Avoidance Of General Anesthesia Research Articles

General Anesthesia for Transcarotid Artery Revascularization Offers Favorable Outcomes in a Symptomatic and High-Risk Population of Patients

Transcarotid artery revascularization (TCAR) was developed as a treatment option for patients deemed to be at high risk for traditional surgical revascularization. Previous reports have suggested superior outcomes with avoidance of general anesthesia, although outcomes beyond the perioperative period have not been published. We have adopted TCAR using general anesthesia for all patients, which include those meeting high-risk physiologic and anatomic criteria for TCAR. The purpose of this study was to evaluate outcomes of this strategy with short-term follow-up. This is a retrospective, observational cohort study of all patients undergoing TCAR at a single tertiary care institution from July 2018 to July 2019. Patients undergoing concurrent operations were excluded. All TCAR patients met high-risk profile criteria as required for reimbursement. Data were obtained from detailed chart review. Descriptive statistics were used to assess primary end points of operative and flow reversal time and morbidity, including death, stroke, myocardial infarction, and cranial nerve injury, as well as length of stay and readmissions for comparison to historical controls. Ninety-one patients underwent TCAR, all under general anesthesia. Mean age was 73 ± 9 years, with 39% of patients older than 75 years. There were 66 patients (72.5%) who met high-risk criteria on the basis of their physiologic condition and 37 (40.7%) by anatomic considerations only. Stenosis of 80% to 99% was observed in 71 (78.0%) patients; and overall, 39 (43%) patients were symptomatic. Mean operative and flow reversal times were 55.0 ± 14.3 minutes and 8.8 ± 3.8 minutes, respectively. There were two postoperative strokes (2.2%), both within 30 days. At a mean follow-up of 119 ± 111 days, there were no deaths, myocardial infarction, or cranial nerve injuries. Three patients (3.3%) required short-term vasopressor support and three (3.3%) required prolonged intravenous antihypertensive management. Mean length of stay was 1.5 ± 1.3 days, and unplanned readmission rate was 1.1%. Exclusive use of general anesthesia for TCAR provides expeditious carotid revascularization and minimal short-term morbidity and length of stay in this high-risk population. On short-term follow-up, we observed excellent outcomes including no additional cardiopulmonary morbidity and only one readmission. Additional study in larger, controlled populations is needed to define TCAR patients who may benefit from an anesthetic strategy other than general anesthesia.

Awake intubation and extraluminal use of Uniblocker for one-lung ventilation in a patient with a large mediastinal mass a case report

BackgroundThe anesthesia of patients with large mediastinal mass is at high-risk. Avoidance of general anesthesia in these patients is the safest option, if this is unavoidable, maintenance of spontaneous ventilation is the next safest technique. In these types of patients, it is not applicable to use double-lumen tube (DLT) to achieve one-lung ventilation (OLV) because the DLT has a larger diameter and is more rigid than single-lumen tube (SLT), so the mass may rupture and bleed during intubation. Even using a bronchial blocker, a small size of SLT is required for once the trachea collapses the SLT can pass through the narrowest part of trachea. However, it is difficult to control the fiberoptic bronchoscopy (FOB) and the bronchial blocker simultaneously within the lumen of a small size SLT with traditional intubation methods.Case presentationThe current study presented a 66 years old female patient with a large mediastinal mass that presented with difficulty breathing when lying flat. In this case, we combined use of dexmedetomidine and remifentanil to preserve the patient’s spontaneous ventilation during intubation and achieved one-lung ventilation with extraluminal use of Uniblocker.ConclusionsExtraluminal use of Uniblocker and maintenance of spontaneous ventilation during intubation may be an alternative to traditional methods of lung isolation in such patients with a large mediastinal mass.

The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion Summary, Number 800.

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting.

The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800.

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting.

