Wael Ali Sakr Esa

Outcomes Research Consortium

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i-10 index

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Daniel I. Sessler

Outcomes Research Consortium

Alparslan Turan

Cleveland Clinic

Kamal Maheshwari

Cleveland Clinic

Ehab Farag

Cleveland Clinic

Loran Mounir Soliman

Cleveland Clinic

Hesham Elsharkawy

MetroHealth Medical Center

Kurt Ruetzler

Outcomes Research Consortium

Guangmei Mao

Cleveland Clinic

Edward J. Mascha

Cleveland Clinic

Rovnat Babazade

John Sealy Hospital

Cooperative Institutions

Cleveland Clinic

128

Outcomes Research Consortium

Case Western Reserve University

American Society of Anesthesiologists

Cleveland Clinic Lerner College of Medicine

Committee on Publication Ethics

Novem (Netherlands)

Universitat de Barcelona

University of California, San Diego

Pain Management Institute

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Tidal Volume and Positive End-expiratory Pressure and Postoperative Hypoxemia during General Anesthesia: A Single-center Multiple Crossover Factorial Cluster Trial

Anesthesiology (2022)

Alparslan Turan Wael Ali Sakr Esa Eva Rivas Jiayi Wang Ömer Bakal

Background Intraoperative mechanical ventilation is a major component of general anesthesia. The extent to which various intraoperative tidal volumes and positive end-expiratory pressures (PEEP) effect on postoperative hypoxia and lung injury remains unclear. We hypothesized that adults having orthopedic surgery, ventilation using different tidal volumes and PEEP levels affect the oxygenation within first hour in the postoperative care unit. Methods We conducted a two-by-two factorial crossover cluster trial at the Cleveland Clinic Main Campus. We enrolled patients having orthopedic surgery with general anesthesia who were assigned to factorial clusters with tidal volumes of 6 or 10 ml/kg of predicted body weight and to PEEP of 5 or 8 cm H2O in 1-week clusters. The primary outcome was the effect of tidal volume or PEEP on time-weighted average peripheral oxygen saturation measured by pulse oximetry divided by the fraction of inspired oxygen (Spo2/Fio2 ratio) during the initial postoperative hour. Results We enrolled 2,860 patients who had general anesthesia for orthopedic surgery from September 2018 through October 2020. The interaction between tidal volume and PEEP was not significant (P = 0.565). The mean ± SD time-weighted average of Spo2/Fio2 ratio was 353 ± 47 and not different in patients assigned to high and low tidal volume (estimated effect, 3.5%; 97.5% CI, –0.4% to 7.3%; P = 0.042), for those assigned to high and low PEEP (estimated effect, –0.2%; 97.5% CI, –4.0% to 3.6%; P = 0.906). We did not find significant difference in ward Spo2/Fio2 ratio, pulmonary complications, and duration of hospitalization among patients assigned to various tidal volumes and PEEP levels. Conclusions Among adults having major orthopedic surgery, postoperative oxygenation is similar, with tidal volumes between 6 and 10 ml/kg and PEEP between 5 and 8 cm H2O. Our results suggest that any combination of tidal volumes between 6 and 10 ml/kg and PEEP between 5 versus 8 ml cm H2O can be used safely for orthopedic surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Positive End-Expiratory Pressure

Crossover study

Single Center

Positive-Pressure Respiration

10.1097/aln.0000000000004342

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Citations (21)

Associations between intraoperative and post-anesthesia care unit hypotension and surgical ward hypotension

Journal of Clinical Anesthesia (2021)

Tetsuya Shimada Barak Cohen Karan Shah Lauretta Mosteller Mauro Bravo

Post-anesthesia care unit

Mean arterial pressure

Mean blood pressure

10.1016/j.jclinane.2021.110495

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Citations (7)

Saline versus Lactated Ringer’s Solution

Anesthesiology (2020)

Kamal Maheshwari Alparslan Turan Natalya Makarova Chao Ma Wael Ali Sakr Esa

Abstract Background Both saline and lactated Ringer’s solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer’s solution than normal saline. Methods The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer’s solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. Results Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer’s solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer’s versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I–III versus 0, occurred in 6.6% of lactated Ringer’s patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. Conclusions In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer’s or saline volume replacement. Clinicians can reasonably use either solution intraoperatively. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Ringer's solution

