Anesthetic Management Research Articles

A SURVEY ON ANESTHESIA MANAGEMENT PRACTICE BY SMALL ANIMAL VETERINARIAN IN DKI JAKARTA AND WEST JAVA PROVINCES

his study was designated to the members of the Indonesian Veterinary Medical Association (IVMA) in DKI Jakarta and West Java Province between May and August 2023. The sample size was calculated with the Slovin method which covered 260 respondents with a significance level of 5.4%. Questions was focused mainly on the respondent’s identity, perianesthesia procedures, and anesthesia topic for continuing professional development. The majority of respondents performed ≤5 cases of anesthesia per week in dogs (76.9%) and cats (36.2%). Preanesthesia physical examination was carried out by 96% of respondents. Premedication was always given to dogs (66.2%) and cats (63.5%). IV catheter placement was always given in 41.2% of dogs and frequently in 38.5% of cats. Atropine was the most widely used premedication agent (88%) and meloxicam mainly used for analgesic (57%). The induction agent widely used was ketamine (34), while the maintenance agent was isoflurane in dogs (43.5%) and ketamine in cats (37.3%). The anesthesia monitoring tools that are widely used were thermometers (89.6%) and pulse oximeters (38.8%). As conclusion, the majority of respondents were considered to have understood anesthesia management in accordance with recommendations, however, this understanding could be improved through continuing education.

The evolution and formalization of anesthesia assistant roles across Canada.

The purpose of this Special Article is to document the evolution of the anesthesia assistant (AA) profession in Canada and summarize AA practice at Canadian institutions as it exists today, five decades after Quebec and 15years after most other provinces formalized AA practice. Through the Management Committee of the Association of Canadian University Departments of Anesthesia (ACUDA), we conducted a purposeful sampling of all ACUDA chairs or their delegates. We requested the following data: history of AAs becoming a reality in their particular province or region; potential recruitment pools; training programs and curricula; pathway to credentialing; funding, pay, retention, recruitment, and status of union representation; and metrics. Data were provided by 19 institutions in 8 provinces: Newfoundland and Labrador, Nova Scotia, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia. Given the different health care governance structures across the provinces, AA roles vary in terms of its associated technical, clinical, and educational responsibilities. The role of AAs in supporting anesthesia care through equipment maintenance and assistance with airway management, resuscitation, and administration of regional anesthesia seems to be well established, as is their role in providing brief intraoperative relief for anesthesiologists during a stable period of anesthesia. Anesthesia assistant duties continue to evolve, becoming more aligned with the specific institution and less dependent on the supervising anesthesiologist. Apart from the initial metrics collected during the Ontario ACT implementation pilot projects, we are not aware of any formal metrics, current or ongoing, being collected across Canada, related to either patient safety events or perioperative efficiency. This compilation of pan-Canadian AA data shows diverse models of practice and highlights the value to patients and the health care system as a whole of incorporating these allied professionals into the anesthesia care team (ACT). The present findings allow us to offer suggestions for consideration during discussions of retention, recruitment, program expansion, and cross-country collection of metrics and other data. We conclude by making six recommendations: 1. recognize that implementation of ACTs is a key element in solving the challenge of an increasing surgical backlog; 2. develop, or facilitate the development of, metrics and increase data-sharing nationally to enable health care authorities to better understand the importance of AAs in patient safety and perioperative efficiency; 3. develop and implement funding strategies to lower the barriers to AA training such as hospital-sponsored positions, ongoing salary support, and return-of-service arrangements; 4. ensure that salaries appropriately reflect the increased level of training and added levels of responsibility of certified AAs; 5. develop long-term strategies to ensure stable funding, recruitment and retention, and a better match between the number of AA training positions and the need for newly certified AAs; and 6. engage all stakeholders to acknowledge that AAs, as knowledgeable and specifically trained assistants, not only fulfill their defined clinical role but also contribute significantly to patient safety and clinical efficiency by assuming nondirect patient care tasks.

Hereditary Angioedema in Pregnancy: A Case Report and Review of Obstetric Anesthesia Management.

