Anesthetic Challenges Research Articles

Pediatrics vascular injury management with total replacement of blood volume- Anesthesia challenges: A case report

Background: Vascular injuries with significant blood loss causing ischemia and revascularization for limb salvage are rarely done in developing countries. Hence, most hospitals and surgeons lack the experience to deal with vascular injuries. Case Presentation: A 9-year-old child presented with left subclavian artery transection and massive hemorrhage. The patient required massive transfusions during the repair of the injured vessel. Herein, we describe the challenges faced during the management of this patient. Conclusion: In an emergency setting, full optimization is not always possible. Every effort should be made to manage the patient by utilizing the available resources without undue delays.

Protocolized awake secondary tracheoesophageal puncture with immediate voicing.

Tracheoesophageal (TE) puncture with voice prosthesis placement is a common method for vocal rehabilitation in patients who have undergone total laryngectomy. Tracheoesophageal voice prosthesis (TEP) placement after laryngectomy, known as secondary TE puncture, is traditionally done in the operating room, using rigid esophagoscopy. Traditional secondary TEP placement carries a number of downsides including risks associated with general anesthesia, high cost, and technical challenges associated with anatomical variables. As a result, in-office secondary TE puncture has become an increasingly utilized procedure with many advantages but currently lacks standardization. Here, we describe a kit-based, awake, in-office secondary TE puncture with primary TEP placement technique. This technique calls for an endoscopic snare in the event there is difficulty passing the guidewire in the cranial trajectory. No surgical technique videos demonstrating in-office secondary TE puncture currently exist. Here, we present a video tutorial of our technique, breaking down the procedure into 10 steps from analgesia to voicing.

A Single-Center Retrospective Review of Patients with Suspected Malignant Hyperthermia Susceptibility.

Purpose The diagnosis of malignant hyperthermia susceptibility (MHS) has significant implications for the perioperative period that may persist for generations. Anesthetic medication options are reduced, anesthetic workstations require preparation to reduce exposure to inhaled volatile anesthetics, and patients may be excluded from surgery at ambulatory centers. In this study, we sought to better characterize the etiology of MHS diagnoses in our health system and the downstream effects of this diagnosis on anesthetic care. Methods We retrospectively reviewed the electronic medical records of 55 patients with a documented concern for MHS who received care at University of Florida (UF) Health between 2014 and 2020. We characterized the etiology of the patient's MHS diagnosis, whether this diagnosis was supported by formal genetic or muscle contracture testing, and the details of the recorded anesthetics that were delivered to these patients. Results The 55 patients with suspected MHS were evenly split between those with a family history of malignant hyperthermia (MH) (28/55) and those with a concern for MHS in their personal medical history (27/55). Of the 28 patients with a family history of MH, 16 reported that the affected family member was a first-degree relative, and two of these 16 reported that the affected family member had undergone confirmatory muscle contracture testing. Of the 27 patients with a personal history suspicious for MHS, two had undergone confirmatory genetic testing, and two patients had anesthetic records available for review where intraoperative MH was suspected and treated with dantrolene. An additional four patients were told of a concern about MHS due to another underlying diagnosis. No patients with a personal history suspicious of MHS had undergone confirmatory muscle contracture testing. These 55 patients underwent 87 anesthetics, and exclusively non-triggering anesthetic techniques were utilized in nearly all cases. In pediatric patients, some perioperative challenges were identified, related to the avoidance of mask inhalational induction. Only six of these 87 anesthetics occurred at our ambulatory surgery centers, a proportion (6.9%) lower than that of the general surgical population at UF Health (20.0%). Conclusions Among patients suspected to be MH susceptible in our health system over a six-year period, a minority (8/55) were supported by clear records of a prior MH event, confirmatory genetic or muscle contracture testing, or an underlying diagnosis closely linked to MH. The vast majority had limited documentation supporting their MH risk but continued to be treated with non-triggering anesthetics and were less likely to have surgery at an ambulatory surgery center than our overall surgical population. Among pediatric patients, some anesthetic challenges related to delivering non-triggering anesthetics were identified. Improving the documentation of index cases of MH and increasing referrals to clinical geneticists and genetic testing may be a viable route to decreasing the proportion of suspected MHS patients with a poorly characterized risk profile.

