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                                              Patient is 38 years old male with history of pancreatic carcinoid for
                                              pancreatectomy. past medical history of NIDDM, hypertension and obesity.
                                              NKDA normal VS and labs. Intraoperative 100 microgram octreotide
                                              infused over 45 minutes. Two hours later heart rate increased to 110 and 4
                                              milligram metoprolol given. 10 minutes later severe hypotension,
                                              bradycardia, decrease end tidal CO2 and saturation noted. TEE showed
                                              biventricular dilation and hypokinesis no PE. resuscitation with epinephrine,
                                              phenyepherine, norepinephrine and octreotide given. Resuscitation
       Anesthesia Management of               measures failed and patient was pronounced dead after 2 hours. post
       Hemodynamic Collapse during            mortem autopsy showed no pulmonary embolism or myocardial infarction.
1      Surgery for Carcinoid Tumor            what happened?

                                             65 y/o male patient with chronic back pain, CAD, HTN and DM, was
                                             scheduled for a spinal cord stimulator placement. Monitored anesthesia
                                             care was delivered with propofol and fentanyl. One gram of vancomycin
                                             was started. Within a few minutes of vancomycin administration, patient
                                             appeared flushed, coinciding with severe bradycardia and hypotension but
                                             not desaturation. Vancomycin and propofol were stopped. Ephedrine,
                                             atropine, phenylephrine and epinephrine were given without success.
                                             Breath sound appeared normal. After 10 units of vasopressin,
       Successful Vasopressin Treatment of hemodynamic stabilized. Procedure was cancelled. Serum tryptase
       Intraoperative Vancomycin             revealed abnormally high(22.2 mcg/L, normal 1.9-13.5). He was
2      Anaphylaxis                           discharged two days later without complication.
                                             55 year old female for parathyroidectomy secondary to primary
                                             hyperparathyroidism. Medical history of depression, on Wellbutrin and
                                             Celexa. Methylene blue given to aid in identifying parathyroid tissue. In the
                                             PACU, restless and agitated with continuous movement of her extremities
                                             and abnormal eye movements. Hypertensive and tachycardic. ABG
                                             revealed mild hypoxia. The patient had loss of vision. She was transported
                                             to the ICU. Neurology diagnosed Serotonin Syndrome. Her anti-
                                             depressants had interacted with Methylene Blue, causing a dangerous
       Disorientation in the PACU: Serotonin increase in serotonin, an unusual and rarely documented reaction. She
       Syndrome after Methylene Blue         required supportive care until symptoms resolved. Thankfully, she
3      Injection                             recovered fully.

                                                                      Page 1

                                           A 70 year-old man, status-post two extensive resections and
                                           myocutaneous flaps for carcinoma of the base of the toungue, presented
                                           for surgery for second recurrence of cancer. Awake fiberoptic intubation
                                           was planned, and glycopyrrolate was the only premedication. After
                                           initializing topicalization of the oropharynx with 4% lidocaine, he complained
                                           of inability to breathe. Use of accessory muscles was evident, followed by
                                           suprasternal retractions and then complete airway obstruction. Mask
                                           ventilation was marginally effective. Emergency tracheostomy was
                                           performed. Studies have shown that significantly decreased inspiratory and
    Total Airway Obstruction Following     expiratory flows, or [quot]dynamic flow obstruction[quot], occur with just
4   Administration of Topical Anesthesia   topical anesthesia to the upper airway.

                                       A 56 year old patient with hypertension, coronary artery disease and
                                       bladder cancer with difficult airway was scheduled for total cystectomy and
                                       ileal conduit under general anesthesia. He has proximal muscle weakness
                                       for last six years and confined to a wheel chair. Muscle biopsy is consistent
                                       with centrinuclear myopathy a rare muscle disorder and creatinine
                                       phophokinase levels were high.Malignant Hyperthermia triggering agents
                                       were avoided and total intravenous anesthesia consisted of sulphite free
                                       propofol , remifentanil and rocuronium infusions.Patient was ventilated
    Management of a Rare Mitochondrial electively overnight in intensive care unit and extubated next day.Avoiding
    Disease for Total Cystectomy Using succinylcholine and overall successful management was challenging in this
5   Total Intravenous Anesthesia       patient.

                                      A 77-year old morbidly obese woman with an eight year history of thyroid
                                      goiter presented with orthopnea and postural dyspnea. Computed
                                      tomography showed a 15 x 7 x 5 cm mass causing near complete
                                      obstruction of the superior vena cava, tracheal deviation to the left, and
                                      less than 40% tracheal compression. Examination revealed a large neck
                                      mass, decreased mouth opening, and Mallampati class IV airway. An
    Thyroid Goiter with Intrathoracic awake fiberoptic intubation in the semi-Fowler's position was performed
    Extension, Tracheal Compression,  with dexmedetomidine, preserving spontaneous ventilation. Anesthesia
    and SVC Syndrome: How Would You was induced, and there was no hemodynamic or airway compromise with
6   Induce This Patient?              initiation of positive pressure ventilation and muscle relaxation.

                                                                   Page 2

                                            55 year old woman with history of squamous cell carcinoma of tongue,
                                            failure to thrive presented for PEG tube placement. Examination revealed
                                            large exophytic friable tongue mass and matted mass occupying right side
                                            of the neck. She had denied surgical resection and tracheostomy.
                                            Anesthetic technique required awake fiberoptic nasal intubation. Following
                                            extubation, she developed dynamic airflow obstruction, desaturation,
    Emergency Airway Rescue in Upper        bradycardia and asystole. Rescue airway was obtained with LMA.
    Airway Obstruction Due to Large         Subsequently fiberoptic assited tracheal intubation via LMA and an Aintree
    Supraglottic Mass Using Laryngeal       intubating catheter performed with smooth rail-roading of tracheal tube.
    Mask Airway Classic and an Aintree      Reporting non-conventional use of the same in emergency cannot ventilate
7   Catheter                                and cannot intubate situation.

                                            A 43 yo man presented for resection of a subglottic mass with the surgeon
                                            requesting jet ventilation. The patient's history included heavy smoking and
                                            challenging intubations. Anesthesia was induced with propofol and
                                            remifentanil. Once ventilation was assured, direct laryngoscopy was
                                            attempted with a Miller 2 blade showing a Cormach-Lehane grade 4 view.
                                            The Medtronic Hunsaker Mon-jet Ventilation tube's design makes
                                            placement with a fiberoptic bronchoscope impossible; however the jet-
                                            ventilating wand was inserted using the Glidescope (a video laryngoscope),
    When Fiberoptic's Can't Be Used…        giving full view of the vocal cords. This device can assist with difficult
8   Now What?                               airways, especially when specialty endotracheal tubes are necessary.

                                          Case of a 28 y/o male patient who was brought to OR for repair of tibio-
                                          fibular fracture. Upon examination, patient was found with Mallampati
                                          Grade 4, thyromental distance of around 3 cm, and limited mouth opening.
                                          Upon history patient referred of having Rothmund-Thomson Syndrome,
                                          which is an extremely rare inherited disorder that appears in infancy, and
                                          that only approximately 250 cases have been reported in English-speaking
                                          medical literature. Controversy in this specific case was whether offering
                                          regional anesthesia to this patient with anticipated difficult intubation could
    Anesthetic Considerations in Patients be first option or proceed with awake fiberoptic intubation to prevent any
9   with Rothmund-Thomson Syndrome catastrophic outcome.

                                                                    Page 3

                                         Hypoxemia associated with methylmethacrylate application continues to
                                         challenge anesthesiologists. In some cases, it becomes refractory to the
                                         usual treatment modalities.The following case demonstrates the use of
                                         inhaled nitric oxide(NO)in reversing refractory hypoxemia during hip
                                         replacement. A patient developed hypoxemia(following femoral cement
                                         insertion) that could not be reversed by FiO2 1.0, recruitment, and PEEP (5-
     Inhaled Nitric Oxide Reverses       10 cm H2O). Continuous inhaled NO (20 ppm) was administered; O2 sat
     Refractory Hypoxemia Associated     increased to 100%(from 87%),and PaO2 to 448 mmHg(from 57) after 1 hr.
     with Methylmethacrylate Placement   NO reverses pulmonary vasoconstriction associated with embolization.
10   during Hip Arthroplasty             Postoperative course was uneventful.
                                         A 72 y.o. male with hepatic cirrhosis presented for liver transplant. After
                                         induction and using ultrasound guidance, the right jugular vein was
                                         punctured with 18Ga. introducer needle. With blood flow and color
                                         suggestive of venous, 9Fr and 12Fr catheters were guided over the wires.
                                         Floatation of PA catheter through 9Fr introducer failed with persistence of
                                         ventricular waveform. Transducing the 12Fr catheter for CVP monitoring
                                         measured 90mmHg! Chest xray revealed 12Fr catheter malposition.
                                         Vascular surgeon consulted, catheter removed and intermitant pressure
     Inadvertant Carotid Artery          applied for 15 minutes. With no hemodynamic instability, minimal neck
     Cannulation Despite Ultrasound      hematoma and carotid patency, surgery proceeded with no adverse
11   Guidance                            outcome.

                                         Sevoflurane has been implicated in prolonging QT-interval that may lead to
                                         polymorphic ventricular tachycardia (PMVT). Our patient was a 30-year-old
                                         male with sickle-cell disease on methadone with preoperative EKG
                                         showing fluctuatuing QTc intervals undergoing internal fixation of tibial
                                         fracture. Anesthetic manangement included midazolam, propofol,
                                         rocuronium with sevoflorane in oxygen/nitrous-oxide. Intraoperatively
                                         patient developed recurrent pulseless PMVT which was successfully
                                         defibrillated twice followed by recurrence in recovery when atrial pacer was
                                         placed. An implanted defibrillator was placed on postoperative- day- 9 due
     Methadone, Long QT and              to persistent prolonged QT. Significant morbidity and mortality can result
12   Intraoperative Torsade de Pointes   due to prolonged QTc if not detected early.

                                                                 Page 4

                                            A 71 y.o. male presents for total shoulder arthroplasty under general
                                            anesthesia and interscalene block for postoperative pain. Shortly after
                                            medullary reaming, the oxygen saturation fell. Tube position was confirmed
                                            and frothy secretions were noted. After administering furosemide the
                                            patient was transferred to the PACU where he became hypotensive.
                                            Epinephrine and dopamine were administered, but he declined further. A
                                            TEE probe was placed and demonstrated systolic anterior motion with
                                            outflow tract obstruction. Albumin and esmolol were administered and the
     Acute Pulmonary Edema with Multi-      patient improved, however radiography demonstrated ARDS. Patient was
     System Organ Failure during Right      placed on oscillatory ventilation and extubated one day later without long
13   Total Shoulder Arthroplasty            term sequelae.

                                            52 year old man with end stage heart disease secondary to rheumatic heart
                                            ,s/p MI, on an LVAD for bridge to transplant therapy.The patient developed
                                            severe subglottic stenosis after prolonged intubation following LVAD
                                            placement. This poster describes the phsiology of the LVAD, anesthetic
                                            management of subglottic stenosis and the physiology of jet ventilation and
14   Jet Ventilation and the LVAD Patient   its effects on the LVAD .

                                           Patient is an 18 y/o male that sustained a GSW to the Left Cheek. The
                                           bullet struck the Left Mandible, bounced off the body of C3, was aspirated,
                                           and came to rest in the Right mainstem without damaging any lung
                                           parenchyma. Patient was intubated and taken to the OR for extraction of
                                           the bullet via Bronchoscopy. Airway was lost on attempt to extract the
                                           bullet through the ET tube. Bleeding from airway manipulation, edema
     Airway Management for Extraction of from the trauma, and limitation of neck extension from C-spine injury
     Aspirated Bullet Following GSW to the resulted in extremely difficult reintubation conditions. Patient was
15   Face                                  reintubated and subsequently required tracheostomy for bullet removal.

                                                                   Page 5

                                           65 y.o. male with ESRD secondary to DM/HTN underwent uneventful
                                           cadaveric renal transplantation. Patient extubated in OR and transported to
                                           PACU in stable condition. During PACU course, he acutely developed
                                           hypoxia from upper airway obstruction. While performing bag/mask
                                           ventilation, progressive facial edema observed. He was emergently re-
                                           intubated and significant airway edema noted during direct laryngoscopy.
                                           Possible allergic reaction to thymoglobulin suspected. Patient extubated on
     Upper Airway Obstruction and          POD#5 in ICU, however, required emergent re-intubation due to acute
     Hypoxia in Renal Transplant Recipient facial edema and respiratory failure after fluid boluses. CT-venogram
     - Is SVC Syndrome in Your             revealed SVC stenosis likely due to existing dialysis catheter. He eventually
16   Differential Diagnosis?               underwent tracheostomy with successful ventilator weaning.

                                            In 1995, a report was published from our institution demonstrating the
                                            successful management of unsuspected subglottic stenosis by acute
                                            dilatation. This prompted us to use this approach in two patient with
                                            tracheal stenosis encountered recently. In one patient, attempts to dilate
                                            the stenotic segment failed, necessitating tracheostomy below the stenosis.
                                            In the other, dilatation was successful, allowing the placement of a 6 mm ID
     Management of Undiagnosed              endotracheal tube and an uneventful anesthetic. Details of the anesthetic
     Tracheal Stenosis during Intubation    management of these two challenging cases will be presented. In addition,
     by Tracheal Dilation - Report of Two   an algorithm for the management of anticipated and unanticipated tracheal
17   Cases                                  stenosis will be proposed.

                                            We present a case report of a 58 year old man with post-polio syndrome
                                            undergoing excision of a large abdominal leiomyosarcoma complicated by
                                            significant persistent bradycardia and hypotension. Shortly after abdominal
                                            incision the patient became bradycardic, hypotensive, and asystolic.
                                            Atropine and ephedrine were administered with restoration of heart rate
                                            and blood pressure. The patient continued to be bradycardic with
                                            abdominal manipulation throughout the case. The asystolic episode may
                                            have been caused by Bezold-Jarisch reflex secondary to IVC compression
                                            by the tumor in the supine position. Potential autonomic dysregulation may
     Autonomic Instability in Post-Polio    have played a role in persistent hemodynamic instability under surgical
18   Syndrome                               stress.

                                                                    Page 6

                                            A 79-year-old motor vehicle accident victim presented for emergent
                                            exploratory laparotomy and subsequent left-sided thoracotomy. While
                                            cutting the endotracheal tube holder in order to perform an intentional right
                                            bronchial main-stem intubation, inadvertent severing of the inflation tube
                                            occurred. Cuff failure ensued, resulting in loss of ventilation. After inserting
                                            a 22-gauge intravenous catheter into the inflation tube, instilling 5 mls of
                                            air, and clamping the inflation tube with a kelly clamp, the cuff leak
                                            disappeared and positive pressure ventilation ensued. The remainder of
                                            the case proceeded uneventfully with an endotracheal tube exchange
19   Pilot Error: An Endotracheal Cuff Leak happening upon surgical completion.

                                              21year old Vietnamese female with huge tumor of head and neck for
                                              excision. Patient weighed 70 kilos ,the tumor weighed 15 kilos ie., a
                                              schwannoma of lingual nerve. Tumor completely occluded mouth and hung
                                              down to mid-abdomen. Oral surgeons refused awake tracheostomy ; they
                                              requested nasal intubation with awake breathing patient. Dexmetomidine
                                              sedation and airway prepared with vasoconstrictors and local anesthetic
                                              .Pediatric fiberoptic scope using the nostril and after 30minutes of difficult
                                              manipulation trachea was intubated using a 6.5mm ETT . 5mg boluses of
     Massive Schwannoma Impinging on          ketamine supplemented precedex sedation. Airway secured,surgery began
20   Airway                                   with 4 liter EBL WITH 6units of blood replacement.

                                         The patient is a 39-year-old female who presents urgently with dyspnea.
                                         Patient has a history of multiple tracheal dilations for subglottic stenosis of
                                         unknown cause. The surgeon does not want the patient intubated. After
                                         discussion a decision is made to place femoral cannulae under local
                                         anesthesia with the patient in a semi-sitting position and initiation of
                                         cardiopulmonary bypass (CPB) before induction of anesthesia. After the
     Femoral Cardiopulmonary Bypass for start of CPB the patient is anesthetized with a Propofol infusion. The
     Patient Presenting for Resection of subglottic lesion is lyzed with a carbon dioxide laser. Afterward an LMA is
21   Symptomatic Subglottic Stenosis     placed, CPB is discontinued, and the patient is awakened.

                                                                       Page 7

                                            25 year old patient with end-stage metastatic spindle cell sarcoma
                                            develops a pathologic left femur fracture causing severe pain/disability.
                                            She is scheduled for palliative left hip hemi-arthroplasty. BUT she has a
                                            large mediastinal mass! The tumor involves the left pleura along the
                                            mediastinal surface, lung apex and axilla, extending directly through the
                                            chest wall laterally and anteriorly. The rapidly growing mass measures
                                            18x15 axially and 11cm cephalad to caudad. The Heart and trachea are
                                            shifted to the right. Cardiac function is presumably good. Positioning will
                                            be lateral with the aerated lung in the dependent position. How should we
22   Mediastinal Mass - Oh My!              proceed?

                                        A 27 y/o male driver s/p MVA, arrived with a GCS of 8 and cervical collar in
                                        place. The patient presented with altered mental status, which we
                                        suspected was secondary to head injury. Airway management included
                                        rapid sequence induction and cervical inline immobilization. Direct
                                        laryngoscopy revealed a pharyngeal mass near the base of the tongue, and
                                        three attempts at intubation failed. An LMA was then successfully placed
     Approach to Difficult Airway in a  beyond the mass, through which an Aintree catheter mounted on a
     Trauma Patient with an Unsuspected fiberoptic scope was introduced into the trachea. After removing the LMA,
23   Pharyngeal Mass                    an ETT was threaded over the Aintree catheter into the trachea.

                                           Orthotopic liver transplantation (OLT) in patients with severe
                                           portopulmonary hypertension (PPH) has been associated with high
                                           morbidity and mortality. We present the case report of a 40 year old woman
                                           with end stage liver disease secondary to autoimmune hepatitis who
                                           presented for a redo orthotopic liver transplant. Right heart catheterization
                                           revealed severe PPH (81mmg) requiring preoperative chronic epoprostenol
     Redo Orthotopic Liver Transplantation infusion for 12 months. Intraoperatively, pulmonary artery pressure was
     in a Patient with Severe              consistently elevated post-induction (62/35) and after graft perfusion
     Portopulmonary Hypertension Treated (51/23). Patient tolerated the procedure, and had gradual reduction of PPH
     with Preoperative Chronic             postoperatively. Epoprostenol infusion was discontinued 3 months after
24   Intravenenous Epoprostenol            discharge, and sildenafil therapy was started.

                                                                    Page 8

                                           A 50 year old female presented to the ER on POD#5 from a
                                           mediastinscopy, having awoken with respiratory distress. A chest CT scan
                                           revealed a collection with mass-effect on the trachea and great vessels that
                                           necessitated OR exploration. Upon application of standard monitors, a-line
                                           and lower extremity IV, with the patient semi-upright the oropharynx was
                                           topicalized for fiberoptic intubation. Bronchoscopy revealed bulging of the
     Airway Management of an Unusual       posterior trachea. After the ETT was secured distal to the bulge,
     Complication of Cervical              anesthesia was induced. As the incision was explored a rush of fluid
     Mediastinoscopy: Tension Chylo-       consistent with chyle was noted. She was admitted to the ICU for
25   Mediastinum                           observation.

                                           Abnormal capnographs are not unusual in clinical anesthesia. Typically,
                                           they can result from uneven ventilation in patients with pulmonary disease
                                           or loose connections between the end-tidal carbon dioxide sample line and
                                           the gas analyzer. We report the first case of an abnormal triphasic
                                           capnograph tracing with a mid-plateau hump. This was discovered to result
                                           from a longer than normal sample line combined with a cracked water trap.
                                           This case requires knowledge of the basics of capnography and the
                                           implication of various changes to the monitoring system. This unique
     The Dromedary Sign - An Unusual       capnograph tracing demands an integrated understanding of capnography
26   Capnograph Tracing                    and anesthesia machine functions.

                                           This case describes the occurrence of a neck hematoma that extended
                                           into the mediastinum, which is a rare complication of attempted central
                                           venous catheter placement. Attempts at placement included inadvertent
                                           puncture of the carotid artery with an 18 gauge needle while locating the
     Mediastinal Extension of a Neck       internal jugular vein. We discuss the concerns of dealing with the effects of
     Hematoma Leading to Tracheal          the hematoma and anesthetic implications of significant tracheal deviation
     Deviation during Attempted Internal   along with the potential for continued blood loss in our Jehovah's Witness
     Jugular Catheter Placement: Causes    patient. We review probable causes and the basic principles for
27   and Management                        management of this situation.

                                                                   Page 9

                                         68 yo female with a history of COPD presents with a mediastinal mass that
                                         was occluding the right main stem bronchus for which she was scheduled
                                         for a bronchoscopy and possibly a bronchial stent insertion. Other
                                         problems include a posterior fossa mass with midline shift and edema, a
                                         possible subarachnoid hemmorhage, a pancreatic head mass with
                                         inflammation, and uncertain cardiac history and function. This patient was
                                         sedated with propofol for her bronchoscopy. Anesthetic concerns include
     Anesthetic Management of a          her precarious respiratory status, her uncertain cardiac function, her
     Mediastinal Mass Obstructing the    increased intracranial pressure, and her impending brain herniation. The
28   Right Main Stem Bronchus            patient did fine with no adverse outcomes.

                                         A 31-year-old male firefighter without significant past medical history
                                         partaking in a boot camp (intense physical training program), developed
                                         right lower extremity fullness, upper thigh discomfort, and decreased urine
                                         output with [quot]tea-colored[quot] urine. Orthopedic surgery consult
                                         diagnosed compartment syndrome with rhabdomyolysis and recommended
                                         surgical fasciotomy. Following rapid rehydration, a total intravenous
                                         anesthetic with renal protective management and malignant hyperthermia
                                         precautions was employed, resulting in an uneventful intraoperative course.
                                         During recovery, dyspnea was noted and the patient was treated for
     Boot Camp Shock: Perioperative      pulmonary edema. Cognizance of potential complications and vigilance in
     Management of a Fire Fighter with   patient management led to successful perioperative anesthetic
29   Training-Induced Rhabdomyolysis     management of this patient.

                                         We report the management of a patient with history of extensive oral
                                         squamous cell carcinoma requiring placement of a portacath. Anesthetic
                                         plan included monitored anesthesia care with local anesthetics and
                                         judicious use of midazolam and ketamine. Preparations were in place for
                                         possible loss of airway. When this did occur jet ventilation provided a
                                         necessary bridge with a laryngeal mask airway as an excellent conduit for
                                         exhalation, allowing the otorhinolaryngologist to perform an onsite
                                         tracheostomy.The interesting aspect of our case was LMA which was not
     An Unusual Role of Laryngeal Mask   useful for ventilation still served as a patent airway for exhalation with the
30   Airway                              transtracheal jet ventilation.

                                                                 Page 10

                                           ALS offers a unique challenge for the Anesthesiologist and diaphragmatic
                                           pacers have recently become available for individuals with ALS to aide with
                                           their respiratory function. We report on an individual with a diaphragmatic
                                           pacer who underwent a PEG tube placement. During conscious sedation,
                                           the patient's diaphragmatic function was monitored by EMG to prevent
                                           respiratory failure. We then proceeded with intubation because of
                                           impending respiratory failure based upon the lack of diaphragmatic EMG
     Respiratory Failure during PEG Tube activity. Following the PEG tube placement the patient was transported to
     Placement in a Patient with ALS and a the PACU. After return of EMG activity, the patient met extubation criteria
31   Diaphragm Pacer                       and was extubated successfully.

                                             55 year old ASA 2 patient underwent a laparoscopic oesophagectomy.
                                             Anaesthesia was established with a left sided double lumen tube, with air,
                                             o2 & Sevoflurane. After Laparoscopy [amp] during the mediastinal
                                             dissection, Patient started dropping the saturation to 87% & the airway
                                             presssures went up at the same time.The blood pressure dropped needing
                                             boluses of metaraminol.The double lumen tube was checked with the
                                             bronchoscopy. With the decrease in the intrabdominal pressures, all the
                                             parameters corrected itself. The possible explanation was during the
                                             mediastinal dissection CO2 passing through the hiatus causing a
     Tension Pneumothorax during             tamponade effect in the mediastinum preventing adequate deflation of the
32   Laparoscopic Oesophagectomy             lungs.

                                             Anterior cervical osteophytes can contribute to perioperative morbidity and
                                             mortality via dysphagia, aspiration, and airway compromise. Two patients
                                             developing significant perioperative morbidity and mortality due to
                                             undiagnosed anterior cervical osteophytes are presented. The first case
                                             describes obstruction of endotracheal tube passage by anterior osteophyte
                                             complexes in a patient undergoing C5 to C6 anterior discectomy. The
                                             second case presents a patient with recurrent post-operative aspiration
     Anterior Cervical Osteophytes: An       after posterior cervical laminectomy for spinal stenosis. Included is a
     Under-Recognized Cause of               discussion about perioperative manifestations of anterior cervical
33   Perioperative Morbidity and Mortality   osteophytes and their management.

                                                                    Page 11

                                         The cardiovascular effect of acute cocaine toxicity and treatment with
                                         sodium bicarbonate is highly documented in medicine. Yet, there is limited
                                         information in anesthesia literature regarding such treatment in human
                                         subjects. Cocaine toxicity causes cardiac membrane disturbances and
                                         metabolic derangements leading to arrhythmia formation. Sodium
                                         bicarbonate possibly reverses cocaine-induced sodium channel blockade,
                                         arrhythmias and acidosis. Increasing prevalence of cocaine use requires
                                         that all anesthetists be prepared to recognize and treat cocaine-associated
                                         cardiovascular complications. We report this case of a 44 year-old cocaine
     A Case Report: Efficacious Use of   intoxicated male undergoing emergent right tibia surgery that developed
     Sodium Bicarbonate for Treatment of intraopertative arrhythmias and acidosis successfully treated with sodium
34   Acute Cocaine-Induced Arrhythmia    bicarbonate.

                                           37 y old female with spontaneously bleeding A-V malformation of the lower
                                           lip as well as the skin of the face till mid neck is schedule for A-V
                                           malformation removal .Surgeon requested nasal intubation. Difficult
                                           intubation is documented in her records. Awake fibroptic intubation resulted
                                           in minimal spontaneous bleeding, but enough to obscure the view. LMA
                                           was inserted after anesthesia depth is increased. ETT tube 6 passed
                                           through it and LMA removed. Tube exchanger passed through ETT which
     Oral A-V Malformation and Difficult   is withdrawn from the vocal cord to allow a nasal ETT 7 to advance through
35   Intubation                            the vocal cords under glidoscope guidance.

                                           Mr X. was a 73 year old undergoing Carotid Endatrerctomy. After induction
                                           of anesthesia his blood pressure (BP) dropped to a mean (MAP) of 40
                                           mmhg. Despite fluids, phenylephrine and ephedrine boluses his MAP's
                                           remained in the 40's. Oxygenation and ventilation were normal.
                                           Epinephrine was given up to 2 mg then vasopressin 5IU. Final resuscitation
                                           required 10 iu vasopressin and 17mg of epinephrine. Tryptase levels
                                           reached 65ng/ml. Allergy testing revealed an allergy to Atracurium. During
                                           the resuscitation there had been little evidence of a histaminic response
     An Unusual Presentation of            nor mast cell degranulation. There were no respiratory signs or symptoms
36   Refractory Hypotension                at any stage.

                                                                  Page 12

                                            A 35 year old male, with multi-nodular goiter, morbid obesity, severe
                                            pulmonary stenosis was scheduled for a total thyroidectomy to relieve rapid
                                            progression of the airway obstruction. In operating room, as soon as the
                                            preparation of the airway for an awake fiberoptic intubation by topical
                                            lidocain started, the patient became agitated, unresponsive and developed
                                            asystole. CPR was initiated immediately and continued for 45 min. The
     Succesful Resuscitation in a Difficult airway management and ventilation were extremely challenging and were
     Airway Patient with Severe Pulmonary completed by performing an emergency tracheostomy. The patient
37   Stenosis                               recovered successfully without neurological deficits.

                                            A 58 y/o, 59 kg woman underwent 8-hour thoracotomy and resection of
                                            lobar non-small cell cancer extending into the thoracic spine. Management
                                            included one-lung ventilation, remifentanil, isoflurane, and vecuronium.
                                            Intraoperative challenges included hypotension, hypothermia, and profound
                                            sensitivity to vecuronium (only 15 mg needed to maintain surgical
                                            relaxation). By case end, she was normothermic, had 4 twitches, and her
                                            NM block was antagonized with neostigmine (sustained tetanus). She
                                            awakened, yet demonstrated unexplained, persistent, generalized profound
                                            weakness necessitating mechanical ventilation for 16 hours
     Profound Postoperative Weakness:       postoperatively. She had received levofloxacin prior to incision.
     Perioperative Diagnosis of             Management and differential diagnosis, including subclinical paraneoplastic
38   Paraneoplastic Syndrome                syndromes, will be presented.

                                            During Le Fort type I osteotomy, a 26-year-old difficult intubation female
                                            who underwent fiberoptic nasal intubation was accidentally extubated.
                                            Repeat fiberoptic intubation failed due to poor visualization. Intubation was
                                            successful using Fastrach LMA. To convert to nasal intubation, a Cook
                                            catheter (CC) was advanced into oral ETT. The ETT was then removed.
                                            Another ETT was advanced though right nare and pulled through pharynx
     Conversion from Oral to Nasal          into the mouth using McGill forceps. CC was bent to feed back through
     Endotracheal Intubation after          ETT and exit the nare. CC and ETT were pushed back to pharynx. The
39   Intubation with Fastrach LMA           ETT was advanced over CC to intubate patient.

                                                                   Page 13

                                           An 83 year-old female with HIT presented for endovascular AAA stenting
                                           and fem-fem bypass. Argatroban, a direct thrombin inhibitor, was used for
                                           anticoagulation. Data for anticoagulation of HIT patients with argatroban for
                                           PCI is well documented. There are no current recommendations for using
                                           argatroban in HIT patients undergoing open vascular surgeries. We chose
                                           to give 0.1 and 0.5 times the loading and maintenance doses
                                           recommended for percutaneous coronary intervention (350mcg/kg and
                                           40mcg/kg/min, respectively). This provided excessive anticoagulation for
     Anticoagulating the HIT Patient for   the case and suboptimal surgical conditions, with no means to reverse this
40   Vascular Surgery                      anticoagulation in a timely manner.

                                           35 year old Polish non-english speaking female with ameloblastoma of
                                           mandible status post resection and multiple grafting presented with bilateral
                                           temporomandibular joint ankylosis and severely contracted and deformed
                                           mandible with bilateral tissue expanders of cheek for flap reconstruction.
                                           She also had had osteointegrated implants and chin implantation. The
                                           airway management was further complicated by patient's persistent refusal
                                           to undergo awake fiberoptic intubation and tracheostomy even with
     Difficult Airway Management in Non-   potential emergency in addition to difficult mask ventilation. Fiberoptics
     English Speaking Uncooperative        under deep sedation with midazolam and ketamine with preserved
     Patient with Bilateral Cheek          spontaneous respirations revealed marked deformity of pharynx and
41   Expanders                             extreme distortion of larynx which was successfully intubated.

                                           An elderly, ill man, status post skin graft septodermoplasties presented for
                                           debridement of nasal myiasis (maggots). After receiving sevoflurane and
                                           succinylcholine, he was intubated via direct laryngoscopy using a modified
                                           rapid sequence technique. He tolerated the procedure well. Reports
                                           describe topical anesthesia for myiasis debridement, but his comorbidities
                                           dictated the need for general anesthesia. Airway management can be
                                           challenging. Larvae can cause airway sloughing and necrosis, respiratory
                                           distress, and laryngospasm. Furthermore, maggot translocation must be
                                           minimized to avoid pneumocephalus, pneumonia, and meningitis.
                                           Inhalation induction, without positive pressure ventilation, and
     Perioperative Management of Nasal     succinylcholine created ideal modified rapid sequence intubating conditions
42   Myiasis                               via direct laryngoscopy.

                                                                  Page 14

                                         A 31-year-old morbidly obese female with a rare laryngeal synovial
                                         sarcoma presented for microdirect laryngoscopy and carbon dioxide laser
                                         excision with possible tracheostomy. The tumor extended to the
                                         aryepiglottic folds, obscuring the vocal folds and the laryngeal inlet
                                         producing severe airway obstruction with symptoms of hoarseness of
                                         voice, dysphagia, orthopnea, and dyspnea. Attempts at awake fiberoptic
                                         intubation were unsuccessful requiring awake rigid laryngoscopy by the
                                         otolaryngologist for intubation. We outline the management of her airway
     Airway Management in a Patient with and emphasize the need for communication and teamwork in securing a
43   Synovial Sarcoma of the Larynx      difficult airway.

                                          Acute hyperkalemia is a complication associated with certain conditions
                                          and potentially serious implications. It can be a difficult diagnosis to make
                                          acutely, in the setting of an emergency. We present a case of suspected
                                          acute intraoperative hyperkalemia in association with cardiac instability and
                                          the need for emergent medical therapy. The case was associated with
                                          significant blood loss, low cardiac output, elevated initial potassium value,
                                          and rapid transfusion of red blood cells through central line. All of these are
     Suspected Acute Intraoperative       known to contribute to the development of hyperkalemia, and the patient
44   Hyperkalemia                         developed an unstable arrythmia responsive to medical therapy.

                                          Severe ventilatory difficulty caused secondary to herniation of cuff of ETT
                                          (NIM™ EMG) during thyroidectomy (to monitor the recurrent laryngeal
                                          nerve) is reported. Ten mins after intubation we observed increasing peak
                                          airway pressures unresponsive to bronchodilators. FOB revealed cuff
                                          herniation with complete tracheal obstruction( Pictures and video).
                                          Interestingly the inflation of the second ETT cuff again resulted in airway
                                          obstruction. Cuff herniation on two different occasions is intriguing and
     Cuff Herniation with NIM™ EMG        closer evaluation of the cuff reveals a compliant, high volume-low pressure
     Endotracheal Tube during             cuff made of highly stretchable material. Awareness of the possibility of cuff
45   Thyroidectomy                        herniation with these tubes is important.

                                                                  Page 15

                                            Central venous lines (CVL) placed in the operating room at the beginning of
                                            non-emergent cases and intended to be the main access for anesthesia
                                            should be confirmed by x-ray prior to use. We present the case of a 3-
                                            month-old infant undergoing surgery for a bowel obstruction. CVL was
                                            placed following induction and subsequently used for anesthetic
                                            maintenance. The case proceeded with difficulty, as administered
                                            medications did not produce the expected results and progressive difficulty
                                            with ventilation was encountered. Intra-operative chest x-ray revealed a
46   Access Confirmed? Think Twice          large amount of fluid as well as the tip of the CVL in the pleural space.

                                          95 yo female with Hypertension, CHF, DM, vertigo, multiple myeloma and
                                          papillary thyroid Cancer presents for total hip arthroplasty of left
                                          intertrochanteric femur fracture she sustained after fall at home. Uneventful
                                          IV induction. Stable intraoperative course. Shortly after placement of
                                          methylmethacrylate cement, she became profoundly hypotensive
                                          unresponsive to bolus doses of phenylephrine, ephedrine. Placed on 100%
                                          FiO2. Resuscitation with epinephrine. TEE probe was placed, revealing
     Cardiovascular Collapse during Total large hyperechoic mass in the right ventricle, which subsequently
47   Hip Arthroplasty                     disappeared. Blood pressure stabilized, wound closed, recovered in SICU.

                                            This is a 83 year old female who presented for an endoscopic repair of a
                                            Zenker's diverticulum. Her history was significant for two episodes of
                                            aspirations which led to her diagnosis. Other medical history included
     Endoscopic Repair of a Zenker's        Myasthenia Gravis (MG) with a recent myasthenic crisis during which she
     Diverticulum in a Patient with         required ventilatory assistance. She also had moderate aortic and mitral
     Myasthenia Gravis and Combined         stenosis along with longstanding DM and hypothyroidism. She was also
48   Moderate Aortic and Mitral Stenosis    being treated for DVT/PE and recently needed plasmapheresis for her MG.

                                                                   Page 16

                                           68 y/o female with ESRD secondary to DM (not on dialysis), HTN, and h/o
                                           DVT 8 years prior to OR for kidney transplantation. Start of case
                                           uneventful. Unexpectedly, acute onset of bradycardia which deteriorated to
                                           PEA. ACLS protocol implemented. Vitals quickly stabilized. Transplant
                                           aborted. Follow-up studies were positive for PE. Queries: (1) Are renal
                                           transplants elective or emergent? and (2) Would your decision to abort be
                                           different if: (a) the patient was much younger and healthier? (b) the patient
     Acute PE during Renal                 was already on dialysis? and (c) there were no other recipients available
49   Transplantation - Proceed or Abort?   and the viable kidneys would be discarded?

                                           The patient presented to a referring institution with signs and symptoms
                                           suggestive of acute appendicitis. He was brought to the operating room,
                                           and following intravenous induction multiple attempts were made to secure
                                           the airway. A surgical cricothyroidotomy was performed. He was purposely
                                           cooled to 33C for neurologic protection and transported to Maine Medical
                                           Center. Upon arrival, the patient was sedated and paralyzed. An
                                           endotracheal tube had been placed through the cricothyroid membrane and
     Emergent Revision of Surgical         was sutured to his chin. Clinical concerns included coagulopathy secondary
     Cricothyroidotomy in a Hypothermic    to hypothermia, suspected upper airway trauma and unknown anatomy,
50   Pediatric Patient                     and the question regarding tracheostomy vs. conventional intubation.

                                          A 26-year old G2P1 at 16 weeks gestation presents for total thyroidectomy
                                          and modified neck dissection. Preoperative evaluation was significant for
                                          documented malignant hyperthermia episode in the father of the fetus.
                                          Furthermore, the father had a muscle biopsy positive for malignant
                                          hyperthermia susceptibility. Maternal history and physical were otherwise
     26-Year Old Female at 16 Weeks       unremarkable. Pertinent issues include documentation of fetal heart tones
     Gestation with Malignant             prior to and following the surgical procedure, removal of triggering
     Hyperthermia Susceptible Fetus       anesthetic agents from the operating room, and avoidance of muscle
     Presents for Total Thyroidectomy and relaxants at surgeon's request. Additionally, we counseled the patient with
51   Modified Neck Dissection             respect to the risk of a malignant hyperthermic episode in the fetus.

                                                                  Page 17

                                           A 56 year-old male with obesity, quadriplegia, severely limited head
                                           extension and infected sacral decubitus ulcer presented for prone
                                           debridement of his ulcer. His previous intubations had been accomplished
                                           with use of a glidescope. This technique was attempted, but was
     Management of an Expected Difficult unsuccessful, as were several other techniques, during which the patient
     Airway in an Obese Quadriplegic Male was unable to be ventialted. Eventually the airway was secured with
     with Limited Neck Extension for Short fiberoptic bronchoscopy through an LMA into which an endotracheal tube
     Prone Position Procedure and          was passed. At the conclusion of the case, the patient was unable to be
     Subsequent Inability To Extubate      weaned from mechanical ventilation and was taken to the PACU intubated
52   Patient Once Surgery Completed        and mechanically ventilated.
                                           19 year old Asian female was a delayed ICU transfer from outside hospital
                                           for management of Stevens-Johnson syndrome and toxic epidermal
                                           necrolysis secondary to ampicillin. The anesthesiology resident was
                                           approached by the ICU fellow to assess need for intubation. On exam the
                                           patient was tachypneic and hypoxic, and had [gt]30% BSA skin sloughing
                                           including face and neck. Airway exam was complicated by copious blood
                                           and secretions from mouth, diffuse mucocutaneous lesions, and 2cm
     Airway Management in Patients with interincisor distance secondary to mouth pain. Airway management to be
53   Toxic Epidermal Necrolysis            discussed.

                                           A middle-aged female presented for liver resection. A general anesthetic
                                           was provided with central venous access and a right radial arterial line.
                                           During the case, a period of hypotension was evaluated by
                                           transesophageal echocardiography. During insertion of the TEE probe the
                                           arterial line tracing flattened as did the pulse oximetry tracing. Right carotid
                                           and left radial pulses were present. An occlusion of an aberrant right
     Aberrant Right Subclavian Artery      subclavian artery by the probe was suspected. The arterial tracing returned
     Occlusion after Insertion of          following removal of the probe. No postoperative complications were
     Transesophageal Echocardiography      observed. Diagnosis was confirmed by chest CT. The findings of this case
54   Probe in Asymptomatic Adult           will be discussed.

                                                                   Page 18

                                            Wegener's granulomatosis (WG) is a vasculitis that affects numerous
                                            organs including the lungs, kidneys, nose, sinuses and ears. Subglottic
                                            stenosis is an infrequent life-threatening manifestation of WG. The
                                            narrowing in the upper airway at the cricoid cartilage and/or upper tracheal
                                            rings presents an airway management dilemma. Treatment consists of
                                            dilatation, steroid/mitomycin application and/or laser ablation. We present a
     Airway Management in a Pregnant        case of a parturient with symptomatic subglottic stenosis secondary to WG.
     Woman with Subglottic Stenosis         The complexity of this case is amplified by the physiologic and anatomic
     Secondary to Wegener's                 changes that occur during pregnancy, increasing the risk for complications
55   Granulomatosis                         such as pulmonary aspiration, hypoxemia, and airway difficulty.

                                            A 68y male, scheduled for hip replacement, had hypertension,
                                            hyperlipidemia, and coronary artery disease. He had 2 coronary artery
                                            stents placed 14 months previously. Surgeon instructed patient to stop
                                            clopidogrel( 75 mg daily) and aspirin (325 mg daily) 1 week preoperatively.
                                            Challenge: should antiplatelets be discontinued? One day before surgery,
                                            the patient developed chest pain and ST elevation. Coronary angiography
                                            revealed thrombosis in proximal circumflex artery; LAD was patent. Ballon
     Stent Thrombosis (Paclitaxel-Eluting   angioplasty restored vessel patency. Message: discontuation of antiplatelet
     Stent) Following Preoperative          therapy carries a high risk of stent stenosis. Recommendation: continue
     Discontinuation of Dual Antiplatelet   antiplatelet therapy or give enoxaparin (1mg/kg every 12h for 1 week and
56   Therapy                                stop 1 day before operation) as a replacement.

                                            Elderly Patient presented to VA Hospital, found to have gangrenous great
                                            toe, scheduled for amputation. PMH of hypertension, DM, and PVD, on
                                            ACE-inhibitor for 7 years. Uneventful ga and recovery in pacu. Floor calls 1
                                            hr later for evaluation of [quot]swollen tongue[quot]. On arrival-pt cyanotic,
     Emergent Airway Management of          marked airway edema, apneic-unable to provide bag-mask ventilation or
     Perioperative Angioedema of the        perform direct laryngoscopy-LMA #$ placed, able to ventilate-pt to OR with
     Airway Using a Laryngeal Mask          surgeons, intubated via fiberoptic visualization through LMA successfully.
57   Airway                                 LMA may have a place in emergent management of airway edema.

                                                                    Page 19

                                          A 25 year old healthy female presented to the ENT service for
                                          management of expanding hypopharyngeal hematoma 1 day after tumor
                                          biopsy. Symptoms included odynophagia, dysphagia, globus, inability to
                                          clear bloody secretions, and chest pain without stridor or intercostal
                                          retractions. Nasal flexible fiberoptic exam by ENT revealed a submucosal
                                          hematoma of the left piriform sinus with almost complete obliteration of the
                                          tracheal inlet and inability to advance beyond the mass. Fiberoptic
     Dexmedetomidine for Awake            intubation was facilitated in the OR with midazolam and a
     Fiberoptic Intubation in             dexmedetomidine infusion. The patient was sedated, cooperative,
     Hypopharyngeal Cavernous             amnestic, and spontaneously ventilating throughout the procedure without
58   Hemangioma and Hematoma              loss of airway tone.
                                          A-78-year-old patient with a tracheostomy after total layngectomy
                                          presented with a tongue cleaner stuck inside the trachea through his
                                          tracheal stoma. In an attempt to remove foreign body by flexible
                                          bronchoscope under local anaesthesia, there was uncontrolled bleeding
                                          from the tracheal stoma. The patient became restless and started
                                          desaturating. The airway was managed by introducing a flexometallic tube
                                          in the tracheal stoma and gradually progressing till bleeding was stopped.
     Management of an Unusual Tracheal Thoracotomy was done to extract the foreign body and ventilation was
     Stoma Cleaner as Tracheal Foreign maintained through the flexometallic tube. Epidural catheter was placed for
     Body in a Laryngectomized Patient: A post operative analgesia. Patient was nursed in ICU and recovered
59   Case Report                          uneventfully.

                                           Cardiovascular complications are the leading cause of nongraft related
                                           death in orthotopic liver transplant. We present a case of acute
                                           intraoperative left ventricular failure immediately following reperfusion in a
                                           patient with unrecognized ischemic heart disease. Sestamibi stress test
                                           with a subdiagnostic chronotropic response due to betablocker therapy,
                                           recent chemotherapy for his HCC and cirrhotic cardiomyopathy failed to
                                           uncover underlying ischemia. All the common causes of reperfusion
                                           syndrome like hyperkalemia, acidosis, hypocalcemia, hypothermia and
                                           thromboembolism were ruled out. A DSE or cardiac catheterization prior to
     Acute Left Ventricular Dysfunction    the transplant would have uncovered this in the preoperative period and
60   during Orthotopic Liver Transplant    prevented the adverse outcome.

                                                                   Page 20

                                          Laparoscopic procedures are becoming more diverse, performed in less-
                                          healthy populations, and causing more complex physiologic changes. This
                                          case presents an episode of acute CHF with relative upper body volume
                                          overload during a robot-assisted laparoscopic hysterectomy in steep
                                          Trendelenburg position, in a morbidly obese (BMI 48) woman without
                                          cardiac disease. CHF developed despite intraoperative fluid restriction,
                                          manifested by facial petechiae, conjunctival edema, and pulmonary edema
                                          requiring brief post-operative intubation. The suspected mechanism is
     Robotic-Assisted Laparoscopic        increased preload secondary to position and increased afterload due to
     Hysterectomy Complicated by          abdominal insufflation and large body habitus. The presentation will also
61   Intraoperative Pulmonary Edema       discuss other potential mechanisms leading to this complication.
                                          We are discussing a case report illustrating how end-tidal carbon dioxide
                                          (EtCO2) monitoring helped in the detection of two major intraoperative
                                          complications, severe subcutaneous emphysema and vascular injury
                                          causing hypovolemic shock. During a da Vinci robotic assisted
                                          laparoscopic hysterectomy, an 82 year-old female suffered a carbon
                                          dioxide insufflation misadventure causing massive subcutaneous
                                          emphysema from the mid-chest to face and EtCO2 levels to peak at
                                          110mmHg. Additionally, rapidly declining EtCO2 levels were instrumental
     Capnography Guided Double            in the early diagnosis of unrecognized severe bleeding requiring emergent
     Catastrophe Detection during Robotic conversion to an open procedure and vascular surgery intervention to save
62   Surgery                              the patient's life.

                                          Loss of dopaminergic neurons from the substantia nigra characterizes the
                                          classical pathology of PD, but persistent activation of NMDA receptors is
                                          also known to be a major component. During difficult airway management
                                          in a patient with advanced PD, the use of low-dose (20 mg) intravenous
                                          ketamine resulted in complete abolition of severe tremor and dysarthria.
                                          This led to the use of ketamine in a second patient for pre-operative
     The Use of Ketamine as a             sedation and dyskinesia attenuation. Prior research and our experience
     Perioperative Treatment of           would suggest that low-dose ketamine, titrated to effect may provide
63   Parkinsonian Dyskinesia              optimal patient comfort and perioperative control of Parkinsonian tremor.

                                                                 Page 21

                                           This case discusses a 63 year old male patient with a history of severe
                                           ciguatera fish poisoning who presents for elective surgery. At the time of
                                           the poisoning he developed severe gastrointestinal and neurologic
                                           symptoms requiring intensive care management. Presently the patient still
                                           has residual neurologic symptoms, including muscle stiffness/spasms,
                                           reversal of temperature sensation and paresthesia of extremities. An
     Ciguatera Fish Poisoning: A           update on ciguatera poisoning and its acute management will be given.
     Channelopathy and Its Potential       The experience with the management of patients in the chronic state of the
64   Anesthetic Implications               disease is limited. Anesthetic implications will be outlined.

                                            A 63 yo female on chronic warfarin therapy secondary to mechanical mitral
                                            valve replacement, presented with bilateral acute on chronic subdural
                                            hematomas. Upon examination preoperatively, the patient was found
                                            unresponsive, with agonal breathing and oxygen saturation of 78%. The
     Craniotomy Performed for Evacuation patient was emergently intubated, central access was obtained and
     of Bilateral Subdural Hematomas in a bedside TEE was performed before transport to the OR. CVP ranged
     Patient with Severe Pulmonary          between 25-35mmHg and TEE revealed severe tricuspid regurgitation,
     Hypertension, Tricuspid Regurgitation, pulmonary hypertension, and depressed systolic function. Chest x-ray
     Atrial Fibrillation, Congestive Heart  showed pulmonary edema and bilateral pleural effusions. Milrinone infusion
     Failure, and a Mechanical Mitral       was begun and the patient underwent general anesthesia maintained with
65   Valve: A Multidisciplinary Dilemma     isoflurane and a remifentanil infusion.

                                           Lesch-Nyhan Syndrome is an x-linked recessive disease in which patients
                                           phenotypically present with a deficiency of hypoxanthine-guanine
                                           phosphoribosyltransferase (HGPRT), an enzyme responsible for the purine
                                           salvage pathway. Symptoms of Lesch-Nyhan Syndrome include
                                           hyperuricemia, movement disorders (including hypotonia, athetosis,
                                           spasticity, dystonia), mental retardation, and self-mutilating behaviors. A six
                                           year old male with severe dystonia and Lesch-Nyhan disease presented for
                                           deep brain stimultion to relieve his symptoms. Anesthetic challenges
                                           included placement and tolerance of stereotactic headframe, diagnostic
                                           MRI scans and intraoperative management. Deep brain stimulation
     Deep Brain Stimulation in a 6-Year    involves recording the cells of the globus pallidus and is best accomplished
66   Old with Lesch-Nyhan Disease          with minimal anesthetic.

                                                                   Page 22

                                           This case involves a 19 year-old female with tricuspid atresia who
                                           underwent a Blalock-Taussig shunt at 2 months of age and subsequent
                                           Fontan repair with bidirectional Glenn shunt and extracardiac conduit 2
                                           years later. The patient suffered from refractory seizures since the age of
                                           12 due to a perioperative parieto-temporal infarct at the time of Fontan
                                           repair and now presents for right parietal craniotomy and seizure focus
     The Fontan Circulation and Right      resection with the use of electrocorticography for seizure mapping. The
     Parietal Craniotomy for Seizures: The intricate management involving the often contradictory physiologic goals of
     Challenges of Adult Congenital Heart a patient with passive pulmonary blood-flow undergoing seizure focus
67   Disease                               resection with electrocorticography is discussed.

                                            A 36 year old man with traumatic brain injury and minimally conscious state
                                            presented for thalamic deep brain stimulation insertion trial. Patient had a
                                            tracheostomy and a PEG tube. The 4-stage procedure consisted of MRI for
                                            localization under general anesthesia, electrodes insertion under monitored
                                            anesthesia care with intermittent propofol sedation, functional MRI to test
                                            the electrode placement under sedation, and generator implantation under
     Thalamic Deep Brain Stimulation for    general anesthesia. Patient showed improved responsiveness. Long
     Minimally Conscious State Following    procedures and patient co-morbidities constitute anesthetic challenges.
     Traumatic Brain Injury - Anesthetic    Careful choice of medications to avoid interference with the stimulation is
68   Management; Case Report                required. Spare use of drugs with GABA-ergic activity is advisable.

                                            An 8 year old 4'0 56lb male GCS 7 presented for emergency
                                            decompressive craniotomy. BP=70/40 mmHg, HR 120 bpm, SaO2 82%
                                            (FM[gt]10L/m O2). He had a history of [ldquo]heart surgery[rdquo] of
                                            unknown type. He had a diminished right radial pulse and a IV/VI
                                            holosystolic murmur with a thrill and heave. His parents had taken him to
                                            the emergency room with complaints of increasing lethargy. CT scan
     General Anesthesia for Emergency       revealed lesions consistent with cysticercosis. During the course of an
     Craniotomy in a Child with             isoflurane anesthetic conducted with invasive monitoring, continuous
     Intracerebral Cysticercosis and        phenylephrine infusion was used to maintain blood pressure and
69   Cyanotic Congenital Heart Disease      saturation. He was extubated uneventfully the next day.

                                                                   Page 23

                                            We present the perioperative implications and management of a patient
                                            with tropical spastic paraparesis. This chronic, progressive upper motor
                                            neuron disease, caused by myelin and axonal destruction at the level of the
                                            middle and lower thoracic spinal cord, is extremely rare with only 1900
                                            cases reported worldwide. This myelopathy is associated with human T-
                                            lymphotrophic virus type 1 (HTLV-1) infection and is associated with
     Perioperative Considerations in a      inflammatory infiltration by T-lymphocytes. Features of this disease,
     Patient with Tropical Spastic          including spasticity, muscle weakness, and sensory disturbances pose
     Paraparesis Undergoing Lumbar          significant intraoperative and postoperative challenges which will be
70   Laminectomy                            discussed.

                                             A 72 year old female patient with nasopharyngeal tumor came with
                                             bleeding from the right ear and oral cavity. Angiogram showed
                                             ulceration/pseudoaneursym of the right internal carotid artery. Any
                                             hypertensive response during intubation carried risk of worsening of
                                             bleeding with danger of loosing the airway. After premedication, patient was
                                             induced with propofol and rocuronium and intubated with ETT 6.5.
     Anesthetic Management of a Case of Nitroglycerine drip was used during laryngoscopy. Intra-operative course
     Nasopharyngeal Cancer with Internal was complicated by worsening of bleeding . Embolization of the right
     Carotid Artery Erosion for              internal carotid artery was done and she was kept intubated. Later, she had
71   Embolization of Internal Carotid Artery infarct of the right posterior temporal and parietal lobe.

                                             MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and
                                             stroke-like episodes) Syndrome is a multisystem disorder with profound
                                             anesthetic concerns, such as malignant hyerthermia (MH), lactic acidosis,
                                             cardiomyopathy and conduction defects, to mention a few. 49-year-old
                                             male with a confirmed family history of MELAS Syndrome presented for
                                             coiling of a ruptured cerebral aneurysm. MH precautions were taken, lactic
                                             acid and electroytes checked, and external pacing capabilities and
                                             inotropes were made available. General endotracheal anesthesia with Total
     Anesthetic Implications in Patient with Intavenous Anesthesia was successfully administered with no anesthetic
     Family History of MELAS Syndrome complications. By presenting this case we hope to increase awareness
72   for Coiling of Cerebral Aneurysm        regarding the anesthetic concerns of this rare syndrome.

                                                                    Page 24

                                            A 67 yr old morbidly obese male presented with acute traumatic paraplegia
                                            and hypotension and was to undergo urgent decompression of the thoracic
                                            spine. Medical history included ankylosing spondylitis, obstructive sleep
                                            apnea, morbid obesity (BMI 43), hypertension, type 2 DM and chronic
                                            anticoagulation for pulmonary embolism. Physical exam revealed a BP
     Morbidly Obese Patient with Cervical   82/40 mm Hg, HR 70/min, SpO2 86% RA, Mallampati 4 airway, a short
     Spine Ankylosing Spondylitis           neck with no range of motion, large panniculus and poor IV access. His
     Presenting with Acute Spinal Shock     laboratory values indicated an INR of 2.4. A CT scan showed cervical
73   and Complex Airway Management          osteophytes pressing against the spinal cord and a T12/L1 fracture .

                                            A 30 year-old female with intractable chronic regional pain syndrome was
                                            scheduled for trial implantation of a thalamic stimulator under monitor
                                            anesthesia care. The patient showed allodynia in the left lower leg. In the
                                            operating room a bolus dose of 1 mcg/kg of dexmedetomidine was
                                            administered which produced significant analgesia. Followed by a
                                            continuous infusion of 0.6mcg/kg/hr along with a short infusion of 50
     Dexmedetomidine Shows Strong           mcg/kg/min of propofol. Throughout the procedure the patient was pain
     Sedative and Analgesic Effects in a    free. Intraoperative moderate sedation lasted almost for 1 hour after the
     Patient with Chronic Regional Pain     dexmedetomidine cessation. In the postanesthetic recovery unit, she only
74   Syndrome                               required 2 mg of hydromorphone intravenously.

                                           43YO female with hydrocephalus s/p VPS, chronic sinusitis, allergic rhinitis
                                           presented with chronic cough x 1 year for FESS and SMR. The presumed
                                           source of cough was postnasal drip. Eleven months previously, the patient
                                           had undergone removal of a VPS and the operative report stated that the
                                           catheter was fragile and removed almost in its entirety. Upon DL a foreign
                                           object was noted in larynx which appeared to be a VPS. Neurosurgery
     Foreign Object in Airway - A Case of confirmed that the object was a VPS. Bronchoscopy revealed the VPS in a
75   Ventriculo-Peritoneal Shunt Migration bronchus and the object was removed without development of a PTX.

                                                                   Page 25

                                             Mr. BK. is a 60 year old with severe kyphosis secondary to long standing
                                             Ankylosing Spondylitis, also known to have a welder's pneumoconiosis and
                                             a 50-pack year smoking history. He presented with an unstable T1
                                             vertebral body fracture, myelopathic and unable to straighten his neck.
                                             Planed for cervical spine instrumentation in the prone position. A
                                             dexmedetomidine facilitated fiberoptic intubation was necessary given the
                                             patient's refusal of an awake procedure. Other challenges included the
     Anesthetic Challenges in a Patient      impossibility to gain central venous access given the unfavorable anatomy
     with Severe Ankylosing Spondylitis      and the difficulty to ventilate a patient with restrictive and obstructive
76   and an Unstable Neck Fracture           pulmonary disease in the prone position.

                                            A 35 year old female presented with massive epistaxis for emergent
                                            exploration after transspheniodal resection of a pituitary adenoma. Her
                                            blood pressure was 85/60 and her pulse was 110/min. Her medical history
                                            was significant for family history of MH and her prior intubation was difficult
                                            requiring the use of a gum elastic bougie. This patient presented a
     Emergency Intubation after             complicated problem of airway management considering the family history
     Transsphenoidal Pituitary Surgery in a of MH, her previous difficult intubation, her full stomach and aspiration risk
     Patient with Suspected Malignant       and her hemodynamic instability. Nasal intubation was contraindicated. A
77   Hyperthermia                           fully awake fiberoptic guided oral intubation was performed successfully.

                                             We describe use of transesophageal echocardiography (TEE) for
                                             successful anesthetic management in a patient with mitral valve disease
                                             who underwent urgent surgery for ruptured intracranial aneurysm. Little
                                             time for preoperative optimization, use of osmotherapy and hyperventilation
                                             placed this patient at an increased risk for hemodynamic instability. TEE
                                             provided rapid and real time assessment of cardiac preload, ventricular and
                                             valvular function. This information was helpful to diagnose and treat
     Utility of Transesophageal              hypovolemia, guide pharmacological therapy and monitor its response.
     Echocardiography in a Patient with      Moreover, venous air embolism was timely diagnosed on TEE. This report
     Mitral Valve Disease for Clipping of    highlights utility of TEE in such circumstances, particularly in neurosurgery
78   Intracranial Aneurysm                   patients.

