Perioperative Considerations Research Articles

Modifying the Stress Response - Perioperative Considerations and Controversies.

The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.

Cancer Immunotherapies: What the Perioperative Physician Needs to Know

Purpose of ReviewFor patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents.Recent FindingsThe perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immune-related adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth.SummarySurgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.

Considerations for Cannabinoids in Perioperative Care by Anesthesiologists.

Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.

The Changing Face of Cystic Fibrosis: An Update for Anesthesiologists.

Cystic fibrosis (CF) is the most common fatal genetic disease in North America. While CF is more common among Whites, it is increasingly being recognized in other races and ethnicities. Although there is no cure, life expectancy has steadily improved, with the median survival exceeding 46 years in the United States. There are now more adults than children with CF in the United States. CF is caused by mutations in a gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR) protein, expressed in many epithelial cells. More than 2100 CFTR mutations have been linked to CF, and newer CFTR modulator drugs are being used to improve the production, intracellular processing, and function of the defective CFTR protein. CF is a multisystem disease that affects primarily the lungs, pancreas, hepatobiliary system, and reproductive organs. Anesthesiologists routinely encounter CF patients for various surgical and medical procedures, depending on the age group. This review article focuses on the changing epidemiology of CF, advances in the classification of CFTR mutations, the latest innovations in CFTR modulator therapies, the impact of the coronavirus disease pandemic, and perioperative considerations that anesthesiologists must know while caring for patients with CF.

Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines.

Purpose:Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications.Methods:Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication.Results/Conclusions:Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient’s individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient’s thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient’s internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.

Aducanumab, the Novel $56,000 Drug: Perioperative Considerations

Aducanumab, the Novel $56,000 Drug: Perioperative Considerations

OHVIRA syndrome obstetric patient for lower segment caesarean section: peri-operative considerations

OHVIRA syndrome is a rare congenital developmental condition manifested by uterus didelphys, lower genital tract obstruction and unilateral renal anomaly. We report a rare case of a full term obstetric patient with OHVIRA syndrome, posted for elective lower segment caesarean section. Peri-operative anaesthetic considerations in a patient with this syndrome have been described. The importances of systemic preoperative assessment and investigations to rule out associated anomalies have also been highlighted.

Management of a Critically Ill Patient With Severe Hypertrophic Obstructive Cardiomyopathy Presenting for Emergent Craniotomy Due to Subdural Hemorrhage

Hypertrophic obstructive cardiomyopathy (HOCM) is an inherited cardiac disorder characterized by asymmetric thickening of the myocardium, most commonly of the interventricular septum. Perioperative considerations for patients with HOCM undergoing surgical procedures are discussed, so as to avoid worsening the existing left ventricular outflow tract (LVOT) obstruction, leading to potential cardiovascular collapse. Of particular interest is managing these patients when confronted with vascular aneurysmal disease or hemorrhagic comorbidities with conflicting hemodynamic goals. In this case report, we present the case of a 77-year-old female with known HOCM and severe LVOT obstruction, presenting with intracranial hemorrhage (ICH), acute on chronic subdural hematoma, and potential cerebral aneurysm, undergoing decompressive craniectomy and hematoma evacuation. Anesthetic management of a patient with HOCM presenting for emergent ICH can be challenging given the complex hemodynamic management goals, often conflicting with a patient's comorbidities. Here we describe the prioritization of the patient's underlying HOCM pathology and favored maintenance of afterload given the potentially lethal risk of cardiovascular collapse if LVOT obstruction was encountered.

Perioperative considerations in the treatment of endometriosis

Endometriosis is one of the most common benign diseases in women of reproductive age. Nearly all gynecological offices and clinics will contain patients with endometriosis; the frequency and severity of the disease will vary from one setting to another. Adjoining specialties, such as internal medicine, general medicine, surgery, urology, orthopedics, neurology and psychosomatic medicine, will be challenged directly or indirectly by various forms of endometriosis and its sequelae. The disease is characterized by pelvic pain, dysmenorrhea, dyspareunia and sterility. Even now, several years may elapse between the onset of the disease and its diagnosis. The diagnosis of endometriosis is complicated by the diversity of the symptoms. A precise documentation of the patient’s medical history and thorough diagnostic procedures are essential to establish a robust diagnosis. This article will discuss the perioperative considerations, diagnosis and treatment of endometriosis.

