Search

Background: The duration of surgery in orthopedic surgeries is often longer than one hour. Therefore, these patients are at further risk of complications induced by general anesthesia. The present study aimed to determine the prevalence of anesthesia complications in orthopedic surgeries and its related factors. Methods: This cross-sectional study was performed on 400 patients undergoing orthopedic surgery in Shahid Beheshti Hospital of Kashan Province, Iran, in 2020. The study subjects were recruited by convenience sampling method. We included those who similarly underwent general anesthesia for elective surgery and were transferred to Post-Anesthesia Care Unit (PACU). The research instruments included a demographic questionnaire and a checklist for recording complications (shivering, pain, nausea, vomiting, & vital signs). The necessary data were recorded after the patient was admitted to the PACU, as well as half an hour and one hour later. The obtained data were analyzed using the Chi-squared test, Independent Samples t-test, one-way Analysis of Variance (ANOVA), Pearson correlation coefficient, and logistic regression analysis in SPSS v. 16. Results: The present research results suggested that the most and least frequent complications were vomiting (91.8%) and changes in blood pressure (5%), respectively. Gender was significantly associated with pain, nausea, and hypertension (P

Crouzon syndrome (CS) is a rare autosomal dominant inherited disorder caused by mutations in the fibroblast growth factor receptor 2 (FGFR2) gene. The disease is characterized by premature fusion of the coronal and sagittal sutures of the skull, resulting in clinical manifestations of midfacial hypoplasia, shallow orbit, maxillary dysplasia, and occasional upper respiratory obstruction. This article presents the case of a child aged 2 years and 7 months with CS scheduled for bilateral tonsillectomy and adenoidectomy. The patient had a difficult procedure of extubation and was reintubated and the tracheal intubation was removed 2 days after surgery. The CS is a rare condition with physical characteristics that can result in difficult airway manipulation. It is important for anesthesiologists to recognize and avoid potential airway complications in the management of such patients through detailed preoperative evaluation and careful observation after surgery to reduce perioperative risks.

A flap is done to cover expose structures such as bone, tendon and ligament. Chest wall flaps are usually performed under general anaesthesia due to a fairly large area of surgery and at two different sites which are the chest and the hand. This is the first known reported case of a chest wall flap for coverage of the hand under Wide awake local anaesthesia no tourniquet technique (WALANT). We here report the case of a 32-year-old man who had a firecracker injury over his right hand with bone exposed in his right index and middle finger and distal amputation of the thumb with first carpometacarpal joint dislocation. Chest wall flap reconstruction for coverage of a severe blast injury in the hand is possible and safe under WALANT. The proper technique and administration will lead to a successful surgery without general anesthesia complications and risks. This alternative option may be useful in districts or smaller hospitals where resources are limited.

Mucopolysaccharidosis (MPS) are a group of rare genetic inherited diseases with a progressive course due to the accumulation of glycosaminoglycans resulting in anatomic abnormalities and organ dysfunction, including the respiratory, cardiovascular, skeletal, and neurological systems that can increase the risk of anesthesia complications. Clinical manifestations are variable, multisystemic, and include severe morphological changes. The anesthetic management of these patients is complex, particularly airway management, which can be planned to include a fiberoptic airway investigation prior to surgery. We present two cases of patients with MPS type VI and VII who underwent fiberoptic airway mapping under conscious sedation, with no complications. Since MPS is a rare but challenging disease concerning the airway management, we propose a safe and effective anesthetic technique that could be used for fiberoptic bronchoscopy and allow fiberoptic-assisted tracheal intubation at the time of surgery.

Rebleeding of aneurysmal subarachnoid hemorrhage (aSAH) is one of the significant risk factors for poor clinical outcome. The rebleeding risk is the highest during the acute phase with an approximate rebleeding rate of 9-17% within the first 24 h. Theoretically, general anesthesia can stabilize a patient's vital signs; however, its effectiveness as initial management for preventing post-aSAH rebleeding remains unclear. The purpose of this study was to determine the feasibility and safety of ultra-early general anesthesia induction for reducing the rebleeding rates among patients with aSAH.We retrospectively evaluated patients with aSAH who were admitted to our department between January 2013 and December 2019. All the patients underwent ultra-early general anesthesia induction as initial management regardless of their severity. We evaluated the rebleeding rate before definitive treatment, factors influencing rebleeding, and general anesthesia complications.We included 191 patients with two-third of them having a poor clinical grade (World Federation of Neurological Society [WFNS] grade IV or V). The median duration from admission to general anesthesia induction was 22 min. Rebleeding before definitive treatment occurred in nine patients (4.7%). There were significant differences in the Glasgow Coma Scale score (p = 0.047), WFNS grade (p = 0.02), and dissecting aneurysm (p0.001) between the rebleeding and non-rebleeding patients. There were no cases of unsuccessful tracheal intubation or rebleeding during general anesthesia induction.Ultra-early general anesthesia induction could be performed safely in patients with aSAH, regardless of the WFNS grade; moreover, it resulted in lower rebleeding rate than that reported in previous epidemiological reports.

