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Peter Szmuk

Publications and source records attributed to Peter Szmuk.

At least 19 recordsLinked to original sources
PubMed2007

The accuracy of electrocardiogram-controlled central line placement.

BACKGROUND: Electrocardiogram (ECG) guidance to confirm accurate positioning of central venous catheters (CVC), placed before surgery in the operating room, is rarely used in the United States. We designed this randomized, controlled trial to investigate whether the use of this technique impacts the accuracy of CVC placement. METHODS: Patients in group ECG (n = 147) had a CVC placed using right-atrial ECG to guide catheter tip positioning. CVCs in group NO-ECG (n = 143) were positioned without this technique. RESULTS: Overall, guidewire-ECG control resulted in more correctly positioned CVCs (96% vs 76%, P < or = 0.001) without increasing placement time. Significantly more CVCs were placed in the middle of the superior vena cava in group ECG (P < or = 0.001), although placement into the right atrium or right ventricle and into other vessels occurred significantly more often in group NO-ECG (P < or = 0.001). Twenty patients in group NO-ECG required repositioning of their CVC after surgery, whereas this maneuver was necessary only in three patients in group ECG (P < or = 0.001). CONCLUSIONS: ECG guidance allows for more accurate CVC placement, and should be considered to increase patient safety and reduce costs associated with repositioning procedures.

Adult↗
PubMed2006

Morbidly obese patients are hemodynamically stable during laparoscopic surgery: a thoracic bioimpedance study.

PURPOSE: Morbid obesity caries an increased risk of cardiovascular morbidity and might be associated with intraoperative hemodynamic instability. Based on clinical observation, we hypothesized that during laparoscopic surgery, morbidly obese patients behave hemodynamically similar to the nonobese patients and remain hemodynamically stable. METHODS: In a prospective trial, thirty nonobese and tthirty morbidly obese (BMI > or = 35 kg/m(2)) patients scheduled for elective laparoscopic surgery were assigned to receive standard balanced anesthesia. We aimed at equianesthetic levels by keeping the BIS (bispectral index) value between 40-50 throughout surgery. End-tidal isoflurane was measured every 5 min. Noninvasive hemodynamic measurements included cardiac index (CI), mean arterial pressure (MAP) and heart rate (HR), recorded every 5 min and at specific predetermined times. Systemic vascular resistance (SVR) was calculated. Episodes of MAP < or = 60 and MAP > or = 130 mmHg or HR < or = 50 and HR > or = 110 bpm occurring throughout surgery and requiring pharmacological intervention were considered main end-points. Additionally, hemodynamic variables were compared at specific time points and overall throughout surgery. Secondary end-points were CI and SVRI. RESULTS: Heart rate was higher in obese patients in head-up position (79 +/- 15 mmHg vs. 65 +/- 12 mmHg - P=0.011). SVR was higher in the nonobese group with head-up position (1978 +/- 665 dynes s cm(-5) vs. 1394 +/- 496 dynes s cm(-5) P=0.01). Mean overall intraoperative MAP, HR, CI and SVR were similar. There were no episodes of MAP < or = 60 and > or =130 mmHg or HR < or = 50 and > or =110 bpm in either of the groups. CONCLUSION: Our study confirmed our hypothesis that for the most periods of laparoscopic surgery, obese patients are hemodynamically as stable as their nonobese counterparts.

Adult↗
PubMed2006

Phosphate salt bowel preparation regimens alter perioperative acid-base and electrolyte balance.

BACKGROUND: Hyperphosphatemic acidosis and severe electrolyte disturbances caused by phosphate salts (PO) used for mechanical bowel preparation have been described in occasional case reports prior to bowel resection surgery. We hypothesized that PO used preoperatively for bowel preparation may cause more pronounced acid base and electrolyte changes than polyethylene glycol (PG). METHODS: Forty American Society of Anesthesiologists physical status II-III patients were randomly allocated to receive either PO or PG for bowel preparation before intra-abdominal surgery (bowel resection or other major elective intra-abdominal surgeries). Measurements of pH, base deficit, blood gases, lactate, hemoglobin, calcium, magnesium, potassium and phosphorus were undertaken before the laxative administration, intraoperatively, and postoperatively. RESULTS: Preoperative demographic, hemodynamic and laboratory data were similar in the two groups. Intraoperative calcium (8.4 [0.6] vs 9 [0.5] mg x dL(-1)) and pH (7.35 [0.04] vs 7.41 [0.03]) were lower, while lactate (1.3 [0.4] vs 0.9 [0.3] mmol x L(-1)) was higher with PO. Postoperative calcium, magnesium and potassium were lower (8 [0.5] vs 8.9 [0.2] mg x dL(-1), 1.68 [0.3] vs 1.8 [0.4] and 3.5 [0.36] vs 3.7 [0.33] mEq x L(-1) respectively) while phosphorus (4.1 [0.3] vs 3.3 [0.2] mEq x L(-1)) was higher with PO. A higher percentage of abnormal values for calcium, potassium, phosphorus and base deficit (66% vs 33%, 25% vs 10%, 19% vs 2% and 28.3% vs 5% respectively) were observed with PO. CONCLUSIONS: Calcium and magnesium changes were more pronounced in patients who received PO for bowel preparation.

