Search Results (263)

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

Background: Down syndrome (DS) is associated with unique anatomical and physiological characteristics that complicate the perioperative management of infants undergoing cardiac surgery. While ventricular septal defect (VSD) repair is commonly performed in this population, detailed data comparing perioperative outcomes in DS versus non-syndromic infants remain limited. Methods: This retrospective matched study analysed 100 infants (50 with DS and 50 without DS) who underwent isolated VSD closure between January 2021 and January 2025. Patients were matched by age and surgical date. Intraoperative anesthetic management, complications, postoperative outcomes, and mortality were compared between groups. Results: DS patients had lower age, weight, and height at surgery. They required significantly smaller endotracheal tube sizes, more intubation and vascular access attempts. The DS group had significantly lower rates of extubation in the operating room and experienced longer durations of mechanical ventilation and ICU stay. However, no significant differences were observed in total hospital stay or mortality between groups. Conclusions: Although DS infants present with increased anesthetic complexity and respiratory challenges, they do not exhibit higher surgical mortality following isolated VSD closure. Tailored perioperative strategies may improve respiratory outcomes in this high-risk group. Full article

Background/Objectives: Sternal pain after cardiac surgery results in considerable discomfort and may contribute to the development of chronic postoperative sternal pain syndrome. Parasternal intercostal plane blocks have been shown to improve postoperative sternal pain and can be an essential part of enhanced recovery after cardiac surgery (ERACS). This cohort study evaluated the postoperative impact of a single-shot deep parasternal intercostal plane block (PIPB) on the requirement of analgesic medication and pain sensation up to 48 h. Methods: This retrospective single-center analysis evaluates the postoperative acute pain in 157 patients undergoing off-pump coronary artery bypass (OPCAB) with median sternotomy. The additive analgesic effects of deep PIPB (38 patients) were compared to a group with standard therapy but without PIPB (119 patients). To strengthen the findings, a propensity score matching analysis was performed. Outcomes included the consumption of emergency pain agents (piritramide), the requirement of the total morphine equivalent (ME), time to extubation, and ICU length of stay. Furthermore, we examined pain sensation with evaluation by using the behavioral pain score (BPS) and numeric rating score (NRS) up to 48 h after extubation. Results: The deep PIPB reduced the piritramide administration 24 h and 48 h after OPCAB surgery. Moreover, the requirement of ME was 24 h and 48 h after bypass surgery also significantly decreased. The one-to-one propensity score matching confirmed our primary findings and showed a decreased requirement for intravenous agents. Additionally, we observed a reduced time for extubation and a decreased NRS rating. However, no significant changes were observed in ICU length of stay, incidence of nausea, and vomiting. Conclusions: Our data suggests that an ultrasound-guided single-shot deep PIPB can be a valuable tool for a multimodal analgesic protocol on patients undergoing OPCAB surgery. Full article

Background: Tracheal intubation and mechanical ventilation are facilitated by neuromuscular blocking agents. We investigated the effectiveness of subjective clinical evaluation of neuromuscular function on retroglossal area size, since it determines spontaneous ventilation adequacy following tracheal extubation. Secondarily, we correlated changes in retroglossal area and depth of neuromuscular block assessed during both respiratory phases using quantitative neuromuscular monitoring. Methods: Once mechanical ventilation was no longer needed, antagonists were used to reverse the neuromuscular block in 21 consenting patients; adequacy of reversal was assessed subjectively by delivering a sequence of four rapid (2 Hz) electrical stimuli (train-of-four, TOF) to a peripheral nerve and assessing attainment of four equal muscle contractions (TOF ratio = 1.0), signifying normal neuromuscular function. Retroglossal area during both inhalation and exhalation were measured pharyngoscopically at various phases of neuromuscular recovery, including at baseline after anesthesia induction but before neuromuscular block onset and at recovery before tracheal extubation; area changes were correlated with depth of quantitatively measured neuromuscular block. Results: Clinicians’ subjective evaluation of readiness for tracheal extubation failed to identify significant residual block in most patients who required rescue antagonism. Markedly decreased retroglossal areas (inhalation: 39.5% of baseline; exhalation: 20.1% of baseline) were present at extubation, and 11 out of 21 (52.4%) patients needed rescue antagonism. In contrast, in patients with neuromuscular recovery to the currently recommended threshold determined quantitatively (TOF ratio > 0.90), retroglossal areas were only 80% recovered but returned to near baseline values when the TOF ratio ≥ 0.95. Conclusions: Quantitative monitoring should guide the timing of tracheal extubation. Current definitions of the minimal threshold for adequate neuromuscular recovery (TOF ratio > 0.90) after mechanical ventilation in postoperative patients should be re-evaluated. A TOF ratio > 0.95 better correlates with return to normal (baseline) retroglossal area during both inhalation and exhalation. Full article

