Anesthetic implications and role of preoperative beta blockade in esophageal substitution with stomach in pediatric surgical patients

Background There is a paucity of literature on the anesthetic management of pediatric esophageal substitution using the stomach. We did a retrospective analysis of all such cases done at our institution. We analyzed the patient’s demography, indication, and type of surgery, co-morbid conditions, anesthesia techniques, duration of postoperative ventilation, hospital stay, complications, and mortality. The use of beta-blockers and their effect on the incidence of intraoperative and postoperative tachycardia in gastric pull-up patients was also analyzed. Results Thirty-four cases of gastric substitution of the esophagus in children were done over 19-year period; gastric pull-up was done in 28 patients and a gastric tube was made in 6 patients. General anesthesia was given to all; a thoracic epidural for pain was sited in 25 patients. Twenty-eight patients were ventilated postoperatively; the mean duration of ventilation is 54 h. Significant intraoperative tachycardia was observed in 85.7% of patients without beta-blocker as compared to 23.8% patients with beta-blocker (p = 0.004). Postoperatively, tachycardia was absent in patients receiving beta-blocker and present in 71.4% of patients not receiving beta-blockers (p < 0.001). Overall mortality was 8.8% but mortality due to cardiac arrhythmia was 42.9% in the patients not receiving beta-blockers (p = 0.001). Conclusions A thorough preoperative preparation, control of tachyarrhythmias, postoperative ventilation, and pain management is recommended for a favorable outcome. In addition, our paper supports the preoperative use of beta-blockers in reducing the incidence of fatal tachyarrhythmias associated with gastric pull-up surgery without any serious adverse effects. Level of evidence Level III

Real and predicted lung function after anatomical lung resections (review of literature)

The function of the respiratory parenchyma remaining after lung resection is one of the determining factors of the immediate result of the operation and the postoperative quality of life. A number of studies have been conducted to objectify the preoperative prognosis of the functional safety limit of thoracic interventions using a variety of methods and formulas. Unfortunately, until now, there is no convincing data on the correctness of at least one of the proposed methods for predicting respiratory function. The process of rehabilitation of postoperative ventilation function in the lungs is affected not only by the volume of parenchymal resection, but also by the area of resection, the method and trauma of access, the severity of emphysema, intraoperative trauma of mediastinal structures, postoperative progression of pulmonary fibrosis, etc., and video assisted surgery and segmental resections do not provide an obvious functional advantage in the long term after operations. During the first year after anatomical resection of the lung, functional indicators usually improve. Reasons (or reason) of such improvements are not always clear and may be associated with compensatory growth of the pulmonary parenchyma in a number of patients.

Acute pulmonary edema due to occult air embolism detected on an automated anesthesia record: illustrative case

BACKGROUNDThe authors report a case of venous air embolism (VAE) during a pediatric posterior fossa craniotomy with resulting pulmonary edema requiring postoperative ventilation. Pulmonary edema is a known but rare complication of VAE, and diagnosis and treatment are discussed.OBSERVATIONSThe embolism was undetected during the surgical procedure, and the first clinical sign of respiratory decompensation appeared an hour after the initial insult, with imaging suggesting acute pulmonary edema. A transient but significant end-tidal carbon dioxide decrease was detected on postoperative review of the anesthesiology record.LESSONSThis report highlights an uncommon sequela of VAE and the importance of post hoc automated record review for intraoperative event analysis.

Myasthenia is a poor prognosticator for perioperative outcomes after robotic thymectomy for thymoma

OBJECTIVES The goal of this study was to compare the early and intermediate surgical outcomes, including the survival of those with and without myasthenic thymoma, following robotic thymectomy. METHODS This is a retrospective analysis of prospectively maintained data of 111 patients who underwent robotic thymectomy for thymoma over 7 years in a thoracic surgery centre in India. We performed a comparative analysis of demographics, intraoperative variables and postoperative outcomes including survival of those with and without myasthenic thymoma. RESULTS Of 111 patients, 68 patients were myasthenic and 43 were non-myasthenic. The need to resect surrounding structures and conversions was greater in the myasthenic group (P = 0.02, P = 0.04). Postoperative complications were significantly higher in the myasthenic group (P = 0.02). No differences were observed in intensive care unit stay, the need for postoperative ventilation and the hospital stay. On correlation, a higher Masaoka stage [odds ratio 1.96, 95% confidence interval (CI) 1.22–3.15] and an aggressive World Health Organization histological diagnosis (odds ratio 1.58, 95% CI 1.10–2.26) were more likely in patients with myasthenia gravis. A total of 7 deaths (6.3%) occurred during the median follow-up of 4.2 years, 5 among those with myasthenic thymoma and 2 among patients with non-myasthenic thymoma. Due to the small number of deaths, there is insufficient evidence to draw any conclusion about the effect of myasthenia gravis on survival after surgery (hazard ratio 0.51, 95% CI 0.09–2.71; P = 0.43). CONCLUSIONS The presence of myasthenia with thymoma is associated with more adjacent structure resection, higher postoperative complications and more conversions. The use of robotic surgery for thymoma resection in patients with myasthenia could not overcome the early postoperative problems related to myasthenia gravis.

