A case report and anesthetic implications of situs inversus totalis in video-assisted thoracoscopic pulmonary resection.

Introduction and importance: Reports are limited on video-assisted thoracoscopic surgery for lung malignancy of patients with situs inversus totalis (SIT). Patients with SIT have significant anatomic differences with implications that are important for surgery, anesthesia, and nursing to understand in order to provide care for this patient population. Case presentation: A 64-year-old man with SIT and lung adenocarcinoma needed flexible bronchoscopy and wedge resection of a 9×8 mm adenocarcinoma in the right upper lobe and underwent video-assisted thoracoscopic surgery. Clinical discussion: Preoperative planning, including collaboration with the surgical team, allowed safe monitoring, induction of anesthesia, and airway isolation in this patient allowing them to have successful resection of their pulmonary malignancy. Postoperative care was enhanced by detailed communication and understanding of the patient's anatomy and implications of this condition for post anesthesia care unit nursing care. Conclusion: Patients with rare clinical conditions and backgrounds may require surgical and anesthetic intervention. The authors describe important anesthetic considerations of preoperative evaluation, airway management, cardiac monitoring, and vascular access that should be noted and taken into account for patients with SIT. Proper preparation, planning, and communication allow for patients with SIT to safely undergo surgical procedures.

Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes.

BACKGROUND: Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution. METHODS: The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis. RESULTS: The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01). CONCLUSIONS: This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.

Intraoperative Dysrhythmias Cease After Venting During Intramedullary Nailing of an Impending Femur Fracture: A Case Report.

CASE: A 76-year-old woman with multiple myeloma and osteoporosis presented with right hip pain and an impending atypical femoral fracture in the setting of chronic bisphosphonate use. After preoperative medical optimization, she was scheduled for prophylactic intramedullary nail fixation. Intraoperatively, the patient experienced episodes of severe bradycardia and asystole associated with intramedullary reaming, which ceased after distal venting of the femur. No additional intraoperative or postoperative complications were encountered, and the patient recovered uneventfully. CONCLUSION: Femoral canal venting may be an appropriate intervention for similar transient dysrhythmias caused by intramedullary reaming.

Reduced Echocardiographic Inotropy Index after Cardiopulmonary Bypass Is Associated With Complications After Cardiac Surgery: An Institutional Outcomes Study.

OBJECTIVE: Despite advances in echocardiography and hemodynamic monitoring, limited progress has been made to effectively quantify left ventricular function during cardiac surgery. Traditional measures, including left ventricular ejection fraction (LVEF) and cardiac index, remain dependent on loading conditions; more complex measures remain impractical in a dynamic surgical setting. However, the Smith-Madigan Inotropy Index (SMII) and potential-to-kinetic energy ratio (PKR) offer promise as measures calculable during cardiac surgery and potentially predictive of outcomes. Using echocardiographic and hemodynamic monitoring data, the authors aimed to calculate SMII and PKR values after cardiopulmonary bypass and understand associations with postoperative outcomes, adjusting for previously identified risk factors. DESIGN: Observational cohort study. SETTING: Tertiary care academic hospital. PATIENTS: The study comprised 189 elective adult cardiac surgical procedures from 2015-2016. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was postoperative mortality or organ system complication (stroke, prolonged ventilation, reintubation, cardiac arrest, acute kidney injury, new-onset atrial fibrillation). After adjustment, SMII <0.83 W/m2 independently predicted the primary outcome (adjusted odds ratio 2.19, 95% confidence interval 1.08-4.42); whereas PKR, LVEF, and cardiac index demonstrated no associations. When SMII and PKR were incorporated into a EuroSCORE II risk model, predictive performance improved (net reclassification index improvement 0.457; p = 0.001); whereas a model incorporating LVEF and cardiac index demonstrated no improvement (0.130; p = 0.318). CONCLUSION: The present study demonstrated that SMII, but not PKR, as a measure of cardiac function was associated with major complications. The study's data may guide investigations of more suitable perioperative goal-directed therapies to reduce complications after cardiac surgery.

Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations.

Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.

Ocular injury during spine surgery.

