Search Results (39)

This case report describes the acute and multidisciplinary management anesthesiologists performed for an intra-operative bronchobiliary fistula during a routine endoscopic retrograde cholangiopancreatography for a patient with intrahepatic cholangiocarcinoma. During the procedure, an unexpected rapid airway deterioration was encountered due to bile infiltration of the right bronchus and anesthesia circuit, necessitating (1) emergent extubation and reintubation with bronchoscopy, (2) extubation and reintubation with double-lumen endotracheal tube with right-bronchial blocker, and (3) transportation of the patient from endoscopy to interventional radiology for biliary drain placement. Overall, this case highlights a rare but serious consideration for patients with intrahepatic cholangiocarcinoma who may present with a bronchobiliary fistula and the steps taken to prevent total airway compromise and ensure rapid patient stabilization through coordination with advanced gastroenterology, interventional pulmonology, and interventional radiology. Full article

Introduction: Propofol is a widely used sedative drug in electrophysiological studies (EPS). However, literature has shown that this drug may interfere with the cardiac conduction system (CCS). Our objective is to evaluate whether propofol interferes with CCS and the inducibility of arrhythmias during EPS. Method: A systematic review and a meta-analysis were performed. The databases were PubMed, Embase, Web of Science, and Scopus. Rayyan software was used to select the studies. Three Mesh terms were used: Propofol, Cardiac arrhythmias, Electrophysiologic Study, and Cardiac. Cohort studies and randomized clinical trials were included. Results: Only one of the six studies showed four cases where it was impossible to induce arrhythmia. We found no significant difference between propofol and the control group in the analyzed variables: cycle length, atrial-His, His-ventricular, corrected sinus node recovery time, atrial effective refractory factor, and ventricular effective refractory period, with low heterogeneity (I² = 0% to a maximum of I² = 8%). A significant difference in favor of the control group was found in the analysis of the atrioventricular node effective refractory period (MD:18.67 {95% CI 4.86 to 32.47} p = 0.008, I² = 44%). Discussion: The meta-analyzed data in this study showed that propofol possibly does not interfere with CCS, making it a safe drug for this type of procedure. Conclusions: However, extra care should be exercised with pediatric patients when the arrhythmia’s mechanism is automatic. More robust studies are still needed in this class. Full article

Background: PP-007 (SANGUINATE^®, PEGylated carboxyhemoglobin, bovine) is under development to treat conditions of ischemia/hypoxia. Hemorrhagic/hypovolemic shock (H/HVS) becomes a life-threatening comorbidity due in part to hypotension and hypoxia. Blood transfusions are indicated, but supply and compatibility issues may limit subject access or when blood is not an option due to religious restriction or concern for clinical complications. PP-007 is universally compatible with an effective hydrodynamic radius and colloidal osmotic pressure facilitating perfusion without promoting extravasation. Methods: A review of previous clinical trials was performed and revealed an Open-Label Phase 1 safety study of acute severe anemia (hemoglobin ≤ 5 g/dL) in adult (≥18 y) patients unable to receive red blood cell transfusion (NCT02754999). Primary outcomes included safety events with secondary efficacy measures of organ function and survival at 1, 14, and 28 days. Additionally, a retrospective review of published, peer-reviewed case reports was performed, evaluating the administration of Sanguinate for Expanded Access in those patient populations where blood was not an option over the past 12 years. Results: A total of 103 subjects were enrolled in the Phase I safety study with significant co-morbidities that most commonly included hypertension (n = 43), acute and chronic kidney disease (n = 38), diabetes mellitus (n = 29), gastrointestinal bleeds (n = 18), and sickle cell disease (n = 13). Enrollment characteristics included decreased hemoglobin and severe anemia (mean baseline hemoglobin of 4.2 g/dL). Treatments included an average of three infusions [range 1–17]. Secondary efficacy measures were mean Hb levels, respiratory support, and vasopressor requirements, all demonstrating clinically relevant improvements. Fourteen additional cases were identified in the literature. Though one patient died due to pre-treatment conditions, all patients but one were discharged home in stable condition. Conclusion: Collectively, these observations are encouraging and provide support for the continued evaluation of PP-007 in advanced clinical trials in severe anemia including H/HVS. The review of published case reports underscored the potential of Sanguinate to reduce early mortality. Adverse effects included transient hypertension, lethargy, dizziness, and troponin elevation. These findings highlight the need for continued research and funding of blood alternatives to improve outcomes when standard blood transfusions are unavailable or contraindicated. Full article

