General Anesthesia Management Research Articles

Management of Frailty and its Challenges in Geriatric Patients on General Abdominal Anesthesia.

Introduction: In that material, we are doing to informed for frailty, how we can measure it, surgical outcome and its management from the anesthesiologist. Frailty is a condition of decreased physiological reserves that often increases with increasing age and decided in adverse outcomes.
 Frailty in elderly surgical patients may be varied from 25,5 -56.1% and is a strong predictor for surgical outcomes.
 The anesthetist needs to predict how a geriatric patient will tolerate the stress of surgery and to do what is necessary to protect and save elderly lives.
 In Albania, there are almost 439 000 elderly people in 2021 and suspect to 626 000 in 2051. According to the WHO, 1 in 25 persons performed surgery, so the number of geriatric patients that done surgery will be very high.
 According to deficits’ in function, mobility, cognition, chronic diseases, and geriatric syndromes we can use the clinical frailty scale, the Edmonton Frailty Scale, or frailty index for calculation of frailty.
 We need frailty patients to evaluated preoperative risk-classification, intra-operative care, management of general anesthesia, early immobilization as well as treatment of postoperative delirium because frailty increased intra-operative morbidity, increased postoperative complications especially delirium, extends hospitalization, non – home discharge, and mortality.
 Anesthesiologists would be always aware to prepare the geriatric patients for surgery, to maintain the intra-operative functional reserve of frailty patients, to manage perfect anesthesia, to realized early mobilization, and discharge back home.
 Conclusion: Many geriatric patients have multi-organ problems. Frailty is a practical, unifying concept in the care of these older people that directs attention away from organ-specific diagnoses towards a more holistic viewpoint of the patient and their medical medicament. All geriatric patients need to screen for frailty.

Manejo anestésico del trauma craneoencefálico e infección por SARS CoV 2

Introducción: El traumatismo craneoencefálico es una entidad patológica compleja y emergente, puede afectar gravemente el estado neurológico posterior del paciente, compromete un riesgo vital eminente por lo que la intervención oportuna y la realización de maniobras que mejoren el pronóstico en cualquier plazo deben realizarse de manera oportuna, dinámica, coordinada y simultánea.
 La infección por SARS CoV 2, compromete variablemente la función respiratoria del individuo y representa un reto anestesiológico en cuanto a manejo de vía aérea, ventilación y oxigenación, la utilización adecuada de equipos de protección es primordial para evitar el contagio en el equipo de salud.
 Objetivo: Describir un caso clínico de traumatismo craneoencefálico e infección por SARS CoV 2.
 Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico.
 Resultados: Se describe un caso clínico de paciente masculino de 38 años de edad con diagnóstico de hematoma epidural derecho y subdural agudo fronto-témporo-parietal derecho secundarios a trauma craneoencefálico e infección por SARS CoV 2 asociada, programado para drenaje de hematoma, a quien se le administra anestesia general y manejo de vía aérea de emergencia. 
 Conclusiones: La intervención oportuno del TEC que requiere drenaje quirúrgico mejora ampliamente el pronóstico neurológico y vital del paciente, una adecuada valoración preanestésica identifica las dianas de intervención, un adecuado mantenimiento de la hemodinamia y perfusión cerebral está indicado, el manejo de la vía aérea de un paciente con TEC e infección por SARS CoV 2, debe contemplar todas los recursos para una vía aérea difícil y de emergencia, se debe poseer todos los equipos de protección personal, usarlos de manera apropiada y reducir al máximo la producción de aerosoles y secreciones.

Anesthetics management strategy for endovascular treatment of acute ischemic stroke. A proposal for anesthetic approach

GEAcute ischemic stroke is one of the leading causes of death and long-term disability for adults. Endovascular therapy is the standard of care for severe acute ischemic stroke, caused by large-vessel occlusion in the anterior circulation; however, the optimal anaesthetic management during the procedure is still a matter of debate. The best anesthetic treatment should mainly be related to patients’ clinical conditions and the site of arterial occlusion. With this article, we share our experience based on the use of ketamine as the choosen hypnotic drug for general anesthesia, in order to avoid a sudden drop in blood pressure. The core of our proposal approach is the general anesthesia management by the medical emergency team with skills on both time-dependent diseases and neurocritical care.

