Chiari
Syndrome and Heparin-induced Thrombocytopenia
Rachel C. Steckelberg, M.D.,M.P.H., Randolph H. Steadman, M.D., Zarah Antongiorgi, M.D.,
Anesthesiology and Perioperative Medicine, UCLA Ronald Reagan Medical Center, Los Angeles, CA
A 32-year-old female with end stage liver disease secondary to Budd-Chiari syndrome, anti-phospholipid
syndrome (status post hand amputation and pulmonary embolism), and heparin-induced
thrombocytopenia presented for liver transplant. She underwent OLT and was started on Bivalirudin.
Thrombosis of the hepatic artery (HAT) occurred repeatedly in the weeks to follow and she was taken
back to the OR for re-do hepatic artery anastomosis and to the IR suite for thrombolysis. One month later
she was taken for repeat OLT. Subsequently, the patient’s LFT’s returned to baseline and the patient’s
status improved. She was discharged to home with follow-up.
MCC01
10:50 AM - 11:00 AM
Anesthetic Management of New Onset Seizures in a Parturient With Essential Thrombocythemia
Maya Garala, M.D., Micheal Maloney, M.B.,B.Ch., Roulhac D. Toldeano, M.D.,Ph.D., Department of
Anesthesiology, University Hospital of Brooklyn- SUNY Downstate Medical Center, Brooklyn, NY
A 28 year-old G4P3 at 38 week gestation with a unknown history presented to our LandD unit after a
witnessed “whole body” seizure. Her blood pressure on arrival was 170/110. The patient complained of
headache, but denied all other symptoms. The obstetrics team initiated a magnesium sulfate infusion and
planned to proceed to cesarean delivery emergently. However, laboratory results were significant for a
platelet count of 1152 K and a review of her history revealed a recent diagnosis of essential
thrombocythemia. At this stage, cortical vein thrombosis and other intracranial lesions had to be ruled out.
MCC01
10:50 AM - 11:00 AM
Intraoperative Induction of Cardiac Standstill for Clipping of a Ruptured Intracranial Aneurysm
Matthew D. Read, M.D., Dimitar I. Dentchev, M.D., Department of Anesthesiology, San Antonio
Uniformed Services Health Education Consortium, Department of Anesthesiology, San Antonio Military
Medical Center, Fort Sam Houston, TX
A 38 year-old woman with rebleeding of an acute subarachnoid hemorrhage underwent craniotomy for
clip placement for a distal left basilar artery aneurysm, after failed attempt at angiography and coiling the
day prior. During attempts at placement of clips by the neurosurgeon, the aneurysm ruptured resulting in
loss of visualization of the aneurysm neck. Multiple escalating doses of adenosine were administered
intravenously, with the largest dose being 24 mg, for a total of 64 mg, to obtain cardiac standstill, thus
allowing adequate visualization of the aneurysm neck and subsequent successful placement of a
permanent clip,
MCC01
10:50 AM - 11:00 AM
Dental Restorations in a Pediatric Patient With a Family History of Malignant Hyperthermia
Chinwe I. Nwosu, Monique Bellefleur, M.D., Anesthesiology, University of Maryland, Baltimore, MD
A 3 year-old female with a family history of malignant hyperthermia (MH) was scheduled for dental
restorations. Preoperatively, the patient was given oral midazolam and an EMLA patch was applied to her
hand. She was taken to the OR for IV placement. General anesthesia was induced intravenously; she
was nasally intubated and maintained on a propofol/alfentanil infusion. Her procedure proceeded without
complication. As MH susceptibility testing was not performed prior to surgery, we believe this was the
safest anesthetic choice for our patient with a family history of malignant hyperthermia and an unknown
personal susceptibility.
MCC01
10:50 AM - 11:00 AM
Pain Medicine (PN)
Managing Pain in a Parturient With Rapidly Progressive ALS
Benjamin S. Maslin, M.D., Rajat Sekhar, M.D., Steven Liu, M.D., Anesthesiology, Yale University School
of Medicine, New Haven, CT
30 year-old G2P0 at term with rapidly progressive ALS with spastic and flaccid paralysis from neck down
requiring mechanical ventilation through tracheostomy presented for elective cesarean section. A
combined spinal-epidural was performed with intrathecal administration of 1.8 cc of 0.75% bupivacaine,
0.2 mg of morphine and 10 mcg of fentanyl. Immediate post-operative pain was controlled with epidural
0.0625% bupivacaine and 10mcg/cc dilaudid at 10 cc/hr. The patient developed neuropathic and myearoldfascial pain postoperatively which was managed successfully with baclofen and amitriptyline. She
exhibited no signs of autonomic hyperreflexia and reported excellent pain control throughout the
perioperative period.
MCC01
10:50 AM - 11:00 AM
Trigeminocardiac Reflex in Open Reduction For TMJ Dislocation
Yeo Jung Kim, M.D., Kyoung-ho Ryu, M.D., Anesthesiology, Wonkwang University Dental Hospital,
Daejeon, Korea, Republic of, Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital,
Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of
Trigeminocardiac reflex occurs after manipulation around any branches of the trigeminal nerve. There
have been only rare reports of such cases attributed to stimulation of division III. We report a case of
trigeminocardiac reflex in open reduction for TMJ dislocation.A 74 year-old female presented for TMJ
dislocation. Manual reduction was failed because of severe lateral pterigoid muscle contracture. Open
reduction under general anesthesia was decided. During surgical manipulation of right mandibular angle,
severe bradycardia(HR=20bpm) occurred. Immediately 0.5 mg atropine was administered intravenously,
and the surgical manipulation was stopped. After 60 seconds, heart rate normalized. The surgery was
completed uneventfully.
MCC01
10:50 AM - 11:00 AM
Epidural Anesthesia for the Treatment of Burn Pain
Charles Minh, Jessica Lovich-Sapola, M.D., Anesthesiology, Case Western / MetroHealth Medical
Center, Cleveland, OH, Case Western / MetroHealth Medical Center, San Diego, OH
Burn injuries can be one of the most painful and scarring forms of trauma, causing considerable suffering
and incapacitation. Pain management for burns is often difficult and despite advances in burn therapy,
inadequate pain relief remains a common problem. Reports of regional and neuraxial anesthesia for the
treatment of burn pain remains limited. We present a challenging case involving a patient with a history of
opioid abuse who suffered large surface area burns leading to substantial pain that was significantly
relieved by a lumbar epidural placed for peri-operative and post-operative pain control.
MCC01
10:50 AM - 11:00 AM
Placement of a Double Lumen Tube While Maintaining Spontaneous Ventilation in a 28 year-old
Female With a Large Anterior Mediastinal Mass
Jason B. McGrady, D.O., Chandrika Garner, M.D., Anesthesiology, Wake Forest Medical Center, Winston
Salem, NC
A 28 year-old female with substernal chest pain and dyspnea was found by CT to have a large anterior
mediastinal mass with compression of the pulmonary trunk and left brachiocephalic vein.A pre-induction
arterial line was placed and showed a 30 mmHg decline in SBP when 5 cm H2O of CPAP was applied.A
sevoflurane based inhaled induction was performed to allow spontaneous ventilation during placement of
a 35Fr double lumen tube under video laryngoscopy. Spontaneous ventilation was maintained until
positioning in the right lateral decubitus position allowed tolerance of a second trial of CPAP.
MCC01
10:50 AM - 11:00 AM
A Novel Approach to Type B Endovascular Aortic Aneurysm Repair
Beata M. Evans, Igor Izrailtyan, M.D., Thomas Bilfinger, M.D., Apostolos Tassiopoulos, M.D.,
Anesthesiology, Cardiothoracic Surgery, Vascular Surgery, Stony Brook Medicine, Stony Brook, NY
Patient with hypertension, CKD 4 presented for endovascular thoracic aortic aneurysm type B repair.
After smooth induction, intubation patient's stomach was suctioned and TEE probe was placed. In most, if
not all cases of endovascular aortic aneurysm at our institution we have relied on aortography,
angiography, TEE to determine the severity and extent of aortic aneurysm. They can be used to locate
site of initial tear, distal and proximal spread along with diameter, shape and aneurysmal plaque. We will
discuss aortography, angiography, TEE and IVUS techniques advantages and disadvantages.
MCC01
10:50 AM - 11:00 AM
Rupture of LTA Catheter Tip and Subsequent Aspiration During Emergency Endotracheal
Intubation in an Edentulous Patient
Sachin (Sunny) Jha, M.D., Anesthesiology, Rush University Medical Center, Chicago, IL
63 year-old female with acute respiratory failure with SpO2 80-90 on non-rebreather mask who required
emergent intubation. She was edentulous and was easily bag mask ventilated. Her oropharynx was
blindly prepped with a 4% lidocaine tracheal atomizer. Upon withdrawing the atomizer, the catheter tip
was ruptured despite the patient not having any teeth and tolerating placement without resistance. Oral
assessment failed to visualize the catheter. Intubation was then performed without issue. Chest x-ray
revealed possible radio-opaque foreign body at the right heart border. Bronchoscopy was performed and
the ruptured catheter tip was retrieved from the right main stem bronchus.
MCC01
10:50 AM - 11:00 AM
Anesthetic Management in a Parturient With Transverse Myelitis: Cesarean Section: To GA, or Not
to GA?
Tomas A. Lazo, M.D., Ola Harrskog, M.D., Brandon Togioka, M.D., Department of Anesthesiology and
Perioperative Medicine, Oregon Health and Science University, Portland, OR
We present a case of a pregnant patient who was found to have diagnosis of transverse myelitis on
review of systems prior to scheduled Cesarean section. We review the patient's perioperative course and
our medical decision making. In addition, we review current evidence for anesthetic options and their
risks/benefits in Cesarean-section patients, implications for patients with existing neurologic disease, and
recommendations for providing optimal care in this patient population.
MCC01
10:50 AM - 11:00 AM
Revisiting ESRD - A Case of Cardiac Arrest During Sedation in a Patient With Renal Disease
Eli Zarkhin, M.D., Surmeet Chhina, M.D., Bryan Tokarchic, M.D., Anesthesiology, Allegheny General
Hospital--Western Pennsylvania Hospital Medical Education Consortium, Pittsburgh, PA
End stage renal disease (ESRD) is a commonly encountered condition in the operative setting. Preoperative optimization, and intra-operative vigilance are key components to successfully caring for these
patients. We report the case of a 55 year-old female with ESRD on hemodialysis, along with several
comorbidities (systemic and pulmonary hypertension, cardiomyear-oldpathy, type 2 diabetes, sleep
apnea), who presents for outpatient vascular surgery under regional anesthesia. This patient had the
unfortunate complication of intraoperative cardiac arrest requiring CPR and tracheal intubation. Our report
highlights the unique risks and considerations that must be accounted for when providing anesthesia to
this patient population.
MCC01
11:00 AM - 11:10 AM
TPA in the PACU: Perioperative Stroke Management
Joshua M. Hauser, M.D., Vincent A. Diaz, M.D., Lauren Powell, D.O., Hanya A. Habib-Nabers, M.D.,
Arthur R. Mielke, M.D., SAUSHEC Anesthesia Residency, San Antonio Military Medical Center, San
Antonio Military Medical Center, San Antonio, TX
A 45 year-old male with known history of CAD, ten years post LAD stenting and angioplasty for in-stent
thrombosis, on aspirin therapy, presented for an elective left foot procedure. The patient had no other
major risk factors and excellent exercise tolerance. Patient underwent an uncomplicated
General/Regional anesthetic. Post-operatively right-sided facial droop, complete hemiplegia and altered
mental status were noted. Supportive care given in PACU and hospital stroke protocol was initiated.
Thrombolytics were administered in PACU following imaging and appropriate consultations with near
immediate motor improvement. IR directed intra-arterial thrombolytics were also administered. The patient
has since made a complete recovery.
MCC01
11:00 AM - 11:10 AM
Anesthetic Considerations for Eagle’s Syndrome
Jeffrey A. Krause, M.D., Sarah C. Parrish, B.A., Gozde Demiralp, M.D., Anesthesiology, University of
Oklahoma, Oklahoma City, OK, University of Oklahoma, Oklahoma City, OK
We would like to present the case of a patient who was provided general anesthetic for surgical treatment
of Eagle’s Syndrome, which is a rare disorder that anesthesiologists should be aware to diagnose
possible perioperative complications and to alter the anesthetic management. Eagle’s syndrome, also
known as stylohyear-oldid syndrome, includes a range of symptoms caused by elongation of the styloid
process and/or mineralization of the stylohyear-oldid ligament which compresses on regional structures.
Depending on the nearby anatomical structures, symptoms may include atypical facial neuralgia including
headache, tinnitus, vertigo, facial pain and even cerebrovascular accidents, most commonly transient
ischemic attacks.
MCC01
11:00 AM - 11:10 AM
Irreversible Electroporation in a Patient With an Implantable Electronic Cardiac Device
Aaron B. Dahl, M.D., Francis Salinas, M.D., Anesthesiology, Virginia Mason Medical Center, Seattle, WA
81 year-old male with a history of hepatocellular carcinoma (HCC) secondary to alcohol induced cirrhosis,
type 2 diabetes mellitus, hypertension and atrial fibrillation requiring an automated implantable
cardioverter/defibrillator and pacemaker set at DDDR 65-130. The patient presented for open irreversible
electroporation of a segment 3 HCC.The patient’s cardiac device was switched to DOO at 70 beats per
minute and general endotracheal anesthesia was induced following pre-operative placement of a thoracic
epidural. Transcutaneous and transesophageal pacemaker pads were placed and a cisatracurium
infusion was utilized to maintain intense neuromuscular blockade.
MCC01
11:00 AM - 11:10 AM
Severe ARDS After Bilateral Total Knee Repalcement
Lulu Ma, Yuguang Huang, Peking Union Medical College Hospital, Beijing, China
A 68-year-old female patient had bilateral knee repalcement under general anesthesia. Her past medical
history was unremarkable unless pacemaker implantation for Mobitz type II second-degree AV block. The
patient developed two episodes of transient hypoxemia after bone cement implantation and was
extubated uneventfully after the surgery. She developed progressive dyspnea and hypoxemia 3 hours
after the surgery and Spo2 was 80-85% with 10L/min oxygen using a face mask with reservoir bag. She
was re-intubated and severe ARDS was diagnosed.BCIS was suspected. She was extubated 7 days later
and discharged 10 days after the surgery.
MCC01
11:00 AM - 11:10 AM
Antepartum Epidural Catheter Placement in a Mutigravida Parturient With History of Factor VII
Deficiency
Phillip H. Mills, D.O., Anterpreet Dua, M.D., Anesthesiology, Georgia Regents University, Augusta, GA
24 year-old G2P1001 with medical history significant for factor VII deficiency that presented for routine
induction at 39 weeks gestation. On admission, coagulation studies displayed a PT of 14.1, INR of 1.3,
PTT of 27.4, and factor VII level of 42%. Following an extensive discussion of the increased risk of an
epidural catheter placement, the patient indicated that she understood the risks and preferred to continue
with the procedure. We discuss the pre-procedure laboratory analysis, possible complications,
appropriate patient populations, and post-procedural follow-up for epidural catheter placement in a
parturient with innate bleeding disorders such as factor VII deficiency.
MCC01
11:00 AM - 11:10 AM
Lactic Acidosis During Anesthesia for Glioblastoma Multiforme Resection: The Warburg Effect
David M. Rothenberg, M.D., Farhan Mazhar, M.D., Anesthesiology, Rush University Medical Center,
Chicago, IL
57 year-old female presented for an awake craniotomy for GBM resection involving the speech center.
Surgical history: gastroplasty and duodenal switch. Medication: dexamethasone. PE: mild gait
impairment.IV PlasmaLyte® was administered. Dexmedetomidine and propofol were
infused.Intraoperative ABG revealed a hyperchloremic and lactic acidoses. IVfs were changed to 1L
0.45% saline with 100 meq of sodium bicarbonate. She had no evidence of hypoperfusion, hypoxemia or
hepatic dysfunction. She only received 128 mg of propofol. Thiamine level was normal. Hyperlactatemia
was attributed to her GBM and the “Warburg effect.”
MCC01
11:00 AM - 11:10 AM
Injection Pressure Induced Alveolar Capillary Leak: Another Cardiac Catheterization Emergency?
Vassili Bazalitski, M.D., Enrico M. Camporesi, M.D., Dava L. Grundhoefer, M.D., SMMC/Palm Beach
Children's Hospital, TeamHealth Anesthesia, West Palm Beach, FL, Tampa General Hospital,
TeamHealth Anesthesia, Tampa, FL
9-week-old male previously diagnosed with absent right pulmonary artery presented for retrograde
pulmonary angiography to delineate anatomy and devise a plan for surgical repair. Immediately following
injection into right upper pulmonary vein patient developed severe bronchospasm and hypoxia,
responsive to beta-2 agonist (albuterol), ETT suctioning and higher PEEP. Apparently, high injection
pressure of radiographic contrast caused capillary leak and extravasation of contrast media into alveolar
space. Child was successfully resuscitated and no long-term adverse outcomes ensued.Anesthetic
vigilance during cardiac catheterization cases should be extended to include imaging process and
manipulations.
MCC01
11:00 AM - 11:10 AM
Pain Medicine (PN)
Chemical Meningitis Following Epidural Steroid Injection
Sunil B. Hari, M.D., M.S., Matthew B. Hoch, D.O., P. Jason Silvestri, D.O., Anesthesiology, Walter Reed
National Military Medical Center, Bethesda, MD
Following epidural or intrathecal steroid injections, a known potential complication is bacterial or viral
meningitis. Much more rarely described is chemical meningitis, where the meninges are inflamed from
contact with an injected agent, not from infection. We describe a case of chemical meningitis following an
epidural steroid injection, methods to differentiate this from other meningitides, and techniques to avoid
this rare sequela from a very common procedure.
MCC01
11:00 AM - 11:10 AM
Arrhythmic ECG Artifact and Falsely High BIS Caused by the Fluid Warming Device and the
Central Venous Catheter Malposition
Ann Hee Yo, M.D., Yongsoon Kim, M.D.,Ph.D., Anesthesiology and Pain Medicine, Kyung Hee University
Medical Center, Seoul, Korea, Republic of
A 60 year-old-female was scheduled for lumbar spine deformity correction with subclavian central venous
catheter inserted by radiologist prior to surgery. When the patient being in prone position during the
operation, arrhythmia was detected and high BIS up to 96 was observed. As the arterial line waveforms
were normal fortunately, we tried to find the reason causing ECG artifact and high BIS. Finally the fluid
warming device was identified as the cause by switching on/off or turning the 3-way stopcock. No
ECG/BIS artifact was induced by the device in supine position. The post-operative chest radiograph
suggested incorrect location of CVC tip.
MCC01
11:00 AM - 11:10 AM
Pain Management After laminectomy/Discectomy in Patient on Suboxone
Anna Barczewska-Hillel, M.D., Avinash D'Souza, D.O., Anesthesiology, Mount Sinai Roosevelt, New
York, NY
40 year-old former heroin addict on 16 mg of Suboxone maintenance was scheduled for L5-S1
laminectomy/ discectomy under GA. She was an inpatient on addiction unit and after long discussion with
surgeon,addiction specialist and patient decision was made to proceed and discharge patient from PACU
to addiction unit as this procedure is done as ambulatory. Options of postponing and stopping Suboxone
for 5 days, converting to methadone,were explored and for patient benefit she was placed on additional
Suboxone dose and managed by addiction unit postoperatively. Intraoperatively she received 250 mcg of
fentanyl which was adequate.
MCC01
11:00 AM - 11:10 AM
Systemic Ventricular Assist Device Implantation Forty-Three Years After Atrial Switch Operation
For Transposition of the Great Arteries
Sreekanth R. Cheruku, M.D., Alina Nicoara, M.D., Madhav Swaminathan, M.D., Carmelo Milano, M.D.,
Kamrouz Ghadimi, M.D., Anesthesiology, Surgery, Duke University Medical Center, Durham, NC
Dextro-transposition of the great arteries is a congenital heart malformation characterized by
atrioventricular concordance and ventriculoarterial discordance. The first surgical correction of this
condition was the atrial switch operation, in which an autologous baffle was used to redirect flow across
the inter-atrial septum. While this procedure was replaced by the arterial switch procedure, atrial switch
recipients continue to present to the peri-operative setting with late complications. We present the case of
a patient presenting forty-three years after his atrial switch procedure with systemic right ventricular failure
for a ventricular assist device. Peri-operative management and echocardiography will be discussed.
MCC01
11:00 AM - 11:10 AM
Management of an Adult Patient With Type III Osteogenesis Imperfecta Presenting for Mitral Valve
Repair
Keith D. Haller, D.O., Viviane Nasr, M.D., Anesthesiology, Boston Children's Hospital, Boston, MA
43 year-old male with Osteogenesis Imperfecta (OI) Type III, presented for mitral valve repair due to
severe mitral regurgitation. He was wheelchair bound with short stature, severe kyphoscoliosis and
restrictive lung disease. His history was notable for difficult intubations secondary to cervical fractures and
unintentional fractures of his extremities during prior surgeries. Patient positioned himself while awake to
avoid manipulation of his neck and extremities after anesthesia induction. He was intubated successfully
with a video-laryngoscope and a stylet. Airway management, avoidance of fractures during positioning
and the difficulty of healing following a sternotomy in OI patients are discussed
MCC01
11:00 AM - 11:10 AM
Right Upper Extremity Weakness and Altered Mental Status Following C-spine Fusion
Ameeka Pannu, M.D., Todd Sarge, M.D., Erin Ciampa, M.D.,Ph.D., Jason Wakakuwa, M.D., Galina
Korsunsky, M.D., Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess
Medical Center, Boston, MA
65 year-old developmentally delayed woman with epilepsy (seizure-free for 35 years off medication)
underwent posterior decompression with C3-7 fusion for severe cord stenosis. Although initially awake
and verbal on POD0, she became unresponsive to voice on POD1. Evaluation revealed normal vital signs
but unresponsiveness to sternal rub that progressed to confusion and RUE weakness. NCHCT ruled out
hemorrhagic stroke. Ischemic stroke considered unlikely due to waxing and waning exam. Neurology
consult determined the presentation was consistent with complex partial seizures related to sleep
deprivation with Todd’s paralysis that explained the motor findings. She returned to her baseline within
hours.
MCC01
11:00 AM - 11:10 AM
Epidural Anesthesia for C-Section in Pregnant Woman With AVM: A Case Report
Alberto J. Rivera Cintron, M.D., Dianne Fontanez, M.D., Manuel Torres, M.D., Ivette M. Hernandez, M.D.,
Luis Ortiz, M.D., Anesthesiology, University of Puerto Rico, School of Medicine, San Juan, PR
25 year-old G1P0 female with previous history of intraparenchymal hemorrhage due to arteriovenous
malformation (AVM), presented to the Operating Room for Cesarean Section at 39 weeks gestational
age. Anesthetic management of intracranial AVM poses multiple challenges to the anesthesiologist in
view of its complexity and absence of established guidelines; our primary goal was to maintain
cardiovascular stability. Therefore epidural anesthesia was chosen for anesthetic management. This case
demonstrates both the importance of recognizing the features of AVM and the predisposing factors that
could influence rupture and hemorrhage, as well as stable hemodynamics in applying anesthesia to
patients with this condition.
MCC01
11:00 AM - 11:10 AM
Anesthestic Management of the Super Morbidly Obese Patient With Multiple Untreated
Comorbidities During Emergent Laparoscopic Appendectomy
Megan L. Albertz, M.D., Daniela Orz, M.D., Anesthesiology, University of Illinois at Chicago, Chicago, IL
50 year-old male with a history of morbid obesity (BMI 75), HTN, OSA and CHF coming with perforated
appendicitis and needs emergent laparoscopic appendectomy. The patient has not taken his medications
in several months, and feels more short of breath than baseline. Physical exam is limited to assess
volume status secondary to body habitus. No pre-operative TTE available. Pre-induction A-line was
placed. Our patient was pre-oxygenated well for 5 minutes, standard IV induction and intubated with
glidescope. Intraoperative TEE was utilized to assess volume status and cardiac function. Pt was taken to
the ICU intubated and extubated on post-operative day 2.
MCC01
11:10 AM - 11:20 AM
Airway and Anesthetic Management of a Adult with Seckel Syndrome
Yvon F. Bryan, Ashley Hodges, B.S., Loren Bauman, M.D., Nichole Taylor, D.O., Anesthesiology, Wake
Forest School of Medicine, Winston-Salem, NC
A case of a 23 year-old, uncooperative female with Seckel syndrome who presented for ophthalmologic
exam and dental restorations with possible extractions. She presented several airway and anesthetic
concerns due to her cognitive dysfunction, uncooperative nature, aggressive behavior, and history of poor
IV access. Additionally, the parents were anxious over starting an IV and her potential in communicating
her need for postoperative pain medications. This case demonstrates issues of potential difficult airway
including intubation and ventilation as well as the use of premedication and induction of anesthesia
including comforting and teaching a distraught family over the issues involved with her care.
MCC01
11:10 AM - 11:20 AM
Spurious Hypoxia and Hemolytic Anemia Following Administration of Isosulfan Blue
Jennifer R. Jutson, M.D., Brooke Chidgey, M.D., Department of Anesthesia, University of North Carolina,
Chapel Hill, NC
A 77 year-old female had spurious hypoxia following injection of isosulfan blue for melanoma removal and
sentinel node biopsy. Decreases in oxygen saturation of 5-6% have been well documented with use of
blue dyes. However, in this case saturations dropped 10-12%, and the patient had noticeable
discoloration of the skin. The situation was further complicated by severe anemia with hemoglobin of 4.7
mg/dL and numerous antibodies on screening for blood transfusion. Further work up was consistent with
hemolytic anemia; however, it remains unclear if this was an acute or chronic process. Labs for
methemoglobinemia and sulfhemoglobinemia were negative.
MCC01
11:10 AM - 11:20 AM
Anesthetic Management of a Patient Presenting With Extreme Hypercarbia and Hypoxia Following
Protamine Administration During Coronary Artery Bypass Grafting
Mamatha Kadiyala, M.B.,B.S., Jesse Saliga, M.D., Anesthesiology, Baystate Medical Center, Springfield,
MA
A 51 year-old male with past medical history of Type 2 DM presented for CABG x 4. He was weaned from
cardiopulmonary bypass uneventfully.15 minutes following administration of protamine patient developed
severe hypercapnia and hypoxia. The first sign was a decline in his 02 sats. Blood gas showed PCo2 of
90. He started to require fluid and vasopressor support. Bronchoscopy was performed. Malignant
hyperthermia was ruled out due to lack of metabolic acidosis.PA pressures were low normal and TEE
showed underfilling with normal function. Leading diagnosis was protamine reaction. Serum tryptase
came back elevated at 74.8 indicating anaphylaxis
MCC01
11:10 AM - 11:20 AM
Massive Transfusion Protocol and Intraoperative Coagulopathy: The Role of TEG
Vanja Contino, M.D., Leah Meisterling, D.O., Anesthesiology, University of Connecticut - Hartford
Hospital, Hartford, CT
A 57 year-old male with RUL adenocarcinoma presented for robotic-assisted lung resection. Intraoperative course was complicated with injury to the pulmonary artery, requiring conversion to open
thoracotomy, initiation of CPB and massive transfusion protocol, and decompression laparotomy for
abdominal compartment syndrome. Patient’s post-operative course was complicated with ARF requiring
CVVH, pulmonary embolism, development of HIT after initiation of Heparin drip and cardiac tamponade
requiring pericardial window. Despite this, patient was discharged home. Case is being presented for the
discussion of how TEG (thromboelastogram) may improve outcomes when used in combination with
MTP-giving the right products at the right time.
MCC01
11:10 AM - 11:20 AM
Uncorrected TOF and Pregnancy: Severity and Outcome
Maria R. Fuertes, M.D., Jaya Ramanathan, M.D., Anesthesiology, Regional One Health, Memphis, TN
21 year-old from Mexico with uncorrected TOF presented at 36 weeks gestation. Cardiovascular
abnormalities included: TOF with Pulmonary Valve Atresia, Mild Aortic Valve Insufficiency, Pulmonary
Arteries arising from a collateral vessel off of the descending aorta Weight was 75.8 pounds, 64 inches
tall with BMI of 15. SOB with exertion and Peripheral Cyanosis. Baseline saturation were in the
80s.Patient received epidural prior induction of labor but she did not tolerated the stress of contractions
presenting with tachycardia and hypotension. She had urgent C Section . We used Esmolol to treat
intraoperative tachycardia. Mother and baby tolerated the procedure well.
MCC01
11:10 AM - 11:20 AM
Acute Cardiovascular Collapse in a Down'’s Syndrome Patient Following Prone Positioning for
Cervical Laminectomy and Fusion
Alexander D. Cohen, M.D., Penny Liu, M.D., Stefan Ianchulev, M.D., Maurice Francis Joyce, III, M.D.,
Anesthesiology, Tufts Medical Center, Boston, MA
A 33F with Down’s Syndrome and no other history was brought to the OR electively for cervical
laminectomy and fusion for symptoms thought related to cervical myelopathy. Pre-operative evaluation
was notable for history of VSD with spontaneous closure and non-reassuring airway. Patient was taken to
the operating room, and general anesthesia was induced without complication. Immediately after prone
positioning, patient became profoundly hypotensive and the procedure was aborted. Intra-operative TEE
found previously unknown cardiomyear-oldpathy. Resuscitation was successful and the patient was
transferred to the NCCU intubated on norepinephrine. Post-operative evaluation found undiagnosed
cardiomyear-oldpathy related to her DS.
MCC01
11:10 AM - 11:20 AM
Severe Hypothyroidism in a Pediatric Patient Presenting for Orthopedic Repair of Bilateral Slipped
Capital Femoral Epiphyses
Ariyah S. Yeskel, M.D., Peter Lichtenthal, M.D., Department of Anesthesiology, Banner University
Medical Center, Tucson, AZ
An obese (89 kg) 11 year-old female presented to our institution with bilateral slipped capital femoral
epiphysis (SCFE) and was scheduled for urgent repair. The perioperative team expressed concern for an
underlying endocrine etiology given the patient’s year-oldung age, bilateral presentation and body
habitus. A preoperative thyroid function test showed a TSH of 453.5 and Free T4 level < 0.4. Surgery was
delayed pending further workup of her hypothyroidism given the risks associated with surgery and
anesthesia in hypothyroid patients. Following three weeks of outpatient treatment the patient’s thyroid
panel normalized and she underwent bilateral hip pinning without complication.
MCC01
11:10 AM - 11:20 AM
Pain Medicine (PN)
Underdiagnosed Bone Metastatic Cancer in a Patient With Coccygodynia
Yoomi Kim, SoYoung Kwon, St. Vincent Hospital, Suwon, Korea, Republic of
An 87 year-old female came to clinic for coccygeal pain. Her symptom was started 1 month ago, and
didn't have any associated symptom.She had diagnosed complete remission from rectal cancer 10 years
ago, and she hadn't gotten follow-up research after that. There was no evidence of fracture on x-ray, but
sonogram for nerve block showed the irregularity of bony cortex.She needed additional diagnostic
procedure, and according to MRI and bone scan, bone metastatic lesion in coccygeal area was
suspected.She was referred to orthopedics, and pathologic finding from incisional biopsy was
adenocarcinoma.
MCC01
11:10 AM - 11:20 AM
Anesthetic Management of a Patient With Familial Dysautonomia
Liliya Pospishil, M.D., NYU, New York, NY
34 year-old man with FamilialDysautonomia and multiple medical problems resulting from natural
diseasecourse (severe GERD, bradycardia with PPM, dysphagia, COPD with CO2 retention,
severescoliosis, epilepsy) who was scheduled for robotic left lower lobe lungresection due to recurrent
pneumonias. Intra-op he exhibited severe autonomic liability.Familial dysautonomia is an autosomal
recessive disorder characterized bysensory and autonomic neuropathy leading to autonomic instability.
Varioussurgical procedures are now being performed to reduce morbidity in patientswith familial
dysautonomia. We discuss anesthetic considerations for hemodynamicand respiratory management in
patients with this disorder.
MCC01
11:10 AM - 11:20 AM
General Anesthesia With Supraclavicular Nerve Block for Ulnar Nerve Transposition in a Patient
With Chronic Pain
Charles A. Sibley, M.D., Kurt Bolin, M.D., Christopher Maani, M.D., Anesthesiology, San Antonio
Uniformed Services Health Education Consortium, San Antonio, TX
35year-old active duty male with right cubital tunnel ulnar nerve compression underwent ulnar nerve
transposition revision. His past medical history was notable for PTSD, suicidality, chronic pain requiring
methadone, spinal cord stimulator, recurrent pulmonary embolisms currently enoxaparin-bridged, OSA,
and a right clavicle fracture. After discussion with surgeons and patient, we elected for a combined
regional and general anesthetic. An ultrasound with stimulation guided supraclavicular nerve block was
performed prior to general anesthetic. Maximizing multimodal analgesia, the operation proceeded
uneventfully. Patient had 0/10 pain on PACU arrival and was discharged uneventfully.
MCC01
11:10 AM - 11:20 AM
Awake Cardiopulmonary Bypass for Excision of Massive Substernal Goiter
Giuseppe Giuratrabocchetta, M.D., Linda W. Yong, M.D., Thiruppathi Sureshkumar, M.D.,
Anesthesiology, UF Health Jacksonville, Jacksonville, FL
41 year-old obese female with substernal goiter, scheduled for excision. On CT, right thyroid lobe
measuring 17 x 6.5 x 7.3 cm, tracheal narrowing with marked leftward shift. Management included
cardiopulmonary bypass (CPB) prior to induction of anesthesia. In the OR, a radial arterial line was
placed, and the right femoral artery and vein were accessed by the cardiothoracic surgeon with infiltration
of bupivacaine. Patient's oxygenation was assured through CPB, and induction of anesthesia was
performed with propofol and rocuronium administered by the perfusionist. After intubation, with good
ventilation, adequate oxygenation and normal peak airway pressures, CPB was discontinued.
MCC01
11:10 AM - 11:20 AM
Importance of Bedside Transthoracic Echocardiogram in Diagnosis of Cardiac Tamponade After
Catheter Ablation
Nathan M. Lee, M.D., Lev Deriy, M.D., Neal Gerstein, M.D., Anesthesiology and Critical Care Medicine,
University of New Mexico, Albuquerque, NM
A 69 year-old female with symptomatic persistent atrial fibrillation underwent an uneventful catheter
ablation with return to normal sinus rhythm. In recovery, she became tachycardic and hypotensive to
systolic pressures in the mid-60s. The anesthesiologist was called to assess. After starting an IV fluid
bolus, he performed a bedside transthoracic echocardiogram that demonstrated a significant pericardial
effusion around the right ventricle with prominent diastolic collapse. Cardiology performed an emergent
pericardiocentesis, with immediate stabilization of patient's blood pressures upon drainage of 350cc of
blood and placement of a pigtail catheter. Patient was transferred to ICU for monitoring and discharged
on POD 1.
MCC01
11:10 AM - 11:20 AM
Lung Re-expansion Injury Following Large Thoracoabdominal Aneurysm Repair
Joel Wood, M.D., Moltu Guy, M.D., Martha Wynn, M.D., Anesthesiology, University of Wisconsin Hospital
and Clinics, Madison, WI
The patient is a 68 year-old 69 kg female with COPD, 50 pack-year smoking history, asthma, dysphagia
and HTN who underwent repair of a 13 cm TAAA under CPB and DHCA. The aneurysm was causing
profound compression of the left lung and tracheobronchial tree. Intra-operatively, she developed
hypoxemic respiratory failure secondary to left lung re-expansion and re-perfusion injury. Her postoperative course was complicated by hypovolemic shock requiring vasopressor and inotropic support,
hypoxemic hypercarbic respiratory failure, severe pulmonary HTN necessitating inhaled nitric oxide
therapy, anuric AKI on CVVH, NSTEMI, HIT, bilateral SAH and post-operative mortality.
MCC01
11:10 AM - 11:20 AM
A Not So Straight-Forward Epidural
Yang Long, M.D., Marie-Louise Meng, M.D., Richard Smiley, M.D.,Ph.D., Anesthesiology, New YorkPresbyterian/Columbia University Medical Center, New York, NY
30 year-old with severe restrictive lung disease due to arthrogryposis (145cm and 37kg) resulting in
kyphoscoliosis and respiratory insufficiency requiring BiPAP (extreme CO2 retention, FEV1 19%, FVC
24%, FEV1/FVC 71%) hospitalized for repeat Cesarean delivery (CD) at 37 weeks gestation. History of
failed neuraxial anesthesia for previous CD. Given the difficult anatomy and pulmonary issues, a low dose
combined spinal epidural was performed (spinal: bupivacaine 4.5mg, fentanyl 7.5 mcg, morphine 50mcg).
Ultrasound identified “midline” and sacrum. Epidural catheter was dosed intraoperatively and
supplemented with ketamine infusion. BIPAP was used throughout the case. Postoperative pain was
controlled with an epidural infusion.
MCC01
11:10 AM - 11:20 AM
Anesthetic Management of a Contained Ruptured Infrarenal Mycotic Abdominal Aortic Aneurysm
Undergoing Open Repair
Alexa C. Kaminski, M.D., Oren T. Guttman, M.D., Anesthesia and Pain Management, University of Texas
Southwestern Medical Center, Dallas, TX
A 73 year-old male was transferred from OSH, hypotensive and short of breath, where he was being
acutely managed for salmonella bacteremia/sepsis, atrial fibrillation with RVR, COPD, recent NSTEMI,
CHF exacerbation, found to have LE weakness and enlarging vs. ruptured AAA. Upon arrival, he was
taken to the OR urgently, and successfully underwent an open repair of a contained ruptured infrarenal
mycotic abdominal aortic aneurysm and left hemicolectomy. Our anesthetic management required an
expedited preoperative evaluation, careful OR preparation/set-up, cautious induction, substantial colloid
transfusion and vigilant cardiac monitoring throughout this difficult and prolonged case.
MCC01
11:20 AM - 11:30 AM
Preoperative Laryngeal Videostroboscopy to Plan Airway Management in a Patient With a Vocal
Cord Mass
David M. Gordon, M.D., David M. Dickerson, M.D., Department of Anesthesia and Critical Care,
University of Chicago Medical Center, Chicago, IL
Laryngeal videostroboscopy is done to evaluate the function and motion of the vocal cords. We present
airway management assisted by preoperative videostroboscopy for a patient with a vocal cord
lesion.CASE REPORTThe patient was a 70 year-old female with a left true vocal cord lesion scheduled
for removal with CO2 laser. Preoperative review of a laryngeal videostroboscopy study was used to plan
the optimal entry point for the endotracheal tube to pass the vocal cord mass. Review of preoperative
laryngeal videostroboscopy is important for planning airway management in the setting of airway masses.
MCC01
11:20 AM - 11:30 AM
Now You See it, Now You Don’t: Airway Difficulty Due to Ankylosing Spondylitis Complicated by
Neck Radiation
Catherine Kuza, M.D., Raimis Matulionis, M.D., Anesthesiology, University of Massachusetts Medical
School, Worcester, MA
A 78 year-old male presented for coronary bypass surgery. His medical history included laryngeal
carcinoma treated with radiation and cervical spine ankylosing spondylitis. The patient exhibited a chinon-chest deformity, as well as small glottic opening resulting from neck radiation. An asleep fiberoptic
intubation was performed; however, it took 4 attempts with different maneuvers and decreasing the
endotracheal tube size to intubate the patient. We present a case of difficult intubation in a patient with
ankylosing spondylitis and history of neck radiation. We will describe the disease and its complications,
as well as implications in anesthetic airway management.
MCC01
11:20 AM - 11:30 AM
Airway Management in a Patient With Toxic Epidermal Necrolysis
Jay R. Vyas, M.D., Samuel DeJoy, M.D., Anjay Khandelwal, M.D., Dept. of Anesthesiology, Department
of Surgery, MetroHealth Medical Center, Cleveland, OH
A 24 year-old healthy female was transferred to our institution after skin biopsies were consistent with
Toxic Epidermal Necrolysis. She was advised to undergo urgent debridement. Pertinent airway exam
findings included a very limited mouth opening, limited neck mobility, and diffuse lesions inside the oral
cavity. The decision was made to intubate via a glidescope. There was significant airway edema and
copious sloughing of the mucosal epithelial layer upon insertion of the glidescope. The patient was
successfully intubated after multiple attempts. The endotracheal tube was secured via intra-oral dental
fixation using silk suture.
MCC01
11:20 AM - 11:30 AM
Internal Mammary Artery Injury During Subclavian Venous Access
Ashraf F. Banoub, M.D., MBA, Christopher Riordan, M.D., Anesthesiology, Promedica Health System,
Cardiothoracic Surgery, Promedica Health System, Toledo, OH
52 male quadriplegia, osteomyelitis intravenous antibiotics. PICC line unsuccessful, left subclavian line in
left mediastinum no pneumothorax. Hemodynamically stable, CVL removed subsequently the patient
developed acute tachycardia left chest pain HR 113, BP 112/57 . CT large anterior mediastinal hematoma
12.4x8.3x13.5 cm mass effect ,active extravasation related to the internal mammary artery. OR urgently,
Malampatti IV airway requiring awake fiber-optic intubation. TEE compression of the LA cavity with under
filled LV, compression of the RV outflow tract and proximal PA with extrapericardial hematoma. Surgical
exploration, median sternotomy, lacerated LIMA. Tracheostomy
MCC01
11:20 AM - 11:30 AM
Todd's Paralysis From Dynamic Hyperinflation and Severe Brady Hypotension After One-lung
Ventilation
aya Konishi, Sr., M.D., Obata Katsuyoshi, Ph.D., Yoshinaga Kouichi, M.D., Iizuka Hospital, Iizuka, Japan
Dynamic hyperinflation describes the phenomenon of progressive gas trapping that occurs in patient with
severe airflow obstruction.It associated with significant hemodynamics instability.Following hemodynamic
collapse secondary to dynamic hyperinflation in patient during one lung ventilation,we report a case of
Todd's paralysis.A 81 years old male,with pulmonary fistula secondary to right upper lobecyearoldmy,was transferred to the operating room for closing the pulmonary fistula.After the operation ,we
returned the patient from lateral decubitus to supine position,sudden ST segment elevation and
bradycardia hypotension occurred.The patient was immediately resuscitated.The next day,he became a
left hemiplagia.After three day,he was full recover.It was likely Todds paralysis.
MCC01
11:20 AM - 11:30 AM
Accidental Intrathecal Catheter and Continuous Spinal Anesthesia for a Cesarean Section for a
Parturient With PDA
Kay H. Lee, M.D., Shamantha Reddy, M.D., Anesthesiology, Montefiore Medical Center, Bronx, NY
A 26 year-old female came for an elective Cesarean section at gestational age of 39 weeks. The patient
had baseline tachycardia and Patent Ductus Arteriosus, which was recently diagnosed in the second
trimester of pregnancy. Prior to the pregnancy, she had no known medical problems. Epidural anesthesia
was planned for the surgery, which was complicated by an accidental dural puncture. It was immediately
decided to pursue with an intrathecal catheter, and the surgery was performed successfully under spinal
anesthesia. The intrathecal catheter was removed immediately after the surgery. The patient was
discharged on post-op day 2 without any Post-Dural Puncture Headache.
MCC01
11:20 AM - 11:30 AM
Perioperative Airway Management of an Adult Patient With Pierre-Robin and Hurler's Syndromes
With Symptomatic Cervical Spinal Cord Compression
Robert T. Naruse, M.D., Otto Thomas, M.D., Jennifer Ross, M.D.,Ph.D., Nadeem Hamid, M.D.,
Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
22 year-old female with Pierre-Robin AND Hurler’s Syndromes was scheduled to undergo C1-4
laminectomy for cervical cord decompression. Surgical history included emergent tracheostomy
necessitated by failure to intubate/ventilate. Airway examination revealed micrognathia with short
thyromental distance. PEAE revealed easy access to the glottis transnasally. IV induction was performed
with the patient’s head/neck maintained with in-line-stabilization. Rocuronium was administered AFTER
effective bag-mask ventilation was established. Transoral fiberoptic intubation was easily performed
through an Ovassapian airway. Pre and post intubation SSEP’s were unchanged. Surgery was completed
5 hrs later. Patient was extubated on POD #1 over an airway exchange catheter.
MCC01
11:20 AM - 11:30 AM
Emergent Craniotomy for Epidural Hematoma Drainage in Patient With Osteogenesis Imperfecta
Gregory T. Simmons, M.D., CamilaLyon, M.D., Anesthesiology, Vanderbilt University, Nashville, TN
We describe a pediatric patient with osteogenesis imperfect type III and multiple fractures who underwent
an emergency craniotomy. 8 year-old F with hx of osteogenesis imperfecta type III presents from the ED
after falling from chair as level 1 emergency craniotomy for evacuation of epidural hematoma. PMH:
Multiple fractures of bilateral upper extremities with baseline deformities. Radiographic evidence of new
fractures of C7, T2, T6 in addition to epidural hematoma.Intraoperative Course Access: 2 peripheral IVs,
radial arterial line Positioning: Memory foam mattress, log roll, no neck movement (cervical collar and/or
in-line stabilization, video laryngoscopy)
MCC01
11:20 AM - 11:30 AM
Pain Medicine (PN)
Undiagnosed Metastatic Lung Cancer Presenting to the Pain Clinic as a Brachial Plexopathy
Ngano F. Takawira, M.B.,Ch.B., Anesthesioly, University of Rochester , New York, Webster, NY
A 57 year-old female who was a former smoker was referred to our pain clinic for evaluation of left
shoulder pain associated with left hand numbness.A 3-month-old cervical MRI had only showed
degenerative changes.Physical exam revealed reduced sensation over left thenar eminence, left axilla
and left lateral chest wall as well as left thenar wasting.Clinically we suspected a left brachial plexopathy
and ordered further imaging and tests which showed showed widespread metastasis to her thoracic and
cervical vertebra from an aggressive primary lung tumor that also involved the brachial plexus.
MCC01
11:20 AM - 11:30 AM
Anesthetic Management for Ovarian Teratoma in a Patient With Anti-NMDA Receptor Encephalitis
Raphael G. Rocha, M.D., Thadeu Alves Máximo, M.D., walkiria wingester vilas boas, Department of
Anesthesiology, Hospital das Clínicas of Federal University of Minas Gerais, Hospital Municipal Odilon
Behrens, Hospital das Clínicas of Federal University of Minas Gerais, Belo Horizonte, Brazil
Anti-NMDA receptor encephalitis is a treatable neuroimmune disease arising from the generation of
antibody targeting synaptic proteins, most commonly the N-methyl-D-aspartate receptor (NMDAr). This
illness is closely associated with ovarian teratoma in year-oldung women. Teratoma resection usually
improves symptoms significantly. Patient management is challenging, since most anesthetic agents
interact with NMDAr and may therefore lead to unexpected effects, or even worsen the clinical
presentation. This case report describes a successful use of the Total Intravenous Anesthesia technique
with remifentanil- dexmedetomidine combined with the transversus abdominis plane block and BIS
monitoring for ovarian teratoma resection in 20 year-old women with anti-NMDAr encephalitis.
MCC01
11:20 AM - 11:30 AM
You Stuck It Where? Transient Nerve Deficit After Anterior Sciatic Single Shot Peripheral Nerve
Block
Braden J. Hestermann, M.D., Adam Braden, M.D., Christopher V. Maani, M.D., Department of Anesthesia
and Operative Services, Brooke Army Medical Center, San Antonio, TX
26year-old male, 4th year medical student, presented for right knee arthroscopy and meniscal repair
following soccer injury. As an aspiring surgeon, he elected for regional anesthesia to allow him to actively
engage in his perioperative care. He received single shot femoral and anterior sciatic peripheral nerve
blocks placed utilizing nerve stimulation with addition of ultrasonography to facilitate anterior sciatic
approach. Although without paresthesia or acute issue during placement, during follow up at 96 hours the
patient reported persistent sensory deficit in peroneal nerve distribution. He elected to continue
monitoring and reported complete resolution of his sensory deficit two weeks post-operatively.
MCC01
11:20 AM - 11:30 AM
Anesthetic Management for Resection of Tumor Tracking From Right Adrenal to Right Atrium
Robert L. Kong, M.D., Jessica Spellman, M.D., Desmond Jordan, M.D., Anesthesiology, Columbia
University Medical Center, New York, NY
A 50 year-old woman with known NSCLC who underwent a left upper lobe lung resection followed by
craniotomy for resection of brain metastasis now presented with a one month history of dyspnea and
lower extremity edema. A large tumor from the right adrenal to right atrium was discovered. A surgical
resection was performed, attempts to remove the tumor without cardiopulmonary bypass were
unsuccessful. The liver was severely congested due to tumor, and large amounts of ascites were drained.
Post bypass the patient experienced profound coagulopathy. TEE post bypass demonstrated no visible
residual tumor. She was successfully extubated POD 1.
MCC01
11:20 AM - 11:30 AM
Left Ventricular Aneurysm After Acute Myear-oldcardial Infarction
David Williams, M.D., Ruben G. Alexander, M.D., Ketan Shevde, M.D., Anesthesiology, SUNY Downstate
Medical Center, Brooklyn, NY
An 83 year-old female with multiple co-morbidities presented with chest pain and was found to have a
STEMI. After cardiac catheterization and angioplasty, initial echocardiogram showed preserved EF.
Subsequent echocardiograms showed progressive heart failure with development of LV aneurysm
requiring urgent open heart procedure. Intraoperative course had significant hemodynamic lability and
difficulty with weaning from CPB. Intraoperative TEE confirmed LV aneurysm and significant VSD. The
cardiac defects were repaired, patient taken to CTICU intubated, requiring vasopressors. Patient expired
due to cardiac failure. An accurate and timely diagnosis of LV aneurysm following MI is necessary for
expediting intervention and maximizing outcome.
MCC01
11:20 AM - 11:30 AM
A Rare Case of Mast Cell Activation Syndrome Manifested As Postoperative Cardiovascular
Collapse and Bleeding
Navneet Kaur, Colin Boettcher, M.D., Elif Cingi, M.D., Ioanna Apostolidou, M.D., Anesthesiology,
Universty of Minnesota Medical Center, Edina, MN, Universty of Minnesota Medical Center, Minneapolis,
MN
A 73year-old male with ESRD secondary to DM, CAD, CHF and HTN developed worsening hypotension
in PACU after kidney transplantation. Initially, hypotension was attributed to hypovolemia (confirmed by >
50% inspiratory IVC collapse by TTE) and gradual onset anemia that was treated with fluids and blood.
Within 20 minutes the patient developed cardiovascular collapse that lead to cardiac arrest requiring
resuscitation, vasopressors, and surgical reexploration that revealed 2500mL of intraabdominal blood.
Over the course of 48hrs the patient had 2 surgical explorations for similar episodes of cardiac arrest and
bleeding. Workup in the ICU revealed mast cell activation syndrome.
MCC01
11:20 AM - 11:30 AM
Sacral Sparing in an Intrathecal Labor Anesthetic
Rockford S. Wright, M.D., Joel Feinstein, M.D., Anesthesiology, University of Alabama- Birmingham,
Birmingham, AL
The patient was a 24 year-old, 135 kg woman for whom a labor epidural was requested and, after
accidental dural puncture occurred, an intrathecal catheter was placed. Following adequate analagesia
for 12 hours the patient developed sacral sparing. Despite a bolus of isobaric bupivicaine 0.125% and
achievement of an adequate superior analgesic level, sacral sparing continued. This rare case of sacral
sparing was successfully treated with 0.5mL hyperbaric bupivacaine 0.75% and keeping her sitting up for
20 minutes. This regimen was repeated about every 4 hours with resolution of her sacral pain complaint
until she delivered via C-section.
MCC01
11:20 AM - 11:30 AM
Was Everything But the Kitchen Sink Much Ado About Nothing? Managing Pulmonary
Hypertension in the Context of Multiple Comorbidities
James J. McKeever, M.D., Kenneth Sutin, M.D., Levon Capan, M.D., Anesthesiology, NYU Langone
Medical Center, New York City, NY
A 54year-old female with pmh of moderate to severe pulmonary hypertension, RV failure, MR/TR,
obesity, OSA on CPAP, hypertension, CKD, PSA on methadone, WPW s/p ablation, depression, was to
go for exploratory laparotomy, total abdominal hysterectomy, BSO for adnexal mass.In consultation with
the surgical team, it was decided the patient would undergo GETA for the surgery. The anesthesia plan
consisted of GETA, awake arterial line placement, central venous line, PA catheter and interop
TEE.Patient did well throughout an uncomplicated procedure, was extubated in the OR, and remained in
SICU for 24 hours before transferring to surgical floor.
MCC01
11:30 AM - 11:40 AM
Anesthetic Management of a Patient With Von Gierke’s Disease
Aram Shahinyan, M.D., Yohannes B. Getachew, M.D., Anesthesiology, Geisinger Medical Center,
Danville, PA
We describe the perioperative course and management of a rare case of a 24-year-old patient with Von
Gierke’s disease (VGD) who underwent a first-stage tympanomastoidectomy. The patient was allowed to
take starch PO until 3 hours prior to the start of his general anesthesia and he was managed with
intravenous dextrose infusion perioperatively to maintain normoglycemia and frequent measurement of
venous blood gas and lactate levels. Despite the tight blood glucose control and adequate hydration the
patient developed severe lactic acidosis (14.9 mmol/L) in the postoperative period and had an unplanned
hospital admission.
MCC01
11:30 AM - 11:40 AM
Anesthetic Management of a Patient With a Severe Case of Atypical Malignant Hyperthermia
Bianca M. Conti, M.D., Christine Lim, Student, Trauma Anesthesiology, R Adams Cowley Shock Trauma
Center - University of Maryland, Baltimore, MD, University of Maryland Medical School, Baltimore, MD
27 year-old undergoing ORIF of humerus has no PMH, or allergies. Neither he nor any family has surgical
history. He received propofol, fentanyl, rocuronium, isoflurane. An hour after tourniquet release his ECG
deteriorated to wide complex and arrest. ACLS drugs, calcium and dantrolene given in two doses and a
drip. Potassium was 11.4 mmol/L, lactate 13.8 mmol/L, CO2 was 64 mmHg treated with increasing
minute ventilation to 13 L/min. Temperature was 38C and treated with cooling blankets; a TEE,
intraoperative dialysis and fasciotomies for diffuse rhabdomyear-oldlysis were performed. Followup
genetic testing proceeded for a diagnosis of MH with atypical presentation.
MCC01
11:30 AM - 11:40 AM
Possible Malignant Hyperthermia in the Setting of Hypothermic Circulatory Arrest for Type A
Aortic Dissection Repair
Bryant Bunting, D.O., Stephen McHugh, M.D., Joshua Knight, M.D., Anesthesiology, University of
Pittsburgh UPMC, Pittsburgh, PA
59year-old M presented from outside hospital with Type A dissection for emergent surgical repair. On
arrival patient noted to be difficult to ventilate requiring high inspiratory pressures but proceeded to the
OR where eventual diagnosis of malignant hyperthermia is made during hypothermic cardiopulmonary
bypass in preparation for circulatory arrest. Requirement of high sweep speeds for CO2 removal from
circuit contributed to diagnosis. MH episode suspected to be triggered by prehospital administration of
succinylcholine.
MCC01
11:30 AM - 11:40 AM
Intraoperative Circulatory Failure In a Case of Unknown Severe Aortic Stenosis
Irina Fishman, M.D., Feroze-Ud-Din Mahmood, M.D., Anesthesia, Critical Care and Pain Medicine, Beth
Israel Deaconess Medical Center, Boston, MA
76 year-old male with a complex medical history including severe PVD, ESRD on hemodialysis, CABG,
afib, and severe pulmonary hypertension presented for palliative bilateral femoral endartectomy. 10
minutes following an uneventful induction/intubation, the patient’s MAP acutely dropped to the 30’s with a
loss of etCO2. He received 4 units of vasopressin and boluses of ephedrine with sudden return of BP and
etCO2. An intraoperative TEE revealed newly found critical aortic stenosis. The surgery was aborted and
the patient was transferred to the ICU where he was later extubated and discharged home the following
day.
MCC01
11:30 AM - 11:40 AM
Deja Vu: A Case of Recurrent Peripartum Cardiomyopathy
Cody Murphy, M.D., Alex J. Cravanas, M.D., Brian Ferguson, D.O., Kari Beth Christie, M.D.,
Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
25 year-old female (G2P1) with hypertension, developmental delay, morbid obesity, and a history of
peripartum cardiomyear-oldpathy presented with a 2 week history of shortness of breath and bilateral
lower extremity swelling. Routine laboratory evaluation revealed a positive serum pregnancy test. An
intrauterine pregnancy (25 weeks estimated gestational age) was confirmed via ultrasound. A subsequent
echocardiogram revealed severe left ventricular hypokinesis with an estimated ejection fraction of 10%,
severe right ventricular hypokinesis, and a left ventricular thrombus. The presentation will include the
anesthetic considerations and management of this patient in the antepartum, peripartum, and postpartum periods.
MCC01
11:30 AM - 11:40 AM
Management of Lumbar Drain During Thoracoabdominal Aortic Procedures-Blood in CSF
Anna Barczewska-Hillel, M.D., Agathe Streiff, M.D., Anesthesiology, Mount Sinai Roosevelt, New York,
NY
80 year-old was scheduled for TEVAR. Lumbar drain was requested by surgeon for spinal cord protection
as Class I indication and CSF was drained to pressure of 10cm H2O. After smooth iv induction and
intubation patient was HD stable until sudden EBL of 1L. Hypotension to 60 systolic was immediately
treated with pressors and transfusion. During the procedure ACT was in 2.5 baseline range. At the end of
the procedure blood was noted in CSF. Patient had delayed emergence with generalized
weakness.Neurosurgery was consulted, CT of the head and lumbar spine were negative and she
improved gradually over 48 hours.
MCC01
11:30 AM - 11:40 AM
Airway Management for Fetus With Prenatally Diagnosed Mandibular Cystic Hygroma in the
Setting of Maternal Refusal for Ex Utero Intrapartum Treatment
Christina A. Jelly, M.D., M.S., Anna Ward, M.D., Michael Leeman, M.D., Pacifico Tuason, M.D.,
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
Ex utero intrapartum treatment (EXIT) is a surgical procedure performed during Cesarean section to allow
safe management of fetal airways at risk for airway compression with preservation of fetal-placental
circulation. We present a case of a fetus with a prenatal diagnosis of cervical cystic hygroma concerning
for life-threatening airway compromise upon delivery born to a G6P5 female patient who refused the EXIT
procedure. The fetus was delivered vaginally in the OR with epidural analgesia and the neonate
demonstrated a cry at delivery and then was intubated via rigid laryngoscopy for airway protection with
subsequent tracheostomy placed several hours after delivery.
MCC01
11:30 AM - 11:40 AM
Pain Medicine (PN)
Clinical Effectiveness of Ganglion Impar Block on Chronic Vulvar Pain Syndrome
Yong-Min Park, M.D., Junmo Park, M.D.,Ph.D., Jae-Min Yang, M.D., Seong-Wook Hong, M.D.,Ph.D.,
Hoon Jung, M.D., Si-Oh Kim, M.D.,Ph.D., Anesthesiology and Pain medicine, Kyungpook National
University Medical Center, Daegu, Korea, Republic of
We treated four patients suffered from chronic vulvar pain for 3 months to more than 10 years with
ganglion impar block under C-arm guidance. We performed ganglion impar block one time to two
patients, two times to one, and four times to one (included neurolysis with alcohol). Initial visual analogue
scale (VAS) scores were from 6 to 9. After performing the procedure, VAS scores were decreased to less
than 4 in all patients. In one patient, symptom was completely improved. In the other three patients,
medication was giving. Follow up period was 3 months to 2 years.
MCC01
11:30 AM - 11:40 AM
Successful Use of High-Frequency Jet Ventilation For An Obese Patient Undergoing
Endobronchial Carcinoid Tumor Ablation
Paula Trigo Blanco, M.D., Robert G. Stout, M.D., Anesthesiology, Yale New Haven Hospital, New Haven,
CT
A 53 year-old male with history of HTN, obesity,OSA and persistent wheeze, was found to have near
complete obstruction of leftmain bronchus by an invasive carcinoid tumor.Patient presented to the
operating room for rigid bronchoscopy withtumor ablation. After ASA standard monitors were placed,
general anesthesia wasinduced and easy manual ventilation confirmed. Rigid bronchoscope was inserted
withoutcomplication and high-frequency jet ventilation initiated. Total intravenousanesthesia with propofol
and fentanyl were used for maintenance. Once the tumorwas completely excised, jet ventilation was held
and rigid bronchoscoperemoved. Patient resumed spontaneous ventilation and transferred
postoperativelyto PACU
MCC01
11:30 AM - 11:40 AM
Regional Anesthesia as Primary Anesthetic for Total Knee Arthroplasty in a Patient With Severe
Congestive Heart Failure and Dilated Cardiomyopathy
Puneet Mishra, Clifford Bowens, M.D., Anesthesiology, Vanderbilt, Nashville, TN
66 year-old male with nonischemic dilated cardiomyear-oldpathy, congestive heart failure (ejection
fraction 15-25%), moderate right ventricular dysfunction status post biventricular implantable cardioverter
defibrillator, hypertension, and osteoarthritis, presenting for left total knee arthroplasty. After discussion
with cardiology, anesthesiology, surgery, and the patient, a regional approach with peripheral nerve
blockade was determined to be the safest due to cardiovascular risks of general and spinal anesthesia.
The patient received ultrasound guided lateral femoral cutaneous, femoral, and obturator nerve blocks. A
subgluteal sciatic nerve block was performed with nerve stimulation technique. The patient received
minimal sedation intraoperatively and had an uneventful postoperative course.
MCC01
11:30 AM - 11:40 AM
Transcatheter Mitral Valve Replacement for Stenosis of a Prosthetic Mitral Valve
Nishita D. Patel, Chandrika R. Garner, M.D., Anesthesiology, Wake Forest School of Medicine, Winston
Salem, NC
Our patient is a 69 year-old female status post mitral valvereplacement presenting with stenosis of the
prosthetic mitral valve. Given herage and previous surgical history, she underwent a catheter based mitral
valvereplacement via the transapical approach under general anesthesia withtransesophageal
echocardiography guidance. The patient’s mean mitral inflow gradienton transesophageal
echocardiography decreased from 16 mm Hg to 3 mm Hgfollowing mitral valve replacement. A small
paravalvular leak directed towardsthe left atrial appendage was noted on the post procedure exam but
was resolvedon a subsequent transthoracic echocardiography exam obtained one month later.
MCC01
11:30 AM - 11:40 AM
Type A Aortic Dissection Complicated by Acute Renal Failure and an Above the Knee Amputation
Sirisha A. Rao, M.D., Ann Marie Melookaran, M.D., Gerard McCloskey, M.D., Department of
Anesthesiology, Yale University School of Medicine, New Haven, CT
59 year-old male with no significant past medical history presented after sudden onset of substernal chest
pain and progressive numbness of his right leg while shoveling snow. CTA demonstrated a type A
dissection originating at the aortic root and extending to the right common femoral artery. The patient was
emergently brought to the operating room for an ascending aneurysm repair, re-implantation of coronary
buttons under deep hypothermic arrest and mechanical AVR, followed by a right Ileofemoral
thrombectomy with femoral-femoral-graft. The patients post -operative course was further complicated by
acute renal failure secondary to rhabdomyear-oldlysis and an eventual AKA.
MCC01
11:30 AM - 11:40 AM
Evaluation and Management of Peristomal Bleeding After Tracheostomy
Rebekah Nam, M.D., Anesthesiology, New York University, New York, NY
63year-old male with a medical history significant for HTN and DM was admitted after sustaining a
hemorrhagic left thalamic stroke. Hospital course included placement of uncomplicated surgical
tracheostomy at the bedside for respiratory failure. On POD#3, patient began to experience small
amounts of bloody secretions around the stoma and was evaluated by ENT. Tracheostomy site was
packed after fiberoptic exam failed to identify any evidence of active bleeding. On POD#7 patient began
to hemorrhage from tracheostomy with desaturation and difficulty establishing ventilation. Patient PEAarrested and was ultimately unable to be resuscitated.
MCC01
11:30 AM - 11:40 AM
Parturient With Hypoplastic Right Ventricle s/p Fontan’s Procedure Presents With Severe
Preeclampsia
Dorothee A. Mueller, Mary Jennette, M.D., Curtis Baysinger, M.D., Anesthesiology, Vanderbilt University,
Nashville, TN
: First case report of a parturient (25year-old G2P1) with fontan’s physiology, chronic hypoxia on home
O2 and asthma presenting with severe preeclampsia for urgent cesarean section. Anesthetic plan
included arterial line placement, phenylephrine infusion and low dose CSE with slow incremental dosing
of lumbar epidural to minimize sudden reduction in afterload. Difficult radial arterial line placement lead to
femoral arterial line. No anesthetic complications during delivery, but near complete occlusion of aorta/
iliac artery on femoral arterial line noted during cesarean section. Post-delivery patient developed
shivering with severe blood pressure readings (SBP 220) prompting transfer to intensive care unit.
MCC01
11:30 AM - 11:40 AM
Massive Pulmonary Embolus and Post Reperfusion Syndrome in Liver Transplant for Fulminant
Hepatic Failure
Kevin D. Hollis, M.D., University of WI, Madison, WI
Presentation discusses the evaluation and diagnosis of Fulminant Hepatic Failure and intraoperative
management during liver transplantation of 18 year-old male. The patient initially displayed the
characteristic hyperfibrinolytic state according to thromboelastography but rapidly deteriorated following
reperfusion of the portal vein suggesting pulmonary embolus. In addition to well recognized PostReperfusion Syndrome, subsequent TEE examination displayed significant clot burden consistent with a
hypercoagulable state. He did not respond to conventional therapy and subsequently required maximal
resuscitative efforts including compressions and fibrinolytics. Prior to transfer to ICU, he was
hemodynamically stable with normal ventilator requirements and decreased clot burden on four chamber
TEE view.
MCC01
11:40 AM - 11:50 AM
Dubowitz Syndrome: Difficult Airway in the Outpatient Setting
Shelly B. Borden, Corey A. Amlong, M.D., Anesthesiology, University of Wisconsin, Madison, WI
52 year-old female patient with Dubowitz syndrome and severe asthma underwent left middle ear
stapedial tendon lysis with tympanoplasty in outpatient surgery center. Airway was notable for <3 cm
incisor gap, limited neck extension, and high arching palate. Video laryngoscopy was successful.
Pediatric Glidescope would have been preferable. Intraoperative course was uneventful, and she was
extubated. Dubowitz syndrome is a rare genetic disorder associated with MR, microcephaly, and
characteristic facial appearance with an increased likelihood of difficult airway. Thorough planning for
intubation/extubation in patients in the outpatient setting should be considered in patients with adult
congenital abnormalities with difficult airway.
MCC01
11:40 AM - 11:50 AM
A Challenging Airway, Severe Cardiomyopathy With Pulmonary Hypertension and Pacemaker
Non-capture: A Trifecta of Risk Factors and Events Leading to Intraoperative PEA and
Resuscitation
Melissa Z. Murphy, M.D., Avinash B. Kumar, M.D., Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN
58 YF with severe cardiomyear-oldpathy (EF < 20%), ventricular tachycardia s/p AICD placement,
subglottic stenosis (goiter) and stridor underwent direct laryngoscopy. Intraoperatively, she became
acutely hypotensive (non-responsive to common vasopressors), deteriorated to PEA requiring CPR.
Patient had ROSC after CPR and ACLS. Intraoperative echo and post op AICD interrogation was nondiagnostic. A precipitous drop in SVR and inadequate SV was the likely mechanism of hypotension. We
are unable to explain pacemaker non-capture. The patient was neurologically intact and was extubated
12 hrs later. Airway, ACLS, transcutaneous pacemaker preparedness, immediate recognition and
response to deteriorating hemodynamics resulted in a good outcome.
MCC01
11:40 AM - 11:50 AM
Systemic Anti-coagulation With Argatroban in a Patient With Suspected Heparin Induced
Thrombocytopenia (HIT) for Endovascular Aneurysm Repair
Morgan R. Marino, M.D., H David Hardman, M.D., Anesthesiology, University of North Carolina, Chapel
Hill, NC
A 77 year-old male with a suspected previous episode of heparin induced thrombocytopenia (HIT)
presented for endovascular thoracoabdominal aortic aneurysm repair. The surgical team requested
anticoagulation with argatroban without running a HIT panel or consulting hematology. Although dosing
recommendations exist for argatroban use during percutaneous coronary intervention, no dosing regimen
exists for its use during endovascular aneurysm repair. This patient received a bolus dose and continuous
infusion of argatroban during the case, which proceeded uneventfully. In retrospect, the use of bivalirudin
may have offered a superior therapeutic option, and is now considered the drug of choice in patients with
HIT.
MCC01
11:40 AM - 11:50 AM
Anesthetic Approach to the Severely Hyponatremic Patient Presenting for Urgent Coronary Artery
Bypass Grafting
Hayden P. Kirby, M.D., Lavinia M. Kolarczyk, M.D., Anesthesiology, University of North Carolina at
Chapel Hill, Chapel Hill, NC
A 57 year-old female was admitted for STEMI after failed recent cardiac stenting. On admission her
sodium was 124 and was treated with free water restriction. Day of surgery, her serum sodium was 127.
To avoid over-correction and risk of central pontine myelinolysis, resuscitation was managed with minimal
lactated ringers only, packed red blood cells during cardiopulmonary bypass, and avoidance of albumin or
normal saline. Serial electrolytes were monitored throughout the case. The final sodium at surgery end
was 128. The patient did well without any neurologic deficits and was discharged home hospital day 5.
MCC01
11:40 AM - 11:50 AM
Unexpected Seizure During a Cesarean Section in a Previously Healthy Female
Brenda Satterthwaite, M.D., Jonathan Waters, M.D., Univ of Pittsburgh Med Ctr, Pittsburgh, PA
Patient was a 26 year-old G2P1 with an uneventful pregnancy course presenting at 38 weeks in labor.
Due to a prior cesarean section, repeat cesarean section was scheduled. Pre-operatively, the patient was
normotensive with a hemoglobin of 11.2 gm/dL and platelet count of 211,000/µL. A spinal anesthetic was
administered with no complications. Ten minutes into the surgery the patient became hypertensive and
complained of a severe bilateral headache. She subsequently had a tonic-clonic seizure which was
suppressed with versed and propofol. Post-operative imaging showed evidence of posterior reversible
encephalopathy syndrome (PRES) and the patient was diagnosed with new onset Eclampsia.
MCC01
11:40 AM - 11:50 AM
A Case of Conradi Hunnerman Syndrome
Stanlies M. D'Souza, M.D.,F.R.C.A, Nishal D'Souza, Richard Nguyen, M.D., Anesthesiology, Baystate
Medical Center, Tufts University School of Medicine, BSEP, Baystate Medical Center, Tufts University
School of Medicine, Springfield, MA,
Conradi Hunnerman syndrome is a rare genetic disorder with skeletal malformations due to punctate
epiphyseal calcifications affecting spine and long bones. Short neck, asymmetric long bones, scoliosis
and tracheal stenosis are the features of this X-linked dominant syndrome affecting females. A 9 year-old
girl presented for cortell cast change for thoracolumbar scoliosis who had prior anesthetic for similar
procedure. We did an inhalational induction with oxygen and sevoflurane and after obtaining an
intravenous line, maintained anesthesia with air/oxygen mixture with sevofluranre vis an LMA. Her
anesthetic and postoperative recovery was uneventful.
MCC01
11:40 AM - 11:50 AM
Pain Medicine (PN)
Cervical Sympathetic Blockade For the Management of Electrical Storm
Rehan B. Ali, M.D., Victor Tseng, D.O., Jeffrey Ciccone, M.D., Anesthesiology, Westchester Medical
Center, Valhalla, NY, Pain Medicine, Mount Sinai School of Medicine, New York, NY
A 75 year-old male presented with dizziness and fatigue secondary to ventricular and supraventricular
arrhythmias. Electrical storm (ES) encompasses a situation of cardiac instability which may present as
several episodes of ventricular tachycardia or ventricular fibrillation in a short period of time. We
performed an ultrasound guided left stellate ganglion block at the bedside which resulted in sinus rhythm
with episodes of sinus tachycardia and abolition of electrical storm. Left stellate ganglion block has
proven to be a successful mode of treatment for those patients with ventricular tachyarrhythmia resistant
to medical management or those who fail AV node ablation.
MCC01
11:40 AM - 11:50 AM
Post-opertaive Sore Throat Found to be Uvular Necrosis
Sangini Punia, M.D., Lovkesh Arora, M.D., Anesthesiology, University of Iowa Hospitals and Clinics, Iowa
City, IA
Sore throat after intubation is common complaint and has been reported to be as high as 40%. However,
a non-resolving sore throat after intubation should raise suspicion for a more serious cause such as
Uvular necrosis. This case describes post-operative uvular necrosis in a healthy ASA1 female who
underwent breast surgery under general anesthesia. She underwent standard induction with atraumatic
intubation and subsequently presented with post-operative sore throat. On examination, she had an
erythematous uvula with an area of ulceration. Due to the rare occurrence and paucity of literature on
uvular ischemia, we’ll review possible etiologies, treatment and prevention aspects.
MCC01
11:40 AM - 11:50 AM
Left Lytic Thoracic Para Vertebral Block of Sympathetic Ganglia in Patient With Refractory
Sustained Ventricular Tachycardia: Case Study
Rafeek A. Hegazy, Anesthesia, Rochester University, Rochester, NY
The autonomic nervous system is known to play a role in the genesis and maintenance of ventricular
arrhythmia. Initiation of Thoracic Epidural Anesthesia (TEA) and Left cardiac sympathetic denervation
(LCSD) in patients with refractory VT has been associated with a subsequent decrease in arrhythmia.A
case study of 71 year-old male with a history of non-ischemic cardiomyear-oldpathy and refractory
ventricular tachycardia has been successfully treated with continuous thoracic paravertebral catheter for 7
days then Left Lytic Thoracic Paravertebral Block of Sympathetic Ganglia.
MCC01
11:40 AM - 11:50 AM
Subarachnoid and Intraventricular Hemorrhage With Obstructive Hydrocephalus After
Endovascular Repair of Thoracoabdominal Aneurysm Under Sedation With CSF Lumbar Drain
Anna Barczewska-Hillel, M.D., Agathe Streiff, M.D., Anesthesiology, Mount Sinai Roosevelt, New York,
NY
64 year-old male with CVA ,hypertension,atrial fibrillation,previous ascending aortic aneurysm repair was
scheduled for EVAR under sedation . Lumbar drain was requested for spinal cord protection and was
placed by neurosurgeon and 10 cc of CSF was drained during surgery and in ICU . On day 3 patient
became obtunded and CT of the head showed intraventricular and SAH for which EVD was placed
without improvement in mental status. Patient was also coagulopathic and received FFP and cryearoldprecipitate. His mental status did not improve and tracheostmy and PEG were placed. He stayed in the
hospital for 2 months.
MCC01
11:40 AM - 11:50 AM
Robotic Mitral Valve Repair With Induced Ventricular Fibrillation Arrest Due to Extensive
Atherosclerotic Disease
Blake W. Perkins, M.D., Deparment of Anesthesiology and Critical Care, University of Chicago, Chicago,
IL
A 75 year-old male presented to our institution, having traveled as a self-referral for robotic mitral valve
(MV) repair. Preoperative CT angiogram revealed extensive atherosclerotic disease of the abdominal
aorta and its branches with bilateral common iliac as well as infrarenal abdominal aortic aneurysms. The
surgical plan was changed from conventional robotic MV repair with aortic EndoClamp and retrograde
cardioplegia to robotic repair with hypothermia and fibrillating heart. The case described includes a
combination of robotic cardiac surgery and advanced anesthetic management to provide the safest
surgical experience for the patient.
MCC01
11:40 AM - 11:50 AM
Vaginal Delivery in a Mother With Repaired Pulmonic Atresia
David L. Seng, Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
Pregnant women with complex congenital heart disease are becoming increasingly more common due to
better pediatric health care. Our patient was a 29 year-old woman with a history of pulmonary atresia with
an intact ventricular septum (PAIVS) and atrial septal defect (ASD) S/P Pulmonary Valvectomy and left
PA stenting who presented in labor. Patient underwent uneventful delivery with sequential spinal-epidural
with close hemodynamic monitoring.
MCC01
11:40 AM - 11:50 AM
The Path Less Traveled: False Lumen in Patient With Previous Palatopharyngeal Surgery
Sheaba Varghese, M.D., Roman Slyvka, M.D., John H Stroger Hospital of Cook County, Chicago, IL
38 year-old male pmh epilepsy on keppra presents for bilateral mandible ORIF. Patient had limited mouth
opening secondary to pain. Patient's past surgical history was significant for knee arthroscopy and neck
cyst removal. Decision was made to place nasal ET tube for the procedure. He was induced and
nasotracheal intubation was attempted, but tip of ET tube was unable to be visualized upon direct
laryngoscopy. In order to establish the airway, he was intubated with oral ET tube via uneventful direct
laryngoscopy. ENT service did a thorough exam which revealed the pharyngeal mucosa tacked up to his
soft palate.
MCC01
11:50 AM - 12:00 PM
Preoperative Atrial Fibrillation and T-wave Inversion are Predictors of Postoperative Pulmonary
Edema: A Case Report
Thomas Hong, D.O., Mohamad S. Hashim, M.D., Anesthesiology, Maimonides Medical Center, Brooklyn,
NY
Diastolic dysfunction is common in patients with longstanding hypertension and manifests as T-wave
inversion on EKG. The co-existence of atrial fibrillation and diastolic dysfunction will impair all four stages
of ventricular filling during diastole and further increase the pressure in the left atrium and pulmonary
veins leading to pulmonary edema.This is a case of 74 years male with history of hypertension who
underwent urology procedure. Preoperative EKG showed atrial fibrillation and T-wave inversion. In the
PACU, he developed fulminant pulmonary edema after a sudden increase in blood pressure. All Cardiac
workup was negative except for diastolic dysfunction on echocardiogram.
MCC01
11:50 AM - 12:00 PM
Beyond Post Operative Cognitive Dysfunction: What to Do When Your Patient Will Not Wake After
General Anesthesia
Jennette D. Hansen, M.D., Michael Pilla, M.D., Anesthesiology, Vanderbilt University, Nashville, TN
60 year-old male with multiple comorbidities including atrial fibrillation, and aortic dissection x 2 s/p repair,
currently off anticoagulation for umbilical hernia repair. Intraoperatively, episode of atrial flutter with RVR
treated with metoprolol. Upon emergence, RVR reoccurred and treatment repeated lowering HR to low
100s. Patient noted to have discoordinated breathing and inability to follow commands, but without
residual neuromuscular blockade. Ventilations assisted and ST reappeared. Concerned for stroke,
administered ASA sublingually and obtained CT and TTE, both of which were negative. Three hours later,
patient returned to neurologic baseline with amnesia of event.
MCC01
11:50 AM - 12:00 PM
Why Are You So Hot? Oh No, Could It Be MH (Malignant Hyperthermia)?
Titilopemi A.O. Aina, M.D., Jamie Wingate, MD, Anesthesiology, Texas Children's Hospital, Houston, TX
8 year-old boy with recurrent headaches, presenting for a brain MRI.PMH: ADHD, Allergic
rhinitisMedication(s): Advil as neededPhysical exam: unremarkable heart/lung/airway examNPO greater
than 8 hoursVS: T 37.4oC P 105 BP 96/40SpO2 100% on room airPrior to induction, he
complained of nausea and headache. He vomited once and received Zofran. After induction of
anesthesia with propofol, a temperature probe was placed for intra-proceduremonitoring. The first readout was 38.7oC. He was treated with intravenous Tylenol and Toradol. Upon arrival to the
recovery room, his temperature was 39.2 oC.
MCC01
11:50 AM - 12:00 PM
Incidental Discovery of a Large Thrombus in the Left Pulmonary Artery on the Pre-CPB TEE of a
Patient Scheduled for LVAD Placement
Armin Shivazad, M.D., Andrew Baudo, M.D., Department of Anesthesiology, Northwestern University,
Chicago, IL
59 year-old female with history of dilated cardiomyear-oldpathy (EF 10%) s/p BiV-ICD, HTN, NIDDM, HL,
who initially presented with syncopal events and ICD firing with progression to polymorphic VF
complicated by acute decompensated HF s/p IABP is scheduled for LVAD placement. During the preCPB TEE, a large echogenic structure is incidentally discovered in the left pulmonary artery measuring
1.8 x 1.8 cm likely to represent a thrombus. Decision was made to convert to full sternotomy and perform
pulmonary thrombectomy. On post-CPB TEE, patient had successfully undergone an embolectomy with
no residual mass seen in the left PA.
MCC01
11:50 AM - 12:00 PM
Chemical Pneumonitis as a Result of Mercury Vapor Inhalation
Keith W. Mulder, M.D., Ross Blank, M.D., University of Michigan, Ann Arbor, MI
Mercury vapor inhalation is a rare cause of chemical pneumonitis. Patients may present with hypoxic
respiratory failure or signs and symptoms of mercury toxicity. We present the case of a 56 year-old man
who presented with burning chest pain after inhaling mercury vapor while amalgamating gold at home. He
developed hypoxic respiratory failure and required intubation, and he subsequently underwent treatment
for ARDS and mercury toxicity in the ICU. His pneumonitis caused severe cavitary lung disease with
innumerable pneumatoceles, requiring prolonged treatment with thoracostomy tubes.
MCC01
11:50 AM - 12:00 PM
The Use of Noninvasive Positive Pressure Ventilation (NIPPV) to Meet the Challenges of
Peripartum and Perioperative Acute Respiratory Failure (ARF) in Super Morbid Obesity (SMO)
Amine El-Amraoui, Benjamin Redmon, M.D., Department of Anesthesiology, University of North Carolina
Hospitals, Chapel Hill, NC
A 38 year-old G1P0 at 38 weeks EGA with SMO (219kg, BMI 80), orthopnea, DOE, and untreated OSA,
presented in labor desiring vaginal delivery. Exam found MP IV, limited neck extension, jaw subluxation,
and mouth opening. A low thoracic epidural was placed for labor analgesia. Patient developed worsening
dyspnea. Serial ABGs revealed worsening respiratory acidosis. NIPPV with BiPAP was initiated to avoid
endotracheal intubation. She underwent a cesarean delivery for failure to progress. NIPPV was continued
with no intraoperative complications. Postoperatively, she was taken to the ICU and weaned to room air.
Epidural analgesia was discontinued.
MCC01
11:50 AM - 12:00 PM
Moyamoya Disease: Anesthetic Management and Prevention of Perioperative Complications in a
Rare Cerebral Revascularization Procedure
Yoann Millet, M.D., Mark Dugas, D.O., Sn Lee, M.D., Anesthesiology, Baylor College of Medicine,
Houston, TX
The aim of this discussion is to explore the evolving practice of anesthetic management and prevention of
perioperative complications in surgical revascularization of Moyamoya disease (MMD). In this rare,
medically challenging case, a 42 year-old woman with MMD and bilateral watershed cerebral infarctions
underwent a difficult but successful right superficial temporal artery to middle cerebral artery (STA-MCA)
bypass. There is no evidence of improved outcomes with any single anesthesia technique but multiple
pre-operative, intra-operative, and post-operative management principles have recently been developed.
These new strategies, as reviewed here, have led to a safer and higher quality anesthetic in MMD patient
populations.
MCC01
11:50 AM - 12:00 PM
Management of Pediatric Patient With Worsening Airway Edema After Caustic Ingestion
Katherine M. Slogic, M.D., Thomas Pennington, D.O., Anesthesiology, San Antonio Uniformed Health
Education Consortium, San Antonio, TX
2 year-old ASA-1E male presented 14 hours after ingesting 3 cc of pool cleaner and progressive
vomiting, respiratory distress and stridor. He was taken to the OR emergently by anesthesia and ENT for
intubation, bronchoscopy and esophagoscopy. Perianesthetic concerns included securing the airway of
an uncooperative pediatric patient with impending airway obstruction. Spontaneous ventilation was
maintained during mask induction followed by successful intubation with a rigid bronchoscope.
Bronchoscopy revealed marked swelling of glottic structures and compromising edema of the supraglottic
airway. Postoperatively, the patient was transferred to the PICU and left intubated until resolution of
airway edema.
MCC01
11:50 AM - 12:00 PM
Pain Medicine (PN)
Spinal Cord Stimulator for Treating Postherpetic Neuralgia
Alaa A. Abd-Elsayed, M.D., University of Wisconsin School of Medicine and Public Health, Madison, WI
A 46 years old man presented with severe bilateral chest pain which was non cardiac in origin. Patient
was diagnosed with postherpetic neuralgia. Patient failed all conservative measures which included
antivirals, neuropathic agents, opioids, physical therapy, analgesic patch. As a last resort patient agreed
to have a spinal cord stimulator trial which was performed with success, about 80 % reduction in pain
levels, improvement in activity and sleep. Patient then had the permanent implant which continued to
provide excellent pain relief which allowed the patient to wean down his medications.
MCC01
11:50 AM - 12:00 PM
Awake Nasal Fiberoptic Intubation in an Adult Patient with Coffin Siris Syndrome, A Case Report
Melissa J. Seelbach, M.D.,Ph.D., Ben Sloop, M.D., Kellie Stivers, M.D., Anesthesiology, University of
Kentucky, Lexington, KY
A 30 year-old male (58 Kg) with allergy to midazolam, history of hypertension, gastroesophageal reflux
disease, and CSS (specifically severe developmental delay, scoliosis, and acute situational anxiety)
presented for full mouth dental restoration. Airway exam revealed coarse facies (flat nasal bridge, wide
mouth, large lips), micrognathia, and hypoplastic / poorly developed mandible with receding chin and
short neck. Based on this information, awake nasal fiberoptic intubation was planned. Nasal endotracheal
tube (ETT) placement was poorly tolerated despite nasal-laryngotracheal lidocaine topicalization.
Ketamine was titrated to adequate sedation enabling bronchoscope insertion and advancement to
chords. ETT appropriately advanced, positioned, and secured.
MCC01
11:50 AM - 12:00 PM
Considerations for Acute Exacerbations of Loin Pain Hematuria Syndrome
Benjamin Aaron Abrams, M.D., Lauren McLaughlin, D.O., Melanie Donnelly, M.D., Anesthesiology,
University of Colorado, Denver, CO
A 25 year-old male with a history of LPHS status post multiple urological interventions, was admitted with
an acute pain exacerbation. His home pain medications included oxycodone, tramadol, pregabalin, and
duloxetine. On admission, he reported 10/10 left flank pain, radiating to the anterior groin. He was initially
started on a hydromorphone PCA with little relief. A ketamine infusion was added, but was discontinued
secondary to hallucinations. A T10-11 epidural catheter was placed, achieving dense T8-11 coverage
with a hydromorphone/bupivacaine infusion. The catheter remained in place for 48 hours providing
significant improvement in symptoms.
MCC01
11:50 AM - 12:00 PM
Unique Challenges in the Management of a Massive Ascending Aortic Pseudoaneurysm
Bilal Lateef, M.D., Muhammad Qadri, M.D., Priya Kumar, M.D., Harendra Arora, M.D., University of North
Carolina, Chapel Hill, NC
We describe the case of a 69-year-old male who presented with a massive pseudoaneurysm (PSA) of the
proximal ascending aorta. This patient had previously undergone an emergent hemi-arch repair of the
ascending aorta for an acute Type A dissection. The giant PSA caused mass effects on the superior vena
cava, right atrium and right ventricle. In order to avoid impending rupture, the surgeons’ planned
placement of an amplatzer device to plug the communication between the ascending aorta and the PSA.
We will discuss the intraoperative management of a massive PSA as well as the role of TEE.
MCC01
11:50 AM - 12:00 PM
Anesthetic Considerations for a Patient With Subacute 'Streptococcus Mitis' Endocarditis Causing
Aortic and Mitral Valve Perforations
Lisa Marie Chargualaf, M.D., David Gursky, M.D., Soma Shanker, M.D., Anesthesiology & Perioperative
Medicine, Saint Barnabas Medical Center, Livingston, NJ
A 48 year-old male, with a history of daily alcohol intake and recent dental procedure, presented to an
outside facility with complaints of fevers, chills, and back pain. Blood cultures revealed Streptococcus
mitis bacteremia and transthoracic echocardiogram revealed aortic and mitral valve vegetations, which
precipitously evolved into aortic valve failure that prompted transfer to our facility for definitive surgical
management. Intraoperative transesophageal echocardiogram revealed frank perforations of aortic and
mitral valve leaflets and invasive hemodynamic monitoring was initiated. Patient was placed on
cardiopulmonary bypass and in vivo laparoscopy revealed aforementioned perforations before
undergoing aortic and mitral valve repair.
MCC01
11:50 AM - 12:00 PM
Anesthetic Management of a Laboring Patient With a Myear-oldcardial Bridge
Ashley E. Gabrielsen, D.O., Tanya Lucas, M.D., UMass Memorial Med Ctr, Worcester, MA
A 34 year-old G4P0212 with a known history of a mid LAD myear-oldcardial bridge seen on cardiac
catheterization, on beta blocker therapy, presented to the labor and delivery suite at 39.1 weeks gestation
for a scheduled Cesarean section. An epidural catheter was placed for anesthesia and a radial arterial
catheter was placed for hemodynamic monitoring. Three milliliters of 2% lidocaine were used as a test
dose and the epidural catheter was periodically bolused with a combination of lidocaine and bupivacaine.
Phenylephrine and esmolol infusions were utilized throughout the delivery for hemodynamic stability. The
patient ultimately had a successful procedure.
MCC01
11:50 AM - 12:00 PM
Idiopathic Acute Liver Failure After Combined Kidney-Pancreas Transplantation
Benjamin W. Brown, M.D., Jimmy Moss, M.D., Steve Aniskevich, M.D., Sher-Lu Pai, M.D., Klaus Torp,
M.D., Mayo Clinic, Jacksonville, FL
We describe a case of fulminant liver failure following general anesthesia in a patient receiving a
simultaneous kidney-pancreas transplant. Despite an aggressive evaluation of structural, immunological,
infectious, and toxicological causes, a definitive cause could not be elucidated. However, isofluraneinduced liver failure was the working diagnosis. The patient required a liver transplant and suffered a
protracted hospital course. We discuss the potential causes of fulminant liver failure and the management
of her subsequent liver transplant from an anesthesiologist’s point of view.
MCC02
1:00 PM - 1:10 PM
A Simple and No-Cost Nasal CPAP Mask/Circuit Assembly Maintaining Spontaneous Respiration
and Oxygenation in a Pediatric Patient With Alveolar Rhabdomyear-oldsarcoma Under Sedation
During MRI and PET Scan
Amanda M. Doucette, Shaul Cohen, M.D., Sylviana Barsoum, M.D., Jessica Perez, M.D., Jacques Lorthe,
M.D., James Tse, M.D.,Ph.D., Anesthesiology, Rutgers Robert Wood Johnson Medical School, New
Brunswick, NJ
7 year-old boy with alveolar rhabdomyear-oldsarcoma of the thigh and heart murmur, s/p chemotherapy,
presented for MRI/PET Scan. He had previous paradoxical reaction to lorazepam and emergent agitation
with sevoflurane. He refused NC O2 and was preoxygenated with a face tent. Patient was sedated with
propofol, neonatal mask was secured over his nose with head-straps, connected to anesthesia
circuit/machine. APL was adjusted to deliver 5 cm H2O CPAP with O2 (2L/min)/air (0.5L/min). Deep
sedation was maintained with propofol infusion (150-250 mcg/kg/min). He maintained spontaneous
respiration and 100% O2 saturation throughout 41/2-hour procedure. He woke up quickly and
comfortably.
MCC02
1:00 PM - 1:10 PM
A Simple, No Cost Nasal CPAP Mask-Circuit Assembly in the Lateral Decubitus Position in a
Morbidly Obese Patient
Sylviana S. Barsoum, M.D., M.S., James Tse, M.D.,Ph.D., Anesthesiology, RWJMS-Rutgers, New
Brunswick, NJ
76 year-old female (BMI= 44.5 kg/m2) with HTN, A-fib, CHF, OSA, spinal stenosis presented with G.I.
bleed and right buttock decubitus.She underwent EGD with propofol sedation, O2 via NC complicated by
desaturation (60% SpO2), prolonged awakening, and mechanical ventilation for 3 1/2 hours.For the
IandD, patient assumed LLD position, an infant mask was secured over her nose and connected to the
anesthesia circuit/machine with O2 (5 lpm) and CPAP (5 cmH2O). SpO2 increased from 93 to
99%.Patient tolerated procedure well under local, propofol (50 mcg/kg/min) and Fentanyl (300
mcg).PACU discharge criteria are met within 30 minute.
MCC02
1:00 PM - 1:10 PM
A Simple and No-Cost Nasal CPAP Mask/Circuit Provided Continuous Oxygenation in a Morbidly
Obese Patient With Respiratory Failure During Emergency Awake Endotracheal Intubation
Andres F. Ocampo-Salazar, M.D., Anesthesiology, Rutgers Robert Wood Johnson Medical School, New
Brunswick, NJ
53 year-old male, BMI 69 kg/m2, unknown medical history, presented with respiratory failure with severe
CO2 retention requiring endotracheal intubation in OR. His O2 saturation was 89’s% with BiPAP
machine. An infant mask was secured over his nose with head-straps and connected to anesthesia
circuit/machine. APL was adjusted to deliver 10-15cm H2O CPAP (O2 10L/min). O2 saturation improved
to low 90’s%. Patient was uncooperative with video-laryngoscopy and required intermittent assisted
ventilation with face mask. With nasal CPAP in place, oral fiberoptic intubation was attempted by two
anesthesia residents and intubation was successfully accomplished by the anesthesia attending.
MCC02
1:00 PM - 1:10 PM
Multimodal Opioid-free Technique Using Serratus Plane Block, Transversus Abdominis Plane
Block, and Ketafol for Ambulatory Breast Surgery
Vijal N. Patel, M.D., Bobbie-Jean Sweitzer, M.D., David Dickerson, M.D., Department of Anesthesia and
Critical Care, University of Chicago, Chicago, IL
A 33 year-old female presented to our ambulatory surgical center for bilateral breast surgery (right breast
reconstruction, left breast revision) and abdominal wound revision. Her past medical history was
significant for severe PONV after recent unilateral mastectomy with abdominal flap reconstruction under
general anesthesia with opioids and inhaled anesthetics. We chose to employ a multimodal approach general anesthesia with a total intravenous technique (midazolam, ketamine, propofol) supplemented with
two regional techniques (serratus plane block and transversus abdominis plane block).
MCC02
1:00 PM - 1:10 PM
Like a Rock: Atypical Presentation of Heavily Calcified Atrial Myxoma
Chinwe I. Nwosu, M.D., Seema Deshpande, M.B.,B.S., Anesthesiology, University of Maryland,
Baltimore, MD
A 50 year-old woman with a past medical history of seizure disorder presented with new-onset atrial
fibrillation and was found to have a left atrial mass suspicious of a myxoma on echocardiogram. She was
scheduled to undergo cardiac mass removal on CPB. Intraoperative TEE showed a heavily calcified mass
in the left atrium. The mass was removed without complication. Myxomas are the most common type of
cardiac tumors, accounting for approximately 3/4 of tumors treated surgically. They are typically friable
without evidence of significant calcification. Perioperatively, these patients are at risk for seizures,
strokes, cardiac valvular dysfunction, and sudden cardiac death.
MCC02
1:00 PM - 1:10 PM
Remifentanil Induced Chest Wall Rigidity and Unanticipated Difficult Airway In Out of OR Setting
Braden J. Hestermann, Arthur R. Mielke, M.D., Christopher V. Maani, M.D., Department of Anesthesia
and Operative Services, Brooke Army Medical Center, San Antonio, TX
61year-old female with 11mm right ICA aneurysm presented for cerebral angiogram and pipeline
placement in the interventional radiology suite. Pre-induction arterial line was placed and induction
proceeded with propofol/remifentanil for hemodynamic stability during laryngoscopy and prevention of
shear stress on the aneurysm. Chest wall rigidity was encountered after induction which significantly
impaired ventilation. Direct laryngoscopy resulted in Grade IV view despite favorable pre-operative airway
assessment prompting urgent call for GlideScope. Depolarizing neuromuscular blockade improved
ventilation and patient was intubated successfully, however, she developed profound hypertension as her
induction dose of Remifentanil had metabolized. The procedure was completed without anesthetic
complication.
MCC02
1:00 PM - 1:10 PM
Pituitary Apoplexy Complicated by Diabetes Insipidus and Intracranial Hypertension in a
Parturient
Leslie A. Schornack, M.D., Avinash B. Kumar, M.D., Department of Anesthesiology, Vanderbilt University
Medical Center, Nashville, TN
A 20Y G1P0 complicated by gestational diabetes and preeclampsia presented in labor at 39 weeks.
During stage II labor she had acute loss of consciousness (GCS 8), with bilateral hyperreflexia and
clonus. She was emergently intubated - CT showed acute hemorrhage above the pituitary stalk with
intraventricular extension. Immediate clinical course progressed to intracranial hypertension requiring
emergent ventriculostomy and trans-sphenoidal exploration of the sella turcica. Post op course was
complicated by severe diabetes insipidus and paradoxically, worsening papilledema. She recovered from
the DI, but required a ventriculoperitoneal shunt. She was neurologically intact at on discharge to an
intermediate facility.
MCC02
1:00 PM - 1:10 PM
Pain Medicine (PN)
Spinal Cord Stimulator for Treating Chemotherapy Induced Peripheral Neuropathy
Alaa A. Abd-Elsayed, Anesthesiology, University of Wisconsin School of Medicine and Public Health,
Madison, WI
A 47 years old man presented with severe bilateral chemotherapy induced peripheral neuropathy in both
hands. Patient failed conservative management which included physical therapy, neuropthic agents and
opioids. Pain made patient unable to use his hands in even simple activities. After exhausting all options
patient agreed to have a spinal cord stimulator trial which was performed and was very successful, it
decreased patient pain by about 80 % and improved his ability to use his hands. Patient decided to
proceed with the permanent implant which will be performed soon.
MCC02
1:00 PM - 1:10 PM
Complications from Cutting a Spring-Wound Peripheral Nerve Catheter
Sarah L. Kittner, M.D., Amber K. Brooks, M.D., Anesthesiology, Wake Forest Baptist Health, WinstonSalem, NC
A 71 year-old female with a history post-operative nausea, hypertension, and trigeminal neuralgia on
chronic opioids, sustained a proximal humeral fracture after a fall. A total shoulder arthroplasty was
performed and an interscalene catheter was placed for post-operative pain control. She was discharged
home with the catheter in place. During a follow-up call on post-operative day four, she stated that she cut
the catheter while trying to remove it and it had unraveled. She presented to the hospital with two 4-inch
wires emerging from her neck. The wire was removed with gentle traction with the catheter tip intact.
MCC02
1:00 PM - 1:10 PM
Brugada Syndrome: Peri-operative Management for a Non-cardiac Case
Dennis B. Thapa, M.D., Jennifer Dominguez, M.D., Anesthesiology, Duke University Medical Center,
Durham, NC
Brugada Syndrome is a rare, autosomal dominant disease responsible for 4% of all sudden deaths. A 58
year-old female with a PMH of BS with an AICD, and family history of a daughter with sudden death at
13, underwent a robot-assisted hysterectomy. Interregation of the patient's AICD was done preoperatively. An awake arterial line and defibrillation pads were placed. Induction was accomplished with
midazolam, fentanyl, etomidate, and cisatricurium, with minimal change in hemodynamics. After
intubation, a tilt table test was performed and monitored for EKG changes. No potential arrhythmogenic
medications were given: propofol, lidocaine, ketamine, glycopyrralate, neostigmine, edrophonium,
metoclopromide.
MCC02
1:00 PM - 1:10 PM
Presentation of Patient Undergoing Emergent Exploratory Laparotomy for Bowel Perforation
Complicated by Pulmonary Embolus and Intraoperative Cardiac Arrest
Darsi N. Pitchon, M.D., Ksenia Guvakova, M.D., Michael Tran, M.D., Clint Fleckenstein, D.O., Abiona V.
Berkeley, M.D., Anesthesia, Temple University Hospital, Philadelphia, PA
Fifty-eight year-old male admitted with a saddle pulmonaryembolus and clostridium difficile
pancolitis causing perforation of the sigmoid colon. During emergent total abdominal colectomy and
ileostomy, patient developed ventricular fibrillation and ACLS was initiated. Emergent TEE showed
severe RV failure due to suspected intraoperative migration of embolus. The patient was placed on
cardiopulmonary bypass and emergent pulmonary thrombectomy was performed. The patient’s hospital
course was complicated by multiple thrombi, heart failure, and shock.
MCC02
1:00 PM - 1:10 PM
Management of Intraoperative Myear-oldcardial Ischemia in Obese Patient During Emergency
Fracture Femur Fixation
Lakshmi N V N S Venkatesh, M.B.,B.S., Abhishek G. Kesarwani, M.B.,B.S., Tarun Tyagi, M.B.,B.S.,
Anesthesiology, Seth G S Medical College, Mumbai, India
A 50 year-old 100KG MALE WITH HISTORY OF OBSTRUCTIVE SLEEP APNEA WITH NO OTHER CO
-MORBIDITIES WAS POSTED FOR EMERGENCY FRACTURE FEMUR FIXATION. PATIENT WAS
MANAGED UNDER REGIONAL ANESTHESIA WITH OXYGEN SUPPLEMENTATION.AFTER 1 HOUR
OF INDUCTION,PATIENT COMPLAINED OF ABRUPT ONSET SEVERE CHEST PAIN WITH
PALPITATION AND NEW ONSET ST SEGMENT DEPRESSION IN LEAD IIand III WHICH IMPROVED
WITH INCREASED OXYGEN SUPPLY, FENTANYL AND SUBLINGUAL NITROGLYCERINE. PATIENT
WAS STABILISED AND SURGERY WAS CONTINUED.PATIENT REQUIRED VASOPRESSORS DUE
TO MASSIVE BLOOD LOSS AND WAS SHIFTED POSTOPERATIVELY TO ICU AND EXTENSIVE
CARDIOLOGY WORK UP WAS DONE.PATIENT WAS DISCHARGED ON 7TH POSTOPERATIVE DAY.
MCC02
1:00 PM - 1:10 PM
Challenging Transport from the Operating Room to the ICU
Kathleen L. Caldwell, D.O., Arvind Rajagopal, M.D., Parag Patel, M.D., Rush University Medical Center,
Chicago, IL
A 58 year-old female with severe COPD and ARDS was scheduled for a tracheostomy. She was
transported to the operating room using a portable ICU ventilator uneventfully. After induction of general
anesthesia she desaturated to 82-84% and remained low despite aggressive treatment measures. ECMO
was not considered an option for her. Multiple unsuccessful attempts were made to transition to a
portable ventilator for transport. A decision made to transport using an anesthesia machine. Multiple
teams coordinated to successfully transport the patient in a short time using battery support for
anesthesia machine. She was then transitioned to an ICU ventilator.
MCC02
1:00 PM - 1:10 PM
Anesthetic Management of Left Atrial Myxoma Resection
Noah Godwin, M.D., Esther Garazi, M.D., Ricardo Martinez, M.D., University of Miami/Jackson Memorial
Hospital, Miami, FL
A 70 year-old female with no cardiac history presented with multiplesyncopal episodes over the previous
six months. A TTE revealed a left atrial mass obstructing outflow through the mitral valve. The induction
goal was to maintain hemodynamic parameters similar to a patient with mitral stenosis, including low
heart rate and high preload. Post induction, TEE revealed a 1.5cm x1.5cm left atrial mass. Resection was
accomplished via transseptal approach under cardioplegic arrest. TEE post-bypass showed no mitral
regurgitation or stenosis. The patient was extubated in the operating room and was discharged home on
postoperative day five.
