Anesthesia-related Complications Research Articles

Anesthesia for Intracavitary Brachytherapy: a 19-month Experience at the Philippine General Hospital during the COVID-19 Pandemic.

Brachytherapy is the only demonstrated technique of delivering the high radiation dose required to control cervical cancer (>80 Gray [Gy]) without causing unwanted side effects. There is still limited data available in the Philippines regarding the anesthetic management of patients receiving intracavitary brachytherapy for cervical cancer. It is the aim of this study to present the anesthetic management of these procedures performed in a non-operating site remote from the main hospital during the first 1 ½ years of the COVID-19 pandemic. A retrospective review of 446 eligible charts was made. Data collected included demographic variables, ASA physical status classification, anesthetic technique, anesthetic agents used, oxygen supplementation device, duration of procedure, intra-procedure complication, intra-procedure pain medications, post-procedure pain medications, recovery room (RR) rescue medications, time to fulfill discharge criteria, and patient disposition. Four hundred forty-six (446) anesthetic encounters involving 117 patients is presented. Charts from 46 patients were excluded as it cannot be located. Mean age of the patients was 49 years with majority having normal BMI. Spinal anesthesia (SA) was more frequently (75%) used compared to total intravenous anesthesia (TIVA). Less than 5% immediate anesthesia-related complications were recorded and all patients were discharged on the same day. Spinal anesthesia and TIVA are safe and effective anesthetic techniques in patients with cervical cancer undergoing high dose intracavitary brachytherapy. Prospective studies to assess other aspects of their care as well as anesthesia-related long-term effects from repetitive anesthetic exposure is recommended.

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

A Combination of Ultrasound-guided Popliteal Sciatic Nerve Block and Adductor Canal Block as a Sole Anaesthetic Technique for below Knee Amputation in High-risk Patients: A Case Series

Below-knee amputation in high-risk patients is associated with significant mortality and morbidity. Spinal anaesthesia is linked to an increased incidence of hypotension and bradycardia, and it is relatively contraindicated in patients with coagulation abnormalities. General anaesthesia is used as an alternative when spinal anaesthesia is contraindicated, but it is associated with a considerable increase in perioperative morbidity and the need for postoperative ventilatory support and Intensive Care Unit (ICU) care. A combination of sciatic nerve block and femoral block has been employed for below-knee surgeries as it provides complete anaesthesia below the knee. Adductor canal block, compared to femoral nerve block, is motor-sparing and, when combined with popliteal sciatic nerve block, offers complete anaesthesia below the knee. Below-knee amputation requires complete motor and sensory blockage, making regional block for below-knee amputation more challenging for the anaesthesiologist. Present case series is of five cases of below-knee amputation performed under a combination of ultrasound-guided popliteal sciatic nerve block and adductor canal block. Ultrasound-guided popliteal sciatic nerve block was administered with a combination of 10 mL of bupivacaine 0.5% and 5 mL of lignocaine 2% with adrenaline (1:200,000) diluted with 5 mL of distilled water to a total volume of 20 mL. Ultrasound-guided adductor canal block was performed with 8 mL of bupivacaine 0.5% and 4 mL of lignocaine 2% with adrenaline (1:200,000), diluted with 4 mL of distilled water to a total volume of 16 mL. All patients achieved adequate surgical anaesthesia, and none experienced any anaesthesia-related complications.

Compared Dexmedetomidine and Fentanyl on Sensory-Motor Block in Unilateral Intrathecal Anesthesia of Lower-limbs Orthopedic Surgeries: A Randomized Duble-blind Trials

Background: One of the alternatives for lower-limb orthopedic surgery is spinal anesthesia. It can affect the hemodynamic status and cause the prolonged motor and sensory blocks, as well as urinary retention, which are less common in the unilateral technique. Different drugs are used to improve the quality of the block and reduce its complications. Dexmedetomidine, a selective alpha-2 adrenergic receptor agonist, and fentanyl, an opioid medication, could administration as an adjuvant to increase the intrathecal block quality. Hence, this study aimed to compare unilateral spinal anesthesia with bupivacaine/dexmedetomidine (BD) and bupivacaine/fentanyl (BF) regimes on the sensory-motor block among patients with lower-limb orthopedic surgeries. Materials and Method: This randomized, double-blind clinical trial was performed on 36 patients who underwent lower-limb orthopedic surgeries in Qaem Hospital, Mashhad, Iran. The patients were randomly divided into two groups. Patients who received 5.7 mg hyperbaric bupivacaine 0.5% plus 10 µg fentanyl (BF group) or 5 µg dexmedetomidine (BD group) were administered for inducing unilateral spinal anesthesia. Patients and investigators responsible for data collection were not awarded from allocation groups. The sensory-motor block level, duration, postoperative analgesia, and complications were recorded and compared between the two groups. Results: No significant difference was observed between the two groups in hemodynamic changes (i.e., systolic and diastolic blood pressure and heart rate) before and after the blockage (P˃0.05). Also, there was no difference in the sensory-motor block level and anesthesia-related complications between BF and BD groups (P˃0.05). Conclusion: In patients for whom the use of opioids for unilateral spinal anesthesia is contraindicated, dexmedetomidine could be considered an appropriate alternative.