Local anesthetic with sedation is a viable alternative to general anesthesia for lumbar spinal decompressions: A retrospective cohort feasibility study and short-term analysis of outcomes

Background: An increasing focus on value-based care in spine surgery has prompted interest in alternative anesthetics. Avoidance of general anesthesia (GA) has gained support due to reductions in postoperative symptoms. Little has been published on local anesthesia with sedation techniques. Methods: A retrospective chart review was performed to compare outcomes of lumbar decompression using local anesthesia with light intravenous sedative (LIS) and lumbar decompression using general anesthesia. Outcomes reported were 90-day adverse events, reoperations, and narcotic use. Results: A total of 65 patients who underwent lumbar decompression were identified. Patients receiving LIS were older and had more comorbidities compared with those receiving GA. Rates of peripheral vascular disease and peptic ulcer disease were higher in patients receiving LIS (P=0.004 and 0.012, respectively). The overall rate of postoperative adverse events was 30% lower in patients with LIS. There were no aborted procedures in the LIS cohort. Rates of reoperation trended towards being lower in LIS (14.3%) versus the GA group (37.8%). There was no difference in postoperative narcotic use (LIS 17.9%, GA 24.3%, P=0.530). After adjusting for age, gender, body mass index, Charlson Comorbidity Index, and peripheral vascular disease, the rate of adverse events remained lower in the LIS group (odds ratio: 0.166 [95% CI: 0.037, 0.617], P=0.011), and the trends towards lower rates of recurrent stenosis (P=0.082) and reoperation (P=0.082) remained. There was still no difference in the rate of postoperative narcotic use beyond the first follow-up (P=0.542). Conclusions: Lumbar spinal decompressions are commonly performed surgeries, and they are increasingly being performed in outpatient settings. We conclude that LIS is a safe alternative to GA. Further work is needed to identify cost savings in LIS spine surgery and define patient characteristics that identify appropriate candidates. Level of Evidence: Level III.

Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome?

Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery. Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency. Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.

P138. Local anesthetic and sedation works as well as general anesthesia for lumbar spinal decompressions: a short-term analysis of outcomes

BACKGROUND CONTEXT An increasing focus on value-based care in elective spine surgery has prompted interest in alternative modalities of surgical intervention. Avoidance of general anesthesia (GA) is one modality that has recently gained support due to reductions in postoperative symptoms related to general anesthetics. Some patients with operative spine pathology cannot tolerate a GA due to comorbidities or other issues that preclude RA or GA. Our goal was to determine the complication rate of lumbar spinal decompression under local anesthesia with IV sedation (LIS) compared to patients decompressed under general anesthesia. PURPOSE Our goal was to determine the complication rate of lumbar spinal decompression under local anesthesia with IV sedation (LIS) compared to patients decompressed under general anesthesia. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients were selected from a single surgeon's case series of lumbar decompression performed with local and sedation only and comapred to the same cases perfmed with GA at approximately the same date. OUTCOME MEASURES Outcomes reported are 90-day complications (wound complication, DVT, PE, dural tear, UTI, urinary retention, neurologic injury or recurrent stenosis) and reoperations, and postoperative narcotic use. METHODS Retrospective chart review of lumbar decompressions with at least 90-day follow up from a single surgeon was performed to evaluate patient outcomes with local anesthetic and sedation only versus GA. Outcomes reported are 90-day complications (wound complication, DVT, PE, dural tear, UTI, urinary retention, neurologic injury or recurrent stenosis) and reoperations, and postoperative narcotic use. Univariate differences between groups were assessed with chi-squared and Fisher's exact tests for categorical variables and independent samples t-tests for continuous variables. Multivariable logistic regression analyses adjusted for age, sex, body mass index (BMI), and Charlson Comorbidity Index (CCI), and any additional factors with p RESULTS A total of 65 lumbar decompression patients were identified (73.9% female, age 75.4±10.8 years): 28 local and 37 GA. The local cohort is the entire group of patients that have undergone the procedure in the past 10 years from the lead surgeon's practice. The GA patients were selected randomly for comparison. LIS patients were older (p =0.004) and more comorbid (CCI p =0.012) than those having GA. Rates of PVD and PUD were higher in local patients (p =0.004 and 0.012, respectively). Despite this, the overall rate of postoperative complications was more than 30% lower in LIS vs GA patients (local =25.0%, GA = 56.8%, p =0.013), in part due to a trend toward lower rates of recurrent stenosis in local patients (p =0.073). Rates of reoperation trended toward being lower in local (14.3%) versus GA (37.8%) patients (p =0.050). There was no difference in postoperative narcotics (local 17.9%, GA 24.3%, p =0.530). After adjusting for age, sex, BMI, CCI, and PVD, the rate of complications was still lower in the LIS group (odds ratio: 0.166 (95% CI: 0.037, 0.617), p =0.011), and the trends toward lower rates of recurrent stenosis (p =0.082) and reoperation (p =0.082) remained. There was still no difference in the rate of postoperative narcotics (p=0.5416) after adjustment. CONCLUSIONS Lumbar spinal decompressions are a commonly performed surgery and there is an increasing trend toward these being performed in the outpatient setting. The use of local anesthetic and sedation for anesthesia may have significant benefits, but there is a paucity of data analyzing spine surgery done in this manner. We analyzed the results of a single surgeon's series of lumbar spinal decompression with LIS and conclude this is a safe alternative to decompressions under general anesthesia. Further work is needed to better identity specific cost savings in LIS spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Awake bedside nasal endoscopy for primary management of neonatal dacryocystoceles with intranasal cysts

