Anesthetic Management of Emergency Insulinoma Resection: Case Report and Review of Literature.

Insulinoma, a neuroendocrine tumor originating from pancreatic islets, presents unique challenges in diagnosis and management. We present a case of a 73-year-old female with recurrent hypoglycemia leading to syncope, who underwent emergency pancreatectomy for a secreting insulinoma with multiple comorbidities. This case report aims to shed light on the complexities of insulinoma management and the importance of tailored perioperative strategies. The patient, presenting with severe hypoglycemia, was admitted for optimization. Preoperative assessment labeled her as ASA IVE and indicated a high risk of perioperative morbidity. General anesthesia, invasive monitoring, and epidural anesthesia were planned. Intraoperative glucose control was crucial, achieved with continuous blood glucose monitoring, octreotide administration, and insulin titration. The patient was extubated post-surgery, and pain was managed with epidural infusion. She was discharged on the 4th postoperative day with follow-up care. Insulinoma diagnosis relies on clinical, biochemical, and imaging tests, with 72-hour fasting as the gold standard. Localizing the tumor within the pancreas is essential for surgical success, often requiring invasive techniques. Surgical resection remains the definitive treatment, while medical management may be necessary in select cases. Anesthetic management should prioritize agents that minimize the cerebral metabolic rate for oxygen. Careful intraoperative glucose control and vigilant postoperative monitoring are essential. This case report highlights the intricate management of insulinoma, emphasizing tailored perioperative strategies that balance glucose regulation, anesthesia techniques, and postoperative care. However, the limited existing literature underscores the need for further research to refine anesthesia protocols, glucose control methods, and postoperative care, ultimately improving outcomes for patients with insulinoma.

A Mental Health Survey of Medical Professionals Working During the COVID-19 Pandemic at Shaukat Khanum Cancer Hospital, Lahore.

Introduction The last months of 2019 saw the emergence of a novel coronavirus, SARS-COV-2, capable of causing widespread disease in humans. The rapid spread of this new disease culminated in one of the biggest pandemics in known history. The far-reaching social, economical, and health effects of this pandemic are still unfolding on a global scale. Given the interconnectedness of social, environmental, and biological factors in manifesting psychiatric illnesses, it is fair to assume that the profound effects of this pandemic would likely increase the strain on mental healthcare systems.  The objective of this study was to assess the mental health burden amongst healthcare workers at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH & RC) at the start of the COVID-19 pandemic and to identify any differences in the mental health scores of anxiety, depression, and sleep disturbance for professionals directly involved in the care of COVID-19 patients as compared to those who were not. Material and methods This was an observational cross-sectional clinical study that used self-reported questionnaires after approval from the hospital's ethical board. The sample size was calculated based on a study published previously by Huang using a 23.04% incidence of anxiety in medical staff. Depression was quantified using the Patient Health Questionnaire-9 score (PHQ-9), anxiety by the Beck Anxiety Inventory, and sleep quality using the Pittsburgh Sleep Quality Index checklist (PSQI). A total of 221 healthcare workers who completed the questionnaires were included in the study and the results were analyzed using SPSS Statistics v. 23 (IBM Corp., Armonk, NY). Levene's test was used to assess the equality of variances, and an independent sample t-test and chi-square test were applied for the comparison of means. A one-way ANOVA test was used to compare means across more than two groups. Results Of the 221 healthcare workers recruited in the study, 57% were males, and 43% were females. Among the sample, 43% of participants were doctors, 27.1% were nurses, and others were technicians and medical assistants. It was observed that 50% of males and 36% of female healthcare workers experienced moderate to severe depression at the onset of the pandemic. Furthermore, 35% of males and 25% of females suffered from moderate to severe anxiety, and more than 80% of our study population reported poor quality of sleep. Conclusion The present study reported a high prevalence of anxiety levels, depressive symptoms, and poor sleep quality among the healthcare professionals working in SKMCH & RC Lahore during the COVID-19 pandemic irrespective of direct contact with COVID-19 patients in a healthcare setting.

Emergency Management of Ventilation Failure Through Blocked Tracheostomy Tube in a Paediatric Patient.