Abdomen↗
PubMed2006

Use of the Rapiscope vs chest auscultation for detection of accidental bronchial intubation in non-obese patients undergoing laparoscopic cholecystectomy.

STUDY OBJECTIVE: Main stem bronchial intubation is not always detected by routine means and may occur more frequently during laparoscopic procedures. Tracheal tube positional changes in non-obese patients undergoing laparoscopic cholecystectomy were detected by either the Rapiscope (Cook Critical Care, Bloomington, Ind) or chest auscultation. DESIGN: Prospective, double-blind, crossover study. SETTING: University hospital. PATIENTS: Forty non-obese patients (BMI <28 kg.m(-2)), aged 18 to 80 years, American Society of Anesthesiologists risk class I-III, who underwent elective laparoscopic cholecystectomy were enrolled in this double-blind, prospective study. INTERVENTIONS: After endotracheal intubation by one anesthesiologist, two other anesthesiologists assessed the tracheal tube's positioning by either the Rapiscope or chest auscultation; the results of one anesthesiologist's measurement were concealed from the other. MEASUREMENTS: Assessments of the endotracheal tube tip's position were performed after intubation, head-down, and head-up positioning, after maximal abdominal insufflation and before extubation. At the same time points, Sp(O2), ET(CO2), and peak inspiratory pressures were also recorded. MAIN RESULTS: Postintubation Rapiscope assessment revealed normal tracheal positioning of the tube's tip in all patients. Changes in tube's position were subsequently detected by the Rapiscope in 16 patients. In 8 cases, the tip moved endobronchially. Half of the endobronchial intubations occurred after maximal abdominal insufflation and the other half after changing the table position from neutral to 30 degrees head-down. Chest auscultation detected bronchial intubation in two cases only (P = .01). There were 4 additional events of downward movements and 4 events of cephalad migration of the tube's tip identified by the Rapiscope only. ET(CO2), Sp(O2), and peak inspiratory pressures did not change in patients who did experience bronchial intubation. CONCLUSION: The Rapiscope detected significantly more events of endobronchial intubation as compared with chest auscultation; it could be considered useful during procedures where tracheal tube movements are potential.

Adolescent↗
PubMed2006

Comparison of hemodynamic profiles in transurethral resection of prostate vs transurethral resection of urinary bladder tumors during spinal anesthesia: a bioimpedance study.

STUDY OBJECTIVE: Transurethral resection of prostate (TURP) is more frequently associated with perioperative fluid and electrolyte disturbances than transurethral resection of bladder tumors (TURT) because of irrigating fluid absorption. Because fluid overload may cause hypertension, we compared the patients' intraoperative hemodynamic profiles (including the incidence of hypertension) during TURP vs TURT, both performed during spinal anesthesia, by using the bioimpedance method. DESIGN: Prospective single-blind study. SETTING: University hospital. PATIENTS: 80 (40 in each group) men, ASA physical status I and II. INTERVENTIONS: Patients underwent TURP or TURT surgery with spinal anesthesia. MEASUREMENTS: Mean arterial pressure, heart rate, cardiac index, and systemic vascular resistance were compared between the 2 groups. A mean arterial pressure greater than 30% from the baseline value was considered as hypertension. Plasma sodium was measured preoperatively, intraoperatively, and postoperatively. MAIN RESULTS: Transurethral resection of prostate patients received more irrigating fluid (7900 +/- 2310 vs 5650 +/- 21560, P < 0.05) and had a higher calculated volume of fluid absorbed: 638 +/- 60 vs 303 +/- 40 mL for the TURT patients (P < 0.05). Mean arterial pressures were higher with TURP, 30 minutes after the onset of surgery and at the end of the procedure (111 +/- 15 vs 100 +/- 10 and 109 +/- 14 vs 99 +/- 14 mmHg, respectively; P < 0.05). However, there was no hypertension in either group. There were no differences in hemodynamic measurements of hyponatremic vs normonatremic patients. Plasma sodium decreased postoperatively more in the TURP group (140.4 +/- 2.6 mEq/L baseline to 134.1 +/- 3.5 mEq/L, P < 0.05) and was lower postoperatively in the TURP group compared with TURT (134.1 +/- 3.5 vs 137.2 +/- 2.9 mEq/L, P = 0.04). CONCLUSIONS: Although more irrigating fluid was absorbed in the TURP group, there were no episodes of hypertension in either group.

