Perioperative Anesthetic Management Research Articles

Anesthetic management of a patient with congenital cyanotic heart anomaly for emergency surgery: A case report

Among congenital cyanotic heart diseases (CHDs), situs inversus totalis with transposition of great vessels with a large ventricular septal defect (VSD) has a very low incidence of around 1 in 10,000. Hereby, we present a 16-year-old man with the aforementioned cardiac anomaly with cardiac arrhythmias, septic shock, and a history of road traffic accident-causing osteomyelitis of the left thigh requiring incision and drainage. The patient was admitted to the intensive care unit with a high-grade fever, narrow pulse pressure, and atrial fibrillation. The patient was operated on under general anesthesia with endotracheal intubation after optimization. Invasive monitoring, antiarrhythmics, and vasopressors were required intraoperatively, and surgery progressed uneventfully. Furthermore, the patient had undergone a series of debridements after 8 days, which were performed under regional anesthesia uneventfully. This case report represents a plan of action for perioperative anesthetic management and anticipates the difficulties for CHD patients in the course of surgery and subsequential prudence.

Anaesthetic Management for a Dilated Cardiomyopathy Patient, Scheduled for Lumbar Spine Surgery

Background: Dilated cardiomyopathy (DCM) is characterized by dilatation and impaired contraction of left or both ventricles. Diagnostic criteria are left ventricular ejection fraction less than 40% or fractional shortening less than 25%. Perioperative anesthetic management of these patients are very challenging for anesthesiologists and intensive care team. Case presentation: A 55-year-old female, presented with complaints of severe low-back ache with bilateral lower limb involvement without involvement of bladder and bowel. Severe cord compression at the L4-5 level and severe lumbar canal stenosis were detected by magnetic resonance imaging. Echocardiography showed that the left ventricle (LV) had global hypokinesia, with an ejection fraction of 25% to 30%. The planed surgical procedures were L4 lumbar laminectomy and L4-5 microdiscectomy. Conclusion: Continuous monitoring and control of hemodynamic parameters as well as central venous pressure guided fluid therapy is the cornerstone in improving outcome in patients with dilated cardiomyopathy for non-cardiac surgery.

The Effect of Intra-abdominal Pressure on Heart Rate Variability and Hemodynamics During Laparoscopic Cholecystectomy: A Prospective Observational Study.

Introduction This study aimed to evaluate hemodynamic changes using heart rate variability (HRV) measurements in diabetic and nondiabetic patients who will undergo laparoscopic cholecystectomy and to provide our preoperative measurements to guide us for better perioperative anesthesia management. Materials and methods The study included 143 patients aged 40 years and older who would undergo elective laparoscopic surgery, did not have any comorbidities other than diabetes mellitus (DM) type II, and were in theAmerican Society of Anesthesiologists(ASA) class I-III risk group. Patients were divided into two groups: the control group (n = 77) and the DM group (n = 66). The preoperativeglycated hemoglobin (HbA1C) level was measured. Peripheral oxygen saturation (SpO2) and hemodynamic parameters such as systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), and HRV parameters were measured preoperatively, perioperatively, and postoperatively. Intra-abdominal pressure (IAP) was administered at 10-12 mmHg. Results Even though SAP, DAP, MAP, and HR decreased with induction, they increased with insufflation, and an overall decrease was seen at the postoperative 24th hour for all parameters. When the groups were evaluated, no difference was observed except that the DAP was significantly lower in the DM group (p = 0.029) at insufflation and the HR was higher in the DM group at induction, and the difference was significant (p = 0.001). Preoperative HRV parameters were significantly lower in the DM group. According to the HRV parameters, although a decrease was observed after induction and insufflation, conversely, an increase was observed postoperatively. When the postoperative and preoperative values were compared, the standard deviation of the NN (R-R) intervals (SDNN), SDNN index, high frequency (HF), low frequency (LF), and LF/HF parameters were found to be significantly lower in the DM group than in the control group. Conclusion Diabetic patients are more sensitive to increased intra-abdominal pressure (IAP) in laparoscopic surgery, and the effects on cardiac autonomic functions can be determined by HRV measurements without clinically reflecting on hemodynamic data. Additionally, in diabetic patients with preoperative LF and/or HF values less than 100, we believe that careful follow-up in terms of autonomic neuropathy complications and anesthesia management should be done more meticulously in these patients.

