Aspiration Prophylaxis Research Articles

Insights into obstetric anesthesia practices: a quantitative survey among physicians across Arab countries

BackgroundObstetric anesthesia guidelines are essential for standardizing obstetric anesthesia practices globally and ensuring high-quality patient care. However, practices may vary across different settings, and there are limited data from Arab countries. This study aims to gain insights into obstetric anesthesia practices in several major hospitals across Arab countries.MethodsA questionnaire was emailed to 85 obstetric anesthesiologists/anesthesia chairpersons in major hospitals, including academic medical institutions and central hospitals, across 11/22 Arab countries. This survey gathered data on key structural and process-related obstetric anesthesia indicators.ResultsOut of 85 contacted, we had 56 responses (65.8%), with 41 being fully completed, providing insights into obstetric anesthesia indicators. Regarding structure: 31 (76%) hospitals had an operating room adjacent to the delivery room, all had intensive care units, and 22 (54%) had a lead obstetric anesthesiologist. For equipment, 19 (46%) had a video laryngoscope in the delivery suite, and 20 (49%) occasionally used ultrasound for epidurals. Regarding process: 33 (81%) held regular meetings, and 21 (51%) conducted research. Before epidural and spinal procedures, 26 (63%) and 28 (68%) required coagulation studies for patients without a history of hemorrhagic complications, while 38 (93%) and 36 (88%) mandated a platelet count, respectively. For labor analgesia, 34 (83%) primarily used epidurals, and 15 (37%) placed preemptive catheters in high-risk pregnancies. For cesarean delivery, 40 (98%) used spinals, with 16 (39%) using intrathecal morphine and 22 (54%) administering aspiration prophylaxis before general anesthesia. Regarding spinal-induced hypotension, 6 (15%) used prophylactic phenylephrine infusion.ConclusionThis survey highlights variations in obstetric anesthesia practices among various major hospitals in several Arab countries, compared to international recommendations. It emphasizes the need for obstetric anesthesia registries in the Arab world for future research. Further studies are required to outline country-specific practices, improve resource allocation, and enhance obstetric population safety and satisfaction.

Comparison of ultrasonographic measurement of gastric antral volume and pH with or without pharmacological acid aspiration prophylaxis in low-risk surgical patients - A randomized clinical trial.

The role of preoperative pharmacological prophylaxis in preventing aspiration pneumonitis under general anesthesia (GA) in patients at low risk of aspiration pneumonitis is still under debate. We addressed the need for routine pharmacological aspiration prophylaxis in at-risk population by assessing the change in gastric volume using ultrasound with and without pharmacological acid aspiration prophylaxis. A single-center, randomized double-blinded trial, with 200 adult patients scheduled for elective surgical procedures under GA, were randomized into a prophylaxis group, in which the patients received oral famotidine and metoclopramide, and a no prophylaxis group, in which the patients did not receive any prophylaxis. Gastric volume derived from preinduction measurement of gastric antral volume by ultrasound, postinduction gastric pH, and incidences of aspiration pneumonitis were compared. Bland-Altman plot was used to determine the level of agreement between measured gastric volume and ultrasonography based on calculated gastric volume. The gastric antral cross-sectional area (CSA) and volume in the no prophylaxis group (3.12 cm2 and 20.11 ml, respectively) were comparable to the prophylaxis group (2.56 cm2 and 19.67 ml, respectively) (P-values 0.97 and 0.63, respectively). Although there was a statistically significant decrease in gastric pH in the no prophylaxis group (P-value 0.01), it was not clinically significant to increase the risk of aspiration pneumonitis based on Roberts and Shirley criteria (P-value 0.39). In an adequately fasted low-risk population, the amount of residual gastric volume was similar and below the aspiration threshold, regardless of the aspiration prophylaxis status.

