Sugammadex versus neostigmine for neuromuscular blockade reversal in outpatient surgeries: A randomized controlled trial to evaluate efficacy and associated healthcare cost in an academic center.

Introduction: Neuromuscular blockade is an essential component of the general anesthesia as it allows for a better airway management and optimal surgical conditions. Despite significant reductions in extubation and OR readiness-for-discharge times have been associated with the use of sugammadex, the cost-effectiveness of this drug remains controversial. We aimed to compare the time to reach a train-of-four (TOF) response of ≥0.9 and operating room readiness for discharge in patients who received sugammadex for moderate neuromuscular blockade reversal when compared to neostigmine during outpatient surgeries under general anesthesia. Potential reduction in time for OR discharge readiness as a result of sugammadex use may compensate for the existing cost-gap between sugammadex and neostigmine. Methods: We conducted a single-center, randomized, double arm, open-label, prospective clinical trial involving adult patients undergoing outpatient surgeries under general anesthesia. Eligible subjects were randomized (1:1 ratio) into two groups to receive either sugammadex (Groups S), or neostigmine/glycopyrrolate (Group N) at the time of neuromuscular blockade reversal. The primary outcome was the time to reverse moderate rocuronium-induced neuromuscular blockade (TOF ratio ≥0.9) in both groups. In addition, post-anesthesia care unit (PACU)/hospital length of stay (LOS) and perioperative costs were compared among groups as secondary outcomes. Results: Thirty-seven subjects were included in our statistical analysis (Group S= 18 subjects and Group N= 19 subjects). The median time to reach a TOF ratio ≥0.9 was significantly reduced in Group S when compared to Group N (180 versus 540 seconds; p = 0.0052). PACU and hospital LOS were comparable among groups. Postoperative nausea and vomiting was the main adverse effect reported in Group S (22.2% versus 5.3% in Group N; p = 0.18), while urinary retention (10.5%) and shortness of breath (5.3%) were only experienced by some patients in Group N. Moreover, no statistical differences were found between groups regarding OR/anesthesia, PACU, and total admission costs. Discussion: Sugammadex use was associated with a significantly faster moderate neuromuscular blockade reversal. We found no evidence of increased perioperative costs associated with the use of sugammadex in patients undergoing outpatient surgeries in our academic institution. Clinical trial registration: [https://clinicaltrials.gov/] identifier number [NCT03579589].

Case report: Disseminated herpes simplex virus 1 infection and hemophagocytic lymphohistiocytosis after immunomodulatory therapy in a patient with coronavirus disease 2019.

Corticosteroids and immunomodulatory therapies are widely used to treat patients with severe coronavirus disease 2019 (COVID-19). Janus kinase (JAK) inhibitors such as tofacitinib have been recently studied as adjuvants in the treatment of COVID-19. Although immunomodulatory therapies may be linked to decreased mortality rates in the acute phase, subsequent severe infectious complications may result from them. We describe a case of a multiorgan system failure secondary to disseminated primary herpes simplex virus 1 (HSV-1) infection and hemophagocytic lymphohistiocytosis (HLH) following treatment with tofacitinib and high-dose dexamethasone therapy for severe COVID-19. Early diagnosis and treatment of these life-threatening conditions may have a significant impact on COVID-19 patients' outcomes.

The Feasibility and Effectiveness of an Online Curriculum for Virtual Onboarding/Orientation of Graduate Medical Education Learners During the COVID-19 Pandemic.

Background: Graduate medical education (GME) orientation/onboarding is conventionally an in-person activity, but the COVID-19 pandemic prompted virtual approaches to learner onboarding. However, online GME onboarding strategies have not been disseminated in the literature. Objective: To determine the usefulness of an online curriculum for GME learner orientation at a large sponsoring institution using an electronic survey. The primary outcome was to discover the usefulness of our online curriculum for GME onboarding, and secondary outcomes included identifying barriers to implementation and weaknesses associated with online GME orientation. Methods: We created an online GME orientation curriculum to onboard incoming learners (from June 1 to August 31, 2020) and electronically surveyed our learners to determine the usefulness of this novel approach. We conducted orientation sessions and electronically recorded questionnaire responses using CarmenCanvas, our institutional learning management system. Linear regression analysis was performed to identify factors predicting satisfaction with virtual GME orientation using IBM SPSS Statistics, Version 26.0 (Armonk, NY, USA). Results: Of 353 trainees, 272 completed the survey for a 77% response rate. 97% of respondents reported that the curriculum supported performance of learner duties. 79% of trainees perceived the overall quality as "very good" or "good", 91% responded that the curriculum provided "effective learning", 94% reported "accessing the course content easily", 92% reported "easily navigating the curriculum", 91% described the curriculum as "well-organized", and 87% reported that the lectures "supported their learning". Conclusion: Online delivery of a comprehensive GME orientation curriculum is useful and facilitates learner education, training, and integration into a large GME institution in the COVID-19 era.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study.