MCC02
1:00 PM - 1:10 PM
Spinal Anesthesia for Cesarean Delivery in a Parturient With Scheuermann's Disease
Wissam H. Mustafa, M.D., Christina Mack, M.D., Boston Medical Center, Boston, MA
A 34 year-old female, gravida 4 para 1, at 39 weeks gestation presented in spontaneous labor. Her past
medical history was significant for Scheuermann's kyphosis, asthma, tobacco use and bipolar disorder.
On exam, she had pronounced thoracic kyphosis, lumbar lordosis, and thoracolumbar scoliosis. Her head
was forwardly protruded; airway exam revealed a Mallampati score of two and a thyromental distance >3
fingerbreadths. Cesarean delivery for nonreassuring fetal heart tracing was performed under spinal
anesthesia given in the L4/5 interspace after multiple attempts. Spine ultrasound is a useful technique for
guiding needle placement but is often under utilized.
MCC02
1:10 PM - 1:20 PM
Urgent Perioperative Management of a 7-day-old Neonate With Life-threatening Decompensation,
Coagulopathy and Acute Subdural Hematoma
Brendan S. Kelley, M.D., M.S., Ronak Patel, M.D., Claude Abdallah, M.D., M.S., Anesthesiology, Walter
Reed National Military Medical Center, Bethesda, MD, Anesthesiology, Sedation, and Perioperative
Medicine, Children's National Medical Center, Washington, DC
A 7 day old male presented to the ED with seizures, vomiting and lethargy. An urgent head CT showed
acute on subacute left SDH with midline shift, transtentorial, subfalcine, and uncal herniation. Patient
history included spontaneous vaginal delivery and severe hemophilia (fVIII<1%, PTT 88). In ED, patient
had two seizures requiring IV midazolam, levetiracetam, and urgent tracheal intubation. Patient was given
3% NaCl, first fVIII dose (50u/kg), and underwent urgent craniotomy. Intraoperatively, patient was given
fVIII (25u/kg), transfused uncrossmatched blood, and arterial access was obtained. Intracranial
hemorrhage in neonates with hemophilia is rare and potentially fatal, with substantial perioperative
challenges.
MCC02
1:10 PM - 1:20 PM
Cesium: Friend or Foe? When Alternative Medicine Goes to the Heart
Robert M. Rowlett, M.D., Gozde Demiralp, M.D., Matthew Moore, Student, Anesthesia, University of
Oklahoma, Oklahoma City, OK, University of Oklahoma, Oklahoma City, OK
We are presenting the diagnosis of Cesium Toxicity at our Preoperative Anesthesia Unit. An elderly
patient, who was scheduled for a nephrectomy secondary to renal cell carcinoma, was found to have a
QT prolongation of 589 msec, during his anesthesia assessment. This new onset QTc prolongation was
attributed to hypokalemia at 2.5 mEq/ml. Further questioning revealed he was self-medicating with over
the counter cesium pills. This controversial therapy is known to lead to life-threatening hypokalemia and
dysrhythmias. He was emergently admitted for management of cesium toxicity and replenishment for
resistant hypokalemia which caused his surgery to be delayed for weeks.
MCC02
1:10 PM - 1:20 PM
Anterior Displacement of the Dens Process into the Posterior Pharynx in a High C-Spine Fracture
Jay Shen, M.D., Navid Alem, M.D., Joseph Rinehart, M.D., Univ of CA-Irvine, Orange, CA
A 96 year-old male presented emergently to the OR after sustaining a fall resulting in a C1/C2 fracture.
We describe an unusual case of upper airway anatomy distortion due to high C-spine fracture. As
demonstrated in Figure 1, the mucosa of the posterior pharynx was anteriorly displaced by the fractured
dens process. This airway alteration was represented by a midline mass unexpectedly visualized upon
fiberoptic bronchoscope intubation. Our case-report reiterates the importance of multidisciplinary
collaboration in emergency situations and underscores the usage of a technique that maintains
spontaneous ventilation when manipulating the airway in patients with high cervical spine fractures.
MCC02
1:10 PM - 1:20 PM
Anesthetic Challenges In Management of A Patient With Sturge-Weber Syndrome Undergoing
Maxillofacial CT Scan
Sahel Keshavarzi, M.D., Simin Saatee, M.D., Anesthesiology, Advocate Illinois Masonic Medical Center,
Chicago, IL
A 32 year-old female with known SWS reported for Maxillofacial CT for assessment of gingival
hyperplasia. The patient displayed severe cognitive impairment, inability to communicate which made
preoperative evaluation more difficult. Following a thorough review of medical history, the decision was
made to proceed with general anesthesia. After establishing peripheral IV access and full ASA monitors,
pre-oxygenation and an uneventful inductuion with IV Ketamine 30 mg and video assisted laryngoscope
intubation was performed under extreme caution due to the possibility of excessive bleeding or rupture of
hemangioma during laryngoscopy and intubation. At the end patient was extubated after meeting
extubation criteria.
MCC02
1:10 PM - 1:20 PM
Challenging Case in an Adult Patient With a History of Dextrocardia and Double Outlet Right
Ventricle for Completing of a Fontan Procedure
Bryan J. Hierlmeier, M.D., Henrique Vale, M.D., Kristen Bell, M.D., Anesthesiology, University of
Mississippi Medical Center, Madison, MS, University of Mississippi Medical Center, Jackson, MS
A 33 year-old female with history of dextrocardia, double-outlet right ventricle and large VSD. At age 2
months she had ligation of her PDA and banding of her PA, and at 3 years had enlarging of the PA band.
She underwent a bidirectional Glenn at age 16, in anticipation of a Fontan procedure. However, she later
developed significantly elevated pulmonary arterial pressures, which precluded surgical Fontan.
Seventeen years later her pulmonary pressures are mildly reduced and a Fontan completion is attempt at
age 33.
MCC02
1:10 PM - 1:20 PM
Venous Air Embolus Upon Scalp Incision During Sitting Craniotomy
Nicole Z. Spence, M.D., Kathryn Faloba, M.D., Zirka Anastasian, M.D., NYP-Columbia University, New
York, NY
Venous air embolism (VAE) is most often associated with sitting position craniotomies and can cause
hemodynamic collapse. VAE has been described as occurring with bone work, but the occurrence of VAE
upon scalp incision has not been widely discussed or reported.We report a case of a patient who
experienced a VAE upon scalp incision.
MCC02
1:10 PM - 1:20 PM
Symptomatic Hepatic Echinococcus Hydatid Cyst in a Gravid Patient
Wissam Tobea, M.D., Daryl Reust, M.D., Department of Anesthesiology, University of Oklahoma Health
Sciences Center, Oklahoma City, OK
36 year-old female, G3P2 at 22 weeks gestation, presents to ER with RUQ pain and fever. Initial imaging
revealed a large right hepatic lobe mass consistent with a hydatid cyst. Subsequent clinical findings
developed suggesting possible cyst leakage. Follow-up imaging revealed enlargement of the original cyst.
Albendazole therapy was initiated and percutaneous transhepatic cyst drainage was performed.
Perioperative concerns were for risks of fetal compromise, hemorrhage, and sequelae of possible cyst
rupture or leakage. Patient was placed under general anesthesia for percutaneous transhepatic cyst
drainage with no perioperative complications.
MCC02
1:10 PM - 1:20 PM
Pain Medicine (PN)
Acute Rhabdomyear-oldlysis in a Patient With Long-Term Exposure to Intrathecal Ziconotide: A
Case Report
Christian Horazeck, M.D., Albert S. Huh, B.S., Billy K. Huh, M.D.,Ph.D., Department of Anesthesiology,
Duke University Medical Center, Durham, NC, Medical College of Georgia, Augusta, GA, Department of
Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
A patient suffering from chronic neuropathic pain associated with failed back surgery syndrome had
received intrathecal ziconotide for two years. Moderate side effects led to discontinuation of the drug. Her
regimen was changed to morphine, which failed to provide adequate analgesia despite titration. A single
intrathecal bolus of ziconotide, as adjunctive therapy, resulted in good pain control. Two months later, she
received a second ziconotide injection. Sixteen hours after the injection, she presented to a local
emergency department with nausea, vomiting, and myalgia. She had significantly increased CK levels,
was admitted for presumed rhabdomyear-oldlysis, and recovered with IV fluids.
MCC02
1:10 PM - 1:20 PM
Mucinous Drainage from Spinal Needle While Trying for Placement of Needle in Subarachnoid
Space for Spinal Anesthesia
Shahram Nafisi, M.D., Antony Tharian, M.D., N. Nick Knezevic, M.D., Kenneth D. Candido, M.D.,
Anesthesia, Advocate Illinois Masonic Medical Center, Chicago, IL
A-60 year-old woman with PSH of laminectomy and L3-L5 fusion, and right total knee arthroplasty,
presented for left total knee arthroplasty. Spinal anesthesia was tried by 25G PENCAN (3-1/2 inch 9cm)
needle at the L4-L5 level, but drained fluid was viscous and did not flow freely. Spinal needle was
removed. CSF was drained after the second attempt at L3-L4 level. The surgery was performed under
spinal anesthesia. Patient was discharged home three days later without any complication. Aspiration of
synovial cyst fluid may occur during spinal anesthesia especially in elderly patients. Ultrasound guidance
may decrease the incidence of synovial cyst aspiration.
MCC02
1:10 PM - 1:20 PM
Management of Thyroid Storm in the Setting of Urosepsis
Mallorie T. Cline, M.D., Christina Riccio, M.D., Anesthesiology, University of Texas Southwestern, Dallas,
TX
A 45yr old female with uncontrolled hyperthyroidismpresented to the ER with abdominal pain, vomiting
and dysuria. Her exam wasnotable for extreme fever (41C) and tachycardia, and labs were remarkable
forundetectable TSH, elevated T4, leukocytosis and a positive UA. CT scan revealeda ureteral stone,
hydronephrosis and pyelonephritis. An endocrine consultrecommended antithyroid medication and beta
blockade for suspected thyroidstorm. The patient was taken urgently to the OR for stent placement.
Intraoperativemanagement consisted of treatment of urosepsis and thyrotoxicosis. Though shetolerated
the procedure, her clinical condition rapidly deterioratedpostoperatively and she expired from
overwhelming urosepsis.
MCC02
1:10 PM - 1:20 PM
Pericaridal Tumor
Nat Dumrongmongcolgul, M.D., Ryan Chadha, M.D., Trevor Banack, M.D., Anesthesiology, Yale school
of medicine, New Haven, CT
39 year-old female with myxoid liposarcoma was found to have a metastatic tumor to the pericardium with
atrial and ventricular compression. She was brought to the OR for tumor debulking where a pre-induction
a-line was placed showing significant respiratory variation. Spontaneous ventilation was maintained
through an inhalational induction and placement of a double lumen tube. Upon initiation of positive
pressure ventilation, the patient become hypotensive requiring pressors. TEE revealed the large mass
and tamponade physiology. Shortly after debulking, there was significant fluid output from the bronchial
lumen likely secondary to reexpansion pulmonary edema. The patient remained stable, and recovered
uneventfully.
MCC02
1:10 PM - 1:20 PM
Use of ECMO as a Bridge Resource for Tracheal Repair in Trauma Surgery
Roseny D. Rodrigues, Daniel Ibanhes Nunes, M.D., Rodrigo Viana Quintas Magarão, M.D., Milton
Gotardo, M.D., João Alexandre Dias e Santos, M.D., Maria Jose Carvalho Carmona, M.D.,Ph.D.,
Anesthesiology, Hospital das Clínicas / University of São Paulo Medical School, Sao Paulo, Brazil.
A 62 years old female, victim of a car versus truck collision was ejected from the vehicle and suffered
severe head injury, a complex facial trauma, respiratory distress and hemorrhagic shock. After failed
intubation attempts at the scene, a cricothyrotomy was performed.On arrival at the ER, further
investigation revealed severe pulmonary contusion. A tracheotomy was successfully performed and she
was taken to the ICU.After 6 hours at the ICU, ventilator parameters progressively worsened and thoracic
subcutaneous emphysema was noticed. Rupture of the posterior tracheal wall and tracheal- mediastinum
fistula were diagnosed by flexible fiberoptic.
MCC02
1:10 PM - 1:20 PM
Overlooked Intraarterial Central Venous Catheter Placement
Olivia Faye Ringo, M.D., Helene Logginidou, M.D., Anesthesiology, SUNY Downstate Medical Center,
SUNY Downstate Medical Center, Brooklyn, NY
53 year-old female with no PMH presented to ED in septic shock. Right sided CVC was placed by ER
physicians and chest X-ray was performed. Levophed, vasopressin were initiated and patient admitted to
MICU. Morning review of CXR noted CVC crossing midline. Pressure tracing and blood gas confirmed
arterial placement. TTE identified the CVC proximal to aortic valve. Catheter was removed by vascular
surgery. Carotid doppler was normal. Patient subsequently with poor neurological function, EEG showed
slowing and head CT revealed no acute processes. Our goal is to emphasize the importance of routine
use of ultrasound for central venous access.
MCC02
1:10 PM - 1:20 PM
Presentation, Differential Diagnosis, and Perioperative Management of Right Atrial Mass
Nathan R. Belt, M.D., Stephanie Cintora, M.D., Brian Gebhardt, M.D.,M.P.H., Nicholas Lunig, B.S.,
Anesthesiology, University of Massachusetts, Worcester, MA
49 year-old female PMH of obesity, smoking, COPD, and recent SBO presented with acute SOB and
abdominal pain found to have bilateral pulmonary emboli. Echocardiogram revealed a 2x2cm right atrial
mass that extended into IVC. After initiation of anticoagulation, she was discharged with hematology
outpatient follow up which was negative except for mild elevation of homocysteine. She later presented
for excision of mass under deep hypothermia and circulatory arrest. She was also found to have right and
left hepatic vein masses that were removed. Final pathology of 4.5x4.0x2.5cm right atrial mass was
thrombus with calcifications and purulent exudate
MCC02
1:10 PM - 1:20 PM
Anesthetic Management for Cesarean Section in a Patient With Pulmonary Emboli, Pulmonary
Hypertension, and Right Heart Failure
Shaun Patel, D.O., Krystal Weierstahl, D.O., Sonalee Shah, D.O., Christina Fidkowski, M.D., Department
of Anesthesiology, Henry Ford Hospital, Detroit, MI
Maternal mortality in patients with severe pulmonary hypertension is reported to be 30 - 50%. Cesarean
deliveries under general, epidural, and combined low dose spinal-epidural anesthesia are reported. We
report cesarean delivery using an intrathecal catheter for a 25 year-old G3P2 morbidly obese (BMI 82)
female with severe pulmonary hypertension and right heart failure on sildenafil and iloprost, pulmonary
embolism on heparin infusion, and obstructive sleep apnea. She required vasopressors with dosing of the
intrathecal catheter and immediately post-delivery. She stabilized and was weaned from vasopressors a
few hours post-delivery. Mother and child were stable on discharge.
MCC02
1:20 PM - 1:30 PM
A Unique Cause of and Solution to Intraoperative Desaturation
Amine El-Amraoui, M.D., Dominika James, M.D., Department of Anesthesiology, University of North
Carolina Hospitals, Chapel Hill, NC
A 50 year-old physically active male smoker with renal cell carcinoma presented for surgical excision.
Preoperative workup demonstrated mild bibasilar atelectasis, multiple small pulmonary nodules likely due
to metastasis without shortness of breath and polycythemia (H/H 17.8/65.3). Patient was intubated
without issue. Intra-operatively, patient’s PaO2 remained below 70 despite FiO2 1.0. ETT suctioning,
position confirmation, and albuterol administration did not improve oxygenation. The case was converted
to open without improvement in oxygenation. Following 2.5L blood loss, oxygenation improved
significantly. Inhaled gas composition was decreased to 60% O2 with saturation rising to 96-97% for the
remainder of the case.
MCC02
1:20 PM - 1:30 PM
Polymixin-induced Recurarization Requiring Postoperative Reintubation
Vikram Bhasin, M.D., Jon Samuels, M.D., Anesthesiology, New York Presbyterian Hospital Weill-Cornell
Medical College, New York, NY
Polymyxins are a class of antibiotics that were previously used less frequently due to concerns for
neurotoxicity and nephrotoxicity. Due to the emergence of multidrug resistant organisms, its use has
increased. One of the major neurotoxic concerns is neuromuscular blockade, manifesting as respiratory
depression. There are very few recent cases reported in the literature of polymyxin induced
neuromuscular blockade. This is a case of polymyxin-induced recurarization, which occurred
postoperatively, and required re-intubation. This case is intended to highlight to possible neuromuscular
complications with polymyxin use in the operating room setting.
MCC02
1:20 PM - 1:30 PM
Anesthetic Management of Patient With CYP4502D6 Mutation, Mastocytosis and Ehlers-Danlos
Syndrome Type 3 Scheduled for Bone Marrow Biopsy
Praveen Kalra, M.D., Alvin Garcia, M.D., Anesthesiology, Stanford school of Medicine, Stanford, CA
22 year female with history of postural orthostatic tachycardia syndrome, dsyrhythmias, mastocytosis with
flushing, CYP4502D6 mutation and Ehlers-Danlos syndrome type 3 is scheduled for Bone marrow
biopsy. She was taking Propranolol, clonidine and hydroxyzine and allergic to Penicillin and gluten .
Significant number of anesthetic drugs are metabolized by CYP4502D6 and certain drugs are be avoided
in patient with Mastocytosis. Case was done under monitored anesthesia care with keeping in mind which
drugs are safer. Patient was positioned and padded for avoiding any pressure injury with Ehlers-danlos
syndrome. General anesthesia was avoided which could have more anesthetic concerns.
MCC02
1:20 PM - 1:30 PM
Aortic Cross-Clamp Physiology in the Setting of Severe Bilateral Iliac Stenosis
Gregory J. Stevens, M.D., Scott Kaser, M.D., Brian Fitzgerald, M.D., Anesthesiology, San Antonio Military
Medical Center, San Antonio, TX
A 61 year-old female ASA-4 was scheduled for aorto-bifemoral bypass secondary to severe bilateral iliac
stenosis causing bilateral lower extremity claudication. Numerous anti-hypertensive agents were available
for the potential perioperative hypertensive response to cross-clamp. When the clamp was applied, there
was no change in the patient’s blood pressure or heart rate. This case highlights the impact of severe
vascular stenosis distal to aortic cross clamp in a critically ill patient. In the setting of this dramatically
elevated baseline afterload, the increased afterload with cross clamp may not be significant enough to
increase systemic blood pressure.
MCC02
1:20 PM - 1:30 PM
Anesthetic Management of a Pregnant Patient Requiring Craniotomy for a Metastatic Malignancy
Rafal Kopanczyk, D.O., Suneeta Gollapudy, M.D., Anesthesiology, Medical College of Wisconsin,
Milwaukee, WI
Perioperative care of a pregnant patient poses a challenge for an anesthesiologist, especially when a
neurosurgical procedure is required. A 28 weeks pregnant female presented with worsening symptoms
related to brain metastases for which surgical debulking was necessary. A multidisciplinary approach
resulted in a comprehensive anesthetic plan ensuring patient’s safety, fetal wellbeing, as well as
satisfactory surgical condition. Its foundation concentrated on reducing risks that could have endangered
both mother and fetus. Our plan resulted in a successful surgery with no adverse affects to both patients.
MCC02
1:20 PM - 1:30 PM
Subdural Catheter Use for Analgesia in Labor and Anesthesia for Cesarean Section
Agnes Lamon, Barbara Orlando, M.D., Sanford Littwin, M.D., Deborah Stein, M.D., Anesthesiology, Mt.
Sinai Roosevelt Hospital, New York, NY
30 year-old female had an uneventful multiorifice epidural catheter placed. Aspiration was negative, a test
dose revealed no change in maternal hemodynamics. The catheter was then bolused 8 ml's of
Bupivicaine. After 3 subsequent contractions; full analgesia was noted, however the patient became
dyspneic. The sensory block extended to T2 with complete motor block of the lower extremities and
partial block to the upper. A subdural catheter was suspected due to extensive spread of local anesthetic,
late onset of high motor block, and relative lack of sympathectomy.4 hours later, a c-section was
performed using the subdural catheter.
MCC02
1:20 PM - 1:30 PM
Pain Medicine (PN)
Occipital Nerve Stimulation Using Ultrasound Guidance
Alison F. Brown, B.A., Matthew Mauck, M.D.,Ph.D., Lance A. Roy, M.D., Duke University, Durham, NC,
Department of Anesthesiology, Duke University, Durham, NC
Occipital nerve stimulation (ONS) is a treatment modality used to treat intractable chronic daily
headaches and occipital neuralgia after failure of conservative treatment. A 59 year-old female with
occipital neuralgia underwent ONS trial using ultrasound guidance, a relatively novel approach that offers
several potential advantages over the traditional method using anatomic landmarks and fluoroscopy.
Ultrasound provides real-time visualization of key anatomic structures and tissue planes, enabling more
precise electrode placement. This could potentially result in lower complication rates, decreased muscle
stimulation, lower voltage requirements, longer charge cycle, and longer battery life compared to
fluoroscopy alone.
MCC02
1:20 PM - 1:30 PM
Epidural Blood Patch Using Epidural Manometry for the Treatment of a Patient Presenting With
the Syndrome of Triphened or Sunken Skin Flap Syndrome
James D. Turner, Sean Dobson, M.D.,Ph.D., Anesthesiology, Wake Forest Baptist Medical Center,
Winston-Salem, NC
A 55 year-old male who fell from a roof and suffered a subarachnoid hemorrhage that required
decompressive craniectomy and cranioplasty and was complicated by an epidural abscess requiring
removal of the bone flap. One month later he developed altered mental status and was diagnosed with
Syndrome of Triphened, consistent with a sunken skin flap and increased midline shift from baseline.
Given the patient’s continual neurologic decline despite trendelenburg positioning and fluid limitations, an
epidural blood patch was requested. Following placement of the epidural blood patch using manometry in
the epidural space, the patient’s neurologic status continually improved throughout hospitalization.
MCC02
1:20 PM - 1:30 PM
In Your Face: A Case for Fiberoptic Orotracheal Intubation With Subsequent Submental Intubation
Erin L. Springer, M.D., James Clune, M.D., John Persing, M.D., Michael Hrycelak, M.D., Department of
Anesthesiology, Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, New Haven,
CT
The patient was a 34 year-old male who was riding an ATV while intoxicated and sustained facial trauma
as well as neck and truncal injury. Significant injuries included right LeFort 3 fracture, left LeFort 2
fracture, comminuted nasal fracture, right comminuted zygoma fracture, right orbital floor fracture, and C1
avulsion type fracture. Despite extensive facial fractures, facial hair, and cervical spine precautions, we
decided that we could ventilate the patient. We induced with muscle relaxation and then performed a
fiberoptic oral intubation. The plastic surgeons subsequently performed a submental intubation, which
allowed for intermaxillary fixation without the complications associated with tracheostomy.
MCC02
1:20 PM - 1:30 PM
Jehovah’s Witness Undergoing Coronary Artery Bypass Graft Surgery (CABG): Anesthetic
Management
Maulin U. Vora, M.B.,B.S., Archit Sharma, M.B.,B.S., Sasha Shillcutt, M.D., Department of
Anesthesiology, University of Nebraska Medical Center, Omaha, NE
About 56.2% of patients who undergo CABG receive packed red blood cells in the perioperative period
(1). As such; the unique set of beliefs of Jehovah’s Witness with regards to blood transfusion can pose a
challenge to the cardiac anesthesiologist (2). We present a case of a 68 year-old male Jehovah’s Witness
with diffuse coronary artery disease who underwent triple vessel CABG and requested bloodless surgery.
This case reviews perioperative management of Jehovah’s Witness patients undergoing cardiac surgery.
We will also discuss the use of retrograde autologous prime (3), cell salvage and intraoperative
autologous blood donation.
MCC02
1:20 PM - 1:30 PM
Ketamine as an Alternative to Volatile Anesthetic for Treatment of Refractory Status Epilepticus
Erica L. Holland, M.D., Robert Hsiung, M.D., Joseph M. Neal, M.D., Anesthesiology, Virginia Mason
Medical Center, Seattle, WA
Our anesthesiology service was consulted to provide isoflurane general anesthesia for treatment of
refractory status epilepticus in the critical care unit (CCU). Considering the novelty and complexity of
isoflurane administration in the CCU, we elected instead a ketamine infusion to wean the patient from a
pentobarbital coma. The infrequent use of volatile anesthetics in the CCU presented the following
challenges: 1) removal of waste gases, 2) Directed titration and refill of the volatile anesthetic, and 3)
CCU staff education. We herein discuss our thought processes as we considered prolonged provision of
general anesthesia in isoflurane in the CCU.
MCC02
1:20 PM - 1:30 PM
Refractory Torsades de Pointes in a Patient Undergoing Amiodarone Therapy Following Aortic
Dissection Repair
Nathan M. Lee, M.D., Neal Gerstein, M.D., Lev Deriy, M.D., Anesthesiology and Critical Care Medicine,
University of New Mexico, Albuquerque, NM
A 54 year-old male diagnosed with an acute Stanford type-A aortic dissection underwent an uneventful
repair. Six hours after arrival to the ICU, the patient developed persistent ventricular arrhythmias and
ventricular fibrillation requiring more than 20 episodes of defibrillation. Per ACLS, a bolus and continuous
infusion of amiodarone was administered, with no improvement. Repeat ECG demonstrated QTc
prolongation to 592ms suggesting Torsades de Pointes. Management included rapid pacing,
administration of magnesium, and discontinuation of amiodarone, with improvement of QTc to 450ms and
resolution of ventricular arrhythmias. However, the patient’s clinical status continued to deteriorate and he
died on POD 4.
MCC02
1:20 PM - 1:30 PM
Anesthetic Management of a Patient With Hemophilia A Undergoing Minimally Invasive Mitral
Valve Repair
Archana Srinivas, M.D., Patrick N. Odonkor, M.D., University of Maryland, Baltimore, MD
Hemophilia A is a bleeding disorder, resulting from a deficiency in Factor VIII, that affects 1 in 4000 males
at birth. We present a case of a 59 year-old gentleman with hemophilia A and severe mitral regurgitation
necessitating a minimally invasive mitral valve repair. Preoperatively, Factor VIII levels were measured
with results suggestive of mild hemophilia. Recombinant Factor VIII infusion was given using standard
dosing formula. Post-infusion and post-bypass Factor VIII levels were checked and showed appropriate
response to the recombinant factor. The patient received no allogeneic blood products, and postoperative
course was free of hemostatic complication.
MCC02
1:20 PM - 1:30 PM
Postpartum Hemorrhage Secondary to Undiagnosed Placenta Accreta in a Patient Undergoing an
Ex Utero Intrapartum Procedure
Wendy Nguyen, M.D., Lester Chua, M.D., Shobana Bharadwaj, M.B.,B.S., Andrew A. Malinow, M.D.,
Anesthesiology, University of Maryland Medical Center, Baltimore, MD
At 34 6/7 weeks EGA, a 34 year-old G3P2002 multigravid whose pregnancy was complicated by fetal
cystic hygroma presented with IUGR and was scheduled for an unanticipated EXIT procedure. After
induction of GETA, inhaled anesthetic was maintained with sevoflurane and a nitroglycerin infusion was
initiated for uterine relaxation. During successful intrapartum intubation of the fetus and delivery, the
patient hemorrhaged. She underwent emergent hysterectomy for undiagnosed placenta accreta. She was
resuscitated with multiple blood products, and extubated two hours after PACU arrival. A rare case such
as this having placenta accreta and fetal condition requiring an EXIT presents unique challenges.
MCC02
1:30 PM - 1:40 PM
Unexpected Difficult Intubation and Endotracheal Tube Obstruction in a Child With Williams
Syndrome
Michael Kallile, M.D., Katherine Gentry, M.D., Anesthesiology and Pain Medicine, University of
Washington, Seattle, WA
A two year-old with Williams syndrome presented for dental restoration under general anesthesia.
Williams includes aortic stenosis, a lesion associated with sudden death during induction, secondary to
tachycardia and hypotension causing coronary hypoperfusion. After induction mask ventilation was
adequate, but the patient had an unexpected difficult airway. Direct and video laryngoscopy failed, and
intubation was achieved by fiberoptic technique. A deep anesthetic plane prevented tachycardia. Later,
the patient developed hypercarbia with VBG 7.0/120, due to complete obstruction of tube with clot, from
mucosal trauma during the intubation attempts. The tube was replaced, and the VBG improved to 7.3/47
prior to extubation.
MCC02
1:30 PM - 1:40 PM
Epidural or Opioids? A Case of Perioperative Priapism
Negin Daneshpayeh, M.D., Sarah Nizamuddin, M.D., Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA
Epidurals have been associated with the development of priapism. Interestingly, they have also been
studied as a possible treatment for priapism. This case is of a patient who presented for a low anterior
resection for sigmoid cancer. A thoracic epidural was placed preoperatively. Following a negative test
dose, fentanyl was administered through the epidural catheter. The patient then promptly developed
priapism, leading to urology consultation and eventual penile phenylephrine injection. On postoperative
day one, the patient had a second erection following a bolus of hydromorphone from an intravenous PCA.
MCC02
1:30 PM - 1:40 PM
Anesthestic Considerations in Airway Management, Ventilation and Maintenance for Tracheal
Resection
Nisha Chhabra, M.D., Cristina Barboi, M.D., Department of Anesthesiology, Rush University Medical
Center, Chicago, IL
A patient with recurrent thyroid cancer invading the trachea and vocal cord paralysis underwent tracheal
resection without a tracheostomy. While resecting tracheal rings 1-3, the oral ETT was removed. A
reinforced ETT was placed in the distal trachea for intermittent ventilation and apneic oxygenation. Before
closing the repair, a retrograde intubation of the trachea was performed and the oral endotracheal tube
advanced distal to the repair. She was extubated post-operative day one. On day two, she developed
stridor and dyspnea that were successfully treated with racemic epinephrine, Heliox and CPAP.
MCC02
1:30 PM - 1:40 PM
Persistent Post-Operative Hoarseness After General Anesthesia that Requires ENT Evaluation
Shahram Nafisi, M.D., Simin Saatee, M.D., N. Nick Knezevic, M.D., Kenneth D. Candido, Anesthesia,
Advocate Illinois Masonic Medical Center, Chicago, IL
A-72 year-old woman with paroxysmal atrial fibrillation presented to EP lab for cryear-oldablation. The
patient received GA and she was intubated for 8.25 hours. Immediately after extubation the patient
developed hoarseness without sore throat, pain, or dyspnea. One month after the first procedure, she
underwent the second procedure under GA without intubation. Patient’s hoarseness lasted for 2 months
without improvement. ENT specialist during indirect laryngoscopy found nodules on the vocal cord
(picture). After a 5-day course of azitramycin and methylprednisolone, she reported 80% improvement
(picture). Further treatment of hoarseness after GA may be necessary if it is not self-resolved.
MCC02
1:30 PM - 1:40 PM
Intrathoracic Mimic: Pulmonary Artery Sarcoma Disguised as a Pulmonary Embolism
Daniel P. Raboin, M.D., David Lowery, M.D., Carl McMullen, M.D., Timothy Mooney, M.D., Christopher V.
Maani, M.D., Anesthesiology, San Antonio Uniformed Services Health Education Consortium, San
Antonio, TX
A 63-year-old woman presented with acute dyspnea on exertion. With a working diagnosis of PE, she
was managed for 2 months withtherapeutic anticoagulation. A repeat CT scan for persistent symptoms
revealed a presumed thromboembolic lesion which was progressive in size. After endovascular attempts
to remove the suspected thrombus failed, the decision was made to pursue an open thrombectomy. Upon
exposure of the right pulmonary artery, the surgeons found cartilaginous appearing tissue involving a
significant portion of the wall of the right PA. We will discuss pulmonary artery sarcoma, anesthetic
management and the associated TEE findings.
MCC02
1:30 PM - 1:40 PM
A Transcranial Doppler Ultrasonography Finding During Carotid Endarterectomy Produced by a
Flap in the Internal Carotid Artery
Alisa Chen, M.D., Eric J. Heyer, M.D.,Ph.D., Anesthesiology, Neurology, Columbia University, New York,
NY
Carotid endarterectomy was performed with electroencephalography and transcranial Doppler
ultrasonography. There was no change in EEG, but decreased flow after cross-clamp removal on
TCD.The patient awoke globally aphasic with right arm weakness. Our differential diagnosis included
weakness secondary to residual neuromuscular blockade, opiate-induced weakness and cerebrovascular
accident.CT angiogram revealed occlusion of the ICA immediately distal to the operative site. Upon
reoperation, a thrombus causing a one way ball-valve lesion was found.This case presents another
differential to consider for postoperative weakness during CEA. We also demonstrate another utility for
TCD, namely to determine that CBF returns to normal.
MCC02
1:30 PM - 1:40 PM
Hypotensive Epidural Anesthesia for Management of Postpartum Hemorrhage in Unanticipated
Placenta Percreta
Amanda R. Moraska, M.D., Justo Gonzalez, M.D., Anesthesiology Institute, Cleveland Clinic, Cleveland,
OH, Anesthesiology, Cleveland Clinic - Hillcrest Hospital, Cleveland, OH
We present a 39 year-old G5P3 woman who underwent repeat Cesarean section with combined spinalepidural anesthesia complicated by massive intraoperative hemorrhage due to unanticipated placenta
percreta. Anesthesia was converted to general with endotracheal intubation and total intravenous
anesthesia. Massive transfusion protocol was initiated, additional IV access gained, and spontaneous
ventilation and hypotensive epidural anesthesia were used to decrease blood loss until hemostasis was
achieved with hysterectomy. This case illustrates an important cause of obstetric hemorrhage, the
incomplete sensitivity of prenatal ultrasound for diagnosis of invasive placenta, and the utility of regional
and other anesthetic techniques in management of surgical blood loss.
MCC02
1:30 PM - 1:40 PM
Pain Medicine (PN)
Cooled Radiofrequency Ablation for Advanced Treatment of Intractable Knee Pain from Diffuse
Osteoarthritis
Anita Gupta, D.O., Mansoor Aman, M.D., Casey Dzuong, B.S., Erin Treacy, M.D., Anesthesiology and
Pain Medicine, Drexel University College of Medicine, Philadelphia, PA
56 year-old female presented for outpatient evaluation of her bilateral knee pain from chronic
osteoarthritis after having failed conservative, pharmacological, and various procedural therapy. She was
not a surgical candidate for total knee arthroplasty and her unremitting pain affected both her functional,
and mental status. Patients that have failed the spectrum of conservative therapies such as aerobic,
aquatic, weight loss, and psychosocial interventions seldom get relief from the more aggressive
treatments such as intra-articular injections. We employed cooled radiofrequency ablation targeting the
superior medial and lateral, inferior medial and lateral, and recurrent tibial genicular nerve branches which
provided relief.$$MISSING OR BAD IMAGE SPECIFICATION {871D0603-CEA5-4B7F-B44662B878AA308C}$$
MCC02
1:30 PM - 1:40 PM
Unanticipated Full Heparinization During Retroperitoneal Sarcoma Resection With Thoracic
Epidural in Place
Matthew D. Parks, M.D., Jason Lane, M.D.,M.P.H., Anesthesiology, Vanderbilt University, Nashville, TN
23 year-old male planned for a Whipple resection of a retroperitoneal sarcoma had a pre-operative
epidural catheter placed. Tumor was found to invade the inferior vena cava (IVC). Resection required IVC
reconstruction. This required anticoagulation with heparin. Concern was raised regarding increased risk
of epidural hematoma given intra-operative anticoagulation. The catheter was discontinued four hours
after the last dose of heparin was administered. The patient was transferred to the SICU for neuro checks
and initiation of heparin drip. The patient did not develop any signs/symptoms of an epidural hematoma,
and was discharged to home one week after his surgery.
MCC02
1:30 PM - 1:40 PM
Postoperative Bleeding in a Hemophiliac With Anti-Factor VIII Inhibitors
David W. Brown, M.D., Adam D. Niesen, M.D., Mayo Clinic, Rochester, MN
A 30 year-old male with Hemophilia A, high titers of anti-factor VIII antibodies, allergy to NovoSeven, and
history of painful hemarthroses was scheduled for bilateral total knee arthroplasty. Hematology
consultation recommended perioperative administration of FEIBA (Factor Eight Inhibitor Bypassing
Activity, an activated prothrombin complex concentrate). He received one dose prior to induction of
anesthesia.Surgery was uncomplicated, and intraoperative blood loss was approximately 150 mL.
Postoperatively, bleeding increased to 800 mL hourly, and total PACU blood loss was 2200 mL.
Hemostasis was eventually achieved through an additional bolus dose of FEIBA. No further bleeding
episodes occurred during his hospital stay.
MCC02
1:30 PM - 1:40 PM
Anesthetic Management for Resection of Giant Anterior Mediastinal Mass
Valerie Ivanova, D.O., Lynn Belliveau, M.D., Kalpana Tyagaraj, M.D., Anesthesiology, Maimonides
65 years female with history of hypertension, mediastinal sarcoma and pericardial effusion, presented for
surgical resection of the tumor. Due to the size of the tumor, the patient was at risk for hemodynamic and
airway collapse. An awake fem-fem bypass was performed via right femoral cut down under local
anesthesia. As the patient went on bypass, general anesthesia was induced with sevoflurane, ketamine,
midazolam and intubated with glidescope. The patient underwent a sertnotomy and tumor resection. She
was left intubated at the end of the case.
MCC02
1:30 PM - 1:40 PM
CVC Insertion Causing Pericardial Effusion With Tamponade Physiology: A Case Report
George Williams, II, William A. Windham, M.D., Bryan K. Lai, M.D., Michelle Daryanani, M.D., Karuna
Puttur Rajkumar, M.D., Anesthesiology, University of Texas-Houston Health Science Center, Houston, TX
Central venous catheterization (CVC) is typically used in the perioperative setting for the management of
patients undergoing major surgery or care of patients in the intensive care unit. However the procedure is
not without risks and known to cause complications. Among the multiple risks for complications,
pericardial tamponade is a rare occurrence, but one of the most fatal complications resulting in significant
morbidity and death. We present the case of a 23 year-old woman who developed pericardial tamponade
following repeated attempts during CVC insertion. As demonstrated in our case, routine use of
ultrasound may reduce the risk of death.
MCC02
1:30 PM - 1:40 PM
The Utility of Transesophageal Echocardiography(TEE) to Assist Diagnosis of Intra-abdominal
Hemorrhage During Cardiac Arrest
Christina A. Jelly, M.D., M.S., Yafen Liang, M.D., Yandong Liang, M.D., Mark Hoeft, M.D., Department of
Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, Department
of Anesthesiology, Vanderbilt University Medicine Center, Nashville, TN
Transesophageal Echocardiography(TEE) has been more frequently employed to identify intrathoracic
pathology during intraoperative cardiac arrest for non-cardiac surgical patients. However, TEE to assist in
the diagnosis of intraabdominal hemorrhage has never been reported. We present a patient who went
into cardiac arrest upon closure of an elective distal pancreatectomy. Rescue TEE performed revealed
hypovolemia with hyperdynamic ventricles. Volume under resuscitation was initially suspected. However
subsequent transgastric TEE views demonstrated a peri-hepatic fluid collection raising concern for
intraabdominal hemorrhage. This prompted re-exploration. We suggest that transgastric views to identify
intra-abdominal collections be considered during a rescue TEE if hemorrhage is suspected.
MCC02
1:30 PM - 1:40 PM
Attempted Fenestrated EVAR in a 79 Male With a 9.5 CM Pararenal Abdominal Aortic Aneurysm
Uvie Whiteru, M.D., Srinivasa S. Thota, M.D., Anesthesiology, State University of New York Upstate
Medical Center, Syracuse, NY
79 year-old male presented with a 9.5 cm pararenal AAA, increased from 8 cm one month prior. Medical
history included HTN, HLD, CAD S/P CABG, ruptured AAA s/p repair, dementia, CVA s/p b/l CEAs,
cerebral aneurysm, and untreated bladder cancer. After placement on an esmolol drip the decision was
made to proceed with EVAR per family wishes and initial DNR/DNI status rescinded.Anesthetic
management included GETA with RSI and arterial-line placement. The EVAR was aborted due to
inoperable anatomy. He was returned to SICU intubated and extubated 2 days later. DNR/DNI status was
reinstated and palliative care consulted.
MCC02
1:30 PM - 1:40 PM
Management of an Epileptic Patient With a Vagal Nerve Stimulator During Labor: A Case Report
Roberto J. Roman, M.D., Ivette M. Hernandez, M.D., Anesthesiology, University of Puerto Rico, San
Juan, PR
A 35 year-old female patient G2P0A1 with history of medically refractory epilepsy who was treated with
antiepileptic drugs and a vagal nerve stimulator arrived to labor room at 39 WGA for vaginal delivery. An
epidural catheter was placed for labor pain management. Labor progressed uneventfully. A plan was
made for management of any potential seizure episode, and the use of the VNS in case an emergency
cesarean section.
MCC02
1:40 PM - 1:50 PM
Anesthetic Management of Omphalopagus Twins
Rita S. Patel, M.D., Katrin Post-Martens, M.D., Steve Collins, M.D., Olinda Renee Gaver, M.D.,
Anesthesiology, University of Florida COM Jacksonville, Anesthesiology, Wolfson Children's Hospital,
Jacksonville, FL
Preterm omphalopagus conjoined twins were born via C-section at a hospital with high risk obstetrics with
an omphalocele that was ruptured, exposing liver and bowel, during delivery. They were transported to a
pediatric hospital and taken to the OR for silo. Each twin had its own anesthetic team and equipment for
management. After induction of twin A, twin A was intubated followed by twin B, noting no desaturation
between either twin, demonstrating shared circulation. Also, medications such as glycopyrrolate
administered to twin A showed effect on twin B. Postoperatively they were transported to the NICU via Yadaptor connecting the ETTs.
MCC02
1:40 PM - 1:50 PM
Emergency Airway Management of an Obtunded Patient With an In-Situ Tracheal T-Tube
James J. Lamberg, D.O., Jonathan A. Anson, M.D., Anesthesiology, Penn State Hershey Medical Center,
Hershey, PA
The Montgomery Tracheal Stent (“T-Tube”) provides unique airway challenges for the anesthesiologist.
Poor familiarity with this airway device can lead to lost airway during management, in particular with
standard direct laryngoscopy and endotracheal intubation. We present a case of emergency airway
management in an obtunded patient with a T-Tube and clenched teeth. Management involved removal of
the T-tube through the tracheostomy over a Cook exchange catheter with nasal fiberoptic visualization
from above the glottis followed by placement of a cuffed tracheostomy tube. The T-tube was found to be
almost completely occluded with mucus.
MCC02
1:40 PM - 1:50 PM
Acute Intraoperative Hyperkalemia, Autosomal Dominant Polycystic Kidney Disease(ADPKD), and
Native Nephrectomy
Joshua B. Knight, M.D., Shashank Saxena, M.D., Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA
47year-old male with ESRD due to ADPKD status-post kidney transplant with allograft nephropathy
presenting for elective bilateral native nephrectomy. Preoperatively, ECG showed sinus rhythm and VBG
showed potassium 4.8. After uneventful induction, vitals stable without ECG abnormalities. After incision
and manipulation of native kidneys, routine ABG revealed potassium 5.9. Minutes later tall peaked T
waves appeared, repeat ABG showed potassium 6.8. Surgeon immediately notified, hyperventilation
instituted, and calcium chloride, insulin-dextrose, albuterol, sodium bicarbonate administered. Potassium
decreased to 5.7 then 5.2 and 4.7. Patient admitted to ICU postoperatively on bicarbonate infusion,
potassium levels stabilized over 3 days prior to discharge.
MCC02
1:40 PM - 1:50 PM
Nasopharyngeal Dissection After Traumatic Nasotracheal Intubation in a Patient With Obstructive
Sleep Apnea
Avinash D'Souza, D.O., Zak Hillel, M.D., Anesthesiology, Mount Sinai St.Luke's Roosevelt Hospital, New
York, NY
A 63 year-old male with sleep apnea (on CPAP) underwent emergency open treatment of mandibular
fracture and interdental fixation. Initial trauma during nasotracheal intubation resulted in loss of
visualization of the endotracheal tube under direct laryngoscopy in the oropharynx. Subsequent
examination of the nasal passages with a fiberoptic scope confirmed dissection of the posterior
nasopharynx. The airway was secured by placing a second nasotracheal tube via fiberoptic guidance.
After completion of the procedure, the patient was transferred to the ICU for management of airway
edema and inflammation. He was extubated on post-op day 4 and discharged home.
MCC02
1:40 PM - 1:50 PM
Total IV Anesthesia For Cardiopulmonary Bypass In a Patient With Risk of Malignant
Hyperthermia
Jeremy J. Hartley, M.D., Katie Goergen, M.D., Anesthsiology, University of Nebraska Medical Center,
Omaha, NE
A 79 year-oldfemale with a history of coronary artery disease, atrial fibrillation,hypertension,
hypercholesterolemia, transient ischemic attack, and rheumatoidarthritis planning for on-pump coronary
artery bypass grafting.Givenpatient’s family history of malignant hyperthermia, the team proceeded
underTIVA after careful coordination with perfusionist team. Additionally, a bispectral index was addedfor
monitoring. TIVA was performed usinga propofol and remifentanil infusion with bolus doses of midazolam.
No adverse events occurred in the care ofthis patient; however their remarkably stable hemodynamic
profile while underTIVA may translate to use in other cardiopulmonary bypass cases.
MCC02
1:40 PM - 1:50 PM
Reactions to Preservative-Containing Medications After a Single Large-Dose Pesticide Exposure
Jillian S. Vitter, M.D., Stacy L. Fairbanks, M.D., Department of Anesthesiology, University of Colorado
Hospital, Aurora, CO
A 59 year-old woman presented for resection of a pituitary macroadenoma. She arrived to pre-op with a
list of 15 medications/preservatives that caused anaphylaxis. She also reported anaphylaxis during
hysterectomy after administration of preservative-containing ondansetron. After consultation with
pharmacy, we planned a preservative-free general anesthetic with desflurane. After induction the patient
developed hypotension without tachycardia refractory to fluids, vasopressin, and epinephrine. The patient
was awakened, neurological status obtained, and re-attempt was made using preservative-free TIVA.
Ultimately, surgery was cancelled and the patient slowly emerged uneventfully. Postoperatively, the
patient’s husband reported the patient’s allergies began after a single large-dose pesticide exposure.
MCC02
1:40 PM - 1:50 PM
Management of Cesarian Delivery in the Parturient With a Retroperitoneal Mass and Hypoxemic
Respiratory Failure
Nicholas Haralabakis, M.D., Jon D. Samuels, M.D., Weill Cornell Medical College, New York, NY
29 year-old female G2P1001 at 31 weeks presented with hypoxemic respiratory failure and bilateral lower
lung lobe collapse as a complication from a rapidly enlarging retroperitoneal mass, which measured 16.8
x 13.3 x 21.8 cm in size. Urgent cesarean section under general anesthesia, via an exploratory
laparotomy, was scheduled due to impending clinical decompensation. A thoracic epidural was placed for
postoperative pain, and the airway was secured via an awake fiberoptic intubation utilizing
glossopharyngeal and SLN blocks, and topicalization. Hypoxemia persisted post delivery, and the patient
necessitated mechanical ventilation postoperatively while under care of the surgical ICU.
MCC02
1:40 PM - 1:50 PM
Pain Medicine (PN)
Targeting Opioid Induced Constipation With Peripherally Acting Mu-Receptor Antagonists
Naloxegol
Anita Gupta, D.O., Mansoor Aman, M.D., Erin Treacy, M.D., Anesthesiology and Pain Medicine, Drexel
University College of Medicine, Philadelphia, PA
62 year-old female with spinal stenosis requiring chronic opioid therapy will be presented. Her regimen
adequately controlled her pain and improved functionality, she developed severe intractable opioid
induced constipation (OIC) limiting her bowel movements to once weekly. Treatment options for OIC
including the recently FDA approved medication for OIC, naloxegol will be discussed. Naloxegol has
unique pharmacologically activity that is naloxone modified as a pegylated moiety, limiting its ability to
penetrate the blood brain barrier. This drug shows potential promise as being both convenient given its
oral route, and rapidly effective alternative to current treatment options for OIC.
MCC02
1:40 PM - 1:50 PM
Combination Interscalene and Axillary Brachial Plexus Blocks in a Patient on Opioid Maintenance
Therapy With Multiple Upper Extremity Fractures: It Takes a Block to Do a Block
Ari S. Balofsky, M.D., Daryl I. Smith, M.D., Department of Anesthesiology, University of Rochester
Medical Center, Rochester, NY
A 29 year-old man with history of heroin abuse for which he was receiving suboxone maintenance
therapy, presented for repair of a long finger extensor tendon injury about one month following
amotorcycle accident. Given a concurrent injury to his clavicle, it was extremely difficult and painful for the
patient to abduct and externally rotate his arm to optimally position for an axillary block of the brachial
plexus. After performing an interscalene block of the brachial plexus, he was able to abduct and rotate his
arm, and an axillary block of the brachial plexus was performed.
MCC02
1:40 PM - 1:50 PM
Endotracheal Intubation in the Lateral Decubitus Position: Airway Management and Hemodynamic
Considerations
Thomas S. White, M.D., Anesthesiology, Baylor College of Medicine, Houston, TX
A 75 year-old Caucasian male presented for a wedge resection of a right lower lobe lung nodule. Given
the fibrotic nature of the lung, calcified pleural plaques, and the extreme posterior position of the lesion, a
CT-guided placement of a localizer wire was performed to aid in the removal of the lesion.With the patient
unable to be placed in the supine position due to the wire protruding from his posterior thorax, induction
and intubation was performed laterally utilizing video-assisted laryngoscopy and a single lumen Univent
tube with an incorporated bronchial blocker, all while avoiding a loose incisor.
MCC02
1:40 PM - 1:50 PM
Open Removal of Common Iliac Stent From the RV With Subsequent Severe Tricuspid
Regurgitation Necessitating Valve Repair
Jamel P. Ortoleva, Sn Garwood, Anesthesiology, Yale New Haven Hospital, New Haven, CT, Yale New
Haven Hospital, New Haven, CT
A 50 year-old female with prior gastric bypass surgery, DVTdue to May-Thurner’s syndrome and s/p left
common iliac vein stent that wasfound to have migrated on a CT scan obtained to workup complaints of
fatigueand abdominal pain. Her stent was was noted to have migrated to the RV andworkup revealed
significant tricuspid regurgitation. She presented forsternotomy, cardiopulmonary bypass and removal of
embolized stent. After successful stent removal the residualtricuspid regurgitation was estimated as
severe. She came back several months laterand underwent an uneventful tricuspid repair.
MCC02
1:40 PM - 1:50 PM
Difficult Airway Management in a Patient With Class III Obesity: A Case Report
George Williams, II, Terra Wubbenhorst, M.D., Eric Sceusi, M.D., Bryan Cotton, M.D., Anesthesiology,
University of Texas-Houston Health Science Center, Houston, TX
With obesity becoming a growing concern in medicine, health care workers must learn how to treat
morbidly obese patients and manage the challenges that come with them. This is a case of a super
morbidly obese (BMI- 86 kg/m2) patient who presented with difficult airway management in the surgical
critical care setting. Tracheostomy insertion was challenging (>12 cm depth) and the tremendous
paracervical fat provided equivalent immobilization to a Miami J cervical collar.Implications of super
obesity for critical perioperative management is discussed.
MCC02
1:40 PM - 1:50 PM
Transurethral Resection Syndrome Secondary to Bladder Perforation
Michael Ting, M.D., Mauricio Perilla, M.D., Alexander Leone, M.D., Anesthesiology, Cleveland Clinic
Foundation, Cleveland, OH
Transurethral resection syndrome (TRS) is an iatrogenic water intoxication characterized by
hyponatremia, mental status changes, and hemodynamic instability. TRS can present as a complication
of transurethral resection of prostate (TURP syndrome), or transurethral resection of bladder tumor
(TURBT syndrome). Management primarily involves correction of hyponatremia with hypertonic saline
and other supportive measures. Here we describe a case of TURBT syndrome to compare and contrast
the pathogenesis of hyponatremia and management approaches between TURP and TURBT syndromes.
MCC02
1:40 PM - 1:50 PM
Transesophageal Echocardiography (TEE) as a Diagnostic Modality for Coronary Artery
Aneurysms (CAA) and Coronary Arteriovenous Malformations (CAVM)
Viviana Freire, Alexander Kahan, M.D., Brian Raffel, D.O., Antonio Chiricolo, M.D., Department of
Anesthesiology, Department of Cardiothoracic Anesthesia, Rutgers Robert Wood Johnson Medical
School, New Brunswick, NJ
63 year-old female presented to ED in shock, suffering from cardiac tamponade. Intra-operatively, we
were able to diagnose a coronary artery aneurysm (CAA) and coronary arteriovenous malformation
(CAVM) with echocardiography, cardiac catheterization with coronary angiography. A left anterior
descending aneurysm with a fistula to the main pulmonary artery had ruptured causing large pericardial
effusion with right ventricular diastolic collapse. Surgical ligation of the CAA and CAVM was successful.
The TEE gave us the ability to diagnose this rare condition in a timely manner and in the absence of the
exam, the patient may have experienced a delay in treatment.
MCC02
1:40 PM - 1:50 PM
Anesthetic Management of the Parutrient With a History of Pneumothoraces
Katherine Gelber, M.D., Hina Aslam, M.D., Suzanne W. Mankowitz, M.D., Department of Anesthesiology,
Columbia University Medical Center, New York, NY
Two parturients presented with a history of pneumothoraces. One parturient had catamenial
pneumothoraces and underwent a VATS procedure and a right upper lobectomy with pleurodesis prior to
pregnancy. The other parturient, who had pulmonary blebs, declined the recommended pleurodesis. Both
parturients had consultation with pulmonologists who recommended cesarean delivery with regional
anesthesia. Here we discuss the physiologic changes that occur during the second stage of labor and
how these may adversely affect the outcome in parturients with pneumothoraces. We will also review the
pulmonary guidelines for delivery in such patients as well as anesthetic management.
MCC02
1:50 PM - 2:00 PM
Anesthetic Management of an Aicardi Syndrome Child With Bronchial Foreign Body
Brian P. Walker, M.D., Xiangtian Hu, M.D., Thomas Mell, M.D., Ramesh Swamiappan, M.D., Georgette
Alexis, M.D., Maria Ramos, M.D., Anesthesiology, State University of New York-Downstate Medical
Center, Anesthesiology, Kings County Hospital Center, New York, NY
A 7 year-old girl with Aicardi Syndrome presented to the ED in respiratory arrest. The EMS team who
responded found the patient in respiratory arrest and PEA. PALS was initiated while in transit to the ED.
Upon arrival, the patient was orally intubated with a cuffed endotracheal tube. The pulse was recovered
after 20 minutes and a chest x-ray was obtained, showing a tubular foreign body overlying the right
mainstem bronchus protruding slightly into the trachea. Fiberoptic bronchoscopy revealed the distal
phalange of the tracheostomy had dislodged and was partially occluding the right mainstem bronchus.
MCC02
1:50 PM - 2:00 PM
NIM Tube Monitoring and Topical Local Anesthesia of the Airway
Benjamin M. Kristobak, M.D., Department of Anesthesiology, Walter Reed National Military Medical
Center, Bethesda, MD
A 62 year-old euthyroid man underwent total thyroidectomy for multinodular goiter. The mass extended
into the mediastinum and he reported orthopnea, but was able to lie at a 30o incline without difficulty
respiratory distress. The surgeon requested a nerve integrity monitor (NIMTM) endotracheal tube during
the case. Lidocaine lubrication is discouraged when using a NIMTM tube as it is expected to impact the
NIMTM tube’s recordings, however, topical anesthesia of the airway is well described. The patient was
intubated easily with video laryngoscopy without the use of airway topical local anesthetic or lidocaine
containing lubrication.
MCC02
1:50 PM - 2:00 PM
Anesthetic Management of Broncholithiasis Resulting in Complete Right Lower Lobe Lung
Collapse
Elena J. Koepke, M.D., MBA, Tiffany Moon, M.D., Amy Woods, M.D., UT Southwestern, Dallas, TX
A 40 year-old woman presented with productive cough and recurrent pneumonia. CT scan revealed
collapse of the RLL and a calcified granuloma. Subsequent bronchoscopy revealed a broncholith
completely occluding the bronchus intermedius. CT surgery planned for a flexible, followed by a rigid
bronchoscopy and possible thoracotomy if necessary for resection of the broncholith. Our anesthetic plan
had to be flexible; we prepared an LMA for the bronchoscopy and had both jet ventilation and double
lumen tube on standby. Ultimately, the broncholith was found to be mobile and removed with the LMA,
and the complex case was resolved rather simply.
MCC02
1:50 PM - 2:00 PM
A Case of Laryngospasm During Awake Fiberoptic Intubation in a Patient With a Large Vocal Cord
Polyp
Richard Nguyen, D.O., Scott Switzer, D.O., Timothy Ungerer, D.O., Srinivasa Gutta, M.D., Nancy O'neil,
C.R.N.A., Baystate Medical Center, Springfield, MA
A 51 year-old female with a BMI of 56, home oxygen dependency, tracheal stenosis, history of difficult
intubation presented for a resection of vocal cord polyp. She had stridor with respirations. We proceeded
with an awake fiberoptic intubation. Fiberoptic exam revealed a large vocal cord polyp moving in and out
of the glottic opening with spontaneous breathing, causing near total occlusion of the airway. During
airway manipulation, the patient developed laryngospasm with loss of airway, requiring induction with
propofol and succinylcholine. Tracheal intubation was achieved through a small opening in the glottis.
The polyp was resected by the surgeon.
MCC02
1:50 PM - 2:00 PM
Double, Double Without Toil and Trouble: Correction of Adult Congenital Double-Chambered
Right Ventricle and Ventricular Septal Defect Causing Severe Right Ventricular Outflow Tract
Obstruction
Blake Watterworth, M.D., Wendy Bernstein, M.D., University of Maryland, Baltimore, MD
Double-chambered right ventricle is a rare, difficult-to-diagnose, congenital heart disease often
complicated by severe RVOT obstruction. A 63 year-old female returns to the U.S. for the first time since
diagnosis of VSD at age 3 with dyspnea on exertion. The patient was scheduled for VSD closure and
myear-oldmectomy of RVOT utilizing cardiopulmonary bypass. The severe nature of her disease required
careful planning of her perioperative management to maintain stable hemodynamics and prevent
cardiovascular collapse. Successful selection and timing of anesthetics, invasive monitoring,
vasopressors, and inotropes facilitated an uneventful hospital course. Discharge occurred on postoperative day four without adverse sequelae.
MCC02
1:50 PM - 2:00 PM
Endoscopic Third Ventriculostomy for Dandy Walker Syndrome in an Older Patient
Bukola Ojo, M.D., Maninder Singh, M.D., Anesthesiology, Case Western Reserve University Metrohealth Medical Center, Cleveland, OH
A 50 year-old woman with a high-school education presented with progressively severe headaches with
onset 10 years prior. Imaging revealed marked hydrocephalus, a retrocerebellar cyst, and a diagnosis of
Dandy-Walker malformation. The patient elected to undergo an endoscopic third ventriculostomy instead
of a shunt. She underwent general anesthesia and with the exception of a moment of bradycardia that
resolved with removal of the scope, the case was uneventful and the patient did well postoperatively. We
present the rare case of Dandy-Walker presenting in middle-age and discuss the anesthetic concerns for
an endoscopic third ventriculostomy.
MCC02
1:50 PM - 2:00 PM
Unique Maternal Anesthetic Management for Twin Gestation Exit Procedure
David M. Gordon, M.D., Joseph R. Guenzer, M.D., Jennifer Hofer, M.D., Mohammed Minhaj, M.D.,
Barbara Scavone, M.D., Department of Anesthesia and Critical Care, University of Chicago Medical
Center, Chicago, IL
OBJECTIVEEx utero intrapartum surgery (EXIT) is performed when there is suspected fetal airway
pathology requiring intervention while fetoplacental circulation is intact. We present unique anesthetic
management for the first reported case of an EXIT procedure with twin gestation involving airway
pathology in both twins.CASE REPORTA 28 year-old G5P3 patient at 39 2/7 wks twin gestation with
pregnancy complicated by severe micrognathia in both twins was scheduled for an EXIT procedure for
intrapartum fetal airway management.DISCUSSIONMultidisciplinary communication and preparation are
key components to a successful EXIT procedure to optimize maternal and fetal outcomes.
MCC02
1:50 PM - 2:00 PM
Pain Medicine (PN)
Challenges of Diagnosing Narcotic Seeking Behavior
Puneet Mishra, M.D., John Corey, M.D., Brian Allen, M.D., Anesthesiology, Division of Pain Medicine,
Vanderbilt, Nashville, TN
50 year-old woman with congenital deafness, depression, and bipolar disorder admitted for acute back
and chronic neck pain. Interview with a sign language interpreter revealed the patient’s home narcotic
regimen, which was corroborated by the state’s controlled substance medical database (CSMD). Our
interpreter revealed he had translated for her in other hospitals (which use the same interpreter service)
where she was labeled a narcotic seeker. Since this occurred inpatient, her true narcotic use was not
reflected in CSMD. This shows how information can come for unexpected sources; however, raises an
ethical dilemma in accurately incorporating opinions provided by non-medical personnel.
MCC02
1:50 PM - 2:00 PM
Regional and Neuraxial Anesthestic Considerations for SNRI-related Platelet Dysfunction With
History of Bleeding Complications
Allison Overmon, M.D., Stuart Grant, M.B.,Ch.B., Anesthesiology, Duke University Medical Center,
Durham, NC
A 51 year-old female with SNRI-induced platelet dysfunction and history of cerebral hemorrhage after
injection for neuralgia presented for repeat, right humerus fracture ORIF subsequent to fall. For primary
ORIF, Hematology recommended platelet transfusion with DDAVP if needed. A transfusion of platelets
and a supraclavicular block were well-tolerated. With repeat presentation, platelet count was 212,000 with
a normal ristocetin assay. She received platelets prior to procedure with a supraclavicular block placed
post-procedure due to nerve monitoring. Anesthestic considerations include complications of managing
patients on SNRIs/SSRIs and their increased bleeding risk per new ASRA guidelines released in 2015.
MCC02
1:50 PM - 2:00 PM
Difficult Ventilation in a Patient With Severe Airway Bleeding
Sarah E. Hartlage, M.D., M.S., Sean Clifford, M.D., Department of Anesthesiology and Perioperative
Medicine, University of Louisville, Louisville, KY
Tracheal intubation of the trauma patient is challenging, especially when there is blood in the airway.
Such bleeding into the lungs can also compromise the ability to ventilate, even when an airway has been
obtained. In such situations, hypoxic hypercarbic arrest may ensue. We present a case of a 43 year-old
male polytrauma patient who suffered severe bleeding from his tracheostomy site, leading to an inability
to ventilate despite presence of a definitive airway; this necessitated a tracheostomy revision, therapeutic
bronchoscopy, and ACLS resuscitation. We review strategies for establishing an airway, maintaining
ventilation, and resuscitating similar critical patients.
MCC02
1:50 PM - 2:00 PM
Percutaneous Coronary Intervention Utilizing Femoral Femoral Bypass and MAC
Matthew Hoyt, M.D., Jeffrey A. Clark, M.D., Anesthesia, Matthew Hoyt, Lebanon, NH, Anesthesia,
Dartmouth Hitchcock Medical Center, Lebanon, NH
An 81 year-old male was admitted for NSTEMI with multiple comorbities including chornic kidney disease,
anemia, and melanoma. His catheterization showed triple vessel disease including left main disease. His
surgical risk was felt to be too high so high risk intervention was offered. Cardiopulmonary bypass was
planned to offer reduced myear-oldcardial oxygen demand as well as back up in case stenting induced
ischemia. He wished to avoid intubation if possible. We planned MAC anesthetic. Bypass was initiated,
and stenting completed successfully. He did have hypoxic respiratory failure post-operatively likely due to
fluid overload from transfusion he received on cardiopulmonary bypass.
MCC02
1:50 PM - 2:00 PM
Adrenal Insufficiency Acute Induced by a Single Dose of Etomidate During Anesthetic Induction
Bruno F. Tonelotto, Sr., Claudia Marques Simões, Ph.D., Enis Silva, M.D., Adeli Alfano, M.D.,
Anesthesia, Sirio-Libanes Hospital, Sao Paulo, Brazil
MAS, female, 77, in septic shock abdominal focus is referred to the surgical center for conducting
exploratory laparotomy. Before the MAP procedure: 70, maintained with noradrenaline 0,10mcg / kg / min
(NOR), heart rate = 110, Well perfused extremities, without DVT. The chosen anesthetic technique was
generally balanced and then proceeded to the induction of anesthesia with etomidate, fentanyl and
cisatracurium, the patient remained stable throughout the surgery with hemodynamically NOR levels
similar to baseline. About 12 hours after being admitted to the ICU patient, previously stable, developed
hypotension no responsive to vasopressors in supratherapeutic doses.
MCC02
1:50 PM - 2:00 PM
Inappropriate Anesthesia Consultation for Polypharmacy Withdrawal
Natasha Smolcic, M.D., Branden Yaldou, M.D., Rhonda Douglas, M.D., Roy Soto, M.D., Beaumont
Health System, Royal Oak, MI
A 36year-old male was transferred from prison for agitation and possible seizures. Anesthesia was
consulted for intubation secondary to agitation. His home medications, including methadone (60 mg/day)
and alprazolam (6 mg/day), had not been given since his DUI arrest. Prior to consultation, patient had
received lorazepam (6mg), haloperidol (0.5mg ), quetiapine (25mg), and methadone (40mg) . Despite
tachycardia to 160s, no alpha-2 agonist or other hemodynamic agents were given. The patient was alert
but agitated, and oxygenating/ventilating adequately. Despite internal medicine insistence, intubation was
not preformed and patient was transferred to ICU for further treatment.
MCC02
1:50 PM - 2:00 PM
Anesthetic Management of a Left Atrial Myxoma Causing Functional Mitral Stenosis
Kelly Kohorst, Frederic T. Billings, IV, M.D., Jeff Ford, C.R.N.A., Vanderbilt University, Nashville, TN
A 57-year-old with left atrial myxoma presents for excision. The patient’s presenting symptoms were
progressive dyspnea, orthopnea, and syncope. Echo diagnosed a 3x5cm atrial myxoma and resultant
severe functional mitral stenosis (mean gradient 20mmHg, peak velocity 2.76m/s on TTE) and severe
pulmonary hypertension. She was managed preoperatively with diuresis. For her surgery we placed a
pre-induction arterial line and kept her in the sitting position until after induction. Patient was hypotensive
requiring levophed and vasopressin infusion. We prompted surgeons to prep the chest and prepare for
incision in case she became unstable. The remainder of the case was uncomplicated.
MCC02
1:50 PM - 2:00 PM
Successful Emergent Extracorporeal Membrane Oxygenation in a Pregnant Patient Undergoing
Hip Fracture Surgery
Payal P. Attawala, M.D., Sachin Kheterpal, M.D., Department of Anesthesiology, University of Michigan,
Ann Arbor, MI
30 year-old G6P2 at 17 weeks gestation with history of melanoma and obesity, presenting with pathologic
femoral neck fracture. Risk factors for venous thromboembolic disease were identified: obesity, fracture,
malignancy, and pregnancy. Patient presented for hip arthroplasty. After uneventful induction and minutes
after incision, patient developed complete cardiovascular collapse and resuscitation was initiated.
Transesophageal echocardiogram revealed dilated right ventricle, and saddle pulmonary embolism.
Patient was emergently cannulated for extracorporeal membrane oxygenation. In the ICU, she suffered
fetal demise. On POD 7, she was decannulated and discharged to rehab on POD 37 with normal cardiac
function.
MCC02
2:00 PM - 2:10 PM
Emergent Airway Management for a Large Retropharyngeal and Posterior Mediastinal Abscess in
an Uncooperative Pediatric Patient
Jack Diep, M.D., Keith A. Kuenzler, M.D., Jill F. Arthur, M.D., Anesthesiology and Perioperative Medicine,
Pediatric Anesthesiology, Rutgers - New Jersey Medical School, Newark, NJ, Pediatric Surgery,
Hackensack University Medical Center, Hackensack, NJ
Retropharyngeal abscesses are deep neck space infections that can lead to life-threatening airway
emergencies and other catastrophic complications. RPAs demand prompt diagnosis and early
management. A definitive airway must be established when there is airway compromise. This can be
difficult in an uncooperative patient. We present the case of a 12 year-old girl with mediastinitis and both
tracheal compression and extreme anterior displacement from a large retropharyngeal and posterior
mediastinal abscess secondary to traumatic esophageal perforation, who received successful awake
nasal fiberoptic intubation.
MCC02
2:00 PM - 2:10 PM
Involuntary Both Arm Movement After General Anesthesia
YoomiKim, St. Vincent Hospital, Suwon, Korea, Republic of
A 53 year-old woman was subjected to laparoscopic both salpingo-oophorectomy for huge ovary cyst.
She didn’t have medical and surgical history. Anesthesia was induced propofol 100mg, rocuronium 50mg,
and continuous infused remifentanil, and maintained with O2-air-desflurane-remifetanil for 2 hours.
Surgery and anesthesia were uneventful. In the recovery room, she developed involuntary both arm jerky
movement. She described a lack of control. Intravenous midazolam 2mg was administered as initial
treatment, which produced sedation but no improvement. Vital sign was stable, and she had no other
neurologic symptom. Arterial blood gas analysis and electrolyte was normal. After 30 minutes,
movements were resolved spontaneously.
MCC02
2:00 PM - 2:10 PM
Single Lung Ventilation in a Patient With a Small Tracheostomy and a Large Oropharyngeal Mass
Sn B. Vinci, M.D., Mary T. Burkhart, M.D., Anesthesiology and Perioperative Medicine, University of
Louisville, Louisville, KY
As anesthesiologists, we are considered to be "masters of the airway" and look forward to an opportunity
that challenges our airway management skills. We present such a case, which combined the challenges
of single lung ventilation and significant airway pathology. The patient is a 65 year-old male with biopsy
proven lung cancer requiring left VATS and upper lobectomy. He had a known large obstructing
oropharyngeal mass requiring previous tracheostomy and gastrostomy tube placement. We will discuss
our airway management and lung isolation technique, as well as, issues encountered in this patient with a
small #4 un-cuffed tracheostomy.
MCC02
2:00 PM - 2:10 PM
Successful Perioperative Management of Acute Type III Hereditary Angioedema Attack With
Plasma Kallikrein Inhibitor
Tom Ju, M.D., Ravnita Sharma, M.D., Department of Anesthesiology, University of Michigan, Ann Arbor,
MI
Type III Hereditary Angioedema is a rare but potent risk factor for airway compromise. We present a 38
year-old female with Grave’s disease and Type III Hereditary Angioedema undergoing orbital
decompression. Despite prophylaxis with fresh frozen plasma, the patient developed an acute
angioedema attack with airway compromise upon extubation over an airway exchange catheter. Her
airway was re-secured and the episode successfully resolved with additional fresh frozen plasma and
Ecallantide, a kallikrein inhibitor. This case highlights the epidemiology, importance of preoperative
screening, international consensus prophylaxis and management guidelines as well as anesthesiaspecific considerations for Hereditary Angioedema.
MCC02
2:00 PM - 2:10 PM
An Unfortunate Incident: Stumbling onto a Primary Cardiac Malignancy
Souhail Karram, M.D., Raja Palvadi, M.D., Sajith Rai, M.D., Baylor College of Medicine, Houston, TX
48 year-old female with history of anemia, obesity, and GERD presented to the emergency department
with nausea and abdominal pain. The pain persisted despite therapy with a PPI, an H2 blocker, and
sucralfate; it also radiated substernally. Review of systems was positive for dyspnea on exertion. She was
sent home after an abdominal ultrasound and basic labs revealed no significant changes from her
baseline. She returned two weeks later, at which point an abdominal CT scan was performed, revealing
an incidental 4 x 3 cm cardiac mass partially obstructing the mitral valve outflow track.
MCC02
2:00 PM - 2:10 PM
Resuscitation of a Patient With Intraoperative Diabetes Insipidus and Acute Massive Blood Loss
From Carotid Artery Injury During Endoscopic Endonasal Resection of Chordoma
Yongeun Cho, Mary M. Lim, M.D., Li Meng, M.D.,M.P.H., Anesthesiology, University of Pittsburgh
Medical Center, Pittsburgh, PA
A 38 year-old male with clival chordoma developed intraoperative diabetes insipidus with urine output of
29 L during endoscopic endonasal resection. The case was further complicated by acute blood loss of 9 L
secondary to the left carotid artery dehiscence during tumor dissection. Hemostasis was difficult but
achieved with rectus muscle flap. Patient was aggressively resuscitated with 30 L of crystalloid, 14 units
of PRBC and FFP, and 13 units of platelets. Postoperatively, patient developed pulmonary edema likely
secondary to transfusion associated cardiovascular overload, and was extubated on postoperative day 4
after significant diuresis.
MCC02
2:00 PM - 2:10 PM
Subclinical Presentation of Acute Fatty Liver of Pregnancy in DIC: A Case Report
Thomas Hong, D.O., Oksana BogatyrYova, M.D., Department of Anesthesiology, Maimonides Medical
AFLP is poorly understood condition that is rare and difficult to diagnose. Due to its sudden and insidious
nature, earlier detection becomes even more difficult unless patients present with symptoms often
associated with liver injury, renal impairment and coagulopathy.Here we present a case where a 31 years
old non-english speaking female with twin gestation who received an emergent cesarean section. The
patient presented with only elevated creatinine and prodromal vomiting and was later discovered to be in
full blown DIC despite normal platelets in the postpartum period.
MCC02
2:00 PM - 2:10 PM
Pain Medicine (PN)
Intrathecal Opioid Pump Placement for a Patient With Intractable Chronic Bilateral Feet Pain Due
to Idiopathic Peripheral Neuropathy
Eduardo J. Jusino, M.D., Priya Agrawal, D.O., Jijun Xu, M.D.,Ph.D., Jianguo Cheng, M.D.,Ph.D., Pain
Management, Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH
This 53 year-old female presented with intractable chronic bilateral feet pain. Her medical history included
depression, hypothyroidism, sarcoidosis, multicentric myelitis of spinal cord, fibromyalgia and idiopathic
peripheral small fiber neuropathy diagnosed by biopsy. The patient did not respond to medications,
physical therapy/aquatherapy, transcutaneous electrical nerve stimulator, lifestyle modifications, two
spinal cord stimulator trials and chronic pain rehabilitation program. The patient underwent intrathecal
opioid (Morphine) infusion trial with greater than 90% improvement of pain. Current medications with pain
pathway interaction include Lidocaine patch, Percocet, Bupropion, and Fluoxetine. An intrathecal pump
was implanted and it continues to provide excellent pain relief.
MCC02
2:00 PM - 2:10 PM
Anesthetic Management of a Patient Undergoing Radical Axillary Lymph Node Dissection With the
Combined Pecs I & II Block
Michael R. Kazior, M.D., James Krakowski, M.D., Jay Schoenherr, M.D., Harold Hardman, M.D.,
Anesthesiology, University of North Carolina, Chapel Hill, NC
A 43 year-old female with history of breast cancer and chronic opioid therapy for back pain presented for
radical axillary lymph node dissection. An ultrasound-guided, combined Pecs I and II block was
performed with 35mL 0.5% ropivacaine, resulting in successful axillary sensory loss extending into the
ipsilateral breast T2-T6 dermatomes. She received general anesthesia and 250mcg fentanyl
intraoperatively for surgical incision extending below the anesthetized area. Postoperatively, she
characterized her surgical site pain as “mild,” complaining only of chronic lower back pain. This regional
technique may successfully serve as part of an opioid-sparing analgesic plan for painful axillary
procedures.
MCC02
2:00 PM - 2:10 PM
An Unexpected Airway Complication in a Male Patient With Goltz Syndrome
Sadie E. Smith, M.D., Kavita Gadhok, M.D., Dmitri Guvakov, M.D., Anesthesiology, Penn State Hershey
Med. Ctr, Hershey, PA
We describe an incidental finding of a laryngeal papilloma in a male patient with Goltz syndrome,
diagnosed via laryngoscopy during induction of general anesthesia. Goltz syndrome is a rare multisystem
syndrome that presents with skeletal, and soft-tissue abnormalities. Our patient had a favorable airway
examination preoperatively. Videolaryngoscopic examination revealed a friable, papillomatous mass in
the airway (Fig 1). After successful intubation, the lesion was debrided and biopsied. The patient was left
intubated for 24hrs to safely allow laryngeal swelling to subside. Four weeks later, the patient was
breathing well, with no areas of concern for residual or recurrent pharyngeal disease.
MCC02
2:00 PM - 2:10 PM
The Curious Case of a Right Atrial Mass
Ata-ul M. Rahman, M.D., Raja Palvadi, M.D., Crystal Wright, M.D., Department of Anesthesiology, Baylor
College of Medicine, Houston, TX
With the exception of myxomas, primary tumors of the heart are rare. Masses that can arise in the right
atrium include thrombi, benign primary tumors, malignant primary tumors, and secondary tumors.This is a
case of a right atrial mass extending down the inferior vena cava to the level of the hepatic vein in a
morbidly obese thirty-eight year-old woman. The anesthesthetic considerations for the surgical removal of
her right atrial mass are discussed.
MCC02
2:00 PM - 2:10 PM
Delayed Central Pontine Myelinolysis in Liver Transplant Recipent
Amit Prasad, Kunal Karamchandani, Anesthesia, Penn State Hershey College of Medicine, Hershey, PA
KS is a 52 year-old male with liver cirrhosis from hepatitis was admitted to the ICU for a sodium level of
110 mEq/L. KS sodium level was corrected to a normal level over the following three weeks. On hospital
day 22 KS underwent a liver transplant. Intraoperative course was uneventful. Post-operative day (POD)
# 2 KS was and subsequently reintubated for failure to protect airway and KS head CT and MRI were
negative. Subsequently, KS failed ventilator weaning and became extremely agitated. On POD#11 KS
had another MRI which showed central pontine myelinolysis.
MCC02
2:00 PM - 2:10 PM
Severe Accidental Hypothermia Rapidly Corrected By Using Continuous Venovenous
Hemodiafiltration
Mazin T. Albert, D.O., Anesthesiology, Albany Medical Center, Albany, NY
Hypothermia can lead to decreased cardiac output, arrhythmia, coagulopathy, neurologic depression, and
often mortality. A 21 year-old male was found unresponsive for an unknown amount of time outdoors
during the night. Upon exam in the SICU, patient’s temperature was 25°C, blood pressure stable,
bradycardic, with junctional rhythm, and had bilateral hand frostbite. Additionally, lab results revealed
severe hypoglycemia and rhabdomyear-oldlysis. Femoral arterial line and hemodialysis catheter were
placed. CVVHDF via CVC and forced air warmer were used as a rewarming strategy. Within 4 hours the
patient’s temperature had improved to 36.3°C, had full neurologic and cardiovascular recovery, and
CRRT was discontinued.
MCC02
2:00 PM - 2:10 PM
Spontaneous Hyphema in a Pediatric Patient following Tetralogy of Fallot Repair
Robert B. Bryskin, M.D., Brooke Maryak, M.D., Michael Shillingford, M.D., Lee Hunter, M.D.,
Anesthesiology, Nemours Childrens Clinic, Opthalmology, Nemours Children's Clinic, Surgery and
Pediatrics, University of Florida, Jacksonville, FL
We present a case of spontaneous hyphema (blood inside the anterior chamber of the eye) in an infant
who underwent Tetralogy of Fallot repair. Throughout the anesthetic course, the CVP, NIRS, ACT and
arterial blood pressure values remained within a strict therapeutic range. Post-operatively patient was
noted to have forming hyphema on the right side and dilated iris vessels on the left. Hematologic
evaluation failed to uncover qualitative or inherited abnormalities. Patient recovered following treatment
with prednisolone/atropine drops, head elevation and Aspirin discontinuation. Elevated right ventricular
pressures secondary to narrow pulmonary arteries were implicated as a possible cause.
MCC02
2:00 PM - 2:10 PM
Inducing a Patient Status-Post Tetrology of Fallot Repair With a Left-to-Right Shunt and
Pulmonary Hypertension for an Emergent Cesarean Section
Lindsay A. Gittens, M.D., Gustavo Lozada, M.D., Tufts Medical Center, Boston, MA, Anesthesiology,
Tufts Medical Center, Boston, MA
22 year-old female presented for an emergent cesarean section with a past medical history of tetrology of
fallot status-post repair as an infant, pulmonary valve replacement, right ventricular resection, and right
ventricular outflow track patch enlargement at age 18, complicated by a ventricular septal defect. A
transthoracic echocardiogram done prior to surgery showed a left to right shunt and pulmonary
hypertension. An epidural was placed and bolused, however the cesarean section needed to proceed
before it had taken effect, and general anesthesia was induced with ketamine, propofol, and
succinylcholine. Management included avoidance of shunt reversal and cor pulmonale
MCC02
2:10 PM - 2:20 PM
Anesthetic Management in a Neonate With Large Neck Mass
Megan Koudelka, C.R.N.A., Stephen Stayer, M.D., Yang Liu, M.D., Pediatric Anesthesiology, Texas
Children's Hospital/Baylor College of Medicine, Houston, TX
Airway management including tracheal intubation is often difficult in children,especially neonates and in
patients with large anterior neck masses. A 6-day-old male presented for direct laryngoscopy and needle
biopsy of a large, vascularized anterior neck mass that caused tracheal compression and deviation. Due
to expected prolonged intubation, associated airway sequelae, and impossibility of tracheostomy,
spontaneous respiration anesthesia with dexmedetomidine sedation was planned. Airway adjuncts
including rigid bronchoscopy and endotracheal tube exchangers were immediately available if the natural
airway failed. We present the successful anesthetic management of this case complicated by brief airway
obstruction, desaturation, and hypotension.
MCC02
2:10 PM - 2:20 PM
Pseudocholinesterase Deficiency: A Case Report
Shawn Reddy, B.S., Uma Munnur, M.D., Baylor College of Medicine, Houston, TX, Anesthesiology,
Baylor College of Medicine, Houston, TX
Pseudocholinesterase is critical in the hydrolysis of the muscle-relaxant succinylcholine. Patients
inherently deficient in this enzyme may suffer from protracted neuromuscular blockade after
succinylcholine administration, resulting in prolonged mechanical ventilation. We report the case of a 44year-old patient presenting with nausea and vomiting after ingestion of cocaine and drain cleaner during
an attempted suicide. After an emergency esophagogastroduodenoscopy, the patient showed no
evidence of spontaneous respiration and could not be extubated for approximately 3 hours. In cases of
prolonged neuromuscular paralysis after use of succinylcholine, one should suspect
pseudocholinesterase deficiency, confirm via blood tests, and educate the patient.
MCC02
2:10 PM - 2:20 PM
Little Fluids and No Pain in an Octogenarian Undergoing a Free Flap
Milt G. Poll, M.D., David Matteson, M.D., Anesthesiology, San Antonio Uniformed Services Health
Education Consortium, San Antonio, TX
84 year-old ASA3 male for 7-hour resection of invasive post-auricular fungating SCC with thigh free flap
reconstruction. Anesthetic management limited by surgeon request for no vasopressors and limited
volume administration to “maintain flap viability” and no paralytics to allow facial nerve monitoring. Patient
had adequate exercise tolerance (4-8 METS) but unknown medical history due to patient avoidance of
regular medical care. Ketamine and lidocaine infusions allowed limited use of volatile anesthetic and
opioids, prevented hypotension, and resulted in no postoperative analgesic use for 30+ hours. Balanced
crystalloid and early colloid administration maintained volume status.
MCC02
2:10 PM - 2:20 PM
Delayed Cardiorespiratory Arrest Following Retrobulbar Block
Rachel Roberts, M.D., Lakshmi N. Kurnutala, M.D., Anesthesiology, University of Mississippi Medical
Center, Jackson, MS
33 year-old female patient with history of HTN, CHF, DM, and ESRD was scheduled for pars plana
vitrectomy. Patient underwent retrobulbar block by ophthalmology with monitors connected with titrated
sedation. During surgical preparation of eye ball, 10 minutes after block, patient became apneic and
bradycardic with HR 36/min, treated with glycopyrrolate 0.4 mg IV with no response then HR<30/min.
ACLS protocol initiated. During 4 minute CPR, patient received 3 mg IV epinephrine and 1.2 mg Atropine,
patient resumed spontaneous circulation with good pulse. Patient was intubated and transferred to ICU
and extubated after 48hrs with no neurological issues.
MCC02
2:10 PM - 2:20 PM
TEE-Guided Open Surgical Removal of Migrated IVC Stent from Right Ventricle
James T. Herbert, M.D.,Ph.D., Erin L. Manning, M.D.,Ph.D., Miklos D. Kertai, M.D.,Ph.D., Duke
University, Durham, NC
A 63-year-old man with hepatitis C cirrhosis and orthotopic liver transplant complicated by recurrent
stenosis of the cavocaval anastamosis underwent IVC stenting followed shortly by chest pain, ectopy,
and non-sustained ventricular tachycardia. Radiography showed stent migration to the right atrium, and
surgical removal was attempted after unsuccessful intravascular retrieval. Intraoperative transesophageal
echocardiogram revealed further stent migration into the right ventricle and PFO. PFO closure and stent
removal was conducted on cardiac bypass and complicated by stent entanglement in the tricuspid
subvalvular chordae. Post-bypass TEE demonstrated significant tricuspid regurgitation requiring
reinitiation of cardiac bypass and repair with annuloplasty ring.
MCC02
2:10 PM - 2:20 PM
Cardiac Arrest After Induction in a Stroke Patient
Mark A. Cheney, Christopher V. Maani, M.D., Alejandro L. Rosas, M.D., Anesthesiology, San Antonio
Uniformed Services Health Education Consortium (SAUSHEC), San Antonio, TX, Anesthesiology, The
Methodist Hospital, Houston, TX
A 41 year-old male with acute ischemic stroke, atrial fibrillation with rapid ventricular response, and
hypertensive crisis was taken emergently to catheterization lab for mechanical revascularization.
Following rapid sequence induction with propofol and succinylcholine arterial waveform was lost and
patient developed pulseless electrical activity requiring Acute Cardiac Life Support. We review cardiac
arrest following induction, the management of anesthesia in a patient with an acute ischemic stroke, and
the management and differential of hypertensive crisis.
MCC02
2:10 PM - 2:20 PM
Subdural Injection: Explaining the Inexplicable
Seth E. Landa, M.D., Sn Dadaian, D.O., Jon Markely, D.O., Noah Rolleri, M.D., Anesthesia, St. Joseph's
Regional Medical Center, Paterson, NJ
We present a case report of exaggerated hypotension,fetal distress and loss of conciousness without
motor block in a parturient having epidural analgesia. We hypothesize this was the result of subdural
injection. Discussion: Numerous reports exist of markedly atypical responses to seemingly uncomplicated
epidurals that have been attributed to unintentional subdural injection. Some were radiologically
confirmed,while others were based on clinical presentation. The presentations are extremely variable in
their clinical characteristics.We explain this incredible variation by detailing the current understanding of
the anatomic structure of the subdural "space" and provide criteria for diagnosis.
MCC02
2:10 PM - 2:20 PM
Pain Medicine (PN)
Novel Approach to Treat Chronic Intractable Knee Pain After Total Knee Arthroplasty
Joseph S. Strebel, M.D., Lakshmi Madabhushi, M.D., Anesthesia/Pain Medicine, Baystate Medical
Center, Tufts University School of Medicine, Springfield, MA
We present a case of a 63 year-old female with a history of intractable right knee pain after a right total
knee arthroplasty in 2005 that was followed by a revision in 2012 . She was also suffering from endstage
arthritis of the left knee but deferred knee replacement given her experience on the right. Her physical
exam demonstrated mild hyperalgesia over the anterior knee. A diagnosis of neuropathic pain was
entertained. She received a fluoroscopic guided Genicular nerve blocks using only one cc of 0.25%
Marcain with complete and ongoing pain relief for the past one year.
MCC02
2:10 PM - 2:20 PM
Medically Challenging Case Report: Patient With Severe Aortic Stenosis Presenting for
Ambulatory Surgery Performed Using Femoral Block
Josue Rivera, M.D., Justo Gonzalez, M.D., Anesthesiology, Montefiore Medical Center, Bronx, NY,
Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH
Few cardiovascular disease present more of a challenge to anesthesia providers than aortic stenosis.
Many patients with this disease have little cardiac reserve and cannot tolerate the stress of surgery. Many
anesthetic techniques produce significant hemodynamic changes that can be disastrous in these patients.
Femoral block placed for intraoperative anesthesia and postoperative anaglesia. For the surgical block,
he received a bolus of 0.5% Bupivacaine 20cc and 0.25% Bupivacaine 12cc along with a propofol
infusion and fentanyl boluses. Our patient tolerated his tendon rupture repair surgery comfortably and
was able to return to his normal daily activities after a few weeks.
MCC02
2:10 PM - 2:20 PM
Team-Based Approach to Perioperative Management of Type IIN von Willebrand Disease
Austin D. Street, M.D., Riley Carpenter, M.D., Anesthesiology, University of Texas Southwestern, Dallas,
TX, University of Texas Southwestern, Dallas, TX
An 84 year-old woman, with Type IIN von Willebrand disease, presented with hematochezia and was
found to have a large cecal mass. She had a unique disease type which conferred an increased rate of
factor clearance compared to other patients with von Willebrand disease.Preoperatively, hematology,
pharmacy and transfusion medicine services were consulted. A plan was formed to infuse Wilate, a
vWF/Factor VIII complex, pre-operatively and intra-operatively. Factor VIII, vWF activity and vWF antigen
were drawn periodically to determine the dose and frequency needed to maintain adequate
hemostasis.Surgery proceeded without major incident and only 100 ml of blood loss.
MCC02
2:10 PM - 2:20 PM
83 year-old Male With Critical Aortic Stenosis, Atrial Fibrillation and COPD Status Post
Transurethral Bladder Tumor Resection Who Presents for Cystourethroscopy, Evacuation of
Obstructing Clot and Fulgaration of Bleeding/Bladder Lesion Immediately After
Paula LeBlanc, B.S., Michael Hofkamp, M.D., Edward W. Petrik, M.D., Anesthesiology, Texas A&M
Health Science Center College of Medicine, Temple, TX
We present an 83 year-old male with critical aortic stenosis, atrial fibrillation and COPD scheduled for
cystourethroscopy due to retained obstructing clot from a previous urological surgery. Immediately prior to
surgery, the patient suffered a syncopal episode while toileting. After determining that the benefits of
surgical intervention outweighed the risks of medical comorbidities, an arterial line was placed and
induction of general anesthesia was carefully titrated. Shortly after intubation, the patient had hypotension
that resolved with phenylephrine and vasopressin. After meeting extubation criteria, the patient was
extubated and later re-intubated in the ICU due to pulmonary decompensation.
MCC02
2:10 PM - 2:20 PM
Acute Onset of Inability to Ventilate Post Positioning for Tracheostomy: An Anesthetic Challenge
Charlotte S. Cattlin, M.B.,B.S., Peter Williamson, M.B.,B.S., Jaspal Bhular, M.B.,B.S., Anaesthesia and
Critical Care, West Hertfordshire Hospitals NHS Trust, Watford, United Kingdom
A 39 year-old male was booked for urgent surgical tracheostomy for airway protection due to a low GCS
secondary to Streptococcus milleri brain abscesses.Uneventful induction of anesthesia and initial
positioning for tracheostomy in theater. Sudden desaturation and dramatically increased airway pressures
with resultant decrease in tidal volumes, inability to maintain saturations above 70% despite multiple
interventions. This case describes the various strategies (drugs/ventilatory/equipment) used to manage a
case of failure to ventilate where no obvious cause could be found.
MCC02
2:10 PM - 2:20 PM
Massive Resuscitation for the Removal of a Retroperitoneal Sarcoma
Avichai Dukshtein, M.D., Laura Shahnazarian, M.D., James Smit, M.D., Anesthesiology, Maimonides
30 year-old m patient with a h/o of retroperitoneal sarcoma with IVC invasion and subsequent
hydronephrosis presented for tumor excision. Prior surgical attempt to remove tumor in another hospital
aborted due to massive hemorrhage and hemodynamic instability. Thoracic epidural placed, double
lumen IJ introducer, 14G IV, a line and CVP placed. Level 1 connected to patient prior to incision. Patient
hemorrhaged 5L of blood for which he was transfused 5PRBC, 2FFP, 1Platelet and 500 ml of 25%
albumin. Vasopressors were not utilized. The patient was successfully extubated in the operating room
and subsequently discharged post op day 3 from the ICU.
MCC02
2:10 PM - 2:20 PM
Management of Embolized ASD Closure Device in Pulmonary Artery
Johanna B. de Haan, M.D., Roy Sheinbaum, M.D., Stephanie Tran, M.D., Anesthesiology, University of
Texas Health Science Center at Houston, Houston, TX
A 54 year-old woman who required emergent cardiac surgery for removal of an Amplatzer ASD closure
device which had embolized to her pulmonary artery. While recovering in the cardiac cath lab postprocedure unit, the patient experienced nonsustained ventricular tachycardia. A bedside transthoracic
echocardiogram was performed which demonstrated the device in the patient’s right ventricle. After
induction of general anesthesia, transesophageal echocardiogram demonstrated that the device had
further migrated to the patient’s main pulmonary artery. Cardiopulmonary bypass was instituted, device
was removed, ASD was closed with bovine pericardial patch, and the patient was taken to the CVICU in
stable condition.
MCC02
2:10 PM - 2:20 PM
Delayed Spinal Hematoma in a Parturient With Fontan Circulation Following Neuraxial Anesthesia
for Cesarean Section
Adam L. Wendling, M.D., Chukwudi Chiagana, M.D., Justin Bremer, M.D., Josh Sappenfield, M.D.,
Anesthesiology, University of Florida, Gainesville, FL
Spinal hematoma is a rare complication of neuraxial anesthesia. However, patients with fontan circulation
present physiologic alterations and coagulation derangements which may predispose to either thrombosis
or coagulopathy. We report a case of spinal hematoma following spinal catheter for cesarean section in a
patient with fontan circulation. The hematoma occurred on postoperative day (POD) 4 following a
transition from prophylactic anticoagulation on POD 1 and 2 to full dose anticoagulation on POD 3 for
suspected pulmonary embolus. The patient underwent surgical decompression on POD 5 and had partial
recovery of neurologic function by 3 months.
MCC02
2:20 PM - 2:30 PM
Anesthetic Management of a Patient With Complex Congenital Anomalies: Micrognathia, HemiCervical Vertebrae, Cleft Palate , Posterior Urethral Valves, Hydronephrosis, Limb Abnormalities,
and a Difficult Airway
Samuel M. Barst, M.D., Gabriella Schoor, Student, Ashley Kelley, M.D., Deven Lombardia, C.R.N.A.,
Anesthesiology, New York Medical College / Westchester Medical Center, Valhalla, NY, SRNA School,
Columbia University, New York, NY
This 10-day-old, 3-kg male with complex congenital anomalies, including micrognathia and fused cervical
vertebrae, presented with preoperative concerns of a difficult airway. The child was scheduled for
cystoscopy and resection of posterior urethral valves. After application of routine monitoring, the child was
induced with atropine and ketamine. Indirect laryngoscopy with a Glidescope 0 Blade confirmed an
anterior larynx. An LMA #1 was inserted without difficulty and the procedure proceeded uneventfully with
assisted ventilation. Emergence and LMA removal were without incident. The case illustrates the use of
an LMA in a very year-oldung infant with a difficult airway.
MCC02
2:20 PM - 2:30 PM
Postoperative PTSD Exacerbation Requiring Admission to the Psychiatry Ward
Benjamin S. Maslin, M.D., Sn Dabu-Bondoc, M.D., Anesthesiology, Yale University School of Medicine,
New Haven, CT
A 61 year-old male with PTSD and poorly controlled GERD presented for laparoscopic inguinal hernia
repair. After premedication with midazolam, an RSI was performed. Maintenance and emergence were
unremarkable. Forty five minutes into an uneventful PACU course, "Anesthesia Stat to PACU" was heard
overhead, and the patient was noted to be aggressive and restless. After ruling out medical causes, a
diagnosis of postoperative delirium was entertained. A psychiatric evaluation revealed the patient recalled
vividly cricoid pressure and mask application as triggering thoughts associated with stressful events in his
past. He was admitted to the psychiatric unit for management.
MCC02
2:20 PM - 2:30 PM
Conversion Disorder Following General Anesthesia
Milt G. Poll, M.D., Jett Mercer, M.D., Crystal Manohar, M.D., Anesthesiology, San Antonio Uniformed
Services Health Educaion Consortium, San Antonio, TX
46 year-old female nurse with depression, anxiety, fibromyalgia, asthma and hypothyroidism presented
for left parotidectomy for mass. Intraoperative GETA was difficult due to labile hemodynamics with tumor
manipulation resolving with excision. Once extubated and transported to the PACU, the patient was noted
to be comatose. Remainder of her neurologic exam was non-focal. Drug effects, metabolic and
neurologic etiologies were investigated, but work up (including labs, imaging and EEG) was nondiagnostic. Diagnosis and definitive treatment were difficult as exhaustive workup was negative. With the
exception of the expected left facial nerve palsy, neurodeficits resolved spontaneously 9 hours later.
MCC02
2:20 PM - 2:30 PM
Severe Trismus After Propofol and Lidocaine Induction in Patient Undergoing Dilation and
Curretage
Oleksiy Lelyanov, D.O., John Denny, M.D., Anesthesiology, Rutgers Robert Wood Johnson Medical
Unexpected bilateral masseter spasm was encountered during propofol induction in a patient undergoing
dilation and curretage under general anesthesia preventing endotracheal intubation or supraglottic airway
placement. Provided the ease of mask ventilation in this patient, and the short duration of the procedure,
patient's airway was managed using ventilator-assisted mask ventilation without further complications.
Patient was informed about the complication and asked to inform future providers prior to anesthesia.
Given the sparsity of propofol-induced trismus reports, and wide use of this medication, providers should
be informed and prepared for an unanticipated difficult airway when using propofol.
MCC02
2:20 PM - 2:30 PM
Anesthetic Management of a Susceptible Malignant Hyperthermia Patient for Open Coronary
Artery Bypass Grafting
Brandon C. Banks, M.D., Daniel Sewell, M.D., Ryan Gordon, M.D., Katherine Redd, Anesthesiology,
University of Tennessee Medical Center- Knoxville, Knoxville, TN
Patient is a 60 year-old Caucasian male presenting for an open coronary artery bypass grafting due to
severe three-vessel disease. The patient has a history of severe hyperthermia and rigidity 40 years ago
during a hand surgery requiring a five-day intensive care stay with ventilator support and cooling with ice.
The patient has never been genetically tested for Malignant Hyperthermia. A non-triggering anesthetic
plan utilizing dexmetetomidine, propofol, and sufentanil infusions was performed for this procedure.
MCC02
2:20 PM - 2:30 PM
Mass Effect on Right Heart from Pericardial Metastasis in a Patient Undergoing Right Occipital
Craniotomy for Melanoma Lesion
Olutoyosi T. Ogunkua, M.D., David McDonagh, M.D., Owen Davenport, M.D., Anesthesiology, University
of Texas Southwestern, Dallas, TX
58 year-old male with a mediastinal mass invading the right heart presented for right occipital craniotomy
for excision of a brain metastasis. Pre-induction, two large bore IV’s and an arterial line were placed. An
albumin bolus was administered. Induction was uneventful with successful establishment of GETA.
Maintenance of anesthesia included a remifentanil infusion, ½ MAC of desflurane and a phenylephrine
infusion. Two units of blood were given intra-op in anticipation of expected blood loss, and pre-induction
hemoglobin of 7g/dl. The patient was hemodynamically stable throughout the case. Postoperative course
was unremarkable with discharge home POD 3.
MCC02
2:20 PM - 2:30 PM
Unanticipated Reintubation Following Wound Dehiscence Repair in Gravid Patient taking HighDose Clindamycin
Rhashedah A. Ekeoduru, M.D., George Williams, M.D., Anesthesiology, University of Texas Health
Science Center at Houston, Houston, TX
28 week gravid female presented for debridement after fetal intrauterine myelomeningocele repair
complicated by dehiscence and MRSA. Patient treated with high-dose gentamicin and clindamycin. After
RSI, no fasciculations were noted. Pt given rocuronium to facilitate intubation. Prior to emergence, 4/4
twitches were noted on TOF, reversal was given and all extubation criteria were met. Ten minutes later,
the patient desaturated and appeared weak, prompting reintubation.High doses of clindamycin can
prolong neuromuscular blockade without relaxants. Blockade can last 20 hours. It is not responsive to
calcium, edrophonium or neostigmine and may result from direct action on muscle contractility by
clindamycin.
MCC02
2:20 PM - 2:30 PM
Pain Medicine (PN)
Co-Occuring Disorders of A Spinal Hematoma and Neuroleptic Malignant Syndrome in a Patient
with AML
Charles R. Sims, M.D., Kenneth E. Oswalt, M.D., University of Mississippi Medical Center, Jackson, MS
D.S. is a 22 year-old black male with CML conversion to AML, s/p BMT and salvage Ara-C/cytarabine
therapy complicated by GVHD, BK virus infection, and pancytopenia who was seen by acute pain for
arthralgias, and new onset lower back pain with deteriorating neurological symptoms. He was diagnosed
with an expanding conus medullaris hematoma. One week later, acute pain was again consulted. He was
exhibiting acute AMS, hyperpyrexia, primitive reflexes, clonus, and tremors that were concerning for
NMS. Following treatment initiation, he recovered completely. After being found in remission two months
later, he was discharged home.
MCC02
2:20 PM - 2:30 PM
Severe Upper Extremity Contracture and Internal-Rotation Release Following a Supraclavicular
Block
Ankur M. Manvar, M.D., Christopher Chiang, M.D., Anesthesiology, University of Illinois-Chicago,
Chicago, IL
A 25M presented with LUE pain and muscle spasms. Arm was contracted, elbow internally-rotated 180
degrees, fingers/wrist were closed without voluntary/forced release. Decreased strength and absent
reflexes.A stellate ganglion was initially performed resulting in partial contracture release. A
supraclavicular block was then performed with 0.25% bupivacaine. Procedures were complicated by
increased involuntary muscle spasms and pain. A repeat supraclavicular block the next day with 0.5%
bupivacaine resulted in normal anatomical position, significant pain relief, full ROM/strength, 2+
reflexes.The patient returned 1yr (symptom-free interim) with a similar presentation and given repeat
supraclavicular block with complete resolution of symptoms.
MCC02
2:20 PM - 2:30 PM
Recognition and Management of Acute Naloxone-induced Pulmonary Edema in a Surgical Patient
With Pre-existing Cardiovascular Disease
Wesley E. Day, M.D., Anesthesiology, Lousiana State University Health Sciences Center-Shreveport,
Shreveport, LA
We present a case involving an elderly male patient with multiple medical co-morbidites including a
significant cardiovascular history who presented for placement of jejunostomy tube under general
anesthesia. Upon completion of the surgical procedure and extubation, the patient experienced prolonged
respiratory depression secondary to opioid administration, prompting the administration of Naloxone, reintubation and progressive ventilator weaning in the PACU. After continued weaning and secondary
extubation in the PACU, the patient experienced a dramatic decline in respiratory function due to acute
pulmonary edema, thus prompting a second re-intubation. This case illustrates the recognition and
management of acute naloxone-induced pulmonary edema.