General practitioners practicing anesthesia care in rural Nepal: rewards and challenges

Safe and accessible anesthetic care is critically limited in Asian countries. Perioperative anesthesia related complications are higher in resource limited countries. Neuraxial regional anesthesia is becoming popular and considered as anesthesia of choice in surgeries below umbilicus due to its safety, accessibility, efficacy and low cost. Due to limited numbers of anesthetists and anesthesia assistants, Medical Doctorate in General Practice (MPGP) are widely practicing different types of anesthetic care and performing varieties of surgeries in remote Nepal. Effective coordination, task sharing approach, clinical updates and specific training programs are required to strengthen anesthetic care of general practitioners in rural Nepal.

Anaesthetic considerations for the surgical management of ocular hypotony in adults.

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

670 DEXMEDETOMIDINE SEDATION FOR PULMONARY VEIN ISOLATION PROCEDURE

Abstract Background Peri-procedural anesthesia for catheter ablation of atrial fibrillation (AF) varies from conscious sedation to general anesthesia. Current guidelines do not suggest any specific strategy, thus the choice between different protocols is mainly driven by local expertise, operator and/or patient preference and availability of a dedicated anesthesiology team. Propofol is often the drug of choice despite the risk of respiratory depression. Few data have recently reported operator-directed nurse-administered dexmedetomidine (DEX) sedation as an effective and safe strategy. Aim of the study To evaluate the outcomes of operator-directed nurse-administered DEX sedation in AF ablation (pulmonary vein isolation-PVI). Method Between May 2022 and August 2022, 41 consecutive patients (male 83%, median age 64 years, IQR 57-71) with drug-refractory paroxysmal (n.27;66%) or persistent AF (n.14;34%) underwent first PVI procedure under DEX sedation. Our sedation protocol consisted of continuous intravenous administration of DEX (0.2–0,7 µg/kg/hr) titrated throughout the procedure to achieve mild to moderate sedation (Modified Observer's Assessment of Alertness and Sedation Scale 2-3). A single dose of Ondansetron (4 mg) was administered in the beginning of procedure. Adjunctive doses of fentanyl (cumulative dose 50-100 µg) were administered before the beginning of radiofrequency (RF) delivery and in case of inadequate control of the pain. A low dose propofol bolus (<1mg/kg) was eventually added for electrical cardioversion (ECV). Sedation-related complications were evaluated, including sustained hypoxemia (SpO2 <90%), need of anesthesiologist support and persistent hypotension (SBP < 90 mmHg). The day after the procedure, patients’ satisfaction and pain (0-100 scale) were assessed by a standardized questionnaire. Results Pulmonary vein isolation was performed either with Low Power Long Duration (LPLD, n.17;41,46%) or High-Power Short Duration (HPSD, n.24;58,54%) RF protocol. Median procedure time was 135’ (IQR 110-170’). Median DEX dose was 0,30 µg/kg/hr (IQR 0,27-0,33 µg/kg/hr). Median fentanyl dose was 75 µg (IQR 50-100 µg). In patients needing for ECV (n. 16; 39%), median propofol dose was 60 mg (IQR 47,5–105 mg). Thirteen patients (31,7%) had one or more significant risk factor (obesity, severe heart failure, pulmonary comorbidity, coronary artery disease) for anesthesia-related complications. Median pain scale value was 20 (IQR 10-50). Majority of patients (90,2%, n.37) reported mild to moderate pain (pain <60/100) during the procedure and satisfaction was overall high (median value 90, IQR 80-100), with a 90,2% of patients declaring a satisfaction of 60/100 or more. These results were independent from baseline characteristics (sex, age, AF type, HF, CAD, pulmonary comorbidity, obesity) and procedural aspects (LPLD vs HPSD, procedure time, need for ECV). A strong linear correlation was found between patients’ satisfaction and reported pain (r=-0,59). Only 1 (2,4%) sedation-related complication occurred, consisting in sustained post procedural hypotension treated with volume repletion. Conclusions in our experience, dexmedetomidine (DEX) sedation protocol during catheter ablation of atrial fibrillation is associated to high patients’ satisfaction and no respiratory complications. It seems to be also feasible in patients at higher risk for anesthesia-related complications (severe heart failure, BMI > 30 kg/m2), generally excluded from previous studies.

