Anesthesia In High-risk Patients Research Articles

Axillary Plexus Block for Anesthesia Management in Patients with Acute Compartment Syndrome after Primary Percutaneous Coronary Intervention (PCI) Transradial Approach: A Case Report

Background: Acute compartment syndrome is a rare complication of the percutaneous Coronary Intervention (PCI) transradial approach but it is very hand-threatening. Treatment for acute compartment syndrome is emergent fasciotomy of the affected compartments to reduce intracompartmental pressure. Axillary plexus block is an excellent choice of anesthesia technique for elbow, forearm, and hand surgery.
 Case presentation: An 80-year-old, 60 kg, 168 cm man was consulted to our department with a painful swelling on his right upper arm and hand that began three hours after a primary PCI procedure. Previously, the patient had a history of hypertension and diabetes mellitus. The supporting examination results were notable for anemia (Hemoglobin 7,5 g/dL), thrombocytopenia (78 x103/uL), elevated hemostasis function (International Normalized Ratio 1.43), and high blood sugar (360 mg/dL) from echocardiography results anteroseptal and lateral hypokinetic. Before we did block, the patient was given ketamine 10 mcg IV and fentanyl 25 mcg IV for sedation. Axillary plexus block, as a type of regional anesthesia under ultrasound guidance, is a reliable substitute for general anesthesia in high-risk patients, and we do it with a dose of 20 ml of solution (50 mg (10 ml) isobaric bupivacaine 0.5% + 200 mg lidocaine 2% diluted with 20 ml normal saline). During the surgery, the patient was hemodynamically stable. After the operation, the patient was readmitted to the intensive cardiac care unit (ICCU).
 Conclusion: Axillary plexus block can be an alternative to general anesthesia in patients who will undergo fasciotomy surgery after percutaneous coronary intervention transradial approach with stable hemodynamics during surgery and well-controlled pain after the surgery.

Is quadratus lumborum block combined with low dose-spinal anesthesia an effective alternative to general anesthesia in patients undergoing percutaneous nephrolithotomy?

General anesthesia in high-risk patients has many complications and needs long preoperative preparations and postoperative intensive care unit (ICU). Therefore the present study aimed to evaluate the efficacy of combined low-dose spinal anesthesia with quadratus lumborum block (QLB) as an alternative to general anesthesia for patients undergoing percutaneous nephrolithotomy. A prospective study was conducted at the urology department of Al-Azhar University Hospitals in Cairo, Egypt, from January 2021 to January 2022. The study included 60 patients of ASA ll-lll scheduled for percutaneous nephrolithotomy. All patients received low-dose spinal anesthesia (5 mg bupivacaine) and QLB (QL1-QL2-QL3) approaches. The primary observation parameter was the efficacy of this technique as an alternative to general anesthesia. The secondary parameters measured were evaluation of need for intraoperative narcotics, postoperative pain score (VAS), and patients satisfaction as assessed using a 5-point Likert Scale. None of the patients was given general anesthesia, and intraoperative sedation was given to nineteen patients (32.2%). No hemodynamic changes were observed in all patients. There was a significant correlation between the use of intraoperative sedation and stone site, intraoperative blood loss, and hospital stay. Pain intensity on VAS at rest and movement was low until the 24th postoperative hour. Patient satisfaction score was 3, 4, and 5 in 1 (1.7%), 4 (6.7%), and 55 (91.6%) patients, respectively. Combined low-dose spinal anesthesia with quadratus lumborum block is an effective alternative to general anesthesia in patients undergoing PCNL procedures with good postoperative analgesia. Patients with lower calyceal punctures have a lower incidence of intraoperative sedation requirements.

Patient Selection and Planning for Image-Guided Peritoneal Dialysis Catheter Placement.

