Anesthetic Management Of Patient Research Articles

Anesthesia management for a child with the Koolen-de Vries syndrome: a case report

BackgroundThe Koolen-de Vries syndrome (KdVS) is a relatively new rare disease caused by micro-deletion of 17q21.31 which was first reported by Koolen in 2006. Typical phenotypes for KdVS include hypotonia, developmental delay, moderate intellectual disability, and characteristic facial dysmorphism. Up to now, there was only one case report about anesthesia management of patient diagnosed KdVS. It was a 2-year-old girl who experienced an MRI exam under anesthesia.Case presentationWe described a 21-month-old boy who planned to undergo an orchidopexy under general anesthesia diagnosed with KdVS. He had an intellectual disability, characteristic facial dysmorphism, tracheo/laryngomalacia, patent foramen ovale, and cryptorchidism related to KdVS. Due to the complex condition especially the presence of tracheo/laryngomalacia, we took some special measures, including reducing the amount of long-acting opioid, keeping the spontaneous breath, performing a caudal block, and applying the laryngeal mask. But the laryngeal mask was changed to an endotracheal tube because it failed to provide adequate ventilation. The boy experienced mild laryngeal spasm and hypoxia after extubation, but lateral position and etomidate eased his breathing problem and re-intubation was avoided. It is indicated that anesthesia management for patients with orphan disease is a real challenge for all anesthesia providers.ConclusionsThe Koolen-de Vries syndrome is a relatively new orphan disease involving multiple systems. Keeping spontaneous breath, evaluating airway potency to anesthetics, applying endotracheal tube, and post-extubation lateral or prone position may be helpful for airway management for patient with hypotonia and tracheo/laryngomalacia. KdVS patient needs prolonged post-anesthesia monitoring and/or medication for airway complications.

Can concurrent use of king vision video laryngoscope and fiberoptic bronchoscope improve efficacy and safety of awake intubation in patients with limited mouth opening? - A case report

Securing the airway by endotracheal intubation in a patient with a restrictive mouth opening poses a challenge to anesthesiologists. Awake tracheal intubation using flexible fiberoptic bronchoscopy is the gold standard in the anesthetic management of patients with restricted mouth openings. Awake video laryngoscopy (VL) is being increasingly used for the management of the anticipated difficult airways. We report a case of temporomandibular joint ankylosis with restrictive mouth opening posted for laparoscopic nephrectomy managed by awake intubation with the combined use of king vision VL (KVVL) and fiberoptic bronchoscope (FOB). KVVL provided an improved and clear view of the airway structures and FOB helped in guiding and maneuvering the tube safely into the larynx. The combined use of KVVL and FOB enhanced the effectiveness and safety of the procedure.

Quality Improvement in Anesthetic Management of Patients with Left Ventricular Assist Device Support Presenting for Non-Cardiac Surgery: A Single Center Experience.

With the growing number of left ventricular assist device (LVAD) recipients requiring non-cardiac surgery and the limited availability of cardiac anesthesiologists, our study reviewed non-cardiac surgeries in HeartMate III patients with LVAD at our institution. We focused on anesthesiologist roles, detailing patient characteristics, anesthetic management, and outcomes and identifying improvement opportunities in this specialized care setting. A retrospective chart review was conducted of all patients with LVAD who underwent non-cardiac surgery at our institution between 2017 and 2022. Patient demographics, surgical characteristics, anesthetic management, and 30-day mortality rates were also assessed. A total of 23 patients were identified, with 17 (73.9%) males and a median age of 61 [53.5, 67.5] years. Cardiac anesthesiologists were present in nine (39.1%) cases. Elective surgeries were more common (73.9%), with intermediate-risk surgeries accounting for 52.2% of all surgeries. General anesthesia was administered to 18 patients (78.3%), with a median duration of 40 [24, 63.5] min. A single patient required reoperation because of bleeding, and two patients (8.7%) experienced 30-day mortality. Despite guidelines lacking detail, involving non-cardiac anesthesiologists in certain cases is essential. Sharing our experience aims to enhance the evolving discourse on non-cardiac surgeries for patients with LVAD, improving their outcomes and safety.

