Overcoming Airway Hurdles: A Case Report of Anesthetic Challenges in Meningomyelocele Complications.

This case report delves into the anesthesia management in a 23-year-old male with complications of meningomyelocele, a catastrophic congenital neural tube defect. The patient, paraplegic since birth with severe scoliosis, presented with a femoral fracture, prompting the need for careful consideration of anesthesia strategies. The challenges included counseling the family on the risks and benefits of surgery under general anesthesia, selecting an appropriate anesthetic plan for an anticipated difficult airway, and addressing ventilation strategies for restrictive lung disease. To tackle the anticipated difficult airway, an awake pediatric fiberoptic bronchoscopy was performed in the recovery room, facilitating a conscious sedation approach. In the operating room, monitored anesthesia care with dexmedetomidine infusion was employed, complemented by careful positioning and padding in the lateral position. The awake fiberoptic checkscopy proved crucial in avoiding unnecessary general anesthesia. A patient-centered approach contributed to the successful execution of a complex anesthesia plan, ensuring optimal care for this unique patient population.

Postoperative Outcomes After Emergency Surgery in COVID-19 Patients: An Ambispective Matched Cohort Study.

Purpose There is limited data from the Indian subcontinent regarding the surgical outcomes of coronavirus disease (COVID-19) patients. In this observational study, we aimed to evaluate the postoperative outcomes after emergency surgery in COVID-19 patients compared to concurrent age and gender-matched controls. We also sought to analyze the possible predictors of postoperative mortality in COVID-19 patients. Methods This matched cohort study was conducted in a tertiary care teaching hospital in central India, between 1st July 2021 and 30th June 2022. COVID-19-positive patients undergoing emergency surgery under anesthesia were recruited as cases. Age and gender-matched COVID-19-negative patients undergoing a similar nature of surgery in the same period served as concurrent controls. The cases and controls were compared for the 30-day mortality and perioperative complications. Results The COVID-19-positive surgical cohort had a 12.3 times greater 30-day postoperative overall mortality risk as compared to a matched cohort of patients with a negative COVID-19 test. A positive COVID-19 status was associated with more postoperative complications of acute respiratory distress syndrome (ARDS), sepsis, shock, and persistent hyperglycemia. On analysis of predictors of mortality, the presence of preoperative dyspnea, ARDS, American Society of Anesthesiologists Physical Status (ASA-PS) Class IIIE/IVE, increase in sequential organ failure assessment (SOFA) score, Quick SOFA>1, higher creatinine, bilirubin, and lower albumin were observed to be associated with increased mortality. Conclusions Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients undergoing emergency surgery is significantly associated with higher postoperative complications and increased 30-day postoperative mortality.

Intramuscular ketamine provides better sedation and scan conditions in children undergoing magnetic resonance imaging: A single-blinded observational study.

Objectives: The objectives of this study were to compare the quality of sedation provided by intravenous (i.v.) and intramuscular (im) ketamine for pediatric magnetic resonance imaging (MRI). Materials and Methods: This study was a non-randomized, single-blinded, and prospective observational study. After receiving approval from the Institutional Ethics Committee, a total of 108 children aged 2-7 years were divided into two groups, with 54 children in each group. In the i.v. group, children received ketamine at a dose of 1.5 mg/kg intravenously, while in the im group, children received ketamine at a dose of 4 mg/kg intramuscularly. If a Ramsay sedation score of 6 (RSS-6) was not achieved, half of the loading dose of ketamine was repeated. In both groups, rescue propofol boluses of 1 mg/kg intravenously were administered whenever the child moved. The primary outcome measure was the quality of sedation, which was assessed by a blinded radiologist. The time taken to reach RSS-6, the number of rescue propofol boluses, the total time wasted in taking repeat sequences, and the time required to achieve a modified Aldrete score of 9 (MAS-9) were recorded. Results: The im group demonstrated significantly better sedation quality. In the i.v. group, the time to achieve RSS-6 was significantly shorter, but it required more rescue propofol boluses to maintain sedation. The i.v. group also experienced a notable increase in the total time wasted during repeat sequences. On the other hand, the i.v. group exhibited a shorter time to reach MAS-9 compared to the im group. Conclusion: The im group showed superior sedation quality when compared to the i.v. group. However, it is important to consider that the im group experienced a longer recovery time.

Assessment of Intraoperative Hemodynamics and Recovery Characteristics in Pediatric Patients Receiving Buprenorphine and Propofol Anesthesia for Cleft Palate Surgery: A Prospective Observational Study.