ObjectiveTo present outcomes of neonatal dacryocystoceles treated through endoscopic intranasal cyst marsupialization (EICM) without general anesthesia and nasolacrimal duct (NLD) probing or irrigation. MethodsRecords of eleven consecutive infants diagnosed with unilateral or bilateral congenital cysts associated with the nasolacrimal system between January 2016 and February 2019 at our institution were retrospectively reviewed. ResultsAge at diagnosis ranged from 0 to 56 days, and 45.5% were male. 54.5% had dacryocystitis before surgical intervention. Patients were initially treated with a combination of massage and topical antibiotics; some received parenteral antibiotics if infected. Nearly all patients (90.9%) had one or more intranasal cysts. Of these patients, two underwent lacrimal probing and EICM in the operating room. One underwent EICM only in the operating room. Another patient initially failed bedside NLD probing and subsequently underwent bedside nasal endoscopy and awake EICM. The final six patients underwent EICM without general anesthesia or NLD probing. No complications were noted. Follow-up ranged from 7 to 906 days. Complete resolution was observed in all ten patients who underwent EICM, regardless of anesthesia. ConclusionsNeonatal dacryocystoceles and/or intranasal cysts are successfully treated at the bedside through nasal endoscopy with simple awake endoscopic intranasal cyst marsupialization. Avoidance of general anesthesia and NLD probing or irrigation would greatly simplify and decrease the cost of dacryocystocele management.

Avoidance of general anesthesia for circumcision in infants under 6\xa0months of age using a modified Plastibell technique

PurposeThere is currently no gold standard for the type of analgesia or preferred circumcision technique in infants requiring circumcision after 1 month of age. Our study presents a modified Plastibell circumcision technique, which offers excellent surgical outcomes, and can be performed under local anesthesia until 6 months of age, thereby avoiding the risks of general anesthesia in delayed circumcision.MethodsThis is a retrospective case series of 508 consecutive male infants between 1 and 6 months of age, from one institution, who all underwent circumcision under local anesthesia, performed by the same pediatric surgeon, from 2013 to 2018. The study parameters included postoperative complications such as re-operation for control of hemorrhage, wound infection, circumcision revision, and urethral meatotomy.ResultsThere were no re-operations for control of hemorrhage, no wound infections, and no circumcision revisions. One patient developed urethral meatal stenosis requiring urethral meatotomy.ConclusionOur modified Plastibell circumcision technique under local anesthesia is a safe and reproducible alternative for infants between 1 and 6 months of age, whose parents desire circumcision and wish to avoid general anesthesia.

Chapter 18 - Hypnosis for cingulate-mediated analgesia and disease treatment

Hypnosis is a technique that induces changes in perceptual experience through response to specific suggestions. By means of functional neuroimaging, a large body of clinical and experimental studies has shown that hypnotic processes modify internal (self-awareness) as well as external (environmental awareness) brain networks. Objective quantifications of this kind permit the characterization of cerebral changes after hypnotic induction and its uses in the clinical setting. Hypnosedation is one such application, as it combines hypnosis with local anesthesia in patients undergoing surgery. The power of this technique lies in the avoidance of general anesthesia and its potential complications that emerge during and after surgery. Hypnosedation is associated with improved intraoperative comfort and reduced perioperative anxiety and pain. It ensures a faster recovery of the patient and diminishes the intraoperative requirements for sedative or analgesic drugs. Mechanisms underlying the modulation of pain perception under hypnotic conditions involve cortical and subcortical areas, mainly the anterior cingulate and prefrontal cortices as well as the basal ganglia and thalami. In that respect, hypnosis-induced analgesia is an effective and highly cost-effective alternative to sedation during surgery and symptom management.

Assessing changes in tissue oxygenation by near-infrared spectroscopy following brachial plexus block for arteriovenous fistula surgery: A prospective observational pilot study.

