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Medically Challenging Cases
ANESTHESIOLOGY™ 2013, the 2013 ASA annual meeting
October 12-16, 2013 • San Francisco, California
MCC Session Number
MCC01
MCC02
MCC03
MCC04
MCC05
MCC06
MCC07
MCC08
MCC09
MCC10
MCC11
MCC12
MCC13
MCC14
MCC15
MCC16
Day
Saturday, October 12
Saturday, October 12
Saturday, October 12
Saturday, October 12
Sunday, October 13
Sunday, October 13
Sunday, October 13
Sunday, October 13
Monday, October 14
Monday, October 14
Monday, October 14
Monday, October 14
Tuesday, October 15
Tuesday, October 15
Tuesday, October 15
Tuesday, October 15
AM Ambulatory Anesthesia
CA Cardiac Anesthesia
CC Critical Care Medicine
FA Fundamentals of Anesthesiology
NA Neuroanesthesia
Time
8:00-9:30 a.m.
10:30 a.m.-Noon
1:00-2:30 p.m.
3:00-4:30 p.m.
8:00-9:30 a.m.
10:30 a.m.-Noon
1:00-2:30 p.m.
3:00-4:30 p.m.
8:00-9:30 a.m.
10:30 a.m.-Noon
1:00-2:30 p.m.
3:00-4:30 p.m.
8:00-9:30 a.m.
10:30 a.m.-Noon
1:00-2:30 p.m.
3:00-4:30 p.m.
Learning Track Codes
OB Obstetric Anesthesia
PN Pain Medicine
PD Pediatric Anesthesia
PI Professional Issues
RA Regional Anesthesia and Acute Pain
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The Medically Challenging Cases are bookmarked by day and session number. Use Ctrl F to find an
author’s name, MCC number, or partial title.
Copyright © 2013 American Society of Anesthesiologists
MCC Session Number – MCC01
Saturday, October 12
8:00 AM - 9:30 AM
CA MC01
Difficult Ventilation and Diagnosis of Tracheoesophageal Fistula (TEF) in a Patient Post Esophagectomy
Rany Abdallah, M.D., Ph.D., Jaber El-Bashir, M.D., Ayman Ads, Rush University Medical Center, Chicago,
IL
A 66-year-old old male with esophageal adenocarcinoma underwent esophagogastrectomy but
developed shortness of breath (SOB) on POD3. On POD7 imaging showed a contrast leak suggesting
anastomotic dehiscence. He was intubated for SOB and planned dehiscence repair. During transport
bubbling was heard from his mouth despite cuff reinflation. In the OR 20cm H2O of PEEP was required
for adequate ventilation. Surgical exploration revealed an esophageal anastomotic defect overlying a
defect in the left main bronchus and confirmed a TEF diagnosis. The ETT was pushed into the right main
bronchus surgical repair completed then repositioned in the trachea; providing adequate ventilation.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC02
Acquired Hemophilia A After Coronary Artery Bypass Graft Surgery
Ahmad Abou Leila, M.D., Abayomi Akintorin, Bozana Alexander, M.D., John H. Stroger Jr. Hospital of
Cook County, Chicago, IL
We are reporting a challenging case of a rare cause of post operative bleeding. Acquired hemophilia A is
rare cause of coaguloathy that we believe was the main culprit . Patient post CABG developed
nonsurgical bleeding with new isolated PTT prolongation. Bleeding was resistant to conventional
therapy. Mixing studies didn't correct PTT thus we ruled out factors deficiencies. Heparin effect
excluded by normal factor X levels. Patient received factor VIII inhibitor bypass therapy after which PTT
corrected and bleeding stopped. The triad of acquired coagulopathy noncorrectable PTT and exclusion
of heparin effect make acquired hemophilia A the most likely diagnosis.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC03
Anesthetic Management of a 53-Year-Old Female With Metastatic Leiomyosarcoma to the Left Atrium
and Right Lower Lobe
Oludayo Adeyefa, M.D., University of Texas Health Science Center at Houston, Houston, TX, Ron
Purugganan, M.D., Dilip Thakar, M.D., The University of Texas MD Anderson Cancer Center, Houston, TX
Leiomyosarcoma is a relatively rare form of cancer and accounts for between 5-10% of soft tissue
sarcomas which are in themselves relatively rare. We present the case of a 53 -year-old female with a
history of uterine leiomyosarcoma s/p hysterectomy who presented with metastatic leiom year-old
sarcoma to the left atrium and right lower lobe with invasion to the left pulmonary veins. Anesthetic
management included one-lung ventilation for a left thoracotomy cardio pulmonary by pass and intraoperative TEE to evaluate the left atrial mass pre and post surgery. Given the carefully planned
perioperative care she had a smooth intraoperative and postoperative course.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CA MC04
Vasoplegia Following AVR in Setting of Severe Sepsis and Infective Endocarditis Treated by Methylene
Blue
Adam Adler, M.D., M.S., Alexander Wolf, M.D., Baystate Medical Center, Springfield, MA
A 67-year-old-male arrived with urosepsis and infective endocarditis with a vegetation on his mechanical
mitral valve. He had acute severe AI and pulmonary hypertension. Intra-op the vegetation was not
present and we proceeded with AVR. While attempting to separate from CPB the cerebral saturation
was 50% below baseline PaO2 on FiO2 of 1.0 was 47mmHg the SpO2 in the high 80s and SBP of 6070mmHg. He was maintained on norepinephrine 40mcg/min epinephrine 0.06mcg/kg/min milrinone
0.375mcg/kg/min vasopressin 0.12Units/min phenylephrine 2mcg/kg/min. Methylene blue 2mg/kg was
added for suspected vasoplegia. This improved the BP to 110mmHg and allowed for separation from
CPB.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC05
Type IV Endoleak Detected by Transesophageal Echocardiography During Endovascular Repair of
Aorta
Shalin Shah, D.O., Gautam Agarwal, M.D., Manuel Castresana, Shvetank Agarwal, Georgia Regents
University, Augusta, GA
A 76-year-old female with traumatic transection of the descending thoracic aorta underwent
endovascular aortic repair (EVAR) with TEE to guide graft placement. A single C-TAG® (W. L. Gore &
Associates Inc. Flagstaff Arizona USA) endograft measuring 26mm X 21mm X 10 cm was deployed
under fluoroscopic and transesophageal echocardiographic (TEE) guidance. Post-stent deployment
angiographically there was no evidence of endoleak. On TEE multiple small high-velocity jets were seen
traversing the entire anterior surface of the stent graft representing early type IV endoleak. We describe
different types of endoleaks their diagnosis implications and management.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC06
Anesthetic Management of Bilateral Thoracoscopic Maze for Recurrent Atrial Fibrillation: Case-Series
Mark Banks, M.D., Mary Arthur, M.D., Vijay Patel, M.D., Shvetank Agarwal, M.D., Georgia Regents
University, Augusta, GA
Four patients with recurrent atrial fibrillation who had previously failed transcatheter ablation
presented for a thoracoscopic bilateral maze procedure and left atrial appendage clipping with
immediate cardiopulmonary bypass availability. Sequential lung ventilation in modified supine position
created ventilatory challenges in these patients with multiple comorbidities including obesity
congestive heart failure and pulmonary hypertension. Intraoperative transesophageal
echocardiography was used to rule out left atrial thrombus measure left atrial and pulmonary vein size
and to guide the clipping of the appendage. In this case-series we discuss the anesthetic management of
sequential lung isolation in supine position and use of intraoperative transesophageal echocardiography.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CA MC07
Anesthetic Management of a Complicated Endovascular Repair of Descending Thoracic Aortic
Transection
Shalin Shah, D.O., Gautam Agarwal, M.D., Manuel Castresana, M.D., Shvetank Agarwal, Georgia Regents
University, Augusta, GA
A 76-year-old female with known severe peripheral arterial disease underwent an endovascular aortic
repair (EVAR) for a traumatic transection of the descending thoracic aorta after a motor vehicle
accident. Anesthetic management included general endotracheal tube anesthesia cardiopulmonary
bypass availability and transesophageal echocardiography (TEE) to guide deployment of the stent-graft.
Challenges included difficult vascular access shorter than usual proximal landing zone and
hemodynamic instability due to rupture of the internal iliac artery during sheath removal. We discuss
the various indications pre- and intra-op imaging modalities anesthetic considerations and
complications of EVAR in traumatic transections of the descending thoracic aorta.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC08
Superior Vena Cava Tear in a 70-Year-Old Female Following Lead Extraction
Chad Agnew, M.D., Amy Duhachek-Stapelman, UNMC, Omaha, NE
Cardiac lead extractions are associated with a number of adverse events that require rapid diagnosis
and treatment. We present a case of a 70-year-old female who underwent lead extraction secondary to
high impedance. Transesophageal echocardiography (TEE) probe was placed for intra-operative
monitoring. During laser extraction a sudden drop in systolic blood pressure from 130s to 80s occurred.
TEE revealed new significant right pericardial fluid collection. Resuscitation measures were initiated
along with emergent sternotomy and cardiopulmonary bypass by cardiothoracic surgeon. A superior
vena cava tear was identified and repaired. The patient was transported to ICU in stable condition.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC09
On Pump Coronary Artery Bypass Grafting and Left Ventricular Pseudo-Aneurysm Repair in a 29-yearold Patient With Systemic Lupus Erythematosus and Antiphospholipid Syndrome and Intraoperative
Heparin Resistance
Nawraz Alan, M.D., Douglas Sharp, M.D., Seol Yang, M.D., Darin Zimmerman, M.D., George Washington
University, Washington, DC
We describe the intraopertaive care of a 29-year-old male with anti-phospholipid syndrome who
required a LV pseudo-aneurysm repair and thrombus evacuation as well as CABG. He had a history of
multiple arterial thromboses resulting in left BKA as well as acute lacunar infarct. Work up of his stroke
revealed a LV pseudo-aneurysm with thrombus and 100% proximal LAD stenosis. In fear of a thrombotic
event on CPB we elected ACT of 800s before proceeding; however this was challenging as the patient
displayed heparin resistance. We will review the pathophysiology and present results of a literature
search regarding intraoperative care.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CA MC10
PEA Arrest From an Argon and/or Carbon Dioxide Gas Embolism During Laparoscopic Renal Cell
Carcinoma Cryoablation
Laura Alexander, M.D., Jodi Sherman, M.D., Trevor Banack, M.D., Jean Charchaflieh, M.D., Yale, New
Haven, CT
A 70-year-old female with RCC underwent GAET for a laparoscopic renal mass cryoablation. Three hours
after abdominal insufflation in trendelenberg/right lateral decubitus positioning intra-abdominal
pressure was raised to 20mmHg during argon beam cauterization. ETCO2 immediately declined from 38
to 6 with declines in O2 HR BP and a new 2mm ST depression. Medications administered; ephedrine
phenylephrine epinephrine and atropine. PEA arrest developed ACLS initiated with stabilization after 6
minutes. TEE revealed; 20% LVEF severe hypokinesis and negative PFO/embolus. The working diagnosis
was a CO2 and/or argon PE with resultant stress induced cardiomyopathy. Patient was extubated 2 days
later and discharged home.
Saturday, October 12
8:00 AM - 9:30 AM
CA MC11
Anesthetic Management of a Large Obstructive Cardiac Hemangioma of the Right Ventricle
Michael Allen, D.O., Sanjay Dwarakanath, M.D., Shvetank Agarwal, M.D., Georgia Regents University,
Augusta, GA
A 40-year-old male underwent a left anterior thoracotomy for tissue biopsy of a hypervascular right
ventricular mass of unknown origin incidentally detected on the chest CT. Arterial and central venous
lines were placed pre-induction in anticipation of hemodynamic instability due to right ventricular
outflow tract obstruction. General anesthesia and lung-isolation was achieved with a single lumen
endotracheal tube and bronchial blocker with preparations for emergent cardiopulmonary bypass.
Intraoperative transesophageal echocardiography revealed a 7x6 cm mass invading the right ventricular
free wall confirming preoperative transthoracic echocardiography without any evidence of tamponade
physiology. The final histopathological diagnosis being a hemangioma.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC12
Methemoglobinemia With the Use of Benzocaine Spray for Awake Fiberoptic Intubation
Samer Abdel-Aziz, M.D., Mohamed Ismaeil, M.D., University of Arkansas for Medical Sciences, Little Rock,
AR
We report a case in which the use of benzocaine spray to facilitate awake fiber optic intubation in a
patient with a difficult airway caused methemoglobinemia intraoperatively. Local benzocaine was
sprayed in the patient's mouth for a total time of 1 second 15 minutes later SpO2 decreased to 85% on
the pulse oximeter. Arterial blood gas showed a MetHb of 24.6% of total Hemoglobin. The patient was
successfully treated with methylene blue intravenously and recovered uneventfully. Small amounts of
local benzocaine sprayed to numb the airway can cause significant methemoglobinemia that requires
immediate recognition and appropriate management.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
FA MC13
Adrenalectomy for Pheochromocytoma Complicated by Considerable Blood Loss and Suspected
Venous Air Embolism
Shivon Abdullah, M.D., Casey Windrix, M.D., Julia Rygaard, M.D., Oklahoma University Health Sciences
Center, Oklahoma City, OK
Pheomochromocytoma is a challenging endocrine disease for the anesthesiologist. The affected patient
requires careful preoperative preparation and intraoperative attention. A 57-year-old female with an
adrenal pheochromyctoma was scheduled for laparoscopic right adrenalectomy. Preoperatively the
patient received adequate alpha-blockade. Planned laparoscopic approach was met with difficulty due
to dense adhesions and converted to an open approach. During dissection the right renal vein was
injured and considerable blood loss and hemodynamic instability ensued. We suspected that venous air
embolism contributed to the instability. With diagnosis and treatment in an expeditious manner the
patient had a favorable anesthetic outcome.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC14
Management of a Symptomatic Long Segment Tracheal Stenosis From a Large Goiter With
Intrathoracic Extension
Shivon Abdullah, M.D., Benjamin Stam, B.S., Pramod Chetty, M.D., Oklahoma University Health Sciences
Center, Oklahoma City, OK
Symptomatic multi-level tracheal compression from neck and mediastinal masses pose a challenge for
the anesthesiologist. We describe a challenging case of a 42-year-old female with a large goiter
complicated by intrathoracic extension resulting in deviation and significant compression of the trachea.
Without the luxury of resorting to a surgical airway in the event of airway collapse femoral arterial and
venous cannulae were placed for possible extracorporeal oxygenation. The airway was secured by
awake fiber-optic intubation using a reinforced tube placed distal to the level of stenosis. Due to
significant tracheomalacia the patient was left intubated overnight and extubated uneventfully.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC15
Airway Management of a Patient With Recurrent Angioedema
Shady Adib, M.D., Julie Marshall, M.D., Alice Landrum, M.D., University of Missouri, Columbia, MO
A 47-year-old female presented to the ER with significant tongue edema and the presumed diagnosis of
lisinopril-induced angioedema. She was taken to the OR for an awake nasal fiberoptic intubation with
ENT present for a possible emergency tracheostomy. The patient was extubated on hospital day two.
Seven days after the initial presentation she returned with stridor but no upper airway edema and was
intubated without difficulty. Our patient developed lower airway edema following resolution of tongue
edema. This emphasizes the need for continued suspicion of airway edema following resolution of
external swelling.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
FA MC16
Anesthetic Management of a Patient With End Stage Amyotropic Lateral Sclerosis and Severe COPD
Adam Adler, M.D., M.S., Neil Connelly, M.D., Baystate Medical Center, Springfield, MA
A 72-year-old female with progressive ALS presented for IR guided percutaneous-gastrostomy. With coexisting severe COPD and CHF she requested general anesthesia and the issue of neuromuscular
relaxation was encountered. Induction was accomplished using propofol. ETT placement without muscle
relaxation proved impossible due to small mouth opening and rocuronium 20mg was administered.
Train of four was checked the presence of 4 twitches and sustained tetany observed at the orbicularis
oculi muscle prior to reversal with Neostigmine+glycopyrrolate. ETT and oral suction was performed
prior to extubation with equipment available for possible re-intubation. She was transferred to PACU
uneventfully and discharged the following day.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC17
Airway Management of Angioedema in the Setting of Emesis and a Grand Mal Seizure and Airway
Compromise
Adam Adler, M.D., M.S., Emad Attallah-Wasif, M.D., Baystate Medical Center, Springfield, CT
A 47-year-old-man arrived to our emergency department with severe tongue angioedema after taking
lisinopril. Initially he had garbled speech and mild respiratory distress. His symptoms were progressively
worsening. Decision was made to secure his airway with an awake nasal fiberoptic intubation. Trauma
surgeon was at bedside for backup surgical airway. While receiving nebulized lidocaine he became
dyspnic and vomited followed by a grand mal seizure which was terminated with IV midazolam. He had
pulseless electrical activity arrest and CPR was initiated for 1 min. Single pass with nasal FFB was
unsuccessfully. Emergency cricothyrotomy was performed and the airway secured.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC18
Mechanical Extraction of a Cannula Aspirated Through a Chronic Post-Laryngectomy
Tracheoesophageal Fistula
Adam Adler, M.D., M.S., Srinvasa Gutta, M.D., Baystate Medical Center, Springfield, MA
A 71-year-old-male arrived to the ED reporting to have lost the plastic cannula used to plug a chronic
tracheoesophageal fistula. The patient underwent laryngectomy 10 years prior complicated by
tracheoesophageal fistula that failed surgical closure on multiple occasions. The patient denied
respiratory symptoms dysphagia or odynophagia. Chest x-ray failed to localize the radiopaque object.
GETA followed by bronchoscopy of the larger airway segments failed to identify the cannula. A rigid
endoscope revealed the cannula in the stomach which was snared and brought to the mouth for
extraction.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
FA MC19
Perioperative Myocardial Infarction as a Cause of Extubation Failure
Avneep Aggarwal, Muhammad Jaffar, M.D., University of Arkansas for Medical Sciences, Little Rock, AR
We report a case of extubation failure following non cardiac surgery complicated by perioperative
myocardial infarction. A 68-year male was scheduled for radical cystectomy with ileal conduit for
bladder cancer. The patient's past anesthetic experience was uneventful. Patient had good functional
capacity and denied any cardiac symptoms. His PMH was significant for CAD COPD and obesity.
Intraoperative course was significant for transient ST depression. Extubation failed despite adequate
neuromuscular blockade reversal and stable hemodynamics. Post operatively elevated cardiac
biomarkers were suggestive of perioperative myocardial infarction. Coronary angiography revealed
triple vessel disease with 60-80% stenosis.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC20
Positioning Pitfalls: Prone to Pulmonary Embolism
Latrice Akuamoah, M.D., M.P.H., Jeffrey Silverstein, M.D., M.S., Melissa Lee, M.D., Mount Sinai Medical
Center, New-York, NY
A 63-year-old man with remote history of atrial fibrillation presented for C2-T1 laminectomy and fusion
to treat symptomatic cervical cord compression. General anesthesia was induced followed by
endotracheal intubation. The patient was turned prone. Within minutes his heart rhythm converted to
atrial fibrillation he became hypotensive minimally responsive to vasopressors and end tidal CO2
decreased. He was turned supine and maintained on vasopressors which improved his hemodynamics.
Arterial blood gas demonstrated increased PaCO2 and decreased PaO2. The case was canceled and he
was transported to the intensive care unit for further management. Postoperative CT scan confirmed
bilateral pulmonary embolism.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC21
Total Intravenous Anesthesia for the Resection of a Large Catecholamine Secreting Tumor
William Fernando Amaya-Zuniga, M.D., Monica Mora-Ortiz, M.D., Darwin Cohen-Manrique, M.D., Jorge
Alvarado-Sanchez, M.D., Fundacion Santa Fe de Bogota, Bogota, Colombia
A 63-year-old female presented with Pheochromocytoma (suprarrenal mass 10X8X6cm). 24-hour urine
metanephrines and vanillylmandelic acid were positive. The preoperative preparation included
administration of terazosin and metoprolol two weeks before the surgery achieving adequate control of
blood pressure and symptoms. Given the size and the complexity of the mass an open surgical resection
was considered. Total Intravenous Anesthesia (target controlled infusion of propofol and remifentanyl)
and infusion of dexmedetomidine were administrated. Anesthesia was guided by Entropy monitoring;
proper intraoperative hemodynamic control was achieved requiring minimum hypotensive and
vasopressive drugs. This technique allowed hemodynamic stability with attenuated sympathetic
response.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
FA MC22
Impending Airway Obstruction
Melody Anderson, M.D., Francesco Resta-Flarer, M.D., Jonathan Lesser, M.D., Jinu Kim, M.D., St. Luke's
Roosevelt Hospital, New-York, NY
A 59-year-old male with fever and increased difficulty breathing over the previous two days presented
to ER with inflamed airway associated with pharyngeal mass and impending airway obstruction. The
patient was brought to OR for emergent airway management. First and second intubation attempts with
GlideScope did not reveal identifiable anatomy. Third and fourth attempts with fiberoptic were
unsuccessful secondary to pharyngeal mass obstruction and inability to enter the airway. The decision
was made to proceed with tracheostomy. Return to OR the following day for tonsillectomy and
pharyngeal neck exploration revealed near complete obstruction of the airway by left paratonsillar
mass.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC23
Acute Decrease of End-tidal CO2 During Pheochromocytoma Resection
Elena Ashikhmina, M.D., Ph.D., Zhiling Xiong, M.D., Ph.D., Brigham & Womens Hospital, Boston, MA
Mr. XXX is a 65-year-old male undergoing laparoscopic right adrenalectomy for pheochromocyroma
developed an acute drop of end-tidal CO2 from 32 to 14 mmHg after insufflation of the abdomen. The
opening pressure was 15 mmHg. About 4 L of CO2 was infused into peritoneal cavity. The patient
remained hemodynamically stable. A transesophageal echocardiography was performed and noted no
evidence of right heart strain but significant collapse of an inferior vena cava. It was concluded that the
patient could not tolerate intraperitoneal pressure of 15 mmHg and the case proceeded with
intraperitoneal pressure of 10 mmHg without complications.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC24
Anesthetic Management for a Patient With Mitochondrial Metabolic Disorder
Ahmed Attaallah, M.D., Ph.D., Eric Lindstrom, C.R.N.A., West Virginia University, Morgantown, WV
Mitochondria is the main intracellular site for ATP production. Patients with mitochondrial metabolic
disorders often have multiple organ systems deterioration predisposing them to perioperative
complications. These patients vulnerable to hypoglycemia and lactic acidosis sensitive to anesthetics
prone to malignant hyperthermia and have respiratory and cardiac compromises. We present a patient
who suffers from refractory seizures muscle weakness decreased respiratory and cardiac reserve and
impaired glucose regulation. There are conflicting reports in the anesthesia literature but most
perioperative complications have been predictable and preventable. We will outline the up-to-date
recommendations for perioperative management and discuss the implications on the anesthetic plan.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
FA MC25
TEE Usage for Non-Cardiac Surgery
Abisola Ayodeji, M.D., Lynn Belliveau, M.D., Kalpana Tyagaraj, M.D., Maimonides Medical Center,
Brooklyn, NY
A 79-year-old woman with past medical history of pulmonary emboli s/p Greenfield filter was brought
to the OR for repair of a colovesicular fistula and urethral obstruction. Induction and intubation were
uneventful. During the procedure two acute episodes of hypoxia and hypotension occurred. Blood
pressure responded to vasopressors. The hypoxia initially nonresponsive to PPV albuterol and ETT
suctioning resolved spontaneously. A central line and an arterial line were placed. The diagnosis of
exclusion was pulmonary microemboli. TEE showed normal cardiac function and no evidence for emboli.
Case is being presented for discussion of TEE use for non-cardiac surgery.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC26
Malignant Hyperthermia: To Be or Not to Be? Does This Patient Deserve a Label?
Neda Sadeghi, M.D., Mari Baldwin, M.D., St. Lukes Roosevelt, New York, NY
We present the case of a 69-year-old female undergoing plastic surgery for treatment of basal cell
carcinoma . She had uncomplicated prior anesthetics. One hour into general anesthesia she became
febrile to 39 degrees F hypercarbic to 80mmHg tachycardic and hypertensive. Volatile anesthesia was
turned off; intravenous anesthesia commenced. Slowly her temperature normalized with active cooling
measures and she improved with both tachycardia and hypercarbia abating. Post-operatively her
potassium was 4.5 CK 1287. Dantrolene was not given. She was scheduled for another anesthetic in 4
weeks. How to proceed and what to tell her?
Saturday, October 12
8:00 AM - 9:30 AM
FA MC27
Tracheal Stent Placement in a 60-year-old Patient With Esophageal Cancer and New TrachealEsophageal Fistula
Philip Bamberger, Maria Cashin, C.R.N.A., Faiz Bhora, M.D., St. Lukes-Roosevelt Hospital Center, New
York, NY
Tracheal stent placement in acute adult tracheal-esophageal fistula. TIVA was selected for 2 reasons: the
airway would have to be shared with the surgeon and the powerful narcotic remifentanyl could be used
to blunt reflex hypertension and tachycardia from tracheal stimulation. Induction was with Sevoflurane
Midazolam 2 mg IV Fentanyl 100 mcg. Anesthesia was maintained with Propofol 150 mcg/kg/min and
Remifentanyl 0.2 mcg/kg/min which was started at the time of induction. Rocuronium 30 mg IV.
Ventilation was via intermittent jet ventilation with FiO2 =1.0. The surgeons suspended the trachea and
larnyx and direct visualization placed a tracheal stent.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
FA MC28
Acute Depression After Postoperative Ondansetron
Harish Bangalore Siddaiah, Ashok Rao, M.D., Shilpadevi Patil, M.D., LSUHSC, Shreveport, LA
39-year-old patient with h/o depression was for a scheduled ureteric stone removal. After completion of
surgery patient was transferred to PACU where patient complained of nausea was administered 2 mg of
intra-venous ondansetron. Immediately after administration patient became unresponsive to verbal and
painful stimuli. Neurology was consulted immediately who assessed the patient by then patient started
responding to painful stimuli and gradually to verbal stimuli but had tearing from both eyes. Focal
neurological exam was within normal limits. Psychiatry team was consulted who interviewed her and
diagnosed her with acute depressive episode started her on anti-depressants.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC29
Intraoperative Management of a Patient With Pheochromocytoma and Gastrinoma
Harish Bangalore Siddaiah, Ashok Rao, M.D., Shilpadevi Patil, M.D., LSUHSC, Shreveport, LA
49-year-old with a h/o severe hypertension NSTEMI was admitted with hematemesis was diagnosed
with peptic ulcer disease due to gastrinoma on routine CT scan of abdomen a large pheochromocytoma
was diagnosed. Patient was then started on prazosin for 10 days on day of surgery patient's preoperative blood pressure was 155/80. Patient was taken to OR and induced with propofol sufentanil
rocuronium and maintained on isoflurane. As surgery progressed patient's blood pressure increased
reaching 250/120 esmolol and nitroprusside drip were started immediately and were titrated to reach
maximum doses though patient's blood pressure remained elevated till excision of the tumour.
Saturday, October 12
8:00 AM - 9:30 AM
FA MC30
Robotic Prostatectomy Impairs Cardiac Contractility
Matthew Barker, M.D., Virginia Commonwealth University, Richmond, VA, John Watkins-Pitchford,
McGuire VAMC, Richmond, VA
An 80-year-old male 70 inches 187 pounds underwent robotic prostatectomy for benign prostatic
hypertrophy. The circulation was monitored with bio-reactance (Cheetah Medical Inc). Stroke Volume
Index Heart Rate and Total Peripheral Resistance were measured. A preoperative passive leg raise
test(PLR) showed normal Starling fluid-responsiveness the stroke volume increasing 30.5%. Uneventful
surgery proceeded with 50ml blood loss and 300ml lactated Ringer's infused. After emergence
extubation and transport to PACU the PLR test was repeated with only 8% increase in stroke volume.
The progreessive intraoperative fall in stroke volume after an initial rise was not accompanied by clinical
pulmonary edema.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC31
Penetrating Injury to the Gravid Uterus: Anesthetic Considerations
Sarah AbdelFattah, M.D., Nicholas Nedeff, M.D., Jackson Memorial Hospital, Miami, FL
Patient is a 27-year-old female G3P2002 at 34 weeks gestation who arrived to trauma center s/p
gunshot wound to head and abdomen/ gravid uterus. Case describes management of the parturient in
Copyright © 2013 American Society of Anesthesiologists
the trauma setting including primary survey and airway management as well as physiologic changes
(hemodynamically hematologically etc) in pregnancy and the considerations that must be accounted
for in order to care for the patient in a penetrating trauma. Also there is discussion of when/ if to deliver
the fetus and when it is appropriate to maintain the pregnant state.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC32
Anesthetic Considerations in a Parturient With Repaired Tetralogy of Fallot and Oral-Facial Digital
Syndrome
Abdullah Abdullah, M.D., Jaya Ramanathan, M.D., Jenna McKinnie, M.S., University of TennesseeMemphis, Memphis, TN
A 25-year-old G2P1 at 36 weeks with a history of repaired Tetralogy of Fallot and oral-facial-digital
syndrome was admitted for labor. Additional cardiac surgeries included mitral valve replacement and
recently pulmonary artery conduit replacement. Her medications were digoxin and lasix. Physical
examination revealed stable hemodynamics and class2 airway. ECHO showed EF 50-55%. A vaginal
delivery was planned. Epidural was performed with a loading dose 10 ml of 0.125% bupivacaine
followed by 0.125% bupivacaine with fentanyl 5ug/ml infusion at 12ml/hour with excellent analgesia. A
forceps-assisted delivery was achieved successfully with estimated blood loss 250 ml. Post-partum
course was uneventful.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC33
Cesarean Delivery and Splenectomy for Severe Idiopathic Thrombocytopenic Purpura: A Case Report
Kulsum Akbar, M.D., Alexander Butwick, M.B. B.S., Stanford Medical Center, Stanford, CA
The medically challenging case involves a 29-year-old G1P0 parturient who presented with lower
extremity petechiae and recently diagnosed Idiopathic Thrombocytopenic Purpura (platelet count =
5x109/L). Her ITP proved refractory to various treatments including plasmapharesis. A
thromboelastogram performed at 37 weeks showed low maximum amplitude (MA) and clot stability (G)
causing inability to measure clot formation time (K) at which time she underwent a cesarean section and
a concomitant splenectomy. Intrapartum removal of the spleen and the subsequent administration of
recombinant FVIIIa proved successful in increasing her platelet count and can be considered for
obstetric patients with severe refractory ITP.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC34
Massive Blood Transfusion in an Obstetrical Patient With Placenta Percreta Complicated by Cardiac
Arrest
Cheen Alkhatib, M.D., Irina Gasanova, M.D., University of Texas Southwestern, Dallas, TX
A 27-year-old G2P1 with previous C-section presented with vaginal bleeding at 34weeks. She was
diagnosed with complete previa and admitted for observation. A week later she started having bleeding
and contractions. A stat C-section was called. Baby was delivered within 10 minutes but due to
extensive invasion of the placenta significant bleeding occurred for which blood/blood products were
administered. She had greater than 15 liters of blood loss and over 100 units of blood product was
given. Patient developed hyperkalemia and went into vtach. ACLS protocol initiated. Patient was
extubated the next morning. Both mother and baby did well.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
OB MC35
Ruptured Splenic Artery Aneurysm During Post Partum Period
Cheen Alkhatib, M.D., Adnan Rafique, M.D., University of Texas Southwestern, Dallas, TX
A 39-year-old G1P0 at 41w0d with uneventful prenatal course presents to L&D for labor induction.
Pitocin was started. After 8 hrs of labor patient had an uncomplicated c-section. 10 hours later mother
became hypotensive tachycardic and stat CBC found acute anemia. Patient was complaining of LUQ
tenderness. She was taken back to the OR and found to be in hemorrhagic shock. Massive blood
transfusion was initiated and surgeons found a large ruptured splenic artery aneurysm. Splenectomy
was performed and patient was taken to the ICU intubated. Patient was extubated 2 days later. Mother
and baby did well. discharged home POD #7
Saturday, October 12
8:00 AM - 9:30 AM
OB MC36
Anesthetic Management of Trial of Labor in a Morbidly Obese Teenager With Corrected Transposition
of Great Vessels and Residual Cardiac Pathology
Jeremy Almon, M.D., Tilak Raj, M.D., University of Oklahoma, Oklahoma City, OK
A 19-year-old G1P0 at 39 weeks presented with corrected transposition of the great vessels morbid
obesity chest pain and echocardiographic evidence of aortic and mitral regurgitation. Patient was
admitted to the Obstetric ICU and ultrasound-guidance was used in both arterial line and epidural
placement prior to induction of labor to monitor hemodynamic control. After 20 hours of labor a
decision was made to proceed to C-Section which was facilitated by the existing epidural. We would like
to present this patient because she highlights someone with multiple complex problems requiring a
multi-disciplinary care involving high-risk obstetrics cardiology anesthesiology and modern technology.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC37
Emergent Management of Maternal Cardiopulmonary Arrest Secondary to Amniotic Fluid Embolism
Walid Alrayashi, M.D., J. David Roccaforte, M.D., Levon Capan, M.D., Douglas Schechter, M.D., New York
University, New York, NY
A 41-year-old G4P2 @ 40 3/7 weeks who presented for post-date induction of labor. After receiving an
epidural the OB service artificially ruptured her membranes. Within 5 minutes she complained of
severe abdominal pain chest pain and dyspnea marked by tachycardia hypotension hypoxia fetal
bradycardia and altered mental status. General anesthesia was delivered and an emergent c-section was
done. Her EKG rhythm transitioned from right heart strain to PEA arrest at which point ACLS was
initiated. Return of circulation was obtained however she developed DIC and required a massive
transfusion with over 25 units of PRBCs and FFP and Platelets.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
OB MC38
To Stick or Not to Stick: Alternative Approaches to Labor Analgesia in a Parturient With Suspected Von
Willebrand Disease
Eric Ashford, M.D., Johannes Dorfling, M.D., Regina Fragneto, M.D., University of Kentucky, Lexington, KY
Von Willebrand disease and other inherited coagulopathies presenting in parturients during labor
complicate the utilization of neuraxial anesthesia for pain management. Analgesia in parturients can be
achieved through various alternative means though providers might not fully integrate the efficacy and
ramifications of different medications and administration techniques. We illustrate the management of
a 26-year-old parturient presenting at night with no previous prenatal care detailing an incomplete
history of an inherited coagulopathy determined to be von Willebrand disease. We also discuss a
literature review of the available pain management modalities and medication administration in
parturients with inherited coagulopathies.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC39
Previously Undiagnosed Anomalous Left Main Coronary Artery in a Parturient With Systemic Lupus
Erythematosus and Anti-Phospholipid Antibody Syndrome
Naola Austin, M.D., Stanford University, Palo Alto, CA, Christopher Ciliberto, M.D., Katherine Podorean,
D.O., Pascal Vuilleumier, M.D., Laurent Bollag, M.D., Ruth Landau, M.D., University of Washington,
Seattle, WA
A 33-year-old G2P1 was diagnosed with Systemic Lupus Erythematosus and Anti-Phospholipid Antibody
Syndrome after having umbilical cord thrombosis. Her baseline mild dyspnea on exertion worsened to
dyspnea at rest (unresponsive to albuterol omeprazole and prednisone) by 28 weeks gestation. She was
afebrile with ambulatory SpO2 88% ejection fraction 32% abnormal wall motion and moderate
pulmonary hypertension. Dyspnea improved with beta-blockade diuresis afterload reduction steroids
and input from a multi-disciplinary care team. She underwent uneventful Cesarean delivery at 34 weeks.
Postpartum she was diagnosed with anomalous left main coronary artery arising from the pulmonary
artery. This was repaired 3 months postpartum.
Saturday, October 12
8:00 AM - 9:30 AM
OB MC40
Anesthetic Challenges in the Obstetric Patient in Sickle Cell Crisis
Mirza Baig, Shayne Roberts, D.O., Wilson Po, M.D., Penn State College of Medicine, Hershey, PA
A 24-year-old G2P101 at 34 weeks who presented with sickle cell crisis and was admitted to intensive
care for management. She was noted to have episodes of destaturations and developed fetal
decelerations resulting in emergent C-section. She developed acute hypoxemia and metabolic acidosis
upon induction with propofol and succinylcholine. She was transfused multiple units of PRBCs which
helped to improve oxygenation. She was suspected to have acute chest syndrome which was further
complicated by anesthetic induction and intubation. Discussion of the case will include appropriate
management of obstetric patients with sickle cell and acute chest syndrome.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
PN MC41
Cervical Spinal Cord Stimulation for the Management of Pain From Brachial Plexus Avulsion: A Case
Report
Samer Abdel-Aziz, M.D., Ahmed Ghaleb, M.D., University of Arkansas for Medical Sciences, Little Rock,
AR
A 25-year-old male patient had right brachial plexus avulsion after a motor vehicle accident 5 years ago.
MRI showed complete nerve root avulsion from C6 to T1. He developed chronic pain resistant to
medical treatment. We implanted a cervical spinal cord stimulator (SCS) at C3-C6 level. With stimulation
the patient reported 50% reduction in pain intensity and complete coverage of his right upper extremity
and right shoulder. A permanent paddle SCS was implanted at C3-C5. After one month the patient
continued to report good coverage of his pain with no recurrence.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC42
Ketamine Infusion for the Treatment of Complex Regional Pain Syndrome
Melissa Adams, Jeffrey Staack, M.D., University of Tennessee, Knoxville, TN
A 24-year-old male presented for treatment of CRPS of his right lower extremity. He was initially treated
with outpatient lumbar sympathetic blocks with limited relief. He was admitted and treated with a
continuous lumbar epidural with resolution of his symptoms. However several days later the patient
experienced return of all symptoms. The decision was made to trial him with a continuous ketamine
infusion. The infusion was titrated and he exhibited significant improvement in his symptoms. It was
weaned off after four days with continued symptom relief. Six months later he has returned to work and
is off all medications.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC43
Acute Myelopathy in Perioperative Period
Snigdha Ancha, M.D., Manish Purohit, Anita Gupta, Drexel University College of Medicine, Philadelphia,
PA
Acute myelopathy in the peripoperative period is a rare condition. We present a patient who developed
acute myelopathy following uneventful general anesthesia for an abdominal surgical procedure. 47year-old male p/w acute abdomen underwent emergent diagnostic laparoscopy which was converted to
an open approach for perforated appendix. 2 days after uneventful hospital stay patient was discharged
home after which patient presented with acutely worsening sensory and motor deficits. Imaging studies
serum CSF biomarkers did not reveal any acute infection/ pathology. The patient was started on an
empiric course of steroids based upon the working diagnosis of idiopathic transverse myelitis.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
PN MC44
Permanent Implantation of Peripheral Nerve Stimulator for Combat Injury Related Ilioinguinal
Neuralgia
Diem Phuc Banh, D.O., Russell Morris, M.D., Pablo Moujan, M.D., Quasi Haque, M.D., Tae-Hyung Han,
M.D., Ph.D., Texas Tech University of Health Sciences, El Paso, TX
26-year-old African American male active duty military presented to the University Pain Clinic with
intractable left lower abdominal neuralgic pain. Six years prior he sustained an IED explosion during
which shrapnel became imbedded in his left lower abdomen and groin. Despite a series of inguinal
herniorrhaphy varicocelectomy and orchiectomy his pain persisted. Previous treatments including oral
analgesics neural blockades and cryoanalgesia provided limited pain relief. After a successful trial with a
peripheral nerve stimulator permanent leads were placed. At three month follow up the patient
reported significant reduction of pain resuming normal activities of daily living.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC45
A Case of Nondiabetic Lumbosacral Radiculoplexus Neuropathy
Alisha Bhatia, M.D., Maria Torres, M.D., John H. Stroger Hospital, Chicago, IL
Patient is a 45-year-old M who presented with new onset of back pain and LLE weakness. His reflexes
were diminished on the left side and he complained of medial thigh numbness. He denied any trauma
incontinence or saddle paresthesias. MRI of the pelvis revealed diffuse edema involving the bilateral
iliopsoas adductor and gluteus muscles which was worse on the left side. He was diagnosed with
nondiabetic lumbosacral radiculoplexus neuropathy. Several medication regimens including a steroid
taper were prescribed for the patient with minimal results. He experienced some relief with methadone
and his symptoms improved as the swelling subsided.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC46
Continuous Ketammine Infusion Through Multiple Surgical Procedures in a Chronic Pain Patient
Elena Bukanova, M.D., Keun Sam Chung, M.D., Yale New Haven Hospital, New Haven, CT
A 42-year-old male with a 2-year history of chronic pain following MVA and remote history of IVDA on
70mg daily methadone maintenance therapy presented for RLE BKA with multiple planned returns to
OR. Patient was started on a ketamine infusion post-operatively after the initial operation and titrated
to 0.2mg/kg/hr. Infusion was maintained for a total of 11 days during which time the patient returned
to the OR three additional times for debridements washouts and wound VAC changes. Patient denied
side effects required less opioid analgesics reported better pain scores and expressed high satisfaction
with pain management efforts compared to prior hospitalizations.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
PN MC47
Phantom Limb and Stump Pain Were Ameliorated After Changing an Existing Constant Voltage Spinal
Cord Stimulator to a Constant Current Device and Adding Two Percutaneous Quadripolar Leads
Jennifer Bunch, M.D., University of Florida, Gainesville, FL, Heidi Goldsteine, M.D., North Florida/South
Georgia VA, Gainesville, FL, Robert Hurley, M.D., University of Florida, Gainesville, FL
We report the case of a patient who suffered from bilateral lower extremity phantom limb and stump
pain refractory to both optimized pharmacological therapy and a constant voltage spinal cord stimulator
(SCS). The patient refused neurosurgical intervention and so we provided percutaneous therapy. We
changed the spinal cord stimulator to a constant current device and added two percutaneous
quadripolar leads. The patient appreciated complete resolution of painful symptoms and was able to
engage in athletic activities. This is the first report of complete resolution of post amputation pain with a
change from a constant voltage to a constant current SCS.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC48
Ketamine Infusion Therapy for Severe Aura Associated With Migraine
Jared Chase, D.O., Sumit Katyal, M.D., Cleveland Clinic, Cleveland, OH
A 60-year-old-female presents with persistent aura and episodic migraines for over a year. She
experiences photophobia motion sensitivity visual field cuts left temporal pain and a persistent
shimmering visual disturbance which interfere with her work as a radiologist. Brain MRI/MRA/MRV were
normal. Her headache and persistent aura had been poorly controlled with amitriptyline meclizine
NSAIDs memantine and prednisone. She failed treatment with depacon and magnesium infusions.
Therapy with intravenous subanesthetic doses of ketamine for 5 days was beneficial in disrupting the
cycle of persistent aura.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC49
A Unique Case: Treatment of Supraorbital Neuralgia Using Pulsed Radiofrequency Ablation
Cassandra Duncan-Azadi, M.D., Amber Brooks, M.D., University of Alabama Birmingham, Birmingham,
AL
Supraorbital neuralgia although an uncommon disorder is the most frequent extra cranial neuralgia of
the trigeminal nerve. There are several small case studies reporting various medical managements and
even surgical treatment. However there are few reports of successful treatment with pulsed
radiofrequency ablation. We present a 36-year-old female patient who developed debilitating
supraorbital neuralgia following a concussion who failed medical management. She underwent two
treatments with pulsed radiofrequency ablation and obtained significant relief allowing her to return to
work. Pulsed radiofrequency ablation offers a less invasive nonsurgical option for patients with this
painful disorder.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
PN MC50
Sinus Bradycardia During Radiofrequency Ablation of Cervical Medial Branch Nerve
Ryan Ensminger, D.O., University of Florida, Gainesville, FL, Egle Bavry, M.D., North Florida/South
Georgia Veterans Health system, Gainesville, FL
A 54-year-old female with cervical facetogenic pain presented for a right sided C3-C6 medial branch
radiofrequency procedure. Preprocedure vitals were BP 106/72 mmHg pulse 87 bpm pulse oximetry
99% on room air. For the procedure patient was prone without sedation. Under fluoroscopic guidance
radiofrequency needles were placed in the proximity of medial branches. Upon initiation of radio
frequency lesion at C6 level the patient developed sinus bradycardia that progressed to a 5 second
pause. Lesioning was terminated after recognition of bradyarrythmia with gradual return of heart rate
to the baseline. Radiofrequency lesioning was attempted two more times with similar bradyarrhythmia.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC51
Challenging Spinal Cord Stimulator Placement in High-Risk Patient With Critical Limb Ischemia on
Antiplatelet Agent
Shrif Costandi, M.D., Yashir, Eshraghi, M.D., Hani Yousef, M.D., Ph.D., Yosaf Zeyed, M.D., Youssef
Saweris, M.D., Nagy Mekhail, M.D., Ph.D., Cleveland Clinic Foundation, Cleveland, OH, Yashar Eshraghi,
Case Western Resrve University/MetroHealth Medical Center, Cleveland, OH
Background: Spinal cord stimulation (SCS) has been advocated to treat critical limb ischemia.
Antiplatelet might render SCS placement challenging. Case History: Sixty seven years-old male
presented with critical limb ischemia. Lumbar sympathetic block produced significant short-term pain
relief. SCS trial was done as a two-staged procedure using perioperative eptifibatide. First stage of the
trial resulted in 100 % pain relief of his rest pain and improved claudication distance. Second stage
followed with implantation of the battery. Conclusion: We are reporting successful and safe use for
perioperative eptifibatide infusion while placement of SCS in high-risk vascular patient on preoperative
prasugrel.
Saturday, October 12
8:00 AM - 9:30 AM
PN MC52
Intrathecal Catheter Placement in the Anticoagulated Patient
Stephen Estime, Dalia Elmofty, M.D., University of Chicago, Chicago, IL
A 13-year-old female with PMH of Neurofibromatosis I complicated by metastatic malignant peripheral
nerve sheath tumor was consulted to pain service for chronic abdominal pain. After failing oral and
intravenous opioid regimens the decision was made to attempt intrathecal pain management via a
continuous catheter. Before catheter placement patient's INR was found to be elevated and expected
to continue to rise. After administration of FFP the INR was reduced. Although it is against ASRA
guidelines for neuraxial catheter placement in a coagulopathic patient after discussing with patient and
family an intrathecal catheter was successfully placed without complications.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
PN MC53
Treatment of Chronic Ilioinguinal Neuralgia With Transversus Abdominis Plane (TAP) Block Under
Ultrasound Guidance
Raghuvender Ganta, M.D., John Young, M.D., OU Medical Center VAMC, Oklahoma City, OK
A 48-year-old man presented to the pain clinic with chronic ilioinguinal neuralgia. He had Right inguinal
hernia repaired two years ago. He has been treated with Gabapentin Non-steroidal antiinflammatory
drugs for his persistent pain. He also had mutiple trigger point injections and also right ilio-inguinal
blocks with local anesthetics with minimal pain relief. On his next visit to the clinic he had severe right
inguinal neuralgic pain. we have used Transversus abdominis block and performed R. ilioinguinal block
under ultrasound guidance. There was a significant pain relief for 6 months.A similar block was repeated
with good pain relief.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC54
Perioperative HIT Management for Patients HITing the OR
Shreya Aggarwal, M.D., Monica Shah, M.D., Bilal Rana, M.D., UT Houston, Houston, TX
Heparin-induced thrombocytopenia Type II is a complex immunological prothrombotic life-threatening
condition targeting platelet malfunction in response to heparin. In this case a 56-year-old male with no
PMH s/p MCC complicated by orthopedic polytrauma sepsis respiratory failure acute renal failure on
CVVHD and suspected PE on heparin drip presented for perioperative assessment on hospital day 14
for abdominal washout and closure with severe thrombocytopenia (5000 platelets) secondary to
suspected type II HIT. We discuss our perioperative evaluation and challenging management of a
critically ill patient with active HIT on day 0 with evidence of thrombosis-induced ischemia for a nonelective procedure.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC55
Panhypopituitarism After Bilateral Neck Dissection
Robert Aitken, M.D., Brad Coker, M.D., University of Alabama at Birmingham, Birmingham, AL
We present a 54-year-old male with carcinoma of the epiglottis and no previous endocrinopathy who
experienced severe intraoperative and postoperative hypotension. The patient was found to have
hypertrophic obstructive cardiomyopathy postoperatively. After extubation the patient developed AMS
hypernatremia polyuria hypothermia and bradycardia. MRI was performed for concern of hypotensive
injury to the pituitary gland causing Simmond's syndrome. MRI diagnosed a pituitary stone. The patient
was successfully treated for panhypopituitarism including central diabetes insipidus adrenal
insufficiency and myxedema coma related to previous apoplexy with recent hypotensive pituitary
injury.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CC MC56
Acute Abdomen and Lactic Acidosis in a Patient With High Grade B-Cell Lymphoma
Abdalrahman Algendy, M.B.Ch.B., Calree Clark, M.D., Medical University of South Carolina, Charleston,
SC
A 22-year-old male underwent an emergent exploratory laparotomy after presenting with an acute
abdomen and severe lactic acidosis. Three weeks prior the patient had undergone an uncomplicated
ileocecectomy for an obstructing high grade B cell lymphoma tumor. Laparotomy revealed no signs of
bowel ischemia or perforation but showed omental thickening and a large amount of tumor burden
throughout the abdomen. Postoperatively the patient acutely declined and was diagnosed with tumor
lysis syndrome that lead to hemolytic anemia acute kidney injury severe metabolic acidosis and
methemoglobinemia resulting from Rasburicase therapy.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC57
Unexpected Vascular Lesions in a Patient With Traumatic Brain Injury
Nada Alkaki, Benjamin Moor, Tufts Medical Center, Boston, MA, Yana Hudcova, Lahey Hospital and
Medical Center, Burlington, MA
We present a case of a previously healthy 61-year-old patient admitted to the SICU with the diagnosis of
traumatic right sided acute on chronic subdural hematoma (SDH). Initial CT scan demonstrated
lenticular subdural lesion with significant cortical compression and midline shift as well as suspicion for
vascular aneurysms at the base of the skull. Patient was treated by evacuation of the hematoma via burr
hole. Three days later CT angiography confirmed multiple intracranial aneurysms and patient underwent
elective clipping of five and coagulation of three aneurysms. We discuss diagnosis operative options
and postoperative care in patients with intracranial aneurysms.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC58
Acute Non-Hepatic Hyperammonemic Encephalopathy
Wesley Allen, M.D., University of Missouri-Columbia, Columbia, MO
A 65-year-old female with ESRD on hemodialysis presented to the hospital malnourished with high
ileostomy output and failure to thrive. TPN was initiated when traditional supplementation measures
failed. Acute decompensation requiring vasopressor support and ETT intubation subsequently ensued.
Ammonia level was elevated at 126mmol/dL. After common etiologies of acute hyperammonemic
encephalopathy were ruled out acute urea cycle failure was identified secondary to deficiencies in
arginine ornithine and citrulline from prolonged high ileostomy output malnutrition and chronic
hemodialysis. With scheduled hemodialysis and IV amino acid replacement the patient showed vast
clinical improvement and was soon discharged from the hospital.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CC MC59
Radiologic Imaging in Diffuse Axonal Injury: What do the Scans Show (or Does Not Show)?
Shaan Alli, M.D., Peter Wong, M.D., Tufts Medical Center, Boston, MA, Veljko Popov, M.D., Jana
Hudcova, M.D., Lahey Clinic, Burlington, MA
We present a case of a healthy 19-year-old patient admitted to the surgical intensive care unit following
a motor vehicle collision. Initial computed tomography of the patient's brain was unremarkable with the
exception of a single punctuate lesion in the left frontal deep white matter. However the patient's
neurologic deterioration with progression to coma was inconsistent with initial radiologic studies.
Repeated computed tomography and magnetic resonance imaging sequences showed multiple deep
white matter foci of hyperdensity findings consistent with diffuse axonal injury. The clinical and
radiologic findings disease course and pathophysiology of diffuse axonal injury will be discussed.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC60
Several Cardiac Arrests Caused By a Massive Pulmonary Embolus. Successful Treatment With
Repetitive Trombolytic Therapy.
Johnny Andersen, M.D., Camilla Asferg, M.D., Niels Anker Pedersen, M.D., Karsten Skovgaard Olsen,
M.Sc., University of Copenhagen Glostrup Hospital, Glostrup, Denmark
This case describes a miraculously survival after double administration of thrombolysis to a patient who
experienced a hemodynamic significant PE complicated by six fold cardiac arrest. A 52-year-old man
had a 5-hour spine surgery. The next day he had several cardiac arrests due to a massive saddle
embolus. The pH was for many hours between 6.6-6.9 and he was in no condition to be transported to
another facility for surgery. He was anticoagulated which was followed by massive bleeding. He was
treated twice with tenecteplase and eventually the pulmonary embolus was completely resolved and
he was admitted to rehabilitation.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC61
Guidewire- Induced Refractory SVT
Lovkesh Arora, M.D., David Traul, M.D., Ph.D., Cleveland Clinic Foundation, Cleveland, OH
A 47-year-old male with history of paraplegia from MVA and chronic lumbar osteomyelitis s/p lumbar
laminectomy with epidural abscess drainage eight weeks ago was scheduled for lumbar iliac fusion.
Patient had no significant cardiac comorbidities. After uneventful anesthesia induction guidewire
insertion</u> during right internal jugular venous catheterization resulted in supraventricular
tachycardia resistant to IV esmolol and precordial thump. The guidewire was withdrawn but SVT
worsened into polymorphic ventricular tachycardia warranting CPR and defibrillation</u>. Rhythm
converted to sinus bradycardia after a single shock. The remainder of the intraoperative course was
uneventful. Postoperatively cardiac enzymes were negative and neurological status was intact.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CC MC62
Massive Transfusion Protocol in a Patient With Left Ventricular Injury
Liliya Aulova, D.O., Kalpana Tyagaraj, M.D., Maimonides Medical Center, Brooklyn, NY
A 58-year-old female intubated with an open ventriculostomy presented emergently to the operating
room immediately after chest tube placement that yielded two liters of frank blood. Patient was POD # 5
after subtemporal cranial decompression for a ruptured right MCA aneurysm. Open thorocotomy was
performed and chest tube was found to be in the left ventricle. Left ventriculotomy was repaired by
cardiac surgeon. Patient was transferred back to SICU. Case is being presented for discussion of
resuscitation of massive hemorrhage and administration of massive transfusion protocol. Patient
underwent an uneventful cranioplasty and closure of the skull two months after discharge.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC63
Postoperative Management of Severe Acute Anemia in a Jehova's Witness
Liana Maria Azi, Ph.D., Fernando Lopes, M.D., Jyrson Klamt, M.D., Ph.D., Luis Garcia, M.D., Ph.D., USP Medicine Faculty of Ribeirao Preto, Ribeiao Preto - SP, Brazil
We report severe anemia case succeeding scoliosis surgery in a young Jehovah's Witness patient.
Several technics were used to minimize intraoperative blood loss. After surgery she was extubated with
hematocrit level of 14% but excessive blood drainage dropped her hematocrit level to 8 6%. Despite
hemodynamic deterioration she was awake and refused transfusion. Two hours later her hematocrit
was 5% (hemoglobin 1 4 g.dl-1). Then she lost conscious her trachea was intubated and aggressive
erythropoietin therapy initiated. After five days she was extubated without organic dysfunction. It's a
challenging case because her critical point of DO2 is lower than previously thought possible.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC64
Multi-Disciplinary Care of a Patient Presenting With Acute Myasthenic Crisis After Major Thoracic
Surgery
Mark Banks, M.D., Shvetank Agarwal, M.D., Manuel Castresana, M.D., Georgia Regents University,
Augusta, GA
A 77-year-old male with Osserman's stage III myasthenia gravis (MG) symptomatic for many years but
only recently diagnosed presented to the ICU after right thoracotomy decortication and wedge
resection for empyema and right-upper-lobe mass. His preoperative FVC and pyridostigmine dose were
3.1 L and 240 mg respectively. Postoperatively he was extubated on second postoperative day (POD).
Despite high dose prednisone immunoglubulins pyridostigmine and plasmapheresis progressed to
myasthenic crisis requiring re-intubation on POD-3. Continued aggressive supportive care enabled
successful extubation on POD-9. This case highlights the role of multi-disciplinary approach to
postoperative management of patients with severe MG undergoing major thoracic surgery.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CC MC65
Anticoagulation Dilemma in a Patient With On-X® Mitral and Aortic Valves
Tiffany Richburg, M.D., John Beatty, M.D., Abigail Hoffman, M.D., Manuel Castresana, M.D., Shvetank
Agarwal, M.D., Georgia Regents University, Augusta, GA
A 57-year-old woman underwent On-X® mitral and aortic valve implantations and de Vega tricuspid
annuloplasty for severe regurgitation. On postoperative day nine while on subcutaneous heparin and
aspirin she developed cardiac tamponade after mediastinal chest tube removal. Following surgical
decompression and resuscitation a waxing and waning course of coagulopathy and thrombocytopenia
that was exquisitely sensitive to even prophylactic anticoagulation attempts ensued. She progressed to
disseminated intravascular coagulopathy requiring multiple blood component transfusions. In this casereport we discuss the clinical dilemma of balancing the need for anticoagulation and managing severe
coagulopathy in the context of two freshly implanted mechanical heart valves.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC66
Use of Salvage Therapy in a Pregnant Patient With Pulmonary Hypertension
Meena Bhatia, M.D., Anthony Delacruz, M.D., Rush University Medical Center, Chicago, IL
The patient is a 25-year-old female who presented 25 weeks pregnant with shortness of breath and
hemoptysis. She was found to have severe pulmonary hypertension with pulmonary hemorrhage and
rapidly decompensated requiring emergent intubation. The patient went into cardiac arrest and was
placed on VA ECMO. The patient's respiratory status continued to deteriorate and she developed severe
ARDS. She was placed on HFOV and slowly started to improve. After 11 days the patient was weaned
back to conventional ventilation and de-cannulated from ECMO. The patient continued to improve with
decreasing respiratory support and was transferred for acute rehabilitation.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC67
Percutaneous Tracheostomy and Mechanical Ventilation in the Treatment of Pickwickian Syndrome
Daniel Borman, Jackson Memorial Hospital, Miami Beach, FL
PG is a 43-year-old African American female with a past medical history of obesity hypoventilation
syndrome pulmonary hypertension systemic hypertension asthma and multiple dvt's. The patient has
a long standing history of obstructive sleep apnea leading to severe pulmonary hypertension and right
heart failure. The patient was treated with home oxygen BiPAP and oral medications however she
presented to a local community hospital obtunded due to apparent carbon dioxide induced narcosis. It
was determined that the patient would benefit from a tracheostomy under general anesthesia allowing
for more aggressive treatment of the patient's disorder.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CC MC68
Refractory Status Epilepticus in the Setting of Propofol Infusion Syndrome
Kenneth Burckardt, M.D., Rainer Lenhardt, M.D., Sujittra Tongprasert, M.D., University of Louisville,
Louisville, KY
We report a case of status epilepticus that was refractory to initial medical therapies responding only to
treatment with propofol. However concerns for propofol infusion syndrome soon arose precluding its
use. Further medical management for seizure control proved difficult and therapies were escalated to
eventually achieve treatment goals. We discuss the treatment challenges encountered with this patient.
We also review status epilepticus and propofol infusion syndrome their treatments and clinical
implications. We provide a systematic algorithm for treatment of status epilepticus in the critical care
setting including possible medication side effects and their clinical significance.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC69
Fatal Cerebral Edema During Management of an Adult With Hyperosmolar Hyperglycemic State
Enrico Camporesi, M.D., Rachel Karlnoski, Ph.D., Collin Sprenker, B.S., Devanand Mangar, M.D., Florida
Gulf-to-Bay Anesthesiology Associates LLC, Tampa, FL, Hesham Omar, M.D., Mercy Hospital, Chicago, IL
A 48-year-old male with type II diabetes mellitus presented with progressive vomiting weakness and
confusion. The patient was managed for hyperosmolar hyperglycemic state (HHS) and was started on an
insulin drip for HHS after 10 units of regular insulin bolus. 12 hours later the patient became
unresponsive to verbal stimuli and was intubated and mechanically ventilated. Computed tomography
scan of the brain revealed diffuse near-complete effacement of sulci in the cerebellar and both parietooccipital regions with subtle loss of gray-white matter distinction. 24 hours after ICU admission the
patient became bradycardic unresponsive to atropine and developed asystole.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC70
Inspiratory Stridor Associated With Subglottic Webbing in an Adult
Muktadir Choudry, M.D., Ashutosh Wali, M.D., Baylor College of Medicine, Houston, TX
A 74-year-old female with significant history of asthma presented with pneumonia and hypoxic
respiratory failure. Patient was administered intravenous antibiotics and underwent tracheal intubation.
Following 24-hour course of treatment the patient's respiratory mechanics improved and was
extubated. Soon after extubation inspiratory stridor and increased work of breathing were noted. She
received inhaled steroid and nebulizer treatment with no improvement. Consequently the patient
underwent bronchoscopy illustrating subglottic webbing. Patient re-intubated secondary to worsening
respiratory status. ENT service consulted and surgically removed subglottic webbing. Patient was
extubated without any further stridor. Pathology of the tissue specimen indicated fibrinous necrotic
material.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
8:00 AM - 9:30 AM
CC MC71
Simultaneous Septic and Hemorrhagic Shock: A Late and Possible Fatal Complication of Gastric Bypass
Surgery
Jeff Christensen, D.O., Cleveland Clinic, Shaker Heights, OH
53F status post revisional bariatric procedure to treat a chronic gastrogastric fistula resulting from a
gastric bypass procedure performed in 2005 presented to ED post op day 10 with dyspnea and diffuse
abdominal pain. Patient was found to be febrile and hypotensive. JP drain showed minimal
serosangenous drainage. Patient admitted to SICU for fluid resuscitation prior to going to OR following
morning. Arterial and central line placed in SICU. 2 hours after SICU admission patient became
hypotensive unresponsive to IV pressors. She was immediately rushed to OR where patient's splenic
artery was found to have ruptured after SICU admission.
Saturday, October 12
8:00 AM - 9:30 AM
CC MC72
Hyperfibrinolysis in Therapeutic Hypothermia After Cardiac Arrest
Thomas Christianson, J. Russell Langdon, M.D., University of Tennesse Medical Center-Knoxville,
Knoxville, TN
A 60-year-old female presented to the intensive care unit after two episodes of witnessed PEA arrest
with proper ACLS management. The longest episode of PEA lasted roughly 25 minutes. On admission
the patient had a GCS of 6T and was requiring vasopressive support. The patient was started on
therapeutic hypothermia. Upon reaching target temperature a thromboelastogram was drawn which
showed normal coagulation. Twelve hours later a repeat thromboelastogram showed hyperfibrinolysis.
Concurrently the patient developed hematochezia worsening hypoxemia despite maximal ventilation
efforts and severe hypotension despite multiple vassopressive agents. The family decided to withdraw
care at that time.
MCC Session Number – MCC02
Saturday, October 12
10:30 AM - 12:00 PM
NA MC73
Transient Ischemic Attack (TIA) After Shoulder Arthroplasty in the Beach Chair Position
Madeel Abdullah, Anna Irwin, M.D., George Hsu, M.D., Thomas Jefferson University, Philadelphia, PA
A 64-year-old man presented for a right shoulder rotator cuff repair. He had an interscalene block
followed by general anesthesia during the surgery. The patient was placed in the beach chair position.
Phenylephrine boluses were used intermittently throughout the case to maintain mean arterial
pressures greater than 75mm Hg. In the PACU the patient suffered a Transient Ischemic Attack (TIA) 2
hours after the surgery ended with right sided weakness dysarthria and deviation of the tongue which
resolved in 1.5 hours. Electrocardiogram Head and Neck CT MRI and Transthoracic Echocardiogram
were all within normal limits.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
NA MC74
Moyamoya Syndrome in a Child With Down Syndrome
John Aidonis, M.D., NYU Langone Medical Center, New York, NY
A 20-year-old male with Down Syndrome ASD Moyamoya disease Vertebral Artery Dissection on ASA
with multiple cerebral infarcts in the posterior circulation. Pt. underwent bilateral occipital craniotomies
for pial encephaloduroarteriosynangiosis (EDAS) and bilateral suboccipital bur holes. General
endotracheal anesthesia was induced invasive monitoring lines for hemodynamic electrophysiologic
monitoring. The Mayfield head holder was affixed. Patient tolerated the procedure well with some HA
postop that responded well to Tylenol.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC75
General Anesthesia With Continuous Infusion Lidocaine and Dexmedetomidine: A Method for
Minimal Opioid Use in Spine Surgery and Neuromonitoring
Thomas Anderson, M.D., Ph.D., Raheel Bengali, M.D., Massachusetts General Hospital, Boston, MA
We describe a novel method for general anesthesia (GA) maintenance using IV dexmedetomidine and
lidocaine infusions with N2O as an inhalational adjunct and an anesthesia depth monitor for titration.
We are currently using the technique for spine surgery cases. There is no current journal article
documenting use of the technique which lends itself to many advantages over other GA methods
including the limited need for opioids after long prone spine surgery cases good analgesic coverage
from two different mechanistic pathways and a neurologic exam post-operatively with adequate
patient participation.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC76
Epinephrine for Anaphylaxis- Lifesaver or Fatal?
Lovkesh Arora, M.D., Maxim Novikov, M.D., Paul Kempen, M.D., Cleveland Clinic Foundation, Cleveland,
OH
49-year-old male known allergic to bee w/pmh of Hyperlipidemia remote crack/cocaine/marijuana got
admitted with acute onset headache generalized seizure lethargy- requiring intubation. Prior to
admission patient got stung by a bee</u> at flea market received epinephrine from EMS and15 min
later c/o severe headache. Initial CT showed minimal Subarachnoid Hemorrhage but patient was
discharged home. After two days c/o worsening/severe headache and neck pain repeat CT brain
significant for increased Subarachnoid hemorrhage with Intraventricular hemorrhage. Complete
Angiography noted for Right vertebral artery fusiform aneurysm vs dissection. EVD was placed
emergently and transferred to NICU for further care.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC77
Sudden Loss of Unilateral Lower Extremity SSEP's During Spinal Surgery: Review of Causes
Kamyar Bahmanpour, M.D., Ramsis Ghaly, M.D., Advocate Illinois Masonic Medical Center, Chicago, IL
A 34-year-old male was brought to operation room for right L5-S1 microdiscectomy. After induction of
general anesthesia and SSEP electrodes placement patient was positioned prone-kneeling on an
Copyright © 2013 American Society of Anesthesiologists
Andrews frame and surgery started with a balanced anesthesia and normal SSEP's findings initially.
However SSEP's amplitude of the left posterior tibial nerve lost gradually. Possible systemic and surgical
causes ruled out immediately and finally the patient was taken out of the kneeling position and SSEP's
amplitude returned to normal. The patient repositioned into a less kneeling and procedure continued
uneventful. Post operative neurological assessment was normal.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC78
Acute Subdural Hematoma in PACU Patient After Cochlear Implant Surgery
Harish Bangalore Siddaiah, M.D., Ashok Rao, M.D., Shilpadevi Patil, M.D., LSUHSC, Shreveport, LA
65-year-old patient scheduled for a right sided cochlear implant surgery was induced with fentanyl
propofol succinylcholine and anesthesia was maintained with isoflurane. Surgery was uneventful
however at emergence patient was not responsive to commands had no head lift but had a normal
train of four ratio. After ruling out pharmacological metabolic abnormalities patient was shifted to
PACU intubated with probable diagnosis of retention of residual anesthestic gas isoflurane vs neurologic
abnormality. Patient deteriorated further in PACU had unequal pupil sizes developed extensor posturing
CT scan showed acute large subdural hematoma with midline shift which was evacuated immediately.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC79
Intrathecal Baclofen Pump Malfunction Challenges of Management of Patients With Multiple Sclerosis
Withdrawal Syndrome Versus Baclofen Overdose
Anna Barczewska-Hillel, M.D., St. Luke's-Roosevelt Hospital Center, New York, NY
A 23-year-old female with h/o Multiple sclerosis for 3.5 years(gait instability RLE spasticity and weakness
urinary incontinence) was scheduled for revision of malfunctioning baclofen pump. Family noticed
worsening of spasticity over 10 days. GA was induced uneventfully and at the end of the procedure
patient was extubated after following commands. In recovery room she became unresponsive with
increased spasticity tachycardia and hypertension.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC80
Challenging Monitored Anesthesia Care in a Patient With Carcinoid Tumor Encasing the Carotid Artery
Zhe Chen, M.D., Patrick McCormick, M.D., Irene Osborn, M.D., The Mount Sinai Medical Center, New
York, NY
56-year-old man with metastatic lung carcinoid status post pneumonectomy presented with neck pain
and was found to have a 4x7 cm carcinoid tumor encasing the right common carotid. The patient came
for a balloon test occlusion study in neuroradiology. An octreotide infusion was started in the
preoperative holding area. Patient was sedated using midazolam and fentanyl but kept conscious for
neurologic examinations. A nitroprusside infusion was used to induce hypotension for the study. After a
successful BTO the right common carotid was coiled. The patient remained stable throughout the
procedure and was discharged to the neurosurgical ICU on octreotide.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
NA MC81
Loss of Intraoperative Evoked Potentials During Resection of a Mediastinal Mass
Saranya Chinnappan, M.D., Cindy Wang, M.D., Muoi Trinh, M.D., Mount Sinai Hospital, New York, NY
A 45-year-old male presented with a posterior mediastinal mass extending into thoracic vertebrae
requiring a posterior laminectomy and thoracotomy. During the laminectomy diminished MEP and SSEP
signals were identified but improved with etomidate. The tumor was removed via thoracotomy and MEP
was lost again without return with a second etomidate dose. Cord perfusion was increased with
phenylephrine and steroids were administered. A wake-up test performed at the end of the 12-hour
procedure demonstrated intact sensation but loss of motor function. Motor function eventually
improved. This case challenged us to respond to changes in intraoperative monitoring signals to prevent
neurologic deficits.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC83
Isolated Spinal Artery of Adamkiewicz Rupture Presenting as Acute Paraplegia and Severe
Hemodynamic Instability
Linda Chung, M.D., Candice Burrier, M.D., University of Illinois, Chicago, IL
Isolated Spinal Artery Aneursyms (SAA) are rare phenomenon with less than 20 reported cases
worldwide. Our case report is of a 22-year-old healthy male with sudden severe chest and neck pain
rapidly progressing to complete paralysis of the lower extremities. A CT demonstrated cerebral
subarachnoid bleeding and blood around the spinal cord at T7. The patient was hemodynamically
unstable with sinus tachycardia malignant hypertension and ST segment changes. Prior to induction of
anesthesia for angiography the patient became altered. Spinal angiogram revealed a ruptured T7 artery
of Adamkiewicz aneurysm. We will discuss anesthetic considerations of this unique case.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC84
Remifentanil-Induced Respiratory Failure in PACU After a Brainstem Tumor Debulking: A Word of
Caution and Review of Remifentanil
Laura Duling, M.D., Annette Rebel, M.D., Grace Liu, B.A., Jeremy Dority, M.D., University of Kentucky,
Lexington, KY
A 66-year-old man developed sudden apnea and unresponsiveness after a large cerebellopontine angle
tumor debulking. Based on the findings of a focused neurologic exam the patient was emergently mask
ventilated with subsequent return of spontaneous ventilation minutes later and recovery without
further complications. Remifentanil bolus from residual infusion in an IV line was suspected due to rapid
return to baseline and acute neurologic findings. We review remifentanil and highlight a challenging
diagnostic dilemma in an acutely apneic patient after major neurosurgery.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
NA MC86
Recurrent Stridor After Ependymoma Resection
Elizabeth Embury, M.D., Letha Mathews, M.B. B.S., Vanderbilt, Nashville, TN
A 31-year-old male presented with a chief complaint of worsening diplopia. CT and MRI imaging
revealed hydrocephalus with a cystic mass filling the fourth ventricle. He underwent an uneventful
twelve hour posterior fossa craniectomy with resection of an ependymoma. He was successfully
extubated at the case end but required reintubation for stridor and respiratory distress on PODs one
three and four leading to tracheostomy. Direct laryngoscopy revealed no significant laryngeal edema
and calcium levels were normal. His symptoms were thought to be secondary to recurrent laryngeal
nerve palsy from traction on the vagus nerve intraoperatively.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC87
Anesthetic Management of a Patient With Recurrent C2 Chordoma and Metastasis to T3 Presenting
for Wide Local Excison and Anterior/Posterior Fusion.
Andrew Feldman, M.D., Scott Blackwell, D.O., San Antonio Uniformed Services Health Education
Consortium, Ft Sam Houston, TX
A 57-year-old female with history of a C2 chordoma was found to have recurrence and T3 metastasis.
She had undergone C2 chordoma excision and posterior spinal fusion from occiput-C7 four years prior.
This was complicated by airway swelling requiring emergent tracheostomy. She presents with significant
sleep apnea and stridor but no neurological deficits. The patient underwent 12+ hour staged
procedures: 1) T3 vertebrectomy with wide local excision and revision posterior spinal fusion occiput-T7
and on POD#5 2) Tracheostomy and transoral C2 vertebrectomy with anterior fusion. Anesthetic
challenges included airway management one-lung ventilation and the use of SSEPs and MEPs.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC88
Subarachnoid Haemorrhage Complicated by Severe Neurocardiogenic Shock
Michael Bokoch, M.D., Thomas Fernandez, M.B.Ch.B., UCSF, San Francisco, CA
A 47-year-old male was admitted with severe SAH shock and hypoxaemic respiratory failure. CXR
suggested ARDS. Labs revealed a PO2 of 55mmHg Troponin 10.72ug/L. Echocardiogram showed EF 30%
and global hypokinesis. CT angiogram revealed a left supraclinoid ICA blister aneurysm bilateral skull
base ICA dissections and evidence of fibromuscular dysplasia. Further cardio-pulmonary stabilization
was allowed prior to aneurysm clipping and extracranial-intracranial bypass. Surgery proceeded on
vasopressors with a PA catheter guiding fluid therapy. Postoperatively the patient deteriorated with
new areas of infarct requiring decompressive craniectomy. He made some improvement yet remains
hospitalized with high risk of poor neurologic outcome.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
NA MC89
Urgent Thoracic Laminectomy and Fusion for Cord Compression From a T4 Mass in a Patient With a
Suspected Hereditary Paraganglioma Pheochromocytoma Syndrome
Kimberly Fischer, M.D., Angelika Kosse, M.D., Montefiore Medical Center the University Hospital for
Albert Einstein College of Medicine, New York, NY
A 70-year-old male has a history of a glomus jugulare paraganglioma and a pheochromocytoma excision.
His son also had a pheochromocytoma excised. The patient started experiencing intermittent worsening
back and chest pain palpitations and headaches. Cardiac causes were ruled out. Eventual spine CT
showed a mass at T4 and MRI confirmed cord compression. The mass was embolized and excised via
thoracic laminectomy and fusion. During mass excision bleeding and hemodynamic instability ensued.
Urgent anesthetic and interdisciplinary management of a T4 mass compressing the spinal cord is
discussed.
Saturday, October 12
10:30 AM - 12:00 PM
NA MC90
Susceptibility of Motor-Evoked Potentials to Dexmedetomidine During Spine Surgery
Ju Gao, M.D., Carl Lo, M.D., Colin Wilson, M.D., West Virginia University, Morgantown, WV
A 41-year-old male s/p MVC sustained multiple injuries including occipital cervical dislocation and
underwent emergent C2-3 fusion with SSEP and MEP monitoring. The anesthetic included: Sufentanyl
0.3mcg/kg/hr IV Isoflurane 0.5 MAC and Dexmedetomidine 0.5 mcg/kg IV bolus over 10 minutes
followed by 0.4 mcg/kg/hr infusion. The patient was placed in the prone position during
dexmedetomidine bolus. After prone positioning the patient's upper and lower MEP's could not be
detected despite maximal stimulation. SSEP's were preserved. We describe the differential diagnosis this
situation presents and review some of dexmedetomidine's underappreciated side effects.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC91
Anesthetic Management of a Patient With Intermittent Wolf Parkinson White Syndrome
Samer Abdel-Aziz, M.D., Thea Rosenbaum, M.D., University of Arkansas for Medical Sciences, Little Rock,
AR
We describe our anesthetic management for patient with intermittent WPW syndrome undergoing
general anesthesia for extracorporeal shock wave lithotripsy. EKG on the day of surgery showed normal
sinus rhythm however previous EKGs showed delta waves. Patients with intermittent WPW syndrome
defined as intermittent loss of the delta wave can present on the day of surgery with a normal EKG
however they are at the risk of developing tachyarrythmias. Anesthetic management is aimed at
avoiding these tachyarrthymias with adequate suppression of the sympathetic response to surgical
stimulation appropriate choice of anesthetic drugs and being ready to manage tachyarrhymias if they
develop.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
AM MC92
Thyroid Mass Invading the Proximal Trachea
Abdenour Abib, M.D., Department of Veterans Affairs, Little Rock, AR
A 90-year-old man with atrial fibrillation on Coumadin complaining of hemoptisis and mild hoarseness.
Evaluation and investigations by both ENT and general surgery showed a thyroid mass invading the
trachea. A thyroidectomy was recommended by general surgery and a resection of the proximal trachea
was contemplated by ENT. Given the patient's age and the location of the mass Pulmonary medicine
was consulted and the patient was taken to the OR on two occasions. An LMA was placed and TIVA was
provided. A flexible bronchoscope was introduced and the size of the mass was reduced and cauterized.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC93
PACU Nurse: I think the Patient is Having a Seizure
Laura Alexander, Ranjit Deshpande, M.D., Robert Lagasse, M.D., Yale, New Haven, CT
31-year-old male with nephrolithiasis underwent general anesthesia with a laryngeal mask airway for
right ureteral stent placement. Anesthetic agents utilized included midazolam fentanyl propofol and
sevoflurane. At the end of the case ondansetron was administered the LMA was removed and the
patient was transferred to the PACU . In the recovery room patient was afebrile normotensive but
noted to have a heart rate of 130bpm with involuntary sustained muscle contractions repetitive
twisting movements abnormal ocular movements and facial grimacing. Mental status and muscle
strength were intact. Symptoms resolved promptly after administration of diphenhydramine
Saturday, October 12
10:30 AM - 12:00 PM
AM MC94
Anesthetic Management of Medically Complex Ambulatory Patient With Hereditary Hemorrhagic
Telangiectasia
Sehar Alvi, M.D., Ranita Donald, M.D., Georgia Regents University, Augusta, GA
68-year-old female with history of hereditary hemorrhagic telangiectasia (HHT) also known as OslerWeber-Rendu syndrome with recurrent epistaxis presented for KTP laser ablation with nasal endoscopy
as ambulatory patient. Co-morbidities included hypertension atrial fibrillation CAD with coronary stents
CHF pacemaker pulmonary hypertension aortic and mitral stenosis hyperlipidemia COPD diabetes
stroke gastric/hepatic/pulmonary arterio-venous malformations oral and nasal telangiectasia chronic
renal insufficiency anemia and depression. Patient underwent carefully planned general anesthesia with
meticulous care of airway management. Case report will highlight the complex management of HHT
patients in general and successful management of our complex patient in an ambulatory setting.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
AM MC95
Intermittent Chest Pain and Loss of Consciousness After Hydrodistention With DMSO
Lila Baaklini, M.D., Ana Lobo, M.D., Yale University, New Haven, CT
A 27-year-old female presents for an outpatient cystoscopy with GA. Intraop course is significant only
for an episode of bradycardia to 40s treated with glycopyrrolate. In the PACU pt is tachycardic
tachypneic and complains of chest pain. A mild garlic odor is noted. Pt subsequently has 2 episodes of
unresponsiveness for approximately 5-10 min each. Upon regaining consciousness pt continues to
complain of chest pain. Bedside Echo shows no RV strain and CT Chest shows no evidence of PE. No
further episodes noted. Systemic DMSO absorption during procedure leading to coronary vasospasm
thought to be the cause of pt's symptoms.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC96
Case Report: Perioperative Extrapyramidal Reaction to Ondansentron
Zafeer Baber, M.D., Sansan Lo, M.D., Columbia University New York Presbyterian Hospital, New York, NY
Ondansentron a serotonin 5-HT3 receptor antagonist is an antiemetic with a relatively good safety
profile. It was first introduced as a novel drug free of any extrapyramidal side effects but there have
been case reports to the contrary since then. We encountered a patient who developed extrapyramidal
movements in the postoperative care unit after ondansantron administration which resolved following
treatment with diphenhydramine.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC97
Postoperative Broca's Aphasia Associated With Beach Chair Positioning During Orthopedic Procedure
in a Patient With Unknown Carotid Artery Disease
Seema Kamisetti, D.O., Sanjana Vig, M.D., Mari Baldwin, St. Lukes Roosevelt, New York, NY
We present a 69-year-old male with a history of hypertension and previous pulmonary stent who
underwent ambulatory surgery for a right rotator cuff repair. He reported no other medical problems.
He underwent a non-eventful interscalene block and the case commenced with propofol sedation. The
operative procedure was uneventful with minimal hemodynamic trespass. After two hours in the post
anesthesia care unit he developed a distinct expressive aphasia. Emergent CT- angiogram and
angiography revealed bilateral severe carotid stenosis with chronically stenotic MCA dependent on
collateral circulation.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC98
A Case of Hypoglossal Nerve Injury After LMA Placement for Arthroscopic Rotator Cuff Repair
Vikram Bansal, M.D., Hanni Monroe, M.D., University of Maryland, Baltimore, MD
A 69-year-old male presented for arthroscopic rotator cuff repair in the beach chair position. He
received an interscalene catheter and general anesthesia with an LMA. The case proceeded
uneventfully. On telephone follow-up post-operative day #1 he complained of difficulty speaking and
swallowing. Symptoms persisted after block resolution. The patient was subsequently diagnosed with
hypoglossal nerve injury attributed to the LMA. The patient received close follow-up and returned to
Copyright © 2013 American Society of Anesthesiologists
baseline after three months. We will examine this uncommon complication of LMA placement and its
implications for ambulatory shoulder surgery.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC99
Right Lateral Tongue Numbness After LMA Supreme Placement
Anna Barczewska-Hillel, M.D., St. Luke's-Roosevelt Hospital Center, New York, NY
A 43-year-old female (58 kg 172cm) with h/o mild asthma and latex sensitivity underwent 2 hours breast
augmentation revision under general anesthesia-LMA (supreme-size4). Anesthetic was uneventful LMA
was placed easily by student nurse anesthetist. One week after surgery anesthesiologist was called that
patient had persistent tongue numbness on the right side. Patient was seen and evaluated. Physical
exam of the mouth and tongue was normal. Patient was reassured and she recovered completely 3
weeks after surgery.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC100
Long Acting Twenty Four Hour Spinal in a Patient With Gilbert's Disease Reporting Allergy to General
Anesthesia Scheduled for Inguinal Hernia Repair
Rohini Battu, M.D., Raymond Pla, M.D., George Washington University, Washington, DC
A 27-year-old male with Gilbert's disease otherwise healthy scheduled for right inguinal hernia repair.
Day of surgery patient reports allergy to general anesthesia. Two years prior status post appendectomy
patient states he went into \liver failure\" which was attributed to general anesthesia. Spinal anesthetic
chosen for surgery which was completed without complications intra-operatively. In PACU patient with
continued saddle anesthesia and urinary retention. Motor function intact. Full neurosurgical
consultation and workup done. Lab work and MRI of lumbar spine within normal limits. Patient then
admitted overnight for observation. 24 hours after administration of spinal full sensation returned
without any further complications."
Saturday, October 12
10:30 AM - 12:00 PM
AM MC101
Development of Tension Pneumothorax Following Total Thyroidectomy in Outpatient Surgery Center
Margaret Brock, M.D., Michelle Kelly, C.R.N.A., Wake Forest University School of Medicine, Winston
Salem, NC
64-year-old 81.6kg 150cm (BMI 36.3) ASA 2 female (papillary thyroid carcinoma obesity) for total
thyroidectomy (intraoperative nerve monitoring). MP 1 airway short neck large breasts (taped tightly
to chest by surgeon). Grade 1 view Miller 2 6.0 NIM ETT placed atraumatically confirmed glidescope.
After incision decreased airway compliance. ETT pulled back increased compliance. Bilateral breath
sounds equal. End of case abruptly lost ETCO2 from ETT. Poor vizualization with DL. ETT removed
+ETCO2 with mask ventilation. Bradycardia responded to atropine. Mild desaturation BP stable.
Diminished breath sounds on right. Chest xray: large right pneumothorax. Chest tube placed.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
AM MC102
Dexmedetomidine: A Complete Anesthetic for the Mediastinal Mass
Tony Bui, M.D., Suman Rajagopalan, M.D., Baylor College of Medicine, Houston, TX
We demonstrate how dexmedetomidine lends itself as a complete anesthetic including amnesia
hypnosis analgesia and immobility. Our patient presented for esophagoscopy and endoscopic
ultrasound guided biopsy of a posterior mediastinal mass. A CT scan of her chest revealed multiple
mediastinal lymph nodes with symptomatic airway compression. High dose dexmedetomidine was
dosed at 7.5 µg/kg/hr and the patient had a smooth and uneventful procedure in the absence of
volatiles muscle relaxants and narcotics while maintaining spontaneous ventilation.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC103
Intraoperative and Postoperative Management of a 34-Year-Old Patient With Prader-Willi Syndrome
Treated at an Ambulatory Surgical Center
Jennifer Bunch, M.D., Linda Le-Wendling, M.D., University of Florida, Gainesville, FL
Our patient is a 34-year-old female with Prader-Willi Syndrome sustained a right displaced olecranon
fracture and underwent open reduction/internal fixation at an ambulatory surgical center. The patient's
manifestations of Prader-Willi Syndrome included hypotonia micrognathia and developmental delay.
Intraoperative management included a single shot supraclavicular nerve block for analgesia and general
endotracheal anesthesia with propofol. Glycopyrrolate was administered for sinus bradycardia.
Postoperative pain control included acetaminophen. Opioids and muscle relaxants were avoided to
minimize respiratory depression due to a history of hypotonia and increased risk of postoperative
hypoventilation. The patient was admitted overnight for monitoring and remained comfortable without
narcotics.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC104
Anesthetic Management of a Patient With Chronic Congenital Superior Mesenteric Artery Syndrome
Complicated by Cerebral Palsy in the Same Day Surgery Setting
Kadia Bundu, Sergey Pisklakov, M.D., Jyotsna Rimal, M.D., UMDNJ-NJMS, Newark, NJ
Superior mesenteric artery (SMA) syndrome is a gastro-vascular disorder characterized by compression
of the duodenum portion by the SMA. Patients with chronic congenital SMA syndrome represent
medical surgical and anesthetic challenge. A patient with chronic congenital SMA syndrome cerebral
palsy(CP) and undifferentiated muscular dystrophy presented for dental rehabilitation. Combination of
SMA and CP made this case a challenge. Case was successfully managed under general anesthesia with
the avoidance of depolarizing muscle relaxant. Volatile anesthetics were considered safe. Fluids
electrolytes and acid base disturbances should be corrected. Aspiration prophylaxis should be provided.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
AM MC105
Continuous Spinal With Dexmedetomidine Infusion on a Patient With Myotonic Dystrophy and Panic
Attacks With Numerous Other Medical Problems Scheduled for Ureteroscopy With Stent Placement
and Laser Ablation of a Ureteral Tumor
Cassie Burns, M.D., Yieshan Chan, M.D., University of Mississippi Medical Center, Jackson, MS
56-year-old male with history of myotonic dystrophy AV Block chronic hypoxia from weakness COPD
history of Pulmonary Embolisms and chronic aspiration presented for ambulatory surgery: rigid
ureteroscopy with stent placement and laser ablation of tumor. In the past patient suffered from panic
attacks and dysarthria with sedation. Patient had multiple urological procedures with adverse
pulmonary outcomes and dissatisfaction by patient and surgeon. Cystoscopies and tumor biopsies
where attempted under MAC in the past surgeons were unable to finish the procedure. Despite history
of panic attacks with sedation patient insisted on avoidance of general anesthesia.
Saturday, October 12
10:30 AM - 12:00 PM
AM MC106
Dexmedetomidine in ERCP for a Patient With Severe Pulmonary Disease and Right Side - CHF
Ofer Burshtain, M.D., Justo Gonzalez, M.D., Myrna Kcomt, M.D., Montefiore Medical Center, New York,
NY
A 49-year-old Jehovah witness woman with history of obesity moderate pulmonary hypertension rightsided CHF COPD/interstitial lung disease on constant 6L NC oxygen and nightly BiPAP (15-10) with
resolved pulmonary emboli on anticoagulation presented with symptomatic choledocholithiasis.
Interventional radiology procedure was unsuccessful. General surgery refused operative management
due to likely terminal intubation. She was then referred to GI for ERCP where she refused intubation.
With a shared airway in the semilateral position the team was concerned with potential obstruction and
hypercapnia resulting in exacerbation of PA pressures leading to cor pulmonale. Dexmedetomidine was
successfully used as the main anesthetic.
Saturday, October 12
10:30 AM - 12:00 PM
PI MC107
Intraoperative Management of Combined Open and Endovascular Thoracic and Abdominal Aortic
Aneurysm Repair
Matthew Andersen, M.D., MBA, Mount Sinai, New York, NY, Stella Tort, M.D., James J. Peters, Joshua
Mincer, M.D., VA Medical Center, Bronx, NY
A 79-year-old ASA 4 59 kg male with PMHx of CAD uncontrolled HTN PVD and hyperlipidemia
presented with a symptomatic 4.2cm thoracic and 10cm abdominal AA presented for elective
laparotomy abdominal aortic debranching and combined open and endovascular repair. Spinal drain
standard ASA monitors and a-line were placed and the patient underwent intravenous induction with
fentanyl propofol and rocuronium. After intubation a central-line was placed. Anesthesia was
maintained with sevoflurane fentanyl and rocuronium. Arterial pressures were monitored and
controlled during incremental aortic cross-clamping and graft anastomoses. The patient was extubated
on POD#2 and discharged on POD#18.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
PI MC108
Should Cardiac Cases be Done Where Cardiac Surgery and Intervention Services Are Not Available?
Hindsight Provides Valuable Insight
Mari Baldwin, St. Lukes Roosevelt, New York, NY, Gerald Bushman, M.D., Childrens Hospital Los Angeles,
Los Angeles, CA
We describe the case of a patient scheduled for pericardial window in our institution where cardiac and
interventional services are not available. He had an extensive cardiac history and we were concerned he
would need some cardiac intervention that we could not provide-yet the surgeon assured this was not
so. After surgery he did decompensate and required transfer to our sister hospital with cardiac services.
This case points out that there should be better collaboration and communication with surgical
colleagues and OR team regarding best patient care and safety before surgery. Should transfer should
have occurred prior to surgery?
Saturday, October 12
10:30 AM - 12:00 PM
PI MC109
Chaos in Off-Site: Bringing the Patient Back to Our Safe Zone
Melissa Flanigan, D.O., Sarah Kadhim, M.D., West Virginia University, Morgantown, WV
Interventional radiology aneurysmal coiling is one of our offsite assignments. A standard general
anesthetic with arterial line is usually performed. In this particular scenario there was undetected
closure device failure that led to severe hemorrhagic shock. Radiology team did not intervene so the
anesthesia team transferred the patient to our main operating room in order to adequately resuscitate.
Since the patient was continuing to decompensate vascular surgery was emergently consulted by the
anesthesiologist to remedy the situation. A stent was placed artery repaired and stabilization followed.
Clearly vigilance teamwork and insistence by the anesthesia team saved this patients life.
Saturday, October 12
10:30 AM - 12:00 PM
PI MC110
Difficult Airway Management - An Alternative Approach
Pedro Freire, Mariana Correia, Iria Figueira, Nidia Goncalves, Nicolas Zwolinski, Centro Hospitalar Lisboa
Ocidental, Lisboa, Portugal
A 51-year-old man with a psychiatric illness was proposed to urgent surgical drainage of a gluteal
abscess. The patient who presented with dysphonia had a cervical mass (supposed abscess) that
extended all the way to the mediastinum conditioning a leftward deviation and compression of the
trachea and limited neck mobility with no surgical indication. Coagulation and infection parameters
prevented a neuro-axial block. Plans for the anesthetic approach included dissociative anesthesia and
awake fiber optic intubation. After careful consideration risks were explained to the patient and the
surgery was made under dissociative anesthesia.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
PI MC111
Greening the Operating Rooms (ORs)
Sabina Khan, M.D., Joshua Chance, M.D., M.Saif Siddiqui, M.D., University of Arkansas for Medical
Sciences, Little Rock, AR, Joe Knight, Arkansas Children Hospital, Little Rock, AR
ORs (Operating Rooms) are some of the most waste generating places in a hospital. This has contributed
towards the increasing trend of natural disasters. Greening the OR helps identify hospital waste
categorization reduces non-regulated waste conserves energy and minimize the exposure patients and
public have to hazardous chemicals. By modifying the anesthetic practices we can reduce the eco
footprint and lead to the formation of dynamic learning community for information exchange through
awareness and education and save millions of dollars by implementation of relevant strategies. A
greener health care delivery will have a positive impact on environmental sustainability.
Saturday, October 12
10:30 AM - 12:00 PM
PI MC112
Massive Transfusion and Refractory Hypotension With Calcium Drug Shortage: What To Do?
Tiffany Moon, M.D., Chen Shi, M.D., Anna Allred, M.D., UT Southwestern, Dallas, TX
Drug shortages are becoming more common with over 40 intravenous medications listed in 2010.
Shortages of certain drugs pose a threat to the optimal treatment of patients especially when
acceptable alternatives are unavailable. Here we present the case of a patient with cirrhosis undergoing
an orthotopic liver transplant requiring massive transfusion (90 units) and exhaustion of the pharmacy's
calcium chloride supply. Resource utilization strategies were employed to open the crash carts on the
medical floors to obtain more calcium. This highlights the need for awareness of drug shortages and
methods to obtain drugs that are crucial to optimal anesthetic management.
Saturday, October 12
10:30 AM - 12:00 PM
PI MC113
Emergent Craniotomy for Intracerebral Bleed in a Critically Ill Patient With LVAD Driveline Related
Sepsis and Supratherapeutic INR: A Case of Futile Care
Amanda Moraska, M.D., Paul Kempen, M.D., Cleveland Clinic Foundation, Cleveland, OH
A 59-year-old obese male with hypertension OSA atrial fibrillation on warfarin CVA MI paroxysmal VT
smoking alcoholism and heart failure with LVAD placement as a bridge-to-transplant was admitted for
driveline-related sepsis. Hospitalization was complicated by extensive intracerebral hemorrhage from
supratherapeutic INR. Emergent craniotomy was done under general anesthesia. Post-operatively he
had no neurologic improvement and after two additional weeks of expensive tests and procedures
further care was deemed futile and withdrawn. This patient illustrates a variety of anesthetic challenges
as well as ethical issues concerning futile care something important to consider with medicine's
increasing emphasis on resource allocation.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
RA MC114
t-PA Administration for Pulmonary Emboli After Spinal Anesthesia
Brian Adams, University of Tennessee Medical Center- Knoxville, Knoxville, TN
A 39-year-old female who underwent cesarean section for breech fetal presentation received t-PA
within 30 hours of spinal anesthesia due to diagnosis of bilateral pulmonary emboli. While fibrinolytic
administration was appropriate based on hemodynamic compromise and presence of right heart strain
use of t-PA is considered higher risk for 10 days after neuraxial anesthesia per ASRA guidelines. The use
of t-PA was fortunately discovered during routine post-operative rounds at which time the patient was
educated on potential complications and neurological checks ordered for 24 hours. Patient follow-up at
discharge and within 1 week of discharge revealed no anesthetic-related complication.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC115
Chronic Pain Localized to the Lliohypogastric Nerve: Treatment Using an Ultrasound Guided Technique
of Hydrodissection for Catheter Placement as a Guide for Surgical Lliohypogastric Nerve Resection
Adam Adler, M.D., M.S., Pranay Parikh, M.D., Baystate Medical Center, Springfield, MA, Daryl Smith,
M.D., University Of Rochester, Rochester, NY
A 58-year-old female was referred to the pain service complaining of burning right lower abdominal pain
for two years. Iliohypogastric nerve blocks were performed using ultrasound guidance. This was
repeated three times after the initial block provided 100% pain relief lasting approximately 4 weeks. A
fluoroscopic guided Iliohypogastric nerve cryoablation provided complete pain resolution lasting 4
weeks however with complete return of symptoms. She decided to proceed with surgical excision of the
right Iliohypogastric nerve. The technique of hydrodissection was employed to isolate the Iliohypogastric
and a catheter was places adjacent to the nerve as a marker for the surgeon.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC116
Bilateral Transversus Abdominus Plane (TAP) Blocks and Their Role in Facilitating Extubation in a
Patient With Intracranial Hypertension
Adam Antflick, D.O., George Williams, M.D., Jaideep Mehta, M.D., M.B.A., Bic Chau, M.D., University of
Texas Health Science Center at Houston, Houston, TX
A 20-year-old Hispanic post-partum female with a past medical history significant for autoimmune
hemolytic anemia and pre-eclampsia presented with an intracranial hemorrhage and interventricular
hemorrhage who on post-operative day #2 following a caesarean section continued to have increased
intracranial pressure. The patient had bilateral TAP blocks in order to provide analgesia and thus reduce
intracranial pressure facilitating extubation.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC117
Continuous Popliteal and Femoral Nerve Catheters in a Patient With Refractory Lower Extremity CRPS
Camellia Asgarian, M.D., Priya Kumar, M.D., Candra Bass, M.D., UNC Hospital, Chapel Hill, NC
Complex regional pain syndrome (CRPS) is a disease process with debilitating consequences. We
describe the case of a 19-year-old woman with a two year history of CRPS type 1 involving her left lower
Copyright © 2013 American Society of Anesthesiologists
extremity. She was severely debilitated and refractory to conventional therapy including lumbar
sympathetic block intravenous ketamine rehabilitation therapy spinal cord stimulation opioids
tricyclic antidepressants anticonvulsants and psychotherapy. Our intervention with continuous
popliteal and femoral nerve catheters allowed for her participation in physical therapy. As a result she
achieved a lower pain score an increased range of motion in her lower extremity and an improved
quality of life.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC118
Use of Regional Anesthesia in a Patient With a Pre-Existing Neuropathy
Alisha Bhatia, M.D., Taruna Penmetcha, M.D., John H. Stroger Hospital, Chicago, IL
Patient is a 44-year-old male who presented with wrist pain and was found to have a chronic scaphoid
fracture five years after an ORIF of the initial injury. He had the hardware removed but continued to
have pain. He then developed numbness of the fourth and fifth digits and forearm pain. An EMG
showed left ulnar neuropathy across the elbow segment. When he presented for cubital tunnel release
decision was made to do a supraclavicular block for anesthesia for the case. The patient continued to
have pain and numbness post-op and developed triceps muscle twitching and fasiculations.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC119
Transversus Abdominis Plane Block in a Patient With Spinal Muscular Atrophy
Shelly Borden, M.D., Bridget Muldowney, M.D., Kristopher Schroeder, M.D., University of Wisconsin,
Madison, WI
A 21-year-old female patient with Spinal Muscular Atrophy (SMA) underwent cystectomy for spastic
bladder. She complained of 10/10 pain POD1; epidural was not safe or viable given spinal hardware for
scoliosis. She remained intubated postoperatively (difficult intubation history); narcotics were used
sparingly to avoid compromising ventilation. TAP block was offered and provided excellent analgesia
(2/10). Extubation occurred on POD3. Atrophied abdominal musculature in SMA made the block
technically challenging but was successful and should be considered an alternative method for
postoperative pain management in patients undergoing abdominal surgery in whom neuraxial analgesia
is contraindicated and narcotics are avoided.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC120
Peripheral Nerve Blockade as Primary Anesthetic for Total Knee Arthroplasty in Anticoagulated
Patient With Severe Ischemic Cardiomyopathy
Clifford Bowens, M.D., Jeremy Jones, M.D., Vanderbilt University School of Medicine, Nashville, TN
We report a case in which peripheral nerve blockade was considered the safest anesthetic for a patient
undergoing total knee arthroplasty. The patient's past medical history was significant for CHF (EF = 10%)
ischemic cardiomyopathy (AICD) and atrial fibrillation. The patient had been anticoagulated with
warfarin and enoxaparin. Ultrasound guidance was used to perform a continuous femoral nerve block
lateral femoral cutaneous nerve block and obturator nerve block. A nerve stimulation technique was
used for the sciatic nerve block. The patient was maintained on a dexmedetomidine infusion during the
surgery and had an uneventful intraoperative and postoperative course.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
RA MC121
Combined Spinal Epidural Anesthesia for Non-Pheochromocytoma-Related Ambulatory Surgery in a
Patient With Metastatic Pheochromocytoma
Sheida Bunting, M.D., Eric Brumberger, M.D., New York Presbyterian/Weill Cornell, New York, NY
The literature is sparse regarding the use of neuraxial anesthesia in patients with pheochromocytoma. A
limited number of case reports describe the intentional use of epidural anesthesia as the primary
anesthetic in patients with pheochromocytoma undergoing non-pheochromocytoma-related surgery.
We present a successful case of a patient with metastatic pheochromocytoma undergoing resection of a
femoral osteochondroma performed under spinal anesthesia using combined spinal-epidural and
sedation in an ambulatory setting; this technique has not been previously reported. We conclude that
the dense sympathectomy and hemodynamic stability resulting from spinal anesthesia make it an ideal
option for patients with pheochromocytoma undergoing non-pheochromocytoma surgery.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC122
Supraclavicular Nerve Block Unmasks Myocardial Infarction
Sneha Chandra, M.D., Michael Bassett, M.D., MetroHealth Medical Center, Cleveland, OH
A 90-year-old female presented with intracranial hemorrhage and non-displaced right proximal humerus
fracture and non-operative management was recommended. The acute pain service was consulted for
management of shoulder pain and performed a right supraclavicular nerve block. Immediately following
the procedure she reported resolution of shoulder pain but complained of abdominal pain and
dyspnea. She became anxious tachypneic and tachycardic with decreasing oxygen saturation and ST
segment depression. Secondary to the temporal nature of her symptoms there was immediate concern
for phrenic nerve paralysis pneumothorax and/or local anesthetic systemic toxicity. After further
evaluation and testing she was diagnosed with NSTEMI.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC123
Epidural Blood Patch for Presumed Post Dural Puncture Headache After Posterior Spinal Fusion
Surendrasingh Chhabada, M.D., Pilar Castro, M.D., Markakis Dorothea, M.D., Cleveland Clinic
Foundation, Cleveland, OH
A 14-year-old female with idiopathic scoliosis who underwent T5-L1 posterior spinal fusion presented as
an outpatient one week post-operatively with severe postural headache. No neuroaxial techniques had
been performed perioperatively. She was admitted to the hospital overnight one week after discharge
with suspected post dural puncture headache (PDPH) which was successfully treated conservatively with
hydration caffeine and bedrest. She required readmission however two weeks post-operatively with
recurrent symptoms of PDPH. Despite an unknown level of dural puncture we decided to treat her with
a lumbar epidural blood patch which resulted in immediate and permanent resolution of PDPH
symptoms.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
RA MC124
Spontaneous Complete Resolution of Paraplegia Caused by Large Epidural Hematoma Associated With
Epidural Anesthesia in a Vascular Surgery Patient
Jae-Young Kwon, Ah-Reum Cho, Jeong-Min Hong, Mi-Jung Cho, Pusan National University Hospital,
Busan, Republic of Korea
A 76-year-old woman taking antiplatelet agents (aspirin clopidogrel) due to coronary stent placement
underwent femoropopliteal revascularization under epidural anesthesia. She had claudication caused
by arteriosclerosis obliterans and spinal stenosis. The antiplatelet agents were discontinued 7 days
before the surgery and were bridged over to intravenous unfractionated heparin until 6 hours before
the surgery. Epidural anesthesia and femoropopliteal revascularization were performed without any
problems. The patient developed paraplegia 11 hours after surgery. The MRI showed large epidural
hematoma extended from T2 to L4 levels. Despite our recommendation the surgical decompression
was refused. However complete recovery occurred in 14 days.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC125
What Goes Up Must Come Down: The Case of Cardiac Arrest & Complete Heart Block During Spinal
Anesthesia
Mack Thomas, M.D., Sharon Couch, M.D., Ochsner Medical Center, New Orleans, LA
Although 1st degree AV blocks and infranodal conduction defects are not considered contraindications
to neuraxial anesthesia they may pose risk in developing higher degree AV blocks or cardiac arrest. We
describe a case of a 73-year-old woman with a complicated history including RBBB syncopal episodes
attributed to BPPV and 1st degree AV block who presented for TKA. Minutes following hyperbaric spinal
anesthesia initiation patient suffered severe bradycardia which progressed to complete heart block and
cardiac arrest. Prompt resuscitation was performed with resolution of cardiovascular collapse. Resultant
cardiac rhythm revealed complete heart block which persisted after recession of spinal block.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC126
Virtual Reality for Ultrasound-Guided Regional Anesthesia - Our Experience
Paul Courtney, M.D., Daneshvari Solanki, M.D., Rene Przkora, M.D., Ph.D., University of Texas Medical
Branch, Galveston, TX
Introduction: Ultrasound-guided regional anesthesia requires coordination between the display of the
target on the ultrasound screen and the hands of the physician. We introduced a head-mounted video
display (HMD) to display the ultrasound image close to the physician`s eyes and evaluated this approach
in a case series. Methods: After IRB approval the HMD was used in 4 patients and compared to 4
patients without HMD for lower extremity blocks. Results: Significant fewer head movements were
observed with the HMD. No complications noted. Conclusion: Virtual reality using the HMD improved
coordination. A larger study is currently conducted to evaluate these findings.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
RA MC127
Total Spinal Anesthesia: A Devastating Complication of Thoracic Paravertebral Block. Implications of
the Anatomical Communications With the Paravertebral Space
Craig Cummings, M.D., Medical College of Wisconsin, Milwaukee, WI
52-year-old obese female with multiple bilateral rib fractures and mild traumatic brain injury on
therapeutic anticoagulation for prosthetic mitral valve. Pharmacological analgesia ineffective including
sub-hypnotic ketamine. No epidural given coagulation status plan for paravertebral catheters.
Ultrasound guidance unsuccessful. Classic landmark technique utilized for uneventful placement of
bilateral T4 catheters. Negative test dose and aspiration. Incremental injection of 20 mL 0.5%
ropivacaine with epinephrine into right catheter. Patient unresponsive with progressive hypoxia
hypotension and bradycardia. ACLS performed with chest compressions and medications. Vital signs
stable without further hemodynamic support. Patient unresponsive for two weeks off sedation on
mechanical ventilation.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC128
Management of a Rare Femoral Nerve Block Complication Involving Extravasation of Body Fluid in an
Elderly Patient
Thuan Dao, M.D., Natalie Wong, M.D., Mahammad Hussain, M.D., UT Houston Medical School, Houston,
TX
Peripheral nerve blocks (PNB) can alleviate perioperative pain decrease narcotic requirement and
improve rehabilitation. Management of rare complications of PNBs has not been extensively published.
We placed a femoral nerve block catheter in our elderly patient who underwent distal femur ORIF for
periprosthetic fracture. Postoperatively 1400 ml of fluid drained from the nerve block site after catheter
removal. The block needle could have punctured the bladder causing urine to track along the catheter
path. However comparison of the fluid and urine composition ruled out bladder injury. We suspect the
fluid was likely extravasation due to the patient's poor nutrition status.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC129
Epidural Hematoma Following Thoracic Epidural Catheter Insertion in a Patient With No Risk Factor
Karine De Oliveira Dias, M.D., Cleveland Clinic Foundation, Cleveland, OH
We describe a case of an Epidural Hematoma on a 34-year-old female otherwise healthy diagnosed
with a non-functional Left Upper Lobe carcinoid tumor who presented for Sleeve Lobectomy.
Laboratorial values were within normal limits. No anticoagulation drugs were administered. A preinduction T5-T6 epidural catheter was inserted easily and surgery completed in 4 hours. Immediately
after extubation patient complained of severe back pain and left lower extremity paresis with
preserved sensation was appreciated. Thoracolumbar MRI showed an extradural hematoma and spinal
cord compression at T5-6. Patient underwent emergent Laminectomy and discharged on PO7 with LLE
motor strength 4/5.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
RA MC130
Liposomal Bupivacaine
Lauren Dies, M.D., Jaideep Mehta, M.D., Gokul Thimmarayan, M.D., Muhammad Hussain, M.D., UT
Health Science Center Houston, Houston, TX
The anticipation of an extended release local anesthetic agent in regional anesthesia is to provide long
acting postoperative pain control without the requirement of a catheter while also decreasing
postoperative opioid requirement. Liposomal bupivacaine an extended-release form of bupivacaine
can provide analgesia for up to 72 hours without having an indwelling catheter. The following case
report describes a 33-year-old male who had a single shot sciatic nerve block with liposomal bupivacaine
following an open reduction and internal fixation (ORIF) of his left lateral malleolus and experienced
excellent post-operative pain relief but a prolonged motor blockade lasting 120 hours.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC131
Supplemental Superficial Cervical Plexus Block After Supraclavicular Block in a Morbidly Obese Patient
for Arthroscopic Shoulder Surgery
Robert Doty, M.D., Luminita Tureaunu, M.D., Dorota Szczodry, M.D., Northwestern University Feinberg
School of Medicine, Chicago, IL
38-year-old female ASA 2 145kg 157cm BMI 59 scheduled for left shoulder arthroscopy. A low volume
ultrasound guided left supraclavicular block with 10mL of 0.5% bupivacaine with 1:300 000 epinephrine
was performed pre-op for postoperative analgesia. Anesthesia was maintained with general anesthesia
with endotracheal tube. Post-op in PACU the patient complained of 7/10 (VAS) pain in the C4 nerve root
distribution. There was no clinical evidence of respiratory compromise. Left ultrasound guided
superficial cervical plexus block with 3mL of 0.5% bupivacaine with 1:300 000 epinephrine was
performed. The patient reported 0/10(VAS)pain denied dyspnea and was discharged home.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC132
Utility of Use of a Continuous Peripheral Nerve Catheter for a Patient Presenting With Muscle CrampFasciculation
Deneene Doyker, M.D., Ghassan Aljafar, M.D., Lori Circeo, M.D., Baystate Medical Center, Springfield,
MA
A 48-year-old male with hypertension hypercholesterolemia diabetic neuropathy of bilateral lowerextremities history of bilateral lower extremity compartment syndrome with surgical intervention left
foot drop gastric adenocarcinoma with surgical resection lumbar spinal stenosis with chronic low back
pain presented with right lower extremity pain muscle cramp and fasciculation similar in presentation
to a past compartment-syndrome episodes. Clinical assessment showed normal compartment
pressures. Treatment with diazepam baclofen and carbamazepine failed to alleviate symptoms.
Successful cessation of muscle fasciculations cramps and pain of right lower extremity with a
continuous sciatic nerve catheter using low concentration bupivacaine.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
RA MC133
Intra-operative Seizure Secondary to Epidurally Administered Lidocaine Toxicity
Dan Drzymalski, M.D., Aranya Bagchi, M.B. B.S., Massachusetts General Hospital, Boston, MA
A 44-year-old African woman with HIV had a low thoracic midline epidural placed prior to general
endotracheal anesthesia for open abdominal myomectomy. Aspiration and test dose were negative so
epidural boluses of lidocaine were administered intra-operatively. After an uneventful surgery she
remained unresponsive exhibiting dysconjugate gaze and lip-smacking movements. Midazolam
propofol levetiracetam and intra-lipid were administered after which she became responsive.
Following extubation she had a negative head CT and was taken to the ICU. Neurology consult
confirmed the diagnosis of local anesthetic toxicity and recommended no further treatment. Within
hours the patient returned to baseline neurological function.
Saturday, October 12
10:30 AM - 12:00 PM
RA MC134
Bilateral Ropivacaine Infused Brachial Plexus Catheters for Postoperative Pain Control in a Trauma
Patient
Mical Duvall, Veerandra Koyyalamudi, M.D., LSU Shreveport, Shreveport, LA
We present a case of a 26-year-old female with bilateral upper extremity fractures after a motor vehicle
collision who received bilateral brachial plexus catheters with an infusion of ropivacaine for post-op pain
control. Placement of brachial plexus catheters above the clavicle is associated with a high incidence of
phrenic nerve involvement and diaphgramatic paralysis. To avoid complications associated with bilateral
phrenic nerve blockade we placed bilateral infraclavicular brachial plexus catheters under ultrasound
guidance.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC135
Anesthetic Management of a Neonate With Obstructing Duodenal Web
Adam Adler, M.D., M.S., Baystate Medical Center, Springfield, MA, Jessica Bland, M.D., Connecticut
Children's Hospital, Hartford, CT
A male child born at 36 weeks was born to a mother with preeclampsia and a history of cocaine use
throughout pregnancy. At birth he weighed 3.02kg and was noted to have wide spaced nipples tongue
tie hypospadias and was devoid of other obvious abnormalities. He was discharged home after two
days and returned on the fifth day of life with poor feeding. Upper GI series demonstrated a bowel
obstruction due to duodenal web for which he underwent an emergent uncomplicated surgical
resection. He will be evaluated by the hospital geneticist for potential associated congenital syndromes.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC136
Anesthetic Management of an Adolescent With Anti-N-methyl-D-Aspartate Receptor Encephalitis
Naila Ahmad, M.D., Patel Ankur, M.D., Brenda McClain, M.D., Saint Louis University, St. Louis, MO
The patient is 14-year-old female scheduled for laparoscopic oophorectomy for teratoma associated
with anti-NMDA receptor encephalitis. Initial presentation included headaches dizziness and abdominal
discomfort. Seizures extrapyramidal movements violent outbursts and loss of consciousness. Laboratory
Copyright © 2013 American Society of Anesthesiologists
findings were positive for NMDA antibodies. Pelvic CT revealed an ovarian neoplasm. Pre-operative
history and physical exam revealed wide swings in blood pressure agitation and dyskinesia. Anesthetic
management consisted of induction with Propofol and vecuronium and maintenance with Sevoflorane
and morphine. Invasive blood pressure monitoring was performed. No perioperative adverse events
occurred. Drug selection rationale for monitoring and planned postoperative care will be discussed.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC137
Laryngoscopy Still Works!
Anita Akbar Ali, M.D., Hess Robertson, M.D., University of Arkansas For Medical Sciences, Little rock, AR,
Hani Hanna, M.D., Edwin Abraham, M.D., Arkansas Children's Hospital, Little Rock, AR
A 3-year-old pediatric trauma patient was scheduled for halo vest placement due to C1 instability. An
intramedullary femur nail insertion was also planned after halo fixation. Per Neurosurgeon's request
patient was kept sedated and spontaneously breathing during halo placement in order to prevent any
unintentional neck movement during airway manipulation. After halo fixation and inhaled induction
multiple unsuccessful attempts were made with glidescope and fiberoptic scope. Eventually a MAC 2
blade was inserted in the mouth and handle was attached after placement of blade in oral cavity and
ETT was placed successfully (figure 1).
Saturday, October 12
10:30 AM - 12:00 PM
PD MC138
Challenges Encountered in the Anesthetic Management of a Patient With Cornelia de Lange Syndrome
Sehar Alvi, M.D., Shvetank Agarwal, M.D., Ranita Donald, M.D., James Mayfield, M.D., Georgia Regents
University, Augusta, GA
A 21-year-old female with Cornelia de Lange syndrome (CdLS) presented for transvaginal ultrasound and
gynecological examination to evaluate her irregular menses. She had severe micrognathia short neck
micromelia of extremities and mental retardation. Anticipating a difficult airway decision was made to
avoid endotracheal intubation. Intramuscular ketamine was administered in the preoperative holding
area followed by assisted mask ventilation with sevoflurane and oxygen in the operating room. Difficult
airway cart was kept on stand-by for an emergent endotracheal intubation or establishing a surgical
airway if need arose. We discuss the anesthetic challenges in managing a patient with a rare congenital
disorder.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC139
A Case of Neonatal Airway Obstruction
Joseph Andre, M.D., Ammar Yamani, M.D., Donald Schwartz, M.D., Baystate Medical Center, Springfield,
MA
A 2-day-old male evaluated for excision a large nasopharyngeal mass with resulting ball-valve effect.
Following uncomplicated delivery he developed cyanosis and desaturation with feeding. MRI revealed a
large soft tissue mass in the nasopharynx. He was taken to the operating room with preparation made
for possible difficult airway including Glidescope* 2.5mm 3.0mm ETT Nasal airway cut and measured.
Desaturation to 85% and a cyanotic episode were successfully managed with judicious use of CPAP. He
was induced with sevoflurane and intubated.. After mass resection he was extubated uneventfully.
