Clicking this button will copy the previous history/ROS to your current pre-evaluation.  At this point you can review the information and update with any changes to history and exam.  This is a tremendous time saver for those quick repetitive procedures.

We are making progress.

Information continues to be added to the Wiki.  Thank you to all contributors!  Remember if you have information or an update on a topic please add it to the Wiki.  We have also created a folder in the Wiki folder for helpful pdfs from the hospital OneChart blog.  

As a side note, the term Wiki may confuse some and I apologize if you are not familiar.  A bit of clarification: 

wi·ki/ˈwikē/  Noun:  A Web site developed collaboratively by a community of users, allowing any user to add and edit content.

Although our file is not technically a website, the intent is the same.  It is a collection of our community’s knowledge.  Let’s keep it growing.

1. Look at the neuron in the room and its designation.  (In the ECT room it is NMC 2CPACU-isol17).
2. Choose Device and Add New in the Intra-op tab.  Choose GE solar 2Cpacu isol-17 and choose the data you wish to Validate and then add.

Also of note, besides removing the device from the pt at the end of the case you would want to discharge them from the GE solar monitor.  This will prevent the possibility of any previous data being pulled from an earlier pt into the current pt’s record. 

Thanks to Dr. Birch for this tip.

Pens: Ancient instruments used for placing marks on paper.

1 .Make a photocopy of the Anesthesia record and put it in the envelope with your narcs for Pharmacy.

2. Let the RT’s know (or give to them) the pink copy of the Anesthesia record and the green sheet for the hospital billing.

3. Send the yellow copy of the Anesthesia record to Melinda in the Anesthesia office in an intercampus envelope. She will send it to the billers.

The white/ original record will stay with the patient.

Thanks to Dr. Ellis for this tip.

1. Open a patient chart and click the orders button along the top
2. Scroll down and open the Order Set you want to edit by checking the box and then clicking the “Open order set” button (in red) – There may be some suggested order sets as shown below. If not, you can search for each of them in the search bar and then after you select each of them, right click and select “add to favorites”
3. After you open the Order set, there will be a black hyperlink that says “manage user order sets” click on this hyperlink
4. Click the “save defaults” hyperlink
5. Make your preferences!  You can change frequency of vitals, medication dosages, anything!

For more complete instructions with screen shots please check out the Epic Wikki file on the J-drive.  Thanks to everyone for contributing to the Wikki. 

Thanks to Kaitlyn Pellegrino for this tip.

1. Click Events.
2. Click L&D.
3. Click Skin Incision.

Special thanks to Dr. Miketic for pointing this tip out.

We all knew it was coming.   It is remarkable how two small words – Go Live – can inspire such anxiety.  Before you start rethinking the use of aersolized midazolam in pre-op, remember there are many resources available to help work through the glitches.  

All superusers may be identified by their red hats.  These red hats provide guidance to all of perioperative services.  They can also issue “tickets” to IT. 

Our department has two dedicated super-users:  Kaitlyn Pellegrino and Ben Jones.  You can contact them via pager (numbers are on the HL board) but they are usually close at hand in pre-op, ORs or the lounge.   We also have a number of embedded superusers. These CRNAs and Physicians are available to point you in the right direction.  Check out the complete list in the Epic Anesthesiology Wikki. 

There are several other resources for information.  Pick up one of the Anesthesia Provider Start Guides.   These booklets are available in the Hixon-Lied lounge and are a great place to start.  You can also check out the  Epic Anesthesiology Wikki – located on the J-drive. TNMC also has a hospital-wide tips blog here.  It is more general but does have some useful information.

Finally, stay tuned to this blog as we will be posting daily tips, tricks and vital info for surviving Epic.

Again.

Every year it approaches in stealth.  One moment you are complaining about the cold and the snow and will-it -ever-be-warm-again?   The next, it is 102 degrees outside and you ask yourself. . . . .

Who are all of these new people? 

It’s time to welcome the newest members of our UNMC Anesthesiology family.   We have 12 CA-1s starting this July.  Some you have seen around as students and some are new to UNMC.  Here are the names to look for:

Bradley Fremming, MD, Ph.D

Virginia Hardie, MD

Cale Kassel, MD

Seth Keiser, MD

Eric Monk, MD

Jeffrey Ottmar, MD

Tyler Ptacek, MD

Brendan Thelen, MD

Konstantin Turchaninov, MD, Ph.D

Charles Walcutt, MD

James Wheeless, MD

Brittany Willer, MD

In addition to our categorical residents, we now have 4 PGY-1 residents starting this year.  You may see them in the operating room, on surgical rotations and around the hospital.  They include:

Austin Adams, MD

Devin Kearns, DO

Shaun Thompson, MD

Maulin Vora, MBBS

 So while many of us may be distracted by the ever-looming approach of Epic and the usual disarray that July brings, remember there are those among us still trying to figure out the basics.  Be sure to point them in the right direction, lend a hand, an encouraging word.  Let’s give them a warm welcome to UNMC.

