Median Anesthesia Time Research Articles

High-Frequency Jet Ventilation Versus Spontaneous Respiration for Percutaneous Cryoablation of Lung Tumors: Comparison of Adverse Events and Procedural Efficiency.

BACKGROUND. High-frequency jet ventilation (HFJV) facilitates accurate probe placement in percutaneous ablation of lung tumors but may increase risk for adverse events, including systemic air embolism. OBJECTIVE. The purpose of this study was to compare major adverse events and procedural efficiency of percutaneous lung ablation with HFJV under general anesthesia to spontaneous respiration (SR) under moderate sedation. METHODS. This retrospective study included consecutive adults who underwent CT-guided percutaneous cryoablation of one or more lung tumors with HFJV or SR between January 1, 2017, and May 31, 2023. We compared major adverse events (Common Terminology Criteria for Adverse Events grade ≥ 3) within 30 days postprocedure and hospital length of stay (HLOS) of 2 days or more using logistic regression analysis. We compared procedure time, room time, CT guidance acquisition time, CT guidance radiation dose, total radiation dose, and pneumothorax using generalized estimating equations. RESULTS. Overall, 139 patients (85 women, 54 men; median age, 68 years) with 310 lung tumors (82% metastases) underwent 208 cryoablations (HFJV, n = 129; SR, n = 79). HFJV showed greater rates than SR for the treatment of multiple tumors per session (43% vs 19%, respectively; p = .02) and tumors in a nonperipheral location (48% vs 24%, p < .001). Major adverse event rate was 8% for HFJV and 5% for SR (p = .46). No systemic air embolism occurred. HLOS was 2 days or more in 17% of sessions and did not differ significantly between HFJV and SR (p = .64), including after adjusting for probe number per session, chronic obstructive pulmonary disease, and operator experience (p = .53). Ventilation modalities showed no significant difference in procedure time, CT guidance acquisition time, CT guidance radiation dose, or total radiation dose (all p > .05). Room time was longer for HFJV than SR (median, 154 vs 127 minutes, p < .001). For HFJV, the median anesthesia time was 136 minutes. Ventilation modalities did not differ in the frequencies of pneumothorax or pneumothorax requiring chest tube placement (both p > .05). CONCLUSION. HFJV appears to be as safe as SR but had longer room times. HFJV can be used in complex cases without significantly impacting HLOS of 2 days or more, procedure time, or radiation exposure. CLINICAL IMPACT. Selection of the ventilation modality during percutaneous lung ablation should be based on patient characteristics and anticipated procedural requirements as well as operator preference.

Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery.

Background and Objectives: The increase in the incidence and diagnosis rate of breast cancer demands the optimization of resources. The aim of this study was to assess whether the supplementation of the interpectoral-pectoserratus plane block (PECS II) reduces surgery and post-anesthesia care unit (PACU) time in patients undergoing breast cancer surgery. Materials and methods: This was a retrospective data-analysis study. In 2016, PECS II block was introduced as a supplement to general anesthesia for all mastectomies with or without axillary resections in South Jutland regional hospital, Denmark. The perioperative data of patients operated 3 years before and 3 years after 2016 was retrieved through the Danish anesthesia database and patient journals and systematically analyzed. Female patients aged over 18 years, with no use of muscle relaxant, intubation, and inhalation agents, were included. The eligible data was organized into two groups, i.e., Block and Control, where the Block group received PECS II Block, while the Control group received only general anesthesia. Parameters such as surgery time, anesthesia time, PACU time, opioid consumption, and the incidence of postoperative nausea and vomiting (PONV) in PACU were retrieved and statistically analyzed. Results: A total of 172 patients out of 358 patients met eligibility criteria. After applying exclusion criteria, 65 patients were filtered out. A total of 107 patients, 51 from the Block and 56 from the Control group, were eligible for the final analysis. The patients were comparable in demographic parameters. The median surgery time was significantly less in the Block group (78 min (60-99)) in comparison to the Control group (98.5 min (77.5-139.5) p < 0.0045). Consequently, the median anesthesia time was also shorter in the Block group (140 min (115-166)) vs. the Control group (160 min (131.5 to 188), p < 0.0026). Patients from the Block group had significantly lower intraoperative fentanyl consumption (60 µg (30-100)) as compared with the Control group (132.5 µg (80-232.5), p < 0.0001). The total opioid consumption during the entire procedure (converted to morphine) was significantly lower in the Block group (16.37 mg (8-23.6)) as compared with the Control group (31.17 mg (16-46.5), p < 0.0001). No statistically significant difference was found in the PACU time, incidences of PONV, and postoperative pain. Conclusions: The interpectoral-pectoserratus plane (PECS II) block supplementation reduces surgery time, anesthesia time, and opioid consumption but not PACU time during breast cancer surgery.

