Goal-directed fluid therapy in the perioperative setting.

Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a "zero-balance" approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications.

Preoperative patient preparation in enhanced recovery pathways.

Enhanced recovery pathways are a novel approach focused on enhancing the care of surgical patients. "Prehabilitation" is the term applied to any intervention administered before surgery to reduce surgery-related morbidity, decrease the length of hospital stay, expedite the return of organ function, and facilitate the patient's return to normal life. A PubMed search was performed with the following key words: enhanced recovery, preoperative preparation, cessation of smoking and euvolemia. The results from this Pubmed search revealed that female patients may have higher levels of anxiety than male patients. Intensive smoking and alcohol cessation 6-8 weeks before elective surgery may reduce the incidence of postoperative morbidity. Preoperative exercise can be effective for reducing the postoperative complications like pulmonary complications and shortening the length of hospital stay. It is safe to allow patients to drink clear fluids up until 2 h before elective surgery (Level II evidence). Perioperative normoglycemia is the single most important factor to prevent surgical site infection. Intermittent pneumatic compression devices and low molecular weight heparin are effective in preventing postoperative thromboembolism. No advantage is gained by preoperative mechanical bowel preparation in elective colorectal surgery. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. Mild perioperative hypothermia may promote surgical wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension.

Caudal and intravenous dexamethasone as an adjuvant to pediatric caudal block: A systematic review and meta-analysis.

BACKGROUND: Dexamethasone has become a popular additive for regional anesthesia. The aim of this meta-analysis was to assess the effectiveness of this additive on the duration of postoperative analgesia, postoperative vomiting, and possible adverse events in pediatrics. METHODS: We searched databases, conference records, and registered trials for randomized controlled trials. The databases included the Cochrane Library, JBI Database of Systematic Reviews, PubMed, ISI Web of Knowledge, Science-Direct, and Embase. Odds ratio, weighted mean difference, and the corresponding 95% confidence intervals were calculated using the REVMAN software, version 5.3, for data synthesis and statistical analysis, which following the PRISMA statement. The main outcomes were duration of postoperative analgesia (time from the end of surgery to first administration of analgesics as evidenced by a pain score) and postoperative vomiting. RESULTS: Seven studies were selected for this meta-analysis, involving 647 pediatric patients. All the patients were randomized to receive caudal or intravenous dexamethasone with caudal block (experimental group) or plain caudal block (control group). There was significantly longer duration of postoperative analgesia in the experimental group compared with control group (weighted mean difference: 238.40 minutes; 95% CI: 193.41-283.40; P < .00001). The experimental group had fewer patients who needed analgesics after surgery (odds ratio: 0.18 minutes; 95% CI: 0.05-0.66; P = .009). Additionally, the number of subjects who remained pain-free to 2, 6, 24, and 48 hours after operation was significantly greater in the experimental group than control group. Side effects in these 2 groups were comparable (odds ratio: 0.94; 95% CI: 0.34-2.56; P = .90). The incidence of postoperative vomiting was significantly decreased in the experimental group compared with control group (odds ratio: 0.29; 95% CI: 0.13-0.63; P = .002). CONCLUSION: Caudal and intravenous dexamethasone could provide longer duration of postoperative analgesia and reduced the incidence of postoperative vomiting with comparable adverse effects than plain caudal block. However, any additive to the caudal space carries with it the potential for neurotoxicity and that caution should always be exercised when weighting the risks and benefits of any additive. The result was influenced by small numbers of participants and significant heterogeneity.

Inferior wall diverticulum of left ventricle coexisting with mental retardation and atrial septal defect.

We report a case of congenital inferior wall left ventricular diverticulum (LVD), atrial septal defect and mental retardation detected by intraoperative transesophageal echocardiography. The combination of three features strongly suggests that genetic factors play important role in the pathogenesis of the disorder. Most LVDs are asymptomatic. Echocardiographers and cardiac anesthesiologists should be aware of this anomaly, and include it in the differential diagnosis of abnormally shaped ventricular wall and seek other congenital abnormalities if LVD is detected.

Novel Rescue Strategy for Endotracheal Intubation Through Severe Subglottic Stenosis by Using a Metal Suction Tube as a Tube Stylet in a Neonate: A Case Report.

