Implementation of Routine In Situ Simulation in Residency Curriculum Targeting Competency in Technical and Decision-Making Skills.

OBJECTIVE: To describe the development and implementation of a comprehensive in situ simulation-based curriculum for anesthesia residents. DESIGN: This is a prospective study. SETTING: This study was conducted at a university hospital. PARTICIPANTS: This single-center prospective study included all 53 anesthesia residents enrolled in the anesthesia residency program. INTERVENTIONS: Introduction of a routine, high-fidelity, in situ simulation program that incorporates short sessions to train residents in the necessary skill sets and decision-making processes required in the operating room. MEASUREMENTS AND MAIN RESULTS: Our team conducted 182 individual 15-minute simulation sessions over 3 months during regular working hours. All 53 residents in our program actively participated in the simulations. Most residents engaged in at least 3 sessions, with an average participation rate of 3.4 per resident (range, 1-6 sessions). Residents completed an online anonymous survey, with a response rate of 71.7% (38 of 53 residents) over the 3-month period. The survey aimed to assess their overall impression and perceived contribution of this project to their training. CONCLUSIONS: Our proposed teaching method can bridge the gap in resident training and enhance their critical reasoning to manage diverse clinical situations they may not experience during their residency.

Neurosurgical Management of Patients with Alpha-Gal Syndrome.

Alpha-gal syndrome (AGS) is an immunoglobulin E-mediated hypersensitivity to galatcose-alpha-1,3-galactose (alpha-gal), a carbohydrate compound present in nonprimate mammalian products. Initial exposure to alpha-gal most often occurs through a tick bite, most commonly the lone star tick in the United States. Repeated exposure to alpha-gal may elicit severe allergic reactions, including anaphylaxis. The allergy restricts dietary intake and may significantly impact perioperative risk, as many medications, anesthetics, and intraoperative surgical products utilize bovine or porcine-derived agents, including those containing magnesium stearate, glycerol, and gelatin. Here, we review the perineurosurgical care of two individuals with AGS and highlight pertinent clinical practices and perioperative management of these patients.

Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring?

PURPOSE: Surgical intervention for lateral compression (LC) 1 and 2 pelvic ring fractures is controversial. Posterior ring stabilization remains the most common mode of initial fixation. However, greater mechanical instability is observed in the anterior component of LC pelvic fractures. This study tested whether reduction and percutaneous superior ramus fixation will decrease the instability of LC pelvic fractures on intraoperative fluoroscopic imaging. METHODS: All adult patients (≥ 18 years) presenting with either a Young-Burgess LC1 or LC2 pelvic ring disruption treated operatively with percutaneous anterior followed by posterior fixation by a single surgeon from July 2021 to June 2023 were retrospectively reviewed. Displacement of the anterior ring to intraoperative manual internal rotation stress examination under fluoroscopy was compared before and after anterior pelvic ring reduction and fixation and prior to posterior pelvic ring fixation. Pre- and post-operative visual analog scores (VAS) for pain were also compared. RESULTS: Twenty-one patients with a mean age of 48.7 years were included. Fifteen patients (71.4%) presented with an LC1, and six (28.6%) with an LC2 injury patterns. Anterior pelvic fixation alone provided 7.5mm reduction in mean displacement of the anterior pelvic ring (pre-operative = 9.2 mm vs. post-operative = 1.6 mm, p < 0.001). VAS significantly decreased from 7.2 one-day pre-operatively to 2.2 twenty-four h post-operatively (p < 0.001). CONCLUSIONS: Reduction and fixation of the anterior pelvic ring prior to posterior fixation for LC1 and LC2 pelvic ring disruptions substantially improves mechanical stability on intraoperative stress examination. Combination of percutaneous anterior and posterior fixation significantly decreased VAS above the MCID 24 h after stabilization.

Evaluation of EMLA cream with microneedle patches in palatal anesthesia in children: a randomized controlled clinical trial.

