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Hindman B.J.,University of Iowa | Palecek J.P.,Iowa Methodist Medical Center | Traynelis V.C.,University of Washington | Tredway T.L.,Rush University Medical Center | Todd M.M.,University of Iowa
Anesthesiology | Year: 2011

Background: The aim of this study was to characterize cervical cord, root, and bony spine claims in the American Society of Anesthesiologists Closed Claims database to formulate hypotheses regarding mechanisms of injury. Methods: All general anesthesia claims (1970-2007) in the Closed Claims database were searched to identify cervical injuries. Three independent teams, each consisting of an anesthesiologist and neurosurgeon, used a standardized review form to extract data from claim summaries and judge probable contributors to injury. Results: Cervical injury claims (n = 48; mean ± SD age 47 ± 15 yr; 73% male) comprised less than 1% of all general anesthesia claims. When compared with other general anesthesia claims (19%), cervical injury claims were more often permanent and disabling (69%; P < 0.001). In addition, cord injuries (n = 37) were more severe than root and/or bony spine injuries (n = 10; P < 0.001), typically resulting in quadriplegia. Although anatomic abnormalities (e.g., cervical stenosis) were often present, cord injuries usually occurred in the absence of traumatic injury (81%) or cervical spine instability (76%). Cord injury occurred with cervical spine (65%) and noncervical spine (35%) procedures. Twenty-four percent of cord injuries were associated with the sitting position. Probable contributors to cord injury included anatomic abnormalities (81%), direct surgical complications (24% [38%, cervical spine procedures]), preprocedural symptomatic cord injury (19%), intraoperative head/neck position (19%), and airway management (11%). Conclusion: Most cervical cord injuries occurred in the absence of traumatic injury, instability, and airway difficulties. Cervical spine procedures and/or sitting procedures appear to predominate. In the absence of instability, cervical spondylosis was the most common factor associated with cord injury.© 2011, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.

Ueda K.,University of Iowa | Puangsuvan S.,University of Iowa | Hove M.A.,University of Iowa | Hove M.A.,Iowa Methodist Medical Center | Bayman E.O.,University of Iowa
British Journal of Anaesthesia | Year: 2013

BackgroundCannulation of the radial artery in infants and small children can be challenging, even for the most experienced providers. Utilizing Doppler to aid in radial artery cannulation has been well described. Recent studies have demonstrated the efficacy of ultrasound (US) image-guided vascular access techniques in the paediatric population. The utility of these two techniques, when used by non-expert personnel, has not been studied.MethodsThis is a randomized prospective study to compare the utility of two different radial arterial cannulation techniques in paediatric patients weighing <12 kg: US-guided technique (US group) vs Doppler-assisted technique (Doppler group) when used by trainees with limited experience. The primary objective was to compare the first-attempt success rate between each group. As a secondary objective, success rate within 10 min was compared.ResultsThe trial was prematurely terminated after 50% of paediatric patients (n=104) were included in the study and 52 of each were randomized to the US or Doppler group. A total of 12 anaesthesia trainees performed radial arterial cannulations. The first-attempt success rate was greater in the US group compared with the Doppler group [17/52 (33%) vs 8/52 (15%), P=0.039, odds ratio (OR): 2.67, confidence interval (CI): 1.03-6.91]. The overall success rate within 10 min was 34/52 (65%) in the US group and 24/52 (46%) in the Doppler group (P=0.048, OR: 2.20, CI: 1.00-4.85).ConclusionsUS-guided radial arterial cannulation in infants and small children provided a greater chance for success at the first attempt compared with the Doppler-assisted technique. © 2012 © The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

Fahler J.,Iowa Methodist Medical Center | Wall G.C.,Iowa Inflammatory Bowel Disease Center | Wall G.C.,Drake University | Leman B.I.,Iowa Inflammatory Bowel Disease Center
Annals of Pharmacotherapy | Year: 2012