                                                                     Page 26

                                            42 y.o. male presented with acute altered vision from a 4.4cm hemorrhagic
                                            pituitary macroadenoma that required emergent resection. RSI was
                                            employed using succinylcholine, and volatile agent was also used for
                                            maintence of anesthesia without complication. POD #2 he developed left
                                            sided weakness related to a developing subdural hematoma with mass
                                            effect. Anesthetic management during the level 1 craniotomy again
                                            included RSI with succinylcholine and use of volatile agent. However,
                                            shortly after induction, patient developed signs of MH which manifested as
     Malignant Hyperthermia during          hyperthermia, severe metabolic acidosis, lactic acidosis, hypercarbia, and
     Emergent Evacuation of Subdural        hemodynamic instability which all resolved after an intraop dose of
79   Hematoma                               dantrolene.

                                          A 36 year old female patient had sustained a first time generalized seizure
                                          of unknown etiology. Imaging studies revealed a rapidly growing right
                                          frontal mass. Urgent craniotomy and tumor resection was planned given
                                          the rapid deterioration of the clinical condition with brain midline shift and
                                          signs of elevated intracranial pressure. Preoperative workup had also
                                          unveiled an 18 week gestation, which the patient was determined to carry
                                          out dispite the risks. Therefore a vast array of serious challenges including
                                          a hemodynamically stable induction, aspiration prophylaxis, brain relaxation
     The Anesthetic Challenges of a Brain techniques, fluid management, brain and uterine perfusion pressures, etc
80   Mass Resection in a Pregnant Patient had to be considered.

                                            46 y/o female, ASA 1 presented with sudden onset of headaches without
                                            neurologic deficits. Was admitted for clipping of a giant aneurysm of the
                                            PICA, Induction was uneventful, maintenance consisted of propofol and
                                            sufentanil infusions. Patient was positioned in lateral decubitus with flexion
                                            of the head. The aneurysm was exposed. The surgeon decided to clip the
                                            aneurysm without interrupting blood flow. Accidental rupture of the
                                            aneurysm occurred with intractable arterial bleeding. A sinus pause was
     Ruptured PICA Aneurysm Clipped         performed using adenosine 12mg IV bolus, producing circulatory arrest for
     after Pharmacologically Induced        30 seconds. The surgeon clipped the aneurysm successfully. Patient
81   Circulatory Arrest!                    emerged from anesthesia without neurologic deficits.

                                                                    Page 27

                                           This is a case report of an awake craniotomy using a balanced anesthesia
                                           technique with propofol, fentanyl and ketamine. Ketamine can help provide
                                           a more stable patient by supporting the respiratory and cardiovascular
                                           system, reducing airway complications, preventing hypercarbia, and has
                                           some neuroprotective properties. Ketamine is a potent analgesic there by
                                           reducing the use of narcotics and hypnotics to prevent over sedation and
                                           apnea. The patient tolerated the surgery very well and did not develop any
                                           anesthesia complications. She was cooperative and coherent for all the
     Case Report of an Awake Craniotomy neurological testing. The patient spent several days in the NICU and was
82   with Ketamine, Propofol, and Fentanyl discharged home.

                                           49 yo male with complex cerebellar vermis tumor was scheduled for
                                           craniotomy with tumor excision in prone position. Induction, intubation,
                                           placement of arterial line, and right internal jugular cordis catheter, and
                                           surgical pinning were uneventful. Minutes after prone positioning, marked
                                           facial discoloration consistent with venous engorgement noted. Patient was
                                           returned supine with resolution of discoloration. Prone positioning was
                                           attempted a second time with similar result. Surgery was cancelled; patient
     Extensive Venous Congestion upon      was awakened without incident and rescheduled as a craniotomy in the
     Prone Positioning Necessitating       sitting position. TEE evaluation in preparation for sitting position craniotomy
83   Cancellation of Elective Craniotomy   revealed a PFO which will be closed prior to surgery.

                                           Endoscopic third ventriculostomy was performed in a 55-year-old man with
                                           an obstructive hydrocephalus due to aqueductal stenosis. Vital sign and
                                           laboratory studies on admission were within normal limit. Anesthesia was
                                           maintained with nitrous oxide in oxygen and 6% desflurane. He received
                                           irrigation with about 2,000 cc normal saline during introduction of the
                                           endoscope and during operation. Anesthesia and operation were
                                           uneventful. He developed postoperative hyperventilation in the recovery
     Acute Respiratory Alkalosis Occurring room, and arterial blood gas analysis showed acute respiratory alkalosis.
     after Endoscopic Third                We report a rare postoperative respiratory alkalosis associated with normal
84   Ventriculostomy                       saline (pH: 6.1) irrigation for endoscopic third ventriculostomy.

                                                                   Page 28

                                            We report the anesthetic management of a 7 year old girl posted for Le
                                            Forte I osteotomy [amp] surgical removal of nasopharyngeal embryonal
                                            rhabdomyosarcoma by transfacial approach. Child was admitted to
                                            neurosurgery ward with 1 month old history of squint, epistaxis,
                                            ophthalmoplegia [amp] proptosis. Submental intubation was planned to
                                            help intra operative dental occlusion and increase operative corridor. Under
     Submental Intubation for Excision of   general anaesthesia submental intubation was performed by rail road
     Nasopharyngeal Embryonal               technique with a guide wire passed through the cricothyroid membrane into
     Rhabdomyosarcoma by Transfacial        oral cavity and then brought out through submental incision. The airway
85   Approach                               and anesthetic management will be discussed.

                                            A 78 year old female has diabetes, severe mitral regurgitation and atrial
                                            fibrillation. She is under evaluation for mitral valve replacement. She was
                                            admitted to the hospital with chest pain and shortness of breath. Diagnosis:
                                            Non-ST elevation myocardial infarction. On hospital day three, she was
     Emergency Interventional Neuro-        found unconscious and bleeding. She had fallen on the floor. She was
     Radiology for Embolic Stroke in a      found to have a new onset L hemiparesis and global aphasia. She was
     Patient with Acute Myocardial          started on IV tPA. Neurosurgery scheduled her for emergency radiology
     Infarction and Congestive Heart        intervention under general anesthesia to remove clot. Neurosurgery asks
86   Failure                                for induced hypertension.

                                            Motor evoked potential (MEPS) monitoring is routinely used for anterior
                                            cervical spinal surgeries. Here I present a case involving a multilevel,
                                            anterior and posterior, repair of the cervical spine. Our TIVA utilized
                                            remifentanil, propofol and dexmedetomidine infusion. Near the end of the
                                            case, MEPS demonstrated pattern consistent with ischemia and after
                                            patient returned supine, wake up test performed which showed 5/5 strength
                                            in all 4 extremities. For discussion, dexmedetomidine infusion has been
                                            showed in isolated instances to depress MEPS; incidence of true ischemia
     Pitfalls of Monitoring Motor Evoked    when suggested by MEPS; efficacy of neuromonitoring (MEPS/SEPS) in
87   Potentials                             detecting cord injury.

                                                                   Page 29

                                           An 83 year old man with a history of coronary artery disease, hypertension,
                                           and diabetes, presented to the operating room as an emergency case for
                                           cervical decompression and posterior spinal fusion of C5-T2 secondary to
                                           progressive neurologic decline. On arrival, the patient was in neurogenic
                                           shock, with significant ST segment depressions on EKG, and had a
                                           troponin leak. His mental status was diminished. The family states that the
     When Treatments Collide: A Case of patient would rather die than live as a quadriplegic. In addition to illustrating
     Progressive Neurologic Decline in the the complexity of treating neurogenic shock in the face of a cardiac event,
88   Face of Cardiac Compromise            this case poses an ethical dilemma.
                                           To the best of our knowledge, we are reporting the first case of Diabetes
                                           Insipidus (DI) occuring shortly after the induction of general anesthesia
                                           (GA) but prior to surgical incision. The patient was a 17 year old male who
                                           presented to the hospital with a history of intermittent left sided weakness
                                           and was diagnosed with a right temporal lobe tumor. Anesthesia was
                                           induced and endotracheal intubation performed during which the patient
                                           was hemodynamically stable. Shortly after induction, the patient developed
                                           polyuria and laboratory tests were consistent with DI. The patient was
     Diabetes Insipidus Triggered by       treated with an incremental vasopressin drip and an emergent
89   Induction of General Anesthesia       ventriculostomy.

                                           Young male presents for Superselective Intraarterial Embolization of AVM
                                           oral-maxillofacial region.Wisdom Teeth removal initially was complicated by
                                           continued bleeding orally which led to aspiration pneumonia.DDX must
                                           include OslerWeberRendu and HereditaryHemorrhagicTelangiectasia HHT
                                           1 and HHT2.AVM is inherited rare congenital disorder 88%
                                           asymptomatic,its sponge-capillary bed represents as flexible soda
                                           straws.AVM angiograms resemble Spaghetti Noodles,a collection of
     Asymptomatic Arteriovenous            vessels lacking capillaries resulting in fragile prone bleeding NIDUS.
     Malfomation of Oral and Maxillofacial Patient underwent SIAE under GETA with 2L EBL FROM ORAL CAVITY.
     Region Presenting after Wisdom        ENT PACKED ORAL CAVITY.PT-PTT drawn,FFP and PRBC given. On
     Teeth Extraction in a 20 Year Old     POD 2 , Subsequent Maxillectomy DONE 6L EBL REPLACED.SIAE and
90   Male Presents for SIAE                Surgery were required here for 100% Cure Outcome.

                                                                    Page 30

                                         After posterior thoracic spinal fusion with neurologic monitoring including
                                         SSEP and Transcranial Motor Evoked Potentials (TCMEP), a patient was
                                         noted to have a swollen tongue, a full thickness laceration, and the tongue
                                         positioned between the teeth. During TCMEP, direct motor stimulus from
                                         electrodes results in strong masseter muscle contraction causing the teeth
                                         to clench, bite down, and possibly result in tongue damage if the tongue is
                                         not protected. Since muscle relaxants are not used, the tongue can move
     Full Thickness Tongue Laceration as intraoperatively, especially with the patient in the prone position. Such a
     a Result of Transcranial Motor      laceration and swelling can potentially result in airway bleeding and
91   Evoked Potential Monitoring         obstruction.

                                           A 48 year-old woman presents for cerebral angiogram and embolization in
                                           neuroradiology. History includes oxygen dependence, COPD,
                                           nasopharyngeal cancer requiring extensive chemotherapy/radiation, and
                                           CVA 8-months ago with residual right-sided weakness. She required an
                                           emergent tracheostomy secondary to difficult intubation. Her history also
                                           includes crack cocaine and marijuana use. She is cachectic and anxious.
                                           VS are: BP 87/63, P 83, R 20, and saturation 94% on 3L O2 by nasal
                                           cannula. She is 50 kg, 68 inches, and has a one finger-breadth mouth
                                           opening. Neck extension is severely limited secondary to radiation. She
     Elective Cerebral Embolization and    has dysphonia, dysphagia, and bilateral rhonchi. She refuses elective
92   the Difficult Airway                  tracheostomy.

                                          54 year old male presented for the removal of Hemovac fragment in the
                                          lumbar fusion wound. The patient has history of morbid obesity (BMI [gt]
                                          55) and unstable c-spine, which required awake fiberoptic intubation for the
                                          prior procedure. The patient suffered bilateral leg weakness and
                                          incontinence due to lumbar stenosis. Lengthy discussion regarding the
                                          anesthetic management ensued since the patient refused and threaten to
     Management of Morbidly Obese         signout AMA if sedated FOI were attempted again. The neurosurgeons
     Patient with Unstable Cervical Spine couldn't perform local anesthesia due to the patient's body habitus and
     for the Removal of Lumbar Hemovac extent of the incision. Isobaric thoracic spinal(Bupivacaine 12.5mg) after
93   Fragment                             locating the epidural space was performed.

                                                                  Page 31

                                          We report a T2-L4 spinal instrumentation and fusion under propofol,
                                          remifentanil and dexmedetomidine in which there was a temporal
                                          association between the use of Dexmedetomidine and loss of Transcranial
                                          Electric Motor Potentials. When the amplitude of TcMEP was lost,
                                          equipment failure, direct injury of the spinal cord, decreased perfusion, and
                                          excessive doses of TIVA agents were considered as part of the differential
     Spinal Surgery and Loss of Evoked    and were ruled out. Therefore, this case suggests that DEX may alter
     Motor Potentials. Is Dexmedetomidine TcMEP and eliminate it all together, despite exiting literature supporting the
94   the Culprit?                         fact that DEX does not alter TcMEP and may even improve it.

                                           A seven-year old patient with familial dystonia presented for bilateral deep
                                           brain stimulator (DBS) placement. The patient was extremely anxious with
                                           uncontrolled dystonic movements. After an uneventul procedure and
                                           anesthetic, the patient was discharged home the following day. Shortly after
                                           discharge, the patient suffered an acute dystonic crisis requiring immediate
                                           hospital readmission. She then received a second anesthetic for the
                                           insertion of a tunneled generator needed for activation of the DBS device.
     A Case of Dystonic Crisis Status Post Described is the anesthetic management for DBS in this patient with
     Placement of Deep Brain Stimulators severe dystonia and clinical improvement of this patient's dystonia after
95   in a Patient with Familial Dystonia   activation of the DBS device.

                                         A thirty eight year old healthy male with pilocytic astrocytoma in the right
                                         thalamus extending into the right superior midbrain underwent endoscopic
                                         resection of thalamic tumor and placement of external ventricular drain.
                                         During emergence from GA patient exhibited paradoxical respiration and
                                         hyperventilation, but was extubated after he followed commands. He was
                                         reintubated because of hypertension and extreme uncontrollable
                                         hyperventilation with minute ventilation of [gt]30 liters. His blood lactate
                                         levels increased from 2.1 mmol to 7.0 within 30 min with normal blood pH.
     Thalamic Storm Following Endoscopic Pt was transferred to Intensive Care Unit and treated with Propranolol.
96   Brain Surgery                       Diagnosis and management of thalamic storm will be discussed.

                                                                   Page 32

                                          63 year-old male, with Parkinson's disease, scheduled for DBS surgery
                                          under sedation with dexmedetomidine and propofol on spontaneous
                                          ventilation. After induction, VS were stable. Following positioning-
                                          placement of bilateral burr-holes patient began to cough. Simultaneously,
                                          decrease in ETCO2 (from 35-17mmHg) and SBP (from 100-82mmHg) and
                                          a slight increase in HR rate (from 47-55bpm) were noticed. VAE was
                                          suspected. Knees were elevated and head of bed was lowered. Surgeon
     Dexmedetomidine Masking the          irrigated field, waxed edges of the burr hole and plugged with fibrin glue.
     Tachycardic Effect of Venous Air     Meanwhile, propofol was discontinued, phenylephrine was given and fluid
     Embolismin in Patients Undergoing    was administered. Patient was stabilized and procedure continued without
97   Deep Brain Stimulation Surgery       further complications.

                                          A 4 y.o. boy was admitted with a posterior fossa epidural hematoma
                                          (TPFEH) two days after falling. He had hypertension, bradycardia, and a
                                          GCS of 14 (E3,V5,M6) upon admission. He was markedly sleepy. A
                                          suboccipital craniectomy was scheduled the next morning. Surgery
                                          proceeded uneventfully, and he was extubated immediately postoperatively
                                          after meeting standard criteria. He developed cardiovascular instability and
                                          an irregular respiratory pattern 25 minutes later. He was reintubated but
     Traumatic Posterior Fossa Epidural   extubated that evening and discharged to home the next day. Discuss the
     Hematoma in Children: Not Just a     pathophysiology, medical management, and extubation criteria in a
98   Bump on the Head                     preschooler with TPFEH in light of current literature.

                                          77 year old male for Right Internal Carotid Artery Aneurysm stent .
                                          HISTORY includes hypertension,TIA .Meds Aspirin,Clopidrogel. Hematocrit
                                          of 47.5 and ACT 337.Physical exam bruised forearms; abdomen soft
                                          nondistended.Anesthesia Management -general endotracheal iv induction ;
                                          parameters requested MAP 90-100mmHg. Neosynephrine infusion
                                          20micrograms/minute for 3hours.Total 6000units heparin given .Patient
                                          stable as 3HOUR PROCEDURE COMPLETED. UPON emergence sudden
                                          drop arterial blood pressure SBP 150 to 60mmHg, NOTED HR 60
                                          increased to 120 pupils dilated abdomen markedly distended.Immediate
                                          ACLS CPRbegun. CT scan revealed extensive right psoas muscle
     Retroperitoneal Hematoma in          intraperitoneal hemoperitoneum hematoma; final hct 36%. Autopsy big
99   Neuroradiology                       pelvic hematoma 22cmx8cm .

                                                                 Page 33

                                              Left Bundle Branch Block (LBBB) is considered equivalent of acute
                                              myocardial ischemia with negative prognostic value in patients with
                                              cardiovascular disease. Our patient was an 83 year-old-female undergoing
                                              lumbar spine surgery with no history of cardiovascular disease.
                                              Immediately after turning prone she developed severe hypotension and
                                              LBBB. This improved with phenylephrine drip but LBBB reappeared with
                                              hypotension and resolved after turning supine. Electrocardiogram
                                              postoperatively showed inferior wall ischemia with no change in cardiac
                                              enzymes. Prone patients are more likely to develop myocardial ischemia
      Effect of Prone Position on Cardiac     even in absence of cardiovascular disease because of decreased venous
100   Function during Spine Surgery           return and cardiac output causing myocardial ischemia.
                                              63 years old female with severe cervical myelopathy extended from C3 to
                                              C7 resulted in bilateral upper and lower motor weakness along with
                                              sensory impairment. Patient refuses awaked intubation despite explanation
                                              of possible adverse effects with using laryngoscope. Under sevoflurane
                                              inhalation induction with in line stabilization, we utilize somatosensory
      Laryngoscope Intubation under           evoked potential (SSPE) guided to perform the intubation. The result was
      Somatosensory Evoked Potential          successful and uneventful. Up to our knowledge no literature evidence of
101   Guide in Severe Cervical Myelopathy such approach done before.
                                              71yo woman, for elective CAS. PMH: Severe emphysema, TIA, HTN and
                                              PVD. CT angiography showed severe stenosis in right PICA (71%) and a
                                              mild stenosis on left internal carotid artery (21%). At the preoperative visit,
                                              the patient refused intubation for the procedure. On the day of surgery,
                                              dexmedetomidine 1mcg/kg was given over 30 minutes and then titrated to
                                              achieve adequate sedation; during procedure patient was cooperative and
      Dexmedetomidine as a Sole Sedative following commands, vitals were stable, RR between 11-19 bpm and SO2
      Agent during Percutaneous Carotid       96-99% on NC 4L/min. Ten minutes before skin closure dexmedetomidine
      Artery Stenting (CAS) in a Patient with was held and then patient transferred to PACU with an uneventfull
102   Severe Chronic Obstructive Disease recovery.

                                                                       Page 34

                                            41 y/o female presented for first general anesthetic exhibiting significant
                                            fear of prolonged postoperative ventilation. Extensive peripheral weakness
                                            including moderate eyelid ptosis and labored dyspnea were present. A 90%
                                            O2Sat precluded preoperative sedatives. MH risk necessitated removal of
                                            triggering agents from OR. Standard monitors and defibrillator/pacer pads
                                            were applied, normothermic maneuvers were employed, RSI ensued with
                                            subsequent Propofol/Remifentanil TIVA maintenance. As surgery
                                            concluded, IV Ketorolac and rectal Acetaminophen were given without
                                            further supplementation. Extubation occurred in PACU after 20 minutes.
      Symptomatic Myotonic Dystrophy        Given Myotonic Dystrophy's anesthetic implications, this case
      Patient Presents for Lumbar           demonstrates how astute preoperative planning and vigilant intraoperative
103   Microdiskectomy                       management yields optimal postoperative outcomes.

                                            This is the case of a 43 year old asian female with severe lumbosacral
                                            radicular symptoms who presented for L4-S1 laminectomy and
                                            decompression of the intervertebral discs. She was found to have an
                                            isolated factor XI deficiency upon analysis after abnormal coagulation
                                            studies were found preoperatively. She had a an uncomplicated vaginal
                                            delivery some years ago and had no symptoms of a bleeding diathesis.
                                            She was transfused with fresh frozen plasma to keep factor levels at 60%
      A Case of Lumbar Laminectomy          normal and underwent a relatively uncomplicated surgical procedure. The
104   Complicated by Factor XI Deficiency   case and review of pertinent literature are reviewed.

                                            A 66 year old male alcoholic had his last drink and fractured his neck 72
                                            hours earlier. The patient was calm and cooperative as informed consent
                                            was obtained. He expressed concern about his gag reflex when I explained
                                            the awake intubation. He was sedated with 4 mg midazolam. He gagged
                                            vigorously when local anesthesia was applied to the airway. Very little
      Consent and Competence: Unstable      lidocaine was given before he became uncooperative, agitated and
      Neck, Becomes Agitated with Airway    appeared as though he would hurt himself as he thrashed around. His
      Topicalization, States Doesn't Want   head moved substantially despite his hard cervical collar. He then stated he
105   Surgery                               did not want the surgery.

                                                                   Page 35

                                            An obese 49 y/o female Jehovah's Wittness presented for preoperative
                                            evaluation and optimization prior to planned cervical 360° fusion for C4
                                            vertebral body osteomyelitis. Several months earlier, she underwent lower
                                            extremity bypass for peripheral vascular disease. This hospitalization was
                                            complicated by line sepsis. Despite prolonged antibiotic therapy, she
                                            developed neck pain which subsequent imaging revealed to be C4
                                            vertebral body osteomyelitis. She concomittantly had severe aortic
                                            stenosis, aortic valve endocarditis and end stage renal disease.
      Cervical Osteomyelitis, Severe Aortic Preoperatively, she was neurologically intact with her cervical alignment
      Stenosis, End-Stage Renal Failure in maintained in a cervical halo. The medical and ethical decisions involving
106   a Jehovah's Witness                   this case will be discussed.
                                            A day after an uneventful hip surgery, a non english speaking korean lady
                                            has enjoyed her breakfast in the morning and soon after, she was found
                                            unconscious. She had a stroke. Her history was significant for hypertension
                                            and patient had swings of blood pressures which were controlled during
      Facing the Ire of Family, One Day     anesthesia. After uneventful stay in recovery room, she was sent to the
      after Surgery in a Hypertensive       floor. Family was upset and felt that patient didn't receive oxygen during
      Patient. Who Caused It and What       anesthesia. No logical or medical explanation was acceptable. Was it
      Caused It? The Mystery of             anesthesia that caused stroke after unconsciousness? Who is blame?
107   Unconsciousness!                      Where does the answer lie?

                                              The patient seized and presented at an outside hospital. Advanced lung
                                              cancer, severe pulmonary compromise and anticoagulation for newly
                                              diagnosed DVT ensued. Tertiary referral to thoracic surgery without primary
                                              care consultation uncovered left ventricular hypokinesis and a pulmonary
      70-Year-Old Man Presents with           tumor encasing and restricting the right pulmonary artery and upper/middle
      Severe and Poly/Co-Morbid Disease lobe bronchii on CT. Bronchoscopy under MAC caused severe hypoxia and
      for Palliative/Diagnostic Neurosurgical near cardiovascular collapse, without tumor diagnosis yesterday. Elective
      Resection and Limited Preoperative      neurosurgical solitary brain metastasis resection is now scheduled. The
      Preparation: Production Pressure, the patient appears ashen-grey on 5 l/m O2 with O2sat=92% and 22
      Anesthesiologist and Primary-           respirations/min. Production pressure limits additional studies. Respiratory
108   Care/Gatekeeping                        acidosis and lactic academia is identified.

                                                                     Page 36

                                               A 6-week old child presents for elective intubation with a large anterior
                                               cystic fluid collection. Direct laryngoscopy was unsuccessful. It was noted
                                               during this time that the size of the mass was enlarging with continued
                                               manipulation of the airway. A flexible fiberoptic scope was passed through
                                               a LMA and a 3.0 ETT was introduced over the scope into the trachea.
                                               Variable CO2 tracing and breath sounds noted. Direct laryngoscopy by the
      Presence of Supraglottic Mass            surgeon showed the endotracheal tube was in the esophagus despite
      Contributes to Effective Ventilation     ETCO2 tracing and 100% SpO2. The patient's trachea was intubated with
109   Despite Esophageal Intubation            another 3.0 uncuffed endotracheal tube.

                                               Patient simulation has been widely incorporated into the educational
                                               programs of many anesthesiology residencies. This educational technique
                                               has been recognized by the Accreditation Council for Graduate Medical
                                               Education (ACGME) as an effective tool to teach domains of competency.
                                               The ACGME and the American Board of Medical Specialties (ABMS) have
                                               also recognized simulation as an effective method for competency
                                               evaluation. We previously reported the use and benefit of a human
      The Use of Multi-Modality Simulation     simulator-based evaluation of a physician with lapsed clinical competence
      in the Retraining of the Physician for   for remediation. Here we report the novel use of simulation for both
110   Medical Licensure                        [bold]retraining[/bold] and evaluation of a physician for medical licensure.

                                         A 47 year old male underwent a right-sided suboccipital craniotomy for
                                         tumor resection. During the nine hour case, the patient was in the park-
                                         bench position with the left side down. Postoperatively the patient
                                         complained of left thigh pain that quickly progressed in severity with the
                                         development of paresthesia, induration, and circumferential edema. Acute
      Post-Operative Leg Pain after a    compartment syndrome was diagnosed and the patient was taken to the
      Suboccipital Craniotomy: A Case of operating room emergently for fasciotomies to the thigh. An extensive
      Compartment Syndrome of the Thigh literature search reveals this case may be the first reported compartment
      Resulting from the Park Bench      syndrome of the thigh resulting from the intra-operative park-bench
111   Position                           position.

                                                                      Page 37

                                            A 60 year old woman with massive left hepatic lobar hydatid cyst was
                                            scheduled for laparascopic excision.Pre-operatively she had
                                            anemia,elevated jugular venous pressure and in the supine position
                                            demonstrated significant hypotension and bradycardia with desaturation
                                            within three minutes. Aortocaval compression was suspected and
      Anesthetic Care during Laparascopic confirmed when her vital signs improved in the lateral position. This was
      Excision of a Massive Hydatid Cyst of followed by uneventful laparascopic excision of the cyst in the supine
      the Liver with Aorto-Caval            position. This challenging case provides numerous points for discussion for
112   Compression                           patients with a large hepatic mass.
                                            The anesthetic management of morbidly obese patients undergoing
                                            thoracotomy with one lung ventilation challenges anesthesiologists. There
                                            are no reported cases of lateral thoracotomy with prolonged one lung
                                            ventilation in extremely obese patients. We report a 193 KG 36- year - old
                                            male (BMI 55) with history of large synovial sarcoma mass involving the
                                            paraspinal and rhomboid muscles on the posterior aspect of the left
      Anesthetic Management of Lateral      hemithorax from T2 to T8 levels. We describe the successful anesthetic
      Thoracotomy with Prolonged One        management of a 12 hour procedure in lateral position with prolonged one
      Lung Ventilation in a Morbidly Obese lung ventilation assisted with frequent hand ventilation in an extremely
113   Patient                               obese patient.

                                            A 49 year old man with a massive lipomatous mediastinal mass, severe
                                            cardiomyopathy (EF [lt]20%), and tracheal stenosis was scheduled for
                                            urgent laser bronchoscopy and stent placement. He also had three prior
                                            mitral valve replacements, pulmonary hypertension, atrial fibrillation, an
                                            AICD and was receiving home oxygen. We decided to keep the patient
      A Patient with a Massive Lipomatous   breathing spontaneously as much as possible. We topicalized the airway
      Mediastinal Mass, Severe              with lidocaine followed by an inhalation induction using sevoflurane. An
      Cardiomyopathy, and Tracheal          LMA was then placed and the pulmonary team operated through it using a
      Stenosis for Urgent Laser             laser-equipped bronchoscope. This was followed by use of a rigid
114   Bronchoscopy and Stent Placement      bronchoscope. The patient did well.

                                                                   Page 38

                                              We present a case concerning a 73yo male with a Type B dissection, who
                                              developed an ischemic right leg after an aortic fenestration via femoral
                                              artery approach. In the fluoroscopy suite, hours into an uneventful
                                              anesthetic for an open thrombectomy, the patient was given catheter
                                              directed thrombolysis with Reteplase. Thirty minutes later he became
                                              progressively hypotensive, not responding to volume or pressors, and not
                                              explained by apparent surgical losses. By searching under the drapes we
      Near Fatal Concealed Hemorrhage         found over 2 liters of blood hidden on the fluoroscopy table coming from
      Following Reteplase Therapy during      the contralateral femoral artery. Bleeding was subsequently controlled and
115   Arterial Revascularization              the patient resuscitated.

                                              WL is an 88 y/o male with a past medical history of CAD, HTN, severe
                                              aortic stenosis and aggressive angiosarcoma s/p multiple resections and
                                              reconstruction. The patient presents one year post-op to his ENT office
                                              with a 3-4 day history of right submandibular triangle swelling with airway
                                              compromise. His face and neck are encased in a recurrence of his
                                              unresectable angiosarcoma. He has severe CAD with evidence of
                                              ischemic EKG changes with any increase in heart rate, but due to his
      A Difficult Intubation in a Man with No terminal cancer, no cardiac intervention is planned. His ENT has
116   Face                                    scheduled him for a tracheostomy and PEG tube placement.

                                          The loin pain-hematuria syndrome characterized often by severe and
                                          unrelenting loin or flank pain is poorly defined in the literature. Epidural
                                          blocks have resulted in good, temporary relief, however narcotic
                                          dependence becomes progressive. We present the perioperative
                                          management of a patient who underwent renal autotransplantation and
                                          interposed polytetrafluoroethylene arterial graft with laparoscopic
                                          nephrectomy in an attempt to reduce the risk of heterotopic renervation.
                                          After autotransplantation pain due to the loin pain-hematuria syndrome
      Perioperative Management of Patient ceases immediately. Anesthetic considerations should be directed at
      with Loin Pain Hematuria Syndrome proper fluid management, position change and perioperative pain
117   for Renal Auto-Transplant           management in narcotic dependent patient.

                                                                      Page 39

                                            A 39 year old, otherwise healthy female was admitted for surgical repair of
                                            a Type 2 dens fracture (throught the base of the odontoid process) due to a
                                            metastatic pheochromocytoma. Multiple bony metastases were noted.
                                            Medications: metroprolol and doxazosin. No allergies. BP 150/70 P 140.
      Anesthetic Management of a            History of very difficult airway requiring awake intubation, which the patient
      Metastatic Dens Fracture in a Patient adamantly refused to have done again. Problems: Metastatic, metabolically
      with Malignant Metastatic             active, pheochromocytoma with suboptimal control of vital signs, history
      Pheochromocytoma and a Difficult      and findings of difficult airway in patient who refuses awake intubation,
118   Airway                                unstable neck with cervical collar.

                                             68 year old white female presented to the emergency department (ED) with
                                             hemoptysis and worsening respiratory status after a direct biopsy of a
                                             laryngeal mass. She had a medical history of 100 pack years,
                                             hypertension, COPD, CHF and left vocal cord paralysis. As she developed
                                             more severe respiratory distress, she was placed on BiPAP, with 100%
      Supraglottic Bleeding Mass in an       oxygen while in the ED, maintaining a saturation of 90%. She was
      Elderly Female Saturating 90% with     scheduled for direct laryngoscopy for control of airway bleeding. The
119   BiPAP and 100% Oxygen                  patient and family were opposed to a tracheostomy at this time.

                                           77 year old male with pseudo colonic obstruction presented for diverting
                                           ostomy. His history included COPD, peripheral vascular disease and HTN
                                           .On CT Scan found to have atrophic right lung and abdominal contents in
                                           chest. Pulmonary function test revealed severe restrictive lung disease,
                                           FEV1 of only 0.49. He was at high risk for coronary artery disease. With
                                           thoracic epidural catheter and arterial line placed preoperatively, general
                                           anesthesia was administered and surgery was done successfully .Patient
                                           was stable intraoperatively and admitted to ICU . Patient was extubated on
      Anesthetic Management of an Adult    second post operative day. After 2 weeks he was discharged home with no
120   with Congenital Diaphragmatic Hernia complications.

                                                                     Page 40

                                          The patient is a 36 year old male who presented to the trauma resuscitation
                                          area with a stab wound to zone 1 of the right side of the neck. The patient's
                                          Glasgow Coma Scale score was 15, however, he was in respiratory
                                          distress. The extent of the airway injury was not immediately evident on
                                          initial physical exam. The patient's airway was secured with a rapid-
                                          sequence fiberoptic technique. The technique was performed using rapid-
                                          sequence induction in conjunction with direct laryngoscopy to insert a
      Airway Management of a Patient with bronchoscope in order to evaluate for airway injury below the vocal cords
121   Traumatic Penetrating Airway Injury and ensure proper endotracheal tube placement.

                                          A 34 year old female required an ex utero intrapartum treatment (EXIT)
                                          procedure for a giant fetal neck mass. The case was complicated by
                                          massive obstetric hemorrhage prior to the intubation of the fetal airway.
                                          Fetal cyanosis and bradycardia were observed during ongoing maternal
                                          hemorrhage. A tracheostomy subsequently proved unsuccessful, however
                                          bag mask ventilation improved fetal bradycardia. Placental support was
                                          terminated after 37 minutes due to concern about the adequacy of
      Massive Obstetric Hemorrhage during placental perfusion. Following delivery, a size 2.0 endotracheal tube was
      an EXIT Procedure for Severe Fetal placed using a 2.5 mm rigid bronchoscope. The patient was successfully
122   Airway Obstruction                  extubated on POD#1 and discharged home on POD#5.

                                            38 years old female G4P3 with a previous history of 3 cesarean sections,
                                            diagnosed antenatal with placenta accrete and percreta. She was admitted
                                            to the obstetrical floor for observation. Suddenly she experienced a severe
                                            per vaginal bleeding estimated a liter blood loss. She underwent to the
      Placenta Accreta/Percreta Bleeding    operating room in a hypovolemic shock for an emergency cesarean
      Controlled by Recombinant Factor      hysterectomy. We utilize a recombinant factor VIIa in order to control the
123   VIIa                                  bleeding Intraoperative. The net result was successful.

                                                                   Page 41

                                         Primary Pulmonary Hypertension is a rare and serious disease in the
                                         pregnant woman. Maternal mortality approaches 40%. We submit a case
                                         of a 14 year old G1P0 who presented at 37 weeks in active labor with
                                         previously undiagnosed severe pulmonary hypertension and right heart
                                         failure. History ascertained nonspecific symptoms of dyspnea on exertion,
                                         shortness of breath and fatigue. Physical exam revealed a 4/6 tricuspid
                                         holosystolic murmur, sinus tachycardia. A stat transthoracic
                                         echocardiography reported severe right ventricular hypertrophy, with right
                                         ventricular pressures [gt]120 mm Hg, and severe tricuspid regurgitation.
      Primary Pulmonary Hypertension and Her subsequent labor, delivery and peripartum management are
124   the Laboring Patient               discussed.

                                          A 35-year-old female, G5P0222 at 35 weeks gestation with diagnosis of
                                          complete placenta previa and accreta by ultrasound and MRI, degenerating
                                          uterine fibroids, past history of polysubstance abuse, anemia, severe
                                          oligohydromnios, fetal restricted ductus arteriosus, was scheduled for
                                          elective cesarean hysterectomy. During cesarean, upon opening the
                                          abdomen, unexpectedly a live fetus was found in the abdominal cavity
      Unexpected Live Abdominal           within the gestational sac. Advanced abdominal pregnancy is a rare and life
      Pregnancy during Scheduled          threatening condition, which presents major challenge for the
      Cesarean Hysterectomy for Diagnosis anesthesiologist. We describe the anesthetic management of this
      of Complete Placenta Previa and     previously undiagnosed live advanced abdominal pregnancy with survival
125   Accreta                             of mother and the fetus.

                                            A 31-yr-old ASA2, G3P1A1 presented with an MRI-confirmed, 28-week
                                            extrauterine pregnancy (adjacent to the liver), and developed abdominal
                                            pain/guarding 1 week after admission, resulting in an exploratory
                                            laparotomy. During delivery, 2000 ml of blood/clots were found in the
                                            abdomen. The placenta was attached to the fundus; there was a 10-15%
                                            abruption. Fluid resuscitation for the hysterectomy included 4 units PRBC,
                                            2 units FFP and 3000 ml crystalloid. A re-exploration for hemorrhage was
                                            performed on POD1, requiring transfusion of 5 units PRBC with wound
      Extra Uterine Pregnancy: A Case       packing. The infant did not survive, but the mother was discharged home in
126   Presentation                          good condition.

                                                                  Page 42

                                             We report a case of a cesarean section via GA with remifentanil for a 27 yr.
                                             old primigravid patient at 38 weeks gestation with an acute (Stanford) Type
                                             B aortic dissection. The aneurysm, which originated distal to the subclavian
                                             artery and extended through the iliac bifurcation, was being medically
      Anesthetic Management: Ceserean        managed with a goal SBP 100-120 mmHg. GA with remifentanil was
      Section under GA with Remifentanil     chosen to maintain hemodynamic stability while minimizing fetal side
      for a 27yo Primigravid at 38wks with   effects. Perioperative TEE was also used to monitor for aneurismal
      an Acute (Stanford) Type B Aortic      propagation. Successful outcomes of baby (Umbilical Artery pH 7.24) and
127   Dissection                             mother (discharged POD#6) were seen with this technique.

                                          A 23 year old nulliparous woman presented at 28 weeks gestation with
                                          severe idiopathic pulmonary arterial hypertension ([gt]100mmHg) treated
                                          with Sildenafil. Spontaneous labor occurred at 39 weeks. A pulmonary
                                          artery catheter, arterial line and epidural were placed. Fetal bradycardia
                                          necessitated an urgent cesarean section. General anesthesia was
                                          administered due to worsening dyspnea and concerns about systemic
                                          hypotension with regional anesthesia. Intravenous epoprostenol was
      Management of a Patient with Severe replaced with inhaled nitric oxide to minimize uterine atony. Throughout
      Idiopathic Pulmonary Arterial       surgery PA pressures were 5-10 mmHg higher than her systemic
      Hypertension Undergoing Urgent      pressures. Cardiac output negatively correlated with CVP, falling if CVP [gt]
128   Cesarean Section                    10 mmHg. Postoperative course was uneventful.

                                             34 yo hispanic female @35 weeks with a [underline]complete transposition
                                             of the great vessels , large VSD, severe pulmonary stenosis, and baseline
                                             SpO2 of 85% was scheduled for a cesarean section 12 days after
                                             presenting with chest pain, diaphoresis and SpO2 of 71% due to new onset
                                             SVT. The plan was to proceed with a slow epidural anesthesia, A-line,
                                             CVP, and avoid a PA catheter. An incomplete block was identified before
      Cesarean Section in a Patient with     the start of the surgery. An intrathecal catheter was placed and slowly
      Uncorrected D-Transposition of the     dosed. She underwent an uneventful surgery, transfered to MICU and later
129   Great Arteries                         discharged home 4 days later.

                                                                    Page 43

                                            A 42 year old parturient with hypertension, angina, and a myocardial
                                            infarction at 12 weeks gestation, presented with dyspnea and angina at 35
                                            weeks. Fetal bradycardia prompted a stat cesarean section with general
                                            anesthesia. The patient's blood pressure (BP) worsened (210/110) with
                                            abdominal manipulation and was treated with labetalol. BP acutely dropped
                                            to 81/66 after delivery. Transesophageal echocardiography revealed
                                            worsened left ventricular ejection fraction. Frothy secretions and bibasilar
                                            crackles were noted. The patient required post-operative mechanical
      Undiagnosed Pheochromocytoma          ventilation and vasoactive infusions to manage her BP. Diagnosis of
      during Cesarean Section with Post     pheochromocytoma was made by radiologic and urine analysis, and LV
130   Partum Diagnosis                      function returned to normal.

                                          A 25yo G1P0 with a history of aplastic anemia presented for anesthetic
                                          labor management at 38 weeks. She received 2 units of PRBC and 2 5-
                                          pack of platelets bi-monthly to maintain a H/H of approximately 10/28 and a
                                          platelet count of approximately 20,000. After consultation with Hematology
                                          a goal platelet count of 80,000 and 50,000 was established for epidural
                                          placement and infusion, respectively. On arrival her platelet count was
                                          25,000. After 4 5-packs of platelets, her platelet count was 100,000 and
      Anesthetic Management of a Laboring epidural was placed. Labor was tolerated well. Platelets were 120,000 post-
131   Patient with Aplastic Anemia        partem, and the epidural was removed. No complications occured.

                                         A 21 year old female at 36 weeks gestation with severe pre-eclampsia and
                                         an AICD implanted at age 14 for congenital bidirectional tachycardia
                                         presented initially in labor requesting epidural analgesia. Her platelet count
                                         was 98000. Her AICD was checked 2 days prior to presentation and her
                                         threshold rate for defibrillation was increased to 220 beats per minute by
                                         her cardiologist. Within minutes after establishing epidural analgesia she
      Anesthetic Management of a Patient developed fetal distress needing emergent Cesarean section. The
      with Severe Pre-Eclampsia and AICD surgeons used bipolar cautery and the procedure had no complications.
      Presenting for Emergent Cesarean   We discuss the anesthetic management of a patient with AICD presenting
132   Section                            for emergent Cesrean Section.

                                                                    Page 44

                                          A 32 year old woman G2 P0 at 32 2 7 weeks gestation presented for
                                          simultaneous elective c-section and suboccipital craniotomy. The patient's
                                          history involved 10 days of nausea, vomiting, headache, and weakness.
                                          MRI showed a left cerebellar mass with brainstem compression and
                                          ventricular effacement. The anesthetic plan included a preoperative
                                          arterial line without sedation, foley catheter, right ventriculostomy, left
                                          uterine displacement, BIS monitor, and SCDs. INDUCTION Remifentanil
      Anesthetic Management of a Preterm with self hyperventilation, sodium thiopental, rocuronium, cricoid pressure,
      Parturient with a Cerebellar Mass   GETA. MAINTENANCE: Sevoflurane, remifentanil; propofol infusion
      Undergoing Simultaneous Elective C- following delivery. EMERGENCE: Extubation and transfer to the
133   Section and Suboccipital Craniotomy Neurosurgical ICU. The patient and her baby tolerated the procedure well.

                                             A 23 year old primagravida is admitted in labor. Fetal heart tone monitoring
                                             reveals a nonreassuring pattern. During the pre-anesthetic evaluation, the
      Anesthetic Management of a Term        patient's mother revealed that her brother and uncle both died of high
      Parturient in Labor, Nonreassuring     temperatures during anesthesia. The patient was unaware of this history.
      Fetal Heart Tones, and a Significant   Problems: Strong potential for cesarian section due to fetal distress, strong
      Family History of Malignant            family history of malignant hyperthermia. Management of mother with
134   Hyperthermia                           maternal and fetal considerations.

                                             A 39 year old non-English-speaking Hispanic woman was admitted after
                                             delivering in her car. Her past medical history was significant for diet-
                                             controlled gestational diabetes and 5 prior SVD's, the last complicated by
                                             PPH and transfusion. 15-minutes after her arrival she became
                                             unresponsive with BP 70/40 and HR 65bpm. She was resuscitated with
                                             pressors and oxygen, there was no bleeding. She became intermittently
                                             responsive but began posturing with her hands R[gt]L in extreme flexion.
      Neurologic Changes Following           She withdrew to pain. We faced challenges with the differential diagnosis,
135   Extramural Delivery                    workup and therapeutic choices for this patient.

                                                                    Page 45

                                           We present a case of cerebral venous sinus thrombosis (CVST) in a
                                           parturient who successfully delivered via Cesarean section under spinal
                                           anesthesia. Pregnancy, being a recognized hypercoagulable state, is
                                           known to increase the risk of CVST. The incidence increases
                                           approximately 30-fold during the third trimester of pregnancy and the
                                           immediate postpartum period. Although spinal anesthesia has been
                                           performed without complications there is a risk of decreased cerebral
      Spinal Anesthesia for Cesarean       perfusion or aggravating brain shifts. Utilizing spinal anesthesia in the
      Section in a Patient with Cerebral   parturient with CVST is controversial; however, we decided that the
136   Venous Sinus Thrombosis              benefits of spinal anesthesia would outweigh the risks for our patient.

                                         A morbidly obese (250 kg, BMI 70) 30 yo G5P2 at 32 weeks gestation was
                                         transferred to our facility for treatment of eclampsia and HELLP syndrome
                                         (platelets 74,000). On admission, she was confused and agitated with a BP
                                         of 248/118. On physical exam, she had facial edema and a class IV airway.
                                         Following placement of an arterial line and a right MAC internal jugular
      Fiberoptic Airway Management Using catheter, she was taken for an emergency C/S under GA. An awake
      Dexmedetomidine in a Morbidly      fiberoptic intubation was performed using dexmedetomidine which was
      Obese Patient with Eclampsia and   very helpful in safely securing her airway while maintaining spontaneous
137   HELLP Syndrome                     ventilation and assisting with BP control.

                                           Gravid patients presenting with concurrent neurologic pathology present
                                           unique challenges for anesthetic managment. Our patient was a 37-year-
                                           old woman who presented at 28-weeks gestation with symptomatic
                                           obstructive hydrocephalus due to right-sided parietal meningioma. She was
                                           initially managed with decadron and underwent C-section at 33-weeks
                                           gestation with external ventriculostomy under general anesthesia.
                                           Anesthetic management included careful induction with modified rapid
                                           sequence intubation and maintenance with remifentanil, isoflurane, air and
      Anesthetic Manangement of            oxygen. On postoperative day 3 she underwent craniotomy for tumor
      Meningioma with Obstructive          resection and was subsequently discharged. This multidisciplinary
138   Hydrocephalus in a Gravid Patient    approach to this patient resulted in excellent maternal and fetal outcomes.

                                                                  Page 46

                                          Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke
                                          (MELAS) is a progressive neurodegenerative disorder requiring careful
                                          anesthetic management. Patients may have seizures, diabetes mellitus,
                                          hearing loss, short stature, and exercise intolerance. A 20 y.o. G1P0
                                          presented for elective c-section at term. PMH includes: MELAS syndrome,
                                          IDDM and sickle cell trait. Spinal anesthesia was safely performed using
                                          intrathecal hyperbaric bupivacaine(11.25mg), fentanyl and morpine. C-
                                          section is preferred in MELAS patients in order to avoid lactic acidosis or
      Anesthetic Dangers in Melas         seizures during painful labor. Regional anesthesia may be complicated by
      Syndrome: Management of a Patient   respiratory compromise, while GA may be complicated by prolonged
139   Undergoing Cesarean Section         muscle weakness and susceptibility to triggering agents.

                                          LD is a 40 y/o woman G5P2 at full term, with no PMH, for repeat cesarean
                                          section under epidural anesthesia. Intra-operative and PACU courses were
                                          uneventful. Post-operative pain control with epidural PCA. Eight hours
                                          post-surgery, patient complains of intense rigors and burning sensation in
                                          both legs. Physical exam revealed euthermia, tachypnea and tachycardia
                                          with transient mental status changes. Epidural was discontinued and
                                          patient was admitted to ICU. Workup showed a lactate of 8.5 mmols/L and
      Rigor-Induced Rhabdomyolysis in a   respiratory alkalosis. Pulmonary embolism was ruled out. POD#1 liver
      Post-Cesarean Section Obstetric     transaminase and creatine phosphokinase levels were elevated. Patient
140   Patient                             treated for rhabdomyolysis presumably due to severe rigors.

                                          It is rare to see a parturient with achondroplastic dwarfism. Such patients
                                          can present immense challenges to anesthesia providers. There are no
                                          uniform guidelines addressing the optimal anesthetic management of this
      Management of an Achondroplastic    patient population in the peripartum setting. This case report illustrates our
      Dwarf Undergoing General            successful perioperative management of an achondroplastic dwarf
141   Anesthesia for Cesarean Section     undergoing general anesthesia for cesarean section.

                                                                  Page 47

                                              33 year old, 37 weeks pregnant lady admitted with severe flank pain.
                                              Otherwise healthy apart from gestational diabetes. Ultrasound revealed left
                                              hydronephrosis with renal stone. She failed conservative treatment and
                                              scheduled for ureteral stent placement. Preoperatively Hydromorphone
                                              was used for renal colic. Patient was induced with G.A. Soon after
                                              deccelerations noted in fetal heart rate. The fetal heart rate briefly improved
                                              with medical management but again developed deccelerations.
                                              Obstetrician decided to proceed with emergency cesarean section to
                                              deliver the baby. A floppy male baby was delivered, resuscitated and
      Emergency Cesarean during a Non-        admitted to NICU. Mother was safely extubated and discharged home 3
142   Obstetric Surgery                       days later.

                                             A 23 YO 2nd gravida post CS pregnancy- came for emergent Csection for
                                             active labor. The patient had multiple clipping of the cerebral aneurism,
      Epidural Anesthesia for C Section in a CVA with residual left sided weakness, seizure disorder, prolapsed
      Patient with Previous Cerebral         intervertebral disc at L4-L5 and L5-S1, and spina bifida at the lower sacral
      Aneurism-S/P Multiple Clipping,        level. Epidural catheter inserted at L3-L4 level, loaded with lidocain 2% total
      Hemiparesis, Seizure Disorder,         of 20 ml over a period of 7 minutes. A healthy baby was delivered with an
      Prolapsed Intervertebral Disc and      Apgar of 8/8 without any complication. Catheter removed after 24 hours of
143   Spina Bifida                           PCEA without any sequelae.

                                             A 21-year-old primigravida at 35 weeks of gestation presented for semi-
                                             elective cesarean section. She had a history of rheumatic heart disease,
                                             mitral valve commisurotomy for severe mitral stenosis, aortic valve
                                             autograft, and pulmonary homograft (Ross procedure) at age 14. Her
                                             preoperative echocardiogram showed severe mitral stenosis. Combined
                                             spinal-epidural anesthesia a T4 sensory block without significant
      Anesthestic Management of a            hemodynamic changes. A healthy child was successfully delivered. As
      Parturient with Severe Mitral Stenosis more pediatric prosthetic heart valve recipients survive onto childbearing
      and History of Ross Procedure          age, an understanding of the underlying valvular defects and previous
      Undergoing Primary Cesarean            valvular surgery becomes paramount in choosing the anesthetic technique
144   Section                                in this parturient population.

                                                                      Page 48

                                              Noonan syndrome is a rare congenital disorder characterized by
                                              abnormalities of the facial, cardiovascular, and skeletal systems.
                                              Parturients with Noonan syndrome present potential significant challenges
                                              to anesthesia providers - namely difficult tracheal intubation, limited
      Management of a Parturient with         cardiorespiratory reserves, and technical problems in performing regional
      Noonan Syndrome Undergoing              anesthesia due to short stature and skeletal anomalies. The case reported
      General Anesthesia for Cesarean         illustrates the perioperative management of a parturient with Noonan
145   Section                                 syndrome undergoing general anesthesia for cesarean section.

                                             We would like to present anesthetic management of a high risk pregnancy
                                             due to recurrent myocarditis. Parturient was admitted to hospital due to
                                             severely impaired left ventricle systolic function. Etiology was suspected to
                                             be recurrent viral myocarditis. This patient's pregnancy and delivery was
                                             followed in a multidisciplinary fashion, by both cardiology and
                                             anesthesiology teams besides obstetricians. An elective cesarean section
                                             was scheduled under regional anesthesia which later, needed to be
      High Risk Pregnancy with Reccurrent converted to general anesthesia. Patient remained stable with intermittent
      Myocarditis and Anesthetic             vasopressor support. She was taken to cardiac intensive care unit for 24
146   Considerations for Delivery            hour observation. She was discharged on postpartum 6th day.
                                             A 26-year-old G3P0 parturient at 33 6/7 weeks gestation presented for
                                             urgent cesarean delivery. At age 7, she underwent Fontan surgery for
                                             single ventricle physiology due to hypoplastic right heart. At 26 weeks
                                             gestation, she developed progressive heart failure treated with diuresis,
                                             bedrest, and prophylactic anticoagulation. Given her elevated aPTT at
                                             delivery, we elected to proceed with general anesthesia. An uneventful
                                             rapid sequence induction was performed with etomidate and
      Urgent Cesarean Delivery in a          succinylcholine. Postoperatively, she remained paralyzed and was
      Parturient with Fontan Circulation and transferred to the ICU for mechanical ventilation until adequate muscle
      Undiagnosed Pseudocholinesterase function returned 9 hours later. Her plasma pseudocholinesterase level
147   Deficiency                             was [lt]100 U/L (normal 1800-6600).

                                                                     Page 49

                                           Regional anesthesia which is the anesthetic of choice in an obstetric
                                           patient, needs to be induced cautiously in a patient with HOCM, because of
                                           the potential danger of total left ventricular outflow tract obstruction. A
                                           pregnant patient with severe HOCM with a left ventricular outflow tract
                                           gradient of 60 mm of Hg, had C-section under Combined spinal Epidural
      Anesthetic Management of a           anesthesia. Two large bore intravenous access, arterial line, phenylephrine
      Pregnant Patient with Severe         infusion, prehydration were done prior to induction. Intrathecal bupivacaine
      Hypertrophic Obstructive             2.5 mg with fentanyl 15 mcgs was followed by intermittent epidural
      Cardiomyopathy (HOCM) for C-         administration of 2% lidocaine with epinephrine 1 in 200,0000, without
148   Section                              significant hemodynamic changes.

                                          Pregnant Jehovah's Witness (JW) patients present a unique challenge in
                                          management. Identifying the parturients with this ethical issue during
                                          antepartum visits and a detailed, discussion of the alternative options to
                                          blood transfusion is very critical in the optimum peripartum management. A
                                          35 year old female was scheduled for C-Section, for breech presentation.
                                          Hematocrit was 29. The patient requested the use of the cell saver. Two
                                          large bore intravenous lines were established. Patient received spinal
      Challenges of Management of a       anesthesia.Cell saver equipment was setup in the OR. Various uterotonic
      Pregnant Patient Who Is a Jehovah's agents were available. C-section went uneventful. 200ml of blood was
149   Witness for C-Section               collected in the cell saver.

                                           We describe the management of a parturient at 37 weeks gestational age
                                           who presented with progressively worsening dyspnea and exertional stridor
                                           due to tracheal stenosis. The patient underwent bronchoscopy, suspension
                                           laryngoscopy and laser ablation of a tracheal web. Symptomatic tracheal
                                           stenosis in pregnancy is uncommon. A review of the literature yielded only
      Anesthetic Management of a Term      six published cases. We report our anesthetic approach and highlight
150   Parturient with Tracheal Stenosis    examples of management options based on previously published cases.

                                                                  Page 50

                                              A 25 year old G3P2002 at 30 3 7 weeks gestation presents with
                                              approximately five days of fever, headache and flu like symptoms. On
                                              admission she is found to be thrombocytopenic. She developed
                                              pancytopenia and hepatic failure then disseminated intravascular
                                              coagulation over the next two days. On her third day at our institution the
                                              fetus experienced late decelerations requiring urgent caesarian delivery.
                                              Perioperatively she received recombinate Factor VIII, FFP and platelets.
                                              Intraoperatively she was examined by a liver surgeon and was noted to
151   Acute Hepatic Failure in the Parturient have a necrotic, ischemic liver, several biopsies were taken.

                                              Adams-Oliver Syndrome (AOS) is characterized by defects of the scalp,
                                              digits, and skin. Some individuals may have unrecognized cardiovascular
                                              and other anomalies, which could affect their anesthesia care. A pregnant
                                              woman with AOS was referred to us because of echocardiographic findings
                                              of severe aortic stenosis and ascending aorta dilation. Repeat evaluation
                                              confirmed a structurally abnormal, stenotic aortic valve. Labor induction
                                              began at 37 weeks, with early epidural placement. When fetal bradycardia
      Anesthetic Management of a              prompted Cesarean section, surgical epidural anesthesia was safely
      Parturient with Adams-Oliver            achieved while invasive arterial pressure monitoring guided fluid and
152   Syndrome                                vasopressor administration. Mother and baby did well.

                                            A 27 year-old, G3P2 parturient, 27 weeks EGA, Factor V Leiden-
                                            heterozygote, presented with pulmonary thromboembolism. CT angiogram:
                                            large emboli, left and right main pulmonary arteries, extending into upper
                                            and lower segmental pulmonary arteries. Echocardiogram: right heart
                                            failure, PA systolic pressure 40-45 mmHg, LVEF 55%. Oxygen 100% non-
                                            rebreather, heparin, iNO 10 ppm were initiated. ABG analysis: PaO 2 90
                                            mmHg (pre-iNO) improved to 280 mmHg (post-iNO). IVC Filter placed.
      Inhaled Nitric Oxide for Treatment of Repeat echocardiogram: improved RV function, decreased PAP. Fetal
      Massive Pulmonary                     monitoring remained reassuring. Subcutaneous Enoxaparin initiated. At 37
      Thromboembolism in a Parturient with weeks gestation, labor was induced. Epidural catheter placed uneventfully.
153   Factor V Leiden Deficiency            Coumadin administered prior to discharge.

                                                                      Page 51

                                            A 19 year-old white female was scheduled for elective Cesarean delivery at
                                            37 weeks gestation. She had a history of Marfan's Syndrome, mildly dilated
                                            aortic root, patent foramen ovale, VP shunt in childhood for arachnoid cyst,
                                            kyphoscoliosis s/p T4-L3 rodding and recurrent pneumothorax s/p
                                            pleurodesis. In addition to the physiologic implications of aortic root
                                            dilatation, the association of Marfan's with dural ectasias may hamper
      Cesarean Delivery in a Patient with   spinal anesthesia. Furthermore, her instrumentation left little room for
      Marfan's and Thoracolumbar Spinal     neuraxial anesthesia. Still it remained the patient preference. We faced
154   Fusion                                challenges developing an anesthetic plan.

                                          32 year old female G 5 P 0131 at 31 weeks gestational age with history of
                                          systemic lupus erythematosis, lupus nephritis with end stage renal disease
                                          on hemodialysis, severe hypertension, antiphospholipid syndrome on
                                          lovenox, prolonged QT interval, and recurrent fetal loss presented with
                                          dyspnea, chest pain, nausea, vomiting, and body aches. Blood pressure
      Parturient with Systemic Lupus      was 162/117. Patient was dialyzed with some improvement in symptoms.
      Erythematosis, Lupus Nephritis      Echocardiogram revealed worsening cardiac function as compared to two
      Requiring Hemodialysis,             weeks ago with ejection fraction decreasing from 51% to 35%. Given
      Antiphospholipid Syndrome, Severe   worsening maternal status and nonreassuring fetal status with breech
      Hypertension, and Acutely Worsening presentation, patient had cesarean section with subarachnoid anesthesia
155   Cardiomyopathy for Urgent Delivery  blockade without complication.
                                          23 YO primigravida at 34 week gestation, severe preeclampsia and platelet
                                          count [lt]151,000, received labor epidural. Pt. had acute drop in platelet
                                          count to [lt]40,000 within 12 hrs, other parameter
                                          (PT/aPTT/INR/Fibrinogen) were normal. She was diagnosed with HELLP
                                          syndrome. Platelet count remained [lt]50,000 in next 2 days following
                                          delivery. Epidural catheter left for 2 days awaiting the spontaneous
                                          resolution of Thrombocytobenia. After 2 days we did qualitative platelet
                                          assay with thromboelastography to assess primary hemostatic capacity of
      Removal of Epidural Catheter in a   patient. Test reported normal while platelet count was 43,000. Epidural
      Post Partum Patient Guided by       Catheter was removed; patient monitored for any sign of neuraxial bleed.
156   Thromboelastography                 No complication noticed.