Background: Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption. Methods: We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups. Results: Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group. Conclusion: PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Postoperative Nausea and Vomiting in Female Patients Undergoing Breast and Gynecological Surgery: A Narrative Review of Risk Factors and Prophylaxis.

Postoperative nausea and vomiting (PONV) have been widely studied as a multifactorial entity, being of female gender the strongest risk factor. Reported PONV incidence in female surgical populations is extremely variable among randomized clinical trials. In this narrative review, we intend to summarize the incidence, independent predictors, pharmacological and non-pharmacological interventions for PONV reported in recently published clinical trials carried out in female patients undergoing breast and gynecologic surgery, as well as the implications of the anesthetic agents on the incidence of PONV. A literature search of manuscripts describing PONV management in female surgical populations (breast surgery and gynecologic surgery) was carried out in PubMed, MEDLINE, and Embase databases. Postoperative nausea and vomiting incidence were highly variable in patients receiving placebo or no prophylaxis among RCTs whereas consistent results were observed in patients receiving 1 or 2 prophylactic interventions for PONV. Despite efforts made, a considerable number of female patients still experienced significant PONV. It is critical for the anesthesia provider to be aware that the coexistence of independent risk factors such as the level of sex hormones (pre- and postmenopausal), preoperative anxiety or depression, pharmacogenomic pleomorphisms, and ethnicity further enhances the probability of experiencing PONV in female patients. Future RCTs should closely assess the overall risk of PONV in female patients considering patient- and surgery-related factors, and the level of compliance with current guidelines for prevention and management of PONV.

Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study.

Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600-800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8-20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes. Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery. Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage. Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.

Effects of Dorsal Column Spinal Cord Stimulation on Neuroinflammation: Revisiting Molecular Mechanisms and Clinical Outcomes on Chronic Lumbar/Leg Pain and Failed Back Surgery Syndrome.

OBJECTIVE: In this narrative review, we reviewed and discussed current literature describing the molecular mechanisms leading to neuroinflammation and its role in the onset and progression of chronic neuropathic lumbar and leg pain in patients with persistent spinal pain syndrome. In addition, we reviewed the proposed mechanisms and impact of spinal cord stimulation (SCS) on neuroinflammation. METHODS: A broad search of current literature in PubMed, Embase, Scopus, Cochrane library, Medline/Ovid, and Web of Science was performed using the following terms and their combinations: "biomarkers", "chronic back and leg pain", "cytokines", "neuroinflammation", "spinal cord stimulation (scs)," and "spinal cord modulation". We selected: 1) articles published in the English language between January 2000 and July 2020 2) preclinical and clinical data 3) case reports 4) meta-analysis and systematic reviews and 5) conference abstracts. Manuscripts not disclosing methodology or without full-text availability were excluded. DISCUSSION: SCS techniques have gradually evolved since inception to include novel methods such as burst-SCS, high frequency SCS, and differential targeted multiplexed SCS. The incidence of chronic pain after spine surgery is highly variable, with at least one third of patients developing persistent spinal pain syndrome. Novel SCS techniques have been associated with improved clinical and functional outcomes thus increasing patient quality of life. CONCLUSION: Currently, health care providers rely on different options and methods for SCS when treating patients with refractory chronic lumbar pain and persistent spinal pain syndrome. Nevertheless, compelling clinical trials remain necessary to elucidate the long-term benefits and mechanisms of neuromodulation of all different types of SCS.

A prospective observational cohort study to evaluate patients' experience during sequential cataract surgery under monitored anesthesia care and topical anesthesia.