A Novel Modified Two-Lobe Holmium Prostate Enucleation Technique: Demirtaş-Erciyes Enucleation Prostatectomy.

ObjectiveEndoscopic enucleation of the prostate has evolved and became popular for the surgical treatment of benign prostatic hyperplasia (BPH) during the last decade. Different surgical techniques have been described so far. We hereby described a new modified two-lobe technique for urologists who are inexperienced in endoscopic enucleation. We aimed here to present the data on a learning curve of this stepwise technique named Demirtaş-Erciyes Enucleation Prostatectomy (DEEP): reverse S-J incision technique and its postoperative outcomes.Material and methodsThe study included 102 patients who underwent holmium laser enucleation of the prostate (HoLEP) with the DEEP technique between October 2020 and December 2021. Demographic, preoperative, and postoperative variables were recorded. The operation was performed with a 150 W holmium laser system (Quanta System, Varese, Italy) with cutting and coagulation settings of 2J × 50 Hz with virtual basket mode and 2J × 12 Hz in bubble blast mode, respectively. Bladder irrigation was done for one day, and then, on the next day, the urethral catheter was removed. Postoperatively, uroflowmetry studies, continence status, and ejaculation status were recorded during follow-up. The data of all patients were divided into two groups (first 51 and final 51 patients). All variables were analyzed between two groups.ResultsThe mean age of the patients was 68.48±8.74 years. The median Charlson Comorbidity Index (CCI) score was 3. The median International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) values ​​were 26 (10-35) and 10 (0-25), respectively. Of the patients, 60.8% had Foley catheters due to urinary retention. The median anesthesia time, laser time, enucleation time, morcellation time, and enucleated tissue amount were 102.5 minutes, 17 minutes, 25 minutes, 20 minutes, and 50 g, respectively. Enucleation was performed in two stages in five patients due to bigger prostate volume or incomplete morcellation. The median catheter removal time was 48 hours. In six patients, the postoperative catheterization time was prolonged due to hematuria. The median increase in Qmax was 19.35 mL/second. The overall complication rate was 5.9%, which were all Clavien grade II. Enucleation time, laser time, and anesthesia time were significantly lower in the last 51 patients.ConclusionDEEP enucleation technique seems to provide effective and safe postoperative results for beginners in prostate enucleation.

Trends and safety of robot-assisted partial nephrectomy during the initial 2-year period after government approval in Japan: A nationwide database study from 2016 to 2018.

To evaluate the trends and safety of robot-assisted partial nephrectomy during the initial 2-year period after government approval for this type of procedure in April 2016. This nationwide retrospective study included 3722 received robot-assisted partial nephrectomy cases carried out from April 2016 to March 2018 in 124 participating institutions. The institutions were divided into lower- and higher-volume institutions according to the median of 19 robot-assisted partial nephrectomy cases during the study period. Surgical outcomes between 616 cases from lower-volume institutions and 3106 cases from higher-volume institutions were compared using propensity score matching. During the study period, both the number of robot-assisted partial nephrectomy surgeries and the number of institutions in which the surgery was carried out steadily increased. Overall, the median anesthesia time was 217min, the median postoperative length of stay was 9days, and the proportion of blood transfusions, complications and readmissions were 0.8%, 5.1% and 1.0%, respectively. There were no significant differences in anesthesia time, incidence of blood transfusions, and complication rates between the lower-volume and higher-volume institutions. However, a slightly, but significantly, longer postoperative length of stay and a lower incidence of readmission were observed in lower-volume institutions both before and after propensity score matching. Robot-assisted partial nephrectomy has become widespread during the initial 2-year period after government approval with an acceptable safety profile, regardless of the institutional caseloads. This technique has become a standard of care for stage1 renal cancer patients in Japan.

Comparative Analysis of Laparoscopic Inguinal Hernia Repair in Neonates and Infants.

