Persistent Postpartum Pain - A Somatic and Psychologic Perfect Storm.

Persistent postpartum pain is common and has a complex etiology. It has both somatic and psychosocial provoking factors and has both functional and psychological ramifications following childbirth. Pain that limits the functional capacity of a person who has the daunting task to take care of all the demands of managing a growing newborn and infant can have debilitating consequences for several people simultaneously. We will review the incidence of persistent postpartum pain, analyze the risk factors, and discuss obstetric, anesthetic, and psychological tools for prevention and management. Based on the current knowledge, early antenatal screening and management is described as the most likely measure to identify patients at risk for persistent postpartum pain. Such antenatal management should be based on the close collaboration between obstetricians, anesthesiologists, and psychologists to tailor peripartum pain management and psychological support-based individual needs.

Safety and Efficacy of Right Axillary Thoracotomy for Repair of Congenital Heart Defects in Children.

BACKGROUND: Minimally invasive repair of congenital heart defects in children has not gained wide popularity yet compared to minimally invasive approaches in adults. We sought to review our experience with this approach in children. METHODS: This study included a total of 37 children (24 girls, 64.9%) with a mean age of 6.5 ± 5.1 years, who underwent vertical axillary right minithoracotomy for repair of a variety of congenital heart defects between May 2020 and June 2022. RESULTS: The mean weight of these children was 25.66 ± 18.3 kg. Trisomy 21 syndrome was present in 3 patients (8.1%). The most common congenital heart defects that were repaired via this approach were atrial septal defects (secundum in 11 patients, 29.7%; primum in 5, 13.5%; and unroofed coronary sinus in 1, 2.7%). Twelve patients (32.4%) underwent repair of partial anomalous pulmonary venous connections with or without sinus venosus defects, while 4 patients (10.8%) underwent closure of membranous ventricular septal defects. Mitral valve repair, resection of cor triatriatum dexter, epicardial pacemaker placement, and myxoma resection occurred in 1 patient (2.7%) each. No early mortality or reoperations. All patients were extubated in the operating room, and the mean length of hospital stay was 3.3 ± 2.04 days. Follow-up was complete (mean 7 ± 5 months). No late mortality or reoperations. One patient required epicardial pacemaker placement due to sinus node dysfunction 5 months after surgery. CONCLUSIONS: Vertical axillary right thoracotomy is a cosmetically superior approach that is safe and effective for repair of a variety of congenital heart defects in children.

Development and Use of an Induction of General Endotracheal Anesthesia Checklist Assessment for Medical Students in a Clinical Setting During Their Introductory Anesthesiology Clerkship.

Background: The American Association of Medical Colleges deemed performing lifesaving procedures, such as airway management, a necessary medical student competency for transitioning to residency. Anesthesiology clerkships provide the unique opportunity for medical students to practice these procedures in a safe and controlled environment. We aimed to develop a checklist that assesses medical students' ability to perform the main steps of a general anesthesia induction with endotracheal intubation in the clinical setting. Methods: We created a Checklist containing items aligned with our clerkship objectives. We modified it after receiving feedback and trialing it in the clinical setting. Medical students were evaluated with the Checklist using a pre- and post-clerkship study design: (1) in a simulation setting at the beginning of the clerkship; and (2) in the operating room at the end of the clerkship. Using paired t-tests, we calculated pre- and post-clerkship Checklist scores to determine curriculum efficacy. A P value of <.05 was determined to be statistically significant. We examined rater agreement between overall scores with intraclass correlation coefficients (ICC). Results: Thirty medical students participated in the study. The ICC for agreement was 0.875 (95% confidence interval [CI], 0.704-0.944). The ICC for consistency was 0.897 (95% CI, 0.795-0.950). There was a statistically significant improvement in the score from baseline to final evaluation of 3.6 points (95% CI, 2.5-5.2; P = .001). Conclusions: The statistically significant change in Checklist scores suggests that our medical students gained knowledge and experience during the introductory clerkship inducing general anesthesia and were able to demonstrate their knowledge in a clinical environment.

The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System.

The American Society of Anesthesiologists (ASA) Physical Status classification system celebrates its 80th anniversary in 2021. Its simplicity represents its greatest strength as well as a limitation in a world of comprehensive multisystem tools. It was developed for statistical purposes and not as a surgical risk predictor. However, since it correlates well with multiple outcomes, it is widely used-appropriately or not-for risk prediction and many other purposes. It is timely to review the history and development of the system. The authors describe the controversies surrounding the ASA Physical Status classification, including the problems of interrater reliability and its limitations as a risk predictor. Last, the authors reflect on the current status and potential future of the ASA Physical Status system.