Image-guided percutaneous peritoneal dialysis (PD) catheter insertion has become increasingly relied upon to provide urgent access for late presenting kidney failure patients, to overcome surgical backlogs and limited operating room access, to avoid general anesthesia in high-risk patients, and, by itself, as an alternative approach to surgical PD access. Advanced planning for the procedure is essential to assure the best possible outcome. Appropriate selection of patients for percutaneous PD catheter placement, choosing the most suitable catheter type, determining insertion and exit site locations, and final patient preparations facilitate the performance of the procedure, minimizes the risk of complications, and improves the likelihood of providing a successful long-term peritoneal access.

A clinical study: Inguinal hernia repair under local block

This study was conducted to evaluate advantages of local anaesthesia in high risk patients and to assess patient’s satisfaction, speed of recovery and postoperative analgesia. In our study we gave combined Ilioinguinal and Iliohypogastric nerve block with field block in 30 patients. The patients were monitored for hemodynamic changes and total duration of analgesia and quality of analgesia. In this study 23% patients were of ASA I, 30% ASA II and 46.7% had ASA III grade. All patients were hemodynamically stable throughout procedure and surgery. Average duration of the analgesia was 188 min (about 3 hours). Quality of analgesia was excellent in 66.6% patients, good in 16.6% patients, poor in 6.6% patients and 10%patients had severe intolerable pain and converted to GA. We found that inguinal hernia repair under local anaesthesia was safe, simple, cost-effective and also provides good postoperative analgesia. It is more useful in high risk patients where we need to avoid effects of general, spinal or epidural anaesthesia for hernia surgeries.

Popliteal Nerve Block as an Alternative to Spinal Anaesthesia for Ankle Surgery in Comorbid Patient- A Case Report

In high-risk patients with significant cardiovascular and other systemic disorders, administration of central neuraxial block or general anaesthesia is usually associated with adverse haemodynamic effects and high perioperative mortality. This case report is about a 57-year-old male patient with known case of Diabetes Mellitus (DM) posted for lower limb debridement. He had comorbidities like cellulitis, sepsis, uncontrolled diabetes, multiorgan dysfunction and was haemodynamically unstable. Peripheral nerve blockade keeps the haemodynamic more stable as compared to central neuraxial blockade and general anaesthesia. Therefore, popliteal nerve block was given to the patient in prone position. Peripheral nerve locator was used and after eliciting the response of foot twitch local anaesthetic drug was deposited. Adequate sensory motor block was achieved and surgery was carried out uneventfully. Patient was vitally stable throughout the surgery. Thus, it was seen that peripheral nerve blocks are an effective alternative to central neuraxial blockade and general anaesthesia in high risk patients undergoing below knee surgeries.

Comparison Of Lumbar Sacral Plexus Block With Spinal Anesthesia In High-Risk Patients Scheduled For Hip Surgeries

BACKGROUND: High risk elderly patients with hip fractures were the greatest challenge to anesthesiologist as they are more prone to perioperative morbidity and mortality. Combined lumbar sacral plexus block have been an effective method of anaesthesia, also considerable in postoperative analgesia in high-risk patients of hip surgeries as it provides fewer complications, better homeostasis, hemodynamic control. OBJECTIVES: The aim of this study was to compare the efficacy of lumbar sacral plexus block with subarachnoid block in terms of onset and duration of sensory and motor blockade, hemodynamic changes and postoperative analgesia. MATERIALS AND METHODS: This prospective randomized study was carried out in 50 patients aged 35-80 years and weighed 40 to 85 kg belonging to ASA physical status III/IV posted for hip surgeries. patients were divided into two groups, SAB (subarachnoid block) group and LSPB (lumbar sacral plexus block) group of 25 each by convenient sampling. Onset of sensory and motor blockade, hemodynamic changes, time for first rescue analgesic were noted and compared. Statistical analysis was done using SPSS Software. RESULTS: The perioperative heart rate and arterial blood pressure were more stable in LSPB group. Postop analgesia duration was significantly prolonged in LSPB group (11.4±1.7 hours) as compared to SAB group (4.3±0.43 hours). Hypotension and bradycardia noted in SAB group. CONCLUSION:Lumbo-sacral plexus block offered more stable intraoperative hemodynamic parameters and prolonged postop analgesia as compared to Subarachnoid block in high-risk patients undergoing hip surgeries.

Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax.

To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points. We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis. The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis. Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions.

Thoracic epidural for modified radical mastectomy in an asthmatic patient

Thoracic epidural anaesthesia is one of the safe and good alternative to general anaesthesia in high risk patients of chronic obstructive pulmonary disease and asthma where general anaesthesia is contraindicated. A 55 years old female patient was scheduled for modified radical mastectomy on account of advanced carcinoma of right breast. The patient was known case of bronchial asthma since 5 years with frequent attacks per week for which she was taking nebulisation with salbutamol and budesonide two times per day. In the pre-operative evaluation, her vitals were within normal limit but on auscultation air entry was reduced all over the chest with bilateral crepts and rhochi present. We did this patient in plaine thoracic epidural anaesthesia without haemodynamic instability. Thoracic epidural anaesthesia and analgesia for mastectomy is feasible, and it offers additional benefits in high-risk patients.

P003 - Rirs and spinal anesthesia in high risk patient

P003 - Rirs and spinal anesthesia in high risk patient

Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function

Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers protection in ischemic heart disease. Major outcome studies have failed to confirm such a benefit, however. In fact, there is growing concern about potential harm associated with the use of thoracic epidural anesthesia in high-risk patients, although underlying mechanisms have not been identified. Since the latest review on this subject, a number of clinical and experimental studies have provided new information on the complex interaction between thoracic epidural anesthesia-induced sympatholysis and cardiovascular control mechanisms. Perhaps these new insights may help identify conditions in which benefits of thoracic epidural anesthesia may not outweigh potential risks. For example, cardiac sympathectomy with high-thoracic epidural anesthesia decreases right ventricular function and attenuates its capacity to cope with increased right ventricular afterload. Although the clinical significance of this pathophysiologic interaction is unknown at present, it identifies a subgroup of patients with established or pending pulmonary hypertension for whom outcome studies are needed. Other new areas of interest include the impact of thoracic epidural anesthesia-induced sympatholysis on cardiovascular control in conditions associated with increased sympathetic tone, surgical stress, and hemodynamic disruption. It was considered appropriate to collect and analyze all recent scientific information on this subject to provide a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.This review provides a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.

Lumbar Spine Surgeries Under Spinal Anesthesia in High-Risk Patients: A Retrospective Analysis

To determine outcomes of spinal anesthesia (SA) in high-risk patients undergoing lumbar spine surgery in whom general anesthesia (GA) was contraindicated. A retrospective study was conducted in Bansal Hospital, Bhopal, India. SA was achieved with a heavy spinal dose of bupivacaine administered in the sitting position. After assessing sensory level, patients were placed into prone position. Throughout surgery, hemodynamic parameters were monitored. At the end of surgery, patients were placed into supine position and taken out of the operating room for monitoring in the recovery room. Postoperatively, time spent in the postanesthesia care unit, hemodynamic changes, incidence of nausea and vomiting, urinary retention, spinal headache, analgesic use, regression of sensory block, and length of hospital stay were documented. Patient and surgeon satisfaction was also assessed. The study included 18 high-risk patients with lumbar spine disease. Twelve patients were classified as American Society of Anesthesiologists IV, and 6 were classified as American Society of Anesthesiologists III. Ten patients underwent microdiscectomy, and 8 patients underwent canal and lateral recess decompression. None of the patients had anesthetic or surgical complications. Postoperative pain relief was excellent. There were no incidences of postoperative vomiting or urinary retention. Only 2 patients (11.11%) developed nausea. Both surgeons and patients reported a high level of satisfaction. SA was 12% cheaper than general anesthesia. SA is a safe, reliable, and satisfactory alternative to general anesthesia in high-risk lumbar spine surgeries. Postoperative morbidity and mortality can be reduced by SA and spinal analgesia techniques. SA allows good perioperative hemodynamic stability. It is also more cost-effective.