BACKGROUND AND AIMS Anesthesia services for endoscopic procedures have proliferated with the promise of increased comfort and safety. Cirrhosis patients are higher risk for sedation, yet limited data are available describing anesthesia complications in this population. APPROACH AND RESULTS This cross-sectional study utilized the National Anesthesia Clinical Outcomes Registry, a multicenter quality-improvement database from 2010 to 2015. Patients with cirrhosis undergoing an endoscopy were identified by International Classification of Diseases, Ninth Revision (ICD-9)/Current Procedures Terminology (CPT) codes. The outcome of interest was serious anesthesia-related complication defined as cardiovascular, respiratory, neurological, drug related, patient injury, death, or unexpected admission. A mixed-effects multivariate logistic regression model determined odds ratios (ORs) between variables and serious complications, adjusting for potential confounders. In total, 9,007 endoscopic procedures were performed among patients with cirrhosis; 92% were esophagogastroduodenoscopies. The majority (81%) were American Society of Anesthesiologists (ASA) class ≥3, and 72% had a history of hepatic encephalopathy, ascites, varices, hepatorenal syndrome, or spontaneous bacterial peritonitis identified by ICD-9/CPT codes. In total, 87 complications were reported, 33 of which were serious. Frequency of serious complications was 0.4% or 378.6 per 100,000 procedures (95% confidence interval [CI], 260.8, 531.3). The majority of serious complications were cardiovascular (21 of 33), including 15 cardiac arrests. Serious complications were significantly associated with ASA 4/5 (OR, 3.84; 95% CI, 1.09, 13.57) and general anesthesia (OR, 4.71; 95% CI, 1.20, 18.50), adjusting for age, sex, ASA class, anesthesia type, inpatient status, portal hypertension history, and variable complication reporting practices. CONCLUSIONS Anesthesia complications among endoscopic procedures in cirrhosis are rare overall. Serious complications were predominantly cardiac and associated with sicker patients undergoing general anesthesia. The complexity of end-stage liver disease may warrant more intensive care during endoscopic procedures, including anesthesia monitoring.

Personalized pediatric anesthesia considering omics, is a novel science in neonates, infants, and children that can improve perioperative care and reduce the complications and adverse events. Valuable evidence in children, especially in anesthesia induced neuroapoptosis and precise opioids administration, have been obtained from the recent studies. Due to vulnerability of this age group, the safe and careful perioperative care is considerable. In the future, translation of omics to clinical pediatric practice will lead to faster and better quality of diagnosis, prevention, and treatment of diseases and anesthesia complications.

Background: Propofol injection pain, despite various interventions, still occurs during the anesthesia induction and causes intense discomfort and anxiety in patients. This study aimed to explore the effect of intravenous dexmedetomidine on propofol injection pain prior to anesthesia induction with propofol at 4°C.Methods: A total of 251 patients (American Society of Anesthesiologists I–II) who underwent oral and maxillofacial surgery were randomly assigned to a combination group (n = 63), lidocaine group (n = 62), dexmedetomidine group (n = 63), and placebo-control group (n = 63); they received 0.5 ug/kg dexmedetomidine prior to anesthesia induction with propofol at 4°C, 40 mg lidocaine, 0.5 ug/kg dexmedetomidine prior to anesthesia induction, and normal saline, respectively. Incidence of pain, pain intensity, and reaction to the pain stimulus were evaluated by using verbal categorial scoring (VCS), a numerical rating scale (NRS), and the Surgical Pleth Index (SPI), respectively. In addition, hemodynamic parameters such as heart rate (HR) and mean arterial pressure (MAP) were also measured. The VCS and NRS were evaluated at 5 s after propofol injection. In addition, SPI, HR, and MAP were evaluated at three time points (before anesthesia induction and 5 and 30 s after propofol injection).Results: The incidence of pain in the combination group (51%) was significantly lower than that in the lidocaine group (71%), dexmedetomidine group (67%), or placebo-control group (94%) (p < 0.001). VCS and NRS scores in the combination group were also lower compared with the other three groups (p < 0.001), with no statistically significant differences between the lidocaine group and dexmedetomidine group (p > 0.05). The SPI of the combination group decreased significantly in comparison with the other three groups at 5 s after propofol injection (F = 96.23, p < 0.001) and 30 s after propofol injection (F = 4.46, p = 0.005). Further comparisons between HR and MAP revealed no significant differences across the groups (p > 0.05).Conclusion: Because of the sedative nature of dexmedetomidine and analgesic effect of low temperature, this study showed that intravenous dexmedetomidine prior to anesthesia induction with propofol at 4°C is highly effective in attenuating the incidence and severity of pain during injection compared with lidocaine (40 mg), dexmedetomidine 0.5 ug/kg) and placebo. This approach was not associated with any anesthesia complications.Clinical Trial Registration:ClinicalTrials.gov, identifier: ChiCTR-2000034663

BackgroundIt is reported that postoperative nausea and vomiting, common general anesthesia complications, may be prevented by perioperative intravenous dextrose administration, but with controversial clinical effectiveness.ObjectiveTo evaluate perioperative intravenous dextrose for preventing postoperative nausea and vomiting through a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis.Data sourcesMEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, clinicaltrials.gov, and the University Hospital Medical Information Network Clinical Trials Registry were searched from inception until 22 June 2019.Eligibility criteriaTrials investigating intravenous dextrose effects vs. placebos on postoperative nausea and vomiting in patients who underwent general anesthesia.ResultsEleven trials (1,250 patients) were included. All participants were ASA1-2. The nine trials included laparoscopic surgeries, and 92.2% of the participants were women. The timing of dextrose infusion was before, during, and after surgery in three, five, and three trials, respectively. Our results revealed intravenous dextrose administration significantly reduced postoperative nausea, but not vomiting, during early and late postoperative periods (risk ratio [95% confidence interval], early nausea: 0.76 [0.59-0.99], late nausea: 0.65 [0.48-0.89]; early vomiting: 1.00 [0.81-1.25], late vomiting: 0.96 [0.43-2.16]). Evidence quality was downgraded to low because the trial sequential analysis indicated more trials are needed for firm conclusions.ConclusionsCompared with placebos, perioperative intravenous dextrose administration may decrease postoperative nausea but not vomiting.Trial registrationUniversity Hospital Medical Information Network Clinical Trials Registry (registration number: UMIN000030901).