Hereditary angioedema (HAE) is a rare disorder due to C1 esterase inhibitor deficiency, causing recurrent swelling. Pregnancy can exacerbate HAE due to estrogen fluctuations alongside peripartum stress and trauma. We present a pregnant patient with HAE who underwent induction of labor and vaginal delivery with neuraxial anesthesia. Management included C1-inhibitor prophylaxis, 48 hours of postpartum monitoring, and a self-treatment plan at discharge. Angioedema prevention involves timely anesthesia consultation, accessible emergency airway equipment, early neuraxial anesthesia, planned vaginal delivery, and 48 to 72 hours of close postpartum monitoring. Readily available C1-inhibitor and a multidisciplinary approach with these recommendations are crucial for peripartum management.

Perioperative anesthetic management of patients with hypoplastic left heart syndrome undergoing the comprehensive stage II surgery-A review of 148 cases.

Patients with hypoplastic left heart syndrome undergo the comprehensive stage 2 procedure as the second stage in the hybrid approach toward Fontan circulation. The complexity of comprehensive stage 2 procedure is considered a potential limitation, and limited information is available on its anesthetic management. This study aims to address this gap. A single-center retrospective cohort study analyzed 148 HLHS patients who underwent comprehensive stage 2 procedure, divided into Group A (stable condition, n = 116) and Group B (requiring preoperative intravenous inotropic therapy, n = 32). Demographic data, intraoperative hemodynamics, anesthetic management, and postoperative outcomes were collected. Etomidate (40%) was the most common induction agent, followed by esketamine (24%), midazolam (16%), and propofol (13%). Inhaled induction was rarely necessary (2%), occurring only in Group A patients. No statistical differences were found between groups for induction drug choice. Post-cardiopulmonary bypass management included moderate hypoventilation, inhaled nitric oxide (100%), and hemodynamic support with milrinone (97%) and norepinephrine (77%). Group B patients more frequently required additional levosimendan (20%) and epinephrine (18%). Extracorporeal membrane oxygenation was necessary in 8 patients (5%) with no between-group differences. Switching from fentanyl to remifentanil reduced postoperative ventilation time overall. However, Group B experienced significantly longer ventilation (6.3 vs. 3.5 h) and ICU stay (22 vs. 14 days). In-hospital mortality was 5% overall (Group A: 4%, Group B: 9%). Long-term survival analysis revealed a significant advantage for Group A. The use of short-acting opioids and adjusted ventilation modes enables optimal pulmonary blood flow and rapid transition to spontaneous breathing. Differentiated hemodynamic support with milrinone, norepinephrine, supplemented by levosimendan and epinephrine in high-risk patients, can mitigate the effects on the preoperatively volume-loaded right ventricle. However, differences in long-term survival probability were observed between groups. Local ethics committee, Medical Faculty, Justus-Liebig-University-Giessen (Trial Code Number: 216/14).

Anesthesia and Operating Room Waste Management

Introduction Operating rooms (ORs) are associated with high waste generation that contribute significantly to the overall hospital waste production, costs, and environmental impact. Hence, this study sought to explore the impact of the revision of single-use surgical packs in waste reduction and hospital cost savings. Methods A systematic review with meta-analysis was conducted to assess waste reduction strategies in operating rooms. A search was conducted on databases to evaluate the impacts of interventions on anesthesia waste reduction and cost savings. The search was limited to studies conducted between 2014 and 2024. Results The findings of the systematic review indicate that the revision of single-use surgical packs was associated with significant reductions in OR and anesthesia waste production and hospital costs. Conclusion The findings show that waste reduction initiatives could be effective in enhancing the sustainability of surgical procedures. The study underscores the role of simple but sustainable practices in addressing persistent environmental and financial challenges in the healthcare sector.

The relationship between anesthesia, surgery and postoperative immune function in cancer patients: a review.

This review comprehensively examines the impact of anesthesia and surgical interventions on the immune function of cancer patients postoperatively. Recent studies have shown that surgery and its accompanying anesthesia management can significantly influence immune function in cancer patients, potentially affecting their prognosis. This review synthesizes clinical studies and basic research to summarize the specific effects of anesthesia methods, drugs, postoperative analgesia, intraoperative transfusion, surgical techniques, and trauma extent on the immune function of cancer patients post-surgery. Additionally, this review discusses optimization strategies based on current research, aiming to refine anesthesia and surgical management to maximize the preservation and enhancement of postoperative immune function in cancer patients, with the potential to improve clinical outcomes.

