Juraj Sprung - Academia.edu (original) (raw)

Papers by Juraj Sprung

American Journal of Physiology-Heart and Circulatory Physiology, 1994

Mild hypothermia enhances cardiac contractility, and volatile anesthetics depress contractility. ... more Mild hypothermia enhances cardiac contractility, and volatile anesthetics depress contractility. Contractile force (tension) and Ca2+ transients were measured in canine Purkinje fibers at 35 and 25 degrees C with and without halothane and isoflurane to examine how anesthetics attenuate the positive inotropic effect of mild hypothermia. Isometric tension and light emitted from the photoprotein aequorin were used to assess contractility and intracellular Ca2+ transients in fibers stimulated at 40–60 pulses/min. At 35 degrees C, each anesthetic depressed peak tension and peak Ca2+ transients and decreased contractile force duration but, for halothane, increased Ca2+ transient duration. Decreases in tension by both anesthetics at 35 degrees C were converted to marked increases in tension at 25 degrees C, whereas Ca2+ transients were little changed. Removal of anesthetics at 25 degrees C greatly increased tension with a small increase in Ca2+ transients that was much lower than that at 3...

Canadian journal of anaesthesia = Journal canadien d'anesthésie, 1990

Pediatric Anesthesia, 2010

Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder associated with p... more Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder associated with potentially fatal episodes of hyperammonemia. Children with OTCD often require anesthesia. There is insufficient information regarding perioperative complications and optimal management of anesthesia in these patients. To retrospectively review the medical records of children with OTCD to ascertain the nature and frequency of peri-procedural complications. The electronic medical records of Mayo Clinic patients with OTCD who underwent anesthesia between the dates of January 2003 and September 2009 were reviewed. Nine patients with OTCD underwent 25 anesthetics using a variety of anesthetic techniques, including four major surgeries. Eleven procedures were performed prior to OTCD diagnosis and those patients were not receiving therapy for a urea cycle disorder. In the other cases, patients were on a variety of therapies for OTCD. Fourteen patients were outpatient procedures. Clinical signs of postoperative metabolic decompensation did not occur. In this series, patients with OTCD tolerated anesthesia well. Choice of perioperative management of OTCD and the choice of anesthetic technique should be individualized and based on clinical circumstances, but should have the underlying aim of minimizing protein catabolism. It appears patients with stable OTCD may undergo minor procedures as outpatients safely.

Mayo Clinic Proceedings, 2013

Objective: To test the hypothesis that exposure to procedures requiring general anesthesia during... more Objective: To test the hypothesis that exposure to procedures requiring general anesthesia during adulthood is not significantly associated with incident dementia using a retrospective, population-based, nested, case-control study design. Participants and Methods: Using the Rochester Epidemiology Project and the Mayo Clinic Alzheimer's Disease Patient Registry, residents of Olmsted County, Minnesota, diagnosed as having dementia between January 1, 1985, and December 31, 1994, were identified. For each incident case, a sex-and age-matched control was randomly selected from the general pool of Olmsted County residents who were dementia free in the index year of dementia diagnosis. Medical records were reviewed to determine exposures to procedures requiring anesthesia after age 45 years and before the index year. Data were analyzed using logistic regression. Results: We analyzed 877 cases of dementia, each with a corresponding control. Of the dementia cases, 615 (70%) underwent 1681 procedures requiring general anesthesia; of the controls, 636 (73%) underwent 1638 procedures. When assessed as a dichotomous variable, anesthetic exposure was not significantly associated with dementia (odds ratio, 0.89; 95% CI, 0.73-1.10; P¼.27). In addition, no significant association was found when exposure was quantified as number of procedures (odds ratios, 0.87, 0.86, and 1.0 for 1, 2-3, and !4 exposures, respectively, compared with none; P¼.51). Conclusion: This study found no significant association between exposure to procedures requiring general anesthesia after age 45 years and incident dementia.

Journal of Clinical Anesthesia, 2005

A patient with unrecognized atypical pseudocholinesterase was given succinylcholine and then vecu... more A patient with unrecognized atypical pseudocholinesterase was given succinylcholine and then vecuronium before neuromuscular monitoring was instituted. Subsequently, when neostigmine and glycopyrrolate were given to reverse what was thought to be a nondepolarizing block, the patient became further relaxed, and his trachea could not be extubated for more than 10 hours. In this report, we discuss drug interactions, phase II block, and the importance of timely neuromuscular monitoring.

