Anaesthesia for mechanical thrombectomy: a narrative review.

Stroke is a leading cause of death and disability, and is associated with a huge societal and economic burden. Interventions for the immediate treatment of ischaemic stroke due to large vessel occlusion are dependent on recanalisation of the occluded vessel. Trials have provided evidence supporting the efficacy of mechanical thrombectomy in ischaemic stroke due to large vessel occlusion. This has resulted in changes in management and organisation of stroke care worldwide. Major determinants of effectiveness of thrombectomy include: time between stroke onset and reperfusion; location of occlusion and local collateral perfusion; adequacy of reperfusion; patient age; and stroke severity. The role of anaesthetic technique on outcome remains controversial with published research showing conflicting results. As a result, choice of conscious sedation or general anaesthesia for mechanical thrombectomy is often dependent on individual operator choice or institutional preference. More recent randomised controlled trials have suggested that protocol-driven general anaesthesia is no worse than conscious sedation and may even be associated with better outcomes. These and other studies have highlighted the importance of optimal blood pressure management as a major determinant of patient outcome. Anaesthetic management should be tailored to the individual patient and circumstances. Acute ischaemic stroke is a neurological emergency; clinicians should focus on minimising door-to-groin puncture time and the provision of high-quality periprocedural care with a particular emphasis on the maintenance of an adequate blood pressure.

The protective role of gastric acidity in neonatal bacterial translocation.

The acid environment of the stomach serves as an important defense against intestinal colonization by potentially pathogenic bacteria. The purpose of this study was to examine the effect of increased gastric pH on bacterial translocation in a neonatal rabbit model. Fifty-nine rabbit pups were delivered by cesarean section and randomly divided into normal acid (NA) and reduced acid (RA) groups. All were gavage fed and challenged with Enterobacter cloacae, 1 x 10(6) CFU/mL. The RA group received ranitidine, 20 mg/kg/d with all feeds. Gastric pH was measured by pH probe before and 4 hours after bacterial challenge. Mesenteric lymph node (MLN), spleen, liver, midjejunum, and cecum were harvested for culture at 72 hours. Gastric pH in the RA group was significantly increased before and 4 hours after the bacterial challenge. The incidence of bacterial translocation to the MLN, spleen, and liver was significantly higher in the RA group. Log cecal and jejunal colony counts were significantly increased in the RA animals. The authors conclude that the gastric acidity is protective against intestinal colonization and translocation of potentially pathogenic bacteria in this neonatal rabbit model.

Is nasogastric tube decompression necessary after major abdominal surgery in children?

Nasogastric (NG) decompression has traditionally been used after major abdominal surgery in pediatric patients. This study was designed to determine if NG tubes could be routinely omitted in pediatric patients undergoing major abdominal procedures. Between January 1993 and December 1995, 83 patients had follow-up prospectively without NG decompression after a variety of major abdominal surgeries. NG tubes were inserted for persistent vomiting or abdominal distension. Exclusion criteria included bowel obstruction, intestinal atresia, and perforation of the stomach or duodenum. Ages ranged from 13 days to 22 years. Seventy-four patients (89%) were treated successfully without postoperative NG decompression. There were no cases of pneumonia, wound dehiscence, anastomotic leak, or delay in return of gastrointestinal function. Nine patients required NG tubes for persistent vomiting or abdominal distension. An anastomotic leak developed in one patient after endorectal pull-through. NG decompression is unnecessary after most major abdominal operations in pediatric patients. The endorectal pull-through may represent a group of patients that benefit from routine decompression.

Management of multiple intestinal atresias and perforation with intraluminal stenting.

Intraluminal stenting of the gastrointestinal (GI) tract in both multiple intestinal atresias and perforations was used in three patients. In the atresia patients (2), a piercing trocar was used to create continuity of the GI tract and as a guide to thread the intestine over the stent. All patients currently demonstrate normal growth and development on routine enteral feeds. None developed anastomotic leaks or strictures.