Analgesic benefits of regional anesthesia in the perioperative management of transition-related surgery: a systematic review.

INTRODUCTION: Transition-related surgery is an effective treatment for gender dysphoria, but the perioperative analgesic management of transgender patients is nuanced and potentially complicated by higher rates of mood and substance use disorders. Regional anesthetic techniques are known to reduce pain severity and opioid requirements; however, little is known regarding the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery. METHODS: We performed a systematic review of the literature to evaluate original reports characterizing the analgesic effectiveness of regional anesthetic techniques for patients undergoing chest and/or genital transition-related surgery. Our primary outcomes were pain severity and opioid requirements on the first postoperative day. RESULTS: Of the 1863 records identified, 10 met criteria for inclusion and narrative synthesis. These included two randomized controlled trials, three cohort studies, and five case reports/series, comprising 293 patients. Four reports described 243 patients undergoing chest surgery, of whom 86% were transgender men undergoing mastectomy with pectoralis nerve blocks or local anesthetic instillation devices. The remaining six reports comprised 50 patients undergoing genital surgery, of whom 56% were transgender women undergoing vaginoplasty with erector spinae plane blocks or epidural anesthesia. Three studies directly compared regional techniques to parenteral analgesia alone. Two of these studies reported lower pain scores and opioid requirements on the first postoperative day with nerve blocks compared with none while the third study reported no difference between groups. Complications related to regional anesthetic techniques were rare among patients undergoing transition-related surgery. DISCUSSION: Despite the ever-growing demand for transition-related surgery, the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery is very understudied and insufficient to guide clinical practice. Our systematic review of the literature serves to underscore regional anesthesia for transition-related surgery as a priority area for future research.

Pericapsular nerve group (PENG) block: what have we learned in the last 5 years?

This educational article discusses the current understanding of the pericaspular nerve group block (PENG) of the hip regarding its mechanism of action and spread patterns, as well as plausible explanations for postblock quadriceps weakness. Finally, we will discuss the recent evidence of PENG block as an analgesic block in hip fractures and in different hip surgeries.

Point-of-Care Gastric Ultrasound to Identify a Full Stomach on a Diabetic Patient Taking a Glucagon-Like Peptide 1 Receptor Agonist.

Recently, there has been increased interest in the relationship between glucagon-like peptide 1 (GLP-1) receptor agonists, delayed gastric emptying, and subsequent risk of aspiration in the perioperative setting. This case illustrates how gastric ultrasound can be incorporated at the bedside to assess the risk of aspiration in patients taking this type of medication for diabetes or weight loss and guide clinical management and anesthetic technique to reduce the risk of aspiration.

Validation of a novel point-of-care ultrasound method to assess diaphragmatic excursion.

INTRODUCTION: Point-of-care ultrasound can assess diaphragmatic function and rule in or rule out paresis of the diaphragm. While this is a useful bedside tool, established methods have significant limitations. This study explores a new method to assess diaphragmatic motion by measuring the excursion of the uppermost point of the zone of apposition (ZOA) at the mid-axillary line using a high-frequency linear ultrasound probe and compares it with two previously established methods: the assessment of the excursion of the dome of the diaphragm (DOD) and the thickening ratio at the ZOA. METHODS: This is a single-centre, prospective comparative study on elective surgical patients with normal diaphragmatic function. Following research ethics board approval and patient written consent, 75 elective surgical patients with normal diaphragmatic function were evaluated preoperatively. Three ultrasound methods were compared: (1) assessment of the excursion of the DOD using a curvilinear probe through an abdominal window; (2) assessment of the thickening fraction of the ZOA; and (3) assessment of the excursion of the ZOA. The last two methods performed with a linear probe on the lateral aspect of the chest. RESULTS: Seventy-five patients were studied. We found that the evaluation of the excursion of the ZOA was more consistently successful (100% bilaterally) than the evaluation of the excursion of the DOD (98.7% and 34.7% on the right and left sides, respectively). The absolute values of the excursion of the ZOA were greater than and well correlated with the values of the DOD. CONCLUSION: Our preliminary data from this exploratory study suggest that the evaluation of the excursion of the ZOA on the lateral aspect of the chest using a linear probe is consistently successful on both right and left sides. Future studies are needed to establish the distribution of normal values and suggest diagnostic criteria for diaphragmatic paresis or paralysis. TRIAL REGISTRATION NUMBER: NCT03225508.