General Anesthesia Management in a Patient with Mitochondrial Encephalomyopathy Undergoing MitraClip® Implantation

General Anesthesia Management in a Patient with Mitochondrial Encephalomyopathy Undergoing MitraClip® Implantation

Anaesthetic Management of Patient with Atrial Septal Defect Posted for Abdominal Hysterectomy

Incidence of Atrial Septal Defect (ASD) in acyanotic congenital heart disease is about 10%. This condition is commonly diagnosed in childhood, although in some cases it is detected in later stages of life. Patients with ASD and Pulmonary Hypertension (PHT) pose a great challenge to anaesthetic management. Authors are presenting a case of general anaesthetic management of 39-year-old lady having ASD with mild to moderate PHT undergoing abdominal hysterectomy, a noncardiac surgery. The patient was induced with Inj. Propofol slow Intravenous (IV) and intubation was achieved with succinylcholine and maintenance was done with atracurium and isoflurane. The primary goal of general anaesthesia was to avoid increase in PHT and to maintain systemic vascular resistance.

An Open Source Patient Simulator for Design and Evaluation of Computer Based Multiple Drug Dosing Control for Anesthetic and Hemodynamic Variables

We are witnessing a notable rise in the translational use of information technology and control systems engineering tools in clinical practice. This paper empowers the computer based drug dosing optimization of general anesthesia management by means of multiple variables for patient state stabilization. The patient simulator platform is designed through an interdisciplinary combination of medical, clinical practice and systems engineering expertise gathered in the last decades by our team. The result is an open source patient simulator in Matlab/Simulink from Mathworks(R). Simulator features include complex synergic and antagonistic interaction aspects between general anesthesia and hemodynamic stabilization variables. The anesthetic system includes the hypnosis, analgesia and neuromuscular blockade states, while the hemodynamic system includes the cardiac output and mean arterial pressure. Nociceptor stimulation is also described and acts as a disturbance together with predefined surgery profiles from a translation into signal form of most commonly encountered events in clinical practice. A broad population set of pharmacokinetic and pharmacodynamic (PKPD) variables are available for the user to describe both intra- and inter-patient variability. This simulator has some unique features, such as: i) additional bolus administration from anesthesiologist, ii) variable time-delays introduced by data window averaging when poor signal quality is detected, iii) drug trapping from heterogeneous tissue diffusion in high body mass index patients. We successfully reproduced the clinical expected effects of various drugs interacting among the anesthetic and hemodynamic states. Our work is uniquely defined in current state of the art and first of its kind for this application of dose management problem in anesthesia. This simulator provides the research community with accessible tools to allow a systematic design, evaluation and comparison of various control algorithms for multi-drug dosing optimization objectives in anesthesia.

General Anesthetic Management for Patient with Brugada Syndrome: A Case Report

Brugada syndrome is an arrhythmogenic cardiopathy characterized by electrocardiography (ECG) pattern of the presence of an atypical right bundle branch block pattern with ST segment elevation in the precordial leads (V1-V3). It is sometimes associated with sudden deaths caused by ventricular arrhythmia. Here, we are reporting a case of a 43-year-old male patient with Brugada syndrome who underwent a tonsillectomy under general anesthesia without any complications.

Case Report: General Anesthetic Management for Laparoscopic Cholecystectomy in Paramyotonia Congenita

Background: Paramyotonia congenita (PC) is a rare disorder affecting skeletal muscle. Patients with this non-progressive condition experience intermittent episodes of sustained myotonia. Due to the predisposition for prolonged muscle contraction, special attention must be given to anesthetic management during operative procedures to prevent complications similar to those experienced in patients with malignant hyperthermia. To date, however, limited reports of anesthetic management in paramyotonia congenita are available.
 The Case: The present report describes successful general anesthetic management given to a patient with paramyotonia congenita using propofol and ketamine for induction, non-depolarizing rocuronium for muscle paralysis, and continuous nitrous oxide and IV propofol infusion for sedation. The patient remained stable throughout the case without myotonic episodes or other complications.
 Conclusion: Our report describes successful anesthetic management in a patient with paramyotonia congenita. This provides a potential management plan that may be applied to PC patients undergoing a variety of surgical procedures and eliminates risk associated with succinylcholine and possibly volatile anesthetics. Further research is needed to determine whether this approach is superior to previously reported techniques and should also identify which agents may be effectively utilized to reverse an intra-operative myotonic episode in PC.