Palatal injections are considered to be one of the most painful dental procedures. As a result, it was important to find alternatives to this painful injection to improve children's cooperation. The dental literature mentioned using EMLA cream as a possible alternative to conventional injections, but its anesthetic effect was debated. Therefore, it was valuable to research the impact of microneedle patches to enhance the effectiveness of this cream. The purpose of this randomized controlled clinical trial was to compare the effectiveness of different methods of anesthesia and pain levels in children aged 7-11 years. The study compared the use of EMLA cream, EMLA with microneedles, and conventional palatal injections. A total of 90 children were randomly assigned to three groups: Group 1 received conventional palatal anesthesia (control), Group 2 received EMLA cream only, and Group 3 received EMLA with microneedles. Pain levels were assessed using the FLACC and Wong-Baker scales at three different time points: T1(during anesthesia), T2(on palatal probing), and T3(during extraction). The FLACC scale revealed a significant difference in pain between groups only at T1 (P value = 0.000). It was found that the conventional palatal injection group had a higher pain level than the EMLA cream-only group and the group using microneedle patches with EMLA cream (P value = 0.000). However, the other groups did not show significant differences in pain levels during the anesthesia (P value = 1.00). Similarly, the Wong-Baker scale also demonstrated a statistically significant difference in pain between groups only at T1 (P value = 0.000). It was found that the conventional palatal injection group had a higher pain level than the EMLA cream-only group and the group using microneedle patches with EMLA cream (P value = 0.000). However, the other groups did not show significant differences in pain levels during the anesthesia (P value = 0.091). The study concludes that both EMLA cream alone and EMLA with microneedles can be used as an alternative to conventional palatal anesthesia for children.

Erector spinae plane infiltration and anterior rami of spinal nerve: a cadaveric study.

BACKGROUND: The erector spinae plane block (ESP block) is frequently employed for thoracic, abdominal, and spinal surgeries, yet its precise mechanism of action remains a subject of debate. While initially postulated to influence both ventral and dorsal rami of the spinal nerve, recent studies indicate a predominant impact on the dorsal rami with limited involvement of the ventral rami. To elucidate this mechanism, we conducted an observational study to assess the distribution of ESP infiltration to the ventral rami. METHODS: We performed 20 ESP infiltrations bilaterally in 10 unembalmed cadavers, targering the T9 transverse process level. A volume of 20 mL of ropivacaine 0.2% and methylene blue 0.01% was used. Dissection was carried out to assess dye distribution, with a focus on involvement of the ventral and dorsal rami, as well as lateral and longitudinal spread within the spinal muscular plane. RESULTS: No evidence of dye staining was observed in the ventral rami in any of the cadavers; however, the dorsal rami consistently displayed staining. The dye exhibited extensive longitudinal diffusion across the paravertebral musculature, spanning a median of 10 vertebral spaces (T5-L2). The range extended from 3 to 18 spaces, with an IQR of 11 levels (T4-L2), predominantly affecting the longissimus and iliocostalis muscles. CONCLUSIONS: The infiltration of injectate into the ESP does not contact the ventral rami of segmental spinal nerves. The inference that an in vivo ESP block is a paravertebral "by-proxy" is, therefore, unlikely.

Effect of epidural anesthesia on the optic nerve sheath diameter in patients with pre-eclampsia: a prospective observational study.

INTRODUCTION: Optic nerve sheath diameter (ONSD) reflects intracranial pressure and is increased in pre-eclampsia. Administrating a significant volume of epidural solution into the epidural space can potentially increase ONSD. We investigated the impact of epidural local anesthetic injection on ONSD in patients with pre-eclampsia. METHODS: Patients with pre-eclampsia (n=11) and normotensive pregnant women (n=11) received de novo epidural anesthesia for cesarean delivery. We administered 21 mL of an epidural solution containing 2% lidocaine and 50 µg fentanyl into the lumbar epidural space in incremental doses. ONSD was measured at baseline, 3, 10, and 20 min after completing the epidural injection, after delivery, and at the end of surgery. Primary outcome was the change in ONSD from baseline to 3 min after epidural injection in patients with pre-eclampsia and normotensive pregnant women. Serial changes in the ONSD were analyzed using a linear mixed model. RESULTS: At baseline and 3 min after epidural drug injection, ONSD was significantly larger in patients with pre-eclampsia than in normotensive mothers (5.7 vs 4.1 mm, p=0.001 and 5.4 vs 4.1 mm, p<0.001, respectively). However, there were no significant changes in ONSD at 3 min after injection from baseline in either group (p>0.999). Linear mixed model demonstrated that ONSD did not change after epidural anesthesia in either group (p=0.279 and p=0.347, respectively). CONCLUSIONS: Despite a higher baseline ONSD in pre-eclampsia, epidural anesthesia did not further increase ONSD. Our findings indicate that epidural anesthesia can be safely administered in patients with pre-eclampsia at risk of increased intracranial pressure, without other intracranial pathology. TRIAL REGISTRATION NUMBER: NCT04095832.