Management of anesthesia in elderly patients, special considerations and challenges

Introduction: Anesthesia management in elderly patients presents distinct challenges due to physiological changes related to aging. Comorbidities, physical frailty and increased risk of postoperative complications are important aspects to be considered. Methods: Systematic reviews of the literature and analyzes of clinical and experimental studies that addressed the management of anesthesia in elderly patients were carried out. Articles published in English, Spanish and Portuguese were selected. The keywords used were "anesthesia in the elderly", "preoperative assessment", "anesthetic techniques", "intraoperative monitoring", "postoperative pain control" and "prevention of complications". Results: Comprehensive and individualized preoperative assessment was identified as crucial for identifying and treating comorbidities and physical frailty in elderly patients. The choice of the appropriate anesthetic technique depends on the type of surgery and the patient's clinical conditions. Careful monitoring during anesthesia, including blood pressure, heart rate, oxygenation and capnography, is essential to detect and intervene early on hemodynamic and respiratory changes. Postoperative pain control in the elderly requires an individualized approach, with appropriate use of analgesics and regional blocks. Complication prevention strategies, such as optimizing hydration, glycemic control, early mobilization and appropriate use of medications, are essential to reduce the risk of delirium, infection and cognitive dysfunction. Conclusion: Anesthesia management in elderly patients requires an individualized and comprehensive approach, taking into account physiological changes related to aging and associated comorbidities. Careful preoperative assessment, appropriate choice of anesthetic technique, strict intraoperative monitoring, postoperative pain control and prevention of complications are essential to ensure a safe perioperative period and successful recovery in the elderly. Keywords: anesthesia in the elderly, preoperative assessment, anesthetic techniques, intraoperative monitoring, postoperative pain control, prevention of complications.

Clinical Implications of HELLP Syndrome in Anesthesia Management of Preeclamptic Pregnant Mothers: A Literature-Based Review

BACKGROUND:Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a serious life-threatening obstetric emergency accompanied with heterogeneous presentation and multisystem dysfunction. It increases the perils of fetal morbidity and mortality and requires complex clinical management during medical and surgical interventions. Hence, it remains a major challenge for anesthesia providers during perioperative management. The current study aimed to explore the main clinical implications of HELLP syndrome in anesthesia management of preeclamptic pregnant mothers who underwent cesarean section.METHODOLOGY:An exhaustive search of the literature was conducted on the available relevant databases, such as PubMed, Google Scholar, and Cochrane Reviews, published from 1990 to 2023, using the terms HELLP syndrome, cesarean section, and anesthetic challenges/complications. All observational studies, randomized controlled trials (RCTs), cohorts, and nonrandomized studies on HELLP syndrome and anesthetic challenges during cesarean section reported in English were included. Nonpregnant mothers with HELLP syndrome and studies with no relevant reports or abstracts, case reports, or case studies were excluded.RESULTS:A systematic search of relevant databases identified 82 studies: 60 from PubMed, 18 from Google Scholar, and 4 from Cochrane Reviews. After removing duplicates, 48 studies were screened and recorded. Eighteen studies were assessed for eligibility after their titles and abstracts were reviewed. Twelve studies were excluded from the current study, as it did not fulfill the inclusion criteria. Finally, six studies, four retrospective studies, one prospective observational study, and one RCT, were included and reviewed.CONCLUSION:Perioperative anesthetic care in patients with HELLP syndrome remains a challenge. Hence, anesthetic techniques should be selected based on the severity of the condition, patient status, urgency surgery, fetal conditions, coagulation status, and safe platelet counts.

