Anesthetic Management Protocol Research Articles

Criteria for immediate extubation after pediatric liver transplantation in a single pediatric liver transplant center in Japan.

This was a retrospective study. The records of all cases undergoing LT in our center from January 2016 to December 2020 were collected. We excluded cases>18 years old at the time of LT. Enrolled cases were divided into two groups: cases with immediate extubation (IE) or without immediate extubation (NIE). We compared preoperative conditions, intraoperative management, and postoperative courses. Finally, we classified NIE group patients into cases extubated at postoperative day 1 (early; E-NIE) and others (delayed; D-NIE) and compared their underlying diseases and postoperative courses. In the IE group, there were 81 cases, while the NIE group consisted of 185 cases. All patients in the IE group were successfully extubated without any instances of re-intubation due to respiratory failure. Within the E-NIE group, comprising 130 cases, all patients were ultimately extubated without the need for tracheostomy. However, in the D-NIE group, which encompassed 53 cases, seven patients required tracheostomy. In our center, the implementation of our anesthesia management protocol and the use of pre/postoperative case selection criteria have allowed for the safe practice of IE following pediatric LT. However, it should be noted that patients who cannot be extubated by Postoperative Day 1 (POD1) may be at an increased risk of requiring a tracheostomy. When contemplating IE, it is crucial to take into account the disease-specific physiological aspects and surgical site situations.

Anesthesia management protocol for liver transplantation as treatment for ornithine transcarbamylase deficiency.

Ornithine transcarbamylase deficiency is an X-linked genetic disorder that induces accumulation of ammonia in the liver and is the most common urea cycle disorder. The clinical manifestation of ornithine transcarbamylase deficiency is hyperammonemia that causes irreversible neurological damage. Liver transplantation is a curative therapy for ornithine transcarbamylase deficiency. The aim of this study is to suggest, from our previous experience, an anesthesia management protocol of liver transplantation for ornithine transcarbamylase deficiency, particularly focused on liver transplantation for cases with uncontrolled hyperammonemia. We retrospectively reviewed our anesthesia-related experience in all cases of liver transplantation for ornithine transcarbamylase deficiency in our center. Twenty-nine liver transplantation cases for ornithine transcarbamylase deficiency were found between November 2005 and March 2021 in our center. Of these, 25 cases were stable through the perioperative period. However, 2 cases with carrier donor graft had hyperammonemia after liver transplantation. Another two cases had uncontrolled hyperammonemia before liver transplantation, even with continuous hemodialysis. They underwent life-saving liver transplantation. Their metabolic status stabilized after the anhepatic phase. Liver transplantation for cases with uncontrolled hyperammonemia can be performed with proper management. Second, liver transplantation with carrier donors should be avoided because of the risk of postoperative recurrence.

Protocols of Anesthesia Management in Parturients with SARS-CoV-2 Infection.

Background: Our hospital became a referral center for COVID-19-positive obstetric patients from 1 May 2020. The aim of our study is to illustrate our management protocols for COVID-19-positive obstetric patients, to maintain safety standards for patients and healthcare workers. Methods: Women who underwent vaginal or operative delivery and induced or spontaneous abortion with a SARS-CoV-2-positive nasopharyngeal swab using real-time PCR (RT-PCR) were included in the study. Severity and onset of new symptoms were carefully monitored in the postoperative period. All the healthcare workers received a nasopharyngeal swab for SARS-CoV-2 using RT-PCR serially every five days. Results: We included 152 parturients with COVID-19 infection. None of the included women had general anesthesia, an increase of severe symptoms or onset of new symptoms. The RT-PCR test was “negative” for the healthcare workers. Conclusions: In our study, neuraxial anesthesia for parturients’ management with SARS-CoV-2 infection has been proven to be safe for patients and healthcare workers. Neuraxial anesthesia decreases aerosolization during preoxygenation, face-mask ventilation, endotracheal intubation, oral or tracheal suctioning and extubation. This anesthesia management protocol can be generalizable.