Background/Objectives: Prone positioning is a key strategy to improve oxygenation in ARDS patients, particularly used during the COVID-19 pandemic. However, its impact on visual function remains poorly investigated. This study assesses the effect of prone positioning on self-perceived visual acuity and functional vision in ARDS patients after ICU discharge. Methods: A single-center observational study was conducted at Santo Stefano Hospital (Prato, Italy) from March 2020 to April 2023. We included adult COVID-19 ARDS patients, ventilated invasively, and subjected to at least one prone positioning cycle. Patients with pre-existing visual disorders were excluded. Visual function was evaluated through the CATQUEST-9SF questionnaire administered via telephone follow-up. Rasch analysis was applied to generate a linear visual function scale. Logistic regression was used to identify predictors of reduced visual function. Results: Out of 300 ICU admissions, 182 met the inclusion criteria, and 39 completed the follow-up. Older age (OR 1.148, p < 0.05), female sex (OR 0.066, p < 0.05), and increased number of prone cycles (OR 3.576, p < 0.05) were significantly associated with reduced visual function. The model’s predictive performance was excellent (AUC = 0.8997). Conclusions: Prone positioning improves respiratory outcomes but may have unintended visual consequences. Monitoring visual function should be integrated into ICU follow-up programs to mitigate long-term visual impairment. Full article

Background/Objectives: The management of patients with severe systemic comorbidities undergoing radiologic interventional procedures presents a significant challenge for anesthesiologists. Selecting an appropriate combination of anesthetic drugs is crucial to ensure a safe, painless procedure, facilitate rapid recovery, and minimalize complications. Here, we present a case of a 68-year-old female patient of ASA V status with a history of diabetes, coronary artery disease, and severe chronic obstructive pulmonary disease due to lung emphysema and dependence on a home oxygenator, requiring sedation for CT-guided percutaneous drainage of the aortic graft infection. Methods: After on-site emergent patient preparation and several position adjustments, sedation was initiated and maintained using continuous infusions of remimazolam and esketamine. Results: Throughout the procedure, the patient remained sedated, comfortable, and free of unwanted movements. The patient was hemodynamically stable and maintained oxygen saturation between 92 and 96%. Conclusions: In our opinion, the combination of remimazolam and esketamine demonstrated an effective and safe profile for procedural sedation. This approach holds the potential to influence standard operating protocols, particularly for patients with severe and multiple comorbidities requiring personalized anesthetic management. Full article

Objectives: Comparative analyses of anesthetic agents on mutants with altered anesthetic sensitivity remain limited in the current literature. This study examines the sensitivity of various Drosophila melanogaster wild-type strains and mutants to the volatile anesthetics chloroform and isoflurane. We utilized recently identified mutants in ion channel-encoding genes and others historically selected for anesthetic resistance, such as AGAR (autosomal general anesthesia resistant) and har (halothane-resistant). Method: Based on the principles of the conventional inebriometer assay used to isolate these mutants, we developed a new, simpler method to measure the anesthetic response in these flies. Results: Interestingly, we discovered that wild-type flies exhibit varying levels of anesthetic resistance. Contrary to previous reports, AGAR and har mutants showed little resistance to anesthesia using our method. Several ion channel mutants displayed increased resistance or sensitivity. Across all strains, isoflurane was more potent than chloroform. To ensure objectivity, all experiments were conducted double-blind. These findings highlight the variability in anesthetic sensitivity among both wild-type and mutant flies and underscore the importance of assay design in assessing resistance. Full article

Background/Objectives: Postoperative delirium has not been well explored in patients undergoing elective hip and knee arthroplasty. This study assessed the incidence of delirium in these patients in the postanesthetic care unit (PACU) and throughout their hospital admission. Predictors of postoperative delirium and impact of delirium on length of stay were also analyzed. Methods: This prospective observational study recruited patients (n = 978) with normal cognitive function presenting for elective primary hip or knee arthroplasty at a single tertiary academic center. Delirium was assessed using the Nursing Delirium Scoring Scale (NuDESC) in the PACU, and twice daily after that on postoperative days 1, 2 and 3, or until discharge, whichever came first. Results: In total, 26 (2.7%) patients developed delirium postoperatively. Unadjusted logistic regression analyses revealed that age; history of cardiovascular, central nervous system, hematologic, endocrinologic, psychiatric disease; postoperative opioid use; and ASA level were associated with an increased risk of delirium, with odds ratios (95% confidence interval) of 1.7 (1.35 to 2.11), 3.6 (1.09 to 12.25), 3.5 (1.53 to 8.03), 2.7 (1.09 to 6.45), 2.3 (1.04 to 4.97), 4.7 (2.10 to 10.70), 0.4 (0.17 to 0.89), and 2.37 (1.05 to 5.33), respectively. A Mann–Whitney U test showed no difference in PACU or hospital length of stay between patients who did and did not have delirium in the PACU (within the first hour). Conclusions: Age, ASA > 3, a history of cardiovascular disease, central nervous system disease, hematologic disease, endocrinologic disease, psychiatric disease and postoperative opioid use are individually associated with postoperative delirium. A future study with an even larger sample size is needed to further evaluate these factors in an adjusted analysis. Full article