Pediatric anesthesia training in Israel and Palestine: Realities versus expectations.

Israel is a young country with a rather young system of medical education. This educational review serves to illuminate the similarities and differences in the training of a pediatric Anesthesiologist in both Israel and Palestine.

Safety and feasibility of early drinking water after general anesthesia recovery in patients undergoing daytime surgery.

BACKGROUND: Patients who are recovering from general anesthesia commonly exhibit symptoms such as dry lips, throat irritation, and thirst, prompting a desire to drink water in the post-anesthesia care unit (PACU). In this study, we aimed to evaluate the therapeutic effects and any potential complications of administering varying quantities of water to such patients. The primary objectives are to assess the safety and feasibility of early water intake after general anesthesia, specifically in the context of daytime surgery. METHODS: A total of 200 nongastrointestinal patients who underwent outpatient surgery were randomly assigned to four groups: Group A (drinking < 1 ml/kg), Group B (drinking 1-2 ml/kg), Group C (drinking > 2 ml/kg), and Group D (no water intake). We monitored changes in the assessment parameters before and after water consumption, as well as the incidence of post-drinking nausea and vomiting, and compared these outcomes among the four groups. RESULTS: Water intake led to a significant reduction in thirst, oropharyngeal discomfort, and pain scores and a notable increase in the gastric antrum motility index (MI), exhibiting statistical significance compared to the values before drinking (p < 0.05). Remarkably, higher water consumption correlated with enhanced gastrointestinal peristalsis. There was a significant difference in the antral MI among groups B, C, and A (p < 0.05). The occurrence of nausea and vomiting did not significantly differ among groups A, B, C, and D (p > 0.05). Early water consumption enhanced patient satisfaction with medical care, significantly varying from Group D (p < 0.05). CONCLUSION: Non-gastrointestinal surgical patients who passed pre-drinking water assessments post GA(general anesthesia)recovery could safely ingest moderate amounts of water in the PACU. Early water intake is both safe and feasible, effectively fostering swift postoperative recovery.

Unilateral Anterior Spinal Artery Syndrome following Spinal Anesthesia for Cesarian Section: A Case Report.

Introduction: Spinal cord infarction is a rare but serious neurologic complication of spinal anesthesia. Direct vessel injury, intra-arterial anesthetic injection, and anesthetic-induced local hypotension are potential mechanisms of infarction during this procedure. The proximity of the artery of Adamkiewicz to the spinal levels used for spinal anesthesia may also play a role. This case of unilateral anterior spinal artery syndrome highlights the potential for an atypical pattern of injury and deficits due to the complexity of the spinal cord's anterior circulation. Case Presentation: We present a 38-year-old female patient who presented with left lower extremity weakness, loss of temperature sensation, and urinary retention following spinal anesthesia for cesarian section. Magnetic resonance imaging of the spine demonstrated T2 hyperintensities in the left central spinal cord from T8 to the conus medullaris. A diagnosis of spinal cord infarction was made after lumbar puncture testing showed no evidence of inflammatory myelitis. The patient was treated with steroids empirically until lumbar puncture testing showed no inflammation. The patient was discharged on daily aspirin with persistent left lower extremity weakness and loss of temperature sensation. A plan for outpatient physical therapy was made for rehabilitation. Conclusion: Awareness of the potential for spinal cord infarction secondary to spinal anesthesia must increase among anesthesiologists, obstetricians, and neurologists. The risk of systemic hypotension during and after spinal anesthesia is important to recognize for both primary and secondary prevention of this complication. The hyperacute onset of myelopathic symptoms should point neurologists to investigate an ischemic etiology in the proper clinical context.