Radiologic images will highlight the discussion of management of neonatal nasopharyngeal masses.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
PD MC140
Post Obstructive Massive Diuresis in a 3-year-old
Candy Anim, M.D., Kang Rah, M.D., UMDNJ-Robert Wood Johnson Medical School, Plainsboro, NJ
A 12-month-old boy was admitted for bilateral urethral re-implantation with re-exploration and urethral
stent placement. In utero he was diagnosed at 24 weeks via abdominal ultrasound with bilateral
hydronephrosis with severe reflux grade 5. Intraoperative management was uncomplicated. However
post procedure observation in the pediatric intensive care unit patient was noted to be voiding ~1liter a
day and his electrolyte demonstrated dehydration. His medical management included daily fluid
replacement therapy as needed. We are going to present his postoperative course including daily urine
output electrolytes and significant hemodynamics.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC141
The Anesthetic Challenges and Perioperative Considerations for the Management of a Toddler With
Schinzel-Giedion Syndrome
Ahmed Attaallah, M.D., Ph.D., Drew Rodgers, M.D., West Virginia University, Morgantown, WV
We present a toddler with Schinzel-Giedion syndrome (SGS) who underwent craniotomy for
craniosynostosis. SGS is an extremely rare genetic disorder characterized by mid-face retraction skull
anomalies neuro-degenerative features seizures urinary malformations skeletal and genital anomalies
severe mental retardation cardiac defects recurrent pneumonias interrupted breathing failure to
thrive and developmental delay. SGS patients typically do not live beyond 2 years. We discuss the
numerous potential challenges of SGS and share our anesthetic techniques resulting in successful
management of our patients. We also review the strategies utilized to avoid and/or treat possible
perioperative compromises in order to minimize adverse outcomes.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC142
Cardiac Arrest After Local Anesthetic Intoxication in a Pediatric Patient
Liana Maria Azi, M.D., Ph.D., Ana Amelia Souza Simas, M.D., Anna Gisele Coutinho, Wilfred Tobon, Diego
Grimaldi Figueiroa, Professor Edgard Santos University Hospital, Salvador, Bahia, Brazil
A 6-year-old 20 kg male presented for hypospadias correction. General anesthesia and caudal block with
Bupivacaine 0 375% 10 ml was performed. One minute later he experienced ventricular tachycardia
reverted by amiodarone but it subsequently evolved to pulseless electrical activity (PEA). Local
anesthetic intoxication was hypothesized and adrenaline and lipid emulsion was administrated followed
by continuous infusion of both. He returned to sinusal rhythmus approximately 1 hour after cardiac
arrest. The patient was transported to the PICU and successfully extubated after 48h. He was discharged
home without any sequelae six days later.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
10:30 AM - 12:00 PM
PD MC143
Acute Airway Obstruction At Induction of Anesthesia
Harish Bangalore Siddaiah, M.D., Shilpadevi Patil, M.D., Ashok Rao, M.D., LSUHSC, Shreveport, LA
A 12-year-old patient with a gun-shot injury to chest admitted to PICU was diagnosed with right
pneumothorax s/p chest tube placement was scheduled for VATS with possible lobectomy. On day of
surgery in the OR patient was initially intubated. However there was no chest rise misting or ETCO2
detected suspecting esophageal intubation patient was re-intubated again with same results. A suction
catheter was introduced into the ETT and thick mucus plugs were suctioned out. Flexible bronchoscope
was used to further determine the cause of ETT obstruction. Thick mucus plugs and blood clots along
with few gun pellets were suctioned.
Saturday, October 12
10:30 AM - 12:00 PM
PD MC144
Right-Sided Eventration Masquerading as RDH
Natalie Barnett, M.D., Francine Yudkowitz, M.D., The Mount Sinai Hospital, New York, NY
A neonate born at 36 weeks 6 days of a twin gestation with APGAR scores of 8/9 was noted to be
tachypneic in the well baby nursery. After transfer to the neonatal intensive care unit pediatric surgey
was consulted and a thoracic ultrasound revealed the liver in the right hemithorax. A right sided
diaphragmatic hernia was suspected and on day of life (DOL) #4 the neonate was brought to the OR.
Surgical finding was diaphragmatic eventration that was repaired without complications. Patient was
discharged home on DOL #16 and was doing well at 6 week follow up.
MCC Session Number – MCC03
Saturday, October 12
1:00 PM - 2:30 PM
FA MC146
Undiagnosed Heart Block In An Out-Of-State Patient
Natalie Barnett, M.D., Steven Neustein, M.D., The Mount Sinai Hospital, New York, NY
A 76-year-old male patient traveled from Georgia to New York for a parathyroidectomy. Other than
hypertension the patient denied any other medical history. Once in the operating room the patient was
noted to be in symptomatic second degree heart block. Patient was brought to the PACU and cardiology
consulted. Due to the unusual circumstance of an out-of-state patient the decision was made to have a
temporary transvenous pacemaker placed and to proceed with the parathyroidectomy later the same
evening. The patient was discharged against medical advice prior to permanent pacemaker placement
and returned home to Georgia.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC147
Perioperative Serotonin Syndrome
Nicole Beatty, M.D., John Eisenach, M.D., Mayo Clinic, Rochester, MN
Serotonin syndrome is gaining attention in perioperative and chronic pain settings due to the growing
prevalence of multi-modal therapies that increase serotonin levels and thereby heighten patient risk. A
Copyright © 2013 American Society of Anesthesiologists
patient's genetic make-up may further add to their risk of serotonin syndrome. Described is a case of
serotonin syndrome upon emergence from general anesthesia. A subsequent cytochrome P4502D6
genetic test result suggested a potential alteration in metabolism. We describe the clinical presentation
and management of perioperative serotonin syndrome as well as a possible genetic predisposition for
this patient taking combination anti-depressant medications and receiving common perioperative
medicines.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC148
An Airway Emergency on Postoperative Day 7
Allan Belcher, D.O., John Doyle, M.D., Ph.D., Maged Gurguis, M.D., Cleveland Clinic, Cleveland, OH
A 66-year-old male underwent cervical fusion surgery. He was discharged on POD 5 but readmitted the
next day for neck pain. On POD 7 his pain increased significantly his neck was actively swelling and he
had respiratory distress. He was taken urgently to the OR awake fiberoptic intubation was attempted
but anatomy was poorly visualized and he rapidly desaturated. ENT and the Anesthesia resident urgently
opened the left neck wound and expressed 50 cc of clotted blood. Awake Glidescope intubation was
used and with marked difficulty he was successfully intubated with a 5.5 MLT tube on 3rd attempt.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC149
Anesthetic Concerns and Considerations for Arcuate Ligament Syndrome
Cole Bennett, M.D., John Jerabek, D.O., Cleveland Clinic Foundation, Cleveland, OH
Surgery for arcuate ligament release can be performed via open or laparoscopic. While it has been
performed safely laparoscopically the rate of conversion to open is high enough that it should be of
significant concern to the anesthesiologist for all patients undergoing this procedure. This case report
describe one such instance in which the celiac artery was severed during the procedure and why it is of
the utmost importance for the anesthesiologist to prepare for a worst case scenario despite the fact
that these patients are often otherwise healthy.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC150
Anesthetic Concerns for a Myasthenia Gravis Patient Undergoing Robot-Assisted Thoracoscopic
Thymectomy
Jennifer Bernard, M.D., Alan Romero, M.D., UT Southwestern Medical Center, Dallas, TX
A 40-year-old male with myasthenia gravis presented for robotic-assisted thoracoscopic thymectomy.
Pre-operatively he was continued on 120mg pyridostigmine TID and 20mg prednisone daily. Anesthesia
was induced with remifentanil lidocaine ketamine and propofol initially trying to avoid paralytics. The
patient had a difficult airway necessitating administration of rocuronium for placement of a SLT and
bronchial blocker. Anesthesia maintenance was achieved with a remifentanil infusion and boluses and
sevoflurane. The patient was able to be extubated in the OR after full reversal and demonstration of
extubation criteria.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
FA MC151
The Devil in Disguise: Malignant Hyperthermia Phenotypes
Francisco Bezerra, M.D., Paras Patel, M.D., Zachary Price, M.D., Henry Ford Hospital, Detroit, MI
A 57-year-old male with history of arthritis and hypothyroidism underwent repeat transphenoidal
resection of pituitary adenoma. Intravenous general anesthesia was induced and maintained with
isoflurane. Approximately 2.5h after induction patient presented gradual increase of temperature
EtCO2 and later tachycardia. Malignant hyperthermia was considered. Isoflurane was discontinued and
a propofol infusion along with active cooling was installed. Administration of Dantrolene was held due
to clinical improvement. Patient was transported to ICU and extubated the same day. Serum CPK peaked
at 1631 IU/L. Submission of blood sample for malignant hyperthermia susceptibility testing was positive
for heterozygous in the RYR1 gene.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC152
Not Just Another Biopsy
Alisha Bhatia, M.D., John H. Stroger Hospital, Chicago, IL
A 29-year-old male with no medical history presented with a productive cough and dyspnea on exertion.
CT scan revealed a large mass within the anterior mediastinum extending into the left lung and inducing
rightward distal tracheal deviation. There was marked attenuation of the SVC and 40% loss of lung
volume. Anesthesia was consulted for sedation for a CT guided biopsy because the patient was unable
to lay flat without coughing and feeling short of breath. General anesthesia was administered due to
concern for the airway given the size of the mass and its location.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC153
Anesthetic Considerations for an ALS Patient Undergoing Diaphragm Pacemaker Placement
Amar Bhatt, M.D., Joshua Lumbley, M.D., The Ohio State University, Columbus, OH
Amyotrophic lateral sclerosis (ALS) is a rare degenerative disease involving both upper and motor
neurons eventually causing failure of pulmonary mechanics requiring tracheostomy and full ventilator
support. At our institution laparoscopically placed diaphragm pacing systems (DPS) have been trialed
for insertion prior to requirement of a tracheostomy and ventilator support. Anesthetic management of
this and other procedures on patients with ALS requires careful intraoperative management for
successful extubation and ventilator independence. We describe the anesthetic management of a
patient with late stage ALS for laparoscopic DPS placement without the use of neuromuscular blockade
successful extubation and no further pulmonary consequences.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC154
Utilization of iPhoneFaceTime™; Application to Facilitate Intraoperative Ultrasound Guided Arterial
Line Placement
Ryan Bialas, M.D., M.P.H., Claude McFarlane, M.D., UNC Chapel Hill, Chapel Hill, NC
Proper patient forearm positioning for placement of a radial arterial catheter is often challenging
intraoperatively. When ultrasound guided line placement is necessary intraoperatively it is often
Copyright © 2013 American Society of Anesthesiologists
impossible to place the ultrasound monitor in a location that can be viewed by the anesthesia provider
placing the line. We describe the use of the iPhone and FaceTime™; application to facilitate successful
intraoperative ultrasound guided placement of difficult arterial lines in two patients. This technique
could be useful in numerous applications when cumbersome ultrasound machines are unable to be
placed in an optimal location for the anesthesia provider performing a procedure.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC155
Awake Emergent Tracheotomy in a Patient With Superior Vena Cava Syndrome
Stephen Bird, D.O., Chris Nagy, M.D., SAUSHEC, San Antonio, TX
62-year-old female with history of breast cancer and subsequent subclavian vein catheter placement for
chemotherapy presented to the ED with severe neck and upper extremity swelling and worsening
dyspnea. Computed tomography of the neck revealed superior vena cava syndrome secondary to
catheter related thrombosis. Shortly after admission to the ICU anesthesia was consulted for emergent
airway management. Significant edema was noted on the airway exam and the patient's respiratory
compromise continued to worsen. After consideration of multiple airway approaches the decision was
made to proceed with an awake emergent tracheotomy. This led to immediate improvement in
oxygenation.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC156
Interruption of Dual Antiplatelet Therapy: Anesthetic Management of a Patient With a < 30 Day Old
Drug Eluting Stent Undergoing Cranioplasty
Gabriel Bonilla, M.D., Mount Sinai School of Medicine - Elmhurst Hospital, Elmhurst, NY
A 78-year-old male with hypertension and a bioprosthetic MVR has a < 30 day old drug eluting stent in a
CABG graft. Dual antiplatelet therapy has been discontinued because of recurrent subdural hematomas
requiring subsequent craniotomy with hematoma evacuation serial bedside aspirations of
postoperative fluid collection and craniectomy with hematoma evacuation. He presents for a scheduled
cranioplasty. This case reviews maintainance of a favorable balance between factors determining
oxygen supply and demand and the different modalities used to monitor perioperative myocardial
ischemia. This case emphasizes the importance of interdisciplinary communication when caring for
patients in the perioperative setting.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC157
Airway Management in a Patient with an Epiglottic Cyst
Robert Bowers, M.D., Jonathan Lesser, M.D., Franco Resta-Flarer, M.D., Migdalia Saloum, M.D., St Luke's
Roosevelt Hospital Center - Columbia University, New York, NY
A 42-year-old with a large epiglottic cyst in the vallecula presented for excision. Preoperative
nasopharyngoscopy demonstrated the cyst obliterating any view of the glottic opening. Intraoperatively
a video Glidescope was used to characterize the anatomy of the cyst and its impact on tracheal access
and corroborated the visual obstruction of the glottis. Initial attempts to lift the cyst or displace it
laterally with the endotracheal tube were unsuccessful. A decision was made to do direct laryngoscopy
with a Miller 2 blade allowing the cyst to be displaced ventrally facilitating intubation with a size 5.0
ETT.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
FA MC158
Airway Fire Inside Rigid Bronchoscope
Daniel Brezina, Slawomir Oleszak, M.D., Renata Kowal, M.D., Yelena Babenko, M.D., Stony Brook
University, Stony Brook, NY
A 70-year-old man underwent bronchoscopy to evaluate hemoptysis. IV induction followed by
placement of rigid bronchoscope was accomplished without incident. A RUL carcinoid tumor was
resected using electrocautery snare. The patient was then ventilated for 5 minutes on RA followed by
application of YAG laser for hemostasis at which time a flame was observed inside bronchoscope. The
fire was immediately extinguished and bronchoscope removed. There was evidence of fire damage to
the plastic suction catheter but bronchoscopy showed no airway damage. The case was completed and
the patient had an otherwise unremarkable postoperative course.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC159
Anaphylactic Reaction to Antithymocyte Globulin Rabbit During Kidney Transplant
Robert Buchmann, M.D., Kyle Dryden, M.D., SLU, St. Louis, MO
We present a 41-year-old male for kidney transplant. History included hypertension and end stage renal
disease. Pt was taken to operating room anesthesia was induced trachea was intubated and arterial
and central lines were placed. Procedure was started without incident. Prophylactic methylprednisone
was administered followed by antithymocyte globulin rabbit infusion. Shortly after infusion was initiated
patient became hypotensive and peak airway pressures rose drastically causing difficult ventilation.
Several epinephrine boluses followed by infusion were started and patient eventually stabilized.
Transplant was aborted and patient was transported to ICU. Patient was extubated and epinephrine
infusion discontinued post-operative day 2.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC160
Collapse of a Large Goiter Causing Immediate Respiratory Collapse During a Routine Pre-Anesthetic
Assessment
Gaurav Budhrani, M.D., Temple University Hospital, Philadelphia, PA
A 50-year-old female presents with an 8x6 cm thyroid mass rightward deviation and direct compression
of the trachea and extension into the anterior mediastinum. She is symptomatic when supine and is
scheduled for surgery. Immediately after the pre-anesthetic evaluation she experiences sudden
dyspnea panics and turns cyanotic. A rapid response is called by the RN while anesthesiology calls for
backup and a fiberoptic cart. She develops bradycardia and a Code Blue is activated. After BMV with the
head of the bed elevated she returns to consciousness. Her airway is topicalized with lidocaine and an
awake glidescope intubation is successful.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
FA MC161
Anesthetic Management of a Patient With a Solitary Fibrous Tumor Occupying the Entire Left
Hemithorax Presenting for Resection via Anterolateral Thoracotomy and Hemisternotomy
Melissa Byrne, D.O., Jennifer Vance, M.D., University of Michigan, Ann Arbor, MI
We present the case of a 54-year-old male with past medical history of hypertension and six months of
progressive dyspnea on exertion found to have a mass occupying the entire left hemithorax causing
rightward mediastinal shift scheduled for left pneumonectomy with possible cardiopulmonary bypass. A
highly vascularized tumor weighing approximately 3.5 kilograms was resected with accompanying
massive blood loss and hemodynamic compromise requiring volume resuscitation and vasopressor
administration. We will discuss the management of altered cardiopulmonary physiology experienced by
re-expansion of a lung which had functionally been collapsed for several months preoperatively.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC162
Airway Management of Patients With Severe Ankylosing Spondylitis
William Carter, M.D., Jennifer Vance, M.D., Gennadiy Voronov, M.D., John H. Stroger Hospital of Cook
County, Chicago, IL
I present a case of a 40-year-old with ankylosing spondylitis who presented for a corrective total hip
replacement. He presented with stiffness of the cervical spine atlanto- occipital temporo-mandibular
and crico- arytenoid joints. The patient was positioned properly and the King Laryngoscope a form of
indirect laryngoscopy was attempted and was successful on the first attempt. An anesthetic plan in
which tracheal intubation is accomplished before anesthetic induction or immediately after an
expeditious induction needs to be in place before the patient arrives in the OR. There are many options
in securing the airway in AS patients.
Saturday, October 12
1:00 PM - 2:30 PM
FA MC163
Anesthetic Concerns for Posterior Lumbar Fusion in Patient With Undiagnosed Myotonic Dystrophy
Courtney Castoro, M.D., Daniel Ferry, M.D., Katalin Scherer, M.D., The University of Arizona College of
Medicine, Tucson, AZ
Myotonic Dystrophy Type 1 (DM1) is the most common form of neuromuscular disease in adults with a
prevalence of 1 in 8 000. It is an autosomal dominant disease caused by a trinucleotide (CTG) repeat in
theDMPK gene. Genetic anticipation is a characteristic feature where the disease appears at an earlier
age and with increasing severity in successive generations. Anesthetic complications are numerous
potentially deadly and not proportional to the severity of the disease. Preoperative screening may be
difficult as patients may not know they have the disease- common due to the neuropsychological and
personality changes characteristic of DM1.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
FA MC164
Dabigatran in the Setting of Urgent Surgery
Dennis Chang, Cleveland Clinic Foundation, Cleveland, OH
A 77-year-old male presented with right intracapsular hip fracture after a syncopal episode. Medical
history includes severe oxygen dependent COPD rheumatoid arthritis medically managed
significant/severe CAD s/p CABG with bioprosthetic Mitral Valve and Tricuspid valve repair sick sinus
syndrome/atrial fibrillation s/p MAZE procedure with pacemaker CML with recurrent pleural effusions.
He had stage 3 Chronic renal failure (creatinine=) and dabigatran maintenance dose was last ingested 46
hours earlier with preop PT/INR PTT abnormal at ( 17.2/1.5 59). The patient appeared cyanotic with
tachypnea on oxygen at 4 l/min reporting this unchanged since the syncope. ABG and Troponin sent.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC165
High Risk Obstetric Patient With Non-Ischemic Cardiomyopathy and Scleroderma
Shayan Bengali, B.S., Mohammed Abdel Rahim, M.D., University of Miami Miller School of Medicine,
Miami, FL
A 23-year-old gravida 2 para 0-1-0-1 at 28 weeks gestational age presents with 2 weeks of worsening
dyspnea. She was admitted into the cardiac ICU and treated for uncompensated CHF. She remained as
an inpatient until delivery due to her scleroderma and severely dilated cardiomyopathy with left
ventricular non-compaction and poor EF status post cardiac resynchronization therapy. She was found
to have an EF of 10% pulmonary edema and restrictive lung disease. The fetus on routine monitoring
was found to have recurrent late-decelerations and it was decided the patient would undergo elective
repeat cesarean section with cardiopulmonary bypass on standby.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC166
Acute Hypoxemic Cardiopulmonary Arrest in a Parturient With Severe Preeclampsia and
Cardiomyopathy: Anesthetic Management for Unanticipated Emergent Cesarean Delivery
John Berry, M.D., Lavinia Kolarczyk, M.D., David Mayer, M.D., UNC Hospitals, Chapel Hill, NC
A 25-year-old G3P0 morbidly obese parturient with severe preeclampsia and 25 week twin gestation
was intubated for respiratory distress and transferred to our facility. Mechanical ventilation was poorly
tolerated and she developed acute hypoxemic bradycardic arrest. Bedside TTE revealed acute
cardiomyopathy. She was brought to the OR for emergent caesarean section. Given the broad
differential diagnosis for her hemodynamic compromise TEE was requested. TEE revealed large pleural
effusions and LVEF 25%. Bilateral chest tubes were placed with immediate improvement in ventilation
and oxygenation. This case illustrates the timely effectiveness of a multidisciplinary approach of
anesthesia and surgical subspecialties.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
OB MC167
Epidural by Flashlight
Daniel Betterly, Brent Luria, M.D., NYU, New York, NY
In the obstetrical suite during hurricane sandy with no light besides flashlights there was a 30-year-old
parturient. She was 40 weeks pregnant and in active labor. She had 3 previous C-Sections and was
attempting to have a vaginal birth. There was no way to effectively monitor fetal heart rate and the
mother was on a transport monitor. An epidural catheter was placed with a flashlight in order to provide
a safer method incase a C-section was needed and to provide some pain relief during labor.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC168
Thrombotic Microangiopathy in Pregnancy
Robert Biechler, M.D., Medical College of Wisconsin, Milwaukee, WI
A 23-year-old African American female without a significant past medical history presented in active
labor. An epidural was placed without complications. Labs were ordered two hours following epidural
placement. Labs illustrated a platelet count of 6 000. Based on the labs the patient was given the
presumed diagnosis of pregnancy induced TTP/HUS. The patient was initially treated with fresh frozen
plasma transfusion. Following delivery by cesarian section the patient was treated with plasma
exchange and diagnosed definitively with TTP. The case illustrates the difficult management decisions
that are required when managing a parturient with newly diagnosed thrombotic microangiopathy.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC169
Prolonged Paralysis After Spinal Anesthesia in a Parturient: A Cause for Concern
Brett Blakeway, M.D., John Carter, M.D., Randall Henthorn, M.D., Abhinava Madamangalam, M.D.,
University of Oklahoma Health Science Center, Oklahoma City, OK
A young gravida at 39 weeks with chronic hypertension Type II DM and obesity underwent a repeat C/S
and tubal ligation under a standard spinal anesthetic. Signs and symptoms of lower extremity paralysis
persisted hours after normal anticipated recovery. Neurosurgical consultation and extensive
investigations including a spine MRI revealed no abnormalities. The patient complained of blindness in
both eyes on post-op day 3. Psychiatric evaluation pointed to a conversion disorder. We will detail the
diagnosis and management of delayed recovery from spinal anesthesia and describe criteria to diagnose
a somatic conversion disorder and management.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC170
Anesthetic Management of an Exit Procedure
Adam Braden, M.D., Christopher Nagy, M.D., San Antonio Uniformed Services Health Education
Consortium, Fort Sam Houston, TX
A 23-year-old primigravid female presented at term for an Ex-Utero Intrapartum Treatment (EXIT)
procedure for severe fetal micrognathia. Following lumbar epidural placement for post-operative pain
control the patient's airway was secured with rapid sequence induction and direct laryngoscopy.
Further large-bore intravenous access and a radial arterial line were then obtained. Anesthesia was
Copyright © 2013 American Society of Anesthesiologists
maintained with 1-1.5 MAC desflurane. Profound uterine relaxation was achieved with a nitroglycerine
infusion. Maternal blood pressure was supported with phenylephrine. After partial delivery pediatric
otolaryngology secured the child's airway without complications. The remainder of the case was
uneventful and the patient was extubated without difficulty.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC171
Management of Placenta Percreta
Daniel Brewer, M.D., San Antonio Military Medical Complex, San Antonio, TX
A 32-year-old G5P2 female with 2 previous C-sections and history of ruptured ectopic pregnancy
presents with placenta percreta. MRI performed at 27 weeks showed invasion into the urinary bladder
with potential bilateral ureteral involvement. Patient underwent planned C-section and hysterectomy at
32 +1 weeks with Urologic repair of bladder and cystoscopy for evaluation of ureteral involvement. RSI
induction followed large bore IV access and arterial line placement. Central venous access obtained
immediately after induction. EBL was 4200ml and patient was resuscitated with 8 units PRBC & FFP.
Patient was adequately resuscitated and extubated following procedure.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC172
Roc Sux or Mag: A Case of Postoperative Paralysis
Bridget Bush, Virginia Mason Medical Center, Seattle, WA
A 34-year-old G6P3 with Hep C h/o IVDU and on Magnesium s/p Cesarean for PIH was taken back for an
ex-lap for bleeding. She remained paralyzed post-operatively with only weak post-tetanic train-of-four
elicited. The case exemplified differential diagnosis and management of post-operative paralysis in the
post-partum pre-eclamptic patient and decision making points for her rapid sequence intubation.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC173
Cesarean Delivery for a Parturient With Pulmonary Hypertension and Thrombocytopenia
William Cederquist, M.D., Anna Dubovoy, M.D., Joanna Kountanis, M.D., University of Michigan Health
System, Ann Arbor, MI
A 31-year-old G6P3 woman at 28+5 weeks gestation was admitted with an insidious onset of dyspnea
and found to have severe pulmonary hypertension (PA pressure 102/55 mmHg mean 75 mmHg PVR 16
WU). Her medical history was notable for cyanotic congenital heart disease repaired at age 3 but
without long term followup. She was initiated on intravenous epoprostenol (prostacyclin) a potent
pulmonary vasodilator and inhibitor of platelet aggregation but subsequently went into preterm labor
at 32+3 weeks gestation. Here we describe the anesthetic management for Cesarean delivery in a
patient with severe pulmonary hypertension.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
OB MC174
A Case of a Stuck Epidural Catheter in the Lateral Recess
Stephanie Cheng, M.D., Thomas Halazynski, M.D., Yale University, New Haven, CT
Epidural catheter was placed for a 20-year-old healthy actively laboring female which subsequently
proved to be ineffective. Multiple attempts at removal with traction and positioning failed. Catheter
stretch was noted. A second catheter for analgesia was placed the first one still in place. Following
delivery repeated removal attempts were unsuccessful and Neurosurgery was consulted. A noncontrast CT scan showed catheter tip terminating in right L1-L2 lateral recess. With the patient in right
lateral decubitus position flexion/extending of the waist arching of the pelvis left and right and saline
injection the epidural catheter was removed with intact catheter tip.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC175
Management of Massive Intraoperative Hemorrhage in Patients With Known Placenta Accreta: A Case
Report
Stephen Chin, D.O., Mari Baldwin, M.D., St Luke's Roosevelt Hospital Center, New York, NY
We present a 37-year-old parturient with a known placenta accreta at 35 weeks gestation. Soon after a
labor epidural was placed she presented to the operating room for caesarian section secondary to nonreassuring fetal tracing. Surgical delivery was complicated and hemodynamics were unstable due to
considerable hemorrhage. General anesthesia was commenced and the infant was delivered
successfully. Massive transfusion and resuscitation and hysterectomy took place. Surgical control of
uterine artery bleeding was inadequate and required a trip to interventional radiology for uterine artery
embolization. She was extubated on POD #1 and had no recall or neurologic or other sequelae.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC176
A Unique Challenge: Obstetric Anesthesia for Harlequin Ichthyosis
Andrea Choate, M.D., Thea Rosenbaum, M.D., UAMS, Little Rock, AR
A 20-year-old with Harlequin Ichthyosispresented for the birth of her first child. She is one of only 12
people in the USA with this rare skin disorder and she is the first documented to give birth. Unique
challenges in our anesthetic approach arose in the inability to tape the epidural catheter the tracheal
tube and EKG and electrocautery pads to the skin. In addition possible upregulation of acetylcholine
receptors and extreme hyperkalemia with succinylcholine use may be associated along with unknown
anesthetic pharmacokinetics. Our choice of anesthesia was a success.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC177
Epidural Anesthesia for Cesarean Section in an Achondroplastic Dwarf
Isaac Chu, M.D., Jonathan Ko, M.D., Melissa Rocco, M.D., Mount Sinai, New York, NY
An 18-year-old woman with achondroplasia presented for cesarean section for a full term intrauterine
pregnancy. The patient had no prior surgeries. Her airway evaluation was characterized by a Mallampati
I classification a large tongue and a depressed nasal bridge. On physical exam her spine was midline
with no scoliosis. A neuraxial anesthetic was chosen because of airway concerns in achondroplasia and
Copyright © 2013 American Society of Anesthesiologists
pregnancy. An epidural provided increased control of the level of the neuraxial block and improved
duration than a spinal anesthetic. The epidural was placed on the first attempt without complications
and the surgery proceeded uneventfully.
MC178
Saturday, October 12
1:00 PM - 2:30 PM
OB MC178
Urgent Cesarean Section in a Morbidly Obese Patient With a Working Epidural
Andrew Crabbe, M.D., Daniel BIggs, M.D., University of Oklahoma COM, Oklahoma City, OK
A 36-year-old morbidly obese G4 P2 female presented in labor at 38 weeks. She has a BMI of 88 severe
obstructive sleep apnea requiring oxygen and CPAP diabetes and hypertension. The patient had a
working epidural but operative delivery was proposed because of failed progression. She was unable to
lie supine thus a general anesthetic was indicated. An awake fiberoptic intubation was planned because
of positioning and expected difficult intubation and was accomplished with topicalization of upper
airway and ketamine sedation. Operative delivery was without event and the patient was electively
ventilated until the following day then extubated.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC179
Anesthesia Considerations of Loeys-Dietz Syndrome in Pregnancy: A Case Report
Jessica Cronin, M.D., MBA, Harry Dietz, M.D., Xiaobo Dong, M.D., Ernest Graham, M.D., Jamie Murphy,
M.D., Gretchen Oswald, M.S., Melissa Russo, M.D., Johns Hopkins Hospital, Baltimore, MD
A 28-year-old primagravida woman with Loeys Dietz Syndrome (LDS) presented at 36 weeks gestation
for scheduled primary elective cesarean delivery. The patient had clinical findings consistent with this
diagnosis including mild aortic root dilation chronic right vertebral dissection with two cerebral
aneurysms and small ectasias of the thecal sac in the lumbar region. Pregnant patients with LDS have
significant risks including aneurysm rupture new aneurysm formation and uterine rupture. After a
thorough preoperative evaluation the patient underwent a successful general anesthetic focused on
maintenance of intraoperative hemodynamic stability and minimal intraoperative blood loss.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC180
Twin Gestation With Placenta Percreta
Matthew Culling, M.D., Eva Szabo, M.D., Eli Torgeson, M.D., University of New Mexico, Albuquerque, NM
We present a 31-year-old G3 P2002 with a dichorionic diamnionic twin gestation with placenta accreta
and placenta previa percreta invading the bladder wall. After a multidisciplinary conference she
underwent cesarean section and hysterectomy at 28 weeks and 5 days. Her surgery was complicated by
ureteral injury near total cystectomy and extensive blood loss. She had a general anesthesia with
invasive monitoring. The massive transfusion protocol was initiated during the operation and she was
taken to IR for emergent embolization of both internal iliac arteries. The intraoperative EBL was 15
liters. She was discharged on post-op day 28.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
OB MC181
Single Subarachnoid Blockade During Delivery of Second Baby in Twin Delivery
Sabrina DaCosta, M.D., Ramsis Ghaly, M.D., Ned Nasr, M.D., John H. Stroger Jr. Hospital of Cook County,
Chicago, IL
34-year-old G5P2112 female at 34 weeks gestation and BMI 35.5 presented with dichorionic-diamniotic
twin gestation in cephalad/transverse lie. She was admitted with PPROM in pre-term labor. Patient was
completely dilated and +1station. After relocation to the operating room for double set up patient
delivered Twin A with several pushes. Twin B's frank breech presentation required urgent C/S. In right
lateral position subarachnoid anesthesia was placed within two minutes. Evidence based
recommendations for multi-gestation deliveries are lagging behind growing clinical demand.
Subarachnoid blockade in lateral position can be performed safely for Twin B delivery when
unanticipated C/S becomes necessary.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC182
Remifentanil Induced Apnea: The Importance of Utilizing CPAP in the Known OSA Patient
Jose De Leon, M.D., Tanya Lucas, M.D., Stephen Heard, M.D., University of Massachusetts Medical
School, Worcester, MA
A 31-year-old G2P3 with diabetes and BMI=40 presents for induction at 38 weeks for HELLP syndrome.
An epidural was contraindicated due to platelets of 71K and falling. The patient consented to a
remifentanil PCA for labor analgesia and the remifentanil was titrated from 25ucg to 50 ucg q 4 minutes.
After 15 minutes at this dose the patient had a witnessed episode of apnea with the lowest spO2 in the
mid-70s. Further investigation revealed the patient had a CPAP machine which was then used after
remifentanil analgesia was resumed. Mother and baby had an uneventful hospital stay.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC183
A Patient With Moya Moya Syndrome Presents for a Crash C-Section Due to Abruption
Jose De Leon, M.D., Tanya Lucas, M.D., Laura Cohen, M.D., Bronwyn Cooper, M.D., Stephen Heard, M.D.,
University of Massachusetts Medical School, Worcester, MA
A 35-year-old G5P0 presented for a high-risk consult at 32 weeks gestation. The following challenges
were addressed: MoyaMoya Sydrome requiring long term Clopidogrel a history of extra- and intracranial anastomosis surgical treatment and deafness. At 36 weeks prior to having the Clopidogrel
stopped the patient presented with abruption planceta and a FHR = 105 bpm with no variablity. An
emergency c-section was called however no one on the team could communicate with the patient and
the pre-natal records including the anesthesia consult could not be accessed. In minutes an anesthetic
assessment and plan was delivered.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
OB MC184
Methadone Mom: Weighing the Risks of Methadone Maintenance in Baby and Mom
Prianka Desai, M.D., Lori Oliver, M.D., Yale, New Haven, CT
MR is a 26-year-old G1P1 with HCV and heroin abuse on methadone maintenance who presented with
preterm labor at 24+6 weeks. Contractions subsided after treatment with steroids and magnesium. Her
250mg methadone dose was continued and EKG showed QTc interval of 526. The pain service was
consulted. Her dose was increased during pregnancy from 225mg due to higher requirements. The
management required input from obstetrics pain service and cardiology due to the risks. Literature
searches on methadone tapering the assessment of QTc and the risks of withdrawal for mom and baby
did not provide consistent guidelines for management.
Saturday, October 12
1:00 PM - 2:30 PM
OB MC185
Anesthetic Management of a Parturient With Prolonged QT Syndrome (LQTS)
Sarah Deverman, M.D., Barbara Scavone, M.D., University of Chicago Medicine, Chicago, IL
A 30-year-old patient 34 6/7 weeks gestation with LQTS presented for peripartum planning. Patient
endorsed history of multiple syncopal events/cardiac arrest; is s/p BiV-ICD-pacer. Maternal b-blocker
therapy is complicated by mild fetal bradycardia. Reports of parturients with LQTS remain scarce; risk
increases peripartum (Drake-2007). With a multidisciplinary approach fundamental to management the
anesthesiologist aims to decrease risk of dysrhythmias by moderating sympathetic activity secondary to
anxiety labor pain laryngoscopy or surgical stimulation; preventing bradycardia/tachycardia; and
avoiding QT-prolonging drugs (Behl-2005). Anesthetic plan included early neuraxial labor analgesia in a
calm quiet setting possible cesarean under neuraxial anesthesia/general anesthesia in reserve.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC186
Anesthetic Management of Living-Donor Renal Transplant Recipient With Prior Orthotopic Heart
Transplant and Severe Pulmonary Hypertension
Paul Anderson, M.D., Raed Abdullah, M.B. B.Ch., University of Pittsburgh Medical Center, Pittsburgh, PA
Patients with pulmonary hypertension who undergo general anesthesia for non-cardiac surgery have
increased risk of morbidity and mortality. We present a 51-year-old female with history of prior
orthotopic heart transplant (for idiopathic cardiomyopathy) CAD with EF 40-45% (post-RCA stenting)
and newly diagnosed pulmonary hypertension and elevated right heart pressures who underwent livingdonor renal transplant for end-stage renal disease secondary to tacrolimus toxicity. A pulmonary artery
catheter was used to help guide management of the hemodynamics and pharmacological interventions
especially during reperfusion of the graft. The patient had an uneventful intraoperative and
postoperative course and went home on POD #4.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC187
A Case of Myocardial Contusion Following a Blunt Chest Injury
Abistanand Ankam, Ghassan Aljafar, M.D., Baystate Medical Center - Tufts University School of
Medicine, Holyoke, MA
An otherwise healthy 21-year-old male involved in a motor vehicle accident. He suffered multiple
fractures and a vascular injury requiring massive transfusion. He was emergently taken to the operating
room for a left femoral to posterior tibial bypass and four-compartment fasciotomies. After 36 hours he
was emergently taken back to the operating room for loss of Left lower extremity pulses. Sudden
refractory hypotension followed by Ventricular fibrillation cardiac arrest was successfully resuscitated as
per Advanced Cardiac Life Support protocol. Transesophageal echocardiography showed severely
depressed right ventricular function suggesting a right ventricular contusion
Saturday, October 12
1:00 PM - 2:30 PM
CA MC188
Spinal Subdural Hematoma After Lumbar Drain Placement for FEVAR
Camellia Asgarian, Robert Isaak, D.O., Harendra Arora, M.B. B.S., UNC Hospital, Durham, NC
Spinal subdural hematoma after lumbar drain placement has not been reported for patients undergoing
endovascular thoracoabdominal aortic aneurysm (TAAA) repairs. We describe the case of a 71-year-old
male who developed a symptomatic spinal subdural hematoma after placement of a lumbar drain for
endovascular TAAA repair. The patient developed weakness in his lower extremities 12 hours postoperatively. MRI showed a spinal subdural hematoma from T12/L3 with cord compression. The patient
did not received surgical decompression but rather replacement of the lumbar drain by the
neurosurgical team. The patient was discharged on POD #9 with 4+/5 strength in both lower extremities.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC189
Epidural Hematoma After Removal of Lumbar Drain for Thoraco-Abdominal Aortic Aneurysm Surgery
Camellia Asgarian, M.D., UNC Hospital, Durham, NC
Epidural hematoma is an uncommon complication after lumbar drain placement for thoracoabdominal
aortic aneurysm (TAAA) repair. We describe the case of an 86-year-old man who underwent an
endovascular TAAA repair with lumbar drain placement. The patient's intraoperative and post-operative
course was uneventful. The lumbar drain was removed and he was discharged on POD 2. On POD 3 the
patient returned with bilateral lower extremity weakness. MRI revealed an epidural hematoma with
cord compression. He underwent emergent laminectomy for hematoma evacuation. At the time of
discharge his only remaining deficit was 4/5 strength in his left hamstring.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC190
Emergent Coronary Revascularization in a Jehovah's Witness With Necrotizing Fasciitis Requiring ReExploration for Massive Surgical Bleeding
Emily Ashford, M.D., Manuel Castresana, M.D., Vikas Kumar, M.B. B.S., Georgia Regents University of
Augusta, Augusta, GA
A 59-year-old Jehovah's Witness male with severe sepsis secondary to necrotizing fasciitis of left upper
extremity was diagnosed with NSTEMI and transferred to our institution for emergency CABG surgery.
The procedure was uneventful and the Hb level on arrival to the ICU was 6.8 g/dl. During the immediate
postoperative period the patient had significant blood loss requiring factor VII desmopressin and
emergency surgical re-exploration. The postoperative recovery was uncomplicated in spite of Hb level of
3.3 g/dl. He was continued on erythropoietin and extubated on day ten and discharged home on day
thirty after resolution of the necrotizing fasciitis.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC191
A Successful Case of Sequential Lung Isolation Using the EZ-Blocker in a Morbidly Obese Patient With
Dilated Cardiomyopathy Who Presented for Bilateral Video-Assisted Thoracoscopic Maze for Atrial
Fibrillation
Emily Ashford, M.D., Mary Arthur, M.D., Georgia Regents University of Augusta, Augusta, GA
43-year-old morbidly obese male presented for a bilateral Video-Assisted Thoracoscopic Maze for
chronic atrial fibrillation. His past medical history included dilated cardiomyopathy requiring a
biventricular ICD. His LV function was globally depressed (EF 20%). After induction of anesthesia the Yshaped EZ-blocker which has two cuffs on the bifurcated distal ends was advanced under fiber-optic
guidance into the right and left main bronchus respectively. Sequential lung isolation was achieved by
inflating the cuff of the corresponding main bronchus. Surgical exposure was good with no episodes of
hypoxemia or cuff dislodgement. The patient was extubated after the procedure with no complications.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC192
Therapeutic Hypothermia After Witnessed Cardiac Arrest Requiring Advanced CPR and Urgent CABG
Surgery
Emily Ashford, M.D., Manuel Castresana, M.D., Sanjay Dwarakanath, M.B. B.S., Vikas Kumar, M.B. B.S.,
Georgia Regents University of Augusta, Augusta, GA
58-year-old male with past medical history of hypertension and diabetes presented to our ICU after
witnessed ventricular fibrillation arrest at his work place with successful return of spontaneous
circulation after 12 minutes of cardio-pulmonary resuscitation. On admission cardiac catheterization
showed multi-vessel coronary disease with EF of 30%. He was placed on intra-aortic balloon pump and
therapeutic hypothermia protocol. The next day he underwent successful coronary artery bypass graft in
spite of peri-operative complications included metabolic acidosis hyperglycemia and coagulopathy.
Post-operatively inotropic vasopressor IABP and ventilatory supports were successfully weaned
extubated on day 10 and later discharged home without neurologic deficit.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC193
Catastrophic Embolism During Laser Lead Extraction
Michael Auerbach, M.D., Lebron Cooper, M.D., Gian Paparcuri, M.D., University of Miami Miller School of
Medicine, Miami, FL
Case presentation: 66-year-old male for laser lead extraction. PSH: CABG 2003 and AICD 1994. Following
induction radial arterial line and femoral venous introducer were placed. TEE: dilated RA with 3.5 cm
vegetation and 2+ TR. After ICD lead extraction acute etCO2 decrease was observed and severe
hypotension ensued. ABG: increased pCO2-etCO2 gradient and acute decrease in pO2 of 456-157. TEE:
RV overload and LV distension. No vegetation seen. Deterioration continued in spite of norepinephrine
and epinephrine. ACLS was initiated. After 32 mins CPR TEE confirmed thrombosis in all four chambers
but embolism was seen in PA. Resuscitation efforts aborted.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC194
Successful Emergency Surgical and Anesthetic Management of a Right Ventricular Perforation From
Laser Lead Extraction
Mark Banks, M.D., Mary Arthur, M.D., Vinayak Kamath, M.B. B.S., Brent Shafer, P.A., Georgia Regents
University, Augusta, GA
Laser lead extractions can result in fatal cardiovascular injuries despite surgical intervention. We report
a successful case of a repair of a right ventricular (RV) and left innominate vein perforation following
laser lead extraction of a malfunctioning RV lead in an 82-year-old female with a history of non-ischemic
cardiomyopathy. A sudden hypotensive episode followed by cardiac standstill confirmed by fluoroscopy
and TEE prompted the initiation of ACLS and an emergent median sternotomy with repair on
cardiopulmonary bypass (CPB). The patient was successfully weaned from CPB requiring inotropic
support ICU care and extubated on postoperative day 5 neurologically intact.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC195
Asymptomatic Cold Agglutinins Discovered the Day of Cardiac Surgery
Emily Sharpe, M.D., David Barbara, M.D., David Cook, M.D., Mayo Clinic College of Medicine, Rochester,
MN
A 49-year-old male with a history of Hodgkin's lymphoma treated with radiation therapy presented for
CABG and pericardiectomy. Blood bank antibody screening revealed a cold autoantibody. He denied
associated anemia or peripheral agglutination. Active warming techniques were utilized
intraoperatively. Normothermia (37C) was maintained on cardiopulmonary bypass and tepid (34C)
blood cardioplegia administered. The patient experienced no perioperative complications. Cold
agglutinins are autoantibodies that may result in red blood cell agglutination on exposure to cold. In
asymptomatic patients cardiac surgery can be safely performed without additional testing using
normothermic cardiopulmonary bypass and avoidance of cold cardioplegia.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC196
Mitral Regurgitation Secondary to Infective Endocarditis Involving the Mitral Valve in a Patient With
Cor Triatriatum
Amit Bardia, M.B. B.S., Feroze Mahmood, M.D., Robina Matyal, M.D., Beth Israel Deaconess Medical
Center, Boston, MA, Mario Gallegos, M.D., University of Costa Rica, San Ramon, Costa Rica
Luyang Jiang, M.D., Peking University People's Hospital, Beijing, China
A 24-year-old intravenous drug user presented with word-finding difficulties secondary to a stroke.
Transthoracic echo demonstrated large mitral valve vegetation with severe mitral regurgitation
necessitating mitral valve replacement. Intraoperative transesophageal echo demonstrated a septum
within the left atrium with all pulmonary vein openings on one side of the septum and the atrial
appendage on the other side. Resection of left atrial appendage and the septum in addition mitral valve
replacement was performed.Resolution of mitral regurgitation was confirmed by post procedure TEE.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC197
Undiagnosed Pheochromocytoma During ECMO Decannulation
Amy Beethe, Amy Duhachek-Stapelman, M.D., University of Nebraska Medical Center, Omaha, NE
Peri-operative care of a patient with pheochromocytoma presents multiple challenges and if
undiagnosed is associated with intraoperative mortality of approximately 80%. A 46-year-old female
who presented with chest pain had rapid deterioration of her cardiac ejection fraction to 5% after
cardiac catheterization requiring emergent ECMO placement. The diagnosis was presumed viral
myocarditis. Following myocardial recovery anesthesiology was consulted for ECMO decannulation.
Intraoperatively three episodes of profound medically resistant hypertension occurred (increased MAP
from 65 to 140mmHg). After consideration of an ultrasound revealing a hemorrhagic adrenal mass she
was treated empirically for pheochromocytoma with phentolamine which resulted in cardiovascular
stability.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC198
Left Atrial Dissection Secondary to Coronary Sinus Cannulation: Evaluation Evolution and Treatment
John Berry, M.D., Nishita Dalal, M.D., Pryia Kumar, M.D., Susie Martinelli, M.D., William Stansfield, M.D.,
UNC Hospitals, Chapel Hill, NC
A 74-year-old male underwent coronary artery bypass grafting aortic valve replacement and thoracic
aortic arch repair. During the course of the operation the appearance of an unusual LA mass on
transesophageal echocardiography examination prompted a search for its cause. It was determined to
be a LA dissection a rare complication linked with specific cardiac surgeries. The natural progression of
this unusual pathology was followed with sequential TEE studies over the course of multiple operations.
We present a case report and literature review focusing on the echocardiographic features for
identification progression and management of this rare complication.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC199
Investigating Pacemaker Dysfunction in the Operating Room
Meghan Bhave, M.D., Victor Pascua, University of California San Francisco, San Francisco, CA
We present a pacemaker-dependent patient undergoing neck dissection. Intraoperatively magnet
placement rendered the device asynchronous. External pacing pads were applied as a further precaution
and the case proceeded uneventfully. Prior to extubation arterial line and plethysmography monitoring
showed no evidence of circulation following magnet removal. Thus the magnet was re-applied to
restore perfusion. We later determined that the external pacer was inadvertently functioning but
charged to a current level insufficient to capture the ventricle. Once this source of interference was off
the pacemaker reverted back to DDD mode after magnet removal and the patient was successfully
extubated.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC200
Coronary Vasospasm With Anomalous Origin of Left Main
Jason Blitz, M.D., Polyana Silver, M.D., Walter Reed National Military Medical Center, Bethesda, MD
Forty-five-year-old male with history of obesity OSA HTN and tobacco use presented for colon resection
due to adenocarcinoma. Preoperative TTE stress test and ECG were unremarkable. After anesthesia
induction three episodes (1-5min) of significant ST elevations occurred resolving spontaneously without
hypotension tachycardia or ectopy. Intraoperative TEE EKG and postoperative cardiac troponins were
negative. Coronary artery catheterization revealed anomalous origin of the left main from the right
coronary sinus. Although cardiology concluded that ST changes were due to vasospasm and the
anomalous anatomy was an incidental finding literature suggests that aberrant coronary artery
anatomy can be directly associated with vasospasm.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC201
Cardiac Tamponade During Attempted Percutaneous Peri-Valvular Leak Closure After Transcatheter
Aortic Valve Implantation (TAVI): Immediate Cardiac Surgical Intervention in the Hybrid Cath Lab
Patrick Britell, M.D., Lebron Cooper, M.D., University of Miami, Maimi, FL
Anterograde percutaneous closure of aortic peri-valvular leak via femoral vein POD2 after TAVI.
Immediately following atrial septotomy tamponade ensued with hemodynamic instability. After
emergent pericardiocentesis 7L blood were drained under constant aspiration. Upon surgeon arrival
patient was too unstable to transport to OR. After sternotomy perforation of dome of LA was identified
and ligated and AVR was performed on CPB in hybrid cath lab. Weaning from CPB required epinephrine
and IABP. Following successful surgical intervention in the cath lab the patient was discharged home on
POD19. Surgical intervention in the cath lab may be safer than OR in certain situations.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC202
The Use of Isoproterenol and Phenytoin to Reverse Prolonged QTc-induced Torsade de Pointes
Enrico Camporesi, M.D., Rachel Karlnoski, Ph.D., Devanand Mangar, M.D., Collin Sprenker, B.S., Florida
Gulf-to-Bay Anesthesiology Associates LLC, Tampa, FL, Hesham Omar, M.D., Mercy Hospital, Chicago, IL
A 31-year-old morbidly obese female with obstructive sleep apnea and schizophrenia (controlled on
medication) presented with shortness of breath due to pulmonary edema. On admission day 1 the EKG
showed prolonged QTc intervals. On hospital day 4 she developed a V-fib cardiac arrest. EKG after ROSC
revealed a QTc of 850 milliseconds. The progression of QTc duration during her hospital course was
recorded. Several medications and comorbidities contributed to torsade de pointes. All culprit
medications were discontinued and electrolytes were replaced. Isoproterenol infusion and intravenous
phenytoin therapy were used to shorten the QTc which normalized in 2 days.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC203
Postoperative Very Late Drug Eluting Stent Thrombosis in a Jehovah's Witness After Plavix Withdrawal
Enrico Camporesi, M.D., Devanand Mangar, M.D., Collin Sprenker, B.S., J. Thompson Sullebarger, M.D.,
Florida Gulf-to-Bay Anesthesiology Associates LLC, Tampa, FL, Hesham Omar, M.D., Mercy Hospital,
Chicago, IL
A 54-year-old Jehovah's Witness gentleman was scheduled for bilateral knee replacement. He had a
history of 3 coronary stent for recurrent anginal pains (1 BMS and 2 DES all deployed >40 months). Last
angiogram showed no occlusive disease. Plavix was stopped 5-days earlier. Postoperatively while in the
PACU he suffered lateral STEMI and a V-fib arrest. Angiography showed thrombosis of 2 DES with
sparing of BMS. AngioJet thrombectomy successfully debulked the thrombus in the LCX and LAD. This
acute thrombosis of DES -but not BMS- exemplify how DES are more prone to this compliacation due to
delayed endothelialization.
Saturday, October 12
1:00 PM - 2:30 PM
CA MC204
A Potentially Devastating Case of Perioperative Vision Loss After Coronary Artery Bypass Grafting
Sneha Chandra, M.D., Hesham Omar, M.D., MetroHealth Medical Center, Cleveland, OH
A 49-year-old male with hypertension hyperlipidemia asthma and sleep apnea was scheduled for CABG.
His past medical history was significant for a gunshot wound to the head with subsequent seizures and
mild dementia. There was mild bilateral carotid artery disease. ECG showed sinus rhythm and anterior
wall STEMI. LV ejection fraction was 45%. After uneventful CABG with cardiopulmonary bypass the
patient's left pupil was dilated at 8 mm and non-reactive to light while his right pupil measured 2 mm
and was reactive. There was worsening of cognition. Eventually the patient became increasingly
oriented and vision returned to baseline.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CA MC205
My Tumor is Blocking My Heart Again: Excision of Massive Atrial Myxoma Causing Ventricular Outflow
Obstruction and Hemodynamic Instability in Patient With Carney's Complex
Judy Chang, M.D., Rachel Androphy, M.D., NYU Medical Center, New York, NY
63-year-old male with Carney's Complex presented with evidence of right heart failure and
hemodynamic instability. Patient found to have mass occupying entire right atrium and crossing
tricuspid valve resulting in significant hypoxia and left ventricular dysfunction. Patient was taken
emergently to the OR requiring pressors prior to induction and intraoperatively. Following excision of
8x9 cm myxoma patient developed severe tricuspid regurgitation. We will discuss anesthetic
implications of Carney's Complex a rare disorder with predisposition for recurrent atrial myxomas. We
will also review intraoperative echocardiography of obstructing lesions management of right ventricular
outflow obstruction and postoperative sequelae following excision.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC206
Suspected Heparin-Induced Thrombocytopenia and Thrombosis Syndrome (HITTS) With Mesenteric
Thrombosis in a Living Liver Donor Patient
Catherine Cooper, M.D., Virginia Commonwealth University Medical Center, Richmond, VA
A 38-year-old liver donor had significant acidosis and rising creatinine at the end of partial hepatectomy.
The following day ultrasound showed low portal vein flow. At reopearation extensive clot was found in
the mesenteric veins and there was evidence of coagulopathy without bleeding. A diagnosis of HITTS
was made and treated with bivalirudin.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC207
Case Report: Long-term Pentobarbital Coma in Treatment of Posterior Reversible Encephalopathy
Syndrome Post Liver Transplant
Elviira Corsi, D.O., Dimitri Bezinover, M.D., Patrick McQuillan, M.D., Subramanian Sathishkumar, M.B.
B.S., Sonia Vaida, M.D., Penn State Milton S. Hershey Medical Center, Hershey, PA
We are presenting a case of 26-year-old female with posterior reversible encephalopathy syndrome
after liver transplantation. She received a deseased donor liver transplant due to fulminant liver failure
secondary to amatoxin mushroom poisoning. The patient developed PRES with symptoms of severe
brain edema and did not improve despite of adjustment of immunosupressive therapy. She required
maximal therapy including cooling mannitol 3% saline and pentobarbital infusion. All attempts to
reduce the dose of pentobarbital failed due to intractable seizure activity. Only after 62 days the therapy
was successfully tapered. The patient was discharged to rehabilitation center without neurologic
deficits.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CC MC208
Massive Air Embolism From Endoscopic Retrograde Cholangiopancreatography
Sarah Dance, Virginia Mason Medical Center, Seattle, WA
A 67-year-old male with pancreatic cancer status post pylorus-preserving whipple presented with
abdominal pain malaise and fevers concerning for recurrent cholangitis. He underwent upper doubleballoon enteroscopy and ERCP under general anesthesia. Following the DBE an air cholangiogram was
obtained. Soon thereafter a drop in end tidal CO2 bradycardia and hypotension ensued. After transient
response to vasoactive medications PEA arrest occurred. ACLS was initiated. Arterial line and central
line were placed. TEE confirmed air in both sides of the heart indicative of venous air and paradoxical
air emboli. Despite aspiration of air from central line resuscitation was unsuccessful.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC209
Subanesthetic Ketamine Infusion to Manage Anxiety in a Chronically Critically Ill Patient
Daniela Darrah, M.D., Vivek Moitra, M.D., Columbia University College of Physicians and Surgeons, New
York, NY
A 55-year-old required ECMO for ARDS. After developing intra-abdominal hemorrhage and sepsis he
became chronically critically ill and complained of severe anxiety. His symptoms were assessed with the
Hospital Anxiety and Depression Scale (HADS). At baseline his score was maximal for anxiety and
consistent with depression. An infusion of ketamine (3 mcg/kg/min) was administered for 72 hours and
the HADS was repeated daily. After 24 hours his score demonstrated a 27% improvement in symptoms;
21% improvement was retained one day after the infusion was completed. He denied any unpleasant
psychotomimetic symptoms.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC210
Early Extubation in an O2 Dependent Patient Following High Risk Surgery With Multiple Blood
Transfusions
Kunal Desai, M.D., Sharline Kashfian-Halimi, M.D., Marianna Mogos, M.D., Pete Roffey, M.D., Duraiyah
Thangathurai, M.D., LAC+USC Medical Center, Los Angeles, CA
An 82-year-old male with PMH of severe COPD on 2L O2 at home moderate aortic stenosis CKD stage V
and anemia with bladder cancer presents for radical cystectomy. The procedure was 6.5 hours and the
patient received 5 units PRBCs. The patient was brought to the ICU as due to comorbid conditions
involving his respiratory cardiac renal and hematologic systems. Within an hour of arriving to the ICU
the decision was made to extubate the patient based on clinical status and risk benefit analysis
regarding documented higher incidence of extubation failure in patients with prolonged mechanical
ventilation.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CC MC211
Use of Bedside Ultrasound in the Management of Unexplained Acute Hypoxemia in a Mechanically
Ventilated Patient With Acute Inflammatory Demyelinating Polyneuropathy
Rasesh Desai, M.D., Avinash Kumar, M.D., Vanderbilt University, Nashville, TN
64-year-old male with acute inflammatory demyelinating polyneuropathy complicated by quadriparesis
respiratory failure and autonomic instability became acutely hypoxemic. Hypoxemia did not resolve
despite increase in PEEP and FIO2. Throughout this episode ventilation dynamic compliance and peak
pressures remained unchanged. Chest X-ray showed low lung volumes with patchy infiltrates. Bedside
thoracic ultrasonography showed no pneumothorax pulmonary edema or pericardial effusion but
revealed significant new right lower lobe consolidation not clearly evident on chest x-ray. Patient was
rolled to contralateral side with resolution of hypoxemia consistent with shunt physiology. Patient
continues to improve from his likely aspiration pneumonia.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC213
Heparin Induced Thrombocytopenia Complicated by Cardiac Ischemia Hemothorax and High Dose
Argatroban
Daltry Dott, M.D., Joseph Schlesinger, M.D., Vanderbilt University Medical Center, Nashville, TN
57-year-old male status post coronary artery bypass surgery who developed chest pain secondary to
ischemia pericarditis and presumptive microvascular thrombi from heparin-induced thrombocytopenia
who required high-dose argatroban to obtain a therapeutic aPTT. Chest pain was attributed to
pericarditis and acute graft thrombosis as demonstrated on EKG and echocardiogram. During dualanticoagulation therapy he developed an expanding left-sided hemothorax that required drainage with
a pigtail catheter placement. This case presents a diagnostic challenge of multifactorial chest pain
juxtaposed with management of anticoagulation while undergoing procedural intervention and weaning
high dose argatroban to warfarin monotherapy and ensuring therapeutic anticoagulation.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC214
Unusual Placement of Left Subclavian Central Venous Catheter After Emergency Craniotomy
Bradley Drury, M.D., Kayiguvwe Kragha, M.D., Solomon Levy, M.D., Detlef Obal, M.D., Ph.D., Matthew
Stephens, M.D., University of Louisville, Louisville, KY
An 83-year-old white female became hemodynamically unstable after developing a combined
subdural/epidural hematoma subsequent to a fall from standing height. After taking the patient to the
operating room for emergency craniotomy the left subclavian central venous catheter (CVC) placed
during surgical preparation exhibited a central venous pressure tracing that suggested an intrathoracic
position of the catheter. Interestingly on the postoperative conformational chest x-ray the tip of the
CVC appeared in the left hemithorax. Possible explanations and rare anatomic variations leading to this
unforeseen finding will be discussed in this case presentation.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
1:00 PM - 2:30 PM
CC MC215
Catheter Directed Thrombolysis: A Reliable Alternative for LVAD Thrombosis?
Stephen Estime, Michael Woo, M.D., University of Chicago, Chicago, IL
An 84-year-old male with a past medical history significant for an ischemic cardiomyopathy s/p
Heartmate II implantation presented to the hospital with signs of LVAD thrombosis. Due to advanced
age compounded by multiple medical problems the patient was not deemed a candidate for emergent
VAD replacement. The patient was taken to the interventional cardiology suite for catheter directed TPA
administered thrombolysis. Several hours into treatment the patient developed mental status changes
and was subsequently found to have a large intraparenchymal hemorrhage.
Saturday, October 12
1:00 PM - 2:30 PM
CC MC216
Altered Mental Status Left Hemiparesis Right Gaze Preference: What's the Diagnosis?
Shahbaz Farnad, M.D., Sandra Goyal, M.D., Arvind Rajagopal, M.D., Rush University Medical Center,
Chicago, IL
Altered mental status hemiparesis and visual gaze preference often cue physicians to a diagnosis of
stroke or other neurologic pathology. Acute aortic dissection rarely presents only with neurologic
symptoms. The potentially fatal nature of aortic dissection necessitates rapid recognition and treatment
and should be considered when faced with a presentation of stroke-like symptoms. We present a case
of a 66-year-old female on anti-coagulation therapy with a history of atrial fibrillation and CAD who
presented with stroke-like symptoms and negative CT findings for hemorrhagic stroke. She was found
to have acute Type A aortic dissection requiring open repair.
MCC Session Number – MCC04
Saturday, October 12
3:00 PM - 4:30 PM
CC MC217
Case Report: Successful Use of Extracorporeal Membrane Oxygenation in a Patient With Toxic-Shock
Induced Cardiogenic Shock
Eilon Gabel, M.D., Vadim Gudzenko, M.D., UCLA, Los Angeles, CA
We present a case of toxic-shock induced cardiomyopathy in a patient brought to UCLA after being
found unarousable on an airplane. Upon presentation the patient was hypotensive with a Left
Ventricular Ejection Fraction (LVEF) of 5-10% leukocytosis and bandemia. The patient became
increasingly unstable requiring vasopressors antibiotics intravenous immunoglobulin antiarrhythmics
and ultimately veno-arterial ECMO. Seven days later the patient's LVEF improved to 35-40% and ECMO
was successfully discontinued. By the next day vasopressors were stopped and the patient was
extubated. Blood cultures remained negative and toxic-shock was diagnosed by exclusion after
staphylococcus aureus was identified in chronic lower extremity wounds.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
CC MC218
Palliative Care for Non-Surgical Bowel Perforation: The Anesthesiologist's Perspective
Sarah Gebauer, M.D., Andrew Dixon, M.D., University of New Mexico, Albuquerque, NM
A 73-year-old woman with stage III-C ovarian cancer was admitted to the Intensive Care Unit with sepsis
and free air under the diaphragm due to ruptured bowel after treatment with bevacizumab (Avastin).
She was started on antibiotics but was not a surgical candidate and the palliative care service was
consulted for a presumed life expectancy of less than 24 hours. However the patient lived over a week
longer much of that time visiting with friends and family. Her nausea and pain were well-controlled by
the palliative care team.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC219
Severe Hypoxia Due to Broncho-Esophageal Fistula and Acute Lung Injury Treated With Differential
Lung Ventilation
Mark Giska, M.D., Beaumont Health System, Royal Oak, MI
An elderly male in the Surgical Intensive Care Unit following esophagectomy developed worsening
hypoxia due to broncho-esophageal fistula and acute lung injury. An attempt at operative repair was
aborted because of failure to adequately oxygenate during one lung ventilation. He developed pulseless
electrical activity upon return to the SICU and was successfully resuscitated. Multiple ventilator
modalities were then employed during differential lung ventilation but ultimately proved to be
unsuccessful. Respecting his wishes for no heroic measures his family decided to withdraw care and the
patient expired later that day.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC220
Is the Central Line on the Left Side of the Heart? Patient With Klippel Trenaunay Weber Syndrome and
Unknown Persistent Left Superior Vena Cava
Andrea Gomez Morad, M.D., Natalie Bruno, M.D., Saint Elizabeth's Medical Center, Boston, MA, Jeffrey
Kane, M.D., Lahey Clinic, Boston, MA
Klippel-Trenaunay-Weber syndrome is associated with vascular malformations. Persistent left superior
vena cava (PLSVC) is a rare condition but a common congenital anomaly of the thoracic circulation. We
present a case of a 42 -year-old Male with Klippel-Trenaunay-Weber syndrome and unidentified PLSVC
admitted to SICU after emergency craniotomy. A left internal jugular vein catheter was placed under
ultrasound guidance Follow up chest X-ray showed a catheter localized in the left hemithorax following
a paramediastinal course. Catheter was removed and right sided subclavian catheter was placed. Later
the presence of a PLSVC was confirmed by a previous CT thorax.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC221
Stroke Patient WIth Cerebral Salt Wasting Developing to Combined Diabetes Insipidus
Joshua Graham, M.D., Sujittra Tongprasert, M.D., University of Louisville, Louisville, KY
Presented is the case of a 42-year-old female presenting with stroke secondary to vasculitis. The
patients mental status declined during this hospital stay to brain death despite treatment. On day 15 the
Copyright © 2013 American Society of Anesthesiologists
patient developed hyponatremia to 129 mmol/L and high urine sodium consistent with cerebral salt
wasting. On day 21 the patient developed hypernatermia to 169 mmol/L with a several liters of urine
output and serum osmolality to 344 mosm/kg consistent diabetes insipidus but urine sodium remained
greater than 300 mmol/L consistent with combinded cerebral salt wasting.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC222
The Role of Anti-Factor Xa Levels in Monitoring Intravenous Unfractionated Heparin Therapy for the
Treatment of Pulmonary Embolus.
Ravindra Gupta, M.D., Geraldine Diaz, D.O., Sacha Pollard, Pharm.D, Sarah Sokol, Pharm.D, University of
Chicago, Chicago, IL
A 65-year-old morbidly obese female with diabetes, hypertension, chronic pancreatitis, and cigarette
smoking underwent a ventral hernia repair. Postoperatively the patient required intubation for
respiratory distress. A chest CT demonstrated a right upper lobe PE and anticoagulation with
intravenous heparin utilizing aPTT monitoring was initiated. While demonstrating therapeutic aPTT
levels the patient received a CT scan for repeated failure to extubate that demonstrated a new PE of the
left lower lobe. In response heparin monitoring utilizing anti-Factor Xa levels was implemented. After 24
hours of therapeutic anti-factor Xa levels (0.3-0.7Units/mL) the patient was extubated with aPTT &gt;
200 seconds.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC223
The Use of Extracorporeal Membrane Oxygenation in Autoimmune Acute Respiratory Distress
Syndrome
Jacob Gutsche, M.D., John Augoustides, M.D., University of Pennsylvania, Philadelphia, PA
39-year-old female transferred from an outside hospital with a diagnosis of fulminant ARDS secondary
to pneumonia. The patient experienced a brief cardiac arrest at the outside hospital before intubation.
Due to difficulties in oxygenating the patient we placed the patient on veno-venous ECMO which
facilitated low stretch mechanical ventilation. The patient's cultures were negative for bacterial or viral
pneumonia. The workup was expanded to include autoimmune disease etiologies and a diagnosis of
acute systemic lupus erythematosus mediated pneumonitis. The patient was started on high dose
intravenous steroids and improved rapidly.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC224
Diabetes Insipidus - A Rare Side Effect of Olanzaprine
Aysha Hasan, Shaul Cohen, M.D., Adil Mohiuddin, M.D., Diane Ridley, M.D., Sahebjit Bhasin, Student,
Christine Hunter, M.D., UMDNJ-Robert Wood Johnson University Hospital, Belle Mead, NJ
77-year-old female (150 cm 72 kg) with HTN DVT diverticulitis and LE weakness presented to ER with
severe abdominal pain. A Hartman's procedure was performed and transferred to ICU. She developed
delirium and treated with Olanzapine. The patient's urine output >5 liters/day. Common etiologies were
explored. Finally after discontinuing olanzapine within 24 hours the patient improved. Central DI is
caused by decreased secretion of ADH. Common laboratory findings include urine osmolality &#60;300
and urine output >50 ml/kg/day. Nephrogenic DI is inability of ADH to bind renal receptors. Many drugs
and medical conditions can cause DI. Management includes discontinuation of drug.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
CC MC225
Critical Care Challenges in the Management of the Jehovah's Witness Trauma Patient
Nazish Hashmi, M.D., Sabina Khan, M.D., Victor Mandoff, M.D., University of Arkansas for Medical
Sciences, Little Rock, AR
83-year-old male was brought to the ER with a self-inflicted gunshot wound to his left face after he
allegedly shot and killed his wife. He was intubated on arrival. He had left facial fractures left
intracerebral hemorrhage and injury to the external carotid artery. He became hypotensive and
bradycardic in the ER and was resuscitated with blood products and vasopressors. On arrival of family
he was identified as a Jehovah's Witness. Blood conservation measures were employed. He failed a trial
of extubation on hospital day 2 and was made DNR/DNI by relatives. He passed away in a few hours.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC226
Usefulness of Novel Multimodal Monitoring During Controlled Hypotension in a Jehovah's Witness
Undergoing Radical Nephrectomy and Liver Resection
Chad Heng, Susan Darrah, Mariana Mogos, Peter Roffey, Duraiyah Thangathurai, Los Angeles
County+Univerity of Southern California Medical Center, Los Angeles, CA
A 47-year-old Jehovah's Witness with renal cell carcinoma and direct invasion of the liver underwent
right radical nephrectomy. To minimize blood loss controlled hypotension was utilized. In the past this
technique has been used without adequate monitoring leading to increased risk of ischemia. A novel
multimodal monitoring strategy including cerebral oximetry TEE venous blood gas and urine output
was implemented to ensure safety and maintain vital organ perfusion. Adequate cerebral myocardial
and renal perfusions were demonstrated even at the lowest levels of hypotension. Blood loss was
minimal and the patient was discharged from ICU on POD #1.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC227
Vasospasm in a Patient With Sickle Cell Disease
Daniel Hernandez-Barajas, M.D., Peggy White, M.D., University of Florida, Gainesville, FL
25-year-old AAM with history of SCD diagnosed subarachnoid hemorrhage. On arrival no neurologic
deficits were noted. Shortly after he had decline in his neurologic status and EVD was placed.
Hematology recommended partial manual exchange transfusion with a goal of HbS of 30% or less
achieved with 8 UPRBC. Days later he underwent a coil embolization of a ruptured left posterior
communicating aneurysm. Patient underwent transcranial doppler to assess for vasospasm afterwards
he was diagnosed with symptomatic vasospasm with AMS responsive to systolic blood pressures
&gt;160 vasopressors were started. He also underwent angiogram with intraarterial verapamil.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
CC MC228
Postoperative Thyrotoxicosis Following Iodine Contrast Administration: A Case of Jod-Basedow
Phenomenon
Maureen Higgs, M.D., Erroll Hull, M.D., Eugenio Lujan, M.D., Naval Medical Center San Diego, San Diego,
CA
An accelerated case of the Jod-Basedow phenomenon following two abdominal CT scans with iodinated
contrast and an exploratory laparotomy in an elderly patient with multiple medical problems. Post
operative day one the patient with no known thyroid disease or cardiac history except for pericarditis
twelve year prior was noted to be in new onset atrial fibrillation. Metabolic and radiologic workup
revealed hyperthyroidism without classic symptoms of hyperthyroidism and a multinodular goiter. The
patient was treated with Tapazole and made complete recovery. This case serves to raise awareness of
the risks of morbidity from uncommon presentations after common diagnostic tests.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC229
Too Much of a Good Thing? The Role of Immunosuppression in Graft Versus Host Disease After Liver
Transplant
Jessica Hobbs, M.D., Christopher Franklin, M.D., Caron Hong, M.D., University of Maryland, Baltimore,
MD
Graft-versus-host disease (GVHD) after liver transplant is rare with an incidence of 0.1%. Our patient was
a 65-year-old male with end-stage liver disease secondary to hepatitis C who underwent liver transplant
without complication. Approximately 3 weeks later the patient experienced fever pancytopenia and
rash which after biopsy were found to be secondary to GVHD. Immunosuppression was increased but
the patient expired 3 months after transplant. Recent studies have shown while increasing
immunosuppressive medications is the current recommendation for GVHD it may be more efficacious to
decrease immunosuppression in order to allow the host's immune system to attack donor T-cells.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC230
A New Discovery that May Not be So New: Anti-N-Methyl-D-Aspartate Receptor Encephalitis
Jessica Hobbs, M.D., Christopher Franklin, M.D., University of Maryland, Baltimore, MD
Anti-N-methyl-D-asparate receptor (NMDAR) encephalitis is a neurological disorder associated with
antibodies against the NMDA receptor. Patients suffering from NMDAR encephalitis present with
psychosis memory deficits seizures and language degeneration. It can progress to a catatonic state
associated with abnormal movements and autonomic and breathing instability. It is often associated
with a tumor and if a tumor is present patients respond faster to immunotherapy after resection than
do patients without a tumor. We describe a 33-year-old female with HIV infection who presented with
seizure activity that progressed to encephalopathy requiring intubation. The patient was subsequently
found to have anti-NMDAR encephalitis.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
CC MC231
Postoperative Management of Severe Fixed Pulmonary Hypertension and Cardiac Dysfunction After
Complex Multi-Valvular Cardiac Surgery
Tiffany Richburg, M.D., Abigail Hoffman, M.D., John Beatty, M.D., Manuel Castresana, M.D., Shvetank
Agarwal, M.D., Georgia Regents University, Augusta, GA
A 57-year-old woman with severe rheumatic mitral aortic and tricuspid valve disease with resultant
group II pulmonary hypertension underwent mechanical mitral and aortic valve replacements as well as
tricuspid annuloplasty. Postoperatively she developed complete right ventricular failure secondary to
severe pulmonary hypertension that was unresponsive to multiple inotropes intra-aortic balloon pump
and pulmonary vasodilators including nitric oxide inhaled prostacyclin and sildenafil. Simultaneously
the patient developed severe pulmonary dysfunction requiring increasing PEEP and oxygen
requirements. This case highlights the challenges in management of patients with severe fixed group II
pulmonary hypertension after complex cardiac surgery.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC232
Anesthetic Considerations for Ex-Vivo Liver Surgery
Ryan Ivie, M.D., Tricia Brentjens, M.D., Columbia University, New York, NY
Ex-vivo liver surgery involves the resection of the liver and potentially neighboring abdominal organs en
bloc resection of the embedded tumor and reimplantation of the organ(s). It is indicated for patients
with liver cancer who have failed alternative treatments and offers the advantage of bloodless
dissection and reconstruction. We describe a series of cases that exemplify the anesthetic management
of ex-vivo liver surgery. Unique characteristics include prolonged anhepatic phase large area of cut
hepatic surface resulting in rapid and difficult to control hemorrhage on reperfusion and massive
transfusion over an unusually brief period of time requiring advance preparation.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC233
Airway Management for Tracheal Disruption: Emergency Department to the Intensive Care Unit
Julie Joseph, M.D., Jefferey Berman, M.D., UNC, Chapel Hill, NC
Tracheal injury following non-penetrating trauma is rare but life threatening. It requires immediate
intervention. A 31-year-old 105 kg ASA 1 male dropped a 200-pound barbell on his neck while bench
pressing. He presented in moderate distress. Anesthesia was called to the emergency department to
intubate. Physical exam demonstrated crepitus in his neck and supraclavicular areas. The trachea moved
with respirations. He was taken emergently to the operating room. Surgical exploration revealed
tracheal disruption with only the membranous trachea intact. The trachea was repaired and a
tracheostomy placed above the injury.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
CC MC234
Rhabdomyolysis After Prolonged Foot Surgery
Arun Kalava, Samuel Leung, M.D., Joel Yarmush, M.D., New York Methodist Hospital, Brooklyn, NY,
Monica Midha, M.D., Jersey Shore University Medical Center, Neptune, NJ
Rhabdomyolysis occurs extremely rarely intra-operatively and post-operatively. Undiagnosed and
untreated rhabdomyolysis may lead to complications the most serious of which are acute renal failure
and death. Prolonged surgical time and immobilization are known risk factors that contribute to
rhabdomyolysis. To our knowledge rhabdomyolysis has not been reported following foot surgery. We
present a patient with Charcot deformity who underwent corrective surgery that was 9 hours in
duration. Intra-operatively the patient developed hyperkalemia acidosis and hypotension and was
subsequently diagnosed with rhabdomyolysis. Additionally muscle damage was not distal to or at the
site of tourniquet application as reported in many cases.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC235
Anesthetic Management of a Patient With Lethal Catatonia Undergoing Emergent ECT
Siri Kanmanthreddy, M.D., Steve Barnes, M.D., Rush University Medical Center, Chicago, IL
A 47-year-old female with history of hypertension diabetes bipolar disorder and neuroleptic malignant
syndrome was transferred to our facility after failed medical management of lethal catatonia at an
outside hospital. She presented with fever tachycardia hypertension altered mentation and rigidity
requiring emergent ECT. General anesthesia was induced with methohexital and rocuronium a laryngeal
mask airway (LMA) placed and mechanical ventilation delivered. Upon ECT completion neuromuscular
blockade was reversed and the LMA removed. She underwent eight more ECTs utilizing comparable
anesthetic agents but varying airway management techniques. At their conclusion her vital signs
stabilized rigidity resolved and mental status improved.
Saturday, October 12
3:00 PM - 4:30 PM
CC MC236
Emphysematous Esophago-Gastritis Associated With Hepatic-Portal Venous Gas Sign as Ominous
Outcome Predictors
Obata Katsuyoshi, M.D., Ph.D., Minobu Ozaki, M.D., Hiroyuki Matsuyama, M.D., Ph.D., Lizuka Hospital,
Lizuka, Japan
A 82-year-old female was admitted to our hospital for urinary tract infection. Four days after admission
she developed to shock status. Abdominal CT showed hepatic portal venou gas sign and
emphysematous esophagitis and gastritis associated with incarcerated obturator hernia.Emergent
surgery was scheduled for hernia repair.Pre-operative medical co-morbities were acute kidney injury
extension of PT-INR:4.45 septic shock status and aspiration pneumonia.Prior to anesthesia induction
radial artery cannulation and naso-gastric tube suction were performed.Soon after tracheal intubation
severe hypotension occurred. Though we tried to stabilize poor hemodyanamic state resuscitation failed
eventually. We will present the ominous outcome predictors seen in this case.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
OB MC237
Anesthetic Management of a Parturient With a Liver Transplantation
Sandeep Dhanjal, Martin Ismawan, M.D., Tiffany Orchard, M.D., Walter Reed National Military Medical
Center, Bethesda, MD
30-year-old female G3P0020 EGA of 34+4 presented to Labor and Delivery for observation of preeclampsia. Medically history is complicated by hypertension primary sclerosing cholangitis requiring
orthotopic liver transplant complicated by deep venous thrombosis. The patient was evaluated by the
complex obstetric anesthesia service for chronic and acute hepatopathy in setting of pre-eclampsia. The
patient was found to have no evidence of coagulopathy liver failure (ascites venous distension
encephalopathy) or medication regimen that would preclude neuraxial anesthesia. She underwent
combined spinal-epidural anesthesia without complications and successfully underwent cesarean
delivery. She was discharged home on post-operative day two.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC238
Anesthesia Management of Combined Cesarean Section and Radical Hysterectomy for Invasive
Cervical Cancer During Pregnancy
Tasneem Dohadwala, M.D., Virgil Manica, M.D., Tufts Medical Center, Boston, MA
We report a case of a 35-year-old G4P3 female with a known diagnosis of locally invasive stage IB1
grade-2 endocervical adenocarcinoma who presented to the gynecology/oncology clinic at 14+ weeks
gestation with her HIV-positive husband. Despite counseling she desired to continue with the
pregnancy. Thus at 34 weeks gestation she had a planned C/section which was done under spinal
anesthesia to honor the patient's desire to be awake for her daughter's delivery. For subsequent radical
hysterectomy we converted to GETA with rapid sequence induction. An arterial line was placed for
invasive monitoring. She remained hemodynamically stable throughout the case.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC239
Anesthetic Management of a Parturient With Cardiovascular and Skeletal Complications of Marfan
Syndrome for Cesarean Section
Jennifer Dominguez, M.D., Terrence Allen, M.B. B.S., Linda Gray, M.D., Abigail Melnick, M.D., Holly Muir,
M.D., Duke University, Durham, NC
A 19-year-old G1P0 woman with Marfan syndrome a dilated aortic root hypertension obesity and
scoliosis s/p Harrington rod placement from T5 to L4 presented for cesarean section at 37 weeks
gestation. A spinal catheter was placed under CT-fluoroscopic guidance. After placement of an arterial
catheter dosing of the spinal catheter did not produce adaquete anesthesia and general anesthesia was
induced and maintained with an inhalational anesthetic and remifentanil to achieve hemodynamic
stability. While neuraxial anesthesia is desirable in parturients with a dilated aortic root its use is
complicated by the high rate of inadequate blocks in these patients.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
OB MC240
Anesthetic Management of a Parturient With Seckel Syndrome for Cesarean Section
Ranita Donald, M.D., Vikas Kumar, M.D., Georgia Regents University, Augusta, GA
24-year-old parturient G1P0 at 37 weeks gestation with history of Seckel Syndrome presented in early
labor for the cesarean section for cephalo-pelvic disproportion. Patient had typical features of Seckel
Syndrome (bird-headed dwarfism mental retardation crowding of vertebra with scoliosis microcephaly
micrognathia beaked nose with severely limited mouth opening and neck mobility). Otolaryngology
consult earlier showed very difficult airway with complete right nasal obstruction very narrow left nasal
passage retroflexed epiglottis and narrowed glottic inlet. Patient required awake tracheostomy (difficult
tracheostomy) followed by cesarean under general anesthesia without any complication. Patient and
baby were discharged home on third postoperative day.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC241
Anesthetic Considerations and Management in a Mother Undergoing Intrauterine Fetal
Thoracoamniotic Shunts for Bilateral Fetal Hydrothorax
Farzad Ebrahimi, M.D., Sergio Gonzalez, M.D., N. Nick Knezevic, M.D., Ph.D., Advocate Illinois Masonic
Medical Center, Chicago, IL
A 37-year-old G2P1 woman was diagnosed with bilateral fetal hydrothorax at 29-weeks gestation. Fetal
thoracocentesis performed under LA at 30-weeks resulted in re-accumulation of fluid within two
weeks. A decision was made to perform ultrasound-guided percutaneous placement of bilateral fetal
thoracoamniotic shunts as minimally invasive fetal surgery. The patient received small intermittent
bolus doses of midazolam and fentanyl for intravenous sedation. An 8-French cook Pigtail catheter was
deployed into the fetal thoracic cavity under US-guidance. The anesthetic goals for both the mother and
fetus included maintaining hemodynamic stability maternal oxygenation normocarbia placental
perfusion uterine relaxation and preparation for a potential C-section.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC242
Bebulin Administration Before CSE Placement in a Parturient With Factor X Deficiency
Ashley Eggers, Christopher Ciliberto, M.D., Laurent Bollag, M.D., Ruth Landau, M.D., University of
Washington, Seattle, WA
A 26-year-old nullipara with an autosomal dominant variation of Factor X Deficiency was induced at 39
weeks gestation and requested neuraxial analgesia. She had a history of significant bleeding during
relatively minor procedures and had received Bebulin (Factor IX complex) on several occasions. After 24
hours of IV PCA remifentanil for early labor pain a Bebulin dose was given followed by an uneventful
CSE. Following delivery the epidural was removed without issues and she was discharged from the
hospital two days later.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
OB MC243
Anesthesia for Endovascular Repair of Coarctation of the Aorta in a Pregnant Woman With Mitral
Stenosis. A Challenging Case for Mother and Fetus
Renata Ferreira, M.D., Christopher Ciliberto, M.D., LaVone Simmons, M.D., Elisa Zaragoza-Macias,
University of Washington, Seattle, WA
34-year-old female with coarctation of the aorta and moderate MV stenosis. Due to persistent
hypertension at 20 weeks of gestation an endovascular stent placement was perfomed by a multidisciplinary team including maternal-fetal medicine interventional cardiology cardiothoracic anesthesia
and obstetric anesthesia.Continuous fetal monitoring was performed. Upon extubation an episode of
fetal asystole followed by prolonged fetal bradycardia was identified. The obstetric anesthesiologist
administered ephedrine nitroglycerin and terbutaline. Upon administration of ephedrine mother
developed hypertension and pulmonary edema treated with furosemide and non-invasive positive
pressure. Appropriate fetal heart rate normalized. By discharge patient was normotensive on no
medications. The pregnancy is ongoing.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC244
Anesthetic Management of a Parturient With Klippel-Trenaunay Syndrome on Therapeutic
Anticoagulation
Melissa Flanigan, D.O., Monica Ata, D.O., Eric Massey, M.D., West Virginia University, Morgantown, WV
34-year-old parturient with a history of Klippel-Trenaunay Syndrome presents to our facility in preterm
labor. On admission she was found to have extensive deep venous thrombosis of her left leg. She was
anticoagulated with heparin during her stay. Multiple providers were consulted who educated the
patient and gave her different options for labor analgesia. The patient ultimately decided on spinal
anesthesia. Upon discontinuing the heparin and reaching normal coagulation values an intrathecal
administration of duramorph with a low-dose isobaric bupivacaine was administered. She received
adequate analgesia during her labor and subsequently had an uneventful delivery.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC245
Epidural Anesthesia in a Patient With Idiopathic Fibrosing Mediastienitis Complicated With
Obstruction of the Superior Vena Cava
Karen Fleming, M.D., Fatimah Habib, M.D., Magdy Takla, M.D., Cooper University Hospital, Camden, NJ
A 34-year-old G3P2 female with a history of morbid obesity and idiopathic fibrosing mediastinitis
presented for induction of labor at 39 weeks gestation. The patient was seen in preadmission testing for
anesthetic evaluation. On physical exam the patient had bilateral upper extremity swelling shortness of
breath with exertion and obesity. New imaging was not recommended by pulmonology. A scheduled
induction of labor with an epidural anesthesia was planned in coordination with the maternal-fetalmedicine team for high risk pregnancy. The epidural was kept at a low infusion rate. Every measure was
taken to avoid general anesthesia in this patient.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
OB MC246
A Case of ECT in a Pregnant Patient
Kenneth Fomberstein, M.D., Lars Helgeson, M.D., Yale-New Haven Hospital, New Haven, CT
A 20-year-old female at 24 weeks gestational age presented for electroconvulsive therapy (ECT) in the
PACU. ASA and fetal heart rate monitors were applied with normal readings. Methohexital &amp;
succinylcholine were used for intubation. Fetal decelerations to the 60s were noted after 2:30 minutes
of seizure. Midazolam was administered and the seizure aborted after 2:50. The FHR tracing became
difficult to obtain so the patient was taken to the OR where FHR was reacquired at 124. The patient was
observed then extubated. Subsequent ECT treatments were induced with propofol with seizure
durations <1:30 with no episodes of fetal bradycardia.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC247
Management of Intraoperative Hypertensive Emergency Later rRevealed to be Undiagnosed
Pheochromocytoma
Marylin Fouche, M.D., University of Mississippi Medical Center, Jackson, MS
29-year-old female with history of chronic untreated hypertension and morbid obesity with pregnancy
at 28 weeks presenting for emergent cesarean due to severely elevated pressures and preeclampsia.
Arterial line pressures were not decreased after delivery of a viable fetus. Multiple IV anti-hypertensives
at maximum doses and oral anti-hypertensives were not successful in decreased pressures. Despite
therapy patient continued to have severe blood pressures with deteriorating mental status. Urine
metanephrine levels obtained and were elevated. Abdominal CT scan revealed pheochromocytoma.
Pressures improved with oral agents; total intensive care time 15 days. Patient then scheduled for
removal of pheochromocytoma.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC248
Management of Aortic Stenosis and Chest Pain in the Parturient
Robert Freundlich, M.D., M.S., Vishrut Naik, M.D., Monica Servin, M.D., University of Michigan, Ann
Arbor, MI
A 23-year-old ASA 4 G2P1 presents at 25 weeks of gestation with a chief complaint of exertional chest
pain. The patient has a history of severe aortic stenosis and mild mitral regurgitation status-post
mechanical aortic and mitral valve replacement at age 13. She receives fonaparinux for prophylactic
anticoagulation. She is admitted for evaluation and the obstetric anesthesiology service is consulted for
recommendations for pre-delivery optimization. She denies signs and symptoms of heart failure. A TTE is
performed and reveals a peak aortic gradient of 80 mmHg and a mean gradient of 50 mmHg. Left
ventricular systolic function is normal.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
OB MC249
EXIT Delivery for the Difficult Fetal Airway
Jessica Galey, M.D., Shobana Bharadwaj, M.B. B.S., University of Maryland, Baltimore, MD
Two cases of EXIT delivery for fetal airway management are discussed. A 33 year-old patient was
treated with intra-amniotic and intra-fetal-muscular injection of levothyroxine for a fetal goiter
compressing trachea and a 36 year-old patient with a fetal neck mass causing tracheal deviation. Direct
Laryngoscopy Rigid bronchoscopy Tracheostomy or EXIT to ECMO was the algorithm proposed for
airway management while on placental perfusion. General anesthesia was initiated and uterine
relaxation was provided with sevoflurane and nitroglycerin infusion and low dose phenylephrine to
maintain maternal blood pressures. The times from uterine incision to clamping the umbilical cord were
25 and 13 minutes respectively.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC250
Management Strategy for a Cesarean Delivery for a Parturient With Severe Cardiomyopathy With No
Prenatal Care in Acute Distress
Jacqueline Galvan, Heather Nixon, M.D., University of Illinois Hospital, Chicago, IL
We present a case of a 22-year-old G2P1 at 33 weeks GA who was transferred from an OSH with
progressive dyspnea chest pain and orthopnea with a PMH of cardiomyopathy (EF=35%) and no
prenatal care. On admission her transthoracic echocardiogram showed an EF of 10% with PHTN (PAP
36mmHg) global hypokinesis and cardiomegaly. Due to her worsening condition and IUGR of the fetus a
cesarean delivery was planned. In this medically challenging case with a high risk of mortality we
describe our successful management strategy including echocardiography invasive monitoring beta
blockers diuretics fluid restriction milrinone bolus and an inhalational induction.
Saturday, October 12
3:00 PM - 4:30 PM
OB MC251
Management of a Large Hemorrhagic Liver Adenoma in an Obese Parturient
Jacqueline Galvan, M.D., Hokuto Nishioka, M.D., University of Illinois Hospital, Chicago, IL
A 31-year-old obese parturient at 17 weeks gestation presented with abdominal pain and anemia
requiring multiple blood transfusions. Her obstetric history was complicated by emesis gravidarum.
Imaging studies revealed a large 10cm x 15cm hemorrhagic liver adenoma. Robotic-assisted
laparoscopic excision of the mass was planned and it was successfully excised with minimal blood loss
and without hemodynamic compromise. The parturient was extubated at the completion of the case
with fetal heart tones at baseline. While resection of liver tumors in pregnancy is rare a careful
anesthetic management is crucial to a successful outcome.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
OB MC252
Anesthetic Considerations for Amyotrophic Lateral Sclerosis in Pregnancy
Harry Garcia, Student, Mohammed Abdel-Rahim, M.D., Gabriel Sarah, M.D., University of Miami Miller
School of Medicine, Miami, FL
A 27-year-old female G1P0 presented to her obstetrician at 10 weeks gestational age complaining of
weakness in the right upper and left lower extremities. Conclusive workup led to the diagnosis of
Amyotrophic Lateral Sclerosis. By 30 weeks gestational age she developed dyspnea at rest and while
supine. At a multidisciplinary meeting the decision was made to schedule delivery by C-section at 34
weeks gestational age. However respiratory decompensation required C-section at 33 weeks
gestational age. To date the literature reports only 11 similar pregnancies. Here we present the perioperative management anesthetic implications and outcomes of this rare and debilitating disease.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC253
Continuous Left Stellate Ganglion Block for Intractable Angina
Ryan Ensminger, D.O., Linda Le-Wendling, M.D., University of Florida, Gainesville, FL
Our patient is a 60-year-old male with coronary artery disease post CABG in 2003 and 2012 fibromyalgia
and intractable chest pain. Previously the patient had undergone cervical spinal cord stimulator
placement for his chest pain which eventually became ineffective. Despite Nitroglycerin infusion and
intravenous dilaudid the patient continued to have severe angina though he was not a candidate for
percutaneous coronary intervention or surgical revascularization. A continuous left stellate ganglion
block was placed under real-time ultrasound guidance and an infusion of ropivicaine initiated with relief
of his angina. The patient refused alcohol ablation of the stellate ganglion.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC254
Patient With a Difficult Airway Undergoing Percutaneous Endoscopic Gastrostomy Tube Placement
Under Ultrasound-Guided Bilateral Rectus Sheath Block
Shahla Escobar, M.D., Enrique Escobar, M.D., Irina Gasanova, M.D., Ph.D., Amin Kamali, D.O., University
of Texas Southwestern Medical Center, Dallas, TX
A 63-year-old male with a past medical history significant for squamous cell carcinoma of the tongue
presented to the interventional radiology suite for a midline percutaneous endoscopic gastrostomy tube
placement for malnourishment. His preoperative physical examination was significant for a Mallampati
class 4 airway small mouth opening short thyromental distance and limited neck mobility. Intravenous
sedation was initiated with a dexmedotomidine infusion. A bilateral ultrasound-guided rectus sheath
block at the T7 and T9 dermatome levels was performed. A mid-abdominal sensory block overlying the
T7-T10 nerve dermatomes was achieved. His procedure was successfully completed without local
anesthetic supplementation.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
RA MC255
Treatment of Severe Neuropathic Acute Pain With Intravenous Lidocaine Infusion and Single Dose
Intravenous Dextrocetamine
Paulo Filho, M.D., Hospital Federal de Bonsucesso, Rio de Janeiro, Nubia Figueiredo, Ph.D., Ismar
Cavalcanti, Ph.D., Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
Patient underwent osteosynthesis of tibia and fibula started neuropathic pain after regression of
regional block in 24h affecting the territory of the peroneal nerve. Pain score 9 refractory to tramadol
dipyrone ketorolac and morphine. Reduction in pain score 9 to 3 in 45 minutes after intravenous
dextrocetamine 0.1 mg.kg-1 and lidocaine 2 mg.kg-1 infused over 30 minutes. Lack of pain within 3 days.
Pregabalin 225 mg given orally per day for 1 month. No neuropathic manifestations in 16 weeks of
follow-up.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC256
Removal of a Thoracic Epidural Catheter After Cardiac Surgery While on Angiomax
Daniel Francis, M.D., Mahammad Hussain, M.D., UT Houston- Texas Medical Center, Houston, TX
In this case we describe a 57-year-old female who received a pre-operative Thoracic Epidural for a multivessel CABG. Her post-operative course was complicated by severe thrombocytopenia concern for HIT
the need for life sustaining mechanical support devices and continuous anti-coagulation. The patient
was transferred to our facility for higher level of care on angiomax due to concern for HIT. The Acute
Pain service was consulted to manage safe removal of the retained thoracic epidural catheter.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC257
Bilateral Tap blocks for an Open Laparatomy
Scott Goldhaber, D.O., Chaiyapat Charoonbara, M.D., Jean Eloy, M.D., Sean McGuirt, Student, UMDNJNJMS, Newark, NJ
Transversus abdominis plane (TAP) block is a relatively new regional technique. It remains underutilized
despite its ease of use. It involves injecting local anesthetic between the internal oblique and
transversus abdominis layers. While many studies demonstrate efficacy in postop analgesia few reports
evaluate its use as a regional technique intraoperatively. We present a case of a 70-year-old man who
underwent exploratory laparotomy with Bilateral TAP blocks under sedation.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC258
Postoperative Rescue Sciatic Nerve Block Performed Using Stimulation Technique for Treatment of
Intractable Stump and Phantom Limb Pain Following Acute Traumatic Amputation of Foot and Ankle
Jonathan Grainger, M.D., Michael Hawryschuk, M.D., University of Cincinnati Medical Center, Dayton, KY
We present a case employing a rescue sciatic nerve block using nerve stimulation for treatment of
intractable postoperative pain following emergent below knee amputation. Nerve stimulation is rarely
used in this scenario secondary to inability to elicit a motor response. Using our understanding of
phantom limb pain we were able to illicit a sensation of sensory nerve stimulation in the non-existent
foot. Despite no evidence of motor stimulation below the knee our patient was pain free within
Copyright © 2013 American Society of Anesthesiologists
minutes. We believe that this stimulation technique may be an alternate end-point if no motor response
can be elicited for post-operative analgesia.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC259
A Case of Transverse Sinus Venous Thrombosis After Post Dural Puncture Headache
Maged Guirguis, M.D., Samuel Samuel, M.D., Cleveland Clinic Foundation, Cleveland, OH
28-year-old patient developed headache after her second C6-C7 inter-laminar cervical epidural steroid
injection with documented dural puncture who presented with classic features of PDPH refractory to
conservative measures. Patient failed both lumbar and cervical epidural blood patch. MRI brain showed
a focal filling defect within the left transverse sinus. MRV showed absent flow-related enhancement in a
large portion of the left transverse sinus. Initiating heparin infusion paralleled with subsiding of
symptoms.Full hypercoagulability panel showed elevated factor-VIII. Patient was started on
warfarin.MRVs in 3 and 6 months were performed and showed partial re-canalization in the left
transverse sinus.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC260
Transient Horner Syndrome and Unilateral Brachial Plexus Blockade Following Epidural Infusion in a
Thoracotomy Patient
Jason Hahn, M.D., Luminita Tureanu, M.D., Northwestern University, Chicago, IL
Epidural catheterization may cause significant adverse effects perioperatively. We describe a case of
transient Horner syndrome and unilateral brachial plexus blockade following epidural infusion of 0.1%
bupivacaine with 10mcg/ml hydromorphone in a thoracotomy patient. The differential diagnosis
included CNS pathology brachial plexus injury and nerve root involvement. The symptoms resolved
with halving the epidural infusion and continuing with hydromorphone only. Such symptoms most likely
due to second order sympathetic neuronal involvement are reported rarely in the literature. Possible
contributing factors include positioning sympathetic fiber hypersensitivity and anatomic variations.
Early recognition may facilitate clinical decision making and avoid unnecessary diagnostic workup.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC261
It Hurts Where My Toes Would Be if They Were There: Phantom Pain After Transmetatarsal
Amputation
Brittani Hale, M.D., Ellen Flanagan, M.D., Duke University, Durham, NC
A 28-year-old female with lupus and ESRD presented for right femoral AV graft placement.
Postoperative course was complicated by acute vasospastic episode of the right lower extremity.
Despite argatroban therapy gangrene developed requiring transmetatarsal amputation under general
anesthesia with PCA post-operative analgesia. Regional analgesia was not considered due to patient's
anticoagulation status. On POD3 the Pain Service was consulted for 10/10 lower extremity pain.
Saphenous and popliteal nerve catheters were placed after single shot blocks for comfort. Despite
complete sensory and motor blockade the patient continued to report severe pain where my toes
would be if they were there.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
RA MC262
Knotting of an Epidural Catheter: A Rare Complication of Neuraxial Analgesia
Kelly Hines, M.D., James Jackson, M.D., University of Louisville, Louisville, KY
A 57-year-old female with an ovarian mass presented for total abdominal hysterectomy. An epidural
catheter was placed preoperatively for postoperative pain control. On postoperative day 2 significant
resistance was met during catheter removal despite multiple maneuvers classically used to aid in
catheter removal. The patient was placed prone on a portable Wilson frame and using fluoroscopy the
catheter location was identified and the catheter ultimately removed. Inspection revealed a single loop
knot less than 1 cm from the catheter tip. We describe a possible mechanism for knotting during
placement and review approaches to removal of entrained epidural catheters.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC263
Anesthetic Management of a Thrombocytopenic Patient on Suboxone Maintenance for Splenectomy
Yili Huang, D.O., Balazs Horvath, M.D., Robert Lagasse, M.D., Yale University School of Medicine, New
Haven, CT
Suboxone has gained popularity as a treatment for opioid addiction and chronic pain but its partial
agonist/antagonist activity makes management of perioperative analgesia difficult. Premorbid
conditions and surgical requirements can also make the use of regional anesthesia controversial in these
patients. Our patient is a former opioid addict previously managed with a physician-monitored
methadone program before transitioning herself to Suboxone maintenance without the input of a
physician. Her history includes pulmonary and portal hypertension secondary to cirrhosis and her preadmission testing revealed a platelet count of 55 000. She is scheduled to undergo splenectomy and
possible spenorenal shunt with postoperative heparinization.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC264
Neuraxial Anesthesia in a Left Ventricular Assist Device Patient Undergoing Gynecologic Surgery
Jacob Hummel, M.D., Brent Dilts, Santiago Gomez, Tulane University, New Orleans, LA
A 33-year-old female with severe non-ischemic cardiomyopathy chronically supported by an LVAD
underwent a salpingo-oopherectomy to remove an ovarian mass. Neuraxial anesthesia was conducted
throughout the case wtih an epidural and dosed with 0.5% ropivacaine and 2% lidocaine along with an
intravenous infusion consisting of propofol and ketamine for sedation. The challenge of maintaining
optimal hemodynamics in the presence of neuraxial anesthesia vasodilation and extensive blood loss
was significant. The patient was admitted to the ICU for vasopressor support and monitoring but was
quickly weaned off vasopressors. The patient was discharged home on postoperative day 3 in stable
condition.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
RA MC265
Use of Regional Anesthesia for VATS in a High Risk Cardiac Patient
Monique Jones, M.D., Philip Bamberger, M.D., Faiz Bhora, M.D., St. Lukes-Roosevelt Hospital Center,
New York, NY
The patient was positioned in the left lateral decubitus position with some lateral hyperextension to
facilitate surgery. Placed on an Oxygen Facemask at 6 liter/ minute. A low dose Propofol Infusion was
started (40 mcg/kg/min.) The classicly described method of Intercostal block was performed at the
posterior angle of each rib T4-12 by first palpating each rib then hitting it with a 25 ga needle and
walking off the inferior aspect. 4 ml of Bupivacaine 0.5% was injected into each neurovascular bundle.
The patient tolerated this well and went on to have Visually Aided Thoracic Surgery (VATS) drainage of
empyema.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC266
Transient Urinary Incontinence After Single Shot Sciatic Nerve Block
Christina Julian, M.D., Stephen Howell, M.D., James Sadler, M.D., West Virginia University, Morgantown,
WV
A 38-year-old female patient experienced transient urinary incontinence after a pre-operative single
shot sciatic nerve block for posterior tibial tendon debridement and tenosynovectomy. The block was
performed via the classic posterior Labat approach stimulating needle was utilized and 20 mL of
Bupivicaine 0.5% was injected without complication. In the 12-hour period immediately post-op the
patient complained of significant perineal numbness and experienced 4 episodes of urinary
incontinence. As the effects of the block dissipated the patient slowly regained sensation and the ability
to void completely returned by 16 hours post block. She has no residual effects.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC267
Successful Treatment With Intralipid of Central and Peripheral Nervous System Symptoms Resulting
From Local Anesthetic Overdose
Ihab Kamel, M.D., Rodger Barnette, M.D., Gaurav Trehan, M.D., Temple University Hospital,
Philadelphia, PA
A 51-year-old 74 kg female scheduled for transvaginal tape placement under general anesthesia had 80
mL of 0.5% bupivacaine with epinephrine injected at the surgical site. In the PACU the patient
experienced dizziness posturing and occulogyric symptoms. The patient could not feel or move her left
lower extremity. On examination the left leg showed rigidity loss of motor strength and decreased
sensation. The patient was treated with 500 mL of 20% intralipid IV (bolus and infusion) over 21
minutes. After treatment neurologic symptoms resolved and the patient had restoration of motor
function and sensation to the left lower extremity.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
RA MC268
A Case of an Interscalene Brachial Plexus Catheter Adherent to a Fascial Band Requiring Surgical
Removal
Muthuraj Kanakaraj, M.D., F.R.C.A, Madhu Shankar Balasubramaniam, Asoka Balage, M.D., F.R.C.A,
M.D., F.R.C.A, Malgorzata Jaworskagrajek, M.D., F.R.C.A, Reginald Edward, M.D., F.R.C.A, Hull and East
Yorkshire Hospitals NHS Trust, Hull, United Kingdom
A 64-year-old male underwent an arthroscopic shoulder rotator cuff repair with ultrasound guided
continuous inter-scalene brachial plexus catheter. After completion of the continuous infusion of local
anaesthetic on the third post-operative day the nurse attempted to remove the catheter as instructed.
But it could not be removed causing pain and discomfort to the patient leading to removal of the
catheter by a plastic surgeon under local anaesthesia. On exposure a fascial band was found trapped
between the distal coils of the catheter which was released and the catheter removed. The patient
recovered without any neurological deficit.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC269
Stuck on You
Muthuraj Kanakaraj, Madhu Shankar Balasubramaniam, M.D., F.R.C.A, Asoka Balage, M.D., F.R.C.A,
Malgorzata Jaworskagrajek, M.D., F.R.C.A, Reginald Edward, M.D., F.R.C.A, Hull and East Yorkshire
Hospitals NHS Trust, Hull, United Kingdom
An 18-year-old female patient with ultrasound guided adductor canal perineural catheter for anterior
cruciate ligament repair was discharged home with continuous infusion by an elastomeric pump along
with written and verbal instructions on catheter care and removal. At the end of the infusion when the
patient attempted removal of the catheter the metal catheter uncoiled and got stuck. She contacted
the anaesthesiologist and needed admission to hospital for catheter removal by plastic surgeons under
local anaesthesia. The coils were found snagged on the fascia and had to be disengaged and removed.
The patient recovered uneventfully without any neurological deficit.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC270
Dabigatran: To bleed or Not to Bleed
Nakiyah Knibbs, Michael Anderson, M.D., Mount Sinai Medical Center, New York, NY
65-year-old female with hypertension PVD recurrent DVT/PEs and renal insufficiency on dabigatran
presents for knee revision for infection with systemic sepsis three weeks prior at an outside hospital.
Significant blood loss was anticipated as her PVD precluded tourniquet use. Her last dabigatran dose
was 4 days prior but her PTT and INR remained elevated (47.3 and 1.4). A thrombin time (TT) was sent
and was 2 times normal. Because of dabigatran's irreversibility the case was delayed and TT monitored
until normalized. The case proceeded 3 days later without incident.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
RA MC271
Combined Interscalene and Superficial Cervical Plexus Blocks for Postoperative Analgesia for
Clavicular Surgery - A Novel Approach
Sudheera Kokkada Sathyanarayana, M.D., Karina Gritsenko, M.D., Konrad Gruson, M.D., Boleslav
Kosharskyy, M.D., Naum Shaparin, M.D., Montefiore Medical Center Albert Einstein College of Medicine,
Bronx, NY
Regional anesthesia for clavicle surgery is not well described in literature. This case series describes 4
patients undergoing open clavicle surgery who received preinduction ultrasound-guided interscalene
brachial plexus and superficial cervical plexus nerve blocks requiring minimal postoperative analgesics.
Intraoperatively balanced general anesthesia was provided with induction narcotic doses only; postoperative day 1 follow-up indicated excellent post-operative analgesia no narcotics in PACU no pain for
24 hours. This case series illustrates effective regional techniques which allow for improved patient
satisfaction decreased narcotic use no pain on ambulation to home and transition to successful PO
regimen. A prospective observational study is planned.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC272
Cranial Nerve Paresis Following Shoulder Surgery: A Cause Analysis
Molly Kraus, M.D., Rachel Cain, Renee Caswell, M.D., David Rosenfeld, M.D., Mayo Clinic, Phoenix, AZ
A retrospective chart review of cranial nerve dysfunction following shoulder surgery was performed with
analysis of operative indication and technique regional anesthesia characteristics of neurapraxia and
postoperative course. Three patients with cranial nerve paresis following shoulder surgery were
identified. All patients underwent ipsilateral preoperative ultrasound-guided interscalene brachial
plexus block with ropivacaine. All surgeries were performed in the beach-chair position. Cranial nerve
paresis was noted immediately postoperatively. Affected nerves included ipsilateral hypoglossal
contralateral hypoglossal and ipsilateral hypoglossal and vagus. Intraoperative patient positioning as
opposed to preoperative regional nerve block or operative technique is the most likely causative factor.
Saturday, October 12
3:00 PM - 4:30 PM
RA MC273
Extraction of A Knotted Interscalene Catheter
Neha Kumar, M.D., Christina Jeng, M.D., Icahn School of Medicine at Mount Sinai, New York, NY
A 61-year-old female presented for shoulder arthroplasty. Ultrasound-guided interscalene catheter was
placed for perioperative analgesia. Post-operative day two the catheter could not be pulled at bedside.
Peripheral catheter entrapment is a rare occurrence; case reports describe catheters hooking or kinking
around the brachial plexus where forceful extraction risks permanent nerve injury. Thus the patient
was monitored for dysesthesias during all extraction attempts. ENT was involved imaging obtained and
it was decided Orthopedics would remove the catheter in the operating room. Effective communication
among pain management specialists anesthesiologists surgeons radiologists and the patient resulted
in a satisfactory outcome.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
AM MC274
Tracheal Stenosis: Always an Airway Management Dilemma for Anesthesiologist
Randall Campbell, M.D., Aurl Neamtu, M.D., University of Louisville, Louisville, KY
We present a safe technique for airway management of a morbidly obese patient with tracheal stenosis
that presents for tracheal dilation. Traditional management includes endotracheal intubation high flow
jet ventilation or spontaneous ventilation. Our airway management technique included a method of
total intravenous anesthesia with spontaneous ventilation along with intermittent endotracheal
intubation to provide optimal operating conditions for the surgeon while maintaining airway protection
of the patient.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC275
Severe Masseter Spasm & Stridor From Muscle Rigidity Associated With the Patient With Lewy Body
Dementia
Won Chee, M.D., The Montefiore Medical Center & Albert Eintein College of Medicine, Bronx, NY
A 52-year-old female was scheduled for multiple tooth extractions under general anesthesia. Her past
medical history was significant for Lewy body dementia diagnosed 3 years ago. The disease had severely
impaired her neurological function both cognitive and motor; she could neither communicate with
others nor care for herself from generalized muscle rigidity . Her medications included Sinemet. During
emergence from anesthesia the patient manifested a severe masseter muscle spasm. After extubation a
loud \stridor-like\" sound was heard but without visible airway obstruction. Eventually administration
of Sinemet via an NG tube resolved all the symptoms."
Saturday, October 12
3:00 PM - 4:30 PM
AM MC276
Postoperative Stridor: A Challenging Diagnosis
Ben Cobb, M.D., Katie Podorean, D.O., Irene Rozet, M.D., University of Washington, Seattle, WA
Reintubation of the patient's airway in the immediate postoperative period increases morbidity and
mortality. We present a case of postoperative stridor of multifactorial nature including paradoxical
vocal cord motion (PVCM) abnormality. A 47-year-old ASA III female after uneventful general anesthesia
for outpatient hysteroscopy developed stridor peri-oral swelling and respiratory depression. After
unsuccessful conservative management for ketorolac allergy her airway was reintubated. After 48 hours
repeated fiberoptic examination revealed PVCM. The patient was extubated with non-improved stridor
and was referred to speech therapy for ongoing treatment. In middle-age women PVCM should be
considered as a cause of stridor.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC277
An Iatrogenic Airway Obstruction in a Former IV Drug User - Abbe Flap Inset
Bryan Currie, D.O., Sanjib Adhikary, M.D., Pennsylvania State University Hershey Med Ctr, Hershey, PA
A 31-year-old man underwent a cleft lip repair with unsatisfactory results. An Abbe flap was created
from the philtrum to the lower lip. He presents for inset of the Abbe flap. Airway exam was remarkable
for midline Abbe flap (upper to lower lip) resulting in extremely limited mouth opening. Contributing to
Copyright © 2013 American Society of Anesthesiologists
the complexity of this case was difficult IV access in this former IV drug user and his demand for a mask
induction before IV placement. A mask induction with nitrous oxide was performed before intravenous
access maintaining spontaneous ventilation. An asleep nasal fiberoptic intubation was then performed.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC278
Anesthetic Management of a Patient With Charcot Marie Tooth Disease Type 2 and Soy Allergy
Presenting for Laparoscopic Paraesophageal Hernia Repair
Anis Dizdarevic, M.D., Columbia University, New York, NY
67-year-old woman with a history of Charcot Marie Tooth Disease Type 2 with associated peripheral
neuropathy and bilateral lower and upper extremity pain presents for a laparoscopic repair of
paraesophegeal hernia with mash and fundoplication. Patient also reports an unknown allergic reaction
to soy and peanuts. This case report describes the anesthetic evaluation and considerations in Charcot
Marie Tooth Disease association between soy and peanut allergy and risk of reaction after propofol
administration analysis of literature and evidence and finally our successful anesthetic technique for
this case.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC279
Postoperative Loss of Taste and Smell
Kelly Elterman, M.D., Richard Urman, M.D., M.B.A., Brigham and Women's Hospital, Boston, MA
Alterations in taste and smell including but not limited to anosmia ageusia hypogeusia and dysgeusia
have been associated with various medications including anesthetic agents. These symptoms typically
occur 1-2 weeks after medication administration and last several months. Our patient a 61-year-old
woman with no neurologic history or prior anesthetics underwent laparoscopic BSO for an ovarian mass
and developed anosmia and ageusia on POD 1. Intraoperatively she received midazolam fentanyl
propofol vecuronium sevoflurane and scopolamine. Her symptoms resolved completely by POD 3.
Anesthesiologists should be aware of this unusual postoperative phenomenon which may impact
patient satisfaction and quality of life.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC280
Ventricular Tachycardia After Prone Positioning in Percutaneous Nephrolithotripsy in a Patient With a
History of Right Bundle Branch Block and Newly Diagnosed Bifasicular Block
Karen Fleming, M.D., Irwin Gratz, D.O., Cooper University Hospital, Camden, NJ
A 73-year-old female with a history of hypertension diabetes morbid obesity and right bundle branch
block was scheduled for percutaneous nephrolithotripsy. The patient was seen in pre-admission testing
because of dyspnea on exertion. An EKG performed in pre-admission testing showed a new bifasicular
heart block. After induction the patient was placed prone. Within 5 minutes the patient experienced 15
beats of ventricular tachycardia. Surgery was aborted; the patient was placed supine and spontaneously
converted to sinus rhythm. Cardiology was consulted and concluded that this was artifact. The patient
remained in the hospital for 24h observation and discharged home.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
AM MC281
Management of Abdominal Compartment Syndrome After Transurethral Resection of the Prostate
Megan Gaut, Jaime Ortiz, M.D., Baylor College of Medicine, Houston, TX
Acute abdominal compartment syndrome (ACS) is most commonly associated with blunt abdominal
trauma although other etiologies include bowel obstruction ascites and massive volume resuscitation.
ACS develops once the intraabdominal pressure increases to 20-25 mmHg and is characterized by
increased airway pressures inadequate ventilation and oxygenation altered renal function and
hemodynamic instability. This case report details a 79-year-old male who developed acute ACS
secondary to extraperitoneal bladder rupture and subsequent intraperitoneal tear during transurethral
resection of the prostate (TURP) under general anesthesia. This case discusses his diagnoses and
management which included re-intubation emergent exploratory laparotomy and drainage of irrigation
fluid.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC282
Refractory Postoperative Hypotension in the Ambulatory Setting After TAP Block for Inguinal
Herniorrhaphy (Was it the TAP Block?)
Christopher Godlewski, M.D., Tilak Raj, M.D., Thomas Tinker, M.D., University of Oklahoma Health
Science Center, Oklahoma City, OK
We present a 54-year-old patient who underwent inguinal herniorrhaphy under GETA with TAP
(transversus abdominis plane) block for postoperative analgesia in our Ambulatory Surgery Center. In
PACU he developed severe (systolic 60mmHg) refractory hypotension; he remained awake and
conversant. Hypotension did not respond to treatment with fluids and pressors nor did it affect his
consciousness. The prolonged and severe nature of the problem warranted admission to the ICU at the
main hospital. Could the TAP block cause this? We discuss the differential diagnosis and management of
such a problem and reveal the pathology responsible for this enigmatic problem.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC283
Humerus Fracture Repair in a Patient With Advanced Multisystem Dysfunction in an Ambulatory
Surgery Setting.
Timothy Harwood, M.D., Wake Forest University, Winston-Salem, NC
A 64-year-old man weighing 92 kg was scheduled in our ambulatory surgery center for a humeral head
ORIF after a fracture. PMH included CAD with CABG/stents CHF with diastolic dysfunction and pleural
effusions and BNP 249 DM with renal insufficiency PVD with CEA OSA but he cannot use CPAP. Because
of these risk factors we chose a continuous ISB and superficial cervical plexus block for surgical
anesthesia with a short-acting LA until we were assured he could tolerate the phrenic block. The ISB
catheter was used for postoperative analgesia and the patient was discharged well on POD 1.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
AM MC284
Sudden Cardiovascular Collapse During Myomectomy
Lee Hingula, M.D., Boonsri Kosarussavadi, M.D., Yale-New Haven Hospital, New Haven, CT
A healthy 42-year-old woman presented for m year-old mectomy. Induction of anesthesia was
uneventful. Surgery was performed with a hysteroscope and bipolar cautery loop. During surgery the
hysteroscope fluid bag was changed. Suddenly the ETCO2 decreased from 30 to 9 blood pressure
dropped to 60/40 and the pulse increased to 110. An air embolus entrained by the hysteroscope into
the uterine veins was suspected. Epinephrine was administered. The blood pressure increased to
130/75. The patient emerged from anesthesia moving all extremities. Within 2 hours she was alert and
oriented hemodynamically stable and ready for discharge.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC285
Management of an Unanticipated Difficult Airway Secondary to Ventral Osteophytes: A Case Report
Jason Hoyos, D.O., Amy Kamat, M.D., Christina Matadial, M.D., University of Miami/Jackson Memorial
Hospital, Miami, FL
This report describes a case in which a large ventral osteophyte resulted in obstruction of the upper
airway and difficult intubation. This structure was visualized while attempting to intubate a 54-year-old
man presenting for a radical prostatectomy who had no prior imaging studies. In this case initial
techniques were performed including an MAC blade and Storz rigid laryngoscope which proved to be
unsuccessful. Eventually a successful hybrid technique was attempted using the rigid fiberoptic scope
and the flexible fiberoptic scope together allowing visualization of the structures and appropriate
navigation around the obstruction.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC286
Airway Management in a Morbidly Obese Patient With OSA for Drug-Induced Sleep Endoscopy and
Uvulopalatopharyngoplasty
Zeena Husain, Quisqueya Palacios, M.D., Baylor College of Medicine, Houston, TX
Drug-induced sleep nasal endoscopy (DISE) prior to uvulopalatopharyngoplasty for obstructive sleep
apnea (OSA) presents anesthesia care providers with clinical challenges for airway management in high
risk patients with significant comorbidities. The majority of OSA patients are obese with potentially
difficult airways. Although RSI is ideal DISE is the opposite with prolonged airway obstruction an
unsecured airway and ineffective oxygen delivery in a patient without protective airway reflexes. It is
imperative to anticipate and plan for possible complications during DISE such as difficult intubation risk
of aspiration respiratory depression and inadequate anesthesia all while maintaining constant
communication with the surgeons.
