Is the use of direct oral anticoagulants after non-cardiac thoracic surgery safe for patients?

PURPOSE: The outcomes of direct oral anticoagulant use after noncardiac thoracic surgery have not been elucidated. We compared the safety and efficacy of the postoperative use of direct oral anticoagulants versus warfarin. METHODS: This retrospective cohort study included patients taking anticoagulants after noncardiac thoracic surgery between 2008 and 2021. Patients were divided into 2 groups based on drug type: Group D (direct oral anticoagulants) and Group W (warfarin). The occurrence of bleeding and thromboembolic events was also assessed. RESULTS: Anticoagulants were administered to 434 postoperative patients. One (0.4%) of the 247 patients in Group D and 3 (1.6%) of the 187 patients in Group W experienced thromboembolic events. Four patients (1.6%) in Group D and 4 (2.1%) patients in Group W experienced bleeding events. All bleeding events in Group D occurred within 1 week of oral administration, whereas only 1 case of bleeding occurred after resumption in Group W. CONCLUSIONS: The outcomes of patients treated with direct oral anticoagulants did not differ from those of patients treated with warfarin. However, major bleeding can occur after the postoperative resumption of direct oral anticoagulant use. Attention should be paid to resuming oral anticoagulants within a few days of non-cardiac thoracic surgery.

[Perioperative management and fast track in knee arthroplasty]. / Perioperatives Management und Fast-Track bei Knieendoprothetik.

BACKGROUND: Knee arthroplasty is an established surgical treatment for advanced osteoarthritis of the knee. In view of the rising number of surgical procedures, increasing costs in the healthcare system with a parallel increase in patient age and comorbidities, an evidence-based perioperative management is gaining importance. Fast Recovery concepts comprise a range of evidence-based strategies for optimizing the perioperative course. By reducing perioperative risks and optimizing pre-, peri- and postoperative processes, complications can be reduced, as well as perioperative morbidity, while comprising faster convalescence. MATERIAL AND METHODS: This review is based on a systematic literature search in the PubMed, Cochrane Library and Web of Science databases on the topic of perioperative optimization and evidence for Fast Recovery programs in knee resurfacing. RESULTS: In knee arthroplasty, Fast Recovery protocols lead to a significant reduction in the length of stay in hospital without an increase in complication rates. Patients also benefit from a faster return to mobility and a reduced level of postoperative pain. The involvement of multidisciplinary teams, the optimization of pain therapy, the minimization of blood loss and early mobilization are key elements of these protocols. The implementation of Fast Recovery protocols in the perioperative care of patients is an effective strategy to improve surgical outcomes. Essential for the success of such programs is individualized multidisciplinary patient care with preoperative risk assessment, optimized pain management and early physiotherapeutic mobilization. Future research should focus on the long-term effects of these approaches and their adaptation to different patient populations.

Perioperative and postoperative management of tympanostomy tube insertion: a survey of otorhinolaryngologists in Israel.

BACKGROUND: Tympanostomy tube insertion is a standard surgical procedure in children to address middle ear infections and effusion-related hearing and speech development issues. Perioperative treatments like ear drops containing antibiotics, steroids, and tube irrigation with saline aim to prevent complications, yet no universal gold standard treatment exists. Despite guidelines, practice preferences among ENT specialists vary, motivating this study to investigate perioperative management practices in Israel. METHOD: A survey was distributed among ENT surgeons, collecting data on their main workplace, sub-specialty, preoperative hearing test requirements, tube irrigation practices, tube selection criteria, and timing of tube removal. Distribution and association with main workplaces were examined. RESULTS: The survey achieved a response rate of 27.33%. Most participants routinely required preoperative hearing tests, with a preference for conducting them within three months prior to surgery (62.2%). Tube irrigation during the procedure was less common among surgeons in the public system (p = 0.007). In response to the COVID-19 pandemic, the majority of respondents maintained their established practices (96.3%), while a small proportion (3.7%) adapted by replacing two in-person meetings with one virtual session. Variations in tube removal timing based on the main workplace were noted, with private practitioners opting for earlier removal (p = 0.002) and were less permissive in water deprivation practices (p = 0.053). CONCLUSION: This study provides insights into the practices and preferences of ENT surgeons in tympanostomy tube insertion procedures in Israel. Adherence to standardized practices was observed, with variations influenced by the primary workplace. Despite the COVID-19 pandemic, minimal changes were made to established practices. Further research and consensus are necessary to optimize patient outcomes and develop tailored guidelines in this field.