Anaesthesia in a Pregnant Female with Infective Spondylodiscitis Posted for Laminectomy with Posterior Instrumentation

Introduction: Spondylodiscitis in pregnancy is an uncommon entity that can inadvertently hamper the pregnancy. Case presentation: A 25-year-old primigravida in the middle of her third trimester presented with new-onset ascending paralysis due to infective spondylodiscitis. The compression of the spinal cord by virtue of spondylodiscitis demanded immediate surgical decompression. The indirect decompression of the spinal cord was successfully accomplished by performing laminectomy with posterior instrumentation while the anesthesiologists provided general anaesthesia, monitored, and maintained maternal and foetal safety. Anaesthetic methods employed include perioperative tocolytic cover, an induction of rapid sequence, aspiration prophylaxis, balanced analgesia, and appropriate maintenance of Mean Arterial Pressure, thereby ensuring maternal and foetal well-being. Conclusion: A prompt surgical intervention and appropriate anaesthesia management resulted in successful decompression of the spinal cord with excellent recovery of paraplegia while avoiding maternal and foetal morbidity and mortality. Keywords: Pregnancy, Laminectomy, Foetal monitoring, Patient positioning, Uteroplacental blood flow.

General anaesthesia for nonobstetric surgery during pregnancy

Nonobstetric surgery may be required in up to 1% of pregnancies. Most common procedures are urgent abdominal surgeries requiring general anaesthesia. Maintaining normal maternal physiology during anaesthesia is vital. Left lateral tilt position prevents aortocaval compression and preserves normal venous return. Preparation for a difficult airway is required in all obstetric patients due to the known anatomical and physiological changes. Aspiration prophylaxis and a rapid sequence induction are traditionally recommended to avoid the (probably overestimated) risk of aspiration. Although the minimum alveolar concentration (MAC) of volatile anaesthetic agents is reduced by 30 to 40%, awareness occurs more frequently in the obstetric population. Maternal outcomes from surgery are comparable with those of nonpregnant women, but increased incidences of foetal loss, preterm delivery, low birth weight and caesarean section have been reported. Although animal studies have observed impaired foetal brain development after antenatal exposure to anaesthesia, the translational value of these studies remain controversial. Clinical evidence is nearly absent. Withholding urgent/essential procedures is certainly more threatening than proceeding with the surgery. To increase the safety of mother and foetus, nonurgent or nonessential procedures should be postponed until after delivery, and if procedures cannot wait, locoregional anaesthesia should be used if possible. Where general anaesthesia cannot be avoided, the duration of exposure should be kept to a minimum. This narrative review summarises the literature of the past 20 years concerning the anaesthetic management and outcomes of nonobstetric surgery under general anaesthesia during pregnancy.

The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia

BackgroundPulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia.MethodsThis survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers.ResultsFour hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration.ConclusionsMore than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

The influence of fasting and carbohydrate-enriched drink administration on body water amount and distribution: a volunteer randomized study

BackgroundFasting prior to anesthesia is considered aspiration prophylaxis. However, prolonged food and drink restrictions may increase the risk of other complications. The aim of this study was to assess whether a carbohydrate-enriched drink (Nutricia™ preOp®), recommended by the enhanced recovery after surgery (ERAS) protocol, can improve body hydration in fasting healthy individuals.MethodsMeasurements were done with the bioelectric impedance analysis with a Fresenius body composition monitor. Body composition, total body water, water distribution, and hemodynamic parameters were measured at the beginning of the study and after 10 h and 12 h of fasting. Patients fasted for 10 h and then were divided into two groups: the control (n = 40) and the pre-op group (n = 41). The pre-op group received 400 mL of Nutricia™ preOp®, as suggested in the ERAS guidance. The two-tailed Student’s t test was used to compare two groups with normally distributed data and homogenous variances; if variances were heterogeneous, Welch’s test was used. The Mann-Whitney U test was used to compare two groups with non-normal data distribution. p < 0.05 was considered statistically significant.ResultsWe found no significant differences between the control and pre-op groups regarding body water distribution and body composition. We did not observe significant losses in the total body water after fasting. Also, blood pressure was not affected by fasting.ConclusionWe have proven that pre-op did not impact either body composition or body water.Trial registrationClinicalTrials.gov, NCT04665349. Registered on 11 December 2020—retrospectively registered.

