Perioperative Considerations Research Articles

Cardiotoxicity and peri-operative considerations in immune checkpoint inhibitor and chimeric antigen receptor T-cell therapy: a narrative review.

Immunotherapy has transformed cancer treatment, particularly with immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy. Despite their efficacy, these therapies can induce cardiotoxicity, presenting significant clinical challenges. Immune checkpoint inhibitors can cause myocarditis; pericarditis; arrhythmias; and myocardial infarction through immune-mediated inflammation. Chimeric antigen receptor T-cell therapy may result in cardiovascular complications due to cytokine release syndrome, including myocardial dysfunction, endothelial damage and arrhythmias. We used PubMed, Embase and Google Scholar to search for peer-reviewed articles in September 2024 without setting any date limits. Our selection criteria encompassed studies focusing on cardiotoxicity related to immune checkpoint inhibitors or chimeric antigen receptor T-cell therapy, comprising original research, meta-analyses, clinical trials and review articles. The findings were reported narratively. Early diagnosis of cardiotoxicity is critical but challenging due to non-specific symptoms. Diagnostic tools include ECG; cardiac biomarkers; echocardiography; cardiac magnetic resonance imaging; and endomyocardial biopsy. However, no single tool is definitive. High-dose corticosteroids are the first-line treatment for immune checkpoint inhibitor-induced myocarditis, with additional immunosuppressive therapies for refractory cases. Standard heart failure management protocols should be followed in cases of heart failure. Tocilizumab and corticosteroids are utilised for chimeric antigen receptor T-cell therapy-induced cytokine release syndrome, alongside supportive care, including fluid resuscitation and vasopressors for severe cases. As the use of immunotherapy expands, understanding the mechanisms, risk factors and management strategies for cardiotoxicity is increasingly important. Collaborative efforts among oncologists, cardiologists and anaesthetists are essential to mitigate these risks, especially in peri-operative settings. Ongoing research is vital to improve the safe and effective use of immunotherapeutic drugs while minimising cardiovascular adverse effects.

Anaesthetic Management of a Neonate with Ebstein’s Anomaly Undergoing a Meningomyelocele Surgery: A Case Report

Ebstein’s Anomaly (EA) is a congenital heart defect characterised by the downward displacement of the posterior and septal leaflets of the tricuspid valve toward the right ventricular apex. Hereby the authors discuss a 16-day-old female neonate with EA who underwent surgery for a ruptured meningocele. The baby, born at full term, had an Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score of 7 at one minute and 9 at five minutes. Upon further observation, she showed multiple episodes of breath-holding and cyanosis. On examination, an enlarged head and swelling on the lumbar spine led to an ultrasound that confirmed hydrocephalus and meningocele. An Electrocardiogram (ECG) showed supraventricular tachycardia, and a chest X-ray revealed cardiomegaly. The diagnosis of EA was confirmed by two-dimensional (2D) echocardiography. General anaesthesia with inhalational induction was planned. Perioperative considerations for this patient included right-to-left shunting with the possibility of paradoxical emboli, prolonged onset time for intravenous drugs due to pooling and recirculation of blood in the right atrium, increased Pulmonary Vascular Resistance (PVR), perioperative pulmonary hypertension, right and left ventricular dysfunction, and arrhythmias. Key cardiovascular goals for this patient included maintaining normal sinus rhythm, ensuring adequate preload while avoiding significant changes in Systemic Vascular Resistance (SVR) or PVR, avoiding medications and factors that depress myocardial function, and promptly identifying haemodynamic instability or inadequate tissue perfusion with appropriate corrections. The surgery for excision and repair of the meningocele was uneventful, and the neonate was sent to the Neonatal Intensive Care Unit (NICU) for further monitoring.

Extension-block pinning versus custom-made plate fixation technique: A comparison of two methods in the treatment of osseous mallet finger injuries.