Perioperative Management of Ehlers-Danlos Type III Syndrome Associated With Postural Orthostatic Tachycardia in Patients Undergoing General Anesthesia

Ehlers-Danlos syndrome (EDS) is an autosomal dominant inherited disorder of connective tissue with common clinical features of skin hyperelasticity, joint hypermobility, and easy bruising. Postural orthostatic tachycardia syndrome (POTS) refers to more than three months of a sustained increase in heart rate of more than 30 beats per minute and symptoms of orthostatic intolerance within 10 minutes of assuming a standing position without associated hypotension. These medical conditions can be associated with each other, potentially creating significant perioperative challenges. This paper describes two cases of young women with POTS and EDS hypermobility type (III) who presented for surgery under general anesthesia. The anesthesiologist performed an extensive preoperative evaluation, provided adequate preoperative hydration, ensured careful positioning during anesthetic induction, and avoided neck hyperextension during intubation. Gentle emergence and extubation were practiced with vigilance towards complications of cervical subluxation and airway mucosal injury. Robust communication between postoperative caregivers was prioritized. All these considerations facilitated the achievement of good outcomes. Here, a literature review and subsequent flow diagram of the anesthetic management and perioperative considerations for these patients is purposed.

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

Demystifying α-gal syndrome: identification and risk management in the perioperative setting.

α-Gal syndrome is among a vexing perioperative consideration for anesthesiologists. Commonly referred to as 'red meat allergy', α-Gal syndrome is precipitated by a lone star tick bite resulting in the formation of immunoglobulin E (IgE) antibodies against the tick salivary glycoproteins and noncatarrhine mammalian tissue. Up to 20% of the population in the southeastern United States may test positive for IgE antibodies to α-Gal. Increasingly, recognition of α-Gal syndrome as an immune response to red meat consumption and certain drugs, many of which may be administered within the perioperative period, has led to greater awareness of the insidious nature of its presentation - from mild urticaria and gastrointestinal symptoms to severe anaphylaxis. With the increasing prevalence and identification of α-Gal syndrome, a safe and tailored perioperative process is needed to integrate a pathway that involves multidisciplinary communication, robust information sharing platform, and a structured peri-procedure management.

Perioperative Considerations for Covid-19 Patients: Implementation Sciencebased Approach for Practicing Perioperative Surgical Home (PSH)

The Covid-19 pandemic presents unprecedented challenges for anesthesia professionals and their surgical patients. Beyond managing the infection risk, positive Covid-19 surgical patients add additional challenges to their perioperative care, where perioperative risk is superimposed onto an already baseline anesthesia risk in real-time in an unknown and unpredictable fashion. Recent evidence suggests that surgical procedures for both current and recovered Covid-19 patients are associated with elevated morbidity and mortality. These risks must be well managed. However, the anesthetic risk aside from transmission is yet to be fully understood; consequently, effective and speedy dissemination of practice changes is vital to effective health care delivery. However, the traditional “knowledge to action gap” of 17 years or more in healthcare is a hinderance. We herein designed and implemented a new but simple perioperative criterion for previous Covid-19 patients based on the principle of the perioperative surgical home (PSH) within the Consolidated Framework for Implementation Research (CFIR). Given these tools, implementation and/or implementation components of the pathways based on recommendations which are fast evolving can readily be done, nearly live

Perioperative Anesthetic Management for Surgical Repair of an Adult with Supracardiac Total Anomalous Pulmonary Venous Communication and Pulmonary Hypertension: A case report and Mini Review

The total anomalous pulmonary venous communication [TAPVC] is a rare cyanotic congenital cardiac defect accounting for 1.5-3% of the congenital heart disease, in which pulmonary venous [PV] blood drains directly into the right side of the heart or into the systemic veins. Neonates with obstructive TAPVC may present with cyanosis, metabolic acidosis, respiratory failure, and shock. A subset of patients with unobstructed TAPVC may remain symptoms free and attain adulthood, or present with pulmonary congestion, pulmonary arterial hypertension [PAH]. The anesthetic management of either obstructed TAPVC or unobstructed with PAH can be quite challenging. The described patient is a 23-year male who presented with self – limiting single episode of chest pain, palpitations and dyspnea, diagnosed as supracardiac unobstructed TAPVC with ostium secundum atrial septal defect [OS – ASD] and PAH, who underwent successful intracardiac repair under cardiopulmonary bypass [CPB]. The protocol for the cardiac surgery during the COVID-19 pandemic for perioperative considerations and triage recommendations was strictly followed to reduce the risk of exposure to patients and healthcare workers. The objective of this case report and review is to recognize the spectrum of various clinical presentations in TAPVC, and to describe the diagnosis and perioperative management of TAPVC. Key Words: Adult Supra cardiac TAPVC, unobstructed, PAH, cardiopulmonary bypass, corrective surgery, balanced general anesthesia