Aged↗
PubMed2006

The role of anesthesiologists in the selection and administration of perioperative antibiotics: a survey of the American Association of Clinical Directors.

The importance of timely administration of antibiotics for prophylaxis of surgical site infections has led to pressure on anesthesiologists to administer antibiotics. We present a survey of members of the American Association of Clinical Directors designed to evaluate the role of the anesthesiologist in the selection and administration of perioperative antibiotics. A 13-question survey was sent via e-mail to all 233 members of the American Association of Clinical Directors. Two requests for survey responses resulted in a response rate of 43%. Based on the responses received, anesthesiologists appear to be integrally involved with the administration, but not selection, of perioperative antibiotics, despite what respondents perceive as inadequate training in antibiotic therapy. Furthermore, perioperative antibiotic therapy in general appears to be poorly monitored, and responsibility for selection and administration of perioperative antibiotics appears to be poorly defined.

Anesthesiology↗
PubMed2005

Use of CobraPLA for airway management in a neonate with Desbuquois syndrome. Case report and anesthetic implications.

We present the anesthetic management of an infant with Desbuquois syndrome (a rare form of micromelic dwarfism) with a possible difficult airway. The anesthetic implications of this syndrome are presented. The airway was managed with a new supraglottic device - the CobraPLA. Although intubation through this device was not possible in this instance, CobraPLA provided a satisfactory supraglottic airway. It was easy to insert and provided satisfactory conditions for positive pressure ventilation. The CobraPLA provides another option for airway management.

Abnormalities, Multiple↗
PubMed2004

Nasal versus oral fiberoptic intubation via a cuffed oropharyngeal airway (COPA) during spontaneous ventilation.

STUDY OBJECTIVE: To compare the success rate of nasal versus oral fiberoptic intubation in anesthetized patients breathing spontaneously via the cuffed oropharyngeal airway (COPAtrade mark). DESIGN: Prospective, randomized, controlled study. SETTING: Two university-affiliated hospitals. PATIENTS: Patients scheduled for general or plastic surgery of the torso or extremities. INTERVENTIONS: Nasal (n=20) and oral (n=20) fiberoptic intubation were performed in patients while breathing spontaneously via the COPA during standardized anesthesia. MEASUREMENTS: Demographic data, mean arterial pressure, heart rate, end-tidal carbon dioxide (ETCO2), oxygen saturation (SpO2), COPA size, difficult airway predictors, rate of failed ventilation via COPA, and frequency of hypoxemia (SpO2 < 90%) during the procedure, and perioperative untoward events were recorded. MAIN RESULTS: The background, airway difficulty, vital signs and untoward effects were similar in the two groups. Nasal fiberoptic laryngeal view (scale 1-4) was better than the oral grading (3 [median] vs. 2, respectively; p <0.05). Eighty percent of the nasal intubations were successful compared with 40% of the oral intubations (p <0.05). Nasal intubations were accomplished within 153 +/- 15 SD seconds compared with 236 +/- 22 seconds (p <0.05) for the oral intubations, and less propofol was needed in the nasal intubations during the procedures (240 +/- 27 mg [nasal] vs. 277+/- 39 mg [oral]; p <0.05). CONCLUSIONS: Nasal fiberoptic laryngoscopy is more successful and easy than the oral approach in anesthetized patients who are breathing spontaneously through the COPA.

Administration, Inhalation↗
PubMed2004

Recent trends in tracheal intubation: emphasis on the difficult airway.

PURPOSE OF REVIEW: Difficult airways can lead to critical incidents during anaesthesia, and death. Although many cases can be anticipated, some still go undiscovered before induction, thereby exposing the patient to unexpected risks and the anaesthesiologist to unexpected challenges. In addition to improving prediction of difficult airways, education for skill acquisition and management planning, and a quest for superior management techniques and airway tools are of the utmost importance in preventing airway catastrophes. RECENT FINDINGS: We review recent advances in predicting difficult airways in special population groups that are known to have a higher incidence of difficult airway. Education, exercising airway skills, management planning with both predicted and unpredicted difficult airways, and the need for adherence to algorithms for management of difficult airway are emphasized as key to successful management. Finally, recent developments in airway management techniques and new airway devices are summarized. SUMMARY: Improving reproducibility and reliability in predicting a difficult airway may limit the number of unpredicted difficult intubations. A safer approach to management of the difficult airway can be achieved by improving airway management skills and adhering to universally accepted and proven airway algorithms, including developing approaches to management of predicted and unpredicted difficult airways. Improving on existing airway techniques and tools (of which there are many), rather than creating new devices, is a desirable trend that may contribute to safer airway management in the future.