Risk of anesthesia-related complications in draft horses: a retrospective, single-center analysis

ObjectiveTo report anesthetic-related complications and determine risks associated with anesthesia in draft horses. Study designRetrospective study. AnimalsA total of 401 anesthetic records for draft horse breeds that underwent general anesthesia from January 2010 through December 2020 were reviewed; horses euthanized during general anesthesia were excluded. MethodsDemographics, perioperative drugs used, procedure type and duration, time to extubation, number of attempts to stand, use of sling in recovery and perioperative morbidity and mortality were investigated. Morbidity and mortality statistical evaluation included univariable logistic regression analysis and ordinal regression analysis. ResultsAmerican Society of Anesthesiologists (ASA) status I–II, ASA III–V and total mortality rate for all cases was 0.69% (2/288), 6.19% (7/113) and 2.24% (9/401), respectively, with Belgian horses being overrepresented (6/9). Cardiac arrest occurred in six out of nine horses that died without euthanasia, and five out of six of these horses underwent colic surgery. Factors associated with increased mortality risk included ASA status of III–V, increased body weight, emergency status and horses presenting for colic. Hypotension, hypercarbia and hypoxemia occurred in 56% (224/401), 46% (186/401) and 14% (58/401) of horses, respectively. During recovery from anesthesia, lighter horses and horses undergoing shorter anesthetic procedures were more likely to be successful on the first or second attempt to stand and were less likely to require a sling in recovery. Conclusions and clinical relevanceDraft horses undergoing general anesthesia had a higher mortality rate than previously reported for all types and breeds of horses.

Laryngeal tie-forward in standing sedated horses.

To investigate the feasibility and describe the clinical experience of performing laryngeal tie-forward (LTF) in standing horses unaffected (experimental) and affected (clinical) by intermittent dorsal displacement of the soft palate (iDDSP). Experimental study and case series. Five normal experimental controls and five client owned horses affected by iDDSP. Standing LTF was performed and evaluated in five experimental horses and five clinical cases diagnosed with iDDSP. Standing LTF was performed under endoscopic guidance with horses sedated and the surgical site desensitized with local anesthetic solution. Short term outcome was assessed using radiography, resting and (in clinical cases) dynamic upper respiratory tract (URT) endoscopy. Standing LTF was well tolerated and completed in all horses. Radiographic assessment demonstrated that compared to preoperatively, the basihyoid bone and thyrohyoid-thyroid articulation were positioned dorsally (9.6 mm, p= .006 and 20.4 mm, p= .007, respectively) at 2 days postoperatively. During repeat dynamic URT endoscopy at 48 hours postoperatively, 3/5 horses showed resolution of iDDSP and 2/5 marked improvement. One horse experienced brief iDDSP associated with neck flexion which corrected after swallowing. The second achieved a greater speed and total distance prior to iDDSP. Standing LTF did not incur any major peri- or postoperative complications. The laryngohyoid apparatus was repositioned dorsally and in a small case series had a similar surgical effect on laryngeal position. Standing LTF is feasible, mitigates the risk of general anesthesia related complications and reduces cost.

Day of surgery cancellation in total shoulder arthroplasty: an analysis of surgical cancellation etiologies

