Laparoscopic cholecystectomy in a patient with Fontan circulation.

BACKGROUND: Fontan circulation is created when a baby is born with only one functioning cardiac ventricle. A series of surgeries are performed to allow the ventricle to provide oxygenated blood to the systemic circulation and to create passive flow of venous blood to the pulmonary circulation via a conduit. Laparoscopic surgery poses several hemodynamic challenges to a patient with Fontan physiology attributable to carbon dioxide insufflation, positive pressure ventilation, and reverse Trendelenburg positioning. CLINICAL FEATURES: A 39-yr-old male with a Fontan physiology was referred to our tertiary care centre because of repeated bouts of cholecystitis requiring a percutaneous drain and now elective laparoscopic cholecystectomy. Because of repeated cardiac surgeries, the patient also had complete heart block and was pacemaker dependent. We placed an arterial catheter prior to induction of general anesthesia with tracheal intubation. Transesophageal echocardiography allowed for real-time intraoperative assessment of venous blood flow through the patient's extracardiac diversion system throughout the surgery. This information was used to guide management and determine circulation tolerance during the various stages of laparoscopy. Inhaled milrinone resulted in the shunt fraction returning to the patient's baseline. Intraperitoneal pressure was kept below 10 mm Hg, and systemic blood pressure was supported with a low-dose norepinephrine infusion. CONCLUSIONS: Intraoperative transesophageal echocardiography is a useful monitoring device during laparoscopic surgery when a patient has Fontan circulation. Knowing how to administer inhaled milrinone is a useful skill to decrease the shunt fraction through a patient's conduit, increasing pulmonary blood flow while avoiding hypotension.

RéSUMé: CONTEXTE: La circulation de Fontan est créée lorsqu'un bébé naît avec un seul ventricule cardiaque fonctionnel. Une série d'interventions chirurgicales est pratiquée pour permettre au ventricule de fournir du sang oxygéné à la circulation systémique et de créer un flux passif de sang veineux vers la circulation pulmonaire via un conduit. La chirurgie par laparoscopie pose plusieurs défis hémodynamiques à une personne présentant une physiologie de Fontan, attribuables à l'insufflation de dioxyde de carbone, à la ventilation par pression positive et au positionnement en Trendelenburg inversé. CARACTéRISTIQUES CLINIQUES: Un homme de 39 ans présentant une physiologie de Fontan a été référé à notre centre de soins tertiaires en raison d'épisodes répétés de cholécystite nécessitant un drainage percutané puis une cholécystectomie non urgente par laparoscopie. En raison de chirurgies cardiaques répétées, le patient avait également un bloc cardiaque complet et dépendait d'un stimulateur cardiaque. Nous avons placé un cathéter artériel avant l'induction de l'anesthésie générale avec intubation trachéale. L'échocardiographie transœsophagienne a permis d'évaluer en temps réel la circulation sanguine veineuse à travers le système de dérivation extracardiaque du patient tout au long de la chirurgie. Cette information a été utilisée pour guider la prise en charge et déterminer la tolérance à la circulation au cours des différentes étapes de la laparoscopie. L'inhalation de milrinone a entraîné le retour de la fraction de dérivation aux valeurs de base du patient. La pression intrapéritonéale a été maintenue en dessous de 10 mm Hg, et la tension artérielle systémique a été soutenue par une perfusion de noradrénaline à faible dose. CONCLUSION: L'échocardiographie transœsophagienne peropératoire est un dispositif de monitorage utile lors d'une chirurgie laparoscopique lorsqu'un patient a une circulation de Fontan. Savoir comment administrer la milrinone par inhalation est une compétence utile pour diminuer la fraction de dérivation à travers le conduit d'un patient, augmentant ainsi la circulation sanguine pulmonaire tout en évitant l'hypotension.

Incidence, Outcomes, and Risk Factors of Intraoperative Cardiac Arrest During Orthotopic Liver Transplantation.

BACKGROUND: Intraoperative cardiac arrest (ICA) during liver transplantation (LT) is a rare surgical complication that results in devastating outcomes. Moreover, previous worldwide studies have found inconsistencies in the risk factors associated with ICA in LT. METHODS: This was a retrospective cohort study of adult patients who underwent LT between January and October 2021 at Siriraj Hospital, a tertiary care hospital. The incidence of ICA and outcomes of patients who experienced ICA were examined. Risk factors associated with ICA were investigated as a secondary objective. RESULTS: Among 342 patients, the incidence of ICA was 3.5% (95% CI 1.8%-6.1%). Of these, 33.3% died intraoperatively. Among patients with ICA, 41.7% died within 30 days, compared with only 7.6% in those without ICA (P = .002). Moreover, the in-hospital mortality rate of those with ICA was 58.3%, which was significantly higher than that of those without ICA (9.7%, P < .001). However, 41.7% of patients with ICA were discharged alive with long-term survival. Because ICA is a rare event, we found only 2 independent factors significantly associated with ICA. These factors include intraoperative temperature below 35°C, with an odds ratio (OR) of 6.07 (95% CI:1.32-27.88, P = .02) and elevated intraoperative serum potassium, with an OR of 4.57 (95% CI:2.15-9.67, P < .001). CONCLUSIONS: ICA is associated with high perioperative and in-hospital mortality. However, our findings suggest that with effective management of ICA, more than 40% of these patients could be discharged with excellent long-term outcomes. Hypothermia and hyperkalemia were independent risk factors significantly associated with ICA.

Qualitative and quantitative gastric ultrasound assessment in highly skilled regional anesthesiologists.

BACKGROUND: Pulmonary aspiration is a major complication in anesthesia, and various studies have shown that gastric sonography can reliably provide valuable information relative to both the qualitative and quantitative aspects of gastric content. This study aimed to determine the accuracy of ultrasound assessment of gastric content compared between two novice anesthesiologist gastric sonographers. METHODS: This prospective cohort study of two anesthesiologists learning to perform qualitative and quantitative ultrasound assessment of gastric content on healthy volunteers was conducted at Siriraj Hospital (Bangkok, Thailand). This trial was registered with ClinicalTrials.gov (reg. no. NCT04760106). RESULTS: Of the 50 enrolled participants, three were excluded due to study protocol violation. Each anesthesiologist performed a qualitative assessment on 47 participants for an overall total of 94 scans. There were 15 males and 32 females (age 42 ± 11.7 years, weight 61.2 ± 13.1 kg, height 160.7 ± 7.3 cm, and BMI 23.6 ± 4.3 kg/m2). The overall success rate for all gastric content categories was approximately 96%. From antral cross-sectional area measurement, as the ingested volume increased, there was a tendency toward increased deviation from the actual ingested volume. Interrater agreement between anesthesiologists was analyzed using intraclass correlation coefficients (ICCs). A larger fluid volume was found to be associated with a lower level of agreement between the two anesthesiologists. The ICCs were 0.706 (95% CI: -0.125 to 0.931), 0.669 (95% CI: -0.254 to 0.920), 0.362 (95% CI: -0.498 to 0.807) for the 100 ml, 200 ml, and 300 ml fluid volumes, respectively. The mean duration to perform an ultrasound examination for each gastric content category and for the entire examination did not differ significantly between anesthesiologists (p > 0.05). CONCLUSION: Our results indicate that qualitative ultrasound assessment of gastric content is highly accurate and can be easily learned. In contrast, quantification of gastric volume by novice gastric sonographers is more complex and requires more training. TRIAL REGISTRATION: ClinicalTrials.gov no. NCT04760106 Date registered on Feb 11, 2021. Prospectively registered.