Yury Khelemsky

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States

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Publications (9)15.38 Total impact

  • Yury Khelemsky, Jacob Schauer, Nathaniel Loo
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    ABSTRACT: Buprenorphine is a partial mu receptor agonist and kappa/delta antagonist commonly used for the treatment of opioid dependence or as an analgesic. It has a long plasma half-life and a high binding affinity for opioid receptors. This affinity is so high, that the effects are not easily antagonized by competitive antagonists, such as naloxone. The high affinity also prevents binding of other opioids, at commonly used clinical doses, to receptor sites - preventing their analgesic and likely minimum alveolar concentration (MAC) reducing benefits. This case report contrasts the anesthetic requirements of a patient undergoing emergency cervical spine surgery while taking buprenorphine with anesthetic requirements of the same patient undergoing a similar procedure after weaning of buprenorphine. Use of intraoperative neurophysiological monitoring prevented use of paralytics and inhalational anesthetics during both cases, therefore total intravenous anesthesia (TIVA) was maintained with propofol and remifentanil infusions. During the initial surgery, intraoperative patient movement could not be controlled with very high doses of propofol and remifentanil. The patient stopped moving in response to surgical stimulation only after the addition of a ketamine. Buprenorphine-naloxone was discontinued postoperatively. Five days later the patient underwent a similar cervical spine surgery. She had drastically reduced anesthetic requirements during this case, suggesting buprenorphine's profound effect on anesthetic dosing. This case report elegantly illustrates that discontinuation of buprenorphine is likely warranted for patients who present for major spine surgery, which necessitates the avoidance of volatile anesthetic and paralytic agents. The addition of ketamine may be necessary in patients maintained on buprenorphine in order to ensure a motionless surgical field. Buprenorphine, anesthesiology, intraoperative, total intravenous anesthesia, pharmacology.
    Pain physician 03/2015; 18(2):E261-4. · 4.77 Impact Factor
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    Jason Siefferman, Yury Khelemsky
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    ABSTRACT: While undergoing full thickness tissue harvest from the posterior scalp, a 72-year-old man experienced immediate severe pain in the right occiput and was unable to complete the procedure. The pain was constant "sharp" and "shocking" with numbness in the distribution of the lesser occipital nerve, exacerbated by physical activity, and local anesthetic blocks provided temporary complete relief. After numerous treatments over several years, including oral analgesics, botulinum toxin injections, and acupuncture, proved ineffective, pulsed radiofrequency neuromodulation provided greater than 80% relief for 5 months.
  • Joshua Hamburger, Ira S Hofer, Yury Khelemsky
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    ABSTRACT: A patient with a drug-eluting stent placed 18 months earlier received a thoracic epidural for perioperative analgesic control as part of her thoracotomy. Postoperatively, the patient was started on clopidogrel for secondary prevention. After consultation with the Hematology service and a platelet function assay, the patient was transfused two pools of platelets and the epidural catheter was removed on postoperative day 4. The patient then underwent hourly neurologic checks for 24 hours and was discharged several days later without any negative sequelae. If neuraxial techniques and the need for clopidogrel prophylaxis come into direct conflict, vigilance is necessary for warning signs of epidural hematoma and platelet transfusion should be considered to reverse the effects of the drug. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Clinical Anesthesia 11/2014; 26(7):577-80. DOI:10.1016/j.jclinane.2014.05.008 · 1.21 Impact Factor
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    ABSTRACT: This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.