Case Report: General Anesthetic Management for Laparoscopic Cholecystectomy in Paramyotonia Congenita

Background: Paramytonia congenita is a rare disorder affecting skeletal muscle. Patients with this condition experience intermittent episodes of sustained myotonia, though the disease is non-progressive. Due to the predisposition for prolonged muscle contraction, special attention must be paid to anesthetic management during operative procedures to prevent complications similar to those seen in patients with malignant hyperthermia. To date, however, limited reports of anesthetic management in paramyotonia congenita are available.
 Case: Therefore, the present report describes successful general anesthetic management in a patient with paramyotonia congenita using propofol and ketamine for induction, non-depolarizing rocuronium for muscle paralysis, and continuous nitric oxide and IV propofol infusion for sedation. The patient remained stable throughout the case without myotonic episodes or other complications.
 Conclusion: Our report describes successful anesthetic management in a patient with paramyotonia congenita. This provides a potential management plan that may be applied to PC patients undergoing a variety of surgical procedures and eliminates risk associated with succinylcholine and possibly volatile anesthetics. Further research is needed to determine whether this approach is superior to previously reported techniques, and should also aim to identify which agents may be effectively utilized to reverse a myotonic episode in PC patients should one occur intra-operatively.

The effectiveness of ramosetron and ondansetron for preventing postoperative nausea and vomiting after arthroscopic rotator cuff repair: a randomized controlled trial

BackgroundArthroscopic rotator cuff repair is a painful procedure, and treatment of emetic events associated with drugs used in the current multimodal pain management remains challenging. This study aimed to evaluate the effectiveness of ramosetron or ondansetron to relieve postoperative nausea and vomiting (PONV) and pain after arthroscopic rotator cuff repair.MethodsIn total, 122 consecutive patients undergoing arthroscopic rotator cuff repair were randomly allocated into three groups: ramosetron group (n = 39), ondansetron group (n = 43), and control group (n = 40). Then, 0.3 mg of ramosetron or 8 mg of ondansetron was administered intravenously at the end of surgery according to group. All patients received general anesthesia and multimodal pain management protocol including preemptive analgesic medication, fentanyl-based intravenous patient-controlled analgesia, and postoperative analgesic medication. Incidence of emetic events, rescue antiemetic requirements (10 mg of metoclopramide, IV), complete response, pain level, and side effects were recorded in three periods: 0–6, 6–24, and 24–48 h postoperatively. The severity of nausea and pain was evaluated using a visual analog scale.ResultsThe ramosetron group tended to have a lower incidence and severity of nausea during the 6- to 24-h postoperative period and fewer rescue antiemetic drug requirements during the 0- to 48-h period than the control group, showing statistical significance. Additionally, the frequency of complete response of the ramosetron and ondansetron groups was significantly higher than that of the control group. No difference was found among the groups in the pain level except during the 0- to 6-h period. The two groups have a higher complete response during the 6- to 24-h period than the control group.ConclusionsRamosetron use led to a lower incidence, mild severity of nausea, and reduced use of rescue antiemetic drug after arthroscopic rotator cuff repair during the 6- to 24-h postoperative period than the control.Level of evidenceLevel I, randomized controlled trials, treatment study

