Anesthetic Challenges Research Articles

Anaesthetic Challenges in An Adolescent with Segawa Syndrome and Recurrent Aspiration Pneumonitis Scheduled For Laparoscopic Fundoplication. A Rare Presentation

Background: Segawa syndrome, or dopamine-responsive dystonia, is a rare genetic disorder that often presents with dystonia and gait disturbances. Literature on the anaesthetic management of these patients is generally limited, with especially minimal information on patients not treated with levodopa, particularly when multisystem complications are involved. Case: A 16-year-old adolescent male with Segawa syndrome, characterised by dystonia of face and neck muscles with global developmental delay, seizures, recurrent aspiration pneumonitis, and gastroesophageal reflux disease, underwent laparoscopic fundoplication. Anaesthesia was administered using propofol for induction, video laryngoscopy was used for intubation, and sevoflurane was used for maintenance. Despite respiratory challenges, including lower lobe infiltrates and a history of aspiration, careful intraoperative management ensured a stable course. Conclusions: This case highlights the need for a tailored anaesthetic approach in Segawa syndrome with multisystem involvement. It underscores the importance of vigilant respiratory management, cautious drug selection, and a multidisciplinary approach, particularly in patients not receiving levodopa therapy.

ANESTHETIC CONSIDERATIONS FOR CRITICALLY ILL PATIENTS WITH SEPSIS

Objective: Sepsis is a life-threatening condition characterized by organ dysfunction due to a dysregulated host response to infection. Critically ill patients with sepsis often require surgical interventions, presenting significant anesthetic challenges due to profound physiological alterations and multiple organ dysfunctions. Methods: This systematic review aims to synthesize current evidence on anesthetic management strategies for critically ill patients with sepsis. A comprehensive literature search was conducted in PubMed, Embase, and Cochrane Library databases for studies published up to October 2023. Inclusion criteria encompassed clinical trials, observational studies, reviews, and guidelines focusing on anesthetic considerations in septic patients. Results: Key findings indicate that thorough preoperative assessment, vigilant hemodynamic monitoring, careful selection of anesthetic agents, and tailored ventilatory strategies are crucial for improving perioperative outcomes. Hemodynamic instability necessitates the use of invasive monitoring and vasoactive medications like norepinephrine. Etomidate and ketamine are preferred induction agents due to their hemodynamic stability, with considerations for their side effects. Maintenance anesthesia often favors total intravenous techniques to minimize cardiovascular depression. Protective lung ventilation strategies are essential due to the high risk of acute respiratory distress syndrome (ARDS). Postoperative care requires multidisciplinary collaboration to manage ongoing sepsis and prevent complications. Conclusion: This review highlights the importance of individualized anesthetic plans and suggests that adherence to evidence-based practices can enhance patient outcomes in this high-risk group.

Effect of invasive acupuncture on awakening quality after general anesthesia: systematic review and meta-analysis.

The process of waking up from general anesthesia is still not well understood, and recovery issues such as delayed awakening, agitation, postoperative cognitive dysfunction, continue to be a challenge for anesthesiologists. Currently, the treatment of these complications is mainly achieved through the antagonistic action of specific drugs, but sometimes the antagonistic drugs are not as effective as they should be and can add to the financial burden of the patient. Acupuncture, a common treatment in Traditional Chinese Medicine, is widely used around surgery. However, there is no enough evidence to show it improves recovery after anesthesia. To explore this, we reviewed relevant randomized trials and conducted a meta-analysis. This systematic review was conducted to explore the effect of perioperative application of invasive acupuncture on the quality of postoperative awakening after general anesthesia. By searching PubMed, Embase, Cochrane Clinical Trials Center, China Knowledge Network (CNKI), China Biomedical Database (CBM), Wanfang Medical Database, Weipu Database, to include randomized controlled trials of invasive acupuncture applied perioperatively. Search is limited from the build-up of the database to March 2022. The statistical analysis was conducted using RevMan 5.3. Quality assessment of the included research literature using Cochrane-recommended risk of bias assessment tool. 18 randomized controlled trials were included with 1,127 patients. 565 patients in invasive acupuncture intervention group, 562 patients in control group. Results showed that invasive acupuncture group had a shorter eye opening time than control group (MD = -6.42, 95% CI [-8.17, -4.66], p < 0.001), shorter extubation times (MD = -5.84, 95% CI [-8.12, -3.56], p < 0.001), lower MAP at extubation (MD = -18.54, 95% CI [-22.69, -14.39], p < 0.001), lower HR at extubation (MD = -14.85, 95% CI [-23.90, -5.81], p < 0.001). No statistical difference in the occurrence of POCD (OR = 0.56, 95% CI [0.28, 1.11], p = 0.10) and postoperative agitation (OR = 0.42, 95% CI [0.11, 1.65], p = 0.21). https://www.crd.york.ac.uk/PROSPERO/, CRD42023410260.

