Anesthesia considerations for patients with an implanted deep brain stimulator undergoing surgery: a review and update.

PURPOSE: Deep brain stimulation (DBS) can be an effective treatment option for patients with essential tremor and Parkinson's disease. This review provides an overview on the functioning of neurostimulators and recent advances in this technology and presents an updated guide on the anesthetic management of patients with an implanted neurostimulator undergoing surgery or medical intervention. SOURCE: A search was conducted on MEDLINE®, EMBASE™, and Cochrane Database of Systematic Reviews databases to identify studies published in English from 1974 to December 2015. Our search also included relevant and available incident reports from the manufacturers, Health Canada, the United States Food and Drug Administration, and the European Medicines Agency. Thirty of 232 articles identified were found to be relevant to this review. PRINCIPAL FINDINGS: Deep brain stimulation systems now offer a range of options, including pulse generators with dual-channel capabilities, rechargeable batteries, and current-control modes. Preoperatively, the anesthesiologist should ascertain the indications for DBS therapy, identify the type of device implanted, and consult a DBS specialist for specific precautions and device management. The major perioperative concern is the potential for interactions with the medical device resulting in patient morbidity. Neurostimulators should be turned off intraoperatively to minimize electromagnetic interference, and precautions should be taken when using electrosurgical equipment. Following surgery, the device should be turned on and checked by a DBS specialist. CONCLUSION: The anesthesiologist plays an important role to ensure a safe operating environment for patients with an implanted DBS device. Pertinent issues include identifying the type of device, involving a DBS-trained physician, turning off the device intraoperatively, implementing precautions when using electrosurgical equipment, and checking the device postoperatively.

Internal jugular vein blood flow in the upright position during external compression and increased central venous pressure: an ultrasound study in healthy volunteers.

BACKGROUND: External compression of the jugular veins is an effective method to increase intracranial blood volume and brain stiffness in rats and healthy volunteers. It has been reported that, on assuming an upright posture, cerebral venous drainage is distributed away from the internal jugular veins (IJVs) to the cervical venous plexus, causing complete collapse of the IJV. If so, it is not clear why external IJV compression would increase intracranial blood volume, but the latter is frequently observed in neurosurgery in the sitting position. The aim of this study was to observe the effect of external IJV compression and the Valsalva maneuver on the change in IJV cross-sectional area and IJV flow in volunteers in the upright posture. METHODS: After Research Ethics Board approval, we used ultrasound to evaluate both IJV cross-sectional areas and peak velocities in ten healthy volunteers in the sitting position. With the volunteers breathing normally at rest, we applied the Valsalva maneuver along with circumferential supraclavicular compression of 15 mmHg. Imaging was performed at the level of the cricoid cartilage and at the most superior level under the mandible. The IJV flow was calculated using the product of Doppler velocity and IJV cross-sectional area. RESULTS: Flow was detected in both IJVs of all subjects. The median [interquartile range] cross-sectional area for the right IJV at the level of the cricoid was 0.04 [0.03-0.08] cm2 (baseline), with collar 0.4 [0.2-0.6] cm2 (P = 0.003 compared with baseline). There were no significant changes in the median blood flow. CONCLUSIONS: Compression of the internal jugular veins or an increase in intrathoracic pressure does not reduce venous drainage but actually may increase intracranial venous volume.

An evaluation of the I-gel supraglottic airway in 70 pediatric patients.

The I-gel is a supraglottic airway device which is commonly used in adult patients undergoing general anesthesia. In this study, we evaluated the speed of insertion, adequacy of ventilation, leak pressure, gastric tube insertion, and problems when using the I-gel in children. We included 70 patients aged between 1 and 16 years old with ASA physical status classification I or II, undergoing elective surgery requiring general anesthesia, for which use of a supraglottic airway would be appropriate. The overall insertion success rate was 96 % with a median insertion time of 25 (18-34) [7-100] s. Seventeen patients (24.3 %) experienced problems including the need for change of airway device, laryngospasm, device displacement, blood on device after removal, and postoperative sore throat. In conclusion, there was a moderate rate of problems when using the I-gel in children, and it was necessary to change the airway in a few patients to optimize ventilation.