10.1097/aln.0000000000003130

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Citations (59)

Injectate spread following anterior sub-costal and posterior approaches to the quadratus lumborum block

European Journal of Anaesthesiology (2017)

Hesham Elsharkawy Kariem El‐Boghdadly Sree Kolli Wael Ali Sakr Esa Sean DeGrande

The dermatomal level of analgesia achieved with quadratus lumborum blocks varies according to the location of injection. The most commonly used approaches are either at the postero-lateral aspect or anterior to the quadratus lumborum muscle.To determine whether the site of injection of contrast dye around the quadratus lumborum muscle of cadavers affects the extent and mechanism of dye spread.Observational human cadaver study.Cleveland Clinic cadaveric laboratory.Six fresh human cadavers.The cadavers received either a posterior quadratus lumborum block or an anterior subcostal quadratus lumborum block on each side.Cadavers were dissected to determine the extent of dye spread.The posterior quadratus lumborum block approach revealed consistently deep staining of the iliohypogastric, ilioinguinal, subcostal nerve, T11 to 12 and L1 nerve roots. In addition, staining of the middle thoracolumbar fascia was seen in all specimens but only variable staining of T10 nerve roots. The anterior subcostal quadratus lumborum block approach in all specimens demonstrated predictable deep staining of the iliohypogastric and ilioinguinal nerves, subcostal nerves, T11 to 12 and L1 nerve roots, and in addition traversing the arcuate ligaments to involve T9 to 12 nerve roots with variable staining of higher thoracic nerve roots.Our cadaveric study demonstrates that injection of dye on the posterior aspect of quadratus lumborum muscle led to injectate spread through the lateral and posterior abdominal wall but with limited cranial spread, whereas the anterior approach produced broader coverage of the lower to mid-thoracic region. Clinical translation of these findings to determine the practical significance is warranted.

Cadaveric spasm

10.1097/eja.0000000000000680

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Citations (144)

Ventriculopleural Shunt Surgery in A Patient with Multiple Skeletal and Neurodevelopmental Anomalies: A True Perioperative Challenge

The Open Access Journal of Science and Technology (2015)

Ashish K. Khanna Alaa Abd‐Elsayed Ehab Farag D. John Doyle Wael Ali Sakr Esa

Introduction: Ventriculopleural shunt placement for decompression of hydrocephalous is an uncommon procedure. The usual indications are adhesions, infection, thrombosis or obliteration of the more commonly done ventriculoperitoneal shunt or an anatomical non-availability of the peritoneum. We present a clinical case of a patient with congenital hydrocephalous complicated by multiple skeletal and neurodevelopmental anomalies who presented for thoracoscopic placement of a ventriculopleural shunt. The anesthetic challenges and perioperative management constituted a complex multi-disciplinary challenge. Case presentation: We present a clinical case of a 42 years old woman with congenital hydrocephalous complicated by multiple skeletal and neurodevelopmental anomalies who presented for thoracoscopic placement of a ventriculopleural shunt. Some of the perioperative concerns included initiation and maintenance of one-lung ventilation in a patient with short stature, dysmorphic skeletal features, severe kyphoscoliosis, restrictive underlying lung disease and multiple neurodevelopmental midline defects. Conclusion: Our presentation highlights the special challenges in this patient based on the need for lung collapse in a severely short statured individual with a dysmorphic severely kyphoscoliotic thoracic cavity along with underlying restrictive lung disease and background neurodevelopmental midline defects.

10.11131/2015/101133

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Preliminary experience with epidural and perineural catheter localization with pulsed wave Doppler ultrasonography

Minerva Anestesiologica (2018)