Difficult Airway in a Patient with Well-Differentiated Epidermoid Carcinoma: A Case Report

Introduction: Cutaneous epidermoid carcinoma (SCC) is a common skin tumor that can arise from precursor lesions or de novo. It is the second leading cause of death from skin cancer and its incidence is expected to double by 2030. Risk factors include gender, ionizing radiation, alcohol and tobacco use, and HPV infection. SCC can be classified into five types according to the Peniche classification, with the ulcerative form being the most frequent. Anesthesia management for head and neck cancers is challenging due to airway complications. Case presentation: An 82-year-old female with a history of biomass combustion smoke exposure and hypertension presented with a painful papular lesion on the left nasal wing. Biopsy revealed well-differentiated epidermoid cancer. Despite treatment, the lesion progressed rapidly, leading to a request for surgical resection. The patient had predictors of difficult intubation and ventilation, and initial intubation attempts were unsuccessful. After aspiration of secretions and intracavitary bleeding, successful intubation was achieved on the second attempt. Controlled ventilation was initiated with specific settings. Clinical discussion: A difficult airway can pose challenges for anesthesiologists, especially in patients with head and neck cancer. Pre-anesthetic evaluation and preparation for rescue devices or maneuvers are crucial. In this case, the patient had a difficult Intubation Prediction Index. General anesthesia allowed for invasive monitoring, venous access, and reliable mechanical ventilation. Direct laryngoscopy was performed due to retro nasal bleeding, with equipment available for difficult airway management and aspiration. Conclusion: Anesthetic management for patients with head cancer presents challenges in airway management and carries the risk of complications. Pre-anesthetic and airway assessment are crucial to prevent complications and ensure successful intubation.

Anaesthesia Management for Giant Intraabdominal Tumours: A Case Series Study.

Due to a lack of randomised controlled trials and guidelines, and only case reports being available in the literature, there is no consensus on how to approach anaesthetic management in patients with giant intraabdominal tumours. This study aimed to evaluate the literature and explore the current status of evidence, by undertaking an observational research design with a descriptive account of characteristics observed in a case series referring to patients with giant intraabdominal tumours who underwent anaesthesia. Twenty patients diagnosed with giant intraabdominal tumours were included in the study, most of them women, with the overall pathology being ovarian-related and sarcomas. Most of the patients were unable to lie supine and assumed a lateral decubitus position. Pulmonary function tests, chest X-rays, and thoracoabdominal CT were the most often performed preoperative evaluation methods, with the overall findings that there was no atelectasis or pleural effusion present, but there was bilateral diaphragm elevation. The removal of the intraabdominal tumour was performed under general anaesthesia in all cases. Awake fiberoptic intubation or awake videolaryngoscopy was performed in five cases, while the rest were performed with general anaesthesia with rapid sequence induction. Only one patient was ventilated with pressure support ventilation while maintaining spontaneous ventilation, while the rest were ventilated with controlled ventilation. Hypoxemia was the most reported respiratory complication during surgery. In more than 50% of cases, there was hypotension present during surgery, especially after the induction of anaesthesia and after tumour removal, which required vasopressor support. Most cases involved blood loss with subsequent transfusion requirements. The removal of the tumor requires prolonged surgical and anaesthesia times. Fluid drainage from cystic tumour ranged from 15.7 L to 107 L, with a fluid extraction rate of 0.5-2.5 L/min, and there was no re-expansion pulmonary oedema reported. Following surgery, all the patients required intensive care unit admission. One patient died during hospitalization. This study contributes to the creation of a certain standard of care when dealing with patients presenting with giant intraabdominal tumour. More research is needed to define the proper way to administer anaesthesia and create practice guidelines.

