General Anesthesia In Prone Position Research Articles

Non-intubated general anesthesia in prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience.

Background and Study Aim:Advance biliopancreatic endoscopies are nowadays performed in non-operating room anesthesia (NORA) under general anesthesia (GA). We evaluate the outcomes of non-intubated patients in prone position who received GA for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in a tertiary referral center for digestive endoscopy.Patients and Methods:Anesthesiological records, anamnestic, and intraoperative data of patients who underwent advanced therapeutic biliopancreatic endoscopies at our tertiary referral center from January 2019 until January 2020 were collected in the present observational study.Results:One hundred fifty-three patients (93 M; median age: 68-year-old; mean ASA status: 2) were considered eligible for a procedure in the prone position with GA in spontaneous breathing. Prone position was always the initial setting. Propofol administration through a target-controlled infusion (TCI) pump was the choice to achieve GA. In our experience, desaturation appears to be the most frequent adverse event, accounting for 35% of cases (55/153). Treatment foresaw additional oxygen through a nasopharyngeal catheter, which proved to be a sufficient measure in almost all patients (52/55). Other adverse events (i.e., inadequate sedative plan, pain, and bradycardia) accounted for 2.6% of cases (4/153).Conclusions:Non-intubated GA in the prone position may be regarded as a safe procedure, as long as the anesthesiological criteria of exclusion are respected and the anesthesiological team has become acquainted with the peculiar NORA setting and familiar with the management of possible adverse events.

Limberg flap as a Primary Treatment for Pilonidal Sinus at Nepal Mediciti Hospital: A Single Unit Experience

INTRODUCTION: Pilonidal Sinus is a common condition with estimated incidence of 260 per million population with more male predilection and is often seen in sacrococcygeal area but has also been described in other areas with hair. The Limberg rhomboid flap was designed by Limberg in 1946 for the closure of a sixty degree rhombus shaped defect with a transposition flap. We would like to share our single unit experience of Rhomboid Limberg flap for Pilonidal sinus in our hospital.
 METHODS: This is an ongoing prospective descriptive study in the Department of General Surgery and Digestive Diseases of Nepal Mediciti Hospital from October 2018. The demographic of the patients, presenting symptoms, duration of symptoms and previous interventions are recorded and the Rhomboid Limberg flap surgery is done under regional or general anesthesia in prone position. The patient is given intravenous antibiotic and is instructed to sleep laterally or in prone position for 24 hours. The dressing is removed and the wound is inspected for flap status in the next morning. The patient is discharged on 1st post-operative day on oral antibiotics for 7 days and is followed on 7th post-operative day for removal of suction drain and alternate sutures in the skin and remaining sutures are removed on 10th post-operative day.
 RESULTS: We have done 28 cases of Limberg flap for Pilonidal Sinus from October 2018 to December 2020 of which 24 were male patients. None of our patients had flap necrosis. One patient presented with accidental removal of suction drain on 5th postoperative day, however he didn’t develop any wound related complication. One patient had superficial wound dehiscence on 10th post-operative day which healed on its own with dressing. One patient developed seroma from 5th postoperative and was managed with dressing and antibiotics and it healed in 2 weeks. None of our patients have developed recurrence and their wounds have healed satisfactorily with minimal scarring and pain. All the patients were able to resume their regular activities within 21 days. All except 2 patients were satisfied with cosmetic outcome.
 CONCLUSION: The Limberg flap is ideal treatment for pilonidal sinus with minimal postoperative pain, short hospital stay, few complications, rapid return to normal activities, good cosmesis, and a low recurrence rate with short learning curve for young surgeons. Hence, Limberg flap should be routinely used as primary treatment for pilonidal sinus.

