SleepTalker March 2018

   Dr. Joshua Dubnau has been officially appointed as Professor of Anesthesiology. Josh arrived in August 2016 after having spent much of his career working at Cold Spring Harbor Labs. He has a lively and productive NIH-funded lab in the Center for Molecular Medicine Building on the West Campus. Visit his lab web pages for details (and great pictures) about his research on Amyotrophic Lateral Sclerosis and Frontotemporal Lobar Degeneration using his favorite organism - the fruitfly. For the last eight months, Josh has been serving as the Chairman of the Research Committee of the department. Congratulations, Josh!

   Wed. Mar 7. Dr. TJ Gan will chair the Faculty Meeting at 7:00 am in Lecture Hall 5.

   Thurs. Mar 8. Journal Club will meet at the Eastern Pavillion in Setauket from 6:00 - 8:00 pm. The discussion topic is "Deliberate Hypotension". See the Journal Club web page for details.

   Wed. Mar 14. Dr. Joshua Miller from the Department of Medicine will present a Faculty Grand Rounds talk at 7:00 am in Lecture Hall 5. Dr. Miller is the Medical Director of Diabetes Care for Stony Brook Medicine and an Assistant Professor of Endocrinology & Metabolism in the Department of Medicine. He is dual board-certified in Internal Medicine and Endocrinology, Diabetes & Metabolism. His main area of clinical research is the relationship between diabetes and colon cancer.

   Wed. Mar 21. Dr. Richard Thalappillil will present his Senior Grand Rounds talk at 7:00 am in Lecture Hall 5.

Kathryn Mince, MD, PGY4, OB/GYN Chief Resident

   I just wanted to make note of two anesthesia residents who were present on the L&D floor and provided amazing, quick care during an emergency case. Dr. Anupam Sharma and Dr. Joseph Cabellero (who were on call for the main OR) graciously came to the L&D floor to provide anesthesia for a fellow resident's wife at the patient's request. They had just reached the floor when a patient came in to triage with a placental abruption and a fetal heart rate that was in the 60s. A STAT cesarean section was called and the patient was rushed to the OR. Although both Joe and Anupam were not rotating on the OB floor, they immediately sprung into action, helping the resident on the floor (Dr. Charles (Trey) Mouch, III) gaining access and getting the patient prepared for general anesthesia. The three residents divided and conquered the tasks needed obtain adequate anesthesia and deliver the baby within a matter of minutes. In all honesty, if Joe, Anupam, and Trey did not spring into action the way that they did, I do not think we would have delivered a live infant. I am truly grateful for the care they provide day and day out, and especially with this difficult case. Thanks!

Patient comments about our Ambulatory Surgery Center staff from the Press Ganey questionnaires:

   This is the first time my anesthesia went so well because Dr. Sherwin Park listened to bad experiences I had at other hospitals.

   Amazing resident did IV. First time I didn't wake up from anesthesia nauseous!

   Everything went very smoothly. Dr. Christine Cokinos was excellent.

   Anesthesiologist was warm, friendly and informative

    Dr. Eleanor Romano was great. First time with anesthesia and it went smoothly.

   Anesthesia doctors are very good. Best experience I have had with general anesthesia. I felt completely informed and was constantly monitored up until discharge great team!

   Dr. Eleanor Romano was great! She listened to what I wanted and gave me just the right sedation.

   The anesthesiologist I had went above and beyond - My sister was in the waiting area and the anesthesiologist passed her - and stopped to tell her how everything went well - I was in recovery

   A figure from the article "Triple S-Phase Labeling of Dividing Stem Cells" by Dr. Grigori Enikolopov and his colleagues Drs. Oleg Podgorny, Natalia Peunova and June-Hee Park was selected for the cover illustration of the February 2018 issue of the journal Stem Cell Reports. Congratulations!!