    03/2014; 28(1):59-79. DOI:10.1016/j.bpa.2014.03.001
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    ABSTRACT: Introduction/Background: Pulseless electrical activity (PEA), a subset of which is electromechanical dissociation (EMD), refers to the absence of a pulse in the presence of electrical activity on electrocardiography.1 PEA can refer to true EMD as well as a reduction of cardiac output to a state of effective pulselessness.2 While the prognosis of this rhythm remains dismal, current evidence for improved survival exists with prompt administration of high quality CPR in conjunction with a search for reversible causes.3 Our team has anecdotally observed a delay in administration of high quality CPR during simulation of non-EMD PEA in the presence of invasive arterial monitoring. We hypothesize that ACLS-trained anesthesia residents will delay initiating CPR during a simulation of non-EMD PEA when an invasive arterial pressure monitor is present. Methods: In this prospective, randomized controlled trial, 18 senior anesthesiology residents underwent high-fidelity simulation of non-EMD PEA upon induction of general anesthesia. Control group participants were provided with noninvasive blood pressure (NIBP) monitoring, while experimental group participants were provided with invasive arterial pressure monitoring. Through review of video recording of the simulated scenarios, time from pulselessness to: 1) attempted palpation of pulse; 2) initiation of chest compressions; and 3) administration of ACLS pharmacologic intervention were recorded. Following the simulation, all participants completed a brief multiple choice examination exploring their knowledge of the pathophysiology and management of PEA. Data were analyzed using a two sample independent T-test. Results: A total of 18 participants were analyzed in this study with nine subjects randomized to each group. There was no difference found between the arterial line group and the NIBP group with respect to time from pulselessness to palpation for pulse (27.3 s vs. 58.2 s, p = 0.68), initiation of chest compressions (72.6 s vs. 68.2 s, p = 0.97), or administration of epinephrine (36.9 s vs. 71.4 s, p = 0.59). Likewise, there was no difference between the two groups in time from palpation of pulse to initiation of chest compressions (44.6 s vs 18.7 s, p = 0.67), and administration of epinephrine (30.3 s vs. 54.3 s, p = 0.28). The baseline characteristics of the two groups were similar with respect to PGY level (4.3 vs 3.67, p = 0.76) and score on an ACLS aptitude test (67% and 59% p = 0.82). Both groups indicated on 4 point Likert scale that an arterial line did/would have helped (3.78 vs. 2.89, p = 0.77). Conclusion: Our study did not show an improved response time in management of PEA for those participants with invasive arterial pressure monitoring. A major indication for invasive arterial monitoring is the potential for rapid onset of hemodynamic instability to allow for faster response.4 Our residents however, did not respond more promptly with the information from the arterial line. Though the result was not statistically significant, our data actually showed a shorter time from palpation of a pulse to compressions in the NIBP group. The fact that the participants in the NIBP group performed as well, if not better, suggests that they used other indicators such as pulse-oximetry and end tidal CO2 level in their management. An unexpected result of the study was the wide variation in the response of anesthesiology residents with the same level of training. (Delay to compressions from pulselessness ranged from 0 to 240 s). A similar scenario could be utilized to assess resident competency in ACLS management. High fidelity simulation offers a unique opportunity to introduce variables into rare critical events and observe the changes in management that result. References: 1. Desbians NA: Simplifying the management of pulseless electrical activity in adults: a qualitative review. Crit Care Med 2008; 36(2) 391-6. 2. Paradis NA, Martin GB, Goetting MG, Rivers EP, Feingold M, Nowak RM: Aortic pressure during human cardiac arrest, identification of pseudo-electromechanical dissociation. Chest 1992; 101(1): 123-8. 3. Field JM: Pulseless electrical activity, Contemporary Cardiology: Cardiopulmonary Resuscitation.Edited by Ornato JP, Peberdy MA. Humana Press Inc. Totowa, NJ, 2007 pp. 147-54. 4. Schroeder RA, Barbeito A, Bar-Yosef, S, Mark JB: Cardiovascular Monitoring, Miller's Anesthesia, 7th edition. Edited by Miller RD. Churchill Livingstone, Philadelphia, 2010, pp 1267-1328. Disclosures: None.