Micro lumbar discectomy: Review and case report

Lumbar discectomy is the most common elective surgery for degenerative lumbar spine lesions. The rates of good and excellent outcomes are as high as 90–95%. Intervertebral disc prolapse occurs because of the tear in the annulus fibrosis and through which jelly like center portion called nucleus pulposis comes out and causing pressure over the nerve roots. Low-back pain causes nearly 80% of injured workers to miss at least 8 weeks of work following a back injury. In persons younger than 45 years old, low-back pain is the most frequent cause of activity limitation. Apart from nonspecific back pain, degenerative disease and disc herniation represent the most common causes for LBP-related physician office consultations. In fact, the majority of lumbar radicular pain symptoms are the result of a disc herniation, defined as bulging of the nucleus pulposus through a fissure or tear within the annulus fibrosus. Although favorable outcomes have been demonstrated for both surgical and nonoperative treatment options, patients who underwent open discectomy for lumbar disc herniation (LDH) were shown to have better self-reported outcomes than conservatively treated individuals.In the present case procedure is done under general anesthesia in prone position on a Bolster or under Wilson’s frame with a flat table. Skin incision was made than a lumbo-sacral fascia was cut with the help of electro cautery. Under the microscope paraspinal muscle was stripped off lamina with the help of periosteal dissector (Cobb’s dissector) upper 2/3rd of the lamina and medial part of the facet joint cut with bone scalpel. Sharp cutting incision is seen in lamina and medial facet. Square shaped incision was made in the disc with the help of No. 15 blade and disc is removed in piece meal or as a big piece if sequestrated. Haemostasis was achieved and patties were removed. Patient is made seat and walk after 6 hours of surgery. Patient is discharged on the next day morning with follow up after 7 days with oral medicines. Micro lumbar discectomy is commonly used very safe procedure, providing direct 3D vision and very effective in relieving the symptoms (98%) of the patient. It minimize the hospital stay and hence reducing the cost of hospitalization and patient can go on his/her duty earlier.

A Comparative Study of Extubation in Prone and Supine Position in Patients Undergoing Lumbar Spine Surgery in Prone Position

Aim: In case of surgeries done in prone position, patients are rolled to supine during extubation which is associated with loss of monitoring and hemodynamic change. Also, incidence of coughing and bucking are noted. Several studies have shown that prone position extubation is associated with reduced frequency of coughing and monitor disconnection in prone position surgeries. The purpose of this study was to compare the safety and efficacy of patients extubated in prone and supine posted for lumbar spine surgery.
 Study Design: 60 patients varying from age 18 - 65 years and posted for lumbar spine surgery under general anaesthesia in prone position were randomly allocated to any one of the two groups Group P - In this group extubation was done in prone position at the end of surgery or Group S – In this group extubation was done in supine position at the end of surgery.
 Place and Duration of Study: Jawaharlal Nehru Medical College, DMIMS (DU), Acharya Vinoba Bhave Rural Hospital (AVBRH), Datta Meghe Institute of Medical Sciences, Sawangi (M), Wardha over the period of 1 year (2019 - 2020).
 Methods: A double blinded randomized controlled comparative study was conducted on 60 patients with primary objective to measure incidence of coughing and severity of coughing in prone vs supine extubation. Patients were anesthetized with fentanyl, nitrous oxide, sevoflurane, and vecuronium. Neuromuscular blockade was reversed in prone position and all patients had spontaneous ventilation at the conclusion of surgery. At time 0, patients were randomly divided into group P or group S. Patients in the group S were then rolled over, while those in the prone position remained undisturbed. Frequency of cough, monitor disconnection and changes in heart rate (HR) and mean arterial pressure (MAP) were noted during extubation. Patient were extubated on purposeful behaviour and eye opening.
 Results: Frequency of coughing was significantly less in prone patients in comparison to supine group (6 vs. 24 coughs) monitor disconnections dysconnectivity was also fewer (p < 0.001), little change in haemodynamics was noted during extubation. Time to extubation from time 0 was comparatively more in Group S. Airway rescue was not needed.
 Conclusions: Extubation in prone position is associated with lesser frequency of coughing, disruption of monitors and significantly less hemodynamic changes as compared to supine position extubation he abstract should be concise and informative. It should not exceed 300 words in length. It should briefly describe the purpose of the work, techniques and methods used, major findings with important data and conclusions. Different sub-sections, as given below, should be used. No references should be cited in this part. Generally non-standard abbreviations should not be used, if necessary they should be clearly defined in the abstract, at first use.

