Anesthetic Management Research Articles

Unilateral modified radical mastectomy with thoracic epidural anesthesia and serratus anterior plane block under dexmedetomidine sedation in a patient with multiple comorbidities: a case report

Anesthesia management in patients with multiple comorbidities is extremely challenging for the anesthesiologist. We aimed to present anesthesia management with dexmedetomidine sedation accompanied by thoracic epidural anesthesia and serratus anterior plane block in a 59-year-old high-risk patient with multiple comorbidities who was planned for modified radical mastectomy. We suggest that serratus anterior plane block can be used combined with thoracic epidural anesthesia as an effective, safe, and feasible method for hemodynamic stability in intraoperative and postoperative pain control in patients undergoing modified radical mastectomy surgery and in reducing the need for postoperative analgesic use and postoperative complications.

Patient with Scleroderma for Elective Cesarean Section: Anesthesia Management

Scleroderma is an autoimmune disease that can cause fibrosis in vital organs, often resulting in damage to the skin, blood vessels, gastrointestinal system, lungs, heart, and/or kidneys. A case report of 37-year-old G2P1SA1 was posted for the elective cesarean section which was safely conducted under subarachnoid blockade than general anesthesia as the latter a higher morbidity rate. The patient manifested with calcinosis, Raynaud’s disease, and sclerodactyly. Patients with scleroderma present with serious comorbidities that can negatively impact anesthetic management; so, the implementation of an anesthetic plan that takes such risks into account is required. So, scleroderma patient was successfully managed under regional anesthesia.

Obstetric and anesthetic management in parturients with ventriculoperitoneal shunt: a case series.

Further study is needed to determine the safest mode of delivery and anesthetic management for parturients with ventriculoperitoneal shunts (VP). Prior recommendation for delivery in women with ventriculoperitoneal shunts was cesarean delivery. However, both vaginal delivery and neuraxial anesthesia have been shown to be safe in women with appropriately functioning VP shunts. We present a case series of parturients with VP shunt. Parturients with VP shunts were identified and VP shunt placement indications, neurologic symptoms during pregnancy, delivery mode, anesthetic type, and postpartum complications were reviewed. Forty patients were identified, and fifteen women with twenty deliveries were included. Two women experienced neurological symptoms during pregnancy and one required postpartum shunt revision for blurry vision and ataxia. There were ten cesarean deliveries and ten vaginal deliveries (eight normal spontaneous, one vacuum assisted, and one forceps assisted). Assisted vaginal deliveries were performed to decrease Valsalva including the patient with neurological symptoms related to shunt malfunction. Of the vaginal deliveries, six (60%) had epidural analgesia. Anesthesia for cesarean delivery included neuraxial anesthesia (n = 5) and general anesthesia (n = 5). In our cohort, women with VP shunt received neuraxial blockade without complication. Neuraxial techniques should be offered to women with appropriately functioning VP shunt.

Peripartum anesthesia management and outcomes of patients with congenital heart disease: a single-center retrospective analysis (2009–2023)

BackgroundAdvances in medicine have enabled more patients with congenital heart disease (CHD) to become pregnant. However, these patients face significant challenges during the peripartum period. Current peripartum anesthesia guidelines for CHD patients mainly rely on case reports and small series. MethodsIn this retrospective study at a high-volume tertiary care center, we analyzed peripartum anesthetic approaches, postpartum hemorrhage (PPH) incidence, and maternal outcomes in CHD patients stratified by the modified World Health Organization (mWHO) classification. ResultsAmong 85 473 deliveries between 2009 and 2023, 409 occurred in 282 patients with CHD. Cesarean deliveries were significantly more frequent in mWHO class III, p=0.005. Labor epidural analgesia was the most common analgesic modality for vaginal deliveries (epidural rate was 71.1% with no differences between mWHO classes). Anesthesia management for cesarean deliveries varied significantly by class p<0.001. While spinal anesthesia was predominant in classes I and II, combined spinal-epidural anesthesia was more common in class III. PPH incidence was 6.4%, with no significant difference across classes, and no association was found between mWHO class severity and PPH risk (OR 0.97; 95% CI; 0.93 to 1.02, p=0.2). Higher mWHO classes correlated with significantly higher intensive care unit (ICU) admission rates, longer hospital stays, and one-year cardiac hospitalizations. ConclusionIn this retrospective study on the peripartum anesthetic management and outcomes of CHD patients stratified by mWHO class, cases with greater mWHO class were more likely to deliver preterm, by cesarean delivery, with a combined spinal-epidural anesthetic and an arterial line placement for that cesarean delivery. They overall had a longer hospital stay and were more likely to be admitted to the ICU. However, the overall risk of PPH did not increase with mWHO class severity.