MCC02
2:20 PM - 2:30 PM
Internal Jugular Vein Wall Dissection: A Rare Puncture-related Complication During Swan-Ganz
Catheter Placement
Shusuke Takeshita, Yoshinobu Nakayama, Shihoko Okabayashi, Teiji Sawa, Yasufumi Nakajima,
Department of Anesthesiology, Kyoto Prefectural University of Medicine, Department of Anesthesiology,
Kanasai Medical University, Kyoto, Japan
The patient was scheduled for coronary artery bypass grafting. Under general anesthesia, we prescanned the right internal jugular vein (IJV) and marked the surface skin. After IJV puncture with an 18G
catheter, we confirmed blood backflow. During guide-wire insertion, we noted slight resistance. After
dilatation, we failed to place the 9Fr/10-cm sheath and Swan-Ganz catheter (SGC) due to some
resistance. After we removed them, we found a dissection of the posterior wall of the IJV. We successfully
placed the SGC into the left IJV with real-time ultrasound guidance. The patient experienced no additional
major complications after the operation.
MCC02
2:20 PM - 2:30 PM
When Five Modes of Ventilation Fail: A Case of Successful Management of Acute Refractory
Hypoxemia With VV ECMO in a Major Burn Patient
Kelly Kohorst, M.D., Avinash B. Kumar, M.D., Jason D. Kennedy, M.D., Anesthesiology, Division of
Critical Care, Division of Cardiothoracic Anesthesiology, Vanderbilt University Medical Center, Nashville,
TN
A 39 year-old M presented with a 40% TBSA burn. After the initial modified Parkland based fluid
resuscitation and partial escharotomy developed worsening hypoxemia and ARDS. BAL samples were
suspicious for infection. His hypoxemia worsened on VC, PRVC, PC, APRV and VDR with PaO2 in the
30’s in a span of 7 hrs. Decision was made to trial the patient on ECMO. Veno-venous ECMO was
successfully initiated and managed for 4 days without complications. Patient was successfully weaned
and extubated on day 7. Early ECMO for isolated respiratory failure in the setting on maintained
hemodynamics resulted in a positive outcome.
MCC02
2:20 PM - 2:30 PM
Rebound Hyperthermia: An Unusual Etiology of Hyperthermia in the Intensive Care Unit
Jared A. Petter, M.D., Juan Claros-Sorto, M.D., Jason S. Lees, M.D., Pamela R. Roberts, M.D.,
Department of Anesthesiology, Dept. of Surgery, University of Oklahoma College of Medicine, Oklahoma
City, OK
A 44 year-old male suffered fractures of three extremities, rib and pelvic fractures, and subdural
hematoma after motor vehicle collision. After extremity operative fixation, he was unable to be extubated.
Two days later, he developed acute respiratory distress syndrome and was treated with nitric oxide,
rotational therapy, and rescue modes of ventilation. He was treated for pneumonia, but later suffered a
four-minute cardiac arrest coinciding with hyperthermia to 42.7 degrees Celsius. He was actively cooled
and treated with dantrolene despite lack of triggering agents. We will review the differential diagnosis,
therapies, and complications of extreme hyperthermia in the ICU.
MCC02
2:20 PM - 2:30 PM
Management of Coronary Artery Bypass Graft on Intra-aortic Balloon Pump With Heparin-Induced
Thrombocytopenia Using Argatroban
David Vahedi, M.D., Helene Logginidou, M.D., Anesthesiology, SUNY Downstate Medical Center,
Brooklyn, NY
A 69 year female with history of CAD, CHF, HTN, DM, CVA and anemia transferred from an outside
hospital on an intra-aortic balloon pump after sustaining NSTEMI in cardiogenic shock and
thrombocytopenia to 24,000. After uneventful induction, lab confirmed diagnosis of HIT. Heparin was
held, Argatroban was used for off-pump CABG. Despite maintaining an ACT between 450-520 seconds
patient had excessive bleeding by the end of surgery requiring multiple units of blood products. Patient
was monitored in OR for six hours; on the third hour chest was re-opened with no obvious signs of
bleeding.
MCC02
2:20 PM - 2:30 PM
Epidural Anesthesia for C-section in a Full-Term Patient With Type I Arnold-Chiari Malformation
Adil Mohiuddin, M.D., Shaul Cohen, M.D., Shruti Shah, M.D., Christine W. Hunter-Fratzzola, M.D.,
Anesthesiology, Rutgers-Robert wood Johnson Medical School, New Brunswick, NJ
A 30 year-old, primig, parturient Hispanic female (height 5'3", weight 173 lbs), with type I Arnold Chiari
malformation and Syringomelia presented with a spontaneous ROM at 38 weeks gestation. Labs: Hgb
14.2 and Plts 208. Due to the significant descent of the cerebellar tonsils and syrinx, a discussion
between OB/Gyn, neurology, and anesthesiology resulted in a decision to pursue elective CS to avoid
increased ICP due to exertion of labor. After risks, benefits, and informed consent, epidural was
performed in a left lat decub position. A transverse CS was performed and a live male infant (Apgar 9/9)
was delivered withoutcomplications.
MCC02
2:30 PM - 2:40 PM
Anesthetic Management of a Pediatric Patient With a Right-sided Congenital Diaphragmatic Hernia
and Respiratory Syncytial Virus
Samuel M. Barst, M.D., Roshanak Mofidi, M.D., Valerie Walker, M.D., Anesthesiology, New York Medical
College / Westchester Medical Center, Valhalla, NY
A 44-day-old infant with respiratory symptoms and RSV had an incidentally noted right-sided congenital
diaphragmatic hernia (CDH). The patient was managed with CPAP and oxygen. Anesthesia was
consulted as to when the CDH should be repaired. Optimizing patients for surgery entails a risk-benefit
analysis. Although no longer feasible to postpone all cases for 6 weeks after a URI, if the patient remains
afebrile and is asymptomatic (no wheeze, cough, sputum production, or tachypnea) there seems to be
little evidence-based data to justify postponing most surgical procedures.
MCC02
2:30 PM - 2:40 PM
Cisatracurium Resistance in a Patient With Mucolipidosis Type III
Christoforos M. Frangopoulos, M.D., Arun Ganesh, M.D., Marc L. Levi, M.D., Jennifer Klein, Department
of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC, North Carolina State
University, Raleigh, NC
A 22 year-old, 42 kg female with Mucolipidosis (ML) Type III presented for a left hip arthroplasty
secondary to osteodystrophy of the left femoral head. During the eight-hour case, cisatracurium was
selected to provide neuromuscular blockade, however, the patient was notably resistant to its effects. ML
Type III is an autosomal recessive, lysosomal storage disease that results in excessive accumulation of
carbohydrates and lipids within cells, resulting in progressive tissue and organ damage, alongside
prominent skeletal abnormalities attributed to high metabolic turnover of bone. This case report describes
cisatracurium resistance in a patient afflicted with Mucolipidosis Type III.
MCC02
2:30 PM - 2:40 PM
Unexpected Recurrent Aspiration During Deep Sedation for Eye Irrigation
Meredith A. Herzog, M.D., James Berry, M.D., Anesthesiology, Vanderbilt University, Nashville, TN
22 year-old healthy female presented with painful alkali burns to her face and eyes, necessitating
sedation for eye exam and irrigation. With standard ASA monitors, sedation was accomplished with
fentanyl boluses and propofol infusion while breathing spontaneously with nasal oxygen. Eye pressure
irrigation with 0.9% saline was started, and despite drainage away from her nares and mouth, she
suffered repeated laryngospasm, necessitating positive airway pressure to resolve. We theorize this was
due to drainage of irrigant via her nasolacrimal ducts into her hypopharynx and larynx. Applying pressure
to her medial canthus occluded her nasolacrimal duct and successfully prevented further laryngospasm.
MCC02
2:30 PM - 2:40 PM
Anesthetic Management in a Patient With Post-Operative Paradoxical Vocal Cord Motion
Andrew J. Anderson, D.O., Richard E. Galgon, M.D., Anesthesiology, University of Wisconsin Hospital
and Clinics, Madison, WI
A 62 year-old man with a tongue base mass presented for biopsy. Pre-operative history revealed a
suffocation feeling on awakening from his last general anesthetic. With the index procedure, mild stridor
and hypoxia developed after extubation, which improved slowly with CPAP. Immediate nasal endoscopy
revealed "twitchy, but open vocal cords." Five minutes later, the event recurred. Suspecting paroxysmal
vocal cord motion (PVCM), midazolam was administered and the patient’s condition quickly improved. A
similar episode occurred in the PACU and similarly resolved with repeat midazolam administration. After
recovery, the patient was admitted for overnight observation and successfully discharged home on
POD#1.
MCC02
2:30 PM - 2:40 PM
Use of 3D-TEE and Cerebral Oximetry Monitor in Optimizing Complex Redo Ascending Aorta
Repair
Scott Licata, M.D., James Taylor, M.D., Harold Fernandez, M.D., Igor Izrailtyan, M.D.,Ph.D., Stony Brook
University Hospital, Stony Brook, NY
A 72 year-old female post aortic repair, aortic valve replacement, and subsequent cardiac pacemaker
insertion eight years ago presented for a repair of an ascending aorta pseudoaneurysm. In the operating
room, 3D-TEE showed a previously unknown aorto-pulmonary fistula (APF). Additionally, once on fullbody circulatory arrest, the left-sided cerebral oximetry signal declined critically despite continual cerebral
perfusion through the right axillary artery. This required clamping of the left common carotid (LCCA) and
subclavian artery, and ultimately LCCA cannulation with additional perfusion. We will discuss implications
of APF and the role of cerebral oximetry in the management of a complex aortic surgery.
MCC02
2:30 PM - 2:40 PM
Urgent Transsphenoidal Hypophysectomy in the Setting of Critical Carotid and Coronary Artery
Disease
William F. Rippe, D.O., T.D. Yonker, M.D., Anesthesiology, University of Missouri, Columbia, MO
Providing safe and effective anesthesia for a transsphenoidal hypophysectomy can be a challenge. The
addition of urgency will expand this challenge, especially in patients with untreated critical comorbidities.
A patient with pituitary apoplexy , rapidly deteriorating vision and recently diagnosed systolic heart failure
presented to our institution for urgent transsphenoidal hypophysectomy. He also had severe COPD and
unknown aorto-occlusive disease with critical bilateral carotid disease. This patient underwent urgent
hypophysectomy, with strict hemodynamic control, prior to systemic heparinization and definitive surgical
treatment of critical carotid and coronary artery stenoses.
MCC02
2:30 PM - 2:40 PM
Interscapular Pain: A Case Series
Thomas T. Klumpner, Paloma Toledo, M.D.,M.P.H., Jason R. Farrer, M.D., Northwestern University
Feinberg School of Medicine, Chicago, IL
Some laboring women experience severe upper back pain, typically between the scapulae, after initiation
of neuraxial labor analgesia. The etiology of this interscapular pain is not well understood, but has
significant clinical consequences. This case series describes three patients who developed interscapular
pain associated with neuraxial labor analgesia. Management of these patients included decreasing the
epidural infusion rate, increasing the concentration of local anesthetic in the epidural infusion,
administering epidural opioids, and replacement of the epidural catheter. All three patients eventually
experienced relief of their interscapular pain. Future work should characterize at-risk patients, as well as
delineate effective treatment options.
MCC02
2:30 PM - 2:40 PM
Pain Medicine (PN)
Novel Treatment of Erythromelalgia With Capsaicin 8% Under Regional Anesthesia
Sailesh Arulkumar, Christoper A. Roberts, D.O., Charles Roberts, M.D., Veerandra Koyyalamudi, M.D.,
Anesthesiology, LSUHSC Shreveport, Shreveport, LA, Pain Medicine, Cornerstone Pain & Restoration,
Washington D.C., MD
A 58 year-old male with past medical history of being diagnosed with erythromelalgia in 2009. The patient
was referred to our pain clinic for episodic pain flare ups in all extremities. After placement of topical
capsaicin, cutaneous nociceptors become less sensitive to a to stimuli. Topical placement of capsaicin
results in a reduction in spontaneous and evoked painful sensations. The main side effect of capsaicin
that makes the treatment modality a difficult choice is the burning pain on application.An axillary and
femoral nerve block was performed prior to the placement of capsaicin patch in this patient.
MCC02
2:30 PM - 2:40 PM
Inferior Alveolar Nerve Block Using Exparel in a Patient With Debilitating V3 Trigeminal Neuralgia
Claudia Villalpando-Leon, D.O., Mahammad Hussain, M.D., Anesthesia, University of Texas, Houston, TX
38 year-old female with debilitating trigeminal neuralgia, underwent urgent craniotomy for microvascular
decompression twice during same admission, and then percutaneous balloon rhizotomy. Post operatively
we managed her pain using multimodal pain regimen including ketamine, NSAIDs, neuroleptics, and
opiates. Oral maxillofacial service performed a left inferior alveolar nerve block using Exparel 1.3% 2ml
after exhausting all medical and surgical therapy. Patient achieved significant improvement in pain
scores, was weaned off opiates and discharged home soon after. We will describe the use of inferior
nerve block for patients with trigeminal neuralgia using Exparel.
MCC02
2:30 PM - 2:40 PM
Airway Management in a Rapidly Expanding Neck Hematoma in a Patient With TTP
Arati M. Patil, M.D., Kenneth Sutin, M.D., Anesthesiology, NYU Langone Medical Center, New York, NY
81 year-old male with a history of thrombotic thrombocytopenic purpura, atypical hemolytic uremic
syndrome, and chronic kidney disease was having a central line placed for urgent plasmapheresis. The
anesthesia team was called out of concern for an expanding neck hematoma following failed line
placement by the MICU team. Initially, room air saturation was 100%, but he quickly decompensated,
desaturated, became bradycardic and went into cardiac arrest. Glidescope and pentax intubations were
attempted with no visualization. A surgical airway was then established and the patient was emergently
taken to the OR. Discussion will include airway management of neck hematomas.
MCC02
2:30 PM - 2:40 PM
Candida Albicans Cardiac Mass Following TPN Use in a Medically Complicated Patient
Joann E. Bolton, M.D., Archer Martin, M.D., Mayo Clinic Florida, Jacksonville, FL
A medically complicated patient on total parental nutrition (TPN) underwent transesophageal
echocardiogram (TEE) due to persistence of candida infection following therapy. This identified a large,
pedunculated, well-circumscribed, freely-mobile echogenic mass consistent with endovascular vegetation
emanating from the superior vena cava and extending into the right atrium. Candida endocarditis is a
common cause of fungal endocarditis. The association of central line access with TPN therapy and
candida infections has been well documented, however the incidence of intracardiac mass of candida
albicans is very rare.
MCC02
2:30 PM - 2:40 PM
Diagnosis of Brugada Syndrome After Level One Trauma
Alexander Schutz, M.D., Gozde Demiralp, M.D., Dept. of Trauma, Surgical Critical Care, Emergency
Surgery, University of Pennsylvania, Philadelphia, PA, Critical Care Division, Dept. of Anesthesiology,
University of Oklahoma, Oklahoma City, OK
A 74 year-old male without known cardiovascular disease was brought to a level one trauma center for
evaluation after a witnessed fall. The initial ECG demonstrated ST segment coved type changes in leads
V1 - V3 consistent with Brugada syndrome. Once his diagnosis was confirmed, an implantable
cardioverter defibrillator (ICD) was placed. He was also started on maintenance quinidine therapy.
Following ICD placement, he was discharged to a rehabilitation center on hospital day 6. Brugada
syndrome has now been recognized as a cause of sudden cardiac death. The majority of cases show
genetic etiology in the SCN5A gene.
MCC02
2:30 PM - 2:40 PM
Udder Causes of Acidemia: A Case of Life Threatening Bovine Ketoacidosis
David Greaney, FRCA, Ph.D, Patrick Benson, M.D., St. Vincent's University Hospital, Dublin, Dublin,
Ireland, St. Vincent's University Hospital, Dublin, Ireland.
A 36 year-old woman presented nine weeks post partum with a 6 hour history of malaise and nausea. Her
ABG showed a profound, raised anion gap acidosis with a pH of 6.8. The glucose and lactate were
normal and blood ketones were raised. She had been skipping meals and avoiding carbohydrates to
loose weight. She exclusively breastfeed her child who demanded frequent large feeds. A glucose 20%
infusion was started to suppress ketogenesis which both improved her symptomatology and her acid
base disturbance within 8 hours. She was subsequently diagnosed with the 5th known case of bovine or
lactation induced ketoacidosis.
MCC02
2:30 PM - 2:40 PM
When Contraindications Seem Endless: Successful Neuraxial Epidural Anesthesia for Cesarean
Section in a Patient on Therapeutic Enoxaparin.
William P. Mulvoy, M.D., Adam Lemmon, M.D., Anesthesiology, Indiana University School of Medicine,
Indianapolis, IN
This is a case of a 23 year-old G2P0101 presenting at 34 weeks gestation with bladder spasms,
abdominal pain and flushing. Her past medical history includes T2 paraplegia, hyperreflexia, neurogenic
bladder and chronic pulmonary emboli on therapeutic enoxaparin. Her family history is significant for
death attributed to malignant hyperthermia. We decided to proceed with neuraxial epidural anesthesia.
Her C-section was complicated by uterine and bladder disruption, requiring hysterectomy and a 3rd redo
monti procedure. Her surgery was conducted successfully under neuraxial anesthesia with moderate
sedation. Post operative there were no complications and she delivered a healthy boy at 34 weeks.
MCC02
2:40 PM - 2:50 PM
Facial Burns Following Prone Positioning in an Adolescent Patient Receiving an Oral Doxycycline
Acne Medication
Samuel M. Barst, M.D., Kelly Bufton, M.D., Jason Rundle, M.D., John A. Cooley, M.D., Anesthesiology,
New York Medical College / Westchester Medical Center, Valhalla, NY
A 12 year-old girl with a history of acne rosacea treated with oral long- and short-acting doxycycline
presented for bone marrow donation. She was positioned prone over an underbody forced hot-air system.
The procedure lasted ~75 min. When the ProneView® head support was removed, small areas of her
face that were in contact with the cushion appeared brightly erythematous with central denuded areas.
Photosensitivity to doxycycline is a recognized complication of therapy. There are reports of patients
experiencing thermal burns while on doxycycline, although these are quite rare (<0.2%). To our
knowledge, this complication has not been reported in the OR.
MCC02
2:40 PM - 2:50 PM
40 year-old Male With Family History of Malignant Hyperthermia Presents for Urgent Repair of
Traumatic Knee Arthrotomy
Micah C. Newton, B.S., Rachel Rhem, M.D., Michael P. Hofkamp, M.D., Texas A&M Health Science
Center College of Medicine, Temple, TX
We present a 40 year-old male scheduled for repair of traumatic knee arthrotomy. According to the
patient, his father’s sister had an episode consistent with malignant hyperthermia and, to the patient’s
knowledge, no family members have been tested for malignant hyperthermia. The anesthetic machine
was flushed with high flow oxygen for greater than twenty minutes, the carbon dioxide absorbent was
changed and the vaporizers were removed. The patient received an uneventful non-triggering anesthetic
and was counseled to obtain a medic alert bracelet for himself and his children until he was able to obtain
definitive testing for malignant hyperthermia.
MCC02
2:40 PM - 2:50 PM
Rising End-Tidal CO2 in a Laparoscopic Case: A Case Report
Veeral Mehta, M.D., Edward Ho, Raja Palvadi, Alice Oswald, M.D., Neil Bailard, M.D., Anesthesiology,
Baylor College of Medicine, Houston, TX
This is a case report of a patient who developed elevated ETCO2 due to subcutaneous emphysema.
Early detection of crepitus can guide management, and careful assessment of respiratory parameters can
differentiate between different causes of perturbations in ETCO2. Elevated ETCO2 can be due to
increased CO2 production or decreased elimination. Elevated CO2 production may be due to
hypermetabolic states or an external CO2 source. Minute ventilation may be impaired in laparoscopic
surgery due to high peak inspiratory pressures, worsened by the Tredelenberg position. Respiratory
acidosis is typically short-lived, though it may persist in the presence of an external CO2 source.
MCC02
2:40 PM - 2:50 PM
Episode of Transient Global Amnesia Following General Anesthesia
Ayesha Zaheer, M.D., Magnus Teig, M.B.,Ch.B., Anesthesiology, University of Michigan Health System,
Ann Arbor, MI
A 51 year-old male with an unremarkable past medical history underwent urethral meatoplasty. The
anesthetic was routine and the intraoperative course was uneventful, except for a brief period of treated
hypotension. Post emergence the patient was disoriented and unable to recognize family members, with
impaired short-term memory; he was otherwise neurologically intact. Medications were reviewed and
flumazenil administered; symptoms did not improve. Blood results and imaging were unremarkable.
Following neurology consultation a diagnosis of transient global amnesia was made. The patient made a
full recovery within forty-eight hours without further intervention. We review this unusual phenomenon and
discuss its implications.
MCC02
2:40 PM - 2:50 PM
The Successful Application of Transesophageal Echocardiography in Zenker's Diverticulum
Michael A. Chyfetz, M.D., Shanna S. Hill, M.D., Nikolaos J. Skubas, M.D., Joel M. Yarmush, M.D.,
Department of Anesthesiology, New York Methodist Hospital, Brooklyn, NY, Department of
Anesthesiology, Weill Cornell Medical College, New York, NY
Transesophageal echocardiography (TEE) presents an invaluable modality for intraoperative diagnostic
monitoring that is relatively safe and noninvasive. The utilization of TEE in cardiac surgery has fueled the
development of innovative minimally invasive techniques including transcatheter aortic valve replacement
(TAVR). Intraoperative transesophageal echocardiography (TEE) is the imaging modality of choice for
TAVR as it allows real time visualization and guidance during valve positioning and deployment; however,
TEE has specific absolute contraindications including abnormalities of the esophagus. We present a
multidisciplinary approach involving the successful application of TEE in a patient presenting for TAVR
with a Zenker’s diverticulum under direct visual guidance.
MCC02
2:40 PM - 2:50 PM
Posterior Fossa Craniotomy for a Jehovah’s Witness
Shaun L. Thompson, Maria Michaelis, M.D., Anesthesiology, University of Nebraska Medical Center,
Omaha, NE
A 27 year-old presented for excision of a 4th ventricle tumor requiring a posterior fossa craniotomy for
excision. The patient was a Jehovah’s Witness and would only accept autologous blood transfusions for
the surgery. One liter of blood was drawn off after placement of a central venous catheter and was kept in
series with the intravenous tubing at all times during the procedure per the patient’s wishes. The volume
of blood was replaced with crystalloid to establish normovolemic hemodilution. Blood loss was estimated
at 300 ml and the patient tolerated the procedure well.
MCC02
2:40 PM - 2:50 PM
Anesthetic Implications of Body Piercings
Madhumani N. Rupasinghe, M.D.,F.R.C.A, Sara Guzman-Reyes, M.D., Peter Doyle, M.D.,
Anesthesiology, UTHSC, Houston, TX
Body jewelry left in place during surgery has been reported to cause burns, pressure-related tissue injury,
and infection. In cases utilizing electro-cautery, body jewelry may conduct the electrical current and cause
electrical burns to the surrounding tissue.We describe a patient who presented for an abdominal
hysterectomy with sub dermal piercings surrounding the upper thoracic spine and discuss the anesthetic
implications. (Image attached)
MCC02
2:40 PM - 2:50 PM
Pain Medicine (PN)
Coiled Intrathecal Catheter Associated With Numerous, Undiagnosed Pump Flips
Ran Dai, Magdalena Anitescu, M.D.,Ph.D., University of Chicago, Chicago, IL
We present a case of a 36 year-old female with a 6 year-old intrathecal pump for CRPS. The patient had
undergone significant weight loss after a gastric bypass with no effect on her pump management for more
than 1 year. During a visit, the pump could no longer be interrogated/refilled. Pump flip was confirmed by
fluoroscopy. During surgical intervention for repositioning, the pump was found in normal position but the
intrathecal catheter had extensive coils, confirming frequent undiagnosed pump flipped. Her pump was
anchored and the proximal catheter was replaced. Vigilence is constantly required with intrathecal pumps.
MCC02
2:40 PM - 2:50 PM
Inadvertent Subdural Catheter Placement: Case Report
Wilson T. Lee, M.D., Joel Stockman, M.D., UCLA Med Ctr, Los Angeles, CA
The subdural space is a potential space between the dura and arachnoid mater. Subdural catheter
placements are estimated to occur approximately 0.82% - 10% out of all epidural placements, but
symptoms are not immediately recognized. We present a case involving a thoracic epidural found in the
subdural space despite little difficulty with initial placement. Aspiration and test dose were negative. 25
minutes after test dose, patient complained of decreased left upper extremity weakness and intermittent
feeling in lower extremities bilaterally. Patient was hypotensive, but heart rate was unchanged. Intrathecal
placement was suspected, but CT myelogram confirmed subdural catheter placement.
MCC02
2:40 PM - 2:50 PM
Foreign Body Aspiration: Denture Glue on the Vocal Cords
Olga Eydlin, M.D., Gordana Stjepanovic, M.D., Anesthesiology, NYU Langone Medical Center, New York,
NY
A 68 year-old female was admitted for management of urosepsis. During the hospital stay, she was found
to be unresponsive and hypoxic. ACLS was started. Upon intubation, a foreign body, which turned out to
be a denture adhesive strip, was noted at the glottic opening and was removed with Magill forceps. The
patient was successfully intubated by direct laryngoscopy with improvement in oxygenation. She was
found to be in ventricular fibrillation and was defibrillated with return of spontaneous circulation. This case
highlights the challenges of airway management with the rarely anticipated event of dental equipment
aspiration.
MCC02
2:40 PM - 2:50 PM
Undiagnosed Congenital Heart Disease in the Adult
Carlo J. Petrillo, M.D., Rana Badr, M.D., UMass Med School, Worcester, MA
An elderly female presents with complains of new onset dyspnea on exertion and orthopnea. Further
evaluation and cardiac work-up revealed a superior sinus venosus defect with an anomalous pulmonary
vein and tricuspid regurgitation. Anesthetic management included placement of arterial line, CVP, TEE,
and PAP prior to surgical incision and standard cardiac induction. After successful repair of her atrial
septal defect, repair of tricuspid valve and re-attachement of the anomalous pulmonary vein to the IVC,
she was successfully weaned off cardiopulmonary bypass.
MCC02
2:40 PM - 2:50 PM
Tumour Lysis Syndrome In Haematological Malignancy- Management Challenges
Vijay Ragothaman, M.D., F.C.A.R.C.S.I., Somasundaram Jeyanthan, M.D., F.C.A.R.C.S.I., Anaesthesia,
Birmingham hospitals NHS trust, Birmingham, United Kingdom.
A 67 year-old male with no past medical problems, was admitted with pancytopenia. Patient was
presumed to have a lymphoproliferative/lymphoma disorder, while awaiting bone marrow biopsy results.
He was admitted to critical care unit with Type 1 respiratory failure and hypotension. As per haemoncologist advice, one gram of methylprednisolone IV was administered. Later within a period of 4-6
hours, deteriorated rapidly with hyperkalemia and severe metabolic acidosis. He did not survive despite
maximal therapy. The case is for discussion, about challenges in recognition and management of tumour
lysis syndrome.
MCC02
2:40 PM - 2:50 PM
Right Intra-Atrial Thrombus in a Patient With End Stage Liver Disease Undergoing Orthotopic
Liver Transplantation
Joshua T. Trester, M.D., Andrew Friedrich, M.D., Department of Anesthesiology, University of Cincinnati,
Cincinnati, OH
A 63 year-old man with ESLD (MELD 51) secondary to alcohol and hepatitis C presented for orthotopic
liver transplantation. Approximately 15 minutes following reperfusion, pulsatile ventricular tachycardia
occurred and rapidly degraded to PEA. Spontaneous circulation returned after five minutes of CPR. Intraop TEE revealed a right intra-atrial thrombus. Given active surgical bleeding, the decision was made not
to anticoagulate the patient or attempt thrombolysis. Repeat TEE at case completion revealed thrombus
resolution. This case represents a derivation from the perception that ESLD patients have only bleeding
diatheses; thromboembolic events occur in liver failure patients and can be life-threatening.
MCC02
2:40 PM - 2:50 PM
A Multidisciplinary Dilemma: An Urgent Cesarean Delivery Three Weeks After STEMI With BMS
Mark A. Banks, Jared Bell, D.O., Angel Cancel, M.D., Department of Anesthesiology and Perioperative
Medicine, Georgia Regents University, Augusta, GA
We describe a case of a 44 year-old female at 35 weeks gestation whose pregnancy had been
complicated by an STEMI 3 weeks prior due to an acute LAD coronary artery dissection with 2 bare metal
stents in place who presents for an urgent cesarean delivery due to pre-eclampsia with severe features
and non-reassuring fetal status. DAPT had been held for less than 72 hours, so she required general
anesthesia. An arterial line was placed followed by a rapid-sequence induction, intubation, and a second
PIV. The case proceeded without complications and the patient was transported to the ICU
postoperatively, as planned.
MCC02
2:50 PM - 3:00 PM
Anesthetic Management of Intraoperative Autonomic Dysreflexia in a Pediatric Patient
Mark-Neil Ledesma, M.D., Fenghua Li, M.D., Reza Gorji, M.D., Karolina Wrzeszcz-Onyenma, M.D.,
Anesthesiology, Upstate Medical University, Syracuse, NY
13 year-old male with T4-T5 SCI one year ago with paraplegia and neurogenic bladder for robotic
Mitrofanoff. Patient transferred to the table; ASA monitors applied. Induction, intubation uneventful. GA
maintained with sevoflurane, remifentanil and rocuronium for paralysis. Left radial arterial catheter placed.
Surgery uneventful. Hypertension observed at the conclusion of surgery. SBP 190 mmHg Nitroprusside
initiated 0.5 mcg/kg/min. Adjusted to keep BP less than 140/90 mmHg. Patient woke up after
discontinuation of anesthesia and reversal. Patient extubated. Hypertension continued to require
nitroprusside 1.5 mcg/kg/min. Admitted to PICU for BP control. Nitroprusside tapered off once his BP
normalized. Patient recovered well.
MCC02
2:50 PM - 3:00 PM
Case Report on Spinal and Epidural Anesthesia Management in Abnormal Position
Lakshmi N V N S Venkatesh, M.B.,B.S., Rajendra D. Patel, M.D., Nirav Kotak, M.D., Navin Pajai, M.D.,
75 year-old male with right sided inguinal mass since 2 years, a known case of chronic obstructive
pulmonary disease with fixed flexion deformity at both the hip joints with inability to lie down in supine
position was posted for right inguinal hernia repair. Patient was given spinal and epidural anesthesia in
lawn chair position with a lesser volume of 0.5% bupivacaine heavy and a Spinal Level of T10 was
achieved. Intraoperatively, 3 pillows were supporting his back and surgery was also performed in lawn
chair position uneventfully and patient was discharged.
MCC02
2:50 PM - 3:00 PM
Awake Transtracheal High-Frequency Jet Ventilation as a Primary Approach to Advanced Upper
Airway Obstruction
Glorilee B. Harper, M.D., Sara Goldhaber-Fiebert, M.D., Sara Nikravan, M.D., Kenneth Lau, M.D.,
Vladimir Nekhendzy, M.D., Anesthesiology, Perioperative, and Pain Medicine, Stanford University,
Stanford, CA
A 19 year-old male with advanced nasopharyngeal adenocarcinoma presented for multiple tumor
debulkings requiring adaptive airway management. Attempts to intubate with fiberoptic bronchoscope and
lighted stylet were unsuccessful, and intubation was achieved via retrograde wire. The following
admission, surgical conditions necessitated a subglottic airway. A transtracheal catheter was placed
awake, and high frequency jet ventilation initiated prior to induction. After debulking, an endotracheal tube
was placed to facilitate further intervention and the catheter capped for possible rescue oxygenation and
ventilation. Postoperatively, the patient developed subcutaneous emphysema, which resolved
spontaneously. Similar airway management was performed on subsequent presentation without
complications.
MCC02
2:50 PM - 3:00 PM
Anaphylaxis from Administration of IV Gadolinium in the MRI Suite
Connor McNamara, Jonathan Lipps, M.D., Ohio State University Med Ctr, Anesthesiology, The Ohio
State University Wexner Medical Center, Columbus, OH
Anaphylaxis from administration of IV gadolinium during magnetic resonance imaging (MRI) is a rare but
potentially devastating condition. Although anesthesiologists are well versed in the diagnosis and
treatment of anaphylaxis during general anesthesia, the MRI suite poses unique challenges to traditional
crisis management algorithms requiring careful consideration and preparation. We present a 48 year-old
female undergoing a brain MRI under general anesthesia. After induction and intubation, the case
proceeded uneventfully until IV gadolinium was administered. Over just a few minutes the patient became
increasingly tachycardic, hypotensive, and hypoxic. After promptly removing the patient from the scanner
she was successfully resuscitated.
MCC02
2:50 PM - 3:00 PM
Anesthetic Management of a Patient With Intraoperative Cardiovascular Collapse Secondary to
Allergic Reaction
Muhammad Ashraf, M.D., Justin Rountree, M.D., Anesthesiology, University of North Carolina, Chapel
Hill, NC
Cardiovascular collapse represents one of the greatest challenges for anesthesiologists. We present a
55-year-old female scheduled for breast tissue expanders and right breast latissimus dorsi flap. She
tolerated paravertebral blocks for pain management. Shortly after induction of GA and removal of a right
Port-A-Cath, the patient remained hypotensive despite multiple vasoactive medications and fluid boluses.
She required ACLS before return of spontaneous circulation. Wheezing was noted with improvement after
administration of bronchodilators. TEE showed relatively under filled LV and an SVC thrombus. A CT was
negative for PE. We present a case of cardiovascular collapse secondary to allergic reaction.
MCC02
2:50 PM - 3:00 PM
Integrative Management of Bilateral Ophthalmic Artery Aneurysms and Subarachnoid Hemorrhage
in Pregnancy
Nabila B. Choudhury, M.D., David McDonagh, M.D., Anesthesiology and Pain Management, University of
Texas Southwestern Medical Center, Dallas, TX
40 year-old G4P2A1 presents with a headache from a ruptured left ophthalmic artery aneurysm resulting
in a subarachnoid hemorrhage. The patient also has a right ophthalmic artery aneurysm. She has
emergent coiling embolization of the left ophthalmic artery with plans for intervention post-delivery of the
right aneurysm. Postoperative course is complicated by worsened visual acuity and severe arachnoiditis
treated with NSAIDS which result in oligohydramnios. The patient undergoes an ASAP cesarean section
under neurosurgical monitoring. Months later, she undergoes a surgical clipping of her right ophthalmic
artery aneurysm. On follow-up, the patient has no long-term post-operative complications.
MCC02
2:50 PM - 3:00 PM
Marfan’s With Pre-eclampsia Presenting in Labor
Madhumani N. Rupasinghe, M.D.,F.R.C.A, Meenakshi Patil, M.D., Christopher Irwin, M.D., Peter Doyle,
M.D., Sara Guzman-Reyes, M.D., Anesthesiology, UTHSC, Houston, TX
We describe the anesthetic management of a 19 year-old parturient G1P0 with undiagnosed Marfan’s(
aortic root diameter 3.9mm) presenting in labor with pre-eclampsia.
MCC02
2:50 PM - 3:00 PM
Pain Medicine (PN)
Benefits of Combining State of the Art Surgical Techniques With Modern Multimodal Analgesia
Approach
Juan Mora, M.D., Peggy James, M.D., Anesthesiology, University of Florida - Jacksonville, Jacksonville,
FL
68 years old male scheduled for robotic nephrectomy. A multimodal analgesic was planned. Clonidine
patch was placed. Induction performed with Propofol, Ketamine, Midazolam and 1mcg/kg of Fentanyl.
Post-intubation Ketorolac and Dexamethasone were administered. Intraoperatively, maintenance
included Sevoflurane, Ketamine and Lidocaine infusions. Prior to cessation of the case, intravenous
Acetaminophen and a second dose of Ketorolac and Midazolam were given. Postoperatively, patient
requested a minimal amount of pain medications and Visual Analog Scale remained less than 5.
Ambulated, voided and tolerated diet on day 0. Was discharged home 20 hours after the procedure. Postdischarge survey with high satisfaction score.
MCC02
2:50 PM - 3:00 PM
Ultrasound Assisted Thoracic Paravertebral Analgesia in a Patient With Breast Cancer Combined
With Ankylosing Spondylitis
Lijian Pei, M.D., Gang Tan, Yuguang Huang, Anesthesiology, Peking Union Medical College Hospital,
Beijing, China.
A 50 year-old female(160 cm, 60 kg, ASA 3) with severe ankylosing spondylitis presented for left breast
cancer undergoing simple mastectomy. Her cervical spine was fixed without any movement. She also
demonstrated limited mouth opening less than 30 mm. The angle between her oral and pharyngeal axes
was measured on her lateral cervical spine radiograph as 85°.Ultrasound assisted thoracic paravertebral
analgesia was performed by multiple-level technique, with 5 ml 0.75% ropivacaine was injected at each
level(T1~T5). Propofol was maintained at 3~4ug/ml with spontaneous breath. Flexible laryngeal mask
was successfully to put with one finger sweep technique without deflation of the cuff.
MCC02
2:50 PM - 3:00 PM
Perioperative Management of a Patient With Congenital Central Hypoventilation Syndrome
Benjamin H. Cloyd, M.D., Jacqueline W. Ragheb, M.B.,B.Ch., Anesthesiology, University of Michigan,
Ann Arbor, MI
Congenital Central Hypoventilation Syndrome (CCHS) is a rare (1000 diagnosed cases worldwide), lifethreatening neurological disorder characterized principally by inadequate ventilation during sleep, which
presents at birth in the absence of other primary disease secondary to a mutation in the PHOX2B
homeobox gene. We present a 25 year-old female with CCHS and congenital long QT syndrome
managed with nightly BIPAP therapy, phrenic nerve stimulation, and a cardiac pacemaker who required
sedation for removal of painful knee hardware. The case was uncomplicated and the patient was
observed overnight in the ICU following an uneventful recovery in the PACU.
MCC02
2:50 PM - 3:00 PM
Atrial Septostomy Allowing Separation From VA-ECMO in Parturient With Severe Pulmonary
Hypertension
Michael J. Balderamos, Neil S. Karjalainen, M.D., Tara Brakke, M.D., Anesthesiology, University of
Nebraska Medical Center, Omaha, NE
A 32 year-old, suffered a cardiac arrest during cesarean section secondary to amniotic fluid embolism.
Upon return of spontaneous circulation, left and right ventricular systolic function was severely depressed
and the patient had severe pulmonary hypertension. An intra-aortic balloon pump and VA-ECMO were
initiated, and a right ventricular assist device was added for additional support. LV and RV function
improved however, pulmonary hemorrhage and severe pulmonary hypertension remained. Intravenous
and inhaled epoprostenol was initiated and when ECMO weaning was unsuccessful, an atrial septostomy
was performed allowing successful ECMO decannulation. The patient was discharged from the hospital 9
weeks after initial presentation.
MCC02
2:50 PM - 3:00 PM
Airway Management for Penetrating Facial Trauma With Impaled Screwdriver
Krishna Shah, M.D., Suman Rajagopalan, M.D., Anesthesia, Baylor College of Medicine, Houston, TX
37 year-old male with facial trauma was brought to the operating room for emergent intubation. He had an
impaled screwdriver to the left maxilla extending all the way into the skull base, which was bleeding
profusely into the oral cavity. He was confused, agitated with no other bodily injuries. Due to the location
of the foreign object, we were unable to perform bag-mask ventilation. We attempted awake fiberoptic
intubation but were unable to obtain a clear image given the significant amount of bleeding and altered
mental status. The second attempt was with C-MAC video-laryngoscopy and we successfully intubated
without any complications.
MCC02
2:50 PM - 3:00 PM
A Novel Case of Fatal Toxic Shock and Capillary Leak Syndrome From Clostridium Endometritis
Aaron M. Mittel, M.D., Junaid Nizamuddin, M.D., Sean F. Monaghan, M.D., Andrew J. Hale, M.D.,
Shahzad Shaefi, M.D., Anesthesia, Critical Care and Pain Medicine, Surgery, Medicine, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA
A 33 year-old female presented with pulsus paradoxus and leukocytosis to 113,000 in the setting of septic
shock. Echocardiography revealed tamponade physiology, but catheterization was more consistent with
hypovolemia. Laparotomy did not identify a source of infection; cultures remained negative. Her condition
deteriorated despite broad spectrum antibiotics and ongoing resuscitation, thus systemic capillary leak
syndrome was considered. She responded briskly to plasmapheresis on day four, achieving negative fluid
balance. Unfortunately as anasarca receded, a fixed, dilated pupil was noted. CT scan revealed tonsillar
herniation; she expired shortly thereafter. Post-mortem uterine cultures revealed probable C.
bifermentans, an exceedingly rare pathogen.
MCC02
2:50 PM - 3:00 PM
Atrial Fibrillation in Pregnancy
Yang Long, M.D., Suzanne Mankowitz, M.D., Anesthesiology, NewYork-Presbyterian/Columbia University
Medical Center, New York, NY
We present two cases of atrial fibrillation in pregnancy. One is of new onset in a previously healthy
parturient and the other in a parturient with known paroxysmal atrial fibrillation and structural heart
disease. The first patient presented at 22 weeks gestation with palpitations and was managed with rate
control. The second patient had a history of hypertrophic obstructive cardiomyear-oldpathy who
presented at 29 weeks gestation with unstable atrial fibrillation. The patient required intubation and
emergent cardioversion. Both patients were successfully converted to normal sinus rhythm.
MCC03
3:15 PM - 3:25 PM
An Unusual Case of “Pseudo-Pseudocholinesterase" Deficiency in a Patient Scheduled for an
Elective Hysterectomy and Salpingo-Oophorectomy
Edward Kosik, D.O., Brent Bushman, M.D., Sarah Parrish, Student, Anesthesiology, University of
Oklahoma HSC, Edmond, OK, School of Medicine, University of Oklahoma COM, Oklahoma City, OK
This case involved a 56 year-old 60kg female scheduled for a vaginal hysterectomy and salpingooopherectomy. The patient was induced with midazolam, fentanyl, proposal and rocuronium. The
procedure was completed in two hours. Neuromuscular blockade reversal was preceded by train of four
monitoring which showed 0/4 twitches of the orbicularis oculi even after tetanic stimulation. After ruling
out twitch monitor failure, we realized that the patient may have had a facial Botox injection and
alternatively monitored the adductor pollicis with success. Dosing of neuromuscular agents can be
underestimated if patients with facial Botox injections are not identified preoperatively.
MCC03
3:15 PM - 3:25 PM
A Simple and No-Cost Nasal CPAP Mask/Circuit Assembly Maintained Oxygenation and
Spontaneous Ventilation in a Patient With Large Submandibular Abscess During Emergency
Awake/Sedated Endotracheal Intubation
James T. Tse, M.D.,Ph.D., Robert Jongco, M.D., Amanda M. Doucette, M.D., Nicole Grayer, M.D.,
Daphne Anudon, C.R.N.A., Sylviana Barsoum, M.D., Anesthesiology, Rutgers Robert Wood Johnson
Medical School, New Brunswick, NJ
50 year-old mentally-challenged male presented for IandD of large submandibular abscess. His mouth
opening was <1 cm. An infant mask was secured over his nose with head-straps and connected to
anesthesia circuit/machine. APL was adjusted to deliver 5-6 cm H2O CPAP with O2 (3L/min) and air
(1L/min). After local anesthetics topicalization, deep sedation was titrated with midazolam,
dexmedetomidine and propofol. Sevoflurane (1%) was added to maintain adequate depth of anesthesia.
Endotracheal intubation was easily accomplished using fiberoptic bronchoscopy with videolaryngoscopic
(#3) guidance. He maintained spontaneous respiration and 100% O2 saturation throughout. He was
extubated on Postoperative Day 5.
MCC03
3:15 PM - 3:25 PM
A Simple and No-Cost Nasal CPAP Mask/Circuit Assembly Maintained Spontaneous Ventilation
and Oxygenation in a Severely Anxious Patient During SVT Ablation
Alexander Kahan, M.D., Rose Alloteh, M.D., James Tse, M.D.,Ph.D., Anesthesia, Rutgers Robert Wood
Johnson Medical School, New Brunswick, NJ
A 63 year-old female with severe anxiety and palpitations presents for an ablation of supraventricular
tachycardia. After a similar procedure done 15 years prior with prolonged paralysis, she was diagnosed
with a butylcholinesterase deficiency.Following modest premedication, an infant facemask was secured
over her nose and connected to an anesthesia breathing circuit. She was pre-oxygenated with 5-6
cmH2O CPAP with O2 3L/min and air 1L/min (0.8 FiO2). Sedation was titrated with a propofol infusion
(60-80 ug/kg/min) and a remifentanyl infusion (0.05-0.06 ug/kg/min). She maintained spontaneous
ventilation and 100% O2 saturation throughout. She was grateful to have not required general
anesthesia.
MCC03
3:15 PM - 3:25 PM
Anesthetic Implications of Multivalvular Surgery in Patients With Carcinoid Heart Disease
Anup P. Patel, M.D., Sherif Afifi, M.D., Dept of Anesthesiology, Northwestern Memorial Hospital, Chicago,
IL
72-year-old M w CHF, DM2 and metastatic carcinoid tumor to liver c/b carcinoid syndrome and carcinoid
heart disease for TVR and PVR. Induced with midazolam, fentanyl, etomidate and rocuronium. Octreotide
started at 100 mcg/hr, later to 200 mcg/hr with norepinephrine from 2 to 15 mcg/min and vasopressin
0.04 u/min for hypotension. Post-bypass TEE with well-placed bioprosthetic pulmonary and tricuspid
valves. To CTICU on vaso, levo and octreotide. Extubated in 2 hours. Octreotide and other drips weaned
off. ASA, statin, BB, diuresis, and coumadin medications initiated. Pt discharged to follow up successfully.
MCC03
3:15 PM - 3:25 PM
Perioperative Catastrophic Complication of Acute Aortic Occulusion
Obata Katsuyoshi, M.D.,Ph.D., Kouichi Yoshinaga, M.D., Yuichiro Takahashi, M.D., Hiroyuki Matsuyama,
M.D.,Ph.D., Anesthesiology, Iizuka hospital, Iizuka city, Japan
A 76-year-old woman presented for total hysterectomy and bilateral salpingo-oophorectomy. Surgery was
completed uneventfully and the patient was transferred to recovery room. 3.5 hours later after transfer to
RR, pulselessness of bilateral popliteal and dorsalis pedis artery developed.Post-operative
anesthesiologist round(8.0 hours after OR discharge) revealed bilateral leg paralysis,paresthesia.After
MRI and CT exam,they showed acute aortic occulusion immediately above the abdominal aortic
bifurcation.However there were no surgical indication(golden hour:6-8 hours).The cause of late ischemia
detection was contributed to post-operative epidural analgesia,which masked pain complaint.We
experienced rare perioperative complication.Every efforts to detect perioperative complication should be
required under epidural analgesia.
MCC03
3:15 PM - 3:25 PM
Severe Electrolyte Abnormalities Secondary to Unrecognized Ectopic ACTH Secretion in Skull
Base Esthesioneuroblastoma
Meredith A. Herzog, Letha Mathews, M.B.,B.S., Anesthesiology, Vanderbilt University, Nashville, TN
52 year-old male with a past medical history of hypertension, DM2, and recently diagnosed skull base
esthesioneuroblastoma presented from home for a bicoronal craniotomy and endoscopic tumor resection.
Abnormal labs at an outside hospital prompted labs to be rechecked the morning of surgery, which
showed severe metabolic alkalosis (pH 7.64, pCO2 44mmHg), hyperglycemia (BG 333mg/dL), and critical
hypokalemia (2.0mmol/L). He was asymptomatic except for fatigue and polyuria. His surgery was
cancelled, and he was admitted for workup and management. Though the tumor was initially considered
inactive, he was subsequently diagnosed with Cushing's Syndrome secondary to ectopic ACTH secretion
from his tumor.
MCC03
3:15 PM - 3:25 PM
Cesarean Section in a Patient With a Pituitary Macroadenoma With Mass Effect
Joshua James Hackett, M.D., Anesthesiology, North Shore-LIJ, New Hyde Park, NY
A 37 year-old female at full term presented for cesarean delivery secondary to a pituitary macroadenoma
with mass effect. MRI revealed a large, hemorrhagic mass with new optic chiasm compression and a
diagnosis of pituitary apoplexy was confirmed. The patient’s symptoms included bitemporal hemianopsia
and constant headache. Due to concerns for increased intracranial pressure the patient underwent
successful general anesthesia with an endotracheal tube. This case demonstrates an example of
worsening pituitary apoplexy in a parturient and the utility of a general anesthetic in cases of suspected
intracranial hypertension.
MCC03
3:15 PM - 3:25 PM
Prothrombin Complex Concentrate and Methylene Blue for Treatment of Coagulopathy and
Vasoplegia in a Pediatric Heart Transplant Patient
Jennifer K. Lee, M.D., Caleb Ing, M.D., Anesthesiology, Columbia University Medical Center, New York,
NY
Ventricular assist devices (VAD) are associated with a number of conditions that may complicate the
intraoperative course during pediatric heart transplant. A 7 year-old girl with dilated cardiomyear-oldpathy
supported by a Toyear-oldbo left VAD and preoperatively anticoagulated with warfarin presented for
orthotopic heart transplant. The course was complicated by persistent bleeding treated with prothrombin
complex concentrate (PCC) and refractory post-bypass vasoplegia treated with methylene blue.
Preoperative anticoagulation and presence of VAD is associated with post-bypass coagulopathy and
vasoplegia. We describe a case in which these conditions were successfully treated with no thrombotic
complications and minimal need of vasopressors for hemodynamic stability.
MCC03
3:15 PM - 3:25 PM
Pain Medicine (PN)
Aphasia and Motor Impairment Induced By Gabapentin and Pregabalin
Jijun Xu, M.D.,Ph.D., Michael Stanton-Hicks, M.D., Pain Management, Cleveland Clinic, Cleveland, OH
An otherwise healthy 45 year-old female was diagnosed with complex regional pain syndrome. She was
prescribed with gabapentin (Neurontin) 300mg TID. The patient took the first capsule at bedtime and the
second capsule on the morning of the next day. She then developed confusion, global aphasia, blurred
vision, facial and throat numbness, and difficulty in moving limbs. She denies hallucination. The
gabapentin was discontinued and a single dose of pregabalin (Lyrica) 50mg produced the same
symptoms. Pregabalin was stopped. Symptoms subsided in two days. Topiramate (Topamax) 50mg was
initiated without significant side effects.
MCC03
3:15 PM - 3:25 PM
A Novel Approach to Local Anesthetic Infiltration Technique for Guillotine Amputation
Brett A. Rebal, M.D., Irina Gasanova, M.D.,Ph.D., Girish Joshi, M.D., Anesthesiology and Pain
Management, University of Texas Southwestern Medical Center, Dallas, TX
63year-old man with history of CAD and DM2 presented in acute heart failure with a productive left foot
ulcer and subcutaneous air on x-ray. Due to 3 pillow orthopnea, new onset anasarca and EF of 20-25%
patient was not a candidate for general anesthesia. Peripheral nerve blocks were not an option as
significant edema distorted anatomy. At the level of the below knee amputation, 23 mL of 1% lidocaine
were infiltrated subcutaneously, intramuscularly and intraperiosteally using a 20G spinal needle. Patient
received midazolam 3mg and ketamine 50mg in divided doses. He tolerated guillotine amputation without
incident and did well postoperatively.
MCC03
3:15 PM - 3:25 PM
Intra-operative Tension Pneumothorax
Jahzreel A. Thompson, M.D., Vincent Odenigbo, M.D., Anesthesiology, Hahnemann University Hospital
at Drexel University, Philadelphia, PA
51 year-old male with Hepato-cellular carcinoma presents for Laparoscopic Microwave Liver Ablation. 30
minutes into the case, Surgery informs Anesthesia that there has been a perforation to the diaphragm.
After a few minutes his Oxygen saturations starts to decrease steadily down to 90%. Recruitment
maneuvers are performed with no improvement. Blood gases are drawn. A tension pneumothorax is
suspected. A bronchoscopy is performed which confirms endotracheal tube placement and also reveals
collapse of the right lung. A needle thoracotomy is done and a chest tube is placed which causes an
immediate improvement in the patient's Oxygen saturation and other vital signs.
MCC03
3:15 PM - 3:25 PM
Dramatic ST Segment Elevation During Laparoscopic Surgery in a Woman With Microvascular
Coronary Disease
Nam Phuong T. Tran, M.D., Yafen Liang, M.D., Yandong Jiang, M.D., Department of Anesthesia, Critical
Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, Department of Anesthesiology,
Vanderbilt Univesity Medical Center, Nashville, TN
A 46 year-old female with hypertension,hyperlipidemia, atypical chest pain, PFO, PE, steroid dependent
asthma, OSA, smoking, obesity, and IDDM undergoes gastric banding removal. Pre-op cardiac
catheterization was normal. Thus, she was diagnosed with coronary microvascular artery disease (MVD).
Upon surgical abdominal insufflation, patient developed 4.2mm ST segment elevation in the setting of
hypertension. The blood pressure was immediately controlled with deepening anesthesia and analgesia,
and ST segments normalized after six minutes. We attributed the event to coronary MVD vasospasm.
The etiology, pathogenesis, prognosis, and management of coronary MVD are discussed as well as the
differential diagnosis for this event.
MCC03
3:15 PM - 3:25 PM
Severe Airway Obstruction And Awake Tracheostomy
Alissa D. Zastrow, M.D., Jerry W. Green, D.O., Anesthesiology and Pain Management, University of
A 52 year-old male presented to the Emergency Department with a 4 month history of progressive
hoarseness, shortness of breath, odynophagia, and stridor. Physical exam revealed a palpable neck
mass. Computed tomography and flexible fiberoptic exam were obtained. These revealed a vegetating
mass on a fixed left true vocal cord with supraglottic extension. The right vocal cord only partially
abducted, leaving almost no patent airway. The patient was taken emergently to the OR for planned
“awake” tracheostomy. Anesthetic management included dexmedetomidine anxiolysis in addition to
infiltration of local anesthetic, and facilitated a successful tracheostomy.
MCC03
3:15 PM - 3:25 PM
Anesthetic Management of a Pediatric Patient With Cutaneous Mastocytosis
John J. Weir, M.D., Lydia M. Jorge, M.D., Anesthesiology, University of Miami, Miami, FL, Pediatric
Anesthesiology, University of Miami, Miami, FL
Mastocytosis is a rare disorder characterized by excessive mast cell accumulation in one or more organs.
The clinical presentation varies and is related to the mast cell burden in a particular organ system and
release of different mediators. Symptoms due to mediator release include hypotension, flushing, and
anaphylaxis. The challenge to the anesthesiologist during the perioperative care of a patient with
mastocytosis includes the prevention of mast cell degranulation and appropriate response to the various
physiological manifestations that result from mediator release. Described is the management of a 22month old boy with mastocytosis presenting for a bone marrow biopsy.
MCC03
3:15 PM - 3:25 PM
Tracheal Tear Following Routine Endotracheal Intubation
Nikita N. Patel, M.D., Krystyna Marable, M.D., Anesthesiology, New York University, New York, NY
57 year-old F with osteoporosis presents for L. olecranon fracture ORIF. IV induction with easy mask
ventilation. DL with MAC 3, single attempt, grade I view, atraumatic ETT 7.0, cuffed to seal.Stomach
suctioned with a salem sump and placed to gravity. Patient positioned in R. lateral decubitus position and
surgery proceeds without complications. Emergence and extubation uncomplicated and patient brought to
recovery room. Five hours later, patient vomits and noted to have significant subcutaneous emphysema.
Chest CT and bedside FDL reveal a 0.5cm lesion on the posterior aspect of the trachea 2cm inferior to
the level of the glottis.
MCC03
3:25 PM - 3:35 PM
Nasal Fiberoptic is Not Always the Safest: Airway Management in a Patient With Facial
Pseudoaneurysm
Danielle K. Bodzin, M.D., J. Marshall Green, III, D.D.S., Robert E. Marx, D.D.S., Roman Dudaryk, M.D.,
Anesthesiology, Jackson Memorial Hospital, Division of Oral and Maxillofacial Surgery, University of
Miami-Miller School of Medicine, Miami, FL
A patient who recently underwent corrective jaw reconstruction outside of the United States presented for
evacuation of post-operative oropharyngeal hematoma. Asleep nasal fiberoptic intubation was attempted,
but a rare and unanticipated complication ensued: rupture of right facial artery psedudoaneurysm. The
difficult airway algorithm was followed up to the point of surgical airway.
MCC03
3:25 PM - 3:35 PM
66 year-old Male With Acute on Chronic Respiratory Failure, Atrial Fibrillation and Alcoholic
Cirrhosis Who Presents for Transjugular Intrahepatic Portosystemic Shunt
Kevin W. Duong, Pete Petrik, M.D., Rodney Smith, M.D., Russell McAllister, M.D., Michael Hofkamp,
M.D., Texas A&M Health Science Center College of Medicine, Department of Anesthesiology, Baylor
Scott & White, Temple, TX
A 66 year-old male with a history of atrial fibrillation, alcoholic cirrhosis with elevated MELD score and end
stage COPD with acute on chronic respiratory failure requiring mechanical ventilation presented for
transjugular intrahepatic portosystemic shunt to alleviate portal hypertension and resultant ascities. The
patient was hemodynamically labile due to atrial fibrillation with variable ventricular response along with
the usual hyperdynamic cardiac output physiology of cirrhosis and required a phenylephrine infusion to
maintain mean arterial blood pressure. The procedure was otherwise well tolerated and the patient was
transported intubated to the intensive care unit upon conclusion of the anesthetic.
MCC03
3:25 PM - 3:35 PM
Acute Intracardiac Thrombosis During Liver Transplantation: Successful Management
Giselle Helo, M.D., Cosmin Guta, M.D., Anesthesiology, Cleveland Clinic Florida, Weston, FL
A 59 year-old male with a MELD score of 30, underwent an urgent liver transplant on veno-venous
bypass (portal and femoral vein to right internal jugular). Continuous intraoperative TEE was performed.
During the veno-venous bypass, flows of 1.5-1.9 L/min were maintained throughout. After an uneventful
reperfusion and completion of the hepatic artery anastomosis the bypass was discontinued. Shortly after
the bypass was stopped, the TEE showed a massive intracardiac thrombus and right heart failure. One
dose of altepase, 4 mg, was followed by complete resolution of the intracardiac thrombus. The patient
underwent a full postoperative recovery .
MCC03
3:25 PM - 3:35 PM
IV Drug Abuser Presenting for Emergent Aortic Valve Replacement
Sirisha A. Rao, M.D., Jamel Ortoleva, M.D., Terrance Rafferty, M.D., Department of Anesthesiology, Yale
University School of Medicine, New Haven, CT
31 year-old male with past medical history of IV drug abuse presented with shortness of breath and fever.
2D echo was highly suggestive of vegetations on the aortic valve along with aortic regurgitation. The
patient was found to have blood cultures positive for Streptococcus viridans. Further evaluation with TEE
showed severe aortic regurgitation with holodiastolic flow reversal in the descending aorta. Antibiotics
were given and blood cultures cleared. Prior to surgical intervention the patient required removal of
several infected teeth to help prevent re-infection of the future mechanical valve. He was then brought to
the operating for urgent aortic valve replacement.
MCC03
3:25 PM - 3:35 PM
Anesthetic Management of a Severely Burned Patient While on ECMO
Peter B. Bell, Bryant Edwards, Christopher Maani, Carlo Alphonso, Department of Anesthesia, San
Antonio Military Medical Center, San Antonio Military Medical Center, ISR, San Antonio Military Medical
Center, San Antonio, TX
We describe the challenging anesthetic management and perioperative care of a burn patient while on
extracorporeal membrane oxygenation. An ASA-2E male suffered 65% TBSA full thickness burns as well
as severe inhalational injury. Subsequent development of pronounced respiratory failure was refractory to
conventional ventilator management and required ECMO. While on ECMO, he underwent non-elective
excision and grafting procedures, airway surgery and limb amputation. Given the perilous risk of transport
with cumbersome equipment, significant coagulopathy, ongoing transfusion requirements, reliance on
invasive monitors, and hemodynamic lability necessitating constant titration of vasoactive medications,
the surgeries were performed in the ICU.
MCC03
3:25 PM - 3:35 PM
Anesthetic Challenges and Management of Venous Air Embolism During a Sitting Craniectomy
Jonathan H. Chow, M.D., David Schreibman, M.D., Department of Anesthesiology, University of
Maryland, Baltimore, MD
A 52 year-old female with a left cerebellopontine angle meningioma was brought to the operating room for
a craniotomy in the sitting position. A precordial doppler and multi-orifice central line were placed. Three
hours later, the tone of the precordial doppler suddenly changed, followed by hypotension, and an abrupt
decrease in ETCO2. The field was flooded with saline, the patient’s head was lowered, and 15mL of air
was aspirated. Venous air embolism recurred multiple times, resulting in 60mL total of aspirated air. The
source of the embolism was never found, and she was extubated successfully at the conclusion of the
case.
MCC03
3:25 PM - 3:35 PM
Postpartum Headache After Dural Puncture: Not Always a Post Dural Puncture Headache
Grant Lynde, M.D., MBA, Regina M. Charrier, M.D., Department of Anesthesiology, Emory University,
Atlanta, GA
27 year-old G3P3 healthy female who presented with a persistent postpartum headache after treatment
for postdural puncture headache (PDPH) with an epidural blood patch (EBP). On PPD2, she underwent a
successful EBP with resolution of symptoms. On PPD3 the patient returned with severe headache
following a coughing episode and again underwent EBP with complete relief of her symptoms. A few
hours after her second EBP, the patient had a generalized tonic clonic seizure lasting 30 seconds before
spontaneously resolving. An emergent CT scan which showed a linear cortical-based hyperdensity within
the left parietal lobe significant for a thrombosed cortical vein.
MCC03
3:25 PM - 3:35 PM
Anesthetic Management of Hip Hemiarthroplasty in a Cerebral Palsy Child
Valerie Ivanova, D.O., Tehilla Adams, M.D., Kalpana Tyagaraj, M.D., Anesthesiology, Maimonides
10 years female with history of Cerebral Palsy, seizures, severe neurological impairment, restrictive lung
disease secondary to severe scoliosis, bronchiectasis, neck and extremity contractures, PEG tube, and
OSA/CPAP at home and bilateral hip subluxation, presented for for right hip hemiarthroplasty. General
anesthesia was induced with propofol , rocuronium and intubated with a glideslope. A post induction
lumbar epidural was placed in lateral position. An arterial line was placed to monitor hematocrit. Patient’s
epidural was loaded slowly with bupivacaine and patient was extubated. The patient experienced
episodes of obstruction that were relieved with positive pressure ventilation via mask and nasal airway.
MCC03
3:25 PM - 3:35 PM
Pain Medicine (PN)
Novel Technique For Placement of Lumbar and Cervical Spinal Cord Stimulator Lead System
Through a Laminotomy
Kevin J. Winegar, D.O., Ali Turabi, M.D., Cesar Velazquez, M.D., David E. Jamison, M.D., Anesthesia,
Walter Reed National Military Medical Center, Bethesda, MD
Pain conditions affecting the lumbar and cervical spineare amenable to treatment with spinal cord
stimulation (SCS). However,concurrent surgical implantation of percutaneous thoracic and cervical
leadscan be lengthy and requires an alert and cooperative patient forintra-operative testing. We describe
a case of combined thoracic and cervicalSCS implant that utilized a thoracic paddle lead and two cervical
percutaneousleads, all of which were placed through a single thoracic laminotomy. This approachallowed
the use of general anesthesia in a military patient with post-traumaticstress disorder who had difficulty
during his SCS trial placements.
MCC03
3:25 PM - 3:35 PM
“Doc, I Need to be Able to Hold My Baby:” Anesthesia for Orthopedic Surgery During Pregnancy
Ruth G. Neary, M.D., Andra Distefano, M.D., Anesthesiology, University of Maryland, Baltimore, MD
Anesthesiologists must be prepared to care for pregnant patients undergoing non-obstetric surgery.
General anesthesia is hazardous for the gravid patient, with increased risk of difficult airway, hypoxemia,
aspiration, and hemodynamic fluctuations. Long-term effects of inhaled anesthetics on fetal
neurodevelopment are unclear. Regional anesthesia can be an alternative in appropriate cases.
Anesthesiologists should consult with the perioperative team to develop safe and effective anesthetic
plans, and counsel patients on the risks and benefits of regional versus general anesthesia. This case
presentation describes the use of interscalene brachial plexus blockade for shoulder arthroscopy with a
peripheral nerve catheter for postoperative pain management.
MCC03
3:25 PM - 3:35 PM
Anesthetic Management and Considerations in Patient With Acute Complete Proximal Abdominal
Aorta Occlusion
Eric R. Wildauer, D.O., MaryBeth Huber, M.D., Anesthesiology, Saint Louis University, Saint Louis, MO
Abrupt occlusion of arterial vasculature deprives distal tissues of oxygen and leads to tissue death. The
following case describes a thromboembolism in a patient with atrial fibrillation that fully occluded the
proximal abdominal aorta resulting in lower extremity and abdominal organ ischemia. The case describes
the anesthetic considerations with such a proximal occlusion such as vascular access, temperature
control, blood pressure management, electrolyte abnormalities, acid-base disturbances, and acute renal
failure following reperfusion. Treatment relies on close monitoring of cardiac rhythm, calcium and insulin
for hyperkalemia, vasoactive drugs, possible intra-op hemodialysis and avoidance of hypovolemia.
MCC03
3:25 PM - 3:35 PM
TAVR Complicated by Left Ventricular Puncture and Cardiac Tamponade
Devin T. Kearns, Katie J. Goergen, University of Nebraska Medical Center, Omaha, NE
An 87 year-old male with severe aortic stenosis, coronary artery disease, and sick sinus syndrome with
pacemaker and Parkinson’s disease presented for transcatheter aortic valve replacement. The case was
uneventful until the patient became hypotensive prior to deployment of valve. Transesophageal
echocardiography was instrumental in identifying etiology of hypotension as tamponade due to LV
perforation. ACLS was performed, but resuscitation difficult due to AS hemodynamics. Patient was then
placed on cardiopulmonary bypass with conversion to open aortic valve replacement. The patient
tolerated the procedure well, receiving multiple blood products and repair of a femoral vessel injury.
MCC03
3:25 PM - 3:35 PM
Intubation Following Iatrogenic Upper Esophageal Perforation
Christina Boncyk, M.D., Andrew Schulz, M.D., Richard Galgon, M.D., Anesthesiology, University of
Wisconsin Hospital and Clinics, Madison, WI
A 72 year-old woman, five days status-post bilateral mastectomy, presented for emergent esophageal
repair and mediastinal washout secondary to mediastinitis from an unrecognized cervical esophageal
perforation, presumably from a difficult intubation. Anesthetic management included rapid sequence
induction and videolaryngoscopic intubation to allow periglottic visualization and to facilitate intubation.
During airway management, active purulent drainage was observed from the right piriform sinus. A singlelumen endotracheal tube (SLT) was first placed. Hypopharyngeal suctioning was then performed,
followed by SLT-to-double-lumen endotracheal tube exchange using 14Fr floppy-tip tube exchanger
under videolaryngoscopic guidance. Her post-operative course required multiple interventions and
prolonged antibiotic therapy.
MCC03
3:25 PM - 3:35 PM
Anesthetic Management of Patient With Epidermolysis Bullosa Undergoing Cholecystectomy
Brandon J. Smoller, M.D., Leah Ciaccio, D.O., Hyun Kee Chung, M.D., Anesthesiology, UMass Medical
School, Worcester, MA
Pt is 19 year-old female with PMH of recessive dystrophic epidermolysis bullosa scheduled to undergo
cholecystectomy. She presented with multiple abrasions and bullae. In the operating room, she self
positioned onto sheepskin cloth on the OR table. Adhesive was trimmed from EKG pads. Nonadhesive
ear probe SpO2 monitor was applied. NIBP cuff was wrapped over gauze. Mask was lubricated before
application. IV induction via port-a-cath was smooth, 5.5 ETT was placed atraumatically with glidescope
and tied. Case proceeded uneventfully, and pt was extubated and transferred to PACU in stable
condition.
MCC03
3:25 PM - 3:35 PM
Medical Mystery: Patient Found Unresponsive in the PACU
Gary Kim, M.D., Angela Vick, M.D., Apolonia E. Abramowicz, M.D., Anesthesiology, Montefiore Medical
Center, Bronx, NY
A 71 year-old male with chronic kidney disease IV not on dialysis, diabetes mellitus, hypertension,
coronary artery disease had a laparoscopic right hemicolectomy when it was discovered that he had
adenocarcinoma of the proximal colon. Surgery was uneventful, and the patient was extubated after
rocuronium induced neuromuscular blockade was reversed. In the PACU, the patient became
unresponsive an hour after arrival. The patient was noted to be hypercarbic and hypertensive. The patient
was reintubated, and mental status improved shortly thereafter. A few hours later, the patient was
extubated with no more instances of respiratory distress.
MCC03
3:35 PM - 3:45 PM
The Wired Burger - A Real Pain in the Neck
Pramod K. Chetty, M.D., Ankit Patel, D.O., Jordan Phillips, John Carter, M.D., Department of
Anesthesiology, Oklahoma University Health Sciences Center, Oklahoma City, OK
A 42 year-old healthy fireman presented with 5 day history of odynophagia after eating at a restaurant.
Complained of sharp pain to left side of the upper neck with swallowing. X-ray showed a wire lodged in
the left side of the oropharynx. After induction, an endotracheal tube was placed using a Glidescope.
Rigid laryngoscopy disclosed a jagged wire protruding from the left lateral base of the tongue. A 1.8cm
wire was removed under direct vision. The patient awoke after an uneventful anesthetic with total relief of
his pain.and was discharged home.
MCC03
3:35 PM - 3:45 PM
Anomalous Tracheal Anatomy and Implications During One-lung Isolation
Armin Shivazad, M.D., Hak Wong, M.D., Department of Anesthesiology, Northwestern University,
Chicago, IL
75 year-old male with history of CAD/MI, HTN, COPD, OSA, GERD, DM presented for bronchoscopy, left
VATS and LUL lobectomy. After induction of general anesthesia, we were unable to advance a 39 Fr leftsided double-lumen ETT. Upon examination of the airway with the fiberoptic scope, the trachea
terminated into: left mainstem bronchus, bronchus intermedius, and RUL bronchus. We then re-intubated
with a single lumen ETT and achieved lung isolation using a Cook bronchial blocker in LMB. Bronchial
blockers are useful in patients with anomalous tracheal anatomy where the LMB opening is located far to
the left with acute angling.
MCC03
3:35 PM - 3:45 PM
Intraoperative Challenges Faced by Anesthesiologists for Otolaryngology Free Flap Head and
Neck Reconstruction
Dierdre J. Cavan, M.D., Jagroop S. Saran, M.D., Anna Kaminski, D.O., Amie Hoefnagel, M.D.,
Anesthesiology, University of Rochester, Rochester, NY
We present a case of 75 year-old male for anterolateral thigh free-flap reconstruction for recurrent postauricular squamous cell cancer. He returned to the OR on POD#3 for evaluation of blood supply to the
flap, and there was concern that intermittent intraoperative vasopressor use at this time later contributed
to partial failure of this free flap. We will present a literature review and discuss the intraoperative
challenges faced by anesthesiologists in these cases. The focus will be on preoperative optimization of
patients, use of vasoactive medications, fluid managment, and management of conflicting comorbidities
to optimize the outcomes for this complex patient population.
MCC03
3:35 PM - 3:45 PM
Switching Sides: Unexpected Venous Anomaly Encountered During Pulmonary Artery
Catheterization
Minji Cho, Vanessa C. Hoy, M.D., Douglas Fetterman, M.D., Anesthesiology, SUNY Upstate Medical
University, Syracuse, NY, Anesthesiology, St. Joseph Hospital Health Center, Syracuse, NY
Venous anomalies are often associated with other cardiac defects without significant sequelae as one
progresses from childhood to adulthood. These unique anomalies may not surface until the patient
undergoes cardiac surgery or other interventions. We present a rare congenital anomaly of an isolated
persistent left superior vena cava (PLSVC) with an absent right superior vena cava (RSVC), which was
discovered during pulmonary artery catheter placement and confirmed through intraoperative
transesophageal echocardiogram in preparation for valvular replacement surgery. The presence of a
PLSVC with absent RSVC may affect cardiac procedures and placement of central venous catheter,
pulmonary arterial catheter, or pacemaker.
MCC03
3:35 PM - 3:45 PM
Using Rotational Thromboelastometry (ROTEM®) to Guide Blood Component Administration in a
Patient With Coagulopathy and Severe ARDS
Jia Wang, M.D., Bryan Romito, M.D., Department of Anesthesiology and Pain Management, University of
79 year-old female with asthmatic bronchitis, allergic bronchopulmonary aspergillosis (ABPA), and
cholangiocarcinoma. On POD #9 s/p Whipple procedure, she developed acute blood loss anemia,
thrombocytopenia, coagulopathy, and hypoxemic respiratory failure requiring ICU admission and
endotracheal intubation. Intubation was complicated by pulmonary aspiration and the development of
severe ARDS. Given her underlying pulmonary disease and degree of hypoxemia that accompanied her
coagulopathy, rotational thromboelastometry (ROTEM®) was used to identify specific, dynamic
coagulation abnormalities in order to minimize the administration of unnecessary products that may
further impair oxygenation. Using this strategy, both her ARDS and coagulopathy were resolved within
five days.
MCC03
3:35 PM - 3:45 PM
Liver Transplantation Under Total Intravenous Anesthesia for a Patient With Acute Liver Failure
and Cerebral Edema
Christine T. Nguyen-Buckley, M.D., Christine C. Myo Bui, M.D., Anesthesiology, University of California at
Los Angeles, Los Angeles, CA
A 32 year-old with recent eclampsia, acute liver failure and cerebral edema presents for liver
transplantation. Veno-venous bypass maintained mean arterial pressure to drive cerebral perfusion, and
minimized hemodynamic changes. Intraoperative dialysis for electrolyte and ammonia regulation helped
prevent exacerbation of cerebral edema, especially given large volume fluid and blood transfusion. To
avoid elevation of intracranial hypertension, we maintained total intravenous anesthesia, using BIS for
anesthetic depth, and elevated head of bed. We continued 3% saline with goal sodium 140-150,
maintained normoglycemia, and controlled PaCO2 30-40. She was discharged 19 days later with good
liver function without neurologic sequelae.
MCC03
3:35 PM - 3:45 PM
Successful Resuscitation During a Perimortem Cesarean Delivery in a Morbidly Obese Patient
With Severe Preeclampsia and Pulmonary Edema
Leslie A. Schornack, M.D., Mary A. Jennette, M.D., David H. Chestnut, M.D., Michael G. Richardson,
M.D., Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
A 25-year-old G1P0 female, BMI 55, presented for induction of labor for severe preeclampsia. Her blood
pressures remained elevated despite escalating doses of anti-hypertensives. Owing to this and a
category 2 FHR tracing, the obstetrician planned cesarean delivery. However, during operative
preparations, the SpO2 acutely decreased to 80% on oxygen, and she began to cough pink frothy
sputum. She became unresponsive, apneic, and cyanotic. The OB Emergency Response Team was
summoned. She was intubated and chest compressions initiated as she was in PEA arrest. . The baby
was delivered in 5 minutes after CPR began. ROSC occurred promptly after delivery.
MCC03
3:35 PM - 3:45 PM
Transcatheter Arterial Embolization for Primary Liver Pheochromocytoma
Pooja Dalsania, M.D., John Scott, M.D., Pediatric Anesthesia; Critical Care, Children's Hospital of
Wisconsin, Milwaukee, WI
16 year-old presenting with blurry vision, headache with BP of 217/130. Found to have a rare primary
hepatic pheochromocytoma. Based on tumor size/location plan to undergo transcatheter arterial
embolization, followed by chemotherapy, and resection. The anesthesiology team followed the patient
preoperatively managing antihypertensive regimen of phenoxybenzamine/labetalol. After confirming
adequate alpha blockade, the patient underwent embolization.Following embolization the patient required
phentolamine, nitroprusside, labetalol to achieve blood pressure control, which deemed difficult. This
case highlights use of trancatheter embolization in a rare pheochromocytoma case, and the critical role
anesthesiologists play in patient care resulting in improved coordination of patient care and outcomes
MCC03
3:35 PM - 3:45 PM
Pain Medicine (PN)
Reprogramming of In Situ Spinal Cord Stimulator for Covering Newly Developed Postthoracotomy
Pain
Utchariya Anantamongkol, M.D.,Ph.D., Nebojsa Nick Knezevic, M.D.,Ph.D., Maunak V. Rana, M.D.,
Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL
A 39 year-old female with Complex Regional Pain Syndrome (CRPS) Type I of the left lower extremity,
was relieved by a spinal cord stimulator (SCS) before developing slipping rib syndrome at T12 rib from
unrelated trauma. The patient eventually underwent thoracotomy, and developed post-thoracotomy pain
syndrome (PTPS). After failed conservative management, an already implanted SCS was reprogrammed
to target additional areas of chest discomfort. This adjustment reduced the pain at chest wall as well as
her left leg after 1-year follow-up. Use of the SCS in this patient provided significant pain relief for both
CRPS and PTPS.
MCC03
3:35 PM - 3:45 PM
Perioperative Management for Partial Hemiarthroplasty Following NSTEMI
Kelly Bruno, M.D., Jay Schoenherr, M.D., Anesthesiology, University of North Carolina, Durham, NC,
University of North Carolina, Durham, NC
An 84 year-old male presented for partial hemiarthroplasty after left femoral neck fracture. Patient had
recent non-ST elevation MI with 90-95% stenosis of long mid RCA and 95% stenosis in proximal rPDA
s/p angioplasty the day prior to surgery, pulmonary hypertension, and acute kidney insufficiency. Preinduction radial arterial catheter was placed. Anesthesia was induced and maintained via epidural with
local anesthetic and IV boluses of ketamine and dexmedetomidine. Intraoperative course was
unremarkable. Twenty hours postoperatively the patient developed refractory hypotension secondary to
subtotal occlusion in the proximal rPDA. Epidural catheter was removed and heparin gtt started, however
patient’s family withdrew care.
MCC03
3:35 PM - 3:45 PM
Masseter Muscle Rigidity (MMR) With Propofol, Sufentanil and Rocuronium: Who is the Culprit?
Thao T. Alite, M.D., Nicole Renaldi, D.O., Anesthesiology, Thomas Jefferson University Hospitals,
Philadelphia, PA
A 55 year-old 86kg male with h/o MVA s/p multiple lumbar surgeries presented for lateral lumbar
decompression and fusion with neuromonitoring. He was induced with propofol, rocuronium and
maintained with propofol and sufentanil infusions. Three minutes following induction, an attempt for direct
laryngoscopy proved difficult secondary to severely limited mouth opening from MMR. Anesthesia was
deepened with additional propofol and rocuronium, however, without improvement of mouth opening.
Intubation reattempted and was successful with grade 3 view. Patient’s masseter rigidity did not resolve
until the end of the case. We discuss potential causes of MMR and management of resultant airway
complications.
MCC03
3:35 PM - 3:45 PM
Tracheo-esophageal Fistula Repair on V-V ECMO Complicated by Abdominal Compartment
Syndrome After Decanulation, A Case Report
Maxim D. Orlov, Nadia Hensley, M.D., Anesthesiology and Critical Care Medicine, Johns Hopkins
Hospital, Baltimore, MD
We present a case of a 32 year-old female with a history of Hodgkin’s Lymphoma status post
chemotherapy and radiation. Her course was complicated by tracheo-esophageal fistula requiring a
tracheal->bronchial Y stent and bilateral brachiocephalic stenosis. She presented to the OR for TEF
repair via right thoracotomy. Her intraoperative considerations included poor peripheral vascular access
and impossible central access given brachiocephalic stenting and planned bilateral femoral venous
ECMO cannulation. She had a difficult airway with a tracheal stent. After de-cannulation she developed
abdominal compartment syndrome from liver lacerations with difficulty ventilating and inability to
recannulate ECMO.
MCC03
3:35 PM - 3:45 PM
General Anesthesia for Posterior Spinal Fusion in a Patient With metastatic Renal Cell Carcinoma,
Stress-induced Cardiomyopathy, and Allergy to an Unknown Induction Agent.
Alessandro R. De Camilli, M.D., Ahmed Shalabi, M.D., Anesthesiology, UCSF School of Medicine, San
Francisco, CA
We present a case of anesthetic management for a 45 year-old patient with chronic pain with opioid
dependence and metastatic renal cell carcinoma undergoing palliative posterior spinal fusion. The patient
had a history of circulatory collapse on two separate inductions of anesthesia suspected to be true
anaphylaxis to propofol or rocuronium, and was subsequently diagnosed with transient systolic heart
failure due to stress cardiomyear-oldpathy. We discuss the management of anesthesia with
neurophysiologic monitoring in the absence of propofol, as well as stress-induced cardiomyear-oldpathy
and the use of less invasive continuous cardiac output monitors.
MCC03
3:35 PM - 3:45 PM
Exploratory Laparotomy for Suspected Anastomotic Leak
Justin Miranda, M.D., Nitin Wadhwa, M.D., Anesthesiology, UT Health, Houston, TX
Thirteen month old, prior full term, with history of imperforate anus and diverting colostomy had scheduled
colostomy take down. Three days postop presented with signs of septic shock (tachycardia, tachypnea,
febrile) thought to be due to anastomotic leak, posted for emergent exploratory laparotomy. NPO was
appropriate, extremely tachypneic/tachycardic, no evidence of peritonitis, abdomen soft and
nondistended, no NGT in place. Induction with gentle mask technique, believed patient would not tolerate
classic RSI. Bilious fluid in mouth after induction, suspected aspiration resulted, desaturation and
increasing peak pressures/FiO2 requirements throughout case. Required oscillatory ventilation
postoperatively and ICU admission.
MCC03
3:35 PM - 3:45 PM
Severe Intraoperative Hypotension in a Patient With Parkinson’s Disease
Jin Jung, M.D., North Shore LIJ, New Hyde Park, NY
68 year-old female with a history of hypertension, hypothyroidism, well-controlled Parkinson’s disease on
carbidopa/levodopa, no signs of infection, and lab results within normal limits in pre-surgical testing went
to the operating room for ventral hernia repair. About 1.5 hours into the procedure during closure she
became severely hypotensive and unresponsive to ephedrine and phenylephrine. A norepinephrine drip
was then started afterwards to augment blood pressure. Insufflation was not used at any point. She was
left intubated, on pressors in the SICU. She was discovered to have pneumonia shortly afterwards. She
was extubated on day 4 after pressors were weaned.
MCC03
3:45 PM - 3:55 PM
Systemic Sclerosis: Ambulatory Anesthesia Pre-Anesthesia Assessment Requirement: How Much
is Enough?
Elizabeth A. Alley, M.D., Anesthesiology, Virginia Mason Medical Center, Seattle, WA
A 63 year-old male presented for laparoscopic cholecystectomy with 100 pound weight loss over 6
months due to gastrointestinal distress. His past medical history included systemic sclerosis, newly
diagnoses chronic lymphocytic leukemia and anemia. He reported a normal cardiac evaluation at outside
institution. His intraoperative and immediate postoperative course was unremarkable. He presented four
weeks postoperatively with heart failure due to severe pulmonary hypertension, he developed small
bowel obstruction and sepsis and expired five weeks after original procedure.
MCC03
3:45 PM - 3:55 PM
Bronchoscopic Removal of Obstructive Bronchial Tumor Leading to Complete Obstruction of
Endotracheal Tube
Veena N. Rao, M.D., Koichi Nomoto, M.D., Department of Anesthesiology, Mount Sinai School of
Medicine, New York, NY
56 year-old female with significant smoking history and pneumonia due to pleomorphic giant cell
carcinoma presented for bronchoscopic recanalization of tumor obstructing right main bronchus. The
patient was intubated with a standard 8.5mm endotracheal tube (ETT). Anesthesia was maintained with
propofol infusion. Tumor removal was attempted by adhesion to a cryear-oldprobe. A large piece of tumor
obstructed the ETT causing severe desaturation and bradycardia. The tumor was pushed back into the
trachea with the bronchoscope. Additional pieces were removed with difficulty during manual ventilation.
She was successfully extubated and made a full recovery with complete right lung expansion.
MCC03
3:45 PM - 3:55 PM
Perioperative Management for a Patient With Anaphylaxis to a Commonly Found Preservative
Sarah D. Moore, M.D., Ellen Park, M.D., Anesthesia, LAC + USC Medical Center, Los Angeles, CA, LAC
+ USC Medical Center, Los Angeles, CA
A 92 year-old femalewith history of atrial fibrillation and anaphylaxis to sulfites, presented foreyelid mass
excision. This case posed unique challenges as sulfite preservativesare in many important medications
including corticosteroids, antiarrhythmics,epinephrine and most other vasoconstrictors. Careful preoperative planningwas performed; medications were reviewed with a pharmacist to exclude
thosecontaining sulfites and a literature search was conducted to determine how totreat anaphylaxis in
the sulfite-sensitive patient. Literature is limited butsuggests supportive care and vasoconstriction with the
sulfite-free, alphaagonist, methoxamine. This case was successfully completed with monitoredanesthestic
care and avoidance of sulfite-containing medications.
MCC03
3:45 PM - 3:55 PM
Delay of Coronary Artery Surgery Resulting From Epetfibide-induced Severe Thrombocytopenia
Brent T. Boettcher, D.O., Paul S. Pagel, M.D.,Ph.D., Timothy J. Olund, M.D., Medical College of
Wisconsin, Milwaukee, WI
67 year-old man with a normal platelet count (212 K/uL) developed respiratory insufficiency and new left
bundle branch block two days after total colectomy consistent with acute coronary syndrome. He received
epetfibide in the catheterization laboratory, where three-vessel coronary artery disease was encountered.
Emergent coronary artery surgery was planned, but a platelet count measured immediately before
surgery was 2 K/uL (confirmed with peripheral smear and sodium citrate sample). The surgery was
postponed. The acute coronary syndrome was managed medically. Platelet transfusions increased the
platelet count to 100 K/uL. The patient underwent successful coronary surgery the following day.
MCC03
3:45 PM - 3:55 PM
Massive Oral Bleeding as the First Manifestation of B-cell Lymphocytic Leukemia/Small
Lymphocytic Lymphoma Reversed With Recombinant Activated Factor VII
Enrico M. Camporesi, M.D., Collin Sprenker, P.A., Hesham R. Omar, M.D., Andrew Powless, D.M.D.,
Devanand Mangar, A.A., TeamHealth Anesthesia, Tampa, FL, Internal Medicine Department, Mercy
Medical Center, Clinton, IA, Florida Special Care Dentistry, Tampa, FL
A 72 year-old male underwent full mouth extraction (18 teeth) due to dental caries. The next day the
patient experienced massive oral bleeding. Following emergent operation and ICU admission, tranexamic
acid at max dose, amicar, and 8 units of PRBC was administered in addition to gauze packing and
thrombin soaked gelfoam due to continued oozing. Following hematologyear-oldncology consultation and
flow cytometry, chronic lymphocytic leukemia was diagnosed. On postoperative day ten, 5000 µg of
recombinant activated factor VII (rFVIIa) was administered due to continued intraoral oozing. Within 2
hours of rFVIIa administration intraoral bleeding ceased. Total measured post-operative blood loss was
1.2L.
MCC03
3:45 PM - 3:55 PM
Management of Intraoperative Seizure in Patient With Subdural Hematoma
Chang H. Park, M.D., Jaime B. Hyman, M.D., Anesthesiology, Icahn School of Medicine at Mount Sinai,
New York, NY
61 year-old male with hypertension and diabetes presented with right-sided headaches and diplopia, and
was found to have a right PCA aneurysm. Patient underwent cerebral angiogram and embolization, which
was complicated by a right ICA dissection and pseudoaneurysm. After a complicated ICU course, he
developed mental status changes due to a subdural hematoma. He underwent emergency surgery to
evacuate the hematoma, and during emergence from anesthesia he experienced a seizure. Midazolam,
propofol, and levetiracetam were administered. Emergent CT scan of the head was performed to rule out
intracranial hemorrhage, and he was transferred to the neurosurgical ICU for further care.
MCC03
3:45 PM - 3:55 PM
Anaesthesia For Caesarean Delivery in a Patient With Ehlers Danlos Syndrome (EDS) Type 3
Vijay Ragothaman, M.D., F.C.A.R.C.S.I., Somasundaram Jeyanthan, M.D., F.C.A.R.C.S.I., Sanjay
Agarwal, M.D.,F.R.C.A, C Brennan, M.D.,F.R.C.A, A Downs, M.D.,F.R.C.A, Russells Hall Hospital,
Birmingham, United Kingdom
EDS type 3 is characterized by, hyper mobile joints, cardiac valvular insufficiency and conduction defects.
Labour can increase the risk of joint dislocations and blood loss. A 26 year-old primigravida with type 3
EDS, presented for an elective caesarean section at 37 weeks gestation. TTE and bloods were
unremarkable. This was performed under spinal, with 2.5mls of heavy 0.5% bupivacaine and 300
micrograms of diamorphine. Special care was taken to protect and pad the anaesthetized lower limbs and
joints to reduce dislocations. Hypotension was managed with a phenylephrine infusion. Intra operative
course was uneventful.
MCC03
3:45 PM - 3:55 PM
Airway Management in a Patient With Wolf-Hirschhorn Syndrome: A Case Report
John F. Gamble, M.D., Dinesh J. Kurian, M.D., Nathaniel H. Green, M.D., Anesthesiology, Duke
University Medical Center, Durham, NC
We present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general
anesthesia for gastrostomy tube placement for failure to thrive, with a focus on the approach to airway
management. WHS is a rare 4p microdeletion syndrome that results in multiple congenital defects
including significant craniofacial deformities such as micrognathia and glossoptosis. These abnormalities
present a challenge in anesthetic administration for these patients, particularly as it relates to
management of the airway. Here we review WHS and discuss our approach to patients with this rare and
challenging condition.
MCC03
3:45 PM - 3:55 PM
Pain Medicine (PN)
Sensory Blockade Caused by Inadvertent Subdural Catheterization During Attempted Epidural
Analgesia
Yuvraj S. Nijjar, M.D., Anjali Patel, D.O., Anesthesiology, St. Louis University, Saint Louis, MO
A 76 year-old female underwent an epidural catheter placement for a laparoscopic antrectomy with rouxen-y procedure. Initial epidural was placed at T10, with negative CSF aspiration via touhy and catheter.
After test dose was administered, patient complained of numbness in right thumb and index finger within
10 minutes. The catheter was removed and reinserted at T12 without complications. Despite excellent
analgesia post operatively, patient complained of bilateral upper extremity numbness, with no motor
weakness, and a headache the following morning. Upon discontinuation of the epidural infusion,
significant improvement was noted immediately with complete resolution in both headache and bilateral
extremity numbness.
MCC03
3:45 PM - 3:55 PM
Tapentadol Use in the Management of Acute on Chronic Pain and McCune-Albright Syndrome Semhar Ghebremichael, M.D., Opal Raj, M.D., Ryan Richards, M.D., Anesthesiology, University of
Texas-Houston, Houston, TX
A 27 year-old F with chronic pain secondary to polyear-oldstotic fibrous dysplasia presented with
progressive vision loss and severe bony pain. She underwent multiple optic nerve decompressions and
presented in December for repeat intervention. We were consulted for pain management after multiple
different failed treatments. Her home regimen was changed from high dose oxycontin and oxycodone to
tapentadol, lyrica, and a lidoderm patch, which decreased her pain scores from 10 to 2. Tapentadol is a
mu agonist and norepinephrine reuptake inhibitor that proves promising for chronic pain and neuropathic
syndromes with lower incidence of side effects seen with stronger opioids.
MCC03
3:45 PM - 3:55 PM
Anesthetic Management of An Orthopedic Patient During A Complete Intraoperative Power Failure
Robin E. Robbins, M.D., Rekha Chandrabose, M.D., Anesthesiology, University of California San Diego,
San Diego, CA
This is a case of a 65 year-old female who presented for bilateral femur open reductions and internal
fixations secondary to a dune buggy accident.Patient underwent an uneventful induction and intubation.
While in the process of closing the right femur incision, a complete OR power outage occurred. Backup
power to the anesthesia machine failed. Endotracheal tube was connected to a Mapleson circuit with a
backup tank as oxygen source, ventilation was confirmed and anesthesia was maintained with propofol.
Power returned eight minutes later. Patient remained stable throughout the remainder of surgery without
evidence of recall upon emergence from anesthesia.
MCC03
3:45 PM - 3:55 PM
Continuous Trans Esophageal Echocardiogram (TEE) Monitoring For Massive Vegetation On
Prosthetic Aortic Valve
Maulin U. Vora, M.B.,B.S., Amy L. Duhachek-Stapelman, M.D., Department of Anesthesiology, University
of Nebraska Medical Center, Omaha, NE
An 84 year-old male with history of Aortic Valve (AV)replacement three months earlier, presented with
fevers, chills and elevated troponin. Investigations revealed infective endocarditis of prosthetic AV. He
underwent removal of infected valve, debridement of aortic root annulus and patch repair of aortic root.
Intraoperative TEE demonstrated massive 2.6cmx0.8cm vegetation on right coronary cusp with severe
aortic insufficiency. Frequent TEE monitoring was used to assess valve pathology, proper placement of
the new valve and guide hemodynamic interventions. We will review TEE assessment of prosthetic AV
along with clinical presentation, surgical indications and complications of prosthetic AV endocarditis.
MCC03
3:45 PM - 3:55 PM
Unanticipated Difficult Airway in a Patient With Lingual Tonsillar Hyperplasia
Roberto A. Neisa, M.D.,Ph.D., Ryan Anderson, M.D., Zana Borovcanin, M.D., Anesthesiology, University
of Rochester School of Medicine and Dentistry, Rochester, NY
A 42 year-old man with prior uvulopalatopharyngoplasty for sleep apnea and Mallampati class III airway
presented for lumbar microdiscectomy. During asleep fiberoptic intubation, the view of epiglottis was
occluded by tissue. Visualization with GlideScope revealed lingual tonsil hyperplasia obstructing
visualization of glottic opening. Given the concern for airway obstruction due to excess tissue, case was
canceled and patient was mask ventilated until he emerged from anesthesia. Transnasal fiberoptic
laryngoscopy performed one week later by ENT surgeon revealed macroglossia. Patient was rescheduled
for surgery and awake fiberoptic intubation was chosen as the safest approach to airway management in
this patient.
MCC03
3:45 PM - 3:55 PM
Whole Lung Lavage for Pulmonary Alveolar Proteinosis
Justin S. Liberman, M.D., Grete Porteous, M.D., Stan Yuan, M.D., Virginia Mason Medical Center,
Seattle, WA
A 38 year-old male presented to the pulmonology clinic with increasing shortness of breath after working
at a construction site. Initial BAL was consistent with PAS positive protinaceous material.We describe a
standardized set up for "Whole Lung Lavage," physiologic changes identified during the procedure, and
potential complications encountered, including an intraoperative pneumothorax during the draining phase
of the procedure.
MCC03
3:55 PM - 4:05 PM
Post-vitrectomy in Prone Position With Delayed Diagnosis of Hypoglycemia: A Case of Complete
Recovery Post Undetectable Blood Glucose
Sn Trinh, Alexander Escobar, M.D., John Stroger Cook County Hospital, Chicago, IL
A 27 year-old woman with uncontrolled Insulin-dependent Type 1 Diabetes Mellitus and prior history of
hypoglycemic episodes with vitreous hemorrhage presented to same-day surgery and underwent an
uncomplicated vitrectomy under general anesthesia. Patient was found to be unresponsive with
undetectable glucose levels in the PACU. She was transferred to MICU with work-up negative for obvious
organic causes and remained comatose for 3 days. She began to regain consciousness and was
eventually discharged home without any focal deficits or sequelae.
MCC03
3:55 PM - 4:05 PM
Toxic Multinodular Goiter in a Patient With an IVC Thrombus Extending From the Renal Vein to the
Right Ventricle
David Y. Kim, mike tran, D.O., Anesthesiology, Temple University, Philadelphia, PA
Transesophageal echo is a commonly used tool for the purposes of dynamic monitoring of
cardiacfunction and hemodynamic status in patients undergoing non-cardiac surgery who have
cardiovascular indicationsthat might compromise the patient during surgery1.Oneusage of TEE during
surgery is monitoring of the inferior vena cava when itcontains a thrombus that was detected
preoperatively. Wepresent an unusual case of large IVC thrombus in a patient with colon cancer,in whom
TEE was used as a method of monitoring the thrombus during surgery.
MCC03
3:55 PM - 4:05 PM
Level 1 Trauma: Nasal Intubation in Patient With Known Maxillary Sinus Fracture
Hubert A. Cios, M.D., Shelly B. Borden, M.D., John Shepler, M.D., Univ of Wisc. Anes Dept, Madison, WI
21 year-old intubated female with bilateral maxillary sinus fractures presented as Level 1 trauma to our
institution. After stabilization, anesthesia with nasal intubation was requested for ORIF of mandibular
fractures. With maxillary fractures as a known contraindication to nasal intubation, ENT was consulted.
After examination, we used nasal trumpets to gently dilate the nares. Fiberoptic scope was passed
through right nare with visualization of glottic opening; nasal ETT was placed successfully. Exchange
catheter was placed in OETT in the event that nasal airway was not secured. Fiberoptic scope with ENT
involvement should be considered for nasal intubation with known contraindications.
MCC03
3:55 PM - 4:05 PM
Anesthetic Management of Type A Dissection in a Patient With Aarskog Syndrome
Lauren Thompson, D.O., Dave Barbara, M.D., Kent Rehfeldt, M.D., Anesthesiology, Mayo Clinic,
Rochester, MN
Aarskog syndrome is a rare X-linked recessive disorder characterized by hypertelorism, craniofacial
anomalies, genital malformations, ligamentous laxity, and short stature. Additionally, associated
neurocognitive disabilities and congenital heart disease has been observed [1, 2]. Due to these various
anomalies, these patients may require numerous operations throughout their lifetime and often have
difficult airways. This case report presents the successful anesthetic management of a 28 year-old male
with Aarskog syndrome with a known difficult airway undergoing emergent Type A aortic dissection
repair.References:1.Genomics, 1997. 43(3): p. 390-4.2.Interactive cardiovascular and thoracic surgery,
2005. 4(1): p. 47-8.
MCC03
3:55 PM - 4:05 PM
Management of a Massive Pulmonary Embolism With Intraoperative Cardiac Arrest
Michael A. Chyfetz, M.D., Joel M. Yarmush, M.D., James A. Osorio, M.D., Department of Anesthesiology,
New York Methodist Hospital, Brooklyn, NY, Weill Cornell Medical College, New York, NY
Massive bilateral pulmonary embolism resulting in acute respiratory distress is a condition with potentially
lethal consequences. Pulmonary embolism is associated with significant morbidity and mortality
secondary to ventilation-perfusion mismatch with resulting pulmonary hypertension, right heart failure and
hemodynamic instability. This case describes a 77 year-old Female with hemodynamically instability,
respiratory distress with reduced right ventricular function, severe tricuspid regurgitation, shock liver and
acute tubular necrosis presenting for emergent pulmonary embolectomy. We describe the anesthetic
management following cardiac arrest on induction and the application of multiple inotropic and
chronotropic support with inhaled nitric oxide to optimize post-bypass cardiac performance and oxygen
delivery.
MCC03
3:55 PM - 4:05 PM
Perioperative Management of a Patient With PAI-1 Gene 4G/5G Genotype for Intracranial
Hematoma Evacuation
Sara M. Aljohani, M.D., Sergey Pisklakov, M.D., Maria Bustillo, M.D., Jamie Bozentka, M.D.,
Anesthesiology, Albert Einstein College of Medicine, New York, NY, Anesthesiology, Albert Einstein
College of Medicine, Bronx, NY
4G/5G polymorphism in the promoter of the PAI-1 gene is a risk factor for a thrombotic event. It is
associated with a vein thrombosis, cerebral thrombosis, retinal thrombosis, purpura fulminans and the
thrombosis in vessels of internal organs. Thromboembolic risks in these patients are usually managed
with coumadin and enoxaparin. We present a case of a successful perioperative management of a patient
with PAI-1 Gene 4G/5G Genotype, cold agglutinins presence and hemolytic anemia for intracranial
hematoma evacuation. The decision to initiate thromboembolism prophylaxis in these patients is based
on an individualized assessment of the risks and benefits.
MCC03
3:55 PM - 4:05 PM
Uterine Inversion in a Multiparous Obstetrical Patient Complicated by Blood Loss
Olutoyosi T. Ogunkua, M.D., Irina Gasanova, M.D., Anesthesiology, University of Texas Southwestern,
Dallas, TX
30 year-old, G3P2A0 female presented at 40 weeks in active labor. Patient had a spontaneous vaginal
delivery complicated by bleeding after placental delivery. Diagnosed with inverted uterus, and failed
attempts at manual reduction. Patient went emergently to the operating room for examination under
general anesthesia with endotracheal intubation. Uterus was successfully reverted to normal anatomical
position. Blood loss was 2500 ml. Bleeding suspended after two units of PRBC’s, uterine massage,
manual curettage, use of prostaglandins and oxytocin infusion. Postoperative course was uneventful with
tubal ligation two days after delivery. Patient was discharged home post-partum day 3.
MCC03
3:55 PM - 4:05 PM
The Anesthetic Management of a Child With Mucolipidosis Type IV Coming for Endoscopic G-T
Replacement Surgery
Samuel M. Barst, M.D., John A. Cooley, M.D., Bernadette Pasamba-Rakhlin, M.D., Irim Salik, M.D.,
Anesthesiology, New York Medical College - Westchester Medical Center, Valhalla, NY
We present a case of a 20 year-old woman with a history of Mucolipidosis Type IV who was scheduled for
endoscopically assisted G-T replacement. Mucolipidosis Type IV is a rare autosomal recessive
neurodegenerative lysosomal storage disease predominantly seen in Jews of Ashkenazi descent. She
presented in infancy with global neurodevelopmental delays and corneal opacifications.
Neurodevelopmental delays in these patients are progressive and the patient required G-T feedings for
fluids and nutrition. After routine monitoring she was intubated with propofol and maintained on
Sevoflurane, ventilation was assisted. No adverse events from the anesthetic were noted.
MCC03
3:55 PM - 4:05 PM
Pain Medicine (PN)
Management of Chronic Post Surgical Pain in Pediatric Hernia Repair
Stephanie Shen, Student, New York University School of Medicine, New York, NY
7year-oldM w/hx of asymptomatic R-indirect inguinal hernia s/p uncomplicated laparoscopicrepair w/mesh
in 07/2014 p/w episodic stabbing 6/10 R-groin pain, increasing frequency x4months, now daily. Pain
triggered by pressure, hyperextension, bearing down, radiates to R scrotum, initially relieved by
Tylenol,ibuprofen, and lifestyle modifications. No e/o injury or infection on pelvic US suggesting
neuropathic pain. Pt started on tramadol, thenhydromorphone and gabapentin w/limited non-sustained
improvement. Pt sent forilioinguinal/iliohypogastric nerve block w/improvement followed by nerveablation.