PURPOSE: Ocular injury and vision loss are rare complications of surgery. Spine surgery has been identified as particularly high risk for postoperative vision loss; nevertheless, ocular injuries have not been comprehensively assessed in this patient population. METHODS: This historical cohort study assessed incidence, cause, and risk factors of perioperative ocular injury after spine surgery at a tertiary care medical centre from January 1, 2006 through January 31, 2018. Patients were included who had ocular injury identified during an ophthalmology consultation in the first seven postoperative days. Differences in demographic, laboratory, intraoperative, and postoperative characteristics between those experiencing or not experiencing ocular injury were assessed with Fisher exact and Wilcoxon signed-rank tests for categorical and continuous variables, respectively. RESULTS: Of 20,128 qualifying spine surgeries, 39 cases of perioperative ocular injuries were identified (39/20,128; 0.19% [95% confidence interval (CI), 0.14 to 0.26]). The most common ocular injury was blurry vision of unknown cause (13/39; 33%; 95% CI, 18.6 to 46.4), followed by ischemic optic neuropathy (9/39; 23%; 95% CI, 12.6 to 38.3) and corneal abrasion (7/39; 18%; 95% CI, 9.0 to 32.7). All cases of blurry vision of unknown cause were diagnosed via ophthalmology consultation and resolved within several days. Patients with perioperative ocular injury were more likely to have baseline anemia, have undergone fusion and instrumentation procedures, and had longer operative times with greater crystalloid, colloid, and transfusion requirements and more blood loss. CONCLUSIONS: Although not representing a causal relationship, these data suggest that surgical factors may have a greater role than demographic characteristics or other clinical factors in the development of perioperative ocular injury. Surgeons, anesthesiologists, and patients should be aware of the increased risk of ocular injury that accompanies longer, more extensive spine operations.

RéSUMé: OBJECTIF: Les lésions oculaires et la perte de vision sont des complications chirurgicales rares. La chirurgie du rachis a été identifiée comme une intervention entraînant un risque particulièrement élevé de perte de vision postopératoire; cependant, les lésions oculaires n'ont pas été évaluées de manière exhaustive chez cette population de patients. MéTHODE: Cette étude de cohorte historique a évalué l'incidence, la cause et les facteurs de risque de lésion oculaire périopératoire après une chirurgie du rachis dans un centre médical de soins tertiaires entre le 1er janvier 2005 et le 31 janvier 2018. Les patients ayant subi une lésion oculaire diagnostiquée lors d'une consultation en ophtalmologie au cours des sept premiers jours postopératoires ont été inclus. Les différences de caractéristiques démographiques, de laboratoire, peropératoires et postopératoires entre les patients ayant subi ou non une lésion oculaire ont été évaluées à l'aide du test exact de Fisher et du test des rangs signés de Wilcoxon pour les variables catégoriques et continues, respectivement. RéSULTATS: Parmi les 20 128 chirurgies du rachis éligibles, 39 cas de lésions oculaires périopératoires ont été identifiés (39/20,128; 0,19 % [intervalle de confiance (IC) 95 %, 0,14 à 0,26]). La lésion oculaire la plus fréquente était une vision floue de cause inconnue (13/39; 33 %; IC 95 %, 18,6 à 46,4), suivie d'une neuropathie optique ischémique (9/39; 23 %; IC 95 %, 12,6 à 38,3) et d'une abrasion cornéenne (7/39; 18 %; IC 95 %, 9,0 à 32,7). Tous les cas de vision floue de cause inconnue ont été diagnostiqués lors d'une consultation en ophtalmologie et se sont résolus après plusieurs jours. Les patients ayant subi une lésion oculaire périopératoire étaient plus susceptibles de présenter une anémie de départ, d'avoir subi des interventions de fusion et instrumentation rachidiennes, et d'avoir subi une chirurgie plus longue nécessitant davantage de cristalloïdes, de colloïdes et de transfusions, ainsi que d'avoir subi des pertes sanguines plus importantes. CONCLUSION: Bien que n'établissant pas de relation causale, ces données suggèrent que les facteurs chirurgicaux pourraient jouer un rôle plus important que les caractéristiques démographiques ou les autres facteurs cliniques dans l'apparition d'une lésion oculaire périopératoire. Chirurgiens, anesthésiologistes et patients devraient être conscients du risque accru de lésion oculaire qui accompagne les opérations du rachis plus longues et plus importantes.

Perioperative risks of narcolepsy in patients undergoing general anesthesia: A case-control study.