Anaesthesia Management of Congenital Alveolar Synechiae Release in a Neonate

Abstract A neonate, with complete fibrous congenital alveolar synechiae and amniotic band syndrome affecting the upper and lower limbs, was posted for surgical release of synechiae under anaesthesia. A neonate with no mouth opening poses many anaesthesia challenges. The surgical and anaesthesia plan was discussed with ear, nose and throat surgeons. Topicalisation of airway, small aliquots of intravenous (IV) ketamine and propofol and sevoflurane inhalation helped achieve adequate depth of anaesthesia to carry out flexible intubating video endoscope-guided nasotracheal intubation successfully. Post-surgery, a check laryngoscopy with D-Blade of C-MACR (Karl Storz Video Macintosh Laryngoscope) video laryngoscope revealed a Cormack Lehane view of grade IV. The trachea was not extubated on table and the baby was shifted back to the neonatal intensive care unit with pressure support ventilation and followed by tracheal extubation next morning. Rest of the course for the baby was uneventful. Anticipation, planning, preparedness, vigilance and team work during anaesthesia management led to a successful outcome in this case.

A Child with a Large Posterior Mediastinal Mass with Intraspinal Extension—Perioperative Anesthetic Challenges and Importance of Postoperative Analgesia

AbstractA 4-year-old girl child with a large posterior mediastinal mass with intraspinal extension (T2–T5) presented with paraplegia and bowel and bladder dysfunctions. She was planned for T1 to T6 laminoplasty and excision of the intraspinal tumor, followed by thoracotomy and excision of the posterior mediastinal tumor. Neurogenic tumors are common posterior mediastinal masses in children. These children pose many anesthetic challenges because of their size, location, and invasiveness. Challenges include difficult intubation, ventilation due to compression of the tracheobronchial tree, hemodynamic fluctuations because of compression of vital structures, associated autonomic dysfunction, and intraoperative bleeding. Pediatric lung isolation for thoracotomy and excision, obtaining motor evoked potential response in a child with poor functional grade status, and selecting appropriate analgesia techniques in the presence of neurological deficits are some of the added challenges. Anesthetic management and the use of a continuous erector spinae plane block for postoperative analgesia are highlighted in this report.

Anaesthetic Challenges in Recurrent Respiratory Papillomatosis with Unyielding Lesion

Abstract Recurrent respiratory papillomatosis (RRP) is one of the most common laryngeal lesions in children. A 14-year-old female presented with complaints of a change in voice and noisy breathing. She underwent excision of laryngeal papillomatosis thrice before. Fibreoptic laryngoscopy revealed that the lesion was occluding the entire glottic chink except for a small opening through which she was breathing. As there was a risk of seeding of the distal airway following tracheostomy, the initial plan of tracheostomy was deferred. Anaesthesia was induced with sevoflurane. C-MAC™ laryngoscopy revealed that the entire glottic chink was occupied with the papillomatous lesion, and no opening was visualised. The lesion could not be negotiated with a 4 mm endotracheal tube and started bleeding. Immediately, surgeon was asked to perform a tracheostomy. With each recurring incidence of RRP, the probability of the papilloma’s non-yielding nature may increase, making the negotiation of the lesion impossible.

392. PLANNING IS THE KEY—ESOPHAGECTOMY WITH COLONIC INTERPOSITION FOLLOWING: WHIPPLE’S, LEFT LOWER LOBECTOMY, RIGHT PLEURECTOMY AND COLONIC SURGERY

Abstract Link to Video: https://www.dropbox.com/s/wpr3s097g50oadl/Colonic%20interposition%20%28ISDE%20SUBMISSION%29.mp4?dl=0. Description of Video: We report our learnings from a complex surgical case of Ivor Lewis esophagectomy with colonic conduit in a patient who had undergone multiple previous abdominal and thoracic operations. This seventy-two-year-old man was found to have an esophageal adenocarcinoma (T4N0M0) in the distal esophagus with a significant surgical background: Whipple’s procedure for pancreatic cancer; Left lower lobectomy for lung cancer; Right pneumonectomy for recurrent pneumothoraces and a defunctioning stoma for chemotherapy associated anal fistula. To our knowledge, no such case of colonic interposition for esophagectomy has been reported in the literature for a patient with such extensive surgical history. This presented significant surgical and anaesthetic challenges which are explored in the video. Principally the need for extensive planning to anticipate risk and modify procedural steps to account for these accordingly. For example, the operation began with a right thoracotomy, given the possibility that dense adhesions from previous surgery could obstruct safe dissection and subsequently the procedure could be aborted before any critical steps were made. Additionally, we consider the importance of involving other surgical specialities to aid with safe dissection and delineation of anatomy. Each of the key operative steps are described and paired with real-time video footage. Post-operatively we describe how the risk of anastomotic leak given a high-risk anastomosis may be reduced through pre-emptive Endoluminal Vacuum therapy. We also discuss the importance of recognising and managing feculent aspiration pneumonia which is common following this surgery. Discussion of this case and our operative approach would serve to highlight how surgery remains a feasible option for patients despite complex anatomy and surgical history; provided risks are anticipated and appropriately managed.