Pain recurred after 1mo, family unamenable to nerve excision. Regularnerve blocks continued
w/acupuncture for management.
MCC03
3:55 PM - 4:05 PM
Double Epidural Catheters in the Chronic Pain Trauma Patient With Multiple Rib Fractures and
Concurrent Pelvic Fractures
Brent Kidd, M.D., Jason McKeown, M.D., Department of Anesthesiology and Perioperative Medicine, The
University of Alabama at Birmingham, Birmingham, AL
A 61year-old white male presented to UAB s/p ATV rollover without helmet. After initial evaluation he was
transferred to the trauma ICU where, after imaging, it was discovered that he had numerous fractures
secondary to the accident including: displaced right rib fractures 2-8, T2 transverse process fracture, right
obturator ring fracture with associated pelvic hematoma, and left sacral ala fracture. The inpatient pain
service was consulted for pain control. Based on his injuries two epidural catheters were placed and
dosed independently. The presentation centers on identifying patients eligible for double epidurals and
management strategies for the catheters once in place.
MCC03
3:55 PM - 4:05 PM
Bougie Saves the Day (A Reliable Back Up Tool in Management of Difficult Airway)
Zilvinas Zakarevicius, M.D., Gennadiy Voronov, M.D., Serge Tyler, M.D., Alexander Nagrebetsky, M.D.,
Anesthesiology and Pain Management, John H. Stroger Jr. Cook County Hospital, Chicago, IL
The difficult airway and failed intubation is the one of the most important cause of anesthesia-related
morbidity. The American Society of Anesthesiologists published a difficult airway management algorithm.
Schematically, after failed awake technique or induction of anesthesia, two concerning respiratory
scenarios are distinguished: “cannot intubate” and “cannot ventilate.” In these circumstances, most
recommended strategies for airway management require the use of airway devices conceived to facilitate
tracheal intubation. We are presenting two challenging cases of difficult intubation in patients with
gunshot wound facial trauma and enormous thyroid mass. In both cases utilization of bougie makes
intubation possible.
MCC03
3:55 PM - 4:05 PM
Risk To Life and Limb: Prosthetic Valve Endocarditis With Subsequent Brachial Artery Thrombus
Paul R. Shekane, M.D., Gregory K. Kim, M.D., Jennie Ngai, Peter Neuburger, M.D., June Rim,
Department of Anesthesiology, New York University Langone Medical Center, New York, NY
38 year-old male with a h/o IV drug abuse s/p MVR for endocarditis presented with fever and chills. The
preoperative echo showed considerable vegetations on his MV. During CPB, additional pressor support
was required despite good flow to maintain MAP’s > 50 mmHg. However, the lactate trended up from a
baseline of 2.3 mmol/L to a peak of 19mm/L. The rising lactate was assumed to be related to his sepsis
and increasing need for pressors. Soon after surgery, a pulseless and swollen extremity was noted. An
emergent thrombectomy was performed to remove a 5 cm thrombus from the brachial artery.
MCC03
3:55 PM - 4:05 PM
Airway Management in Severe SVC Syndrome
Antonio Thomas, M.D., David J. Brenneman, M.D., Thomas J. Martin, M.D., Thomas C. Mort, M.D.,
Hartford Hospital, Hartford, CT
A 51 year-old-man with end stage renal disease and obstructive sleep apnea who developed severe
superior vena cava (SVC) syndrome secondary to multiple hemodialysis access procedures presented on
ten occasions for hemodialysis access revision. During his first anesthetic, the patient experienced
difficult ventilation and intubation on induction of general anesthesia, as severe airway edema resulted in
obstruction less than a minute after reclining his head of bed. Subsequently, we successfully employed a
variety of anesthetic and airway management techniques for his remaining nine anesthetics, including
awake fiberoptic intubation, awake video laryngoscopic intubation, and sedation with regional anesthesia.
MCC03
3:55 PM - 4:05 PM
Recurrent Pneumothorax With a Thoracic Paraneural Mass: Unique Location, Unusual
Presentation of Tarlov Cyst
Katrina M. Von Kriegenbergh, M.D., Kallol Chaudhuri, M.D.,Ph.D., Texas Tech University Health
Sciences Center, Lubbock, TX
A 16 year-old female with history of recurrent spontaneous pneumothorax was admitted with sudden
shortness of breath. MRI revealed an intrathoracic mass at left lung apex, traversing through left T1-T2
neural foramina, extending inferiorly to T2-T3 intervertebral disc space. She underwent a video-assisted
thoracoscopic procedure; the mass was untangled from cervical nerve roots and excised via a posterior
cervical spine approach. Significant unexpected bleeding from intrathoracic vessels challenged the
anesthetic management. Patient was extubated at the end of the procedure; postoperative course was
uneventful, and she was discharged on POD#4. Neurologic sequelae had completely resolved at 3-month
follow-up.
MCC03
3:55 PM - 4:05 PM
Difficult Airway and Pulsatile Bronchial Mass in a Patient With Severe Scoliosis
Thomas W. Mader, M.D., David Dickerson, M.D., Anesthesia and Critical Care, University of Chicago,
Chicago, IL
62 year-old female with severe scoliosis and T1-L1 spinal fusion with internal fixation rodding presents for
bilateral mastectomy and reconstruction. Intubation required 5 attempts with direct and video-assisted
laryngoscopy. Oxygen saturation was 90% with elevated airway pressures and absent left chest rise
following intubation. She exhibited ectopy and significant hypotension with positive pressure ventilation.
Flexible bronchoscopy revealed a pulsatile mass occluding >50% of the left main stem bronchus. The
case was aborted. CT showed rightward shift of the thoracic contents, with close approximation of the left
bronchus and pulmonary artery. There was no intrinsic vascular or airway pathology.
MCC03
4:05 PM - 4:15 PM
Physostigmine Use in the Perioperative Management of Restless Leg Syndrome
Taghreed Alshaeri, M.D., Ananthamurthy Nagabhushana, M.D., Anesthesiology, Detroit Medical Center,
Detroit, MI
Restless legs syndrome (RLS) is a neurological disorder that affects approximately 10% of the US
population. Presented is a case of a 61 year-old male with a history of RLS undergoing right knee
arthroplasty under spinal anesthesia. During the procedure, the patient exhibited involuntary jerky
movements involving the arms and trunk. The differential diagnosis included; seizure, akathisia, and
acute exacerbation RLS. As a lower extremity motor block was used, the operation did not have to be
interrupted. Postoperatively, the patient’s clinical condition worsened. Subsequently, when Physostigmine
(1 mg IV) was administered, complete resolution of symptoms occurred within 2 minutes.
MCC03
4:05 PM - 4:15 PM
A Central America Immigrant With TBI Developed Malignant Hyperthermia After Induction for
Emergency Craniotomy
Xiqing C. Cao, M.D., Anesthesiology, Medstar Washington Hospital Center, Washington, DC
A 22 year-old, male, Guatemala immigrant, was brought to OR for emergency craniotomy and evacuation
of hematoma after suffering from left occipital depressed skull fracture and subarachnoid hemorrhage due
to unrestrained drunk driving MVA. Patient developed fulminant malignant hyperthermia after induction
with succhinocholine and was successfully treated with dantrolene. He stayed at ICU postoperatively with
significant CK elevation. Continuous IV dantrolene and then PO dantrolene due to phlebitis was used for
seven days. He was diagnosed with Exon 39 mutation of Ryanodine receptor1 by UHSMS MH lab. One
of his maternal cousin carries the same mutation.
MCC03
4:05 PM - 4:15 PM
Hypopharyngeal Perforation as a Consequence of Multiple Attempts During Emergency
Intubation: Validation for Utilizing the Most Experienced Providers in High-risk Settings
Elizabeth A. Dryland, D.O., Steven Cataldo, M.D., David Mandell, M.D., Anesthesiology, SUNY
Downstate Medical Center, Brooklyn, NY
60M with HTN, CHF, and DM presented to ED in hypoxemic respiratory failure secondary to congestive
pulmonary edema. Patient failed BiPAP therapy and emergent intubation was initiated. After many
unsuccessful attempts including difficult placement of and impossible passage of the ETT over a bougie,
Anesthesia was consulted. Despite uneventful successful orotracheal intubation by Anesthesia, severe
subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and pneumothorax developed due
to hypopharyngeal perforation resulting in prolonged intubation and hospital course complicated by
pneumonia and sepsis. Complication rates are shown to decline as airway training increases, thus early
Anesthesia involvement may significantly reduce airway-related complications in high-risk patients.
MCC03
4:05 PM - 4:15 PM
A 36 year-old Healthy Female Develops RV Failure Requiring Permanent RVAD/ Heart Transplant
Following Isolated Mitral Valve Repair
John Zaki, M.D., Matthew Pauley, M.D., Victoria Gascoyne, M.D., Dallis Clendeninn, M.D.,
Anesthesiology, UT Health Science Center, Houston, TX
A year-oldung, healthy female who presented for repair of mitral valve prolapse with no other PMHx,
following CBP developed cardiogenic shock secondary to isolated RV failure and subsequently required
RVAD support as a bridge to transplant.
MCC03
4:05 PM - 4:15 PM
Sugar and Salt: Maintenance of a Hypertonic State With 3% Saline Solution During the Correction
of Severe Hyperglycemia in a Patient Presenting With Concomitant DKA and ICH
David J. Graham, M.D., Jace Perkerson, M.D., Anesthesiology, University of Tennessee, Knoxville, TN
A 65 year-old F was admitted to the Neurosurgical ICU with DKA and an ICH. Our patient was at risk for
cytotoxic edema from DKA, osmotic edema from rapid correction of hyperglycemia, and vasogenic edema
from inflammation caused by the hemorrhage. The patient was also at risk of developing a critical rise in
ICP from both the correction of hyperglycemia and the mass effect from the ICH. Of competing interest
was the need to treat the patient’s life threatening DKA while avoiding an increase in ICP. Hypertonic
saline was used prophylactically to sustain serum osmolarity while treating her DKA.
MCC03
4:05 PM - 4:15 PM
Sitting Craniotomy, Anesthetic Management of a Super, Super Morbidly Obese Patient With Pineal
Tumor and Postoperative Complications
Chidi N. Achilefu, M.D., Jacqueline Smith, M.D., Anesthesiology, University of Oklahoma, Oklahoma City,
OK
The sitting craniotomy approach has proven to improve surgical access for posterior fossa tumors, but as
we know, not without risk of serious complications. We describe a case of a 65 year-old male with super,
super morbid obesity, who presented with increasing confusion and parinaud’s syndrome and found to
have a pineal region tumor. Neurosurgery requested the sitting position for this case which proved
technically challenging. We will discuss the management of this patient as well as challenges faced both
intra-operatively and postoperatively.
MCC03
4:05 PM - 4:15 PM
Arteriovenous Malformation of the Palate in an Obstetric Patient
Sonya C.D. Randazzo, M.D., Yukiko Yamanaka, M.D., Shetal Patel, M.D., Anesthesiology, University of
Southern California, Los Angeles, CA
Airway AVMs in obstetric patients are challenging due to the risk of rupture either with valsalva during
vaginal delivery or with securing the airway during cesarean section. A patient with an AVM of the palate
presented at 36.5 weeks with clots in her mouth. She was admitted for urgent delivery as she was
showing signs of labor. Epidural anesthesia was performed and cesarean section was uneventful. This
case report describes an interdisciplinary delivery plan created by obstetrics, anesthesiology, and
otolaryngology to minimize the risk of bleeding and safely control the airway for a patient with an AVM of
the palate.
MCC03
4:05 PM - 4:15 PM
Ebstein's Anomaly: Intraoperative Considerations for Managing A Teenage Patient Undergoing
Blalock-Taussig Shunt Placement
Ray S. Choi, M.D., Alexander B. Froyshteter, M.D., Behnoosh Shayegan, M.D., Sapan Amin, M.D., Rush
University Medical Center, Chicago, IL
18 year-old female presented from Mexico with severe hypoxemia (room air saturation 58%) and nonexertion fatigue. She appeared cyanotic with an obvious heart murmur. Echocardiogram revealed a
severe Ebstein’s anomaloy and large atrial septal defect. A meeting was held regarding the treatment
plan with complete valve repair/replacement, Glenn proceure, or a Blalock-Taussig shunt. Given disease
severity and progression, a palliative Blalock-Taussig shunt was planned. During surgery, she
experienced one episode of atrial flutter and ventricular fibrillation requiring defibrillation. Post-operatively,
saturations increased to 84% on room air and she was extubated with an uncomplicated post-operative
course.
MCC03
4:05 PM - 4:15 PM
Pain Medicine (PN)
CRPS Without Allodynia/Hyperalgesia
Rashad Albeiruti, M.D., Rohit Mahajan, M.D., Paul Hilliard, M.D., Department of Anesthesiology,
University of Michigan, Ann Arbor, MI
A 37 year-old female presented with a 5 month history of right upper extremity pain. She was struck by a
softball on the dorsum of her right hand. Her entire right upper extremity up to the elbow was involved.
She denied sensory changes such as allodynia and hyperalgesia. She endorsed vasomotor symptoms
(cooler temperature and skin color change), motor/trophic symptoms (decreased range of motion and
weakness of the right wrist), and edema. On physical exam, she had no sensory signs of
allodynia/hyperalgesia; positive for vasomotor signs; positive for motor/trophic changes (decreased hair
growth; decreased ROM); negative for sudomotor/edema signs.
MCC03
4:05 PM - 4:15 PM
Lower Extremity Tourniquet Failure in the Anasarcous Patient
Brett A. Rebal, M.D., Irina Gasanova, M.D., Girish Joshi, M.D., Anesthesiology and Pain Management,
University of Texas Southwestern Medical Center, Dallas, TX
63year-old man with history of CAD and DM2 presented in acute CHF with a productive left foot ulcer and
subcutaneous air on x-ray. Patient was obese with new onset anasarca and reported 30 lb weight gain
over the last month. Tourniquet was applied to left lower extremity and inflated prior to incision. For a
below knee guillotine amputation under local anesthesia, tourniquet was inflated to 300 mmHg prior to
incision. However, tourniquet provided minimal control of bleeding despite confirmation that it was
working properly. An estimated blood was 1 L. Patient remained hemodynamically stable and did well
postoperatively.
MCC03
4:05 PM - 4:15 PM
Difficult Airway - Beginning at the End of the Algorithm
Shea L. Stoops, D.O., Gregory Unruh, M.D., Anesthesiology, University of Kansas, Kansas City, KS
Difficult airways can be present at anytime. This case report describes a 40 year-old female who
presented with a greater than 6 month history of shortness of breath. CT scan revealed a subglottic 2mm
airway from an invading tumor mass. The patient did have a history of prolonged intubation for sepsis
with known multiple self extubations. Multiple services were consulted, however, the ultimate question
remained how to secure the airway. Careful planning and meticulous thought was required for a
successful outcome. Beyond all avenues on the difficult airway algorithm, cardiopulmonary bypass was a
consideration.
MCC03
4:05 PM - 4:15 PM
Severe Ischemic Mitral Regurgitation Complicating Minimally Invasive Aortic Valve Replacement
Brittany Straka, M.D., Daniel Verrill, M.D., Michael Essandoh, M.D., The Ohio State University Wexner
Medical Center, Columbus, OH
A 71 year-old patient with severe aortic stenosis underwent a mini-aortic valve replacement with
antegrade cardioplegia. Retrograde cardioplegia was deferred due to limited surgical exposure. Postbypass TEE revealed a normal functioning AV prosthesis. Severe MR was noted due to posterior leaflet
tethering. There was globally normal LV function. These findings suggested likely poor myear-oldcardial
protection or subclinical ischemia of the inferior wall. Myear-oldcardial oxygen delivery was improved by
perfusing the LV with higher blood pressures, and the MR severity was monitored with TEE. This
improved posterior leaflet tethering and MR severity to mild. The case was completed without mitral valve
intervention.
MCC03
4:05 PM - 4:15 PM
Failed High-Frequency Jet Ventilation in an Interventional Bronchoscopy Procedure
Ann Ng, M.D., Cliff Schmiesing, M.D., Department of Anesthesiology, Perioperative and Pain Medicine,
Stanford University, Stanford, CA
High-frequency jet ventilation has been applied to interventional bronchoscopy procedures as it provides
a way for ventilation during the procedure to be maintained. However, while no absolute contraindications
exist, there are conditions where jet ventilation can prove difficult.Case: A 65 year-old male with recurrent
lung adenoid cystic carcinoma and a known metastatic right upper lobe endobronchial lesion presented
for rigid bronchoscopy and tumor debridement. In the setting of known pulmonary hypertension and
multiple thoracic surgeries, the patient decompensated with the initiation of jet ventilation, and surgery
was ultimately performed with intermittent positive pressure ventilation.
MCC03
4:05 PM - 4:15 PM
The Elective Subclavian Mass Removal That Went Wrong
Aysha Hasan, Leila Reduque, M.D., Anesthesia, Children's National Medical Center, Washington, DC
17 year-old male with neurofibromatosis type 2 presented with bilateral extremity weakness for
thorascopic removal of subclavian artery mass. Pt was intubated with a double lumen tube, and during
surgery the artery was inadvertently cut and major resuscitation measures were taken while patient
exsanguinated. Pt underwent PEA, massive blood transfusion and survived with poor hand circulation
despite repair. This medically challenging case describes the importance of delivery of resuscitation
medication, blood and fluid administration and anesthesia help needed alongside with surgical and
operating room cooperation in order for survival.
MCC03
4:05 PM - 4:15 PM
Novel Use of Nylon Epidural Catheter for Airway Topicalization During Awake Videolaryngoscopy
in a Critically Ill Post-Partum Patient
Manan Trivedi, M.D., Jacqueline M. Galvan, M.D., Department of Anesthesiology, University of Illinois at
Chicago, Chicago, IL
Epidural catheters in obstetrics are associated with neuraxial analgesia, but may play a role in difficult
airway management. Our case describes a septic, obese, hypoxemic post-partum parturient requiring
emergent ICU reintubtation on post-partum day 2. During Bi-Pap preoxygenation, a nylon epidural
catheter was advanced into the mouth until cough reflex elicited, through which lidocaine was applied to
the posterior pharynx. Spontaneous ventilation was maintained during successful videolaryngoscopy.
Advanced Mallampati score in obstetrics and ICU airway emergencies are both risk factors for difficult
airway. We describe the novel use of nylon epidural catheter for airway topicalization during such
challenging circumstances.
MCC03
4:15 PM - 4:25 PM
Negative Pressure Pulmonary Edema After Biting Classic LMA Tube
Michael Kallile, M.D., Peter Dunbar, M.B.,Ch.B., Anesthesiology and Pain Medicine, University of
A 20 year-old healthy female presented for outpatient removal of hand hardware. She was unable to
tolerate wrist block, prompting conversion to general with a classic LMA. During emergence she bit
forcefully on the LMA tube and inspired against the occluded lumen. Propofol was administered to regain
control of the airway and place a bite block. Bloody, frothy fluid appeared in the tube. She woke again and
the LMA was removed. Post-op she was hypoxic and CXR showed bilateral pulmonary infiltrates,
confirming negative pressure pulmonary edema. She was admitted to ICU for CPAP and diuretics, and
discharged home the next day.
MCC03
4:15 PM - 4:25 PM
Intraoperative Transesophageal Echocardiographic Detection of Intracardiac Thrombus and
Pulmonary Embolism During Orthotopic Liver Transplant
Mathew J. Lopez, M.D., Amie Hoefnagel, M.D., Anesthesiology, University of Rochester School of
Medicine, Rochester, NY
A 44 year-old male presented for orthotopic liver transplantation. Prior to transplantation, the patient
required blood products for genitourinary hemorrhage and was initiated on aminocaproic acid infusion.
After anesthetic induction a transesophageal echocardiogram (TEE) probe was placed. During the
dissection phase, there was sudden hemodynamic collapse with TEE evidence of severe enlargement of
the right atrium and ventricle. A massive intracardiac thrombus (ICT) and pulmonary embolism (PE) was
identified followed by pulseless electrical activity (PEA) requiring chest compressions and epinephrine.
The transplant was aborted and organ reallocated. We will discuss the diagnosis and management of
PE/ICT in this patient population.
MCC03
4:15 PM - 4:25 PM
IR Embolization of Bleeding Right Hepatic Artery Pseudoaneurysm After Orthotopic Liver
Transplantation
Patrick J. McConville, M.D., MBA, Bret Alvis, M.D., Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN
58 year-old male who underwent orthotopic liver transplantation was brought back emergently to the
operating room for ongoing hemorrhage. Upon arrival, hemorrhagic shock was diagnosed. Massive
transfusion resuscitation with a rapid infusion system (RIS) was immediately initiated. Surgeon performed
an exploratory laparotomy but was unable to identify a bleeding source. A joint decision was made to
pack the abdomen, continue massive resuscitation with RIS, and transport the patient to interventional
radiology. There, a pseudoaneurysm of the posterior branch of the right hepatic artery was identified and
embolized. Patient then returned to operating room for abdominal closure before transport to the ICU.
MCC03
4:15 PM - 4:25 PM
Not So Trivial: A Case of Severe Tricuspid Regurgitation Following Pulmonary Artery
Catheterization
Ashley M. Yager, M.D., Zack Zimmerman, M.D., Ayman Ads, M.D., Anesthesiology, Rush University
Medical Center, Chicago, IL
A 56 year-old female with coronary artery disease, presented for revascularization. Preoperative
echocardiogram revealed an ejection fraction of 70-80% with grade 1 diastolic dysfunction and trivial
tricuspid regurgitation (TR). A pulmonary artery catheter (PAC) was threaded via an introducer sheath in
the right internal jugular until proper position was confirmed via tracing. After placement, a baseline
transesophageal echocardiogram (TEE) examination showed severe TR. Discussion took place regarding
possible valve replacement given new TEE findings. However, when the PAC was withdrawn, the TR
returned to baseline. The PAC was re-advanced into appropriate position and the procedure was
completed uneventfully.
MCC03
4:15 PM - 4:25 PM
A 23 year-old Man With a Mediastinal Mass and Sudden Cardiac Arrest
Matthew William Vanneman, M.D., Karim Fikry, M.D., Sadeq Quraishi, M.D., William Schoenfeld, M.D.,
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
A previously healthy 23-year-old man was admitted to the ICU with dyspnea, orthopnea, and a large
mediastinal mass. Diagnostic work-up revealed T-cell ALL. 30 minutes after initiating chemotherapy, he
suddenly developed respiratory distress and cardiac arrest. CPR and ACLS protocols were initiated. A
bedside transthoracic echocardiogram (TTE) demonstrated a dilated, hypokinetic right ventricle and an
underfilled left ventricle, concerning for massive pulmonary embolism. He was successfully cannulated for
extracorporeal life support (ECLS) during ongoing CPR. He underwent successful thrombolysis of his PE.
ECLS was weaned, the patient made a full neurologic recovery, and he was discharged from the hospital.
MCC03
4:15 PM - 4:25 PM
Acute Development of Cardiac Tamponade During Ventriculo-atrial Shunt Placement
Nathan Painter, M.D., UNC Anes. Dept., Chapel Hill, NC
A 56 year-old woman presented to the OR for ventriculo-atrial shunt placement. The surgery proceeded
uneventfully until skin closure, when there was a sudden decrease in blood pressure as well as drop in
end-tidal CO2. Boluses of epinephrine created no improvement, so a transesophageal echocardiogram
was performed, which showed a pericardial effusion, creating cardiac tamponade physiology, likely from a
tear in the SVC during guide-wire advancement. Cardiothoracic surgery was notified and a
pericardiocentesis was performed, with drainage of 150cc of hematoma. The patient’s vital signs
stabilized, and she was transferred to the ICU for further management.
MCC03
4:15 PM - 4:25 PM
Systemic Sclerosis & Rheumatoid Arthritis, Anesthetic Implications
Madhumani N. Rupasinghe, M.D.,F.R.C.A, Patricia Heath, C.R.N.A., Sara Guzman-Reyes, M.D., Peter
Doyle, M.D., Anesthesiology, UTHSC, Houston, TX
Systemic sclerosis is a complex disease that involves multiple organ systems. We present a 48 year-old
female with rheumatoid arthritis and progressive systemic sclerosis with a difficult airway and multi-organ
problems and discuss the anesthetic considerations for a hysterectomy.
MCC03
4:15 PM - 4:25 PM
Hydrocephalus in a Neonate Status-post Fetal Repair of Myelomeningocele
Titilopemi A.O. Aina, M.D., Anesthesiology, Texas Children's Hospital, Houston, TX
6 day-old female, with hydrocephalus, presenting for Endoscopic Third Ventriculostomy. PMH is
significant for myelomeningocele status-post repair in utero at 23 weeks of gestation. She was
subsequently delivered via a scheduled cesarean section, at 37 weeks. After delivery, she was noted to
have macrocephaly. A head ultrasound confirmed severe hydrocephalus. She also had an MRI of the
brain that revealed findings consistent with severe enlargement of lateral and third ventricles. She
underwent an uneventful surgical repair under general endotracheal anesthesia. She was extubated upon
completion of the surgery and transferred to the recovery room.
MCC03
4:15 PM - 4:25 PM
Pain Medicine (PN)
Talc Granulomatosis and Right Heart Failure Secondary to Crushed Oxycodone Injected via
Hickman Catheter
Joshua B. Knight, M.D., Trent D. Emerick, M.D., Haibin Wang, M.D.,Ph.D., Anesthesiology, University of
Pittsburgh Medical Center, Pittsburgh, PA
38 year-old femalewith Crohn’s disease, chronic abdominal pain, short gut syndrome and no priorcardiac
history presented to ED with dyspnea. For several months prior she hadescalating oxycodone usage
secondary to overmedicating despite weekly painclinic visits. She also had a recent admission for a
Hickman catheterinfection. Chest CT showed scattered nodular opacities and no embolism.
Afteradmission, transthoracic echocardiogram revealed RV dysfunction and estimated PApressure of 82.
Later she admitted to crushing oxycodone and injecting via theHickman catheter. Lung biopsy confirmed
classic talc granulomas consistent withintravenously injected crushed oxycodone.
MCC03
4:15 PM - 4:25 PM
Thoracic Epidural Catheter for Postoperative Pain Control Following an Ineffective TAP Block
Using EXPAREL
Charles C. Stehman, M.D., David Espinoza, D.O., Gabriel Rodriguez, M.D., Brian Terrien, M.D., Nicholas
Connolly, M.D., Anesthesiology and Pain Medicine, Surface Warfare Medical Institute, Naval Medical
Center San Diego, San Diego, CA
There is little safety data regarding the use of liposomal bupivacaine (EXPAREL) administered via a
transversus abdominis plane block in combination with bupivacaine delivered via the epidural route. We
hypothesized that the administration of a bupivacaine thoracic epidural following EXPAREL would result
in plasma concentrations far below levels of cardiac and neurotoxicity. In our case, we documented the
plasma bupivacaine concentrations following administration of EXPAREL via TAP blocks and after
administration of a continuous bupivacaine thoracic epidural. We propose continued study of the safe use
of EXPAREL and other formulations of bupivacaine as needed to provide adequate analgesia.
MCC03
4:15 PM - 4:25 PM
Use of Transesophageal Echocardiography for Early Detection of Intracardiac Clot Formation
During Liver Transplantation
Caroline Protin, M.D., Dmitri Bezinover, M.D.,Ph.D., Anesthesiology, Penn State Hershey Medical Center,
Hershey, PA
A 42 year-old female with a history of extrahepatic cholangiocarcinoma, who developed high-grade
recurrence, presented for live-donor liver transplantation. She received 5000 units of subcutaneous
heparin as routine deep vein thrombosis prophylaxis prior to surgery. Six-hours after anesthesia
induction, transesophageal echocardiography (TEE) indicated a clot in the right atrium (Image 1).
Considering the patient’s hemodynamic stability, intravenous heparin was administered to prevent an
increase in clot size. After graft reperfusion, TEE demonstrated a decrease in the size of the initial clot,
and stable right ventricle function. TEE is a useful tool for early detection of clot formation.
MCC03
4:15 PM - 4:25 PM
Intraoperative Diagnosis of a Stuck Biological Valve Leaflet by 3D TEE After Mitral Valve
Replacement
Natsuki Anada, M.D., Yasufumi Nakajima, M.D.,Ph.D., Akiko Ando, M.D., Koji Akiyama, M.D., Shusuke
Takeshita, M.D., Teiji Sawa, M.D.,Ph.D., Koh Shingu, M.D.,Ph.D., Anesthesiology and Intensive Care,
Kansai Medical University Hirakata Hosp, Osaka, Japan, Anesthesiology and Intensive Care, Kyoto
Prefectural University of Medicine, Kyoto, Japan
Here, we present the case of a 75-year-man with mitral regurgitation and moderate aortic stenosis
combined with mild aortic regurgitation, who was scheduled for double valve replacement with biological
prostheses. Intraoperative transesophageal echocardiography (TEE) after cardiopulmonary bypass
revealed transvalvular regurgitation in the bioprosthetic mitral valve. Further, we clearly identified one
stuck leaflet by 3D TEE. In the second run of cardiopulmonary bypass, surgeons identified a suture loop
jamming beneath the bioprosthetic valve. In this case study, we discuss the intraoperative differential
diagnosis of bioprosthetic valve leakage by TEE.
MCC03
4:15 PM - 4:25 PM
Anosmia and Hypogeusia After General Anesthesia
Hannah Chung, M.D., Richard Banchs, M.D., Anesthesiology, University of Illinois at Chicago, Chicago, IL
A 24 year-old female underwent resection of a left maxillary cystic lesion under general anesthesia. She
received midazolam as an anxiolytic, and propofol, lidocaine, and rocuronium for induction and tracheal
intubation. Sevoflurane was given for maintenance, and acetaminophen, fentanyl, and hydromorphone
were administered for intraoperative analgesia. She also received dexamethasone and ondansetron for
PONV prophylaxis. The patient was discharged from the PACU without complaints. Eight days after
surgery, the patient presented with complaints of anosmia and hypogeusia. A sinus CT and brain MRI did
not show any abnormality. She was followed-up for 9 months without improvement of her symptoms.
MCC03
4:15 PM - 4:25 PM
Managing Emergent Airway After Ingestion of Mutiple Foreign Bodies
Matthew M. Johnson, M.D., Christina Curcio, M.D., Anesthesiology, Rutgers Robert Wood Johnson
Medical School, New Brunswick, NJ, Anesthesiology, Rutgers Robert wood Johnson medical school,
New Brunswick, NJ
17 year-old male with PICA, autism, and bipolar disorders presents after ingestion of a pen several hours
prior to admission. After several hours pt developed dysphasia, and neck pain with difficulty speaking. CT
Head/Neck/chest demonstrated cylindrical foreign body with metal tip in left prevertebral area (C3-T3) not
within trachea or esophagus. Combative pt was induced in CT suite with propofol (200mg) and
succinylcholine (100mg) and intubated under direct laryngoscopy with single lumen ETT. Standard ASA
monitors were applied and pt was transported to OR. ENT performed rigid laryngoscopy in OR and
removed pen from false passage in retropharyngeal area.
MCC03
4:15 PM - 4:25 PM
A Case of Myoclonic Reaction After Ondansetron
Aram Shahinyan, M.D., Matthiew Kauffman, Student, Xianren Wu, M.D., Anesthesiology, Geisinger
Medical Center, Danville, PA
Purpose: To present a case report of a 23 year-old male with history of SLE who presented with multiple
brief myear-oldclonic episodes after emergence from general anesthesia for closed reduction of right
fourth and fifth metacarpal fractures. He received 4 mg of Ondansetron for PONV prophylaxis 20 minutes
before the myear-oldclonic episode.
MCC03
4:25 PM - 4:35 PM
Use of Tse/Alloteh Nasal CPAP in an Overweight Patient During an MRI
Oleksiy Lelyanov, D.O., James Tse, M.D.,Ph.D., Anesthesiology, Rutgers Robert Wood Johnson Medical
This case demonstrates use of nasal CPAP in a 59 year-old female with history of advanced pancreatic
cancer undergoing an MRI of abdomen requiring anesthesia due to anxiety. After initiation of anesthetic
with a propofol infusion with only a Salter cannula, patients O2 saturation consistently declined to below
92% secondary to airway obstruction. Application of nasal CPAP at 6-8mm H2O effectively brought O2
saturation to 100% on 5L O2, and provided consistent EtCO2 tracing in a spontaneously ventilating
patient.
MCC03
4:25 PM - 4:35 PM
Tongue Edema Resulting From the Mechanical Compression by the Endotracheal Tube Positioned
Diagonally Across the Tongue
Won K. Chee, M.D., MBA, Andrew D. Nam, M.D., Department of Anesthesiology, The Montefiore Medical
Center & Albert Einstein College of Medicine, Bronx, NY
A 53 year-old female without any PMH was scheduled for laparoscopic vaginal hysterectomy. After
induction of general anesthesia direct layngoscopy with a Macintosh 3 blade revealed Cormack-Lehane
View IV; a McGrath videoscope was used for successful intubation.The procedure required steep
Trendelenburg position for 4 hours. Airway inspection before extubation showed the edematous and
erythematous tongue tightly engaged between the teeth and extruding. [Figure 1] A closer examination
revealed the endotracheal tube positioned across the tongue. The tube was repositioned off the tongue;
the patient remained intubated with her head elevated for 3 hours before extubation. [Figure 2]
MCC03
4:25 PM - 4:35 PM
An Innovative Technique for Securing a Difficult Airway
Cindy K. Hernandez, M.D., Tracey Straker, M.D.,M.P.H., Montefiore Medical Center, Bronx, NY
A 79 year-old man with a significant morbidity is diagnosed with squamous cell carcinoma of the
hypopharynx. He presented to the emergency room for dysphagia and throat pain. Patient was taken to
the OR for hypopharynx mass biopsy and was found to be a difficult intubation requiring assistance from
the ENT surgeons. A unique intubation technique utilizing a bougie, microlaryngeal tube and suspension
laryngoscopy sucessfully intubated the patient.
MCC03
4:25 PM - 4:35 PM
Serotonin Syndrome: An Unusual Complication
Sonampreet Sehdev, Jayakar Guruswamy, M.D., Prabhkiran Nakai, M.D., Anesthesiology, Henry Ford
Health System, Detroit, MI
51 year-old female with Non-ischemic Cardiomyear-oldpathy with EF of 15% for LVAD placement with
history of Depression on anti-depressants, severely vasoplegic after weaning off 166 minutes of
bypass.After maxing out on Vasopressors started on Methylene blue infusion for vasoactive support
following which patient developed ocular clonus, lower extremity clonus, hyper-reflexia and dilated and
fixed pupils with absent brainstem reflexes turned out to be Serotonin Syndrome due to drug interactions
between Celexa and Methylene blue.The mechanism of this interaction is twofold: Firstly, the medications
are synergistic in their pro-serotonergic effects and secondly, Methylene blue reversibly inhibits
Monoamine Oxidase
MCC03
4:25 PM - 4:35 PM
Anesthetic Management During Emergency Surgical Ligation for Carotid Blowout Syndrome
Henri J. de Graaff, M.D., M.S., Casper G.A. Klein Nulent, M.D., Aniel Sewnaik, M.D.,Ph.D., Rein
Ketelaars, M.D., Iscander M. Maissan, M.D., Department of Anesthesiology, Department of
Otorhinolaryngology Head and Neck surgery, Erasmus MC, Rotterdam, Netherlands, Department of
Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
A 44 year-old male was transported to our emergency department with pharyngeal hemorrhage, six
weeks after total laryngectomy, extended neck dissection and radiotherapy. Briefly after arrival, there was
massive arterial bleeding relieving from the mouth and a dehiscence of the neck. Considering the
hemodynamic instability and the inability to tamponade the bleeding, the decision was made to explore
the neck at the emergency department. The head and neck surgeon successfully ligated the common
carotid artery during this procedure. We describe the induction of general anesthesia and the
tromboelastometry (ROTEM) guided damage control resuscitation after massive hemorrhage.
MCC03
4:25 PM - 4:35 PM
Cardiac Arrest With Adenosine for Cerebral Aneurysm Clipping
Christopher G. Franzen, M.D., Semhar Ghebremichael, M.D., Anesthesiology, University of Texas Health
62- year-old 62kg female with PMHx of hypertension presented with sudden onset severe headache, CT
scan consistent with SAH. Patient had no neurological deficits. Angiogram revealed a large complex
fusiform aneurysm (12x14x8mm) at the A1-A2 junction of the right ACA adhered to the skull base. The
surgeon requested adenosine to facilitate clipping of the aneurysm. Under burst suppression with
methohexital, we gave 6mg adenosine, causing approximately 10s asytole. Two subsequent doses of 12
mg resulted in 20-30s asystole, ultimately returning to baseline normal sinus rhythm. Clipping of the
aneurysm was successful and patient was extubated with no neurological deficits.
MCC03
4:25 PM - 4:35 PM
The Renal Failure Parturient With Ventricular Tachycardia and HELLP Syndrome
Lawrence D. Garcia-Reyes, M.D., Ben Leahy, Kelly Hines, M.D., Laura Clark, M.D., Anesthesiology,
University of Louisville, Louisville, KY
The 28 year-old G1P0 was transferred to ULH with 2 days of chest pain, weakness, easy bruising and
low urinary output. During transfer, she experienced ventricular tachycardia and was electrically
cardioverted. Past medical history was positive for recent UTI, Membranous Glomerulonephritis,
Hypothyroidism and Hypertension. Lab work revealed acute renal failure, severe hyperkalemia, and
evidence of HELLP syndrome. Betamethasone was administered at outlying hospital based on
ultrasound. Emergent C-section with General Anesthesia was performed and a small, IUGR neonate was
successfully delivered. Post-operative pain was managed with an Exparel TAP block. Patient was then
observed in the ICU.
MCC03
4:25 PM - 4:35 PM
General Anesthesia for a Child With Complete Tracheal Rings and Hypoplastic Left Lung
Ellise C. Cappuccio, M.D., Ngoc Famulare-Nguyen, M.D., Anesthesiology, Montefiore Medical
Center/Albert Einstein College of Medicine, Bronx, NY
11 year-old male with complete tracheal rings, hypoplastic left lung, hypoplastic left pulmonary artery,
PFO with left to right flow, horseshoe kidney, and reactive airway disease for repair of hidden penis and
flexible bronchoscopy. Chest CT and ECHO were done preoperatively. IV was placed after inhalational
induction with sevoflurane. Patient was maintained spontaneously breathing with an LMA on sevoflurane
3%, oxygen 100%, dexmedetomidine 0.5 mcg/kg/h and small boluses of fentanyl titrated to respiratory
rate. After the urologic procedure, flexible bronchoscopy was performed through the LMA. The LMA was
removed at the conclusion of the bronchoscopy. The recovery phase was uneventful.
MCC03
4:25 PM - 4:35 PM
Pain Medicine (PN)
Thoracic Outlet Syndrome Successfully Treated With Normal Saline Trigger Point Injection
Badie S. Mansour, M.D., Gretchen M. Wienecke, M.D., John W. Blackburn, M.D., Nathan J. Smith, M.D.,
Anesthesiology & Pain Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK
A 48 year-old male athletic director experiencing increasing left pectoralis and triceps weakness initially
treated with infraspinatus and pectoralis major saline trigger point injection showed some improvement of
the triceps only. Five week follow-up found magnetic resonance imaging, electromyear-oldgram, and
nerve conduction studies consistent with subacute cervical radiculopathy. Middle scalene trigger point
injection, confirmed via ultrasound, elicited immediate, significant improvement of the pectoralis. Four
weeks later, there was considerable improvement of atrophy and strength. Four months of continued
physical therapy resulted in pectoralis and triceps strength and function returning to baseline levels with
expected exercise capability.
MCC03
4:25 PM - 4:35 PM
Local Anesthetic Resistance in a Patient With Emery-Dreifuss Muscular Dystrophy
Alexander J. Kim, M.D., Samrawit Goshu, M.D., Barbara Nzegwu, M.D., Lori Ann Oliver, M.D.,
Anesthesiology, Yale School of Medicine, New Haven, CT
We present a 31 year-old male with medical history significant for Emery-Dreifuss muscular dystrophy (Xlinked condition primarily affecting skeletal and cardiac muscle), undergoing bilateral achilles lengthening
for equinoplanovalgus feet. Plan for intraoperative and postoperative pain control included bilateral
popliteal approach sciatic nerve blocks with catheter placement and bilateral single-shot femoral nerve
blocks. Despite ultrasound guidance of appropriate local anesthetic spread, he had only slight change in
temperature and touch sensation. Local anesthetic resistance has been described in connective tissue
disorders, but not muscular dystrophies. During postoperative management of nerve catheters, he
exhibited symptoms concerning for local anesthetic systemic toxicity (LAST).
MCC03
4:25 PM - 4:35 PM
Advocating for Patient Safety in the GI Endoscopy Suite
Patrick John Matthews, Arthur Mielke, M.D., Anesthesiology, San Antonio Military Medical Center, San
Antonio, TX
82M ASA-4 was admitted for AMS s/p fall with workup revealing profound anemia. PMH included GERD,
HTN, severe OSA, COPD, 50PPD tobacco history and NSCLC. Hospital course was complicated by
respiratory failure, DVT, PE, NSTEMI, and shock. Gastroenterologists scheduled EGD/EUS in endosuite
for possible UGI bleed. With Anesthesiologists consulted, discussion turned to the undue risk of remote
site anesthesia. Case was moved to OR where anesthetic included stable induction; cardiopulmonary
monitoring via ECG, arterial line, Vigileo; and careful precise resuscitation. Despite baseline preoperative
room air oxygen saturation of 85%, perioperative course was uneventful with extubation and return to
inpatient wards.
MCC03
4:25 PM - 4:35 PM
Mechanical Electrical Dissociation in the Setting of a Type B Aortic Dissection Repair
Erik E. Davila-Moriel, M.D., Brian Mecklenburg, M.D., Anesthesiology, Naval Medical Center San Diego,
San Diego, CA, Naval Medical Center San Diego, San Deigo, CA
47 year-old AA female with PMHx of poorly controlledhypertension admitted with type B aortic dissection
extending from left carotidto renal arteries requiring surgical intervention. GETA induced; A-line, C-line,
PAC and TEEplaced. After adequate surgical exposure, patient placed on partial CPB.
Duringcannulation, significant HD instability was treated with 2U of PRBC and 1UFFP. Initially noted on
EKG, and confirmed on TEE, that the patient developed mechanicalelectrical dissociation. 2 P waves
produced 1 QRS. Patient treated with 1 gm ofCaCl with return of NSR. After prolonged surgery, patient
had an excellent clinicaloutcome.
MCC03
4:25 PM - 4:35 PM
Anesthetic Considerations in a Patient With Geleophysic Dysplasia, Pulmonary Hypertension,
Restrictive Lung Disease and Severe Subglottic Stenosis
Erin E. Holl, M.D., Devon O. Aganga, M.D., Anesthesiology, Mayo Clinic, Rochester, MN
A 22 year-old woman with geleophysic dysplasia presented for rigid bronchoscopy to evaluate known
upper airway obstruction and severe subglottic stenosis. Four months prior, during a similar procedure,
the patient rapidly progressed to hypoxemic PEA arrest during induction of general anesthesia followed
by the inability to intubate or ventilate. The patient’s known restrictive lung disease and pulmonary
hypertension contributed to rapidity of hypoxemia, resulting in cardiorespiratory collapse. With a
tracheostomy now in place, optimized medical management, and a pulmonary hypertensive crisis action
plan, we were able to safely induce and maintain general anesthesia in this complicated patient.
MCC03
4:25 PM - 4:35 PM
A Case of Malignant Hyperthermia and the Need for Surgery One Year Later
Helen Harvey, M.D., Robert Greenberg, M.D., Anesthesiology and Critical Care Medicine, Johns Hopkins,
Baltimore, MD
This case describes an eleven year-old girl with idiopathic scoliosis requiring a posterior spinal fusion.
One year prior, during induction for this procedure she had a cardiac arrest requiring admission to the
PICU with suspicion of malignant hyperthermia. After full recovery and a presumptive diagnosis of
malignant hyperthermia she returned to OR one year later for a posterior spinal fusion. Anesthetic
management included avoidance of malignant hyperthermia triggers and total intravenous anesthesia.
She tolerated this surgery without complications.
MCC03
4:25 PM - 4:35 PM
Difficult Airway Management in Substernal Goiters
Vincent S. Lin, M.D., Govind Rajan, M.D., Anesthesiology, UC Irvine, Orange, CA
The patient is an 80 year-old female with a 20 year history of a substernal goiter presenting with
shortness of breath and productive cough going for mediastinotomy and goiter removal. Her past medical
history significant for CAD status post CABG/PCI, DM2, and asthma. Physical exam significant for MP2,
<3cm mouth opening, and stridor, but saturating 100% on 5L simple face mask. She is able to speak in
almost complete sentences but with a slightly altered mental status. Imaging for severe tracheal stenosis
(narrowest point approximately 5.0mm in diameter) and right deviation on CT chest.
MCC03
4:35 PM - 4:45 PM
Central Anticholinergic Syndrome With Atypical Presentation and Resolution
Roy K. Kiberenge, Allison Wagner, M.D., Anesthesiology, Univ. of Iowa, Iowa City, IA
A 79 year-old male undergoing a pancreaticoduodenectomy developed intraoperative bradycardia and
hypotension due to a mobitz type 2 conduction block. This was treated with atropine. Upon case
completion, the patient was not rousable even to painful stimuli. He was noted to have bilateral mydriasis.
He received physostigmine and was able to be extubated. More physostigmine resulted in a slight
improvement in his mental status although this was waxing and waning between hyperactivity with myearoldclonic jerks and hypoactive delirium. The following morning, he woke up and was at his baseline
neurologically.
MCC03
4:35 PM - 4:45 PM
Management of a Case of Plunging Ranula With Modified Molar Approach of Intubation
35 year-old male was posted for excision of plunging ranula which is a difficult case for securing airway
due to limited intraoral space. After induction with general anesthesia , Boyle -Davis mouth gag was
inserted from the right angle of mouth to maintain patency of oropharnyx and McCoy Blade with a stubby
handle was introduced from left angle of mouth into the groove between tongue and tonsil and
endotracheal tube was introduced under vision when the glottis opening was visualized and patients
airway was secured and case was managed uneventfully.Patient was extubated and discharged in 24
hours.
MCC03
4:35 PM - 4:45 PM
Arterial Line Tracing in Severe Aortic Regurgitation Pre and Post Relief of High Intra-Abdominal
Pressure
Anne H. Kancel, D.O., Scott Switzer, D.O., Anesthesiology, Baystate Medical Center, Springfield, MA
58 year-old female with a PMHx of severe aortic regurgitation secondary to radiation valvulitis,
cardiomyear-oldpathy with EF 35%, pAfib, breast and cervical cancer s/p radiation and chemotherapy
admitted with urosepsis and gross hematuria in the setting of known chronic ureteral obstruction. Patient
presented to the OR for urgent cystoscopy, with irrigation the patient was found to have intraperitoneal
bladder rupture resulting in increasing abdominal distention. Arterial line placed at this time revealed
classic tracing of a patient with severe aortic regurgitation with significant change in waveform noted
when abdominal pressure and distention was relieved by laparotomy.
MCC03
4:35 PM - 4:45 PM
Anesthetic Implications of Dysphagia Lusoria
Aric Steinmann, M.D., Anesthestiology, San Antonio Uniformed Services Health Education Consortium,
San Antonio, TX
48year-old ASA 2 female underwent a staged surgical repair for dysphagia lusoria. She initially presented
to our emergency department with shortness of breath and chest pain for which she underwent a CT
angiogram to rule out as suspected pulmonary embolism. However, this study revealed an aberrant right
subclavian artery. The vascular surgery consultants proposed a two-phase surgical correction to the
patient. Phase one: open right carotid to subclavian bypass. Phase two: placement of thoracic
endovascular aortic repair (TEVAR) to cover congenital right subclavian artery. These surgeries have
interesting and important anesthetic implications regarding anesthetic maintenance, temperature
regulation, and vascular access.
MCC03
4:35 PM - 4:45 PM
Complex Presentation of Prolonged Serotonin Syndrome in a Vasoplegic Patient Treated With
Cyproheptadine
Olga S. Leavitt, M.D., Abbas Al-Qamari, M.D., Department of Anesthesiology, Northwestern University
Feinberg School of Medicine, Chicago, IL
44 year-old female with depression on sertraline developed severe, prolonged serotonin syndrome after
receiving methylene blue for vasoplegia post cardiac surgery. Patient developed following neurologic
abnormalities: unresponsiveness, severe generalized tremors, inducible myear-oldclonus, dilated pupils,
ocular myear-oldclonus and fevers. Hemodynamic and common postoperative neurologic disturbances
complicated the presentation. Diagnosis was made after imaging and EEG according to Hunter Rules .
No reports of protracted serotonin syndrome or treatment with serotonin antagonist cyproheptadine exist
in cardiac surgery patients. Due to severity of presentation and favorable side effect profile, we elected to
treat with cyproheptadine. Symptoms gradually resolved with complete recovery on POD4.
MCC03
4:35 PM - 4:45 PM
Anesthetic Management of a Patient With Multiple Prior Episodes of PACU Delirium
Matthew K. Whalin, M.D.,Ph.D., Matthias Kreuzer, Ph.D., September Hesse, Ph.D., Margaret A. Riso,
M.D., Paul S. Garcia, M.D.,Ph.D., Emory University / Grady Memorial Hospital, Atlanta, GA, Emory
University / Atlanta VAMC, Decatur, GA, University of Californina, Irvine, CA
A 36 year-old woman required 22 surgeries over six months following a pedestrian versus automobile
accident. She had a history of depression with psychotic features and cocaine use. She was enrolled in a
prospective clinical trial of emergence in patients who require multiple surgeries. Early in her course the
patient had several episodes of hyperactive delirium in PACU. These episodes were transient and often
associated with complaints of an urgent need to void. A change to total intravenous anesthesia greatly
reduced these episodes of delirium. Quantitative analysis of frontal surface EEG provides some insight
into her postoperative course.
MCC03
4:35 PM - 4:45 PM
Elective Repeat C-Section in a Parturient With a Difficult Airway and a Suprasellar Mass Resulting
in Elevated ICP
Adam J. Canter, M.D., Jeffery Bernstein, M.D., Anesthesiology, Montefiore Medical Center / Albert
Einstein College of Medicine, Bronx, NY
41y G4P4004 w/ hx of altered mental status, obesity, and a newly-diagnosed suprasellar mass invading
the 3rd ventricle and compressing the optic chiasm presented for repeat c-section. She had optic
neuropathy w/ bitemporal visual defects, headaches, and DI. Neurosurgery wanted to resect the mass
postpartum. The patient experienced a MVA years prior and had hardware placed in her jaw, resulting in
poor mouth-opening. A CSE was placed using 27g Gertie Marx at the L4-L5 interspace and the C-section
was performed uneventfully. The APGARs were 9/9 and the mother did not experience any symptoms
consistent w/ worsening of her elevated ICP.
MCC03
4:35 PM - 4:45 PM
Pain Management of a 3 year-old boy With Primary Erythromelalgia
Giorgio C. Veneziano, M.D., David P. Martin, M.D., Ahsan Syed, M.D., Tarun Bhalla, M.D., Joseph D.
Tobias, M.D., Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital,
Columbus, OH
Erythromelalgia is a very rare neurovascular disorder which results in episodic, debilitating pain
symmetrically in the feet and/or hands. Burning pain and skin erythema in the involved areas are typical.
Literature describing the medical management of erythromelalgia consists of a limited number of case
reports describing diverse treatments. We describe the management of a 3 year-old boy admitted with
severe bilateral foot pain due to primary erythromelalgia. Based on available evidence, therapy included
the use of cooling pads, clonidine, pregabalin, aspirin, and nitroprusside infusion. Satisfactory analgesia
was ultimately achieved with lidocaine and low-dose ketamine infusions that were transitioned to
mexilitine.
MCC03
4:35 PM - 4:45 PM
Pain Medicine (PN)
Poppy Seed Tea as a Form of Opioid Dependence
Amy C.S. Pearson, M.D., Jason S. Eldrige, M.D., W. Michael Hooten, M.D., Anesthesiology and
Psychiatry, Mayo Clinic, Rochester, MN
We present the case of a 24 year-old man with a history of polysubstance abuse and newly-diagnosed
malignancy who reported consuming “tea” prepared from 1-2 pounds of poppy seeds daily for back and
abdominal pain. Without the tea, he had significant withdrawal symptoms. Urine morphine, codeine, and
hydromorphone concentrations were 37,600ng/ml, 2580ng/ml, and 1430ng/ml, respectively. Poppy seeds
are known to cause elevated morphine and codeine levels on urine toxicology screening. Herein, we
discuss potential forms of poppy seed use and challenges in differentiating poppy seed from other opioids
and opiates based on the results of a urine toxicology screen.
MCC03
4:35 PM - 4:45 PM
Spinal Anesthesia Utilizing Intrathecal Catheter for Surgical Repair of Femur Fracture on a 90
Years Old Patient With Severe Pulmonary Hypertension
Mi Wang, M.D., Justo Job Gonzalez, M.D., Anesthesiology, Cleveland Clinic, Cleveland, OH
We present a 90 year-old female who sustained a left intertrochanteric femur fracture presented for
intramedullary nailing. Significant comorbidities included severe pulmonary hypertension with pulmonary
systolic pressure of 81 mmHg, CAD with multiple stents, atrial fibrillation and myelodysplastic anemia. An
intrathecal catheter was placed and 2.5 mg isobaric bupivacaine with 10 mcg fentanyl were injected
through the catheter which was sufficient for anesthesia. An arterial line was also placed and the patient
maintained hemodynamic stability with minimal fluid and vasopressor administration. The patient was
maintained on supplemental oxygen and did not require any further intrathecal dosing.
MCC03
4:35 PM - 4:45 PM
Polysubstance Drug Addict With Mediastinal Mass Causing Major Vessel Compression and
Tracheal Deviation in Off-site MRI Suite
David R. Sisco, M.D., Jamey Eklund, M.D., Anesthesiology, University of Illinois Chicago, Chicago, IL
A 63 year-old alcoholic heroin-addict with metastatic cancer presented for 9-T MRI to determine
operability of a hemorrhagic left cerebellar mass. 12 hours earlier, an EVD had been placed to relieve
hydrocephalus. An attempt at awake MRI had failed due to claustrophobia and intractable back pain.
Patient co-morbidities included severe COPD and the presence of a 10cm right suprahilar mass causing
leftward tracheal deviation, compression of the SVC and left distal brachiocephalic vein. Limited
anesthesia personnel in off-site MRI posed additional challenges. MRI was successful after fentanyl
titration to ameliorate back pain and subsequent sedation with dexmedetomidine and versed.
MCC03
4:35 PM - 4:45 PM
Cardiac Tamponade Physiology With An Open Chest
Michael P. Puglia, M.D.,Ph.D., Alexander S. Kuo, M.D., Vipin Mehta, M.D., Anesthesia Critical Care and
Pain Medicine, Massachusetts General Hospital, Boston, MA
An 81 year-old woman with PMH of Marfan's syndrome s/p aortic graft for aortic root aneurysm,
hypertension, severe mitral regurgitation, severe tricuspid regurgitation, and atrial fibrillation presented for
mitral and tricuspid valve annuloplasty, and endocardial cryear-oldmaze due to decreasing functional
status. After uneventful surgical course, while weaning from cardiopulmonary bypass there was a sudden
decrease in MAP, increase of CVP, and increase in pulmonary artery pressure. Echo imaging revealed
an intrapericaridal fluid collection not seen on the surgical field. We discuss the differential diagnosis and
intraoperative management of cardiac tamponade physiology during liberation from cardiac bypass.
MCC03
4:35 PM - 4:45 PM
Laparoscopic Cholecystectomy in a Patient With a Left Ventricular Assist Device (LVAD)
Richard A. Sedlak, M.D., Alexander Greene, M.D., Michael A. Pilla, M.D., Vanderbilt University Medical
Center, Nashville, TN
A 61 year-old male with a history of ischemic cardiomyear-oldpathy, s/p VAD placement 6months prior as
a bridge to transplantation, presented with cholecytitis forlaparoscopic cholecystectomy. After planning
with the surgical team, patientunderwent placement of a preinduction radial arterial line and GETA was
induced.Patient was maintained with isoflurane, and decreases in MAP and pulse index weretreated with
fluids and pressors. Pneumoperitoneum and reverse Trendelenbergwere possible, but performed
gradually. The case duration was 4 hours.Only 2 directly relevant case reports were found 12.Nonetheless, discussion andplanning with surgical colleagues produced an excellent outcome.
MCC03
4:35 PM - 4:45 PM
Anterior Mediastinal Mass and Thrombosis: Relevant Challenges in Approaching the Airway and
Vascular Access
Abisola Ayodeji, Emil Malamud, Kalpana Tyagaraj, Maimonides Medical Center, Brooklyn, NY
13 year-old male presented with 2 days of acute onset increased coughing, difficulty breathing in the
supine position. A CT scan demonstrated a 2.5cm x 9.5cm x 16.5cm anterior mediastinal mass with
complete right sided lung compression. Thrombosis of axillary, basillic, and subclavian veins noted.
Standard ASA monitors were placed on the patient and aleft radial arterial line was placed. A right
femoral vein Cordis line was placed while patient awake. Extensive topicalization of the airway occurred
Titration of sedation with Midazolam 2mg and Fentanyl 150mcg with an awake fiberoptic intubation.
MCC03
4:35 PM - 4:45 PM
Anesthetic Management of a Patient With a Large Renal Mass
Robert M. Rowlett, M.D., Kofi B. Vandyck, M.D., Praveen Maheshwari, M.D., Anesthesia, University of
Oklahoma, Oklahoma City, OK
Patient is a 48 year-old male with a history of metastatic renal cell carcinoma who presents for a palliative
radical nephrectomy. There was a large 22 cm mass which was also invading the inferior vena cava. TEE
probe was placed early in the case for monitoring. During the final stages of resection, the patient
suffered a pulmonary embolus and coded. ACLS was performed for thirty minutes without return of
spontaneous circulation. We present the case and initiate a discussion for alternative preparation,
including but not limited to planning for cardiopulmonary bypass.
MCC03
4:45 PM - 4:55 PM
In Resource Scarce India: Successful Laparoscopic Cholecystectomy With Laryngeal Mask
Airway ProSeal for an Unexpected Difficult Airway
Zachary Turnbull, M.D., Anesthesiology, New York Presbyterian - Weill Cornell Medical College, New
York, NY
A 40 year-old female was scheduled for a laparoscopic cholecystectomy. Patient had no known past
medical or surgical history. Her airway exam: Mallampati II, 2-finger breaths thyromental distance, wide
mouth opening and full neck flexion/extension. After induction with propofol, butorphanol and rocuronium
patient was masked ventilated without difficulty. Intubation with a Macintosh 3 blade provided a class IV
view. After switching to a Macintosh 4 blade and repositioning the view did not improve. Without a
fiberoptic scope available in the hospital secondary to costs and resources an LMA ProSeal was placed
and ventilation was achieved. Case proceeded uneventfully.
MCC03
4:45 PM - 4:55 PM
Airway Block for Blunting Intubation Response in Known Case of Dilated Cardiomyopathy for
Emergency Surgery
Harick Shah, M.B.,B.S., Anesthesiology, Seth G S Medical College, Mumbai, India
28year-old female, known case of dilated cardiomyear-oldpathy with ejection fraction of 20 % in
biventricular cardiac failure was posted for exploration laparotomy for intestinal obstruction with deranged
coagulation profile. In order to attenuate intubation response, patient received airway blocks with 0.125%
bupivacaine and was managed under general anesthesia with intraoperative ketamine and propofol
infusions with inhalational agent. Patient was monitored intraoperatively with invasive arterial blood
pressure monitoring, central venous pressure, electrocardiograph, pulse oximetry and capnography.
Patient was shifted to ICCU for observation and then discharged on day 7 postoperatively.
MCC03
4:45 PM - 4:55 PM
A Multidisciplinary Approach to Perioperative Exposure Keratopathy
Amanda Xi, M.D., Lori A. Stec, M.D., Roy G. Soto, M.D., Oakland University William Beaumont School of
Medicine, Department of Ophthalmology, Department of Anesthesiology, William Beaumont Hospital,
Royal Oak, MI
7 hours following uneventful laminectomy, a 66year-old female complained of left eye pain. She
described having blurry vision with “sand in my eye” and on examination, had conjunctival injection. Due
to multiple similar complaints from other patients, our anesthesiology and ophthalmology departments
developed an algorithm for postoperative eye pain. This patient’s symptoms and lack of predisposing risk
factors for significant ocular morbidity led to treatment with Bacitracin ointment. This case presentation
will discuss appropriate screening, prophylaxis, and treatment for exposure keratopathy with a focus on
effective resource utilization and multidisciplinary care planning.
MCC03
4:45 PM - 4:55 PM
Paraganglioma: A Rare Cardiac Tumor
Sophie Provenchere, M.D., Lydia Deschamps, M.D., Jean-Pierre Laissy, M.D.,Ph.D., Department of
Anesthesiology and Intensive Care, Department of Anatomo-pathology, Department of Radiology,
Hopital Bichat Claude-Bernard, Paris, France
A man withhypertension presented a left atrial mass confirmed by transoesophagealechography. After the
implantation of the CPBdevice, a mass taking a large part of the posterior wall of the left atrium
wasobserved.After the induction of anesthesia,the patient experienced a high blood pressure level but
after weaning for CPB,he required high doses of norepinephrine. Macroscopic examination revealed
asolid tumor which was a paraganglioma.The cardiac primitive paraganglioma israre. Most of them are
functionallyactive and present with systemic symptoms of cathecholamine excess .
MCC03
4:45 PM - 4:55 PM
Anesthetic Management of a 26 year-old Burn Victim on Veno-Venous ECMO
Bryant S. Edwards, D.O., Peter Bell, M.D., Christopher V. Maani, M.D., Carlo Alphonso, M.D., San
Antonio Uniform Services Health Education Consortium, San Antonio Military Medical Center, United
States Army Institute of Surgical Research, San Antonio Military Medical Center, San Antonio, TX
26 year-old ASA 2E female was admitted following 21% TBSA burns and inhalational injuries. Hospital
course was complicated by Stenotrophamonas pneumonia, polymicrobial bacteremia, C. difficile,
saphenous vein thrombosis and severe ARDS requiring ECMO (since refractory to ARDSNET
protocol/iNO/prone ventilation). Emergent burn surgery performed in ICU requiredanesthesia during
ECMO. For the burn patient requiring intraoperative ECMO, anesthetic considerations include general
anesthesia (balanced IV/Inhalational vs TIVA), suboptimal compatibility of volatile anesthetics with and
sequestrationof IV anesthetics by ECMO circuits, decreased pulmonary blood flow, anticoagulation,
hemodynamic lability, airway management, vascular access, transfusions requirements, electrolyte
monitoring and intravascular fluid management.
MCC03
4:45 PM - 4:55 PM
Early Onset Autonomic Dysreflexia in a Patient With a Recent Cervical Spine Injury Undergoing
Cervical Laminectomy and Fusion
Elvera L. Baron, M.D.,Ph.D., Gabriel Bonilla, M.D., Anesthesiology, The Mount Sinai Hospital, New York,
NY, Anesthesiology, Elmhurst Hospital Center (Mount Sinai Affiliate), Queens, NY
A 59 year-old morbidly obese male with hypertension, diabetes mellitus 2, and a drug eluting stent
presented for a cervical laminectomy and fusion (c2-c7) with neuromonitoring after sustaining a cervical
spinal cord injury 17 days prior. Intraoperatively while receiving a dexmedetomidine infusion in
preparation for an awake fiberoptic intubation, the patient experienced autonomic dysreflexia during a
radial arterial line placement. We discuss the incidence, signs, symptoms, triggers, pathophysiology, and
pharmacological management of autonomic dysreflexia in awake and anesthesized patients. We also
present how to formulate an appropriate anesthetic plan for patients with high spinal cord lesions.
MCC03
4:45 PM - 4:55 PM
34 year-old With a Complicated Medical History Presents for Termination of Pregnancy
Erica M. Johnson, M.D., Dawn Mannings-Williams, M.D., Grant Lynde, M.D., Anesthesiology, Emory
University, Atlanta, GA
A 34year-old G3P1011 at 19weeks with NYHA class IV CHF secondary to pregnancy-associated
cardiomyear-oldpathy presented to the obstetric ICU. Patient had moderate pHTN secondary to her CHF,
morbid obesity (BMI 50), NIDDM, and a seizure disorder. TTE revealed LVEF 35%, valvular disease,
RWMAs, and RSVP 60mmHG. Airway exam was consistent with a mallampati 3, short neck, and
macroglossia. Termination of pregnancy was necessary secondary to rapidly progressive and worsening
cardiopulmonary function. Patient was managed with a multidisciplinary care team consisting of
cardiology, obstetrics, and anesthesiology. Planned induction was performed with considerations of
pHTN, CHF, orthopnea, airway, analgesia, and anxiolytics.
MCC03
4:45 PM - 4:55 PM
Arytenoid Prolapse: Why Do We Struggle With Supraglottic Airway Intervention?
Ali Kandil, D.O., Rajeev Subramanyam, M.D., Stacey L. Ishman, M.D.,M.P.H., Robert Fleck, M.D.,
Mohamed Mahmoud, M.D., Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati,
OH, Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
13 year-old, former 26 week premature male with severe obstructive sleep apnea and acquired subglottic
stenosis, status post laryngotracheoplasty, who presents for MRI sleep study. During induction of
anesthesia, difficulty was immediately encountered in maintaining an adequate airway; the Spo2
decreased to 78% despite breathing 100% oxygen, placement of an oral airway and applying continuous
positive airway pressure (CPAP). The airway obstruction was finally relieved by jaw thrust. During
imaging airway patency was maintained by taping chin to the MRI coil in addition to the oral airway.
Endoscopic evaluation revealed significant bilateral arytenoid prolapse, completely obstructing the glottis
(figure).
MCC03
4:45 PM - 4:55 PM
Pain Medicine (PN)
The Role of Ketamine in Treatment of Phantom Leg Pain Syndrome
Nikolay Manuylov, M.D., Daryl Smith, M.D., Anesthesiology, University of Rochester, Rochester, NY
58 year-old male received combined spinal epidural injection prior to BKA. Complete absence of
sensation below T10 was established. Upon awakening in PACU he immediately complained of 10/10
pain in the missing limb. The sensory level was confirmed. IV opioids didn’t relieve pain. Shortly patient
received 20 mg bolus of IV ketamine which completely resolved pain. To provide continuous pain control
we decided to run ketamine drip. Patient had excellent response and drip was weaned off. At this point
phantom pain was minimal. At one month follow-up patient reported no evidence of phantom limb pain.
MCC03
4:45 PM - 4:55 PM
Pneumocephalus: Saline Versus Air, The Choice Matters
Kush Tripathi, M.D., Chiranjeev Saha, M.D., Anesthesia, Rush University Medical Center, Chicago, IL
A 77-yr-old female with a past medical history significant for diabetes mellitus, hypertension and L2-5
laminectomy presented for a Right revision knee arthroplasty. An 18 G Touhy was introduced with glass
syringe for epidural placement. Bone was persistently encountered with questionable Loss of Resistance
(LOR), resulting in air injection. The patient developed sudden onset headaches. Epidural placement was
aborted and immediate head CT scan demonstrated significant intracerebral air. She was treated with
100% oxygen and repeat CT showed complete reabsorption of air without any neurologic deficits.
Pneumocephalus, incidence is higher with air LOR and requires high suspicion and immediate treatment.
MCC03
4:45 PM - 4:55 PM
Approach to Difficult Airway Management in a Developmentally Delayed Adult With a Large
Thyroid Mass
Neeta Singh, D.O., Elisabeth Goldstein, M.D., Anesthesiology, New York University Langone Medical
Center, New York, NY
31 year-old female with history of stroke, seizure disorder, VP shunt, hemiparesis, wheelchair bound
presented with severe dysphagia worsening over a year. MRI showed large thyroid goiter resulting in
mass effect of the aerodigestive tract and mass effect on the vocal cords. Patient was scheduled for hemi
thyroidectomy. The plan was an awake fibreoptic intubation with sedation which ultimately was not
successful. An awake tracheostomy was performed under local after progression down the difficult airway
algorithm. The patient had severe tracheomalacia after removal of the mass. We will explore difficult
airway management in developmental delayed adults with obstructive lesions.
MCC03
4:45 PM - 4:55 PM
Localized Pericardial Tamponade Diagnosed by Venous Saturation
Nakia M. Hunter, M.D., David Stahl, M.D., Anesthesiology, The Ohio State University Wexner Medical
Center, Columbus, OH
A 71 year-old woman with a history of hypertension, CAD s/p PCI (on clopidogrel) was admitted to the
ICU after an uncomplicated single-vessel CABG. Pre- and intraoperative TEE revealed normal LV
function and a PFO. Postoperatively, the patient was in cardiogenic shock with an inability to wean
inotropes by the second postoperative day. Further investigation revealed: mixed venous O2 saturation of
77%, central venous O2 saturation of 49%, with a Qp/Qs 1.8. TTE demonstrated a large fibrinous
pericardial effusion compressing the LA, with LV ejection fraction of 60-65%. The patient returned to the
OR for mediastinal exploration.
MCC03
4:45 PM - 4:55 PM
Emergent Fiberoptic Intubation for Ludwig’s Angina in a Patient With Local Anesthetic Allergy
Zackary A. Chancer, M.D., Robert Noorani, M.D., Jeremy Kaplowitz, M.D., Department of Anesthesiology,
University of Maryland Medical Center, Baltimore, MD
LK is a 59 year-old female with mild airway compromise presenting for emergent surgical intervention of a
large dental related facial abscess. Imaging showed a large abscess in the left submasseteric and
pterygomandibular space with infratemporal fossa extension. An awake fiberoptic nasal intubation was
planned due to trismus in the setting of airway compromise. However, the patient reported a documented
severe allergy to all local anesthetics except for bupivacaine. Pretreatment was performed with
glycopyrrolate and midazolam, and topicalization was achieved with 10cc 0.5% bupivacaine to her right
nares, oropharynx via atomizer, and glottis through the bronchoscope prior to smooth nasal intubation.
MCC03
4:45 PM - 4:55 PM
Ketamine Infusion in an Autistic Pediatric Patient With Self-injurious Behavior in the Recovery
Room
Kuntal Jivan, Shawn Lea, R.N., Georgetown Univ Hosp Anes Dept, Medtstar Georgetown University
Hospital, Washington, DC
A 10 year-old male with severe autism and self-injurious behavior, taking daily oral naltrexone.The patient
was given preoperative oral acetaminophen, hydrocodone andmidazolam. After mask induction and
intubation, maintenance was withsevoflurane dexmedetomidine infusion andfentanyl for the duration of
the 2.5 hour case. After extubation, In PACU, a dexmedetomidineinfusion was initiated with fentanyl ,
morphine and propofol boluses ashe remained agitated followed later by a propofol drip and a ketamine
drip. He remainedsedated and cooperative overnight while on the ketamine infusion. The patientwas then
discharged the next day without any complications.
MCC03
4:45 PM - 4:55 PM
Prolonged Paralysis After Thyroid Surgery
Andrea M. Keohane, M.D., Douglas L. Hester, M.D., Anesthesiology, Vanderbilt University Medical
We present the case of a 72 year-old male undergoing a thyroidectomy for cancer. The patient received
100 mg of succinylcholine for induction of anesthesia and the surgery proceeded without complication.
Afterwards, the patient was too weak to extubate, requiring post-operative mechanical ventilation. The
patient was extubated approximately four hours after induction. He then complained of chest pain. EKG
revealed inferior STEMI. Patient was taken to the cath lab for intervention. This case discusses the
anesthetic implications of undiagnosed pseudocholinesterase deficiency.
MCC03
4:55 PM - 5:05 PM
Electroconvulsive Therapy and the Development of Takotsubo Cardiomyopathy in a Young
Healthy Female
Ajay Malhotra, M.D., Lawrence Chinn, M.D., Hayder Hashim, M.D., Anesthesiology, Medicine Cardiology, Rutgers - New Jersey Medical School, Newark, NJ
A 37 year-old female with schizoaffective disorder presented for electroconvulsive therapy (ECT)
maintenance. The history was only significant for inpatient ECT and hypertension and presented
asymptomatic and stable on home medications. Following induction (brevital and succinylcholine) and
treatment, the patient began having multiple desaturation episodes and developed cardiac dysrhythmia.
In recovery, the patient converted back to sinus rhythm, but began complaining of severe chest pain.
Cardiology was called and a diagnosis of Takotsubo cardiomyear-oldpathy was made. In this report, we
describe our perioperative management for this patient. We also detail future concerns for ECT in
patients with history of Takotsubo cardiomyear-oldpathy.
MCC03
4:55 PM - 5:05 PM
Management of Refractory Hypotension in Patient on Perioperative Multimodal Anti-Hypertensive
Therapy
William J. Watkins, Student, Matthew Guidry, M.D., Anesthesiology, Emory University School of Medicine,
Anesthesiology, Emory Saint Joseph's Hospital, Atlanta, GA
62 year-old male presenting with lumbar spondylolisthesis and L3-S1 stenosis, scheduled for
Transforaminal Lumbar Interbody Fusion. Patient presents with concurrent administration of Beta-blocker,
Calcium Channel Blocker, and Angiotensin Converting Enzyme Inhibitor. Minutes after propofol and
fentanyl induction and prone positioning, the patient lapses in to profound hypotension refractory to first
line vasopressors. Patient requires boluses of vasopressin, norepinephrine, and epinephrine; and
infusions of vasopressin and norepinephrine before stabilizing at a safe blood pressure. Patient was
eventually weaned off of vasopressin infusion intraoperatively and norepinephrine infusion in the PACU.
Patient incurred no discernable deficits from sustained hypotension.
MCC03
4:55 PM - 5:05 PM
Pitfalls of Using the King LT
Gregory S. Maves, M.D., Kimberley Nichols, M.D., Department of Anesthesiology, University of North
Carolina Hospitals, Chapel Hill, NC
Patient presented as transfer from outside hospital with a subarachnoid hemorrhage. King LT airway was
placed by EMT en route for somnolence after failed intubation. Anesthesia was consulted for exchange of
King LT to ETT in ICU. We were unable to pass an exchange catheter or fiberoptic scope through the
King LT. The patient’s airway was edematous, but a Glidescope yielded a grade I view; Thus, the King LT
was removed. Repeat Glidescope view was grade IIb, but we were unable to pass an ETT. An LMA was
placed for rescue ventilation. The patient was intubated through the LMA.
MCC03
4:55 PM - 5:05 PM
A Mirror Image Artifact During 3-Dimensional Transesophageal Echocardiography
Anastasia Grivoyannis, M.D., Anup Pamnani, M.D., Nikolaos Skubas, M.D., Anesthesiology, NY
Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
A 28 year-old man presented for mitral valve repair secondary to mitral regurgitation. Following initiation
of anesthesia, a transesophageal echocardiographic (TEE) transducer was inserted and connected to a
three dimensional ultrasound system. Following two unsuccessful attempts to advance the pulmonary
artery catheter (PAC), the PAC balloon was inflated with 1.5ml of saline and flotation was performed
under TEE guidance. Following flotation into the right ventricle, it is noteworthy that the fluid-filled PAC
balloon produced two different artifacts while traversing the right ventricle: an attenuation artifact (echo
drop-out) in the apex and multiplication artifact (mirror image) close to the right ventricular outflow tract.
MCC03
4:55 PM - 5:05 PM
The Use of VV ECMO in Severe Tracheal Stenosis
Krystle A. Leacock, M.D., Michelle Haines, M.D., Anesthesiology, UMKC - St. Luke's Hospital, Kansas
City, MO
35 year-old morbidly obese male with history of chronic systolic heart failure underwent LVAD placement.
Tracheostomy was performed 11 days postoperatively for failure to wean from mechanical ventilation.
The tracheostomy site was decannulated 24 days later. He presented 2 months after with stridor. He
underwent flexible bronchoscopy which revealed severe tracheal stenosis approximately 3 cm below the
cords. Tracheostomy wasn’t an option. He couldn’t be mask ventilated. He was placed on VV ECMO in
the OR while spontaneously breathing. Rigid bronchoscopy, tracheal dilation, and intubation was
completed over 22 minutes. The patient underwent tracheal resection 3 days later.
MCC03
4:55 PM - 5:05 PM
Spinal Is In... Oh We Have a Placenta Accreta
Omonele O. Nwokolo, Erikka Washington, M.D., Anesthesiology, University of Texas Medical School,
Houston, TX
We present the case of a 31 year-old G3P2 with 2 prior C-Sxn at 37 weeks GA with multiple fetal
abnormalities. MRI performed showed fetal hydrocephalus. Patient presented to the hospital with
ruptured membranes and brought into OR suite for a C-section. After placement of spinal and abdominal
incision, an intraoperative diagnosis of placenta accreta was made. Abdomen packed to await a surgical
consult. The wait time enabled a change in the anesthetic plan, addition of lines and activation of massive
transfusion protocol. As well as time for a regression in effect of spinal anesthesia. Could this have been
predicted?
MCC03
4:55 PM - 5:05 PM
Anesthetic Management of a Complex Pediatric Patient With a Mitochondrial Disorder and History
of Anesthetic Complications
Kaitlyn P. Pellegrino, Jessica R. Easton, M.D., Huiling Pang, M.D., Department of Anesthesiology,
University of Nebraska Medical Center, Omaha, NE
A 16 year-old female with a mitochondrial disorder and chronic pain presented for exploratory laparotomy
and G-button closure. She has a history of multiple adverse anesthetic events including drug reactions
requiring cardiopulmonary resuscitation, intraoperative awareness, uncontrolled postoperative pain, and
prolonged weakness. An anesthetic plan was developed after thorough review of her previous
anesthetics and complications. Inhalational induction was performed until IV access was established, and
ketamine was administered. Anesthesia was maintained with sevoflurane and remifentanil infusion. A
TAP block was performed prior to emergence, and fentanyl was given. The patient did well
perioperatively with good pain control and no recall.
MCC03
4:55 PM - 5:05 PM
Pain Medicine (PN)
Pain Management in Erythromelalgia
Timothy P. Smith, M.D., Senthil Krishna, M.D., Anesthesiology & Pain Management, Nationwide
Children's Hospital, Columbus, OH
Recently we encountered two pediatric patients who were diagnosed with erythromelalgia. This extremely
rare condition presents with excruciating pain in the extremities. There is no known successful pain
management regimen. We shall discuss our experiences in managing these difficult and challenging
cases.
MCC03
4:55 PM - 5:05 PM
Brachial Plexus Injury With Resolution in the Setting of Open Reduction and Internal Fixation of
the Humeral Head, Following an Interscalene Nerve Block
Charles E. Griffin, M.D., Jack M. Berger, M.D.,Ph.D., Ruby Castellanos, M.D., Anesthesiology, University
of Southern California, Los Angeles, CA
A 59 year-old male presented for open reduction and internal fixation of a left proximal humerus fracture.
After receiving an interscalene nerve block using nerve-stimulation and ultrasound-guided technique,
general anesthesia was induced. Complicating factors included large body habitus, short neck, beach
chair position, and a complicated surgical procedure. Complete sensory and motor loss was observed the
following day, longer than the expected duration of the local anesthetic. Subsequent EMG studies
suggested severe C5-C8 nerve root injury, with full recovery seeming unlikely. Over the next year, full
neurologic recovery was achieved. Potential mechanisms of injury will be discussed.
MCC03
4:55 PM - 5:05 PM
Mandibular Fracture With Difficult Nasal Intubation
Ngoc B. Truong, D.O., Alice Tsao, M.D., Riverside County Regional Medical Center, Moreno Valley, CA,
Riverside County Regional Medical Center, Moreno Valley, CA
49 year-old male with right mandible fracture presented for ORIF necessitated nasal intubation. The
deformed mandible made mask ventilation moderately difficult. The anterior vocal cord was not visualized
with direct laryngoscope, nor obtainable by Bougie. Glidescope with neck compression showed the vocal
cord, but the extreme angle rendered intubation unsuccessful. Neither fiberopticscope nor Bougie was
long enough for the nasal rae. Therefore 3 cm length of the rae was cut to accommodate the Bougie, with
special tapping to secure the nasal rae. The patient was extubated at the end of surgery without adverse
event.
MCC03
4:55 PM - 5:05 PM
Malposition of a Dual Lumen Veno-Venous ECMO Catheter Resulting in Cardiovascular Collapse
in a Patient With Pulmonary Fibrosis
Meghan Cook, M.D., Michael Andritsos, M.D., Anesthesiology, The Ohio State University Wexner Medical
60 year-old male with pulmonary fibrosis presented with acute on chronic respiratory failure refractory to
conventional ventilatory strategies. Veno-venous ECMO via an Avalon catheter was initiated as bridge to
lung transplantation. Whilst an inpatient, he developed hemorragic cholecystitis requiring subtotal
cholecystectomy. Upon transfer from the OR table to his bed, he acutely decompensated with
hypotension and subsequent ventricular fibrillation arrest. ACLS protocol was initiated with conversion to
femoral veno-arterial ECMO support obtaining return of circulation. We highly suspect Avalon catheter
displacement upon patient transfer to his bed resulting in re-circulation of blood and ensuing left
ventricular collapse.
MCC03
4:55 PM - 5:05 PM
General Versus Regional Anesthesia for Pathological Fracture of Femur in a Patient With an
Anterior Mediastinal Mass
Omar Dyara, D.O., John Jerabek, D.O., Anesthesia, Cleveland Clinic Foundation, Mayfield Heights, OH,
Anesthesia, Cleveland Clinic Foundation, Cleveland, OH
50 year-old female, with a history of metastatic lung adenocarcinoma, admitted for right leg pain. She was
noted to have metastasis to her brain, contralateral lung, adrenal glands, and a documented anterior
mediastinal mass. After a discussion involving surgical and anesthesia teams, regardings risks and
benefits of anesthesia with patient and her family, surgery proceeded. After extensive discussions with
multiple anesthesia staff, it was decided to proceed with general anesthesia. Patient was induced with
propofol, but was kept spontaneously breathing. No muscle relaxants were given. Patient was intubated
with a glidescope, and surgery continued as planned with no complications.
MCC03
4:55 PM - 5:05 PM
Acute Pulmonary Edema
John OHara, M.D., BIDMC, Boston, MA
This case involves a 65 year-old male who underwent ureteral stent placement with a general anesthetic
that was complicated by pulmonary edema upon extubation requiring emergent reintubation.
MCC03
5:05 PM - 5:15 PM
Anesthetic Management of a Patient With Mitochondrial Myopathy and a Vocal Cord Mass
Rishi Vashishta, M.D., Lee Stein, M.D., Harsha Nalabolu, M.D., Anesthesiology, NYU Langone Medical
A 45 year-old male with mitochondrial myear-oldpathy presented with worsening voice hoarseness. He
had an established diagnosis of MERRF syndrome, with a history of seizures and hearing loss. He was
taken to the operating room for micro-direct laryngoscopy with vocal cord biopsy under general
endotracheal anesthesia. An inhaled induction was performed. Sevoflurane with remifentanil infusion was
used for maintenance. Propofol, muscle relaxants, and lactated Ringer’s solution were avoided to prevent
further impairment in mitochondrial function and increases in metabolic demand that could trigger a crisis.
We will discuss the anesthetic implications of mitochondrial myear-oldpathies with a review of literature
and recommendations.
MCC03
5:05 PM - 5:15 PM
70 year-old Female With History of COPD, Hypertension, Coronary Artery Disease and Mesenteric
Ischemia Presents for Superior Mesenteric Artery Bypass
Derek C. Blankenship, Michael Hofkamp, M.D., Rita Saynhalath, M.D., Texas A&M Health Science
Center, Austin, TX, Scott & White, Temple, TX
We present a 70 year-old female with a history of COPD, hypertension, coronary artery disease and
recent onset mesenteric ischemia scheduled for superior mesenteric artery (SMA) bypass grafting.
Arterial access was ultimately obtained via a brachial arterial catheter placed by the vascular surgeon. A
triple lumen catheter was placed in the right internal jugular vein for definitive venous access.
Preoperatively, the patient had a hemoglobin of 7.2 gm/dl and was given two units packed red blood cells.
At the conclusion of the procedure, the patient met extubation criteria but was subsequently reintubated
due to hypoventilation and low oxygen saturations.
MCC03
5:05 PM - 5:15 PM
Abdominoperineal Resection in a Patient With Ischemic Cardiomyopathy, Sick Sinus Syndrome
and Pulmonary Hypertension
Mark R. Bombulie, M.D., Bret D. Alvis, M.D., Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN
87 year-old male with CAD, ischemic cardiomyear-oldpathy, sick sinus syndrome, and pulmonary
hypertension presented for laparoscopic abdominoperineal resection for rectal carcinoma. Pre-operative
echocardiogram demonstrated an EF of 40% and RVSP of 52 mmHg. After several attempts, central
venous access was unable to be successfully obtained; therefore, the decision was made to abort the
laparoscopic plan and perform an open procedure. TEE was used to guide fluid, vasopressor and
ionotropic management. The patient was maintained on a milrinone infusion and required intermittent
phenylephrine and norepinephrine boluses for arterial pressure control. The patient tolerated the
procedure and was extubated at the end.
MCC03
5:05 PM - 5:15 PM
Elderly Patient With Severe Aortic Stenosis and Significant Tracheobronchomalacia Presenting
for Transfemoral Aortic Valve Replacement
Paula Trigo Blanco, M.D., Hossam Tantawy, M.D., Yale New Haven Hospital, New Haven, CT
A 90 year-old male with severe aortic stenosis presented for transfemoral aortic valve replacement
(TAVR). Thoracic CT revealed greater than 70% collapse of the trachea and mainstem bronchi,
compatible with tracheobronchomalacia. Due to acute CHF, patient was unable to lie flat and was
preoxygenated in the sitting position. Inhalational induction was performed with maintenance of
spontaneous ventilation. Positive pressure ventilation was well tolerated, succinylcholine given,
endotracheal intubation with videolaryngoscopy. Hemodynamic stability was accomplished by intermittent
boluses of phenylephrine and vasopressin. After TAVR patient was kept intubated and transferred to
CTICU where 1.5 liters of pleural effusion drained and patient uneventfully extubated
MCC03
5:05 PM - 5:15 PM
Splenic Rupture After Screening Colonoscopy
Marian E. Von-Maszewski, M.D., Critical Care, MD Anderson Cancer Center, Houston, TX
A patient underwent colonoscopy for evaluation of reported melena and fatigue. A polyp was removed
and the procedure was otherwise uneventful. A few hours later he developed hypotension with SBP in the
70s. Hemoglobin was found to be 6. He was transferred to the ICU for further evaluation and
management. He underwent massive transfusion and eventually required intubation due to abdominal
distention and hemodynamic instability. CT was delayed by instability. Once obtained, it showed free fluid
and a stage III splenic laceration. Embolization was performed but the patient expired due to continued
hemorrhage and resultant multisystem organ failure.
MCC03
5:05 PM - 5:15 PM
Diagnosis and Management of Intraoperative Venous Air Embolism (VAE) in a Patient With
Chronic PE and COPD
Manan Patel, M.D., Kenneth Sutin, M.D., Anesthesiology, NYU Langone Medical Center,
Anesthesiology, Bellevue Hospital Center, New York, NY
71 year-old male PMH HTN, HLD, COPD, chronic PE, metastatic colon adenocarcinoma with brain
metastases who underwent supine frontal craniotomy. During resection of the tumor, SpO2 decreased
from 100% to 80% on 50% FiO2, EtCO2 decreased from 28 to 8, and HR increased to 105. Anesthesia
team notified the surgical team to flood the field with saline. The patient was placed in Trendelenburg and
on 100% FiO2. Subsequently, the surgical team noted entry into the parasagittal sinus. The sinus was
closed. Shortly, SpO2 improved with increasing EtCO2 to 20. ABG sent post-VAE pH 7.47, pCO2 47,pO2
47, HCO3 25
MCC03
5:05 PM - 5:15 PM
Extreme Parturient Pulse During Labor - Anesthetic or Obstetric Complication?
Garett Jackson, M.D., Corinne Davis, M.D., Rodney Sclater, D.O., Thomas Pennington, D.O., Christopher
Nagy, M.D., San Antonio Military Medical Center, San Antonio, TX
We report on a laboring 31 year-old parturient who developed a sinusoidal pattern of symptomatic
tachycardia during contractions. Following epidural placement and initiation of oxytocin infusion each
painless contraction resulted in a dramatic rise of maternal heart rate from a baseline of 70 to a maximal
rate of 150 beats per minute with concomitant chest pressure and dyspnea. Ten days postpartum, the
patient experienced acute myear-oldcardial infarction requiring emergent percutaneous coronary
intervention and then symptomatic heart failure requiring AICD placement for primary prevention.
Hemodynamic instability in the parturient requires rapid evaluation and treatment for optimal outcomes.
MCC03
5:05 PM - 5:15 PM
Dexmedetomidine and Ketamine as Sole Anesthetic for Drug-induced Sleep Endoscopy in a
Patient With Williams Syndrome, With Known Severe Supraaortic Stenosis
Ali Kandil, D.O., Rajeev Subramanyam, M.D., Mohamed Mahmoud, M.D., Anesthesiology, Cincinnati
Children's Hospital Medical Center, Cincinnati, OH
16 year-old male with Williams Syndrome, known severe supraaortic stenosis and severe obstructive
sleep apnea, presented for drug-induced sleep endoscopy (DISE). Given the patient’s cardiac history and
need for natural sleep physiology, anesthetic management was challenging. DISE is real-time evaluation
of the upper airway under anesthesia and allows otolaryngologists to identify the source of obstruction
and intervene surgically during the same anesthetic. To keep the patient spontaneously breathing with
adequate anesthetic depth, we administered dexmedetomidine and ketamine as our sole anesthetic for
the DISE-portion of surgery. DISE revealed significant palatal obstruction at the level of the velum,
necessitating further intervention.
MCC03
5:05 PM - 5:15 PM
Pain Medicine (PN)
Complex Pain Management for a Pediatric Patient With Relapsed Refractory Metastatic
Neuroblastoma at End of Life
Aimee A. McAnally, M.D., Pain Management, Palliative Care, and Integrative Medicine, Children's
Hospitals and Clinics of Minnesota, Minneapolis, MN
The patient was a 19 year-old diagnosed with neuroblastoma hospitalized for end of life care. During his
several month admission, he required escalating doses of opioid pain medications. He was initially on
PCA hydromorphone with both continuous and demand dosing. Doses continued to be escalated and
methadone infusion was added. He also required benzodiazepines for significant anxiety. Ketamine
infusion was initiated and pain did improve for a time. He also found relief from hypnosis, massage, and
acupuncture treatment. When his pain became more difficult to treat, the role of propofol infusion and
palliative sedation was discussed.
MCC03
5:05 PM - 5:15 PM
Intra-pleural Placement of a Thoracic Epidural Catheter in a Patient With Spinal Stenosis
Kiran Belani, M.D., Mario Montealegre-Gallegos, M.D., Robina Matyal, M.D., Anesthesiology, Beth Israel
Deaconess Medical Center, Boston, MA
74 year-old obese woman with a history of spinal stenosis presented for thoracoscopic left upper
lobectomy for non-small cell lung carcinoma. A thoracic epidural catheter was placed pre-operatively and
a sensory level was confirmed after local anesthetic injection. Intra-operatively, the catheter was noted to
be inside the pleural space, and therefore it was removed. Post-operatively, two additional attempts were
made to place an epidural catheter due to increased narcotic requirements. After the third attempt, the
patient developed hypotension and hypoxia concerning for tension pneumothorax. Emergent re-intubation
and needle decompression were performed. A chest tube was placed, and respiratory status
subsequently improved.
MCC03
5:05 PM - 5:15 PM
Superficial Peroneal Nerve Injury With Intra-operative Use of Intermittent Pneumatic Compression
Devices
Angelica A. Vargas, M.D., Arvind Rajagopal, M.D., Parag Patel, M.D., Anesthesiology, Rush University
A 35 yr-old healthy woman presented for nasal surgery. Pneumatic compression devices (IPC’s) were
placed bilaterally for DVT prophylaxis. The six hour intra-operative course was uneventful. In the PACU
she began to complain of “excruciating” left lateral leg pain from the knee down. Exam was significant for
4/5 weakness in left dorsal and plantar flexion, tenderness to palpation of left lateral leg, and decreased
pinprick sensation in superior mid portion of left foot. Neurology diagnosed her with superficial peroneal
neuropathy due to use of IPC’s intra-operatively. Proper sizing, positioning and monitoring is needed to
ensure patient safety when using IPC’s.
MCC03
5:05 PM - 5:15 PM
Severe Tricuspid Regurgitation and Heart Failure From a Ruptured Sinus of Valsalva Aneurysm in
a Patient With Situs Inversus Abdominalis and Polysplenia
Ngoc Chu, D.O., Srinivasa Gutta, M.D., Taras Grosh, M.D., Anesthesiology, Baystate Medical Center,
Springfield, MA
A 57 year-old female with PMH significant for obesity status post gastric bypass, OSA, and situs inversus
abdominalis presented with acute CHF secondary to severe tricuspid regurgitation diagnosed by transthoracic echocardiogram. A subsequent trans-esophageal echocardiogram evaluation by cardiologist
revealed a ruptured sinus of Valsalva aneurysm into right atrium with systolic and diastolic flow. Patient
underwent a composite root replacement, a prosthetic valve was sewn into the sinus of Valsalva graft
with coronary re-implantation, under general anesthesia. Intra-operative TEE evaluation was limited to
mid-esophageal views secondary to gastric bypass. TEE exam post-CPB revealed adequate surgical
repair.
MCC03
5:05 PM - 5:15 PM
Perioperative Anesthetic Considerations For Patient With Hereditary Multiple Exostoses
Eric R. Leiendecker, M.D., Christina Boncyk, M.D., Laura Hammel, M.D., Anesthesiology, University of
Wisconsin Hospital and Clinics, Madison, WI
Patient is 48 year-old male with past medical history significant for hereditary multiple exostoses (HME)
who presented for partial cystectomy, exploratory laparotomy and excision of pelvic mass. HME is an
uncommon autosomal-dominant condition that involves multiple benign exostoses which pose the risk of
progression to osteochondrosarcoma, for which our patient was being explored given changes
appreciated on pre-operative pelvic MRI. Complications of HME include bony malformation, neural
impingement, fracture, vascular impingement, and/or malignant transformation all resulting in multiple
operations for many of these patients. To our knowledge, no anesthetic-based case study has been
presented regarding perioperative management for these patients.
MCC03
5:05 PM - 5:15 PM
Difficult Airway Management in Treacher Collins Syndrome After Accidental Extubation
Shoeb Mohiuddin, M.D., Heather Nixon, M.D., Anesthesiology, University of Illinois at Chicago, Chicago,
IL
We present a case of a 19year-old male with PMH of Treacher Collins Syndrome undergoing an
odontectomy who had an accidental extubation during neck preparation and subsequent challenging
reintubation. Beforehand, the patient was fiberoptically intubated with an oral RAE taped at 23cm at the
lip. Re-intubation attempt was complicated by copious secretions, difficult 2 hand bag mask ventilation,
and brief desaturation. Multiple fiberoptic intubations were attempted with placement of an oral ETT
sutured at 25 cm at the gum line. Increased oral-glottic distance, micrognathia, and absent cheekbones
hindered ventilation and resulted in unintended extubation making this a medically challenging case.
MCC04
Sunday, October 25, 2015
10:00 AM - 10:10 AM
and Oxygenation in a 15 Year-Old Morbidly Obese Patient During EGD
Jessica Perez, M.D., Gianna Casini, M.D., Viviana Freire, M.D., Rose Alloteh, M.D., Andrea Poon, M.D.,
James Tse, M.D.,Ph.D., Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick,
NJ
15 year-old boy, BMI 51 kg/kg2, presented for screening EGD prior to gastric sleeve. His baseline O2
saturation was 92%. His mother gave consent for using nasal CPAP mask/circuit. An infant facemask (#2)
was secured over his nose with head-straps and connected to anesthesia breathing circuit/machine. He
was pre-oxygenated comfortably with 4-5 cm H2O CPAP with O2 3L/min and air 1L/min (0.8 FiO2). After
pre-oxygenation, deep sedation was slowly titrated with propofol boluses and infusion (150-200
ug/kg/min) to maintain spontaneous ventilation. Patient tolerated the procedure well and maintained
100% O2 saturation throughout. He woke up quickly and was very elated.
MCC04
10:00 AM - 10:10 AM
A Simple and No-Cost Nasal CPAP Mask/Circuit Assembly Maintaining Spontaneous Ventilation
and Oxygenation in a Hemophiliac Patient With Nasal Congestion During Anal Fistulectomy Under
Local Anesthesia
Jennifer Cowell, M.D., Sylvia Barsoum, M.D., Amanda Doucette, M.D., James Tse, M.D.,Ph.D.,
28 year-old male with hemophilia, Hepatitis B/C and allergic rhinitis/nasal congestion presented for anal
fistulectomy under local anesthesia. He was consented for nasal CPAP setup to avoid epistasis. Once in
jackknife position, an infant face-mask was secured over nose with head-straps and connected to the
anesthesia circuit/machine with 3L O2/min and 1L air/min. Deep sedation was titrated with 2mg
midazolam, propofol (total 130mg) and fentanyl (2x25ug) prior to local anesthetic injection. Sedation
maintained with propofol infusion (150-200ug/kg/min). APL valve was adjusted to deliver 10-12cm H2O
CPAP, maintaining patent nasal airway and spontaneous ventilation. His oxygen saturation remained
100% throughout.
MCC04
10:00 AM - 10:10 AM
and Oxygenation in a Patient With Right Maxillary Tumor Excision and Facial Asymmetry
Viviana Freire, M.D., Sylviana Barsoum, M.D., Alexander Kahan, M.D., James Tse, M.D.,Ph.D.,
Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
58 year-old male with facial asymmetry; needing Ex-Lap. A right zygomatic body, ramus of mandible and
maxilla asymmetry was noticed. The facial deformity precluded routine adult face mask ventilation with
appropriate seal. An Infant mask with fully inflated air cushion was placed over his nose and secured with
head straps in an attempt to mirror the contour and seal along his zygomatic and maxillary bone
deformity. After preoxygenation, RSI with cricoid pressure was performed. Subsequent videolaryngoscopy was succesful; maintaining 100% SaO2. Upon extubation nasal CPAP 4-5 cm H2O was
applied to ensure spontaneous ventilation and oxygenation.
MCC04
10:00 AM - 10:10 AM
Acute Serotonin Toxicity or Psychogenic Non-Epileptic Seizures: Differential Diagnosis in the
PACU
Austin Wade Pulliam, M.D., Peggy James, M.D., Anesthesiology, University of Florida College of
Medicine - Jacksonville, Jacksonville, FL
MW, a 26 year-old female presented to the OR for right laparoscopic salpingo-oophrectomy for chronic
pelvic pain. She was classified as an ASA 2. The patient underwent general inhalational anesthesia with
endotracheal intubation and the surgery proceeded without complication. On arrival to PACU, she
developed shivering, and was administered meperidine for treatment. Shortly thereafter, myear-oldclonus
developed and the patient was unresponsive. Ultimately she was treated with midazolam and a neurology
consult was obtained for concern of seizures. She met diagnostic criteria for both acute serotonin toxicity
and psychogenic non-epileptic seizures.
MCC04
10:00 AM - 10:10 AM
Anesthetic Management of An Elderly Patient Undergoing Removal of A Renal Carcinoma With
Extensive Thrombus In the Inferior Vena Cava
Paula Trigo Blanco, M.D., Wanda M. Popescu, M.D., Yale New Haven Hospital, New Haven, CT
A 79 year-old male with a right renal mass and an IVC thrombus extending 1.5 cm inferior to the right
atrium, presented for radical nephrectomy and caval thrombectomy. Due to high risk of embolization the
anesthesia team requested cardiopulmonary bypass standby. Standard ASA monitors, large bore
peripheral and central venous catheters, arterial line and thoracic epidural were placed. After general
anesthesia induction, a transesophageal echocardiographic examination revealed a friable and mobile
thrombus. Before IVC manipulation, in order to avoid thrombus embolization the surgeon placed a suprahepatic clamp. The patient remained hemodynamically stable throughout, and was transferred
postoperatively to intensive care unit
MCC04
10:00 AM - 10:10 AM
Management of a Patient With Endobronchial Hodgkin's Lymphoma and RSV Pneumonitis
Marian E. Von-Maszewski, M.D., Cristina Gutierrez, M.D., Diego de Villalobos, M.D., John Crommett,
M.D., Critical Care, MD Anderson Cancer Center, Houston, TX
A 27 year-old patient was transferred to the ICU with acute respiratory failure due to RSV pneumonia in
the setting of treatment-refractory Hodgkin’s lymphoma. Bronchoscopy revealed endobronchial
lymphoma. Although she had advanced disease and a poor long-term prognosis, her plan of care was
aggressive due to her year-oldung age and lack of involvement of other organ systems. The RSV
pneumonia was successfully treated and she received salvage chemotherapy but her oncologic disease
caused prolonged respiratory failure and need for continued mechanical ventilation. After a prolonged
ICU course, she was transferred to a long-term acute care facility with mechanical ventilation via
tracheostomy.
MCC04
10:00 AM - 10:10 AM
Perioperative Management of Pheochromocytoma in Patient With Severe Dialated NICM and
Complete Heart Block
Matt Ploger, D.O., Mary Beth Huber, M.D., Anesthesiology and Critical Care, St. Louis University, Saint
Louis, MO
We describe a 20year-old male with dilated cardiomyear-oldpathy (EF 10%) and complete heart block
with PPM. Previously the patient’s cardiomyear-oldpathy was believed to be secondary to Uhl’s anomaly
with resultant thin walled RV and intermittent AV block. He was admitted with CHF exacerbation and
found to have new dilated LV systolic HF. After being diuresed, he was later re-admitted with AKI.
Pheochromocytoma was incidentally diagnosed after imaging on renal U/S. Pre-operative preparation
was achieved with doxazocin and the patient successfully underwent laparoscopic right adrenalectomy
requiring brief cardiovascular support with epinephrine and dobutamine. TEE was used to monitor cardiac
function intra-operatively.
MCC04
10:00 AM - 10:10 AM
Neuroanesthesia Management of a Suboccipital Craniotomy for a C1-C2 Mass Excision
Luis L. Llamas, M.D., Rachel M. Maldonado, M.D., Department of Anesthesiology, University of Texas
Health Science Center, San Antonio, TX
A 70 year-old female with rheumatoid arthritis and cervical spine myelopathy presented for a suboccipital
craniotomy for C1-C2 mass excision. We performed an awake fiberoptic intubation with a neurological
exam before induction of anesthesia. We kept her breathing spontaneously throughout the case to ensure
C3,4,5 phrenic nerve integrity. SSEP’s were also obtained. An arterial line and a central line were placed
in case of cord transection and neurogenic shock. The patient was extubated immediately postoperatively
with a preserved neurological exam. This case is an example of proper teamwork between
anesthesiology and neurosurgery to ensure a good patient outcome.