                                                                   Page 52

                                            After prenatal diagnosis of bilateral fetal hydrothorax, ascities, and
                                            polyhydramnios, bilateral thoracoamniotic shunts were placed at 29 weeks
                                            gestation using an ultrasound-guided minimally invasive technique.
                                            Bilateral fetal hydrothorax with resultant hydops fetalis is a life threatening
      Bilateral Fetal Hydrothorax Requiring malformation, but is potentially correctable in utero with minimally invasive
      Intra-Uterine Fetal Thoracoamniotic   fetal surgery. Anesthetic care was managed using intravenous sedation
      Shunts Anesthetic Considerations and with local anesthesia. In this report we present the anesthetic challenges
157   Management                            and management when caring for the mother and fetus in such a condition.
                                            A 27-year-old women (5' 6", 289 lb) with a medical history of stable asthma
                                            with no recent episodes, tobacco use (1/2 pack per day for 4 years), reflux
                                            and gestational diabetes mellitus was G3 P2002 at 37 4/7 weeks of
                                            gestation when she presented to Temple University Hospital with low partial
                                            placental previa with cephalic presentation with a fetal heart rate in the
                                            140s with moderate variability. There are a number of case reports that
                                            describe the successful use of rFVIIa following obstetrical hemorrhage, but
      A Case Report: Use of Recombinant this may be the first report of its use in a patient with placenta previa and
158   Factor VIIa in Placenta Accreta       accreta.
                                            A 33 yo G2P1 was admitted to the hospital secondary to orthopnea and
                                            tachycardia. A CT scan demonstrated an anterior mediastinal mass (5.1
                                            cm by 13.7 cm) extending along the right heart border compressing the
                                            vasculature and the left mainstem bronchus. The patient had a sitting room
                                            air saturation of 98-99%, was unable to lie supine, and a pulse in the 150's.
                                            It was decided that she needed a cesarean delivery with the head up 30
                                            degrees. She was managed with an epidural with the level slowly
      Anterior Mediastinal Mass Discovered advanced. She had standard monitors with an a-line and large bore IV
159   at 31 wks GA                          access.
                                            A multigravid pregnant woman at 39 weeks gestation presented with
                                            spontaneously ruptured membranes. The patient had a known history of
                                            Type 1 von Willebrand's disease and a family history of hemophilia A.
                                            Regional anesthesia was requested for labor pain when the patient was
                                            dilated to 4 cm. After careful consideration and informed consent, a
                                            combined spinal epidural was performed and a dilute local anesthetic
                                            solution started in order to avoid a dense motor block. The woman
                                            delivered several hours later. Both mother and baby did well with no
      Regional Anesthesia in the Parturient complications. The implications of regional anesthesia in von Willebrand's
160   with von Willebrand's Disease         disease are discussed

                                                                     Page 53

                                           A 27-year-old G1P0 woman presented at 39 weeks of gestation and history
                                           of Marfan's syndrome. She had dilated aortic root, blindness due to retinal
                                           detachment and seizure disorder besides other symptoms. Preoperatively,
                                           CT scan of thorax and abdomen showed dilated aortic root of 4.3 cm with
                                           recent increase from 3.83cm. Echocardiography showed preserved cardiac
                                           function. Beta-1 selective blocker esmolol was continued as per cardiology
                                           consultation. Cesarean section was planned to avoid vaginal delivery.
                                           Intraoperatively, (Right radial a-line for BP monitoring) a slowly dosed and
                                           relatively dense epidural anesthesia was administered with a goal to
      Successful Management of Marfan's    maintain cardiovascular stability. Postoperatively, the patient recovered
161   Syndrome in Pregnancy                uneventfully.

                                           24 year old G2P1 in active labor refused epidural analgesia and delivered
                                           vaginally. Anesthesia called 45 minutes later to the operating suite for
                                           assistance with inverted uterus and resuscitation. Patient had EBL of
                                           1000+ mL, was actively bleeding, clearly in hypovolemic shock. Volume
                                           resuscitation, sedation with ketamine/midazolam, and intravenous
                                           nitroglycerin in divided doses helped successful uterine replacement.
                                           Uterine relaxation and patient comfort are important to stop the bleeding
                                           from an inverted uterus. Volatile inhalation anesthetics and nitroglycerin
                                           both cause uterine relaxation. Although nitroglycerin administration to a
                                           hypotensive patient may be unnerving, it is described in literature and
162   Hypotension and an Inverted Uterus   worked efficiently and safely.
                                           Atrial tachycardia (AT) is distressing to the patient especially when it occurs
                                           during pregnancy. Symptoms of AT may be exacerbated by the
                                           cardiovascular changes that follow pregnancy. We will discuss the
                                           anesthetic management of a patient with AT that was resistant to medical
      Anesthetic Implications of DC        treatment and to multiple attempts at DC Cardioversion under a short GA.
      Cardioversion under GA for Atrial    We highlight the challenges presented to us by the combination of
      Tachycardia in Pregnancy Resistant   pregnancy and an unstable heart rhythm. We will also discuss the
163   to Medical Treatment                 implications of electrical cardioversion on the fetus.

                                                                   Page 54

                                            A 28 year old, 70 Kg, 5' 4" tall primigravida was admitted to the labor floor
                                            at 32 weeks complaining of severe headache. She had a history of
                                            diabetes mellitus, which was diagnosed 2 years ago. She was scheduled
                                            for emergent cesarean delivery for non-reassuring fetal heart tracing. She
                                            had generalized edema. Her blood pressure was 240/120, P 110, platelet
      Severe Preeclamptic Parturient with   count 40,000/ mm-3, Hgb 10.2, UA shows 4+ proteinuria, and UO was 25
      Swollen Upper Airway and Platelet     ml/hr. Examination of the patient's airway showed edema (swollen lips and
164   Count of 40 K for Emergent C/S        tongue) and a Mallampati 4 classification airway.

                                            A 19 yo parturient G2P1 with Klippel-Trenaunay-Weber Syndrome (KTWS)
                                            underwent cesarean section (CS) at 36 weeks. She exhibited a
                                            hypertrophied left lower extremity, an enlarged labia and a lower uterine
                                            segment vascular malformation which precluded transverse hysterotomy
                                            during previous CS. MRI of the lumbar spine demonstrated no evidence of
                                            spinal vascular malformations. With crossmatched blood available and
                                            large bore intravenous access obtained she underwent spinal anesthesia
                                            and CS via a classical hysterotomy. A vigorous infant was delivered without
      Anesthetic Management of a            complications. Careful preoperative preparation and effective
      Parturient with Klippel-Trenaunay-    communication among specialties facilitates optimal anesthetic care in
165   Webber Syndrome (KTWS)                patients with rare diseases such as KTWS.

                                           A woman with mitochondrial myopathy, encephalopathy, lactic acidosis,
                                           and stroke-like episodes (MELAS) requested pain relief in labor. An
                                           electronic literature search raised concerns about malignant hyperthermia,
                                           succinylcholine-induced hyperkalemia, and resistance to cis-atracurium,
                                           but was silent about obstetric regional anesthesia in MELAS patients. We
                                           achieved adequate lumbar epidural analgesia, but the sensory block was
      Obstetric Anesthesia for a Woman     patchy. When cesarean section became necessary, we provided spinal
      with Mitochondrial Myopathy,         anesthesia with bupivacaine and fentanyl. No unusual drug responses were
      Encephalopathy, Lactic Acidosis, and noted. Recovery was clinically normal. The mitochondrial myopathies
      Stroke-Like Episodes (MELAS)         provide reasons for caution, but affected obstetric patients may be able to
166   Syndrome                             benefit from standard obstetric anesthetic techniques.

                                                                    Page 55

                                              A 25-year-old African-American female, G3P2, at 34 weeks gestation with
                                              idiopathic cardiomyopathy (presumed peripartum) with preoperative EF 5-
                                              10% presents for scheduled caesarean section and BTL. General
                                              anesthetic planned and managed with preinduction arterial line, central
                                              venous catheter with pulmonary artery catheter and intraoperative TEE.
                                              Throughout case run on 0.5 MAC isofluorane with remifentanil infusion (0.5
                                              mcg/kg/min) and dobutamine for inotropic support. Patient tolerated
                                              procedure well and delivered 3100 gm infant with transient respiratory
      Elective Ceasarean-Section in a 25-     depression. Infant intubated, briefly ventilated, and extubated in delivery
      Year-Old with Peripartum                room. BTL performed. Patient transported intubated to CVICU for postop
167   Cardiomyopathy                          management. Extubated POD 1 and discharged POD 5.

                                              30 yo G3P2 at term was found unresponsive, spontaneously ventilating 5
                                              hours after CSE placement. With onset of fetal bradycardia, the patient was
                                              taken for C-section, complicated by maternal bradycardia and uterine
                                              hemorrhage. Pt was resuscitated with massive transfusion and
                                              vasopressors. Postoperative course was complicated by EMD, ARF, and
                                              hypoxic brain injury. Pt was extubated POD10 and discharged after 3wks
                                              with full recovery. Newborn was treated with hypothermia brain protocol
      Amniotic Fluid Embolism: Case           and returned home after 12 days in the hospital. Mortality following AFE is
      Report of Classical Presentation with   86% with only 15% remaining neurologically intact. Early recognition and
168   Atypical Outcome                        aggressive resuscitation contributed to this exceptional outcome.

                                            A 33 year old female for repeat c-section, past medical history significant
                                            for hypothyroidism, underwent routine spinal anesthesia with 12 mg of
                                            hyperbaric bupivicaine. Immediately following the spinal, the patient
                                            became anxious, complained of weakness and pain in her right shoulder
                                            and her BP decreased to 48/31. This initially responded to divided doses of
                                            epinephrine. Intraoperatively, the patient continued to have similar episodes
      Severe Hypotension Leading to         requiring multiple doses of ephedrine and neosynephrine to maintain
      Ventricular Tachycardia Following     adequate BP. Thirty minutes after the spinal, the patient developed ectopy
      Spinal Anesthesia for Elective Repeat leading to ventricular tachycardia, treated with lidocaine 100mg. Oxygen
169   Cesarean Section                      saturation was always 100%. Cardiac workup was negative.

                                                                     Page 56

                                            32 year old, G3P1 healthy parturient, had CSE at 4cm. Intrathecal
                                            administration of 15mcg of fentanyl with 1.25mg of bupivacaine was
                                            followed by continuous infusion of 0.1% bupivacaine with 2.5mcg/ml of
                                            fentanyl at 12ml/hour. Pt was brought to OR for cesaerean delivery due to
                                            arrest of labor after 7 hours. After administration of 3ml of 1.5% lidocaine
                                            with epinephrine 5ml of 2% bicarbonated lidocaine with epinephrine was
      Back Pain on Injection of 5 ml of     administered, when patient complained of severe back pain. Pt's airway
170   Lidocaine Via Labor Epidural Catheter was unfavorable. How do you proceed now?

                                             A 39 year old female, gravida-4, para-1 at 29-weeks gestation presented to
                                             the obstetrics service with syncope, fatigue, and abdominal pain. She was
                                             anemic with a tender abdomen without rebound and had reassuring fetal
                                             heart tones. Subsequent fetal biophysical profile was non-reassuring and
                                             she underwent emergent C-section under general anesthesia for
                                             presumptive placental abruption or uterine rupture. Profuse bleeding was
                                             encountered upon entering the abdomen. Further exploration revealed a
                                             ruptured splenic artery aneurysm. The patient was aggressively
      A Case of Splenic Artery Aneurysm      resuscitated with packed cells and fresh frozen plasma. Although the fetus
171   Rupture during Pregnancy               did not survive, the patient recovered and was discharged 9 days later.
                                             A 24-year-old, 113-kg. gravida 3, para 1, with single gestation was admitted
                                             for a cesarean section at 34 week's gestation because of deteriorated
                                             cardiac function. Her cardiopulmonary symptoms dated from the first
                                             trimester of pregnancy, with several admissions to a local hospital with
                                             cough, dyspnea and orthopnea, suggestive of LV dysfunction. Cardiology
                                             was consulted and further echocardiogram revealed enlarged LV, LV
                                             hypokynesia, EF [lt] 20%, moderate MR. Her condition was optimized and a
      Modified CSE Anesthesia for            multidisciplinary team decided to end her pregnancy at 34 weeks after
      Cesarean Section in a Patient with     reaching fetal maturity. Pre-anesthetic vitals were BP 150/75, HR 100, and
172   Severe Cardiomyopathy                  SpO 2 100% room air.

                                                                     Page 57

                                         A 19-year-old G 2 P 0 at 40 2/7 weeks was admitted for oligohydraminos.
                                         Upon physical examination, a painful, non-vesicular and non-erythematous
                                         fissure was noted on the left labia. Two prior skin swabs for herpes simplex
                                         virus (HSV) culture had been negative within the past trimester, and a third
                                         swab was performed upon admission. In the interim, however, both HSV
                                         IgG and IgM serologies returned positive. Due to spontaneous rupture of
      Epidural Anesthesia in Suspected   membranes, the patient was urgently scheduled for a primary Caesarean
      Non-Primary, First-Episode Genital section. Body mass index was 37 kg/m 2, with a neck circumference of 38
173   Herpes                             cm.
                                         A 22 yr old with history of SLE, anti-ro anti-la positive, cardiomyopathy and
                                         posterior reversible encephalopathy syndrome, seizure disorder presented
                                         at 35 weeks of gestation .She complained of worsening fatigue, weakness,
                                         dizziness, SOB, palpitations, headache for last 2 weeks. High risk antenatal
                                         consultation obtained and prednisone dose increased. ECHO shows EF 55-
                                         60%, mild concentric LVH. Patient was also on keppra, plaquenil, protonix.
                                         Anti-coagulation was discontinued pre-pregnancy. Patient delivered
      Successful Management of Pregnant vaginally under epidural analgesia with careful dosing and epinephrine was
      Patient of SLE Complicated with    avoided. Arterial line for BP monitoring set up considering her
      Cardiomyopathy and Posterior       cardiomyopathy. Stress dose steroid was used intra-op. Patient was stable
174   Reversible Encephalopathy Syndrome post op.
175   Not available

                                           A 22 year old asthmatic G4P2012 at 38 weeks gestation presented for
                                           ceasarean section. Ceasarean section indication included: mild
                                           preeclampsia, and non-reassuring fetal heart tones. Spinal anesthesia was
      The Acute Intra-Operative            instituted using Bupivicaine and Astromorph. Following delivery of placenta,
      Management of Cardiovascular         the patient acutely developed hypotension of 55/22. She also complained
      Collapse and Bronchospasm in a       of difficulty breathing and was noted to be wheezing. The patient was
      Parturient during Ceasarean Section subsequently intubated. Her blood pressure was stabilized with pressors.
      While under Spinal Anesthesia, Noted Patient was stabilized in the ICU. It was reported on post op day one that
      To Have Recently Consumed            patient had smoked marijuana on the day of surgery. This was
176   Cannabis                             substantiated by UDS.

                                                                   Page 58

                                              An urgent C-section was started with a combined spinal-epidural
                                              anesthetic. An hour into surgery patient complained of sharp pain indicating
                                              waning spinal block. After negative aspiration 3ml 2%lidocaine was injected
      Cradiorespiratory Collapse during C-    via epidural catheter as top-up. Cardiorespiratory collapse followed in next
      Section after Test Does in a CSE        few minutes. Possible causes, management and implications for CSE
177   Anethetic                               technique to be discussed.

                                              M.D. is a 44 year old that presents for Caesarean section. She is G1P0
                                              with gestational diabetes. Her past medical history is significant for spina
                                              bifida and myelomeningocele which was corrected shortly after birth and
                                              diagnosis of Arnold-Chiari malformation type II. She has a history of
                                              headache involving the whole head and neck exacerbated by laughing. She
                                              has had perianal numbness and incontinence of bowel and bladder. ROS
                                              also positive for hypertension, asthma, and psychiatric disturbance.
      Arnold-Chiari Malformation Type II in   Physical examination reveals 5' 8" 119 kg Malampati class 3airway.
      an Obstetric Patient Presenting for     Neurologic examination is significant for sharp optic disks and decreased
178   Ceasarean Section                       sensation in sacral 2-4.

                                              Subdural hematoma is a serious, rare complication of dural puncture.
                                              Diagnosis of Postdural puncture headache does not rule out other
                                              pathologies. A 24 years old female, who delivered vaginally under epidural
                                              analgesia presented with a posture dependent frontal headache.
                                              Conservative management was not effective and EBP was done with 20 ml
                                              of autologus blood. Two hours later, patient had an episode of generalized
                                              seizures effectively treated by midazolam and Phenytoin infusion. MRI of
                                              the brain showed small bilateral enhancing subdural collections, suggestive
      Postpartum Seizure in a Parturient      of Subacute subdural hematomas or empyemas. Seizure Work up was
179   after Epidural Blood Patch (EBP)        negative. Patient was discharged home, 48 hours later.

                                                                     Page 59

                                              A 24 yr woman G1P0 initially presented at 35 weeks gestation with
                                              blackout spells, palpations and dyspnea at rest consistent with her history
                                              of congenital sick sinus syndrome. In lieu of her symptoms, her
                                              pacemaker was changed and cardiac symptoms resolved. She presented
                                              for an elective C-section at 38 wks secondary for a breech presentation. A
                                              subarachnoid block was done with careful intraoperative monitoring and
      Spinal Anesthesia in Elective C-        appropriate treatment. Her clinical course was uneventful with no further
      Section for a Patient with Congenital   cardiac complications. Spinal anesthesia is safe and effective for an
180   Sick Sinus Syndrome                     elective C-section in a congenital sick sinus syndrome patient.

                                              Pneumonia poses a special hazard for pregnant women, because of the
                                              altered immune system, the altered physiology, decreased FRC, increased
                                              intra-abdominal pressure and the increased metobolic rate. A 22-year old
                                              female at 32 weeks gestation, presented with malaise, back pain,
                                              tachycardia, hypotension and SpO2 88%. A CT Chest showed extensive
                                              consolidation of the left lung and a right sided effusion. Serial blood gases
                                              showed deteriorating pulmonary function. As per multidisciplinary case
                                              discussion, urgent cesarean section was performed under General
      A Challenge: Pregnant Patient with      anesthesia, to improve the pulmonary function. APGAR scores of the baby
      Severe Community Acquired               8 and 8. ABGs improved remarkably post C-Section. Extubated on the 2nd
181   Pneumonia                               postoperative day.

                                              A 60 year old female with situs inversus totalis underwent a left
                                              adrenalectomy for a pheochromocytoma. She required in-patient admission
                                              for blood pressure management with phenoxybenzamine, metoprolol, and
                                              nicardipine. Anesthesia management included midazolam pre-medication,
                                              pre-induction arterial catheter, and thoracic epidural. Monitoring included a
                                              right internal jugular central line and esophageal Doppler. The drug of
                                              choice for hypertensive management was magnesium infusion and bolus.
                                              With peritoneal retraction, the patient had one brief intra-operative episode
      Anesthesia for Adrenalectomy for        of profound hypotension and bradycardia that responded to a bolus of
      Pheochromocytoma in a Patient with      atropine and vasopressin. She had an uneventful post-operative ICU
182   Situs Inversus Totalis                  course and was discharged 7 days later.

                                                                     Page 60

                                           A 75yo male with Eisenmenger's physiology and an ASD, with significant
                                           flow across the defect, presented for direct laryngoscopy and rigid
                                           bronchoscopy by ENT. The anesthetic considerations in this case invloved
                                           achieving an appropriate plane of anesthesia while maintening cardiac
      Anesthetic Management of a Patient   output and avoiding worsening pulmonary hypertension, right to left shunt
183   with Eisenmenger's and ASD           and hypoxia.

                                           Fibrodysplasia Ossificans Progressiva (FOP) is an inherited autosomal
                                           dominant trait with complete penetration. Incidence of reproduction is low;
                                           most cases occur by mutation. There are 600 known cases worldwide.
                                           Congenital malformation of the toe is disease hallmark. Ectopic bone
                                           formation usually starts in life's first decade. It has predilection to ligaments,
                                           tendons, striated muscle, paraspinal and intercostals muscles. New bone
                                           formation is progressive, following tissue trauma but may occur
                                           spontaneously, leading to deformities, immobilization and cardio-respiratory
      Anesthetic Management of a Patient   complications. We present a 25 y/o female diagnosed with FOB needing
      with Fibrodysplasia Ossificans       multiple teeth extractions. We review this disease's unique anesthetic
184   Progressiva                          considerations and describe anesthetic management.

                                           We are reporting an unexpected difficult intubation in a 54 year old female
                                           for cystoscopy. Airway examination revealed normal mouth opening,
                                           adequate neck extension, Mallampati class II and previous reporting of
                                           easy intubation. After induction, laryngoscopy revealed a grade 4 view.
                                           Laryngeal mask airway was placed and she was intubated with the Aintree
                                           exchange catheter and fiberoptic bronchoscope. In PACU, the patient
                                           revealed a change in her voice after a chin implant possibly contributing to
                                           the change in her laryngoscopic view. We conclude that special airway
      Unexpected Difficult Airway after    attention should be given to patients with previous cosmetic surgery of the
185   Cosmetic Surgery                     upper airway.

                                                                    Page 61

                                           A 33 year old female weighing only 18 kg with a diagnosis of
                                           dermatomyositis which was diagnosed at age 7 and progressed rapidly and
                                           severely until age 18, currently in remission, was diagnosed with a right
                                           renal cell carcinoma. The Urology team contacted the anesthesiologist,
                                           recognizing the complexity of this patient's severely restrictive lung disease,
                                           diminutive body habitus and multiple anatomical anomalies(scoliosis,
      An Approach to a Patient with        contractures, calcinosis of the thorax and abdomen, myopathy) which
186   Dermatomyositis                      would require attention by the anesthesia team.

                                           A 41 year old male with a BMI of 47 presented for laparoscopic gastric
                                           bypass. The patient failed the airway exam on multiple standard
                                           parameters. The recurrent laryngeal nerve and internal branch of the
                                           superior laryngeal nerve were blocked and the airway was topicalized with
                                           4% Lidocaine; sedation included 2.5mg of Droperidol and 1mg of
                                           Midazolam. An Ovassapian airway was inserted but was of little assistance
                                           due to macroglosia. Multiple attempts with the fiber-optic bronchoscope by
                                           several experienced anesthesiologists yielded no visualization of the
      Awake GlideScope Intubation for a    airway. An awake GlideScope intubation was successfully performed
187   Failed Awake Fiberoptic Intubation   without difficulty or patient distress.

                                           68-yr-old man demonstrated ST-depression in ECG leads II and V6, BP
                                           180/100, and HR 90 bpm during emergence from anesthesia after repair of
                                           a retinal detachment. He has stage II hypertension treated with
                                           hydrochlorthiazide, enalapril, and metoprolol. He had an uncomplicated
                                           myocardial infarction 3 yrs ago. He takes atorvastatin and low dose aspirin.
                                           Only metoprolol was administed preoperatively. Does this ST-depression
                                           indicate inducible ischemia or a perioperative myocardial infarction? If it
                                           resolves with acute treatment, should this patient spend the next 24 hrs
      ST-Depression during Emergence       monitored for possible evolution of a myocardial infarction? How could the
188   from Anesthesia                      ST-depression have been avoided?

                                                                   Page 62

                                          35 year old Haitian female with Fibrous dysplasia mandible with abnormal
                                          formed fibrous tissue growing and expanding with severe deformity of
                                          facialones causing vision and hearing loss, a condition caused by gene
                                          mutation. Operation for staged reduction by oral maxillo-facial surgeons.
                                          Upper airway anatomy distorted on physical exam withasketball sized
                                          tumor in lower mandible with limited mouth opening. Anesthesia plan
      Nasopharyngeal Airways Cut Length- included awake firberoptic intubation with xylocaine 4% topicalization of
      Wise To Facilitate Awake Fiberoptic nares and oral cavity. Dexmetomidine 1microgram/kg bolus with 0.4mcg/kg
      Endotracheal Intubation in Patient  infusion IV WITH 0.2MG ROBINUL. Nasopharyngeal bilateral airways
      with Fibrous Dysplasia of Facial    inserted after Afrin use. Nasal airways were cut lengthwise so when
      Bones for Staged Reduction by Oral fiberoptic placed with preloaded ETT the nasal airway was removed once
189   Maxillo Facial Surgery              vocal cords were visualized and trachea intubated.

                                              54 year old female (5' 1", 54kg) for right lower lobectomy. After induction, a
                                              37F double lumen endotracheal tube was placed uneventfully under direct
                                              laryngoscopy. Upon isolation of the right lung with the patient in the lateral
                                              position, and following confirmation of tube and balloon position, the
      Failure of Lung Isolation by a Double   surgeon stated that the isolation was inadequate post thoracotomy. A 7Fr
      Lumen Endotracheal Tube; Rescued        Arndt blocker was placed through the right side of the DLT, under direct
      by the Concomitant Use of an Arndt      visualization with a pediatric bronchoscope, resulting in good isolation.
      Bronchial Blocker under Direct          Reports discuss the use of blockers for failed DLT isolation; therefore, this
190   Visualization                           technique may prevent ETT replacement in the lateral position.

                                              A 57 year old female with myasthenia gravis presented to the operating
                                              room for emergency airway dilation with stridor and hypoxia secondary to
                                              tracheal stenosis. Her past medical history included poorly controlled
                                              myasthenia gravis requiring more than 25 lifetime intubations, inoperable
      A Complicated Case of Myasthenia        meningioma, and morbid obesity. We will explore the anesthestic
      Gravis, Tracheal Stenosis, and          implications of myasthenia gravis, tracheal stenosis, and elevated
191   Elevated Intracranial Pressure          intracranial pressure in this complicated, obese patient.

                                                                      Page 63

                                            A 42- year old female with carcinoid tumor metastatic to the liver underwent
                                            radiofrequency ablation of three hepatic lesions in close proximity to the
                                            portal vein. During the radiofrequency ablation, the patient developed an
                                            increase in core temperature from 36.4 to 43 C in 90 minutes, an increase
                                            in end-tidal CO2, acidosis, and tachycardia. Intraoperative studies showed
                                            normal creatine kinase levels, and hemoglobinuria. Aggressive cooling
                                            measures, intravenous mannitol and renal-dose dopamine were instituted.
      Intraoperative Hyperthermia during    Postoperatively, the patient successfully recovered from the mild ATN
192   Radio Frequency Ablation of the Liver without the need for dialysis.

                                             TURP Syndrome resulting in hyponatremia occurs in traditional monopolar
                                             electrode resection, but rarely in bipolar electrode or laser resection of the
                                             prostate. Presented are two non-TURP cases of severe hyponatremia
                                             syndrome. Transurethral Resection of Bladder Tumor was performed
                                             under intrathecal anesthesia complicated by bladder perforation. The result
                                             was accumulation of several liters of intraperitoneal sterile water in one
                                             case and retroperitoneal glycine in the second. Diagnosis and perioperative
                                             management was different in each case. Discussion centers on
      Non-TURP Hyponatremia Syndrome         interventions, intravenous fluid selection (hypertonic saline), post-bladder
193   Case Presentations                     perforation serum sodium levels, and patient outcome.

                                            This is a case report of the use of Dexmedetomidine(Dex) as a sedative
                                            anesthetic, and adjuvant to trans-tracheal blockade with local anesthesia in
                                            the management of a patient who presented with a difficult airway ,
                                            secondary to left facial basal cell carcinoma , scheduled for elective split
      The Safe Use of Dexmedetomidine as thickness skin graft of the maxillo-facial lesion under general endotracheal
      a Sedative Adjuvant with              anesthesia. Patient had a history of maxillary debulking procedure with
      Transtracheal Blockade for Fiberoptic rhinotomy ,which resulted in distortion of facial anatomy resulting in a small
      Intubation in Anesthetic Management mouth opening without nostrils. Patient was successfully intubated using
      of a Difficult Airway: A Challenging  high dose infusion of Dex, general anesthesia was induced,and
194   Case Report                           hemodynamics remained stable.

                                                                     Page 64

                                             A patient with a fenestrated, uncuffed tracheostomy tube placed following a
                                             gunshot wound to the face, presented from home for reconstructive
                                             mandibular surgery. No connection existed between his trachea and
                                             mouth. Preoxygenation was accomplished via spontaneous ventilation with
                                             a mask over the tracheostomy. Following propofol induction, attempts at
                                             ventilating through the tracheostomy tube were unsuccessful. We were
                                             also unable to remove the trach. An otolaryngologist forcefully removed the
                                             tracheostomy tube. This relieved the obstruction and allowed placement of
      Acute Airway Obstruction Following     a reinforced endotracheal tube. Examination revealed tracheal granulation
      Induction in a Patient with a          tissue invading through the fenestration and occluding the tracheostomy
195   Fenestrated Tracheostomy Tube          tube lumen.

                                             This case presents a young woman who exhibited a dramatic vasovagal
                                             reaction in response to an attempted IV cannulation. Subsequently, local
                                             anesthetic was administered via jet injection and IV access was
                                             established without adverse reaction. Approximately 10% of the general
                                             population suffers from needle phobia, a complex issue related to age,
                                             previous experience and situation. Many people dislike needles but those
                                             with needle phobia often avoid encounters with the medical world.
      Scared to Death of IVs? It Could       Responses to IVs, ranging from fear to extreme vasovagal reactions and
196   Happen!                                death, can be attentuated by prior jet injection of local anesthetic.

                                             Heparin induced thrombocytopenia (HIT) is a serious and widely
                                             recognized syndrome. The avoidance of intravascular heparin is essential
                                             in the treatment of HIT. Thrombosis caused by intraoperative use of
                                             heparin-containing irrigation solution has not been previously reported. We
                                             report a 77 year old male, previously diagnosed with HIT, who presents for
      Interoperative Thrombosis from         elective AAA repair. Anticoagulation is maintained with argatroban, with
      Heparin Containing Irrigation Solution ACT values ranging in the 300s. Intra-abdominal clotting is observed after
      in a Patient with Heparin-Induced      heparin containing saline is used as irrigation. Once recognized, the
197   Thrombocytopenia                       solution was removed, and no further clotting was observed.

                                                                    Page 65

                                              A 20 year old female was transferred to the intensive care unit for
                                              autonomic dysfunction, tachycardia, hypertension, fever, rigidity, mutism,
                                              and stupor. Multiple tests were performed and a likely diagnosis of
                                              malignant catatonia was highly suspected. A trial of benzodiazepines did
                                              not work and emergent electroconvulsive therapy (ECT) was deemed
                                              necessary. We used light sedation with methohexital and a small dose of
                                              succinylcholine. We were prepared for hemodynamic instability, but her
      A Patient with Malignant Catatonia      ECT treatments were uneventful. The patient's condition improved and was
198   Requires Electroconvulsive Therapy      noticeable even after the first ECT.

                                              53 y/o male with history of Parry Romeberg's disease (Progressive
                                              Hemifacial Atrophy), HTN, GERD, and asthma, presents for facial
                                              reconstruction. Physical examination revealed atrophy of bilateral maxilla,
                                              frontal bone, and hard palate. Airway exam revealed class IV Mallampati,
                                              large tongue, and nasolabial fistula. We were concerned about difficulty
                                              ventilating the patient secondary to the lack of facial bones. We therefore,
                                              proceeded with awake FOI. Preparation for awake FOI included nebulizer
                                              treatment with 4% lidocaine, transtracheal block, and b/l superior laryngeal
                                              block. FOI was followed by IV induction. Patient remained intubated post
      Patient with Parry Romberg's            procedure secondary to significant oropharyngeal edema. Patient
199   Syndrome                                extubated POD#2.

                                               43 year old female with history of recurrent nasopharyngeal carcinoma, had
                                               undergone endoscopic resection followed by radiation to the face and later
                                               radical neck dissection presented to the OR for repeat endoscopic
                                               examination and resection. Examination of the airway revealed a difficult
                                               airway. Plan was for lidocaine topicalization and awake FOB intubation,
      Intubation of a Difficult Airway with    patient failing lidocaine topicalization, ketamine used allowing for William's
      Ketamine Anesthesia and Two-             airway to be placed -still no view obtainable related to stiffness of soft
      Person Direct-Laryngoscopy-Assisted tissues with bronch. Decision was made to attempt two person technique of
      Fiberoptic Intubation after Failed Local DL with FOB and successful. Suggest as alternate technique for difficult
200   Topicalization                           airways.

                                                                      Page 66

                                             Portopulmonary Hypertension and Hepatopulmonary Syndrome are
                                             unrelated complications of cirrhosis which may be present in patients
                                             undergoing liver transplantation, particularly since significant symptoms of
                                             either increase the corrected MELD score and chance of receiving a donor
                                             organ. Despite both disease processes involving the lungs, the
                                             presentation and management are very different. The physiology of
                                             portopulmonary hypertension closely resembles that of pulmonary
                                             hypertension from other causes, with profound pulmonary vascular
                                             vasoconstriction and associated cardiac dysfunction. Hepatopulmonary
      Hepatopulmonary Syndrome Versus        syndrome is characterized by excessive pulmonary vasodilation, leading to
      Portopulmonary Hypertension in the     hypoxia. Two clinical cases compare and contrast the presentation,
      Liver Transplant Patient: Very         physiology and management of Hepatopulmonary Hypertension and
201   Different Diseases and Management      Portopulmonary Syndrome.

                                             Patient SC is a 77 year old female with no significant past medical history
                                             who presented for a whipple procedure due to a pancreatic head lesion.
                                             Within seconds after entering the abdominal cavity there was abrupt and
                                             profound bradycardia to 30 s leading to asystole and loss of end tital CO2.
                                             Atropine 1 mg was given and chest compressions started, then 0.5 mg of
                                             epinephrine administered. Within 2-3 minutes there was return of
                                             spontaneous sinus tachycardia 120s-130s and she eventually became
      Intraop Cardiac Arrest Minutes after   hemodynamically stable with HR in 80s-90s. The case was cancelled and
202   Initial Incision                       abdomen closed and patient transported to the ICU.

                                         A 63-yr-old male with hepatocellular carcinoma, atopy, obstructive sleep
                                         apnea and reactive airway disease presented for liver transplant. Patient
                                         had allergic predisposition to clopidogrel, penicillin, nifedipine, oxycodone.
                                         With only 50cc mannitol 25% bolus, reperfusion was followed by mean
                                         blood pressure drop to 40mmHg and airway pressure increase above
                                         45cmH2O. Albuterol puffs were administered to no avail. Hypotension and
                                         bronchospasm responded to repeated 30 micrograms epinephrine boluses
                                         and later to a 2 micrograms/minute infusion. Solumedrol 1 gram and
                                         diphenhydramine 50 mg were given. Following surgery, patient was found
      Bronchospasm Following Reperfusion to have urticaria. He was transferred to ICU and investigated for
203   during Liver Transplant            anaphylactic reaction.

                                                                    Page 67

                                         We present a 42 year old female with thoracic outlet syndrome who
                                         underwent left common carotid to axillary artery bypass grafting.
                                         Anesthesia was smoothly maintained with sevoflorane, and remifentanil
                                         infusion; converted to propofol infusion for the last hour of the procedure.
                                         At that time, patient's blood pressure declined precipitously to 80s/40s,
                                         requiring intermittent boluses of neosynephrine. Twenty minutes into PACU
                                         recovery she again became tachycardic and hypotensive, requiring
                                         hemodynamic support. Chest radiograph revealed left hemothorax.
                                         Emergent chest tube placement drained 750ml of blood and resolved the
      Hemodynamic Complications of Acute hemodynamic instability. This case reflects urgent management of a rare
204   Post-Operative Hemothorax          but dangerous cardiothoracic complication.

                                              70 year old female cardiac transplant recipient with end-stage renal
                                              disease underwent renal transplantation. Past medical history significant for
                                              heart transplant, IDDM, ESRD secondary to cyclosporin
                                              immunosuppresion, hypertension, right heart failure, and deep vein
                                              thrombosis. Intraoperative monitoring included CVP measurement and
                                              TEE. Echo showed moderate tricuspid regurgitation, and dilated right
                                              atrium. Anesthetic and renal transplantation were uneventful. 1. Review
                                              etiology of right heart failure in a post cardiac transplant patient. 2. Discuss
                                              interrelationship between right heart failure and renal transplant. 3. Discuss
      Renal Transplantation in a Patient      the interrelationship between cardiac transplant, tricuspid regurgitation,
      with Right Heart Failure 12 Years after ventricular-biopsy, right heart failure, and renal failure and its implications
205   Cardiac Transplant                      for anesthetic management

                                               A 72 yo female presented for extensive head and neck tumor resection
                                               with myocutaneous free flap. General endotracheal anesthesia was
                                               induced and maintained without complications. Approximately six hours
                                               into the procedure a large circuit leak was noted which led to difficulty in
                                               delivering an adequate tidal volume. The leak was isolated to the body of
                                               the endotracheal tube. Delivering larger set tidal volumes to compensate
      My Bellows Have Fallen and Can't         would compromise the flap integrity so TIVA was initiated to provide
      Get up - Management of an                anesthesia and limit OR pollution. Once surgery concluded, the tube was
      Intraoperative Endotracheal Tube         exchanged using a Glidescope-assisted fiberoptic technique to visualize
206   Perforation                              the altered anatomy.

                                                                       Page 68

                                             Ankylosing spondylitis may result in spontaneous fractures with spinal cord
                                             compression. A 64 year-old male with ankylosing spondylitis and a C5
                                             fracture was scheduled for spinal fusion. In the OR he was positioned from
                                             supine to prone wearing a cervical collar. After repositioning, the SSEP
                                             signals were completely lost. The patient was rushed to MRI which
                                             revealed a complete C4-C5 fracture/subluxation and severe spinal cord
      Spontaneous Spinal Cord                compression. The patient's fracture/subluxation was reduced with
      Compression during Positioning in a fluoroscopy. He never recovered from his quadriplegic state. Immediate
      Patient with a Cervical Spine Fracture intraoperative fluoroscopy may provide diagnosis and treatment which
207   and Ankylosing Spondylitis             should be considered before moving the patient to MRI.

                                              The anesthesiologist's and cardiologist's perioperative evaluation and
                                              management of cardiac patients for non-cardiac surgery may deviate from
                                              the ACC/AHA published guidelines depending on their responsibility to the
                                              patient. A 71 year old man with CAD and stable angina presented for a
                                              lumbar laminectomy. The cardiologist cleared him for surgery
                                              recommending medical management. The anesthesiologist followed the
                                              ACC/AHA guidelines and refused to proceed. A cardiac catheterization
      Gambling with the ACC/AHA               revealed significant CAD and a drug-eluting stent was placed. This delayed
      Guidelines… Will You Lay the Odds       surgery by one year. The decision to pursue invasive cardiac testing prior
208   on the Risks or the Benefits?           to spine surgery was felt beneficial compared to the risk to proceed.

                                              An otherwise healthy 27-year old woman with pheochromocytoma was
                                              scheduled for laparoscopic adrenalectomy. Phenoxybenzamine had been
                                              started approximately 20 days prior to the procedure. Induction, central
                                              venous catheter placement, and positioning were uneventful. With
                                              insertion of the Veress needle and CO 2 insufflation, there was rapidly
                                              progressive bradycardia culminating in asystole for 10-15 seconds that
      Asystole: A Profound Response to        responded to atropine. Upon reassessment, it was felt that the patient was
      Peritoneal Insufflation in the Presence medically optimized, surgical excision was the only definitive treatment, the
      of Pheochromocytoma and                 risks of induction and line placement were mitigated, and the risk of
      Preoperative alpha-1 Adrenergic         recurrent dysrhythmia was outweighed by the risk of further delay in
209   Blockade                                treatment.

                                                                      Page 69

                                           We report the anesthetic management of a 32-year-old 800+ lb (BMI
                                           [gt]125 kg/m 2 patient for tracheotomy. The procedure was performed on
                                           the bed. Seven people were required for transport and positioning.
                                           Anesthesia consisted of sevoflurane, O 2, and rocuronium. An assistant
                                           retracted redundant mandibular soft tissue and maintained head position to
                                           facilitate surgical exposure. A standard tracheotomy tube proved too short
                                           and a Bivona adjustable neck flange size 8 tracheotomy tube was
                                           eventually placed. Management of this patient requires proper
      Anesthetic Management of an          understanding of anatomic, physiologic, and pharmacologic principles,
      Extraordinarily Obese Obstructive    cooperation between the surgeon and anesthesiologist, and attention to
210   Sleep Apnea Patient                  detail in overcoming technical problems.

                                           A 48yo male with worsening dyspnea underwent tracheal resection and
                                           reanastamoses after a CT scan and bronchoscopy revealed 80% tracheal
                                           stenosis at C5-C6, the site of a previous spinal fusion. Dexmedetomidine
                                           1 mcg/kg was administered, and general anesthesia was induced with
                                           sevoflurane while maintaining spontaneous ventilation. A rigid
                                           bronchoscopic telescope revealed 80 - 90 % stenosis collapsing the right
                                           anterior tracheal wall. An MLT endotracheal tube was placed, rocuronium
                                           was administered and mechanical ventilation initiated. After the procedure,
      Dexmedetomidine and Sevoflurane      neuromuscular blockade was reversed, and spontaneous ventilation was
      for Induction of Anesthesia in a     confirmed. The patient was deeply extubated and transported to PACU with
211   Patient with Tracheal Stenosis       10L of oxygen.

                                           High Dose Interleukin-2 is an FDA approved drug used for the treatment of
                                           renal cell carcinoma. Vascular leak syndrome is a known complication of
                                           this drug that can lead to pulmonary edema. We report the case of an
                                           emergency code involving a patient on day 5 of high-dose IL-2 therapy.
                                           Multiple attempts at intubation and obtaining a surgical airway resulted in
                                           laryngeal injury. He required emergent tracheostomy and laryngeal repair.
      Unanticipated Surgical Airway: Hi-   Post-operative course was complicated by PTSD and tracheal stenosis.
      Dose Interleukin-2 Can Lead to       The purpose of this case is to increase awareness of the possible airway
212   Vascular Leak Syndrome               difficulties encountered with patients on this drug.

                                                                  Page 70

                                           An 80y old female,with hypertension, presented for knee arthroplasty.
                                           Preoperative BPs ranged from 140-160/80-95. Immediately preoperatively
                                           BP was 200-225/100-112 Challenge:proceed or not.To proceed was based
                                           on:1)patient was in pain and could not walk; 2)anesthesiologists can
                                           attempt to control BP before induction; and 3)patient was anxious and had
                                           no cardiac history. A-line was placed,and increments of midazolam,
                                           metoprolol and labetalol were given. BP decreased to 155/92.During
                                           anesthesia, BP fluctuated between 126-178/84-88.Intraoperative course
                                           was uneventful.On emergence,BP increased to 225/108.Labetalol and
      Uncontrolled Hypertension in the     metoprolol were given.In the PACU, BP decreased to 100/70 after 1
      Immediate Preoperative Period. The   hr.Phenylephrine infusion was administered until BP stabilized .Cardiac
213   Challenge: To Proceed or Not!        enzymes were negative.

                                           Pulmonary hypertension (PH) is a very significant preoperative risk factor.
                                           This is a report of successful anesthetic management of a 72-year-old
                                           Hispanic male who underwent L4-S1 posterior lumber inter-body fusion.
                                           His past history was significant for: 1. Non-ischemic dilated
                                           cardiomyopathy. 2. Severe pulmonary hypertension with pulmonary (PA)
                                           systolic pressure of 75 on echo report. 3. Obstructive sleep apnea. 4. Atrial
                                           fibrillation. 5. Hypertension. 6. Diabetes. 7. Asthma. 8. Moderate obesity. 9.
      Successful Anesthetic Management     Rheumatoid arthritis. Challenges of the case were smooth induction, keep
      of an Elective Spinal Surgery with   the PA pressure at or below base line and prevent failure of the right
214   Pulmonary Hypertension               ventricle, and smooth emergence.

                                           The physiologic changes associated with lapraroscopic surgery are well
                                           known. Laparoscipic surgery utilizing Trendelenberg position poses
                                           additional risks and morbidity. In this report we describe an unexpected
                                           outcome of diplopia after pneumoinsufflation in the head down position. A
                                           70 year old woman underwent a laparoscopic colectormy for
                                           adenocarcinoma. Preoperatively, she denied hypertension, bleeding history
                                           and existing vision problems. After two hours of general anesthesia
      Retro Orbital Hematoma after         including one hour in Trendelenberg, she emerged with unilateral proptosis,
      Laparoscopic Surgery in the Head     diploplia and cranial nerve palsy. On MRI she was found to have a soft
215   down Position                        tissue mass behind the left orbit suggesting a retro orbital hematoma.

                                                                   Page 71

                                            A 32-year-old woman who underwent primary c-section under spinal
                                            anesthesia complained of nausea in the recovery room. She was
                                            supposed to receive metoclopramide. Subsequently, she developed
                                            headache, severe hypertension, and bradycardia. Accidental
                                            phenylephrine administration was discovered. She was emergently treated
                                            with intravenous nitroglycerin. Immediate recognition of medication errors
                                            is critical in avoiding potentially fatal cardiac and neurologic complications.
                                            In this case, priority is given to counteracting excessive vasoconstriction
                                            with a direct vasodilator such as nitroglycerin. Similar medication
      Caution with Colors: Management of    packaging may lead to medication errors. Maintaining vigilance during
      Inadvertent Phenylephrine Induced     administration of all medications must be emphasized as an integral
216   Hypertensive Crisis                   component of anesthesia care.
                                            This case is about a patient scheduled for a Microlaringeal endoscopic
                                            biopsy. He had criteria for difficult intubation (Mallampati III,Upper lip bite
                                            test score 3,small mouth opening,range motion of neck limited). We
                                            decided to do fiberoptics aided intubation, with the patient awake. It started
                                            to bleed and the airways structures were distorted. We intubated him with
                                            glidescope. We think this case shows the utility of glidescope in the
                                            management of difficult airway, although he also had criteria for difficult
217   Glidescope-Rescue Intubation          intubation with glidescope.

                                            Hypoxemia is a common problem during one lung ventilation. Hypercarbia
                                            however is a rare occurrence due to carbon dioxide diffusibility. We
                                            describe the case of a 43 year old male with isolated pulmonary lesions
                                            consistent with fungal pneumonia for lobectomy with persistent
                                            intraoperative and postoperative hypercarbia despite adequate
                                            oxygenation. Pulmonary function tests showed mild obstructive disease
                                            with no gas transfer defect and good exercise tolerance. Single lung
      Single Lung Ventilation: Persistent   ventilation produced a significant alveolar-arterial CO 2 gradient despite
      Hypercarbia and Acidosis Despite      proper position of the double lumen tube, normal tidal volumes and plateau
      Adequate Oxygenation in a 43 Year     pressures, and ventilation maneuvers including two lung ventilation.
218   Old Male for Lung Lobectomy           Hypercarbia continued two days postoperatively.

                                                                    Page 72

                                             A 65 year old man scheduled for a Whipple procedure developed
                                             dysrhythmia after induction of anesthesia. He denied past medical
                                             problems except for unexplained tachycardia during a previous surgery.
                                             Before induction he was in sinus rhythm with a heart rate of 64. After
                                             induction he suddenly accelerated to a rate of 120 and was in a junctional
                                             rhythm. Cardiology was consulted and agreed with our decision to proceed.
                                             However, throughout the case the patient experienced dysrhythmias and
                                             variable heart rates. In retrospect we think this case merits further
      When Is It Prudent To Defer Surgery    discussion regarding risks and benefits of proceeding with surgery under
219   for Intraoperative Dysrhythmias?       these circumstances.

                                             A 33 year old morbidly obese female with a difficult airway history
                                             presented for an elective bilateral mammoplasty and ventral herniorrhaphy.
                                             A preoperative negative leak test was obtained for our Datex-Ohmeda
                                             Aestiva 3000 anesthesia machine. Following intravenous induction and a
                                             challenging intubation, ventilation became progressively more difficult with
                                             monitors showing high peak airway pressures and inaccurate tidal
                                             volumes. A hissing sound was detected emanating from the machine and
                                             the entire flow sensor apparatus was replaced intraoperatively with
      Intraoperative Flow Sensor Leak in a   resolution of the leak; examination of the flow sensor tubing revealed a 2
220   Datex-Ohmeda Anesthesia Machine        mm defect. The patient had an uneventful postoperative course.

                                             A 22 year old with CCHS required a pacemaker for sinus node dysfunction
                                             post NSVD without intrapartum anesthetics. Though initially stable, she
                                             noted palpitations and exhaustion. Holter monitoring revealed asystolic
                                             pauses and junctional bradyarrhythmias. Less than 200 cases of CCHS
                                             exist, limiting the information for an anesthetic plan. A multidisciplinary
                                             discussion outlined her peri- and post-operative management. She
                                             received an inhalational induction with incisional local anesthetic. Her small
      Ondine's Curse for Both the Patient    tracheostomy had a large leak that required airway packing without further
      and Anesthesiologist: Peri-Operative   events. Overnight monitoring in the ICU included capnography and
      Management of Congenital Central       oximetry while on BIPAP. She went home the following morning with
221   Hypoventilation Syndrome (CCHS)        Tylenol.

                                                                     Page 73

                                            Failure to confirm tracheal intubation can have very serious consequences
                                            including extuabtion and loss of airway control. We describe a situation
                                            where all the conventionally used tests (moisture condensation, ETCO2,
                                            auscultaion) in the operating room for confiming ETT placement failed to
                                            detect a properly placed ETT leading to multiple reintuabtion/ extubations,
                                            loss of airway control and hypoxemia. The patient was eventually intubated
      Airway Crisis Due to Failure of       and ETT was confirmed with direct visualization, absence of stomach
      Intubation Confirmation Test at       insufflation on auscutation. Patient rseponded to ventilating with low tidal
222   Induction of Anesthesia               volume and high airway pressures and administration of bronchodilators.

                                           Hemothorax can result from a variety of causes. Here we describe a
                                           patient who was POD#1 from iliac conduit and thoracic aortic stent graft.
                                           Upon re-exploration for suspected bleeding, copious blood was evacuated
                                           and hemostasis was achieved. However, hypotension persisted with rising
                                           CVP and mirroring of the CVP and arterial pressure waveforms. We
                                           discovered that the distal lumen of the subclavian venous catheter had
                                           eroded through the vessel wall and was filling the chest with transfused
      Hemothorax and the Equalization of blood, thereby transmitting the arterial pressure waveform to the CVP
      Measured Central Venous and Arterial transducer. This rare possibility should be considered in persistent
223   Pressures                            hypotension with rapidly rising CVP.

                                            The patient has a history of malignant nasopharyngeal cancer treated with
                                            local resection and radiation. There was local recurrence in mandible and
                                            upper airway. Airway examination revealed minimal oral opening with
                                            limited neck range of motion. Nebulized lidocaine was administered
                                            followed by transtracheal lidocaine injection. A McGrath scope was placed
                                            without patient discomfort. The larynx was unable to be visualized
                                            secondary to tumor. An endotraceal tube was placed in proximity to the
      Woman with Obviously Difficult Airway larynx and a flexible bronchoscope passed through the tube to visualize the
      Presents for Emergent Exploratory     larynx. The bronchoscope passed easily into the trachea, and the
224   Laparotomy                            endotracheal tube was advanced without complication.

                                                                   Page 74

                                             A 63 yo male with a history of hyperlipidemia, AAA, CAD status post
                                             coronary stents 7 years ago, and hypertension underwent a a cystoscopy,
                                             cystolitholapaxy, percutaneous nephrolithotomy and removal of a retained
                                             ureteral stent. Preoperative medications included Plavix and ASA, which he
                                             discontinued 7 days and 1 day preoperatively, respectively. In the PACU he
                                             developed angina with ST elevations in V3 - V4 and ST depressions in
                                             leads II and III. He emergently underwent coronary angiography which
      Postoperative Myocardial Infarction in revealed thrombosis in the area of the coronary stent. The procedure was
225   a Patient with Corony Stents           uncomplicated, and he was discharged 6 days later.

                                            71 year old female, scheduled for laparoscopic, hand assisted, partial
                                            nephrectomy for renal mass, with a past medical history of rheumatic heart
                                            disease, left breast cancer, chemotherapy and radiation treatment;
                                            presented an extremely difficult intubation due to distorted anatomy,
                                            requiring fiber-optic intubation via an intubating LMA. During insufflation,
                                            she developed decreasing saturation with increasing shunt and worsening
      An Unusual Case of Sudden             compliance, despite increased FIO2 and PEEP, resulting in aborting the
      Desaturation during an Attempted      procedure. Intraoperative chest x-ray showed increased left lung opacity,
      Laparoscopic Partial Nephrectomy in   while immediate bronchoscopy was negative. Patient was admitted to SICU
      a Patient with Recent Breast Cancer   and discharged home after successful extubation and unremarkable
226   and a Difficult Airway                postoperative course.

                                            A 72-year-old female with isolated melanoma of the right foot presented for
                                            hyperthermic isolated limb chemotherapy. As the concentration of
                                            melphalan in the limb can be 10 times the systemic dose, the focus of
                                            anesthesia is to detect and prevent limb-to-systemic leak. Anesthesia was
                                            maintained with propofol and remifentanil; the perfusionist administered 3%
                                            desflurane into the by-pass circuit. A continuous detection of [gt] 0.08%
                                            end-tidal desflurane would suggest systemic leak. To prevent systemic
      Anesthetic Considerations for         leak, a gradient [gt] 2mm Hg between CVP and limb venous pressure was
      Hyperthermic Isolated Limb            maintained. Small leaks were treated by manipulation of pump flow,
227   Chemotherpy                           systemic BP, and CVP.

                                                                   Page 75

                                              7-year-old male with sickle cell disease presented with a 12-hour history of
                                              priapism. Past medical history significant for 3 previous acute chest
                                              syndromes with one ICU admission and numerous pain crises.
                                              Hemoglobin/hematocrit was 7.1/24.3. In ER, attempts to reduce priapism
                                              unsuccessful. Brought to OR emergently for Winter shunt procedure as
                                              urology felt risk of fibrosis and impotence. Compatible blood not
                                              immediately available. ASA monitors were placed, 4L/min nasal cannula
      Caudal Anesthesia for an Emergent       oxygen provided and room warmed to 80 degrees. Midazolam 2mg and
      Winter Shunt Procedure in a 7-Year-     Ketamine 5mg IV given for sedation. Caudal block was performed using
228   Old Sickle Cell Patient with Priapism   10ml 0.5% bupivicaine. Winter shunt peformed and priapism resolved.

                                              A 35 year-old morbidly obese female presented urgently for tracheal repair
                                              via right posterolateral thoracotomy. Patient had skin lesions excised
                                              under GETA without complications the previous day but developed
                                              progressive subcutaneous emphysema and hemodynamic instability
                                              overnight. Bronchoscopy revealed 4.5cm posterior tear 2.5cm from carina
                                              with esophageal herniation. Left bronchus mainstemed with 7.5mm ETT
                                              placed under GlideScope and fiberoptic guidance. Anesthesia maintained
                                              with one lung ventilation, sevoflurane, and FiO2 1.0. Patient manually
                                              ventilated but later tolerated PC mode, PEEP 6, and VT [sim]400ml.
      Anesthetic Management of Tracheal       Patient extubated in OR and discharged home POD#5. Iatrogenic
229   Injuries                                tracheal injuries are rare and often challenging to manage.

                                           Female patient with large newly diagnosed tumor at the head of the
                                           pancreas presented for routine pre-operative abdominal/pelvic CT. She
                                           was noted to have an enlarged bronchial artery which occluded the
                                           posterior region of the tracheal lumen. She was recently diagnosed with
      Complex Whipple Surgery in a Patient myasthenia gravis based on bulbar symptoms and started low dose
      with Myasthenia Gravis and Extensive pyridostigmine. Pre-operative concerns for prolonged intubation leading to
      Bronchial Artery Dilation: Regional  erosion of bronchial artery into tracheal lumen versus requirement for
      Technique Resolves the Dilemma of muscle relaxation to adequately approximate surgical site. Thoracic
      Muscle Paralysis for Surgical        epidural and high dose volatile anesthetic used intraoperatively, along with
      Exposure vs Risk of Bronchial Artery pressors for hemodynamic stability, allowed for surgical exposure without
230   Rupture from Prolonged Intubation    muscle relaxation.

                                                                     Page 76

                                             A wide variety of esophageal foreign bodies are seen in clinical practice.
                                             Coins are the commonest, whereas denture in the digestive tract has been
                                             reported rarely. We report an impacted denture in the esophagus. A 78
                                             years old woman was admitted to the hospital with one month history of
                                             dysphagia. There was no history of swallowing a foreign body. Radiological
                                             examination did not reveal anything but subsequent endoscopic
                                             examination showed impacted denture in upper esophagus. It could not be
                                             retrieved because of impaction. Cervical esophagotomy was performed
      Removal of Impacted Denture in         under general anesthesia and denture was removed. The anesthetic
231   Esophagus                              challenges will be discussed.

                                             Decisions to proceed with surgery are often difficult in light of a recent
                                             positive stress test. However, sometimes the benefits of surgery outweigh
                                             the risks of any delay to undergo coronary artery revascularization. In this
                                             case report, we present the dilemna of a 65 year old patient with a positive
                                             stress test, in addition to esophageal carcinoma, and is in desperate need
                                             of an open jejunostomy tube for alimentation. The decision making process
232   To J or Not to J: That Is the Question as well as the anesthetic management and outcome are discussed.

                                             44 year old Hispanic male with severe Rhabdomyolysis with acute onset of
                                             pain in calves,thighs,shoulders and back with some weakness. He was on
                                             Zantac and Diclofenac. No significant past medical history. Increased
                                             CPK,BUN 56, Creatinine 4, 3+ blood in urine,CPK 103,934,AST 2900,ALT
      When You Smell a Rat! If We Didn't     907 with acute renal failure were few findings. HIV -ve, P/E showed pitting
      Tell You the Final Diagnosis, What     edema in lower extremities with pain and tenderness in calves.
      Would Be Your Plan for Anesthesia      Hepatomegaly noted. Symptomatic treatment was initiated without resolve.
233   for This Case?                         Patient was scheduled for Muscle biopsy.
                                             An Eritrean patient with an oral mass limiting both oral excursion and
                                             obstructing the oral and nasal pharynx receiving awake fiber optic
                                             intubation, without the benefits of any radiologic workup or visualization of
                                             the anatomy. After multiple failed attempts, the patient received a
                                             tracheostomy to proceed with surgery, which later revealed the anatomic
      Difficult Airways in Medically         challenges to establishing an airway. Resource, medication, and staffing
      Underserved Areas: The Challenges      limitations are discussed as well as the means by which they were
234   of Limited Resources                   overcome.

                                                                    Page 77

                                          46 years old male patient underwent general anaesthesia with epidural
                                          block for hip replacement. Preoperative clinical examination revealed no
                                          abnormalities (normal echocardiography,E.F 55%). Following midazolam
                                          premeditations he developed hypotension and bradycardia , This picture
                                          continued intraoperatively(with additions of hypothermia) requiring fluids
                                          and ephedrine intermittent to maintain systolic blood pressure to 100 ,pulse
                                          60.This persisted postoperatively, EKG showed Twave changes. All
                                          possible causes of hypotension were ruled out .Blood tests showed normal
                                          troponin,very high CK,Thyroid functions profile (very high TSH, very low T4,
      Hashimoto's Thyroiditis Unmasked by extremely high antithyroglobulin and anti TPO).Hashimoto's thyroiditis was
235   Surgery                             diagnosed and treatment was commenced.

                                            We present a 63 year-old female with a retroperitoneal leiomyosarcoma
                                            involving multiple major abdominal vessels. Following aortic and caval
                                            clamping, the supraceliac to infrarenal aorta and infrahepatic inferior vena
                                            cava were resected en bloc and replaced with gortex grafts. The renal
                                            arteries were reimplanted to the graft. The stomach, liver, pancreas,
                                            spleen, and small and large intestines were removed. Ex vivo resection of
                                            the tumor was performed in a bloodless field with clean surgical margins
      Ex-Vivo Resection of a                obtained. Finally, multivisceral autotransplantation was performed. The
      Retroperitoneal Leiomyosarcoma - A    implications of aortic and vena cavae cross-clamping, spinal and renal
      Novel Approach to Bloodless Tumor     preservation, and multivisceral abdominal autotransplantation/reperfusion
236   Resection                             will be discussed.
                                            JM is a patient scheduled for a CABG. [bold]On the MORNING OF
                                            SURGERY, [/bold]vital signs are stable except pulse oximetry on RA is
                                            84%. With 10L O2 via FM, pulse oximetry is 95%. After intubation, ETCO2
                                            is 20 and SpO2 decreases from 95% to 69%. We evaluate for all the
                                            causes of low ETCO2 and low SpO2. We conclude the patient had
                                            developed a PE. Heparin given. TEE showed atrial septal aneurysm, PFO;
                                            clot in the RVOT, RA and right PA. IN THE CATH LAB, Pulmonary
      Detection and Management of           angiogram reveals bilateral PE. The cardiologists used angiojet and tPA to
237   Pulmonary Emboli                      resolve the PE.