Comparison of the cost-effectiveness and safety between staged bilateral total knee arthroplasty and simultaneous bilateral total knee arthroplasty: a retrospective cohort study between 2001 and 2022.

INTRODUCTION: A substantial proportion of Hong Kong's aging population suffers from osteoarthritis in both knees. Bilateral total knee arthroplasty (BTKA) is a surgical option for addressing this condition and can be performed via two approaches: simultaneous (SimBTKA) and staged (StaBTKA) bilateral TKAs. We compared the cost-effectiveness and safety of these two methods in our institution. METHODS: We retrospectively reviewed 2,372 patients (SimBTKA, 772; StaBTKA, 1,600; female, 1,780; male, 592; mean age at SimBTKA, 70.4 ± 7.99 years; mean age at StaBTKA, 66.4 ± 7.50 years; p < 0.001) who underwent bilateral TKA in our institution from 2001 to 2022. Patients were categorized according to surgical approach. Patients undergoing BTKA in our institution were included. Particularly for SimBTKA, patients were assessed by anesthetists to be medically fit before undergoing SimBTKA according to their age, American Society of Anesthesiologists status, and osteoarthritis severity. Primary outcome was the length-of-stay (LOS) after surgery. Secondary outcomes were the 30-day unintended readmission, intensive care unit (ICU) admission, and death. RESULTS: SimBTKA had a short mean total LOS (acute hospital + rehabilitation center; SimBTKA, 13.09 days; StaBTKA, 18.12 days; p < 0.001) and mean LOS in acute hospital (SimBTKA, 7.70 days; StaBTKA, 10.42 days; p < 0.001). However, no significant difference was found in mean LOS in rehabilitation centers (SimBTKA, 5.47 days; StaBTKA, 6.32 days; p > 0.05) between the two approaches. The 30-day unintended readmission rate was low in SimBTKA (SimBTKA, 2.07%; StaBTKA, 3.30%; OR = 1.60; p > 0.05) but statistically insignificant. SimBTKA was less costly than StaBTKA by US$8,422.22. per patient. No significant differences in ICU admission and death rates were found (p > 0.05) between the two groups. CONCLUSION: SimBTKA had a shorter LOS and lower cost than StaBTKA and comparable complication rates. Therefore, SimBTKA should be indicated in medically stable patients.

Acute reversal of respiratory distress after a preoperative single-shot interscalene nerve block.

BACKGROUND: Diaphragmatic paresis is a known complication of the interscalene block used for postoperative analgesia in shoulder surgery. A technique involving the injection of normal saline through the interscalene catheter to alleviate this condition has shown promise. This method, termed the "washing-off" technique, dilutes the local anesthetic around the phrenic nerve, mitigating respiratory symptoms. CASE PRESENTATION: A 65-year-old male patient with multiple comorbidities (American Society of Anesthesiologists physical status classification 4) was scheduled for arteriovenous brachiocephalic fistula creation under regional anesthesia. Following an interscalene block with 32 mL of mepivacaine 1.5%, the patient experienced acute respiratory distress, with SpO2 at 88% despite 6 L O2 via nasal cannula. To avoid intubation, a 20 mL normal saline injection was administered through single-shot interscalene injection under ultrasound guidance. Within 5 min, respiratory distress markedly improved, allowing the patient to converse. Surgery proceeded without complications, maintaining SpO2 at 99% with 6 L O2. Postoperatively, the patient remained stable, with SpO2 at 98% on 2 L O2, and was discharged from the recovery room without additional oxygen requirements. CONCLUSIONS: The "washing-off" technique's mechanism may involve dilutional effects, pH changes or local sodium concentration alterations affecting the phrenic nerve. This case demonstrates its effectiveness in an acute setting, enabling surgery under regional anesthesia without intubation or any additional analgesia. The previously considered placebo effect appears unlikely here.

Retromolar intubation for the general anesthesia of maxillofacial fracture patients.