COMPARATIVE ANALYSIS OF PRESSURE CONTROLLED AND VOLUME CONTROLLED VENTILATION ON RESPIRATORY MECHANICS, HAEMODYNAMICS AND SYSTEMIC STRESS RESPONSE IN PATIENTS UNDERGOING SURGERY IN PRONE POSITION.

BACKGROUND: General Anaesthesia in prone position is related with increased airway pressure, decreased pulmonary and thoracic compliance. AIM: Comparision of pressure controlled and volume controlled ventilation in patients undergoing lumbar spine surgery in prone position.METHODS: After ethics committee approval & written informed consent, a comparative randomized interventional study was conducted from July-December 2017. Randomization was done using random number tables. Patients of either sex, ASA grade I&II, age 25-55 yrs were included while those with severe pulmonary ,cardiovascular, endocrine disease & BMI> 30kg/m2 were excluded. Patients were randomly assigned to VCV group (n = 30), or PCV group (n = 30). Haemodynamic (HR,SBP,DBP,MAP), Respiratory (P-Peak,P-mean,C-dyn) variables,blood glucose,S.cortisol were measured and ABG analysis was done 10 minutes after intubation (T1), 30 minutes after prone positioning(T2) and 60 minuts after extubation(T3). RESULTS: Demographic parameters , perioperative hemodynamic values were comparable with no significant statistical difference.The P-Peak levels were lower and dynamic compliance was higher in PCV group during both T1 and T2 with p value of less than 0.05 Postoperative PaO2 level was significantly higher in Group PCV compared with Group VCV.The difference between post operative and preoperative serum cortisol and blood glucose levels was significantly less in patients ventilated with PCV mode.CONCLUSION: According to our study,PCV mode is associated with lower P-peak levels during prone position, better oxygenation postoperatively and lesser systemic stress response.We concluded that PCV mode might be more appropriate in prone position surgeries.

Effect of Preoperative Nebulised Dexamethasone and Nebulised Magnesium Sulphate on Postoperative Sore Throat in Prone Position Surgeries- A Randomised Double-Blind Study

Introduction: Postoperative Sore Throat (POST) is a frequently encountered complication after general anaesthesia with tracheal intubation and positional changes. Magnesium Sulphate (MgSO4) is a N-Methyl D-Aspartate (NMDA) receptor antagonist and dexamethasone is a glucocorticoid, both drugs helps in reducing POST by various mechanisms. Aim: To compare the effects of preoperative dexamethasone nebulisation vs preoperative MgSO4 nebulisation on sore throat in prone position surgeries. Materials and Methods: Eighty patients undergoing lumbar spine surgeries from October 2017 to April 2019, under general anaesthesia in prone position, were randomly allocated into two groups- A and B. Thirty minutes before surgery patients in each group were nebulised with respective drugs, dexamethasone 8 mg in group A and 250 mg of MgSO4 in group B. Haemodynamic parameters during laryngoscopy were noted. A standardised protocol for providing general anaesthesia was followed for all patients. After extubation, at 0, 4, 6 and 24 hours all patients were asked to grade POST, hoarseness and cough. The severity of POST was graded with four-point scale. Continuous variables were expressed as mean±SD and analysed using student t-test. The p-value <0.05 was considered statistically significant. Results: The overall incidence of sore throat in dexamethasone group was 37.5% and 20% in MgSO4 group. The incidence (p=0.026) and severity (p=0.011) of POST was significantly decreased in MgSO4 group at 6 hours where none of the patient had sore throat compared to dexamethasone where 15 (37.5%) of them had sore throat (p=0.026). None of the patients had cough and hoarseness in both groups. Conclusion:Nebulisation with MgSO4preoperatively significantly decreases the incidence and severity of POST when compared to dexamethasone and there was no statistically significant haemodynamic variability between the two groups.