Journal Article↗
PubMed2003

Increased body mass index per se is not a predictor of difficult laryngoscopy.

PURPOSE: We investigated the association between morbid obesity and difficult laryngoscopy (DL). METHODS: In a prospective, controlled study we evaluated the impact of different variables on the prediction of DL in 200 morbidly obese (study group-SG), and 1272 non-obese (control group-CG) patients undergoing elective surgery. Variables assessed included age, sex, body mass index (BMI), protruding, loose, and missing upper teeth, thyro-mental distance, temporo-mandibular joint (TMJ) function, neck extension, and Mallampati class. A Cormack grade III or IV was considered DL. RESULTS: The SG patients were younger (P < 0.000), there were more females in the SG (P < 0.000) and more in the SG had teeth problems (P = 0.026). More patients in the SG (10% vs 1%), had obstructive sleep apnea (P < 0.001) with 90% of them in the SG having a grade III laryngoscopy. High BMI did not affect the laryngoscopy difficulty (P = 0.56). Multivariable regression analysis revealed that morbid obesity, increased age, male sex, pathology of TMJ, and higher Mallampati class, were independent predictors of DL. When interaction between the predictors and the group was added to the multivariable model, the SG was no longer a predictor by itself, rather its association with abnormal upper teeth turned to be significant for prediction of DL. CONCLUSIONS: Increased age, male sex, TMJ pathology, Mallampati 3 and 4, a history of obstructive sleep apnea and abnormal upper teeth were associated with a higher incidence of DL. The magnitude of BMI had no influence on difficulty with laryngoscopy.

Adult↗
PubMed2003

Difficult airway management practice patterns among anesthesiologists practicing in the United States: have we made any progress?

STUDY OBJECTIVE: To determine the extent instruction and practice in the use of airway devices and techniques varies among anesthesiologists practicing in the United States. DESIGN: Survey questionnaire. SETTING: University medical center. MEASUREMENTS: Questionnaires were completed by American-trained anesthesiologists who attended the 1999 American Society of Anesthesiologists (ASA) Annual Meeting. Data collected included demographics, education, skills with airway devices/techniques, management of clinical difficult airway scenarios, and the use of the ASA Difficult Airway Algorithm. MAIN RESULTS: 1) DEMOGRAPHICS: 452 questionnaires were correctly completed; 62% attending anesthesiologists, 70% <50 years, 81% males, 44% from academic institutions, 63% >10 years of practice, 81% night duty, 77% board certified. 2) Education: 71% had at least one educational modality: difficult airway rotation, workshops, conferences, books, and simulators. 3) Skills: Miller blade 61%, Bullard laryngoscope 32%, LMA 86%, Combitube 43%, bougie 43%, exchangers 47%, cuffed oropharyngeal airway (COPA) 34%, retrograde 41%, transtracheal needle jet ventilation 34%, cricothyrotomy 21%, fiberoptics 59%, and blind nasal intubation 78%. The average reported use of special airway devices/techniques was 47.5%. 4) Management choices: failed intubation/ventilation: LMA (81%) and for all other situations: fiberoptic intubation. Use of ASA Difficult Airway Algorithm in clinical practice (86%). CONCLUSION: Fiberoptic intubation and the LMA are most popular in management of the difficult airway.

Anesthesia, Conduction↗
PubMed2003

Anaesthesia for magnetoencephalography in children with intractable seizures.