General anesthesia for emergency cesarean delivery: simulation-based evaluation of residents

IntroductionDecreased rates of General Anesthesia (GA) for Cesarean Section (C-section) create a learning problem for anesthesia trainees. In this context, training the management of GA for C-section using simulation techniques allows a safe environment for exposure, learning, performance improvement, and capability retention. ObjectiveAnalyze anesthesia residents’ performance regarding a simulated clinical case of GA for emergency C-section and identify specific deficits in skill acquisition. MethodsBetween 2015 and 2018, we evaluated the performance of 25 anesthesiology residents challenged by a simulated clinical case of GA for emergency C-section after the conclusion of the obstetric anesthesia rotation. Each resident performed the clinical case once followed by the assessment of their performance. Final scores were given according to the completion rate of 14-tasks, going from 0% to 100%. Two study groups were considered according to residency year for subsequent comparison of results (Group 1, second and third residency years and Group 2, fourth and fifth residency years). Results and discussionMean score was 64.29% ± 13.62. Comparatively, Group 1 obtained a higher score than Group 2 (70.63% ± 14.02 vs. 60.27% ± 11.94), although with no statistically significant difference (p = 0.063). The tasks most frequently accomplished were opioid administration (100%), rapid sequence technique (100%), pre-oxygenation (92%), gastric content aspiration prophylaxis (84%), and previous clinical history (84%). Conversely, the tasks less frequently accomplished were confirming presence of pediatrician (64%), oxytocin administration (56%), PONV prophylaxis (56%), and preoperative airway assessment (48%). ConclusionThe performance of the residents observed in this study was comparable to results previously published. The final score did not depend on the residency year.

Anesthesia for Cesarean Delivery

Cesarean delivery is a cornerstone of obstetric anesthesia and it is imperative for providers to have a deep understanding of the indications, preparation, techniques, and potential complications of both the procedure and the anesthesia. It is necessary to obtain a focused but thorough history and physical and to develop an appropriate individual by considering a multitude of factors including co-morbid maternal and fetal conditions, timing of delivery, technical needs of the surgeon, potential adverse events, and systems based decision making. Anesthesia providers need to determine the safest method to provide anesthesia for the mother with an aim to minimize risk to the fetus. Once the decision of which anesthetic technique will be utilized is made, the provider must have the knowledge of how to best execute the plan and remain vigilant by maintaining a back-up plan in the case of complications. Obstetric anesthesia for cesarean delivery carries a set of unique challenges and potential risks in addition to the standard risks associated with general and neuraxial anesthesia. This review contains 5 figures, 6 tables, and 86 references. Keywords: Maternal Physiology, Maternal-Fetal Considerations, Systemic Medications, Cesarean Delivery, Difficult Airway, Aspiration Prophylaxis, Supine Hypotensive Syndrome, Aspiration of Gastric Contents, Vaginal Birth After Cesarean Section (VBAC)

P055: Canadian emergency physician attitudes toward endotracheal intubation for aspiration prophylaxis