10.4314/ajns.v9i2.70411

Background Deliberate self-harm with stone- or hammer-driven nail through the cranium is unusual. The need is stressed for comprehensive radiological evaluation with computed tomography (CT) scan, with or without angiography, and removal through an open cranial procedure under general anaesthesia, rather than extraction through a burrhole under local anesthetic infiltration. Methods We present here a 27-year old male who presented at our Teaching Hospital setting with a self-inflicted hand-driven intracranial nail to the left parietal region. He had a detailed neurological examination, was evaluated pre-operatively with computerised tomography of the brain and underwent an open cranial procedure under general anaesthesia for nail retrieval. Psychiatric unit evaluated and managed him for chronic depression. Results The transparietal, intraventricular 10cm long nail was retrieved and associated abscess evacuated by an open cranial procedure. Pre-operative neurological impairments regressed and his mood stabilized with anti-depressants. He was discharged without further deficits and has remained well for over four years Conclusion Self-inflicted hand-driven intracranial nail is a very rare form of penetrating cranio-cerebral trauma. Preoperative computerised tomography scan of the brain, meticulous open cranial removal under general anaesthesia and psychiatric management enable discharge without further injury or deficits. On the other hand, removal through a burrhole or just pulling out the nail would not allow intraoperative visualisation of associated lesions; the latter also predispose to further vascular and parenchymal brain injuries, worsening neurolological impairments. Key words: Intracranial Nail; Open Cranial Procedure; Psychiatric Evaluation.

General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study.

There are no current descriptions of general anaesthesia characteristics for obstetric surgery, despite recent changes to patient baseline characteristics and airway management guidelines. This analysis of data from the direct reporting of awareness in maternity patients' (DREAMY) study of accidental awareness during obstetric anaesthesia aimed to describe practice for obstetric general anaesthesia in England and compare with earlier surveys and best-practice recommendations. Consenting patients who received general anaesthesia for obstetric surgery in 72 hospitals from May 2017 to August 2018 were included. Baseline characteristics, airway management, anaesthetic techniques and major complications were collected. Descriptive analysis, binary logistic regression modelling and comparisons with earlier data were conducted. Data were collected from 3117 procedures, including 2554 (81.9%) caesarean deliveries. Thiopental was the induction drug in 1649 (52.9%) patients, compared with propofol in 1419 (45.5%). Suxamethonium was the neuromuscular blocking drug for tracheal intubation in 2631 (86.1%), compared with rocuronium in 367 (11.8%). Difficult tracheal intubation was reported in 1 in 19 (95%CI 1 in 16-22) and failed intubation in 1 in 312 (95%CI 1 in 169-667). Obese patients were over-represented compared with national baselines and associated with difficult, but not failed intubation. There was more evidence of change in practice for induction drugs (increased use of propofol) than neuromuscular blocking drugs (suxamethonium remains the most popular). There was evidence of improvement in practice, with increased monitoring and reversal of neuromuscular blockade (although this remains suboptimal). Despite a high risk of difficult intubation in this population, videolaryngoscopy was rarely used (1.9%).

Comparison of 1-year recurrence-free survival between sevoflurane and propofol use for general anesthesia management in primary breast cancer surgery.

We evaluated the influence of anesthetic management with sevoflurane or propofol on recurrence in patients undergoing breast cancer surgery. This single center, retrospective study, included patients who received either sevoflurane or propofol during primary breast cancer surgery between 2008 and 2012. Our primary outcome was recurrence-free survival (RFS) at 1year. Recurrence was defined as locoregional recurrence and distal metastasis. Propensity scores were calculated using seven variables (age, sex, body mass index, cancer stage, tumor size, intrinsic subtype, and deviation from standard therapy), and Kaplan-Meier survival curves were constructed from the date of diagnosis of recurrence. Hazard ratios (HRs) were estimated using univariable Cox proportional hazard regression analysis. Two-hundred-twelve patients received sevoflurane and 814 patients received total intravenous anesthesia with propofol. The median follow-up was 59 (interquartile range, 44-75) months. Regional anesthetic techniques were not used. Recurrence occurred in 95 patients (9.26%), with 19 (8.96%) and 76 (9.33%) in the sevoflurane and propofol groups, respectively. The HR was 1.167 (95% confidence interval, 0.681-2.000, p = 0.574) for the use of sevoflurane over propofol. After 1:1 propensity-score matching, 318 patients were analyzed. The 1-year RFS rates were similar between the groups (sevoflurane group: 7.5% [n = 12], propofol group: 8.2% [n = 13]), yielding an HR of 1.002 (95% confidence interval 0.457-2.198, p = 0.995) associated with the use of sevoflurane over propofol. In patients undergoing primary breast cancer surgery, the use of either sevoflurane or propofol without regional anesthesia did not appear to affect the risk of recurrence after 1year.