BackgroundCancellation of elective total shoulder arthroplasty (TSA) is an expected occurrence. The typical cost of canceled elective surgeries is estimated to be $3000 per patient and can lead to hospital losses of nearly $1 million per year. With the growing interest of same-day TSA, understanding and minimizing unexpected same-day cancellation will reduce impact on patients, surgeons, and health care system. The purpose of the study is to identify the frequency and causes of unexpected same-day cancellations in TSA and determine which treatment path those patients take following their cancellation. MethodsA consecutive series of 1189 TSA (anatomic and reverse) patients operated at a single-academic institution across two tertiary care hospitals from 2010 to 2020 were reviewed. All patients who were scheduled for TSA and subsequently canceled were identified. The etiology of cancellation, time to rescheduling, date of actual TSA procedure, and subsequent work-up were recorded. Descriptive statistics of the canceled patient cohorts were analyzed. Univariate analysis, chi-square test, and analysis of variance were used to compare patients who canceled on the day of surgery (DOS) to prior to surgery. ResultsOf the 1189 TSA patients, 964 were TSA for primary glenohumeral osteoarthritis or cuff tear arthropathy. Ninety-eight (10.2%) TSA had cancellations, of which 49.0% were on the DOS. Most common causes of DOS cancellations were due to medical reasons (45.8%) and anesthesia-related complications (27.1%). Infection (40.9%) was the most frequent medical reasons for cancellations. Fifty-four percent of the anesthesia-related complication cancellations underwent additional diagnostic and therapeutic intervention, despite 100 % of those patients receiving preoperative clearance. DiscussionDOS cancellations in TSA are unavoidable, but there are modifiable factors that can minimize the risk of cancellation. Contrary to studies that attributed cancellations to inadequate cardiovascular-related medical clearance, our study found that the majority of these cancellations are due to infection-related issues. A higher proportion of patients with inadequate medical clearance will cancel prior to the DOS. Despite preoperative optimization, certain patient risk factors need additional diagnostic and therapeutic interventions prior to undergoing shoulder arthroplasty. Through coordination and planning, health care providers and patients can identify those factors and address these issues early on to avoid cancellation and ultimately proceed with a TSA.

Body Mass Index (BMI) Impact on Anesthetic Safety among Adolescents Undergoing Bilateral Reduction Mammaplasty.

A medical record query was performed to retrospectively identify patients who underwent bilateral reduction mammaplasty at our institution between January 2021 and December 2021. Patient demographics and clinical/surgical data were obtained from medical records. Pearson's chi-square, Fisher exact, and Median tests were used to examine associations between body mass index (BMI) category and clinical/demographic data. Two hundred patients were included in analyses, with a median age at surgery of 18.0 years. The majority of patients were obese (63.5%, n = 127), and none were underweight. The most common comorbidity was asthma (27.0%, n = 54). There were no anesthetic-related intraoperative complications or delayed waking. The following did not significantly differ by BMI category: proportion of patients who experienced oxygen desaturation (pre-, intra-, or postoperatively), frequency of postoperative complications, and length of postanesthesia care unit and total hospital stays (P > 0.05, all). While institutions may implement weight-based surgical policies due to anesthesia-related complication concerns in patients with obesity, our study showed that BMI category did not significantly impact anesthetic-related adverse events/surgical complications in our sample. This suggests that such policies are not warranted in all situations, and that decisions regarding their necessity be data-driven.

Hysteroscopic management of a "hernia-like" uterine myoma within the uterine cavity

To introduce a case of a uterus "hernia-like" myoma within the uterine cavity that was successfully treated with hysteroscopy. Step-by-step explanation of the case and surgical procedure using a video and slides. The Medical Ethics Committee of Women and Children's Hospital of Chongqing Medical University approved the study and decided for this video to be exempt from formal approval, and informed consent was obtained from the patient. Hospital. A 37-year-old woman, gravida 1, para 1, with a history of secondary infertility for 2 years and heavy menstrual bleeding for 7 months, which eventually resulted in anemia, was diagnosed with a type 1 (International Federation of Gynecology and Obstetrics leiomyoma subclassification system) myoma approximately 4 cm in diameter using ultrasonography. Her hemoglobin level was 8.6 g/dL (11.5-15.0 g/dL), red blood cell count was 3.6 ×10-12/L (3.8-5.1 ×10-12/L), and hematocrit was 26.7% (35%-45%). Hysteroscopic myomectomy with bipolar resectoscope and transabdominal ultrasound guidance was used to resect the hernia-like myoma. Blunt dissection combined with oxytocin (20 U I.V.) and uterine dilation pressure reduction was used to induce the hernial content (myoma) protrusion into the uterine cavity. The hernia-like myoma was completely resected by hysteroscopy, and all symptoms disappeared. The hernia-like myoma was successfully and completely resected by hysteroscopy. The operative time was 37 minutes. No surgical-related or anesthesia-related complications occurred. During the follow-up period, the patient had regular menstrual cycles without hypermenorrhea, and her anemia had improved. The 5-month follow-up ultrasound examination and hysteroscopy revealed that the uterine cavity had recovered well. The patient conceived 7 months after the procedure and delivered at term (39 weeks 1 day) via cesarean section. A hernia-like myoma covered with endometrium is a degenerative myoma that herniates into the myometrium and forms a hernia sac-like defect. Hysteroscopy is an effective and feasible method for treating hernia-like myoma.