Copyright © 2013 American Society of Anesthesiologists
Saturday, October 12
3:00 PM - 4:30 PM
AM MC287
Importance of Thorough Preoperative Interviews to Evaluate and Manage Mastocytosis
Gurdev Rai, M.D., Charles Johnson, B.S., ECHCS/ Denver VA, Denver, CO
An obese 41-year-old male with Addison's hypertension GERD OSA and poorly controlled mastocytosis
initially presented to pre-op at the VA in Denver Colorado to receive general anesthesia for teeth
extraction and alveoplasty. During an extensive pre-op interview it was discovered that the patient's
mastocytosis was uncontrolled contrary to his medical record. His surgery was postponed one month
while his condition was stabilized with cromolyn prednisone diphenhydramine and promethazine. The
purpose of this case report is to discuss the importance of thorough pre-op evaluation and management
using an example of a patient undergoing general anesthesia presenting with mastocytosis.
Saturday, October 12
3:00 PM - 4:30 PM
AM MC288
Great Auricular Neuropraxia With Beach Chair Position: A Case Report
Miinal Joshi, M.D., Mohammad Abidi, M.D., H Kamath, M.D., Joel Yarmush, M.D., Joseph Schianodicola,
M.D., NY Methodist Hospital, Brooklyn, NY
Arthroscopy is a frequent method for shoulder procedures. We report a case of greater auricular
neuropraxia associated with horseshoe headrest used for shoulder surgery in beach chair position. In
this case an interscalene block was performed under ultrasound guidance and a nerve stimulator
technique. The patient was comfortable through out the procedure for 143 minutes and discharged
home. Following day the patient described numbness in the lobule of the left ear extending to the
mandibular angle. MRI studies were negative. Injury of the greater auricular nerve was diagnosed. After
five months her symptoms decreased to the point of minimal irritation.
Copyright © 2013 American Society of Anesthesiologists
MCC Session Number – MCC05
Sunday, October 13
8:00 AM - 9:30 AM
FA MC289
Anxiety Pain and Acute Myocardial Ischemia in a Patient With Bilateral Femoral Fractures in the
Preoperative Holding Area.
Vikram Chawa, M.D., Hui Yuan, M.D., Saint Louis University, St. Louis, MO
This case is about a 75-year-old male with greater than four Metabolic Equivalents of Task and without
any risk factors from the Revised Cardiac Risk Index who was scheduled for open reduction internal
fixation of bilateral femoral fractures. Upon requesting medication for his fracture pain our patient was
found to also have chest pain and ischemic changes on ECG. After standard acute treatment was
administered coronary catheterization was performed which showed severe triple vessel disease. This
underlying severe disease was symptomatically unmasked secondary to anxiety pain and anemia.
Surgery was delayed until patient underwent revascularization.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC290
Pneumothorax Following Laparoscopic Extraperitoneal Inguinal Hernia Repair
Amanda Chehval, D.O., Anjali Patel, D.O., Saint Louis University, Saint Louis, MO
Pneumothorax is a rare complication of laparoscopic surgery due to the extravasation of insufflated
carbon dioxide into the pleural space. We describe a 31-year-old healthy male who presented for
laparoscopic repair of a right inguinal hernia. After insufflation with CO2 the ETCO2 and peak airway
pressures began to increase with decreased breath sounds bilaterally. The patient remained
hemodynamically stable and the surgery was completed. A post-operative chest x-ray revealed bilateral
pneumothoraces. The patient was admitted overnight for observation and chest x-ray the following day
demonstrated resolution of the pneumothoraces. He was discharged without further complication.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC291
En Bloc Resection Neck Dissection and Rectus Abdominis Microvascular Free Flap for Management of
Recurrent Right Periorbital Sarcoma
Tiffany Chen, M.D., NYU Langone Medical Center, New York, NY
A 67-year-old man with history of HTN HLD CAD s/p MI complete heart block s/p PPM IgA nephritis and
right sphenoid wing meningioma status post resection and radiation therapy in 2008 presents with
increasing right periorbital swelling. The patient underwent right composite craniofacial resection and
orbital exenteration orbital and zygomatic osteotomies frontotemporal craniectomy lumbar drain
placement and reconstruction with a rectus abdominis microvascular free flap. The patient experienced
mental status changes on POD 5. NCHCT showed edema and small intraparenchymal hemorrhage with
mild midline shift and mass effect. Lumbar drain was clamped with improvement in mental status.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
FA MC292
Complex Airway Management in a Patient With Two Separate Intratracheal Masses Causing Tracheal
Stenosis
Katherine Chiu, M.D., MBA, Ramon Abola, M.D., Slawomir Oleszak, M.D., SUNY Stony Brook, Stony
Brook, NY
A 67-year-old man with esophageal cancer with acute shortness of breath at rest and hemoptysis for
tracheal stent placement. Airway is a mallampati class 3 with limited range of motion. CT shows large
hilar mass obstructing left main bronchus and separate 10cm diameter goiter causing proximal tracheal
stenosis to 5 mm. After awake flexible bronchoscopy rigid bronchoscope was placed and the bronchial
tumor was partially ablated by laser. Then a left main bronchus stent was placed. Next tracheal stenosis
was managed by placement of another stent. After removal of rigid bronchoscope LMA was placed and
removed when patient woke up.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC294
Split Thickness Skin Grafting for a Circumferential Neck Burn in the Ecuadorian Jungle: A Case Report
Chien Chow, M.D., Rady Children's Hospital, San Diego, CA, Robert Stephenson, D.O., St. Elizabeth's
Medical Center, Boston, MA
Our patient is a 49-year-old Ecuadorian mother of 9 who sustained circumferential flame burns to her
neck from a kitchen stove accident several years ago. In this medically challenging case we discuss the
unique challenges of securing an expected difficult airway during a medical missions trip in the
Ecuadorian jungle where advanced airway equipment like fiberoptic bronchoscopy or video-assisted
laryngoscopy is not available. By carefully titrating sedation with intravenous anesthetic agents that did
not induce apnea we maintained the patient's oxygen stores and allowed adequate time to secure the
patient's airway. Her surgery and post-anesthetic course were uneventful.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
FA MC295
Management of the Airway in the Pierre Robin Syndrome Using C-Mac D Blade and Fiberoptic Scope
Elif Cingi, Nathan T. Beerling, M.D., University of Minnesota, Minneapolis, MN
Airway management with Pierre Robin syndrome is diagnostically and therapeutically challenging. It is a
rare condition first described by the Pierre Robin in 1923. The severity of the syndrome varies widely
and associated upper airway obstruction is the most difficult problem to overcome. The triad of
glossoptosis micrognathia and cleft palate provides a challenge in airway management for the
anesthesiologist in newborn. Adult Pierre Robin syndrome patients with multiple corrective surgeries
may have altered normal anatomy. We present a case in which the nasal airway was successfully
managed with a C-MAC D blade and fiberoptic scope while patient was awake.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC296
Management of Tracheostomy Migration in the Pickwickian Patient
Catherine Cleland, M.D., Christopher Jackson, M.D., George Washington University Hospital, Washingon,
DC
A 24-year-old ventilator dependent morbidly obese female with obesity hypoventilation syndrome and
known difficult airway presented one day status post tracheostomy with decreasing tidal volumes and
an air leak. The trach had migrated anteriorly and the patient was taken emergently to the OR. Prior to
attempted exchange of the trach over a pediatric tube exchanger a Glidescope was placed in an attempt
to visualize the cords (grade 4 view). Trach exchange was unsuccessful tidal volumes were low and
oxygen saturation started to decrease. Airway management was then turned over to the Anesthesia
team followed by successful endotracheal intubation.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC297
Utilization of Continuous Ventilation During Intubation of an Unfavorable Airway
Catherine Cleland, Chris Edwards, M.D., George Washington University Hospital, Washington, DC
A 49-year-old male with a history of cirrhosis and esophageal varices presented to the operating room
with a cervical abscess from breakdown of cervical hardware. Risks and benefits of an awake intubation
were discussed with the patient who ultimately refused. The patient was induced with propofol
lidocaine and fentanyl and a 4.5 intubating LMA was placed with the c-collar still in position.
Spontaneous respirations were maintained with the use of a bronchoscopy elbow. A 7.0 ETT was placed
through the LMA guided with a fiberoptic scope. End-tidal CO2 was confirmed before and after the LMA
was removed.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
FA MC298
Emergent Airway Management in Patient With Traumatic Removal of Mid-Face Status Post Self
Inflicted Gunshot Wound to the Face
Kevin Costello, M.D., Colin Wilson, M.D., West Virginia University Hospital, Morgantown, WV
The patient is a 38-year-old male who presented as a transfer from an outside facility with a traumatic
cricothyrotomy after two self-inflicted gunshot wounds to the face. The patient fired two large caliber
rounds under his chin essentially removing his mid face obscuring all relevant upper airway anatomy.
The surgical team requested an intubation from above be maintained during their revision to
tracheostomy. We discuss our approach to intubation in a patient with obliterated upper airway
anatomy hemorrhage and florid edema
Sunday, October 13
8:00 AM - 9:30 AM
FA MC299
Perioperative Management for Extensive Liver Resection in a Patient With Polycystic Liver Disease
Major Cunningham, M.D., Hui Yuan, M.D., St. Louis University, St. Louis, MO
This patient was a 47-year-old female with polycystic kidney and liver disease with destruction of her
right liver by giant size of cysts causing abdominal pain and dyspnea. With previous liver resection she
presented for repeat extended right hepatectomy. An epidural catheter was placed preoperatively. In
OR hemodynamics status were monitored with A-line and CVP. For reducing the blood loss CVP was
maintained at the lowest level and BP was supported with vasopressin. Hemostasis was managed by real
time of thromboelastography and significant blood loss was replaced with the transfusion. The patient
was recovered after operation without any complications.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC300
Medical and Ethical Challenges in a Patient With a Known History of Anaphylactic Reaction to Contrast
Dye Presenting for Endovascular Surgery
Nishita Dalal, Robert Isaak, D.O., University of North Carolina, Chapel Hill, NC
80-year-old female with a history of TAAA s/p TEVAR and AAA s/p EVAR presented for repeat
fenestrated TEVAR of TAAA. Patient had a known history of an anaphylactic reaction to IV contrast dye
and was prophylatically pretreated prior to the procedure. Despite pretreatment the patient had an
anaphylactic reaction following administration of 3ml of IV contrast. Following a lengthy discussion
amongst the surgical team and with the family the decision was made to continue the surgery with the
use of gadolinium dye. The patient's postoperative course was complicated by a mesenteric embolic
event requiring small bowel resection.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
FA MC301
Providing Anesthesia and Analgesia to a Patient With Reported Allergies to Multiple Opiates
Shannon Dare, M.D., Amy Robertson, M.D., Vanderbilt University, Nashville, TN
A 79-year-old female with a history of coronary artery disease ventricular fibrillation requiring an
implantable cardioverter defibrillator and melanoma presented for wide excision of right chest wall
melanoma with possible split thickness skin graft for closure. She reported several allergies to pain
medication including anaphylaxis to demerol dilaudid codeine morphine fentanyl and naproxen.
Consequently this case presents challenges to safely provide analgesia fosters discussion regarding the
prevalence of true opiate allergies questions the possibility of pre-anesthetic allergy testing and
exemplifies the long term consequences of incorrectly labeling a patient with a drug allergy.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC302
Acute Post-Intubation Airway Obstruction Following a TIPS Procedure
Maurice Davis, M.D., Timothy Schmale, M.D., Beaumont Health System, Royal Oak, MI
A 47-year-old male with history of alcohol/hepatitis C-induced end-stage liver disease (MELD 23) endstage renal disease diabetes and bilateral vocal cord paralysis underwent a 7-hour TIPS procedure.
Patient was extubated with reassuring cuff leak test but reintubated for respiratory distress and
transported to PACU. CXR revealed a large right pleural effusion. After two stable hours on IMV patient
desaturated to 41%. Manual ventilation proved difficult breath sounds were diminished bilaterally and
suction catheter failed to traverse the tube. Following a third intubation endotracheal tube examination
revealed a distal secretion-blood concretion with near complete Murphy's eye occlusion. Thoracentesis
removed 2L.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC303
Accelerated Idioventricular Rhythm (AIVR) and Hemodynamic Instability in a Blunt Trauma Patient
Undergoing Femur Fracture Repair
Vimal Desai, M.D., Charles Smith, M.D., Michael Howkins, D.O., Nathaniel Bolli, M.D., Case Western
Reserve University MetroHealth Medical Center, Cleveland, OH
A 20-year-old man sustained a high speed MVC. During transport he had multiple PVCs. ECG showed
sinus tachycardia but was otherwise normal. He was scheduled for femur fracture repair. Shortly after
rapid sequence induction he developed a wide complex accelerated idioventricular rhythm (AIVR).
Whenever heart rate fell below 95-100 the same AIVR would ensue. Administration of glycopyrolate
maintained ST with hemodynamic stability. Postoperatively there were frequent PVCs and AIVR.
Echocardiography and cardiac MRI revealed mild global LV dysfunction and focal RV dysfunction
consistent with myocardial contusion. Troponins were negative. Outcome was favorable without
syncope chest pain or heart failure.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
FA MC304
Management of Intraoperative Ventricular Tachycardia During Video-Assisted Thoracoscopic Surgery
Vimal Desai, M.D., Charles Smith, M.D., Case Western Reserve University MetroHealth Medical Center,
Cleveland, OH
A 30-year-old man with dyspnea and chest pain was scheduled for decortication of an empyema. PMH
included substance abuse (cocaine heroin). Echocardiography was negative for endocarditis. Heart
function was normal. ECG showed NSR 66 bpm QTc 404 ms. Anesthesia management was with
midazolam propofol rocuronium isoflurane fentanyl and dexmedetomidine. One hr after beginning onelung ventilation the patient had multiple runs of monomorphic VT. BP was supported with vasopressors.
Arrhythmias were treated with magnesium lidocaine and bicarbonate. The patient stabilized. After
surgery the trachea was extubated. He was discharged home 4 days later neurologically intact without
further episodes of VT.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC305
Management of Nephrectomy With IVC Thrombectomy and Resultant Blood Loss
Anjali Dogra, M.D., Sherwin Park, M.D., Thomas Bilfinger, M.D., Shang Loh, M.D., Igor Izrailtyan, M.D.,
Stony Brook University Hospital, Stony Brook, NY
AS is a 64-year-old female who presented for left radical nephrectomy and IVC thrombectomy due to
left renal mass and level III IVC tumor thrombus. TEE imaging was utilized throughout this case and welldemonstrated the thrombus and thrombectomy. IVC tumor thrombus occurs in only 4-10% of renal cell
carcinoma and thrombectomy carries a mortality rate of 1.5%. This patient required vasopressor
support to tolerate IVC clamping and suffered sudden blood loss of approximately 3000cc during
thrombectomy management of which highlights the importance of close communication amongst the
entire operating room team to expedite resuscitation and transfusion of blood products.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC306
Renal and Cerebral Protection During High Risk Surgery for Renal Tumor With Atrial Caval and Hepatic
Extension
Cora Dong, M.D., Travis Dang, M.D., Armen Kara, M.D., Mariana Mogos, M.D., Peter Roffey, M.D.,
Duraiyah Thangathurai, M.D., LAC University of Southern California, Los Angeles, CA
A 73-year-old ASA IV man with multiple medical co-morbidities including COPD diabetes CAD previous
CVA and carotid artery stenosis underwent a right radical nephrectomy and inferior vena cavotomy with
cardiopulmonary bypass for a Level IV renal cell tumor. The tumor thrombus extended into the vena
cava hepatic vein and right atrium. In this case report we will discuss monitoring techniques used for this
case like cerebral oximetry and TEE. We will also discuss the use of nitroglycerin mannitol and dopamine
to preserve the function of the remaining kidney and to maintain adequate cerebral oxygenation.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
FA MC307
Acute Intraoperative Occlusion of the Endotracheal Tube in the Prone Patient
Erik Dong, D.O., Riverside County Regional Medical Center, Riverside, CA
45-year-old female for L5-S1 posterior spinal fusion undergoes general anesthesia. Smooth induction
and intubation with 7.0 ETT and positioned prone. One hour later acute rise in PIP from 14 to 38 tidal
volumes decreased from 500mL to 150mL. ETT suctioned circuit inspected fiberoptic bronchoscopy
utilized. SP02 dropped to low 80's. Patient turned supine. ETT exchanged with mucous plug occluding
the lumen of the ETT. SP02 increased patient repositioned to prone. Extubated without complication
when surgery completed.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC308
Ondansetron Induced Extrapyramidal Symptoms
Erik Dong, D.O., Riverside County Regional Medical Center, Moreno Valley, CA
37-year-old female coming for right femoral aortogram received general anesthesia. Smooth induction
and intubation with a 7.0 ETT. Surgery was uneventful. Ondansetron was given for post operative
nausea prophylaxsis. Half hour later patient demonstrates lip smacking akinesia akathesia and dystonia.
Patient becomes tachycardic to the 140's from a baseline of 80 and blood pressure increases to 150/100
from a baseline of 110/70. Diphenhydramine 50mg IV given. Symptoms improved within 5 minutes and
vitals also began to return to baseline.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC309
Lactic Acidosis of Unknown Etiology
Megan Dorsey, M.D., David Healy, M.D., University of Michigan, Ann Arbor, MI
41-year-old ASA 2 male presented for resection of vagal schwannoma. His only comorbidity was
hypertension. General anesthesia was induced with propofol fentanyl and vecuronium. Maintenance
was with isoflurane and sufentanil infusion. Rountine ABG revealed an elevated lactate peaking at 10.2
without further evidence of hypoperfusion. The lactic acidosis did not improve with volume loading. A
pyruvate level was similarly elevated confirming a type B lactic acidosis. The likely culprit was
epinephrine-soaked pledgets in the surgical field. By its affect on glucose metabolism epinephrine
increases circulating lactate without compromising tissue perfusion. The acidosis resolved and recovery
was uneventful.
Sunday, October 13
8:00 AM - 9:30 AM
FA MC310
A Case of Extreme Obesity and Severe Subglottic Tracheal Stenosis: Airway Management
Victoria Dotchev, M.D., Ramsis Ghaly, M.D., J. Stroger Jr. Hospital of Cook County, Chicago, IL
Postintubation tracheal stenosis has estimated incidence 4.9 cases/million/year in general population
whereas prevalence of obesity is 32%. Male age-22 BMI-53 presented in respiratory distress (PCO2-101)
for urgent tracheostomy. History: asthma two prior intubations symptomatic subglottic tracheal stenosis
(transverse dimension 6 mm 15 mm below true vocal cords length 19 mm). Inability to tolerate supine
position eliminated option of awake tracheostomy. Anesthetic management: awake fiberoptic
Copyright © 2013 American Society of Anesthesiologists
intubation with the tip of the ETT above the stenosis maintenance: 0.25 MAC of sevoflurane midazolam
fentanyl spontaneous respirations. Prevention of tracheal mucosal injury: high-volume pressure cuffs
maintain intracuff pressure <30mmHg appropriate size ETT.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC311
Airway Management With a Mediastinal Mass: A Case Report of a Difficult Airway in a Pediatric
Patient
Amir Batman, Amir Butt, M.B. B.S., Alberto De-Armendi, M.D., M.B.A., University of Oklahoma,
Oklahoma City, OK
A 12-year-old obese patient with an acquired anterior mediastinal mass and a difficult airway causing
tracheal obstruction was scheduled for a supraclavicular biopsy. Our anesthesia team devised a
sequentially algorithmic plan of action to manage any encountered complications allowing us to escalate
the invasiveness of care in a stepwise fashion to counter any impediments in securing an airway. Our
team resorted to MAC sedation leading to a comfortable patient and a successful operation. We opted
to avoid general anesthesia to side step potential difficult intubation difficulties as well as decrease the
risk of post procedural nausea and aspiration.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC312
Fiberscope Access To Larynx And Trachea Via A Supraglottic Device In An MPS1 Child With A Difficult
Airway
David Beebe, M.D., University of Minnesota Medical School, Minneapolis, MN, Kumar Belani, M.B. B.S.,
Amplatz Children's Hospital, Minneapolis, MN
This challenging case describes a 5-year-old with advanced MPS1H disease requiring anesthesia for
multiple procedures. During a previous attempt he could not be intubated by an anesthesiologist for
tonsillectomy and adenoidectomy. We used sevoflurane for induction and i.v. placement and while the
patient was breathing spontaneously continued anesthesia with propofol infusion during which time an
AirQ® LMA was placed. A pediatric fiberscope was preloaded with an endotracheal tube and successfully
introduced into the trachea via the supraglottic airway that allowed continued spontaneous breathing.
The child was then successfully intubated. The procedures were completed and the child was
successfully extubated.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC313
Neuraxial Anesthesia in the Presence of Clinical Anticoagulation: What Are Our Options for Pediatric
Patients?
Ralph Beltran, M.D., Tarun Bhalla, M.D., Senthil Krishna, M.D., Joseph Tobias, M.D., Nationwide
Childrens Hospital/Dept of Anesthesiology, Columbus, OH
Our case was an 11-year-old girl with a history of Ewing's sarcoma. She presented for re-operationof
limb fixation and muscle flap with contralateral fibular bone harvesting. Intraoperatively an epidural
catheter was placed for postoperative pain management. Seven hours into the surgery an acute arterial
thrombosis occurred during vascular anastomosis of the muscle flap requiring emergent anticoagulation
with heparin. Postoperatively the heparin infusion was discontinued and enoxaparin (1 mg/kg every 12
Copyright © 2013 American Society of Anesthesiologists
hours) initiated. The epidural catheter was removed uneventfully on POD#5 after the enoxaparin had
been held for a 24-hour period
Sunday, October 13
8:00 AM - 9:30 AM
PD MC314
Anesthetic Management in Patient With Marfans Syndrome Diffcult Airway Full Stomach With
Significant Right Sided Spontaneous Pneumothorax
Angelina Bhandari, M.D., Javier Joglar, M.D., Driscoll's Children Hospital/ UTMB, Corpus Christi, TX
A 17-year-old cachetic male with hx of Marfan syndrome severe asthma Mitral Valve prolapse aortic
root dilatation pectus carinatum who presents to the ER with sudden onset of chest pain. CXR reveals
90% Right sided spontaneous pneumothorax. The patient had short TM distance about 4 cm and NPO
status was NOT met prior to arriving to the OR. He was also on a partial rebreather. The surgeon
requested strongly to do be done under GA. Mask anestheisa instituted and spontaneous ventilation
maintained. Addition of IV ketamine also used. First attempt revealed a grade 4 view.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC315
Cardiac Toxicity Associated With Bupivacaine Penile Blockade in an Infant
Richard Blum, M.D., Charles Nargozian, M.D., Alfonso Casta, M.D., Sharon Redd, M.D., David Waisel,
M.D., Boston Children's Hospital, Boston, MA
A former premature six-month-old presented for circumcision. Following inhalation induction and
planned spontaneous mask ventilation the urology team placed a penile block using with 1 ml/kg of
0.25% bupivacaine. Within 1-2 minutes the patient's HR and BP dropped to 90's and 40's/20's.
Spontaneous ventilation ceased while ECG demonstrated ST-T wave abnormalities and wide complex
sinus rhythm. Controlled ventilation was started and a weak femoral pulse led to 4 minutes of chest
compressions. 1.5 ml/kg of 20% intralipid was administered over about 90 seconds with a prompt return
of stable vital signs and improvement in ECG changes.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC316
Anesthesia for a Combative Child With DiGeorge Syndrome and Autism Requiring Sedation for
Frequent Immunoglobulin Infusion
Kadia Bundu, Shridevi Pandya Shah, M.D., UMDNJ-NJMS, Newark, NJ
A case of a nine-year-old boy with severe nonverbal autism and 22Q11.2 microdeletion syndrome. Due
to panhypogammaglobulinemia and recurrent sinopulmonary infection he receives immunoglobulin
infusion therapy every three months with each session lasting six hours under sedation. He has verbal
apraxia sensory disintegration and seizure disorder. He requires premedication and sedation due to high
anxiety and severe combative behavior. Children with impaired communication skills and restricted
behaviors can be uncooperative and difficult to manage perioperatively. A care plan for types and route
of premedication use of restraint choice of induction technique and recovery plan needs to be
established.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC317
Risks of Transfusions in Neonates and Infants With Chromosomal Abnormalities Undergoing Cardiac
Surgery.
Lisa Caplan, Emad Mossad, M.D., Texas Children's Hospital, Houston, TX
A 10-month-old with a ventricular septal defect required anesthesia for surgical repair. As per our
institutional practice only infants less than one month of age routinely receive irradiated and
cytomegalovirus (CMV) negative packed red blood cells for the cardiopulmonary bypass (CPB) prime.
After median sternotomy was performed the thymus was absent in a patient who had no pre surgical
genetics testing. Due to the concern for graft versus host disease the entire cardiopulmonary bypass
circuit required repriming with CMV negative irradiated blood. The CMA which was sent intraoperatively
did confirm a 22q11 deletion several days later.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC318
Anesthetic Challenges in a 7-Year-Old Boy With Prader-Willi Syndrome Who Presented for Eye Muscle
Surgery
Daniel Carinci, M.D., NYU Langone Medical Center, New York, NY
7-year-old boy with Prader-Willi syndrome (BMI of 39) presented for eye muscle surgery. He was
admitted the night prior; noisy breathing episodes of apnea and desaturation to upper 80s were noted.
After mask induction patient desaturated to low 80s requiring two-man technique to maintain adequate
ventilation. Glidescope revealed a grade 2 view and an ETT was secured. After extubation patient with
airway obstruction and saturations as low as 80% requiring nasal trumpet and chin lift. On arrival to
PACU patient lethargic with SpO2s remaining around 90%. He was admitted to the PICU for monitoring
and discharged the next day.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC319
Ex Utero Intrapartum Treatment to Resection of a Bronchogenic Cyst Causing Airway Compression
Debnath Chatterjee, M.D., Children's Hospital Colorado, Aurora, CO, Joy Hawkins, M.D., University of
Colorado Hospital, Aurora, CO, Henry Galan, M.D., Timothy Crombleholme, M.D., Colorado Fetal Care
Center/Colorado Institute for Maternal & Fetal Health, Aurora, CO
A 28-year-old female with a singleton pregnancy was referred to us for evaluation of a fetal
bronchogenic cyst at the level of the carina that was progressively enlarging and compressing the left
main stem bronchus with resultant hyperinflation of the entire left lung and rightward mediastinal shift.
The management options included conventional delivery and neonatal resuscitation EXIT-to-ECMO
followed by thoracotomy and EXIT-to-resection. An EXIT-to-resection of the fetal bronchogenic cyst via a
fetal thoracotomy was performed at 36 weeks gestational age. The EXIT-to-resection strategy allowed a
planned resection of a large bronchogenic cyst circumventing a potentially complicated airway
emergency at birth.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC320
Management of Anesthesia in a Case of Mediastinal Mass Compressing the Trachea in a Pediatric
Patient
Minji Cho, M.D., Jadwiga Bednarczyk, M.D., SUNY Upstate Medical University, Syracuse, NY
A 3-year-old previously healthy male was admitted to the hospital for workup of mediastinal mass. He
initially presented to the primary physician with dyspnea and was given albuterol without improvement.
Subsequently he presented to the ER and CT scan showed a mediastinal mass compressing the trachea.
A diagnostic axillary node biopsy was planned. The need to keep the airway patent precluded general
anesthesia. The decision was made to use sedation with ketamine and distraction in combination with
local anesthetic cream and infiltration. The patient tolerated the procedure well while maintaining
spontaneous ventilation.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC321
A Case of Anaphylactic Shock to Albumin During T2-L2 Spinal Fusion in a Prone Pediatric Patient
Maggie Chou, M.D., Columbia University New York Presbyterian, New York, NY, Manon Hache, M.D.,
Morgan Stanley Children's Hospital of New York, New York, NY
Anaphylaxis in a prone patient presents challenges for the anesthesiologist: diagnosis identifying the
triggering agent and particularly medication administration and resuscitation. The most common
triggering agents are antibiotics neuromuscular blockers and latex. There have been only a handful of
reports of anaphylaxis to albumin and none in pediatric patients thus far. We describe the first reported
case of anaphylaxis to albumin in a 15-year-old male patient undergoing T2-L2 spinal fusion and discuss
the treatment options in a prone patient and the decision to halt or continue surgery.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC322
Emergent Surgery in a Child With Diabetic Ketoacidosis
Melissa Coleman, M.D., Sanjib Adhikary, M.D., Uma Parekh, M.D., Pennsylvania State University,
Hershey, PA
A 5-year-old girl weighing 27 kg with diabetic ketoacidosis was scheduled for emergent laparotomy after
worsening abdominal pain increasing abdominal circumference persistent metabolic acidosis and portal
gas on abdominal x-ray. Intravenous induction was done with fentanyl lidocaine propofol and
rocuronium. Five minutes after intubation the patient decompensated into PEA and progressed to
ventricular fibrillation. ACLS was initiated and the abdomen was simultaneously decompressed with a
midline incision. Spontaneous circulation returned after approximately 40 minutes. The patient was
transported to PICU for further stabilization before surgery. Propofol in an acidotic patient with
abdominal compartment syndrome caused this adverse event.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC323
Life Threatening Croup - And Nowhere To Go
Paul Coleman, D.O., Sutter Gould Medical Group, Modesto, CA
There is nothing like practicing in a community hospital and receiving The Page-Hi doctor, there is a sixmonth-old morbidly obese infant in the ER with life threatening croup in respiratory failure that needs
intubation now. Oh, by the way two experienced ER doctors can't intubate the baby. What ensues is a
day long process including ER intubation attempts, two trips to the OR for airway management and the
nightmare of coordinating transport of an infant too unstable for RN/EMT helicopter transport, no ICU
beds available at any nearby paediatric hospitals and a subsequent two week intubation.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC324
5-year-old Girl With HB Southampton Status Post-Splenectomy Diagnosed With Gall Bladder Stones
Presents for Laparoscopic Cholecystectomy
Andrew Costandi, M.D., Allyson Morman, M.D., Mohamed Mahmoud, M.D., Cincinnati Children's
Hospital, Cincinnati, OH
A 5-year-old girl diagnosed with Hb Southampton presented for splenectomy due to numerous episodes
of hemolytic anemia. Procedure was performed uneventfully. Three months later the patient was
diagnosed with pigment gallstones and presented for laparoscopic cholecystectomy. After induction of
general anesthesia via facemask oxygen saturation (Spo2) values of 85-95% were noted. Arterial blood
gas showed arterial oxygen saturation = 100% and PaO2 of 376 mmHg. The anesthesiologist should be
aware that the pulse oximeter is not an accurate monitor for patients with Hb Southampton.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC325
Don't Burn Your Bridges: Anesthetic Considerations for a Pediatric Patient With Anterior Mediastinal
Mass
Craig Cummings, M.D., Lynn Rusy, M.D., Medical College of Wisconsin, Milwaukee, WI
15-year-old AA female with large anterior mediastinal mass. CT demonstrating narrow left PA and
mainstem bronchus partially collapsed left lung with significant effusion and mass effect on proximal
descending aorta and SVC. Tamponade physiology evident on echocardiogram. Worsening respiratory
distress refractory hypoxia and increasing facial edema in ICU concerning for SVC syndrome.
Transported to OR for intubation otolaryngology present with rigid bronchoscope. Careful titration of
midazolam and ketamine. Spontaneous ventilation maintained in semi-upright position gentle
assistance via increasing positive pressure mask ventilation stable hemodynamics. Rocuronium to
facilitate uneventful intubation via direct laryngoscopy. Extubation following reduced tumor burden
with steroid therapy.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC326
Perioperative Considerations in Children With Long QT Syndrome: A Case Report
Nicholas Davis, M.D., New York Presbyterian Hospital-Columbia University, New York, NY
Patient is an 8-year-old boy with a history of long QT syndrome and two cardiac arrests in the past who
presented for dental extractions under general anesthesia. Patient was currently undergoing evaluation
for implantable cardiac defibrillator and carried a portable defibrillator in the interim. The case
proceeded uneventfully. Perioperative management of children with long QT syndrome is discussed
including pathophysiology and medication recommendations.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC327
Anesthetic Challenge: An 8-Month-Old With Severe Pulmonary Hypertension Undergoing PEG Tube
Placement
Jose De Leon, Farajallah Habib, M.D., Stephen Heard, M.D., University of Massachusetts, Worcester, MA
8-month-old born at 26 4/7 weeks via primary C-section due to preterm incompetent preterm labor and
breech presentation presenting for PEG tube placement. His hospital course had been complicated by
bronchopulmonary dysplasia (48 ventilator days) severe pulmonary hypertension (treated with
furosemide chlorothiazide and sildenafil) small restrictive PDA moderate ASD with left to right flow and
lack of intravenous access. Due to a very liable volume cardiovascular/pulmonary status and hypoxemia
requiring oxygen supplementation an anesthetic plan proved to be a challenge. A neuroaxial and
sedation anesthetic was for the procedure. The procedure and postoperative course were a success.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC328
Wait! There's a Second Fistula Here: A Case of Double Tracheoesophageal Fistulas Identified
Intraoperatively
Reza Mohammad, M.D., Francina Del Pino, M.D., Golnaz Alemzadeh, M.D., John Stroger Hospital of Cook
County, Chicago, IL
We present a case of a neonate who underwent right thoracotomy for Tracheoesophageal Fistula repair.
The fistula was identified soon after birth by inability to pass a nasogastric tube and a chest x-ray
showing coiling of the tube in the esophagus. Mask induction was used and endotracheal intubation was
performed while keeping spontaneous breathing. After ligation of the fistula while checking for any
possible leak by applying positive pressure ventilation a second fistula was identified intraoperatively.
Both fistulas were ligated successfully with no leak. The proximal and distal ends of the esophagus were
primarily anastomosed. Recovery was uneventful.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC329
Case Report: Paediatric Cardiac Surgery With Cold Agglutinins Disease
Fiona Desmond, M.B. B.Ch., William Casey, M.B. B.Ch., Our Lady's Hospital for Sick Children, Dublin,
Ireland
Cold agglutinins present in the blood can lead to intravascular thrombosis together with complement
activation and subsequent haemolysis. This is usually not clinically significant but can become more
Copyright © 2013 American Society of Anesthesiologists
applicable when hypothermia develops when for example someone undergoes cardiopulmonary bypass
and cardiac surgery. We describe the case of a one-year-old child who underwent cardiac surgery where
intra-operatively it was discovered that the child had a high cold agglutinin titre. The management of the
case is discussed together with the change in guidelines we implemented as a result.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC330
The Use of Dexmedetomidine for a Pediatric Patient With Mastocytosis
Fred Dooley, Joy Allee, M.D., Sonia Deshmukh, M.D., Giuseppe Giuratrabocchetta, M.D., University of
Florida, Gainesville, FL
Mastocytosis is most common in children and presents with symptoms ranging from headache to
cardiovascular collapse and death during anesthesia. Routinely used anesthetic agents may be
associated with mast cell degranulation and symptom provocation but no known documentation of the
use of dexmedetomidine exists in these patients. This drug offers no tie to mast cell degranulation a safe
cardiorespiratory profile reduced anesthetic requirements and analgesic needs making it a superior
agent. Here we report our use of dexmedetomidine in a pediatric patient with known mastocytosis
presenting for elective surgery.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC331
20-Year-Old With an Unrepaired Single Ventricle With Amiodarone Induced Thyrotoxicosis for
Emergent Thyroidectomy
Laura Downey, M.D., David Clendenin, M.D., Boston Children's Hospital, Boston, MA
We present the case of a 20-year-old female with history of unrepaired single right ventricle Dtransposition and mitral/pulmonary atresia who was admitted with persistent atrial flutter and
worsening cardiac function from amiodarone induced thyrotoxicosis. Despite maximal medical therapy
she continued to have uncontrolled thyrotoxicosis and required emergent thyroidectomy. After
induction of general endotracheal anesthesia with fentanyl vecuronium and etomidate the patient
tolerated cardioversion and maintained sinus rhythm for 90 minutes before reverting back to atrial
flutter. She underwent an uncomplicated thyroidectomy with isoflurane and fentanyl anesthetic. She
was extubated after the procedure and transferred to the ICU without complication.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC332
A Case Report: Anesthetic Management of EXIT Procedure for Fetal Airway Anomaly
Mical Duvall, Brian Gelpi, M.D., Shilpadevi Patil, M.D., Hoa Luu, M.D., LSUHSC Shreveport, Shreveport, LA
The Exit Procedure decreases fetal morbidity and mortality with the diagnosis of fetal airway anomaly.
The goals are; to provide for uterine relaxation and maintain placental blood flow utilizing deep
inhalational anesthesia and to reduce maternal hypotension with medications that reduce maternal
blood loss. We present a 19 -year-old G2P0 female with an agnathic fetus found on routine screening.
The exit procedure was decided upon as the only option for delivery. The patient was intubated
cesarean section performed and fetus delivered. The placenta supported the fetus during the
tracheotomy. After successful tracheotomy the umbilical cord was clamped and placenta delivered.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC333
Airway Management in a TE Fistula Repair in a Newborn With Smith-Lemli-Opitz Syndrome
Allen Eckhoff, M.D., Barbara Hurlbert, M.D., University of Nebraska Medical Center, Omaha, NE
Smith-Lemli-Opitz syndrome is an autosomal recessive disorder that occurs in 1:60 000 live births. It
occurs from an inborn error of cholesterol biosynthesis. The congenital abnormalities that are
associated with this syndrome provide difficulty in mask ventilation and intubation. This case
presentation is a TE fistula repair in a 3-day-old newborn with Smith-Lemli-Opitz syndrome. The patient
had microcephaly and micrognathia. The patient was intubated under general anesthesia with video
laryngoscopy while the infant was spontaneously breathing. The endotracheal tube was right mainstemmed and then pulled back until bilateral breath sounds were auscultated. The patient was
successfully ventilated.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC334
Anesthetic Management of Pediatric Patients With Stuve Wiedemann Syndrome
Odinakachukwu Ehie, M.D., Anita Patel, M.D., New York University Langone Medical Center, New York
City, NY
A 56-day-old infant male with Stuve Wiedemann syndrome and myoclonic seizures was scheduled for
laparoscopic G-tube placement given his high risk of aspiration. He was born with a history of
respiratory insufficiency requiring intubation at birth along with an echo that estimated PAS pressures
around 30 mmHg (2/3 systolic pressure). He was subsequently weaned to FiO2 of 35% and extubated
while managed with nitric oxide. Given the high risk of a difficult airway ENT performed a laryngoscopy
pre-operatively to confirm no need for a tracheostomy. The patient then underwent a rapid sequence
induction and was intubated with no intraoperative complications.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC335
Anesthetic Management of Tracheoesophageal Fistula/Esophageal Atresia Repair Complicated by a
Vascular Ring and Congenital Heart Disease
Justin Farmer, M.D., Michael Sroka, M.D., Wake Forest, Winston Salem, NC
We present a 3-day-old female born at 36 weeks gestation found to have a tracheoesophageal fistula
with esophageal atresia after failure of orogastric tube placement. Additional workup revealed a right
aortic arch patent ductus arteriosus and complete vascular ring. The patient was brought to the OR
induced and intubated. Flexible bronchoscopy confirmed ETT placement and pericarinal TEF. A second
intravenous line and arterial line were placed. Anesthetic maintenance was continued with sevoflurane
and rocuronium. Surgery proceeded with vascular ring and TEF ligation in addition to gastrostomy tube.
The patient was returned to the intensive care unit intubated.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC336
Focus on a Known Difficult Airway Results in Sevoflurane Exposure in an MH-Susceptible Patient
Tanna Ferrara, D.O., Devika Singh, M.D., Ronald Litman, D.O., Children's Hospital of Philadelphia,
Philadelphia, PA
A 6-year-old female with difficult airway neuromuscular scoliosis thoracic insufficiency syndrome
(nightly bipap 14/6 x 8) and known RYR-1 receptor mutation was scheduled for VEPTR expansion x 2. A
primary and backup plan for intubation were readied in the OR. The room was set for MH precautions
with activated charcoal filters in line with the inhalation and exhalation ventilator tubing but the tape
and sign across the inhaled agents was missed by all members of the anesthesia team. We discuss the
care of this patient post-op after inadvertent Sevoflurane exposure and the importance of safety checks
in the OR.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC338
Anesthetic Management of an Emergency Case for a Patient With Trisomy 7p: A Very Rare Genetic
Abnormality.
Melissa Flanigan, D.O., Eric Massey, M.D., Monica Ata, D.O., Kristen Dragan, M.D., West Virginia
University, Morgantown, WV
14-year-old female presented to our facility with rapidly deteriorating respiratory status and abdominal
compartment syndrome. Past medical history included a partial Trisomy 7p and all its sequelae and an
unspecified psychotic disorder. A very brief preoperative exam showed a nonverbal patient with no
obvious airway abnormality and no cardiac issues. Emergently she was taken to the operating room for
an exploratory laparotomy emphasizing her multiple abdominal issues. A basic anesthetic plan along
with intravenous resuscitation was initiated with adjustments for her rare abnormality.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC339
Anesthetic Management of Pediatric Patients With Trifunctional Protein Deficiency
Stephen Flynn, M.D., Tara Wenger, M.D., Can Ficicioglu, M.D., Ronald Litman, D.O., The Children's
Hospital of Philadelphia, Philadelphia, PA
Trifunctional protein (TFP) is responsible for metabolism of long chain fatty acids (FA). During fasting or
stress buildup of FA in muscle of TFP deficient patients can result in detergent-like reactions inducing
rhabdomyolysis. Although mechanisms for rhabdomyolysis in TFP deficiency are different than more
common perioperative forms of rhabdomyolysis (e.g. muscular dystrophies) many anesthesiologists
avoid volatile anesthetics and succinylcholine for fear of causing rhabdomyolysis. We report three TFP
deficient children receiving multiple anesthetics. CK levels prior to and following anesthetics(total
n=26)were charted and analyzed to determine if there existed any association between CK level and
TIVA vs. volatile general anesthesia.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
PD MC340
Anisocoria in a Four Month Old Child Under General Anesthesia
Daniel Ford, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA, Thomas Chalifoux, M.D.,
University of Pittsburgh School of Medicine, Pittsburgh, PA
The appearance of anisocoria in the perioperative period is alarming as it may represent serious
neurologic pathology. Although this finding is rare particularly in the pediatric population the
anesthesiologist should be able to recognize anisocoria understand the etiology and potential
differential diagnoses and begin an appropriate evaluation. Balancing the priorities of the anesthetic
operative procedure and workup of unexpected anisocoria can be challenging. We report a case of
anisocoria in a four-month-old child under general anesthesia for an elective inguinal hernia repair and
review our approach to this diagnostic dilemma.
Sunday, October 13
8:00 AM - 9:30 AM
PD MC341
Congenital Lipomatosis: A Rare Condition Contributing to a Challenging Pediatric Airway
Anne Savarese, M.D., Jessica Galey, M.D., University of Maryland School of Medicine, Baltimore, MD
We present a 3-year-old boy with congenital lipomatosis and a large facial tumor presenting for radical
resection and reconstruction. He had significant right sided facial swelling enlargement of the right
hemimandible maxilla zygoma as well as tonsil parotid and submandibular glands. The contours of his
mouth were distorted and his trachea was significantly deviated. We secured his airway while
maintaining spontaneous ventilation using nasal fiberoptic bronchoscopy assisted with a video fiberoptic
laryngoscope to obtain a clear view of the glottis. The surgery proceeded uneventfully he was extubated
in the OR and discharged home on POD 3.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC342
Intraoperative Cerebral Vascular Accident During Spinal Surgery
Carlos Garcia, M.D., Dimiter Arnaudov, M.D., LAC+USC Medical Center, Los Angeles, CA
This case involves a 64-year-old male who presented to the operating room for anterior cervical
decompression and fusion for unstable cervical spine. After a smooth induction he was intubated using a
pediatric fiberoptic bronchoscope. He was place in mayfield pins and cervical traction. During the
dissection of the neck the patient lost somatosensory and motor evoked potentials on the right side of
his body. The procedure was cancelled and the patient was taken to MRI which was initially negative.
Repeat MRI showed an internal capsule infarct. He had complete right sided hemiplegia and
hyperalgesia resulting from the infarct.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC343
Anesthetic Implications of a Carotid Body Tumor Resection
Mauricio Garcia Jacques, M.D., Robina Matyal, M.D., Feroze Mahmood, M.D., BIDMC, Boston, MA
43-year-old F who presented recurrent episodes of loss of balance and shaking with associated slurred
speech and confusion. She only recalled the shaking and loss of balance as presenting symptoms. The
patient was found to have bilateral carotid body tumors left larger than right. Her laboratory work up
Copyright © 2013 American Society of Anesthesiologists
was negative for carcinoid or pheochromocytoma. Imaging revealed highly vascularized masses from C2C4 around the internal carotid. Balloon occlusion test developed delayed areas of left sided brain
ischemia. After tumor embolization she underwent successful excision of the left sided mass sparing the
internal carotid and the laryngeal nerves.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC344
Emergent Craniotomy in a Pregnant Patient With Rapidly Rising Intracranial Pressure
Danielle Gluck, M.D., Irene Osborne, M.D., Mt. Sinai Hospital, New York, NY
A 37-year-old female with no PMH P3013 at 22 weeks gestation presented with 2 weeks of worsening
headaches emesis lethargy with left upper extremity weakness and photophobia. On exam patient had
slurred speech left homonymous hemianopsia left hemiparesis and hemisensory neglect. MRI showed a
large partially cystic mass in right temperoparietal region with midline shift uncal herniation and right
mid brain compression. After discussion with patient OB-GYN neurosurgery and anesthesia decision was
made to proceed with right temporal craniotomy and tumor resection. This patient poses concerns
including management of pregnant patient for emergent non-obstetric surgery with increasing
intracranial pressure.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC345
Anesthetic Considerations for a Patient With an Implanted Neurostimulator Device
Stephen Goldberg, M.D., Tara Kennedy, M.D., Thomas Jefferson Univerity Hospital, Philadelphia, PA
A paucity of information exists in the literature regarding the intraoperative management of deep brain
stimulators. A number of special concerns for implanted neurostimulators exist specifically the risk for
interference with routinely used devices such as electrocardiography electrocautery cardiac pacemakers
and external defibrillators and MRI. We will discuss the perioperative management used to face these
challenges in two cases; a 57-year-old male with DBS placed for essential tremors that underwent Right
bronchoscopy and video assisted thoracic surgery and a 78-year-old female with DBS placed for
refractory Parkinson's disease who underwent open repair of a nasal fracture.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC346
Use of Ketamine as an Induction Agent in Craniotomy for Traumatic Brain Injury
Michelle Gonta, M.D., Corey Scher, M.D., NYU School of Medicine/Bellevue Hospital Center, New York,
NY
20-year-old healthy female s/p multiple stab wounds to the torso and head taken emergently to
operating room for craniotomy and exploration of stab wound to skull and washout and closure of stab
wounds to torso. Prior to induction patient was noted to be somewhat hypotensive with SBP 80s-90s
and decision was made to use ketamine for induction to improve hemodynamics. Rapid sequence
intubation performed without difficulty. BP following induction was 101/72. ICP remained stable
intraoperatively both by neurosurgeon's visual assessment and ICP monitoring. Discussion will focus on
newer studies showing benefits of using ketamine in traumatic brain injury.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
NA MC347
Emergent Cesarean Section and Endovascular Coiling in a Parturient With Ruptured Cerebral
Aneurysm
Emily Hattrup, M.D., Amy Duhachek-Stapelman, M.D., University of Nebraska Medical Center, Omaha,
NE
Subarachnoid hemorrhage during pregnancy is a rare event but carries with it a grave prognosis. The
anesthetic management of such a patient must encompass principles of both obstetric and
neuroanesthesia for the safety of the mother and fetus. Presented here is the management of a 33year-old female with twin gestation at 34 weeks and ruptured intracranial aneurysm requiring emergent
endovascular coiling. Additional discussion will focus on the challenges faced after a sustained
deceleration in fetal heart tones led to emergent cesarean delivery immediately following induction of
anesthesia.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC348
Stroke Prevention During Basilar Artery Stenting for Symptomatic Occlusion
Mada Helou, Ehab Farag, M.D., Cleveland Clinic Foundation, Cleveland, OH
73-year-old M with PMHx of basilar artery stenosis stroke severe aortic stenosis (peak 68 mmHg) HTN
CHF nephrolithiasis presents with syncopal episode and dysarthria. Admitted for percutaneous
transcatheter stenting of basilar artery occlusion distal to the anterior inferior cerebellar arteries with
lack of collateral flow due to diffuse disease in the circle of Willis. Induction maintenance with
midazolam / lidocaine / remifentanil / rocuronium. Norepinephrine started with induction to prevent
low blood pressure and ischemic stroke. Chosen for its ionotropic properties & minimal effect on
myocardial oxygen consumption; was continuously escalated to maintain cerebral perfusion pressure &
ensure successful outcome.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC349
Intubating Laryngeal Mask Airway Placed in Awake Morbidly Obese Patient With Ankylosing
Spondylitis and Unstable Thoracic Spine
Abbey Herman, M.D., Michael Mahla, M.D., University of Florida, Gainesville, FL
A 65-year-old female with history of morbid obesity and ankylosing spondylitis presented for thoracic
spine fusion after suffering a fall that resulted in T10 and T11 compression fractures. Patient positioning
for airway management was difficult secondary to her unstable thoracic spine a body mass index of 58
and limited mobility of cervical spine. An intubating LMA was placed in the awake patient and after
passing the ETT through the LMA the entire LMA and ETT device was secured and remained in place
throughout surgery. SSEP and MEP monitoring were used before and after prone positioning and
intraoperatively.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
NA MC350
Rare Type of Arnold Chiari Malformation (Type III) With Large Encephlomeningocele in Stridor 3
Month Old Boy
Nattakhan Hoontanee, Ramathibodi Hospital, Bangkok, Thailand
Three-month-old boy who presented by 10*15 cms.mass at occiput and aspirated pneumonia with
remarkable inspiratory stridor ( both TVC paralysis ) with supraspinal nocth retraction with ASD
secondum has been diagnosed to ACM type III and evaluated to ASA PS class IV. Spontaneous breathing
with sevoflurane with oxygen with air upto 2.5% were used for induction and intubation (with
vediolaryngoscope) in neutral positon for preventing further neuro deficits. We maintenaced case by
atracurium fentanyl sevoflrane standarded monitoring A-line( CPP DTX ABG) and CVP. When repaired
meningocele prcedure finished we could extubate ETT with no complication.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC351
The Anesthetic Concerns of Cervical Vagal Schwannomas
Grace Huang, M.D., Mount Sinai, New York, NY
Schwannomas can occur anywhere in the body and between 25-45% of reported cases arise in the head
and neck. Schwannomas can arise from various origins. Cervical vagal schwannomas are rare
parapharyngeal neoplasms that are included in a differential diagnosis that is important to understand
because of the varied pathophysiological consequences. Surgical manipulation of vagal schwannomas
can cause severe bradycardia and in some cases asystole. Furthermore resection of this tumor can result
in deficits such as vocal cord palsy. Thus it is important to review the implications of this subset of head
and neck masses.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC352
Intraoperative Diagnosis and Management of Dapsone Induced Methemoglobinemia in a Patient
Undergoing Intraoperative MRI Guided Craniotomy for Tumor
Matthew Hulse, M.D., Athir Morad, M.D., J.P. Ouanes, M.D., Johns Hopkins Hospital, Baltimore, MD
A 32-year-old female presented for craniotomy to resect recurrent glioblastoma multiformans (GBM).
During the patient's preoperative chemotherapy treatment she was placed on PCP prophylaxis with
diamino-diphenyl sulfone (Dapsone). On the day of surgery physical examination findings revealed
cyanosis of the patient's digits but were attributed to preexisting Raynaud's disease. Pulse oximetry
intermittently revealed saturations >90%. After induction of general anesthesia pulse oximetry more
consistently registered saturations at 85%. An arterial blood sample demonstrated a methemoglobin
concentration of 16.7%. The methemoglobenemia was treated with 1mg/kg of 1% methylene blue and
serial arterial blood samples confirmed resolution of the episode.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
NA MC353
Anesthetic Management of Moyamoya Disease
Yashar Ilkhchoui, M.D., Pramod Panikkath, M.D., University of New Mexico School of Medicine,
Albuquerque, NM
We present a 49-year-old woman who was diagnosed to have moyamoya disease since her childhood.
Her past medical history was also significant for hypertension dyslipidemia hypothyroidism and
fibromyalgia. She had presented with multiple episodes of neurologic deficits in her life time compatible
with cerebral infarctions. She was planned for a revascularization surgery including left superficial
temporal artery to left middle cerebral artery bypass. Perioperative risk factors affecting morbidity of
this particular condition and anesthetic management to decrease these risks are going to be discussed in
this case report.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC354
66-year-old Female With Deep Brain Stimulator Presenting for Electroconvulsive Therapy
Yashar Ilkhchoui, M.D., Eli Torgeson, M.D., University of New Mexico, Albuquerque, NM
We report the case of a 66-year-old woman with past medical history of major depressive disorer
diabetes mellitus type 2 end-stage kidney disease kidney transplant essential tremor for which she
underwent a deep brain stimulator (DBS) a year ago. She presented with worsening depression with
catatonic features and was elected for electroconvulsive therapy (ECT). Her deep brain stimulator was
turned off a week prior to ECT to avoid any potential interference between ECT electrical impulse and
DBS electrodes. For ECT sessions general anethesia was induced with methohexital and succinylcholine
and entire procedure and recovery were uneventful.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC355
Anesthetic Management for Human Spinal Cord Schwann Cell Transplantation
Craig Jabaley, M.D., Thomas Fuhrman, M.D., Jackson Memorial Hospital/University of Miami, Miami, FL
Herein we describe the anesthetic management for the first enrollee in a Phase 1 clinical trial of
autologous Schwann cell transplantation following acute thoracic spinal cord injury. A motionless
surgical field is required during intramedullary injection which necessitates prolonged apnea. Following
endotracheal intubation maintenance of general anesthesia with intravenous versus volatile agents
demonstrated a minor improvement in PaO2. CPAP was used to facilitate apneic oxygenation with a
concomitant linear increase in PaCO2 which the patient tolerated well. Our experience reaffirms the
minimal impact of volatile agents on hypoxic pulmonary vasoconstriction and highlights the modern
utility of apneic oxygenation.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
8:00 AM - 9:30 AM
NA MC356
Milrinone and Norepinephrine Infusion for Emergent Craniectomy in Patient With VSD/Eisenmenger's
Syndrome
Beverly Jong, M.D., Ehab Farag, M.D., Cleveland Clinic, Cleveland, OH
28-year-old female with an uncorrected VSD and subsequent Eisenmenger's Syndrome baseline SaO2
80% on 2L home O2 CVA in 2003 on warfarin and recent sinusitis presented with left-sided weakness
and slurred speech. She was found to have a ring-enhancing mass with midline shift and uncal
herniation on head CT and emergently taken to the OR for decompression of suspected brain abscess.
Anesthesia was induced with etomidate fentanyl and esmolol. Milrinone and norepinephrine infusions
were started to maintain cardiac output and SVR during maintenance of anesthesia with sevoflurane
and remifentanil infusion.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC357
Femur Surgery in Multi-System Atrophy
Danny Joseph, Amar Talati, Stanlies D'Souza, Baystate Medical Center, Springfield, MA
A 67-year-old female with a history of multi-system atrophy and dysautonomia who was managed for
right femur open reduction internal fixation with a continuous spinal catheter. The patient was brought
to the operating room and initially a right radial arterial line was placed. Then a continuous spinal
catheter was achieved by threading an epidural catheter through an 18 guage Touhy needle into the
intrathecal space. Subsequently 0.25% bupivicaine local anesthetic was slowly titrated in 1 ml
increments with periodic assessment of the sensory level. Titrating intrathecal local anesthetic yielded
surgical anesthesia to the T9 dermatome without vascular compromise.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC358
Cortical-Subcortical Intraparenchymal Hematoma: A Complication of Cranioplasty Surgery
Yenabi Keflemariam, Chizoba Mosieri, M.D., LSUHSC-Shreveport, Shreveport, LA
Patient was suspected of having an acute episode of Cushing's Reflex during General endotracheal
anesthesia as noted by severe hypertension and bradycardia. Appropriate medical management was
instituted and intraoperatively patient was noted to have acute bleeding into an indwelling
ventriculoperitoneal shunt. Upon emergence patient was noted to have new-onset left sided
hemiparesis and was diagnosed with a cortical-subcortical intraparenchymal hematoma. Patient was
taken back to the operating room and had the hematoma evacuated. Post-operative course
demonstrated patient regained majority of left sided upper and lower extremity function.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC359
Posterior Reversible Encephalopathy Syndrome
Suzanne Kellman, M.D., Jennifer Hofer, M.D., The University of Chicago, Chicago, IL
21F at 37 weeks gestation is admitted after a seizure with altered mental status and severe
hypertension and taken to the operating room for a stat c-section. She is found to have Posterior
Reversible Encephalopathy Syndrome (PRES) and after delivery she is started on anticonvulsant and
Copyright © 2013 American Society of Anesthesiologists
antihypertensive therapy with complete resolution of her neurological symptoms. PRES is characterized
by bilateral symmetrical vasogenic edema in the posterior parietal lobes identifiable on MRI. If
diagnosed early patients can have a full recovery and avoid complications such as permanent neurologic
impairment or death.
Sunday, October 13
8:00 AM - 9:30 AM
NA MC360
Prolonged Wakeup Caused by Pneumocephalus Following Resection of Craniopharyngioma
Lorraine Kerchum, Stanlies D'Souza, M.D., Baystate Medical Center, Springfield, MA
Two years after resection of a large craniopharyngioma compressing the optic chiasm with resultant
panhypopituitarism a 66-year-old male developed new visual symptoms. Imaging revealed tumor
recurrence with several cystic outpouchings the largest being 3cm causing significant pressure upwards
into the hypothalamic area. He subsequently underwent a left pterional craniotomy and resection of
recurrent craniopharyngioma using sevoflurane and remifentanil anesthesia. The case was complicated
by internal carotid artery rupture but no significant blood loss resulted. Upon cessation of general
anesthesia he was unable to follow commands and experienced significant right-sided weakness. Reimaging showed pneumocephalus causing a left-to-right 6mm midline shift.
MCC Session Number – MCC06
Sunday, October 13
10:30 AM - 12:00 PM
CA MC361
Liver Transplantation in a Patient With Significant Pulmonary Hypertension
Hovig Chitilian, M.D., Worasak Keeyapaj, M.D., Jonathan Charnin, M.D., Massachusetts General
Hospital, Boston, MA
Liver transplantation (LTx) in patients with mean pulmonary artery pressure (mPAP) >35mmHg is
associated with significant mortality. We report a case of successful LTx in a patient with a mPAP of
40mmHg. He had been managed on sildenafil and epoprostenol. Intraoperative pulmonary hypertension
was treated with escalating doses of epoprostenol (to 13ng/kg/min) as well as inhale nitric oxide. Right
ventricular (RV) function was monitored with TEE. Following reperfusion the mPAP increased to
50mmHg but responded to diuresis and inotropic support. His postoperative course was characterized
by persistent pulmonary hypertension. He was ultimately weaned off epoprostenol and maintained on
sildenafil.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC362
Management of New Hemodynamically Significant Bundle Branch Block During Open ThoracoAbdominal Aortic Aneurysm Repair
Yi Jia Chu, M.D., Pema Dorje, M.D., Univ of Michigan, Ann Arbor, MI
During a thoracoabdominal aortic aneurysm repair using distal perfusion a peculiar intermittent
hemodynamic change was noted. Bypass was achieved via a large bore cannula in the right IJ with its tip
at the superior atrial-caval junction per TEE. During the later half of the case bundle branch pattern with
prominent venous pulsation associated with a decrease in arterial pressure was noted. No ST changes or
Copyright © 2013 American Society of Anesthesiologists
no wall motion abnormalities were noted. We hypothesize the cannula tip irritated the SA node and the
internodal conduction pathways leading to premature atrial contraction and resultant hemodynamics.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC363
Active Automatic Cardioverter-Defibrillator During Laser Transurethral Resection of the Prostate
Bryan Cohen, M.D., Armin Deroee, M.D., Jerome O'Hara, M.D., Cleveland Clinic, Cleveland, OH
Two patients each with an implanted cardioverter defibrillator device underwent a laser vaporization of
the prostate without deactivation of the device. Both surgeries proceeded without complication and on
follow up no unnecessary defibrilator firing had occurred in the postoperative period. Based on the
technology involved in green light laser prostate surgery no interference with the device should be
expected. Although more studies are needed it is reasonable to believe that due to lack of interference
between laser surgery and implantible cardioverter defibrillators these devices need not be deactivated
prior to certain laser procedures.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC364
Perioperative Management of Patient With Gastropericardial Fistula
Matthew Culling, M.D., Lev Deriy, M.D., Kathleen Reyes, M.D., University of New Mexico, Albuquerque,
NM
A 70-year-old female with history of 3 vessel CABG and Nissen fundoplication presented to the
emergency department with chest pain and shortness of breath. An ECG demonstrated diffuse T-wave
abnormalities and atrial fibrillation with RVR. A CT with contrast revealed a pneumopericardium and a
communication between the gastric fundus and pericardium. She underwent a gastropericardial fistula
repair under general anesthesia with invasive monitoring and central venous access. Her post-op course
was complicated by infection and she was discharged on POD #35.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC365
Acute Bronchospasm Following Adenosine Administration in the Cardiac Catheterization Lab: A Case
Report
Nicholas Davis, M.D., Maya Jalbout-Hastie, M.D., New York Presbyterian Hospital-Columbia University,
New York, NY
Patient is a 65-year-old woman with a history of SVT and mild adult-onset exercise-induced asthma who
presented to the cardiac catheterization lab for radio frequency ablation. Immediately following
administration of adenosine the ventilator indicated elevated peak pressures and end tidal CO2 tracing
was lost. Acute bronchospasm was recognized and treatment begun with isoproterenol inhalational
agent and albuterol with resolution of symptoms. Indications and uses of adenosine as well as
evaluation and treatment protocols for acute bronchospasm are discussed.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CA MC366
Hepatocellular Carcinoma With IVC and Right Atrial Extension Requiring Autologous Liver Transplant
on Cardiopulmonary Bypass
Laura Downey, M.D., Vanessa Chin, M.B. B.S., Alfonso Casta, M.D., Shoaib Mohammad, M.D., Boston
Children's Hospital, Boston, MA
We present a 13-year-old male with HCC extending to the IVC and right atrium who underwent
complete hepatectomy with ex-vivo dissection and re-transplantation of the malignancy-free liver on
cardiopulmonary bypass. Despite normal coagulation studies severe portal hypertension contributed to
uncontrollable blood loss after incision. Due to the rapid blood loss estimated as high as 1.5L/min the
patient was placed on cardiopulmonary bypass to facilitate the procedure. The patient required massive
transfusion Factor VII and vasoactive infusions to maintain adequate blood volume and perfusion. He
was stabilized transferred to the ICU for ongoing resuscitation and discharged neurologically intact POD
20.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC367
Diagnosis of Tetralogy of Fallot in an Adult Patient by Transesophageal Echocardiography and
Anesthetic Management of the Surgical Repair
Michael Dutt, M.D., New York University Medical Center, New York, NY
A 55-year-old female presented with several months of general fatigue and exertional dyspnea and preoperative transthoracic echocardiogram findings of severe aortic stenosis and regurgitation. She was
scheduled for aortic valve replacement but pre-cardiopulmonary bypass transesophageal
echocardiogram (TEE) revealed a previously undiagnosed Tetralogy of Fallot. She underwent successful
surgical repair at a later date. Anesthetic management was guided by intraoperative TEE to ensure
careful control of hemodynamics. Post-operative EKGs revealed widening of her QRS complex and
occasional ventricular ectopy. Electrophysiology study showed no inducible ventricular arrhythmias and
the patient was discharged home on post-operative day 13.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC368
Bivalirudin Anticoagulation in a Patient With Heparin Antibodies and Renal Failure During Transition
From ECMO to LVAD
Guy Efune, M.D., Philip Greilich, M.D., UT Southwestern Medical Center Dallas, Dallas, TX
Patients with heparin antibodies and renal failure requiring anticoagulation for cardiac bypass present a
distinct challenge in anesthetic management. We present the case of a 67-year-old male patient who
experienced an MI and subsequently developed heparin antibodies and renal failure. The patient was
subsequently placed on ECMO after suffering a cardiac arrest during an attempted placement of an
Impella device. Bivalirudin anticoagulation was successfully used during his transition from ECMO to
LVAD. Intraoperative CRRT was performed to assist in removal of residual Bivalirudin at the completion
of his procedure.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CA MC369
The Anesthetic Considerations and Management in Patients With Autoimmune Hemolytic Anemia
Undergoing Aortic Valve Replacement
Carol Eisenstat, M.D., Frank Seifert, M.D., Thomas Bilfinger, M.D., Igor Izrailtyan, M.D., SUNY Stony
Brook University Hospital, Stony Brook, NY
Autoimmune hemolytic anemia (AIHA) a condition where warm or cold-reactive autoantibodies are
directed against antigens located on the surface of erythrocytes poses a significant anesthetic challenge
in the management of such patients undergoing cardiac surgery involving cardiopulmonary bypass
(CPB). Formation of the antibody-antigen complex in AIHA along with inherent destabilization of the
erythrocyte membrane from CPB results in severe hemolysis. Thorough assessment and coordination
between medical surgical perfusion and anesthesia teams are essential for optimal outcomes. We
present two cases of AIHA in patients undergoing successful aortic valve replacement and compare
perioperative considerations in patients with warm- and cold-reactive AIHA.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC370
Acute Myocardial Infarction and Cardiac Tamponade Following Left Pneumonectomy
Enrique Escobar, M.D., Shahla Escobar, M.D., Chen Shi, M.D., Lisa Morse, M.D., University of Texas
Southwestern Medical Center, Dallas, TX
A 71-year-old male patient with a left lung adenocarcinoma presented to the hospital for a left
pneumonectomy. On emergence from anesthesia the patient developed severe hypotension with STsegment elevation in the inferolateral leads. The patient was emergently transported to the cardiac
catherization suite where the cardiologists deployed a bare metal stent in the right coronary artery and
gave a loading dose of eptifibatide. A transesophageal echocardiogram at that time demonstrated a
significant pericardial effusion. The patient was taken back to the operating room where the surgeons
performed a median sternotomy to successfully repair a hole in the left atrium.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC371
Monitored Anesthesia Care in Cardiac Ablation Therapy for Recurrent Ventricular Tachycardia in a
Patient With Obstructive Sleep Apnea
Karen Fleming, M.D., Amanda Burden, M.D., Erin Pukenas, M.D., Keyur Trivedi, M.D., John Andriulli,
M.D., Cooper University Hospital, Camden, NJ
A 77-year-old male with a history of obstructive sleep apnea CAD and ischemic heart disease presented
with rapid sustained ventricular tachycardia (VT) and hypotension with multiple shocks from his ICD.
Medical management with PO amioderone was unsuccessful. Intra-operative ablation was planned
under monitored anesthesia care (MAC) using a Propofol infusion. This infusion resulted in hypotension
and hypoxemia which were both treated. During the procedure the patient had two episodes of
sustained ventricular tachycardia that required external shock at 300J. Successful ablation occurred after
stabilization of vital signs. The patient remained on PO amioderone and was discharged to rehab.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CA MC372
Total Artificial to Cadaveric Heart Transplant
Ilana Fromer, M.D., Amanda Rhee, M.D., Icahn School of Medicine, New York, NY
55-year-old male status-post multiple sternotomies and cardiac surgeries now with a total artificial heart
presenting for cadaveric heart and kidney transplant. Pre-induction arterial line was placed under
ultrasound guidance. After induction two large-bore peripheral intravenous lines were placed for fluid
and medical management during the case as there was concern that subclavian and internal jugular
access would interfere with the artificial heart. Pre-operative TEE evaluation was also not possible with
the artificial heart. After sterile prep and drape the cardiac surgeons placed a femoral introducer and
pulmonary artery catheter which was floated after the cadaveric heart was transplanted.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC373
Anesthetic Considerations for a Patient With a Large Invasive Mediastinal Mass Undergoing
Sternotomy and Tumor Debulking Surgery
Jeffrey Fujii, M.D., Galina Dimitrova, M.D., The Ohio State University, Columbus, OH
The patient is a young male with no significant past medical history diagnosed with an anterior
mediastinal tumor that invades the superior vena cava right atrium and right ventricle and has
significant metastases to both lungs. Thoracic surgery performed a median sternotomy with partial
debulking of the mediastinal and pulmonary tumor burden. Planning the successful anesthetic was a
collaborative effort between anesthesia surgery and perfusion. The patient was given a general
anesthetic with alternating left and right lung ventilation arterial blood pressure monitoring femoral
central venous access transesophageal echocardiography standby massive transfusion capability and an
epidural for postoperative pain control.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC374
General Anesthesia in a Patient With Bullous Pemphigoid
Lauren Ganderson, M.D., Baylor College of Medicine, Houston, TX
A 39-year-old male with active bullous pemphigoid presented with a pericardial effusion necessitating
an urgent pericardial window. Bullous pemphigoid an autoimmune mediated subepidermal blistering
disease causes bullae on the trunk extremities oropharynx and esophagus. His skin was protected from
development of bullae by coating the endotracheal tube and arterial and central lines secured with
sutures in petroleum jelly with no complications. His eyes were covered with low adhesive paper tape
but skin erosions on the eyelids did develop. He was stable throughout the procedure on a
norepinephrine infusion which was weaned with emergence and he was extubated in stable condition.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC375
Aortic Arch Thrombus Emergent Urgent or Elective Resection?
Mauricio Garcia Jacques, Robina Matyal, M.D., BIDMC, Boston, MA
64-year-old female recently taken off systemic anticoagulation for history of lower extremity ischemia
who presents with left upper extremity pallor and loss of peripheral pulses. Duplex of the affected
Copyright © 2013 American Society of Anesthesiologists
extremity demonstrated thrombosis in her mid ulnar and distal radial arteries. Given her poor response
to heparin infusion she was taken for emergent thrombectomy. We performed a general anesthetic to
do a TEE evaluation. Two mobile echogenic densities were found in the distal aortic arch the larger
measuring 2x1 cm. These findings raised the question of how to proceed? Is this an urgent emergent or
elective aortic arch thrombectomy.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC376
Intraoperative Fire Following Unrecognized Pulmonary Injury During Redo-Sternotomy
Stephen Gleich, M.D., Jonathan Fox, M.D., Mayo Clinic, Rochester, MN
A 72-year-old male with prior history of aortic valve replacement underwent redo-sternotomy and
aortic valve re-replacement for bioprosthetic aortic regurgitation. After induction and sternal split a
large circuit leak occurred. Because no gross air leak was observed in the surgical field an equipment
malfunction was the presumed cause and FiO2 and fresh gas flows were increased. While
troubleshooting cautery use ignited a surgical sponge in the superior chest which was quickly
extinguished. Closer inspection revealed a 2 cm round area of pulmonary injury which was oversewn. No
gross tissue injury was evident and the case proceeded uneventfully.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC377
Gathering the Missing Pieces of a Challenging Puzzle
Wendy Bernstein, M.D., Nicholas Goehner, University of Maryland, Baltimore, MD
Resection of an atrial myxoma should prevent embolic phenomenon not cause it. We present a 59-yearold female with increasing dyspnea and stroke with a left atrial myxoma. After induction intubation and
invasive line placement sternotomy was completed. During venous cannulation SBP acutely decreased
to 38mm Hg. TEE revealed obstruction of the LV inflow tract by the myxoma. Successful cannulation was
achieved despite large hemodynamic fluctuations. Separation from cardiopulmonary bypass was
complicated by biventricular akinesis which could have been attributed to embolization of friable tumor
down the coronary arteries.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC378
Sometimes You Don't Want to be in the Right
Andrew Goldberg, M.D., Ralph Dilisio, M.D., Menachem Weiner, M.D., Gregory Fischer, M.D., Ichan
School of Medicine at Mount Sinai, New York, NY
Our patient had a history of surgically corrected L-type transposition of the great vessels and
ventriculoseptal defect (VSD) now presenting for left ventricular assist device (LVAD) placement. The
patient required an LVAD secondary to right ventricle (systemic ventricle) failure from chronic strain.
Also his three previous pacemakers were no longer enough to help his cardiac output. After difficult line
placement secondary to multiple previous cardiac surgeries the case progressed uneventfully. Once the
LVAD was placed and activated the previously corrected VSD re-opened from the newly created
pressure gradient. The patient required significant hemodynamic support for the rest of the case.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CA MC379
Anticoagulation for Urgent CABG Procedure in a Patient With Hx of HIT
Leonid Gorelik, M.D., Ping Wang, M.D., Ryan Colapietro, D.O., University of Cincinnati Medical Center,
Cincinnati, OH
75-year-old male with a history of heparin induced thrombocytopenia (HIT) CAD and DMII transferred
from outside hospital for urgent CABG. Reportedly developed HIT 10 years ago when hospitalized for
sepsis as confirmed by family. This case illustrates anticoagulation with Bivalirudin instead of the
standard heparin protocol used for on-pump CABG. We discuss the diagnosis and future implications of
developing HIT alternatives for anticoagulation during CPB as well as the titration and monitoring of
Bivalirudin. In this case the intra-op coarse was complicated by significant bleeding multiple transfusions
of products and the administration of factor VII.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC380
Transcatheter Aortic Valve Implant in an Orthotopic Heart Transplant Recipient Via the Subclavian
Artery
Sheena Gormley, M.D., Peter McGuigan, M.B. B.Ch., Adesh Ramesewak, M.B. B.Ch., Andrew McKinley,
M.D., Ganesh Manoharan, M.D., Mark Spence, M.D., Royal Victoria Hospital Belfast, Belfast, United
Kingdom
Symptomatic aortic stenosis has a mortality of 40% at one year. Transcatheter Aortic Valve Implantation
(TAVI) offers a therapeutic alternative for those patients who are deemed high risk for surgery. There
have been three reported cases in the literature of TAVI being carried out in orthotopic heart transplant
recipients using either a trans-apical or femoral approach. We present the fourth case of TAVI in an
orthotopic heart transplant recipient and the first to be carried out via a subclavian approach. We
discuss the evidence for TAVI and the role of the anaesthetist in the multidisciplinary management of
the patient.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC381
Anesthetic Management for Bentall Procedure in a Patient With History of Malignant Hyperthermia
Kevin Graham, D.O., Shvetank Agarwal, M.B. B.S., Vijay Patel, M.D., Manuel Castresana, M.D., Georgia
Regents University, Augusta, GA
65-year-old-female with a large ascending aortic aneurysm and severe aortic regurgitation was
scheduled for a Bentall procedure. Her history was significant for an episode of malignant hyperthermia
(MH) during a previous anesthetic. Perioperative anesthetic management included meticulous
preparation of anesthetic machine avoidance of triggering anesthetic agents and continued monitoring
in the postoperative period. In view of the prolonged cardiopulmonary bypass time of approximately 5
hours patient was rewarmed to a core temperature of 36.5C to avoid worsening of coagulopathy while
closely monitoring for early signs of MH. The patient remained free from MH through her ICU and
hospital stay.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CA MC382
Crashing on Bypass With Two Peripheral IVs: The Benefit of Immediate and Continuous Chest
Compressions on Neurologic Outcome After Cardiac Arrest at Induction for Emergent CABG
Mary Graham, Mike Hosking, M.D., University of Tennessee Medical Center, Knoxville, TN
58-year-old female with critical coronary disease in stable condition after cardiac catheterization acutely
decompensated in the preoperative holding area prior to central line placement for urgent CABG. She
was immediately taken to the OR where cardiac arrest occured at induction followed by immediate and
continuous cardiac massage and ACLS protocol which allowed time to crash onto cardiopulmonary
bypass within 30 minutes. Postoperatively the pt was extubated in 48 hours without sustaining any
anoxic insult and was discharged 9 days later. Early and continuous cardiac massage may have been a
key factor contributing to favorable neurologic outcome.
Sunday, October 13
10:30 AM - 12:00 PM
CA MC383
Clinical Implication of Pulmonary Flow Assessment Affected by Single Lung Ventilation in Minimally
Invasive Cardiac Surgery
Radhika Grandhe, M.D., Shiva Sale, M.D., Cleveland Clinic, Cleveland, OH
59-year-female underwent robotic excision of left atrial myxoma. Anesthetic management included
double lumen ETT invasive lines and TEE. Intraop TEE showed LA mass attached to interatrial septum
situated close to the RPV. The mass was excised via left atriotomy and LA closed after complete deairing.
While weaning off bypass with left lung ventilation TEE showed normal pulmonic vein inflow on color doppler interrogation. Post CPB and chest closure double lung ventilation was resumed and TEE
revealed RUPV flow acceleration. The incision was reopened and a repair stitch along RUPV was
removed which normalized flow on TEE.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC384
A Balancing Act: Managing Ischemic Stroke in the Setting of Ventricular Pseudoaneurysm
Hannah Keirnes Lovejoy, M.D., Donald Crabtree, M.D., Roy Neeley, M.D., Vanderbilt University, Nashville,
TN
56-year-old F with h/o familial hyperlipidemia CAD with multiple MI's (most recent 2 wk prior) and aortic
stenosis s/p apicoaortic bypass who presented with R sided weakness and expressive aphasia. Pt was
diagnosed with L MCA infarct treated with clot retrieval complicated by hemorrhagic conversion. An
echo revealed a density in the apicoaortic conduit. Subsequent cardiac MRI showed contained rupture
and pseudoaneurysm formation of the cardiac apex. Fibrinous material flowed between the rupture and
apex during diastole. Her course was further complicated by HIT. ICU management goals included
reduction of cardiac workload maintenance of CPP and anticoagulation.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC385
Acute Baclofen Withdrawal Presenting as Respiratory Distress and Difficult Airway in the Post
Anesthesia Recovery Unit
Sandeep Khanna, M.D., Roshni Sreedharan, M.D., Antonio Ramirez, M.D., Cleveland Clinic Foundation,
Cleveland, OH
31-year-old woman with cerebral palsy and spastic quadriparesis presented to the hospital for removal
of her intrathecal baclofen pump secondary to erosion of skin. She was started on oral baclofen prior to
pump extraction. Intraoperative course was uneventful with successful extubation in the operating
room. However she developed sudden respiratory distress in the Post Anesthesia Recovery Unit. Her
emergent reintubation was complicated by generalized rigidity and difficulty in opening the mouth
despite adequate dosing of muscle relaxant secondary to acute baclofen withdrawal. She underwent a
tracheostomy on post-operative day 5 due to inability to wean.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC386
Broken Heart Syndrome in a Patient With Myelofibrosis After Splenectomy: A Case Report
Eugene Kim, M.D., Peter Roffey, M.D., Duraiya Thangathurai, M.D., University of Southern California, Los
Angeles, CA
A 65-year-old male with myelofibrosis and massive splenomegaly presented for splenectomy. His
cardiac history was unremarkable and a preoperative echocardiogram was normal. His intraoperative
course was unremarkable and the patient was extubated in the operating room and transferred to the
ICU. The patient continued to have an uneventful recovery in the ICU and was subsequently transferred
to the ward. On postoperative day 4 the patient was readmitted to ICU with atrial fibrillation with rapid
ventricular rate to 170s beats per minute. Transthoracic echocardiogram demonstrated wall motion
abnormalities with retained contractility of basal segment and akinesis of distal segments and apex.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC387
Acute Kidney Injury and Ischemic Hepatitis Due to Huge Hematoma After Catheteriztion of Subclavian
Vein
Jae-Young Kwon, Eunsoo Kim, M.D., Jeong-Min Hong, M.D., Yun-Hee Han, M.D., Pusan National
University Hospital, Busan
A 74-year-old male presenting left leg pain and numbness underwent thrombectomy of superficaial
femoral artery. Central vein catheter was inserted through the subclavian vein under general anesthesia.
Catheterization and thrombectomy were performed without any problems. Heparin was administered
during intraoperative and postoperative period. On second postoperative day He had syncope due to
hemorragic shock. Chest computed tomography showed a large hematoma between pectoralis major
and minor muscle on left chest wall. He developed acute kidney injury and ischemic hepatitis. He had
contiunous renal replacement therapy and mechanical ventilation. He was transferred to general ward
on the 19th ICU day.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC388
Challenges in the Medical Management of Multiple Different Intracranial Pathologies
Martin Krause, M.D., Navaz Karanjia, M.D., Brian Lemkuil, M.D., University of California San Diego, San
Diego, CA
A 34-year-old developmentally delayed male presented with a right periorbital abscess pansinusitis and
sepsis. Initial management included broad-spectrum antibiotics and surgical debridement of
sinuses/orbit. Subsequent mental status deterioration led to neuroimaging that revealed: 1) abscesses
involving the right frontal lobe adjacent to the ethmoid sinus and a second involving the hypothalamus
optic chasm and anterior cerebral arteries; 2) anterior cerebral artery mycotic aneurysm; 3)
noncommunicating hydrocephalus; 4) ischemic strokes to the corpus callosum and left pons. Laboratory
evaluation revealed hyponatremia (126) and coagulopathy (INR 1.9) of unknown etiology. He was
transferred to Neurocritical Care for medical management/surgical optimization.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC389
Case of Neuroleptic Malignant Syndrome Secondary to Haloperidol and Quetiapine: Experience With
Bromocriptine Therapy
Jonathan Kremer, M.D., Jonathan Ratcliff, M.D., Betty Tsuei, M.D., Christopher Droege, Pharm.D,
University of Cincinnati, Cincinnati, OH
68-year-old male with significant narcotic and benzodiazepine use admitted to the ICU with respiratory
failure after cervical spine fixation. Haloperidol and quetiapine were used for the treatment of ICU
delirium. A 107 F fever with severe autonomic instability developed on post operative day 5.
Bromocriptine therapy was successfully initiated with symptomatic improvement and following two
days of treatment dose taper was initiated. However he developed recurrent autonomic dysfunction
without fever. Increased bromocripitine dose for an additional ten days followed by a week long taper
resulted in complete resolution of symptoms.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC390
Recurrent Cardiac Arrests Associated With Sepsis Complicating Prosthetic Valve Replacement
Vikas Kumar, Shalin Shah, Sanjay Dwarakanath, Manuel Castresana, Georgia Regents University,
Augusta, GA
49-year-old female with PMH of HTN ESRD hepatitis C spina bifida decubitus ulcer underwent bioprosthetic aortic valve replacement for aortic stenosis and extubated on day of surgery. On
postoperative day two she developed sudden bradycardia cardiac arrest with successful resuscitation
and had severe hypoglycemia and sepsis. TTE showed mild aortic regurgitation and mild perivalvular
leak. Later patient was extubated but had similar episode of bradycardia leading to cardiac arrest with
successful resuscitation on post-operative day eighteen. TEE showed worsening aortic regurgitation
perivalvular leak and aortic annular abscess not diagnosed earlier on TTE.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC391
Unrecognized Sepsis in a Patient Undergoing Elective Coronary Artery Bypass Graft Surgery
Vikas Kumar, Shalin Shah, Mary Arthur, M.D., Manuel Castresana, Georgia Regents University, Augusta,
GA
77-year-old female with PMH of hypertension OSA multi-vessel CAD presented to ER with unstable
angina and scheduled for CABG next morning. Despite being somnolent and temperature of 39.8 C on
morning of surgery decision was made to proceed. Intraoperatively she was difficult to wean off bypass
requiring inotropic vasopressors balloon pump and developed abdomen distension. Post-operative
course was complicated by severe cardiogenic and septic shock with E. coli from blood culture multiorgan failure and severe acidosis despite aggressive antibiotics therapy and hemodynamic support. Her
condition continued to deteriorate and went into cardiac arrest;and died on post-operative day four.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC392
A Rare Cause for Dyspnea: Acute Fibrinous and Organizing Pneumonia
Catherine Kuza, M.D., Theofilos Matheos, M.D., Stephen Heard, M.D., University of Massachusetts
Medical School, Worcester, MA
A 60-year-old male smoker presented with worsening dyspnea and hemoptysis. Chest x-ray and CT scan
showed bilateral diffuse opacities and ground glass densities respectively. Bronchoscopy was negative
for malignancy granulomas and bacteria. Open lung biopsy revealed acute fibrinous and organizing
pneumonia (AFOP). AFOP is a rare disease that is idiopathic or occurs due to environmental exposures
infections or collagen vascular diseases. Patients present with dyspnea cough fever or acute respiratory
distress syndrome. Definite diagnosis requires an open lung biopsy. Treatment includes antibiotics
corticosteroids and cyclophosphamide with varying responses. The optimal duration of therapy is
unknown.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC393
Postoperative Central Venous Catheter Migration Detected by Abnormal Central Venous Pressure
Tracing
Karim Ladha, Cheryl Bline, M.D., Joseph Hyder, M.D., Ph.D., Massachusetts General Hospital, Boston, MA
The patient was a 58-year-old man with a history of hypertension who underwent an open AAA repair.
The procedure was preceded by an uneventful placement of a left internal jugular triple-lumen catheter
confirmed to be in the left innominate vein by chest x-ray in the OR. He was transferred post-operatively
to the ICU still intubated. Approximately four hours after arrival to the ICU CVP tracing began displaying
intermittent pulsatilty correlated to the respiratory cycle during mechanical ventilation. A chest film was
obtained and showed that the tip had straightened 90 degrees and migrated into the left superior
intercostal vein.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC394
Intra-Cardiac and Pulmonary Artery Direct Injection of tPA for Pulmonary Emboli
Gong Lee, Methodist Dallas Medical Center, Dallas, TX
A 28-year-old female with a history of end stage renal disease was undergoing surgery to remove the
thrombosed left HeRo graft under GETA. During the procedure patient suddenly became hypotensive
with a significant drop of ETCO2. CPR proceeded with SBP maintained above 70mmHg throught the
chest compression. TEE showed dilated RA and RV and a normal LVF. A clinical diagnosis of PE was
made. A total of 4mg of tPA was administered directly to the pulmonary artery through the PA
cath.Shortly after the patient's hemodynamics dramatically improved and stabilized. Patient had a full
recovery.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC395
Management of Patient With Ruptured Intracerebral Aneurysm With Concurrent Abdominal Aortic
Aneurysm
Shea Stoops, M.D., Ben Chen, M.D., Abhijit Lele, M.D., University of Kansas Medical Center, Kansas City,
KS
A 66-year-old Caucasian man with a history of COPD CAD MI CVA smoking and DVT presented with a
Hunt and Hess 1 Modified Fisher Grade 1 subarachnoid hemorrhage due to ruptured 6 mm bilobed
anterior cerebral artery aneurysm. He also had a 7 cm infra renal aortic aneurysm that required repair.
Patient underwent successful endovascular repair of cerebral aneurysm on post-bleed day 1 and
endovascular aortic aneurysm repair (EVAR) on post-bleed day 2. The patient was discharged on post
bleed day 9 without evidence of vasospasm or hydrocephalus and absence of focal neuro deficit.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC396
Perioperative Management of a Previously Undiagnosed Giant Pericardial Effusion
Marcos Lopez, Patrick Henson, D.O., Michael Pilla, M.D., Vanderbilt University School of Medicine,
Nashville, TN
A 56-year-old M with PMH COPD L BKA s/p multiple failed thrombectomies and a-fib was transferred
from an OSH with concern of R leg ischemia. Emergency thrombectomy vs. bypass was scheduled. Postinduction TEE showed a large pericardial effusion. He underwent axillary-femoral bypass and was
transferred to the CVICU post-op. He began to show tamponade physiology so underwent
pericardiocentesis at the bedside with acute drainage of 1 L of bloody fluid and additional 2L over 2
days. This complex case lends to a detailed discussion of clinical decision making for pericardial effusion
and tamponade in the perioperative period.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC397
Successful Fibrinolitic Therapy for Massive Pulmonary Embolism in Immediate Postoperative Period: Is
it Really an Absolute Contraindication?
Jack Louro, M.D., Roman Dudaryk, M.D., UM/ Jackson Memorial Hospital, Miami, FL
We will be presenting the case of a 48-year-old morbidly obese female with multiple medical problems
admitted with Fournier's gangrene that experienced cardiovascular collapse leading to cardiac arrest
postoperatively in the ICU. We will review the differential for her decompensation and diagnostic
modalities available to the critical care physician. We will discuss the diagnosis and treatment of massive
pulmonary embolism in a patient with hemodynamic instability and open surgical wounds. Emphasis will
be placed on the use of TEE as a primary diagnostic modality and the use of IV thrombolytics in the postoperative period.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC398
Mixed Cardiogenic and Septic Shock From Suppurative Pancarditis
Ayumi Maeda, M.D., Massachusetts General Hospital, Boston, MA, Hayley B. Gershengorn, M.D., Beth
Israel Medical Center, New York, NY
A 53-year-old cirrhotic male presented with chest pain and fever. EKG showed diffuse ST-elevations and
initial transthoracic echocardiography revealed global hypokinesis. He was diagnosed with MSSA aortic
valve endocarditis and shock which persisted despite antibiotics. Repeat TTE showed massive pericardial
effusion with tamponade. Emergent pericardiocentesis drained purulent discharge (700ml); sanguineous
pleural fluid was also drained from the left--both grew MSSA. His course was complicated by acute
kidney injury requiring hemodialysis respiratory failure requiring mechanical ventilation disseminated
intravascular coagulation and death. This case demonstrates that aortic valve endocarditis can cause
suppurative pancarditis and thoracic empyema with mixed cardiogenic and septic shock.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC399
Anesthetic Management of a Parturient With Congenital Complete AV Block for Elective C-Section.
Sandeep Mayur, M.D., Kalpana Tyagaraj, M.D., Maimonides Medical Center, Brooklyn, NY
A 20-year-old pregnant female G1P0 at 39 weeks gestation with history of congenital complete heart
block presented for elective C-Section. Preop. cardiac consult was obtained. Preoperative vital signs
were BP 104/75 HR 52 SpO2 100% and the patient showed no signs of heart failure on physical exam.
EKG showed third degree AV block. Echocardiogram revealed ejection fraction of 60% with no significant
valvular disease normal chamber sizes. A-line and external pacing pads were placed. Atropine 0.2 mg
was given prophylactically. C-Section was performed uneventfully under CSE anesthesia. Patient was
monitored in CICU for 48 hours before discharge.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC400
Delirium Hypoxia Hyperthermia & Hypertensive Crisis After Uncomplicated Total Hip Arthroplasty in
an HIV-Positive Patient
Antonio Conte, M.D., MBA, Kevin McElroy, M.D., Roya Yumul, M.D., Ph.D., Brad Penenberg, M.D.,
Cedars-Sinai Medical Center, Los Angeles, CA
A 59-year-old man ASA II with history of HIV hypertension hypogonadism osteopenia and recent
bilateral hip replacement underwent an uncomplicated revision total hip arthroplasty with spinal
anesthesia and propofol sedation. Intraoperative period was uneventful. The patient was taken to the
PACU in stable condition. One hour after arriving in the PACU the patient developed shivering;
meperidine was ordered. After administration of meperidine the patient became severely agitated and
was unable to communicate verbally; vital signs: pulse 144 blood pressure 187/102 O2 saturation 93 and
respiratory rate 32. The patient became hyperthermic reaching a maximum temperature of 40 degrees
Celsius.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC401
A Multimodal Approach of Intraoperative Ultra Rapid Partial Opioid Detoxification in a Surgical
Patient With Chronic Pain
Arash Motamed, M.D., MBA, Armen Kara, M.D., Navid Alem, M.D., Mariana Mogos, M.D., Duraiyah
Thangathurai, M.D., University of Southern California, Los Angeles, CA
A 51-year-old male with history of bladder cancer chronic pain opioid tolerance and dependency
presented for bladder augmentation and cystoplasty. His daily baseline hydromorphone usage was
60mg intravenous morphine equivalent. General anesthesia was performed and maintained with
Ketamine Propofol and Isoflurance. Naloxone was administered incrementally maintaining
hymodynamic and thermodynamic stability. Patient was extubated on postoperative day (POD) one in
the Intensive Care Unit (ICU) on an infusion of Ketamine-Fentanyl-Midazolam and Dexmedetomidine.
Adjunct medications were added as needed. Opioid requirement peaked at 143% above baseline on
POD two and returned to baseline by POD six upon hospital discharge.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC402
Patient Safety Lessons From a Tracheostomy Emergency
Linda-Jayne Mottram, M.B. B.Ch., Lynn Cromie, M.B. B.Ch., Michael McGinlay, M.B. B.Ch., South Eastern
Health and Social Care Trust, Belfast, United Kingdom
We describe the sequence of events which ensued following the urgent exchange of a surgical
tracheostomy in one of our intensive care patients. Loss of end-tidal carbon dioxide surgical emphysema
and failure to adequately ventilate the patient resulted in a cardiorespiratory arrest. Despite initially
hypothesising that an upper airway false passage had been created it became apparent that lower
airway trauma had occurred and a left sided bronchopleural fistula was present. We postulate the
mechanism of such an injury and share the patient safety lessons we have learned about tracheostomy
management in our institution.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
CC MC403
Cytokine Release Syndrome Requiring Postoperative Reintubation in Operating Room in Kidney
Transplant Patient
Kristina Natan, M.D., NYU Langone Medical Center, New York, NY
43-year-old male with history of IDDM diabetic nephropathy on hemodialysis HTN HLD GERD presents
for kidney transplant. Uneventful induction and intubation. In the middle of a case surgeon requested to
give antithymocyte globulin. Half hour later patient became hypertensive and tachycardic despite
adequate anesthesia and analgesia which was controlled with labetalol. Solumedrol given. Patient
extubated at end of case. After extubation patient developed severe hypertension tachyacrdia and
desaturated to mid 80's. HeHeheCXR showed pulmonary edema with hypercarbia on ABG. Patient
reintubated. Hypoxia and hypertension thought to be secondary to cytokine release syndrome
secondary to administration of antithymocyte globulin.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC404
Pulmonary Artery Rupture in a Patient With Orthotopic Heart Transplant After Total Artificial Heart
Placement
Koichi Nomoto, M.D., Adam Evans, M.D., MBA, Mount Sinai Medical Center, New York, NY
A patient s/p orthotopic heart transplant involving an explanted total artificial heart (TAH) was brought
to the ICU with a pulmonary artery catheter which was removed on POD#4. On POD#5 he was
extubated but refused to take anything orally. A Nasogastric tube was placed and associated with
coughing. This was complicated by increased chest tube output and need for emergent intubation. A TEE
revealed cardiac tamponade. He underwent emergent re-exploration where bleeding was found from
the left PA distal to the transplant anastomosis. Our case illustrates that a patient can still have a PA
rupture despite TAH and replacement.
Sunday, October 13
10:30 AM - 12:00 PM
CC MC405
ECMO Failure in Severe Idiopathic Giant Cell Interstitial Pneumonia and Pulmonary Hypertension
William O'Byrne, M.D., Robert Atiken, M.D., University of Alabama School of Medicine, Birmingham, AL
The patient is a 64-year-old female with past medical history significant for rheumatoid arthritis and
polymyalgia rheumatica. She was diagnosed with giant cell interstitial pneumonia via VATS and admitted
to the MICU at the University of Alabama Hospital. She was treated aggressively with open lung
ventilation steroids and antibiotics. She underwent right and left heart catheterization which showed
pulmonary arterial hypertension and no coronary disease. She was subsequently placed on veno-venous
ECMO via the right internal jugular approach as a bridge to lung transplantation. However the patient
could not be effectively oxygenated despite 100% FiO2 for seven days.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC406
A Heads Up to Uterine Rupture: A Multi-Disciplinary Approach
Erin Giles, D.O., Brian Keyes, D.O., Riverside County Regional Medical Center, Moreno Valley, CA
This is a rare case report of a spontaneous rupture of an unscarred uterus. Uterine rupture is defined as
a disruption of the uterine myometrium with extrusion of membranes and fetal parts into the
peritoneum. There is usually associated bleeding and abdominal pain. Despite an expedient diagnosis
and early surgical intervention morbidityand mortality is high. This is a concern for all the providers
involved including anesthesiologists obstetricians surgeons and neonatologists. Fortunately the vital
communication and coordination between the multiple teams involved in this case resulted in favorable
outcomes for both mother and neonate.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC407
Anesthetic Management for Labor and Delivery of a Patient With Severe Cystic Fibrosis
Ravpreet Gill, M.D., Jaya Ramanathan, M.D., University of Tennessee Health Science Center, Memphis,
TN
A 20-year-old G1P0 with history of cystic fibrosis presented in labor at 36.4 weeks gestation. Past
medical history was also significant for cholestasis and respiratory insufficiency requiring intubation 2
months earlier. Meds: Albuterol pancrealipase tobramycin VS: Temp 36.6 C HR 114 RR 18 BP 103/72
SpO2 95% on room air. Airway: Mallampati 2. Lungs: decreased air entry b/l with diffuse wheezing. An
early labor epidural was placed humidified oxygen was delivered and continous pulse oximetery was
used. The patient also received regularly scheduled albuterol nebulizer treatments. The second stage of
labor was assisted and vaginal delivery was uneventful.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC408
Anesthetic Management of a Parturient With Complex Regional Pain Syndrome: A Case Report and
Review of Literature
Ramon Go, Tricia Desvarieux, M.D., Marianne David, M.D., Sean Malin, M.D., George Washington
University Hospital, Washington, DC
The patient is a 38-year old G1P0 parturient who presents at 383 weeks gestation age for elective
cesarean section with a history of CRPS. The patient has had 11 sympathetic blockades and stopped
taking gabapentin during the pregnancy. A combined spinal epidural (CSE) is opted to provide rapid
dense block for c-section, for management of potential CRPS symptoms, and post-op incisional pain. Her
intraoperative course is unremarkable. She received a patient controlled epidural anesthesia infusion of
bupivacaine 0.0325% with fentanyl for post-operative pain control. The catheter was discontinued 24
hours after delivery.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC409
Acute Incapacitating Spinal Cord Compression From Epidural Air Necessitating Emergent Cesarean
Delivery
Chaim Golfeiz, B.A., Manuel Vallejo, M.D., Magee-Womens Hospital of the University of Pittsburgh
Medical Center, Pittsburgh, PA
A 31-year-old G1P0 at term requested an epidural for labor analgesia. An epidural catheter was placed
without complication. The patient subsequently complained of constant sharp bilateral subscapular back
pain with radiation to her left shoulder and arm that was incapacitating. She was unable to lye supine or
in the lateral decubitus position. Gross neurological exam was unremarkable. Electrocardiogram
revealed sinus tachycardia with no ischemic changes; chest roentgenogram was within normal limits.
The epidural catheter was replaced yet she remained acutely symptomatic. An emergency cesarean
section was considered in order to expedite treatment for her potentially life threatening condition.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC410
Anesthetic Management of Cesarian Delivery for a Patient With Symptomatic Obstructive Goiter
Brian Gregson, M.D., Caleb Zelenietz, M.D., University of Manitoba, Winnipeg, MB
A 33-year-old female presented with an increasingly symptomatic goiter in the second trimester of
pregnancy. The patient was a recent immigrant with a long-standing goiter and a previously attempted
thyroidectomy in her home country which was cancelled because of failed intubation. She had become
stridorous at rest and had worsening exertional dyspnea but no positional symptoms. Endocrinology
optimized her medical therapy and Head &amp; Neck Surgery deferred thyroidectomy until the
postpartum period. We elected to avoid natural labour and instead use epidural anesthesia for cesarian
delivery in a controlled setting. The child was successfully delivered without adverse outcome.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC411
Management of Ceasarean Section in a Patient With Placenta Previa and Accreta and Strong Family
History of Malignant Hyperthermia
Shaun Gruenbaum, M.D., Jacob Baranoski, B.Sc., Alice Li, B.Sc., Benjamin Gruenbaum, M.D., Alan
Weinstock, M.D., Yale University School of Medicine, New Haven, CT
A 38-year-old G3P2 female with prior cesarean section x 2 strong family history of malignant
hyperthermia known posterior placenta previa and suspected placenta accreta was admitted at 33+3
weeks with spontaneous rupture of membranes. During cesarean section with hysterectomy patient
was maintained on 60% N2O in 40% O2 intermittent propofol boluses with sufentail 1 mcg/kg/hr and
midazolam 2 mcg/kg/hr. The procedure was complicated by 7L blood loss resuscitated with 5L
crystalloid 10u PRBC's 7u FFP and 10u platelets. The patient remained hemodynamically stable and
normothermic throughout the case and was extubated within 1 hour of transport to SICU.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC412
Analgesia for Labor and Delivery While Receiving Temporary Transvenous Pacing for Complete Heart
Block
Carl Guild, M.D., Abhinava Madamangalam, M.D., University of Oklahoma College of Medicine,
Oklahoma City, OK
Evaluation of significant bradycardia at 36 weeks gestation in a 17-year-old revealed a complete heart
block. She required a temporary transvenous pacer and was admitted to our in situ L&D ICU for
telemetry ICU for telemetry. She received epidural analgesia for her labor that was augmented with
Pitocin. The epidural was bolused to achieve anesthesia and a forceps delivery was performed to
shorten the 2nd stage of labor. A permanent pacemaker was implanted prior to her discharge. We will
discuss the management of bradycardia and anesthetic implications of transvenous pacing and neuraxial
anesthesia in our presentation.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC413
A Case of Sheehan Syndrome: Pituitary Hemorrhage and Cerebral Vasospasm Resulting From Covert
Severe PostPartum Hemorrhage
Fatimah Habib, M.D., Cooper University Hospital, Camden, NJ
A 39-year-old female at 38 weeks gestation presented with eclampsia and developed occult postpartum
intra-abdominal hemorrhage following a cesarean section. Following emergent exploratory laparotomy
her condition continued to deteriorate and she began displaying varied neurological deficits with
evidence of PRES syndrome on imaging. Further imaging revealed a hemorrhagic pituitary gland and
cerebral vasospasm. She was diagnosed with Sheehan syndrome. Treatment with Nimodipine was
begun to alleviate the cerebral vasospasm. This case demonstrates an example of Sheehan syndrome
PRES syndrome the minimal treatment options for cerebral vasospasm and pituitary hemorrhage
following severe postpartum hemorrhage and the utility of Nimodipine.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC414
Unusual Cause of Postpartum Headache
Mona Halim-Armanios, M.D., Ohio State University Medical Center, Columbus, OH
A rare cause of Post-Partum Headache: Another reason for earlier imaging: Differential diagnosis of a
post-partum headache includes a wide variety of medical conditions. The diagnosis could be
compounded by the likely possibility of post-dural puncture headache. We present a rare cause of
postpartum headache in a patient who has received labor epidural analgesia.She developed left
hemiparesis & global -aphasia. A diagnosis of Call-Fleming Syndrome or Reversible Cerebral
vasoconstriction Syndrome was based on her presentation and imaging. This case demonstrates a rare
cause of postpartum headache that has not been published in the anesthesia literature before.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC415
Pulmonary Embolism During Emergent Cesarean Section in a Patient With Preeclampsia and Twin
Gestation
Sabrina Haque, M.D., MBA, Jeremy Grayson, M.D., UMDNJ Robert Wood Johnson, New Brunswick, NJ
A 38-year-old G2P0 at 36 weeks with twin gestation presented for induction of labor for severe
preeclampsia. The patient required general anesthesia for delivery of Twin B secondary to cord
prolapse. During uterine closure end tidal carbon dioxide (etCO2) oxygen saturation and blood pressure
decreased precipitously. Vasopressors were administered to maintain SBP 120-140. ABG at this time
revealed pH 7.27 pCO2 49 paO2 175 on FiO2 100%. Within minutes etCO2 oxygen saturation and blood
pressure normalized with supportive treatment. Postoperatively a CT angiogram of the chest indicated
pulmonary embolus in the right main and segmental pulmonary arterial branches.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC416
Anesthetic Considerations for Obstetric Patients With Spinal Muscular Atrophy
Frederick Isaacson, D.O., Heather Nixon, M.D., University of Illinois Chicago, Chicago, IL
Spinal muscular atrophy (SMA) is a rare degenerative disease that affects the anterior horn cells of the
spinal cord. We present a medically challenging case of a 39-year-old multiparous patient with spinal
muscular atrophy type III who presented for repeat elective cesarean delivery that was complicated by
postpartum hemorrhage due to profound atony necessitating conversion from neuraxial blockade to
general anesthesia. The patient's course was further complicated by prolonged weaning from
mechanical ventilation due to residual muscle weakness and the development of disseminated
intravascular coagulopathy. This case highlights the anesthetic considerations for obstetric patients with
SMA.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC417
Neurofibromatosis in the Parturient Patient: A Case Report and Review
Andrea Johnson, D.O., Alice Tsao, M.D., Riverside County Regional Medical Center, Moreno Valley, CA
29-year-old 37 week parturient laboring patient requested an epidural for 10/10 labor pain. PMHx was
significant for neurofibromatosis 1 Brown-Sequard Syndrome and Chronic Pain Syndrome. Neurosurgery
evaluation revealed stable neurological deficits since 2007 with no pre-gravid MRI changes. PSHx
consisted of C2-C7 neurofibroma resection in 2007 posterior C2-C7 spinal fusion in 2009 and multiple
neurofibroma excisions. PE found limited cervical ROM narrow incisor gap and Mallampati 4. Epidural
catheter placement was deemed safe anesthetic plan however MRI to r/o new neurofibromas was not
possible due to precipitous labor. We propose lumbar ultrasound as an alternative diagnostic tool.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC418
Neuraxial Analgesia in the Laboring Parturient With Arnold-Chiari Type I Malformation - Relief of Pain
in Unchartered Terrain?
Suneil Jolly, M.D., Ana Lobo, M.D., M.P.H., Yale New Haven Hospital, New Haven, CT
A 17-year-old G1P0 @40w+2 diagnosed with Arnold-Chiari type 1 malformation during her first
trimester presented in labor requesting pain relief. She was diagnosed via CT scan after experiencing
headaches vision changes and dizziness; an MRI was unsuccessful secondary to anxiety with plans to
follow-up postpartum. Upon assessment the patient was asymptomatic during the prior two weeks
except for occasional numbness in two fingers bilaterally. After considering the limited data on ACT-1
with neuraxial analgesia and lack of recent symptoms an epidural was placed successfully with
significant pain relief. The patient had NSVD without complications or exacerbation of symptoms.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC419
Cerebrospinal - cutaneous Fistula in a Parturient Following Neuraxial Blockade
Danny Joseph, Stanlies D'Souza, Baystate Medical Center, Springfield, MA
A 26-year-old primigravida at 37 weeks with notable history of oxycodone abuse presented for a
scheduled cesarean section. Intra-operative management included a single shot spinal combined with a
lumbar epidural catheter. Postoperatively patient was noted to have an intrathecal-cutaneous fistula
with persistent cerebrospinal fluid leak. This fistula was initially observed for the first two days
postoperatively with no resolution. A neurosurgical consult was obtained and the decision was made to
suture the fistula closed at the skin. The patient initially did not report any post dural puncture
headache symptoms but at six month follow up reports chronic headaches.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC420
Emergency Exploratory Laparotomy and C-Section in a 37-Week Parturient Who Was Pinned by an
SUV
Michael Jourden, Jennifer Eismon, Case Western Reserve University MetroHealth Medical Center,
Cleveland, OH
Trauma complicates 7% of pregnancies with fetal death occurring in 55% of major traumas. A 32-yearold 37-week pregnant previously healthy female presented after being hit by an SUV. At presentation
she was hypotensive in the 60's with fetal heart rate in the 40's and was immediately taken for
emergency c-section and exploratory laparotomy. Rapid sequence induction was performed and the
patient was intubated using a glidescope. She remained intubated post-op and was taken to the SICU.
She and baby are currently hospitalized (day #38). The mother is improving however the baby has
suffered severe hypoxic encephalopathy.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC421
Anesthetic Management for Cesarean Section in a Paraplegic Parturient With Multiple Comorbidities
Including Urosepsis and Pulmonary Embolus
Sarah Kadhim, M.D., Lance Parks, D.O., West Virginia University, Morgantown, WV
Pregnant patients with spinal cord injuries present unique anesthetic challenges. Several complications
have been identified including autonomic hyperreflexia premature labor pressure sores urinary tract
infections and failure to progress. The following case report describes a primigravid female with a
history of thoracic spinal cord injury and intrapartum complications including urosepsis decubitus ulcer
pulmonary embolus requiring treatment with heparin and increased narcotic tolerance. On induction of
labor at 37 weeks gestation failure to progress necessitated anesthetic management for Cesarean
section. The successful use of general anesthesia is described as well as special considerations for both
general and regional anesthesia.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC422
Management of a Parturient With Amyotrophic Lateral Sclerosis (ALS)
Jerry Kalangara, M.D., Daria Moaveni, M.D., J. Sudharma Ranasinghe, M.D., University of Miami, Miami,
FL
A 34-year-old female who is 34 weeks pregnant was suffering from weakness of the upper and lower
extremities due to ALS. She was requiring nasal cannula/ BiPAP to maintain adequate oxygen saturation.
A multi-disciplinary team closely followed her. Due to her worsening condition the patient needed a
cesarean delivery and all attempts were made to avoid intubation and the use of sedatives and
hypnotics. Epidural anesthesia with ultrasound guidance was performed. An appropriate sensory level
was achieved via careful titration of 2% lidocaine. A baby boy was delivered and the mother's
respiratory symptoms improved significantly after delivery.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC423
Challenge in the OB Suite: Handling Cardiac and Neurologic Issues in a Pediatric Primigravida
Megha Karkera, M.D., University of Arkansas for Medical Sciences, Little Rock, AR
This challenging case is a 16-year-old primigravida who was found to have severe long segment aortic
stenosis during her pregnancy as well as multiple spinal lipomas during this time. Planning the
anesthetic of this case required a significant amount of research and multi-disciplinary
meetings/agreements. After considerable thought she was planned for an elective Cesarean Section
under general anesthesia with placement of a preinduction arterial line as neuraxial anesthesia of any
kind was considered unwise given her recent diagnosis of spinal lipomas.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC424
ADAMTS13 Missense Mutant R1060W Presenting as TTP in Pregnancy
Catriona Kelly, M.B.Ch.B., Conor McCarroll, M.B. B.Ch., Royal Hospital, Belfast, United Kingdom
A 31-year-old primigravida presented at 33 weeks gestation with a rash and feeling generally unwell.
She was anaemic Hb 38g/L and thrombocytopenic <10x 109/L. On examination the fetal heart was
Copyright © 2013 American Society of Anesthesiologists
absent and there had been no fetal movement for 12 hours. She was diagnosed with TTP and
immediately transferred to tertiary care for plasma exchange and for obstetric management of the
intrauterine death. When her platelets reached 20x 109/L labour was induced. Investigation revealed a
R1060W mutation of the ADAMTS13 protein as the cause for her TTP which was precipitated by
pregnancy.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC425
Multidisciplinary Approach to Successful Craniotomy in Patient Presenting During the 3rd Trimester
Bradley Kelsheimer, Jeffry Ostrander, Abhinava Madamangalam, University of Oklahoma, Oklahoma
City, OK
A 31-year-old female at 31 weeks gestation required a craniotomy for a recurrent ganglioglioma. We
detail the planning process for her cranial surgery including positioning to optimize surgical exposure
and left uterine tilt. Additionally she requested continuous perioperative and intraoperative fetal heart
rate monitoring and an operative delivery for fetal deterioration during craniotomy. We will describe
our multidisciplinary approach to achieving these goals including preparing for a Cesarean section during
a craniotomy in the non L&D ORs at our institution as well as other contingency planning that was
involved for a successful outcome for both mother and fetus.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC426
Pelvic Peritoneal Block Stops Pain Nausea Vomiting and Retching During Cesarean Section Under
Spinal Anesthesia
Stephen Kennedy, M.D., Inova Fairfax Hospital, Falls Church, VA
30-year-old G2P1 female experienced pain nausea vomiting and retching during Cesarean Section under
spinal anesthesia when the uterus was undergoing repair. Instillation of 20ml of 1% lidocaine onto the
posterior wall of the uterus blocks the nerves traversing the peritoneum and immediately stops the
reaction to uterine manipulation. Nerves traversing the peritoneum originate from the pelvic plexus and
include parasympathetic nerves S2 3 4 as well as sympathetic nerves T10-L1. This represents a novel use
for local anesthesia during an open surgical procedure to eliminate pain as well as reflex nausea
vomiting and retching.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC427
Pneumocephalus: Etiology of a Headache After Epidural Placement
Firdous Khan, M.D., Crystal Wright, M.D., Baylor College of Medicine, Houston, TX
This case describes a 34-year-old woman who developed a severe headache after attempted epidural
placement for labor and delivery. Loss of resistance to air was the technique chosen for placement and
the procedure was complicated with breech of dura. A head CT later diagnosed pneumocephalus. In the
setting of a headache pneumocephalus-- although a severe complication--is often overlooked as
opposed to the more well-known post puncture dural headache. Large volumes of air in the brain can
cause serious neurologic complications and questions the advantage of using loss of resistance to air vs.
saline in labor epidural placement.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC428
Anesthetic Management of Cervical Varices in a Parturient
Janelle Kho, M.D., Barbara Scavone, M.D., University of Chicago, Chicago, IL
A 39-year-old patient at 21 2/7 weeks gestation presented with vaginal bleeding and was found to have
cervical varices. She experienced multiple bleeding episodes over several days (total EBL 2 liters) and
presented for cervical compression sutures and possible hysterotomy/hysterectomy. Reports of this rare
cause of bleeding are limited with obstetric management ranging from bed rest to emergent
hysterectomy for massive hemorrhage (Yoshimura: J Ob Gyn Res 2004; 30:323). Anesthetic
management has not been described; optimal practice remains unclear. Our anesthetic plan consisted
of neuraxial anesthesia with general anesthesia held in reserve due to the unpredictable intraoperative
course.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC429
Ex Utero Intrapartum Treatment of Fetal Micrognathia
Nicole King, M.D., Brandon DaValle, D.O., Erik Nagel, M.D., Sara Gonzalez, M.D., Naval Medical Center
San Diego, San Diego, CA
Ex Utero Intrapartum Treatment (EXIT) procedures have emerged as an option for potentially life-saving
procedures in fetuses with predicted airway compromise at birth. A 26-year-old female presents with a
20 week ultrasound and imaging demonstrating severe fetal micrognathia glossoptosis polyhydramnios
absence of a gastric bubble and suspected microtia. An EXIT procedure was completed with successful
intrapartum endotracheal intubation with a flexible fiberoptic bronchoscope through a Laryngeal Mask
Airway (LMA). This case represents the first EXIT procedure at Naval Medical Center San Diego and to
our knowledge only the second EXIT procedure performed in the DOD Military Health System.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC430
Anesthesia for C-Section in a Patient With Marfan Syndrome Complicated by Lumbar Tarlov Cyst
John Kissko, M.D., Emily Baird, M.D., Ph.D., Richard Month, M.D., University of Pennsylvania,
Philadelphia, PA
A 41-year-old G2P1 presented at 38 weeks for elective Cesarean delivery. Her past medical history was
significant for Marfan syndrome with dilated aortic root severe rheumatoid arthritis and multiple Tarlov
and nerve root cysts from L2-S1. During this pregnancy she experienced new onset of numbness and
paresthesias in her right lateral thigh. Surgical anesthesia was provided with a thoracic epidural placed
at the T11/12 space and epidural 1.5% lidocaine with epinephrine 1:200 000 was administered (total
volume 26mL maximum sensory level T3 bilaterally). Low-transverse Cesarean delivery was performed
without neurologic cardiovascular obstetric or surgical complication.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
10:30 AM - 12:00 PM
OB MC431
Anesthetic Management of a Rare Case of Cervical Pregnancy Presented With Vaginal Bleeding:
Coordinated Team Work of the Anesthesiologist the Gynecologist and the Interventional Radiologist
Ahmad Elsharydah, M.D., MBA, Maria Lasala, M.D., UT Southwestern Medical Center, Dallas, TX
A 33-year-old F with cervical pregnancy (9 wks) admitted for vaginal bleeding. Treatments with
intraamniotic injection of KCl and IM injection of Methotrexate failed. Patient's desire was to conserve
uterus for future pregnancies therefore she was scheduled for D&C and possible hysterectomy. To
minimize hemorrhage during D&C an interventional radiologist placed Fogarty balloons in the both iliac
arteries. Balloons were inflated just before the surgery. She received 5 units PRBCs 2 units of FFPs and
one unit of platelets in the OR and post-op ICU care. She recovered fully and was discharged few days
later.