Mallet finger injuries, characterized by a flexion deformity caused by trauma to the extensor mechanism at the base of the distal phalanx, can lead to significant functional impairment if not treated appropriately. Surgical interventions for osseous mallet finger injuries often include techniques such as extension-block pinning and perioperative modifying plate fixation. When comparing these two methods, it is critical to assess factors such as technical ease, perioperative considerations, and postoperative outcomes. This study aims to compare these two techniques to provide valuable insights into the optimal surgical approach for treating osseous mallet finger injuries, improving patient care and outcomes. From 2017 to 2022, a retrospective study of 89 patients with Doyle classification type IVB and IVC mallet finger injuries was conducted. The patients were divided into two groups using a surgical technique called block randomization. Group 1 included 46 patients treated with the extension-block pinning fixation technique, while Group 2 comprised 43 patients treated with the perioperative modifying plate fixation technique. Observations included nail deformities and dorsal prominence at the distal interphalangeal (DIP) joint. All patients were deemed eligible for surgical intervention due to the time elapsed since injury or ineffectiveness of prior conservative treatment. No significant differences in patient demographics were observed between the two groups. While Crawford classification and pain scores showed no significant differences between the groups (p>0.05), the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score and time to return to work significantly favored Group 2, which underwent perioperative modifying plate fixation (p<0.05). Extension-block pinning is noted for its simplicity and favorable postoperative range of motion outcomes. In contrast, perioperative modifying plate fixation enhances stability and mechanical performance, positively impacting overall functional recovery. The choice between these techniques should consider procedural simplicity, perioperative demands, mechanical efficiency, and postoperative functional outcomes.

Cancer-Related Coagulopathy and Perioperative Considerations.

Cancer-related coagulation abnormalities are characterized by complex dysregulation of the hemostatic system, predisposing patients to increased risk of thrombotic and hemorrhagic complications and associated increased morbidity and mortality. Advances in anticancer therapies with improved outcomes have led to better survival and older age of patients living with or having survived cancer. There is also a significant increase in the number of patients diagnosed with cancer. All these factors will increase the number of patients presenting for surgical procedures, both cancer-related and noncancer related. It is important for the anesthesiologist to understand the magnitude of cancer-related coagulation derangement, its types, pathophysiology, and clinical presentation, to optimize the perioperative management of this high-risk rapidly growing patient population.

Perioperative considerations for patients exposed to hallucinogens

Hallucinogen exposure in patients in the perioperative period presents challenges for anesthesiologists and other anesthesia providers. Acute and chronic exposure to these substances can cause physiological impacts that can affect...

Perioperative Considerations for Hip Arthroplasty in Patients with Rheumatoid Arthritis.

Due to its distinct features, rheumatoid arthritis (RA), an inflammatory autoimmune disorder, poses challenges in planning for surgical interventions. This review includes available evidence regarding perioperative considerations in management of RA patients, with a focus on hip surgery. RA can affect multiple joints, with development of extra-articular manifestations; therefore, preoperatively, comprehensive medical assessments, including cardiovascular or pulmonary evaluation must be considered in addition to surgical considerations. Modification of medications capable of controlling RA-related disease activity is critical, and requires collaboration with rheumatologists. Surgical considerations include the choice of surgical approach, implant selection, and problems related to weakened soft tissues, fragile bone density, and bony deformity such as protrusio acetabuli. Careful monitoring and more active rehabilitation are recommended for RA patients due to higher risk of postoperative complications. For achievement of optimal outcomes, use of a multidisciplinary perioperative approach is required for patients with RA.

Perioperative Considerations in Patients with Rett Syndrome as Compared to Those with Cerebral Palsy.

Retrospective cohort study. This study aimed to compare perioperative outcomes of Rett syndrome and Cerebral palsy patients undergoing posterior spinal fusion for neuromuscular scoliosis. Surgical correction in the treatment of scoliosis for patients with Rett syndrome (RS) has been shown to increase survival rate. Cerebral palsy (CP) patients, like RS patients, are often nonverbal, nonambulatory, with frequent surgical complications. Retrospective review of 36 RS and 80 CP patients undergoing PSF from 2005-2023. Data and x-ray measurements were collected pre- and post-operatively. Sub-analysis was performed comparing non-ambulatory patients (GMFCS IV-V). Wilcoxon-Rank Sum, Fisher's Exact, and Chi-square tests were utilized. The primary outcome measure, complication rates, was similar between the groups (P=0.09). Preoperative Cobb angle, levels fused, fixation points, and LOS were similar (P>0.05). EBL was significantly higher in CP patients as was rate of transfusion (P=0.001) and surgical time (P=0.001). Postoperative Cobb angle (P=0.002) was significantly higher for CP patients. There was no significant difference between CP and RS patients in both preoperative (P=0.383) and postoperative (P=0.051) coronal decompensation. Nonambulatory status was associated with increased odds of having a postoperative complication (OR=6.17, 95% C.I. 1.36 - 28.04). Sub-analysis of non-ambulatory RS and CP patients revealed significantly higher postoperative Cobb (P=0.008), EBL (P=0.019) and surgical time (P=0.017) in CP patients compared to RS patients. There were no significant differences in preoperative Cobb, levels fused, fixation points, hospital stay, or complication rate (P>0.05). RS patients are shown to have better outcomes to CP patients in terms of surgical, perioperative, and radiographic variables. Ambulatory status was identified as an independent risk factor for complications.

Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation, A Retrospective Observational Cohort Study

ObjectivesTo summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF). DesignRetrospective observational study. SettingSingle center quaternary teaching hospital. ParticipantsAdult patients with atrial fibrillation undergoing the convergent procedure before January, 2024. InterventionsRetrospective chart review. Measurements/main resultsA total of 40 patients were included; of them 35 patients had persistent longstanding AF. The mean age (SD) was 64 (6) years and 33 patients (83%) were male. Common comorbidities included obesity 27 (68%), obstructive sleep apnea 29 (73%), history of tachycardia-mediated cardiomyopathy 10 (25%), and significant alcohol use 10 (25%). Sixteen of 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) required a cardioversion in the past. In all, 39 patients (98%) were anticoagulated and 38 (95%) were on at least 1 anti-arrhythmic medication prior to the procedure. All patients received general anesthesia; 39 patients (98%) inhalational and 1 patient (3%) total intravenous, with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of 40 patients (93%) were extubated in the operating room, and 11 (28%) of patients required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 and 4 days, respectively. ConclusionsThis retrospective analysis of medical records showed that many patients with recurrent atrial fibrillation presenting for convergent procedure carry a burden of multiple comorbidities (obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy, potentially complicated and requires meticulous preparation (endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population, while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and a possibility of cardiopulmonary bypass.

Challenges of Hip and Knee Arthroplasty in Patients With Osteopetrosis.

Osteopetrosis is a rare metabolic bone disease, characterized by dysfunction of osteoclasts, resulting in increased bone density and brittleness leading to pathological fractures and bone deformities. Hip and knee osteoarthritis (OA) are common long-term complications in patients with osteopetrosis. Joint arthroplasty surgery remains an effective and recommended treatment for these patients with an end-stage OA because it provides favorable outcomes. However, in osteopetrosis, joint arthroplasty surgery carries an increased risk of complications, and specific preoperative and perioperative considerations are required to deal with the technical challenges related to the disease. The aim of this article was to review some of the key aspects of osteopetrosis, provide technical recommendations, and answer clinically relevant questions related to hip and knee arthroplasty surgery.

Bariatric surgery in patients with obesity and end-stage heart failure with left ventricular assist devices: a brief guide

The prevalence of obesity is increasing worldwide, leading to a rise in several comorbidities, and is itself an important risk factor for heart failure. Patients with end-stage heart failure and obesity are often not eligible for heart transplantation (HT) and instead receive cardiac support from left ventricular assist devices (LVAD). In the absence of other contraindications, patients with obesity who are on LVAD support can lose enough weight to later qualify for HT. Bariatric surgery had been explored as an approach for weight loss in this patient population and was found to be a safe and effective option. One recent systematic review and meta-analysis has shown 67.4% of patients with LVAD support are able to be listed for transplantation after bariatric surgery and subsequent weight loss (95%CI: 0.477-0.871). Of these, 32.5% would go on to receive a heart transplant (95%CI: 0.201-0.448). There were also numerous cases of patients whose cardiac function improved after bariatric surgery such that they were delisted for HT and some had subsequent removal of their LVAD. There are many perioperative considerations when evaluating patients with LVADs for bariatric surgery. However, with careful patient selection by a multidisciplinary team and mindful preparation, patients with obesity and end-stage heart failure have an opportunity for longer years of life.

Nutrition support in children with medical complexity and chronic critical illness: A narrative review.

Children with medical complexity (CMC) and children with chronic critical illness (CCI) represent growing populations with high healthcare use and dependence on specialized care, both in the hospital and community setting. Nutrition assessment and delivery represent critical components of addressing the short-term and long-term health needs for these populations across the care continuum. This article provides a framework and reviews existing literature for the assessment of nutrition status and subsequent delivery of nutrition prescriptions in CMC and children with CCI. The specific aims are to (1) describe the epidemiology of health services experience for CMC and children with CCI, with a focus on their nutrition outcomes; (2) detail how to assess their nutrition status and energy requirements; (3) review methods of delivery of the nutrient prescription; (4) introduce perioperative considerations; (5) highlight examples of special populations of CMC and children with CCI; and (6) propose future research initiatives to improve nutrition and overall outcomes for these populations.