Journal of Cardiothoracic and Vascular Anesthesia, 2014

Objectives: LEOPARD syndrome is a rare congenital disease that can manifest with cardiac anomalie... more Objectives: LEOPARD syndrome is a rare congenital disease that can manifest with cardiac anomalies, multiple lentigines, ocular hypertelorism, growth retardation, and deafness. The purpose of this case series was to review the most prominent comorbidities associated with LEOPARD syndrome, and describe perioperative outcomes in a series of patients undergoing anesthesia. Design: Retrospective case series review Setting: Tertiary care institution Participants: Patients diagnosed with LEOPARD syndrome who underwent surgical procedures requiring anesthesia at this institution. Intervention: The medical and anesthesia records of patients with LEOPARD syndrome were reviewed. Demographic information, clinical features of LEOPARD syndrome, comorbidities, intraoperative and postoperative events and complications were recorded. A systematic literature review also was conducted. Measurements and Main Results: Nine patients with LEOPARD syndrome underwent 49 procedures under general anesthesia (n ¼ 40) or monitored anesthesia care (n ¼ 9). The majority of operations were related to correction of cardiac anomalies (n ¼ 20). The most common cardiac malformations were ventricular septal hypertrophy and pulmonary (or subpulmonary) stenosis, and major perioperative complications were related to severe arrhythmias and/or cardiac decompensation. Conclusions: Dominant pathology associated with perioperative complications in patients with LEOPARD syndrome is related to cardiac disease. A large proportion of patients with this condition have ventricular septal hypertrophy, which tends to progress with age; therefore, these patients undergoing anesthesia should have recent cardiologist evaluation.

Journal of Anesthesia, 2013

Purpose-Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disease characterized ... more Purpose-Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disease characterized by capillary malformation leading to multisite cutaneomucosal telangiectasias and multiorgan arteriovenous malformations, which can present challenges to anesthetic care. The primary aim of this report is to present a large cohort of patients with hereditary hemorrhagic telangiectasia undergoing general anesthesia at our institution in regard to comorbid conditions and complications of surgical and anesthetic management. Methods-A computerized search from January 1, 2002 through December 31, 2011 of the Mayo Clinic medical records database was performed for patients with hereditary hemorrhagic telangiectasia who underwent general anesthesia. Medical records were reviewed. Eligibility criteria included patients with definite or suspected hereditary hemorrhagic telangiectasia based on the Curacao diagnostic criteria who underwent general anesthesia during the study period. Results-We identified 74 patients with hereditary hemorrhagic telangiectasia who underwent 163 surgeries. The majority had pulmonary arteriovenous malformations (56.7 %) and iron deficiency anemia (64.7 %), and high levels of disease burden with a median American Society of Anesthesiologist Physical Status score of 3. Most surgeries were related to treating conditions associated with hereditary hemorrhagic telangiectasia, with the majority being procedures to the nasal mucosa for recurrent epistaxis (47.2 %). A sizeable proportion of procedures to the nasal mucosa required transfusion of blood (12/77). One case of epistaxis required 11 units of blood until it was successfully controlled. Another notable complication included migration of a coil to pulmonary arteriovenous malformations into the cerebral circulation. Conclusion-Surgical patients with hereditary hemorrhagic telangiectasia often present with multiorgan involvement. The anesthesia provider needs to be aware of the high prevalence of

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose To review the anesthetic management and perioperative outcomes of patients diagnosed with... more Purpose To review the anesthetic management and perioperative outcomes of patients diagnosed with Brugada syndrome (BrS) who were treated at a single centre and to compare those results with a comprehensive review of the existing literature. Clinical features A retrospective chart review of anesthesia records from patients diagnosed with BrS at the Mayo Clinic was undertaken with the emphasis on administered drugs, ST segment changes, and occurrence of complications, including death, hemodynamic instability, and dysrhythmias. Eight patients were identified who underwent a total of 17 operative procedures from 2000 through 2010. A total of 20 significant ST segment elevations were recorded in four patients, several of which occurred in close temporal relation to anesthetic drug administration. These elevations resolved uneventfully. There were no recorded dysrhythmias, and recovery from anesthesia proceeded uneventfully. A literature review of patients with BrS yielded 52 anesthetics in 43 patients. The only recorded complications included unmasking of a Brugada ECG pattern, one episode of polymorphic ventricular tachycardia, which converted spontaneously to