PD59-12 THE EFFECT OF PRIOR PROSTATE CANCER TREATMENT ON PERIOPERATIVE AND PATHOLOGICAL OUTCOMES AFTER CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive V (PD59)1 Sep 2021PD59-12 THE EFFECT OF PRIOR PROSTATE CANCER TREATMENT ON PERIOPERATIVE AND PATHOLOGICAL OUTCOMES AFTER CYSTECTOMY Kassem Faraj, Weslyn Bunn, Victoria Edmonds, and Mark Tyson Kassem FarajKassem Faraj More articles by this author , Weslyn BunnWeslyn Bunn More articles by this author , Victoria EdmondsVictoria Edmonds More articles by this author , and Mark TysonMark Tyson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002096.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Many men who undergo cystectomy have previously been diagnosed and treated for prostate cancer. This study describes the effect of prior prostate cancer treatment on perioperative and pathological outcomes after cystectomy. METHODS: This was a retrospective review of all male patients who underwent cystectomy at our institution from 01/01/2007-01/01/2020. Patients who were previously diagnosed and treated for prostate cancer were identified and outcomes were assessed. RESULTS: In 525 male patients, 132 (25.1%) had a diagnosis of prostate cancer prior to cystectomy. In the patients with a history of prostate cancer, 59 (46.2%) patients underwent prior radical prostatectomy (RP), 52 (39.4%) underwent some form of radiation therapy and the remaining 21 were managed with other modalities, including 11.4% who were on active surveillance. When comparing perioperative outcomes, there were no significant differences in outcomes, though a rectal injury appeared to be more common in patients who previously underwent a RP (5.1%, p=0.303). Pathological outcomes revealed that pT4 disease was more common in the RT cohort (19.2%, p=0.05). Median lymph node count was highest in the group with no prior history of prostate cancer and those who were previously on active surveillance (p <0001). In patients with no history of prostate cancer, 151 (40.2%) were found to have incidental prostate cancer at the time of cystectomy. Most (67.5%) patients with incidental prostate cancer had Gleason <7 disease and only 1.3% developed metastatic prostate cancer on follow-up, compared to over 10% of the patients previously treated for prostate cancer (p <0.05). CONCLUSIONS: Patients who underwent prostate cancer treatment prior to cystectomy may be at increased risk for worse perioperative and pathologic outcomes after cystectomy. Therefore, these patients require special perioperative considerations such as referrals to experienced cystectomy centers and/or medical oncology referral for assessment for appropriateness of neoadjuvant/adjuvant systemic therapies in those who have advanced bladder cancer. Source of Funding: This study was supported by Grant Number P30 CA015083 from the National Cancer Institute (NCI). Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NIH. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1059-e1059 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kassem Faraj More articles by this author Weslyn Bunn More articles by this author Victoria Edmonds More articles by this author Mark Tyson More articles by this author Expand All Advertisement Loading ...

Surgical management of Encapsulating Peritoneal Sclerosis (EPS) in children: international case series and literature review

BackgroundEncapsulating Peritoneal Sclerosis (EPS) is a rare phenomenon in paediatric patients with kidney failure treated with peritoneal dialysis (PD). This study highlights clinical challenges in the management of EPS, with particular emphasis on peri-operative considerations and surgical technique.MethodsRetrospective analysis of all paediatric patients with EPS treated at the Manchester Centre for Transplantation.ResultsFour patients were included with a median duration of 78 months on PD. All patients had recurrent peritonitis (> 3 episodes), and all had symptoms within three months of a change of dialysis modality from PD to haemodialysis or transplant. In Manchester, care was delivered by a multi-disciplinary team, including surgeons delivering the adult EPS surgical service with a particular focus on nutritional optimisation, sepsis control, and wound management. The surgery involved laparotomy, lavage, and enterolysis of the small bowel + / − stoma formation, depending on intra-abdominal contamination. Two patients had a formal stoma, which were reversed at three and six months, respectively. Two patients underwent primary closure of the abdomen, whereas two patients had re-look procedures at 48 h with secondary closure. One patient had a post-operative wound infection, which was managed medically. One patient’s stoma became detached, leading to an intra-abdominal collection requiring re-laparotomy. The median length of stay was 25 days, and patients were discharged once enteral feeding was established. All patients remained free of recurrence with normal gut function and currently two out of four have functioning transplants.ConclusionsThis series demonstrates 100% survival and parenteral feed independence following EPS surgery. Post-operative morbidity was common; however, with individualised experience-based decision-making and relevant additional interventions, patients made full recoveries. Health and development post-surgery continued, allowing the potential for transplantation.Graphical abstractA higher resolution version of the Graphical abstract is available as Supplementary information