Background: Perioperative arrhythmia is a common general anesthesia complication of cardiothoracic surgeries. Sudden or acute onset of life threatening perioperative arrhythmias are rare clinical events in non-cardiac surgical patients.1,2 Electrolytes imbalance, particularly hypokalemia and dyskalemia, is one of the main possible underlining cause for the occurrence of these arrhythmias.3,4,5 We present two cases of severe hypokalemia leading to life threatening cardiac arrhythmias in the post-operative period. Case 1: A 30-year old healthy female patient without significant past medical history had emergency laparoscopic cholecystectomy and appendicectomy. Pre- and intra-operative periods were uneventful. Her pre-operative potassium level was 3.7 mmol/L. 18 hours post-operatively, she suddenly developed palpitations and went into ventricular fibrillation (VF) cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated followed by defibrillation which reverted the heart to a sinus rhythm. She was transferred to the intensive care unit (ICU) sedated and connected to the ventilator. In ICU, her serum electrolytes showed severe hypokalemia (serum potassium level 2.2 mmol/L) (Figure 1) so she was immediately started on 20 mmol of potassium chloride (KCl) over 30 minutes through central venous catheter (CVC) with complementary intravenous fluids with KCl. In the next 36 minutes she had four episodes of VF requiring CPR and defibrillation with a positive outcome. She received amiodarone infusion as well as continuous KCl supplementation and calcium gluconate 2 g. She received 100 mmol of KCl in 6 hours and a total of 220 mmol of KCl in 24 hours, and then she became stable. She was extubated after 48 hours. Echocardiogram and cardiac conduction studies showed no pathological changes. Cardiac conduction studies (electrophysiology study - EPS) were normal. She was discharged home and followed in the outpatient clinic. Case 2: A 78-year old known hypertensive male patient on angiotensin converting enzyme inhibitors was admitted to intensive care unit (ICU) for observation after laparoscopic cholecystectomy. Pre-operative serum electrolytes were within normal range. After one hour he started to have tachycardia and then went into pulseless ventricular tachycardia requiring defibrillation. His serum electrolytes results showed severe hypokalemia (2.4 mmol/L) (Figure 1) so this was corrected by rapid potassium chloride administration through CVC and supplementation of KCl in intravenous fluids. After 10 minutes he went into VF requiring defibrillation and a bolus of amiodarone. In the next 20 minutes he had three more episodes of VF requiring CPR and defibrillation. In six hours he required 90 mmol of KCl to reach a serum potassium level of 3.7 mmol/L. A total of 210 mmol of KCl was needed in 24 hours. He was extubated after 24 hours. He was transferred to the ward on day 3 and discharged home on day 6, and later followed in the outpatient clinic. Conclusion: Perioperative severe hypokalemia can lead to life threatening cardiac arrhythmias. Early recognition and aggressive correction through perioperative potassium supplementation is essential for better outcome. Daily potassium level assessment and supplementation should be done in the perioperative period.

Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.

Insight into the causes and outcomes of malpractice claims against surgeons will help inform practitioners and may support better patient care. The purpose of this study was to characterize national malpractice claims against oral and maxillofacial surgeons (OMSs).A comprehensive review of all claims against OMSs from 2000 to August 2018 in the National Practitioner Data Bank was performed. Primary outcomes were claims against OMSs, payment amount, claim duration, and percentage of anesthesia-related claims. Other variables of interest included demographic characteristics, nature of allegations, clinical outcome of injury, outcome of claim, and number of payments of $1 million or greater ("catastrophic payments"). Student t tests and Wilcoxon rank-sum test were performed, and P .05 was considered significant.This was a retrospective cohort study of malpractice claims against OMSs. There were 2,643 claims against OMSs during the study period. The average age of the claimant was 35.5 ± 18.4 years, and 47.6% were female patients. Most claims (94.7%) were settled out of court for a mean of $130,824 ± $402,633.8. Court-adjudicated claims had significantly higher payments with a mean of $247,554.69 ± $414,655.51 (P .0001). The average duration from time of event to conclusion of claim was significantly shorter for settled claims (3.5 ± 2.3 years) than for claims that were court adjudicated (5.2 ± 2.7 years) (P .0001). Anesthesia-related claims made up 3.63% of the total, and 0.56% of claims were pediatric anesthesia related. Anesthesia-related payments were significantly higher than other claims (P .0001). The most common type of allegation was "surgery-related" injuries (63.1%), followed by "treatment-related" injuries (22.2%). The most common clinical outcome was minor permanent injury (34.6%).Most claims against OMSs were settled. Only a small portion of claims were associated with anesthesia complications, but payment amounts for these were significantly higher than for other claims. Settlements were made more quickly and for significantly lower rewards compared with judgments. Claims against OMSs during the past 2 decades were most commonly associated with minor permanent injuries occurring in the outpatient setting.

Aim: Explore if dexmedetomidine (DEX) improves neurodevelopment and cognitive impairment in infants with congenital heart disease. Materials & methods: We retrospectively analyzed 256 pediatric patients aged less than 2 years with heart disease undergoing thoracic surgery. The intelligence quotient and neurodevelopment were tested. Mortality, incidence of postoperation adverse events, duration of mechanical ventilation, and length of stay were recorded and compared. Results: Compared with those not administered DEX, intelligence quotient scores and neurodevelopment evaluation scores increased in patients receiving perioperative DEX. There were no significant differences in mortality, duration of mechanical ventilation or length of stay. Conclusion: The administration of DEX might improve neural development and reduce the adverse effects of general anesthesia in infants with congenital heart disease undergoing surgery and extracorporeal circulation.

Background Two-thirds of the world's population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesia-related and postoperative complications during a 2-year surgical mission in Madagascar. Methods As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification. Results Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4-2.6). The majority (85% CI, 74-96) of adverse events occurred intraoperatively with 15% (CI, 3-26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3-12.0) per surgery and 9.4% (CI, 8.1-10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0-41.3 and 33.2%; CI, 31.1-35.3 of all complications, respectively). The most common (42.9%; CI, 40.7-45.1) grade of complication was grade II. There was 1 death. Conclusions This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia.

Gynecologic brachytherapy procedures require targeted procedural and anesthetic needs including optimization of intra- and post-procedure analgesia, low rate of complications, and appropriate and timely transitions of care. It is uncertain whether neuraxial or general anesthesia is superior for these and other anesthetic outcomes. After a targeted search of the recent literature for anesthesia and analgesia studies for gynecologic brachytherapy, twenty studies were identified and appraised for potential review. Meta-analysis showed a decreased frequency in rescue analgesic administration in patients who underwent neuraxial anesthesia compared with general anesthesia for the procedure and literature review showed a comparable rate of anesthesia-related complications. Neuraxial anesthesia may be considered for gynecologic brachytherapy because of improved pain control, decreased opioid consumption, and similar rate of anesthesia complications.

