Preprocedural Assessment for Sedation in Gastrointestinal Endoscopy.

The role of the anesthesia service in sedation for gastrointestinal endoscopy (GIE) has been steadily increasing. The goals of preprocedural assessment are determined by the specific details of the procedure, the issues related to the illness that requires the endoscopy, comorbidities, the goals for sedation, and the risk of complications from the sedation and the endoscopic procedure. Rather than consider these issues as separate entities, they should be considered as part of a continuum of preparation for GIE.

Practical considerations in the management of sedation for colonoscopy.

Purpose Of Review: The purpose of this review is to discuss the unique elements of providing anesthesia services for colonoscopy including the practical issues within an endoscopy suite, nothing by mouth status for colonoscopy, chronic medication instructions, appropriate anesthesia equipment, informed consent, pharmacology of agents for sedation, anesthetic techniques, and issues related to postprocedural care.

Recent Findings: The national trend is toward increasing number and complexity of colonoscopy procedures using anesthesia services. Providing anesthesia services in a dedicated endoscopy suite has unique elements related to open scheduling and the rapid turnover environment.

Time to Loosen the Apron Strings: Cohort-based Evaluation of a Learner-driven Remediation Model at One Medical School.

Background: Remediation in the era of competency-based assessment demands a model that empowers students to improve performance.

Aim: To examine a remediation model where students, rather than faculty, develop remedial plans to improve performance.

Setting/participants: Private medical school, 177 medical students.

Nonoperating room anesthesia for the gastrointestinal endoscopy suite.

Anesthesia services are increasingly being requested for gastrointestinal (GI) endoscopy procedures. The preparation of the patients is different from the traditional operating room practice. The responsibility to optimize comorbid conditions is also unclear.

Massive pulmonary embolism in a patient undergoing Cesarean delivery.

A case of a 40 year old, 86 kg, G7P1 woman with a history of hypercoagulability, at 39.1 weeks' gestation, who presented for elective Cesarean section during spinal anesthesia, is presented. During closure of the uterus, she became unresponsive and went into asystolic cardiac arrest.

Electromagnetic interference in a cardiac pacemaker during cauterization with the coagulating, not cutting mode.

Electromagnetic interference in pacemakers has almost always been reported in association with the cutting mode of monopolar electrocautery and rarely in association with the coagulation mode. We report a case of electrocautery-induced electromagnetic interference with a DDDR pacemaker (dual-chamber paced, dual-chamber sensed, dual response to sensing, and rate modulated) in the coagulating and not cutting mode during a spine procedure. We also discuss the factors affecting intraoperative electromagnetic interference.

Assessment of competence in anesthesiology.

Purpose Of Review: This review is designed to evaluate various aspects of the teaching, demonstration and assessment of competence in anesthesiology.

Recent Findings: The approach to evaluation of competence has evolved from global impressions to an understanding of the elements of performance that determine competence. This assessment of performance to measure competence has been applied to cognitive performance, technical skills, and behavior.

Assessment of competency in anesthesiology.

Assessment of competency in traditional graduate medical education has been based on observation of clinical care and classroom teaching. In anesthesiology, this has been relatively easy because of the high volume of care provided by residents under the direct observation of faculty in the operating room. With the movement to create accountability for graduate medical education, there is pressure to move toward assessment of competency.

Microdiscectomy: spinal anesthesia offers optimal results in general patient population.

Spinal anesthesia provides a safe and highly satisfactory alternative to general anesthesia in patients undergoing limited lumbar surgery. Nevertheless, it is not commonly used for spinal surgery, and in some centers it is not even considered as an option for spinal procedures. This study presents the current anesthetic technique for patients undergoing microdiscectomy and compares the peri- and postoperative outcomes in 76 patients drawn from a case-controlled study group.

Change in Cardiopulmonary Arrest Response in an Anesthesiology Residency: A practice-based learning initiative.

Because of increases in the acuity in our patient population, increasing complexity of the care provided and the structure of our residency, we decided to systematically alter our participation in the hospital-wide cardiac arrest system. The need to provide optimum service in an increasingly complex clinical care system was the motivation for change. With substantive input from trainees and practitioners, we created a multi-tier-system of response along with predefined criteria for the anesthesiology response.

Anesthetic management of a patient with stiff person syndrome.

We describe the successful anesthetic management of a patient with stiff-person syndrome (SPS) undergoing a right inguinal hernia repair, using a somatic paravertebral block supplemented with conscious sedation. We also present the implications of general anesthesia in patients with SPS. The use of regional anesthetic techniques in patients with SPS has the advantage of avoiding exposure to muscle relaxants.

Teaching and evaluating professionalism for anesthesiology residents.

The Accreditation Council for Graduate Medical Education Outcome Project requires teaching and evaluation of 6 core competencies, one of which is professionalism. Because of this initiative, anesthesiology residency programs are obliged to teach and evaluate professionalism for anesthesiology residents. We decided to create a system that would allow the teaching and evaluation of professionalism in the specific context of anesthesiology.

Inadvertent dural puncture during attempted thoracic epidural catheter placement complicated by cerebral and spinal subdural hematoma.

Minor complications of inadvertent dural puncture during attempted epidural anesthesia are common, related to the size of the needle and the incidence of postdural puncture headache. Serious complications are much less common. We report a case where inadvertent dural puncture with an 18-gauge epidural needle was associated with the creation of intracranial and spinal subdural hematoma.

Hetastarch allergy and positive latex radioallergosorbent test in a patient suffering cardiovascular decompensation during multiple perioperative periods.

The cause of sudden cardiovascular collapse in the perioperative period can be elusive. Allergy may be overlooked as a cause. When allergy is considered, latex is often suspected.

Epidural analgesia improves early rehabilitation after total knee replacement.

Study Objective: To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement.

Design: Randomized prospective study.

Setting: Tertiary care, academic medical center.

Changing of an anesthesiology clinical base year to create an integrated 48-month curriculum: experience of one program.

To allow for growth in our anesthesiology residency, we assumed control of the clinical base year (postgraduate year 1[PGY-1]) and adjusted the curriculum to accommodate the expanded size. With this opportunity to change the curriculum, we created a clinical base year to prepare PGY-1 for clinical anesthesia training in PGY-2 to PGY-4 using, for this purpose, the best resources of our clinical site. We describe the process and preliminary results of the change.

Comparison of spinal and general anesthesia in lumbar laminectomy surgery: a case-controlled analysis of 400 patients.

Object: Despite a history of safety and efficacy, spinal anesthesia is rarely used in lumbar surgery. Application of regional anesthetics is widely preferred for lower-extremity surgery, but general anesthesia is used almost exclusively in spine surgery, despite evidence that spinal anesthesia is as safe and may offer some advantages.

Methods: In this case-controlled study the authors analyzed outcomes obtained in 400 patients in whom either spinal anesthesia or general anesthesia was induced to perform a lumbar decompression.