Perioperative Visual Loss Following Transanal Endoscopic Microsurgery in Prone Position: Medico Legal Consideration

A 67-yr-old man developed Perioperative Vision Loss (POVL) after Transanal Endoscopic Microsurgery (TEM) under general anesthesia in prone position with head-down and turned to one side. After surgery, he complained of ocular pain and no light perception in the left eye. The examination revealed lid edema, ptosis, exotropia, proptosis, chemosis and fixed pupil not reactive to direct light. At funduscopy examination a pathognomonic cherry-red spot in the macula and retinal and disk ischemic pallor were appreciable. The right eye was normal. A diagnosis of left central retinal artery occlusion (CRAO) due to intraoperative extrinsic pressure on the eye was suspected. He never regained vision. POVL is frequently involved in malpractice claims. We discuss the legal implication for anesthesia practitioners.

Dilated Cardiomyopathy and Prone Position: An Anesthetic Challenge

AbstractThe anesthetic management of a patient with dilated cardiomyopathy (DCM) for noncardiac surgery is challenging due to associated congestive heart failure, malignant dysrhythmias, sudden cardiac arrest, implanted rhythm devices, and thromboembolism. We report successful conduct of a case of DCM on cardiac resynchronization device with Cauda equina syndrome (CES) under general anesthesia in prone position. The anesthetic concerns specific to the pathophysiology of DCM are also discussed.

Negative-pressure pulmonary edema following percutaneous nephrolithotomy

Negative pressure pulmonary edema (NPPE) or post-extubation pulmonary edema is an infrequent complication that usually occurs immediately or within several minutes after tracheal extubation in healthy, muscular adolescents and young adults. NPPE begins when upper airway obstruction occurs which causes an increase in negative intrathoracic pressure to pull fluid from the pulmonary capillary bed and into the alveoli which leads to ventilation and perfusion difficulties. Presenting here a case of bilateral renal stone posted for percutaneous nephrolithotomy under general anesthesia in prone position who desaturated immediately in the post-operative period after extubation. It also suggests the importance, prevention, diagnosis and treatment of NPPE.

Evaluation of Low Tidal Volume During General Anesthesia in Prone Position on Respiratory Functions

<i>Background:</i> Surgery is accompanied by postoperative pulmonary functions impairment especially in the prone position. There is evidence suggested that using low tidal volume during general anesthesia may decrease post-operative lung injury. This study aimed to evaluate the effect of low tidal volume on lung functions during mechanical ventilation for general anesthesia while patients lying in the prone position. A prospective clinical trial was performed on 88 patients ASA I&II scheduled for elective surgery while patients lying prone and were randomly assigned to either protective ventilation group A with tidal volume; 5-7 ml/kg, 10 cm H₂O positive end expiratory pressure (PEEP) with recruitment maneuver (RM) or conventional group B with Tidal Volume; 10-12 ml/kg, without both PEEP and RM. The primary efficacy variables were assessed by pulmonary function tests, performed before surgery, and 6, 12 and 24 hours postoperatively. Improvement of lung functions were found in the first post-operative 6 and 12 hours in the low tidal volume group and significant difference was found in all parameters P value 0.001 except PaO₂/FIO₂ ratio P value 0.4. After 24 hours there were significant difference in the FVC, predicted FEV1 and FVC and FEV1/FVC ratio being higher in the low tidal volume group with P value 0.001. Patients in both groups showed similar rates of postoperative chest complications without significant difference. Lung protective ventilation improved lung functions in the first post-operative 24 hours. There was no significant postoperative chest complications difference between the two groups.

Cerebral Oxygenation Under General Anesthesia Can Be Safely Preserved in Patients in Prone Position: A Prospective Observational Study.