Sunday, October 13
10:30 AM - 12:00 PM
OB MC432
Anesthetic Management for Labor and Cesarean Section of a Parturient With Pseudotumor Cerebri
and Substance Abuse
Christina Lee, M.D., Patricia Dalby, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA
A 33-year-old G10P5 with a history of chronic hypertension diabetes mellitus type 2 pseudotumor
cerebri with prior VP and current LP shunts opioid abuse on Subutex asthma obesity hypothyroidism and
anxiety was admitted at 38w2d gestation for induction of labor. After review of prior imaging showing
the shunt catheter location an epidural was placed at L1-L2. She was taken for cesarean section for
arrest of dilation and intolerance of labor but was unable to tolerate epidural anesthesia secondary to
dyspnea. She underwent a general endotracheal anesthetic was extubated upon completion of surgery
and had an uncomplicated postoperative course.
MCC Session Number – MCC07
Sunday, October 13
1:00 PM - 2:30 PM
PN MC433
Successful Treatment of Peripheral Neuropathic Pain With Duloxetine Following Neruoinvasive West
Nile Virus Infection
Ross Gliniecki, M.D., Ian Fowler, M.D., Lauren Mattingly, M.D., Naval Medical Center San Diego, San
Diego, CA
A 57-year-old female patient presented with severe burning extremity pain two weeks after diagnosis
with neuroinvasive West Nile Virus infection. She had been treated with transdermal fentanyl for
musculoskeletal pain but this was not effective for her presenting neuropathic symptoms. On evaluation
she met DSM-IV criteria for Major Depressive Disorder and was treated with Duloxetine for both MDD
and neuropathic pain. Significant improvement in neuropathic pain symptoms were observed by day 7
and Duloxetine was continued for 5 months until eventual resolution of pain and depressive symptoms.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
PN MC434
Perioperative Alpha-2 Agonist Adjunct Therapy for a Chronic Pain Patient Receiving
Buprenorphine/Naloxone
Brendan Griffis, D.O., John Capacchione, M.D., Matthew Hoch, D.O., Thomas Hayes, M.D., Walter Reed
National Military Medical Center, Bethesda, MD
A 25-year-old male with bilateral hip disarticulations who was taking buprenorphine/naloxone for
chronic pain presented for heterotopic ossification excision of his sacrum and pelvis. He declined
regional anesthesia and received general anesthesia with ketamine dilaudid and sevoflurane. Despite
receiving large doses of opioids and a continuous ketamine infusion his pain remained 10/10 in the
PACU. He was transferred to the ICU and started on a dexmedetomidine infusion in addition to the
ketamine which reduced his pain to 5/10. This case illustrates the utility of alpha-2 agonist adjunct
therapy for a chronic pain patient receiving opioid agonist/antagonists in the perioperative period.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC435
A Novel Use of a Spinal Cord Stimulator in a Patient With Loin-Pain Hematuria Syndrome
Samuel Grodofsky, M.D., Peter Yi, M.D., University of Pennsylvania, Philadelphia, PA
Loin pain hematuria syndrome (LPHS) is a rare poorly understood diagnosis of exclusion characterized by
flank pain and hematuria. We present a case of a 24-year-old woman with LPHS who presented to our
clinic seeking minimally invasive intervention to reduce her pain and opioid requirements. She
underwent a trial and then permanent implantation of spinal cord stimulator (SCS) with leads placed in
paramedian position which brought relief and improved physical functioning. This is the first
documented report of SCS for LPHS which is a much less invasive procedure than renal
autotransplantation the most effective treatment described to date.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC436
Severe Stevens-Johnson Syndrome; How Do I Control Your Pain?
Jessica Hayes, M.D., Bruce Skolnik, M.D., Roy Soto, M.D., Beaumont Health Systems, Royal Oak, MI
AF a 23-year-old male with a history of chronic back pain treated with six to ten Vicodin pills daily and
prescribed marijuana presented to the Emergency Department with complaints of sore throat
conjunctivitis and oral sores. He had recently started taking NSAIDs at home. His symptoms eventually
progressed to severe Stevens-Johnson Syndrome necessitating hospitalization for management of
severe pain and treatment to prevent infection and progression of this disease. His continuing epidermal
and mucosal damage and baseline opiate tolerance necessitated pain service consultation with complex
management of his pain including enteral mucosal topical and parenteral opiates and anticonvulsants.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
PN MC437
Altered Mental Status and Severe Hypotension in a Patient With Intrathecal Baclofen Pump
Yashar Ilkhchoui, M.D., Eugene Koshkin, M.D., Brian Starr, M.D., Suzanne Numan, M.D., Ph.D., University
of New Mexico School of Medicine, Albuquerque, NM
A 53-year-old woman underwent an intrathecal baclofen pump placement to treat severe spasticity
secondary to multiple sclerosis. 6 days after pump refill she developed severe hypotension and
respiratory failure necessitating tracheal intubation and ICU admission. Her pump was interrogated and
no error was noted. Her mental status and muscle tone improved after intrathecal medicine dose was
reduced. She was extubated the day after but remained somnolent. The pump was emptied and it was
noted that baclofen reservoir contained 6 ml less medicine than was programmed. Her intrathecal pump
was replaced and her symptoms resolved in 24 hours.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC438
A Case of Subdural Hematoma After Epidural Blood Patch in a Spontaneous Intracranial Hypotensive
Patient With Multi-Level Cerebrospinal Fluid Leakage
Young Joo, M.D., M.S., Kangwon National University Hospital, Chuncheon-Si Gangwon-Do, Republic of
Korea
A forty-two-year-old male presents to pain clinic with one-month history of spontaneous headache. The
headache is postural and is refractory to conservative therapies and the radionuclide cisternography
showed CSF leaks at T1 and L2 levels. An autologous interlamins epidural blood patches at L1-2 and T1-2
level under fluoroscopy has dramatically relieved symptoms. However he presents to ER 3days later
with severe headache. The computed tomography revealed bilateral subdural hemorrhage (SDH). The
patient underwent craniotomy to remove SDH. Subsequently headache has resolved completely and
patient was discharged without any complication.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC439
High Dose Lamotrigine for Chronic Post Stroke Pain
Danny Joseph, Alfred McKee, Baystate Medical Center, Springfield, MA
A 65-year-old male who had suffered a stroke presented with persistent chronic pain with residual right
hemiparesis. With no relief with conservative and pharmacological therapy his chronic pain became
debilitating to the point that he had attempted suicide. Subsequently he was started on lamotrigine
which showed improvement of his central pain syndrome. The dose of lamotrigine was then titrated
upwards until the pain had resolved reaching a dose of 700 mg per day.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC440
Massive Intracranial Bleed After Intrathecal Pump Revision
Enas Kandil, M.D., University of Texas Southwestern, Dallas, TX
A 64-year-old male with Complex regional pain syndrome of left lower extremity underwent an
Intrathecal pump revision. Past medical history included hypertension coronary artery disease obesity
and depression. Medications included beta-blockers a diuretic gabapentin and duloxetine. Under
Copyright © 2013 American Society of Anesthesiologists
sedation utilizing fluoroscopic guidance while in the lateral position pump was revised with some
difficulty placing the intrathecal catheter requiring multiple needle punctures to the Dura. Patient
tolerated the procedure well and was admitted over night for observation. Over night patient became
unresponsive was found to have suffered a massive intracranial bleed with a large midline shift on CT.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC441
When Breathing is Affected: Pitfalls of Peripheral Nerve Catheters
Michael Kaufmann, M.D., Ravi Singh, M.D., Tariq Malik, M.D., Dalia Elmofty, M.D., Magdalena Anitescu,
M.D., University of Chicago, Chicago, IL
A 52-year-old male with a history of CRPS underwent an ultrasound guided brachial plexus catheter
placement for pain. The catheter was tunneled 2 in. posterior from the supraclavicular fossa. Patient
had excellent pain relief for 3 weeks when he suddenly developed severe chest pain worse with
inspiration. CT image was consistent with catheter migration close to pleura and attempts to remove it
were unsuccessful. Further interventions under fluoroscopy guidance ensured removal of an intact but
significantly stretched catheter with wire uncoiling. This case illustrates the pitfalls of wire reinforced
peripheral nerves catheters and need for deeper tissues tunneling.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC442
Severe Sciatica in a Parturient Patient
Chang-Po Kuo, National Defense Medical Center/Tri-Service General Hospital Duke University Medical
Center, Taipe; Billy Huh, Duke Universisty Medical Center, Durham, NC
A 32-year-old parturient 21 weeks of gestation suffered from acute low back pain with radiculopathy.
The MRI revealed disc protusion at L5/S1 with nerve root compression. Physical therapy and bed rest
didn't provide much help. Her sleep was severely interupted. She could hardly walk or stand for a while.
For the sake of the fetus the parturient refused any medication. After well explaination Enrac
acupressure therapy was applied on her. The pain decreased and she regained normal activities again
soon after the treatment. The life quality returned to her like before as she was not pregnant.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC443
Successful Treatment of Refractory Complex Regional Pain Syndrome With Low-Dose Ketamine
Infusion
Jason Longwell, M.D., Terry Stambaugh, M.D., Walter Reed National Military Medical Center, Bethesda,
MD
A 30-year-old male with a one-year history of bilateral lower extremity Complex Regional Pain Syndrome
(CRPS) refractory to multiple lumbar sympathetic blocks and to neuropathic pain agents (gabapentin
pregabalin duloxetine) was admitted to the hospital for treatment with a low-dose ketamine infusion.
The patient's symptoms resolved completely after 72 hours of ketamine infused at 20 mg/hr and he was
discharged home. He did not require neuraxial or peripheral nerve blockade nor did he require
admission to the intensive care unit. This case illustrates the successful treatment of CRPS without the
potential complications associated with high-dose ketamine treatment.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
PN MC444
Epidural Blood Patch for Spontaneous CSF Leak in the Presence of Immune Mediated
Thrombocytopenia: Between a Rock and a Hard Place.
Ankit Maheshwari, M.D., Akhil Singh, M.D., Shrif Costandi, M.D., Cleveland Clinic, Cleveland, OH
A 32-year-old female presented with complaints of orthostatic headache suggestive of intracranial
hypotension. Imaging demonstrated cerebrospinal fluid leak at the lower thoracic level. Patient was a
known case of immune mediated thrombocytopenia common variable immunodeficiency Sjogren's
syndrome drug induced liver injury chronic steroid use and Diabetes. She also demonstrated persistent
thrombocytopenia in spite of conventional treatment for immune mediated thrombocytopenia. We
describe the considerations involved in planning an epidural blood patch in a patient with spontaneous
CSF leak in the presence of active immune mediated thrombocytopenia.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC445
Pemphigus Vulgaris Related Pain
Apryl Martin, M.D., Azzam Alkhudari, M.D., John H. Stroger Jr Hospital of Cook County, Chicago, IL
A paucity of data exists in the medical literature on pain treatment modalities for patients with
pemphigus vulgaris. Pemphigus vulgaris is a chronic relapsing autoimmune blistering disease of the skin
and mucous membranes that causes extreme pain. However it remains exceedingly rare and few studies
describe the pain component of the disease and treatment outcomes. In patients such as ours with
pemphigus pain that is diffuse nociceptive with coexisting neuropathic components pain management is
complex. We utilized dual morphine therapies for basal and breakthrough pain gabapentin for nerverelated pain and continued disease modifying immunosuppressive therapy to provide optimal pain
relief.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC446
Ketamine Therapy for Opioid Induced Hyperalgesia in a Chronic Pain Pediatric Patient
Mike Martinez, D.O., University of Missouri, Columbia, MO
Chronic pain therapeutic modalities are constantly expanding; however our knowledge of Opioid
Induced Hyperalgesia and its treatments are still very sparse. In this case report we will discuss the
usage of Ketamine for OIH specifically because of its antagonism of the N-methyl-D-aspartate receptor.
Obviating the activation of this ligand-gated calcium channel enables the prevention or interruption of
the wind-up phenomenon which leads to central sensitization. Titrating Ketamine to effect over 6 days
in the pediatric intensive care unit we were able to completely discontinue opioid therapy in a 15-yearold boy with chronic pain stemming from multiple abdominal surgeries.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
PN MC447
Technique for Repositioning Occipital Nerve Stimulator Leads After Migration: A Challenging Case
Report
Matthew Mauck, M.D., Ph.D., Thomas Hopkins, M.D., M.B.A., John Hsia, M.D., Billy Huh, M.D., Ph.D.,
Duke University, Durham, NC
Occipital neuralgia refractory to pharmacologic therapy responds favorably to peripheral stimulation of
the occipital nerves. Electrode migration is a significant complication in occipital nerve stimulation (ONS)
partly because of the mobile anatomical location of electrode placement. We report a patient with
occipital neuralgia who experienced loss of stimulation efficacy and muscle spasm during ONS therapy
secondary to electrode migration which required three electrode revisions to achieve therapeutic
benefit. We describe a method to revise electrode location without replacing the electrodes or accessing
the generator using a Touhy placed along the desired trajectory though which the previously implanted
electrode was passed.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC448
The Naltrexone Conundrum: Perioperative Pain Management of the Patient on Naltrexone
Brian Mirante, M.D., Keun Chung, M.D., Donna-Ann Thomas, M.D., Yale University School of Medicine,
New Haven, CT
39-year-old F presents for robotic assisted radical hysterectomy. Patient in Naltrexone rehabilitation
program for history of alcohol and heroin abuse. Presented for surgery after having never discontinued
her Naltrexone. Neuroaxial and non-opioid technique planned but aborted after vasovagal event during
attempted epidural placement. Surgery postponed and patient later presented off Naltrexone.
Perioperative anesthetic pain management included Ketamine bolus and infusion Propofol infusion
Ketorolac intravenous Acetaminophen. Post-operatively patient complained of mild-to-moderate pain
effectively supplemented with Dilaudid 0.6 mg IV. Patient discharged POD#1 without complication and
with pain adequately controlled. No additional opioids used.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC449
Placement and Management of a Thoracic Epidural Catheter for Postoperative Analgesia in a Patient
With Dual Spinal Cord Stimulators
Rahul Modi, M.D., Michael Sniderman, M.D., Keck School of Medicine of USC, Los Angeles, CA
65-year-old woman (ASA 3) undergoing laparoscopic esophagectomy with gastric pullup for severe
dysphagia secondary to scleroderma. She had two spinal cord stimulators implanted for Chronic
Regional Pain Syndrome (CRPS) in the right lower extremity and post-herpatic neuralgia. Her pain was
never controlled with the SCSs thus they were turned off and her pain physician started a regimen of
Baclofen cymbalta neurontin and oxycodone. Given her history of chronic pain and the potential for
converting to an open procedure we placed and managed a thoracic epidural catheter in a patient with
existing dual spinal cord stimulators.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
PN MC450
Sphenopalatine Ganglion Block for Treatment of Malnutrition Related to Odynophagia and Dysphagia:
A Case Report
Arash Motamed, M.D., MBA, Kartik Ananth, M.D., Steven Richeimer, University of Southern California,
Los Angeles, CA
A 69-year-old male with tonsillar malignant squamous-cell carcinoma presented with refractory
dysphagia and odynophagia secondary to severe radiation induces oral mucositis and 12.7kg weight
loss. Sphenopalatine ganglion block with 1ml of 4% lidocaine instilled in each nares was performed with
immediate and complete resolution of symptoms for about 10 minutes allowing time for intake of high
calorie drinks. After appropriate training the patient performed this block twice daily at home.
Subsequently the patient's mood and caloric intake improved bypassing the need for a gastric tube. He
continued to apply the lidocaine drops for the duration of his radiation therapy.
Sunday, October 13
1:00 PM - 2:30 PM
PN MC451
Challenges in Treating Pain in a Patient With Systemic Botulism
Shahryar Mousavi, Anthony Lebario, M.D., Donna-Ann Thomas, M.D., Steven Surrett, M.D., SUNY
Upstate University Hospital, Syracuse, NY
Botulism is a rare but serious paralytic illness caused by a nerve toxin that is produced by the
bacteriumClostridium botulinum. This leads to paralysis usually requiring ventilation assistance. We
present a 43-year-old male status-post lap band placement which was complicated by gastric erosion
requiring surgical removal of the band. The patient was readmitted for symptoms of blurry vision
numbness in the tip of his tongue and dizziness. He was found to be positive for Botulinum toxin from
swabs of his rectum. He had resistant abdominal pain which was found to be neuropathic after response
to gabapentin.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC452
Emergency Intubation in a Patient With an Endobronchial Stent
Matthew Draughon, M.D., Baylor College of Medicine, Houston, TX
As anesthesiologists we should be knowledgeable about endobronchial stents and understand how to
manage patients with these devices in elective and emergent situations. In our case a lung cancer
patient with an in situ endobronchial silicone Y-stent had a code blue event and required emergent
intubation. Due to the complex nature of the patients airway and poor communication there was
difficulty with intubation. We learned that effective communication understanding the stent types and
their complications and bronchoscopic visualization of the trachea and stent with careful guidance of
the ETT into position are vital in securing the airway in these patients.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC453
An Imposssible Airway in the Emergency Department
William Dudney, M.D., Vanderbilt University Hospital, Nashville, TN
N.F. arrived to our ED after being found down. She had obvious craniofacial defects. Intubation by ED
physicians had failed. The anesthesia airway team arrived with patient being ventilated by LMA.
Intubation was attempted using portable video laryngoscope without success. Markedly abnormal
anatomy was noted. LMA was placed but ventilation was tenuous due to aspiration. A fiberoptic
intubation also failed and he patient could not be ventilated. Her airway was managed with
simultaneous bronchoscopy and cricothyroidotomy by the anesthesia and ED teams respectively.
Patient arrested during cricothyroidotomy and ACLS initiated. Airway could not be established and she
expired.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC454
Anesthetic Management in a Patient With Advanced Fibrodysplasia Ossificans Progressiva
Cary Effertz, M.D., Edwin Rho, M.D., Mayo Clinic, Rochester, MN
A 55-year-old male with Fibrodysplasia Ossificans Progressiva (FOP) presented for ureteroscopic stone
extraction. Extensive heterotopic ossification of the spine jaw and larynx created unique anesthetic
challenges. General anesthesia was chosen over neuraxial technique due to extensive spinal
calcifications and avoidance of causing post traumatic ossification. An 18g IV was placed atraumatically.
He was positioned awake and intubated via oral fiberoptic intubation. ENT was at bedside during
intubation with a drill (due to overlying calcification) to assist with emergency tracheostomy if
necessary. The procedure extubation and postoperative period were uncomplicated and the patient was
discharged to home the following morning.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC455
Presumed Tension Pneumothorax
Nihal Eisa, M.D., Johns Hopkins Hospital, Baltimore, MD
56-year-old male with mental retardation and congenital hydrocephalus comes in after having a seizure.
He has limited verbal interaction and comprehension at baseline. He was taken to the OR for VP shunt
revision with no intra-op complications. Shortly after being transported to the PACU patient developed
shortness of breath hypoxia hypotension and agitation. Lung sounds were diminished on the right.
Neurosurgery noted they threaded the shunt with the wrong end of the wire intra-op. They performed
immediate needle decompression of the right lung after which CXR showed massive right lung
atelectasis. Patient was re-sedated intubated and chest tube placed.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC456
Whether It Is Nobler to do Regional Anesthesia: Part 2 of 2
Jennifer Eldredge, M.D., Jason McKeown, M.D., University of Alabama Birmingham, Birmingham, AL
A 60-year-old female with a recognized difficult airway due to a severely curved cervical spine deformity
presented to an outside hospital with a right hip fracture. She could not be intubated for fixation of her
Copyright © 2013 American Society of Anesthesiologists
hip fracture so she was transferred to UAB for further management. The patient also had a history of
lumbar spine instrumentation so the anesthesia team elected to place an intrathecal catheter for
continuous spinal anesthesia. After initial difficulties the intrathecal catheter was successfully placed
under fluoroscopic guidance. The patient underwent right hip hemiarthroplasty with continuous spinal
anesthesia for intraoperative and postoperative pain management.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC457
Submental Intubation: An Alternative to Tracheostomy in Maxillofacial Trauma
Macdale Elwin, M.D., Michael Perrino, M.D., Parwane Pagano, M.D., David Koslovsky, M.D., Columbia
University, New York, NY, Edward Chen, M.D., North Shore-LIJ Health System, Long Island, NY
21-year-old male presented after an assault during which he sustained facial trauma. Imaging showed
extensive maxillofacial fractures requiring a Le Fort I fracture reduction and fixation and orbital floor
reconstruction. As an oral endotracheal tube (ETT) would interfere with intraoperative occlusion and
nasal intubation was contraindicated the decision was made to proceed with submental intubation. The
patient was intubated orally with a flexible reinforced ETT. The surgeon then created a passage in the
submental region allowing the proximal end of the ETT to be externalized while its distal portion was
stabilized. ETT position was reconfirmed with fiberoptic bronchoscopy.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC458
Abdominal ICD Replacement for a Patient With Fontan Cardiac Physiology and on Long-term
Amiodarone Therapy: Anesthetic Options and Implications
Joshua Emmett, M.D., Ahmad Elsharydah, M.D., UT Southwestern Medical Center, Dallas, TX
A 34-year-old male was admitted for abdominal pacemaker/ICD replacement. The device was placed for
sinus node dysfunction and syncope secondary to recurrent atrial arrhythmia. His cardiac history
included transposition of the great vessels and single ventricle with left ventricle morphology s/p several
cardiac surgeries including Glenn and modified Fontan procedures. He was started on oral Amiodarone
for better control of his arrhythmia. Additionally he had a history of moderate asthma GERD and
obstructive sleep apnea on CPAP. Anesthetic options were discussed with the patient and the procedure
was done under uneventful MAC/local anesthesia.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC459
Perioperative Blood Transfusion Considerations for a Patient With IgA Deficiency Presenting for
Cardiac Surgery
Timothy Erpelding, M.D., Lavinia Kolarczyk, M.D., UNC Hospital, Chapel Hill, NC
71-year-old male with a history of coronary artery disease severe aortic stenosis IgA deficiency and
thrombocytopenia presented for CABG and AVR. Perioperative hematologic considerations included risk
of coagulopathy as well as a risk of anaphylaxis to FFP and non-leukoreduced blood products. Given the
high likelihood of transfusion a perioperative transfusion strategy was established. Blood conservation
strategies were employed and the availability of leukoreduced blood products and FFP (donated by a
known IgA deficient donor) was confirmed prior to surgery. This case illustrates the importance of
perioperative collaboration between anesthesiology hematology cardiac surgery and the blood blank.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC460
An Adult Patient With Acute Epiglottitis and Croup - Approach to Emergency Airway Management
Enrique Escobar, M.D., Shahla Escobar, M.D., Carl Adkins, M.D., Gerald Matchett, M.D., University of
Texas Southwestern Medical Center, Dallas, TX
A 48-year-old woman with a past medical history significant for psoriasis on etanercept and adalimumab
presented to the emergency department with a three day history of a barking cough and throat pain.
The patient developed worsening respiratory distress and was emergently transported to the operating
room for airway management. After pretreatment with midazolam the patient was sedated with
ketamine which improved her bronchospasm and stridor. She underwent an uneventful inhalational
induction of general anesthesia with a mixture of heliox and sevoflurane with no muscle paralysis. While
spontaneously breathing the patient was successfully intubated with a video laryngoscope.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC461
Massive Postoperative Pulmonary Embolism : Cause of Cardiac Arrest in the Post Anesthesia Care Unit
Arash Esmailzadegan, M.D., Roman Dudaryk, M.D., University of Miami Miller School of Medicine,
Miami, FL
A 54-year-old male who suffered a cardiac arrest in the PACU following operative fixation of a right
femur neck and shaft fracture. ACLS algorithm was initiated leading to return of spontaneous circulation.
TEE was performed immediately post arrest and demonstrated a massive pulmonary embolism and right
heart strain. Infusion of tissue plasminogen activator was initiated as acute treatment of the PE in the
PACU. The following day pulmonary embolectomy was performed.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC462
When a Ruptured Uterus Turns Into a Ruptured Lung
Nicole Fairweather, M.B. B.S., Francesca Rawlins, M.B. B.S., Princess Alexandra Hospital, Brisbane,
Australia
Failed intubation occurs in approximately 1:250 obstetric general anesthetics and despite advances in
airway management devices this incidence has not changed in 20 years. Failed intubation is an
important factor contributing to both maternal and fetal morbidity and mortality. With an increasing
incidence of cesarean section deliveries prediction and management of the obstetric difficult airway
remains an important learning point. We present a case of 'can't intubate can't ventilate' in an
emergency cesarean section complicated by the development of a tension pneumothorax and
bronchopleural fistula. We describe the subsequent management of the difficult obstetric airway for
one lung ventilation.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC463
Liver Biopsy and Excision of Pelvic Masses in a Patient Suspected to Have Carcinoid Syndrome
Michael Fakhry, M.D., NYU Medical Center, New York, NY
The patient is a 49-year-old female with a history of a T3N1 ileocolic carcinoid tumor s/p resection two
years prior presenting with increasing liver and ovarian masses on MRI as well as an elevated serum
Copyright © 2013 American Society of Anesthesiologists
serotonin level. She underwent a diagnostic laparoscopy liver biopsy left salpingo-oophorectomy and
right ovarian biopsy under GETA with an arterial line. She was pretreated with diphenhydramine
famotidine and dexamethasone with octreotide readily available. The case proceeded successfully with
no significant cardiopulmonary instability attributed to neuroendocrine mediators. The pathology report
for the liver masses and left ovarian mass indicated metastatic carcinoid tumor.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC464
When a Chance to Cut is Not the Best Option: An Anesthesiologist's Perspective
Tania Faruque, Cleveland Clinic Foundation, Cleveland, OH
An 82-year-old female presented to the ER of an outside hospital with dyspnea thyroid mass and was
transferred for thyroidectomy. Her medical history there included recent pacemaker implantation with
baseline 2-3rd degree heart block raising questions of adequate pacemaker function. Echocardiography
revealed pulmonary pressures of 88 sytolic with good LV function and mild right ventricular dysfunction.
Chest CT demonstrated tracheal compression from right-posterior mass extending to the carina
including calcifications and pleural effusion. Preoperative anesthetic consultation occurred regarding
potential median sternotomy but was postponed for pacemaker evaluation medical consult and repeat
echocardiography to confirm outside findings. Thoracocentesis was performed.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC465
Airway Management in Patient With Tracheal Impalement
Robert Fiala, M.D., Monique Espinosa, M.D., Jackson Memorial Hospital/ University of Miami Miller
School of Medicine, Miami, FL
A 30-year-old male presented to our trauma center after being struck in the neck with several pieces of
shrapnel from a lawnmower. Vitals were stable. There was no crepitus nor blood in the oropharynx.
Physical examination revealed a high probability of tracheal impalement. The patient was taken to the
OR. We performed a rapid sequence fiberoptic intubation in order to visualize any tracheal injuries and
allow for both surgeons and the anesthesia team to see. The exam confirmed that the debris had
penetrated the trachea. The airway management of this case was medically challenging and discussion
would be enlightening.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC466
Airway Management in a Subject with Tracheal Injury Esophageal Injury and Subcutaneous
Emphysema
Daria Flores, M.D., Suman Rajagopalan, M.D., Raja Palvadi, M.D., Baylor College of Medicine, Houston,
TX
Traumatic penetrating injury to the neck can pose a challenge to the anesthesiologist depending on the
structures involved. A 23-year-old patient with multiple gunshot wounds to the neck and thorax was
brought to the operating room for bronchoscopy and esophagoscopy. Endotracheal intubation was
done after taking necessary cervical spine precautions. His examination revealed tracheal injury 2.5
centimeters proximal to the carina and a complete esophageal transection 25 centimeters from the
incisors. The endotracheal tube was emergently exchanged for a left-sided double lumen tube while
Copyright © 2013 American Society of Anesthesiologists
trying to maximize oxygenation and prevent further subcutaneous emphysema in order to facilitate the
surgical repair.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC467
Postoperative Ischemic Optic Neuropathy Following Short Non-Spine Surgery in the Prone Position
Marylin Fouche, University of Mississippi Medical Center, Jackson, MS
This case illustrates the increased risk of ischemic optic neuropathy after non-spine prone surgery
involving a 61-year-old male with history of morbid obesity diabetes mellitus and hypertension
scheduled to undergo hip fracture repair. Prone positioning proved difficult due to body habitus; eyes
free from pressure and neck was maintained in the neutral position. Intraoperative management
involved large fluid shits subsequent to large blood loss exogenous blood administration and liberal
crystalloid administration. Upon resumption of the supine position patient exhibited significant
periorbital edema. Post-operative visit revealed patient with significant bilateral visual loss later shown
to be ischemic optic neuropathy.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC468
A Great Big Urology Job: But What About the Patient?
Steven Boggs, M.D., MBA, Ram Roth, M.D., Elizabeth Frost, M.D., The Icahn School of Medicine,
Manhattan, NY
67-year-old male with multiple medical problems including hypertension congestive heart failure CAD
s/p bypass EF = 30% atrial flutter s/p ablation pulmonary hypertension (210/120) COPD asthma renal
failure on dialysis anemia DM Type I opioid and cocaine dependent. Pt. had distal right ureterectomy for
ureteral carcinoma the previous year now with recurrence in both bladder and right kidney and desired
curative procedure - radical cystoprostatectomy with bilateral nephroureterectomies. We examine the
considerations in managing a patient with significant comorbidities for an extensive procedure.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC469
Anesthesia Considerations and Positioning Issues in a Patient With Multiple Sclerosis and Bilateral
Severe Limb Contractures Needing Prone Positioning for Surgery
Marc Galland, D.O., Tilak Raj, M.D., University of Oklahoma Health Sciences Center, Oklahoma City, OK,
Raghuvendar Ganta, M.D., VA Medical Center, Oklahoma City, OK
Patient is a 53-year-old female with history of severe MS bed-ridden with bilateral severe limb
contractures worse in the lower limbs Hx of seizure disorder CVA and DM. She was scheduled for a
percutaneous nephrolithotomy for removal of staghorn calculi. Particularly challenging in this case was
the pharmacologic management of the patient with severe MS and the need for prone positioning for
surgery made difficult by her limbs in fixed flexion. We present our successful anesthetic management
and describe with clinical pictures our approach in successfully managing her positioning. Which is
better for padding - foam or gel?
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC470
Successful Single Lung Ventilation With Low Fi02 During an Anterior Mediastinal Mass Excision on a
Patient at Risk of Bleomycin Oxygen Toxicity
Mauricio Garcia Jacques, M.D., Marc Mecoli, M.D., BIDMC, Boston, MA
28-year-old with an anterior mediastinal mass concerning for Hodgkin Lymphoma sp 5 cycles of ABVD
resistant to therapy who presents to the OR for excision of residual mass and lung decortication via
VATS. Her last cycle of chemotherapy was administered 20 days prior to day of surgery. The patient was
induced general anesthesia with a 50% FiO2 preoxygenation and intubated with a 37F left DLT with FOB
assistance and maintained with FiO2 of 30% during the case with 50% for emergence. We tolerated
SpO2 of 90%. She was extubated in OR and discharged home POD#3.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC471
Intraoperative Anaphylaxis to Thymoglobulin During Renal Transplantation
Brittany Garel, M.D., The Johns Hopkins Hospital, Baltimore, MD
A 50-year-old male with polycystic kidney disease presented for kidney transplantation. Induction and
intubation as well as arterial and central venous catheter placement were performed uneventfully.
Cefazolin dexamethasone and thymoglobulin were administered. Intraoperatively the patient abruptly
became hypotensive and hypoxic developed elevated peak airway pressures and end-tidal carbon
dioxide tracing declined to zero. This was followed by pulseless electrical activity. The patient was
extubated reintubated and evaluated using fiberoptic bronchoscopy and TEE. The patient was treated
primarily with epinephrine and albuterol. Transplantation was aborted and he was transferred to the
SICU. He was extubated the following day without sequelae.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC472
A Case of Atypical Butyrylcholinesterase and Postoperative Awareness
Anthony Giberman, M.D., Richard Hirasuna, M.D., Naval Medical Center San Diego, San Diego, CA
A 31-year-old female presents for tonsillectomy. Induction was with alfentanil lidocaine and propofol
followed by succinylcholine oral intubation and desflurane for maintenance. At surgical completion
desflurane was discontinued but the patient remained unresponsive for another hour and could not be
extubated until two hours following induction. The patient was conscious but paralyzed in the OR for
over 30 minutes before the diagnosis of atypical butyrylcholinesterase was suspected. Post-operative
labs revealed a Dibucaine number of 27. This case highlights atypical butyrylcholinesterase as a cause of
delayed awakening and the risk of awareness for affected patients while paralyzed in the operating
room.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC473
A Rare Case of Laryngeal Mask Airway Breakage in a Patient With Acute Airway Obstruction.
Matthew Gilbert, M.D., M.P.H., Jessica Lovich-Sapola, M.D., Case Western Reserve University
Metrohealth Medical Center, Cleveland, OH
One use of laryngeal mask airways (LMA) is in the ASA difficult airway algorithm. This is exemplified in
our case of a 68-year-old male undergoing an exploratory laparotomy with a presumed airway
obstruction after post-operative extubation. An LMA was placed and succinylcholine was administered
for re-intubation. While attempting to remove the LMA the laryngeal mask separated from the plastic
tubing a situation that has not yet been cited in literature. After the remaining LMA was removed the
trachea was re-intubated. Post-operatively he was transported to the SICU trachea extubated on postoperative day 5 and discharged 4 days later.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC474
Toxic Oxygen? Managing a Patient After Bleomycin Chemotherapy
Laura Gilbertson, M.D., Jay Roby, M.D., University of Southern California, Los Angeles, CA
A 29-year-old male with stage 3 metastatic testicular cancer presented for RPLND after three rounds of
bleomycin chemotherapy. Due to concerns about development of bleomycin induced lung toxicity room
air was used for induction. The patient was maintained throughout the procedure with an FiO2 below
25%. Fluid restriction was used as fluid overload has been shown to increase the incidence of pulmonary
insufficiency and ARDS in patients with bleomycin exposure. The patient was extubated on room air at
the end of the nine hour procedure without development of respiratory complications.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC475
Anesthesia in an Austere Environment and Sea Lion Dive Physiology: Measuring Heart Rate and Stroke
Rate in Diving California Sea Lions
Ross Gliniecki, M.D., Naval Medical Center San Diego, San Diego, CA, Birgitte McDonald, Ph.D., Paul
Ponganis, M.D., Ph.D., Scripps Institution of Oceanography, San Diego, CA
This study measured heart rate response in sea lions foraging deep in the ocean on a single breath. The
mammals were anesthetized in the field and equipped with digital electrocardiograms and
time/depth/3-axis acceleration loggers. Anesthesia equipment was compact and portable: O2 tank
circuit CO2 absorber volatile anesthetic vaporizer zalophyscope endotracheal tube and bite block.
Anesthesia involved mask induction laryngoscopy and endotracheal intubation. Sea lions displayed
bradycardia often below 10 beats min-1 in dives longer than 6 minutes. Flipper stroke rate was low for
most of the dive suggesting that muscle relies primarily upon myoglobin-bound O2 for energy
metabolism.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC476
To Trach Or Not To Trach (Part 1 of 2): Management of a Known Difficult and Highly Unusual Airway
During Tracheocutaneous Fistula Closure
Lee Goeddel, M.D., M.P.H., Damon Cox, M.D., Jason McKeown, M.D., University of Alabama at
Birmingham, Birmingham, AL
52-year-old female presents for tracheocutaneous fistula closure. Three months prior a type II odontoid
fracture required emergent tracheostomy and occiput - C4 fusion. Exam demonstrates trismus narrow
oral opening narrow palate hypertrophic tongue base reduced O-C2 angle and severe tracheal stenosis.
After induction ventilated only with 4.0 stomal ETT. Intubation succeeded only with retrograde passage
of pediatric bougie through the stoma. Closure of the stoma was uneventful. After extubation audible
stridor appreciated with rapid desaturation. Trans tracheal jet ventilation through vessel dilator
cricothyrotomy maintained oxygenation until oral fiberoptic intubation was successful. Patient
extubated after two SICU days.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC477
Capnothorax With Abdominal Insufflation - Tension Running High
Caron Hong, M.D., Nicholas Goehner, M.D., University of Maryland, Baltimore, MD
A 57-year-old female presented for recurrent hiatal hernia repair. After induction with propofol fentanyl
and rocuronium a 7.0 ETT was placed and the patient positioned supine. The abdomen was insufflated
with CO2 to 15mmHg. While mobilizing the stomach end-tidal CO2 increased from 35 to >100 mmHg.
ETT placement was confirmed circuit continuity assured and the surgical team informed. CO2
insufflation and surgical dissection was discontinued. The patient was hyperventilated to normocapnea
within minutes. Given timing of hypercapnea with dissection around the espophageal hiatus
capnothorax was suspected. The surgery was completed laparoscopically utilizing higher PEEP and lower
insufflation pressures successfully.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC478
Anesthetic Challenges in a Patient With Carcinoid Syndrome and Carcinoid Heart Disease Presenting
for a Non-Cardiac Surgery
Andrea Gomez Morad, M.D., Lisa Vukalcic, M.D., Saint Elizabeth's Medical Center, Boston, MA
Carcinoid tumors are uncommon neoplasms capable of producing bioactive substances resulting in a
variety of physiologic changes. Carcinoid syndrome can cause tricuspid and pulmonic valvular disease
which can lead to severe right ventricular failure. We present a case of a 63 -year-old female with
obstructive acute renal failure scheduled for a cystoscopy and bilateral nephrostomy tubes placement.
She had diagnosis of carcinoid syndrome with cardiac involvement (severe tricuspid regurgitation and
right heart failure). We are going to describe our management discuss the preoperative considerations
intraoperative goals and postoperative care of patients with carcinoid syndrome and carcinoid heart
disease.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC479
Profound Hypotension Without Identifiable Cause: Anesthetic Management of SIRS Response to
Trauma
Michelle Gonta, M.D., Jennifer Alt, M.D., Alexander Nacht, M.D., NYU School of Medicine/Bellevue
Hospital Center, New York, NY
66-year-old female with PMH DM struck by garbage truck and sustained right tibia-fibula fracture and
disruption of popliteal artery. Patient emergently taken to OR for external fixation of fracture and right
popliteal artery angioplasty. External fixation done without complication 2 units PRBCs transfused.
During angioplasty patient became transiently hypotensive with SBP 90s. Hematocrit dropped from 27
to 20 2 more units transfused however patient becoming increasingly hypotensive requiring multiple
pressor boluses without improvement and finally infusion of 2 pressors. Multiple possible sources of
bleeding surgically explored however source never found. Continued hypotension attributed to SIRS
response to trauma.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC480
To Cancel or Not to Cancel? Challenges in the Management of Repeated Intraoperative Urticaria in a
Nonelective Surgery
Silpa Goriparthi, M.D., Tara Kennedy, M.D., Thomas Jefferson University Hospital, Philadelphia, PA,
Michael Gollotto, M.D., Our Lady of Lourdes Medical Center, Camden, NJ
A 71-year-old male smoker with a history of renal cell carcinoma presented with a suspicious lung mass.
Shortly after induction significant truncal urticaria was noted. The case was cancelled and allergy
consultation was obtained. Skin testing of several anesthetic agents was negative. The patient returned
for surgery and was pretreated with diphenhydramine and decadron. After induction he was found to
have even more severe urticaria. After discussion with the allergist the case was cancelled again. We will
discuss limitations of allergic skin testing of anesthetic agents and the differential diagnosis and
treatment of perioperative urticaria in a non-elective surgery.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC481
An Unusual Difficult Airway Related to Severe Kyphosis
Sandra Goyal, M.D., Rush University Medical Center, Chicago, IL
An 85-year-old female with a complex medical history including colon cancer and restrictive lung disease
presented for right hemicolectomy. Following induction of anesthesia attempted intubation with a 7.5
endotracheal tube (ETT) failed when the ETT could not be passed beyond the vocal cords despite their
grade one view with direct laryngoscopy and glidescope visualization. No tracheal stenosis or overt
abnormality was seen upon airway assessment with a fiberoptic bronchoscope. Intubation was finally
achieved with repeat laryngoscopy and use of a 6.0 ETT. A cervico-thoracic CT later revealed severe
kyphosis with extreme tracheal curvature likely complicating passage of the 7.5 ETT.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC482
GlideScope-Assisted Fiberoptic Bronchoscopy for Tracheal Intubation of the Difficult Airway
Heather Gray, M.D., Shawn Statzer, M.D., St Louis University, St Louis, MO
44-year-old male with cervical spinal stenosis presented for anterior cervical spinal fusion. Physical exam
was significant for severely limited neck movement limited thyromental distance and Mallampati score
of III. After standard IV induction intubation with a GlideScope and bougie failed. Cords were visualized
however the angle was too severe to introduce the bougie. Fiberoptic bronchoscopy also failed as the
cords were unable to be visualized. GlideScope was then placed and fiberoptic bronchoscope loaded
with ETT was introduced into the trachea under visualization via GlideScope. ETT was then placed over
bronchoscope.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC483
No End-Tidal CO2 Secondary to Bronchospasm
Mark Boswell, M.D., Ph.D., Kyle Greer, M.D., University of Louisville, Louisville, KY
We describe an 18-year-old pregnant female at 23 weeks gestation with a history of asthma who
presented for left video-assisted throracoscopic surgery for pneumonia and pleural effusion. Following
intravenous induction and an atraumatic intubation with a double-lumen endotracheal tube no endtidal carbon dioxide was observed on capnography. The patient experienced rapid desaturation.
Removal of the double-lumen tube and mask ventilation returned saturations to normal. Reintubation
resulted again in no end-tidal carbon dioxide and rapid desaturation. A diagnosis of bronchospasm was
made and treatment with volatile and intravenous anesthetics eventually resulted in normal waveform
capnography.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC484
Sudden drop in SaO2 With Left Lung White-Out After Induction of General Anesthesia in a Patient
Undergoing Pituitary Resection for Cushing's Disease
Shaun Gruenbaum, M.D., Harika Nagavelli, M.D., Alice Li, B.Sc., Benjamin Gruenbaum, M.D., Michael
Hrycelak, M.D., Yale University School of Medicine, New Haven, CT
A 27-year-old female with history of Cushing's disease obesity was scheduled for endonasal
transsphenoidal resection of a pituitary tumor. After uneventful induction of general anesthesia and
endotracheal intubation the patient had sudden drop in Sa02 to 81% that did not improve with
manipulation of mechanical ventilation settings. ABG revealed PaO2 of 82 despite FiO2 of 100%. After
several minutes of ventilation PaO2 improved to 130 chest x-ray demonstrated complete white-out of
the left lung. The case was cancelled and the patient was transported to NICU where she improved and
was extubated within a few hours.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
FA MC485
Symptoms of Pheocromocytoma in a Patient With Cushing's Disease Scheduled for Pituitary
Resection: To Delay or Not Delay?
Shaun Gruenbaum, M.D., Benjamin Gruenbaum, M.D., Alice Li, B.Sc., Harika Nagavelli, M.D., David
Silverman, M.D., Yale University School of Medicine, New Haven, CT
A 27-year-old female with a history of Cushing's Disease secondary to pituitary tumor was evaluated in
the preoperative clinic. She had a 90 lbs weight-gain over 4 years insomnia buffalo hump moon facies
acne depression and borderline hyperglycemia. On questioning she reported daily episodes of
unprovoked tachycardia to 120 associated with palpitations and dyspnea. Per the patient's primary
doctor she had previously demonstrated runs of supraventricular tachycardia and atrial fibrillation of
unclear etiology on Holter monitor. A pheocromoctyoma was suspected and we considered whether the
case needed to be delayed for further workup.
Sunday, October 13
1:00 PM - 2:30 PM
FA MC486
Anesthetic Implications and Considerations During Paraganglioma Resection
Ryan Gualtier, M.D., NYU School of Medicine, New York, NY
35-year-old female with PMH of HTN and HCV presented with two-year history of right flank pain night
sweats and palpitations. Upon initial workup the 24-hour urine metanephrines were highly positive. MRI
CT and MIBG scans confirmed presence of 3.5cm hypervascular mass medial to the IVC consistent with a
paraganglioma. The patient was medically optimized for surgery including blood pressure control with
Phenoxybenzamine and Metoprolol. Intra-operatively blood pressure was extremely labile due to IVC
compression and manipulation of the paraganglioma causing massive catecholamine surges.
Dexmedetomidine Phenoxybenzamine Nitroglycerin and Esmolol were utilized to blunt the
catecholamine response and rapidly control blood pressure.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC487
Naltrexone Induced Opioid Supersensitivity
Rocco Landi, M.D., Mark Shulman, M.D., St. Elizabeth's Medical Center, Brighton, MA
Naltrexone is a pure antagonist of the mu opioid receptor with up-regulatory effects on receptor
expression with chronic exposure. We present the case of a 61-year-old female with a hepatic mass
scheduled for segmental liver resection and cholecystectomy. Unbeknownst to the anesthetic team the
patient had undergone chronic naltrexone treatment under the care of her psychiatrist. After receiving
0.6 mg of epidural hydromorphone intraoperatively the patient experienced profound respiratory
depression resistant to naloxone reversal. We describe our management and review the literature
exploring the effects of chronic naltrexone treatment on mu-opioid receptor expression and activity.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
RA MC488
Acute Perioperative Pain Management With Combined Epidural Analgesia and Ketamine Infusion
Therapy for Major Thoracoabdominal Surgery in a Patient on a High Maintenance Methadone Dose
Julianne Lee, M.D., Keun Sam Chung, M.D., Yale University School of Medicine, New Haven, CT
32-year-old male with history of testicular cancer presented for a Retroperitoneal Lymph Node
Dissection. Patient's history also included IV Heroin use several years ago on Methadone 130 mg daily at
the time of presentation. A low thoracic epidural was placed before induction of general anesthesia.
Epidural Bupivicaine/Hydromorphone continuous infusion in combination with a low dose Ketamine
infusion was started intraoperatively and continued postoperatively. The patient received a total of 75
mg Methadone IV during the procedure requiring no additional opioid. This combination provided
effective acute pain control for this opioid tolerant patient demonstrating its synergistic and opioidsparing effects.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC489
A Case of Mistaken Identity: Epidural Hematoma Versus Abscess
Parul Maheshwari, M.D., Mahammad Hussain, M.D., Praveen Maheshwari, M.D., Aseem Hemmad, M.D.,
University of Texas Houston, Houston, TX
72 M s/p complicated colon resection. Platelet 236 PT 16.3 PTT 48.5 INR 1.29. For Lt Radical
Nephrectomy. Preop epidural done. Postop day 1 getting confused and requiring off and on
vasopressor. Epidural out post op day 4 Lab Pl 220 PT 18.6 PTT 59.8 INR 1.54. Vit K and FFP given. Blood
culture positive for MRSA. 3 days after removal of epidural patient not able to move lower extremity
MRI showed extensive blood clot filling the epidural space from T1 through T12 compressing the spinal
cord. Patient taken to OR for emergent laminectomy of T3-T10. Pathology showed epidural abscess.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC490
Bilateral Transversus Abdominis Plane Catheters for Peri-perative Pain Control in a Patient With
Reflex Sympathetic Dystrophy With a Spinal Cord Stimulator Undergoing an Open Right
Hemicolectomy: A Case Report.
Natasha Malackany, D.O., Hesham Elsharkawy, M.D., Kamal Maheshwari, M.D., Wael Ali Sakr Esa, M.D.,
The Cleveland Clinic, Cleveland, OH
We report the peri-operative management of bilateral transversus abdominis plane (TAP) catheters in a
patient with reflex sympathetic dystrophy with a spinal cord stimulator who underwent an open right
hemicolectomy. Bilateral TAP catheters were placed pre-operatively under ultrasound-guidance and
tunneled backward away from the surgical field. 15 mL of ropivicaine 0.5% was injected to each side and
ropivicaine 0.2% was infused continuously at 8mL/hour. The patient required minimal narcotics postoperatively only while her spinal cord stimulator was off. TAP catheters are an option for peri-operative
pain management in patients with reflex sympathetic dystrophy and spinal cord stimulators undergoing
abdominal surgery.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
RA MC491
What to do With an Epidural Catheter in a Patient who Becomes Placed on ECMO?
Behram Mehta, M.D., Ehab Farag, M.D., Cleveland Clinic, Cleveland, OH
This was a 79-year-old male with a past medical history of T2N0M0 esophageal adenocarcinoma and
prostate cancer who underwent an esophagectomy. The patient had a T8-9 epidural placed
preoperatively for postoperative pain control. Early in the postoperative course the patient had an
evolving posterolateral MI from an occluded left circumflex which was treated with stent placement
IABP and initiation of V-V ECMO. Patient received clopidogrel and abciximab during stenting and was
subsequently started on a heparin drip. Now that the patient was receiving full anticoagulation the
medically challenging question was when could the patient's epidural catheter be removed?
Sunday, October 13
1:00 PM - 2:30 PM
RA MC492
Using a Double Epidural Technique for Postoperative Analgesia: A Case Study
Tucker Mudrick, M.D., Brian Allen, M.D., Vanderbilt University Medical Center, Nashville, TN
A 46-year-old male taking 950mg PO morphine per day underwent abdominoperineal resection with
end colostomy sacrectomy bilateral gluteal rotational flaps and bilateral ureteral stents for invasive SCC
of his anus and sacrum. Patient was extubated on POD#1 and complaining of excruciating pain despite
being on ketamine and high dose fentanyl infusions. We performed a double epidural technique at T10
and L3 which resulted in almost complete resolution of the patient's pain. Ketamine and fentanyl
infusions were weaned off shortly afterwards and patient was able to actively participate in physical
therapy. Patient was discharged on POD#9 in excellent condition
Sunday, October 13
1:00 PM - 2:30 PM
RA MC493
Bilateral Continuous Thoracic Paravertebral Block and Intrathecal Duramorph for Hand-Assisted
Laparoscopic Hepatectomy in a Patient With Type 1a Glycogen Storage Disease: A Case Report.
Anastacia Munro, Trusha Govindji, M.D., Donald Bohannon, M.D., Andre Boezaart, M.D., UF Shands,
Gainesville, FL
A 16-year-old male with Type Ia glycogen storage disease underwent a hand-assisted laparoscopic left
lateral hepatectomy for a hepatic adenoma-hepatocellular carcinoma. Surgcally-induced stress and pain
are triggers for elevation of lactate and problems with glucose homeostasis therefore adequate pain
control was imperative. This was achieved with intrathecal morphine and bilateral continuous thoracic
paravertebral blocks placed pre-operatively and supplemented with a hydromorphone patientcontrolled analgesia on postoperative day (POD) 1. Catheters were removed on POD 3. During
hospitalization glucose and lactic acid levels were monitored frequently and returned to pre-operative
levels prior to discharge. Patient was discharged home on POD 7.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
RA MC494
Ultrasound-Guided Axillary Nerve Block in a Patient With Chronic Inflammatory Demyelinating
Polyneuropathy: A Case Report
Kristen Pastor, M.D., Emily Nelson, M.D., Brigham and Women's Hospital, Boston, MA
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an immune-mediated disease of the
peripheral nervous system. We present a case of a 69-year-old man with CIDP for upper extremity
surgery performed under axillary block. He presented with lower extremity numbness and weakness;
previous upper extremity symptoms had improved with IVIG infusions. An ultrasound guided axillary
nerve block with 40 mL of 1.5% mepivicaine provided successful anesthesia of the patient's distal arm
for the case and he received minimal intravenous sedation with a natural airway. Postoperatively he had
complete resolution of the block with no residual motor or sensory deficits.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC495
Combined Interscalene-Superficial Cervical Plexus Blocks for Surgical Repair of Clavicular Fracture in a
Pregnant Patient of 15 Week's Gestation
Eamon O'Murchu, M.D., Malikah Latmore, M.D., Admir Hadzic, M.D., St Luke's Roosevelt Hospital Center,
New York, NY, Catherine Vandepitte, M.D., University Hospitals Leuven K.U.L, Leuven, Belgium
A 32-year-old woman at 15 weeks gestation was admitted with a unilateral mid-shaft displaced
clavicular fracture sustained during an automobile collision. A single injection interscalene brachial
plexus block and a superficial cervical plexus block were performed under ultrasound guidance followed
by successful surgical reduction of the fracture. Interscalene brachial plexus blocks are commonly used
at our institution as a single anesthetic modality for surgery on the clavicle. While most anesthetic
agents are considered safe in pregnancy recent animal studies suggest that anesthetic agents may
present harm to the developing fetus and a regional technique may be preferred.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC496
Posterior Thigh Abscess Following Continuous Popliteal Sciatic Nerve Block in the Ambulatory Setting
Jason Panchamia, D.O., Michael Ritchey, M.D., Cleveland Clinic, Cleveland, OH
A 61-year-old female was scheduled for elective right ankle surgery. A preoperative popliteal sciatic
nerve catheter was placed in a sterile fashion under ultrasound guidance. Intraoperative course was
uneventful and the patient was discharged with an ambulatory infusion pump. On postoperative day
four the patient was hospitalized for right leg cellulitis and a deep posterior thigh abscess located at the
popliteal catheter site which was confirmed with imaging studies. Subsequently she underwent multiple
incision and drainage in addition to a prolong course of intravenous antibiotics.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
RA MC497
Bad Lungs Bad Heart Bad Hip: The Anesthestic Management of a 93-year-old With Mycobacterium
Avium Intracellulare and Aortic Stenosis
Laura Park, M.D., Michael Bialos, M.D., Icahn School of Medicine at Mount Sinai, New York, NY
93-year-old M with h/o CAD moderate AS and Mycobacterium avium intracellulare presenting with L
femur fracture requiring hemiarthroplasty. As the pt had poor pulmonary function pt's pulmonologist
felt that avoiding GA would be best due to probable difficulty weaning from ventilator. Surgery team
and pulmonologist urged for a regional anesthestic technique to be implemented. Given the AS large
bore IV's and a preinducation A-line were established after which multiple attempts at placing an
epidural were unsuccessful. Though a relative contraindication due to the AS a spinal anesthetic was
placed and pt was started on a phenylephrine infusion with close hemodynamic monitoring.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC498
Use of Continuous Spinal Anesthesia in a Patient With Severe Aortic Stenosis and Pulmonary
Hypertension
Ronak Patel, Sarah Clarke, D.O., Michael Terreri, M.D., TJUH, Philadelphia, PA
Pulmonary hypertension and aortic stenosis are two disease processes associated with increased
morbidity and mortality. These conditions present the unique challenge of creating a fine balance
between sympathetic activity cardiac output coronary perfusion pulmonary vascular resistance and
systemic vascular resistance. Central neuroaxial anesthesia has historically been contraindicated in
patients with severe aortic stenosis secondary to marked decreases in systemic vascular resistance. In
addition general anesthesia has been the method of choice for intraoperative management of the
patient with pulmonary hypertension. Here we discuss the use of continuous spinal anesthesia for a
patient with severe aortic stenosis and severe pulmonary hypertension.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC499
Horner's Syndrome After Thoracic Epidural in a Patient With Ehler-Danlos Syndrome
Ravi Pathak, M.D., Jingping Wang, M.D., Massachusetts General Hospital/Harvard Medical School,
Boston, MA
Presented is a case of miosis and ptosis in a 43-year-old female with history of Ehler-Danlos syndrome
underwent sigmoid resection rectopexy and urethral sling under general anesthesia and low thoracic
epidural which was placed pre-operatively. Post-operatively the pain service was asked to come
evaluate the patient for blown pupil. Upon evaluation the patient had miosis and ptosis of the right eye
with no other neurological signs or symptoms. The symptoms resolved within 24 hours with no
sequelae. With a brief review of the literature risk factors for miosis and ptosis are discussed.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
1:00 PM - 2:30 PM
RA MC500
The Addition of Dexamethasone in a Peripheral Nerve Block in Lieu of a Peripheral Nerve Catheter
Christopher Paul, M.D., Anjali Patel, D.O., Saint Louis University, St. Louis, MO
A 19-year-old female presented in the recovery room for peripheral nerve block for postoperative pain
control status post open reduction and internal fixation of a lisfranc injury. In order to provide a long
acting block while avoiding the potential complications of a peripheral nerve catheter we have begun
adding dexamethasone to single shot peripheral nerve blocks. This patient had sustained complete
sensory and motor block for greater than 30 hours with complete resolution at 56 hours after single
shot lateral popliteal block placement. Patient had no residual sensory/motor deficits at outpatient
follow-up.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC501
Thromboelastography for Evaluation of Epidural Removal in a Thrombocytopenic Patient
Christopher Paul, M.D., Anjali Patel, D.O., Saint Louis University, St. Louis, MO
A 52-year-old male s/p liver and liver/kidney transplant presented for ventral hernia repair. Based on
previous labs and no other contraindications an epidural for analgesia was placed. It was requested the
epidural be removed on POD #5 for discharge the subsequent day. However due to platelet count of 75
000 the epidural was not removed. As platelet transfusion was not an option for this patient a
thromboelastogram was performed the following day with subsequent epidural removal. Neurologic
examination by nursing was ordered every hour for 24hours for evaluation of epidural hematoma.
Patient discharged without complications.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC502
Isolated Lower Extremity Motor Block Following Thoracic Epidural Placement
Kelly Price, Stephanie Yacoubian, M.D., Brigham and Women's Hospital, Boston, MA
84-year-old female with a new right sided lung mass scheduled for robotic assisted wedge resection. In
the pre-op holding area thoracic epidural was placed under minimal sedation at T6-T7 in two attempts
with no unusual observations at time of placement. Following placement aspiration of the catheter was
negative for CSF and a test dose of 3cc 1.5% lidocaine with 1:200 000 epinephrine was administered. On
exam prior to induction of anesthesia patient was noted to have an appropriate T4-T9 sensory level and
complete motor block of the left lower extremity in the absence of any lower extremity sensory
changes.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC503
Rotation of Continuous Peripheral Nerve Catheters to Provide 18+ Days of Pain Relief
Yawar Qadri, M.D., Ph.D., Arun Ganesh, M.D., Cody Rowan, M.D., Randall Coombs, M.D., University of
North Carolina at Chapel Hill, Chapel Hill, NC
A 37-year-old male suffered a degloving injury of his dominant upper extremity. As the limb was
neurovascularly intact multiple operations were attempted to salvage the limb. A supraclavicular
brachial plexus catheter was placed for surgical anesthesia. After an initial salvage operation localized
Copyright © 2013 American Society of Anesthesiologists
bacterial and fungal osteomyelitis was noted. Due to the need for multiple operations nerve catheters
were rotated to provide almost three weeks of continuous brachial plexus blockade minimizing opioid
and general anesthetic exposure. A multimodal management plan for the patient's orthopedic injuries
was established. Unfortunately the patient went on to require amputation and developed phantom limb
pain.
Sunday, October 13
1:00 PM - 2:30 PM
RA MC504
Assessing Platelet Function Prior to Removal of Epidural Catheter From Patient Given Clopidogrel
John Reynen, M.D., Kristopher Schroeder, M.D., University of Wisconsin, Madison, WI
A 68-year-old male with CAD and remote coronary stent placement received a thoracic epidural for
postoperative pain control for an Abdominoperineal Resection. While on heparin and aspirin the
primary team restarted his home medication clopidogrel POD#3-5. Risk of epidural hematoma versus
epidural abscess was balanced when planning catheter removal. Thromboelastography was utilized on
the day of planned removal to assess for platelet function as well as his functional coagulability. The
epidural catheter was removed POD#8 without complication after the thromboelastogram
demonstrated normalized platelet function. No neurologic deficits presented after 24 hours of close
monitoring.
MCC Session Number – MCC08
Sunday, October 13
3:00 PM - 4:30 PM
FA MC505
Perioperative Management of the Patient With Oral Basal Disorder
Ethan Reynolds, M.D., Hui Yuan, M.D., Saint Louis University, Saint Louis, MO
A 38-year-old female at 27 weeks gestation presented to the operating room emergently for incision
and drainage of a submental odontogenic abscess. Awake fiberoptic intubation in the operating room
allowed successful placement an ETT. With little improvement in the airway anatomy the decision was
made to keep the patient intubated. Self extubation in the recovery area required emergent
reintubation. The ETT was initially removed and successful bag mask ventilation commenced. Following
an unsuccessful attempt using a video laryngoscope an LMA was placed allowing successful ventilation.
Fiberoptic bronchoscope was then used through the LMA to secure the airway.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC506
Management of Von Willebrands Disease in a Jehovah's Witness Presenting for Radical Nephrectomy
Justin Richads, M.D., Jonathan Wanderer, M.D., Vanderbilt University, Nashville, TN
WB is a 60-year-old male with a history of von Willebrands disease who presents with a right renal mass
for laparoscopic radical nephrectomy. He is a Jehovah's Witness and refuses blood products.
Preoperatively he was evaluated by the hematology service which recommended infusion of
antihemophilic factor/von willebrand factor complex in the perioperative period. He underwent the
above procedure without complication; intraoperative estimated blood loss was 50ml. Postoperatively
he completed the prescribed antihemophilic factor/von willebrand factor complex infusion. He was
Copyright © 2013 American Society of Anesthesiologists
discharged on post-operative day three with a hemoglobin of 8.3 mg/dl and without signs or symptoms
of anemia.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC507
Anesthetic Management of a Patient With Severe Wegener's Granulomatosis Undergoing
Laryngotracheobronchoplasty
Janice Riso, M.D., Franco Resta-Flarer, M.D., Jonathan Lesser, M.D., Junping Chen, M.D., Ph.D., St. Luke’s
Roosevelt Hospital Center Columbia University College of Physicians and Surgeons, New York, NY
A 54-year-old female with Wegener's Granulomatosis acute renal failure on hemodialysis and multiple
hospitalizations secondary to respiratory failure underwent a tracheoplasty for worsening respiratory
status due to tracheal stenosis. The patient continued to deteriorate and was taken back to the OR 21
days later for laryngeal dilation and excision of granulomatous tissue. Over the next 2 months her
symptoms continued to decline and tracheostomy became necessary. Tracheostomy was performed
along with bronchoscopy and tracheal balloon dilation. 9 days later the patient required additional
laryngotracheoplasty endoscopic bronchial dilation and tracheostomy exchange.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC508
Management of Massive Airway Bleeding in a Patient With a History of Descending Thoracic Aortic
Aneurysm Repair
Pragati Rohatgi, M.D., Soumya Nyshadham, M.D., Lars Helgeson, M.D., Yale University School of
Medicine, New Haven, CT
A 36-year-old male with 10 years prior history of thoracic aortic aneurysm repair presented with massive
hemoptysis and cardiac arrest. Patient was resuscitated and intubated in ED with X-ray revealing left
lung opacity and widened mediastinum. Anesthesiology was consulted for right lung isolation and
tamponade of left sided intrapulmonary bleed. Fiberoptic bronchoscopy via ETT failed to identify any
anatomical structures due to massive bleeding. Ventilation and oxygenation became compromised. The
endotracheal tube was successfully replaced with a left-sided DLT over cook exchange catheter and bag
ventilation continued. Patient again arrested was resuscitated and subsequently expired. Autopsy
revealed left aorto-pulmonary erosions.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC509
Laparoscopic Cholecystectomy in an Adult Patient With Complicated Cystic Fibrosis
Santiago Rojas Paez, M.D., Thea Rosenbaum, M.D., University of Arkansas for Medical Sciences, Little
Rock, AR
A 20-year-old male patient with acute cholecystitis was scheduled for cholecystectomy. He has history
of Cystic Fibrosis complicated by severe airway obstructive involvement prior pneumothorax and
diabetes. He was medically optimized and pulmonary consultation recommended elective extubation in
ICU. Patient underwent procedure with general endotracheal anesthesia. At the end of surgery opioid
analgesics were generously tritiated based on respiratory rate to provide comfort on emergence. Patient
met extubation criteria and was extubated in close communication with surgeon and pulmonologist. He
was transferred to ICU with continued Cystic Fibrosis care. Discharged home on the fourth postoperative
day without complications.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC510
Iatrogenic Pneumothorax and Bronchopleural Fistula Following Bougie-Assisted Cricothyrotomy
Bryan Romito, M.D., Laila Makary, M.D., UT Southwestern Medical Center, Dallas, TX
This is a case report of a patient with a difficult airway ultimately needing a bougie-assisted surgical
cricothyrotomy to establish airway control. The cricothyrotomy was complicated by a traumatic
pneumothorax which resulted from incorrect placement of the bougie intubating introducer. This case
both illustrates a potential complication of this airway technique and highlights the need for vigilance to
diagnose and manage a pneumothorax.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC511
Anesthetic Management of a Patient With Post-Legionnaires' Anti-Acetylcholine Antibody Syndrome
(anti-AChR) and Ischemic Cardiomyopathy
David Dahl, M.D., Michael Hosking, M.D., University of Tennessee Knoxville, Knoxville, TN
A 76-year-old male requiring surgical incision and drainage of a peri-rectal abscess. Approximately one
year prior he contracted Legionnaires' Disease. He developed progressive skeletal muscle weakness
leading to prolonged intubation and tracheostomy. Extensive evaluation was negative for malignancy
and he was diagnosed with post infectious anti-AChR syndrome. He remained unable to to ambulate but
no longer required tracheostomy. Other complicating medical factors included ischemic cardiomyopathy
with an EF of 25% and presence of an ICD. Anesthetic management was complicated by uncertain effect
of neuromuscular blockers compromised cardiac function and the need for prone positioning.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC512
Unknown Pseudocholinesterase Deficiency in a Patient With Extensive Previous Surgical History
Julia Rosenbloom, M.D., Jeremy Burke, M.D., Jodi Sherman, M.D., Yale University School of Medicine,
New Haven, CT
43-year-old white female with poorly-controlled type-two diabetes and hypertension presented for
emergency cystoscopy. Past anesthetics including for acute appendicitis were reported unremarkable
and patient denied familial anesthetic complications. Patient underwent RSI with succhinylcholine in the
operating room; at the end of the procedure (15 minutes from induction) patient had 0/4 twitches. After
45 additional minutes under GA patient had 1/4 twitches. Patient was transported to ICU with presumed
diagnosis of pseudocholinesterase deficiency and required ventilator assistance for four hours prior to
extubation. Pseudocholinesterase deficiency may not have been evident with prior anesthetics due to
variations in practice or patient-centered features.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC513
Anesthesia Management for Extensive Tracheal Papillomatosis
Omolola Salaam, M.D., Mohamad Hashim, M.D., Maimonides Medical Center, Brooklyn, NY
48-year-old male with extensive tracheal papillomatosis presented with severe stridor and dyspnea. CT
scan showed over 90% obstruction of the trachea extending from the vocal cord to the carina. He was
scheduled for tracheal balloon dilatation and stent placement. General anesthesia was induced and jet
ventilation was placed at the level of the vocal cord to maintain adequate oxygenation. Tracheal balloon
dilatation was performed over a guide wire followed by deployment of two tracheal stents to maintain
the lumen patency. He was recovered and discharge home the same day.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC514
Total Thyroidectomy in a Pregnant Patient
Craig Samford, M.D., Wolf Kratzert, M.D., University of New Mexico, Albuquerque, NM
A 28-year-old female with a past medical history significant for Grave's disease complicated by a goiter
bilateral hemianopsia atrial tachyarrhythmia and several spontaneous abortions was admitted to the
Otolaryngology service for elective thyroidectomy following unsuccessful medical management. The
patient presented with tachyarrhythmia at 150 bpm and an anterior neck mass measuring 9-10
centimeters. Due to suboptimal treatment of her hyperthyroidism surgery was delayed with the goal of
rate and arrhythmia control and euthyroid labs. On preoperative anesthesia evaluation the patient
reported difficulties breathing when lying flat on her back. Routine urine pregnancy test in the
preoperative area was positive.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC515
Intrathoracic Fire
Rohin Sarkar, M.D., University of New Mexico, Albuquerque, NM
60-year-old male with BPH asthma and a chronic empyema with chest tube presented for a
bronchoscopy partial open thoracoplasty and revision of the Eloesser flap. A single lumen tube was
placed in the trachea for a video bronchoscopy and then exchange to a double lumen tube was tried.
However the double lumen tube did not pass and the single lumen was too short to mainstem therefore
the procedure was begun with double lung ventilation. During the lysis of an adhesion between the lung
and the chest wall a flame was noted in the surgical field with the use of electro-cautery.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC516
Anesthetic Management of Donor Nephrectomy for a Recipient With a History of Malignant
Hyperthermia
Jacob Schaff, M.D., Rob Maniker, M.D., Columbia University, New York, NY
A 56-year-old woman presented for living-related donor nephrectomy. The recipient had reported a
personal history of malignant hyperthermia (MH) requiring ICU admission. Sevoflurane levels have been
measured in rat kidneys up to two days after its discontinuation. With this in mind we chose a nontriggering anesthetic with propofol and remifentinil infusions for the donor to avoid possible triggering
Copyright © 2013 American Society of Anesthesiologists
via the transplanted kidney to the MH-susceptible recipient. Both patients had uneventful procedures
and were discharged without complications. This example underscores the importance of
communication among anesthesia teams to promote patient safety especially in the context of living
related transplantation.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC517
The Effects of Buprenorphine on Anesthetic Dosing
Jacob Schauer, M.D., Yury Khelemsky, M.D., Mount Sinai Medical Center, New York, NY
A 44-year-old female on buprenorphine-naloxone maintenance for opioid dependence presented for
emergent anterior decompression and stabilization of a cervical spine fracture. Intraoperative
neurophysiological monitoring prevented use of paralytics and inhalational anesthetics. Anesthetic
maintenance included propofol and remifentanil infusions. Intraoperative patient movement was
uncontrolled with very high doses of propofol and remifentanil. Movement in response to surgical
stimulation was ablated only after the addition of ketamine. Seven days later after discontinuation of
buprenorphine-naloxone and transition to maintenance with methadone a posterior cervical arthrodesis
was performed. She had drastically reduced anesthetic requirements during this case illustrating
buprenorphine's profound effect on anesthetic dosing.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC518
The Use of a Fiberoptic Bronchoscope as a Steerable Stylet for a Glidescope Assisted Intubation of a
Difficult Airway
Krystal Scherrer, M.D., Michael Lasky, M.D., Saint Louis University, St Louis, MO
A 46-year-old M presented for craniotomy. This patient's PMH included left tonsil SCC s/p
chemotherapy/radiation. On exam the patient was a Mallampati I had a normal thyromental distance
marginal mouth opening and left facial paralysis. DL was performed with a MAC 4 blade but only the
epiglottis could be visualized. We then attempted with the GlideScope™; and found the patient's airway
deviated significantly and could not pass a styletted ETT. The ETT was then loaded onto the
bronchoscope. With the bronchoscope acting as “steerable” stylet we inserted the ETT between the
cords under direct view of the GlideScope™.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC519
Cricothyrotomy in the Post Anesthesia Care Unit Due to Expanding Hematoma Following Anterior
Cervical Spine Surgery
Rupa Sekhar, M.D., Zana Borovcanin, M.D., University of Rochester Medical Center, Rochester, NY
52-year-old female presented with neck hematoma one hour after anterior cervical decompression and
fusion. Anesthesia was paged emergently to PACU due to respiratory distress. A left neck hematoma
expanding to midline and right neck was visible. Surgical team attempted to evacuate the hematoma.
Trauma surgery was present with cricothyrotomy tray. Airway topicalization was performed. Attempted
awake intubation with Glidescope was unsuccessful resulting in can't ventilate can't intubate situation.
Decision was made to proceed with cricothyrotomy. After securing the airway the patient was taken to
the OR for formal wound exploration and conversion to tracheostomy.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC520
Challenges of Airway Management Posed by Upper Airway Fistulas
Goonjan Shah, Harendra Arora, M.D., University of North Carolina, Chapel Hill, NC
We describe a case of a difficult airway in a 68-year-old male patient who presented for sinus surgery.
The patient had a large left orbital defect from a previous left orbital exenteration. After anesthesia
induction with propofol mask ventilation was extremely difficult due to air-leak from a communication
between the nasopahrynx and the orbit. Despite the use of saline-soaked gauze to cover up the orbital
defect mask ventilation was extremely difficult. Once patient was breathing spontaneously endotracheal
intubation was achieved with a fiberoptic. We will discuss the challenge posed by upper airway fistulas
and review the difficult airway algorithm.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC521
Difficult Airway in a Patient With Tracheal Stenosis
Mehul Shah, Stanlies D'Souza, M.D., Toni Chahla, M.D., Baystate Medical Center, Springfield, MA
A 51-year-old female with known tracheal stenosis secondary to prior traumatic emergent intubation
presented for CABG with triple vessel disease. During asleep fiberoptic intubation an abnormal soft
tissue web-like structure was noticed in the right lateral trachea at 18 cm from incisor level. Following
unsuccessful attempted intubation with 6.0 size tube an LMA was placed and patient was awakened. In
a separate setting asleep fiberoptic aiway evaluation showed 7-10 mm long tracheal stenosis beginning
3.5 cm distal to the vocal cords. This stenosis required ballon dilatation and the procedure was
performed over an properly positioned LMA.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC522
Pneumothorax During Laparoscopic Paraesophageal Hernia Repair
Jessica Shanahan, M.D., T. Anthony Anderson, M.D., Massachusetts General Hospital, Boston, MA
A 64-year-old male with paresophageal hernia GERD and emphysema with no recent flares underwent
laparoscopic paraesophageal hernia repair. An hour after induction the patient became acutely
hypoxemic and hypotensive. No breath sounds were auscultated on the left. Increasing FiO2
hyperventilation and cessation of abdominal insufflation initially improved hypoxemia. Emergency
flexible bronchoscopy revealed mucus plugging which was aggressively suctioned. Stat chest x-ray
showed a very small left apical-medial pneumothorax unable to be appreciated on the OR monitors.
Hypoxemia and hypotension recurred with reinsufflation of the abdomen. Definitive management was a
left-sided chest tube.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC523
Malignant Hyperthermia in a Healthy 23-year-old Male During the Second of Two Anesthetic in One
Day
Anna Shapiro, M.D., Jesse Shurter, M.D., University of California San Diego, San Diego, CA
A healthy 23-year-old man underwent two procedures 10 hours apart. First was a traumatic abdominal
hernia repair. Anesthesia induced with lidocaine 100mg etomidate 20mg and succinylcholine 100mg and
Copyright © 2013 American Society of Anesthesiologists
maintained with sevoflurane was uneventful. Ten hours later with a nearly identical anesthetic
technique he underwent scapula wash-out. He became rigid during prepping and within ten minutes
developed tachycardia hypercarbia and elevated airway pressures. Sevoflurance was discontinued IV
dantrolene administered and he remained intubated overnight. CPK peaked at 11 755 and muscle
biopsy showed necrosis. Malignant hyperthermia can present in patients who have very recently
undergone a potentially triggering anesthetic without incident.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC524
Carcinoid Crisis Brought on by Laryngoscopy
Alok Sharma, M.D., Michael Alvarado, M.D., Pablo Guzman, M.D., University of California San Francisco,
San Francisco, CA
We describe the case of a 62-year-old female with small bowel carcinoid tumor metastatic to liver who
developed carcinoid crisis (whole body flushing severe hypotension) upon induction of general
anesthesia for a toe amputation for melanoma. Preoperatively she had daily episodes of flushing and
wheezing despite therapy with octreotide. On the day of surgery she took her prescribed octreotide and
received another subcutaneous octreotide injection prior to OR. Intraop resuscitation was successful
with vasopressin IV octreotide infusion and epinephrine and surgery was aborted. Her toe ampuation
was later completed uneventfully under spinal after overnight pretreatment with intravenous
octreotide.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC525
Reishi Mushroom's Antiplatelet Like Effects Leads to Unexpected Intraoperative Complications
Shelly Sharma, M.D., Bernadette Cracchiolo, M.D., Shubhangi Kesavan, M.D., Steve Shulman, M.D., M.S.,
Anthony Sifonios, M.D., UMDNJ New Jersey Medical School, Newark, NJ
Reishi mushroom has antihypertensive anti-tumor and antiplatelet effects. A 64-year-old female with
cervical cancer properatively without disclosing it. Robotic radical hysterectomy was planned and begun
but blood oozed from all sites of dissection despite use of cautery. Therefore procedure was converted
to laparotomy. FFP did not improve her coagulation. After administration of platelets clot formation was
visualized and oozing stopped. She required 3 units of PRBC. Reishi mushroom contains protease and
polysaccharides that contribute to its antiplatelet effect. It should not be ingested before surgery as this
can lead to unexpected blood transfusion and prolong intubation.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC526
Cardiovascular Collapse in a Patient With Multiple Co-Morbidities Undergoing Parathyroidectomy
Uttam Shastri, M.D., University of Texas Southwestern, Dallas, TX
A 67-year-old female with PMH of stable angina HTN and IDDM was scheduled for a parathyroidectomy.
Echo showed normal LV function and diastolic dysfunction. After induction the head was positioned in
extension. Maintenance included sevoflurane and remifentanil infusion. The patient then became
bradycardic hypotensive and lost carotid pulse. The head was immediately placed in neutral position.
Chest compressions were started atropine 1 mg IV was given. The HR increased to 85 with systolic BP
remaining 60-65. Vasopressin 15 units was administered. The case was aborted and patient was
transferred to the ICU intubated. She was discharged without residual effects.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC527
Intraoperative Hyperkalemia and CRRT Initiation
Lisa Shaw, M.D., University of Michigan, Ann Arbor, MI
This is a 66-year-old male for repair of an enterocutaneous fistula with end-stage renal disease (ESRD)
severe gastroparesis and history of tracheostomies. We were faced with managing his airway and
contending with hyperkalemia thereafter. Continuous renal replacement therapy (CRRT) was initiated
which then led to hypothermia and coagulopathy. Research surveyed includes a review of potassium
and hyperkalemia the use of succinylcholine versus rocuronium for rapid sequence intubations the use
of succinycholine and lactated ringers in ESRD patients the potential existence for potassium tolerance
and finally treatment options for hyperkalemia including indications for and complications of
intraoperative CRRT.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC528
Anesthetic Management of a Patient With Fibrodysplasia Ossificans Progressiva
John Shepler, George Arndt, M.D., Richard Galgon, M.D., University of Wisconsin School of Medicine and
Public Health, Madison, WI
A 46-year-old man with severe global heterotopic ossification and extra-articular joint ankylosis from
fibrodysplasia ossificans progressiva presented for ureteroscopy and laser lithotripsy. Anesthesia
management was challenged by complete mandibular and cervical spine fixation extensive anterior neck
soft tissue ossification precluding a surgical airway global joint fixation requiring positioning attention
and severe restrictive lung disease. Successful anesthetic management included small gauge intravenous
cannulation an awake bronchoscopic wire-guided nasal intubation careful intra-operative positioning
neuromuscular blocking drug use avoidance non-opioid analgesia an awake extubation and a careful
post-operative monitoring plan. Safe home discharge occurred on post-operative day 1.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC529
Perioperative Coagulation Status Monitoring: Thromboelastography (TEG) or Laboratory Testing?
Shashank Shettar, M.D., Kyota Fukazawa, M.D., Ernesto Pretto, M.D., M.P.H., Jackson Memorial Hospital
and Miller School of Medicine University of Miami, Miami, FL
A 59-year-old patient with HCV cirrhosis and prosthetic valves (aortic mitral) presented for liver
transplantation. The patient was anti-coagulated (warfarin) until the day of transplant. Pre-transplant
labs showed prolonged PT-INR APTT but normal fibrinogen and platelets. In contrast TEG in the OR
showed normal &#8216;time to coagulation' (R) with wide maximum amplitude (MA). The discrepancy
between laboratory tests and TEG posed a dilemma: (i) administer FFP and vitamin-K to prevent
bleeding or (ii) anti-coagulate to protect valves. Heparin was administered with serial TEGs for
coagulation monitoring. Surgery was uneventful and heparin switched to warfarin on the third
postoperative day.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC530
A Case of Succinylcholine Induced Bronchospasm
Kara Siegrist, M.D., Shannon Kilkelly, D.O., Vanderbilt University, Nashville, TN
Our case was a 24 year-old male who presented for irrigation and debridement of a leg wound.
Anesthesia was induced by rapid sequence with propofol lidocaine fentanyl and succinylcholine.
Immediately post-induction and intubation it was noted that the patient had increasing peak airway
pressures and oxygen desaturation. Bronchospasm was suspected and treated with multimodal therapy
eventually broken with volatile anesthetic and epinephrine. Bronchoscopy revealed copious
bronchorrhea. Succinylcholine is believed to be the trigger for this patient's bronchospasm due to the
large muscarinic component of the bronchorrhea. Succinylcholine induced bronchospasm is described in
the literature though no recent cases have been reported.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC531
Management of Brugada Syndrome in Non-Cardiac Surgery
Jonathan Silva, M.D., Baylor College of Medicine, Houston, TX
Brugada syndrome is a hereditary arrhythmia that occurs from a loss of function of sodium channels. It
is characterized by ST-elevation in leads V1-V3 on ECG in patients with a structurally normal heart. A
transmural gradient between the epicardium and endocardium results in ST-elevation and may lead to
ventricular arrhythmias. The anesthesiologist must be aware of the drugs that exacerbate Brugada
syndrome including beta blockers alpha agonists calcium channel blockers and certain local anesthetics.
Propofol and volatile anesthetics should be used with caution. Achieving adequate pain control
normothermia normocapnia and glucose and electrolyte balance may also reduce risk of
tachyarrhythmias.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC532
Difficult Airway Management in a Patient With Huge Scalp Tumor: A Case Report
Marco Silvestrini, M.D., Victor Cardona, M.D., Dimaris Dominguez, M.D., University of Puerto Rico, San
Juan, PR
Case of a 29-year-old female patient with past medical history of bronchial asthma and atopic dermatitis
allergic to aspirin presented with a slow growing scalp mass for excision. Head CT with tridimensional
construction showed a highly vascular mass measuring 15.5cm x 15cm x 17.6cm. Due to the scalp mass
dimensions the patient was unable to lay flat at the OR table. For the airway management an awake
anterograde fiberoptic intubation was performed with the patient in fully sitting position. A
comprehensive literature review revealed no similar cases have been reported in Puerto Rico and the
United States.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC533
Unexpected Hemodynamic Changes in a Case of Metastatic Ovarian Carcinoma.
Asha Singh, M.D., Ursula Galway, M.D., The Cleveland Clinic Foundation, Cleveland, OH
54-year-old female with PMH of HTN and Hyperglycemia diagnosed with ovarian carcinoma with
Omental caking and Adrenal metastasis scheduled for Ex-lap BSO Omentectomy and Adrenal mass
removal. PreInduction Epidural placement was complicated by Bradycardia and vasovagal symptoms
treatment with Glycopyrrolate and Ephedrine lead to Hypertension and transient SVT. Adrenal resection
was complicated by Hypertensive crisis treated with NTG Esmolol and Labetalol. After Adrenalectomy
she had refractory hypotension requiring high dose of Norepinephrine Vasopressin IV fluids and ICU
admission. Vasopressors were weaned off on POD # 2 and patient was extubated. Later Adrenal mass
was diagnosed as Pheochromocytoma.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC534
Avoiding Perioperative Complications in Patient With History of Ross Procedure Undergoing NonCardiac Surgery
Gurbinder Singh, D.O., Sherif Zaky, M.D., Ph.D., Cleveland Clinic, Cleveland, OH
Ross procedure replaces defective aortic valve with patient's own pulmonic valve and pulmonic valve is
substituted with homograft. We describe intraoperative management of long-term complications
resulting from this procedure. Most common complications include aortic and homograft regurgitation.
A 63-year-old gentleman with history of Ross procedure performed 16 years ago underwent revision of
hip arthroplasty. We placed invasive monitors including pre-induction arterial line central venous
catheter and transesophageal echocardiogram to monitor hemodynamics and myocardial depression.
We used Etomidate Rocuronium Fentanyl and Isoflurane to maintain forward flow without causing
bradycardia or increasing systemic vascular resistance. Patient underwent surgery without
complications.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC535
The Role of Complement Activation in the Early Stages of Trauma
Alexander Sinofsky, M.D., Corey Scher, M.D., NYU Langone Medical Center, New York, NY
A 48-year-old male presenting with an abdominal gunshot was taken to the OR for ex-laparotomy. The
patient showed signs of complement activation; he developed refractory hypotension and unresponsive
to crystalloids/colloids and disordered coagulation. His BP was ultimately controlled by vasopressors and
massive blood transfusion protocol. The patient developed ARDS and had a prolonged stay in the SICU.
There arenno drugs available that could have controlled compliment activation and hypertonic saline 7%
which has been shown to be beneficial in trauma was not available at our institution. There is likely a
future role for complement inhibitors in an anesthesiologists' hands.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC536
A Simple Nasal Mask Improved Oxygenation in a Morbidly Obese Patient With Obstructive Sleep
Apnea under Propofol Sedation During Upper GI Endoscopy for Post-Gastric Banding Gastric Outlet
Obstruction
Sameet Syed, M.D., Heather Skiff, D.O., Andy Burr, D.O., Rose Alloteh, M.D., James Tse, M.D., Ph.D.,
UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ
A 40-year-old 5'10 360 lb BMI 52 kg/m2 male with OSA was scheduled for EGD with dilation of gastric
outlet obstruction. He was NPO for 4 days since gastric banding. After pre-oxygenated with a nasal mask
using an infant mask O2 saturation increased from 95% to 100%. Pop-off valve was closed to provide
continuous flow of O2 (6 L/min) and air (2 L/min). Deep sedation was induced with small boluses of
propofol (total 150 mg) and maintained with infusion (150 mcg/kg/min). He maintained spontaneous
respiration and 99-100% O2 saturation throughout with FiO2 of 0.7-0.8. He tolerated the procedure
well.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC537
Cardiac Arrest in an Elderly Patient With Severe Aortic Stenosis Having Occiput-C4 Decompression and
Fusion
Karen Slocum, M.D., M.P.H., Christopher Jackson, M.D., George Washington University, Washington, DC
An 80-year-old male presents for occiput-C4 decompression and fusion due to cervical spinal cord
compression. His past medical history is significant for severe aortic stenosis myocardial infarction and
atrial fibrillation. Surgery is in the prone position with approximately 2 liters of blood loss requiring
blood transfusion and a phenylephrine drip. At the end of the case upon turning the patient to the
supine position blood pressure and pulse can no longer be attained and CPR is initiated with success.
Patient is transferred to the ICU where he is treated for hypotension and discharged home 3 weeks
later.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC538
Anesthetic Concerns in a Patient With Mitochondrial Myopathy
Mark Smeltzer, M.D., Lois Connolly, M.D., Medical College of Wisconsin, Milwaukee, WI
68-year-old female with history of ESRD T2DM HTN and mitochondrial myopathy presented for a kidney
transplant. She was maintained on D5/0.45 NS the night prior to surgery. Utilizing standard ASA
monitoring induction was accomplished with lidocaine 5mg IV propofol 100mg IV fentanyl 100mcg IV
and cisatracurium 0.15mg/kg IV. Anesthesia was maintained with desflurane. Maintenance of
neuromuscular blockade was achieved with a cisatracurium infusion at 1mcg/kg/min and blockade was
reversed with glycopyrrolate 0.01mg/kg IV and neostigmine 0.07mg/kg IV after completion of the
procedure. The patient was transported intubated to the PACU and placed on pressure support
ventilation until meeting extubation criteria.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC539
Severe Hypotension in a Patient With a High Spinal Cord Injury: Is Methyl Methacrylate the Culprit?
Elizabeth Smith, M.D., University of Louisville, Louisville, KY
There are many causes of intraoperative hypotension in chronic spinal cord injury patients undergoing
orthopedic procedures. We present a case of an 18-year-old female with a 1 year history of paraplegia
resulting from T3 spinal cord injury after a motor vehicle accident who returned to the operating room
with an infected femurrod. Intraoperatively the patient developed sudden severe hypotension. Various
diagnoses and treatment strategies will be discussed in presentation of this case including differential
diagnosis of hypotension in the chronic spinal cord injury patient which in our case included methyl
methacrylate toxicity pulmonary embolus and hemorrhage.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC540
The Challenges of Adult Onset Acromegaly
Michale Sofer, M.D., Arthur Atchabahian, M.D., NYU Langone Medical Center, New York, NY
A 50-year-old male with acromegaly presented for left TKR. A previous anesthetic necessitated
emergent tracheostomy. Spinal anesthesia was challenging. Sedation resulted in airway obstruction and
airways were unhelpful. Obstruction resolved with jaw thrust. Despite femoral and spinal block
tourniquet pain appeared after 80 minutes. The procedure could be completed without general
anesthesia. The patient underwent a washout to evacuate a hematoma 10 days later. Despite numerous
attempts the spinal could not be performed. Femoral and sciatic blocks with minimal sedation were
initially effective but as airway obstruction worsened an LMA was inserted with good results. Recovery
was uneventful.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC541
Difficult Airway Resulting From Unusual Laryngeal Pathology: A Review of Management Strategies
and Diagnostic Modalities
Che Solla, M.D., Walter Reed National Military Medical Center, Bethesda, MD, Fernando Resano, M.D.,
Medstar Washington Hospital Center, Washington, DC
88-year-old male undergoing trans-catheter aortic valve replacement. Following induction several
endotracheal tubes (ETT) of different diameters were attempted unsuccessfully. A fiberoptic
laryngoscopy revealed left vocal cord palsy. A computerized tomography scan revealed a calcified Teflon
granuloma within the left vocal cord and a circular orifice with a diameter of 7 mm towards the
posterior commissure. Because of the unyielding pathology towards the middle of the vocal cords a 5.5
mm ETT was successfully placed by maintaining the tube against the vocal cords and gently flexing the
head to advance the tube through the posterior orifice.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
FA MC542
Retroperitoneal Tumor Resection Complicated by Pulmonary Embolism
Carlos Soto, NYU Medical Center, New York, NY
A 77-year-old male presented for resection of a retroperitoneal leiomyosarcoma extending into the
infra-hepatic IVC. After an hour of dissection significant bleeding and hypotension developed; an
elevated ACT suggested coagulopathy. Vasopressors and massive fluid/blood product resuscitation were
initiated. After another hour the patient developed high peak and plateau airway pressures desaturation
and a drop in EtCO2. TEE demonstrated a dilated RV and a mass in the right pulmonary artery consistent
with pulmonary embolism. Dramatic hypotension was treated with brief chest compressions and
epinephrine. After transport to the PACU all life support was discontinued per family request.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC543
A Failed Attempt to Place a Carotid Stent
Carlos Soto, NYU Medical Center, New York, NY
A 78-year-old woman with severe carotid stenosis presented for carotid stent placement. She had a
history of multiple TIAs as well as severe hypertension DM2 PVD and CKD. The patient expressed
significant anxiety but received no anxiolytics per surgeon request in order to accurately monitor any
changes in mental status during the procedure. Blood pressure was difficult to control with multiple
anti-hypertensive meds with systolic in the 220's. An episode of agitation and movement was shortly
followed by dysarthria facial droop hemiparesis and episodes of bradycardia. A stroke code was called.
Sunday, October 13
3:00 PM - 4:30 PM
FA MC544
Partial Hepatectomy Complicated by Hyperkalemia Associated Cardiac Arrest
Liza Starecki, M.D., Wojciech Reiss, M.D., St. Lukes - Roosevelt Hospital, New York, NY
A 39-year-old female with a giant cavernous hemangioma of liver presented for right hepatic lobectomy.
The procedure was complicated by blood loss requiring massive transfusion. After 6 units of pRBC were
transfused over one hour patient experienced a transfusion-associated hyperkalemic cardiac arrest. The
EKG showed a sine wave which rapidly progressed to ventricular tachycardia and asystole. An ABG
sample taken 3 minutes before any EKG changes revealed a potassium level of 9.3 mEQ/ dL. The
hyperkalemia was managed with epinephrine insulin glucose and calcium and the patient returned to
sinus rhythm.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC545
Use of the Lariat Device for Left Atrial Appendage Closure
Suzanne Kellman, M.D., Megan Lanigan, M.D., Mark Chaney, M.D., The University of Chicago, Chicago, IL
73F with atrial fibrillation (AF) whose warfarin was stopped secondary to GI bleeding presents for
percutaneous left atrial appendage (LAA) exclusion. AF increases risk of embolic stroke with most
thrombi originating in the LAA. Exclusion of this appendage may reduce stroke risk in patients with
contraindications to oral anticoagulation. The Lariat procedure in which an exclusion device is threaded
from the subxiphoid into the pericardium to snare the LAA is a new technique with unique anesthetic
Copyright © 2013 American Society of Anesthesiologists
considerations. In comparison with other LAA exclusion procedures it has a higher success rate and does
not require continuation of anticoagulation post-operatively.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC546
Severe Bronchospasm With Unilateral Right Main Bronchus Collapse and Tracheal Swelling During
Ross Procedure in a 28-year-old Male
Divya Kestur Rajasekhar, M.D., Trevor Banack, M.D., Yale University School of Medicine, New Haven, CT
28-year-old M with severe AR presented for AVR. PMH includes: morbid obesity hypertension childhood
asthma and current smoker. CPB time was 257minutes. ABG after CPB was 7.37/344/43/ 95/24.9.
Protamine and FFP/platelets were administered. After starting platelets/FFP the patient became difficult
to ventilate peak airway pressure increased blood pressure decreased and ABG 7.21/49/63/78/25. FOB
revealed a collapsed/swollen trachea and right bronchus beyond the ETT. Transfusion reaction was
suspected. Blood products were stopped and medications administered: IV steroids/epinephrine
infusion/Benadryl/inhaled steroids/epinephrine/inhaled albuterol. After 1.5hours airway swelling
decreased and ABG improved 7.33/40/95/20.5/98.The patient was brought to CTICU stable.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC547
Fixing Broken Hearts With Saline
Ansar Khan, M.D., University of Maryland Medical Center, Baltimore, MD
An anxious 14-year-old male with dilated cardiomyopathy presented to the OR secondary to acute
exacerbation of his biventricular failure. Commonly used drugs including propofol etomidate
dobutamine and calcium chloride were in critically low supply or not available secondary to national
shortage. Using the IABP low dose midazolam and fentanyl with phenylephrine flush were used to safely
induce anesthesia. A BIVAD was successfully placed as a bridge to heart transplant. This case illustrates
how national drug shortages are forcing anesthesiologists to develop novel and potentially precarious
anesthetic plans for once practical and predictable induction maintenance and emergence.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC548
Such a Big Heart. Or is it an Aneurysm?
Swapnil Khoche, Mahesh Sardesai, M.D., Sudhakar Yennam Reddy, M.B. B.S., University of Pittsburgh
Medical Center, Pittsburgh, PA
A 69-year-old female was scheduled for resection of a ventricular aneurysm related to recent inferior
MI. Her reported EF was 10%. After uneventful induction of general anesthesia transesophageal
echocardiography revealed a larger basal posterior aneurysm (6.2 x 5.3cm) with otherwise good
ventricular wall motion moderate mitral regurgitation and no left ventricular thrombus. The patient
underwent the operation uneventfully. Aside from the unusual size and location of the aneurysm our
case highlights the utility of real time 3D echocardiography in structural and functional quantification
during complex and dynamic conditions during the perioperative period
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC549
3D Echocardiography During Right Heart Intracardiac Thromboembolectomy
Eugene Kim, M.D., Christopher Tam, M.D., Sandeep Gupta, M.D., Igor Izrailtyan, M.D., Stony Brook
Medicine, Stony Brook, NY
Although no evidence-based management guidelines for right heart intracardiac thromboemboli exist
surgical thromboembolectomy remains as a valuable option for certain patients. We present an 85-yearold female referred to our institution after outpatient echocardiography diagnosed a large mobile
thrombus originating in the inferior vena cava extending into the right atrium and prolapsing through
the tricuspid valve. Following extraction of the thrombus intraoperative 3D echocardiography was
utilized to guide decision-making for right pulmonary artery thromboembolectomy.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC550
Difficulty Achieving Asystole When the Procedure Requires a Temporary Cessation of Pulsatility
Sang Kim, M.D., Andrew Leibowitz, M.D., Icahn School of Medicine at Mount Sinai, New York, NY
83-year-old male sustained an endoleak after endovascular repair of his infrarenal abdominal aortic
aneurysm (AAA) and presented for an open AAA banding procedure. Surgical technique required
transient (5 seconds) asystole. Escalating bolus doses of adenosine of 6 12 18 and 24 mgs were
ineffective. A bolus of adenosine 24 mg with esmolol 45 mg yielded a brief episode of bradycardia and
then a combined bolus dose of adenosine 30 mg with esmolol 60 mg resulted in asystole sufficient to
accomplish the repair. The history of the use of adenosine in endovascular surgery will be explored in
this presentation.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC551
Left Ventricular Outflow Tract Obstruction With Systolic Anterior Motion of the Mitral Valve
Diagnosed by Transesophageal Echocardiography in Refractory Hypotensive Patient After Heart
Transplantation
Tae Kyong Kim, M.D., Jeong Jin Min, Yunseok Jeon, Deok Man Hong, Jae-Hyon Bahk, Seoul National
University Hospital, Seoul, South Korea
A 44-year-old man presented for urgent heart transplantation due to dilated cardiomyopathy which
rapidly progressed to multi-organ failure. Transthoracic echocardiography revealed pulmonary
hypertension and global hypokinesia with ejection fraction of 20%. Heart transplantation was performed
under cardiopulmonary bypass (CPB) and separation from CPB was tried using infusion of dobutamine
and milrinone. However hypotension and tachycardia aggravated and transesophageal
echocardiography showed left ventricular outflow tract obstruction (LVOTO) with systolic anterior
motion of the mitral valve. After discontinuation of dobutamine and administration of norepinephrine
LVOTO was improved and his blood pressure was restored. CPB was weaned successfully.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC552
Anesthetic Management of Combined Single Lung and Renal Transplant
Francis Kirk, M.D., Vivek Arora, M.D., Charles Brown, M.D., Johns Hopkins Hospital, Baltimore, MD
A 61-year-old ventilator-dependent man on hemodialysis presented for combined single lung and renal
transplant. An arterial line was inserted anesthesia was induced the airway was secured and central
lines were placed. A thoracotomy was preformed and cardiopulmonary bypass was instituted due to
pulmonary artery hemorrhage. The donor lung was reperfused and CPB was weaned. Massive
transfusion continued for persistent mediastinal hemorrhage so the chest was packed. An ICU ventilator
was instituted and the renal transplant began. Mild hypoxia persisted throughout the renal transplant.
The chest was closed after hemostasis was deemed adequate. The patient was transferred to the ICU.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC553
Tick Associated Adult Onset Anaphylaxis and its Impact for CPB
Amanda Kleiman, M.D., Keith Littlewood, M.D., Danja Groves, M.D., University of Virginia,
Charlottesville, VA
We present two separate cases in which patients with known tick bite associated delayed anaphylaxis to
red meat presented for cardiopulmonary bypass. In each case the decision was made to proceed with
the use of heparin prior to initiation of bypass and varying degrees of prophylaxis were used. Despite
prophylaxis including dexamethasone and H1 blockers one patient exhibited a severe anaphylactic
reaction. With the addition of an H2 blocker for the 2nd patient the patient exhibited only a moderate
rash.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC554
Acute Aortic Dissection Requiring CPB and DHCA
Scott Klier, D.O., Arjang Khorasani, M.D., Advocate Illinois Masonic Medical Center, Chicago, IL
We present the case of a 70-year-old female who presented with an acute ascending aortic dissection
requiring emergent repair. This repair was accomplished using femoral-femoral cardiopulmonary bypass
and deep hypothermic circulatory arrest to ensure adequate neuroprotection while antegrade vascular
flow was suspended. A coordinated effort between the surgeon anesthesiologist and perfusionist
allowed for successful surgical repair and avoidance of the multiple complications that are frequently
associated with this surgery. The patient had an uneventful post-operative course and was able to be
discharged home within one week of her surgery.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC555
Managing the Hypercoagulable Bypass Patient
Natalia Klosak, M.D., Albert Robinson, M.D., University of Florida, Gainesville, FL
A 24-year-old female with known Antithrombin III deficiency presented two weeks post-partum with
venous thromboembolism. The patient underwent bilateral iliac and caval thrombectomy and
experienced post-operative dyspnea chest pain and hypotension. Bedside TTE in the ICU revealed severe
RV dysfunction following which the patient arrested and received large dose inotropic support and
Copyright © 2013 American Society of Anesthesiologists
continuous CPR en route to OR. She was found to have a massive saddle embolus and required
pulmonary embolectomy and RVAD placement on cardiopulmonary bypass. Due to her hypercoagulable
status unconventional management of anticoagulation was required with excess heparin and FFP to
maintain the bypass circuit.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC556
Approach to Medical and Surgical Management of Aortic Insufficiency in Patients With Heartmate II
LVAD: A Case Report
Vibhuti Kowluru, M.D., Jeremy Poppers, M.D., Columbia University- New York Presbyterian Hospital, New
York, NY
Patient is a 75-year-old man with NIDCM rheumatic heart disease with moderate AS/MR afib AICD who
underwent Heartmate II LVAD insertion with MV ring as Destination Therapy. His post VAD course was
notable for right heart failure and recurrent GI bleeds requiring suspension of anticoagulation. Following
patient developed device thrombosis requiring LVAD exchange. Consequently he developed dyspnea on
exertion and was found to have severe aortic insufficiency. Given elevated creatinine and inability to
increase LVAD speeds due to severe hemolysis patient underwent Amplatzer closure of aortic valve.
Approach to aortic insufficiency in patients with Heartmate II LVAD is discussed here.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC557
Broken Hearted: A Case Presentation of Atrioventricular Disruption Following Aortic and Mitral Valve
Replacement
Dinesh Kurian, M.D., MBA, Arun Jayaraman, M.D., Ph.D., Jacob Klapper, M.D., Jeffery Gaca, M.D., Mark
Stafford-Smith, M.D., Duke University, Durham, NC
Atrioventricular disruption (AVD) is a devastating complication of cardiac surgery. We present a case of
AVD in a patient undergoing aortic and mitral valve replacement. In addition to severe aortic and mitral
stenosis TEE identified mitral annular calcification requiring debridement. Following separation from
cardiopulmonary bypass bleeding was noted from the posterior aspect of the heart. It was judged that
the patient would not tolerate return to bypass for surgical repair prompting non-surgical attempts to
treat AVD. Despite these efforts the patient died eight hours after surgery. In this case we discuss the
risk factors diagnosis and treatment of AVD.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC558
Unstable Supraventricular Tachycardia Due to Prescription Stimulant Use in an Adult Patient With
ADHD
Robert LaCivita, Giuseppe Trunfio, M.D., Maimonides Medical Center, Brooklyn, NY, Christopher Ovanez,
M.P.H., St. George's University School of Medicine, Grenada
A 51-year-old woman with adult attention deficit hyperactivity disorder on multiple stimulant and
psychotropic medications presented for elective total hip arthoplasty. After the induction of general
anesthesia and positioning in the absence of any surgical stimulation the patient unexpectedly and
abruptly developed unstable SVT . She was electrically cardioverted returned to normal sinus rhythm
and surgery was cancelled. Post operative work up including echocardiogram EKG and lab work was
unremarkable. It was hypothesized that the paroxysmal SVT was likely attributable to her use of
Copyright © 2013 American Society of Anesthesiologists
Dextroamphetamine/Amphetamine in association with other commonly prescribed psychotropic
medications.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC559
Case of Prolonged QT Type 3 Revealed Under General Anesthesia After Episode of Sudden Cardiac
Arrest in a 10-year-old
Lisa Lee, M.D., Drexel University College of Medicine, Philadelphia, PA
A 10-year-old female presented after collapsing after running. CPR was initiated by school staff and she
was successfully defibrillated with AED. There was no family history of sudden cardiac death. Exercise
stress testing showed no exercise-induced arrhythmias. Cardiac MRI and echocardiography were
normal. An ICD was deemed necessary as the cause of her ventricular fibrillation had not been
discovered. During ICD implantation under general anesthesia her QTc became extraordinarily long. This
had not been noted previously at rest or with exercise. A diagnosis of Long QT Type 3 was made. No
further episodes of prolonged QT were noted post-procedure.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC560
Implant of Syncardia® Total Artificial Heart in an ACHD Patient With an LVAD
Erica Lin, M.D., Renee Kreeger, M.D., Lori Aronson, M.D., Cincinnati Children's Hospital Medical Center,
Cincinnati, OH
Advancements in congenital heart disease care have led to improved survival and the evolution of a
unique patient population: the adult with congenital heart disease (ACHD). As a referral center for ACHD
care within a pediatric hospital setting and with an expertise in ventricular assist devices (VAD) our team
assumed care of a 34-year-old ACHD patient with right heart failure and an implanted LVAD. The
perioperative experience surrounding her conversion to a biventricular device epitomizes the challenges
faced by a multidisciplinary team when caring for an ACHD patient who presents with fulminant cardiac
failure.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC561
Cardiac Amyloidosis and Anesthetic Management for Cardiac Surgery
John Liu, M.D., Lynn Belliveau, D.O., Kalpana Tyagaraj, M.D., Maimonides Medical Center, Brooklyn, NY
74-year-old male with medical history of prostate cancer HTN CAD s/p CABG and stents presented for
tricuspic valve replacement. Most recent cardiac imaging was suggestive of cardiac amyloidosis which
was not noted at the first cardiac surgery 8 years prior. Physical exam EKG and intraop TEE showed
characteristic findings of amyloid cardiomyopathy. Patient presented with signs and symptoms of right
heart failure. Intraoperative TEE showed severe right and left heart failure severe TR and MR. The
perioperative management of the patient was complicated and required multiple vasopressors
inotropes and inhaled pulmonary vasodilators to wean from cardiopulmonary bypass
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC562
Orthotopic Cardiac Transplantation After a Post-Infarction Ventricular Septal Rupture
Pingle Reddy, M.D., Geoffrey Lively, Vigneshwar Kasirajan, M.D., Virginia Commonwealth University,
Richmond, VA
This is a 44-year-old male who initially presented to an outside hospital with a massive inferior wall
STEMI. During catheterization he developed cardiogenic shock and required emergent placement of
ECMO. At the time the patient was found to have a large ventricular septal defect (VSD) secondary to
ventricular septal rupture (VSR). After a complicated hospital course including a failed VSD closure the
patient was transported to our hospital for further care. Approximately three weeks later a Total
Artificial Heart was placed for bridge to transplantation which occurred five months after the initial
injury.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC563
Anesthetic Management of a 40-Year-Old With Uncorrected Tetralogy of Fallot Receiving
Radiofrequency Ablation for Metastatic GI Stromal Tumors
Nathaniel Loo, M.D., Jonathan Gal, M.D., Mount Sinai Hospital, New York, NY
The most common cyanotic congenital heart defect tetralogy of fallot (TOF) results in adverse
cardiopulmonary changes. Early surgical treatment of TOF attenuates long term effects of hypoxia and
cyanosis from shunting on cardiac remodeling. Only 3% of uncorrected TOF patients survive past 40
years and these surviving patients pose multiple anesthetic challenges. This 40-year-old patient with
uncorrected TOF underwent radiofrequency ablation for metastatic GI stromal tumors. Challenges in
anesthetic management from the severity of his underlying right ventricular hypertrophy pulmonary
stenosis and intraoperative shunting are discussed.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC564
Aortic Valve Replacememnt-Bentall Procedure Complicated by Profound Vasoplegia and Transfusion
Related Lung Injury During Cardiopulmonary Bypass Requiring Methylene Blue Infusion and IntraAortic Balloon Pump Insertion
Antonio Hernandez Conte, M.D., MBA, Nir Maghen, M.D., Ali Khoynezhad, M.D., Cedars-Sinai Medical
Center, Los Angeles, CA
A 55-year-old -female ASA 4 with a past medical history of severe aortic stenosis and ascending aortic
aneurysm presented for an elective aortic valve replacement and Bentall procedure. After initiating CBP
the patient was transfused with autologous and donor directed packed red blood cells. Almost
immediately after transfusion was initiated the patient developed severe hypotension and copious
pulmonary secretions and required large doses of vasopressin epinephrine and norepinephrine.
Differential diagnoses included anaphylactoid reaction or TRALI. Persistent systolic and diastolic
hypotension required use of methylene blue during CPB and insertion of an intraaortic balloon pump in
order to wean off CPB.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC565
Aortic Valve Replacement in a Patient With Malignant Hyperthermia
Tammy Mai, D.O., John Medley, M.D., Univeristy of Missouri, Columbia, MO
Patient is a 71-year-old female with a history of malignant hyperthermia and severe aortic stenosis
scheduled for an aortic valve replacement. Glidescope was used for anticipated difficult airway and
hemodynamic goals of aortic stenosis were maintained throughout surgery. Anesthetic plan included
avoiding triggering agents volatile anesthetics were removed from anesthesia machine CO2 absorbent
canister was changed anesthesia machine was flushed with O2 at 10L/min for 20 minutes before start of
case and TIVA was used for anesthesia with dexmedetomidine infusion for maintenance. Patient
underwent an uneventful surgery and post op course and was discharged on post-op day 15.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC566
Pulmonary Embolism in a Patient Undergoing CABG
Tammy Mai, D.O., Mitch McKamey, D.O., Univeristy of Missouri, Columbia, MO
62-year-old female transferred from an outside hospital with severe triple vessel CAD and intra-aortic
balloon pump for post infarction angina scheduled for CABG. After completion of protamine the patient
became unstable with pulmonary hypertension hemorrhage and cardiogenic shock requiring inotropic
support and return to bypass. A bronchial blocker was placed and the patient was taken to IR lab.
Imaging revealed an aneurysm in the bronchial artery segment to the right lower lobe and a large
embolus to the right main pulmonary artery. She was returned to the OR for embolectomy but
continued to have hemodynamic deterioration.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC567
A Patient With Severe Asthma and Moderate Aortic insufficiency From Bicuspid Valve for
Laparoscopic Inguinal Hernia Surgery
Bryan Marchant, M.D., Chuanyao Tong, M.D., Sandy An, B.S., Nichole Taylor, D.O., Wake Forest,
Winston-Salem, NC
Despite being minimal invasive and allowing for faster recovery laparoscopic CO2 insufflation places a
significant strain on the cardiovascular and pulmonary systems. A morbidly obese patient with bicuspid
induced aortic insufficiency and ascending aneurysm CAD severe asthma and other comorbidities is
scheduled for redo laparoscopic inguinal hernia surgery. During the presentation we will discuss the
preanesthesia evaluation-the discrepency between the lab tests and history acquiring and physical
examination; form a practical anesthesia plan and the outcome of the anesthesia care.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC568
The Pitfalls of Transthoracic Echocardiography in Evaluation of Endocarditis: A Case Report of
Artifactual Mitral Stenosis
Rebecca Margolis, D.O., Sarah Armour, M.D., Mark Nelson, M.D., Virginia Commonwealth University,
Richmond, VA
We present a patient with a history of liver and renal transplant heparin induced-thrombocytopenia and
endocarditis who presented for a third time mitral valve replacement after transthoracic
echocardiogram demonstrated thrombus causing severe mitral stenosis. Intraoperative transesophageal
echocardiography revealed that the presumed thrombus was in fact an acoustic shadow. Due to this
finding the management of the patient was dramatically altered and the case was cancelled. This case
highlights the superiority of TEE over TTE for the detection of complications related to endocarditis and
the inherent pitfalls of TTE such as acoustic shadowing and poor acoustic windows
Sunday, October 13
3:00 PM - 4:30 PM
CA MC569
Rare Ventricular Wall Mass With RVOT Obstruction
Eric Massey, WVU, Morgantown, WV
Patient is a 41-year-old female with no pertinent PMH who presented with shortness breath mild chest
discomfort and complaints of malaise and worsening cough. CT scan of the chest revealed a
questionable intraventricular mass. Cardiac work-up included transesophageal echocardiogram and
cardiac MRI which confirmed the presence of cardiac tumor with involvement of the right atrium and
right ventricle. Endomyocardial biopsy returned as a likely rhabdomyoma. Cardiac function ejection
fraction chamber pressures and coronary arteries were normal at rest. This discussion will focus on the
anesthetic management and implications of a RVOT mass.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC570
Diagnosis and Management of Incidental Aortic Dissection During Bilateral Lung Transplantation With
Cardiopulmonary Bypass
Michael Mathis, M.D., Matthew Caldwell, M.D., University of Michigan, Ann Arbor, MI
We describe a 29-year-old male with medically refractory cystic fibrosis presenting for double-lung
transplant. After induction of general anesthesia and initiating mechanical ventilation worsening
pulmonary hypertension prompted initiating cardiopulmonary bypass. The surgery proceeded
uneventfully; however upon weaning from cardiopulmonary bypass and decannulation intraoperative
transesophageal echocardiography demonstrated a previously undiagnosed retrograde Type B aortic
dissection. An intraoperative cardiac surgery consult was obtained and due to concern for retrograde
extension the patient underwent an ascending aortic arch replacement. The aortic arch replacement
proceeded as planned and upon completion the patient was transferred to the intensive care unit in
stable but critical condition.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC571
Metastatic Leiomyosarcoma Compressing the Left Ventricle
Sharon McCartney, M.D., George Whitener, M.D., Duke University, Durham, NC
A 44-year-old female who previously underwent total abdominal hysterectomy for uterine
leimyosarcoma developed a left lower lung metastasis measuring 22 x 14 x 10cm. This tumor extruded
outside of her skin on the lateral border and compressed her left ventricle on the medial border. She
had poor functional status including dyspnea and chest pain with minimal exertion. We describe the
intraoperative anesthetic management of her left lower lobectomy excision of seven ribs pericardium
and left hemidiaphragm as well as reconstruction of the left hemidiaphragm pericardium and chest wall.
We also describe the patient's postoperative course and analgesia management.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC572
Left Ventricular Perforation After Transcatheter Aortic Valve Replacement (TAVR) Deployment
Sharon McCartney, M.D., Arun Jayaraman, M.D., George Whitener, M.D., Duke University, Durham, NC
A 73-year-old female with severe aortic stenosis coronary artery disease status post prior coronary
artery bypass surgery hypertension and peripheral vascular disease had NYHA class III symtpoms of
dyspnea and chest pain with minimal exertion. Due to small caliber femoral vessels she underwent
transcatheter aortic valve replacement (TAVR) with a partial sternotomy and direct aortic approach.
After deployment of a 26 mm Medtronic CoreValve the patient developed profound hypotension
refractory to pharmacologic support. Transesophageal echocardiography revealed an expanding
hemorrhagic pericardial effusion and large left ventricular rupture. We discuss this case as a
complication of TAVR.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC573
Aspiration in Asymptomatic Patient With Remote History of Gastrectomy
Daniel McGuire, M.D., Abraham Fura, D.O., Erika Cyr, M.D., Jeffrey Sagel, D.O., Walter Reed National
Military Medical Center Bethesda, Besthesda, MD, Victor Rivera, M.D., Naval Health Clinic Cherry Point,
Cherry Point, NC
A 74-year-old male with remote history of esophagectomy-gastrectomy presented for coronary artery
bypass graft. Surgery was complicated by an aspiration event on induction despite asymptomatic
Gastroesophageal Reflux Disease H2 blocker therapy and appropriate npo status. Suction of aspirated
fluids was performed and bronchoscopy revealed clean bilateral airways. Surgery was continued after
serial arterial blood gasses demonstrated appropriate oxygenation; however separation from bypass
was complicated by significant hypoxemia requiring inhaled nitric oxide and Airway Pressure Release
Ventilation. The development of Acute Respiratory Distress in this case is presumed multifactorial to
include both aspiration pneumonitis and cardiopulmonary bypass-associated lung injury.
Copyright © 2013 American Society of Anesthesiologists
Sunday, October 13
3:00 PM - 4:30 PM
CA MC574
3D TEE Diagnosis of an Acute Atrioventricular Valve Thrombosis in a Patient With a Single Ventricle for
Impella Implantation
Renata Miketic, M.D., Sasha Shillcutt, M.D., Univ of Nebraska Med Ctr, Omaha, NE
Mechanical valve thrombosis is a severe complication post-valve replacement. Risk factors for
thrombosis include hypercoagulability blood stasis and endothelial damage. Acute mechanical valve
thrombosis is a critical event with significant morbidity and mortality. Urgent diagnosis is imperative to
treatment and survival. Because 3D TEE has increased spatial and temporal resolution of intra-cardial
masses it has allowed cardiac anesthesiologists to expand their diagnostic capabilities. We describe the
use of 3D TEE to diagnose acute valve thrombosis in a patient with a functional single ventricle who
presented for Impella implantation to treat acute heart failure two weeks after mechanical tricuspid
valve placement.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC575
Hypotension on Cardiopulmonary Bypass During Closure of a Potts Shunt in an Adult Congenital Heart
Disease Patient
Jeffrey Moore, D.O., Mark Lischner, D.O., Richard McAffee, M.D., University of Pittsburgh Medical Center,
Pittsburgh, PA
A 47-year-old female with congenital atrial septal defect ventricular septal defect hypoplastic right
ventricle and a palliative Potts shunt (aorta to left pulmonary artery) presents for shunt closure and
cardiac transplant. Profound hypotension occurred with the initiation of cardiopulmonary bypass
despite adequate flow resistance and vasopressors. Left to right shunting across the Potts shunt was
diagnosed from physiologic signs and compression of the pulmonary artery. The patient suffered anoxic
brain injury but fortunately recovered to near baseline status.