Introduction: In recent years, a greater number of adults have been undergoing spinal surgery. The main complications in the postanesthetic care unit (PACU) include respiratory and cardiovascular problems, pain, and nausea or vomiting. The aim of this study was to describe the preoperative characteristics and intra-anesthetic management of adult patients who underwent elective spinal surgery with balanced general anesthesia and to identify the predictive factors associated with supplemental oxygen requirement upon discharge from the PACU. In addition, we sought to develop a risk index on the basis of multivariable analysis allowing stratification of the probability of supplemental oxygen requirement upon discharge from the PACU. Materials and Methods: In this cross-sectional, retrospective, observational study, the pre- and intra-anesthetic characteristics of adult patients who underwent spinal surgery at any vertebral level under balanced general anesthesia in a tertiary hospital were retrieved. Descriptive statistics are provided, and comparison (Kruskal–Wallis) or correlation analyses (chi-square) were conducted between the characteristics of the patients grouped according to the need for supplemental oxygen upon discharge from the PACU. Receiver operating characteristic (ROC) curves and a multivariate logistic regression model were generated. All tests were performed at the α = 0.05 level. Results: Among 349 patients initially considered, only 211 were included in the analysis. A total of 45.50% of the patients who underwent spinal surgery under balanced general anesthesia required supplemental oxygen upon discharge from the PACU; these patients had significantly greater age, body mass index (BMI), surgery time, and anesthesia time. In addition, the use of norepinephrine and the use of fentanyl were associated with the need for supplemental oxygen. Our proposed risk index for predicting the need for supplemental oxygen upon discharge from the PACU, according to the implementation of a multivariable logistic model based on three simple variables (age ≥ 48 years, BMI ≥ 26.5, and use of fentanyl infusion), achieved an area under the curve (AUC) of 0.740. Conclusions: Age, BMI, and the use of fentanyl can be used to predict the need for supplemental oxygen upon discharge from the PACU. Multicenter and/or longitudinal studies with large sample sizes are needed to confirm the results of this study and improve the prediction of the need for supplemental oxygen upon discharge from the PACU. Full article

Background/Objectives: Propofol is a preferred agent for ICU sedation. Hypertriglyceridemia occurs in up to 45% of patients on propofol and has been linked with adverse effects. Data extrapolated from acute pancreatitis suggests intravenous (IV) insulin infusions may be effective in reducing serum triglyceride (TG) values in patients with propofol-induced elevated TG. The objective is to describe and compare serum TG levels in critically ill patients receiving concomitant insulin infusions and propofol versus propofol alone. Methods: This is a retrospective cohort study of mechanically ventilated adult patients admitted to a medical intensive care unit who received a propofol infusion alone or propofol and IV insulin infusions and who had a minimum of two serum TG levels while on propofol infusion. The primary outcome was median change in the serum TG concentration in patients receiving concomitant propofol and IV insulin infusions, as compared to those receiving propofol alone. Results: A total of 263 patients were screened and 32 met inclusion criteria (16 in each group). The median change between first and last obtained TG level was 0.35 (−0.31–1.33) vs. −0.07 (−1.08–+0.42) mmol/L (p = 0.051) in the propofol vs. propofol and IV insulin groups, respectively. Each day on propofol was associated with an estimated 0.21 mmol/L (95% confidence interval (CI) 0.0.004 to 0.41, p = 0.046) increase in TG, and each additional day of IV insulin was associated with a 0.14 mmol/L (95% CI −0.63 to 0.35, p = 0.571) decrease in TG. Conclusions: Each additional day of propofol was associated with an increase in serum TG levels. IV insulin infusions did not lead to a significant difference in triglyceride values. Full article