The effects of prone position (PP) on cerebral tissue metabolism are not well known. The aim of this investigation was to evaluate regional cerebral oxygen desaturation in patients undergoing lumbar spine surgery in PP during routine anesthesia management. Between July 2013 and October 2013, 50 consecutive patients undergoing lumbar spine surgery under general anesthesia in PP were enrolled. The anesthetic technique was standardized. Using near-infrared spectroscopy, bilateral regional cerebrovascular oxygen saturation was recorded during the surgery. After 30 and 60 minutes of prone repositioning, significant decreases in bilateral regional cerebral oxygen saturation were observed compared with the values in the supine position (from 76.24% to 73.18% at 30 min and 72.76% at 60 min on the right side and from 77.06% to 73.76% at 30 min and 72.92% at 60 min on the left side; P<0.05). These changes were not clinically important and returned to supine values after 90 minutes of prone positioning. Decreases in cerebral oxygen saturation were accompanied by reductions in heart rate and mean arterial pressure (P<0.05). Older age and higher perioperative risk had a significant effect on the reduction of cerebral oxygen values (P<0.05). The results of our study show that margin of safety against impaired cerebral oxygenation can be maintained in PP. Preventing bradycardia and arterial hypotension is crucial. Older patients and those at higher perioperative risk need more meticulous attention.

Transpedicular Approach for Subaxial Cervical Spine

Cervical spine decompression, fusion and fixation are required when pathologies like trauma, degeneration, infection or tumor destabilizes the spine or cause compression on neurovascular structures. Many approaches and instrumentation technique have evolved to achieve a stable spine closest to its natural state, preserving the anatomy and the function. Transpedicular approach to cervical spine has been a new addition to the attempt. Here, our experience of the procedure is presented.Total of 38 cases underwent this procedure from 2014 February to 2015 December. Twenty-four cases had unstable spine due to trauma, twelve had severe multilevel spondylotic cord compression and two had dump bell schwannomas. Their age ranged from 24 to 76 years with 22 males and 16 females. The procedures were done under general anesthesia in prone position on Gardner-Wells pins and a horseshoe headrest. After exposing the pedicles, 3.5 mm by 22 mm titanium poly-axial screws where inserted through the pedicles using the technique described by Professor Abumi. The pedicle screws were connected by a connecting rod, which had been bent in accordance with the normal cervical lordosis. Fusion was done using the bones obtained from the spinous process and laminae.There were fifty-six screws which were mis-directed, and had to be immediately corrected. There was no incidence of significant pedicle penetration or injury to neuro-vascular structures. There was temporary weakness of upper limbs postoperatively in seven patients, which recovered fully in two months’ time. There were six deaths due to uncontrolled septicaemia triggered by chest infection. The rest of the patients were discharged between one to six weeks after surgery.Transpedicular fixation of unstable cervical spine provides biomechanically a very rigid and good correction of sagittal alignment with a high-fusion rate and a few surgical complications. After realizing these advantages, transpedicular screw fixation in cervical spine is becoming an increasingly popular spine surgeon's armamentarium.Nepal Journal of Neuroscience 13:11-18, 2016

Posterior Spinal Fixation with Fusion versus without Fusion in Treatment of Dorsolumbar and Lumbar Fractures