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2010

Background Myotonic dystrophy type 2 (DM2) is a genetically distinct disorder that shares some ph... more Background Myotonic dystrophy type 2 (DM2) is a genetically distinct disorder that shares some phenotypical features of myotonic dystrophy type 1 (DM1). However, anesthetic management of patients with DM2 has not been described. The purpose of this study is to report the anesthetic management of a series of patients with DM2 and to describe their response to anesthesia. Methods We performed a computerized search of the Mayo Clinic medical records database looking for patients with DM2 who underwent general anesthesia. The medical records were reviewed for anesthetic technique, medications used, and postoperative complications. Results We identified 19 patients with DM2 who underwent 39 general anesthetics, 17 monitored anesthetic care cases, and two regional anesthetics. The patients exhibited normal responses to succinylcholine, nondepolarizing neuromuscular blockers, neostigmine, induction agents, and volatile anesthetics. Serious postoperative complications related to DM2 did not occur. Conclusion In our series, patients with DM2 tolerated commonly used anesthetics without obvious complications,

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose Serial measurements of parathyroid hormone (PTH) serum concentrations aid parathyroidecto... more Purpose Serial measurements of parathyroid hormone (PTH) serum concentrations aid parathyroidectomy surgery. There are concerns that propofol may increase PTH concentrations and/or interfere with PTH assays. The primary purpose of this study is to determine the effects of propofol on PTH concentrations in patients with primary hyperparathyroidism and to determine its effect on PTH assays. Methods Thirty patients with primary hyperparathyroidism were assigned randomly to induction and maintenance with either propofol or sevoflurane. Blood samples for PTH assays were obtained pre-induction, immediately after induction, ten minutes after induction,

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELA... more Purpose Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELAS) is a rare inherited mitochondrial disorder associated with severe multiorgan pathology and stress-induced episodes of metabolic decompensation and lactic acidosis. The purpose of this case series is to review the medical records of patients with MELAS who underwent anesthetic care at the Mayo Clinic to observe their perioperative responses to anesthesia and to assess outcomes. Principal findings From September 1997 to October 2010, nine patients with MELAS were identified who underwent 20 general anesthetics, 12 prior to MELAS diagnosis. Debilitating neurologic symptoms involved eight patients, and three patients had substantial cardiac comorbidities. The patients tolerated commonly used anesthetics and muscle relaxants, including succinylcholine. Lactated Ringer's solution was used frequently. One patient was noted to have elevated postoperative serum lactate, but his serum lactate was chronically elevated. Metabolic acidosis was not observed in any patient. Hyponatremia and hyperkalemia, sometimes profound,

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2007

To determine 30-day mortality and predictors of mortality following perioperative pulmonary embol... more To determine 30-day mortality and predictors of mortality following perioperative pulmonary embolism (PE). Methods: We searched both the Mayo Clinic electronic medical records and Autopsy Registry, between January 1, 1998 and December 31, 2001, for patients who developed PE within 30 days after noncardiac surgery performed under general or neuraxial anesthesia. Medical records of all identified patients were reviewed using standardized data collection forms. The association between risk factors for PE and 30-day post-PE mortality was assessed using t tests, exact binomial tests, and logistic regression. Results: We identified 158 patients with probable or definite perioperative PE. The overall 30-day mortality from the day of PE was 25.3%, i.e., 40 patients died. Hypotension requiring treatment, need for mechanical ventilation, and intensive care unit admission were the prominent univariate predictors of 30-day mortality (all P ≤ 0.001). Other significant factors were exact bi normal tests, and higher ASA physical status (P = 0.002), longer surgical time (P = 0.030), recent central vein cannulation (P = 0.021) and intraoperative use of either blood transfusions or other blood products (P = 0.010). Using multivariable analysis, hemodynamic instability was found to be the dominant independent risk factor associated with mortality. Conclusions: Perioperative PE is associated with a high 30-day mortality. Patients who experience hemodynamic instability and require vasoactive treatment at presentation of PE have extremely low survival rates; therefore, for these patients the most aggressive therapeutic modalities should be considered.