S1119 Safety and Efficacy of Pediatric Endosonography: A Multi-Center Retrospective Cohort Study

Introduction: Endoscopic ultrasound (EUS) is widely used in the adult population for a wide range of diagnostic and therapeutic purposes. In the pediatric population, the use of EUS has been historically diagnostic, however, EUS-guided therapy is increasing. In this retrospective study, we aim to describe the safety and efficacy profiles of EUS in pediatric patients across a spectrum of EUS procedures. Methods: This is a retrospective multi-center cohort study of pediatric patients who underwent EUS procedures for diagnostic or therapeutic purposes between January 2011 and March 2022. Data including demographics, procedural details, and adverse events (AE) were collected. Outcomes were diagnostic success, defined as successful diagnosis using only EUS without any additional diagnostic tools, and therapeutic success, defined as using only EUS without additional therapeutic interventions. Results: 61 pediatric patients between the age of 0 to 18 years underwent 77 EUS procedures, of which 35 were females (56.5%). The mean age at the procedure was 16.2 ± 4.2 years and the median weight was 70.2 kg (IQR 49.7-91.2). The indications for EUS were gastrointestinal lumen evaluation ± fine needle biopsy/aspiration (FNB/A), pancreaticobiliary tree evaluation ±FNB/A, surveillance for tumor syndrome, suspected lymph node (LN), or gastrointestinal (GI) mass, celiac plexus block and cyst gastrostomy creation (Table). The median procedure time was 35 minutes (IQR 18 – 49). The diagnostic success rate was 98.7% and the therapeutic success rate was 100%. The complication rate was 2.6% which included 2 cases of pancreatitis after fine-needle aspiration of the pancreas. No case had any anesthesia-related complications. Conclusion: In this multicenter retrospective cohort study, the use of EUS in pediatrics has shown to be safe and effective in a wide range of diagnostic and therapeutic intents. Table 1. - Baseline characteristics, procedural and clinical outcomes of pediatric patient EUS procedures N=77 (%) Females 35 (56.5) Weight (n=66) 70.2 [49.7 – 91.2] Age at procedure (years) 16.2 ± 4.2 Indication Diagnostic GI lumen Evaluation 9 (11.7) GI lumen Evaluation with FNB/A 5 (6.5) Pancreaticobiliary tree evaluation 37 (48.1) Pancreaticobiliary tree evaluation with FNB/A 6 (7.8) Surveillance for tumor syndrome 7 (9.1) Suspected LN or mass 8 (10.4) Therapeutic Celiac Plexus Block 1 (1.3) Cystgastrostomy 4 (5.2) Anesthesia Type Monitored Anesthesia Care (MAC) 48 (62.3) General Anesthesia 29 (37.7) Mean procedure Time in minutes (N= 59) 35.0 [18.0 - 49.0] Diagnostic Success 76 (98.7) Therapeutic Success (n=5) 5 (100) EUS related complications 2 (2.6) Anesthesia complications 0 (0) EUS = endoscopic ultrasound, FNA/B = fine needle aspiration/biopsy, LN = lymph node.Continuous variables presented as mean ± SD or median (IQR).Categorical variables presented as n (%).

A Prospective Comparative Study to Assess the Management Outcomes of Patients with Infantile Hypertrophic Pyloric Stenosis Using Ramstedt’s Pyloromyotomy and Double ’Y’ Pyloromyotomy