STUDY OBJECTIVE: To compare the perioperative outcomes between patients with narcolepsy and matched controls undergoing anesthetic management. DESIGN: Retrospective 2:1 matched study design. SETTING: Large tertiary medical center. PATIENTS: Narcoleptic patients who underwent general anesthesia from January 1, 2011, through September 30, 2015, were matched with controls by age, sex, and type and year of surgery. MEASUREMENTS: Medical records were reviewed for episodes of respiratory depression during phase I recovery and for other meaningful perioperative outcomes. MAIN RESULTS: The perioperative courses of 76 narcoleptic patients and their controls were examined. Compared to controls, narcoleptic patients were more often prescribed central nervous system stimulants (73.7% vs 4.0%, P<0.001) and antidepressants (46.1% vs 27.6%, P=0.007) and more often had obstructive sleep apnea (40.8% vs 19.1%, P<0.001). The intraoperative course was similar. The number of episodes of respiratory depression was not different between patients and controls (5 [6.6%] vs 12 [7.9%], respectively; P=0.80). Narcoleptic patients had a higher frequency of emergency response team activations (5 of 76 [6.6%]; 95% CI, 2.2%-14.7%) compared to controls (2 of 152 [1.3%]; 95% CI, 0.2%-4.7%) (P=0.04). Hemodynamic instability was the indication for all emergency response team activations except 1, which was for a narcoleptic patient who had excessive postoperative sedation and respiratory depression. CONCLUSIONS: Narcoleptic patients had similar intraoperative courses as the matched controls, including phase I anesthetic recovery. However, they had a higher rate of emergency response team activations than the controls, which suggests that patients with narcolepsy may be at increased perioperative risk.

Perioperative blood product administration and thromboembolic events in patients with treated polycythemia vera: a case-control study.

BACKGROUND: Patients with polycythemia vera (PV) have historically been considered to be at high risk for perioperative hemorrhagic and thromboembolic complications. However, no recent studies have compared these outcomes between treated PV patients and patients without PV undergoing similar procedures. STUDY DESIGN AND METHODS: Patients with PV who underwent surgery with anesthesia from June 1, 2006, to May 31, 2011, were randomly matched (sex, age, type of surgical procedure, surgical year) at a ratio of 1:4 with control patients without PV. Conditional logistic regression analysis adjusting for surgical duration, preoperative hemoglobin, platelet count, and cardiovascular disease was used to assess the association between PV and blood product transfusions, thromboembolism, and other major cardiovascular and pulmonary complications. RESULTS: Fifty-six PV patients who underwent 79 surgeries were matched with 312 controls. During hospitalization, 35 (44.3%) and 82 (25.9%) PV and control patients, respectively, were transfused with blood products. PV patients were at increased risk for transfusion intraoperatively (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.79-10.57; p = 0.001) and during hospitalization (OR, 4.35; 95% CI, 1.84-10.31; p < 0.001). The likelihood of thromboembolic complications and/or other major complications did not differ between the two study groups (thromboembolic-OR 1.53, 95% CI 0.39-6.02, p = 0.540; other major complications-OR 2.15, 95% CI 0.93-4.96, p = 0.073). CONCLUSIONS: Medically managed PV patients had an increased likelihood of receiving blood products perioperatively. Given the low number of observed thromboembolic events, we cannot make definitive conclusions regarding the association between PV and thromboembolism.

Anesthesia and myotonic dystrophy type 2: a case series.

BACKGROUND: Myotonic dystrophy type 2 (DM2) is a genetically distinct disorder that shares some phenotypical features of myotonic dystrophy type 1 (DM1). However, anesthetic management of patients with DM2 has not been described. The purpose of this study is to report the anesthetic management of a series of patients with DM2 and to describe their response to anesthesia. METHODS: We performed a computerized search of the Mayo Clinic medical records database looking for patients with DM2 who underwent general anesthesia. The medical records were reviewed for anesthetic technique, medications used, and postoperative complications. RESULTS: We identified 19 patients with DM2 who underwent 39 general anesthetics, 17 monitored anesthetic care cases, and two regional anesthetics. The patients exhibited normal responses to succinylcholine, nondepolarizing neuromuscular blockers, neostigmine, induction agents, and volatile anesthetics. Serious postoperative complications related to DM2 did not occur. CONCLUSION: In our series, patients with DM2 tolerated commonly used anesthetics without obvious complications, and they exhibited normal responses to muscle relaxants. These observations suggest that these medications may be used safely in patients with DM2.