COVID-19: General considerations and anesthetic management

Corona virus emerged as a surprise to the world, just three months back, and within the matter of only a few weeks engulfed whole of the globe in a state of despair and fear. From Wuhan to New York, the clinicians found them on the forefront of a world war like condition. Most of the healthcare systems found them ill prepared to deal with the ever-growing number of victims. As expected, the brunt of this catastrophe had to bear by the intensivists, anesthesiologists, pulmonologists and the nursing staff, besides almost every trade and discipline of the workers in a hospital. (Please select one option in the questions given below).

Anticipated difficult airway during obstetric general anaesthesia: narrative literature review and management recommendations.

We reviewed the literature on management of general and regional anaesthesia in pregnant women with anticipated airway difficulty. We identified 138 publications comprising 158 cases; these either described equipment or techniques for the provision of general anaesthesia, or the management of women with regional analgesia or anaesthesia, with the aim of avoiding general anaesthesia. Most of the former group described women requiring caesarean section alone, or in combination with other surgery, which was sometimes airway-related. Management techniques were largely similar to those in non-obstetric patients requiring surgery who have airway difficulties, although suggested differences related to physiological changes of pregnancy and avoidance of nasal intubation. In the reports discussing regional anaesthesia, consideration was often given to the possible requirement for urgent out-of-hours anaesthetic intervention, and the predicted difficulty of management of general anaesthesia should it be required. In a number of reported cases, multidisciplinary planning led to the conclusion that elective caesarean section should be performed in order to avoid emergency airway management. Based on this literature review, we advise antenatal planning that includes: assessment of the patient's clinical characteristics; consideration of the equipment and personnel available to provide safe airway management out-of-hours; and elective caesarean section should these be lacking. If general anaesthesia is required, a risk assessment must be made as to the probability of safe airway management after the induction of anaesthesia, and awake tracheal intubation should be used if this cannot be assured. Decision aids are provided to illustrate these points. Online appendices include a comprehensive compendium of case reports on the management of a number of rare syndromes and airway conditions.

The effects of cannabis and cannabinoids on anesthesia and analgesia during the perioperative period

Cannabis is the most frequently used recreational drug worldwide. Moreover, the use of cannabinoids for medical purposes is also constantly growing and medical cannabis products are legalised by an increasing number of countries. First clinical reports have shown enhanced requirements for propofol and analgesics used for general anesthesia and perioperative pain management in cannabis users. Therefore, this article discusses the potential impact of medical or recreational cannabis use on patients with regard to the recent literature. Besides the significantly increased requirement for propofol and fentanyl during anesthesia and for postoperative analgesia, ahigher risk for tachycardia, pulmonary and cardiovascular complications was observed. With respect to these data, the authors recommend asking patients pre-operatively about recreational or medical cannabis use or cannabinoid-based medication.

General anesthesia management with laryngeal mask airway in a patient with epidermolysis bullosa: Case report

General anesthesia management with laryngeal mask airway in a patient with epidermolysis bullosa: Case report

A prospective randomized comparative study of the efficacy of atracurium and cisatracurium during general anaesthesia

