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ABSTRACT BOOK

7th Networking World Anesthesia Convention (NWAC) New York (USA), April 20-23, 2016

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7th Networking World Anesthesia Convention (NWAC) New York (USA), April 20-23, 2016

NWAC ABSTRACTS

NWAC - 1 Massive pulmonary embolism  during total knee arthroplasty

S. Luis1, T. Jamroz2 1Anesthesia, Cleveland Clinic Florida, Weston, FL, United States of America, 2Anesthesiology, Cleveland Clinic Florida, Weston, FL, United States of America

Introduction: Cardiac arrest is a significant predictor of PE mortality, it can occur due to many mechanisms in massive PE. PE in intra-operative patients requires early diagnosis and intervention by the anesthesiologist. We present a case of Massive PE in the operative room who was successfully treated with thrombolytics. Case description: A 76 year old for revision of right total knee arthroplasty surgery. During surgery patient developed sudden decrease in SpO2 and EtCO2 and a preliminary diagnosis of PE was made. A TEE was performed and identified a pulmonary emboli migrating to pulmonary artery.Mild decrease in blood pressure responded to phenylephrine and fluid administration at this time. Patient continued to decompensate with PEA and another pulmonary emboli was identified in right ventricle. The resuscitative measures were employed and patient stabilized with intra operative thrombolytics, advanced cardiac life support and the insertion of an IVC filter. Surgery continued while medical stabilization was occurring to prevent the patient from having a flail knee. ECMO was considered however O2 saturation improved after TPA and Nitric Oxide were administered. Patient was weaned off the ventilator and returned to baseline cognition. Conclusion: Conclusion: The previous literature has shown cases treated with ECMO for intra-operative PE. This is a rare case being treated with thrombolytics. Early diagnosis and aggressive treatment of intraoperative pulmonary embolism with thrombolytic can be life-saving. 

NWAC - 2 Hygiene practice among anesthesiologists – pilot study results from an international focus group interview at NWAC 2015

S. Schulz-Stübner1, F. Falter2 Control, Deutsches Beratungszentrum für Hygiene, Freiburg, Germany, 2Anesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom

1Infection

Introduction:  Despite recent progress uptake of infection control measures is slow amongst anesthesia practitioners. With approval of the Scientific Committee we used the Networking World Anesthesia Convention 2015 as a forum to get an overview over infection control practices in different parts of the world. Objectives: To perform a focus group interview about hygiene pracice in anesthesia. Methods: 60 congress delegates were presented with a questionnaire and were asked to reflect on their own practice.  Results: 57 returned questionnaires were included in the analysis and 5 distinct regions were well represented. Nearly 100% of respondents reported that they routinely used maximal barrier precautions for central line insertions. Needle free connectors are used increasingly, however only a small number of practitioners disinfect them appropriately. Disinfection of regular taps of stopcocks follows a similar pattern. Simple measures like disinfection of the outer surface of the breathing circuit or dividing the anesthesia workspace into a clean and a dirty area are still not widely used. Conclusion:  Anesthesia practitioners are mostly aware of infection control bundles and adhere to them when placing central venous access. The majority of anesthesiologists we interviewed diligently disinfected their hands after potential contact with bodily fluids, however only a minority does so before carrying out aseptic tasks. There is little awareness of the anesthesia delivery unit and attached breathing circuits as a source of contamination. Although progress has been made in past years, more educational efforts are necessary to improve awareness of the anesthesia workplace as a potential vector for clinically relevant infections.

NWAC - 3 Post-procedure arachnoiditis following obstetric spinal anaesthesia: a rare case report I. Chattopadhyay Anaesthesiology, B R Singh Hospital and Centre for Medical Education and Research, Kolkata, INDIA

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Vol. 107 - Suppl. 2 to No. 3

Introduction:  Adhesive arachnoiditis is a crippling disorder in which the pia-arachnoid undergoes an extensive inflammatory reaction to any form of injurious stimulus. Given the evident iatrogenic etiology of ad-

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Figure 3.