MCC04
10:00 AM - 10:10 AM
Rapidly Progressive Glomerulonephritis in Pregnancy: Rare Case
Miriam Flaum, D.O., Ranjan Gupta, D.O., John Gantomasso, D.O., Kalpana Tyagaraj, M.D., Maimonides
Rapidly Progressive glomerulonephritis is a rare kidney disorder described as rapid deterioration of
kidney function with progression to end stage renal disease and dialysis. This is a case of 30 years
female with a history of chronic hypertension, rapid progressive IgA crescentic glomerulonephritis, and
Gestational Diabetes. Patient came to the hospital at 35+weeks with worsening of kidney function,
hyperkalemia and superimposed preeclampsia. Multidisciplinary care plan was to perform Cesarean
Section and transfer to MICU. Introperative course was uneventful. In the MICU patient received a
permacath and hemodialysis. Patient was discharged home 8 days later with plan to f/u as outpatient.
MCC04
10:00 AM - 10:10 AM
A Case of a DEHP-Allergic Patient
Christian Mabry, M.D., Valerie McRae, M.D., Anesthesia, Rutgers Robert Wood Johnson Medical School,
New Brunswick, NJ
We present a patient with a history of anaphylactic reaction to di(2-ethylhexyl) phthalate (DEHP). The
purpose of DEHP is to make hard plastics more malleable. Almost all of the commonly used medical
products for a procedure like this, including the breathing circuit, facemask, endotracheal tube, pulse
oximetry, and intravenous fluid tubing contain plastics embedded with DEHP. Although the scheduled
procedure was one of the most common surgeries performed at our hospital, the patient's severe reaction
to such a common chemical in medical equipment presented a challenge that needed diligent
preoperative planning from all members of the operating room team.
MCC04
10:00 AM - 10:10 AM
Pain Medicine (PN)
Acute Cerebellar Herniation and the Case for a Stat Epidural Blood Patch
Thomas W. Mader, M.D., Dalia Elmofty, M.D., Anesthesia and Critical Care, University of Chicago,
Chicago, IL
18 year-old female with history of migraines who is 9 weeks postpartum following NSVD with placement
of lumbar epidural for pain control, who now presents to the emergency room with 3 weeks of worsening
headaches, gait instability, nausea and vomiting, and bilateral abducens palsy. In emergency room,
patient became acutely unresponsive and quadriplegic and was intubated for airway protection. Imaging
revealed acute bilateral cerebellar herniation, which was initially potentially thought to be secondary to
CSF leak from her labor epidural. Pain service was consulted for consideration of a “stat” epidural blood
patch.
MCC04
10:00 AM - 10:10 AM
Acute Pain Management and Peripheral Nerve Blockade in Patient With Complex Regional Pain
Syndrome I
Kristin Ondecko Ligda, M.D., Zachary Cohen, M.D., Anesthesiology, University of Pittsburgh Medical
Center, Pittsburgh, PA
Acute pain management in a patient with Complex Regional Pain Syndrome I presents a perioperative
challenge when the affected extremity is the operative extremity. This patient had a multi-year history of
inflammation, burning pain sensations, painful movement, and vasomotor dysfunction of her left lower
extremity. She had an unknown insult to lateral foot that progressed over several weeks to a painful
wound for which she presented for multiple incisions and drainages with inpatient antibiotics and wound
vacuum therapy. Peripheral nerve blockade (sciatic and saphenous) and multimodal anesthesia were
performed with successful relief of pain intensity in the perioperative period.
MCC04
10:00 AM - 10:10 AM
Ultrasound Pulsed Wave Doppler Detected an Intrathecal Location of Epidural Catheter Tip
Rovnat Babazade, M.D., Bimal Patel, D.O., Hesham Elsharkawy, M.D., Anesthesiology-Outcomes
Research, Anesthesiology, The Cleveland Clinic Foundation, Cleveland, OH
73 year-old male scheduled for bowel resection. Patient underwent epidural placement at T9-10 level. It
was a challenging case and after 3 failed trials; using ultrasound with the aid of loss of resistance to
saline, then the epidural catheter inserted. CSF was obtained upon aspiration (+glucose analysis) but
CSF aspiration was not typical and with a negative test dose. Alternative technique; u/s pulse waved
Doppler (Image) was used to detect NS flow at the posterior complex (negative) and in the intrathecal
space (positive). This case emphasizes the importance of availability of alternative novel technique to
verify the catheter tip
MCC04
10:00 AM - 10:10 AM
The Safe Perioperative Management of a Patient Undergoing Left Atrial Myxoma Resection With
Mitral Outflow Obstruction
Samina Chowdhury, M.D., Esther Garazi, M.D., Anesthesiology, University of Miami, Miami, FL
A 70 year-old female presented with multiple syncopal episodes. A transthoracic echocardiogram
revealed a left atrial mass with mitral valve outflow obstruction but no mitral regurgitation. Induction goals
were to maintain hemodynamic parameters similar to mitral stenosis, including low heart rate and high
preload. Post-induction transesophageal echocardiogram (TEE) revealed a left atrial mass with a stalk
attached to the posterior mitral annulus and an obstructive pathophysiology. The tumor was removed via
transeptal approach under cardioplegic arrest. TEE post-bypass demonstrated resection of the tumor with
no mitral regurgitation/stenosis or tissue damage. Patient was extubated in the OR and discharged day 5.
MCC04
10:00 AM - 10:10 AM
Management of a Presumed Pulmonary Embolism in a Patient Requiring Urgent D&E
Anthony Fernandes, M.D., Jonathan Groden, M.D., Richard Smiley, M.D.,Ph.D., Columbia University
Medical Center, New York, NY
44 year-old G5P0 with cervical insufficiency underwent abdominal cerclage; within 24 hours was
diagnosed with IUFD. She was being brought back to LandD for DandE; upon transfer from bed to
stretcher she became SOB, tachycardic (130 bpm) and hypoxemic (SpO2 92% on FMoxygen).
Presumptive diagnosis was pulmonary embolism. After a shortinterdisciplinary discussion regarding
procedural timing versus heparinization the decision was made to proceed with DandE under paracervical
block. After uneventful procedure, CTA confirmed pulmonary embolus, completely occluding LPA with
partial occlusion RPA . Heparin was initiated and she was transferred to SICU for further management.
MCC04
10:00 AM - 10:10 AM
Penetrating Chest Trauma and Resulting Pulmonary Artery and Left Lung Hilar Injury
Puneet Mishra, M.D., Yandong Jiang, M.D., Jessica Mudrick, M.D., Anesthesiology, Vanderbilt University,
Nashville, TN
45 year-old trauma patient with penetrating left chest injury presented to OR as level 1, hemodynamically
unstable. Sternotomy performed and left PA and left lung hilar injury identified. Patient went into cardiac
arrest, open cardiac massage was initiated, and 1mg intramyear-oldcardial epinephrine was administered
by the surgeon. He regained spontaneous rhythm with a blood pressure. Massive transfusion protocol
was activated and over 50 units of product were administered. Patient was deliberately right
mainstemmed to provide left lung isolation and a pulmonary artery repair and pneumonectomy were
performed. He was extubated on POD 1 with an intact neuro exam.
MCC04
10:10 AM - 10:20 AM
A Spinal Anesthetic in a Premature Infant With Bronchopulmonary Dysplasia Undergoing a
Laparoscopic Inguinal Herniorrhaphy
Donald A. Schwartz, M.D., Daniel Robinson, D.O., Anesthesiology, Baystate Medical Center, Springfield,
MA
A 2 month old male former 27 week 900 gram infant presented for outpatient hernia repair. The infant had
BPD requiring nasal cannula oxygen and apnea and bradycardia. A spinal anesthetic was chosen,
despite the surgeon planning to do the case laparoscopically. A bupivacaine lumbar spinal was placed
and laparoscopic herniorrhaphy proceeded. Insufflation pressures were minimized and the infant
displayed no hemodynamic or pulmonary compromise. There are no previous reports of spinal
anesthesia in premature infants for laparoscopic inguinal herniorrhaphy. This technique reduces exposure
to potentially neurotoxic agents, lessens the risk of apnea and the possible need for postoperative
ventilation.
MCC04
10:10 AM - 10:20 AM
A Morbidly Obese Patient Undergone Tracheal Resection With T-tube Stent Placement
Elva B. Bian, D.O., Stanley Hoang, M.D., Amanda Taylor, M.D., Husong Li, M.D., Anesthesiology,
University of Texas Medical Branch, Galveston, TX
This case report discusses the use of an LMA for positive pressure ventilation (PPV) in a morbidly obese
patient with tracheal T-tube stent following failed tracheal re-anastamosis, as well as its application for
emergent ventilation in the ICU. A T stent is a 3 way open ended T shaped tube without a balloon that
seals the airway, creating a leak to the path of least resistance (oro- and nasopharynx) if PPV is
administered via t-tube. In the case of a Montgomery T-stent, we suggest using LMA and ET as a sealing
device to facilitate PPV as an emergent temporizing measure.
MCC04
10:10 AM - 10:20 AM
Renal Allotransplantation in a Patient With Mitral Stenosis, Mitral Regurgitation, and Pulmonary
Hypertension
Mark R. Bombulie, M.D., Joel Musee, M.D.,Ph.D., Jason S. Lane, M.D.,M.P.H., Anesthesiology,
Vanderbilt University Medical Center, Nashville, TN
69 year-old female with moderate-severe mitral stenosis, mitral regurgitation, and pulmonary
hypertension presented for cadaveric renal allotransplantation. Pre-operative echocardiogram
demonstrated a mitral valve gradient of 13 mmHg and pulmonary artery systolic pressure of 65 mmHg.
Pre-induction radial arterial line was placed. The patient required phenylephrine infusion to maintain
MAPs >65 mmHg, despite receiving 4 liters of crystalloid. The transplant was completed and the patient
extubated; however, the transplanted kidney failed to function. Use of vasopressors in renal
transplantation is controversial. Surgeons tend to discourage their use, but in this case, vasopressor
support was required for the patient to tolerate anesthesia.
MCC04
10:10 AM - 10:20 AM
Glucagon-Induced Hyperkalemia During Endoscopic Retrograde Cholangiopancreatography
(ERCP)
Terri G. Monk, M.D., Steven R. McAfee, M.D., Lisa R. Romkema, C.R.N.A., Department of
Anesthesiology and Perioperative Medicine, University of Missouri, Columbia, MO
A 45 year-old male, ASA 3, with Type 1 diabetes mellitus, hypertension, and chronic kidney disease
underwent ERCP with general anesthesia for evaluation of a bile duct stricture. Fasting glucose on the
morning of surgery was 170 mg/dL. After administration of 0.75 mg glucagon (0.25 mg doses over an
hour) tall, peaked T-waves were noted on the ECG. Labs were drawn and potassium was 6.6 mEq/L and
glucose was 393 mg/dL. Intravenous calcium chloride, 1000 mg, was titrated. Repeat potassium was
6.1mEq/L and glucose 568 mg/dL. The remainder of the procedure was uneventful and postoperative
potassium was 5.2 mEq/dL
MCC04
10:10 AM - 10:20 AM
Perioperative Management of Eisenmenger Syndrome in the Setting of a Critical Airway, Likely
Secondary to Delayed Radiation-Induced Pathology
Josianne Abboud, M.D., Jackie Ragheb, M.D., Department of Anesthesiology, University of Michigan,
Ann Arbor, MI
Survival of acute high dose radiation exposure is associated with delayed radiation induced pathologies.
A 36 year-old male immigrant from Micronesia Bikini Atoll, a previous U.S. nuclear testing site, presented
with 1-week history of bilateral lower extremity edema and dyspnea on exertion. He had no prior medical
history or medical care. Work up revealed decompensated congestive heart failure and severe pulmonary
hypertension due to Eisenmenger Syndrome secondary to large undiagnosed VSD. There was an
incidental finding of a large papillary thyroid carcinoma causing significant airway distortion. He
underwent thyroidectomy including perioperative management of critical airway, Eisenmenger syndrome
and CHF.
MCC04
10:10 AM - 10:20 AM
Planned Evacuation of an ICU - Lessons Learned Through Simulation
Marian E. Von-Maszewski, M.D., Gregory Botz, M.D., Critical Care, MD Anderson Cancer Center,
Houston, TX
A 42 year-old with lymphoma was admitted to the ICU with multiorgan failure and respiratory failure
requiring intubation. He developed ARDS and required high levels of ventilatory support. In preparation
for a generator test which could affect electrical and gas supplies, patients were stratified according to
tolerance to transport and need for high levels of oxygen support. Due to this patient’s risk of instability, a
simulation was conducted with multi-disciplinary personnel prior to the planned event. Transport
ventilation, maintenance of necessary medications and modes of transport were practiced in order to
avoid an adverse outcome to this critically ill patient.
MCC04
10:10 AM - 10:20 AM
Ventricular Bigeminy During Desflurane Anesthesia: A Case Report
Dominic V. Pisano, M.D., Maurice F. Joyce, M.D., Kathleen Claus, M.D., Gustavo Lozada, M.D.,
Bhawana Dave, M.D., Anesthesiology, Tufts Medical Center, Boston, MA
Inhalational agents provide many anesthetic advantages in the operating room but are not without side
effects. One well known but infrequently observed side effect of inhalational agents is cardiac
dysrhythmias. Desflurane has not be reported to cause ventricular dysrhythmias; here, we report on a
case of ventricular dysrhythmia under desflurane anesthesia.
MCC04
10:10 AM - 10:20 AM
Right Carotid Endarterectomy With a Known Arteriovenous Malformation
Elizabeth J. Michael, M.D., Brigitte Messenger, M.D., Anesthesiology, University of TN at Knoxville,
Knoxville, TN
A 60 year-old man was seen for preoperative evaluation of severe right carotid artery stenosis and was
noted to complain of a debilitating right sided headache. Emergency department workup found a right
frontal arteriovenous malformation on CT angiogram. The decision was made to proceed with carotid
endarterectomy prior to AVM repair. Care was taken to prevent extremes of blood pressure as
hypertension could have resulted in ruptured AVM and hypotension could have resulted in CVA given
significant carotid stenosis. Ultimately, the patient did quite well with stable hemodynamics throughout the
case and is now scheduled for AVM clipping.
MCC04
10:10 AM - 10:20 AM
Pulmonary Embolism in a Parturient During Cesarean Section
Laura A. Shahnazarian, M.D., Kalpana Tyagaraj, M.D., Anesthesiology, Maimonides Medical Center,
Brooklyn, NY
Pregnancy and the puerperium are well-established risk factors for venous thromboembolism (VTE). The
incidence of VTE is 1.0 to 1.7 events per 1,000 pregnancies. Fifteen to 24 percent of pregnant women
with untreated DVT develop pulmonary thromboembolism (PE) which is responsible for about 15% of all
direct maternal deaths. The overall rate of maternal deaths because of PE has decreased. Early
recognition of at risk patients, thrombophylaxis, diagnosis, prompt resuscitation and anticoagulation can
reduce the incidence of morbidity and mortality associated with PE. We present a parturient who had PE
during C-Section and was resuscitated successfully.
MCC04
10:10 AM - 10:20 AM
Perioperative Management of a Patient With 1q43-q44 Chromosomal Deletion Syndrome
Shaconda M. Junious, M.D., Nikhil Thakkar, M.D., Anesthesiology, Baystate Medical Center, Springfield,
MA
Two year-old boy with 1q43-q44 chromosomal deletion syndrome presenting for release of chordae with
circumcision for phimosis and hypospadias. His medical history included agenesis of the corpus callosum,
microcephaly, micrognathia with history of difficult intubation, pulmonary hypertension, and Atrial Septal
Defect. Anesthetic goals included; first, maintenance of spontaneous ventilation with mask induction and
placement of an LMA, limiting airway manipulation in a patient with a history of difficult airway. Second,
avoiding neuromuscular blockade in a patient with known hyear-oldtonia/dystonia. Third, utilizing caudal
anesthesia to avoid polypharmacy, opioid use, and provide effective post-operative pain control. Patient
was discharged home without complications.
MCC04
10:10 AM - 10:20 AM
Pain Medicine (PN)
Ketamine Influenced Long QT Syndrome
Zachary C. Cohen, M.D., John Hache, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA
The chronic pain service was consulted for opinion on management of a patient’s pain given his history of
IVDA, after mitral and aortic valve replacment secondary to endocarditis. At the time of consultation the
patient’s pain was being controlled with PCA dilaudid, oxycodone, acetaminophen and ketamine at
7mg/hr. The chronic pain service made the following recommendations: increase the ketamine infusion
rate to 10 mg /hour, begin oxycontin 10 mg, begin gabapentin 300 mg at night and Tylenol 1000mg every
8 hours. On postoperative day two the patient suffered a cardiac arrest with notable Torsades de Pointes.
MCC04
10:10 AM - 10:20 AM
Quantitative Sensory Testing and Genetic Characterization of Hereditary Local Anesthetic
Resistance
Daniel Sisti, M.D., Lance Patak, M.D., MBA, Geoffrey L. Sheean, M.D., Stephen G. Waxman, M.D.,
Sulayman Dib-Hajj, Ph.D., Tony Yaksh, Ph.D., Anesthesiology, University of California, Neurology,
Scripps Health, San Diego, CA, Neurology, Yale School of Medicine, New Haven, CT
A patient was found to have localanesthetic resistance (LAR) after attempted block of his distal radialand
lateral antebrachial cutaneous peripheral nerves under ultrasoundguidance forright first dorsal wrist
compartment release.He reported a similar experience with two dental procedures and indicated
hismother experienced the same problem. Weinvestigated this case of LAR by performing
electrophysiological testing on thepatient before and after repeating nerve blocks with an amideand ester
and performed genetic analysis on the patient and his mother toidentify sodium channel polymorphisms
that may explain his LAR.
MCC04
10:10 AM - 10:20 AM
81 year-old Female With Left Femoral Neck Fracture, CHF, Presenting With Elevated Troponins
From Recent NSTEMI , and New LBBB. Patient Also Has Hypertension and Mild Dementia
Erikka L. Washington, Madu Rupasinghel, M.D., Pilar Suz, M.D., Anesthesiology, University of Texas
Health Science Center, Houston, TX
81 year-old female presents after a fall, breaking her femoral neck. The patient Has CHF, Hypertension
and a recent MI with troponins which are still elevated. Patient also suffers from Dementia and now has a
new LBBB.
MCC04
10:10 AM - 10:20 AM
An Unusual Presentation of Carcinoid Heart Syndrome and Implications for Anesthetic
Management
Ryan D. Allor, M.D., Jackie Ragheb, M.D., Anesthesiology, University of Michigan, Ann Arbor, MI
Carcinoid heart syndrome is a complication appearing late in approximately 50% of cases of metastatic
carcinoid syndrome. Herein we present a case of a 38 year-old female whose first presenting symptom of
metastatic carcinoid disease with mesenteric primary was acute congestive heart failure secondary to
carcinoid heart syndrome. The patient underwent tricuspid and pulmonic valve replacement for severe
valvular regurgitation. Strict hemodynamic monitoring was required given the risks of hypotension,
dysrhythmia, and exacerbation of right heart failure secondary to serotonin release. Octreotide was
administered pre-, intra-, and post-operatively to mitigate carcinoid cardiovascular effects. The patient’s
perioperative course was uneventful.
MCC04
10:10 AM - 10:20 AM
Epidural Analgesia in a Parturient With a Spinal Cord Stimulator
Adil Mohiuddin, M.D., Shaul Cohen, M.D., Antanique Brown, B.A., Brian Shen, M.D.,Anesthesiology,
Rutgers-Robert wood Johnson Medical School, New Brunswick, NJ
A 36 year-old primiparous at 38.5 wks (200lbs, 67 in) with oligohydrominios was taken for C-section for
induction failure. Patient had chronic LBA bilateral sciatica, epidural spinal electrode at T7-8, neurologist
recommended epidural analgesia to be safe, to be placed 3" above the incision or below the incision. An
epidural catheter was placed with patient in the sitting position, blockade was achieved at levels T7-S5,
CS for arrest of descent. The epidural catheter was “working well”. The fetus was extracted with Apgars of
9 and 9. postoperative course was uncomplicated. Concerns included damage to the electrodes, leads, or
extensions.
MCC04
10:10 AM - 10:20 AM
Anesthetic Management In a Patient With Coffin Siris Syndrome.
Navneet Kaur, Rehan Siddiqui, M.D., Emiro Granados, Elif Cingi, Anesthesiology, Universty of Minnesota
Medical Center, Edina, MN, Universty of Minnesota Medical Center, Minneapolis, MN
Coffin-Siris syndrome is a rare genetic disorder with characteristic craniofacial abnormalities which can
lead to difficult intubation. We are reporting a case of 33 year-old male with history of Coffin-Siris
syndrome, schwannomatosis, OSA, asthma, hypertension, GERD, cervical spondylosis and CVA
presented for parotidectomy and glossectomy for rapidly growing schwannomas. Preoperative
assessment of patient revealed short neck, broad mouth, thick lips, flat nasal bridge, macroglossia,
limited ROM of neck, developmental delay, poor dentition and large tumor of tongue with mallampati IV
view. We will discuss the anesthetic management of the patient.
MCC04
10:20 AM - 10:30 AM
Heart and Liver Transplant in Failing Fontan
Prabhat Mishra, M.D., Jacob L. Christensen, M.D., Angela Saettele, M.D., Daniel Nieva, M.D., Pediatric
Anesthesiology, Washington University in St. Louis, Saint Louis, MO
17 year-old male with hypoplastic left heart now with failing Fontan and incidentally discovered
hepatocellular carcinoma presented for combined heart and liver transplantation. Epinephrine infusion
and radial arterial cannulation preceded a stable induction. Venous access was secured with appreciation
of Fontan physiology as well as anticipation of redo sternotomy. Low dose inotropes and nitric oxide
facilitated separation from cardiopulmonary bypass with good biventricular function noted on
transesophageal echocardiogram. Liver transplantation followed. Careful management yielded
reperfusion with little change in cardiac function. ROTEM thromboelastometry was used to direct and
minimize blood component therapy throughout.
MCC04
10:20 AM - 10:30 AM
Intraoperative Air Embolism and Cardiac Arrest Following Blunt Chest Trauma
Daniel L. Kohut, M.D., Department of Anesthesiology, New York University, New York, NY
37 year-old female presented with blunt right chest trauma. A chest tube drained 2 liters of blood, but the
patient responded well to resuscitation. CT chest revealed significant right lung parenchymal injury. After
single-lumen intubation and positive pressure ventilation, the patient became extremely hypotensive. Her
endotracheal tube was switched to a double-lumen, but the patient went asystolic prior to commencing
single-lung ventilation. Thought to be secondary to hemorrhage, a crash-thoracotomy and ACLS were
performed simultaneously. Although no overt bleeding was found, TEE revealed extensive venous air
embolism.
MCC04
10:20 AM - 10:30 AM
Anesthetic Management of a Patient With Central Airway Obstruction
Keth M. Pride, M.D., Shalini Borden, M.D., Kenneth Van Dyke, M.D., Anesthesiology, University of
Wisconsin-Madison Hospital and Clinics, Madison, WI
91 year-old male with cervical rheumatoid spondylitis and congestive heartfailure presented in acute
respiratory failure due to centrally obstructing lesion within the right main bronchus. Bronchoscopy with
laser debulking andstenting was performed by the pulmonologist; limited neck mobility, cardiaccoCopyright © 2015 American Society of Anesthesiologists
morbidities, and a brief episode of complete airway obstruction due tomishandled tumor specimen
presented significant challenge to the anesthesiologyteam. Successful anesthetic management included
in-line neck stabilization fortracheal intubation, avoidance of sedative pre-medication, low FiO2
duringelectrocautery, and close communication with the surgeon. The patient remainedintubated postoperatively during ICU recovery.
MCC04
10:20 AM - 10:30 AM
Anesthetic Management of Whipple Surgery With Right Atrial Thrombus and Abdominal Aortic
Aneursym
Ramesh Kumar Swamiappan, M.B.,B.S., Marina Svyatets, M.D., Michael Pedro, M.D., Ryan Toole, D.O.,
Anesthesiology, SUNY Downstate Medical Center, Brooklyn, NY
Adenocarcinoma of duodenum rarely presents with thrombus in right atrium (RA). Coexisting atrial
fibrillation, pulmonary embolism and abdominal aortic aneurysm makes anesthetic management more
challenging. We present our experience with patient, who underwent Whipple procedure. Patient was
anticoagulated and IVC filter was placed preoperatively. Limited recommendations are available for
Central Venous Cannulation (CVC) with preexisting RA thrombus. Routine use of Transesophageal
Echocardiography (TEE) in CVC placement for non cardiac surgeries is not common. But in our case real
time TEE was a valuable tool not only for CVC but also to assess right atrial thrombus mobility and
displacement intraoperatively and postoperatively.
MCC04
10:20 AM - 10:30 AM
Severe Hypoxemia On A Patient With A Large Patent Foramen Ovale Undergoing Right Atrial Mass
Resection
Paula Trigo Blanco, M.D., Gnana S. Simon, M.D., Trevor Banack, M.D., Yale New Haven Hospital, New
Haven, CT
71 year-old woman was admitted for severe hypoxemia, found to have a large right atrial mass. Patient
presented to the OR for mass excision, standard ASA monitors and arterial line were placed. Patient was
preoxygenated with 100% oxygen prior to intravenous induction and intubation. Shortly after, desaturation
to 80% was noted. Controlled ventilation with 100% oxygen and inotropes administration resulted in a
saturation of 100%. Intraoperative echocardiogram revealed the large mass and an undiagnosed patent
foramen ovale. Findings were shown to the surgeon. Following mass excision and PFO closure, paO2
and saturation improved. Postoperatively patient was transferred to the CTICU
MCC04
10:20 AM - 10:30 AM
Inter-Institutional Transport of a Patient With ARDS
Marian E. Von-Maszewski, Gregory Botz, M.D., Cristina Gutierrez, M.D., John Crommett, M.D., Critical
Care, MD Anderson Cancer Center, Houston, TX
A patient with ARDS was accepted for transfer to a nearby institution for possible ECMO. He required
ventilation in APRV mode to maintain adequate oxygenation. Transport personnel were uncertain of a
method to transport the patient with portable equipment and adequate provision of ventilator support.
Respiratory and ICU staff assisted with transition to a mode which would maintain higher airway
pressures using assist control with pressure control. The patient was observed at bedside and stable for
15 minutes without desaturation. A respiratory therapy supervisor agreed to accompany the team on
transport. He was moved to the receiving institution without incident.
MCC04
10:20 AM - 10:30 AM
Anesthetic Plan for a Patient With Recent Acute Inflammatory Demyelinating Polyneuropathy and
a Potentially Challenging Airway
Sn R. Vishneski, M.D., Amy T. Campos, M.D., Wake Forest School of Medicine, Winston-Salem, NC
A morbidly obese patient scheduled for transanal endoscopic microsurgery presents with residual
weakness after recent acute inflammatory demyelinating polyneuropathy. He has further history of
obstructive sleep apnea. He is a Mallampati class III, with thick neck, retrognathia and limited neck
extension. Due to the identified difficult airway indices, recent AIDP and residual weakness, and desire to
avoid neuromuscular blockade, an awake fiberoptic intubation was performed. A remifentanil infusion
provided akinesis and analgesia with the goals of optimizing conditions for extubation, avoiding prolonged
intubation, and minimizing postoperative pulmonary complications.
MCC04
10:20 AM - 10:30 AM
A Case of Flipped Learning: Cardiovascular Collapse Secondary to Massive Emboli During a
Prone Spinal Fusion With Instrumentation
Brent M. Bushman, M.D., Edward Kosik, D.O., Teodora Nicolescu, M.D., Daryl Reust, M.D.,
Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
A 59 year-old female with severe COPD, presented for Harrington Rod removal and posterior spinal
fusion and instrumentation. The patient was induced and positioned prone with intravenous lines, and
arterial line. During one point in the case, the surgeon warned about potential for blood loss. Immediately
afterwards, a swoosh was heard and end-tidal CO2 and blood pressure decreased suddenly. Surgeons
were notified and flooded the field, packed the wound and closed. The patient was resuscitated and
turned supine. TEE and CT scan supported massive bilateral pulmonary emboli. Days later, a Greenfield
filter was place and the procedure completed.
MCC04
10:20 AM - 10:30 AM
Inadvertent Prolonged Subdural Anesthesia Following Para Cervical Block With a Presentation of
Profound Motor and Sensory Deficit
Hosni M. Mikhael, M.D., Nalini Vadivelu, M.D., Ferne Braveman, M.D., Anesthesiology, Yale University,
North Haven, CT
.A 29 year female 22 weeks gestation presented for termination of pregnancy. A paracervical block was
performed by surgeon with a spinal needle with lidocaine and vasopression The patient developed a
prolonged profound motor and sensory blockof both lower extremities for several hours post procedure
.Subdural block is oftenpoorly recognized as a complication of neuraxial analgesia with an even
lowerincidence occurring as a complication of a Para cervical block.The unpredictable and variable
presentation ofsubdural block with disproportionate extent of the block makes the diagnosisand
management of such patients immensely challenging.
MCC04
10:20 AM - 10:30 AM
Anesthetic and Airway Management of a Child With Goldenhar Syndrome for Emergent
Tarsorrhaphy
Anna Korban, M.D., S Pandya Shah, M.D., Rutgers, South River, NJ, Rutgers, Newark, NJ
10 months old female with Goldenhar syndrome, prior history of fiber optic intubation planned for
emergent tarsorrhaphy. The preoperative assessment revealed Malampatti score of 4, severe hemifacial
microsomia, short thyromental distance, limited neck movement and mouth opening. ENT team on
standby in operating room in case of failed intubation attempt. Preexisting IV access was used,
remifentanil infusion was titrated along with slow inhalation induction using sevoflurane with ultimate goal
to preserve spontaneous breathing until airway was secured. Oral intubation performed using glidescope
and cricoid pressure. Underwent tarsorrhaphy, followed by MRI of the orbit and return to operating room
for extubation.
MCC04
10:20 AM - 10:30 AM
Post-Operative Analgesia for Patient Undergoing Hyperthermic Intraperitoneal Chemotherapy
Surgery
Andrew T. Leitner, Anesthesiology / Interventional Pain Management, City of Hope National Medical
Center, Duarte, CA
A 49 year-old female was scheduled to undergo colon resection, cytoreduction, and heated
intraperitoneal chemotherapy with mitomycin C. Pre-operatively, she expressed concerns about her
intolerance of most narcotics, including morphine, hydromorphone, and oxycodone. A multi-modal plan
for perioperative pain control was implemented, with goals of analgesia, opioid-sparing, and return to
bowel function. Intraoperatively, transversus abdominus plane catheters were placed with continuous
infusion of 0.2% ropivacaine. Postoperatively, patient also received a ketamine infusion, fentanyl patch,
and gabapentin. Patient achieved appropriate analgesia and was discharged without complication on
post-operative day eight. Follow up at one month indicated minimal ongoing abdominal pain or
dysfunction.
MCC04
10:20 AM - 10:30 AM
Management of Lumbar Epidural in the Setting of Pregnancy Induced Liver Failure
Francisco I. Buendia, M.D., Semhar Ghebremichael, M.D., Anoop Pathikonda, M.D., Anesthesiology,
University of TX at Houston, Houston, TX
32 year-old African American female transferred from OSH with labor epidural and acute liver failure
secondary to fatty liver of pregnancy after IUFD at 39 weeks. We were consulted for management of
epidural in the setting of profound coagulopathy and thrombocytopenia. Her hospital course was
complicated by ongoing liver failure, coagulopathy despite treatment with infusions of FFP and platelets
and prolonged epidural placement. Patient’s clotting status was monitored daily via TEG and INR.
Decision was made on day number 7 of epidural to remove catheter despite persistent thrombocytopenia
and prolonged (but improved) INR and documented normal TEG.
MCC04
10:20 AM - 10:30 AM
Acute Onset of Aortic Insufficiency in a 65 year-old Trauma Patient During Repair of Intrathoracic
Aortic Pseudo-aneurysm With Intramural Hematoma
Jennifer Cowell, M.D., Thomas Jan, M.D., Oren Ambalu, M.D., Vincent DeAngelis, M.D., Anesthesiology,
Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
65 year-old female s/p MVA with multiple orthopedic injuries and traumatic aortic pseudoaneurysm/mediastinal hemorrhage brought to OR for endovascular repair of aorta. Standard ASA
monitors, radial artery invasive BP monitor with 16g x2 used. Induced with Propofol(200mg),
Fentanyl(200mcg), Succinylcholine(80mg), and maintained with Desflurane5.5% with 0.30-O2/Air ratio.
After introduction of graft through the right groin, episode of non-sustained ventricular-tachycardia
prompted TEE, showing new regurgitant jet from AV-cusp. Remained hemodynamically stable despite
widened pulse-pressure. Swan-Ganz catheter placed for post-op monitoring. Transferred to ICU for
observation, cardiology/cardiac surgery consults for possible AVR the same admission. Subsequent
operations this admission complicated by multiple PVCs.
MCC04
10:20 AM - 10:30 AM
Anesthetic Management of 37-week Parturient With Chiari I Malformation and MRI Demonstrating
Herniation and Intraventricular Clots
Andrew P. Agoliati, M.D., Samion Shabashev, M.D., Kaitlin Guo, M.D., Michale Sofer, M.D.,
Anesthesiology, New York University Medical Center, New York City, NY
16F 37 weeks gestation. PMH: recently diagnosed papilledema, MRI revealing Chiari I malformation,
tonsillar herniation and intraventricular clots. Pt. was recommended not to labor secondary to risks of
elevating ICP. Scheduled elective c-section. Prior to surgery, pt. was assessed by OB, peds-neuro,
neurosurgery and anesthesia. Neurosurgery recommended avoiding neuraxial anesthesia due to risk of
dural puncture and herniation. All teams concerns heard and addressed. Pt underwent general
anesthesia, with rapid sequence intubation and smooth IV induction synchronized with OB operative start.
Induction with propofol/fentanyl/rocuronium. Remifentanyl infusion for smooth narcotic wake-up. Pt was
extubated without complications and experienced uneventful recovery.
MCC04
10:20 AM - 10:30 AM
Anesthetic Management for 70-year Female With Mandibular Abscess
Sandeep Singh, Kulwinder Singh, M.B.,B.S., Dayanand Medical College and Hospital, Ludhiana, India
We describe airway management in a 70yr old female with a left mandibular abscess scheduled for
incision and drainage. This developed in her after she underwent tooth extraction 5 months ago. Airway
was assessed pre-op using standard bedside methods and then anesthetic management of this case was
planned. There is currently no universal agreement on the ideal method of airway control for these
patients because this depends on various factors including available expertise and equipment. Difficult to
intubate and difficult to ventilate together with the sharing of working area with the surgeon makes this
case most challenging.
MCC04
10:30 AM - 10:40 AM
Massive Transfusion With 5 U PRBC, 3 U FFP and 160 cc of Platelets in 14-month-old Patient for
Parietooccipital Tumor Resection
Tanaya Sparkle, M.B.,B.S., Lisa Evans-Weiss, M.D., Staci Cameron, M.D., Anesthesiology, University of
Texas Health Science Center at Houston, Houston, TX
14 month old with 4X5X5cm parietooccipital tumor. Severe acute blood loss was encountered during
surgical resection leading to hypotension. Transfusion was initiated after receiving indication from
surgeon about acute blood loss. Total of 5 U PRBC, 3 U FFP, 160 cc platelets, 200 ml albumin and 500
cc normal saline was given during the 5 hour case. Patient was also given mannitol, lasix, decadron and
keppra in the OR to deal with anticipated neurosurgical complications and fluid overload. Estimated blood
loss was 1.3 L. Patient was transported to PICU, extubated the next day and discharged after 6 days.
MCC04
10:30 AM - 10:40 AM
Penetrating Trauma Complicated by Massive Intraoperative Pulmonary Embolism after
Tranexamic Acid treatment
Michael S. Thompson, D.O., Theresa A. Gelzinis, M.D., Department of Anesthesiology, University of
A healthy 24 year-old male presented to the Emergency Department after a single stab wound to the left
chest. He was hemodynamically unstable and was administered 4 units of PRBCs and 1,000mg of
tranexamic acid. One hour into the thoracotomy he developed cardiac arrest. During resuscitation
attempts a TEE was performed by the on-call cardiothoracic anesthesiologist who diagnosed a large
pulmonary artery saddle embolus. Autopsy revealed additional bilateral lower extremity DVTs. It is
unknown if population subsets might be susceptible to thrombosis after tranexamic acid treatment and
may benefit from either a reduced dose or no antifibrinolytic treatment.$$MISSING OR BAD IMAGE
SPECIFICATION {EF44CAFA-F68F-4499-889B-7A000F4F2BB3}$$
MCC04
10:30 AM - 10:40 AM
Emergent Surgical Airway in a Can’t Intubate, Can’t Ventilate Trauma Patient
Gianella Russo, M.D., Adrienne Warrick, M.D., Anesthesia, UF Health, Jacksonville, FL
A 40 year-old morbidly obese male with no known past medical history presents to the trauma
department with a GSW to the left flank. The patient was hypotensive and complained of pain in the left
flank and abdomen. On physical exam the patient was a GCS 15, tender on palpation of abdomen, with a
positive FAST exam, and was taken to the OR for an emergent exploratory laparotomy.
MCC04
10:30 AM - 10:40 AM
Diagnosis of Subclavian Artery Stenosis After Anesthetic Induction
David M. Shapiro, M.D., Andrew T. Goldberg, M.D., Anesthesiology, Icahn School of Medicine at Mount
Sinai, New York, NY
85 year-old female presented for nasal carcinoma resection and forehead advancement flap. She had no
cardiac history, >4 METs exercise tolerance, and preoperative blood pressure of 130/77 in the left arm.
Standard ASA monitors were placed and included a BP cuff on the left arm. After induction of general
anesthesia, the blood pressure fell to 58/35 and remained refractory to resuscitative drugs. ST
depressions were noted in the inferior leads. During resuscitation, a right radial arterial line was placed,
revealing a blood pressure of 210/92. The case was cancelled. Postoperative cardiology workup
(including dopplers) revealed left subclavian artery stenosis.
MCC04
10:30 AM - 10:40 AM
Intra-cardiac Coaxial Cable Causing Ventricular Septal Defect and Severe Mitral Regurgitation
Austin J. Adams, M.D., Nathan R. McIntire, M.D., Amy L. Duhachek-Stapelman, M.D., University of
Nebraska Medical Center, Omaha, NE
A 44 year-old male with paranoid schizophrenia presented for extraction of multiple intra-cardiac copper
wire fragments. Following induction of anesthesia, intraoperative TEE confirmed several intra-cardiac
wires. One fragment passed from the right ventricle into the left ventricle causing a VSD. A second wire
passed from the right ventricle trans-septally through the LVOT, abutting the anterior leaflet of the mitral
valve. Two separate regurgitant jets originated from the anterior leaflet of the MV. Extraction of five wire
fragments and repair of two 2mm tears in the MV were performed utilizing TEE to assess adequacy of
repair.
MCC04
10:30 AM - 10:40 AM
Coagulopathy Following Thoracic Surgery in the Intensive Care Unit
Jesse J. Kiefer, M.D., Christopher Franklin, M.D., Department of Anesthesiology, University of Maryland,
Baltimore, MD
AW is a 37 year-old male admitted to the surgical intensive care unit following thorascopic unroofing of
mediastinal hematoma with subsequent repeat thoracotomy for hemothorax and repair of iatrogenic
esophageal injury. AW continued to require intensive care unit care secondary to hemorrhage requiring
daily transfusions in the setting of abnormal coagulation studies. A coagulopathy workup including
thromboelastograms, mixing studies, dilute Russell’s viper venom, and individual factor studies was
performed. AW was found to have an acquired factor inhibitor and lupus anticoagulant, which ultimately
responded to FEIBA.
MCC04
10:30 AM - 10:40 AM
Anesthetic Challenges in Polycystic Kidney and Liver Disease Presenting for Nephrectomy and
Liver Cyst Fenestration
Andrea M. Keohane, M.D., Jason S. Lane, M.D., Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN
A 49 year-old female with polycystic kidney and liver disease, chronic kidney disease and chronic pain
presented for right nephrectomy and liver cyst fenestration for painful, symptomatic cysts. The patient
developed precipitous hypotension with mobilization of the kidney, which was responsive to fluid boluses
and norepinephrine. Intraoperative TEE showed normal ventricular function but underfilled ventricles. The
hypotension cause was likely retractor placement and size and location of large cysts decreasing venous
return. Patient responded to a liberalized fluid approach to resuscitation. She was admitted to the ICU for
postoperative monitoring given kidney disease and potential difficulty mobilizing the large volume
resuscitation.
MCC04
10:30 AM - 10:40 AM
Use of Draeger Apollo to Deliver Bilevel Positive Pressure Ventilation for Patient With Severe
COPD During Awake Frontal Craniotomy
Susie S. Lee, M.D., Mitchell F. Berman, M.D.,M.P.H., Anesthesiology, Columbia University Medical
A 62 year-old woman with severe COPD (FEV1 28%), history of right upper lobectomy, and moderate
pulmonary hypertension presented for craniotomy for removal of a frontal tumor.The case was performed
under MAC with BIPAP delivered through a standard mask with elastic straps and a Draeger anesthesia
machine set on Pressure Support Mode, titrated to generate volumes of 300-350 mL. Low doses of
Dexmedetomidine, Remifentanil and Propofol were administered. At the end of the case, PaO2 was
310mmHg on FiO2 of 60% and PaCO2 was 54 mmg (baseline 50 mmHg). She awoke promptly and
demonstrated a stable neurologic exam.
MCC04
10:30 AM - 10:40 AM
Labor Analgesia in a 21-week Gestational Age Woman With Possible Carcinoid Crisis
Micah Burns, M.B.,B.Ch., Sangeeta Kumaraswami, M.B.,B.S., New York Medical College, New York, NY,
New York Medical College, Valhalla, NY
A 36 year-old female conceived while on chemotherapy for metastatic carcinoid tumor metastatic. She
remained asymptomatic during pregnancy despite discontinuing chemo/octreotide. She presented for
abortion at 21 weeks secondary to anencephaly. Anesthesia was called for epidural placement prior to
oxytocin commencement and told that misoprostol administration had precipitated a carcinoid crisis with
diarrhea and nausea. In consultation with an oncologist it was determined this was a side effect of the
misoprostol. Both pain and a precipitate drop in BP can initiate carcinoid crisis, the epidural was placed
after 1L bolus LR and slowly titrated.
MCC04
10:30 AM - 10:40 AM
Anesthetic Management for Craniosynostosis Repair in a Child With Williams Syndrome and
Micrognathia-glossoptosis Syndrome
Ali Kandil, D.O., Mohamed Mahmoud, M.D., Rajeev Subramanyam, M.D., Anesthesiology, Cincinnati
Children's Hospital Medical Center, Cincinnati, OH
17 month-old female with Williams Syndrome (WS), concomitant supravalvar aortic and pulmonic
stenosis, micrognathia-glossoptosis syndrome, status post EXIT to tracheostomy, presents for
craniectomy and posterior vault remodeling for sagittal craniosynostosis. Anesthetic management for this
child was exceedingly challenging given cardiac, airway, and neurologic implications. There are very few
published reports of patients with craniosynostosis and WS. Complicating anesthetic management was
the patient’s tracheostomy-dependence and concern for access to the airway during the repair. Patient
tolerated inhalational induction, arterial line was placed for tight blood pressure control, and anesthetic
maintenance was augmented with remifentanil infusion.
MCC04
10:30 AM - 10:40 AM
Pain Medicine (PN)
Intractable Polyneuropathic Pain Syndrome Status Post Bariatric Surgery
Anita Gupta, D.O., Talinn H. Toorian, M.D., Marlene Barnhouse, M.D., Anesthesiology and Pain
Medicine, Drexel University College of Medicine, Philadelphia, PA
We will describe a female with sudden onset of weakness, seizures, ataxia, ocular apraxia. She had a
history of morbid obesity with recent gastric bypass. Post procedure she developed polyneuropathic pain
syndrome. She developed increased left-sided weakness with an inability to walk. Later he returned with
increasing pain and decreased motor function. Diagnostic workup revealed decreased thiamine, copper
and ceruloplasmin, low TSH, and persistently elevated B1, B12 and aldolase. She continues to be without
complete resolution of her chronic pain, muscle spasms and residual weakness despite medical
management.
MCC04
10:30 AM - 10:40 AM
Serial Peripheral Nerve Blocks in Complex Regional Pain Syndrome (CRPS) Treatment
Tuan T. Nguyen, D.O., Hui Yuan, M.D., Anesthesiology and Critical Care, St. Louis University School of
Medicine, Saint Louis, MO
A 41 year-old male suffered trauma to his right ankle after ATV rollover. He required multiple operations
and subsequently developed chronic pain. Patient exhibited signs of CRPS. This was refractory to
conservative measures. The pain was debilitating and patient could not work or participate in physical
therapy. Serial peripheral nerve blocks were then performed at the popliteal region with 0.2% ropivacaine
and 10 mg dexamethasone to block the sciatic nerve. Analgesia was sustained on average of 3 days and
patient was able to participate in physical therapy and ADLs. Six subsequent PNBs were performed
before lumbar sympathectomy.
MCC04
10:30 AM - 10:40 AM
Awake Nasotracheal Intubation of a Parturient With Submandibular Abscess Using
Dexmedetomidine for Sedation and Transtracheal and Superior Laryngeal Block
Justo Gonzalez, Michael Akerman, M.D., Cleveland Clinic, Cleveland, OH, Anesthesiology, Cornell
University School of Medicine, New York, NY
We report a 31 year-old female G5P4 who presented at 30 weeks gestation for debridement of a right
submandibular abscess. She had increased secretions and limited mouth opening <1cm.
Demedetomdine infusion was utilized for sedation and topicalization and dilation of the right nare
performed. Bilateral superior laryngeal blocks and a transtracheal block was performed and
glossopharyngeal block was omitted/. An endotracheal tube size 6 was inserted into the nare and a
fiberoptic was used for intubation. Uneventful surgery was performed and a 14F cook catheter was left in
place and removed in PACU in case of need for reintubation.
MCC04
10:30 AM - 10:40 AM
Mishap During Esophageal Perforation Repair
Irida Nikolla, M.D., Benjamin Peng, M.D., Anesthesiology, University of Illinois Hospital and Health
Systems, Chicago, IL, Anesthesiology, Advocate Christ Medical Center, Oak Lawn, IL
We present the case of a 63 year-old with pericardio-esophageal fistula, secondary to Atrial fibrillation
ablation a month prior, who now was offered a lattisimus dorsi pedicle flap in efforts to create a
permanent seal between esophagus and pericardium. In perioperative planning, besides surgical
approach details, great thought was given to need of cardiopulmonary bypass, personnel available,
venous access, as well as blood products. The day of the surgery during the esophageal dissection,
nicked the left Atria with 600ml blood loss noted instantaneously, what followed was a calculated plan that
went in action skillfully.
MCC04
10:30 AM - 10:40 AM
General Anesthesia for Caesarean Section in a Full-Term Patient With Chiari Type I Malformation
Adil Mohiuddin, M.D., Oleksiy Lelyanov, D.O., Shaul Cohen, M.D., Neethu kumar, M.D., Anesthesiology,
Rutgers-Robert wood Johnson Medical School, New Brunswick, NJ
A 23 year-old, G2P0010 female, with known Chiari malformation Type 1, at 39 wks IUP (ht 5’7”, wt
200lbs) presented with rupture of membranes. The patient’s surgical history was significant for DandC in
2010 for spontaneous abortion. The patient underwent a neurosurgical evaluation which included an MRI
showing a stable Chiari I malformation with cerebellar tonsils occupying the foramen magnum.This case
demonstrates the relative safety of using general inhalational anesthesia with rapid sequence induction in
order to minimize possible complications accompanying accidental dural puncture resulting in CSF leak in
pregnant patients with Chiari I malformation during delivery.
MCC04
10:30 AM - 10:40 AM
Anesthetic Considerations in a Patient With Phosphatase and Tensin Homologue (PTEN) Gene
Mutation- Hamartoma Tumor Syndrome Ammar Mahmoud, M.D., Ned Nasr, M.D., Reza Borna, M.D., Anesthesiology, John H Stroger Hospital of
Cook County, Chicago, IL
Phosphatase and tensin homologue (PTEN) mutations present a wide spectrum of clinical features that
challenge perioperative, intraoperative and postoperative anesthetic management. We present a patient
with known PTEN Hamartoma tumor syndrome with multiple large pulsatile cutaneous arteriovenous
malformations (AVM’s) in the upper extremity and deep pulmonary and abdominal wall AVM’s who
underwent multiple anesthetic exposures for the management of choledocholithiasis. There are no
previous reports discussing the management of such massive widespread AVM’s. Concerns surrounding
adequate vascular access, massive intraoperative hemorrhage, undiagnosed high-output cardiac disease
and unpredictable drug pharmacokinetics are unique to this patient and require careful consideration.
MCC04
10:40 AM - 10:50 AM
Anesthetic Considerations for a Child With Hyperkalemic Periodic Paralysis
Donald A. Schwartz, Ngoc Chu, D.O., Anesthesiology, Baystate Medical Center, Springfield, MA
A 7 year-old male with Hyperkalemic Periodic Paralysis presented for adenoidectomy. On the day of
surgery he had moderate weakness in his lower extremities. He was instructed to maintain hydration with
carbohydrate-rich fluids up to 3 hours before surgery. Mask inhalation induction minimized stress; muscle
relaxants, hypothermia and K-containing fluids were avoided. Adequate hydration was provided with
D5NS. In the PACU respiratory function was monitored closely and the patient discharged home without
increased weakness. Anesthetic management of this disorder in children is not well documented in the
literature. Management differs significantly from the more common Hypokalemic Periodic Paralysis.
MCC04
10:40 AM - 10:50 AM
Anesthetic Management of a Mediastinal Mass
Maribeth Guletz, D.O., T. Anthony Anderson, M.D.,Ph.D., Anesthesiology, Massachusetts General
Hospital, Boston, MA
We describe the anesthetic management of a healthy 18 year-old male who presented for mediastinal
mass excision via median sternotomy. Important anesthetic considerations for patients with a mediastinal
mass include cardiovascular collapse and perioperative respiratory complications, including total
occlusion of the airway. The anesthetic plan requires intensive preoperative assessment of clinical signs
and symptoms, as well as chest imaging to assess the severity and extent of airway and vascular
compromise prior to choosing an anesthetic plan. Although avoidance of general anesthesia is safest, it is
often required. Our case exemplifies cardiovascular instability upon induction and resection of the
mediastinal mass.
MCC04
10:40 AM - 10:50 AM
A Simple Nasal Mask/Circuit Assembly Maintained Oxygenation in a Patient With a Rigid Cervical
Collar and Limited Mouth Opening During Video-Laryngoscopic Endotracheal Intubation Quynh-Tien Mai, M.D., Ryan Sison, M.D., Christine Hunter Fratzola, M.D., James Tse, M.D., Department
of Anesthesiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
53 year-old female with recent anterior cervical discectomy complicated by infected hardware and neck
abscess presented for posterior C3-C4 fusion. A rigid cervical collar limited airway exposure. An infant
facemask was secured over her nose with head-straps and connected to anesthesia circuit/machine.
After pre-oxygenation with CPAP and general induction, nasal ventilation was successful. Video
laryngoscopy (#3 blade) revealed laryngeal edema that resulted in an esophageal intubation. Further, #4
blade failed to reveal a better view. Subsequent re-attempt with a #3 blade resulted in atraumatic
endotracheal intubation. Oxygen saturation remained 100% throughout with intermittent nasal ventilation.
The patient was successfully extubated postoperatively.
MCC04
10:40 AM - 10:50 AM
Air Embolism During Endoscopic Retrograde Cholangiopancreatography
Angie A. Geiger, M.D., Ellen K. Roberts, M.D., Nicholas W. Markin, M.D., Tara R. Brakke, M.D., M Megan
Chacon, M.D., James N. Sullivan, M.D., Anesthesiology, University of Nebraska Medical Center, Omaha,
NE
Air embolism during ERCP is uncommon, but associated with infection, stenting, and insufflation. A 75
year-old male with recurrent intrahepatic biliary obstruction and cholangitis status post biliary stent
placement presented for repeat ERCP under general anesthesia. After deployment of a new biliary stent,
end-tidal carbon dioxide decreased from 36mmHg to 5mmHg, and he became profoundly hypotensive
and hypoxic. The procedure was aborted and advanced cardiac life support was initiated. A
transesophageal echocardiogram demonstrated air in the left atrium, left ventricle, and aorta. He was
stabilized and received hyperbaric oxygen therapy with complete recovery.
MCC04
10:40 AM - 10:50 AM
An Interesting Case of Postoperative SVC Obstruction After Cardiac Surgery
Aimee Pak, M.D., Slawomir Oleszak, M.D., Sandeep Gupta, M.D., Anesthesiology, Surgery, Stony Brook
A 69 year-old male had undergone an unremarkable repeat sternotomy for MV replacement and CABG
on cardiopulmonary bypass and transferred to the Cardiothoracic ICU on minimal vasopressor support,
but increased CVP. Postoperatively, the CVP remained in the 30s with a swollen, mottled upper body.
TTE excluded cardiac tamponade; however, the patient was taken back to the OR. The surgeon
confirmed SVC stenosis, placed a pericardial patch to expand the SVC and RA, and performed an
innominate to RA bypass for SVC obstruction under CPB with CVP normalization. Minimal vasopressors
were required postoperatively and clinical improvement was seen on POD#2.
MCC04
10:40 AM - 10:50 AM
RVOT Thrombus Associated With Bivalirudin Anticoagulation for VA-ECMO
Kaitlin Moore, D.O., Victor Davila, M.D., Ohio State University Med Ctr, Columbus, OH
The use of bivalirudin has been previously described as a potential alternative to heparin-based
anticoagulation for ECMO. Bivalirudin, unlike heparin, is eliminated to a greater extent by proteolytic
enzymes. Thus, it has been suggested that the use of bivalirudin anticoagulation could lead to increased
risk of intra-cardiac thrombi in VA-ECMO patients with low pulmonary arterial flow. We report a case of
right ventricular outflow tract thrombus and pulmonary infarct in a 47 year-old male on VA-ECMO with
bivalirudin-based anticoagulation. While the thrombosis in our patient was multifactorial, pharmacokinetic
properties should be considered when selecting alternative anticoagulants for VA-ECMO.
MCC04
10:40 AM - 10:50 AM
Emergent Airway Management in the Traumatic Patient with Undiagnosed Goiter Suffering from
C1/C2 Fracture
Kristen E. Strehl, D.O., Anesthesiology and Critical Care, St. Louis University, Saint Louis, MO
We describe an 87 year-old female with DM, COPD, and atrial fibrillation whom suffered a fall from
standing and found to have a C1-C2 unstable fracture and a multinodular goiter causing tracheal
deviation. After extubation, she had aspirated and was placed on BiPAP. She developed respiratory
distress and anesthesia was called for emergent airway management. Prior to intubation the patient was
pretreated with nebulized lidocaine, midazolam, and a dexmedetomidine infusion was started. While
maintaining the patient’s spine in a stable position and maintaining spontaneous respirations an ETT was
placed over a fiberoptic bronchoscope and the airway was secured without complication.
MCC04
10:40 AM - 10:50 AM
Transitioning from GA to Sedation to Avoid Violent Post-operative Delirium in a Young Healthy
Epileptic
Aron Legler, M.D., Suneil Jolly, M.D., Michael Hrycelak, M.D., Department of Anesthesiology, Yale New
Haven Hospital, New Haven, CT
A 31 year-old gentleman with longstanding frequent generalized seizures was referred to our hospital for
a series of brain mapping procedures. Following the first two cases the patient suffered tonic-clonic
seizures and extreme agitation with post-operative delirium which were a threat to his own safety and that
of the providers. For the third case, we transitioned the general anesthetic to sedative dosing of an alpha2 agonist as well as opiate infusion which served to facilitate a much safer extubation and subsequent
transfer to the NSICU. The use of the electronic medical record was instrumental in our care plan
decision-making.
MCC04
10:40 AM - 10:50 AM
Intraoperative Use of Point of Care Ultrasonography (POCUS) for Stat Cesarean Delivery With
Refractory Hypoxemia
Nicholas J. Schott, M.D., Dana Leonelli, B.S.N., Sn McElroy, D.O., Anesthesiology, University of
A gravid female brought in to the OR for emergent c-delivery. RSI conducted with end tidal CO2 and
bilateral breath sounds. SpO2 was 71% on 100% fio2. Airway pressures 25-38mmHg with use of
bronchodilators and airway maneuvers. In order to assist in diagnosing and planning, a portable point-ofcare ultrasound was brought into the operating room. TTE windows obtained suggested that the patient
had a pericardial effusion, LVH and gross pulmonary edema. Given findings, 1:1 crystalloid replacement
to blood was undertaken. Post procedure, SpO2 was 88-91%. Re-imaging of views revealed
improvement of edema and transfer of care to an ICU team.
MCC04
10:40 AM - 10:50 AM
Effectivity of Brachial Plexus Block With a Coracoid Approach Used in Supracondylar Fractures in
Children
Erica Diaz, M.D., Erika Romo, M.D., Anesthesiology, Hospital Civil FAA, Pediatric Anesthesiology,
Hospital Civil FAA, Guadalajara, Mexico.
Prospective clinical trial in 98 patients 2-16year-old, requiring closed reduction of supracondylar elbow
fracture. Non invasive monitoring and IV sedation maintaining spontaneous ventilation with O2 and
sevoflurane. Using Wilsons technique with modified distance to the puncture site according to age 1, 1.5
and 2cm caudal and medial to the coracoid apophysis; guided with neurostimulation using 25-35mm
needles looking for median nerve motor response and radial nerve; stimulation started with 100ms 2Hz
with a 0.8 mA, applying 0.5-1ml of 1% lidocaine at 0.4-0.5mA without motor response. We used 0.2%
Ropivacaine at 1ml/kg volume 20 minutes previous to the fracture manipulation.
MCC04
10:40 AM - 10:50 AM
Pain Medicine (PN)
Radiofrequency Neurotomy of the Genicular Nerve for Persistent Knee Pain
Babak Balakhaneh, D.O., Shantha Ganesan, M.D., Ramesh Swamiappan, M.D., SUNY Downstate
Medical Center, Kings County Medical Center, Brooklyn, NY
Our patient was a 62 year-old female with chronic knee pain from sever osteoarthritis. Due to issues with
insurance the patient was not able to receive a total knee replacement which her orthopedic surgeon had
recommended. Medications had only provided minimal relief and the patient had negative side effects
with opoids. Under fluoroscopic guidance we performed a radio-frequency neurotomy of the genicular
nerve. This procedure provided relief and improved activities of daily living tremendously for the patient.
This procedure can provide a therapeutic alternative for patients with chronic knee pain.
MCC04
10:40 AM - 10:50 AM
Entrapped Thoracic Epidural Catheter Due to Knotting: The Utility of 3D-CT Scans
Kentaro Tokuda, M.D.,Ph.D., Kenzo Araki, M.D., Hidekazu Setoguchi, M.D.,Ph.D., Jun Maki, M.D.,Ph.D.,
Sumio Hoka, M.D.,Ph.D., Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine,
Kyushu University Hospital, Fukuoka, Japan
A 35 year-old woman received pancreatic surgery with general and epidural anesthesia. A 19-gauge
Arrow FlexTipPlus® epidural catheter was inserted without difficulty. An anesthesiologist
attempted to remove the catheter on POD 5, however, the catheter was entrapped. After X-rays showed
no problems, the catheter was fixed on the skin with firm traction. A 3D-CT scan was performed on POD
8 since the penetrating skin became reddish. The scan revealed that the catheter made a knot in the
epidural space without breakage. The patient received surgical extraction of the catheter with dissection
of the paraspinal muscle under general anesthesia without any complications.
MCC04
10:40 AM - 10:50 AM
Low Thoracic Paravertebral Blockade and TAP Block Catheter Placement for Inguinal
Herniorrhaphy Surgery in a Patient With OSA and Abdominal Obesity
Justo Gonzalez, David Wildt, M.D., Cleveland Clinic, Cleveland, OH
We report a 54 year-old male with a noted history of OSA and abdominal obesity who presented for right
inguinal herniorrhaphy. A single level paravertebral block was performed at T11-T12 with a 21 g 4 inch
stimulating needle using nerve stimulaton. After a single shot bolus of 20 cc bupivicaine 0.5% with 1:200k
epinephrine, the patient was laid supine and a TAP block catheter was placed for postoperative
analgesia. The patient had sedation with a ketofol infusion for surgery without airway management.
Postoperatively, he had 1-2 numeric pain score during 72 hour infusion without opioid use.
MCC04
10:40 AM - 10:50 AM
Left Ventricular Wall Rupture from a True Aneurysm
Jeny Ng, M.D., Matthew Benshoff, M.D., Lisa Rong, M.D., Weill Cornell Medical College, New York, NY
An 83 year-old female with history of coronary artery disease and prior coronary artery bypass graft
presented to the emergency department with chest pain and was found to have a posterior STEMI. She
underwent an emergent catheterization showing 100% stenosis of the venous graft to the left circumflex
artery. She then developed cardiogenic shock and transthoracic echocardiography in the ICU showed
hemopericardium. She was taken to the operating room for left ventricle repair on bypass. Intraoperatively
it was determined based on transesophageal echocardiography findings that the patient had rupture of
the left ventricular wall from a true aneurysm.
MCC04
10:40 AM - 10:50 AM
Management of the Parturient With Hypertrophic Cardiomopathy
Jessica V. Lumsden, D.O., Alla Spivak, D.O., Stephen McCaughan, D.O., Temple University Hospital,
Philadelphia, PA
A 38 year-old gravida 1, para zero woman at thirty six weeks and five days presented to OB triage with
decreased fetal motion. Recent echocardiography showed an ejection fraction of 90%, apical thickening
and basal hypokinesis. After a multidisciplinary discussion, the decision was made to proceed with
elective primary c-section. Epidural analgesia was chosen for delivery along with an arterial line and two
large bore IVs. The patient was maintained on a phenylephrine infusion during delivery, which had an
estimated blood loss of 1600mL. The patient had stable vital signs postoperatively and was discharged
home on postpartum day four.
MCC04
10:40 AM - 10:50 AM
Phentolamine in the Management of Loss of Pulse Oximeter Waveform
Gabriel A. Fierro-Fine, M.D., James Markey, M.D., Anesthesia, OU Medical Center VAMC, Oklahoma
City, OK
Difficulty in obtaining, or the loss of, the pulse oximeter waveform during the intraoperative period occurs
not infrequently. This case concerns a 61year-old male with laryngeal cancer presenting for total
laryngectomy in a position that required both arms to be tucked and inaccessible. Shortly after anesthetic
induction, the pulse oximeter waveform was lost. Multiple attempts using multiple sites to obtain a
waveform were unsuccessful. Success was ultimately achieved via radial intra-arterial injection of
phentolamine. We discuss the potential causes for loss of the pulse oximeter waveform and possible
corrective approaches, including the use of intra-arterial vasodilators, to restore absent waveforms.
MCC04
10:50 AM - 11:00 AM
Bronchoscopy on a BiPAP-dependent Child With Nemaline Myopathy: Accommodating for MH
Susceptibility While Managing Difficult Ventilation
Hersh Patel, M.D., MBA, Anesthesiology, NYU Langone Medical Center, New York City, NY
Two year-old female with Nemaline myear-oldpathy, G-tube dependence,nocturnal CPAP dependence,
and recurrent pneumonia who presented with fevers and SOB x5 days. Patient was admitted to the PICU
for respiratory failure with complete opacification of the left lung in setting of RSV with likely bacterial
super-infection. She continued to require elevated settings on BiPAP to maintain ventilation and
oxygenation with no improvement in spite of maximal CPT and antibiotic therapy. She was scheduled for
a bronchoscopy with BAL to optimize medical management. We willexplore the anesthetic and airway
management of pediatric patients with congenital myear-oldpathies undergoing bronchoscopy.
MCC04
10:50 AM - 11:00 AM
Multiple Anesthetics for a Patient With Stiff-Person Syndrome
Jessica M. Cassavaugh, M.D.,Ph.D., Todd M. Oravitz, M.D., Anesthesiology, University of Pittsburgh,
Pittsburgh, PA
A 45 year-old female with Stiff-Person Syndrome (SPS), a progressive disease of muscle rigidity and
spasticity due to a deficiency in the production of gamma-aminobutyric acid (GABA), presented for three
separate general anesthetics. Because of the rarity of the condition, little is known about effects of
anesthesia on patients with SPS. Her anesthetics included use of both volatile agents and neuromuscular
blockade, both depolarizing and non-depolarizing. Unlike several previous reports regarding anesthesia
and SPS, the post-operative period for this patient did not require prolonged intubation or result in any
residual weakness.
MCC04
10:50 AM - 11:00 AM
Beyond Morbidly Obese: BMI of 85.6 and Surgical Repair of Ruptured Knee Ligaments
Caryn M. Hertz, M.D., Christopher W. Howard, M.D., Anesthesiology, University of North Carolina,
Chapel Hill, NC
A 58 year-old male with a body mass index (BMI) of 85.6 was scheduled for operative stabilization of
knee ligamentous rupture. Co-morbidities included congestive heart failure, chronic obstructive pulmonary
disease, and obstructive sleep apnea. We chose to administer an ultrasound-guided nerve block, which
was complicated by suboptimal imaging related to the BMI. Nonetheless, we were able to provide
adequate analgesia and sedation for the surgery, with a combination of dexmedetomidine, ketamine, and
local anesthetic supplementation, while allowing the patient to breathe spontaneously and maintain
acceptable oxygen saturation. We will discuss the anesthetic challenges associated with the
management of this case.
MCC04
10:50 AM - 11:00 AM
Anesthetic Management of Unexpected Subglottic Stenosis
Joshua Finkel, M.D., Shaheen Shaikh, M.D., Anesthesiology and Critical Care Medicine, University of
Massachusetts Medical School, Worcester, MA
An elderly male with traumatic brain injury, left hemiparesis, and remote history of tracheostomy
presented for esophagogastroduodenoscopy. A smooth mask induction was performed followed by
peripheral IV placement. Easy mask ventilation was confirmed prior to administering rocuronium. A grade
one view was obtained on direct laryngoscopy, but significant resistance was met at 20 cm depth with a
7.5 endotracheal tube. After four attempts, a 6.5 ETT was eventually placed. The patient was easily mask
ventilated between attempts and remained hemodynamically stable. Once extubation criteria were met, a
cuff leak was confirmed and he was successfully extubated.
MCC04
10:50 AM - 11:00 AM
BiVAD in the Setting of Multi-organ Failure Complicated by Multiple Thrombi
Aimee Pak, M.D., Slawomir Oleszak, M.D., Allison McLarty, M.D., Anesthesiology, Surgery, Stony Brook
A 56 year-old male with non-ischemic cardiomyear-oldpathy was readmitted for cardiogenic shock,
secondary renal and hepatic failure. After failing pharmacologic vasosupport, an Impella® was implanted,
and ultimately BiVAD was placed. Intraoperatively, biventricular thrombi were seen on TEE and around
the Impella®. Thrombectomy was performed to relieve vascular compromise to the lower extremity.
Massive transfusion of blood products and recombinant Factor 7 were administered. The patient tolerated
the procedures and was brought to the Cardiothoracic ICU on vasopressor and inotropic support. The
chest was kept open from bleeding, and was later washed out and closed on POD#3.
MCC04
10:50 AM - 11:00 AM
Tubing Misconnections in the Critically Ill: Accidental Injection of High-dose Gadolinium into an
External Ventricular Drain
Sepehr Rejai, Sumit Singh, M.D.,Anesthesiology and Perioperative Medicine, UCLA, Los Angeles, CA
A 59 year-old male who presented with headaches was found to have a right tentorial meningioma. He
underwent an uncomplicated craniotomy with external ventricular drain (EVD) placement. After the postoperative MRI, the patient developed nausea, hypertension, and seizures. Gadolinium contrast was
discovered to have been mistakenly administered into the EVD via the ubiquitous leur-lock connector.The
patient was then re-intubated, hyperventilated, initiated on keppra/phenytoin therapy and a lumbar drain
was placed to evacuate CSF. The patient developed non-convulsive status epilepticus and further
deteriorated. He ultimately required tracheostomy, gastrostomy and was discharged to a long term
nursing facility with permanent neurological injury.
MCC04
10:50 AM - 11:00 AM
Anesthesia Management of the Geriatric Patient With Severe Aortic Stenosis During Nailing of
Femoral Fracture
Andrew L. Leinweber, M.D., Shawn Statzer, M.D., Anesthesiology & Critical Care, Saint Louis University,
Saint Louis, MO
We describe a 92 year-old female admitted for L supracondylar femur fracture from fall and scheduled for
retrograde IMN. TTE revealed a low flow, normal EF aortic stenosis characterized as severe/critical.
Given patient’s comorbidities, poor functional capacity, and poor candidacy for valvuloplasty/TAVR, she
was considered a high risk for surgery. Intra-operative hypotension could lead to VT, MI, and cardiac
arrest. To avoid this, our anesthetic plan included placement of an a-line, 2 large-bore IVs. For induction,
we used ketamine and a low dose fentanyl bolus. For maintenance we used a TIVA approach that
included remifentanil and ketamine infusions.
MCC04
10:50 AM - 11:00 AM
Unexpected Case of Bradycardia During Mechanical Thrombectomy of Internal Carotid Vessel
Kevin P. Fitzmartin, M.D., Nikhil Chawla, M.D., Yale New Haven Hospital, New Haven, CT
A 30 year-old woman with past medical history of untreated hyperlipidemia, multiple miscarriages, being
post-partum for one year, and CIN III presented to the ED as a stroke code, developed sudden cardiac
arrest twice with contrast injection near the carotid sinus during neuroembolectomy. Spontaneous
circulation and normal sinus rhythm returned within a few seconds without intervention, and did not recur
following pre-emptive glycopyrolate prior to subsequent contrast injections. Communication between the
anesthesia team and surgical team allowed quick identification of the problem, as well as a plan and
quick action to remedy it.
MCC04
10:50 AM - 11:00 AM
Rapid Deterioration Late in Labor
Maulik Rajyaguru, Tricia Fullerton, Alice Tsao, Brian Keyes, RCRMC, Moreno Valley, CA
A 28 year-old G3P2 with a previous C-section, presented at 38wks in labor. Hours later, she developed
sinus tachycardia (HR 140, BP 145/80) but denied chest pain or shortness of breath. A labor epidural was
placed uneventfully with the cervix 5cm dilated. At 9cm dilation, she acutely developed tachypnea,
hypoxia with impending respiratory failure, perioral/peripheral cyanosis, and hysteria requiring emergent
C-section under general anesthesia. Post-operative echocardiography demonstrated moderate RV and
severe LV dysfunction. Differential diagnosis included both peripartum cardiomyear-oldpathy and
amniotic fluid embolism. On POD 3, the cardiac echocardiogram significantly improved, and the patient
was discharged subsequently.
MCC04
10:50 AM - 11:00 AM
Pediatric Lung Isolation in Congenital Lobar Emphysema Using a Fogarty Catheter
Irem Kaplan, M.D., Bettina Smallman, M.D., Michael Miller, D.O., Anesthesiology, State University of New
York Upstate Medical University, Syracuse, NY
9 month old male, with a history of congenital lobar emphysema, presented for left upper lobe resection
under general anesthesia. The patient underwent sevoflurane mask induction, placement of three
peripheral IVs, radial a-line, direct laryngoscopy and endotracheal intubation. Spontaneous ventilation
was maintained while a size 2-French fogarty catheter was deployed into the left mainstem bronchus,
visualized by flexible bronchoscopy. The fogarty catheter was found to be dislodged when desaturations
were later observed. Upon repositioning into the same bronchus, an appropriate seal was not achievable
after multiple attempts. The catheter was removed and up-sized to a 3-French fogarty with successful
isolation.
MCC04
10:50 AM - 11:00 AM
Pain Medicine (PN)
Iatrogenic Drug Induced Complex Regional Pain Sydrome and Associated Chronic Pelvic Pain
Anita Gupta, D.O., Leigh Stevens, M.D., Erin Treacy, M.D., Anesthesiology and Pain Medicine, Drexel
University College of Medicine, Philadelphia, PA
We will describe a 29 year-old female with progressive atrophy of her feet along with discoloration after
she was treated for chronic vaginal pain with 5-flurouracil inadvertantly intravaginally. Chronic use of this
drug via this route, caused vaginal erosions, scarring, bleeding and severe pelvic pain. Our initial
assessment confirmed the diagnosis of CRPS and chronic pelvic pain due to erosions. Conservative
medical management included baclofen, gabapentin, aquatic therapy, and psychosocial support. In
addtion, she underwent a successful series of interventional procedures including a ganglion impar block
and lumbar sympathetic blocks which resulted in significant improvement of her painful symptoms.
MCC04
10:50 AM - 11:00 AM
Epidural Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm: A Reasonable
Alternative to a General Anesthetic in a Patient With End-Stage Chronic Obstructive Pulmonary
Disease
Sara M. Aljohani, M.D., Sergey Pisklakov, M.D., Maria Bustillo, M.D., Louvonia Boone, M.D.,
Anesthesiology, Albert Einstein College of Medicine, New York, NY
The low invasiveness of Endoluminal Abdominal Aneurysm Repair (EAAR) appears optimal for the use of
epidural anesthesia (EA). We report EAAR in the patient with End-Stage COPD. When general
anesthesia could cause significant respiratory deterioration in postoperative period an epidural anesthetic
seemed to be the most optimal alternative to optimize perioperative analgesia and reduce opioid use in
patients with COPD, where respiratory depression is especially dangerous. Regional anesthesia has not
become accepted on a large scale, owing to a traditional surgical attitude preferring general anesthesia.
In EAAR, EA is well tolerated and potentially associated with fewer respiratory complications.
MCC04
10:50 AM - 11:00 AM
Ipsilateral Thoraco‐lumbar-sacral Anesthesia After Single Shot Paravertebral and TAP Block
Catheter Placement for Hernia Repair
Justo Gonzalez, David Wildt, M.D., Cleveland Clinic, Cleveland, OH
We report a 35 year-old male with history of drug abuse who presented for left inguinal hernia repair.
Utilizing nerve stimulation a single shot T11-T12 paravertebral block was placed using 20 cc bupivicaine
0.5% with 1:200K epinephrine. A TAP block catheter was placed with 10 cc bupivicaine 0.25% used to
expand the space. 45 minutes later the patient noted inability to lift his left leg and found unable to
mobilize his foot. The patient had uneventful surgery under sedation and his leg weakness resolved over
the course of 5 hours and was able to ambulate home without assistance.
MCC04
10:50 AM - 11:00 AM
Cobalt Toxicity Requiring Left Hip Arthroplasty Revision in Left Ventricular Assist Device Patient
Shaina M. Sheppard, Rudolfo Perez, M.D., Anesthesiology, University of Texas Health Science Center
Houston, Houston, TX
A 51 year-old male with a left ventricular assist device in situ presented for a total hip arthroplasty revision
secondary to rare cobalt toxicity.Standard ASA monitors used with post induction arterial line and two 16g
PIVs. Induction with propofol 70 milligrams and Fentanyl 100 micrograms. Hip revision, anesthetic
emergence and recovery were uncomplicated.Cobalt toxicity should be suspected in patients with metal
on metal hip prosthesis, elevated cobalt levels, and new onset systemic symptoms (neuropathy, hearing
and visual loss, cardiomyear-oldpathy and hypothyroidism). Cobalt inhibits oxidative metabolism at the
mitochondrial level. Methionine and cysteine cheleate cobalt, effectively removing it.
MCC04
10:50 AM - 11:00 AM
Cesarean Section in a Patient With Geleophysic Dysplasia and a Difficult Airway Who Refuses
Regional Anesthesia
Kelly Kohorst, Mary Dimiceli, M.D., Mary Jennette, M.D., Patrick McConville, M.D., Vanderbilt University,
Nashville, TN
A G1 23 year-old with geleophysic dysplasia, scoliosis, tracheal stenosis and history of difficult airway
presented for scheduled cesarean. Although we advised regional, the patient insisted on general
anesthesia. Given her anxiety we did not attempt awake fiberoptic intubation. After pre-oxygenation we
performed RSI with remifentanyl, propofol, and succinylcholine. Indirect laryngoscopy with McGrath was
unsuccessful. We were able to mask effectively. We decided to emerge the patient and perform an awake
fiberoptic intubation. Once awake we noted stridor and were concerned about airway swelling. We
advised regional anesthesia and she consented. After a difficult epidural placement we proceeded with
cesarean.
MCC04
10:50 AM - 11:00 AM
Renal Transplantation Complicated by Bradycardia Refractory to Medical Therapy and Pacing
Equipment
Christian M. Taylor, M.D., Paul St. Jacques, M.D., Andrea Keohane, M.D., Anesthesiology, Vanderbilt
University Medical Center, Nashville, TN
66 year-old male with past medical history of coronary artery disease, severe pulmonary hypertension,
atrial fibrillation treated with sotalol, and end stage renal disease presented for renal transplantation. The
patient was in normal sinus rhythm preoperatively, but developed severe sinus bradycardia after
induction, with heart rates in the 30's. Attempts to increase the heart rate with ephedrine, glycopyrrolate,
atropine, and epinephrine all failed. Ultimately, a TAP scope was used, but only captured intermittent
pacing capability. Postoperatively,the patient was taken to the ICU and a pacemaker was placed after
development of a new high grade AV block.
MCC04
11:00 AM - 11:10 AM
The Anesthetic Management of a Child With Ectodermal Dysplasia Coming for Closed Reduction
of a Supracondylar Fracture
Samuel M. Barst, M.D., Cynthia Rupp, M.D., Ashley Kelley, M.D., Robert Cristofaro, M.D.,
Anesthesiology, Orthopedic Surgery, New York Medical College, Westchester Medical Center, Valhalla,
NY
We present a case of a 5 year-old child with ectodermal dysplasia who was scheduled for emergency
orthopedic surgery. The patient demonstrated the triad of anhidrosis, hypotrichosis, and micrognathia with
hypoplastic dentition. Perioperative concerns include difficult airway management with potential for tooth
dislodgement as well as development of hyperthermia. The patient’s airway was managed using a
laryngeal mask airway and ventilation was supported using pressure support ventilation. Care was taken
to establish a euthermic environment and the patient’s temperature was monitored throughout the
procedure. No adverse events from the anesthetic were noted.
MCC04
11:00 AM - 11:10 AM
Ludwig's Angina, Myear-oldcardial Infarction, And The Use of Imaging To Help Guide Airway
Management
Branden M. Engorn, M.D., Sean S. Barnes, M.D., Allan Gottschalk, M.D., Department of Anesthesiology
and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
40 year-old male with CAD, DM, and poor dentition presented in DKA with recently elevated troponins
and LVEF of 25% with akinesis of multiple walls. He developed submental swelling and stridor and was
diagnosed with Ludwig's Angina, necessitating neck exploration. CT scan showed an edematous
epiglottis deviated to the right. An awake fiberoptic intubation was performed after anesthetizing his
airway. His presenting tachycardia was controlled with esmolol and his blood pressure, heart rate, and
EKG remained unchanged. The scope was advanced down the right side of his tongue obtaining
visualization of his glottic opening and a 6.0 ETT was secured.
MCC04
11:00 AM - 11:10 AM
Airway Management in a Patient With Tracheal and Esophageal Stents and Associated TracheoEsophageal Fistula
Michael E. Franklin, Pushpa Koyyalamudi, M.D., Anesthesiology, LSUHSC, Shreveport, LA
This patient is a 50 year-old male with a past medical history of esophageal cancer, who had previously
had tracheal and esophageal stents placed for palliative treatment for advanced malignancy, and TE
fistula. His presenting complaint was persistently decreased oral intake and weight loss, due to constant
aspiration. Awake fiberoptic intubation was performed, and the tracheal stent was assessed for possible
migration. The endotracheal tube was placed distal to the fistula. An EGD was performed by GI. The
remainder of the intraoperative course was uneventful, and the patient was extubated the following day.
MCC04
11:00 AM - 11:10 AM
Unilateral Mydriasis After Lefort Osteotomy
Angie A. Geiger, Platt D. Niebur, M.D., Anesthesiology, University of Nebraska Medical Center, Omaha,
NE
Lefort I osteotomy for malocclusion was performed in a 15 year-old male who developed unilateral
mydriasis. Deep extubation followed a stable operative course. Unilateral mydriasis and hypoxia were
identified in recovery. Emergently, the patient was re-intubated and sent for CT scan. His neurological
exam in the ICU was otherwise normal and pupil diameter soon returned to normal. Unilateral mydriasis
can represent uncal herniation, an intra-orbital or intra-cranial hemorrhage, or nerve injury from skull base
or orbital fractures. As in our case, it can also result from administration of anticholinergic medications,
local anesthetics, or mucosal absorption of phenylephrine.
MCC04
11:00 AM - 11:10 AM
Anesthetic Management of Patient With a Large Chest Wall Tumor Invading the Superior Vena
Cava
Milad Sharifpour, M.D., M.S., Joshua Dilley, M.D., Jeremi Mountjoy, M.D., Department of Anesthesia,
Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
A 62 year-old female with past medical history of breast cancer, status post right mastectomy and
chemoradiation, was diagnosed with radiation induced chest wall sarcoma. She did not complain of
orthpnea or shortness of breath. A contrast enhanced chest CT showed a mass involving the manubrium
with pre- and retrosternal components, as well as soft tissue within the SVC, measuring 20 x 38 mm,
consistent with tumor and/or thrombus. There was evidence of airway involvement. The patient was
scheduled for resection of tumor, chest wall reconstruction, and resection and graft replacement of the
SVC.
MCC04
11:00 AM - 11:10 AM
Urgent Ultrasound-guided Bilateral Stellate Ganglion Blocks in a Patient With Medically Refractory
Ventricular Arrhythmias
Maura M. Scanlon, Shane Gillespie, M.D., Cha Yong-Mei, M.D., Hartzell Schaff, M.D., Erica Wittwer,
M.D., Department of Anesthesiology, Department of Cardiology, Department of Cardiac Surgery, Mayo
Clinic, Rochester, MN
A patient with coronary artery disease underwent coronary artery bypass grafting. Postoperatively she
required several vasopressors, and developed recurrent ventricular fibrillation. Despite multiple
defibrillations per day, the patient still had ventricular arrhythmias. Bilateral stellate ganglion blocks under
ultrasound guidance were performed bedside and terminated the ventricular dysrhythmias. The patient
was eventually discharged to home after serial stellate blocks. This procedure was also performed in a
patient with an LVAD/ RVAD for biventricular cardiomyear-oldpathy with refractory ventricular tachycardia.
Afterwards, he remained in sinus rhythm for one week. Stellate ganglion blocks with ultrasound are
beneficial for patients who have refractory ventricular arrhythmias.
MCC04
11:00 AM - 11:10 AM
Hypercarbic Cardiac Arrest With Preserved Ventilation: The Diagnosis and Management of a Rare
and Potentially Lethal Video-assisted Thoracic Surgery (VATS) Complication
Danielle K. Bodzin, Sripad Rao, M.D., Roman Dudaryk, M.D., Anesthesiology, Jackson Memorial
Hospital, Miami, FL
A patient presenting with retained hemothorax status post gunshot wound to the chest underwent VATS
for evacuation of hematoma. Intraoperatively, he developed worsening hypotension associated with
progressively increasing end tidal carbon dioxide measurement eventually resulting in cardiac arrest,
despite preservation of ventilation and confirmation of appropriate positioning of the bronchial blocker.
This hypercarbic cardiac arrest with preserved ventilation was likely secondary to undiagnosed
bronchopleural fistula. He was successfully resuscitated and the surgery was converted to open
thoracotomy.
MCC04
11:00 AM - 11:10 AM
Epidural Hematoma Following Spinal Cord Stimulator Placement
Daniel P. Tighe, D.O., Nicole Hollis, D.O., John Tiernan, M.D., Anesthesiology, University of Connecticut,
Farmington, CT
50 year-old female, past medical history of chronic back pain presented with rapid development of cauda
equina syndrome, post-op day 0 from a spinal cord stimulator placement. On initial assessment patient
was hypertensive with a blood pressure of 222/103mmHg. CT scan showed a thoracic epidural
hematoma. Due to the emergent nature of the procedure no neurological monitoring was available. To
ensure spinal cord perfusion a minimum MAP of 80mmHg was established. Following evacuation of the
thoracic hematoma and emergence from anesthesia patient was able to detect stimulation of the bilateral
lower extremities. Motor function returned within 24 hours.
MCC04
11:00 AM - 11:10 AM
Detection and Management of Amniotic Fluid Embolism During Emergent Cesarean Section
Adrienne R. Gleit, M.D., Inna S. Maranets, M.D., Department of Anesthesiology, University of
Connecticut, Farmington, CT, Saint Francis Hospital and Medical Center, Hartford, CT
A 28 year-old woman, Gravida 2 Para 1, required emergent cesarean section for fetal distress. General
anesthesia was initiated without difficulty. After the neonate was delivered the patient was noted to have
several transient oxygen desaturations into the 50s. Several minutes later she developed severe
cardiopulmonary collapse which was responsive to resuscitative measures. The diagnosis of amniotic
fluid embolism was highly suspected. AFE is a rare and often fatal condition that requires prompt
recognition to minimize morbidity and mortality. This case reports demonstrates how immediate initiation
of supportive care led to a successful outcome.
MCC04
11:00 AM - 11:10 AM
Another RYR1 Gly4820Arg Related Unrecognized Awake Malignant Hyperthermia (MH) Emergency
Room Death in an 11 Year-Old
Lena M. Mayes, M.D., Mari Mori, M.D., John Capacchione, M.D., Kyle J. Rehder, M.D., Vandana Shashi,
M.D., Pediatric Anesthesiology, University of Colorado/ Children's Hospital Colorado, Aurora, CO,
Anesthesiology, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD, Medical
Biochemical Genetics,Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Duke
Pediatric Medical Genetics, Duke University, Durham, NC
An 11 year-old female presented to the ED with 2 days of upper extremity muscle pain followed by
extreme fever, mental status changes, muscle rigidity, and loss of consciousness. On arrival, she had
contracted arms, BP 174/73, HR 196, peaked T-waves on ECG, and temperature of 106.8F. She
developed seizure-like clonic movements followed by cardiac arrest, and was given succinylcholine for
intubation due to jaw rigidity. Return of spontaneous circulation failed and ECMO was initiated. Treatment
for presumed MH was unsuccessful. Postmortem genetic analysis revealed a Gly4820Arg RYR1 mutation
previously reported in another child with similar clinical presentation.
MCC04
11:00 AM - 11:10 AM
Pain Medicine (PN)
Altered Mental Status in the Setting of CYP3A4 Inhibition
Megan C. Hamre, M.D., Sn M. Moeschler, M.D., William Brian Beam, M.D., Anesthesiology, Mayo Clinic,
Rochester, MN
A 66 year-old gentleman with metastatic multiple myeloma presented to the emergency department with
a two-week history of fever, cough and increasing weakness. Aspergillus serology was positive and
voriconazole was initiated. Due to severe chest wall pain secondary to skeletal metastases, the patient’s
home dose of oxycodone was doubled. On hospital day five he was found to be unresponsive and
hypoxic, and responded transiently to 0.7 mg naloxone bolus. He was transferred to the intensive care
unit and naloxone infusion was initiated. Interestingly, his last dose of oxycodone was approximately 1618 hours prior to his episode of altered mental status.
MCC04
11:00 AM - 11:10 AM
Brachial Plexus Neuropraxia Following Shoulder Arthroscopy
Mark A. Goldman, M.D., M.S., Todd Permut, M.D., Dalia Elmofty, M.D., Anesthesia and Critical Care,
University of Chicago, Chicago, IL
A 48 year-old female with a history of left upper extremity neuropathy presented to our ambulatory
surgery center for left shoulder arthroscopy with suprascapular nerve release. A pre-operative ultrasoundguided interscalene block was placed for post-operative analgesia, and general endotracheal anesthesia
was induced with an unremarkable intraoperative course. The patient was discharged to home. The
patient presented to the emergency department on post-operative day 2 with decreased motor and
sensation to light touch throughout the left upper extremity. MRI of the brachial plexus was unrevealing,
however EMG was consistent with probable neuropraxia involving the lower trunk of the brachial plexus.
MCC04
11:00 AM - 11:10 AM
The Epidural Catheter is Not Coming Out: What Now?
Steven Y. Chinn, M.D., Tarang Safi, M.D., Andrew Sim, M.D., Jeffrey Bernstein, M.D., Juan DavilaVelazquez, M.D., Anesthesiology, Montefiore Medical Center, Bronx, NY
19 year-old nullipara requested epidural analgesia. CSF is seen from epidural needle on second attempt.
Epidural needle removed. Epidural is reattempted at same interspace successfully. Epidural catheter
threaded without resistance or difficulty. Excellent analgesia provided thru labor. After delivery, resistance
is encountered upon catheter removal. Different maneuvers are attempted: flushing with saline, flexion,
extension, taping to tension; all without success. Imaging obtained. Neurosurgery, IR and ortho-spine
services consulted. In the OR, with moderate sedation, catheter is removed with gentle, continuous
traction by surgeon. Epidural catheter noted to be looped at the end.
MCC04
11:00 AM - 11:10 AM
Pulsus Paradoxicus Without Electrical Alternans in Acute Type A Aortic Dissection and Cardiac
Tamponade
Joel Musee, Bantayehu Sileshi, M.D., Anesthesiology Department, Vanderbilt University Medical Center,
Nashville, TN
58 year-old male presented emergently to the operating room with type A aortic dissection extending from
the aortic root to the right iliac artery. Upon placement of pre-induction left brachial arterial line the
waveform demonstrated a narrow pulse pressure and pulsus paradoxicus. No electrical alternans was
noted. The patient was sedated with ketamine and midazolam, maintaining spontaneous ventilation, while
the surgeon cannulated the femoral vessels for institution of cardiopulmonary bypass (CPB). Additional
ketamine and succinylcholine were administered for induction of anesthesia, after which the patient
arrested. CPB was instituted shortly thereafter. The patient’s aorta was deemed unrepairable and patient
expired intraoperatively.
MCC04
11:00 AM - 11:10 AM
Combined Spinal Epidural for Cesarean Section in a Patient With Intracranial Hemorrhage
David Frey, D.O., Carlos Delgado, M.D., Jeff Harless, M.D., Anesthesiology and Pain Medicine,
University of Washington, Seattle, WA
A previously healthy 24 year-old, G2P1, 92kg  woman presented at 32 weeks’ gestation with sudden
onset of severe headache and nausea refractory to medication. She denied visual changes or neurologic
deficits. Her pregnancy was uncomplicated; and vital signs and exam remained normal. CT scan
demonstrated intraventricular hemorrhage without evidence for ventriculomegaly or obstructive
hydrocephalus. MRI and MR angiogram demonstrated a ateriovenous malformation (AVM) involving the
corpus callosum and right frontal lobe measuring 4x3 cm with a large vein draining into the vein of Galen
posteriorly making it a Spetzler-Martin grade 3-4 AVM. Anesthesia was conducted with a successful
combined spinal-epidural (CSE).
MCC04
11:00 AM - 11:10 AM
A Tale of Two Tracheas: A Novel Approach to Stent Usage in Tracheal Trauma
Jordan T. Nguyen, M.D., LaToya C. Mason, M.D., Anesthesiology, Baylor College of Medicine, Houston,
TX
This case report discusses difficulties in ventilation associated with tracheal dehiscence. The focus will be
on management when existing comorbidities deem the patient a poor candidate for surgical intervention.
A novel algorithmic approach of when to consider tracheal stenting for closure of airway defects is
introduced.
MCC04
11:10 AM - 11:20 AM
The Anesthetic Management of a Child With Peter’s Anomaly and DiGeorge Syndrome
Samuel M. Barst, M.D., Nausheen Zia, M.D., Michael Lyew, M.D., Gerald Zaidman, M.D., Anesthesiology,
New York Medical College, Westchester Medical Center, Valhalla, NY, Ophthalmology, New York
Medical College, Westchester Medical Center, Valhalla, NY
A 21 week ex-full term infant with Peter’s Anomaly (PA) and DiGeorge Syndrome (DGS) was scheduled
for eye exam under anesthesia. He initially presented with “jitteriness” secondary to hypocalcemia and
was diagnosed with DGS. He was also noted to have an opacified cornea consistent with PA requiring
corneal transplant. PA is a relatively rare sporadic congenital lesion affecting the anterior segment of the
eye. Anesthetic considerations for DGS include cardiac lesions, calcium metabolism and immunological
competency. We utilized a LMA but controlled ventilation to maintain normocapnea to prevent fluctuations
in ionized calcium secondary to a respiratory acidosis.
MCC04
11:10 AM - 11:20 AM
Completion Right Pneumonectomy in a Super Obese Male With a BMI of 48
Samuel Vanderhoek, M.D., T. Anthony Anderson, M.D.,Ph.D., Department of Anesthesia, Critical Care
and Pain Medicine, Massachusetts General Hospital, Boston, MA
We present the case of 51 year-old male with a history of obesity (BMI 48), obstructive sleep apnea,
chronic obstructive pulmonary disease and recurrent lung cancer who underwent right completion
pneumonectomy. We review the physiologic and anatomic changes associated with obesity, describe
their impact on anesthetic management during thoracic surgery, and offer techniques that can be utilized
to minimize intra- and post-operative anesthetic complications in this patient population. These include
options for gaining vascular access and optimizing intubating conditions, opioid-sparing techniques, and
tools for maximizing chances for post-operative respiratory success.
MCC04
11:10 AM - 11:20 AM
Anesthesia Management in a Patient With Friedreich’s Ataxia
Andrea Corujo Rodriguez, M.D., Srikanth Sridhar, M.D., Anesthesiology, University of Texas Health
A 33 year-old man with Friedreich’s ataxia presented with scrotal avulsion during a call at our institution
for an urgent scrotal washout and repair. He was wheelchair bound due to muscle weakness in both
legs/loss of coordination and fell upon transferring. These patients can have multiple comorbidities
including arrhythmias and hypertrophic cardiomyear-oldpathy that in conjunction with the ataxia can make
for a challenging case. This case presents a successful induction of general anesthesia and extubation in
this population.
MCC04
11:10 AM - 11:20 AM
Intraoperative Delayed Onset Ace-Inhibitor Induced Angioedema During Maxillofacial Surgery
Jian Azimi-Bolourian, M.D., Evan G. Pivalizza, M.D., Samuel W. Robinson, D.D.S., Mark E. Wong,
D.D.S., Sn Pacheco, M.D., Anesthesiology, Oral and Maxillofacial Surgery, Allergy and Immunology, UTHouston, Houston, TX
67 year-old woman with a medical history of hypertension controlled with ACE inhibitors, who presented
from home for elective outpatient revision of bilateral mandibular fractures. After uneventful nasotracheal
intubation, she intraoperatively developed acute angioedema manifested by diffuse swelling of her lips
and tongue that altered surgical management and required an unanticipated post-operative admission to
the ICU. Patient care included coordination between Anesthesia, OMFS, Critical Care and
Allergy/Immunology teams. Case discussion includes Ace-inhibitor induced angioedema and risk factors
that lead to its potential development while under anesthesia as well as management and future
prevention.
MCC04
11:10 AM - 11:20 AM
A Case of Intraoperative Cardiopulmonary Resuscitation in the Lateral Position
Kazuma Yunoki, M.D., RYo Sasaki, M.D., Kazuo Yamazaki, M.D., Anesthesiology and Critical Care, Kobe
City Medical Center General Hospital, Kobe, Japan
Tumorectomy for a 65 year-old man with a right pulmonary tumor was performed. Just before extubation,
massive bleeding appeared from the drainage tube and emergent rethoractomy for hemostasis was
performed in the lateral position. He was hemodynamically unstable and developed ventricular fibrillation.
We immediately applied 200J biphasic shock and started chest compression maneuver in the lateral
position. After 25 min of cardiopulmonary resuscitation, his rhythms returned to sinus and systolic arterial
blood pressure to 80mmHg with high-dose catecholamine infusion. He recovered his awareness in the
ICU and discharged from ICU without any neurological deficit.
MCC04
11:10 AM - 11:20 AM
Anesthetic Considerations for an Interventional Pulmonary Procedure Involving Upper Airway
Stenosis
Christian Mabry, M.D., Antonio Chiricolo, M.D., Anesthesia, Rutgers Robert Wood Johnson Medical
A 78 year-old female with recent intubation and mechanical ventilation developed post-intubation upper
airway stenosis. A cervical MRI was read by the radiologist as “an area of stenosis approximately 3.5 to 4
cm below the vocal cords, measuring approximately 6 mm in diameter at T1, and extends for a length of
approximately 1.5 cm.” Anesthetic management had to incorporate how to oxygenate and ventilate a
stenotic airway when interventional pulmonology was attempting balloon angioplasty.
MCC04
11:10 AM - 11:20 AM
Dilation and Currettage in an Obese Patient After Multiple Failed Peri-neural Attempts, With a
Known Difficualt Airway
Erikka L. Washington, M.D., Omonele Nwokolo, M.D., Sara Guzman, M.D., Sonya Alexis Johnson, M.D.,
Anesthesiology, University of Texas Health Science Center at Houston, Houston, TX
A 59 year-old female, with hypertension, asthma,and BMI >45, presents for Dilation and Curettage after
previous cancellation secondary to the Anesthesiologist waking the patient up after experiencing difficult
and inadequate ventilation and the inability to intubate the patient. The decision was made to perform an
neural axial procedure and to keep the patient awake and spontaneously breathing. However, after
multiple spinal and epidural attempts failed over a 90 minute period with 3 attending anesthesiologist, the
patient became combative and angry. The decision was made to perform an awakeFOB for a 20 minute
Dilation and Curettage procedure.
MCC04
11:10 AM - 11:20 AM
When the Brain Bleeds: A Complex Intracranial Tumor Resection Complicated by Postoperative
Intracranial Hemorrhage
Margaret M. Collins, M.D., Laurel E. Moore, M.D., University of Michigan, Ann Arbor, MI, University of
MIchigan, Ann Arbor, MI
Postoperative intracranial hemorrhage is one of the most serious intracranial complications with high
morbidity and mortality. Clinical deterioration and radiologic evidence differentiate postoperative
hemorrhage from expected residual bleeding in the surgical bed. Medical, surgical, and anesthetic risk
factors increase the incidence of postoperative intracranial hemorrhage. We discuss the case of a 58
year-old male who presented for resection of a right temporal intraventricular meningioma. During a
period of arterial bleeding, somatosensory evoked potentials were lost unilaterally. CT scan immediately
post-procedure revealed a venous hemorrhage within the tumor bed.
MCC04
11:10 AM - 11:20 AM
Management of Hypertrophic Obstructive Cardiomyopathy in the Parturient for Elective Cesarean
Section
Felicia Truong, M.D., Richard Lilly, M.D., University of Connecticut, Farmington, CT, Hartford Hospital,
Hartford, CT
26year-old G1P0 at 39wks with history of hypertrophic obstructive cardiomyear-oldpathy s/p prophylactic
ICD placement is scheduled for elective primary c-section due to intrauterine breech position. The patient
was asymptomatic up until a syncopal episode occuring at 29wks of pregnancy. Echocardiogram
revealed 17mm of septal hypertrophy and moderate LVOT obstruction. A slowly dosed epidural was
planned to minimize the effects of a total sympathectomy associated with a spinal by dosing only until an
adequate level was achieved. An A-ine was placed and phenylephrine infusion was titrated for
MAP>65mmHg. Postoperatively, patient was monitored for signs of CHF. The patient's course was
uneventful.
MCC04
11:10 AM - 11:20 AM
Perioperative Management of a Pediatric Patient With Cardiofaciocutaneous Syndrome
Jagroop Saran, M.D., Sarah J. Cano, M.D., Department of Anesthesia, University of Rochester,
Rochester, NY
Cardiofaciocutaneous syndrome is a rare genetic condition characterized by congenital heart defects,
dysmorphic craniofacial features and ectodermal anomalies. The diagnosis is based on clinical, medical,
developmental history and associated with certain genetic mutations. We report the case of a 12 year-old
female with known de novo BRAF gene mutation and cardiofaciocutaneous syndrome that underwent a
complicated orthopedic procedure. Past medical history was significant for repaired Tetralogy of Fallot
and coarctation of the aorta, developmental delay, seizure disorder, severe thoracogenic scoliosis, and
distinctive craniofacial characteristics. We describe challenges posed by the patient’s cardiac and
dysmorphic features to our perioperative anesthetic management.
MCC04
11:10 AM - 11:20 AM
Pain Medicine (PN)
Continuous Interscalene Blockade for Poorly Controlled Cancer Pain
Vishal Dhandha, M.D., Brooke Chidgey, M.D., Blair Herndon, M.D., Ravindra Prasad, M.D.,
Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
A 48 year-old female, despite a multi-modal medication regimen including high-dose opioids, has
constant and severe left arm pain due to metastatic pancreatic cancer encasing the brachial plexus. Her
pain is primarily in the ulnar nerve distribution. Tumor and radiation changes distorted the ultrasound
anatomy in the supraclavicular region. An ultrasound-guided interscalene brachial plexus catheter was
placed and dosed with local anesthetic. She had significant improvement in her pain score and was
discharged home with a continuous catheter infusion, ultimately receiving an intrathecal pump 10 days
later.
MCC04
11:10 AM - 11:20 AM
Successful Epidural Steroid Injection in a Patient on Apixaban
Timothy P. Rohman, M.D., Manoj B. Wunnava, M.D., MBA, Department of Anesthesiology, University of
North Carolina, Chapel Hill, NC
A 69 year-old male with chronic hip and lower back pain was admitted to the hospital for an exacerbation
of his chronic pain. A formal pre-procedure timeout was performed prior to an uneventful lumbar epidural
steroid injection. On post-procedure day one, the patient was seen on rounds and endorsed complete
resolution of his back and hip pain. It was identified that the patient had been taking apixaban as a home
medication, which was continued during his hospital stay, and he had received his twice daily dose of
apixaban the morning of the procedure, as well as three hours following the procedure.
MCC04
11:10 AM - 11:20 AM
Subdural Injection and Prolonged Motor Blockade in Parturient
Kadhiresan Murugappan, M.D., Patricia Perry, M.D., Anesthesiology, Rush University Medical Center,
Chicago, IL
A 37 year-old G7P5015 at 36 weeks and 6 days was induced due to chronic hypertension with
superimposed pre-eclampsia. At patient request, epidural was placed requiring two attempts due to
scoliosis. In spite of negative aspirate and minimal dosing, patient experienced prolonged sensory and
motor blockade of lower extremities bilaterally as well as weakness in left upper extremity. In spite of
extensive workup and imaging, no organic etiology was confirmed. However, weakness of lower
extremities persisted for seven days prior to spontaneous, rapid resolution.
MCC04
11:10 AM - 11:20 AM
Hip Arthroplasty in a 48 year-old Patient With Unrepaired Tetralogy of Fallot
Rasesh A. Desai, Mias Pretorius, M.D., Anesthesiology, Vanderbilt University, Nashville, TN
48 year-old female with known unrepaired Tetralogy of Fallot presented after fall for hip arthroplasty. The
patient is cyanotic at baseline with room air saturations in low 80s, for which she has compensated with
hematocrit in high 50s. Meticulous attention was made to de-air all lines. Pre-induction arterial catheter
was placed for hemodynamic monitoring. After induction, transesophageal echo was placed which
confirmed a large VSD with right-to-left shunt, overriding aorta, RV outflow tract obstruction and RV
hypertrophy. Pharmacological agents were used to reduce PVR and increase SVR to reduce shunt and
emboli risk. No neurological deficits were found on emergence.