                                                                   Page 78

                                            On July 16, 2007, Dr. Bradley Schiff of the Albert Einstein College of
                                            Medicine completed the first robotic assisted total laryngectomy in the
                                            United States. The patient was a 77 year old white male who was
                                            previously treated for primary glottic cancer and had undergone radiation
                                            therapy in 2006. He now presented with recurrent disease in the
                                            interarytenoid space as well as the posterior glottis on the left. The patient
      The First Robotic Assisted Total      was brought to the OR where an awake tracheostomy was performed
238   Laryngectomy in the United States     followed by the robotic assisted total laryngectomy.

                                           The case at hand is a 48 y.o. woman with essential thrombocythemia
                                           resulting in Budd-Chiari syndrome with large thrombus extending from the
                                           inferior vena cava to the right atrium. Multiple TIPS procedures had failed
                                           due to rethrombosis. Pt had renal failure and ESLD with MELD 35.
                                           Orthotopic liver transplant was complicated by post reperfusion syndrome.
                                           Significant hypotension required high doses vasopressor support. Pt
                                           maintained on vasopressin and norepi infusions as surgery continued for
                                           two hours. At this time, pt deteriorated into ventricular fibrillation and
      Liver Transplant Complicated by      asystole. ACLS protocol initiated and continued for 30 minutes upon which
239   Essential Thrombocythemia            pt was declared dead.
                                           56yo male with hepatitis C with refractory ascites and esophageal variceal
                                           bleeds presented for TIPS. Pertinent pre-operative evaluation included
                                           cirrhosis without hepato-renal syndrome, without hepatic encephalopathy,
                                           and included a low MELD score. Patient was lucid and consented to his
                                           procedure. General anesthesia was induced with propofol, cis-atracurium
                                           and intubatation was uneventful. Maintainence included desflurane and
                                           oxygen. After 3hr procedure, pt was extubated and exhibited
                                           [quot]emergence delirium[quot] requiring 4point restraint. When the pt
                                           settled down, pt was unable to answer questions appropriately and was
      Post-Operative Cognitive Dysfunction disoriented x 3. Neurology consultation suggested prolonged anesthetic
      Following Transjugular Intrahepatic  effect. Liver transplant anesthesia consultation strongly suggested hepatic
240   Portosystemic Shunting               encephalopathy.

                                                                    Page 79

                                         A 64 year old, 51kg female with difficult airway secondary to neck
                                         chemoradiation presents to the PACU post esophageal dilation. The patient
                                         was extubated in the OR after demonstrating deep breaths to command
                                         and a strong hand-grip; however upon PACU arrival the patient became
                                         lethargic. This was unexpected after receiving 50mg propofol, 20mg
                                         rocuronium, and 2mg midazolam for induction, and maintenance with
                                         sevoflurane without opioid administration. Emergent fiberoptic intubation
                                         occurred and the initial ABG showed a pH of 6.90, PaCO[sub]2 of[/sub] 163
      Unexpected Hypercapnea in the      and a PaO 2 of 120. We conclude hypoventilation is still a possibility after a
241   PACU with a Difficult Airway       short case without narcotics.
                                         41 year-old female involved in motor vehicle collision arrived to OR for
                                         emergent sternotomy. Patient had multiple injuries including laceration of
                                         atrial/caval junction. A Trauma Exsanguination Protocol (TEP) was
                                         activated. The TEP supplied the OR with PRBC, FFP, and Platelet units in
                                         a predetermined ratio and in an automatic fashion. During sternotomy and
                                         surgical repair, estimated blood loss was over 30 liters. Surgery was
                                         completed with 44 units of packed red blood cells, 20 units of fresh frozen
      Resuscitation of Patient Using a   plasma, and 12 units of platelets. The patient was transported to the ICU in
242   Trauma Exsanguination Protocol     critical but stable condition.

                                         43-year-old male presents for thoracic spine surgery. He had no prior
                                         surgeries. Past medical history included hypertension, anxiety and heavy
                                         alcohol use. He was taken to the operating room for a standard general
                                         endotracheal anesthetic. Attempts to intubate were unsuccessful. Attempts
                                         at securing the airway using an intubating laryngeal mask airway and
                                         fiberoptic bronchoscope were unsuccessful. Adequate ventilation was still
                                         possible, however the patient's oxygen saturations remained 86%. A
                                         surgical airway was decided on rather than awakening the patient due to
      Successful Management of an        respiratory concerns. Evaluation of the patient after this event showed no
243   Unanticipated Difficult Airway     signs of sequelae from his hypoxemic episode.

                                                                 Page 80

                                             A 7w.o infant was diagnosed with a Shones complex-a parachute MV,
                                             critical AS , coarctation of the aorta, TR and left ventricular dysfunction due
                                             to endocardiofibroelastosis (EFE). He was considered unsuitable for a
                                             norwood procedure, having already undergone an atrial septoplasty and an
                                             Aortic valuloplasty. He was scheduled for a Hybrid procedure wherein a
                                             sternotomy was performed by the surgeons for pulmonary banding. The
                                             patent ductus arteriosus was then stented by the interventional cardiologist.
      Anesthetic Management of an Infant     We present the various anesthetic challenges involved in the management
      Undergoing a Hybrid Procedure for a    of this child with a rare and highly complex CHD undergoing a Hybrid
244   Shones Complex                         procedure.

                                             A 7-month-old infant was scheduled for cranioplasty under general
                                             anesthesia. Patient's history was significant for frontal craniosynostosis,
                                             developmental delay and hypotonia. Uneventful inhalation induction with
                                             sevoflurane/O2/N2O, easy intubation, invasive monitors and precordial
                                             Doppler placed; patient was placed in supine position. After incision, end-
                                             tidal CO 2 progressively diminished over a 45 minute period followed by a
                                             sudden bradycardia. Participants will discuss the etiologies for loss of end-
                                             tidal CO 2: that is, air embolism, atelectasis of lung, tension pneumothorax,
                                             and cardiac tamponade. The proper actions should be taken to resuscitate
      Loss of End Tidal CO2 and              this patient: PALS, CXR, flexible Fiberoptic bronchoscopy, ENT
245   Bradycardia during a Cranioplasty      consultation.

                                             Laryngotracheal stents are life-saving measures in children with severe
                                             laryngotrachealmalacia. But when a child developes an upper respiratory
                                             infection with a fresh stent in place, an anesthetic nightmare developes. A 7
                                             year-old male with severe laryngotrachealmalacia underwent a stenting
                                             procedure despite a productive cough. The surgeon found that the copious
                                             mucus would allow downward displacement of the stent below the level of
      A Nightmare on 210th Street -          the defect with each cough, and airway obstruction would still occur. Our
      Laryngotracheal Stents, Upper          mission was to safely anesthetize the child while the surgeon removed the
      Respiratory Infections, and Productive stent, performed a tracheostomy, and replaced the stent above the
246   Coughs                                 tracheostomy tube to anchor the stent.

                                                                     Page 81

                                             14 year old Achondroplastic dwarf with Jeune's syndrome (Asphyxiating
                                             Thoracic Dystrophy) and a tracheostomy undergoing surgery in the prone
                                             position. The patient presented with C2-C3 spinal cord compression
                                             requiring posterior cervical spine decompression and fusion. Difficulties
                                             encountered with prone ventilation through a cuffed tracheostomy tube
                                             necessitated aborting mid case. During a subsequent surgery,
                                             tracheostomy tube was exchanged with an armored endotracheal tube
                                             eliminating ventilatory difficulties. There are no consensus guidelines for
      Tracheostomy Complications in an       perioperative management for prone surgery with a tracheostomy. We
      Achondroplastic Dwarf with Jeune's     advocate exchanging a tracheostomy tube to an armored endotracheal
247   Syndrome                               tube for patients undergoing surgery in the prone position.

                                             A 16year old girl presented for an emergency laparoscopy to rule out
                                             ovarian torsion. In the holding area, patient's mother informed the
                                             anesthesiologist that she was forced to sign the consent for this procedure.
                                             Her daughter was placed on 96 hours hold by the ER physician after she
                                             expressed her desire for naturopathic consultation. What are the ethical
                                             ramifications? Should the anesthesiologist participate in the surgery? Does
                                             the 96 hour hold obtained by the ER physician also cover procedures
                                             prescribed by other hospital physicians? Should a minor patient, be allowed
248   To Proceed or Not To Proceed...        to accept or refuse the procedure?

                                              GN is a 10-kg child with significant joint contractures to undergo RLE
                                              tendons release. Born FT with severe craniofacial and skeletal anomalies,
                                              s/p mandibular distraction x2, cleft palate repair, and coronoidectomy with
                                              8mm residual mouth opening. Inhalational induction with oxygen, N2O and
                                              sevofluorane. Nasal airway inserted and connected to anesthesia circuit via
                                              ETT connector with patient breathing spontaneously. Mouth taped closed.
      Management of Known Difficult           IV access obtained. Neonatal FOB assisted endotracheal intubation via
      Intubation and Difficult IV Access in a contralateral naris. After passage of FOB through vocal cords 10 mcg
      22 Month-Old Patient with Escobar's Fentanyl/30 mg Propofol administered. 4.0 uncuffed nasal RAE ETT
249   Syndrome                                passed. ETT position established clinically and confirmed with FOB.

                                                                    Page 82

                                        A 12 y/o female with scoliosis and AV canal repair presented with bilateral
                                        pheochromocytomas for subtotal adrenalectomies. Pre-operatively, [alpha]-
                                        blockers, then [beta]-blockers, were titrated to control hypertension. Prior to
                                        induction of general anesthesia, a lumbar epidural catheter was placed
                                        successfully for post-operative pain control. After securing the airway, a
                                        triple lumen catheter was placed for fluid management. Care was taken to
                                        avoid any histamine-releasing agents. A bispectral index monitor was used
      Management of Bilateral           to gauge the depth of anesthesia and follow the catecholamine effect on
      Pheochromocytoma in Child Post AV minimum alveolar concentration. Post-operatively, patient was extubated
250   Canal Repair and with Scoliosis   and transferred to pediatric intensive care unit for close observation.

                                            NEC is the most common neonatal gastrointestinal emergency requiring
                                            surgery and prolonged intravenous access for antibiotics and parenteral
                                            nutrition. It affects approximately 10% of infants weighing less than 1500 g,
                                            with mortality rates of 50% or more depending on severity. A 27-week
                                            premature neonate with multiple bowel resections was scheduled for
      Iatrogenic Cardiac Tamponade after    Broviac placement. Post procedure patient became unstable necessitating
      Broviac Catheter Placement in a       several boluses of epinephrine and resuscitation in the NICU.
      Premature Neonate with Necrotizing    Transthoracic echocardiogram showed cardiac tamponade. Emergent
      Enterocolitis (NEC): A Serious        median sternotomy was performed and right ventricular laceration was
      Complication after a Simple           repaired. Intraoperative PRBC transfusion was required. The child did well
251   Procedure                             post-operatively and was discharged home within weeks.

                                          Case discusses a 15 y.o with severe hypertrophic cardiomyopathy s/p
                                          arrest and AICD insertion 2 yrs ago, with subsequent ischemic cerebral
                                          palsy. He has had progressive extreme scoliosis and presents for
                                          thoracoscopic treatment of empyema following aspiration pneumonia.
                                          Parents desire a full code status. Poster discusses the risks and
                                          challenges managed perioperatively. These include: code status, one lung
                                          ventilation, dehydration,agitation, hypoxemia, avoidance of a hyperdynamic
      Thoracoscopy for Empyema in a Child state, positioning and access challenges. Photographs demonstrate the
      with Pneumonia, Extreme Scoliosis   scoliosis severity and positioning issues. Charts describe decision
252   and Hypertrophic Cardiomyopathy     management strategies, which require balancing diverse objectives.

                                                                   Page 83

                                             Duchenne Muscular Dystrophy (DMD) is a well-known myopathic disorder
                                             with a wide range of complications including scoliosis. A 15 year-old male
                                             with DMD presented for posterior spinal fusion. The patient had significant
                                             cardiomyopathy with LV ejection fraction of 20%, and obstructive sleep
                                             apnea requiring CPAP. Total intravenous anesthesia with propofol and
                                             remifentanil was administered to facilitate motor and somatosensory
                                             evoked potential monitoring. Transesophageal echocardiography was
                                             utilized for intraoperative cardiac function monitoring. Potential triggering of
                                             malignant hyperthermia, risks of prone position, and cardiopulmonary
      Posterior Spinal Fusion in a Patient   comorbidities pose significant anesthetic challenges, and need to be
253   with Duchenne Muscular Dystrophy       addressed in the plan for management.

                                             A 4-week old female, 3 kg, with Pierre Robin Sequence(PRS) presented for
                                             madibular distraction. Physical exam revealed severe micrognathia,
                                             glossoptosis, and cleft palate. After inhalation induction, both direct and
                                             video layngoscopy were unsuccessful. A #1 LMA was inserted and a
                                             bronchial Y connector was attached. This enabled us to provide continuous
                                             oxygen and sevoflurane to the patient. We successfully intubated through
                                             the LMA using a neonatal fiberoptic bronchoscope as a guide. A #3.5
      Difficult Intubation in an Infant with standard ETT was inserted and the LMA was removed using another ETT
      Pierre Robin Sequence - A Case         as a stabilizer. We describe the anesthetic considerations and
254   Report                                 management of our patient with PRS.
                                             A two-and-a-half week old infant presented with hypotonia and failure to
                                             thrive with undiagnosed congenital myopathy. As many congenital
                                             myopathies are sensitive to malignant hyperthermia, a prudent anesthetic
      Spinal Anesthesia in a Two-Week-Old plan was devised so as to allow for vastus muscle biopsy to confirm the
      Full Term Neonate Presenting with      diagnosis. Pt had spinal anesthesia done with tetracaine and MH
      Hypotonia and Failure To Thrive with precautions used in preparation of machine. Vastus biopsy confirmed
      Suspected Congenital Myopathy for      diagnosis of nemaline rod myopathy. Discussion outlines course of
255   Vastus Muscle Biopsy                   anesthetic procedure and outcome.

                                                                     Page 84

                                             A 4 month old ex-premie baby boy with arthrogryposis multiplex congenita
                                             was admitted in intensive care unit because of respiratory distress. His
                                             condition deteriorated necessitating intubation and mechanical ventilation.
                                             Anesthesiology was consulted to manage a possible difficult airway. On
                                             physical examination, he was tachypneic, with intercostal retractions and
                                             his oxygen saturation was 92% on 100% non-rebreathing face mask. His
      Emergent Airway Management in an       mouth opening and his chin looked adequate but his neck was severely
      Infant with Arthrogryposis Multiplex   extended and immobile. His occiput was touching the upper part of his
256   Congenita                              back and because of this he could only lie on his side.

                                             The anesthetic management for surgery of exceptionally large venous
                                             malformations (VMs) can be problematic for the anesthesiologist. The loss
                                             of exterior compression and muscle tone of the supporting tissue of the VM
                                             during general anesthesia can lead to excessive blood pooling to the VM.
                                             We report a case of healthy 18-year-old male patient with congenital
                                             extensive lower limb VM who was scheduled for VM excision but became
      Extensive Venous Malformation          severely hypotensive after patient positioning. Hemodynamic impairment
      Causing Hemodynamic Impairment         was caused by rapid blood pooling to the VM after changing patient
257   during General Anesthesia              position to the prone position during general anesthesia.
                                             We present a case of a normal functioning 6 yo male with congenital
                                             anomalies undergoing resection of hemivertebra and spinal fusion with
                                             instrumentation. The anesthetic plan was designed to allow optimal
                                             monitoring of neurologic function. During the case both sensory and motor
                                             monitoring were lost and 3 wake up tests were required to confirm intact
                                             neuro status. The anesthetic regimen was modified and the child
                                             performed the required movement during 3 separate episodes. The child
      The Wake-Up Test and Pediatric         was re-anesthetized after the third [quot]wake-up[quot] and extubated at
      Spine Surgery - Does It Work for a 6   the end of the case neurologically intact. The patient denied recall of the
258   Year Old?                              wake up events.

                                                                    Page 85

                                         11 month old infant was scheduled for rigid bronchoscopy for a history of
                                         chocking. An inhalational induction was performed. A "bead" was found
                                         occluding the left main bronchus. The surgeon tried to retrieve it, but the
      Anesthetic Challenges in "Passing- patient developed oxygen desaturation. Rocuronium was given and manual
      Through" Technique Using a Fogarty jet ventilation started. Intermittently, we intubated the patient's and used
      Catheter To Remove an              conventional manual ventilation. A Fogarty catheter was used to remove
      Endobronchial Foreign Body from an the beads. Plans and equipments for alternative methods of oxygenation
259   Infant                             and ventilation should be always available in endoscopic procedures.

                                            The child for radiation simulation under anesthesia with current active URI
                                            presents challenges to the Anesthesiolgist especially with parent who
                                            refuses General endotracheal anesthesia .Apparently this child had
                                            presented to the Eye Hospital for workup under anesthesia for evaluation of
                                            bilateral retinoblastoma.Patient had received previous general
                                            endotracheal anesthesia and apparently endotracheal intubation was
                                            difficult or traumatic.Contention arises regarding anesthesia for the child
                                            with active URI as to cancelling or proceeding with elective radiation
                                            simulation under generalendotracheal anesthesia as procedure poses
      The Child for Radiation Simulation    controversy for all concerned.Anesthesiologist must be vigilant for
      under Anesthesia with URI with        laryngospasm,bronchospasm,desaturation coughing,breathholding.Under
      Parent Who Refuses General            inhalation induction,with iv placement and ketamine sedation,patient
260   Endotracheal Anesthesia               underwent procedure uneventfully.

                                            This case report describes the succesful use of blind nasal intubation with
      Unique Airway Management in           tracheal manipulation to intubate a pediatric patient following complete
      Traumatic Tracheolaryngeal            tracheolaryngeal seperation and esophageal rupture from a clothesline
261   Transection                           type injury experienced while riding an all-terrain vehicle.

                                                                   Page 86

                                             Urgent surgical case for substantial buttock wound and cellulitis involving 3
                                             year old male patient with Mitochondrial Cytopathy. Patient had history of
                                             daily seizures, occurring as often as every 15 minutes with a duration of a
                                             few seconds to over a minute. Patient complication arose due to patient's
                                             allergies and his parent's refusal to allow typical anesthetics of propofol and
                                             inhalational anesthetics. As an alternative, sodium thiopental and fentanyl
      Anesthetic Challenges in a Three       was effectively used by anesthesiologist for induction and maintenance.
      Year Old Male with Mitochondrial       Also, oxygen was given via mask with no intubation. The patient recovered
262   Cytopathy                              uneventfully in the PACU and was discharged the following day.

                                            Life threatening hypersensitivity reactions to hydroxyethyl starch (HES)
                                            carry an incidence of 0.006%. Our patient is a 13-year-old, 37-kg male with
                                            moderate asthma and minor facial congenital abnormalities who underwent
                                            otoplasty for a left ear deformity. The operative course was complicated by
                                            a severe hypersensitivity reaction, which occurred 10 min after the initiation
      Devastating Hypersensitivity Reaction of a HES infusion. The reaction presented as a severe bronchospasm
      to Hydroxyethyl Starch in an          followed by hypotension, both of which were only responsive to significant
      Asthmatic Pediatric Patient. Our Case doses of epinephrine, followed by a 24 hour infusion. This case resembles
      Supports the Identification of a      several rare occurrences of life threatening hypersensitivity reactions to
263   Population at Risk for Such Reactions HES in asthmatic patients.

                                          A 2 day old male with a tracheoesophageal fistula and imperforate anus
                                          presented for repair of TEF and colostomy. Following repair of the TEF
                                          and prior to the colostomy, a caudal epidural catheter was placed in the
                                          lateral position. The catheter was tunneled until the tip was approximated
                                          to be in the low thoracic region. The infant received 0.25% bupivacaine
      Repair of Tracheoesophageal Fistula through the catheter during the remainder of the case. No intravenous
      in a Neonate Managed with a         narcotic was administered following placement of the catheter. Upon
      Caudally Placed Thoracic Epidural   completion of surgery, the patient was extubated and the epidural catheter
264   Catheter                            was removed prior to leaving the operating room.

                                                                     Page 87

                                            9 year old child with Idiopathic Generalized Dystonias presented for
                                            Implantable Pulse Generator for Deep Brain Stimulation therapy to control
                                            severe dystonias which were causing difficulty writing, balancing and gait
                                            problems after failing optimal medical therapy. Under normal
                                            circumstances, this case would be done under general anesthesia because
                                            children donot tolerate being awake and donot cooperate during such
                                            procedures. Propofol (0-300 mcg/kg/min) and Dexmedetomidine (0.05-0.5
      Implantation of Pulse Generator for   mcg/kg/min) infusions were titrated very precisely so the child could be
      Deep Brain Stimulation Therapy in a   awake during the critical portions of the surgery. This presents as a
      Child under Deep Sedation - A         challenging situation for the anesthesiologist especially because the patient
265   Challenging Case Scenario             is a child.

                                            A 13-year-old female with cleft lip and palate presented for an elective
                                            reconstructive procedure. Following a mask induction and IV placement
                                            she was paralysed with vecuronium. Dexamethasone and ondansetron
                                            were administered for post operative nausea and vomitting. Shortly
                                            thereafter she developed ventricular tachycardia requiring cardiopulmonary
                                            resuscitation.Subsequently, 12-lead EKG revealed QT interval to be 460
                                            ms. Cardiac enzymes were negative. Serial EKG's over the next two days
      Ventricular Tachycardia Following     revealed no improvement of QT interval which remained
      Administration of Ondansetron         prolonged([gt]460). Cardiology diagnosed our patient with prolonged QT
      (Zofran) in Child with Prolonged QT   syndrome and ordered a genetic evaluation for evidence of inherited long
266   Syndrome                              QT syndrome (genetic report is pending).
                                            A 12 y/o male presenting for palliation of neuromuscular scoliosis with
                                            posterior spinal fusion was positioned prone following induction of
                                            anesthesia. Two hours following incision, he developed severe metabolic
                                            acidosis (MA) that was rapidly accompanied by hypotensive shock.
                                            Marginal improvement was obtained with appropriate pharmacologic
                                            support (fluids, sodium bicarbonate, dopamine, phenylephrine, and
                                            vasopressin). MA and vital signs improved only by ending surgical
                                            compression and changing to supine position. Clinical manifestations (MA
                                            and shock) were classic for anhepatic phase of liver transplant.
      Profound Intraoperative Metabolic     Anesthesiologists often underestimate the physiological effects of the
      Acidosis and Hypotension in a Child   prone position, where splanchnic and hepatic perfusion can be
267   Undergoing Multilevel Spinal Fusion   compromised.

                                                                   Page 88

                                           Awake craniotomy is frequently utilized during the resection of
                                           epileptogenic foci near eloquent areas of cerebral cortex in patients with
                                           intractable epilepsy. Anesthetic techniques for the performance of awake
                                           craniotomies range from local anesthesia with light or deep sedation to
                                           general anesthesia during the asleep awake asleep method. We describe
                                           the anesthetic management of an awake craniotomy for a seven-year-old
                                           female with intractable epilepsy. The asleep awake asleep technique was
      Anesthetic Management of an Awake performed. We believe that this is the youngest patient described to have
      Craniotomy for Epilepsy Surgery in a this procedure. With appropriate patient selection this is a safe and
268   Seven Year Old Female                acceptable anesthetic technique for children.

                                             KP is a 10 year old female who presented to the ED with a one day history
                                             of emesis, a 3 month history of intermittent chest pain and a clinical picture
                                             consistent with hypovolemic shock. CXR revealed congenital
                                             diaphragmatic hernia. Chest CT showed volvulus of the stomach through a
                                             diaphragmatic defect with acute rupture of the gastric wall into the left
                                             hemithorax resulting in tension hydropneumothorax. The patient presented
      Anesthetic Care of a Ten Year Old      to the OR for decompression of the left chest and operative repair of the
      Child Presenting with Ruptured         perforation. We discuss the anesthetic management of this uncommon
269   Strangulated Bochdalek Hernia          presentation of congenital diaphragmatic hernia.

      Four Month Old Hospice Care Male
      with Amniortic Bands, Facial Clefts,
      Acrania and Total
      Meningoencepalocele for VP Shunt,
      Laparoscopic Hernia Repairs and        Four Month Old with massive craniofacial malformations, previously to
      Peritoneal Shunt Placement, Plastic    have no interventions but comfort care, presents for a long list of
      Surgical Reduction of Redundent        procedures after Ethics Committee Consultation allows surgical
270   Scalp and Sundry Other Procedures      intervention for Parent's complaint of headache/discomfort.

                                                                     Page 89

                                         Opclonus-Myoclonus syndrome is a rare neurologic disorder manifesting
                                         with twitching and involuntary eye movements. A 2-yr old boy presents for
                                         adrenalectomy for neuroblastoma with OMS. Sources suggest
                                         benzodiazepenes, opiates, and any psychotropic agents should be avoided
      Anesthetic Management of           for patients with OMS. Data is insufficient regarding the effects of using
      Opsoclonus-Myoclonus Syndrome: A these drugs. We present our peri-operative management strategy for this
      Rare Associated Syndrome of        patient, whose post-operative course revealed no noticeable residual
271   Neuroblastoma                      effects from our anesthetic.
                                         A new and innovative procedure now offered at Children's Memorial
                                         Hospital is the hybrid procedure in place of the norwood operation for stage
      The Children's Memorial Hybrid     I palliation in neonates with hypoplastic left heart syndrome. I will present
      Experience. The Perioperative      the perioperative anesthetic management of this special patient population
      Management of the Neonate with     based on the ten patients that we have cared for at Children's Memorial
      Hypoplastic Left Heart Syndrome    Hospital. We will pay special attention to the intraoperative physiological
272   Scheduled for the Hybrid Procedure changes that we have experienced.

                                            Botulinum toxin type A has been used off-label for several applications. The
                                            patient is a 14 years old male, with cerebral palsy scheduled for
                                            chemodenervation with Botox. Anesthesia was induced and maintained
                                            with oxygen/nitrous oxide and sevoflurane. He developed a dystonic
                                            reaction of his extremities, predominantly his tongue which was protruding
                                            from his mouth. Gradual improvement occurred the following days. This
                                            adverse event after intramuscular local injection of Botox could be
                                            explained by different mechanisms. Although self limited, patients with
                                            communication problems experiencing postoperative complications pose a
      Dystonic Reaction after Botox         challenge for the care team, especially in the context of prescheduled
273   Injection in a Pediatric Patient      ambulatory care.

                                                                   Page 90

                                               We present a case of 15 y/o female with Goldenhar syndrome who
                                               underwent mandibular osteotomy and genioplasty at an outside hospital.
                                               The post-operative course was complicated by acute left hemispheric
                                               stroke secondary to MCA dissection on POD # 1. The patient was
                                               subsequently started on enoxaparin to reduce the risk of recurrent stroke.
      Airway Management of Patient with        On POD #5, she developed massive epistaxis and was scheduled for
      Goldenhar Syndrome and Massive           bilateral distal internal maxillary artery embolization by the interventional
      Epistaxis Following Facial               radiologists. We present the anesthetic management of this complicated
274   Reconstruction Surgery                   patient with known difficult airway and upper airway bleeding.
                                               A 9 year old boy with bipolar disorder suffers a type III supracondylar
                                               fracture and is currently on Ziprasidone (Geodon) and Lithium. In this
                                               presentation we will discuss special considerations of the bipolar child as
                                               well as the toxicity, side effects and anesthetic interactions of both of these
                                               drugs. Several scenarios will be presented, some of which include
                                               prolonged QTc and torsades de pointes, malignant hyperthermia vs
                                               neuroleptic malignant syndrome, prolonged muscle paralysis, and the
      Anesthetic Considerations for the        decision process on whether or not to proceed in the face of lithium toxicity
275   Pediatric Bipolar Patient                and if so, what should be done.
                                               The diagnostic workup for a patient with a mediastinal mass includes a
                                               lumbar puncture and bone marrow aspiration for diagnosis and therapy.
                                               Any sedation or anesthesia for this procedure can place the patient at risk
                                               for life threatening airway obstruction. Here, we present a case of a patient
                                               with a large life threatening mediastinal T-Cell lymphoma who received
      Intrathecal Fentanyl for Combined        excellent analgesia for her bone marrow aspiration by receiving IT fentanyl
      Lumbar Puncture and Bone Marrow          with her first IT dose of cytarabine. Intrathecal fentanyl can provides a safe
      Aspiration in a Pediatric Patient with a alternative form of analgesia for patient's with fragile cardiopulmonary
276   Mediastinal Mass                         status.

                                           During a routine Spica cast replacement on a 14 month old child with
                                           congenital bilateral hip dysplasia, cardiac arrest occurred after
                                           lagysgospam followed LMA removal and succynylcholine administration.
                                           What followed tested the readiness of the OR team to handle this clinical
                                           scenario, demonstrate clinical skills needed for logical decisions and prove
      Is Your OR Team Ready To Handle a whether or not the OR team communications are effective and timely.
277   Cardiac Arrest during a Simple Case? Outcome and lessons learned during the event will be shared.

                                                                       Page 91

                                             We describe a novel approach to managing a difficult airway in an 18-
                                             month-old child, who had an abnormal facial and cervical anatomy
                                             following burn injury. An inter-disciplinary approach with involvement of
                                             experienced personnel lead to a clear pre-formulated plan of action. The
                                             first step was the establishment of a safe method for gas exchange as a
      Preemptive Extra-Corporeal             precautionary measure. This was achieved by ECMO via cannulation of
      Membrane Oxygenation (ECMO) for femoral vein during ketamine sedation and analgesia. The second step
      Gas Exchange Prior to Establishment was induction of general anesthesia while the child was on ECMO. The
      of Safe Airway for Surgical Release of third step was the release of neck contractures to facilitate endotracheal
278   Face and Neck Contractures             intubation.

                                          2,4-Dienoyl-CoenzymeA Reductase Deficiency is a newly discovered
                                          mitochondrial disorder with unknown anesthetic implications. The only
                                          surviving patient with this condition is a 31-month-old, 9kg boy with global
                                          hypotonia and developmental delay who was scheduled for open Nissen
                                          fundoplication and gastrostomy tube. General anesthesia augmented by
                                          ultrasound-guided rectus sheath and transversus abdominis plane blocks
                                          facilitated an uneventful intraoperative course, while avoiding
      Novel Pediatric Regional Anesthetic neuromuscular blockade and minimizing intraoperative and postoperative
      Technique in the Unconventional     opioid requirement. Discussion will focus on the anesthetic implications of
      Management of a Patient with a Rare this metabolic disorder and ultrasound images of the regional anesthetic
279   Mitochondrial Disorder              techniques.

                                             Baby A has an in-utero diagnosis of HLHSIS. Without prompt intervention
                                             to decompress the left atrium and alleviate pulmonary venous obstruction
                                             this complex cardiac condition is fatal soon after birth . The parents are
                                             aware of the severity of the diagnosis but wish for everything to be done to
                                             save their baby. Plans are made to deliver the baby via Cesarian section at
      Anesthetic Management of the           38 weeks gestation in a cardiac catheterization lab at the children's
      Newborn with Hypoplastic Left Heart    hospital. After delivery the baby will be taken to an adjoining catheterization
      Syndrome and Intact Atrial Septum      lab for femoral vascular access and emergency atrial septostomy and atrial
280   (HLHSIS)                               stent placement.

                                                                     Page 92

                                        Six year old female child with Goldenhar syndrome and complex congenital
                                        heart disease including pulmonary atresia and single ventricle physiology
                                        who presented for a second opinion regarding surgical options. Medical
                                        history was significant for oculo-auriculo-vertebral anomalies with
                                        dysmorphic facial features including right hemifacial microsomia, maxillary
                                        and mandibular hypoplasia, microtia, significant alar collapse, right
                                        anophthalmia, severe kyphoscoliosis, obstructive sleep apnea, failure to
                                        thrive, developmental delay, s/p BT shunt and Glenn procedure. We report
                                        anesthetic management addressing issues such as difficult airway, single
      Complex Pediatric Case Management ventricle physiology combined with remote location of the Cardiac MRI
281   in Remote Location                suite in order to delineate cardiac anatomy.

                                            4 year old 20 kg, male presented with complaints of several days of facial
                                            and neck fullness, headaches and difficulty sleeping in the supine position.
                                            A CXR revealed an enlarged mediastinum; CT was consistent with large
                                            anterior mediastinal mass causing significant compression of the
                                            intrathoracic trachea to as far as the carina. At its most flattened level the
                                            trachea measured 1.2 mm x 16 mm. The patient was scheduled to have
                                            mass biopsy, bone marrow biopsy and a lumbar puncture. A combination
      Large Anterior Mediastinal Mass       of dexmedetomidine and ketamine provided adequate depth of anesthesia
282   Biopsy Challenges                     while maintaning spontaneous respirations.

                                         This 6 month old infant female presented for direct laryngoscopy and
                                         bilateral tibial osteotomies. She was diagnosed at birth with multiple
                                         pterygiium sydrome also known as Escobar syndrome. Her parents were
                                         told that this particular syndrome was associated with malignant
                                         hyperthermia and she was to tell all of her physicians this fact. Despite a
                                         literature reviewe and talking with the parents, it was decided to treat the
      Anesthesia in a Child with Escobar patient as malignant hyperthermia susceptible. Should this have been
      Syndrome. Does She Have Malignant handle in such a manner since their are no anethesia reports of malignant
283   Hyperthermia?                      hyperthemia in children with Escobar syndrome.

                                                                    Page 93

                                           13 year old female underwent AV/MV repair. Preoperatively on 2D echo the
                                           AV was described as unicuspid but was noted to be bicuspid on 3D echo
                                           intraoperatively. Post Cardiopulmonary bypass (CPB), two jets of MR were
                                           noted on 3D TEE. CPB was reinstated for further repair. PICU discharge
                                           occured on POD #1. This case represents a favorable outcome for valve
      The Usefulness of Intraoperative     repair in a pediatric patient utilizing 3D TEE. This technology offers
      Three-Dimensional Transesophageal detailed evaluation of cardiac anatomy, flow velocities, and fuction. The
      Echocardiography (TEE) in Pediatric future of 3D echo is promising and may soon become an integral part of
284   Aortic/Mitral Valvular Heart Surgery cardiac evaluation in the surgical patient.

                                             We want to present the typical after hours emergency type of case when
                                             the anesthesia provider needs to make a clinical decision. The clinical
                                             scenario is that of an infant with full stomach coming with a significant CSF
                                             leak and the mother is telling you that the patient has been difficult IV stick
      Challenging Induction in a Pediatric   in the past . The neurosurgeon informs you that he wants to go to the OR
285   Patient                                immediately because of the risk of CNS infection.

                                             CHARGE association is a nonrandom pattern of congenital anomalies that
                                             has an estimated prevalence of 1:10,000. The acronym stands for
                                             colobomas of the eye, heart anomalies, atresia of the choanae, retarded
                                             growth or central nervous system anomalies, genital anomalies or
                                             hypogonadism, ear anomalies or deafness. Features associated with
                                             CHARGE association such as micrognathia, laryngomalacia and facial
                                             nerve palsy may result in difficult airway management. We describe the
      The Anesthetic and Airway              airway and anesthetic management of a 10-year-old female, 21 kg, with
      Management of a Patient with           CHARGE association and history of difficult airway who presents for dental
286   CHARGE Association                     rehabilitation.

                                                                     Page 94

                                              A 20-month old female with Marden-Walker syndrome presents for
                                              bronchoscopy. As the product of consanguineous marriage, both the
                                              patient and her twin brother have multiple congenital abnormalities.
                                              Anesthetic considerations include small mouth, retrodisplaced jaw, choanal
                                              stenosis s/p tracheostomy, diffuse spasticity, developmental delay,
                                              epilepsy, and ventriculoperitoneal shunt. She requires CPAP with oxygen
                                              supplementation and repeated tracheal suctioning. GA initiated by smooth
                                              inhalation induction via tracheostomy; maintenance with sevoflourane and
                                              fentanyl. IV access was challenging secondary to significant contractures of
      Anesthetic Considerations in a          the fingers, pronator deformities of the legs, muscular hypotonia and dense
      Toddler with Marden-Walker              connective tissues. Glycopyrollate given for excess tracheal secretions. No
287   Syndrome                                anesthetic complications.
                                              A 16-year old male presented to the intensive care unit with virulent
                                              Influenza A, Group A Streptococcus pneumonia, and septic shock. The
                                              patient had left lung consolidation and right lung hyperaeration. Our
                                              pediatric anesthesia group was consulted to place a double lumen
                                              endotracheal tube to allow for differential lung ventilation. Differential
                                              ventilation was continued until the patient was stable enough to resume
                                              identical two lung ventilation. The request for double lumen tube
                                              placement in the PICU is rare. We review steps taken to insure patient
      Differential Lung Ventilation in the    safety by establishing a protocol for proper use of this endotracheal tube by
288   Pediatric Intensive Care Unit           pediatric intensivists.
      Successful Completion Fontan in a 4
      y/o Male with Double Outlet Right       In this case report we describe the anesthetic management of a 4 year old
      Ventricle and D-Transposition of the    male with D-TGA, DORV, and pulmonary atresia, status post successful
      Great Vessels Status-Post Ventricular   ventricular septum stenting in the cardiac catheterization lab complicated
      Septum Stenting with Intraoperative     by an intraoperative MI 6 months previously, with a complex medical and
289   MI                                      surgical history, undergoing a completion Fontan.

                                                                     Page 95

                                             Our case involves a 15 year old with Duchennes Muscular Dystrophy
                                             having a posterior spinal fusion levels T4 to L1. Secondary to a decreased
                                             ejection fraction and severly impaired PFT's it was decided that a TIVA
                                             using dexmedetomidine, propofol and sufentanil would be optimal.
                                             Monitors used included ASA standard CVP. and arterial line . There was an
      Use of Dexmedetomidine for a           initial suggestion that SSEP's might be used, but this was not available for
      Posterior Spinal Fusion in a 15yo with the case. The case lasted under five hours and the patient was awake with
290   Duchennes Muscular Dystrophy           stable vitals, and responding to questions upon arrival to the PICU.
                                             With major advances in congenital cardiac surgery over the past 30 years,
                                             an increased number of children born with congenital heart disease (CHD)
                                             are surviving into adulthood. Consequently, the incidence of an
                                             anesthesiologist caring for patients with repaired CHD has also risen. This
                                             case report describes an 18-year-old female with Down's syndrome status-
                                             post complete avtrioventricular canal repair presenting for
                                             esophagoduodenoscopy. Her past medical history was complicated by
                                             GERD, autism, remote history of seizures, and history of difficult intubation.
      Anesthetic Management of a Patient Aside from the anesthetic implications of CHD, this case was particularly
      Status-Post Complete Atrioventricular challenging since the patient was uncooperative and had multiple co-
291   Canal Repair                           morbidities.

                                              A 2-year-old male status post gunshot wound to the abdomen was
                                              transported to Ryder Trauma Center on 4/18/2008. Patient arrived awake
                                              yet lethargic with evidence of bilateral lower extremity paraplegia. Rapid
                                              sequence induction with thiopental and succinylcholine followed by the
                                              administration of Sevoflurane for maintenance was performed for emergent
                                              exploratory laparotomy. One hour and 45 minutes after induction the
                                              patient developed increased EtCO 2, acidosis, tachycardia, and
                                              hyperthermia. The patient was treated successfully for Malignant
      Emergency Treatment of Malignant        Hyperthermia with the help of the Malignant Hyperthermia Hotline physician
      Hyperthermia in a Pediatric Patient     and diagnosed three days later in the ICU after control of the Malignant
292   with an Abdominal Gunshot Wound         Hyperthermia symptoms.

                                                                     Page 96

                                            RD, 3 months, presented to Interventional Radiology for US-guided
                                            sclerotherapy. Of note, coagulopathy was identified and corrected 24 hours
                                            preoperatively. RD was cautiously intubated, IVs secured, labs sent, and
                                            case initiated. He deteriorated unexpectedly (exsanguination), requiring
                                            significant product and pressor resuscitation. RD and one anesthesiologist
                                            endured similar anesthetics over 4 months (biopsies, MRI/CT,
                                            bronchoscopies), culminating with extensive facial/neck mass resection.
                                            Each case posed numerous challenges: Optimal location (operating room,
                                            NICU, radiology); Optimal admitting service (hematology, otolaryngology,
                                            radiology, plastic surgery); Difficult airway: traumatic intubations; Vascular
      Grapefruit-Sized Facial/Neck Mass -   access: peripheral versus central; Dependency/withdrawal; Consultants;
      A Case of Misdiagnosis and            When to postpone; When to abort; Incorrect diagnosis; Pathology report:
      Anesthetic Implications: Presumed     complete absence of lymphatic-vascular tissue; Diagnosis: infantile
293   Lymphatic-Vascular Malformation       myofibroma.

                                            Anaphylaxis can be one of the most devastating complications of the
                                            perioperative period.We present a case of a 14 year old patient undergoing
                                            right thoracotomy for excision of a large right upper lobe cystic mass. Soon
                                            after induction and positioning, the patient suffered cardiopulmonary arrest.
                                            In this case report, we discuss diagnosis of anaphylaxis incuding the use
                                            serum tryptase level to support the diagnosis . We shall also discuss the
      Anaphylactic Shock under General      treatment of acute anaphylactic shock with a[sub]1[/sub]-agonist therapy
294   Anesthesia in a 14 Year Old Boy       and its support in the literature.

                                            A pedriatic patient mask induced and NDMR with easy direct laryngoscopy
                                            and intubation but impossible ventilation without capnograph curve in three
                                            subsequent occasions. Carefully examination of the ETT showed a
                                            complete obstruction of the lumen of the ETT connector by a thin clear
                                            membrane. Small-sized ETTs are prone obstruction with potential harmful
                                            consequences previously reported from diverse sources but none for a
                                            manufacturing defect like this. ETT is part of the routine checklist of
                                            anesthesia equipment and includes its patency and absence of leakage.
      A Challenging Acute Airway            Awareness about acute airway obstruction and systematic approach when
295   Obstruction in a Pediatric Patient    dealing with such critical events is important.

                                                                    Page 97

                                          Infant female with Pierre Robin Syndrome, admitted in respiratory distress
                                          at 14 days old to pediatric ICU. At 15 days old, patient was intubated with
                                          placement of bilateral mandibular osteotomies and external distraction
                                          device. Patient, a difficult intubation, required fiberoptic intubation through
                                          an LMA. At 23 days old, patient was extubated. Airway occulusion occurred
      A 23 Day Old Female Patient with    when patient's chin kept falling forward, resulting in oxygen desaturation.
      Pierre-Robin Syndrome Who           An alternative airway stabilization device, the Jimbo, consisting of soft
      Developed Airway Complications of   foam, was fit around the existing external distraction device. The Jimbo
      Airway Occlusion and Oxygen         effectively prevented the chin from slipping forward. Airway oxygen
296   Desaturation                        saturation was thereafter maintained at 100%.

                                          The Pierre Robin Sequence is a birth defect characterized by micrognathia,
                                          cleft palate, and glossoptosis. The clinical implications of these features
                                          include airway obstruction and problematic intubations. A 1 year old 8kg
                                          female with Pierre Robin Sequence was scheduled for bilateral
                                          myringotomy and palatoplasty under general anesthesia. Two attempts at
                                          direct laryngoscopy with a Miller #1 blade failed to visualize vocal cords.
                                          Initial attempt at visualization with glidescope revealed a leftward deviated
      Pierre Robin Sequence: Is Video     larynx with narrow glottic opening. We describe the management of the
      Laryngoscopy a Good Fit for the     airway in a patient with Pierre Robin Sequence with the use of video
297   Airway?                             laryngoscopy.

                                          A fourteen year old autistic male who lived in a group home presented for
                                          right hepatectomy accompanied by his 24 year old brother/guardian. PMH
                                          included autism and morbid obesity. Medications included Risperidone and
                                          Quetiapine. When the anesthesiologist put his arm around the patient to
                                          calm him, the patient ran aimlessly around the holding area and had to be
                                          forcibly restrained as a Ketamine dart was injected. Postoperatively, the
                                          patient was required to remain intubated until discharge as not to interfere
      Anesthesia for Autistic Spectrum    with postoperative care. Knowledge of autistic spectrum disorders at the
298   Disorder                            time of this case could have avoided this chaotic course.

                                                                  Page 98

                                              Distal type spinal muscular atrophy (SMA) is a rare condition of anterior
                                              horn cell degeneration which results in weakness and atrophy of the distal
                                              extremity muscles. There are no medline reports of anesthetic
                                              management for distal SMA. We present the case of a 10 year old female
                                              with distal SMA who presented for growing rod insertion, with anesthetic
                                              management complicated by difficult airway and intraoperative arrest.
      Anesthetic Management of a Child        Interesting discussion points from this case include: anticipation and
      with Distal Spinal Muscular Atrophy     preparation for difficult airway, avoidance of halogenated inhalational
      Complicated by Difficult Airway and     agents, neuromuscular blockade, and succinylcholine in this population,
299   Intraoperative Arrest                   and resuscitation in the prone position.

                                              3 month baby with cleft lip scheduled for routine cardiac catheterization for
                                              ASD. After intubation there was immediate desaturation despite the
                                              ETTube being placed at the recommended depth for infants. Since there
                                              was no improvement with withdrawal of the ETTube, a fluoroscopic look
      "Pig Bronchus" or "Bronchus Suis" as showed the ETTube placed well above the carina but below the abnormal
      the Cause for Persistant Atelectasis in take off of an aberrant right upper bronchus- a condition called Bronchus
      a Newborn after Intubation for Cardiac Suis. For this rare condition, fluoroscopy is a quick method of diagnosis.
      Catheterization - A Fluoroscopic        For the remaining case, the patient was ventilated by maintaining the tip of
300   Diagnosis!                              the ETTube above the origin of this orifice.

                                              37year old right handed male, presented with 2 years of burning pain and
                                              numbness on right side of the body. He had a history of left MCA territory
                                              stroke with residual right sided weakness and right leg numbness affecting
                                              his gait. Multiple regimens: antidepressants, antiepileptics, membrane
                                              stabilizing agents, oral and IV infusions of sodium channel blockers in
                                              combination with opiates and NMDA receptor antagonists did not help
                                              alleviate pain. Ketamine infusion was performed helped for 1 day. Oral
      Central Post Stroke Pain: Ketamine      ketamine did not help. Patient wants a cure! Should I do Dorsal column
301   Doesn't Help Me                         stimulation trial Or Is motor cortex stimulation next?

                                                                      Page 99

                                              31-year old female with intractable deafferentation pain of the left orbit s/p
                                              left eye evisceration secondary to orbital cellulitis and endophthalmitis. Pain
                                              described as boring, deep, throbbing in the left retro-orbital area, extending
                                              to the left cheek, ear and upper gums. Constant pain with exacerbations.
                                              Triggers: eye movement, reading, computer work, bright sunlight, wind,
                                              and cold food. Minimally responsive to: morphine, methadone, nortriptyline,
                                              gabapentin, topamax, acupuncture, biofeedback, retrobulbar nerve block
                                              and gasserian ganglion RF ablation. Diagnostic lidocaine infusion test 30%
      Intractable Deafferentation Pain of the pain improvement; subsequently started on Mexiletine 150mg PO QHS
302   Left Orbit: A Case for Mexiletine       escalated to 450mg PO QHS with a reported 40% improvement.

                                              Standard treatment failed to provide adequate pain relief for two patients
                                              with radiation induced mucositis, a commonly-seen complication of head
                                              and neck radiation. Both failed traditional swish-and-swallow medications.
                                              When the formulation changed to include gabapentin, both experienced
                                              significant relief: Patient 1 had chronic disease but tolerated discontinuation
      Use of Compounded Topical               of both the compound and all opioids by day 60 and Patient 2 had a 75%
      Lidocaine, Diphenhydramine Hcl,         decrease in his acute mucositis pain by day 2 of treatment. Thus, adding
      Nystatin, and Gabapentin for Pain       swish-and-swallow gabapentin provided rapid and effective pain relief,
303   Control in Mucositis                    suggesting it may be useful in alleviating pain secondary to mucositis.

                                             The is a 75 year old male with a history of left posterior tongue pain that is
                                             described as intermittent, lancinating, and burning which limits his ability to
                                             speak and eat. The patient has failed multiple procedures and it was
                                             decided to perform a diagnostic glossopharyngeal nerve block via the
                                             intraoral approach. The patient experienced six hours of relief and the
      Use of Intraoral Cryoneuroablation for decision was made to pursue cryoneuroablation via the intraoral route.
      the Treatment of Intractable Posterior Follwing the the procedure, the patient reported greater than 95% pain
      Tongue Pain in a Patient with          relief. On follow up, the patient reported that the pain relief was sustained
304   Glossopharyngeal Neuralgia             at [gt]75% for six weeks.

                                                                      Page 100

                                           Patient is 79 YOF with herpes zoster; she had epidural injection at T5-6. At
                                           second injection, she had no active lesions. Tuohy needle was advanced at
                                           the T7-8, yellow, cheesy material was produced from the needle hub
                                           following stylet removal. The procedure was cancelled, and an emergent
                                           MRI revealed a multi-loculated posterior epidural abscess causing marked
                                           posterior cord compression from T4 to T7. The patient was afebrile, with
                                           normal WBC count, and neurologically intact. Bilateral hemi-laminotomies
                                           from T4-T7 was done for evacuation, and cultures were positive for
                                           Staphylococcus aureus. The patient fully recovered and was sent home on
305   Asymptomatic Epidural Abscess        IV PenicillinG.

                                           This case involves a married woman with two young children, who was
                                           experiencing excruciating and seemingly intractable pain from metastatic
                                           adenocarcinoma of the cervix. She was experiencing dose-limiting adverse
                                           effects, and poor pain control, from conventional analgesic therapies.
                                           Interventional (regional) techniques were not an option. Subanesthetic
                                           ketamine was used effectively to manage symptoms through the patient's
                                           terminal phase of disease, allowing comfort and communication with family.
                                           Discussion will include safe and efficacious use of ketamine as an
      Management of Intractable            adjunctive agent in the management of otherwise difficult-to-control pain
      Neuropathic Pain in Far Advanced     syndromes, especially at end of life and mechanisms involved in
306   Cancer                               augmenting opioid analgesia.

                                           Pudendal Neuralgia (PN) involves severe pain along the distribution of the
                                           pudendal nerve. A female with 1.5y of sharp, burning pain of the left gluteal
                                           and perineal regions. Patient had sitting intolerance and was unemployed
                                           as a result. She failed multianalgesic therapy and was requiring SR/IR
                                           opioids. She had a positive short-term response to pudendal nerve blocks.
                                           Patient underwent pulsed radiofrequency of the left pudendal nerve. She
      Successful Treatment of Refractory   decreased her opioids and sitting tolerance improved to 4-5h. PRF for the
      Pudendal Neuralgia with Pulsed       treatment of PN hasn't been reported in the literature and offers promise as
307   Radiofrequency                       a potential treatment of PN.

                                                                  Page 101

                                          65 year old woman with history of squamous cell carcinoma of the tongue
                                          status post radiation therapy and chemotherapy. She subsequently
                                          developed tongue pain with ulcerative lesions that was recalcitrant to anti-
                                          infectious, antiepileptic, antidepressant and opioid therapy. Pain level was
                                          6/10 on presentation. We elected to perform a stellate ganglion block, with
      Pulsed Radiofrequency of Stellate   significant, but transient pain relief. Pain was reduced to 1-2/10 for two
      Ganglion To Treat Chronic Tongue    weeks, then returned to baseline. We then performed pulsed
      Pain Secondary to Squamous Cell     radiofrequency of the stellate ganglion. After this treatment, patient had
308   Carcinoma                           significant pain relief that has lasted [gt]6 months with local tissue healing.
                                          A 14 y/o, 64 kg, female with increased abdominal pain was diagnosed with
                                          Sclerosing Mesenteritis. She underwent several abdominal surgeries
                                          during her hospital stay with severe pain uncontrolled with high doses of
                                          opioids (hydromorphone 9 mg/h intravenously), gabapentin, and local
                                          anesthetics through an epidural catheter. The only way to control her pain
                                          was to admit her to the ICU where deep sedation was provided by
      General Anesthesia Required To      ketamine infusion (15-80 mcg/kg/h) for eight days. She was discharged
      Control Pain in a Teenager with     home on methadone 25 mg q 6 h with oxycodone for breakthrough pain
309   Sclerosing Mesenteritis             control.

                                          A previously healthy 38-year old male was involved in a motorcycle
                                          accident and subsequently underwent uneventful repair of a transected
                                          aorta via left thoracotomy. The patient was transported to the intensive care
                                          unit intubated and sedated. The following morning, a thoracic epidural was
                                          placed without difficulty. The patient was successfully extubated. Following
                                          extubation, the nursing staff noticed unilateral motor block, and the
                                          anesthesia service was notified. Physical examination revealed unilateral
                                          partial motor block with intact sensation. Given this presentation, a
      Unilateral Hemiparesis Following    neurologic consult was initiated. MRI/MRA was performed that
310   Placement of Thoracic Epidural      demonstrated a dissection of the left internal carotid artery.

                                                                  Page 102

                                           A 51 y.o. male with metastatic rectal carcinoma (Duke's D) was referred for
                                           palliative care. He had achieved 50% pain reduction using long-acting
                                           opioids. However, he had prohibitive side effects including urinary
                                           retention, pruritus, and bradypnea. A caudal block using 6 mL of 0.25%
      Dilute Phenol (3% in Glycerin)       Bupivacaine provided temporary relief, with S-1 motor block. Using 3 mL of
      Administered Via a Caudal Racz       3% phenol in glycerin via a caudal Racz catheter, complete analgesia was
      Catheter Provides Profound Analgesia attained without any motor deficits, persisting for 88 days until his death.
      While Sparing Motor Function in      Opioid reduction was profound, as well. This case illustrates the salubrious
311   Advanced Rectal Carcinoma            effect of reduced dose phenol in chronic intractable pain.

                                           An adolescent traumatic C6 tetraplegic with C6-7 posterior spinal fusion,
                                           presented to our pain clinic with neuropathic pain and left upper extremity
                                           itching. Maximal dose of gabapentin, transcutaneous electrical nerve
                                           stimulation (TENS), topical lidocaine, oxycodone and acupuncture
                                           improved her pain over the next 6 mo., but the itching persisted. An IV Bier
      Dilemma of the Intarctable Pruritus: block did not stop her pruritus. A stellate ganglion block transiently
      Management of Neuropathic Pain and abolished it prompting a continuous infusion via a stellate ganglion
      Pruritus after a Traumatic Cervical  catheter. Careful titration of dose was determined over 24 hrs and she was
312   Spine Injury                         discharged home with an infusion for 7 days with resolution of symptom.

                                               A 53 year-old male with right-sided piriformis syndrome was unable to
                                               undergo a radiographically-guided piriformis muscle injection due to a
                                               severe radiocontrast agent allergy. We describe the first case of the
                                               injection of air rather than a radiocontrast agent under direct fluoroscopic
                                               guidance to perform this procedure. The result is a hypolucent band of air
      A Novel Alternative Technique to a       that clearly identifies the belly of the piriformis muscle. Advantages include
      Radiographically-Guided Piriformis       the avoidance of allergic reaction in a patient with no previous exposure to
      Muscle Injection in a Patient Allergic   radiocontrast agents, an unobscured view after multiple injections of
313   to Radiocontrast Agent                   contrast agent, and low expense.

                                                                      Page 103

                                            We present a series of case studies describing the results from placing
                                            peripheral nerve stimulators (PNS) in fifteen patients to treat occipital
                                            neuralgia. In each case, the patient had intractable pain diagnosed as
                                            occipital neuralgia which failed treatment with other conservative methods
                                            including opioids, anti-depressants and anti-epileptics. After appropriate
                                            evaluation, including from a pain psychologist, we proceeded with a PNS
                                            trial. Each trial produced excellent results prompting the placement of
      Peripheral Nerve Stimulation in the   permanent leads. The majority of patients report significant pain relief
      Treatment of Occipital Neuralgia: A   resulting in improved quality of life, greater functionality and decreased
314   Compilation of 15 Case Studies        requirement for pain medications.

                                         A thirteen year old girl sprained her ankle and developed severe burning
                                         foot pain. The pain progressed. She could not bear weight, had impressive
                                         allodynia. She was treated with Neurontin, Elavil and physical therapy. The
                                         severe pain continued. She was hospitalized. An epidural catheter was
                                         placed. Continuous low dose marcaine was given and her pain diminished.
                                         However, she developed a headache, diplopia and papilledema. A lumbar
      A Thirteen Year Old with CRPS Type puncture showed an opening pressure of 55 mm/Hg. After a negative w/u,
      1 Had an Epidural Catheter, a      including CT and MRI, she was diagnosed with pseudotumor cerebri. Her
315   Headache, and Papilledema          headache did not resolve and she later had a VP shunt.
                                         A 58-year-old, 60kg women with thyroid cancer controlled with
                                         levothyroxine 0.1mg daily for 11 monthsunderwent total thyroidectomy. The
                                         patient received no medication except for anesthesia. when tramadol 90mg
                                         for postoperative pain control was given 30 min before the end of surgery.
                                         arterial blood pressure immediately increased frome 130/82 to 217/128
                                         mmHg with little effect on heart rate and bispectral index. Blood pressure
                                         was controlled by nicardipine and desflurane. We propose that the
                                         increasing effect of serotonine receptor sensitivity of levothyroxine in
                                         combination with tramadol reuptake inhibition of serotonine and
      Severe Hypertension Due to         norepinephrine or release serotonine may have caused the hypertensive
316   Intraoperative Use of Tramadol     episode.

                                                                  Page 104

                                          This case is about a patient that communicated with hand gestures signing
                                          yes or no due to spastic quadriplegic CP. Previous contracture releasing
                                          surgeries were ineffective. The decision to place a baclofen pump was
                                          made by an interdisciplinary team of an Internist, Pain management, and
      An Ethical Dilemma, a Practice in   an ethics committee. The patient had severe reflux and was an aspiration
      Planning, Execution Foraclofen Pump risk. Preop planning and execution of the placement of a trial baclofen
      Placement in a Patient with         pump was accomplished however there were many challenging issues
      Quadriplegic Spastic Cerebral Palsy confronted after placement. This poster will allow for audience participation
317   at High Risk for Aspiration         by asking difficult questions based on the case. Fill out the questionnaire.

                                            Control of visceral pain from chronic pancreatitis is medically challenging.
                                            We successfully treated two cases of chronic pancreatitis with celiac
                                            plexus blocks using 30 ml of 0.25% Bupivacaine, with complete pain relief
                                            for 10-12 weeks. Celiac blocks were performed under fluoroscopic
                                            guidance, using a trans-aortic approach at the L1 vertebral level. Both
                                            patients reported immediate pain relief, with pain scores of 0/10 by NRS.
                                            Repeated blocks were performed when pain returned, at 10-12 week
      Repeated Celiac Plexus Blocks with intervals for five years. Opioid requirements decreased. This data suggests
      0.25% Bupivacaine for Pain            a sympathetically mediated visceral hypersensitivity. Pain relief is achieved
318   Management in Chronic Pancreatitis by interruption of autonomic and nociceptive pathways.
                                            39 year old with a history of right coracoid process adenocarcinoma, status
                                            post resection 1 year prior, presents with intractable 10/10 right arm pain
                                            for 1 week. Continuous epidural infusion (bupivicaine 0.3%, fentanyl
                                            5mcg/cc, clonidine 5mcg/cc) is started at 5cc/hr through a right sided C6,
      A Case of Intractable Arm Pain 1 Year fluoroscopic placed catheter. During next 8 days patient is weaned off
      after Coracoid Process Resection,     epidural clonidine and discharged home, with pain scores 2/10, on a patient
      Successfully Treated with an Epidural controlled epidural regimen (bupivicaine 0.0625%, fentanyl 2mcg/cc),
      Mixture of Clonidine, Fentanyl and    4cc/hr continuous infusion, 2 cc every 30 minutes demand dose. Catheter
      Bupivicaine Administered through a    is discontinued 3 weeks after hospital discharge with pain stabilized
319   C6 Continuous Catheter                thereafter to 3/10.