    Simulation in healthcare: journal of the Society for Simulation in Healthcare 01/2013; 8(6):560. DOI:10.1097/01.SIH.0000441626.84197.f3 · 1.59 Impact Factor
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    Yury Khelemsky, Christopher J Noto
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    ABSTRACT: This article provides a concise overview of post-thoracotomy pain syndrome, describes anesthetic and surgical factors that have been investigated to reduce the incidence of the syndrome, and explores the effectiveness of various treatments for this condition. Although some interventions (both procedural and pharmacologic) have been investigated in both preventing and treating post-thoracotomy pain syndrome, definitive studies are lacking and firm conclusions regarding the benefit of any intervention cannot be drawn. The problem is compounded further by our lack of understanding of the pathophysiologic mechanisms underlying the development of chronic pain after surgery. Going forward, it will be important to elucidate these mechanisms and conduct well-designed trials involving novel therapeutic agents for both prevention and treatment of post-thoracotomy pain syndrome.
    Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 01/2012; 79(1):133-9. DOI:10.1002/msj.21286 · 1.56 Impact Factor
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    ABSTRACT: The development of medical students' perceptions of different medical specialties is based on many factors and influences their career choices and appreciation of other practitioners' knowledge and skills. The goal of this study was to determine if participation in a series of anesthesiologist-run, simulation-based physiology labs changed first year medical students' perceptions of anesthesiologists. One hundred first-year medical students were surveyed at random three months before completion of a simulation-based physiology lab run by anesthesiologists. All participants received the same survey instrument, which employed a 5-point Rating Scale to rate the appropriateness of several descriptive terms as they apply to a particular specialist or specialty. A post-simulation survey was performed to track changes in attitudes. Response rates to the survey before and after the simulation labs were 75% and 97% (ofthe initial cohort responding), respectively. All students who filled out the post-simulation surveys had been exposed to anesthesiologists in the prior three months whereas none had interacted with surgeons in the interim. Nearly all had interacted with internal medicine specialists in that time period. No changes in the medical students' perceptions of surgeons or internal medicine specialists were evident. Statistically significant changes were found for most descriptors of anesthesiologists, with a trend towards a more favorable perception after the simulation program. Using a survey instrument containing descriptors of different medical specialists and specialties, we found an improved attitude towards anesthesiology after medical students participated in an anesthesiologist-run simulation-based physiology lab series. Given the importance of providing high quality medical education and attracting quality applicants to the field, integrati-on of anesthesiology staff into medical student courses at the non-clinical level appears useful.
    Middle East journal of anaesthesiology 10/2011; 21(3):347-53.
  • Michael Mazzeffi, Yury Khelemsky
    Journal of cardiothoracic and vascular anesthesia 09/2011; 25(6):1163-78. DOI:10.1053/j.jvca.2011.08.001 · 1.48 Impact Factor
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    ABSTRACT: Cancer-related bladder spasms may be a rare but severe symptom of bladder or metastatic cancer or its related treatments. Various treatments described in the literature include systemic medications, intravesical or epidural medications, or even sacral neurolectomies. We present 3 patients who have suffered from bladder spasm either from invasion of the bladder wall by tumor (2 patients) or from intravesical chemotherapeutic treatment. Case Report. Cancer pain management hospital. For each patient, we describe the use of lumbar sympathetic block to successfully treat the bladder spasms. Sympathetic blockade was performed at the left anterolateral border of lumbar vertebra L4. We used 10 mL of local anesthetic (0.25% bupivacaine) delivered in 2 mL aliquots, each given after negative aspiration for heme. Each procedure was performed with fluoroscopic guidance (both AP and lateral views) with the use of iodine contrast (Omnipaque-180) to confirm the location of the medication and its resulting spread. All 3 patients had a reduction in the frequency and intensity of spasms, with 2 out of 3 patients not having a recurrence of the spasms for up to 2 months post procedure and follow up. Case Report. Lumbar sympathetic blockade could be a useful treatment for recurrent bladder spasm in the oncologic population. Based on these findings, we feel that the branches of the sympathetic nerve set at L4 may be a good target for neurolytic procedures, such as radiofrequency ablation, for long term treatment of bladder spasms. Further research is necessary to determine the efficacy of this technique for the treatment of bladder spasms in the oncologic population.
    Pain physician 05/2011; 14(3):305-10. · 4.77 Impact Factor