Anestesias de pacientes de alto risco durante a abordagem cirúrgica: Estratégias adaptadas para pacientes com comorbidades

Introduction: The anesthetic management of high-risk patients, especially those with significant comorbidities, represents an important clinical challenge. This study reviews the anesthetic strategies adapted for these patients, focusing on interventions that can minimize perioperative complications and improve surgical outcomes. Methods: Studies published between 2010 and 2024 were analyzed, using databases such as PubMed, Scielo, and the Brazilian Journal of Anesthesiology. The review included randomised controlled trials that compared different anaesthetic techniques and their implications for high-risk patients. Studies without a control group were excluded from the analysis. Results: The results indicated that patients at high risk of obstructive sleep apnea have a higher incidence of adverse respiratory events, which highlights the importance of specific anesthetic strategies for this population. Pressure-controlled volume-assured ventilation (PCV-VG) was superior to volume-controlled ventilation (VCV) in obese patients undergoing laparoscopic surgery in the Trendelenburg position, providing better ventilatory parameters and oxygenation. Costoclavicular block has been identified as an effective and safe technique for upper limb anesthesia in obese patients, reducing the need for general anesthesia. In cardiac surgeries, glucose-insulin-potassium (GIK) administration has been shown to be beneficial, reducing adverse cardiac events and improving hemodynamic stability. Finally, spinal anesthesia has been shown to be preferable to general anesthesia in lumbar spine surgeries for high-risk patients, promoting greater intraoperative stability. Conclusion: It is concluded that the personalization of anesthetic strategies is essential to optimize the management of high-risk patients, taking into account individual characteristics and comorbidities. Careful choice of anesthetic techniques can minimize complications, improve postoperative outcomes, and ensure a safer recovery. The integration of new evidence and the adoption of multidisciplinary approaches are essential to improve perioperative care and promote better outcomes in complex and vulnerable patients.

Understanding the anatomy of pelvic fascia: implications for regional anesthesia.

The fascia, a continuous structure around the whole body across various anatomical locations, remains underexplored in regional anesthesia. The pelvic fascia is a particularly controversial and complicated anatomical structure. It holds significant relevance not only for surgeons but also in the realms of regional anesthesia and pain management. Many regional nerve blocking techniques in the pelvis are closely related to fascial anatomy, such as fascia iliaca compartment block, circum-psoas block, inferior hypogastric plexus block, and ganglion impar block. The continuity of fascia and interfascial spaces profoundly influences both the efficacy of blockades and the incidence of complications. A thorough understanding of pelvic fascia anatomy is crucial for understanding the potential pathways and barriers for spread of local anesthetics, enhancing analgesia, and minimizing side effects. Currently, a systematic discussion of pelvic fascia from the perspective of regional anesthesia and pain therapy is notably absent. This narrative review aims to consolidate knowledge on the anatomy of pelvic fascia pertinent to regional anesthesia and pain management, detailing relevant pelvic nerves, and associated peripheral nerve blocking techniques.

Small incisions still require great anesthesia: anesthesiology techniques to enhance recovery in robotic coronary bypass grafting.

Robotic coronary artery bypass grafting (CABG) has emerged as a promising minimally invasive surgical technique for the treatment of coronary artery disease. This paper provides an in-depth analysis of the anesthetic management for robotic CABG. Challenges associated with robotic CABG are discussed and various anesthetic techniques, perioperative elements and pain management modalities that can contribute to enhanced patient recovery are explored.

Evaluating Large Language Models in Dental Anesthesiology: A Comparative Analysis of ChatGPT-4, Claude 3 Opus, and Gemini 1.0 on the Japanese Dental Society of Anesthesiology Board Certification Exam.