                                                                    Page 105

                                          33 year-old female with long history of sickle cell disease and chronic pain
                                          secondary to sickle crises treated with long term opioids including
                                          oxycontin and methadone. She was admitted with sickle cell crisis with
                                          excruciating low-back pain VAS 10/10. Initial therapy involved escalating
                                          doses of parenteral hydromorphone totaling 140mg over 12 hours which
                                          resulted in worsening of pain scores. Decreasing the hydromorphone did
                                          not decrease her pain, however the addition of neurontin, elavil and
                                          methadone produced marked decrease in her pain scores. Perhaps
      Opioid-Induced Hyperalgesia as a    pathways for opioid-induced hyperalgesia overlap with chronic pain
320   Type of Chronic Pain?               pathways.

                                          A 61 year-old woman with metastatic breast and ovarian cancer presented
                                          with severe right buttock and radicular pain. She had a six month
                                          prognosis. An MRI without contrast revealed mild neural compression and
                                          L4-L5 spondylolisthesis. An L5 transforaminal ESI for presumed lumbar
                                          radiculitis provided total pain relief. The next day she developed new left-
                                          sided weakness. An MRI showed drop metastases studding the cauda
      Unusual Presentation of             equina and the conal peel surface. There was no epidural hematoma. In
      Leptomeningeal Carcinomatosis       the setting of radiculopathy and known metastases, leptomeningeal
      Involving a Lumbar Transforaminal   carcinomatosis (CNS metastasis to the meninges) must be highly
321   Epidural Steroid Injection          considered. An MRI with contrast should be mandatory.

                                          Forty-five year-old male with a history of schizophrenia and recurrent
                                          abdominal pain secondary to chronic pancreatitis underwent an uneventful
                                          celiac plexus block. Upon arrival to PACU, the patient developed lower
                                          extremity myoclonus, hyperreflexia, diaphoresis, and flushing but without
                                          sensory deficits. Pre-procedure medications included psychiatric
                                          medications, opioids, gabapentin, and tramadol. The neurolytic block was
                                          performed with lidocaine, bupivacaine and alcohol. Midazolam and
                                          fentanyl were used for conscious sedation. Thoracolumbar MRI showed
                                          no evidence of spinal hematoma, cord compression, or ischemia. The
      An Unexpected Complication after    working diagnosis was idiosyncratic reaction to fentanyl. His symptoms
322   Celiac Plexus Block                 resolved several days later without sequelae.

                                                                 Page 106

                                            Intrathecal Baclofen has been utilized to treat spasticity in multiple sclerosis
                                            patients. We present a case of uneventful intrathecal Baclofen pump
                                            placement with excellent relief of symptoms postoperatively. The patient
                                            had an uneventful early postoperative period. She later developed a leak
                                            at the incision site and symptoms consistent with meningitis. Work-up was
      Unintentional Intrathecal Baclofen    negative for meningitis. The patient's symptoms persisted and she was
      Leak and Baclofen Withdrawal in a     found to have a wound dehiscence. The Baclofen pump was removed
323   Multiple Slerosis Patient             when a malfunctioning intrathecal catheter was detected.

                                           A 17 year old male with Ewing sarcoma of the right heel was found to have
                                           pulmonary metastases. His treatment consisted of chemotherapy, as well
                                           as radiation of his heel and a thoracotomy. He developed throbbing,
                                           burning pain in his heel, poorly controlled with high doses of morphine and
                                           methadone. He became wheel chair bound and depressed. A trial of
      17 Year Old with Severe Chronic Heel epidural narcotics resulted in a significant decrease of his pain. Following
      Pain Secondary to Ewing Sarcoma      this successful trial, an intrathecal pain pump, infusing Duramorph, was
      Treated with an Intrathecal Pain     placed. He weaned down to 5 mg of Methadone. He is ambulating for the
324   Pump                                 first time in two years.

                                           43 year old female with history of CRPS of the left lower extremity
                                           secondary to gunshot wound was treated with various medications and
                                           underwent a spinal cord stimulator trial that was non-efficacious. She then
                                           had an intrathecal pain pump placed in 8/2007. Postoperatively she
      A Complex Case of Intrathecal Pump developed severe pruritis to the point of causing self inflicted open wounds.
      Placement and Management for         The question of allergy to metal in the pump was raised. A formal allergy
      Refractory Complex Regional Pain     evaluation revealed her allergy to more than 10 different substances, but
      Syndrome of the Left Lower Extremity not to metal. Today she is managed with a bupivacaine only solution and
325   Secondary to Gunshot Wound           demonstrates some improvement of her symptoms.

                                                                    Page 107

                                           A 52 year-old man with non-small cell lung cancer and spinal metastases
                                           presented with uncontrolled back pain despite administration of high doses
                                           of fentanyl and bupivacaine via implanted intrathecal pump. Catheter-
                                           related problems with spinal drug administration systems occur in up to
                                           25% of patients. The differential diagnosis should include: obstruction,
                                           kinking, disconnection, migration and granuloma formation. In this case, a
                                           lumbar spine MRI revealed the possibility of epidural catheter placement.
      Cancer Pain Refractory to Spinal     This was confirmed by an x-ray catheter dye study. Following catheter
      Analgesics: The Importance of Spinal revision with intrathecal placement, pain relief was much improved and the
326   Infusion Device Evaluation           patient was able to be discharged to home.

                                            35-year old male presented to pain clinic for chronic low back pain. Patient
                                            agreed to receive a lumbar epidural steroid (LES) injection which provided
                                            back pain relief, but caused positional headache which was managed
                                            conservatively in absence of apparent dural puncture. After 3 days an
                                            epidural blood patch was performed. Headache went away but restarted 24
                                            h later. Afterwards he presented with a right side facial palsy. MRI of brain
                                            w/wo contrast showed marked diffuse thickening and subtle contrast
                                            enhancement of bilateral facial nerves. Facial palsy resolved within 1
      Unilateral Facial Nerve Palsy after   month. This case suggests that cranial nerves other than abducent can
327   Dural Puncture                        also be affected after dural puncture.

                                            An eighteen year old female with sickle cell disease suffered from severe
                                            chronic pain. She also experienced intermittent crises requiring frequent
                                            hospital admissions for intravenous opioids. She continued with an
                                            escalating opioid requirement. Her pain was severe in her hips and her
                                            shoulder. Her morphine equivalent dose was 300 mg a day. An epidural
      An Eighteen Year Old Female with      catheter was placed. A fentanyl/marcaine infusion was given. She felt
      Sickle Cell Disease and Severe        dramatic relief. After this trial, a decision was made to place an intrathecal
      Chronic Pain Treated with an          pain pump. For 8 months she has had no hospitalizations for sickle cell
328   Intrathecal Pain Pump                 crises, and her quality of life has greatly improved.

                                                                   Page 108

                                           A case of spontaneous intracranial hypotension in a 55-year-old female
                                           with a 7 week history of progressive headache is described. The patient
                                           presented with an orthostatic headache with associated nausea and
                                           vomiting. MRI revealed signs of intracranial hypotension. CT myelogram
      Thoracic Epidural Blood Patch for    revealed cerebrospinal fluid leak extending from C6-7 to T1-2 with dural
      Spontaneous Intracranial Hypotension tear at C6-7. Fluoroscopic-guided thoracic epidural blood patch was
      Caused by Cerebrospinal Fluid Leak performed at T6-7 with 10 cc of autologous blood. The patient experienced
329   at C6-7                              complete relief within 24 hours that persisted at the 2 month follow up.

                                            41 year male with severe pseudotumor cerebri on acetazolamide presented
                                            with symptoms of post dural puncture headache. The patient responded to
                                            conservative treatment and discontinuation of acetazolamide with a
                                            decrease in the VAS pain score to 4/10. Upon restarting the acetazolamide
                                            his headache increased dramatically to 10/10 with flattened optic discs.
                                            The patient was treated with an epidural blood patch with complete
                                            recovery and resolution of his headache. Perhaps patients with
      Acetazolamide and Post Dural          pseudotumor cerebri requiring acetazolamide treatment may not respond
      Puncture Headache in the Presence     as well to conservative treatment for post dural puncture headache
330   of Pseudotumor Cerebri                compared to an epidural blood patch

                                            Patient with NSCLCA scheduled for upper lobectomy had thoracic epidural
                                            placed for pain control. Intraoperatively the tumor was densely adherent to
      Removal of Thoracic Epidural          the LIMA, she was transferred to the SICU. Decision was made in the
      Catheter Guided by TEG                catheterization lab that the LIMA was not patent, and she underwent
      (Thromboelastograph) in a             complete lobectomy with LIMA resection. Her postoperative course was
      Thoracotomy Patient Emergently        complicated by VF arrest. She underwent emergent cardiac catheterization
      Placed on Integrilin and Plavix -     and stent placement. Integrilin infusion with plavix load was started.
      Balancing the Risk of Coronary Artery Eighteen hours after integrilin drip was stopped, thromboelastograph(TEG)
      Stent Occlusion Versus Epidural       and platelet count were normal. The epidural was removed and patient
331   Hematoma - Is There a Good Time? remained stable without developing epidural abscess or hematoma.

                                                                   Page 109

                                           The patient had a past medical history of hypertension, anxiety and obesity.
                                           The procedure was initially uneventful, with successful block and light
                                           sedation. After the first hour, the patient began to obstruct and desaturated
      Airway Obstruction in a 62 Year Old  to the low 80s. Upon completion of the surgery, severe asymmetric swelling
      ASA 3 Female for Scheduled           of the right neck was noted. She was able to breathe easily however, and
      Outpatient Right Shoulder            her saturation returned to 99%. CT of the Neck showed extensive
      Arthroscopy and Rotator Cuff Repair subcutaneous edema with a patent but narrowed airway with the right
      under Ultrasound-Guided Interscalene vallecula smaller than the left. Swelling improved overnight and the patient
332   Block                                was discharged the next morning.

                                               We report the case of a 72 year old gentleman scheduled for repair of a
                                               right intertrochanteric fracture. His multiple comorbidities included newly
                                               diagnosed aortic stenosis, rapid atrial flutter, an ejection fraction of 20
      Low Dose Dexmedetomidine and             percent, chronic obstructive pulmonary disease, pulmonary edema, acute
      Ketamine Sedation Combined with          renal insufficiency, and thrombocytopenia. Surgical anesthesia was
      Lumbar Plexus and Sciatic Nerve          provided using combined posterior lumbar plexus and sciatic nerve blocks.
      Blocks for Hip Fracture Repair in a      Sedation was provided using a combination of low dose dexmedetomidine,
      Patient with Aortic Stenosis [Instruct1] ketamine, and midazolam. The patient remained hemodynamically stable
      Be Concise but Informative. Include      throughout peripheral nerve block placement and fracture repair without the
333   Species When Appropriate                 need for vasopressor support.
                                               A 43 yo WF presented with severe hand pain and ischemia, including
                                               necrotic ulcers on 7 fingers, secondary to Raynaud's disease that was
                                               refractory to medical therapy. Arteriograms revealed poor blood flow to
      Treatment of Refractory Hand Pain        both hands. Hand surgery felt that surgical intervention was not possible at
      and Ischemia with Continuous             this time. Bilateral paravertebral catheters were placed at T2 for
      Bilateral Paravertebral                  pharmacologic sympathectomy and blood flow was restored to both hands
      Sympathectomies in a Patient with        with resolution of cyanosis and some healing of the necrosis by Day 10.
      Severe Refractory Raynaud's              Surgical sympathectomies were then performed and the blocks were
      Syndrome: A Diagnostic and               discontinued on POD2. The patient is recovering well with good hand
334   Therapeutic Tool?                        perfusion.

                                                                     Page 110

                                             A 64 y/o woman underwent a left total knee arthroplasty under spinal
                                             anesthesia. Her history was significant for an uneventful right total knee
                                             arthroplasty four years ago. Her preoperative neurological exam was
                                             normal except for a 3/5 motor exam strength on the right leg. For the
                                             anesthetic, a 22 gauge needle was used and a 11.25mg of hyperbaric
                                             bupivacaine was placed after several attempts. Surgery was uneventful. On
      Neurologic Deficits after a Spinal     post op day one, the right leg strength declined from 3/5 to 0/5 and the left
      Anesthetic. What Is in the             leg strength strength declined from 5/5 to 0/5. What should be included in
335   Differential?                          the ensuing workup?

                                              The use of continuous interscalene catheter blockade has been used
                                              greatly for postoperative pain management after shoulder surgery.
                                              However, it has rarely been applied as the sole anesthetic during surgery.
                                              This case is of a 27 year old male with metastatic sarcoma and severely
                                              decreased pulmonary function scheduled for shoulder disarticulation. The
                                              patient's metastatic disease and complex pulmonary history required
                                              avoidance of general anesthesia due to the high risk for ventilator
      The Use of Continuous Interscalene dependence. Use of an alternative regional technique was required.
      Catheter Nerve Block as the Sole        Continuous interscalene catheter provided sufficient conditions for surgery
      Anesthetic for Shoulder Disarticulation and allowed for continuous assessment of the anesthetic's effect on
336   in a Patient with Poor Lung Function respiratory function.

                                             A 23 year old male construction worker presents for bilateral radius open
                                             reduction and internal fixation after a fall. He is in bilateral upper extremity
                                             casts and reports 8/10 pain on the Visual Analog Scale. After locating the
                                             coracoid process on the right, our stimulating needle is inserted one
                                             centimeter medial and caudal. Acceptable twitches were obtained, 40 mL
                                             of 0.5% Bupivicaine with 1:200,000 epinephrine is injected. Fifteen minutes
                                             later, the contralateral side is also blocked with 20 mL of 0.25% Bupivicaine
      Bilateral Infraclavicular Block for    with 1;200,000 epinephrine. Successful and uneventful blocks are
337   Bilateral Upper Extremity Fractures    obtained. The patient is pleased with the perioperative anesthetic care.

                                                                     Page 111

                                          A 33 year old morbidly obese female with a history of lower back pain and
                                          previous spinal fusion presents for symptoms consistent with Meralgia
                                          Paresthetica. Symptoms included severe burning dysesthesias in the
                                          distribution of the lateral femoral cutaneous nerve. Temporary relief
                                          occurred with multiple lateral femoral cutaneous nerve and fascia lata
                                          blocks at two different institutions. The patient requested further treatment.
      Successful Pulsed Radiofrequency of At this time we located the anterior superior iliac spine and reproduced
      the Lateral Femoral Cutaneous Nerve concordant dysesthesia. Pulsed radiofrequency was undertaken at 43
      after Multiple Blocks for Meralgia  degrees Celsius for 120 seconds followed by dexamethasone and
338   Paresthetica                        bupivicaine. Patient reports exceptional and prolonged pain relief.

                                             A 51-year-old male status post traumatic injury to left knee complicated by
                                             possible complex regional pain syndrome presented for Left ACL
                                             reconstruction. The patient elected to have a left femoral nerve block for
                                             post operative pain management. Standard motor nerve stimulation
                                             settings (0.1 msec duration, 1 Hz, 1.5 mA) failed to elicit a motor response
                                             and the patient denied femoral nerve paresthesias. Yet, the patient
                                             intermittently reported the perception of [quot]knee-cap[quot] movement,
                                             despite the lack of objective patellar movement. This perceived motor
      Perceived Motor Response during a      response was taken as the endpoint for needle placement and a
339   Femoral Nerve Block Placement          successful block was obtained.

                                           A 46yo female with uterine fibroids underwent general anesthesia for an
                                           abdominal myomectomy, salphingostomy, and lysis of adhesions through a
                                           lower transverse abdominal incision. Prior to wound closure, bilateral
                                           catheters were placed between the rectus abdominis muscles and the
                                           posterior rectus sheath and brought to the skin through an epidural Tuohy
                                           needle on each side of midline. Catheters were bolused with 15cc of .2%
                                           Ropivicaine postoperatively and set at an infusion rate of 8cc/hour. Patient
                                           reported good pain relief with loss of sensation over the lower abdomen.
      Rectus Abdominis Catheters for Post- Catheters were removed on post-operative day 1 with transition to oral pain
340   Operative Analgesia                  medications.

                                                                    Page 112

                                            A 40 year old woman with a history of Kearns-Sayer syndrome and
                                            cardiomyopathy was presented for elective total abdominal hysterectomy
                                            and bilateral salpingo-oopherectomy.She has past medical history of spinal
                                            anesthetic for her C-section complicated by cardiac arrest soon after baby
                                            was delivered.After successful resuscitation patient developed
                                            hypertension,congestive cardiac failure.This patient with a [bold]rare form
                                            of mitochondrial myopathy has been associated with multiple complications
                                            with general anesthesia such as conduction block, congestive heart failure,
                                            and dysrhythmias. Epidural anesthesia has not been previously described
                                            as an anesthetic for this patient.This patient was successfully managed
      Epidural Anesthesia and Kearns-       peri-operatively with Epidural anesthesia and aggressive invasive
341   Sayre Syndrome                        monitoring.

                                            Epidural hematoma can potentially cause devastating neurological
                                            sequelae. A case of an epidural hemaotma occurred in an end-stage renal
                                            disease patient. She had a resection of the femur prior to her hip
                                            arthroplasty under combined spinal-epidural anesthesia without
                                            complications. However, after the arthroplasty, the patient developed an
                                            epidural hematoma measuring approximately 9x9x19mm. Despite having a
                                            successful regional anesthetic with her previous surgery, this case
      A Case of Epidural Hematoma after     illustrates the systemic ramifications of ESRD in multi-organ dysfunction.
      Combined Spinal-Epidural and          We discuss the efficacy of certain treatments (hemodialysis and dDAVP)
      Catheter Placement in an End-Stage    for uremia. Although epidural hematomas are exceedingly rare, uremia
342   Renal Disease Patient                 plays a tremendous role in their incidence.

                                            The spinal headache that accompanies placement of an intrathecal drug
                                            delivery system (IDDS) requires particular care in management related to
                                            concerns for trauma to the indwelling catheter. Over a sixteen month
                                            period, we retrospectively reviewed charts of 4 patients referred from the
                                            neurosurgical service with complaints of postural headache within a week
      Epidural Blood Patch in the           following IDDS implant. After failing conservative measures, an epidural
      Management of Postural Headache       blood patch was performed using fluoroscopy to verify the position of the
      Following Intrathecal Drug Delivery   intrathecal catheter prior to placement of an epidural needle. All four
343   System Implant                        patients reported an average of 90% reduction in postural headache.

                                                                  Page 113

                                            A female (26yrs) G3P2 at 33 weeks with intrauterine pregnancy was
                                            admitted to high risk labor ward for management of sickle cell crisis pain.
                                            The patient exhibited pain in the lower back and bilaterally in legs.
                                            Anesthesia pain service was contacted and an epidural catheter was
                                            placed at T11-L1 without incident. The patient showed significant reduction
                                            in pain scores, 0-6/10 from the previous 10/10, and 48 hours later was
                                            discharged on morphine sulfate contin and morphine sulfate immediate
      The Use of Epidural Analgesic for a   release. Pain relief from epidural analgesia is a viable and alternative
      Non-Laboring Patient in Sickle Cell   treatment option in non-laboring pregnant women suffering from sickle cell
344   Crisis                                pain.

                                            Discoloration of Forearm with Bier's Block. A 29-yr-old male, 63-kg, ASA
                                            physical status I patient was posted for release of left trigger thumb. AN IV
                                            cannulation with a 22-gauge cannula was performed on the forearm of the
                                            operative limb. 40 mL of 0.5% lidocaine was slowly injected through the
                                            cannula on the operative limb. The surgical procedure was started and
      A 29-yr-Old Male, ASA I Patient Was   completed in 35 min without any difficulty or complications. The night of the
      Posted for Release of Left Trigger    same day patient complaine of pain, oedema and discolouration of his arm.
345   Index                                 Admitted to ICU, back to his room 4 days latter completly free.

                                            A 74-yr-old male underwent left total knee replacement under general
                                            anesthesia supplemented with lumbar plexus block. A 22gauge, 100mm
                                            stimuplex needle and Braun nerve stimulator used. Quadriceps twitches
                                            were elicited at a current strength 0.5-1 mA. Total of 30ml 0.5%
                                            Bupivacaine was injected. No immediate complications were noticed.
                                            There was good sensory block in the distribution of left lumbar plexus only.
                                            The patient was then administered general anesthesia. After the
                                            procedure, the distribution of sensory block was evaluated, when the
      Unusual Complication of Lumbar        patient demonstrated dense sensory and motor block in both the lower
346   Plexus Block                          limbs extending from T10-S3 dermatomes. No further complications noted.

                                                                   Page 114

                                            72 y/o male scheduled for AAA repair. PMH of CAD with placement of 2
                                            DES (Drug Eluted Stents). Thoracic epidural catheter was placed.
                                            Following induction, he developed persistent hypotension. EKG showed
                                            evidence of inferior STEMI. He underwent emergent thrombectomy .He
                                            was started on abciximab infusion, clopidogrel, ASA and heparin. The
                                            patient subsequently developed thrombocytopenia. We transfused platelets
                                            to raise count [gt]100,000 and the catheter was removed while on
                                            clopidogrel therapy. Close neurocheck was performed. DES increased the
      Patient on Clopidogrel Treatment:     challenges facing regional anesthesia .ASRA guidelines are not clear on
      When To Discontinue Epidural          when to discontinue the epidural in patients with ongoing clopidogrel
347   Catheter                              therapy.
                                            Spring loaded peripheral nerve block catheters are at risk for uncoiling of
                                            the internal wire and entrapment of the catheter and wire in nearby
                                            structures. We report on two cases of entrapped catheters following
                                            politeal nerve block utilizing a stimulating continuous nerve block catheter.
                                            Upon removal of these catheters, the support wire became uncoiled and
                                            entrapped within the popliteal fossa. Identification and removal of the
      Entrapment of a Continuous            catheters was facilitated by the use of ultrasound. We will report on
      Peripheral Nerve Catheter Following   assessment and management of entrapped peripheral nerve block
348   Popliteal Nerve Blockade              catheters.

                                            The case is a 31 y/o male who is s/p re-attachment of his right hand after
                                            traumatic amputation. Despite the placement of a peripheral nerve block
                                            catheter at the infraclavicular site, the patient began experiencing
                                            uncontrollable pain at the surgical site. Pain was so significant, a decision
                                            to intubate and sedate the patient was made. Thirty hours post-operatively
                                            he underwent a re-vascularization procedure. Management of his
                                            postoperative pain, as well as, the differential diagnosis of phantom limb
      Pain Control for a Traumatic          pain versus ischemic pain versus acute postoperative pain secondary to
349   Amputation                            failed peripheral nerve block catheter will be discussed.

                                                                   Page 115

                                          A 48 year-old female with severe idiopathic primary pulmonary
                                          hypertension (PAP 90/45 mmHg by heart catheterization) unresponsive to
                                          Nitric Oxide, and complicated by a history of pulmonary embolism and cor
      Interscalene Catheter Placement for pulmonole, presented for ORIF of right humerus. After securing an arterial
      Anesthetic and Postoperative Pain   line and cordis, a Short Axis view of the brachial plexus was obtained by
      Management for an Open Reduction Ultrasound. An 18 g Tuohy advanced under direct visualization and an
      Internal Fixation of a Nonunion     epidural catheter was inserted. 25mL of Mepivicaine 1.5% injected
      Humeral Fracture in a Patient with  incrementally. Surgery was well tolerated with minimal sedation. A 6cc/hr
      Severe Idiopathic Primary Pulmonary infusion of 0.2% ropivicaine started in the PACU and continued until
350   Hypertension                        discharge on POD #3.

                                           A morbidly obese patient with severe mysthenia gravis and endocarditis
                                           was scheduled to undergo removal of infected hardware of his shoulder in
                                           the sitting position. An ultrasound-guided interscalene block was placed,
      A Morbidly Obese Patient with Severe and general endotracheal anesthesia induced. His trachea was intubated
      Mysthenia Gravis and Endocarditis    without the use of muscle relaxants. He was permitted to breath
      Undergoing Surgery of the Shoulder spontaneously, and maintained his end-tidal CO 2 at 32 mmHg, which was
      in the Sitting Position with an      considered evidence of diaphragmatic function. A cerebral oximeter was
      Interscalene Block, General          applied and interventions were planned to treat cerebral saturations 55%
      Anesthesia and Cerebral Oximetry     and MAPs 60. At the conclusion of the procedure his trachea was
351   Monitoring                           successfully extubated.

                                            A 71 yr old male patient underwent urgent laparoscopic cholecystectomy
                                            under general anesthesia supplemented by interpleural block for analgesia.
                                            His co-morbidity included obesity, sleep apnea, hypertension, coronary
                                            artery disease, chronic obstructive pulmonary disease, hyperlipidemia,
                                            gastro-esophageal reflux disease, diabetes mellitus, cerebrovascular
                                            accident, chronic renal insufficiency, nausea and vomiting. In the post
                                            anesthesia recovery room, the patient continued to have severe nausea
                                            and vomiting. An urgent 12-lead EKG showed normal sinus rhythm. He
                                            denied any chest pain. Urgent chest x-ray showed no abnormality. The
      Undetected Perioperative Myocardial   Troponin-I level was elevated. Urgent coronary angiogram showed stenosis
352   Infarction - A near Miss              within the stented segment of the right coronary artery.

                                                                  Page 116

                                            A 13 year-old male sustained a shotgun wound to his left distal foot.
                                            Femoral and sciatic nerve blockade was performed for intraoperative
                                            anesthesia and perioperative analgesia for over 2 weeks. For split-
                                            thickness skin grafting, femoral and sciatic nerve sheath catheters were
                                            used with deep sedation. Post-operatively, the patient denied pain, but
                                            complained of intense focal pruritis poorly controlled with diphenhydramine
                                            and hydroxyzine. The pruritis was localized to the skin graft's donor site,
      Intense, Focal Pruritis Despite Well- leading to vigorous yet painless itching. Sensory testing revealed intact
353   Functioning Femoral Nerve Blockade femoral nerve blockade throughout and surrounding the area of pruritis.

                                          As the second most common cause for professional liability in anesthetic
                                          practice, nerve injuries are a well recognized complication. Lateral
                                          antebrachial cutaneous neuropathy has not been described in the
                                          anesthesia literature, to the best of our knowledge. In the orthopedic and
                                          sports medicine literature, less than 100 cases have been described to
                                          date. We present a case of lateral antebrachial cutaneous neuropathy after
                                          prolonged general anesthesia for left medial meniscal transplant and micro-
                                          fracture surgery. We discuss possible causes and propose surgical
      Lateral Antebrachial Cutaneous      positioning as the most likely cause of post-operative lateral antebrachial
354   Neuropathy after General Anesthesia cutaneous neuropathy in our patient.

                                             An 89 year old man with severe COPD presented for emergency colectomy
                                             for toxic megacolon following antibiotic therapy for his pulmonary
                                             exacerbation. On exam, SpO2 on 4 L O2 was 88%, he was coughing up
                                             green sputum, and rales were heard bilaterally. He was febrile and oliguric.
                                             As we felt that GA with intubation would likely result in prolonged ventilation
      Emergency Total Colectomy under        and tracheostomy, epidural anesthesia as sole technique was chosen. A
      Thoracic Epidural as Sole Anesthetic   catheter was placed in the T8/9 interspace and abdominal blockade
      Technique in an 89 Year Old Patient    achieved with lidocaine 2%. Throughout the 5 hour case, the patient was
355   with Severe COPD Exacerbation          awake and comfortable. Full recovery was made postoperatively.

                                                                    Page 117

                                           A 53 year old male with malignant fibrous histiocytoma underwent
                                           postoperative continuous lumbar epidural analgesia complained of pain
                                           and numbness in lower extremities. Epidural infusion was stopped and
                                           catheter removed intact. MRI revealed a fluid collection extending from L1
                                           to L4 with compression of cauda equina and distal cord. No hematoma or
      Spinal Cord Compression in a Patient abscess identified. Additional findings included neuroforaminal stenosis at
      with Degenerative Neuroforaminal     multiple levels. Symptoms resolved in 24 hours. Repeat MRI showed
      Stenosis Undergoing Postoperative    complete resolution of the spinal fluid collection. Patients with degenerative
      Continuous Lumbar Epidural           spinal pathology have reduced lateral leakage due to sclerotic closure of
356   Analgesia                            intervertebral foramina. Their epidural infusion volume should be limited.
                                           A 67-year-old male underwent right pneumonectomy for non-small cell
                                           carcinoma. He was diagnosed with Shy-Drager-Syndrome 9yrs ago. He
                                           had severe orthostatic hypotension caused by autonomic dysfunction. His
                                           usual systolic blood pressure(SBP) in the morning was 60mmHg, with
                                           episodes of syncope. This improves with midodrine and fludrocortisone.
                                           SBP in the evening is between 220-240mmHg. He also had GERD and
                                           erectile dysfunction. EKG and other labs were unremarkable. General
                                           anesthesia was administered with etomidate, suxamethonium, sevoflurane
                                           and 39Fr left double lumen tube. Remifentanil 0.1-0.5mcg/kg/min,
                                           Nitroglycerin 10-50mcg/min, amiodarone 1mg/hr infusions used for
      Anesthesia of Pnemonectomy in a      hemodynamic stability. Patient was extubated uneventfully at the end of
357   Patient with Shy-Drager Syndrome     procedure.
                                           A 20-year-old with recent diagnosis of acute lymphocytic leukemia
                                           presented with recurrent pulmonary embolism on full anticoagulation. CT
                                           scan showed a 1.2 cm low-density area near the tricuspid valve and
                                           smaller areas in the right ventricular apex that were suspicious for clot. The
                                           scan also indicated a moderate pericardial effusion, bilateral pleural
                                           effusions, and a large mediastinal mass. Follow-up ECHO showed a large
                                           right ventricular thrombus. Patient was scheduled for emergent right
                                           ventricular thrombectomy. We present a case and anesthetic management
                                           of a patient with anterior mediastinal mass, pericardial effusion, and
                                           extensive right-sided cardiac thrombus with impending massive pulmonary
358   Emergent Right-Heart Thrombectomy embolism

                                                                    Page 118

                                          A 65yo patient allergic to heparin required an AVR. Argatroban instead of
                                          bilvalirudin was used for anticoagulation secondary to ESRD. A bolus of
                                          175mcg/kg and a drip of 3mcg/kg/min were chosen based on literature
                                          case reports. Baseline TEG showed hypercoaguability in factor and platelet
                                          function. During CPB a clot was seen in the reservoir and rapid TEG
                                          indicated excessive platelet activity, therefore eptifibatide was indicated,
                                          since unlike heparin, argatroban does not inhibit platelet activation and the
                                          patient was still platelet hypercoaguable. Rapid TEG correlated closely with
      The Use of Argatroban and the Rapid the clinical picture, where as simultaneously drawn I-Stat ACT values
359   TEG for Cardiopulmonary Bypass      varied drastically.
                                          The patient is a 78 year old female who underwent a right shoulder reverse
                                          arthroplasty. Postoperatively the patient developed a severe RV MI,
                                          ultimately necessitating the emergent placement of an RVAD along with a
                                          bypass to her RCA, both performed off-pump. During the course of this
                                          operation, the patient's core temperature had decreased to 33.7 C. A
                                          percutaneous rewarming catheter was then placed via the right femoral
      Use of a Warming Catheter To Treat vein. The patient was rewarmed to 37 degrees Celsius within 6 hours
      Perioperative Hypothermia in a      postoperatively. Subsequent to her operation, the patient ultimately
      Patient Undergoing Salvage Off-     underwent RVAD removal and was discharged home by 3 months after her
360   Pump RVAD Insertion                 initial surgery.
                                          A 59-year old woman with right adrenal cortical carcinoma extending into
                                          the inferior vena cava and right atrium presents for a right adrenalectomy
                                          and inferior vena cava/ atrial tumor excision. During right adrenalectomy
                                          and tumor manipulation, the massive right atrial tumor thrombus is
                                          witnessed embolizing to the right pulmonary artery on transesophageal
                                          echocardiography. Swift institution of cardiopulmonary bypass and
      Witnessed Intraoperative Pulmonary circulatory arrest facilitate the immediate removal of the tumor thrombus by
361   Embolism                            cardiac surgery team.

                                                                   Page 119

                                          A patient with a bicuspid aortic valve and anomalous coronary artery is
                                          scheduled for aortic valve replacement. An incidental right internal jugular
                                          and carotid artery dissection is identified on surface ultrasound prior to
                                          central line placement. No reports exist of isolated spontaneous dissection
                                          of the jugular vein. This aside, central line placement within the false lumen
                                          of the dissected vessel may have precipitated inadequate drug delivery,
                                          including heparinization and inotropic support following CPB. Routine
      Spontaneous Internal Jugular Vein   ultrasound use prior to central line placement may increase chance
362   Dissection                          findings that affect decision making and hopefully improve patient safety.
                                          The adult patient with congenital heart disease poses a number of issues
                                          to the anesthesiologist. A 58-year-old female presented to our institution
                                          with Eisenmenger's Syndrome secondary to an aorto-pulmonary window
                                          with significant hypoxia, and polycythemia for excision of a left carotid body
                                          tumor. Although the anesthetic management of these patients may vary,
      Dexmedetomidine with Cervical       we decided to perform this procedure under regional anesthesia and
      Plexus Block for Carotid Body Tumor sedation with dexmedetomidine. We describe the anesthetic
      Excision in Patient with            considerations and management of a patient presenting with
363   Eisenmenger's Syndrome              Eisenmenger's Syndrome.

                                           A 5' 8" 73 kg 62 year old Caucasian male with a functioning AICD
                                           developed refractory amiodarone-induced acute thyrotoxicosis and
                                           presented for urgent thyroidectomy. BP=90/55 mmHg, EF=15%, ECG
                                           revealed chaotic rhythm, RA SaO2=97%. Medications included
                                           dobutamine, milrinone, methimazole, sodium iodide and hydrocortisone. A
                                           large multinodular goiter was present. The patient complained of
                                           "smothering" whenever he lay down. He did not tolerate attempted sitting
      An Inhalation Anesthetic for Urgent  awake fiberoptic intubation. Inhalation induction and intubation using an
      Thyroidectomy in a Patient with End- Eschmann introducer were accomplished with sevoflurane without muscle
      Stage Heart Disease and Amiodarone- relaxants in the sitting position. The intraoperative course was
364   Induced Thyrotoxicosis               unremarkable. He was extubated uneventfully at the conclusion of surgery.

                                                                   Page 120

                                            59 y.o. male with CAD, IDDM, HTN, and HAE presented for 3- vessel
                                            CABG. Patient received Danazol 200 mg and increased to 400 mg prior to
                                            procedure. The C1INH level - 33% 68%) and C4 concentration - 10 (16-
                                            47). The OP-CABG was chosen to minimize complement cascade
                                            activation. FFP were administered to reinstitute C1INH. The induction
                                            included midazolam, fentanyl, atracurium, and etomidate. The patient
                                            received heparin, ACT 480. The grafts were done. FFP given to maintain
                                            C1INH. Heparin was reversed with reduced dose of protamine, ACT
      CABG Patient with Hereditary          normalized. The extubation was uneventful with anesthesia personnel
365   Angioedema                            present on postoperative day 2.

                                          A 48 year-old male with nonischemic cardiomyopathy requiring Heartmate
                                          2 LVAD for 20 days presents for heart transplant. Following transplant with
                                          appropriate immunosuppression, the donor heart failed despite maximal
                                          support. Immediate re-consultation with the transplant coordinator revealed
                                          a second donor heart to be available within 8 hours. The patient was
                                          converted to an ECMO circuit pending arrival of the second donor heart.
                                          Retransplantation with the second donor heart was completed without
      One Day, Three Hearts, One Patient: difficulty, patient weaned from bypass and transported to the ICU for
      Anesthetic Considerations for       uneventful recovery. Total combined CPB/ECMO time was 884 minutes.
366   Tandem Heart Transplant             The patient was discharged without gross neurologic compromise.

                                            A 44 yo female had a right pneumonectomy for adenocarcinoma with an
                                            uneventful intraoperative course. After skin closure, the patient developed a
                                            wide-complex, irregular tachycardia and arterial blood pressure of
                                            30mmHg. Resuscitation with epinephrine, calcium chloride, and lidocaine.,
                                            followed by magnesium, Amiodarone and norepinephrine restored sinus
                                            rhythm. Hemodynamics were maintained on Norepinephrine and Milrinone
                                            infusions. Persistently elevated central venous pressure and vascular
                                            congestion of the head and neck dictated an intraoperative chest x-ray,
                                            showing cardiac herniation into the right hemithorax. The chest was re-
      Management of Cardiac Torsion         explored and the heart was returned to normal position with a Gore-Tex
367   Following Pneumonectomy               patch pericardial repair.

                                                                   Page 121

                                             The presence of heart failure presents unique challenges for patients
                                             undergoing laparoscopic surgery. A 17 year old obese male (180kg) with
                                             dilated cardiomyopathy and severe secondary PHTN presented for
                                             laparoscopic gastric bypass in preparation for heart transplant. Initial post-
                                             induction pulmonary artery pressures (PAP) were 75/52 mmHg, which
                                             remained unresponsive to nitroglycerin and inhaled nitric oxide. However,
      Laparoscopic Gastric Bypass as         the addition of milrinone provided significant improvement of cardiac output
      Bridge to Cardiac Transplant in        and PAP (41/29 mmHg). Intraoperative combination of nitrate therapy and
      Severe Dilated Cardiomyopathy with     milrinone successfully treated our patient's cardiac failure and PHTN, as
      Secondary Pulmonary Hypertension       right-sided pressures were reduced while improving inotropy in the face of
368   (PHTN)                                 the changes of pneumoperitoneum.

                                             A 62 year old HIV + male with a history of a large mediastinal mass
                                             positioned over both main bronchi and a large LV thrombus, presented for
                                             drainage of a large pericardial effusion via a pericardial window. An
                                             inhalational induction was performed and supplimented with a small dose
                                             of ketamine. After the airway was secure the surgeons requested muscle
                                             relaxation. The patient was given two positive pressure breaths with a
      Pericardial Window for Pericardial     bronchoscope in place to observe the bronchi during positive pressure
      Effusion in a Patient with a Large     ventilation. No collapse was noted and muscle relaxant was given without
369   Mediastinal Mass                       subsequent problem and the case was completed.

                                             Coronary artery disease is common in older patients presenting for lung
                                             transplant. Traditionally, the presence of coronary artery disease would
                                             exclude a patient from having a lung transplant. We describe the dilemma
                                             of managing patients with surgically correctable coronary artery disease
                                             who also have end stage pulmonary disease. We believe that the
                                             combined coronary revascularization and lung transplantation is technically
                                             feasible and carries an acceptable morbidity and mortality. We describe the
      Off Pump Coronary Artery Bypass        anesthetic management of a 64 year old man with coronary artery disease
      Graft Immediately Prior to Single Lung who underwent concomitant surgery of unilateral lung transplant and off
370   Transplant: Anesthetic Considerations pump CABG.

                                                                    Page 122

                                             A 83 years-old man was diagnosed pericardial tamponade due to ruptured
                                             coronary artery aneurysm (CAA). Intraoperative TEE depicted CAA clearly.
                                             TEE confirmed that right ventricle hypertrophy and enlarged coronary sinus
                                             (CS). We identified the coronary artery fistula (CAF) draining into the CS.
      Intraoperative Transesophageal         First, we opened the CAA and could easily find the CAF and removed the
      Echocardiography Identifies the        CAA. Subsequent TEE confirmed that the flow through the CAF was no
      Precise Location of Ruptured           longer present and that left ventricular contractility was normal. In
      Coronary Artery Aneurysm with          conclusion, intraoperative TEE was useful in identifying the precise location
371   Coronary Sinus Fistula                 of the CAA and the CAF.

                                            Patient was s/p Ivor-Lewis esophagectomy complicated by anastamotic
                                            leak, esophageal stent placement, and bronchoesophageal fistula. Rapid
                                            sequence induction was performed for emergency repair via right
                                            thoracotomy. A bougie was used to position a double lumen tube (DLT) just
                                            subglottically because of known difficult airway and bilious secretions. The
                                            DLT was guided into position with a fiberoptic bronchoscope to avoid
      Separate Circuit Bilateral Lung       further right bronchial injury. Following surgical repair, a second ventilator
      Ventilation Following Repair of Right was used to provide protective, selective ventilation of the right lung.
      Mainstem Bronchus from Esophageal Independent lung ventilation continued for 3 days in the ICU. The patient
372   Stent Erosion                         survived and returned to preoperative activities.

                                           58 year old female underwent bronchoscopic biopsy for change of voice
                                           and cough. Several hours later she developed severe progressive dyspnea
                                           and was referred to our institution. Despite the use of Heliox gas mixture,
                                           her respiratory status continued to deteriorate, and she was brought to the
                                           operating room for bronchoscopy. A combination of ketamine and
                                           dexmedetomidine was used for induction and management of anesthesia,
                                           keeping her spontaneously breathing in an upright position. Flexible
      Intraoperative Management of Patient bronchoscopy through a LMA revealed near total bronchial mass
      with Progressive Severe Airway       obstruction of both mainstem bronchi. After successful placement of
      Obstruction Following Bronchoscopic bronchial stents, patient was extubated, postoperative course remained
373   Biopsy                               unremarkable.

                                                                    Page 123

                                             We present a 38 year old female patient scheduled for ACDF for cervical
                                             radiculopathy. She presented with complaints of intermittent pain,
                                             numbness, clumsiness, progressive weakness in the right arm, palpitation
                                             and mild shortness of breath. ECG revealed LBBB. Holter revealed
                                             occasional PVCs with no ischemia. ECHO, a DSE and a cardiac MRI
                                             revealed isolated left ventricular noncompaction, mildly depressed left
      Noncompacted Left Ventricle - A        ventricular function and no overt ischemia. She had an awake fiber-optic
      Unrecognised and Underdiagnosed        intubation followed by induction using fentanyl, propofol and rocuronium
374   Lesion on ECHO                         and maintained with sevoflurane. She had an uneventful recovery.

                                             A 56 year-old man with a history of NASH cirrhosis and End-Stage Liver
                                             Disease, complicated by esophageal varices and encephalopathy (MELD
                                             score 12) who, in evaluation for angina, underwent cardiac catheterization
                                             which revealed triple-vessel CAD with preserved EF of 50%. He presented
                                             for Off-Pump CABG. The challenges brought forth in this case included
                                             how to maintain hepatic blood flow and oxygenation during the course of
                                             variable perfusion with changing position of the heart, blood and blood
                                             product transfusion requirements, choice of anesthetic agents and optimal
      Liver Transplant Candidate, Needs      monitoring. Morbidity associated with cardiopulmonary bypass in the setting
375   CABG Now, What Are the Options?        of cirrhosis will be discussed.

                                             57 yo female with anterior mediastinal mass and superior vena cava
                                             syndrome (SVC) underwent anterior mediastinotomy and biopsy. Focussed
                                             examination revealed grade 3 Mallampati airway with gross facial and neck
                                             swelling. CT scan showed 5x7 cm mass with partial extrinsic compression
                                             of SVC. Patient underwent awake fiberoptic intubation and was extubated
                                             at the end of surgery. Ten minutes after extubation, patient became
                                             unresponsive and apneic and was reintubated by direct laryngoscopy.
                                             Patient was successfully extubated next day. Caution must be exercised
                                             with SVC syndrome as airway edema, compromised hemodynamic
      Post-Extubation Hypoxia in a Patient   circulation and cerebral edema may contribute to apnea immediately after
376   with Superior Vena Cava Syndrome       extubation.

                                                                   Page 124

                                         Acute airway obstruction caused by a mucous plug simulating severe
                                         bronchspasm with chest ronchi, high airway pressure during CABG surgery
                                         is presented and its management described. The worsening airway
                                         obstruction not responding to bronchodilators and ETT suctioning
                                         prompted us to call for a chest radiograph and fiberoptic bronchoscopy.
                                         The FOB revealed a pin hole diaphragm looking obstruction at the distal tip
                                         of the endotracheal tube causing an intrathoracic bidirectional obstruction
                                         precipitating severe ventilatory compromise and hemodinamic instability
      An Unusual Mucous Plug: Simulating which developed acutely over minutes and was a diagnostic challenge. The
      Severe Bronchospasm with Auto      role of energent FOB during severe unresponsive bronchospastic
377   PEEP                               emergencies will be discussed.

                                           Ventilatory difficulty during disengagement from CPB have been
                                           infrequently reported. A case of complete airway obstruction with inabillty to
                                           ventilate the patient after a prolonged bypass run unresponsive to
                                           bronchdilator therapy is presented. Subsequent bronchoscopy revealed
                                           complete collapse of the trachea distal to the ETT. The obstruction
                                           appeared dynamic in nature with the obstruction becoming complete during
                                           expiration. We had to apply a PEEP of 15-18 cm H[sub]2[/sub]O to keep
      Complete Airway Collapse Due to      the airway from collapsing. Presentation of mediatinal swelling causing this
      Mediastinal Swelling: Role of        rare clinical enitity and it diagnosis with FOB and successful treatment with
378   Bronchscopy and High PEEP            application of High PEEP is discussed.

                                           50 year old female with interstitial lung disease was transported to our
                                           hospital for emergent repair of a bronchial injury caused by unsuccessful
                                           placement of a 39-Fr left-sided double-lumen tube (DLT) during her
                                           scheduled thoracoscopic biopsy at a nearby community hospital. The DLT
                                           was changed to a single lumen tube (SLT) for ventilation. Upon arrival to
                                           operating room, flexible bronchoscopy revealed proximal posterior wall
                                           rupture of the right mainstem bronchus. SLT was changed to a 35-Fr left-
      Iatrogenic Rupture of Right Mainstem sided DLT under fiberoptic guidance. Surgery was successfully completed.
      Bronchus after Double Lumen Tube We extubated her in the operating room and she had an uneventful
379   Intubation                           recovery.

                                                                  Page 125

                                            60 year old male had undergone emergent coronary revascularization and
                                            placement of extracorporeal membrane oxygenator (ECMO) 48 hours
                                            previously. Serial chest radiographs were improving; however, the patient
                                            was experiencing acute renal failure, thrombocytopenia, and increased
                                            clinical bleeding. The conversion from ECMO to LVAD was uneventful.
      Conversion of ExtraCorporeal          Following separation from cardiopulmonary bypass, there was severe right
      Membrane Oxygenator (ECMO) to         ventricular failure that required escalating inotropic support, and finally
      Left Ventricular Assist Device (LVAD) placement of right ventricular assist device. An oxygenator was added due
      Complicated Acute Right Ventricular to inadequate gas exchange. Clinical concerns include severe acidosis in a
380   Failure                               patient with acute renal failure, right ventricular failure, and fluid overload.

                                              60year-old male with bicuspid aortic valve, aortic valve insufficiency and
                                              marked functional limitation, underwent elective aortic valve replacement
                                              with 23mm On-X mechanical bileaflet prosthesis under general anesthesia.
                                              Dobutamine 12mcg/kg/min, amiodarone 30mg/hr continued. On first
                                              postop day arterial blood gas showed PO2 of 64mmHg on 50% inspired
                                              oxygen. Oxygenation did not improve despite increasing FiO2 to 100% and
                                              optimizing PEEP. Chest X-ray showed patchy infiltrates bilaterally. Multiple
                                              bronchoalveolar lavage, blood and urine cultures showed no growth. TTE
                                              showed well seated prosthesis, hyperdynamic LV with ejection fraction
      Amiodarone Induced Acute Lung           70%. Refractory hypoxemia required placement of ECMO. Lung biopsy
381   Injury                                  suggested acute pneumonitis secondary to amiodarone.

                                             After hydrocelectomy, a 56 year old African male decompensated with
                                             cardiac failure. He had history of hypertension and anemia. Ejection
                                             fraction was 40% preop. Hypotension was treated with fluids. Patient
      The Audacity To Hypothesize the        reintubated in Post Anesthesia Care Unit. Had respiratory acidosis. A
      Limitation of Frank-Starling's Curves. transthoracic echo showed an ejection fraction of 15%.Chest x-ray showed
      A Possible Superior Application of     congestion. The time honored Frank-Starling curves didn't seem to work in
      Law of Laplace. A Simple Case of       the outcome of the case. Theoretically there seems to be room for
382   Interest!                              questioning and debating one of the greatest physiological curves.

                                                                     Page 126

                                             An 86 year-old female, with history of hypertension, presents with episodic
                                             10/10 abdominal pain in the mid-abdomen. While living a sedentary
                                             lifestyle, she has no history of angina or syncope. She was scheduled for
                                             laparoscopic ventral hernia repair and cholecystectomy. On examination, a
                                             IV/VI systolic ejection murmur was auscultated. An echocardiogram
                                             revealed a hyperdynamic left ventricle with moderate concentric
                                             hypertrophy and an ejection fraction of 65%, aortic valve area 0.7 cm 2 and
      Severe Aortic Stenosis and Elective    a resting maximum AV gradient of 86 mmHg. This case emphasizes the
      Abdominal Surgery: An Ethical          dilemma of an apparently asymptomatic patient with severe aortic stenosis
383   Dilemma                                presenting for elective non-cardiac surgery.

                                             39 year old male underwent general endotracheal anesthesia for
                                             endovascular repair of descending thoracic aortic aneurysm. Surgical
                                             repair mortality averages 5-8%. Endovascular abdominal aortic aneurysm
                                             repair tecniques are now applicable to dtaas. Procedure has 2 incisions
                                             made in both groins with gore tag(r)thoracic endoprosthesis graft placed
                                             inside aneurysm excluding the dtaa from the circulation. Available in the
      Endovascular Repair of Descending      USA as FDA trials only. Endovascular surgery of TAA is the first choice of
      Thoracic Aortic Aneurysm, Requiring    therapy for TAA and type B dissection. Anesthesia included 2 intraarterial
      Two Arterial Lines, Using the Gore     lines placed in radial arteries as surgeon used left line to perform selective
384   TAG Thoracic Endoprosthesis            angiograms of left subclavian artery before graft placement.

                                              A 32 year old woman with hereditary telangectasia developed fulminant
                                              hepatic failure due to post-partum cholecyctitis and pancreatitis with
                                              Enterococcus faecium septicemia. As Status I, she underwent orthotopic
                                              liver transplantation. Within 15 minutes of donor liver reperfusion,
                                              pulmonary arterial pressure increased without evidence of hypoxia or intra-
                                              cardiac clot by TEE. After platelet and cryoprecipitate transfusions,
                                              hypotension and cardiac arrest occurred. TEE then revealed intracardiac
      Fatal Pulmonary Embolism during         clots in the RA and RV. CPR and tPA restored cardiac rhythm, but the LV
      Liver Transplantation in a Patient with had global akinesis. VA-ECMO was unsuccessful. The patient expired of
385   Fulminant Hepatic Failure               pulmonary embolism and was declared 90 minutes after cardiac arrest.

                                                                    Page 127

                                           We present two cases of suprasystemic secondary pulmonary
                                           hypertension in patients undergoing mitral valve replacement, one for mitral
                                           stenosis and one for mitral regurgitation. Both had moderate pulmonary
                                           hypertension by estimate on preoperative trans-thoracic echocardiography.
                                           After placement of PA catheters in the OR, both demonstrated
                                           suprasystemic pulmonary hypertension. These patients were treated with
                                           alprostadil and dobutamine infusion in the pre-bypass period, and post-
      Managing Unexpected Supra-           bypass as indicated, with clinically significant improvement in
      Systemic Pulmonary Hypertension in   hemodynamics. In both cases, the patients were successfully weaned from
      Patients Presenting for Cardiac      cardiopulmonary bypass and had uneventful recoveries with extubation in
386   Surgery                              the ICU at 24 hours.

                                           A young female was involved in single-car accident with multiple injuries
                                           including fractures of two cervical vertebrae. Intra-arterial catheter was
                                           placed, and intravenous induction was performed without complication.
                                           Intubation was difficult but ultimately accomplished with a McGrath scope.
                                           A digital bronchoscope was advanced into the left mainstem bronchus
                                           without difficulty; however, we were unable to advance bronchial blocker
                                           over bronchoscope, meeting resistance probably at the carina.
                                           Visualization demonstrated the catheter in the right mainstem bronchus.
                                           The process was repeated several times without success. Further
      Aortic Transection Complicated by    instrumentation of the airway was abandoned, and the procedure was
387   Cervical Fractures                   performed without lung isolation.

                                           A 27-year-old female with interstitial lung disease presented for sequential
                                           bilateral lung transplantation. Left lung was isolated and transplanted.
                                           Following re-inflation PaO 2 and EtCO 2 decreased. Immediately after right
                                           lung isolation SpO 2 dropped and peak inspiratory pressures increased. To
                                           decrease shunt fraction, the right pulmonary artery was clamped.
                                           Hypoxemia persisted and PA pressures remained increased. TEE showed
                                           RV dilation and severe TR. Patient was persistently hypotensive and
                                           hypoxemic. Emergent cardiopulmonary bypass was initiated and the right
                                           lung was transplanted. CPB separation was complicated by hypoxemia,
      Primary Graft Dysfunction during     resulting in veno-arterial ECMO initiation. Post-op course was complicated
388   Bilateral Lung Transplantation       by ventilator dependency, sepsis and multiorgan failure

                                                                 Page 128

                                            A 77 year old male presented for endovascular repair of a large aortic arch
                                            aneurysm involving the origin of the left subclavian artery. During the
                                            endovascular surgery, a stent-graft was deployed distal to the innominate
                                            trunk. Endoleak was noted after stent placement. The surgeon chose to
                                            employ a Palmaz stent to seal the endoleak which requires Inflation of an
                                            occluding balloon in the ascending aorta. Overdrive pacing using
                                            transveonous pacing wire lowered the SBP to 40s allowing the surgeon to
      Overdrive Pacing for Endovascular     deploy the Palmaz stent. The patient reverted to sinus rhythm with no
389   Repair of an Aortic Arch Aneurysm     evidence of ischemia at the conclusion of overdrive pacing.

                                            A sixty one year old male scheduled for peripheral vascular surgery
                                            suffered a cardiac arrest after induction of general anesthesia. During
                                            resuscitation with intravenous epinephrine and chest compressions, a
                                            transesophageal echo examination showed a severely hypokinetic right
                                            ventricle, and thick spontaneous echo contrast (SEC) in the ascending and
                                            descending thoracic aorta. In response to this finding, ten thousand units of
                                            unfractionated heparin were administered intravenously. An intravenous
                                            bolus dose and infusion of milrinone were also given. The SEC gradually
      Heparin Administration during         cleared and biventricular function improved. He made a full recovery and
390   Cardiopulmonary Resusitation          was discharged from the hospital a few days later.

                                            A 71 year old male was undergoing a right sided talc pleurodesis for the
                                            treatment of recurrent malignant effusion. After entering the right chest
                                            cavity, talc poudrage was initiated using a Freon based propellant system.
                                            Immediately upon spraying the mediastinum (the first place to undergo talc)
                                            the patient's heart rate dropped suddenly into the 30's with a corresponding
                                            decrease in BP. The surgeons were notified immediately and stopped the
                                            procedure which resulted in resolution of the bradycardia. We hypothesize
      Bradycardia during Right Lung Freon   the cold Freon propellant against the mediastinum, specifically the vagus
391   Pleurodesis                           nerve, triggered the event.

                                                                   Page 129

                                            Patient presents with a type I endovascular leak at the level of the
                                            subclavian artery. She had been treated for TAA with two endolumenal
                                            stents in the descending thoracic aorta and now presents with a proximal
                                            aortic leak involving the aortic arch with a significant left sided hemothroax.
                                            The proposed surgery was: aortic-L-subclavian, aortic- innominant and
                                            aortic to left carotid bypass followed by the insertion of two endovascular
                                            stent to the aortic arch. We did not place a subarachnoid drain, we
                                            managed blood pressure during cerebral bypasses with the aid of a
392   Off-Pump Aortic Arch Repair           processed EEG. We measured femoral artery pressure .

                                            A 47 year old male presented with esophageal cancer for esophagectomy.
                                            Shortly after induction of anesthesia he developed ST segment elevation
                                            which deteriorated into cardiac arrest. After 2 hours of resuscitation he
                                            arrived in the ICU and received propofol and rocuronium for changing his
                                            endotracheal tube. He was noted to have ST segment elevation and
                                            treated with steroid, antihistamine and nicardipine. He went on for a full
                                            recovery, had skin testing for anesthetics and returned 2 months later for
                                            esophagectomy. He was managed without muscle relaxants, antihistamine
                                            blockade and perioperative diltiazem infusion. Allergic coronary vasospasm
393   A Case of Coronary Wheezing           was the likely cause of his cardiac event.

                                            40 year-old male with severe mitral insufficiency underwent valve repair.
                                            Monitors included PAC and TEE. A right subclavian CVC was placed for
                                            prolonged venous access. An uneventful repair was performed via a left
                                            atriotomy approach. Routine post-operative CXR showed the CVC to
                                            possibly be in the RA. Patient did well post-operatively but on POD#3 the
                                            CVC was unable to be removed. CT revealed the CVC tip to be in the
                                            medial aspect of the SVC-RA junction. It was assumed that the catheter
      Entrapment of a Central Venous        was entrapped in the left atrial suture line. Repeat sternotomy was done
394   Catheter during Mitral Valve Repair   with subsequent removal of the catheter.

                                                                   Page 130

                                             A 54 years old, 100 Kg female with no previous documented significant
                                             medical history presented to the ER with severe chest pain. EKG and
                                             cardiac enzymes indicated an acute non-ST MI. Cardiac catheterization
                                             revealed severe triple vessel disease. A TSH of 187 lead to the initiation of
                                             oral syntroid administration. Subsequently she developed unstable angina
                                             leading to insertion of IABP prior to urgent CABG. Case discussion will
      CABG in a Patient with Severe          focus on the myriad medical effects of hypothyroidism and the acute
395   Hypothyroidism                         management of severe myocardial dysfunction in the face of myxedema.

                                             A 42 yo, 70 kg previously healthy Vietnamese male with an unremarkable
                                             airway exam presented for urgent appendectomy. The patient was febrile
                                             (T 39.5°C) and dehydrated. An ER ECG was initially interpreted as an
                                             acute AMI. Upon review, the cardiologist described the ECG changes as
                                             suggestive of the Brugada Syndrome. Invasive monitoring was
                                             established. Defibrillator pads were placed on the patient prior to induction
      An Inhalation Anesthetic for           of general anesthesia, which was accomplished with thiopental. Anesthesia
      Appendectomy in a Patient with         was maintained with sevoflurane. The intraoperative course was
      Electrocardiographic Changes           unremarkable, albeit prolonged. As the patient defervesced (37.1°C) in
396   Suggestive of Brugada Syndrome         PACU, the ECG changes rapidly resolved.

                                             The Florida Sleeve procedure was developed to repair ascending aortic
                                             aneurysms with associated aortic insufficiency to avoid use of the Bentall
                                             procedure and the concomitant risks of lifelong anticoagulation. Successful
                                             application of the Florida Sleeve operation requires TEE expertise to
                                             evaluate the degree of aortic insufficiency, aortic valve pathology and
                                             obtain precise measurements of the aortic annulus and proximal aortic
                                             structures. We describe our first two patients who underwent Florida
                                             Sleeve procedures and the management challenges inherent in performing
      Anesthetic Challenges of the Florida   a complex repair of the aortic valve and aortic aneurysm vs. standard
397   Sleeve Operation                       treatment with the Bentall operation.