This study analyzed our cohort of infants (age below 12 mo) who underwent laparoscopic inguinal hernia repair (LIHR), comparing those 3 months and below (corrected premature) to above 3 months (term infants) corrected age at the time of surgery. Retrospective analysis of a single surgeon and associated trainees' experience of LIHR in infants below 12 months over a 5-year period (2013-2018) was performed. The operative technique involved a 5-mm scope and 3-mm instruments for herniorrhaphy with 4/0 Prolene purse-string suture. Data collected included patient demographics, prematurity (<37 wk), corrected age and weight at surgery, preoperative hemoglobin level, comorbidities, anesthetic time, major perioperative complications, and inguinal hernia recurrence. A comparison was made between those operated at 3 months and below and above 3 months corrected age. Perioperative issues affecting infants 3 months and below were identified and analyzed. Statistical analysis includes T test and Fisher exact test (P<0.05 significance). Eighty infants underwent LIHR (age below 12 mo), of which 67 (84%) were male with a median corrected age of 10.5 (range 2.5 to 44) weeks, the median weight of 5.5 kg (range 2.1 to 10.8). A total of 47 (59%) infants had a unilateral inguinal hernia repair and 33 (41%) had a bilateral repair. The median anesthetic time was significantly greater for infants 3 months and below at 93 (range 61 to 125) minutes, compared with 83 (range 47 to 146) minutes for the above 3 months age group (P=0.001) There were no perioperative complications or mortality. One patient had a recurrence of an inguinal hernia. Low hemoglobin levels, comorbidities, and extreme prematurity required more attention during preoperative assessment and postoperative management. Comparable cohorts demonstrated no significant difference in recurrences despite significant differences in weight and median anesthetic time. Preoperative hemoglobin is an important factor that needs to be addressed in infants 3 months and below for scheduling the procedure date (transfusion vs. iron supplementation).

Three-year experience with immediate extubation in pediatric patients after congenital cardiac surgery

BackgroundIn pediatric cardiac anesthesiology, there is increased focus on minimizing morbidity, ensuring optimal functional status, and using health care resources sparingly. One aspect of care that has potential to affect all of the above is postoperative mechanical ventilation. Historically, postoperative ventilation was considered a must for maintaining patient stability. Ironically, it is recognized that mechanical ventilation may increase risk of adverse outcomes in the postoperative period. Hence, many institutions have advocated for immediate extubation or early extubation after many congenital heart surgeries which was first reported decades ago.Methods637 consecutive patient charts were reviewed for pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Patients were placed into three groups. Those that were extubated in the operating room (OR) at the conclusion of surgery (Immediate Extubation or IE), those that were extubated within six hours of admission to the ICU (Early Extubation or EE) and those that were extubated sometime after six hours (Delayed Extubation or DE). Multiple variables were then recorded to see which factors correlated with successful Immediate or Early Extubation.ResultsOverall, 338 patients (53.1%) had IE), 273 (42.8%) had DE while only 26 patients (4.1%) had EE. The median age was 1174 days for the IE patients, 39 days for the DE patients, whereas 194 days for EE patients (p < 0.001). Weight and length were also significantly different in at least one extubation group from the other two (p < 0.001). The median ICU LOS was 3 and 4 days for IE and EE patients respectively, whereas it was 9.5 days for DE patients (p < 0.001). DE group had a significant longer median anesthesia time and cardiopulmonary bypass time than the other two extubation groups (p > 63,826.88 < 0.001). Regional low flow perfusion, deep hypothermia, deep hypothermic circulatory arrest, redo sternotomy, use of other sedatives, furosemide, epinephrine, vasopressin, open chest, cardiopulmonary support, pulmonary edema, syndrome, as well as difficult intubation were significantly associated with delayed extubation (IE, EE or DE).ConclusionsImmediate and early extubation was significantly associated with several factors, including patient age and size, duration of CPB, use of certain anesthetic drugs, and the amount of blood loss and blood replacement. IE can be successfully accomplished in a majority of pediatric patients undergoing surgery for congenital heart disease, including in a minority of infants.