A comparative evaluation of LMA® Gastro™ versus Gastro Laryngeal Tube for airway management in patients undergoing endoscopic retrograde cholangiopancreatography under general anesthesia: A randomized control study

BackgroundEndoscopic Retrograde Cholangio-Pancreatography is fraught with anesthetic challenges. Various anesthesia techniques have been studied, ranging from sedation to general anesthesia with tracheal intubation or specialized supra-glottic airway devices. MethodsThis randomized control trial included 70 patients undergoing endoscopic retrograde cholangio-pancreatography under general anesthesia and divided equally into two groups, LMA® Gastro™ or Gastro-Laryngeal tube. The primary objective was to compare the 1st time success rate and the secondary outcomes included, ease of insertion, number of attempts, oropharyngeal leak pressure, occurrence of adverse events; hemodynamic and ventilatory parameters. They were also compared in terms gastroenterologist's feedback about the device. ResultsThe first-time success rate for LMA® Gastro™ group was 88.5% and for Gastro-Laryngeal tube group was 77.1% (p value = 0.10). The mean difference for ease of insertion (p value = 0.001), oropharyngeal leak pressure (p value < 0.0001), peak airway pressure (p value < 0.0001) at different time intervals were significant for LMA® Gastro™ group. Hemodynamic response in terms of mean arterial pressure at 0 min (p value = 0.021) and gastroenterologist's feedback (p value < 0.0001) for Gastro-Laryngeal tube group was shown to be statistically significant. The mean difference between two groups for number of attempts, complications, hemodynamic response, end tidal volume, EtCO2 and recovery time were statistically insignificant (p value > 0.05). There was no desaturation in both the groups. ConclusionTo conclude, LMA® Gastro™ had performed better in terms of an airway device and ventilatory efficiency even in anticipated difficult airway, on the other hand, Gastro-Laryngeal tube is more conducive for the insertion and maneuvering of a gastro-endoscope.

Mode of Mechanical Ventilation in a Case of Venolymphatic Malformation: Spontaneous-Saves, Positive-Precludes.

Mediastinal venolymphatic malformations (VLM) are rare tumours, with very few reported cases in the literature. Arising often from the anterior mediastinum, VLM manifests symptoms based on invaded surrounding structures. Masses from the anterior and superior mediastinum pose an anaesthetic challenge for airway and hemodynamic management. A 7-month-old male child presented with a progressively growing mass over the left anterior chest wall for one month, about 4x4 cm, with diffuse margins and now expanded to involve the root of the neck and into the axilla. The patient was free from any apparent systemic illness. The breathing difficulty worsened in the past week with noisy respiration associated with feeding difficulty and hence sought medical admission to the paediatrics emergency unit. In conclusion, such huge mediastinal masses are managed better under spontaneous ventilation with an adequate surgical depth of anaesthesia to maintain appropriate respiratory compliance and necessitate lower peak inspiratory pressure. Given rare cases reported in the literature, similar topics would help choose the modus of ventilation and their safe management.

Surgery on the Unborn: Anesthesia for Intrauterine and Fetal Surgery – A Review

Advancements in medical science have paved the way for unprecedented interventions within the realm of intrauterine and fetal surgery. This review explores the pivotal role of anesthesia in these intricate procedures, delving into the nuances of anaesthetic techniques, challenges, and advancements. Fetal surgery involves medical interventions performed on a developing foetus while it is still in the womb. The types of fetal surgery can vary based on the medical condition or anomaly being addressed. The review delineates the primary objectives of this comprehensive analysis: to elucidate the evolving landscape of anesthesia for intrauterine and fetal surgery, to present an overview of established and innovative anesthesia modalities, and to underscore the collaboration between multidisciplinary teams in achieving successful outcomes. Additionally, the review provides a comprehensive analysis of established and emerging anesthesia methods utilized in fetal surgery. It examines the delicate balance between maternal comfort and fetal well-being, discussing the challenges associated with achieving optimal uterine relaxation and fetal immobility.