Anaesthetic Management for Charcot Joint Surgery in a Previously Operated Meningomyelocele Patient: A Case Report

Charcot joint, a degenerative condition characterised by bone and joint destruction, often requires surgical intervention to alleviate pain and prevent complications. However, when this condition coexists with a history of meningomyelocele repair, additional considerations are necessary to ensure patient safety. The anaesthesia management for Charcot joint surgery in a meningomyelocele patient who has previously undergone surgery presents a unique challenge. Preoperative assessment should involve a comprehensive evaluation of the patient’s medical history, including previous surgical procedures, neurological status, and associated co-morbidities. Given the possible problems such as scarring, adhesion, and altered anatomy that may affect the choice of anaesthetic approach and airway management, particular attention should be paid to the site of the meningomyelocele repair. Here, the authors report a case of failed spinal anaesthesia in a 20 years old male patient with a history of operating meningocele who underwent surgery for Charcot’s joint. Charcot’s joint is a rare complication of syringomyelia or meningomyelocele, which can cause severe neurological deficits and deformities. Surgery is often required to correct the deformity and relieve the symptoms. Spinal anaesthesia is a commonly used technique for surgeries involving the lower limbs. This abstract highlights anaesthetic management in patients with Charcot joint and a history of meningomyelocele repair.

Effects of Anesthetics on Cardiac Repolarization in Adults: A Network Meta-Analysis of Randomized Clinical Trials.

Prolongation of cardiac repolarization, especially the heart rate-corrected QT (QTc) interval, is associated with life-threatening dysrhythmias. This study aimed to identify the anesthetic with the lowest risk of prolonging cardiac repolarization and provide guidance for anesthesia management in patients with cardiac diseases or long QT syndrome. Randomized controlled trials (RCTs) comparing the effects of anesthetics on cardiac repolarization indices were searched for in multiple databases. The primary outcome was QTc; and the secondary outcomes were other repolarization indices. A network meta-analysis was conducted using a frequentist approach and registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42022304970). Thirteen RCTs investigating 953 adults with normal QTc interval and without cardiovascular diseases were included. Direct meta-analyses found that propofol had less influence than sevoflurane (95% confidence interval (CI): 16.10, 33.54) and desflurane (95% CI: 4.85, 35.36), and sevoflurane had less influence than desflurane (95% CI: 6.96, 19.39) on QTc prolongation. Network analysis found that propofol had less influence than sevoflurane (95% CI: 17.78, 29.63), halothane (95% CI: 11.29, 41.24), desflurane (95% CI: 23.79, 39.88), and isoflurane (95% CI: 20.11, 46.10), and sevoflurane had less influence than desflurane (95% CI: 0.43, 15.82) on QTc prolongation. The rank order of cumulative ranking curve analysis was propofol (100%), sevoflurane (63.8%), halothane (49.5%), desflurane (21.1%), and isoflurane (15.6%). The direct meta-analysis found that propofol had less influence than sevoflurane on QT prolongation (95% CI: 23.12, 57.86). Other secondary outcomes showed no conclusive findings. This meta-analysis found that propofol had a minimal effect on QTc prolongation, followed by sevoflurane and desflurane in adults with normal QTc interval and without cardiovascular diseases. Propofol is the best anesthetic for adult patients with long QT syndrome or cardiac diseases, but still needs more robust evidence.

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.

General anesthesia versus nongeneral anesthesia during endovascular therapy for acute ischemic stroke: A systematic review and meta-analysis.