Perioperative Considerations for the Emerging Alpha-gal Allergy

Alpha-gal syndrome is a constellation of symptoms resultant to an immune-mediated hypersensitivity reaction to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal). This type 1 allergic reaction has been diagnosed in an increasing number of patients worldwide, including patients in the United States, Australia, Spain, Sweden, France, and Japan.1,2 It was first identified during clinical trials of the monoclonal antibody, cetuximab, where a disproportionate number of study participants in the southeastern United States experienced anaphylactic reactions compared to other regions of the US (22% vs 1.2%).

Perioperative management considerations in patients taking prescribed psychoactive medications (including those for depression and Parkinson's disease).

Given the number of drugs available in the anaesthetist's armamentarium, drug interactions need to be managed. This is particularly true of psychoactive medications which primarily act on the central nervous system, targeting neurotransmitter pathways often affected by anaesthetic agents. This review gives an overview of the potential interactions of commonly used psychoactive medications with anaesthetic agents and hence their perioperative considerations. As anaesthetists will already be very familiar with the benzodiazepines, they will not be discussed here. Electroconvulsive therapy will also not be discussed. A wide range of psychoactive medications can interact with drugs commonly used in perioperative care including anaesthetic agents. There is limited clinical research into their effects and hence these interactions are based on known pharmacological actions. A cautious, pragmatic approach is recommended when managing patients on psychoactive medications requiring anaesthesia as part of their medical care.

Development of an International Standardized Curriculum for Laparoscopic Sleeve Gastrectomy Teaching Utilizing Modified Delphi Methodology.

The performance of laparoscopic sleeve gastrectomy has increased markedly to become the single-most performed bariatric surgical procedure globally. To date, a means of standardized trainee teaching has not been developed. The aim of this study was to design a laparoscopic curriculum for trainees of bariatric surgery utilizing modified Delphi consensus methodology. A panel of surgeons was assembled to devise an academic framework of technical, non-technical and cognitive skills utilized in the performance of laparoscopic sleeve gastrectomy. The panel invited 18 bariatric surgeons experienced in laparoscopic gastrectomy from 11 countries to rate the items for inclusion in the curriculum to a predefined level of agreement. A consensus of experts was achieved for 24 of the 30 proposed elements for inclusion within the first round of the curriculum Delphi panel. All components pertaining to anatomical knowledge, peri-operative considerations and non-technical items were accepted. A second round further examined six statements, of which three were accepted. Agreement of the panel was reached for 27 of the cognitive, technical and non-technical components after two rounds. Three statements found no consensus. Utilizing modified Delphi methodology, a curriculum outlining the most important components of teaching the procedure of laparoscopic sleeve gastrectomy, has been determined by a consensus of international experts in bariatric surgery. The curriculum is suggested as a standard in proficiency-based training of this procedure. It forms a generic template which facilitates individual jurisdictions to perform content validation, adapting the curriculum to local requirements in teaching the next generation of bariatric surgeons.

Optimizing Safety for the Postradiation Face Lift

Background: The growing population of aging patients who have received head or neck radiation has brought attention to the unique considerations for surgical face lifts. Tissue fibrosis and impaired microcirculation can compromise wound healing and increase overall complication rates. Our review of the literature identified few reported cases of postradiation face lifts. Methods: Three patients who underwent postradiation face lift procedures were identified within two senior surgeons’ practices. Patient demographics, medical history, surgical technique, postoperative course, and photographs were obtained. Complications were analyzed, including infections, hematomas, seromas, wound dehiscence, delayed healing, necrosis, nerve injuries, poor scarring, and systemic events. Results: None of the patients experienced immediate or major complications. All patients reported satisfaction with the procedure. One patient required a revision of the earlobe. Conclusions: Our limited series suggests that with a comprehensive approach and a deliberate surgical technique, safe and desirable outcomes may be achieved in the appropriately selected patient. We outline perioperative considerations to assist surgeons in caring for these patients. Additional research is necessary to assess the impact of patient and therapeutic variables.