BACKGROUND: Magnetoencephalography (MEG), a noninvasive technique for evaluation of epileptic patients, records magnetic fields during neuronal electrical activity within the brain. Anaesthesia experience for MEG has not yet been reported. METHODS: We retrospectively reviewed records of 48 paediatric patients undergoing MEG under anaesthesia. Thirty-one patients (nonprotocol group) were managed according to the anaesthesiologist's discretion. Premedication included oral midazolam, chloral hydrate or fentanyl oralet, intravenous midazolam or inhalational anaesthesia with sevoflurane. Anaesthesia was maintained with propofol, midazolam, fentanyl, alone or in combination. A subsequent protocol group (17 patients) received chloral hydrate as premedication and propofol for maintenance of anaesthesia. RESULTS: There was an overall 25% failure of interictal activity and localization on the MEG scan. In the nonprotocol group, 11 scans failed (35.5%). Of these, eight (72.7%) received midazolam orally. Only one failure (5.8%) was recorded in the protocol group in a patient who received chloral hydrate as sedation supplemented by sevoflurane. CONCLUSIONS: In our experience, midazolam premedication resulted in a high MEG failure rate (73%). Chloral hydrate premedication and propofol maintenance resulted in a lower incidence of MEG failure (5.8%). General anaesthesia with a continuous infusion of propofol or sevoflurane appears acceptable, although, lighter levels of anaesthesia might be required to avoid interference with interictal activity of the brain.

Anesthesia, General↗
PubMed2003

The endotracheal tube moves more often in obese patients undergoing laparoscopy compared with open abdominal surgery.

UNLABELLED: We compared the incidence of movements of the endotracheal tube (ETT) within the trachea in morbidly obese patients undergoing either laparoscopic or open gastroplasty. In a double-blinded, prospective, controlled study, 60 patients (body mass index, 35-60 kg/m(2)) were equally allocated to either laparoscopic LapBand gastroplasty (study group; Group 1) or open laparotomy gastroplasty (control; Group 2), both under standardized general anesthesia. Movements of the ETT were assessed with chest auscultation, peak inspiratory pressure, ETCO(2), SpO(2), and the Rapiscope at predetermined time points: after intubation (baseline values), 5 min before peritoneal inflation in Group 1 and 10 min postintubation in Group 2, at maximal abdominal inflation in Group 1 and 20 min into the procedure in Group 2, 5 min before and 5 min after changing the patient's position from neutral to 10 degrees head up and 10 degrees head down in Group 1 and 30 and 40 min into the procedure in Group 2, 2 min after abdominal deflation and table repositioning in Group 1 and at 50 min in Group 2, and just before extubation in both groups. Twenty-one events of ETT tip movement occurred in both groups. The tube moved in 15 (50%) study (laparoscopy) group patients compared with 6 (20%) controls (laparotomy; P < 0.05), 12 of the former having moved downward either after maximal abdominal insufflation or in association with head-down positioning. The tubes of five study group patients (17%) advanced into the right bronchus, compared with none in the controls (P < 0.05). All changes in position were rectified only by the Rapiscope. IMPLICATIONS: Abdominal insufflation and changes in table position lead to more frequent movements of the endotracheal tube in obese patients undergoing laparoscopic versus open gastroplasty. The Rapiscope identifies all these changes, but not the clinically available variables.

Abdomen↗
PubMed2003

The effects of hydration on core temperature in pediatric surgical patients.

BACKGROUND: Reduced vascular volume might influence body temperature by diverting heat flow from peripheral tissues to the central organs. We therefore tested the hypothesis that mild hypovolemia helps to prevent intraoperative hypothermia in pediatric patients. METHODS: Twenty-two pediatric patients (aged 1-3 yr) undergoing prolonged minor surgery were randomly assigned to conservative (n = 12) or aggressive (n = 10) perioperative fluid management. The conservative group fasted 8 h before surgery and received a crystalloid at 1 ml. kg-1. h-1 during surgery. The aggressive group was allowed to drink liquids until 3 h before surgery and was given a maintenance crystalloid at 8 ml. kg-1. h-1. Anesthesia was induced and maintained with halothane in nitrous oxide. Ambient temperature was kept near 25 degrees C, but the patients were not actively warmed. During recovery from anesthesia, additional fluid was given to the conservative group so that perioperative fluid totaled 9.5 ml. kg-1. h-1 in both groups. RESULTS: Intraoperative body weight remained unchanged in the aggressive group and decreased only 1% in patients managed conservatively. Heart rate was slightly greater in the conservative group (107 +/- 9 vs. 95 +/- 4 beats/min, P = 0.002), but blood pressure was similar. Esophageal temperature in patients whose fluid was managed conservatively increased significantly, by 0.4 +/- 0.3 degrees C, to 37.1 degrees C; in contrast, temperature in the aggressive group decreased significantly, by 0.4 +/- 0.2 degrees C, to 36.4 degrees C (P < 0.001 between groups). Temperatures remained significantly different 1 h after surgery. CONCLUSIONS: Conservative fluid management, which decreased body weight by only 1%, prevented reduction in core body temperature, presumably by reducing dissipation of metabolic heat from the core thermal compartment to peripheral tissues.

Anesthesia↗