Ruchir Gupta, MD

    From January 9-14, 2018, three members of the Anesthesia department: myself and Drs. Minxi Weng, and Justin Smith had the opportunity to participate in a medical mission to Santa Elena, Ecuador. This mission was sponsored by Blanca’s House, a medical non-profit which was started in 2008 right here on Long Island. It was a whirlwind of trip. We flew on an overnight flight to Ecuador, and then, after traveling for hours from the airport to the clinic, we set up and started cases on the first day. It was very challenging at times due to limited resources. The anesthesia machines often didn’t work, or only worked in a limited capacity, and we were always looking for the necessary drugs so that we could start the next case.

    We learned how to improvise, at one point even doing general anesthesia cases

with just an oxygen tank at our disposal. On one day, we repaired nearly 16 hernias. The patients were immensely grateful for the care they received and family members continued to thank us in the hallways. Despite all the challenges, it was immensely rewarding. We were able to help so many of the local people with surgical care that they might not have received otherwise. On this mission there were a lot of ophthalmology cases, hernia repairs, cholecystectomies, and many pediatric and adult plastics cases. The days began early in the morning and extended well into the night, but those long hours helped us form friendships with the other volunteers and the long hours flew by. We are looking forward to more opportunities to contribute on medical missions in the future.

   We want to thank Dr. TJ Gan and the Anesthesia Department for sponsoring this trip. This experience helps physicians like us truly give back to society and find ways to intertwine our own practice down the road to include volunteer work. We hope this experience remains intact for future residents.

   View the photo album from this mission.

    We're #4! In 2017, our department ranked #4 (up from #6 in 2016) among US Anesthesiology Departments in NIH support as compiled by the Blue Ridge Institute for Medical Research. Congratulations to all of our hard-working research faculty and staff!

Joseph Gnolfo III, MS, CRNA

    It is with great pleasure that I announce the appointment of Melissa A. Day, CRNA to the position of Clinical Support Manager. This position was designed to meet the needs of the department and its valuable anesthesia team members. Ms. Day will continue to work closely with our valued anesthesia technician specialist Ms. Josephine Pace (supervisor) to ensure clinical excellence and compliance with the current standards of practice while working to provide innovative guidelines for the future practice of the anesthesia technicians/technologists at Stony Brook Medicine. Josephine will continue with her current position and responsibilities but will now answer to Ms. Day. This is a formalization of the role Ms. Day had already taken on and should promote a smooth transition.

    Ms. Day commenced her career at Stony Brook Medicine as a CRNA in 2006 after graduating from SUNY Downstate Medical Center’s School of Nurse Anesthesia in December of 2006. Melissa has proven to be an outstanding clinician who is well respected by her attending physicians, CRNAs, anesthesia techs, and all members of the peri-operative care team. Melissa also serves as Lieutenant Colonel in the United States Air Force Reserves Nurse Corps contributing to the care of our military personnel and their families. Before becoming a CRNA she had earned her Bachelor of Science in Nursing, Master of Science in Adult Health Nurse Practitioner and practiced nursing in many capacities including the SICU here at SUNY Stony Brook.

    Congratulations to Melissa on her formal appointment and to Mary Catalano, the former Clinical Support Manager, on her approaching retirement!!

Justin Smith, MD

    The current CA-3 class recently made an instructional video about epidurals. The video was designed to instruct patients about what to expect from epidurals prior to their delivery date. We found that many patients coming into the hospital had very little information, or in some cases, misinformation about what an epidural is, and what they can expect from epidurals during delivery. When patients arrive at the hospital in active labor it can be stressful for them to learn about epidurals for the first time and then decide whether to receive one for their labor pain.

    We started by creating a survey to assess patient’s understanding of epidurals and also their experience receiving an epidural during their hospital stay. Then, we developed a short script and vision for what we would like the video to include. After our script and storyboard were completed, we found a videographer to come and shoot and edit the video. It was fun and educational working with the videographer as he taught us what would work best for the different segments we wanted to produce. The CA-3 class acted as narrators, patients, nurses, and family members to complete the video. Working with the media relations staff for the hospital, we now have a finished video which we are going to start showing to patients prior to labor.