Amy Beethe
INTRAOPERATIVE MANAGEMENT OF PATIENT WITH CONGENITAL TETRA-AMELIA
1st Place General Case Presentations

Nicholas Markin
PARTIAL HEPATECTOMY AND PNEUMONECTOMY FOR METASTATIC PULMONARY CARCINOID
3rd Place Cardiovascular Case Presentations

Jennifer Hansen
NEUROGENIC PULMONARY EDEMA
3rd Place Neuroanesthesia Case Presentations

Kyle Ringenberg
POST-OPERATIVE SUPPLEMENTAL OXYGEN THERAPY ASSOCIATED WITH INCREASED RISK FOR POST-OPERATIVE MYOCARDIAL INFARCTION IN NON-CARDIAC SURGICAL PATIENTS

Martha Chacon
COMPLICATIONS FOLLOWING BIVENTRICULAR ASSIST DEVICE IMPLANTATION IN A PATIENT WITH CARDIOGENIC SHOCK

Archit Sharma
TACHYARRHYTHMIA -FIRST PRESENTATION OF ADVERSE EFFECTS WITH REMIFENTANIL

Dustin Sorenson
EXTRACARDIAC TAMPONADE POST-CENTRAL LINE PLACEMENT

Marci Franzen
DIFFICULT AIRWAY MANAGEMENT AND INTRAOPERATIVE ALLERGIC REACTION IN A PATIENT WITH SPINAL MUSCULAR ATROPHY

Aaron Kinney
IDENTIFICATION OF SUPERIOR VENA CAVA OBSTRUCTION USING CEREBRAL OXIMETRY AFTER FAILING TO SEPARATE FROM CARDIOPULMONARY BYPASS

Nathan McIntire
ANESTHETIC MANAGEMENT FOR SURGICAL REPAIR OF A CONGENITAL DIAPHRAGMATIC HERNIA IN A FOUR DAY OLD NEONATE

Congratulations to all the residents who presented. Everyone did an outstanding job. A special congrats to Drs. Beethe, Markin and Hansen for bringing home top category awards. Thanks to all who helped with presentations, critiques and coverage of clinical duties.

The use of transesophageal echocardiography (TEE) in liver transplantation is often used to manage hemodynamics, measure pulmonary artery pressures, and guide therapeutic interventions.  After graft implantation, the caval clamps are removed, and is often a time of significant cardiopulmonary changes.  Anesthesiologist can use TEE to watch for right ventricular failure, a common cause of hypotension and arrhythmias after unclampling. TEE can be used to identify proper filling, right ventricular distention, right ventricular function, tricuspid regurgitation and right-sided cardiac outputs.

With improvements in survival of post liver transplantation, older patients have become eligible for transplantation.¹  These patients often have higher prevalence of coronary artery disease and other coronary risk factors.  Recent studies show that echocardiography perioperatively reduces incidence of cardiac and pulmonary events.  Cotton, et al uses positive predictive value to show that echocardiography is a useful tool in estimating pulmonary artery systolic pressure in liver transplant patients as part of the preoperative evaluation.² The use of transesophageal echocardiography (TEE) performed continuously through liver transplantation has shown to provide clarification the mechanism of myocardial dysfunction, visualize and lyse thrombous or embolisms, and asses ventricular function following transplantation.^3-12

Common echocardiography findings after unclamping during liver transplantation associated with right ventricular failure are right ventricular dilation, right ventricular dysfunction, intraatrial septal bowing to the left, right to left shunting through a patent foramen ovale, worsening tricuspid regurgitation from baseline, pulmonary hypertension, microemboli consistent with air and/or debris, and acute thromboemboli.