Transoral flexible laser surgery of the upper aerodigestive tract with blue laser.

PURPOSE: The introduction of fiber-guided lasers was a breakthrough in laryngology practice, opening the path for treating different pathologies with minimally invasive procedures, both in the operating room and in the office. The most recent technology in the area is the blue laser, which combines photoangiolytic and cutting properties, characteristics that make this equipment suitable for its use in upper aerodigestive tract surgery. However, there is not enough experience in this area. The authors present a case series of patients with different pharyngeal, laryngeal, and tracheal pathologies who were treated by means of transoral procedures using fiber-guided blue laser. METHODS: The surgical records of patients with different upper aerodigestive tract pathologies who were treated with fiber-guided blue laser in the operating room, under general anesthesia with jet ventilation or supraglottic ventilation using suspension laryngotracheoscopy techniques between February 2018 and March 2022 were reviewed. RESULTS: A total of 80 surgical interventions in a group of 38 patients were performed. A wide variety of procedures was executed, either using the laser alone or in combination with other techniques to treat different pathologies of the aero-digestive tract safely and effectively, with adequate functional results. CONCLUSIONS: Following all necessary precautions, blue laser is a reliable tool to perform minimally invasive surgeries in the operating room using TOFLS techniques. It can be used alone or in combination with other devices to achieve the desired goals.

Is There a Role for Transesophageal Echocardiography in the Perioperative Trauma Patient?

Purpose of Review: This review article summarizes the advantages and potential uses of focused transesophageal echocardiography (TEE) in the perioperative period for trauma patients. We suggest a locally developed TEE protocol for trauma and provide strategies to achieve widespread use of TEE in the anesthesia care of trauma patients. Recent Findings: In recent years, TEE has gained interest as an additional modality as point-of-care ultrasound (POCUS) for the resuscitation of acutely ill patients in whom transthoracic echocardiography is not feasible or non-diagnostic. Nevertheless, its use among non-cardiac anesthesiologists is still limited compared to the more traditional POCUS applications. Summary: A goal-directed, focused TEE can be performed at the bedside in different locations and mechanically ventilated patients. TEE provides relevant diagnostic information to guide the resuscitation of acutely injured patients, particularly to identify life-threatening hidden thoracic injuries in the scenario of patients with multi-system trauma.

Síndrome antifosfolípido (SAF): diferencias clínicas e inmunoserológicas entre SAF primario y secundario en una cohorte colombiana / Antiphospholipid syndrome (APS): Clinical and immunoserological differences between primary and secondary APS in a Colombian cohort