                                                                    Page 131

                                          Elderly patient sustained a contained esophageal dissection from TEE
                                          probe placement prior to minimally invasive mitral valve repair. After
                                          several attempts TEE probe was inserted without resistance; few
                                          centimeter distal resistance was encountered. For fear of esophageal
                                          injury, thoracic surgeon was consulted. Endoscopy detected false passage
                                          adjacent to upper esophageal sphincter; involving dissection of the mucosa
                                          without perforation of esophageal musculature. Surgery was cancelled.
                                          Barium swallow video esophagograms were used to evaluate and follow
      Use of Multi-Imaging Modalities in  up. Two months later, he returned for surgery. TEE was not utilized.
      Detection [amp] Management of False Epicardial echocardiogram was performed using transthoracic probe
398   Passage of TEE Probe                placed through thoracotomy incision without further complications.

                                             A 74-year-old white male status post cardiac transplant presented with end
                                             stage renal disease (ESRD) secondary to Cyclosporin toxicity. He was
                                             admitted to to undergo living related renal transplant from his daughter.
                                             The patient's past medical history was significant for myocardial infarction
                                             with subsequent congastive heart failure. This necessatited implantable
                                             cardiac defibrillator (ICD) and subsequent reart transplantation in 1997.
                                             The patient presented uniquely difficult challenges because of heart
      Peri-Operatve Management of a          transplant and ESRD. These included denervated heart, impaired renal
      Renal Transplant Patient after         function, metabolic and electrolyte derangements. A clear understanding of
      Cardiac Transplantation - Anesthetic   these issues and appropriate perioperative plan is essential for safe care of
399   Considerations                         these patients.

                                             A sixty one year old male scheduled for peripheral vascular surgery
                                             suffered a cardiac arrest after induction of general anesthesia. During
                                             resuscitation with intravenous epinephrine and chest compressions, a
                                             transesophageal echo examination showed a severely hypokinetic right
                                             ventricle, and thick spontaneous echo contrast (SEC) in the ascending and
                                             descending thoracic aorta. In response to this finding, ten thousand units of
                                             unfractionated heparin were administered intravenously. An intravenous
                                             bolus dose and infusion of milrinone were also given. The SEC gradually
      Heparin Administration during          cleared and biventricular function improved. He made a full recovery and
400   Cardiopulmonary Resuscitation          was discharged from the hospital a few days later.

                                                                    Page 132

                                             63 year old male with a newly placed left ventricular assist device (LVAD)
                                             was emergently taken to the operating room for mediastinal exploration
                                             secondary to decreased LVAD flow and hemodynamic instability.
                                             Intraoperative transesophageal echocardiography (TEE) revealed LVAD
                                             inflow cannula intermittently aspirating the posterior left atrial wall resulting
                                             in occlusion of the cannula. On surgical exposure, the cannula appeared
                                             inappropriately inserted in the atrium. This was confirmed by gradually
                                             withdrawing several centimeters of cannula thereby producing dramatic
      Inadvertent Misplacement of LVAD       improvement in LVAD flow and tissue perfusion. In this case, intraoperative
      Cannula Detected by                    TEE played an important role in diagnosis and management of LVAD
401   Transesophageal Echocardiography       cannula misplacement.

                                             A 22 y.o. female presented for elective bilateral reduction mammoplasty.
                                             The planned procedure was previously attempted at an outside hospital,
                                             where after induction of anesthesia, the patient had severe respiratory
                                             compromise resulting in hypoxemia and cardiac arrest. She was referred
                                             for a pulmonary evaluation prior to elective surgery, where she was
                                             diagnosed with Swyer-James Syndrome (unilateral hyperlucent lung). After
                                             induction of anesthesia, low volume, low pressure mask ventilation was
                                             performed with 100% oxygen prior to placement of a double lumen tube to
      Single-Lung Ventilation in a Patient   ventilate only the unaffected lung. There were no complications and the
402   with Swyer-James Syndrome              patient was discharged home on postoperative day one.

                                             A 64yo female patient was scheduled to undergo an insertion of a
                                             pacemaker / Defibrilator with percutaneous lead placement using the left
                                             subclavian vein approach under local anesthesia with Intarveouns
                                             Sedation. Suddenly she became tachycardic, hypotensive, and
                                             unresponsive. The surgeon was informed, the patient intubated
                                             emergently, and a TEE probe placed as the surgeon was prepping the
      Iatrogenic Injury of the Pulmonary     chest. TEE showed an acute cardiac tamponade. The surgeon did a
      Artery during Pacemaker Lead           mediansternotomy, identified an injury to the pulmonary artery which he
403   Placement: A Case Report               repaired. The patient did well and transferred to the ICU.

                                                                     Page 133

                                           A 9 year old girl suffering from supracardiac total anamolous pulmonary
                                           venous connection and atrial septal defect was scheduled for correction of
                                           defects on cardio-pulmonary bypass (CPB) under general
                                           anesthesia.Administration of 70% of the dose of protamine after weaning of
                                           CPB, resulted in desaturation. Bloody froth was found in tracheal tube.
                                           Right lung was not getting ventilated. Oxygenation improved with 100%
                                           oxygen ventilation and tracheal suction. But right lung remained collapsed.
                                           Provisional diagnosis of pulmonary edema due to protamine induced
                                           pulmonary vasoconstriction was made and treated by lung recruiting
                                           strategy. Despite all resuscitative measures she expired on postoperative
404   A Rare Fatal Protamine Reaction      day.

                                           A 72 year old male with severe aortic stenosis underwent percutaneous
                                           aortic valve replacement. Surgical replacement was considered too risky
                                           due to close proximity of the right ventricle and saphenous vein grafts from
                                           previous two CABG to the sternum. Postoperative TEE revealed severe
                                           aortic regurgitation. The patient was taken back to the catheterization lab to
                                           place a second generation corevalve bioprosthesis, successful deployment
      A Redo Percutaneous Aortic Valve     within the first prosthetic valve was aided by tight hemodynamic control.
      Replacement: Challenges to the       Our greatest challenge was to be ready to proceed emergently with surgery
      Anesthesiologist in a Remote         if complications happened, a surgery that was considered too risky in the
405   Location                             first place.

                                           We are reporting two cases in the past year of simultaneous, sequential
                                           heart and liver transplants; 33 year old male with restrictive cardiomyopathy
                                           and hepatitis B and a 66 year old male with amyloid disease of the heart
                                           and liver. Both patients presented unique challenges for both heart and
                                           liver transplant teams. Some of the conflicting goals are (1) Fluid
                                           administration in the presence of right heart dysfunction and pulmonary
                                           hypertension, (2) Extra-corporeal circulation, (3) Cannula insertion sites, (4)
      Simultaneous Heart and Liver         Choice of vasopressor support, (5) Management of reperfusion. The pros
406   Transplant: Care of Contradictions   and cons of these issues will be thoroughly discussed.

                                                                  Page 134

                                            A six-year-old male with an ASD underwent placement of a HELEX device
                                            under general anesthesia. The right atrial disc positioning was suboptimal
                                            without evidence of any obstruction to inflow. The left disc was in the
                                            proper position. Positioning did not change after emergence from
                                            anesthesia. Twelve hours later, the patient experienced chest pain and
      The Anesthetic Challenge of a Patient had an episode of desaturation into the mid 80s. Echocardiography
      with Pulmonary Artery Embolization of showed the device in the pulmonary artery. The patient was taken to the
      a Helex Occluder Implanted into a     OR and underwent device retrieval and closure of his ASD. Surgical
407   Secundum Atrial Septal Defect         retrieval was uncomplicated and caused no sequelae.

                                            Acute aortic dissection is a rare but potentially catastrophic complication
                                            during cardiopulmonary bypass (CPB). Transesophageal echo (TEE) can
                                            facilitate early diagnosis, aiding in the management of acute aortic
                                            dissection intraoperatively. In this uncommon case, the dissection occurred
                                            after aortic cannulation but prior to the initiation of CBP, with a
                                            hemodynamically stable patient. Our use of TEE in all CPB cases, led to
      Diagnosis of an Acute Aortic          prompt recognition and successful management in an otherwise
      Dissection during Cardiopulmonary     unrecognizable scenario. This presentation will graphically illustrate
      Bypass with Intraoperative            management of acute aortic dissection, including the utility of a focused
408   Transesphogeal Echo                   TEE examination, highlighting its added benefit in routine cases of CPB.

                                            A 72 year old female with a 8cm aortic aneurysm involving the ascending,
                                            arch, and descending portions of the aorta was scheduled for a Bentall
                                            procedure as well as replacement of the arch under circulatory arrest. After
                                            induction and intubation, the aneurym became apparent as the source of
      Perioperative Management of           mechanical compression of the airway and the heart. Thus, difficulty with
      Mediastinal Mass Compressing          ventilation and cardiopulmonary instability ensued. This compression was
409   Airway and Heart                      relieved by turning the patient to a lateral position.

                                                                   Page 135

                                              A 70-kg 53-year-old male presented to the ER with severe substernal chest
                                              pain. Acute coronary syndrome was suspected and the patient received
                                              clopidogrel 300mg and aspirin 324mg prior to emergent cardiac
                                              catheterization, which displayed a type I aortic dissection. Surgical
      Catastrophic Post Cardiopulmonary       intervention consisted of aortic dissection repair with aortic valve
      Bypass Hemorrhage after Emergent        replacement complicated by post CPB iatrogenic coagulopathy despite
      Thoracic Aortic Dissection Repair       platelet transfusion therapy and the use of the aprotinin regimen A protocol.
      Following Clopidogrel 300 mg Given      A growing body of evidence corresponds with our experience that intra-
      Prior to Coronary Angiography for       operative use of antifinbrinolytics, Factor VIIa and desmopressin is more
      Misdiagnosed Acute Coronary             efficacious in clopidogrel related coagulopathy reversal than platelet
410   Syndrome                                transfusions alone.
                                              33 Year old female, with a paraganglioma mass of 15.3x13.6x19.5cm
                                              found in the left chest. MRI of the chest, shows no involvement of the
                                              chest wall or great vessels. The Left lung was found to be collapsed with
                                              medialstinal structures shifted to the right. Patient was started ona course
                                              alpha then beta blockade. Intraoperatively, Lung isolation with a double
                                              lumen was found to be difficult to place; bronchial blocker was utilized.
                                              Patient remained hemodynamically stable throughout the case, even with
      Resection of Left Chest                 manipulation of the mass. Upon mass removal, the left lung was re-
411   Pheochromoctyoma                        expanded without difficulty.

                                            Our patient was a 75-year-old-male after 3 syncopal events and with 15%
                                            LVEF. He underwent an urgent, off-pump CABG for LAD stenosis via left
                                            thoracotomy and one lung ventilation. His history included type-II diabetes
                                            and total laryngectomy followed by chest/neck irradiation, which precluded
      Urgent Off-Pump Coronary Artery       midline sternotomy. After IV induction, a left double lumen endotracheal
      Bypass Graft Surgery Via Left         tube was placed through the patient's stoma. Surgery was performed under
      Thoracotomy in a Patient with History balanced anesthesia and the patient's vital signs were kept stable. At the
      of Laryngectomy and Neck/Chest        conclusion of the operation DLT was replaced with a Laryngoflex tube and
412   Radiation                             the patient was transported to the ICU in good condition.

                                              56 y/o female presented with recurrent stroke. Work-up revealed
      Transesophageal Echocardiographic       transesophageal echocardiographic evidence of aortic valve leaflet mass.
      Evidence as Cause for Recurrent         Patient underwent thoracotomy and surgical evaluation of the aortic valve,
      Cerebrovascular Accidents-              revealing no abnormality. Postoperatively, patient had new-onset
413   Controversies in Image Interpretation   hemiplegia. Further work-up and discussion presented in poster.

                                                                     Page 136

                                             A 65 year old caucasian male with end stage idiopathic pulmonary fibrosis,
                                             presented to the operating room for left lung transplantation. His
                                             preoperative PA pressure was 30/16 mmHg. After uneventful induction of
                                             anesthesia and placement of a left sided double lumen tube, he was placed
                                             in the right lateral decubitus position for left thoracotomy approach. Shortly
                                             after placement of the left PA clamp, severe pulmonary hypertension (PA
      Successful Management of Acute         102/39 mmHg) accompanied by systemic hypotension and bigeminy on
      Severe Pulmonary Hypertension          EKG were noticed. Immediate aggressive pharmacologic management
      during Left Lung Transplantation,      including inhaled NO allowed completion of the transplant without CPB, and
414   without Cardiopulmonary Bypass         resulted in good perioperative outcome.

                                             An eighty year old female was scheduled to undergo peripheral vascular
                                             surgery under general anesthesia (GA). GA was induced uneventfully with
                                             etomidate and fentanyl. A few minutes later she became hypotensive
                                             (Blood pressure 65/40 mm Hg) with sinus tachycardia (90 beats/minute)
                                             without any evidence of ischemia. Due to failure to respond to resuscitation
                                             (Phenylephrine and Fluid administration) a transesophageal echo (TEE)
                                             probe was placed. TEE revealed a thick interventricular spetum (2.2 cm)
                                             causing systolic anterior motion of mitral valve (SAM) and severe mitral
      Unanticipated Left Ventricular Outflow regurgitation. With heart rate and afterload control and fluid administration
415   Obstruction                            SAM improved and her hemodynamic condition stabilized.

                                          A 31-year-old female with a history of self-inflicted gun shot wound to the
                                          upper abdomen and left thorax two weeks prior presented emergently to
                                          the OR with cardiac tamponade. A chest CT could not confirm the
                                          diagnosis; however, TEE revealed a large, loculated pericardial effusion.
                                          She was hemodynamically unstable with CVP's [gt]30mmHg and MAP
                                          50mmHg on epinephrine and norepinephrine. Following sternotomy with
      A 31 Year-Old Female Presenting     evacuation, the CVP immediately returned to normal and TEE showed
      with Cardiac Tamponade Two Weeks normal filling and function. Other challenging aspects included prior
      Following a Self-Inflicted Gun Shot abdominal surgeries and left thoracotomies with a large, chest wall defect,
416   Wound                               a fresh tracheostomy, and a DVT with anticoagulation.

                                                                    Page 137

                                             65-year old male presented at a referring institution with substernal chest
                                             pain. Electrocardiogram demonstrated significant ischemia; acute
                                             myocardial infarction was diagnosed, and the patient was treated with
                                             thrombolytic therapy. Upon arrival at Maine Medical Center, the patient was
                                             hypotensive with significant ECG changes. Cardiac catheterization
                                             demonstrated significant pericardial fluid, type A dissection and normal
                                             coronary arteries. The patient was obtunded upon arrival in the operating
                                             room, and we were unable to palpate pulses. Cardiopulmonary
                                             resuscitation was initiated, and emergent cardiopulmonary bypass was
      Type A Aortic Dissection Complicated initiated via femoral cannulation. Completion of the procedure was notable
417   by the Administration of Thrombolytics for significant bleeding requiring activated factor VII.

                                             61 year old male experienced cardiac arrest in the community; patient was
                                             successfully defibrillated and transferred to Maine Medical Center. Cardiac
                                             catheterization demonstrated complete occlusion of left anterior
                                             descending artery that was opened by angioplasty. Despite maximal
                                             medical therapy, the patient remained hypotensive with a left ventricular
                                             ejection fraction of 10%. Placement of LVAD was complicated by necrotic
                                             myocardium that required surgical reconstruction. Following separation
                                             from cardiopulmonary bypass, the patient developed increasing right
      Decompensated Cardiac Failure for      ventricular failure requiring escalating inotropic support. Patient transported
      Placement of Left Ventricular Assist   to the intensive care unit with acute renal failure and decompensated right
418   Device (LVAD)                          ventricular failure.

                                             Replacing a double lumen tube with a single lumen tube can be challenging
                                             task for the anesthesiologist especially in patients with swollen airways.
                                             Number of reports in the literature have indicated the complexity of the task
                                             and the potential for loss of airway. We describe a simple reliable method
                                             of switching a double lumen tube with a single lumen tube using a
                                             exchange catheter (Aintree catheter), cook airway exchange catheter and
      A Novel Technique to Safely            pediatric fiberoptic bronchoscope. The technique is simple, swift and works
      Exchange a Double Lumen to a           every time. In addition the beauty is that the exchange is accomplished
419   Single Lumen Endotracheal Tube         under the direct fiberoptic visualization.

                                                                    Page 138

                                           The patient is a 47 year old woman in whom manifestation of left atrial
                                           myxoma initially suggested Raynaud's disease (claudication, TIA).
                                           Exposure to cool air caused severe claudication in her hands. Patient was
                                           scheduled for excision of myxoma. Anesthetic management included
                                           avoidance of peripheral vascular access, femoral arterial line, right internal
      Left Atrial Myxoma Masquerading as   jugular CVP and maintaining ambient temperature above 70F. Surgery was
      Raynaud's Disease: A Rare            uneventful. Postoperatively, patient's symptoms significantly improved. She
420   Manifestation                        was discharged in a few days.

                                           We report on cardiac anaphylaxis following preoperative cephalosporin
                                           administration in a 65-year-old male scheduled for OPCAB surgery. This
                                           presented as diffuse erythrema and urticaria followed by hemodynamically
                                           stable ST-segment elevation, which resolved with H1+2-receptor
                                           antagonist and corticosteroid administration. Limited case reports describe
                                           acute coronary syndromes-some in angiographically normal coronary
                                           arteries-that complicate anaphylactic reactions. Pathogenesis involves
                                           vasoactive mediator-induced vasoconstriction of coronaries with underlying
                                           endothelial dysfunction. Activation of mast cells within atherosclerotic
                                           lesions may also precipitate plaque rupture - precipitating acute myocardial
      Cardiac Anaphylaxis: Necessitates    infarction. Anesthesiologists should recognize the risk of cardiac
      Awareness in a Hemodynamically       anaphylaxis during allergic reactions even in the absence of anaphylactic
421   Stable Patient                       shock.
                                           A 3 year old child with TOF repaired in infancy with resultant complete
                                           heart block S/P pacemaker placement complained after breakfast of
                                           headache followed by brief loss of consciousness. EMS was called and
                                           found him appearing cyanotic with a pulse of 40. On transport pacemaker
                                           was nonfunctional. Echo showed free PI, moderate TR, markedly dilated
                                           right ventricle with paradoxical septal motion and normal LV shortening.
                                           CXR revealed a ventricular lead fracture and an isoproterenol infusion was
                                           started at 0.05 mcg/kg/min. Urgent lead placement and pacemaker
      3 Year Old with Complete Heartlock   generator change were scheduled. Heart rate continued to trend downward
422   and Acute Pacemaker Failure          while awaiting an OR.

                                                                  Page 139

                                             The patient is 60 year old male who underwent normothermic beating heart
                                             on cardiopulmonary bypass coronary artery bypass grafting. The
                                             immediate postoperative myoglobin level was 1269.7ng/ml and rose to
                                             2716ng/ml by six hours after surgery. Bumetanide infusion was started at
                                             0.25-6mg/hr to keep urine output[gt]100ml/hr. Sodium bicarbonate 139.8
                                             mEq and mannitol 25gm are added to D5W1000ml and infused at
                                             100ml/hr. Additional sodium bicarbonate is given to keep urine pH[gt]6.5.
                                             This protocol was continued until the myoglobin decreased to less than
                                             2000ng/ml. His serum myoglobin continued to rise postoperatively peaking
      Rhabdomyolysis after Beating Heart     on postoperative day two at 36,043ng/ml. Etiology of complication remains
423   Coronary Artery Bypass Grafting        elusive.

                                               A 58 year old woman with severe aortic stenosis and normal coronaries
                                               underwent aortic valve replacement. Just before transferring to the ICU
                                               bed, ventricular fibrillation (VF) occurred. VF recurred several times over
                                               the next 15 min despite CPR and defibrillation. Etiologies of recurrent VF
                                               must be sought and treated such as electrolyte abnormality, acidosis, and
                                               hypoxia. Myocardial ischemia was suspected. TEE showed new wall
                                               motion abnormalities. Two coronary artery bypass grafts were emergently
      Recurrent Ventricular Fibrillation after done. Postoperative TEE demonstrated preserved ventricular function and
      Stentless Aortic Valve Replacement competent valve. There were no further arrhythmias. Neurological outcome
424   for Aortic Stenosis                      was good.
                                               A 61 yo male presents with a TIA. He has a history of CAD and PVD.
                                               Preoperative TEE demonstrated two distinct left ventricular thrombi.
                                               Catheterization showed severe three vessel disease. He was scheduled for
                                               CABG and removal of LV masses. Intraoperative TEE revealed but one
                                               thrombus. At induction, the right lower extremity was noted to be slightly
                                               cool. Consequently, a vascular surgery consult was obtained. Patient
                                               underwent an unplanned right femoral, popliteal, and post tibial
      Unplanned Femoral Embolectomy            embolectomy following separation from cpb. Recovery was uneventful.
      Secondary to Thrombus Migration          This case illustrates the importance of intraoperative TEE in operative
425   Identified by Intraoperative TEE         decision making.

                                                                    Page 140

                                           A primigravida developed massive pulmonary embolism postpartum day 2
                                           after an elective caesarean section for fibroid uterus. The patient required
                                           emergent intubation and CPR. The diagnosis of PE was confirmed rapidly
                                           with transesophageal echocardiogram, and the patient was taken
                                           immediately to the operating room for thromboembolectomy. In the event of
                                           acute, severe hemodynamic collapse, TEE is an advantageous modality for
                                           confirming diagnosis of PE when other diagnostic modalities are precluded.
      Evaluation of Postpartum Massive     This patient was at high risk for DVT/PE and correlation of DVT/PE and
      Pulmonary Embolism by                fibroids in pregnancy is relevant as PE has become the leading cause of
426   Transesophageal Echocardiography     mortality in this population.

                                           We describe a case of CABG anticoagulation with bivalirudin in a patient
                                           with heparin induced thrombocytopenia. A 59 yo obese, African American
                                           male with a history of CRF, CAD, and ITP presented in congestive heart
                                           failure requiring dialysis and cardiac catherization. He developed severe
                                           thrombocytopenia on post catherization day 3. Despite aggressive heart
                                           failure management the patient remained symptomatic and required urgent
                                           CABG. The perioperative care required coordination between all parties as
                                           argatroban was not available for anticoagulation; rather bivalirudin was
      Management of HIT and                used. The patient's post operative course required emergent dialysis,
427   Anticoagulation in Cardiac Surgery   massive transfusion and complex hemodynamic management.

                                           75 year old female was in Intensive Care with pneumonia. She developed a
                                           hemothorax as a complication of central venous cannulation. The line was
                                           repositioned and the hemothorax drained with an intercostal drain. Initially
                                           she was stable but became hypotensive and unresponsive to fluid,
                                           ionotropes and vasopressors. Chest X Ray showed tension hemothorax.
                                           Severe hypotension developed requiring urgent decompression. Draining
                                           the hemothorax may improve the tension but may lead to death due to
                                           uncontrolled haemorrhage. With no other option we drained the
      Tension Hemothorax - Dilemma of      hemothorax. Initially we noticed hemodynamic improvement but later she
428   Treatment                            became hypotensive and unresponsive to treatment and died.

                                                                 Page 141

                                              The patient was initially cared for in the SICU during postoperative days 1
                                              and 2 for fluid resuscitation. On postoperative day 5 she complained of
                                              acute and complete vision loss and was readmitted to the SICU.
      46 Year Old Female with Crohn's         Ophthalmologic exam confirmed cortical blindness but could find no ocular
      Disease and Asthma with Complete        explanation. Head CT showed edema of the white matter in the posterior-
      Vision Loss on Postoperative Day 5      occipital area. MRI confirmed the diagnosis of PRES. The patient had
      after Hemicolectomy: A Case of          moderately elevated blood pressures which were treated with labetalol and
      Posterior Reversible                    nicardipine. Blood pressures normalized after 2 days and her vision
429   Leukoencephalopathy Syndrome            improved. On postoperative day 10 she had complete return of her vision.

                                              We experienced emergency surgery for acute abdomen presenting hepatic
                                              portal venous gas(HPVG) sign. In most severe case, the patient died 6
                                              hours after surgery. We reviewed all 23469 abdominal CT cases
                                              retrospectively, which performed our hospital for three years. There are 44
                                              cases presenting HPVG sign. There were few reports focused on the
      Anesthesia for the Patient with Acute   relationships between anesthesia for acute abdomen and the CT finding of
      Abdomen, Presenting Hepatic Portal      HPVG sign. We will report what is HPVG sign, outcomes after surgery,
430   Venous Gas Sign                         unique features about HPVG sign.

                                              We present the complex perioperative management of a 26 year old
                                              gentleman with super morbid obesity who sustained numerous injuries
                                              after being carried 100 feet and dropped by a tornado. The most severe
                                              injury sustained was a 25cm x 25cm closed internal degloving injury (Morel
                                              Lavallee lesion) to his left thigh which extended up his left flank and ended
                                              in a 20cm x 15cm similar lesion on his chest. He required numerous
                                              operations for orthopedic injuries as well as numerous debridements of this
      Extensive Morel Lavallee Lesion in a    lesion. He ultimately succumbed to multiorgan failure after one week of
431   550 Pound Tornado Victim                critical management.

                                                                     Page 142

                                            A 42 year old female, BMI of 75 scheduled for Parathyroidectomy. Past
                                            medical history included hypertension, IDDM, GERD and OSA. She had
                                            limited exercise tolerance, unremarkable airway examination. Normal labs .
                                            She was premedicated with Sodium citrate and ranitidine, and positioned
                                            with a RAMP. Using a rapid sequence induction with propofol and
                                            succinlycholine, trachea was easily intubated. Intraoperative course was
                                            uneventful. Because of her neck dissection and resultant edema, we
                                            planned for post operative ventilation. Patient's post operative course was
                                            complicated by respiratory failure, rabdomyolysis, acute renal failure
      BMI of 75 and That Was the Least of requirimg dialysis, secondary to propofol infusion syndrome? (details in the
432   the Problems!                         poster).
                                            Undiagnosed Pheochromocytoma, found in 1 in 1000 hypertensive
                                            patients, has a 25-50% mortality which occurs either during induction or
                                            during operations for other reasons. 70 years old female with recently
                                            diagnosed hypertension, abdominal pain, nausea, vomiting and a duodenal
                                            mass, was scheduled for Whipple operation. Induced with Versed,
                                            Fentanyl, Propofol and Vecuronium. Duodenal manipulation was
                                            associated with increased BP to 200/102. Increased analgesia, Propofol
                                            and Lopressor were ineffective. BP returned to baseline on stopping the
      Uncontrolled Hypertension during      manipulation. A mass from the upper pole of the right kidney was removed
      Whipple Procedure: An Undiagnosed with stabilization of the BP. Pathology confirmed the diagnosis of
433   Pheochromocytoma!                     Pheochromocytoma.
                                            This is a 48 year old male with end stage liver disease secondary to
                                            hepatitis C. His course was complicated with severe Aortic insufficiency
      End Stage Liver Disase with           after an episode of endocarditis while on the transplant waiting list;
      Superimposed Severe Aortic Valve      prompting a combined AVR/OLT procedure. After induction of anesthesia
      Insufficiency for Combined Orthotopic and insertion of PA catheter, initial pulmonary artery pressures were 78/33
      Liver Transplant (OLT) and AV         mmHg (Mean= 48 mmHg) and pre pump TEE showed an incidental small
      Replacement (AVR) with Incidental     PFO (L R shunt). After the AVR, PAP remained elevated. Would you
      PFO after Induction and Persistent    recommend the surgeon to close the PFO? Would you proceed with the
434   Elevated PAP after AVR                OLT?

                                                                   Page 143

                                           A 68-year-old male was admitted to the CVICU following CABG, MV and
                                           AV replacement. Following separation from CPB, the patient required
                                           inotropic and vasopressor support for cardiac dysfunction and hypotension.
                                           Pulmonary edema fluid was noted in the ETT. Upon admission, he had
                                           adequate hemodynamic and respiratory parameters. Gradually, CI
                                           decreased while PAP increased. Diuretics, inotropes, and ventilator
                                           modifications were ineffective in increasing CI or improving gas exchange.
                                           An emergent transthoracic echocardiogram revealed underfilled cardiac
      Echocardiographic Guidance for Fluid chambers with adequate contractility. Cautious fluid resuscitation was
      Resuscitation in Noncargiogenic      initiated. Over the next two hours, CI and MAP increased, PAP decreased,
435   Pulmonary Edema                      PaO 2 improved and acidosis slowly resolved.

                                            ARDS is a common entity in ICU. We report management of two cases of
                                            ARDS with non invasive ventilation (NIV) using BiPAP. A 19 yrs female
                                            patient developed SIRS and ARDS after an extensive pelvic trauma
                                            following RTA. Another, 48 yrs male developed SIRS and ARDS following
                                            incision and drainage of gluteal abscess. Both cases were managed with
                                            NIV using BiPAP. Supportive management included appropriate antibiotics,
                                            proper nutrition and aggresive physiotherapy. In both clinical improvement
                                            became obvious in one week. Their total ICU stay was 10 days. Clinical,
      Role of NIV (BiPAP) in the            radiological and laboratory findings will be discussed and presented in
436   Management of ARDS                    detail.
                                            We report a case of postoperative stroke caused by paradoxical embolism
                                            though a PFO during right thoracoscopy/laparoscopy. A 59 y/o gentleman
                                            with paralyzed right hemidiaphragm underwent a prolonged endoscopic
                                            procedure for diaphragmatic plication under general anesthesia with use of
                                            single lung ventilation. Postoperatively, the patient awoke with left-sided
                                            hemiparesis. MRI showed scattered thromboembolic or ischemic right
                                            cerebral infarcts. TEE demonstrated interatrial shunt and atrial septal
                                            aneurysm (ASA). Stroke was most likely caused by paradoxical gas
      Right Lung Insufflation Leading to    embolism during elevated right atrial pressure of intrapleural insufflation in
      Stroke from Paradoxical Gas           a patient at high risk due to hemidiaphragmatic paralysis and ASA with a
437   Embolism                              PFO.

                                                                   Page 144

                                          A previously healthy 39 year old man collapsed and developed seizures
                                          followed by cardiac arrest. BLS immediately started but for 35 minutes
                                          patient stayed in PEA till ALS restored cardiac output. Activated charcoal
                                          was administered after history revealed cocaine ingestion. Deranged
                                          clotting, rhabdomyolysis, renal and cardiovascular failure required ICU
                                          admission. Lower GI bleeding, high lactate levels and subsequent CT
                                          confirmed large bowel ischemia. This ischemia was treated conservatively
                                          using Dopexamine infusion. He fully recovered from multi-organ
                                          dysfunction by day 8 and was discharged home. This case report highlights
      Cocaine Induced Bowel Ischaemia; Is the reversibility of bowel ischemia secondary to vasoconstriction caused by
438   It Reversible?                      ingested cocaine.

                                              A 45 year old male with colon cancer was scheduled for colectomy. On the
                                              day of surgery, the patient reported [ldquo]coughing up brown
                                              material[rdquo]. Chest Xray revealed a left lower lobe infiltrate with a
                                              corresponding broncho-enteric fistula. After induction of anesthesia, a
                                              double-lumen endotracheal tube was placed for lung isolation.
                                              Bronchoscopy revealed a normal right lung and a left lung soiled with stool.
      Management of Bronchoenteric            The left lung was aggressively suctioned and the patient underwent a
      Fistula with Double Lumen               diverting ileostomy. Postoperatively, the patient remained intubated with a
439   Endotracheal Tube                       double-lumen tube for 48 hours until the left lung produced no secretions.

                                              A 22 YO female was admitted to the ICU in status epileptics. She
                                              continued to have seizures by EEG despite increased doses of
                                              pentobarbital. Isoflurane general anesthesia was chosen utilizing an
                                              anesthesia machine with appropriate monitoring. The barriers to delivery of
                                              volatile anesthetics in the ICU include: use of anesthesia ventilator and a
                                              circle breathing circuit; delivery of GA for extended time; replacement of
                                              carbon dioxide absorber, and use of appropriate scavenging systems;
      General Inhalational Anesthesia for     monitoring and titration of desired levels of general anesthesia;
      the Treatment of Status Epileptics in   management of associated hemodynamic perturbations associated with
440   Intensive Care Unit                     GA; and legal implication of administering GA in ICU environment.

                                                                    Page 145

                                            76-year-old obese man with subglottic stenosis underwent an awake
                                            fiberoptic intubation with a 6.5 cm ETT. Extubation occurred from POD# 4-
                                            8. On POD # 9, a sudden respiratory arrest lead to re-intubation using an I-
                                            LMA. On POD # 14, tracheostomy placement with a 8.0 Shiley® occurred.
                                            Due to ARDS, high peak airway pressures up to 68 cm H 2 O resulted in a
      A Nightmare in the SICU: Massive      26L minute ventilation leak one night. The insertion of 5.0 cm ETT through
      Airleak in an Intubated Obese Patient the Shiley® allowed for effective ventilation. Subsequent replacement with
441   with Subglottic Stenosis              a Bivona® TTS decreased airway pressures and airleak.

                                            72 yo male with CAD status post placement of five drug eluting stents last
                                            of which was 15 months prior to elective AAA repair. Cardiac
                                            catheterization then revealed 0% RCA stenosis. Preoperative stress test
                                            was unremarkable. Plavix and aspirin were withheld 10 days prior to
                                            surgery.45 minutes after anesthesia induction MAP decreased significantly,
                                            requiring vasopressor support. TEE revealed akinetic RV, EKG revealed
                                            ST elevation in the inferior leads. Cardiac catheterization revealed 100%
                                            RCA in-stent stenosis. Angioplasty was performed successfully. ACC/AHA
      Should We Hold Antiplatelet Therapy guidelines recommend stopping antiplatelet medications for as short time
      for Patients with Drug Eluting Stents as possible after stent placement, we question the safety of discontinuation
442   Undergoing Major Vascular Surgery? altogether.

                                             We report a case of a brain dead patient who presented periods of
                                             elevated BIS.Monitoring included BIS for continuous one-channel EEG
                                             evaluation.Sedatives and muscle relaxants weren't given, vasopressors
                                             were.Initially, BIS was 0 with isoelectric EEG, SR 100 and maximum SQI.
                                             BIS value increased for a few minutes and then returned to 0; this
                                             phenomenon repeated a few times, over 90 minutes, with BIS reaching
                                             91.EMG also increased, SQI was good and SR decreased to close to
      BIS Elevation in a Brain Death         0.EEG display presented electric activity.EMG activity caused by better
      Patient: Importance of the Raw EEG     tissue perfusion due to the blood pressure increase (increase in
443   and EMG in Its Interpretation          noradrenaline), most likely contaminated BIS.

                                                                   Page 146

                                             46 yo male with neuroendocrine tumor in the intestine devoloped
                                             irresecable metastasis lesions in the liver. He was severely sick with
                                             chronic diarrhea and dehydration related to the secreting hormons. Did not
                                             responded to medical treatment and the only possible treatment was liver
                                             transplant. He was in waiting list and living in a nursing home because his
                                             severe chronic diarrhea an dihydration. Patient arrived to the Operating
                                             room with PH of 6.9 and severe electrolytes imbalance. During 12 hours
      Liver Transplant in a Patient with     surgery period we were able to normalies his acid-base status. Patient
444   Neuroendocrine Tumor                   remained in ICU overnight and was extubated the next day.

                                           66 y/o male with Paget's disease presented for laminectomy. 2 large bore
                                           IV's and an a-line were placed preoperatively. Cell-saver was arranged.
                                           Once the bone resection started, profuse bleeding was noted. The
                                           procedure took 10hrs. EBL 17 liters. The massive transfusion protocol
                                           (MTP) was activated and the patient received Cellsaver: 6L; PRBC:13
                                           units; FFP:11; Platelets:15 and Crystalloids:17L. Paget's disease is a
                                           localized disorder of bone remodeling. Although, the presence of a difficult
                                           airway is a major concern, due to the hypervascularization of the bone
      Massive Blood Loss in a Patient with bleeding can pose a major challenge. Use of the MPT allowed proper
445   Paget's Disease during Laminectomy resuscitation of the patient.
                                           A 67-year old male presents to the cardiac intensive care unit status post
                                           tissue aortic valve replacement for critical aortic stenosis. The patient was
                                           treated with chest radiation for mediastinal sarcoma in 1961, resulting in
                                           severe restrictive heart and lung pathology. The patient displayed near
                                           systemic pulmonary hypertension in response to pain and sympathetic
                                           stimulation. Subsequently the patient developed persistent respiratory
      Persistent Respiratory Failure       failure, despite multiple modes of therapy including fluid management
      Secondary to Restrictive Heart and   strategies, sedation, ventilatory manipulation, and vasopressor and
446   Lung Pathology                       inotropic support.

                                                                    Page 147

                                             Unexplained, rhabdomyolysis and metabolic acidosis in the settings of
                                             propofol infusion is usually attributed to propofol infusion syndrome,
                                             although the evidence suggesting the very existence of this syndrome is at
                                             best from sketchy anecdotal reports. In every case reported so far the PIS
                                             was a diagnosis of exclusion. We discuss the management of a patient
                                             admitted after intractable seizures who was sedated with propofol and
                                             developed rhabdomyolysis, metabolic acidosis and ARDS which was
      The Propofol Infusion Syndrome:        initially diagnosed as PIS. Further aggressive workup revealed massive
      Bitter Fact or Mere Figment of Our     myonecrosis of the abdominal, psoas and spinal muscles most probably
447   Imagination                            caused by intractable unrelenting seizures.

                                             Incidence of idiopathic dilated cardiomyopathy is 5-8 per 100,000 live births
                                             per year. Clinical and Echocardiogram findings and medical management
                                             are similar to Peripartum cardiomyopathy. The cardiovascular and
                                             pulmonary changes, aortocaval compression and decreased vascular
                                             responsiveness- all have a negative impact. 36 year old pregnant female
                                             was scheduled for elective repeat C-Section. History of severe dilated
                                             cardiomyopathy, hypertension and multiple episodes of congestive failure.
                                             Echocardiogram showed severe LV dilation, global hypokinesis and EF
      Anesthetic Management of a             35%. General anesthesia induced with Etomidate, Remifentanil, Lidocaine
      Parturient with Idiopathic Dilated     and Succinylcholine. Radial arterial line, pulmonary artery catheter and
      Cardiomyopathy Undergoing Repeat       TEE inserted. Extubated in the OR and monitored in cardiac unit for 48
448   C-Section                              hours.

                                           20 y.o. male with Hemophilia A presents to the SICU after a right
                                           hemicolectomy for transmural colonic necrosis. His Hemophilia A is only
                                           moderate in severity but this patient has a high level of factor VIII inhititor
                                           and is refractory to traditional therapies. His single best and most effective
                                           treatment in the setting of significant bleeding is recombinant Factor VIIa
      The ICU Management of a              given q2-6 hours which costs $7,000 per dose. Reimbursement for such
      Hemophiliac with Acute Severe        treatments is rare, forcing hospitals to pay for the enormous pharmacy bill.
      Gastrointestinal Bleeding: A Resouce This case highlights one of the ethical delimmas of ICU medicine, resource
449   Allowance Ethical Dilemma            management and appropriate patient care.

                                                                    Page 148

                                             Patient X is a 74 year old Caucasian male with a history of prior pontine
                                             CVA, CAD, PVD and rectal adenocarcinoma who presented with acute
                                             dysarthria and dysphagia requiring intubation and admission to the
                                             neurological ICU. Initial work-up for suspected CVA was negative. On
                                             hospital day 2, Patient X was extubated with resultant upper airway
                                             obstruction and respiratory failure requiring emergent re-intubation with mid-
                                             line, paralyzed vocal cords observed. Further work-up revealed
                                             characteristic findings of myasthenia gravis on EMG, positive anti-
      Myasthenic Crisis: An Uncommon         acetylcholine receptor antibodies and a left upper lobe mass on chest x-ray
450   Mimic of Stroke in the ICU             and CT scan suggestive of a paraneoplastic phenomenon.

                                             A toddler with single ventricle physiology after a modified Fontan operation
                                             at the age of 18 months was admitted with dyspnea and coughing with
                                             deteriorating oxygen saturation. Mother noted white plastic white pieces in
                                             his mouth after coughing. An urgent rigid bronchoscopy done by the ENT
                                             surgeon revealed a large white solid arborizing rubbery cast 10 cm long
      Nothing Artificial about This "Plastic from the right bronchial tree with temporary improvement in ventilation and
      Bronchial Cast" Removed by Urgent oxygenation. Plastic Bronchitis cast formation - a rare but fatal complication
      Rigid Bronchoscopy in a Toddler with after Fontan operation is a real critical event that requires early diagnosis,
451   Fontan Physiology!                     rapid treatment and close monitoring in the CICU

                                            A 59 year old female being treated for enteritis and DVT was transferred to
                                            our hospital for suspected PE. On admission she was found to have a large
                                            submandibular mass. After multiple attempts at submandibular gland
                                            massage, the patient coded and shortly thereafter a black eschar appeared
                                            on the patient's neck. A delayed diagnosis of necrotizing fasciitis was made
                                            and multiple surgical debridements of the skin and soft tissues were
      To Dive or Not To Dive: Perioperative required. The patient also underwent postoperative hyperbaric oxygen
      Hyperbaric Oxygen Therapy for         therapy in an attempt to prevent further morbidity and to decrease the
452   Necrotizing Fasciitis                 number of debridements required to achieve wound control.

                                                                    Page 149

                                           69y.o. female scheduled for laproscopic gastric bypass surgery. History
                                           significant for morbid obesity, OSA, mandibular osteotomies, and prior
                                           cardiopulmonary arrest during surgery. Mallampati airway class 4 with
                                           micrognathia, thyro-mental distance less than one centimeter and restricted
                                           movement of the TMJ. With multiple devices available, the patient was
                                           successfully intubated using the AIRTRAQ guided over a gum elastic
                                           bugie. Patients with suspected difficult airway, the airway can be
      Anesthesia Management of a Difficult successfully managed when a variety of intubation devices are available.
      Airway and Intubation in a Patient   Recommendations of difficult airway management from ASA guidelines
      Undergoing Gastric Bypass for Morbid can be modified based on the availability of modern devices and provider
453   Obesity and Severe Sleep Apnea       training.

                                             A 30 year-old man with a blood alcohol level of 286 mg/dL and a known
                                             history of familial hypokalemic periodic paralysis underwent orbital fracture
                                             repair under general anesthesia. He had uneventful intra-operative and
                                             PACU courses with a post-operative potassium of 3.9 mEq/L.
                                             Approximately 9 hours post-operatively, the patient experienced acute
                                             paralytic crisis due to a potassium of 1.9 mEq/L, requiring ICU admission.
                                             His potassium was subsequently overcorrected to 8.3 mEq/L and
      Acute Post-Operative Paralytic Crisis accompanied by peaked T waves on EKG. He was then treated for
      in a Patient with Familial Hypokalemic hyperkalemia, ultimately normalizing his potassium to 5.5 mEq/L and
454   Periodic Paralysis                     resolving his weakness. He was then discharged home.

                                         Management of the airway and resuscitation outside the operating room
                                         has always been a challenge. Absence of the equipment, trained personal
                                         and surgical team makes it very difficult, especially for patients with difficult
                                         airway after neck surgery who required prolong intubation for airway
                                         protection. It is still open question to keep patients profilactically intubated
                                         or not, to paralyze patients or not. Our case is about resuscitation of the
      Recovery Room Airway Management: patient after neck abscess drainage who had uneventful fiberoptic nasal
      "Is the Tracheostomy Always a Back intubation for his surgery, left intubated for airway protection and developed
455   up Plan?"                          cardio-pulmonary arrest in recovery room.

                                                                     Page 150

                                            A patient with Charcot-Marie-Tooth disease (CMT) developed respiratory
                                            failure and complete heart block with hemodynamic instability one hour
                                            after an uneventful general anesthetic for colectomy. We present our
                                            successful treatment of this patient with extubation 2 days later and
                                            hospital discharge on the 6th postoperative day, as well as literature
                                            information regarding peri-operative management for patients with CMT
                                            including fears of regional anesthesia and possible worsening of
      Peri-Operative Management of a        neurological symptoms, unusual response to neuromuscular blocking
      Patient with Charcot-Marie-Tooth      drugs, development of cardiac conduction abnormalities and arrhythmias,
456   Disease                               and different modalities of postoperative mechanical ventilation.

                                       36 year-old male admitted to ICU following acoustic neuroma resection with
                                       pulmonary non-compliance and autonomic instability. The labile
                                       hemodynamics were unresponsive to sedation/analgesia and
                                       antihypertensive medications. Poor lung compliance was refractory to
                                       bronchodilators, necessitating muscle relaxants. These presumed
                                       catecholamine surges (HR 150/min and BP of 210/120 mmHg) occurred 2-
                                       3 times/day. BIS monitoring demonstrated no increased cortical activity.
                                       Work up for pheochromocytoma was negative. Methamphetamine
                                       withdrawal was suspected and confirmed via toxicology screen. Patient
                                       was started on clonidine and benzodiazepines and ultimately extubated
      Acute Methamphetamine Withdrawal and discharged home. This case illustrates the implications of
458   in the Perioperative Setting     methamphetamine abuse on anesthetic and ICU management

                                            A 56-year-old male was brought urgently to the OR for CABG and MV
                                            repair. During conduit harvesting, the patient became asystolic. Open
                                            cardiac massage were immediately instituted. CPB was initiated after 7
                                            minutes of CPR. The patient then underwent surgery and subsequently
                                            weaned from CPB. By 12 hours postop, however, the patient showed no
                                            signs of arousal, was having recurrent seizures, and became febrile to over
                                            40[deg]C. Therapeutic hypothermia to 33.0 C was then instituted and
      Perioperative Therapeutic             maintained for 48 hours with an intravascular catheter. While the patient
      Hypothermia for Intraoperative        remained comatose for a week, he gradually awakened and had an
459   Cardiac Arrest during Cardiac Surgery unremarkable recovery thereafter.

                                                                   Page 151

                                             To present an airway management case on a morbidly obese patient, with
                                             facial/neck edema, in acute respiratory distress.]Case Report:A 40 year-old
                                             man, 5' 6", 300 pounds, was in the CCU for a large, left submandibular
                                             abscess. PMH included HIV, HepC, and NIDDM. Patient was found
                                             dyspneic, spo2 91% on facemask, and was unable to open his mouth.
                                             Transported to the OR for an awake nasal fiberoptic intubation.
      Challenging Airway in a CCU Obese      Transported back to CCU after nasotracheal intubation achieved, vitals
      Patient with Neck and Facial           stable. Conclusions: Awake fiberoptic intubation can be a life saving
460   Abscesses                              measure, when a surgical airway maybe too difficult.
                                             A patient with hemophilia B and known factor antibody suffered significant
                                             burns following a trauma. He was initially managed at an outside facility
                                             where his physicians had been unable to address his burns due to
                                             uncontrollable bleeding. Two weeks post accident the patient was
                                             transferred to the Burn ICU for tertiary care. Anesthesia was consulted for
                                             his future perioperative course. Our management included a regimen of
                                             blood products, activated factor seven, FEIBA (factor eight inhibitor by-
      Perioperative Management of a Burn     passing activity product), and a carefully timed procedure schedule. The
      Patient with Type B Hemophilia and     management of burn patients with Hemophila B and factor antibody will be
461   Factor Antibody                        discussed.

                                            The possible causes for intraoperative hypotension include effect of the
                                            inhalation anesthetics, blood loss, allergic reaction, myocardial
                                            ischaemia/infarction and arrhythmia. A 58 year old male with history of
                                            Hypertension, Morbid Obesity and Left Renal Mass was scheduled for
                                            elective left nephrectomy. Unevntful induction and intubation. Patient was
                                            placed in right lateral decubitus position. Patient developed severe
                                            hypotension, not responding to fliud resuscitation and vasopressors. In the
                                            absence of any obvious source for this persistent hypotension,
                                            Transesophageal Echocardiogram was done which revealed severe Left
      Unexplained Persistent Intraoperative ventricular outflow obstruction from septal hypertrophy. Hypotension
462   Hypotention                           improved with aggressive fluid resuscitation- seven liters of crysalloids.

                                                                   Page 152

                                              A 37 year old male underwent bilateral sequential lung transplant for
                                              primary pulmonary hypertension with tacrolimus and methylprednisolone
                                              used for immunosuppresion. He was weaned off mechanical ventilation
                                              and extubated on postoperative day (POD) #3. On POD #8-10, the patient
                                              displayed signs of rejection and methylprednisolone 500mg IV was
                                              administered with subsequent acute mental status changes noted on POD
                                              #11. Work up included complete metabolic panel, complete blood count,
                                              arterial blood gas, thyroid panel and head computer tomography imagine.
      Postoperative Encephalopathy in         Ammonia was 717 mcg/dL, liver enzymes were AST 22 U/L, ALT 129 U/L,
463   Patient with Lung Transplant            alkaline phsophatase 116 U/L, bilirubin 2.4 mg/dL.
                                              A 19 year old was admitted with a near transection of her descending
                                              thoracic aorta, along with hepatic, splenic and pulmonary injuries and long
                                              bone fractures. She was awake and alert. Vital signs were stable. The
                                              Aortic injury was repaired via a thoracotomy using the "clamp and sew"
                                              technique. She developed significant metabolic acidosis. The planned
                                              intramedullary nailing was deferred for 3 days while her femur was
                                              stabilized using external fixators. The patient was discharged from the
      Anesthetic Management of a Patient      hospital after full recovery. Managing a patient with multi-system injuries
      with Traumatic Aortic Injury with Co-   requires a multidisciplinary approach with clear communication between
464   Existing Injuries                       teams to prioritize treatment.

                                           The Combitube is intended to establish emergency ventilation when there
                                           is simple supraglottic obstruction, or when the operator lacks the skills for
                                           mask ventilation or tracheal intubation. While the Combitube is an
                                           invaluable airway adjunct for both in-hospital and out of hospital difficult
                                           airway scenarios, its use is time-limited to approximately eight hours due to
                                           excessive pressure on the pharyngeal mucosa. Multiple techniques have
                                           been described for exchange of the Combitube for a more definitive airway.
      A Novel Approach to Exchange of the Our case report describes an additional, as yet undescribed technique for
465   Combitube in the Esophageal Position exchange of a Combitube in the esophageal position utilizing a light wand.

                                                                    Page 153

                                             The patient is a 76-year-old female with numerous comorbidities who
                                             underwent urgent coronary artery bypass surgery. The patient was
                                             extubated the day of surgery, and had been recuperating well until the
                                             second postoperative day. That morning the patient developed a focal
                                             neurologic deficit consisting of left-sided hemiplegia. The patient was
                                             reintubated and underwent placement of a percutaneous intravascular
                                             cooling catheter. She was rapidly cooled down to 33° C and was
      Reversal of Stroke by the Early        maintained there for 48 hours. The patient was then gradually rewarmed.
      Institution of Therapeutic Hypothermia After complete rewarming, the patient had no further neurological deficit.
466   after Cardiac Surgery                  The remainder of her hospital course was uneventful.

                                           A 29 yo gravid female presented to the ICU with a large right basal ganglia
                                           intracranial hemorrhage. Presenting GCS was 15, with focal findings of left
                                           sided weakness and fascial droop. Her IUP was estimated at 33 weeks,
                                           without distress, and of appropriate development. Her neurological exam
                                           declined significantly two days later, requiring emergent management of
                                           her intractable intracranial hypertension, and concomitant cerebral edema.
                                           The details of the case presents the competing issues surrounding
                                           treatment of the patients life-threatening illness and the patient's desired
      Intracerebral Hemorrhage in a Gravid wish to preserve her baby's life. Coordinated management by six separate
467   Patient                              teams enabled a successful outcome.

                                             We present a 47 yo patient, diagnosed with metastatic colon cancer and
                                             scheduled for colon resection who preoperatively developed a saddle
                                             pulmonary embolism leading to acute right ventricle failure and cardiogenic
                                             shock. Surgery was cancelled and the patient management included
                                             transferring the patient to the SICU where an IVC filter was placed and
                                             thrombolytic and anticoagulant therapies were immediately started. One
                                             week later an echocardiogram showed normal right ventricular function and
      Management of Preoperative Saddle      left ventricular ejection fraction. The patient was then taken for the originally
468   Embolus                                scheduled surgery.

                                                                     Page 154

                                            A 28 yo female was admitted with "the worst headache of her life." Head
                                            CT showed diffuse subarachnoid hemorrhage. Management included
                                            ventriculostomy, ventricular drain, clipping of 7 x 2 mm ACOM aneurysm,
                                            seizure and vasospasm prophylaxis. Norepinephrine infusion was started
                                            on post-operative day three after patient had decline in mental status and
                                            increased mean flow velocities in the basilar artery. ABG showed serum pH
                                            7.53, PaCO 2 25 and PaO 2 64. Cardiac enzymes were elevated; chest x-
      Pulmonary Complication Following      ray showed bilateral pleural effusions and left basilar atelectasis. The
      Subarachnoid Hemorrhage in a          patient was electively intubated, extubated four days later and discharged
469   Previously Healthy Young Woman        home on post-op day 14.

                                            34 year-old female admitted to NICU with diagnosis of intracerebral
                                            hemorrhage with mild mass effect. Medical history included chronic
                                            myeloid leukemia, treated with imatinib in the past. On admission A/Ox3,
                                            pulse-oximeter 96% and significant leukocytosis (700K). On day 2 coursed
                                            with pulse-oximeter 92% with stable physical exam. ABG showed pH 7.34,
                                            pO2 49, satO2 72, lactate 2.3 and metHb 5.2 on FiO2 of 60%. Patient was
                                            intubated, methylene blue, leukoplasmapheresis and hydrea treatment
                                            were started. Chest CT showed questionable minimal chronic embolism.
                                            Course complicated by ST-elevation (V1/V2) and negative troponin. Patient
      A Case of Extreme Leukocytosis:       was extubated in 5 days after substantial leukocytosis/hypoxia
470   True or Spurious Hypoxaemia?          improvements.

                                           A 54 Y.O. woman with no PMH undergoing TAH with BSO for uterine
                                           fibroid developed tachycardia, hypotension, bronchospasm and hypoxia
                                           approximately 45 minutes after uneventful induction and intubation. Patient
                                           started improving over a period of 20- 30 minutes with 100% oxygen, IV
                                           fluid, intermittent boluses of epinephrine. Procedure was abandoned. TEE
                                           showed no evidence of PE or MI. Chest xray showed RUL and LLL
                                           collapse. Bronchoscopy showed no significant abnormality. Pt was kept on
                                           PEEP overnight -extubated next day. LE venous duplex and spiral CT of
      Intra Operative Delayed Anaphylactic chest showed no DVT and PE.Coagulation studies were normal. SPT
471   Reaction to Latex                    revealed hypersensitivity to latex.

                                                                  Page 155

                                             Non-cardiogenic pulmonary edema is one of the serious complications of
                                             Radiographic Contrast Media (RCM). We report one such case of
                                             pulmonary edema in a 19year old man admitted with chest trauma. The
                                             patient developed severe respiratory distress after a contrast CT scan. The
                                             presence of bilateral patchy infiltrates on chest radiograph and PAOP
                                             18mm Hg on Swan Ganz confirmed the diagnosis of Non Cardiogenic
      Non-Cardiogenic Pulmonary Edema pulmonary edema. This complication in a patient with no prior exposure to
      Secondary to Radiographic Contrast RCM has been reported infrequently in the literature. The Differential
      Media in a Patient with Stab Wound to diagnosis and management of RCM induced pulmonary edema in a
472   Chest                                  Trauma patient are discussed.
                                             54 y.o. male with history of rectal cancer presented with small bowel
                                             obstruction and taken to OR for resection. Epidural catheter placed 12
                                             hours postoperatively for pain control. Patient then developed left-sided
                                             weakness and neglect, and right gaze preference in the setting of
                                             hypotension possibly exacerbated by epidural placement. Symptoms
                                             completely resolved by maintaining controlled hypertension and transfusing
                                             to HCT of 30. POD 3 had similar hypotensive episode and same
                                             neurodeficits as before this time unlikely related to epidural. MRI/MRA
      Ischemic Stroke in the ICU after Small showed acute ischemic right parietal-occipital infarct with complete right
      Bowel Resection and Epidural           ICA occlusion. Symptoms did not resolve and permanent neurological
473   Catheter Placement                     deficit ensued.

                                          We present two cases of gravid women with pre-existing dilated
                                          cardiomyopathy that developed during their first pregnancy. Cardiologists
                                          told both women to avoid future pregnancies. The first parturient had an
                                          AICD, an ejection fraction (EF) of 30%, and a history of tobacco abuse and
                                          asthma. Her AICD had been activated twice during the current pregnancy.
                                          With invasive hemodynamic monitoring placed preoperatively, she labored
                                          and delivered vaginally with vacuum assistance. The other patient with an
                                          EF of 35% was managed conservatively without invasive hemodynamic
      Pre-Existing Peripartum             monitors and underwent a scheduled cesarean section. Both patients had
474   Cardiomyopathy in the Gravid Female epidurals placed and successfully delivered without complications.

                                                                   Page 156

                                              A 25 year old G3P1A1 admitted at 28 weeks gestation for close
                                              observation and medical management of previously diagnosed severe
                                              peripartum cardiomyopathy (EF 15-20%). Elective C-section scheduled to
                                              be performed at 36 weeks gestation. At 33+5 weeks gestation patient
                                              developed preeclampsia with concern for developing HELLP syndrome.
                                              Hence, decision was made to perform urgent C-section. Secondary to her
                                              severe cardiomyopathy and pulmonary hypertension, right heart
      Urgent C-Section in a Parturient with   catheterization and Swan-Ganz catheter placed per cardiology. C-section
      Known Severe Peripartum                 was performed under general anesthesia without complication. Patient was
      Cardiomyopathy Complicated by           then admitted to Cardiac ICU for monitoring. Postoperative course was
475   Preeclampsia                            uncomplicated and patient was discharged home.

                                              25 y/o G7P3, 31 weeks gestation presented with SOB, CP, and large
                                              goiter. PMH: hyperthyroidism, hypertension. Labs: TSH 0.016, fT4 3.2. CT:
                                              goiter -- airway compression, tracheal narrowing (6mmx19mm) - radiologist
                                              concerned enough to call anesthesiologist. ECHO: pulmonary HTN (mPAP
                                              49) - confirmed by cath. Plan formulated for management in case of
                                              emergent delivery. Potential for difficult intubation, difficult trach, and
                                              possibility of thyroid storm. Spinal less ideal given pulm HTN. Plan to place
      Anesthetic Concerns in the Pregnant     epidural vs awake fiberoptic intubation if c-section needed. Pt underwent
      Hyperthyroid Patient with Airway        diuresis, BP control, and treatment with PTU. Pt euthyroid by delivery and
476   Compression                             labor with epidural -- SVD.

                                              A 25 year-old primigravida at 37 weeks gestation with classic Fontan
                                              physiology presents with spontaneous rupture of membranes and breech
                                              presentation for emergent caesarian section at midnight. Her pregnancy
                                              was complicated by reentrant tachycardia requiring pharmacologic
                                              treatment. After a cardiology consult, a regional anesthetic was performed
                                              under a lumbar epidural with slow titration of local anesthetic to a T5 level
                                              of analgesia. An arterial line was placed for instantaneous blood pressure
                                              monitoring. The patient tolerated the procedure and delivered a viable
      Emergent Caesarian Section in a         infant with Apgars of 8 and 9. Both mother and infant were discharged
477   Patient with Fontan Physiology          three days later in stable condition.