Figure 4.

hesive arachnoiditis today, prevention and caution shall be an integral part of the health strategies to address this condition. The prevention of post-procedure and postinjection complications are key to stop the development of new cases or the deterioration of existing ones through evidence-based clinical guidelines. Case Description: A 35-year-old woman developed adhesive arachnoiditis after spinal anaesthesia with hyperbaric bupivacaine, without any definitive precipitating cause. The patient presented eleven days postpartum with urinary incontinence and loss of sensation over the perineal region and buttocks. Gradually, she also developed complete loss of bowel control. Attempted treatments included conservative management with steroids, gabapentinoids and physiotherapy, which proved partly successful and she remains considerably better twelve months later now. We highlight the pathophysiology of adhesive arachnoiditis following central neuraxial blocks and its probable causes, including contamination of the injectate and anaesthetic drug neurotoxicity, with reference to other such published cases around the world.  Conclusion:  In the absence of more definitive data, spinal and epidural anaesthesia should be done under stringent aseptic, atraumatic techniques after discarding all probable sources of contamination. It also seems pertinent to explain to the patient the risks of late, permanent neurological deficit while obtaining informed consent.

Few case reports have reported the misplacement of esophageal devices into the tracheobronchial tree . We report the misplacement of an esophageal temperature probe into the left bronchus during left lung lobectomy surgery. Case Description: A 66 year old man presented for left lower lung lobectomy. General anesthesia was induced and a 37 French left double lumen endotracheal tube was inserted. The tracheal and bronchial cuffs were inflated and lungs were mechanically ventilated. A 9 French temperature probe (M1024229, GE) was nasally placed and blindly advanced for 30 cm. No cuff leakage was detected and airway pressure remained constant. Surgery proceeded following left lung isolation and after dissection, the left bronchus was stapled. A foreign material was transected with the bronchus that was identified as the temperature probe. Specimen was removed and the ligature was opened to allow withdrawal of the probe and the proximal stump was ligated. The trachea was extubated at the end of surgery. Patient was discharged home on day 4 postoperatively with no postoperative complications. Conclusion:  Espohageal temperature monitoring should be reconsidered in lung surgery.

NWAC - 4 Misplacement of an esophageal temperature probe

A. Dabbous1, M. Y. El Ghoul2, M. H. Ibrahim3 American University of Beirut Medical Center, Beirut, Lebanon, 2American University of Beirut Medical Center, Riad El Solh, Lebanon, 3Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon

1Anesthesiology,

Introduction:  Core temperature measurement during surgery that lasts more than thirty minutes under general anesthesia is considered standard of care .Esophageal temperature monitoring is used, because of its high accuracy, ease of insertion and no reported significant side effects .

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NWAC - 5 Anesthetic challenges of ivc filter retrieval in the interventional radiology suite L. Nguyen, D.-T. Truong, A. Truong Anesthesiology And Perioperative Medicine, MD Anderson Cancer Center, Houston, United States of America

Introduction: Even under monitored anesthesia care (MAC), cases involving patients with severe co-morbidities that are performed in non-operating room locations may present formidable challenges. When an emergency arises in remote locations, equipment for invasive monitoring and resuscitation, supply of blood products and expert assistance may not be readily available. Case Description: A 78 year-old male presented to the Interventional Radiology suite for removal of a retrievable inferior vena cava filter. Past medical history included

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NWAC ABSTRACTS

Figure 5.

prostate cancer, hypertension, cardiomyopathy, implanted cardioverter defibrillator, and right femoral vein thrombus. He received MAC with a propofol infusion. During repeated unsuccessful removal attempts, the filter migrated into the right atrium where its arms partially deployed. Even though the patient remained hemodynamically stable, the decision was made to abort the procedure, obtain vascular consultation and transfer him to a cardiac hospital. He underwent successful removal of the filter via open heart surgery without adverse consequences. Conclusion: IVC filter retrieval in Interventional Radiology carries the potential for catastrophic complications. Filter migration may cause caval and right atrial injury and catastrophic hemorrhage. Life-threatening cardiac dysrhythmias may also occur. Arterial and central venous access may be urgently needed for monitoring and management. Heightened awareness of the potential complications, timely discontinuation of the procedure, early expert consultation, and a multidisciplinary approach contributed to a favorable outcome.