RESUMEN Introducción: El síndrome antifosfolípido (SAF) es una enfermedad autoinmune sistémica, caracterizada por trombosis recurrente, que puede afectar la circulación arterial y venosa. Objetivo: Analizar las diferencias inmunológicas y farmacológicas, así como los desenlaces clínicos de una cohorte de pacientes con SAF primario y secundario. Materiales y métodos: Estudio de corte transversal que incluyó 352 pacientes con diagnóstico de SAF atendidos entre los arios 2014 y 2018. Se analizaron variables sociodemográficas, clínicas e inmunológicas y se realizó un análisis univariado y un análisis bivariado mediante la prueba chi-cuadrado para determinar diferencias entre los pacientes con SAF primario y SAF secundario. Finalmente, se hizo un análisis multivariado para buscar asociaciones con los desenlaces clínicos trombóticos en los pacientes con SAF. Resultados: La edad promedio de la población fue de 42,4 ± 14 años; el 84,6% correspondió a sexo femenino. El 67,6% de los pacientes tenía diagnóstico de SAF primario y un 32,4% de SAF secundario, siendo el lupus eritematoso sistémico (LES) la enfermedad asociada en un 84%. Dentro de los eventos trombóticos, el más frecuente fue la trombosis venosa profunda (17,3%), seguida por el ataque cerebrovascular (9,9%). En los eventos obstétricos existió una prevalencia del 39,4% para abortos. No se encontraron diferencias en el perfil sociodemográfico ni en el perfil inmunoserológico entre los pacientes con diagnóstico de SAF primario y aquellos con SAF secundario. Los eventos trombóticos tuvieron mayor frecuencia en el grupo de SAF primario, pero solo la tromboembolia pulmonar alcanzó significación estadís tica. Eventos obstétricos como los abortos no fueron diferentes entre ambos grupos. Dentro de los factores asociados a los eventos trombóticos, se encontró que el sexo femenino tiene una probabilidad 5 veces mayor de accidente cerebrovascular y 3 veces mayor de trombosis venosa profunda. Los anti- β2GPI tipo IgM aumentaron alrededor de 3 veces la probabilidad de presentar abortos en mujeres con SAF. Conclusión: Se presenta una de las cohortes colombianas más grandes de pacientes con SAF reportadas hasta el momento en la literatura. La población es comparable clínica y sociodemográficamente con lo encontrado en otros estudios, aunque la prevalencia de SAF primario fue mayor y las complicaciones trombóticas fueron menores. La tromboembolia pulmonar fue significativamente mayor en el grupo de SAF primario.

ABSTRACT Introduction: Antiphospholipid syndrome (APS) is a systemic autoimmune disease charac terized by recurrent thrombosis that can affect the arterial and venous circulation. Objective: To analyze the immunological and pharmacological differences, as well as the clinical outcomes of a cohort of patients with primary APS and secondary APS. Materials and methods: A retrospective cohort study was conducted that included 352 records of patients diagnosed with APS and treated between 2014 and 2018. A description is pre sented of the sociodemographic, clinical, and immunological profile of the population. A bivariate analysis performed using the chi-squared test to determine differences between groups with primary APS and secondary APS, and finally a multivariate analysis to search for associations with thrombotic clinical outcomes in patients with APS. Results: The mean age was 42.4 ± 14 years, and 84.6% were females. Two-thirds (67.6%) of the patients had a diagnosis of primary APS, and 32.4% of secondary APS, of which 84% were associated with systemic lupus erythematosus (SLE). Among the thrombotic events, the most frequent were deep vein thrombosis (17.3%) and stroke (9.9%). Obstetric events were frequent, with a prevalence of 39.4% for miscarriages. No differences were found in the sociodemographic or immunoserological profile when comparing the group of primary vs. secondary APS. Thrombotic events were more frequent in the primary APS group, although only pulmonary embolism reached statistical significance. There were no differences bet ween the two groups as regards obstetric events, such as miscarriages. Women were found to be 5 times more likely to have a stroke and 3 times more to have deep vein thrombosis. The anti-β2GPI type IgM increased the probability of presenting miscarriages about 3 times in women with APS. Conclusion: The study contains one of the largest Colombian cohorts with APS reported so far, and although it is both clinically and sociodemographically similar to other cohorts, there is a higher prevalence of primary APS. There was a lower frequency of thrombotic complications compared to other cohorts. Patients with primary APS had a tendency to develop thrombosis, as has already been reported in the literature.

Surgical anesthesia for proximal arm surgery in the awake patient.

This education article discusses a combination of brachial plexus and peripheral nerve blocks aimed at providing complete surgical anesthesia to the proximal arm, while consistently avoiding diaphragmatic paresis. This type of approach may be warranted in patients with respiratory compromise of any etiology. In these settings awake surgery is recommended to preserve respiratory function and at the same time minimize the risk of infection of the healthcare team by avoiding the aerosol-generating medical procedures associated with general anesthesia.

Clinical and sociodemographic factors associated with lupus nephritis in Colombian patients: A cross-sectional study.