Anesthesia in High-Risk Patients, 1st ed

Anesthesia in High-Risk Patients, 1st ed

Limb amputation of an infant with transposition of great arteries using spinal anesthesia

Introduction: Spinal and caudal anesthesia are useful anesthetic techniques for infants compared to general anesthesia. In case of infants lumbar puncture can be safely performed at or just below the intercristal line. Due to the presence of loose fatty tissues in the caudal extradural space, it becomes safe and easy to insert a cannula enabling easy cranial spread of local anesthetic drugs. Increased production and absorption of cerebrospinal fluid in infants lead to administration of higher doses of local anesthetics. However, this spinal and caudal anesthesia has lesser risk of post-operative apnea in infants compared to general anesthesia. Case Report: A three-month-old male infant, whose body weight was seven and half kilograms, was afflicted with ischemia which extended to half of his right leg. There was gangrene on his right big toe as well. These developments occurred after cardiac catheterization was implemented through right femoral vein cannulation. Due to high-risk of transposition of great arteries in general anesthesia, the surgeons finalized under spinal anesthesia in order to bypass the infected respiratory system, prevent aspiration because of full stomach, and to get better postoperative analgesia. Conclusion: Spinal anesthesia is an alternative option to general anesthesia in high risk patients owing to its safety. However, in case of spinal complications or failure of spinal anesthesia, the anesthetist should always get ready with the high risk general anesthesia.

Anaesthesia in High-Risk Patients

Anaesthesia in High-Risk Patients

Laparoscopic cholecystectomy under spinal anesthesia in high risk patients: A single center experience

Aim: Laparoscopic cholecystectomy is routinely done with general anesthesia except for patients that are considered too sick for general anesthesia. The goal of this study was to investigate the availability, safety, and side effects of spinal anesthesia in laparoscopic cholecystectomy. Material and Methods: Patients with high risk for general anesthesia who admitted for laparoscopic cholecystectomy were given the choice of spinal anesthesia instead of general anesthesia. In Ortadogu Private Hospital, Adana, Turkey; 371 subjects were prospectively admitted for laparoscopic cholecystectomy under spinal anesthesia between January 2015 and January 2018. All volunteers provided informed consent. The spinal anesthesia procedure was done similar to the general anesthesia protocol with no modifications. Intra-abdominal pressure was sustained within the 8-10 mmHg range. A 3.5mL bupivacaine (0.5%)/fentanyl (20 μg) mixture was used for spinal anesthesia. Data collected for demographics, ASA scores, surgery duration, comorbidities, and sedation medication/dosage were reviewed. Results: A total of 232 women (62.6%) and 139 men (37.4%) comprised the study. The subjects averaged 51 years of age (range: 37-89). Patients were classified into the following ASA categories: ASA II: 48 subjects (12.9%), ASA III: 197 subjects (53.1%), ASA IV: 126 subjects (34.0%). Surgery was performed successfully in 371 patients. Spinal anesthesia was adapted to general anesthesia for 2 (0.5%) subjects. The average operation time was 38.1 minutes (range: 16-74 minutes). O2 saturation was 97.8% on average for all patients. Right shoulder pain was documented in 14.5% of the patients, and a shoulder massage alleviated the discomfort in most subjects. Conclusions: Spinal anesthesia should be the anesthesia of choice dues to its numerous advantages in high-risk patients related to general anesthesia.

