Perioperative Management of Massive Anterior Encephalocele in a Newborn: A Case Report.

Anterior encephaloceles are rare neural tube defects posing anesthetic challenges. While anterior encephaloceles can cause airway obstruction at birth, this presentation is very rare and to our knowledge not reported in the literature. This case report describes a 34 weeks +0 days gestation, 2.6 kg, newborn with a massive nasoethmoidal anterior encephalocele creating significant external airway obstruction, necessitating emergent and thoughtful airway management and anesthetic care. Our most important perioperative considerations for this newborn included spontaneous ventilation using awake fiberoptic bronchoscopic intubation with lidocaine airway topicalization, secure endotracheal tube attachment, and avoiding noninvasive positive airway pressure postoperatively to avoid pneumocephalus.

Management of Extracorporeal Membrane Oxygenation Anticoagulation in the Perioperative Period: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference.

OBJECTIVES: To derive systematic review-informed, modified Delphi consensus regarding the management of children on extracorporeal membrane oxygenation (ECMO) undergoing invasive procedures or interventions developed by the Pediatric Anticoagulation on ECMO CollaborativE (PEACE) Consensus Conference. DATA SOURCES: A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION: ECMO anticoagulation and hemostasis management in the perioperative period and during procedures. DATA EXTRACTION: Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Seventeen references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS: Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Four good practice statements, 7 recommendations, and 18 consensus statements are presented. CONCLUSIONS: Although agreement among experts was strong, important future research is required in this population for evidence-informed recommendations.

Effectiveness of Erector Spinae Plane Block as Perioperative Analgesia in Midline Sternotomies: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

ABSTRACT: With the advancements in regional anesthesia and ultrasound techniques, the use of non-neuraxial blocks like the erector spinae plane block (ESPB) has been increasing in cardiac surgeries with promising outcomes. A total of 3,264 articles were identified through a literature search. Intervention was defined as ESPB. Comparators were no regional technique performed or sham blocks. Four studies with a total of 226 patients were included. Postoperative opioid consumption was lower in the group that received ESPB than the group that did not (weighted mean difference [WMD]: -204.08; 95% CI: -239.98 to -168.19; P < 0.00001). Intraoperative opioid consumption did not differ between the two groups (WMD: -398.14; 95% CI: -812.17 to 15.98; P = 0.06). Pain scores at 0 hours were lower in the group that received ESPB than the group that did not (WMD: -1.27; 95% CI: -1.99 to -0.56; P = 0.0005). Pain scores did not differ between the two groups at 4-6 hours (WMD: -0.79; 95% CI: -1.70 to 0.13; P = 0.09) and 12 hours (WMD: -0.83; 95% CI: -1.82 to 0.16; P = 0.10). Duration of mechanical ventilation in minutes was lower in the group that received ESPB than the group that did not (WMD: -45.12; 95% CI: -68.82 to -21.43; P = 0.0002). Given the limited number of studies and the substantial heterogeneity of measured outcomes and interventions, further studies are required to assess the benefit of ESPB in midline sternotomies.

Effects of Dexmedetomidine on Perioperative Glycemic Control in Adult Diabetic Patients Undergoing Cardiac Surgery.

BACKGROUND AND OBJECTIVE: To study the effects of dexmedetomidine (DEX) on perioperative blood glucose levels in adult diabetes mellitus (DM) patients undergoing cardiac surgery. METHODS AND MATERIAL: A prospective, observational study was conducted on 100 adult diabetic patients aged between 18 and 75 years undergoing cardiac surgery with cardiopulmonary bypass (CPB). The patients were divided into two groups (group D and group C) of 50 each. Group D patients received DEX infusion, whereas the group C patients received 0.9% normal saline infusion. RESULTS: The blood glucose levels, heart rate, mean arterial pressure, and serum potassium levels at different time points were comparable between the two groups (P > 0.05). The mean dose of insulin required in the combined population as well as in both controlled and uncontrolled DM patients was significantly less in group D than in group C (combined population - 36.03 ± 22.71 vs 47.82 ± 30.19 IU, P = 0.0297; uncontrolled DM - 37.36 ± 23.9 IU vs 48.16 ± 25.15 IU, P = 0.0301; controlled DM - 34.7 ± 21.5 IU vs 47.63 ± 35.25 IU, P = 0.0291). Duration of mechanical ventilation and VIS were comparable between the two groups. The incidence of arrhythmias (20% vs 46%, P = 0.0059) and delirium (6% vs 20%, P = 0.0384) was significantly less in group D than in group C. None of the patients in either group had stroke, myocardial ischemia, and mortality. CONCLUSION: The results suggested that DEX infusion during the intraoperative period was very effective for perioperative glycemic control and reduction of insulin requirement in DM patients undergoing cardiac surgery.

Novel Peri-Operative Strategy for Sickle Cell Disease with Tetralogy of Fallot.

ABSTRACT: Peri-operative management of cyanotic congenital heart disease in a patient of sickle cell disease (SCD) can be challenging. We report a case of Tetralogy of Fallot and homozygous SCD with history of multiple blood transfusions and sickle cell crises who underwent intracardiac repair. Hemoglobin S level was reduced from 75% pre-operative to 21.8% postoperative with a combination of pre-operative blood transfusion, intraoperative exchange transfusion, and normothermic cardiopulmonary bypass (CPB). Pre-operative optimization and safe intraoperative conduct were essential to avoid sickling crises.