Purpose Large language models (LLMs) are increasingly employed across various fields, including medicine and dentistry. In the field of dental anesthesiology, LLM is expected to enhance the efficiency of information gathering, patient outcomes, and education. This study evaluates the performance of different LLMs in answering questions from the Japanese Dental Society of Anesthesiology Board Certification Examination (JDSABCE) to determine their utility in dental anesthesiology. Methods The study assessed three LLMs, ChatGPT-4 (OpenAI, San Francisco, California, United States), Gemini 1.0 (Google, Mountain View, California, United States), and Claude 3 Opus (Anthropic, San Francisco, California, United States), using multiple-choice questions from the 2020 to 2022 JDSABCE exams. Each LLM answered these questions three times. The study excluded questions involving figures or deemed inappropriate. The primary outcome was the accuracy rate of each LLM, with secondary analysis focusing on six subgroups: (1) basic physiology necessary for general anesthesia, (2) local anesthesia, (3) sedation and general anesthesia, (4) diseases and patient management methods that pose challenges in systemic management, (5) pain management, and (6) shock and cardiopulmonary resuscitation. Statistical analysis was performed using one-way ANOVA with Dunnett's multiple comparisons, with a significance threshold of p<0.05. Results ChatGPT-4 achieved a correct answer rate of 51.2% (95% CI: 42.78-60.56, p=0.003) and Claude 3 Opus 47.4% (95% CI: 43.45-51.44, p<0.001), both significantly higher than Gemini 1.0, which had a rate of 30.3% (95% CI: 26.53-34.14). In subgroup analyses, ChatGPT-4 and Claude 3 Opus demonstrated superior performance in basic physiology, sedation and general anesthesia, and systemic management challenges compared to Gemini 1.0. Notably, ChatGPT-4 excelled in questions related to systemic management (62.5%) and Claude 3 Opus in pain management (61.53%). Conclusions ChatGPT-4 and Claude 3 Opus exhibit potential for use in dental anesthesiology, outperforming Gemini 1.0. However, their current accuracy rates are insufficient for reliable clinical use.These findings have significant implications for dental anesthesiology practice and education, including educational support, clinical decision support, and continuing education. To enhance LLM utility in dental anesthesiology, it is crucial to increase the availability of high-quality information online and refine prompt engineering to better guide LLM responses.

Dexmedetomidine versus Ketofol for Moderate Sedation in Endoscopic Retrograde Cholangiopancreatography.

To compare the efficacy of dexmedetomidine versus ketofol for moderate sedation in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Randomised controlled trial. Place and Duration of the Study: Department of Anaesthesia, SICU and Pain Management, Sindh Institute of Urology and Transplantation, Karachi, Paksitan, from December 2021 to June 2022. Sixty-two patients aged 20-60 years of any gender scheduled for elective ERCP were included. Patients were randomly divided into Dexmedetomidine group (2ml ampule of 100ug/ml diluted in 18ml of normal saline) and Ketofol group (2ml ketamine and 10ml of propofol 1% diluted in 8ml of normal saline) for sedation. The mean difference in time to achieve Ramsay Sedation Scale (RSS) score of 4 and Modified Aldrete's Score (MAS) of 9 were noted as outcomes in each group. In addition, complications during the procedure and recovery were also noted. The mean age was 39.15 ± 9.82 years. There were 33 (53.2%) males and 29 (46.8%) females. The mean time to achieve RSS 4 was significantly lower in patients who were treated with Dexmedetomidine as compared to Ketofol, i.e., 11.84 ± 1.77 minutes vs. 13.10 ± 1.64 minutes respectively (p-value 0.005, 95% CI -2.12 to -0.39). Similarly, the mean time to achieve MAS score 9 was significantly lower in patients who were treated with Dexmedetomidine as compared to Ketofol, i.e., 11.19 ± 1.72 minutes vs. 12.23 ± 1.84 minutes, respectively (p-value 0.026, 95% CI -1.94 to -0.13). Dexmedetomidine proved to be more effective than Ketofol for sedation in ERCP, achieving faster sedation and quicker recovery. Dexmedetomidine, Ketofol, Sedation, Endoscopic Retrograde Cholangiopancreatography.

Anesthesia-Related Closed Claims in Free-Standing Ambulatory Surgery Centers.