BMC Research Notes, 2009

Background: The Croatian higher education system is in the process of reforming its medical curri... more Background: The Croatian higher education system is in the process of reforming its medical curricula to comply with European Union standards. We conducted a survey of students enrolled at the University of Zagreb (Croatia) asking them to rate their perception of preparedness for clinical practice prior to initiation of the reform process. The purpose of the survey was to identify self-perceived deficiencies in education and to establish a reference point for the later assessment of ongoing educational reform. Findings: One-hundred and forty seven (N = 147) graduates reported the levels of perceived preparedness on 30 items grouped into 8 educational domains. Main domains were: understanding science, practical skills/patient management, holistic care, prevention, interpersonal skills, confidence/coping skills, collaboration, and self-directed learning. For each item, graduates self assessed their preparedness on a scale ranging from 1 to 4, with 1 = "Very inadequate", 2 = "Somewhat inadequate", 3 = "Somewhat adequate", and 4 = "Very adequate". In 7 out of 8 domains the achieved median score was ≥ 3. Students expressed low confidence (defined when ≥ 25% of respondents supplied a rating for the survey question as: "very inadequate" or "somewhat inadequate") with interpersonal skills (discussing terminal disease, counseling distraught patients, balancing professional and personal life), and in performing certain basic semi-invasive or invasive procedures. Conclusion: Zagreb medical graduates identified several deficiencies within educational domains required for standard clinical practice. Ongoing educational efforts need to be directed towards the correction of these deficiencies in order to achieve standards required by the European Union.

Anesthesia & Analgesia, 2007

Primary amyloidosis is a result of proliferation of a population of plasma cells that leads to an... more Primary amyloidosis is a result of proliferation of a population of plasma cells that leads to an increased secretion of monoclonal immunoglobulins (amyloid). Amyloid protein infiltrates increase capillary fragility. Such capillaries can burst, even after minor stress, resulting in periorbital hemorrhage. We describe a 64-yr-old man with primary amyloidosis who underwent general anesthesia. His eyes were gently closed with tape. Upon removal of the tape bilateral periorbital purpura was noted. All coagulation studies were normal. The periorbital hemorrhage was attributed to amyloidosis-induced capillary fragility.

Anesthesia & Analgesia, 1997

Anesthesia & Analgesia, 2001

latelet receptor glycoprotein (GP) IIb/IIIa antagonists (abciximab, eptifibatide) are antithrombo... more latelet receptor glycoprotein (GP) IIb/IIIa antagonists (abciximab, eptifibatide) are antithrombotic agents that provide comprehensive blockade of receptors necessary for the final common pathway of platelet aggregation. Perioperative bleeding, a concern whenever platelet function is inhibited, has been described in surgical patients after treatment with abciximab (1,2). To allow recovery of platelet function and to prevent bleeding, the infusion of abciximab should be discontinued 12-24 h before surgery (3). For eptifibatide, with an elimination half-life of 2.5 h, this interval is even shorter. We report a patient who preoperatively received several antiplatelet drugs (aspirin, clopidogrel, abciximab, and eptifibatide) and consequently experienced massive perioperative bleeding although surgery was performed at a time when, according to pharmacodynamic and pharmacokinetic properties of individual drugs, the antiplatelet action should have been terminated. This case illustrates a need to preoperatively assess resolution of platelet function after exposure to these antiplatelet drugs. In addition, this case indicated that Sonoclot ® (SNC; Sienco, Wheat Ridge, CO) might detect platelet dysfunction in the presence of an apparently normal Thrombelastograph ® (TEG ® ; Haemoscope, Skokie, IL) tracing. This led us to conduct the in vitro study to examine the sensitivity of these two methods for detecting platelet dysfunction in the presence of the GP IIb/IIIa inhibitor, eptifibatide, which was the last antiplatelet drug our patient received before surgery.