Perioperative allogeneic nonleukoreduced blood transfusion and prostate cancer outcomes after radical prostatectomy.

BACKGROUND: Allogeneic blood transfusion induces immunosuppression, and concern has been raised that it may increase propensity for cancer recurrence; however, these effects have not been confirmed. We examined the association of perioperative transfusion of allogeneic blood long-term oncologic outcomes in patients with prostate cancer who underwent prostatectomy. STUDY DESIGN AND METHODS: We reviewed medical records of patients who underwent radical prostatectomy between 1991 and 2005 and received allogeneic nonleukoreduced blood. Each transfused patient was matched to two controls who did not receive blood: matching included age, surgical year, prostate-specific antigen level, pathologic tumor stages, pathologic Gleason scores, and anesthetic type. Primary outcome was systemic tumor progression, with secondary outcomes of prostate cancer death and all-cause mortality. Stratified proportional hazards regression analysis was used to assess differences in outcomes between the transfused and nontransfused group. RESULTS: A total of 379 prostatectomy patients who were transfused and 758 nontransfused controls were followed for 9.4 and 10.2 years (median), respectively. In a multivariable analysis that took into account the matched study design and adjusted for positive surgical margins and adjuvant therapies, the use of allogeneic blood was not associated with systemic tumor progression (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.39-1.99; p = 0.76), prostate cancer-specific death (HR, 1.69; 95% CI, 0.44 to 6.48; p = 0.44), or all-cause death (HR, 1.20; 95% CI, 0.87 to 1.67; p = 0.27). CONCLUSIONS: When adjusted for clinicopathologic and procedural variables transfusion of allogeneic blood was not associated with systemic tumor progression and survival outcomes.

Outcomes after radical prostatectomy for cancer: a comparison between general anesthesia and epidural anesthesia with fentanyl analgesia: a matched cohort study.

BACKGROUND: The use of regional anesthesia for cancer surgery has been associated with improved oncologic outcomes. One of the proposed mechanisms is a reduction in the use of systemic opioids that may cause immunosuppression. We used a retrospective matched cohort design to compare long-term oncologic outcomes after prostatectomy for cancer performed under general anesthesia with systemic opioids or with epidural anesthesia with epidural fentanyl analgesia. Since epidural fentanyl is quickly reabsorbed systemically, we hypothesized that there would be no difference in long-term oncological outcomes between the 2 groups. METHODS: There were 486 men who underwent prostatectomy performed under epidural anesthesia between January 1, 1991, and January 31, 1996. They were 1:1 matched based on age (±5 years), surgical year (±1 year), and baseline prostate cancer pathology to patients who had general anesthesia with systemic opioids. Long-term cancer outcomes and all-cause mortality were examined. Analyses were performed using stratified proportional hazards regression models, with hazard ratios >1 indicating worse outcome for general anesthesia only compared with epidural anesthesia and fentanyl analgesia. RESULTS: After adjusting for positive surgical margins and adjuvant therapies, patients in the general anesthesia group were found not to be at increased risk of prostate cancer recurrence (hazard ratio [HR] = 0.79, 95% confidence interval [CI], 0.60-1.04], systemic tumor progression (HR = 0.92, 95% CI, 0.46-1.84), cancer-specific mortality (HR = 0.53, 95% CI, 0.18-1.58), or overall mortality (HR = 1.23, 95% CI 0.93-1.63) when compared with patients who received epidural anesthesia. CONCLUSIONS: Compared with general anesthesia with systemic opioids, epidural anesthesia and analgesia with fentanyl were not associated with improvement in oncologic outcomes in patients undergoing radical prostatectomy for cancer.

Anesthesia and LEOPARD syndrome: a review of forty-nine anesthetic exposures.