As higher acuity procedures continue to move from hospital-based operating rooms (HORs) to free-standing ambulatory surgery centers (ASCs), concerns for patient safety remain high. We conducted a contemporary, descriptive analysis of anesthesia-related liability closed claims to understand risks to patient safety in the free-standing ASC setting, compared to HORs. Free-standing ASC and HOR closed claims between 2015 and 2022 from The Doctors Company that involved an anesthesia provider responsible for the claim were included. We compared the coded data of 212 free-standing ASC claims with 268 HOR claims in terms of severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. Free-standing ASC claims accounted for almost half of all anesthesia-related cases (44%, 212 of 480). Claims with high severity of injury were less frequent in free-standing ASCs (22%) compared to HORs (34%; P = .004). The most common types of injuries in both free-standing ASCs and HORs were dental injury (17% vs 17%) and nerve damage (14% vs 11%). No difference in frequency was noted for types of injuries between claims from free-standing ASCs versus HORs--except that burns appeared more frequently in free-standing ASC claims than in HORs (6% vs 2%; P = .015). Claims with alleged improper management of anesthesia occurred less frequently among free-standing ASC claims than HOR claims (17% vs 29%; P = .01), as well as positioning-related injury (3% vs 8%; P = .025). No difference was seen in frequency of claims regarding alleged improper performance of anesthesia procedures between free-standing ASCs and HORs (25% vs 19%; P = .072). Technical performance of procedures (ie, intubation and nerve block) was the most common contributing factor among free-standing ASC (74%) and HOR (74%) claims. Free-standing ASC claims also had a higher frequency of communication issues between provider and patient/family versus HOR claims (20% vs 10%; P = .004). Most claims were not associated with major comorbidities; however, cardiovascular disease was less prevalent in free-standing ASC claims versus HOR claims (3% vs 11%; P = .002). The mean ± standard deviation total of expenses and payments was lower among free-standing ASC claims ($167,000 ± $295,000) than HOR claims ($332,000 ± $775,000; P = .002). This analysis of medical malpractice claims may indicate higher-than-expected patient and procedural complexity in free-standing ASCs, presenting patient safety concerns and opportunities for improvement. Ambulatory anesthesia practices should consider improving safety culture and communication with families while ensuring that providers have up-to-date training and resources to safely perform routine anesthesia procedures.

PERI-OPERATIVE ANAESTHETIC CONCERNS IN COVID-19 ASSOCIATED MUCORMYCOSIS

Introduction: Mucormycosis is a fulminant life-threatening fungal infection requiring emergency surgical debridement. It is associated with immune-compromised status, multi-systemic involvement, and difficult airway posing challenges to anesthetic management. We conducted this study to find the peri-operative anesthesia concerns in patients of COVID-19-associated mucormycosis Methods: This retrospective observational study included COVID-19-infected patients operated for invasive mucormycosis under general anesthesia. Cases operated under local anesthesia were excluded from the study. Results: A total of 30 patients were included in the study where the majority of the patients were ASA physical status III. ASA classification uses a grading system of l(one) through V( five), with I identifying a person in good health and V as a person with a severe, life-threatening condition. The most common co-morbidity was diabetes mellitus plus hypertension 66% (n=20), followed by only diabetes 30% (n=9). Out of all patients, 33.3% (n=10) were intubated at the first attempt using direct laryngoscope, rest 66.6% required other interventions like the use of video laryngoscope, bougie, or external laryngeal pressure. Perioperative blood transfusion was required in 40% (n=12) of the patients. Of patients who required intensive care unit (ICU) admission 40% (n=12) out of them, 10% patients (n=3) did not survive. The average hospital stay was 55.9 +/-15.8 days with a maximum of 95 days and a minimum of 15 days. Conclusion: Mucormycosis is mostly associated with uncontrolled diabetes milletus in post-COVID patients. These require utmost care peri-operatively as they are associated with a difficult airway, intraoperative complications, prolonged morbidity, and mortality.

Perioperative Anesthetic Considerations for Catheter-Based Pulmonary Vein Interventions in Fibrosing Mediastinitis

IntroductionFibrosing mediastinitis is a rare disease characterized by abnormal proliferation of fibrous tissue, causing compression, and narrowing of the airway, blood vessels and other mediastinal structures, including the pulmonary veins. Catheter based interventions are available palliative strategies. Due to the complex nature of the disease and the profound respiratory and hemodynamic sequela that may ensue, anesthetic management requires meticulous interdisciplinary planning. MethodsWe performed a retrospective descriptive study including patients with Fibrosing Mediastinitis undergoing catheter-based interventions for pulmonary vein stenosis from January 2020 to April 2024. A total of fourteen patients underwent chart review and we reported patient sex, preprocedural pulmonary artery pressures, comorbidities, lung isolation strategies, intra-procedural anesthestic complications, post procedural ICU admissions and length of stayResults: All patients underwent pulmonary vasculature angioplasty, with or without stent placement, under general anesthesia with lung isolation capabilities and echocardiogram guidance. 11 of 18 (61%) cases were uncomplicated. 4 of 18 (22%) required unanticipated postoperative ICU care, 2 (11%) in the setting of pulmonary hemorrhage, one due to hypoxic respiratory failure, and one due to difficult airway. One patient developed self-limiting postoperative hemoptysis in two different occasions and one patient developed a vascular access related complication. Mean hospital length of stay (LOS) was 2.6 days (0-13 days) and mean ICU LOS was 1.75 days (1-4 days). One patient presented 6-weeks postoperatively with massive hemoptysis likely secondary to PV rupture and passed away following a protracted ICU course. ConclusionPatients with FM can achieve successful intraprocedural outcomes by ensuring a comprehensive understanding of the disease, addressing significant anesthetic concerns and considerations, and engaging a multi-disciplinary team.

