Emergency exploratory laparotomy in a COVID-19 patient - A case report.

BACKGROUND: Surgeries in patients with coronavirus disease 2019 (COVID-19) put medical staff at a high risk of infection. We report the anesthetic management and infection control of a mechanically ventilated COVID-19 patient who underwent exploratory laparotomy for suspected duodenal ulcer perforation. CASE: A 73-year-old man, mechanically ventilated for confirmed COVID-19, showed clinical and radiographic signs of a perforated duodenal ulcer, and he was transferred under sedation and intubation to a negative-pressure operating room. The operating and assistant staff wore personal protective equipment. High-efficiency particulate absorbing filters were inserted into the expiratory circuits of the anesthesia machine and portable ventilator. No participating staff contracted COVID-19, although the patient later died due to pneumonia. CONCLUSIONS: This report can contribute to establishing clinical guidelines for the surgical management and operation room setting of COVID-19 patients.

Airway obstruction during pneumonectomy using a single lumen tube: A case report.

RATIONALE: Endotracheal intubation is an essential step for airway management during general anesthesia. When surgeons carry out thoracic surgery such as pneumonectomy, they usually request lung isolation to secure a clear surgical view. A double lumen endotracheal tube is used for lung isolation in routine thoracic surgeries. PATIENT CONCERNS: A 56-year-old man was previously diagnosed with left Aspergilloma, a tuberculosis destroyed lung, and diabetes mellitus. According to his chest x-ray and chest computed tomography, his left lung was nearly collapsed, and the result of a pulmonary function test was severely restricted. The patient's diffusing capacity for carbon monoxide was 63% and predicted postoperative forced expiratory volume in 1 second was 23.5% DIAGNOSES:: Due to his previous history, radiologic findings and laboratory test results, he was diagnosed with left Aspergilloma and tuberculosis destroyed lung. INTERVENTIONS: Due to recurrence of Aspergilloma in his left lung, the patient was scheduled for a left pneumonectomy. Since the patient's partial oxygen concentration was adequate despite his left lung being nearly totally collapsed, we thought that we would be capable of performing the pneumonectomy using a single lumen tube (SLT). For a better surgical view, we planned lung isolation via insertion of a SLT deep into the bronchus. OUTCOMES: During pneumonectomy, after tracheal suction was performed, we tried a lung recruitment maneuver. Suddenly end-tidal carbon dioxide did not show on the monitor. The patient's blood pressure dropped and heart rate was decreasing. We thought that cardiopulmonary resuscitation was needed and an approximately 2 cm sized hematoma was removed from the endotracheal tube after vigorous suctioning. After getting rid of the hematoma, we changed the single tube to a double lumen tube (DLT). LESSONS: This case led us to the conclusion that a DLT should be used for safety when carrying out thoracic surgery. We report a rare case of an airway obstruction using a SLT during pneumonectomy.

Transforaminal Epidural Balloon Adhesiolysis via a Contralateral Interlaminar Retrograde Foraminal Approach: A Retrospective Analysis and Technical Considerations.

Several treatment modalities have been proposed for foraminal stenosis, but the treatment options remain unsatisfactory. Previous studies have shown that transforaminal balloon adhesiolysis may be effective in patients with refractory lumbar foraminal stenosis. However, in patients with a high iliac crest, balloon catheter insertion may be difficult via a conventional transforaminal approach (particularly targeting the L5-S1 foramen). It has been reported that an epidural catheter can be placed easily by a contralateral interlaminar retrograde foraminal approach. Therefore, we applied this approach to L5-S1 transforaminal balloon adhesiolysis in patients with a high iliac crest. We retrospectively analyzed data from 22 patients who underwent combined epidural adhesiolysis and balloon decompression (balloon adhesiolysis) using the novel foraminal balloon catheter via a contralateral interlaminar retrograde foraminal approach. The pain intensity significantly decreased over the three-month period after balloon adhesiolysis (p < 0.001). There were no complications associated with the balloon procedure. The present study suggests that balloon adhesiolysis for L5-S1 foramen via a contralateral interlaminar retrograde foraminal approach may be an effective alternative for patients with a high iliac crest and refractory lumbar radicular pain due to lumbar foraminal stenosis. In addition, detailed procedural aspects are described here.

Factors Associated with Successful Responses to Transforaminal Balloon Adhesiolysis for Chronic Lumbar Foraminal Stenosis: Retrospective Study.