Anesthetic Considerations for Minimally Invasive, Off-Pump, HeartMate III Implantation

The authors developed and utilized an anesthetic protocol for the management of an off-pump approach for minimally invasive Heartmate III (HM3) implantation. Their goal was to determine if this method was safe and feasible for patients with in-situ mechanical support. The authors performed a retrospective study of consecutive patients undergoing off-pump HM3 implantation via bilateral minithoracotomies. This was a single-institution study at the University of Rochester Medical Center, using the same cardiac anesthesiologist and cardiac surgeon pair. The authors studied 8 consecutive patients undergoing off-pump HM3 implantation from June 2019 to July 2020. The authors developed an anesthetic management protocol for off-pump HM3 implantation via bilateral minithoracotomies. As a result, the authors evaluated 88% of men with a mean age of 55.0 ±13.0 years. The median time to extubation was 19.7 hours, with a median intensive care unit length of stay of 6.5 days. Fifty percent of patients required blood transfusions during the first 24 hours after surgery (postoperative), and 63% of patients were free from all postoperative complications. No patients required a right ventricular assist device. The mean hospital stay was 26.3 ± 11.3 days, with an 88% survival to discharge. In this single-center study, the authors have described the anesthetic consideration for the implantation of the HM3 left ventricular assist device using a complete sternal-sparing technique without the use of cardiopulmonary bypass. Their results have shown, in a case series of 8 patients, that this is a safe and feasible alternative to traditional techniques in patients with existing mechanical support.

Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up

An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure. A retrospective cohort study. A single academic center. Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019. The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients. Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve=0.676; 95% confidence interval, 0.611-0.741). Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.

Sevoflurane versus PRopofol combined with Remifentanil anesthesia Impact on postoperative Neurologic function in supratentorial Gliomas (SPRING): protocol for a randomized controlled trial

BackgroundPatients with intracranial tumors are more sensitive to anesthetics than the general population and are therefore more susceptible to postoperative neurologic and neurocognitive dysfunction. Sevoflurane or propofol combined with remifentanil are widely used general anesthetic regimens for craniotomy, with neither regimen shown to be superior to the other in terms of neuroprotective efficacy and anesthesia quality. There is no evidence regarding the variable effects on postoperative neurologic and neurocognitive functional outcome under these two general anesthetic regimens. This trial will compare inhalational sevoflurane or intravenous propofol combined with remifentanil anesthesia in patients with supratentorial gliomas and test the hypothesis that postoperative neurologic function is equally affected between the two regimens.MethodsThis is a prospective, single-center, randomized parallel arm equivalent clinical trial, which is approved by China Ethics Committee of Registering Clinical Trials (ChiECRCT-20,160,051). Patients with supratentorial gliomas diagnosed by magnetic resonance imaging will be eligible for the trial. Written informed consent will be obtained before randomly assigning each subject to either the sevoflurane-remifentanil or propofol-remifentanil group for anesthesia maintenance to achieve an equal-desired depth of anesthesia. Intraoperative intervention and monitoring will follow a standard anesthetic management protocol. All of the physiological parameters and other medications administered during the intervention will be recorded. The primary outcome will be neurologic function change assessed by National Institute of Health Stroke Scale (NIHSS) within 4 h after general anesthesia when observer’s assessment of alertness/sedation (OAA/S) reaches 4. Secondary outcomes will include NIHSS and modified NIHSS change 1 and 2 days after general anesthesia, hemodynamic stability, intraoperative brain relaxation, quality of anesthesia emergence, quality of anesthesia recovery, postoperative cognitive function, postoperative pain, postoperative neurologic complications, as well as perioperative medical expense.DiscussionThis randomized equivalency trial will primarily compare the impacts of sevoflurane-remifentanil and propofol-remifentanil anesthesia on short-term postoperative neurologic function in patients with supratentorial gliomas undergoing craniotomy. The exclusion criteria are strict to ensure that the groups are comparable in all aspects. Repeated and routine neurologic evaluations after operation are always important to evaluate neurosurgical patients’ recovery and any newly presenting complications. The results of this trial would help specifically to interpret anesthetic residual effects on postoperative outcomes, and perhaps would help the anesthesiologist to select the optimal anesthetic regimen to minimize its impact on neurologic function in this specific patient population.Trial registrationThe study was registered and approved by the Chinese Clinical Trial Registry (Chinese Clinical Trial Registry, ChiCTR-IOR-16009177). Principle investigator: Nan Lin (email address: linnan127@gmail.com) and Ruquan Han (email address: hanrq666@aliyun.com) Date of Registration: September 8th, 2016. Country of recruitment: China.

Reduction of oxidative stress a key for enhanced postoperative recovery with fewer complications in esophageal surgery patients: Randomized control trial to investigate therapeutic impact of anesthesia management and usefulness of simple blood test for prediction of high-risk patients.