Perioperative considerations for non-cardiac procedures in patients with congenital heart disease: A practical overview

Providing thorough care for children with congenital heart disease (CHD) undergoing non-cardiac surgery requires a strong understanding of common heart defects and the procedures used to treat them. To care for these patients, multidisciplinary teams must consider the severity of the underlying cardiac disease, comorbid conditions, and preoperative severity of illness. The American Heart Association's Scientific Statement on Perioperative Considerations for Pediatric Patients with Congenital Heart Disease Presenting for Noncardiac Procedures offers valuable guidance.

Perioperative considerations in anesthesia for minimally invasive repair of pectus excavatum, Nuss procedure

Pectus excavatum (PE) is a common anterior chest wall deformity that affects the heart and lungs depending on the severity of compression. The Nuss procedure, a minimally invasive repair of pectus excavatum, has evolved over the years with thoracoscopic assistance and minimal incision. Despite improved surgical techniques, pain and nausea are often the most common factors determining hospital length of stay. This review will explore the preoperative, intraoperative, and postoperative anesthetic considerations necessary for improving patient outcomes, reducing surgical stress, and shortening hospital stays for patients undergoing the Nuss procedure.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations.

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients.To address thischallenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung TransplantationStandards and Guidelines Committee.International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods.Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria.These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

Perioperative considerations in anesthesia for pediatric bariatric procedures

Obesity is a global epidemic affecting a broad range of individuals, regardless of economic and social strata. In 2022, the World Health Organization (WHO) reported that 16 % of adults and 160 million children were living with this condition. The economic impact is significant, with a recent Milken report estimating the annual cost of obesity in the US at 1.4 trillion dollars, accounting for almost 7 % of the United States gross domestic product. It is widely recognized that the most severe forms of pediatric obesity (120 % of the 95th percentile for age and sex) represent an epidemic within an epidemic, given their potential for diminished long-term health and shortened lifespan. The treatment paradigm for obesity covers a range of approaches, with the American Academy of Pediatrics (AAP) recommending behavior and lifestyle modification as initial components of care. Since 2004, bariatric surgery has increasingly been utilized as an additional option for treating adolescent obesity, as long-term findings have shown sustained reductions in BMI and improvements in comorbid conditions. For anesthesiologists, these patients present specific challenges that require review.

Management of von Willebrand disease for orthognathic surgery: Evidenced-based recommendations and scoping review of the literature

BackgroundThe general management of von Willebrand Disease has evolved over the past several decades. Advances in blood product replacement manufacturing have led to changes in perioperative management of the bleeding diathesis in its various subtypes. Surgical management follows changes in medical management, but unique perioperative considerations exist depending on the type of surgery. Orthognathic surgery is considered a major surgery that can have life-threatening complications in patients with von Willebrand Disease (vWD) and updates in evidenced-based management are presented. ObjectivesThe objectives of this report are to review available literature regarding management of patients with von Willebrand Disease and other bleeding disorder undergoing orthognathic surgery and to provide a case report regarding the management of a patient vWD type 2M undergoing orthognathic surgery. Eligibility criteriaArticles included for review were studies addressing patients with bleeding disorders undergoing orthognathic surgery. Sources of evidencePubMed and Ovid were queried using the terms “orthognathic surgery OR jaw deformity” AND “von Willebrand OR bleeding disorders OR hemophilia.” Additional references relevant to the review were obtained from the reference lists of available articles ultimately deemed appropriate for inclusion in the review. MethodsA recent example case of a patient with type 2M vWD undergoing orthognathic surgery and the patient's perioperative management is presented for consideration. A scoping review of the literature was undertaken for evaluation of available literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR). ResultsInsufficient evidence exists for significant analysis of perioperative management strategies previously reported compared to the currently utilized management strategy for the case presented. A review of the available literature with reference to updated literature regarding management of patients with vWD undergoing surgical procedures other than orthognathic surgery yields primarily case reports, two randomized controlled trials, and one systematic review. The results indicate that an evolution in the general management of patients with vWD undergoing surgery can be applied to patients undergoing orthognathic surgery and that the addition of hemostatic agents such as tranexamic acid may be considered with a low level of evidence. ConclusionsFor patients undergoing orthognathic surgery, the use of cryoprecipitate in large quantities has been replaced with the use of Humate-P infusion and will likely be replaced with the use of recombinant von Willebrand factor (VWF). The timing of infusion of adjuncts preoperatively for patients with vWD can potentially be extended to the previous day, and the addition of medications to aid in hemostasis such as tranexamic acid may be considered. Prophylactic use of additional VWF adjuncts should be considered in the postoperative setting, and close monitoring is prudent. The use of newer agents may allow for the expansion of craniomaxillofacial surgery procedures that can be safely considered in patients with vWD.