ERAS-Based Anesthetic Management of Patients Undergoing Abdominal-Based Free Flap Breast Reconstruction: A Narrative Review.

Microsurgical breast reconstruction after mastectomy is emerging as the standard of care for patients with breast cancer. The enhanced recovery after surgery (ERAS) pathway in abdominal-based free flap breast reconstruction is in its early stage of development and lacks established consensus or guidelines. In the multidisciplinary ERAS team, the anesthesia sub-team is responsible for the provision of several core elements in the ERAS pathway including anesthetic protocol optimization, perioperative fluid management and homeostasis regulation, normothermia maintenance, perioperative analgesia, and postoperative nausea and vomiting prophylaxis. Here, we summarized the state-of-the-art in anesthetic practice for the patients undergoing abdominal-based free flap breast reconstruction within an ERAS framework, and also introduced the perioperative strategy for this surgical population based on the ERAS pathway in our center, aiming to improve free flap outcome and patient satisfaction, and accelerating their recovery following surgery.

Screening and Perioperative Management of Obesity Hypoventilation Syndrome.

Obesity hypoventilation syndrome (OHS) can often be underdiagnosed or misdiagnosed and has been shown to pose significant risks in perioperative situations. Patients with OHS have a higher prevalence of baseline morbid conditions like hypertension, congestive heart failure (CHF), diabetes mellitus, atrial fibrillation, and pulmonary hypertension (PH), which contribute to adverse postoperative outcomes. The potential challenges include difficult intubation and loss of airway, postoperative respiratory failure, worsening heart failure, pulmonary hypertensive crisis, and opioid-induced respiratory depression (OIRD). It is, therefore, important to screen all obese patients for obstructive sleep apnea (OSA) and OHS before elective surgical procedures. The aim of this review is to discuss the preoperative screening and evaluation and safe anesthetic and up-to-date ventilatory management of this complex group of patients. This review also intends to increase the awareness of OHS in the adult population among hospitalists, surgeons, and cardiologists who may find themselves taking care of these patients in complex multidisciplinary settings.

Management of Congenital Methemoglobinemia in the Perioperative Setting: A Case Report and Review of Current Literature.

Background: Methemoglobin is an altered state of hemoglobin where iron in hemoglobin is oxidized and incapable of binding oxygen; leading to complications such as cyanosis, dyspnea, headache, and heart failure. Methemoglobinemia can be congenital or acquired. Congenital methemoglobinemia is a rare disease and its worldwide incidence is unclear. We recently encountered the first documented case of congenital methemoglobinemia at our institution, necessitating perioperative care. Case Presentation: In the present case, a 22-year-old man with congenital methemoglobinemia underwent general anesthesia for dental extraction. The surgeon was informed to avoid local anesthetics and oxygenation was performed with FiO2 of 1.0. Arterial blood gas analysis showed a PH of 7.337, PaO2 of 302 mm Hg, PaCO2 of 44 mm Hg, oxyhemoglobin level of 63.4%, and methemoglobin level of 37.8%. The patient had a stable course. No methylene blue therapy was required, although cyanosis was observed during surgery. Conclusion: In summary, though rare, congenital methemoglobinemia poses fatal risks during surgery. Its management involves preoperative recognition and optimization, oxygenation status, multidisciplinary care, avoiding precipitating or oxidizing agents, discussing treatment options, maintaining cardiopulmonary stability, and ensuring perioperative safety measures with the medical team.

Remimazolam Anesthesia for a Pediatric Patient With Glutaric Aciduria Type I: A Case Report.