Introduction: Emergency patients with decreased level of consciousness often undergo intubation purely for airway protection from aspiration. However, the true risk of aspiration is unclear and intubation poses risks. Anecdotally, experienced emergency physicians often defer intubation in these patients while others intubate to decrease the perceived clinical and medico-legal consequences. No literature exists on the intubation practices of emergency physicians in these cases. Methods: An online questionnaire was circulated to members of the Canadian Association of Emergency Physicians. Participants were asked questions regarding two common clinical cases with decreased level of consciousness : (1) acute, uncomplicated alcohol intoxication and (2) acute, uncomplicated seizure. For each case, providers’ perceptions of aspiration risk, the standard of care, and the need for intubation were assessed. Results: 128 of the 1546 Canadian physicians contacted (8.3%) provided responses. Respondents had a median of 15 years of experience, 88% had CCFP-EM or FRCPC certification, and most worked in urban centers. When intubating, 98% agreed they were competent and 90% agreed they were well supported. A minority (17.4%) considered GCS &lt; 8 an independent indication for intubation. For the alcohol intoxication case, 88% agreed that aspiration risk was present but only 11% agreed they commonly intubate. Only 17% agreed intubation was standard care, and only 0.8% felt their colleagues always intubate such patients. For the seizure case, 65% agreed aspiration risk existed but only 3% agreed they commonly intubate, 1% felt colleagues always intubated, and 5% agreed intubation was standard of care. Additional factors felt to compel intubation (394 total) and support non-intubation (366 total) were compiled and categorized; the most common themes emerging were objective evidence of emesis or aspiration, other standard indications for intubation, head trauma, co-ingestions, co-morbidities and clinical instability. Conclusion: It is acceptable and standard practice to avoid intubating a select subset of intoxicated and post-seizure emergency department patients despite aspiration risk. Most physicians do not view the dogma of “GCS 8, intubate” as an absolute indication for intubation in these patients. Future research is aimed at identifying key factors and evidence supporting intubation for the prevention of aspiration, as well as the development of a validated clinical decision rule for common emergency presentations.

Anaesthesia considerations and management in case of first trimester heterotopic pregnancy undergoing a laparoscopic ectopic excision

Heterotopic pregnancy is a presence of intrauterine and extra-uterine gestation concurrently. It might be rare but possess great challenge for an anaesthetist as both maternal and foetal safety are at risk. We report a case of 28 years primigravida diagnosed as heterotopic pregnancy and shifted for an emergency laparoscopic ectopic excision under General anaesthesia. Our primary concern for maternal and foetal safety for undergoing surgery in first trimester pregnancy was achieved by Meticulous attention to preoperative counselling, airway management, aspiration prophylaxis, haemodynamic stability, choice of anaesthesia and anaesthetic drugs which have minimal impact on utero-placental perfusion and uterine relaxation. On follow up the patient delivered a healthy full term live female child weighing 2.7 kg by elective cesarean section.

Anesthetic Management of Nonobstetric Surgery during Pregnancy

This article reviews several controversial aspects of management of nonobstetric surgery during pregnancy, including the optimal timing for nonurgent surgery, when to perform intraoperative fetal monitoring, modifications to anesthetic techniques to account for the physiologic changes of pregnancy, and management of maternal cardiac arrest. There have been several advances in the management of nonobstetric surgery during pregnancy, including the increased use of laparoscopic techniques, an improved understanding of the importance of adequate pain management, and new initiatives to improve the maternal cardiac resuscitation algorithm. Traditional dogma regarding aspiration prophylaxis during pregnancy and concerns about abortifacient and teratogenic properties of diagnostic imaging and anesthetic agents have also recently been reevaluated. Urgent and emergent surgeries should proceed without delay during pregnancy in order to ensure optimal outcomes for both the mother and fetus. Anesthetic management may require several modifications to account for physiologic changes of pregnancy. In general, uteroplacental perfusion is best maintained by avoidance of maternal hypoxemia, hypotension, hyper- and hypocapnia, temperature extremes, and stress.

A 10-year update: national survey questionnaire of obstetric anesthesia units in Israel