Evaluation of the effectiveness of GASMAN anesthesia simulation software combined with case-based learning versus traditional lecture-based learning in inhalation anesthesia education.

To evaluate the effectiveness of integrating GASMAN anesthesia simulation software with case-based learning (IGC) compared to traditional lecture-based learning (LBL) in teaching inhalation anesthesia to undergraduate anesthesiology students. Fourth-year students from two academic years (2022, n = 110; 2023, n = 131) enrolled in a five-year anesthesiology program were assigned to either traditional lecture-based learning (LBL) or IGC groups. The LBL group received traditional lectures using PowerPoint slides, while the IGC group engaged with GASMAN anesthesia simulation software (a tool designed for anesthesia simulation and gas monitoring) combined with case-based learning. The cases used in the IGC group were structured around realistic clinical scenarios, simulating real-world challenges in inhalation anesthesia. These scenarios were integrated with the GASMAN software to provide interactive simulations, enhancing students' understanding of pharmacokinetics and pharmacodynamics. Teaching effectiveness was evaluated through expert assessments and student feedback, with learning outcomes compared via post-course assessments. The IGC group scored significantly higher in student evaluations in areas such as comprehending and mastering theoretical knowledge, resolving clinical challenges, nurturing clinical reasoning, increasing learning interest, enhancing learning efficiency, consolidating memory, improving analytical skills, and refining application proficiency (adjusted P < 0.001), however, there were no significant differences between the two groups in the improvement of practical skills. Post-course test scores were also higher in the IGC group for both total post-course test and subjective questions scores (adjusted P < 0.001), though no difference was found for objective question scores. After applying false discovery rate (FDR) correction, expert evaluation scores showed no significant differences between the two groups. The integration of GASMAN software with case-based learning significantly enhances the quality of inhalation anesthesia education by improving student engagement, critical thinking, and conceptual understanding. This approach demonstrates promise for advancing clinical education, although further research is needed to evaluate its long-term impact.

“Subarachnoid block in active burn injury”: A case report of anesthetic challenges and considerations

ABSTRACT Anesthetists pose different challenges in burn cases associated with polytrauma. Here, we present a case of a 35-year-old male electrician with an electric burn and a fall from height who sustained major chest trauma (hemothorax, pneumothorax, emphysema, and multiple rib fracture, and bilateral femur fracture). The collocated burn over the spinal region posed the challenge to administering a subarachnoid block, which was overcome with a paramedian approach anesthesia. The surgical outcome was good, and the patient was stable post-surgery. The paramedian approach provides an excellent alternative to the midline approach for spinal anesthesia. It should be considered in burn patients where it is impossible for the patient to flex, where the intervertebral space is very low, or when there is a burn present over the spinal region. Ultimately, early therapy and mobility goals, two essential components of burn care and rehabilitation, can be achieved with the use of paramedian regional anesthesia.

The anesthetic and recovery profiles of low-dose hypobaric mepivacaine and bupivacaine for spinal anesthesia in total hip and knee arthroplasty: a prospective observational study.