Background:Oxidative stress may be an integral determinant of surgical stress severity. We examined whether the preoperative level of derivatives of reactive oxygen metabolites (d-ROMs), an oxidative stress biomarker based on total hydroperoxides in circulating blood, is predictive of increased risk of delayed recovery and complications after surgery, as well as the effects of anesthesia management on postoperative recovery in light of oxidative stress.Methods:Patients (American Society of Anesthesiologists physical status I-II) scheduled for a radical esophagectomy (n = 186) were randomly selected to receive inhalational sevoflurane (n = 94) or intravenous propofol (n = 92) anesthesia. Preoperative blood d-ROMs level, as well as pre-and postoperative plasma ferric-reducing ability, were analyzed to assess oxidative stress, with white blood cell (WBC) count, C-reactive protein (CRP) level, incidence of severe postoperative complications, and postoperative recovery process within 30 days after surgery also examined in a double-blind fashion.Results:Postoperative normalization of WBC and CRP was extended in patients with elevated preoperative d-ROMs [WBC versus d-ROMs: correlation coefficient (r) = 0.58 P < .001; CRP versus d-ROMs: r = 0.46 P < .001]. Receiver operating characteristics analysis of d-ROMs in relation to incidence of severe postoperative complications revealed an optimum d-ROMs threshold value of 410 UCarr and that patients with ≥410 UCarr had a greater risk of complications as compared to those with lower values (odds ratio = 4.7). Plasma ferric-reducing ability was decreased by 61 ± 185 mmol·l−1 (P < .001) after surgery, demonstrating development of surgery-related oxidative stress, the magnitude of which was positively correlated with preoperative d-ROMs level (r = 0.16, P = .043). A comparison of the 2 anesthesia management protocols showed that patients who received propofol, an antioxidant anesthetic, had no postoperative decrease in ferric-reducing ability, lower incidence of severe postoperative complications (7 of 92 versus 18 of 94, P = .030, odds ratio = 0.35), and faster uneventful recovery time (WBC normalization days 7.1 ± 5.2 versus 13.6 ± 10.2, P < .001) as compared to those who received sevoflurane.Conclusions:Elevated preoperative blood d-ROMs predicts greater intraoperative oxidative stress and increased postoperative complications with prolonged recovery, thus is useful for identifying high-risk patients for delayed and complicated surgical recovery. Reduction of oxidative stress is vital for enhanced recovery, with control by antioxidants such as propofol a possible solution.

Anesthesia for Emergency Preservation and Resuscitation (EPR) for Traumatic Cardiac Arrest: a Brief Review

We present the anesthesia management protocol currently in development at our institution for those patients enrolled into the Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) Clinical Trial. Emergency preservation and resuscitation (EPR) utilizing saline and deep hypothermia is a novel approach for management of trauma patients who present with life threatening non-compressible hemorrhage. This pioneering technique has transitioned from laboratory animal studies to human clinical trials. Patients who experience witnessed cardiac arrest from penetrating trauma and fail conventional therapy are eligible for enrollment in the EPR-CAT trial. This concept involves replacing the patient’s blood volume with cold saline to rapidly induce hypothermia and drastically reduce the metabolic rate of the heart, brain, and other vital organs. It is expected that this approach should give surgeons up to 1 hour to operate and gain surgical hemostasis before hypoxic brain damage would otherwise occur. After surgical control of hemorrhage, patients are reperfused via cardiopulmonary bypass (CPB) with balanced blood products and rewarmed back to near normal temperatures. During cooling and CPB, the patients are anticoagulated with heparin with the goal of restoring normal coagulation after liberation from CPB. The primary outcome measure is survival to hospital discharge with minimal neurologic deficits.

Abstract T MP28: Rigorous Anesthetic Management Protocol for Prevention of Perioperative Stroke in Patients with Intracranial Arterial Stenosis