Spinal or general anaesthesia for lower‐limb amputation in peripheral artery disease – a retrospective cohort study

The present study aimed to determine which method of anaesthesia (spinal anaesthesia or general anaesthesia) is better in reducing post-operative analgesic requirements in patients undergoing major limb amputation for lower-limb ischaemia. Another aim was to find out if anaesthesiologists use neuraxial anaesthesia in high-risk patients despite abnormal coagulation profile or use of anticoagulation. The study was a retrospective cohort study. All patients undergone above-the-knee amputation or below-the-knee amputation due to peripheral artery disease between 1996 and 2010 were reviewed to evaluate post-operative opioid consumption and complications. A total of 434 amputations in 323 patients were included in the study. The number of surgical complications, the need for surgical revision and the number of intensive care unit admissions were significantly higher in the general anaesthesia group. The need for post-operative opioid medication was significantly lower in patients with above-the-knee amputation and spinal anaesthesia. The use of post-operative epidural analgesia did not reduce analgesic requirements. In the present study, there were patients who received neuraxial anaesthesia despite abnormal coagulation profile or uninterrupted warfarin or clopidogrel. There were no reported cases of spinal or epidural haematoma. Patients with spinal anaesthesia had a lower rate of surgical complications, re-operations and intensive care unit admissions. Patients with above-the-knee amputation and spinal anaesthesia had a lesser need for opioid medication in the post-operative period than patients with general anaesthesia. Anaesthesiologists performed neuraxial anaesthesia and/or analgesia in high-risk patients despite abnormal coagulation profile or ongoing anticoagulation, but no adverse outcomes were reported.

Feasibility of percutaneous cryoablation of vertebral metastases under local anaesthesia in ASAIII patients

Purposespine metastases are common concern from several primary neoplasms, modern management include percutaneous techniques such as ablation and cementoplasty. This research aims to evaluate the treatment under local anaesthesia in high-risk patients (ASA III). Methods and materialfrom January 2013 up to September 2016 we treated via percutaneous cryoablation 11 advanced oncological patients classified as ASA III, then retrospectively a review of their clinical history has been performed. Interventions were managed under local anaesthesia, injecting low doses of bupivacaine 2,5mg/ml (from10 to 30ml). Cryoprobes of 17G were introduced under CT guidance. VAS scores were evaluated pre, intra and post operative up to the 3rd month and further, statistical analyses were obtained using T student test. Resultsthirteen spinal metastases were cryoablated in 11 patients (6W, 5M; mean age of 53 years, range 52–81). Tumour location was: sacrum (n=6), lumbar spine (n=3), thoracic spine (n=2). The average VAS value during the procedure was 5,27 (standard deviation 0,90). There were statistically significant decreases in the median numeric VAS scale score at 1-week, 1-month, and 3-month time points (P<.001 for all). Technical success was achieved in all cases. Among patients with neurological deficit, some clinical improvement was assessed. Conclusioncryoablation with or without subsequent cement injection can be safely performed with local anaesthesia for pain relief also in patients with high ASA score with higher risk of complications, in the absence of any other suitable treatment.

Local anaesthesia with analgosedation in patients qualified for transcatheter aortic valve implantation (TAVI): first institute's results and experiments.

The authors present their own experience of the treatment of patients qualified for transcatheter aortic valve implantation (TAVI) carried out in a modern hybrid operating room. The objective of the present study was to demonstrate the initial results of conducting anaesthesia in high-risk patients qualified for the TAVI procedure (transcatheter aortic valve implantation). In addition, the authors' aim was also to point out to the special challenges of an anaesthesiologist conducting local anaesthesia in such a type of procedures and to evaluate the safety and efficacy of the TAVI procedure conducted under remifentanil analgosedation. A retrospective analysis included patients treated during the period from September 2015, when local anaesthesia for the transcatheter aortic valve implantation was used for the first time at our centre, up to February 2016. The studied population consisted of 11 patients treated for severe aortic valve stenosis. The mean age of patients was 80 ± 7 years. Three patients were men (27%) and eight were women (73%). The study included all subsequent patients (n = 11), treated in our centre, for whom it was decided to perform TAVI under local anaesthesia. The total hospital mortality rate was 0%. All procedures were performed in a hybrid operating room. Despite the complications observed in the described group, the hospital mortality rate during TAVI was 0%. All patients, after 12 ± 5 days of treatment, left the hospital in a good neurological condition, which was assessed based on the CPC-1 (Cerebra Performance Categories Scale) and GCS-15 (Glasgow Coma Scale) scales. With an ejection fraction of the left ventricle of 53 ± 11%, the transcatheter aortic valve was successfully implanted. Percutaneous aortic valve implantation can be successfully conducted under remifentanil analgosedation. TAVI procedures should be performed in the conditions of a modern, well-equipped hybrid room. The aim of the anaesthesiologist should consist of conducting the least invasive anaesthesia/analgesia, bearing in mind the safety and comfort of the patient.