Cataract surgery is the most common ambulatory surgery at our outpatient surgery center. Several studies have shown that patients with bilateral cataracts may experience different levels of anxiety, pain, and awareness during the first and second cataract extraction.A prospective observational cohort study was conducted at The Ohio State University Wexner Medical Center Eye and Ear Institute in order to compare anxiety, general comfort, awareness, and pain levels in patients undergoing sequential cataract surgeries. Likert and numerical rating scale were used to assess the outcomes. Patients receiving monitored anesthesia care and topical anesthesia were included.A total of 198 patients were enrolled in this study, 116 patients (59%) were female and 157 patients (78%) were Caucasians with a median age of 67 years among participants. Patients with rating "no anxiety" or feeling "somewhat anxious" were significantly higher during surgery 2 (P =< .001). Most of the patients felt "extremely comfortable" during surgery 1 when compared to surgery 2 (54% vs 42.9%; P = .08). No significant differences were found between surgeries regarding intraoperative awareness (P = .16). Overall, patients experienced mild pain during both procedures (92.4% in surgery 1 compared to 90.4% in surgery 2; P = .55). During the postoperative visit, 54% of the patients associated surgery 2 with less anxiety levels, 53% with no differences in general comfort, 60% felt more aware, and 59% had no differences in pain levels.Previous exposure to surgery could have been associated with a significant reduction in anxiety levels reported during surgery 2. Non-pharmacological strategies aiming to reduce perioperative anxiety may be considered an alternative or additional approach to premedication in patients undergoing consecutive cataract surgeries.

New-Onset Atrial Fibrillation Detected by Continuous Capnography Monitoring: A Case Report.

BACKGROUND Asymptomatic postoperative atrial fibrillation (AF) may go undetected. As part of a multicenter observational trial designed to develop a risk prediction score for respiratory depression, the respiratory patterns of patients admitted to standard wards were continuously assessed with capnography and pulse oximetry. The monitor measured end-tidal carbon dioxide, respiratory rate, heart rate (HR), and oxyhemoglobin saturation. CASE REPORT Two men ages 75 and 72 experienced abrupt and variable postoperative changes in HR consistent with AF with rapid ventricular response, coinciding with an abnormal breathing pattern with apneic episodes. In both cases, the changes were not detected by routine clinical monitoring. CONCLUSIONS Continuous capnography identified respiratory distress in 2 patients who experienced symptoms of AF. Continuous monitoring devices can help health care providers minimize the risk of morbidity and mortality for patients at risk of respiratory depression.

Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Narrative Review.

Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.

The Effects of Patient Positioning on the Outcome During Posterior Cranial Fossa and Pineal Region Surgery.

Background: Surgery on posterior cranial fossa (PCF) and pineal region (PR) carries the risks of intraoperative trauma to the brainstem structures, blood loss, venous air embolism (VAE), cardiovascular instability, and other complications. Success in surgery, among other factors, depends on selecting the optimal patient position. Our objective was to find associations between patient positioning, incidence of intraoperative complications, neurological recovery, and the extent of surgery. Methods: This observational study was conducted in two medical centers: The Ohio State University Wexner Medical Center (USA) and The Burdenko Neurosurgical Institute (Russian Federation). Patients were distributed in two groups based on the surgical position: sitting position (SP) or horizontal position (HP). The inclusion criteria were adult patients with space-occupying or vascular lesions requiring an open PCF or PR surgery. Perioperative variables were recorded and summarized using descriptive statistics. The post-treatment survival, functional outcome, and patient satisfaction were assessed at 3 months. Results: A total of 109 patients were included in the study: 53 in SP and 56 in HP. A higher proportion of patients in the HP patients had >300 mL intraoperative blood loss compared to the SP group (32 vs. 13%; p = 0.0250). Intraoperative VAE was diagnosed in 40% of SP patients vs. 0% in the HP group (p < 0.0001). However, trans-esophageal echocardiographic (TEE) monitoring was more common in the SP group. Intraoperative hypotension was documented in 28% of SP patients compared to 9% in HP group (p = 0.0126). A higher proportion of SP patients experienced a new neurological symptom compared to the HP group (49 vs. 29%; p = 0.0281). The extent of tumor resection, postoperative 3-months survival, functional outcome, and patient satisfaction were not different in the groups. Conclusions: The SP was associated with, less intraoperative bleeding, increased intraoperative hypotension, VAE, and postoperative neurological deficit. More HP patients experienced macroglossia and increased blood loss. At 3 months, there was no difference of parameters between the two groups. Clinical Trial Registration: ClinicalTrials.gov: registration number NCT03364283.

Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols.

Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.

Efficacy of Intravenous Tranexamic Acid in Reducing Perioperative Blood Loss and Blood Product Transfusion Requirements in Patients Undergoing Multilevel Thoracic and Lumbar Spinal Surgeries: A Retrospective Study.