Background: Children with cleft palate are usually operated on before 18 months of age. Cleft palate surgery demands stable hemodynamic parameters, a bloodless surgical field, and an awake and pain-free child after surgery. Aims: We aimed to study the anesthesia technique using buprenorphine and propofol for cleft palate surgery. Settings and Design: The design involves prospective observational study. The study was conducted at a tertiary care hospital. Materials and Methods: After the Institutional Ethics Committee approval, 42 patients aged 6 months to 12 years undergoing cleft palate surgery were enrolled. Anesthesia induction commenced with sevoflurane or propofol 3 mg.kg-1. After intubation, buprenorphine 3 µg.kg-1 was given, and propofol infusion was started at 2-8 mg.kg-1.h-1. Hemodynamic parameters, awakening time, and surgeon's satisfaction score were noted. After extubation, pain score, emergence agitation (EA) score, sedation score, recovery score, and adverse events were noted. Statistical Analysis: All statistical analyses were performed using the 20.0 version of the Statistical Package for the Social Science (SPSS) software program. Continuous data were summarized as mean and standard deviation, and were analyzed using a two-sided Student's unpaired t-test. Categorical data were represented using frequencies and proportions. Results: The single dose of buprenorphine with propofol infusion started immediately postintubation causes a significant decrease in heart rate after 1 h. This contributed to a favorable operative field, increasing the surgeon's satisfaction score. In the recovery room, patients were essentially pain-free till 2.5 h after surgery, with only one patient requiring rescue analgesia. Furthermore, 90% of patients showed a smooth and calm recovery with no EA. The Steward's recovery score remained high throughout without any complication. Conclusions: In cleft palate surgeries, a single-dose buprenorphine 3 µg.kg-1 and propofol maintenance infusion 2-8 mg.kg-1.h-1 were effective in maintaining hemodynamic parameters and a bloodless surgical field and managing postoperative pain with a good recovery profile.

Undiagnosed laryngocele: an airway emergency.

Laryngoceles are rare dilated laryngeal saccules that can present as acute airway obstruction and lead to airway emergencies. A man, presented to the emergency room, with difficulty in breathing and change in voice. An unevaluated pulsatile swelling was present on the left side of neck. Since, the patient was in stridor, an awake fiberoptic bronchoscopy (FOB)-guided intubation was planned with readiness for emergency tracheostomy, if needed. On FOB, an edematous supraglottic area with a narrowed glottic opening was observed. The procedure was abandoned and a surgical tracheostomy was performed to secure the airway. Postoperative contrast-enhanced CT neck revealed a huge laryngocele in left cervical region. We recommend that a high index of suspicion for presence of laryngocele should be kept in mind when a patient presents with stridor with pulsatile neck swelling. Timely aspiration of laryngocele may help in amelioration of the respiratory distress avoiding emergency tracheostomy.

The Effect of Normal Saline and Plasmalyte on Acid-Base Status in Patients Undergoing Head-and-Neck Surgery with Free Flap Reconstruction: A Prospective, Observational Cohort Study.

Background: Intraoperative fluid strategy may affect the graft viability in head-and-neck surgeries with free flap reconstruction (HNS-FFR). Studies to guide regarding association of intraoperative fluid with metabolic parameters during such surgeries are infrequent. Aim: This study aimed to compare plasmalyte (PL) and normal saline (NS) (0.9%) in terms of acid-base balance and electrolytes in the peri-operative period along with graft viability during above-mentioned surgeries. Settings and Design: Prospective, observational cohort study was conducted in patients, 18-65 years, undergoing HNS-FFR at a tertiary care center. Materials and Methods: The cohort was categorized into two groups based on the intraoperative fluid used, i.e., PL (Group A) and NS (Group B) group. The primary objective was to compare arterial blood gas parameters at seven time points till the 3rd postoperative day. We studied the effect on graft viability and length of hospital stay. Statistical Analysis Used: The independent t-tests, Chi-square, or Fisher's exact test were used to evaluate the categorical variables with a repeated measures analysis of variance for inter-group comparison with P < 0.05 as significant. Results: Seventy-one (36 in Group A and 35 in Group B) patients were included in the study with comparable baseline characteristics. Group A had a better acid-base status, especially after the conclusion of vascular anastomosis (pH 7.37 ± 0.06 vs. 7.33 ± 0.04, P = 0.014) and in the postoperative period (pH 7.35 ± 0.07 vs. 7.31 ± 0.05, P = 0.013). No statistically significant difference was observed in outcome parameters between the groups. Conclusions: PL may be preferred over NS due to better metabolic milieu during HNS-FFR surgery.