BACKGROUND: Evaluate the possibility of retromolar intubation for general anesthesia in patients with maxillofacial fractures. METHODS: The medical records of 54 patients with maxillofacial fractures who visited the Oral and Maxillofacial Surgery Department of Nantong First People's Hospital from January 2020 to August 2022 were collected. The retromolar areas of each patient were measured from the coronal CT images, and correlated with the patient's age, sex, type of fracture (i.e., maxillary fracture, mandibular fracture, or complex fracture of multiple maxillofacial bones), and the presence of the third molar (verified from 3D CT). The dimensions of the retromolar areas were finally compared with the outer diameter (OD) of standard endotracheal tubes (ETTs), most importantly the size 7.5 ETT (OD 10.3 mm) for male and the size 7.0 ETT (OD 9.8 mm) for female. RESULTS: The survey included 38 male and 16 female patients, with an average age of 44.1 and 54.3 years, respectively. The dimensions of the retromolar area (height × width) were as follows: male, (9.39 ± 1.77) mm × (12.08 ± 0.98) mm on the left and (9.81 ± 2.23) mm × (11.77 ± 1.08) mm on the right; female, (8.82 ± 1.53) mm × (10.51 ± 1.00) mm on the left and (9.73 ± 1.60) mm × (10.63 ± 1.58) mm on the right. The width was always larger than the OD of the routinely used ETT, but the height could be smaller by less than 1 mm. However, the oral mucosa can be compressed to allow the ETT to fit in the retromolar area. CONCLUSIONS: The retromolar area provided appropriate space to place a reinforced ETT for patients with maxillofacial fractures needing general anesthesia that must not interfere with intermaxillary ligation. Retromolar intubation can help maxillofacial fracture surgeries that focus on occlusal restoration.

Dexmedetomidine as a total intravenous anesthetic in pediatric patients undergoing cleft lip and palate surgery: a case series.

BACKGROUND: Surgery for pediatric cleft lip and palate repair often utilizes high-dose opioids and inhaled anesthesia, thereby causing postoperative complications such as desaturation and/or severe agitation after anesthesia. These complications are detrimental to the child and medical personnel and cause tremendous psychologic stress to parents. Our aim is to decrease these complications through dexmedetomidine, an alpha-2 receptor agonist with anxiolytic, sympatholytic, and analgetic properties. Devoid of respiratory depressant effect, it allows patients to maintain effective ventilation and reduce agitation, postoperatively. Its unique anesthetic property may shed light on providing safe anesthesia and gentle emergence to this young, vulnerable population. CASE PRESENTATION: A total of 21 patients of Sundanese ethnicity, aged 3 months to 8 years (9 males and 12 females), underwent cleft lip or cleft palate surgery using total intravenous dexmedetomidine. Anesthesia was induced using sevoflurane, fentanyl, and propofol, and airway was secured. Intravenous dexmedetomidine 1.5 µg/kg was administered within 10 minutes, and a maintenance dose of 1.5 µg/kg/hour was continued as the sole anesthetic maintenance agent thereafter. Hemodynamics and anesthetic depth using Patient State Index (SEDLine™ monitor, Masimo Corporation, Irvine, CA, USA) were monitored carefully throughout the surgical procedure. Dexmedetomidine did not cause any hemodynamic derangements or postoperative complications in any of our patients. We found agitation in 9.5% (2/21) of patients. CONCLUSION: Dexmedetomidine can be used as a total intravenous anesthetic agent to maintain anesthesia and provide gentle emergence to infants and young children undergoing cleft lip and palate repair.

Comparison of remimazolam tosilate and propofol during induction and maintenance of general anesthesia in patients undergoing laparoscopic cholecystectomy: a prospective, single center, randomized controlled trial.