Improving safety: Neuraxial blockade guided by thromboelastography for patients with uncertain coagulation profile.

Neuraxial blockade procedures are essential for anesthesia and pain management but pose risks in patients with uncertain coagulation profiles. Traditional coagulation tests often fail to predict bleeding risks associated with neuraxial blockade. Thromboelastography (TEG) offers real-time insights into coagulation status, potentially improving safety outcomes. In this case series, six patients underwent neuraxial blockade guided by TEG analysis. An individualized anesthetic plan was formulated based on TEG findings to mitigate bleeding risks while ensuring pain management. Tailoring anesthetic techniques to real-time TEG data improved safety outcomes with minimized bleeding complications and satisfactory pain control. In conclusion, neuraxial blockade guided by TEG enhances safety in patients with uncertain coagulation profiles. Further studies are needed to validate benefits in broader clinical settings.

Anesthesia Management of a Patient Having Allgrove Syndrome

Abstract Background: Allgrove syndrome is an autosomal recessive disorder characterized by achalasia cardia, alacrimia and adrenocorticotropic hormone resistant adrenal insufficiency with progressive neurological impairment with or without mental retardation. Materials and Methods: Patient had undergone Heller’s myomectomy under GA. PAC was done, all routine investigations, oesophageal motility tests, ACTH level, Schirmer test was done. She was pre-medicated with glycopyrrolate, midazolam and induced with fentanyl, propofol, vecuronium, intubated with cuffed ET tube 6.5 and reversed with Neostigmine and glycopyrrolate. Result and Conclusion: Careful pre-operative evaluation, choice of sedatives, induction agents, muscle relaxant to avoid hyperventilation, hypokalemia, close monitoring of ABG and electrolytes, careful glycaemic control, eye protection, care to avoid aspiration and regurgitation are imperative for optimal management with Allgrove syndrome. The co-ordination of care for these patients require a multidisciplinary team of endocrinologist, neurologist, gasteroenterologist, ophthalmologist, surgeons and anaesthesiologists. We successfully conducted this case of 22 yrs old female with ALLGROVE SYNDROME.

Anesthesia Management of a Patient with Idiopathic Thrombocytopenic Purpura Undergoing Laparoscopic Esophageal Hiatal Hernia Surgery: A Case Report

Abstract Perioperative management of patients with immune thrombocytopenic purpura (ITP) has significant challenges for anesthesiologists. Perioperative bleeding due to thrombocytopenia in patients with ITP can be an essential challenge and is the most significant risk to anesthetists. Laparoscopic surgery can also be an additional challenge in such patients because of the risk of pneumoperitoneum that can lead to hemodynamic instability and bleeding deterioration. We present a 77-year-old successful anesthesia management of a female patient with ITP who underwent elective laparoscopic esophageal hiatal hernia surgery. A multidisciplinary team approach and comprehensive perioperative assessment and treatment are critical to ensure successful perioperative management of patients with ITP. We also aim to suggest that intravenous immunoglobulins therapy is not always mandatory in perioperative management of patients with ITP.

Anaesthetic management of a patient with idiopathic pulmonary arterial hypertension, suprasystemic pulmonary artery pressures and carcinoma of the ascending colon.

A 35-year-old woman with severe pulmonary arterial hypertension underwent open hemicolectomy with cholecystectomy under combined general and epidural anaesthesia. Intra-operative pulmonary artery pressure, as measured by Swan-Ganz catheter, was suprasystemic and managed with inodilators. She developed postoperative right ventricular dysfunction requiring inotropes, incremental pulmonary vasodilators and prolonged oxygen supplementation. One year after surgery, she is recurrence-free with oxygen saturations of 88-90% on air. This case highlights that with meticulous care and multidisciplinary team input, patients with severe pulmonary arterial hypertension can have favourable outcomes after major cancer surgery.

Anesthetic Choice for Percutaneous Transcatheter Closure of the Left Atrial Appendage: A National Anesthesia Clinical Outcomes Registry Analysis.