IMPORTANCE: Tonsillectomy is a common pediatric procedure for the treatment of sleep-disordered breathing and chronic tonsillitis. Up to half of children having this procedure experience a perioperative respiratory adverse event. OBJECTIVE: To determine whether inhaled albuterol sulfate (salbutamol sulfate) premedication decreases the risk of perioperative respiratory adverse events in children undergoing anesthesia for tonsillectomy. DESIGN, SETTING, AND PARTICIPANTS: A randomized, triple-blind, placebo-controlled trial (the Reducing Anesthetic Complications in Children Undergoing Tonsillectomies [REACT] trial) was conducted at Perth Children’s Hospital (formerly Princess Margaret Hospital for Children), the only tertiary pediatric hospital in Western Australia. Participants included 484 children aged 0 to 8 years who were undergoing anesthesia for tonsillectomy. The study was conducted between July 15, 2014, and May 18, 2017. INTERVENTIONS: Participants were randomized to receive either albuterol (2 actuations, 200 μg) or placebo before their surgery. MAIN OUTCOMES AND MEASURES: Occurrence of perioperative respiratory adverse events (bronchospasm, laryngospasm, airway obstruction, desaturation, coughing, and stridor) until discharge from the postanesthesia care unit. RESULTS: Of 484 randomized children (median [range] age, 5.6 [1.6-8.9] years; 285 [58.9%] boys), 479 data sets were available for intention-to-treat analysis. Perioperative respiratory adverse events occurred in 67 of 241 children (27.8%) receiving albuterol and 114 of 238 children (47.9%) receiving placebo. After adjusting for age, type of airway device, and severity of obstructive sleep apnea in a binary logistic regression model, the likelihood of perioperative respiratory adverse events remained significantly higher in the placebo group compared with the albuterol group (odds ratio, 2.8; 95% CI, 1.9-4.2; P

Generalanesthesia in cats and dogs is the factor that directly affects the quality andcomfort of the surgery. Inhalation anesthesia is an anesthetic technique thathas been successfully used in veterinary surgery in recent years. Anesthesiacomplications can be reduced to minimum level with this anesthesia technique. Thepatient's introduction to anesthesia and recovery time from the anesthesia goeson without any problem. Inhalation anesthesia technique is more successful andadvantageous than other techniques. However, equipment and used drugs are noteconomical. In this review the latest information about the technique ofinhalation anesthesia and used drugs to provide general anesthesia in cats anddogs was evaluated., Kedi ve köpeklerde genel anestezi;yapılacak olan cerrahinin kalite ve konforunu direk etkileyen faktördür.İnhalasyon anestezisi veteriner cerrahide son yıllarda başarılı bir şekildekullanılmaya başlanmış bir anestezi tekniğidir. Anesteziye bağlıkomplikasyonlar bu anestezi tekniği ile minumum seviyeye düşürülebilmektedir.Hastanın anesteziye girişi ve anesteziden uyanışı sorunsuz bir şekildeolmaktadır. İnhalasyon anestezi tekniği diğer tekniklere göre daha başarılı veavantajlıdır. Ancak ekipman ve kullanılan ilaçlar ekonomik değildir. Buderlemede; kedi ve köpeklerde genel anestezi sağlamak için uygulanan inhalasyonanestezisi tekniği ve kullanılan ilaçlar hakkındaki son bilgiler değerlendirilmiştir.

The analysis of complaints in different fields of medicine helps understand medical malpractices. This study investigated the complaints related to anesthesia services raised in Kermanshah Medical Council. A total of 35 complaints were found, among which were 16 cases of death and eight cases concluded the malpractice of anesthesiologist. In 21% of cases, the anesthesiologist was found guilty. About half of the complaints and confirmed cases of malpractices pertained to death or permanent brain damage.

To evaluate the safety of midazolam and diazepam for adolescents during third molar extraction and whether any differences in perioperative complications exist when using the 2 benzodiazepines alone or in combination.A prospective study was performed in adolescents (21 yr old) who underwent at least 1 third molar extraction by an oral and maxillofacial surgeon in the ambulatory setting from January 2001 through December 2010 using the Oral and Maxillofacial Surgery Outcomes System. The primary predictor variable was type of benzodiazepine used, divided into the total number of patients who received diazepam with or without midazolam. The outcome of interest was adverse complications resulting from anesthesia. Multivariable logistic regression was applied to measure the association between benzodiazepine type and adverse complications.Patients in the diazepam group (n = 4,213) and in the combination group (n = 426) had a complication rate of 1.4%, whereas those in the midazolam group (n = 13,451) had a complication rate of 1.0% (P = .027). Multiple logistic regression analysis showed a 50% increased odds of adverse complications in patients receiving diazepam (adjusted odds ratio = 1.50; 95% confidence interval, 1.05 to 2.16; P = .027).Adolescent patients who received intravenous diazepam during third molar procedures had an increased odds of anesthesia-related complications compared with those given midazolam.

