Search Results (57)

Minimally invasive coronary artery bypass grafting (MI-CABG) has emerged as a transformative approach to coronary revascularization, offering reduced morbidity, faster recovery and improved cosmesis compared to conventional coronary artery bypass grafting (CABG). Performed without full sternotomy and commonly without cardiopulmonary bypass (CPB), MI-CABG encompasses a variety of techniques. These procedures present unique challenges for the anesthesiologist, necessitating a tailored perioperative strategy. This review explores the anesthetic management of MI-CABG, focusing on preoperative assessment, intraoperative techniques, and postoperative care. Preoperative evaluation emphasizes cardiac, respiratory, and vascular considerations, including suitability for one-lung ventilation (OLV) and the impact of comorbidities. Intraoperatively, anesthesiologists must manage hemodynamic instability, ensure effective OLV, and maintain normothermia. Postoperative strategies prioritize multimodal analgesia, early extubation, and rapid mobilization to leverage the benefits of a minimally invasive approach. By integrating surgical and anesthetic perspectives, this review underscores the anesthesiologist’s pivotal role in navigating the physiological demands of MI-CABG. As techniques evolve and experience grows, a comprehensive understanding of these principles will enhance the safety and efficacy of MI-CABG, making it a viable option for an expanding patient population. Full article

Background: Among patients with congenital heart disease, particularly those with a history of undergoing the Fontan operation, pregnancy presents a significant maternal–fetal risk, especially when complicated by severe valvular dysfunction. Lung reperfusion syndrome (LRS) is a rare but life-threatening complication occurring following valve intervention. Multidisciplinary management, including by Cardio-Obstetrics teams, is essential for optimizing outcomes in such high-risk cases. Methods: We present the case of a 37-year-old pregnant patient with previously repaired tetralogy of Fallot (via the Fontan procedure) who presented at 24 weeks gestation with worsening severe pulmonary stenosis and right-ventricular dysfunction. The patient had been lost to cardiac follow-up for over a decade. She experienced recurrent arrhythmias, including supraventricular and non-sustained ventricular tachycardia, prompting hospital admission. A multidisciplinary team recommended transcatheter pulmonic valve replacement (TPVR), performed at 28 weeks’ gestation. Results: Post-TPVR, the patient developed acute hypoxia and hypotension, consistent with Lung Reperfusion Syndrome, necessitating intensive cardiopulmonary support. Despite initial stabilization, progressive maternal respiratory failure and fetal compromise led to an emergent cesarean delivery. The neonate’s neonatal intensive care unit (NICU) course was complicated by spontaneous intestinal perforation, while the mother required intensive care unit (ICU)-level care and a bronchoscopy due to new pulmonary findings. She was extubated and discharged in stable condition on postoperative day five. Conclusions: This case underscores the complexity of managing severe congenital heart disease and valve pathology during pregnancy. Lung reperfusion syndrome should be recognized as a potential complication following TPVR, particularly in pregnant patients with Fontan physiology. Early involvement of a multidisciplinary Cardio-Obstetrics team and structured peripartum planning are critical to improving both maternal and neonatal outcomes. Full article

Objective: The present study aimed to evaluate the feasibility and safety of performing extubation in the operating room following aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT), as the safety profile of this approach has not been fully established. Methods: We conducted a retrospective analysis of patients who underwent isolated AVR through a RAMT between February 2012 and December 2023. Emergency cases and reoperations were excluded. Patients were categorized according to the location of extubation—either in the operating room (on-table) or in the intensive care unit (ICU). Multivariable logistic regression analysis was used to identify predictors associated with successful on-table extubation. Results: Among 423 patients who underwent non-emergent isolated AVR, 73.3% were extubated in the operating room. This group was characterized by younger age, lower EuroSCORE II, and higher preoperative serum albumin levels. While the surgical techniques did not differ between groups, those extubated on-table had significantly shorter cardiopulmonary bypass times (84.0 [68.0–104.0] vs. 104.0 [85.0–131.5], p < 0.001). Although early postoperative outcomes were comparable, the on-table extubation group had significantly shorter ICU stays (24.0 [22.0–26.0] vs. 25.0 [23.0–30.0], p < 0.001) and hospital stays (5.0 [4.0–6.0] vs. 6.0 [5.0–8.0], p < 0.001). A predictive model incorporating age, albumin levels, and cardiopulmonary bypass time demonstrated a predictive accuracy of approximately 78.4% for on-table extubation success. Conclusions: Extubation in the operating room was found to be both safe and effective for the majority of patients undergoing isolated AVR via RAMT. It was associated with low reintubation rates and significantly reduced lengths of ICU and hospital stays. These findings support the adoption of routine on-table extubation in suitable patients undergoing this procedure. Full article