BACKGROUND: Recently, transforaminal balloon adhesiolysis was introduced to manage patients with chronic radicular pain occurring with or without low back pain. However, the factors associated with successful responses to transforaminal balloon adhesiolysis are not known. OBJECTIVE: To evaluate the factors associated with successful responses to transforaminal balloon adhesiolysis for chronic lumbar spinal stenosis. STUDY DESIGN: This is a retrospective observational study. SETTING: A single pain clinic of tertiary medical center in Seoul, Republic of Korea. METHODS: From January 2013 to December 2014, a retrospective review of 199 patients with chronic lumbar foraminal stenosis, who were scheduled for transforaminal balloon adhesiolysis, was performed. Patients were considered successful responders if they showed either of the following: 1) a decrease of more than 50% on the numerical rating scale or 2) a decrease of more than 30% on the numerical rating scale and improved functional status 3 months after transforaminal balloon adhesiolysis. Logistic regression analysis was performed to determine the factors associated with successful responses to this surgical procedure. RESULTS: Three months after the transforaminal balloon adhesiolysis, 49.4% of patients were considered successful responders. Multivariate logistic regression analysis showed that factors other than degenerative disc herniation were independently associated with successful responses 3 months after this surgical procedure (odds ratio = 0.327; 95% confidence interval = 0.129 - 0.827; P = 0.018). LIMITATIONS: The definition of successful response used in this study differed from the ones used in previous studies; a different definition may have led to different results. Further, the effects of other factors (ballooning, drugs, and saline washes) could not be excluded from our study. In addition, the correct method of assessing functional status, the Oswestry Disability Index, could not be used in this study; hence, the final results may have been affected. CONCLUSION: These results suggest that transforaminal balloon adhesiolysis can successfully lead to improvement of symptoms in patients with chronic lumbar foraminal stenosis caused primarily by degenerative disc herniation.Institutional Review Board (IRB) approval number: 2016-0228.Key words: Balloon, epidural adhesiolysis, chronic pain, radicular pain, lumbar spine, foraminal stenosis, degenerative disc.

Comparison of Acute Kidney Injury After Robot-Assisted Laparoscopic Radical Prostatectomy Versus Retropubic Radical Prostatectomy: A Propensity Score Matching Analysis.

Acute kidney injury (AKI) is associated with extended hospital stay, a high risk of progressive chronic kidney diseases, and increased mortality. Patients undergoing radical prostatectomy are at increased risk of AKI because of intraoperative bleeding, obstructive uropathy, older age, and preexisting chronic kidney disease. In particular, robot-assisted laparoscopic radical prostatectomy (RALP), which is in increasing demand as an alternative surgical option for retropubic radical prostatectomy (RRP), is associated with postoperative renal dysfunction because pneumoperitoneum during RALP can decrease cardiac output and renal perfusion. The objective of this study was to compare the incidence of postoperative AKI between RRP and RALP.We included 1340 patients who underwent RRP (n = 370) or RALP (n = 970) between 2013 and 2014. Demographics, cancer-related data, and perioperative laboratory data were evaluated. Postoperative AKI was determined according to the Kidney Disease: Improving Global Outcomes criteria. Operation and anesthesia time, estimated blood loss, amounts of administered fluids and transfused packed red blood cells, and the lengths of the postoperative intensive care unit and hospital stays were evaluated. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences between the RRP and RALP groups.After performing 1:1 propensity score matching, the RRP and RALP groups included 307 patients, respectively. The operation time and anesthesia time in RALP were significantly longer than in the RRP group (both P < 0.001). However, the estimated blood loss and amount of administered fluids in RALP were significantly lower than in RRP (both P < 0.001). Also, RALP demonstrated a significantly lower incidence of transfusion and smaller amount of transfused packed red blood cells than RRP (both P < 0.001). Importantly, the incidence of AKI in RALP was significantly lower than in RRP (5.5% vs 10.4%; P = 0.044). Furthermore, the length of hospital stay in RALP was also significantly shorter (P < 0.001).The incidence of AKI after RALP is significantly lower than after RRP. RALP can therefore be a better surgical option than RRP in terms of decreasing the frequency of postoperative AKI.

FIBTEM of Thromboelastometry does not Accurately Represent Fibrinogen Concentration in Patients with Severe Hypofibrinogenemia During Liver Transplantation.

BACKGROUND: Among rotation thromboelastometry (ROTEM®) parameters, the maximum clot firmness (MCF) of EXTEM (MCFEX), INTEM (MCFIN) and FIBTEM (MCFFIB) are influenced by both the platelet count and fibrinogen concentration. We evaluated the relative contribution of laboratory variables to MCF amplitude and determined whether the severity of hypofibrinogenemia could affect the relationship between these variables during liver transplantation (LT). MATERIAL AND METHODS: Retrospective ROTEM® assays with simultaneous laboratory tests in 282 patients receiving LT were analyzed. Relative contribution of platelet and fibrinogen to MCF was assessed and a subgroup analysis based on fibrinogen concentration was performed. RESULTS: Platelet count accounted for 60% of the variability in both MCFEX and MCFIN, whereas fibrinogen concentration explained 12% and 9%, respectively. In subgroup analysis, platelets accounted for 56-57% of MCFEX and MCFIN variability with fibrinogen <100 mg/dL, and 59% of the variability with fibrinogen ≥100 mg/dL. Fibrinogen was the primary determinant of MCFFIB, accounting for 73% of the variability. However, in severe hypofibrinogenemia (fibrinogen<100 mg/dL), fibrinogen explained only 22% of MCFFIB variability. CONCLUSIONS: Regardless of the fibrinogen concentration, the platelet count is a constant primary determinant of the MCFEX and MCFIN during LT. However, MCFFIB may predict the fibrinogen concentration less reliably in cases of severe hypofibrinogenemia.