This study compares the safety and efficacy of general anesthesia (GA) and nongeneral anesthesia (non-GA) on functional outcomes in patients receiving endovascular therapy for ischemic stroke. All available studies on the anesthetic management of patients with acute ischemic stroke in PubMed, the Cochrane Central Register of Controlled Trials, and Embase were included. We also compared the clinical outcomes in the studies with subgroup analyses of the occlusion site (anterior vs. posterior circulation) and preretriever group versus retriever group. Functional independence, mortality, successful recanalization, hemodynamic instability, intracerebral hemorrhage, and respiratory complications were considered primary or secondary outcomes. A total of 24,606 patients in 60 studies were included. GA had a lower risk of 90-day functional independence (OR=0.67, 95% CI 0.58 to 0.77), higher risk of 90-day mortality (OR=1.29; 95% CI 1.15 to 1.45), and successful reperfusion (OR=1.18; 95% CI 1.94 to 6.82). However, there were no differences in functional independence and mortality between GA and non-GA at 90 days after the procedure. The study shows poorer results in the GA group, which may be due to the inclusion of nonrandomized studies. However, analysis of the RCTs suggested that the outcomes do not differ between the two groups (GA vs. non-GA). Thus, general anesthesia is as safe as nongeneral anesthesia under standardized management.

Cochlear Implantation with Fontan Circulation: A Rare Case of Non-Cardiac Pediatric Surgery

Background: Fontan circulation is a cardiac circulation following the Fontan procedure in patients with a single ventricle congenital heart defect. This circulation depends on the difference in pressure between pulmonary capillaries and central venous pressure to achieve optimal cardiac output. This case report aims to discuss intraoperative anesthesia management in a patient with Fontan circulation undergoing a non-cardiac surgical operation.
 Case presentation: The patient is a 7-year-old male with a history of congenital heart disease who has undergone the Fontan circulation procedure and is now undergoing Cochlear implantation surgery. The patient was managed with general anesthesia - endotracheal intubation and controlled ventilation during the operation, following the principle of minimizing intrathoracic positive pressure, low PEEP, and low tidal volume with a target peripheral saturation > 95%. Cardiac output monitoring during the intraoperative period is done using intra-arterial blood pressure. After 5 hours of surgery, the patient was extubated with stable hemodynamics. 
 Conclusion: The primary goal of intraoperative anesthesia management in patients with Fontan circulation is to maintain an optimal transpulmonary gradient by ensuring optimal transpulmonary blood flow, thus preserving cardiac output.

Anesthetic Management of Patients With Class 3 Obesity Undergoing Elective Cesarean Delivery: A Single-Center Historical Cohort Study

(Can J Anesth/J Can Anesth. 2023; 70:202–210) Rising obesity rates have reached a high of one third or one fourth of adults in the United States and Canada, respectively. This leads to many individuals with this condition requiring medical care including anesthesia for labor and delivery. Obesity is known to be associated with complications in the administration and effectiveness of anesthesia as well as after cesarean delivery. Prior research has not focused on the nuances of specific categories of body mass index (BMI) and their association with outcomes, specifically for anesthesia during cesarean delivery. This study aimed to describe different techniques and outcomes for anesthesia in elective cesarean delivery in patients with class 3 obesity (BMI ≥40), specifically in groups with BMI 40.0 to 49.9, 50.0 to 59.9, and >60.0.

Remimazolam sedation with regional anesthesia in difficult airway due to huge thyroid goiter: A case report.

Remimazolam, a novel benzodiazepine, is known to have less respiratory depression compared to other anesthetic agents, and it also has a reversal agent that can be used in emergency situations. Remimazolam with these characteristics can be usefully utilized in the anesthetic management of patients with difficult airway. A 78-year-old female patient was scheduled proximal humerus fracture surgery. The patient occasionally complained dyspnea and had multiple comorbidities including thyroid goiter, dementia, and delirium. The patient had a large thyroid goiter compressing and deviating the trachea. A short neck with increased circumference was confirmed. A difficult airway was anticipated in the preanesthetic evaluation. Sedation with remimazolam followed by regional anesthesia was performed for the surgery. The surgery was completed without complications. The patient recovered and was discharged on 15th postoperative days. The use of remimazolam for sedation may be an appropriate option in the anesthetic management of patients with difficult airway.