MCC04
11:10 AM - 11:20 AM
Neuraxial Block for Cesarean Section in the Achondroplastic Dwarf
Jillian N. Yanow, M.D., Clara Espi, M.D., Anesthesiology, Los Angeles County - USC, Los Angeles, CA
A 21 year-old achondroplastic parturient with a normal sized fetus and an uneventful pregnancy was
undergoing a planned cesarean section. Neuraxial block was the anesthetic management chosen for the
case. Though a combined spinal-epidural technique was planned, there were difficulties threading the
epidural catheter in the small epidural space, thus only a spinal anesthetic was performed. The spinal
anesthetic reached an optimal level at T4, and the cesarean section was done without any complications.
There are, however, many unique considerations and risks involved when doing either general
anesthesia or neuraxial block in the achondroplastic dwarf patient.
MCC04
11:10 AM - 11:20 AM
Peripartum Cardiomyopathy: Delivering its Presentation in the Operating Room
Monica Cheriyan, M.D., Dinesh Ramaiah, M.B.,B.S., Anesthesiology, University of Kentucky, Lexington,
KY
A 30 year-old morbidly obese G2 P3 female who presented to the hospital post-operative day 8 status
post repeat Cesarean section for dichorionic diamniotic twins and preeclampsia with severe features
complicated by type 1 Diabetes Mellitus is admitted for concern of postoperative wound infection. She is
taken to the operating room for revision of fascial dehiscence. Rapid sequence induction, intubation and
intraoperative course were unremarkable. The patient was awake, following commands prior to and
immediately post extubation. She then became confused, hypoxic and bradycardic requiring reintubation,
epinephrine and chest compressions. In the PACU, cardiac workup was ordered for evaluation.
MCC04
11:20 AM - 11:30 AM
Anesthetic Management of a Patient With Chromosome 2 Deletions and a Difficult Airway
Samuel M. Barst, Micah Burns, M.D., Boeu Chon, D.O., Lorie Dyer, M.D., Anesthesiology, New York
Medical College - Westchester Medical Center, Valhalla, NY
A 4 year-old, 11 kg female with ambiguous genitalia and Chromosome 2 deletion (45, XY) presented for
laparoscopic orchiectomy. She had previously undergone cleft lip and palate repair. Dysmorphic features
included low set ears, broad flat nose, small mandible and abnormal dentition. She had profound mental
retardation and was assessed as a difficult intubation. After a mask induction and IV placement, a
pediatric glidescope (size 2 blade) was used to visualize her larynx. Her pharyngeal and laryngeal tissue
was narrowed. A 4 un-cuffed ETT was inserted without difficulty and the case proceeded uneventfully.
MCC04
11:20 AM - 11:30 AM
Airway Management in Patient With Pedunculated Plasmatcytoma in the Airway
Simon Yu, M.D., Steven Chinn, M.D., Anesthesiology, Montefiore Medical Center, Bronx, NY
A 71 year-old male presents to ED with respiratory distress. He has a history of Hepatitis C, liver cirrhosis
and marginal lymphoma of left eyelid. A CT thorax revealed a 1.5 x 1.5 cm mass attached to posterior
tracheal wall. He reported dyspnea, but on exam, he had no audible stridor or wheezing. After careful
planning and preparation with the ENT service, the patient was brought to O.R. for intubation. Via direct
laryngoscopy, he was intubated with a microlaryngeal tube around the mass after inhalational induction.
The mass was resected, and he was extubated after the procedure.
MCC04
11:20 AM - 11:30 AM
Unanticipated Difficult Airway in a Patient With Herpes Zoster in the Maxillary and Mandibular
Branches of the Trigeminal Nerve
Namrata Khimani, M.D., May Hua, M.D., Anesthesiology, Columbia University Medical Center, New York,
NY
72 year-old female with metastatic pancreatic cancer and unanticipated difficult airway in the setting of
trigeminal maxillary (V2) and mandibular (V3) branch herpes zoster. To our knowledge, this is the only
report of maxillary/mandibular herpes zoster with intraoral vesicular lesions causing significant
oropharygneal and arytenoid edema. Despite a recent history of easy intubations and laryngoscopic
grade 1 view and unchanged Mallampati 2 airway, our patient had airway changes resulting in a
laryngoscopic grade 4 view ultimately requiring fiberoptic intubation. We recommend advanced airway
equipment in patients with maxillary/mandibular herpes zoster as there can be unrecognized edema
leading to a difficult airway.
MCC04
11:20 AM - 11:30 AM
Pneumothorax and Systemic Air Embolism During Endobronchial Cryear-oldspray Ablation and
Balloon Dilation
Bradley M. Hammond, D.O., Bilal Ahmad, M.D., Chris Witkowski, C.R.N.A., Anesthesiology and Critical
Care, Temple University Hospital, Philadelphia, PA
A 59 year-old female presented for cryear-oldspray ablation and balloon dilation of a bronchus
intermedius lesion. Cryear-oldspray ablation was performed via flexible bronchoscopy. Next, the
bronchus intermedius was dilated with an endobronchial balloon. After withdrawing the bronchoscope, the
patient became bradycardic, refractory to atropine, and hypotensive, minimally responsive to epinephrine.
Stat chest x-ray revealed a large right pneumothorax, pneumomediastinum, and subcutaneous
emphysema, necessitating chest tube placement. Following decompression, the patient deteriorated into
ventricular fibrillation. ACLS was initiated and the patient was defibrillated twice before restoration of
sinus rhythm. Following ROSC, intraoperative rescue TEE revealed air bubbles within the left ventricle.
MCC04
11:20 AM - 11:30 AM
Intraoperative Evaluation of the Impella Ventricular Assist Device and Potential Complications
Using Transesophageal Echocardiography
Derek N. Lodico, D.O., Anesthesia and Pain Medicine, Naval Medical Center Portsmouth, Chesapeake,
VA
The Impella 2.5 Ventricular Assist Device is a short term temporizing measure often used as a bridge to
more definitive therapy such as placement of a HeartMate Left Ventricular Assist Device. The literature
describes potential pitfalls of improper positioning and its dynamic effect on cardiac function. This case
describes the transthoracic echocardiographic intraoperative evaluation of an Impella device during
Heartmate LVAD placement in a 53 year-old male with CHF during which the Impella device was causing
valvular flow dysfunction and subsequently became fixated surgically resulting in difficulty in removing the
device.
MCC04
11:20 AM - 11:30 AM
A Case of Hemophagocytic Lymphohistiocytosis Complicating Post-operative Recovery in a
Surgical Intensive Care Setting
Joseph C. Kuhn, D.O., Anesthesiology, Ohio State University Medical Center, Columbus, OH
Hemophagocytic lymphohistiocytosis (HLH), is a severe, life-threatening disease associated with
systemic inflammation and “cytokine storm” due to over proliferation and activation of the mononuclear
phagocytic immune system. It is caused by acquired defects in lymphocyte function triggered by an
underlying infectious, autoimmune, or malignant disorder. Due to its rarity, variable etiology and similarity
in presentation to sepsis, a diagnosis of HLH is often overlooked or missed. This is a case of a 51 yearold male whose post-operative care was complicated by the onset of acute HLH and the challenges to
diagnosis in a surgical intensive care setting.
MCC04
11:20 AM - 11:30 AM
Left Hypoglossal Nerve Weakness After Breast Reconstruction Surgery
Blair H. Herndon, M.D., Candra R. Bass, M.D., Anesthesiology, University of North Carolina Health Care,
Chapel Hill, NC
Hypoglossal nerve injury is an uncommon perioperative complication. We present the case of a left CN
XII injury in a 35 year-old female following intubation for an 11.5 hour bilateral breast reconstruction with
transverse rectus abdominis myear-oldcutaneous flaps. Her history and physical examination was
unremarkable aside from breast cancer. Induction and intubation proceeded uneventfully. Immediately
following the case, she was successfully extubated. Post-operatively, she complained of tongue
numbness, difficulty swallowing, speaking and spitting. Otolaryngology suggested the neuropathy was
secondary to compression from the endotracheal tube. Symptoms resolved completely within 3 months
with the help of steroids and speech therapy.
MCC04
11:20 AM - 11:30 AM
Snapped Towing Chain Resulted in Scalping and Skull Splitting With External Brain Matter
Herniation: Anesthetic Challenges
Kevin J. Donnelly, M.D., Jeff Gardner, D.O., Ramsis Ghaly, M.D., Ned Nasr, M.D., Gennady Vornov,
M.D., Anesthesiology, John H. Stroger Jr Hospital of Cook County, Chicago, IL
35 year-old male sustained massive head trauma 2/2 a tow chain snapping and striking his head at over
35 mph. Presented intubated with an open frontal skull, CT head showed extensive facial and basal skull
fractures, elevation of frontal bone flap, and external brain matter herniation. Intracranial hypertension
following TBI is widely treated with intraoperative decompressive craniectomy. Complications of this
procedure include contralateral subdural hematomas and expansion of the cerebral herniation.
Decompressive craniectomy occurring in the field will present later in the timeline of expected
complications. Recognizing the timeline of complications is imperative to appropriate medical
management by the anesthesiologist.
MCC04
11:20 AM - 11:30 AM
Nerve Injury on the Labor and Delivery Floor
Jonathan Edward Scholl, M.D., M.S., Tracey Vogel, M.D., Anesthesiology, West Penn Allegheny,
Pittsburgh, PA
32 year-old G5P1031 at 38.0 weeks gestation with a history of 3rd trimester posterior left thigh
paresthesia presenting in labor with a near complete cervical exam. During combined spinal/epidural
procedure, a significant left-sided, transient paresthesia occurred during spinal technique. 3ml of 0.1%
ropivicaine with 6 mcg of fentanyl were injected intrathecally. Baby delivered 6 minutes after epidural
catheter test dose was given. Four hours post-partum patient denied sensation of or ability to move left
lower extremity. Despite negative spinal MRI, patient experienced 8 weeks of chronic weakness of left hip
flexors and sensation abnormalities of left lateral upper thigh.
MCC04
11:20 AM - 11:30 AM
A Review of Cohen Syndrome and a Focus on Pediatric Anxiety on Induction
Dorothea Kadarian, D.O., Luis Rodriguez, M.D., Anesthesiology, Jackson Memorial Hospital/University of
Miami, Miami, FL
Cohen syndrome is a rare genetic disorder that involves facial dysmorphism, mental retardation,
hypotonia, joint laxity, truncal obesity, neutropenia and ocular abnormalities. Many patients exhibit
microcephaly with downward slanting palpebral fissures, prominent noses and an upturned philtrum.
There is concern for possibility of difficult airway due to craniofacial deformities with micrognathia, high
arched palate, microcephaly and prominent incisors in addition to concerns with an uncooperative patient
due to mental retardation. We report the case of a nine year-old highly combative child undergoing
ophthalmologic surgery requiring a change of practice for induction demanding intense parental
involvement.
MCC04
11:20 AM - 11:30 AM
Pain Medicine (PN)
Utilization of an Epidural Blood Patch Technique to Prevent Formation of Intracranial Subdural
Hematoma in Patient With Post-dural Puncture Headache Undergoing Stereotactic Brain Mass
Biopsy
Zilvinas Zakarevicius, M.D., Azzam Alkhudari, M.D., Adrian Sonevytsky, M.D., Abed Rahman, M.D.,
Taruna Penmetcha, M.D., Maria Torres, M.D., Anesthesiology and Pain Management, John H. Stroger Jr.
Cook County Hospital, Chicago, IL
Each year, 400.000 diagnostic lumbar punctures (LP) are performed in US. Up to 40% of these patients
develop post-dural puncture headache (PDPH) and 0.05% acquired serious complications including
formation of intracranial subdural hematoma. There is a hypothetical concern that persistent intracranial
hypotension in the setting of intracranial mass and a diagnostic LP might predispose to the development
of an extra-axial hematoma either spontaneously or following surgical intervention. We are presenting
challenging case where utilization of an epidural blood patch technique was successful in prevention
formation of intracranial subdural hematoma in patient with PDPH undergoing stereotactic brain mass
biopsy.
MCC04
11:20 AM - 11:30 AM
Case Report: Treating Severe Anaphylaxis in the Setting of Spinal Anesthesia
Sebastian M. Baquero, Brian M. Osman, M.D., Anesthesiology, University of Miami Hospital, Miami, FL
Cardiac arrest has been reported after spinal anesthesia, usually as a severe bradycardia progressing to
asystole. Mechanisms are elusive or not entirely known. Other types of cardiovascular collapse can occur
under spinal anesthesia. We report a case of a non-bradycardic pulseless arrest after an acute
anaphylactic reaction induced by a cephalosporin administered after spinal anesthesia. Successful
resuscitation and treatment of anaphylaxis becomes difficult to manage with a significant partial
sympathectomy due to a working spinal anesthetic. We report successful resuscitation despite an intial
refractory response to conventional treatment for severe anaphylaxis.
MCC04
11:20 AM - 11:30 AM
Transversus Abdominis Plane Block as a Primary Anesthetic for Appendectomy in a Patient With
Severe Pulmonary Hypertension
Chase E. Smith, M.D., Jeremy Kaplowitz, M.D., Anesthesiology, University of Maryland Medical Center,
Baltimore, MD
A 55 year-old female with severe pulmonary hypertension presented for emergent appendectomy. The
patient was on home oxygen and her medical history revealed a recent TTE which showed pulmonary
artery pressures above 80mmHg. Our goal was to avoid general anesthesia and use an epidural as our
primary anesthetic. Coagulation labs however, revealed an INR of 1.6 making neuraxial techniques
contraindicated. The decision was made to employ TAP blocks for surgical anesthesia. We performed the
TAP blocks and proceeded with the case using minimal sedation. The surgery was uneventful and the
patient was discharged two days later.
MCC04
11:20 AM - 11:30 AM
The Conundrum of Pancytopenia in Pregnancy
Avneep Aggarwal, M.D., Harjot Kaur, M.D., Victor L. Mandoff, M.D., Department of Anesthesiology,
Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
A 35 year-old G4P3 at 38 weeks presented in active labor with previously undiagnosed pancytopenia.
Her platelet count was 34 K on admission. All other labs were unremarkable. Schistocytes were absent.
She denied any recent bleeding, thrombosis, infections or family history of blood dyscrasias. She reported
history of previous three cesarean deliveries and blood transfusion in all her previous pregnancies.
Hematology was consulted and IVIG was administered for suspected ITP. After discussion with
obstetrician, hematologist and patient, it was decided to go ahead with caesarean under general
anesthesia. She received PRBCs and platelets transfusion intra-operatively and her surgery was
uncomplicated.
MCC04
11:20 AM - 11:30 AM
Phrenic Nerve Injury: A Serious Complication of Atrial Fibrillation Cryear-oldablation
Malwina Wloch, M.D., Samir Shah, Wesam Andraous, M.D., Stony Brook University Hospital, Stony
Brook, NY
We present a 61 year-old female with history of paroxysmal atrial fibrillation who presented for an elective
cryear-oldablation. General anesthesia was administered for morbid obesity and possible difficult airway.
Intraoperatively, the applied phrenic nerve stimulator showed no diaphragmatic movement on the right
side, leading to a suspicion of right phrenic nerve injury. The case was aborted and an intraoperative
chest X-ray was obtained, which showed elevated diaphragm on the right. Subsequent attempts to
extubate the patient were unsuccessful due to tachypnea and inadequate tidal volumes. She was
transferred to the CCU and extubated to BiPAP ventilation the next morning.
MCC04
11:30 AM - 11:40 AM
The Need for Increased Vigilance to Maintain Sterility and Patency of Central Venous Catheters in
Pediatric Hematology-Oncology Patients
Samuel M. Barst, Nathan Liu, M.D., John A. Cooley, M.D., Irim Salik, M.D., Anesthesiology, New York
Medical College - Westchester Medical Center, Valhalla, NY
A 17 year-old female with metastatic rhadomyear-oldsarcoma presented for flexible bronchoscopy. Both
lumens of the patient’s broviac catheter (BC) were accessed for infusing medications and platelets.
Following the procedure, PACU nursing noted that one lumen was clamped off and could not be flushed.
A functioning double lumen line was deemed essential for the patient’s care. Indwelling BCs are
associated with risks of infection, catheter dislocation, leakage and breakage. While it has been
suggested that thrombotic line occlusions are more frequent in children with malignancy, meticulous care
of these devices is essential to care for this patient population.
MCC04
11:30 AM - 11:40 AM
Airway Management In A Patient With Previous Emergent Cricothyroidotomy and Lidocaine
Allergy Presenting For Renal Transplantation
Jerri Chen, M.D.,Ph.D., Robert L. Kong, M.D., Richard K. Raker, M.D., Department of Anesthesiology,
Columbia University Medical Center, New York, NY
A 59 year-old man presented for cadaveric renal transplant with a history of failed intubation requiring
emergent cricothyroidotomy three years prior at a different institution; renal transplant at that time was
aborted. Additional airway risks included C4-C5 spinal fusion, chronic SVC thrombosis, OSA, tracheal
stenosis, and history of allergic reaction to topical lidocaine resulting in angioedema. A preoperative
fiberoptic exam revealed edematous arytenoids prolapsed over the vocal cords and reduced abduction of
the vocal cords. With an otorhinolaryngologist on standby for a possible awake tracheotomy, an awake
fiberoptic intubation was successful using dexmedetomidine for sedation and chloroprocaine for airway
topicalization.
MCC04
11:30 AM - 11:40 AM
Unexpected Hypotension in Cancer Patient Receiving Albumin Infusion
Joshua J. Herskovic, M.D., Bryan Dehner, C.R.N.A, Anesthesiology, Midwestern Regional Medical
Center, Zion, IL
A 57 year-old female with ovarian cancer was scheduled to undergo ileostomy reversal under general
anesthesia. After an uneventful induction albumin was initiated for hypovolemia. Shortly after the start of
the infusion the patient became tachycardic. Monitors were unable to obtain an oxygen saturation by
pulse oximetry or blood pressure by cuff. Patient assessment demonstrated a red torso, neck and upper
extremities. Resuscitative measures included: giving IV Epinephrine, Dexamethasone, Glycopyrolate, and
IV fluids. Within 10 minutes, the blood pressure began to stabilize and the redness subsided. After case
and history review, albumin was determined to be the primary culprit.
MCC04
11:30 AM - 11:40 AM
Cerebral Embolism Associated With Endoscopic Retrograde Cholangiopancreatography
Jerry W. Green, D.O., Jenny Ringqvist, Anesthesiology & Pain Management, University of Texas
A 60 year-old female patient presented for repeat endoscopic retrograde cholangiopancreatography
(ERCP) 3 weeks after laparoscopic cholecystectomy. Retrieval of 8 large gallstones was technically
difficult and involved cholangiography with insufflation of the biliary tree. General anesthesia was
uneventful. Despite stable vitals and oxygenation throughout, the patient had a seizure 20 minutes after
arrival in recovery. Imaging eventually showed widespread embolic damage to brain and spinal cord. A
patent foramen ovale was present on echocardiogram with no other apparent source of emboli. Despite
aggressive treatment the patient still had significant residual neurologic deficits 2 months after the event.
MCC04
11:30 AM - 11:40 AM
Conversion of Rapid Atrial Fibrillation to Normal Sinus Rhythm After Propofol Bolus In a Patient
With Wolfe-Parkinson-White Syndrome
Holly E. Careskey, M.D.,M.P.H., Henna Tirmizi, M.D., Anesthesiology, Tufts Medical Center, Boston, MA
I.N. is an 18 year-old female with a history of WPW Syndrome, depression and anxiety undergoing
radiofrequency ablation with sedation. During the atrial mapping, the patient develops atrial fibrillation with
a rapid ventricular response rate of 220 bpm with stable blood pressure. The anesthesia team is called to
administer general anesthesia for cardioversion. After preoxygenation, 1.5mg/kg IV propofol bolus is
administered to facilitate cardioversion. Within 30 seconds of administration, the patient spontaneously
converts to NSR at a rate of 75 bpm eliminating the need for cardioversion. We hypothesize interruption
in sympathetic tone is primarily responsible for the return to sinus rhythm.
MCC04
11:30 AM - 11:40 AM
Probable Allergic Reaction To Latex: A Case Report
Yolanda L. Araujo, M.D., Carlos Andre Cagnolati, Paulo Sergio Serzedo, Thiago De Freitas Gomes,
Clínica de Anestesiologia de Ribeirão Preto (CARP), Ribeirão Preto, Brazil
19 year-old man, P1, with a medical history of allergy to the glove talc. Sterile surgical gloves without talc
were used during surgery. Anesthesia proposal: BIER+sedation. Started with O2 mask, midazolam (5mg)
EV, fentanyl (40mcg) EV, and propofol TCI. Venipuncture MSD and tourniquet with smarch range without
talc were performed. 15 minutes after injection of 40 ml of lidocaine (0.5%), skin rash on the face, chest
and MSD, accompanied by major face edema and dyspnea. 0,2 mg adrenaline, 1 mg difenidrina, 500 mg
hydrocortisone and 50 mg ranitidine were intravenously administered, followed by infusion of crystalloid
and O2 uptake.
MCC04
11:30 AM - 11:40 AM
Perioperative Evaluation, Diagnosis and Management of Acute Pulmonary Thromboembolism
Spencer W. Drotman, M.D., Anesthesia, NYU Langone Medical Center, New York, NY
68 year-old female with diabetes and hypertension presented after MVA with external fixation of a right
pilon fracture requiring ORIF of left tibia. Perioperatively patient febrile and tachycardiac with acute
intraoperative hypoxemia, hypotension and a decreased end tidal capnography tracing. Concerns
discussed with surgical team. Patient extubated to oxygen mask and transferred to PACU. ABG with
large Aa gradient and CTA revealed saddle pulmonary embolus. Patient started on Heparin drip, brought
for urgent pulmonary embolectomy, PFO closure and IVC filter. 7 days after patient returned to OR to
finish orthopedic correction. Will discuss hemodynamics, EBM evaluation and treatment of perioperative
PE.
MCC04
11:30 AM - 11:40 AM
Anesthetic Considerations for C-Section in Patient With Primary Chiari Malformation and History
of Spina Bifida
Rhonda R. Douglas, Jack Folbe, Julie Kado, Beaumont Health, Royal Oak, MI
This is a 32 year-old female with a history of Spina Bifida and Type 1 Chiari Malformation who presented
for scheduled Cesarean Section requesting general endotracheal anesthesia. After careful consideration,
it was decided to proceed with a lumbar spinal anesthetic using only bupivacaine. Surgery was performed
without complications and neurological assessment post-operatively revealed no progression of
symptoms. The successful management of pregnant women with a diagnosis of Chiari malformation
requires individual assessment of risk factors and current neurological status.
MCC04
11:30 AM - 11:40 AM
Management of a Parturient With Recent History of Ischemic Stroke: A Case of Paradoxical
Embolization!
Kalpana C. Tyagaraj, M.D., Gaurav Sharma, D.O., Department of Anesthesiology, Maimonides Medical
The incidence of stroke in the United States is approximately 500,000 per year, of which 35-40% are
cryptogenic (i.e., without an identifiable source). Patent Foramen Ovale (PFO) is found in approximately
20-30% of those who sustain cryptogenic strokes. We present the management of a parturient who had a
recent episode of ischemic stroke. A 32 years female (36 weeks pregnant) with past medical history
significant for Familial Mediterranean fever, chronic daily smoker and recent history of ischemic stroke
(left midbrain) with no residual weakness, delivered under epidural analgesia. She was placed on low
molecular weight heparin for 6 weeks postpartum.
MCC04
11:30 AM - 11:40 AM
Management of Children With Peter's Anomaly: Anesthetic Considerations
Samuel M. Barst, Nausheen Zia, M.D., Irim Salik, M.D., Gerald Zaidman, M.D., Anesthesiology,
Opthamology, New York Medical College - Westchester Medical Center, Valhalla, NY
We present our experience with 12 infants who were managed at our institution with Peter's Anomaly in
2014. Peter’s anomaly is characterized by corneal opacification necessitating corneal transplant. Most
cases are sporadic but may also have an autosomal recessive inheritance pattern. Affected children
require a diagnostic workup and evaluation under general anesthesia; they are then scheduled for
corneal transplantation and followup evaluation. We will present a case series for a one year period .
Each patient required a minimum of three general anesthetics (evaluation, transplane and post-transplant
evaluation).
MCC04
11:30 AM - 11:40 AM
Pain Medicine (PN)
Can We Treat Tinnitus in the Pain Clinic?
Christopher L. Eddy, M.B.,B.Ch., Sravankumar R. Polu, M.D., Miguel Telleria, M.D., Constantine
Sarantopoulos, M.D., Department of Anesthesiology, Perioperative Medicine and Pain Management,
University of Miami, Jackson Memorial Hospital, Miami, FL
In addition to pain, other maladies impair quality of life. We report the resolution of tinnitus after trigger
point (TP) injections of local anesthetics.A 61 year-old male suffered from myear-oldfascial pain, with
tenderness and TPs in his right paraspinal lumbar region, and chronic intractable tinnitus. He received
two sessions of TPIs with 150mg lidocaine and ketorolac, and later with 25mg bupivacaine IM. After 1
month, both his pain and tinnitus had resolved completely.This highlights that local anesthetic injections
and systemic sodium channel blockers (commonly used for treatment of pain) have a potential in treating
tinnitus.
MCC04
11:30 AM - 11:40 AM
Peripheral Nerve Blocks for Above-knee Amputation in Elderly and Septic Patient With Aortic
Stenosis
Telmo Santos, M.D., Carolina Santos, M.D., Célia Pinheiro, M.D., Pilar Carballada, M.D., Anesthesia and
Pain Medicine, Centro Hospitalar de Trás os Montes e Alto Douro, Vila Real, Portugal
79 year-old women with a history of hypertension, diabetes, aortic stenosis presented for above-knee
amputation following dry gangrene of the left foot with sepsis.We opted for ultrasound-guided peripheral
nerve blocks, injecting levobupivacaine 0,5% to block the femoral (20ml), lateral femoral cutaneous (5ml),
obturator (10ml) and sciatic (25ml) nerves.Surgery was performed under regional anesthesia with minimal
sedation, and patient maintained stable hemodynamics throughout the procedure.This case shows that
peripheral nerve blocks are a safe and good alternative to general or neuraxial anesthesia in these
procedures in septic patients with unstable cardiovascular systems.
MCC04
11:30 AM - 11:40 AM
Isolated Femoral Nerve Palsy Following Exploratory Laparotomy With Thoracic Epidural
Chase E. Smith, M.D., Ron Samet, M.D., Michelle Kim, M.D., Anesthesiology, University of Maryland
Medical Center, Baltimore, MD
A 72 year-old female with history of small bowel obstruction presented for exploratory laparotomy and
lysis of adhesions. Preoperatively a thoracic epidural was placed. After an uneventful surgery the patient
was noted to have complete sensory and motor deficit in the distribution of the left femoral nerve. Given
the low concentration/low volume solution being used we were concerned for intrathecal catheter
placement. The infusion was stopped and the catheter removed. 24 hours after discontinuation the
patient continued to have a left sided femoral nerve palsy with no other deficits. We review the possible
surgical and anesthetic causes of this injury.
MCC04
11:30 AM - 11:40 AM
Epidural Anesthesia for Cesarean Delivery in a Parturient With Osteogenesis Imperfecta
Emily E. Sharpe, M.D., John A. Thomas, M.D., Anesthesiology, Wake Forest School of Medicine, Winston
Salem, NC
A 26 year-old G2P1001 presented for cesarean delivery (CD) at 39 weeks with a past medical history of
osteogenesis imperfecta (OI) and previous CD under general anesthesia. Her airway was reassuring,
weight 44kg, and height 112cm. Lumbar ultrasonography was used to guide epidural placement.
Incremental dosing with 2% lidocaine + epinephrine achieved T2 sensory block and two mg epidural
morphine provided postoperative pain control. OI is characterized by skeletal abnormalities, short stature,
connective tissue abnormalities, and hearing loss. A titratable epidural was chosen to minimize risks of
high spinal and ultrasound was helpful in minimizing chances of a difficult placement.
MCC04
11:30 AM - 11:40 AM
Transorbital Endotracheal Intubation: A Non-standard Approach to a Difficult Airway
Nathan H. Waldron, M.D., Michael Ogilvie, M.D., David B. Powers, M.D., Bryant W. Stolp, M.D.,Ph.D.,
Michael R. Shaughnessy, M.D., Anesthesiology, Plastic, Maxillofacial, and Oral Surgery, Duke University
Medical Center, Durham, NC
Our patient was a 49 year-old gentleman with a history of adenoid cystic carcinoma of the left nare. He
underwent a curative resection and adjuvant radiotherapy, but thereafter experienced optic neuropathy
requiring orbital exenteration, which was complicated by oro-antral fistula. His course was also
complicated by severe radiation trismus, for which he was to undergo coronoidectomies. Given his limited
mouth opening, the surgeon requested a nasal endotracheal tube. Due to concerns of traumatizing his
nare, we utilized a flexible fiberoptic bronchoscope to perform a trans-orbital intubation. The surgery
proceeded uneventfully and the patient was extubated in the OR.
MCC04
11:40 AM - 11:50 AM
The Anesthetic Management of a Premature Neonate for Thoracoscopic Repair of a Rare Type
Tracheoesophageal Fistula
Samuel M. Barst, M.D., Olena Pryjdun, M.D., Kristopher Kuhl, D.O., Anesthesiology, New York Medical
College - Westchester Medical Center, Valhalla, NY, New York Medical College - Westchester Medical
Center, Valhalla, NY
We present a case of an 8 days old ex-33 week premie (1.83 kg) scheduled for evaluation of an
esophageal atresia (EA). An N-G tube could not be passed into the stomach and barium swallow
revealed a dilated esophageal pouch consistent with EA. Rigid bronchoscopy initially did not reveal a
tracheoesophageal fistula (TEF)but during bronchoscopy the stomach became progressively distended. A
laparoscopic G-T was placed for nutrition as well as decompression. A subsequent gastric dye study
revealed a TEF arising from the corina.
MCC04
11:40 AM - 11:50 AM
Should Thrombelastography be Used to Guide Transfusion in Trauma Patients Who are Taking
Warfarin?
Chyong-jy J. Liu, D.O., Yashar Ettekal, M.D., Anesthesiology, Albany Medical Center, Albany, NY
Drug-induced coagulation caused by Warfarin use is a potential concern in trauma patients. Recently
thromboelastography has been used to guide transfusion in trauma. Here, we present a case series of
trauma patients on Warfarin whose TEG profile revealed a hypercoagulable state, but whose INR and PT
were elevated, indicating an anticoagulated state. Thus, we question the effectiveness of TEG use in
trauma patients who are taking Warfarin. We propose further studies are needed regarding the accuracy
of TEG in these patients, and clinical judgment should be used to guide therapy in trauma patients taking
Warfarin to optimally manage their care.
MCC04
11:40 AM - 11:50 AM
Difficult Airway - Median Sternotomy for Securing the Airway
Megan M. Rashid, M.D., Christian Diez, M.D., Department of Anesthesiology, Perioperative Medicine and
Pain Management, University of Miami/Jackson Health System, Miami, FL
We describe a case of a 51 year-old man who presented to the Emergency Department in respiratory
distress with a previous unknown tracheal surgery, leading to drastic measures to secure his airway. He
ultimately required a median sternotomy with direct intubation of his trachea 4cm above the carina, which
was subsequently secured through his chest wall.
MCC04
11:40 AM - 11:50 AM
One Lung Ventilation for Exposure of CT-Guided Ablation of Hepatic Dome Lesion: A Case Report
Sam Nia, M.D., Anthony Sifonios, M.D., Anesthesiology, UMDNJ-New Jersey Med School, Newark, NJ
66 year-old female with hepatocellular carcinoma suffering from high hepatic dome lesion for alcohol
ablation. Pre-procedure tomography demonstrated that the lesion was abutting the diaphragm.
Interventional radiology requested trans-pulmonary approach, therefore, one lung ventilation technique
was utilized to facilitate surgical exposure. Typically, this type of procedure is performed in the inpatient
setting, but this case demonstrates the use of advanced anesthesia techniques in the ambulatory care
setting. This is an example of how an anesthesia team facile with different techniques can work in concert
with the proceduralist to not only provide anesthesia, but to also facilitate surgical exposure.
MCC04
11:40 AM - 11:50 AM
Takotsubo Cardiomyopathy Under General Anesthesia
Aliya S. Bynum, M.D., Anesthesiology, The George Washington University Hospital, Washington, DC
A 50 year-old female was administered general anesthesia for right breast implant removal and tissue
expander placement. Patient was hemodynamically stable for the majority of the case. During closure of
surgical incision, patient was noted to be diffusely erythematous on anterior chest wall. The patient then
became severely hypertensive with increasing ectopy until NIBP measurements lost. Patient was
resuscitated and stabilized in the operating room and then immediately evaluated with cardiac
catetherization showing normal coronaries, anterior, apical, and inferior akinesis, and an LVEF 10%. After
supportive care in the critical care unit, heart function normalized by post-operative day 5.
MCC04
11:40 AM - 11:50 AM
The Use of Intra-Aortic Balloon Pump Counterpulsation in Cerebral Vasospasm: A Case Report
Sarah M. Khorsand, M.D., K. H. Kevin Luk, M.D., Matthew Triplette, M.D., Anesthesiology and Pain
Medicine, University of Washington, Seattle, WA, Pulmonary and Critical Care Medicine, University of
We report the case of a 55 year-old female with severe aneurysmal subarachnoid hemorrhage who
developed cerebral vasospasm. TTE demonstrated LV dyskinesis with an EF of 14%, consistent with
stress cardiomyear-oldpathy, and she required high-dose pressors to maintain adequate cerebral
perfusion pressure. Despite initiation of goal-directed therapy, she became comatose. IABP
counterpulsation was initiated with improvement in her neurologic exam. This highlights two concepts in
managing cerebral vasospasm with concomitant stress cardiomyear-oldpathy: 1) the use of LiDCO and
continuous ScvO2 to achieve goal-directed optimization of hemodynamics; and 2) the use of IABP to
augment CPP as the stress cardiomyear-oldpathy recovers.
MCC04
11:40 AM - 11:50 AM
Metallosis Identified by the Use of Intraoperative Cell Salvage
Lauren M. Parker, M.D., Jonathan H. Waters, M.D., Anesthesiology, Univ of Pittsburgh Med Ctr,
Pittsburgh, PA
Metal-on-metal (MoM) hip prostheses frequently undergo corrosion over time. Deposition of metal debris
within the surrounding tissue, known as metallosis, manifests as pain, joint dislocation, or implant failure.
Furthermore, the release of metal from the joint space into the bloodstream may result in heavy metal
toxicity. The following case describes an elderly patient with a MoM hip prosthesis who underwent
revision total hip arthroplasty. Post-procedure, black particulate matter later identified as cobalt and
chromium was found within the cell salvage reservoir. This finding questions whether blood collected via
cell salvage during MoM implant revision can be safely re-administered to patients.
MCC04
11:40 AM - 11:50 AM
Intracranial Pressure Management During Carotid Endarterectomy: Circumventing Herniation on
Heparin
Patricia Hooper, J. Arthur Saus, M.D., Anesthesiology, LSU Health Sciences Center Shreveport,
Shreveport, LA
An 84 year-old male presented to our institution after suffering a left MCA stroke. He had obstructive
hydrocephalus secondary to a large posterior fossa tumor occupying the fourth ventricle and was found to
have high grade stenosis of the left ICA. Neurosurgery was consulted and felt that the tumor was likely a
chronic issue and deferred surgical intervention until after he stabilized from his stroke. Vascular surgery
elected to perform a left CEA under general anesthesia. Given the size of the brain mass and risk for
herniation neurosurgery placed a bolt for intracranial pressure monitoring during the case.
MCC04
11:40 AM - 11:50 AM
Anesthesia for Placenta Percreta: A Team-Based Approach
Nicolas A. Pipito, M.D., Sivasenthil Arumugam, M.D., Anesthesiology, Univ of Connecticut, Farmington,
CT, St. Francis Hospital and Medical Center, Hartford, CT
A 42 year-old, G7P3 female presented to the ED at 28.1 weeks with profuse vaginal bleeding. After
controlling the hemorrhage, MRI of the abdomen revealed a placenta percreta involving portions of her
bladder and left ureter. Cesarean section with total abdominal hysterectomy and bilateral salpingooophorectomy was planned electively at 32 weeks to prevent further growth of the placenta. A
coordinated effort was made between the anesthesia, obstetric, urology, and interventional radiology
teams for the safe and efficient care of this patient.
MCC04
11:40 AM - 11:50 AM
Accidental Subcutaneous Injection of Rocuronium and the Potential Consequences
Namrata Khimani, M.D., Caleb Ing, M.D., Anesthesiology, Columbia University Medical Center, New
York, NY
12 year-old female with horizontal gaze palsy progressive scoliosis syndrome and cyclic vomiting requires
central venous access. During rapid sequence intubation with rocuronium the peripheral intravenous
access infiltrated resulting in subcutaneous depot of rocuronium. After delayed onset of action, ulnar
train-of-four stimulation of 4/4 at 14 minutes and 0/4 at 27 minutes, we were concerned for prolonged
duration of action or recurarization. Given the paucity of information regarding the pharmacokinetics of
subcutaneous neuromuscular blockade, we waited 125 minutes for extubation. Delayed onset and
prolonged blockade maybe due to the slow systemic absorption from the subcutaneous site; we therefore
recommend close monitoring.
MCC04
11:40 AM - 11:50 AM
Pain Medicine (PN)
Two Cases of Genicular Nerve Blocks (GNBs) for Chronic Knee Pain
Erica Patel, D.O., Shruti Shah, M.D., Adil Mohiuddin, M.D., Anesthesia, Rutgers University Robert Wood
Chronic osteoarthritis (OA) can cause chronic/debilitating knee pain. A genicular nerve block (GNB)
involves disrupting pain perception that travels to the knee via the genicular nerve. We describe two
cases of successful GNBs in patients failing other treatment modalities. Case 1 is a 78 yr old female s/p
bilateral TKR with constant, throbbing bilateral knee pain treated with oral pain medications. Patient
received a diagnostic left genicular block with 100% pain relief. Case 2 is a 61 yr old male (Ht: 6’, Wt:
311lbs) with continuous knee pain treated with multiple pain medications. Patient underwent bilateral
GNBs with >80% improvement.
MCC04
11:40 AM - 11:50 AM
Liposomal Bupivacaine for Post-operative Pain Control in Patient With Severe Chronic Back Pain
Sean T. DeGrande, M.D.,Ph.D., Hesham Elsharkawy, M.D., M.S., Anesthesiology, Cleveland Clinic
Foundation, Cleveland, OH
A 56 year-old male with a PMH significant for Crohn’s disease and chronic back pain presented for right
partial colectomy with ICA. His back pain resulted from trauma sustained nine ago and he was currently
being weaned from his chronic opioid use by the chronic pain service. His perioperative pain was
successfully controlled with single shot nerve blocks using liposomal bupivacaine. This case describes
the potential benefit of liposomal local anesthetic formulations. The discussion will demonstrate the
ongoing need for further evaluation of clinical outcomes associated with the use these anesthetic
formulations compared to other regional anesthesia techniques.
MCC04
11:40 AM - 11:50 AM
Extended Release Bupivacaine in Peripheral Nerve Catheters Achieves Adequate Post-Operative
Analgesia
Yoon-Jeong Cho, M.D., Hesham Elsharkawy, M.D., Wael Saasouh, M.D., Anesthesiology Institute,
Cleveland Clinic Foundation, Cleveland, OH
A 23 year-old male with ulcerative colitis, persistent postsurgical pain, fentanyl and oxycodone allergies
presented for completion proctectomy. Bilateral quadratus lumborum blocks with catheters were placed
postoperatively in OR under general anesthesia. Catheters were infused with 0.2% ropivacaine as part of
multimodal analgesia with IV acetaminophen, ketorolac and hydromorphone PCA. On POD3 each
catheter was bolused with 10mL (133mg) of Exparel in 10mL NS (20mL each, 40mL and 266mg total)
prior to removal. Adequate pain control was noted until POD6. Extended-release local anesthetics can
potentially be used in place of home infusion device and can be bolused every 3 days.
MCC04
11:40 AM - 11:50 AM
Peripartum Management of a High Ischemic Risk Patient With Factor 8 Deficiency
Jenny Woo, M.D., Manju Prasad, M.B.,B.S., Anesthesiology, Albany Medical Center, Albany, NY
A 33 year-old woman with a history of malignant hypertension since childhood with resultant stroke and
myear-oldcardial infarction presents to labor and delivery at 35 weeks with hypertension. She also has
Factor VIII deficiency and suspected hypercoagulability. After discussion of peripartum coagulopathy,
cardiovascular optimization and the risks/benefits of delivery and anesthetic methods, she underwent
urgent cesarean section with general anesthesia. She was administered Factor VIII and von Willebrand
factor complex without excessive blood loss which suggests that in cesarean delivery, factor replacement
may be beneficial for those at risk for perioperative ischemic event with acute blood loss anemia.
MCC04
11:40 AM - 11:50 AM
Subcutaneous Emphysema: A Rare Cause of Difficult Airway
Jennifer L. Anderson, M.D., Anesthesia and Critical Care, University of Chicago, Chicago, IL
An obese male with a lung abscess causing subcutaneous emphysema throughout the chest, head and
neck presented in respiratory distress. Anesthesiology and otolaryngology jointly planned for awake
intubation with crichothyroidotomy as backup. All equipment was available. Upon attempted awake
fiberoptic intubation it became clear that air tracking into the subcutaneous tissue of the tongue, larynx,
and pharynx prevented intubation orally or nasally. After onset of bradycardia ventilation with mask and
supraglottic airway were unsuccessful. Although landmarks were difficult to find, surgical
cricothyroidotomy was successful.
MCC04
11:50 AM - 12:00 PM
The Anesthetic Management of a Child With Severe Systemic Mastocytosis Scheduled for AdenoTonsillectomy
Samuel M. Barst, M.D., Trevor Goodman, M.D., Michael Lyew, M.D., David Merer, M.D., Anesthesiology,
Otolaryngology, New York Medical College - Westchester Medical Center, Valhalla, NY
We present a case of a 2 year-old child with systemic masotocytosis scheduled for elective tonsillectomy.
These patients are at significant risk for systemic histamine release and anaphylactoid reaction which can
cause airway obstruction and edema. The patient was premedicated with ranitidine, diphenhydramine
and a steroid bolus to both minimize mast cell degranulation as well as manage the release of systemic
histamine. A deep level of anesthesia was obtained using an inhalation agent and propofol. Avoidance of
histamine releasing drugs was observed. No adverse effects were noted and patient had an uneventful
anesthetic.
MCC04
11:50 AM - 12:00 PM
Tracheostomy After Successful Awake Nasal Fiber-optic Intubation Secondary to Aspiration
Peter Yeh, M.D., Li Meng, M.D., Department of Anesthesiology, University of Pittsburgh Medical Center,
Pittsburgh, PA
We present a case of a 52 year-old female with history of tracheostomy, PEG, and anoxic dystonia
status-post cardiac arrest resulting in trismus undergoing insertion of a deep brain stimulator. Because of
her severe limited oral aperture, an awake nasal fiber-optic intubation was performed. Post operatively,
her nasogastric tube was not reconnected to suction and she subsequently aspirated. Her SpO2
decreased to 93% with high-flow oxygen and respiration rate was 45. A pediatric fiber-optic scope could
only be partially passed through her nasal passage. She was taken emergently to the operating room for
an emergent awake tracheostomy.
MCC04
11:50 AM - 12:00 PM
Ballvalving Supraglottic cyst
Bina E. Dara, M.B.,B.S., Anesthesiology, Michael E DeBakey VA Medical Center, Houston, TX
Sixty year-old former smoker scheduled electively for direct laryngoscopy under general anesthesia for a
supraglottic mass ball valving in the airway.After local lidocaine 4% spray, nasal endoscopy by the
anesthesiologist preoperatively revealed the non-obstructing cyst.Midazolam and Dexmedetomidine used
for sedation. DL was done by surgeon using Miller 2 with obstructing view of cords and intubated with 5.0
ETT followed by general anesthesia. The large broad based supraglottic cyst was nearly completely
obstructing the airway and was excised and marsupialised as were the two vocal cord cysts. Patient was
extubated and discharged home the same day.
MCC04
11:50 AM - 12:00 PM
Successful Extubation and Discharge of a Patient With Post-Polio Syndrome Using a Personal
Ventilator
Truc-Anh T. Nguyen, M.D., Vimal Desai, M.D., Kanwaljit Sidhu, M.D., Anesthesiology, Case Western
University - Metrohealth Medical Center, Cleveland, OH
A 73 year-old female with a post-polio syndrome presented for a cystoscopy. The patient underwent the
cystoscopy under general anesthesia with a laryngeal mask airway (LMA). She had an unremarkable
intraoperative course and LMA was removed postoperative. The patient was immediately transitioned to
her personal ventilator with a mouth piece which supplied comfortable assisted ventilation until the
anesthetics wore off and patient was fully emerged and able to ventilate adequately independently. She
was discharged after 3 hours of recovery. We discuss the postoperative management of a patient with
respiratory failure secondary to polio.
MCC04
11:50 AM - 12:00 PM
Severe Bilateral Ocular Hypotony After Emergent Coronary Artery Bypass Graft Surgery
Complicated With Cardiogenic Shock
Gustavo M. Munoz, M.D., shvetank agarwal, M.D., manuel R. castresana, M.D., Department of
Anesthesiology and Perioperative Medicine, Georgia Regents University, Augusta, GA
A 78-yr-old male without any ophthalmic history underwent an emergent CABG surgery that was
complicated with postcardiotomy cardiogenic and vasoplegic shock requiring multiple interventions to
maintain hemodynamics. On arrival to the ICU, he was found to have extreme lactic acidosis and both
corneas were noticed to be severely distorted, with an intraocular pressure (IOP) of zero. Twelve hours
later, as the patient’s condition improved, the corneas recovered completely with repeat IOP values of 8
and 9 mmHg in the right and left eyes respectively. After two weeks the patient was discharged from the
SICU with no visual deficit.
MCC04
11:50 AM - 12:00 PM
Tracheo-innominate Artery Fistula: A Rare but Catestrophic Complication of Tracheostomy
Patrick T. Laughlin, M.D., Hiep Dao, M.D., Courtney Whedbee, Student, Anesthesiology, Georgetown
Univ Hospital, Washington, DC
49 year-old female with a history of diabetes, renal failure, and cirrhosis underwent tracheostomy
placement. 43 days later, she acutely began bleeding from her trach site. She quickly underwent
bronchoscopy, but hemorrhage worsened. Massive transfusion protocol was initiated and tracheostomy
tube was removed; direct manual pressure was held on the innominate artery, which hadformed a fistula
with the tracheostomy stoma site, as the patient was taken emergently to the OR for median sternotomy.
Between MICU and OR, patient received total of 15 units pRBCs, 8 units FFP, and 1 unit platelets, but
expired due to exsanguination.
MCC04
11:50 AM - 12:00 PM
Perioperative Considerations in Patients Presenting for Resection of Malignant
Pheochromoctyear-oldma
Paul J. Hoffmann, D.O., Bryan D. Laliberte, M.D., Gosia Kasperska, D.O., Joseph Le, M.D.,
Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD
A 64-year-old female initially presented for excision of a right renal mass. On intraoperative pathology, it
was diagnosed as a pheochromocytoma. On 6-week follow up; her metanephrines were still elevated. A
PET scan was completed, and noted to have a lesion of her right parietal/temporal skull region. After
being placed on appropriate alpha and beta blockade medications, she returned to the operating room for
craniectomy of the lesion of interest. She underwent a successful general anesthetic. On follow up labs,
her metanephrines decreased as expected. This case represents a rare site of pheochromocytoma
malignancy.
MCC04
11:50 AM - 12:00 PM
Global and Cerebral Metabolism and Systemic and Cerebral Oxygenation During and After Intraoperative Seizures in Three Patients Undergoing Brain Tumour Surgery
Mariana M. Cunha, M.D., Lúcia Cordeiro, M.D., Ana Catarina Ferreira, Student, Helena Silva, B.Sc.,
Pedro Amorim, M.D., Centro Hospitalar Tâmega e So, Penafiel, Portugal, Centro Hospitalar Tondela
Viseu, Viseu, Portugal, Centro de Investigação Clínica em Anestesiologia, Centro Hospitalar do Porto,
Porto, Portugal, Neurinbloc, Porto, Portugal
Little was reported in humans regarding cerebral metabolism/flow during seizures. We report three
patients with generalized tonic-clonic intraoperative seizures during motor area stimulation(10mA) for
brain tumour removal, in spite of IV-Levetiracetam. Cold saline cerebral irrigation stopped seizures in
<90sec. Propofol/remifentanil target-controlled-infusion effect-site concentrations were maintained during
seizures so that observed changes in global(VO2/VCO2) and cerebral metabolism(BIS/bilateral) and
cerebral oximetry(INVOS) were the effect of the seizures. BIS and EMG (frontal) increased during ictus,
INVOS increased largely (or was stable), blood-pressure decreased. After seizures VO2/VCO2 and
ETCO2 markedly increased. Burst-suppression was present for up to 20 minutes. Fig1 documents
observed changes.
MCC04
11:50 AM - 12:00 PM
Parturient With PDPH (Post Dural Puncture Headache) and PRES (Posterior Reversible
Encephalopathy Syndrome): A Rare Combination!
Kalpana C. Tyagaraj, M.D., Stanislav Sidash, M.D., Anesthesiology, Maimonides Medical Center,
Brooklyn, NY
Cases of concurrent PRES and postdural puncture headache are rare in medical practice. The opposing
pathophysiologic features of the two conditions - decreased intracranial pressure (ICP) and increased
intraparenchymal pressure (IPP) - pose an exclusive diagnostic and management challenge. We present
a case series of parturients with PRES syndrome with varying presentations. Combination of toxemia
and/or vasculopathy carries a considerable risk of permanent neurological damage and mortality.
Immediate recognition and goal directed, expeditious management is essential for complete resolution of
symptoms. Early involvement of critical care, neuroimaging, neurophysiology, anesthesiology and
obstetrical experts cannot be overemphasized.
MCC04
11:50 AM - 12:00 PM
Severe Pulmonary Edema in a Toddler Following Intracerebral, Intravascular Administration of
Dimethyl Sulfoxide (DMSO)
Ji Yeon Kang, M.D., Jamey Eklund, M.D., Carina Cheung, M.D., Anesthesiology, University of Illinois,
Chicago, IL
Pulmonary edema is a rare complication after DMSO administration in adults and hardly reported in
pediatric patients. Our patient is a 21 month-old who underwent DMSO-embolization of a hypervascular
petrous lesion. Following surgery, she developed tachycardia, tachypnea and clear secretions. Despite a
facile intubation, the patient desaturated to SpO2 <20%. Copious secretions were suctioned from the
endotracheal tube; pulmonary toilet improved oxygen saturation were performed. Chest X-ray showed
bilateral lung opacification that resolved 3 hours post-biopsy. The brief time-frame for development and
resolution of clinical and radiological symptoms compels us to consider DMSO-associated pulmonary
edema as a differential diagnosis.
MCC04
11:50 AM - 12:00 PM
Pain Medicine (PN)
The Weight of Her Heart on Her Back
Diana M. Diaz, M.D., James Cyriac, M.D., Shalini Shah, M.D., Anesthesiology, University of California
Irvine, Orange, CA
61 year-old female received thoracic epidural for postoperative analgesia s/p renal transplant.
Postoperative day four, she developed NSTEMI, was started on heparin drip and received clopidogrel
300 mg with epidural insitu. Major issue involved high likelihood of epidural abscess or hematoma
compounded by major irreversible anticoagulation use. Decision made to continue anticoagulation and
keep epidural in place as concern was that risk of continued cardiac ischemia was more detrimental than
risk of epidural complication. Postoperative day six clopidogrel was held. Postoperative day eight platelets
were transfused and epidural removed. Anticoagulation restarted 24 after removal. No epidural
complications ensued.
MCC04
11:50 AM - 12:00 PM
Employing Regional Anesthesia Using Ropivicaine in a Patient With Brugada Syndrome: A Case
Report
Hashim J. Qureshi, D.O., Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
Brugada syndrome is a genetically inherited sodium channel defect that can lead to ventricular
arrhythmias in afflicted patients. Certain local anesthetics including Bupivicaine are avoided in Brugada
syndrome due to electrocardiographic changes that can lead to sudden cardiac death. We report the
regional anesthetic management of a patient presenting for carpal tunnel release utilizing an Axillary
nerve block using the local anesthetic Ropivicaine. There are few reports of using Ropivicaine in patients
with Brugada syndrome so we believe that this would be a good learning case to present.
MCC04
11:50 AM - 12:00 PM
Presumed S1 Transforaminal Epidural Steroid Injection-Induced Reactivation of Herpes Zoster
Along the Corresponding Dermatome
Brandon J.D. Rein, D.O., Bunty Shah, M.D., Julia Caldwell, M.D., Vitaly Gordin, M.D., Department of
Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA
A 52 year-old female who developed a herniated L5-S1 disk and underwent successful left-sided L5-S1
diskectomy, presented with persistent pain, weakness, and paresthesias. A left-sided S1 transforaminal
epidural injection with local anesthetic and corticosteroid was performed without technical difficulty. Within
2-3 days after the procedure, a S1 dermatome vesicular rash developed. Shingles was diagnosed, she
was started on gabapentin, and the rash eventually resolved. The varicella zoster virus (VZV) lesion was
observed only in the dermatome corresponding exactly to the target level of intervention, unlike previous
case reports. This case reviews theories accounting for VZV reactivation following interventional
procedures.
MCC04
11:50 AM - 12:00 PM
Anesthetic Management of a Parturient With Treatment Resistant Depression for
Electroconvulsive Therapy
Avneep Aggarwal, M.D., Victor L. Mandoff, M.D., Anesthesiology, University of Arkansas for Medical
Sciences, Little Rock, AR
A 29 year-old female patient, G2P1 at 30 weeks gestational age presented with severe depression
resistant to pharmacological treatment. Psychiatry team decided to proceed with trial of electroconvulsive
therapy and obstetrician was consulted to coordinate the patient care. Anesthesia was induced with
Methohexital and Succinylcholine was used for intubation. Fetal heart monitoring was documented before
and after the treatment by obstetrician. Patient had significant mood improvement following six cycles of
ECT over 2 weeks. There have been no adverse effects to the fetus. The pregnancy is ongoing. We will
discuss the anesthetic challenges and considerations for ECT during pregnancy.
MCC04
11:50 AM - 12:00 PM
The Power of Anxiety
Alaa Saghbini, M.D., Anesthesiology, Rush University Medical Center, Chicago, IL
A 28 year-old female, non-smoker, with history of depression and anxiety. She underwent a
unicompartment knee-arthroplasty under GA. NPO status was confirmed prior to proceeding. Preoperatively, a single-shot adductor canal block was performed for anticipated post-operative pain.
Following block, a brief episode of bradycardia and emesis occurred. Intra-op, the stomach was emptied
through an LMA supreme, at the beginning and end of the case. On emergence, bilious fluid was seen in
the ventilator tubing. The LMA was removed, Trendelenberg position was achieved and her oropharynx
was suctioned. She remained hemodynamically stable throughout. No sequela from the event observed
post-operatively.
MCC05
1:00 PM - 1:10 PM
In-flight Hematemesis in a Chronic Alcoholic Patient
Kadhiresan Murugappan, M.D., Chiranjeev Saha, M.D., Anesthesiology, Rush University Medical Center,
Chicago, IL
A 50 year-old male with history of alcohol abuse and chronic pancreatitis was noted to have hematemesis
during a transatlantic flight. The patient was unable to provide detailed history due to constant retching at
30-second intervals. He produced <20 cc of blood-tinged emesis. The patient appeared anxious and
diaphoretic. Vital signs were significant for tachycardia and tachypnea. Radial pulse was palpable, though
no blood pressure could be obtained. In spite of consensus among physicians on the plane that the
patient was experiencing alcohol withdrawal, the airline did not permit the administration of diazepam.
MCC05
1:00 PM - 1:10 PM
A Simple Nasal CPAP Mask/Circuit Assembly Maintained Spontaneous Ventilation and
Oxygenation in a High Risk Obese Patient With OSA and Lower Extremity Hardware Removal
Oren Ambalu, M.D., Matthew Johnson, M.D., James Tse, M.D.,Ph.D., Anesthesiology, Rutgers Robert
Wood Johnson Medical School, New Brunswick, NJ
59 year-old female with BMI 36.6 kg/m2, OSA, diabetes, hypertension, multiple sclerosis, osteomyelitis,
with multiple foot surgeries presented for left foot hardware removal. Her room air SaO2 was 90%. An
infant facemask (#2) was secured over her nose with straps and connected to the anesthesia circuit. The
APL valve was adjusted to provide 4-5 cm H2O CPAP with O2 3L/min and air 1L/min. Following preoxygenation, sedation was started with a propofol infusion (25-150 ug/kg/min). The patient tolerated with
procedure well with stable vitals and spontaneous respiration with 100% SaO2 throughout. She woke up
quickly upon completion without problems.
MCC05
1:00 PM - 1:10 PM
Huge Right Atrial Thrombus Due to Heparin-induced Thrombocytopenia and Urgent Open Heart
Surgery for Decompensated Severe Mitral Stenosis
Heiko Kaiser, M.D., Samuel Hurni, M.D., Gabor Erdoes, M.D., Lars Engelberger, M.D., Balthasar Eberle,
M.D., Dept. of Anesthesiology and Pain Medicine, Dept. of Cardiac and Vascular Surgery, University
Hospital Bern, Bern, Switzerland.
A 74 year-old woman with acute decompensated heart failure due to severe mitral stenosis presents to
undergo mitral valve surgery. She has atrial fibrillation, bilateral pleural effusions and acute on chronic
kidney disease. On admission she is on LMWH since one week, Amiodarone and Torsemide. During
preoperative assessment skin necrosis and platelet count of 47,000/µL are concerning. The suspicion
heparin-induced thrombocytopenia is confirmed by 4 T's score, positive heparin-PF4 antibodies and
serotonin release assay. Patient does not recompensate and must undergo urgent surgery. In the TEE
right before cardiopulmonary bypass a huge thrombus is identified in the right atrium.
MCC05
1:00 PM - 1:10 PM
Delayed Development of Malignant Hyperthermia Following Cardiopulmonary Bypass
David L. Stahl, M.D., Ankur Bhakta, D.O., Department of Anesthesiology, The Ohio State University,
Columbus, OH
A 53 year-old man was admitted to the ICU following CABG. 40 minutes after admission (180 minutes
after CPB) he rapidly developed fever (to 39.8°C), rigidity, and metabolic acidosis. A presumptive
diagnosis of malignant hyperthermia was made, and dantrolene as well as active cooling measures were
initiated. Therapy was continued until hyperthremia resolved and CK normalized (24h). The diagnosis of
MH during and after CPB can be obscured by iatrogenic dysthermia, acidosis, and electrolyte
abnormalities. Even with prompt diagnosis, management can be complicated by comorbid hemodynamic
instability, volume resuscitation limited by cardiac function, and electrolyte abnormalities compounded by
AKI.
MCC05
1:00 PM - 1:10 PM
Supraglottic Jet Oxygenation and Ventilation Saved a Patient With Cannot Intubate and Cannot
Ventilate Emergent Difficult Airway
Huafeng Wei, Qiaoyun Li, Ping Xie, Zhiyun Wu, University of Pennsylvania, Philadelphia, PA, The 180th
Hospital of the People's Liberation Army, Quanzhou, China.
A 34 year-old female weighing 41 kg was anesthetized and paralyzed. Intubation failed after two direct
laryngoscopies using a video laryngoscope. Mask ventilation became partially difficult due to bleeding.
Light wand intubation was attempted twice but also failed, making ventilation impossible by either mask or
a # 3 LMA. SaO2 dropped to 50% and the supraglottic jet oxygenation and ventilation (SJOV) via nasal
approach was initiated with the assembly demonstrated in Figure 1. The SaO2 improved from 10% to
85% within 3 min. SJOV was continued to maintain SaO2 above 90% until spontaneous breathing
recovered 30 minutes later.
MCC05
1:00 PM - 1:10 PM
Hyperventilation Instituted for Better Surgical Conditions in a Large Brain Tumor Case, Resulted
in Potentially Severe Cerebral Ischemia, Avoided by Cerebral Oxygenation Monitoring
Telmo Santos, M.D., Pedro Amorim, M.D., Anesthesia and Pain Medicine, Centro Hospitalar de Trás os
Montes e Alto Douro, Vila Real, Portugal, Centro Hospitalar do Porto, Porto, Portugal
18-years-old man with large posterior-fossa brain tumour and intracranial hypertension, underwent
surgery in the sitting position. Cerebral oxygenation was monitored with INVOS and jugular-bulb oxygenvenous saturation by repeated blood gas analysis. Hyperventilation was started before dural opening:
ETCO2 was 30mmHg, BP 142/61, SpO2 100%, BIS 35 and PaCO2 29mmg. At that moment INVOS
decreased to<50% and SVJO2 was 33% indicating severe cerebral global oxygen dessaturation.
Hypertonic-saline, dexamethasone, had been administered, propofol(TCI) increased and minute-
ventilation was lowered allowing CO2 to increase to 36mmHg. SVJO2 increased to 63% and INVOS to
78%. Patient awoke minutes after end of surgery, which was successful.
MCC05
1:00 PM - 1:10 PM
A Case of Massive Pulmonary Embolism
Jeffrey A. Krause, M.D., Sarah C. Parrish, B.A., Praveen Maheshwari, M.D., Parul Maheshwari, M.D.,
Anesthesiology, University of Oklahoma, Oklahoma City, OK
The patient is a 50 year-old, previously healthy, female who presented with a saddle pulmonary embolism
leading to severe right heart strain and hypotension. Emergent sternotomy and pulmonary embolectomy
were performed. Intraoperatively, the patient had cardiac arrest requiring cardiac massage and was
emergently placed on cardiopulmonary bypass. The embolus was successfully removed and the patient
was transferred to the ICU on multiple pressors. She remained intubated and required inotropic support
until postoperative day six when she was weaned from all drips and extubated. The remainder of her
hospital course was unremarkable and she was discharged home in good condition.
MCC05
1:00 PM - 1:10 PM
Utility of The Transthoracic Echocardiogram In The PACU: Diagnosing A Postoperative
Pulmonary Embolism
Rebecca L. Scholl, M.D., Dennis Grech, M.D., Michal Gajewski, D.O., Anesthesiology, Rutgers--New
Jersey Medical School, Newark, NJ
Our case underscores the relevance, and perhaps underutilization of transthoracic echocardiogram (TTE)
in the PACU setting, for diagnosing acute cardiopulmonary compromise. Our case involves a 63 year-old
female with history of pulmonary embolism (PE) and squamous carcinoma of the vagina complicated by:
small bowel obstruction requiring enterocolostomy, sepsis, acute kidney injury, and suspected heparininduced thrombocytopenia. In the PACU, she rapidly decompensated, demonstrating tachycardia,
tachypnea, and hypoxia, requiring emergent intubation. The patient’s AKI and precarious hemodynamics
precluded a CT-angiography, therefore, we used TTE to confirm our suspicion of a PE, allowing us to
begin anticoagulation without delay.
MCC05
1:00 PM - 1:10 PM
A Stable and Unremarkable Case for Several Hours
Heewon Lee, Daniel Nyhan, M.D., Anesthesiology and Critical Care Medicine, The Johns Hopkins
Malignant Hyperthermia (MH) is a rare disorder occurring in genetically susceptible patients who have
mutations in the Ryanodine Receptor gene. We describe a case of MH in a 23 year-old patient who
underwent unilateral schwannoma resection. The patient who had a prior GA had an unremarkable
anesthetic course for four hours, was maintained on a combination of isoflurane, nitrous oxide, and
remifentanil, but then developed progressive tachycardia and increasing tidal CO2and temperature. He
was treated as a case of MH, with reversal and resolution of the above perturbations. MH may still
present in patients who had previous anesthetic exposure.
MCC05
1:00 PM - 1:10 PM
Clonidine Epidural for Cesarean Section and Postoperative Pain in Patient With COPD
Exacerbation and Opioid Dependence
Kevin Wong, D.O., Jill Cooley, M.D., Justo Gonzalez, M.D., Anesthesiology, Cleveland Clinic Foundation,
Cleveland, OH
We report a 34 year-old G2P1 smoker with COPD, heroin abuse on methadone, admitted to ICU at 36
weeks for presumptive postinfluenza pneumonia. Patient was placed on high flow oxygen via nasal
cannula due to anxiety with mask application. With worsening oxygenation, an uneventful emergent
cesarean section was performed with a low thoracic epidural, pre-induction arterial line and low threshold
for converting to general anesthesia. Postoperative pain was controlled with the epidural using PCEA
infusion of bupivacaine 0.1% and clonidine 1.2mcg/ml, avoiding the use of additional narcotics. Patient
was eventually weaned off oxygen and discharged to home.
MCC05
1:00 PM - 1:10 PM
She's Not Breathing
Noreen E. Murphy, M.D., Peter M. Popic, M.D., Anesthesiology, University of Wisconsin, Madison, WI
36mth old, 11.5kg, Hmong, female born at 34 and 3/7 weeks gestation underwent tonsillectomy and
adenoidectomy for tonsillar hypertrophy complicated by sleep disordered breathing and apneic pauses.
She had a smooth inhalation induction, atraumatic intubation, uncomplicated surgery, and unremarkable
awake extubation. After moving from the OR table to the transport cart, she laryngospasmed and
desaturated. Succinylcholine and propofol were given intravenously. Mask ventilation improved and
oxygen saturations climbed. The patient was mask ventilated, and after 60 minutes, was not
spontaneously breathing. An LMA was placed and she recovered in the PACU. Labs drawn showed
pseudocholinesterase level was 58L (2900-7100).
MCC05
1:00 PM - 1:10 PM
Intraoperative and Postoperative Pain Management for Urgent Repair of a Ruptured Umbilical
Hernia in a Patient Taking Suboxone
William Gostic, II, M.D., Kevin Blackney, M.D., Thomas Anderson, M.D.,Ph.D., Massachusetts General
Hospital, Boston, MA
A 65 year-old female with a history of end-stage liver disease and opiate addiction on suboxone
presented urgently with a 10cm ruptured umbilical hernia and sepsis. She noted severe post-operative
pain following prior surgeries. Relative contraindications to neuraxial anesthesia included severe
abdominal pain and difficulty with positioning as well as concern for extrusion of bowel contents and
ascites during positioning. Intraoperative analgesia was ultimately obtained with a combination of
esmolol, ketamine, and lidocaine infusions. Prior to extubation, bilateral rectus sheath catheters were
placed. The patient awoke with 0/10 pain which was maintained for five days.
MCC05
1:00 PM - 1:10 PM
HELLP Syndrome, Postpartum Hemorrhage, and Massive Transfusion: A Case for Extracorporeal
Membrane Oxygenation
Suzanne K. Mankowitz, M.D., Thomas Pfeiffer, M.D., Anesthesiology, Columbia University Medical
Extracorporeal membrane oxygenation (ECMO) has been used during pregnancy in parturients with
pulmonary and cardiac disease. ECMO is contraindicated in severe hemorrhage. We present a case
involving a patient with preeclampsia/HELLP syndrome who required massive transfusion after a
cesarean delivery. Venovenous ECMO was initiated after the patient developed TRALI. Hemorrhagic
shock required conversion to venoarteriovenous ECMO. The patient’s course was complicated by hepatic
capsular rupture, cardiac and hepatic failure and acute kidney injury. However, the patient was
discharged on POD 21 with complete resolution of her cardiac and renal status with only mildly elevated
liver function tests.
MCC05
1:00 PM - 1:10 PM
Challenge of the Unknown: Providing Anesthesia in the Setting of Schinzel-Giedion Mid Face
Retraction Syndrome
Elizabeth M. Wasson, D.O., Marla Matar, M.D., David Ninan, D.O., Riverside County Regional Medical
Center, Moreno Valley, CA, Children's Hospital Los Angeles, Los Angeles, CA
CS was a 15 month male with a history complicated by Schinzel-Giedon midface retraction syndrome and
JMML. No previous anesthesia records or case studies are present in the literature for patients with
Schinzel-Giedon midace retraction syndrome. CS underwent successful placement of laparoscopically
assisted percutaneous gastrostomy tube, after induction of anesthesia with Propofol, and administration
of neuromuscular blockade with Rocuronium. No intraoperative or immediate postoperative complications
were noted during the case. Although this is only a single anesthesia experience with a single patient,
complications as a result of administration of non-depolarizing neuromuscular blockade was not apparent.
MCC05
1:00 PM - 1:10 PM
Management of Perioperative Pulmonary Aspiration: To Extubate or Not to Extubate
Che A. Solla, M.D., Tripler Army Medical Center, Honolulu, HI
44 year-old male with no significant past medical history undergoing laparoscopic cholecystectomy.
Despite performance of rapid sequence induction, apparent aspiration noted by wheezing, desaturation,
and continued low oxygen saturation following initial event despite 100% FiO2. Arterial blood gas
performed with PaO2 of 92 mmHg. The patient was able to maintain greater than 90% SpO2 with an
FiO2 of 40%. Decision made to extubate patient once fully awake and meeting other extubation criteria.
Post-extubation the patient required a nonrebreather facemask to maintain SpO2 greater than 90%.
Chest x-ray findings were consistent with aspiration event.
MCC05
1:10 PM - 1:20 PM
Addicted to One’s Profession
Osa Obanor, B.A., Corey S. Scher, M.D., New York University SoM, New York, NY, New York University
SoM, New York City, NY
A resident is overheard by an Attending slandering the reputation of the hospital to his patient. The
Attending alerts the Residency Coordinator, with the thought that the resident is most likely experiencing
hardships causing him to act out of character. When confronted, the Resident confesses to drug
dependence since age 11, including heroin. He says he applied to anesthesiology knowing that it would
feed his addiction, which he does by smuggling morphine from the OR. He ultimately volunteers to go to
rehab: 90 day inpatient followed by an outpatient portion and eventual halfway house. He wants to
continue his residency.
MCC05
1:10 PM - 1:20 PM
Anesthetic Management of a Patient With a Large Symptomatic Goiter With Significant Tracheal
Compression and a History of Crack Cocaine Abuse
Jessica Newman, Subramanian Sathishkumar, M.B.,B.S., Department of Anesthesiology, University of
Michigan, Ann Arbor, MI
A 47 year-old female with a large symptomatic goiter with substernal extension and significant tracheal
compression presented for a thyroidectomy. The patient also reported current crack cocaine use. The
surgeons were unable to visualize her vocal cords in clinic and she was started on prednisone one week
prior to surgery. An awake fiberoptic intubation was performed and a 6.0 EMG endotracheal tube was
placed. The patient was maintained on remifentanil, dexmedetomidine, and isoflurane. The patient was
extubated over a cook catheter after a glidescope visualization demonstrated space around the
hypopharynx and glottis and a cuff leak was confirmed.
MCC05
1:10 PM - 1:20 PM
Total Hip Replacement on a 67 year-old Male With Severe Pulmonary Hypertension, Hepatic
Insufficiency, and Renal Insufficiency
Jonathan Kay, St. Lukes Hospital, Milwaukee, WI
A 67 year-old male with severe pulmonary hypertension was scheduled for elective total hip replacement
under spinal anesthesia (cardiologist request). Past surgical history included mitral valve replacement,
tricuspid annuloplasty, myear-oldcardial revascularization and permanent pacemaker implantation.
Medical history included (in addition to severe pulmonary hypertension) atrial fibrillation, hypertension,
chronic renal insufficiency, and hepatic cirrhosis. He required drainage of ascites every 6 to 8 weeks.He
ultimately underwent general anesthesia with extensive vasoactive and inhalational support of the right
ventricle. His intraoperative course was uneventful. Severe hypotensive one hour postoperatively
required additional vasoactive support, volume resuscitation, and ultimately renal replacement therapy.
MCC05
1:10 PM - 1:20 PM
Delayed Extreme Metabolic Alkalosis and Hypernatremia in the Setting of Massive Transfusion
Protocol
Teri Tianlu Zhang, M.D., Sofia Peeva, M.D., Rodney McKeever, M.D., Peter Roffey, M.D., Durao
Thangathurai, M.D., Anesthesiology, University of Southern California, Los Angeles, CA
We are reporting two cases of renal cell carcinoma with concomitant IVC thrombus requiring massive
transfusion protocol. Both patients received over 50 units of blood products intra-operatively. Postoperatively, serum pH level reached 7.5 and 7.56 respectively, with bicarbonate peaks at 40.8 in both
patients. Hypernatremia was also observed, with maximum sodium levels reaching 154 and 149. Diuretic
therapy with Furosemide, Bumetanide, and Acetazolamide was used to correct the alkalosis and
hypernatremia. Massive transfusions lead to delayed metabolic alkalosis secondary to citrate metabolism
in the liver. Sodium retention occurred to maintain electroneutrality and evolved parallel to the metabolic
alkalosis.
MCC05
1:10 PM - 1:20 PM
Difficult Positive Pressure Ventilation via Tracheostomy in an Adult With Airway Malacia
Li Li, M.D.,Ph.D., David Dorsey, M.D., Tanya K. Meyer, M.D., Sanjay M. Bhananker, M.B.,B.S.,
Department of Anesthesiology & Pain Medicine, Department of Otolaryngology – Head and Neck
Surgery, University of Washington, Seattle, WA
A 57 year-old woman with Weill-Marchesani syndrome, tracheobronchomalacia, and a permanent
tracheostomy presented for a microlaryngoscopy and tissue excision. She was induced with alfentail and
sevofluorane and was ventilated via an endotracheal tube through her tracheostomy. She was given
intermittent positive pressure ventilation (IPPV), but had difficulty maintaining adequate ventilation,
oxygenation, and tidal volumes even with PEEP addition. These respiratory metrics, however, markedly
improved with spontaneous respiration, but worsened again when IPPV was re-trialed. The endotracheal
tube was checked to ensure it was neither kinked nor obstructed. Thus, the patient was allowed to
breathe spontaneously for the remainder of the case.
MCC05
1:10 PM - 1:20 PM
Refractory Intraoperative Seizure Activity During Craniotomy for Occipital Arteriovenous
Malformation Resection
Corrie A. Burke, M.D., Verna Baughman, M.D., Lisa Adiutori, D.O., Anesthesiology, University of Illinois
Hospital & Health Sciences System, Chicago, IL
A 31 year-old male presented for surgical resection of an incidentally discovered, asymptomatic left
occipital AVM. Anesthesia was induced and maintained with sevoflurane, propofol and remifentanil. A
burst suppression EEG pattern was observed prior to dural incision. Upon dural opening, acute onset of
cerebral edema and rhythmic extremity movement was observed. Seizure activity was confirmed by EEG.
Sevoflurane was discontinued and full TIVA was implemented. Despite additional midazolam,
fosphenytoin, lorazepam, and levetiracetam, episodic EEG spike and wave activity persisted throughout
the case upon a background of burst suppression. The patient remained intubated postoperatively for
ongoing seizure management.
MCC05
1:10 PM - 1:20 PM
Dexmedetomidine Sedation for Corneal Transplant in Patient With End Stage Cardiac Disease and
Liver Failure
David K. Chen, M.D., Faraz Chaudhry, M.D., Anesthesiology, Rutgers- New Jersey Medical School,
Newark, NJ
Sixty-four year-old man, history of end stage liver disease and dilated cardiomyear-oldpathy presented
with a perforated left eye corneal ulcer requiring urgent corneal transplant surgery. Corneal surgery
requires a plane of anesthesia with adequate immobility and analgesia to prevent the risk of expulsion of
intraocular contents in response to surgical stimulation.Though general anesthesia is routine for these
cases, this patient was high risk for peri-operative morbidity and mortality. This patient successfully
underwent surgical repair with dexmedetomidine sedation and limited peribulbar block without event.
MCC05
1:10 PM - 1:20 PM
Intracoronary Air Embolism in Patient Undergoing Pulmonary Cryear-oldablation of Lung
Metastasis
Heather C. Wurm, M.D., Michael J. Brown, M.D., Mayo Clinic, Rochester, MN
A 48 year-old male underwent percutaneous cryear-oldablation of a left lung mass secondary to
metastatic thyroid carcinoma. Two hours into the procedure, he developed abrupt ST-elevation which
rapidly progressed onto cardiovascular collapse and ventricular fibrillation. ACLS was successful. A large
left pneumothorax and intracoronary and intraventricular air were noted on CT imaging. Neurologic exam
revealed decerebrate posturing. Fearing significant neurologic insult due to presumed intercerebral air
embolism, emergent transfer for hyperbaric oxygen therapy occurred within two hours of the event. He
was extubated two days post-arrest and was neurologically intact with the exception of minor right upper
extremity weakness.
MCC05
1:10 PM - 1:20 PM
Conscious Sedation for Transurethral Fulguration of Bladder Tumor in a High Risk Patient
Anthony S. Bonavia, M.D., Allison Weinstock, B.A., Saifeldin Mahmoud, M.D., Anesthesiology, Penn
State Milton S. Hershey Medical Center, Hershey, PA
A 64 year-old, super-obese male with spinal stenosis and poor functional capacity presented for an
elective rigid cystoscopy with transurethral fulguration of bladder tumor. He had a history of symptomatic
carotid artery occlusion (with multiple daily transient ischemic attacks) as well as unstable angina (on
chronic anticoagulation) and chronic obstructive pulmonary disease. While the preferred anesthetics for
this urologic procedure are general or neuraxial anesthesia, the patient was a poor candidate for either.
We describe our anesthetic technique of conscious sedation combined with local anesthesia. We also
describe our management of his transient ischemic attack in the recovery room.
MCC05
1:10 PM - 1:20 PM
Acute Normovolemic Hemodilution for a Jehovah’s Witness With Extreme Polyhydramnios and
Twin Gestation
Sn C. Cosgrove, M.D., Marie-Louise Meng, M.D., Richard Smiley, M.D.,Ph.D., Anesthesiology, Columbia
University, New York, NY
A 32 year-old G1P0 at 31 weeks with a twin gestation complicated by polyhydramnios presented for an
urgent cesarean delivery for suspected amnio-chorion separation. The patient is a Jehovah's Witness
(JW) and refused blood products. A combined spinal epidural was performed. An arterial line (AL) and a
central venous catheter (CVL) were placed. 2L of blood was removed via the AL into 6-CPDA units kept
in continuity with the patient. EBL was 800mL and ending Hct was 24. Autologous blood was reinfused
via the CVL, which was in continuity with the CPDA units and the patient at all times.
MCC05
1:10 PM - 1:20 PM
Airway Management in a Newborn With Prenatally Diagnosed Pierre Robin Sequence
Sonia T. Kannadan, M.D., Kenneth Wayman, M.D., Anesthesiology, Baylor College of Medicine,
Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
Pierre Robin sequence (PRS) is characterized by micrognathia, glossoptosis with U-shaped cleft palate
leading to upper airway obstruction during anesthesia and at rest. PRS children present a challenge in
airway management as they are particularly difficult to intubate and are at risk for catastrophic airway
obstruction upon extubation. We present a case report of a prenatally diagnosed PRS infant born via
urgent C-section who immediately developed respiratory distress requiring emergent intubation. We
highlight the airway management undertaken by a multidisciplinary team, the importance of preparing for
a difficult airway and the different approaches in handling a challenging pediatric airway.
MCC05
1:10 PM - 1:20 PM
Juvenile Idiopathic Arthritis: Regional Anesthesia a Successful Option
Carolina C. Santos, Telmo Santos, Ana Isabel Pereira, Anesthesiology, Centro Hospitalar de Trás-osMontes e Alto Douro, Vila Real, Portugal
We present a case report of a 26-years-old-man who was proposed to urgent orthopedic surgery for distal
humerus fracture. He had a history of polyarticular type of Juvenile Idiopathic Arthritis from 3 years old,
with systemic effects of therapy with corticosteroids. Outstanding the growth retardation (height 100cm
and weight 23kg), cervical stiffness, small mouth opening, Cushing's syndrome and great limitation of
generalized joint. It was made an ultrasound/nerve stimulator guided axillary brachial plexus block. The
intervention progressed uneventfully and pain in the immediate post operative was controlled.
MCC05
1:10 PM - 1:20 PM
Emergency Cesarean Delivery in a Patient With Aortic and Mitral Valve Endocarditis
Amy Penwarden, M.D., Sreenath Vellanki, M.D., James Greg Balfanz, M.D., Department of
Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC
A 32 year-old G3P2002 woman at 32 weeks gestation with an endocardial cushion defect was admitted
for endocarditis. Echocardiogram showed moderate-severe aortic and mitral regurgitation with
vegetations on both valves. She was planned for a cesarean section under epidural with cardiac surgery
available for maternal decompensation. Before this plan could be carried out, the patient progressed into
active labor with fetal distress. The patient was emergently brought to the OR and was induced for
general endotracheal anesthesia. She tolerated the surgery well despite the circumstances and
successfully underwent aortic and mitral valve replacements on post-partum day 20.
MCC05
1:10 PM - 1:20 PM
Inadvertent Intraperitoneal Caudal Catheter Placement
Victor A. Rivera, M.D., Christian T. Petersen, M.D., Naval Medical Center, Portsmouth, VA
A neonate with malrotation was taken to the operating room for an open Ladd’s procedure under general
anesthesia with continuous caudal catheter. After several attempts to introduce an 18g angiocath into the
caudal space, an 18g Touhy needle was used with profound loss of resistance, and a 21 g styletted
caudal catheter was threaded easily to 15 cm. Fluoroscopy showed the catheter to be intraperitoneal.
Surgical exploration revealed no bowel or bladder damage, and the abdomen was closed with the
catheter in place. After a rectal exam showed no evidence of perforation, the catheter was removed.
MCC05
1:10 PM - 1:20 PM
Inadvertent Vertebral Artery Puncture From Central Venous Catheter Placement
Alia Safi, M.D., Caitlin Dore, M.D., Gennadiy Voronov, M.D., John H. Stroger Hospital of Cook County,
Chicago, IL
Ultrasound guided central venous catheter (CVC) placement has become the standard of care, though
this can give a false sense of safety. We present a case where use of ultrasound for placement of CVC
resulted in a detrimental situation. Short axis view was used and consequently the distal tip of the
catheter was not visualized. Decision to explore the neck by vascular surgery was made; this revealed
the distal tip of the catheter piercing the left vertebral artery. Reviews have shown an increased
visualization with ultrasound long axis approach compared to short axis view.
MCC05
1:20 PM - 1:30 PM
Unexpected Blood Clot-induced Acute Airway Obstruction in a Patient With Recent Lung Surgery
After Repositioning of the Patient for Right Chest Wall Reconstruction
Dongho Jung, Sue Yong Lee, Department of Anesthesiology and Pain Medicine, Seoul National
University Hospital, Seoul, Korea, Republic of
Fatal airway obstruction has numerous causes. And it must be recognized and managed immediately.
We experienced airway obstruction due to an unexpected blood clot in a patient with a recent lung
surgery. 49-years-old male with right upper lobectomy 5 days ago was scheduled for right chest wall
reconstruction. Intubation was performed with an 8.0 mm armored tube. After repositioning the patient
from the supine to the left lateral decubitus, oxygen saturation (SpO2) decreased to 40%. Intraoperative
fiberoptic bronchoscopy showed a large blood clot occluding the left main bronchus. After bronchoscopic
suction and irrigation, SpO2 was improved.
MCC05
1:20 PM - 1:30 PM
Suspected Intraoperative Anaphylaxis in a Patient With Undiagnosed Hypertrophic Obstructive
Cardiomyopathy Leading to Left Ventricular Outflow Obstruction and Pulseless Electrical Activity
Arrest
Bradford Ballenger Smith, M.D., Hans P. Sviggum, M.D., Anesthesiology, Mayo Clinic, Rochester, MN
A 75 year-old female with controlled hypertension presented for left total hip reimplantation. Preoperative
peripheral nerve blockade followed by induction of general anesthesia was uneventful. Upon positioning
and administering vancomycin she became acutely hypotensive and then suffered PEA arrest.
Resuscitation was achieved according to ACLS protocol. Echocardiography showed an under-filled left
ventricle, hypertrophic obstructive cardiomyear-oldpathy (HOCM) with asymmetrical septal thickening,
dynamic left ventricular outflow obstruction, and severe mitral regurgitation related to systolic anterior
motion of the mitral valve. Laboratory analysis showed a tryptase level of 209. After medical optimization
and cardiology consultation, the patient made a full recovery.
MCC05
1:20 PM - 1:30 PM
Misadventures of a Pigtail: Intraoperative Management of a Chest Tube Placed into the Left Atrium
Jonathan H. Chow, M.D., Brittney Williams, M.D., Seema Deshpande, M.B.,B.S., Department of
Anesthesiology, University of Maryland, Baltimore, MD
A 63 year-old male with atrial fibrillation and chronic right-sided pleural effusions presented with 2 liters
drainage of blood from a chest tube after placement of a 12 French pigtail. He was brought to the
operating room for a thoracotomy, and intraoperative fluoroscopy revealed the catheter entering the right
lower lobe, piercing the pulmonary vein and exiting into the left atrium. He was placed on
cardiopulmonary bypass and the tip was removed with a large clot intact. His chest was left open, and a
VATS was performed to remove the remainder of the pigtail four days later.
MCC05
1:20 PM - 1:30 PM
Severe Intraoperative Shock Related to Mesentery Traction Syndrome
Hugo Camara Tinoco de Siqueira, M.D., Alfredo Guilherme Haack Couto, Rogerio Luiz da Rocha Videira,
Ph.D., Ismar Lima Cavalcanti, Ph.D., Pablo Pulcheira Brasileiro, Anestesiologia, Universidade Federal
Fluminense, Niteroi, Brazil.
Mesenteric traction syndrome (MTS) has been described as arterial hypotension, facial flushing and
tachycardia, related to mesenteric traction. We describe an MTS case refractory to catecholamines and
vasopressin infusions. A Crohn’s disease patient, undergoing resection of an intestinal inflammatory
mass, presented severe distributive shock after mesenteric traction accompanied by facial flushing while
pulse oximetry, capnography and bispectral index remained unaltered. Absence of tachycardia was
attributed to chronic timolol use. Arterial pressure returned to baseline values after about 60 min.
Postoperative period was uneventful.
MCC05
1:20 PM - 1:30 PM
Anesthetic Considerations in Super Super-morbid Obesity
Megan E. Burger, M.D., Jaime Ortiz, M.D., Maria Lozano-Gorena, M.D., Anesthesiology, Baylor College
of Medicine, Houston, TX
We investigated the numerous effects of obesity on anesthetic management through the dramatic
example of a patient with BMI in the super- super obese range (BMI = 79) who sustained intraoperative
through-and-through liver lacerations from trocar placement, extremely difficult ventilator management,
positioning injuries, and significant blood loss. Given the wide range of physiologic effects that such
severe obesity can demonstrate, super-morbid obesity should be taken very seriously as a risk factor for
perioperative complications. It may be appropriate to further charge anesthesiologists with the role of
counseling such patients on preoperative weight loss in an effort to improve anesthetic safety.
MCC05
1:20 PM - 1:30 PM
Cerebral Oxygen Desaturation Successfully Reversed With the Administration of Atropine:
Usefulness and Benefits of Near Infrared Spectroscopy (NIRS) Monitoring Beyond its Usual
Recommendations
Ana C. Dias Ferreira, Pedro Amorim, M.D., Centro de Investigação Clinica em Anestesiologia, Serviço
de Anestesiologia, Centro Hospitalar do Porto, Porto, Portugal
A patient under sedation/anesthesia had INVOS(SrO2) monitored during a 9min endoscopic-procedure.
When the endoscope was removed, bradycardia(34 bpm) and hypotension(73/48) occurred,
accompanied by a sudden drop in SrO2 from 63 to 49%, while SpO2 remained 97%. Atropine(0,5mg)
was given, the propofol was halted and in less than 1minute HR was 87bpm , BP was 147/93 and SrO2
was restored but SpO2 was still 95%. SpO2 dropped below 90% only 2,5minutes after the bradycardia
and recovered after 4,5minutes(Fig-1). This case illustrates how a patient’s brain can be affected by
hemodynamic changes and the usefulness of cerebral-NIRS as faster indicator of oxygenation.
MCC05
1:20 PM - 1:30 PM
A Challenging Case: Acute Transient Intracardiac Thrombus During Reperfusion of Orthotopic
Liver Transplant Recipient
Arushi Kak, M.D., Sohail Mahboobi, M.D., Igor Braverman, Anesthesiology, St. Elizabeth's Medical
Center/Tufts University School of Medicine, Boston, MA, Anesthesiology, Lahey Clinic, Burlington, MA
54 year-old female with cirrhosis and MELD score of 29 taken for orthotopic liver transplantation. ROTEM
was used to guide coagulopathic management with Amicar, cryear-oldprecipitate, and PRBC prior to
reperfusion phase. After reperfusion, pt became acutely hypotensive (50-60/25-34), hypoxic (72%), and
bradycardic (40’s). This instability ultimately improved with initiation of epinephrine. TEE evaluation was
only significant for mobile thrombus in RAandRV (adherent to PA catheter). Hemodynamics stabilized
within 15 minutes, ROTEM was evident for hyperfibrinolysis, and repeat TEE evaluation revealed gradual
resolution of thrombus. Successful outcome was secondary to quick diagnosis via rapid evaluation with
TEE, management, and supportive care.
MCC05
1:20 PM - 1:30 PM
Malignant Ventricular Tachycardia-induced Cardiovascular Collapse Caused by Epicardial
Pacemaker (R-on-T Phenomenon)
Connor McNamara, M.D., David Stahl, M.D., Ibrahim Warsame, M.D., Anesthesiology, Ohio State
University Med Ctr, Anesthesiology, OSU Wexner Medical Center, Columbus, OH
44 year-old man was admitted to the ICU following CABG x2. He developed hemodynamically significant
bradycardia and his epicardial pacemaker was activated. Atrial wires failed to capture and ventricular
pacing immediately resulted in ventricular fibrillation (R-on-T phenomenon). ACLS was initiated and a
single defibrillation resulted in ROSC, but he remained in profound cardiogenic shock. He deteriorated
clinically and was placed on Veno-Arterial ECMO, after which he stabilized and was taken back to the OR
for CABG revision. He ultimately improved, was decannulated from ECMO, and had had no further
malignant rhythms throughout his hospital stay.
MCC05
1:20 PM - 1:30 PM
Rare Case of Intraoperatively Diagnosed Nodular Carcinoid Tumor: a True Anesthetic Challenge
Sara M. Aljohani, M.D., Sergey Pisklakov, M.D., Josue Rivera, M.D., Anesthesiology, Albert Einstein
College of Medicine, New York, NY
Carcinoid tumors secrete many different types of substances (e.g. serotonin, bradykinin) that may
produce potentially fatal intraoperative reactions such as hypotension and bronchoconstriction. The most
effective treatment for the deleterious cardiovascular and pulmonary effects of serotonin and bradykinin is
octreotide, a somatostatin analogue. We present a rare case of intraoperatively diagnosed nodular
carcinoid manifested with severe sustained hypertension. More patients with carcinoid tumors and
carcinoid syndrome are requiring anesthesia and surgery. Intraoperative blood pressure management
could be a true challenge as it was extremely labile during our case.
MCC05
1:20 PM - 1:30 PM
Failed Epidural and Need for Urgent Cesarean Delivery
Brent S. McNew, M.D., Brian Allen, M.D., Anesthesiology, Vanderbilt University Medical Center,
Nashville, TN
A G1P0 Nepali-speaking female presents in term labor. Despite epidural replacement at a different
interspace, there is persistent inadequate analgesia at the left groin as the diagnosis of chorioamnionitis
is made. The epidural infusion is discontinued and 45 minutes later the patient arrives in the operating
room for Cesarean delivery. A spinal is administered and the patient quickly begins to experience distress
and becomes unresponsive, but without hemodynamic instability. An endotracheal tube is placed and
emergency Cesarean Delivery is undertaken. The patient is emerged from general anesthesia at
conclusion of the case with mother and baby having an uneventful recovery.
MCC05
1:20 PM - 1:30 PM
Grossly Delayed Subcutaneous Emphysema and Pneumomediastinum Following Laparoscopic
Appendectomy
Nareg Gharibjanians, M.D., Vahe Tateosian, M.D., Anesthesia, Saint Barnabas Medical Center,
Livingston, NJ
A 13 year-old healthy male underwent a laparoscopic appendectomy for acute appendicitis.
Pneumoperitoneum was induced via trocars, and at the end of surgery, was released without
complications. Oxygen saturation remained above 98% throughout with no increases in peak inspiratory
pressures. The perioperative course was unremarkable and the patient was discharged home on POD-1.
On POD-3, he complained of severe chest pain and shortness of breath. Physical examination
demonstrated crepitus over the chest. Radiographic studies showed significant subcutaneous
emphysema and pneumomediastinum. We present a rare case of pneumomediastium 3 days after an
unremarkable anesthetic, the possible etiology and our management.
MCC05
1:20 PM - 1:30 PM
Continuous Infraclavicular Brachial Plexus Block for Phantom Limb Pain
Jenny A. Varughese, M.D., Jennifer Eismon, M.D., Anesthesiology, MetroHealth Medical Center,
Cleveland, OH
Continuous peripheral nerve catheters (cPNC) have been shown to decrease opioid consumption and
improve pain control and satisfaction. A 27 year-old male presents with a crush injury with an exposed
ulna. On POD # 1 a right infraclavicular nerve block with catheter placement for continuous infusion was
placed under ultrasound guidance. The patient underwent 3 subsequent surgeries and discharged home
with the cPNC. The impact of cPNC on analgesia include a decrease in supplemental opioids and opioid
related side effects. The decreased time to adequate ambulation and time to start physical therapy with
an ambulatory cPNC have also been described.
MCC05
1:20 PM - 1:30 PM
Amniotic Fluid Embolism Syndrome
Melissa Anne Burger, M.D., M.S., Anthony J. Netzer, M.D., Joseph L. Reeves-Viets, M.D., MBA,
Anesthesiology, University of Missouri-Columbia, Columbia, MO
Amniotic fluid embolism syndrome is a frequently fatal event that presents as severe pulmonary
hypertension, progression of right to left ventricular failure, and cardiovascular collapse. Entry of fetal
antigens into maternal circulation provokes an inflammatory immune response leading to a later
hemorrhagic phase characterized by disseminated intravascular coagulation and multi-organ system
failure. We present the case of a 38 year-old female undergoing elective repeat Cesarean section who
developed an amniotic fluid embolism during manual perforation of an anterior placenta to allow fetal
delivery. We discuss initial emergent intraoperative stabilization followed by later phase supportive care in
the intensive care unit.
MCC05
1:20 PM - 1:30 PM
Anesthetic Management of a Patient With End Stage Duchennes Muscular Dystrophy for a
Pallative Procedure
Jason Pollack, M.D., Deborah Richman, M.D., Zvi Jacob, M.D., Dept of Anesthesiology, Stony Brook
A 29 year-old man with advanced Duchene’s muscular dystrophy presents for a palliative girdlestone
procedure for a chronic dislocated hip. He was successfully weaned from his trach a few years ago, but in
recent months has become BiPap dependent. His past medical history is significant for malignant
hyperthermia including an intraoperative arrest, an implanted AICD for an EF of 29%, and a
dysfibrinogenemia which was diagnosed at the time of his scoliosis surgery and required a massive
transfusion. Careful consideration of the multiple medical and ethical issues and intensive planning was
needed. Our anesthetic management is presented and discussed.
MCC05
1:20 PM - 1:30 PM
A Unique Case: Intraoperative Seizures With Neuropathic Ipsilateral Transient Hyperemic Rash
With Post-operative Contralateral Hemiparesis: Todd's Palsy
Govind R. Rajan, Michael Ross, M.D., University of Irvine Medical Center, Anesthesiology and
Perioperative Care, UCI Medical Center, Orange, CA
During Flexible Bronchoscopy and biopsy for newly diagnosed RUL lung mass, a 75 year-old male with
throat cancer, hydrocephalus (s/p VP Shunt) developed under general anesthesia severe unexplained
bradycardia and intractable hypotension and a distinct hyperemic rash over ipsilateral half of the body. On
emergence from anesthesia he developed contralateral hemiparesis with severe contralateral itching. He
was later diagnosed with Todd’s Paralysis s/p intraoperative seizures, neuropathic transient skin rash and
Neuropathic Itching. We discuss the clinical presentation, diagnosis and treatment of this very rare and
challenging case.
MCC05
1:30 PM - 1:40 PM
Temporomandibular Joint Dislocation During Airway Evaluation: A Case Report
Telmo Santos, M.D., Carolina Santos, M.D., Célia Pinheiro, M.D., Isabel Gouveia, M.D., Anesthesia and
Pain Medicine, Centro Hospitalar de Trás os Montes e Alto Douro, Vila Real, Portugal
A 74 year-old man, in the pre-admission clinic evaluation, during airway examination, after opening the
mouth to assess the Mallampati score, the patient complained of sudden pain in preauricular regions,
having been unable to close the mouth and difficulty in speaking.Suspecting of temporomandibular joint
dislocation, the oral surgery team was consulted who confirmed the diagnosis and performed a manual
reduction with success.This case reminds us that TMJ dislocation is a potential complication not only in
upper airway manipulation but also in their evaluation. Anesthesiologists should be aware of this problem
and be prepared for its occurrence and management.
MCC05
1:30 PM - 1:40 PM
Acute Hemopericardium Due to Coronary Sinus Puncture During ICD/CRT Placement
Jia Wang, M.D., David McDonagh, M.D., Department of Anesthesiology and Pain Management,
64year-old female with ischemic cardiomyear-oldpathy (EF 35%), multiple cardiac stents on clopidogrel,
and controlled hypertension. Scheduled for cardiac resynchronization therapy to improve her heart failure
and implantable cardiodefibrillator placement (ICD/CRT device) for primary prevention of lethal
dysrhythmias. The procedure was performed in the electrophysiology lab under sedation (MAC) without a
secured airway. Inadvertent coronary sinus puncture caused a gradually expanding pericardial effusion.
Initial hemodynamic stability but progressively increased vasopressor requirements; supplemental
sedative doses due to increased procedure length with resulting intermittent airway obstruction.
Postoperative TTE confirmed hemopericardium: pericardial drain was placed and the patient transferred
to ICU for hemodynamic monitoring.
MCC05
1:30 PM - 1:40 PM
Explant of Aortic Endo-Graft, Case Report and Anesthetic Considerations
Mark Teen, M.D., Alexandru Gottlieb, M.D., Brain Eaton, D.O., Cleveland Clinic, Cleveland, OH
1. A 66 year-old female, presented with weakness and severe back pain radiating to lower extremities.
CT showed a growing aneurysm with stent, inflammatory changes in the paravertebral muscles with fluid,
and gas collection. MRI displayed L4/5 osteomyelitis, spondylodiscitis, and epidural phlegmon. Patient
underwent exploratory laparotomy to explant the infected stent via ‘syringe bevel technique’ and open
repair of supra-celiac abdominal aortic aneurysm (AAA). General anesthesia and invasive lines were
performed. Estimated blood loss was 10 liters; multiple blood products, 1250 mL Colloids, and 7600 ml
Crystalloids were administered. Patient was extubated at POD-1 and discharged 8-POD.
MCC05
1:30 PM - 1:40 PM
Management of Inadvertent Large-Bore CVP Catheter Placement in the Pleural Space
Samuel M. Barst, Glenn Brady, M.D., John Cooley, M.D., Renee Garrick, M.D., Anesthesiology,
Nephrology, New York Medical College - Westchester Medical Center, Valhalla, NY
We present two cases (over a three year period) which were reviewed by the Anesthesiology
Department’s QA Committee involving the inadvertent entry of large bore CVP catheters into the pleural
space. As a result of these two cases hospital-wide guidelines were formulated by the Departments of
Critical Care, Vascular Surgery and the Anesthesia Department. When catheters of 7 Fr-diameter (or
less) are involved the device may be removed in the ICU setting. Larger bore catheters (8 Fr and 9 Fr)
must be removed in the OR with thoracic surgery in attendance.
MCC05
1:30 PM - 1:40 PM
Worsening Post-operative Delirium, Asthma, Hypoxia and Failed Intubation!
Tyler T. Kloven, D.O., Thomas Tinker, M.D., Tilak Raj, M.D., Thomas Luscomb, M.S., Department of
Anesthesiology, OU Medical Center, Oklahoma City, OK
We present a patient with a BMI of 42.8 and multiple co-morbidities who had an uneventful thyroidectomy
and excision of pharyngeal lesion. After meeting criteria, he was extubated and taken to the PACU where
he progressively deteriorated with delirium, agitation, wheezing, desaturation, and ST-T wave changes on
EKG. His airway now became difficult to secure, even with a glidescope. We discuss further management
of his airway and the differential diagnosis of his delirium and worsening ‘asthma’!
MCC05
1:30 PM - 1:40 PM
Moyamoya: Implications for Perioperative Anesthetic Management for Posterior Cervical
Decompression and Lateral Mass Fusion
Kevin K. Bradley, M.D., Edwin Herron, M.D., Anesthesia, LSUHSC, Shreveport, LA
40 year-old female with PMH of multiple CVAs, DM2, CAD, and HTN who presented to the hospital for
multilevel posterior cervical decompression with lateral mass fusion secondary to central cord syndrome
associated with cervical spinal stenosis. MRI brain showed significant decrease in right internal carotid
artery blood flow and a new diagnosis of Moyamoya disease. Pre-induction arterial line was placed and
asleep fiberoptic intubation was performed. Propofol-remifentanil TIVA was administered and
intraoperative monitoring of SSEP, MEP, and EEG was done. Upon completion of surgery patient was
extubated without complication and transported to ICU with subsequent resolution of neurological
symptoms.
MCC05
1:30 PM - 1:40 PM
Case Report: Perioperative Management of a 40 year-old Male With Hypertrophic Cardiomyopathy
and History of Massive Pulmonary Edema for Atrial Tachycardia Ablation
Edward C. Yang, M.D., Aladino De Ranieri, M.D., Anesthesiology, Advocate Illinois Masonic Med Ctr,
Chicago, IL
40 year-old male with hypertrophic cardiomyear-oldpathy, morbid obesity, and OSA, s/p cardiac
myectomy and ICD placement, s/p multiple ablations for atrial fibrillation, presents for repeat ablation of
atrial tachycardia. Previous ablation was complicated by massive pulmonary edema secondary to
diastolic heart failure post-procedure, which required overnight intubation. Intraoperatively, MAC
anesthesia was used with euvolemia maintained, but the patient progressively became more dyspneic
and eventually required CPAP. Post-operative CXR demonstrated signs of fluid overload. Patient was not
fatigued and non-invasive ventilator management was continued with additional diuresis. Followup urine
output was adequate, the tachypnea improved, and serial ABGs showed improving oxygenation.
MCC05
1:30 PM - 1:40 PM
High Dose Insulin Therapy as Treatment for Calcium Channel Blocker Overdose
Michael B. Tang, M.D., Michael D. Maile, M.D., M.S., Department of Anesthesiology, University of
Michigan, Ann Arbor, MI
A 40 year-old male was transferred for persistent hypotension, hypoxemic respiratory failure, and acute
renal failure three days after an intentional CCB overdose. On arrival he was intubated, sedated, and on
high dose vasoconstrictor infusions. Chest radiography demonstrated severe pulmonary edema. Large
doses of calcium and high dose insulin (HDI) therapy (up to 1400 units/hour) along with a dextrose
infusion were given to counteract the effects the CCB toxicity (Figure 1). Hemodynamics rapidly
improved, and the vasoconstrictors were discontinued. The patient was then able to tolerate renal
replacement therapy, and increased gastrointestinal perfusion allowed for increased metabolism of
ingested drug.