36. Anesthesia for high risk patients undergoing percutaneous mitral valve repair with the mitraclip system in the catheterization laboratory

MitraClip system implantation is used inhigh-risk patients with severe mitral regurgitation.anesthetic management for mitral clip implantation. The study included 34patients scheduled for MitraClip implantations in the catheterization laboratory. An arterial line and central venous line were inserted under local anesthesia before induction. Epinephrine was started before induction and milrinone infusion was started after induction. The anesthetic technique for induction and maintenance was the same for all patients. All patients were hemodynamically stable intra- and postoperatively. The intervention was successful in 33 cases and aborted in one case because of severe posteromedial leaflet tethering. The epinephrine and milrinone were weaned and all patients were extubated, except, one case mortality happened within the first 8 hours postoperatively. Percutaneous mitral valve repair with MitraClip implantation is a successful alternative in high-risk patients with symptomatic severe mitral regurgitation. Starting epinephrine before anesthetic induction and milrinone infusion induction resulted in decreased pulmonary artery pressure, increased ejection fraction and maintained arterial blood pressure during procedure inspite of worse preoperative conditions.

Abstract TP299: The Feasibility of the Aldrete-FAST Screening Tool to Detect Stroke in the Post Cardiac Catheterization Setting: FAST-PC Study

Introduction: Peri-procedural cardiac catheterization related stroke (CRS) remains a feared complication. Risk estimates reach 7% but vary widely by institution and operator experience. Given the volume (&gt;2 million/yr in US), the impact of CRS is substantial. Evidence-based data on diagnosis/treatment are lacking for these patients despite being ideal targets for acute stroke treatment. Many CRS go undetected due to a lack of a standardized assessment tool. Hypothesis: A novel screening tool will be feasible to perform and effective in standardizing rapid diagnosis of CRS. Methods: Two validated tools form the basis of this screen 1) Aldrete score: 10-pt scale used in anesthesia cases to assess activity, respiration, circulation, consciousness and color 2)FAST screen designed to reliably diagnose stroke in &lt; 1 min: Facial droop, Arm weakness, Speech changes, Time. Patients are assessed pre/post procedure and catheterization sheath left in place until protocol completion to allow for CRS IA therapy. Feasibility criteria: Excellent if ≥80%; moderate if ≥50% had successful completion. Uni/multivariable logistic regression analysis assessed interaction with age, sedation &amp; sheath location. Results: 906 patients were enrolled over 7 months. Mean age was 64.9±13.6; 65% male. 727 cases completed 100% of Aldrete-FAST (80.2%, 95% CI: 77.5% - 82.8%). High dose Midazolam (&gt;2mg) was associated with completion of Aldrete-FAST (P&lt;0.001, OR 3.14 CI:1.79-5.52) while Fentanyl (100-200mcg) was a deterrent (P 0.027, OR 0.45 CI: 0.22-0.91). Fentanyl &gt;200mcg had no association (30 patients). 748 maintained the sheath (88.0%, 95%CI: 85.6%-90.1%). There was no association between age, sex or access site location (femoral, radial or both) on outcomes. Conclusions: This single-center prospective study demonstrates that the Aldrete-FAST score is a simple, safe screening tool with excellent feasibility to evaluate for CRS. No association between age, sex or access site implies generalizability. We found an interaction with sedation as midazolam and fentanyl had an inverse relationship regarding successful completion of the score. Further study is warranted to determine the optimal anesthesia for high risk patients undergoing cardiac catheterization.