Roya Yumul - Academia.edu (original) (raw)

Papers by Roya Yumul

Journal of Clinical Anesthesia, Jun 1, 2016

Study objective: To compare three different video laryngoscope devices (VL) to standard direct la... more Study objective: To compare three different video laryngoscope devices (VL) to standard direct laryngoscopy (DL) for tracheal intubation of obese patients undergoing bariatric surgery. Hypothesis: VL (vs DL) would reduce the time required to achieve successful tracheal intubation and improve the glottic view. Design: Prospective, randomized and controlled. Setting: Preoperative/operating rooms and postanesthesia care unit. Patients: One hundred twenty-one obese patients (ASA physical status I-III), aged 18 to 80 years, body mass index (BMI) N 30 kg/m 2 undergoing elective bariatric surgery.

Research Square (Research Square), Aug 8, 2022

We present an EKG monitoring strategy to detect pneumothorax during high-risk surgery. In the lit... more We present an EKG monitoring strategy to detect pneumothorax during high-risk surgery. In the literature, EKG changes and pneumothorax are well described. However, anesthesiologists only monitor lead II on a three-lead EKG system in the operating room. In our case, there was only a subtle change in lead II for a left-sided pneumothorax, which could have been easily missed. On the other hand, there was a marked QRS amplitude reduction and T wave attening/inversion in lead I and V5. We recommend lead V5 be added to the continuous monitoring and lead I be periodically checked for surgeries known to potentially cause pneumothorax. Case Description 57-year-old male with a history of thoracic aortic aneurysm and non-ST elevation myocardial infarction (NSTEMI) three months prior, underwent da Vinci robotic partial nephrectomy for a left renal mass. Preoperative laboratories including complete blood count, basic metabolic panel and coagulation were normal. EKG showed normal sinus rhythm, incomplete right bundle branch block, Left anterior fascicular block and left axis deviation at negative 44 degrees. Angiogram following the last episode of NSTEMI

Medical research archives, Jul 21, 2015

The Visual Facial Anxiety Scale is a simple tool which could be used for assessing preoperative a... more The Visual Facial Anxiety Scale is a simple tool which could be used for assessing preoperative anxiety in the preoperative holding area. Anesthesiologists do not routinely evaluate patients" anxiety levels preoperatively.

Rhabdomyolysis is not an uncommon occurrence; it has been observed from antiquity. The etiology o... more Rhabdomyolysis is not an uncommon occurrence; it has been observed from antiquity. The etiology of this long-standing condition is diverse. We report two classic cases that were managed successfully.

Annals of Noninvasive Electrocardiology, Nov 22, 2022

Journal of Neurosurgical Anesthesiology, Oct 1, 2014

PubMed, Nov 1, 2016

Background: It has been previously reported that subhypnotic doses of propofol could offer an adv... more Background: It has been previously reported that subhypnotic doses of propofol could offer an advantage over midazolam for premedication. This study was designed to test the hypothesis that a 20 mg IV dose of propofol would be more effective than a standard 2 mg IV dose of midazolam for reducing acute anxiety prior to induction of anesthesia. Methods: One hundred twenty outpatients scheduled to undergo orthopedic surgery were randomly assigned to one of three study groups: control (saline); propofol (20 mg); or midazolam (2 mg). Immediately before administering the study medication, each patient evaluated their level of acute anxiety and sedation on 11‑point verbal rating scales (VRSs) 0=none- 10=highest, and they were also shown a picture. Upon arrival in the OR ~5 min after administering the study medication, anxiety and sedation levels were reassessed and a second picture was shown. At discharge from the recovery area, anxiety and sedation levels and their ability to recall the two pictures were reassessed. Results: Compared to the saline group, both propofol and midazolam produced significant increases in the patient's level of sedation upon entering the OR (+2.5±2.4 vs. +4.6±2.5 and +5.2±2.3, respectively [p<0.001]). Propofol was effective as midazolam compared to saline in reducing the patient's level of preinduction anxiety (from 3.2±2.2 to1.8±1.8 vs. 3.1±2.2 to 2.3±2.1 and 2.7±1.8 to 2.8±2.1, respectively). Propofol produced more pain on injection and midazolam significantly reduced recall of the second picture. Conclusions: When administered ~5 min prior to entering the OR, propofol, 20mg IV, was as effective as midazolam 2mg IV in reducing anxiety.