Introduction: Acute perioperative blood loss is a common and potentially major complication of multilevel spinal surgery, usually worsened by the number of levels fused and of osteotomies performed. Pharmacological approaches to blood conservation during spinal surgery include the use of intravenous tranexamic acid (TXA), an anti-fibrinolytic that has been widely used to reduce blood loss in cardiac and orthopedic surgery. The primary objective of this study was to assess the efficacy of intraoperative TXA in reducing estimated blood loss (EBL) and red blood cell (RBC) transfusion requirements in patients undergoing multilevel spinal fusion. Materials and Methods: This a single-center, retrospective study of subjects who underwent multilevel (≥7) spinal fusion surgery who received (TXA group) or did not receive (control group) IV TXA at The Ohio State University Wexner Medical Center between January 1st, 2016 and November 30th, 2018. Patient demographics, EBL, TXA doses, blood product requirements and postoperative complications were recorded. Results: A total of 76 adult subjects were included, of whom 34 received TXA during surgery (TXA group). The mean fusion length was 12 levels. The mean total loading, maintenance surgery and total dose of IV TXA was 1.5, 2.1 mg per kilo (mg/kg) per hour and 33.8 mg/kg, respectively. The mean EBL in the control was higher than the TXA group, 3,594.1 [2,689.7, 4,298.5] vs. 2,184.2 [1,290.2, 3,078.3] ml. Among all subjects, the mean number of intraoperative RBC and FFP units transfused was significantly higher in the control than in the TXA group. The total mean number of RBC and FFP units transfused in the control group was 8.1 [6.6, 9.7] and 7.7 [6.1, 9.4] compared with 5.1 [3.4, 6.8] and 4.6 [2.8, 6.4], respectively. There were no statistically significant differences in postoperative blood product transfusion rates between both groups. Additionally, there were no significant differences in the incidence of 30-days postoperative complications between both groups. Conclusion: Our results suggest that the prophylactic use of TXA may reduce intraoperative EBL and RBC unit transfusion requirements in patients undergoing multilevel spinal fusion procedures ≥7 levels.

Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States.

OBJECTIVES: The objective of this study was to review the current scientific evidence on the role of Enhanced Recovery After Surgery (ERAS) implementations in reducing postoperative opioid consumption and their potential association with the risk reduction for long-term opioid use, physical opioid dependency, and opioid addiction. METHODS: A literature search was conducted using the following medical subject heading keywords: "postoperative pain," "postoperative pain management," "multimodal analgesia," "ERAS," "Enhanced Recovery," "opioid-free analgesia," or "opioid crisis." DISCUSSION: Identification and management of pre-existing psychosocial factors, comorbid pain entities, and chronic opioid use have a significant impact on the severity of postoperative pain. Different multimodal analgesia approaches have been associated with reduced postoperative pain scores and opioid consumption. Health care providers, patients, and family members should recognize the advantages of opioid-free analgesia techniques in postoperative pain management. As part of ERAS protocols, transitional pain services may consider current therapeutic alternatives for acute and long-term pain management that include minimizing perioperative opioid use and establishing adequate opioid prescription practices.

Perioperative care of cannabis users: A comprehensive review of pharmacological and anesthetic considerations.

According to the 2015 National Survey on Drug Use and Health, marijuana continues to be the most common illicit recreational drug used in the US. Cannabis is associated with systemic reactions that potentially affect perioperative outcomes. We have reviewed the most important pharmacological aspects and pathophysiological effects that should be considered during the perioperative management of chronic cannabis/cannabinoids users. The synthetic analogues provide higher potency with increased risk for complications. High cannabinoid liposolubility favors rapid accumulation in fatty tissue which prolongs its elimination up to several days after exposure. The multi-systemic effects of cannabinoids and their pharmacological interactions with anesthetic agents may lead to serious consequences. Low doses of cannabinoids have been associated with increased sympathetic response (tachycardia, hypertension and increased contractility) with high levels of norepinephrine detected 30 min after use. High doses enhance parasympathetic tone leading to dose-dependent bradycardia and hypotension. Severe vascular complications associated with cannabis exposure may include malignant arrhythmias, coronary spasm, sudden death, cerebral hypoperfusion and stroke. Bronchial hyperreactivity and upper airway obstruction are commonly reported in cannabis users. Postoperative hypothermia, shivering and increased platelet aggregation have been also documented.