Anesthesia & Analgesia, 2008

American Journal of Physiology-Heart and Circulatory Physiology, 1994

Mild hypothermia enhances cardiac contractility, and volatile anesthetics depress contractility. ... more Mild hypothermia enhances cardiac contractility, and volatile anesthetics depress contractility. Contractile force (tension) and Ca2+ transients were measured in canine Purkinje fibers at 35 and 25 degrees C with and without halothane and isoflurane to examine how anesthetics attenuate the positive inotropic effect of mild hypothermia. Isometric tension and light emitted from the photoprotein aequorin were used to assess contractility and intracellular Ca2+ transients in fibers stimulated at 40–60 pulses/min. At 35 degrees C, each anesthetic depressed peak tension and peak Ca2+ transients and decreased contractile force duration but, for halothane, increased Ca2+ transient duration. Decreases in tension by both anesthetics at 35 degrees C were converted to marked increases in tension at 25 degrees C, whereas Ca2+ transients were little changed. Removal of anesthetics at 25 degrees C greatly increased tension with a small increase in Ca2+ transients that was much lower than that at 3...

Canadian journal of anaesthesia = Journal canadien d'anesthésie, 1990

Pediatric Anesthesia, 2010

Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder associated with p... more Ornithine transcarbamylase deficiency (OTCD) is an X-linked urea cycle disorder associated with potentially fatal episodes of hyperammonemia. Children with OTCD often require anesthesia. There is insufficient information regarding perioperative complications and optimal management of anesthesia in these patients. To retrospectively review the medical records of children with OTCD to ascertain the nature and frequency of peri-procedural complications. The electronic medical records of Mayo Clinic patients with OTCD who underwent anesthesia between the dates of January 2003 and September 2009 were reviewed. Nine patients with OTCD underwent 25 anesthetics using a variety of anesthetic techniques, including four major surgeries. Eleven procedures were performed prior to OTCD diagnosis and those patients were not receiving therapy for a urea cycle disorder. In the other cases, patients were on a variety of therapies for OTCD. Fourteen patients were outpatient procedures. Clinical signs of postoperative metabolic decompensation did not occur. In this series, patients with OTCD tolerated anesthesia well. Choice of perioperative management of OTCD and the choice of anesthetic technique should be individualized and based on clinical circumstances, but should have the underlying aim of minimizing protein catabolism. It appears patients with stable OTCD may undergo minor procedures as outpatients safely.

Mayo Clinic Proceedings, 2013

Objective: To test the hypothesis that exposure to procedures requiring general anesthesia during... more Objective: To test the hypothesis that exposure to procedures requiring general anesthesia during adulthood is not significantly associated with incident dementia using a retrospective, population-based, nested, case-control study design. Participants and Methods: Using the Rochester Epidemiology Project and the Mayo Clinic Alzheimer's Disease Patient Registry, residents of Olmsted County, Minnesota, diagnosed as having dementia between January 1, 1985, and December 31, 1994, were identified. For each incident case, a sex-and age-matched control was randomly selected from the general pool of Olmsted County residents who were dementia free in the index year of dementia diagnosis. Medical records were reviewed to determine exposures to procedures requiring anesthesia after age 45 years and before the index year. Data were analyzed using logistic regression. Results: We analyzed 877 cases of dementia, each with a corresponding control. Of the dementia cases, 615 (70%) underwent 1681 procedures requiring general anesthesia; of the controls, 636 (73%) underwent 1638 procedures. When assessed as a dichotomous variable, anesthetic exposure was not significantly associated with dementia (odds ratio, 0.89; 95% CI, 0.73-1.10; P¼.27). In addition, no significant association was found when exposure was quantified as number of procedures (odds ratios, 0.87, 0.86, and 1.0 for 1, 2-3, and !4 exposures, respectively, compared with none; P¼.51). Conclusion: This study found no significant association between exposure to procedures requiring general anesthesia after age 45 years and incident dementia.

Journal of Clinical Anesthesia, 2005

A patient with unrecognized atypical pseudocholinesterase was given succinylcholine and then vecu... more A patient with unrecognized atypical pseudocholinesterase was given succinylcholine and then vecuronium before neuromuscular monitoring was instituted. Subsequently, when neostigmine and glycopyrrolate were given to reverse what was thought to be a nondepolarizing block, the patient became further relaxed, and his trachea could not be extubated for more than 10 hours. In this report, we discuss drug interactions, phase II block, and the importance of timely neuromuscular monitoring.