Left atrial appendage closure (LAAC) was developed as a novel stroke prevention alternative for patients with atrial fibrillation, particularly for those not suitable for long-term oral anticoagulant therapy. Traditionally, general anesthesia (GA) has been more commonly used primarily due to the necessity of transesophageal echocardiography. Compare trends of monitored anesthesia care (MAC) versus GA for percutaneous transcatheter LAAC with endocardial implant and assess for independent variables associated with primary anesthetic choice. Multi-institutional data collected from across the United States using the National Anesthesia Clinical Outcomes Registry. Retrospective data analysis from 2017-2021. Independent-sample t tests or Mann-Whitney U tests were used for continuous variables and Chi-square tests or Fisher's exact test for categorical variables. Multivariate logistic regression was used to assess patient and hospital characteristics. A total of 19,395 patients underwent the procedure, and 352 patients (1.8%) received MAC. MAC usage trended upward from 2017-2021 (P < 0.0001). MAC patients were more likely to have an American Society of Anesthesiologists (ASA) physical status of≥ 4 (33.6% vs 22.89%) and to have been treated at centers in the South (67.7% vs 44.2%), in rural locations (71% vs 39.5%), and with lower median annual percutaneous transcatheter LAAC volume (102 vs 153 procedures) (all P < 0.0001). In multivariate analysis, patients treated in the West had 85% lower odds of receiving MAC compared to those in the Northeast (AOR: 0.15; 95% CI 0.03-0.80, P = 0.0261). While GA is the most common anesthetic technique for percutaneous transcatheter closure of the left atrial appendage, a small, statistically significant increase in MAC occurred from 2017-2021. Anesthetic management for LAAC varies with geographic location.

Anesthetic Management of Intracardiac Migration of Medical Devices

The use of endovascular, percutaneous interventions for treatment of cardiac, arterial, and venous pathologies is becoming increasingly common in medical practice. While endovascular device placement typically carries low risk, device migration remains a persistent problem with these procedures for which anesthesia providers must have high index of suspicion. Anesthesia providers should be aware of the wide range of indications for such devices, potential migration locations, and hemodynamic consequences of both the inciting pathology as well as from device migration so they can safely care for patients in these settings. This article aims to discuss a case series of five different device migration events, review the literature surrounding migration of each device, and propose unique anesthetic considerations as well as a systematic approach by which to approach these complications.

A single-center prospective study of perioperative anesthetic complications in cleft lip, alveolus, and palate surgeries in a teaching hospital in Lagos, Nigeria

ABSTRACT Background: Cleft lip and/or palate are one of the most common congenital craniofacial anomalies that require surgical management. Patients undergoing primary cleft repair are at increased risk of perioperative anesthetic complications due to their young age and anatomical defects. Aim: This study aimed to present the frequency of perioperative airway-related morbidities in the anesthetic management of cleft lip, alveolus, and palate surgeries. Patients and Methods: This study was conducted at Lagos University Teaching Hospital, Nigeria. Patients undergoing cleft lip, alveolus, or palate repair were prospectively studied from January 2015 to December 2019. Data on patient demography, type of cleft, presence of syndromes and other deformities, and intra- and postoperative complications were collected. Results: A total of 150 patients were included, with a median age of 15.5 months, and 67 (44.7%) of the patients were &lt;12 months old. Most patients were female (56%), and the most common type of cleft was lip, alveolus, and palate (36.6%). Sixteen (10.7%) of the patients had associated syndromes. Notably, intraoperative complications were observed in 5 (3.3%) patients, including laryngospasm and difficult intubation. Postoperative complications were rare, with one case of nasal bleeding. Significant associations between presence of other deformities and syndromes and intraoperative complications were noted (P &lt; 0.05). Conclusion: Patients with orofacial clefts and other deformities tend to be predisposed to anesthetic complications. However, the incidence of anesthetic complications in this study was low (3.3%) probably because the current protocol used in the author’s hospital for cleft surgeries was followed and appropriate.

Anaesthetic management of duodenal perforation in a patient of acute coronary syndrome: A case report

Anaesthetic management of duodenal perforation in a patient of acute coronary syndrome: A case report

Successful Anesthesia Management in Landau–Kleffner Syndrome Undergoing Laparoscopic Surgery: A Case Report