Background/Objectives: Critically ill patients with acute neurological injury commonly require intubation. The true incidence of and risk for extubation failure in pediatric patients with an acute neurologic injury is not well reported, making the assessment of these patients for extubation readiness or the need for tracheostomy challenging. This study aims to better delineate the incidence of extubation failure and factors associated with the need for tracheostomy in pediatric patients surviving an acute neurologic injury. Methods: We conducted a retrospective cohort study using the Virtual Pediatric System (VPS) database of neonates, infants, children, and adolescents < 18 years of age with a neurological injury requiring intubation from 2012 to 2022. Demographic and clinical variables were compared between subjects that were successfully extubated, those with early tracheostomy placement (≤14 days), and those with late tracheostomy placement (>14 days). Results: Of the 38,810 enrolled subjects, 37,661 (97.04%) were successfully extubated, 481 (1.24%) underwent early tracheostomy, and 668 (1.72%) underwent late tracheostomy. The most common etiologies were seizures (60.6%), trauma (20.9%), and intoxication (9.1%). The successfully extubated subjects had a higher median initial GCS score (8 vs. 5 and 4, p < 0.001) and fewer extubation attempts (1 vs. 3 and 3, p < 0.001) than the tracheostomy cohorts. There was a significant difference in median ICU days between the three groups (2.52 vs. 18.3 vs. 38.3, p < 0.001). Conclusions: The majority of pediatric patients requiring intubation following an acute neurological injury can be successfully extubated. Among patients requiring a tracheostomy, those who received it early had significantly shorter ICU and hospital stays. Full article

In patients undergoing living donor liver transplantation (LDLT) with immediate postoperative extubation in the operating room (OR), rapid recovery of consciousness and spontaneous ventilation are essential, requiring effective analgesia without compromising respiratory function. This study evaluated whether intraoperative nefopam administration improves early postoperative pain control and reduces opioid consumption in this physiologically distinct population. A retrospective cohort of 376 adult LDLT recipients who met the criteria for OR extubation was analyzed. After propensity score matching, 182 patients who received intraoperative nefopam were compared with 182 matched controls. Pain intensity was measured using the visual analog scale (VAS), and total fentanyl consumption and opioid-related complications were recorded over the first 24 h postoperatively. Nefopam administration was associated with significantly lower VAS scores during the first 12 h after surgery (p < 0.001) and reduced 24 h fentanyl consumption (53.2 ± 20.8 mL vs. 58.6 ± 27.5 mL, p = 0.035). No serious adverse effects related to nefopam were observed. The incidence of postoperative nausea and vomiting did not differ significantly between the groups. These findings indicate that nefopam offers effective early analgesia and an opioid-sparing effect in LDLT recipients undergoing OR extubation, suggesting its clinical utility as a component of multimodal analgesia in this high-risk group. Although the reduction in opioid use did not translate into a decreased incidence of opioid-related complications, the favorable safety profile and analgesic efficacy of nefopam support further investigation through prospective trials to define its role in enhanced recovery protocols for OR-extubated LDLT recipients. Full article

Background/Objectives: Premature infants are often referred for the definitive procedural closure of the patent ductus arteriosus (PDA) with the failure of, or contraindication to, pharmacotherapy and the inability to wean respiratory support. However, once this need is identified, the importance of expedited closure is unclear. The objective of this study was to compare the effect of the timing of definitive closure (i.e., surgical ligation or device occlusion) on early respiratory outcomes in premature infants. Method: We first specify a hypothetical randomized trial (the “target trial”) that would estimate the effect on extubation of early (0–4 days from referral) vs. late (5–14 days from referral) definitive PDA closure. We then emulate this target trial using a single-institution registry of premature infants (born <30 weeks or with a birth weight < 1500 g) who underwent the definitive closure of PDA between January 2014 and October 2023. Results: We identify 131 eligible infants. At the end of the follow-up, 70 and 38 infants were adherent to early and late PDA closure strategies, respectively. The cumulative incidence of extubation in the early group was higher than that in the late group until day 40 (maximum risk difference: 22 percentage points at day 13; 95% CI: −11 to 56). Outcomes were similar at the end of the 45-day follow-up period (risk difference: −1 percentage point; 95% CI: −46 to 42). Conclusions: The need for mechanical ventilation was equivalent between early and late PDA closure strategies at the end of a 45-day follow-up period although infants in the early intervention group were extubated sooner. Full article