Hesham Elsharkawy Theresa Barnes Rovnat Babazade Maria Huarte Wael Ali Sakr Esa

Various methods for peripheral nerve and epidural catheter location assessment exist, with varying degrees of ease of use, utility, and accuracy. Pulsed wave Doppler (PWD) evaluates the presence of fluid flow and is possible modality to assess the location of a percutaneously inserted perineural catheter.A retrospective chart review was conducted in which PWD ultrasonography was used to confirm the position of nerve catheters for regional anesthesia. Data was collected to assess 24-hour postoperative pain scores, opioid consumption, complications, and the incidence of catheter replacement.Eighty-six patients were included; average age was 58 years and a 27% incidence of chronic pain. These catheters were left in place based on the PWD images. Three catheters failed and a total of 16 catheters were repositioned. In the first 24 hours average pain scores ranges between 3.5 to 5.9 and median postoperative opioid consumption range was 11.3 mg to 60.8 mg. For epidural catheters, PWD changes were more obvious with air injection and there was only one episode of hemodynamic instability.Our preliminary experience with PWD ultrasonography suggests that they may offer the ability to selectively assess flow at different locations to identify the proper location of epidural and perineural catheters. Future randomized, controlled investigations are warranted to further evaluate the effectiveness and safety of this modality.

10.23736/s0375-9393.18.12552-1

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Citations (4)

Acute Postoperative Pain Is Associated With Myocardial Injury After Noncardiac Surgery

Anesthesia & Analgesia (2020)

Alparslan Turan Steve Leung Gausan Ratna Bajracharya Rovnat Babazade Theresa Barnes

BACKGROUND: Uncontrolled pain after noncardiac surgery activates the sympathetic nervous system, which causes tachycardia, hypertension, and increased cardiac contractility—all of which may increase myocardial oxygen demand. We therefore determined whether time-weighted average pain scores over the initial 72 postoperative hours are associated with myocardial injury after noncardiac surgery (MINS). METHODS: We conducted a retrospective cohort analysis of adults with routine postoperative troponin monitoring after noncardiac surgery under general, regional, or combined anesthesia at tertiary level centers in Cleveland from January 2012 to December 2015. Time-weighted average pain scores were calculated from all the available pain scores, typically at 4-hour intervals, until a troponin elevation was detected. MINS was defined as peak troponin T concentrations exceeding 0.03 ng/mL within 72 hours after surgery. We used a generalized linear mixed model to assess the association between pain and MINS with 3 hospitals as clusters, adjusting for potential confounders. RESULTS: Among 2892 eligible patients, 4.5% had myocardial injury within 72 hours after surgery. Higher time-weighted average pain scores were associated with increased hazard of myocardial injury. The estimated hazard ratio for a 1-unit increase in pain score was 1.12 (95% confidence interval [CI], 1.02–1.22; P = .013), adjusting for confounding variables. CONCLUSIONS: Among patients undergoing noncardiac surgery, time-weighted average pain scores within 72 hours after surgery were significantly associated with myocardial injury.

10.1213/ane.0000000000005033

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Citations (38)

Importance of vigilant monitoring after continuous nerve block: lessons from a case report.

PubMed (2013)

Gopakumar Nair Loran Mounir Soliman Kamal Maheshwari Wael Ali Sakr Esa

Continuous peripheral nerve block achieves good pain control. However, uncontrolled pain despite an effective block in the target areas of the nerve can be an early sign of ischemia. We report a case of iatrogenic injury to the axillary artery during shoulder surgery in a patient who had continuous supraclavicular block and demonstrate how vigilant monitoring helped the diagnosis and resulted in timely management of upper limb ischemia.A 58-year-old female underwent total revision surgery of her right shoulder under continuous supraclavicular block. Postoperatively, she complained of pain along the medial side of her forearm despite clinical evidence of nerve block. Continuous neurovascular monitoring and timely angiography confirmed axillary artery injury, and subsequent vascular repair saved the patient's limb.Iatrogenic injuries to vessels or nerves sometimes occur during orthopedic surgical procedures. Regional anesthesia can mask and delay the onset of these symptoms. Postoperative monitoring and the ability to differentiate between the effects of local anesthetics and the body's response to ischemia are important for avoiding postoperative complications. This case report aims to improve awareness about the need for vigilant monitoring of the distal pulses after peripheral nerve blocks.

Neurovascular bundle

Axillary artery

Hand surgery

Nerve Injury

Source

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Citations (4)

Cervical erector spinae plane block catheter for shoulder disarticulation surgery

Canadian Journal of Anesthesia/Journal canadien d anesthésie (2019)

Hassan Hamadnalla Hesham Elsharkawy Tetsuya Shimada Kamal Maheshwari Wael Ali Sakr Esa

Disarticulation

Erector spinae muscles