Near-infrared spectroscopy (NIRS) can be used to measure tissue oxygen saturation (StO2) in different sites and in a wide range of clinical scenarios. Peripheral regional anaesthesia induces vascular changes causing increased arterial blood flow and venodilatation, but its effect on StO2 is still under debate. This is especially so for patients undergoing arteriovenous fistula surgery, wherein latest data suggest an improved outcome under brachial plexus block (BPB) compared with local anaesthesia, but no data are available. The aim of this study was to investigate changes in StO2 following BPB prior to arteriovenous fistula surgery using NIRS. A prospective observational study. A secondary teaching hospital from August 2016 to March 2017. Fifteen patients undergoing arteriovenous fistula surgery. Ultrasound-guided BPB in 15 patients undergoing arteriovenous fistula surgery. StO2 at baseline and compared with baseline and the contralateral arm following BPB measured using NIRS of the thenar eminence (NIRSth). Baseline values of StO2 assessed by NIRSth were 42.6 ± 7.7% in the arteriovenous fistula arm and 42.7 ± 9.7% in the contralateral arm. There was no significant difference between the two. Five minutes after BPB, there was a significant increase in StO2 of the blocked arm, compared with the control arm expressed as difference of absolute values (7.1 ± 9.7%). At 60 min, an absolute difference of 21.0 ± 13.5% was reached. The absolute increase in StO2 of the blocked arm compared with baseline reached significance after 5 min (8.8 ± 4.6%) and increased up to 23.2 ± 8.2% after 60 min. NIRSth indicates that BPB significantly increases StO2 of the arteriovenous fistula arm in patients undergoing haemodialysis. Clinicaltrials.gov: NCT03044496.

Percutaneous Endovascular Aortic Aneurysm Repair for Abdominal Aortic Aneurysm.

This review discusses the benefits of a completely percutaneous approach to endovascular aortic aneurysm repair (EVAR), and provides an outline as to how this is performed by a multidisciplinary team of cardiologists and cardiovascular surgeons at a quaternary care community hospital. Percutaneous endovascular aortic aneurysm repair (PEVAR) as compared to EVAR utilizing surgical femoral artery exposure is associated with a significant reduction in operation time, length of stay, access site complications, patient discomfort, and procedural cost. Furthermore, PEVAR may be the preferred approach in patients presenting with aneurysm rupture, as the avoidance of general anesthesia has been associated with improved 30-day mortality. Assuming no contraindication based on vascular anatomy, clinical status, or patient preference, these findings suggest that in properly selected patients, PEVAR should be the primary method for abdominal aortic aneurysm repair in both stable and unstable patients.

Initial experience with a novel resection and plication (RAP) method for acid reflux: a pilot study.

Background and study aims Current endoscopic therapies for gastroesophageal reflux disorder (GERD) are limited by technical complexity, and/or cost. We sought to evaluate the success of a novel resection and plication (RAP) anti-reflux procedure. Patients and methods RAP was performed on 10 patients with GERD refractory to proton pump inhibitor (PPI) therapy. RAP consists of semi-circumferential mucosectomy along with full-thickness plication of the lower esophageal sphincter (LES) and cardia. We assessed the technical success and safety as well as followed GERD-Health Related Quality of Life (GERD-HRQL) scores and medication usage. Results All patients underwent RAP without adverse events and were discharged on the same day. Only half of the patients required general anesthesia. Follow-up ranged from 5 to 24 months (median 9 months) and all patients had a significant improvement in their GERD-HRQL scores ( P < 0.0001, 95 % CI 19.3 – 25.3). 8 of 10 eliminated their daily PPI dependence. Conclusions The RAP method has potential as an effective anti-reflux option. Its main advantages include a short procedure time, simple approach using readily available equipment, and possible avoidance of general anesthesia.