                                                                     Page 157

                                            Pre-existing heart disease is the number one non-obstetric cause of
                                            mortality in parturients. We present the case of a 22-year-old full term
                                            parturient with a history of surgically corrected tetrology of Fallot at 3
      Anesthetic Management for Urgent      months of age and an additional pulmonic valve replacement at the age of
      Cesarean Section in a 22 Year Old     15. Recent echocardiogram demonstrated pulmonary outflow tract
      Parturient with Pulmonary Outflow     obstruction, pulmonary artery hypertension and right ventricular
      Tract Obstruction and Pulmonary       hypertrophy. The patient admitted to dyspnea on exertion and syncope
      Artery Hypertension Resulting from    and denied worsening of symptoms with pregnancy. Our case discusses
      Surgically Corrected Tetralogy of     the anesthetic management for urgent cesarean section in a patient with
478   Fallot                                preload dependent congenital cardiac condition.

                                            33 y/o female on warfarin for a St. Jude Aortic valve was switched to
                                            enoxaparin due to pregnancy. She suffered a thrombotic NSTMI requiring
                                            thrombolysis and reinitiation of warfarin and enoxaparin. A
                                            [ldquo]bridge[rdquo] from warfarin/enoxaparin into heparin infusion was
                                            initiated a week before C/S. Heparin was stopped 4 hours prior to surgery
                                            and coagulation parameters checked. An arterial line was placed for
      Perioperative Anesthetic Management hemodynamic monitoring. An epidural, for careful titration of local
      of a Patient after NSTMI during First anesthetic aimed to prevent unwanted hemodynamic changes, was placed.
      Trimester of Pregnancy Who Comes No perioperative complications. Heparin was resumed 6 hours after
479   for Elective Cesarean Section         catheter removal. Hourly neurochecks were performed for 24 hours.

                                            Eisenmenger syndrome in parturients poses many anesthetic challenges.
                                            We report a 26 weeks pregnant, 28 YO female with placenta accreta for
                                            emergency C-section. She has history of Eisenmenger syndrome, large
                                            ASD and anomalous pulmonary vein and had refused elective termination
                                            of pregnancy. She was managed conservatively for continuation of
                                            pregnancy. She presented with massive antepartum hemorrhage
                                            secondary to placenta abruption. General anesthesia was administered
                                            with etomidate and rocuronium for induction, and midazolam and fentanyl
      Anesthetic Management for an          for maintenance. C-Section was performed. Multiple units of PRBC,
      Emergency Cesarean Section in an      platelets and FFP were transfused. Patient was extubated the next day and
480   Eisenmenger Syndrome                  discharged home later that week

                                                                  Page 158

                                             Various side effects of oxytocin have been reported including ventricular
                                             tachycardia in patients with preexisting prolonged Q-T syndrome and
                                             myocardial ischemia with oxytocin bolus administration. We report a case
                                             of oxytocin induced ventricular tachycardia in an otherwise healthy
                                             parturient under neuraxial anesthesia for cesarean section. Oxytocin
                                             infusion coincided with development of increasingly frequent premature
                                             ventricular contractions and several episodes of hemodynamically stable
                                             ventricular tachycardia. After holding the oxytocin infusion the cardiac
                                             dysrhythmias resolved but returned again after the infusion was restarted.
      Oxytocin Induced Ventricular           This case report describes the intraoperative and postoperative
481   Tachycardia: A Case Report             management of this side effect of oxytocin administration.

                                             A 36 year old female presents for Laparoscopic Excision of an Ovarian
                                             Cyst. One hour into the case, the end tidal carbon dioxide level gradually
                                             increased while all other vital signs were stable. Despite increasing the
                                             ventilation, our patient's end tidal CO2 continued rising. At the end of the
                                             case, the patient's neck area was noted to be erythematous and crepitus
                                             was appreciated in many areas. Subcutaneous Emphysema is a rare
                                             complication of routine laparoscopic surgery. With laparoscopic surgery
      Conventional Laparoscopy as a          performed more frequently, the potential increase in this phenomenon is
      Cause of Increasing Intraoperative     possible and its rapid recognition is imperative for proper perioperative
482   CO2 on an Otherwise Stable Patient     management.

                                            Preoperative anxiety can affect perioperative anesthetic care. This has
                                            been studied in patients undergoing pediatric surgery, dental surgery,
                                            general surgery and mentally challenged patients Data on the impact of
                                            preoperative anxiety in anesthetic decision making for perioperative
                                            anesthesia in obstetric is rare. Here we report a case of a pregnant patient
                                            with hemolytic anemia, elevated liver enzymes and low platelet (HELLP
      The Effect of Preoperative Anxiety on syndrome) pulmonary and pharyngeal edema with a spinal-epidural who
483   Obstetric Anesthesia                  had to undergo general anesthesia solely because of anxiety.

                                                                    Page 159

                                          Puerperal uterine inversion ia an uncommon, potentially life-threatening
                                          obstetric complication, associated with hemorrhage, cardiovascular
                                          collapse and death. A 29-year old female, G2P1, s/p normal vaginal
                                          delivery was rushed to the OR, with a diagnosis of acute uterine inversion.
                                          Patient was hypotensive- BP 60/40 mm of Hg and tachycardic. Rapid
                                          sequence induction was done with Ketamine and succinylcholine. Volume
                                          resuscitation started with crystalloids, colloids and blood products. Uterus
                                          was repositioned but noted to be markedly hypotonic, not responding to
                                          uterotonic agents. Hysterectomy was performed for control of hemorrhage.
      Uterine Inversion - A Catastrophic  Patient was in DIC and transferred to SICU. Stabilized and extubated 48
484   Puerperal Complication              hours later.
                                          33 yo, P0100 at 33 weeks EGA (DM (F/R) and chronic hypertension)
                                          admitted for glycemic control and anasarca. Airway exam was MP-IV due
                                          to facial/neck/tongue edema. Severe labial edema precluded vaginal
                                          delivery. Immediately before cesarean, a right chest tube was placed;
                                          draining 1L associated with significant improvement in orthopnea and
                                          oxygenation. Epidural anesthesia was induced. During surgery, 1.5L
                                          ascites drained and 1L blood lost. At end of surgery, with increasing
      Anesthetic Management of Parturient dyspnea and desaturation, patient was intubated (fibreoptic assistance). A
      with Anasarca, Pleural Effusion and left chest tube was placed and drained 1.5L with prolonged mechanically
485   Ascites                             ventilation (5 days).

                                            Amniotic fluid embolism can present in a myriad ways. Our patient
                                            developed acute respiratory distress in active labor requiring bedside
                                            intubation and emergent cesarean section. She progressed to full-blown
                                            DIC in the following few hours. We will discuss the demands imposed on
                                            anesthesiologists in effectively managing such an emergent situation. We
                                            hope to highlight the anesthetic concerns and the critical role that
      The Role of Anesthesiology in Acute   teamwork and preparedness for emergenies play to facilitate a favorable
486   Respiratory Failure in a Parturient   outcome for both fetus and mother.

                                                                  Page 160

                                             Botox injection to the laryngteal adductor muscles is used to treat adductor
                                             spasmodic dysphonia. Our case highlights the anesthetic considerations
                                             for microlaryngoscopy surgery, severe complications of botox injection to
                                             the vocal cords, and postoperative treatment of stridor. Our patient was a
                                             45 yo female with persistent hoarseness. She had received prior uneventful
                                             botox injection surgery and presented for repeat injection. Her
                                             intraoperative course was uneventful. Postoperatively she developed
                                             significant stridor in the recovery room. Our management included multiple
                                             exams and ABG's, facemask O[sub]2[/sub]/heliox, BiPAP and eventual
      Respiratory Distress Following Vocal   reintubation for three days. She was subsequently discharged home in
487   Cord Injection Surgery                 stable condition.

                                             A 68 year old female, with significant psychiatric history, treated with
                                             multiple serotonergic medications, with a surgical diagnosis of infiltrating
                                             ductal carcinoma was scheduled for a left mastectomy and sentinel node
                                             biopsy. Patient received general anesthetic for the procedure during which
                                             she received Fentanyl and Ondansetron. At the end of surgery she seemed
                                             confused, but met criteria for extubation and was extubated and taken to
                                             the PACU. In the PACU she exhibited tachycardia, hypertension,
                                             hyperthermia and became apnoeic and unresponsive. She was emergently
                                             intubated. She showed hyperreflexia, more so in the lower extremities.
                                             Considering the preexisting conditions it was assumed to be a probable
488   Serotonin Syndrome a Case Report       case of Serotonin syndrome.

                                             A 56yo female patient presented to ambulatory surgery for a breast biopsy.
                                             The patient had several confounding medical conditions including: McArdle
                                             phosphorylase deficiency myopathy; Guillian Barre ascending
      McArdle Phosphorylase Deficiency       polyneuropathy with permanent hemi-paresis; Adult-onset Type 1 Diabetes;
      Myopathy and Guillian Barre            idiopathic edema; chronic hypokalemia with EKG changes; atypical gouty
      Ascending Polyneuropathy in an         arthritis; renal insufficiency of undetermined etiology, and a latex allergy.
490   Ambulatory Surgery Patient             The anesthetic implications of each condition will be discussed.

                                                                    Page 161

                                              A "super-obese" 40 year old male with BMI greater than 51 and co-morbid
                                              non-insulin dependent diabetes, obstructive sleep apnea (CPAP settings of
                                              12 on supplemental oxygen), symptomatic GERD, osteoarthritis, and
                                              medically treated depression, requires surgical treatment for a symptomatic
      Four Hundred and Seventy-Five           right renal staghorn calculus. The surgery requires prone positioning after
      Pound Male with Obstructive Sleep       cystoscopy for percutaneous nephrolithotomy. The Surgeon prefers to do
      Apnea, GERD, Diabetes, Arthritis, and   this in the Cystoscopy Suite. The patient is extremely anxious, has a needle
      Depression for a Quick Percutaneous     [quot]phobia[quot], and wants to return home this evening although the
491   Nephrolithotomy in the Prone Position   case is starting in the late afternoon. He lives two hours away.
                                              The ASA Difficult Airway Algorithm outlines multiple interventions that can
                                              be utilized to secure a difficult airway. Here we describe integrating more
                                              than one technique to safely secure an airway. We present the case of a
                                              50 year-old, 74kg, ASA 2 man who presented for right ulnar nerve
      An Unexpected Case of a Difficult       transposition and turned out to be a difficult airway. In this case report, we
      Airway Secured Using an Aintree         describe how we emergently secured the airway successfully by using an
      Catheter for Intermittent Ventilation   Aintree catheter as a means of intermittent ventilation and for the exchange
      and Exchange of a LMA for an            of an endotracheal tube via the classic LMA using flexible fiberoptic
492   Endotracheal Tube                       bronchscopy.
                                              A 13 month old presented for myringotomy and tube placement with a
                                              tympanic temperature of 102 degrees F. She was being treated for otitis
                                              media. The father had a history of fever after anesthesia , advised to get a
                                              muscle biopsy but failed to do so, and had had multiple subsequent
                                              procedures under anesthesia with no complications. The patient was
                                              playful. Vital signs stable. Lungs clear to auscultaion. The operating room
      A 13 Month Old with Fever and Family    was set up per guidelines. A non triggering general anesthetic was used.
      History of MH Scheduled Forilateral     Recovery was uneventful. Does fever mandate that the procedure be
      Myringotomy and Tubes at an             cancelled? Should MH susceptible patients be anesthetised at outpatient
493   Ambulatory Surgery Center               locations?

                                                                     Page 162

                                               Samter's triad is a condition consisting of asthma, aspirin sensitivity, and
                                               nasal polyposis. The exact cause of aspirin intolerance is unknown, but it
                                               has been suggested that an abnormality in the arachadonic acid cascade
                                               causes increased production of leukotrienes when
                                               prostaglandin/thromboxane production is blocked by aspirin or NSAIDs.
                                               While it's unlikely aspirin would be administered intraoperatively, the use of
                                               ketorolac, an intravenous NSAID, has increased, especially in orthopedic
                                               and thoracic surgeries; therefore, its use may precipitate reactions in
      Status Asthmaticus after Ketorolac       aspirin intolerant patients. This case report describes the post-operative
      Administration in a Patient with Aspirin management of status asthmaticus in a patient with Samter's triad after
494   Intolerance                              ketorolac administration.

                                              An 83 year old male with metastatic adenocarcinoma of the trachea
                                              presented for palliative bronchoscopy and argon-beam ablation. The tumor
                                              was visualized by flexible bronchoscopy under monitored anesthesia care
                                              and seen to occlude 70% of the trachea just distal to the vocal cords. To
                                              facilitate access to the tumor by bronchoscopy while maintaining
      Trans-Cricoid Cartilage Jet Ventilation oxygenation beyond the occlusive tumor, a Saunders Injector needle was
      with a Saunders Injector in a Patient placed through the cricothyroid membrane and jet ventilation was instituted.
      Undergoing Bronchoscopy and Argon- Following ablation of the sub-vocal cord tumor the patient was intubated
      Beam Ablation of an Occlusive           with a standard 8.0 cm endotracheal tube, allowing ablation of tumor more
495   Tracheal Tumor                          distal in the airway.

                                           A 70 y/o was scheduled for vitrectomy, epimacular membrane proliferation
                                           removal and laser. Co-morbidities included unilateral vocal cord paralysis
                                           for which surgery was planned, NIDDM, hypertension, GERD, OSA
                                           compliant with CPAP, and hyperlipidemia. Myoview stress test was
                                           clinically and electrically negative with inferior akinesis and EF 46%.
                                           Epimacular membrane peeling requires a still surgical field usually with
                                           endotracheal intubation and paralysis. Reluctant to intubate this patient with
                                           known vocal paralysis and having had success in preventing the "rocking
      PSV Pro® Eliminates the "Rocking     eye" with other retinal surgery, it was elected to utilize a LMA with PSV
496   Eye" during Retinal Surgery with LMA Pro® provided by a 7900 Aestiva® anesthesia machine.

                                                                      Page 163

                                            An 85 yo male suffered a STEMI and underwent coronary angioplasty with
                                            BMS placement. Early stent thrombosis occurred as a result of antiplatelet
                                            therapy noncompliance. Subsequently, he suffered a retinal detachment
                                            and underwent urgent vitrectomy and scleral buckle. Dual antiplatelet
                                            therapy was continued, and intraoperative bleeding was minimal. The
      Urgent Ophthalmologic Surgery in a    surgery restored his vision. Early discontinuation of dual antiplatelet therapy
      Patient with a Recent Myocardial      after coronary stent placement increases the risk of stent thrombosis.
      Infarction and Early Restenosis of    Anesthesiologists must balance competing perioperative concerns: the risk
      Bare Metal Stents Due to Dual         and consequences of surgical delay versus intraoperative hemorrhage with
497   Antiplatelet Therapy Noncompliance    the benefits of surgery and continued dual antiplatelet therapy.

                                           A 60 y/o female with a massive thyroid swelling (20cm x 20cm) and acute
                                           respiratory distress was scheduled for an emergency total thyroidectomy
                                           under general anaesthesia. Radiological examination revealed severe
                                           tracheal compression and deviation. Patient refused awake intubation.
                                           Inhalational induction with incremental sevoflurane (upto end tidal
                                           concentration 3%) in oxygen was initiated with optimal head extension in
                                           left lateral position. Airway was secured by fibreoptic guided endotracheal
      Fibreoptic Airway Management in a    intubation (cuffed ETT 7.0mm ID). Postoperatively, there was a significant
      Large Thyroid Swelling with          suspicion of tracheomalacia and consequently a tracheostomy was done.
      Respiratory Compromise - A Breath of The perioperative concerns unique to this life threatening scenario will be
498   Fresh Air                            discussed.

                                          A 21 yo male presented for septoplasty and sinus endoscopy. He had OSA
                                          and used CPAP. Remifentanl/propafol/nitrous without muscle relaxant was
                                          chosen to avoid post-op sedation. When the pt was fully awake his trachea
                                          was extubated. Fifteen minutes after PACU arrival, he become apenic and
                                          O2 sat decreased to 60s. The EKG displayed VF and chest compressions
                                          were delivered while O2 was administered. HR returned to sinus rhythm
      Obstructive Sleep Apnea, Airway     and the pt regained consiousness. We will review the occurrence and
      Surgery, and Ambulatory Anesthesia: pathophysiology of OSA after anesthesia for ENT surgery and the suitibality
499   A Dangerous Combination             for OSA patients to undergo ambulatory procedures.

                                                                   Page 164

                                             A 36 year old female scheduled for endoscopic sinus surgery with no
                                             known drug allergies. Following surgery patient was extubated. Medications
                                             included midazolam, metoclopramide, cefazolin, lidocaine, propofol,
                                             fentanyl, sevoflurane, glycopyrrolate and neostigmine. Diffuse rash, goose
                                             bumps and hypotension were noted prior to transfer. The patient
                                             responded to epinephrine and IV fluids and was treated with
                                             diphenhydramine, hydrocortisone, and famotidine. She was reintubated
                                             and observed for 2 hours, then extubated. Vital signs were stable but
                                             diffuse maculopapular rash reappeared and was again treated with
      Anaphylaxis Following Endoscopic       epinephrine. Serum tryptase was 53 ug/L. She was observed in intensive
500   Sinus Surgery                          care overnight and discharged in 2 days.

                                             Catamenial anaphylaxis (C.A.) is a rare syndrome of hypersensitivity
                                             induced by endogenous release of prostaglandins and progesterone from
                                             the uterus after menstrual cycle. A 41 year-old female underwent bilateral
                                             oophorectomy with a history of severe C.A. and multiple medication, food
                                             and dye allergies. Patient was premedicated with hydroxyzine,
                                             hydrocortisone, diphenhydramine, ranitidine, and montelukast.
                                             Intraoperative general anesthetic course (propofol, vecuronium and
                                             fentanyl) was unremarkable. However, immediately post-op patient
                                             developed severe respiratory and hemodynamic anaphylaxis symptoms,
      Rare Catamenial Anaphylaxis            responsive to an epinephrine infusion. Hydrocortisone, diphenhydramine
      Syndrome: Perioperative                and ranitidine were continued for 24 hrs, and epinephrine was weaned.
501   Management                             Patient was discharged POD 3 in stable condition.

                                            A 65 yo male for outpatient excision of invasive squamous cell carcinoma
                                            of the scalp and cranium with skin flap reconstruction. Past medical history
                                            includes cardiac transplant followed by PCTA with stents, pacemaker, renal
                                            failure requiring dialysis, GERD, hiatal hernia, and dyspnea requiring
                                            oxygen therapy. Laboratory results: potassium 4.1 meq/l, BUN 50, Cr 5.9,
                                            HCT 33.3%. Cardiac studies included MPS LVEF 51%, fixed deficit without
                                            ischemia. Echocardiogram showed mild MR, mild AI and pulmonic
                                            insufficiency, LV/LA enlargement and decreased LV systolic function.
                                            Anesthetic considerations include hemodynamic stability for the denervated
      Cardiac Transplant Patient Presenting heart, pacemaker/ defibrillator management, and graft rejection in
502   for Ambulatory Surgery                ambulatory surgery.

                                                                   Page 165

                                             A 56 year-old wheelchair-bound female with advanced myotonic dystrophy
                                             presented for retinal surgery. Dyspneic in the seated position, she required
                                             a wedge to support her limp torso. Her head dangled to the left,
                                             unsustained by her weak neck musculature. Interrogation revealed a
                                             history of BiPAP-dependent obstructive sleep apnea, gastroesophageal
      No Regional Anesthesia for Me! I       reflux, orthopnea, dyslipidemia and possible cardiomyopathy. EKG
      Want To Sleep. A Challenging           demonstrated a left axis deviation with 1st degree atrio-ventricular block,
      Ophthalmic Anesthesia Case of a        and anterior fascicular hemiblock. Gripping the gurney rail and unable to
      Patient with Advanced Myotonic         release her grasp voluntarily, she was visibly anxious. Emphatically, she
503   Dystrophy                              proclaimed, "No regional anesthesia for me! I want to sleep."

                                            Incorrectly identifying patient as having STEMI and initiating therapy can
                                            result complications. 47 y/o man presented to operating room for tibial
                                            external fixator removal. 4h intraoperatively, tachycardia and hypotension
                                            developed. Electrocardiogram revealed sinus tachycardia, marked ST
                                            segment elevation, and tall, broad T waves in lead II and V 5 consistent
                                            with myocardial infraction. Arterial blood gas results showed pH 7.28, K+
      Perioperative Acute                   8.2meq/l and glucose 736 mg/dl. Management included intravenous CaCl
      Electrocardiographic Pseudoinfarction 2, HCO 3, saline and insulin. Postoperative 12 lead electrocardiogram
      Pattern in the Setting of Diabetic    following treatment showed sinus tachycardia with complete resolution of
      Ketoacidosis and Severe               the ST elevation. Troponins were normal resulting in a diagnosis of
504   Hyperkalemia                          myocardial pseudoinfarction.

                                            A 55 yr 72 kg female ASA II for depression underwent robotic colpopexy.
                                            GETA was maintained with O 2 in air, isoflurane, fentanyl and vecuronium
                                            with Pressure Mode with Peak Airway Pressures of 35 cmH 2 O, I:E ratio of
                                            1:2 and rate of 15-20/min (MV:10-12lit/min) in steep trendelenberg position.
                                            Arterial pH remained around 7.25 with PaCO 2 of 55-60 mmHg inspite of
                                            FGF of 4 lit/min and fresh absorbent. During 8 hr procedure, 4800 ml of
                                            crystalloid administration resulted in urine output of 3000 ml.
      Uncontrolled Hypercapnia Resulting in Disproporionate urine output probably resulted from lymphatic obstruction
      Disproportionate Diuresis during      secondary to pulmonary hyperinflation and nonosmotic mechanisms from
505   Robotic Colpopexy                     CO 2 retention.

                                                                    Page 166

                                            Combined spinal epidural (CSE) can provide excellent labor analgesia.We
                                            describe a patient who undergoing a caesarean delivery with (CSE) and
                                            developed unintentional subdural block then had a conversion disorder.
                                            Conversion disorder (CD) is a type of somatoform disorder in which there is
                                            dysfunction of a voluntary sensory or motor activity, without objective
                                            neurologic findings.It is thought to be multifactorial in etiology, and is
                                            relatively uncommon in western society.Treatment involves informing the
                                            patient that they have a somatoform condition, and approaching them in an
      Conversion Disorder Following         empathetic rather than confrontational manner. Exhaustive medical tests
506   Unintentional Subdural Block          and pharmacotherapy should be minimized.

                                         32-year-old healthy female received lumbar epidural catheter for labor-
                                         analgesia. The test dose of 1.5%lidocaine with epinephrine didn't elicit any
                                         symptoms suggestive of intra-thecal/intra-vascular placement. 5mins after
                                         loading 10cc of 0.125% Bupivacaine with 2mcg/cc Fentanyl, patient
                                         complained of difficulty in swallowing, slight dyspnea. BP decreased from
                                         105/55-90/40mmHg, and SPO2 decreased to 89% on room-air. She had a
                                         dense sensory block to T10 level without any motor block. She was
                                         promptly administered O2, ephedrine and fluids. Patient remained
                                         borderline hypotensive with low SPO2 despite the above measures. A
      Incidental Subdural Catheter       chest-CT showed aspiration pneumonia. A blood-patch was performed for
507   Placement and Aspiration Pneumonia headache 3 days after.
                                         A healthy 23 year-old male underwent a minor plastic surgery under
                                         uneventful LMA general anesthesia with sevoflurane. Fentanyl, a total
                                         dose, 250 mcg was administered during the procedure without
                                         compromizing his spontaneous respiration. In the PACU, he started to
                                         complain of pain for which fentanyl, 50 mcg was administered.The patient
                                         soon developed what appeared to be a grand mal seizure for a few
                                         seconds and became unresponsive to verbal command and to vigorous
      Seizure-Like Movements and         shaking. Midazolam,1 mg was given but the patient continued to be
      Prolonged Unconsciosness in a      unresponsive with occasional seizure-like movements. One hour later,he
      Young Male after a Small Dose of   woke up without recall. Magnetic resonance angiography study revealed
508   Fentanyl in the PACU               negative findings.

                                                                  Page 167

                                          A 27 year old female patient with mild mental retardation presented for
                                          knee arthroscopy as an outpatient. She also had mitral regurgitation and
                                          latex allergy. General endotracheal anesthesia was planned. Minutes after
                                          induction but before start of surgery the patient developed episodic, severe
                                          hypertensive episodes and severe flash pulmonary edema. ECG showed
                                          tachycardia and possible infarct. TEE showed severe global hypokinesis,
                                          EF 10-20%. Urgent cardiac cath was negative for coronary artery disease
      Severe Complication of Anesthetic   but EF was 20% which improved 3 days later to 40-50%. Ventilated for 6
      Induction - Acute Stress-Induced    days and further complications included bilateral occipital stroke and
509   Cardiomyopathy                      blindness due to abnormally narrow vertebral arteries.

                                          This is an oral surgery procedure that turned out to be a case of post
                                          obstructive pulmonary edema, ITP, and hypovolemic shock. A 54 y/o male
                                          was scheduled for maxillary tori removal. After IV induction, nasal
                                          intubation with glidescope was difficult necessitating conversion to oral.
                                          Thirty minutes after surgical start, there was 1,000ml of blood loss totally
                                          2,500ml by the end of the 1.5hr case. At emergence, the pt was extubated
                                          following appropriate extubation criteria, but obstructed due to tongue
                                          edema/hematoma. Reintubation was difficult with unstable hemodynamics.
      There Is No Such Thing as a Small   Platelets from 112 to 6. Hematology diagnosed ITP secondary to
510   Case                                aripiprazole use.

                                          50 year old morbidly obese male presents for cystoscopy, left ureteroscopy
                                          and stent replacement for left nephrolithiasis. Past medical history includes
                                          type II diabetic, uncontrolled HTN, CRI, OSA using home CPAP and
                                          obesity hypoventilation syndrome. Related to the length of surgery
                                          neuroaxial technique not option and general anesthesia elected. Induction
                                          with Fentanyl and rapid sequence, no other narcotics given, maintenance
      Fulminate Pulmonary Edema in        on Sevoflurane, 7 hour case, IVF given 1.6 liters per Anesthesia and 8 4L
      Lengthy Cystoscopy, Ureteroscopy    bottles used per Urology for visualization. Patient failing extubation related
511   Case                                fulminate pulmonary edema felt secondary to irrigating solution.

                                                                 Page 168

                                         64 y/o male h/o HTN, BPH experienced TURP Syndrome under General
                                         Anesthesia . Pt had no past anesthetic complications and no known drug
                                         allergies. 45 mins after induction pt became flushed, Hypotensive and
                                         bradycardic with lungs clear to ascultation. Treated With ephedrine, Fluid
      Transuretheral Resection of the    bolus. ABG showed serum sodium: 110. Procedure aborted LR changed to
      Prostate Syndrome under General    Nacl 0.9%, lasix 40 mg given. In the PACU patient stable, Nacl 0.9%
512   Anesthesia                         continued. 18 hrs after event: serum Na+ was 143.

                                         73 year old female for lamellar keratoplasty. Patient has morbid obesity,
                                         COPD, and severe sleep apnea. After uneventful surgery, the patient
                                         complained of moderate pain in PACU. Fentanyl was given with good
                                         response. The surgeon then states that because there is a bubble in the
                                         anterior chamber of the eye to hold the corneal graft in place, the patient
                                         must lie flat on her back for one hour. The patient lies supine and the
      Hypoxemia in PACU after Lamellar   saturation drops to 70%. Topical local anesthetic was given for analgesia.
513   Corneal Transplant                 Naloxone was then administered with improvement in oxygenation.

                                         A 61 year old female with a history of a thyroid mass eroding into the
                                         trachea presented with acute respiratory distress. Awake tracheostomy
                                         was attempted under local anesthesia and monitoring. Upon incision there
                                         was profuse bleeding, leading to hypotension and oxygen desaturation.
                                         The airway was temporarily secured with a 6.5 mm ETT through the
                                         tracheostomy site. Total blood loss was 5000 mL and the patient expired.
                                         On autopsy, the mass was reported as a Hurthle cell tumor which had
      Emergent Awake Tracheostomy for    grown dramatically since the last CT image taken one month previously.
514   Thyroid Cancer                     The bleeding was presumed to have originated from the mass.

                                         A 70 y/o female was scheduled for amniotic membrane placement over a
                                         recurrent perforated corneal ulcer. Co-morbidities included: mitochondrial
                                         myopathy, pulmonary hypertension, OSA compliant with CPAP, DVT with
                                         PTE, CML status post bone marrow transplant in remission but with chronic
                                         graft versus host disease, CAD status post PTCA and stent, small
      Open Globe Repair for General      pericardial effusion, depression and anxiety as well as peristent cough. The
      Anesthesia in Patient with         patient stated her mitochondrial myopathy had caused her to have weak
      Mitochondrial Myopathy, OSA, and   breathing muscles. The surgeon stated since it was an open globe, he
515   Room Air Oygen Saturation 88%      would need general anesthesia. Management will be discussed.

                                                                Page 169

                                            Urgent esophagogastroduodenoscopy was scheduled for a 90-year-old
                                            female with agoraphobia and congenital goiter of euthyroidism, who
                                            presented with increasing hoarseness, dysphagia, and shortness of breath
                                            while supine. On examination, she was in a sitting position, with hoarse
                                            voice, asymmetrical neck, and a deviated trachea. Awake endotracheal
                                            intubation in sitting position was performed with a Storz-VideoScope. The
      Upper Airway Obstruction Secondary vocal cords were severely distorted and the upper airway was highly
      to Severe Edema besides Mechanical edemateous. Only a 6.0 mm or smaller endotracheal tube could be
      Factors in a Geriatric Patient with a advanced through the vocal cords. This case illustrates that severe upper
      Massive Thyroid Goiter: A Case        airway edema can develop in patients of congenital goiter with
516   Report                                euthyroidism.
                                            55 y/o male with a noncontributory PMHx under went an uneventful right
      Previously Undiagnosed Severe         shoulder arthroscopy via GETA. In the PACU, he was noted to be in
      Dextroscoliosis as a Possible Cause respiratory distress and had rhoncorous BS. ABG revealed
      of Post Operative Respiratory         hypoxia/hypercapnia and CXR showed left lung white out and a radio
      Distress in a 55 Year Old Male        opaque lesion in the right lung field. Following reintubation and suctioning
      Undergoing Ambulatory Right           of copious secretions via bronchoscopy, repeat CXR showed re expansion
517   Shoulder Capsulorrhaphy               of the lungs and severe dextroscoliosis.

                                             A 54 yo female with past history of Hypothyroidism, Diabetes Mellitus,
                                             Hypertension underwent elective laparoscopic cholecystectomy. Her pre-
                                             operative EKG was within normal limits. Intra-operatively she was
                                             hypotensive for a brief period of time. EKG in the recovery room revealed
                                             diffuse T wave inversions. Serial troponin measurements were elevated but
                                             less than 0.04. The patient remained entirely asymptomatic and did not
                                             develop any new EKG changes. She was discharged on post-operative day
      Postoperative T Wave Inversion in an # 2. In the immediate post op period, MI is rarely accompanied by chest
      Asymptomatic Patient. Is It Myocardial pain and therefore symptomatic EKG changes with mild troponin leak
518   Ischemia?                              present a dilemma for Anesthesiologists.

                                                                    Page 170

                                             Takotsubo cardiomyopathy is a new diagnostic entity with a clinical
                                             presentation similar to an acute coronory syndrome. 78 year old female
                                             with Small Bowel Obstruction presented for emergent exploratory
                                             laparotomy. Pre-operative EKG was normal except for short PR.
                                             Intraoperative course was uneventful. In the post operative care unit, EKG
                                             done showed ST elevation in anterio-septal and lateral leads with elevated
                                             cardiac enzymes. 2D echo showed apical hypokinesia. Echo repeated 3
      Perioperative ST Elevation -           days later was normal and cardiac-cath 10 days later showed clean
      Increasing Awareness of Rare           coronories. Takotsubo syndrome was diagnosed. By presenting this case
519   Cardiac Syndromes                      we would like create awareness about this rare syndrome.

                                             A 24 year old female with a history of CRPS Type I of the right lower
                                             extremity and occasional syncope presented for removal of a spinal cord
                                             stimulator; her medications included a lidocaine patch, ibuprofen and
                                             allegra-D. Following a prone MAC anesthetic the patient was noted to have
                                             jerking and thrashing movements in all extremities which the PACU nurses
                                             controlled by firmly holding her extremities on the bed. The patient
                                             remained conscious yet followed commands inappropriately. Following
                                             diphenhydramine and midazolam administration, the patient's symptoms
      Dystonia Following the Perioperative   completely resolved. The patient was discharged with no residual
520   Adminsitration of Ondansetron          neurologic sequelae two hours following this event.

                                             To present the anesthetic implications of a patient with Factor X deficiency,
                                             the rarest of all inherited coagulation disorders. Case Report:A 30 year-old
                                             woman presented with acute cholecystitis for an urgent cholecystectomy.
                                             PMH included Factor X deficiency, Menorrhagia, Epistaxis, and Hematuria.
                                             Labs revealed severe hepatic/cholestatic dysfunction, INR 2.83, and a
                                             factor X level of 7(70-150). She received 5 units FFP pre-operatively and
                                             repeat INR was 1.63. She underwent a laparoscopic cholecystectomy
                                             under GETA. The anesthetic/surgical course went uneventful. Conclusions:
      Anesthetic Implications of a Patient   Anesthesiologists have limited experience caring for patients with this
521   with Factor X Deficiency               extremely rare factor deficiency.

                                                                    Page 171

                                            Medication error is a leading cause of anesthesia-related morbidity and
                                            mortality. This case is an example of [quot]syringe-swap[quot] medication
                                            administration error. A 60 year-old female was admitted for arthrotomy and
                                            debridement of a finger mass. She opted for iv regional anesthesia. During
                                            the administration of the Bier Block, a syringe containing 40 mL of
                                            Remifentanyl, 50 mcg/mL, was injected into the vein of the operative
                                            extremity instead of 40 mL 0.5% lidocaine. This report will review the
      Bier Block Failure from Drug          management of the error and will suggest measures to promote safer drug
522   Administration Error                  administration in anesthesia.

                                            Methemoglobinemia is a known complication of dapsone therapy.
                                            Dapsone, a sulfone antibiotic, is metabolized in the liver to hydroxylamines
                                            which can cause methemoglobinemia. Although dapsone is widely used as
                                            a treatment for leprosy, it is also used infrequently for patients with
                                            immunodeficiencies. This case report describes an immunocompromised
                                            patient on dapsone therapy for PCP prophylaxis presenting for
                                            parathyroidectomy and was found to have an SpO2 of 91% despite
      Pre-Operative Assessment of           preoxgenation; the patient did not appear hypoxic or in respiratory distress.
      Dapsone-Induced                       In this case report, the clinical findings and management of dapsone-
523   Methemoglobinemia                     induced methemoglobinemia will be discussed.

                                          Loss of electrical power occurred during an extracorporeal shockwave
                                          lithotripsy in a remote, office-based setting. The loss of power was to a
                                          whole section of the city and it was unknown if the power loss was fleeting
                                          or of a longer duration. This presentation discusses ventilation, monitoring
                                          and care of a patient during an electrical power loss in a remote setting and
                                          the importance of communication with staff, building, and utility company
      Loss of Electricity during an       personnel. Also there is a professionalism component involved regarding
      Anesthetic in a Remote Office-Based aborting the procedure, and discussing the event with the patient
524   Setting                             afterwards.

                                                                   Page 172

                                            A 34 y/o male with xeroderma pigmentosa with extreme photophobia and
                                            painful eyes, presented for an evaluation of an amniotic membrane placed
                                            previously for a symblepharon (fibrous tissue connecting the conjunctiva to
                                            the eyelid). He had numerous skin cancers removed since age 8.
                                            Currently, his proturberant overbite was greater than his thyromental
                                            distance, compounded by neck contractures, near absent nares, and
      Extreme Photophobia with Overbite     inability to open his mouth more than two finger breadths. During two
      Greater Than Thryomental Distance     recent MAC anesthetics airway obstruction occurred.One was converted to
      in a Patient for Ambulatory Eye       general with difficult insertion of LMA while the other was completed with
525   Surgery                               ketamine and propofol with chin lift.

                                            Current guidelines within cardiology recommend that dual antiplatelet
                                            therapy be continued for 12 months after placement of a coronary drug
                                            eluting stent (DES). We report on a patient suffering a very late (12
                                            months) stent thrombosis during elective laparoscopy with subsequent
                                            mortality. These guidelines may be inadequate for the surgical population,
                                            where acute withdrawal of antiplatelet and other therapies (e.g. statins) in
                                            combination with prothrombotic comorbidities (e.g. malignancy, renal
                                            insufficiency, erythropoietin use) and the proinflammatory-prothrombotic
                                            milieu of surgical stress are not considered. Careful management of
526   Late In-Stent Coronary Thrombosis     patients with DES (even after 12 months) will be discussed in detail.

                                            A 20 y/o, severely pre-eclamptic G2P0010 was transferred at 35 3/7
                                            weeks. History included controlled asthma, Crohn's, recent pneumonia,
                                            splenomegaly(26cm), and Evan's syndrome (autoimmune hemolytic
                                            anemia/thrombocytopenia). Medications included an inhaler prn. Airway
                                            exam was normal except hoarseness from VC stripping. Decelerations
                                            prompted a multi-disciplinary meeting; classic C-section was planned.
                                            GETA was decided given risks of regional anesthesia and bleeding
                                            potential. Patient was prepped while large pIVs and a-line were placed.
                                            After aspiration prophylaxis, the patient underwent RSI with cricoid
      Management of Labor and Delivery in pressure (difficult airway equipment available) and attention to
      a Preterm, Pre-Eclamptic Patient with hemodynamic stability. Blood products were primed and general surgeon
527   Evan's Syndrome                       was scrubbed. Outcome was successful.

                                                                   Page 173

                                           A 24 year old G3P2 with severe preeclampsia at 38 weeks gestation
                                           required urgent cesarean section for nonreassuring fetal heart rate tracing .
                                           Blood pressure was 160/90 upon evaluation .On OR arrival BP was
                                           220/150. Aggressive antihypertensive treatment resulted in BP 160/92 :
                                           epidural anesthesia was initiated. Test dose of 2% lidocaine with
                                           epinephrine 1:200,000 was negative. Maternal bradycardia and nausea
                                           developed following injection of 8 cc of 2% lidocaine. Maternal BP was
                                           120/72. Fetal heart tones became unobtainable. Maternal blood pressure
      Hypotension and Bradycardia          was increased without improvement in fetal HR.Emergent general
      Associated with Epidural Anesthesia: anesthesia was induced. Evolving placental abruption was discovered upon
528   The Classic "Red Herring"            uterine incision.

                                             A 72 kilogram woman required Cesarean section for nonreassuring fetal
                                             heart tracing. Following appropriate evaluation of her labor epidural, we
                                             administered 20 mL of 2.0% lidocaine with epinephrine 1:200,000 in
                                             divided doses over 20 minutes, achieving a T-4 sensory level. Two minutes
                                             later, frequent premature ventricular contractions appeared, progressing to
                                             sustained, intermittent ventricular tachycardia. The patient remained
                                             conscious, but was symptomatic. Amiodarone was given by bolus and
      Ventricular Tachycardia during         infusion, with prompt resolution of the arrhythmia. Neonatal Apgar scores
      Epidural Anesthesia for Caesarian      were 8 and 9. Maternal recovery was uneventful, with no further ectopy
529   Section                                during 24 hours of telemetry monitoring.

                                             42 yr old gravida 3, para 2, a known case of SLE with Lupoid hepatitis
                                             presented with palpitation at 36 weeks of pregnancy. She had arthralgia
                                             and rashes which has been controlled on prednisone since 1 trimester of
                                             pregnancy. She also had few episodes of shortness of breath along with
                                             palpitation. EKG showed premature ventricular complexes along with T
                                             wave inversion. ECHO showed good cardiac function. High risk
                                             consultation was obtained in view of ischemic cardiac changes and SLE.
                                             She had elective Cesarean section under spinal anesthesia and received
      Successful Management of SLE with      single dose of hydrocortisone. Intra-operative blood pressure was
530   Lupoid Hepatitis in Pregnancy          maintained with vasopressors.

                                                                   Page 174

                                            Ebstein's anomaly is associated with downward displacement of the
                                            tricuspid valve, an atrial septal defect, and paroxysmal arrhythmias, and
                                            pregnancy increases the risk of congestive heart failure. A 23-yr-old
                                            primigravida with history of Ebstein's anomaly, and occasional palpitation,
                                            received epidural analgesia for active labor. After judicious preloading an
                                            epidural was inserted with loss of resistance to saline. Bupivacaine 0.125%
                                            with fentanyl 2 mcg/ml at a rate of 6-8 ml/hr continuous infusion was
                                            administered. With 10 l/min O2 via a face mask, she remained
      Successful Epidural Analgesia in a    hemodynamically stable. No episode of cyanosis was noticed during labor.
531   Parturient with Ebstein's Anomaly     After delivery patient was cardiovascularly stable.

                                            This is a 32 y/o female presenting for VTOP. The patient has Klippel
                                            Trenauney Weber Syndrome and an arteriovenous malformation was also
                                            present. She had a previous TOP 6 years earlier and required a massive
                                            transfusion. Currently, the patient was 10 weeks pregnant and admitted for
                                            anemia and suspected DIC. Her uterine arteries were embolized and she
                                            was given blood products prior to the procedure. The patient underwent
      Termination of Pregnancy in Patient   GA, induced with midazolam, fentanyl, propofol, and succinylcholine and
      with Klippel Trenauney Weber          was maintained on 60% nitrous oxide and a remifentanil infusion. She
532   Syndrome                              tolerated the procedure well with minimal blood loss.

                                            34 y.o. G3P0 with twins at 35 weeks was admitted for preeclampsia. She
                                            has a history of paroxysmal nocturnal hemoglobinuria and
                                            thrombocytopenia. She previously suffered a SMA thrombosis and was
                                            placed on chronic warfarin. She presented with LE edema but was
                                            otherwise stable. Preoperative labs: platelet 50,000, hematocrit 29.5, INR
                                            1, PTT 56.5. Ultrasound revealed twins in breech/transverse positions. She
                                            proceeded for elective C-Section. Platelets and pRBC were transfused
      Cesarian Delivery in a Patient with   preoperatively. General anesthesia was induced in rapid sequence. The
      Paroxysmal Nocturnal                  airway was secured and anesthesia was maintained with N2O and
      Hemoglobinuria and                    isoflurane. The mother and babies suffered no complications
533   Thrombocytopenia                      perioperatively and were successfully discharged.

                                                                  Page 175

                                           Sensitization to latex has been shown to be more common in women than
                                           men and in patients undergoing obstetric procedures. The case being
                                           presented is of a 21-year old parturient scheduled for an elective repeat
                                           cesarean section. The patient became dyspneic and developed intractable
                                           hypotension under spinal anesthesia. She complained of severe pruritis
                                           after delivery of the baby. The patient was noted to have a rash on her
      Anaphylactic Reaction in a Third     upper extremities and chest. All of her symptoms improved 45 minutes
      Trimester Parturient Undergoing a    after the operation with successful resuscitation and medical management
      Repeat Elective Cesarean Section     with epinephrine. Postoperative investigation revealed a new onset allergic
534   with a Subarachnoid Block Anesthetic reaction to latex.

                                         A 42yo woman, G3P2, with one prior C-section was diagnosed at 28wks
                                         gestation by both ultrasound and MRI with placenta previa and placenta
                                         percreta with bladder invasion. Following appropriate pre-operative
                                         evaluation, including end-of-life discussions, the patient was scheduled for
                                         C-section at 35wks gestation. On the day of surgery the patient had
                                         bilateral uterine artery catheters placed under spinal anesthesia before
                                         undergoing a C-section under general anesthesia with standard monitors,
                                         arterial line and large bore central venous access. With the exception of
      The Case of the Placenta Percreta… uterine atony treated with multiple uterotonics, the operative course was
535   That Wasn't                        notable for the absence of the anticipated placenta percreta.

                                            A 22 yr 32 5/7 week parturient with severe PAH presented for cesarean
                                            delivery. Echo showed 1.3 cm diameter defect between LVOT and septal
                                            aspect of mitral prosthesis from incomplete congenital AV canal repair.
                                            Estimated EF was 45-50% with systolic RV pressure of 65-70 mmHg and
      Management of a Parturient with       diastolic PA pressure of 62-67 mmHg. After placing PA catheter and awake
      Severe Pulmonary Arterial             A-line and administration of sildenafil and loading dose of milrinone,
      Hypertension for Cesarean Delivery    anesthesia was induced with etomidate and fentanyl and maintained with O
      under General Endotracheal            2, 1% sevoflurane, fentanyl and milrinone. She delivered 1580 gms infant
536   Anesthesia                            with Apgars of 8 and 8, and was extubated with favorable outcome.

                                                                  Page 176

                                              A 15-year-old, 4-ft-11-inch, 54-kg, full-term primipara underwent lumbar
                                              epidural labor analgesia. A bolus followed by a 7ml/hr infusion of 0.2%
                                              ropivacaine with 2mcg/ml fentanyl yielded a T10 sensory block. Failed
                                              vacuum extraction warranted cesarean section at which time the epidural
                                              became nonfunctional due to catheter displacement. Lateral decubitus
      High Spinal Converted to General        position L4-5 spinal blockade with 12mg of hyperbaric bupivacaine with
      Anesthesia Following a Failed           20[micro]g of fentanyl was placed. C6 sensory blockage, diminished grip
      Epidural for Cesarean Section. A        strengths and difficulty breathing precipitated, followed by general
      Discussion on the Significant Effects   anesthesia. This case underscores the effects of position and dose on
      of Patient Position and Dose on         spinal block height in the controversial management of spinal block
537   Spinal Block Height                     following failed epidural.

                                              Peripartum complications of placenta accreta are hemorrhage,
                                              hysterectomy and pelvic organs injuries. Conservative management by
                                              leaving the placenta in situ in select cases with methotrexate therapy or
                                              awaiting spontaneous resorption can reduce morbidity amd mortality.
                                              Nineteen year old female, 37 weeks of gestation, three previous C-Sections
                                              and total previa was scheduled for repeat C-Section. Two large bore
                                              intravenous lines and 4 units of PRBCs were obtained prior to Combined
      Conservative Management of              Spinal Epidural block. Placenta was adherent to the lower segment and left
      Placenta Accreta: An Innovative         in situ. Postoperatively, bilateral ballooon catheters were placed in the
538   Approach                                nterventional Radiology suite and cystogram was done which was negative.

                                              A pregnant woman with surgically repaired aortic coarctation presented for
                                              term labor induction. Maternal echocardiogram showed moderate residual
                                              coarctation and mild-to-moderate aortic valve stenosis. Regional
                                              anesthesia was requested to facilitate stress-free first stage and passive
                                              second stage labor. A subarachnoid catheter was placed, and pain was
                                              initially controlled by intermittent boluses of sufentanil. When tachyphylaxis
                                              appeared, we began a slow, dilute local anesthetic infusion. Subsequent
      Anesthesia for Labor and Cesarean       fetal bradycardia prompted emergency Cesarean delivery, performed under
      Delivery in a Woman with Residual       general anesthesia to avoid sympathectomy from spinal anesthesia.
      Aortic Coarctation and Aortic Valve     Mother and baby did well. Alternative management strategies that might
539   Stenosis                                have avoided general anesthesia are discussed.

                                                                     Page 177

Authors                                            Learning Track

Mona G. Sarkiss, M.D., Ph.D.                       Fundamentals of Anesthesiology

Miguel A. Morillo, M.D., Worasak Keeyapaj, M.D., Ehab Farag, M.D. of Anesthesiology

                                                   Fundamentals of Anesthesiology
Elyssa Pohl, M.D., Diane Anca, M.D., John Fernandez, M.D., Geoffrey Pollack, M.D.

                                                                     Page 178

Tony Chiang, M.D., Adam Levine, M.D.             Fundamentals of Anesthesiology

                                               Fundamentals of Anesthesiology
Ramakrishnan Usha, M.D., Raghuvender Ganta, M.D., F.R.C.A., Pramod Chetty, M.D., Srikiran Ramarapu, M.D.

Carey M. Pilo, D.O., Elifce Cosar, M.D.          Fundamentals of Anesthesiology

                                                                  Page 179

                                                    Fundamentals of Anesthesiology
Sujatha P. Bhandary, M.D., Micheal de Ungria, M.D., John Seif, M.D., Tatyana Kopyeva, M.D., Ehab Farag, M.D., F.R.C.A.

Michael R. Anderson, M.D., Adam Levine, M.D.       Fundamentals of Anesthesiology

Victor Cardona, M.D., Normidaris Rodriguez, M.D.   Fundamentals of Anesthesiology

                                                                     Page 180

Nabil R. Fahmy, M.D., F.R.C.A.                     Fundamentals of Anesthesiology

                                                    Pretto, Jr., M.D., M.P.H.
Fouad G. Souki, M.D., Vadim Shatz, M.D., Ernesto A. Fundamentals of Anesthesiology

Suwarna A. Bhide, M.D., Michael R. Ritchey, M.D.   Fundamentals of Anesthesiology

                                                                    Page 181

James Freidenstein, M.D., Steven Clendenen, M.D. Fundamentals of Anesthesiology

Tracey Straker, M.D., M.P.H.                     Fundamentals of Anesthesiology

                                                  A. Rogic, M.D.
Thomas A. Nicholas, M.D., Terry Huang, M.D., NancyFundamentals of Anesthesiology

                                                                  Page 182

Elisabeth M. Lee, M.D., Amy Robertson, M.D.      Fundamentals of Anesthesiology

                                                  Salem, M.D.
Jessen J. Mukalel, M.D., Kay Yeung, M.D., M. RamezFundamentals of Anesthesiology

Richa Dhawan, M.D., Mohammed Minhaj, M.D.        Fundamentals of Anesthesiology

                                                                  Page 183

                                                 Fundamentals of Anesthesiology
Josef N. Mueksch, M.D., M.B.A., Subramanya S. Bandi, M.D., F.R.C.A., F.C.A.R.C.S.I., Gagandeep Goyal, M.D.

                                                  Fundamentals of Anesthesiology
Ronald Lee Samson, M.D., Carlos Mateo Mijares, M.D.

Joseph W. Szokol, M.D., Glenn S. Murphy, M.D.     Fundamentals of Anesthesiology

                                                                    Page 184

Maggie A. Jeffries, M.D.                          Fundamentals of Anesthesiology

Jerry Daniel, M.D., Richard McNeer, M.D., Ph.D.   Fundamentals of Anesthesiology

                                                     Brown, M.D.
Dragos M. Galusca, M.D., Cheryl Mordis, M.D., MorrisFundamentals of Anesthesiology

                                                                    Page 185

                                                   Frendl, M.D., of Anesthesiology
Sean Garvin, M.D., Christopher Ducko, M.D., George FundamentalsPh.D.

                                                      Fundamentals of Anesthesiology
Jennifer M. Hah, M.D., Richard A. Jaffe, M.D., Ph.D., Jason A. Talavera, M.D., John G. Brock-Utne, M.D., Ph.D.

                                                  Fundamentals of Anesthesiology
Daniel R. Skelly, B.S., Abhinava S. Madamangalam, M.D., Teodora O. Nicolescu, M.D., James Simonson, M.D.

                                                                       Page 186

Pik Ki Lee, M.D., Donald Mathews, M.D.            Fundamentals of Anesthesiology

Cyril N. Philip, M.D., Maunak V. Rana, M.D.       Fundamentals of Anesthesiology

                                                     Amardeep S. of Anesthesiology
Subramanya S. Bandi, M.D., F.R.C.A., F.C.A.R.C.S.I.,Fundamentals Heyer, M.D., Jack Cohen, M.D., Gagandeep Goyal, M.D.

                                                                   Page 187

                                                Fundamentals of Anesthesiology
James K. Fortman, M.D., Subhalkshmi Sivashankaran, M.D.

                                                  Fundamentals of Anesthesiology
Kanthimathinathan Muthusamy, M.B.B.S.; M.D., F.R.C.A.

Brian C. Bane, M.D., Shawn T. Beaman, M.D.       Fundamentals of Anesthesiology

                                                                  Page 188

Nancy M. Scott, M.D., Glen Atlas, M.D.                Fundamentals of Anesthesiology

Bruce Saltzman, M.D., Myriam Beniamin, M.D.           Fundamentals of Anesthesiology

                                                       M.D., Srinivas Pyati, M.D., M.B.B.S., F.F.A.R.C.S.I.
Charles Brudney, M.B.B.Ch., F.R.C.A., Atilio Barbeito,Fundamentals of Anesthesiology

                                                                         Page 189

                                                      C.P.E., Sergei Tyler, M.D., Dimitry
Doris Ore Sosa, M.D., Lowell Feinstein, D.O., M.B.A., Fundamentals of Anesthesiology Voronov, M.S., Alexandra Lelchuk, M.S.

                                                    Fundamentals of Anesthesiology
Daniel F. Lonergan, M.D., Steven Harrison, M.D., Michael G. Richardson, M.D.

Amir S. Gholami, M.D., Masozi Muwowo, M.D.         Fundamentals of Anesthesiology

                                                                    Page 190

Tracy L. Jobin, M.D., Michael A. Pilla, M.D.     Fundamentals of Anesthesiology

Jagan Devarajan, M.D., Lokesh Ningegowda, M.D.   Fundamentals of Anesthesiology

                                                  Fundamentals of Anesthesiology
Rebekah L. Wheatley, M.D., Gurinder M. Vasdev, M.D.

                                                                  Page 191

                                                     Fundamentals of Tarnal, F.R.C.A.,
John Alfa, M.B.B.S., D.A., F.R.C.A., Michelle B. Cederburg, M.D., Vijay Anesthesiology Carol Bradford, M.D.

Christopher Patrick Henson, D.O.                    Fundamentals of Anesthesiology

Govind R. Rajan, M.B.B.S., Jennifer Burke, M.D.     Fundamentals of Anesthesiology

                                                                      Page 192

David W. Boldt, M.D., Ned Nasr, M.D.         Fundamentals of Anesthesiology

William Costello, M.D., Lisa Weavind, M.D.   Fundamentals of Anesthesiology

Sidharth Panchamia, M.D.                     Fundamentals of Anesthesiology

                                                             Page 193

                                                   Fundamentals of
Scott J. Wiesenberger, M.D., Roger Marks, M.D., Carlos Mijares, M.D. Anesthesiology

                                                    Fundamentals of Anesthesiology
Ted G. Papalimberis, M.D., Rebecca A. Hall, M.D., Angus A. Christie, M.D., Kristen Fahrner, M.D.

Ted G. Papalimberis, M.D., Sarah A. Patterson, M.D. Fundamentals of Anesthesiology

                                                                      Page 194

Bjorn T. Olsen, M.D.                                 Fundamentals of Anesthesiology

Pavandeep S. Bagga, M.D., M.B.A., M.S.               Fundamentals of Anesthesiology

                                                    Fundamentals M.D.
Elizabeth Lee, M.D., Rigoberto Sierra-Anderson, M.D., Michael Pilla, of Anesthesiology

                                                                       Page 195

Marcos W. Gomes, M.D., Andrew Zura, M.D.             Fundamentals of Anesthesiology

Nabil R. Fahmy, M.D., F.R.C.A.                       Fundamentals of Anesthesiology

                                                    Fundamentals of Anesthesiology
Christina Matadial, M.D., Andrew Loukas, M.D., Daniel Castillo, M.D., Ricardo Martinez-Ruiz, M.D.

                                                                       Page 196

Aaron D. Anderson, M.D., Giuditta Angelini, M.D.   Fundamentals of Anesthesiology

Gokul Toshniwal, M.D.                              Fundamentals of Anesthesiology

                                                 Argalious, M.D.
Sekar S. Bhavani, M.D., Amgad Hanna, M.D., Maged Fundamentals of Anesthesiology

                                                                   Page 197

William E. Corcoran, M.D., Beverly K. Philip, M.D.   Fundamentals of Anesthesiology

Adam M. Brown, D.O., Vrinda Kartha, M.D., Watson Gomez, M.D. of Anesthesiology

Mathew D. McEvoy, M.D., Peter D. Goodnight, M.D., Justin J. Wright, M.D.

                                                                     Page 198

Sascha Beutler, M.D., Ph.D., Venkatesh Srinivasa, M.D.

Brandy M. Watson, M.D., Michael P. Kinsky, M.D.    Neuroanesthesia

Steven Rogovic, M.D., David J. Chen, B.S., Irene P. Osborn, M.D.

                                                                       Page 199

Coleen A. Vernick, D.O., Anna Greschner, M.D., William J. Vernick, M.D.

Amgad H. Hanna, M.D., Ehab Farag, M.D., Ali Rezai, Neuroanesthesia

Dirk Younker, M.D.                                  Neuroanesthesia

                                                                      Page 200

Andrew Franklin, M.D., Jane Easdown, M.D.           Neuroanesthesia

Kishore Tolani, M.B.B.S., Alexandru Apostol, M.D.   Neuroanesthesia

Sumit P. Singh, M.D., Vimi Kapur, M.D., David Boldt, M.D.

                                                                       Page 201

Ulrike Berth, M.D., Shaheen Shaikh, M.D., Bronwyn Cooper, M.D., Stephen O. Heard, M.D.

Juan P. Cata, M.D., Andre Machado, M.D., Ali Rezai, M.D., Zeid Ebrahim, M.D., Ehab Farag, M.D., F.A.R.C.

Karlyn J. Powell, M.D., David Misita, M.D.         Neuroanesthesia

                                                                     Page 202

                                                    Student, Lance Holton, M.D., Michelle Lotto, M.D.
Miguel A. Morillo, M.D., Matthew Monteleone, MedicalNeuroanesthesia

Sherryl Gaughn, M.D., Edward C. Nemergut, M.D., Jacob Raphael, M.D.

Sonal Sharma, M.D., Ashish Jain, M.B.B.S., Nikhil Ajmera, D.A., Hemant Bhartiya, M.S, M.Ch., Rajeev Ranjan, M.S., M.Ch.

                                                                      Page 203

Robert D. Todd, M.D., Stuart McGrane, M.D., Jason Pop, M.D., Steve Hyman, M.D., Lisa Weavind, M.D.

Miguel Morillo, M.D., Andres F. Sepulveda, M.D., Ehab Farag, M.D.

Claudia E. Perez, M.D.                            Neuroanesthesia

                                                                      Page 204

Bao Chau M. Tran, M.D., Charles J. Prestigiacomo, M.D., Glen M. Atlas, M.D.

Brian F.S. Allen, M.D., Liza Weavind, M.B.B.Ch.    Neuroanesthesia

Ju-Tae Sohn, M.D.                                  Neuroanesthesia

                                                                     Page 205

Mangu H. Rao, M.D., A.K.S. Reddy, M.D., Rajnish K. Jain, M.D., Raghuvender Ganta, M.D.

Steven Dillon, M.D., Marc A. Feldman, M.D., M.H.S. Neuroanesthesia

Christopher Patrick Henson, D.O., Letitia J. Easdown,Neuroanesthesia

                                                                       Page 206

Akara Forsythe, M.D., Coletta Richards, M.D.       Neuroanesthesia

Binit Shah, M.D., Reza Gorji, M.D.                 Neuroanesthesia

Carlos Mateo Mijares, M.D., Ginetta Speziani-Elie, C.R.N.A., Susan Sonson, C.R.N.A.

                                                                     Page 207

Michael Feiler, M.D., Andrew D. Rosenberg, M.D., Jeffrey Spivak, M.D., David B. Albert, M.D., Mitchell H. Marshall, M.D.

Bernadette J. Pasamba-Rakhlin, M.D., Keshav Kubal,Neuroanesthesia

Mitchell Y. Lee, M.D., Sunmi Kim, M.D., Jennie Ngai, M.D., Maki Morimoto, M.D.

                                                                        Page 208

Luciana M. Guerra, M.D., Anuradha Patel, M.D.        Neuroanesthesia

Jess W. Brallier, M.D., David J. Chen, B.S., Irene P. Osborn, M.D.

Letha Mathews, M.B.B.S., F.F.A.R.C.S.(I), McKay H. Bateman, M.D.