Journal of Cardiothoracic and Vascular Anesthesia, 2014

Objectives: LEOPARD syndrome is a rare congenital disease that can manifest with cardiac anomalie... more Objectives: LEOPARD syndrome is a rare congenital disease that can manifest with cardiac anomalies, multiple lentigines, ocular hypertelorism, growth retardation, and deafness. The purpose of this case series was to review the most prominent comorbidities associated with LEOPARD syndrome, and describe perioperative outcomes in a series of patients undergoing anesthesia. Design: Retrospective case series review Setting: Tertiary care institution Participants: Patients diagnosed with LEOPARD syndrome who underwent surgical procedures requiring anesthesia at this institution. Intervention: The medical and anesthesia records of patients with LEOPARD syndrome were reviewed. Demographic information, clinical features of LEOPARD syndrome, comorbidities, intraoperative and postoperative events and complications were recorded. A systematic literature review also was conducted. Measurements and Main Results: Nine patients with LEOPARD syndrome underwent 49 procedures under general anesthesia (n ¼ 40) or monitored anesthesia care (n ¼ 9). The majority of operations were related to correction of cardiac anomalies (n ¼ 20). The most common cardiac malformations were ventricular septal hypertrophy and pulmonary (or subpulmonary) stenosis, and major perioperative complications were related to severe arrhythmias and/or cardiac decompensation. Conclusions: Dominant pathology associated with perioperative complications in patients with LEOPARD syndrome is related to cardiac disease. A large proportion of patients with this condition have ventricular septal hypertrophy, which tends to progress with age; therefore, these patients undergoing anesthesia should have recent cardiologist evaluation.

Journal of Anesthesia, 2013

Purpose-Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disease characterized ... more Purpose-Hereditary hemorrhagic telangiectasia is a rare autosomal dominant disease characterized by capillary malformation leading to multisite cutaneomucosal telangiectasias and multiorgan arteriovenous malformations, which can present challenges to anesthetic care. The primary aim of this report is to present a large cohort of patients with hereditary hemorrhagic telangiectasia undergoing general anesthesia at our institution in regard to comorbid conditions and complications of surgical and anesthetic management. Methods-A computerized search from January 1, 2002 through December 31, 2011 of the Mayo Clinic medical records database was performed for patients with hereditary hemorrhagic telangiectasia who underwent general anesthesia. Medical records were reviewed. Eligibility criteria included patients with definite or suspected hereditary hemorrhagic telangiectasia based on the Curacao diagnostic criteria who underwent general anesthesia during the study period. Results-We identified 74 patients with hereditary hemorrhagic telangiectasia who underwent 163 surgeries. The majority had pulmonary arteriovenous malformations (56.7 %) and iron deficiency anemia (64.7 %), and high levels of disease burden with a median American Society of Anesthesiologist Physical Status score of 3. Most surgeries were related to treating conditions associated with hereditary hemorrhagic telangiectasia, with the majority being procedures to the nasal mucosa for recurrent epistaxis (47.2 %). A sizeable proportion of procedures to the nasal mucosa required transfusion of blood (12/77). One case of epistaxis required 11 units of blood until it was successfully controlled. Another notable complication included migration of a coil to pulmonary arteriovenous malformations into the cerebral circulation. Conclusion-Surgical patients with hereditary hemorrhagic telangiectasia often present with multiorgan involvement. The anesthesia provider needs to be aware of the high prevalence of

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose To review the anesthetic management and perioperative outcomes of patients diagnosed with... more Purpose To review the anesthetic management and perioperative outcomes of patients diagnosed with Brugada syndrome (BrS) who were treated at a single centre and to compare those results with a comprehensive review of the existing literature. Clinical features A retrospective chart review of anesthesia records from patients diagnosed with BrS at the Mayo Clinic was undertaken with the emphasis on administered drugs, ST segment changes, and occurrence of complications, including death, hemodynamic instability, and dysrhythmias. Eight patients were identified who underwent a total of 17 operative procedures from 2000 through 2010. A total of 20 significant ST segment elevations were recorded in four patients, several of which occurred in close temporal relation to anesthetic drug administration. These elevations resolved uneventfully. There were no recorded dysrhythmias, and recovery from anesthesia proceeded uneventfully. A literature review of patients with BrS yielded 52 anesthetics in 43 patients. The only recorded complications included unmasking of a Brugada ECG pattern, one episode of polymorphic ventricular tachycardia, which converted spontaneously to