Same-day mobilization and early hospital discharge is increasingly emphasized following hip and knee arthroplasty. One challenge of spinal anesthesia in this setting is achieving adequate block height while avoiding excessively large local anesthetic doses and prolonged motor and sensory blockade. Using a hypobaric local anesthetic solution is one potential strategy, as its intrathecal distribution can be reliably manipulated by patient positioning to achieve adequate block height independent of dose. We conducted a prospective observational study to determine the clinical characteristics of spinal anesthesia with low-dose hypobaric mepivacaine and bupivacaine in patients undergoing hip and knee arthroplasty. Thirty patients scheduled for same-day discharge received 51mg of hypobaric 1.5% mepivacaine and 30 patients scheduled for inpatient stay received 10mg of hypobaric 0.33% bupivacaine. The mean (standard deviation) time to achieve sensory blockade at or above L1 and T10 in the operative limb was 5.7 (1.8) and 7.3 (3.3) min with mepivacaine and 6.2 (2.6) and 8.1 (4.8) min with bupivacaine, respectively. Anesthesia was adequate for surgical commencement in all patients regardless of spinal injection level. Four patients required anesthetic supplementation for surgical completion. Sensory block duration at or above T10 and L1 in the operative limb was 97 (27) and 115 (37) min with mepivacaine and 127 (32) and 161 (34) min with bupivacaine, respectively. Motor function returned by 145 (37) and 217 (43) min in mepivacaine and bupivacaine groups, respectively. The anesthetic profiles of low-dosehypobaric mepivacaine and bupivacaine were favorable for fast-track hip and knee arthroplasty with short and predictable operating times.

Successful Awake Fiberoptic Intubation and Ultrasound Guided Epidural Placement in Anaesthesia Management of a Case of Ankylosing Spondylitis

Ankylosing spondylitis (AS) is a chronic autoimmune spondyloarthropathy involving spine and sacroiliac joints resulting in characteristic bamboo spine (fused and rigid spine). A 41yr old male patient with Ankylosing spondylitis with history of Left THR presented with periprosthetic fracture posted for ORIF with plating. He had a classical bamboo spine with cervical involvement, MPC- 3 and restricted neck mobility. Preoperative Ultrasound scan (USG) of lumbar region done to identify spinal spaces. Awake Fiberoptic Nasal intubation done to secure difficult airway and induction done with Propofol and Vecuronium. Epidural catheter inserted at L1-L2 space using paramedian approach under USG under General Anesthesia in lateral position and Epidural analgesia given with 1% Ropivacaine. Extubation was done uneventfully with Sugammadex 2mg/kg used as reversal at end of surgery. Anaesthetic challenges in AS were both difficult airway and difficult regional anesthesia which was successfully managed with detailed evaluation and planning with USG

Anaesthetic Management in a Patient with Pituitary Macroadenoma: A Case Report

Pituitary tumours are the second most common intracranial tumours. The anaesthetic management of pituitary tumours requires an in-depth understanding of the principles of neuroanaesthesia and pituitary disorders. Immaculate preanaesthetic evaluation, intraoperative management and postoperative care with interdisciplinary teamwork are essential for successful outcomes in surgeries for pituitary tumours. This case report discusses a 34-year-old female patient presenting for the management of a pituitary macroadenoma, illustrating the anaesthetic challenges faced in such cases. The presence of acromegaly, along with co-morbidities such as hypertension, necessitated a detailed anaesthetic management plan. The patient underwent thorough preanaesthetic evaluation and had a transnasal trans-sphenoidal tumour excision under general anaesthesia, following standard protocols for difficult airway management. The patient was intubated using a video laryngoscope and invasive blood pressure and central venous pressure monitoring were conducted. Following surgery, the patient was transferred to the neurosurgery intensive care unit and was subsequently discharged on the 10th postoperative day

Anesthetic Challenges in a Patient with Nodular Sclerosing Classical Hodgkin’s Lymphoma complicated by Cervical Metastasis and SVC Syndrome: A Case Report

This case presents the anesthetic complexities involved in managing a patient with nodular sclerosing classical Hodgkin’s Lymphoma, who presented with severe airway compromise, limited neck mobility due to C7 vertebra involvement, and superior vena cava syndrome. The patient, with an extensive anterior neck mass extending into the mediastinum, post-auricular, and axillary areas, exhibited symptoms such as dyspnea, orthopnea, facial swelling, and upper extremity edema, complicating traditional airway management techniques. Faced with these challenges, the team anticipated significant difficulty with ventilation, direct laryngoscopy, and invasive airway access. To address the airway obstruction effectively before initiating radiotherapy, the anesthesiologists employed awake nasotracheal intubation using a fiberoptic scope with minimal sedation using Remifentanil. This approach successfully secured the airway and facilitated an extended tracheostomy. The patient tolerated the procedure well and was eventually discharged. This case underscores the critical role of fiberoptic intubation in managing complex airway scenarios, particularly in patients with complex malignancies and associated complications.