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 and Clinical Significance: The incidence of persistent ductus arteriosus (PDA) in preterm infants is the highest and depends on their birth weight (BW) and respiratory condition after birth. Previously, after the unsuccessful drug treatment, surgical ligation was the primary treatment option. However, according to clinical studies, the Amplatzer Piccolo Occluder was approved for PDA closure for patients ≥700 g. In our country, percutaneous PDA embolization has not been performed yet. Case Presentation: We present three premature infants with hemodynamically significant patent ductus arteriosus (hsPDA) in whom percutaneous occlusion was performed using the Amplatzer Piccolo Occluder (APO). The average gestational week (GW) was 27 ± 1, while body weight was 1030 ± 60 g. All patients had respiratory deterioration, with dilatation of the left heart chambers, and renal failure. The second developed a severe form of broncho-pulmonary dysplasia. Transthoracic echocardiography (TTE) examinations revealed a hemodynamically significant PDA (LA/Ao 1.8–2.2) and medical closure was unsuccessfully carried out. Due to the hemodynamically significant PDA maintenance in all neonates, transvenous PDA closure was performed using the APO (APO 9-PDAP-04-02-L, 9-PDAP-04-04-L, 9-PDAP-05-054L, respectively). The entire devices, with both retention discs, are implanted within the duct. TTE pointed out adequate device position without descending aorta, left pulmonary artery obstruction, residual shunt, and reverse remodelling of the left ventricle and left atrium. The first newborn was weaned from mechanical ventilation three days after the procedure and discharged three weeks after. The second patient was extubated 2 weeks after the procedure, and even the severe BPD, X-ray showed improvement. The third patient’s renal failure completely resolved, weaned from inotropic drug support and mechanical ventilation. Conclusions: Due to a significantly lower complication rate than surgical ligation, we will strive to make percutaneous PDA occlusion a new standard for treatment in newborns, especially preterm newborns, in our country. 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

Background/Objectives: Preterm neonates with a birth weight (BW) of 500–1250 g who receive prophylactic methylxanthine have a lower rate of bronchopulmonary dysplasia and neurodevelopmental disability than their counterparts. In a meta-analysis of previous studies (published during 1985–1993, with no routine continuous positive airway pressure), extubation failure rates in preterm neonates with BW < 2500 g who received and did not receive methylxanthine were 25.0% and 50.6%, respectively (risk difference, −0.27; 95% confidence interval [CI], −0.39 to −0.15). However, no study to date has assessed the effects of prophylactic methylxanthine use on endotracheal extubation in infants weighing 1250–2499 g until now. Methods: First-time extubation was compared between 1:1 propensity score-matched methylxanthine and non-methylxanthine groups from a retrospective cohort of 541 neonates (born during 2014–2024). Results: The domains from the overall cohort and propensity-matched data included 541 and 192 neonates, respectively. In the propensity score-matched sample, the mean gestational age and BW were 30.9 ± 1.9 weeks and 1584 ± 273 g, respectively. The median 5-min Apgar score was 9 (range of 7–9). Extubation failure within 7 days occurred in 10 (10.4%) and 13 (13.5%) neonates in the methylxanthine (n = 96) and non-methylxanthine (n = 96) groups, respectively, with a risk difference (95% CI) of −0.03 (−0.12 to 0.06), p = 0.50, and hazard ratio (95% CI) of 0.76 (0.33 to 1.72), p = 0.51. Conclusions: In the current era with new non-invasive ventilation approaches, extubation failure in preterm neonates with a BW of 1250–2499 g is not significantly affected by the use of methylxanthine. Full article