Abstract Background: Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of gastric outlet obstruction in infancy in which the pyloric portion of the stomach becomes hypertrophied, leading to obstruction of gastric emptying. Various approaches have been tried for surgical management of IHPS. The first successful surgery was performed by Dufour and Fredet in which the hypertrophic pyloric muscle is longitudinally splitted and closed transversely. However, Ramstedt introduced extramucosal pyloromyotomy, introduced in 1912 which still remains the gold standard for surgical management of IHPS. Later on, in 2009, Alayet et al. introduced a new technique known as Alayet’s double-Y (DY) pyloromyotomy which he claimed to have a better functional outcome compared to Ramstedt’s pyloromyotomy (RP) while maintaining a safety profile similar. The objective of this study was to compare the outcome of surgical management of IHPS between DY pyloromyotomy and Ramstedt’s pyloromyotomy. Materials and Methods: It was a prospective study conducted in the Paediatric Surgery Department of SVPPGIP, SCB Medical College, Cuttack, from January 2019 to April 2022. All the IHPS cases were admitted and optimised thoroughly with regard to hydration, acid-base status and electrolyte imbalance. We have included 60 patients and were divided into two groups; every alternate patient was pooled into one group. Detailed and informed consent was taken from parents regarding the surgical procedure of their baby. The patients were selected alternatively, i.e., if one patient underwent Ramstedt’s pyloromyotomy then in the next patient Alayet’s DY pyloromyotomy procedure was done. The demographic characteristics of all patients, operative procedure performed, duration of surgery, intraoperative anaesthesia or surgical complication, post-operative vomiting patterns and weight gain data were collected and analysed in Microsoft Excel sheet and SPSS software. The student’s t-test was used to compare both groups. Results: We found that both groups were similar while considering the demographic characteristics as there were no significant statistical differences noticed in the patient population with regard to age (DY Group 42.73 ± 9.01 days vs. RP Group 40.63 ± 7.6 days; P = 0.8209), sex (DY 4F/26M vs. RP 6F/24 M), weight at presentation (DY 3.3 ± 0.33 kg vs. RP 3.2 ± 0.21 kg; P = 0.33449), symptoms and clinical condition. All patients were optimally resuscitated before proceeding to surgery with regard to hydration, electrolyte imbalance and acid-base status. While considering anaesthesia, both groups were equal in terms of it and no anaesthesia-related complications were recorded in our study. However, during the first post-operative week, a significant difference was noted between DY versus RP groups with regard to vomiting (DY 1.33 ± 0.59 days vs. RP 2.8 ± 0.76 days; P = < 0.0001) and weight gain (299.86 ± 41.90 g vs. 199.03 ± 21.72 g; P = 0.008), respectively. Patients were followed up for 6 months post-operatively. No long-term complications were noticed in both groups. Weight gain after 1 month DY 577.46 ± 169.96 g versus RP 574.70 ± 170.10 g, (P = 0.949969), after 2 months DY (758.43 ± 94.53 g vs. RP 758. 8 ± 94.68 g, P = 0.98699) and after 3 months DY (593 ± 20.01 g vs. RP 591.16 ± 20.89 g, P = 0.61136). Overall, the operative time duration was the same in both groups. We had not noticed any intraoperative complications, post-surgical site infections were encountered. There was no need to redo pyloromyotomies in our study. Conclusion: Our study demonstrated that the double-Y pyloromyotomy procedure provides a better functional outcome with regard to vomiting and weight gain in the early post-operative period. It seems to be due to the wider opening of the pyloric canal at both ends of pyloromyotomy incision with a wide angle compared to Ramstedt’s pyloromyotomy. Obviously, the chance of mucosal perforation is also less as the enforce of the mucosa is divided into two directions. The method is suitable for both conventional and laparoscopic surgery. The small sample size was a limiting factor in this study. However, more studies need to be done on this technique to prove its efficacy and establish it as a standard technique for the future.

Hemivertebra Resection in Small Children. A Literature Review.

Systematic review. To evaluate the lowest possible age to resect an HV in very young patients with a congenital deformity. We sought to retrieve all studies reporting age at HV excision in patients with congenital scoliosis. Studies written in English were included. No publication date restrictions were imposed. A search of the PubMed and LiLacs databases was conducted. Additionally, a hand search was performed to supplement the database search. We found 140 articles. Twenty two studies were included into the final assessment. There was considerable heterogeneity in the included studies, both regarding age and the surgical techniques used. There was also a broad spectrum of recommendations regarding suggested age for treatment. The youngest patient undergoing resection and fusion was 3months of life at the time of surgery. How young a patient could and should be submitted to HV resection surgery is still a matter of debate in the literature. Prophylactic surgery might be a proper treatment for young children with congenital scoliosis before malformation becomes a deformity, adding no additional neurological, vascular, or anesthesia-related complications. The defect can be treated early while the deformity is treated late.