Introduction: Perioperative ischemic stroke results in increased morbidity and mortality. As part of the ongoing EDAS Revascularization for Symptomatic Intracranial Arterial Stenosis (ERSIAS) Trial we have developed a strict anesthesia protocol to prevent fluctuations in patient parameters affecting cerebral perfusion: systolic blood pressure (SBP) and end-tidal CO2 (ETCO2). The hypothesis of this study is that the ERSIAS Anesthesia Management protocol reduces the variability of SBP and ETCO2 compared with a control group of non-stenosis-related vascular neurosurgical interventions. Methods: This is a prospective matched controlled cohort study of patients undergoing EDAS surgery vs. standard neurovascular interventions. ERSIAS patients had strict perioperative management including intentional hypertension and normorcarbia, meticulous fluid balance management, and antiplatelets use. Control patients received routine anesthetic standard of care. Minute-by-minute intra-operative vitals were electronically collected. Heterogeneity of variance test was used to compare variance across groups. Vitals standard deviations were compared with Welch’s tests for unequal variances and mean values were compared with t-test and Wilcoxon rank sums as appropriate. Results: Study population: 10 ERSIAS Trial patients (7 ICASD, 3 MMD) and 11 controls (7 aneurysm, 4 AVM), aged 27 to 75 (mean 51, SD: 15.0), 19 females (91%). There were significant reductions in the variability of SBP and ECO2 in the ERSIAS group below the permutation simulation computed lower boundary decision limit (p&lt;0.05). There was a significant reduction in the SBP SD 31.45 vs. 34.97 (p=0.035), and a trend reduction in ETCO2 SD 2.65 vs. 3.35. As intended, the mean ERSIAS cases SBP and ETCO2 were higher (149.5 vs. 110.9, p&lt;0.0001, and 36.5 vs. 31.2, p=0.0006, respectively). No patients in either group presented strokes. Conclusions: The rigorous ERSIAS peri-operative management protocol was successful in reducing intraoperative fluctuations of blood pressure and ECO2. The protocol was also successful in achieving the intended hypertension and normocarbia.

Safe anesthesia management protocol of a child with congenital long QT syndrome and deafness (Jervell and lange-nielsen syndrome) for cochlear implant surgery.

Safe anesthesia management protocol of a child with congenital long QT syndrome and deafness (Jervell and lange-nielsen syndrome) for cochlear implant surgery.

An Anesthetic Management Protocol to Decrease Respiratory Complications After Adenotonsillectomy in Children With Severe Sleep Apnea

An Anesthetic Management Protocol to Decrease Respiratory Complications After Adenotonsillectomy in Children With Severe Sleep Apnea

An Anesthetic Management Protocol to Decrease Respiratory Complications After Adenotonsillectomy in Children with Severe Sleep Apnea

A high incidence of respiratory morbidity after adenotonsillectomy is reported in children with obstructive sleep apnea syndrome (OSAS). In an effort to decrease this morbidity, we implemented perioperative guidelines recommending an adjustment in the administration of opioids, dexamethasone, and atropine in children with OSAS who demonstrated recurrent episodes of profound hypoxemia during the perioperative sleep study. We performed a retrospective review and compared results with historic data from 2001. The primary outcome variable was a major respiratory medical intervention (MMI(Respiratory)). The severity of OSAS was classified with the McGill Oximetry Scoring (MOS) system, and our focus was on those children demonstrating repetitive desaturation <80% (MOS4). The medical records of 292 children who underwent adenotonsillectomy between October 2002 and February 2006 met the inclusion criteria and 97 had been assigned MOS4. Eleven children (11.3%) required an MMI(Respiratory). In 2001, 8 children (29.6%), assigned MOS4, required an MMI(Respiratory). Comparing the new and old guidelines, the adjusted odds ratio for MMI(Respiratory) in MOS4 was 0.30 (95% CI: 0.10-0.85). The key elements achieving this reduction in MMI(Respiratory) were dexamethasone administration and a reduced opioid dosage. In 2002 to 2006, the intraoperative opioid dose, expressed in morphine equivalents, administered to the MOS4 group was 0.10 mg . kg(-1) (0.06-0.12 mg . kg(-1)), and the postoperative morphine dose was 0.02 mg . kg(-1) (0-0.07 mg . kg(-1)). Both doses were lower than the ones administered to the concurrent comparison group, P values <0.001. A change in practice that included a dexamethasone administration and a reduction in opioid administration to children with profound recurrent hypoxia reduced the incidence of MMI(Respiratory) by >50%.

Blood glucose control during selective arterial stimulation and venous sampling for localization of focal hyperinsulinism lesions in anesthetized children.