OBJECTIVES: LEOPARD syndrome is a rare congenital disease that can manifest with cardiac anomalies, multiple lentigines, ocular hypertelorism, growth retardation, and deafness. The purpose of this case series was to review the most prominent comorbidities associated with LEOPARD syndrome, and describe perioperative outcomes in a series of patients undergoing anesthesia. DESIGN: Retrospective case series review SETTING: Tertiary care institution PARTICIPANTS: Patients diagnosed with LEOPARD syndrome who underwent surgical procedures requiring anesthesia at this institution. INTERVENTION: The medical and anesthesia records of patients with LEOPARD syndrome were reviewed. Demographic information, clinical features of LEOPARD syndrome, comorbidities, intraoperative and postoperative events and complications were recorded. A systematic literature review also was conducted. MEASUREMENTS AND MAIN RESULTS: Nine patients with LEOPARD syndrome underwent 49 procedures under general anesthesia (n = 40) or monitored anesthesia care (n = 9). The majority of operations were related to correction of cardiac anomalies (n = 20). The most common cardiac malformations were ventricular septal hypertrophy and pulmonary (or subpulmonary) stenosis, and major perioperative complications were related to severe arrhythmias and/or cardiac decompensation. CONCLUSIONS: Dominant pathology associated with perioperative complications in patients with LEOPARD syndrome is related to cardiac disease. A large proportion of patients with this condition have ventricular septal hypertrophy, which tends to progress with age; therefore, these patients undergoing anesthesia should have recent cardiologist evaluation.

Perioperative management of patients with DiGeorge syndrome undergoing cardiac surgery.

OBJECTIVE: DiGeorge syndrome is a genetic disorder with multisystem involvement resulting in craniofacial and cardiac anomalies and parathyroid and immune system dysfunction. This study describes perioperative management of a large cohort of patients with DiGeorge syndrome undergoing cardiac surgery. DESIGN: Retrospective cohort study. SETTING: Major academic tertiary institution. PARTICIPANTS: The medical records of patients diagnosed with DiGeorge syndrome and undergoing cardiac surgery at this institution, from January 1, 1976, to July 31, 2012, were reviewed for phenotypic characteristics and intraoperative and postoperative complications, with specific attention to hemodynamic instability, perioperative perturbations of plasma calcium homeostasis, and airway difficulty. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-two patients underwent 136 cardiac surgical procedures; 47 patients (76%) had multiple operations. Sternotomies for reoperations often were complex (8 complicated by vascular injury or difficulty achieving hemostasis and 5 requiring bypass before sternotomy). Two patients had persistent hypocalcemia intraoperatively, requiring infusion of calcium chloride, and hypocalcemia developed postoperatively in 8 patients. Prolonged mechanical ventilation (>24 hours) was required after 48 procedures (35%), and 25 (18%) required prolonged inotropic support (>72 hours). Infectious complications occurred after 31 procedures (23%). There was no in-hospital or 30-day mortality. CONCLUSIONS: Patients with DiGeorge syndrome often have complex cardiac anomalies that require surgical repair. The postoperative course is notable for the frequent need for prolonged respiratory and hemodynamic support. Patients can develop hypocalcemia and may require calcium supplementation. Immunodeficiencies may be associated with the increased rate of postoperative infections and may dictate the need for specific transfusion management practices.

Association between chronic kidney disease and blood transfusions for knee and hip arthroplasty surgery.

The study aim is to assess associations between chronic kidney disease (CKD) and blood transfusions during hospitalization for joint arthroplasty. Patients with Stage IV-V CKD who underwent elective total knee or hip arthroplasty from 2007 to 2010 were matched 2:1 with age, gender, and surgery type controls without kidney disease. Multivariable analyses for transfusion risk with preoperative hemoglobin, body mass index, cardiovascular disease, and surgical complexity as explanatory variables were performed. Ninety CKD patients were identified and had lower preoperative hemoglobin, higher incidence of cardiovascular disease and blood transfusions. CKD was independently associated with increased odds of transfusions (2.88, 95% confidence interval 1.33-6.23, P=0.007). Preoperative optimization of CKD patients should be considered to reduce transfusion rates.

Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors.