Glutaric aciduria type I (GA-1) is a rare metabolic disorder caused by an autosomal, recessive, inherited deficiency of glutaryl-CoA dehydrogenase. Reports on the anesthetic management of patients with GA-1 are limited. It has been suggested that inhalation anesthesia is safer than propofol due to the mitochondrial dysfunction inherent in GA-1. However, inhalation anesthesia poses a risk, albeit rare, of malignant hyperthermia, which can result in severe neurological damage in GA-1 patients. Therefore, we considered that management using remimazolam might be effective and, provided a successful general anesthesia using it for a pediatric patient with GA-1. We report a case of a four-year-old girl with GA-1 who underwent a laparoscopic gastrostomy under general anesthesia. Remimazolam was used for both induction and maintenance of anesthesia. Our perioperative management also included measures to prevent a hypercatabolic condition such as adequate hydration and blood glucose control. The patient had an uneventful perioperative course and was discharged on postoperative day 7. Thus, remimazolam is proposed as a new option for anesthetic management in patients with GA-1. Additionally, tailored perioperative management that addresses the unique characteristics of GA-1 is crucial for favorable outcomes.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS: A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

The Patient with Hip Fracture.

Hip fractures are a frequent cause of hospitalization in the elderly population and can lead to significant morbidity and mortality. As the population continues to age, the incidence of hip fractures is expected to increase. The internist/hospitalist plays a critical role in the care of this population as many patients have multiple medical comorbidities. Management of the fragility hip fracture patient requires knowledge of several perioperative topics including preoperative risk assessment, risk reduction strategies, the optimal timing of surgical repair, venous thromboembolism prevention, and postoperative care considerations such as early mobilization with physical therapy, and osteoporosis treatment.

Endocrine Care for the Surgical Patient: Diabetes Mellitus, Thyroid and Adrenal Conditions.

Patients with hyperglycemia, thyroid dysfunction, and adrenal insufficiency face increased perioperative risk, which may be mitigated by appropriate management. This review addresses preoperative glycemic control, makes evidence-based recommendations for the increasingly complex perioperative management of noninsulin diabetes medications, and provides guideline-supported strategies for the perioperative management of insulin, including suggested indications for continuous intravenous insulin. The authors propose a strategy for determining when surgery should be delayed in patients with thyroid dysfunction and present a matrix for managing perioperative stress dose corticosteroids based on the limited evidence available.

Preoperative Chest Computed Tomography Screening Reduces the Perioperative Stroke Rate in Patients at Risk of Aortic Calcification.

OBJECTIVES: We evaluated the effect of preoperative chest computed tomography (CT) screening on the perioperative stroke rate in cardiosurgical patients at risk of aortic calcification. METHODS: Between May 2019 and April 2020, 129 patients at risk of aortic calcification underwent non-contrast chest CT screening before their procedure. They were assigned to Group 1 and compared with a historical Group 2, who were treated the previous year without a preoperative CT scan. The primary endpoint was to determine postoperative stroke occurrence. The secondary outcomes were the rate reintubation/tracheostomy, the length of hospital stay, and any change in surgical strategy based on the CT findings. RESULTS: Groups 1 and 2 comprised 129 and 261 patients, respectively. Group 1 had a lower left ventricular ejection fraction, less carotid stenosis, a history of carotid endarterectomy, and a longer cross-clamp time. The surgical strategy was changed for 6 patients in Group 1. Group 1 had a significantly lower stroke rate. No significant differences were observed in reintubation and tracheostomy rates, or length of hospital stay. Lack of CT screening, age, aortic valve surgery, aortic surgery, and rethoracotomy were identified as independent risk factors for a stroke. CONCLUSIONS: Preoperative non-contrast chest CT screening of patients at risk of aortic calcification reduces postoperative stroke through adaptation of the surgical approach and should be used routinely in these patients.

Domino Liver Transplantation: Anesthetic Considerations for a Patient With Maple Syrup Urine Disease and Type I Diabetes Mellitus.

In this report, we describe the case of a patient with concomitant maple syrup urine disease (MSUD) and type I diabetes mellitus (T1DM) who underwent domino liver transplantation (DLT) , and the associated perioperative management. To the best of our knowledge, a DLT in an adult with both MSUD and T1DM has not been previously reported in the literature. Intensive care admission with multidisciplinary oversight is necessary for metabolic preconditioning prior to surgery. The complex interplay between these two disease processes presented with grossly elevated baseline insulin requirements and refractory intraoperative hyperglycemia. Following the successful procedure, the patient maintained excellent glycemic control on a normal diet. Four months post transplant, the patient presented with mild to moderate cellular graft rejection.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS: A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Brugada Syndrome: Anesthetic Implications in an Incidentally Diagnosed Patient.