BACKGROUND: Remimazolam tosilate (RT) is a new, ultrashort-acting benzodiazepine. Here, we investigated the efficacy and safety of RT for general anesthesia in patients undergoing Laparoscopic Cholecystectomy (LC). METHODS: In this study, 122 patients undergoing laparoscopic cholecystectomy were randomly allocated to receive either remimazolam tosilate (Group RT) or propofol group (Group P). RT was administered as a slow bolus of 0.3 mg kg- 1 for induction, followed by 1.0-2.0 mg kg- 1 h- 1 for maintenance of general anesthesia. Propofol was started at 2 mg kg- 1 and followed by 4-10 mg kg- 1 h- 1 until the end of surgery. The primary outcome was the time to bispectral index (BIS) ≤ 60. The secondary outcome included the time to loss of consciousness (LoC), and the time to extubation. Adverse events were also assessed. RESULTS: A total of 112 patients were recruited for study participation. Among them, the time to BIS ≤ 60 in Group RT was longer than that in Group P (Group RT: 89.3 ± 10.7 s; Group P: 85.9 ± 9.7 s, P > 0.05). While the time to LoC comparing remimazolam and propofol showed no statistical significance (Group RT: 74.4 ± 10.3 s; Group P: 74.7 ± 9.3 s, P > 0.05). The time to extubation in Group RT was significantly longer than that in Group P (Group RT: 16.0 ± 2.6 min; Group P: 8.8 ± 4.3 min, P < 0.001). Remimazolam tosilate had more stable hemodynamics and a lower incidence of hypotension during general anesthesia. CONCLUSIONS: Remimazolam tosilate can be safely and effectively used for general anesthesia in patients undergoing Laparoscopic Cholecystectomy. It maintains stable hemodynamics during induction and maintenance of general anesthesia compared with propofol. Further studies are needed to validate the findings. TRIAL REGISTRATION: Chictr.org.cn ChiCTR2300071256 (date of registration: 09/05/2023).

National survey on the current status of airway management in China.

Apparently, understanding airway management status may help to reduce risk and improve clinical practice. Given these facts, our team conducted a second survey on the current status of airway management for mainland China following our 2016 national airway survey. The national survey was conducted from November 7 to November 28, 2022. An electronic survey was sent to the New Youth Anesthesia Forum, where Chinese anesthesiologists completed the questionnaire via WeChat. A total of 3783 respondents completed the survey, with a response rate of 72.14%. So far, in 2022, 34.84% of anesthesiologists canceled or delayed surgery at least once due to difficult airway. For the anticipated difficult airway management, 66.11% of physicians would choose awake intubation under sedation and topical anesthesia, while the percentage seeking help has decreased compared to the 2016 survey. When encountering an emergency, 74.20% of respondents prefer to use the needle cricothyrotomy, albeit less than a quarter have actually performed it. Anesthesiologists with difficult airway training experience reached 72.96%, with a significant difference in participation between participants in Tier 3 hospitals and those in other levels of hospitals (P < 0.001). The videolaryngoscope, laryngeal mask, and flexible intubation scope were equipped at 97.18%, 95.96%, and 62.89%, respectively. Additionally, the percentage of brain damage or death caused by difficult airways was significantly decreased. The study may be the best reference for understanding the current status of airway management in China, revealing the current advancements and deficiencies. The future focus of airway management remains on training and education.

The Influence of Piriform Recess Instillation with Lidocaine Before Bronchoscopy on Post-General Anesthesia Cough: A Randomized Controlled Trial.

Background and Importance: Postoperative cough is a common complication of general anesthesia after bronchoscopy. The aim of the present study was to determine the safety profile and efficacy of piriform recess instillation with lidocaine in reducing the incidence of coughing. Objective: To what extent could piriform recess instillation with lidocaine decrease the incidence of cough at 10min after extubation? Outcome Measures and Analysis: Eighty-eight consecutive patients were equally randomized to a lidocaine group receiving piriform recess instillation with 2mL 2% lidocaine, and a normal saline group receiving piriform recess instillation with 2mL saline. The primary outcome was the incidence of cough after extubation, and the secondary outcomes were throat score at 10 min and 6 h after extubation assessed by the numerical rating scale, cough severity at 10 min and 6 h after extubation assessed by the Visual Analog Scale (VAS), 24 h 40-item Quality of Recovery Score (QoR-40), and subject-rated satisfaction score on a VAS. Main Results: Compared with saline group, the incidence of cough in lidocaine group was significantly lower (63.6% vs 86.4%, P=0.014). The sore throat score at 10 min after extubation was significantly lower (0[0,0] vs 1[0,2], P<0.001). The subject-rated overall anesthesia satisfaction score was significantly higher (84.8[±6.2] vs 76.6[±8.6], P<0.001). The severity of cough at 10 min after extubation was significantly lower (Mild: 36.4% vs 11.4%, P=0.006; Severe: 9.1% vs 43.2%, P<0.001). There was no significant difference in the sore throat score at 6 h after extubation, severity of cough at 6 h after extubation, or QoR-40 at 24 h after extubation between the two groups. Conclusion: Piriform recess instillation with lidocaine before bronchoscopy is a simple and effective method for reducing early cough intensity and alleviating early sore throat. At 6 hours, there were no differences observed between the groups. Clinical Trial Registration: Chinese Clinical Trial Registry (identifier: ChiCTR2200067087).