Anesthetic effects of dexmedetomidine-ketamine-midazolam administered intramuscularly in five-striped palm squirrels (Funambulus pennantii)

To evaluate efficacy and safety of anesthesia with dexmedetomidine-ketamine-midazolam (DKM) in five-striped palm squirrels (Funambulus pennantii). 8 male squirrels. Squirrels were anesthetized with DKM (dexmedetomidine, 0.1 mg/kg; ketamine hydrochloride, 30 mg/kg; and midazolam, 0.75 mg/kg) administered IM. Atipamezole (0.15 mg/kg) and flumazenil (0.1 mg/kg) were administered IM 40 minutes after induction of anesthesia. Vital signs and responses were recorded every 5 minutes during anesthesia. Anesthetic induction and recovery from anesthesia were rapid and without complications in all squirrels. Median anesthetic induction time was 67.5 seconds (interquartile [25th to 75th percentile] range, 5.5 seconds), and mean ± SD recovery time after drug reversal was 147 ± 79 seconds. Heart rate, respiratory rate, and rectal temperature significantly decreased during the anesthetic period. All squirrels became hypothermic by 40 minutes after induction. The righting reflex was absent during the 40-minute anesthetic period in all squirrels, with variable responses for the palpebral reflex, jaw tone, forelimb withdrawal reflex, and hind limb withdrawal reflex. Only 2 of 8 squirrels had loss of the limb withdrawal reflex in both the forelimbs and hind limbs from anesthetic induction to 25 minutes after induction. DKM appeared to provide safe and effective anesthesia in five-striped palm squirrels, but oxygen and thermal support were indicated. At the doses administered, deep surgical anesthesia was not consistently achieved, and anesthetic depth of individual squirrels must be determined before surgical procedures are performed in palm squirrels anesthetized with this drug combination.

Adequacy of Preoperative Resuscitation in Laparoscopic Pyloromyotomy and Anesthetic Emergence.

Pyloromyotomy is one of the most common surgical procedures performed on otherwise healthy infants. Pyloric stenosis results in a hypochloremic, hypokalemic metabolic alkalosis that is considered a medical emergency. This alkalotic state is believed to be associated with an increased incidence of apneic episodes. Because apnea tends to occur during anesthetic emergence, we sought to examine the association between the preoperative serum bicarbonate level and anesthetic emergence time after laparoscopic pyloromyotomy. Data were collected from patients who underwent laparoscopic pyloromyotomies from April 2014 to October 2018. To estimate the correlation between preoperative bicarbonate level and emergence time while accounting for the positive skew of emergence time and potential confounding variables, a weighted quantile mixed regression was used. Due to a nonlinear association with emergence time, preoperative serum bicarbonate was split into 2 continuous intervals (<24 and ≥24 mEq/L) and the slope versus outcome was fit for each interval. A total of 529 patients who underwent laparoscopic pyloromyotomy were analyzed in this study. After controlling for confounders, the preoperative serum bicarbonate interval of ≥24 mEq/L was linearly associated with median emergence time (median increase of 0.81 minutes per 1 mEq/L increase of bicarbonate; 95% confidence interval [CI], 0.42-1.20; P < .001). Only 3 patients (0.6%) had apneic episodes after pyloromyotomy despite all having preoperative serum bicarbonate levels <29 mEq/L. Preoperative serum bicarbonate was positively associated with median anesthetic emergence time in a linear manner for values ≥24 mEq/L, although this correlation may not appear to be clinically substantial per 1 mEq/L unit. However, when preoperative serum bicarbonate levels were dichotomized at a commonly used presurgical threshold, the difference in median emergence time between ≥30 and <30 mEq/L was an estimated 5.4 minutes (95% CI, 3.1-7.8 minutes; P < .001).

Use of non-contrast-enhanced computed tomography to identify deep digital flexor tendinopathy in horses with lameness: 28 cases (2014-2016).

To describe the use of non-contrast-enhanced CT to identify deep digital flexor (DDF) tendinopathy in horses with lameness attributed to pain in regions distal to the metatarsophalangeal or metacarpophalangeal joints. Retrospective case series. 28 client-owned horses. Medical records were searched to identify horses that underwent non-contrast-enhanced CT with or without high-field MRI as part of an evaluation for lameness localized to areas distal to the metacarpophalangeal or metatarsophalangeal joint in ≥ 1 limb. Horses were included in the study if they had ≥ 1 DDF tendon lesion (DDF tendinopathy) identified. Signalment, lameness examination findings and response to perineural anesthesia, imaging modality, anesthetic agents and duration of anesthesia, and imaging findings were recorded. Data were summarized descriptively. Bilateral imaging was performed for all horses, irrespective of unilateral or bilateral lameness. Nine of 28 horses underwent both CT and MRI, and all DDF tendon lesions identified by one modality were identified by the other. Of 48 limbs with DDF tendinopathy, 46 (96%) had core lesions and 35 (73%) had dorsal border irregularities. Median anesthesia time for CT and CT followed by MRI was 15 and 110 minutes, respectively. Results suggested that non-contrast-enhanced CT was useful for identifying DDF tendinopathy in horses with lameness localized to the phalangeal regions, and this was supported by consistency of findings in a subset of horses that underwent MRI. Further research is needed to confirm these results.