Background and Objectives: Minimally invasive valve surgery (MIVS), integrated within enhanced recovery after surgery (ERAS) programs, is a pivotal advancement in modern cardiac surgery, aiming to reduce perioperative morbidity and accelerate recovery. This systematic review analyzes the integration of ERAS components into MIVS programs and evaluates their impact on perioperative outcomes and patient recovery. Materials and Methods: A systematic search of PubMed/Medline, conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, identified studies on ERAS in MIVS patients. Coronary and robotic surgery were excluded to prioritize widely adopted minimally invasive valve methods. Studies were included if they applied ERAS protocols primarily to MIVS patients, with at least five participants per study. Data on study characteristics, ERAS components, and patient outcomes were extracted for analysis. Results: Eight studies met the inclusion criteria, encompassing 1287 MIVS patients (842 ERAS, 445 non-ERAS). ERAS protocols in MIVS were heterogeneous, with studies implementing 9 to 18 of 24 ERAS measures recommended by the ERAS consensus guideline, reflecting local hospital practices and resource availability. Common elements include patient education and multidisciplinary teams, early extubation followed by mobilization, multimodal opioid-sparing pain management, and timely removal of invasive lines. Despite protocol variability, these programs were associated with reduced morbidity, shorter hospital stays (intensive care unit-stay reductions of 4–20 h to complete omission, and total length of stay by ≥1 day), and cost savings of up to EUR 1909.8 per patient without compromising safety. Conclusions: ERAS protocols and MIVS synergistically enhance recovery and reduce the length of hospital stay. Standardizing ERAS protocols for MVS could amplify these benefits and broaden adoption. Full article

Background/Objectives: Early extubation is crucial for enhancing recovery from coronary artery bypass grafting (CABG). Residual neuromuscular blockade (NMB) effects can hinder early extubation, potentially leading to reintubation, lung infection, and prolonged post-anesthesia stay. Sugammadex, a modified gamma-cyclodextrin, reverses the non-depolarizing NMB effects of the steroidal muscle relaxants rocuronium and vecuronium. The American Society of Anesthesiologists recommends sugammadex administration when patients display a train-of-four (TOF) ratio of less than 0.9. Previous studies show that sugammadex decreases extubation times, reduces postoperative complications, and enhances patient comfort. Methods: This single-center, retrospective cohort study evaluated the efficacy of sugammadex in achieving extubation within six hours of intensive care unit (ICU) arrival post-CABG, defined as fast-track extubation (FTE). Results: Here, we report that although the total time of intubation in the ICU following CABG did not drop to the six-hour benchmark, it was substantially reduced by the administration of sugammadex in accordance with an FTE protocol. Furthermore, the risks of adverse events (e.g., anaphylaxis, heart failure) and postoperative complications (e.g., acidemia, hypoxemia, tachypnea) were unaltered. Conclusions: The use of sugammadex could, thus, reduce costs associated with prolonged intubation time and related complications without increasing morbidity or mortality. Full article

Background/Objectives: Continuous epidural analgesia is desirable for improving infant outcomes after surgeries. However, its contribution to facilitating extubation is not well known. Methods: A retrospective chart review was conducted at the UPMC Children’s Hospital of Pittsburgh to identify all infants who received an epidural catheter between 2018 and 2024 and required postsurgical admission to the Neonatal Intensive Care Unit (NICU). The study examined the timing of extubation and reintubation, along with associated factors, in 100 infants who underwent major surgeries. Results: In total, 100 infants, 43 females and 57 males, 40 (38.39–42.07) weeks corrected gestational age, 3 (2.52–3.42) kg received epidural catheters. Sixty-two patients had a pulmonary condition. Of 45 infants extubated in the operating room, 32 received fentanyl intraoperatively, and 16 required a morphine infusion in the NICU. Among 55 infants that remained intubated, 24% underwent a thoracic procedure, 46 received intraoperatively fentanyl, and 21 needed an opioid infusion postoperatively. The extubation day was median (IQR) 2 (1–4), and 24% remained intubated beyond day 5. Twelve infants were intubated preoperatively, and six required prolonged ventilation beyond day 5. Of 15 infants that required reintubation, 8 received a morphine infusion. The medians (IQR) of the average of three pain and sedation scores before reintubation were 1.67 (1–3) and 0 (−1.67–0), respectively. Conclusions: Epidural analgesia may facilitate early extubation in some infants undergoing surgeries. Morphine infusion was administered at a similar rate between infants extubated and those who remained intubated, and its role in delaying extubation timing remains unclear. Full article