Anaesthetic Management in Patients with Placenta Accreta: A Case Report

Anaesthetic Management in Patients with Placenta Accreta: A Case Report

Is the Patient State Index a reliable parameter as guide to anaesthesiology in cranial neurosurgery? A first intraoperative study and a literature review

BackgroundPatient State Index (PSI) and Suppression Ratio (SR) are two indices calculated by quantitative analysis of EEG used to estimate the depth of anaesthesia but their validation in neurosurgery must be done. Our aim was to investigate the congruity PSI and SR with raw EEG monitoring in neurosurgery. MethodsWe included 34 patients undergoing elective cranial neurosurgery. Each patient was monitored by a SedLine device (PSI and SR) and by raw EEG. To appraise the agreement between PSI, SR and EEG Suppr%, Bland-Altman analysis was used. We also correlated the PSI and SR recorded at different times during surgery to the degree of suppression of the raw EEG data by Spearman's rank correlation coefficient. For a comparison with previous data we made an international literature review according to PRISMA protocol. ResultsAt all recording times, we found that there is a strong agreement between PSI and raw EEG. We also found a significant correlation for both PSI and SR with the EEG suppression percentage (p < 0.05), but with a broad dispersion of the individual values within the confidence interval. ConclusionThe Masimo SedLine processed EEG monitoring system can be used as a guide in the anaesthetic management of patients during elective cranial neurosurgery, but the anaesthesiologist must be aware that previous correlations between PSI and SR with the suppression percentage may not always be valid in all individual patients. The use of an extended visual raw EEG evaluated by an expert electroencephalographer might help to provide better guidance.

Anesthetic Management of Patients with Dilated Cardiomyopathy Undergoing Noncardiac Surgery.

Dilated cardiomyopathy (DCM), a primary myocardial disease, is characterized by dilation of the left or both ventricles and systolic dysfunction with or without congestive heart failure. DCM per se is a well-recognized risk factor for sudden cardiac death and poor surgical outcomes following noncardiac surgery. Surgical trauma/stress represents unique challenges for DCM patient management. Unfortunately, there is a big knowledge gap in managing DCM patients undergoing non-cardiac surgery. Therefore, the aim of our review is to provide basic facts and current advances in DCM, as well as a practical guideline to perioperative care providers, for the management of surgical patients with DCM, who are quite rare compared with the general surgical population. This review summarizes recent advances in the medical management of DCM as well as perioperative assessment and management strategies for DCM patients undergoing noncardiac surgery. Optimal surgical outcomes depend on multiple-disciplinary care to minimize perioperative cardiovascular disturbances.

Waardenburg Syndrome Anesthetic Management: Two Cases Experiences

This article presents the anesthetic management of two cases of Waardenburg syndrome (WS) in patients undergoing cochlear implantation. Mutations in genes that control the neural crest cell migration and division during the embryonic period are the hallmark of the hereditary disorder known as WS. White forelock, bright blue eyes, heterochromia from iris coloring deficiency, unusual facial deformities, and sensorineural deafness are the key phenotypic characteristics of WS. The anesthetic management of patients with WS poses challenges due to their multisystem abnormalities.

Dental management of patients with recessive dystrophic epidermolysis bullosa:

Introduction:&#x0D; Epidermolysis bullosa (EB) is a group of rare inherited disorders uniquely characterised by skin, and in some instances, mucosal blistering. In the most severe form of the disease, recessive dystrophic EB (RDEB), the blister-inducing split occurs below the lamina densa. Extensive scarring of the oral mucosa results in limited mouth opening, making speech and mastication difficult. At the same time, oral mucosal blisters often lead to patients restricting their diets to soft, and generally cariogenic, foods, and battling with oral hygiene practices. This results in poor plaque control, a high caries burden and complex dental management.&#x0D; Aims and objectives:&#x0D; This paper presents a report on two siblings suffering from generalised RDEB affecting the oral cavity and their extensive dental treatment needs.&#x0D; Design/Methods:&#x0D; The siblings were referred to the University of Pretoria Oral Health Centre, complaining of painful teeth and oral mucosal discomfort. Their clinical features, dental condition and subsequent management are presented.&#x0D; Results:&#x0D; Restricted mouth opening, limited personal plaque control, and diets limited to soft, carbohydrate-rich foods because of oral mucosal discomfort, resulted in extensive dental decay that required multiple extractions.&#x0D; Conclusions:&#x0D; The dental and anaesthetic management of patients with RDEB is complex, and due to the friable tissues, requires the most atraumatic care possible. Ideally, patients with this condition need to have early dental intervention where preventive programmes can be implemented to reduce the need for later extensive and complicated dental interventions. Maintenance of the patient’s oral health is essential to ensure adequate nutrition, yet, reducing the consumption of soft cariogenic diets which increased their caries risk.