Circulation, Nov 14, 2017

Introduction: Increases in partial pressure of arterial CO2 (PaCO2) has been known to modulate my... more Introduction: Increases in partial pressure of arterial CO2 (PaCO2) has been known to modulate myocardial blood flow (MBF). However, challenges in blood gas control and limited availability of vali...

Jacc-cardiovascular Imaging, Nov 1, 2014

F1000Research, Aug 13, 2020

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain comm... more Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

The Journal of Nuclear Medicine, Mar 2, 2017

Myocardial blood flow (MBF) is the critical determinant of cardiac function. However, its respons... more Myocardial blood flow (MBF) is the critical determinant of cardiac function. However, its response to increases in partial pressure of arterial CO 2 (PaCO 2), particularly with respect to adenosine, is not well characterized because of challenges in blood gas control and limited availability of validated approaches to ascertain MBF in vivo. Methods: By prospectively and independently controlling PaCO 2 and combining it with 13 N-ammonia PET measurements, we investigated whether a physiologically tolerable hypercapnic stimulus (;25 mm Hg increase in PaCO 2) can increase MBF to that observed with adenosine in 3 groups of canines: without coronary stenosis, subjected to non-flow-limiting coronary stenosis, and after preadministration of caffeine. The extent of effect on MBF due to hypercapnia was compared with adenosine. Results: In the absence of stenosis, mean MBF under hypercapnia was 2.1 6 0.9 mL/min/g and adenosine was 2.2 6 1.1 mL/min/g; these were significantly higher than at rest (0.9 6 0.5 mL/min/g, P , 0.05) and were not different from each other (P 5 0.30). Under left-anterior descending coronary stenosis, MBF increased in response to hypercapnia and adenosine (P , 0.05, all territories), but the effect was significantly lower than in the left-anterior descending coronary territory (with hypercapnia and adenosine; both P , 0.05). Mean perfusion defect volumes measured with adenosine and hypercapnia were significantly correlated (R 5 0.85) and were not different (P 5 0.12). After preadministration of caffeine, a known inhibitor of adenosine, resting MBF decreased; and hypercapnia increased MBF but not adenosine (P , 0.05). Conclusion: Arterial blood CO 2 tension when increased by 25 mm Hg can induce MBF to the same level as a standard dose of adenosine. Prospectively targeted arterial CO 2 has the capability to evolve as an alternative to current pharmacologic vasodilators used for cardiac stress testing.

BJA: British Journal of Anaesthesia, Jul 1, 2014

† Immune suppression by perioperative opioids has been implicated in cancer recurrence after surg... more † Immune suppression by perioperative opioids has been implicated in cancer recurrence after surgical resection. † A single-centre retrospective analysis was conducted on patients undergoing video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer. † Patients with cancer recurrence at 5 yr after resection received greater total opioid dose in the first 96 h postoperative period. † This association requires confirmation in a large prospective study. Background. Evidence suggests that opioid-sparing anaesthetic techniques might be associated with increased cancer-free postoperative survival. This could be related to suppression of natural killer cells by opioid analgesics in the perioperative period. This retrospective analysis tested the hypothesis that greater opioid use in the postoperative period is associated with a higher incidence of recurrences after surgery for lung cancer. Methods. The medical records of 99 consecutive patients who underwent video-assisted thoracoscopic surgery with lobectomy for Stage I or IIa biopsy-proven non-small-cell lung cancer (NSCLC) were reviewed. Perioperative information including patient characteristics, laboratory data, and surgical, anaesthetic, nursing, and pharmacy reports were collected. Doses of opioids administered intra-operatively and for the first 96 h after operation were converted into equianalgesic doses of oral morphine using a standard conversion table. Data were then compared with the National Cancer Registry's incidence of disease-free survival for 5 yr. Results. A total of 99 patients with similar characteristics were included in the final analysis, 73 of whom were NSCLC recurrence-free at 5 yr and 26 had NSCLC recurrence within 5 yr. Total opioid dose during the 96 h postoperative period was 124 (101) mg of morphine equivalents in the cancer-free group and 232 mg (355) mg in the recurrence group (P¼0.02). Conclusions. This retrospective analysis suggests an association between increased doses of opioids during the initial 96 h postoperative period with a higher recurrence rate of NSCLC within 5 yr.