Abstract Landau–Kleffner syndrome (LKS), also known as acquired epileptic aphasia, is a childhood disease associated with acquired aphasia and epileptiform abnormalities on the electroencephalographic. We report the uneventful anesthesia management of a 17-year-old female patient with LKS syndrome. Her vital signs and laboratory results were normal, and plasma levels of valproic acid (73.6 µg/mL) were within therapeutic limits. She had mild micrognathia, short thyromental distance, and normal neck movements and mouth opening. An intravenous induction was performed with 100 mg lidocaine, 100 µg fentanyl, 200 mg propofol, and 60 mg rocuronium intravenously. After preoxygenation with 80% O2 for 3 min, she was intubated without complications with a number 7.5 mm endotracheal tube connected to a ventilator. Anesthesia maintenance was provided with 2.2% sevoflurane and 50% oxygen–50% air mixture, 0.01–0.05 μg/kg/min infusion of remifentanil. The target partial pressure of carbon dioxide was 30–35 mm Hg. Care was taken to ensure that intra-abdominal pressure did not exceed 14 mm Hg. Spontaneous breathing returned in 5 min after discontinuation of sevoflurane. She was extubated after following commands and transferred to the post-anesthesia care unit. It is unknown whether general anesthesia has a short- or long-term effect on patients with LKS. Since epileptic seizures are essential in patients with LKS, the correct selection of anesthetic agents is significant. In addition, hypoxemia, hypercarbia, hypocapnia, high positive end-expiratory pressure, and acidosis should all be avoided as they may trigger seizure activity.

Anesthetic Management of a Patient with Occipito-Cervical Fusion for Elective Cesarean Section

A 25-year-old primi, with a history of occipto-cervical fusion (OCF) performed at the age of 13 years, presented for an elective cesarean section. A combined spinal–epidural anesthetic (CSE) was administered, with a successful maternal and fetal outcome. The spinal component of the CSE was unsuccessful at providing surgical anesthesia.

Management of anaesthesia in children with neuromuscular dis­eases

Management of anaesthesia in children with neuromuscular dis­eases

Anaesthetic Management in Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Patient Posted for Total Knee Replacement: A Case Report

Anaesthetic Management in Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Patient Posted for Total Knee Replacement: A Case Report

Anesthesia and Multidisciplinary Team Management throughout the Exit Procedure and Excision of a Huge Congenital Cervical Teratoma: A Case Report

Anesthesia and Multidisciplinary Team Management throughout the Exit Procedure and Excision of a Huge Congenital Cervical Teratoma: A Case Report

Strategies for Safe Transurethral Injections of Botulinum Toxin into the Bladder Wall.

Introduction: Transurethral injections into the bladder wall with botulinum toxin are an established treatment for refractory overactive bladder or detrusor overactivity. With the current injection technique, an average of approx. 18% and up to 40% of botulinum toxin is injected next to the bladder wall, potentially causing reduced efficacy or non-response. The article aims to evaluate the reasons for incorrect injections and propose strategies for complete delivery of the entire botulinum toxin fluid into the bladder wall. Material and Methods: Unstructured literature search and narrative review of the literature. Results: Incorrect injection of botulinum toxin fluid next to the bladder wall is caused by pushing the injection needle too deep and through the bladder wall. Bladder wall thickness decreases with increasing bladder filling and has a thickness of less than 2 mm beyond 100 mL in healthy individuals. Ultrasound imaging of the bladder wall before botulinum toxin injection can verify bladder wall thickness in individual patients. Patient movements during the injection therapy increase the chance of incorrect placement of the needle tip. Conclusions: Based on the literature search, it is helpful and recommended to (1) perform pretreatment ultrasound imaging of the bladder to estimate bladder wall thickness and to adjust the injection depth accordingly, (2) fill the bladder as low as possible, ideally below 100 mL, (3) use short needles, ideally 2 mm, and (4) provide sufficient anesthesia and pain management to avoid patient movements during the injection therapy.

Anaesthetic Management of a Parturient with Mixed Connective Tissue Disorder

Anaesthetic Management of a Parturient with Mixed Connective Tissue Disorder

Update on the anesthesia management in adult patients with moyamoya disease.

The anesthetic management of patients with Moyamoya disease (MMD) is challenging and continues to evolve. The goal of this review is to provide updated recommendations on the anesthetic management of adult MMD patients based on the relevant existing literature. Key findings include the importance of aggressive hydration preoperatively to sustain cerebral perfusion. Hypertension induced intraoperatively may prevent cerebral hypoperfusion. Vigilance against cerebral hyperperfusion after revascularization is necessary, with specific blood pressure targets recommended. Fluid management should aim for normovolemia to mild hypervolemia. Maintaining body temperature helps prevent cerebral vasospasm induced by hypothermia. Maintaining adequate oxygen supply during surgery is crucial. In cases of ischemic stroke, managing hematocrit and oxygen carrying capacity is essential to prevent further ischemia. Extubation decisions should consider baseline neurological function, while postoperative normocapnia helps prevent cerebral hyperperfusion and hypertension. In intensive care, cautious blood pressure management is crucial to prevent secondary complications. Strategies in the preoperative, intraoperative, and postoperative anesthetic management of MMD patients should aim to maintain adequate cerebral perfusion to prevent cerebral ischemia.