Background: Regional anesthesia techniques are increasingly used for pain management in minimally invasive cardiac surgery (MICS). We aimed to evaluate whether the combination of interpectoral plane block (IPB) and superficial serratus anterior plane block (SAPB) provides non-inferior postoperative analgesia compared to erector spinae plane block (ESPB) in adult patients undergoing MICS. Methods: In this prospective, single-center, double-blind, randomized, non-inferiority trial, 40 adult patients scheduled for MICS were allocated to receive either ESPB (n = 20) or a combination of IPB + SAPB (n = 20) prior to surgical incision. All patients received standardized anesthesia. Pain was assessed using the Critical-Care Pain Observation Tool (CPOT) during intubation and the Numerical Rating Scale (NRS) at 6–48 h postoperatively, following extubation. The primary outcome was the NRS score at 24 h. A non-inferiority margin of 2 NRS points was pre-specified, and non-inferiority was evaluated using between-group differences with 95% confidence intervals. Opioid consumption was recorded via PCA fentanyl and rescue analgesics, converted to morphine milligram equivalents (MMEs). Secondary outcomes included extubation time and postoperative nausea and vomiting (PONV). Results: Median 24 h NRS was 3.0 (0–5.0) in the ESPB group and 2.5 (0–5.0) in the IPB + SAPB group. The between-group difference remained within the predefined two-point margin (95% CI: −0.8 to 1.2). Opioid consumption (p = 0.394), extubation time, and PONV incidence were comparable (all p > 0.05). No block-related complications occurred. Conclusions: IPB + SAPB was non-inferior to ESPB for postoperative analgesia in MICS. Despite requiring two injections, it remains an effective alternative. Larger trials are needed to confirm these findings. Full article

Background/Objectives: Remifentanil and dexmedetomidine are widely used agents for pain management during general anesthesia. Adropin acts as a regulator of endothelial function by affecting nitric oxide bioavailability and various hemodynamic factors, including blood flow, vascular dilatation, and mean arterial pressure. We aimed to evaluate the effects of remifentanil and dexmedetomidine on adropin and eNOS levels and hemodynamic parameters in patients undergoing unilateral single-level lumbar microdiscectomy under controlled hypotension. Methods: This study included 40 patients who underwent lumbar microdiscectomy and were randomly assigned to two groups: 20 patients received remifentanil, and 20 received dexmedetomidine. Hemodynamic parameters, preoperative and postoperative VAS scores, and intraoperative blood loss were recorded. Adropin and eNOS mRNA levels were measured with RT-qPCR at three time points: preoperative (T1), intraoperative (T2), and postoperative (T3). Adropin protein levels were evaluated using ELISA. Results: The remifentanil and dexmedetomidine groups had similar heart rate, arterial pressure, intraoperative blood loss, surgery time, and VAS scores. The extubation time was longer with remifentanil. Adropin mRNA level was higher in remifentanil at all time points. At T2, the eNOS mRNA level was higher in the remifentanil group. In the dexmedetomidine group, adropin mRNA levels decreased at T2 compared to T1. Adropin protein levels were higher in the remifentanil group at T2 and T3. In the dexmedetomidine group, serum adropin levels decreased at T3 compared to those at T1. Preoperative VAS scores in patients receiving both remifentanil and dexmedetomidine were higher than postoperative VAS scores. No significant correlation was observed between VAS scores and adropin levels or between intraoperative blood loss and adropin protein levels. Conclusions: Both drugs demonstrated similar effects on the hemodynamics of the patients, and adropin levels were not associated with the VAS score and intraoperative blood loss. These findings suggest that dexmedetomidine mediates vasodilation through adropin-independent mechanisms, while remifentanil may provide more favorable surgical conditions through adropin in patients undergoing unilateral single-level lumbar microdiscectomy. 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: Stress-induced cardiomyopathy (SI-CM) is a transient left ventricular dysfunction triggered by emotional or physical stress, often resolving with supportive care. However, severe cases may progress to cardiogenic shock (CS), requiring mechanical circulatory support (MCS). High-profile transvalvular pumps (HPTP), a form of percutaneous ventricular assist device, offer promising hemodynamic support in acute heart failure. This report explores HPTP use in SI-CM-related CS through two complex clinical cases. Case Summary: Two elderly female patients presented with severe CS secondary to apical-variant SI-CM. Case 1 involved a 67-year-old woman with sepsis, colonic perforation, and recurrent SI-CM, leading to profound low-output shock despite multiple vasopressors and inotropes. HPTP was implanted via the axillary artery, allowing for surgical management of intra-abdominal pathology and eventual cardiac recovery. Case 2 featured a 77-year-old woman with multifocal pneumonia, severe mitral regurgitation, and complete heart block. HPTP implantation stabilized her hemodynamics, facilitated extubation, and led to full recovery of ventricular function. Results: Both patients showed marked improvement in cardiac output and systemic perfusion following HPTP insertion. Echocardiograms post-device removal revealed normalization of left ventricular ejection fraction (55–64%). Hemodynamic data confirmed reduced pulmonary capillary wedge pressure and systemic vascular resistance. Conclusion: These cases highlight the potential of HPTP in managing SI-CM-related CS, especially when traditional therapies are inadequate or contraindicated. HPTP can rapidly restore hemodynamic stability and support myocardial recovery. While current data are limited, these observations underscore the need for broader investigation into the role of HPTP in this setting. 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