The primary objective of this study was to assess the risk of perioperative anesthesia-related complications in a cohort of obese and non-obese women undergoing outpatient surgical abortion under IV sedation without tracheal intubation.We performed a retrospective cohort study of all surgical abortions through 22 6/7 weeks' gestation at an outpatient clinic from 2012 to 2013. Women receiving IV sedation were included. Obesity status was defined by the World Health Organization criteria. The primary outcome was the rate of perioperative anesthesia complications defined as tracheal intubation, pulmonary aspiration, hospital transfer for an anesthesia indication, or anesthesia-related adverse events (persistent hypoxemia and allergic reaction). The use of opioid reversal (naloxone) was assessed as a secondary outcome measure. Multivariate analysis for the secondary outcome measure was performed with adjustment for confounding factors.During the study period, 9348 abortions were performed. Of the 5579 patients who received IV sedation, 1438 (25.8%) were obese, 1707 (30.6%) were in the second trimester, and 851 (15.3%) were ≥17 weeks' gestation. No patients experienced a primary outcome measure. Based on the upper 95% confidence interval (CI) for the sample size, the maximal risk of an anesthesia-related complication is 1 in 1860 procedures. Naloxone use occurred in 13 (0.2%) patients and was not more frequent among obese patients (0.14% vs 0.27%; 95% CI of odds ratio [OR], 0.12-2.36; P = 0.54) or procedures at ≥17 weeks' gestation (0.47% vs 0.19%; 95% CI of OR, 0.76-8.06; P = 0.12). These negative findings should be interpreted with caution, given the limitations of the sample size to assess these secondary outcome measures. Naloxone use was associated with fentanyl doses200 μg (0.82% vs 0.13%; P = 0.002), an association that remained significant when we controlled for confounding factors (adjusted OR, 5.51; 95% CI, 1.61-18.91). Further analysis revealed that fentanyl dose200 μg was associated with naloxone use for procedures in the first trimester (incident rate ratio, 9.02; 95% CI, 3.73-21.80) but not in the second trimester (incident rate ratio, 0.92; 95% CI, 0.23-3.70).Among women receiving IV sedation without tracheal intubation for surgical abortion, anesthesia complications are rare and may not be greater for obese women or procedures at gestational age ≥17 weeks. IV sedation without tracheal intubation may be considered for women undergoing first- and second-trimester surgical abortion; however, the rarity of anesthesia-related complications in our cohort precludes a definitive conclusion regarding the overall safety of IV sedation without tracheal intubation.

Purpose To examine the complications resulting from moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction and determine whether any differences in complication risks exist between the 2 levels of sedation. Materials and Methods We performed a prospective study of the Oral and Maxillofacial Surgery Outcomes System from January 2001 to December 2010. The primary predictor variable was the level of sedation, divided into 2 groups: moderate sedation versus deep sedation/general anesthesia. The primary outcome was the incidence of adverse complications resulting from the sedation level. Differences in the cohort characteristics were analyzed using the independent samples t test, χ 2 test, and analysis of variance, as appropriate. Multivariable logistic regression was used to measure the effect the level of sedation had on the adverse complication rate. Results Patients in the moderate sedation group had a complication rate of 0.5%, and patients in the deep sedation/general anesthesia group had a complication rate of 0.9%. Compared with moderate sedation, deep sedation/general anesthesia did not pose a significantly increased risk of adverse anesthesia complications (adjusted odds ratio 1.63, 95% confidence interval 0.95 to 2.81; P = .077). Conclusions The results of our study have shown that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction.

Purpose: The goal of this research was to evaluate the effectiveness of burr hole drainage under local anesthesia in geriatric patients with chronic subdural hematoma.Material and Methods: This retrospective study involved 21 geriatric patients with chronic subdural hematoma who applied to the department of neurosurgery in an education and research hospital between 2011 and 2014. Sedoanalgesia was performed on 21 patients, then awake burr hole drainage was performed after scalp and periosteal local anesthesia with bupivacaine HCI 5mg/ml (Marcaine %0,5enj. Astrazeneca). Cranial motor perforator was used for burr hole trepanation. Age, sex, trauma history, examination findings, site of the pathology, systemic disease, ASA risk, glasgow coma scale, modified rankin scale, mortality and morbidity were evaluated. Results: The youngest patient was 68-year-old, the oldest was 90-year-old. The average age was 72.9 years. Eleven of the cases were male and 10 were female. Head trauma was the etiology in 20 cases. 2 burr hole drainages were performed in 18 cases and 1 burr hole drainage was performed in 3 cases under local anesthesia. 3 cases were re-operated. No mortality was seen in the early post-operative period. Cases were kept in the intensive care unit for 1 day. The average hospital stay was 7 days.Conclusion: Surgical interventions under local anesthesia in geriatric patients with chronic subdural hematoma can provide short operation time, early mobilization, early oral intake, avoidance of possible general anesthesia complications. Herewith, this intervention decrease mortality and morbidity in this age group., Amaç: Bu araştırmanın amacı kronik subdural hematomu bulunan ileri yaş hastalarda lokal anestezi altında burr hole drenajın etkinliğini değerlendirmektir.Gereç ve Yöntem: Bu retrospektif çalışma 2011-2014 yılları arasında bir eğitim ve araştırma hastanesinin beyin cerrahisi kliniğinde kronik subdural hematom nedeniyle değerlendirilen 21 ileri yaşlı hastayı içermektedir. Sedoaneljezi 21 hastaya uygulandı. Sonrasında bupivacaine HCI 5mg/ml (Marcaine %0,5enj. Astrazeneca) ile yapılan scalp ve periostal lokal anesteziyi takiben hastalara uyanık burr hole drenaj uygulandı. Burr hole açılırken kranial motor perforatör kullanıldı. Yaş, cinsiyet, travma hikayesi, fizik muayene bulguları, patolojinin yeri, sistemik hastalık, ASA, glasgow koma skalası, modifiye rankin skalası, mortalite ve morbidite değerlendirildi.Bulgular: En genç hasta 68, en yaşlı hasta 90 yaşındaydı. Ortalama yaş 72.9’ du. 11 hasta erkek, 10 hasta bayandı. 20 hastada etyoloji kafa travmasıydı. 18 hastada 2 burr hole ile drenaj, 3 hastada tek burr hole ile drenaj lokal anestezi altında uygulandı. 3 olgu tekrar opere edildi. Erken postoperatif periyotta mortalite görülmedi. Olgular yoğun bakım ünitesinde 1 gün tutuldular. Ortalama hastanede kalma süresi 7 gündü.Sonuç: Kronik subdural hematomlu ileri yaş hastalarda lokal anestezi altında yapılan cerrahi girişim kısa operasyon zamanı, erken mobilizasyon, erken oral alım, genel anestezinin olası risklerinden kaçınmayı sağlar. Bu sebeple, yöntem bu yaş grubunda mortalite ve morbiditeyi azaltır.