Effects of alfaxalone administered intravenously to healthy yearling loggerhead sea turtles (Caretta caretta) at three different doses.

OBJECTIVE To compare physiologic and anesthetic effects of alfaxalone administered IV to yearling loggerhead sea turtles (Caretta caretta) at 3 different doses. DESIGN Randomized crossover study. ANIMALS 9 healthy yearling loggerhead sea turtles. PROCEDURES Animals received each of 3 doses of alfaxalone (3 mg/kg [1.4 mg/lb], 5 mg/kg [2.3 mg/lb], or 10 mg/kg [4.5 mg/lb]) administered IV in randomly assigned order, with a minimum 7-day washout period between doses. Endotracheal intubation was attempted following anesthetic induction, and heart rate, sedation depth, cloacal temperature, and respirations were monitored. Times to first effect, induction, first voluntary muscle movement, first respiration, and recovery were recorded. Venous blood gas analysis was performed at 0 and 30 minutes. Assisted ventilation was performed if apnea persisted 30 minutes following induction. RESULTS Median anesthetic induction time for all 3 doses was 2 minutes. Endotracheal intubation was accomplished in all turtles following induction. Heart rate significantly increased after the 3- and 5-mg/kg doses were administered. Median intervals from alfaxalone administration to first spontaneous respiration were 16, 22, and 54 minutes for the 3-, 5-, and 10-mg/kg doses, respectively, and median intervals to recovery were 28, 46, and 90 minutes, respectively. Assisted ventilation was required for 1 turtle after receiving the 5-mg/kg dose and for 5 turtles after receiving the 10-mg/kg dose. The 10-mg/kg dose resulted in respiratory acidosis and marked hypoxemia at 30 minutes. CONCLUSIONS AND CLINICAL RELEVANCE IV alfaxalone administration to loggerhead sea turtles resulted in a rapid anesthetic induction and dose-dependent duration of sedation. Assisted ventilation is recommended if the 10 mg/kg dose is administered.

Ratio of intra-operative fluid to anesthesia time and its impact on short term perioperative outcomes following gastrectomy for cancer: A retrospective cohort study

BackgroundThis study evaluates the short-term impact of fluid administration during gastrectomy for cancer. MethodsA multi-institutional database of patients undergoing gastrectomy for cancer from three tertiary centers was reviewed. Logistic and linear regression analyses were performed. Results205 patients were included. The majority of patients (n = 116, 57%) underwent proximal or total gastrectomy. Median anesthesia time was 280 min (range 95–691 min). Median intraoperative crystalloid administration was 2901 ml (range 500–10,700 ml). Median colloid administration was 0 (range 0–3835 ml), although only 66 patients (32%) received colloid. On multivariate analysis, patients who received <10.0 ml total fluid per minute of anesthesia had a significantly higher risk of complications (OR 4.12, p = 0.010). Crystalloid and total fluid administration ratios did not significantly affect LOS or discharge disposition. ConclusionsRestricting intra-operative fluid resuscitation to <10 ml total fluid per minute anesthesia is associated with an increased risk of complications in patients undergoing gastrectomy for cancer.

Robotic Single- and Multisite Cholecystectomy in Children.

Elective cholecystectomy is a high-volume, simple procedure, well suited for the development of a pediatric robotic surgery program. Surgical robot software, by "reversing" the surgeon's hands, simplifies single-site cholecystectomy through a single incision at the umbilicus. Data were reviewed on the first nine children who had robotic cholecystectomy, with the Da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) device, at our institution. All cases were performed by a single surgeon, proctored by an experienced robotic general surgeon. There were 9 patients: the first 4 patients had robotic multiport cholecystectomy, and the last 5 had robotic single-site cholecystectomy. Eight were girls. They were 10-18 years of age (median, 14 years). Diagnoses were biliary dyskinesia (n = 5) and symptomatic cholelithiasis (n = 4). Median body mass index was 24.9 (range, 20.2-43.8) kg/m(2). Median anesthesia time for multiport cholecystectomy was 139 (range, 120-162) minutes; median anesthesia time for single-site cholecystectomy was 169 (range 122-180) minutes. Median console time for multiport cholecystectomy was 47 (range, 44-58) minutes; median console time for single-site cholecystectomy was 69 (range, 66-86) minutes. Eight of the 9 patients went home on the day of surgery, and 1 stayed overnight. Patients were seen at 13-20 days after surgery (median, 14 days). There were no complications. There were no conversions to open surgery and none from single-site to multiport surgery. Robotic cholecystectomy is safe and efficacious and is a suitable introductory procedure for pediatric surgeons considering a robotic surgery program. Single-site robotic cholecystectomy is a cosmetically attractive option but takes longer than multiport robotic cholecystectomy.

