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Introduction. Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy. Methods. This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires. Results. The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P=0.03). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores. Conclusions. Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Background. Utilization of intraoperative transesophageal echocardiography (TEE) during orthotopic liver transplantation (OLT) is expanding annually in high-volume transplant centers. During OLT intraoperative TEE is used to gather real-time information on cardiovascular function and intravascular volume status. Although standardized TEE views exist, there are nontraditional views described in the literature which have the potential to diagnose evolving pathology and define normal variants of hepatic vasculature. Methods. A literature review was completed utilizing the PubMed database for English-only, peer-reviewed publications discussing nontraditional use of intraoperative TEE during OLT and hepatic vascular-related surgeries from 2009 to 2019. Both case reports and review articles were considered. Results. The PubMed literature search offered 8 publications for analysis, including 7 case reports and 1 article review, revealing several nontraditional TEE views not included in a comprehensive transesophageal echocardiographic examination. These nontraditional views were generally obtained using modifications to the transgastric and bicaval views to visualize liver vasculature. We present the various techniques for obtaining these views from the 8 articles identified. Conclusions. At high-volume transplant centers, TEE use during OLT is increasing. Intraoperative TEE is a valuable tool to assess hepatic vascular structures critical to allograft/organ function without interruption of the surgical procedure. Nontraditional use of TEE to diagnose intraoperative noncardiac pathology in OLT appears underutilized and underreported. The modified hepatic and modified transgastric views we describe can be used to evaluate hepatic vasculature, influence surgical decision-making and ultimately improve patient care.

This article presents three cases of cranial nerve palsy following shoulder surgery with general anesthesia in the beach chair position. All patients underwent preoperative ultrasound-guided interscalene nerve block. Two cases of postoperative hypoglossal and one case of combined hypoglossal and recurrent laryngeal nerve palsies (Tapia’s syndrome) were identified. Through this case series, we provide a literature review identifying postoperative cranial nerve palsies in addition to the discussion of possible etiologies. We suggest that intraoperative patient positioning and/or airway instrumentation is most likely causative. We conclude that the beach chair position is a risk factor for postoperative hypoglossal nerve palsy and Tapia’s syndrome.

Introduction: Sexual dysfunction is a well‐known side effect of antidepressants. Painful ejaculation is a rare side effect that has been reported with the use of some psychiatric drugs such as triclyclic antidepressants. Cyclobenzaprine is a muscle relaxant that is structurally similar to tricyclic antidepressants. It is the most commonly prescribed muscle relaxant in the United States and accounts for 18% of all prescriptions written for chronic back pain. Methods: A 55‐year‐old man was referred to our pain medicine clinic for evaluation and treatment of pain with ejaculation. Main outcome Measure: The main outcome measure was to review the current published literature and case reports on painful ejaculation from medication use, in particular tricyclic antidepressants. Results: After discontinuation of cyclobenzaprine, our patient's sexual dysfunction resolved. This result was consistent with the literature reviewed on the topic. Conclusion: Painful ejaculation is likely an underreported side effect of tricyclic antidepressants and cyclobenzaprine use. Fortunately, these symptoms are reversible and discontinuation of these medications is typically an effective cure. Kraus MB, Wie CS, Gorlin AW, Wisenbaugh ES, and Rosenfeld DM. Painful ejaculation with cyclobenzaprine: A case report and literature review. Sex Med 2015;3:343–345.

Background and Aims: There are limited data on the effect of ampule size on drug dosing. The objective of this study is to determine the effect of ampule size on perioperative opioid dosing and post-anesthesia care unit (PACU) outcomes. Material and Methods: This was a retrospective review of patients undergoing robotically assisted laparoscopic radical prostatectomy before and after a 5-ml fentanyl ampule was discontinued. The primary outcome was intraoperative opioid administration divided into fentanyl at induction of anesthesia, total fentanyl, and total opioid. Secondary outcomes observed in PACU included the opioid administered, visual analog scale (VAS) pain scores, postoperative nausea and vomiting, and length of stay in PACU. Results: A total of 100 patients (50 PRE and 50 POST) were included. In the intraoperative opioid administration, mean (SD) of fentanyl at induction was 117.0 (49.3) in PRE group and 85.0 (35.4) μg in POST group (P < 0.01). The total fentanyl requirement was 247.0 (31.0) in PRE group and 158.5 (85.1) μg in POST group (P < 0.01). The total opioid in intravenous morphine equivalents (IVME) was 34.1 (5.8) in PRE group and 23.2 (6.8) mg in POST group (P < 0.01). Among the secondary outcomes, mean (SD) of IVME of opioid was 7.7 (8.2) in PRE group and 9.9 (8.1) mg in POST group (P = 0.18). The VAS pain score on arrival was 0.7 (1.4) in PRE group and 3.8 (3.3) in POST group (P < 0.01). The cumulative VAS pain score was 2.3 (2.0) in PRE group and 3.3 (2.2) in POST group (P < 0.01). The length of stay was significantly more in POST group, 193.8 (75.8) minutes, as compared with PRE group, 138.6 (61.0) minutes (P < 0.01). Conclusions: A change in the ampule size significantly affected intraoperative dosing, PACU pain scores, and PACU length of stay in patients undergoing robotically assisted laparoscopic radical prostatectomy under general anesthesia. This was explained by clinician's desire to conserve the drug and avoid the complex process of narcotic waste disposal.

Ketamine, an N-methyl-d-aspartate antagonist, blunts central pain sensitization at sub-anesthetic doses (0.3 mg/kg or less) and has been studied extensively as an adjunct for perioperative analgesia. At sub-anesthetic doses, ketamine has a minimal physiologic impact though it is associated with a low incidence of mild psychomimetic symptoms as well as nystagmus and double vision. Contraindications to its use do exist and due to ketamine′s metabolism, caution should be exercised in patients with renal or hepatic dysfunction. Sub-anesthetic ketamine improves pain scores and reduces perioperative opioid consumption in a broad range of surgical procedures. In addition, there is evidence that ketamine may be useful in patients with opioid tolerance and for preventing chronic postsurgical pain.