Objective Holmium laser enucleation of the prostate (HoLEP) is an alternative to prostatic adenomectomy for the surgical treatment of benign prostatic hypertrophy. We analyzed our learning curve for this technique, and we compared it in a secondary manner with prostatic adenomectomy. Materials and methods A retrospective comparative study was conducted that included the first 100 cases of HoLEP performed in our center and the latest 50 cases of retropubic adenomectomy. We collected data on the patients, the surgery, the anesthesia, the perioperative variables, the anesthesia complications and the postoperative variables, with a 6-month follow-up. We analyzed the learning curve without mentors for HoLEP and compared the characteristics of HoLEP in 2 separate phases (learning and stabilization phases) with the latest retropubic prostatic adenomectomies performed. Results Intradural anesthesia was the most common technique. The transfusion needs, length of stay ( P P P P Conclusion In our center, HoLEP was introduced as a valid alternative to open retropubic adenomectomy, with excellent results in terms of morbidity and reduced hospital stay. In terms of the learning curve, we consider that approximately 50 patients (without mentor) is an appropriate cutoff. Local anesthesia is a good choice for the anesthesia technique.

Introduction: The uses of general anesthesia in outpatient invasive procedures have increased, especially in dermatology. Being uncooperative, children often require general anesthesia since surgical skin operations are mostly painful. Purpose: The aim of this study is to evaluate the safety, significant adverse events, and the complication rates related to general anesthesia when used among pediatric population underwent skin procedures. Methods: A retrospective cohort study of a patient chart review from the period (September 1, 2017, to September 2019). All patients admitted for pediatric skin procedures during this period have participated in our study. We reviewed selected charts to document any unexpected admissions, adverse events, or complications. Surgical outcomes and anesthesia complications were reviewed by three anesthesiologists. We assessed inter-rater reliability. Results: A total of 211 procedures were reported for 211 patients with 19 diagnoses. No adverse events related to anesthesia were recognized, apart from minor complications noticed in 12 patients. Kappa value ranges between 0.78 and 1.00 (95% confidence interval, 0.46809–1.00). Conclusion: Dermatologists and pediatricians can safely do necessary procedures under general anesthesia with the supervision of pediatric-trained anesthesiologists while considering other safety and risk precautions and pediatric age group.

Background: Multiple invasive procedures are routinely performed in diagnosis and treatment of hematologic/oncologic diseases. Because these procedures are painful, they may cause stress and anxiety in patients and their parents. Especially in patients with malignancies, the repeating procedures can lead to psychiatric disorders like depression and post-traumatic stress disorders. Therefore, general anesthesia is recommended during these invasive procedures for pain control. Objectives: The goal of this study was to evaluate safety and outcome of deep sedation with general anesthesia in hematology/oncology patients during invasive interventions in pediatric outpatient sedation unit. Methods: We retrospectively analyzed records of 129 patients (59 girls and 70 boys) who had undergone 155 invasive procedures with general anesthesia. Patient demographics, reason of operations, anesthesia complications, duration of procedures, and time for recovery from anesthesia were recorded from anesthesia charts. Patients received ketamine (maximum dosage 2 mg/kg) plus midazolam, ketamine plus midazolam plus sevoflurane inhaler (sevoflurane inhaler was added when 2 mg/kg of ketamine was inadequate to obtain deep sedation) and sevoflurane inhaler in 140, 10 and 5 of operations, respectively. Results: Complications occurred in 31 (20%) of these operations. Majority of complications were mild and included post-op agitation, vomiting and local pain which occurred in 6, 5 and 4 of the operations, respectively. Only 2 patients developed severe complications (fall off the stretcher and bronchospasm) which did not lead to any long term morbidity. The complication rate did not differ according to the anesthetic drugs, reason of operations or patient demographics. Conclusions: In this group of patients, deep sedation with general anesthesia in an outpatient sedation unit, administered by trained professionals, was safe, quick, and effective for short-term invasive painful procedures.

Background: Despite preventive strategies, hypotension is the most common complication of spinal anesthesia in cesarean section. Objectives: The aim of this study was to assess the effect of glucose-containing crystalloid infusion on maternal hemodynamic status after spinal anesthesia for cesarean section. Methods: In this prospective, randomized, double-blind clinical trial, 80 parturients undergoing elective cesarean section with spinal anesthesia were studied. In group A (n = 40) ringer with 1% glucose solution (10 gr glucose in 1000 mL ringer) and in group B (n = 40) only ringer solution infused before and after spinal anesthesia. Demographic data, hemodynamic change, complications and their treatments, maternal blood sugar level and neonatal APGAR (appearance, pulse, grimace, activity and respiration) score, intraoperative fluid, duration of surgery, and anesthesia were recorded in the two groups. Results: The incidence of hypotension in group A was significantly lower than group B (27.5% vs 75%) (P = 0.002). Other complications (sustained hypotension, nausea, pallor, and shivering were significantly lower in parturients of the group A (P < 0.05). Maternal blood sugar (BS), before and after surgery, was not significantly different in the two groups (P = 0.207 and P = 0.239, respectively). There was no statistically significant difference in the APGAR score of neonates at the 1st and 5th minutes of the birth between the two groups (P = 0.076). Conclusions: It seems that adding 1% glucose to crystalloid solution improves the hemodynamic status and decreases post-spinal anesthesia complications without significant changes in the maternal blood sugar level and APGAR score of neonates.

