Stewart, Thomas M.

Background. Anesthesia providers categorize patients utilizing the American Society of Anesthesiologists Physical Status (ASA-PS) classification originally created by the ASA in 1941. There is published variability and discordance among providers when assigning patient ASA scores in part due to the subjectivity of scoring utilizing patient medical conditions, but variability is also found using objective findings like BMI. To date, there are few studies evaluating the accuracy of anesthesia providers’ ASA assignment based on objective body mass index (BMI) alone. The aim of this retrospective chart review is to determine improvement in accuracy of anesthesia providers to correctly assign patient ASA scores, based on BMI criteria added to the ASA-PS in October of 2014, utilizing a multifaceted strategy including creation of an active finance committee in the fall of 2015, multiple e-mail communications about the updated definitions and recommendations for ASA-PS scoring in the fall of 2015 and spring of 2016, a department grand rounds presentation in February 2016, placement of laminated copies of the ASA definitions and recommendations in the anesthesia chartrooms, and the development of a tool embedded into our EMR providing a recommendation of ASA-PS based on patient comorbidity findings. Methods. After attaining IRB approval, all eligible patients over the age of 18 who had surgical procedures under general anesthesia at Mayo Clinic in Rochester, MN, between January 1, 2010, and December 31, 2020, were retrospectively analyzed. A segmented logistic regression model was used to estimate the trends (per-year change in odds) of ASA under classification according to severity of obesity during 3 epochs: preimplementation (2010–2014), implementation (2015), and postimplementation (2016–2020). Results. A total of 16,467 patients of the 200,423 (8.2%) patients with obesity (class 1, 2, and 3) were underscored based on BMI alone. Accuracy of ASA-PS classification, as it pertains to BMI alone, was found to show meaningful improvement year-to-year following the updated ASA-PS guidelines with examples released in October of 2014 (P<0.001). Most of the improvement occurred in 2015–2017 with relatively little between-year variability in the rate of underscoring from 2017–2020. Conclusion. Despite updated ASA-PS published guidelines, providers may still be unaware of the updated guidelines and inclusion of examples used within the ASA-PS classification system. Accuracy of scoring did improve annually following the release of the updated guidelines with examples as well as department-wide educational activities on the topic. Additional education and awareness should be offered to those responsible for preanesthesia evaluation and assignment of ASA-PS in patients to improve accuracy as it pertains to BMI.

Introduction and importance: Reports are limited on video-assisted thoracoscopic surgery for lung malignancy of patients with situs inversus totalis (SIT). Patients with SIT have significant anatomic differences with implications that are important for surgery, anesthesia, and nursing to understand in order to provide care for this patient population. Case presentation: A 64-year-old man with SIT and lung adenocarcinoma needed flexible bronchoscopy and wedge resection of a 9×8 mm adenocarcinoma in the right upper lobe and underwent video-assisted thoracoscopic surgery. Clinical discussion: Preoperative planning, including collaboration with the surgical team, allowed safe monitoring, induction of anesthesia, and airway isolation in this patient allowing them to have successful resection of their pulmonary malignancy. Postoperative care was enhanced by detailed communication and understanding of the patient’s anatomy and implications of this condition for post anesthesia care unit nursing care. Conclusion: Patients with rare clinical conditions and backgrounds may require surgical and anesthetic intervention. The authors describe important anesthetic considerations of preoperative evaluation, airway management, cardiac monitoring, and vascular access that should be noted and taken into account for patients with SIT. Proper preparation, planning, and communication allow for patients with SIT to safely undergo surgical procedures.

AbstractBackground and ObjectivesOptimizing perioperative analgesia for patients undergoing major lower‐extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower‐extremity amputation is unknown.MethodsWe conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower‐extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression.ResultsA total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59).ConclusionsPeripheral nerve blockade is associated with reduced opioid requirements after lower‐extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.

Trichorhinophalangeal syndrome (TRPS) is a genetic disorder that may pose anesthetic challenges. We present a case of airway management for urgent surgery in a 56-year-old female with TRPS and difficult airway (macroglossia, narrow glottic opening, and hypoplastic epiglottis). Intubation was successful with video laryngoscopy using a size 2.5 pediatric blade and size 5.0 endotracheal tube. During emergence, she experienced bronchospasm and persistent urosepsis, necessitating intensive care unit (ICU) admission. Her pulmonary reserve was hindered by a Morgagni hernia causing lung compression. Our case demonstrates challenges in TRPS including challenging airway, decreased pulmonary reserve, and joint laxity introducing potential for spinal cord injury.

Postoperative vision loss is a rare complication. When visual loss does occur, it is rarely associated with ophthalmoplegia. We report a case of postoperative bilateral visual field deficits with concomitant complete bilateral ophthalmoplegia in a patient with a known pituitary macroadenoma after surgical excision of a small cell carcinoma of the bladder. Emergency postoperative imaging showed that the macroadenoma had increased in size and was associated with new right optic nerve edema. The patient underwent urgent excision of the macroadenoma 5 days after the onset of symptoms. Visual field deficits and associated ophthalmoplegia had completely resolved at 3-month follow-up.

* Rates of opioid use and abuse continue to rise in the United States, as do opioid-related deaths. Many patients who misuse opioids receive their first exposure in the perioperative setting. * Postoperative opioid use reduction in patients who have undergone an upper-extremity procedure can be difficult secondary to the often-painful nature of orthopaedic procedures. Postoperative pain can prevent timely discharge from hospitals and is a major cause for emergency medicine visits following outpatient upper-extremity surgical procedures. * Utilization of a multidisciplinary, multimodal, home-going continuous peripheral nerve block catheter protocol may be able to comfortably allow patients to recover in an outpatient setting after an upper-extremity surgical procedure, with a diminished opioid requirement.