Southern Medical Journal, Nov 1, 1999

Survey of Anesthesiology, Feb 1, 2012

Radiology, Aug 1, 2014

To examine whether controlled and tolerable levels of hypercapnia may be an alternative to adenos... more To examine whether controlled and tolerable levels of hypercapnia may be an alternative to adenosine, a routinely used coronary vasodilator, in healthy human subjects and animals. Materials and Methods: Human studies were approved by the institutional review board and were HIPAA compliant. Eighteen subjects had end-tidal partial pressure of carbon dioxide (PetCO 2) increased by 10 mm Hg, and myocardial perfusion was monitored with myocardial blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging. Animal studies were approved by the institutional animal care and use committee. Anesthetized canines with (n = 7) and without (n = 7) induced stenosis of the left anterior descending artery (LAD) underwent vasodilator challenges with hypercapnia and adenosine. LAD coronary blood flow velocity and free-breathing myocardial BOLD MR responses were measured at each intervention. Appropriate statistical tests were performed to evaluate measured quantitative changes in all parameters of interest in response to changes in partial pressure of carbon dioxide. Results: Changes in myocardial BOLD MR signal were equivalent to reported changes with adenosine (11.2% 6 10.6 [hypercapnia, 10 mm Hg] vs 12% 6 12.3 [adenosine]; P = .75). In intact canines, there was a sigmoidal relationship between BOLD MR response and PetCO 2 with most of the response occurring over a 10 mm Hg span. BOLD MR (17% 6 14 [hypercapnia] vs 14% 6 24 [adenosine]; P = .80) and coronary blood flow velocity (21% 6 16 [hypercapnia] vs 26% 6 27 [adenosine]; P. .99) responses were similar to that of adenosine infusion. BOLD MR signal changes in canines with LAD stenosis during hypercapnia and adenosine infusion were not different (1% 6 4 [hypercapnia] vs 6% 6 4 [adenosine]; P = .12). Conclusion: Free-breathing T2-prepared myocardial BOLD MR imaging showed that hypercapnia of 10 mm Hg may provide a cardiac hyperemic stimulus similar to adenosine.

Anesthesia & Analgesia, Dec 1, 2009

Postgraduate Medicine, Sep 30, 2021

ABSTRACT Background: This review article discusses the pharmacodynamic effects of the most common... more ABSTRACT Background: This review article discusses the pharmacodynamic effects of the most commonly used chronic medications by patients undergoing elective surgical procedures, namely cardiovascular drugs (e.g., beta blockers, alpha-2 agonist, calcium channel blockers, ACE inhibitors, diuretics, etc.), lipid-lowering drugs, gastrointestinal medications (H2-blockers, proton pump inhibitors), pulmonary medications (inhaled β-agonists, anticholinergics,), antibiotics (tetracyclines, clindamycin and macrolide, linezolid.), opioids and non-opioids analgesics (NSAIDs, COX-2 inhibitors, acetaminophen), gabapentanoids, erectile dysfunction (ED) drugs, psychotropic drugs (tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAOI], selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], and cannabinol-containing drugs). In addition, the potential adverse drug-interactions between these chronic medications and commonly used anesthetic drugs during the perioperative period will be reviewed. Finally, recommendations regarding the management of chronic medications during the preoperative period will be provided. Materials and Methods: An online search was conducted from January 2000 through February 2021 with the Medline database through PubMed and Google Scholar using the following search terms/keywords: “chronic medications in the perioperative period”, and “chronic medications and anesthetic implications.” In addition, we searched for anesthetic side effects associated with the major drug groups. Results and Conclusions: An understanding of the pharmacodynamic effects of most used chronic medications is important to avoid untoward outcomes in the perioperative period. These drug interactions may result in altered efficacy and toxicity of the anesthetic medications administered during surgery. These drug-drug interactions can also affect the morbidity, mortality, recovery time of surgical patients and acute relapse of chronic illnesses which could lead to last minute cancellation of surgical procedures. Part II of this two-part review article focuses on the reported interactions between most commonly taken chronic medications by surgical patients and anesthetic and analgesic drugs, as well as recommendations regarding the handling these chronic medications during the perioperative period.