IntroductionOperative treatment in the form of posterior fixation with or without fusion has moved to the forefront of fracture management as it helps decreasing morbidity and mortality with better return to work and satisfactory functions. The aim of the study is to compare the results of posterior spinal fixation with fusion versus without fusion in cases of dorsolumbar and lumbar fractures both clinically and radiologically. Material and MethodsA randomized clinical trial conducted on 60 patients in Ain Shams University Hospitals in two groups: Group (A): posterior spinal fixation with fusion (30 patients); Group (B): posterior spinal fixation without fusion (30 patients). All patients have dorsolumbar and/or lumbar spine fractures and are candidates for posterior spinal fixation. Inclusion criteria: Age group (<45 years). Both sexes. Neurologically intact patients with kyphotic angle more than 20° or decreased vertebral body height more than 50% or a canal compromise more than 50%. Single or multilevel spinal injury. Exclusion criteria: Any patient who will need anterior fusion according to load sharing classification (≥7). Incomplete or complete neurological deficit. Advanced spondylosis. Fracture of pars interarticularis. Fracture of facet joints. Preoperative evaluation includes history, examination, and radiological evaluation. All patients were done under general anesthesia in prone position. A standard midline posterior approach was used to expose the desired levels for fixation. Posterior instrumentation using pedicular screws (in non-fusion group, only top loading rod systems were used as side loading and plate systems may damage facet joints). Posterior and intertransverse fusion was used in fusion group. ResultsOperative time was shorter in non-fusion group (107.5 minute) than fusion group (140.83 minute). Intraoperative blood loss was less in non-fusion group (330.33 ml) than fusion group (368.33 ml). The mean of lost correction of vertebral body height % in fusion group was 7.9 while the mean of lost correction of vertebral body height % in non-fusion group was 8.07. This is statistically not significant with P-value > 0.05 (0.917). The mean of lost correction of Cobb angle in fusion group was 6.7° while the mean of lost correction of Cobb angle in non-fusion group was 8.65°. This is statistically significant with P-value < 0.05. The mean segmental motion after removal in fusion group was 1.73° while the mean segmental motion after removal in non-fusion group was 11.62°. This is statistically significant with P-value < 0.001. ConclusionPosterior spinal fixation without fusion yielded satisfactory results similar to those of posterior spinal fixation with fusion in patients with dorsolumbar fractures with a load sharing score < 7.

Oxygen embolism: an unusual consequence of hydrogen peroxide irrigation

Three-percent solution of hydrogen peroxide is commonly used as a wound antiseptic agent to irrigate the operative field in Neurosurgical cases. We report a case of 45 year male who had undergone lumbar laminectomy under general anaesthesia in prone position and irrigation of surgical wound with hydrogen peroxide led to massive gas embolism during the surgery.

Pressure controlled vs. volume controlled ventilation during prone position in high-level spinal cord injury patients: a preliminary study.

Pressure controlled vs. volume controlled ventilation during prone position in high-level spinal cord injury patients: a preliminary study.

Perioperative Respiratory Compromise in Patients Undergoing PCNL-A Case Series

Percutaneous Nephrolithotomy (PCNL) is a surgical procedure which is used to extract renal pelvic stones. An optimum access tract, without traumatizing the surrounding structures, is essential for the surgery. Trauma to the surrounding structures and extra-vasation of the irrigating fluid may result in complications like hydrothorax, pneumothorax, hydro pneumothorax etc. These complications may produce intra- operative respiratory compromise leading on to arterial hypoxemia and its sequelae. A series of three case reports with review is presented here. First case is accumulation of irrigating fluid in the pleura causing hydrothorax and oxygen desaturation. Second case is extra-vasation of fluid in the abdominal wall and the patient was ventilated artificially for 24 hours. Third patient developed pneumothorax and he needed chest drainage.PCNL is done under general anaesthesia in prone position. The anaesthesiologist should be vigil enough to identify the situation and take appropriate measures to correct it.

Henna dye: A cause of erroneous pulse oximetry readings

Pulse oximetry is a noninvasive and continuous monitoring of the pulsed saturation of hemoglobin oxygen. Because of its simplicity and usefulness, it is part of monitoring recommended for any anesthesia in the operating room. Different factors may limit the use of this monitoring. We report a case of difficulty monitoring by the presence of henna in a patient scheduled for general anesthesia in prone position.

The Comparison of Four Different Methods of Perioperative Eye Protection under General Anesthesia in Prone Position

The Comparison of Four Different Methods of Perioperative Eye Protection under General Anesthesia in Prone Position

Postoperative Bilateral Palsy of Terminal Laryngeal and Pharyngeal Branches of the Vagal Nerve

We report a rare case of a postoperative bilateral laryngeal and pharyngeal lesion of the extracranial vagal nerve following a routine general anaesthesia in prone position. It documents a possible way of a serious complication de- pending to the positioning of the patient in prone position. Etiological factors and measures to avoid this rare but critical complication are discussed. For the clinical practise it should give an advice to minimize the risk of injuries by malpositioning.