A real-time anatomy identification via tool based on artificial intelligence for ultrasound-guided peripheral nerve block procedures: an accuracy study.

We aimed to assess the accuracy of an artificial intelligence (AI)-based real-time anatomy identification software specifically developed to ease image interpretation intended for ultrasound-guided peripheral nerve block (UGPNB). Forty healthy participants (20 women, 20 men) were enrolled to perform interscalene, supraclavicular, infraclavicular, and transversus abdominis plane (TAP) blocks under ultrasound guidance using AI software by anesthesiology trainees. During block practice by a trainee, once the software indicates 100% scan success of each block associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 5-point scale by expert validators. When trainees reached 100% scan success, accuracy scores of the validators were noted. Correlation analysis was used whether the relationship (r) according to demographics (gender, age, and body mass index: BMI) and block type exist. The BMI (kg/m2) and age (year) of participants were 22.2 ± 3 and 32.2 ± 5.25, respectively. Assessment scores of validators for all blocks were similar in male and female individuals. Mean assessment scores of validators were not significantly different according to age and BMI except for TAP block, which was inversely correlated with age and BMI (p = 0.01). AI technology can successfully interpret anatomical structures in real-time sonography while assisting young anesthesiologists during UGPNB practice.

Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses.

BACKGROUND: Intrahepatic cholestasis of pregnancy is associated with adverse perinatal outcomes, but the association with the concentration of specific biochemical markers is unclear. We aimed to quantify the adverse perinatal effects of intrahepatic cholestasis of pregnancy in women with increased serum bile acid concentrations and determine whether elevated bile acid concentrations were associated with the risk of stillbirth and preterm birth. METHODS: We did a systematic review by searching PubMed, Web of Science, and Embase databases for studies published from database inception to June 1, 2018, reporting perinatal outcomes for women with intrahepatic cholestasis of pregnancy when serum bile acid concentrations were available. Inclusion criteria were studies defining intrahepatic cholestasis of pregnancy based upon pruritus and elevated serum bile acid concentrations, with or without raised liver aminotransferase concentrations. Eligible studies were case-control, cohort, and population-based studies, and randomised controlled trials, with at least 30 participants, and that reported bile acid concentrations and perinatal outcomes. Studies at potential higher risk of reporter bias were excluded, including case reports, studies not comprising cohorts, or successive cases seen in a unit; we also excluded studies with high risk of bias from groups selected (eg, a subgroup of babies with poor outcomes were explicitly excluded), conference abstracts, and Letters to the Editor without clear peer review. We also included unpublished data from two UK hospitals. We did a random effects meta-analysis to determine risk of adverse perinatal outcomes. Aggregate data for maternal and perinatal outcomes were extracted from case-control studies, and individual patient data (IPD) were requested from study authors for all types of study (as no control group was required for the IPD analysis) to assess associations between biochemical markers and adverse outcomes using logistic and stepwise logistic regression. This study is registered with PROSPERO, number CRD42017069134. FINDINGS: We assessed 109 full-text articles, of which 23 studies were eligible for the aggregate data meta-analysis (5557 intrahepatic cholestasis of pregnancy cases and 165 136 controls), and 27 provided IPD (5269 intrahepatic cholestasis of pregnancy cases). Stillbirth occurred in 45 (0·83%) of 4936 intrahepatic cholestasis of pregnancy cases and 519 (0·32%) of 163 947 control pregnancies (odds ratio [OR] 1·46 [95% CI 0·73-2·89]; I2=59·8%). In singleton pregnancies, stillbirth was associated with maximum total bile acid concentration (area under the receiver operating characteristic curve [ROC AUC]) 0·83 [95% CI 0·74-0·92]), but not alanine aminotransferase (ROC AUC 0·46 [0·35-0·57]). For singleton pregnancies, the prevalence of stillbirth was three (0·13%; 95% CI 0·02-0·38) of 2310 intrahepatic cholestasis of pregnancy cases in women with serum total bile acids of less than 40 µmol/L versus four (0·28%; 0·08-0·72) of 1412 cases with total bile acids of 40-99 µmol/L (hazard ratio [HR] 2·35 [95% CI 0·52-10·50]; p=0·26), and versus 18 (3·44%; 2·05-5·37) of 524 cases for bile acids of 100 µmol/L or more (HR 30·50 [8·83-105·30]; p<0·0001). INTERPRETATION: The risk of stillbirth is increased in women with intrahepatic cholestasis of pregnancy and singleton pregnancies when serum bile acids concentrations are of 100 µmol/L or more. Because most women with intrahepatic cholestasis of pregnancy have bile acids below this concentration, they can probably be reassured that the risk of stillbirth is similar to that of pregnant women in the general population, provided repeat bile acid testing is done until delivery. FUNDING: Tommy's, ICP Support, UK National Institute of Health Research, Wellcome Trust, and Genesis Research Trust.