BackgroundThis nationwide survey was conducted to provide data about the obstetric anesthesia services in Israeli labor and delivery units in 2016. MethodsProspective survey questionnaire was emailed to obstetric anesthesia unit directors/chairperson of all 25 labor and delivery services units within the jurisdiction of the Israeli Ministry of Health. ResultsThe response rate was 100%. Nineteen (76%) units have dedicated anesthesiologist cover. Fifteen (60%) units offered nitrous oxide, four units (16%) offered patient-controlled intravenous fentanyl and six units (24%) offered patient-controlled intravenous remifentanil for alternative labor analgesia. The median (range) epidural rate was 60% (22–85%). The median (range) cesarean delivery rate was 20% (10–26%). Overall, general anesthesia was performed for median (range) 10% (1–25%) of cesarean deliveries. Neuraxial anesthesia was performed for 95% (40–99%) of elective and 60% (0–90%) of urgent cesarean deliveries. Intrathecal morphine was administered routinely for spinal anesthesia for post-cesarean delivery analgesia in 11 (44%) units. Nineteen (72%) units had a written aspiration prophylaxis protocol; 20 (80%) had a written labor analgesia protocol; 19 (76%) had a postdural puncture headache management protocol; 20 (80%) had a local anesthetic toxicity protocol; 24 units had Intralipid available in the unit. ConclusionNo new labor units have opened since 2005, despite huge increases in delivery volume in many units. These units manage increased numbers of epidurals and cesarean deliveries. Use of intrathecal morphine for spinal anesthesia has become more widespread. Future efforts should focus on availability of emergency equipment, separate obstetric anesthesia staffing, and establishing emergency protocols.

Difficult airway associated with bifid glottis and coexistent subglottic stenosis in a patient with Pallister\u2013Hall syndrome: a case report

BackgroundPallister–Hall syndrome is a rare disorder characterized by hypothalamic hamartoma, hypopituitarism, bifid epiglottis, and micrognathia.Case presentationWe describe the airway management under general anesthesia of a 15-year-old female with Pallister–Hall syndrome whose airway was compromised with bifid epiglottis and acquired subglottic stenosis. The three options considered for airway management were tracheal intubation, a supraglottic device, and surgical tracheotomy. Tracheal intubation provides a secured airway, but extubation can be difficult. A supraglottic device minimizes airway injury, but it does not completely protect the airway from aspiration.ConclusionsThe patient’s airway was successfully managed using a supraglottic device with aspiration prophylaxis. Airway management devices should be selected according to each patients’ individual circumstances.

Perioperative Management of Patients with Down Syndrome: A Review

Introduction: Down syndrome (DS) or Trisomy 21 is associated with a higher morbidity, mortality and surgery need. This syndrome presents a characteristic set of morphologic features regarding several systems: cardiovascular, respiratory, gastrointestinal, nervous, musculoskeletal, immune, hematologic, endocrine, ophthalmic and hearing. Therefore, special care is required to maximize safety before, during and after surgery. This study’s objective is to systematically review these needs in the perioperative (pre, intra and postoperative) period, and how to approach them. Methods: PubMed and Web of Science were searched and 32 articles selected for this revision. Results: DS patients have commonly pulmonary arterial hypertension and congenital heart defects. They may have swallow function abnormalities or gastro-esophageal reflux disease. Airway and respiratory tract conditions, such as aspiration pneumonia, obstructive sleep apnea, congenital tracheal stenosis, and recurrent infections, are common. In addition, cervical instability and nociception disorders may be present. Discussion: In order to prevent perioperative complications, several practices are suggested. In the preoperative period: assess the surgical risk using Aristotle and RACHS-1 scoring systems, analyze a recent echocardiogram, consider prophylactic antibiotic therapy and take strict aseptic precautions. Performing an X-ray looking for cervical instability is a controversial topic. In the intraoperative period: administer intravenous sedation in dental treatments, have anticholinergic agents available, consider aspiration prophylaxis, and position the neck particularly. However, there is no agreement on the best airway device. In the postoperative period: provide longer hospitalizations or stay in intensive unit care, remove catheters as soon as possible, assess the pain with specific tools, administer lower weight-adjusted doses of dexmedetomidine (controversial topic) and use morphine, once no opioid resistance was found. Conclusion: There are variations in the approach to the perioperative period, and even lack of agreement in some topics, making clear the need for specific guidelines to standardize this process and reduce morbidity.