Regional Anesthesia for Clavicle Fracture Surgery- What is the Current Evidence: A Systematic Review

Introduction: The sensory innervation of the clavicle remains controversial. It might come from both the cervical plexus and brachial plexus. Peripheral nerve blocks used to anesthetize the clavicle include cervical plexus blocks, brachial plexus blocks, and combined cervical and brachial plexus blocks. Objectives: The review was to determine whether there is a difference in pain scores and pain medication consumption intraoperatively and postoperatively among these blocks. Secondary endpoints were block success and serious adverse events. Methods: A comprehensive literature search of PubMed and Web of Science was performed. Only English-written randomized controlled studies were included. Results: Compared with patients with general anesthesia, patients with combined ultrasound-guided superficial cervical and interscalene brachial plexus block spent a shorter time in PACU (35.60 ± 5.59 min vs. 53.13 ± 6.95 min, P < 0.001), had a more extended pain-free period (324.67 ± 41.82 min vs. 185.27 ± 40.04 min, P < 0.001), and received less opioid consumption (Tramadol 213.33 ± 57.13 mg vs. 386.67 ± 34.57 mg, P < 0.001) in first 24 h postoperatively. Compared with patients with ultrasound-guided superficial cervical and interscalene brachial plexus block, patients with ultrasound-guided intermediate cervical and interscalene brachial plexus block had a higher success rate (100% vs. 80%) and longer duration of post-operative analgesia (7.5±0.8 h vs. 5.7± 0.4 h, P<0.001). Without ultrasound guidance, patients with combined superficial, deep cervical, and interscalene brachial plexus block had a higher success rate (96% vs. 60%), lower pain score at two h postoperatively (1.96±0.17 vs. 3.22±0.88, p=0.000), and a more extended pain-free period (1h vs 6h) compared to combined superficial cervical and interscalene brachial plexus block. There were no regional anesthesia-related complications reported in all studies. Conclusion: Patients with regional anesthesia have a more significant pain-free period and less intraoperative and postoperative opioid consumption than patients with general anesthesia. Combined intermediate or deep cervical plexus and Interscalene brachial plexus blocks provide better analgesia than combined superficial cervical plexus and Interscalene brachial plexus blocks. Ultrasound guidance improved the success rate of regional anesthesia. Combined cervical plexus and brachial plexus block can be used as sole anesthesia for clavicle fracture surgery.

Surgical outcomes of supine PCNL in spinal deformity patients: A tertiary care hospital experience.

Percutaneous nephrolithotomy (PCNL) is treatment of choice now a days in patients with spinal deformity with large kidney stones. Objectives of our present study to compare in which position it is better to perform and costs minimum complications after surgery. A total of 14 patients with spinal deformity having nephrolithiasis were selected randomly. No preferences for age, gender, size, location, and laterality of stone or BMI. All the patients were fit according to AUA guideline criteria for management by PCNL. Preoperative and postoperative data were collected in all operated patients. Descriptive statistics were performed as means, standard deviations, and ranges using Microsoft excel. For categorical variables percentage were used. A total of 14 patients with spinal deformity having nephrolithiasis underwent PCNL. Seven patients operated in prone position and seven patients operated in modified supine position within approximately 2 years. As compared to prone position in supine position there were reduced operative time, little or no change in Hb concentration, shorter hospital stay, little intraoperative blood loss, and higher significant stone free rate were detected. Supine PCNL in spinal deformity patients with nephrolithiasis is an alternative to the standard prone PCNL. It provides an additional benefit of large operative field performing the procedure in a single position, reduces total operating time, less anesthesia related complications, less neuromusculoskeletal injury, and reduce physical strain on operating surgeon.

Orthopedic complications after osteotomy in patients with classic bladder exstrophy and cloacal exstrophy: a comparative study