Pseudocholinesterase deficiency is a rare genetic as well as an acquired disorder that affects the body's ability to metabolize choline esters such as succinylcholine and mivacurium. It can be inherited as an autosomal recessive trait, occurring in approximately 1 in 3,200 to 1 in 5,000 people. In most cases of pseudocholinesterase deficiency, no signs or symptoms of the condition exist. It is first suspected after a prolonged recovery from paralysis following general anesthesia in which succinylcholine or mivacurium are administered. We emphasize the importance of obtaining a detailed history prior to any endoscopic intervention or surgery requiring monitored anesthesia care or general anesthesia. In addition, a family history of anesthesia complications may help identify patients at risk. This article examines a case of a patient who underwent a successful endoscopic pneumatic dilation under general anesthesia for the treatment of achalasia, but was subsequently admitted to the intensive care unit, requiring mechanical ventilator support, for 18 hours. The patient made a complete recovery and was discharged home with no further complications. This case stimulated a review of this entity and we provide recommendations relevant to all proceduralist and anesthesia staff, as well as all personnel involved in procedures.

Objective To determine the anesthesia cost from ultrasound-guided lumbar plexus and sciatic nerve blocks confirmed with electrostimulation for unilateral tibial plateau leveling osteotomy (TPLO) surgery in dogs. Study design Prospective, randomized, blinded clinical trial. Animals A group of 20 dogs weighing 33.9 ± 6.0 kg (mean ± standard deviation). Methods All dogs were administered hydromorphone and atropine, propofol for induction of anesthesia and isoflurane for maintenance. Hydromorphone and carprofen were administered for recovery. The dogs were randomly assigned to one of two groups, lumbar plexus and sciatic nerve blocks with ropivacaine [regional anesthesia (RA)] or sham blocks with saline [control (CON)]. Fentanyl was administered for rescue analgesia intraoperatively and postoperatively. The cost to manage anesthesia was divided into fixed and variable costs using the micro-costing method. The variable costs were compared using Student’s t test or Mann–Whitney U test. Results The fixed anesthesia costs were equal between groups at US$354.00 per case. The variable anesthesia cost range was US$27.90–100.10 for RA and US$21.00–180.50 for CON. Overall, cost per dog in CON was from –US$6.9 to US$80.4 compared with RA. For 160 TPLO cases per year, hospital cost when RA is performed decreased the cost by $12,864 per year up to increased cost by $1104 per year, depending on the requirements for systemic drugs and incidence/severity of anesthesia complications. The estimated fee charge per case for service necessary to reimburse the cost of a new ultrasound (US$25,000.00) and nerve locator (US$925.00) over their life span of 6 and 10 years, respectively, is US$26.62. Conclusions and clinical relevance Ultrasound-guided lumbar plexus and sciatic nerve blocks with electrostimulation confirmation can increase the anesthesia cost through use of specific equipment. However, in most cases, the anesthesia cost decreased as a result of decreased costs for pain management and treatment of complications.

Mucopolysaccharidoses (MPS) are rare, inherited, lysosomal storage diseases that cause accumulation of glycosaminoglycans, resulting in anatomic abnormalities and organ dysfunction that can increase the risk of anesthesia complications. We conducted a systematic review of the literature in order to describe the anesthetic management and perioperative outcomes in patients with MPS. We reviewed English-language literature search using an OVID-based search strategy of the following databases: 1) PubMed (1946-present), 2) Medline (1946-present), 3) EMBASE (1946-present), and 4) Web of Science (1946-present), using the following search terms: mucopolysaccharidosis, Hurler, Scheie, Sanfilippo, Morquio, Maroteaux, anesthesia, perioperative, intubation, respiratory insufficiency, and airway. The review of the literature revealed nine case series and 27 case reports. A substantial number of patients have facial and oral abnormalities posing various challenges for airway management, however, evolving new technologies that include videolaryngoscopy appears to substantially facilitate airway management in these patients. The only type of MPS that appears to have less difficulty with airway management are MPS III patients, as the primary site of glycosaminoglycan deposition is in the central nervous system. All other MPS types have facial and oral characteristics that increase the risk of airway management. To mitigate these risks, anesthesia should be conducted by experienced anesthesiologists with expertise in using of advanced airway intubating devices.

Patient awareness during general anesthesia and the later recall of what happened during surgery can be experienced by patients as horrifying events that leave lasting mental trauma in the form of posttraumatic stress syndrome (PTSS). Awareness is related to a temporary insufficient depth of anesthesia. This phenomenon has been discussed for more than 20 years. According to randomized controlled studies, in the absence of risk factors awareness phenomena occur in 1-2 per 1000 operations involving general anesthesia (0.1-0.2%) and are classified as occasionally occurring critical events. An astonishing twist occurred elicited by the recent data from the 5th National Audit Project from Great Britain (NAP5) published in the British Journal of Anaesthesia and in Anaesthesia. The NAP5 evaluated patient reports of accidental awareness during general anesthesia (AAGA) in a multicenter manner in more than 2.7 million cases and indicated incidences of awareness of only 1:19,600, a frequency 20 times less than previously reported. These results gave rise to some controversy. It seems likely that, due to the absence of structured interviews, the NAP5 data only demonstrated the tip of the iceberg and may have vastly underestimated the real incidence of intraoperative awareness. The present overview summarizes the current knowledge about awareness. Furthermore, it addresses the question whether the awareness problem has been overestimated by evidence-based criteria or underestimated by the results of the NAP5. The responsibility for sufficient anesthesia in the clinical routine requires knowledge of awareness risks and potential sequelae. A formal recommendation from the German Society of Anesthesia and Intensive Care Medicine (DGAI) concerning awareness is not yet available; however, the recognition of evidence-based strategies in the management of anesthesia may minimize the occurrence of awareness and its sequelae.

Nail procedures require an effective and reliable approach to anesthesia of the distal digit. Several techniques have been described in the literature. Herein, the relevant anatomy of the nail unit, pain pathways, anesthetic options, and several injection approaches to achieve complete anesthesia are reviewed. Also considered are the potential pitfalls and complications and their management. Ultimately, the physician's approach must be individualized to the patient, procedure, and setting.