Wolff-Parkinson White syndrome in a parturient with rheumatic heart disease for caesarean section - Anaesthesia management.

Wolff-Parkinson White syndrome in a parturient with rheumatic heart disease for caesarean section - Anaesthesia management.

Postoperative management with dexmedetomidine in a pregnant patient who underwent AVM nidus removal: a case report

BackgroundFollowing cerebral arteriovenous malformation (AVM) surgery, severe brain edema and hemorrhage may be caused by postoperative normal perfusion pressure breakthrough (NPPB). Sedation is necessary for this population. It is a challenge for the anesthesiologist to maintain hemodynamic stability without interfering with the neurological assessment. In Japan, propofol is contraindicated for pregnant patients. Dexmedetomidine is a versatile drug in anesthesia practice and may be useful for this situation. There is no report using dexmedetomidine for the purpose of NPPB control in pregnant patients. We describe the postoperative management with dexmedetomidine for a pregnant patient who underwent cerebral AVM nidus removal.Case presentationA 32-year-old patient presented with headache at the 16th week of gestation. Neuroimaging revealed an intraventricular hemorrhage and an AVM at the right anterior horn of the lateral ventricle which caused bleeding. A multidisciplinary team discussion was done, and then a craniotomy for AVM nidus removal was performed under general anesthesia. Preanesthetic aspiration prophylaxis and rapid sequence induction were added to our conventional anesthetic management. Hypotension occurred after anesthetic induction but the patient recovered by volume resuscitation and vasopressors. Anesthesia was maintained with 50% O2 in air and sevoflurane. The AVM was completely removed, and no perioperative complications occurred. Postoperative sedation with dexmedetomidine was used to prevent breakthrough hyperperfusion and cerebral edema.ConclusionsDexmedetomidine infusion was used for postoperative sedation without causing any side effects, and it can be an alternative for sedation, especially when propofol is contraindicated.

To evaluate the use of ProSeal laryngeal mask airway in patients undergoing elective lower segment cesarean section under general anesthesia: A prospective randomized controlled study

Background: Anaesthesia for caesarean section poses challenges unique to the obstetric patient due to changes in the airway and respiratory system. The choice of anaesthesia for caesarean section depends on various factors; however, general anaesthesia (GA) is necessary in certain situations. Supraglottic airway devices are an emerging method to secure the airway, especially in difficult situations. Of these devices, ProSeal laryngeal mask airway (PLMA) is designed to provide better protection of the airway. Use of PLMA has been reported to be successful as a rescue device in difficult intubation situations and in patients undergoing elective caesarean section without any complications. Hence, this prospective randomized study was designed to compare the use of PLMA with endotracheal tube (ETT) in patients undergoing elective lower segment caesarean section (LSCS). Material and Methods: Patients undergoing LSCS under GA belonging to the American Society of Anaesthesiologists (ASA) grades 1 and 2 were included. Patients with history of less than 6 h of fasting, known/predicted difficult airway, obesity, gastro-esophageal reflux disease, and hypertensive disorder were excluded. A standard anaesthesia protocol was followed. All patients received aspiration prophylaxis. The airway was maintained with either PLMA or ETT. The parameters including ease of insertion, adequacy of ventilation, hemodynamic changes at insertion and removal of device, and incidence of regurgitation and aspiration were noted. Statistical analysis: The data were analyzed by unpaired t-test, chi-square/Fisher's test. Results: Findings of the study indicated that PLMA was easy to insert (20.67 ± 6.835 s) with comparable insertion time to ETT (18.33 ± 4.971, P = 0.136) and adequate ventilation was achieved with very minimal hemodynamic changes seen with PLMA as compared to ETT at the insertion and removal of devices (P = 0.01). There was no incidence of regurgitation with the use of PLMA. The incidence of postoperative sore throat was minimal (6.7%) with PLMA (P Conclusion: PLMA appears to be a safe alternative to ETT for selected obstetric patients undergoing elective LSCS. A further study with a large group of patients is required to establish the safety of PLMA in obstetric patients.