How neuraxial labor analgesia differs by approach: dural puncture epidural as a novel option.

BACKGROUND AND AIM: Neuraxial analgesia techniques are not limited to just standard epidural and CSE blocks. A novel approach called dural puncture epidural (DPE) which is a modification of CSE in terms of practice has gained popularity after its description and use in the obstetric population.  The aim of this review is to address the practice of DPE technique as a novel option by reviewing its benefits as well as side and/or adverse effects and to understand how neuraxial labor analgesia differs by approach based on the information available in the current literature DISCUSSION: Despite controversies and concerns, more rapid onset of analgesia, early bilateral sacral analgesia, lower incidence of asymmetric block and fewer maternal and fetal side effects are provided with DPE when compared to epidural. CONCLUSION: DPE offers a favorable risk-benefit ratio for management of neuraxial analgesia as a novel option.

Antinociceptive Effect of Liposomal Bupivacaine Formulations After Intrathecal Administration in Rats

Background/aim: Based on our previous in vitro study with multilamellar liposomal bupivacaine (MLB) versus bupivacaine alone in artificial cerebrospinal fluid, we aimed to investigate in vivo antinociceptive effect of intrathecal MLB by determining tail flick latency (TFL) time after thermal stimulation in rats. Materials and methods: After preparing MLB and high-yield drug entrapment in liposome (HYDEL) bupivacaine, 18 female Wistar rats were assigned to 3 groups as control (bupivacaine) and study groups (MLB and HYDEL bupivacaine) including 6 rats in each group to administer these drugs intrathecally. Antinociceptive activity was determined in terms of TFL time after thermal stimulation. Maximum possible effect (MPE) calculated from TFL times and rats with motor block were documented. Results: TFL times after intrathecal injection of HYDEL bupivacaine were significantly longer than that of the control and MLB groups (P < 0.05) and returned to baseline 180 min after intrathecal injection. MPE (100%) with intrathecal HYDEL bupivacaine occurred between 10 to 45 min. Afterwards, MPEs were 70% and 50% for the control and MLB groups, respectively. Motor block disappeared after 20 min in the study groups while it lasted 75 min in the control. Conclusion: Intrathecal administration of MLB and HYDEL bupivacaine in rats resulted in longer duration of antinociceptive activity with shorter motor block duration.

Epidural patch with autologous platelet rich plasma: a novel approach.

We aimed to perform an epidural patch using platelet rich plasma (PRP), which has the potential to regenerate and heal tissues via degranulation of platelets, in a 34-year-old parturient suffering from persistent post-dural puncture headache (PDPH) after failed epidural blood patch (EBP). After her admission to our unit, we reconfirmed the clinical and radiologic diagnosis of PDPH. Cranial MRI with contrast showed diffuse pachymeningeal thickening and contrast enhancement with enlarged pituitary consistent with intracranial hypotension. Clinical and radiological improvements were observed 1 week after the epidural patch using autologous PRP. Therefore, we recommend using autologous PRP for epidural patching in patients with incomplete recovery after standard EBP as a novel successful approach.

Retrospective evaluation of the effects of traditional interscalene block alone versus combined with superior truncus block-associated diaphragm paralysis during arthroscopic shoulder surgery.