Sunday, October 13
3:00 PM - 4:30 PM
CA MC576
Impossible to Induce Safely - SVC Narrowing With Adrenal Insufficiency?
Allison Moriarty, M.D., Daniel Sizemore, M.D., West Virginia University, Morgantown, WV
A 33-year-old female was admitted to our hospital with bradycardia and urosepsis. The bradycardia
required placement of a temporary transvenous pacemaker. After stabilization she presented to the
operating room for epicardial pacemaker lead placement via left thoracotomy. Permanent transvenous
leads were not being attempted due to chronic SVC narrowing observed on CT scan. She had a history of
a gunshot wound to the head with subsequent stroke seizures and hypopituitarism. Her medications
included hydrocortisone 30mg qAM and 20mg qPM DDAVP and synthroid. We discuss anesthetic
planning and induction in a pacemaker-dependent patient with SVC narrowing and adrenal insufficiency.
Copyright © 2013 American Society of Anesthesiologists
MCC Session Number – MCC09
Monday, October 14
8:00 AM - 9:30 AM
AM MC577
Apneic Technique for Tracheal Dilation in a Patient With Tracheobronchopathia Osteochondroplastica
Donna LaMonica, Jeena Jacob, M.D., Mount Sinai, New York, NY
A 55-year-old man with a past medical history of tracheobronchopathia osteochondroplastica presented
for repeat tracheal dilation. We utilized an inhalation induction using sevoflurane in order to maintain
spontaneous ventilation with assistance after which a bolus of remifentanil and an infusion of propofol
were started. The patient's airway was surrendered to the otolaryngologist who intubated using direct
laryngoscopy and a 5.0 cuffed standard endotracheal tube. We utilized periods of apnea at two minute
intervals after which the patient was mask ventilated to an end tidal oxygen if 90%. The patient was
dilated up to a size 7.5 endotracheal tube.
Monday, October 14
8:00 AM - 9:30 AM
AM MC578
Anesthetic Management of a Patient With a Cardiac Life-Vest Undergoing a TURP Procedure
Alec Lawrence, M.D., Kenneth Moran, M.D., The Ohio State University Wexner Medical Center,
Columbus, OH
The cardiac LifeVest is a wearable external defibrillator used for patients at high risk for sudden cardiac
arrest who are not currently candidates for implantable ICD placement such as unknown permanent risk
or infection. This case involved a patient with severe LV systolic dysfunction and a LifeVest due to an
infected sternal wound that was scheduled to undergo a TURP procedure. We will discuss the anesthetic
considerations including how the vest functions whether it should be continued intraoperatively and the
implications of concurrent use of electrosurgical units.
Monday, October 14
8:00 AM - 9:30 AM
AM MC579
Abnormal EKG in a Patient With History of Substance Abuse
John Lee, M.D., University of Southern California, Los Angeles, CA
24-year-old male with history of substance abuse and unknown abnormal cardiac rhythm scheduled for
ankle fracture ORIF. On arrival to OR patient begins having multiple PVCs while in NSR. The patient
becomes anxious and tachycardic NSR becomes solely PVCs resembling Vtach or an accessory pathway
rhythm. Still the patient is hemodynamically stable. Lidocaine is given and has no effect. Esmolol is given
and NSR returns interspersed with PVCs. Intraoperatively patient continues to have a tachycardic and
abnormal rhythm and esmolol is no longer effective. Patient is admitted and cardiology is consulted.
Monday, October 14
8:00 AM - 9:30 AM
AM MC580
The Land of the Unknown: Spinal Anesthesia in a Patient With Kennedy's Disease
Brittany Maggard, M.D., Marina Varbanova, M.D., Gary Loyd, M.D., University of Louisville, Louisville, KY
We are presenting a case of spermatocelectomy on a 68-year-old patient with Kennedy's disease.
Kennedy's disease is a rare X-linked recessive neurodegenerative disorder of lower motor neurons
Copyright © 2013 American Society of Anesthesiologists
characterized by progressive proximal limb and bulbar muscular atrophy. Patients with the disease have
an increased risk of spontaneous laryngospasm postoperative glottic edema and may require prolonged
ventilatory support. There is no literature reporting the use of spinal anesthesia in patients with
Kennedy's disease. We felt a spinal anesthetic would be a reasonable alternative for our patient who
tolerated the blockade well with no delay in his postoperative recovery.
Monday, October 14
8:00 AM - 9:30 AM
AM MC581
Choking Patient in PACU: Airway Management of Patient With T-Tracheal Tube
Tariq Malik, Atul Gupta, M.D., University of Chicago, Chicago, IL
76-year-old Polish speaking male with bladder cancer left hemiparesis hypertension subglottic/tracheal
stenosis with T-tube presented for TURBT. No records were available for similar procedure done under
GA previously at an outside facility. Patient refused neuraxial anesthesia. After propofol induction Ttube was switched to 7.0 cuffed endotracheal tube. At the end t-tube was replaced after multiple
attempts. In PACU patient woke up combative requiring sedation. A family member brought in to help
communicate with the patient pointed out that the t-tube had been placed in reverse orientation like
the last time. ENT then placed the tube under bronchoscopic guidance.
Monday, October 14
8:00 AM - 9:30 AM
AM MC582
I've Fallen Asleep and I Can't Get Up: A Rare Complication: Conversion Disorder After General
Anesthesia for Ambulatory Surgery
Chawla LaToya Mason, M.D., Damien Larkins, M.D., Baylor College of Medicine, Houston, TX
A 46-year-old healthy woman presented for breast biopsy. She received general anesthesia comprised
of midazolam fentanyl lidocaine propofol and sevoflurane. During recovery she reported loss of motor
and sensory function in bilateral extremities below level of the knees. Neurosurgery and neurology
teams were immediately consulted for further evaluation that included computed tomography. No
organic explanation for the patient's symptoms was found. After psychiatric evaluation a presumptive
diagnosis of conversion disorder was made. At time of discharge he required a walker for ambulation
assistance. Several months later she returned to the hospital for an unrelated visit with no neurologic
deficits.
Monday, October 14
8:00 AM - 9:30 AM
AM MC583
A Successful Perioperative Management of Liver Transplantation Case With Idiopathic Pulmonary
Fibrosis
Takashi Matsusaki, M.D., Keishi Kawano, M.D., Norihiko Obata, M.D., Ryuji Kaku, M.D., Hiroshi
Morimatsu , M.D., Okayama University Hospital, Okayama, Japan
A 46-year-old female cirrhotic patient due to hepatitis of type C presented with progressive dyspnea
hypoxemia and increased alveolar-arterial oxygen gradient (A-a) requiring home oxygen therapy due to
Idiopathic Pulmonary Fibrosis. Her Model for End-stage Liver Disease was 16 however she also had
progressive hepatocelluar carcinoma within the Milan criteria. She had received the living-donor liver
transplantation from her husband. We gave her lowered her concentration of oxygen and tidal volume
during the operation. Fortunately she was extubated at postoperative Day 3 and had never experienced
acute exaggeration of IPE for one month after surgery.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
AM MC584
Left Gluteal Compartment Syndrome After Right Robot-Assisted Laparoscopic Partial Nephrectomy
Venod Narine, M.D., NYU, New York, NY
A 61-year-old male with a history of right renal incidentaloma to undergo elective robot-assisted
laparoscopic partial nephrectomy. Our patient was placed in a left lateral position. His time in the room
lasted approximately 8 hours and surgery proceeded uneventfully. Upon PACU arrival he complained of
9/10 left buttock pain. Left gluteal compartment pressure measured 40 mmHg. He was taken for an
emergent left gluteal fasciotomy. Intraoperatively we found muscle ischemia. He was able to ambulate
within two months of fasciotomy. His partial nephrectomy pathology report revealed papillary renal cell
carcinoma with negative margins.
Monday, October 14
8:00 AM - 9:30 AM
AM MC585
Critical Bronchospasm
Peter Oleszak, M.D., Sherwin Park, M.D., Stony Brook University Hospital, Stony Brook, NY
50-year-old female history of mild asthma sinusitis and GERD presented for sinus surgery. Patient
preoxygenated induction uneventful easy mask ventilation. Grade IV laryngoscopy ETT placement via
Bougie. Extreme resistance on bag ventilation no ETCO2 and absent breath sounds on auscultation.
Reintubated via Bougie with same outcome. Extubated and mask ventilated with extreme resistance.
Patient's O2 saturation decreased to 80%. Bronchospasm suspected high Desflurane concentration
multiple doses of albuterol and high positive pressure mask ventilation started. O2 saturation improved
to upper 90%'s. Difficult intubation performed with combined technique using Glidescope and flexible
fiberoptic scope.
Monday, October 14
8:00 AM - 9:30 AM
AM MC586
Anesthetic Management of Achondroplastic Dwarf
Mayur Patel, M.D., Victor Mandoff, M.D., University of Arkansas for Medical Sciences, Little Rock, AR
A 67-year-old female achondroplastic dwarf presenting with metastatic colon cancer to liver was
scheduled to have segmentectomy of segment 8 of liver and cholecystectomy. Patient was 49 inches tall
and weighed 40 kg. Patient appeared very anxious in preoperative holding. Smooth IV induction to
facilitate intubation. Once patient stabilized 16 gauge and 14 gauge intravenous lines were inserted
peripherally and in external jugular respectively. Although patient had bounding radial pulses on
palpation bilaterally we had multiple failed attempts to thread arterial catheters in the radial arteries.
After these failed attempts a catheter was placed in the femoral artery.
Monday, October 14
8:00 AM - 9:30 AM
AM MC587
Prolonged Paralysis After an Intubating Dose of Intermediate Non-Depolarzing Muscle Relaxant
Thao Pham, M.D., Tara Kennedy, M.D., Silpa Goriparthi, M.D., Thomas Jefferson University Hospitals,
Philadelphia, PA
A healthy 40-year-old 73 kg African American female with a malignant right breast mass was scheduled
for partial mastectomy. Pre-operative labs revealed a stable hemoglobin of 6.3 g/dl and normal
Copyright © 2013 American Society of Anesthesiologists
metabolic panel and liver function tests. 40mg (0.48mg/kg) of rocuronium was given intravenously to
facilitate intubation. Two hours later the train of four was 0/4 with no post-tetanic response. Recovery
of neuromuscular function did not occur until four hours after induction. We will discuss possible causes
of this unique clinical predicament and the need for quantitative measurement of neuromuscular
blockade even after a single dose of paralytic.
Monday, October 14
8:00 AM - 9:30 AM
AM MC588
Aspiration in a Patient With Delayed Gastric Emptying: What to Do When NPO Guidelines Fail?
Taylor Plumer, Mercy Udoji, University of Alabama at Birmingham, Birmingham, AL
57-year-old WF with systemic sclerosis gastric bypass &amp; esophageal dilations presents for
amputation of bilateral ischemic digits. Patient brought to OR noting last PO intake 48-72hrs prior.
Before RSI for GETA patient received IV ranitidine for nausea. As propofol and lidocaine were
administered copious amounts of bilious emesis were noted. With head turned in trendelenburg
position immediate suctioning of oropharynx returned bilious content with particulate matter.
Intubation proceeded with 5cc of similar content suctioned from the endotracheal tube and an
additional 2400mL of bilious content suctioned from a nasogastric tube resulting in case cancellation
and hospitalization for aspiration pneumonia.
Monday, October 14
8:00 AM - 9:30 AM
AM MC589
Spontaneous Ventricular Fibrillation and Torsade De Pointes in an Elderly With Undiagnosed Severe
Hypomagnesemia
Govind Rajan, University of California Irvine, Irvine, CA, Kristin Satterfield , M.D., Maxime Cannesson ,
M.D., Ph.D., UCI Medical Center, Irvine, CA
Acquired renal magnesium wasting due to aging and mild interstitial renal disease is increasingly being
recognized. The incidence is further increased among patients with history of diabetes and those on
diuretic therapy. We present a case unprovoked ventricular fibrillation and torsades de pointes in an
elderly with undiagnosed severe hypomagnesemia in the immediate post operative period following
wide local excision of right cheek melanoma. The discussion focusses on the importance of undiagnosed
hypomagnesemia among elderly and its clinical implications in the perioperative period.
Monday, October 14
8:00 AM - 9:30 AM
AM MC590
Isosulfan Blue Dye Anaphylaxis Presenting as Inability to Ventilate With an LMA
Heather Reed, M.D., Huong Le, M.D., Christiana Shaw, M.D., Mark Rice, M.D., University of Florida,
Gainesville, FL
A 44-year-old woman presented for sentinel node biopsy and segmental mastectomy. After induction an
LMA was placed with adequate ventilation. Three minutes after isosulfan blue dye injection for sentinel
node location ventilation became difficult. The LMA was removed and an ETT was placed easily. Twenty
minutes later she became hypotensive and unresponsive to phenylephrine ephedrine and vasopressin.
With erythema and swelling in her arm and chest low dose epinephrine was titrated until her MAP
stabilized. At the conclusion of the procedure she had no cuff leak and remained intubated for eight
hours. Serum tryptase was elevated at 27.2 ug/L.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
AM MC591
Stat Bilateral Needle Thoracostomies: A Case of Severe Bilateral Tension Pneumothoraces During a
Routine Colonoscopy
Carmen Rivera, University of Illinois Hospital, Chicago, IL
80-year-old woman ASA VI presented for a colonoscopy. During the procedure oxygen desaturation was
noted and massive subcutaneous emphysema was palpated. Her cardiac rhythm rapidly deteriorated to
pulseless electrical activity and ACLS protocol was initiated. Immediate presumptive diagnosis of tension
pneumothoraces was made. Bilateral needle thoracostomies were performed with immediate return of
blood pressure and improved ventilation. Surgical intervention revealed a large cecal tear. After
appropriate ICU care patient was discharged home without any long term sequelae. This case highlights
the importance of anesthesia providers' ability to quickly recognize and treat this life threatening
complication.
Monday, October 14
8:00 AM - 9:30 AM
AM MC592
The Use of Glidescope for Tracheal Intubation in Patients With Ankylosing Spondylitis
Sara Robertson, M.D., Victor Mandoff, M.D., University of Arkansas for the Medical Sciences, Little Rock,
AR
This patient with ankylosing spondylitis presented for a left CFE. The patient's positioning was a
challenge. After being transported to the operating room the patient was positioned on the OR table
with several blankets under his back. With fiberoptic intubation equipment immediately available the
patient was intubated with the glidescope. This case brings to light a possible equally effective
alternative to awake fiberoptic intubation of patients with ankylosing spondylitis-the use of the
Glidescope.
Monday, October 14
8:00 AM - 9:30 AM
OB MC593
Anesthetic Considerations for an EXIT Procedure for a Venolymphatic Malformation
Christina Lee, M.D., Manuel Vallejo, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA
A 37-year-old G1P0 female with a history of chronic hypertension underwent an EXIT procedure at 36
weeks 6 days GA for a fetal venolymphatic malformation involving the left parotid space with
encroachment into the pharynx. General endotracheal anesthesia was induced with a rapid sequence
induction. Maintenance was achieved with desflurane and nitrous oxide. After uterine incision the fetal
head and right upper extremity were exteriorized. An intravenous catheter was placed in the fetal hand.
The fetal airway was secured by pediatric ENT via endotracheal intubation by direct laryngoscopy. The
patient was extubated upon completion of surgery and recovered uneventfully.
Monday, October 14
8:00 AM - 9:30 AM
OB MC594
Peripartum Cardiomyopathy in a Patient With Mild Pre-eclampsia and Twin Gestation
Alice Li, Loretta Grecu, M.D., Yale University, New Haven, CT
A 32-year-old G1P1002 woman with pre-eclampsia presented with acute shortness of breath and low
SaO2 on POD5 after Cesarean-section. Chest X-ray revealed bilateral patchy hazy opacities while TTE
Copyright © 2013 American Society of Anesthesiologists
showed severe biventricular failure (LVEF 15%). She was diagnosed with peripartum cardiomyopathy.
Emergent intubation and intra-aortic balloon pump followed. Despite maximal ventilatory support and
management with diuretics and vasodilators she continued to deteriorate with MVO2 35% and SaO2
85%. She underwent emergency BIVAD implantation with ECMO. Three days later ECMO was removed
and she was extubated. The BIVAD was removed the following week. Her last LVEF was 55% before
being discharged home.
Monday, October 14
8:00 AM - 9:30 AM
OB MC595
Quadriplegic Parturient With Autonomic Dysreflexia on Therapeutic Anticoagulation for Pulmonary
Embolism
K. Grace Lim, M.D., Anne Lavoie, M.D., Manoj Kalayil, M.D., Brian Braithwaite, M.D., Christopher Cambic,
M.D., Northwestern University Feinberg School of Medicine, Chicago, IL
The patient is a 32-year-old G3P1 with C5 quadriplegia after a motor vehicle collision at the age of 19.
She has severe autonomic dysreflexia at baseline and had two successful vaginal deliveries in the past
under epidural analgesia. During this pregnancy however she was diagnosed with bilateral pulmonary
embolisms six weeks prior to labor and delivery requiring therapeutic anticoagulation. We discuss and
weigh the evidence risks and benefits of regional anesthesia - an arguably superior mode of control of
dysreflexia - in the setting of therapeutic anticoagluation in an immobile parturient.
Monday, October 14
8:00 AM - 9:30 AM
OB MC596
Venous Sinus Thrombosis After Unintended Dural Puncture and Blood Patch
James Lincoln, M.D., Snigdha Ancha, M.D., Mary Im, M.D., Marcus Zebrower, M.D., Drexel University
College of Medicine, Philadelphia, PA
A 34-year-old female requested elective labor epidural placement. During placement there was return
of CSF through 18g Tuohy needle at L3-4 Level. Subsequently an epidural catheter was successfully
advanced at the L4-5 level with LOR at 4cm. The epidural facilitated an uncomplicated spontaneous
vaginal delivery. Later on PPD#9 patient presented from home for severe positional headache. An
epidural blood patch was placed with immediate relief and patient was discharged. On PPD #10 patient
was admitted for recurrent headache and found to have right venous sinus thrombosis on MRI.
Neurology was consulted and patient improved clinically with therapeutic anticoagulation.
Monday, October 14
8:00 AM - 9:30 AM
OB MC597
Management of Hypercoagulable Laboring Patient in Rapid Atrial Fibrillation
Jon Livelsberger, D.O., Michael Brotspies, D.O., William Somerset, D.O., Temple University Hospital,
Philadelphia, PA
27-year-old G8P0250 at 38 weeks with history notable for protein C deficiency, multiple DVTS, and PE
presented in early labor. Decision made to provide epidural analgesia, however since anticoagulation
would be held during labor, decision made by OB to place IVC filter. After filter placed, via right IJ
approach, she returned to L&D in rapid atrial fibrillation (BP 90/50). Cardiac consultation obtained, they
advised against cardioversion without anticoagulating. OB was against anticoagulating and soon after
declared arrest of labor. A neuraxial technique was attempted; however inadequate sensory blockade
mandated induction of general anesthesia in the face of hemodynamic instability.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC598
Postdural Puncture Headache With Associated Subdural Hematoma
Oscar Lopez, NYU, New York, NY
30-year-old Gravida 2 Para 0010 at 35 3/7 weeks gestation presentes for caesarean section for
gestational hypertension. Planned for CSE. Positioned sitting midline attempt L3-L4. Tuohy needle
advanced to LOR. Positive clear CSF was noted. Second attempt at L2-L3 without complications.
Cesarean section performed uneventfully. Remained asymptomatic in hosital. POD 5 developed severe
positional frontal headache relieved in supine position. Went to ED CT head showed bilateral 1cm
subdural hematomas no midline shift. Patient had no neurologic deficit. Blood patch performed on
POD#6. Headache completely resolved on POD #7. Eventually discharged home after 2 days of
monitoring.
Monday, October 14
8:00 AM - 9:30 AM
OB MC599
Delayed Epidural Local Anesthetic Response in a Patient With Severe Preeclampsia Undergoing
Cesarean Delivery
Sean Malin, M.D., Howard Lee, B.S., Marianne David, M.D., George Washington University, Washington,
DC
The patient was a 46-year-old G2P0 parturient with sarcoidosis MVP who presents at 26.3 weeks with
triplets and severe preeclampsia/HELLP syndrome for urgent Cesarean delivery. The anesthetic plan was
for neuraxial blockade by epidural infusion. An epidural catheter was placed and bupivacaine 100mg
thirty minutes later lidocaine 100mg fifteen minutes later lidocaine 90mg failed to provide anesthesia
adequate for surgery. The decision was made to proceed with general anesthesia. Rapid sequence
induction was performed with direct laryngoscopy using a C-mac and a size 6.0 endotracheal tube.
Interestingly post-operative pain was well controlled with PCEA through the same catheter.
Monday, October 14
8:00 AM - 9:30 AM
OB MC600
Subdural Injection or Epidural Anesthesia in a Hypovolemic Patient? A Case Report Looking at
Maternal Heart Rate Variation During Contractions.
Caroline Martinello, M.D., Felipe Medeiros, M.D., Justin Davis, M.D., Michelle Simon, M.D., Rakesh
Vadhera, M.D., F.R.C.A., The University of Texas Medical Branch, Galveston, TX
Maternal heart rate (MHR) variability with uterine contractions may be a predictor of volemic status and
blood pressure response to neuraxial anesthesia in laboring patients. Limited data is available but there
are case reports of hypovolemic patients developing a sinusoidal pattern of MHR on fetal strips with the
trough of the MHR curve corresponding to the uterine contractions. We describe a case of shock and
respiratory arrest following labor epidural anesthesia with focus on MRH pattern. We additionally
discuss possible causes and differential diagnosis such as subdural injection of local anesthetic.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC601
The Clinical Management of a Suspected Subdural Catheter Placement in a Preeclamptic Parturient
Brian McClure, D.O., Ashraf Farag, M.D., Texas Tech University Health Sciences Center, Lubbock, TX
This is a case of suspected subdural injection of local anesthetic in an 18-year-old preeclamptic
parturient. The patient underwent routine placement of an epidural catheter with a test dose injection
of local anesthetic with epinephrine. Approximately four minutes after injection the patient began to
feel drowsy light headed and short of breath. Oxygen was administered however the patient
desaturated subsequently losing consciousness. She was immediately intubated and ventilated
transferred to the operating room where a healthy infant was delivered via forceps. The patient
remained stable and was extubated 4 hours later without apparent complications to mother or
newborn.
Monday, October 14
8:00 AM - 9:30 AM
OB MC602
Loss of Airway in a Pregnant Trauma Patient Resulting in Emergent Cesarean Section
Shady Adib, M.D., Melanie McMurry, M.D., University of Missouri, Columbia, MO
A 34-year-old pregnant female EGA 30 weeks post MVA with multiple facial fractures was scheduled for
a tracheostomy and ORIF of facial fractures. She was intubated with a central line and fetal monitoring.
After an uneventful surgical course the surgeon inadvertently pulled out the central line and lost the
tracheosomy access. The patient became hypoxic and fetal heart tones diminished. The patient was
intubated orally. OB performed an emergency cesarean section. The infant required CPR. IV access was
eventually regained. The infant was transported to NICU. The patient returned to the ICU with an oral
ETT in stable condition.
Monday, October 14
8:00 AM - 9:30 AM
OB MC603
Complicated Autoimmune Hepatitis and Cesarean Delivery
Gustavo Mendes, M.D., Fernanda Mehlmann, M.D., Anibal Vicuna, M.D., Daniel Kim, Monica Siaulys,
M.D., Ph.D., ISCMSP, Sao Paulo, Brazil
A 22-year-old ASA Physical Status III women presented for cesarean delivery. Past history was significant
for autoimmune hepatitis with signs of acute recrudescence (ascites dyspnea and ecchymosis) with few
treatment options due to pregnancy. In preoperative evaluation the echocardiogram was unremarkable
and blood bank ready for massive blood transfusion. Since patient had clinical signs of coagulopathy
general anesthesia technique was chosen and uneventful. During surgery were used 7 platelets units 7
cryoprecipitate units and 3 fresh frozen plasma units and no unexpected bleeding detected. Patient
subsequent course was uneventful.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC604
Postdural Puncture Headache Treatment and Prophylaxis: Treating an Immediate Onset Postdural
Puncture Headache With an Epidural Blood Patch Via an Existing Epidural Catheter and then
Administering Prophylactic Cosyntropin
Jennifer Mendoza, M.D., Heather Nixon, M.D., University of Illinois at Chicago, Chicago, IL
We present a parturient (G4P2 at 37wks GA with twin pregnancy) whose first attempt at a labor epidural
resulted in an inadvertent dural puncture with the rapid onset of a postdural puncture headache(PDPH).
Migration of the placed intrathecal catheter led to inadequate analgesia and a subsequent epidural
catheter was placed for labor analgesia. After successful delivery of twins an epidural blood patch was
performed utilizing the epidural catheter with immediate relief of PDPH. Then 1 mg of cosyntropin was
administered intravenously for PDPH prophylaxis of future headache. The patient was discharged on
postpartum day 3 without complication or headache.
Monday, October 14
8:00 AM - 9:30 AM
OB MC605
Management of Labor Analgesia in a Parturient With a Giant 5 cm Vestibular Schwannoma
Keric Menes, M.D., Arti Ori, M.D., Maimonides Medical Center, Brooklyn, NY
25-year-female at 40 weeks presented in active labor. History was significant for resection of a giant
cerebropontine angle vestibular schwannoma five years ago. Post resection a residual tumor of 6 x 3
mm tumor was left behind. Recent MRI demonstrated a larger 2.5 x 5.4 x 4.0 cm tumor. Physical exam
showed bilateral visual loss persistent imbalance and tinnitus in the left ear. The parturient was placed
on PCA morphine pump at a dose of 1 mg every 8 min without an infusion. An arterial line was placed.
The parturient delivered vaginally after 10 hours without incident.
Monday, October 14
8:00 AM - 9:30 AM
OB MC606
Anesthetic Management of a Pregnant Patient With Suspected Placenta Percreta.
Daniela Micic, Jae Park, University of Southern California, Los Angeles, CA
A 28-year-old G3P2 female pregnant with twins in active labor was urgently brought to the operating
room for caesarian section. The patient had suspected placenta percreta. Quickly an anesthetic plan was
formulated with the obstetricians and urologists. An arterial line and central line were placed while the
patient was awake for monitoring and access. The surgeons scrubbed and sterilely prepped the patient
prior to anesthesia induction. Rapid sequence induction and intubation were performed and a caesarian
section was safely and successfully carried out. The patient then underwent a hysterectomy without
complications.
Monday, October 14
8:00 AM - 9:30 AM
OB MC607
Neuraxial Analgesia for Labor After Epidural Steroid Injections
Merrick Miles, UNC, Durham, NC, Kimberley Nichols, UNC Hospitals, Chapel Hill, NC
A 37-year-old laboring multiparous female requested a lumbar epidural for analgesia. Her past medical
history was notable for chronic low back pain treated with lumbar epidural steroid injections. The
epidural placement was uneventful via a loss of resistance technique but the patient had a positive test
Copyright © 2013 American Society of Anesthesiologists
dose for intrathecal placement. No significant analgesia was experienced and the decision was made to
replace the catheter. The second catheter threaded easily but CSF was aspirated. This catheter was
managed successfully as an intrathecal catheter but the patient suffered a post-dural puncture
headache that required an epidural blood patch for resolution.
Monday, October 14
8:00 AM - 9:30 AM
OB MC608
Anesthetic Management of a Parturient With Limb-Girdle Muscular Dystrophy for Caesarean Section
Larkin Mitchell, M.D., Eric Hutto, M.D., Arthur Calimaran, M.D., University of Mississippi Medical Center,
Jackson, MS
A 25-year-old 59 in 32 kg G1P0 at 34 weeks gestation presented for scheduled caesarean section due to
malpresentation and worsening oligohydramnios. She had limb-girdle muscular dystrophy with
associated scoliosis and severe restrictive lung disease. Her pre-operative pulmonary function tests
revealed FVC 30% of predicted FEV1 31% of predicted and severe decrease in DLCO and she used BiPap
at night. History of difficult airway.The anesthetic implications of limb-girdle muscular dystrophy
presented a challenging scenario for the peri-operative management of this patient.
Monday, October 14
8:00 AM - 9:30 AM
OB MC609
Postpartum Hemorrhage in a Parturient With Von Willebrand Factor Disease Type 2A
Daria Moaveni, M.D., Katherine Hoctor, M.D., J. Ranasinghe, M.D., University of Miami-Jackson
Memorial Hospital, Miami, FL
A 31-year-old G2P1001 with von Willebrand factor disease type 2a presented for trial of labor after
cesarean at 39 weeks gestation. She requested a labor epidural but the ristocetin cofactor activity was
not available to determine the safety of performing a neuraxial technique. Remifentanil PCA was used
successfully for labor analgesia. Antihemophilic factor/von Willebrand factor complex (vWFC) was given
preemptively during labor. A cesarean delivery was performed for arrest of labor and general anesthesia
was administered; vWFC was given during surgery. Despite no excessive intraoperative bleeding in the
PACU she developed postpartum hemorrhage requiring additional treatment.
Monday, October 14
8:00 AM - 9:30 AM
OB MC610
A Multidisciplinary Approach to Acute Aortic Dissection in the Third Trimester of Pregnancy
Dominique Moffitt, M.D., Hans Sviggum, M.D., Laura Chang, M.D., Brigham and Women's Hospital,
Boston, MA
We report a complex case of a 27-year-old female with Marfan's who presented at 28 weeks gestation
with a descending thoracic aortic dissection. A multidisciplinary team including obstetrics anesthesia
cardiology along with vascular and cardiac surgery coordinated her management and care. She
underwent cesarean delivery at 30 weeks gestation in a hybrid operating suite under epidural
anesthesia. She returned two weeks postpartum with expansion of the dissection which was then
repaired. The cardiovascular physiology of pregnancy and how it influences the risk of aortic dissection
in patients with Marfan's will be discussed along with the anesthetic considerations.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC611
Curious Incidence of Recurrent Postpartum Angioedema
Cody Motley, M.D., B.J. Haywood, M.D., Brian Seacat, M.D., Abhinava Madamangalam, M.D., OU Health
Sciences Center, Oklahoma City, OK
We present a multigravida at 34 weeks gestation complicated by severe gestational hypertension who
developed impressive bilateral periorbital and perioral pruritic erythematous edema post-operatively.
Onset occurred several hours following an uncomplicated cesarean section with a spinal anesthetic.
Resolution of symptoms occurred over the next 24 hours. Her angioedema correlated closely with the
mast cell-mediated variety. Interestingly the patient experienced similar symptoms with her previous
pregnancy. She denied having known allergies. We will discuss the clinical features causes management
and potential risks associated with angioedema in the parturient.
Monday, October 14
8:00 AM - 9:30 AM
OB MC612
Fever Back Pain and Tenderness 6 Days After a Labor Epidural; Now What?
Cody Motley, M.D., Tilak Raj, M.D., B.J. Haywood, M.D., OU Health Sciences Center, Oklahoma City, OK
We present a 33-year-old female who presented six days postpartum following an uncomplicated
vaginal delivery and epidural analgesia with complaints of fever chills and lower back pain. Exam
revealed fever tachycardia and profound tenderness and heat throughout her lower back. Concern for
an epidural abscess prompted immediate lumbar spine MRI. Imaging revealed inflammation and
cellulitis in the subcutaneous tissues following the epidural needle tract within the L2-3 interspace
sparing the epidural space. We will discuss the diagnostic workup treatment and potential risks
associated with subcutaneous cellulitis threatening the epidural space and its differentiation from an
abscess with images.
Monday, October 14
8:00 AM - 9:30 AM
OB MC613
Management of Refractory Headache in the Postpartum Patient With Suspected Dural Puncture
Jason Mulawa, M.D., William Mansfield, M.D., Roy Soto, M.D., William Beaumont Hospital, Royal Oak,
MI
AM a 34-year-old G1P0 received a combined spinal-epidural for management of labor pain. PMH was
significant for migraines epilepsy scoliosis and spondylolysis. Her epidural provided moderate pain
control for 3 hours but required replacement at that time. Repeat epidural provided appropriate pain
relief but unexpected motor block suggestive of intrathecal spread of anesthetic. 24hrs after an
uneventful NSVD patient presented with positional bifrontal headache. Blood patch was performed with
relief of symptoms but patient returned with same symptoms 18hrs after initial presentation. Repeat
blood patch similarly relieved symptoms for 18hrs and neurology was consulted for evaluation of
persistent symptoms.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC614
Anesthetic Challenges in Management of an Achondroplastic Dwarf With Preeclampsia Undergoing
Cesarean Delivery
Shweta Narang, M.D., Neelam Malhotra, M.D., Ramsis Ghaly, M.D., Craig Malk, M.D., John H Stroger Jr.
Hospital of Cook County, Chicago, IL
29-year-old G3P1102 parturient at 28.4 weeks gestation with known achondroplastic dwarfism history
of 2 previous Cesarean deliveries presents with elevated blood pressures proteinuria diagnosed with
severe preeclampsia. She had a class 4 Mallampati classification and limited neck extension. Laboratory
data was remarkable for platelet count of 92 000/microliter (downtrending) with normal liver functions
and coagulation. For Cesarean delivery and tubal ligation continuous lumbar epidural was placed early.
In the OR 2% lidocaine with epinephrine was titrated in 3 ml increments and T4 sensory level was
achieved with 15 ml. Surgery proceeded uneventfully with delivery of a baby with APGARS 4/7.
Monday, October 14
8:00 AM - 9:30 AM
OB MC615
Anesthetic Management of a Jehovah's Witness Parturient With Complete Placenta Previa and
Unicornuate Uterus for Cesarean Section.
Michael Nayshtut, D.O., Zana Borovcanin, M.D., University of Rochester, Rochester, NY
We present a 35-year-old G5P3 term Jehovah's Witness scheduled for an elective cesarean section for a
complete placenta previa. Despite multiple risk factors for intraoperative hemorrhage the patient
refused transfusion of all blood products other than cryoprecipitate autologous blood via cell saver
Factor VII Factor VIII and volume expanders for religious reasons. Prior to the operative day thorough
discussion with the patient took place along with extensive planning and coordination among the
obstetric and anesthesiology teams in order to achieve the best possible outcome. Fortunately the
caesarean section was uneventful resulting in a viable delivery with APGARS 8 9.
Monday, October 14
8:00 AM - 9:30 AM
OB MC616
Anesthetic Considerations in Parturients With CNS Shunts for Hydrocephalus: A Case Series
Karl Nazareth, M.D., Nenna Nwazota, M.D., Baylor College of Medicine, Houston, TX
The prevalence of women with CNS shunts surviving to reproductive age is increasing as diagnosis and
treatment of intracranial abnormalities improves. Thus the anesthetic considerations for labor
management in these patients are an increasing challenge. This case series involves three parturients
with hydrocephalus of varying etiologies who underwent either neuraxial or general anesthesia for
delivery. Several important issues regarding use of neuraxial anesthesia in the setting of intracranial
hypertension and special considerations for cesarean deliveries under general anesthesia are discussed
in-depth. This case series is the first to date in this unique patient population.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC617
Obstetric Epidural Catheter Placement in a Patient With a Myelomeningocele
David Nguyen, M.D., Timothy Bednar, M.D., Husong Li, M.D., Ph.D.,The University of Texas Medical
Branch, Galveston, TX
The parturient patient with spina bifida meningocele or a myelomeningocele can often be a challenging
patient to manage from an anesthetic perspective. Reviewing the anatomy and pathophysiology in these
patients can help in the obstetric patient. A detailed neuraxial anesthetic plan with backup plans
including general anesthesia is recommended after discussion with the patient and obstetrician. We
describe a case of a patient with a myelomeningocele requiring a Cesarean-section after a failed trial of
labor. We describe our approach to neuraxial anesthesia in this parturient population and expand the
discussion to gravid patients with spina bifida or a meningocele.
Monday, October 14
8:00 AM - 9:30 AM
OB MC618
Maternal Cardiac Arrest From Amniotic Fluid Embolism in the Setting of Severe Pre-Eclampsia
Intrauterine Fetal Demise (IUFD) and Disseminated Intravascular Coagulation (DIC)
Travis Nickels, M.D., Olusegun Senbore, M.D., Cleveland Clinic Foundation, Cleveland, OH
36-year-old G5P4 at 29 weeks gestation with known pre-eclampsia was transferred to our facility after
diagnosis of placental abruption and IUFD. Upon admission to our Labor and Delivery unit the patient
was hypertensive and complaining of painful contractions. She was also noted to be anemic and in
severe DIC. Our team worked with Obstetrics to stabilize the patient and correct the coagulopathy.
Following Cytotec induction and artificial rupture of membranes the patient became dyspneic and
cyanotic. 20 minutes later she acutely deteriorated and went into cardiopulmonary arrest. She was
intubated and taken immediately to the OR for emergency cesarean.
Monday, October 14
8:00 AM - 9:30 AM
OB MC619
Difficult Emergent Endotracheal Intubation in the Setting of Postpartum Flash Pulmonary Edema
Karmin Nissan, Heather Nixon, M.D.,University of Illinois Chicago Medical Center, Chicago, IL
A 32-year-old parturient (BMI 52) developed severe pre-eclampsia in the postpartum period with flash
pulmonary edema necessitating emergent endotracheal intubation. The obstetric anesthesiology team
who were previously aware of the patient responded to the decompensation in the intensive care unit
with advanced equipment which ultimately allowed for difficult but successful endotracheal intubation.
This clinical scenario demonstrates the risks of severe pre-eclampsia in the immediate postpartum
period the utility of obtaining an obstetric anesthesiologist to assist in the management of postpartum
patients and the yield of using advanced airway equipment as first-line management in an emergency
off-site postpartum airway.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC620
Pneumocephalus After Labor Epidural Anesthesia
Beatriz Nistal Nuno, M.D.Complexo Hospitalario Universitario A Coruna, A Coruna, Spain
34-year-old female G1P0 with bicuspid aortic valve and mild postductal coarctation of the aorta
admitted at 38 weeks. Epidural analgesia in sitting position at L3-L4 with the loss of resistance to air
technique. Patient presents frontal headache after technique without evidence of dural puncture. After
normal labor worsening postural occipital headache with vomiting at the 2 day. At the 6 day head CT
scan due to clinical worsening showing air in the ventricular system and an inflammatory subdural
collection. Neurosurgery recommends conservative treatment and CT scan 48 h later. At 13 day patient
is completely asintomatic and is discharged.
Monday, October 14
8:00 AM - 9:30 AM
OB MC621
Anesthetic Management of Labor and Delivery in a Parturient With Pseudotumor Cerebri
Junaid Nizamuddin, M.D., Massachusetts General Hospital, Boston, MA, Laura Chang, M.D., Brigham
and Women's Hospital, Boston, MA
An 18-year-old female with a history of pseudotumor cerebri status post recent removal of infected
ventriculoperitoneal shunt presented with preterm labor at 31 weeks gestation. She reported recurrent
headaches accompanied by blurry vision during pregnancy suggesting worsening of her intracranial
hypertension. An intrathecal catheter was placed to allow for drainage of cerebrospinal fluid and for
analgesia during labor and delivery. She was able to Valsalva with uterine contractions and with a
spontaneous vaginal delivery without worsening of her neurologic symptoms and delivered a healthy
female.
Monday, October 14
8:00 AM - 9:30 AM
OB MC622
Anesthetic Implications of Narcolepsy/Cataplexy Regarding Neuraxial Anesthesia for Cesarean Section
Casey Windrix, M.D., Alexander Nowlin, Student, Abhinava Madamangalam, M.D., University of
Oklahoma, Oklahoma City, OK
An urgent Cesarean delivery was required for a 35 week gestation in breech presentation and severe
preeclampsia. Narcolepsy/Cataplexy was the only significant medical history characterized by daily
episodes of sleepiness and loss of muscle tone precipitated by intense emotions or extreme stress. The
patient desired to be awake for the birth of the child; though she was concerned that during regional
anesthesia she would experience a cataplectic event a sentiment shared by the obstetricians. After
careful planning and focused patient counseling we administered neuraxial anesthesia for an uneventful
Cesarean section. We detail the anesthetic planning.
Monday, October 14
8:00 AM - 9:30 AM
OB MC623
Management of Parturient With Malaria Requiring Caesaran Section
Christiana Obi, D.O., Steven Halle, M.D., SLR Hospital Center NY, New York, NY
This case discusses the anesthetic management of a 36-year-old G5P4 at 36 weeks gestation with newly
diagnosed malarial infection undergoing an emergent c-section. The patient recently returned from a
Copyright © 2013 American Society of Anesthesiologists
two week stay in the Ivory Coast where she manifested constitutional symptoms two weeks after
returning to the U.S. Consultation by OB/Gyn as well as Infectious Disease and Hematology-Oncology
was done with presumptive diagnosis of malaria. Peripheral smear consistent with Plasmodium.
Emergent c-section decided secondary to signs of fetal distress with subsequent administration of
general anesthesia. Anesthetic considerations for the gravid patient with malaria discussed.
Monday, October 14
8:00 AM - 9:30 AM
OB MC624
Challenging Case Report:Peripartum Anaphylaxis Versus Amniotic Fluid Embolism
Mauricio Jacques, M.D., Jason O'Neal , Stephen Pratt, M.D., Beth Israel Deaconess Medical Center
Harvard Medical School, Boston, MA
A 38-year-old woman G4P2 with no significant medical history presented at 39.2 weeks of gestation. A
combined spinal/epidural was administered. The patient developed hypotension with associated fetal
bradycardia after the placement. An emergent cesarean section was performed. The patient developed
a generalized rash and hypotension with persistent tachycardia without respiratory symptoms. She was
treated for anaphylactic shock. Postoperatively the patient continued to bleed in recovery. Coagulation
tests were consistent with DIC. The patient returned to the OR for surgical re-exploration. Massive
transfusion protocol was initiated. A TTE showed evidence of severe right ventricular failure suspicious
for pulmonary embolism.
Monday, October 14
8:00 AM - 9:30 AM
OB MC625
Anesthesia Practice in Rural Zambia: Massive Blood Loss Due to Uterine Rupture
Alicja Orkiszewski, M.D., Private Practice, Palo Alto, CA, Aleksandra Orkiszewska, , M.D., Private Practice,
Chicago, IL, Laura Marijke Heman, M.D., Lumezi Mission Hospital, Lundazi, Zambia
27-year-old pregnant multiparous female was brought to OR in unstable condition for emergency
laparotomy (uterine rupture). Local hospital did not have anesthesia machine electrocoagulation or
oxygen. Surgery was performed under i.v. Katamine and Propofol. Vital signs were monitored visually
and with NIBP stethoscope and pulsoxymeter. Hemostasis was achieved with uterus repair and laps that
were removed later. EBL was 3 liters. During surgery patients received 5 l of fluids and 1 unit of blood.
2nd unit was transfused later postoperatively. After surgery pain was controlled with Acetaminophen
Ibuprofen and Vicodin. Patient was dischared home POD # 9 with Hb-6.
Monday, October 14
8:00 AM - 9:30 AM
OB MC626
The Difficulties Of Epidural Analgesia in a Patient With Right Sided Heart Lesions : A Bleeding Diathesis
Post Spinal Fusion
Jeffrey Pack, M.D., University of New Mexico, Albuquerque, NM
A 28-year-old female G-1 P-0 with history of Bernard-Soulier disease severe scoliosis with T-1-L2 fusion
and tetralogy of Fallot S/P multiple repairs now with severe pulmonary outflow stenosis and valvular
regurgitation presented to Obstetric Triage with spontaneous rupture of membranes. For labor
analgesia a multi-modal approach was discussed including risks and benefits; the patient desired
epidural analgesia. A platelet transfusion was given to address her platelet dysfunction. Ultrasound was
considered for use in placement of the epidural but after exam an L-3-4 epidural was placed easily in
Copyright © 2013 American Society of Anesthesiologists
traditional manor. The epidural was bolused incrementally; safety and excellent analgesia were
achieved.
Monday, October 14
8:00 AM - 9:30 AM
OB MC627
Intrathecal Catheter Use in Morbidly Obese Pregnancy
Anuj Patel, M.D., Jeron Zerillo, M.D., Andrew Perez, M.D., Mount Sinai School of Medicine, New York, NY
A 34-year-old morbidly obese (BMI 72) and severely pre-eclamptic G4P3 at 29 weeks GA admitted with
ARF on CKD presented for caesarean section from ICU. Neuraxial epidural anesthesia was selected for
management of her delivery. After achieving adequate loss of resistance without CSF return threading of
the catheter resulted in CSF leakage. At this point we chose to place the catheter intrathecally for the
procedure anticipating difficulty in placing an epidural catheter at a different lumbar level. The
caesarean section proceeded without incident. Subsequently the patient was discharged but readmitted with respiratory distress several months later ultimately expiring.
Monday, October 14
8:00 AM - 9:30 AM
OB MC628
Anesthetic Management of a Parturient With Congenital Prolonged QT Syndrome Requiring a Life Vest
Kelly Peretich, M.D., Andrew Gentilin, M.D., Manuel Vallejo, M.D., University of Pittsburgh Medical
Center, Pittsburgh, PA
A 28-year-old G3P2 woman with congenital prolonged QT syndrome presented for planned repeat
Cesarean section. In her second trimester she began having symptomatic palpitations requiring a Zoll
defibrillator Life Vest and was started on atenolol. Baseline QTc was 489 ms and preoperative serum
electrolytes were within normal limits. In the OR the vest was removed Zoll pads were placed on her
chest and set to monitor and pace mode. A spinal anesthetic was performed and a phenylephrine
infusion was used to maintain blood pressure. The procedure was completed without complication and
the Life Vest was replaced immediately post-operatively.
Monday, October 14
8:00 AM - 9:30 AM
OB MC629
Survival of a Parturient After a Massive (50cm) Saddle Pulmonary Embolism Causing Cardiac Arrest
Following Cesarean Hysterectomy Due to Uterine Rupture
Christy Crockett, M.D., Cathleen Peterson-Layne, M.D., Ph.D., Duke University, Durham, NC
30-year-old parturient with connective tissue disorder status-post C-section for failed 2-day induction
for IUFD 35/6 weeks; concern for chorioamnionitis sepsis. After 24 hours of satisfactory labor epidural
analgesia sudden tachycardia plus higher dose requirement; 48 hours later new oxygen requirement. At
C-section general anesthesia required given inconsistent left-sided level yet complete motor block. On
incision uterine rupture noted; hysterectomy performed complicated by hemorrhage. In route to ICU intubated monitored - PEA arrest. CT and ECHO consistent with pulmonary embolus. Emergent
thrombectomy performed to remove 50cm thrombus. One week later she was discharged home at
baseline physical and neurological status.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC630
Conservative Treatment of Placenta Accreta With Uterine Artery Embolization Under Neuraxial
Technique
Bich-Tran Pham, Manjunath Shetty, M.D., Natalie Wong, M.D., University of Texas at Houston Health
Sciences Center, Houston, TX
Placenta accreta is a pregnancy complication with risks including post-partum hemorrhage and death.
This occurs from a defect in the decidua basalis resulting in chorionic villi invasion into myometrium.
This condition is often managed by cesarean hysterectomy; however recent advances allow for uterine
preservation via uterine artery embolization. We present a patient with complete placenta previa and
accreta who underwent repeat cesarean and bilateral uterine artery embolization under combined
spinal-epidural anesthesia. An epidural was placed at T9-T10 for post-op pain control and spinal was
done at L4-L5. The procedure was completed without significant bleeding and post-op pain was well
controlled.
Monday, October 14
8:00 AM - 9:30 AM
OB MC631
Bronchospastic Reaction to Rocuronium During Cesarian Section
Marc Pinn, D.O., University of Connecticut, Farmington, CT
19-year-old female presenting for stat c-section after failed vacuum delivery. Asked to give relaxation for
closure. Immediately unable to ventilate patient. ETT suctioned and ultimately replaced albuterol
without response. Pt SpO2 dropped to 70's with bradycardia. Epinephrine given. Called for help. TEE
performed to rule out right heart strain. A-line started and ABG sent. Bronchospasm and ability to
ventilate pt improved.
Monday, October 14
8:00 AM - 9:30 AM
OB MC632
Management of SVT in a Perturient With Thyroid Goiter
Victor Polshin, Kalpana Tyagaraj, M.D., Arti Ori, M.D., Maimonides Medical Center, New York City, NY
29-year-old pregnant female with thyroid tumor euthyroid with tracheal deviation presented in labor.
The patient was in pain and tachycardic to 180 with blood pressures of 105/65. An epidural catheter was
placed for pain relief was tested and loaded slowly. Tachycardia persisted despite adequate analgesia.
EKG was obtained showing narrow complex tachycardia with delta waves consistent with WPW.
Cardiology was consulted and the patient was cardioverted with adenosine.Subsequently patient
underwent Cesarean Section because of nonreassuring fetal heart rate under epidural anesthesia.
Intraopertaive tachycardia was managed with esmolol IV.
Monday, October 14
8:00 AM - 9:30 AM
OB MC633
Postdural Puncture Headache (PDPH) and Posterior Reversible Encephalopathy Syndrome (PRES)
Ana Lisa Ramirez - Chapman, M.D., Oscar Quintana, M.D., Srikanth Sridhar, M.D., Davide Cattano, M.D.,
The University of Texas Health Science Center at Houston, Houston, TX
We present a case of a post-partum patient who was diagnosed with PRES five days after an initial
diagnosis of PDPH. Presenting symptoms included postural occipital headache and neck stiffness. She
Copyright © 2013 American Society of Anesthesiologists
underwent three epidural blood patches and developed decreased vision the evening after the third
blood patch. Ophthalmology Neurology and Neurosurgery were consulted. Initial MRI was concerning
for subdural hemorrhage however a repeat MRI showed white matter changes associated with PRES.
The patient was diagnosed with PRES in the setting of post-partum hypertension. Presenting symptoms
of PRES and PDPH may be similar making the initial diagnosis of PRES challenging.
Monday, October 14
8:00 AM - 9:30 AM
OB MC634
Cesarean Section Convulsion Coagulopathy and Cardiovascular Collapse
Shervin Razavian, M.D., Frank Sahli, M.D., Venesa Ingold, M.D., The University of Kansas Medical CenterKansas City, Kansas City, KS
We present the case of a cesarean section delivery that was complicated by an intraoperative seizure
with simultaneous cardiovascular collapse and patient hemorrhage which we believe to be likely
secondary to an amniotic fluid embolism (AFE). AFE remains a rare complication of obstetrical
procedures with a recently estimated incidence of 2 per 100 000 deliveries. If not recognized quickly and
treated promptly and properly the condition is fatal. In total our patient was resuscitated with 8 units of
packed red blood cells 7 units of platelets 6 units FFP and 10 units of cryoprecipitate. She was
discharged home on POD 4.
Monday, October 14
8:00 AM - 9:30 AM
OB MC635
A Combustion in the Anesthesia Machine in the Labor and Delivery Suite
Leah Reimer, NYU Medical Center, New York, NY
A 31-year-old G1P0 woman was admitted for induction of labor. Co-morbidities included scoliosis s/p
Harrington rod placement through L4. An epidural in the L5-S1 interspace resulted in incomplete relief
during labor. An uncomplicated c-section under GETA ensued due to non-reassuring fetal status. As the
patient was extubated a loud bang and burning smell emanated from the anesthesia machine. The
patient was immediately transferred unharmed. Investigation revealed that a foreign material
introduced into the Spirolog expiratory flow sensor in the Draeger Apollo anesthesia machine lead to
ignition and combustion. An ongoing investigation commenced including recommendations from the
ECRI institute.
Monday, October 14
8:00 AM - 9:30 AM
OB MC636
Anesthetic Management for Cesarean Delivery in the Setting of Acute Hepatic Failure and Pulmonary
Hypertension
Goran Ristev, Bryan Mahoney, M.D., Ohio State University Wexner Medical Center, Columbus, OH
A 38-year-old female G4P3 at 28w5d presents with jaundice epistaxis edema and transaminitis.
Evaluation revealed acute hepatic failure in the setting of hepatitis C cirrhosis further complicated by
coagulopathy and pulmonary hypertension. At 28w5d cesarean delivery was performed due to absent
umbilical artery end-diastolic flow and worsening maternal condition. A male infant was successfully
delivered under general anesthesia utilizing invasive arterial and central venous pressure monitoring for
potential hemodynamic instability. Intraoperative bleeding and coagulopathy were managed with 5U
FFP 4U PRBC 2U cryoprecipitate and 1U platelets followed by successful extubation in the operating
room.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC637
Continuous Spinal Anesthesia in a Scimitar Syndrome Patient for a Bilateral Partial Salpingectomy:
Case Report
Victor Rivero, Ivette Hernandez, M.D., Hector Casiano, M.D., University of Puerto Rico Medical Sciences
Campus, San Juan, PR
Scimitar syndrome is a rare congenital vascular malformation in the pulmonary venous return from the
right lung. They often present with right lung hypoplasia and heart failure. We report a 19-year-old
obese woman diagnosed with scimitar syndrome three years earlier after signs of pulmonary
sequestration ASD and obstructive airway disease. A year later she underwent cardiopulmonary surgery
with intraoperative complications culminating in right pneumonectomy. Currently she presents for
postpartum bilateral partial salpingectomy. Continuous spinal anesthesia was performed to achieve
hemodynamic stability. No postoperative complains or signs of post-dural puncture headache.
Monday, October 14
8:00 AM - 9:30 AM
OB MC638
Epidural Management in a Parturient With Undiagnosed Congenital Factor VII Deficiency
L. Bell, M.D., Jennifer Matos, M.D., Laura Roberts, M.D., Medical University of South Carolina,
Charleston, SC
A 22-year-old gravida four para three at term gestation received an epidural for management of labor
pain. Following epidural placement the patient experienced vaginal bleeding with non-reassuring fetal
activity suggesting possible placental abruption. Studies revealed an isolated elevated prothrombin time
of 35.2 seconds with an international normalized ratio of 3.54. A cesarean delivery was later performed.
Blood products and uterotonic medications were given for moderate hemorrhage. Subsequent studies
revealed a Factor VII activity level <3%. Prior to epidural catheter removal recombinant activated Factor
VII was given. The patient was discharged on post-partum day 4 neurologically intact.
Monday, October 14
8:00 AM - 9:30 AM
OB MC639
Intrathecal Narcotic Side Effect Versus Allergic Reaction Versus Intravascular Injection of Local
Anesthetic
Lisa Ross, M.D., M.B.A., Harlem Hospital Center Affliliate Of Columbia University College of Physicians
and Surgeons, New York, NY
A primagravida in active labor requested labor epidural analgesia. CSE was inserted via an 18 gauge
Tuohy and a 26-gauge WhitacreR needle through which 25 micrograms of fentanyl were injected. A 20gauge catheter was then threaded with the return of blood through the catheter which upon
withdrawing slightly cleared with sterile water flush and repeated repeated negative aspirations. A test
dose of lidocaine 1.5% with epinephrine 1:200 000 3 ml was injected. The patient complained of a racing
heart jittery and tingly hands. She then experienced SEVERE total body pruritus. Approximately 10
minutes later the patient complained of difficulty breathing.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC640
Previously Undiagnosed Pheochromocytoma Presenting During Caesarian Section
Abigail Rubin, D.O., Mark Shulman, M.D., Usha Vellayapan, M.D., St. Elizabeth's Medical Center, Boston,
MA
A 39-year-old African Woman G1P1 at 40 weeks gestation with history of hypertension was admitted for
normal vaginal delivery. After failure of labor to progress she was brought for Cesarian under spinal
anesthesia. Following an uncomplicated induction she experienced chest pain and abruptly went into a
hypertensive crisis after manual abdominal pressure from infant delivery. Initially she was treated with
magnesium for assumed preeclampsia but the hypertension was refractory to multiple drug therapy.
She was transferred to the ICU postoperatively. After extensive workup an adrenal mass was incidentally
found on CT. The diagnosis of pheochromocytoma was confirmed with urine metanephrines.
Monday, October 14
8:00 AM - 9:30 AM
OB MC641
An Obstetric Dilemma
Madhumani Rupasinghe, M.D., F.R.C.A, Peter Doyle, M.D., Sonya Johnson, M.D., UTHSC, Houston, TX
Late termination of pregnancy is an issue of grave concern with many ethical questions and professional
dilemmas. In patients with CRF necessitating dialysis pregnancy adds further risks including preeclampsia polyhydramnios intrauterine growth retardation preterm delivery low birth weight and
stillbirths. We describe the management of a 44-year-old Hispanic woman G6P3 at 15 weeks with PMHx
Type II diabetes chronic hypertension hyperlipidemia coronary artery disease with h/o of MI requiring
PCI hypothyroidism stage 3 chronic kidney disease with anemia and reactive airway disease who
presented to our emergency room with shortness of breath and volume overload refusing medical
termination.
Monday, October 14
8:00 AM - 9:30 AM
OB MC642
Anesthesia for Cesarean Section in a Patient With Diabetic Keto-Acidosis
Madhumani Rupasinghe, M.D., F.R.C.A, Pilar Suz, M.D., Aseem Hamad, M.D., Peter Doyle, M.D., UTHSC
Houston, TX
DKA in pregnancy tends to occur at lower plasma glucose levels and more rapidly than in non-pregnant
patients usually in the second and third trimesters. Increase in insulin resistance and enhanced
lipolysis/ketosis associated with pregnancy account for the greater risk of DKA during gestation. We
present the management of a 22-year-old G3P1 at 29 weeks with history of Type I DM poorly controlled
on insulin who was admitted via the emergency room tachycardic to the 150's and tachypneic with a RR
of 30's noted to have a blood glucose of 278 pH 7.05 and bicarb of 6.
Monday, October 14
8:00 AM - 9:30 AM
OB MC643
Anesthetic Management of Moyamoya With H/O CVA for Caesarian Section
Madhumani Rupasinghe, M.D., F.R.C.A, Hrishikesh Modi, M.D., Dana Parker, M.D., UTHSC, Houston, TX
Moyamoya disease is a rare progressive occlusive disease of the internal carotid arteries. We report a
case of combined spinal-epidural anesthesia in a patient with Moyamoya disease presenting for
Copyright © 2013 American Society of Anesthesiologists
Cesarean section. Patient was an African American female presenting with an intrauterine pregnancy at
34 wks. She had an extensive h/o Sickle cell disease Moyamoya with H/o CVA Severe pre eclampsia and
Hemochromatosis. In order to reduce the risk of complications such as intracerebral hemorrhage due to
increased blood pressure and sickling related vaso occlusive crisis a combined spinal epidural was
performed for surgery and continued for post-operative pain control.
Monday, October 14
8:00 AM - 9:30 AM
OB MC644
Diagnosis of Epidural Abscess in Patients Following Continuous Epidural Analgesia
Abiona Berkeley, M.D., Yidy Salamanca, Gaurav Trehan, M.D., Temple University Hospital, Philadelphia,
PA
Anesthesiology consult was requested post-delivery day number seven for an eighteen-year-old Gravida
1 Para 1 with positional headache. The headache began following delivery of patient's infant and
removal of an intrathecal catheter. She had been discharged following conservative treatment but
sought medical attention shortly after when the headache returned with severe back pain. On
readmission patient had nuchal rigidity and mild tenderness to palpation. Although afebrile her white
blood cell count and erythrocyte sedimentation rate were elevated. Magnetic Resonance Imaging of the
lumbar spine showed epidural phlegmon and patient was started on antibiotics for presumed epidural
abscess.
Monday, October 14
8:00 AM - 9:30 AM
OB MC645
Patient With Anterior Horn Cell Disease for Cesarean Section: Neuraxial or General Anesthesia?
Usha Saldanha, M.D., Sergey Pisklakov, M.D., UMDNJ-NJMS, Newark, NJ
Anterior Horn Cell Disease (AHCD) is caused by degeneration of motor neurons. Some anesthesiologists
consider neuraxial anesthesia contraindicated in this group due to possible further neurologic decline.
We report a case of a patient with a long history of AHCD where spinal anesthesia was successfully used
for cesarean section. Her recent electromyography showed involvement of lower cervical and upper
thoracic roots and her neurologic status was stable for the last two decades. After weighing all risks and
benefits we decided to proceed with spinal anesthesia. Cesarean section was uneventful. Patient
regained full function postoperatively with no exacerbation of her condition.
Monday, October 14
8:00 AM - 9:30 AM
OB MC646
Anesthetic Management of Hyperthyroid Storm With Congestive Heart Failure and Pulmonary Edema
in Pregnancy
Mical Samuelson Duvall, M.D., Shilpadevi Patil, M.D., LSUHSC Shreveport, Shreveport, LA
We present a patient with diagnosis of uncontrolled hyperthyroidism congestive heart failure (CHF) and
pulmonary edema in the setting of third trimester pregnancy. Hyperthyroidism is a difficult disease in
terms of diagnosis and maintaining patient compliance with medication. Non-compliance leads to
significant cardio-pulmonary morbidity. As a consequence successfully treating uncontrolled
hyperthyroidism presents a unique challenge in pregnant patients. In these patients it is clinically
important to place hemodynamic monitoring. C-section may also be necessary to treat patients who are
refractory to medical management.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
8:00 AM - 9:30 AM
OB MC647
Disaster Readiness: Anesthesia for the Viable Abdominal Pregnancy
Joseph Sanford, M.D., Mark Stevens, Victor Mandoff , Hess Robertson , University of Arkansas for
Medical Sciences, Little Rock, AR
Viable abdominal pregnancies represent 1% of all ectopic pregnancies which in turn occur in only 1% of
all pregnancies. This rarity coupled with a high morbidity and mortality put such cases in a class of their
own. We present a case of a patient that presented at 19 weeks gestation who was progressed to 25
weeks before operative delivery became necessary with a focus on peri-operative logistical planning as
well as intraoperative management.
Monday, October 14
8:00 AM - 9:30 AM
OB MC648
Hypoalbuminemia and Anasarca Complicating Severe Preeclampsia
Rohin Sarkar, M.D., Saul Wiesel, University Of New Mexico, Albuquerque, NM
A 20-year-old morbidly obese G1P0 female with poorly controlled DM type 1 presented at 35 weeks to
the OB clinic with worsening edema and mild-range blood pressures and was diagnosed with
preeclampsia. During her pregnancy she started noticing edema in her lower extremities which moved
up to the level above her breasts. This led to the diagnosis of anasarca. Epidural Anesthesia was
initiated. Her course was complicated by an emergent cesarian and respiratory distress post-partum
from fluid shifts.
MCC Session Number – MCC10
Monday, October 14
10:30 AM - 12:00 PM
CA MC649
Undiagnosed ASD Presenting as Aortic Occlusion and Paraplegia
Malani Gupta, M.D., Peter Panzica, M.D., Beth Israel Deaconess Medical Center, Boston, MA
A 40-year-old male with history of DVT and PE not currently anticoagulated presented to outside
hospital with near-complete paraplegia and incontinence. MRI of lumbar spine was unremarkable.
Patient lacked lower extremity pulses; subsequent CTA revealed bilateral massive PE and acute distal
aortoiliac thromboembolic occlusion. Upon transfer he underwent emergency endovascular aortoiliac
thombectomy. Intraoperative TEE revealed previously undiagnosed ASD. Patient was extubated
successfully after the procedure and transferred to the ICU. He remained stable throughout hospital
stay however had only minimal improvement in paraplegia. Patient underwent percutaneous ASD
closure POD#5 and was discharged to rehabilitation facility on POD#8.
Monday, October 14
10:30 AM - 12:00 PM
CA MC650
Mitral Regurgitation From Lead Extraction
Jason Harig, M.D., Jennifer DeCou, M.D., Joshua Zimmerman, M.D., University of Utah, Salt Lake City, UT
We report the case of a 59-year-old female who presented to the University of Utah Hospital for ICD
lead extraction for a malfunctioning lead. Her history was also significant for L-transposition of the great
Copyright © 2013 American Society of Anesthesiologists
arteries (L-TGA) with an estimated ejection fraction (EF) of 20%. Initial transesophageal
echocardiography (TEE) examination revealed an atrial septal defect (ASD) and a patent ductus
arteriosus (PDA). Imaging also demonstrated moderate mitral regurgitation classified by a vena
contracta of 0.5cm. Following ICD lead extraction the measured vena contracta increased to 1.6cm
classifying the patient with severe mitral regurgitation.
Monday, October 14
10:30 AM - 12:00 PM
CA MC651
Takotsubo Cardiomyopathy Following Endoscopy and Bronchoscopy
Ricky Harika, M.D., Ryan Ball, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA
64-year-old female with history of hypertension CAD s/p MI DM COPD and obesity s/p gastroplasty who
presented with dysphagia for an endoscopy with dilation. Pre-operative TTE showed preserved ejection
fraction with inferior hypokinesis. The intraoperative course was uncomplicated under general
anesthesia. In the PACU a 12-lead EKG showed new ST-elevation and troponin levels peaked to 3.55. TTE
showed EF 25-30% with significant hypokinesis and akinesis that met the criteria for Takotsubo
cardiomyopathy. Heart catheterization showed non-obstructive CAD. Repeat TTE and catheterization
showed no change during her hospitalization. The patient was medically managed and had other
complications but remained stable.
Monday, October 14
10:30 AM - 12:00 PM
CA MC652
Patient With Left Venttricular Assist Device and Peripheral Vascular Disease Presents for a Carotid
Endarterectomy: Anesthetic Implications and Challenges
Aysha Hasan , M.D., Shaul Cohen, M.D., Adil Mohiuddin, M.D., Ali Dinani, M.D., Vincent DeAngelis, M.D.,
UMDNJ-Robert Wood Johnson University Hospital, New Brunswick, NJ
53-year-old patient presented to the OR with LVAD >3 years for CEA. PMH: Hypertension
hypercholesterolemia CABG and AICD LVAD placement. MAC with sedation was administered. BP
controlled with phenylephrine to maintain MAP (>=20% above baseline). Procedure was successful and
patient transferred to Cardiac ICU. The LVAD is a temporary measure to sustain life until the patient gets
a heart transplant. Carotid endarterectomy (CEA) is performed to prevent stroke. Anesthetic challenges:
Maintaining BP for cerebral perfusion adequate anesthesia for rapid awakening and assessment
neurologic function.
Monday, October 14
10:30 AM - 12:00 PM
CA MC653
Postoperative Hypotension in a Patient Receiving Low-dose Prednisone (5mg/day): Addisonian Crisis?
Sarah Herbst, M.D., Ryan Chadha, M.D., Brian Mirante, M.D.,Paul Barash, M.D.,Yale-New Haven
Hospital, New Haven, CT
A 61-year-old male is scheduled for muscle biopsy for new onset rhabdomyolysis. He is s/p kidney
transplantation and received his daily dose of prednisone (5mg) prior to the twenty-minute biopsy
(general anesthesia) with stable hemodynamics. Over a four-hour period in the PACU asymptomatic
hypotension (76/30) was only transiently responsive to fluid boluses ephedrine and phenylephrine.
Following administration of hydrocortisone 100mg his hemodynamics stabilized (112/51). A low
morning cortisol (4.0 ug/dL normal 7.0-25.0 ug/dL) drawn during a subsequent episode of urosepsis
Copyright © 2013 American Society of Anesthesiologists
confirmed our previous suspicion of acute adrenal insufficiency. Stress dose steroids were
recommended for all future operations.
Monday, October 14
10:30 AM - 12:00 PM
CA MC654
Hematologic Considerations in a Hemophilia: A Carrier Undergoing Septal Myectomy
Richard Herd, M.D., Martin Abel, M.D., Mayo Clinic, Rochester, MN
67-year-old woman with hypertrophic cardiomyopathy and systolic anterior motion (SAM) of the mitral
valve presented for septal myectomy. She is a Hemophilia A carrier by family history without previous
signs of a bleeding diathesis. Preoperative labs were normal except for Factor VIII activity of 28%. In
concert with Hematology a plan for pre- and postoperative factor replacement was instituted. The
surgical course was complicated by episodes of brisk bleeding and three runs of CPB. We discuss our
intraoperative management of blood products factor concentrates and anti-fibrinolytics. Major
outcomes for hemophilia patients undergoing cardiac surgery are also reviewed.
Monday, October 14
10:30 AM - 12:00 PM
CA MC655
Elective Placement of a Novel Left Atrial Appendage Exclusion Device in a 58-year-old Male With
Chronic Atrial Fibrillation Increased Risk of Stroke and Contraindication to Anticoagulation
Raquel Hernandez, D.O., Ayman Ads, M.D., Rush University Medical Center, Chicago, IL
A 58-year-old male with chronic atrial fibrillation and contraindication to anticoagulation secondary to
gastrointestinal bleeding presented for left atrial appendage ligation/LARIAT device under fluoroscopic
guidance and TEE. Induction intubation and maintenance of general anesthesia were uneventful until
administration of IV contrast into the left atrial sheath to confirm occlusion of the appendage. Acute ST
segment depression and hypotension ensued. LV dysfunction was noted by TEE and was considered
consistent with transient ischemia from air embolism. Hemodynamic instability resolved with
epinephrine 10mcg IV fluid bolus and FiO2 (100%). A subsequent TEE confirmed recovered LV function
and a completely ligated appendage.
Monday, October 14
10:30 AM - 12:00 PM
CA MC656
Two HIV-Infected Patients Undergoing Cardiac Transplantation: Perioperative Considerations
Antonio Hernandez Conte, M.D., M.B.A., Lorraine Lubin, M.D., Fardad Esmailian, M.D., Cedars-Sinai
Medical Center, Los Angeles, CA
67-year-old and 66-year-old males with idiopathic and ischemic cardiomyopathy respectively underwent
cardiac transplantation. PMH significant for HIV-infection no previous diagnosis of AIDS. During
induction midazolam and fentanyl doses were reduced secondary to multiple anti-retroviral agents. Preand post-CPB immune function studies were performed. Both patients successfully underwent
transplantation. In the ICU one patient experienced delayed awakening. Both patients required
significant monitoring and adjustments to immune suppressant therapy (cyclosporine). HAART was reinitiated within 24 hours of initial surgery. No evidence of primary/secondary infections noted within 12
month period; both patients are alive at 13 and 16 months respectively.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
CA MC657
Anesthetic Considerations for an Adult Undergoing Fontan Revision and Right Atrial Reduction in a
Patient With Congenital Tricuspid Atresia
Amanda Hester, M.D., Susan Eagle, M.D., Vanderbilt University, Nashville, TN
The patient is a 30-year-old male with congenital tricuspid atresia with hypoplastic right heart VSD and
transposition of the great vessels who had an atriopulmonary Fontan palliation at age five. Currently he
has good but decreasing functional capacity due to atrial arrhythmias resulting from a dilated right
atrium. He presents for revision of his Fontan with conversion to extracardiac conduit to create a total
cavopulmonary connection as well as right atrial reduction and cryoablation for control of his
arrhythmias. A review of Fontan anatomy recognition of failing Fontan and anesthetic considerations for
adults with Fontan physiology is presented herin.
Monday, October 14
10:30 AM - 12:00 PM
CA MC658
Management of a Septic Jehovah's Witness Patient Undergoing CABG and Subsequently Surgical
Bleeding
Tao Hong, Emily Ashford, M.D., Manual Castresana, M.D., Phillip Catalano, M.D., Georgia Regents
University, Augusta, GA
Management of a Septic Jehovah's Witness Patient Undergoing CABG and Subsequently Surgical
Bleeding A 59-year-old Jehovah's witness presented for emergency CABG after debridement of his right
arm necrotizing fasciitis. Postop hemoglobin was 7.5 g/dl. After CABG the patient developed surgical
bleed in SICU. His care was optimized except his hemoglobin was 3.5 g/dl during the mediastina reexploration. The patient was extubated 10 days after CABG. After one month of stay in the hospital for
the treatment of his fasciitis he was discharge home. He has no noticeable neurological defect.
Monday, October 14
10:30 AM - 12:00 PM
CA MC659
Re-op MVR in Patient With ITP APS HIT and ESRD in Acute Right Heart Failure
Wei-Ann Hsueh, Amy Crane, M.D., New York Presbyterian- Weill Cornell, New York, NY
The patient was a 43-year-old man with a complex medical history most notable for idiopathic
thrombocytopenia heparin-induced thrombocytopenia anti-phospholipid syndrome and ESRD who
presented for a re-op MVR. Noted to have 4+ MR/TR and equivalent PA and systemic pressures
preoperatively. Exposure and repair were complicated because of prior surgery and patient anatomy.
With closure the patient developed a significant coagulopathy and vasoplegia requiring massive
transfusion. With resuscitation his RHF worsened. Resuscitation continued for four hours during which
the patient received several rounds of blood products desmopressin and Factor IX infusion to correct
coagulopathy.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
CA MC660
Mitral Valve Replacement and Tricuspid Valve Repair for Patient With Idiopathic Hypereosinophilic
Syndrome (HES)
Yolanda Huang, M.D., Ph.D., Jessica Spellman, M.D., Columbia University, New York, NY
We report a case of a 52-year-old female with a rare hematologic disease of idiopathic hypereosinophilic
syndrome (HES) that presented with progressive dyspnea on exertion. Echocardiography showed
deformed MV leaflet and thickened subvalvular apparatus with severe mitral valve stenosis and
regurgitation consistent with HES cardiac manifestation as well as moderately reduced right ventricular
systolic function and severe pulmonary HTN. Anesthesiologists should recognize that perioperative
steroid treatment in HES a disease with variable clinical presentation and multisystem involvement may
reduce or prevent post-operative complications such as acute respiratory distress syndrome (ARDS) or
thromboembolic events.
Monday, October 14
10:30 AM - 12:00 PM
CA MC661
Anesthetic Considerations in a Patient With an Intracardiac Vegetation Causing Septic Emboli
Zeena Husain, M.D., Anna Weyand, M.D., Baylor College of Medicine, Houston, TX
A 43-year-old man with a history of HIV and previous PFO repair with a STARFlex device presented to
our institution with multiple significant thrombi including a large pulmonary embolism mural thrombi of
the infrarenal aorta splenic infarct and a renal abscess. He was taken to the OR for debridement and
excision of the PFO device after TTE showed a large vegetation adherent to the ASD closure device
concerning for endocarditis causing septic emboli. Anesthetic management was further complicated by
PE-induced hypoxia and pulmonary hypertension causing acute RV failure.
Monday, October 14
10:30 AM - 12:00 PM
CA MC662
Intraoperative Dexmedetomidine and Clevidipine for Removal of Pheochromocytoma in a Patient
With Left Ventricular Thrombus
Eric Hutto, M.D., Kevin Sijansky, M.D, Juan Villani, M.D., University of Mississippi Medical Center,
Jackson, MS
A 40-year-old male was scheduled for pheochromocytoma removal. Five months prior he had a
myocardial infarction with stents placed. He was also found to have a left ventricular thrombosis as well
as severe systolic heart failure. Maintenance anesthesia included Dexmedetomidine and Clevidipine
infusions. Throughout manipulation of the tumor hemodynamic parameters were well controlled. While
there are case studies that focus on the both the usage of Dexmedetomidine and Clevidipine for
pheochromocytoma removal there are few that describe the combination of these two agents. We
describe how Dexmedetomidine combined with Clevidipine may help prevent the hemodynamic
fluctuations during tumor manipulation.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
CA MC663
Would-You Place This Patient on Bypass?
Ardeshir Jahanian, M.D., University of Southern California, Pasadena, CA
62-year-old M renal cell carcinoma scheduled for IVC thrombectomy which on imaging was only thought
to extend to below the entry of hepatic veins. Intraoperatively a mass was seen in the right atrium on
TEE as a result for concern for intracardiac thrombus case was cancelled to do it the next day on cardiac
bypass so as to be able to perform atriectomy and extract right atrial thrombus. Atriectomy was
performed there was no atrial thrombus visualized or palpated. Mass seen on TEE later determined to
have been prominent pectinate muscle mistakenly thought to have been a thrombus.
Monday, October 14
10:30 AM - 12:00 PM
CA MC664
First Do No Harm...
Brinda Jeyakumar, M.D., Wendy Bernstein, M.D., MBA, University of Maryland Medical Center,
Baltimore, MD
Anesthetic complications including intraoperative awareness are not uncommon in extremely high risk
patients who experience preoperative hypotension biventricular failure and other comorbidities. A 53year-old female with LV and RV failure (EF<5%) pulmonary hypertension and severe tricuspid
regurgitation was urgently scheduled for LVAD TVR and closure of PFO. Anesthetic management was
challenged by the need to maintain hemodynamic stability in light of her impending cardiovascular
collapse and still prevent intraoperative awareness using a careful choice of anesthetic agents
vasopressors inotropes as well as invasive monitors and BIS.
Monday, October 14
10:30 AM - 12:00 PM
CA MC665
Emergent Sternotomy and Cardiopulmonary Bypass for Removal of a Foreign Body During Pacemaker
Replacement
Charles Jones, M.D., Samuel Dejo, M.D., Metro Health Medical Center, Cleveland, OH
We are presenting a 20-year-old female with a history of congenital heart block scheduled for a
pacemaker removal and reimplantation. After routine induction and endotracheal intubation anesthesia
was maintained with isoflurane fentanyl propofol and rocuronium for muscle relaxation. Intraoperatively cardiology was unable to remove the right ventricular epicardial lead or retrieve their
guidewire. At this point an emergent sternotomy was performed and the patient was placed on cardiopulmonary bypass to remove the foreign bodies. Post-operatively she was taken to the surgical intensive
care unit trachea extubated on post-op day 1 and discharged home on post-op day 3.
Monday, October 14
10:30 AM - 12:00 PM
CA MC666
Anesthetic Management of a Parturient With Newly Diagnosed Hereditary Hemorrhagic
Telangiectasia
Zachary Jones, M.D., UT Houston, Houston, TX
The patient is a 25-year-old F G2P1 at 36wks gestation presenting with worsening dyspnea and lower
extremity edema. CXR showed pulmonary edema. An echo showed a 4.2cm dilated aortic root. She had
Copyright © 2013 American Society of Anesthesiologists
a history of a pulmonary AVM and a saccular right internal carotid aneurysm increasing in size. CT
showed hepatic AVMs. She was newly diagnosed with Hereditary Hemorrhagic Telangiectasia (HHT).
Due to risk of worsening acute heart failure rupture of carotid aneurysm and dissection of aortic root pt.
received successful epidural and had an urgent c-section. Echo unchanged post-partum.
Monday, October 14
10:30 AM - 12:00 PM
CA MC667
Postoperative Takotsubo Cardiomyopathy After Pneumoperitoneum Induced Asystole
Pranjali Kainkaryam, M.D., Lori Circeo, M.D., Baystate Medical Center, Springfield, MA
A 48-year-old woman with severe gastro-esophageal reflux disease presented for a laparoscopic Nissen
fundoplication. Rapid sequence induction and intubation were uneventful. Asystole occurred
immediately after insufflation of carbon dioxide in the peritoneal cavity. ACLS was initiated and normal
sinus rhythm was restored after 3.5 minutes. Laparoscopy ruled out an intra-abdominal injury. Transesophageal echocardiography showed no intra-cardiac air but demonstrated global hypokinesis and
apical ballooning of left ventricle. No coronary artery disease was found on cardiac catheterization
which confirmed the diagnosis of Takotsubo Cardiomyopathy. She required post-operative ICU care and
was discharged home in good condition on post-operative day 6.
Monday, October 14
10:30 AM - 12:00 PM
CA MC668
Aortic Valve Replacement Via Minithoractomy: Cerebral Desaturation During Aortic Cross Clamp
Aruna Kamath, Albert Perrino, M.D., Wanda Popescu, M.D., Yale-New Haven Hospital; Veterans Affairs
Medical Center - West Haven, New Haven, CT
A 52-year-old male with a quadricuspid aortic valve and severe aortic regurgitation presented for aortic
valve replacement via right minithoracotomy. Cerebral oximetry values were within normal limits until
the aortic cross clamp was applied. Significant cerebral desaturation was noted values < 65%
concomitant with a large backflow of blood in the side port of the cordis catheter. Upon surgical
inspection the aortic cross clamp was found to have obstructed two thirds of the superior vena cava.
The anesthetic challenge was to recognize complications associated with minithoractomy and to discern
signs symptoms and physiology of superior vena cava obstruction.
Monday, October 14
10:30 AM - 12:00 PM
FA MC669
How Should a Patient With ICD be Managed for Upper Extremity Surgery?
Cosmin Guta, Razvan Hurezeanu, M.S., Cleveland Clinic Foundation, Weston, FL
65-year-old male with an ICD/pacemaker and history of hepertension diabetes presented for surgery on
the left elbow. Anesthesia team planned to use a magnet for the deactivation of the ICD. Despite the
magnet use four discharges from the ICD were noticed during the case. Several attempts to reposition
the magnetic device proved unsuccessful probably due to the position of the left arm in right lateral
decubitus. The ineffectiveness of the deactivation method has prompted us to reevaluate our practice
to use a magnet to deactivate an ICD instead of a reprogramming approach.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC670
Intracranial Hemorrhage Following a Liver Mass Resection
Cosmin Guta, M.D., Wagih Gobrial, M.D., Cleveland Clinic Foundation, Weston, FL, Razvan Hurezeanu,
M.S., Ross University School of Medicine, Dominica
A 61-year-old male with a history of new onset hypertension for the previous 2 months was scheduled
for hepatic/adrenal tumor removal. Initial Preop work up for the hypertension indicated
pheocromacytoma but repeat testing found this to be negative. Intraoperatively the patient went into
hypertensive crisis with a systolic pressure in the 300s subsequently developing a left basal ganglia ICH.
Postop the patient recovered from the ICH while the BP normalized with no paroxysmal events. The
events noted intraoperatively are classically associated with peochromacytoma but multiple pathology
exams were unable to confirm it.
Monday, October 14
10:30 AM - 12:00 PM
FA MC671
Anesthetic Challenges Associated With a New Treatment for Severe Asthma
Cosmin Guta, M.D., Carlos Cajina, M.D., Wagih Gobrial, M.D., Cleveland Clinic Foundation, Weston, FL,
Anthony Han, M.D., Ph.D.,Texas Tech University, El Paso, TX
Anesthetic Challenges Associated with a New Treatment for Severe Asthma Bronchial Thermoplasty (BT)
is an alternative for refractory severe asthma. BT utilizes controlled radiofrequency to ablate smooth
muscles lining the airways thereby limiting constrictive potential of airway muscles. Four patients
underwent three sessions of BT each in our department. A balanced general anesthesia (GA) technique
was used. Oxygen flows were maintained at 8L during the procedure due to significant leakage around
the bronchoscope. Patients tolerated the procedure without any significant complication. GA facilitated
stable intraoperative hemodynamics and provided a secure airway while maintaining complete
suppression of the cough reflex.
Monday, October 14
10:30 AM - 12:00 PM
FA MC672
Extreme Acidosis After Multisystem Trauma: How Low Can-You Go?
Jonathan Hadaway, M.D., Nicole Dobija, M.D., Matthew Waldron, M.D., University of Florida College of
Medicine, Gainesville, FL
We present a case of intraoperative resuscitation of a 44-year-old male undergoing emergent
exploration for intraabominal hemorrhage after high-impact multisystem trauma. The patient arrived to
OR in extremis; perioperative course was complicated by ongoing hemorrhage coagulopathy and severe
acidosis (baseline ABG 6.68/72.6/125/8). Treatment included massive transfusion correction of
respiratory component electrolyte and coagulation abnormalites and ~400 mEq sodium bicarbonate.
The patient was transferred to ICU stable. Hospital course included 4 more operations and 2 weeks
intensive care. After 3 weeks the patient was extubated neurologically intact and planned for discharge
to inpatient rehabilitation.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC673
Protectors of the Airway
Mohammed Hamdani, M.D., Ammar Alamarie, M.D., Sarah Stuart, M.D., SUNY Upstate Medical Center,
Syracuse, NY
The case is about a 35-year-old morbidly obese male admitted to MICU with acute pancreatitis
secondary to hypertriglyceridemia complicated by respiratory failure and acute kidney injury. The
patient was scheduled for a tracheostomy due to prolonged intubation. In route to the OR the patient
had desaturations down to the 60's requiring recruitment maneuvers and manual ventilation to
maintain saturations. At the onset of the procedure the surgeon elected to perform a bronchoscopy
during which the tip of the bronchoscope was sheared in the ETT causing airway obstruction. This
required emergent reintubation.
Monday, October 14
10:30 AM - 12:00 PM
FA MC674
Anesthesia and Acute Myelopathy: Offender or Bystander
Elizabeth Hankinson, M.D., Ahmed Zaky, M.D ., University of Washington VAPSHCS, Seattle, WA
A 71-year-old gentleman with esophageal carcinoma underwent esophagectomy under general and
epidural anesthesia following neoadjuvant therapy. Post-operatively the patient recieved fluids for
hypotension and developed atrial fibrillation. Post-operative day two the patient had sensory and motor
deficits below L1. Spine MRI showed non-compressive increased T2 signal T9 to the conus with central
cord enlargement suggestive of transverse myelitis. Steroids were started with mild improvement in
sensory function. Subsequently the patient developed multi-organ failure secondary to surgical
complications and care was withdrawn.
Monday, October 14
10:30 AM - 12:00 PM
FA MC675
Airway Management in a Patient With Hereditary Angioedema and Allergies to Danazol and C1Esterase Inhibitor Concentrates
Virginia Hardie, M.D., Allyson Hascall, M.D University of Nebraska Medical Center, Omaha, NE
Hereditary angioedema is a potentially life-threatening condition characterized by spontaneous swelling
of the gastrointestinal tract and airway. It is triggered by minor tissue trauma and does not respond to
antihistamines steroids or epinephrine. A 66-year-old female with a history of hereditary angioedema
presented for esophagogastroduodenoscopy. The patient had a history of allergic reaction to danazol
and C1-esterase inhibitor concentrates which are standard prophylactic treatments. Our management
plan included a secured airway prior to pharyngeal manipulation and a prophylactic dose of the
treatment medication ecallantide which is normally reserved for acute attacks only. The patient's
perioperative course was uneventful.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC676
Saved by the Tube: A Case of Threatened Airway Obstruction Following Arthroscopic Shoulder Repair
Nazish Hashmi, M.D., Sabina Khan, M.D., University of Arkansas for Medical Sciences Little Rock, AR,
Teodora Terlea, M.D., John L. McClellan Memorial Veterans Hospital, Little Rock, AR
A 51-year-old healthy male presented for a right arthroscopic rotator cuff repair. He had a previous
shoulder arthroscopy with no complications. General anesthesia was induced with propofol fentanyl and
succinylcholine. He was intubated and positioned in left lateral decubitus. The operation lasted three
hours. Upon removal of drapes significant facial and upper chest swelling was noted. He was left
intubated and transferred to the PACU on sedation. The head of the bed was elevated to 30 degrees.
One hour postoperatively his facial swelling decreased significantly and he was extubated and
subsequently discharged home.
Monday, October 14
10:30 AM - 12:00 PM
FA MC677
The Epiglottis is Where? The Case of a Displaced Epiglottis Obscuring the Glottic Opening Following
Glidescope Intubation and Other Complications of Glidescope Use
Elizabeth Healy, M.D., Tripti Kataria, M.D., Jonathan Lusardi, M.D., University of Chicago, Chicago, IL
A 58 F with history of left tonsil and base of tongue cancer presents for panendoscopy and esophageal
dilation after completion of CRT. Rapid sequence induction with atraumatic Glidescope® intubation was
performed. Direct laryngoscopy by surgeon revealed subluxation of the epiglottis into the tracheal inlet
with complete blockage of the glottic opening. Suction was passed along edge of ETT and with
concurrent laryngeal manipulation the epiglottis was flipped back into position with no apparent injury.
Patient extubated transferred to PACU and discharged the same day. Potential post-operative
complications could include sore throat hoarseness vocal cord injury and upper airway obstruction.
Monday, October 14
10:30 AM - 12:00 PM
FA MC678
Anesthetic Management of a Patient With Acute Polysubstance Intoxication Presenting With
Traumatic Open Globe Injury
Joshua Heller, M.D., Richard Abel, M.D., Nicole Ansell, M.D., Stanley Kang, M.D., Icahn School of
Medicine at Mount Sinai, New York, NY
A 34-year-old morbidly obese man with no known past medical history presented with a traumatic open
globe rupture. Upon interview with the patient the anesthesiology team learned that he had been
actively abusing cocaine methamphetamine and ethanol and had not slept for several days. Physical
exam revealed a potentially difficult airway.
Monday, October 14
10:30 AM - 12:00 PM
FA MC679
Unexpected Myocardial Infarction Status Post Low Risk Procedure
Mada Helou, M.D., Paul Kempen, M.D., Cleveland Clinic Foundation, Cleveland, OH
39-year-old male presented with otherwise minimal past medical history (including hyperlipidemia and
active tobacco abuse) for urethral stricture. A reportedly uneventful anterior stage I urethroplasty
occurred under Sevoflurane rocuronium fentanyl and hydromorphone anesthetic with the exception of
Copyright © 2013 American Society of Anesthesiologists
a short period of tachycardia during emergence lasting one minute. After two hours in the PACU
retrosternal chest pain with hypotension 66 mmHg systolic ensued leading to immediate EKG
transcription revealing hyperacute anterior ST elevation and TTE echo documenting anterior wall motion
abnormality. Emergent mobilization into the catheterization lab occurred concomitant to stabilizing and
lifesaving interventions.
Monday, October 14
10:30 AM - 12:00 PM
FA MC680
Intraoperative Anaphylaxis After Temporally Related Administered of Intravenous Albumin
Emily Herschmiller, M.D., Robert Weller, M.D., Wake Forest University, Winston-Salem, NC
A 60-year-old male with obesity diabetes and ulcerative colitis s/p proctocolectomy underwent
emergent surgery for strangulated parastomal hernia. He received cephazolin and rocuronium prior to
incision. After uneventful two hours he developed hypotension treated with albumin 5%. Hypotension
worsened and wheezing tachycardia and erythema developed. Anaphylaxis was suspected and BP and
ventilation improved after epinephrine dexamethasone and diphenhydramine. The patient showed
extensive urticaria and required postoperative ventilation and epinephrine infusion. He was extubated
on POD 1 and recovered to discharge. Tryptase was elevated at 24 µg/L Albumin was suspected as the
allergen. Allergy consultation and testing is scheduled.
Monday, October 14
10:30 AM - 12:00 PM
FA MC681
Prehospital Laryngotracheal Injury: Complication of Esophageal Sealing Cuffed Supraglottic Airway
Devices (SADs)
Kenneth Hiller, M.D., University of Texas at Houston, Houston, TX
This case details prehospital respiratory arrest and complications from King LTS™ insertion following
unsuccessful endotracheal intubation (ETI) and SAD placement attempts. On hospital arrival chest tubes
relieved pneumothoraces however subcutaneous emphysema (Panel A) continued to increase.
Laryngotracheal injury was suspected. Fiberoptic exam revealed arytenoid edema (Panel B). Open
surgical dissection revealed air bubbles distal to the glottis. The tracheostomy balloon was inflated distal
to the laryngotracheal tear. Subsequent chest x-ray (Panel C) demonstrated significant resolution of
subcutaneous emphysema. Maintaining SAD placement and avoiding ETI ensured visual confirmation of
the presence and location of the tear and prevented exacerbation of injury.
Monday, October 14
10:30 AM - 12:00 PM
FA MC682
Irregular Heart Rate In An Otherwise Healthy Woman
Lee Hingula, M.D., Tori Myslajek, M.D., Yale New Haven Hospital, New Haven, CT
A 64-year-old woman presented for laparoscopic cholecystectomy. The patient was noted to have an
irregular heart rhythm on the pulse oximeter with a rate of 77 beats per minute. When asked about her
medical history she recalled having an irregular heart rhythm since childhood but did not know the
diagnosis. She never experienced palpitations chest pain or symptoms consistent with heart failure. An
EKG demonstrated ventricular trigeminy. The patient was brought to surgery induced uneventfully and
her rhythm reverted to normal sinus. She remained in normal sinus rhythm until her discharge from the
post-anesthesia care unit.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC683
Severe Persistent Succinylcholine-Induced Hyperkalemia in an Ambulatory Patient
Juliann Hobbs, M.D., M.P.H., Charles Brudney, M.B.Ch.B., Duke University Medical Center, Durham, NC
An obese 66-year-old male with no known renal disease and normal serum chemistry values presented
for outpatient shoulder surgery. Approximately one hour after induction of anesthesia and
administration of succinylcholine the ECG demonstrated signs of hyperkalemia and his serum potassium
was found to be 7.4 mmol/liter. He was treated with calcium insulin and furosemide and recovered
uneventfully. Calculation of his glomerular filtration rate (GFR) revealed significant renal dysfunction
despite serum creatinine within normal limits. Anesthesiologists should consider the risk of
hyperkalemia when using succinylcholine and evaluate patients' renal function based on GFR rather
than solely on serum creatinine values.
Monday, October 14
10:30 AM - 12:00 PM
FA MC684
Anesthetic Management of Difficult Double-Lumen Endobronchial Tube and Bronchial Blocker
Placement
Nicole Hollis, D.O., Jeffery Gross, M.D., University of Connecticut, Farmington, CT
48-year-old woman with recurrent lung cancer to her right middle lobe presented for a right
thoracotomy. Significant medical history included lung cancer (s/p right upper lobectomy). Resection
required one-lung ventilation. Airway management included initial failed placement of a 35French left
double-lumen endobronchial tube (DLT); despite fiberoptic assistance the bronchial lumen persistently
entered the right mainstem. A 35French right DLT was easily inserted but did not provide adequate lung
isolation. Finally lung isolation was accomplished with a bronchial blocker through a single lumen
endotracheal tube. We suspect that difficulty placing the DLT was due to altered anatomy from the prior
thoracotomy.
Monday, October 14
10:30 AM - 12:00 PM
FA MC685
Anesthetic Management for Removal of a Sewing Pin From the Trachea
Christopher Howson, M.D., Stephen McHugh, M.D., Li-Ming Zhang, M.D., University of Pittsburgh
Medical Center, Pittsburgh, PA
Providing anesthesia for patients with inhaled foreign bodies presents a unique challenge for
anesthesiologists. Standard methods of airway management frequently cannot be used. Communication
with the proceduralist and an understanding of the procedure and physiologic consequences of
common anesthetic medications are of vital importance. This case involves a 31-year-old woman who
presented for suspension laryngoscopy after accidentally inhaling a sewing pin into her trachea.
Anesthetic considerations included maintenance of spontaneous ventilation obtaining an adequate
depth of anesthesia to tolerate prolonged suspension laryngoscopy without the use of muscle relaxants
and the avoidance of endotracheal intubation.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC686
Retrograde-Assisted Fiberoptic Intubation in a Patient With Unanticipated Difficult Airway
Jia Huang, M.D., Edwin Weeks, M.D., George Vaida, M.D., NYU Medical Center, New York, NY
A 67-year-old female with an otherwise normal airway exam was scheduled for laparoscopic bilateral
salphingo-oophorectomy. General anesthesia was induced with propofol and fentanyl; and the patient
was paralyzed with rocuronium. She was easily ventilated but found to be difficult to intubate. Attempts
to intubate her with direct laryngoscopy using different blades the glidescope fiberoptic intubation +/glidescope guidance and the intubating LMA +/- fiberoptic guidance all failed. Patient was eventually
intubated using a retrograde wire-assisted fiberoptic intubation technique. At the end of procedure she
was extubated over a tube exchanger without any untoward sequelae.
Monday, October 14
10:30 AM - 12:00 PM
FA MC687
Anesthetic Management in a Patient Status-Post Double Lung Transplant for Living-Related Donor
Renal Transplant
Caroline Hunter, M.D., Massachusetts General Hospital, Boston, MA
A 51-year-old female with a history of cystic fibrosis complicated by insulin dependent diabetes
respiratory failure status post bilateral living lobar lung transplant and end-stage renal disease
secondary to diabetes and calcineurin inhibitor toxicity presented for renal transplant. The challenges
we faced during anesthetic care included monitoring in the setting of a double lung transplant. We
placed an arterial line and CVP catheter to monitor arterial blood gases and CVP respectively.
Approximately 1 800 double lung transplants are performed annually in the United States and this
operation causes anatomical and physiological changes that affects anesthetic management for
subsequent operations.
Monday, October 14
10:30 AM - 12:00 PM
FA MC688
Difficult Airway Management in a Patient With Acromegaly and OSA Complicated by an Unexpected
Supraglottic Mass
Afzaal Iqbal, M.D., Zana Borovcanin, M.D., University of Rochester Medical Center, Rochester, NY
A 52-year-old male with acromegaly and OSA presented for trans-sphenoidal pituitary tumor resection.
During awake fiberoptic intubation a mobile polypoid mass was observed on the right vocal cord. With
the endotracheal tube in place ENT attempted a biopsy with substantial manipulation. The patient was
kept intubated and a tracheostomy was placed on POD#3 due to edema and ease of surgical exposure.
An attempt to remove the mass failed one week later due to persistent edema. The mass was removed
three months later with laser ablation once the edema subsided; the tracheostomy was then
successfully decannulated.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC689
An Awake Malignant Hyperthermia-Like Death in a Patient Taking Dietary Supplements
Johanes Ismawan, M.D., John Capacchione, M.D., Walter Reed National Military Medical Center,
Bethesda, MD, Sheila Muldoon, Nyamkishig Sambuughin, Patricia Deuster, Uniformed Services University
of the Health Sciences, Bethesda, MD
A physically-fit 24-year-old female presented to the emergency department with tachycardia (HR 200)
muscle rigidity and hyperthermia (105oF). Efforts to control her heart rate and temperature were
unsuccessful: she died of multi-organ failure. She had a documented malignant hyperthermia (MH)
event during surgery at age 11. Postmortem analyses identified a MH-causative RYR1 gene mutation
(Gly2434Arg) and one month use of a weight-loss dietary supplement (OxyElite Pro) containing multiple
stimulants. The pathologist identified caffeine and alcohol consumption as other contributing factors. It
is possible that dietary supplements are a previously unknown risk for MH susceptible patients or
persons with RYR1 mutations.
Monday, October 14
10:30 AM - 12:00 PM
FA MC690
Management of Massive Hemoptysis in the Bronchoscopy Suite: A Case Report
Pankaj Jain, Paul Kempen, Cleveland Clinic, Cleveland, OH
A 61-year-old female patient with a history of double lung transplant for Interstitial Pneumonia and
subsequent declining pulmonary function underwent an outpatient transbronchial biopsy under
sedation. She had no risk factors for hemorrhage. Following the fourth biopsy from the right middle lobe
massive hemoptysis was noted with hypoxemia on the pulse oximeter. Emergent endotracheal
intubation was performed and positive pressure ventilation was achieved. Hemostasis was subsequently
achieved. Endotracheal intubation though potentially challenging is of utmost priority to optimize
ventilation and oxygenation and for clearing the airway and hemostatic treatment of bronchial bleed.
Monday, October 14
10:30 AM - 12:00 PM
FA MC691
Anesthetic Management of a Patient With Hypokalemic Periodic Paralysis Undergoing Ascending
Aortic Aneurysm Repair With Aortic Valve Replacement
Vanita Jain, D.O., James Khoury, M.D., Baystate Medical Center, Springfield, MA
A 56-year-old male with a history of hypokalemic periodic paralysis arrived for ascending aortic
aneurysm repair and aortic valve replacement. Due to concern for hypokalemia causing prolonged
paralysis and mechanical ventilation the goal of anesthetic management was to minimize the risk of
hypokalemia. Normothermia was maintained throughout the case as hypothermia can cause
intracellular shift of potassium. All intravenous fluids were free of dextrose and the patient was not
given insulin intra-operatively to further reduce the risk of hypokalemia. Non-depolarizing paralytics
were utilized and re-dosed at the surgeon's request. The patient was extubated without complications
in the cardiac ICU.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC692
Perioperative Management of a Patient With Hemophilia A and Known Factor VIII Inhibitory
Antibodies Undergoing Drainage of a Chest Wall Abscess
Vanita Jain, D.O., Frederick Conlin, M.D., Baystate Medical Center, Springfield, MA
A 48-year-old Hispanic male with a history of hemophilia A and factor VIII inhibitor antibodies arrived for
chest wall abscess drainage. Because of his hemophilia and past history of hemorrhage we decided to
transfuse factors prior to surgery. The standard prophylaxis for hemophilia A is to administer factor VIII
however the patient had developed inhibitory antibodies to factor VIII rendering it useless. Instead
factor VIII was by-passed and he received factor VIIa prior to surgery which was then tapered during the
postoperative period. Intraoperatively he tolerated the procedure well with minimal blood loss. He was
discharged home without complications.
Monday, October 14
10:30 AM - 12:00 PM
FA MC693
Successful Use of a Total Intravenous Anesthetic Technique for a Patient With Stiff Person Syndrome
Undergoing Multilevel Posterior Lumbar Spine Surgery
Jessica Jajosky, M.D., William Tippets, D.O., WVU, Morgantown, WV
Stiff Person Syndrome (SPS) is an autoimmune disorder that affects GABA-ergic neurons and results in
rigidity and spasms of axial muscles. Patients with SPS may experience postoperative hypotonia when
exposed to volatile agents and muscle relaxants. In this case the patient underwent posterior lumbar
surgery (L2-S1) for spinal stenosis and disc herniation. Her anesthetic included IV propofol remifentanil
dexmedetomidine and ketamine. Neuromuscular blocking agents and volatile anesthetics were avoided.
Agents acting via GABA receptors were minimized. Surgical conditions were adequate and the patient
experienced an uneventful postoperative course. A TIVA technique may be a feasible option for patients
with SPS.
Monday, October 14
10:30 AM - 12:00 PM
FA MC694
Intraoperative Diagnosis of a Tension Pneumothorax During a Laparoscopic Gastrectomy
Zachary Jones, UT Houston, Houston, TX
92-year-old F with gastric cancer presenting for a robot assisted laparoscopic gastrectomy. She is highly
functional at baseline with only a remote history of asthma and infrequent inhaler use. During surgery
peak pressures increased from 20 to 30 and her blood pressure dropped from normotensive to 60s/40s.
Breath sounds were absent over the left lung. The differential was right mainstem intubation mucous
plugging bronchospasm and pneumothorax. Steroids and albuterol were given with no improvement. A
bronchoscope confirmed ET tube above the carina and clear airways. Intraoperative CXR revealed left
pneumothorax requiring decrease in insufflation and upgrade to ICU status.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC695
Extensive Thyroid Mass Encasing the Trachea to the Level of the Carina: Approach to Airway
Management
Julie Joseph, M.D., Lavinia Kolarczyk, M.D., University of North Carolina, Chapel Hill, NC
A 77-year-old female presented with stridor and respiratory distress. CT scan revealed a large thyroid
mass which encased the trachea and extended to the level of the carina. Significant mid tracheal
narrowing (0.3 cm in smallest diameter) and tracheal deviation were noted. Approach to airway
management included careful consideration of both upper and lower airway distortion mid tracheal
narrowing and distal extent of the mass. Given the risk of airway collapse at multiple anatomic levels we
performed an awake fiberoptic intubation using an extended length thin diameter endotracheal tube
and electively intubated the right mainstem bronchus.
Monday, October 14
10:30 AM - 12:00 PM
FA MC696
Difficulties With Emergency Intubation in a Polymorbid Patient With Acutely Expanding Neck
Hematoma Incision and Drainage
Eduardo Jusino-Montes, M.D., Michael Tran, D.O., Paul Kempen, M.D., Cleveland Clinic Foundation,
Cleveland, OH
This 65-year-old male presented with stridorous respiratory distress from acute neck hematoma
expansion after heparin intravenous infusion began in preparation for renal/hemo-ultrafiltration. He
was admitted from an outside hospital for management of acute decompensated heart failure. His
medical history included diabetes mellitus type II hypertension cerebrovascular disease
thrombocytopenia pulmonary hypertension chronic kidney disease and dilated cardiomyopathy.
Previous bilateral internal jugular venous catheterization attempts occurred under ultrasound guidance
with normal coagulation studies except for thrombocytopenia (65K/mm3). Six hours after anticoagulant
therapy began coagulation test results included an INR= 1.3 PT= 15.0 aPTT= >180 and platelet count
(49K/mm3).
Monday, October 14
10:30 AM - 12:00 PM
FA MC697
Emergency Exploratory Laparotomy in a Patient With Recent NSTEMI and Bilateral Lung Transplant for
Severe COPD and Pulmonary Hypertension
John Kanaan, M.D., Cleveland Clinic Foundation, Rocky River, OH
63 year-old female POD#11 from bilateral lung transplant developed abdominal distention and
leukocytosis with bowel pneumatosis on imaging; taken for emergent laparotomy. History: POD#9
developed AFlutter with RVR EKG changes in anteroseptal leads and positive cardiac enzymes. DC
cardioversion produced sinus rhythm with return of R waves ST return to baseline and incomplete RBBB;
troponin (peak 0.35ng/mL) decreased though still positive (0.23ng/ml) on POD#11. Echocardiogram
obtained two days post-cardioversion demonstrated maintained LV function with resolution of
pulmonary hypertension small pericardial effusion and dilated left atrium. History includes recent onset
hyponatremia (126 mEq/L) schizophrenia hepatitis C hypertension and DM2 with neuropathy.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
FA MC698
Preoperative Volume Optimization Using Nitroglycerin in a Patient Scheduled for Pheochromocytoma
Resection
Armen Kara, M.D., University of Southern California, Los Angeles, CA
Classically patients scheduled for pheochromocytoma resection are preoperatively started on
adrenergic blockade however recent controversial studies have questioned the need for preoperative
irreversible alpha blockade in normotensive patients. As such we have recently been encountering
patients on the day of surgery that have little to no preoperative adrenergic blockade. We present one
such patient whom we admitted the evening before scheduled adrenalectomy for pheochromocytoma
in order to optimize her volume status using a nitroglycerin infusion. With this fluid optimization we
were easily able to manage her vital signs intraoperatively without much fluctuation in her blood
pressure throughout the entire case.
Monday, October 14
10:30 AM - 12:00 PM
FA MC699
Cleidocranial Dysostosis and Severe Refractory OSA: Challenges in Airway Management
Marcin Karcz, M.D., M.S., Zana Borovcanin, M.D., University of Rochester, Rochester, NY
51-year-old morbidly obese male with cleidocranial dysostosis (CD) and severe refractory OSA was
admitted for telegnathic maxillomandibular advancement (MMA) surgery. Airway exam showed a
mouth opening only wide enough to visualize the tip of the tongue. After using a needle-less local
anesthetic technique for airway topicalization an awake nasal fiberoptic intubation was performed.
Postoperatively the patient was remained intubated due to the complexity of his surgery and significant
airway edema. An approach to intubation and strategy for safe extubation of high risk patients with CD
morbid obesity and severe refractory OSA undergoing MMA surgery will be discussed.
Monday, October 14
10:30 AM - 12:00 PM
FA MC700
Anesthesia Considerations of Deceptive Paradoxical Vocal Cord Motion Disorder
Ami Karkar, M.D., Yi Hua, M.D., Georgia Regents University, Augusta, GA
64-year-old ASA III female with CLL mild asthma and HTN underwent a diagnostic laryngoscopy for left
tonsillar mass. Patient tolerated the procedure well with general anesthesia intubated with a 7.0 mm
endotracheal tube. After extubation with extubation criteria met she developed partial upper airway
obstruction that presented with a rare intraoperative presentation of persistent gasping of air with
100% oxygen saturation and stable vital signs. Initially a trial of albuterol nebulizer positive pressure
ventilation nasal trumpet placement IV epinephrine and racemic epinephrine were given. Fiberoptic
laryngoscopy showed paradoxical vocal cord motion which was successfully treated with IV versed.
Monday, October 14
10:30 AM - 12:00 PM
FA MC701
Anesthesia Management of Patients With Parry-Romberg Syndrome
Ami Karkar, M.D., Tao Hong, M.D., Georgia Regents University, Augusta, GA
Parry-Romberg Syndrome (PRS) is a rare condition manifesting in severe progressive hemifacial atrophy
involving skin soft tissue and bone. It is often found in the first decade of life more frequently in females.
Copyright © 2013 American Society of Anesthesiologists
It is known to cause severe facial pain and is associated with other auto-immune disorders and
inflammatory changes noted on MRI (Moseley). Although many have studied its etiology and the
complexities of surgical grafting the intraoperative anesthesia management of the multiple systems
affected by PRS has not yet been studied. Consideration should be given to potentially difficult airways
and connective tissue cardiovascular and neurologic aspects of PRS.
Monday, October 14
10:30 AM - 12:00 PM
FA MC702
Anesthetic Implications of Hypothyroidism
Suzanne Kellman, M.D., Jennifer Hofer, M.D., The University of Chicago, Chicago, IL
A 51F with interstitial lung disease is scheduled for a lung biopsy. She has a TSH level of 13 and
symptomatic hypothyroidism. There are several possible perioperative implications of hypothyroidism
including coma and cardiac arrest. Patients have increased peripheral vascular resistance decreased
blood volume and impaired baroreceptor reflexes. Respiratory depressants specifically narcotics can
lead to respiratory failure as both hypoxic and hypercapnic respiratory drives are decreased. The stress
of surgery may unmask adrenocortical insufficiency requiring steroid supplementation. The degree of
elevation in TSH corresponds to the severity of hypothyroidism. Properly diagnosed and treated
hypothyroidism may mitigate these complications.
Monday, October 14
10:30 AM - 12:00 PM
FA MC703
Oesophagectomy in a Patient With Corrected Congential Cardiac Disease and Situs Invertus
Catriona Kelly, M.B.Ch.B., Aoibhin Hutchinson, M.B.Ch.B., Royal Hospital, Belfast, United Kingdom
A male patient presented for oesphagectomy two years after adulthood surgery for correction of
congential cardiac disease. He was born with a single atrium and had two superior vena cavae draining
into this. He also had situs invertus. He had atrial septation performed and his right SVC was
reimplanted to the right atrium. He also had a mitral and tricsupid valve replacement. This case
demonstrates the difficulties with managing venous access and one lung ventilation in a patient with
altered anatomy and following successful cardiac corrective surgery.
Monday, October 14
10:30 AM - 12:00 PM
NA MC704
Transient Global Amnesia After General Anesthesia Reversed With Flumazenil in the PACU
Joyce Kim, M.D., University of Michigan, Ann Arbor, MI
A 39-year-old woman underwent removal of IUD under anesthesia. She had no significant past medical
history medications or allergies. Midazolam was given as premedication. General anesthesia was
induced with Fentanyl and Propofol and maintained with Isoflurane and Nitrous Oxide. In PACU the
patient could not provide her birth date age day month or year. She could not recognize her companion.
On neurologic exam she had no sensory or motor deficits. Flumazenil was administered and within
minutes she was fully oriented to person place and time. She did not recall her confusion and had no
further events postoperatively.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
NA MC705
Neurogenic Shock Requiring Transvenous Pacing
Saman Kohanof, D.O., Srikanth Sridhar, M.D., UT Houston, Houston, TX
Patient DP 78-year-old male with a PHx of Hypertension Hyperlipdemia is admitted after a mechanical
fall. Physical exam is significant for progressively decreasing upper extremity strength. MRI of the
cervical spine shows central cord syndrome and neurosurgery plans an urgent posterior spinal fusion.
Secondary to his injury we anticipate neurogenic shock and prepare for transvenous pacing. Roughly 5
min after induction patient became hypotensive to 70/40 and bradcardic to 45. Tapscope placed and
paced until cardiology emergently came and placed a transvenous pacer. DP was paced for the next 40
min until his intrinsic heart rate surpassed the pacer.
Monday, October 14
10:30 AM - 12:00 PM
NA MC706
Staged Embolization Resection of a Carotid Body Tumor
Geoffrey Lively, M.D., Pingle Reddy, M.D., Sarah Armour, M.D., Virginia Commonwealth University,
Richmond, VA
This is a 33-year-old female with bilateral carotid body tumors (CBT) left larger than right. Initially sixvessel cerebral angiogram with onyx embolization of the left carotid body tumor was performed.
Anesthesia obtained ultrasound images pre and post embolization which correlated well to angiographic
images of the CBT. The next day the patient returned to the operating room for CBT resection. Both
procedures were performed under general anesthesia and utilized arterial line monitoring and
somatosensory evoked potentials. No major fluctuations in blood pressure or reduction of evoked
potentials were observed during either procedure.
Monday, October 14
10:30 AM - 12:00 PM
NA MC707
Management of Severe Intracranial Hypertension in Orthotopic Liver Transplantation
Derek Lowe, M.D., Elizabeth Sunu, M.D., Ahmed Darwish, M.D., Eugenia Ayrian, M.D., University of
Southern California, Los Angeles, CA
Severe cerebral edema leading to intracranial hypertension (ICH) can be a lethal consequence of liver
failure. A 25-year-old girl with acute liver failure and ICH was brought to the OR for liver transplantation.
Preoperatively her MELD was 20 and intracranial pressures (ICP) in 30 mmHg range via bolt monitor. We
focused on strategies to reduce ICP maintain cerebral perfusion pressure and reduce cerebral metabolic
rate. Despite aggressive intraoperative efforts to control ICH her ICP remained in 40 mmHg range.
However her cerebral edema resolved by postoperative day 2 and discharged on postoperative day 8
without neurological deficits.
Monday, October 14
10:30 AM - 12:00 PM
NA MC708
Complex Scoliosis Repair in a Toddler: A Case of Paraplegia With Normal Neuromonitoring Signals
Morgan Mathie, D.O., Mary Herman, M.D., University of Florida, Gainesville, FL
2-year-old female with a history of VACTERL congenital anomalies including scoliosis cardiac anomalies
including right sided arch ASD VSD anomalous pulmonary circuitry. Surgical repair was undertaken
Copyright © 2013 American Society of Anesthesiologists
somatosensory and motor evoked potentials were used. Throughout the duration of the case there was
no loss of signals. Upon conclusion and during emergence it became apparent that the patient was no
longer moving her lower extremities. An emergent CT was done showing a hematoma formation. She
was taken back to the OR for revision. MEPs were absent prior to her revision upon opening the incision
MEPs returned.
Monday, October 14
10:30 AM - 12:00 PM
NA MC709
Neuroprotection for Open Cerebral Aneurysm Clipping After Failed Coiling
Caitlin McGinty-Froncek, M.D., Myles Boone, M.D., Beth Israel Deaconess Medical Center, Boston, MA
52-year-old male presented after mechanical fall with head trauma and positive LOC. CTA showed 1.6cm
x 1.5cm aneurysm arising from the bifurcation of the right M1. After an unsuccessful endovascular
coiling the patient was taken to the OR for an open clipping. Neuroprotective stratagies for open
aneurysm clipping will be discussed including; cooling and pentobarbital coma. The patient was allowed
to cool passively. Additionally a bolus of pentobarbital followed by an infusion was used to achieve burst
suppression on EEG. Due to the pharmacokinetics of pentobarbital we were unable to obtain a
neurologic exam concluding the surgery.
Monday, October 14
10:30 AM - 12:00 PM
NA MC710
Adenosine in the Setting of Refractory Hemorrhage of Cerebral Arteriovenous Malformation
Carl McMullen, D.O., San Antonio Military Medical Center, San Antonio, TX
We present a case of a 35-year-old otherwise healthy female who underwent a parietotemporal
craniotomy for a symptomatic 3.5x3.0cm middle cerebral artery arteriovenous malformation.
Anatomical position of the malformation and an inability to embolize it complicated the surgical
resection which resulted in significant blood loss. Burst suppression was pharmacologically induced on
multiple occasions during placement of temporary surgical clips. Despite multiple clips placed profuse
hemorrhage continued from the surgical site. After discussion with surgeons adenosine was used to
facilitate placement of more clips. Eventually recombinant factor VII was given to achieve definitive
hemostasis.
Monday, October 14
10:30 AM - 12:00 PM
NA MC711
Decision Making in a Terminally Metastatic Cancer
Maria Mendoza, M.D.,Theodore Marks, M.D., Rafi Avitsian, M.D., Cleveland Clinic, Cleveland, OH
A 60-year-old male was emergently scheduled for relieve of spinal cord compression. His medical history
was significant for hepatitis C with metastatic hepatocellular carcinoma and spinal stenosis with cauda
equine syndrome. The patient was receiving enoxaparin for IVC thrombosis last dose given 6 hours
before surgery. Before proceeding with the case Anesthesia and Surgical team explained to the patient
the high risk of acute embolization and intraoperative death patient understood the risks but the most
important thing for him was to be able to walk. We proceeded with the case the patient survived.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
NA MC712
Anesthetic Considerations for Hemicorporectomy
Tiffany Moon, M.D., Pamela Fox, M.D., Irina Gasanova, M.D., Ph.D., Albert Nguyen, M.D., Jeffrey Janis,
M.D., UT Southwestern, Dallas, TX
The hemicorporectomy is an uncommonly performed operation of last resort for patients with life
threatening disease. The literature has a robust description of the surgical approach but lacks discussion
of the intraoperative physiological challenges of patients undergoing this rare and lengthy procedure.
Here we describe our approach to the perioperative management of an opioid-tolerant T10 paraplegic
undergoing a hemicorporectomy for refractory pelvic osteomyelitis. We discuss our anesthetic
technique volume resuscitation strategy physiologic challenges and concerns and plan for postoperative pain control. Ultimately good communication with the surgeons and a strong understanding
of the stages of the operation is essential.