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2010

Background Myotonic dystrophy type 2 (DM2) is a genetically distinct disorder that shares some ph... more Background Myotonic dystrophy type 2 (DM2) is a genetically distinct disorder that shares some phenotypical features of myotonic dystrophy type 1 (DM1). However, anesthetic management of patients with DM2 has not been described. The purpose of this study is to report the anesthetic management of a series of patients with DM2 and to describe their response to anesthesia. Methods We performed a computerized search of the Mayo Clinic medical records database looking for patients with DM2 who underwent general anesthesia. The medical records were reviewed for anesthetic technique, medications used, and postoperative complications. Results We identified 19 patients with DM2 who underwent 39 general anesthetics, 17 monitored anesthetic care cases, and two regional anesthetics. The patients exhibited normal responses to succinylcholine, nondepolarizing neuromuscular blockers, neostigmine, induction agents, and volatile anesthetics. Serious postoperative complications related to DM2 did not occur. Conclusion In our series, patients with DM2 tolerated commonly used anesthetics without obvious complications,

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose Serial measurements of parathyroid hormone (PTH) serum concentrations aid parathyroidecto... more Purpose Serial measurements of parathyroid hormone (PTH) serum concentrations aid parathyroidectomy surgery. There are concerns that propofol may increase PTH concentrations and/or interfere with PTH assays. The primary purpose of this study is to determine the effects of propofol on PTH concentrations in patients with primary hyperparathyroidism and to determine its effect on PTH assays. Methods Thirty patients with primary hyperparathyroidism were assigned randomly to induction and maintenance with either propofol or sevoflurane. Blood samples for PTH assays were obtained pre-induction, immediately after induction, ten minutes after induction,

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Purpose Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELA... more Purpose Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELAS) is a rare inherited mitochondrial disorder associated with severe multiorgan pathology and stress-induced episodes of metabolic decompensation and lactic acidosis. The purpose of this case series is to review the medical records of patients with MELAS who underwent anesthetic care at the Mayo Clinic to observe their perioperative responses to anesthesia and to assess outcomes. Principal findings From September 1997 to October 2010, nine patients with MELAS were identified who underwent 20 general anesthetics, 12 prior to MELAS diagnosis. Debilitating neurologic symptoms involved eight patients, and three patients had substantial cardiac comorbidities. The patients tolerated commonly used anesthetics and muscle relaxants, including succinylcholine. Lactated Ringer's solution was used frequently. One patient was noted to have elevated postoperative serum lactate, but his serum lactate was chronically elevated. Metabolic acidosis was not observed in any patient. Hyponatremia and hyperkalemia, sometimes profound,

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2011

Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2007

To determine 30-day mortality and predictors of mortality following perioperative pulmonary embol... more To determine 30-day mortality and predictors of mortality following perioperative pulmonary embolism (PE). Methods: We searched both the Mayo Clinic electronic medical records and Autopsy Registry, between January 1, 1998 and December 31, 2001, for patients who developed PE within 30 days after noncardiac surgery performed under general or neuraxial anesthesia. Medical records of all identified patients were reviewed using standardized data collection forms. The association between risk factors for PE and 30-day post-PE mortality was assessed using t tests, exact binomial tests, and logistic regression. Results: We identified 158 patients with probable or definite perioperative PE. The overall 30-day mortality from the day of PE was 25.3%, i.e., 40 patients died. Hypotension requiring treatment, need for mechanical ventilation, and intensive care unit admission were the prominent univariate predictors of 30-day mortality (all P ≤ 0.001). Other significant factors were exact bi normal tests, and higher ASA physical status (P = 0.002), longer surgical time (P = 0.030), recent central vein cannulation (P = 0.021) and intraoperative use of either blood transfusions or other blood products (P = 0.010). Using multivariable analysis, hemodynamic instability was found to be the dominant independent risk factor associated with mortality. Conclusions: Perioperative PE is associated with a high 30-day mortality. Patients who experience hemodynamic instability and require vasoactive treatment at presentation of PE have extremely low survival rates; therefore, for these patients the most aggressive therapeutic modalities should be considered.

