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Objective To investigate whether the addition of liposomal bupivacaine abdominal wall blocks to a multimodal analgesic regimen improves postoperative numeric rating scale pain scores and reduces opioid consumption in patients undergoing living liver donation. Patients and Methods We conducted a single-center, retrospective review of patients who underwent living liver donation from January 1, 2011, through February 19, 2016, and received multimodal analgesia with (block group) or without (control group) abdominal wall blockade. The block solution consisted of liposomal bupivacaine (266 mg) mixed with 30 mL of 0.25% bupivacaine. Both groups received intrathecal hydromorphone. Main outcome measures were pain scores, opioid requirements, time to full diet, and bowel activity. Results Postoperative day 0 pain scores were significantly better in the block group (n=29) than in the control group (n=48) (2.4 vs 3.5; P=.002) but were not significantly different on subsequent days. Opioid requirements were significantly decreased for the block group in the postanesthesia care unit (0 vs 9 mg oral morphine equivalents; P=.002) and on postoperative day 0 (7 vs 18 mg oral morphine equivalents; P=.004). Median (interquartile range) time to full diet was 23 hours (14-30 hours) in the block group and 38 hours (24-53 hours) in the control group (P=.001); time to bowel activity was also shorter in the block group (45 hours [38-73 hours] vs 67 hours [51-77 hours]; P=.01). Conclusion Abdominal wall blockade with liposomal bupivacaine after donor hepatectomy provides an effective method of postoperative pain control and decreases time to full diet and bowel activity.

To determine whether glove use modifies tactile and psychomotor performance of health care providers when compared with no glove use and to evaluate factors that influence the selection of sterile glove brand.Forty-two anesthesia providers (nine anesthesiologists, seven nurse anesthetists, 20 residents, six student nurse anesthetists) enrolled in and completed this cross-over randomized trial from May 2010 until August 2011. Participants underwent standardized psychomotor testing while wearing five different types of protective gloves. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The manufacturer's suggested retail price was collected for each glove tested.There were statistically significant differences in touch sensitivity for all nerve distributions, with all glove types resulting in less sensitivity than a bare hand. When compared with the non-sterile glove, only the thickest glove tested (Ansell Perry Orthopaedic) was found to have less touch sensitivity. Fine motor dexterity testing revealed no statistically significant differences in time to completion amongst glove types or bare handed performance. In hand-eye coordination testing across treatment conditions, the thickest glove tested (Ansell Perry(®) Orthopaedic) was the only glove to show a statistically significant difference from a bare hand. There were statistically significant differences in glove comfort ratings across glove types, with latex-free, powder-free (Cardinal Esteem(®)), and latex powder-free (Mölnlycke-Biogel(®)) rated highest; however, there were no statistically significant differences in subjective performance ratings across glove types.Given the observed similarities in touch sensitivity and psychomotor performance associated with five different glove types, our results suggest that subjective provider preferences, such as glove comfort, should be balanced against material costs.

Summary Background Patients undergoing total knee arthroplasty usually receive a multimodal analgesic regimen including peripheral nerve blockade, but may still experience significant pain. This study examined whether preoperative gabapentin decreases acute postoperative pain and opioid consumption in this setting. Methods Retrospective chart review of single institution, hospital-based orthopaedic practice. Consecutive patients undergoing unilateral elective primary knee arthroplasty were evaluated for perioperative gabapentin use. Sixty-one consecutive patients received gabapentin; for each, an age- and gender-matched control was identified. Results Patients in both groups demonstrated similar demographics, all received lumbar plexus blockade. Catheters were removed on postoperative day 2 (95%). There were no differences in postoperative pain scores or opioid use between groups. Overall, median verbal pain scores (IQR) were 0(1), 0(3), 1(3) and 3(3) in the post-anaesthesia care unit and postoperative days 0, 1 and 2, respectively. Postoperative consumption of other analgesics was not different across groups. Patients in the gabapentin group received a single-injection sciatic nerve block less often than patients in the control group (77% vs. 94%, respectively; p Conclusions Patients undergoing unilateral total knee arthroplasty experience low pain scores utilizing a multimodal analgesic regimen including continuous lumbar plexus blockade independent of gabapentin use.

Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful resuscitation of bupivacaine-induced cardiac arrest treated with i.v. lipid emulsion by providers who had recently participated in simulation training involving a scenario nearly identical to this case. Upon debriefing, it was determined that the previous training influenced execution of the following steps: rapid problem recognition, prompt initiation of specific therapy in the setting of supportive advanced cardiac life support measures, and coordinated team efforts. Although the true cause of efficient resuscitation and ultimate recovery cannot be proven, the efficiency of the resuscitation process, including timely administration of lipid emulsion, is evidence that simulation may be useful for training providers to manage rare emergencies.