MCC05
1:30 PM - 1:40 PM
Anesthesia Challenges in Dentistry for SHCN (Special Health Care Needs) Patients
Alicja Orkiszewski, M.D.,Ph.D., Kriss Ghafourpour, D.D.S., Amy Herrick, C.R.N.A., Thurman Hunt, M.D.,
Janey Kunkle, M.D., Anesthesiology, Attending Dental Surgeon, AHS, Highland Hospital, Oakland, CA
During the last 29 months at Highland Hospital in Oakland, CA, we performed 170 EUA, x-rays and
dental restorations in SHCN patients, most of whom were non-verbal and combative. Preoperative
sedation was achieved with I.M. Ketamine or P.O. benzodiazepine (Lorazepam or Midazolam). Vascular
access was then established. Standard monitoring was used. Airway was mostly secured with a nasal
RAE tube and general anesthesia was conducted. Due to these patient's mental status and often
concurrent comorbidities, these cases are frequently medically and technically challenging.
MCC05
1:30 PM - 1:40 PM
Placental Abruption in the Setting of Septic Shock
Erica Grant, M.D., The University of Texas Southwestern Medical Center, Dallas, TX
A 42 year-old gravida 6 para 5 Hispanic woman at 18 5/7weeks gestation presented with
suspectedpyelonephritis. The anesthesia team was called for the first time forrespiratory distress in labor
and delivery. She was suspected to be in septicshock and was transferred to the ICU for escalation of
care. During assessment,prior to transfer, she was noted to have profuse vaginal bleeding presumed tobe
placental abruption. Within 1 hour of arriving in ICU, she was transferred toOR for a hysterotomy to stop
the hemorrhage. She required a hysterectomy andprolonged ventilation for ARDS.
MCC05
1:30 PM - 1:40 PM
Anesthesia for a Pediatric Patient With Marfan Syndrome, Complete Heart Block, Coagulopathy,
and Hematemesis, Presenting for Emergent Endoscopy
Alberto J. de Armendi, M.D.,Ph.D., Cassandra R. Duncan-Azadi, M.D., Amir L. Butt, M.D.,M.P.H.,
Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
A 14 year-old male with Marfan syndrome presented for emergent endoscopy for hematemesis on postop day one status post aortic root dilatation and Nuss Bar placement. The patient had intermittent
complete heart block (CHB), was anemic with a hematocrit of 19.7%, and was coagulopathic with an INR
of greater than three.Chest Xray and transthoracic echocardiography showed bilateral effusions. We
describe the preoperative preparation undertaken and the intraoperative management of CHB, atrial
flutter, and 1st degree atrioventricular heart block that developed throughout the case. We
also discuss the multidisciplinary preoperative and postoperativemanagement this patient required.
MCC05
1:30 PM - 1:40 PM
Bilateral Lower Extremity Paraplegia and Sensory Deficit After Lung Volume Reduction Surgery
and Placement of Thoracic Epidural
Ashley Colletti, M.D., Eric Pan, M.D., Anesthesiology and Pain Medicine, University of Washington
Medical Center, Seattle, WA
A 63 year-old male with COPD developed acute bilateral lower extremity paraplegia on postoperative day
4 following preoperative thoracic epidural placement for lung volume reduction surgery. Etiology of his
neurologic deficit remains unclear, as imaging studies were inconsistent with spinal cord infarct, epidural
hematoma, or direct cord trauma. Neuroradiology suggested venous compression as a possible
explanation, though to our knowledge no prior case reports or studies describe this. Motor strength
gradually improved over a period of weeks following removal of the epidural catheter. Sensory deficit and
urinary incontinence persisted at 4 months, consistent with partial spinal cord injury.
MCC05
1:30 PM - 1:40 PM
Management of a Parturient Following Trauma
Ryan F. McKenna, M.D., Terri Monk, M.D., JL Reeves-Viets, M.D., Anesthesiology, University of
Missouri, Columbia, MO
A 24 year-old female presented to the Operating Room for emergent Exploratory-Laparotomy following a
motor vehicle collision. She was 16 weeks pregnant and had sustained a splenic laceration, placental
abruption, fetal demise, multiple orthopaedic fractures, and was actively hemorrhaging. After Dilation and
Evacuation, the patient developed coagulopathy and uterine atony, which was unresponsive to numerous
interventions including uterine massage, methylergonovine, carboprost, oxytocin, and decreasing volatile
anesthetics. A hysterectomy was ultimately required, and the patient’s coagulopathy, disseminated
intravascular coagulation, was reversed with a massive transfusion protocol. The patient was extubated
prior to leaving the operating room.
MCC05
1:30 PM - 1:40 PM
Catastrophic Arterial Thrombosis in an Infant Undergoing Neuroblastoma Resection
Rohan Panchamia, M.D., Anahita Dabo, M.D., Dept. of Anesthesiology, New York Presbyterian HospitalWeill Cornell Medical Center, Dept. of Anesthesiology and Critical Care Medicine, Memorial Sloan
Kettering Cancer Center, New York, NY
We present an unusual case of a 14 month old female with stage III neuroblastoma who underwent a left
thoracoabdominal resection complicated by a superior mesentery artery (SMA) clot, resulting in diffuse
bowel ischemia with the patient needing an SMA embolectomy and Whipple procedure. She developed a
significant lactic acidosis with associated vasoplegia requiring multipressor therapy. Her postoperative
course was complicated by shock, DIC, and respiratory failure. Testing for prothrombotic risk factors
revealed the patient to be homozygous for methyltetrahydrofolate reductase mutation (MTHFR). Genetic
variations of this gene have been associated with the development of thrombotic-occlusive events.
MCC05
1:30 PM - 1:40 PM
Carbon Monoxide (CO) Poisoning in a Patient Undergoing Parotid Gland Excision With Unilateral
Radical Neck Dissection, First Case on Monday Morning
Alina D. Hulsey, M.D., Richard E. Moon, M.D., FRCPC, Michael R. Shaughnessy, M.D., Andrew Peery,
M.D.,M.P.H., Anesthesiology, Duke University Medical Center, Durham, NC
An 82 year-old female underwent parotidectomy/unilateral radical neck dissection. ABG 1.5 hours into the
case revealed 20% COHb. FIO2 was then increased to 1.0 and the top CO2 absorbent canister (GE
Medisorb®) was replaced. COHb continued to rise, reaching a peak of 25% (45 min later). After replacing
the second absorbent, COHb started decreasing. Desflurane was switched to sevoflurane and patient
was kept on high flow FIO2=1.0 for the remainder of the case. She was extubated without symptoms and
discharged home on POD7. Incubation of each absorbent canister with desflurane for 4 days produced
CO >2000 ppm.
MCC05
1:40 PM - 1:50 PM
That's a Mouth Full: Near Miss Critical Dental Mishap in Scheduled Regional Anesthesia
Teruya Asahina, D.M.D., Masao Katayama, M.D.,Ph.D., Katsuyuki Miyasaka, M.D.,Ph.D., Department of
Anesthesia & ICU, Perioperative center, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
An obese Caucasian female (age 59, 130 kg, 157 cm, BMI 53, ASA PS 2) was scheduled for removal of
crural chondrosarcoma.The dental anesthesiologist advised the use of mouth-guards or fiberscopic nasalintubation to protect the patient's expensive but cracky ceramic dental implants. The anesthesiologist in
charge refused, thinking teeth looked fine and the need for tracheal intubation was minimum.The
placement of a spinal needle was unsuccessful. General anesthesia was induced immediately with
propofol and rocuronium, but several trials of oral intubation were unsuccessful.An atraumatic intubation
was obtained by use of video-laryngoscope and mouth-guards discreetly prepared in advance.
MCC05
1:40 PM - 1:50 PM
Perioperative Management of a Patient With Extensive Hemangioma of the Oropharynx
Richard Nguyen, Brian Martin, M.D., Toni Chahla, Taras Grosh, Anesthesiology, Baystate Medical
Center, Springfield, MA
A 72 year-old woman with a congenital hemangioma presented to the hospital with dyspnea and
dysphagia following an acute episode of tongue swelling. She was unable to lay supine and the
increasing size of the tongue hemangioma raise the concern for complete airway obstruction. The risk of
excessive bleeding from tissue trauma posed a significant risk to securing the airway. An awake-flexible
fiberoptic oral intubation was performed, which revealed diffuse hemangioma involvement down to the
vocal cords. A tracheostomy tube was inserted without complication. An MRI revealed an expansile mass
involving the entire tongue, oropharynx, nasopharynx, hypopharynx and right maxillary region.
MCC05
1:40 PM - 1:50 PM
Complication From Weight Loss Surgery: Gastrocardiac Fistula
Cindy Ku, M.D., Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center,
Boston, MA
62 year-old female with extreme obesity (BMI 66) and status post open gastric bypass, atrial fibrillation,
peptic ulcer disease, and recurrent cholangitis presented with abdominal pain and signs of upper
gastrointestinal bleeding. Patient became hypotensive one day after initial presentation, and abdominal
CT revealed intraperitoneal hemorrhage of unclear source. Patient then experienced PEA arrest, was
successfully resuscitated, and then brought to the operating theater for exploratory laparotomy. Massive
hemorrhage occurred as a mature thickened gastrocardiac fistula was encountered, requiring emergent
sternotomy for left ventricular repair, diaphragmatic repair, and subtotal gastrectomy. Despite the surgical
repair and extensive resuscitation efforts patient expired.
MCC05
1:40 PM - 1:50 PM
Adult Post-Tonsillectomy Hemorrhage Due to Facial Artery Pseudoaneurysm
Yinghui Low, M.D., Anesthesiology, Duke University Hospital, Durham, NC
37 year-old female with a severe post-tonsillectomy hemorrhage 2 weeks after original surgery that
required return to the OR twice. Her intubation was complicated by BMI of 58, profuse bleed, patient
anxiety and inability to cooperate with awake fiberoptic intubation, and was secured with a video
laryngoscope and RSI. In addition, she had difficult venous access for resuscitation and blood sampling,
and required transfusion of pRBCs. She developed periods of bigeminy interspersed with sinus
bradycardia which may have been due to surgical manipulation. Eventually the source of bleeding was
found to be a facial artery pesudoaneurysm and this was embolized.
MCC05
1:40 PM - 1:50 PM
Successful Resuscitation of Massive Intraoperative Pulmonary Embolus
Autumn D. Brockman, M.D., Amanda K. Anastasi, M.D., Sajid Shahul, M.D., Brian Osman, M.D., Beth
Israel Deaconess Medical Center, Boston, MA, University of Chicago, Chicago, IL, University of Miami
Health System, Miami, FL
A healthy and very active 72 year-old male presented for hemiarthropplasty for nondisplaced femoral
neck fracture approximately two weeks after a mechanical fall. Shortly after the surgeon began reaming,
the patient became tachycardic and profoundly hypotensive (MAPs 30-40) with drastically decreased
ETCO2 and eventual PEA arrest. TEE revealed massive intra-cardiac clot. He was emergently placed on
ECMO with partial clot retrieval via the femoral cannulae. He was decannulated the following day,
extubated on post-operative day 8, and discharged to a rehabilitation facility two weeks after the event
with no neurologic deficits.
MCC05
1:40 PM - 1:50 PM
Patients With POTS: An Anesthetic Approach To Little Patients With Big Autonomic Disorders
Matthew C. Stansbury, M.D., Tracey Danloff, M.D., Univ of Michigan Hospital, Ann Arbor, MI
Patients with dysautonomic syndromes often struggle with simple activities of daily living and frequently
present for surgery with numerous other medical conditions. Safe delivery of anesthesia requires careful
planning and knowledge of potential complications associated with their co-morbidities. We present an 11
year-old female with a history of severe Postural Orthostatic Tachycardia Syndrome undergoing removal
of right navicular bone. Due to the patient’s history of rapid hemodynamic changes, regional technique
was used in combination with sedation to prevent any deleterious episodes. This case required careful
approach and smooth application of anesthesia to provide safe patient care and an optimal outcome.
MCC05
1:40 PM - 1:50 PM
Case Report: Management of Recurrant Cardiac Tamponade Complicated by Bleeding Malignancy
and Pleural Effusion
Edward C. Yang, M.D., Anna Moskal, M.D., Anesthesiology, Advocate Illinois Masonic Med Ctr, Chicago,
IL
45 year-old female with history of metastatic breast cancer on chemotherapy, s/p pericardial window for
tamponade four months ago, presents with SOB with exertion. CT scan revealed a large left pleural
effusion with loculation and a large pericardial effusion with mass effect on ventricles, and echo revealed
a large loculated pericardial effusion with RV and RA collapse in systole and diastole. Patient underwent
an emergent thoracotomy and pericardial window, and was positioned in lateral tilt for anterior
thoracotomy incision. Significant pleural effusion, pleural fluid, and bleeding from malignancy were
encountered, requiring vasoactive agents and transfusions until hemostasis was achieved.
MCC05
1:40 PM - 1:50 PM
Diffuse Cerebral Edema and Central Herniation Following Status Asthmaticus: A Case
Presentation
Joelle B. Karlk, M.D., Ryan Laterza, M.D., Ansgar M. Brambrink, M.D., Anesthesiology, Oregon Health
and Sciences University, Portland, OR
A 24 year-old female in acute status asthmaticus was emergently intubated and paralyzed. Mechanical
ventilation was complicated by high auto-PEEP, plateau pressures, elevated central venous pressure
(CVP) and hypercarbia. On hospital day two, she developed a fixed dilated right pupil. Non-contrast head
CT showed diffuse cerebral edema with central herniation. Supportive care included mannitol and an
external ventricular drain. A comprehensive workup for intracranial causes was negative, suggesting that
hypercarbia and elevated CVP contributed to her cerebral edema, elevated intracranial pressure and
eventually effacement of intracranial compliance. The course was further complicated by extensive
subcutaneous emphysema and rhabdomyear-oldlysis.
MCC05
1:40 PM - 1:50 PM
Anesthesia In The Trailer: A Study in Non-traditional Settings
Sravankumar R. Polu, M.D., Christina Matadial, M.D., Anesthesiology, Miami VA Medical CenterUM/JMH, Miami, FL
At times, circumstances dictate that we administer anesthesiaunder remote and unfamiliar conditions.
With the renovation of the ORs at the Miami VAMC, all operations were displaced to a temporary trailer
facility for a period of 32 months. These self-contained OR/PACU trailers were equipped with the same
anesthesia machines, medication carts, equipment, and staff as the main ORs. During this time period, a
total of 14 cardiopulmonary events and airway emergencies were successfully managed. We found that
with proper preparation and open lines of communication anesthesia can be safely administered in a
variety of nontraditional settings.
MCC05
1:40 PM - 1:50 PM
Repeat Cesarean Section in a Parturient With a History of Peripartum Cardiomyopathy
Salim Durrani, M.D., Kalpana Tyagraj, M.D., Anesthesiology, Maimonides Medical Center, Brooklyn, NY
25 years female,G4P1, at 39 weeks gestational age with history of peripartum cardiomyear-oldpathy and
prior history of intraoperative cardiac arrest presents for repeat Cesarean Section.A multi-disciplinary
meeting took place including anesthesiology, obstetrics, and cardiology. She was deemed optimized on
carvedilol and her ejection fraction was stable at 50%. Cardiothoracic surgery was consulted for
intraoperative standby and requested the operation take place in the main operating floor in case of need
for emergent intervention.Cesarean section took place uneventfully under combined spinal epidural
anesthesia with an arterial line, and the patient was transferred to the SICU for close postoperative
monitoring.
MCC05
1:40 PM - 1:50 PM
Anesthetic Management and Considerations in a Neonate With Carbamoyl Phosphate Synthetase I
Deficiency
Belinda Lee, M.D., Elif Cingi, M.D., Anesthesiology, University of Minnesota, Minneapolis, MN
We will discuss anesthetic management of a neonate with CPS I deficiency. CPS1 is a mitochondrial
enzyme that catalyzes the first step of the urea cycle, the primary system for removing nitrogen produced
by protein metabolism using N-acetylglutamate. CPS I deficiency causes increased levels of ammonia
that results in serious neurological sequelae and death. The liver is the only organ in which ammonia is
significantly transformed to urea through the Krebs urea cycle. Liver transplantation has been considered
as a cure for this disease. Our patient required four different anesthetics, including emergent dialysis
access at 1 day of life.
MCC05
1:40 PM - 1:50 PM
Prolonged Weakness Post Femoral Nerve Catheter and Left Knee PFL Reconstruction
Ryan F. McKenna, Sanjay Mehta, M.D., Quinn Johnson, M.D., JL Reeves-Viets, M.D., Anesthesiology,
University of Missouri, Columbia, MO
The etiology of prolonged quadriceps weakness related to femoral nerve block in knee surgery remains
unclear in many instances. Suggested etiologies include mechanical trauma from the needle, nerve
edema and/or hematoma, pressure effects of local anesthetics, neurotoxicity of injected solutions and
confounding factors such as surgical manipulation, tourniquet application, or preexisting neuropathies.
This case explores a sixteen year-old female athlete who presents for repair of left knee patellofemoral
instability with femoral nerve catheter placement complicated by six weeks of isolated motor weakness in
quadriceps. The two etiologies discussed in detail are tourniquet placement and non-mechanical nerve
block complications.
MCC05
1:40 PM - 1:50 PM
Cesarean Section in a Parturient With Herniated Brain Tumor: An Anesthetic Challenge
Samhati Mondal, Vimal Desai, M.D., Norman Bolden, M.D., Maninder Singh, M.D., Anesthesiology,
Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH
A 22 year parturient presented at 26 weeks with brainstem mass lesion with minor neurological changes.
Observed closely, she returned at 34 weeks with severe headache, right sided weakness and impending
herniation. Careful anesthetic and surgical management with multidisciplinary collaboration was executed
for successful performance of cesarean delivery followed by tumor resection without negative
consequence. Brain tumors resulting in neurological changes and herniation are rare especially during
pregnancy making anesthetic consideration challenging in order to avoid even minor hemodynamic
fluctuations. Monitoring, communication and precise predictive hemodynamic management were critical in
preventing any detrimental sequelae.
MCC05
1:40 PM - 1:50 PM
Novel Use of the Laryngeal Mask Airway: An Air Leak Sealant
Mark A. Banks, M.D., Pankaj Chhatbar, M.B.,B.S., Department of Anesthesiology and Perioperative
Medicine, Georgia Regents University, Augusta, GA
The LMA has gained popularity as an airway management device (AMD). We present a series of cases of
a novel use of the LMA: an adjunct to patch an air leak around the primary AMDs. One case consists of
an infant who presents for a tracheostomy with an uncuffed ETT in place and significant air leak after
induction and muscle relaxation. This was fixed by placing an LMA with the lumen occluded by
Tegaderm. Two other cases consist of elective tracheostomies with significant air leaks after placement of
uncuffed tracheostomy tubes also fixed with the placement of LMAs without complications.
MCC05
1:40 PM - 1:50 PM
Bleomycin Pulmonary Toxicity and Anesthesia
Scott M. Lawson, M.D., John Flynn, M.D., Department of Anesthesia, Walter Reed National Military
Medical Center, Bethesda, MD
A 24 year-old male with history of testicular cancer s/p orchiectomy and 4 cycles of bleomycin
chemotherapy presents for a retroperitoneal lymph node dissection for persistent lymphadenopathy.
Patient's last dose of chemotherapy was 3 weeks prior to surgery. After RSI using 3 minutes of preoxygenation with 100% FiO2, and managing a moderately difficult airway, we were unable to maintain
oxygenation while using a low FiO2 per current guidelines. After discussion with care team, case was
postponed, patient was extubated and admitted overnight for observation. We will discuss management
of patients treated with bleomycin and our role in preventing pulmonary toxicity.
MCC05
1:50 PM - 2:00 PM
A Case Report of Suspected Perioperative Anaphylaxis Associated With Sugammadex
RYotaro Nagai, Yoshinori Nakata, Hirokazu Nagatani, Hidefumi kyan, \shigehito Sawamura, Teikyo
University Hospital, Tokyo, Japan
A 38 year-old male without known drug allergies underwent closed reduction for nasal fracture. General
anesthesia was induced with propofol, rocuronium and fentanyl andmaintained with sevoflurane and
remifentanil. During emergence he was given sugammadex and extubated in the OR. Subsequently
systemic flush appeared and systolic blood pressure went down to 30-40 mmHg at PACU ten minutes
later. Our presumed diagnosis was anaphylaxis of sugammadex. We administered vasopressors and
successfully stabilized his hemodynamic state. He was transferred to the ICU for BP monitoring and
recoverd without any complications on the next day.
MCC05
1:50 PM - 2:00 PM
Anesthetic Implications of Stiff Person Syndrome: A Case Report
Sailesh Arulkumar, M.D., Katie Stammen, M.D., Anesthesiology, LSUHSC Shreveport, Shreveport, LA
Stiff-person syndrome (SPS) is a neurological disease characterized by painful involuntary episodes of
severe muscle rigidity affecting the axial muscles and extremities. Although the etiology of SPS is
unknown, it thought to possibly have an interaction on the synthesis of gamma aminobutyric acid (GABA).
Inhalational agents and neuromuscular blockers have the potential to cause patients with SPS to have
prolonged hypotonia following anesthesia that can cause respiratory failure despite full neuromuscular
blocker reversal, possibly though interactions with GABA and NMT. This case report highlights the
anesthetic management of a 56 year-old female with SPS undergoing a hemicolectomy under TIVA.
MCC05
1:50 PM - 2:00 PM
Thromboembolism in the Anticoagulated Elderly Patient During Orthopedic Surgery
Carlo J. Petrillo, M.D., Eleanor Duduch, M.D., Anesthesiology, UMass Medical School, Worcester, MA
Thromboembolism of varying etiologies is a concern when anesthetizing patients for orthopedic
procedures. This case is a medically complex elderly female who presented for IM nail of femur fracture.
After warfarin reversal with Vitamin K, the procedure was begun under spinal anesthesia. During lag
screw placement, the patient became hypoxemic, hypotensive and bradycardic. Resuscitation was
instituted. TEE demonstrated a large right ventricular echogenic mass, which disappeared after several
rounds of chest compression. Large amounts of ETT blood emerged and FAST exam of the chest
revealed a right-sided collection. Resuscitative efforts were discontinued after determination that the
insult was Beyond recoverable.
MCC05
1:50 PM - 2:00 PM
Acute Respiratory Distress Syndrome From Gastrografin Contrast Media Aspiration Pneumonitis
Mala N. Gurbani, D.O., Meera Gonzalez, M.D., Anesthesiology, Temple University Hospital, Philadelphia,
PA
Our patient is a 49-year-old morbidly obese male with multiple comorbidities who underwent an
uncomplicated laparoscopic Roux-en-Y gastric bypass. Results from standard post-operative contrast
studies necessitated further evaluation with endoscopy on the first post-operative day. After intubation,
the patient suffered aspiration which ultimately resulted in life threatening pulmonary compromise from
the previously administered contrast media. A well known complication of Gastrografin aspiration is
extensive osmotic effusion into the airway. Multiple techniques were employed to both diagnose and
support the patient’s respiratory status. These efforts culminated in veno-venous extracorporeal
membrane oxygenation with success and resolution of the profound hypoxia.
MCC05
1:50 PM - 2:00 PM
Pneumothorax Presenting as Delayed Emergence During Prone Cervical Fusion
Shawn Kumar, M.D., Jeron Zerillo, M.D., Anesthesiology, Icahn School of Medicine at Mount Sinai, New
York, NY
We present the case of a 70 M with HTN, CKD, asthma, DVT/PE history following spine surgery,
undergoing C2-C7 laminectomy and fusion. The procedure was uncomplicated and, after return to supine
position, the patient had a significant delay in emergence. ABG analysis demonstrated severe
hypercarbia and progressively worsening hypoxia despite normal oxygen saturation, minute ventilation
and ETCO2. Lung sounds remained present on both sides, fiberoptic bronchoscopy confirmed tube
position, and CXR was performed in the OR. Diagnosis of a very large left sided tension pneumothorax
was made and CT surgery was immediately consulted to place an emergent chest tube.
MCC05
1:50 PM - 2:00 PM
Anesthetic Care and Serotonin Syndrome: A Case Report
Andrew T. Shen, M.D., MetroHealth Medical Center, Cleveland, OH
We present a 59 year-old female who underwent left modified neck dissection due to recurrent squamous
cell carcinoma. Her past medical history included prior right modified neck dissection, hypertension,
migraines, depression, anxiety, smoking, and alcohol abuse. Her home medications included metoprolol,
lisinopril, fluoxetine, trazodone and percocet. Post-operatively, nausea/vomiting, headaches and
depression were treated. The patient became "confused, yelling out, disoriented, [and] complaining of not
being able to see" and later "appeared to be having seizures." She also had "rhythmic jerking of [right]
upper and lower extremity and generalized rigidity." Several doses of Ativan were administered with
improvement in symptoms.
MCC05
1:50 PM - 2:00 PM
Rescue Valve-in-Valve Technique After CoreValve® Aortic Prosthesis Dislodgement
Ludmil V. Mitrev, M.D., Jessica Siegelheim, M.D., Anesthesiology, Cooper University Hospital, Camden,
NJ
A 54 year-old Caucasian man with a PMH significant for HTN, COPD, OSA, CHF and type II DM,
presented for an elective TAVR after being diagnosed with AS with a bicuspid aortic valve. The patient
underwent TAVR via transfemoral approach with a 29 mm CoreValve®. Five minutes after transannular
deployment, the initial CoreValve® prosthesis spontaneously dislodged into the ascending aorta and its
proximal end was found close to the takeoff of the innominate artery. A second 29 mm CoreValve® was
then placed via the valve-in-valve technique and it was maintained in the proper position with one balloon
post-dilatation.
MCC05
1:50 PM - 2:00 PM
Staged VA-ECLS Configuration Changes as Bridge to Transplantfollowing Catastrophic Idiopathic
Spontaneous Coronary Artery Dissection in a Young Healthy Woman
Nathaniel J. Brown, Gregory M. Weiss, M.D., Anesthesiology, University of Colorado, Aurora, CO
We report a 34 year-old athletic woman who developed chest pain while skiing. Evaluation revealed
troponin elevation and cardiac catheterization showed dissection of all three main coronary vessels, one
possibly iatrogenicly. The study noted significant collateralization, indicating a chronic component. She
failed conventional medical treatment, including coronary artery stenting, and was centrally cannulated for
VA ECLS (RA to aorta), which was subsequently revised to BiVAD (RA to PA and LV to aorta) after a
thrombotic event. Orthotopic heart transplant followed ten days later. Connective tissue disease workup
was negative, and pathology revealed no evidence of vasculitis.
MCC05
1:50 PM - 2:00 PM
The Use of Cross-Field Ventilation to Achieve One-Lung Ventilation in a Patient With a Distal
Trachea Mass
Brian G. Ferguson, D.O., Brian Derhake, M.D., Anesthesia and Perioperative Medicine, University of
Louisville, Louisville, KY
A 61-year-old male with PMHx significant for pseudopapillary neoplasm of the pancreas s/p splenectomy
and pancreatectomy. Patient presented with increased SOA, flexible bronchoscopy revealed a metastatic
lesion consistent with pseudopapillary neoplasm of the distal trachea. Right sided thoracotomy with distal
trachea resection and reconstruction was performed. The use of a DLT was contraindicated, OLV
achieved using a 7.0 ETT advanced via fiberoptic bronchoscopy to the left mainstem bronchus.
Intraoperative cross field ventilation was used as an alternative method to achieve OLV - the surgeon
placed a separate ETT into left mainstem bronchus and oral ETT withdrawn to proximal trachea.
MCC05
1:50 PM - 2:00 PM
Amniotic Fluid Embolism During Cesarean Section
Emily L. McQuaid-Hanson, M.D., Melanie Donnelly, M.D., Anesthesiology, University of Colorado, Aurora,
CO
31 year-old G8P2 at 34w4d with severe preeclampsia, presents for repeat c-section under spinal.
Pregnancy was complicated by twin gestation, morbid obesity, lupus, and anti-phospholipid antibody
syndrome. Exposure, hysterotomy, and delivery were uneventful. After delivery, patient complained of
shortness of breath, followed by seizure-like activity. Following a difficult intubation she was noted to be in
PEA arrest. ACLS was performed with eventual ROSC. Surgeons then noted uterine atony and massive
blood loss from surgical field and vagina, and hysterectomy was performed. She was resuscitated with
massive transfusion protocol, and transported to the SICU with an open abdomen.
MCC05
1:50 PM - 2:00 PM
Anesthetic Management of a Child With ROHHAD Syndrome
Dylan M. Mindich, M.D., Anesthesia Department, Baystate Medical Center Tufts University, Springfield,
MA
A 11 year-old male child, with a BMI of 61.83 diagnosed with ROHHAD syndrome presented to MRI for
imaging of the spine secondary to chronic back pain. PMH included tracheostomy for respiratory failure
decannulated by patient, autism, diabetes type II, OSA, and hypertension. Anticipating a difficult airway,
we had advanced airway equiptment available. We proceeded with general anesthesia after accessing
his venous port. We encountered difficulties with induction and positioning the child in the MRI scanner.
With adequate planning, preparation, and discussion before the case began we were able to safely
perform the MRI.
MCC05
1:50 PM - 2:00 PM
Safety and Efficacy of Using a Lidocaine Infusion for the Management of Acute on Chronic
Abdominal Pain in a Patient Receiving Intralipid via Total Parenteral Nutrition
Jordan M. Ruby, M.D., Michael G. Ozawa, M.D.,Ph.D., Jordan L. Newmark, M.D., Anesthesiology,
Perioperative and Pain Medicine, Pathology, Stanford University, Palo Alto, CA
28 year-old female with a history of Roux-en-Y gastric bypass and chronic pain presented to Stanford
University Hospital with an intestinal volvulus which subsequently required three separate bowel
resections. Total parenteral nutrition (TPN) needed to be initiated for nutrition given the patient’s severe
gastrointestinal disease. Additionally, the patient progressively developed increasing opioid requirements
for her post-operative pain. The pain service initiated an intravenous Lidocaine infusion 1mg/kg/hr. We
hypothesized that the intralipid in the patient’s TPN would interfere with therapeutic pain management.
Lidocaine levels were drawn every eight hours and reflex assays for intralipid interference were
completed by Pathology.
MCC05
1:50 PM - 2:00 PM
Acute Intraoperative Peripartum Pulmonary Embolism During Nephrectomy
Surmeet S. Chhina, M.D., Ritesh Senapati, M.D., Mark O. Stypula, M.D., Christopher A. Troianos, M.D.,
Anesthesiology, Allegheny Health Network, Pittsburgh, PA
A 31 year-old G1P0 woman was found to have a renal mass at 32 weeks gestation. Elective induction of
labor was planned at 37 weeks, to be followed by a radical nephrectomy the day after delivery. The
nephrectomy was aborted when the patient developed acute, severe cardiovascular collapse. An
intraoperative TEE revealed massive pulmonary embolism, and mobile echodensities in the right atrium
and inferior vena cava (IVC). The following day the patient underwent nephrectomy and removal of the
right atrial and IVC masses during cardiopulmonary bypass. She was discharged home 9 days later in
stable condition.
MCC05
1:50 PM - 2:00 PM
Anesthesia Management in an Infant With Bronchogenic Cyst With Severe Airway Compression
Elena Brusseau, Boston Children's Hospital, Boston, MA
This is a case report of a 1year-old with a large recurrent bronchogenic cyst with T3, carinal and left
mainstem compression. An ECMO cannula was placed in case control of the airway was lost. The patient
was left-mainstem intubated with a modified 3.0 ETT which was placed distal to the obstruction to
facilitate right thoracotomy. After the bronchogenic cyst was removed, the patient was re-intubated with a
4.0 ETT to allow flexible bronchoscopy to evaluate tracheomalacia and also to help the surgeons doing
the posterior tracheopexy. The problems faced and their management during anesthesia are described.
MCC05
1:50 PM - 2:00 PM
Anesthetic Management of a Patient at 16 Weeks of Twin Pregnancy With Incarcerated Giant
Paraesophageal Hernia
Kathryn Rosenblatt, M.D., Rosanne Sheinberg, M.D., Lauren Berkow, M.D., Anesthesiology and Critical
Care Medicine, Johns Hopkins University, Baltimore, MD
Giant paraesophageal hernia is an uncommon disorder with risk of catastrophic complications such as
bleeding, strangulation, incarceration, volvulus and perforation. Acute presentations should be
decompressed by nasogastric tube, imaged with water-soluble contrast if perforation suspected, and
endoscopy performed to detect ischemia. We present a 33 year-old, 16 weeks' twin gestation, with
intractable nausea and vomiting, requiring emergent esophagogastroduodenoscopy for gastric volvulus
followed by laparoscopic repair of incarcerated hiatal hernia. A tailored plan, optimizing fetal safety and
integrating considerations of pregnant physiology and laparoscopy, included nasopharyngeal
topicalization for NGT insertion, RSI, maintenance of normal oxygenation and blood pressure, and
avoidance of hyperventilation.
MCC05
2:00 PM - 2:10 PM
A Cannot Ventilate, Cannot Intubate Situation in a Patient for Urgent Evacuation of Post Cervical
Discectomy Hematoma
Telmo Santos, M.D., Pedro Amorim, M.D., Anesthesia and Pain Medicine, Centro Hospitalar de Trás os
Montes e Alto Douro, Vila Real, Portugal, Centro Hospitalar do Porto, Porto, Portugal
56 year-old man, for urgent evacuation of post cervical discectomy hematoma. After pre-oxygenation and
induction, with successful face-mask ventilation, 50mg of rocuronium was administered. Face-mask
ventilation was lost and laryngoscopy was impossible due to complete oropharyngeal obstruction. Given
rapid dessaturation to SpO2 <20%, emergent cervical hematoma drainage with non-sterile scissors
available was performed. After this, adequate ventilation was archived followed by intubation without
difficulty. Patient was extubated 12h later in ICU without sequelae.This case is to alert anesthetists that
muscle relaxation can cause expansion of cervical hematoma precipitating one of the most feared
anesthetic emergencies.
MCC05
2:00 PM - 2:10 PM
Post-Induction Refractory Hypotension Due to ACE Inhibitors
Jia Wang, Laila Makary, M.D., Department of Anesthesiology and Pain Management, University of Texas
There are no guidelines for management of refractory hypotension due to ACE inhibitors in non-cardiac
surgery, and the literature is neutral regarding perioperative continuation of ACE inhibitors. Post-induction
refractory hypotension requiring continous pressor support prior to the start of an anticipated lengthy and
extensive procedure, such this presented case of an aortoiliac arterial reconstruction, can lead to
consideration of cancellation of an elective case to allow perioperative optimization for the rescheduled
procedure.
MCC05
2:00 PM - 2:10 PM
Cesarean Section for Eisenmenger's Syndrome With Severe Pulmonary Hypertension
Seri A. Carney, M.D., William J. Mauermann, M.D., Katherine W. Arendt, M.D., Mark M. Smith, M.D.,
Thomas M. Stewart, M.D., Anesthesiology, Mayo Clinic, Rochester, MN
A 38 year-old female with an intrauterine pregnancy and Eisenmenger's syndrome with severe pulmonary
hypertension, was delivered via cesarean section at 33 weeks gestation. General anesthesia was
induced. The anesthetic was tailored to optimize pulmonary blood flow. Immediately after delivery the
patient was given Cytotec and an Oxytocin infusion was started. Uterine tone was further improved by
switching from a volatile to an intravenous anesthetic. The case and postoperative course were
uneventful. Pulmonary hypertension in pregnancy carries a high rate of mortality, especially combined
with Eisenmenger’s syndrome. These women require extensive preoperative evaluation and perioperative
management by multidisciplinary services.
MCC05
2:00 PM - 2:10 PM
Delayed Discharge Due to Barium Masquerading as a Foreign Body
Ibrahim A. Warsame, M.D., Thanh Nguyen, D.O., Michael K. Essandoh, M.D., Thomas J. Papadimos,
M.D.,M.P.H., Anesthesiology, Surgical Critical Care, Cardiac Anesthesiology, Anesthesiology and
Critical Care Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
A 64 year-old male presented with right-sided axilla/shoulder pain radiating to his right lower chest/ right
upper quadrant and epigastrium three months after heart transplantation. Chest roentgenogram
demonstrated trace right pleural effusion and he was admitted. On hospital day 1 he reported resolution
of chest pain, but complained of "food not going down completely." A barium swallow confirmed
esophageal dysmotility and a computed tomography (CT) of the chest ruled out a pulmonary embolus.
However, the radiologist reported an “indwelling metallic device," on CT (figure 1) that was actually
barium masquerading as a foreign body thereby delaying discharge.
MCC05
2:00 PM - 2:10 PM
Ruling Out Esophageal Perforation Important Prior to Direct Laryngoscopy
Dimitry Voronov, M.D., Ramsis F. Ghaly, M.D., N. Nick Knezevic, M.D., Kenneth D. Candido, M.D.,
A 44 year-old professional sword-swallower presented to the ED with substernal chest and neck pain,
sustained while removing a sword from her mouth. CT imaging was suspicious for esophageal perforation
at the subglottic level. ENT surgery planned to take the patient to the OR for visualization of the injury
under anesthesia. Preoperatively, the anesthesia team conducted a multi-disciplinary discussion with the
cardiothoracic and trauma surgery services, and a less invasive gastrograffin study was ordered. The
gastrograffin study confirmed an esophageal perforation, and avoided a potentially more dangerous direct
laryngoscopy. The patient was transferred to high volume center for further management.
MCC05
2:00 PM - 2:10 PM
Transient Perioperative Vision Loss Following Craniectomy for Occipital Lobe Meningioma
Vishal Dhandha, M.D., Claude McFarlane, M.D., Anesthesiology, University of North Carolina School of
Medicine, Chapel Hill, NC
A 27 year-old female with right visual field defect presented for occipital meningioma resection. Her head
was secured with Mayfield frame in modified park bench position free of ocular compression. Furosemide,
mannitol and transient hyperventilation were administered for inadequate brain relaxation and 1.5% NaCl
infusion for hyponatremia was required. An acute 500 ml blood loss resulting in hypotension (MAP’s in
the 50s-60s) was treated with blood transfusion and transient vasopressor support. The remainder of the
case was uneventful and the patient was extubated in the OR. She was found to have bilateral vision
deficit on routine postoperative check.
MCC05
2:00 PM - 2:10 PM
Anesthetic and Surgical Considerations in a Patient With Renal Cell Carcinoma Needing Radical
Nephrectomy and Right Atrial/IVC Thrombectomy Due to Tumor Thrombus Extending from Right
Renal Vein to Right Atrium
Natalie Dean, M.D., Shane Gillespie, D.O., Anesthesiology, Mayo Clinic, Rochester, MN
A 69 year-old female presented with hematuria and flank pain. CT showed a right renal mass with tumor
thrombus extending from the right renal vein into the RA. She underwent radical nephrectomy and
thrombectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest. A central line and
PA catheter were placed as well as brachial and femoral arterial lines. The IVC and RA were opened and
the entire tumor was removed without evidence of adherence. The IVC and RA were repaired. CPB was
discontinued easily and RV function was maintained immediately post-operatively. Subsequent TTE
demonstrated new moderate RV dysfunction with moderate/severe TR.
MCC05
2:00 PM - 2:10 PM
Bilateral Lower Extremity Compartment Syndrome Requiring Above the Knee Amputations
Following Coronary Artery Bypass Grafting
Hooman Heravi, M.D., Bryan Romito, M.D., Department of Anesthesiology and Pain Management,
66 year-old male with PVD and CAD who underwent uncomplicated CABG. On POD #1 he reported RLE
pain unrelieved by opioid administration. Physical examination was consistent with acute compartment
syndrome, and he was taken immediately to the OR for RLE fasciotomy. On POD #2 he reported severe
LLE pain and his physical examination was again consistent with acute compartment syndrome
necessitating emergent LLE fasciotomy. Despite these interventions, 11 days later the patient required
bilateral AKAs for refractory vascular insufficiency. The etiology of his LE ischemia is believed to be nonpulsatile flow during CPB superimposed on severe baseline PVD.
MCC05
2:00 PM - 2:10 PM
An Exclusive Dopamine-Secreting Carotid Body Paraganglioma Associated With a Succinate
Dehydrogenase B (SDHB) Mutation
Emily R. Johnson, M.D., Anesthesiology, Mayo Clinic, Rochester, MN
A 46 year-old female presented with a neck mass, tachycardia, insomnia, hair loss, and abdominal pain.
Imaging revealed a 5.3 cm carotid body paraganglioma. Labs showed significantly elevated plasma
dopamine in the setting of normal metanephrines and normetanephrines. A V140F missense mutation of
the succinate dehydrogenase B (SDHB) gene was discovered. A 6.0 oral RAE ETT facilitated CN X
monitoring. Hemodynamic instability was managed with esmolol, nitroprusside, vasopressin, and
norepinephrine. Post-operatively, she suffered from right true vocal fold immobility and hypoglossal nerve
dysfunction. A right vocal fold injection was performed but dysphagia and dysarthria persisted,
necessitating feeding tube placement.
MCC05
2:00 PM - 2:10 PM
A Patient With ARVD and a Successful Epidural Anesthesia for Labor and Delivery: A Case Report
and Review of Literature
Cody Dickson, Geoffrey Wilson, M.D., Anesthesiology and Critical Care Medicine, Walter Reed National
Military Medical Center, Bethesda, MD
Arrhythmogenic right ventricular dysplasia (ARVD) is a heritable disease characterized by changes in
right ventricular cardiomyear-oldcytes leading to ventricular arrhythmias, congestive heart failure and
sudden cardiac death. We report the successful labor epidural and vaginal delivery in a 25 year-old
female with diagnosed ARVD. Pt presented at 41 weeks EGA for induction of labor with no anesthesia
evaluation prior to admission. We discuss the anesthetic concerns relating to pregnancy and ARVD, the
successful utilization of epidural analgesia for labor and delivery and review the literature regarding AVRD
and anesthetic management for routine labor and delivery.
MCC05
2:00 PM - 2:10 PM
An Infant Without a Diagnosis: Dandy Walker Syndrome, Hepatic Calcifications, and Seizure
Ajay Malhotra, M.D., Shridevi Pandeya Shah, M.D., Department of Anesthesia, Rutgers - New Jersey
Medical School, Jersey City, NJ
A 3-month-old 5 weeks premature baby presented for surgical repair of bilateral club feet. The patient’s
birth history was complicated by a Neonatal ICU stay for hypoglycemia and a Pediatric ICU admission at
5 weeks of life for seizure. The patient was medically stable on presentation, but had a possible diagnosis
of Dandy-Walker malformation and hepatic calicifications which were being worked up by Pediatrics.
Perioperatively, our concerns were regarding airway and anesthetic management. In this case report, we
describe our management regarding a potential anterior airway associated with Dandy-Walker and an
unknown metabolic syndrome which may have affected anesthetic technique.
MCC05
2:00 PM - 2:10 PM
Supraclavicular Block For Elective AV Fistula Placement As An Alternative To RSI In A Patient
With Delayed Gastric Emptying
Jessica Meister, J.D., Sylvia Dolinski, M.D., Ana Cox, M.D., Medical College of Wisconsin, Milwaukee, WI
A 59 year-old woman with ESRD, HTN, and CAD presented for placement of an elective AV fistula. She
consumed eggs at 5am the morning of surgery. Given her ESRD, there was concern for delayed gastric
emptying and theoretical full stomach even with delaying the procedure. Due to the patient’s social
complexities and difficulties with transportation, rescheduling was not feasible.Rapid sequence induction
would have likely necessitated an increased dose of propofol, thus increasing cardiac risk given the
patient’s history of CAD. Supraclavicular block without sedation was successfully utilized for placement of
her AV fistula, with no intra- or post-operative complications.
MCC05
2:00 PM - 2:10 PM
Anesthetic Considerations in a Parturient With Bacterial Endocarditis and Acute Mitral
Regurgitation on Anticoagulation
Shaan Sudhakaran, M.D., Mohammed Minhaj, M.D., Barbara Scavone, M.D., Department of
Anesthesiology and Critical Care, University of Chicago Hospital, Chicago, IL
A 36 year-old G3P0020 patient 29and3/7-wk EGA presented with streptococcus bovis endocarditis and
severe MR. Patient had prior history non-bacterial thrombotic endocarditis of mitral valve with embolic
stroke. Systemic antibiotics, blood culture surveillance, enoxaparin were initiated. Non-reassuring fetal
well-being necessitated cesarean. Patient preference and risk of airway failure/aspiration in pregnancy
favored neuraxial. There was concern for CNS infection in setting of bacteremia (Wedel-2006), spinal
hematoma while receiving enoxaparin (Horlocker-2010), and inability to mount tachycardic response to
maintain CO with severe MR (Chestnut-2014). Spinal anesthetic was administered 24-hr after
enoxaparin, 4-wk after antibiotics. Patient tolerated procedure well, with hemodynamic stability, no
infection/hematoma.
MCC05
2:00 PM - 2:10 PM
Use of Sequential Surgical and Pain Management Procedures Under One Sequentially Modified
Sedation Regimen to Safely Accommodate a Pediatric Patient’s Wishes for End of Life Care (or,
How To Do a Scary Case That No One Else Wants To Do)
Roland Brusseau, Boston Children's Hospital, Boston, MA
Our patient was a 13year-old male with metastatic end-stage Ewing’s Sarcoma of the right femur, leftsided pneumonia, right-sided paraneoplastic effusion, s/p radiation therapy to a mediastinal mass, and
bony involvement of mandibulo-maxillary area (mouth opening to <1cm). The patient was admitted for
dyspnea and refractory pain from soft tissue metastases in the lumbar region. The patient sought effusion
drainage and palliation of the lumbar mets with sclero- and cryear-oldtherapy in order “to go home.” The
interventional radiologist requests a prone general anesthetic. We explore anesthetic and procedural
options that balance safety, efficacy, and patient wishes surrounding end of life care.
MCC05
2:00 PM - 2:10 PM
Recognition and Management of Malignant Hyperthermia and its Post-Operative Complications
Vicky I. Liu, M.D., Douglas Schechter, M.D., Alexander Nacht, M.D., Anesthesiology, Bellevue Hospital,
New York, NY
This was a case of a 37 year-old male with no significant past medical history, prior surgery, or family
history of anesthestic complications for emergent laparoscopic surgery for acute appendicitis. Shortly,
after rapid sequence induction with succinylcholine followed by maintenance on inhalation anesthetic,
patient presented with signs of malignant hyperthermia (MH). Prompt treatment for MH ensued which
stabilized the patient’s hemodynamics and electrolyte disturbances. Yet, the patient developed
complications such as acute kidney injury and stroke in the post-operative period. This case
demonstrates that treatment of MH extends Beyond the intraoperative phase.
MCC05
2:10 PM - 2:20 PM
Perioperative Management of Carcinoid Syndrome, Involving Intravenous Octreotide Infusion, a
Case Report
Melissa J. Seelbach, M.D.,Ph.D., Robert McLennan, M.D., Dinesh Ramaiah, M.D., Anesthesiology,
University of Kentucky, Lexington, KY
A 41 year-old male (114 Kg) with known metastatic midgut carcinoid tumor, arrived for tumor resection
following 3 months of outpatient subcutaneous octreotide therapy. In pre-operative holding, patient was
symptomatic for active carcinoid syndrome with facial and chest flushing. Prophylactic antihistamines,
steroids administered and octreotide drip started. Anesthetic triggers of tumor secretion avoided. Surgical
manipulation of tumor during resection was associated with wide swings in blood pressures and
worsening cutaneous flushing. Symptoms improved with octreotide drip titration, fluid, and appropriate
blood pressure medication bolus. Hemodynamics further stabilized upon tumor excision and surgery
continued uneventfully with normal recovery.
MCC05
2:10 PM - 2:20 PM
Alternative to Regional and Endotracheal Intubation in a Patient With Poor Respiratory Mechanics
Ana C. Costa, M.D., Sherwin Park, M.D., Anesthesiology, Stony Brook School of Medicine, New York, NY
29 year-old man for cystoscopy, ureteral stent, and renal stone manipulation. PMH significant for
malignant hyperthermia as an infant leading to cardiac arrest, Duchene’s muscular dystrophy, bleeding
disorder, cardiomyear-oldpathy with EF 25% s/p AICD, poor respiratory effort on positive pressure
ventilator 24 hours/day, multiple pneumonias, respiratory failure requiring mechanical
ventilation/tracheostomy s/p decannulation. PE: AandO x3, bed-bound, MP 3, limited ROM, decreased
BS bilaterally, ventilator-dependent, contracted extremities. Vaporizers and succinylcholine removed from
OR, MH cart and Dantrolene readily available. PIV placed, patient’s own ventilator brought to OR,
Dexmedetomidine and Remifentanil infusions titrated slowly. Patient remained stable throughout
intraoperative course.
MCC05
2:10 PM - 2:20 PM
Takotsubo Cardiomyopathy Unmasked in a Patient Undergoing Left Upper Lobe Resection
Gurleen Sidhu, M.D., Charles Fox, III, M.D., Sailesh Arulkumar, M.D., Anesthesia, LSU Health Sciences
Ctr, Shreveport, LA
Broken-heart-syndrome is a non-ischemic cardiomyear-oldpathy, also referred to as Takotsubo
Cardiomyear-oldpathy (TC). Defined as heart failure, triggered by emotional or physical stress. It
manifests with weakness of the muscular portion of the heart, leading to ballooning of the apex. We
present a middle-aged woman with LUL-Adenocarcinoma who was anesthetized for resection. Her
intraoperative course included what we thought to be an acute MI and a resulting cardiac arrest, but after
emergent coronary angiography the diagnosis of TC was made. We believe the emotional/physical
contributor in this patient to be lung cancer, which lead to a catecholamine surge and coronary
vasospasm.
MCC05
2:10 PM - 2:20 PM
Non-surgical Bleeding With Normal Thromboelastogram in a Severe Blunt Trauma Case: What is
Going On?
Kathryn Iwata, Corey Scher, M.D., New York University School of Medicine, New York, NY,
Anesthesiology, New York University Langone Medical Center, New York, NY
Struck by a car, 29 year-old man sustained multiple pelvic fractures. He was alert with a normal
neurological exam and intubated for hemodynamic instability. Angiography showed multiple bleeding
sites. Iliac vessels were embolized, followed by a damage control laparotomy. Surgical bleeding was
controlled, but no clot was visualized. At the 20 minute mark, thromboelastography (TEG) demonstrated
normal clotting. Blood tests, sent at the start of TEG, revealed D-dimers, indicating fibrinolysis. Consistent
with the CRASH trial, TEG was misleading. Fibrinolysis, which TEG eventually demonstrated, was poorly
controlled. TEG delayed antifibrinolytic therapy and led us to administer more blood products.
MCC05
2:10 PM - 2:20 PM
Emergent Intubation in a Patient With Osteogenesis Imperfecta and Recent Complete Spinal Cord
Transection During Transport From CT
Hannah Hsieh, M.D., Carolina Echevarria, M.D., Richard Sommer, M.D., NYU, New York, NY
58 year-old female with osteogenesis imperfecta who suffered a fall with resultant left femoral and iliac
wing fracture. While being transferred from CT scanner, she felt a crack in her back and experienced
sudden loss of motor and sensation to both legs. Was found to have T12 spinal fracture dislocation with
large hematoma and complete spinal cord transection. Patient became lethargic and required emergent
sedated fiberoptic intubation prior to T7-L5 fusion, complicated by right pleural tear. Hospital course
complicated by need for emergent awake fiberoptic intubation, pneumonia and severe pain. Patient was
ultimately transferred to a rehabilitation facility.
MCC05
2:10 PM - 2:20 PM
No Airway, No Central Access: Venous Air Embolism in Awake Deep Brain Stimulation Surgery
Anuj K. Aggarwal, M.D., Boris Heifets, M.D.,Ph.D., Richard Jaffe, M.D.,Ph.D., Department of
Anesthesiology, Perioperative, and Pain Medicine, Stanford, Stanford, CA
A 57 year-old female was admitted for MRI-guided placement of deep brain stimulators for Parkinson’s
disease. The patient was brought to the operating room and pinned in a semi-seated position secondary
to the patient’s dystonia and kyphosis. During the procedure, the patient began to cough with change in
precordial doppler tone, hypoxemia and development of wide complex ventricular tachycardia with
subsequent evidence of myear-oldcardial ischemia. Secondary to continued hypoxemia despite
supplemental oxygen, the patient required emergent intubation and was managed with supportive
measures. At the end of the case, the patient was extubated and transferred to the ICU.
MCC05
2:10 PM - 2:20 PM
Anesthetic Management of Adults Undergoing Repair of Anomalous Left Coronary Artery
Emanating from the Pulmonary Artery (ALCAPA)
Paul J. Hoffmann, D.O., B Mathew Kattapuram, M.D., Chris Andrews, M.D., Ammar S. Bafi, M.D.,
Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, Anesthesiology, Medstar
Washington Hospital Center, Washington, DC
A 44-year-old male presented to his primary care physician with gradually decreased exercise tolerance.
Workup revealed anomalous left coronary artery emanating from the pulmonary artery (ALCAPA), a rare
congenital heart defect. He underwent cardiopulmonary bypass for excision of his left coronary artery off
of the pulmonary artery and reimplantation onto the aorta. While this defect is known to the pediatric
literature, very few instances exist in adults presenting with this condition. We discuss the anesthetic
management of adult patients presenting with this rare congenital heart defect.
MCC05
2:10 PM - 2:20 PM
Dexmedetomidine for the Treatment of Paroxysmal Sympathetic Hyperactivity Refractory to
Standard Therapy
Robert C. Call, M.D., Yosef Ahmed, Thuy Lin, Nicki Tarant, Anesthesiology, Naval Medical Center
Portsmouth, Portsmouth, VA, Feinberg School of Medicine, Northwestern University, Chicago, IL
Paroxysmal sympathetic hyperactivity (PSH) is a rare but life-threatening constellation of symptoms
associated with various cerebral insults including traumatic brain injury, hydrocephalus, brain tumors,
subarachnoid hemorrhage, and intracerebral hemorrhage. We present a unique case of a 36 year-old
female who underwent craniotomy for partial resection of a grade 4 glioblastoma multiform thalamic mass
and subsequently developed diagnostic criteria for PSH. Symptomatic management was accomplished
for several days using dexmedetomidine following inadequate response to standard therapies. Given its
hemodynamic profile and pharmacodynamics, dexmedetomidine warrants further clinical investigation as
consideration as a first line therapy for symptomatic control of PSH.
MCC05
2:10 PM - 2:20 PM
General Anesthesia for a Myasthenia Gravis Patient Who Had a Prolonged Intubation 13 Years
Prior
Brian D. Terrien, Heather Martin, Eugenio Lujan, M.D., Eric Bopp, Anesthesia, Naval Medical Center San
Diego, San Diego, CA
The patient is a 77 year-old female with a history of myasthenia gravis, hypertension and osteoarthritis
who underwent an uncomplicated general anesthetic for a right total hip arthroplasty. Thirteen years prior,
she had left hip surgery with neuraxial anesthesia complicated by respiratory failure due to Guillan-Barre
syndrome requiring treatment with IVIG, plasmapheresis, prednisone, pyridostigmine, azathioprine and
required six months of ventilator support. For this case she requested general anesthesia and was
extubated in the operating room and discharged from the intensive care unit on postoperative day one.
This case report reviews the epidemiology, pathophysiology, and anesthetic implications of MG.
MCC05
2:10 PM - 2:20 PM
Epidural Placement for Cesarean Section in a Patient With Congenital Arthrogryposis
Thomas R. Pfeiffer, M.D., Anesthesiology, New York-Presbyterian Hospital, Columbia University Medical
This is a description of the challenges of providing anesthesia for a patient with arthrogryposis for
cesarean section. Her medical history is complicated by a T3-12 spinal arterio-venous malformation and
restrictive lung disease with carbon dioxide retention requiring BiPAP. We were able to successfully place
an epidural catheter with much difficulty and avoided general anesthesia in a patient where airway
management would be fraught with significant morbidity. Strategy of epidural placement, choice of
medication and dosing, airway management, and postoperative pain control were extremely challenging
and our approach will be outlined for further discussion.
MCC05
2:10 PM - 2:20 PM
Mitral Valve Replacement in an Infant With Geleophysic Dysplasia
Allen Friedman, M.D., Caleb Ing, M.D., Anesthesiology, New York Presbyterian- Columbia University,
New York, NY
A 9 month-old 5.2kg girl with geleophysic dysplasia, a rare disorder associated with cardiac valvular
lesions and tracheal narrowing, is found to have respiratory distress secondary to worsening mitral
stenosis and is subsequently scheduled for mitral valve replacement. Once in the OR, the infant proved to
be a difficult intubation requiring multiple attempts at direct laryngoscopy due to an inability to advance an
appropriately sized endotracheal tube (ETT) with a cuff leak. She was ultimately intubated with an
uncuffed ETT though a cuff leak was absent, demonstrating that our patient had severe tracheal stenosis
not previously diagnosed.
MCC05
2:10 PM - 2:20 PM
Ultrasound-guided Brachial Plexus Anesthesia in a Patient With Severely Affected Dystrophic
Form of Epidermolysis Bullosa Hereditary
Chiharu Takikawa, M.D., ChiYo Ootaki, M.D., Haruka Hashimoto, M.D., Anesthesiology and Intensive
Care, Osaka University Graduate School of Medicine, Suita, Japan
A 12 year-old female, known as EBH since birth presented for left hand syndactyly release. Preoperative
findings included generalized scars, pustules, and joint contractures (Figure 1). Airway assessment
revealed limited opening of the mouth secondary to the scar and loose pustules on oral mucosa. Patient
could not brash teeth due to blister formation, which expected intubation could be a cause of blister
formation. We obtained a intravenous line without a tourniquet, and we applied ultrasound guided axially
block (1% xylocaine and 0.375% ropivacaine)with ketamine and dexmedetomidine for sedation. Patient
tolerated well for surgery. The axially bock well covered postoperative analgesia.
MCC05
2:10 PM - 2:20 PM
Are Pain and Gain Really Equivalent? Unique Challenges Controlling Pain During Labor in a
Parturient With Multiple Sclerosis, Fibromyalgia, Atrial Fibrillation on Anticoagulation, and a Local
Anesthetic Allergy
David K. Monaghan, M.D., Pankaj Jain, M.D., Arthur Calimaran, M.D., University of Mississippi Medical
Center, Jackson, MS
28 year-old, G3P0020, at 37 weeks gestation for induction of labor with past medical history of multiple
sclerosis, chronic hypertension, seizure disorder, TIA, Afib on rivaroxaban prior to admission,
fibromyalgia, and history of DVT. Intra-dermal injection was positive for allergy to amide local anesthetics.
Regional anesthesia was avoided due to recent anticoagulation and local anesthetic allergy. Remifentanyl
PCA and dexmedetomidine infusion were theorized for labor analgesia but were unable to be used
because of nursing unfamiliarity. Patient received Fentanyl PCA for labor, however, due to intolerable
pain, the patient decided to have an elective c-section under GETA.
MCC05
2:10 PM - 2:20 PM
Suspected Mitochondrial Cytopathy in an Infant: An Anesthetic Challenge
Sonia D. Duarte, Angela Mota, Alexandra Saraiva, Marta Araújo, Marta Carvalho, Filipa Pereira, Manuela
Ramos, Pedro Pina, Centro Hospitalar do Porto, Porto, Portugal
Hypotonic diseases present as a challenge after birth, mitochondrial cytopathies should be
considered.Eight-month-old male, dysmorphic syndrome, delayed growth, respiratory insufficiency
requiring non-invasive ventilation, with suspected metabolic disease. Admitted for glaucoma study.
Submitted to evaluation of eye pressure under general balanced anesthesia, propofol induction,
maintenance with sevoflurane; difficult intubation with macroglossia and anterior glottis (grade 2
laryngoscopy with BURP), glottis edema. Procedure uneventful. Postoperative in ICU for
surveillance.New evaluation at 11 months, due to difficult airway history the team decided to proceed with
a propofol sedation, no airway manipulation and maintenance of spontaneous ventilation, anesthesia and
procedure successfully accomplished.
MCC05
2:10 PM - 2:20 PM
Severe Pulmonary Hypertension: A Multidisciplinary Approach Can Make a Difference
Vânia Ferreira, M.D., Catarina Marques, Carina Gouveia, Leina Spencer, Ana Agapito, Rita Poeira,
Centro Hospitalar Lisboa Central, EPE, Lisboa, Portugal
A 42 year-old man with a medical history of severe chronic thromboembolic pulmonary hypertension
(pulmonary artery systolic pressure 81 mmHg) and heart failure (NYHA/WHO functional class 3),
medicated with a pulmonary vasodilator and anticoagulant therapy.He was submitted to a total hip
arthroplasty under balanced general anesthesia.Before GA induction with IV etomidate and fentanyl we
started to administer dopamine. During the intraoperative period occurred hypotension with necessity of
treatment with norepinephrine and dobutamine, in close cooperation with cardiologists.He was admitted
to the intensive care unit, where the vasopressor infusion was incrementally decreased and stopped after
48h.
MCC05
2:20 PM - 2:30 PM
The Synergistic Effects of Partial Pseudocholinesterase Deficiency and Impaired Liver Function
Justin Yao-Lun Tsai, M.D., Jason Wells, M.D., Ihsan Asbahi, M.D., Ashraf Farag, M.D., Department of
Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX
A 46 year-old male with alcohol related liver disease, malnutrition, and cholelithiasis with
choledocholithiasis presented for endoscopic retrograde cholangiopancreatography. The patient was
induced with fentanyl, propofol, and succinylcholine, and was intubated. He was maintained with
desflurane, without additional paralytics. Post-procedure, the patient had prolonged paralysis, requiring 4
additional hours of ventilator support. Serial labs returned critically low levels of serum cholinesterase
activity. Subsequent investigation revealed that the patient received succinylcholine during previous
surgeries in the distant past without incident. We hypothesize that the synergistic effects of underlying
heterozygous pseudocholinesterase deficiency and interval deterioration of hepatic function caused
prolonged paralysis.
MCC05
2:20 PM - 2:30 PM
Postextubation Obstructive Fibrinous Tracheal Pseudomembrane in a Patient With Hypertrophic
Obstructive Cardiomyopathy
Katerina Reznikova, M.D., Robert S. White, M.D., Matthew T. Murrell, M.D., Anesthesiology, Weill Cornell
Medical College, New York, NY
A 45 year-old male with hypertrophic obstructive cardiomyear-oldpathy s/p septal myear-oldmectomy and
MVR POD 9 presented with acute dyspnea and biphasic stridor. Patient was brought to the operating
room for flexible and rigid bronchoscopy with jet ventilation. This revealed an inflamed, erythemtous
trachea with severe subglottic narrowing and pseudomembranous tissue that dynamically obstructed the
glottic space with respirophasic variation. Rigid electrocautery and psuedomembrane removal from
trachea was performed. Patient’s respiratory status subsequently improved. Diagnosis was made as
obstructive fibrinous tracheal pseudomembrane, a rare condition that causes sudden upper airway
obstruction post-extubation and can present as stridor with respiratory insufficiency.
MCC05
2:20 PM - 2:30 PM
Transesophageal Echocardiography Useful in Detecting Cardiac Tamponade Post Coronary
Artery Bypass Graft
Dimitry Voronov, M.D., Ramsis F. Ghaly, M.D., N. Nick Knezevic, M.D., Kenneth D. Candido, M.D.,
A 79 year-old patient became hypotensive after conclusion of a triple-vessel CABG. The surgery course
was uneventful; the sternotomy was closed and the surgeon had left the OR. Shortly after, the
anesthesiologist noticed a gradual decrease in the patient’s blood pressure. Attempts to correct the blood
pressure with dobutamine and norepinephrine infusions were unsuccessful. Given a high suspicion of
cardiac insult, anesthesia performed a TEE, which detected a cardiac tamponade. The surgeon reopened
the chest, and 800 ml of clotted blood was removed from the pericardial sac - hemodynamic status
immediately improved. Bleeding was determined to originate from a leaking anastomosis.
MCC05
2:20 PM - 2:30 PM
A Case of Prolonged QTc syndrome With Post-operative Ventricular Tachycardia
Gong Wong Lee, M.D., Anesthesia, Methodist Dallas Medical Center, Dallas, TX
A 32 year-old female suffered an ulnar fracture from a MVA and brought to OR for ORIF. Her preoperative evaluation was negative except a history of hypothyroidism on Synthroid. She was induced and
maintained on GETA without complications. In PACU, She started experiencing frequent PVCs that
transitioned to sustained ventricular tachycardia (torsades de pointes) with loss of consciousness. CPR
was started and consciousness regained with normal sinus rhythm. 2 grams of Magnesium Sulfate was
given. A cardiology consult was obtained and the echocardiogram was normal. EKG showed a QT
interval of 521 ms. A prolonged QTc syndrome was diagnosed.
MCC05
2:20 PM - 2:30 PM
Christmas Lights and Hypoxemia
Mary L. Jarzebowski, M.D., Arvind Rajagopal, M.D., Department of Anesthesiology, Rush University
Our patient is an 83 year-old male with no significant pastmedical history who presented to the ER with a
left femoral neck fracture afterfalling from a ladder while putting up Christmas lights. He was taken to the
ORfor femoral neck pinning. Spinal anesthesia was attempted, but not successfulgiven extreme pain with
positioning. General anesthesia was induced and asupraglottic airway device was placed. Despite
oxygen saturations of 100% priorto induction, he became progressively more hypoxemic, with an A-a
gradient of330mmHg despite hemodynamic stability. Post-operative CT of the chest showed likely
scattered fat emboli.
MCC05
2:20 PM - 2:30 PM
Posterior Fossa Craniotomy for Removal of Brainstem Glioma in Gravid Patient at 26 Weeks
Gestation With Factor V Leiden and a Patent Foramen Ovale
Jacqueline A.M. Curbelo, D.O., Roger Marks, M.D., Department of Anesthesiology, Perioperative
Medicine and Pain Management, University of Miami / Jackson Memorial Hospital, Miami, FL
An IVC filter was placed prior to surgery due to Factor V Leiden. OB consented patient for intraoperative
monitoring of fetal tones and stat cesarean delivery if nonreassuring. Anesthetic management included
RSI of the parturient, an arterial line, and a central line due to history of PFO. TIVA was administered due
to intraoperative neurophysiological monitoring (BSEP, MEP, SSEP). A precordial Doppler was utilized for
diagnosis of air embolism. Neurosurgery placed a lumbar CSF drain. Patient positioning was modified
from sitting to left lateral to accommodate the gravid uterus and to prevent venous air embolism in the
setting of the PFO.
MCC05
2:20 PM - 2:30 PM
Acute Onset of Myear-oldcardial Ischemia During Ablation of Atrial Fibrillation
Tina W. Law, D.O., Laura Shahnazarian, M.D., Giuseppe Trunfio, M.D., Anesthesiology, Maimonides
A 59 year-old male with persistent atrial fibrillation refractory to medical therapy and repeated
cardioversions presented for a Convergent Atrial Fibrillation Ablation procedure. As the surgeon
attempted to dissect the subxiphoid space in order to obtain the pneumopericardium necessary for the
procedure, sudden and very pronounced ST elevations in the inferior leads were noted on the EKG.
While TEE interrogation did not manifest any new segmental wall motion abnormalities, persistent
hemodynamic instability warranted a mediastinal exploration via a median sternotomy, which revealed an
injury to a branch of the right coronary artery.
MCC05
2:20 PM - 2:30 PM
When All Treatments Fail: A Case of Chronic Aspergillosis and Multi-Drug Resistant
Pseudomonas Pneumonia
Joshua Finkel, M.D., Khaldoun Faris, M.D., Anesthesiology and Critical Care Medicine, University of
Massachusetts Medical School, Worcester, MA
An elderly male with severe COPD and chronic aspergillosis presented with septic shock and acute
respiratory failure requiring intubation. The patient was diagnosed with pseudomonas pneumonia and had
bi-apical cavities with air fluid levels on CT scan. Cultures obtained from IR drainage of the right apical
cavity were positive for multi-drug resistant pseudomonas, which had only intermediate sensitivity to
colistin. A tracheostomy was placed for recurrent respiratory failure and the patient repeatedly failed
ventilator weaning trials due to copious airway secretions. After frequent complicated family meetings, the
patient was eventually made CMO due to lack of viable treatment options.
MCC05
2:20 PM - 2:30 PM
Fragile: Do Not Intubate!
Sónia Duarte, M.D., Helena D. Figueira, M.D., Patricia Ramos, M.D., Jacinta Sá, M.D., Fátima Cruz,
M.D., Fátima Martins, M.D., Department of Anaesthesiology, Centro Hospitalar do Porto, Porto, Portugal
The management of difficult airway continues to be a challenge. Male, 60 years-old, respiratory failure
due to infiltrative supraglotic, glotic and infraglotic larynx lesion with cricoid, thyroid and trachea invasion.
Smaller airway internal diameter 4mm. Proposed for urgent surgical tracheostomy and biopsy. Proceeded
under local anesthesia and sedation due to be highly risky to intubate. Complicated with abundant
bleeding, difficulty to find tracheal references, progressive desaturation (SatO2 50%). Emergent tracheal
intubation through the incision (8.0 endotracheal tube), secretions and blood aspiration. Insertion of a
number 10 tracheostomy cannula followed by respiratory distress due to bilateral pneumothorax. Chest
tubes uneventfully inserted.
MCC05
2:20 PM - 2:30 PM
Managing a Parturient With DiGeorge Syndrome and Thrombocytopenia for Caesarian Section
Jerry Tee Todd, M.D., Dawn Manning-Williams, M.D., Emory University, Grady Memorial Hospital,
Atlanta, GA
A 17 year-old G1P0 parturient at 40w1d of gestation presentedfor induction of labor. She had a history of
DiGeorge syndrome, cleft palaterepair, asthma, and obstructive sleep apnea. Her BMI was 43.3 on
admission, andplatelet count on admission was 67,000. Labor arrested due to cephalopelvicdisproportion,
and a caesarian section was planned. General anesthesia was chosendue to thrombocytopenia.
Otolaryngology was at the bedside in casecricothyrotomy was needed. A video laryngoscope was used to
obtain a grade 1 view ofthe vocal cords, and the patient was easily intubated with a 6.5 mm
oralendotracheal tube.
MCC05
2:20 PM - 2:30 PM
Blissful Ignorance? The Medical Ethical Considerations of a Pediatric Jehovah's Witness Patient
Undergoing Corrective Surgery for Severe Scoliosis-Kyphosis
Dorothea Kadarian, D.O., Alecia L. S. Stein, M.D., Kimberly Kimmel, M.D., Anesthesiology, Nicklaus
Children's Hospital/Miami Children's Health System, Miami, FL
A 17 year-old Jehovah’s Witness male presented for multi-level posterior spinal instrumentation and
laminectomy due to extremely severe congenital scoliosis and kyphosis. Newly from Cuba, the patient
presented severely symptomatic with demonstrated myelopathy and restrictive pulmonary disease. The
case was further complicated by significant transfusion restrictions for religious reasons. Surgery for such
advanced disease carried significant risk of hemorrhage requiring transfusion. The anesthetic goal was to
maintain sufficient spinal perfusion; where the alternative, risks cord ischemia and paralysis. Careful
family discussion, anesthetic planning and management was required aiming to minimize transfusion
balanced with prevention of permanent cord damage.
MCC05
2:20 PM - 2:30 PM
Pre-operative Regional Technique Changes Surgical Management
Christopher R. Jackson, M.D., Derek Woodrum, M.D., Anesthesiology, University of Michigan, Ann Arbor,
MI
A 51 year-old male with ESRD was scheduled for a brachiobasilic fistula as the first stage of a basilic vein
transposition. An ultrasound performed in the surgical clinic showed insufficient caliber of veins for either
a radiocephalic or a brachiocephalic fistula. After a brachial plexus block was performed on the day of
surgery, repeat ultrasound showed that the resulting sympathectomy produced sufficient venodilation
throughout the upper extremity for choice of any of the three fistulas listed above. A brachiocephalic
fistula was then chosen by the surgeon, which avoided a two-stage basilic vein transposition.
MCC05
2:20 PM - 2:30 PM
Double Trouble: Anesthetic Considerations for Labor and Cesarean Section in a Morbidly Obese
Parturient With Difficult Airway, Increased Aspiration Risk, and Low Platelets
David K. Monaghan, M.D., Arthur Calimaran, M.D., Natesan Manimekalai, M.D., University of Mississippi
Medical Center, Jackson, MS
45 year-old, G2P0010, at 37 week gestation admitted for induction of labor due to multiple co-morbidities
with past medical history of chronic hypertension, asthma, diabetes mellitus, gastroparesis, polycystic
ovarian syndrome, low platelets (60,000), morbid obesity, cervical spinal fusion and difficult airway.
Epidural analgesia was avoided due to thrombocytopenia. Remifentanyl PCA and precedex infusion were
unable to be used due to nursing staff unfamiliarity. Fentanyl PCA was used for 24 hours for labor
analgesia, however, we proceeded with cesarean section for failure to progress under spinal, after
platelet transfusion was given due to concern of surgical bleeding, with good outcome.
MCC05
2:20 PM - 2:30 PM
Airway and Anesthetic Management of Several Children With Mobius Syndrome
Yvon F. Bryan, M.D., Jorge Barrios, M.D., Anesthesiology, Wake Forest School of Medicine, Winston
Salem, NC, Anesthesiology, AACD, Sao Paolo, Brazil
Several pediatric patients with Mobius syndrome will be presented and a description of the challenges
involved in the airway and anesthetic management will be discussed.The different cases had common
elements regarding difficulties encountered by experienced anesthesiologists and the need for
improvisation and use of alternative airway devices and techniques to secure the airway. One child had a
failed intubation and case cancellation and later required flexible fiberoptic bronchoscopy (FFB) using
sedation and topical anesthesia. Another child required a tracheostomy as the primary airway technique.
These cases demonstrate the range of alternative techniques needed in these children.
MCC05
2:20 PM - 2:30 PM
Anesthesia Specifics and Complications of Extreme Trendelenburg Position Focus: Robotic
Assisted Laparoscopic Prostatectomy
Priscilla D. Clark, M.D., Jerome F. O'Hara, M.D., Anesthesiology Institute, Cleveland Clinic Foundation,
Cleveland, OH
A 55 year-old male with no significant past medical history except +PSA and prostate tumor, is
undergoing a robotic assisted laparoscopic prostatectomy under general anesthesia with 2 IVs. There
was no difficulty encountered with induction and intubation. There were expected hemodynamic changes
observed with the creation of pneumoperitoneum and trendelenberg positioning. During dorsal venous
resection there was significant hypotension. CO2 insufflation was held and the blood pressure was
restored. Hypotension reoccurred with continued CO2 insufflation. There was no appreciable change in
ETCO2. It was determined that subclinical CO2 embolism was the most likely cause. The patient was
treated accordingly.
MCC05
2:30 PM - 2:40 PM
Successful ACLS Resuscitation of Intra-operative Cardiovascular Collapse in a Patient With
Severe Aortic Stenosis Aided by a Novel TEE Approach
Charles Weston Whitten, M.D., Justin Traunero, M.D., Wake Forest Baptist Medical Center, Winston
Salem, NC
LB was a 57 year-old female who underwent laryngopharyngectomy and free flap for laryngeal SCC.
Medical history included severe aortic stenosis (AVA: 0.58), CAD, SVC stenosis, and severe COPD. Four
hours into surgery, she suffered cardiovascular collapse, prompting ACLS. Despite severe AS, chest
compressions were effective with pulsatile waveform on arterial line tracing and pulse oximetry. ACLS
was further guided by a TEE probe that was passed through the surgical field into the exposed
esophageal stump. Despite 24 minutes of asystole, ROSC was obtained, the surgery completed, and the
patient was extubated in the PACU with completely intact neurological function.
MCC05
2:30 PM - 2:40 PM
Inadvertent Loss of End Tidal CO2 and Tidal Volumes
Miss Hina, M.D., Maninder Singh, M.D., Anesthesia, Case Western Reserve University (MetroHealth
Medical Center), Cleveland, OH
Nasogastric tube (NGT) placement for gastrointestinal decompression is a common procedure for most
abdominalsurgeries. We report a case of inadvertent loss of end tidal carbon dioxide (ETCO2), low
delivered tidal volumes and persistent air leak causing ventilator failure due to inadvertent endobronchial
misplacement of NGT in a patient who received general anesthesia with endotracheal tube for a
laparoscopic appendectomy. A major discrepancy b/w the delivered tidal volume and exhaled tidal
volume with loss of ETCO2 in a mechanically ventilated patient requires urgent evaluation and early
recognition to prevent life threatening hypoventilation and complications related to misplaced NGT.
MCC05
2:30 PM - 2:40 PM
Lateral Thinking: How a Failure of Right Upper Lobe Isolation Lead to Emergent Cardiopulmonary
Bypass in the Left Lateral Position
Bryan E. Marchant, M.D., Ben Morris, M.D., Department of Anesthesiology, Wake Forest University
Baptist Medical Center, Winston Salem, NC, Department of Anesthesiology, Wake Forest University
Baptist Medical Center, Winston-Salem, NC
Bronchial blockers have been described as being equally efficacious at lung isolation when compared to
double lumen endotracheal tubes. We describe a case in which a bronchial blocker proved to be suboptimal for right upper lobe isolation when used after difficult airway anatomy prevented passage of a
double lumen tube. Subsequent loss of isolation lead to decreased surgical visibility potentially
contributing to a pulmonary artery injury. Ultimately, emergent femoral AV cannulation and initiation of
cardiopulmonary bypass while in the lateral position was necessary for pulmonary artery repair.
MCC05
2:30 PM - 2:40 PM
Delirium and Decompensation
Allison M. Janda, Liza Weavind, M.B.,B.Ch., Department of Anesthesiology, Vanderbilt University Medical
61 year-old male with atrial fibrillation, CAD, and right lower lobe lung adenocarcinoma underwent right
lower lobe wedge resection and left VATS with atrial appendage resection. His delirium was persistent
with multiple agents so three nights of dexmedetomidine infusions were attempted, and transitioned to
quetiapine and haloperidol with improvement. After floor transfer on POD 19, he became somnolent and
had a PEA arrest with ROSC after 35 minutes of ACLS with subsequent cardiovascular deterioration,
acidosis, and hypotension. Care was withdrawn. Autopsy showed a pericardial fibrinous exudate without
clear cause of death. Differential diagnosis includes pericarditis, pericardial effusion, and antipsychoticinduced arrhythmia.
MCC05
2:30 PM - 2:40 PM
Severe Intra-operative Hyperkalemia During Renal Transplantation
A 44 year-old male with end stage renal disease (not on renalreplacement therapy) presented for living
related kidney transplant. Pre-operativepotassium was 5.1. Following induction of anesthesia and
paralysis withcisatracurium, acute peaked t-waves were noted on EKG. His serum potassium was7.4
mEq. Despite aggressive treatment with insulin, dextrose, calcium, sodiumbicarbonate and
hyperventilation, repeat potassium was 7.7 meq. Further measures were considered to control
hyperkalemia with possibleintraoperative hemodialysis or aborting donor nephrectomy.
Continuedaggressive treatment measures finally improved serum potassium levels andtransplant
progressed without incident. No etiology could be obtained forhyperkalemia.
MCC05
2:30 PM - 2:40 PM
Anesthetic Considerations for Non Syndromic Supravalvular Aortic Stenosis
Laura A. Shahnazarian, M.D., Tina Law, D.O., Giuseppe Trunfio, M.D., Anesthesiology, Maimonides
A 41 year-old male with no significant medical history or known genetic anomalies, presented with an
unremarkable aortic root but with a stenotic, tubular ascending aorta (1cm diameter and 3.8 cm length) by
MRI and TEE. The surgical repair consisted of replacement of the ascending aorta with a tube graft with
coronary reimplantation. Anesthetic management required invasive monitoring, deep hypothermic
circulatory arrest with cerebral oximetry. Post-repair 3D TEE images were used to evaluate the repair.
Postoperative course was complicated by the formation of a large clot in the left atrium, but recovery was
otherwise uneventful.
MCC05
2:30 PM - 2:40 PM
Intraoperative Cardiac Arrest As a Result of Anaphylactic Shock Caused by Gelatin
Weiyun Chen, M.D., Department of Anesthesiology, Peking Union Medical College Hospital, Beijing,
China.
A 53 year-old male diagnosed as gastric cancer underwent laparoscopic gastrectomy under general
anesthesia. His medical history was uneventful except for lamb allergy. A sudden EtCO2 drop was
observed followed by cardia arrest intraoperatively during succinylated gelatin infusion. Anaphylactic
shock was suspected but pulmonary embolism (PE) could not be ruled out. Transesophageal
echocardiography (TEE) was performed and there was no evidence of PE. The patient had a full recovery
after successful resuscitation. Serological workup afterwards showed strong positive results for galactosealpha-1,3-galactose (alpha-Gal), indicating succinylated gelatin was the allergen, as alpha -Gal could be
the target of reactivity to gelatin.
MCC05
2:30 PM - 2:40 PM
Anesthetic Management of a Patient With a Massive Goiter
Khalid W. Khayr, B.S., Richard E. Galgon, M.D., M.S., University of Wisconsin School of Medicine and
Public Health, Madison, WI
A 57 year-old woman with a massive goiter (12.8 x 6.6 x 7.7cm), hyperthyroidism, and shortness of
breath presented for a total thyroidectomy. Co-morbidities included diabetes mellitus and chronic heart
failure (EF = 30%) with diastolic dysfunction due to her longstanding hyperthyroidism. Anesthetic
management was challenged by airway compression (5 mm) at the thoracic inlet and heart failure.
Successful anesthetic management included pre-induction arterial cannulation, fiberoptic nasotracheal
intubation under CPAP, and transesophageal echocardiography. Safe home discharge occurred on postoperative day two after an uncomplicated procedure.
MCC05
2:30 PM - 2:40 PM
Maintaining Hemodynamic Stability During Post-partum Hemorrhage Treatment in a Marfan's
Parturient
Sailesh Arulkumar, Sudipita Sen, M.D., Gurleen Sidhu, M.D., Anesthesiology, LSUHSC Shreveport,
Shreveport, LA
Marfan syndrome is the leading cause of aortic dissection in parturient, with the risk of aortic dissection
reporting to be five times great than that seen during the non-pregnant state. Pregnancy induced increase
of cardiac output by 30-50%. The third trimester is the period of maximal hemodynamic stress; there are
maximal increases in heart rate, stroke volume, cardiac output, left ventricular wall stress and enddiastolic dimensions. The risk of life threatening dissection is particularly seen when the aortic root
diameter is larger than 40mm. The anesthetic management of these patients presents a challenging
scenario as no guidelines have been established.
MCC05
2:30 PM - 2:40 PM
Management of a Difficult Airway in an Ethically Challenging Pediatric Patient: Please Intubate
This Very Difficult Airway Urgently, but No Tracheostomy in the Event of Can't Ventilate/Can't
Intubate Situation
Guelay Bilen-Rosas, M.D., Bridget Muldowney, M.D., Anesthesiology, University of Wisconsin and Public
Health Madison, Madison, WI
We are presenting a 16 year-old SMA type 1 girl with nasal CPAP dependence and known difficult airway
in respiratory distress who requires urgent intubation. During consent the family refuses a tracheostomy
in the event of “can’t ventilate/can’t intubate” situation. Subsequent discussions lead to an agreement for
a preliminary crico-thyroidotomy if needed. The patient was sedated and continuous nasal CPAP
provided via a self-manufactured nasal trumpet and a standard 15 mm ETT connector. Successful
intubation achieved via a challenging fiber-optic intubation. This case highlights the importance of crossdepartmental discussions and anesthesia policies in ethically challenging patients.
MCC05
2:30 PM - 2:40 PM
Anesthesia Versus Ortho: A Regional Approach to Hip Surgery During Cardiac Instability
Shreya Aggarwal, M.D., Erikka Washington, M.D., Department of Anesthesiology, University of Texas
Medical School at Houston, Houston, TX
New onset cardiac insufficiency poses a serious risk for geriatric patients undergoing non-cardiac surgery
under general anesthesia, and this risk may be reduced using regional techniques. In this case, an 81
year-old female with hypothyroidism presented for hip hemiarthroplasty after sustaining a femoral neck
fracture. Preoperative assessment revealed acute coronary syndrome resulting in new apical kinesis and
EF 30%. We discuss preoperative evaluation of high risk patients and the approach to developing a safe
and effective anesthetic plan using regional anesthesia to optimize the perioperative management of a
challenging geriatric patient with a high risk of intraoperative mortality.
MCC05
2:30 PM - 2:40 PM
Spinal Anesthesia for Cesarean Section in a Patient With Congenital Long QT Syndrome
Katherine Lee, D.O., Laurel Hortvet, M.D., Department of Anesthesiology, University of Connecticut
Health Center, Farmington, CT
A 21-yr-old female, gravida 1 para 0 with diagnosed congenital long QT syndrome after her sister died of
MI at age 16, presented for scheduled cesarean section under spinal anesthesia. Special consideration
was taken given patient's LQTS, history of PONV, expected hypotension under spinal anesthesia and
myriad of medications normally administered intraoperatively during cesarean sections known to cause
QT prolongation. An external pacemaker/defibrillator was placed prior to surgery and magnesium sulfate
was available in the event the patient had an episode of Torsades de Pointes. Intraoperative course was
uneventful and the patient delivered a healthy baby under spinal anesthesia.
MCC05
2:30 PM - 2:40 PM
Airway and Anesthetic Management in a Child With Charge Syndrome
Yvon F. Bryan, M.D., Jorge Barrios, M.D., Anesthesiology, Wake Forest School of Medicine, Winston
Salem, NC, Anesthesiology, AACD, Sao Paolo, Brazil
This is a case of a 5 year-old female with Charge syndrome who presented for lower extremity orthopedic
procedures. She presented several airway and anesthetic concerns due to her cognitive dysfunction,
uncooperative nature and small mouth opening. A flexible fiberoptic intubation was performed and
intravenous anesthetics were administered for the procedure. This case demonstrates many issues of a
potential difficult airway including intubation and ventilation as well as the use of premedication and
induction of anesthesia.
MCC05
2:30 PM - 2:40 PM
Lumbar Cerebrospinal Fluid Drainage in a Patient With Altered Coagulation Status: The
Usefulness of ROTEM
Nuno Veiga, M.D., Patrícia Conde, M.D., Anesthesiology, Instituto Português de Oncologia de Lisboa
Francisco Gentil, Anesthesiology, Hospital de Santa Maria - Centro Hospitalar Lisboa Norte, Lisbon,
Portugal
75 year-old patient admitted with a contained aortic arch aneurism rupture, requiring urgent supra-aortic
vessel debranching and TEVAR.Due to the location and extent of the aneurism, the placement of a
lumbar cerebrospinal fluid drainage was considered. However, the patient presented with an INR=1.7.
Considering the urgency of the procedure, prothrombin complex concentrate was administered and
ROTEM was performed to rapidly document normalization of the coagulation status before placement of
the lumbar CSF drainage.Performance of the technique and surgery were uneventful. There were no
postoperative neurological complications. The drainage was removed 72h after surgery.
MCC05
2:40 PM - 2:50 PM
Positive Pressure Ventilation in Lacerating Lung Trauma
Liliya Pospishil, Anesthesiology, NYU, New York, NY
32 year-old male with no known medical history presented with gunshot trauma to the right lung, occipital
bone, thoracic and cervicalspine. He was taken to the OR for occipital wound washout. On physical exam
hewas tachycardic, tachypneic with SpO2 94% on RA, right chest tube draining blood.Chest CT showed
right lower lobe parenchymal contusion, laceration, hemothoraxand pneumothorax. Anesthetic
management included GETA, RSI with cervical spineprecautions and early lung isolation with left-sided
double lumen to preventcontamination, air embolism, and tension pneumothorax. Our discussion
willfocus on airway management and ventilation strategy in lung trauma.
MCC05
2:40 PM - 2:50 PM
Temperature Probe Position Confounding Double-Lumen Endotracheal Tube Placement for
Ventriculopleural Shunt
Jacob Schaff, M.D., Michael Hershey, M.D., Minjae Kim, M.D., Sumeet Goswami, M.D., Department of
Anesthesiology, NYP - Columbia University Medical Center, New York, NY
A 52 year-old man was scheduled for a ventriculopleural shunt to relieve obstructive hydrocephalus after
having failed multiple other CSF diversions. General anesthesia with a double lumen endotracheal tube
(DL ETT) was chosen to allow lung isolation. After intubation and confirmation of position, a temperature
probe and an orogastric tube were placed. After lateral decubitus positioning, there was difficulty
reconfirming position given a second blue object in addition to the bronchial cuff of the DL ETT. Heavy
secretions made clear visualization difficult and there was concern for cuff rupture. We describe
temperature probe placement complicating confirmation of DL ETT position.
MCC05
2:40 PM - 2:50 PM
Heparin Resistance in a Patient With Severe Thrombocytosis: A Medically Challenging Case
During Cardiac Surgery
Lisa M. Einhorn, M.D., Michael Manning, M.D.,Ph.D., Department of Anesthesiology, Duke University
Medical Center, Durham, NC
Heparin resistance during cardiac surgery is defined as the inability to achieve therapeutic anticoagulation
as measured by activated clotting time prior to initiating cardiopulmonary bypass. We present a case in
which heparin resistance developed in a 50 year-old male with a history of recent myear-oldcardial
infarction requiring urgent three-vessel coronary artery bypass grafting. His course was complicated by
preoperative heparin overdose due to a medication error and a history of chronic myelogenous leukemia
with a thrombocytosis greater than 1,300,000/mL. We will discuss how we managed his perioperative and
postoperative anticoagulation, risk factors for heparin resistance, and evolving research in this field.
MCC05
2:40 PM - 2:50 PM
Unexpected Complication from Aortic Endograft Placement Leads to Potentially Life-Saving
Diagnosis
David Butten, M.D., Brent W. Earls, Student, Teodora O. Nicolescu, M.D., Pamela R. Roberts, M.D.,
Department of Anesthesiology, University of Oklahoma Health Sciences Center, University of Oklahoma
College of Medicine, Oklahoma City, OK
An 88 year-old male admitted after a fall, with subarachnoid hemorrhage and femur fracture, underwent
placement of an endograft for an abdominal aortic aneurysm found incidentally. Anesthetic was provided
with MAC and LMA; OR course was complicated by desaturations and required intubation. In ICU,
significant gastrointestinal bleeding was discovered on placement of a nasogastric tube, required multiple
acute transfusions, and subsequent endoscopy led to discovery of a large cratered duodenal ulcer. This
unfortunate event, exacerbated by intraoperative heparin, led to discovery of an undiagnosed problem
that could have led to more severe consequence if simply discharged on therapeutic anticoagulation as
planned.
MCC05
2:40 PM - 2:50 PM
Can’t Intubate, Can’t Ventilate and Need to Decannulate the Tracheostomy
Medical Center, Chicago, IL, Rush University Medical Center, Chicago, IL
67 year-old female with known history of squamous cellcarcinoma of the tongue with previous
glossectomy, tracheostomy (nowdecannulated) along with radiation presented with severe airway
hemorrhage fromher healing tracheostomy site. She was scheduled for emergent tracheostomyrevision in
the OR. She had documented inability to be intubated or maskventilated. Emergently, an endotracheal
tube was passed through her healingtracheostomy site to establish an airway. A formal tracheostomy was
notpossible given an exposed innominate artery at the site. A retrograde intubationthrough her
tracheostomy was performed to intubate her orally, allowing herbleeding tracheostomy site to heal.
MCC05
2:40 PM - 2:50 PM
The Use of Cerebral Oximetry in the Management of Cerebral Perfusion During Hypothermic
Circulatory Arrest for Aortic Arch Repair
Alexander Praslick, Thomas V. Bilfinger, M.D., Igor Izrailtyan, M.D., Anesthesiology, Surgery, Stony
Brook Medicine, Stony Brook, NY
A 66 year-old man presented for emergent repair of a Type A aortic dissection. During hypothermic
circulatory arrest bloodflow to the brain was maintained via the right axillary artery, while blood returned
via the left common carotid artery (LCCA). Within fifteen minutes of circulatory arrest, left cerebral
oximetry signal decreased over 30% below baseline. The discrepancy between right and left cerebral
oximetry signals likely represented a steal phenomenon. The surgeon placed a retrograde balloon tipped
cannula to occlude LCCA. The left cerebral oximetry signal soon equalized with the right. After hemi-arch
replacement the patient remained without neurological deficits upon hospital discharge.
MCC05
2:40 PM - 2:50 PM
Abrupt Hemodynamic Changes During Anesthesia for Intrapleural Hyperthermic Chemotherapy
Hae Kyu Kim, Ph.D., Hyae Jin Kim, M.D., Eunsoo Kim, M.D., Hyeon Jeong Lee, Ph.D., Anesthesia and
Pain Medicine, Pn National University Hospital Dept. of Anesthesia and Pain Medicine, Bn, Korea,
Republic of
In the case of lung cancer with pleural seeding, it is preferred method to treat with intrapleural
chemotherapy for local control. Here in case, we report anesthetic experience in 3 cases of intrapleural
hyperthermic chemotherapy (IPHC). During the procedure, body temperature was gradually increased to
around 38℃. With the start of IPHC, cardiac output, right ventricular ejection fraction, systemic vascular
resistance decreased. Pulmonary vascular resistance and mean pulmonary artery pressure increased.
Blood pressure was decreased at the beginning of the IPHC, we infused dopamine for maintain stable
vital sign. Oxygen saturation, BIS, cerebral oximetry was remained stable during the procedure.
MCC05
2:40 PM - 2:50 PM
Immediate Cardiac Arrest After Cementing Femoral Rod for Hemiarthroplasty
Chris T. Schroff, M.D., Jessica Rodriguez, M.D., Raymond Pla, M.D., Anesthesiology & Critical Care, The
George Washington University School of Medicine & Health Sciences, Washington, DC, Anesthesiology,
Loma Linda University, Loma Linda, CA
83 year-old female with PMH of Afib, Sick sinus syndrome, Hyperlipidemia, HTN, CHF, history of CVA,
who was presenting for right hemiarthroplasty after ground level fall day before. Preoperative complicated
by elevated INR, requiring FFP and Vit. K. Interop complicated by circulatory arrest immediately after
cement and femoral rod placement. CPR started immediately and continued for 45 minutes without return
of spontaneous circulation. This case reviews the complications associated with bone cement and
rodding for hip hemiarthroplasties (Bone Cement Implantation Syndrome and Pulmonary Embolism), and
how devastating these complications are in the geriatric population with multiple comorbidities.
MCC05
2:40 PM - 2:50 PM
Urgent Ex-Utero Intrapartum Treatment (EXIT) Procedure in Pre-Eclamptic Female for Fetus With
Ectopia Cordis and Pentalogy of Cantrell
Arney S. Abcejo, M.D., Richard Scott Herd, M.D., Paul E. Stensrud, M.D., Robert C. Chantigian, M.D.,
Department of Anesthesiology, Mayo Clinic, Rochester, MN
A 25 year-old G1P0 preeclamptic patient at 36 weeks presented for urgent delivery due to prolonged FHR
decelerations during her prenatal visit. The fetus had prenatally diagnosed Pentalogy of Cantrell with
ectopia cordis, double-outlet right ventricle, and omphalocele. Due to concerns for hemodynamic
instability upon delivery, an EXIT procedure was planned under spinal anesthesia with a nitroglycerin
infusion (spinal was chosen for maternal wishes and less cardiac depression). After uterine incision and
partial delivery, the neonate was intubated prior to cord clamping. Central and arterial access was
obtained, and the child underwent successful reduction of the heart into the chest cavity.
MCC05
2:40 PM - 2:50 PM
A Patient With Long Chain Acyl-CoA Dehydrogenase Deficiency for a Posterior Spinal Fusion
Neil Patel, M.D., Mario Patino, M.D., Arpa Chutipongtanate, M.D., Anesthesiology, Cincinnati Children's
Hospital Medical Center, Cincinnati, OH, Ramathibodi Hospital, Bangkok, Thailand
A 14 year-old male with a complex past medical history significant for very long chain acyl-CoA
dehydrogenase deficiency (VLCAD), Pierre-Robin sequence, severe scoliosis with multiple bronchial
compressions, recurrent rabdomyear-oldlysis, and concentric left ventricular hypertrophy presented for
flexible bronchoscopy and posterior spinal fusion with neuro-monitoring. Significant perioperative risks
include recurrent hypoglycemia and rabdomyear-oldlysis that mandates frequent monitoring. TIVA with
propofol infusion carries a contraindication secondary to its long carbon chain. TIVA anesthetic with
ketamine, midazolam, and remifentanil possesses challenges given the prolonged context-sensitive half
times of midazolam and ketamine..
MCC05
2:40 PM - 2:50 PM
Supraclavicular Brachial Plexus Block for a Patient With SVC Syndrome
Ling Wang, B.M., Anesthesiology, Cleveland Clinic, Cleveland, OH
46 year-old female with PMH/o SVC syndrome 2/2 multiple central line placements for antibiotic treatment
for poyderma pangrenosum who presented for left arm amputation. Patient was status post left rib
resection, resection of the medial third of both clavicles.Left supraclavicular brachial plexus block was
performed successfully with US guidance. 25 ml of 0.25% Bupivacaine injected. Post-op pain was well
controlled with continuous infusion of 0.1% ropivacaine.The missing/distorted anatomical landmarks
secondary to surgical treatments presents a special challenge to the performance of block. Careful use of
US guidance has been proved to be extremely useful in this situation .
MCC05
2:40 PM - 2:50 PM
Fetal Umbilical Artery Monitoring by Intravascular Echography During Cardiac Surgery
Yuko Aki, M.D., ChiYo Ootaki, M.D., Tomonori Yamashita, M.D., Akira Iura, M.D., Anesthesiology and
Intensive Care, Osaka University Graduate School of Medicine, Suita, Japan
A 43 year-old nulliparous woman presented scheduled sinus of valsalva aneurysm surgery under CPB at
18 weeks, following infertility treatment. Patient has been diagnosed as SVA prior to the pregnancy. The
size of the aneurysm extended to 49 mm in diameter at 17 weeks. A heart surgery became mandatory
due to the risk of rupture. An IVE was inserted via the left femoral vein The Doppler signals of fetal
umbilical artery were monitored during entire surgery (Figure 1). Aesthesia and hemodynamics were
managed based on the IVE information. Both mother and fetus kept in good condition during and after the
surgery.
MCC05
2:40 PM - 2:50 PM
Central Sleep Apnea Post Vagal Nerve Manipulation and Stimulation During Neck Tumor
Resection: A Case Report
Louise A. Alexander, M.D., Stephanie N. Grant, M.D., Rhonda S. Tucker, C.R.N.A., Chin A. Peter, M.D.,
James L. Netterville, M.D., Camila B.Lyon, M.D., Anesthesiology, Otolaryngology, Vanderbilt University
School of Medicine, Nashville, TN
15 year-old female with right parapharyngeal space schwannoma presents for tumor resection.
Anesthetic induction and maintenance were standard, uncomplicated. Operative course complicated by
tumors extensive involvement of sympathetic trunk and vagus nerve. Emergence and awake extubation
uncomplicated. PACU course notable for 2 episodes of desaturation to 50% while sleeping, longest
lasting 26 seconds. Desaturations resolved upon wake up and with nasal cannula oxygen. While asleep,
no respiratory effort, chest rise, or end tidal CO2. Upon wake up, alert and oriented with no sedation or
altered mental status. Transferred to PICU for postoperative monitoring. One episode of apnea and
desaturation witnessed.
MCC05
2:40 PM - 2:50 PM
Complicated Foreign Body Removal From Trachea
Lara Dean, M.D., Kelly Hines, Anesthesiology, University of Louisville, Louisville, KY
27 year-old male scheduled for flexible vs. rigid bronchoscopic removal of tracheal foreign body followed
by ORIF of Le Forte I fracture. Patient arrived to OR with 7.5 subglottic ETT in situ. Attempts to pass FOB
beside ETT were unsuccessful as visualization was poor due to airway secretions and edema. Patient’s
oral ETT was exchanged for 7.0 nasal rae ETT, and tooth was snared with ureter calculus basket;
however, tooth would not pass through ETT. Ultimately, nasal rae with FOB and tooth were removed
through the nose as patient was intubated with 8.0 subglottic ETT and case continued.
MCC05
2:50 PM - 3:00 PM
The Unintubatable Man! A Case of Airway Management in a Patient With Subglottic Stenosis
Vincent M. Tupper, M.D., Geeta Nagpal, M.D., Anesthesiology, Northwestern Medicine, Chicago, IL
49 year-old male with SOB presents for microsuspension laryngoscopy and tracheal dilatation after
decannulation of his tracheostomy. Preoperatively, ENT diagnosed grade 3 subglottic stenosis with a
tracheal transverse width of 6mm, declaring him unintubatable. His past medical history is significant for
OSA, BMI 41, COPD, and current tobacco use. He was breathing at 22 with 95% saturation on RA.
Audible stridor and wheezes were present during conversation and auscultation. Airway exam was
remarkable for limited neck extension and neck circumference >40cm. The procedure required a general
anesthetic, however, the patient refused to have another tracheostomy if ventilation was not possible.
MCC05
2:50 PM - 3:00 PM
Complete Airway Collapse After Induction of General Anesthesia From an Anterior Mediastinal
Mass
Armin Shivazad, M.D., Rima Griauzde, M.D., Department of Anesthesiology, Northwestern University,
Chicago, IL
A 60 year-old female with dyspnea was scheduled to undergo mediastinoscopy for an anterior
mediastinal mass. On CT, the mass encased the ascending aorta and great vessels, without evidence of
airway compression. Following rapid sequence induction and uneventful tracheal intubation, ventilation
was impossible. Ventilation did not improve despite confirmation of tube location and position changes.
Using a fiberoptic scope, the airway was noted to be collapsed, but the ETT was able to be advanced into
the right mainstem bronchus with resumption of ventilation. Despite lack of tracheal compression on
imaging, complete airway collapse on induction is possible.
MCC05
2:50 PM - 3:00 PM
Switching to Aggressive Ventilation Strategy in Preventing Need for Oxygenator
Dipti Ghatol, M.D., Fadi Haddad, D.O., Joseph Sanders, M.D., Lebron Cooper, M.D., Anesthesiology,
Henry Ford Hospital, Detroit, MI
A 64 year-old female underwent emergent CABG and LVAD placement due to poor LV function. s/p PCI
native vessels complicated by iliac artery rupture requiring massive resuscitation resulting in
uncontrollable pulmonary edema. Refractory hypoxemia resulted in RV failure. Emergent ECMO
considered, but aggressive diuresis with mannitol/furosemide and abandonment of lung-protective
ventilation strategies using high TV with increased PAPs, avoided need for oxygenator, risks, and
complications associated. Patient extubated POD#2. Bi-VADs weaned POD#10. D/C home POD#16.
MCC05
2:50 PM - 3:00 PM
Initiation of Deliberate Tachycardia to Prevent Further Torsades de Pointes VT Arrest in Patient
With Takotsubo Cardiomyopathy
Michael A. Pudenz, M.D., Erich Marks, M.D., Anesthesiology, University of Wisconsin Hospital and
Clinics, Madison, WI
A 57 year-old woman with fibromyalgia, methadone dependence, and newly diagnosed Takotsubo
cardiomyear-oldpathy was admitted to the ICU for acute respiratory failure. Following empiric antibiotic
coverage for HCAP, interaction between ciprofloxacin and methadone likely caused an increase in her
QTc to 580. On hospital day 2, she developed Torsades de pointes, which evolved to VF. CPR was
initiated and 2 grams of magnesium sulfate delivered. She was defibrillated and had ROSC. However,
two hours post arrest she reverted to Torsades VT, requiring defibrillation as well as dopamine and
dobutamine infusions to maintain mild tachycardia and prevent further Torsades.