BACKGROUND: With increasing fiscal restraints on health care systems, procedural cost-effectiveness has become an important metric for evaluating surgical procedures. While outpatient craniotomy has been shown to be safe and effective, the economic implications of this procedure has yet to be examined. Here, we present the first cost analysis comparing inpatient versus outpatient awake craniotomy for tumor resection/biopsy. METHODS: We conducted a retrospective chart review on consecutive patients undergoing awake craniotomy for tumor resection/biopsy at a publicly funded tertiary care center from Sept 2014 to Aug 2015. Patient demographics, comorbidities and surgical factors were recorded. Direct and indirect costs for each patient visit were calculated based on institutional records. RESULTS: A total of 50 consecutive patients undergoing awake craniotomy for tumor resection were included in this study (29 outpatients, 21 inpatients). Rates of complications and 30-day readmission were similar between groups. The total costs associated with inpatient surgery were nearly double that of outpatient surgery ($10649 versus $5242, P < 0.001). In-patient surgery resulted in a nearly 6-fold increase in unit/bed costs compared to out-patient surgery ($4142 versus $758, P < 0.001). There were no differences in the costs incurred from the operating room, laboratory, or anesthesia departments. CONCLUSIONS: Costs associated with outpatient craniotomy are nearly half compared to inpatient craniotomy and this is largely driven by reductions in bed resource utilization and allied health services. Outpatient neurosurgery for tumor resection is therefore a safe and feasible option for appropriately selected patients and confers an overall cost reduction.

Anesthesia and cor triatriatum.

AIMS AND OBJECTIVES: Cor triatriatum sinistrum (CTS) and cor triatriatum dextrum (CTD) are rare congenital anomalies characterized by the presence of a perforated septum which divides the respective atrium into a proximal and distal chamber. This report reviews the perioperative course of patients with uncorrected cor triatriatum (CT) undergoing procedures requiring anesthesia. In addition, we performed a literature search that examines the experience of others regarding the peri-operative course of patients with CT. MATERIALS AND METHODS: A computerized search of a medical record database was conducted to identify patients with a clinical diagnosis of uncorrected CTD and CTS undergoing surgical procedures. Descriptive statistics were used. RESULTS: We identified 12 adult patients with asymptomatic CTS (n = 7) and CTD (n = 5) who underwent 23 anesthetics. There were no perioperative complications which could be attributed directly to the anatomy of CT. CONCLUSIONS: Our observation and review of the literature suggest that patients with asymptomatic CT typically tolerate anesthesia and surgical procedures well.

Hospitalization for partial nephrectomy was not associated with intrathecal opioid analgesia: Retrospective analysis.

BACKGROUND: The aim of this retrospective study is to test the hypothesis that the use of spinal analgesia shortens the length of hospital stay after partial nephrectomy. MATERIALS AND METHODS: We reviewed all patients undergoing partial nephrectomy for malignancy through flank incision between January 1, 2008, and June 30, 2011. We excluded patients who underwent tumor thrombectomy, used sustained-release opioids, or had general anesthesia supplemented by epidural analgesia. Patients were grouped into "spinal" (intrathecal opioid injection for postoperative analgesia) versus "general anesthetic" group, and "early" discharge group (within 3 postoperative days) versus "late" group. Association between demographics, patient physical status, anesthetic techniques, and surgical complexity and hospital stay were analyzed using multivariable logistic regression analysis. RESULTS: Of 380 patients, 158 (41.6%) were discharged "early" and 151 (39.7%) were "spinal" cases. Both spinal and early discharge groups had better postoperative pain control and used less postoperative systemic opioids. Spinal analgesia was associated with early hospital discharge, odds ratio 1.52, (95% confidence interval 1.00-2.30), P = 0.05, but in adjusted analysis was no longer associated with early discharge, 1.16 (0.73-1.86), P = 0.52. Early discharge was associated with calendar year, with more recent years being associated with early discharge. CONCLUSION: Spinal analgesia combined with general anesthesia was associated with improved postoperative pain control during the 1(st) postoperative day, but not with shorter hospital stay following partial nephrectomy. Therefore, unaccounted practice changes that occurred during more recent times affected hospital stay.