The most common complication of tracheostomy tubes in children is blockage of the tube. We report a case where ventilation after induction of anaesthesia was not possible even though there were no signs of impending obstruction. An eight-year-old child, recently diagnosed with left tonsillar embryonal rhabdomyosarcoma, presented for an MRI face and bone marrow biopsy before starting treatment. Due to difficulty in breathing, the patient had undergone a tracheostomy at a different institute and a size six uncuffed tracheostomy tube was in situ. There was difficulty in ventilating the patient due to blockage in the tracheostomy tube which was addressed and the patient was discharged after successful completion of both the procedures. This case highlights the importance of following an emergency algorithm for failure to ventilate in a patient with a tracheostomy tube, identifying the cause and treating it.

Use of an Endobronchial Blocker Where a Double-Lumen Tube Failed to Ventilate: A Case Report of a Distorted Tracheobronchial Anatomy.

One-lung ventilation (OLV) during video-assisted thoracoscopic surgery (VATS) can be accomplished through several different techniques, including bronchial advancement of an endotracheal tube (ETT), use of a double-lumen tube (DLT), or placement of an endobronchial blocker. In most cases, a DLT is a mainstay of isolating and ventilating a single lung during cardiothoracic procedures. The reasons to deploy a DLT over other techniques include ease of placement, less chance of malposition, quick placement time, and quality of lung deflation. However, this case report highlights the importance of a bronchial blocker in a patient where a double-lumen tube failed to ventilate the lungs. Briefly, this young female patient had a right thoracic mass associated with ipsilateral lung collapse and moderate pleural effusion. CT-guided biopsy was planned but was deferred by the radiologist, as the patient was unable to lie in a prone position. The case was then referred to the cardiothoracic surgeon who planned a right VATS and biopsy of the lesion. In the operation theater, after induction of anesthesia, the patient could not be ventilated through a DLT, and high peak airway pressures were encountered. Initially, a size 37 left-sided DLT was used, and subsequently, sizes 35, 32, and 28 were also tried, but all these attempts to ventilate the patient remained futile. A bronchoscopy was done, which did not show any abnormality in the airway. The surgery was postponed due to an inability to ventilate the patient with a double-lumen tube. After a repeat CT scan and draining of 9.3 liters of pleural effusion over a week, the patient was again scheduled for the same procedure but with a changed anesthetic plan. This time around, the anesthetic plan was implemented successfully using a bronchial blocker to isolate the right lung. The surgery went ahead, and the patient had an uneventful postoperative period. The anesthetic management of this patient presented a unique set of challenges, which are shared in this case report.

Clinical Practice for Venous Thromboembolism Prophylaxis in Patients Undergoing Oncological Surgeries.

Objective To determine the proportion of patients receiving venous thromboembolism (VTE) prophylaxis after oncological surgeries as per the hospital standards and its comparison with the international guidelines. Methodology In the month of September 2019, all patients after elective oncological surgeries were reviewed for VTE prophylaxis administration and education. Results were shared with the department of surgery and Hospital Quality and Patient Safety Department. Education was provided to the relevant staff and hospital policy for VTE prophylaxis was revised followed by a loop audit which was done in October 2020. The primary endpoint was to compare the proportion of patients receiving prophylaxis as per the hospital guidelines. Results Total 425 patients were included in this audit (209 in September 2019 and 216 in October 2020). Compliance with mechanical prophylaxis increased from 84.7 % to 98.6% and pharmacological prophylaxis improved from 39.7% (n=83) to 73.1% (n=158). Adherence to local protocols enhanced significantly from 1.9% (n=4) to 56.4% (n=122). The main cause of non-compliance was lack of risk assessment for VTE. Conclusion VTE prophylaxis can be improved by setting protocols in accordance with the international guidelines and local protocols. This can prevent significant morbidity and mortality in surgical patients as well as hospital costs.

Comparison of Two Different Sizes of Endotracheal Tracheal Tube for Postoperative Sore Throat in Breast Cancer Patients Undergoing Surgeries.