Background: Effective pain management is essential to early extubation and recovery in living donor liver transplantation (LDLT). The subcostal transversus abdominis plane (TAP) block has emerged as a potential strategy to address postoperative pain while reducing opioid consumption. This study evaluated the effectiveness of the TAP block in facilitating early extubation in the OR and examined its impact on re-intubation rates, postoperative fentanyl requirements, and pain intensity upon ICU admission to determine its role in perioperative pain management. Methods: This retrospective cohort study included adult patients who underwent LDLT for hepatocellular carcinoma within the Milan criteria. Propensity score matching was performed to compare outcomes between patients who received the subcostal TAP block and those who did not. The primary outcome was the rate of successful extubation in the operating room (OR). Secondary outcomes included re-intubation rates, postoperative fentanyl requirements, and peak numeric rating scale (NRS) pain scores upon ICU admission. Results: The subcostal TAP block was associated with a significantly higher rate of successful OR extubation compared with no TAP block. Multivariable analysis revealed that the TAP block independently increased the likelihood of successful extubation. Patients receiving the TAP block required less fentanyl for pain management and demonstrated lower peak NRS pain scores upon ICU admission. No complications related to the TAP block were observed, underscoring its safety in this high-risk population. Conclusions: The subcostal TAP block facilitates early OR extubation by effectively managing postoperative pain and reducing opioid requirements, promoting smoother recovery without increasing adverse events. These findings support its inclusion in multimodal analgesia protocols for optimizing perioperative outcomes in LDLT patients. Full article

Introduction: According to the results of the APRICOT study, airway and respiratory complications constitute 60% of all anesthesia-related complications and may be life-threatening. The primary aim of this study was to evaluate the effect of lidocaine and mometasone spray on the hemodynamic stress response during tracheal intubation and extubation in children. Our secondary aim was to determine its effect on the incidence of postoperative airway complications. Materials and Methods: Following Ethics Committee approval (No: KIIA 2018/489) and clinical trial registration (No: NCT04085744), patient recruitment was initiated only after obtaining parental consent. Children of ASA I-II aged 0 to 16 years and undergoing elective surgery were included. A total of 91 patients were randomly divided into 3 groups. Group M: Patients treated with a topical corticosteroid 0.05% mometasone furoate spray (n = 30). Group L: Patients sprayed with 10% lidocaine (n = 30). Control group: Patients treated with 0.9% normal saline applied around the cuff (n = 31). The systolic, diastolic, and mean blood pressures, heart rate, and SpO₂ values were recorded before operation, after induction, before and after tracheal intubation, and before and after extubation. Patients were followed up for 24 h postoperatively. Results: A statistically significant decrease was found in the lidocaine group for diastolic and mean arterial pressures measured after tracheal intubation (p = 0.018 and p = 0.027, respectively). There was a significant decrease in heart rate values in Group L after extubation (p = 0.024). Cough was observed in 5 patients in the control group at the postoperative 12th hour, but not in the other groups (p = 0.009). The distribution of sore throat severity, dyspnea, and hoarseness and the incidence of early postoperative bronchospasm, recorded in all follow-up periods, decreased; however, it did not show a statistically significant difference. Conclusions: In conclusion, this study revealed that the topical application of lidocaine and mometasone around the tracheal tube cuff in children not only reduces postoperative cough but also, in the case of lidocaine, suppresses the hemodynamic stress response during both tracheal intubation and extubation. Full article

Acute cardiovascular disorders are incriminated in up to 33% of maternal deaths, and the presence of sickle cell anemia (SCA) aggravates the risk of peripartum complications. Herein, we present a 24-year-old Caribbean woman with known SCA who developed a vaso-occlusive crisis at 36 weeks of gestation that required emergency Cesarean section. In the early postpartum period, she experienced fever with rapid onset of acute respiratory distress in the context of COVID-19 infection that required tracheal intubation and mechanical ventilatory support with broad-spectrum antibiotics and blood exchange transfusion. Shortly thereafter, transthoracic echocardiography documented severe biventricular dysfunction associated with raising levels of cardiac troponin and ECG signs of myocardial ischemia. Medical treatment with incremental dobutamine and noradrenaline infusion failed to improve cardiac output and blood gas exchange. After consultation with the regional cardiac center, a prompt decision was made to provide cardiac and respiratory support via implantation of femoral cannula and initiation of veno-arterial extracorporeal membrane oxygenation (ECMO, Cardiohelp^®). Under stable ECMO, the patient was transferred by helicopter to a specialized cardiac center. There were no signs of ongoing hemolysis, and progressive recovery of the right and left ventricular function facilitated forward blood flow through the aortic valve. Three days after implantation, ECMO was weaned, and the cannula were removed. One day later, the patient’s chest X-rays showed partial resolution of lung edema. The patient was successfully extubated, and non-invasive ventilation with pulmonary rehabilitation was initiated to speed up her functional recovery. Full article