OBJECTIVE: To report a case of refractory nausea in a patient with idiopathic gastroparesis successfully treated with aprepitant. CASE SUMMARY: A 41-year-old female with idiopathic gastroparesis demonstrated by a delayed gastric emptying time experienced significant nausea, vomiting, and abdominal pain. This resulted in numerous hospital admissions and regular outpatient intravenous fluid administration. Over a 3-year period the patient had been treated with numerous agents for nausea and vomiting, including metoclopramide 10 mg 3 times daily, ondansetron 8 mg 2 times daily, and promethazine (various doses from 12.5 to 25 mg orally up to 3 times daily). No treatment tried was either tolerated or effective. As a last option before considering gastric pacing the patient was started on aprepitant 40 mg daily. The patient had a dramatic response to aprepitant and reported that her nausea had decreased significantly after 48 hours of starting the medication (2 doses). She was able to tolerate oral feeding and her need for outpatient intravenous hydration abated. Over the course of 2 months while using aprepitant her gastroparesis symptoms continued to improve. She reported no adverse effects attributable to aprepitant. After the first 2 months of aprepitant treatment, the patient was unable to continue the medication due to cost. Although her symptoms did worsen after discontinuation, they did not return to their initial severity. At 4 months after the trial of aprepitant, she continued to have improved symptoms. She claimed not to have daily nausea or vomiting, but still required high-dose promethazine and occasional outpatient intravenous fluids. At that point, she had gained 7.2 kg from the time that she had started aprepitant. DISCUSSION: Aprepitant, a neurokinin-1 receptor antagonist, is approved in the US for nausea and vomiting associated with surgery and cancer chemotherapy. To our knowledge, this is the second reported case of its use in gastroparesis-induced nausea. Our patient reported relief of nausea and vomiting despite existing evidence showing that aprepitant has no significant effect on accelerating gastric emptying. Despite its acquisition cost, our patient avoided hospital admission and the administration of intravenous hydration, suggesting aprepitant may be cost-effective in this case. CONCLUSIONS: Aprepitant may have some utility in treating refractory nausea caused by gastroparesis. This case suggests that the drug's antiemetic effect may be successfully used in areas not approved by the Food and Drug Administration. A controlled trial examining aprepitant in patients with such challenging clinical conditions may be warranted.

Halub M.E.,The Surgical Center | Sidwell R.A.,Iowa Methodist Medical Center | Sidwell R.A.,University of Iowa
Surgical Clinics of North America | Year: 2015

The goal of preoperative cardiac evaluation is to screen for undiagnosed cardiac disease or to find evidence of known conditions that are poorly controlled to allow management that reduces the risk of perioperative cardiac complications. A careful history and physical examination combined with the procedure-specific risk is the cornerstone of this assessment. This article reviews a brief history of prior cardiac risk stratification indexes, explores current practice guidelines by the American College of Cardiology and the American Heart Association Task Force, reviews current methods for preoperative evaluation, discusses revascularization options, and evaluates perioperative medication recommendations. © 2015 Elsevier Inc.

DeVore K.J.,Iowa Methodist Medical Center
Pharmacotherapy | Year: 2010

Solar burn reactivation, a rare and idiosyncratic drug reaction, has been reported with the use of a variety of drugs. This reaction is believed to be the result of exposure to ultraviolet light during the subsiding phase of an acute inflammatory reaction. It affects areas of the body that have been previously sunburned. We describe a 16-year-old girl who was receiving treatment for acute lymphoblastic leukemia and experienced a second-degree solar burn reactivation reaction to methotrexate. The patient had a mild sunburn on her face and shoulders the day she went to the oncology clinic for her interim maintenance chemotherapy with vincristine 1.5 mg/m2/dose and methotrexate 100 mg/m2/dose. Three days later, she returned to the clinic with a 2-day history of fever (≤ 100.2°F), nausea, vomiting, and malaise; the sunburn on her face and shoulders also had become severe, without further sun exposure. Laboratory results revealed elevated blood urea nitrogen and serum creatinine concentrations, and her methotrexate level was elevated at 0.9 mM. The patient was diagnosed with acute renal failure, dehydration, methotrexate toxicity, and second-degree solar burn reactivation reaction. She was admitted to the children's hospital and treated with sodium bicarbonate, acetaminophen with codeine, ondansetron, and silvadene cream. On hospital day 3, the patient's methotrexate level decreased to less than 0.1 mM. The sunburn continued to heal, and after a 14-day hospital stay, complicated by a streptococcal infection, grade 3 mucositis, bacteremia, and mild gastritis and duodenitis, the patient recovered and was discharged. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 6) between the patient's solar burn reactivation and methotrexate. Although methotrexate-induced solar burn reactivation is rare, clinicians should be aware of this potential adverse reaction and consider delaying administration of methotrexate by 5-7 days if a patient reports ultraviolet-related erythema in the past 2-4 days or presents with a notable sunburn.

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