Preoperative Echocardiogram Does Not Contribute to Surgical Risk Assessment in Patients With Large Curve Scoliosis and No Cardiac Risk Factors.

Severe scoliosis can affect thoracic organs, potentially leading to cardiovascular abnormalities. Thus, echocardiograms have been suggested for use in preoperative screening in patients with significant scoliosis. However, the utility of preoperative heart screenings in patients without known or suspected heart problems is not well understood. This study aims to find the incidence of cardiac findings in patients with severe scoliosis ≥90° without cardiac history. A single-institution retrospective chart review was performed. Inclusion criteria were scoliosis patients with curves ≥90 degrees and a screening echocardiogram performed within 6 months of spine surgery. Patients with a previous cardiac history, diagnosis associated with cardiac comorbidities (eg, connective tissue disease), or major coronal curves <90 degrees were excluded. Echocardiogram reports and perioperative clinical notes from involved services (including orthopaedics, cardiology, and anesthesia) were reviewed. Any postoperative use of vasopressors and reasons for their use were recorded. Overall, 50 patients met the inclusion criteria. The mean age at surgery was 14.0 ± 4.9 years old (range: 2 to 33). The mean major curve was 108 ± 19 degrees (range: 90 to 160 degrees). A normal echocardiogram was seen in 38 (76%), whereas 6 patients (12%) had mild dilation of the aortic sinus or root, 4 (8%) had mild valvular regurgitation, 1 patient had a small atrial septal defect, and 1 had a trace pericardial effusion. No patient had any changes made to their perioperative plan and one patient was advised to see a cardiologist postoperatively. Postoperatively, 8 patients (16%) received vasopressors to raise blood pressure to meet preset goal MAP, but only one of these 8 had a positive echocardiogram (mild valvular insufficiency), which was not seen as a contributing factor to the use of pressors. This study suggests that screening echocardiograms for patients without a cardiac history or related symptoms does not contribute to the evaluation of perioperative risk or anesthetic management. Creating clear, evidence-based guidelines for the utilization of perioperative testing, like echocardiograms, can reduce the social, time, and financial burdens on families. Such guidelines are vital for appropriate risk assessment and proper utilization of health care resources. Level III.

A survey of practice in the anesthetic management of adolescent idiopathic scoliosis spine fusion by the North American Pediatric Spine Anesthesiologists Collaborative.

Adolescent Idiopathic Scoliosis (AIS) affects 2%-4% of the general pediatric population. While surgical correction remains one of the most common orthopedic procedures performed in pediatrics, limited consensus exists on the perioperative anesthetic management. To examine the current state of anesthetic management of typical AIS spine fusions at institutions which have a dedicated pediatric orthopedic spine surgeon. A web-based survey was sent to all members of the North American Pediatric Spine Anesthesiologists (NAPSA) Collaborative. This group included 34 anesthesiologists at 19 different institutions, each of whom has a Harms Study Group surgeon performing spine fusions at their hospital. Thirty-one of 34 (91.2%) anesthesiologists completed the survey, with a missing response rate from 0% to 16.1% depending on the question. Most anesthesia practices (77.4%; 95% confidence interval [CI], 67.7-93.4) do not have patients come for a preoperative visit prior to the day of surgery. Intravenous induction was the preferred method (74.2%; 95% CI 61.3-89.9), with the majority utilizing two peripheral IVs (93.5%; 95% CI 90.3-100) and an arterial line (100%; 95% CI 88.8-100). Paralytic administration for intubation and/or exposure was divided (51.6% rocuronium/vecuronium, 45.2% no paralytic, and 3.2% succinylcholine) amongst respondents. While tranexamic acid was consistently utilized for reducing blood loss, dosing regimens varied. When faced with neuromonitoring signal issues, 67.7% employ a formal protocol. Most anesthesiologists (93.5%; 95% CI 78.6-99.2) extubate immediately postoperatively with patients admitted to an inpatient floor bed (77.4%; 95% CI 67.7-93.3). Most anesthesiologists (87.1%; 95% CI 80.6-99.9) report the use of some form of an anesthesia-based protocol for AIS fusions, but our survey results show there is considerable variation in all aspects of perioperative care. Areas of agreement on management comprise the typical vascular access required, utilization of tranexamic acid, immediate extubation, and disposition to a floor bed. By recognizing the diversity of anesthetic care, we can develop areas of research and improve the perioperative management of AIS.