Venous blood gas analytes during isoflurane anesthesia in black-tailed prairie dogs (Cynomys ludovicianus)

To describe changes in venous blood gas analytes during isoflurane anesthesia in black-tailed prairie dogs (Cynomys ludovicianus). Prospective study. 16 black-tailed prairie dogs. Black-tailed prairie dogs were placed in an anesthesia chamber for induction of general anesthesia, which was maintained with isoflurane in oxygen delivered via mask. Immediately following anesthetic induction, a venous blood sample was obtained from the medial saphenous vein; a second venous blood sample was obtained just prior to anesthetic gas shutoff. An evaluation of venous blood gas analytes was performed on each sample. General linear mixed models with repeated measures were used for data analyses. Median anesthetic time was 90 minutes (range, 60 to 111 minutes). A significant increase from immediately after induction to completion of anesthesia was observed in Pco2 and mean blood chloride ion, BUN, and creatinine concentrations. A decrease in Po2, mean blood pH, and anion gap was observed from induction of anesthesia to completion. No significant differences during anesthesia were observed in mean base excess or blood bicarbonate, sodium, potassium, calcium, magnesium, blood glucose, lactate, and total CO2 concentrations. No complications occurred during or after anesthesia for any animal. Examination of prairie dogs often requires general anesthesia, with isoflurane currently the inhalation agent of choice. Results suggested respiratory acidosis and relative azotemia may occur during isoflurane anesthesia of prairie dogs. Given the increased risk associated with anesthesia in small mammals and the propensity for respiratory disease in prairie dogs, insight into physiologic changes associated with isoflurane anesthesia in healthy prairie dogs can aid in perioperative evaluation and anesthetic monitoring in this rodent species.

Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation.

Thoracoscopic surgery without endotracheal intubation is a novel technique for diagnosis and treatment of thoracic diseases. This study reported the experience of nonintubated thoracoscopic surgery in a tertiary medical center in Taiwan. From August 2009 through August 2013, 446 consecutive patients with lung or pleural diseases were treated by nonintubated thoracoscopic surgery. Regional anesthesia was achieved by thoracic epidural anesthesia or internal intercostal blockade. Targeted sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. The demographic data and clinical outcomes were evaluated by retrospective chart review. Thoracic epidural anesthesia was used in 290 patients (65.0%) while internal intercostal blockade was used in 156 patients (35.0%). The final diagnosis were primary lung cancer in 263 patients (59.0%), metastatic lung cancer in 38 (8.5%), benign lung tumor in 140 (31.4%), and pneumothorax in 5 (1.1%). The median anesthetic induction time was 30 minutes by thoracic epidural anesthesia and was 10 minutes by internal intercostal blockade. The operative procedures included lobectomy in 189 patients (42.4%), wedge resection in 229 (51.3%), and segmentectomy in 28 (6.3%). Sixteen patients (3.6%) required conversion to tracheal intubation because of significant mediastinal movement (seven patients), persistent hypoxemia (two patients), dense pleural adhesions (two patients), ineffective epidural anesthesia (two patients), bleeding (two patients), and tachypnea (one patient). One patient (0.4%) was converted to thoracotomy because of bleeding. No mortality was noted in our patients. Nonintubated thoracoscopic surgery is technically feasible and safe and can be a less invasive alternative for diagnosis and treatment of thoracic diseases.