INTRODUCTION: Over the past decades, incidence of SLE (Systemic Lupus Erythematosus) has increased due to early case detection and improved survival of patients. SLE presents at an earlier age and has a more severe presentation in African-American, Native American, Asian, and Hispanic populations. Worldwide, lupus nephritis (LN) is observed in 29-60% of SLE patients, it has a negative impact in renal survival and patient mortality. Several cohorts have established potential risk factors associated with lupus nephritis, such as male sex, serological markers, and some extra-renal manifestations. OBJECTIVES: To describe sociodemographic, clinical, immunological, and environmental risk factors in Colombian SLE patients and to compare the population with and without nephritis, in order to establish risk factors and possible associations. MATERIALS AND METHODS: A total of 1175 SLE patients participated in this study. During medical care, an interview and structured survey was conducted and later registered in a database. Sociodemographic, clinical, immunological, and environmental exposure variables were analyzed. Bivariate and multivariate analyses were performed using presence of LN as an outcome. RESULTS: Prevalence of LN was 38.7%. Variables significantly associated with LN included being male (OR 1.98), a duration of SLE>10 years (OR 1.48), positive anti-DNA (OR 1.34), positive anti-Sm (OR 1.45), and smoking (OR 1.66). Being non-smoker was a protective factor (OR 0.52). CONCLUSION: This study describes potential factors associated with lupus nephritis in a Latin American population. Smoking status could be a target for intervention as it is a modifiable risk factor. The association between being male and LN is observed in Latin-American populations such as presented here. Further research in other large-scale population studies and more efforts are needed to gain better insights to explicate these relationships.

Diaphragm-sparing brachial plexus blocks: a focused review of current evidence and their role during the COVID-19 pandemic.

PURPOSE OF REVIEW: Given that COVID-19 can severely impair lung function, regional anesthesia techniques avoiding phrenic nerve paralysis are relevant in the anesthetic management of suspected/confirmed COVID-19 patients requiring shoulder and clavicle surgical procedures. The objective of this review is to provide an overview of recently published studies examining ultrasound-guided diaphragm-sparing regional anesthesia techniques for the brachial plexus (BP) to favor their preferent use in patients at risk of respiratory function compromise. RECENT FINDINGS: In the last 18 months, study findings on various diaphragm-sparing regional anesthesia techniques have demonstrated comparable block analgesic effectivity with a variable extent of phrenic nerve paralysis. The impact of hemi-diaphragmatic function impairment on clinical outcomes is yet to be established. SUMMARY: Existing diaphragm-sparing brachial plexus regional anesthesia techniques used for shoulder and clavicle surgery may help minimize pulmonary complications by preserving lung function, especially in patients prone to respiratory compromise. Used as an anesthetic technique, they can reduce the risk of exposure of healthcare teams to aerosol-generating medical procedures (AGMPs), albeit posing an increased risk for hemi-diaphragmatic paralysis. Reducing the incidence of phrenic nerve involvement and obtaining opioid-sparing analgesia without jeopardizing efficacy should be prioritized goals of regional anesthesia practice during the COVID-19 pandemic.

Aortitis sifilítica: manifestación olvidada de la sífilis / Syphilitic aortitis: forgotten manifestation of syphilis

Resumen La sífilis es una infección bacteriana producida por el Treponema pallidum (espiroqueta). Consta de varias etapas: primaria, secundaria y terciaria, según el tiempo de evolución desde el momento en que se adquiere la infección. Cada etapa comprende diferentes manifestaciones clínicas; los síntomas cardiovasculares forman parte de la sífilis terciaria, en cuyo caso la aortitis sifilítica es la principal forma de presentación. Se expone el caso de un paciente que consultó por déficit neurológico focal, en quien por medio de estudios de extensión se documentó neurosífilis e insuficiencia valvular aórtica severa secundaria a perforación de la válvula coronaria derecha, que requirió recambio valvular aórtico por bioprótesis. Adicionalmente, se hace una revisión de las principales manifestaciones cardiovasculares de esta enfermedad. Aunque en la era postantibiótica este tipo de manifestaciones tardías son cada vez menos frecuentes, es imperativo conocerlas.