   We hope that patients will have the opportunity to view the video when they come for tours of the obstetric suite and in some clinical situations prior to coming to the hospital in labor. The video is posted on the Stony Brook OB anesthesia patient information website for all to see. We plan to follow up with another survey after patients have seen the video to see if patient satisfaction and understanding of epidurals improves after seeing the video.

   Looking back on the experience so far, we realize the importance of being very particular about what is scripted and how we want the different segments to be staged. Putting some more thought into the specifics of the story board would have made the day we spent making the video go more smoothly. Also, getting media relations involved earlier in the process would have been a great aid in developing this video since they had a lot of great recommendations that we could have incorporated earlier in the planning process. Overall, making this video has been very enjoyable and educational. We look forward to continuing this project over the next few months.

Melissa Day, CRNA and Josephine Pace

    Anesthesia Tech Day is March 31, 2018. The Department of Anesthesiology has a dedicated group of Anesthesia Techs who are a vital part of the Anesthesia Team. Our Anesthesia Techs work in the Ambulatory Surgical Center, Endoscopy and the Main Operating Room. The Anesthesia Techs ensure that the operating rooms and procedural rooms are ready for cases that come in at any time of the day. They also assist the Anesthesia Provider, turnover rooms and obtain equipment and supplies at a moments notice for Anesthesia Providers.

    Our Anesthesia Techs play an integral role in providing quality patient care. Please take a moment to acknowledge our Anesthesia Techs for their hard work, dedication and assistance to Anesthesia Providers.

Ronald Jasiewicz, DO, MBA, FAAP

    This winter I was the New York invitee to "Cutting Edge Topics in Pediatric Anesthesia", a Philadelphia Pediatric Anesthesiology consortium meeting. The keynote speaker, Alan Flake MD, a pediatric CHOP surgeon/researcher, presented a glimpse of the potential for the human artificial placenta.

    Flake reiterated that the pulmonary system takes the biggest hit with premature births. In simplicity, "no ventilation modality when studied by RCT has reduced death or BPD in extreme premature infants." Current ventilation strategies include a myriad of approaches ranging from nCPAP to HFOV, have not had significant impact. The issue is an arrest of lung development due to gas ventilation in the extra-uterine environment.

    The solution is EXTEND, an artificial placenta that has shown significant success in the sheep model. [Partridge et al. 2017] Extra-pulmonary benefits of a fluid environment include:

1. Facilitates normal fluid balance - fetal swallowing and minimal insensible losses
2. Provides gut trophic factors for gut maturation and nutrition
3. Stable temperature controlled environment that insulates the newborn from sound, light, mechanical pressure or injury, and has a swaddling effect
4. Isolates the newborn from environmental pathogens/iatrogenic infection

    The translucent and sonolucent 'Biobag' has evolved in the animal model with a very low sepsis incidence. It provides continuous fluid exchange. The 2015 prototype IV placenta is a pumpless, low resistance, low surface area, heparin coated oxygenator circuit allowing for sheep fetal TPN, systemic antibiotics, PGF₂ and low heparin. This has resulted in hemodynamic stability, normal combined cardiac outputs, normal ductus arterioles flows and shunt fractions, and normal umbilical venous PaO₂.

    In brief, the EXTEND animal model had normal: oxygen parameters, somatic growth and maturation, lung development and maturation, and brain growth and maturation.

• CDH: EXIT to Extend at 35 weeks - 3-4 weeks of EXTEND prior to gas ventilation - Pharmacologic treatment of PHTN +/- lung growth strategies, diaphragmatic hernia repair
• Premature delivery of fetal surgery patients
• Fetal Growth Restriction/placental insufficiency
• Support of infants with congenital heart disease for organ/brain maturation prior to cardiac repair
• Gene therapy/cell therapy

    In the sheep model, when these fetuses are 'born' the assessment is that they are normal in development. This is very promising research and at the point of a FDA-IDE early feasibility study.