Recent Updates and Emerging Challenges in Anaesthesia, Critical Care and Pain Medicine

Recent Updates and Emerging Challenges in Anaesthesia, Critical Care and Pain Medicine

Common error traps in anesthesia for neonatal surgical emergencies.

Neonatal surgical emergencies are challenging, often high-risk procedures for the pediatric anesthesiologist. Though each emergency presents different anesthetic challenges, several error traps exist that are common to all procedures in this patient population. These error traps include errors in surgical timing, airway management, maintenance of normothermia and normoglycemia, and recognition of pharmacologic and physiologic differences. In this narrative review, we will discuss each error trap to aid the clinician in recognizing, planning for, and mitigating adverse events.

Error traps in patients with congenital heart disease undergoing noncardiac surgery.

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.

Unraveling anesthetic challenges of a patient with dilated cardiomyopathy posted for lower limb amputation surgery -A case report

This case report details the anesthetic management of a 64-year-old male with dilated cardiomyopathy (DCM) and a significantly reduced ejection fraction, undergoing lower limb amputation for peripheral arterial disease. Managing anesthesia in such patients poses considerable challenges due to the complexities associated with congestive heart failure. The successful administration of general anesthesia in this case can be attributed to a rigorous preoperative assessment and a meticulously devised anesthetic plan. The systematic approach included careful monitoring, fluid management, and the use of specific anesthetic agents that minimize cardiovascular stress, thereby ensuring an uneventful anesthetic course. This report emphasizes the importance of strategic planning and expert execution in the anesthesia management of patients with severe cardiomyopathy undergoing major surgical procedures.

Anesthetic management for fetal surgery: Lessons from a single-center experience (2019–2023)

Fetal surgery presents distinctive anesthetic challenges due to the need to balance maternal and fetal safety. This retrospective study evaluates the anesthetic management strategies used at a single center for various fetal interventions, including fetoscopic laser photocoagulation, fetal endoluminal tracheal occlusion, bipolar cord coagulation, and fetoscopic spina bifida repair.We reviewed 195 fetal procedures performed between 2019 and 2023 at Rabin Medical Center. Data collected included maternal and fetal characteristics, anesthetic techniques (spinal, combined spinal-epidural, general), intraoperative hypotension, and perioperative complications. We examined the evolution of anesthetic practice, particularly focusing on hemodynamic management and postoperative pain control.Spinal anesthesia was increasingly preferred for shorter procedures such as fetoscopic laser photocoagulation and bipolar cord coagulation, while general anesthesia was used exclusively for spina bifida repair. Intraoperative hypotension was a significant issue, leading to the implementation of prophylactic phenylephrine infusions, which improved blood pressure control. A shift from volatile anesthesia to total intravenous anesthesia in spina bifida repair resulted in fewer complications, including reduced bleeding. Postoperative pain management was optimized with a multimodal approach, improving pain scores.This study underscores the importance of tailoring anesthetic techniques to the specific fetal surgery. Key improvements in hypotension management, adopting total intravenous anesthesia for complex surgeries, and optimized postoperative pain control have contributed to better maternal and fetal outcomes. Ongoing reassessment and adaptation of anesthetic protocols remain critical as fetal surgery evolves.

A bite of death: Anaesthetic challenges in frostbite.

Frostbite is defined as tissue damage that is sustained as a result of prolonged exposures to less than 0°C resulting in ice crystallisation, microvascular occlusion and subsequently thrombosis. A 33-year-old mountaineer with cold burn over 20% of the total body surface area with eschar formation, acute renal failure, upper limb venous thrombosis and bilateral pleural effusion. We hereby report a successful anaesthetic management of this patient undergoing debridement and escharotomy for frostbite injuries and review its perioperative concerns. Frostbite injuries pose a challenge to the anaesthetic team due to the multi-systemic nature of its involvement.

Cardiac and Renal Transplantation in Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like Symptoms: Anesthetic Challenges and Considerations

Cardiac and Renal Transplantation in Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like Symptoms: Anesthetic Challenges and Considerations

Anesthesia Challenges in Cancer Patients

Anesthesia Challenges in Cancer Patients

Impact of anesthesiologist experience on neuraxial anesthesia outcomes in cesarean sections.