Abstract Syphilis is a bacterial infection caused by Treponema pallidum (spirochete). It has various stages: primary, secondary and tertiary; depending on the time to progression from the moment the infection is acquired. Each stage involves various clinical manifestations; cardiovascular symptoms are part of tertiary syphilis, and syphilitic aortitis is the main form of presentation. We present the case of a patient who consulted with a focal neurological deficit, in whom extension studies reported neurosyphilis and severe aortic failure secondary to perforation of the right coronary valve, which required aortic valve replacement by bioprosthesis. We also undertake a review of the main cardiovascular manifestations of this disease. Although in the post-antibiotic era this type of late manifestation is increasingly less frequent, it is imperative that we are aware of it.

Características de pacientes adultos con cáncer y su atención en el Hospital Universitario San José de Popayán, Colombia / Characteristics of adult cancer patients and their care at the San José University Hospital, Popayán, Colombia

Resumen Objetivo: Describir las características sociodemográficas y clínicas de los pacientes adultos con diagnóstico de cáncer atendidos en el Hospital Universitario San José (HUSJ) de Popayán, Colombia. Métodos: Estudio observacional con datos rutinarios de cáncer que incluyó pacientes mayores de 18 años atendidos entre 2012 y 2017 en los servicios de urgencias y hospitalización con diagnóstico de cáncer, según el Manual CIE 10 (Clasificación Internacional de Enfermedades, décima versión) en el HUSJ. Se aplicó una estrategia de muestreo aleatorio simple con afijación proporcional por años y se analizaron de forma descriptiva y gráfica. Resultados: Se incluyeron 245 pacientes. El 51% de los cuales correspondió al género femenino y la mediana de edad fue de 64 años. El cáncer más frecuente en ambos sexos fue el de estómago, seguido por el cáncer de ovario y cérvix en mujeres y por el cáncer de próstata, de tejido sanguíneo y de médula ósea en hombres. Los tipos histológicos de cáncer registrados en la mayoría de los pacientes fueron los carcinomas y adenocarcinomas. En el 36,7% de los pacientes se documentó la presencia de metástasis. La mortalidad durante la última hospitalización fue del 20% y el 12% de los pacientes requirieron remisión a otro nivel de atención superior. Conclusión: Los resultados de este estudio muestran similitudes con el comportamiento de la enfermedad en el país, con excepción del cáncer ginecológico. Adicionalmente, aporta información valiosa tanto a nivel regional como a la institución y crea conciencia de la necesidad de la implementación y mantenimiento de registros hospitalarios de cáncer.

Abstract Objective: To describe the socio-demographic and clinical characteristics of adult cancer patients who received treatment at the San José University Hospital (HUSJ) in Popayán, Colombia. Methods: Observational study with routine cancer data, which included patients aged over 18 years, who received treatment between 2012 and 2017 in the emergency and hospitalization departments, with cancer diagnosis according to the ICD Manual 10 (International Statistical Classification of Diseases, tenth revision) in the HUSJ. It was applied a simple random sampling strategy, with proportional allocation by years, and they were analyzed descriptively and graphically. Results: 245 patients were included, 51% of which corresponded to female gender; median age, 64 years. The most frequent cancer in both sexes was stomach cancer, followed by ovary cancer and cervix cancer in women; and cancer of the prostate, blood tissue, and bone marrow in men. The histological types of cancer registered in most of the patients were carcinomas and adenocarcinomas. The presence of metastases was documented in 36.7% of the patients. The mortality during the last hospitalization was 20%; and 12% of patients required referral to another higher level of care. Conclusion: The results of this study show similarities with the behavior of the disease in the country, with the exception of gynecological cancer. Additionally, it provides valuable information both regionally and at institution level, as well as it raises awareness of the need for the implementation and maintenance of hospital cancer records.