                                                                         Page 209

Sandra B. Machado, M.D., Andre G. Machado, M.D., Ph.D., Ali Rezai, M.D., Zyed Ebrahim, M.D., Ehab Farag, M.D.

Norma J. Klein, M.D., Tahani Liyanage, M.D.       Neuroanesthesia

Carlos M. Mijares, M.D.                           Neuroanesthesia

                                                                    Page 210

Anupa Deogaonkar, M.D., William Bingaman, M.D., Ehab Farag, M.D., F.R.C.A.

Osama Alabdulhadi, M.D., F.R.C.P.C.               Neuroanesthesia

Andres F. Sepulveda, M.D., Juan P. Cata, M.D., Theodore Marks, M.D., Ph.D.

                                                                    Page 211

                                                    Kempen, M.D., Ph.D.
Neal F. Campbell, M.D., Zulfaqar Alam, M.D., Paul M.Neuroanesthesia

Richard S. Gist, M.D., Harshpal Singh, M.D., Scott Silverman, M.D., Corey Scher, M.D.

David E. Swanson, M.D.                              Professional Issues

                                                                      Page 212

Adam L. Wendling, M.D., Michael E. Mahla, M.D.      Professional Issues

F.C.Kumar MD, Christa Rylanta MD, Jeff Miller MD,
Jeff Reid MD, Harper Ward MD
                                                    Professional Issues

John J. Hache, M.D., Paul M. Kempen, M.D., Ph.D.    Professional Issues

                                                                     Page 213

                                                  Professional Issues
Tae W. Kim, M.D., Teresa L. Moon, M.D., Binoy Chandra, M.D., Lewis A. Coveler, M.D.

Sam DeMaria, M.D., Adam I. Levine, M.D., Ethan O. Bryson, M.D. Issues

Shreyas Bhavsar, D.O.                             Fundamentals of Anesthesiology

                                                                    Page 214

                                                 Fundamentals of Anesthesiology
Hanumanth Rao Mangu, M.B.B.S., M.D., Janaki S. Peyyety, M.B.B.S., M.D., Raghuvender Ganta, M.D., F.R.C.A.

Ayse O. Kula, M.D., Suyan Liu, M.D., Ph.D., Harvey Woehlck, M.D. of Anesthesiology

                                                    Fundamentals M.D., Michael Machuzak, M.D., James Sable, M.D.
Ursula Galway, M.D., John D. Doyle, M.D., Ph.D., Thomas R. Gildea,of Anesthesiology

                                                                    Page 215

                                                  Fundamentals of Anesthesiology
Patrick A. Armstrong, M.D., Watson Gomez, M.D., F.R.C.A., Vrinda Kartha, M.D., F.R.C.A.

Alison R. Perate, M.D., Nabil Elkassabany, M.D.    Fundamentals of Anesthesiology

                                                 Fundamentals of
Hesham A. Elsharkawy, M.D., Fady Nageeb, M.D., Rafi Avitsian, M.D. Anesthesiology

                                                                     Page 216

David A. Cross, M.D., James B. Hulin, D.O.       Fundamentals of Anesthesiology

Ronald M. Roan, M.D., Jennifer Badia, M.D.       Fundamentals of Anesthesiology

Saadia Zafar, M.D., Sivasenthil Arumugam, M.D.   Fundamentals of Anesthesiology

                                                                 Page 217

Brent A. Carroll, M.D., Richard McNeer, M.D., Ph.D. Fundamentals of Anesthesiology

Neil Chadha, M.D., Alexander J. Butwick, F.R.C.A.   Obstetric Anesthesia

Osama Alabdulhadi, M.D., F.R.C.P.C.                 Obstetric Anesthesia

                                                                     Page 218

Rayna A. Clay, M.D., Livia S. Marica, M.D.            Obstetric Anesthesia

Ranita R. Donald, M.D.                                Obstetric Anesthesia

                                                      Obstetric Anesthesia
Igor Ianov, M.D., Izabela L. Barnes, M.D., Gentry B. William, M.D., Chakraborty Indranil, M.D., Rashid Khalil, M.D.

                                                                         Page 219

                                                   Obstetric Anesthesia
Matthew W. Martin, M.D., Alexandra S. Bullough, M.B.ChB.

                                                   Obstetric Anesthesia
Katherine L. Haeck, D.O., Joanna M. Davies, M.B.B.S., F.R.C.A., H.S. Chadwick, M.D.

Ryan G. Michaud, M.D., Arpad Zolyomi.              Obstetric Anesthesia

                                                                     Page 220

                                                    Obstetric Anesthesia
Helene Finegold, M.D., Christopher A. Troianos, M.D., Veena Basava, M.D., Marc F. Metcalfe, M.D.

                                                    M.D., Sabri Barsoum,
Sarah B. Kane, M.D., Chiyo Ootaki, M.D., Ihab Toma, Obstetric Anesthesia M.D.

                                                    Obstetric Anesthesia
Tilak D. Raj, M.D., Kathryne K. Cates, M.D., Anne Morgan, M.D.

                                                                     Page 221

Erin S. Williams, M.D., Barbara Dabb, M.D.   Obstetric Anesthesia

David A. Cross, M.D., Aaron Cade, M.D.       Obstetric Anesthesia

Tyson Ulmer, M.D., Tammy Y. Euliano, M.D.    Obstetric Anesthesia

                                                              Page 222

Richard C. Month, M.D., Sonia J. Vaida, M.D.       Obstetric Anesthesia

                                                    Obstetric Anesthesia
Lori D. Conklin, M.D., William S. Cox, Mohamed Tiouririne, M.D.

                                                 Obstetric Anesthesia
Eugene Kim, M.D., Anupa Deogaonkar, M.D., Miguel Morillo, M.D., Michelle Lotto, M.D., Karen Steckner, M.D.

                                                                     Page 223

Joan Spiegel, M.D.                              Obstetric Anesthesia

Glenn E. Mann, M.D., Jerry Chu, M.D.            Obstetric Anesthesia

                                                Obstetric Anesthesia
Chawla L. Mason, M.D., Shobana Chandrasekhar, M.D., Maya S. Suresh, M.D.

                                                                 Page 224

                                                  Obstetric Anesthesia
Gregory Rutkowski, M.D., Sivasenthil Arumugam, M.D.

Biswajit Ghosh, M.D., Jessen Jacob, M.D., Christine Kim, M.D. Anesthesia

Jolly L. Ombao, M.D., Ben Toure, M.D., Ivan Velickovic, M.D. Anesthesia

                                                                     Page 225

Chawla L. Mason, M.D., Maya S. Suresh, M.D.       Obstetric Anesthesia

Alina Justiz, M.D., Gozde Demiralp, M.D.          Obstetric Anesthesia

                                                    Obstetric Anesthesia
Kendra J. Grim, M.D., Katherine W. Arendt, M.D., Adam K. Jacob, M.D., Mark T. Keegan, M.D.

                                                                    Page 226

                                                  Obstetric Anesthesia
Dawn McNiel, M.D., Shayom Ortiz, M.D., Kalpana C. Tyagaraj, M.D.

Ravpreet Gill, M.D., Kalpana C. Tyagaraj.         Obstetric Anesthesia

Adam O. Spencer, M.D., M.Sc., Saul Pytka, M.D., F.R.C.P.C. Anesthesia

                                                                   Page 227

Maggie W. Mechlin, M.D., Lesley Gilbertson, M.D.     Obstetric Anesthesia

                                                   Obstetric Anesthesia
Melissa S. Flanigan, D.O., Channing Willoughby, M.D., Christine Bezouska, M.D., Todd Unger, M.D., Matthew Watkins, D.O.

                                                      Obstetric Anesthesia
Nichole L. Taylor, D.O., Daniel Redford, M.D., Craig Palmer, M.D.

                                                                       Page 228

Tammy Y. Euliano, M.D.                              Obstetric Anesthesia

Laura H. Ferguson, M.D., Patricia L. Dalby, M.D.    Obstetric Anesthesia

                                                     Obstetric Anesthesia
Rashid Khalil, Saleem Majid, M.D., Carmelita Pablo, M.D.

                                                                      Page 229

John J. Hache, M.D., Manuel C. Vallejo, D.M.D., M.D.Obstetric Anesthesia

                                                   Obstetric Anesthesia
David Y. Kim, M.D., Ihab Kamel, M.D., Ann Warner, Rodger Barnett, M.D.

                                                     Obstetric Anesthesia
Meredith A. Albrecht, M.D., Ph.D., Yumiko Ishizawa, M.D., Ph.D., M.P.H.

                                                     Obstetric Anesthesia
Matthew B. Ellison, M.D., Christine Bezouska, M.D., Channing Willoughby, M.D.

                                                                      Page 230

                                                     Carabuena, M.D., Jie
Amarjeet Singh, M.B.B.S., D.A., F.R.C.A., Jean Marie Obstetric Anesthesia Zhou, M.D.

Daniel R. Beck, M.D., M.S., Gita Rupani, M.D.      Obstetric Anesthesia

                                                 Obstetric M.D., Jeff Miller, M.D.
Jeff S. Ostrander, Abhinava Madamangalam, M.D., Vaidy Rao, Anesthesia

                                                                     Page 231

Amy Evers, M.D., Takeko Toyama, M.D., Donald Penning, M.D.Anesthesia

                                                   Obstetric Anesthesia
Kalen J. Rogers, James R. Dyer, M.D., Johnny A. Thomas, M.D., Dan Biggs, M.D.

Smokey J. Clay, M.D., Christine A. Bezouska, M.D.   Obstetric Anesthesia

                                                                     Page 232

                                                    Obstetric Anesthesia
Sarah Fandre, M.D., Curtis Baysinger, M.D., Robert Deegan, M.D.

Stacy Serebnitsky, M.D.                            Obstetric Anesthesia

Jason Daras, D.O., Ellen Steinberg, M.D., Ming Tsang, M.D. Anesthesia

                                                                     Page 233

Takeko M. Toyama, M.D.                           Obstetric Anesthesia

Kieu X. Luu, M.D., Ph.D., Peter D. Dwane, M.D.   Obstetric Anesthesia

                                                 Obstetric Anesthesia
German E. Luzardo, M.D., Jayanthie Ranasinghe, M.D.

                                                                  Page 234

Luke Y. Wang, M.D., Monica R. Servin, M.D.           Obstetric Anesthesia

                                                     Carabuena, M.D.
Amarjeet Singh, M.B.B.S., D.A., F.R.C.A., Jean Marie Obstetric Anesthesia

Faisal Motlani, M.D., Avijit Mookerjee, M.D., Aaron Lewis, M.D. Anesthesia

                                                                       Page 235

Jaspreet Singh, M.D., Laurence Susser, M.D.        Obstetric Anesthesia

Michael L. Owens, M.D., Cheryl J. Mordis, M.D.     Obstetric Anesthesia

                                                    Obstetric Anesthesia
Agnes Miller, M.D., Martin Miller, M.D., Ram Manchandani, M.D., Kalpana C. Tyagaraj, M.D.

                                                                     Page 236

Ashvin K. Amara, M.D., Farag Ayman, M.D.             Obstetric Anesthesia

Joel Waring, M.D., Martin Miller, Kalpana C Tyagaraj. Obstetric Anesthesia

Kieu X. Luu, M.D., Ph.D., Anthony M. Roche, M.B., ChB., F.R.C.A. of Anesthesiology

                                                                       Page 237

Andrea Orfanakis, M.D., Ann Walia, M.D.            Fundamentals of Anesthesiology

Lourdes G. Burgos, M.D., Suyan Liu, M.D.           Fundamentals of Anesthesiology

                                                     Fundamentals of Anesthesiology
Shivani Chadha, M.D., Rafi Avitsian, M.D., John Tetzlaff, M.D.

                                                                     Page 238

Barbara Gasior, M.D., Rupal Kalariya, M.D.           Fundamentals of Anesthesiology

                                                      Fundamentals M.D.
Ira S. Hofer, B.S., B.A.S., Jackson S. Cheung, B.A., Corey S. Scher, of Anesthesiology

Raymond C. Roy, M.D., Ph.D.                          Fundamentals of Anesthesiology

                                                                       Page 239

Carlos M. Mijares, M.D., Carlos M. Mijares, M.D.   Fundamentals of Anesthesiology

Michelle R. Beam, D.O., Stephen Bader, M.D.        Fundamentals of Anesthesiology

Jason D. Schaechter, M.D., Andrey Apinis, M.D.     Fundamentals of Anesthesiology

                                                                   Page 240

                                                     W. Lew, M.D., Walter L. Chang,
Eugene L. Bak, M.D., Andres Falabella, M.D., MichaelFundamentals of Anesthesiology M.D.

Jerry F. O'Hara, Jr, M.D.                         Fundamentals of Anesthesiology

Dina E. Soliman, M.D., Jeffrey A. Lewis, D.O.     Fundamentals of Anesthesiology

                                                                    Page 241

                                                     Fundamentals of Anesthesiology
Bridget L. Muldowney, M.D., Carrie L. Meyer, M.D., Kristopher M. Schroeder, M.D.

                                                      Fundamentals of Anesthesiology
Karen G. O'Niell, M.D., Matthew V. Satterly, M.D., Heidi M. Koenig, M.D.

Anjali Patel, D.O., Heidi K. Atwell, D.O.           Fundamentals of Anesthesiology

                                                                      Page 242

Justin W. Wilson, M.D., Scott Hoffman, M.D.       Fundamentals of Anesthesiology

                                                    Fundamentals of Anesthesiology
Erum Ali, M.D., Audree Bendo, M.D., Dominck I. Golio, M.D.

Ryan G. Michaud, M.D., Soul Wiseal, M.D.          Fundamentals of Anesthesiology

                                                                    Page 243

Catherine L. Cooper, M.D.                           Fundamentals of Anesthesiology

                                                   Leo Hsiao, M.D.
LaKiesha K. Crawford, M.D., Matthew R. Vana, M.D., Fundamentals of Anesthesiology

                                                  Fundamentals of M.D., M.P.H.
Fouad G. Souki, M.D., Aharon Avramovich, M.D., Ernesto A. Pretto, Jr.,Anesthesiology

                                                                      Page 244

                                                    T. Norris, M.D., Anesthesiology
Matthew T. Pena, M.D., Michael L. Kent, M.D., JamesFundamentals ofTara M. Sexton, M.D.

                                                      Fundamentals of Anesthesiology
Jason S. Lane, M.D., M.P.H., William B. Byrd III, M.D., Ramprasad Sripada, M.D., M.M.M., C.P.E.

Henry C. Chen, M.D., Meg A. Rosenblatt, M.D.        Fundamentals of Anesthesiology

                                                                      Page 245

                                                  Fundamentals A. Wallace, D.O.
Melissa A. Carter, M.D., Subhalakashmi Sivashankaran, M.D., Davidof Anesthesiology

                                                      Leon-Ruiz, M.D.
Erik W. Shupe, D.O., David A. Wallace, D.O., Elias N.Fundamentals of Anesthesiology

Carey M. Pilo, D.O., Gustavo Angaramo, M.D.        Fundamentals of Anesthesiology

                                                                     Page 246

                                                  Fundamentals of
Arthur J. Klowden, M.D., M. Ramez Salem, M.D., Edward J. Lee, M.D. Anesthesiology

                                                     R. Lorenz, M.D., Rafi Avitsian, M.D.
Sarah B. Kane, M.D., John Doyle, M.D., Ph.D., RobertFundamentals of Anesthesiology

Anasuya Vasudevan, M.D.                             Fundamentals of Anesthesiology

                                                                       Page 247

Nabil R. Fahmy, M.D., F.R.C.A.           Fundamentals of Anesthesiology

Kabir Ahmed, M.D.                        Fundamentals of Anesthesiology

Toni Manougian, M.D., Camay Chiu, M.D.   Fundamentals of Anesthesiology

                                                         Page 248

Jolly L. Ombao, M.D., Orson Go, M.D., Jun Lin, M.D., Fundamentals of Anesthesiology

Aurea Almeida, M.D., Fernando Correia, M.D.        Fundamentals of Anesthesiology

                                                   Christopher L. Wu, M.D.
Brandon K. Lenox, D.O., M.P.H., Robert Wong, M.D., Fundamentals of Anesthesiology

                                                                     Page 249

Toni Manougian, M.D., Tina Leung, M.D.                 Fundamentals of Anesthesiology

George W. Williams, II, M.D., Irving A. Hirsch, M.D.   Fundamentals of Anesthesiology

Natalia Skachkova, M.D., Dimitris T. Giannaris, M.D. Fundamentals of Anesthesiology

                                                                       Page 250

                                                 Fundamentals of Anesthesiology
Govind R. Rajan, M.B.B.S., Stephanie Rasmusen, M.D., Pete Towns, M.D., Anjali Patel, D.O.

Benjamin Abraham, M.D.                              Fundamentals of Anesthesiology

Chris W. Cary, M.D., Matthew A. Green, M.D., Timothy J. Hall, M.D. of Anesthesiology

                                                                      Page 251

Amanda M. Russell, M.D., Saraswathi Karri, M.D.       Fundamentals of Anesthesiology

James Bell III, M.D., Ph.D., Valerie Makarick, M.D.   Fundamentals of Anesthesiology

Amir S. Gholami, M.D., Kamesiau Premmer, M.D.         Fundamentals of Anesthesiology

                                                                      Page 252

Michael Gorena, M.D.                              Fundamentals of Anesthesiology

                                                 King, M.D., Cannon Clifton, M.D.,
Sokchea Doeung, M.D., Sally Combest, M.D., AndreaFundamentals of Anesthesiology Tania Mehta, C.R.N.A.

                                                 Fundamentals M.D.
Sayeh Hamzehzadeh, M.D., Richard Rivers, M.D., Ph.D., Tina Tran, of Anesthesiology

                                                                    Page 253

                                                    Fundamentals of Anesthesiology
Rajnish K. Jain, M.D., Mangu H. Rao, M.D., A.K.S. Reddy, M.D., Raghuvender Ganta, M.D.

Bill Alexander, M.D., Wendy Bernstein, M.D.       Fundamentals of Anesthesiology

                                                 Fundamentals of Anesthesiology
F.C. Kumar MD., Stephen Heimbach MD., Justin Gulledge MD., Charles Cotton MD., Lauren Sparks MS IV

Danesh Mazloomdoost, M.D., Haitham Al-Grain, M.D.Fundamentals of Anesthesiology

                                                                    Page 254

                                                     Fundamentals of Anesthesiology
Siham M. Elrouby, M.B.B.Ch., D.A., Nizar Khalifah, M.D., Ibrahim A. Kashkari, M.D.

Jennifer L. Miano, M.D., Yehuda Raveh, M.D.        Ambulatory Anesthesia

Lisa Vu, M.D., Jayeshkumar Patel, M.D.             Fundamentals of Anesthesiology

                                                                     Page 255

Adam M. Debin, D.O., Tracey Straker, M.D.           Fundamentals of Anesthesiology

Ronit Keisari, M.D., Corey Scher, M.D.              Fundamentals of Anesthesiology

                                                      Fundamentals of Anesthesiology
Allison J. Sudol, B.A., Corey Scher, M.D., Nicole Ansell, M.D.

                                                                      Page 256

Devin P. McCullough, D.O., Rafi Avitsian, M.D.     Fundamentals of Anesthesiology

                                                   Fundamentals of Anesthesiology
McKay H. Bateman, M.D., Justin Wilson, M.D., Paul J. St. Jacques, M.D.

Melissa S. Flanigan, D.O., Melanie Mcmurry, M.D.   Fundamentals of Anesthesiology

                                                                   Page 257

Tunga Suresh, M.D., Edmund Jooste, M.D.      Pediatric Anesthesia

Shu-Ming Wang, M.D., Inna Maranets, M.D.     Pediatric Anesthesia

Joan A. Ascher, M.D., Raffi Chemsian, M.D.   Pediatric Anesthesia

                                                              Page 258

                                                  Pediatric Anesthesia
Ramon Abola, M.D., David Wallach, M.D., Jonathan M. Tan, MPH, Meghan C. Whitley, B.S., Peggy A. Seidman, M.D.

                                                  Pediatric Anesthesia
Mamatha Punjala, M.D., Shu-Ming Wang, M.D., Lori Kwan, M.D.

Stephanie M. Chia, M.D., Gordana Stjepanovic, M.D. Pediatric Anesthesia

                                                                    Page 259

Maria A. Kimovec, M.D., Utpal Patel, M.D., Janet Meller, M.D. Anesthesia

                                                   Pediatric Anesthesia
Alexander Shorshtein, M.D., Michael Shulman, M.D., Evan Salant, M.D.

Adam L. Shires, D.O., Susan R. Staudt, M.D., M.S.Ed. ediatric Anesthesia

                                                                     Page 260

                                                    Pediatric Anesthesia
Robert L. Nesselrode, M.D., Judith Ponder, M.D., Abhaya Seshachar, M.D.

Cheryl Gooden, M.D., Jeena Jacob, M.D.             Pediatric Anesthesia

                                                  Pediatric Anesthesia
Neal Puthumana, M.D., Bettina Smallman, M.D., David Romano, M.D.

                                                                     Page 261

Shirley N. D'Souza, M.D., Jesus S. Apuya, M.D.     Pediatric Anesthesia

                                                     Pediatric Anesthesia
Emi Kitashoji, M.D., Sho C. Shibata, M.D., Ph.D., Osamu Uchida, M.D., Takahiko Kamibayashi, M.D., Ph.D., Yukio Hayashi, M.D., Ph.D.

Joyce F. Phillips, M.D., Tony Yen, M.D.            Pediatric Anesthesia

                                                                     Page 262

                                                 Pediatric Anesthesia
Hesham A. Elsharkawy, M.D., Rami Karroum, M.D., Julie Niezgoda, M.D., George Youssef, M.D., Loran Mounir Soliman, M.D.

Carlos M. Mijares, M.D.                           Pediatric Anesthesia

Ben B. Adams, D.O.                                Pediatric Anesthesia

                                                                   Page 263

Melissa M. Koshel, D.O., Debnath Chatterjee, M.D.   Pediatric Anesthesia

                                                   Pediatric Anesthesia
Jacob C. Carman, D.O., Brett Pate, M.D., Charles Cassady, M.D.

Cynthia Wang, M.D., Richard Marn, M.D.              Pediatric Anesthesia

                                                                     Page 264

                                                   Pediatric Anesthesia
Sonia Saini, M.D., D.N.B., Gracie Almeida-Chen, M.D., Glenn DeBoer, M.D., Miguel Morillo, M.D., Sekar Bhavani, M.D.

                                                   Pediatric Anesthesia
Charles Edwards, M.D., John Miles, M.D., Govind R. Rajan, M.D.

                                                     Pediatric Anesthesia
Jonathan A. D'Angelo, B.S., Eric Neller, M.D., Mohanad Shukry, M.D.

                                                                      Page 265

John P. Scott, M.D.                          Pediatric Anesthesia

Gina M. Whitney, M.D., Steven Samoya, M.D.   Pediatric Anesthesia

Charles C. Baldwin, M.D.                     Pediatric Anesthesia

                                                              Page 266

Tony C. Yen, M.D., Nivine Doran, M.D.               Pediatric Anesthesia

Courtney A. Hardy, M.D., Amod Sawardekar, M.D.      Pediatric Anesthesia

Claude Abdallah, M.D., M.Sc., Raafat Hannallah, M.D. ediatric Anesthesia

                                                                     Page 267

Chhaya Patel, M.D., Olubukola O. Nafiu, M.D.        Pediatric Anesthesia

Tracey Ann Danloff, M.D.                            Pediatric Anesthesia

                                                   Pediatric Anesthesia
James M. Caswell, M.D., Bettina Smallman, M.D., F.R.C.P.C.,, Jesse Aron, M.D., See Wan Tham, M.D., Sara Giorgi, D.O.

                                                     Pediatric Anesthesia
Leslie Medley, M.D., Steven Stayer, M.D., Carlos J. Campos Lopez, M.D.

                                                                      Page 268

                                                   Pediatric Anesthesia
Gennadiy Fuzaylov, M.D., Arthur Tokarczyk, M.D., Robert L Sheridan, M.D., Jeevendra Martyn, M.D., F.C.C.M., Daniel P. Ryan, M.D.

                                                    Pediatric Anesthesia
Stephanie G. Vanterpool, M.D., Robert B. Bryskin, M.D.

Mark D. Twite, M.B.B.Chir., Robert H. Friesen, M.D. Pediatric Anesthesia

                                                                     Page 269

                                                    Pediatric Anesthesia
Sujatha P. Bhandary, M.D., Allen Keebler, D.O, Sudha Rajagopalan, M.D., Pablo Motta, M.D.

                                                 Pediatric Anesthesia
Mohamed Mahmoud, M.D., Tana Tyler, M.D., Senthilkumar Sadhasivam, M.D.

James F. Mayhew, M.D.                              Pediatric Anesthesia

                                                                     Page 270

                                                     Pediatric Anesthesia
Marisa A. Rosol, D.O., Julie Niezgoda, M.D., Robert Savage, M.D., Pablo Motta, M.D.

Denisa M. Haret, M.D., Shailesh Shah, M.D.          Pediatric Anesthesia

Kinnari P. Khatri, M.D., Cheryl K. Gooden, M.D.     Pediatric Anesthesia

                                                                      Page 271

Stacy Serebnitsky, M.D.                             Pediatric Anesthesia

                                                     Pediatric Anesthesia
Meenal Kulkarni, M.D., Scott Johnstone, M.D., Ira Landsman, M.D.

                                                    Pediatric Anesthesia
Emily J. Parke, D.O., Jose L. Diaz-Gomez, M.D., Pablo Motta, M.D.

                                                                      Page 272

Dan C. Rogers, M.D., Michelle Moro, M.D.         Pediatric Anesthesia

Erica Stein, M.D., Igor Tkachenko, M.D.          Pediatric Anesthesia

Joseph F. Borau, M.D., M.P.H., Richard McNeer, M.D., Ph.D. Anesthesia

                                                                   Page 273

Jennifer L. Dearden, M.D.                         Pediatric Anesthesia

                                                  Pediatric Anesthesia
James Sable, M.D., Rami E. Karroum, M.D., Margarita Martirena, M.D., George Youssef, M.D., Sergio Bustamante, M.D.

Miguel A. Cruz, M.D.                              Pediatric Anesthesia

                                                                    Page 274

Melissa M. Koshel, D.O., Bettina Smallman, M.D.    Pediatric Anesthesia

                                                   Pediatric Anesthesia
Olubunmi Akinbajo, M.D., Irene P. Osborn, M.D., Cheryl K. Gooden, M.D.

Ira S. Hofer, B.A.S., B.S., Corey S. Scher, M.D.   Pediatric Anesthesia

                                                                    Page 275

                                                     Pediatric Anesthesia
Elaina E. Lin, M.D., Gregory J. Latham, M.D., Devika Singh, M.D.

Angela Lee, M.D.                                    Pediatric Anesthesia

Gita Rupani, M.D., Daniel Leung, M.D.               Pain Medicine

                                                                      Page 276

Adam J. Carinci, M.D., Srinivasa N. Raja, M.D.     Pain Medicine

                                                   Pain Medicine
James W. Ibinson, M.D., Ph.D., Dean S. Mozeleski, M.D., Victor Georgescu, M.D., Nashaat N. Rizk, M.D.

Rafael Justiz, M.D., Camden Kneeland, M.D.         Pain Medicine

                                                                     Page 277

George Andrews, M.D., Sameh Yonan, M.D.            Pain Medicine

Perry G. Fine, M.D.                                Pain Medicine

                                                    Pain Medicine
Ellen E. Rhame, M.D., Christopher G. Gharibo, M.D., Kenneth A. Levey, M.D.

                                                                     Page 278

                                                   Pain Tamimi,
Jason P. Krutsch, M.D., Heather R. Davids, M.D., Mazin Al Medicine M.D.

                                                   Pain Medicine
Jiss Mathew, B.S., LesaBeth Romans, R.N., Alberto J. de Armendi, M.D., Mohanad Shukry, M.D.

                                                   Pain Medicine
Barbara A. Ryan, M.D., Jeremy O. Comin, D.O., Orion Nohr, M.D., Seth D. Blank, M.D., Angus A. Christie, M.D.

                                                                      Page 279

                                                 Pain Mackerley,
Kenneth D. Candido, M.D., Maunak V. Rana, M.D., Sara L.Medicine D.O., Benjamin S. Salter, D.O., Cyril N. Philip, M.D.

Jerry Kim, M.D., Anjana Kundu, M.B.B.S., D.A.      Pain Medicine

Rafael Justiz, M.D.                                Pain Medicine

                                                                     Page 280

Alan Brewer, M.D., Heather R. Davids, M.D.        Pain Medicine

Claudia Y. Venable, M.D., Margaret Shaw, P.N.P.   Pain Medicine

                                                 Pain Medicine
Sanghun Kim, M.D., Ph.D., Keum Young So, M.D., Ph.D., Chong Dal Chung, M.D., Ph.D., Tae Hun An, M.D., Ph.D., Hyun Young Lee, M.D.

                                                                  Page 281

                                                  Pain Linda Edwards, M.D.
Ricardo F. Nieves-Ramos, M.D., Timothy Sternberg, M.D., Medicine

Jennifer A. Gargano, M.D., Annie G. Philip, M.D.    Pain Medicine

                                                    Connie Wright,
Magdalena Anitescu, M.D., Ph.D., Gita Rupani, M.D., Pain Medicine R.N., A.P.N., C.P.S., Annette Martini, M.D.

                                                                      Page 282

                                                     Pain M.D., Keunsam Chung, M.D.
Jorge A. Galvez, M.D., Javier Lopez, M.D., Nalini Vadivelu,Medicine

Melissa A. Carter, M.D., Patrick J. McIntyre, M.D.   Pain Medicine

                                                   Pain Medicine
Long H. Huynh, M.D., Robert Burns, M.D., Ivan Antonevich, M.D.

                                                                     Page 283

Kanchana Gattu, M.D., Brian T. Le, D.O.           Pain Medicine

Claudia Y. Venable, M.D., Margaret Shaw, P.N.P.   Pain Medicine

                                                   Pain Medicine
Melody Hu, M.D., Joel Kent, M.D., Thelma Wright, M.D., Seung Lee, M.D.

                                                                    Page 284

                                                   Pain Medicine
Edward B. Braun, M.D., Michael M. Bottros, M.D., Swarm A. Robert, M.D.

Nandak S. Choksi, M.D., Carlo Franco, M.D., Andrzej Pain MedicineM.D., Maria Torres, M.D., Taruna Penmetcha, M.D.

Claudia Y. Venable, M.D., Margaret Shaw, N.P.      Pain Medicine

                                                                    Page 285

                                                      Pain Medicine
Robert T. Rinnier, D.O., Robert A. Hirsh, M.D., Marc Torjman, Ph.D., Michael E. Goldberg, M.D.

Yu-Fan R. Zhang, M.D., Nalini Vadivelu, M.D.        Pain Medicine

Melody Hu, M.D., Kanchana Gattu, M.D.               Regional Anesthesia and Acute Pain

                                                                      Page 286

Arielle Ochoa Fenig, M.D., Stella Tort, M.D., Nirmal Patel, M.D. Anesthesia and Acute Pain

                                                      Regional Anesthesia and Acute Pain
Nikki B. Rekito, M.D., Michael F. Aziz, M.D., Jean-Louis Horn, M.D.

                                                    Bassam Anesthesia
Matthew D. McEvoy, M.D., Joel L. Bridgewater, M.D., RegionalKadry, M.D. and Acute Pain

                                                                       Page 287

                                                      Regional Anesthesia and
Jennifer Ng, M.D., Fatima Salas, M.D., M.P.H., Eli Bryk, M.D., Matt Wert, M.D. Acute Pain

Lisa Jaeger, M.D., Vikas Shah, M.D.                 Regional Anesthesia and Acute Pain

Cyril N. Philip, M.D., Kenneth D. Candido, M.D.     Regional Anesthesia and Acute Pain

                                                                       Page 288

Cyril N. Philip, M.D., Kenneth D. Candido, M.D.     Regional Anesthesia and Acute Pain

                                                      Regional Anesthesia and Acute Pain
Melissa S. Flanigan, D.O., Mario Serafini, D.O., Stephen Howell, M.D.

                                                  Regional Anesthesia and Acute Pain
Amanda M. Russell, M.D., Loran Mounir Soliman, M.D.

                                                                      Page 289

                                                   F.R.C.A., Chuan Kwan, Acute Pain
Jacqueline J. Smith, M.D., Raghuvender Ganta, M.D.,Regional Anesthesia andM.D., Lankike Abeyewardene, M.D.

Daniel S. Tongbai, M.D., Bita Zadeh, M.D., Ali Sadoughi, M.D. Anesthesia and Acute Pain

Naeem Haider, M.D., Srinivas Chiravuri, M.D.       Regional Anesthesia and Acute Pain

                                                                     Page 290

                                                    Regional Anesthesia and M.D., Michael Marsh, M.B.B.S.
Nazario Villasenor, M.D., Eric Young, M.D., Hares Akbary, M.D., Samuel Perov,Acute Pain

Abdelhakim A. Massoud, M.D.                       Regional Anesthesia and Acute Pain

                                                   Regional Charles Cassady, M.D., Harper Ward, M.D.
Srikiran Ramarapu, M.D., Stephen Bass, M.D., Jeff Reid, M.D., Anesthesia and Acute Pain

                                                                    Page 291

                                                 Regional M.D., George Acute Pain
Reda Tolba, M.D., Rami Karroum, M.D., Loran Mounir Soliman,Anesthesia andYoussef, M.D.

                                                     Regional Anesthesia and Acute Pain
James B. Hulin, D.O., Russell K. McAllister, M.D., Don J. Daniels, M.D.

                                                     Regional Anesthesia and Acute
Jorge A. Fernandez-Silva, M.D., Binit Shah, M.D., Joanna Wroblewska-Shah, M.D. Pain

                                                                     Page 292

                                                       Regional Anesthesia and Acute Pain
Nichole L. Taylor, D.O., Patrick K. Boyle, M.D., John J. Badal, M.D.

Steven P. Milo, M.D., Meg A. Rosenblatt, M.D.       Regional Anesthesia and Acute Pain

                                                  Jason Pooler, M.D., and Gleaves, M.D., Raghuvender Ganta, M.D.
Srikiran Ramarapu, M.D., Usha Ramakrishnan, M.D., Regional Anesthesia ToddAcute Pain

                                                                       Page 293

                                                        Regional Anesthesia and Acute Pain
Patrick J. Tighe, M.D., Clint Elliott, M.D., Linda Le-Wendling, M.D.

                                                 Regional Anesthesia
Amy M. Judge, M.D., Karamarie Fecho, Ph.D., Brandon Winchester, M.D. and Acute Pain

                                                     Regional Anesthesia and Acute Pain
Ali Shariat, M.D., Seema Patel, D.O., Jeff Gadsden, M.D.

                                                                       Page 294

Shu Zhang, M.D., Linda Rever, M.D.                 Regional Anesthesia and Acute Pain

                                                    Cardiac Anesthesia
Srikiran Ramarapu, M.D., Michael D. Taylor, M.D., Ph.D., Usha Ramakrishnan, M.D., John Thomas, M.D., Brett C. English, M.D.

Kellie C Hancock, M.D., Ferenc Puskas, M.D.        Cardiac Anesthesia

                                                                     Page 295

                                                   Cardiac Anesthesia
Michael P. Gallagher, M.D., Joe Monk, M.D., Steve Sutton, C.C.P., Dan Mason, Carl Henry, M.D.

                                                    Cardiac Anesthesia
Arie Blitz, M.D., Heather McFarland, M.D., George Williams, M.D., Jeffrey Foster, C.C.P., James C. Fang, M.D.

Ashley E. Norman, M.D., Marc S. Kanchuger, M.D.     Cardiac Anesthesia

                                                                      Page 296

Justin W. Wilson, M.D., Bernhard Riedel, M.D.      Cardiac Anesthesia

                                                    Cardiac Anesthesia
Milaurise Cortes, B.A., Sabrina Bhagwan, M.D., Steven Neustein, M.D., Cheryl K. Gooden, M.D.

Dirk Younker, M.D.                                 Cardiac Anesthesia

                                                                     Page 297

                                                      Cardiac Anesthesia
Vladislav I. Shick, M.D., Vajubhai Sanchala, M.D., Kathryn McGoldrick, M.D.

                                                      Cardiac Anesthesia
Patrick J. Tighe, M.D., Julia Bauerfeind, M.D., Gregory M. Janelle, M.D.

                                                    Cardiac Anesthesia
Crystal C. Wright, M.D., B. Thompson, M.D., J.L. Reeves-Viets, M.D., M.B.A.

                                                                       Page 298

                                                    Cardiac Anesthesia
Ilka D. Theruvath, M.D., Ph.D., Matthew D. McEvoy, M.D.

                                                      Cardiac M.D.
Sally A. Fortner, M.D., Angela Douglas, M.D., Elizabeth Baker,Anesthesia

Wendy K. Bernstein, M.D., Bianca M. Conti, M.D.     Cardiac Anesthesia

                                                                      Page 299

                                                  Cardiac M.D., Toshiaki Minami, M.D., Ph.D.
Toshiyuki Sawai, M.D., Masayuki Oka, M.D., Junko Nakahira, Anesthesia

                                                       Cardiac Anesthesia
Nathan A. Dahle, M.D., Keith E. Littlewood, M.D., Tiffany F. Harris, M.D.

                                                     Cardiac Anesthesia
James Bell III, M.D., Ph.D., Daniel Baram, M.D., Thomas Bilfinger, M.D., Igor Izrailtyan, M.D.

                                                                         Page 300

Sekar S. Bhavani, M.D., M.S., F.R.C.S., Karri Saraswati, M.D. Anesthesia

Julie L. Huffmyer, M.D., Keith E. Littlewood, M.D.   Cardiac Anesthesia

Mayank Gupta, M.D., Mahoua Ray, M.D., Simin Saatee, M.D. Anesthesia

                                                                      Page 301

Govind R. Rajan, M.B.B.S., John Hagen, M.D.         Cardiac Anesthesia

                                                    Cardiac M.D., Pete
Govind R. Rajan, M.B.B.S., Heidi Orsega, D.O., Baragur Ravi,Anesthesia Towns.

                                                     Cardiac Anesthesia
Ming Tsang, M.D., Igor Izrailtyan, M.D., Slawomor Oleszak, M.D., Daryn Moller, M.D., Thomas Bilfinger, M.D.

                                                                      Page 302

                                                     Cardiac Anesthesia
Angus A. Christie, M.D., Louis Russo, M.D., Paul F. Lennon, M.D., Chase W. Boyd, M.D.

                                                  Cardiac Anesthesia
Srikiran Ramarapu, M.D., Gustin Bateman, M.D., Lauren Sparks, M.S. 4, Andrea Dillard, M.S. 4, Paul Long, M.S. 4.

                                               Cardiac Anesthesia
F.C. Kumar MD, Bret Pate, MD, Guston Bateman MD, Julie Warden MD, Jamie Koch MD

                                                                      Page 303

William Travis Lau, M.D., Michael England, M.D.      Cardiac Anesthesia

Carlos Mateo Mijares, M.D., Ediberto Cecilio, M.D.   Cardiac Anesthesia

                                                   Cardiac Anesthesia
Mariam M. El-Baghdadi, M.D., Tetsuro Sakai, M.D., Ph.D.

                                                                     Page 304

                                                     Cardiac Wright, M.D.
J.L. Reeves-Viets, M.D., M.B.A., John Porter, M.D., Crystal C. Anesthesia

                                                    Raessler, M.D., John
Angus A. Christie, M.D., Jeremy O. Comin, D.O., Ken Cardiac Anesthesia Braxton, M.D.

Ellen P. Convery, M.D., Andrej Alfirevic, M.D.      Cardiac Anesthesia

                                                                      Page 305

                                                    Cardiac Anesthesia
Sherif S. Zaky, M.D., Ph.D., Theodore Marks, M.D., Ph.D.

Robina Matyal, M.D.                                Cardiac Anesthesia

                                                   Cardiac Lucas, M.D.,
Stephen D. Markewich, M.D., Robert W. Kyle, D.O., Warner J.Anesthesia D.D.S.

                                                                    Page 306

Ivan Kangrga, M.D., Ph.D.                            Cardiac Anesthesia

                                                      Cardiac Anesthesia
Cathy Ifune, M.D., Ph.D., Charles B. Hantler, M.D., Ivan Kangrga, M.D., Ph.D.

                                                      Cardiac Anesthesia
Benjaminn H. Sickler, M.S. IV, Brian E. Harrington, M.D.

                                                                       Page 307

Alain Ruiz Zaita, M.D., Hugh B. Martin, M.D.    Cardiac Anesthesia

Dirk Younker, M.D.                              Cardiac Anesthesia

                                                Cardiac Anesthesia
W. Sherman Turnage, M.D., Derek M. Muehrcke, M.D.

                                                                 Page 308

Tawfik Ayoub, M.D.                          Cardiac Anesthesia

Jawad U. Hasnain, M.D., M.B.A.              Cardiac Anesthesia

Robina Matyal, M.D., Feroze Mahmood, M.D.   Cardiac Anesthesia

                                                            Page 309

                                                 Cardiac Anesthesia
Theresa Cumpstone, M.D., Yong G. Peng, M.D., Ph.D.

Jeffrey A. Green, M.D.                            Cardiac Anesthesia

                                                   M.D., Hong Wang,
Robert Raad, M.D., Walid Osta, M.D., Eric Pezhman, Cardiac AnesthesiaM.D., Ph.D.

                                                                    Page 310

                                               Cardiac M.D., F.R.C.A, Samantaray Aloka, M.B.B.S., M.D.
Hanumanth Rao Mangu, M.B.B.S., M.D., Raghuvender Ganta,Anesthesia

Negmeldeen F. Mamoun, M.D., Pitas Grzegorz, M.D. Cardiac Anesthesia

                                                  Cardiac Anesthesia
Ashanpreet S. Grewal, M.D., Ramon Cao, M.D., Ileana Gheorghiu, M.D., Obi Udekwu, M.D., Mary J. Njoku, M.D.

                                                                   Page 311

                                                   Cardiac Pablo Motta,
Gracie M. Almeida-Chen, M.D., M.P.H., Julie Niezgoda, M.D., Anesthesia M.D.

Anita K. Patel, M.D., Alexander Mittnacht, M.D.    Cardiac Anesthesia

                                                   Cardiac Anesthesia
Jayeshkumar M. Patel, M.D., Kenneth Tsai, M.D., Lisa Vu, M.D., Susan Payrovi, M.D.

                                                                     Page 312

                                                  Cardiac Anesthesia
Jacob C. Carman, D.O., Charles P. Cassady, M.D., Teodora O. Nicolescu, M.D.

                                                     Cardiac Anesthesia
Pooya Pouralifazel, M.D., Jonathan Katz, M.D., Jennifer Vaughn, M.D.

                                                  Cardiac Anesthesia
Damon P. Dozier, M.D., Sanja Raucher, M.D., Anna Lerant, M.D., Giorgio Aru, M.D.

                                                      Cardiac Anesthesia
Ricardo Martinez-Ruiz, M.D., Daniel Castillo, M.D., Christina Matadial, M.D.

                                                                        Page 313

                                                      Cardiac Anesthesia
Stavroula I. Nikolaidis, M.D., Zachariah Pederson, D.O.

Robina Matyal, M.D., Feroze Mahmood, M.D.           Cardiac Anesthesia

Erik Cooper, M.D., Cynthia M. Wells, M.D.           Cardiac Anesthesia

                                                                      Page 314

                                                    Cardiac Anesthesia
Jessica Hathaway, M.D., Angus Christie, M.D., Paul Lennon, M.D., W. Chase Boyd, M.D., Reed Quinn, M.D.

                                                    Cardiac Anesthesia
Jessica Hathaway, M.D., Angus Christie, M.D., Louis Russo, M.D.

Govind R. Rajan, M.B.B.S.                          Cardiac Anesthesia

                                                                    Page 315

Alexander Shorshtein, M.D., Avtar Gill, M.D.       Cardiac Anesthesia

                                                   Cardiac Anesthesia
Meenal Kulkarni, M.D., Daniel Nahrwold, M.D., Bernhard Riedel, M.D., Ph.D.

Laura K. Diaz, M.D., Aruna T. Nathan, M.B.B.S.     Cardiac Anesthesia

                                                                     Page 316

                                                  Raghuvender Ganta,
Srikiran Ramarapu, M.D., Usha Ramakrishnan, M.D., Cardiac Anesthesia M.D., Adam Cotton, M.D., Eric Neller, M.D.

Megan M. Quinn, M.D., Charles E. Smith, M.D.       Cardiac Anesthesia

                                                      M.D., Daniel Swistel,
Cortessa Russell, M.D., Diane Anca, M.D., Zak Hillel, Cardiac Anesthesia M.D., John Wasnick, M.D.

                                                                    Page 317

Alison C. Rudy, M.D., Jayanta Mukherji, M.D.       Cardiac Anesthesia

Ankeet Udani, Glenn Brady, M.D.                    Cardiac Anesthesia

                                                   Critical Care M.B.C.hB., F.C.A.R.C.S.I.
Anand T. Shirgaonkar, M.B.B.S., M.D., F.R.C.A, Andrew P. Gratrix,Medicine

                                                                     Page 318

                                                      Critical Care Medicine
Arielle Ochoa Fenig, M.D., Joel S. Delfiner, M.D., Raymond V. Wedderburn, M.D., F.A.C.S.

Osamu Miyoshi, M.D., Hiroyuki Matsuyama, M.D.      Critical Care Medicine

Andrew Franklin, M.D., Steve Hyman, M.D.           Critical Care Medicine

                                                                     Page 319

                                                Critical Care Medicine
Ramesh Ramaiah, M.B.B.S., FCARCSI, F.R.C.A, Lollo Loretto, M.D., Sanjay M. Bhananker, M.D., F.R.C.A.

                                                   Critical Care Medicine
Michael Shulman, M.D., Rao Sarojini, M.D., Kalpana Tyagaraj, M.D.

                                                   Critical Care M.D., Robert Helfand, M.D.
Sergio Bustamante, M.D., Ivan Parra-Sanchez, M.D., Marius Gota, Medicine

                                                                     Page 320

Shanaka R. Peiris, M.D., Jean-Pierre Yared, M.D.     Critical Care Medicine

                                                       Critical Care Medicine
Rajnish K. Jain, M.D., Rajiv Modi, M.D., Saifullah Tipu, M.D., Shubha Singhai, Rajkumari Sahu.

                                                    Critical Care Medicine
Sarah L. Richard, M.D., Michael A. Maddaus, M.D., Ioanna Apostolidou, M.D.

                                                                       Page 321

                                                    Critical Care Medicine
Moein Tavakkolizadeh, M.D., Natalie Gravell, M.B.B.S., Alireza T. Zavareh, M.D., Behnam Shayegi, M.D., M.R.C.S.

                                                     W. Lew, M.D., Walter
Eugene L. Bak, M.D., Andres Falabella, M.D., MichaelCritical Care Medicine L. Chang, M.D.

                                                  Critical Care M.D.
Stephanie Rasmussen, M.D., Nahel N. Saied, M.D., Govind Rajan,Medicine

                                                                     Page 322

Promil Kukreja, M.D., Ph.D., Sylvia Dolinski, M.D.   Critical Care Medicine

Ramsey N. Saad, M.D., Shiva Birdi, M.D.              Critical Care Medicine

                                                 Critical Care Medicine
Pedro Amorim, M.D., Joao SaPeixoto, M.D., Ana Castro, Catarina Celestino, M.D., Jos[eacute] Martins, M.D.

                                                                       Page 323

                                                     Critical Care Medicine
Maria R. Fuertes, M.D., Claudine Pritchard, M.D., Jada Reese, M.D.

                                                 Lopes, Care Ruben Azocar, M.D.
Oleg Gusakov, M.D., Kamiseau Premmer, M.D., Joel Critical M.D., Medicine

Shana Walton, M.D., Arna Banerjee, M.D.              Critical Care Medicine

                                                                       Page 324

Govind R. Rajan, Heidi Orsega, Stephanie Rasmussen, M.D. Care Medicine

Boris Veksler, M.D., Kalpana C. Tyagaraj, M.D.     Critical Care Medicine

                                                   Critical Care Medicine
Robert D. Todd, M.D., Kevin Sexton, M.D., Lisa Weavind, M.D.

                                                                     Page 325

Justin Sandall, D.O.                              Critical Care Medicine

Pichaya Waitayawinyu, M.D.                        Critical Care Medicine

Oluyemisi M. Odugbesan, M.D., Jill Faraci, M.D.   Critical Care Medicine

                                                                    Page 326

Mitsuru Nakatsuka, M.D., William S. Leighton, D.O.   Critical Care Medicine

                                                    Critical Care Medicine
Vidya K. Rao, M.D., Paul Matharoo, M.D., Ibtesam Hilmi, M.D.

                                                 Critical Care Medicine
Gennadiy Voronov, M.D., Hyang W. Paek, M.D., Ihuoma C. Ofoma, M.D., Alexandra Lelchuk, Dimitry Voronov.

                                                                       Page 327

Ahmed F. Attaallah, M.D., Matthew Ellison, M.D.      Critical Care Medicine

Marc A. Hayes, M.D., Smithson Kenneth, D.O., Ph.D. Critical Care Medicine

                                                     Critical Care Medicine
Arie Blitz, George Williams, M.D., Shoichi Okada, B.S., Heather McFarland, M.D., Jeff Foster, C.C.P.

                                                                       Page 328

Raed Rahman, M.D., Carlo D. Franco, M.D.            Critical Care Medicine

Andrea Orfanakis, M.D., Liza Weavind, M.D.          Critical Care Medicine

                                                    Critical Care Medicine
Piyush M. Gupta, M.D., Nina Chaya, M.D., Martin Miller, M.D., James Smit, M.D.

                                                                      Page 329

Daniel Rubin, M.D., Zdravka Zafirova, M.D.        Critical Care Medicine

                                                  Critical Care Medicine
Srikantha L. Rao, M.B.B.S., MS, David Goodspeed, M.D., David Campbell, M.D.

Edward R. Bryan, M.D., D.M. Anderson, M.D.        Critical Care Medicine

                                                                    Page 330

                                                         Critical Care Medicine
Arie Blitz, M.D., Jeff Foster, C.C.P., Robert E. Botti, M.D.

                                                      M. Shupe, M.D., Kenneth G. Smithson, D.O., Ph.D.
Tracy L. Jobin, M.D., Mayshan Ghiassi, M.D., JenniferCritical Care Medicine

Neha Chaturvedi, M.D., Marco Maurtua, M.D.             Critical Care Medicine

                                                                           Page 331

Jennifer K. Hansen, M.D., Gloria Walters, M.D.        Critical Care Medicine

Sandra B. Machado, M.D., Ehab Farag, M.D.             Critical Care Medicine

                                                     Critical Care Medicine
Biswajit Ghosh, M.D., Ravi Naik, M.D., Kishore Tulani, M.D., Amit Punia, M.D., Julia Griffin, M.D.

                                                                         Page 332

                                                  Critical Care Medicine
Dhamodaran Palaniappan, M.D., Edgar J. Pierre, M.D.

Daniel A. Nahrwold, M.D., Liza Weavind, M.D.        Critical Care Medicine

                                                    Obstetric Anesthesia
Erik A. Cooper, D.O., Bupesh Kaul, M.D., Manuel C. Vallejo, D.M.D., M.D., Debra Sines, N.P.

                                                                      Page 333

                                                   Obstetric Anesthesia
Richard M. Kruba, M.D., Vikas Shah, M.D., Stefan Smietana, D.O., Celeste Williams, M.D.

Abha A. Shah, M.D., Grace Shih, M.D.               Obstetric Anesthesia

Terrance A. Yemen, M.D., Kathryn M. Goins, M.D.    Obstetric Anesthesia

                                                                     Page 334

                                                    Cates, M.D.
Jacob Cyrus Carman, D.O., Tilak Raj, M.D., Kathryne Obstetric Anesthesia

                                                  Obstetric Anesthesia
Fernando L. Almenas, M.D., Nina Zachariah, M.D., Ruben J. Azocar, M.D.

Rashid Khalil, M.D., Danny Wilkerson, M.D.         Obstetric Anesthesia

                                                                     Page 335

Chandrashekar J. Kalmat, M.D., Amy Evers, M.D.        Obstetric Anesthesia

Cyril N. Philip, M.D., Ramsis F. Ghaly, M.D., F.A.C.S.,Obstetric Anesthesia

                                                     Obstetric Anesthesia
Nalini Vadivelu, M.D., Mani Vindhya, M.D., Jim Kim, M.D., Ferne Braveman, M.D.

                                                                        Page 336

                                                     Obstetric Anesthesia
Ravpreet Gill, M.D., Alexander Shorshtein, M.D., Kalpana C. Tyagaraj.

                                                 Obstetric Anesthesia
Shobana Bharadwaj, M.B.B.S., Andrew M. Malinow, M.D.

                                                Daniel A. Biggs, M.D.,
James C. Layton, Abhinava S. Madamangalam, M.D.,Obstetric Anesthesia Timothy Tye, M.D.

                                                                      Page 337

Jeremy Wells, M.D., Thomas McLarney, M.D., Paul Sloan, M.D. Anesthesia

Vikram Kumar, M.D., Suneeta Gollapudy, M.D.          Ambulatory Anesthesia

                                                     Daniel K. O'Neill, M.D.
Christopher E. DeNatale, M.D., Andre S. Motie, M.D., Ambulatory Anesthesia

                                                                       Page 338

Patricia L. Dalby, M.D., Angela Wooditch, M.D.   Ambulatory Anesthesia

Tameka M. Broussard, M.D., Ashu Wali M.D.,
F.F.A.R.C.S.I, Jaime Ortiz M.D.
                                                 Ambulatory Anesthesia

Niraja Rajan, M.D.                               Ambulatory Anesthesia

                                                                 Page 339

                                                    Ambulatory Anesthesia
Erica Stein, M.D., Todd Permut, M.D., Gita Rupani, M.D.

Bradley D. Reber, M.D., Corey Scher, M.D.         Ambulatory Anesthesia

                                                 Ambulatory M.D., Gwendolyn L. Boyd, M.D.
Myra Aultman, C.R.N.A., Hayden Hughes, M.D., Robert E. Morris,Anesthesia

                                                                    Page 340

Eric J. Neller, M.D., James R. Dyer, M.D.        Ambulatory Anesthesia

                                                 Ambulatory Anesthesia
Satinder Gombar, M.D., Gagandeep Goyal, M.D., Ashish K. Khanna, M.D., Shami R. Jagtap, M.D.

Scott D. Lipson, M.D., Adam Levine, M.D.         Ambulatory Anesthesia

                                                                   Page 341

Jeffrey P. Stanley, M.S. IV, Mary M. Joseph, M.D.   Ambulatory Anesthesia

                                                    Flanagan, Anesthesia
Richard D. Urman, M.D., Lauren Gavin, M.D., Hugh L.Ambulatory M.D.

                                                   Thomas G. Higley, M.D.
Stephen K. Patteson, M.D., Amber G. Hampton, M.D.,Ambulatory Anesthesia

                                                                    Page 342

                                                      Don Hoa, Anesthesia
Howard D. Palte, M.D., Steven I. Gayer, M.D., M.B.A.,AmbulatoryM.D.

                                                  Ambulatory Anesthesia
Gagandeep Goyal, M.D., Michael S. Green, D.O., Mary J. Im, M.D., Mian Ahmad, M.D.

Harry Singh, M.D., David S. Baker, M.D.           Ambulatory Anesthesia

                                                                    Page 343

                                                   Obstetric Anesthesia
Hesham A. Elsharkawy, M.D., Syed Ali, M.D., Sabri Barsoum, M.D.

Jing Song, M.D., Sujatha Ramachandran, M.D.        Ambulatory Anesthesia

Dawood Sayed, M.D., Dominic Peraud, M.D., Hiroshi Goto, M.D. Anesthesia

                                                                    Page 344

                                                      Smith, M.D., Anne Morgan, M.D.
Tilak D. Raj, M.D., Jacob Carman, D.O., Jacqueline J.Ambulatory Anesthesia

Mary Njoku, M.D., Maudy Kalangie, D.O.             Ambulatory Anesthesia

Ryan G. Michaud, M.D., Brook Baker, M.D.           Ambulatory Anesthesia

                                                                     Page 345

Usman Saleem, M.D.                                 Ambulatory Anesthesia

                                                  Ambulatory Anesthesia
Shivani Chadha, M.D., Marc A. Feldman, M.D., M.H.S.

                                                     Ambulatory Anesthesia
Jeffrey P. Stanley, M.S. IV, Edward Hsu, M.D., Mary M. Joseph, M.D.

                                                    Ambulatory Anesthesia
Carol Craig, C.R.N.A., Charles Reed, C.R.N.A., John Parker, M.D., Myra Aultman, C.R.N.A., Gwendolyn L. Boyd, M.D.

                                                                     Page 346

Jin Cai, M.D., Ph.D., Sheila J. Ellis, M.D.   Ambulatory Anesthesia

Swapneel K. Shah, M.D., Albert Woo, M.D.      Ambulatory Anesthesia

Mayank Gupta, M.D., Mahoua Ray, M.D.          Ambulatory Anesthesia

                                                              Page 347

                                                 Ambulatory Anesthesia
Taruna Penmetcha, M.D., Mark Panarese, B.S.N., M.S.N., C.R.N.A.

                                                     Ambulatory Anesthesia
George W. Williams, II, M.D., Girish D. Mulgaokar, M.D.

Raed Rahman, M.D., Ljuba Stojiljkovic, M.D., Ph.D. Ambulatory Anesthesia

                                                                     Page 348

Carolyn J. Farrell, M.D.                          Ambulatory Anesthesia

                                                    Ambulatory Anesthesia
Erica Stein, M.D., Gita Rupani, M.D., Todd Permut, M.D.

Gregory L. Rose, M.D.                             Ambulatory Anesthesia

                                                                    Page 349

                                                 Ambulatory Anesthesia
Gwendolyn L. Boyd, M.D., Hayden R. Hughes, M.D., Myra Aultman, C.R.N.A., Michael A. Callahan, M.D.

Christopher Patrick Henson, D.O., Bernhard Riedel, M.D., Ph.D. Anesthesia

Erin W. Pukenas, M.D., Michael E. Goldberg, M.D.   Obstetric Anesthesia

                                                                    Page 350

Ann M. Carey, M.D.                                  Obstetric Anesthesia

                                                   Obstetric Anesthesia
Smokey Clay, M.D., Christine Bezouska, M.D., Richard Driver, M.D.

                                                     Carabuena, M.D.
Amarjeet Singh, M.B.B.S., D.A., F.R.C.A., Jean Marie Obstetric Anesthesia

                                                                      Page 351

                                                  Nasr, M.D., Zerin P.
Hyangwon Paek, M.D., Doris Ore Sosa, M.D., Ned F. Obstetric AnesthesiaDadabhoy, M.D.

Jose L. Castro, M.D., Liane M. Germond, M.D.     Obstetric Anesthesia

Henry Chou, M.D., Virgil Manica, M.D.            Obstetric Anesthesia

                                                                  Page 352

Srijaya K. Reddy, M.D., Vikas Shah, M.D.           Obstetric Anesthesia

Laurence E. Ring, M.D., Pamela Flood, M.D.         Obstetric Anesthesia

Harry Singh, M.D., David R. Mareth, M.D., Ryan P. Casey, M.D.Anesthesia

                                                                    Page 353

                                                  Obstetric Anesthesia
Jacob C. Carman, D.O., Badie S. Mansour, M.D., Morgan McCaleb, M.D.

Kalpana C. Tyagaraj, M.D., Ashraf Miekhaeil, M.D.   Obstetric Anesthesia

                                                     Obstetric Anesthesia
Christine Bezouska, M.D., Matthew Ellison, M.D., Phillip Legg, D.O., Jason Shepherd, D.O.

                                                                      Page 354

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