MEGDEL Syndrome and Its Anesthetic Implications.

MEGDEL syndrome gains its name for its following features: 3-methylglutaconic aciduria (MEG), deafness (D), encephalopathy (E), Leigh-like syndrome (L). This syndrome is caused by biallelic mutations in the serine active site-containing protein 1 (SERAC1 ) gene. When these patients present with hepatopathy (H) in addition to the above manifestations the syndrome is labeled as MEGD(H)EL. The pathology of the disease shares features with different types of inborn errors of metabolism. We present the anesthetic management of a neonate who was diagnosed with MEGD(H)EL syndrome and underwent diagnostic magnetic resonance imaging of the brain at 14 days of postnatal age. We describe the epidemiology and important features of this rare disease that are pertinent for the anesthesiologist.

Pulmonary valve replacement via left anterior minithoracotomy: Lessons learned and early experience.

OBJECTIVE: Median sternotomy has been the standard for pulmonary valve replacement (PVR) in patients with free pulmonary regurgitation (PR) and right ventricular enlargement. With the introduction of transcatheter therapy, the search for an alternate to sternotomy is mandated. We present our early experience with a limited anterior left thoracotomy approach. METHODS: We used a left anterior mini-thoracotomy in six male patients (15 ± 1.94 years of age) who developed progressive right ventricular enlargement due to chronic PR. RESULTS: Primary diagnoses were tetralogy of Fallot in five patients and pulmonary atresia with an intact septum in another. Four patients had previous median sternotomy with transannular patch repair. The mean right ventricular end-diastolic volume index was 189 ± 27.13 ml/m2 . The procedure was feasible in all patients. All patients had satisfactory adult size pulmonary bioprosthesis (25 or 27 mm valve), with a mean peak gradient of 18 ± 2.40 mmHg across the prosthesis at discharge. All patients were extubated intraoperatively at the end of the procedure and required no intraoperative transfusions. There were no early or late mortalities. Early morbidities included left hemidiaphragm paralysis in one patient, and re-sternotomy for prosthetic valve endocarditis in one. One patient required late reoperation for a common femoral artery pseudoaneurysm. CONCLUSIONS: Minimally invasive access for PVR is feasible in both primary and repeat settings, through a limited anterior left minithoracotomy in the absence of intracardiac shunts and the need for other concomitant cardiac procedures. Longer-term studies with a larger number of patients are needed to compare the efficacy of this approach to standard sternotomy.

Computer-Generated Three-Dimensional Airway Models as a Decision-Support Tool for Preoperative Evaluation and Procedure-Planning in Pediatric Anesthesiology.

Technology improvements have rapidly advanced medicine over the last few decades. New approaches are constantly being developed and utilized. Anesthesiology strongly relies on technology for resuscitation, life-support, monitoring, safety, clinical care, and education. This manuscript describes a reverse engineering process to confirm the fit of a medical device in a pediatric patient. The method uses virtual reality and three-dimensional printing technologies to evaluate the feasibility of a complex procedure requiring one-lung isolation and one-lung ventilation. Based on the results of the device fit analysis, the anesthesiology team confidently proceeded with the operation. The approach used and described serves as an example of the advantages available when coupling new technologies to visualize patient anatomy during the procedural planning process.

Resection of a large left atrial myxoma combined with mitral valve repair via a vertical right axillary thoracotomy in a pediatric patient.

Cardiac myxomas are extremely rare in the pediatric population; however, if they do develop, they occur most often in the left atrium. We present a 16-year-old male who had a murmur discovered during a routine sport examination. A transthoracic echocardiogram showed a large left atrial tumor that caused severe inflow obstruction to the left ventricle and at least moderate mitral valve regurgitation. Through a minimally invasive, muscle-sparing vertical right axillary thoracotomy, he underwent complete resection of the mass, combined with posterior mitral valve annuloplasty. A histopathological examination confirmed a cardiac myxoma.

Anesthetic management of pediatric patients diagnosed with X-linked adrenoleukodystrophy: A single-center experience.