Perioperative management and neuraxial analgesia in women with factor XI deficiency (<60 IU/dL): a French multicenter observational study of 314 pregnancies.

Background: Factor (F)XI deficiency is a rare bleeding disorder with a poor correlation between bleeding tendency and FXI level. Management of pregnant women with FXI deficiency is not clearly established, especially regarding neuraxial analgesia (NA). Objectives: A retrospective multicenter observational study was conducted in French hemostasis centers on pregnant women with FXI of <60 IU/dL. Methods: Data to report were (i) FXI levels before pregnancy and at time of delivery, (ii) type of NA and delivery management modalities, and (iii) possible complications related to NA and bleeding complications. Results: Three hundred fourteen pregnancies in patients with FXI deficiency of <60 IU/dL were reported (from 20 centers); among them, 199 NA procedures have been completed (137 epidurals and 61 spinals, 1 had both). The period of childbirth was mostly from 2014 to 2020 (281/314; 89.5%). Congenital FXI deficiency was established with certainty by investigators in 32.8% patients (n = 103). Previous bleedings were described in 20.4% of the patients (64/314; 45.3% cutaneous, 31.3% gynecologic, and 15.6% postsurgical). Thirteen deliveries had an NA procedure with FXI of <30 IU/dL, 42 with FXI of 30-40 IU/dL, and 118 with FXI of 40-60 IU/dL. Median FXI levels at delivery in the epidural and spinal groups were not significantly different but were significantly lower in the group without NA by medical staff contraindications. There were no complications related to NA. A 17.5% postpartum hemorrhage or excessive postpartum bleeding incidence was reported, which is consistent with previous data. Conclusion: Our data support the use of a 30 IU/dL FXI threshold for NA, as suggested by the French proposals published in August 2023.

Propofol total intravenous anesthesia vs. sevoflurane inhalation anesthesia: Effects on post­operative cognitive dysfunction and inflammation in geriatric patients undergoing laparoscopic surgery.

Propofol total intravenous anesthesia (TIVA) or sevoflurane inhalation anesthesia (IA) affects post-operative cognitive dysfunction in geriatric patients undergoing laparoscopic surgery; however, relevant real-world clinical evidence on the matter is limited. The present study aimed to compare the effects of propofol TIVA and sevoflurane IA on post-operative cognitive dysfunction in the aforementioned type of patients. The present prospective study enrolled 197 geriatric patients undergoing laparoscopic surgery. Patients were assigned to the propofol TIVA group (n=97) and sevoflurane IA group (n=100) according to the actual anesthesia regimens. The mini-mental state examination (MMSE) score was assessed before surgery and on day (D)1, D3 and D7 following surgery in both groups. The MMSE score on D1 was higher in the TIVA group compared with the IA group (P=0.006). The change in the MMSE scores from before surgery to D1 (P<0.001), D3 (P=0.011) and D7 (P=0.003) was smaller in the TIVA group vs. the IA group. Multivariate linear regression analyses suggested that the anesthesia method of TIVA (vs. IA) was independently related to the increased MMSE score on D1 (b=0.803; P=0.001) and D7 (b=0.472; P=0.025). The levels of interleukin (IL)-17A, IL-6 and tumor necrosis factor-α on D1, D3 and D7 exhibited a slightly decreasing trend in the TIVA group vs. the IA group, although the difference was not statistically significant (all P>0.05). Notably, the levels of IL-17A before surgery (P=0.015), on D3 (P=0.016) and D7 (P=0.002), as well as those of IL-6 on D1 (P=0.027), were negatively associated with the MMSE score at the corresponding time points. Overall, the present study demonstrates that propofol TIVA ameliorates post-operative cognitive dysfunction on D1 compared with sevoflurane IA and exerts a potentially suppressive effect on inflammation in geriatric patients undergoing laparoscopic surgery.