NWAC - 6 Comparative study of the pharmacokinetics of bupivacaine after ultrasound-guided femoral nerve block versus neurostimulation H. Mehdi, S. Boughariou, M. Boussofara Anesthesiology, Trauma Center, Ben Arous, Tunisia

Introduction: The femoral block with single injection provides effective analgesia after arthroscopic knee surgery. Objectives:  The objective of this study is to compare the kinetics of bupivacaïne after ultrasound-guided femoral nerve block performed by technical versus neurostimulation. Methods: Carried Prospective, double-blind, included 40 patients (ps) for knee arthroscopy. The femoral block,

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Then, we start an intravenous general anesthetic and we inflate the tourniquet. Ps included were randomized into two groups of 20 patients, gr. ultrasound (GE) where the block is provided by ultrasound guidance and gr. neurostimulation (GN). It was administered nervous perished, according to conventional safety rules, isobaric bupivacaïne 0.125% (0.3mg / kg). Plasma samples bupivacaïne are made on lithium heparin tubes from the outer jugular vein before injection of bupivacaïne (T0), A5 (T5), 10 (T10), 15 (T15), 30 (T30) , 60 (T60), 90 (T90), 120 (T120) 180 (T180), 240 minutes (T240) and 24 hours (T1440) . The pharmacokinetic assay was carried out by chromatography (HPLC). Statistical analysis was performed using SPSS 22 software (significant if p≤0.05). Results:  There was no significant difference observed between the two groups and neurostimulation ultrasound for demographic characteristics (age: GE 34.2 ± 4.6 years vs GN 33,7 ± 5.4 years p: 0.87, BMI (kg / m²): GE 24,87 ± 3.6 vs GN 2.9 ± 24,45 p: 0.62, sex ratio: GE 1,5 vs GN 1,22 p: 0.47), The duration of the procedure of the femoral block was 3.4 ± 1.2 min in GE vs 5.2 ± 1.6 min in GN (p = 0.023).The block installation time is 8.6 ± 2.2 min in GE vs 7.4 ± 1.8 min in GN (p = 0.35).The injected volume of bupivacaïne was 27.4 ± 4.3 ml in GE vs 26.8 ± 3.6 ml in GN. the anesthesia duration (GE 63,28 ± 24.85 vs GN 61.49 ± 26.39 p: 0.38), the duration of arthroscopy (GE 41,28 ± 17.45 min vs GN 51,28 min± 21.13 p: 0 , 54) and the duration of tourniquet (GE 39,63 ± 12.25 vs GN 40,57±5.36 min p: 0.66). The pharmacokinetics between GE and GN groups was virtually superimposed: Cmax = 0.35 ± 0.29 mg / ml and was seen at T90 (34.7 ± 17.4 min after dropping the withers). Tmax was 33.22 ± 8.14 minutes and the T ½ is 169 ± 54 min. Cl is 0.586 ± 0.287 L / min or 6,83ml / kg.min-1 and Vd is 196 ± 76 2.45 ± 0.84 liters or l / kg.min-1 The AUC is 1134 ± 534 mg / l.min-1. Analysis of the correlation between the duration of tourniquet and clearance of bupivacaïne using Pearson´s test shows a negative correlation between these two parameters -0.634 (p= 0,011). Conclusion:  pharmacological assay showed relatively high plasma levels of bupivacaïne in all patients (but sufficiently below the toxic threshold) between T30 and T90. These results can be explained by the increase in cardiac output by effect of tourniquet between T30 and T60. Postoperatively (T90), the lifting of the tourniquet will induce a mixed acidosis, responsible for the decrease in the fraction bound to the alpha-1 acid glycoprotein bupivacaïne and therefore increase the free fraction, and a worsening of hypothermia per -opératoire, inhibiting hepatic clearance of the local anesthetic.

NWAC - 7 Quality improvement initiative: develop a standardized hand-off protocol for utilization amongst anesthesia providers to enhance intraoperative communication T. Kundu, P. Upadya Anesthesiology, Saint Joseph’s Medical Center, Paterson, NJ, United States of America

Introduction:  The interest in handoffs in medicine grew partly in response to The Joint Commission’s

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Figure 7.