Despite the requirement for meticulous management of cesarean anesthesia, no study has explored the impact of novice trainee anesthesiologists in this field. This study assessed challenges in neuraxial anesthesia for cesarean sections and compared outcomes between novice and senior anesthesiologists. We retrospectively analyzed 446 cesarean sections with neuraxial anesthesia. The primary objective was to evaluate the impact of anesthesiologists' experience on the time required to administer neuraxial anesthesia and whether maternal body mass index (BMI) influenced this relationship. Secondary objectives included examining maternal hemodynamic variability, operative details, and newborn outcomes relative to the anesthesiologist's experience. Novice anesthesiologists required a significantly longer time to perform neuraxial anesthesia (24.9 [7.1] min vs. 18.2 [7.0] min, P<0.001) than their senior counterparts. A significant interaction was observed between anesthesiologist experience and maternal BMI on the time to administer neuraxial anesthesia (P=0.017), with a moderate correlation between BMI and administration time for novices (r=0.50, P<0.001) and only a slight correlation for seniors (r=0.17, P=0.001). Experience level did not significantly affect intraoperative hemodynamics, Apgar scores, or umbilical cord blood gas analyses. The effect of maternal BMI on the difficulty of performing neuraxial anesthesia in parturients can be more pronounced for novice anesthesiologists than for experienced ones. Despite requiring more time to perform neuraxial anesthesia, novice anesthesiologists do not significantly affect maternal hemodynamics or newborn distress during obstetric anesthesia, provided that they are under the supervision of experienced anesthesiologists.

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

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

Does Use of GLP-1 Agonists Increase Postoperative Complications in Patients Undergoing Shoulder Arthroplasty?

Amidst the rising prevalence of type 2 diabetes mellitus (T2DM) and obesity among individuals undergoing total shoulder arthroplasty (TSA), the impact of glucagon-like peptide-1 (GLP-1) therapy on surgical outcomes merits thorough investigation. Though it is known that GLP-1 therapy poses an interesting challenge for anesthesia during the perioperative period, little is known regarding the effects of these medications on surgical outcomes. This study aimed to evaluate the influence of GLP-1 on postoperative outcomes and length of stay (LOS) in patients T2DM undergoing TSA. A retrospective cohort analysis was performed using a national database to identify primary TSA patients aged 18 and above with T2DM prescribed GLP-1 therapy at the time of surgery. Exclusion criteria included revision surgery, TSA for fracture, type 1 diabetes, steroid-induced diabetes, and contraindications for GLP-1 therapy. A control group of T2DM TSA patients not on GLP-1 therapy was used, and a 1:4 propensity-score match was performed. Incidence rates and odds ratios via multivariable logistic regression were calculated. The primary outcomes were 90 days major medical complications and LOS. Secondary outcomes included 2-year joint-related complications. In the 90-day follow-up cohort, 64,567 patients met inclusion criteria, with 8481 (13.1%) on GLP-1 therapy. No significant increase in 90 days major complications, including deep vein thrombosis, cardiac arrest, myocardial infarction, cerebrovascular accident, pneumonia, pulmonary embolism, urinary tract infection, surgical site infection, hypoglycemic event, sepsis, or readmission, was found between GLP-1 and non-GLP-1 cohorts after multivariable logistic regression. In the 2-year follow-up cohort, 47,814 patients were included, with 5969 (12.5%) on GLP-1 therapy. Similarly, 2-year joint-related complications, including all-cause revision, prosthetic joint infection, periprosthetic fracture, and aseptic revision, showed no significant differences between the GLP-1 and non-GLP-1 cohorts. No significant difference was observed in LOS in the 90-day cohort. This study provides a comprehensive analysis of GLP-1 therapy's impact on TSA outcomes, revealing no significant change in postoperative complications or LOS. The lack of increased postoperative risk underscores the potential of GLP-1 therapy in managing T2DM without adverse effects on TSA recovery. These insights contribute to understanding postoperative management in orthopedic surgery, indicating that we did not note any increased risk with GLP-1 use perioperatively in TSA patients, unlike in other populations like the total knee arthroplasty patients. Future research should focus on prospective analyses to further elucidate the role of GLP-1 therapy in surgical outcomes, aiming to enhance patient care and optimize postoperative strategies for patients with T2DM undergoing TSA.