2260 AN INSTITUTIONAL REVIEW OF ANESTHETIC TIMES FOR URINARY STONES IN PREGNANT WOMEN

INTRODUCTION AND OBJECTIVES: Management options for urolithiasis during pregnancy include trial of passage, temporizing ureteral stent or nephrostomy tube, and definitive treatment with ureteroscopy. Prior research suggests children can suffer adverse long term effects from exposure to medications used for general anesthesia. Specifically, anesthesia exposure greater than two hours or greater than two separate anesthesia exposures prior to the age of four years has been associated with the development of learning disabilities. The goal of this study is to compare the potential anesthesia risk to the fetus when temporizing stents are placed compared to definitive management with ureteroscopy. METHODS: We retrospectively reviewed the records of patients diagnosed with urolithiasis during pregnancy who underwent surgical intervention from 1997 to 2012. Patients were evaluated for a confirmed stone event, defined as a stone visualized on imaging or at surgery, along with management strategy including duration and frequency of anesthetic events. RESULTS: We identified 26 women with urolithiasis during pregnancy who met our inclusion criteria, of which 15 (58%) were managed with stents and 11 (42%) underwent ureteroscopic intervention. In the stent group 6 (40%) required multiple stent exchanges for a mean of 1.47 (range 1-3) anesthetic events and median anesthetic time of 70 minutes (range 29-208 min). Seven (47%) of the women managed with ureteral stent exchange were induced prior to term due to inability to tolerate the stent. Overall the ureteroscopy group had a mean of 1.18 anesthetic events (range 1-2) and 80 minutes (range 37-126 min) of anesthetic exposure. Two (18%) required two procedures either for infection or narrow ureter. None were induced early for pain. Comparing the two groups, there was no significant difference in number of events (p 0.208) or total anesthetic time (p 0.503). CONCLUSIONS: Ureteroscopic intervention appears safe and effective in treating acute stone events with equivalent if not less anesthetic exposure to the fetus compared to temporizing ureteral stents. Furthermore, early induction of labor due to pain is not a concern with ureteroscopy, as it has been shown to be with ureteral stenting. Our study provides further support to the role of definitive stone management instead of temporizing measures during pregnancy.

Magnetresonanztomografie bei Kindern in Sedierung - anästhesiologisches Prozedere, Zeitbedarf und Determinanten verzögerter Prozessabläufe

MRI examinations in children under sedation or general anesthesia are a multidisciplinary challenge for pediatric, radiology and anesthesiology departments. This article presents findings about patient population, anesthesiology procedures and process times in pediatric MRI procedures under sedation or general anesthesia. The analysis is focused on the potential to optimize process times. Retrospectively over a 5-year period, data from diagnostic radiology procedures in children requiring sedation or general anesthesia were retrieved from anesthesia records and analyzed statistically. The median anesthesia time in patients without an airway device was 6 min. In patients with a laryngeal mask (19 min) and in patients receiving endotracheal intubation (20 min), the anesthesia time was significantly longer (p < 0.001). The need for airway management in the age groups was 67 % for neonates, 25 % for infants, 8 % for toddlers and 7 % for school children. Improved clinical pathways could potentially save additional time up to 69 hours in our period of investigation. In relation to older children, toddlers, infants and neonates had the longest process times in diagnostic radiology procedures, caused by the need to secure the airway. Improved pre-MRI processes have an enormous potential to generate additional examination time.

Peri-operative Morbidity Associated with Ovariohysterectomy Performed as Part of a Third-Year Veterinary Surgical-Training Program

The present study describes the morbidity associated with ovariohysterectomy (OVH) when performed by third-year veterinary students as part of a surgical-training program. Data recorded from medical records included signalment, concurrent illness(es), surgical procedure(s), anesthesia and surgery time, anesthetic and surgical complications, and semester performed. The students' surgical training before the OVH included 39 lecture and 26 laboratory hours. In the present study, 513 animals (206 dogs and 307 cats) were included, of which 120 (23.4%) animals had concurrent illnesses. Median anesthesia time was 145 minutes (ranging from 65 to 240) for cats and 180 minutes (ranging from 90 to 360) for dogs. Median surgery time was 105 minutes (ranging from 50 to 210) for cats and 140 minutes (ranging from 65 to 265) for dogs. There were two (0.4%) major anesthetic complications, one resulting in death. There were 206 (41.7%) minor anesthetic complications, the most common being hypothermia. There were 17 (3.3%) major surgical complications, the most common being body wall dehiscence (n=15), and 49 (9.5%) minor surgical complications, the most common being seroma formation (n=35). Complications were comparable to previous reports. Specific aspects of the program identified for improvement included placing greater emphasis on securely tying the terminal knot of a simple continuous suture pattern to prevent body wall dehiscence, improved measures to reduce post-operative hypothermia, and implementing stricter health screening of animals before enrollment into the program. Faculty program coordinators are encouraged to conduct similar studies so that best practices can be shared and outcomes can be compared as we work toward determining the ideal methods of training students to instill core surgical competencies.