Monday, October 14
10:30 AM - 12:00 PM
NA MC713
Mannitol Extravasation Leading to Compartment Syndrome
John Patzkowsky, M.D., Xueqin Ding, M.D., University Hospitals Case Medical Center, Cleveland, OH
A 58-year-old male with history of coronary artery disease diabetes mellitus and morbid obesity
presented for craniotomy and resection of giant chondrosarcoma. He was placed in a semi-right lateral
position requiring his left arm to be secured across his body. The surgeon requested mannitol
administration which was infused through a 16-gauge IV catheter located in the left hand. Decreased
SSEPs signals from the left upper extremity prompted discovery of a tensely swollen left hand with
sloughing skin. After immediate discontinuation of the IV a diagnosis of compartment syndrome was
made by orthopedic surgery who subsequently performed an emergent fasciotomy.
Monday, October 14
10:30 AM - 12:00 PM
NA MC714
Emergent Evacuation of Subdural Hemorrhage in a Patient With Acute Hemorrhagic
Leukoencephalopathy
Lauren Potts, M.D., Pedro Rios, M.D., Christopher Roberts, D.O., John Capacchione, M.D., Walter Reed
National Military Medical Center, Bethesda, MD
A 33-year-old female who presented with headache vomiting and left-sided weakness underwent a right
frontal lobe biopsy of a lesion diagnostic for acute hemorrhagic leukoencephalopathy (AHLE) a rare
disorder with an 80% mortality rate. On hospital day #29 declining mental status prompted head CT
showing subdural hematoma worsening cerebral edema and developing uncal herniation. Emergent
SDH evacuation with right frontal and temporal lobectomies required multiple blood products for
ongoing hemorrhage and hemodynamic instability. This case illustrates the challenging management of
a patient with AHLE as well as the ethical dilemma of surgical intervention for a patient with a poor
prognosis.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
10:30 AM - 12:00 PM
NA MC715
Use of Serum Prolactin as a Marker for Seizure
Keri Propst, M.D., Jeffrey Pasternak, M.D., Mayo Clinic, Rochester, MN
A 71-year-old female with essential tremor who underwent deep brain stimulator lead placement one
week prior presented for battery and lead extension implantation via general anesthesia. She had no
prior history of seizure. Upon emergence the patient became acutely hypercarbic hypertensive
developed masseter spasm and clonic movements and awakening was delayed. She remained afebrile
throughout the event. Given concern for seizure serum prolactin was measured immediately following
the event and was found to be elevated at 67 ng/mL (institution normal range: 3-27 ng/mL). A repeat
serum prolactin obtained 6 h later was 6 ng/mL.
Monday, October 14
10:30 AM - 12:00 PM
NA MC716
Winning Hearts and Minds: A Case of Being Stuck Between a Rock and a Heart Place
Joshua Quick, M.D., Marianna Crowley, M.D., Massachusetts General Hospital, Boston, MA
82-year-old male with a large right meningioma abutting the sagittal sinus found to have severe CAD on
work-up for surgery. Scheduled for CABG but experienced worsening of hemiparesis with falls and
inability to ambulate. Concern that CPB would worsen edema around tumor and lead to further damage
decision made to remove tumor first. Anesthetic concerns include known severe CAD with diastolic HF
paroxysmal A flutter h/o brainstem CVA mod L ICA stenosis coagulopathy ITP GERD and risk of air
embolus in setting of previous Boerhaav's esophagus making surveillance difficult.
Monday, October 14
10:30 AM - 12:00 PM
NA MC717
Anesthetic Management of an Adult Moyamoya Disease Patient
Andrey Rakalin, M.D., Karl Nazareth, M.D., Henry Vu, M.D., Jaime Ortiz, M.D., Neil Bailard, M.D., Baylor
College of Medicine, Houston, TX
A 39-year-old Hispanic male presented with symptoms of acute right homonymous hemianopsia mild
gait instability and persistent headache. Cerebral angiogram showed high grade stenosis of the left
middle cerebral artery and a distal reconstitution by the collateral vasculature resulting in the
characteristic Moyamoya disease findings. A superficial temporal artery to middle cerebral artery bypass
was performed. Goals of maintaining normocarbia normothermia and hypervolemia should be
prioritized. Unique challenges are prolonged burst suppression and tight blood pressure control needed
to maintain optimum cerebral oxygen delivery. The key concepts are reviewed and possible
improvements over our own anesthetic technique are suggested.
Monday, October 14
10:30 AM - 12:00 PM
NA MC718
When a Middle Cerebral Artery Aneurysm Ruptures Intraoperatively
Sebastian Ramos, B.S., Shaheen Shaikh, M.D., University of Massachusetts Medical School, Worcester,
MA
48-year-old healthy male sustained a mild concussion while working on his deck. CT revealed an
incidental finding of a small cerebral aneurysm. He agreed for stent assisted coiling and was placed on
Copyright © 2013 American Society of Anesthesiologists
aspirin and Plavix. Intraoperatively the aneurysm ruptured with increased ICP that presented as severe
hypertension bradycardia and pulmonary edema. Measures to reduce ICP were implemented. BP was
elevated to maintain CPP once aneurysm was secured. Neurosurgery declined EVD since patient was on
Plavix and placed a lumbar drain instead. Patient did not wake up postoperatively. Family agreed for
organ donation after brain death criteria were met.
Monday, October 14
10:30 AM - 12:00 PM
NA MC719
Cardiopulmonary Resuscitation in Prone Position
Silvia Rios, M.D., Daiana Gomes, M.D., Ana Carolina Teixeira, M.D., Luis Armando Abreu, M.D., Marcos
Lopes de Miranda, M.D., Carlos Darcy Bersot, M.D., Lagoa Federal Hospital, Rio de Janeiro, Brazil
A 77-year-old female was admitted for excision of a parietal-occipital meningioma in the prone position
with the head fixed on a Mayfield head holder. During the surgery the sagittal sinus was injured and the
patient presented an abrupt hemorrhagic shock leading to a cardiac arrest. Cardiac massage was
promptly initiated in the prone position. Methods to ensure high-quality CPR were perfomed. After two
minutes of CPR there was a return of the spontaneous circulation. Cardiac arrest in unusual positions
represents a challenge for anesthesiologists however the patient was discharged without sequelae
Monday, October 14
10:30 AM - 12:00 PM
NA MC720
Anesthetic Management of a Symptomatic Sphenoid Wing Meningioma Resection After Cesarean
Delivery of a 27 Weeks Fetus: Case Report
Victor Rivero, Myrna Morales, M.D., Hector Torres, M.D., University of Puerto Rico Medical Sciences
Campus, San Juan, PR
Sphenoid wing meningiomas are challenging due to proximity to carotid arteries. Pregnancy sex
hormones accelerate tumor growth. We report a 31-year-old woman with symptomatic meningioma in
27th week of pregnancy for cesarean delivery and tumor resection. She complained of headache
dizziness difficulty walking nausea vomiting and memory loss. Also had motor aphasia dysarthria and
oriented in person not place and time. At OR rapid sequence induction was granted and maintenance
with volatile anesthetics opioids and paralyzing agents as well as lidocaine drip as neuroprotectant. Then
patient was transferred to the Neurosurgery intensive care unit for postoperative management.
MCC Session Number – MCC11
Monday, October 14
1:00 PM - 2:30 PM
FA MC721
Possible Coronary Air Embolism During Flexible Bronchoscopy
Monika Nanda, M.B. B.S., John Berry, M.D., University of North Carolina, Chapel Hill, NC
A 51-year-old man with adenocarcinoma of the right lung presented for flexible bronchoscopy and
bronchial stent. Preoperative EKG was normal. Intra-operatively the surgeons delivered positive
pressure oxygen through the scope to improve visualization. ST elevations were noted in leads II and V5.
The surgeons were notified and insufflation was stopped immediately. The patient was given 100%
oxygen and morphine. EKG came back to normal within 10 minutes and patient remained
hemodynamically stable . The transient nature of intramural ischemia immediately after insufflation
Copyright © 2013 American Society of Anesthesiologists
strongly suggests air embolism. Immediate recognition and management prevented further worsening
and led to a successful recovery.
Monday, October 14
1:00 PM - 2:30 PM
FA MC723
A Rare Presentation of Delayed Emergence Due to Non-Convulsive Status Epilepticus After NonNeurologic Surgery
Faiz Nasser, M.D., Stephen Heimbach, M.D., University of Oklahoma, Oklahoma City, OK
Delayed emergence poses challenges to the anesthesiologist. Differential diagnosis includes residual
anesthetic narcotic overdose electrolyte abnormalities or ischemic events. Non-convulsive seizures as a
cause of delayed emergence have rarely been described in the literature especially after non-neurologic
cases. We present a case of a 36-year-old female with multiple comorbidities but no history of seizures
who did not regain consciousness after a general anesthetic for amputation formalization. She did not
display any outward signs of a seizure. After ruling out other causes of delayed emergence an EEG was
obtained which showed she was in a non-convulsive status epilepticus state.
Monday, October 14
1:00 PM - 2:30 PM
FA MC724
Perioperative Management of a Patient With Digoxin Toxicity Presenting for Emergency Surgery
Jack Neil, M.D., Sanjay Dwarakanath, M.D., Medical College of Georgia, Augusta, GA
An 80-year-old male poor historian on digoxin presented for emergent revision of a hemorrhaging
arterio-venous fistula existing in-situ for dialysis. EKG showed slow junctional rhythm and ventricular
escape beats with stable Blood Pressure. Digoxin levels were drawn and BMP was checked. K+ level was
normal. Surgery performed under regional anesthesia by ultrasound guided brachial plexus block via
infraclavicular approach. Intraoperatively transcutaneous pacing pads were placed electrolytes
monitored frequently isoproterenol was available and pharmacy requested for digibind. Postoperatively
elevated digoxin levels confirmed. Cardiology consulted transvenous pacemaker placed and digibind
administered. Nephrology consulted for plasmapheresis vs dialysis.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC725
A Case of EKG Conductance Through Saline in a Burns Patient
Proshad Nemati, M.D., Amin Kamali, D.O., UT Southwestern Medical Center, Dallas, TX
31-year-old M with 60% total body surface area burns who presented for excision debridement and split
thickness skin grafting. As the EKG leads would not stick to the patient's skin we placed the EKG leads on
the mattress of the operating table near the left flank left shoulder and right shoulder. We then applied
normal saline to the leads and surrounding mattress. As such the EKG impulses were transmitted from
the patient to the leads via the salt solution and a normal EKG waveform was displayed throughout the
case.
Monday, October 14
1:00 PM - 2:30 PM
FA MC726
Anesthetic Management of an Adult Patient With Central Hypoventilation Syndrome and Bilateral
Phrenic Nerve Paralysis
Jessica Newman, M.D., Emily Peoples, M.D., University of Michigan, Ann Arbor, MI
A 52-year-old woman with a history of central hypoventilation syndrome secondary to stroke and
bilateral phrenic nerve paralysis presented for repair of phrenic nerve stimulator. General endotracheal
anesthesia was induced without complication and the patient's intraoperative course was uneventful.
She was taken to the recovery room intubated and breathing spontaneously. After 15 minutes in
recovery she was extubated to home VPAP machine. Her pain was controlled with ketorolac and
intravenous clonidine to minimize opioid use. This case will highlight the challenges of anesthetic
management of patients with central hypoventilation syndrome and bilateral phrenic nerve paralysis.
Monday, October 14
1:00 PM - 2:30 PM
FA MC727
Anterior Osteophyte as a Cause of Airway Compromise
Ha Nguyen, M.D., Trevor Banack, M.D., Yale School of Medicine, New Haven, CT
An 83-year-old man with complaints of chronic aspiration dysphagia and weight loss presented for C3-6
anterior osteophyte resection. A preoperative CT scan of his neck demonstrated a 2cm osteophyte from
C3-7 causing extrinsic compression of his esophagus and trachea. The patient was taken to the OR and
an awake fiberoptic intubation was performed. ENT surgery was present during intubation as backup for
possible rigid bronchoscopy or tracheostomy. FOB revealed distortion of the anatomy however the
patient was intubated without incident. At the end of the case following resection of the C2-C6
osteophyte the patient was assessed and successfully extubated.
Monday, October 14
1:00 PM - 2:30 PM
FA MC728
Planning the Anesthetic: An Unstable 18-year-old With Cardiac Tamponade and a Huge Intrathoracic
Lymphoma With Mass Effect
Vinh Nguyen, D.O., Richard Barboza, M.D., Michael Rasmussen, M.D., Patricia Pang, M.D., Georgetown
University Hospital, Washington, DC
An 18-year-old male with known T-cell lymphoma presents to our tertiary care center with tachycardia
in the 200s JVD and dyspnea. CT Chest shows anterior mediastinal and neck mass with tracheal shift and
Copyright © 2013 American Society of Anesthesiologists
a tension hydrothorax. Echocardiography reveals pericardial tamponade physiology. After tube
thoracostomy in the emergency department the patient requires urgent creation of a pericardial
window. We explore anesthetic considerations in this complex patient.
Monday, October 14
1:00 PM - 2:30 PM
FA MC729
Transurethral Resection of Bladder Tumor in an Anticoagulated Patient With an Incidental LV
Thrombus
Tameka Noel, M.D., Girish Joshi, M.D., Jin Meng, M.D., UT Southwestern at Dallas, Dallas, TX
A 62-year-old man with bladder malignancy and severe vasculopathy (carotid coronary and peripheral
disease) presented for scheduled TURBT. Past medical history also was significant for COPD ongoing
tobacco abuse GERD and prior CVA. Preoperative TTE revealed a 47% EF and LV apical thrombus.
Nuclear stress testing was aborted due to syncope; however resting images were consistent with prior
infarct. Patient was admitted and treated with a heparin infusion until the day of surgery. Surgery was
performed under general anesthesia. An arterial catheter was placed before induction. Patient did well
postoperatively and was discharged home with appropriate follow-up on POD1.
Monday, October 14
1:00 PM - 2:30 PM
FA MC730
Anesthetic Management of Penetrating Cardiac Injury
Peter Norstedt, M.D., University of Washington, Seattle, WA
A healthy 28-year-old man was stabbed and airlifted to Harborview Medical Center. In the field SBP was
70 where he was intubated. Upon admission 2U PRBC were infused and a chest tube was placed with
200ml blood return. He was transported to the OR where general anesthesia was induced and
laparotomy revealed hemoperitoneum and hemothorax. Further exploration demanded sternotomy and
hemopericardium was found to originate from the ventricular apex. During repair the patient
experienced ectopy followed by asystole. Cardiac massage and atropine resumed normal sinus rhythm.
The remainder of the operation was unremarkable.
Monday, October 14
1:00 PM - 2:30 PM
FA MC731
Perioperative Care of a 68-year-old Female With Multiple Comorbidities: An Acute Femoral Neck
Fracture and Recent Onset SVC Syndrome.
Suzanne Numan, M.D., Ph.D., Amy Babb, M.D., Eva Boyd, M.D., Niels Chapman, M.D., University of New
Mexico, Albuquerque, NM
The patient is a 68-year-old female with diabetes COPD and recent ischemic stroke (2/12) who was
admitted to the hospital with a right femoral neck fracture following a fall at home. During her
preoperative assessment right upper extremity and facial swelling were noted as well as dyspnea in
supine position. CT of the chest demonstrated a right hilar mass with encasement of the SVC. Biopsy of
tumor via bronchoscopy revealed small cell carcinoma. Interventional Radiology placed a stent in the
SVC and a round of chemotherapy was completed prior to her right hemiarthroplasty under general
anesthesia.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC732
Airway Management in a Trauma Patient With Relapsing Polychondritis and Laryngotracheal
Involvement
Frederick O'Donnell, Loreen Mane, M.D., T. Dirk Younker, M.D., University of Missouri Hospitals and
Clinics, Columbia, MO
Relapsing polychondritis (RPC) is an inflammatory arthritis of cartilaginous structures including the
tracheobronchial tree. We describe the case of a 22-year-old male with RPC presenting for operative
fixation of a traumatic tibia fracture. The anesthetic plan was complicated by laryngotracheal
involvement with 80% subglottic stenosis. The patient was asymptomatic but had no history of
endotracheal intubation. His risk for intrathoracic and/or extrathoracic obstruction under general
anesthesia was unknown. We elected to do the case under neuraxial anesthesia with a contingency plan
for airway management.
Monday, October 14
1:00 PM - 2:30 PM
FA MC733
Management of Perioperative Hypotension in the Setting of an Undiagnosed Neuroendocrine Tumor.
Tyler Pagel, M.D., Steve Hyman, M.D., Vanderbilt University Medical Center, Nashville, TN
A 69-year-old male underwent general anesthesia for resection of a pre-sacral mass. He had
hypertension treated with losartan. He developed intraoperative hypotension unresponsive to fluids but
responsive to phenylephrine infusion. Pathology revealed a neuroendocrine tumor. Phenylephrine was
weaned at emergence but resumed in PACU because of persistent hypotension and tachycardia.
Somatostatin was considered but delayed pending final pathology. Phenylephrine was continued for
approximately 24 hours postoperatively. The patient remained hemodynamically stable and was
discharged home on POD#7. This case prompts discussion of perioperative hypotension in the setting of
neuroendocrine tumors and possible ARB-induced vasoplegia.
Monday, October 14
1:00 PM - 2:30 PM
FA MC734
Successful Management of a Fulminant Myopericarditis for Exploratory Laprotomy and Subsequent
Colectomy
Rakhi Pal, Andrea Kurz, Cleveland Clinic Foundation, Cleveland, OH
25-year-old with no past medical history developed URI like symptoms and subsequently pericardial
effusion pleural effusion left ventricular hypertrophy and cardiomyopathy with severe diastolic
dysfunction .Pericardiocentesis was complicated by cardiogenic shock with ejection fraction 10 %
requiring intubation and intra aortic balloon pump placement .Myocardial biopsy shows microvesicular
steatosis suggestive of congenital or toxic cause of fulminant myopericarditis. She had exploratory
laprotomy for pneumatosis intestinalis during which total colectomy was done for bowel infarction .We
describe a successful perioperative management of this case with invasive monitoring and post
operative intensive care transfer.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC735
Anesthetic Management of Severe Rheumatoid Arthritis With Systolic Lt Ventricular Dysfunction and
Moderate Mitral Regurgitation
Rakhi Pal, Alparslan Turan, M.D., Cleveland clinic, Cleveland, OH
70-year-old lady severe Rheumatoid arthritis with extensive cardiac disease (systolic Heart failure with 2
+ mitral regurgitation) DM uncontrolled HTN PAD was scheduled to undergo exploratory laprotomy for
intra peritoneal abscess. After placing a pre-induction arterial line rapid sequence induction was
performed and central venous access was achieved. . Since patients with MR are prone to hemo
dyanamic fluctuations during the operative procedures optimal and timely management can effectively
reduce peri operative complication. We describe the successful peri operative management of severe
rheumatoid arthritis with heart failure who had undergone exploratory laprotomy .
Monday, October 14
1:00 PM - 2:30 PM
FA MC736
A Complicated Case of Hypertrophic Obstructive Cardiomyopathy ( HOCM ) With Myesthenia
Gravis(MG) Undergoing Percutenous Nephrolithotomy(PCNL) in Prone Position
Rakhi Pal, John Jerabek, D.O., Cleveland Clinic, Cleveland, OH
This 65-year-old lady with HOCM and MG had undergone PCNL in prone position after getting clearance
by cardiologist at preoperative clinic . Her ECHO finding was consistent with HOCM and LV diastolic
dysfunction . She received titrated dose of etomidate for induction and b blocker to prevent any
sympathetic stimulation during intubation .Intubation was performed with a smalll dose of
succenylcholine while avoiding non depolarizing muscle relaxants throughout the case. At the end of the
procedure patient was transferred to PACU intubated where she was extubated few hours later.
Monday, October 14
1:00 PM - 2:30 PM
FA MC737
Perioperative Management of Robotic Laproscopic Pheochromocytoma With Aortic Regurgitation
Rakhi Pal, John Jerabek, D.O., Cleveland Clinic, Cleveland, OH
Anesthetic management of a robotic laproscopic adrenalectomy for pheochromocytoma with aortic
regurgitation A 38-year-old lady with known past medical history of HTN and aortic regurgitation and
recent ly confirmed diagnosis of pheochromocytoma with left adrenal mass on magnetic resonance
imaging. The patient was treated with alpha- followed by beta-blockade with phenoxybenzamine and
metoprolol. The goal in peri operative management of pheochromocytoma was to prevent hypertensive
crisis but in this case it was challenging in presence of aortic valve regurgitation .We describe the
successful peri-operative management of pheochromocytoma in the setting of moderate aortic valve
regurgitation .
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC738
Rhabdomyolysis After Multilevel Spine Surgery
Vahiia Pamidimukkala, Richard Kim, M.D., Elena Brasoveanu, M.D., Huai-Jen Yang, M.D., Boston Medical
Center, Boston, MA
Rhabdom year-old lysis is a known complication of spine surgery. Our patient had an elective T10-S1
posterior spine fusion. The intra operative course was uneventful and immediate post operative course
was complicated by Acute renal failure secondary to rhabdom year-old lysis requiring hemodialysis. Due
to the time spent in prone position fluid management could be a challenge with potential risk of airway
edema and vision loss. Urine output and serial ABGs were monitored in this case to guide fluid
management raising a question of whether serial CPKs and creatinine should also be monitored and if
indicated liberal fluid strategy used.
Monday, October 14
1:00 PM - 2:30 PM
FA MC739
Live Donor Liver Transplantation in Patient With Hemophilia Hepatitis and HIV
Gabrielle Paoletti, B.A., Ibtesam Hilmi, MB.CH, FRCA, University of Pittsburgh School of Medicine,
Pittsburgh, PA
A 33-year-old male with a history of hemophilia underwent living-related donor liver transplantation for
ESLD secondary to Hepatitis C. His co-morbidities are: HIV controlled on antiviral therapy hepatorenal
syndrome autoimmune hemolytic anemia multiple joint deformities and difficult IV access due to
multiple cannulations. He tolerated the procedure well due to a delicately managed intraoperative
course. Post-operative course was complicated by the development of small liver syndrome respiratory
failure tacrolimus toxicity and AKI with hospital stay of 54 days. Patient was followed up for over 5-year
period at our institution and then discharged to local facility at his hometown.
Monday, October 14
1:00 PM - 2:30 PM
FA MC740
A Case of Unexplained Hypoxia
Helen Pappas, M.D., John Lawrence, M.D., University of Cincinnati, Cincinnati, OH
49-year-old female w/ Hx of Obesity GERD PUD and s/p Gastric Bypass w/revision presented with
feculent N/V and acute abdomen. BP90/67 HR 98 RR18 Sat 87% FM. Patient intubated L chest tube
arterial line and TLC placed. Ex lap performed. Patient developed hypotension hypoxia and large air leak
in circuit. Surgeons identified broncho-enteric fistula gastro-pleural fistula chronic intra-peritoneal
abscess with perforation of the gastric pouch and colonic soiling of the peritoneum. 7F bronchial blocker
placed in the L main bronchus which eliminated air leak and improved oxygenation. Transferred to SICU
w/BB and temporary closure where she expired 24hours later.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC741
Anesthesia for a 19 Week Pregnant Patient Requiring Orthotopic Liver Transplant Complicated by
Tachycardia
Raj Parekh, M.D., David Wax, M.D., ICAHN School of Medicine, New York, NY
Our patient was a 29-year-old 19 week pregnant female with a past medical history significant for
Grave's disease and two miscarriages who was sent to Mount Sinai Hospital by her primary care
physician after presenting with a six day history of epigastric pain nausea vomiting and jaundice. The
patient developed fulminant hepatic failure while hospitalized and underwent an orthotopic liver
transplant complicated by tachycardia during the hospitalization. Pt was extubated POD #1 and although
fetal heart rates immediately after surgery were within normal limits intrauterine fetal demise was
diagnosed the following day.
Monday, October 14
1:00 PM - 2:30 PM
FA MC742
Recognizing Partial Endotracheal Tube Obstruction With Normal Peak Airway Pressure
Bimal Patel, D.O., Robert Helfand, M.D., Cleveland Clinic Foundation, Cleveland, OH
36-year-old female with history of breast cancer presented for bilateral simple mastectomies with free
flap reconstruction under general anesthesia. The patient started to desaturate during emergence when
switched to spontaneous ventilation. Endotracheal tube suctioning and 100% FiO2 was unsuccessful and
patient was extubated. The tube was plugged with a thick mucus plug and patient was adequately mask
ventilated. In this situation a rise in peak airway pressure did not alert us in detecting partial ET tube
obstruction. We will go into the early recognition of this problem and available interventions for
management of ET tube obstruction.
Monday, October 14
1:00 PM - 2:30 PM
FA MC743
Respiratory Obstruction After Thyroid Surgery Plus a Flood
Neel Patel, Virginia Mason Medical Center, Seattle, WA
65-year-old female with thyroid papillary carcinoma causing left vocal cord paresis presented for a total
thyroidectomy. Upon extubation from thyroidectomy patient experienced respiratory failure requiring
immediate reintubation. During this time of respiratory failure the OR also began to flood with water
due to sprinkler damage in nearby OR.
Monday, October 14
1:00 PM - 2:30 PM
FA MC744
Unusual Complication Preventing Guidewire Removal in Veno-Venous Bypass Catheter Placement
Christopher Paul, M.D., Hui Yuan, M.D., Saint Louis University, St. Louis, MO
In preparation for a liver transplant a veno-venous bypass catheter placement was attempted using the
Seldinger technique. After placement of the catheter over the guidewire guidewire removal was
attempted. After difficulty with removal ultrasound images were obtained. The guidewire appeared to
be curled in on itself. It was decided to leave the guidewire in the catheter for the remainder of the case
and other access was obtained. After the end of the procedure a venous cut-down was performed. The
Copyright © 2013 American Society of Anesthesiologists
guidewire was then easily removed with the distal end of the wire in a knot-like shape. No complications
were noted.
Monday, October 14
1:00 PM - 2:30 PM
FA MC745
Trans-Orbital Tracheal Intubation of a Multiple Cancer Patient
Alicia Pearce, M.D., John Eichhorn, M.D., University of Kentucky College of Medicine, Lexington, KY
A 32-year-old F with her third cancer needed a full-mouth extraction prior to chemo-radiation therapy.
Retinoblastoma as infant s/p enucleation radiation. Osteosarcoma of maxilla age 13 s/p excision
radiation. New SCCA tongue. Orbit open directly to pharynx. Extensive radiation scars occluding nose
severely limiting jaw opening prevented usual intubation. Following thorough evaluation and
contingency planning (e.g. how to mask ventilate in emergency) awake intubation over a fiberoptic
bronchoscope passed through orbit into trachea was accomplished. This challenging unusual intubation
went smoothly and was fully documented photographically. Patient extubated next day. Case illustrates
a creative approach that is widely applicable.
Monday, October 14
1:00 PM - 2:30 PM
FA MC746
Lidocaine-Based Opioid Free Anesthesia for Robotic Surgery in a CAD Patient
Ana Cristina Pereira, M.D., Anna Lucia Rivoli, M.D., Renato Migon, M.D., Tania Carla Cortez, M.D., Paulo
Sergio Lavinas, M.D., NCI Brazil (INCA), Rio de Janeiro , Brazil
Minimally invasive procedures decrease injury response a especially important issue in CAD patients. We
report a non-opioid based protective approach that potentiates such benefit. Male 66 85kg ASA 3 NYHA
2 history of CAD submitted to robotic-assisted Hartman surgery. Induction with dexmedetomidine 80
mcg lidocaine 600 mg MgSO4 3g propofol 100 mg rocuronium 90 mg; maintenance included
dexmedetomidine 0.5 mcg/Kg/h lidocaine 1.5 mg/kg/h sevoflurane epinephrine 1-5 mcg/h.
Postoperative period was uneventful including adequate non-opioid pain control and deambulation on
day one. We conclude our lidocaine-based technique offered both cardiovascular protection and faster
GI recovery due to the high lidocaine doses.
Monday, October 14
1:00 PM - 2:30 PM
FA MC747
Lingular Tonsilar Hyperplasia and Difficult Awake Nasal Fiberoptic Intubation
Reid Phelps, M.D., Ph.D., Christopher Canlas, M.D., Vanderbilt University, Nashville, TN
Patient was a 64-year-old female with a history of difficult intubation who presented for excisional
biopsy of the base of the tongue. Our plan was for awake nasal fiberoptic intubation using
dexmedetomidine for sedation. Patient was successfully intubated however vocal cords were poorly
visualized. Biopsy demonstrated lingular tonsilar hyperplasia. Patient remained intubated
postoperatively. On postoperative day 5 the surgical team attempted extubation despite evidence of
persistent airway edema. Patient failed extubation with progressive dyspnea and stridor. ENT and
intensive care teams were unable to reintubate and she was taken to the operating room for emergent
tracheostomy.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC748
A Thousand Words: Examining the Utility of Photography in Clinical Practice
Steven Price, M.D., Jason Hoefling, M.D., Georgetown University Hospital, Washington, DC
A patient suffered an unavoidable perioperative dental injury to a tooth that was noted as very loose on
preoperative assessment. Photography was used to document the necrotic nature of the tooth after its
removal. This report examines the strategic use of digital photography in the practice of anesthesia.
When employed with mind to HIPAA rules and regulations it can be a cost-effective method to aid in
objectivity of potentially high-risk clinical findings improve anesthetic management and provide better
evidence to refute prospective mediolegal claims.
Monday, October 14
1:00 PM - 2:30 PM
FA MC749
Paying Attention to EtCO2 During Laparoscopic Surgery Leads to Prompt Treatment and Prevention of
a Possible Catastrophic Outcome
Dritan Prifti, M.D. CCF, Brenda Lewis, M.D.CCF, Cleveland, OH
48-year-old F with PMH of Morbid obesity GERD Hx of Gastric banding brought to OR for Laparoscopic
Roux en-Y. Induction and Intubation were uneventful. 15-20 minutes after incision time a sudden
decreasse in EtCO2 was noticed. Prompt evaluation and communication with surgical team confirmed a
bleed from inferior phrenic vein. Venous air embolism was suspected. Patient was stabilized. Procedure
was converted to open Laparotomy for management of Accute blood loss/hemorrhagic shock and
patient was transferred to SICU for hemodynamic support and mechanical ventilation. She was
successfully extubated the next morning and discharged home in few days.
Monday, October 14
1:00 PM - 2:30 PM
FA MC750
Not a Simple EGD. Anesthetic Challenges of an Aortoesophageal Fistula.
Aaron Primm, M.D., New York University, New York, NY
A 91-year-old male with a history of CAD dyslipidemia HTN afib multiple AAA and thoracic aortic
aneurysms with penetrating ulcers and ischemic colitis presented to urgent care with multiple episodes
of hemetemesis. CT chest angiography with contrast suggested an aortoesophageal fistula and the
patient was brought to the OR for EGD. An arterial line was placed before a modified rapid-sequence
induction with glidescope intubation. EGD revealed a large posterior linear clot with active oozing in the
mid esophagus with a pigmented protuberance suggestive of fistula. Patient remained intubated for
airway protection and brought to the PACU hemodynamically stable.
Monday, October 14
1:00 PM - 2:30 PM
FA MC751
Severe Restrictive Lung Disease Complicating Robotic-Assisted Laparoscopic Prostatectomy
Meghan Prin, M.D., Emily Vail, M.D., Ryan Ivie, M.D., Richard Raker, M.D., New York PresbyterianColumbia University, New York, NY
We report the case of a patient with morbid obesity coronary artery disease dyspnea on exertion and
prostate cancer who developed high peak inspiratory pressure a decline in tidal volumes hypercapnea
and hypoxemia following steep Trendelenburg position and pneumoperitoneum for robotic-assisted
Copyright © 2013 American Society of Anesthesiologists
laparoscopic prostatectomy. The pulmonary disturbances resolved only on desufflation and return to
supine position. The procedure was aborted. Subsequent cardiopulmonary testing revealed severe
restrictive lung disease severe obstructive sleep apnea and moderate aortic stenosis. An open
prostatectomy was recommended by the anesthesiologist and performed without pulmonary
complications.
Monday, October 14
1:00 PM - 2:30 PM
FA MC752
Postoperative Hemiplegic Migraine: A Possibly Frightening Prospect
Albin Quiko, Joseph Happel, M.D., Huy Phun, M.D., Amy Mortensen, M.D., Naval Medical Center San
Diego, San Diego, CA
We present a 36-year-old female who developed acute right sided total hemiparesis and hemi-sensory
loss after an uneventful general anesthetic for laparoscopic cholecystectomy. Subsequent diagnostic
studies were negative. The patient later endorsed a history of classic migraine headaches as well as an
aunt and grandmother who had occurrences of hemiparesis lasting 2-3 days. Complete resolution
occurred within 10 days and she was later diagnosed with familial hemiplegic migraines. Workup of
frightening perioperative neurologic deficits must be done in a systemic manner to include an in-depth
history and evaluation. This syndrome is not a simple diagnosis of exclusion.
Monday, October 14
1:00 PM - 2:30 PM
FA MC753
Airway and Anesthetic Management of Superior Vena Cava Syndrome
Shuo Rainosek, M.D., Jill Irby, M.D., UAMS, Little Rock, AR
A 51-year-old female with superior vena cava syndrome presented for percutaneous transluminal
angioplasty of the innominate vein for symptomatic relief. The patient's chronic neck edema was
complicated by acute stridor an inability to lay flat and vocal changes over the prior three days. Airway
exam revealed Mallampati II mouth opening 2 centimeters and severe neck edema. The airway was
anesthetized with a nebulized lidocaine updraft. Midazolam was given for sedation. Lidocaine and
phenylephrine were applied to the left nasal cavity and dilatation was performed with nasal trumpets.
Awake intubation was performed using flexible fiberoptic bronchoscope with a 6.5 ETT.
Monday, October 14
1:00 PM - 2:30 PM
FA MC754
Anesthetic Management for a Laryngeal Procedure in a Patient With Severe Posterior Glottic Stenosis
Ramesh Ramaiah, M.D., F.R.C.A, Elizabeth Hankinson, M.D., Sanjay Bhanaker, M.D., F.R.C.A, University
of Washington, Seattle, WA
A 41-year-old female with severe posterior glottic stenosis from prolonged intubation presented for
direct laryngoscopy and laser excision of scar tissue. CT scan showed the narrowest point of trachea to
be 6mm x 8mm at glottic area. Surgeon requested that the patient remain spontaneously breathing for
adequate surgical exposure. Patient was anesthetized with TIVA using low-dose propofol remifentanyl
and ketamine infusions supplemented with superior laryngeal nerve block. The surgery lasted two
hours. This anesthetic technique provided deep sedation adequate ventilation attenuation of
sympathetic reflexes with excellent surgical exposure and reduced the risk of airway fire.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC755
Pulmonary Hypertension and Steep Trendelenburg Position for Robotically Assisted Laparoscopic
Prostatectomy: Development of Hypoxemia and Right to Left Shunt
John Raytis, M.D., Michael Lew, M.D., City of Hope, Duarte, CA
A 73-year-old male with moderate pulmonary hypertension (PAP 55mmHg) presented for robotic
prostatectomy. Two hours into the procedure the patient's oxygen saturation decreased acutely to 90%.
After ruling out obvious causes for hypoxia an ABG was obtained on 100% FiO2 and showed
7.35/40/79/22 (A-a gradient 584mmHg) consistent with right-to-left intracardiac shunt. Desaturation
resolved on removal from the trendelenburg position. Right-to-left shunt is a known cause for
hypoxemia in non-surgical patients with pulmonary hypertension. In our case the development of the
right-to-left shunt occurred intraoperatively and was likely brought on by the physiologic changes
accompanying steep trendelenburg position and pneumoperitoneum.
Monday, October 14
1:00 PM - 2:30 PM
FA MC756
Challenges in the Management of a Mycotic Aneurysm of the Left Subclavian Artery
Katie Reding, M.D., Harendra Arora, M.D., Priya Kumar, M.D., Kasey Fiorini, M.D., University of North
Carolina, Chapel Hill, NC
We describe a rare presentation of a mycotic aneurysm involving the left subclavian artery and its
subsequent management that necessitated a collaborative team effort on the part of anesthesia
vascular surgeons and cardiothoracic surgeons. A 21-year-old male patient with history of IV drug abuse
presented with left elbow osteomyelitis two large brain abscesses and a left subclavian mycotic
aneurysm. A left carotid to subclavian artery bypass graft was performed by the surgeons using a trap
door approach. We will further discuss the anesthetic management that involved left lung isolation
intraoperative TEE significant resuscitation and multi-modal approach to pain management.
Monday, October 14
1:00 PM - 2:30 PM
FA MC757
Operative Management of Ongoing Myocardial Ischemia in the Urgent Setting
Stephanie Reed, Brian Rothman, Vanderbilt University Medical Center, Nashville, TN
A 58-year-old male with coronary artery disease and obesity presented after a motor vehicle collision for
operative intervention to prevent loss of limb. The patient had global ST depression on ECG elevated
cardiac enzymes and chest pain. Anti-platelet agents were contraindicated due to his traumatic injuries.
General anesthesia bore excessive risk so fracture fixation was performed under lumbar epidural.
Management included an awake arterial line large bore peripheral IV access and epinephrine for
hemodynamic support. Post-operatively inferior lead ST elevation and elevated cardiac enzymes were
observed. Diagnostic angiography revealed occlusion of two of six coronary artery bypass grafts.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
FA MC758
Patient With Refractory Portopulmonary Hypertension (PPH) for Liver Transplant
Keith Reid, M.D., Patrick McQuillan, M.D., Dmitri Bezinover, M.D., Penn State College of Medicine Milton
S. Hershey Medical Center, Hershey, PA
A 48-year-old male presented for deceased donor othotopic liver transplant due to hepatitis C and
alcohol abuse. His preoperative course was complicated by severe portopulmonary hypertansion
treated with epoprostenol and sildenafil. A first attempt at transplant was cancelled in the operating
room due to extremely high pulmonary pressures (PP) not responsive to maximal treatment. His
transplant was successfully performed 5 weeks later after aggressive preoperative medical management
and optimization of PP. The patient again developed high PP during surgery. This was effectively
managed with a combination of hyperventilation milrinone inhaled NO and IV nitroglycerine.
Monday, October 14
1:00 PM - 2:30 PM
FA MC759
Airway & Anesthetic Management of a Patient With Bannayan-Zonana Syndrome
Nicole Renaldi, D.O., Coleen Vernick, D.O., Thomas Jefferson University Hospital, Philadelphia, PA
Bannayan-Zonana syndrome is a rare genetic disease characterized by multiple benign tumors and
hemangiomas. Additional manifestations of the syndrome include macrocephaly neurologic disability
and phenotypic features including high palate pectus excavatum and hypotonia. Little literature exists as
to management of these patients especially in the context of the operating room. Described is a case of
successful airway and anesthetic management in a 21-year-old female with Bannayan-Zonana syndrome
with multiple cervical mediastinal and paratracheal masses mental retardation and other syndromic
features presenting for biopsy and debulking of nasopharyngeal mass.
Monday, October 14
1:00 PM - 2:30 PM
FA MC760
Anesthetic Management of a Patient With Hemoglobin Cheverly
Joseph Resti, M.D., Robert Krohner, D.O., University of Pittsburgh Medical Center, Pittsburgh, PA
A 34-year-old female presented for elective panniculectomy under general anesthesia. Her medical
history was significant for Hemoglobin Cheverly a disease with a variant hemoglobin molecule resulting
in hemolytic anemia and inaccurate pulse oximetry reading. Preoperative pulse oximetry showed a SpO2
of 78% on room air. An arterial cannula was placed prior to induction and blood gas analysis reflected a
SaO2 of 96% and a PaO2 of 94mmHg on room air. Frequent blood gas analysis was performed
throughout the surgery as well as close monitoring of mucosal surfaces for cyanosis. The patient had no
complications during the anesthetic and post-operatively.
Monday, October 14
1:00 PM - 2:30 PM
PD MC761
Ventilation Challenge in a Flap Tracheoplasty Infant: A Case Report
Goverdhan Puri, M.D., Ph.D., Sandip Rana, M.S., Rajarajan Ganesan, M.B. B.S., Postgraduate Institute of
Medical Education and Research, Chandigarh, India
A nine-month-old child with pulmonary vascular sling - complete tracheal ring complex involving almost
half of the trachea and the right bronchus presented with stridor. After pulmonary vascular correction
Copyright © 2013 American Society of Anesthesiologists
and pericardial flap tracheoplasty child developed flap malacia and dynamic obstruction with difficulty
to ventilate in spite of different inspiratory-expiratory ratios and was successfully managed with an ETT
modified to have a side hole placed such that the tube is in the right bronchus and the side hole
ventilates the left lung thus avoiding the need for endobronchial or external stenting while awaiting the
stabilisation of the flap
Monday, October 14
1:00 PM - 2:30 PM
PD MC762
Intraoperative Management of a Giant Sacrococcygeal Teratoma (GSCT) in a Preterm Infant With
Respiratory Distress Syndrome(RDS) Pulmonary Hypertension (PPHTN) and Consumptive
Coagulopathy With Thrombocytopenia and Neutropenia.
Meera Gangadharan, M.B. B.S., University of Texas Medical Branch at Galveston, Corpus Christi, TX,
Angelina Bhandari, M.D., Adolph Koska, M.D., Driscoll Childrens Hospital, Corpus Christi, TX
Patient is a 5-day-old male 28 weeks gestation. GCST had been antenatally diagnosed and the mother
had undergone amnio reduction with fetal transfusion 3 days prior to emergent c-section. The baby
weighed 1.5kg tumor weighed 1.2kg. Patient was intubated and placed on HFOV secondary to
pulmonary hypertension. Excision was undertaken when patient could be transitioned to a conventional
ventilator and nitric oxide had been discontinued. Estimated blood loss was 400ml. Baby received one
unit prbc 120ml FFP one unit platelets and 500ml Lactated Ringers intraoperatively. Epinephrine
0.1mcg/kg/min and nitroglycerine 0.5mcg/kg/min were started at the end of the case.
Monday, October 14
1:00 PM - 2:30 PM
PD MC763
Anesthetic Implications of a Patient With Alagille Syndrome
Giuliana Geng-Ramos, M.D., Madhavi Naik, M.D., University of Maryland Medical Center, Baltimore, MD
Alagille Syndrome is a congenital disorder characterized by paucity of the interlobular bile ducts with
chronic cholestasis leading to abnormalities involving cardiac hepatic renal facial and
neurodevelopmental systems. To achieve successful management of these patients it is prudent for
anesthesiologists to have a clear understanding of the associated anomalies and clinical implications.
We describe a case of an infant with AD presenting for bilateral inguinal hernia repair. She had
syndromic features of cholestasis multiple congenital cardiac anomalies dysplastic kidneys
thrombocytopenia and cleft palate. We discuss our anesthetic technique involving combined general
and epidural anesthesia with awake intubation for airway security.
Monday, October 14
1:00 PM - 2:30 PM
PD MC764
Loss of MEPS and SSEPS in a Teenager Undergoing Posterior Spinal Fusion: Challenges of a Wake-Up
Test
Giuseppe Giuratrabocchetta, M.D., Sonia Deshmukh, M.D., University of Florida, Gainesville, FL, Mario
Patino, M.D., Cincinnati Children's Hospital, Cincinnati, OH
14-year-old female with severe idiopathic scoliosis underwent posterior fusion. TIVA with propofol and
remifentanil. Left MEPs lost after rod placement. Rod realigned still 60-90% loss of left MEPs so rod was
removed. MAPs kept 60-70's with infusion of neosynephrine. Rod was replaced but still 90% loss of left
MEP with a change in right SSEPs. MAP then increased to 80's and blood transfused to Hct >30% no
Copyright © 2013 American Society of Anesthesiologists
improvement of MEP and SSEPs. It was proceeded with a wake up test. Patient followed commands and
moved all extremities. Reassurance to the pediatric patient was critical during the wake up test.
Monday, October 14
1:00 PM - 2:30 PM
PD MC765
The Princess and the Pea: Delayed Emergence in a Child With Mitochondrial Myopathy Congestive
Heart Failure and Pulmonary Hypertension
Lee Goeddel, M.D., M.P.H., Katherine Hoops, M.D., M.P.H., Brad Steenwyk, M.D., University of Alabama
at Birmingham, Birmingham, AL
2-year-old female with mitochondrial myopathy CHF RVH and Pulm HTN presents for right heart
catheterization. Exam demonstrates a well hydrated interactive child with a 3/6 harsh systolic murmur
at the left upper sternal border and diffuse hypotonia in all extremities. Induction with ketamine and
intubation were uneventful. Small propofol boluses and fentanyl 25ucg were given for maintenance. At
the end of the case the patient had delayed emergence. Exam suggested opioid induced respiratory
depression. The patient responded to narcan and was extubated but required additional narcan four
hours later on the floor though no further opioids were given.
Monday, October 14
1:00 PM - 2:30 PM
PD MC766
Perioperative Care for an Adolescent With a Massive Intra-thoracic Lesion During the Second
Trimester of Pregnancy
Omar Hajmurad, Amanda Brown, M.D., Mercer University School of Medicine, Macon, GA
14-year-old female with assumed recurrent reactive airway disease presents with progressive dyspnea
and new hemoptysis. Imaging reveals right lung mass (19.3 x 20.3 cm) bilateral pleural effusions
pericardial effusion and diaphragmatic inversion. Concurrent 26week gestational pregnancy also
identified. To expedite diagnosis lung biopsy planned with pediatric surgery obstetrics and
cardiothoracic surgery present. Anesthetic concerns included possible mediastinal compromise
ventilatory obstruction massive hemorrhage and fetal loss. Intra-operative challenges included
contralateral pneumo- and hemothorax with loss of ventilation and near code event. Pathology revealed
CLL. Cesarean proceeded days later due to further maternal compromise and to allow oncologic therapy
to commence.
Monday, October 14
1:00 PM - 2:30 PM
PD MC767
Anesthetic Considerations for Excision of Giant Occipital Meningoencephalocele in a Newborn
Keith Haller,D.O., Jinu Kim, M.D., Franco Resta Flarer, M.D., Jonathan Lesser, M.D., St. Lukes Roosevelt
Hopsital System, New York, NY
1-day-old male born at 34 weeks via cesarean section secondary to prenatal diagnosis of giant occipital
meningoencephalocele presents for resection and dural repair. Anesthesia was induced and the patient
was intubated in right lateral position using a Glidescope. Following intubation and transduction of the
UA tracing the patient was placed in the prone position with the head in a padded horseshoe. During the
resection the patient became bradycardic and hypotensive and was unresponsive to IV atropine.
Epinephrine boluses and infusion was required to maintain hemodynamics. Upon surgical completion
the patient was successfully extubated and returned to NICU in stable condition.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC768
Postoperative Management of Hyponatremia in a Symptomatic 6 Month Old
Matthew Hamilton, Humphrey Lam, M.D., Vanderbilt Medical Center, Nashville, TN
A 6-month-old female with a history of a non-functioning right kidney hemivagina and solitary left
kidney presented for a cystoscopy vaginoscopy and transurethral incision of her vagina septum. Her
intraoperative course was complicated by perforation of the posterior vaginal wall and administration of
hypotonic irrigation in the peritoneum. In the postoperative period the patient had seizures.
Hyponatremia in association with neurologic disease of the brain is a medical emergency. Early
identification and intervention of cerebral edema reverses most complications of hyponatremic
encephalopathy which is imperative as pre-pubertal children are more susceptible to brain damage from
hyponatremia than adults.
Monday, October 14
1:00 PM - 2:30 PM
PD MC769
Prolonged VA ECMO as a Bridge to Heart Transplant
Ryan Hamlin, M.D., Gregory Schears, M.D., Mayo Clinic - Rochester, Rochester, MN
We present a case of prolonged veno-arterial extracorporeal membrane oxygenation support as a
bridge to orthotopic heart transplant. The patient is 6-year-old male with complex congenital heart
disease (situs inversus mesocardia AV discordance large VSD double-outlet right ventricle) and
decompensated biventricular failure. The patient was placed on ECMO after a prolonged
cardiopulmonary resuscitation and remained on ECMO for 199 days until orthotopic heart
transplantation. His hospital course will be described as well as the challenges associated with
extracorporeal membrane oxygenation.
Monday, October 14
1:00 PM - 2:30 PM
PD MC770
Neonatal Pulmonary Thromboembolism- An Exceedingly Rare and Challenging Case
Dudley Hammon, M.D., Michael Sroka, M.D., Wake Forest University, Winston-Salem, NC
We present the case of a neonate with pulmonary thromboembolus scheduled for embolectomy on
cardiopulmonary bypass. A one-day-old 3.7 kg male born at 36.3 weeks gestation presented to the
neonatal ICU for hypoglycemia hyperbilirubinemia and presumed sepsis. Soon after admission the
patient developed respiratory distress and cardiovascular collapse secondary to a pulmonary
thromboembolus. After 30 minutes of resuscitation return of spontaneous circulation was achieved and
the patient was placed on ECMO. On day four of life the patient underwent urgent embolectomy on
cardiopulmonary bypass and was transitioned back to ECMO support. He was successfully decannulated
from ECMO on POD #3.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC771
Airway Management in a Pediatric Patient With a Supraglottic Mass
Ziyad Haque, D.O., Franco Resta-Flarer, M.D., Johnathan Lesser, M.D., Patricia Brous, M.D., St. Luke's
Roosevelt Hospital, New York, NY
Airway Management in a Pediatric Patient with a Supraglottic Mass 5-year-old female with history of
noisy breathing and frequent apneic/obstructive episodes during sleep after returning from camp s/p
T&A at outside hospital presents for evaluation of supraglottic mass. Pt. noted to have eosinophilia on
CBC all other labs WNL a hallmark of Kimura disease. Pt. intubated using video glidescope and
transported from MRI suite to OR for microlayrngoscopy supraglotoplasty and lymph node dissection.
Pt. kept intubated post op extubated POD#2 after positive leak test. Pathology showed lymphoid
hyperplasia.
Monday, October 14
1:00 PM - 2:30 PM
PD MC772
Dexmedetomidine and Ketamine Sedation for a Patient With Presumed Mitochondrial Disease and
Malignant Hyperthermia
Jarrett Heard, M.D., Wexner Medical Center at The Ohio State University Department of Anesthesiology,
Columbus, OH, David Martin, M.D., Joseph Tobias, M.D., Brian Schloss, M.D., Nationwide Children's
Hospital, Columbus, OH
A 20-year-old 59 kg male with a presumed mitochondrial disorder presented for outpatient dental
rehabilitation under anesthesia. Dexmedetomidine was administered as a loading dose of 1 µg/kg over
10 minutes followed by an infusion of 1 µg/kg/hour and the infusion was increased to 2 µ;g/kg/hour
along with ketamine (60 mg) and midazolam (4 mg)in divided doses for adequate sedation. The
procedure lasted approximately 2 hours and 15 minutes. An additional 140 mg of ketamine was
administered along with 100 µg of fentanyl for post-operative analgesia. The patient's vital signs
remained stable and spontaneous respirations were maintained without difficulty.
Monday, October 14
1:00 PM - 2:30 PM
PD MC773
Endotracheal Intubation of an Infant With Pierre-Robin Syndrome and a Known Difficult Airway
Jeffrey Herrold, M.D., Maine Medical Center, Portland, ME
We describe a process of providing general anesthesia requiring endotracheal intubation in an eighteen
month old infant with Pierre-Robin syndrome who presented for recurrent left cleft foot release with
tendon transfer. The patient had known micrognathia and difficult airway in the past. The patient was
brought to the operating room and underwent General Anesthesia via mask induction and placement of
an intravenous catheter. After intravenous access was obtained the patient was intubated using a
pediatric Glidescope video laryngoscope and the airway was secured prior to the beginning of the
surgery.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC774
Anesthetic Planning and Management of Conjoined Twins: One With Complex Congenital Heart
Disease: Undergoing Surgical Separation.
Scott Hines, M.D., Philip Bailey, D.O., Children's Hospital of Philadelphia, Philadelphia, PA
We present a case of surgical separation of thoraco-omphalopagus conjoined twins one with hypoplastic
left heart syndrome (HLHS). The twins underwent an extensive preoperative evaluation following a
period of nutritional support and growth. Prior to separation they required a number of surgical and
radiologic interventions each requiring requisite preparation team planning and appreciation of the
unique and intermingled physiology of the two infants. An overview is provided from the perspective of
anesthetic management of the conjoined twins focusing on the surgical separation with emphasis on
planning teamwork physiology and the added challenges of managing HLHS in this setting.
Monday, October 14
1:00 PM - 2:30 PM
PD MC775
Anesthetic Management in a Child With Familial Dysautonomia Undergoing Surgery
Jia Huang, M.D., NYU Medical Center, New York, NY
A 15-year-old male with familial dysautonomia presented to our institution for right orchiopexy under
GETA. He was admitted three hours prior to the procedure for preoperative fluid hydration. Intravenous
rapid sequence induction was smooth and airway was secured with a 6.0 mm ETT with a glidescope.
Intraoperatively patient's erratic hemodynamic changes were controlled with increasing the depth of
anesthesia as well as doses of diazepam. Postoperative course was relatively uneventful. Because this
disease affects virtually all organ systems patients with familial dysautonomia present numerous
challenges to the anesthesiologist. This case describes the specific anesthetic management to overcome
these challenges.
Monday, October 14
1:00 PM - 2:30 PM
PD MC776
The Anesthetic Management of a 13-year-old Female With Central Core Disease: Severe
Kyphoscoliosis and Restrictive Airway Disease
Hallie Huls, M.D., William R. Clarke, M.D., Medical College of Wisconsin, Milwaukeee, WI
A 13-year-old 28-kilogram girl with central core disease severe restrictive airway disease and
kyphoscoliosis presented for posterior spinal fusion. Preoperative testing showed an FEV1 32% and FVC
33% of predicted. She was induced using a non-triggering anesthetic followed by careful placement into
the prone position. Standard ASA NIRS and arterial monitors were used throughout the case. After
undergoing a successful anesthetic we transferred her to the PICU intubated and sedated. On postoperative day one she was extubated to continuous BiPAP. On day five she was weaned to her home
BiPAP settings and on day seven she was discharged home.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC777
Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) in a Pediatric Patient for
Laparoscopic Appendectomy
Zachary Jones, M.D., Tamara Norwood, M.D., UT Houston, Houston, TX
A 15-year-old male with a PMHx of Chronic Inflammatory Demyelinating Polyradiculoneuropathy
presented with acute appendicitis and was posted for a laparoscopic appendectomy. CIDP is
characterized by symmetrical weakness with large fiber sensory loss impaired balance/areflexia. It is
rare in children at 0.48 per 100 000. Diagnosis based on clinical presentation electrodiagnostic testing
elevated CSF protein and MRI. Steroids were given pre-op and intra-op. On induction we avoided
paralytics in favor of higher dose narcotics. Maintenance was isoflurane 1.6% and a remifentanil drip.
Muscle relaxation was adequate for laparoscopic appendectomy however strength remained intact and
patient was extubated in the OR.
Monday, October 14
1:00 PM - 2:30 PM
PD MC778
Total Anomalous Systemic Venous Connection - A Rare Cause of Cyanosis in a Child With ASD & VSD
Anita Joselyn, David Martin, M.D., Joseph Tobias, M.D., Nationwide Childrens Hospital, Columbus, OH,
Alistair Phillips, M.D., Cincinnati Childrens Hospital, Cincinnati, OH
Systemic venous return to the left atrium is known as total anomalous systemic venous connection
(TASVC). A 4-year-old boy presented for repair of an ASD and VSD. The initial SPO2 was 82% on room air.
The saturation did not improve despite the administration of an inspired oxygen concentration of 100%.
No change in the pulse oximeter value was noted when varying the FiO2. Intraoperatively it was found
that there was bilateral superior vena cava with the inferior vena cava in the midline. The anomaly was
successfully repaired on bypass. The patient's post-CPB PaO2 was greater than 500 mmHg.
Monday, October 14
1:00 PM - 2:30 PM
PD MC779
Perioperative Management of a Patient With Rett Syndrome
Hiromi Kako, M.D., David Martin, M.D., Richard Cartabuke, M.D., Joseph Tobias, M.D.,Nationwide
Children's Hospital, Columbus, OH
The patient was an 11-year-old 22.1 kilogram girl undergoing posterior spinal fusion for the treatment of
progressive scoliosis. Her past history was significant for Rett syndrome with a seizure disorder and
mental retardation; bronchomalacia and severe obstructive sleep apnea that required home bilevel
positive airway pressure at night; insulin-dependent diabetes mellitus; and a prolonged QT interval.
Preoperative physical examination revealed a cachectic girl with multiple joint contractures a
Mallampati III view with limited mouth opening moderate micrognathia and limited range of motion of
the neck. Perioperative management for the patients will be discussed and options for anesthetic care
presented.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC780
Inability to Ventilate at Lung Re-Inflation During Pulmonary Segmentectomy in an Infant: A Review of
the Challenges Associated With Single Lung Ventilation in Infants and Children
Brian Keech, M.D., The University of Colorado, Denver, CO
Single lung ventilation is highly desired by pediatric surgeons during more extensive pulmonary
resections. However options for achieving this in pediatrics are limited. Our case involved a healthy 11
month old presenting for pulmonary segmentectomy. Lung separation was successfully achieved via
fiberoptic intubation of the non-operative bronchus. Upon operative lung re-inflation we began
experiencing progressive ventilatory difficulty ultimately requiring emergent re-intubation as a result of
mucous plugging. This case illustrates that while lung separation can be reliably achieved in pediatrics
lung isolation can't potentially exposing the non-operative lung to blood secretions and contaminated
material at operative lung re-inflation.
Monday, October 14
1:00 PM - 2:30 PM
PD MC781
Perioperative Management of Partial Liver Resection for Metastatic Hepatocellular Carcinoma With
Doxorubicin-Induced Cardiomyopathy and Recent Cardiac Arrest
Christina Kendrick, M.D., Kai Schoenhage, M.D., Wallace Nogami, M.D., University of Arizona, Tucson, AZ
A 14-year-old girl with recently diagnosed metastatic hepatocellular carcinoma presented for right
hemihepatectomy. On pre-operative evaluation she was found to have an ejection fraction of 25-30%
likely secondary to doxorubicin. Upon induction of anesthesia with propofol the patient developed
ventricular tachycardia and became pulseless. She was successfully resuscitated and taken to the
intensive care unit. Upon evaluation no clear etiology for her cardiac arrest could be elucidated.
Echocardiogram and EKG were unchanged and CT of her chest was negative. Two weeks later the
patient was brought back to the operating room and successfully underwent resection of her liver mass.
Monday, October 14
1:00 PM - 2:30 PM
PD MC782
Mycobacterium Avium Complex Presenting as a Mediastinal Mass in an 8 Month Old Infant
Christina Kettelle, M.D., University of Arizona, Tucson, AZ
This patient is an 8-month-old girl who at age 6 months was initiated four-drug therapy for presumed
pulmonary mycobacterium tuberculosis. Her diagnosis was based on a positive PPD and a right middle
lobe infiltrate. She presented to our institution after 2 months treatment with a worsening cough. Her
cough was worse upon waking and when she was upset. She also experienced poor weight gain. Her CXR
revealed a large anterior mediastinal mass which had caused a near collapse of the right bronchus and
right middle lobe. Anesthesia was required for imaging and further diagnostic workup.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC783
Induction and Airway Management in an Infant With a Large Postcricoid Mass
Maseeha Khaleel, Blake Hyde, Jennifer Adams, M.D., University of Nebraska Medical Center, Omaha, NE,
Carol Lydiatt, M.D., Childrens Hospital of Omaha, Omaha, NE
A postcricoid cushion is a normal but rare anatomical variant seen in-young children. A large cushion is
rare and poses anesthetic complications. Cushions may engorge during agitation necessitating smooth
mask induction with spontaneous ventilation. Preparation for emergent intubation or a surgical airway
is required. After ablation or resection of the mass late postoperative swelling can occur and the need
for intubation or prolonged mechanical ventilation may be needed to protect the airway. In this abstract
we discuss a case report of an infant with a large postcrioid mass undergoing evaluation and a coblator
procedure to decrease the mass size.
Monday, October 14
1:00 PM - 2:30 PM
PD MC784
Anesthetic Management of a Child With Pulmonary Arteriovenous Malformation
Faiza Khan, Laura Moore, M.D., University of Arkansas for Medical Sciences, Little Rock, AR
Pulmonary arteriovenous malformations (AVM)are caused by anomalous communications between
pulmonary arteries and veins. These are mostly congenital in nature. They are usually diagnosed during
the work up for hypoxemia and pulmonary nodules. We present a case of an 11-year-old child with
Rendu Osler Weber syndrome presenting for embolisation of a symptomatic pulmonary AVM. He had a
family history of similar syndrome and symptoms. Anesthetic care involves understanding the
physiology of the shunt lesion along with managing the specific challenges of the pediatric patient.
Monday, October 14
1:00 PM - 2:30 PM
PD MC785
Neonate with Enlarged Neck Mass Diagnosed With Kasabach-Merritt Syndrome (KMS) - Perioperative
Anesthetic Management and Implications.
Sabina Khan, M.D., Nazish Hashmi, M.D., M.Saif Siddiqui, M.D., University of Arkansas for Medical
Sciences, Little Rock, AR
A 40 week Caucasian male was noted to have a large right neck mass at birth. It measured 5.4 x 4.5 cm
on CT scan extending into the infratemporal fossa with compression effects. Labs demonstrated anemia
and thrombocytopenia with coagulopathy. Diagnosis of KMS was established. Anesthesia service was
consulted on 24th day of birth for definitive airway access due to concerns of impending airway
compromise. Patient was successfully intubated and handed over back to the NICU team for further
management.
Monday, October 14
1:00 PM - 2:30 PM
PD MC786
Anesthetic Challenges in a Patient With Prader-Willi Syndrome and Upper Respiratory Infection for
Adenotonsillectomy: Intraoperative Pulmonary Hypertensive Crisis
Sarah Khan, M.D., Joseph Tobias, M.D., Nationwide Childrens Hospital, Columbus, OH
A 6-year-old with a BMI of 40 URI severe OSA asthma Prader-Willi syndrome increased RV pressures and
ASD presented for adenotonsillectomy. Despite the high anesthetic risk her condition was felt unlikely to
Copyright © 2013 American Society of Anesthesiologists
improve. Toward the end of the case copious secretions were noticed in the endotracheal tube and
there was profound bronchospasm. Simultaneously blood pressure was unattainable with a sudden
decrease of the end-tidal CO2. Epinephrine boluses were administered an arterial cannula placed and a
milrinone infusion started. Oxygen saturation remained in the 90's. Once stabilized she was transported
to the PICU and extubated the next day to a BIPAP.
Monday, October 14
1:00 PM - 2:30 PM
PD MC787
Anesthetic implications of a Premature Infant With Pulmonary Interstitial Emphysema - Mainstem
intubation With a Cause
Ashish Khanna, M.D., Tara Hata, M.D., Cleveland Clinic Foundation, Cleveland, OH
A 7-week (34 weeks PCA) infant with severe left sided Pulmonary Interstitial Emphysema presented for
an endotracheal tube exchange & rigid bronchoscopy. Extensive cystic changes of the left upper lobe
with significant mediastinal shift and lack of aeration of the right upper lobe were noted on radiology. As
a part of a lung protective ventilation strategy oxygenation was maintained using a selective right main
stem intubation. Anesthetic challenges included amongst others maintenance of spontaneous
ventilation with intermittent apnea avoidance of positive pressure ventilation with mask (danger of
mediastinal shift) apnea of prematurity & right upper lobe atelectasis with impaired oxygenation.
Monday, October 14
1:00 PM - 2:30 PM
PD MC788
Congenital Long QT Syndrome Was Unmasked by Accidentally Injected Epinephrine With Local
Anesthetics Into Vein.
Hae Kyu Kim, Hyeon Jeong Lee, Won Sung Kim, Eun Soo Kim , Pusan National University Hospital, Busan,
Republic of Korea
A 4-year-old female patient with normal ECG was scheduled for correction of velopharyngeal
dysfunction. For hemostasis and clear local field 1% lidocaine with epinephrine (1:100000) was injected
in soft palate and posterior of pharynx. At that time BP increased from 100/60 to 150/70 mmHg and HR
rose from 113 to 175 bpm. Tachyarrhythmia was detected and esmolol was injected intravenously. After
transfer to ICU pulmonary edema and ECG detected prolong QT (QTc 556 ms) were checked so she was
tested in pediatrics and the result was congenital long QT syndrome.
Monday, October 14
1:00 PM - 2:30 PM
PD MC789
Frequent and Profound Anoxic Spell in Palliated TOF Infant During Thoracoscopic Thymus Cyst
Removal
Sang-Wook Shin, M.D., Hyae-Jin Kim, Seung-Hoon Baek, Eun-Jung Kim, Hee-young Kim, Pusan Nat'l Univ
Hosp Anes & Pain Med, Yangsan-si, Republic of Korea
A 3-month-old female baby was scheduled for thoracoscopic thymus cyst removal. She previously had
palliative balloon valvuloplasty for tetralogy of Fallot (TOF). She had been well after the procedure and
determined to be lower risk for thymus cyst removal before correction of TOF by consultation with
cardiologist and surgeon. During the operation frequent and profound hypoxic spell occurred despite
appropriate management CO2 retention was not improved. After surgery she was sent to intensive care
unit. Frequent spell occurred in ICU. We found peripheral IV access was not functioning. Central line was
kept she became stable gradually.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
1:00 PM - 2:30 PM
PD MC790
Anesthetic Concerns for a Patient With Ebstein's Anomaly and Pectus Excavatum
Scott Klier, D.O., Jani Jai, M.D., N. Nick Knezevic, M.D., Caroline Ryan, M.D., Advocate Illinois Masonic
Medical Center, Chicago, IL
We present the case of a four-year-old male undergoing bilateral myringotomy tube placement. Review
of symptoms was positive for progressive exertional dyspnea and patient was noted to have severe
pectus excavatum as well as a systolic murmur on physical exam. The patient's mother was unable to
give any additional information on the child's medical condition with the exception of a history or
repaired congenital diaphragmatic hernia. Further chart review revealed the patient had a known but
untreated diagnosis of Ebstein's anomaly. The case was postponed to allow for a more thorough cardiac
evaluation and patient optimization.
Monday, October 14
1:00 PM - 2:30 PM
PD MC791
Tetralogy of Fallot With Congenital Diaphragmatic Hernia and Left Lung Agenesis
Kristen Labovsky, M.D., John Scott, M.D., Children's Hospital of Wisconsin, Milwaukee, WI
A five-day-old female presented for repair of antenatal diagnosed congenital diaphragmatic hernia. An
echocardiogram shortly after birth also revealed Tetralogy of Fallot and complete AV canal defect and a
left pulmonary artery that was not visualized. Upon direct visualization during repair of the
diaphragmatic hernia no left lung was identified. The repair was completed successfully and left lung
agenesis was confirmed with CT angio that showed absence of a left pulmonary artery. The patient
subsequently underwent placement of a central shunt on day 13 of life.
Monday, October 14
1:00 PM - 2:30 PM
PD MC792
A Neonate With Multiple Congenital Airway and Neurologic Abnormalities Causing Severe Respiratory
Distress - Does this Strike a (noto) Chord?
Susan Taylor, M.D., Kristen Labovsky, M.D., Children's Hospital of Wisconsin, Milwaukee, WI
An eight-day-old neonate presented for evaluation of multiple airway anomalies including Pierre Robin
sequence and a multilobulated mass of the palate and surgical repair of esophageal duplication cyst.
Progressive airway obstruction occurred when moved from the right lateral decubitus position to supine
for MRI. A 3.0 uncuffed endotracheal tube functioned as a nasopharyngeal airway for diagnostics and
prior to surgery. Additional anomalies included an esophageal duplication cyst and anterior defects of
the cervical and thoracic vertebral bodies. A meningocele at the craniocervical junction protruded
anteriorly contributing to the neonate's upper airway obstruction.
Copyright © 2013 American Society of Anesthesiologists
MCC Session Number – MCC12
Monday, October 14
3:00 PM - 4:30 PM
CA MC793
Re-Do OPCAB in Jehovah's Witness With ESRD
Kara Siegrist, M.D., Robert Deegan, M.D., Ph.D., Vanderbilt University, Nashville, TN
68-year-old Caucasian male who presented for repeat off pump coronary artery re-vascularization. Case
was complicated by patient's history of ESRD on HD anemia secondary to chronic kidney disease and
platelet dysfunction secondary to uremia. The patient was a Jehovah's witness and refused blood
products including those that may be life saving.
Monday, October 14
3:00 PM - 4:30 PM
CA MC794
Re-Do Off Pump Coronary Artery Bypass in Jehovah's Witness With End Stage Renal Disease
Kara Siegrist, M.D., Robert Deegan, M.D., Ph.D., Vanderbilt University Medical Center, Nashville, TN
A 68-year-old Jehovah's Witness presented for coronary revascularization. He had multiplerisk factors
for bleeding: previous sternotomy (CABG) hemodialysis-dependent endstage renal disease and heparininduced thrombocytopenia. Surgery was postponed to ensure HIT-antibody negativity and resolution of
anemia with erythropoietin treatment. The patient came to surgery with a Hct of 43. An OPCAB was
performed with aminocaproic acid and DDAVP. Blood loss was 250cc with 150cc returned to patient via
closed-loop cell-saver. Post-op a closed loop connection allowed chest-tube output to be returned to
the patient. Hct remained >36% throughout hospital stay.
Monday, October 14
3:00 PM - 4:30 PM
CA MC795
Anesthetic Management of a Patient With Severe Constrictive Pericarditis which Required Emergent
Cardiopulmonary Bypass
Yoshihisa Morita, M.D., Koichi Nomoto, Mount Sinai School of Medicine, New York, NY
29-year-old male with history of suspicious tuberculosis underwent pericardiectomy for constrictive
pericarditis involving all four cardiac chambers. Right atrium (RA) was exposed in case of urgent
cardiopulmonary bypass (CPB). Subsequently he was emergently placed on CPB when several RA holes
were accidentally made to free RA from adhesions. After weaning from CPB TEE revealed severe
biventricular dysfunction requiring multiple inotropic supports. He became severely coagulopathic
requiring multiple surgical packings and massive transfusion. Our case illustrates the importance to
prepare for the massive bleeding before and after CPB for cardiac surgeries.
Monday, October 14
3:00 PM - 4:30 PM
CA MC796
Atrioesophageal Fistula After Percutaneous Radiofrequency Ablation for Atrial Fibrillation
Jayanta Mukherji, Lisa Solomon, M.D., Ricky Shah, M.D., Loyola University Medical Center, Maywood, IL
Atrioesophageal fistula (AEF) following RF ablation carries an extremely high mortality. Decreased
awareness delayed diagnosis have resulted in increased mortality. 59-year-old male who underwent RF
ablation one month prior presented with fever bacteremia.and cerebral embolic infarcts. Imaging
Copyright © 2013 American Society of Anesthesiologists
studies were unhelpful. Based on clinical suspicion he underwent surgical repair of AEF.. The case
highlights a life-threatening delayed complication following AEF which necessitates prompt diagnosis
and management. Multiple risk factors incriminated include RF catheter size power settings atrial
anatomic sites. Anesthesiologists should insist on esophageal temperature monitoring as intraluminal
esophageal temperature > 41 C can predispose to this complication.
Monday, October 14
3:00 PM - 4:30 PM
CA MC797
Previous Heparin-Induced Thrombocytopenia Does Not Preclude Heparin Anticoagulation
Sagar Mungekar, M.D., Enrique Pantin, M.D., Robert Wood Johnson UMDNJ, New Brunswick, NJ
A 56-year-old woman with severe mitral valve stenosis presented for valve replacement. Preoperatively
her platelet count was below 100x10^9/L. Her past medical history was significant for heparin-induced
thrombocytopenia (HIT) systemic lupus erythematosus and end-stage renal disease. Given the
irreversibility of heparin alternatives a multidisciplinary decision was made to use heparin during
extracorporeal circulation avoiding it before and immediately after. Postoperatively the patient's
thrombocytopenia did not worsen; nor did she suffer any thrombotic events. We discuss the decision
tree for choosing an anticoagulation regimen for patients with HIT and illustrate that with careful
management heparin can still be safely administered.
Monday, October 14
3:00 PM - 4:30 PM
CA MC798
Elevated Airway Pressures and Inability to Ventilate on Cardiopulmonary Bypass During Aortic Valve
Replacement Surgery
Anand Nagori, M.D., Peter Neuburger, M.D., New York University, New York, NY
50-year-old female with history of hypertension hypothyroidism and childhood asthma underwent
aortic valve replacement for aortic stenosis. Prior to coming off cardiopumonary bypass patient was
difficult to ventilate. She was oxygenating well via bypass machine but attaining tidal volumes of 180 ml
with peak airway pressures of 40 mm Hg. Fiberoptic bronchoscope was used to confirm tube placement
and rule out mucus plugs. Epinephrine drip started intravenously and isoflurane was added via bypass
machine. Albuterol 100 mg hydrocortisone and 30 mg ketamine were given for bronchodilation. Tidal
volumes returned to 400 ml with peak pressures of 17 mm Hg.
Monday, October 14
3:00 PM - 4:30 PM
CA MC799
Anesthetic Management of Tricuspid Valve Replacement in a Patient With Metastatic Carcinoid
Syndrome
Faiz Nasser, M.D., Sean Summers, M.D., Benjamin Stam, B.S., Pramod Chetty, M.D., University of
Oklahoma, Oklahoma City, OK
Patients with metastatic carcinoid syndrome and carcinoid heart disease pose challenges to the
anesthesiologist. Carcinoid crisis and low cardiac output states are of special concern. Octreotide has
been used to prevent carcinoid crisis. We present a case of a 53-year-old male with metastatic carcinoid
syndrome who underwent a tricuspid valve replacement for severe tricuspid regurgitation. Using a
higher dose of octreotide than has been traditionally described in the literature along with
intraoperative echocardiography and a balanced general anesthetic we were able to provide an
Copyright © 2013 American Society of Anesthesiologists
anesthetic experience free of carcinoid crisis or cardiac decompensation with successful separation from
cardiopulmonary bypass.
Monday, October 14
3:00 PM - 4:30 PM
CA MC800
Ruptured Sinus of Valsalva Aneurysm in a 52-year-old Patient
Thienkim (Kim) Ngo, M.D., Jae Park, M.D., University of Southern California, Los Angeles, CA
Sinus of Valsalva aneurysms (SVAs) are rare anomalies that are usually congenital more frequent in men
or acquired. We describe a case of ruptured SVA in a previously healthy 52-year-old man with sudden
chest pain. Transthoracic echocardiogram identified the ruptured SVA from the noncoronary sinus into
the right atrium (RA) and severe tricuspid regurgitation (TR). Using transesophageal echocardiogram we
demonstrated the TR to be multidirectional flow from the aorta into the RA. The tricuspid and aortic
valves were normal. The SVA was successfully repaired with primary suture closures and
cardiopulmonary bypass was discontinued without inotropic or vasopressor support.
Monday, October 14
3:00 PM - 4:30 PM
CA MC801
Difficulty Weaning Off Cardiopulmonary Bypass: Role of Diabetic Cardiomyopathy
Thomas Nguyen, M.D., Ahmed Zaky, M.D., M.P.H., University of Washington, Seattle, WA
A 51-year-old male with a history of type I diabetes hypothyroidism obesity hypertension and smoking
was taken to the OR for three-vessel CABG. Despite a preoperative EF>60% and successful
revascularization he required high-dose pharmacologic inotropy intra-aortic balloon pump and LVAD to
wean off cardiopulmonary bypass. Intraoperative echocardiography showed significant abnormality
ofMyocardial motion in the longitudinal axis that was characteristic of diabetic cardiomyopathy.
Postoperatively in the ICU hisMyocardial function continued to deteriorate. Ultimately he was moved to
comfort care. In diabetics how well the myocardium functions longitudinally may be a better predictor
than ejection fraction of survival following revascularization.
Monday, October 14
3:00 PM - 4:30 PM
CA MC802
Management of Anticoagulation and Vascular Access for Cardiovascular Surgery in a Patient With
Heparin Induced Thrombocytopenia
Alexandria Nickless, D.O., Elizabeth Sinz, M.D., Penn State Hershey Medical Center, Hershey, PA
Heparin induced thrombocytopenia (HIT) is a rare but serious complication associated with the
administration of heparin. Patients with this disorder experience an immune-mediated reaction
ultimately leading to platelet aggregation and thromboembolic events. When anticoagulation is
required usually for cardiovascular surgery alternative therapies must be used. A 57-year-old female
with history of HIT vasculopathy end stage renal disease requiring hemodialysis and multiple
thromboses presented with sepsis from infected subclavian bypass graft. This case presents the
complicated management of a patient with difficult vascular access requiring anticoagulation for
carotid-subclavian bypass.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC803
Failure to Deflate the Bronchial Blocker
Stavroula Nikolaidis, M.D., Ali Hassanpour, M.D., Temple University School of Medicine, Philadelphia, PA
Left lung isolation was achieved with placement of a Uniblocker in the left main stem bronchus with
fiberoptic guidance. Upon surgeon's request attempt to deflate the blocker and reinflate the lung failed:
lung still atelectatic after usual aspiration of the pilot balloon till flat. Bronchoscopy confirmed that the
blocker stayed inflated obstructing the entry to the left main stem bronchus. How can we safely remove
this blocker? How can we reinflate when placement of a new may not be quick easy or available.
Monday, October 14
3:00 PM - 4:30 PM
CA MC804
Cold Antibody in a Patient With Acute Type A Aortic Dissection Requiring Emergent Repair With
Circulatory Arrest
Stavroula Nikolaidis, M.D., Amol Patel, M.D., Temple University School of Medicine, Philadelphia, PA
A 70-year-old female with history of diabetes and hypertension presented to the operating room for
emergent repair of acute type A aortic dissection requiring circulatory arrest. Shortly after induction of
anesthesia the blood bank notified us that they could not release blood because the patient was positive
for a yet unidentified antibody. Suspicion was high for presence of cold antibody. The risks of hemolysis
at low temperature antibody identification thermal amplitude time to blood availability were unknown
yet. Should we wait for antibody identification and specific advice or proceed with emergent release of
blood and cool circulatory arrest?
Monday, October 14
3:00 PM - 4:30 PM
CA MC805
Perioperative Treatment of a Man Receiving a Left Lung Transplant Combined With Coronary
Revascularization Without Use of Extracorporeal Circulation
Beatriz Nistal Nuno, M.D., Cesar Bonome Gonzalez, M.D., Ph.D., Complexo Hospitalario Universitario A
Coruna, A Coruna, Spain
Patients with significant coronary artery disease (CAD) were once traditionally rejected as candidates for
lung transplants (LT) because of higher risk of morbidity and mortality. We report the case of a man who
received a left LT and coronary revascularization without extracorporeal circulation (ECC) in a combined
procedure after being diagnosed with significant CAD during the preoperative study for acceptance as a
candidate for LT. We review the history of such combination procedures and discuss advantages of
performing surgery without ECC. To our knowledge this is the first report of a combined procedure that
took place in a Spanish hospital.
Monday, October 14
3:00 PM - 4:30 PM
CA MC806
A Unique Case of Bronchial Blocker Placement
Gary Okum, M.D., Gregory Simmons,M.D., Drexel University College of Medicine, Philadelphia, PA
New techniques and equipment for video assisted thoracic surgery enable the accomplishment of a
broadening range of surgical procedures with less blood loss and postoperative pain than with classical
thoracotomy. However the limited workspace available mandates separation of the lungs and renders
Copyright © 2013 American Society of Anesthesiologists
impractical the classically taught techniques for avoiding hypoxemia (particularly CPAP to the nonventilated lung). We report a challenging case of lung separation in a woman with a small stoma from
previous tracheostomy in whom a small glottic opening had rendered futile the placement of both a
double lumen tube and a size 7.0 single lumen tube.
Monday, October 14
3:00 PM - 4:30 PM
CA MC807
A Unique Case of Bleeding From the Pulmonary Artery Catheter Oximetry Connection Port
Raja Palvadi, M.D., Raj Singh, M.D., Suman Rajagopalan, M.D., Baylor College of Medicine, Houston, TX
Pulmonary artery catheters (PAC) malfunctions are rare and may pose a threat to patient safety. We
present a case of a 57-year-old patient who underwent open repair of coarctation of aorta and
pseudoaneurysm of the aorta. After the placement of the PAC cardiac output readings could not be
obtained and fresh blood was noted to ooze from the oximetry optical module. The PAC was replaced
without any complications. No external defects/tears were noted on close examination of the removed
PAC. Further testing by Edward lifesciences revealed a tear in the webbing of the catheter which was
due to manufacturing defect.
Monday, October 14
3:00 PM - 4:30 PM
CA MC808
Successful Use of Nitroglycerine Through the Pulmonary Artery Catheter PA Port to Treat Severe
Pulmonary Hypertension
Raja Palvadi, Khodadad Namiranian, M.D., Suman Rajagopalan, M.D., Baylor College of Medicine,
Houston, TX
Nitric oxide inhaled nitroglycerine inhaled milrinone and inhaled prostacyclins have been used to
produce selective pulmonary vasodilatation. We report the successful use of nitroglycerine infused
directly into the pulmonary artery through the pulmonary artery catheter to treat severe pulmonary
hypertension. A 24-year-old male underwent emergent surgery with cardiopulmonary bypass to remove
the dislodged Amplatzer device and repair of the ASD with pericardial patch. While attempting to wean
from the CPB pump high pulmonary artery pressures were noted. Nitroglycerine was infused through
the PAC which decreased the pulmonary artery pressure and facilitated the weaning from the pump.
Monday, October 14
3:00 PM - 4:30 PM
CA MC809
RVAD Placement for RV Rupture During Redo Sternotomy
David Parisian, M.D., Joseph Goldstein, M.D., Dustin Hegland, M.D., Malcom Randall VAMC /University
of Florida, Gainesville, FL
66-year-old male with CAD s/p 3V CABG and HTN presents for redo-sternotomy for AV repair for severe
AS. During mediastinal dissection RV sustains a 3cm laceration and patient undergoes urgent fem-fem
bypass. RV is repaired with pericardial patch and AV replaced. Patient is unable to separate from CPB
with Inotropes and IABP; and TEE reveals poor RV contractility with large hematoma and hyper-dynamic
LV. During separation attempts RA distends and CVP rises from 20 to 45. RVAD placement enables
separation from CPB and coagulopathy from 11hr CPB run is corrected. RVAD is removed on POD #4
with improved RV contractility.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC810
To Bleed or Not To Bleed: An Alternative Approach to Intraoperative Management of Von Willebrand
Disease During Mitral Valve Repair
Roshan Patel, M.D., Seema Deshpande, M.B. B.S ., Caron Hong, M.D., M.S., University of Maryland,
Baltimore, MD
A 68-year-old male with Type1 von Willebrand disease underwent mitral valve repair for mitral
regurgitation. Conventional guidelines recommend administration of DDAVP peri-operatively. However
there have been instances of successful intra-operative management with von Willebrand factor
concentrate when there is concern for variable severity of disease. Furthermore since decreased factor
levels are a known cause of coagulopathy after cardiopulmonary bypass our goal was to minimize
hemorrhagic complications in this high risk patient. The patient received 40-60IU of Humate-P after
cardiopulmonary bypass and was transferred to ICU in stable condition. He required no additional blood
products and was discharged home POD6.
Monday, October 14
3:00 PM - 4:30 PM
CA MC811
Pacemaker Failure During Anesthesia for Epicardial Lead Change in a Patient With Twiddler's
Syndrome
Stacy Peterson, M.D., Susan Taylor, M.D., Kristen Labovsky, M.D., Children's Hospital of Wisconsin,
Milwaukee, WI
A four-year-old male with Tetrology of Fallot pulmonary atresia and aortopulmonary collaterals suffered
complete heart block following repair in infancy necessitating permanent pacemaker placement. The
patient was diagnosed with Twiddler's syndrome 16 months prior to admission for repair of pacemaker
leads. Recent interrogation demonstrated high impedance and the pacemaker was reprogrammed to
generate maximum output. He had been asymptomatic and active during periods of pacemaker failure
despite an idioventricular rhythm of 40. Following induction of anesthesia pacemaker failure to capture
resulted in periods of asystole. A temporary transvenous pacemaker was placed.
Monday, October 14
3:00 PM - 4:30 PM
CA MC812
Resection of Posterior Mediastinal Mass Encompassing the Left Atria
Phung Pham, M.D., Edward Gologorsky, M.D., Jackson Memorial Hospital, Miami, FL
19-year-old male with severe elevations in blood pressure and headaches. CT showed a subcarinal mass.
He was medically optimized prior to surgery. The initial operation was an exploratory thoracotomy with
planned resection. This surgery was subsequently abandoned as our intraoperative TEE showed that the
mass encompassed the left atria. A second operation was planned with cardiac bypass. The surgeons
were able to dissect a paragangliomia measuring 4 cm by 3cm. This case demonstrates the challenges of
the perioperative management of neuroendocrine secreting mass and the challenge of an on-pump
dissection of mass encompassing the left atria.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC813
Complex Mycotic Ascending Aortic Pseudoaneurysm Repair Complicated by Surgical Bleeding
Biventricular Failure and Significant Post Bypass Coagulopathy
Christine Piascik, M.D., Lavinia Kolarczyk, M.D., University Of North Carolina, Chapel Hill, NC
Eight weeks after central V-A ECMO cannulation (and subsequent decannulation) for acute biventricular
failure after CABG a 73-year-old male was incidentally found to have a large ascending aortic
pseudoaneurysm (8 cm x 6.8 cm). Perioperative planning focused on risk of massive hemorrhage during
complex revision sternotomy. Despite attempts to decompress the aneurysm by initiating axillaryfemoral cardiopulmonary bypass prior to sternotomy the aneurysm sac was inadvertently entered.
Pump-sucker bypass provided short term stability until hypothermic circulatory arrest could be safely
achieved. Post bypass course was complicated by biventricular failure and significant coagulopathy.
Monday, October 14
3:00 PM - 4:30 PM
CA MC814
Incidental Finding of Mitral Stenosis in a Patient Having Non-Cardiac Surgery
Charles Poppell, M.D., Al San Juan, M.D., David Ruffin, M.D., Tripler Army Medical Center, Honolulu, HI
48-year-old Marshallese female with stage IV endometrial cancer was transferred for chemotherapy and
en bloc resection of a large abdominal tumor. Her tumor burden caused large bowel obstruction and
severe disability. Her course was complicated by incidental finding of severe mitral stenosis (mean
gradient 25mmHg) and pulmonary hypertension (PASP 70-75mmHg). Percutaneous balloon
valvuloplasty was complicated by atrial perforation and tamponade which required emergent
sternotomy. Two weeks later a second balloon valvuloplasty was successful. Subsequently an
exploratory laparotomy under combined general and epidural anesthesia proceeded without incident.
This case illustrates the challenges of cardiac patients presenting for non-cardiac surgery.
Monday, October 14
3:00 PM - 4:30 PM
CA MC815
Catastrophic Intraoperative 3 Vessel Thrombosis
Michael Queen, M.D., Baylor College of Medicine, Houston, TX, Bina Dara, M.D., Michael E. DeBakey VA
Medical Center, Houston, TX
A 61-year-old man with a history of mesothelioma and nonobstructive CAD was scheduled for left
pneumonectomy. Two hours into the procedure the patient presented with intraoperative STEMI and
cardiogenic shock. TEE confirmed severe wall motion abnormalities. The patient required large doses of
pressors and cardiac massage. The surgery was aborted and following coronary angiogram the patient
was transferred to the cardiac catheterization lab for an emergency multivessel PCI with bare metal
stenting of the LAD LCX and RCA. These vessels were in spasm and contained thrombi. The patient was
transferred to SICU on IABP and Abciximab.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC816
Neonate with Heterotaxy Transposition of Great Vessels TAPVR VSD Situs Inversus and Biliary Atresiafor Kasai Procedure
Muhammad Rafique, M.D., Nazire Ozcelik, M.D., University of Texas Medical School at Houston,
Houston, TX
3-week-old 3.8 kg child with complex congenital cardiac lesion presented for Kasai procedure. His
diagnosis included Hetrotaxy TGA TAPVR VSD and common atrium. Also he had abdominal situs
inversus and biliary atresia. His room air SpO2 was 90's.We used standard ASA monitors arterial line and
CVP monitoring. We administered general endotracheal tube anesthesia with balanced technique i.e
isoflurane rocuronium and fentanyl. Regional techniques avoided due to coagulopathy. Patient lost 120
ml blood and received 60 ml PRBCs 50 ml FFP and 100 ml crystalloid during the surgery. Patient was
successfully extubated at the end of surgery.
Monday, October 14
3:00 PM - 4:30 PM
CA MC817
Unusual Presentation of Hypoxia During Radiofrequency Ablation for Atrial Fibrillation
Saima Rashid, M.D., Insung Chung, M.D., Mount Sinai Medical Center, New York, NY
A patient with atrial fibrillation presents for intracardiac radiofrequency ablation under general endotracheal anesthesia. The patient became progressively hypoxic requiring recruitment maneuvers and
100% FiO2. An expanding pericardial effusion was noted on intracardiac echocardiography with
increased vasopressor requirement. A percutaneous drain was placed in the pericardial space and
continuous aspiration improved hemodynamics. An arterial catheter and large bore IV were inserted
and blood products ordered. Blood was observed in the endotracheal tube. Fiberoptic bronchoscopy
revealed bronchial bleeding which was treated with endotracheal epinephrine flushes and increased
PEEP. A central line was inserted. Emergent exploratory mediansternotomy revealed a pulmonary artery
perforation.
Monday, October 14
3:00 PM - 4:30 PM
CA MC818
High LVOT Gradient With Dobutamine After Septal Myomectomy
Pingle Reddy, M.D., Sarah Armour, M.D., Derek Williams, M.D., Derek Brinster, M.D., Virginia
Commonwealth University Medical Center, Richmond, VA
31-year-old male presented for septal myomectomy . His preoperative resting gradient was 34 mm Hg
and peak gradient was 53 mm Hg. Following septal myomectomy patient was started on Dobutamine to
elicit a gradient in the LVOT. Post resection peak gradient was determined to be 64 mm Hg. Tthe patient
was also noted to have SAM of the AML. Dobutamine was stopped and the mean and peak gradients
were determined to be 7 and 15 mm Hg respectively. This elicits the importance of determining LVOT
gradients post induction under anesthesia and prior to septal myomectomy.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC819
Intraoperative TEE to Assess Repair of Sinus Venosus Atrial Septal Defect Associated With Anamalous
Drainage of Right Pulmonary Vein to Superior Vena Cava
Pingle Reddy, Ned Hembree, M.D., Vigneshwar Kasirajan, M.D., Virginia Commonwealth University
Medical Center, Richmond, VA
Intraoperative TEE to assess repair of Sinus Venosus Atrial Septal Defects associated with anomalous
drainage of the Right Upper Pulmonary vein to the Superior Vena Cava Sinus Venosus ASDs constitute
10% of ASDs and the majority are located just below the junction of the SVC and Right Atrium and are
invariably associated with anomalous pulmonary venous drainage. We present a case of a 41-year-old
patient with an incidental finding of this lesion that was detected during a routine workup for a
cholecystectomy and the role of TEE in assessing intraoperative repair of such a defect
Monday, October 14
3:00 PM - 4:30 PM
CA MC820
Use of Recombinant Coagulation Factor VII a (NovoSeven RT) in Emergent Repair of Stanford Type B
Dissection in a Jehovah's Witness- Did We Have a Choice?
Pingle Reddy, M.D., David Farr, M.D., Kofi Vandyck, M.D., Derek Brinster, M.D., Virginia Commonwealth
University Medical Center, Richmond, VA
66-year-old Jehovah's Witness presented for an emergent repair of a Stanford Type B dissection. He
refused all blood products. Starting Hb was 10gms/dl. He received 90 micrograms per kg of NovoSeven
RT. His Hb at the end of the case was 8mg/dl.
Monday, October 14
3:00 PM - 4:30 PM
CA MC821
Deep Hypothermic Circulatory Arrest for Renal Carcinoma Involving Inferior Vena Cava and Right
Atrium
Pingle Reddy, Spencer Liebman, M.D., Vigneshwar Kasirajan, M.D., Virginia Commonwealth University
Medical Center, Richmond, VA
Deep Hypothermic Circulatory Arrest (DHCA) for Renal Tumors Involving Inferior Vena Cava and Right
Atrium A 67-year-old male with renal carcinoma presented for right nephrectomy and IVC tumor
resection and reconstruction under Deep Hypothermic Circulatory Arrest. Intra-operative Transesophageal Echocardiography confirmed the diagnosis of the tumor involving the IVC and RA. The tumor
was removed and the IVC was reconstructed under DHCA for a total duration of 51 minutes. He was
hemodynamically stable and successfully extubated within 3 hours of arrival in ICU.
Monday, October 14
3:00 PM - 4:30 PM
CA MC822
Intraoperative Transesophageal Echocardiography Assessment of Moderate Mitral Paravalvular Leak:
Controversial Management Decisions
Benjamin Redmon, M.D., Lavinia Kolarczyk, M.D., University of North Carolina, Chapel Hill, NC
While the management of trivial and severe paravalvular leaks is relatively straightforward the difficulty
in intraoperative TEE assessment and unknown prognosis of immediate moderate PVLs present
controversial management decisions. A 25-year-old female with a cleft mitral valve severe MR and large
Copyright © 2013 American Society of Anesthesiologists
primum ASD presented for MV repair. TEE exam after two MV repair attempts revealed a moderate
eccentric MR jet and a new moderate PVL. After eventual MV replacement post-cardiopulmonary
bypass TEE revealed global hypokinesis and the patient was placed on ECMO. This case highlights the
critical role of intraoperative TEE assessment and its influence on surgical decision making.
Monday, October 14
3:00 PM - 4:30 PM
CA MC823
Resuscitation of a 46-year-old Woman With HeartMate II LVAD: Two Resuscitations Two Outcomes
Lance Retherford, M.D., Steven Miller, M.D., Columbia University, New York, NY
In our case report we describe a 46-year-old woman with a HeartMate II LVAD (Thoratec Corporation
Pleasanton CA) in extremis requiring cardiopulmonary resuscitation upon presentation with a
subsequent arrest later in her admission. We compare and contrast these two resuscitations and discuss
the need for standard resuscitation protocols for patients with LVADs.
Monday, October 14
3:00 PM - 4:30 PM
CA MC824
Anesthetic Management of 3 Patients With Electrical Storm Presenting for Emergent VT Ablation
Tiffany Richburg, M.D., Nadine Odo, B.A., Mary Arthur, M.D., Georgia Regents University, Augusta, GA
A higher prevalence of congestive heart failure has led to more implantable cardioverter-defibrillator
(ICD) procedures and a higher incidence of electrical storm (10-20% of ICD recipients). This lifethreatening syndrome is defined as 3 or more sustained ventricular tachycardia (VT) episodes
ventricular fibrillation (VF) or appropriate shocks from an ICD within 24 hours. Electrical storm can
manifest duringMyocardial infarction in structural heart disease or an inherited arrhythmic syndrome.
Outcomes are usually poor. During a VT storm episode patients' refractory to pharmacological
treatment may present for emergent radiofrequency catheter ablation to treat the arrythmia. We
present 3 patients undergoing this procedure.
Monday, October 14
3:00 PM - 4:30 PM
CA MC825
Pulse Oximetry Waveforms Analysis Vascular Tone and Chronic Fatigue
M. Zundel, M.D., Medical College of Wisconsin, Milwaukee, WI, Matthias Riess, M.D., Ph.D., Clement J.
Zablocki VA Medical Center, Milwaukee, WI
Background: The pulse oximeter waveform represents vascular flow in the periphery. Physiologic
parameters such as vascular compliance vascular tone stroke volume body size and the closing of the
aortic valve all contribute to its shape. Case: An otherwise healthy 28-year-old male with a history of
chronic fatigue and postural orthostatic tachycardia syndrome (POTS) presented for an MRI. Vitals were
stable in the supine position (HR 76 BP 130/72) but upon standing he rapidly became tachycardic (HR
111). Pulse oximeter waveforms were abnormal and detailed waveform analysis provided valuable
insight into the pathophysiology and cause of the syndrome.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC826
Anesthesia for an Adult Patient With Double-Inlet Left Ventricle With D-Transposition of Great
Arteries
Efrain Riveros-Perez, M.D., Cleveland Clinic, Woodmere, OH, Miguel Morillo, M.D., Nelson Ricardo
Riveros-Perez, M.D., Cleveland Clinic, Cleveland, OH
A 25-year-old male known to have a double-inlet left ventricle D-transposition of the great arteries and
severe pulmonary hypertension is presented. Lost to follow-up since infancy the patient returns due to
functional capacity deterioration. The echocardiogram showed a double-inlet left ventricle and anterior
semilunar valve giving origin to the coronary ostia and a small atrial septal defect. Right heart
catheterization revealed elevated pulmonary resistance and good vascular reactivity. The patient
underwent pulmonary artery banding and atrial septostomy. General anesthesia was administered
based on meticulous balance between peripheral and pulmonary resistance to avoid pulmonary
overflow and systemic hypoperfusion.
Monday, October 14
3:00 PM - 4:30 PM
CA MC827
Anesthetic Management of Emergency Laparoscopy in an Adult With Fontan Physiology and Situs
Inversus
Kathryn Rosenblatt, M.D., Nurudin Cemer, D.O., Nadia Nathan, M.D., SUNY Upstate Medical University,
Syracuse, NY
Improved surgical technique is increasing the population of CHD survivors with myriad structural
abnormalities. We present a 23-year-old female with Fontan physiology and situs inversus requiring
emergency laparoscopy for acute abdomen. She is status post multi-stage univentricular palliation for
hypoplastic LV double-outlet RV and spinal fusion for scoliosis. Laparoscopy has potential for
hypotension and hypoxemia in Fontan patients; emergent surgery adds risk with little time for
hemodynamic optimization. A delicately tailored plan integrating different anesthetic considerations
was implemented despite limited pre-operative information. Continuous communication between
surgeons and anesthesiologists especially concerning insufflation allowed smooth and tight control of
her complex physiology.
Monday, October 14
3:00 PM - 4:30 PM
CA MC828
Not for the Faint-Hearted: Anesthesia for Revascularization in Patient With Takayasu's Arteritis
Alecia Sabartinelli, M.D., Edward Gologorsky, M.D., University of Miami Miller School of Medicine,
Miami, FL
A 23-year-old female presented with sudden onset syncope transient weakness vision changes and
absent radial pulses. Work-up revealed Takayasu's arteritis with severely compromised flow within the
bilateral carotid brachiocephalic and left axillary arteries. Treatment plan included corticosteroids
administration followed by aortic debranching with grafts bypassing areas of occlusion. Approach was
planned via interdisciplinary consultations among the vascular cardio-thoracic and anesthesia services
with provisions made for possible cardiopulmonary bypass and deep hypothermic circulatory arrest.
Complete revascularization with GorTex grafts was achieved utilizing ascending aortic partial crossclamp
beating heart and INVOS and EEG monitoring. Patient was extubated in the OR neurologically intact.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
CA MC829
Anesthesia Management of an Ebstein Type B Tricuspid Valve Malformation in an Adult
Mical Samuelson Duvall, M.D., Pushpa Koyyalamudi, M.D ., Lucas Duvall, M.D., LSUHSC Shreveport,
Shreveport, LA
We present a case of anesthetic management during tricuspid valve replacement of a patient with an
Epstein type B malformation. Anesthetic management goals of these patients should include
interventions to improve right ventricular contractility and avoid increases in RV afterload. Placement of
PA catheter can be technically difficult and care should be taken to avoid arrhythmias. TEE can
accurately identify the lesion its severity and associated cardiac defects. Intra-operative TEE is a valuable
tool to help guide intravenous fluid therapy and pharmacologic interventions by assessing the right and
left ventricular preload and changes in ventricular function.
Monday, October 14
3:00 PM - 4:30 PM
OB MC830
Considerations for Neuraxial Anesthesia for Cesarean Section in the Setting of Cerebral Autosomal
Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy (CADASIL Syndrome)
Abhinava Madamangalam, M.D., Robert Schoaps, B.S., University of Oklahoma Health Sciences Center,
Oklahoma City, OK
A patient with CADASIL Syndrome presented to us for Cesarean section at 38-weeks gestation with a
history of cerebral artery occlusion and residual left-sided sensory deficits. The patient demonstrated
allodynia of her left hemibody. The pregnancy was otherwise uncomplicated. We performed a standard
spinal anesthetic after careful consideration of her clinical status as she desired to be awake. We wish to
elaborate on the anesthetic implications of regional and general anesthesia in a patient with CADASIL
syndrome.
Monday, October 14
3:00 PM - 4:30 PM
OB MC831
Pregnancy Induced Hyperthyroidism
Brian Seacat, M.D., Courtney Seacat, M.D., Daniel Biggs, M.D., M.S., University of Oklahoma Health
Sciences Center, Oklahoma City, OK
We report the case of a 21-year-old pregnant female with development of severe hyperthyroidism. She
was started on propylthiouracil but was noncompliant. At 29 weeks gestation she presented to the
emergency department with weakness and significant hypertension. The patient subsequently went into
thyroid storm and cardiovascular collapse requiring cardiopulmonary resuscitation resulting in fetal
death. Urgent cesarean section was later performed because of DIC. Patient was managed in the
intensive care unit with eventual extubation. One month following the catastrophic event patient
underwent total thyroidectomy and was discharged with minimal neuromuscular deficits to
rehabilitation fifty days post event.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC832
ABG and TEG Guided Massive Transfusion Protocol in a G11 P(10) Patient During a
Cesarean/Hysterectomy With Unanticipated Placenta Percreta
Nathaniel Sharp, Edward Kosik, D.O., Oklahoma University Health Science University, Oklahoma City, OK
Patient was a Gravida 11 Para 10 with a history of 6 prior cesarean sections who presented for a
cesarean section/hysterectomy. Patient received combined spinal/epidural for anesthesia. Baby was
delivered without complication. Eventually what was thought to be a placenta accreta turned out to be
percreta. Surgery was complicated perfuse bleeding was encounterd and patient was converted to
general anesthesia. Massive transfusion protocol was initiated. Resuscitative efforts were driven by the
information gained from ABG's and TEG. Our goal is to emphasize the importance of utilizing these
modalities to guide resuscitation in a massive blood loss situation.
Monday, October 14
3:00 PM - 4:30 PM
OB MC833
Idiopathic Intracranial Hypertension and Pregnancy
Zafar Siddiqui, M.D., Tanya Lucas, M.D., UMass Memorial Medical Center, Worcester, MA
A 25-year-old G1P0 at 24 weeks pregnant presented with visual changes headache and marked
papilledema. She had no hypertension proteinuria mass lesion or CSF pathology. She did have an ICP of
55 cm H2O and a diagnosis of idiopathic intracranial hypertension was made. She had 2 lumbar
punctures for CSF drainage to decrease ICP and thus the chance of permanent sequelae including
blindness. She was placed on acetazolamide with resolution of her symptoms and papilledema prior to
discharge. Presently the plan is for NSVD if she remains asymptomatic. Her delivery is imminent and an
early epidural is recommended.
Monday, October 14
3:00 PM - 4:30 PM
OB MC834
Pregnant Patient With a Large Anterior Mediastinal Lymphoma
Loveleen Sikka, M.D., Steven Shulman, M.D., Lawrence Chinn, M.D., UMDNJ, Newark, NJ
Perioperative management of patients with an anterior mediastinal mass (AMM) is an anesthetic
challenge. We describe the management of a patient who is 14 weeks pregnant with a massive AMM
causing superior vena cava syndrome requiring thoracic biopsy and later D&C in order to begin
chemotherapy. Chest CT showed compression of the carina and both mainstem bronchi. Incisional
biopsy was performed under ketamine and local lidocaine. That evening the patient reported
hallucinations and anxiety. Four days later D&C was performed under saddle block with
dexmedetomidine infusion and midazolam. The patient remained hemodynamically stable and
maintained spontaneous respirations throughout both procedures.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC835
Saggital Venous Sinus Thrombosis Following Uncomplicated CSE for Cesarean Section
Philip Smith, Firdous Khan, M.D., Ashutosh Wali, M.D., Quisqueya Palacios, M.D., Baylor College of
Medicine, Houston, TX
28-year-old female G4P4 A1DM gHTN presented with severe headache on POD#5 s/p cesarean section
#3 with IUD placement. Patient had CSE performed at L3-L4 level without evidence of a dural puncture.
Patient reported sudden onset of 10/10 headache awakening her from sleep at 3AM POD#5. She denied
nuchal rigidity fever photophobia or positional component. Neurological exam was non-focal and
patient reported blurred vision which self-resolved. CT head was negative for acute bleed. CT venogram
revealed 1.5cm superior sagittal sinus focal thrombosis. Patient was started on heparin drip PO
ibuprofen for pain control with resolution of symptoms.
Monday, October 14
3:00 PM - 4:30 PM
OB MC836
Labor-Induced Pulmonary Edema and Cardiac Arrest in a Patient With Rheumatic Mitral Stenosis
Sarah Smith, D.O., Cuong Vu, M.D., Baystate Medical Center, Springfield, MA
A 37-year-old gravida 4 para 3 at 39 weeks gestation with rheumatic mitral valve disease presented in
active labor. She was in acute respiratory distress with copious pink frothy secretions representing an
airway emergency. She was emergently taken to the operating room for delivery of the fetus via
cesarean section. Prior to induction of anesthesia she underwent hypoxic pulmonary arrest and
circulatory collapse requiring resuscitation. Her airway was immediately secured and pulses returned
after one round of chest compressions. The fetus was delivered after return of spontaneous circulation
and the patient transferred to the ICU in stable condition.
Monday, October 14
3:00 PM - 4:30 PM
OB MC837
Management of a Parturient With Coronary Artery Disease and Cerebral Aneurysms for Cesarean
Section
Katherine Stammen, M.D., Frank Zavisca, M.D., Ph.D., Louisiana State University Health Sciences Center
Shreveport, Shreveport, LA
A 43-year-old female presented at 38 weeks gestation for delivery. The patient had a complicated
medical history of coronary artery disease with triple vessel bypass in 2001 but with subsequent
Myocardial infarctions twice after requiring stent placement. She also had a history of cerebral
aneurysms of which two were repaired and one was still present. Her medical history also included
hypertension asthma diabetes mellitus and a seizure disorder. We discuss the implications of such a
complicated medical history on the anesthetic considerations for this patient including anesthetic type
preoperative optimization strategies and delivery management.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC838
Anesthetic Management of a Pregnant Patient With History of Mustard Procedure for Correction of
Transposition of Great Arteries
Ksenia Stark, M.D., N. Sean Ohanian, M.D., Beaumont Health System, Royal Oak, MI
A 24-year-old pregnant female with a past medical history of Mustard procedure for childhood
correction of d-TGV presented for dilation and evacuation. The anesthetic risk for this patient was
significantly increased by the fact that she had CHF severe pulmonary edema and cardiac arrest
complicating her previous pregnancy. Subarachnoid block was initiated in an effort to reduce right
ventricular strain and cardiac morbidity. An increasing number of patients with corrected TGV now
survive to adulthood with the accompanying increased risks of anesthesia. Anesthetic management in
this patient with d-TGV and its physiologic implications are discussed.
Monday, October 14
3:00 PM - 4:30 PM
OB MC839
Does the Patient REALLY Need a Blood Patch?
Panthea Taghizadeh, M.D., John H. Stroger Jr. Hospital of Cook County, Chicago, IL
A 24-year-old female with a history of polysubstance abuse status post spontaneous vaginal delivery
under epidural analgesia was readmitted complaining of a non-positional headache. Pain service was
consulted for possible blood patch. Detailed history and physical examination revealed signs of
meningismus. Based on clinical evaluation additional diagnostic work up was requested and proved
negative for infectious etiology. Within 48 hours patient developed a seizure with a resulting brain MRI
revealing sub-acute infarcts. This raised the concern for an underlying vascular etiology such as
postpartum cerebral angiopathy. Patient fully recovered after recommended treatment with
vasodilators and steroids.
Monday, October 14
3:00 PM - 4:30 PM
OB MC840
A Case of Cesarean Hysterectomy for Placenta Previa and Percreta
Amar Talati, D.O., Praveen Prasanna, M.D., Ananth Kashikar, M.D., Stanlies D'Souza, M.D., Baystate
Medical Center Tufts University School of Medicine, Springfield, MA
A 35-year-old G8P4 with history of multiple D&Cs and c-section presented with complete placenta
previa and percreta for elective c-section and hysterectomy. The percreta invaded the bladder with
close proximity to iliac vessels. Multidisciplinary planning and simulation was conducted prior to surgery.
Thoracic epidural was placed for pre-operative iliac artery balloon catheter insertion and post-operative
analgesia. C-section was performed under general anesthesia and maintained with TIVA. Balloon
catheters were inflated following fetal delivery. Placenta was left in situ and hysterectomy performed
with minimal blood loss. Patient was extubated and both the patient and baby had uneventful recovery.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC841
Electroconvulsive Therapy (ECT) During Pregnancy: Is it safe? A Positive Outcome for Mother and Child
Brian Tevlin, M.D., Elifce Cosar, M.D., Tatyana Steinlukht, M.D., Shubjeet Kaur, M.D., UMass Memorial
Health Care, Worcester, MA
A 28-year-old woman G2P0010 at 21 weeks gestation with history of bipolar disorder depression and
anxiety presented with acute worsening of symptoms despite pharmacologic therapy. ECT has been
demonstrated to be effective in the treatment of severe mental illness during pregnancy. In our
institution ECT and obstetric services are located at separate campuses. Despite the difficulties trying to
get the two services together ECT was performed under general anesthesia. Fetal heart monitoring was
documented before and after the treatment. After multiple treatments the patient had remission and
there have been no adverse effects to the fetus.
Monday, October 14
3:00 PM - 4:30 PM
OB MC842
Caesarean Section in a 19-Year-Old With HIV-Related Dilated Cardiomyopathy
Brent Toland, M.D., Uma Munnur, M.D., Baylor College of Medicine, Houston, TX
HIV has long known to affect multiple organ systems with the cardiovascular system being one of the
most prominent. HIV-related dilated cardiom year-old pathy (DCM) is one such sequelae that has a
particularly high incidence of mortality. We present a case of a 19-year-old female at 32 weeks gestation
with clinically significant HIV-related DCM undergoing urgent c-section. In this case we highlight the use
of the Vigileo-Flotrac™ monitor for minimally-invasive hemodynamic monitoring and the placement of
an epidural with incremental boluses to achieve a stable hemodynamic environment and successful csection without complication to mother or fetus.
Monday, October 14
3:00 PM - 4:30 PM
OB MC843
Postpartum Foot Drop: Is Epidural Block the Culprit?
Giselle Torres, M.D., David Rahmani, M.D., Monica Taneja, M.D., Mayer Halpern, M.D., Kalpana
Tyagaraj, M.D., Maimonides, Brooklyn, NY
We are reporting 2 cases of postpartum foot drop in parturients who received CSE anesthesia. Cases are
presented for discussion of neurological complications of anesthesia. CASE 1: 34 years G7P4 parturient
at 41 weeks gestation received CSE with epidural infusion for labor analgesia. Patient delivered vaginally
6.5 hours afterwards. One day later the patient reported left foot numbness. CASE 2: 22 years G1P0
parturient at 39 weeks gestation in labor received CSE with epidural infusion. Patient underwent a Csection for 2.5 hours later because of non-reassuring fetal heart rate. On POD 1 the patient reported
right foot weakness.
Monday, October 14
3:00 PM - 4:30 PM
OB MC844
Epidural Neuraxial Anesthesia for Cesarean Section in a Parturient With Coarctation of Aorta
Alan Torrey, M.D., Anesh Rugnath, M.D., University of Mississippi Medical Center, Jackson, MS
Patient is a 32-year-old F at 39 weeks gestation who presents for cesarean section in breech
presentation. She was recently diagnosed with coarctation of aorta at time of conception and will be
Copyright © 2013 American Society of Anesthesiologists
repaired after delivery. Upper extremity blood pressure was 145/85 while lower extremity blood
pressure was 88/45. Coarctation was located preductal with a gradient of 65 mmHg. The patient also
has aortic stenosis with a bileaflet valve. Epidural neuroaxial anesthesia was chosen as well as invasive
blood pressure monitoring all which will be discussed as well as cardiology findings and
ECHO/catheterization findings.
Monday, October 14
3:00 PM - 4:30 PM
OB MC845
A MuSK Antibody Positive Myasthenia Gravis Patient With Severe Pre-Eclampsia Requiring Urgent
Cesarean Section
Stephanie Tran, M.D., Vinh Nguyen, D.O., Georgetown University, Washington, DC
A 30-year-old female with MuSK antibody positive myasthenia gravis presented for urgent cesarean
section at 33 weeks gestational age due to IUGR and severe hypertension. Prior to admission the patient
suffered multiple myasthenia crises requiring tracheostomy and PEG tube and trials of high dose
steroids Mestinon IVIG plasmapheresis and Rituxan. Epidural anesthesia was administered successfully
by gradually dosing 2% lidocaine with 1:200 000 epinephrine. The patient also received a dose of stress
steroids and antiepileptic for seizure prophylaxis. The procedure was tolerated well with delivery of a
live baby. On post-operative day 5 she developed a suspected myasthenia crisis.
Monday, October 14
3:00 PM - 4:30 PM
OB MC846
In the Right Place at the Right Time
Dan Trinh, M.D., University of Connecticut Health Center, Middletown, CT
A 32-year-old 29-weeks pregnant female was visiting her husband in the hospital ED. While there she
developed severe abdominal pain coinciding with hypotension and fetal bradycardia. A STAT C-section
was called. After induction of general anesthesia and surgical exposure massive intraabdominal bleeding
was discovered. After rapid delivery of the baby the surgery team became emergently involved while
continuous blood product and hemodynamic support were provided. The patient was diagnosed with a
ruptured splenic artery aneurysm and required splenectomy and vessel ligation. The mother and baby
survived. If not for being in the hospital mortality is usually significant for both.
Monday, October 14
3:00 PM - 4:30 PM
OB MC847
How Low Is Too Low? Thrombocytopenia and Spinal Anesthesia for Caesarian Section
Matthew Ufberg, M.D., Sumita Bhambhani, M.D., Temple University Hospital, Philadelphia, PA, Ari
Bensimhon, , Student, Temple University School of Medicine, Philadelphia, PA
A 37-year-old G8P6016 female with two prior C-sections presented at 36 weeks for scheduled Cesarean.
PMH was notable for morbid obesity (BMI 50) and recently developed large thyroid mass. She also had
developed thrombocytopenia with platelet count of 46 000 at her office visit. On the day of scheduled
Cesarean she was transfused two pools of cross-matched platelets. Despite this her platelets fell to 33
000. Given the likelihood for difficult airway and lack of bleeding bruising or petechiae decision was
made to administer spinal anesthesia. Spinal and subsequent operation proceeded without incident. The
patient delivered a healthy baby without post-operative complications.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC848
Anesthesia Managment of a Patient With Fibrosing Mediastinitis in Labor
Aruna Vaddadi, Jaya Ramanathan, M.D., University of Tennessee Health Sciences Center, Memphis, TN
Fibrosing mediastinitis (FM) causes excessive fibrotic reaction in mediastinal structures airways and
great vessels. Common etiology is histoplasmosis and immune response (HLAA2). A multigavida with five
years history of severe FM underwent cesarean section. A combined spinal-epidural anesthesia was
administered successfully. Her postpartum course was uneventful. FM presents as granuloma with
leakage of fungal antigen causing fibrosis of mediastinal structures with V/Q mismatch hypoxemia
pulmonary hypertension and pulmonary edema aggravated by increased blood volume in pregnancy.
General anesthesia may be associated with difficult ventilation and oxygenation. Regional anesthesia is
the anesthetic of choice in pregnant patients with fibrosing mediastinitis.
Monday, October 14
3:00 PM - 4:30 PM
OB MC849
Anesthesia Management and Inflammatory Profiles of an Obstetric Patient With History of GuillainBarre Syndrome
Ivan Velickovic, M.D., Lin-Lin Wang, B.S., Giorgio Medranda, B.S., Ming Zhang, M.D., Ph.D., SUNY
Downstate Medical Center, Brooklyn, NY
Guillian Barre syndrome (GBS) is a rare autoimmune neuropathy characterized by systemic inflammation
as indicated by activation of complement factors. A 38-year-old woman G2P1 with a previous history of
GBS had Cesarean Section under GA (patient refused any regional anesthetic). Complement factors in
maternal and fetal cord blood were analyzed. MBL of the lectin complement pathway was deficient in
both the maternal and fetal circulation while the factors of the other 2 complement pathways were
intact. Thus it is likely that the autoimmune response in GBS involves classical and alternative pathways
of complement but not the lectin pathway.