Acta Anaesthesiologica Scandinavica, Oct 20, 2014

Background: Despite its widespread use, the beneficial effect of low-dose fentanyl administered a... more Background: Despite its widespread use, the beneficial effect of low-dose fentanyl administered at induction of anesthesia on perioperative outcomes has not been studied in the ambulatory setting. Therefore, this study was designed to test the hypothesis that administration of small-dose fentanyl vs. saline during induction reduces coughing and movements without adversely affecting recovery after day-surgery. Methods: One hundred consenting outpatients scheduled to undergo superficial surgical procedures under general anesthesia with a laryngeal mask airway (LMA) device for airway management were randomly assigned to one of two treatment groups: control (n = 50) or fentanyl (n = 50). After administration of 2 ml of the unlabelled study medication containing either fentanyl (100 μg) or saline, anesthesia was induced with lidocaine 30-50 mg and propofol 2 mg/kg IV followed by the insertion of an LMA device. General anesthesia was maintained using a propofol infusion, 75 μg/kg/min, and desflurane (2-5% end-tidal) in 100% oxygen. Results: Coughing was observed in six (12%) and ten (20%) in the fentanyl and control group, respectively (P = 0.41). The incidence of movements during surgery was lower in the fentanyl group (18% vs. 31%, P < 0001). There were no significant differences in early and late recovery times or pain scores between the two groups. Conclusion: Administration of a small-dose of fentanyl at induction of anesthesia significantly reduced purposeful movements during day-surgery under propofol-desflurane anesthesia. No significant difference was found in coughing or recovery times.

PLOS ONE, Feb 14, 2017

Background There is currently no widely accepted instrument for measuring preoperative anxiety. T... more Background There is currently no widely accepted instrument for measuring preoperative anxiety. The objective of this study was to develop a simple visual facial anxiety scale (VFAS) for assessing acute preoperative anxiety. Methods The initial VFAS was comprised of 11 similarly styled stick-figure reflecting different types of facial expressions (Fig 1). After obtaining IRB approval, a total of 265 participant-healthcare providers (e.g., anesthesiologists, anesthesiology residents, and perioperative nurses) were recruited to participate in this study. The participants were asked to: (1) rank the 11 faces from 0-10 (0 = no anxiety, while 10 = highest anxiety) and then to (2) match one of the 11 facial expression with a numeric verbal rating scale (NVRS) (0 = no anxiety and 10 = highest level of anxiety) and a specific categorical level of anxiety, namely no anxiety, mild, mild-moderate, moderate, moderate-high or highest anxiety. Based on these data, the Spearman correlation and frequencies of the 11 faces in relation to the 11-point numerical anxiety scale and 6 categorical anxiety levels were calculated. The highest frequency of a face assigned to a level of the numerical anxiety scale resulted in a finalized order of faces corresponding to the 11-point numeric rating scale. Results The highest frequency for each of the NVRS anxiety scores were as follow: A0, A1, A2, A3, A4, A5, A7, A6, A8, A9 and A10 (Fig 2). For the six categorical anxiety levels, a total of 260 (98.1%) participants chose the face A0 as representing 'no' anxiety, 250 (94.3%) participants chose the face A10 as representing 'highest' anxiety and 147 (55.5%) participants chose the face A8 as representing 'moderate-high' anxiety. Spearman analysis showed a significant correlation between the faces A3 and A5 assigned to the mild-moderate anxiety category (r = 0.58), but A5 was ultimately chosen due to its higher frequency compared to PLOS ONE |

Current Opinion in Anesthesiology, Dec 1, 2016

Purpose of review The aim of this review is to provide an overview of the drugs and techniques us... more Purpose of review The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting. Recent findings Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in 5 min with a duration of action up to 4 h.