MCC05
2:50 PM - 3:00 PM
Anesthetic Challenges in a Coagulopathic Patient With Decompensated Liver Cirrhosis
Sible B. Antony, M.D., Viji Kurup, M.D., Anesthesiology, Yale-New Haven Hospital, New Haven, CT
A 55 year-old male with Hepatitis C cirrhosis, a right hydrothorax, and thrombocytopenia presented for
emergent incision and drainage of a L3-S2 epidural abscess. Given thrombocytopenia and predicted EBL
> 400mL, 1 unit of platelets was given prior to incision. Due to significant bleeding, a phenylephrine
infusion was initiated along with 6 units of FFP and 1 more unit of platelets. Upon transport to the ICU, the
patient was weaned off vasopressors and remained stable despite 2L blood loss. We will discuss the perioperative considerations in patients with advanced liver disease and the hematological implications on
anesthetic management.
MCC05
2:50 PM - 3:00 PM
Transesophageal Investigation of a Thymoma With an Atrial Septal Aneurysm
Chase Clanton, M.D., John Wasnick, M.D., Anesthesiology, Texas Tech University Health Sciences
Center, Lubbock, TX
This case demonstrates the role of echocardiography in the management of a patient with a mediastinal
mass. A 45 year-old patient presented with cough and shortness of breath. She was taken to the
operating room and a median sternotomy with excision of mediastinal thymoma was performed. TEE
examination revealed a large mass next to the right atrium, an aneurysmal interatrial septum, and a small
PFO. The mediastinal mass compressed the superior vena cava and pulmonary veins resulting in right-toleft shunting across the PFO. The patient was taken to the CICU in stable condition and recovery was
uneventful.
MCC05
2:50 PM - 3:00 PM
Hemorrhagic Gastroesophageal Ulceration Due to Cryear-oldtherapy With Placement of TEE
Probe in Cardiac Surgery
Hyae Jin Kim, Hae Kyu Kim, Eunsoo Kim, Hyeon Jeong Lee, Ph.D., Pn National University Hospital Dept.
of Anesthesia and Pain Medicine, Bn, Korea, Republic of
Upper gastrointestinal injury associated with cryear-oldablation during cardiac surgery is rare complication
but potentially fatal. Especially, cryear-oldenergy can have effect on the esophagus and resulting in
reversible esophageal ulceration (17%).In this case report, the authors describe the gastroesophageal
injury with massive bleeding occurred after cryear-oldablation therapy which was aggravated by
movement of inserted TEE probe in a cardiac surgery patient.Immediate endoscopy (figure A) exhibits
sharp and linear ulceration with massive bleeding. Follow up endoscopy (figure B) shows linear ulceration
undergoing healing process. Withdrawal of TEE probe before the cryear-oldablation might be an
important prophylaxis for gastroesophageal injury.
MCC05
2:50 PM - 3:00 PM
Negative Pressure Pulmonary Edema in a Patient Following Uvulopharyngopalatoplasty
Brandon G. Claxton, M.D., John Jerabek, D.O., Anesthesiology Institute, Cleveland Clinic Foundation,
Cleveland, OH
This is a case of 42 year-old male who underwent a septoplasty, turbinate reduction and
uvulopharyngopalatoplasty for treatment of severe obstructive sleep apnea. He had an uneventful
procedure however upon extubation, the patient developed laryngospasm and was initially responsive to
positive pressure ventilation, but subsequently demonstrated severe obstruction making ventilation
increasingly more difficult. Emergent re-intubation was performed with a glidescope after an initial attempt
with direct laryngoscopy was unsuccessful. Frothy, pink-tinged sputum from the patient and findings on
chest x-ray were each consistent with a diagnosis of negative pressure pulmonary edema.
MCC05
2:50 PM - 3:00 PM
Anesthetic Management of a Laboring Parturient With an NSTEMI
Joshua R. Lebenson, M.D., Michael Stockin, M.D., Ryan Pomicter, M.D., Cesar Velazquez Negron, M.D.,
Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD
35 year-old G2P0 female at 38+5 EGA presented in labor with acuteradiating chest pain, dyspnea,
positive troponins, non-specific T wave changes and normal bedside echocardiogram. Neuraxial
anesthesia and C-section were complicated by therapeutic heparinization. However, vaginal delivery
without neuraxial blockade may have worsened her ACS. A severe iodine allergy prevented immediate
CT Angiography and TEE was avoided secondary to anesthetic risk. After SROM and failure to progress,
a heparin window was obtained, epidural placed and C-section performed successfully. We present an
interesting clinical dilemma of managing a parturient with an NSTEMI of unknown cause and minimal
diagnostics.
MCC05
2:50 PM - 3:00 PM
Acute Cardiac Tamponade Following Central Line Placement in a 6 Month Old Patient
Amanda N. Lorinc, M.D., Suanne Daves, M.D., Anesthesiology, Vanderbilt University, Nashville, TN
We present a case of a 6 month old patient with an adrenal mass, liver lesions and ear abnormalities who
presented for myringotomy tubes, central line placement, liver biopsy and hearing testing. During the
closure of the central line, the patient exhibited hypocarbia followed by bradycardia. Epinephrine was
administered while assessing breath sounds and endotracheal tube location. There was no
pneumothorax via fluroscopy. Cardiology performed a stat echocardiogram and a small posterior effusion
was noted. Chest compressions were initiated, interventional cardiology and the ECMO team were called.
After a large anterior effusion was evacuated, the patient returned to baseline.
MCC05
2:50 PM - 3:00 PM
Open Distal Tibia and Fibia Fracture Repair in 48 year-old Patient With Uncontrolled
Pheochromocytoma
Rasesh A. Desai, M.D., James Berry, M.D., Anesthesiology, Vanderbilt University, Nashville, TN
A 48 year-old male with past medical history of adrenal mass presents fall for distal right tibial and fibial
fracture repair. Initial case was cancelled shortly after induction due to hypertensive emergency and
tachycardia due to concerns of previously unrecognized pheochromocytoma. Lab test showed elevated
urine metanephrine and normetanephrine levels. Given urgency of his injury, he was brought back to the
OR after receiving peripheral nerve blocks to blunt afferent sensory pathways. The patient exemplified
some liability in hemodynamics but were able to be controlled with nicardipine, phenylephrine and
phentolamine. Remainder of case and hospitalization were uncomplicated.
MCC05
2:50 PM - 3:00 PM
Echocardiographic Findings in Amniotic Fluid Embolism: Combined Right and Left Ventricular
Failure
Brian J. Kelly, D.O., Fred Cobey, M.D., Tufts Medical Center, Boston, MA
Amniotic fluid embolism (AFE) is accompanied by profound hemodynamic collapse. Due to conflicting
data from pulmonary artery catheter data and echocardiography reports, it has been theorized but not yet
shown that the hemodynamic response to AFE is biphasic with initial increased pulmonary vascular
resistance and right ventricular failure, followed by left ventricular failure. We report a case of AFE in a
healthy 31 year-old female who underwent dilation and evacuation with trans esophageal
echocardiographic findings to support this hypothesis. Echocardiographic findings helped guide
hemodynamic therapy with milrinone, nitric oxide, and epinephrine until cardiopulmonary bypass was
instituted.
MCC05
2:50 PM - 3:00 PM
When All Else Fails: The Last Resort for Intraoperative Hypoxia
Ruth G. Neary, Yvette Fouche-Weber, M.D., Anesthesiology, University of Maryland, Baltimore, MD
Anesthesiologists must be prepared to diagnose and treat intraoperative hypoxia. Common causes
include atelectasis, mucous plugging, bronchospasm, or endobronchial intubation. Conventional
treatment options include recruitment of atelectatic areas, aggressive suctioning with bronchoscopy, or
bronchodilators. Traumatic pulmonary contusions can be refractory to these straightforward treatments.
At our center, airway pressure release ventilation is commonly used to recruit severely atelectactic lung
parenchyma and decrease shunt fraction. This case describes a patient with severe pulmonary
contusions after high speed motor vehicle accident that failed all conventional methods of improving
oxygenation and ventilation, and ultimately was started urgently on extracorporeal membrane
oxygenation.
MCC06
3:15 PM - 3:25 PM
A Case of Hemolysis Caused by Heart Displacement-Induced Severe Aortic Regurgitation
Takao Okuda, M.D., Satoru Fujii, M.D., Tsunehisa Tsubokawa, M.D., Jikei University Hospital, Tokyo,
Japan
A 70 year-old man with severe stenoses in three main branches of the coronary artery underwent offpump coronary artery bypass grafting surgery. When the patient's heart was displaced and stabilized,
sudden hematuria was observed. Hemolysis was suspected based on blood works. Intraoperative TEE
showed severe aortic regurgitation (AR) jet hitting the posterior wall of the left ventricle. Subsequently,
haptoglobin products were administered to no avail. After the displaced heart was placed back in the
normal position, hematuria improved instantaneously. This led us to speculate that AR jet hitting the
posterior wall of the LV caused mechanically induced hemolysis.
MCC06
3:15 PM - 3:25 PM
A Simple Nasal CPAP Mask/Circuit Assembly Maintained Spontaneous Ventilation and
Oxygenation in a High-Risk 95 year-old Patient With Septic Shock During ERCP
Quynh-Tien Mai, M.D., Arpit Patel, M.D., Rose Alloteh, M.D., James Tse, M.D., Department of
95 year-old female with CAD, complete heart block, pacemaker and obstructive pancreatic mass
complicated by septic shock, presented for an ERCP. Her room air O2 saturation was 90%. An infant
facemask (#2) was secured over her nose with head-straps and connected to anesthesia breathing
circuit/machine. Pressure-relief valve was adjusted to provide 4-5cm H2O CPAP with O2 3L/min and air
1L/min. After pre-oxygenation, sedation was slowly titrated with a total of 2mg midazolam and propofol
infusion (25-75 ug/kg/min). Patient maintained spontaneous respiration with O2 saturation of 100%
throughout. At the conclusion of the procedure, she regained consciousness quickly without any
complications.
MCC06
3:15 PM - 3:25 PM
Optimization of a 53 year-old Man With Pulmonary Alveolar Proteinosis and Suspected Lung
Cancer for Elective Left Upper Lobectomy
William C. Ng, FANZCA, Katherine Marseu, M.D., FRCPC, Peter Slinger, M.D., FRCPC, Department of
Anesthesia, University of Toronto, Toronto, ON, Canada.
This case describes the optimization of a patient with pulmonary alveolar proteinosis and lung cancer for
VATS lobectomy. He was dyspneic at rest with room air saturation 86%. His chest xray demonstrated
bilateral opacification with greater disease on the right (image-1). He was firstly scheduled for bilateral
pulmonary lavage and chest physiotherapy under general anesthesia with lung isolation. An elective left
lobectomy was planned one week after discharge, with a backup plan of repeat right lung lavage if he did
not tolerate single lung ventilation. The patient eventually underwent a successful left upper lobectomy
without need for postoperative ventilation.
MCC06
3:15 PM - 3:25 PM
Intraoperative Use of Octreotide for Hemodynamic Control in a Patient With Preoperatively
Asymptomatic Gastric Carcinoid Tumor
Luz M. Aguina, M.D., Marina R. Varbanova, M.D., Anesthesiology and Perioperative Medicine, University
of Louisville Hospital, Louisville, KY
The incidence of carcinoid tumors is much greater than previously recognized; Carcinoid tumors secrete
different types of substances that produce unpredictable and potentially fatal intraoperative reactions.We
present a case of an asymptomatic 65 years old patient with accidentally found gastric carcinoid tumor,
who had negative biomarkers and required subtotal gastrectomy under general anesthesia. Severe
hypertension was observed with incision and tumor manipulation intra-operatively, despite adequate
levels of anesthesia. Stroke Volume Variations monitoring and the use of Octreotide were the mainstay of
intraoperative control of the extremes in hemodynamic fluctuations.
MCC06
3:15 PM - 3:25 PM
Clinical Uses of Supraglottic Jet Oxygenation and Ventilation via Nasal Approach
Huafeng Wei, University of Pennsylvania, Philadelphia, PA
Various cases have described the use of superaglottic jet oxygenation and ventilation (SJOV) via nasal
approach with either WEI NASAL JET or its equivalent assembly (Figure 1) to maintain adequate
oxygenation and ventilation during difficult airway management (e.g., cannot inbutate and cannot ventilate
emergent airway) or during monitored anesthesia care (MAC) under intravenous infusion of propofol (e.g.,
upper gastrointestinal endoscopy, endoscopic retrograde cholangiopancreatography, cystoscopy,
hysteroscopy, cardiac catheterization, etc.). This case report discusses its effectiveness and limitations in
maintaining adequate oxygenation and ventilation in patients with severe respiratory depression or
apnea.
MCC06
3:15 PM - 3:25 PM
Epidermolysis Bullosa: Anesthetic Management for Cesarean Section - No Touch Principle
Luis M. Ferreira, Sr., M.D., David Fernandes, M.D., Joana Alves, M.D., Rita Araújo, M.D., Filipa Lança,
M.D., FIlomena Morais, M.D., Anestesiologia, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
Dystrophic epidermolysis bullosa is a rare inherited severe bullous condition characterized by extreme
skin fragility and blistering in response to shearing forces applied to the epiderme. We present one
obstetric case with recessive dystrophic epidermolysis bullosa who underwent elective caesarean section
at 37 weeks of gestation performed under combined spinal-epidural anesthesia. Anesthetic care plan was
focused on comprehensive preoperative assessment, appropriate and careful managing of the monitoring
instruments and invasive techniques to avoid skin trauma and postoperative analgesia.
MCC06
3:15 PM - 3:25 PM
Anesthetic Concerns of A Child With Denys-Drash Syndrome Status Post Renal Transplant
Rebecca L. Scholl, M.D., Shridevi Pandya Shah, M.D., Anesthesiology, Rutgers--New Jersey Medical
School, Newark, NJ
Denys-Drash Syndrome consists of congenital nephropathy, intersex disorder, and Wilms tumor, with 200
cases reported worldwide. They are at high risk for cancer, specifically Wilms and gonadal tumors. DDS
patients exhibit seizures, anemia, developmental delay, hypertension, and growth retardation due to renal
osteodystrophy. Many signs and symptoms of DDS stem from nephrotic syndrome in the first year of life
progressing to ESRD, requiring dialysis or renal transplantation, by age three. Our case discusses the
anesthetic concerns of a five year-old girl with DDS, status post kidney transplant, undergoing dental
surgery.
MCC06
3:15 PM - 3:25 PM
Anesthetic Management of a Patient With a Left Atrial Spindle Cell Sarcoma
Lisa To, M.D., Aaron Wolfe, M.D., Amanda Fox, M.D., Anesthesia and Pain Management, University of
A 37 year-old woman presented with slow insidious onset of atypical left chest pain, headaches,
presyncope and dyspnea. CT scan demonstrated a large multilobar tumor which encompassed the left
atrium, demonstrated a dilated right ventricle with flattening of the interventricular septum.
Echocardiogram showed a mass in the left atrium obstructing the mitral valve orifice, prolapsing into the
left ventricle during the ventricular filling phase. Due to her physiology of severe mitral stenosis, the mass
was resected in the operating room and was found to be a spindle cell sarcoma. Although she has done
well postoperatively, her prognosis remains guarded.
MCC06
3:15 PM - 3:25 PM
Successful VA-ECMO and Atrial Septostomy as Salvage Therapy for Suspected GadoliniumInduced Profound Respiratory Failure: A Challenging Case Report
Marissa Leigh Kauss, M.D., John K. Bohman, M.D., Anesthesiology, Mayo Clinic, Rochester, MN
A 56-year-old male with history of dextrocardia and non-ischemic cardiomyear-oldpathy who experienced
flash pulmonary edema shortly after completing a routine cardiac MRI with gadolinium contrast. VAECMO was initiated to correct persistent hypoxemia (PO2 <60mmHg on 100% FiO2 and PEEP 15) and
hypotension refractory to epinephrine and glucocorticoids. Despite a negative coronary angiogram and
TEE depicting normal valvular function, the patient had global left ventricular dysfunction and an atrial
septostomy was performed to facilitate LV decompression. He was decannulated after two days of
ECMO, was discharged home 15 days later and was doing well at his one-month cardiology follow-up.
MCC06
3:15 PM - 3:25 PM
Ethically Guided Decision Making in Surrogate-fetal Conflict, A Case Report
Maxim D. Orlov, M.D., Molly Cason, M.D., Anesthesiology and Critical Care Medicine, Johns Hopkins
We present a challenging ethical case involving a paid surrogate mother with an intermittently
incarcerated paraesophageal hernia that could not be ideally managed without the delivery of preterm
twin babies; this situation called into question her motives and goals of care. We utilize the principles of
autonomy, beneficence, nonmaleficence and justice as well as the ACOG committee opinion on
surrogate motherhood in order to examine the ethical issues in this case.
MCC06
3:15 PM - 3:25 PM
Pain Medicine (PN)
A Novel Outpatient Intravenous Infusion Therapy for Fibromyalgia
Vijay Parekh, M.D., Kutaiba Tabbaa, M.D., Anesthesiology, Metro Health Campus of Case Western
Reserve University, Cleveland, OH
We looked at charts of patients who had a diagnosis of fibromyalgia and were on chronic neuroleptic
and/or anti-depressant therapy. We identified the patients who were offered our intravenous outpatient
infusion therapy consisting of ketamine, ketorolac, propofol, and lidocaine in 0.9% NS. ASA monitors
were applied and the infusion was delivered over 30 minutes. The Numeric Rating Scale (NRS-11)
showed an average decrease of 6.9 points during the immediate post-infusion period. During the followup telephone conversations the patients reported feelings of 80% pain relief for two weeks and up to 60%
of pain relief for weeks three and four.
MCC06
3:15 PM - 3:25 PM
A Case of Epidural Emphysema
Pavan M. Rao, M.D., Dalia Elmofty, M.D., Anesthesia, University of Chicago Medical Center, Chicago, IL
We describe a case of posterior neck and upper back pain with tinnitus but no headache starting 48-72
hours after thoracic epidural placement for post-operative pain control with known dural puncture by a 17gauge Touhy needle in a 44 year-old female undergoing extensive abdominal, surgery for advanced
cervical cancer. Secondary to atypical presentation of possible post-dural puncture headache and neck
pain, a c-spine x-ray was ordered which revealed a “gas density within the posterior soft tissues of the
neck.” This was followed by a CT to help further clarify findings leading to the identification of epidural air
from C1-C4.
MCC06
3:15 PM - 3:25 PM
Dexmedetomidine for Sedation in the MRI Suite for a 5 year-old Patient With Severe Hypotonia
Elizabeth Starker, M.D., Franklin Chiao, Department of Anesthesiology, New York Presbyterian Medical
A 5 year-old female with history of 18q Deletion syndrome causing severe hypotonia, leukodystrophy, and
seizures presented for MRI. Important pre-anesthetic considerations for hypotonic pediatric patients
include poor airway tone, increased resistance/sensitivity to neuromuscular blocking drugs (NMBD),
difficulty in adequately assessing NMBD reversal, and an increased incidence of malignant hyperthermia
when exposed to triggering agents. Volatile agents potentiate the effects of NMBD, leading to
prolongation of duration of action and recovery from neuromuscular blockade.A dexmedetomidine
infusion was chosen as an anesthetic to allow for spontaneous breathing during sedation with avoidance
of volatile agents and NMBDs.
MCC06
3:15 PM - 3:25 PM
Anaphylactic Shock After Anesthetic Induction in a Non-cardiac Case Involving a Patient With
Palliated Left Hypoplastic Heart
Jakob Z. Guenther, M.D., Amy Henry, M.D., John Scott, M.D., Beth Drolet, Anesthesiology, MCWAH,
Wauwatosa, WI, MCW, Milwaukee, WI
16 year-old male with HLHS status post fontan completion with good functional status presented with
possible appendicitis. After anesthetic induction, transfusion of fresh frozen plasma (Warfarin reversal),
antibiotic surgical prophylaxis and traumatic foley catheter placement, the patient developed hives, facial
edema, and anaphylactic shock, which were treated with antihistamines, steroids and epinephrine. The
surgical team cancelled the procedure opting to medically manage the appendicitis. Patient remained
intubated on epinephrine overnight in the ICU. He was extubated the next day without further
complication. His abdominal symptoms resolved with medical therapy. The causing agent of the
anaphylaxis remains unclear.
MCC06
3:15 PM - 3:25 PM
Successful Epidural Anesthesia After Recent Epidural Blood Patch
Jason Pollack, M.D., Ramon Abola, M.D., William Stuart, B.A., Joy Schabel, M.D., Dept of
Anesthesiology, Stony Brook University Hospital, Stony Brook, NY
A 40 year-old woman presented for external cephalic version at 37.3weeks gestation. Initial attempts at
version by her obstetrician were unsuccessful and epidural anesthesia was requested to facilitate external
cephalic version. An inadvertent dural puncture occurred necessitating an epidural blood patch. Six days
post blood patch successful epidural analgesia was obtained for labor. Here we present the anesthetic
management of a partituant post epidural blood patch.
MCC06
3:25 PM - 3:35 PM
Central ECMO Cannulation After Ischemic Muscular Ventricular Septal Rupture
Matthew S. Bell, M.D., Theodore Cios, M.D.,M.P.H., Srikantha Rao, M.D., M.S., Department of
Anesthesiology, Penn State M.S. Hershey Medical Center/ College of Medicine, Hershey, PA
A 63 year-old man with an anterior ST-elevation myear-oldcardial infarction (MI) underwent percutaneous
coronary intervention. Echocardiography revealed a muscular ventricular septal rupture. He was initially
supported using vasopressors and an intra-aortic balloon pump. Subsequently, central veno-arterial
extracorporeal membrane oxygenation (VA-ECMO) was initiated in the operating room. VA-ECMO was
successfully begun, but later in the ICU a massive thrombus formed in the circuit and the patient died.
Muscular VS rupture occurs in 0.2% of acute MI and results in left to right shunt with acute RV volume
and pressure overload. VA-ECMO can relieve the RV overload, allowing time for definitive management.
MCC06
3:25 PM - 3:35 PM
Severe Anaphylaxis Following Anesthetic Induction
Ashley K. Amsbaugh, M.D., Jerrad Businger, D.O., Department of Anesthesiology and Perioperative
Medicine, University of Louisville, Louisville, KY
A 55 year-old male presented for a wide local excision of malignant melanoma. The patient was induced
with midazolam, fentanyl, propofol, rocuronium, and received preoperative cefazolin. Shortly after the
induction, the patient became acutely hypotensive with severe diffuse swelling and rash. The patient was
administered solu-cortef, diphenhydramine, and famotidine in addition to epinephrine boluses and
eventually an epinephrine infusion. The surgery was cancelled and the patient was transferred to the
intensive care unit intubated. Over the next twelve hours, epinephrine was weaned off and the patient
extubated. Upon discharge home, the patient was referred for allergy testing.
MCC06
3:25 PM - 3:35 PM
Never Let Your Guard Down: A Case of ICU Management of Stress-Induced Postoperative
Malignant Hyperthermia
Marjorie A. Pierre, M.D., Darin Zimmerman, M.D., Stephanie Esposita, M.D., Anesthesiology, University
of Maryland Medical Center, Baltimore, MD
A 69 year-old male with a history of anxiety, hypothyroidism, hypertension and piriform sinus cancer
presented with shortness of breath and stridor. After failing bipap, he was intubated for airway protection
then transferred to an ICU. Medical records indicated an allergy to succinylcholine. This was relayed to
the anesthesia providers on the day of surgery for mass biopsy and tracheostomy. He had an uneventful
procedure under TIVA. After returning to the ICU, he began exhibiting hypercarbia, hypertension,
tachycardia, and muscle rigidity. After considering other causes for this clinical presentation, successful
MH therapy was initiated, including the administration of dantrolene.
MCC06
3:25 PM - 3:35 PM
Acute Hypotensive Transfusion Reaction After a Packed Red Blood Cell Transfusion
Yoon-Jeong Cho, M.D., Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
A 49 year-old female presented for open sacral colpopexy, perineorrhaphy with removal of previous
sacral mesh. After uneventful induction of anesthesia and intubation, surgical procedure was started.
During removal of the previously implanted mesh, the mesh was noted to be in close proximity of the iliac
vessels with significant scarring, leading to brisk hemorrhage. A rapid transfusion protocol was called.
Immediately upon infusion of a unit of packed red blood cell, patient’s blood pressure was noted to drop
significantly on arterial line reading despite hemostasis on the surgical field. No changes in EKG or
capnography were appreciated.
MCC06
3:25 PM - 3:35 PM
Esophageal Doppler Monitoring in Patient Undergoing Robotic Assisted Partial Nephrectomy
Pariza Rahman, M.D., Brian Vander Werf, M.D., Anesthesiology, UC San Diego, San Diego, CA
Robotic-assisted partial nephrectomy (RPN) has emerged as a preferred technique for small renal mass
with excellent short-term cancer and functional outcomes in selected patients, however there is concerns
of impaired renal function due to increased warm ischemia time associated with RPN. We presented a
patient with a small renal mass and baseline renal impairment who underwent RPN ; goal directed fluid
management was successfully employed using esophageal Doppler monitoring and stroke volume
optimization protocol. It is proposed that, goal directed fluid therapy will decrease perioperative renal
impairment after RPN.
MCC06
3:25 PM - 3:35 PM
Management of Postpartum Hemorrhage from Disseminated Intravascular Coagulation
Eduardo E. Icaza, M.D., Baskar Rajala, M.D., Anesthesiology, University of Michigan, Ann Arbor, MI
A 34 year-old female G1P0 at 41 weeks with an uncomplicated prenatal course was admitted for postdate induction. A healthy 3.5kg boy was delivered vaginally with lumbar epidural analgesia. Following
delivery, she developed a massive obstetric hemorrhage and became hemodynamically unstable. Initial
therapies of uterine massage, packing and uterotonic medications were unsuccessful. A massive
transfusion protocol was initiated for suspected amniotic fluid embolism. Initial laboratory studies revealed
an abnormal coagulation profile and a clinical picture concerning for disseminated intravascular
coagulation. She was transferred to the intensive care unit and was discharged postpartum day 8
MCC06
3:25 PM - 3:35 PM
Malignant Hypertension Under General Anesthesia in a 3 year-old Male With Undiagnosed Renal
Artery Stenosi
Marcus Tholin, M.D., Joseph Resti, M.D., Anesthesia, SUNY Upstate Hospital, Syracuse, NY
A three year-old male with history of developmental delay underwent general anesthesia for an MRI to
evaluate the cause of hyponatremia, hypokalemia, hypomagnesemia, proteinuria and elevated cortisol.
Blood pressure upon intravenous induction with propofol was in excess of 240/140. Reduction in blood
pressure was achieved through use of deepening the anesthetic with sevoflurane and addition of
hydralazine and labetalol. Following the procedure the patient had placement of an arterial and infusion of
sodium nitroprusside. He was admitted to the PICU service and followed by nephrology upon discovering
renal artery stenosis on ensuing CT scan.
MCC06
3:25 PM - 3:35 PM
Trans Femoral AVR Complicated by Left Ventricular Laceration and Emergent Cardiopulmonary
Bypass
Robert A. Hitchcock, D.O., Sudhakar Subramani, M.D., Anesthesiology, University of Iowa Hospitals and
Clinics, Iowa City, IA
During a TAVR procedure on a 76 year-old woman, after the introduction of an extra-stiff guidewire to aid
placement of the mechanical valve, multiple ectopic beats were noted followed by precipitous
hypotension and an associated large pericardial effusion. Opening a pericardial window to relieve the
tamponade lead to an immediate 1.5 liter blood loss. Emergent open cardiac surgery was initiated and
repair of two lateral wall lacerations as well as replacement of the stenotic aortic valve was completed.
The patient survived the procedure and was discharged. This case highlights a less common cause of
cardiac tamponade during trans-catheter valve procedures.
MCC06
3:25 PM - 3:35 PM
Intraoperative Bronchospasm Secondary to Stent Deployment Responsive Only to Continuous
Epinephrine Infusion
Kyle L. Bruns, D.O., Anesthesiology, Loyola University Medical Center, Maywood, IL
Intra-operative bronchospasm is classically attributed to a few common etiologies, including: secretions,
inadequate depth of anesthesia, endobronchial intubation, pulmonary embolus, mechanical obstruction of
endotracheal tube. Foreign bodies are frequently noted as a cause in pediatric patients, but we describe a
case of a bronchial stent in a post-lung transplant patient contributing to bronchospasm in an adult.
MCC06
3:25 PM - 3:35 PM
Intrapartum Tonic-clonic Seizure in a Patient Undergoing Cesarean Delivery During Spinal
Anesthesia With Bupivacaine
Abdalhai H.M. Alshoubi, M.D., Stanlies D'Souza, M.D., Department of Anesthesiology and Pain Medicine,
Baystate Medical Center, Tufts University Medical Center, Springfield, MA
42 year-old, G11 P4, 39 weeks gestation, underwent an emergent C-section for fetal distress under spinal
anesthesia. She has remote history of epilepsy, otherwise uneventful pregnancy. The spinal puncture
was performed at L4-L5 interspace. A total of 9 mg of Bupivacaine with 200 ug of Morphine and 10 ug of
Fentanyl was injected. During the surgery she had 3 episodes of tonic-clonic seizures, during which she
was hemodynamically stable, the seizures were treated and resolved with benzodiazepines. The baby
had normal Apgar score at 1 and 5 minutes. The patient didn’t have further episodes of seizures in the
postnatal period.
MCC06
3:25 PM - 3:35 PM
Pain Medicine (PN)
Sever's Disease Pain Management
Neil Malhotra, M.D., Adam Yong, M.D., Anesthesiology, Rush University Medical Center, Chicago, IL
The patient is a 10 year-old male with past medical history of left Sever's Disease who presents with left
heel pain for 1 week. The pain originates at his heel and occasionally includes the dorsum of the foot and
proximal achilles tendon. He denies allodynia, but endorses hyperalgesia. An epidural catheter under
flouroscopy was placed with infusion of fentanyl, bupivicaine, and clonidine for 5 days. His pain improved
to a 0/10 from 10/10 after 5 days of infusion. He could ambulate without pain and was discharged from
hospital with follow up in pain clinic scheduled in 1 month.
MCC06
3:25 PM - 3:35 PM
Epidural Blood Patch via Closed Circuit Administration for a Jehovah’s Witness
Robert H. Jenkinson, M.D., Richard L. Wolman, M.D., Mark E. Schroeder, M.D., University of Wisconsin,
Madison, WI
A 36 year-old male Jehovah’s Witness with a history of obesity and longstanding hypertension presented
with a post-dural puncture headache after removal of a spinal drain placed during thoracic endovascular
aortic repair. The patient refused the administration of blood separated from his body but would accept
his own blood kept in a continuous circuit. A modified epidural blood patch technique was utilized to
maintain a circuit of blood from the patient’s vein to the epidural space utilizing two sterile sets of
extension tubing interposed with a three-way stopcock and 60 mL syringe. Symptomatic relief was
achieved while respecting patient autonomy.
MCC06
3:25 PM - 3:35 PM
A Balancing Act: Emergent Off-site Anesthesia in a Pediatric Patient With a History of Malignant
Hyperthermia and Metabolic Disorder
Madhuri V. Gupta, M.D., Katari Carello, M.D., Anesthesiology, University of Michigan Health Systems,
Ann Arbor, MI
Difficult cases often arise when multiple patient factors are at odds. The anesthesiologist is charged with
prioritizing these factors; doing so involves weighing risk to determine the best anesthetic course. We
present a case of a nine year-old girl with a history of malignant hyperthermia, difficult airway, and a
metabolic disorder who required an emergent offsite procedure.* We will discuss how the patient’s
medical history and delivery of an off-site anesthetic created unique challenges that required prioritization
and risk/benefit estimation to create a safe anesthetic plan.*Details irrelevant to anesthetic management
changed to protect child’s identity.
MCC06
3:25 PM - 3:35 PM
Open Left Radical Nephrectomy with IVC Thrombectomy Complicated by a Right Atrial Clot and
Bilateral Pulmonary Artery Emboli: Anesthetic Implications
Katherine E. Turk, M.D., Benjamin Tuck, M.D., Department of Anesthesiology and Perioperative
Medicine, University of Alabama, Birmingham, AL
A 78 year-old CF presented for a Left Radical Nephrectomy with IVC Thrombectomy for invasive Renal
Cell Carcinoma removal. Preoperatively, she received a thoracic epidural. Intraoperative TTE was used to
visualize the IVC thrombus prior to mass excision, and it was noted to be more extensive than scans
indicated. Bilateral pulmonary emboli and a right atrial clot were noted on a post excision TEE
necessitating emergent sternotomy, high dose anticoagulation, and extracorporeal circulation for the right
atrial thrombectomy and bilateral pulmonary artery embolectomies. Once the clot burden was removed,
the patient stabilized and was taken to the CICU for recovery.
MCC06
3:25 PM - 3:35 PM
Continuous Labor Epidural in a Patient With Charcot Marie Tooth Disease (CMTD): A Possible
Culprit for a Rapidly Rising Intrapartum Fever Ammar Mahmoud, M.D., Reza Borna, M.D., Ned Nasr, Anesthesiology, John H Stroger Hospital of Cook
County, Chicago, IL
Epidural analgesia is associated with a rise in maternal intrapartum temperature. We present a G1P0 with
known Charcot Marie Tooth Disease and a history of difficult intubation with spontaneous rupture of
membranes. A labor epidural was placed with no immediate complications. Eight hours following insertion
she reported poor analgesia and was febrile to 101.6 F with tenderness at the insertion site. The catheter
was removed, and an urgent cesarean section was planned utilizing awake fiberoptic intubation and total
intravenous anesthesia. Defervescence occurred 48 hours post-op. Future focus should surround the
etiology of epidural fevers and the identification of high-risk patients.
MCC06
3:35 PM - 3:45 PM
Treatment of Innominate Vein Rupture During Superior Vena Cavaplasty
Joseph C. Kuhn, D.O., Ahmet Kilic, M.D., Erica Stein, M.D., Ohio State University Wexner Medical
Incidence of non-malignant/non-infectious central venousobstruction and stenosis, has been increasing
over the past three decades and is thought to reflect the increasing use of chronic indwelling devices.
Patients undergoing hemodialysis represent a high risk population for central venous obstruction and
stenosis. First line treatment of obstructions in this population includes the use of percutaneous
transluminal angioplasty (PTA), which has been found to be a successful and safe treatment option.
Rupture and perforation of the vessel are rare but feared complications of this procedure. We present a
case of innominate vein rupture during routine recanalization.
MCC06
3:35 PM - 3:45 PM
True, Difficult Airway Complicated by Perioperative Type I and Type II Pulmonary Edema
Maulik Rajyaguru, Patricia Lowery, D.O., Mackenzie Pullee, Student, John Agapian, M.D., Norma
Dominguez, D.O., Anesthesia, RCRMC, Riverside, CA
Management of a true difficult airway involves a preoperative evaluation, an intraoperative plan, and
postoperative management partnering with other surgical specialties. A 52-year-old Caucasian female,
who arrived to the emergency department with dysphagia, stridor, and shortness of breath, was urgently
transported to the OR for a rapidly enlarging, unevaluated 7cm x8cmx6cm neck mass located anterior to
the crico-thyroid membrane. Her past medical history was significant for hypothyroidism and a 15 year
smoking history. The intubation was compounded by inability to perform an emergency tracheotomy, and
the perioperative development of both Type I and Type II negative pressure pulmonary edema.
MCC06
3:35 PM - 3:45 PM
Surgical Resection of a Massive Mediastinal Sarcoma Occupying the Lung Fields and
Compressing the Heart
Christine T. Nguyen-Buckley, M.D., Nir Hoftman, M.D., Anesthesiology, University of California at Los
Angeles, Los Angeles, CA
A 75 year-old man with a very large intrathoracic sarcoma and significant postural and exertional dyspnea
presented for surgical resection. The tumor arose from the anterior mediastinum but extended to
compress the heart, great vessels, and bilateral lungs. General anesthesia was induced and airway
management performed to achieve lung isolation. The case was complicated by a previously
undiagnosed post-obstructive pneumonia as well as anticipated major hemorrhage. Massive transfusion
was initiated and transesophageal echocardiography was used to guide management of volume
resuscitation.
MCC06
3:35 PM - 3:45 PM
Challenges of One Lung Ventilation: Pneumonia With Empyema on the Side of the Dependent
Lung
Shin Wakatsuki, M.D., Hiroko Asaba, M.D., Yusuke Ikeda, M.D., Shigehito Sawamura, M.D.,
Anesthesiology and Critical Care, Teikyo University Hospital, Tokyo, Japan
A 70 year-old male presented for esophagectomy via right thoracotomy due to esophageal perforation
from chronic empyema. His past surgical history included open surgical repair of thoracic aortic aneurysm
and open window thoracostomy due to chronic empyema from prosthetic vascular graft infection. We
inserted a bronchial blocker in the right main bronchus. When the right lung was collapsed, there was
difficulty maintaining oxygenation in the setting of left-sided pneumonia with empyema. Selective lobar
bronchial blockade was performed by placing the bronchial blocker in the right upper lobe bronchus and
we successfully obtained sufficient oxygenation and the optimal surgical field.
MCC06
3:35 PM - 3:45 PM
Labor Analgesia in a Brugada Syndrome Mutation Carrier
Rocco A. Addante, M.D., Suzanne K. M. Mankowitz, M.D., Anesthesiology, Columbia Univesity Medical
Canter, New York, NY
Brugada syndrome is characterized by abnormal electrical activity of the heart leading to an increased
risk of arrhythmia and death. Among asymptomatic patients, the hormonal changes associated with
pregnancy have been implicated as a triggering event. We present the management of labor analgesia in
a 19 year-old at thirty-nine weeks gestation with a mutation known to cause Brugada syndrome. Given
the risk of using local and intravenous anesthetics in this patient, we offered a remifentanil and
dexmedetomidine infusion instead of neuraxial anesthesia to control labor pain. Cardiac monitoring was
continued throughout pregnancy and she delivered vaginally without complication.
MCC06
3:35 PM - 3:45 PM
Mile High Dyspnea: A Case of Post-operative High Altitude Pulmonary Edema in an 8 year-old in
Ecuador
Nirav S. Shah, M.D., MBA, Robert P. Stephenson, D.O., Chien-Hsiang Chow, M.D., Satrajit Bose, M.D.,
Richard T. Silverman, M.D., Department of Anesthesiology & Pain Medicine, Steward St. Elizabeth's
Medical Center, Boston, MA
High Altitude Pulmonary Edema (HAPE) is a noncardiogenic cause of pulmonary edema which is likely
not part of the differential diagnosis of many anesthesiologists for shortness of breath. Our patient, a 8
year-old female, who presented for a excision of keloid from back, excision and reduction of triceps scar,
and release of axillary scar contracture during our annual mission trip in Ecuador. The patient's
intraoperative course was uneventful, but postoperatively, the patient developed tachycardia, tachypnea,
and her chest x-ray showed bilateral patchy infiltrates. The patient was treated for HAPE, recovered fully,
and was sent back to her village in Ecuador.
MCC06
3:35 PM - 3:45 PM
Perioperative Management of Concurrent Surgery for Inferior Vena Cava Thrombus Extending to
the Right Atrium in Addition to Pelvic Exenteration
Eman Nada, M.D.,Ph.D., Madiha Syed, M.D., Mohamed Ismaiel, M.D.,Ph.D., Anesthesiology Department,
University of Arkansas for Medical Sciences, Little Rock, AR
Anesthesia for concurrent surgery for IVC and intracardiac mass and pelvic exenteration .59 year-old F
with recurrent adenosarcoma of uterus with invasion of the u bladder, L common iliac, IVC and right
atrium . PMH: HTN, MH in a 1st degree relative, previous sternotomy.Management:MH
precautions.TIVA.A line and Cordis.TEE .Cardiopulmonary Bypass.Massive blood transfusion: 27 units of
PRBCs, 22 FFP, 6 platelets, 4 doses of Cryear-oldglobulin.Vasoactive medications.The procedure ended
after 11 hours and the patient was taken the ICU off the vasoactive drips, with normal Coags, ABGs
except for lactate of 5.3.
MCC06
3:35 PM - 3:45 PM
A Sucsseful Case of Perioperative Extensive Saddle Embolus With Right Ventricular Strain
Miss Hina, Matthew Joy, M.D., Anesthesiology, Case Western Reserve University (MetroHealth) Hospital,
Cleveland, OH
We report a case of a 45 year-old male who involved in blunt trauma and sustained auto-amputation of
left lower extremity, multiple bony injuries, and hypovolemic shock requiring massive blood transfusion.
He developed saddle embolus during the perioperative period which was diagnosed in the intensive care
unit during the investigation for the cause of his intraoperative hypoxia episodes. A chest computed
tomographic scan showed a large saddle embolus with clot extension into the bilateral main and distal
pulmonary arteries and greater clot burden on the left associated with right ventricle strain which was
successfully managed with high intensity heparin infusion,
MCC06
3:35 PM - 3:45 PM
Catastrophe in Cath Lab: A Pregnant Patient With Fibrosing Mediastinitis for Pulmonary Artery
Stenting
Peggy L. Boles, Madhankumar Sathyamoorthy, M.B.,B.S., Douglas Maposa, M.D., Univ of Mississippi
Medical Center, Jackson, MS
A 27 year-old AAF G2P0101 with an IUP at 20w2d with fibrosing mediastinitis and pulmonary
hypertension scheduled for right heart catheterization (RHC) and pulmonary artery(PA)
ballooning/stenting for worsening heart failure. The OB team was on standby prepared for emergency
caesarian section. She tolerated IV induction with fentanyl, etomidate, and rocuronium. RHC showed
severe bilateral PA stenosis. Balloon angioplasty of the LUL branch and a stent in the RLL branch was
done. At the end of the procedure, patient lost pulses and went into asystole. ACLS protocol for pregnant
patient was followed but was unsuccessful and a stillborn fetus was delivered.
MCC06
3:35 PM - 3:45 PM
Pain Medicine (PN)
Perioperative Ketamine to Mitigate Acute Pain in the CRPS Patient
Max Snyder, M.D., Gritsenko Karina, M.D., Anesthesiology, Montefiore Medical Center, Bronx, NY
A 35 year-old woman with a history of Complex Regional Pain Syndrome (CRPS) originally diagnosed
following a brachial plexus injury sustained after a fall was scheduled for Loop Electrosurgical Excision
Procedure of the cervix. Chronic therapy included multimodal analgesia with ketamine boosters. Due to
concerns of eliciting an acute CRPS exacerbation, the patient was managed with perioperative ketamine
and midazolam. The use of a perioperative ketamine infusion as an adjunct to the general anesthetic
employed in this case successfully prevented an acute exacerbation of the patients chronic CRPS.
MCC06
3:35 PM - 3:45 PM
Anesthetic Management of Combined Surgical Fixation of Upper and Lower Extremities in a
Patient With Recent Traumatic Aortic Injury
Stephanie Opusunju, M.D.,M.P.H., Whalin Matthew, M.D.,Ph.D., Emory University, Atlanta, GA
A 58 year-old man suffered a fall with multiple broken bones and injury to his ascending aorta requiring
emergent ascending and hemiarch replacement. Seven days later he was scheduled for fixation of his
calcaneal and radius fractures. We believed that multiple peripheral blocks carried risk of local anesthetic
toxicity. We therefore performed a spinal with hypobaric bupivacaine in the lateral position and sedated
the patient with dexmedetomidine. When an hour remained in the calcaneal fixation we placed a
supraclavicular block in the lateral position. He had a surgical block by the time we turned supine to fix
the radius.
MCC06
3:35 PM - 3:45 PM
EXIT Procedure for Twin Fetuses With Mandibular Hypoplasia
Anthony T. Tantoco, M.D., Mark A. Goldman, M.D., M.S., Alina Lazar, M.D., Department of Anesthesia &
Critical Care, University of Chicago Medicine, Chicago, IL
A 28 year-old G4P2012 at 30w3d with monoamniotic-dichorionic twin gestation complicated by IUGR and
severe fetal micrognathia presented with PPROM. Given the risk of infection, a cesarean section was
planned with both fetuses to be delivered by EXIT procedure given their difficult airways and potential
need for invasive respiratory support. After uneventful induction of general anesthesia and uterine
incision, both airways were secured by the otolaryngologist using nasal fiberoptic intubation prior to
placental separation. The twins then proceeded to have tracheostomies shortly after delivery.
MCC06
3:35 PM - 3:45 PM
Biventricular ICD Insertion in the Patient With L-Transposition of the Great Arteries, Congestive
Heart Failure, and Severe Pulmonary Hypertension and Obstructive Sleep Apnea
Nathaniel J. Lata, M.D., Jeff Gardner, M.D., Anesthesiology, Wake Forest Baptist Medical Center,
Winston-Salem, NC
Levo-transposition of the great arteries is an acyanotic congenital heart defect in which the aorta,
pulmonary arteries, and left and right ventricles are transposed resulting in congenitally corrected lesion.
Although patients can be asymptomatic at a year-oldung age, the abnormal morphology may later result
in congestive heart failure, conduction abnormalities, and valvular dysfunction. We present a 46 year-old
female with levo-transposition of the great arteries who presents with congestive heart failure requiring
biventricular ICD placement. Her case is complicated by morbid obesity, difficult intravenous access,
pulmonary hypertension, obstructive sleep apnea, and previous substance abuse.
MCC06
3:35 PM - 3:45 PM
Epidural Anesthesia With Intra-arterial Blood Pressure (IABP) Monitoring for Cesarean Section in
a Parturient With Worsening Global Cardiomyopathy
Mun Wong, M.D., Natalie Yonger, M.D., Kalpana Tygaraj, M.D., Anesthesiology, Maimonides Medical
A 35 years G5P3023 40-week gestation parturient with history of chronic hypertension, asthma, morbid
obesity (BMI 49) was presented with worsening global cardiomyear-oldpathy scheduled for cesarean
section. Patient was diagnosed with peripartum global cardiomyear-oldpathy two months earlier, but
repeat echocardiogram performed three days ago showed reduced LVEF from 50% to 40%. We decided
to perform epidural anesthesia with invasive IABP. IABP allowed us to monitor vasodilatory effects of
epidural anesthetics and to treat hypotension readily. Patient had an uneventful cesarean section, was
admitted to telemetry for overnight observation and was discharged POD#4.
MCC06
3:45 PM - 3:55 PM
The ABCs of Myear-oldtonic Dystrophy Type 1 for Coronary Artery Bypass Grafting
Loren M. Babirak, M.D., Janie Nguyen, D.O., James Gagnon, M.D., Angus Christie, M.D.,
Anesthesiology, Maine Medical Center, Portland, ME
56 year-old male with past medical history of Myear-oldtonic Dystrophy type 1, restrictive lung disease,
and CAD s/p multiple PCIs presented with unstable angina and ruled in for NSTEMI by serial cardiac
enzymes. Cardiac catheterization demonstrated progression of CAD; the lesions were determined to not
be amenable to PCI. The patient underwent CABG under general endotracheal anesthesia with
normothermia maintained and use of hyperkalemic cardioplegia. The patient successfully underwent
surgery without significant perioperative complications commonly associated with Myear-oldtonic
Dystrophy by careful perioperative planning.
MCC06
3:45 PM - 3:55 PM
The Perioperative Management of a Patient With Factor V Leiden Thrombophilia and
Pseudocholinesterase Deficiency Presenting for Orthopedic Surgery
Agathe Streiff, M.D., Kevin Sanborn, M.D., Anesthesiology, Mount Sinai St Lukes, Mount Sinai Roosevelt
Hospitals, New York, NY
A 76 year-old woman presented for open reduction and internal fixation of the left ankle. Her past medical
history included asthma, migraines, hypothyroidism, cervical radiculitis, factor V Leiden thrombophilia and
pseudocholinesterase deficiency. Anesthesia was a continuous popliteal fossa sciatic nerve block and left
saphenous nerve block, as well as light sedation. Tourniquet use was avoided to minimize the risk of
venous thrombosis in the leg. Post-operatively, a thromboprophylactic regimen of enoxaparin 40mg once
daily subcutaneously was immediately begun. The popliteal nerve block catheter was removed on postop day 3.
MCC06
3:45 PM - 3:55 PM
Acute Coagulopathy in an Otherwise Healthy Woman: Nutrient Deficiency in a Sea of Plenty
Linda J. Demma, M.D.,Ph.D., Jerrold H. Levy, M.D., Michael J. Connor, Jr., M.D., Department of
Anesthesiology, Division of Pulmonary, Allergy, Critical Care, & Sleep Medicine, Emory University,
Atlanta, GA, Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, NC
A 43 year-old, obese female presented with three days of violaceous skin lesions on her legs and
abdomen. Laboratory results showed elevated transaminases and thrombocytopenia. Extensive
rheumatologic, hematologic and infectious workups were negative. Five days later, the patient had severe
epistaxis and hemoptysis requiring transfer to the intensive care unit. She received 12 units of packed red
blood cells, 2 units of fresh frozen plasma, and 2 units of platelets. Severe vitamin C deficiency was
found, she was started on high-dose vitamin C supplementation and improved. The etiology of
coagulopathy was determined to be scurvy.
MCC06
3:45 PM - 3:55 PM
Intraoperative Pulmonary Embolus in a Morbidly Obese Patient Presenting for Removal of Infected
Hip Hardware
Aaron Low, M.D., Harendra Arora, M.D., Anesthesiology, University of North Carolina at Chapel Hill,
Chapel Hill, NC
A 60-year-old male with a history of obesity, hypertension, diabetes mellitus, and remote history of
superficial venous thrombosis presented to the operating room for removal of an infected hip prosthesis.
The intraoperative course was unremarkable until the patient emerged from anesthesia. Immediately
following repositioning of the patient to the supine position, the patient went into a PEA arrest. Advanced
cardiac life support (ACLS) was immediately initiated. Transesophageal echocardiography revealed direct
evidence of a massive pulmonary embolism. The treatment options, including tissue plasminogen
activator (tPA), extracorporeal membranous oxygenation (ECMO) and emergent thrombectomy will be
discussed.
MCC06
3:45 PM - 3:55 PM
Controversial Use of Sedatives During Awake Intubation in the Anticipated Difficult Airway
Boo Hwi Hong, Seong Hyun Song, Tzung Min Hsu, Ann Misun Yon, Anesthesiology & Pain Medicine,
Chungnam National University Hospital, Daejeon, Korea, Republic of
Awake intubation is the gold standard in patients with presumptuously difficult airway.Although sedatives
are titrated to relieve pain, complications including agitation, un-cooperation, self-respiration depression,
fluctuation of vital signs, prolonged mask ventilation, and airway compromise can occur, contraindicating
the concept of “awake” intubation.Under circumstances where the patient is cooperative, minimal
intervention with proper airway preparation can ease intubation without unnecessary sedatives.We report
a fully conscious 38 year-old woman who underwent awake fiberoptic intubation due to intubation
granuloma with full explanation of the procedure and airway preparation, which ended successfully
without any sedatives or opioids.
MCC06
3:45 PM - 3:55 PM
Anesthetic Management of Parturient With Stage IV Renal Failure, Focal Segmental
Glomerulosclerosis and Severe Hyperkalemia
Michelle E. Kim, M.D., Lester Chua, M.D., Shobana Bharadwaj, M.B.,B.S., Douglas Martz, M.D., Andrew
M. Malinow, M.D., Anesthesiology, University of Maryland Medical Center, Baltimore, MD
At 36 2/7 weeks EGA, a 19 year-old nulliparawith worsening chronic kidney disease (Stage IV- focal
segmental glomerulosclerosis) presented for an urgent cesarean delivery. Her serum potassium was
measured at 6.2 mEq/L; EKG changes were present. Hyperkalemia was corrected with intravenous
insulin/glucose and inhaled albuterol. Calcium was also intravenously injected. After TEG confirmation of
adequate coagulation, we inserted both intra-arterial and hemodialysis (internal jugular) catheters. A
combined spinal-epidural anesthetic was induced. Both mother and neonate tolerated the anesthetic and
surgery without complication. Mother was then taken for immediate hemodialysis.
MCC06
3:45 PM - 3:55 PM
Anesthetic Concerns in a Four year-old Boy With Noonan Syndrome Undergoing Complete Oral
Rehabilitation
Edwin Yue-Hang Chan, M.D., Dorgam Badran, M.D., Margarita Dela Peña, M.D., Anesthesiology, SUNY
Downstate Medical Center, Brooklyn, NY
This is a four year-old boy with Noonan syndrome who presented for oral rehabilitation. Preoperative
examination showed that he had developmental delay, along with pulmonary stenosis and pectus
excavatum causing restrictive lung disease. The patient was orally intubated due to risk of coagulopathy,
and maintained on total intravenous anesthesia as opposed to inhalational agents due to possible
increased risk of malignant hyperthermia. He had increased peak airway pressures at the start, which
was attributed to his restrictive lung disease, and was resolved with changes in ventilator settings. After
the surgery, the patient was extubated, sent to recovery, and discharged home.
MCC06
3:45 PM - 3:55 PM
Emergent Removal of an Intra-cardiac Foreign Body in a Patient With End-stage Renal Disease on
Hemodialysis
Timothy P. Rohman, M.D., Lavinia Kolarczyk, M.D., Department of Anestheisology, University of North
Carolina, Chapel Hill, NC
A 68 year-old male with end-stage renal disease on hemodialysis presented to an outside facility for
symptomatic right subclavian vein stenosis. Subclavian vein angioplasty failed, and stent placement was
attempted. The stent became dislodged and migrated to the heart causing intermittent wide complex
tachycardia. TTE showed the stent entangled in the tricuspid valve. Attempts to remove the stent in
vascular radiology failed and the patient presented to the OR for emergent sternotomy. He continued to
have intermittent episodes of non-sustained ventricular tachycardia until cardiopulmonary bypass. The
stent was removed without significant injury to the tricuspid valve.
MCC06
3:45 PM - 3:55 PM
Propofol Infusion Syndrome at Moderate Doses in an Obese Patient
Craig Belon, M.D.,Ph.D., Oliver Panzer, M.D., Anesthesiology, Columbia University, New York, NY
A 27 year-old, 152 kg, 193 cm male (BMI 41) with non-ischemic dilated cardiomyear-oldpathy and severe
mitral and tricuspid regurgitation presented for elective MV repair and TV replacement and HeartMate II
LVAD. Post-op he was transferred to the CT-ICU intubated with an open chest, on V-A ECMO and
sedated with propofol, fentanyl, midazolam and ketamine drips. By postop day #2, he had developed
rising lactate, CK of 587 U/L and green urine. Propofol infusion syndrome was suspected; the infusion
was discontinued with resolution of symptoms. He was transferred out of the CT-ICU post op day #22.
MCC06
3:45 PM - 3:55 PM
Perioperative Management of a Rare Bleeding Disorder, Alpha-2-Antiplasmin Deficiency, in Patient
Undergoing Bladder Sling Removal
Brenda Satterthwaite, M.D., Fatima Zahir, M.D., Univ of Pittsburgh Med Ctr, Pittsburgh, PA
Patient was a 60 year-old female with past medical history of alpha-2-antiplasmin (A2AP) deficiency
presenting for bladder sling removal. Patient was originally diagnosed with A2AP deficiency in 2008
following an exploratory laparotomy with extreme intraoperative blood loss leading to massive
intraoperative and postoperative blood transfusions with a prolonged ICU stay. For the bladder sling
removal, patient preoperatively received six units of fresh frozen plasma and 250mg of Amicar. Patient
was placed under general anesthesia with no complications. Intra-operative blood loss was within normal
limits of 75mL and patient was sent home safely the same day.
MCC06
3:45 PM - 3:55 PM
Pain Medicine (PN)
Sudden Leg Weakness in HIV Positive Male One Week After a Sacroiliac Joint Steroid Injection
Kathleen Chan, M.D., Pavan Tankha, D.O., Anesthesiology, Yale New Haven Hospital, New Haven, CT,
Anesthesiology, VA Connecticut Healthcare System, West Haven, CT
66 year-old HIV positive male on HAART with history of substance abuse received sacroiliac joint steroid
injections every 4 months under fluoroscopic guidance with good pain relief for several years. One week
after routine injection of 40mg triamcinolone in left sacroiliac joint, he experienced sudden bilateral leg
weakness while on the treadmill and was emergently admitted with additional findings of moon facies and
dorsocervical fat pad. Neurology, Endocrinology, and Infectious Disease were consulted. Iatrogenic
Cushing syndrome secondary to altered P450 metabolism was suspected. Ritonavir was temporarily held
leading to significant resolution of Cushing symptoms.
MCC06
3:45 PM - 3:55 PM
Bilateral Continuous Quadratus Lumborum Nerve Block for Acute Post-Operative Abdominal Pain
After Failed Epidural Analgesia - A Case Presentation
Michael G. Morgan, Ehab Farag, M.D., Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
We present a case of acute abdominal pain after complex abdominal surgery in an ulcerative colitis
patient. Analgesia was achieved with bilateral continuous quadratus lumborum (QL) blocks after a
preoperative T9-T10 epidural was deemed ineffective on post-operative day 1. The blocks covered levels
from T8-L3 dermatomes bilaterally, resulted in improved pain scores (reduced from 7 to a 4/10), and
decreased the need for opiates. We experienced no significant changes in hemodynamics or appreciable
muscular weakness as assessed by ambulation. This represents the first successful bilateral continuous
QL block used in place of epidural for postoperative analgesia and patient comfort.
MCC06
3:45 PM - 3:55 PM
Unexpected Pediatric Difficult Airway (DA) in a Healthy Child: Case Report
Angela C. Mota, M.D., Marta Araújo, M.D., Filipa Pereira, M.D., Alexandra Saraiva, M.D., Sónia Duarte,
M.D., Miguel Pereira, M.D., Zélia Moreira, M.D., Isabel André, M.D., Ana Machado, Anesthesiology,
Centro Hospitalar do Porto, Porto, Portugal, Centro Hospitalar do Porto, Porto, Portugal
Girl,7 yr,ASA I,adenotonsillectomy.Outpatient OR:facial mask (FM) ventilation ok;orotracheal intubation
(OTI)- laryngoscopy grade IV,4 attempts,2 experienced operators,rigid stylet (RS) and Bougie®,no
success>unexpected difficult laryngoscopy.No hemodynamic alterations,SatO2>80%.Surgery postponed
to inpatient OR with DA Team support.Inpatient OR: Airway evaluation ok (Mallampati II). 2
anesthesiologists in OR: decided to do a videolaryngoscopy. Induction: Sevoflurane+N2O+Fentanyl,good
cooperation.Ventilation ok (FMnr2+1 operator+Guedel nr2).Laryngoscopy: Glidescope®+ pediatric blade
nr2; 1st try: adenotonsillar hypertrophy,“videolaringoscopy grade II"- tried to put oral RAE 6 with cuff +
RS>difficulty guiding tube.2nd try: same operator,RS exchanged for Glidescope® stylet (adult,no pediatric
available;due precautions)>successful OTI.Surgery, extubation and recovery uneventful.DA reference
letter elaborated
MCC06
3:45 PM - 3:55 PM
Dextrocardia And Perioperative Considerations
Samir Shah, Malwina Wloch, M.D., Peter Oleszak, M.D., Renata Kowal, M.D., Stony Brook University
Hospital, Stony Brook, NY
We present a 76 year-old male with dextrocardia presenting with triple vessel disease with severe mitral
regurgitation and mildly diminished left ventricular function. The CT scan of his chest confirmed
dextrocardia with situs solitus. He subsequently underwent a three vessel coronary artery bypass grafting
with mitral valve repair and ligation of persistent left SVC on a cardiopulmonary bypass. Intraoperatively,
the patient underwent a smooth transition to cardiopulmonary bypass with a subsequent surgical
intervention, followed by an uneventful separation from cardiopulmonary bypass. An understanding of the
underlying anatomy and physiology allowed for successful perioperative management of a patient with
dextrocardia.
MCC06
3:45 PM - 3:55 PM
A Case of Acute Fatty Liver of Pregnancy: Obstetric and Anesthetic Implications
Martin Krause, David Gambling, M.D., FRCPC, Arturo Mendoza, M.D., Anesthesiology, University of
California San Diego, Anesthesiology, Pathology, Sharp Memorial Hospital San Diego, San Diego, CA
A 23 year-old female gravida 3 para 1 abortus 1 at 36 weeks presented with nausea, vomiting, abdominal
pain, pruritus and icterus. Her past medical history was significant for newly diagnosed gestational
diabetes. Otherwise her pregnancy has been uneventful. Her laboratory work revealed elevated
transaminases, impaired hepatic and renal function and hypoglycemia. Her platelet and red blood cell
count were normal and markers of hemolysis were negative. Her hepatitis serology was negative,
ceruloplasmin and alpha-1-antitrypsin were within normal limits. Abdominal ultrasound revealed hepatic
steatosis but no signs of cholecystitis or cholelithiasis.
MCC06
3:55 PM - 4:05 PM
Anesthetic Management of a Patient With a Large Posterior Mediastinal Mass
Yasuko Nagasaka, Tong-Yan Chen, M.D., Anesthesia, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA
A 40 year-old man with Type 1 neurofibromatosis and complicated medical/surgical history, presented
with worsening dyspnea and swelling in his face and upper extremities. Chest CT (Image) revealed a
right posterior mediastinal mass with compression on the airway,right lung, SVC and heart. The patient
underwent resection of the mass via combined mediastinostomy and right thoracotomy. Anesthesia was
challenged by potential difficult airway, SVC syndrome, right lung compression, cardiac compression and
major intraoperative blood loss. The surgery was successful. The patient was extubated on postoperative
day 1 with significant improvement of his symptoms. He was discharged home on postoperative day 10.
MCC06
3:55 PM - 4:05 PM
Perioperative Management of an Adult Patient With Idiopathic Subglottic Stenosis
Frances L. Karam, M.D., Neil Bailard, M.D., Baylor College of Medicine, Houston, TX
This is a 36 year-old otherwise healthy woman who presents to pre-operative clinic for direct
laryngoscopy and biopsy with dilation. The patient has biphasic stridor but with 100% saturations on room
air and while laying flat. The patient has a 2 cm long focal stenosis, 2 cm below level of vocal cords with
airway measuring 9 mm at the level of the stenosis. We designed an algorithm that aids in the anesthetic
management of such patients. Based on this we decided for an IV induction and both supraglottic
ventilation and ventilation through the bronchoscope.
MCC06
3:55 PM - 4:05 PM
Recurrent Hemoptysis Secondary to Gastropulmonary Fistula Following Bariatric Surgery in a
Patient With Hemophilia B
Leila W. Zuo, M.D., Bryan T. Romito, M.D., Anesthesiology and Pain Management, University of Texas
The patient is a 44 year-old male with morbid obesity that underwent laparoscopic sleeve gastrectomy in
2013 complicated by excessive postoperative bleeding. He was admitted to the ICU in March 2015 for
LUQ pain, left chest pleurisy, and persistent cough with the production of blood and food. CT scan
revealed evidence of gastric leakage with gastropulmonary fistula formation. Bronchoscopy demonstrated
pooling of blood in the LLL. Given his recurrent bleeding, coagulation studies were sent and the patient
was found to have hemophilia B. Endotracheal intubation with directed bronchial blocker placement was
performed to secure his airway and isolate pulmonary hemorrhage.
MCC06
3:55 PM - 4:05 PM
Use of Ventrain Expiratory Ventilation Assistance Device in a Patient With Subglottic Stenosis
Secondary to Recurrent Squamous Cell Carcinoma
Michael D. Casimir, M.D., Fanny Wong, M.D., Samrawit Goshu, M.D., Yale-New Haven Hospital, New
Haven, CT
We present the successful use of the Ventrain® expiratory ventilation assistance device in a 68 year-old
female with history of tongue and floor of mouth squamous cell carcinoma s/p resection, radiation, and
chemotherapy. She presented to the OR for urgent resection of partial subglottic obstruction with
symptoms of dyspnea and inability to lie flat. Direct laryngoscopy was performed by surgeon after
inhalational induction. High pressure flow-controlled ventilation was initiated with Ventrain® device.
Oxygen saturation remained 100% during placement of urgent tracheostomy. Ventrain® is a useful
modality to be employed in management of difficult airways and airway emergencies.
MCC06
3:55 PM - 4:05 PM
Familiarizing the Difficult Airway Management Algorithm: Taking the Alternative When
Encountering Unanticipated Postintubation Tracheal Stenosis
Tzung Min Hsu, Seong Hyun Song, Ann Misun Yon, Seok Hwa Yoon, Anesthesiology & Pain Medicine,
Chungnam National University Hospital, Daejeon, Korea, Republic of
Encountering patients with unanticipated laryngotracheal stenosis during anesthetic induction is
challenging. Anesthesiologist must be familiar with the practice guidelines on difficult intubation and have
backup plans in case first attempts at intubation are unsuccessful. Preoperative assessment and
postoperative airway maintenance considered crucial to avoid complications such as airway edema,
bleeding, obstruction, and ultimately respiratory failure. We report an unanticipated tracheal stenosis
during anesthetic induction which hindered endotratreal intubation in a 69 year-old woman. After multiple
attempts with smaller diameter tubes and supraglottic airway devices failed, we postponed surgery until
localizing the stenosis, and performed a successful continuous epidural block
MCC06
3:55 PM - 4:05 PM
Successful Management of Autonomic Dysreflexia in the Gravid Quadriplegic
Lauren C. Hodgson, D.O., Lori Kral Barton, M.D., Brandon Gish, M.D., Luke Bennett, M.D., Regina
Fragneto, M.D., Anesthesiology, University of Kentucky, Lexington, KY
A C6 quadriplegic female, presented at 33 weeks with urinary tract infection. Past medical history was
significant for preeclampsia prior to neurological accident. During admission, patient was diagnosed with
deep vein thrombosis requiring heparin infusion. Within 24 hours, she developed severe hypertension
with cervical changes. Given concern for autonomic dysreflexia, heparin infusion was held. Once
activated prothrombin time was <40 seconds, epidural was placed. Epidural dosing was titrated to blood
pressure. She had no further episodes of hypertension during labor or several hours after spontaneous
vaginal delivery. Low molecular weight heparin was started two hours following removal of epidural
catheter.
MCC06
3:55 PM - 4:05 PM
Epidural Blood Patch for Management of a Post-surgical Pseudomeningocele in a Pediatric
Patient
Carrie C.M. Menser, M.D., Andrew Franklin, M.D., Robert Naftel, M.D., Anesthesiology, Pediatric
Neurosurgery, Vanderbilt University Medical Center, Nashville, TN
A pediatric patient with cerebral palsy and spastic quadriparesis was referred to the pediatric pain service
regarding management of a post-surgical pseudomeningocele. The patient recently underwent baclofen
pump placement for spasticity. Postoperatively, she developed swelling around her lumbar spine and
abdominal incisions, consistent with a CSF cutaneous fistula and a postsurgical pseudomeningocele.
Conservative therapy with an abdominal binder was unsuccessful. To seal the CSF fistula and reduce the
pseudomeningocele, a lumbar epidural blood patch was performed using fluoroscopic guidance to avoid
disruption of the existing intrathecal catheter. The procedure provided complete resolution of the
pseudomeningocele without recurrence.
MCC06
3:55 PM - 4:05 PM
Cardiac Herniation After Pulmonary Wedge Resection With Pericardial Resection
Julia R. Menshenina, M.D., Maya Jalbout Hastie, M.D., Department of Anesthesiology, Columbia
University Medical Center, New York, NY
Cardiac herniation is a rare complication of pneumonectomy/lobectomy not reported after wedge
resection. A 62 year-old man underwent VATS wedge resection of 50% of the left upper lobe for lingular
adenocarcinoma. Three square inches of pericardium were removed with adherent tumor.
Postoperatively, the patient developed ventricular fibrillation refractory to resuscitation. Other causes of
cardiovascular collapse were eliminated and cardiac herniation through the pericardial defect was
suspected. Bedside thoracotomy confirmed herniation with cardiac apical strangulation. The pericardium
was opened and cardiac massage performed. The patient required ECMO support until cardiac function
recovered. Cardiac herniation is catastrophic and necessitates prompt diagnosis and treatment.
MCC06
3:55 PM - 4:05 PM
Anesthetic Management of Toxic Shock Syndrome
Benjamin E. Illum, M.D., Lance Patak, M.D., Anesthesiology, UC San Diego, San Diego, CA
A 20 year-old male was taken to the operating room for emergent washout of a septic joint with rapidly
expanding erythema and systemic toxicity. He presented with fever, tachycardia, and hypotension
requiring vasopressors. He also had nausea, vomiting, increased work of breathing, bilateral pleural
effusions, acute kidney injury, thrombocytopenia, and coagulopathy. The case was complicated by
persistent hypoxia and hemodynamic collapse. Intraoperative management included rapid placement of
central access, escalation of inotropic and vasopressor support, and use of transesophageal ECHO to
guide therapy. Wound cultures later revealed S. pyear-oldgenes, a rare, aggressive infection with
mortality rates 30-60%.
MCC06
3:55 PM - 4:05 PM
Obstetric Anesthetic Management of Two Patients With Spontaneous Intracranial Hypotension:
Differing Scenarios
Sangeeta Kumaraswami, M.D., Ashley T. Kydes, M.D., Shivakeerthy S. Ubranimath, M.D.,
Suryanarayana M. Pothula, M.D., Anesthesiology, New York Medical College, Valhalla, NY
Spontaneous Intracranial Hypotension(SIH) occurs in approximately five per 100000 people. The
anesthetic management of two obstetric patients with SIH is further described. The first patient was
diagnosed with SIH three years prior to her pregnancy, while the second developed the pathology during
her pregnancy. The first patient was managed with epidural blood patches at six month intervals. She had
an uneventful vaginal delivery with epidural analgesia. The second patient developed orthostatic
headaches at 35 weeks gestation and diagnosis of SIH was made by MRI. She received an epidural
blood patch and later had an uneventful elective cesarean section under general anesthesia.
MCC06
3:55 PM - 4:05 PM
Pain Medicine (PN)
Spine on Fire: Unprecedented Pain of Pachymeningitis
Manmeet S. Bedi, M.D., Robert Nastasi, M.D., Sebastian Thomas, M.D., SUNY Upstate Department of
Anesthesiology and Pain Medicine, Syracuse, NY
Hypertrophic Pachymeningitis s a rare, inflammatory condition that causes thickening of the cranial and
spinal dura mater, leading to symptoms associated with mass effect, nerve compression, or vascular
compromise.Two forms of this condition have been described: “Primary” or “Idiopathic Hypertrophic
Pachymeningitis” and “Secondary” where identifiable causes have been demonstrated to co-exist with the
conditions. The differential diagnosis of HP includes malignancies (Lymphoma), immune-mediated
conditions (Wegener’s Granulomatosis), and infections. We present a case of a 36 year-old male with a
history of multiple attacks of infectious meningitis, combined variable immunodeficiency disease,
hypogonadism, and MRI evidence of Pachymeningitis.
MCC06
3:55 PM - 4:05 PM
Treatment of an Ischemic Stroke With TPA and Thrombectomy on a Patient With Recent Epidural
Catheter Removal
Sachin (Sunny) Jha, M.D., Anesthesiology, Rush University Medical Center, Chicago, IL
64 year-old male with a history of atrial fibrillation uneventfully underwent TKA via epidural catheter and
MAC. He received transexamic acid intraoperatively. Epidural was discontinued on POD one. Two hours
afterwards, he developed acute left hemiplegia, dysarthria and left hemi sensory loss. CT demonstrated
ischemic right MCA CVA. TPA was given 43 minutes with thrombectomy performed 60 minutes after
symptom onset. Afterwards, his neurologic exam had normalized except for a slight LUE pronator drift. He
was subsequently placed on epidural hematoma precautions. He did not develop a hematoma and was
discharged with a normal neuro exam.
MCC06
3:55 PM - 4:05 PM
Neonatal Catecholamine Secreting Neuroblastoma: A Case Undergoing Laparoscopic Surgery
KYosuke Takahashi, M.D., Soichiro Obara, M.D., Norifumi Kuratani, M.D.,Ph.D., Anesthesiology, Saitama
Medical Center, Saitama, Japan
A 3-week-old 3kg neonate was scheduled for laparoscopic tumor resection. He was born at term with
hypertension and tachycardia, and abdominal echography identified a left suprarenal tumor. He was
sequentially administered an ACE inhibitor, α-blocker, and β-blocker. During the laparoscopic procedure,
sodium nitroprusside, nicardipine, and esmolol were administered because of hypertensive crisis on
tumor manipulation. His SBP and HR were maintained at less than 100 mmHg and 200 bpm,
respectively. The tidal volume decreased with pneumoperitoneum; therefore, high airway pressure and
FiO2 were needed during the laparoscopic procedure. Hypertension persisted after the surgery, and it
was controlled with oral medications.
MCC06
3:55 PM - 4:05 PM
Atrial Myxoma In A Pregnant Patient
Malwina Wloch, M.D., Samir Shah, M.D., Renata Kowal, M.D., Peter Oleszak, M.D., Stony Brook
We present a 25 year-old female no past medical history, in third trimester of pregnancy, who presented
to the emergency department with two week history of cough and hemoptysis. Further work up of the
patient showed a large mobile left atrial mass attached to the fossa ovalis of interatrial septum, consistent
with atrial myxoma. An interdisciplinary approach was initiated by the obstetric, cardiothoracic surgery,
and anesthesia teams. Subsequently, the patient underwent an open heart surgery requiring
cardiopulmonary bypass with successful removal of the mass. Approximately ten weeks later, the patient
delivered a full-term baby via C-section without any complications.
MCC06
3:55 PM - 4:05 PM
Cesarean Hysterectomy And Placenta Percreta
Bailor L. Hardman, M.D., Jerry W. Green, D.O., Anesthesiology and Pain Management, University of
Texas Southwestern, Dallas, TX
A 22 year-old term pregnancy patient (gravida 4 parity 2 with 2 previous cesarean sections) presented
with extensively invasive placenta percreta for cesarean hysterectomy. Invasive monitors were placed
and blood products available. Uneventful delivery was accomplished with spinal analgesia, allowing time
for bonding. General anesthesia was induced. Subsequent hysterectomy resulted in a significant
consumptive coagulopathy which was managed with early fibrinogen, massive transfusion protocol, and
minimal crystalloid dilution. Excess fibrinolysis was avoided. Acid base status was optimized and used to
guide resuscitation. The patient and healthy neonate were discharged 6 days later after uneventful
postoperative recovery.
MCC06
4:05 PM - 4:15 PM
Pacemaker-Induced Severe Mitral Regurgitation After Minimally Invasive Aortic Valve Repair
Muhammad Muntazar, M.D., Ahmed Awad, M.D., Andrea Creamer, B.S., Taral Patel, D.O., Michael
Rosenbloom, M.D., Cardiothoracic Anesthesia, Cardiac Surgery, Anesthesiology, Cooper Medical School
of Rowan University, Camden, NJ
We report a case of a 78 year-old man who underwent minimally invasive aortic valve replacement for
aortic stenosis. At the end of common pulmonary bypass, the patient developed complete heart block and
required right epicardial pacing. Post-operative TEE revealed severe mitral regurgitation. A midline
sternotomy, re-institution of common pulmonary bypass, and mitral valve repair was planned to correct
the mitral regurgitation. Instead of mitral valve repair, the pacing wire was moved from the right ventricle
to the left ventricle. This change in the lead position resolved the mitral regurgitation and patient did not
require any further intervention.
MCC06
4:05 PM - 4:15 PM
Super Obesity: A Case of a Difficult Airway Outside the Operating Room
Lisa L. Klesius, M.D., Shalini Borden, M.D., Jeffrey Lee, M.D., Anesthesiology, University of Wisconsin
Hospital and Clinics, Madison, WI
42 year-old male with super obesity (BMI of 120, 365 kg) and IDDM presented to the emergency
department with respiratory failure secondary to Fourier’s gangrene-induced sepsis. Emergent intubation
was attempted with awake fiberoptic intubation by resident and staff anesthesiologist with visualization
impaired by redundant soft tissue. LMA was placed, and bronchoscope guided through LMA in
conjunction with Arndt exchange catheter to place ETT. Saturations were maintained above 90,
hemodynamics were stabilized, and the patient was treated successfully in the ICU thereafter. LMA with
bronchoscopy and exchange catheters should be considered in presumed difficult airways inside and
outside the operating room.
MCC06
4:05 PM - 4:15 PM
An Intraoperative Presentation of a Spontaneous and Rare Cardiomyopathy.
Erica Patel, D.O., Adil Mohiuddin, M.D., Boris Veksler, M.D., Anesthesia, Rutgers University Robert Wood
A 46 year-old female (Ht 5’4, Wt 150lbs) with a PMH of hyperlipidemia presented for an elective
hysterectomy. Patient was given Midazolam prior to induction of anesthesia. Patient was induced with
Propofol, Fentanyl, and Rocuronium. She was hemodynamically stable following induction. During the
procedure, the patient became asystolic and hypotensive. Atropine and epinephrine was administered.
An urgent intraoperative transesophageal echocardiogram showed hypokinesis in the apical region and
an ejection fraction of 35%. An EKG/echocardiogram showed “classic” findings of Takotsubo
cardiomyear-oldpathy. A cardiac catherization was negative for coronary disease. Repeat
echocardiogram one week later showed an ejection fraction of 60%.
MCC06
4:05 PM - 4:15 PM
Sidestepping the Triple Low in the Case of an Emergent High Five
Richard S. Thorsted, M.D., Christopher V. Maani, M.D., Daniel R. Stypula, M.D., Anesthesiology, Brooke
Army Medical Center, San Antonio, TX
78 year-old ASA 5E with PMH significant for acute NSTEMI, severe CAD, CHF with EF 10%, and CRI
presented with bowel ischemia requiring emergent exploratory laparotomy. Anesthetic challenges also
included marked aniongap metabolic acidosis, severe anemia, and recent Plavix/ASA use. After RSI
using fentanyl, etomidate, and succinylcholine, GETA was maintained with BIS-guided low MAC
Sevoflurane and high dose Fentanyl to maintain MAPs above 60 mmHg. After uneventful anesthetic
course, patient wastransported to SICU intubated. Aggressive monitoring with IBP, BIS and continuous
STs helps tailor anesthetic management of critically ill elderly patients.
MCC06
4:05 PM - 4:15 PM
Intraoperative Cardiovascular Collapse Associated With Methylmethacrylate Use
Natalie Trautman, M.D., Kelly Bolkus, D.O., Richard Domsky, M.D., Talia Ben-Jacob, M.D., Cooper
University Hospital, Camden, NJ
An 89 year-old female with a traumatic right femoral neck fracture presented to the operating room for hip
hemiarthroplasty. Cardiac arrest occurred intraoperatively immediately following methylmethacrylate
application into the joint space. Bedside TTE showed RV dilation and hypokinesis. She underwent
multiple rounds of CPR with transfer to the ICU but was ultimately unable to be resuscitated. We discuss
the pathophysiology, early recognition, and management of intraoperative BCIS due to
methylmethacrylate use in hip arthroplasty.
MCC06
4:05 PM - 4:15 PM
Perioperative Management of Disseminated Intravascular Coagulation in the Peripartum Period in
a Patient With Intrauterine Fetal Demise
Nicole A. Wielandt, D.O., Martha M. Chacon, M.D., University of Nebraska Medical Center, Omaha, NE
27 year-old female 32weeks pregnant was admitted for induction of labor after symptoms of abdominal
pain, ultrasound confirming intrauterine fetal demise and possible abruption. Medical history was
complicated by SSA and SSB antibodies, HTN, IUGR, ITP and Rh negative status. She was found to
have Preeclampsia and maternal DIC and was transfused with FFP and PRBCs. She ultimately required
cesarean section under GETA for continued bleeding and symptoms of severe preeclampsia. This case
describes the management of a patient in DIC during the peripartium period and offers an opportunity to
review the pathophysiology and anesthetic considerations in this patient population.
MCC06
4:05 PM - 4:15 PM
Non Invasive Ventilation(NIV) In Pediatric Population- A Tool For Improved Oxygenation
Alia Safi, M.D., AbaYomi Akintorin, M.D., Ned Nasr, M.D., Reza Borna, M.D., Anesthesiology and Pain
Management, John H. Stroger Hospital of Cook County, Chicago, IL
Rapid arterial desaturation in the pediatric population is a problem anesthesiologists face. This challenge
was overcome by preoxygenating using RAM cannula(heated high flow nasal cannula) to prevent hypoxic
events. We present a case of a premature infant scheduled for gastric tube placement. Anesthetic
consideration for the patient to be high risk for aspiration brought us to proceed with rapid sequence
induction with the RAM cannula in place. This resulted in successful intubation without any arterial
desaturation. Neonates are well known obligate nasal breathers; therefore the RAM cannula was the
most suitable method to use for oxygenation and non invasive ventilation.
MCC06
4:05 PM - 4:15 PM
Echocardiogrpahy and its Application for Managing Patients With Clear Cell Carcinoma
Benjamin Krasne, M.D., Miguel Cobas, M.D., Hani Murad, M.D., Oscar Aljure, M.D., Anesthesia,
University of Miami, Miami, FL
62y F with right renal mass who underwent right radical nephrectomy with IVC reconstruction. TEE was
used intraoperatively to identify the tumor thrombus in the IVC and to evaluate degree of extension.
Concern was for extension of tumor thrombus into the right atrium necessitation placing the patient on
cardiopulmonary bypass. With the use of TEE the mass was seen to not extend into the RA and the
tumor thrombus was not adherent to the IVC. Use of intraoperative TEE aided in the surgical approach
and successful resection of the tumor with IVC reconstruction as well as avoidance of CPB use.
MCC06
4:05 PM - 4:15 PM
Massive Hemoptysis in a Patient Previously Treated With Bleomycin Leads to Death by Diffuse
Alveolar Hemorrhage
Jennifer B. Evansmith, M.D., Theofilos Matheos, M.D., Dept of Anesthesia, Univ of Massachusetts
Medical Center, Worcester, MA
A 63 year-old female with a history of Hodgkins’ lymphoma treated with bleomycin 40 years ago
presented with dyspnea and fever. She was recently diagnosed with lymphoma recurrence and
pulmonary embolism treated with home oxygen and anticoagulation. She was admitted to the ICU for
increased oxygen requirements and hemoptysis. She required emergent intubation, upon which the
endotracheal tube filled with blood. She remained hypoxic and difficult to ventilate. Bronchoscopy
revealed diffuse alveolar hemorrhage (DAH). She continued to have marked hemoptysis and died shortly
after admission. We will discuss the management of DAH and review the current literature on bleomycin
pulmonary toxicity.
MCC06
4:05 PM - 4:15 PM
Trauma During Pregnancy
Seiha T. Kim, D.O., Ashley L. Talbott, M.D., Anesthesiology, Wake Forest Baptist Health, Winston Salem,
NC
A 39 year-old, 102 kg, female with no PMH was a restrained passenger involved in a MVA where she
was ejected from the vehicle en route to an OSH in active labor with a term pregnancy. Per OSH report
prior to transfer, patient was HDS, GCS 14, with physical exam findings to include anisocoria, bilateral
femur fractures, gravid uterus, regular contractions, and 3 cm cervical dilation. Within minutes of arrival to
our hospital, she becomes combative, confused, tachypneic, and hypoxic with increasing oxygen
requirement. What to do next?
MCC06
4:05 PM - 4:15 PM
Pain Medicine (PN)
Continuous Paravertebral Infusion for Analgesia in a Patient With Lytic Thoracic Spine Metastasis
Andrew T. Leitner, M.D., Anesthesiology / Interventional Pain Management, City of Hope National
Medical Center, Los Angeles, CA
A 61 year-old male with treatment-refractory lymphoma and thrombocytopenia presented with progressive
right unilateral interscapular pain, particularly with prolonged sitting and standing. PET-CT scanning
showed epidural tumor extension from lytic metastases at the T3 level. Oral hydromorphone and
gabapentin caused excessive sedation and insufficient analgesia. The patient expressed his wish to
tolerate standing for four hours at his upcoming wedding ceremony. Following platelet transfusion, a rightsided ultrasound-guided paravertebral catheter was placed at the T3-T4 level. An infusion of 0.2%
ropivacaine via On-Q* system was utilized, achieving 75% pain reduction during his ceremony and for the
following week with catheter in place.
MCC06
4:05 PM - 4:15 PM
Harlequin Syndrome Due to Extrapleural Catheter
Frederick Hasty, Jarrod Wilson, M.D., Adriana Vivas, David Taylor, Anesthesiology, Mt Sinai Medical
Center, Miami Beach, FL
78 f underwent an uneventful robotic left lower lobe resection of the lung with an On-Q extrapleural
catheter for post-op analgesia and was brought to the recovery room. Approximately 2 hours later, the
patient developed demarcated facial flushing of the right face. All vitals signs remained stable and the
flushing resolved the same day in the ICU. However, at the time of presentation, both surgeon and
anesthesiologist alike could not explain the finding. This case seeks to review acquired Harlequin
syndrome paying particular attention to the anatomy of the sympathetic nervous system and how to
manage this rare condition.
MCC06
4:05 PM - 4:15 PM
Fiberoptic Intubation Through an I-gel® Laryngeal Mask in a Patient With Severe Head and Neck
Post-burn Contractures
Cátia Real, Joana Guimarães, Rita Frada, Anesthesiology, Centro Hospitalar do Porto, Porto, Portugal
A 15 year-old adolescent with severe post-burn contractures of the upper body, including the face and
neck, was scheduled for upper limb plastic surgery. Extreme anxiety during medical procedures excluded
the option for regional anesthesia. Presented with limited mouth opening, Mallampati III, reduced neck
mobility and tyromental distance. Anesthesia was induced with sevoflurane. An oropharyngeal tube was
used to overcome upper airway obstruction maintaining spontaneous ventilation until the airway was
secured. Fiberoptic intubation (orotracheal tube 6.0) through a laryngeal mask airway size 4 (I-gel®) was
proceeded with success. A tube exchanger was applied to safe mask removal. Extubation occurred
without complications.
MCC06
4:05 PM - 4:15 PM
Atrial Flutter Ablation in Patient With Previous MVR, Cardiac Stent Placement, and Anthracycline
Treatment
Tthomas Blanchette, M.D., University of Wisconsin, Madison, WI
44 year-old obese male with PMH of lymphoma s/p anthracycline and bleomycin therapy is scheduled for
atrial flutter ablation in the cath lab. Previous MVR, cardiac stent placement X2, and current cocaine and
marijuana abuse. Current symptoms include dyspnea even while at rest. Known difficult airway with failed
direct laryngoscopy in past.
MCC06
4:05 PM - 4:15 PM
Unintentional Catheterization of the Intrathecal Space: A Case of Difficult Detection and Injection
of a High Volume, Low Concentration Local Anesthetic Bolus
Deepa Asokan, M.D., Antonio Gonzalez-Fiol, M.D., Department of Anesthesiology, Rutgers University New Jersey Medical School, Newark, NJ
Patient is a 20 year-old female who presented for induction of labor. She had an epidural placed for labor
pain. Test dose through the epidural catheter was negative and there was no CSF upon aspiration. Pt
was bolused with 8cc of 0.25% bupivicaine through the catheter and was found to have a dense spinal
block. This case discusses the difficulty in detecting an intrathecal catheter, the efficacy of the test dose,
and how high volumes of low concentration of local anesthetic in the intrathecal space can provide a
dense block.
MCC06
4:15 PM - 4:25 PM
Repeated Cardioplegic Arrest of Donor Allograft During Orthotopic Heart Transplant
Natalia Martinez Acero, M.D., M.S., Theodore J. Cios, M.D.,M.P.H., Erina Ng, Dmitri Guvakov, M.D.,
M.S., Anesthesiology, Penn State Hershey Medical Center, Hershey, PA
Primary graft failure is the leading cause of death in the first month after orthotopic heart transplant
(OHT)¹. The main risk factor is prolonged ischemic time of the donor allograft² ³. We report an OHT in a
57 year-old man with multiple significant comorbidities. Intraoperative course was complicated by LVAD
outflow graft injury, traumatic aortic tear of the donor graft identified after reperfusion requiring repeated
cardioplegic arrest, stunned myear-oldcardium, right ventricular failure and severe pulmonary
hypertension. Total graft ischemic time was 217 minutes. We demonstrate a successful outcome in the
first year with aggressive pharmacological management, avoiding high-risk mechanical circulatory
support.
MCC06
4:15 PM - 4:25 PM
Hypercoagulability from Elevated Factor VIII in a Jehovah’s Witness Presenting for Vascular
Surgery
Michael P. Bokoch, M.D.,Ph.D., Nathalia G.A. Ferreira, M.D., Ahmed Shalabi, M.D., Anesthesia and
Perioperative Care, University of California, San Francisco, San Francisco, CA, Anesthesia, Federal
University of Rio de Janeiro, Rio de Janeiro, Brazil
A 49 year-old male Jehovah’s Witness presented with rapidly enlarging bilateral femoral artery
pseudoaneurysms. He had a history of multiple prior arterial thromboses (infrarenal aortic occlusion,
cerebrovascular accident, and recurrent peripheral occlusions) but no history of venous
thromboembolism. Hematology workup revealed elevated plasma levels of coagulation Factor VIII as the
likely cause of hypercoagulability. There was preexisting anemia, and thorough preoperative discussion
was held regarding which blood products and fractions were acceptable to the patient. As the patient
refused allogeneic RBC transfusion, it was necessary to perform a staged repair of the aneurysms to limit
surgical blood loss.
MCC06
4:15 PM - 4:25 PM
Perioperative Management of a Patient With Acquired Factor VIII Inhibitors
Paul Lapis, B.S., Joseph Kimmel, M.D., J. David Roccaforte, M.D., Department of Anesthesiology, New
York University, New York, NY
45 year-old man with unknown PMH presented with left lower extremity pain, denying recent trauma.
Initial workup was consistent with compartment syndrome. Significant airway bleeding was observed
during intubation after failed attempts in the ED. Patient underwent emergency posterior leg fasciotomy
and intraoperatively received two units of pRBCs. Patient was transferred to SICU hemodynamically
stable. Patient underwent DIC workup due to excessive bleeding, isolated PTT elevation, and nonreactive
thromboelastogram requiring continued transfusions. Patient was found to have decreased factor VIII
levels and diagnosed with Acquired Factor VIII Inhibitors. Further operative care for fasciotomy was
managed with Novoseven repletion without requiring transfusion.
MCC06
4:15 PM - 4:25 PM
Quadriparetic Man With a Cervical Fusion and an Indwelling Intrathecal Catheter to Undergo
Femoral ORIF
Jacob Esquenazi, M.D., Philip Lebowitz, M.D., Anesthesiology, Montefiore Medical Center, Bronx, NY
65 year-old obese quadriparetic male crashed his van into the hospital and required right femur ORIF.
PMHx cervical fracture leading to qudriparesis treated with C4-C7 fusion, intractable leg pain s/p
intrathecal morphine pump, HTN, CAD, CHF, OSA on BiPAP, and GERD. Uses a motorized wheelchair
but could ambulate with platform crutches for short distances. Physical exam: short thick neck, goatee,
edentulous, Mallampati 3, limited neck extension, and short thyromental distance. Alert and oriented,
sensation intact. Vitals stable and labs normal. ECG: NSR with pulmonary disease pattern.
Pharmacologic stress test revealed asymptomatic inferior wall ischemia. Recent transthoracic
echocardiogram showed no hypokinesis.
MCC06
4:15 PM - 4:25 PM
The Anesthetic Management of a Patient With McArdle's Disease
Debra E. Lederman, D.O., Lyle Leipziger, M.D., Sheldon Newman, M.D., Anesthesiology, Surgery, Long
Island Jewish Medical Center, New Hyde Park, NY
We present a case of a 30 year-old woman with a history of McArdle's Disease (Glycogen Storage
Disease Type V) coming for breast reconstructive surgery. McArdle's Disease is a rare autosomal
recessive condition ( ~1 in 100,000 people) affecting skeletal muscle caused by a non-functioning myearoldphosphorylase C enzyme responsible for glucose metabolism. Patients present with fatigue and
severe pain after exertion. Anesthetic management included maintaining normothermia, infusion of
glucose containing solutions, maintaining adequate hydration, maintenance of normal electrolytes and
prevention of fasciculations with non-depolarizing muscle relaxants. Postoperative pain management is
also important.
MCC06
4:15 PM - 4:25 PM
Massive Hemorrhage After Spontaneous Uterine Rupture Caused by Placenta Percreta
Aly D. Branstiter, M.D., David L. Stahl, M.D., Anesthesiology, Ohio State University, Columbus, OH
A 34 year-old G5P1122 with monoamniotic-monochorionic twins and suspected placenta accreta by
ultrasound acutely developed abdominal pain and hypotension with fetal bradycardia. The patient was
brought to the operating room for an emergent cesarean section under general anesthesia. She was
found to have uterine rupture and placenta percreta with invasion into the bladder. Following delivery,
emergent hysterectomy and bladder resection were performed. The patient had ongoing massive
hemorrhage and required coordinated resuscitation with a high volume of blood products. With excellent
communication and multidisciplinary teamwork, the patient and twins had a successful outcome.
MCC06
4:15 PM - 4:25 PM
Bronchoscopic Concerns in Proteus Syndrome: A Case Report
Eunsoo Kim, M.D., Hyeon-Jeong Lee, M.D.,Ph.D., Jeong-Min Hong, M.D., Hae-Kyu Kim, M.D.,Ph.D.,
Hye-Jin Kim, M.D., Ki-Chan Yoo, M.D., Department of Anesthesia and Pain Medicine, Pn National
University Hospital, Bn, Korea, Republic of
Proteus syndrome (PS) is a rare congenital hamartomatous disorder with multisystem involvement. PS
has highly clinical variability caused by overgrowth of the affected areas,and several features can make
anesthetic management challenging. Little is known about the airway problem associated with anesthesia
in PS patients. An 11 year-old girl with PS scheduled for ear surgery under general anesthesia. She had
features complicating intubation such as facial asymmetry and disproportion, abnormal teeth, limitation of
neck movement due to torticollis, and thoracolumbar scoliosis. This study presents a case of deformed
airway of PS patients under fiberoptic bronchoscopy.
MCC06
4:15 PM - 4:25 PM
Bariatric Surgery After Heartware-Ventricular Assist Device as Bridge-to-Transplantation
Christine AYob, D.O., Tariq Naseem, M.D., Frederick Cobey, M.D., Tufts Medical Center, Boston, MA,
UCSD, San Diego, CA
Pre-transplant BMI >30kg/m2 is associated with poor outcomes following cardiac transplantation. Bariatric
surgery often excludes patients with heart failure owing to increased perioperative risks. We present a
case of a morbidly obese patient with heart failure treated with a Heartware Ventricular Assist device as a
bridge-to-transplant who underwent bariatric surgery to meet UNOS criteria. Anticipating a drop in preload
and decrease in pulsatility of the patient’s device with pneumoperitoneum, cerebral oximetry was used as
an additional marker for perfusion. After insufflation, a drop in HVAD flows and cerebral saturation
occurred, which responded to volume administration and ionotropic support.
MCC06
4:15 PM - 4:25 PM
Airway Options for Rigid Instrumented Occipital-Cervico-Thoracic Fusion in ICU
Utchariya Anantamongkol, M.D.,Ph.D., Ramsis F. Ghaly, M.D., Niki Tsuruta, M.D., Nebojsa Nick
Knezevic, M.D.,Ph.D., Kenneth D. Candido, M.D., Anesthesiology, Advocate Illinois Masonic Medical
Center, Chicago, IL
A 60 year-old male with prior three surgeries that resulted in entire occipital-cervico-thoracic fusion was
admitted for altered mental status. The anesthesia team was called in the ICU for emergent intubation.
The patient had severe cervical kyphosis with 1-finger breadth mouth opening and was precluded with
adequate exposure for tracheostomy. Following failed direct laryngoscopy, Glidescope and fiberoptic oral
intubation, an LMA was placed and able to ventilate for three hours. Finally, nasal fiberoptic intubation
was successfully performed while deflating and removing the LMA. With rigid fixation of the entire cervical
spine, nasal fiberoptic intubation is considered the first choice.
MCC06
4:15 PM - 4:25 PM
A Case of A Cesarean Section In A Patient With Heart Failure, Pulmonary Hypertension, And
Previous Lumbosacral Spine Surgery
Robin E. Robbins, M.D., John J. Finneran, M.D., Yosun Chung, M.D., Thomas Archer, M.D., Alyssa
Brzenski, M.D., Anesthesiology, University of California San Diego, San Diego, CA
This is a case of a 29 year-old G1P0 female with history of non-ischemic cardiomyear-oldpathy and
remote history of lumbosacral tumor resection that presented for Cesarean section at 35 weeks due to
worsening right-sided heart failure.The patient was started on a nitroglycerine infusion prior to the
surgery. A spinal-epidural anesthetic was utilized, combining an opiate only spinal with a slowly titrated
continuous epidural. Ultrasound guidance was employed for epidural placement due to abnormal lumbar
anatomy. Patient and neonate tolerated the procedure well under neuraxial anesthesia, but required
milrinone post-operatively for cardiac augmentation. Patient was transitioned to enalapril prior to
discharge.
MCC06
4:15 PM - 4:25 PM
Pain Medicine (PN)
A Differential Diagnosis of Post-Procedural Skin Lesions
Sam Li, M.D., Rohit Purnak, M.D., Taruna Penmetcha, M.D., Maria Torres, M.D., Anesthesiology and
Pain Management, John H Stroger Hospital, Chicago, IL
45 year-old AAF with PMH of obesity, depression, tension headache, and CLBP. In clinic, she received
bilateral MBBs under fluoroscopy to L3-L5 and sacral ala with a mixture of 0.25% Bupivacaine and 40 mg
of Dexamethasone. Her visit was uneventfully, however, post-procedure day 4 the patient phones in
reporting of drainage of purulent material directly adjacent to her injection site. Although the etiology of
her skin lesion was unclear, given the temporal relationship of the lesion to the procedure, we explored
the differentials, consulted our burn/ wound care service early, and continued medical management of her
CLBP.
MCC06
4:15 PM - 4:25 PM
Proximal Ultra Sound Guided Medial Sural Cutaneous Nerve
Zachary C. Cohen, Emerson Conrad, III, M.D., UPMC Department of Anesthesiology, Pittsburgh, PA
Despite multimodal management a burn patient status post STSG was complaining of severe pain in the
burn area on the lateral aspect of the foot and lateral posterior aspect of the calf, corresponding to the
sural nerve distribution. Due to the patient's burn injury and dressings, access to the lower leg was
impossible and a proximal block was necessary. To minimize the associated motor block, ultrasound was
used to isolate the sural cutaneous nerve between the two gastrocnemius muscle heads. After nerve
blocking the patient reported a 0/10 VAS pain score and no further analgesics were required for 24 hours
MCC06
4:15 PM - 4:25 PM
Saline Washout Syndrome After Prolonged Endoscopic Shunt Revision: A Case Report
Kerry Zajicek, M.D., Bridget Muldowney, M.D., Lana Volz, M.D., Anesthsiology, University of Wisconsin
Hospitals and Clinics, Madison, WI
A 2 year-old with a history of thalamic astrocytoma presented for endoscopic shunt revision. The patient’s
anesthetic course was uneventful, however the surgery itself was challenging. A significant volume of
saline irrigation was used in the 2.5 hour procedure. Following an uneventful extubation, the patient
displayed seizure-like activity with airway obstruction. Pharmacologic treatment with midazolam resulted
in transient improvement of symptoms. Any stimulation thereafter resulted in similar seizure-like activity.
The patient was taken to the ICU for monitoring. Within 8 hours, the patient’s neurologic status and
laboratory abnormalities returned to baseline. The patient’s symptoms were likely due to saline washout
syndrome.
MCC06
4:15 PM - 4:25 PM
Anesthetic Management of a Young Adult Patient With Congenital Heart Disease Presenting for
EGD
Abisola Ayodeji, M.D., Jason Fu, M.D., Kalpana Tyagaraj, M.D., Anesthesiology, Maimonides Medical
An 18 year-old male with a history of severe developmental delay, severe scoliosis, GERD,Tetralogy of
Fallot and Hypoplastic Left Heart Syndrome status postbidirectional Glenn procedure and main
pulmonary artery ligation as an infant, presented with vomiting for 10 days.Patient’s baseline O2
saturations were 70s. Standard ASA monitors were applied to the patient. He was sedated with IV
midazolam and apre-induction radial arterial line was placed.Rapid sequence induction withetomidate,
lidocaine, fentanyl and rocuronium. A dexmedetomidine infusion at 0.3 mcg/kg/hr was initiated for
maintenance of anesthesia.
MCC06
4:15 PM - 4:25 PM
Obstetric Anesthesia for a Parturient With a Known Carotid Artery Intracerebral Aneurysm
Sean M. Ormond, M.D., Cristian M. Prada, M.D., Case Western Reserve University - MetroHealth
Medical Center – Cleveland, Ohio, Cleveland, OH
29 year-old with history of obesity, diabetes mellitus, and gestational hypertension presenting for preterm
delivery with a known 4.5 x 4.2 mm cerotic-ophthalmic aneurysm. Cesarean delivery was performed
under slowly titrated epidural neuraxial anesthesia with 2% lidocaine. Preinduction invasive arterial line
was placed to monitor fluctuations in blood pressure. Successful delivery was performed and recovery
was uneventful. We will discuss the obstetric anesthesia strategies in the setting of an intracranial
aneurysm.
MCC06
4:25 PM - 4:35 PM
Anesthetic Management of an Adult Patient Undergoing Surgical Division of a Double Aortic Arch
Colt D. Brunson, D.O., Ritesh Patel, M.D., St. Louis Univ, Saint Louis, MO
We describe a 26 year-old female with pleuritic chest pain and asthmatic symptoms who presented to the
OR after CT imaging incidentally revealed an aortic vascular ring with mild narrowing of the supracarinal
trachea. Following induction, a left double-lumen endotracheal tube, left radial and left femoral arterial
lines were placed. A left-sided thoracotomy was performed under one-lung ventilation and surgical
division of the anterior (left) aortic arch was completed. A sodium nitroprusside infusion was initiated just
prior to surgical division to reduced shear stress on the aorta. The patient tolerated the procedure well
and was discharged on postoperative day 4.
MCC06
4:25 PM - 4:35 PM
Severe Bronchospasm in Asthmatic Requiring Epinephrine Drip
Jatandra Morton-Howard, M.D., Neil Bailard, M.D., Connie Tran, M.D., Anesthesiology, Baylor College of
Medicine, Houston, TX
A case of refractory bronchospasm in a year-oldung patient with poorly controlled asthma presenting for
endoscopic sinus surgery. After induction, there were noted problems with ventilation and elevated peak
airway pressures and after assessment patient believed to be having an episode of bronchospasm. First
line treatment was unable to effectively break the bronchospasm and the patient subsequently required
repeated bolus doses of epinephrine as the drug broke the bronchospasm shortly before symptoms
returned. An epinephrine drip was required to maintain resolution of bronchospasm and adequate
ventilation. The case was cancelled.
MCC06
4:25 PM - 4:35 P

ASA Annual Meeting Medically Challenging Cases Guide 2015

Transcription

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MIDDLE EAST JOURNAL OF ANESTHESIOLOGY Department of