Surgical management of congenital hyperinsulinism is improved by accurate localization of small, focal dysregulated pancreatic lesions using the arterial stimulation and venous sampling (ASVS) test, which can demonstrate increased hepatic venous insulin concentrations after selective arterial injections of calcium. However, anesthesia-related increases in blood glucose can induce insulin secretion, making it difficult to interpret ASVS test data. In this retrospective study, we examined the effect of anesthetic interventions on blood glucose concentrations in 68 children undergoing ASVS testing. We considered only the glucose concentrations observed before calcium stimulation in the final analysis. The choice of drugs for induction (sevoflurane, propofol, or thiopentone), maintenance inhaled anesthetics (sevoflurane, desflurane, or isoflurane), and the use of caudal epidural bupivacaine were not associated with significant differences in the mean blood glucose concentration before ASVS. However, patients receiving remifentanil infusions had smaller mean glucose concentrations (80 +/- 18 versus 100 +/- 44 mg x dl(-1), P = 0.01). These concentrations were also significantly smaller if tracheal intubation was delayed for at least 10 min after induction while patients received inhaled anesthetics via a face mask along with remifentanil infusions (79 +/- 14 for delayed intubation versus 95 +/- 39 mg x dl(-1) for early intubation, respectively, P = 0.03). The percentage increase in glucose concentrations from preintubation values was significantly smaller in these subjects (3.7% +/- 21.9% for delayed intubation versus 31.7% +/- 60.4% for early intubation, P = 0.02). We conclude that the anesthetic management protocol for these patients should include the use of remifentanil infusions and the administration of inhaled anesthetics and remifentanil infusions for a minimum of 10 min to establish a deep plane of anesthesia before tracheal intubation.

Complete myocardial revascularization on the beating heart with epicardial stabilization: Anesthetic considerations

Objective: To describe an anesthetic management protocol for patients undergoing cardiac surgery with multiple coronary artery bypass grafts without cardiopulmonary bypass (off-pump CABG surgery) by median sternotomy with mechanical stabilization. Design: Retrospective nonrandomized analysis. Setting: Tertiary care hospital. Participants: Sixty-six consecutive patients on whom off-pump CABG surgery by median sternotomy was attempted. Interventions: Anesthesia was induced with a combination of etomidate and fentanyl; pancuronium bromide was given for muscle relaxation; and anesthesia was maintained with isoflurane, desflurane, or sevoflurane in 100% oxygen. Maintenance of normothermia was attempted by keeping the room temperature at 70°F, warming all fluids to 41°C, and using 2.5 L/min of fresh gas flows and a heat and humidity exchanger. When available, a convective forced-air blanket was used to cover patients' head and shoulders. Patients who were not slated for revascularization of the circumflex vessels and who had good ventricular function received central venous pressure monitoring (26%); all other patients received a pulmonary artery catheter. Measurements and Main Results: Of the 66 patients, 36% required an epinephrine infusion at a mean rate of 1.45 ± 2.05 μg/min intraoperatively to maintain hemodynamic stability; 25% required inotropic support for <12 hours in the intensive care unit. Conclusion: Institution of systematic hemodynamic management was associated with the successful completion of the surgical procedure in 61 patients (92%). Only 5 patients required conversion to regular CABG surgery with cardiopulmonary bypass. Copyright © 2000 by W.B. Saunders Company

Duration of Intubation and ICU Stay After Open Heart Surgery

One hundred four consecutive patients undergoing open heart surgery were studied to determine the duration of intubation and ICU stay associated with an anesthetic management protocol designed to avoid prolonged postoperative respiratory depression. The results document the feasibility and safety of early extubation and shortened ICU stay in patients having operations for ischemic and acquired valvular heart disease. Patients with complex congenital heart defects require significantly longer periods of respiratory support and intensive care.

Evaluation of Myocardial Damage in Patients Undergoing Coronary-Artery Bypass Procedures with Halothane-N2O Anesthesia and Adjuvants

During a 6-month period in 1975, 102 patients undergoing scheduled coronary-artery bypass grafting were studied by both conventional ECG and heart-specific enzymatic methods to evaluate the incidence and estimate the extent of myocardial damage associated with an anesthetic management protocol using halothane as a primary agent with adjuvant agents. Anesthetic interventions were made to maintain heart rate and systolic pressure at resting levels or below the heart rate systolic pressure product documented during exercise-induced angina. These interventions included adjustment of halothane concentration in all patients, the use of adjuvant agents in 88.2 percent, vasodilators in 26.5 percent, and the precardiopulmonary bypass use of vasoconstrictor or cardiostimulants in 9.8 percent. There were 2 early postoperative deaths. ECG evidence of infarction was observed in 4 surviving patients. Sustained release of heart-specific CPK-MB isoenzyme occurred in 78 percent of surviving patients. Isoenzyme activity was detected in only 1 patients prior to cardiopulmonary bypass (CPB), in 1 patient during CPB, and in all others after termination of CPB. The extent of myocardial damage as estimated by integrating CPK-MB values over time was directly related to number of vessels grafted and to aortic cross-clamp and CPB times. The ECG and enzymatic data both document a low level of myocardial damage associated with this anesthetic management protocol.