The more recently reported phenomenon of intraoperative cardiopulmonary thromboembolism has been a major contributor to patients mortality and morbidity during and following liver transplantation.^6,7  Although this is a rare event, it is often a lethal complication during orthotopic liver transplantation.  Frequent clinical symptoms include systemic hypotenstion and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse.⁸  Retrospective studies show a relationship between cardiopulmonary-related mortality and initial (untreated) pre-orthotopic liver transplantation pulmonary hemodynamics.¹³  Additional pulmonary complications that arise from liver transplantation include heptaopulmonary syndromes and portopulmonary hypertension and generally believed to adversely affect outcome after liver transplantation. Echocardiography is able to detect severe pulmonary hypertension syndrome, and information can be used to diagnose, treat and follow critical cardiac events during the intraoperative period.^14,15,16

Learning Objectives:

1.  Right heart failure is a complication of unclamping the vena cava during liver transplantation.

2.  Causes of right heart failure during liver transplantation can be microemboli from air and debris, thromboembolus, acute or chronic (or both) pulmonary hypertension, severe tricuspid regurgitation, acute distension from volume overload, acidosis, hyperkalemia or ischemia (multiple factorial).

3.  Transesophageal echocardiography (TEE) can rapidly identify thrombus, emboli, right ventricular function, triscuspid regurgitation, filling pressures, right sided cardiac output, as well as left-sided function and filling.

Figure 1

Figure 2

References:

1. Tiukinhoy-Liang SD, Rossi JS, Bayram M, De Luca L, Gafoor S, Blei A, Flamm S, Davidson CJ, Gheorghiade M. Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation. Am J Cardiol 2006;98:178-81
2. Mejia A, Mendoza ML, Kieta D, Guiden H, Aramoonie AES, Lee GW, Cheng S. Nonfatal intracardiac thromboembolism during liver transplantation. J Cardiothorac Vasc Anesth 2010;24:109-11
3. Cotton CL, Gandhi S, Vaitkus PT, Massad MG, Benedetti E, Mrtek RG, Wiley TE. Role of echocardiography in detecting portopulmonary hypertension in liver transplant candidates. Liver Transpl 2002;8:1051-4
4. Ellis JE, Lichtor JL, Feinstein SB, Chung MR, Polk SL, Broelsch C, Emond J, Thislethwaite JR, Roizen MF. Right heart dysfunction, pulmonary embolism, and paradoxical embolization during liver transplantation. Anesth Analg 1989;68:777-82
5. Ellenberger C, Mentha G, Giostra E, Licker M. Cardiovascular collapse due to massive pulmonary thromboembolism during orthotopic liver transplantation. J Clin Anesth 2006;18:367-71
6. Lerner AB, Sundar E, Mahmood R, Sarge T, Hanto DW, Panzica PJ. Four cases of cardiopulmonary thromboembolism during liver transplantation without the use of antifibrinolytic drugs. Anesth Analg 2005;101:1608-12
7. Xia VW, Ho JK, Nourmand H, Wray C, Busuttil RW, Steadman RH. Incidental intracardiac thromboemboli during liver transplantation: incidence, risk factors, and management. Liver Transpl 2010;16:1421-27
8. O’Connor CJ, Roozeboom D, Brown R, Tuman KJ. Pulmonary thromboembolism during liver transplantation: possible association and antifibrinolytic drugs and novel treatment options.  Anesth Analg 2000;91:296-9
9. Warnaar N, Molenaar IQ, Colquhoun SD, Sloof MJH, Sherwani S, De Wolf AM, Porte RJ. Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review. J Thromb Haemost 2008;6:297-302
10. Gologorsky E, De Wolf AM, Scott V, Aggarwal S, Dishart M, Kang Y. Intracardiac thrombus formation and pulmonary thromboembolism immediately after graft reperfusion in 7 patients undergoing liver transplantation. Liver Transpl 2001;7:783-89
11. De Wolf AM, Begliomini B, Gasior TA, Kang Y, Pinsky MR. Right ventricular function during orthotopic liver transplantation. Anesth Analg 1993;76:562-8
12. Krowka MJ, Plevak DJ, Findlay JY, Rosen CB, Wiesner RH, Krom RAF. Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. Liver Transpl 2000;6:443-50
13. Plotkin JS, Scott VL, Pinna A, Dobsch BP, De Wolf AM, Kang Y. Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation.  Liver Transpl Surg 1996;2:426-30
14. Krowka MJ, Mandell MS, Ramsay AE, Kawut SM, Fallon MB, Manzarbeita C, Pardo Jo M, Marotta P, Uemoto S, Stoffel MP, Benson JT. Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl 2004;10:174-82
15. Starkel P, Vera A, Gunson B, Mutimer D. Outcome of liver transplantation for patients with pulmonary hypertension. Liver Transpl 2002;8:382-88
16. Hofer CK, Zollinger A, Rak M, Matter-Ensner S, Klaghofer R, Pasch T, Zalunardo MP.  Therapeutic impact of intra-operative transesophageal echocardiography during noncardic surgery. Anaesthesia 2004;59:3-9