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Optimizing Surgical Conditions with the Use of a Modified Spontaneous Respiration, Intravenous Anesthesia and High-Flow Nasal Oxygen for Pediatric Laser Laryngeal Surgery

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Open Journal of Anesthesiology 2023年第11期13卷 234-240页

作者： Dennis E. Feierman Daniel Escobar Kim T. Lam mark kronenfeld Jacob Sutton Evan P. Salant Maimonides Medical Center Department of Anesthesiology Brooklyn NY USA Northwell Staten Island University Hospital New York USA

The use of SponTaneous Respiration using IntraVEnous anesthesia and High-flow nasal oxygen (STRIVE-Hi) in laryngeal surgery has become more widely reported. This method eliminates the endotracheal tube as a fuel for a potential fire. However, little has been published on its use in the pediatric population. Our case report describes its use in a 2-year-old undergoing micro-direct laryngoscopy with CO2 assisted supraglottoplasty and rigid bronchoscopy for airway obstruction from congenital laryngomalacia. The STRIVE-Hi technique was modified for the pediatric patient by using a lower flow through the nasal cannula (4 L). No major changes in SpO2 were detected during the 30-minute procedure. With back up airway safety equipment in place, STRIVE is proving to be a safe technique with major advantages when used in this unique scenario.

关键词： STRIVE Pediatric Direct Laryngoscopy Laryngomalacia

Improved Hemodynamics with the Use of Prophylactic Infusion of Epinephrine and/or Norepinephrine during Transcatheter Aortic Valve Replacement (TAVR)

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Open Journal of Anesthesiology 2015年第6期5卷 130-134页

作者： Walter Bethune Steven Konstadt Giuseppe Trunfio Lynn Belliveau mark kronenfeld Charles Keilin Dennis E. Feierman Department of Anesthesiology Maimonides Medical Center Brooklyn USA

Background: Transcatheter Aortic Valve Replacement (TAVR) is a new minimally-invasive surgical procedure in which a bioprosthetic aortic valve is placed via a small skin incision in the groin, over either the left or right iliac artery. TAVR was recently approved by the FDA as a treatment option for aortic stenosis in patients who may be too frail to undergo open heart surgery. Anesthetic management of TAVR is complicated by the fact that rapid left ventricular pacing (to at least 180 beats per minute) is required at multiple points throughout the procedure. Aim: This rapid pacing creates a profound pathophysiologic stress on the heart, sometimes leading to severe left ventricular dysfunction and resultant complete hemodynamic collapse. We report that the use of prophylactic infusion of epinephrine and/or norepinephrine in patients undergoing TAVR results in improved recovery from rapid pacing as reflected by intraoperative trends in systolic systemic blood pressure and systolic pulmonary arterial pressure. Cases: Here we report three cases. During the first of these, we reacted to intraoperative hemodynamic changes by administering boluses of vasoactive medications as needed. During the other two cases, we preemptively infused vasopressors to facilitate a more rapid recovery from some of the hemodynamic disturbance associated with either TAVR or rapid pacing. Conclusion: The two patients in this series who were managed with a preemptive strategy had higher ratios of systemic systolic blood pressure to pulmonary arterial systolic blood pressure at the end of the case than did the patient who was managed reactively. This suggests that the preemptive strategy may lead to decreased left ventricular impairment and improved overall cardiac function after TAVR.

关键词： Anaesthetics Intravenous Propofol Analgesics Opioids Alfentanil Sedation

Chart Review of PACU Outcomes for Patients Who Had Ambulatory Shoulder Surgery with Peripheral Nerve Block (PNB) and General Anesthesia Compared to General Anesthesia (GA)

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Open Journal of Anesthesiology 2015年第7期5卷 173-176页

作者： Dennis E. Feierman Eliezer Klinkowitz Charles Keilin mark kronenfeld David Rahmani Darlene Saberito Piyush Gupta Department of Anesthesiology Maimonides Medical Center Brooklyn NY USA

Introduction: Today, regional anesthetics are frequently used in combination with general anesthesia. The purpose of two different techniques is to attain distinct goals. We believed that the use of PNB with the minimization of GA in the ambulatory setting would result in a decreased opioid requirement and subsequently fewer treatment-related side effects, more awake and pain free patients and shorter PACU stays and earlier discharges when compared with general anesthesia alone. Methods: Prior to the start of this retrospective chart review, IRB approval was obtained. Patient’s charts were selected based on the following criteria: The control group had a general anesthetic (GA) and did not have a PNB, and the experimental group (PNB/GA) had a PNB and a general anesthetic. Our primary endpoints were PACU length of stay, pain scores, use of opioids and uses of anti-emetics. Results: We found that patient with blocks used less analgesic in the PACU, 3.97 mg vs. 1.39 mg (morphine equivalents). They also appeared to use less antiemetic drugs: 14/19 (patient s without PNB) vs. 7/18. Additionally, the patients that received a block had a statistically shorter PACU stay 107 min vs. 163 min. Conclusion: Patients that did not receive PNB had a significantly longer PACU stay. Additionally the data suggest that the use of PNB’s reduces the use of post-op narcotics, which may be related to the lower use of postoperative antiemetic drugs observed.

关键词： Ambulatory Nerve Block PACU Length of Stay

Randomized Trial of the Use of Dexmedetomidine vs. Propofol after Regional Blockade in Shoulder Surgery Patients in Beach Chair Position

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Open Journal of Anesthesiology 2015年第8期5卷 187-191页

作者： Piyush Gupta Ofer Wellisch mark kronenfeld Jack Choueka Kenneth D. Eichenbaum Murali Pagala Peter Homel Dennis E. Feierman Department of Anesthesiology Maimonides Medical Center Brooklyn NY USA Department of Surgery Maimonides Medical Center Brooklyn NY USA Department of Biostatistics Maimonides Medical Center Brooklyn NY USA

Background: Propofol is often the drug of choice for ambulatory orthopedic cases. However, propofol can be associated with apnea or other events requiring airway interventions. Dexmedetomidine (Dex) has the unique pharmacologic profile of providing sedation without respiratory depression. This is particularly relevant in patients with morbid obesity and/or challenging airways. The hypotheses were: 1) Propofol would cause more apnea or require more airway manipulations than dexmedetomidine;2) Propofol would have shorter post anesthesia unit recovery times;and 3) Dexmedetomidine would be associated with more bradycardia and hypotension. Methods: After IRB approval, 50 patients were randomized to receive either propofol or Dex for Total Intravenous anesthesia (TIVA) after interscalene brachial plexus block was performed preoperatively under ultrasound guidance. The main end points that we measured where: airway interventions, intra-operative bradycardia, hypotension, and PACU length of stay. Results: There were more airway interventions in the propofol group compared to the Dex group. Additionally, the Dex group had significantly longer PACU stays. Conclusion: We would recommend that Dex should be preferentially considered for patients predisposed to airway obstruction;however, the standard use of Dex over Propofol needed to reconsider since the use of Dex as the agent for TIVA was associated with longer PACU stays.

关键词： Dexmedetomidine Propofol Beach Chair Regional Block