Objective The purpose of this study was to compare two different sizes of an endotracheal tube (ETT), with inner diameters (ID) of 6.5 mm and 7.5 mm, for the frequency of postoperative sore throat in patients undergoing elective breast cancer surgery. Methodology This study was a randomized controlled trial conducted in the Shaukat Khanum Memorial Cancer Hospital and Research Center from December 3, 2016, to February 3, 2017. This study included 110 patients, 55 from each group, who were selected from the elective surgery list fulfilling the inclusion criteria. Group A patients were intubated with 6.5-mm ID ETTs and group B patients with 7.5-mm ID ETTs. All patients were carefully extubated in the operating room when fulfilling extubation criteria. Any concerns of sore throat were recorded 24 hours postoperatively. All relevant data were recorded on a pro forma. Results In this study, the mean age was 46.6 ± 13.2 years (range: 18-65 years). The mean body mass index (BMI) was 29.50 ± 07.12 kg/m2, with a minimum and maximum of 19 kg/m2 and 38 kg/m2, respectively. The mean four-point scale was 2.98 ± 1.3, with a minimum and maximum of 1.0 and 4.0, respectively. Of the 110 patients, 47 patients reported a sore throat at 24 hours after surgery, whereas 63 patients did not report a sore throat. In this study, 14 patients in group A were diagnosed with a postoperative sore throat, whereas 33 patients in group B were diagnosed with a sore throat at 24 hours. A chi-square test was significant, and a poststratification chi-square test was applied to compare sore throat at 24 hours postoperative between the groups with respect to age and BMI. Conclusions ETT sizes produced a significant difference in the frequency of postoperative sore throat in patients undergoing breast surgery. Physicians should consider this impact on clinical practice to optimize patient outcomes. Additional studies with a larger sample size are warranted to further explore this impact.

Role of Cardiopulmonary Exercise Testing in Predicting Perioperative Outcomes in Cancer Patients Undergoing Thoracoabdominal Surgeries; An Observational Cohort Study.

Introduction: The cancer patients are at a high risk of developing perioperative complications. Cardiopulmonary exercise testing (CPET) is a non-invasive, perioperative risk stratification tool that predicts perioperative morbidity and mortality. Prior literature has concluded that CPET has a valuable role in predicting post-operative complications in major surgical procedures. However, the data on the effectiveness of CPET in evaluating the perioperative risk in cancer-specific populations are limited. This study assessed the usefulness of CPET in perioperative risk stratification of patients with thoracoabdominal cancer who underwent elective major thoracoabdominal surgeries. Materials and Methods: A retrospective observational cohort study was conducted on cancer patients that underwent pre-operative CPET at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, from September 2017 to September 2019. All adult male and female patients with a significant medical history for cancer of the thoracoabdominal region who underwent CPET before a major thoracoabdominal surgery were included in the study. Results: A total of 32 patients were included in the present investigation. The mean age of the sample was 62.75 ± 10.18 years, and the majority of the participants were female. Following surgery, 53% of the participants had post-operative complications in terms of morbidity and mortality. Fifteen participants had an anaerobic threshold (AT) of ≥11.0 ml/ kg/min. Among these, 12 participants had an uneventful surgery. On the contrary, among 17 participants that were considered to have a high risk (<11.0 ml/kg/min) for surgery, 14 subjects (82%) had at least one complication (including mortality). The sensitivity and specificity of CPET to anticipate complications during oncological surgery were calculated to be 82% and 80%, respectively. The mean AT of participants with uneventful surgery was calculated to be 11.83 ± 1.01 ml/kg/min. This was statistically greater than the AT of subjects that had morbidity (9.86 ± 1.20 ml/kg/min) or mortality (8.95 ± 0.35 ml/kg/min) (P < 0.001). Conclusion: CPET, when using AT alone as an indicator, can provide a good-excellent prediction of perioperative outcome among oncology patients undergoing major thoracoabdominal surgical procedures.

Early multifocal recurrence of hepatoblastoma in the residual liver after R0 liver resection with ALPPS procedure: a case report.

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been successfully employed in adults to avoid potential liver insufficiency in patient with small future liver volume (FLV) when subjected to conventional right trisectionectomy. We are reporting an infant with hepatoblastoma, who underwent a technically successful ALPPS procedure with R0 resection. However he developed very early recurrence within the first month after the procedure. We present this report with a view to share our unexpected finding of early multifocal recurrence of hepatoblastoma in the residual liver after ALPPS procedure in a very young patient.