Comparative evaluation of gastric pH and volume in morbidly obese and lean patients undergoing elective surgery and effect of aspiration prophylaxis

IntroductionThe anesthetic management of patients with morbid obesity is challenging. There is no consensus on the routine use of aspiration prophylaxis in morbidly obese patients undergoing elective surgery. AimThe aim of this study is to assess the risk of pulmonary aspiration and effect of premedication with ranitidine and metoclopramide on gastric pH and volume in morbidly obese and lean patients. MethodsGastric volume and pH were measured in 3 groups of 20 patients each: group I (lean, no aspiration prophylaxis), group II (morbidly obese, no aspiration prophylaxis), and group III (morbidly obese; tablet ranitidine, 150 mg; and tablet metoclopramide, 10 mg administered the night before and 2 hours before surgery). Patients with critical gastric volume >25 mL and critical pH <2.5 (Roberts and Shirley criteria) were considered to be at risk for pulmonary aspiration. ResultsThe percentage of patients with gastric volume >25 mL and pH <2.5 was 5%, 30%, and 0% in groups I, II, and III, respectively. Statistically significant difference existed between groups I and II (P = .04) and groups II and III (P = .006). Premedicated morbidly obese and lean patients were comparable (P = .46). ConclusionMorbidly obese patients undergoing elective surgery are at a higher risk for regurgitation and pulmonary aspiration when compared with lean patients. Preoperative aspiration prophylaxis decreases gastric volume and increases gastric pH and thus should be routinely prescribed.

Bundled Payment and Care of Acute Stroke: What Does it Take to Make it Work?

With nearly 800 000 strokes occurring a year, stroke remains the leading cause of disability and the fourth most common cause of death in the United States.1 Stroke also imposes an enormous economic burden, including long-term care costs and productivity losses. Total direct medical stroke-related costs to US economy are projected to triple from $71.6 billion in 2012 to $184.1 billion in 2030.1 Although treatment for acute stroke is generally not vividly effective, the type and quality of stroke care can effect outcomes. Appropriate and prompt use of tissue-type plasminogen activator, reducing risk of acute medical complications, such as deep vein thrombosis, prophylaxis, and prevention of aspiration, secondary prevention, such as anticoagulation for atrial fibrillation, and early institution of aggressive rehabilitation can have substantial impacts on survival and disability.1,2 Moreover, given the high cost of disabling strokes, even care that is modestly effective in reducing functional loss can be highly cost-effective.3 Evidence suggests we could treat patients with acute stroke more effectively and at lower cost. A review showed large variation in patient-level cost of strokes (between 2 and 4-fold difference) across hospitals that is not explained by improved process of care or clinical outcomes.4 Other studies found similar wide cost variation.5–7 Substantial variation also exists in clinical outcomes of stroke patients that is unexplained by patient and hospital characteristics.8 Programs such as Get-With-The Guidelines have documented that systematic improvements in stroke care are possible.9 The high variation in costs of stroke and outcomes reflects not only the complex nature of the process of treating and managing stroke patients but also points to inefficiencies in the process of care. It has been argued that these inefficiencies are partly attributable to the current payment system, which is mostly based on …

Dobutamine infusion for complex congenital heart disease with pulmonary hypertension in an infant posted for open pyloromyotomy

Infantile hypertrophic pyloric stenosis (IHPS) is one of the most common gastrointestinal medical emergencies that occur during the first 2 months of life. Anaesthetic considerations in management of IHPS includes, aspiration prophylaxis and correction of metabolic derangements. An associated complex congenital cardiac lesion along with pulmonary hypertension and airway difficulties poses a further great challenge for the anaesthesiologist. We report a case of perioperative anesthetic management of a 2 month infant posted for open pyloromyotomy having complex congenital heart disease with pulmonary hypertension and bilateral cleft lip, the use of dobutamine in this setting is highlighted.