Anesthesia for lung transplantation in children under 12 years of age: a single center experience of China

PurposeThis study aims to provide a comprehensive overview of anesthesia management strategies employed in pediatric lung transplantation.MethodsA retrospective analysis was conducted on data from 14 pediatric patients who underwent lung transplantation at the Wuxi Center between September 2019 and November 2022. Patient demographics, surgical particulars, airway management, utilization of extracorporeal support, fluid administration, blood gas and electrolyte profiles, and postoperative outcomes were systematically documented and subsequently summarized.ResultsOf the 14 patients, 7 received extracorporeal membrane oxygenation (ECMO) and 1 received cardiopulmonary bypass (CPB). The average operation time was 303 ± 53 min, with the median extubation time of 26 h. The entirety of pediatric lung transplant procedures was executed successfully, resulting in the discharge of thirteen patients postoperatively. Regrettably, one patient died due to infectious shock on the fourth postoperative day.ConclusionThe achievement of successful pediatric lung transplantation necessitates effective perioperative anesthesia management, with a focal emphasis on circulatory control. Real-time measurements serve as the cornerstone for decision-making. Proactive administration of vasoactive agents is integral to sustaining hemodynamic stability. The judicious assessment of ECMO necessity is paramount, favoring central ECMO during the surgical intervention.

Perioperative analgesic management in patients with bladder exstrophy: A clinical study

Background: Bladder exstrophy is a complex, rare congenital malformation with an incidence of 3.3 cases in every 100000 live births and is slightly more common in males. Primary surgical repair requires many hours of surgery with fluid and blood loss. Because of wide fluctuations in hemodynamics, a longer duration of surgery, smaller age, risk of hypothermia and post-operative intensive care may be required. We evaluated the use of continuous caudal epidural infusion of bupivacaine and fentanyl under general anesthesia for urinary bladder exstrophy-epispadias surgery in children. Aims and Objectives: Aim of the study was to evaluate the postoperative analgesia in patients undergoing surgery for bladder exstrophy. The primary objective was to assess the postoperative pain using FLACC scale and sedation score after successful caudal administration. Secondary objective was to assess the hemodynamic changes after caudal administration. Materials and Methods: A total of 13 patients aged between 9months and 13 years of either sex, weighing between 5kg to 30kg, belonging to ASA grade II to IV, underwent surgery for epispadias–exstrophy complex. Initial bolus 0.75ml/kg of 0.25% bupivacaine with fentanyl 1ug/kg was given through epidural. Postoperative analgesia was maintained by continuous infusion of 0.0625% bupivacaine @0.1ml/kg/hr in young children and 0.125% bupivacaine with fentanyl 1ug/ml in older children for 4-5 days with the help of ON-Q pump or infusion pump. Baseline hemodynamic parameters including MAP, heart rate and SpO2 was recorded at various time intervals. Postoperative pain was assessed using face, legs, activity, cry and consolability (FLACC) pain scale and sedation score was assessed by using ramsay sedation score. Results: There was a statistically significant decrease in mean pulse rate in the study group from baseline to thirty minutes after reversal (p&lt;0.001). Similar observation was made for mean arterial pressure which also showed statistically significant decrease from baseline to thirty minutes after reversal (p&lt;0.001). No change was observed in SpO2 from baseline to any other follow-up interval. Conclusion: Perioperative anesthetic and analgesic management of the bladder exstrophy patient can improve the success rate. Epidural bupivacaine with or without fentanyl infusions for short duration can provide safe analgesia.

Anaesthesia Management of Child with Congenital Cystic Adenomatoid Malformation Posted for Lobectomy

Congenital cystic adenomatoid malformation (CCAM) is a benign lung lesion that appears before birth as a cyst or mass in the chest. It is made up of abnormal lung tissue that does not function properly, but continues to grow. These lesions compress the adjacent normal lung tissues. CCAMs occur sporadically, and there is no genetic predisposition. They are usually unilobed and unilateral, with arterial supply and venous drainage from the pulmonary circulation. The postnatal management of symptomatic CCAM varies on whether the patient has respiratory distress or is asymptomatic. Symptomatic patients require a lobectomy or pneumonectomy. Perioperative anaesthetic management is challenging because it involves thoracotomy in a young patient that may lead to hemodynamic compromise and inadequate ventilation.

Attenuation of intestinal ischemia-reperfusion-injury by anesthetics: a potentially protective effect of anesthetic management in experimental studies.