BMC Research Notes, 2009

Background: The Croatian higher education system is in the process of reforming its medical curri... more Background: The Croatian higher education system is in the process of reforming its medical curricula to comply with European Union standards. We conducted a survey of students enrolled at the University of Zagreb (Croatia) asking them to rate their perception of preparedness for clinical practice prior to initiation of the reform process. The purpose of the survey was to identify self-perceived deficiencies in education and to establish a reference point for the later assessment of ongoing educational reform. Findings: One-hundred and forty seven (N = 147) graduates reported the levels of perceived preparedness on 30 items grouped into 8 educational domains. Main domains were: understanding science, practical skills/patient management, holistic care, prevention, interpersonal skills, confidence/coping skills, collaboration, and self-directed learning. For each item, graduates self assessed their preparedness on a scale ranging from 1 to 4, with 1 = "Very inadequate", 2 = "Somewhat inadequate", 3 = "Somewhat adequate", and 4 = "Very adequate". In 7 out of 8 domains the achieved median score was ≥ 3. Students expressed low confidence (defined when ≥ 25% of respondents supplied a rating for the survey question as: "very inadequate" or "somewhat inadequate") with interpersonal skills (discussing terminal disease, counseling distraught patients, balancing professional and personal life), and in performing certain basic semi-invasive or invasive procedures. Conclusion: Zagreb medical graduates identified several deficiencies within educational domains required for standard clinical practice. Ongoing educational efforts need to be directed towards the correction of these deficiencies in order to achieve standards required by the European Union.

Anesthesia & Analgesia, 2007

Primary amyloidosis is a result of proliferation of a population of plasma cells that leads to an... more Primary amyloidosis is a result of proliferation of a population of plasma cells that leads to an increased secretion of monoclonal immunoglobulins (amyloid). Amyloid protein infiltrates increase capillary fragility. Such capillaries can burst, even after minor stress, resulting in periorbital hemorrhage. We describe a 64-yr-old man with primary amyloidosis who underwent general anesthesia. His eyes were gently closed with tape. Upon removal of the tape bilateral periorbital purpura was noted. All coagulation studies were normal. The periorbital hemorrhage was attributed to amyloidosis-induced capillary fragility.

Anesthesia & Analgesia, 1997

Anesthesia & Analgesia, 2001

latelet receptor glycoprotein (GP) IIb/IIIa antagonists (abciximab, eptifibatide) are antithrombo... more latelet receptor glycoprotein (GP) IIb/IIIa antagonists (abciximab, eptifibatide) are antithrombotic agents that provide comprehensive blockade of receptors necessary for the final common pathway of platelet aggregation. Perioperative bleeding, a concern whenever platelet function is inhibited, has been described in surgical patients after treatment with abciximab (1,2). To allow recovery of platelet function and to prevent bleeding, the infusion of abciximab should be discontinued 12-24 h before surgery (3). For eptifibatide, with an elimination half-life of 2.5 h, this interval is even shorter. We report a patient who preoperatively received several antiplatelet drugs (aspirin, clopidogrel, abciximab, and eptifibatide) and consequently experienced massive perioperative bleeding although surgery was performed at a time when, according to pharmacodynamic and pharmacokinetic properties of individual drugs, the antiplatelet action should have been terminated. This case illustrates a need to preoperatively assess resolution of platelet function after exposure to these antiplatelet drugs. In addition, this case indicated that Sonoclot ® (SNC; Sienco, Wheat Ridge, CO) might detect platelet dysfunction in the presence of an apparently normal Thrombelastograph ® (TEG ® ; Haemoscope, Skokie, IL) tracing. This led us to conduct the in vitro study to examine the sensitivity of these two methods for detecting platelet dysfunction in the presence of the GP IIb/IIIa inhibitor, eptifibatide, which was the last antiplatelet drug our patient received before surgery.

Anesthesia & Analgesia, 2008