OBJECTIVES: The aim of this study was to investigate the effects of traditional interscalene block (ISB) alone and ISB combined with superior truncus block (STB)-associated diaphragm paralysis evaluated by ultrasound, duration of analgesia, and rate of complication in patients undergoing arthroscopic shoulder surgery. PATIENTS AND METHODS: Between January 2020 and December 2022, a total of 285 patients (158 males, 127 females; mean age: 48.0±15.1 years; range, 18 to 80 years) who underwent arthroscopic shoulder surgery under ISB, either alone or combined with STB, were retrospectively analyzed. The patients were operated under ISB alone using 30 mL 0.5% bupivacaine (n=140) or ISB using 10 mL (n=67) or 5 mL 0.5% bupivacaine (n=78) combined with STB using 20 mL 0.5% bupivacaine. Ultrasound reports of all patients' diaphragm function were also retrieved. Duration of analgesia, need for additional analgesics, and the type of analgesic drugs, and evaluations of patient and surgeon satisfactions were evaluated. Degree of diaphragm paralysis considered as complete (≥75%), partial (25.1 to 74.9%) and no paralysis (≤25%) were evaluated for comparison between the block types. RESULTS: The patients underwent operation due to rotator cuff rupture (n=218) or Bankart (n=67). Duration of analgesia, need for additional analgesia, and the type of analgesic drugs used were comparable between the block types. The most common complication was Horner syndrome (n=96, 33.68%) which was significantly lower in ISB (5 mL) +STB (20 mL) than the others (17.9% vs. 41.4% and 37.3%, p=0.002). The ISB (5 mL bupivacaine 0.5%) + STB (20 mL bupivacaine 0.5%) resulted in less complete diaphragm paralysis with adequate surgical anesthesia not requiring general anesthesia. CONCLUSION: The ISB using 5 mL of 0.5% bupivacaine + STB instead of traditional ISB alone can be preferred due to the low rate of complete hemi-diaphragm paralysis with adequate surgical anesthesia/analgesia and high patient and surgeon satisfaction.

Evaluation of the effectiveness of artificial intelligence for ultrasound guided peripheral nerve and plane blocks in recognizing anatomical structures.

BACKGROUND: We aimed to assess the accuracy of artificial intelligence (AI) based real-time anatomy identification for ultrasound-guided peripheral nerve and plane block in eight regions in this prospective observational study. METHODS: After obtaining ethics committee approval and written informed consent from 40 healthy volunteers (20 men and 20 women, between 18 and 72 years old), an ultrasound device installed with AI software (Nerveblox, SmartAlfa, Turkey) were used to scan regions of the cervical plexus, brachial plexus, pectoralis (PECS), rectus sheet, femoralis, canalis adductorius, popliteal, and ESP by three anesthesiology trainees. During scanning by a trainee, once software indicates 100 % scan success of associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 6-point scale between 0 and 5 by two expert validators. Evaluation scores of the validators for each block were compared according to demographics (gender, age, and BMI) and block type exists. RESULTS: The scores were not different except ESP, femoralis, and cervical plexus regions between the experts. The mean scores of the experts for the PECS, popliteal and rectus sheath were significant between males and females (p < 0.05). In terms of BMI, significant differences in the scores were observed only in the canalis adductorius, brachial plexus, and ESP regions (p < 0.05). CONCLUSIONS: Ultrasound guided AI-based anatomy identification was performed in commonly used eight block regions by the trainees where AI technology can successfully interpret the anatomical structures in real-time sonography which would be valuable in assisting anesthesiologists.

Management of Postpartum Haemorrhage.

Postpartum haemorrhage is the leading cause of maternal mortality worldwide. However, postpartum haemorrhage-related deaths are potentially preventable with timely diagnosis and management. The present review addresses the management of postpartum haemorrhage algorithm that includes the use of uterotonics, non-surgical (balloon tamponade) or surgical (sutures, artery ligations, and/or hysterectomy) techniques, and/or endovascular radiologic interventions, antifibrinolytic (tranexamic acid), and procoagulant (fibrinogen concentrate) drugs based on the international and national guidelines updated with recent evidences.