Anesthesia can be safely provided for children in a high-field intraoperative magnetic resonance imaging environment

To describe the challenges associated with providing safe anesthesia and perioperative care for children in a remote intraoperative magnetic resonance (iMR) operating room (OR) and to identify perioperative anesthesia outcomes, including adverse events related to the iMR environment. Increasingly, children undergo neurosurgical procedures in a high-field iMR OR. We describe a 10-year experience of providing anesthesia for children in this environment with a mobile 1.5-Tesla magnet. A 10-year retrospective analysis was conducted of children who underwent neurosurgical procedures in a high-field mobile iMR OR. Primary outcomes related to perioperative adverse events and recovery profiles. Results were expressed as mean ± sd or median (range), as appropriate. One hundred and five procedures were performed on 98 children, aged 4 months-18 years, weighing 6-112 kg. The commonest two diagnostic categories were tumor (n = 52) and seizures (n = 27). Median anesthetic time was 439 (185-710) mins. There were no significant adverse events related to the iMR environment. The mean postanesthetic care unit admission temperature was 37 ± 0.9°C and the mean modified Aldrete Score at 30 mins was 7.2 ± 0.9. Two patients experienced seizures in the immediate postoperative period, readily controlled with propofol. There was one breach of MR safety protocol, and no adverse events related to patient transport. Anesthesia and perioperative care of children in an iMR setting were associated with a very low incidence of complications, despite the duration of the procedures involved. Such success depends upon a cohesive team-based approach.

Analgesic and antiemetic needs following minimally invasive vs open staging for endometrial cancer

We sought to assess perioperative outcomes of minimally invasive vs open endometrial cancer staging procedures. A total of 181 consecutive patients underwent open or minimally invasive hysterectomy with or without lymphadenectomy. Perioperative outcomes, analgesic, and antiemetic use were compared. In all, 97 and 84 women underwent open and minimally invasive staging procedures, respectively. In the open staging group, median anesthesia time was shorter (197 vs 288 minutes; P < .0001), but recovery room stay (168 vs 140 minutes; P = .01) and hospital stay (4 vs 1 day; P < .0001) were longer. Median narcotic (13 vs 43 mg morphine equivalents; P < .0001) and antiemetic (43% vs 25%; P = .01) use were lower for minimally invasive surgery in the first 24 hours postoperatively. Median estimated blood loss was lower for minimally invasive procedures (100 vs 300 mL; P < .0001). Minimally invasive staging for endometrial cancer is associated with lower use of narcotics and antiemetics, and shorter hospital stay compared to open procedures.

Case series: anesthesia for retrograde percutaneous aortic valve replacement — experience with the first 40 patients

Purpose: To describe both the evolution and the main associated complications in the anesthetic management of the initial 40 patients at our centre who underwent percutaneous retrograde aortic valve replacement, a novel technique utilizing a catheterguided femoral artery approach. Clinical features: With institutional Research Ethics Board approval, we retrospectively reviewed the medical records of the first 40 patients who underwent percutaneous retrograde aortic valve replacement between January 2005 and March 2006. Information obtained included patient characteristics, anesthetic management, details of the procedure, and complications. All procedures were scheduled to be performed in the cardiac catheterization laboratory. The first four patients received monitored anesthesia care, and the subsequent 36 underwent general anesthesia. There were no anesthesia-related adverse events. The prosthetic valve was placed successfully in 33/40 patients (83%). Median anesthetic time was 3.5 hr (range, 1.25–7.25 hr). Thirty-two/40 patients required vasopressor support. The most common, serious procedural complications were myocardial ischemia and arrhythmia following rapid ventricular pacing, hemorrhage from vascular injury secondary to the placement and removal of the large-bore sheath in the ilio-femoral artery, aortic rupture, and prosthetic valve maldeployment; 30-day mortality was 13% (n=5/40). Conclusions: Percutaneous retrograde aortic valve replacement is a novel procedure that presents the anesthesiologist with unique challenges. Careful preoperative assessment, intraoperative monitoring appropriate for a major vascular procedure, and meticulous management of hemodynamics are imperative for a successful outcome. Serious complications, including major hemorrhage from vascular injury as well as arrhythmia and myocardial ischemia following rapid ventricular pacing, must be anticipated and managed in an expeditious fashion.