Recommendation for the practice of total intravenous anesthesia.

This Recommendation was developed by the Japanese Society of Intravenous Anesthesia Recommendation Making Working Group (JSIVA-WG) to promote the safe and effective practice of total intravenous anesthesia (TIVA), tailored to the current situation in Japan. It presents a policy validated by the members of JSIVA-WG and a review committee for practical anesthesia management. Anesthesiologists should acquire and maintain the necessary knowledge and skills to be able to administer TIVA properly. A secure venous access is critically important for TIVA. To visualize and understand the pharmacokinetics of intravenous anesthetics, use of real-time pharmacokinetic simulations is strongly recommended. Syringe pumps are essential for the infusion of intravenous anesthetics, which should be prepared according to the rules of each individual anesthesia department, particularly with regard to dilution. Syringes should be clearly labeled with content and drug concentration. Whenmanaging TIVA, particularly with the use of muscle relaxants, monitoring processed electroencephalogram (EEG) is advisable. However, the depth of sedation/anesthesia must be assessed comprehensively using various parameters, rather than simply relying on a single EEG index. TIVA should be swiftly changed to an alternative method that includes inhalation anesthesia if necessary. Use of antagonists at emergence may be associated with re-sedation risk. Casual administration of antagonists and sending patients back to surgical wards without careful observation are not acceptable.

SIMBA-A Single-Puncture Approach to Lower Limb Block.

Peripheral nerve blocks provide a safe and reliable alternative in the anesthetic management of femur fractures in elderly subpopulations associated with significant comorbidities. Single-Insertion Multiple Nerve Block Anesthesia (SIMBA) is a technique where a single needle insertion is used to block all four nerves that supply the femur shaft: the femoral nerve, obturator nerve, lateral femoral cutaneous nerve, and sciatic nerve. The authors performed this technique in 11 cardiac compromised geriatric patients with midshaft/distal femur fractures, and the surgery was conducted successfully without any significant hemodynamic change and good postoperative analgesia.

P.433: Bridge to heart transplantation: Preoperative etiology, intraoperative anesthesia management and postoperative follow-up findings and complications in patients with heart support device.

P.433: Bridge to heart transplantation: Preoperative etiology, intraoperative anesthesia management and postoperative follow-up findings and complications in patients with heart support device.

Anaesthetic challenges of carinal resection and reconstruction: A case report.

Carinal resection of tumour involving trachea and carina remains as a challenge for thoracic surgeons and anaesthesiologists. Resection is technically demanding and can be associated with significant morbidity and mortality. In this case report, we describe the successful management of carinal tumour with carinal resection in a 45-year-old female. The tumour was involving lowermost trachea, carina and bilateral primary bronchi causing 60% narrowing of the lower trachea just before carina, more than 90% narrowing of right main bronchus and 50% luminal narrowing of left main bronchus. Carinal resection and reconstruction were successfully performed under general anaesthesia. Patient was managed with conventional orotracheal intubation with Micro laryngeal endotracheal tube and positioned in left principal bronchus railroaded over a paediatric bronchoscope for lung isolation. After thoracotomy, the left main bronchus was intubated directly across the operative field with a sterile flexometallic endotracheal tube. With intermittent ventilation, anastomosis was completed. During anastomosis Micro laryngeal endotracheal tube cuff was damaged twice and we had to reintubate the patient twice in lateral position itself. At the end of anastomoses, flexometallic tube was removed and wound repaired. After confirming no leakage at anastomotic site, Micro laryngeal endotracheal tube was removed and Laryngeal Mask Airway was inserted and bronchial toileting done with adult bronchoscope. Meticulous planning and communication between the anaesthesia and surgical teams are mandatory for the safe and successful anaesthetic management of carinal resection surgeries.