Management of an Uncorrected Tetralogy of Fallot for Caesarean Section Using Low-Dose Combined Spinal Epidural Anaesthesia Under Advanced Haemodynamic Monitorization.

Since management of parturients with uncorrected tetralogy of Fallot reported until now lacks advanced cardiac haemodynamic monitoring, we aimed to present anaesthetic management of a parturient with uncorrected tetralogy of Fallot scheduled for caesarean section by addressing the challenges in the management based on the advanced haemodynamic monitoring due to the expected high-risk maternal morbidity and mortality in this particular case. Hereby, we provided haemodynamic stability with little requirement for vasopressor medication by using low-dose combined spinal epidural anaesthesia in a parturient with uncorrected tetralogy of Fallot scheduled to undergo caesarean delivery.

The effects of delivery route and anesthesia type on early postnatal weight loss in newborns: the role of vasoactive hormones.

OBJECTIVE: To investigate the effects of delivery route and maternal anesthesia type and the roles of vasoactive hormones on early postnatal weight loss in term newborns. METHODS: Ninety-four term infants delivered vaginally (group 1, n=31), cesarean section (C/S) with general anesthesia (GA) (group 2, n=29), and C/S with epidural anesthesia (EA) (group 3, n=34) were included in this study. All infants were weighed at birth and on the second day of life and intravenous (IV) fluid infused to the mothers for the last 6 h prior to delivery was recorded. Serum electrolytes, osmolality, N-terminal proANP (NT-proANP), brain natriuretic peptide (BNP), aldosterone and plasma antidiuretic hormone (ADH) concentrations were measured at cord blood and on the second day of life. RESULTS: Our research showed that postnatal weight loss of infants was higher in C/S than vaginal deliveries (5.7% vs. 1.3%) (p < 0.0001) and in EA group than GA group (6.8% vs. 4.3%) (p < 0.0001). Postnatal weight losses were correlated with IV fluid volume infused to the mothers for the last 6 h prior to delivery (R = 0.814, p = 0.000) and with serum NT-proANP (R = 0.418, p = 0.000), BNP (R = 0.454, p = 0.000), and ADH (R = 0.509, p = 0.000) but not with aldosterone concentrations (p > 0.05). CONCLUSION: Large amounts of IV fluid given to the mothers who were applied EA prior to the delivery affect their offsprings' postnatal weight loss via certain vasoactive hormones.

Effects of maternal supplementary oxygen on the newborn for elective cesarean deliveries under spinal anesthesia.

PURPOSE: The aim of this investigation was to determine whether supplementary oxygen provided by either nasal cannula or face mask versus room air might affect fetal oxygenation during elective cesarean section under spinal anesthesia by assessing maternal and neonatal regional cerebral oxygenation (rSO(2)) with a cerebral oximeter. METHODS: Ninety parturients were randomly allocated into three groups: two groups received 5 L/min oxygen by either nasal cannula (Group NC, n = 30) or face mask (Group FM, n = 30), respectively, and the third group was allowed to breathe room air (Group RA, n = 30). After maternal mean arterial pressure, heart rate and peripheral oxygen saturation had been monitored, rSO(2) was determined by cerebral oximeter. Umbilical artery (UA) and venous (UV) blood samples were collected for blood gas analysis. Neonatal rSO(2) and Apgar scores were recorded. RESULTS: The mean maternal rSO(2) which was recorded 3 and 5 min after administration of the spinal block in Group FM was lower than that of Group NC (p = 0.033 and 0.042, respectively). Neonatal rSO(2), UA pH, UV pH and UA base excess (BE) were lower in Group FM than in the other groups (p < 0.05). The Apgar score (1 min) in Group FM was lower than that of Group RA (p = 0.046). CONCLUSION: The effect of maternal supplementary oxygen on the newborn has been demonstrated by a cerebral oximeter monitor and supported by umbilical cord blood gas analysis and Apgar scores.