The addition of pelvic osteotomy to the armamentarium of tools for correction of classic bladder exstrophy (CBE) and cloacal exstrophy (CE) has undeniably served as one of the most effective advancements in improving the likelihood of successful primary bladder closure. Osteotomy-related complications have been studied and documented extensively in patients with CBE, yet evaluation remains limited in CE concordant with its relative rarity. To compare orthopedic complications in patients with CBE and CE who underwent primary bladder closure with osteotomy. A prospectively maintained, IRB-approved database of 1401 exstrophy-epispadias patients was reviewed for patients with CBE or CE after primary closure and pelvic osteotomy performed at a single institution from 1975 to 2021. Failed closure was defined as dehiscence, bladder prolapse, or vesicocutaneous fistula at any point. Surgery or anesthesia-related complications were captured within 6 weeks of osteotomy or closure. A total of 146 patients were included in the analysis with 109 and 37 patients with CBE and CE, respectively. Between the CBE and CE cohorts, there were significant differences in median age at primary closure (68 days [IQR 10-260] vs 597 [448-734]; p<0.001), diastasis width (4cm IQR [3.8-4.6] vs 6.1 [5.0-7.2]; p<0.001), osteotomy at time of closure (99.1% vs 75.7%; p<0.001), and utilization of external hip fixation (67.9% vs 89.2%; p=0.011). There was no significant difference by gender, osteotomy technique, or hip immobilization technique. Regarding exstrophy closure outcomes, there were 5 failures in the CBE group and 1 in the CE group (p=1.000). Complications were experienced in 38.5% and 56.8% of CBE and CE patients (p=0.054) with a significant difference in orthopedic complications (primarily consisting of superficial pin-site infections) between the cohorts (4.6% vs 16.2%, p=0.031). There was no significant difference in grade 3 or higher complications between cohorts (5.5% vs 13.5%, p=0.147). This was the first study comparing orthopedic complications after osteotomy between CBE and CE, providing valuable insight into which factors vary among cohorts and which are associated with increased complication rates. Despite availability of high case numbers for these rare disorders, the analysis continued to be limited sample size and missing data for retrospective analysis. While exstrophy closure success and overall complications rates are similar in patients with CBE and CE, patients with CE experience more superficial pin-site infections after pelvic osteotomy. External hip fixation may be associated with the increase in orthopedic complications, though further research is required to elucidate the underlying cause of these complications.

Is Circumcision a simple Operation? A Study about Parents’ Anxiety and Fears

Objectives: To determine the factors which affect the anxiety of the parents of children undergoing circumcision. Patients and methods: A self-structured survey and Statefulness and Trait Anxiety Inventory (STAI-1 and STAI-2) were applied to both mothers and fathers (n=240) in the period prior to circumcision. STAI-1 State Anxiety Inventory was given to the parents on the day of the procedure. STAI-2 trait anxiety inventory was filled by the parents in the outpatient clinic during the preoperative preparation. Results: The average age of the mothers was 33.21±6.00 and the average age of the fathers was 36.74±7.34. There was a significant difference between the mean scores of STAI-1 state anxiety levels between the mothers and fathers (p=0.001), showing higher state anxiety levels among both. The STAI-2 trait anxiety level scores of mothers were found to be significantly higher than fathers (p=0.002). The anxiety levels of both mothers (p=0.001) and fathers (p=0.001) increased significantly on the day of circumcision. The parental anxiety was significantly associated with education level, father’s income level, number of children, and the child’s chronic health problem. Families were mostly worried about anaesthesia complications (72.5%); risk of infection (71.7%); post-operative pain (70%); post-operative bleeding (60.3%); and inadequate removal of the foreskin (55%). Conclusion: The anxiety levels of both parents increased significantly on the day of circumcision, but mothers’ anxiety levels were higher than fathers. Families were mostly concerned about the anaesthesia-related complications

The effect of age on electroencephalogram measures of anesthesia hypnosis: A comparison of BIS, Alpha Power, Lempel-Ziv complexity and permutation entropy during propofol induction.

BackgroundImproving anesthesia administration for elderly population is of particular importance because they undergo considerably more surgical procedures and are at the most risk of suffering from anesthesia-related complications. Intraoperative brain monitors electroencephalogram (EEG) have proved useful in the general population, however, in elderly subjects this is contentious. Probably because these monitors do not account for the natural differences in EEG signals between young and older patients. In this study we attempted to systematically characterize the age-dependence of different EEG measures of anesthesia hypnosis.MethodsWe recorded EEG from 30 patients with a wide age range (19–99 years old) and analyzed four different proposed indexes of depth of hypnosis before, during and after loss of behavioral response due to slow propofol infusion during anesthetic induction. We analyzed Bispectral Index (BIS), Alpha Power and two entropy-related EEG measures, Lempel-Ziv complexity (LZc), and permutation entropy (PE) using mixed-effect analysis of variances (ANOVAs). We evaluated their possible age biases and their trajectories during propofol induction.ResultsAll measures were dependent on anesthesia stages. BIS, LZc, and PE presented lower values at increasing anesthetic dosage. Inversely, Alpha Power increased with increasing propofol at low doses, however this relation was reversed at greater effect-site propofol concentrations. Significant group differences between elderly patients (>65 years) and young patients were observed for BIS, Alpha Power, and LZc, but not for PE.ConclusionBIS, Alpha Power, and LZc show important age-related biases during slow propofol induction. These should be considered when interpreting and designing EEG monitors for clinical settings. Interestingly, PE did not present significant age differences, which makes it a promising candidate as an age-independent measure of hypnotic depth to be used in future monitor development.