Monday, October 14
3:00 PM - 4:30 PM
OB MC850
Anesthesia Management of a Morbidly Obese Parturient Going for Caeasarean Section With Coronary
Artery Disease and Recent Stent Placement
Catherine Vu, M.D., Jennifer Hochman, M.D., Jayanthie Ranasinghe, M.D., Jackson Memorial Hospital,
Miami, FL
Cardiac disease is one of the leading causes of maternal mortality. However the prevalence of coronary
artery disease is uncommon among parturients (incidence of 1:10 000). We present a case of a 40-yearold G4P1203 at 34 weeks BMI of 60 Mallampati score of 4 diabetic preeclampsia superimposed on
chronic hypertension coronary artery disease with placement of two bare metal stents after a NSTEMI
and immediately before the current pregnancy currently on plavix presented to the labor floor for an
urgent c-section. The patient had a c-section at 34 weeks by placement of epidural catheter and
recovered in SICU without any complication.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC851
The Anesthetic Management of a Pre-Eclamptic Parturient Delivering an Neonate With Congenital
Long QT Syndrome
Eric Vu, M.D., Ashutosh Wali, M.D., F.C.A.R.C.S.I., Baylor College of Medicine, Houston, TX
Congenital long QT syndrome (LQTS) is a rare cardiac arrhythmia characterized by a prolonged QT
interval (Qtc > 440-480 ms). We present a case of a morbidly obese 25-year-old G6P0232 at 37 and 4
weeks carrying a fetus with LQTS. The patient was admitted with pre-eclampsia and posted for urgent
cesarean section. Careful consideration was made regarding her anesthetic plan to avoid drugs that
could precipitate life-threatening arrhythmias. A combined spinal-epidural technique was utilized with
co-loading of IV fluid to maintain maternal blood pressure. The baby was safely delivered and
transferred to the NICU in stable condition for further management.
Monday, October 14
3:00 PM - 4:30 PM
OB MC852
Optimization of Fetal and Maternal Outcomes During an Urgent Cesarean Section on a Preterm
Parturient With Congenital Transposition of Great Vessels and Complex Single Ventricle Physiology
Jeremie Walker, Richard Driver, David Rosen, WVU, Morgantown, WV
The 36 week and 1 day preterm parturient in this case required an urgent cesarean section for nonreassuring fetal heart tones. At 22-year-old she had significant cardiac history including transposition of
great vessels and a complex single ventricle physiology. In addition the husband had transposition of
great vessels. With initial resistance from the patient for an awake cesarean section we delivered a
healthy infant after placing an epidural awake arterial line awake central line and relocating the patient
from the obstetric unit to the pediatric cardiac operating suite for unexpected intra-operative
complications that might require emergent intervention.
Monday, October 14
3:00 PM - 4:30 PM
OB MC853
Bezold-Jarisch Reflex and Seizure Observed During Acute Hemorrhage in a Cesarean Section
Cindy Wang, M.D., Edward Mathney, M.D.I, Icahn School of Medicine at Mount Sinai, New York, NY
A 32-year-old gravida 3 woman at 38 weeks gestation in active labor presented for a tertiary Cesarean
section with epidural anesthesia. After delivery of a healthy infant the patient became unresponsive
severely bradycardic and hypotensive with brisk bleeding from a transected artery. Aggressive
resuscitation and arterial ligation resulted in quick hemodynamic recovery but neurologic alteration
persisted. This episode of hemorrhage and sympathetic blockade likely incited a Bezold-Jarisch reflex
and revealed an underlying seizure disorder. This case suggests that hemorrhage in the setting of
neuraxial anesthesia may incite a Bezold-Jarisch reflex and uncover other co-existing diagnoses in
obstetric patients.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC854
The Magnification of Neuromuscular Blockade In the Obstetric Patient With Renal Insufficiency
Abiona Berkeley, M.D., Joshua Wert, D.O., Vincent Cowell, M.D., Temple Univerity Hospital, Philadelphia,
PA
A 38-year-old Gravida 10 Para 7 parturient presented to Labor and Delivery with blurred vision and
headache. Patient was found to have severe preeclampsia and intrauterine fetal demise. Patient was
started on magnesium sulfate infusion hydralazine and labetalol. Following a seizure documented serum
magnesium level of 9.5 mg/dL and creatinine of 2.5 mg/dL she was taken to the operating room for
emergent Caesarean section. Included in her induction regimen was rocuronium. Patient did not attain
4/4 response to train-of-four testing until approximately 8 hours after the administration of rocuronium.
Monday, October 14
3:00 PM - 4:30 PM
OB MC855
To Clean or Not To Clean
Jackie White, D.O., Saninuj Malayaman, M.D., Mary Im, M.D., Hahnemann University Hospital,
Philadelphia, PA
A 36-year-old female G9P6116 at 37 weeks gestation with medical history significant for PCP abuse
requests a labor epidural. An uncomplicated lumbar labor epidural was placed under the aseptic
protocol for the instituiton. Post delivery the epidural catheter was removed approximately 3 hours
after placement. On POD 1 no signs of anesthesia complications. On POD 2 patient was febrile and
developed LLE pain and weakness. Lumbar MRI revealed left paraspinal iliacus muscle and sacroiliac
joint abscess. Patient was started on IV antibiotics and treated appropriately. Her symptoms gradually
resolved and the patient was discharged home.
Monday, October 14
3:00 PM - 4:30 PM
OB MC856
Peripartum Cardiomyopathy Presenting As Severe Preeclampsia
Melanie Wilson, M.D., Melissa Pant, M.D., University of Chicago Hospitals, Chicago, IL
22-year-old morbidly obese G1P0 at 31 6/7 weeks with breech fetus presents overnight with shortness
of breath and cough. Per family patient had a cold. Blood pressure was 147/103 pulse 125
oxygensaturation 92% on RA. Chest auscultation revealed crackles over both bases andedema of
extremities. ABG revealed 7.28/42/52. Oxygen was administered viaHFNC. Significant laboratory values
were Cr. 1.3 and proteinuria. CXR revealedpulmonary edema and cardiomegaly. Furosemide was
administered with symptomaticimprovement. TTE was unavailable. Decision made to deliver for severe
preeclampsia with complicating pulmonary edema and ARI. Postoperative echo revealed LVEF of 17%.
Monday, October 14
3:00 PM - 4:30 PM
OB MC857
Altered Mental Status During Labor Secondary to Hyponatremia
Steven Wright, M.D., Frank Jaime, M.D., Lev Deriy, M.D., University of New Mexico, Albuquerque, NM
A 33-year-old female began having altered mental status 36 hours after admission for delivery. Concern
for intracranial etiology required urgent cesarean section performed under general anesthesia because
of potential increased intracranial pressure and patient's inability to cooperate with neuraxial
Copyright © 2013 American Society of Anesthesiologists
techniques. After induction arterial blood gas demonstrated sodium level of 118 Meq/L. Patient
remained intubated in the ICU postoperatively. Hyponatremia was self-corrected within 12 hours and
the patient was extubated without neurologic sequelae. Etiology was determined to be caused by
increased production of ADH from prolonged labor in the setting of a large ingestion of water.
Monday, October 14
3:00 PM - 4:30 PM
OB MC858
Anesthetic Management for Cesarean Section in a Parturient With Moyamoya Disease
Jijun Xu, Matvey Bobylev, Cleveland Clinic, Cleveland, OH
Anesthetic management for cesarean section (CS) in a 29-year-old parturient with Moyamoya disease
(MMD) is discussed. Pre-induction arterial line placed and IV fluids given. Anesthesia maintained with
slow epidural anesthesia induction and intermittent IV boluses of fentanyl. Systolic blood pressure was
maintained using LUD IV fluids and phenylephrine boluses to preserve adequate cerebral perfusion.
Normal hemocrit temperature (IV fluid warmer used) and normocapnia were maintained
intraoperatively with an uneventful anesthetic course. Postoperative pain controlled with epidural. She
was monitored in the neurological ICU postoperatively and was discharged without neurological deficit
three days later with a healthy baby.
Monday, October 14
3:00 PM - 4:30 PM
OB MC859
Management of Delivery and Diagnostic Mediastinoscopy in Parturient With Newly Diagnosed
Symptomatic Anterior Mediastinal Mass
Jordan Yokley, M.D., Tiffany Orchard, D.O., Walter Reed National Military Medical Center, Bethesda, MD
A 22-year-old F G1P0 at 36 weeks presented with a 2 month history of nonproductive cough SOB 2-3
pillow orthopnea tachycardia and sternal chest pain. Clinical evaluation revealed a 7cm PET-active
anterior mediastinal mass that encircled the right mainstem bronchus. TTE revealed normal cardiac
function with no great vessel compression. Patient was admitted for induction of labor with arterial line
lumbar epidural and continuous pulse oximetry. Spontaneous vaginal delivery was uneventful. She
underwent a diagnostic mediastinoscopy on PPD#1 under general anesthesia. The patient was
inhalationally induced in a head-up position with preservation of spontaneous ventilation. The patient
tolerated the procedure well.
Monday, October 14
3:00 PM - 4:30 PM
OB MC860
Management of Pheochromocytoma in Parturient With Newly Diagnosed Von Hippel-Lindau Disease
Jordan Yokley, M.D., Tiffany Orchard, D.O., Walter Reed National Military Medical Center, Bethesda, MD
A 30-year-old F G1P0 at two weeks gestation was found to have Von Hippel-Lindau Disease after having
confirmational genetic testing prompted by her father's own testing for recurrent hemangioblastomas.
Further evaluation revealed a right sided pheochromocytoma cystic lesions of the pancreas and kidney
and multiple small cerebellar and cervicothoracic hemangioblastomas. She proceeded with an
uneventful elective open adrenalectomy at 20 weeks under general anesthesia with thoracic epidural
and arterial line. Pregnancy was uncomplicated and she was admitted for induction of labor at 40
weeks. She had an uncomplicated vaginal delivery with a lumbar epidural.
Copyright © 2013 American Society of Anesthesiologists
Monday, October 14
3:00 PM - 4:30 PM
OB MC861
Suspected Pseudocholinesterase Deficiency in a Parturient During an Emergency C-Section
John Zaki, M.D., Napolean Campos, M.D., Texas Tech Health Science Center-El Paso, El Paso, TX
This is a case report of a Parturient who was sent to the OR for an emergent C-Section after the fetus
has episodes of bradycardia. Patient received a standard induction dose of etomidate and
succinycholine. Patient had no twitches or muscle strength for about an hour and half after induction.
Patient was suspected to have a PC deficiency and dibucaine labs were sent off.
Monday, October 14
3:00 PM - 4:30 PM
OB MC862
Anesthetic Management of Labor Analgesia for a 27-year-old Female With New Onset Pituitary Macro
Adenoma
Caleb Zelenietz, M.D., Brian Gregson, M.D., University of Manitoba, Winnipeg, MB
We describe the anesthetic management of labor analgesia for a 27-year-old female with new diagnosis
of pituitary macro adenoma. The patient was a previously healthy primigravida developing new onset
headaches during the second trimester of pregnancy. Bilateral visual field defects onset in the third
trimester prompting her to be diagnosed with pituitary macro adenoma. She was unsuccessfully treated
with dopamine agonists. After consultation with neurology and neurosurgery it was decided to induce
labor at 36 weeks gestation. She underwent epidural analgesia for vaginal delivery without
complication. Post partum she underwent neurosurgical resection of her pituitary macro adenoma.
Monday, October 14
3:00 PM - 4:30 PM
OB MC863
Anesthetic Management for a Parturient with Arnold-Chiari and Tethered Cord Syndrome
Eric Zelman, M.D., Jong Lee, M.D., Amol Patwardhan, M.D., Ph.D., Kai Schoenhage, M.D., University of
Arizona, Tucson, AZ
Our case report describes the anesthetic management of a 35-year-old parturient with both a previous
occiput to C5 cervical fusion and a tethered cord release. She was scheduled for an elective caesarean
section and was referred to the pre-operative anesthesia clinic by her obstetrician and neurosurgeon.
Multiple anesthetic options were discussed and the patient ultimately elected and tolerated a single
shot spinal. The main learning points from this case come from the preparation involved the variety of
contingency plans and the vigilance of the pre-operative assessment.
Monday, October 14
3:00 PM - 4:30 PM
OB MC864
PostpartumTransient Focal Neurological Deficit Related to Hypoglycemia
Liang Zhang, M.D., M.S., Banu Lokhandwala, M.D., Jun Lin, M.D., Ph.D., SUNY Downstate Medical Center
at LICH State University of New York, Brooklyn, NY
36-year-old G2P1 underwent repeat C-section with CSE. On POD 2 patient developed fever dysarthria
left facial droop with right lower extremity weakness. CT head MRA and MRI (head and full spine) were
negative. LP yielded negative chemistry and bacterial panel. U/A showed positive ketone without WBC.
Blood culture was negative. Neurological deficits were reported when blood glucose dropped from 65
mg/dl to 49 mg/dl on POD2 and were completely resolved on POD3 when blood glucose was 112mg/dl.
Copyright © 2013 American Society of Anesthesiologists
We hypothesize that hypoglycemia induced by long fasting and worsened by postpartum endometritis
led to the acute focal neurological deficits.
Copyright © 2013 American Society of Anesthesiologists
MCC Session Number – MCC13
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC865
Anesthesia for Deep Brain Stimulator Inplantaion in a Case of Meige's Syndrome.
Craig Samford, M.D., Arpad Zolyomi, M.D., University of New Mexico, Albuquerque, NM
Meige's syndrome is a rare dystonia comprised of blepharospasm and involuntary movements of the
face jaw and neck muscles. Severe symptoms lead to difficulties with speaking eating and drinking and
social isolation. Systemic medications and botulinum toxin injections are often ineffective. We present a
case of deep brain stimulator implantation in a patient with a five-year history of medically refractory
Meige syndrome. Microelectrode recordings could not be interpreted due to severe craniofacial
dystonia. During remifentanil infusion the dystonia improved and the microelectrode recordings became
useable for guidance.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC866
Management of Parturient With Ruptured Grade IV Arteriovenous Malformation
Christopher Schrock, M.D., Russell Langdon, M.D., University of Tennessee Medical Center, Knoxville, TN
A parturient with a history of an arteriovenous malformation presented to the hospital with a sudden
headache that rapidly progressed to loss of consciousness. Computed Tomography was consistent with
a ruptured AVM resulting in a large hemispheric intracranial hemorrhage. She was emergently taken to
the operating room for a decompressive craniotomy. Afterwards she was monitored in the ICU for
several days until ultimately being taken back to the operating room for staged endovascular
embolization of her AVM. On the 23rd hospital day she was discharged to a rehabilitation facility with
neurologic deficits including dysphagia expressive aphasia and right hemiparesis.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC867
Perioperative Management of a Large Highly Vascularized Metastatic Cervical Spine Tumor With
Dislocated Spine and Severe Spinal Cord Compression
Milad Sharifpour, M.D., M.S., Oleg Evgenov, M.D., Ph.D., Massachusetts General Hospital, Boston, MA
Surgical management of spine metastases is associated with life-threatening blood loss and significant
morbidity and mortality. A 54-year-old male presented with a large highly vascularized C4-T1 metastatic
renal cell carcinoma with complete anterior cervical spine listhesis and severe spinal cord compression.
Posterior instrumentation/debulking was attempted but terminated due to a 10.2L blood loss.A Halo
brace was placed. Following chemotherapy/radiation the patient underwent tumor embolization
followed by anterior cervical corpectomy with fusion. During the 16-hr procedure blood loss was 8L
requiring administration of blood products and intravenous fluids through a rapid infuser. He was
ultimately discharged following rehabilitation therapy.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC868
Anesthetic Management of Patients Undergoing Vagal Nerve Stimulator Placement as Treatment for
End Stage Heart Failure
Matthew Sigakis, M.D., Michele Szabo, M.D., Massachusetts General Hospital, Boston, MA
A 73-year-old man with NYHA functional classification III (EF 13%) presented for vagus nerve stimulator
implantation. Recently vagal nerve stimulation has been investigated as a treatment for heart failure
where sympathetic dysregulation plays a significant role in the disease pathogenesis. This experimental
procedure required perioperative coordination between surgeon cardiologist electrophysiologist and
anesthesiologist. Preoperative anesthetic evaluation emphasized the characterization of heart failure
management of the pacemaker and building rapport with an anxious patient. Perioperative goals
included minimizing sympathetic stimulus hemodynamic support and management of arrhythmias and
fluids. Certain precautions were taken and procedural phases anticipated by the anesthesiology team.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC869
Delayed Emergence After Suboccipital Craniectomy for Chiari I Malformation
Natalie Silverton, Mark Harris, M.D., University of Utah, Salt Lake City, UT
A healthy 30-year-old woman with Chiari I malformation presented for suboccipital decompression. The
conduct of the case was uneventful. After dural closure 10 ml of 0.5% bupivacaine was injected into two
small catheters placed in the suboccipital musculature. On emergence the patient's pupils were
unreactive and dilated bilaterally. She remained apneic and unresponsive. A nerve stimulator confirmed
no residual neuromuscular blockade. Arterial blood gas panel was normal. The patient awoke 66
minutes later with transient bilateral leg numbness. Subsequent CT showed one of the catheters
beneath the dura. The catheters were removed and the patient had an otherwise unremarkable course.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC870
Airway Management in a Female Patient With Intrauterine Pregnancy of 35 Weeks With Grisel
Syndrome: A Case Report
Marco Silvestrini, M.D., Victor Rivero, M.D., Hector Torres, M.D., University of Puerto Rico, Yauco, PR
Grisel Syndrome is defined as a non-traumatic subluxation of the atlantoaxial joint. Case of a 29-year-old
woman with symptomatic atlantoaxial subluxation at 35 weeks of intrauterine pregnancy who was
taken to the operation room for cesarean delivery. The patient was found with left hemiparesis
dysphagia and shortness of breath of two days of evolution. An awake fiberoptic orotracheal intubation
was The presence of a symptomatic atlantoaxial subluxation combined with the anticipated changes of
pregnancy makes this an interesting and challenging case. This is the first case reported of an adult
pregnant female with Grisel syndrome.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC871
Multiple GSW With Traumatic Artery Aneurysm: Anesthetic Considerations
Adrian Sonevytsky, M.D., Ramsis Ghaly, M.D., Bozana Alexander, M.D., John H. Stroger Jr. Hospital of
Cook County, Chicago, IL
28-year-old male presented with multiple GSW including lower extremities abdomen chest right neck
zone II and left forehead. Patient underwent an exploration of right neck with ligation of right ICA and IJ
for right internal carotid artery pseudoaneurysm and an AVF between RICA and RIJ. This was followed by
an emergent decompressive laparotomy for abdominal compartment syndrome and left decompressive
craniectomy. Anesthetic management included massive transfusion neuroprotective measures and
maintenance of adequate CPP in a patient with HD instability 3L acute blood loss and elevated ICP.
Postoperatively patient recovered full neurological function except for partial vision loss.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC872
Anesthetic Management of Neonate With Vein of Galen Malformation and Congestive Heart Failure
Liza Starecki, M.D., Franco Resta-Flarer, M.D., St. Luke's- Roosevelt Hospital, New York, NY
A 1-day-old neonate presented at birth with CHF and was diagnosed with Vein of Galen malformation.
He was intubated transferred to our institution and taken emergently for MRI cerebral angiogram and
embolization of malformation. Umbilical venous and arterial lines were placed. The CHF was managed
with dopamine dobutamine milrinone and nitric oxide perioperatively. Deliberate hypotension
necessary for gluing was achieved with sevoflurane. After partial embolization of malformation patient
was transferred to neonatal ICU. His CHF improved and he was discharged on digoxin and furosemide
twenty days later. His postoperative course was complicated by seizures which were managed with
phenobarbital.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC873
Delayed Onset Juvenile Stroke Due To Blunt Traumatic Internal Carotid Artery Dissection
Nazneen Sudhan, Addenbrookes Hospital UK, Cambridge, United Kingdom, Akash Prashar, M.B. B.S.,
Norfolk and Norwich University Hospital, Norwich, United Kingdom
A juvenile patient presented following road traffic accident with GCS 14 and no focal neurology. Initial
head scan was normal. Unstable haemodynamics necessitated emergency laparotomy. Patient was
ventilated for next 48 hours for re-exploration surgery. Dense left sided hemiplegia was noted 72 hours
post injury when weaning of sedation was attempted. CT angiography confirmed right internal carotid
dissection with thrombosis and ischaemic infarct in the middle cerebral artery territory. Patient was
managed conservatively and made good neurological recovery without cranial decompression. This rare
injury demands a high index of suspicion to enable prompt specialist management to ameliorate severe
neurological damage.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC874
Epidural Anesthesia for Lumbar Decompression Surgery in the High-Risk Geriatric Patient
Amar Talati, D.O., Brian Martin, M.D., Stanlies D'Souza, M.D., Baystate Medical Center Tufts University
School of Medicine, Springfield, MA
A 91-year-old diabetic male with a history of three-vessel coronary artery disease which was medically
managed and myocardial infarction one month prior presented for removal of synovial cyst and
decompression due to symptomatic lumbar stenosis at L4-L5. In collaboration with the neurosurgeon we
planned for epidural anesthesia due to high risk obstructive coronary artery disease. A thoracic epidural
catheter was placed at the T10-T11 level and anesthesia was maintained with epidural infusion 0.125%
bupivacaine along with low-dose propofol and fentanyl sedation. The catheter was immediately
removed upon arrival to recovery. The patient had an uneventful perioperative course.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC875
Diaphragmatic Pacing: New and Expanded Indications for an Old Technique.
Ahmed Haque, M.D., Christopher Tam, M.D., Shaji Poovathoor, M.D., Deborah Richman, M.B.Ch.B., Dana
Telem, M.D., Stony Brook University Hospital, Stony Brook, NY
Diaphragmatic pacing had been used successfully in the past to wean ventilator dependent patients with
quadriplegic spinal cord injuries. Amyotrophic lateral sclerosis (ALS) is a progressive and fatal
neurodegenerative disorder. Respiratory and bulbar dysfunction are the leading causes of death and
respiratory support is uniformly needed in the later stages of the disease. Initially non-invasive Bi-Pap is
helpful but tracheostomy and mechanical ventilation follow - not always acceptable to patients. We
present the case of a 48-year-old man with ALS presenting for diaphragmatic pacing. Our anesthetic
management successful wean and discharge home of this patient are discussed.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC876
Acute STEMI Presenting During an Awake Craniotomy for Removal of Brain Tumor
Jacob Tiegs, M.D., Daniel Betterly, M.D., Mitch Lee, M.D., New York University, New York, NY
51-year-old male with HTN CAD and brain tumor presenting for awake craniotomy for tumor removal.
Patient initially intubated and headpins placed. Next patient extubated and given local infiltration over
pins while sedated with remifentanyl and dexmedetomidine. Suddenly the patient complained of chest
pain. ST elevations noted on monitor. The surgeons made aware no aspirin given. Surgery concluded
and skull closed. Cardiology made aware and PACU 12 lead EKG showed STEMI in LAD distribution. Cath
showed occlusion of LAD. Occlusion suctioned and balloon angioplasty performed. No heparin or stents
used due to recent brain surgery. Patient transferred to ICU.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC877
Swing and a Miss in a Patient With Lou Gehrig's Disease
Matthew Torre, D.O., Scott Miller, M.D., Wake Forest University, Winston-Salem, NC
We discuss the first two cases performed at our institution for placement of the newly approved
Diaphragm Pacing System (DPS) in patients with Amyotrophic Lateral Sclerosis (ALS). Important
Copyright © 2013 American Society of Anesthesiologists
anesthetic implications and airway management are discussed including the avoidance of paralytics
during the case. Our first patient was induced with remifentanil and propofol which caused rigidity likely
due to remifentanil. Rescue intubation was achieved with a lightwand. Our second case underwent
awake fiber-optic intubation due to severe respiratory compromise and poor airway predictors without
incident. Both patients were successfully extubated in the O.R without adverse outcomes postoperatively.
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC878
Acute Hypotensive Transfusion Reaction With Concomitant Use of Angiotensin-Converting Enzyme
Inhibitors in a Neurosurgery Case
Catherine Vu, M.D., Scott Eber, M.D., Jackson Memorial Hospital, Miami, FL
The pathophysiology of AHTR involves bradykinin a vasoactive peptide that binds endothelium receptors
and causes hypotension. ACE inhibitors prevent bradykinin breakdown. Thus patients who take ACE
inhibitors have higher levels of bradykinin and are prone to AHTR. Our case involves a 59-year-old
female who took ACE inhibitors on the day of surgery for intracranial aneurysm repair. Her SBP dropped
from 130mmHg to 60mmHg within minutes of starting blood transfusion. The transfusion was stopped
and the patient's SBP increased back to 130mmHg range. The patient later received 1 unit of leukocytereduced PRBC prepared by the blood bank without changes in hemodynamics
Tuesday, October 15
8:00 AM - 9:30 AM
NA MC879
A Case Report: Anesthetic Management of A Patient With Kennedy's Syndrome Undergoing Peripheral
Re-vasculization
Jiang Wu, M.D., Lee Wallace, M.D., Shiva Sale, M.D., Cleveland Clinic, Beachwood, OH
Patients with Kennedy's disease(KD) might be at risk of laryngospasm aspiration and postoperative
respiratory failure. We describe the anesthetic management of a patient with KD with past anesthetic
history significant for postoperative larygospasm and acute respiratory failure requiring re-intubation
presenting for peripheral revascularization. Supraglottic airway was used and anesthetic was devoid of
neuromuscular blockade. The perioperative course was uneventful; there was no exacerbation of
neurologic signs or symptoms. We suggest that a patient with Kennedy's disease may be successfully
managed by supraglottic airway with assisted ventilation for peripheral vascular procedure if there are
no contraindications.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC881
Rett Syndrome: Double Epidural Catheter for the Control of Postoperative Pain After Scoliosis Surgery.
A Literature Review
Beatriz Nistal Nuno, M.D., Enrique Freire Vila, M.D., Complexo Hospitalario Universitario A Coruna, A
Coruna, Spain
Rett syndrome is a severe neurological disease caused by a structural defect in the short arm of the X
chromosome (Xq28). Scoliosis appears in more than 50% of patients. We present the case of a patient
affected by this syndrome and scoliosis who was scheduled to have an instrumented thoracolumbar
spine arthrodesis with general anaesthesia which passed without incident. We evaluate the specific
details of this syndrome its potential complications pre-anesthetic assessment and its management
Copyright © 2013 American Society of Anesthesiologists
from an anaesthetic point of view emphasising the control of postoperative pain using a double epidural
catheter with an infusion of local anaesthetics and fentanyl.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC882
Seven Years of Hand Pain Resolved With Scar Neuroma Injection and Trigger Point Injection
Stacie Oliver, M.D., Badie Mansour, M.D., John Young, M.D., Andrew Fine, M.D., Alberto de Armendi,
M.D., University of Oklahoma, Oklahoma City, OK
51-year-old male presented with seven years of pain in the web space between the thumb and index
finger. A spider bite led to infection multiple surgical debridements and a rotational flap to cover the
first web space of his hand. He developed scarring of this area with severe chronic pain that had lead the
patient to seek amputation of his hand. In our pain medicine clinic he was given a neuroma block with
0.25% bupivacaine and a normal saline injection into a trigger point in his flexor digitorum superficialis
radial head with complete resolution of his pain.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC883
Percutaneous Interferential Current Therapy Relieves Abdominal Pain
Phung Pham, M.D., Konstantinos Sarantopoulos, M.D., Ashish Udeshi, M.D., Jackson Memorial Hospital,
Miami, FL, Maria Forrest, M.D., Harvard, Boston, MA
Interferential Current Therapy (ICT) uses alternating criss-crossing 3000-5000 Hz of electrical current.
When applied percutaneously over areas of pain it can produce analgesia and stimulate muscle function.
While ICT has been used extensively for the relief of musculoskeletal pain its potential against visceral
and neuropathic pain remains unclear. We report two cases of successful application of percutaneous
ICT for the management of abdominal pain from diabetic gastroparesis and chronic pancreatitis. ICT has
a potential as a simple and possibly cost-effective therapy for abdominal pain. In addition to analgesia
ICT may promote GI motility by stimulation of GI smooth muscles.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC885
Gasserian Ganglion Pulsed Radiofrequency Acupuncture and Biofeedback for Severe Trigeminal
Neuralgia
Abed Rahman, M.D., David Wahba, M.D., Cook County Health System, Chicago, IL, Raed Rahman, D.O.,
Cancer Treatment Centers of America, Zion, IL
32-year-old male with multiple sclerosis presenting with several year history of severe unilateral
trigeminal neuralgia not responsive to local anesthetic and steroid injections currently maximal doses of
medications. Patient progressively becoming depressed lost job due to severity of pain now dependant
on opiods. Started with psychological biofeedback with pain psychologist for 1 month acupuncture
weekly. Had 2 injections 1 month apart Pulsed Radiofrequency at 41C for 120 seconds through the
foramen ovale. Pain decreased 75% with increased quality of life and return to work. Off of all opiods.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC886
Pain Management: Integral Component of Nephrogenic Systemic Fibrosis Treatment
Stephanie Reed, M.D., John Corey, M.D., Vanderbilt University Medical Center, Nashville, TN
Nephrogenic Systemic Fibrosis (NSF) is related to gadolinium exposure in patients with compromised
renal function and leaves patients with severe immobility and pain. NSF has few treatment options
relying on evidence comprised of case series. This case highlights a 44-year-old female on dialysis who
received gadolinium and developed NSF refractory to kidney transplant imatinib pentoxyfylline and
plasmapheresis who receives maximal benefit from total body intralesional injections with local
anesthetic and corticosteroids. Discussion will include diagnostic criteria of NSF literature review of
treatment options and pathogenesis as a basis for response to intralesional injections with local
anesthetic with glucocorticoids.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC887
Management of Opiod-Induced Hyperalgesia Following Brachial Plexus Injury
Nicholas Riegels, Kaiser Oakland, Oakland, CA
A 20-year-old man sustained lung contusions pneumothorax subdural hematoma mandibular fracture
occipital condylar fracture and right brachial plexus injury in a high-speed MVA. He responded favorably
to stabilization of his injuries but experienced severe burning tingling right arm pain with bouts of
generalized myoclonus; pain service consultation ensued. His analgesic regimen included gabapentin
nortriptyline hydromorphone and fentanyl amounting to 2280 mg of oral morphine equivalents daily.
Opiate rotation to methadone was undertaken out of suspicion for opiod-induced hyperalgesia.
Hydromorphone was weaned over several days followed by weaning of fentanyl and then methadone.
The patient's analgesia improved markedly; myoclonus resolved.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC888
Management of an Opioid Tolerant Patient After Extensive Spine Surgery
Najmeh Sadoughi, M.D., Margaret Miller, M.D., University of Southern California, Los Angeles, CA
A 54-year-old female with history bipolar fibromylagia dystonia and chronic pain admitted for repair of
her scoliosis. She was on chronic pain medications at home equivalent to 260 mg Intravenous morphine
daily and was scheduled for L1-Pelvis Posterior spinal Fusion and L5-S1 anterior Lumbar Interbody
Fusion. Pain control immediately post operatively was achieved with Fentanyl Ketamine and Versed
infusion without intubation. On postoperaion Day 4 patient's home oral pain medication regimen was
converted to transdermal fentanyl patch and supplemented with oxycodone for breakthrough pain.
Fentanyl patch was then slowly titrated down over hospital stay as tolerated by patient.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC889
Lagophthalmos Following Selective V2 Maxillary Nerve Block
Amit Shah, M.D., Yale University School of Medicine, New Haven, CT, Srdjan Nedeljkovic, M.D., Brigham
and Women's Hospital/Harvard Medical School, Boston, MA
There are a number of complications associated with maxillary nerve blockade. Fluoroscopic guidance
can reduce procedure time and complications from needle misplacement. We report a case of
lagophthalmos that has not been described in literature. Following a successful maxillary block from an
infrazygomatic approach the patient reported an inability to close her ipsilateral eye. Symptoms
resolved in 40 minutes. Conclusion: The zygomatic branches of the facial nerve are relatively superficial
and in close proximity to the cutaneous point of entry to maxillary nerve blockade. The spread of
subcutaneous local anesthetic infiltration can involve these branches resulting in transient ipsilateral
lagophthalmos.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC890
Damaged Radiofrequency Cannula: Effects on a Patient Undergoing Thermal Radiofrequency Ablation
of Cervical Medial Branch Nerve and Examination of the Damaged Radiofrequency Cannula
Bharat Sharma, M.S., Satvik Munshi, M.D., Louisiana State University School of Medicine, New Orleans,
LA, Sanjay Sharma, M.D., VA Medical Center, New Orleans, LA, James Cronin, Ph.D.; Tulane University,
New Orleans, LA
A 62-year-old man felt discomfort even after injection of local anesthetic prior to thermal
radiofrequency lesioning of the cervical medial branch. He did not feel any pain after the cannula was
replaced with a new cannula in exactly the same location. Macro photography showed some damage to
the insulation of the 22G cannula possibly during the procedure. Coagulation was observed when a
simulated lesion was produced in albumin at 80°C. We plan to check for current leaks along the length
of the needle with a multimeter and perform a light microscopic and surface electron microscopic
examination.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC891
Accidental Massive Morphine and Bupivacaine Dose Delivered Subcutaneously During Refill of
Implantable Drug Delivery Device for Intrathecal Analgesia: A Case Report
Paramvir Singh, M.D., Gunar Subieta, M.D., Pratiksha Trivedi, M.D., Taruna Penmetcha, M.D., Maria
Torres, M.D., John H Stroger Hospital of Cook County, Chicago, IL
47-year-old female FBSS had Intrathecal pump placed for analgesia. Dose- Morphine 3mg/day
Bupivacaine 4mg/day. During one visit for refill of the pump with 240mg Morphine and 320 mg
Bupivacaine by the fellow the needle apparently became dislodged and the drug was injected into a
subcutaneous pocket. The patient complained of being sleepy and nauseated. The misdirected injection
was quickly suspected. The pump reservoir was accessed and found to be empty. Immediately the
patient was given 0.04 mg of naloxone intravenously begun on a continuous infusion 0.1mg/hr. The
patient was monitored overnight. No sequelae of LA toxicity noticed.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC892
Evolution of Vertebrobasilar Insufficiency Masked by Coexisting Pain Syndromes: A Case Report
Daryl Smith, M.D., University of Rochester, Rochester, NY, Svetlana Pyatigorskaya, R.N., Canton-Potsdam
Hospital, Potsdam, NY
A 56-year-old male with a 40 year smoking history alcoholism and depression; presented to the Pain
Clinic with neck and thoracic back pain. Physical examination revealed symmetrical peripheral pulses;
cervical and upper back trigger points; and a positive bilateral Spurling's test. Cervico-thoracic MRI
revealed foraminal stenoses in both regions; and thoracic facet joint hypertrophy. Trigger point
injections topiramate and meloxicam trials provided variable limited relief. Tension headaches and
decreased right hand strength began around treatment day 360. Peripheral pulses were symmetrical
until asymmetrical pulses were found on day 678. Angiography revealed right subclavian artery
occlusion with subclavian steal.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC893
Capacity Competency and Consent in a Severely Traumatic Injury
Carlyle Hamsher, M.D., Mount Sinai Medical Center, NewYork, NY, Christopher Spevak, M.D.,
Georgetown University School of Medicine, Washington, DC
A 22-year-old service member presents after sustaining a dismounted complex blast injury with multiple
limb amputations and severe neuropathic pain in a remaining extremity due to sciatic nerve avulsion.
The pain was treated with a multimodal and multidisciplinary approach including high dose oral and IV
opioids membrane stabilizers nonsteroidal anti-inflammatories anti-depressants ketamine infusion
regional anesthesia physical therapy TENS acupuncture and cognitive behavioral therapy. The team
considered spinal cord stimulation. The issue facing the team was how to obtain consent for an elective
surgical procedure in a patient with severe pain receiving a combination of opioids and other
medications affecting neurocognition.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC894
Low Back Pain From Bertolotti's Syndrome Successfully Treated With CT-Guided Dehydrated Amnion
and Chorion Membrane (AmnioFix) Injection
Charles Stehman, M.D., Jeremy Hackworth, M.D., Naval Medical Center San Diego, San Diego, CA
Human amnionic membrane has potent regenerative and anti-inflammatory properties. We present a
case where injectable dehydrated amnionic and chorionic membrane was injected to a patient with low
back pain presumably from the psuedoarticulation present in Bertolotti's syndrome which resulted in
near complete resolution of back pain at the injection area. After temporarily responding to a local and
steroid injection once the pain returned the patient was injected with steroid on the left and amnionic
membrane on the right. After 3 months the patient had near complete resolution of the pain on the
right with no resolution on the left.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC895
Pulsed Radiofrequency Ablation of the Dorsal Root Ganglion Dramatically Improves Pain in the
Treatment of Refractory Post Herpetic Neuralgia
Matthew Ufberg, M.D., Gaurav Trehan, M.D., Temple University Hospital, Philadelphia, PA
A 52-year-old female presented with complaints of left torso pain secondary to shingles. Past medical
history was significant for lumbar radiculopathy and diverticulosis and she had no significant surgical or
social history. She was prescribed voltaren gabapentin and pregabalin none provided relief. She
concurrently received three thoracic epidural injections which relieved her symptoms for only a week
each time. At that point pulsed radiofrequency ablation of the left T8 T9 and T10 dorsal root ganglion
was performed. She experienced significant improvement and on 6-month follow-up she reported
sustained 60-70% pain relief. Furthermore on one-year follow-up she noted 50% continued relief.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC896
Spinal Cord Stimulation for Electrical Storm Refractory to Conventional Medical Treatment
Hong Vo, M.D., David Walega, M.D., Northwestern University Feinberg School of Medicine, Chicago, IL
Our patient is a 35-year-old male with familial dilated cardiomyopathy s/p biventricular internal cardiac
defibrillator (ICD) placement. Despite being medically treated with sotalol and amiodarone he presented
to the ER with an electrical storm after his ICD delivered 13 shocks. He was admitted to the cardiac
intensive care unit (CICU) treated with amiodarone suppressive therapy and discharged home under
stable condition. The following day he was readmitted to the CICU after his ICD fired multiple shocks. In
this case report we describe the potential benefit of spinal cord stimulation in treating intractable
ventricular tachyarrhythmias.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC897
Detoxification as a Treatment for Opioid-Induced Hyperalgesia
Jenna Walters, M.D., Kurt Dittrich, M.D., Vanderbilt University Medical Center, Nashville, TN
57-year-old female with systemic lupus erythematosus and sarcoidosis presented with complaints of
chronic uncontrolled fibromyalgia pain. Her treatment regimen included Morphine SR 100mg twice daily
and Ibuprofen which had slowly escalated over four years. She endorsed symptoms of depression
despite treatment with Risperidone and denied suicidal ideation. Due to concern for opioid-induced
hyperalgesia she completed seven days of hospital based inpatient detoxification utilizing a protocol of
buprenorphine clonidine and psychological counseling. She was discharged completely off Morphine but
continued on Tramadol 50mg every four hours and Risperidone. She remains opioid free and feels she
has her life back.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC898
Ultrasound Guided Intrathecal Pump Refill
Xueyuan Wang, M.D., Hung-Lun Hsia, M.D., Lance Roy, M.D., Billy Huh, M.D., Ph.D., Duke University
Medical Center, Durham, NC
Intrathecal pump refills can be challenging in patients with difficult anatomy or pump positioning.
Catastrophic overdoses can occur if pump medication is inadvertently injected outside the reservoir. We
describe using Doppler ultrasound for difficult pump refills whereby the refill port is located using direct
ultrasound guidance and the medication flow path is directly visualized using Doppler technology. This
method allows for immediate confirmation that medication is being delivered into the reservoir and not
extravasating into surrounding tissue. In addition to visualization of flow use of ultrasound may be
preferable to fluoroscopy due to lack of radiation and flexibility in positioning.
Tuesday, October 15
8:00 AM - 9:30 AM
PN MC899
Flipped Intrathecal Pump Identified Using Ultrasound
John Young, M.D., James Stephens, D.O., Robert Rowlett, M.D., Tilak Raj, M.D., Randall Henthorn, M.D.,
University of Oklahoma HSC, Oklahoma City, OK
A 29-year-old obese female with severe CRPS was in need of a refill of her intrathecal baclofen pump.
Her pump was hyper-mobile and frequently flipped in the subcutaneous pocket. X-rays were difficult to
obtain due to her condition and were unreliable in identifying the current pump orientation because the
pump would flip while moving off the x-ray table. Ultrasound was used at bedside to identify not only
the location of the pump but also it's orientation at the time of refill. Ultrasound is a simple safe and
effective way to identify pump orientation.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC900
The Utility of Peripheral Nerve Block for Positioning of Multiple Trauma Victim in Adjunct to
Conduction Anesthesia
Elizabeth Rivas, M.D., Hana Teissler, M.D., Texas Tech University Health Sciences Center at El Paso, El
Paso, TX
75-year-old male sustained automobile vs. pedestrian accident with multiple open fractures in bilateral
lower extremities. The patient medical history was significant for CAD MI CHF Af HTN AICD placement
pulmonary HTN and OSA. Echo showed global systolic dysfunction with LVEF 20%. Interdisciplinary
communication with the orthopedic surgeons was necessary to provide the safest and most appropriate
anesthetic management. Due to his co-morbidities the decision for regional anesthesia was made. PNB
was conducted to minimize the positional pain. Then combined spinal/epidural anesthesia was
performed. After the uneventful surgery the patient was taken to PACU in stable condition with minimal
pain.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC901
Continuous Spinal Anesthesia for Hip Replacement in an Elderly Patient With a Large Anterior
Mediastinal Mass: Case Report
Victor Rivero, Osmar Creagh, M.D., Daniel Fernandez, M.D., Cesar Hernandez, M.D., University of Puerto
Rico Medical Sciences Campus, San Juan, PR
Continuous spinal anesthesia (CSA) allows for better control of adverse effects caused by sympathetic
nerve blockade. We report a 91-year-old female with a left intertrochanteric fracture and a large thyroid
mass causing displacement of the trachea and great vessels. We conducted a detailed investigation of
the different techniques used in such circumstances and the consequences each may have. CSA is an
anesthetic alternative to consider on elderly patients with an anterior mediastinal mass undergoing hip
fracture surgery.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC902
Delayed Recognition of Inadvertent Intrathecal Catheterization: The Next Step?
Pragati Rohatgi, M.D., Keun Chung, M.D., Yale University School of Medicine, New Haven, CT
A 71-year-old female undergoing bilateral knee arthroplasty had L2-L3 epidural catheter placed for
postoperative analgesia. Test dose with lidocaine/epinephrine was negative. Upon completion of the
operation (general anesthesia) 5cc 0.125% bupivacaine was given epidurally after negative aspiration
(CSF). Patient awoke complaining of knee pain. Additional 5cc 0.125% bupivacaine was injected after
negative aspiration. In PACU she was awake but hypotensive and hypoxemic and sensory blockade to
T4. BP responded to IV ephedrine and phenylephrine. CSF was aspirated from epidural catheter. For the
next 24 hours this catheter was employed for continuous spinal analgesia with pain scores 2-4/10
without complications.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC903
Warming Blanket Induced Increased Transcutaneous Fentanyl Absorption as Cause of Postoperative
Somnolence
Martin Samborski, M.D., Rose Campise Luther, M.D., Medical College of Wisconsin, Wauwatosa, WI
A patient presents for open right cytoreductive nephrectomy renal cell carcinoma. Preoperative
medication included a 50mcg Fentanyl Patch and Oxycodone. He had a thoracic epidural placed bolused
with 1mg of dilaudid and bupivacaine 0.25% with epi. Additionally he received 300mcg of Fentanyl over
6h. The patient remained somnolent 12h postoperatively with respiratory rates as low as 6 even after
changing the epidural infusion to a non narcotic solution 5h postoperatively and the fentanyl patch
removed. We hypothesized that the patient received a transcutaneous opoid overdose by placing the
patch under a warming blanket and increasing absorption.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC904
Aortic Stenosis and Continual Spinal Anesthesia
Maricela Sanchez, Anthony Brown, M.B.Ch.B., Danielle Ludwin, M.D., Columbia University Medical
Center, New York, NY
A patient with severe aortic stensosis presented with a hip fracture and is scheduled for urgent hip
hemiarthroplasty. The chief anesthetic goal in the setting of aortic stenosis is the avoidance of sudden
reduction in systemic vascular resistance. Neuraxial anesthesia is traditionally considered to be a
contraindicated due to associated hypotension. However the use of a continuous spinal anesthetic is
associated with a decreased risk of hypotension compared to a single shot spinal anesthetic and yet
provides a more reliable and dense sensory and motor block than an epidural anesthetic.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC905
Tracking Success: In-Plane Approach to Continuous Popliteal Catheter Placement
Krystal Scherrer, M.D., Atilla Kerner, M.D., Saint Louis University, St Louis, MO
58-year-old M without significant PMH who presented s/p trauma with an open tibia fracture. A
continuous popliteal nerve catheter was placed using an in-plane technique. After positioning the probe
was rotated to view the nerve in the long axis. A block needle was positioned via an in-plane approach
to the posterior LAX in a caudal to cephalad direction. The catheter was visualized as it was threaded
parallel to the nerve. Placement was confirmed using motor twitch. Analgesia was achieved via a ON-Q
C-bloc pump. The patient had pain relief for 9 days without migration or kinking of the catheter.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC906
Shoulder Surgery Under Regional Anesthesia in a Patient With Partial Lung Resection
Eric Schwenk, M.D., Jaime Baratta, M.D., Kishor Gandhi, M.D., Jefferson Medical College, Philadelphia,
PA
An 89-year-old female with history of heavy smoking and left lung lobectomy presented for right
shoulder arthroplasty. She insisted on regional anesthesia. A multimodal approach including
interscalene block acetaminophen ketorolac and opioids was taken. Surgery proceeded uneventfully and
postoperative analgesia was excellent. Interscalene block impairs ipsilateral lung function and lung
disease is a relative contraindication. We present a successful outcome in a patient with pre-existing
reduced left lung function who then received a continuous interscalene block causing right-sided
hemidiaphragmatic paresis. To accommodate the wishes of the patient's family a multimodal approach
that avoided general anesthesia and minimized opioids was emphasized.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC907
Prolonged Spinal Anesthesia (>10 Hours) Following CSE Placement for Emergent Ankle Fracture Repair
and It's Not What You Think
Brian Seacat, M.D., Tilak Raj, M.D., Praveen Kalra, M.D., University of Oklahoma Health Sciences Center,
Oklahoma City, OK
We report a 65-year-old female with an interesting and complicated past history which included a
mediastinal mass and cardiac arrest on induction presenting to us with an open ankle fracture following
an accident requiring urgent repair. CSE was performed with adequate surgical anesthesia. Five hours
following 1.6 mL 0.75% bupivacaine with 20 mcg fentanyl no neurological function had returned. Urgent
MRI showed spinal ischemia above the block level. Patient was transferred to the trauma ICU and
phenylephrine infusion was initiated to maintain MAP >75 mmHg. Neurological function returned 10hours post-puncture with an uncomplicated further hospital course.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC908
Use of Diphenhydramine 0.5% as a Local Anesthetic for a Pacemaker Placement in a Patient With
Severe Aortic Stenosis Mobitz Type II AV Block With RBBB and True Allergy to Amide and Ester Local
Anesthetics
Tanvi Shah, M.D., Ph.D., Ahmad Elsharydah, M.D., UT Southwestern Medical Center, Dallas, TX
An 85-year-old male (98 kg 183 cm) was admitted to our institution for a work-up of syncope. He was
found to have a severe aortic stenosis with a normal EF and Mobitz type II atrio-ventricular block with
RBBB. His other medical problems include HTN stroke and trigeminal neurolgia. He has a true allergy to
local anesthetics (amides and esters) according to his medical chart. A single chamber pacemaker was
implanted utilizing Diphenhydramine 0.5% as local anesthetic and MAC. Patient tolerated procedure
very well.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC909
Don't Place That Regional Block: I'm Monitoring for Compartment Syndrome!
Mourad Shehebar, M.D., Meg Rosenblatt, M.D., Icahn School of Medicine Mount Sinai, New York, NY
Compartment syndrome (CS) is rare and devastating. CS is caused by trauma with subsequent increased
tissue pressure resulting in ischemia muscle necrosis and increased pain. Regional blocks have been
eschewed by surgeons as possibly masking symptoms of CS which could delay diagnosis and treatment.
A 31-year-old female presented for a tibia ORIF. Single shot popliteal and femoral blocks with 0.25%
bupivacaine were performed preoperatively with subsequent LMA placement under GA. Vigilance
understanding the signs and symptoms of CS ongoing patient assessment and having a high index of
suspicion permitted the use of these techniques to provide optimal analgesia.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC910
68-Year-Old 51 kg Female With Bilateral Transversus Abdominus Plane (TAP) Catheters Presented
With Bilateral Quadricep Muscle Weakness T4 Sensory Level and Shortness of Breath on POD#2
Meredith Shepherd, M.D., Jonathan House, M.D., Kristen Spisak, M.D., Indiana University, Indianapolis,
IN
68-year-old 51kg ASA3 Female with bilateral Transversus Abdominus Plane (TAP) Catheters placed for
post operative pain control for a cystectomy was found to have bilateral quadricep weakness T4 sensory
level and shortness of breath on POD#2. Pt reported 0/10 pain at this time with TAP Catheters infusing
0.2% Ropivicaine at 8ml/hr on each side. Pt's TAP catheters were discontinued at this time. Five hours
after discontinuation normal sensation returned and shortness of breath resolved. Ten hours after
discontinuation normal motor function of her lower extremities also returned.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC911
Subcostal TAP Block With the Lateral Classic TAP Block to Control Pain in a Patient With a Large
Complex Adnexal Mass Undergoing Surgical Debulking
Kimberly Simms, M.D., Clara Espi, M.D., University of Southern California, Los Angeles, CA
A 66-year-old female with worsening abdominal pain was found to have a 17-cm complex adnexal mass
and was scheduled for a total abdominal hysterectomy, bilateral salpingo-oophorectomy and surgical
debulking. The patient refused epidural analgesia, but agreed to a transversus abdominis plane (TAP)
block. Bilateral subcostal TAP blocks below the rectus abdominus muscle, and bilateral lateral classic
TAP blocks were performed, both with ultrasound. This dual TAP block eliminated the need for
analgesics during incision of the abdominal wall and minimized subsequent analgesic requirements. For
cases with extensive vertical abdominal incisions, the bilateral dual TAP block should be considered.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC912
A Laminar Approach to the Paravertebral Block in a Patient With Pleural Effusion
James Slotto, M.D., Justin Heil, M.D., Naval Medical Center San Diego, San Diego, CA
The thoracic paravertebral block is a standard pain management tool for breast surgery but carries the
notable risk of pneumothorax. The risk of a small pneumothorax is generally outweighed by the pain
control benefits. We present a patient undergoing palliative mastectomy for malignant breast cancer
complicated by chronic pleural effusion requiring a contralateral chest tube. To avoid a bilateral
pneumothorax a traditional paravertebral block was contraindicated. A laminar approach to the
Paravertebral block was used; whereby the needle is kept external to the intercostals space. This block
provided excellent pain control while reducing the risks of an otherwise difficult block.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC913
Anesthetic Management for Hemiarthroplasty in a Pulmonary Cripple With Lumbar Spine
Hemangioma
Stephen Vose, M.D., M.S., Jozsef Endredi, M.D., University of Florida College of Medicine North
Florida/South Georgia VA Medical Center, Gainesville, FL
66-year-old M with PMH of severe COPD is admitted with right femoral neck fracture and RLL
pneumonia. Surgical intervention is postponed in favor of medical optimization. By hospital day (HD)
three the patient requires ventilatory support and MICU admission. It is HD nine before his medical
team clears him for surgery. Anesthesia Pre-Op Assessment discovers a previously unrecognized history
of L3 Hemangioma. After further workup and consultation was performed the patient was able to safely
undergo epidural placement under fluoroscopic guidance. The operation proceeded successfully under
epidural anesthesia thus avoiding general anesthesia in this high risk patient.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC914
Arthroscopic Rotator Cuff Repair in a Patient With Eisenmenger Physiology: Ambulatory Interscalene
Catheter
Tariq Malik, Nihir Waghela, M.D., Anthony Tantoco, M.D., University of Chicago Hospitals, Chicago, IL
A 58-year-old woman with pulmonary HTN and ASD on remodulin infusion needed rotator cuff repair.
Regional anesthesia with a superficial cervical block was planned for the procedure. An Interscalene
catheter was placed with ultrasound guidance. Lidocaine 2% was administered at 2 ml every 15 min up
to 6 ml over 45 min to block C5 and C6. The patient tolerated 3 hr of surgery with no other sedation.
After the surgery the catheter was infused with 0.125% bupivacaine 4 ml/hr. She was discharged with
the catheter which provided excellent analgesia. The catheter was removed on POD 3.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC915
Management of Thoracic Epidural in the Setting of Complete Anticoagulation During Emergent Cardiac
Catheterization for Intraoperative RCA Occlusion
Christian Walker, M.D., Sujatha Bhandary, M.D., The Ohio State University, Columbus, OH
A 65-year-old male with a history of CAD with MI s/p CABG hyperlipidemia DMII PVD and laryngeal
cancer presented for resection of right upper lobe mass by thoracotomy. A pre-operative thoracic
epidural was placed for pain control. The patient developed intra-operative MI needing pacer placement
and bleeding necessitating re-exploration before proceeding to cardiac catheterization. He required
anti-platelet therapy with aspirin loading dose clopidogrel and full anticoagulation with bivalirudin
infusion for placement of three bare metal stents for complete RCA occlusion. The thoracic epidural was
removed on post-operative day 7 and the patient was discharged home without neurological
complications.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC916
Diagnostic and Therapeutic Occipital Nerve Blocks for Reported Trauma Induced Occipital Neuralgia
Jeremie Walker, M.D., Stephen Howell, WVU, Morgantown, WV
The patient described in this case report developed post-traumatic headaches following a motor vehicle
collision with head injuries. After non-invasive approaches to the management of his occipital neuralgia
failed (4 week hospital course) bilateral greater occipital nerve blocks conferred symptom relief in a
matter of hours. This case report highlights an interesting presentation of post-traumatic occipital
neuralgia and underscores the utility of occipital nerve block as a therapeutic and potential diagnostic
modality.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC917
Regional Anesthetic Management of a Turner's Syndrome Patient for a Non-Cardiac Procedure
Mi Wang, Rakhi Pal, Kenneth Cummings, Cleveland Clinic Foundation, Cleveland, OH
A 39-year-old woman with Turner's syndrome was scheduled to undergo orthpedic surgery. She had
compromised heart function with coarctation of the aorta and multiple other comorbidities. She had a
short stature with a short webbed neck and severe scoliosis. We chose regional anesthesia
supplemented with intravenous sedation. Due to her short webbed neck infraclavicular block was
considered anatomically more favorable than supraclavicular block. A single injection of local anesthetic
was administered under ultrasound and sedation was achieved with propofol infusion. Her blood
pressure was within normal limits no arrthymia occurred and anesthesia was uneventful with a
satisfying outcome.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC918
Lower Extremity Peripheral Nerve Block in a Patient With Charcot-Marie-Tooth Disease
Michael Wassef, M.D., Ali Shariat, M.D., St. Luke's-Roosevelt Hospital Center, New York, NY
An 18-year-old man suffering from Charcot-Marie-Tooth disease was scheduled for right foot osteotomy
and tendon transfer. The patient refused GA due to history of severe post-operative nausea and
vomiting. A right-sided popliteal block was performed under triple monitoring using ultrasound guidance
peripheral nerve stimulation and in-line pressure manometry (to assure an injection pressure below 15
psi). Ropivacaine 0.5% 20 mL was injected under ultrasound visualization. Sensory and motor block
ensued within 10 minutes and surgery proceeded uneventfully. The patient had full recovery of motor
function 6-7 hours after the block was performed with pain relief lasting 28 hours.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC919
Subcostal Transversus Abdominis Plane Block to Facilitate Laparoscopic Cholecystectomy Without
Neuromuscular Blockade in a Patient With Myasthenia Gravis
Douglas Wetmore, M.D., Lucas Bejar, M.D., Meg Rosenblatt, M.D., Icahn School of Medicine at Mount
Sinai, New York, NY
A 68-year-old female with myasthenia gravis on chronic pyridostigmine requiring recent plasmapheresis
presented for laparoscopic cholecystectomy. Pyridostigmine was continued until the operation. Our goal
Copyright © 2013 American Society of Anesthesiologists
was to avoid neuromuscular blockade subsequent reversal and potential cholinergic crisis. Anesthesia
was induced with propofol and remifentanil. A subcostal transversus abdominis plane block with 30mg
of 0.25% bupivacaine was performed using ultrasound-guided block technique for perioperative
analgesia. Anesthesia was maintained with remifentanil titrated to effect and sevoflurane at &gt;1 MAC.
TOF was .65 after induction and 1 prior to extubation. Only 50mcg of fentanyl in addition were required
for analgesia during the perioperative period.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC920
Bilateral TAP Blocks in Early Stage of Postoperative Abdominal Wall CRPS
Judd Whiting, M.D., Kerry Hollenbeck, M.D., Naval Medical Center San Diego, San Diego, CA
32-year-old male underwent midline laparotomy for left renal vein transposition. Postoperative day two
he endorsed 10/10 pain of the abdominal wall diagnostic for CRPS type 1. He couldn't tolerate
positioning for epidural placement. Bilateral ultrasound-guided TAP blocks were performed using classic
and subcostal needle insertion points resulting in complete pain relief. He then tolerated a thoracic
epidural placement. Return of allodynic pain 2 days later was treated with a ketamine infusion and a
hydromorphone PCA. Epidural was continued until postoperative day eight. The patient was discharged
the same day with pain controlled on only oral opioids.
Tuesday, October 15
8:00 AM - 9:30 AM
RA MC921
Management of Acute on Chronic Pain in the Trauma Patient
Lara Zador, M.D., Donna Thomas, M.D., Yale New Haven Hospital, New Haven, CT
Pt is a 24-year-old male construction worker with chronic pain presents with radius fracture after falling
25-feet at work. Acute Pain Service consulted for management of acute chronic and post-surgical pain.
Pt's home medication includes fentanyl patch pregabalin gabapentin oxycodone and alprazolam. Intraoperatively pt started on ketamine infusion with dilaudid fentanyl and midazolam boluses. Postoperatively pt continued to complain of 10/10 surgical and chronic neuropathic pain despite significantly
increased doses of multi-modal analgesia including hydromorphone PCA NMDA receptor antagonist and
maintenance of home medications. Pt appeared comfortable vital signs normal. Patient responded
positively to discussions with Pain Service team.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC922
Post Liver Transplantation Cardiomyopathy: Case Report
John Siu, M.D., Christopher Franklin, M.D., University of Maryland, Baltimore, MD
56-year-old female with ESLD due to alcoholic cirrhosis s/p orthotropic liver transplant extubated POD 1
with uneventful recovery. POD 3 she developed respiratory distress requiring intubation new findings of
NICM with EF 20% global LV hypokinesis and preserved RV. CT chest showed multiple opacities.
Antibiotics given for presumed pneumonia. POD 5 repeat TTE demonstrates EF 55%. POD 8 she was
successfully extubated. Over the next 5 days patient with worsened pulmonary status requiring
reintubation. Of note patient received blood transfusions within 24 hrs of each respiratory distress
event. Bronchoscopy demonstrated minimal secretions. Cultures sent.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC923
Status Epilepticus Following ECT Treatment
Andrew Sternlicht, M.D., Roy Braid, M.D., Michael Moffitt, M.D., St. Elizabeth's Steward Medical Center,
Brighton, MA
A 66-year-old female presented for first ECT treatment for severe depression. Her past medical history
was significant for a remote history of seizure attributable to a drug reaction and currently treatment
with valproate for mood stabilization discontinued 7 days prior to ECT. She had successful ECT
treatments 7 months previously. After anesthetic induction with etomidate and succinylcholine a
threshold delivered stimulus produced a prolonged seizure of approximately 15 minutes which was
treated unsuccessfully with midazolam and propofol followed by dilantin which terminated the seizure.
The patient recovered uneventfully with post-ictal signs. The background workup treatment and
recovery are discussed.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC924
Palliative Splenectomy in a Patient With Myelofibrosis and Severe Symptomatic Anemia Secondary to
Hemolysis and Splenic Sequestration
Jessica Stevens, M.D., Susan Martinelli, M.D., University of North Carolina, Chapel Hill, NC
Myelofibrosis is a chronic myeloproliferative disorder in which the accumulation of myeloid progenitors
leads to pathologic enlargement of the spleen resulting in anemia secondary to hemolysis and splenic
sequestration. Splenectomy has been shown to be an effective palliative procedure with acceptable
morbidity in select patients with myelofibrosis. We present a case of a 66-year-old male with severe
symptomatic anemia from myelofibrosis scheduled for palliative splenectomy. Due to the patient's
severe transfusion dependent anemia and multiple red cell antibodies this case required significant
perioperative communication and preparation with the blood bank and the surgical team .
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC925
Ethical Dilemmas In Managing A Brain Stem Dead Pregnant Patient
Nazneen Sudhan, Sridhar Nallapareddy, M.D., F.R.C.A, Addenbrookes Hospital, Cambridge, UK
A preterm parturient with history of severe headaches for one month presented with seizures. An MRI
head showed a frontal mass lesion with enhancement. After 12 hours of stable neurology patient
developed dilated fixed pupils needing emergency craniotomy and debulking of tumor histologically
confirmed as anaplastic oligodendrglioma. There was no improvement in the neurological status despite
neurosurgical intervention and patient was pronounced brainstem dead. Great ethical issues were
encountered in context of alive non-viable fetus. Patient's family chose to not continue the somatic
support prolongation to save the life of fetus however allowed to procure the maternal organs for
transplantation.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC926
Anesthetic Management of Ruptured Pulmonary Artery Rasmussen Aneurysm and Massive
Hemoptysis
Madiha Syed, M.B. B.S., Jill Irby, M.D., University of Arkansas for Medical Sciences, Little Rock, AR
Massive hemoptysis secondary to pulmonary artery aneurysm rupture is a rare phenomenon presenting
unique challenges in airway management and stabilization of oxygenation ventilation and blood
pressure. We present a case of a 35-year-old female with necrotizing cavitatory tuberculosis
complicated by ruptured pulmonary artery Rasmussen aneurysm and massive hemoptysis. Patient
required emergent intubation resuscitation and hemodynamic stabilization prior to undergoing
emergent embolization by interventional radiology.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC927
Abdominal Compartment Syndrome Post Splenic Artery Embolisation
Ngano Takawira, M.B.Ch.B., Pablo Moujan, M.D., John Zaki, M.D., Elizabeth Rivas, M.D., Texas Tech El
Paso, El Paso, TX
A 64-year-old male presented with an acute abdomen .A CT scan revealed a large pancreatic mass with
erosion into the splenic artery and splenic artery extravasation.A diagnosis of a metastatic pancreatic
malignancy was made and Interventional Radiology embolized the splenic artery but the patient
continued to deteriorate in the ICU the patient's bladder pressures were grossly elevated and a
diagnosis of abdominal compartment syndrome was made.A decompressive laparotomy was performed
and although the abdominal pressure came down it did not normalize.The patient developed multiorgan
failure and his family decided to withdraw care and he subsequently expired.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC928
Steroids to the Rescue
Yarnell Lafortune, M.D., Ezekiel Tayler, D.O., Helen Stutz, D.O., Albany Medical Center, Albany, NY
Airway management of the patient with a mediastinal mass requiring general anesthesia is clearly
outlined in the literature. We present a case of a patient with newly diagnosed mediastinal Hodgkin's
Lymphoma and worsening respiratory distress in the ICU. Subsequent treatment with high dose steroids
showed rapid improvement and avoided an airway emergency. Such therapy sheds light on the efficacy
of high dose steroids with rapidly progressing mediastinal lymphoma and airway compromise.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC929
Laryngospasm Leading to ECMO Rescue
Jordan Taylor, M.D., Roman Dudaryk, M.D., University of Miami / Jackson Memorial Hospital, Miami, FL
Case Description 36-year-old male status post gun shot wound to left lower extremity went to operating
room for ORIF of left femoral condyle. Induction intubation and surgery were smooth and uneventful.
Upon extubation patient developed laryngospasm causing severe negative pressure pulmonary edema.
He required emergent reintubation and had refractory hypoxia despite exploration of numerous
ventilatory options. Vasopressor infusions were required to maintain hemodynamics while CT surgery
Copyright © 2013 American Society of Anesthesiologists
placed cannulas and initiated V-V ECMO. Patient remained on ECMO with lung protective ventilation
until he was weaned to decannulation and eventually walked out of hospital neurologically intact 39
days later.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC930
Don’t Get Behind on Compartment Syndrome: A Rare Case of Postoperative Gluteal Compartment
Syndrome in the Intensive Care Unit
Beth Teegarden, M.D., Hokuto Nishioka, M.D., University of IL Hospital & Health Sciences System,
Chicago, IL
A morbidly obese male with multiple knee surgeries presented for resection arthroplasty with knee
arthrodesis. After a prolonged procedure and significant blood loss the patient was brought to the
intensive care unit. Several hours after extubation he complained of pain numbness and weakness in the
non-operative lower extremity. With progressively worsening pain in the left buttock a diagnosis of
gluteal compartment syndrome and rhabdomyolysis was made. He underwent an emergent fasciotomy
and critical care management. For patients with morbid obesity presenting for prolonged procedures
anesthesiologists should carefully consider positioning and have a suspicion for compartment syndrome
in the perioperative period.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC931
Severe Carcinoid Crisis: Touch to Believe
Nickole Teel, M.D., Mattew Torre, M.D., Chuanyao Tong, B.A., Wake Forest University School of
Medicine, Winston Salem, NC
A 56-year-old female with terminal metastatic carcinoid cancer presents for ureteral stent exchange.
High dose octreotide was administered before and during surgery. Following induction of anesthesia
whole body flushing occurred followed by progressive hypotension and significant ECG changes
including sinus tachycardia ST-T elevation complete heart block and widening QRS which did not
respond to multiple doses of vasopressors. Palpation of the carotid revealed a bounding pulse and two
boluses of nitroglycerin restored the ECG to sinus rhythm. The surgeons were able to complete the
procedure. The patient was extubated monitored overnight and discharged home next day
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC932
Recurrent Cardiac Arrests in the Setting of Severe Illness: A Case Report
Yi Cai Isaac Tong, M.D., Joshua Vacanti, M.D., Brigham and Women's Hospital, Boston, MA
The patient is a 36-year-old male with 80% total body surface area burn whose course was complicated
by recurrent asystolic arrests linked to intractable colonic distention. Following initial stabilization the
patient was admitted to the ICU. Several asystolic arrests were seen and thought to be precipitated by
changes in respiratory pattern and ventilator dyssynchrony. We suspected that these arrests were
linked to severe colonic distention confirmed by abdominal imaging. The patient's distention and
asystolic events persisted despite standard promotility interventions. An enteral infusion of
polyethylene glycol was initiated resulting in laxation and resolution of the patient's cardiac instability.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC933
Left Stellate Ganglion Block for the Treatment of Ventricular Tachyarrhythmias in Two Patients
Requiring Biventricular Assist Devices for Cardiogenic Shock After Myocardial Infarction
Emily Vail, M.D., Thomas Pfeiffer, M.D., Barry Fine, M.D., Ph.D., Staffan Wahlander, M.D., Michael
Weinberger, M.D., Columbia University College of Physicians and Surgeons, New York, NY
We describe two patients requiring biventricular assist devices for cardiogenic shock and recurrent
ventricular arrhythmias after myocardial infarction in whom left stellate ganglion blocks were
performed. In one patient the block was effective in terminating arrhythmias and facilitated
biventricular assist device explantation. In the other patient whose ventricular arrhythmias were caused
by atrial flutter stellate ganglion block failed to terminate ventricular arrhythmias. Both patients
experienced adverse effects of stellate ganglion block which were poorly tolerated due to their tenuous
clinical status and poor physiologic reserve.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC934
Perioperative Management of Brain Dead Female at 17 Weeks Gestation
Robert Vietor, M.D., Phillip Mason, San Antonio Uniformed Services Health Education Consortium, San
Antonio, TX
24-year-old female status post motor vehicle accident brought to trauma bay with GCS of 3. Intubated
and on head CT noted to have severe brain injury with central herniation. On CT of her aorta it was
noted she had an intra-uterine pregnancy with EGA of 17 weeks. Patient went to OR for emergent
craniectomy. Plan made to keep mother alive until fetus viable for delivery. In this presentation we will
discuss issues unique to peri-operative management of pregnant and head injured patients. We will also
discuss factors contributing to determining code status in a pregnant brain dead patient.
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC935
Moya Moya Disease Presenting With Acute Intracranial Hypertension and Acute Pneumomediastinum
Jonathan Weaver, M.D., Avinash Kumar, M.D., Vanderbilt University, Nashville, TN
A 25-year-old female presented with acute intraparenchymal hemorrhage (due to moyamoya disease).
The patient was intubated on admission and had an emergent placement of an external ventricular
drain to control intracranial hypertension. During diagnostic angiography and decompressive
craniotomy for malignant intracranial hypertension she developed sudden circulatory collapse in spite of
a normal intraoperative TEE and with bilateral breath sounds necessitating aggressive hemodynamic
resuscitation. She was stabilized and transferred back to the ICU. The cause was found to be a tension
mediastinum of unclear etiology. The unusual complication in a medically complex case presented a
challenge to management.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
8:00 AM - 9:30 AM
CC MC936
Extracorporeal Membrane Oxygenation (ECMO) Support of One-Lung Ventilation During Adult
Thoracic Surgery: A Case Series
Robert Weaver, M.D., Eric Ashford, M.D., Jeremy Dority, M.D., Zaki-Udin Hassan, M.D., University of
Kentucky, Lexington, KY, Michael Harned, M.D., Lexington Clinic, Lexington, KY
Extracorporeal Membrane Oxygenation (ECMO) is an intensive treatment used to support patients with
severe respiratory or cardiac disease who have failed more conventional means of management. ECMO
historically has been utilized in neonates with increasing evidence for adult use. Novel applications for
ECMO are increasingly described in the literature for hemodynamic support during surgery with
favorable outcomes. We present a case series in which ECMO was utilized during thoracic surgery in
three adult patients with severe pulmonary pathology to permit favorable cardiopulmonary conditions
during one lung ventilation.
MCC Session Number – MCC14
Tuesday, October 15
10:30 AM - 12:00 PM
CC MC937
Case Report: A Cerebellar Hematoma From a kKown Arteriovenous Malformation
Peter Wong, M.D., Tufts Medical Center, Boston, MA, Jana Hudcova, Lahey Clinic, Burlington, MA
A 61-year-old female with a known AVM presented with sudden onset headache altered mental status
nausea and vomiting. En route to a referring hospital she was intubated for a GCS of 3. Offical imaging
demonstrated significant compression of the brainstem from a large 5 cm cerebellar 4th ventricle
hematoma. She had been evaluated neurosurgeon previously but her AVM not amenable to surgical
treatment. The patient had been presented the option of radiosurgery but declined. On hospital day 5
her family chose to procede with organ procurement as her prognosis was poor secondary to lack of
meaningful neurologic function.
Tuesday, October 15
10:30 AM - 12:00 PM
CC MC938
Anemia With Hyperbilirubinemia Isolated Azotemia and Altered Mental Status in the Setting of Blood
Transfusion in the Trauma Patient
Adam Wright, Student, Tufts University School of Medicine, Boston, MA, Jana Hudcova, M.D., Lahey
Hospital & Medical Center, Burlington, MA
We present the case of an 86-year-old male who fell 25 feet from a ladder sustaining multiple pelvic
fractures with hemorrhage as well as multiple spinal and extremity fractures. There was no loss of
consciousness or head injury. The patient had a history of blood transfusion reactions with multiple
antibodies. Initial treatment included coiling of the left L4 lumbar artery transfusion of multiple blood
products and spinal immobilization. His hospital course was complicated by persistent anemia requiring
transfusion with subsequent rash elevated bilirubin with jaundice isolated azotemia and persistent
altered mental status.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
CC MC939
Anesthetic Management of a Boston Marathon Blast Injury Victim With Family History of Malignant
Hyperthermia
Huai Jen Yang, M.D., Jeanette Lee, M.D., Bobby Chang, M.D., Roya Saffary, M.D., Boston Medical Center,
Boston, MA
65-year-old male presented emergently with a near fatal vascular injury sustained from the Boston
Marathon bombing. En route to the OR patient's wife alerted staff about family history of Malignant
Hyperthermia. Anesthesia machine was emergently prepared with an activated charcoal filter.
Anesthesia was delivered using a trigger-free technique. Intraoperative course was complicated by PEA
arrest. Patient was successfully resuscitated. There were no perioperative signs of Malignant
Hyperthermia. We discuss the importance of obtaining family history of anesthetic complications and
methods of delivering MH trigger free anesthesia in the trauma setting.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC940
You Can't Judge a Book By Iis Cover: An Unexpected Difficult Airway in a Patient With Ehlers-Danlos
Syndrome
Jesse Rojas, M.D., Tilak Raj, M.D., Thomas Tinker, M.D., University of Oklahoma Health Sciences Center,
Oklahoma City, OK
We present a 19-year-old patient who underwent an arthroscopic knee procedure in our surgery center.
During induction of general anesthesia unanticipated difficult airway was encountered. After multiple
failed attempts at direct laryngoscopy initial airway patency with mask ventilation became impossible.
The patient's airway anatomy forced us to resort to a glidescope-fiberoptic bronchoscope combination
to accomplish successful tracheal intubation. Post-intubation we discovered the patient has an unknown
variant of the connective tissue disorder Ehlers-Danlos Syndrome. Literature discussing EDS anesthesia
and difficult airway management is scarce. We discuss the variants of EDS and implications for
anesthesia when they present for surgery.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC941
Difficult Airway and Malignant Hyperthermia
Eugenio Sabalvoro, M.D., Covenant Hospital, Saginaw, MI
The patient is a 24-year-old morbidly obese male for emergent incision and drainage of a left neck
abscess. He has a known history of muscle dystrophy mitochondrial myopathy and cardiac
dysrhythmias.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC942
Takutsubo Syndrome in a Healthy 54-year-old for Orthopedic Surgery
Eugenio Sabalvoro, M.D., Covenant Hospital, Saginaw, MI
She is a 54-year-old female for knee surgery. A few minutes after spinal she became bradycardic and
atropine was given. BP was normal at 120/60 but started coughing frothy secretions and felt short of
breath. Intubation was done. Patient was noted to have PEA and epinephrine chest compressions done.
Copyright © 2013 American Society of Anesthesiologists
BP was immediately achieved but still labile and hypotensive. She was maintained on levophed. DIC
panel showed excessive D-dimer after A-line placed. Cath and echo showed takutsubo cardiomyopathy
and IABP placed and pressors maintained until patient was stable enough to be extubated and
discharged home.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC943
Airway Management of a Patient With Port Wine Stain Affecting the Face
Keith Schmidt, M.D., Dmitry Voronov, M.S., Ned Nasr, M.D., Cook County Hospital, Chicago, IL, Paulina
Voronov, M.D., Lurie Childrens Hospital, Chicago, IL, Magdalena Schmidt, D.O., Rush Hospital, Chicago, IL
5-year-old 22kg Caucasian female with port wine stain affecting the left and right side of the face
presented for pulsed die laser therapy. She was otherwise healthy and had seven prior treatments
without complication. Anesthesia was administered with Nitrous Oxide and Sevoflurane via face mask
then when surgeons were ready an oral airway with a 1/2 precut size 4.5 et tube was strategically placed
through the oral airway for ventilation. This technique allowed for greater surgical access and the circuit
to be utilized if positive pressure was needed. The case was completed uneventfully.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC944
Successful Management of Peripheral Nerve Catheter in a Disabled Patient
Tina Sharma, M.D., Igor Tkachenko, M.D., Tariq Malik, M.D., University of Chicago, Chicago, IL
Peripheral nerve blockade is an effective mode of pain control in patients undergoing single extremity
surgery. Peripheral nerve catheters enhance pain control post-operatively by providing a continuous
infusion of local anesthetic. Patients are instructed on the use of the catheter and are sent home with
instructions on catheter management. Previously a mentally or physically disabled patient would be a
relative contraindication to placing a peripheral nerve catheter due to their inability to manage it after
surgery. However we describe a case in which a physically disabled patient had successful analgesia via a
peripheral nerve catheter with support from family members.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC945
Esophageal Fibrovascular Polyp and Acute Airway Obstruction in the GI Lab
Taizoon Dhoon, M.D., Jennifer Gerber, M.D., Thuy Tran, M.D., Karen Sibert, M.D., Cedars-Sinai Medical
Center, Los Angeles, CA
A 74-year-old man presented with progressive dysphagia and sensation of a foreign body in his throat.
PMH was significant for HIV asthma GERD and Zenker's diverticulum. EGD demonstrated a mass in the
upper esophagus. The endoscopist opted not to excise the mass and withdrew the endoscope. The
patient's airway immediately became obstructed; mask ventilation was impossible. Vocal cords could
not be visualized with laryngoscopy. The esophageal mass had prolapsed cephalad into the supraglottic
space producing airway obstruction. Emergent tracheostomy was performed. The patient later
underwent surgical excision of the mass; pathology revealed giant esophageal fibrovascular polyp.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC946
Postoperative Vision Lost After Bronchoscopy Spray Cryotherapy Balloon Dilation
John Siu, M.D., University of Maryland, Baltimore, MD
22-year-old hx of bilateral lung transplant undergoing repeat balloon dilations with spray
cryotherapy(SCT) for bronchial stenosis under general anesthesia. During cycle 4 of SCT expansion of
liquid nitrogen gas did not have adequate exhaust pathway building up intrathoracic pressure. The cycle
immediately stopped but face lips and tongue turned white for several seconds. Brief drop in end tidal
CO2 hemodynamics stable otherwise. Case resumed and completed. Uneventful emergence and
extubation. Post-operatively complained of nausea. At 4 hrs after case patient had non-painful bilateral
vision loss with acute increased intraocular pressure s/p anterior chamber tap. Blindness resolved in 2
days.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC947
Spontaneous Tracheal Tear During a Routine Robotic-Assisted Cholecystectomy
Christina Smmith, U of Illinois Chicago, Chicago, IL
Tracheobronchial tear represents a rare but serious and potentially fatal complication following
endotracheal intubation. Prompt recognition and evaluation of the tracheal injury is crucial. Importantly
anesthesiologists are known leaders in patient safety and quality of care by the anesthesia team is not
to be discounted in an urgent and critical setting. This report presents one incidence of tracheal injury
occurring after routine elective cholecystectomy. The goal is to detail the patient's clinical presentation
diagnosis and management of the tracheal tear as well as to examine the quality of care throughout the
process in order to identify areas for team improvement.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC948
Let Sleeping Dogs Lie: Avoiding Periopertaive Exacerbation of Systemic Mastocytosis
Sean Summers, M.D., Tilak Raj, M.D., Gozde Demiralp, M.D., OUHSC, Oklahoma City, OK
Systemic mastocytosis is a rare disease prone to exacerbations under general anesthesia and various
other conditions. When anesthetizing affected patients care must be taken to avoid flares that risk
decreased quality of life or even anaphylactic shock. A 44-year-old female with a history of previous
perioperative worsening of her systemic mastocytosis presented to us for a hysteroscopy with
endometrial ablation. We discuss the disease its anesthetic implications the Mastocytosis society
recommendations and our management of this patient which she claimed was ‘the best anesthetic
ever!'
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC949
Difficult Airway in Hereditary Angioedema
Thales Tedoldi, M.D., Anibal Vicuna, M.D., Daniel Kim, M.D., Ligia Mathias, M.D., Ph.D., ISCMSP, Sao
Paulo, Brazil, Wilma Forte, M.D., Ph.D., FCMSCSP, Sao Paulo, Brazil
A 28-year-old ASA Physical Status II man presented for laparoscopic cholecystectomy. Past history was
significant for hypertension and hereditary angioedema. The immunology service recommended
Copyright © 2013 American Society of Anesthesiologists
perioperative infusion of fresh frozen plasma to reduce the risk of upper airway edema and also
provided icatibant (specific antagonist of bradykinin B2 receptors) as a rescue drug. Although patient
had some difficult airway predictors (Mallampati Class III and thick neck) the risk of angioedema
precluded awake intubation technique. Induction of general anesthesia in head elevation positioning
was chosen and patient subsequent course was uneventful.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC950
Anesthetic Management of a Patient With Osteogenesis Imperfecta for Elective Repair of Umbilical
Hernia
Jeffrey Waldman, M.D., Jeffrey Gross, M.D., Nathan Mark, D.O., University of Connecticut Health Center,
Farmington, CT
A 30-year-old ASA 4 Caucasian female with osteogenesis imperfecta presented for elective repair of
umbilical hernia. She was three feet tall and weighed 63kg. Past medical history included restrictive lung
disease hypertension and kyphoscoliosis. Airway exam was significant for limited neck extension
decreased mouth opening and poor dentition. The patient received general anesthesia for the
procedure. Awake tracheal intubation was unsuccessful using a fiberoptic bronchoscope Glidescope and
Airtrack laryngoscope. Mask ventilation was difficult and the case was performed with a laryngeal mask
airway. Post-operative course was complicated by acute on chronic respiratory failure but the patient
recovered without further sequelae.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC951
Esophageal Retrieval of Foreign Body With Video Laryngoscope and Magill Forceps After Failed EGD
Jeremie Walker, M.D., Matthew Ellison, M.D., WVU, Morgantown, WV
A 55-year-old male presents in the middle of the night for esophageal foreign body retrieval (7inch
plastic comb) on a full stomach and hemoptysis. After an uncomplicated rapid sequence intubation
esophageal retrieval via GI specialists and EGD failed. Given the superior esophageal location of the
foreign body a C-Mac video laryngoscope and large Magill forceps were used to dislodge and extract the
comb without esophageal insult. Extra aspiration precautions were implemented upon conclusion of the
case to minimize aspiration risks
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC952
Anesthetic Management of Cystinosis
Kristal Wilson, M.D., Marjorie Robinson, M.D., University of Louisville, Louisville, KY
We present a 30-year-old white male with the rare disease Cystinosis who presented for multiple teeth
extraction due to significant dental caries. The patient was diagnosed with this lysosomal storage
disorder as a child when he presented with chronic kidney failure later diagnosed as Fanconi syndrome
requiring bilateral kidney transplant. Other organ involvement includes vision impairment and chronic
pancreatitis. Past surgical history included 7 surgeries all with significant post-operative nausea and
vomiting. We present the management of this case along with a literature review discussing the disease
its process and anesthetic recommendations.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC953
Unscheduled Stress Testing
Anna Wright, M.D., MetroHealth Hospital Case Western Reserve University, North Olmstead, OH
The patient is a 71-year-old woman with history of HTN and HLD who presented for an elective shoulder
arthroscopy. Prior stress test 4-5 years ago was reported as \normal\" during PSE evaluation.
Interscalene block performed intra-operatively followed by induction. After laryngoscopy she developed
tachycardia (HR 120s) associated with concomitant ST depressions confirmed by a 12-lead EKG.
Shoulder arthroscopy cancelled and medical management of cardiac ischemia ensued. A cardiac
catheterization was performed and patient scheduled for CABG of 3 vessels. Intra-aortic balloon pump
placed pre-operatively prior to surgery. Complicated course of CABG followed by prolonged SICU stay."
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC954
A Case Report: Difficult Ventilation and Hypercapnia Narcosis in a Patient With Relapsing
Polychondritis Undergoing Bronchoscopic Intervention
Jiang Wu, M.D., Ursula Galway, M.D., Cleveland Clinic, Cleveland, OH
Patients with Relapsing polychondritis (RP) are at risk of difficult oxygenation intubation ventilation and
extubation due to both upper and lower airway destruction and collapse. We report the airway
management of a RP patient with past anesthetic history of sudden difficult ventilation via an
endotracheal tube (ETT) inserted through tracheostomy stoma resulting in 15 min of hypoxemia and
hypercarbia during his previous bronchoscopy. We demonstrate the importance of establishing a
reliable airway and maintaining positive end expiratory pressure to keep airways open in correcting poor
oxygenation ventilation and hypercapnia narcosis during his next bronchoscopic airway interventions.
Tuesday, October 15
10:30 AM - 12:00 PM
AM MC955
Asystole During an Elective Laparoscopic Procedure
Huai Jen Yang, M.D., Oleg Guszkov, M.D., Roberto Ballivian, M.D., Vahila Pamidimukkala, M.D., Boston
Medical Center, Boston, MA
A healthy 44-year-old woman suffered cardiac arrest during laparoscopic hysterectomy; deflation of
peritonenium and CPR were required to reinitiate cardiac rhythm. Patient was rescheduled for open
hysterectomy. Precautious steps were taken and surgery completed without complication. Several cases
of cardiovascular collapse during gynecologic laparoscopic procedures have been reported. Nearly all
the episodes occurred during CO2 insufflation or with traction on pelvic structures. Causes for
cardiovascular collapse include hypercapnia anoxia decreased venous return secondary to elevated
intra-abdominal pressure gas embolism and profound vagal response. By promptly recognizing and
treating these complications the surgical and anesthesia teams can minimize morbidity and mortality.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC956
Rhabdomyolysis After Prolonged Surgery: A Case Report and Literature Review
Mary Kelly, M.D., Jingping Wang, M.D., Ph.D., Massachusetts General Hospital, Boston, MA
Presented is a case of rhabdomyolysis in a 30-year-old patient following a 16 hour surgery consisting of a
LeFort I osteotomy bilateral arthroplasties and bilateral TMJ total joint replacements. Upon
postoperative admission to the SICU two large pressure ulcers were noted consisting of 10x12cm nonblanchable area on coccyx/buttock and an 18x5cm non-blanchable area on left scapula. CPK was 33 000
and he was diagnosed with rhabdomyolysis. The patient was treated promptly with large volumes of
hydration forced diuresis and alkalization when appropriate. The patient fully recovered. Risk factors
and treatment for intraoperative rhabdomyolysis are discussed.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC957
Elevated End Tidal Carbon Dioxide Intraoperatively: A Diagnostic Dilemma
Nicole Khetani, M.D., Tara Kennedy, M.D., Michele Mele, M.D., Thomas Jefferson University Hospital,
Philadelphia, PA
A 32-year-old 158 kg male with morbid obesity recurrent pulmonary embolism and schizophrenia on
antipsychotics underwent a posterior thoracic decompression and fusion for spinal stenosis.
Remifentanil and propofol were used for induction and maintenance. Fifteen minutes before surgery
end the maintenance agents were switched to Desflurane. Within thirty minutes of Desflurane use
rigors and tachypnea with a minute ventilation up to 24L/minute were noted. Core temperature rose to
39.3°C. Malignant hyperthermia was suspected but an arterial blood gas revealed only respiratory
acidosis. We review precipitating factors and the differential diagnosis for intraoperative rigors fever
and hypercarbia.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC958
Intraoperative Adrenergic Crisis
Ellen Freire, M.D., Daniel Kim, M.D., Christiano Matsui, M.D., Ligia Mathias, M.D., Ph.D., ISCMSP, Sao
Paulo, Brazil
A 42-year-old ASA Physical Status I man presented for total hip arthroplasty. He had undergone three
uneventful hip surgeries before. Following epidural catheter placement and induction of general
anesthesia the patient presented sinus tachycardia arterial hypertension and hypercapnia. Surgical
procedure was postponed and in the following hours he developed hyperthermia and acute pulmonary
edema. As malignant hyperthermia was suspected dantrolene was given unsuccessfully and patient died
fourteen hours later. Necroscopy found bilateral tumors in suprarenal gland and medullary thyroid
cancer with final diagnosis of Multiple Endocrine Neoplasia type 2A.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC959
Digoxin Toxicity in a 90-year-old Gentleman Following Open Reduction Internal Fixation of Left
Femoral Neck Fracture
Michael Kim, M.D., Roya Saffary, M.D., Carlos Guzman, M.D., Boston Medical Center, Boston, MA
Timothy Woodward, B.S., Boston University School of Medicine, Boston, MA
Digoxin toxicity is a commonly encountered adverse drug reaction largely attributed to its narrow
therapeutic window which is affected by a multitude of interacting factors. Essentially every known
arrhythmia can manifest as a result of digoxin toxicity. We present a case of an elderly patient who
developed an accelerated idioventricular rhythm immediately after a routine orthopedic surgery and
was found to have an elevation in serum digoxin levels necessitating Digibind therapy. This report
discusses the potential for intraoperative pharmacokinetic interactions resulting in post-operative
digoxin cardiotoxicity emphasizing the importance of early post-operative recognition of digoxin toxicity
in the high-risk elderly population.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC960
Factors Affecting Outcomes After Perioperative Advanced Cardiovascular Life Support
Michelle Kim, M.D., Daniella Smith, M.D., University of Maryland Medical Center, Baltimore, MD
Two weeks after a cadaveric liver transplant a 50-year-old female presented with an acute hepatic
artery thrombosis and partial hepatic infarction. Interventional Radiology was unable to re-establish
hepatic artery blood flow and a large peri-hepatic hematoma developed. Fulminant hepatic failure
ensued and the patient became increasingly acidotic and hypotensive. Shortly after emergent
laparotomy was performed the patient became severely hypotensive and asystolic. Advanced
Circulatory Life Support (ACLS) and massive blood transfusion were instituted with only transient
restoration of circulation. After 55 minutes and six rounds of ACLS the decision was made to cease our
efforts.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC961
Anesthetic Management of Laparoscopic Adrenalectomy for Pheochromocytoma
Francis Kirk, M.D., Aaron LacKamp, M.D., Johns Hopkins Hospital, Baltimore, MD
We provided general anesthesia for a 27-year-old woman undergoing a laparoscopic adrenalectomy for
pheochromocytoma. Preoperatively she was managed for 8 weeks with phenoxybenzamine and
propranolol. The patient was premedicated with midazolam and fentanyl and a radial arterial line was
placed. General anesthesia was induced with remifentanil propofol and vecuronium. The airway was
secured and another large peripheral IV was placed. Anesthesia was maintained with isoflurane and
remifentanil. Blood pressure was labile during insufflation surgical manipulation and adrenal vein
ligation. Vasoactive infusions were prepared but not initiated. The patient was extubated and
transferred to the ICU for observation.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC962
TTE Video Demonstrating Massive Thrombus
Saman Kohanof, D.O., Davide Cattano, M.D., UT Houston Medical Center, Houston, TX
Our Patient CC is a 77-year-old male with numerous medical problems including atrial fibrillation was
scheduled for a tracheostomy after initially being admitted for a severe ischemic stroke which required
intubation to secure his airway. Shortly after being moved to the OR table the patient became
hemodynamically unstable end tidal carbon dioxide dropped off and chest compressions were started.
An Intraoperative TEE was preformed which showed what appears to be a massive thrombus in the right
atrium and right ventricle.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC963
Does Inhalational Heroin Abuse Matter? A Case of Pneumothorax and Tracheal Tear in a Patient With
Tracheal Stenosis.
Fathima Kolonda, M.D., Hokuto Nishioka, M.D., University of Illinois- Chicago, Chicago, IL
A 38-year-old female with tracheal stenosis presented for laser excision of her stenosis under jet
ventilation. Her medical history included asthma and chronic inhalational heroin abuse. Though
appropriate jet ventilation techniques were used the patient developed a pneumothorax which was
promptly decompressed. Because of the complication a tracheostomy tube was placed but after
multiple failed attempts at ventilation a tear in the posterior tracheal wall was identified. To better
understand why these complications occurred we reviewed jet ventilation techniques risk factors and
complications in patients with inhalational drug abuse history.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC964
A Case of Airway Bleeding Managed by Embolization
Meri Koski, D.O., Kamal Maheshwari, M.D., Hesham Elsharkawy, M.D., M.S., Wael Ali Sakr Esa, M.D.,
Ph.D., Cleveland Clinic, Cleveland, OH
A 34-year-old male with a past medical history significant for bilateral pulmonary artery aneurysms was
scheduled for a bronchoscopy for new onset hemoptysis. During the procedure fresh blood was found in
the right mainstem and bronchus intermedius. Cauterization was unsuccessful. The patient was
intubated and a bronchial blocker was placed in the right mainstem bronchus. The patient was taken
emergently to interventional radiology for an angiogram with successful embolization of the right
intercostal bronchial trunk. The patient was transported to the ICU in stable condition with the bronchial
blocker in place which was removed 24 hours later.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC965
Pseudocholinesterase Deficiency
Rohini Kotha, M.B. B.S., Li Meng, M.D., University of Pittsburgh, Pittsburgh, PA
63-year-old F with PMH of obesity htn was scheduled for Kyphoplasty (T7-8). Induction of anesthesia
was uneventful with propofol and succinylcholine. Subsequently 30mg of rocuronium was adminstered.
Pt remained paralysed with no twitches for about 4hrs after which she developed a fade response on a
Copyright © 2013 American Society of Anesthesiologists
TOF 2/4. Upon reversal with neostigmine and glycopyrollate TOF was noted to be diminshed 1/4. Her
cholinesterase level and Dibucaine number were 352 and 33 respectively. She remained apneic and was
electively sedated and remained intubated for 12hrs after which she was extubated and recovered
safely.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC966
Supine Hypotensive Syndrome - But She's Not Pregnant
Daniel Kovacs, Andrea Strathman, M.D., Wake Forest Baptist Health, Winston-Salem, NC
50-year-old F with a h/o MV regurgitation s/p MVR CHF beta-thalassemia and morbid obesity scheduled
for exploratory laparotomy. Imaging demonstrated a 40cm multiseptated mass which arose from the
ovary extending into an abdominal wall hernia which contained part of the left lobe of the liver and
bowel with IVC compression and ascites noted. On exam the patient was hypotensive and hypoxic when
supine. The case was complicated by hypoxemia and difficultly with ventilation requiring high PEEP
multiple ventilator maneuvers and fiberoptic confirmation of ETT placement. The patient required
extensive resuscitation vasopressor use with the successful resection of a 26kg mass.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC967
The Anesthestic Considerations for the Placement of a Diaphragmatic Pacemaker in a Patient With
ALS
Molly Kraus, M.D., Lopa Misra, D.O., Kristi Harold, M.D., Mayo Clinic, Phoenix, AZ
The diaphragm pacing system is a device that stimulates the diaphragm to maximally contract so
patients can breath more effectively. A fifty-year-old female recently diagnosed with ALS presented for a
diaphragmatic pacer insertion. From an anesthetic perspective both the surgery and the patient
population present several unique challenges. Since the surgeon laparoscopically tests muscle
contraction of the diaphragm for placement of electrodes paralytics cannot be used. Remifentanil an
ultra-short-acting opoid provides a superb adjunct to sevoflurane. Remifentanil depresses the
respiratory drive which facilitates mapping of the diaphragm so the patient will not augment respiration.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC968
Iatrogenic Airway Foreign Body During Rigid Bronchoscopy in a Two-Year-Old Girl
Jason Kreiner, M.D., Tigran Sukiasyan, M.D., Joshua Silverman, M.D., Erica Lai, SUNY Health Science
Center at Brooklyn, New York, NY
We present the case of a two-year-old girl who underwent a rigid bronchoscopy which resulted in an
iatrogenic airway foreign body. This case highlights the importance of routine instrument inspection and
iatrogenic foreign body aspiration as a possible postoperative diagnosis.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC969
Case of Malignant Hyperthermia
Alan Kulig, M.D., Baystate Medical Center, Springfield, MA
A 41-year-old female with a difficult airway and unremarkable personal and family anesthetic history
presented for a laparoscopic gastric bypass. The patient was induced with propofol and succinylcholine
and maintained on O2 N20 and sevoflurane. Vital signs were stable throughout. The ETCO2 and
temperature increased slightly during the first two hours of surgery but markedly increased between 2.5
and 4 hours. The MH protocol was initiated with prompt normalization of both ETO2 and temperature.
The patient remained intubated and sedated overnight and was extubated the following morning
without sequellae. Subsequent muscle biopsies tested positive for MH.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC970
Anesthetic Management for Amiodarone-Induced Thyrotoxicosis Complicated by Failed Medical
Therapy: A Case Report
Catherine Kuza, M.D., Antonio Aponte-Feliciano, M.D., University of Massachusetts Medical School,
Worcester, MA
A 60-year-old morbidly obese female with a past medical history of pulmonary hypertension ventricular
tachycardia atrial fibrillation (s/p ablation) and congestive heart failure presented with amiodaroneinduced thyrotoxicosis (AIT) and neutropenia secondary to methimazole treatment. Methimazole
proved to be an ineffective and potentially lethal medical treatment. She was treated with filgrastim
potassium iodide sotalol and methylprednisolone without salutary effects. An urgent total
thyroidectomy was performed. We present the perioperative and airway management of a challenging
patient with amiodarone-induced thyrotoxicosis and review the literature on the safety of performing
anesthesia in these patients.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC971
Management of Pheochromocytoma in a Patient With Fontan Circulation
Kathleen Kwiatt, D.O., David Fish, M.D., Cooper University Hospital, Camden, NJ
A 26-year-old patient with completed Fontan circulation presented for resection of pheochromocytoma
under general anesthesia. The patient was pre-medicated with phenoxybenzamine yet experienced
complications related to both acute and chronic excess catecholamine exposure. She experienced
extreme hemodynamic variation the treatment of which required diligent awareness of her underlying
congenital heart disease with passive pulmonary circulation. Hypertension was managed primarily with
clevidipine and hypotension required norepinephrine phenylephrine and epinephrine in addition to
resuscitation with IV fluid and blood. The patient ultimately tolerated the procedure and was discharged
to home 8 days post-operatively.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC972
Pre and Perioperative Management of Suspected Multiple Endocrine Neoplasia Men in a 54-year-old
African American Woman
Jeanne Ky, B.S., Kimberly McClelland, M.P.H., Richard Barrett, M.S., David Holliday, M.D., Clairmont
Griffith, M.D., Howard University College of Medicine/ Hospital, Washington, DC
The pre- and perioperative management of MEN requires consideration of thyroid parathyroid and
adrenal gland physiology as well as efficient application of anesthesiology fundamentals. We present a
54-year-old African-American female with a past medical history of SLE NIDDM hypertension
dyslipidemia CVA (x2) and CHF who presented with hypertensive emergency headache and retrosternal
chest pain unrelieved by aspirin. An enlarged thyroid was noted upon exam and after cardiac
stabilization the patient received a neck CT showing a large mass and an abdominal CT showing an
adrenal gland mass and an intrauterine fibroid. She was subsequently diagnosed with
pheochromocytoma and underwent adrenalectomy.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC973
Profound Systemic Reaction After Bone Cement Application in Total Knee Arthroplasty
Robert LaCivita, M.D., Avichai Dukshtein, M.D., Piyush Gupta, M.D., Maimonides Medical Center, New
York, NY
A 61-year-old patient with past medical history of nonischemic dilated cardiomyopathy presented for
elective left knee replacement. Spinal anesthesia was administered as the main anesthetic. Application
of bone cement resulted in profound hypotension initially refractory to various resuscitative treatments.
The patient also developed difficulty in speech associated with swelling of the mouth and tongue. The
patient regained hemodynamic stability with epinephrine and antihistamines. Histamine and tryptase
level drawn at this time were elevated suggesting that patient likely had an anaphylactic reaction to
bone cement.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC974
Ability to Perform a Needle Cricothyrotomy: An Essential Skill for Every Anesthesiologist
Anjana Lal, M.D., Carl Adkins, M.D.,UT Southwestern Medical Center at Dallas, Dallas, TX, Chinwe
Ononogbu, C.R.N.A., Parkland Hospital, Dallas, TX
A 64-year-old male with prior neck dissection/radiation wound dehiscence and Mallampati IV airway
presents for GI Suite procedure. After induction and paralysis bag/mask ventilation is difficult but not
impossible. Initial attempt to intubate with Glidescope® is unsuccessful. Next a bougie cannot be passed
into the trachea. Subsequently ventilation with both bag/mask and LMA becomes impossible. Needle
cricothyrotomy is performed with 16-guage angiocath 3 mL syringe barrel and 7.0 ETT adapter which is
attached to the machine breathing circuit. ENT surgeons arrive and perform endotracheal intubation via
endoscopic guidance. Patient is transported to ICU in stable condition.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC975
Trauma and Hemorrhagic Shock: The Dangers of Intra-Arterial Massive Transfusion
Agnes Lamon, M.D., Seema Kamisetti, D.O., Sanford Littwin, M.D., St. Luke's- Roosevelt Hospital Center,
New York, NY
This is a 56-year-old male in hemorrhagic shock from bilateral lower extremity traumatic amputations.
He was intubated and resuscitated with 10 UPRBC's and 1U platelets through a femoral line by ED
personnel. Unbeknownst to the anesthesia provider this line was an intra-arterial cordis. Upon arrival to
the OR he was tachycardic in the 140's and hypotensive with systolic blood pressures in the 50's. Once a
subclavian central line was placed and additional blood products were transfused intravenously the
patient's condition drastically improved. This case reviews the physiologic changes associated with
arterial transfusions and the pronounced improvement following appropriate venous access.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC976
What is a Reninoma?
Alice Landrum, M.D., Martha Schuessler, B.S., Alan Zaggy, M.D., Sarah Schaak, C.R.N.A., University of
Missouri-Columbia, Columbia, MO
An 18-year-old female presented for robotic laparoscopic resection of a renal mass. The patient had
developed malignant hypertension one year ago. Extensive workup including a saline suppression test
ultrasounds CT angiography MRI and renal vein sampling revealed a mass in the upper pole of the right
kidney which was secreting renin. A reninoma is an extremely rare cause of severe hypertension.
Resection may be curative but careful attention must be paid to preoperative management of hydration
and blood pressure as well as during the immediate post resection phase when residual renin may still
be in the circulation.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC977
Management of Upper Airway Trauma
Ryan Laterza, M.D., Mount Sinai Medical Center, New York, NY
The anesthesiology resident was called to the Emergency Department. Upon arrival he discovered a
trauma victim who suffered severe oral maxillary trauma after being struck by a motor vehicle. The
emergency medicine physicians were attempting to intubate with a video laryngoscope but their
attempts were futile secondary to blood and debris obstructing the camera. The anesthesiology resident
performed a direct laryngoscopy with a Macintosh 3 blade. On laryngoscopy the oropharynx was
completely saturated with blood and a yankauer was used to suction the oropharynx yielding enough
time for the glottic opening to be visualized and the patient was successfully intubated.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC978
Acute Hemorrhage in an Awake Patient Leading to Bezold-Jarisch Reflex and Conversion to General
Anesthesia
Sarah Latif, M.D., Jeremi Mountjoy, M.D., Paul Alfille, M.D., Massachusetts General Hospital, Boston, MA
A 63-year-old male underwent a femoral artery exploration under spinal anesthesia. An episode of
massive and unexpected blood loss occurred during which time the patient was initially
hemodynamically stable. However a delayed yet abrupt episode of bradycardia hypotension and nausea
followed leading to an unplanned conversion to general anesthesia. The Bezold-Jarisch reflex which
leads to vagal stimulation and withdrawal of sympathetic tone in times of severe hypovolemia was
thought to be the culprit of the sudden hemodynamic changes. After aggressive resuscitation with
intravenous fluids and blood products the patient was extubated and had a stable post-operative
recovery.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC979
Anesthesia Management of Broncho-Esophageal Fistula
Robert Lehn, M.D., Evan Burke, M.D., Jeffrey Gross, M.D., University of Connecticut, Farmington, CT
A 65-year-old-man with a history of esophagogastrectomy for esophageal cancer presented with
pneumonia. Bronchoscopy diagnosed a distal bronchoesophageal fistula but the procedure was aborted
before the site was identified because of copious gastric secretions in the airway. Repeat anesthesia was
required for esophageal stent placement. To avoid gastric inflation we kept the patient breathing
spontaneously with a small dose of propofol and sevoflurane; because the fistula site was unknown we
used a single lumen ETT during esophagoscopy which was completed uneventfully. When CO2 was
insufflated during endoscopy end-tidal CO2 rose to 300 mmHg confirming the widely-patent
esophagobronchial fistula.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC980
Perioperative Management of Severe Aortic Stenosis During Whipple Procedure
Pulsar Li, D.O., Richard McAffee, M.D., UPMC, Pittsburgh, PA
71-year-old F w h/o asymptomatic severe aortic stenosis (AV area 0.6 cm 2) with pancreatic
adenocarcinoma for robotic-assisted whipple. Though the patient's cardiologist recommended against
surgery due to high perioperative mortality risk the surgeon consulted cardiac anesthesia for additional
evaluation. In the preoperative clinic after we led a comprehensive discussion and reconciliation of the
conflicting views of her cardiologist and surgeon the patient chose to proceed with the significant risk of
surgery over palliation and hospice. She underwent uneventful open whipple with uneventful ICU
recovery. One year later she underwent successful aortic valve replacement for symptomatic AS.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC981
Spontaneous Vertebral Artery Aneurysm Rupture in a Patient With Neurofibromatosis Type 1 Causing
a Difficult Airway
Susan Lien, M.D., Jeanine Wiener-Kronish, M.D., Mazen Maktabi, M.B. B.Ch., Massachusetts General
Hospital, Boston, MA
Vascular abnormalities have been described in neurofibromatosis type 1 (NF1) patients. Vertebral artery
(VA) aneurysms however are a rare finding. We report a case of a 26-year-old female with NF1 and a left
VA aneurysm who developed acute neck swelling and respiratory distress. Mask ventilation and
intubation proved impossible and an emergent surgical airway was obtained. CT head/neck revealed
rupture of the VA aneurysm causing a large retropharyngeal hematoma. The patient underwent
emergent coiling of the ruptured aneurysm and survived with minimal neurological deficits. This case
demonstrates successful teamwork in application of the difficult airway algorithm and crisis
management.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC982
Intraoperative Hyperthermia as Initial Presentation of Babesiosis Acquired Through Blood Transfusion
Melanie Liu, M.D., Marcelle Blessing, M.D., Yale New Haven Hospital, New Haven, CT
A 66-year-old woman presented for robotic hysterectomy under general endotracheal anesthesia. Preoperative temperature was 36.4°C. Shortly after induction patient was noted to be hyperthermic to
39.4°C. All inhalational agents were stopped and patient was actively cooled to 37.4°C. No muscle
rigidity metabolic acidosis or hypercarbia were noted however hematocrit had fallen to 26 from 32 preoperatively. Further workup revealed hemolytic anemia and blood smear positive for inclusion bodies.
Patient was diagnosed with babesiosis likely acquired through recent blood transfusion. She received a
full course of treatment for babesiosis and subsequently underwent robotic hysterectomy under general
endotracheal anesthesia without further complications.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC983
Unique Airway Challenge for Excision of a Middle Mediastinal Mass Excision via Thoracotomy: Severe
Tracheal Deviation and Congenital Tracheal Anomaly
Andrew Lobonc, M.D., Lavinia Kolarczyk, M.D., UNC at Chapel Hill, Chapel Hill, NC
A 78-year-old male with history of hypertension and gastroesophageal reflux disease presented with
acute dysphonia. He was found to have a large middle mediastinal mass suspicious for esophageal
duplication cyst. He was brought to the operating room for vocal cord injection right thoracotomy and
resection of the mediastinal mass. Left sided double lumen tube placement was difficult due to tracheal
deviation and final positioning was complicated by abnormal anatomy. The right upper lobe bronchus
originated from the distal trachea. This anomaly would not have allowed for lung isolation with a
bronchial blocker in the right main stem bronchus.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC984
Iatrogenic Hypernatremia to Treat Severe Cerebral Edema During Liver Transplantation
Brett Longlais, Elif Cingi, M.D., University of Minnesota, Minneapolis, MN
41-year-old female patient with end stage liver disease secondary to Acetaminophen overdose admitted
for orthotropic liver transplantation. Patient had cerebral edema; brainstem dysfunction acute renal
failure and MELD score of 46. Neurosurgery suggested maintaining the goal of pCO2 30-35 and Na 155165 to avoid brain herniation. Hypertonic saline therapy was initiated. Concerns regarding fluid overload
during the transplant a HD catheter placed with plans to do HD. Hypertonic saline infusion was used to
maintain hypernatremia during a surgery known for large fluid and electrolyte shifts. Transplantation
was successful and she was discharged to a long term care facility.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC985
Anesthetic Management of a Pheochromocytoma With ACTH Secreting Properties
Brandon Lopez, M.D., Christopher Cropsey, M.D., Liza Weavind, M.B. B.Ch., Vanderbilt Medical Center,
Nashville, TN
A 37-year-old female presented with acute hypoxia hypertension hyperglycemia and elevated cardiac
enzymes. History and physical exam revealed abdominal distention weight loss and night sweats.
Abdominal CT scan confirmed a 15 cm left adrenal mass. Her preoperative hospital course was
complicated by severe hyperglycemia multiple hypertensive episodes and flash pulmonary edema.
During surgical resection she experienced extremely labile blood pressure despite maximal therapies.
Postoperatively the patient had severe refractory hypotension for several hours prior to normalization.
Pathology revealed a pheochromocytoma with both catecholamine and ACTH secreting properties.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC986
Cardiovascular Collapse From Traumatic Placement of Chest Tube Status Post Robotic Assisted
Thoracoscopic Surgery
Daniel Loren, M.D., University of Connecticut Medical Center, Farmington, CT, Rabi Panigrahi, M.D.,
Hartford Hospital, Hartford, CT
34-year-old woman presented to the hospital for robotic assisted thoracoscopic surgery for upper lobe
resection. The case was uneventful until closing of skin wounds and bolusing of epidural catheter.
Patient subsequently developed cardiovascular collapse and CPR was initiated along with aggressive
resuscitation measures. Diagnosis of hemorrhagic shock confirmed after placement of transesophageal
echocardiography probe. After emergent thoracotomy performed and repair of pulmonary artery injury
patient was stabilized and transferred to the ICU. She was extubated one day later and eventually
discharged from the hospital without any further sequelae.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC987
Airway Management in Penetrating Neck Injury: Asleep Fibreoptic Intubation in a Spontaneous
Breathing Patient Using TIVA
Peta Lorraway, Anton Booth, FANZCA, Princess Alexandra Hospital, Brisbane, Australia
A 19-year-old woman presented with an anterior neck laceration after a self harm episode with a knife.
She was maintaining her airway despite an obvious air leak from the wound. Urgent airway
management was arranged in theatre with ENT surgeons present. General anesthesia was induced and
spontaneous ventilation successfully maintained using propfol TCI. At an adequate depth laryngoscopy
was performed and co-phenylcaine applied to the glottis. A fibreoptic bronchoscope successfully guided
an ETT below the laceration. The procedure was smooth and uneventful. Surgical exploration revealed
an isolated cricothyroid laceration through which a cricothyroidotomy tube was placed for ongoing
management.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC988
The importance of Teamwork in Managing a Difficult Intubation With a Hunsaker Tube
Rohit Mahajan, M.D., University of Michigan, Ann Arbor, MI
A 46-year-old female with a history of subglottic stenosis presented for balloon dilation. Intubation was
attempted using a CMAC. Despite a Cormack-Lehane grade 1 view a Hunsaker tube was unable to be
passed due to an anterior glottis and lack of maneuverability of the floppy tube. Our Otolaryngology
colleagues were also unable to pass the tube using suspension laryngoscopy. Ultimately the Hunsaker
tube was placed within a 6.5 ETT with a longitudinal slit from end to end. The combined device was
passed through the glottis and the overlying 6.5 ETT was peeled off leaving the Hunsaker in place.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC989
Pheochromocytoma With Multiple Co-Morbidities
Parul Maheshwari, M.D., Praveen Maheshwari, M.D., Srikanth Sridhar, M.D., University of Texas,
Houston, TX
47-year-old female with pheochromocytoma for excision. Co-moridity emphysema OSA CHF HTN CHD
s/p repair 2 CVA DM hypothyroidism cirrhosis. TTE severe asymmetric interventricular septal
hypertrophy normal EF diastolic dysfunction RVSP of 35mmHg. Admitted for uncontrolled HTN. Treated
with labetolol phenoxybenamine doxazosin. Invasive monitoring. Maintained on sevoflurane
remifentanyl drip magnesium infusion. Intraoperative TEE right heart failure. Started on milrinone drip.
After tumour resected started on Norepinephrin drip. At the end drip turned off extubated. Shortly
tachypnic and hypoxic with increase CVP. Considering right sided failure reintubated and restarted on
milrinone. Shifted to ICU extubated next day and gradually off milrinone.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC990
Autologous Blood in Healthy Bone Marrow Donors: What Triggers Transfusion?
Solmaz Manuel, M.D., Yumiko Ishizawa, M.D., Ph.D., Massachusetts General Hospital, Boston, MA
Preoperative autologous blood donation is frequently offered to bone marrow donors. When
transfusion is necessary autologous blood protects against hemolytic febrile or allergic transfusion
reactions. Risks of autologous blood transfusion however include clerical error bacterial contamination
hemolysis of stored units volume overload of transfusion and TRALI. Furthermore although increasing
evidence suggests that a restrictive allogenic blood transfusion strategy decreases morbidity and
mortality long-term outcomes in patients receiving autologous transfusion is not known. This case
report examines the role of preoperative autologous blood donation in a healthy 36-year-old male bone
marrow donor and the decision to transfuse during this procedure.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC991
Planned Laparoscopic Cholecystectomy Status Post Aortic Balloon Valvuloplasty With Residual Severe
Aortic Stenosis
Michael Marotta, M.D., The Mount Sinai Hospital, New York, NY
An 89-year-old female presents for a laparoscopic cholecystectomy for pericholecystic abscess. The
patient has recently undergone a balloon valvuloplasty for sever aortic stenosis resulting in a post
balloon valve area of 0.9cm sq. The patients past medical history is also significant for hypertension
coronary artery disease aortic aneurysm hyperlipidemia and GERD. In addition to concerns raised by the
patient's comorbidities the surgeon predicts the case will be technically challenging and would like to
discuss an open versus the planned laparoscopic approach.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC992
Cardiac Complications Related to Postoperative Nausea and Vomiting (PONV) Prophylaxis
Kimberly McClelland, M.P.H., Richard Barrett, M.S., David Holliday, M.D., Clairmont Griffith, M.D.,
Howard University Hospital /Howard College of Medicine, Washington, DC
PONV prophylaxis has become a mainstay in perioperative anesthesiology. In the case presented a 22year-old African-American G3P2002 scheduled for a D&C as a result of a missed abortion experienced
retrosternal chest pain with ST-segment depression and elevated troponins (3.9 ng/mL) after receiving
ondansetron and metoclopramide. The patient received a 2-D echocardiogram showing normal
ventricular function and an ejection fraction of 60-65%; cardiac catheterization showed normal coronary
arteries. Her ST-segment depression resolved on subsequent EKGs and her troponins normalized over
the next 48 hours. Following resolution of chest pain with normal EKG findings a diagnosis of coronary
artery spasm was made.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC993
Propofol Increases Risk for Severe Bradycardia Progressing to Sinus Pause With Spontaneous
Resolution During Induction of General Anesthesia
Brian McClure, D.O., Ashraf Farag, M.D., Cooper Phillips, M.D., Texas Tech University Health Sciences
Center, Lubbock, TX
An otherwise healthy 42-year-old male underwent induction of general anesthesia using propofol dosed
at 2 mg/kg for an open reduction of a tibial fracture. The patient was not on any medication prior to the
procedure. Immediately after induction with propofol the patient developed profound bradycardia
progressing to a brief sinus arrest which quickly resolved without additional drug therapy. At the time of
the sinus arrest direct laryngoscopy was initiated and the patients pulse returned to normal. It is the
authors' belief that the laryngoscopy and intubation provided the stimulation necessary to regain
spontaneous elevation of the heart rate.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC994
General Anesthesia in an Adult With Rubinstein-Taybi Syndrome
Steven McGrath, M.D., James Heitz, M.D., Thomas Jefferson University Hospital, Philadelphia, PA
A 34-year-old woman presented for multiple dental extractions with general anesthesia. Past medical
history was significant for Rubinstein-Taybi Syndrome a rare autosomal dominant genetic disorder with
multiorgan involvement including severe cognitive impairment and craniofacial abnormalities.