Anesthetic Management of an Unusual Case of Severe Pulmonary Hypertensive

The perioperative management of pulmonary hypertension continues to be a great challenge for anesthesiologists. Among the various types of pulmonary hypertension, pulmonary hypertension associated with left heart disease is the most common, while pulmonary hypertensive crisis is one of the causes of perioperative mortality in these patients. We present the case of a 54-year-old female with severe valvular heart disease complicated by severe pulmonary hypertension and massive hemothorax, who underwent emergency exploratory thoracotomy, mitral valve replacement, and tricuspid valvuloplasty. The patient was in critical condition and suspected to have a pulmonary hypertension crisis. The rationale for this case report is to learn about the anesthetic management of patients with severe pulmonary hypertension.

Perioperative hypertension and anesthetic management in patients undergoing resection of neuroblastoma.

Neuroblastoma is the most common extracranial pediatric tumor, accounting for 5-8% of all childhood cancers. Neuroblastomas arise from catecholamine-secreting neural crest cells and their metabolites, vanillylmandelic acid and homovanillic acid, that are readily detected in urine. Although rarely seen in clinical practice, case reports exist documenting severe intraoperative hypertension. However, data on the incidence of intraoperative hypertension are lacking. This report is a single-center retrospective review of patients with neuroblastoma who underwent surgical resection (n = 102) at Boston Children's Hospital from July 1, 2012 to February 28, 2021. Significant intraoperative hypertension was defined as maximum systolic blood pressure greater than 95th percentile +12 mmHg based on normative blood pressure data. Statistical analysis was performed using Fisher's exact test, Wilcoxon rank-sum test, and logistic regression. The overall incidence of intraoperative hypertension was 13% (n = 13/102). Higher American Society of Anesthesiologists (ASA) physical status was associated with intraoperative hypertension. Antihypertensive medications were administered intraoperatively in 9% of cases (n = 9), and the use was significantly associated with intraoperative hypertension. Of patients with preoperative urine catecholamine data (n = 82), all 10 patients who had intraoperative hypertension were noted to have elevated preoperative urine catecholamines. Intraoperative hypertension was not associated with postoperative hypertension, postoperative hypotension, or increased intensive care unit length of stay. Intraoperative hypertension in patients with neuroblastoma remains a relatively uncommon occurrence; however, it does occur at a frequency higher than previously described. While intraoperative hypertension is associated with an increased use of antihypertensive medications in the operating room, it is not associated with adverse perioperative outcomes.

Anesthetic Management and Bispectral Index in a Child with Miller–Dieker Syndrome: A Case Report

Miller-Dieker syndrome (MDS) is a genetic disorder characterized by classic lissencephaly, distinctive facial features, intellectual disability, seizures, and early death. The anesthetic management of patients with MDS should focus on airway manipulation with the risk of potentially difficult intubation, seizure control due to lissencephaly, and any other clinical complications. Herein, we report a case of anesthetic management in a child with MDS and describe relevant clinical features in a perioperative anesthetic setting. This case highlights the importance of difficult airway manipulation using a videolaryngoscope, seizure management with regard to anesthetics use, and the low validity of BIS monitoring in patients with MDS.