Background: Neuromuscular blocking agents play an important role in modern anesthesia by facilitating optimal surgical conditions through deep muscle relaxation. Additionally, neuromuscular monitoring and reversal ensure swift and reliable recovery from neuromuscular blockade. The evolution of neuromuscular blocking agents, from early curare derivatives to contemporary agents such as rocuronium and cisatracurium, has significantly enhanced the safety and efficacy of anesthesia. Methods: This review examines the historical development, pharmacological mechanisms, clinical applications, and innovations in managing neuromuscular blockade. Results: It underscores key milestones in the advancement of neuromuscular blockade, including the introduction of neuromuscular monitoring techniques like Train-of-Four, which improve patient safety by reducing residual neuromuscular blockade. Pharmacological advancements, particularly the emergence of sugammadex, have further revolutionized clinical practice by enabling rapid and reliable reversal of steroidal neuromuscular blocking agents. The discussion covers the role of deep neuromuscular blockade in optimizing surgical conditions, especially in minimally invasive procedures. Conclusion: Comparative analyses of standard versus deep blockade reveal potential advantages in certain surgical scenarios, although patient-specific factors and associated risks must be carefully evaluated. Future directions involve developing innovative neuromuscular blocking agents and reversal agents aimed at achieving faster onset, shorter duration, and fewer side effects. The management of neuromuscular blockade continues to evolve, propelled by advancements in pharmacology and monitoring technology. Anesthesiologists should embrace a personalized approach, integrating advanced monitoring tools and customized pharmacological strategies to enhance patient outcomes. Ongoing research into next-generation neuromuscular blocking agents and reversal agents holds the promise of further improving safety and efficiency in anesthesia practice. Full article

Background: Language discordance occurs when the patient and the healthcare provider are not proficient in the same language. Language discordance in the critical care setting is a significant global issue because of its implications in the quality of care and outcomes of patients who do not speak the primary language of the country in which they receive healthcare. Studies show that language-discordant, critically ill patients have increased use of restraints during mechanical ventilation, increased length of stay, and more frequent complications. Communication challenges are magnified in the intensive care unit because of the medical complexity and frequent need for challenging conversations regarding goals of care. To address language-based disparities in critical care, numerous qualitative studies in recent years have attempted to understand the barriers that providers face when caring for language-discordant patients. Our systematic review is the first to analyze this developing body of literature and identify barriers for which solutions must be sought to ensure equitable care. Methods: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Embase, and Scopus from inception up to 20 February 2024. From among 2150 articles, nine articles were selected, which included eight qualitative studies and one cross-sectional study. Three studies were high quality, five were moderate quality, and one was low quality. Results: We found four major barriers to caring for language-discordant patients in the critical care setting. These included limitations in providers’ knowledge of best practices in professional medical interpreter use, challenges in navigating interpreters’ multiple roles, and limitations with different interpretive modalities and system constraints. These barriers caused clinicians distress due to clinicians’ desire to provide empathic care that respected patients’ autonomy and ensured patients’ safety and understanding. Conclusion: Interventions to increase providers’ knowledge of best practices, integrate interpreters into the critical care team, strategize the use of interpretation modalities, and address system-based barriers are needed to improve the care of language-discordant, critically ill patients worldwide. Full article

Introduction: Cardiopulmonary exercise testing (CPET) is the gold-standard assessment of functional capacity and predicts postoperative outcomes in major abdominal and thoracic surgery, as well as in older individuals undergoing elective surgery for colorectal cancer. However, CPET is resource-intensive and not universally available. Simpler objective assessments of functional capacity, such as Clinical Frailty Scale (CFS) scoring, predict postoperative complications and may be useful in aiding shared decision and perioperative planning. Objectives: This study aimed to assess local cohort data and investigate the association between Clinical Frailty Scoring, CPET outcomes, and length of hospital stay. Methods: We conducted a retrospective cohort analysis of all patients who had received a cardiopulmonary exercise test as part of their preoperative assessment for major abdominal and thoracic surgery between May 2018 and December 2022 in four district general hospitals. Results: This study featured 174 patients, age 73 (mean), CFS 3 (mean), who underwent CPET with associated CFS scoring. The CFS scores were weakly correlated with the anaerobic threshold, VO₂ peak, and ventilatory equivalents, coefficients measuring −0.34, −0.36, and 0.31 (all p < 0.001), respectively. Linear regression demonstrated a negative coefficient for the association of CFS with the VO₂ peak and the AT, measuring −1.22 and −1.70, respectively, both p < 0.001. The CFS score was not predictive of 1-year mortality in this group. In a subgroup analysis (n = 59), there was no association between the CFS score and the length of stay. Conclusions: Our data suggest a weak relationship between the CFS score and the CPET results. Further investigations with larger prospective datasets are required to explore the use of CFS as a surrogate for CPET and its use as an independent predictor for perioperative outcomes. This study supports the limited literature available on this subject. Full article

