Anticoagulation for cardiopulmonary bypass is maintained with heparin. The primary mechanism of action of this drug is the activation of antithrombin III, which prevents thrombin transformation from prothrombin. Thus, it reduces the formation of clot. However, in some cases, despite a standard heparin dose, the intended active coagulation time cannot be obtained which is known as heparin resistance. Heparin resistance occurs in up to 22% of patients undergoing cardiac surgery requiring cardiopulmonary bypass and it is associated with decreased levels of antithrombin. Heparin resistance, although seen rare, can occur in varying severity in clinic. Treatment options for heparin resistance include administration of antithrombin or fresh frozen plasma. In this case presentation, we have reported the strategy for a planned pulmonary artery reconstruction operation under cardiopulmonary pypass in a patient that we could not maintain the adequate ACT levels despite a cumulative dose of 12 mg/kg heparin and 20 ml/kg fresh frosen plasma transfusion.

A 51-year-old man with obstructive jaundice who underwent an endoscopic retrograde cholangiopancreatography (ERCP).

A 6 month old patient with multiple congenital anomalies and adrenal neuroblastoma with hepatic metastasis underwent subclavian port placement under general anesthesia. During routine placement of the device into the vessel the patient developed acute hypotension progressing to bradycardic arrest due to cardiac tamponade. Hemodynamic compromise resolved immediately after pericardiocentesis and placement of a pericardial drain. This rare complication of central access placement should be considered with hemodynamic changes during these procedures.

Pain management in patients who have undergone hip surgery is a difficult and challenging aspect of post operative care. The Fascia Iliaca Compartment Block (FICB), placed either prior to, or after hip surgery, as a means to control post-operative pain, has been well defined in the evidence to be a very successful approach in controlling post-operative pain. The use of this block reduces opioid requirements and incidents of delirium in elderly patients. The evidence compares FICB to alternative approaches such as neuraxial anesthesia and General Anesthesia (GA). Among the benefits for the anesthetist performing the FICB is the relative technical ease of placing the block, and cost the established efficacy. A review of the current evidence regarding the use of FICB demonstrates that the FICB is highly effective in controlling post-operative pain following hip surgeries.

According to the National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center, the overall prevalence of chronic kidney disease is approximately 14 percent in the general population of the United States [1] This prevalence has remained relatively stable since 2004 [1] with approximately 468,000 Americans on dialysis as of 2015. [2] With diabetes and hypertension being the most common primary causes of End-Stage Renal Disease (ESRD), patients undergoing procedures for arteriovenous access tend to present with multiple co morbidities. For this specific patient population, these comorbidities may have specific anesthetic implications. This article focuses on the anesthetic considerations throughout the entire perioperatively period with special emphasis on the role of regional anesthesia.

Background: For patients undergoing spinal fusion, anesthesiologists are required to provide adequate intraoperative anesthesia that is conducive to swift emergence, patient comfort and reproducible participation in the neurological examination. The use of intraoperative low-dose ketamine infusion as part of the anesthetic regimen for spinal fusion surgery has waxed and waned in popularity. We analyzed a study to compare the effectiveness of low-dose ketamine in spinal fusion surgery in patients with idiopathic scoliosis.

Methods: A retrospective study was conducted to analyze 49 patients who underwent spinal fusion using one of the two TIVA protocols: propofol with Remifentanil (Protocol A), and propofol with Remifentanil in addition to low-dose ketamine infusion (Protocol B).

Results: Low-dose ketamine infusion did not improve post-operative pain scores, but patients were less sedated, and more neurologically intact when they arrived in the PACU.

Conclusion: We adapted our practice to include intraoperative infusion of low-dose of ketamine attempting to reduce intraoperative anesthetic requirements and to improve the recovery state. Our results demonstrate the benefit of low-dose intraoperative ketamine in prompt postoperative recovery in pediatric spinal fusion surgery.

Case report: A 54-year old man with no prior medical history fell from a height of about 3 meters. He reported pain to the chest and fractures of both forearms fracture of the first rib with a pneumothorax and a large injury of the IV segment (III grade AAST).

The EKG showed an ST elevation on the anterolateral leads and an ST depression on the inferior leads; echocardiographic evaluation showed an akinetic mid-apical septum and apex and a severe impairment of the left ventricle

The coronarography revealed a dissection of the proximal Left Anterior Descending (LAD) coronary artery and of the Left Main Coronary Artery (LMCA). Two Drug-Eluting Stents (DES) were positioned. The following day echocardiographic examination showed a Left Ventricular Ejection Fraction (LVEF) of 40%.

Discussion: Coronary dissection following blunt chest trauma is a rare but potentially fatal event. The most affected vessel is the LAD coronary artery, probably for the more vulnerable anatomic position. It’s difficult to recognize and there are no guidelines that can help identify patients at risk, but its early diagnosis is essential to minimize the morbidity and mortality of this event. For the treatment every case needs to be discussed considering the associated injuries and their bleeding risk.

Conclusion: The implementation of trauma team protocols, availability of all the members of the trauma team and the possibility to perform all the diagnostic and therapeutic procedures H24 allows a more efficient triage and a reduction of the time that passes between patient arrival and the performance of life-saving procedures.

Bilateral brachial plexus blocks for bilateral upper extremity surgery carry significant risks which may dissuade practitioners from offering them to patients. Here we report a case series of successful and uneventful bilateral brachial plexus blocks performed at our institution and offer a discussion of strategies to guide management. We contend that slight modifications in block technique, local anesthetic administration, and patient selection can make bilateral brachial plexus blocks safe and effective for routine use.

Background: Transfers of care between healthcare providers are a focus of recent patient safety efforts. Anesthesia providers often transfer care in noisy operating rooms where music or other noise is present during the handover. This study aimed to determine if presence of background music during an intraoperative handoff between anesthesia providers affected quality of handoff and subsequent recall.

Methods: Anesthesia providers including staff anesthesiologists, anesthesia residents, Certified Registered Nurse Anesthetists (CRNA), and Certified Anesthesia Assistants (C-AA) were recruited to participate in this prospective randomized comparative trial. Anesthesia providers (N=19) were randomized into one of two study groups: presence or absence of background music during transfer of care. Experimental and control groups received verbal handoff in their respective sound environments. After five minutes the study participants were given a data collection form and asked to recall as much information from the transfer of care as possible.

Results: Nineteen anesthesia providers participated in the investigation. Initial descriptive analysis showed that the total scores for the control group (no music) had a lower average score based on the correct answers (18.89 vs. 24.1 out of 44) but smaller standard deviation (3.9 vs. 5.8) compared to the experimental group (music on) (CI 95%, P=0.037).

Conclusion: The presence of background music playing in a simulated operating room did not impair the ability of the anesthesia providers to recall information from a transfer of care from another anesthesia provider.