Early Outcomes with Fast-Track EVAR in Teaching and Nonteaching Hospitals

The influence of hospital teaching status on fast-track endovascular aneurysm repair (EVAR) outcomes is unknown. This study explored the feasibility, safety, and effectiveness of a fast-track EVAR protocol at teaching and nonteaching hospitals. Patients underwent a fast-track EVAR protocol composed of bilateral percutaneous access using a 14F stent graft, avoidance of general anesthesia and intensive care admission, and next-day discharge. Patients were followed up for 1month post-treatment. Participating hospitals were categorized by teaching status (teaching versus nonteaching) and compared for perioperative and 30-day outcomes. Between October 2014 and May 2016, 250 patients were enrolled at 31 centers in the United States. The study included 186 patients treated among 21 teaching hospitals and 64 patients treated among 10 nonteaching hospitals. Fast-track EVAR protocol completion was higher at teaching hospitals (91% vs. 73%, P=0.01). Intensive care admission was avoided in 99% of patients at teaching hospitals versus 84% at nonteaching hospitals (P<0.001). The ability to complete all other fast-track EVAR elements was proportionally higher at teaching hospitals, but differences were not statistically different. In-hospital outcomes by teaching status were comparable overall. Median time to discharge was 25 and 26hr, respectively. There were no reports of type III endoleak, abdominal aortic aneurysm rupture, or secondary intervention. Comparing teaching versus nonteaching hospitals, there were no differences in major adverse events (1% vs. 0%), type I endoleak (0% vs. 2%), limb occlusion (1% vs. 0%), all-cause mortality (1% vs. 0%), and 30-day readmissions (1% vs. 3%). A fast-track EVAR protocol can be implemented with high success in well-selected patients at teaching and nonteaching hospitals. Health care resource utilization, perioperative data, and 30-day outcomes were excellent overall, with higher frequency of intensive care admission at nonteaching hospitals.

Closed diaphyseal fractures of femur in children treated by hip spica: early result of a clinical study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Diaphyseal fracture of femur is a common injury in children with bimodal age distribution. The treatment modality of these fractures depend on several factors such as age of the patient, characteristics of the fracture– degree of displacement, location of fracture in femur, comminution, and open or closed injury. With the invention of titanium elastic nails, the recent trend in treating these fractures is by closed reduction and TENS, but the surgical management is not without complications hence we share our experience to reemphasize the role of hip spica cast immobilisation in treating these injuries.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;This is a prospective study of 30 cases of diaphyseal fractures of femur in children between the ages of 6 month to 6 years. History and mode of injury were recorded and complete physical examination was done. Plain anteroposterior and lateral radiographs confirmed diagnosis. Hip spica cast was applied under sedation or short general anesthesia. One and half spica was applied over thick padding with hip flexed 45 degrees abducted 30 degrees and external rotation of 10 degree.&lt;strong&gt; &lt;/strong&gt;No attempt was made to obtain an end to end reduction. Patients were allowed to go home the same day after giving instructions regarding spica care. Follow up was done and radiographs were taken at 1, 2, 4 and 12 weeks. Any malunion– LLD, angulation or rotation were recorded&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The mean age of patients was 3.5 years (range 0.5 to 6 years). Of these 12 (40%) were male and 18 (60%) were female. The commonest mode of injury was fall while play in 73.33% (n=22) of patients. Mid shaft fractures are more common 53.33% (n=16) followed by upper third 40% (n=12). Average time for fracture union was 6 weeks (range 4-10 weeks). At one year all fractures healed in a satisfactory position without any LLD. Two patients had minor skin problems which were easily treated and cast continued. No stiffness of hip, knee or ankle was noted. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Hip spica casting is an effective and reliable method for treating femoral shaft fractures in children with a union rate of 100%. The advantages of conservative treatment such as the avoidance of general anaesthesia on two occasions and the avoidance of surgery make a compelling argument in favour of this form of treatment.&lt;/span&gt;&lt;/p&gt;

Awake caudal anaesthesia in neonates/young infants for improved patient safety

Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform...

A systematic review of management of inadvertent arterial injury during central venous catheterisation.

Central venous catheterisation (CVC) is a technique commonly used to obtain vascular access and over five million CVCs are inserted annually. This systematic review of CVC-related arterial injury aims to compare outcomes reported with different management strategies. PRISMA guidelines were followed. A search of Medline, Embase, Central and CINAHL was performed. Results were limited to papers in humans and in English with duplicates removed. Details of cases including site and nature of arterial injury, use of ultrasound, methods for identifying arterial placement, management methods used, and any reported outcomes were collated from all papers. Successful management was defined as control of haemorrhage without evidence of further complications. We screened 2187 abstracts and 78 full manuscripts were obtained and reviewed. Twenty-four papers were of relevance and were included in this review. Amongst the papers, 80 cases of arterial injury were reported. Successful treatment by removal and compression, endovascular methods, and open surgical repair were 5.6%, 94.6% and 100%, respectively. Removal and compression of the arterial site is a poor management method and is associated with a high rate of complications. Endovascular approaches had a high rate of success with advantages of endovascular techniques including access to arteries which are difficult to expose surgically and avoidance of general anaesthesia. Endovascular repair might be considered depending on site of injury or local expertise though surgical repair reported the best results in this review with no complications seen.