National Patient Safety report in 2006, which required that institutions “implement a standardized approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.” Each anesthetic handoff increased the risk of any major in-hospital morbidity or mortality by 8%. Objectives:  To develop a standardized handoff protocol to be used intraoperatively for transitions of care. Methods:  Anesthesiologists were asked to rate the importance of a subset of elements in regards to the handoff process. After reviewing other institutions’ hand-off models and comparing them to our current practice’s needs, we compiled and presented a prototype hand-off tool to our department. Subsequent feedback required reformatting for which a formal tool was constructed. Results:  The culminating hand-off tool developed was as follows. Conclusion:  Assessing both provider and patient needs enabled the design of a concise, formatted checklist for intraoperative use. Based on collaborative efforts, the hand-off tool has been implemented

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during this critical transition of care. With this intraoperative handoff tool, a more systematic approach to handoffs will be used and thereby satisfaction of handoffs amongst providers is expected to increase. Consequently a decrease in mistakes that occur during the handoff process is predicted, and compliance to the tool will be measured across all anesthesia providers.

NWAC - 8 Cardiotocographic response to epidural analgesia in labour : a double blinded randomised control study A. K. Jha1, S. Basu1, A. Basu2, B. Chatterjee2 B.R.Singh Institute for Medical Education and Research, Kolkata, INDIA, 2Obstetrics & Gynaecology, B.R.Singh Institute for Medical Education and Research, Kolkata, India

1Anaesthesiology,

Introduction: Neuraxial technique is the gold standard for pain relief in labour. The widespread acceptance of epidural analgesia for labour is still lacking due to the various

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NWAC ABSTRACTS

Figure 8.

myths and controversies associated with it. It’s controversial if epidural analgesia causes changes in fetal heart rate pattern by direct or indirect myocardial side effect. Objectives: To study the effect of epidural analgesia on the fetal heart rate by way of cardiotocography. Methods:  After ethical committee clearance, informed consent was taken. Study done from 1st May to 31st July. Inclusion criteria were booked singleton term pregnancy with cephalic presentation without any obstetric complication, taking 30 subjects each as cases and controls. Simple randomization technique of tossing a coin was used to allocate the subjects into cases and controls. MedCalc version 11.6 [Mariakerke, Belgium: MedCalc Software 2011] was the software used for statistical analysis and a ‘p’ value 0.05) 0.96 (>0.05)

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ODDS Ratio

1.0500 1.5273

95% CI

0.1683 to 6.5516 0.3395 to 6.8696

P value

0.95 (>0.05) 0.58 (>0.05)

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NWAC ABSTRACTS 

of the diaphragm to using the following formula: ET = (EI -EE) / EI. Measuring the thickness of the diaphragm was performed by an ultrasound probe with a planar-type Sonosite head, high-frequency (10 MHz) used in muscle mode in 2D mode and at a depth of 4 to 6 cm. the probe was placed perpendicularly in the frontal plane between the 8th and 9th intercostal space.measurements was redone 30 min, 2 h, 6 and 24 h after the ISB. Statistical analysis was performed using SPSS 22 software. Results: We found no cases in the 2 groups, and in no time, the fall of ET < 20%, PEF < 80% theoretical value or PO2S< 95%.the VFBAwas increased by 2 times to H2 and H6 after ISB in both groups. GE

Age(years) BMI(kg/m2) bupivacaine (ml) onset time of sensory block the axillary nerve(min) Onset of the motor block of the axillary nerve(min) The duration of the act (min)

GN

p

39.7 ± 4.3 37.8 ± 6.8 0.77 26.4 ± 1.4 5.4 ± 1.7 0.36 19.6 ± 4.3 21.2 ± 3.6 0.17; 14.1 ± 2.3) 17.6 ± 3.9 0.35 14.1 ± 2.3

17.6 ± 3.9 0.35

54.6 ± 18.9 61.2 ± 19.4 0.42

Conclusion:  The paralysis of the phrenic nerve is a common complication of BIS without having a clinical impact on breathing.

NWAC - 11 A comparative study of postoperative hypothermia between patients receiving intraoperative IV fluid warming devices and forced-air warming

J. Jiarpinitnun, W. Ittichaikulthol, R. Komonhirun Anesthesiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Introduction:  Patients undergoing surgery under anesthesia lead to increased risk of postoperative hypothermia and complications. One of the risk factors is the operating room temperature. Objectives: To compare the incidence of postoperative hypothermia in obstetric and gynecologic patients at Ramathibodi Hospital between patients receiving intraoperative IV fluid warming devices (group: S) and forced-air warming (group: C) in operating room temperature