Background/Objectives: A recent retrospective study conducted by our team identified a high percentage of postoperative pneumonia in children with neuromuscular scoliosis. Based on the findings in that study and our clinical experience, we aimed to assess the effectiveness of an optimized perioperative care protocol. Methods: As part of a prospective study, a multidisciplinary team developed a protocol that included preoperative nutritional and respiratory optimization, intra- and postoperative intravenous glucose infusion, early extubation, and postoperative nutritional optimization. Non-ambulant children between 6 and 18 years of age with neuromuscular scoliosis were eligible for inclusion in the study. The primary outcome was the rate of postoperative pneumonia within 30 days of surgery. The secondary outcome measures were the rate of postoperative complications, including readmissions. All the outcomes were compared to a retrospective control group that was receiving standard care during the same period. Results: Eleven children were included in the intervention group and 14 in the control group. In regard to the intervention group, the nutritional and respiratory assessment before surgery resulted in optimized treatment in 8/11 patients (73%) and 9/11 patients (82%), respectively. One patient (9%) in the intervention group and three patients (21%) in the control group developed postoperative pneumonia (relative risk 0.42, 95% confidence interval 0.05–3.50). The intervention and control groups did not differ significantly in terms of postoperative complications or readmission rates. Conclusions: The multidisciplinary care protocol is feasible, with a high compliance rate in regard to study procedures. A numerical reduction in the 30-day pneumonia rate did occur in the intervention group; however, this reduction did not reach statistical significance. Full article

Transoral robotic surgery (TORS) for tongue base reduction (TBR) and/or epiglottic surgery is an effective treatment option for selected patients with moderate to severe obstructive sleep apnoea (OSA). This systematic review aims to provide an up-to-date overview of current practices and challenges associated with TORS for OSA. PubMed and Embase databases were searched up to December 2022 following PRISMA guidelines. Primary outcome measures were surgical technique, intraoperative measures, postoperative management and complications. A total of 32 articles, including 2546 patients, met the inclusion criteria. TORS was most commonly performed as part of a multilevel surgical approach. Nasotracheal intubation was the preferred method for general anaesthesia. The surgical technique for TORS tongue base and epiglottis did not differ significantly among institutions, although some variations exist. Postoperative management varied, with most authors aiming for immediate postoperative extubation, routine postoperative ward admission and early oral intake initiation. Common postoperative complications were dysphagia and bleeding, with no reported mortality. TORS is established as a safe and feasible surgical option for selected OSA patients, addressing tongue base and/or epiglottic obstruction. However, further studies are required to determine patients’ selection criteria, preferred volume of excised tongue tissue and to assess the necessity for postoperative intensive care unit monitoring. Full article

Thoracic surgery is a highly complex field requiring collaboration between surgeons, anesthesiologists, pulmonologists, and other specialists. Successful outcomes depend on thorough preoperative evaluations that consider the patient’s overall health, lifestyle habits, and surgical risks. Key elements include proper intraoperative anesthesia management, postoperative pain control, and the integration of enhanced recovery after surgery (ERAS) protocols to optimize recovery. Double-lumen tubes (DLTs) are essential for one-lung ventilation during thoracic procedures, although they can be invasive. Recent advancements, such as video-assisted laryngoscopes, have improved the success of DLTs and reduced the invasiveness of DLT intubation and extubation. Postoperative pain management is crucial for minimizing complications and enhancing recovery. Techniques like epidural analgesia, nerve blocks, and patient-controlled analgesia improve patient outcomes by allowing early mobility and deep breathing. Dexmedetomidine (DEX), a sedative with minimal respiratory impact, has shown promise in reducing delirium and aiding recovery. This review highlights the importance of teamwork, pain management, and emerging technologies in improving thoracic surgery outcomes. Advances in these areas, particularly within ERAS protocols, continue to enhance patient care and overall surgical success. Full article