BACKGROUND: X-linked adrenoleukodystrophy is a progressive demyelinating disease that primarily affects males with an incidence of 1:20 000-30 000. The disease has a wide spectrum of phenotypic expression and may include adrenal insufficiency, cerebral X-linked adrenoleukodystrophy and adrenomyeloneuropathy. The condition has implications for the administration of anesthesia and reports of anesthetic management in those patients are limited at this point. AIM: To review the perioperative care, complications and outcomes of patients diagnosed with X-linked adrenoleukodystrophy at the University of Minnesota Masonic Children's Hospital. METHOD: After obtaining IRB approval, we performed a retrospective chart review of pediatric patients diagnosed with X-linked adrenoleukodystrophy who underwent either surgery or diagnostic/therapeutic procedures that included anesthesia services between January 2014 and December 2016. Data included demographics, American Society of Anesthesiologists classification, preoperative diagnosis, history of hematopoietic stem cell transplant, anesthetic approaches, airway management, medications used, intra- and postoperative complications, and patient disposition. RESULTS: We identified 38 patients who had a total of 166 anesthetic encounters. The majority of patients underwent procedures in the sedation unit (75.9%) and received a total intravenous anesthetic with spontaneous ventilation via a natural airway (86.1%). Preoperative adrenal insufficiency was documented in 87.3% of the encounters. Stress-dose steroids were administered in 70.5% of the performed anesthetics. A variety of anesthetic agents were successfully used including sevoflurane, isoflurane, propofol, midazolam, ketamine, and dexmedetomidine. There were few perioperative complications noted (6.6%) and the majority were of low severity. No anesthesia-related mortality was observed. CONCLUSIONS: With the availability of skilled pediatric anesthesia care, children with X-linked adrenoleukodystrophy can undergo procedures under anesthesia in sedation units and regular operating rooms with low overall anesthesia risk.

Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery.

The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.

Anesthetic Management During Atrial Septostomy in a Conjoined Thoraco-Omphalopagus Twin With Tricuspid Atresia and d-Transposition of the Great Arteries Before Separation: A Case Report.

Conjoined twins are uncommon with reported incidences of 1 in 30,000-200,000 births. They represent a heterogeneous population in regard to location of joint body parts and presence/extent of internal organ fusion. Positioning, airway management, possible presence of cross-circulation, and the fact that 2 patients require anesthesia for each procedure present significant challenges to the anesthesiologist. We report the anesthetic care of a conjoined twin set in which one of the patients presented with tricuspid atresia, d-transposition of the great arteries, and both atrial and ventricular septal defect. A balloon atrial septostomy was performed to allow survival after a separation procedure.

Incidence and predictors of massive bleeding in children undergoing liver transplantation: A single-center retrospective analysis.

BACKGROUND: Liver transplantation represents a major surgery involving a highly vascular organ. Reports defining the scope of bleeding in pediatric liver transplants are few. AIMS: We conducted a retrospective analysis of liver transplants performed at our pediatric tertiary care center to quantify blood loss, blood product utilization, and to determine predictors for massive intraoperative bleeding. METHODS: Pediatric patients who underwent isolated liver transplantation at Boston Children's Hospital between 2011 and 2016 were included. The amount of blood product transfused in the perioperative period and the incidence of postoperative complications were reported. Univariable and multivariable logistic regressions were used to determine predictors for massive bleeding, defined as estimated blood loss exceeding one circulating blood volume within 24 hours. RESULTS: Sixty-eight children underwent liver transplantation during the study period and were included in the analysis. Multivariable logistic regression analysis identified the following independent predictors of massive bleeding: preoperative hemoglobin level <8.5 g/dL (OR 11.09, 95% CI 1.87-65.76), INR >1.5 (OR 11.62, 95% CI 2.36-57.26), platelet count <100 109 /L (OR 7.92, 95% CI 1.46-43.05), and surgery duration >600 minutes (OR 6.97, 95% CI 0.99-48.92). CONCLUSIONS: Pediatric liver transplantation is associated with substantial blood loss and a significant blood product transfusion burden. A 43% incidence of massive bleeding is reported. Further efforts are needed to improve bleeding management in this high-risk population.

Anesthetic Management of Patients With Inborn Errors of Metabolism.

Inborn errors of metabolism (IEM) are characterized by the body's inability to convert food into energy. The pathogenetic mechanism is based on defects in a variety of cellular enzymes. In addition to impairment of energy generation, accumulation of substrates may occur, which can deposit in tissue and lead to organ dysfunction. IEM can have profound implications for perioperative management, including difficult airway management, cardiac dysfunction, aspiration risk, seizures, and metabolic dysregulation. For the anesthesiologist, comprehensive knowledge is difficult to attain because of the heterogeneity of this group and the low prevalence of specific diseases. The first part of this article reviews intermediary metabolism, whereas the second part aims to highlight important aspects in perioperative management of patients with IEM. Instead of reviewing each single disorder within the vast group of IEM, we provide a conceptual framework that will facilitate the understanding of main problems encountered in each of the disease subgroups.