Introduction: Difficult airway management is a critical challenge in anesthesia, often necessitating advanced techniques to ensure patient safety. A patient presented with a malignant lesion on the epiglottis, significantly altering the airway anatomy. Flexible rhinolaryngoscopy revealed a laryngeal carcinoma affecting the entire epiglottis, causing thickening and displacement, which suggested the potential for difficult intubation. Methods: Given the expected feasibility of bag-mask ventilation and front-of-neck access, an asleep intubation technique was selected. The combined use of a McGrath video laryngoscope and C-MAC video stylet allowed for fast and easy atraumatic intubation on the first attempt. The anesthetic and surgical course was uneventful. Discussion: This case report highlights the successful use of a combined approach involving a video laryngoscope and video stylet for intubation in a patient with known difficulties in airway management, providing insights into the benefits of enhanced visualization and maneuverability. The rigid design and steerable tip of the C-MAC video stylet provide advantages over traditional flexible optics, offering better maneuverability and reducing the need for a second operator. Although this technique was successful in this case, its use in patients with complex airway pathologies warrants careful preoperative assessment and collaboration with an experienced airway management team. Full article

Background/Objectives: The rapid development of Large Language Models (LLMs) presents promising applications in healthcare, including patient education. In anesthesia, where patient anxiety is common due to misunderstandings and fears, LLMs could alleviate perioperative anxiety by providing accessible and accurate information. This study explores the potential of LLMs to enhance patient education on anesthetic and perioperative care, addressing time constraints faced by anesthetists. Methods: Three language models—ChatGPT-4, Claude 3, and Gemini—were evaluated using three common patient prompts. To minimize bias, incognito mode was used. Readability was assessed with the Flesch–Kincaid, Flesch Reading Ease, and Coleman–Liau indices. Response quality was rated for clarity, comprehension, and informativeness using the DISCERN score and Likert Scale. Results: Claude 3 required the highest reading level, delivering detailed responses but lacking citations. ChatGPT-4o offered accessible and concise answers but missed key details. Gemini provided reliable and comprehensive information and emphasized professional guidance but lacked citations. According to DISCERN and Likert scores, Gemini had the highest rank for reliability and patient friendliness. Conclusions: This study found that Gemini provided the most reliable information, followed by Claude 3, although no significant differences were observed. All models showed limitations in bias and lacked sufficient citations. While ChatGPT-4o was the most comprehensible, it lacked clinical depth. Further research is needed to balance simplicity with clinical accuracy, explore Artificial Intelligence (AI)–physician collaboration, and assess AI’s impact on patient safety and medical education. Full article

Background: While multimodal analgesia is the standard of care for postoperative pain relief, opioid medications continue to be a part of the treatment regimen, especially for more invasive surgeries such as spinal fusion, craniofacial reconstruction, laparotomy, and others. In pediatric patients, safe usage, storage, and dosing are especially important, along with clear instructions to caregivers on how to manage their child’s pain. Combination opioids such as hydrocodone with acetaminophen and acetaminophen with codeine are the most commonly prescribed opioid medications for postoperative pain control. However, these combination products can lead to acetaminophen toxicity, limit the ability to prescribe acetaminophen or ibuprofen, and add to caregiver confusion. Administering acetaminophen and ibuprofen individually rather than in combination products allows the maximal dosing of these nonopioid medications. The primary aim of this quality improvement (QI) project was to increase the utilization of single-agent opioids for postoperative pain control, primarily oxycodone, by the various surgical groups here at Cook Children’s Medical Center (CCMC). Methods: The project setting was a tertiary-level children’s hospital with a level 2 trauma center, performing over 20,000 surgeries annually. The opioid stewardship committee (OSC) mapped the steps and overlapping activities in the intervention that led to changes in providers’ prescription practices. A Plan–Do–Study–Act continuous improvement cycle allowed for an assessment and modification of implementation strategies. Statistical control process charts were used to detect the average percentage change in surgical specialties using single-agent opioid therapy. Data were monitored for three periods: one-year pre-intervention, one-year post-intervention, and one-year sustainment periods. Results: There were 4885 (41%) pre-intervention procedures, 3973 (33%) post-intervention procedures, and 3180 (26%) sustainment period procedures that received opioids. During the pre-intervention period, the average proportion of single-agent opioids prescribed was 8%. This average shifted to 89% for the first five months of the post-intervention period, then to 91% for the remainder of the study. Conclusions: The methodical application of process improvement strategies can result in a sustained change from outpatient post-surgical combination opioid prescriptions to single-agent opioid prescriptions in multiple surgical departments. Full article