We report a novel technique for the management of subglottic stenosis in a neonate. The initial endotracheal intubation did not provide adequate mechanical ventilation due to a significant air leak. We then performed suspension laryngoscopy and used a metal suction tube as an intubating stylet. We successfully inserted an endotracheal tube deep enough to maintain adequate mechanical ventilation. This technique is a viable rescue strategy in this clinical scenario.

Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: is commonly used for children undergoing hypospadias repair. However, the safety of caudal block for hypospadias repair in children is controversial in terms of surgical complications such as urethrocutaneous fistula and glans dehiscence. We sought to perform a meta-analysis to estimate the analgesic efficacy and relative complications of caudal block for hypospadias repair in children. METHODS: We identified comparative studies of caudal block versus peripheral nerve block or no caudal block; studies were published or presented through 1 January 2018, and reports of analgesic efficacy or surgical complications of hypospadias repair in children were identified. Peripheral nerve block includes dorsal nerve penile block and pudendal nerve block. Data were abstracted from studies comparing caudal block with peripheral nerve block or no caudal block; original source data were used when available. We prespecified separate assessments of randomized controlled trials (RCTs) and observational studies given the inherent differences between types of study designs. Data from 298 patients in four RCTs and from 1726 patients in seven observational studies were included. RCT and observational data were analyzed separately. RESULTS: In RCTs, caudal blocks (compared with peripheral nerve blocks) showed no detectable differences in terms of need for additional analgesia within 24 hours after the surgery (OR 10.49; 95% CI 0.32 to 343.24; p=0.19), but limited data showed lower pain scores 24 hours after the surgery (standardized mean difference (SMD) 1.57; 95% CI 0.29 to 2.84; p=0.02), a significantly shorter duration of analgesia (SMD -3.33; 95% CI -4.18 to -2.48; p<0.0001) and analgesics consumption. No significant differences were observed in terms of postoperative nausea and vomiting (OR 3.08; 95% CI 0.12 to 77.80; p=0.50) or motor weakness (OR 0.01; 95% CI -0.03 to 0.05; p=0.56). Only one randomized study showed that caudal blocks (compared with peripheral nerve blocks) were associated with detectable differences in urethrocutaneous fistula rate (OR 25.27; 95% CI 1.37 to 465.01; p=0.03) and parental satisfaction rate (OR 0.07; 95% CI 0.02 to 0.21; p<0.00001). In observational studies, caudal block was not associated with surgical complications in all types of primary hypospadias repair (OR 1.83; 95% CI 0.80 to 4.16; p=0.15). To adjust for confounding factors and to eliminate potential selection bias involving caudal block indication, we performed subgroup analysis including only patients with distal hypospadias. This analysis revealed similar complication rates in children who received a caudal block and in children not receiving caudal block (OR 1.02; 95% CI, 0.39 to 2.65; p=0.96). This result further confirmed that caudal block was not a risk factor for surgical complications in hypospadias repair. The direction of outcomes in all the other subgroup analyses did not change, suggesting stability of our results. CONCLUSIONS: In RCTs, only limited data showed peripheral nerve blocks providing better analgesic quality compared with caudal blocks. In real-world non-randomized observational studies with greater number of patients (but with admitted the potential for a presence of selection bias and residual confounders), caudal blocks were not associated with postoperative complications including urethrocutaneous fistula and glans dehiscence.

[Sevoflurane used for induction and maintenance of anaesthesia in children].

OBJECTIVE: To observe the effect of sevoflurane on the induction and maintenance of anaesthesia in children, and to evaluate its safety and effectiveness. METHODS: Forty child patients who conformed to the selection standard were operated under anaesthesia with intubation.Without premedicant, all the patients inhaled 100% oxygen(1L/min) and sevoflurane by mask, and escalated the concentration of sevoflurane (to the maximum concentration 7%) until the lash reflex disappeared, and the maintenance concentration was controlled under 4%. All the patients were intubated, together with vecuronium 0.1mg/kg. RESULTS: With little tract excretion, the achievement ratio of induction by sevoflurane was 100%, and the children tolerated well. With stable hemodynajmics,1% approximately 4.0% maintenance concentration of sevoflurane during the operation showed effective anaesthesia, no decreased heart rate or blood pressure appeared, and all the patients' body temperature was normal. CONCLUSION: Sevoflurane for children induction can bring fewer stimuli in the respiratory tract,less cardiac vascular inhibition and palinesthesia time. Anaesthesia in children induced by sevoflurane is safe and effective.