Introduction: The neuromuscular blocking drugs (NMBDs) has revolutionized the management of balanced General Anaesthesia (GA). Atracurium and Cisatracurium are intermediate-acting muscle relaxants without any much side effects and recovery due to non-organ dependent elimination. Aim: To compare the efficacy of Atracurium and Cisatracurium in general anaesthesia with endotracheal intubation.Methods: In this prospective randomized comparative study 156 patients who fulfilled the eligibility criteria were systematically randomized into two groups of 78 each, Group. A (Atracurium) and Group B (cisatracurium). Patients' duration of surgery, vital parameters, intubation score were recorded. Results: Cisatracurium Besylate subjects had a mean onset time of 165.95 seconds, mean duration of action of 57.41 minutes and mean recovery time of 121.62 minutes. Similarly group Atracurium Besylate subjects had a mean onset time of 196.95 seconds, mean duration of action of 34.58 minutes and mean recovery time of 150.65 minutes. Cisatracurium Besylate subjects had a mean jaw relaxation score of 2.90, mean vocal cord score of 2.77, mean intubation response score of 2.85 and mean intubating score of 8.51. Similarly, group Atracurium Besylate subjects had a mean jaw relaxation score of 2.55, mean vocal cord score of 2.42, mean intubation response score of 2.43 and mean intubation score of 7.38. There were no adverse drug reactions observed in both groupsConclusion: Cisatracurium with lesser side effects and a better hemodynamic profile is safe and more efficacious as compared to atracurium.

Cervical epidural analgesia combined with general anesthesia for head and neck cancer surgery: A randomized study.

Background and Aims:The role of cervical epidural analgesia in head and neck cancer surgery is not fully explored. The aim of this study was to evaluate cervical epidural analgesia in terms of opioid and anesthetic requirements and stress response in patients undergoing head and neck cancer surgery.Material and Methods:After institutional ethical committee approval and written informed consent, 30 patients undergoing elective head and neck cancer surgery were randomized into two groups: Group E (cervical epidural analgesia with general anesthesia), and group G (general anesthesia alone). In group E, an 18 gauge epidural catheter was placed at cervical (C) 6 – thoracic (T) 1 level. After test dose, a bolus of 10 ml of 0.2% ropivacaine was given followed by continuous infusion. Technique of general anesthesia and post-operative management was standardized in both the groups. Opioid and anesthetic drug requirement was observed. Blood glucose and serum cortisol levels were measured at baseline; post-incision and after surgery.Results:There was significant reduction in the requirement of morphine (P < 0.001), isoflurane (P = 0.004) and vecuronium (P = 0.001) in group E. Post-operative, blood glucose and serum cortisol levels were significantly reduced (P = 0.0153 and 0.0074, respectively). Early post-operative pain was reduced with the lesser requirement of post-operative morphine.Conclusions:The use of combined cervical epidural analgesia with general anesthesia reduces opioid, anesthetic drug requirement and stress response as compared to general anesthesia alone in patients undergoing head and neck cancer surgery.

Sedoanalgesia modality during laser photocoagulation for retinopathy of prematurity: Intraoperative complications and early postoperative follow-up.

Laser photocoagulation (LPC) is a surgical procedure used in the treatment of premature retinopathy that may cause retinal detachment and blindness if not diagnosed and treated early. The anesthesia method used in LPC varies from sedoanalgesia to general anesthesia and airway management varies from spontaneous ventilation to endotracheal intubation. In this study, we aimed to evaluate the effectiveness of sedoanalgesia applications and this anesthesia procedure concerning intraoperative and postoperative complications by avoiding intubation and mechanical ventilation in premature infants with a fragile population. This retrospective study included 89 patients who underwent laser photocoagulation under anesthesia for premature retinopathy. Patients' demographic characteristics, preoperative risk factors, anesthesia technique, especially airway management, changes in ventilation status during surgery, intraoperative complications, postoperative complications, and intensive care follow-up, were recorded and analyzed statistically. Two of the 89 patients who underwent laser photocoagulation were excluded from this study because they were followed up intubated. The number of patients who received mask ventilation due to intraoperative complications was 12 (13.8%). The mean operation time was 36.2±10.1 minutes. In 86.2% (n=75) of the patients, the surgical procedure was completed with sedoanalgesia while maintaining spontaneous ventilation. Sedoanalgesia application during the surgical intervention of patients with Retinopathy of Prematurity (ROP) requiring early diagnosis and emergency treatment will minimize intraoperative and postoperative complications. We believe that sedoanalgesia as an anesthetic method can be applied as an effective alternative method while preserving spontaneous ventilation.