Verdiner, Ricardo

ABSTRACTThis case report describes the novel use of oxybutynin and acetaminophen as a substitution for oxycodone for the express purpose of diverting oxycodone in a hospital‐based post‐anesthesia care unit (PACU). The report outlines how the physical properties and pharmacologic effects of non‐controlled medications in the PACU, like oxybutynin, can be visually mistaken and even mimic the side effects of controlled substances like oxycodone. Substituting oxybutynin for controlled substances can circumvent diversion surveillance software. The authors describe how the diversion was identified and the process improvements that should be implemented for proactive identification moving forward.

Background. Utilization of intraoperative transesophageal echocardiography (TEE) during orthotopic liver transplantation (OLT) is expanding annually in high-volume transplant centers. During OLT intraoperative TEE is used to gather real-time information on cardiovascular function and intravascular volume status. Although standardized TEE views exist, there are nontraditional views described in the literature which have the potential to diagnose evolving pathology and define normal variants of hepatic vasculature. Methods. A literature review was completed utilizing the PubMed database for English-only, peer-reviewed publications discussing nontraditional use of intraoperative TEE during OLT and hepatic vascular-related surgeries from 2009 to 2019. Both case reports and review articles were considered. Results. The PubMed literature search offered 8 publications for analysis, including 7 case reports and 1 article review, revealing several nontraditional TEE views not included in a comprehensive transesophageal echocardiographic examination. These nontraditional views were generally obtained using modifications to the transgastric and bicaval views to visualize liver vasculature. We present the various techniques for obtaining these views from the 8 articles identified. Conclusions. At high-volume transplant centers, TEE use during OLT is increasing. Intraoperative TEE is a valuable tool to assess hepatic vascular structures critical to allograft/organ function without interruption of the surgical procedure. Nontraditional use of TEE to diagnose intraoperative noncardiac pathology in OLT appears underutilized and underreported. The modified hepatic and modified transgastric views we describe can be used to evaluate hepatic vasculature, influence surgical decision-making and ultimately improve patient care.

In response to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic and the potential need for physicians to provide critical care services, the American Society of Anesthesiologists (ASA) has collaborated with the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF) to develop the COVID-Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) Intensive Care Unit (ICU) workgroup. CAESAR-ICU is designed and written for the practicing general anesthesiologist and should serve as a primer to enable an anesthesiologist to provide limited bedside critical care services.