A retrospective analysis on patients at high-risk for obstructive sleep apnea undergoing ear, nose, and throat surgeries.

Background: Obstructive sleep apnea (OSA) may be related to episodes of oxygen de-saturation, hypercapnia, cardiovascular dysfunction, cor-pulmonale, and pulmonary hypertension. STOP-BANG is an acronym for eight specific questions used to assess the likelihood of OSA. If the individual exhibits three or more of these indicators, he/she should be considered to be at high risk for OSA complications. Therefore, the decision of proceeding with inpatient versus outpatient ENT surgery still remains controversial. The primary objective of the study was to identify and correlate desaturation (SPO2 <90%) episodes and risk factors. Methods: We conducted a single-center retrospective study between October 1, 2011 and August 31, 2014 in order to identify postoperative complications during the first 24 hours that justify postoperative monitoring and hospital admission. A total of 292 subjects were included for data analysis. Patients were divided into two groups based on the number of OSA risk factors: group A with 3-4 risk factors (n = 166), and group B with ≥5 risk factors (n = 126). The following information was collected: demographics, ASA, preoperative STOP-BANG score, length of surgery, intraoperative complications, opioid consumption, post anesthesia care unit (PACU) and overall length of stay, supplemental oxygen requirement, oxygen desaturation, and postoperative opioid consumption. Results: No statistically significant difference was found when comparing demographic variables between both groups. All STOP-BANG variables showed statistical significance. PACU and inpatient variables were similar among both groups, with the exception of length of hospital stay (longer stay in group B when compared to group A [p = 0.003]). Desaturation differences between both groups during PACU were statistically significant (p = 0.008). A post-hoc analysis showed a 0% incidence of overall desaturation in the group with three STOP-BANG indicators. Conclusions: Our retrospective analysis concluded that patients diagnosed with three STOP-BANG risk factors did not experience postoperative complications and hospital admission was not justified. Level of Evidence: 4.

Perioperative Management of Subarachnoid Hemorrhage in a Patient with Alagille Syndrome and Unrepaired Tetralogy of Fallot: Case Report.

Alagille syndrome (ALGS) is a genetic disorder associated with multisystem dysfunction involving the hepatic, cardiovascular, and neurologic systems. Tetralogy of Fallot (TOF), a congenital cardiac anomaly, is commonly found in these patients. Patients with ALGS may also have an increased risk of cerebrovascular abnormalities and bleeding. Ruptured cerebral aneurysm and subarachnoid hemorrhage (SAH) may be developed, increasing the incidence of morbidity and mortality. Advances in neuroimaging and neurosurgery have allowed early identification and treatment of such vascular abnormalities, improving patients' outcomes and reducing life-threatening complications such as intracranial bleeding. Authors describe the perioperative management of a patient with ALGS and TOF who was admitted to the emergency department due a ruptured intracranial aneurysm with concomitant SAH. Surgical treatment included diagnostic cerebral arteriography with coil embolization of a left posterior communicating artery aneurysm, and placement of right external ventricular drain (EVD). The combination of neuroprotective anesthetic techniques, fast emergence from anesthesia, and maintenance of intraoperative hemodynamic stability led to a successful perioperative management. A multidisciplinary approach in specialized centers is essential for the treatment of patients with SAH, especially in patients with ALGS and complex congenital heart disease such as TOF.

Advanced Analgesic Drug Delivery and Nanobiotechnology.

Transdermal administration of analgesic medications offers several benefits over alternative routes of administration, including a decreased systemic drug load with fewer side effects, and avoidance of drug degradation by the gastrointestinal tract. Transdermal administration also offers a convenient mode of drug administration over an extended period of time, particularly desirable in pain medicine. A transdermal administration route may also offer increased safety for drugs with a narrow therapeutic window. The primary barrier to transdermal drug absorption is the skin itself. Transdermal nanotechnology offers a novel method of achieving enhanced dermal penetration with an extended delivery profile for analgesic drugs, due to their small size and relatively large surface area. Several materials have been used to enhance drug duration and transdermal penetration. The application of nanotechnology in transdermal delivery of analgesics has raised new questions regarding safety and ethical issues. The small molecular size of nanoparticles enables drug delivery to previously inaccessible body sites. To ensure safety, the interaction of nanoparticles with the human body requires further investigation on an individual drug basis, since different formulations have unique properties and side effects.