    When the question arose during the Q&A: Who will manage these fetuses in Biobags? The consensus from the surgeon and the audience of pediatric anesthesiologists was unanimously ... the neonatologists!

    Aysha Hasan M.D. was also present and sends her regards to all. As you may not know, Aysha left the SB Anesthesiology Pediatric Team to pursue a Pediatric Regional Anesthesia Fellowship at Boston Children's. The Monday following the meeting she commenced her new position as Director of the Acute Pain Service at St. Christopher's Children's hospital in Philadelphia. She is proudly expecting her first child this March!

James P. Dilger, PhD

    Last month, I received an email from Dr. Robert Katz. Bob became an Attending in our department on July 1, 1983. Between 1985 and 1987, he was Director of OB Anesthesia. He then became Chief of VA Anesthesia, a position he held until 1994. Bob left Stony Brook for three years to be Site Director at the Jack D. Weiler Hospital, Montefiore Medical Center, Albert Einstein College of Medicine. He returned to Stony Brook near the end of 1997. After returning, he was at various times, Chief of the General Anesthesia Team, Director of Pre-Operative Services, Chief of Neuro/ENT Anesthesia and Professor and Vice-Chairman for Administration, Department of Anesthesiology. In December 2010, Bob left Stony Brook to be Clinical Professor, Department of Anesthesiology, University of Florida and Chief, North Florida/South Georgia Veterans Health System. He retired from both of those positions on January 20, 2016.

    Bob wrote:

• Makaryus R, Miller TE, Gan TJ. Current concepts of fluid management in enhanced recovery pathways. Br J Anaesth. 2018 Feb;120(2):376-383
• DeMaria S Jr., Bennett-Guerrero E. Examining the Methodology of the Transfusion Requirements in Cardiac Surgery-III (TRICS-III) Trial: Third Time's a Charm? J Cardiothorac Vasc Anesth. 2018 Feb;32(1):130-131
• Doronin DA, Barykina NV, Subach OM, Sotskov VP, Plusnin VV, Ivleva OA, Isaakova EA, Varizhuk AM, Pozmogova GE, Malyshev AY, Smirnov IV, Piatkevich KD, Anokhin KV, Enikolopov GN, Subach FV. Genetically encoded calcium indicator with NTnC-like design and enhanced fluorescence contrast and kinetics. BMC Biotechnol. 2018 Feb 13;18(1):10
• Bogdan D, Falcone J, Kanjiya MP, Park SH, Carbonetti G, Studholme K, Gomez M, Lu Y, Elmes MW, Smietalo N, Yan S, Ojima I, Puopolo M, Kaczocha M. Fatty acid binding protein 5 controls microsomal prostaglandin E synthase 1 (mPGES-1) induction during inflammation. J Biol Chem. 2018 Feb 13
• Mineyeva OA, Enikolopov G, Koulakov AA. Spatial geometry of stem cell proliferation in the adult hippocampus. Sci Rep. 2018 Feb 21;8(1):3444
• Hamilton J, Marion M, Figueiredo A, Clavin BH, Deutsch D, Kaczocha M, Haj-Dahmane S, Thanos PK. Fatty acid binding protein deletion prevents stress-induced preference for cocaine and dampens stress-induced corticosterone levels. Synapse. 2018 Feb 19
• Kaczocha M, Azim S, Nicholson J, Rebecchi MJ, Lu Y, Feng T, Romeiser JL, Reinsel R, Rizwan S, Shodhan S, Volkow ND, Benveniste H. Intrathecal morphine administration reduces postoperative pain and peripheral endocannabinoid levels in total knee arthroplasty patients: a randomized clinical trial. BMC Anesthesiol. 2018 Feb 27;18(1):27

   In the February 2018 issue of SleepTalker we inadvertently gave the wrong name for Megan Lindstadt's husband. The newlyweds are Megan Lindstadt and John Felsberg! We regret the error; it has been corrected in the online version of the newsletter. We wish Megan and John much happiness in their future together!