Background and Objectives: Extensive research has demonstrated that various approaches to the quadratus lumborum (QL) block offer superior postoperative analgesia compared to the transversus abdominis plane (TAP) block, particularly in reducing opioid consumption. This study aims to compare postoperative analgesia between the blocks in laparoscopic colorectal surgery. Materials and Methods: A retrospective analysis was performed on patients with elective colorectal surgeries who received bilateral US TAP blocks in the supine position or US anterior QL block in the lateral position at the end of the surgery and before extubating, with Ropivacaine 0.25%. Total opioid consumption and time to first intravenous analgesic were noted. Results: Between January 2020 and December 2024, 410 patients underwent elective laparoscopic colorectal oncology surgery under general anesthesia, with peripheral nerve blocks. Of these, we analyzed 116 patients with localized diseases who underwent elective surgeries and who did not require conversion to classical surgery and received either QL or TAP blocks. A total of 62 patients underwent QL block and 54 received TAP block. For the primary outcome, in the QL group, significantly fewer opioids were used than in the TAP group (p < 0.001), and time to first rescue analgesic was prolonged in the QL group at 16 h (IQR 14–18) compared to the TAP group, where the requirement occurred earlier at 8 h (IQR 8–8) postoperatively (p < 0.001). Conclusions: Postoperative bilateral US anterior QL block reduced morphine consumption and improved time to rescue analgesia and LOS compared with midaxillary line bilateral US TAP block. Full article

Background: The optimal timing of high-flow nasal cannula (HFNC) application in acute respiratory failure patients remains uncertain. This study aimed to investigate the impact of HFNC on the outcomes of patients with acute respiratory failure, focusing on its use after extubation. Methods: This multicenter retrospective study enrolled adult acute respiratory failure patients requiring invasive mechanical ventilation during the first major outbreak of the COVID-19 pandemic in Taiwan from April to July 2021. Endpoints included prognosis after extubation as 28-day post-extubation mortality. Results: Among the patients, 107 received HFNC before intubation and 461 received conventional oxygen therapy (COT). Pre-intubation HFNC failure did not significantly affect hospital mortality but was associated with prolonged durations of mechanical ventilation and intensive care unit stay. Among 375 patients who underwent planned extubation, 158 received post-extubation HFNC and 217 received COT. HFNC application after extubation was associated with significantly reduced post-extubation 28-day mortality compared with COT. Conclusions: HFNC application after extubation is associated with reduced post-extubation 28-day mortality risks in acute respiratory failure patients who received planned extubation. Full article