Anesthetic challenges in a child with congenital pulmonary airway malformation for right lower lobectomy

Abstract Congenital pulmonary airway malformation is a rare benign airway malformation, affecting the trachea, bronchi, bronchiolar, or alveolar systems with cystic and adenomatous lesions. This sequestered part of the lung becomes nonfunctioning and causes recurrent pulmonary infections. The definitive treatment is surgical resection of the diseased segments by thoracotomy requiring general anesthesia and controlled ventilation. The anesthetic challenges in pediatric lung surgeries are airway management, the requirement of one-lung ventilation, and maintaining saturation. The lung separation maneuvers in pediatric patients are difficult due to the nonavailability of appropriate size double-lumen endotracheal tube (ETT) or one-lung ventilation with bronchial blockers. We present how we managed to provide general anesthesia and controlled ventilation using single-lumen ETT to provide a good operating condition for right lower lobectomy.

Emerging Anesthetic Nanomedicines: Current State and Challenges.

Anesthetics, which include both local and general varieties, are a unique class of drugs widely utilized in clinical surgery to alleviate pain and promote relaxation in patients. Although numerous anesthetics and their traditional formulations are available in the market, only a select few exhibit excellent anesthetic properties that meet clinical requirements. The main challenges are the potential toxic and adverse effects of anesthetics, as well as the presence of the blood-brain barrier (BBB), which makes it difficult for most general anesthetics to effectively penetrate to the brain. Loading anesthetics onto nanocarriers as anesthetic nanomedicines might address these challenges and improve anesthesia effectiveness, reduce toxic and adverse effects, while significantly enhance the efficiency of general anesthetics passing through the BBB. Consequently, anesthetic nanomedicines play a crucial role in the field of anesthesia. Despite their significance, research on anesthetic nanomedicines is still in its infancy, especially when compared to other types of nanomedicines in terms of depth and breadth. Although local anesthetic nanomedicines have received considerable attention and essentially meet clinical needs, there are few reported instances of nanomedicines for general anesthetics. Given the extensive usage of anesthetics and the many of them need for improved performance, emerging anesthetic nanomedicines face both unparalleled opportunities and considerable challenges in terms of theory and technology. Thus, a comprehensive summary with systematic analyses of anesthetic nanomedicines is urgently required. This review provides a comprehensive summary of the classification, properties, and research status of anesthetic nanomedicines, along with an exploration of their opportunities and challenges. In addition, future research directions and development prospects are discussed. It is hoped that researchers from diverse disciplines will collaborate to study anesthetic nanomedicines and develop them as a valuable anesthetic dosage form for clinical surgery.

Successful neuraxial blockade under lumbar X-ray guidance in patients with ankylosing spondylitis: A series of 3 cases

Ankylosing spondylitis poses several anesthetic challenges ranging from difficult airway to difficult neuraxial blockade. Limited cervical spine mobility, restricted opening of the temporomandibular joint, and cardiorespiratory compromise makes neuraxial anesthesia the preferred technique in these patients. However due to the ossification of the interspinous ligament and ligamentum flavum, and also syndesmophytes between adjacent vertebrae, neuraxial anesthesia poses its own set of challenges. We present a series of 3 cases in which a preoperative lumbosacral X-ray spine and fluoroscopic guidance in the operation theater allowed for an easy and more effective technique for neuraxial anesthesia in ankylosing spondylitis patients posted for transurethral resection of prostate.

Rare incidental presentation of urinary bladder paraganglioma and the anaesthetic challenges faced: A case report

Urinary bladder paraganglioma is an extra-adrenal pheochromocytoma. As it lacks specific symptoms and because of its rare occurrence, it presents incidentally while tumour handling. A forty-eight-year-old female who presented with nausea, vomiting, weight loss, pain abdomen and hematuria was diagnosed with a bladder mass. She was scheduled for transurethral resection of the bladder tumour. On tumour manipulation, it showed numerous fluctuations in heart rate and blood pressure, from where a differential diagnosis of urinary bladder paraganglioma was made. Histopathology revealed a zellbellan pattern of paraganglioma. This case was discharged successfully postoperatively. But if undiagnosed preoperatively, it can be a real challenge because of the fatal hypertensive crisis and life-threatening cardiopulmonary complications.

Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study.

A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.