Postoperative Acute Parotitis After Cesarean Delivery Under Spinal Anaesthesia.

Postoperative acute painless parotid gland swelling, which is a rare complication has been reported after caesarian section (CS) under neuraxial anaesthesia. Hereby, we aimed to present a parturient suffering from acute parotitis complication for her elective CS under spinal anaesthesia who had a previous history of acute parotitis after epidural anaesthesia.

Retrospective Evaluation of Effects of Preoperative Anaemia Treatment in Gynaecological and Obstetric Surgical Patients.

OBJECTIVE: In anemic patients undergoing surgery, there is an increase in the requirement of blood transfusion, longer hospital stay and higher intensive care unit adimission. In this study we aimed to evaluate the efficacy of iv iron treatment before elective obstetric or gynecological operations retrospectively. METHODS: After obtaining approval of ethics committee, records of 5688 patients underwent either obstetric or gynecological surgery between January 1st of 2016 to December 31st of 2018 were documented retrospectively and 241 anemic cases were identified. Eighty-one anemic patients who did not receive any iv iron treatment preoperatively were excluded and 160 cases treated with either iv iron (either sucrose or ferric carboxy maltose) were included. The laboratory results including haemoglobin (Hb), MCV,MCH and serum iron binding capacities, ferritin, iron and transferrin levels were documented before (preoperative) and after iv iron treatment (postoperative 10th day) were collected from files. Difference between preoperative and postoperative Hb, MCV, MCH, TIBC, serum ferritin, iron and transferrin levels of these cases were determined. RESULTS: In 97 obstetric cases, the differences of Hb, MCV, MCH, serum iron, ferritin, iron binding capacity values before surgery and postoperative 10th day were respectively found as 1.3 g dL-1 (p=0.000); 1.9 fL (p=0.000); 0.3 pg (p=0.01); 44.4 µg dL-1 (p=0.008); 85.9 µg L-1 (p=0.009); 211.7 µg dL-1 (p=0.001). In 63 gynecologic cases, same measurements were evaluated and similar differences in Hb, MCV, MCH, serum ferritin and transferrin saturation values were 1.25 g dL-1 (p=0.000); 2.2 fL (p=0.000); 0.8 pg (p=0.000); 215.6 µg L-1 (p=0.002); 41.5% (p=0.044). Two obstetric patients and 7 gynaecologic patients were transfused erytrocyte suspensions after surgery. CONCLUSION: Efficacy of preoperative iv iron therapy in gynaecologic-obstetric patients with IDA has been demonstrated and its importance has been revisited once again.

Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis.

