Review Course Lectures presented at the 2010 Annual Meeting of the International Anesthesia Research Society Honolulu, Hawaii March 20-23, 2010 IARS 2009 REVIEW COURSE LECTURES The material included in the publication has not undergone peer review or review by the Editorial Board of Anesthesia and Analgesia for this publication. Any of the material in this publication may have been transmitted by the author to IARS in various forms of electronic medium. IARS has used its best efforts to receive and format electronic submissions for this publication but has not reviewed each abstract for the purpose of textual error correction and is not liable in any way for any formatting, textual, or grammatical error or inaccuracy. ©2010 International Anesthesia Research Society 2 ©International Anesthesia Research Society. Unauthorized Use Prohibited. IARS 2009 REVIEW COURSE LECTURES Table of Contents Ultrasound Guided Regional Anesthesia in Infants, Neuroanesthesia for the Occasional Children and Adolescents Neuroanesthesiologist Santhanam Suresh, MD FAAP .................1 Adrian W. Gelb ............................36 Vice Chairman, Department of Pediatric Anesthesi- Professor & Vice Chair ology, Children’s Memorial Hospital Department of Anesthesia & Perioperative Care Prof. of Anesthesiology & Pediatrics, Northwestern University of California San Francisco University’s Feinberg School of Medicine, Chicago, IL Perioperative Control Of Hypertension: When Does Neuromuscular Blockers and their Reversal in 2010 It Adversely Affect Perioperative Outcome? François Donati, PhD, MD.....................6 John W. Sear, MA, PhD, FFARCS, FANZCA .......39 Professor, Departement of Anesthesiology Nuffield Department of Anesthetics, Université de montréal University of Oxford, John Radcliffe Hospital Montréal, Québec, Canada Oxford, United Kingdom Anaphylactic and Anaphylactoid Perioperative Approach to Patients with Reactions in the Surgical Patient Respiratory Disease: Is There a Role \Jerrold H. Levy, MD, FAHA ..................11 for Pulmonary Function Evaluation? Professor and Deputy Chair for Research, Emory Thomas J. Gal, MD .........................46 University School of Medicine Emeritus Professor of Anesthesiology Co-Director of Cardiothoracic Anesthesiology, Car- University of Virginia Health System, diothoracic Anesthesiology and Critical Care Charlottesville, Virginia Emory Healthcare, Atlanta, Georgia Vexing Pediatric Anesthesia Issues for the Generalist Update on Thoracic Epidurals: Anesthesiologist Are the Benefits Worth the Risks? Peter J. Davis, MD ..........................50 Hugo K. Van Aken, MD, PhD, FANZCA, FRCA ....17 Anesthesiologist-in-Chief, Professor, Department of Anesthesiology and Children’s Hospital of Pittsburgh Intensive Care, Professor of Anesthesiology & Pediatrics University Hospital Müenster University of Pittsburgh School of Medicine, Muenster, Germany Pittsburgh, Pennsylvania Perioperative Glucose Control Valvular Heart Disease in the Patient George M. Hall, MB, BS, PhD, DSc, (Med), CBiol, Undergoing Noncardiac Surgery FSB, FRCA, FCARCSI.........................24 Nancy A. Nussmeier, MD ....................54 Professor of Anaesthesia Chair, Department of Anesthesiology St George’s University of London SUNY Upstate Medical University, Syracuse, NY London, United Kingdom Postoperative Nausea and Vomiting: Can Regional Anesthesia Coexist Past, Present, and Future with DVT Prophylaxis? Paul F. White, PhD, MD, FANZCA ..............60 Terese T. Horlocker, MD .....................28 Department of Anesthesiology & Pain Management, Department of Anesthesiology University of Texas Southwestern Medical Center, Mayo Clinic, Rochester, MN Dallas, Texas and the Departments of Anesthesia at Policlinico Abano Terme and Parma University in Italy, and Does Blood Save Lives? Cedars Sinai Medical Center in Los Angeles Colleen Koch, MD, MS, MBA .................34 Professor of Anesthesiology, (continued) Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Department of Cardiothoracic Anesthesia Cleveland Clinic Foundation, Cleveland, Ohio ©International Anesthesia Research Society. Unauthorized Use Prohibited. i Table of Contents, continued News You Can Use: Obstetric Anesthesia in the 21st Century Cynthia A. Wong, MD.......................62 Professor, Northwestern University Feinberg School of Medicine Medical Director, Obstetric Anesthesiology Northwestern Memorial Hospital, Chicago, IL Obstructive Sleep Apnea Patients: A Challenge for Anesthesiologists Frances Chung, MD FRCPC ...................68 Professor of Anesthesia, Department of Anesthesia University Health Network, University of Toronto Toronto, Ontario, Canada Does fluid restriction improve outcomes of surgical patients? Tong J Gan, MD, FRCA, MHS .................77 Department of Anesthesiology, Duke University Medical Center, North Carolina, USA What’s New in Critical Care Medicine? Robert N. Sladen, MD .......................80 Professor and Executive Vice-Chair, and Chief, Division of Critical Care Department of Anesthesiology College of Physicians & Surgeons of Columbia University New York, NY How does an injury cause pain? Tony L. Yaksh, PhD .........................89 Department of Anesthesiology, University of California, San Diego Update on Malignant Hyperthermia Denise Wedel, MD ........................101 Professor of Anesthesiology Mayo Clinic College of Medicine ii ©International Anesthesia Research Society. Unauthorized Use Prohibited. Ultrasound Guided Regional Anesthesia in Infants, Children and Adolescents Santhanam Suresh, MD FAAP Vice Chairman, Department of Pediatric Anesthesiology, Children’s Memorial Hospital Prof. of Anesthesiology & Pediatrics, Northwestern University’s Feinberg School of Medicine, Chicago, IL INTRODUCTION of significant ossification. The largely cartilaginous Regional anesthesia is experiencing resurgence posterior vertebral column of neonates and infants in pediatric anesthesia. The use of a variety of enables good US beam penetration to view the spinal techniques has improved with the use of ultrasound structures and can in some cases may enable a view guidance. The increased safety of performing regional of the needle tip trajectory. anesthesia with US-guidance has encouraged the practitioner to attempt to perform more difficult TECHNIQUES blocks compared to previously described using Sonoanatomy: A moderate-high frequency probe landmark techniques.1 The use of US-guidance (hockey stick, 13-6 frequency probe) is utilized can also allow minimal volumes of local anesthetic using a paramedian longitudinal view. The ‘window’ solutions thereby decreasing the potential risk of between the two spinous processes (appearing as toxicity.2 This lecture will describe the equipment a saw tooth hypoechoic structure) will allow the used for ultrasound guided pediatric regional operator to visualize the anterior complex (anterior anesthesia along with common applications of duramater, and the posterior longitudinal ligament), ultrasound guided nerve blocks. Central neuraxial as the posterior duramater and the ligamentum flavum. well as peripheral nerve blocks will be described with Our preference is to visualize the neuraxis using a clinical techniques as well as images for reference paramedian approach. In a paramedian longitudinal while performing these blocks. Comprehensive view at the thoracic spine, the spinous processes are reviews are available for greater depth of knowledge represented by slanted hyperechoic lines beneath the in this relatively newer field in pediatric anesthesia.3 homogeneous-appearing paravertebral muscle mass. Dorsal shadowing will be apparent deep to the spinous EQUIPMENT processes and other posterior vertebral elements. The As the field of regional anesthesia is exploding, highly hyperechogenic ligamentum flavum and dura the use of ultrasound imaging is undergoing constant mater are captured lying in the alternate ‘windows’, improvement. Several ultrasound imaging systems and the underlying spinal cord appears largely with the capability of offering a variety of applications hypoechoic with an outer bright covering of the including echocardiography have entered the market pia and a central line of hyperechogenicity (median with greater emphasis on user-friendliness and sulcus). In the first report of US imaging in central portability. This may be of greater importance in blockade, Chawathe et al. performed a pilot study in the pediatric population since most of these blocks 12 patients (1 day old to 13 months) to evaluate the are performed in the operating room under general possibility of detecting catheters, and verifying their anesthesia. In children, it may be easier to perform placement, within the epidural space after placement regional anesthesia with deep sedation or under (within 24 hours) via the direct lumbar route.5 The general anesthesia4 US probes commonly used in important point from this paper is that US imaging children include a high frequency hockey stick probe (specifically using the midline approach) of static and a linear 25 mm high frequency probe. Since structures such as catheters can be performed, yet most of the neurovascular structures are located only reliably in very young patients where much of superficially in children, visualization of neural the posterior bony elements of the spinal column may structures is easier with a high frequency probe. The exist as cartilage allowing good US beam penetration. physics and equipment descriptions can be found An optimal