Intestinal ischemia-reperfusion injury (IRI) is a potentially severe clinical syndrome after major surgical procedures. In addition to causing intestinal mucosa injury, intestinal IRI further damages distant organs, causing the severity of the condition in patients. So far, effective therapy for intestinal IRI is still absent, and the survival rate of the patients is low. Previous experimental studies have shown that some anesthetics can alleviate intestinal IRI and protect organs while exerting their pharmacological effects, indicating that reasonable perioperative anesthesia management may provide potential benefits for patients to avoid intestinal IRI. These meaningful findings drive scholars to investigate the mechanism of anesthetics in treating intestinal IRI in-depth to discuss the possible new clinical uses. In the present mini-review, we will introduce the protective effects of different anesthetics in intestinal IRI to help us enrich our knowledge in this area.

Perioperative management of kidney transplantation in China: A national survey in 2021.

Perioperative anaesthesia management has an important significance for kidney transplantation; however, the related consensus remains limited. An electronic survey with 44 questions was developed and sent to the chief anaesthesiologist at 115 non-military medical centres performing kidney transplantation in China through WeChat. A response rate of 81.7% was achieved from 94 of 115 non-military medical centres, where 94.4% of kidney transplants (10404 /11026) were completed in 2021. The result showed an overview of perioperative practice for kidney transplantations in China, identify the heterogeneity, and provide evidence for improving perioperative management of kidney transplantation. Some controversial therapy, such as hydroxyethyl starch, are still widely used, while some recommended methods are not widely available. More efforts on fluid management, hemodynamical monitoring, perioperative anaesthetics, and postoperative pain control are needed to improve the outcomes. Evidence-based guidelines for standardizing clinical practice are needed.

Laser Interstitial Thermal Therapy (LITT) for Neurosurgical Procedures: Facts You Need to Know About the Anesthetic Management of LITT Procedures.

The field of medicine is constantly advancing to improve patient care. As physicians, we must improve our knowledge by listening, reading, and practicing evidence-based medicine. Laser treatment has evolved over the years in many surgical specialties. Laser interstitial thermal therapy (LITT), also known as stereotactic laser ablation (SLA), was developed in neurosurgical procedures to treat recurrent or metastatic brain tumors, radiation necrosis, and epilepsy lesions. LITT procedures are advantageous in providing better patient outcomes, decreased hospital length of stay, and reduced total hospital cost. These procedures are performed as a multi-disciplinary approach; this article discusses the different types of LITT systems, indications, contraindications, types of anesthesia, perioperative anesthetic management,safety precautions, complications, recovery during and after LITT procedures, and the future of LITT procedures.

Clinical characteristics and anaesthetic management of severe scoliosis patients with spinal muscular atrophy: case series

Introduction and importance: There is no expert consensus or guidance on perioperative anaesthesia management for spinal surgery of spinal muscular atrophy (SMA) patients with severe scoliosis (Cobb≧90°). We provide a comprehensive summary of the perioperative characteristics observed in patients with SMA and propose an optimized perioperative management strategy for anaesthesia. Methods: This study is a retrospective single-centre research. Twenty-six SMA patients with severe scoliosis underwent posterior spinal fusion surgery from September 2019 to September 2022 were enroled. The main outcomes were to show the patients’ characteristics in anaesthesia, intra- and post-operative periods. Outcomes: Nineteen patients underwent awake transnasal/transairway intubation. The median anaesthesia time of 25 patients treated under total intravenous anaesthesia was 425 min. After operation, the Cobb angle and correction rate in the coronal plane were median 54.0° and 54.4%. The length of mechanical ventilation with endotracheal intubation in ICU was median 17.5 h in 8 patients. The ICU length of stay of postoperative hospital was median 19 days. Postoperative pneumonia developed in nine patients, atelectasis in two patients, and pleural effusion in six patients. All patients did not need special oxygen therapy after discharge. Conclusion: Multidisciplinary consultation, lung-protective ventilation strategy, appropriate anaesthetic drugs and reasonable blood transfusion scheme and postoperative monitoring were important in anaesthesia, intraoperative and postoperative periods in the patients of severe scoliosis with spinal muscular atrophy.

Surgical Video Projection onto a Mannequin: An Educational Tool for Simulation Practice of Perioperative Anesthetic Management.