Percutaneous thoracolumbar decompression combined with percutaneous pedicle screw fixation and fusion: a method for treating spinal degenerative pain in a biplane angiography suite with the avoidance of general anesthesia.

Spondylytic degeneration of the axial lumbar spine is a major cause of pain and disability. Recent advances in spinal surgical instrumentation, including percutaneous access and fusion techniques, have made possible the performance of instrumented fusion through small incisions. By blending strategies of interventional pain management, neuroradiology, and conventional spine surgery, it is now feasible to treat spinal axial pain using permanent fixation techniques and local anesthesia in the setting of a fluoroscopy suite using mild sedation and local anesthesia. The author presents a series of percutaneous thoracolumbar fusion procedures performed in a biplane neuroangiographic suite and without general anesthesia for the treatment of spondylytic pain. All procedures utilized pedicle screw fixation, harvesting of local bone autograft, and application of bone fusion material. In this series of 13 patients, a statistically significant reduction of pain was seen at both the 2-week post-operative timepoint, as well as at the time of longest follow-up (mean 40 weeks). The advanced and rapid imaging capabilities afforded by a neuroangiographic suite can be safely combined with percutaneous fusion techniques so as to allow for fusion therapies to be applied to patients where the avoidance of general anesthesia is desirable.

Fast-track endovascular aneurysm repair: rationale and design of the multicenter Least Invasive Fast-Track EVAR (LIFE) registry.

BackgroundConsiderable technological advancements have recently been made with endovascular stent grafts for the treatment of abdominal aortic aneurysm (AAA). However, there is opportunity to further improve the efficiency of endovascular aneurysm repair (EVAR), which may yield better patient outcomes and lower perioperative treatment costs.Methods/DesignThe Least Invasive Fast-Track EVAR (LIFE) registry was developed to determine the clinical utility and cost effectiveness of the Ovation® Prime stent graft when used under least invasive conditions using a defined fast-track protocol. The LIFE study is a prospective multicenter post-market registry of the ultra-low profile (14F) Ovation Prime stent graft when used in the treatment of patients with AAA using a fast-track protocol, consisting of appropriate patient selection, bilateral percutaneous access, avoidance of general anesthesia and intensive care unit admission, and next-day discharge. The primary endpoint of the study is the proportion of subjects that experience a major adverse event within 30 days of the initial procedure. Primary endpoint data will be compared to a target performance goal. A total of 250 subjects will be enrolled at up to 40 sites in the United States. The first subject in this study was enrolled in October 2014 and enrollment is anticipated to continue through mid-2016.DiscussionThe recent development of ultra low-profile stent grafts enables EVAR using least invasive methods. A structured fast-track EVAR protocol may yield clinical and cost benefits versus standard EVAR.Trial registrationClinicalTrials.gov Identifier: NCT02224794

Mandatory Child Life Consultation and Its Impact on Pediatric MRI Workflow in an Academic Medical Center

Pediatric patients undergoing MRI often require general anesthesia, which may improve image quality but is associated with significant medical risk and economic cost. It has previously been shown that certified child life specialists using high-tech interventions (eg, MRI-compatible video goggles) significantly reduce the number of pediatric MRI patients who require sedation. Most imaging centers lack such technology, however, and it remains unclear whether simpler and less costly child life interventions may be equally effective in avoiding general anesthesia. The aim of this study was to assess the impact of requiring mandatory child life evaluation for all patients aged 5 to 18 years undergoing MRI before referral for general anesthesia. Inserting this simple step into the scheduling workflow significantly reduced the use of general anesthesia in this population: general anesthesia was required in 564 of 2,433 MRI cases during the 1-year baseline period compared with 484 of 2,526 cases during the 1-year intervention period (P < .01 by z test for proportions; absolute reduction, 4.0%; relative reduction, 14.8%). The authors estimate that instituting mandatory child life evaluation avoided the use of general anesthesia in approximately 102 patients during the intervention period. Further subgroup analysis revealed that avoidance of general anesthesia was highly significant in the 5- to 10-year-old age group, whereas those aged 11 to 18 years experienced only a trend toward modestly decreased use of general anesthesia. These results suggest that mandatory evaluation for standard child life interventions is a worthwhile step that can save many children from unnecessary exposure to the risks, cost, and inconvenience of general anesthesia.