A retrospective audit of anaesthesia for caesarean section in parturients with eclampsia at a tertiary referral hospital in Cape Town

Background: Anaesthesia for caesarean section (CS) in women with eclampsia is a major clinical challenge, and there are limited data concerning the rationale for the choice of technique, and short-term outcomes. A retrospective audit was performed on practice at a tertiary referral centre in Cape Town. Methods: The primary outcome of the audit was the proportion of patients with eclampsia receiving either spinal anaesthesia (SA) or general anaesthesia (GA) for CS, and an assessment of the rationale for the choice of method. In addition, short-term maternal and neonatal outcomes were recorded. Results: There were 11 exclusions in 100 patient records screened, therefore 89 were analysed. Seven/89 (7.9%) patients received SA and 82/89 (92.1%) GA. Overall, 63/89 (70.8%) patients had a preoperative GCS < 14, and 26/89 (29.2%) ≥ 14. Seven/26 patients with GCS ≥ 14 had SA; the remaining 19/26 received GA. GA was performed because there was no platelet count available in three, pulmonary oedema in two, difficult airway due to a bitten tongue in two, fetal bradycardia in two, HELLP syndrome in one, renal failure in one, and patient refusal in one patient. In seven women, there was no clear reason for GA. Median (IQR) Apgar scores at 1 minute in SA patients (8 [8–9]) were higher than those in GA patients with GCS ≥ 14 (5 [3–6]) and < 14 (4 [2–6]), p = .008 and .001 respectively. At five minutes, neonates of SA patients had median scores of 10 [9–10], compared with 8 [7–8] in those of GA patients with GCS ≥ 14, and 8 [7–9] in those with GCS < 14, p = .007 and .019 respectively. There were two stillbirths and two neonatal deaths in the GA group. Patients with GCS ≥ 14 receiving GA required mechanical ventilation for 0 [0–1] days, and those with GCS < 14 were ventilated for 1 [1–2] days. No patients receiving SA required postoperative ventilation, compared with 5/19 (26.3%) patients with GCS ≥ 14 who received GA. Seven/63 patients with GCS < 14 had cerebral oedema, and two had a cerebral infarct. There were two maternal deaths. Conclusions: The small percentage of women with eclampsia who received SA for CS, experienced good maternal and fetal outcomes, and more patients could have safely received SA. Larger prospective audits in high- and low-resource environments are required to establish factors influencing the context-sensitive choice of method of anaesthesia, and risk versus benefit of GA versus SA for CS in women with eclampsia.

Acute kidney injury in patients operated on for type A acute aortic dissection: incidence, risk factors and short-term outcomes

OBJECTIVES Acute kidney injury (AKI) is a relatively common complication after an operation for type A acute aortic dissection and is indicative of a poor prognosis. We examined the risk factors for and the outcomes of developing AKI in patients being operated on for thoracic aortic diseases. METHODS We retrospectively analysed 712 patients with acute type A dissection who had deep hypothermic circulatory operations from January 2014 to December 2018, emphasizing those who developed AKI. Logistic regression models were used to identify predisposing factors for the postoperative development of AKI. RESULTS Among all enrolled patients, 359 (50.4%) had AKI; of these, 133 were diagnosed as stage 1 (18.7%), 126 were stage 2 (17.7%) and 100 were stage 3 (14.0%). Postoperative haemodialysis was required in 111 patients (15.9%). The development of AKI after aortic surgery contributed to the higher mortality rate within 30 days after surgery (P &lt; 0.001), longer stay in the intensive care unit (P = 0.01) and longer hospital stay (P &lt; 0.001). Binary logistic regression analysis showed that preoperative cystatin C levels [odds ratio (OR) 2.615, 95% confidence interval (CI) 1.139–6.002; P = 0.023] and postoperative ventilation time (OR 1.019, 95% CI 1.005–1.034; P = 0.009) were independent risk factors for developing AKI. Multiple ordinal logistic regression analyses showed that the preoperative cystatin C level (OR 2.921, 95% CI 1.542–5.540; P = 0.001) was an independent risk factor associated with the severity of AKI. CONCLUSIONS Our data suggested that the development of AKI after surgery for type A acute aortic dissection was common and associated with an increased short-term mortality rate. The preoperative cystatin C level was identified as an indicator for the occurrence and severity of AKI postoperatively. Furthermore, we discovered that longer postoperative ventilation time was also associated with the development of AKI.

Analysis of 87 cases of laparoscopic choledochotomy with primary suture

To investigate the feasibility and clinical effect of laparoscopic choledochotomy for primary suture of bile duct. Methods: There were 190 cases of cholecystolithiasis with choledocholithiasis. They were randomly divided into endoscopic group and open group. In the endoscopic group ,87 patients underwent laparoscopic choledocholithotomy and primary bile duct suture. A total of 103 patients in open group were treated with open bile duct incision and T tube drainage. The operative time, intraoperative blood loss, postoperative ventilation time, hospital stay and postoperative complications were compared between the two groups. Results: The length of hospital stay, the amount of bleeding during operation and the time of postoperative ventilation were less than those in open group. The operation time was longer than that in open group, P <0.01. There were 0 cases of postoperative incision infection ,2 cases of bile leakage and 1 case of residual stone in endoscopic group. The incidence of complications was 5.7%. The open group was 5,3,3 and 10.7% respectively. Comparison of complications between the two groups, P<0.01. Conclusion: Select the right case strictly, Laparoscopic and choledochoscopy combined with cholecystolithiasis with choledocholithiasis is effective, safe and minimally invasive, short hospitalization time and less complications.