Simulation practice is known to be effective in anesthesiology education. In our simulation practice of general anesthesia for open cholecystectomy at the Tohoku University simulation center, we projected a surgical video onto a mannequin's abdomen. In this observational study, we investigated whether video-linked simulation practice improved students' performance. We retrospectively compared the general anesthesia simulation practice scores of fifth-year medical students in a video-linked or conventional group. In the simulation practice, we evaluated the performance of each group in three sections: perioperative analgesia, intraoperative bleeding, and arrhythmia caused by abdominal irrigation. The primary endpoint was the total score of the simulation practice. The secondary endpoints were their scores on each section. We also investigated the amount of bleeding that caused an initial action and the amount of bleeding when they began to transfuse. The video group had significantly higher total scores than the conventional group (7.5 [5-10] vs. 5.5 [4-8], p = 0.00956). For the perioperative analgesia and arrhythmia sections, students in the video group responded appropriately to surgical pain. In the intraoperative bleeding section, students in both groups scored similarly. The amount of bleeding that caused initial action was significantly lower in the video group (200 mL [200-300]) than in the conventional group (400 mL [200-500]) (p = 0.00056).Simulation practice with surgical video projection improved student performance. By projecting surgical videos, students could practice in a more realistic environment similar to an actual case.

Preoperative preparation and postoperative care in children in thoracic surgery.

Anesthesia for pediatric patients undergoing thoracic surgery continues to be distinctive due to differing anatomical and physiological characteristics compared to adults. Adequate preoperative preparation, appropriate tool selection for providing one-lung ventilation, perioperative pain management, and a multidisciplinary approach can ensure higher quality postoperative care. In this review, the perioperative anesthesia management for pediatric patients undergoing thoracic surgery will be discussed, starting from the preoperative preparation phase. Additionally, the issues related to the application and management of one-lung ventilation will also be assessed.

Perioperative and Anesthetic Considerations in Shone's Complex.

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Removal of Bronchial Thrombus and Perioperative Anesthetic Management in a Cardiac Case: A Case Report

A 63-year-old male with a history of Rheumatic heart disease with post-balloon mitral valvuloplasty (BMV) presented with a carcinoid tumor of the right lower lobe, posted for lobectomy plus regional lymph node resection. Anesthetic challenges and management of this patient is well described here. A rare post-operative complication i.e, blood clots in the bronchus, resulting in hypoxia and desaturation was found during the extubation time. Handling such complications with a bronchoscope is also discussed in this case report.

Impact of Adverse Childhood Experiences on Health-Related Outcomes in Adults: Potential Implications for Perioperative Anesthetic Management

Impact of Adverse Childhood Experiences on Health-Related Outcomes in Adults: Potential Implications for Perioperative Anesthetic Management

Perioperative anaesthesia management of renal transplant recipients - A national cross-sectional survey.

Perioperative anaesthesia management of renal transplant recipients - A national cross-sectional survey.

PERSUADE Survey—PERioperative AnestheSia and Intensive Care Management of Left VentricUlar Assist DevicE Implantation in Europe and the United States

ObjectiveTo comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DesignProspective data analysis. SettingOnline survey. ParticipantsLVAD-centers in Europe and the United States. InterventionsAfter investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and post-operative intensive care aspects. Measurements and Main ResultsThe survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years’ experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was more often used for maintenance in Europe (p<0.001). Choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and US). Use of quantitative methods for defining right ventricular function was reported more often from European compared to US centers (p<0.05). Temporary mechanical circulatory support for treatment of right ventricular failure was more often used in Europe. Nitric oxide appears to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European vs. US centers. ConclusionsDespite the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.

Anesthetic Considerations in Multisystem Inflammatory Syndrome in Children: A Case Series

Multisystem inflammatory syndrome in children (MIS-C) is an immune response inciting multiorgan dysfunction and a shock-like state which is typically seen in children 2 to 6 weeks after either a coronavirus disease-19 infection or exposure. When such a child comes for any surgery, perioperative anesthetic management demands multidisciplinary involvement and individualized case-based decision-making. Due to the novelty of the condition, there are limited data on anesthetic implications in these patients. Anesthetic management in the affected children is dynamic depending on the organ systems involved and the progression of the disease state. Though the long-term effects of the syndrome are largely unknown, we hope that awareness of the MIS-C-associated complications may help anesthesiologists involved in childcare. Herein, we put forward challenges and clinical dilemmas we faced during the anesthetic management of three children with MIS-C presenting for emergency and elective surgery.