BACKGROUND: Ursodeoxycholic acid is commonly used to treat intrahepatic cholestasis of pregnancy, yet its largest trial detected minimal benefit for a composite outcome (stillbirth, preterm birth, and neonatal unit admission). We aimed to examine whether ursodeoxycholic acid affects specific adverse perinatal outcomes. METHODS: In this systematic review and individual participant data meta-analysis, we searched PubMed, Web of Science, Embase, MEDLINE, CINAHL, Global Health, MIDIRS, and Cochrane without language restrictions for relevant articles published between database inception, and Jan 1, 2020, using search terms referencing intrahepatic cholestasis of pregnancy, ursodeoxycholic acid, and perinatal outcomes. Eligible studies had 30 or more study participants and reported on at least one individual with intrahepatic cholestasis of pregnancy and bile acid concentrations of 40 µmol/L or more. We also included two unpublished cohort studies. Individual participant data were collected from the authors of selected studies. The primary outcome was the prevalence of stillbirth, for which we anticipated there would be insufficient data to achieve statistical power. Therefore, we included a composite of stillbirth and preterm birth as a main secondary outcome. A mixed-effects meta-analysis was done using multi-level modelling and adjusting for bile acid concentration, parity, and multifetal pregnancy. Individual participant data analyses were done for all studies and in different subgroups, which were produced by limiting analyses to randomised controlled trials only, singleton pregnancies only, or two-arm studies only. This study is registered with PROSPERO, CRD42019131495. FINDINGS: The authors of the 85 studies fulfilling our inclusion criteria were contacted. Individual participant data from 6974 women in 34 studies were included in the meta-analysis, of whom 4726 (67·8%) took ursodeoxycholic acid. Stillbirth occurred in 35 (0·7%) of 5097 fetuses among women with intrahepatic cholestasis of pregnancy treated with ursodeoxycholic acid and in 12 (0·6%) of 2038 fetuses among women with intrahepatic cholestasis of pregnancy not treated with ursodeoxycholic acid (adjusted odds ratio [aOR] 1·04, 95% CI 0·35-3·07; p=0·95). Ursodeoxycholic acid treatment also had no effect on the prevalence of stillbirth when considering only randomised controlled trials (aOR 0·29, 95% CI 0·04-2·42; p=0·25). Ursodeoxycholic acid treatment had no effect on the prevalence of the composite outcome in all studies (aOR 1·28, 95% CI 0·86-1·91; p=0·22), but was associated with a reduced composite outcome when considering only randomised controlled trials (0·60, 0·39-0·91; p=0·016). INTERPRETATION: Ursodeoxycholic acid treatment had no significant effect on the prevalence of stillbirth in women with intrahepatic cholestasis of pregnancy, but our analysis was probably limited by the low overall event rate. However, when considering only randomised controlled trials, ursodeoxycholic acid was associated with a reduction in stillbirth in combination with preterm birth, providing evidence for the clinical benefit of antenatal ursodeoxycholic acid treatment. FUNDING: Tommy's, the Wellcome Trust, ICP Support, and the National Institute for Health Research.

A rare complication of nasotracheal intubation: accidental middle turbinectomy.

In this paper, we are presenting a rare case of accidental middle turbinectomy, a complication of nasotracheal intubation. We have reviewed the literature and addressed important parameters on nasotracheal intubation to avoid damage to the turbinates and its possible serious complications.

Intermittent pneumatic sequential compression of the lower extremities restores the cerebral oxygen saturation during laparoscopic cholecystectomy.

BACKGROUND: Pneumoperitoneum causes intracranial pressure elevation and blood stasis at lower extremities. This study investigates cerebral oxygen saturation changes during laparoscopy and the effects of intermittent sequential compression (ISC) of the lower extremities in patients during elective laparoscopic cholecystectomy. PATIENTS AND METHOD: Sixty patients were randomly divided into two groups according to the application of ISC to the lower extremities. Group I served as control group whereas ISC was applied to group II. Cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure, and associated changes have been recorded during the operation. RESULTS: Peripheral blood oxygen saturation and mean blood pressure values did not change significantly after pneumoperitoneum. Cerebral oxygen saturation levels of the group II patients were higher in than the group I patients and the difference between the groups was statistically significant (p = 0.0001). The difference became more prominent following the 35(th) minute of the operation. Mean heart rate of the patients in group II was lower than the patients in group I and the difference was also statistically significant (p = 0.0001). CONCLUSION: In this study, it was found that the decrease in cerebral oxygen saturation was recovered with ISC application. This simple and reliable technique helps to restore cerebral oxygen saturation levels while increasing blood return from the lower extremities.

Unique Liver Disease of Pregnancy Requiring Anaesthesia Support: A Case with Severe Hyperemesis Gravidarum.

Hyperemesis gravidarum (HG) is one of the common unique liver diseases that occurs during pregnancy. Mild cases can be spontaneously resolved in time but severe cases usually require supportive medical treatment to relieve symptoms. Moreover, differential diagnosis may be required in severe cases that manifest with persistent nausea-vomiting, dehydration and weight loss refractory to treatment. Thus, to rule out any gastrointestinal pathology, this case was referred to the outpatient anaesthesia clinic after the first unsuccessful awake endoscopy attempt without sedation. Therefore, anaesthetic support for endoscopy of a pregnant woman with severe HG was presented in this case report.