Anaesthetic Management of a Case of Down Syndrome with Chronic Kidney Disease Undergoing Major Orthopaedic Surgery

Background: Down syndrome is one of the common congenital chromosomal disorders. Renal complications in Down syndrome patients are rare but is increasing in number due to increased survival. Anaesthesia in such patients is challenging due to intellectual disability, anatomical complications and multiple comorbidities. Case: This case report describes the pre-operative evaluation and anaesthetic management of a 19 -year-old male patient with Down syndrome with hypothyroidism with Chronic Kidney Disease stage 4 who underwent open reduction internal fixation with plating for bilateral subtrochanteric fracture under general anaesthesia. It was a complicated surgery for both surgeon and anaesthetist because the patient was anaemic with significant anticipated blood loss along with fluid restriction during the perioperative period. We had major challenges like patient positioning, significant blood loss, hypotension, and early fluid overload. But an extensive preoperative evaluation, optimization prior and proper coordination we overcame the challenges. Conclusion: Major orthopaedic surgeries in patients like Down syndrome with chronic kidney disease create a major anaesthetic challenge due to expected significant blood loss, chances of fluid overload, multiple comorbidities and intellectual disability. Thorough preoperative evaluation, intraoperative monitoring as well as postoperative period is important as several complications are envisaged. So a closed group management with orthopaedic surgeon, nephrologist, anaesthesiologist, endocrinologist, nursing team is required to handle such complicated cases.

Against All Odds

Against All Odds

Mucormycosis in post-COVID patients: loose cannon waiting to fire at the anaesthesiologist

BackgroundRecently, several cases of mucormycosis in people with coronavirus disease 2019 (COVID-19) have been increasingly reported worldwide, in particular from India. As an increasing number of post-COVID patients with mucormycosis are presenting for surgical management, the onus is on the anaesthesiologists to adequately evaluate and optimise such patients.Case presentationWe present three cases to highlight the anaesthetic challenges in patients undergoing functional endoscopic sinus surgery (FESS) with debridement surgery for mucormycosis through a series of three cases. In our manuscript, two cases had comorbidities as a challenge uncontrolled diabetes and hypertension. The third case had difficult intubation due to a small mouth opening which was probably due to swelling and tenderness as a result of rhino orbital mucormycosis.ConclusionsProper anticipation, optimization and timed promptness to deal with the anaesthetic challenges pertaining to the multisystemic involvement and sequelae of mucormycosis should be done.

A parallel epidemic of sino-nasal mucormycosis post-COVID pneumonia, and its anesthetic implications: a case report

BackgroundThere has been a rise in cases of sino-nasal mucormycosis in patients who contracted the COVID-19 virus and were on steroids. Population at risk includes diabetics and on immunosuppressant therapy and/or immunocompromised state. Perioperative management becomes challenging due to residual pulmonary disease secondary to COVID pneumonia and complication following systemic antifungal therapy. Such patients often have other associated illnesses like hypertension, obesity, and deranged renal functions, either as a part of metabolic syndrome or post-systemic antifungal therapy.Case presentationWe report a case of a 64-year-old female, a poorly controlled hypertensive, with class 1 obesity, and diabetic on oral hypoglycemic agents, hypothyroid on oral medications, and post-COVID pneumonia with recently diagnosed sino-nasal mucormycosis who was posted for debridement of the sino-nasal fungal mass. The gamut of co-morbid conditions along with post-COVID pneumonia status presents an anesthetic challenge apropos the optimization of the clinical conditions and timing of the surgery considering the emergent nature of the surgery.ConclusionsThe timing of operative intervention for such patients is imperative and the treating team of anesthesiologist and the otorhinolaryngologist should aim to strike a balance between timely intervention to negate the spread of the infection to the orbit and brain causing potential irreparable damage and optimizing the cardio-respiratory and renal functions.

Common Anesthesia Challenges in a Case of Ankylosing Spondylitis Posted for the Correction of Spinal Deformity

Background: Ankylosing spondylitis (AS) is a type of inflammatory arthritis. Due to the rigid and brittle nature of spinal joints and multisystem involvement in the patients affected by ankylosing spondylitis, they are more prone to developing various complications. Different deformities require several surgical manipulations and perioperative anesthetic challenges, such as difficult intubation and positioning within the operating room. Case presentation: A 42-year-old man was diagnosed with ankylosing spondylitis, which has progressed over the last six years. He suffered from increasing pain and could not look forward, therefore; he has been scheduled for a corrective surgical procedure to address his spinal deformity to alleviate his pain and enhance the quality of his life by improving his functional abilities. Conclusion: Effective management of difficult airway cases with ankylosing spondylitis involving anatomical changes and reduced spinal mobility can be achieved by using awake fiberoptic-assisted nasal intubation. Intraoperative neuromonitoring and careful attention to proper positioning should be considered during the corrective spinal surgery to reduce complications.