Brugada syndrome (BS) is characterized by abnormal repolarization in cardiac cells, occurring in the absence of structural heart disease, which elevates the risk of ventricular arrhythmias and sudden cardiac death. While most BS patients are asymptomatic, a notable percentage experience syncope or sudden cardiac death. Diagnosis is primarily based on electrocardiographic (ECG) findings. A 40-year-old male with a history of syncope and a family history of sudden cardiac death was scheduled for urgent clavicle osteosynthesis. Preoperative ECG revealed type 1 BS. A multidisciplinary approach was taken, and anesthetic management involved combined general and regional anesthesia, utilizing ultrasound-guided clavipectoral and superficial cervical blocks. Postoperative pain was managed with paracetamol and ketorolac. The patient remained stable throughout the procedure, was monitored for 36 hours postoperatively, and was discharged without complications. BS poses significant perioperative risks, necessitating careful anesthetic management. This case report highlights the successful use of combined general and regional anesthesia in a BS patient, contributing to the limited evidence on safe anesthesia practices for this pathology.

Perioperative infection prevention during inflatable penile prosthesis surgery: a narrative review.

Background and Objective: Penile prostheses are an option for the management of erectile dysfunction (ED). Over the years penile prosthesis surgery has become increasingly safe owing to improvements such as antibiotic usage, coated devices, and surgical techniques. However, infection remains a dreaded complication during prosthesis surgery. Efforts to minimize risk of infection in the perioperative period have been extensively studied. Herein, we performed a narrative review on preoperative, intraoperative, and postoperative strategies for infection prevention during placement of a penile prosthesis with a comparison of infection prevention strategies to other surgical fields. Methods: A literature review was performed using PubMed and Google Scholar. Studies evaluating perioperative management of penile prosthesis infection were included. The following search terms were used to for our literature search: penile prosthesis, inflatable penile prosthesis, infection, prevention, perioperative management. Articles were graded based on the 2011 Oxford Centre for Evidence Based Medicine (OCEBM) guidelines and a table was generated with each intervention discussed and its level of evidence based on current literature. Key Content and Findings: Optimization of patient's comorbid conditions can help reduce risk during prosthesis operations. Monitoring and optimizing a patient's glycemic control has been investigated, but the current literature does not necessarily support a strict hemoglobin A1c (HbA1c) or pre-operative blood glucose level. Surgical field preparation using chlorhexidine-based solutions has been shown to be superior to iodine-based solutions. Appropriately selected peri-operative antibiotics have also been shown to reduce infection risk. Intraoperatively, the use of coated devices in addition to a 'no touch' technique have been shown to significantly reduce the risk of inflatable penile prosthesis (IPP) infection. Post operatively, available evidence of antibiotic use has not been demonstrated to be effective in reducing infection rates. Conclusions: Surgical infection following placement of an IPP is a devastating and morbid complication with infection rate up as high as 1-3% in virgin cases and 7-18% in revision cases. While perioperative techniques exist and have reduced risk of infection, more prospective data is needed to evaluate the clinical significance of these different approaches. More research in these areas, along with future options such as nanoparticles, antibiotic coated suture, and next generation sequencing (NGS) for bacterial pathogens, may shed light on further ways to optimize infection reduction strategies for prosthesis surgery.

A literature review assessing the perioperative efficacy and safety of tranexamic acid in elective total hip and knee arthroplasty in UK practice.

Hip and knee arthroplasty are frequently associated with significant blood loss, often necessitating blood transfusions. A variety of methods are employed to minimise blood loss and consequently mitigate the necessity for transfusions. This review explores the incidence of blood loss in hip and knee arthroplasty alongside perioperative strategies aimed at its reduction in UK practice. Given the increasing prevalence of tranexamic acid utilisation, we systematically examine the extant literature concerning its application in patients undergoing hip and knee arthroplasty. Our analysis discerns a prevailing consensus within published studies favouring the implementation of tranexamic acid as a safe and efficacious measure for reducing blood loss during hip and knee arthroplasty procedures.

Intracranial Pressure Monitoring Location: A Pilot Study on the Validation of Subdural Site with the Intraventricular Site.