Additionally afflicted individuals may have congenital cardiac conduction abnormalities with
documented adverse reactions to Succinylcholine and vasoactive drugs. Furthermore these patients can
have severe gastroesophageal reflux and poor pulmonary reserve with histories of recurrent
pneumonias. Familiarity with Rubinstein-Taybi Syndrome and its myriad of anesthetic implications
beyond difficult airway management is crucial for safe perioperative management of these challenging
patients.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC995
Continuous Spinal Anesthesia in a Patient With Severe Pulmonary Hypertension
Janette McVey, M.D., Melanie McMurry, M.D., University of Missouri, Columbia, MO
A patient with an open ankle fracture was scheduled for emergent internal fixation of her fracture. Her
past medical history was extensive and included severe pulmonary hypertension. Mean pulmonary
pressures were 40-42 mmHg. After an arterial line was secured a continuous spinal catheter was placed
and dosed incrementally with 0.5% isobaric bupivacaine until surgical anesthesia was achieved. A
vasopressin infusion was started and adjusted as needed to maintain her blood pressures at her
baseline. A dexmedetomidine infusion was started to alleviate anxiety during the surgery. The patient
tolerated the anesthetic well and had no respiratory compromise during the surgery.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC996
Truth is Stranger Than the Fiction: Impact of Preoperative Assessment on Diagnosis of a Rare
Condition
Anthony McPherson, M.D., Gozde Demiralp, M.D., University of Oklahoma, Oklahoma City, OK
We would like to present you a challenging preoperative assessment of a rare condition. A 54-year-old
female who was being assessed for an uro-gynecological procedure reported to have recurrent Bell's
Palsy after every surgery. However further investigation reflected more complicated central nervous
system pathology involving a familial heritage and hemiplegia. Preoperative work up for transient
ischemic attack and stroke were negative. Via referral to Neurology patient was diagnosed with
Hemiplegic Migraine. She was prescribed Nimlodipine and was given preemptively during perioperative
stage. For the first time in 5 years she was successfully discharged home without any complications.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC997
Difficult Emergency Airway Management in Osteitis Fibrosa Cystica
Joshua Melvin, Stanford, Santa Clara, CA
The patient is a 30-year-old woman with history of ESRD complicated by secondary hyperparathyroidism
hospitalized for shortness of breath attributable to severe mitral regurgitation secondary to bacterial
endocarditis. Twelve hours after admission she was tachypneic to the thirties with a pulse oximeter
saturation of 80%. Upon observation the patient had severe facial deformity with extreme bony
enlargement of the mandible maxilla and frontal bones; she had a flattened nose spreading of the teeth
and protrusion of the palate. The difficult airway cart was called for as a size 3 video laryngoscope could
not reach the vallecula.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC998
Safe and Successful Utilization of an LMA With Muscle Paralysis and Mechanical Ventilation in the
Event of Unsuccessful Tracheal Intubation and Difficult Bag-Mask Ventilation
Andrew Messiha, M.D., Charles Smith, M.D., Case Western Reserve University MetroHealth Medical
Center, Cleveland, OH
A 56-year-old male with hematuria bladder tumor and multiple medical problems was scheduled for
elective cystourethroscopy and TURBT. He had a very thick beard but the airway exam was otherwise
favorable. Urology requested muscle paralysis to prevent surgical difficulty from obturator contraction.
After preoxygenation anesthesia was induced with midazolam propofol fentanyl and rocuronium. Bag
mask ventilation was difficult due to an inadequate seal and tracheal intubation was unsuccessful (MAC
4 blade). It was then decided to proceed with placement of an LMA and mechanical ventilation. Surgery
proceeded uneventfully and there were no postoperative anesthesia complications.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC999
Urgent Awake Fiberoptic Intubation in a Patient With a Rapidly Enlarging Neck Mass
Andrew Messiha, M.D., Charles Smith, M.D., Case Western Reserve University MetroHealth Medical
Center, Cleveland, OH
A 71-year-old female with coronary artery disease atrial fibrillation and sleep apnea was admitted to the
medical floor because of an acutely enlarging neck mass with odynophagia. Anesthesia was consulted
for urgent tracheal intubation prior to transfer to the medical ICU. Upon evaluation it was decided she
should be taken immediately to the operating room for awake fiberoptic intubation with ENT surgeons
at the bedside. The airway was secured after topicalization (lidocaine) and sedation (dexmedetomidine
ketamine and midazolam). The patient was subsequently found to have necrotizing fasciitis of the neck
and required extensive surgeries including tracheostomy.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1000
An Unnecessary and Expensive Complication: Should We Continue to Teach Landmark-Guided
Techniques for Central Venous Catheter Placement to Our Residents?
Merrick Miles, M.D., H David Hardman, M.D., MBA, University of North Carolina at Chapel Hill, Chapel
Hill, NC
A 73 kg male was scheduled to undergo aorto-bifemoral bypass surgery. After anesthetic induction the
faculty anesthesiologist encouraged the anesthesiology resident to use landmark-guided techniqueseven though a ultrasound machine was readily available- to place an internal jugular catheter. Despite
the presence of good anatomical landmarks and the use of a 22-gauge seeker needle the carotid artery
was inadvertently punctured with a larger catheter resulting in a neck hematoma tracheal deviation and
case cancellation. We will discuss whether or not we should continue to teach landmark techniques to
anesthesiology residents in 2013 along with the economic costs of this complication.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1001
Retrograde Intubation After Unsuccessful Tracheotomy
Benjamin Miron, Student, Dan Betterly, M.D., Mitchell Lee, M.D., NYU School of Medicine/ NYU Langone
Medical Center, New York, NY
Pt is a 58-year-old male with metastatic thyroid cancer s/p total thyroidectomy neck dissection and
irradiation presents for tracheotomy. Preop airway exam significant for Mallampati 4 limited neck ROM
and mouth opening. Patient was induced for general anesthesia and intubated w/ difficulty. During
tracheotomy due to abnormally calcified trachea the surgeons were unable to place tracheostomy tube.
After multiple attempts surgical manipulation caused the ETT to be dislodged. Pt was temporarily
ventilated via 5.5 ETT through tracheotomy hole. Patient was then successfully intubated via emergency
retrograde technique using an OG via tracheotomy. Ultimately tracheotomy tube was successfully
placed.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1002
Hypertensive Crisis in a Burned Patient With Spinal Cord Transection
Rahul Modi, M.D., Michel Kearns, M.D., Keck School of Medicine of USC, Los Angeles, CA
28-year-old man with a past medical history of T11 spinal cord transection suffered bilateral lower
extremity burns (18% BSA). Three hours into debridement and grafting surgery he became extremely
hypertensive. He received approximately 600mL of epinephrine 1:1000000 subcutaneously one hour
prior. Hypertension was refractory to increased depth of anesthesia narcotics and intravenous
nitroglycerine. Hypertension resolved with intravenous bolus dose of nicardipine. We attribute this
hemodynamic response to the TelfaTM dressings soaked in 1:10000 epinephrine applied during the
procedure. The differential diagnosis includes autonomic hyperreflexia in a patient with spinal cord
injury.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1003
Anesthetic Management In an Adult With MELAS Syndrome Undergoing Intertrochanteric ORIF
Asif Mohammed, M.D., San San Lo, M.D., NYPH- Columbia University, NYC, NY
A 55-year-old man with recently diagnosed Mitochondrial encephalomyopathy lactic acidosis and
stroke-like episodes (MELAS) syndrome presented for ORIF of a right intertrochanteric fracture. MELAS
is a rare genetic disorder that affects multiple organ systems secondary to a defect in oxidative
phosphorylation. It may result in lactic acidosis electrolyte abnormalities dysrhythmias and temperature
disturbances. Our anesthesic plan was spinal anesthesia with dexmedetomidine for sedation and an
arterial line for monitoring electrolytes. The patient was initially calm but became increasingly aggitated
which necessitated conversion to general anesthesia with propofol induction. No post or intraoperative
lactic acidosis/anion gap was noted.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1004
The Unusual Treatment of Intraoperative Bronchospasm in a Patient With Severe COPD
Henry Monsour, D.O., Scott Miller, M.D., Wake Forest University Baptist Medical Center, Winston Salem,
NC
A 59-year-old woman presented for T9 to sacrum spinal fusion due to continued lower back pain. Her
past medical history was significant for several comorbidities including severe COPD with an FEV1 of
40%. She was medical optimized by her pulmonologist with multiple medications including theophylline.
Intraoperatively the patient experienced severe bronchospasm which required multiple interventions
and included the use of aminophylline. The patient had no further bronchospasm throughout the case
and was extubated upon completion of her surgery without issue.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1005
Perioperative Management of Rhabdomyolysis and Acute Kidney Injury in the Setting of PCP
Intoxication and Bilateral Compartment Syndrome
Micah Moseley, M.D., Baylor College of Medicine, Houston, TX
28-year-old male presents to EC with significant swelling to forearms and hoarseness. Denies traumatic
mechanism. UDS positive for PCP. Sinus tachycardia 120s no ectopy; 96% O2 sat on room air. Airway
patent able to manage secretions; slightly swollen tongue slurred speech no stridor. Significant edema
to bilateral forearms with blanching non-pruritic erythematous areas to hands. Significant labs include:
CKT 67 299 K 6.5 BUN 21 Cr 1.9m AST 890 ALT 114. Striker needle exam performed showing pressure of
115mmHg and 65mmHg to forearms. Taken to OR for emergent bilateral fasciotomies for compartment
syndrome in setting of rhabdomyolysis and AKI.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1006
PEA Arrest Due to a Tension Hemothorax: A Case Study
Tucker Mudrick, M.D., Jonathan Wanderer, M.D., Vanderbilt University Medical Center, Nashville, TN
A 63-year-old male with a history of aortic dissection s/p aortic arch repair as well as recent thoracic
aortic aneurysm s/p endovascular repair presented for revision of his thoracic aortic graft. Patient's
intraoperative course was complicated by celiac and superior mesenteric artery occlusions requiring
bypass grafts as well as significant intraoperative blood loss and an open abdomen. Immediately postop
patient went into PEA arrest secondary to a tension hemothorax. While undergoing CPR patient had
return of spontaneous circulation after needle decompression was performed; chest tube was then
placed. He was discharged on postoperative day 24 in excellent condition
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1007
Challening Anesthetic in a Patient With Neuromyelitis Optica (Devic's Disease)
Fernando Mujica, M.D., John Pawlowski, M.D., Beth Israel Deaconess Medical Center, Boston, MA
A 51-year-old female with Neuromyelitis Optica (NMO) chronic pain on high dose opioids and severe
kyphoscoliosis presented for a right total hip replacement. Pre-operatively ultrasound was used to assist
in placement of a lumbar epidural for analgesia. A video laryngoscope was used for anticipated difficult
airway and the case was performed under general anesthesia with an endotracheal tube. This case will
review the features associated with NMO and specific anesthetic considerations in patients affected
with the disease.
Tuesday, October 15
10:30 AM - 12:00 PM
FA MC1008
Anesthetic Management of a Patient Undergoing Concomitant Adrenalectomy for
Pheochromocytoma and Abdominal Aortic Aneurysm Repair
Hani Murad, M.D., Ricardo Martinez-Ruiz, M.D., Christina Matadial, M.D., Jackson Memorial Hospital/
University of Miami/ Miller School of Medicine and Miami VA Medical Center, Miami, FL
A 65-year-old man in whom the diagnosis of a 5.8 cm abdominal aortic aneurysm and 4.5cm right
adrenal mass on CT scan had been made incidentally while being investigated for hematuria. A
Copyright © 2013 American Society of Anesthesiologists
multidisciplinary team approach was utilized to formulate a management plan. The patient was planned
for concomitant resection of the pheochromocytoma and aneurysm repair. The main concern was for
maintaining hemodynamic stability throughout the perioperative period. Discussion will focus on
monitoring pharmacological manipulation of the patients hemodynamics as well as postoperative
concerns in the intensive care unit.
MCC Session Number – MCC15
Tuesday, October 15
1:00 PM - 2:30 PM
FA MC1009
Cold Agglutinin Hemolytic Anemia
Thomas Myers, M.D., Melody Ritter, Ochsner Medical Center, New Orleans, LA
A 70-year-old male presented for percutaneous nephrolithotomy to remove a large staghorn calculus. In
preoperative clinic he was found to have cold agglutinin disease and chronic lymphocytic leukemia.
Management of his cold agglutinin disease involved avoidance of cold weather rituxan therapy
erythropoietin and multiple blood transfusions. A plan of care was started in the preoperative clinic. On
the day of surgery normothermia was maintained through a multimodal warming approach verified by
measuring temperature at multiple sites. Despite an uneventful anesthetic and surgical course on post
operative day number one he developed a post operative myocardial infarction.
Tuesday, October 15
1:00 PM - 2:30 PM
FA MC1010
Glidescope-Assisted Nasal Fiberoptic Intubation in an Unanticipated Difficult Airway
Anand Nagori, New York University, New York, NY
An otherwise healthy 50-year-old female was given general anesthesia for abdominal hysterectomy.
Preoperative assessment revealed airway anatomy predictive of easy intubation. Patient was induced
and easy to mask ventilate. Direct laryngoscopy failed to visualize vocal cords. Upon Glidescope
laryngoscopy the tube could not be directed anteriorly towards the vocal cords. Fiberoptic intubation
failed due to secretions and airway edema from previous laryngoscopy. Oral fiberoptic intubation with
Glidescope view attempted but it was impossible to direct the scope anteriorly. Nasal fiberoptic
intubation with Glidescope view was successful. Ventilation was provided between attempts at
intubation.
Tuesday, October 15
1:00 PM - 2:30 PM
FA MC1011
Profound Vasoplegia After Albumin Administration
Tran Nguyen, M.D., Sharanya Nama, M.D., Mark Hudson, M.D., University of Pittsburgh Medical Center,
Pittsburgh, PA
A 72-year-old male with diabetes cardiomyopathy (ejection-fraction 35%) and recurrent esophageal
carcinoma who was on an ACE-inhibitor underwent a redo-esophagectomy. An arterial line and internal
jugular introducer with Swan-Ganz catheter were placed prior to induction. Induction and endobronchial
intubation were uneventful and surgery proceeded as planned. Albumin was administered for
preoperative volume depletion. Within minutes of starting albumin the patient's blood pressure
plummeted to a mean arterial pressure of 32. Hypotension was refractory to phenylephrine and
Copyright © 2013 American Society of Anesthesiologists
vasopressin and ultimately required epinephrine boluses with norepinephrine dopamine and
dobutamine infusions. Vasoplegia resolved in 6 hours and vasoactive agents were weaned off.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1012
A Puzzling Case of Monckeberg's Arteriosclerosis: Is it Just Me or Is this Patient Persistently
Hypotensive for No Apparent Reason
Stacie Oliver, M.D., Pamela Roberts, M.D., William Havron, M.D., Gozde Demiralp, M.D., University of
Oklahoma, Oklahoma City, OK
57-year-old female with a past medical history of diabetes hypertension right carotid endarterectomy
and 40 pack-year smoking history presented to a level one trauma center after a motor vehicle collision
with persistent hypotension despite fluid resuscitation. Endocrinology and cardiovascular workup did
not reveal an etiology for her hypotension. After orthopedics revised a splint exposing her right arm it
was found she was normotensive in her right arm after noninvasive and arterial lines in every other
extremity had measured hypotension. The woman was found to have subclavian steal of the left upper
extremity and Monckeberg's arteriosclerosis in her lower extremities.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1013
Life Threatening Anemia From Hemorrhage Complicated by Hyperkalemia: A Case Report
Lawrence Ota, Eugene Kim, M.D., Peter Roffey, M.D., Marianna Mogos, M.D., Duraiyah Thangathurai,
University of Southern California, Los Angeles, CA
A 77-year-old male was admitted from clinic to the ICU for severe anemia complicated by hyperkalemia.
He had Comorbidities that included DM HTN CAD and bladder ca. The patient laboratory values from
clinic were significant for potassium of 6.4 mmol/L hemoglobin of 4.6 g/dL bicarbonate of 15 and Cr 4.4.
Vital signs stable. Patient was admitted to the ICU. Pt was resuscitated with 5 units prbc. A Multi-modal
approach was used (diuretic lasix nahco3 kayhexalate epinephrine) to correct anemia while not
worsening hyperkalemia. 12 hours later the patients hemoglobin was 31. Cr decreased to 2.7. Potassium
decreased to 4.0.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1014
Complete Hepatectomy as Treatment for Failed Liver Transplant
Francisco Pasdar-Shirazi, Harendra Arora, University of North Carolina Hospitals, Chapel Hill, NC
A 60-year-old male with end-stage liver disease underwent an uneventful liver transplantation. On POD2
ultrasound exam demonstrated diminished flow to the hepatic artery thought to be from splenic artery
steal. The patient was taken to the OR for aorto-hepatic artery bypass. After initial recovery his clinical
picture declined around POD 12 with marked increase in LFT's worsening coagulopathy and acidosis.
Upon emergent re-exploration the intra-op pathology revealed marked liver necrosis. A total
hepatectomy was performed as a rescue measure with the intention of re-transplantation. We discuss
issues related to perioperative management of liver allograft failure and the anhepatic patient
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1015
Venovenous Bypass During Liver Transplantation in a Patient With Fulminant Hepatitis B
Mayur Patel, M.D., Esamelden Abdelnaem, M.D., University of Arkansas for Medical Sciences, Little Rock,
AR
Patient was a 60-year-old Caucasian male with history of multiple myeloma who developed fulminant
hepatitis secondary to hepatitis B virus one month prior to presentation. This was evidenced by
worsening coagulopathy and altered mental status. Patient was also complicated by septic shock acute
kidney failure hospital acquired pneumonia emphysema and dvt in right subclavian. It was decided that
he was a candidate for liver transplantation. Rapid sequence induction was performed and airway was
easily secured. Adequate venous and arterial access was established. During anhepatic phase of surgery
venovenous bypass for hemodynamic support was used.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1016
Anesthetic Management of a Parturient in Acute Respiratory DIstress Syndrome (ARDS)
Ronak Patel, Lakhmir Chawla, Katrina Hawkins, M.D., GWU, Washington D.C, DC
A 36-year-old female in her third trimester of pregnancy presented to the hospital with symptoms of
acute respiratory distress syndrome (ARDS). The patient had no significant medical history. Initially the
patient had presented with fever and cough but subsequently developed shortness of breath. She was
transferred to the intensive care unit and soon required intubation. Initial studies were inconclusive as
to causation of her illness and treatment with antibiotics and anti-viral medication were not improving
her clinical situation. It was determined that a semi-elective caesarean section was the most appropriate
course of action for both mother and the fetus.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1017
Lung Volume Reduction Coil (LVRC) Treatment: The First Clinical Case in the United States
Eric Ponte, Tetsuro Sakai, M.D., Ph.D., University of Pittsburgh School of Medicine, Pittsburgh, PA
Emphysema is a common disease. Lung Volume Reduction Coil (LVRC) Treatment is a novel procedure
designed to improve quality of life of patients with emphysema. During Standard bronchoscopy metal
coils are inserted into emphysematous lobe to reduce lung volume through various mechanisms and
improve overall lung function. Potential complications of the procedure could pneumothorax
hemothorax pneumonia COPD exacerbation and mild hemoptysis. Anesthetic management should be
modified to those reduce complications by reducing tidal volumes and PIP avoidance of NO2 etc. We
present a case of 65-year-old female who was the first to receive this therapy in the United States.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1018
Cerebroprotective Hypothermia After Cardiopulmonary Bypass Pump Malfunction
Sudheer Potru, D.O., Jackson Memorial Hospital, Miami, FL, Giri Srikanthan, M.D., University of Miami,
Miami, FL
61-year-old male with history of MIx2 and CVA presented for CABG. After starting CPB and aortic crossclamp the patient was found to have low-CO state(< 1 L/min) and BIS dropped to zero. After aortic
dissection and venous cannula malposition were ruled out the roller pump was exchanged but the
patient continued with low flows for 45 minutes. Cerebroprotection measures were initiated with
cooling to 24C; the procedure was completed. Hypothermia was continued coming off CPB and
maintained in the ICU for 15 hours. Twelve hours later he returned to neurologic baseline and was
extubated. There were no further complications.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1019
Adult Congenital Heart Disease - A Complicated Postoperative Course
Harish Ram, M.D., Wolf Kratzert, M.D., Ph.D., University of New Mexico, Albuquerque, NM
Incidence of congenital heart disease though stable in pediatrics has been growing by about 5% each
year in adults. Ebstein anomaly (EA) consists of wide anatomic spectrum of abnormalities of tricuspid
valve and right ventricle along with associated anomalies. Perioperative management is guided by
structural abnormality present and extent to which hemodynamics compromise functional status.
Arrhythmia and right ventricular failure are common and early operative mortality varies from 4% to
5.9%. We present an interesting case of a 41-year-old male with EA who underwent atrial septal defect
closure with a fenestration and had a complicated post-operative course.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1020
Sevoflurane in refratory Status Asthmaticus in the ICU Setting
Ashraf Resheidat, M.D., John Pennant, M.D., Paul Sheran, M.D., University of Texas Southwestern,
Dallas, TX
10-year-old AAM uncontrolled asthma admitted to the PICU after 5 hr SOB wheezing. ABG pH 7.1 PaCO2
60 SpO2>95%. He was treated with nebulized albuterol terbutaline aminophylline magnesium sulfate
steroids. His respiratory status worsened; placed on noninvasive ventilation. he became somnolent ABG
PH 6.9 PCO2 >100 acidosis. pt intubated and placed on mechanical ventilator. pt difficult to ventilate
with high peak airway pressures. Different modes of ventilation attempted but pt no chest rise. Manual
hand bag ventilation ineffective . Sevoflurane administered at 1MAC via anesthesia ventilator. He
gradually improvemed. Sevoflurane stopped 8 hours later; switched to ICU ventilator. Pt improved
extubated
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1021
Successful Use of Sugammadex on a Cocaine User Patient
Clarissa Ribeiro, M.D., Mariana Palis, M.D., Hospital Quinta D`or, Rio de Janeiro, Brazil
A 48-year-old male, HIV+, arrives at the Emergency Room complaining of rectal pain and bleeding after
introducing a carrot in its anus. The patient refers neurotoxoplasmosis and recent use of cocaine. The
surgical team promptly decides to remove the foreign body under anesthesia as the bleeding was
increasing. We decided to perform a rapid sequence of intubation using Rocuronium .The removal
through the rectum was not successful and a Laparotomy had to be performed. Two hours later we used
sugammadex uneventfully, showing its secure use on these patients.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1022
Dexmedetomidine Sedation and High Degree AV-Block
Gabriel Rice, M.D., Yawar Qadri, M.D., Ph.D., Janakiram Ravulapati, M.D., M.P.H., University of North
Carolina at Chapel Hill, Chapel Hill, NC
A 68-year-old female was admitted to the ICU after an emergent laparotomy for perforated viscus. In an
attempt to wean her ventilator support she was transitioned to low dose dexmedetomidine infusion for
sedation. After initiation of dexmedetomidine she had episodes of hemodynamic instability with heart
rates in the 30s and hypotension. The high-grade heart block ceased with discontinuation of
dexmedetomidine. A 20-year-old female admitted to the ICU after extensive surgery for mandibular
osteosarcoma was sedated with dexmedetomidine. She also developed AV-block at high doses of
dexmedetomidine which resolved with a dose reduction.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1023
Rapidly Progressing Bullous Skin Lesions With Acute Respiratory Failure Rhabdomyolysis and Acute
Kidney Injury
Bradley Rodgers, M.D., Avinash Kumar, M.D., Vanderbilt University, Nashville, TN
60-year-old female with an unclear PMH presents to the ICU with a rapidly evolving bullous skin
eruptions acute respiratory failure acute kidney injury rhadomyolysis after being found down and
unresponsive at home. The patient had a blistering congealing rash covering 70-80% TBSA mucosal and
ocular involvement and hemorrhagic conversion. She was recently diagnosed with gout. Toxic epidermal
necrolysis is suspected and confirmed with biopsy. The precipitating cause was likely allopurinol. The
ICU course involved IVIG therapy RRT aggressive wound care acute respiratory failure necessitating a
tracheostomy. The complex presentation and comorbidities made ICU management challenging in this
patient.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1024
High Grade Subarachnoid Hemorrhage and Massive Pulmonary Embolism: What is Your Plan?
Dorothea Rosenberger, M.D., Ph.D., Rebecca Desso, M.D., Medical University of South Carolina,
Charleston, SC
We present a complicated course of high grade angiographic negative SAH in a 64-year-old female.
Recovery was slow on NSICU and the patient was transferred to the step down unit after three weeks.
She suddenly presented with respiratory distress when mobilized. Chest CT showed massive bilateral
pulmonary embolism. The patient underwent emergent thrombectomy by interventional radiology. She
sustained cardiac arrest during the procedure but was successfully resuscitated with ROSC. The
procedure was aborted and the patient was transferred to NSICU immediately initiating hypothermia
protocol. After rewarming the patient's neurostatus remained poor and the family decided to withdraw
care.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1025
Anesthetic Management in the Setting of an Expanding Neck Hematoma in a Patient Following a
Carotid Endarterectomy
Roya Saffary, M.D., Michael Kim, M.D., Richard Pedro, D.O., Timothy Kubicki, M.D., Boston Medical
Center, Boston, MA
Three weeks after a carotid endarterectomy a 69-year-old man presented with purulent drainage from
his wound. He was taken to the operating room for washout. On postoperative day 1 an expanding neck
hematoma from acute bleeding was noted and he was taken emergently to the operating room. Rapid
sequence induction was performed and the patient was intubated under direct laryngoscopy. During the
surgery the patient remained hemodynamically stable while on a phenylephrine drip. We will discuss
airway management in the setting of an expanding neck hematoma and a full stomach and overall
anesthetic management of an emergent carotid endarterectomy.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1026
Enemy Behind the Wall: Ruptured Breast Implant Complications After Chest Trauma
Brian Seacat, M.D., Roxie Albrecht, M.D., Gozde Demiralp, M.D., University of Oklahoma Health Sciences
Center, Oklahoma City, OK
We report one of the rare examples of chest trauma related breast implant rupture and its severe
complications in trauma intensive care unit (TICU). 49-year-old female was hospitalized with multiple
injuries to her chest and abdominal wall. Her pulmonary status was compromised with multiple rib
fractures and pulmonary contusions along with a unilateral ruptured breast implant. Shortly after she
developed a breast-implant capsule-pleural fistula which complicated her course with multiple
thoracostomy tube placements urgent thoracotomies and significant ventilator dependence with
chronic respiratory failure. After 5 months of TICU stay she recently got diagnosed with pulmonary
hypertension.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1027
Posterior Reversible Encephalopathy Syndrome: Case Report &amp; Management
Troy Seelhammer, Nishant Sadana, M.B. B.S., Paul Picton, M.D., University of Michigan, Ann Arbor, MI
Acute intra-operative venous air embolism was encountered in a patient presenting for orthotropic liver
transplantation with transient but significant hemodynamic perturbations and post operative neurologic
sequelae. On post-op day three a neurologic exam demonstrated intact extra ocular range of motion but
absent blink to threat and visual acuity resolving to light perception only. Subsequent MRI with swelling
and T2 signal abnormality in bilateral occipital parietal temporal-parietal and frontal regions consistent
with posterior reversible encephalopathy syndrome (PRES). The patient was managed conservatively
with supportive measures and medication adjustment with gradual improvement but residual cortical
visual loss remained two months post transplantation.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1028
Familial Mediterranean Fever: ICU and Intraoperative/Anesthetic Considerations
Jasjit Sehdev, M.D., Irwin Gratz, D.O., Cooper University Hospital, Camden, NJ
32-year-old Female with a PMHx of Familial Mediterranean Fever and PSHx of a non-diagnostic ex-lap
presented with abdominal pain and clinical features of peritonitis. Abdominal CT was not diagnostic. An
initial diagnosis of an acute FMF flare was made. The patient was admitted to the ICU for several days
with a septic-like picture and remained there for about two weeks. She deteriorated with respiratory
failure leukocytosis and sepsis. Serial abdominal CT scans were negative. She was taken for an
exploratory laparotomy and found to have perforated bowel.
Tuesday, October 15
1:00 PM - 2:30 PM
CC MC1029
Long Term Sedation in the Pediatric Intensive Care Unit: An Unusual Reaction to Propofol
Goonjan Shah, M.D., Peggy McNaull, M.D., University of North Carolina, Chapel Hill, NC
An 8-year-old with a history of tracheotomy for severe subglottic stenosis presented to PICU for postoperative management of laryngotracheal reconstruction. After an uneventful surgery he was kept
intubated seven days for post-surgical healing. His course was complicated by difficulty with sedation.
He was trialed on various sedatives including dexmedetomidine fentanyl ativan morphine and ultimately
propofol. After extubation he had dyskinesia. Of note the patient had a history of bipolar and was
talking olanzapine. Anesthesia was consulted with a differential including narcotic withdrawal and
reaction to propofol. This case examines a rare but distressing side effect of propofol.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1030
Push Pin Pushed Too Far
Yarnell Lafortune, M.D., Branko Furst, M.D., Albany Medical Center, Albany, NY
16-year-old female presented for removal of an airway foreign body. The ENT surgeon made several
attempts but the push pin migrated further into the right bronchus. A thoracic surgeon was consulted
and further attempts to retrieve the foreign object failed. With every attempt there was increasing
trauma and bleeding. After nearly three hours the decision was made to intubate the trachea start
Copyright © 2013 American Society of Anesthesiologists
steroids and continue attempts on the following day. Unfortunately attempts by an experienced
bronchoscopist and two thoracic surgeons were unsuccessful. A double-lumen tube was then placed
and the patient underwent a thoracotomy and segmentectomy.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1031
Intraoperative Opioid-Free Anesthesia for a 16-year-old Male With TBSA 40% Electrical Burns Using
Simultaneous Intravenous Lidocaine and Dexmedetomidine Infusions
Brian Lee, Agnieszka Lesicka, M.D., T. Anthony Anderson, M.D., Ph.D., Massachusetts General Hospital,
Boston, MA
16-year-old male with history of electrical burn TBSA 40% involving bilateral lower extremities resulting
in bilateral below knee amputations. The patient was then scheduled for a penile/perineum
reconstruction with donor tissue and free flap from his thighs. Regional anesthesia was considered but
not used due to the extent of the burn injury to his lower body. To minimize intraoperative opioid use a
dexmedetomidine and lidocaine simultaneous infusions (never studied in the pediatric literature) with
isoflurane 1% was used and upon emergence and extubation the patient was pain free alert and
required no opioids in the PACU.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1032
Intraoperative Opioid-Free Anesthesia for a 19-Year-Old Male Undergoing Right Radial Forearm Free
Flap to the Right Lower Extremity WIth Split Thickness Skin Graft Using Simultaneous Intravenous
Lidocaine and Dexmedetomidine Infusions
Brian Lee, M.D., Agnieszka Lesicka, M.D., T. Anthony Anderson, M.D., Ph.D., Massachusetts General
Hospital, Boston, MA
Intravenous lidocaine and dexmedetomidine infusions have been separately shown to decrease post
operative pain anesthetic and opioid requirements but not studied together in the pediatric anesthesia
literature. 19-year-old male with osteomyelitis of an open tibia fracture from a MVA who required a free
flap coverage from the right forearm flap to the RLE with a split thickness skin graft. We used an opioid
free anesthetic with simultaneous intravenous lidocaine and dexmedetomidine infusions with isoflurane
1.0% instead of regional anesthesia. Upon emergence and extubation the patient was alert pain free
with no opiate requirement in the PACU.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1033
Innovative Airway Management in a Boy With Dandy Walker Syndrome
John Liu, Xiaoqi Liu, M.D., Kalpana Tyagaraj, M.D., Maimonides Medical Center, Brooklyn, NY
We present a 3-year-old boy with history of Dandy-Walker lissencephaly Walker-Warburg syndrome was
admitted to PICU in respiratory failure for emergent intubation. After multiple unsuccessful attempts
anesthesiologists were called. Direct laryngoscopy and pediatric glidescope assisted intubations were
unsuccessful due to increasing secretions edema and angle of the cords. Intubating LMA and oral
fiberoptic attempted intubations failed because of secretions blocking the camera. Nasal fiberoptic with
aid of direct vision from Glidescope was successful in maneuvering through angled cords. Pediatric
surgeon was at bedside for emergency tracheostomy backup throughout.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1034
A 27-Year-Old Male With Fenestrated Fontan and Biventricular ICD for Emergency Inguinal Hernia
Repair
Yang Liu, Michael Lin, M.D., Wanda Miller-Hance, M.D., Texas Children's Hospital, Houston, TX
A 27-year-old male with heterotaxy single ventricle physiology_L-TGA AVC CoA post balloon subaortic
stenosis resection PDA closure and fenestrated Fontan with a biventricular ICD for AV block. He
presented with incarcerated inguinal hernia. Bedside reduction was unsuccessful and was scheduled for
an urgent inguinal hernia repair. He was diagnosed 2 weeks prior with a viral URI with cough and
orthopnea. His pacemaker was interrogated and set to DOO mode; the ICD function was turned off; and
Zoll pads were placed. He underwent general endotracheal anesthesia with an ilioingunal nerve block
and remifentanil for analgesia.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1035
Case of a Four-year-old With Trisomy 8 for Wilms' Tumor Resection and Pulmonary Nodule Biopsy: An
Anesthetic Perspective.
Jack Louro, UM/ Jackson Memorial Hospital, Miami, FL, Kimberly Kimmel, M.D., Miami Children's
Hospital, Miami, FL
We will discuss the case of a 4-year-old with trisomy 8 who was recently found to have a large left renal
mass and pulmonary nodules. The patient had a history of multiple anomalies from his chromosomal
abnormality including cleft palate hypospadias and tethered cord which had previously required surgical
correction. We will discuss the anesthetic implications of Wilms' tumor resection and thoracoscopy for
nodule biopsy. We will also review the anesthetic approach of a patient with previous difficult airway
and cleft palate along with an overview of anesthetic concerns in patients with chromosomal
abnormalities.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1036
Awake Craniotomy in a 9-year-old
Matthew McDaniel, M.D., Alicia Shook, M.D., Duke University, Durham, NC
A nine-year-old female presented for surgical management of intractable seizures. She underwent
craniotomy for placement of strip electrodes and returned to the operating room for resection of
epilepsy focus ten days later. The patient underwent a total intravenous anesthetic (TIVA) using
propofol dexmedetomidine and remifentanil with an LMA while the neurosurgeon dissected down to
the target area. The patient was awakened and the LMA removed for the speech mapping portion of the
procedure utilizing intermittent fentanyl boluses for patient comfort. After completion of the awake
portion the TIVA was resumed and the case proceeded uneventfully.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1037
Perioperative Management of the Pediatric Patient With Shone's Syndrome During Mitral Valve
Replacement With a Melody Valve
Matthew Monteleone, M.D., William Schechter, M.D., Columbia University, New York, NY
A 2-year-old boy with Shone's complex presented for MV replacement with a Melody valve: a stentmounted valved vein graft. The intra-operative course was notable for three bypass runs each
highlighting a potential complication of this valve replacement technique. A key advantage of the
Melody valve is that it is expandable and can be adjusted by balloon catheterization as the child grows.
However the potential requirement for multiple bypass runs as well as disruptions to the cardiac
conduction system coronary blood flow and overall cardiac function caused by a physical obstruction
from the valve itself make this surgery particularly challenging.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1038
Anesthetic Management of One Lung Ventilation in a One-year-old With Diffuse Pulmonary
Hemangiomas
Meeta Patel, M.D., Lauren Moore, Venkata Sampathi, M.D., SUNY Upstate Medical University, Syracuse,
NY
Pulmonary hemangiomas are extremely rare with only a few reported cases. The anesthetic plan and
management for single lung ventilation is challenging when considering various issues including but not
limited to lung isolation and extubation/ postoperative care. We are presenting the case of a one-yearold that underwent open lung biopsy for recurrent upper respiratory infection fevers and
thrombocytopenia. One lung ventilation was accomplished by using a fiberoptic bronchoscope and a
Fogarty embolectomy catheter. The surgery proceeded uneventfully and successfully.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1039
Persistent Hypotension in a 12-year-old Male With Klippel-Feil Syndrome for Cervical Disk Fusion and
Thoracic Scoliosis Correction
Neelima Myneni, M.D., Scott Hines, M.D., The Children's Hospital of Philadelphia, Philadelphia, PA
A 12-year-old boy from Kuwait with a history of Klippel-Feil syndrome moderate pulmonary
hypertension severe restrictive lung disease secondary to kyphoscoliosis and morbid obesity underwent
an occiput to T8 posterior spine fusion. Intraoperative course was significant for intractable hypotension
that began immediately after prone positioning and resolved spontaneously when patient was turned
supine. In this case intraoperative hypotension lead to loss of neuromuscular signals and evidence of
end organ dysfunction.This case will highlight the proper preoperative evaluation of a patient with
Klippel-Feil syndrome. A discussion of the physiological derangements in the prone position will be
reviewed highlighting the need for proper positioning.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1040
Worth the Risk? Airway Complications Among Two Outpatient Pediatric Patients With Mild URI
Undergoing Elective Surgery
Wendy Nguyen, M.D., Caron Hong, M.D., M.S., University of Maryland School of Medicine, Baltimore,
MD
Here we describe two cases of patients with mild URI symptoms who developed laryngospasm during
anesthesia. Case 1 is a 15-month-old male with mild nasal purulence who underwent mask GA for
circumcision. Succinylcholine was required on emergence to overcome severe laryngospasm. Case 2 is a
17-month-old female with resolving URI symptoms who underwent GA with ETT for gastrostomy
reversal. She developed laryngospasm immediately after intubation that resolved with propofol. She
also had delayed reinitiation of breaths after deep extubation requiring reintubation. Deciding whether
to perform an elective procedure in similar cases may not be straightforward.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1041
Myotonic Muscular Dystrophy Type I
Ngoc Nguyen-Famulare, M.D., Harshini Dani, D.O., Montefiore Medical Center, Bronx, NY
Myotonic muscular dystrophy patients can present several anesthetic challenges. We intend to present
a case of a 14-year-old female with history of myotonic muscular dystrophy type 1 developmental delay
attention deficit-hyperactivity disorder and history of 1st degree AV block. She experienced successful
management of her primary experience under general anesthesia for laparoscopic cholecystectomy. We
credit this to a careful detailed discussion with the surgical team regarding use of neuromuscular
blocking agents discussion with family about possible post operative ventilation careful administration
of intraoperative opioids and vigilant monitoring during recovery followed by 24 hour postoperative
observation.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1042
Airway Management in a Case of Morbid Obesity and Severe Obstructive Sleep Apnea With
Fibrodysplasia Ossificans Progressiva
Ngoc Nguyen-Famulare, M.D., Children's Hospital at Montefiore, Bronx, NY, Michael Akerman, M.D.,
Albert Einstein College of Medicine, Bronx, NY
A 5-year-old female with fibrodysplasia ossificans progressiva (FOP) severe obstructive sleep apnea
(OSA) and morbid obesity was evaluated for bilateral myringotomy and tubes (BMT) for conductive
hearing loss and recurrent otitis media. She had 4+ tonsillar hypertrophy and apnea-hypopnea index of
125. Tonsillectomy was contraindicated due to risk of temporomandibular joint ankylosis. Her OSA was
being treated with CPAP of 14. While mask anesthesia is typically sufficient for BMT her co-morbidities
posed challenging airway management. With careful multidisciplinary perioperative consideration an
Intubating Laryngeal Airway (ILA) was planned. ILA can be a primary airway or a conduit for fiberoptic
intubation.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1043
Massive Transfusion in Pediatric Trauma
Shannon Ong, M.D., Kim Poteet-Schwartz, M.D., University of Arkansas for Medical Sciences, Little Rock,
AR
Trauma-related injuries are one of the few scenarios where a massive transfusion protocol (MTP) may
be activated as part of the initial damage control resuscitation. Some complications of Massive
Transfusion occur more readily in children one of them being transfusion-associated hyperkalemia. This
case involved an 18-month-old female with an acute subdural hematoma taken to the OR for an
emergent craniotomy and hematoma evacuation. The patient developed profound hemorrhage after
cerebral exposure requiring rapid massive transfusion and thereafter acutely deteriorated coded and
was eventually resuscitated. The patient developed suspected life-threatening transfusion-associated
hyperkalemic cardiac arrest secondary to Massive Transfusion.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1044
Anesthetic Management of Arthrogryposis and Its Related Complications
Jose Otero, M.D., Shridevi Pandya Shah, M.D., UMDNJ-NJMS, Newark, NJ
Arthrogryposis multiplex congenita is a syndrome involving the neuromuscular system with an incidence
of 1:3000 live births. This is a case of a 3-year-old male born at term with low birth weight congenital
skeletal dysplasia with arthrogryposis features of dextroscoliosis multiple joint contractures bilateral hip
dislocations global developmental delay generalized hypotonia micrognathia high arched palate difficult
intravenous access and tracheostomy secondary to chronic respiratory failure on home ventilator
requiring high peak pressures presenting for surgical correction of bilateral severe equinus foot
deformities. Muscle biopsy was done at the age of 10 months and malignant hyperthermia susceptibility
was ruled out.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1045
Anaphylaxis After Ophthalmic Artery Infusion Chemotherapy
Mario Patino, M.D., Todd Abruzzo, M.D., Mohamed Mahmoud, M.D., Cincinnati Children's Medical
Center, Cincinnati, OH
8-year-old with relapsed retinoblastoma presented for cerebral angiogram with ophthalmic artery
infusion chemotherapy of melphalan carboplatin and topotecan. 15 minutes after the infusion was
started significant hypotension with generalized flushing compatible with anaphylaxis was found.
Volume resuscitation epinephrine corticosteroids and transfer to the ICU were necessary. Tryptase
levels at 1 and 3 hours after the beginning of the episode were significant elevated. The child recovered
successfully from this episode. Postoperative evaluation by allergies found carboplatin and vecuronium
as the triggers of her anaphylaxis with an allergy prick test positive for carboplatin and positive
intradermal skin test for vecuronium.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1046
Anesthetic Complications in a Child With Down Syndrome Undergoing a SIPES Based Excision of
Duodenal Web
Todd Payne, D.O., Donald Schwartz, M.D., Baystate Medical Center, Springfield, MA
A 3-year-old male with Down Syndrome presented for a modified SIPES procedure (Single Incision
Pediatric Endo Surgery) to excise a duodenal web. He had a pre-existing gastric tube through which the
endosurgical instrumentation was placed after a gastroscope was advanced from his mouth. During the
case we encountered gastric insufflation profound bradycardia subglottic narrowing and a dislodged
endotracheal tube. We discuss in our presentation the important anesthetic factors to consider for a
SIPES Procedure as well as for children with Down Syndrome in general. SIPES is becoming more
frequent and anesthesiologists need to be aware of the anesthetic implications.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1047
Anesthetic Management of an Infant With Congenital Macroglossia
Todd Peacock, Wake Forest Baptist Health, Winston-Salem, NC
We present the case of a male infant with congenital macroglossia secondary to lymphovenous
malformation for tongue debulking procedure. The patient was delivered and intubated via EXIT
procedure; however he was extubated and discharged home without the need for airway support. He
returned at 6 months at which time a tracheostomy was performed prior to tongue debulking. Following
inhalation induction the patient was intubated via tracheostomy. Surgery proceeded with the use of an
argon laser for resection. Significant blood loss called for red blood cell transfusion; otherwise the case
proceeded without incident. The patient was transported to the ICU post-operatively.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1048
Infant Found to Have Subglottic Mass on Intubation for Cardiac MRI
Blake Perkins, M.D., James Priepot, M.D., Andrea Guyon, M.D., University of Illinois, Peoria, IL
A 3-month-old girl with a history of inspiratory stridor for 7 weeks was found to have a subglottic mass
during intubation for cardiac MRI. Previously the patient had a 2D echo performed with concern for
vascular ring and was undergoing cardiac MRI for further evaluation. During induction of anesthesia a
Grade 1 Cormack-Lehane view was obtained with direct laryngoscopy using a Miller 1 blade. However a
3.0 cuffed endotracheal tube was unable to be passed due to a subglottic obstruction. The obstruction
was later found to be a subglottic hemangioma and the patient was started on propranolol for
treatment.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1049
Anesthetic Management of a Subglottic Mass in a Pediatric Patient
Liem Pham, University of Michigan Health System, Ann Arbor, MI
RK is a 10-week-old healthy female infant who presented with inspiratory stridor. Flexible nasal
laryngoscope exam was performed by ENT in the ED and showed a normal larynx with a subglottic mass.
She was taken to the OR for flexible bronchoscopy and biopsy of the mass. She was induced by mask
Copyright © 2013 American Society of Anesthesiologists
with sevoflurane and nitrous oxide and IV access was obtained. Her anesthesia was maintained with a
propofol infusion and ketamine during the DL/Bronch. She maintained spontaneous respiration
throughout with adequate oxygenation. Her subglottic mass was visualized and diagnosed as a
hemangioma.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1050
Surviving Ectopia Cordis
Bretonya Phillips, M.D., John H. Stroger Hospital of Cook County, Chicago, IL, Chike Gwam, M.D.,
Advocate Christ Hospital, Chicago, IL
3-year-old female w/ intrauterine diagnosis of ectopia cordis was born term delivery via c-section. Pt
underwent multiple staged cardiac procedures including repair of tetrology of fallot multiple ventricular
septal defects and double outlet right ventricle. The patients final surgical procedure was complicated
by an unexpected early closure of the tracheostomy stoma postop day one requiring a second operation
to revise the tracheostomy. This unexpected morbidity requiring pt. to have to undergo a second
surgery questions how compromised the immunological response/healing properties are in patients
with conditions in which so much of the cardiovascular system is dysfunctional.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1051
Saturation Versus. Peak Airway Pressure Case Report of Pleuropulmonary Blastoma
Bretonya Phillips, M.D., John H. Stroger Hospital of Cook County, Chicago, IL, Nnaneme Mgbodille, M.D.,
Advocate Christ Hospital, Chicago, IL
2-year-old male previously presented w. upper respiratory symptoms w/ diagnosis of pneumonia. After
two weeks of antibiotics w. no resolution of symptoms pt. began having shortness of breath and
subsequently underwent a VATS for working diagnosis of plueral effusion w/ empyema. VATS procedure
w/minimal effusion and negative empyema. Two months later pt. presented w. significant shortness of
breath and acute respiratory distress requiring emergent intubation. Subsequent CT of chest found
12*14cm heterogenous mass in right hemithorax compressing pulmonary artery trachea and heart. Pt
emergently underwent debulking procedure successfully removing ninety percent of tumor.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1052
Urgent Management of Congenital Cystic Adenomatoid Malformation in a Neonate
Cooper Phillips, M.D., Ashraf Farag, M.D., Brian McClure, D.O., Texas Tech University Health Sciences
Center, Lubbock, TX
A term infant with congenital cystic adenomatoid malformation was delivered via cesarean section with
respiratory distress which resulted in intubation and mechanical ventilation. Further deterioration of
respiratory status necessitated urgent resection of the lesion. Shortly after entering the operating room
breath sounds on the left side became diminished and then absent. After proper endotracheal tube
placement was confirmed a preliminary diagnosis of spontaneous pneumothorax was made. Further
expansion of the pneumothorax compromised surgical exposure ventilation and hemodynamics
requiring conversion to open thoracotamy. The malformation was successfully removed without further
complications.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1053
A Neonate With Unsuspected Grade IV Laryngeal Cleft
Joyce Phillips, M.D., Sally Vender, M.D., University of New Mexico, Albuquerque, NM
A 37-week newborn developed feeding problems which included cough and difficulty swallowing.
Barium swallow revealed massive aspiration with a diagnosis of a large H-type tracheo-esophageal
fistula. In the OR inhalation induction was uneventful. Rigid bronchoscopy identified a proximal fistula.
Laryngoscopy appeared normal. Intubation was accomplished without problem. Following incision there
appeared to be a massive leak and end tidal CO2 was lost. Subsequent bronchoscopy revealed a large
vestibule from the larynx to the carina. Case discussion will compare and contrast the embryology
clinical presentation evaluation and management of a newborn with a tracheoesophageal fistula vs. a
laryngeal cleft.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1054
TEE as a Monitor of Intraoperative Ventricular Volume and Function and IV Fluid Management: The
Impact of TEE on Pre-Intra and Postoperative Management in the Partial Separation of Conjoined
Twins
Claire Rezba, M.D., Iolanda Russo-Menna, M.D., Virginia Commonwealth University, Richmond, VA
Thoracoabdominal conjoined twins presented for partial separation after worsening hemodynamic and
respiratory compromise. They had a large volume shunt causing high output cardiac failure in BG2 and
hypotension and oliguria in BG1. Their unique anatomy and shared systems required innovative imaging
to optimize their preoperative intraoperative and postoperative course. In this case study an
intracardiac echocardiogram probe was utilized as a transesophageal echocardiogram for preoperative
evaluation as well as for intraoperative fluid management and cardiac monitoring during the partial
separation of conjoined infants.
Tuesday, October 15
1:00 PM - 2:30 PM
PD MC1055
Foreign Body Removal at Rt. Main Bronchus in a Neonate Patient
Hyunsu Ri, Sangwook Shin, Seunghoon Baek, Jiyoung Yoon, Eunjung Kim, Pusan National University
Yangsan Hospital, Yangsan, Republic of Korea
Foreign body in the airway could be a life-threatening risk especially to pediatric patients. A 6 day old
neonate with foreign body which was located deep in the rt. main bronchus was admitted. Although we
tried three times to remove it with rigid bronchoscope and forcep we failed. Before switching to surgical
treatment we decided to move the foreign body near to the forcep. The position became trendelenburg
and we tapped the back several times. Finally we caught it. We suggest that back percussion with
trendelenburg position is an useful solution to remove a foreign body in a deep airway.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1056
Tracheal Compression Secondary To A Mediastinal Hematoma
Douglas Schechter, NYU Medical Center, Forest Hills, NY
The patient is a 34-year-old woman with a past medical history of Marfan syndrome aortic valve
replacement and aortic arch replacement who presents with innominate artery aneurysm and
hematoma. The case was challenging due to the presence of a mediastinal mass (the hematoma) with
resultant tracheal compression and difficulty in achieving adequate ventilation. The unique challenges to
ventilation that are posed by tracheal compression the tools that were used to definitively diagnose
tracheal compression and the ultimate treatment of the tracheal compression caused by the hematoma
will all be discussed in the case presentation.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1057
Autonomic Dysfunction After Combined Epicardial and Endocardial Atrial Fibrillation Ablation
Procedure
Jay Schoenherr, M.D., Lavinia Kolarczyk, M.D., UNC Hospital, Chapel Hill, NC
A 57-year-old male with a history of non-ischemic cardiomyopathy and paroxysmal atrial fibrillation
presented for combined epicardial and endocardial atrial fibrillation ablation. Epicardial ablation was
performed via a right sided thoracotomy incision followed by a traditional endocardial ablation
technique. The patient developed hypotension one hour into the endocardial portion requiring a
phenylephrine infusion. He emerged from general anesthesia uneventfully but his pressor requirement
remained elevated. Attempts to wean phenylephrine were unsuccessful. After ruling out hypovolemia
and ongoing blood loss transient autonomic dysfunction from inadvertent autonomic fiber ablation was
suspected. Dopamine was initiated and was weaned within 24 hours.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1058
Anesthetic Management of a Sickle Cell Trait Patient Requiring Thoracoabdominal Aortic Aneurysm
Repair With Possible Hypothermic Circulatory Arrest
Joshua Sebranek, M.D., Richard Wolman, M.D., Martha Wynn, M.D., University of Wisconsin School of
Medicine and Public Health, Madison, WI
A 61-year-old male with sickle cell trait presented for Crawford type II thoracoabdominal aortic
aneurysm repair with possible cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest
(DHCA). Preoperative hemoglobin was 12.0 g/dL hemoglobin A1 55.6% (reference range 94.3-98.5%)
and hemoglobin S 40.1% (0%). On the day prior to surgery the patient underwent an exchange
transfusion with 12 units of packed red blood cells. The aneurysm was repaired without CPB or DHCA.
The patient's temperature reached a minimum of 31.7 degrees Celsius. He had an uneventful
postoperative course and was discharged home on postoperative day six.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1059
Balloon Valvuloplasty in a Parturient With Severe Mitral Stenosis and Twin Gestation
Amit Shah, M.D., Bijal Patel, M.D., Trevor Banack, M.D., Yale University School of Medicine, New Haven,
CT
33-year-old G5P0 with DCDA twin gestation underwent percutaneous balloon valvuloplasty for severe
mitral stenosis/rheumatic heart disease at 29+4 weeks. Post-procedure echo showed the severity of
mitral stenosis had decreased but worsening right ventricular systolic pressure mitral regurgitation and
tricuspid regurgitation and a new interatrial shunt. Patient returned at 34+5 weeks in preterm labor and
underwent cesarean section. She received 5L fluid intraoperatively and developed pulmonary HTN and
edema. She was reintubated and transferred to the CCU. After successful diuresis Patient was extubated
and discharged from the hospital with plans to follow up for possible future mitral valve replacement.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1060
Hemi-Arthroplasty Under Continuous Spinal in a 94-year-old With NSTEMI 3 Days Prior
Anna Shapiro, M.D., Randolph Hastings, M.D., University of California San Diego, San Diego, CA
A 94-year-old deaf man presented for left hemi-arthroplasty after a fall. On admission he was diagnosed
with a NSTEMI which was managed conservatively. After arterial line placement in the pre-operative
area he was brought to the operating room where a continuous spinal catheter was placed at the L4/L5
interspace. He was given 2cc 0.5% bupivacaine and 2mg tetracaine resulting in a T6 sensory level. His
operative and post-operative courses were uneventful. This case illustrates the successful use of
continuous spinal anesthesia in a patient with a recent NSTEMI. The details of management will be
presented and discussed.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1061
Management of Post Operative Hypoxemia in Patient With Uncontrolled Pulmonary Hypertension.
Nathaniel Sharp, M.D., Amanda Gomes, M.D., Oklahoma University Health Science University, Oklahoma
City, OK
A noncompliant 26-year-old F with congenital pulmonary artery stenosis resulting in severe pulmonary
hypertension mean PA pressure of >85 required an emergent cholecystectomy. After an uneventful
induction and stable intraoperative course she was extubated after meeting extubation criteria but
quickly became hypoxic and agitated. We avoided re-intubation with interventions including sedation
analgesia mask ventilation inhaled iloprost and IV magnesium. She was transported to ICU with CPAP
and discharged the following day without further complications. Our case demonstrates the anesthetic
management in response to the pathophysiology of severe pulmonary hypertension and unanticipated
post-extubation hypoxia.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1062
Endovascular Stent Grafting Under Regional Anesthesia in a Patient With A History of Heparin Induced
Thrombocytopenia
Mourad Shehebar, M.D., Andrew Leibowitz, M.D., Icahn School of Medicine Mount Sinai, New York, NY
Endovascular stent graft repair (ESGR) of abdominal aortic aneurysms have become increasingly
common. Patients undergoing this procedure require anticoagulation intraoperatively which is usually
accomplished with unfractionated heparin. Patients with a history of HIT must be anticoagulated with an
alternative agent. A 80-year-old male with CAD HTN COPD and a history of HIT presented with a 8.3 cm
infrarenal AAA for an elective ESGR. Bivalirudin has been approved for use in PCIs but has never been
reported specifically in patients with HIT undergoing ESGR. We have demonstrated the successful use of
bivalirudin for anticoagulation in this case.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1063
Persistent Hypotension During Cardiopulmonary Bypass in a 51-year-old Woman Undergoing Mitral
Valve Repair
Timothy Sims, M.D., Peter Neuburger, M.D., NYU Medical Center, New York, NY
A 51-year-old woman who is otherwise healthy is scheduled to undergo mitral valve repair secondary to
severe mitral regurgitation. After an unremarkable induction and early operative course the patient
became acutely hypotensive at the initiation of cardiopulmonary bypass. Blood pressure was confirmed
by measurement at aortic root and poor perfusion was suspected with a peak lactate of 4.0mg/dl. The
hypotension was minimally responsive to vasoactive agents methylene blue transfusion and an
increased bypass flow rate however the blood pressure normalized immediately upon separation from
cardiopulmonary bypass. Vasoactive infusions were discontinued and the patient had an unremarkable
postoperative course.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1064
Coronary Artery Bypass Grafting in a Patient With Severe Hypothyroidism
Maninder Singh, M.D., Jonathan Hastie, M.D., Columbia University Medical Center, New York, NY
Our case involves a 53-year-old female with severe hypothyroidism (HT) who presented to the ER with
an NSTEMI. Workup revealed TSH 142 mIU/L. TTE demonstrated EF of 45% with a large pericardial
effusion. Levothyroxine was initiated and after two weeks she underwent CABG surgery at a TSH level of
78mIU/L. Upon anesthetic induction the patient developed hypotension and PEA arrest and was
resuscitated after 4 minutes of ACLS. CABG was preformed and CPB weaned using IABP. We will discuss
the pathophysiology of myocardial depression in severe HT and associated factors leading to premature
atherosclerosis in this disease group.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1065
Acquired Von Willebrand Syndrome and Cardiac Surgery
Mark Smith, M.D., David Barbara, M.D., William Mauermann, M.D., Mayo Clinic, Rochester, MN
A 77-year-old female with chronic anemia and aortic stenosis presented for aortic valve replacement.
Preoperative hematologic workup revealed acquired von Willebrand syndrome (AvWS). No specific
treatment for AvWS was required intraoperatively. Surgery was performed uneventfully without
significant perioperative bleeding. AvWS is a rare disorder associated with various cardiac conditions
including aortic stenosis. Despite normal levels of von Willebrand factor (vWF) AvWS patients have a
deficiency of the more active high molecular weight vWF multimers. Treatments must be individualized
and are divided into those that increase vWF levels and modalities that reduce depletion of high
molecular weight vWF multimers.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1066
Perioperative Management of Pulmonary Embolectomy
Pingping Song, Rosemary Uzomba, M.D., Michael D'Ambra, M.D., Brigham and Women's Hospital,
Boston, MA
42-year-old male presented to the operating room with saddle pulmonary embolus for pulmonary
embolectomy. Radial arterial and central venous catheters were placed without sedation while patient
remained fully awake and breathing spontaneously. After patient was prepped and draped for
sternotomy anesthesia was induced with midazolam sufentanil succinylcholine and epinephrine bolus.
Cardiopulmonary bypass (CPB) was rapidly established and pulmonary embolectomy was completed
uneventfully. Patient was weaned off CPB and taken to ICU on inhaled epoprostenol as well as
intravenous epinephrine milrinone and vasopressin. ICU discharge occurred on postoperative day (POD)
8 and patient was discharged home on POD11.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1067
Rhabdomyolysis (RML) Associated Acute Kidney Injury (AKI ) After Coronary Artery Bypass Grafting
(CABG)
Suraj Sudarsanan, M.D., Heart Hospital Hamad Medical Corporation, Doha, Qatar
Prolonged surgery due to difficult coronary grafting lead to Rhabdomyolysis induced AKI in a 55 years
old male patient. Peak Creatinine kinase and Myoglobin levels were 39000 IU/ml 40000ng/ml
respectively. Patient developed heart failure which along with AKI and supervening sepsis lead to
prolonged ICU stay and hospitalization. The patient's renal function recovered over 4 weeks aided by
Renal replacement therapy in the form of hemodialysis Early recognition of Rhabdomyolysis induced AKI
in prolonged surgery is important in reducing the post-operative morbidity and mortality. Key words:
Acute kidney injury (AKI) Rhabdomyolysis Coronary artery bypasses graft Prolonged surgery.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1068
Diagnosis of a Type 1 Aortic Dissection by Intraoperative TEE: A Case Report and Discussion
Jessica Sumski, M.D., George Washington University Medical Center, Washington, DC, Travis
Weddington, M.D., Washington Hospital Center, Washington, DC
A 60-year-old male presented with an intraaortic balloon pump for a 2 vessel off pump CABG. A TEE was
placed after bruising was noted on the aorta. Using the TEE we were able to diagnose a Type I
circumferential aortic dissection involving the root and valve that resulted in significant AI. The
dissection was previously unidentified prior to the TEE by the Anesthesiology team. The case proceeded
with an on-pump type I dissection and valve repair with circulatory arrest.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1069
Anesthetic Management in an Adult Patient With Double-Chambered Right Ventricle and Severe
Obesity
Takahiro Tadokoro, Hisae Higa, Tetsuya Kawabata, Kouji Yoza, M.D., Okinawa Prefectural Nanbu
Medical Center & Children's Medical Center, Shimajiri-gun Okinawa, Japan, Manabu Kakinohana, M.D.,
Kazuhiro Sugahara, M.D., University of the Ryukyus, Nishihara-cho Okinawa, Japan
We experienced an anesthetic management of an adult obese patient undergoing repair of doublechambered right ventricle.This patient was preoperatively complained of dyspnea chest pain and
tachycardia following light exercise. After anesthetic induction as soon as manual ventilation with high
positive airway pressure started blood pressure rapidly decreased. Thus intermittent iv phenylephrine
and fluid loading were performed against hypotension. In this case high airway pressure might reduce
cardiac preload resulting in augmentation of right intraventricular stenosis causing hypotension.
Therefore we should be aware that adequate cardiac preload may be crucial for stabilizing
hemodynamics in patients with double-chambered right ventricle.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1070
Von Willebrand's Disease in the Setting of Aortic Stenosis: Acquired Disease? Incidental Diagnosis?
Barbara Meinecke, M.D., Susan Taylor, M.D., Children's Hosp. of Wisconsin, Medical College of
Wisconsin, Milwaukee, WI
A fifteen-year-old male presented for elective resection of a subaortic membrane and aortic valve
repair/replacement. Significant history included ventricular septal defect and subarotic stenosis repaired
in infancy as well as sickle cell trait. Personal and family histories were negative for bleeding events.
Preoperative hematology consultation revealed prolonged PT PTT reduced factors X XI and VWF
consistent with abnormal platelet function. Similar results were reported in 2009 at which time MRI
demonstrated significant acceleration of flow across the aortic valve annulus. Hematology interpretation
of the findings was von Willebrand's Type 1 disease and consequently recommended DDAVP
preoperatively. Surgery proceeded without incident.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1071
Incidental Finding of Severe Mitral Regurgitation in a Patient Undergoing Aortic Arch Aneurysm in a
Prior Heart Transplanted Patient
Michael Tran, D.O., Eduardo Jusino Montes, M.D., Brian Johnson, M.D., Cleveland Clinic Foundation,
Cleveland, OH
77-year-old male with PMHx of HTN HLD CABG x4 in 1999 s/p heart transplant in 2000 for ICM CKD
hypothyroidism and gout was presented with complaints of intermittent sub-sternal chest pain. CXR
demonstrated mediastinal widening and a CT chest w/o contrast revealed a saccular thoracic aortic
aneurysm measuring up to 7 cm in transverse diameter. The aneurysm involves the ascending aorta and
aortic arch terminating at the level of the left subclavian artery. After induction of anesthesia and upon
TEE examination we incidentally found out that the patient has severe mitral regurgitation prompting a
change to the surgical approach.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1072
TEE Diagnosis of Right-to-Left Shunt Through a Patent Foramen Ovale in a Patient With a Renal Tumor
Invading the Right Atrium
Dam-Thuy Truong, M.D., Dilip Thakar, M.D., Angela Truong, M.D., University of Texas MD Anderson
Cancer Center, Houston, TX
A 53-year-old male with a renal mass invading the IVC and right atrium presented for nephrectomy and
thrombectomy. TEE was performed for continuous intraoperative monitoring. A patent foramen ovale
(PFO) with left-to-right shunt was detected. During surgical manipulation of the heart sudden severe
desaturation occurred. A new right-to-left shunt through the PFO was diagnosed. After the atrial
thrombus was removed right atrial pressure decreased and the flow through the PFO returned to a leftto-right shunt with resolution of hypoxemia. TEE in this case allowed for an instantaneous diagnosis of
reversal of shunt and ruled out other potential causes of desaturation.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1073
Treatment of Severe Mitral Regurgitation Following Transcatheter Aortic-Valve Implantation: A Case
Report
Laura Tunke, M.D., Jafer Ali, M.D., Case Western Reserve University/University Hospitals Case Medical
Center, Cleveland, OH
Transcatheter aortic-valve implantation (TAVI) is an innovative procedure for patients with severe aortic
stenosis that are not candidates for surgical replacement. Our patient is an 88-year-old male with severe
aortic stenosis mild mitral regurgitation (MR) and systolic heart failure status post pacemaker implant
who underwent a TAVI procedure and developed severe MR post-implantation evidenced on TEE. After
the pacing swan was discontinued and intrinsic pacer activity resumed severe MR resolved and mild MR
consistent with pre-TAVI TEE was demonstrated. This is an uncommon complication of TAVI procedures
and resumption of an intrinsic pacemaker is a simple effective intervention.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1074
Orthopedic Surgery Prior to Cardiac Surgery in a Patient With Obstructive Left Atrial Myxoma
Eleanor Vega, M.D., Edward Kahl, M.D., Oregon Health and Science University, Portland, OR
52-year-old with history of pre-syncope presented with a hip fracture after a fall. Transthoracic
echocardiogram revealed a left atrial myxoma obstructing the mitral valve during diastole. Patient
required both myxoma resection and fixation of hip fracture but which should occur first? Cardiac team
felt the risk of morbidity after cardiac surgery in a non-ambulatory patient was higher than potential
myxoma-related complications during the orthopedic procedure. Patient underwent intramedullary nail
placement under spinal anesthesia followed by atrial myxoma resection one week later. There are very
few case reports in the literature describing non-cardiac surgery in the setting of atrial myxoma.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1075
An Uncommon Indication for TAVI
Marc Vives, M.D., Ph.D., Erik Horlick, M.D., Mark Osten, M.D., Massimiliano Meineri, M.D., Toronto
General Hospital, Toronto, ON
A 47-year-old female presented with acute rejection and refractory cardiogenic shock after a heart
transplant for idiopathic cardiomyopathy. Given a LVEF of 20%. an Impella device was inserted the antirejection regimen readjusted and plasmapheresis started. The LV function fully recovered in a week but
likely as a result of mechanical damage the patient developed severe aortic insufficiency. TAVI was
considered a viable option. Prior to TAVI a left femoral-femoral A-V ECMO for hemodynamic rescue was
electively inserted. A Corevalve was successfully deploied without rapid ventricular pacing though a
percutaneous femoral approach. The patient was discharged home two weeks later.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1076
Flash Pulmonary Edema During Management of Evolving Myocardial Ischemia
Matthew Waldron, M.D., Yong Peng, M.D., University of Florida, Gainesville, FL
A 65-year-old male presented with acute coronary syndrome. He had emergent left heart
catheterization and found to have severe 3- vessel coronary artery disease not amendable to stenting.
His LVEDP was elevated at 39 mmHg and as intra-aortic balloon pump (IABP) was placed for improving
coronary perfusion. The patient quickly developed respiratory insufficiency. He subsequently was
intubated and a large amount of pink frothy liquid was expelled from the endotracheal tube.
Echocardiography then revealed severe aortic insufficiency. This case highlights the importance
utilization of (IABP) for coronary perfusion and the subsequent development of pulmonary edema.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1077
Intraoperative Management of a Tracheo-Innominate Fistula
Andrea Westman, M.D., Annemarie Thompson, M.D., Vanderbilt University, Nashville, TN
71-year-old with radiation-treated thyroid cancer as an adolescent and chronic radiation vasculitis and
laryngitis requiring recent tracheostomy presented with hemoptysis. On admission the patient sustained
a sudden 1.5 L hemorrhage from his tracheal stoma. Imaging studies were nondiagnostic but a high
Copyright © 2013 American Society of Anesthesiologists
clinical suspicion for tracheoinnominate fistula remained. After consideration of both surgical and
nonsurgical options the patient underwent successful repair of the TI fistula and ligation of the
innominate artery after a right axillary-femoral artery bypass was performed. Despite establishment of
an alternate cerebral circulation the patient suffered a left-sided stroke but was eventually discharged
from the hospital.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1078
Cardiac Herniation After Repair of Penetrating Trauma
Raj Singh, M.D., Anna Weyand, M.D., John Porter, M.D., Sloan Youngblood, M.D., Baylor College of
Medicine, Houston, TX
25-year-old male presented with hemopericardium after penetrating trauma to the chest. Eleven hours
after initial repair of a small right ventricular puncture wound during which he required multiple
episodes of cardioversion oxygen saturation acutely dropped into the 50s. Bedside TTE revealed a
grossly dilated right atrium and right ventricle with severely depressed ventricular function and noncompressible IVC. Emergent exploration on cardiopulmonary bypass revealed cardiac herniation
through the pericardium with kinking of the pulmonary artery on the edge of the trauma-induced
pericardial defect. Dissection of the atria revealed an acquired secundum atrial septal defect with a torn
membrane.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1079
Anesthetic Implications of Extended Right Hepatectomy in a Patient With Fontan Physiology: A Case
Report
Paul Weyker, M.D., Christopher Webb, M.D., Tricia Brentjens, M.D., Taylor Johnston, M.D., Columbia
University, New York, NY
Patients who have undergone complete caval-pulmonary anastomosis-the Fontan procedure-have
direct passive venous blood flow from the superior and inferior vena cava into the pulmonary circulation
without passing through the morphologic right ventricle. Although this procedure has been shown to be
an effective means of palliation for these patients chronic elevated central venous pressure lead to
several types of hepatic dysfunction including chronic passive congestion cardiac cirrhosis and even
hepatocellular carcinoma. This is the first case report of a patient with Fontan associated hepatocellular
carcinoma who successfully underwent a right hepatectomy for curative therapy.
Tuesday, October 15
1:00 PM - 2:30 PM
CA MC1080
Perioperative Considerations for Left Ventricular Assist Devices in the Pediatric Population: A Case of
Fulminant Myocarditis Secondary to Influenza A
Jordan Wicker, Cesar Rodriguez-Diaz, M.D., Icahn School of Medicine at Mount Sinai, New York, NY
The patient was a 2-year-old male with influenza A developing acute myocarditis. Significant objective
findings included fever refractory hypotension TEE revealing severe left ventricular dysfunction and
positive troponins. The patient required cardiopulmonary resuscitation and was sustained on increasing
doses of inotropic and vasopressor agents. The patient was brought to the OR for ventricular assist
device (VAD) placement to optimize hemodynamics with eventual decannulation and discharge home.
This case reviews perioperative management of pediatric patients with acute heart failure and
Copyright © 2013 American Society of Anesthesiologists
exemplifies VAD use in this population as a means to hasten and permit recovery rather than bridge to
cardiac transplant.
MCC Session Number – MCC16
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1081
Intraoperative Emergency Veno-Venous ECMO Application Via Avalon Cannula for PostCardiopulmonary Bypass Hypoxemia in an Infective Endocarditis Patient
Melanie Witte, M.D., Oksana Klimkina, M.D., The University of Kentucky, Lexington, KY
A 17-year-old male with a history of intravenous drug abuse presented with headache and fever. He was
diagnosed with infective endocarditis severe aortic and mitral insufficiency. The patient became septic
and developed ARDS. He emergently underwent replacement of mitral and aortic valves but postcardiopulmonary bypass couldn't maintain oxygenation despite normal cardiac function. ECMO was
instituted via the Avalon cannula placed in the internal jugular vein. Placement of the cannula was
guided by fluoroscopy and transesophageal echocardiography. Within 48 hours the patient's
oxygenation improved and he no longer required ECMO. The patient was discharged from the hospital
within six weeks.
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1082
Eptifibatide as Bridging Anti-Platelet Therapy Prior to Lumbar Cerebro-Spinal Fluid Drainage (LCFD)
Hak Wong, M.B. B.S., Saadia Sherwani, M.D., Northwestern University Feinberg School of Medicine,
Chicago, IL
A 70-year-old female presented for endovascular repair of distal thoracic aneurysm (TEVAR). She had
multiple prior procedures on her thoracic and abdominal aorta. 7 weeks before TEVAR 2 drug-eluting
coronary stents (DES)were implanted. To permit safe insertion of LCFD oral anti-platelet therapy was
discontinued. 4 days before TEVAR Eptifibatide was started as 11.8 mg iv bolus followed by continuous
infusion until 7 hours before a LCFD was inserted. 20 hours after TEVAR the LCSD was removed.
Clopidogrel therapy was re-instituted 6 hours later. The patient exhibited no signs of cardiac ischemia or
neurological compromise during the entire hospital course.
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1083
Myxedema Coma After Coronary Artery Bypass Grafting in a Patient With Untreated Hypothyroidism.
Kyle Wright, M.D., Yale New Haven Hospital, Irena Vaitkeviciute, M.D., Yale School of Medicine, New
Haven, CT
A 52-year-old female suffered a myocardial infarction and medical workup included findings of severe 4
vessel coronary disease and untreated hypothyroidism. Preoperative optimization of hypothyroidism
was discussed however she did not receive thyroid hormone replacement therapy preoperatively due to
the severity of her unstable angina. The patient underwent coronary artery bypass grafting and upon
separation for cardiopulmonary bypass experience cardiac arrest and heart failure. Post operative
course was complicated by anasarca heart failure respiratory failure and stroke all sequelae of
myxedema coma.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1084
Anesthetic Management of an Adult Wiith Surgically Corrected Hypoplastic Right Heart Syndrome.
Nicholas Lam, M.D., Steven Wright, M.D., University of New Mexico, Albuquerque, NM
A 29-year-old male with a history of hypoplastic right heart syndrome presented with a symptomatic
incisional hernia and was scheduled for repair. The patient had a complicated congenital heart history
with several palliative procedures including aortopulmonary shunt Glenn procedure and Fontan
procedure. Goals for the anesthetic included maintaining systemic vascular resistance and preload while
augmenting heart contractility and avoiding fluid overload. General anesthesia was induced with
etomidate and the patient was kept ventilating spontaneously with a laryngeal mask airway. Inotropy
was increased with small boluses of epinephrine. The procedure was completed without difficulty and
no anesthetic complications were observed.
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1085
Anesthetic Management of a Patient With LVAD for Wrist Debridement
Boris Yaguda, M.D., Giuseppe Trunfio, M.D., Maimonides Medical Center, Brooklyn, NY
73-year-old male with existing LVAD on anticoagulation presented for left wrist debridement secondary
to septic arthritis. Patient's main concern was adequacy post op pain control. The decision was made to
proceed with ultrasound guided left axillary block for postoperative pain management and general
anesthesia via LMA. Case is being presented for discussion of use of LVAD as destination therapy and
successful management of regional anesthesia in the presence of anticoagulation. At the end of the case
right IJ TLC was placed under US guidance for IV access and patient was successfully extubated with
good pain control.
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1086
Peripartum Cardiomyopathy in a Laboring Parturient
John Gantamasso, M.D., Jason Yu, M.D., Kalpana Tyagaraj, M.D., Maimonides Medical Center, Brooklyn,
NY
We describe a case of a 29 years G5P2 Nigerian female at 40 weeks with a history significant for recent
fever and cough who presented for induction of labor. Shortly after arrival labor analgesia was initiated
with CSE and the patient was comfortable over the next several hours. As labor progressed the patient
developed acute shortness of breath progressively worsening hemoptysis hypoxia and ensuing fetal
bradycardia. An emergent C-Section was performed with supportive management of symptoms
consistent with flash pulmonary edema. Further work up by cardiology and obstetrics revealed the
diagnosis of peripartum cardiomyopathy.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1087
Sudden Hemodynamic Instability in a Patient With Undiagnosed Systolic Anterior Motion of the Mitral
Valve
John Zaki, Adeel Qaisar, Texas Tech University Health Science Center, El Paso, TX
Patient came in for a elective back surgery. Upon induction patient became hemodynamically unstable.
On examination it was noted patient had crackles in the chest and a new systolic mumor. EKG showed
early repolarization. Patient was stabilized and patient was transfered to ICU. Subsequent echo showed
dydtolic anterior motion of the mitral valve.
Tuesday, October 15
3:00 PM - 4:30 PM
CA MC1088
Complex Central Venous Cannulation Due to Unusual Bilateral Non-Thrombotic IJV Architecture
Suzana Zorca, M.D., Bijal Patel, M.D., Denise Hersey, M.A., Gerard McCloskey, M.D., Yale-New Haven
Hospital, New Haven, CT
A 62-year-old gentleman with chronic atrial fibrillation on pradaxa systemic hypertension and severe
mitral and tricuspid regurgitation presented for Mitral and Tricuspid Valve repair. After smooth
induction of general anesthesia the patient was placed in Trendelenburg position for internal jugular
vein (IJV) cannulation. Ultrasound imaging of the right IJV revealed a valvular flap vs.possible preexisting vein dissection. Contralateral scanning of the left IJV revealed a similar anomaly. Fluoroscopy
was helpful in assessing and cannulating the left-sided IJV and placing a Swan-Ganz catheter over a
Cordis. We review the literature on non-thrombotic IJV anomalies and their implication for central
venous cannulation.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1089
Paroxysmal Nocturnal Hemoglobinuria Under General Anesthesia: Avoiding Hemolysis
Sean Summers, M.D., Shivon Abdullah, M.D., Gozde Demiralp, M.D., Lyle Stefanich, M.D., OUHSC,
Oklahoma City, OK
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare form of hemolytic anemia. We report a 73-yearold female with PNH presenting for laparoscopic cholecystectomy and highlight the importance of
preoperative evaluation and planning to promote a safe operative course. The coordination of efforts
between anesthesiology general surgery and hematology provided a brief hospital stay free of
exacerbation of her condition and a favorable outcome for this patient. Patients with PNH are at risk of
aplastic anemia thrombosis and acute intravascular hemolysis. The risk of hemolysis is increased by
metabolic derangements produced by surgery and general anesthesia.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1090
Challenging Airway Management for Removal of Foreign Body From the Trachea
Jonathan Tan, M.D., M.P.H., Slawomir (Peter) Oleszak, M.D., Christopher Tam, M.D., Renata Kowal,
M.D., Stony Brook University School of Medicine, Stony Brook, NY
59-year-old male with difficult appearing airway presented for removal of foreign body located proximal
to the carina. After induction the patient had easy mask ventilation and multiple failed attempts at rigid
Copyright © 2013 American Society of Anesthesiologists
bronchoscopy. Despite laryngoscopy cricoid manipulation and changes in patient position rigid
bronchoscopy was unable to be placed. Patient was then intubated with a tube exchanger using a
Jackson laryngoscope. Fiberoptic flexible bronchoscope was placed in the left nare. The rigid
bronchoscope was placed over the tube exchanger and guided into the trachea with direct visualization
from the fiber optic bronchoscope. The object was removed successfully.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1091
Sleeve Resection of a Left Main Bronchial Mass Via Right Thoracotomy. The Challenge of One Lung
Ventilation.
Minyi Tan, M.D., New York Presbyterian, New York, NY, Tehmina Akhtar, M.D., Alessia Pedoto, M.D.,
Memorial Sloan Kettering Cancer Center, New York, NY
A healthy 36-year-old nonsmoker female (84kg 163cm) with a 1.7x1.1 cm left mainstem mass presented
to the OR for a sleeve resection via right thoracotomy. Left lobar ventilation and perfusion were
decreased in the setting of obstructive lung disease. When the right lung was collapsed there was
difficulty in maintaining oxygenation despite changes in the ventilator parameters the use of CPAP and
jet ventilation beyond the lesion. The case was performed by ventilating the non-dependent lung which
was partially compressed by the surgeon.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1092
Facial Trauma and Difficult Airway Management
Jonathan Teets, M.D., New York University, New York, NY
88-year-old male pedestrian struck by bicycle presented with acute C3 vertebral body fracture and
LeFort I II and III facial fractures. Transtracheal and bilateral superior laryngeal nerve blocks were
completed in addition to topicalization of oropharynx with local anesthetic. Two unsuccessful attempts
at awake fiberoptic intubation revealed extensive bloody secretions and airway edema so the team
proceeded with awake tracheotomy. This case focuses on difficult airway management in facial trauma
patients with discussion of specific types of facial trauma that may precipitate the need for surgical
airway access.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1093
An Unusual Cause of Intraoperative ST Segment Changes
Brian Telesz, M.D., Xun Zhu, M.D., Mayo Clinic, Rochester, MN
A 74-year-old female with PMH significant for renal cell carcinoma is scheduled for a lung wedge
resection due to metastasis. Previous echocardiogram showed no regional wall motion abnormalities.
Anesthetic induction was uncomplicated. Upon lateral decubitus positioning ST segment depressions
were noted and persisted despite adequate hemodynamic and HR control; the procedure was cancelled.
Troponins returned negative and ECG showed resolving ST segment depressions. Coronary angiography
showed no significant obstruction but did show hypervascular lesions near the coronary sinus. Cardiac
MRI confirmed renal cell carcinoma metastasis which might have impacted coronary blood flow upon
left lateral positioning intraoperatively.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1094
Anesthetic Management For A Patient With Haw-River Syndrome
Eric Tesoriero, D.O., Brian Kornrumpf, M.D., Kelly Baird, M.D., Wake Forest Baptist Health, Winston
Salem, NC
46-year-old female with past medical history significant for Haw-River Syndrome (Dentato-RubroPallido-Luysian Atrophy) and seizure disorder presents with strangulated umbilical hernia. She was
posted for an emergent hernia exploration and reduction. She underwent RSI with propofol and
succinylcholine. Despite a MAC of 1.3 with full return of neuromuscular relaxation from succinylcholine
the surgeons reported difficulty reducing hernia defect and requested neuromuscular blockade. At the
conclusion of the case with full reversal she had no signs of neuromuscular weakness and was extubated
without difficulty. The remainder of her perioperative course was unremarkable for seizure activity or
other events.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1095
Awake Intubation Using Video Laryngoscopy in the Extremely Difficult Airway
Neel Thomas, M.D., Peter Rivera, M.D., Wake Forest Baptist Health, Winston-Salem, NC
A Level 1 agricultural trauma patient was brought to WFUBMC after a devastating tractor injury resulted
in the avulsion of his maxillary segment and midface. Though bleeding profusely without identifiable
airway landmarks the patient maintained a patent airway in the lateral position. The patient and surgical
team were brought to the OR where SLN and trans-tracheal airway blocks were performed and topical
anesthesia administered to the oropharynx. Fiberoptic intubation was unsuccessful due to bloody
secretions and distorted tissue planes obstructing view. A C-MAC was used to carefully expose the
glottis allowing an ETT to be passed through the vocal cords.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1096
Pushing the Boundaries of the Laryngeal Mask Airway and Your Comfort Zone in Order to Avoid
Unnecessary Awake Fiberoptic Intubation
Nicholas Tinkham, M.D., M.P.H., H. David Hardman, M.D., MBA, University of North Carolina at Chapel
Hill, Chapel Hill, NC
A 63-year-old male with a prior gunshot wound to his neck and subsequent formation of a massive
keloid measuring 14cm X 8cm on his anterior neck was scheduled for surgical resection of his neck mass.
He was in no apparent respiratory distress but his airway exam demonstrated limited mouth opening. A
recent clinic fiberoptic laryngoscopy exam documented normal airway anatomy. Although he had
recently undergone awake fiberoptic intubation for a prostatectomy the anesthesia team elected to
place a laryngeal mask airway (LMA) for this procedure. We will discuss the pros and cons of utilizing a
LMA in this setting.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1097
Transtracheal Jet Ventilation: More Than Just Rescue Ventilation
Sheel Todd, M.D., Jessica Booth, M.D., Wake Forest Baptist Health, Winston Salem, NC
A 62-year-old male with morbid obesity (BMI 46.5) Mallampati IV with a large tongue a short and thick
neck OSA and diabetes presented for a whipple procedure for pancreatic cyst. Despite factors predicting
a difficult airway he had a prior history of successful two hand ventilation and intubation so we chose to
attempt intubation after induction of general anesthesia. Adequate ventilation through facemask was
easily established. After multiple unsuccessful intubation attempts with 3 different modalities and
multiple providers transtracheal jet ventilation with an 18g angiocath was used to aid in obtaining a
view with a flexible fiberoptic bronchoscope.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1098
Management of Post Intubation Distal Tracheal Stenosis
Stephanie Tran, M.D., Mahammad Hussain, M.D., Roy Soham, M.D., Elton Lambert, M.D., University of
Texas Health Science Center, Houston, TX
Case of a 34-year-old ASA 4 female who experienced life threatening long segment tracheal stenosis
down to the level of the carina after an emergent endotracheal intubation. For four days after
extubation she experienced dyspnea and stridor that was unresponsive to pharmacologic therapy. After
the diagnosis was made she presented to our institution in respiratory distress and an emergent
tracheostomy was successfully placed with ECMO lines in place in case of failure. She experienced a
prolonged hospital course and because of the recurrence of stenosis there is no foreseeable
decannulation.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1099
Perioperative Airway Management in a Patient With Difficult Airway and Bilateral Vocal Cord Paralysis
for Laparoscopic Cholecystectomy
Dam-Thuy Truong, M.D., Dilip Thakar, M.D., Angela Truong, M.D., University of Texas MD Anderson
Cancer Center, Houston, TX
A 61-year-old man with bilateral vocal cord paralysis known difficult airway diabetes and severe GERD
presented for laparoscopic cholecystectomy. He had a MP class 4 airway with a 2 mm maximal glottic
opening on laryngostroboscopy. Perioperative implications included risks for pulmonary aspiration
intubating laryngeal trauma and vocal cords edema. An awake nasal fiberoptic intubation with a second
fiberscope inserted through the contralateral naris was performed to visualize the atraumatic passage of
the tracheal tube through the narrowed glottis. Dexamethasone racemic epinephrine and high humidity
oxygen were used to minimize postop laryngeal edema which may cause complete airway obstruction.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1100
A Technically Simple and Effective Nasal CPAP Mask for a Morbidly Obese Patient With Obstructive
Sleep Apnea Under Propofol Sedation/Local Anesthesia for Irrigation and Debridement of Bilateral
Posterior Calf Ulcers
James Tse, M.D., Ph.D., Rose Alloteh, M.D., Trishna Upadhyay, M.D., Sylviana Barsoum, M.D., Shaul
Cohen, M.D., UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ
A 71-year-old male was scheduled for irrigation/debridement of bilateral posterior calf ulcer under
MAC. He had atrial fibrillation CAD hypertension obesity (BMI 45 kg/m2) and OSA. He couldn't tolerate
facial CPAP because of claustrophobia. After pre-oxygenation using a TSE Mask he received deep
propofol sedation (50 mg bolus and 125-75 mcg/kg/min infusion). Nasal cannula was then replaced with
a makeshift nasal CPAP mask using an infant mask. Pop-off valve was adjusted to deliver CPAP of 5 cm
H2O with 5-7 L O2/min and 2 L air/min. He maintained spontaneous respiration and 99-100% O2
saturation throughout with FiO2 of 0.8.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1101
Diagnosis of Aortic Thrombosis After Pelvic Surgery
Kenneth Tseng, M.D., M.P.H., Christina Jeng, M.D., The Mount Sinai Hospital, New York, NY
A 62-year-old gentleman was diagnosed with an acute aortic thrombus in the recovery room after
undergoing an abdominal perineal resection for repair of a recto-urethral fistula. Although uncommon
post-operative aortic thrombus can be a devastating complication if not recognized early. Pre-operative
clinical characteristics that may predispose patients to thrombosis include hypercoagulability from
neoplastic disease dehydration from bowel prep or cigarette use. Intraoperatively prolonged lithotomy
positioning duration of surgery or hypoperfusion of the legs may increase the likelihood of thrombus
formation. In our case all of these factors were present which raised the clinical suspicion of a
thrombotic event.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1102
Anesthetic Management in a Patient With Bilateral Diaphragmatic Paralysis
Kosta Turchaninov, M.D., Daniel Johnson, M.D., University of Nebraska Medical Center, Omaha, NE
We describe the anesthetic management of a 63-year-old male with bilateral diaphragmatic paralysis
secondary to cervical stenosis and brachial plexopathy who presented for anterior cervical discectomy
and fusion. This case highlights the importance of knowledge of the pathophysiology of diaphragmatic
dysfunction in the formulation of a successful anesthetic plan to prevent perioperative complications.
BiPAP in the sitting position was used for pre-oxygenation induction emergence and extubation to
optimize respiratory mechanics. TIVA with short-acting titratable anesthetic agents proved to be safe
and adequate for this patient with bilateral diaphragmatic paralysis.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1103
Failed Airway Management During Induction for Difficult Case of Subglottic Stenosis.
Kim Vidhani, FANZCA, Anton Booth, FANZCA, Princess Alexandra Hospital, Brisbane, Australia
A 40-year-old man with subglottic stenosis presented for balloon dilatation. He had exertional stridor
weighed 135kg and had other difficult airway features. A spontaneous breathing TIVA induction was
complicated by regurgitation laryngospasm inadequate ventilation and significant hypoxia.
Administration of suxamethonium facilitated bag mask ventilation and rapid re-oxygenation. Intubation
was attempted but no ETT could be passed beyond the stenosis. An inflated MLT 5 cuff was pressed
onto the glottis which allowed adequate ventilation oxygenation and airway protection. Surgery
proceeded and successful dilatations were facilitated by periodic removal of the MLT. Extubation was
difficult but the patient recovered uneventfully.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1104
Intraoperative Tension Pneumothorax During an Intramedullary Nail Placement
Jay Vyas, M.D., Michael Bassett, M.D., MetroHealth Medical Center/Case Western Reserve University,
Cleveland, OH
45-year-old female was admitted for femoral nailing secondary to trauma with no other known injuries.
Positive medical history of HTN asthma. NKDA. ETOH was elevated. RSI performed with fentanyl
propofol and succinylcholine. Maintenance with sevoflurane. Shortly after the surgical start acute
hypotension hypoxia hypocapnea and tachycardia requiring hemodynamic support developed. Left
hemithorax breath sounds were absent. Bronchoscopy revealed no significant findings. A tension
pneumothorax was suspected and needle decompression was performed. Hemodynamics oxygenation
and ventilation improved. A chest tube was placed. For the remainder of the case the patient remained
relatively stable. She was extubated and recovered without complications.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1105
When the Rubber Bag Turns to Rock: A Case of Intraoperative Bronchospasm During Parathyroid
Surgery
Ammar Wahood, M.D., Brian McAlary, M.D., Joel Biala, M.D., Arvind Rajagopal, M.D., Rush University
Medical Center, Chicago, IL
A 60-year-old non-smoking male with HIV undergoing parathyroidectomy for primary
hyperparathyroidism developed severe bronchospasm after removal of his hyperplastic parathyroid
gland. When manual ventilation failed his airway-irritating ETT was removed and bag mask ventilation
attempted. Four forceful breaths plus sevoflurane eased bag-mask ventilation. Following rocuronium
(50mg) administration topicalization of the vocal cords and larynx and reoxygenation he was successfully
re-intubated. With albuterol (3 puffs) and decadron (8mg) administered his wheezing improved and his
anesthesia was uneventfully maintained with sevoflurane and remifentanil. At extubation his total
calcium was 5.9. Postoperatively upon further questioning he confirmed recent symptoms of respiratory
infection.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1106
Anesthetic Management of an Adolescent With a Mitochondrial Disease: Complex V Mutation
Charles Walcutt, M.D., Seth Keiser, M.D., Corey Zetterman, M.D., Terry Huang, M.D., Steven Lisco, M.D.,
University of Nebraska Medical Center, Omaha, NE
Common anesthetic practices and medications may exacerbate the symptoms of mitochondrial
disorders or precipitate new problems. We present three cases involving a 14-year-old female with a
mutation of Complex V of the respiratory chain causing severe gastrointestinal hypomotility. Several
commonly used anesthetic agents (e.g. propofol) are relatively contraindicated in mitochondrial
disorders as they inhibit complexes involved in oxidative phosphorylation. In this case the patient's care
was made especially challenging due to documented adverse reactions to benzodiazepines and
etomidate. Inhaled inductions were used for two intra-abdominal surgeries while remifentanil and
dexmedetomidine infusions were used for an endoscopic procedure.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1107
Intracardiac Thrombus Development During Orthotopic Liver Transplantation
Sara Walls, M.D., Ram Pai, M.B. B.S., Vanderbilt University Medical Center, Nashville, TN
A 70-year-old female with cryptogenic cirrhosis from autoimmune hepatitis presented for orthotopic
liver transplantation. The patient underwent uneventful induction of anesthesia and liver resection.
Anhepatic phase was initially complicated by right pneumothorax which was promptly treated. While
anhepatic the patient developed hemodynamic instability with cardiac arrest suggestive of an embolic
event. Transesophageal echo revealed massive intracardiac and pulmonary artery thrombus. Chest
compressions and maximal medical management ensued with brief clearance of the thrombus. Clot reaccumulated and a second arrest occurred. Tissue Plasminogen Activator was administered in a last
attempt to clear thrombus. The patient expired intraoperatively.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1108
How to Diffuse A Ticking Bomb: Management of Carcinoid Crisis
Christina Wang, M.D., Baylor College of Medicine, Houston, TX, Binh Higley, M.D., VA Medical Center
Houston, Houston, TX
The patient is a 62-year-old Caucasian male with history significant for symptomatic metastatic carcinoid
tumor diagnosed in 2007 HTN HLD DMII OSA and long-standing smoking history who was undergoing
exploratory laparotomy for resection of a primary mesenteric carcinoid tumor. He had two episodes of
intraoperative crises one during tumor manipulation and another after tumor removal. In this case we
describe the signs and symptoms of carcinoid crisis how our patient was managed during these crises
and how intraoperative use of epinephrine and other sympathomimetic vasopressors concurrently with
octreotide is an acceptable and effective method of management.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1109
Membranous Tracheal Rupture During Zenker's Diverticulum Repair
Derrick Wansom, M.D., Vijaykumar Tarnal, M.D., University of Michigan, Ann Arbor, MI
Postintubation tracheal rupture is an uncommon complication but is associated with high morbidity and
mortality. In this case report a 61-year-old female's Zenker's diverticulum repair was complicated by
tracheal rupture. After uncomplicated tracheal intubation the surgeon perforated the esophagus with
the rigid esophagoscope necessitating external repair. A tracheal tear of the posterior portion of the
trachea was noted when the neck was explored by the surgeon. The cause of the tracheal rupture in this
case is unclear. The posterior membranous wall of the trachea lacks cartilaginous support making it
susceptible to tearing or rupture by mechanical causes.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1110
Management of Acute Respiratory Distress in a Patient With Acquired Tracheal Stenosis
Michael Wassef, M.D., David Kramer, M.D., St. Luke's-Roosevelt Hospital Center, New York, NY
The patient a 35-year-old male with IDDM and recent admission for DKA and respiratory failure
requiring intubation. Anesthesiology evaluated him for acute shortness of breath and emergent
intubation. Review of the CT revealed high-grade tracheal stenosis. He was managed with Heliox and
instructed to practice pursed-lip breathing prior to ENT evaluation and transfer to OR. In OR he
underwent mask induction with Sevoflurane and was maintained with Remifentanil infusion. Rigid
laryngoscopy was performed by the surgeon and oxygenation was provided by low-frequency manual
jet ventilation at 30 psi via Sander's injector. He was extubated uneventfully after tracheal dilation.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1111
Massive Hemoptysis Caused by Arteriovenous Malformation.
Timothy Webb, M.D., Jiwon Lee, M.D., Brian Egan, M.D., Jerry Young, M.D., Indiana University,
Indianapolis, IN
A 15-year-old previously healthy female presented to the ED for worsening hemoptysis with tachypnea
and hypoxemia. CT imaging revealed a right lower lobe bronchial mass. To facilitate lung isolation a leftsided double lumen tube was emergently placed using direct laryngoscopy. Bronchoscopy revealed a
pulsating mass in the right bronchus intermedius. The patient underwent right middle and lower
lobectomy. The mass proved to be an arteriovenous malformation. This case illustrates isolation and
protection of the unaffected lung is a priority in patients with massive hemoptysis. Our report discusses
options for lung isolation and protection and anesthetic management in hemoptysis patients.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1112
Anesthetic Management of a Patient With Airway-Threatening Ameloblastoma of the Jaw and Severe
Anemia
Mary West, Ranjit Deshpande, M.D., Yale University School of Medicine, New Haven, CT
A 28-year-old Creole-speaking woman flew directly from Haiti to our hospital for treatment of a large
jaw tumor (17.8 x 13.5 x 12.8 cm). It had consumed her jaw and mandible and rendered her short of
Copyright © 2013 American Society of Anesthesiologists
breath and unable to lie flat or speak normally. She arrived without an anesthetic preoperative
evaluation or labs but it was not feasible to delay the operation which required three surgical services.
We planned an awake fiberoptic intubation which was made even more difficult by our patient's
anxiety. Intraoperatively we encountered additional challenges with vascular access and unexpectedly
severe anemia.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1113
Emergency Surgery for a Patient in Diabetic Ketoacidosis
Kimberly Wheeler, D.O., Esamelden Abdelnaem, M.D., University of Arkansas for Medical Sciences, Little
Rock, AR
This is the case of a 68-year-old woman presenting in diabetic ketoacidosis with a thrombus occluding
her common femoral artery requiring emergency thrombectomy and common femoral endarterectomy.
DKA is often encountered in medical patients but its presence in surgical patients is usually considered a
contraindication to elective surgery.The case presented challenges in addressing the common fluid shifts
involved with vascular surgery compounded by the massive fluid deficit of DKA.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1114
Management of a Cirrhotic Patient With Massive Hemmorhage
Jared Wilson, M.D., San Antonio Uniformed Services Health Education Consortium, San Antonio, TX
A 54-year-old female ASA III for alcoholic cirrhosis complicated by severe coagulopathy and
thrombocytopenia presents to our trauma center for exploratory laparotomy for massive intraabdominal hemorrhage due to a liver laceration suffered in a low speed motor vehicle collision. She
arrived to the operating room in pulseless cardiac arrest with approximately 3L free blood in the
abdomen. She was successfully resuscitated using massive transfusion of blood products and novel
recombinant coagulation factor therapy. She decompensated in the ICU over the first postoperative
hour due to continued bleeding returned urgently to the OR and again was successfully resuscitated.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1115
Airway and Positioning Challenges in the Morbidly Obese and the Complications That May be
Encountered
Garrett Wright, M.D., Marcos Gomes, M.D., OU Medical Center, Oklahoma City, OK
Twenty-nine-year-old super obese male BMI 56 neck circumference 60 cm Mallampati IV scheduled for
posterior spinal fusion in the prone position. We describe our topicalization technique for awake
fiberoptic intubation which was so efficacious that it allowed for awake video laryngoscopy with
successful intubation. In addition despite extra precaution dedicated to positioning postoperative upper
extremity paresthesia and weakness emerged so we discuss the management of peripheral neuropathy
in such population. Finally we emphasize the importance of reviewing anesthesia records as this patient
returned to the OR and knowledge of his previous airway management facilitated the subsequent
choice.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1116
Hypotension and Delayed Awakening Secondary to Polypharmacy
Boris Yaguda, M.D., Lynn Belliveau, M.D., Maimonides Medical Center, Brooklyn, NY
57-year-old female with PMedHx of anxiety depression HTN GERD DM and hypothyroid presented for
posterior cervical fusion. Home medications included cyclobenzaprine fluphenazine fluoxetine
clonazepam benztropine losartan amlodipine insulin aspart and glargine levothyroxine fluticazone
celecoxib and dicolfenac. Patient was induced with propfol midazolam fentanyl succynlcholine and
intubated uneventfully. Anesthesia was maintained with propfol and remifentanil infusion. After prone
positioning patient became hypotensive MAP 30s resistant to phenylephrine and ephedrine responsive
only to vasopressin. Although surgery was uncomplicated and drug infusions were ended 20 minutes
prior to closure patient experienced delayed awakening. Refractory hypotension and delayed awakening
were contributed to polypharmacy.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1117
Anesthesia and Airway Management for Endoscopic Removal of a Self-Expandable Metallic Airway
Stent
Ying Ye, M.P.H., Michael Machuzak, M.D., D. John Doyle, M.D., Ph.D., Cleveland Clinic, Cleveland, OH
Endoscopic removal of self-expandable metallic stents from the airway is occasionally necessary but may
pose special challenges including severe tracheal damage and even loss of the airway itself. An obese
hypertensive 61-year-old man with a history of myocardial infarction left ventricular failure (EF 25%)
atrial fibrillation AICD placement COPD and remote tracheotomy presented for endoscopic stent
removal necessitated by the formation of extensive granulation tissue. Total intravenous anesthesia
with etomidate rocuronium and a propofol infusion was used with an iGel supraglottic airway and later
rigid bronchoscopy. Stable conditions were met through the 2-hour procedure and the patient
recovered uneventfully.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1118
Compartment Syndrome of the Thigh in the PACU
David Yehsakul, M.D., Michael Bassett, M.D., MetroHealth, Cleveland, OH
We present a 23-year-old AAM victim of multiple GWS to the legs who underwent an intra-medullary
nailing of a fractured femur.In PACU the patient had a markedly swollen thigh became increasingly
tachycardic and demonstrated possible ST depressions. Our anesthesia team raised concern for
compartment syndrome. Definitive action was undertaken following the third surgical PACU reevaluation. The intra-compartmental pressure was found to be severely elevated.The patient was then
taken for an emergent fasciotomy of his thigh. This coincided with a rapid improvement of his vitals and
laboratory values.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1119
Implications of Multiple Comorbidiites on Anesthetic Management During a Complicated Thoracic
Procedure
Natalie Younger, M.D., Agnes Miller, M.D., Maimonides Medical Center, Brooklyn, NY
Acute blood loss causing hemodynamic instability is not an uncommon problem during thoracic
procedures. A patient with significant co-morbidities poses added on challenges to the management of
intraoperative blood loss and other acute events. 49-year-old female with history of mitral aortic and
tricuspid valve replacement ESRD on dialysis and endocarditis was admitted with shortness of breath
secondary to pleural effusion . She developed hemothorax after pigtail catheter placement. She was
scheduled for a left sided VATS and evacuation of hemothorax. The case is being presented for
highlighting the management of intra-op hypoxia hypotension and bleeding in this complex patient.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1120
Perioperative Management of a Patient With Hermansky-Pudlak Syndrome
Kelly Zach, M.D., Lopa Misra, D.O., Mayo Clinic, Phoenix, AZ
A 53-year-old female with a history of an overactive bladder presented for botox injection of the
bladder. She underwent evaluation in the preoperative clinic revealing a medical history significant for
Hermansky-Pudlak syndrome a rare genetic condition that results in platelet dysfunction and
oculocutaneous albinism. Late complications include pulmonary fibrosis renal insufficiency and colitis.
On the day of surgery she was administered a dose of desmopressin and tolerated the procedure
without complications. This case outlines the perioperative management in a patient with HermanskyPudlak syndrome specifically the consideration for bleeding tendencies in these patients.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1121
Difficult Airway and Repeated Cuff Leak in a Nasally Intubated Patient Despite Use of Airway
Exchange Catheter and Glidescope
Kamaal Zaidi, New York University, New York, NY
Patient is a 20-year-old woman with Class III Skeletofacial Deformity who was scheduled to undergo
LeFort I and Mandibular Osteotomies. Patient was nasally intubated with Magill forceps but prior to
start of case was found to have a significant cuff leak. New endotracheal tube (ETT) was placed utilizing
an airway exchange catheter (AEC) and Glidescope but with much difficulty. After placement new ETT
was again found to have a substantial cuff leak. Decision was made to cancel the case and with AEC in
place patient was orally intubated with Glidescope and regular ETT.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1122
A Challenging Intubation in a Patient With Severe Ludwig's Angina
John Zaki, M.D., Ngano Takawira, M.D., Deborah Ortega, M.D., Texas Tech Health Science Center, El
Paso, TX
This is a case report about a patient who presented to the ER with complaints of shortness of breath and
found to have severe ludwig's angina. Patient was immediately taken into the OR where an awake
Copyright © 2013 American Society of Anesthesiologists
fiberoptic intubation was successful while surgeons were standing by ready to assist with an emergency
airway if awake intubation had failed.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1123
Anesthetic Management for an Attempted Resection of a Thoracic Pheochromocytoma in a 49-yearold Male
Caleb Zelenietz, M.D., Andrea Petropolis, M.D., University of Manitoba, Winnipeg, MB
We describe the presentation of a 49-year-old male presenting for resection of a mediastinal
pheochromocytoma. The patient had been diagnosed several months previously during work up for
headache. He was appropriately medically optimized with alpha blockade. Pre-operative imaging was
not suggestive of invasion into mediastinal structures and he had no symptoms of vascular or
tracheobronchial compression. The patient underwent combined thoracic epidural and general
anesthesia along with one lung ventilation. Intra-operatively the mass was deemed unresectable due to
pericardial invasion and significant vasularity. The operation was aborted and the patient is now
awaiting cardiac surgery consultation.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1124
Repeat Liver Transplant Complicated by Massive Hemorrhage Cardiac Arrest and Undiagnosed PFO
After Tetralogy of Fallot Repair
Jeron Zerillo, M.D., Andrew Perez, M.D., Alan Sim, M.D., The Mount Sinai Hospital, New York, NY
45-year-old M w/hx of Tetralogy of Fallot repair HCV cirrhosis hepatorenal syndrome RBBB paroxysmal
SVT and RV dysfunction presented for liver retransplantation. Preinduction aline was followed by RSI
central line PAC and TEE placement. TEE demonstrated an undiagnosed PFO and allowed cardiac
monitoring. Following incision significant hemorrhage ensued and massive transfusion was initiated.
Despite resuscitation the patient became hypovolemic and VT arrest was successfully managed with 2
rounds of epinephrine and defibrillation. Venovenous bypass was utilized during the anhepatic phase
and patient successfully underwent OLT. He was extubated off CVVH and pressors and out of the ICU by
POD 5.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1125
Fixation Error: Common Things are Common
Sophy Zheng, M.D., BobbieJean Sweitzer, M.D., University of Chicago, Chicago, IL
29-year-old with metastatic papillary thyroid cancer hypocalcemia and hydronephrosis requiring
frequent ureteral stents developed 2 cardiac arrests after MAC inductions for stent changes. Acute
refractory hypotension began within 2-5 minutes then PEA arrest requiring CPR and epinephrine.
Intraoperative TEE revealed profound hypovolemia but no cardiac abnormalities. Labs were relatively
normal. On several previous anesthetics there was a pattern of increasing hypotension after induction.
After detailed review of many records the arrests occurred 2-5 minutes following cefazolin but no
arrests without antibiotics. Interesting the patient tolerated cefazolin 2 years prior but developed
increasing hypotension with subsequent dosing.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1126
Catch 22: A Case of Pneumoperitoneum and Acute Myocardial Infraction
Nan Zhu, M.D., Matthew Tulis, M.D., Caron Hong, M.D., University of Maryland, Baltimore, MD
A 54-year-old man with CAD and medication noncompliance was found to have pneumoperitoneum. A
preoperative EKG did not demonstrate any acute findings and the patient had a slight troponin
elevation. Cardiology was consulted and since emergency surgery was required they recommended no
further cardiac workup and perioperative beta-blockade. Upon arrival to the operating room the patient
was noted to be having a STEMI. Surgery was not started and the patient was sent to the cath lab where
he expired. We discuss the decision-making process when faced with these two life-threatening
emergencies and the intraoperative management of an acute MI.
Tuesday, October 15
3:00 PM - 4:30 PM
FA MC1127
Perioperative Management of a Patient With Mitochondrial Myopathy and G6PD Deficiency
Nan Zhu, M.D., Megan Anders, M.D., University of Maryland, Baltimore, MD
A 63-year-old man presenting for shoulder arthroplasty had both adult-onset mitochondrial myopathy
and G6PD deficiency. Mitochondrial myopathies are a polymorphic group of disorders affecting multiple
organ systems caused by mutations in mtDNA encoding enzymes in the respiratory chain. G6PD
deficiency is the most common enzymatic disorder of red blood cells in humans leading to acute
hemolysis in the setting of stress infection and certain medications. The perioperative care of this
patient is reviewed and strategies for intraoperative management of patients with these two diseases
are discussed.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1128
Neurologic Changes in the Neonate for Cardiac Surgery
Kristin Richards, M.D., Laura Hastings, M.D., Children's Hospital Los Angeles/USC, Los Angeles, CA
Term 2.6 kg newborn was cyanotic. Echocardiogram showed D-TGA restrictive atrial septum and PDA;
coarctation of the aorta. PGE initiated intubated and had a balloon atrial septostomy. Afterwards he had
rigid flexed posture decreased responsiveness and no spontaneous movements. Cranial ultrasound and
MRI normal. EEG with low amplitude. He presented for repair of TGA . Anesthetic concerns included
modifying the management based on the neurologic status and optimal timing of surgery with CPB
based on neurologic status. He underwent full repair days after the septostomy without further change
in neurological exam
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1129
Anesthetic Approach to a Cyanotic Teenager With Unknown Cardiac Anatomy Resulting in a Glenn
Kristin Richards, M.D., Melanie Ward, M.D., Laura Hastings, M.D., Children's Hospital Los Angeles/USC,
Los Angeles, CA
13-year-old for cardiac catheterization to evaluate cyanosis. She was followed for L-TGA hypoplastic RV
interrupted IVC LSVC RSVC not visualized and concern for common atrium. Oxygen saturations were
60%. Unclear anatomy and physiology complicated anesthetic management. There was concern for
Copyright © 2013 American Society of Anesthesiologists
Eisenmenger's. Initially sedation worked well however general anesthesia was requested. The
catheterization added: all systemic and pulmonary veins drain into RA which flows into the morphologic
LV to the aorta. LSVC drains to unroofed coronary sinus mostly to the LA. LA flows through the
hypoplastic RV to pulmonary arteries. Qp:Qs is predicted ~ 0.1:1. . She underwent a Glenn.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1130
Airway Implications During Anesthesia in an Infant With Undiagnosed Long Segment Congenital
Tracheal Stenosis
Zachary Robbins, M.D., Tufts Medical Center, Boston, MA
76-day-old female has a history of imperforate anus s/p loop sigmoid colostomy. She presented to the
hospital with jaundice and elevated billirubin and required liver biopsy and cholangiogram under general
anesthesia. After mask induction and intravenous catheter placement mask ventilation was performed
without difficulty. Direct laryngoscopy was performed with a miller one blade. A grade one view was
achieved however when a 3.5 cuffed endotracheal tube was placed resistance was met just distal to the
vocal cords. A 3.0 uncuffed was attempted with resistance. Third attempt at a 2.5 uncuffed ET tube was
placed with resistance.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1131
Perioperative Management of T-ALL Patient Undergoing Novel CART-19 Therapy With Cytotoxic Shock
David Roberts, D.O., Erin Pukenas, M.D., Cooper University Hospital, Camden, NJ, Mohamed Rehman,
M.D., Children's Hospital of Philadelphia, Philadelphia, PA
CART19 (chimeric antigen receptor T-cells) is a novel immunotherapy that genetically engineers a
patient's T-cells to attack CD19 positive leukemic lymphocytes. Although initial outcomes have been
positive side effects from this new treatment present the need for intercurrent surgical procedures. This
patient is a 17-year-old female with recurrent T-cell acute lymphoblastic leukemia with recent CART19 Tcell infusion who was admitted with fever cytotoxic shock and pancytopenia. Patient required central
venous access placed by interventional radiology under general anesthesia. Airway management was
complicated by hypopharyngeal hemorrhage which resolved with platelet transfusion. Perioperative
management of cytotoxic shock and pancytopenia are presented.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1132
Anesthetic Considerations for Rett Syndrome
Drew Rodgers, M.D., Andrew Criser, M.D., West Virginia University, Morgantown, WV
We present a 9-year-old girl with Rett Syndrome who presented for bilateral lower extremity tendon
lengthening. Rett Syndrome is a rare progressive neurodegenerative disorder characterized by behavior
disorder movement disorder seizures and scoliosis. There are multiple anesthetic implications for this
patient population including risk for aspiration difficult airway and extreme sensitivity to anesthetics.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1133
Severely Elevated ICP in a Pediatric Liver Transplant Patient
Faith Ross, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA, Doreen Soliman, Children's
Hospital of Pittsburgh, Pittsburgh, PA
A 14-year-old male presented with idiopathic fulminant hepatic failure with severe encephalopathy. An
epidural ICP monitor was placed to assist in management of the increased intracranial pressure and the
patient was being cooled at the time that he presented to the operating room for liver transplantation.
Severe intracranial hypertension was noted throughout the intraoperative period and was exacerbated
by rewarming. After completion of the case the patient developed an epidural hematoma with
herniation and returned to the OR for a craniotomy. The patient recovered and was discharged with
complete neurologic recovery and excellent graft function.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1134
Postoperative Fever: When Do You Suspect Malignant Hyperthermia?
Jesus Rubio, M.D., Sanjay Bhananker, M.D., University of Washington, Seattle, WA
8-month-old female underwent nasolacrimal duct probing with stent placement. Sevoflurane anesthesia
via LMA was administered with supplemental Morphine IV. Initial PACU vital signs were unremarkable
however 2 hours post-operatively the patient's heart rate and temperature were noted to be 200 and
41.2 respectively. Examination demonstrated skin mottling and jerking movements. Initial VBG
demonstrated pH of 7.19. Crystalloid boluses were given and expert consultation was received.
Dantrolene was prepared pending evidence of hypermetabolism. Myoglobin CK electrolytes and CBC all
within normal limits. ABG analysis demonstrated pH 7.40 and lactate of 0.9. Patient admitted to PICU for
observation and remained stable.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1135
Selective Bilateral Bronchial Intubation in a Pediatric Patient With Tracheal Rupture
Maria Sanchez, M.D., Miguel Marrero, M.D., Elisa Quintero, M.D., Carlos Ocasio, M.D., University of
Puerto Rico School of Medicine, San Juan, PR
We report the case of a 9-year-old female who suffered a gunshot wound to the chest resulting in
tracheal rupture with ongoing air-leak and difficult ventilation. An attempt was made to initially bypass
the defect with a single lumen cuffed endotracheal tube and subsequently with a left double lumen
tube. Both strategies proved to be ineffective. The patient was ultimately managed with bilateral
bronchial intubation using fabricated extra-long tubes. Two 4.5 mm ID ETT's were used to construct
each tube resulting in adequate length and stability. Air-leak ceased and the patient received long-term
ventilatory support with an uneventful recovery.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1136
Bronchoscopy Following a Peanut Aspiration in a Child With a Possible Full Stomach
Natalie Maida, D.O., Donald Schwartz, M.D., Baystate Medical Center, Springfield, MA
A 3-year-old female presented for bronchoscopy after a suspected peanut aspiration. She was not NPO
but because of significant desaturations the procedure was not delayed. Rapid sequence induction with
endotracheal intubation was performed after which her stomach was suctioned. Rigid bronchoscopy
revealed a tracheal bronchus but no foreign body. Flexible bronchoscopy through an LMA noted food
material obstructing the left bronchus which was eventually removed. We discuss management issues
related to pediatric foreign body aspiration including induction (inhalation versus IV) ventilation
(spontaneous versus controlled) foreign body location and significance of a tracheal bronchus.
Bronchoscopic images accompany the discussion.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1137
Anesthetic Challenges in a Patient With Methyl Malonic Acidemia
Bunty Shah, M.D., Priti Dalal, M.D., F.R.C.A, Eugene Raggi, Penn State Milton S. Hershey Medical Center,
Hershey, PA
Methylmalonic acidemia (MMA) is an inherited disorder characterized by an inability to metabolize
organic acid catabolic. Acute elevations in organic acid may occur during the perioperative period posing
a challenge to the anesthesiologist. We present a case of a 14-year-old female patient with a history of
MMA who presented for surgery. The period of fasting was minimized as the patient had a jejunal tube.
Nitrous oxide was avoided and dextrose containing intravenous fluid was administered intraoperatively.
Frequent monitoring of blood glucose levels was performed. The patient made an uneventful recovery
and was discharged to home.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1138
Use of Video Laryngoscopy for Intubation and Extubation of Pediatric Patients Undergoing Head and
Neck Sclerotherapy
Mariam Sheikh, D.O., Franco Resta-Flarer, M.D., Jonathan Lesser, M.D., Jinu Kim, M.D., Leroy Sutherland,
M.D., St. Lukes Roosevelt Hospital Center, New York, NY
2-year-old male with post-birth tracheostomy s/p decannulation presented with a large submandibular
lymphangioma for sclerotherapy. The patient was intubated using video laryngoscopy revealing
persistent supraglottic disease and was left intubated following sclerotherapy and transferred to PICU.
Accidental extubation occurred 90 minutes later; an emergent LMA was placed and the patient was
brought to the OR for re-intubation. Two senior anesthesiologists attempted GlideScope with a 2.5
reusable then 3.0 disposable blades successfully visualizing the glottic structures and the ETT was
secured. Four days later extubation in the OR was guided by video laryngoscopy and showed resolution
of glottic edema.
Copyright © 2013 American Society of Anesthesiologists
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1139
Unexpected PICU Admissions After Routine Outpatient Procedures
Plinio Silva, M.D., M.P.H., Melissa Ehlers, M.D., Archana Mane, M.D., Albany Medical Center, Albany, NY
We describe two common outpatient procedures complicated by negative pressure pulmonary edema.
First a 3-year-old male with recurrent tonsillitis OSA and RAD presented for tonsillectomy
adenoidectomy and myringotomy tubes placement. The intraoperative course was unremarkable but
post operative course was complicated by severe laryngospasm oxygen desaturation re-intubation and
transfer to PICU for further management. Second a 12 month old male with recurrent emesis presented
for esophagogastroduodenoscopy. Intraoperative course was complicated by laryngospasm with oxygen
desaturation followed by endotracheal intubation with pink frothy secretions. The procedure continued
without further complication but patient was transferred to PICU for postoperative management.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1140
Difficult Airway in a Pediatric Patient With Smith-Lemli-Opitz Syndrome for Hernia Surgery
Alexander Sinofsky, M.D., NYU Langone, New York, NY
A 6-year-old male with Smith-Lemli-Opitz syndrome (SLOS) presented for an umbilical hernia repair.
SLOS is a metabolic congential disorder of cholesterol synthesis that results in craniofacial dysmorphism
cleft palate growth retardation and intellectual disability. Given this patient's prominent microcephaly
and micrognathia an extensive plan for airway management was developed prior to the start of
anesthesia. The patient was easily mask ventilated but multiple attempts at intubation using direct
laryngoscopy glidescope and fiberoptic failed. A laryngeal mask airway was used to ventilate the patient
and the hernia repair was completed without complications.
Tuesday, October 15
3:00 PM - 4:30 PM
PD MC1141
Perioperative Management of a Two-year-old With Pierre Robin Sequence Developing Acute Airway
Edema Following Tonsillectomy and Adenoidectomy in the Post Anesthesia Care Unit
Katherine Stammen, M.D., Tomasina Parker-Actlis, M.D., Louisiana State University Health Sciences
Cen