Aortic stenosis (AS) is a major risk factor for perioperative cardiac events in patients undergoing noncardiac surgery. We previously showed that selected patients with AS who were not candidates for, or refused, aortic valve replacement could undergo noncardiac surgery with acceptable risk. We extended our previous experience over a subsequent 5-year period by retrospectively analyzing the perioperative course of all patients with severe AS (aortic valve area index0.5 cm2/m2 or mean gradient50 mm Hg), determined with Doppler echocardiography or cardiac catheterization, who underwent noncardiac surgery. Nineteen patients underwent 28 surgical procedures: 22 elective and 6 emergency. The types of these procedures were 12 orthopedic, 6 intraabdominal, 4 vascular, 4 urologic, 1 otolaryngologic, and 1 thoracic. Mean age was 75 +/- 8 years. Of the 19 patients, 16 (84%) hador = 1 symptom: dyspnea, angina, syncope, or presyncope. Mean left ventricular ejection fraction was 61 +/- 11%. The type of anesthesia was general in 26 procedures and continuous spinal in 2. Intraarterial monitoring of blood pressure was used in 20 of the 28 surgical procedures. Intraoperative hypotensive events were treated promptly, primarily with phenylephrine. In all cases the anesthesia team was aware of the severity of the AS and integrated this into the anesthetic plan. Two patients (elective operation in 1 and emergency in 1) had complicated postoperative courses and died. There were no other intraoperative or postoperative events in any of the other patients. Although aortic valve replacement remains the primary treatment for patients with severe AS, selected patients with severe AS, who are otherwise not candidates for aortic valve replacement, can undergo noncardiac surgery with acceptable risk when appropriate intraoperative and postoperative management is used.

Objective: We describe BIS values for a patient undergoing breast surgery under self-hypnosis in order to access the value of global surface EEG measures occurring during this process. Methods: Following verbal consent, a BISTM monitor (Aspect Medical, Newton MA) was placed and values measured while the patient performed self-hypnosis for a simple mastectomy and sentinel node biopsy. Results: Thirty-nine minutes after incision the BIS value decreased transiently to 72 followed by several other transient decreases, the lowest of which was 59. Values remained at approximately 90 throughout most of the operative period. The BIS value returned to baseline after completion of the operation. Conclusions: Our findings support the hypothesis that hypnosis is a dynamic cerebral process incorporating many changes within brain activation centers and one distinct from dissociative patterns seen under anesthesia. Current algorithms employed by the BISTM monitor add little to the management of patients utilizing hypnosis for analgesia.

Introduction. Indirect video laryngoscopes are altering the landscape of airway management. The primary aim of this prospec-tive randomized patient simulator analysis was to objectively compare video laryngoscopes to standard airway management techniques in novice users.Methods. "First year medical students were exposed to high-fidelity simulated normal and difficult airway scenarios while using an array of indirect video laryngoscopes (e.g., the GlideScope, McGRATH or Pentax AWS-100) that were compared to Macin-tosh laryngoscope and fiberoptic bronchoscope (i.e., historic gold standards for normal and difficult airways, respectively)." Results. In the normal airway scenario, the best glottic view (both subjective and objective) was obtained with the video laryngoscopes and intubation success rates were highest with the video laryngoscopes (100% success rate for each device) and Macintosh (80%). In the difficult airway scenario, the best glottic view was achieved with all video laryngoscopes and the fiberoptic bronchoscope; however, tracheal intubation was best achieved with the video laryngoscopes (100% success rate for each device) whereas the success rate with the bronchoscope was only 36%.Discussion. Our findings support the use of the GlideScope, McGRATH, or Macintosh laryngoscopes for novice users mana-ging a normal airway. When managing the difficult airway, there was no difference between any video or Macintosh laryngosco-pe in the time to successfully intubate the trachea. Over time, study participants demonstrated learned behavior as they became more facile with all devices. When comparing the video laryngoscopes, all three performed similarly overall and proved useful in the hands of novice users. Regardless of airway difficulty, the fiberoptic bronchoscope yielded the worst results.

BACKGROUND: Although few studies have been performed recently, several have suggested that some practitioners are not well able to detect preset anesthesia machine faults. METHODS: We performed a prospective study to determine whether there is a correlation between duration of anesthesia practice and the ability to detect anesthesia machine faults. Our hypothesis was that more anesthesia practice would increase the ability to detect anesthesia machine faults. This study was performed during a nationally attended anesthesia meeting held at a large academic medical center, where 87 anesthesia providers were observed performing anesthesia machine checkouts. The participants were asked to individually check out an anesthesia machine with an unspecified number of preset faults. The primary outcome measures were the written listing of faults detected during an anesthesia machine checkout. RESULTS: Of the five faults preset into the test machine, participants with 0-2 yr experience detected a mean of 3.7 faults, participants with 2-7 yr experience detected a mean of 3.6 faults, and participants with more than 7 yr experience detected a mean of 2.3 faults (P < 0.001). CONCLUSIONS: Our prospective study demonstrated that anesthesia machine checkout continues to be a problem.

Non-focal postoperative mental status changes can be challenging. Single patient case report and medical literature review. We describe a 67-year-old male who was admitted for radical cystectomy and ileal conduiturinary diversion. General anesthesia was uneventful and the patient remained hemodynamically stable throughout the procedure. At the end of the procedure, the patient's tracheal was extubated. Initially, he was arousable, able to move all extremities, and answer questions appropriately. Over the next 2 hours, his mental status waxed and waned and respirations became irregular. An emergent head computed tomogram without contrast revealed a hyperdense basilar artery consistent with acute thrombosis. Vascular radiology intervention occurred approximately 9 hours after the onset of symptoms, but there was no improvement in the patient's neurological status and the subsequently died. Although nonfocal postoperative mental status changes are common and often secondary to benign etiologies, they may herald more significant pathology, including stroke. Patients with postoperative mental status changes should be evaluated carefully to identify like-threatening and treatable etiologies. Recent advance in the acute care of stroke such as thrombolysis and angioplasty, can improve outcome if instituted promptly.