Introduction Knowledge of preoperative and intraoperative intracranial pressure (ICP) enables the neuroanesthesiologist to optimize cerebral perfusion pressure. However, ICP is rarely monitored during the intraoperative period. In this report, subdural site ICP measurement is validated with intraventricular ICP measurement, and the feasibility of subdural ICP monitoring during the intraoperative period is discussed. Materials and Methods In this prospective pilot study, ICP measurement at the subdural site was achieved with an intravenous cannula and the ventricular site with a ventricular cannula. Both were transduced using a fluid-filled pressure transducer and connected to the monitor for display of the number and the waveforms. Monitoring of intraoperative ICP using both the techniques was done in all patients recruited into the study. The correlation between the two modalities of measurement was studied by the Spearman correlation test and their limits of agreement were studied using the Bland-Altman plot. A case series describing the perioperative management based on the subdural ICP values are also described. Results Subdural ICP showed a strong correlation with intraventricular ICP ( r s = 0.93, p = 0.01). Agreement analysis using the Bland-Altman plot showed that the mean difference of ICP between the modalities was 1.44 mm Hg (95% confidence interval, -0.6 to 3.49, p = 0.122). Discussion This study validates the ICP values measured at the subdural site with the intraventricular site. Subdural site ICP monitoring can be achieved rapidly with readily available systems and helps in making intraoperative clinical decisions. Conclusion Cannula-based subdural ICP is a satisfactory alternative to intraventricular ICP monitoring in the intraoperative period.

Identification and optimisation of perioperative factors for patients with von Willebrand disease undergoing elective total hip and knee arthroplasty.

Von Willebrand disease stands as the most prevalent bleeding disorder seen in both medical and surgical practice. Due to recurrent bleeding episodes within the joints, many patients endure arthropathy, leading to substantial pain and restricted function. Total joint arthroplasty emerges as a final option for managing such cases. Nevertheless, the existence of von Willebrand disease presents several challenges in this regard. This review aims to explore the perioperative strategies tailored for patients with von Willebrand disease undergoing elective total joint arthroplasty.

Ruptured giant omphalocele with congenital short small intestine: a case report.

We herein present a case of a ruptured giant omphalocele with congenital short small intestine. Vacuum-sealing drainage and carboxymethylcellulose silver dressing promoted wound healing after repair, avoided abdominal compartment syndrome, and reduced the risks of multiple procedures. We review the perioperative management of omphaloceles in congenital short small intestines.

Managing Placenta Accreta and Massive Hemorrhage: A Case Report on Anesthetic and Surgical Interventions.

Obstetric haemorrhage is a leading cause of maternal morbidity and mortality and is a common reason for intensive care unit (ICU) admission in the postpartum. Primary postpartum obstetric haemorrhage is associated with four main causes: tone, thrombin, trauma, and tissue. Regarding the last one, placenta accreta is an abnormal invasion of the placenta into the myometrium. Early diagnosis of placenta accreta allows for better perioperative management; however, it is sometimes only identified during caesarean delivery when the placenta cannot be removed. We report a case of a 37-year-old woman with a history of caesarean section due to placenta previa, who was admitted at 36 weeks and 1 day for an urgent caesarean section (c-section) due to cord presentation. A subarachnoid block (SAB) was used for anaesthesia. It was chosen over general anaesthesia because it allows the patient to experience the birth of her children, enhances pain control, and avoids complications associated with general anaesthesia. Besides our centre has expertise in neuraxial anaesthesia. During the procedure, placental accretism and massive haemorrhage occurred, and a life-saving abdominal hysterectomy was needed. The patient experienced hypotension, partially responsive to volume replacement and vasopressors, leading to norepinephrine infusion and conversion to general anaesthesia. The surgery lasted 2.5 hours with a blood loss of 3500 ml. The patient was extubated without complications and transferred to the post anaesthesia care unit (PACU). Risk factors for placenta accreta spectrum (PAS) include previous surgery and placenta previa with a prior c-section. Antenatal diagnosis is crucial, and women with risk factors should undergo imaging at experienced centres. Delivery centres must have protocols for unexpected PAS and major obstetric haemorrhage. Both general and neuraxial anaesthesia can be suitable for managing PAS, and caesarean hysterectomy is often required to control haemorrhage. Postoperatively, adequate monitoring and care is essential. PAS management should involve excellent communication between a multidisciplinary team in specialised centres.