Rovnat Babazade

Background: Renal autotransplantation is a complex procedure performed for various indications such as treatment of renal vascular and urologic lesions and loin pain hematuria syndrome (LPHS). Because of the rarity of the procedure, few reports have been published, and little is known about anesthetic management and postoperative outcomes of patients with LPHS. The goal of this study was to review and describe all cases of renal autotransplantation performed at Cleveland Clinic during a specified period, focusing on anesthetic management and postoperative 30-day outcomes. Methods: We performed a retrospective review of the records of all patients who underwent renal autotransplantation from 2005 to 2014 at the Cleveland Clinic and collected demographic, anesthetic, surgical, and postoperative data. Results: A total of 64 patients underwent renal autotransplantation from 2005 to 2014. The most frequent indications were nephrolithiasis and LPHS. General endotracheal anesthesia with epidural for pain control was used in 47% of cases. Median duration of anesthesia was 528 minutes. Most patients were sent to a regular nursing floor postoperatively, but 28% of patients required intensive care unit admission. Two patients developed graft ischemia, and 1 patient developed graft failure requiring nephrectomy. No anesthetic-related complications and no mortality were associated with this procedure during the study. Conclusion: Renal autotransplantation is a safe option for patients with LPHS. Additional studies are needed to assess the effect of intraoperative anesthetic management on outcomes in this patient population.

Objective Our objective was to evaluate the efficacy of perioperative multimodal pain management in reducing opioid use after elective cesarean delivery (CD). Study Design A single-center, double-blinded, placebo-controlled randomized trial of women undergoing elective CD. Participants were allocated 1:1 to receive the multimodal protocol or matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48 hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake, neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7. Data were analyzed using parametric and nonparametric tests and quantile regression as appropriate. Results A total of 242 women were screened with 120 randomized, 60 to the multimodal group and 60 to control group. There was no significant difference in the primary outcome of opioid use nor in the secondary outcomes. Smokers and patients with a history of drug use had higher median postoperative opiate use and earlier administration. On POD 7, only 40% of prescribed opioids had been used, and there was no difference between the groups. Conclusion This perioperative multimodal pain regimen did not reduce opioid use in 48 hours after CD. Patients who smoke or with a history of drug use required more opioids in the postoperative period. Providers significantly overprescribed opioids after CD.

Historically, anesthesia machines were designed to deliver oxygen along with other anesthetic agents to patients. Today, anesthesia machines, more appropriately called anesthesia workstations, have evolved to incorporate numerous complex mechanical and electrical components deep within them. This internalization of components makes troubleshooting difficult.1 We present a unique instance of a high-pressure oxygen line leak in an anesthesia workstation (Narkomed GS; Dräger, Telford, PA) during the administration of anesthesia to a 33-year-old parturient scheduled for elective cesarean delivery under spinal anesthesia. She was the first patient of the day. The anesthesia workstation in the labor and delivery operating room was tested by using American Society of Anesthesiologists recommendations for preanesthesia checkout procedures (2008) and passed tests successfully. The sounds of the air handler and continuous low suction droned in the background during the insertion of the spinal needle. Subsequently, when we were positioning the patient for surgery, we noticed a loud hissing noise that appeared to be coming from inside the anesthesia workstation. The sound did not disappear when the suction line was kinked or when suction was turned off. When the workstation was disconnected from the oxygen supply, the hissing sound stopped. This result leads us to believe that there was a leak in the high-pressure oxygen line inside the workstation. We had no idea as to the flux of additional oxygen into the operation room. We immediately swapped a workstation from another operating room, and the surgery continued uneventfully. Ultimately, bioengineers found a leak in a piece of tubing going to the flow control valve (Figure) that is internal to the workstation and not serviceable by medical personnel. Later, when we reached out to the Dräger representative, he explained that these pieces of internal tubing are not on any kind of routine maintenance program. Therefore, after 8 to 10 years of minimal workstation use, but constant oxygen pressure, this tubing blew without warning. The Narkomed GS anesthesia workstation has 2 oxygen safety checkpoints: the oxygen ratio controller and the oxygen sensor. These safety points prevent the delivery of a hypoxic mixture of anesthetic gases to a patient. However, even with these safety checks functioning normally, you would not be able to ventilate parturient because of the no/decreased oxygen flow to the bag. However, if an alternative oxygen source was used for ventilation, then the failed bellow drive/low-flow alarm would be triggered after initiating mechanical ventilation. A possible near catastrophic event was avoided by the early detection of this high-pressure oxygen leak if for some reason a switch from spinal to general anesthesia was required. In summary, the actions of operating room personnel were appropriate: notification of authorities, complete gas supply disconnection, and swapping out the malfunctioning anesthesia workstation. Anesthesiologists should check anesthesia workstations properly and be vigilant for any unusual sounds or alarms. Rovnat Babazade, MD Sarah M. Shabot, MD Rakesh B. Vadhera, MD, FRCA, FFARCS Department of Anesthesiology University of Texas Medical Branch Galveston, Texas rb@or.

We tested the primary hypothesis that surgical site infections (SSIs) are more common in patients who had longer periods of intraoperative low blood pressure. Our secondary hypothesis was that hospitalization is prolonged in patients experiencing longer periods of critically low systolic blood pressure (SBP) and/or mean arterial pressure (MAP). Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection, but the extent to which low blood pressure contributes remains unclear. We considered patients who had colorectal surgery lasting at least 1 hour at the Cleveland Clinic between 2009 and 2013. The duration of hypotensive exposure and development of SSI was assessed with logistic regression; the association between hypotensive exposure and duration of hospitalization was assessed with Cox proportional hazard regression. A total of 2521 patients were eligible for analysis. There was no adjusted association between SBP hypotension < 80 mm Hg and SSI, with an estimated odds ratio (95% confidence interval) of 0.97 (0.81, 1.17) per 5-minute increase in SBP hypotension (P = 0.54). There was also no adjusted association between MAP hypotension time and SSI, with estimated odds ratio of 0.97 (0.81, 1.17) for a 5-minute increase in MAP hypotension < 55 mm Hg time (P = 0.71). There was no association between duration of hypotension and time to discharge. Intraoperative hypotension does not seem to be a clinically important predictor of SSI after colorectal surgery, probably because the outcomes are overwhelmingly determined by other baseline and surgical factors—and perhaps postoperative hypotension.