Perioperative Considerations for ASD Device Closure in the First Trimester: A Case of Secundum ASD with Bidirectional Shunt

Introduction: Atrial septal defect (ASD) closure during pregnancy is a complex procedure requiring careful consideration of maternal and fetal risks. This case report highlights the perioperative management of a secundum ASD with a bidirectional shunt in a patient during her first trimester. Case presentation: A 31-year-old woman, G3P2A0, presented at approximately 10-11 weeks gestation with a recently diagnosed large secundum ASD and pulmonary hypertension. She was on Sildenafil and Bisoprolol. Due to the potential risks associated with an unrepaired ASD during pregnancy, the decision was made to proceed with percutaneous ASD closure. General anesthesia was administered with meticulous hemodynamic monitoring. The procedure was successful, and the patient recovered without complications. Conclusion: ASD closure during the first trimester can be safely performed with careful planning and execution. Multidisciplinary collaboration and vigilant monitoring are crucial for optimal maternal and fetal outcomes.

GLP-1 Receptor Agonists: Beyond Diabetes—What the Neurosurgeon Needs to Know

BACKGROUND AND OBJECTIVES: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have gained increasing popularity since the approval of semaglutide by the United States Food and Drug Administration for chronic weight management. Significant benefits have been noted in glycemic control and cardiovascular health. However, as increasing numbers of patients are started on these medications, it is important for neurosurgeons to have knowledge of any perioperative considerations and side effects related to this class of drugs. METHODS: We performed a qualitative literature review using the PubMed and Embase databases, using the following key words: GLP-1 RAs adverse events; GLP-1 RAs and anesthesia; substance use disorders; and addiction, functional neurosurgery, nervous system rehabilitation, and spinal cord injury. Articles of relevance to perioperative management of these medications and specific benefits in the neurosurgical field were discussed. RESULTS: Recent guidance from the American Society of Anesthesiologists demonstrates the importance of tailored management of GLP-RA drugs for surgical patients. In addition, certain positive effects have been noted with relation to substance use disorders, neural protection and rehabilitation, and neurodegenerative disorders such as Alzheimer's disease. CONCLUSION: In this article, we review what the neurosurgeon needs to know about the perioperative management of GLP-1 RAs and discuss existing literature in clinical and preclinical studies for potential indications and benefits of these medications, which can influence the management of conditions treated by neurosurgeons.

Thorough perioperative and anesthetic considerations for cerebellar syndrome induced by posterior fossa tumors

Posterior fossa tumors are relatively rare pathologies, predominantly observed in pediatric populations. Nevertheless, there have been documented cases in adults, where these tumors are often associated with a higher prevalence of vascular lesions compared to those found in children. Given the inherent high mortality risk associated with this condition, meticulous anesthetic management is paramount. A comprehensive evaluation of patient-specific factors, including existing comorbidities, hemodynamic stability, and neurological status, is essential. Moreover, perioperative considerations such as patient positioning, the choice of anesthetic technique, and the duration of the surgical procedure must be carefully planned to optimize outcomes. This article presents a case review of a young adult patient with no significant medical history who was diagnosed with a posterior fossa tumor. The discussion encompasses the anatomical considerations of this pathology, critical preoperative assessments, anesthetic strategies tailored to this surgical context, and an analysis of the patient’s postoperative course.

More than pacemakers and defibrillators: perioperative management of implantable devices for patient safety.

The use of implantable medical devices (IMDs) continues to increase with estimates that 10% of the American population will have an IMD in their lifetime. IMDs require special considerations for management in the perioperative period to ensure optimal patient care and patient safety. This review summarizes the current perioperative considerations for IMDs. This review summarizes perioperative recommendations for spinal cord stimulators, deep brain stimulators, peripheral nerve stimulators, vagus nerve stimulators, muscle stimulators, intrathecal drug delivery systems, implantable infusion pumps, artificial pancreas devices, continuous glucose monitors, and cochlear implants. There are multiple publications and guidelines regarding the perioperative considerations of cardiac implantable electronic devices; thus, this review excludes those devices. This review includes recommendations on management of the device perioperatively, the potential complications, and postoperative care of the device. There are very few guidelines regarding the perioperative management of IMDs. Given the significant impact that these devices have on patient care and safety, evidence-based guidelines should be established.