Background: Advances in modern medicine and surgical technique have allowed patients with multiple comorbidities to undergo invasive surgery electively. This places additional stress on hospital resources to anticipate and deal with potential complications. We have introduced a preoperative safety concept called “Anesthesia Alert”. The surgeon or preoperative interviewing anesthesiologist assigns an Anesthesia Alert when booking to denote possible difficulty with anesthesia induction or intubation. As a result, two anesthesiologists and fiber optic equipment are made available on the day of surgery. Methods: A retrospective study of patients from all surgical specialties who were assigned Anesthesia Alerts between January 2012 and November 2012. Records were analyzed for reasons requiring Anesthesia Alerts. Patient demographics, comorbidities, and perioperative complications were reviewed. Results: A total of 112 patients formed this study group. Difficult airway comprised the majority of Anesthesia Alerts (n = 75, 67.0%). Hypertension was the most prevalent comorbidity among patients. There were only 7 patients (6.3%) admitted to the ICU postoperatively and no mortalities. Conclusion: Perioperative patient safety is an evolving concept that requires a team approach amongst the surgeon, anesthesiologist, and operating room staff. An Anesthesia Alert raises awareness for possible complications during anesthesia induction as well as allocates resources to increase patient safety and avoid preoperative delays. Most importantly, this concept places the onus on the surgeon to alert the anesthesiologist for possible complications during induction and extubation.

Objectives Phenylephrine, ephedrine and norepinephrine are the vasopressors most commonly used in the operating room to treat anaesthesia-induced hypotension. Two new diluted forms of phenylephrine were released in 2011 (500 μg/10 mL and 500 μg/5 mL). We initiated a study to evaluate trends in the use of vasopressors in the operating room in French hospitals over the period 2011–2014. Methods We conducted a longitudinal, retrospective, observational study between 2011 and 2014 in French teaching and military hospitals. A questionnaire was sent in February 2015 to hospital pharmacists of each centre to retrospectively collect the consumption of each type of vasopressor. Yearly numbers of vasopressor ampoules were divided by the yearly numbers of anaesthetics recorded. For each vasopressor, we calculated the number of ampoules per 100 anaesthetics recorded (/100A). Results Thirty-two hospitals (82%) completed the questionnaire. One hundred per cent of hospitals had registered the diluted form of phenylephrine (61% had chosen the dilution 500 μg/10 mL), whereas concentrated ampoules were available in 68% of hospitals. Over the period, an exponential increase in the use of diluted phenylephrine was observed (from 1.0 ampoule/100A in 2012 to 31.7 in 2014), the use of ephedrine remained stable (26 ampoules and 17 prefilled syringe/100A), and use of norepinephrine trended upwards (from 6.7 to 8.2 ampoules/100A). Conclusions The use of diluted phenylephrine has exponentially increased without reducing consumption of other vasopressors. This trend might be secondary to practice changes in hypotension treatment following the release of French guidelines in 2013 related to fluid management, the restriction of indications of hydroxylethyl-starch solutions in 2013, and a better knowledge of the benefit of blood pressure optimisation to reduce postoperative morbidity. © 2017 Academie Nationale de Pharmacie

Background Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED). Methods In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant. Results PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%). Conclusion The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible.

Background Past research has explored patients' expectations about the informed consent process. However, it is currently unknown if the complexity of the surgical procedure influences the type of anesthesia-related risks that patients wish disclosed. This study explored fears of anesthesia-related complications and whether these changed based on severity of surgery classification. Methods Patients presenting to our pre-operative evaluation clinic from February 2013 to May 2013 were asked to participate in a survey-based study meant to evaluate their perception of five possible anesthetic risks (peripheral nerve injury, death, nausea and vomiting, heart attack and stroke) when confronted with differing levels of surgical severity. Results One thousand surveys were administered, and 894 were returned for an overall response rate of 89%. Fear of death was the greatest concern as compared to the other risk factors independent of the severity of surgery. The level of fear for all risk factors, with the exception of stroke and heart attack, were dependent on the severity of surgery. Fear of death decreased as the severity of surgery decreased (major 46%, moderate 38%, minor 25%). For major surgery, the fear of perioperative death differed significantly with age (P

Background: Different treatment modalities and procedures have been tried for the management of infantile hypertrophic pyloric stenosis. But surgery remains the mainstay for management of IHPS. Ramstedt’s pyloromyotomy was described almost over a hundred years ago and to date remains the surgical technique of choice. An alternative and better technique is the double-Y pyloromyotomy, which offer better results for management of this common condition. Methods: A prospective comparative interventional study of 40 patients with IHPS was carried out over a period of 2 years from July 2008 to July 2010. The patients were divided into 2 equal groups of 20 patients in each. The study was designed that all patients selected for study were optimized preoperatively regarding to hydration, acid-base status and electrolytes imbalance. All surgeries were performed after obtaining informed consent. Standard preoperative preparation and postoperative feeding regimes were used. The patients were operated on an alternate basis, i.e., one patient by Double-Y Pyloromyotomy(DY) and the next by aRamstedt’s Pyloromyotomy (RP). Data on patient demographics, operative time, anesthesia complications, postoperative complications including vomiting and weight gain were collected. Patients were followed up for a period of 3 months postoperatively. Statistical assessments were done by using t test. Results: From July 2008 through July 2010, fourty patients were finally analyzed for this study. Any statistical differences were observed in patient population regarding age, sex, weight at presentation, symptoms and clinical condition including electrolytes imbalance and acid-base status were recorded. Significant differences were found in postoperative vomiting and weight gain. Data of post operative vomiting and weight gain in both groups were collected. Vomiting in double-Y(DY) pyloromyotomy group (1.21 ± 0.45days) vs Ramstedt’s pyloromyotomy (RP) group(3.03 ± 0.37days) p= 0.0001.Weight gain after 1st 10 days DY vs RP is ( 298 ± 57.94 gm vs193±19.8 gm p=0.0014), after 1 month (676.67±149.84 gm vs 466.67 ± 127.71 gm, p=0.0001), after 2months (741.33± 278.74 gm vs 490±80.62 gm, p=0.002) and after 3 months (582±36.01gm vs 453.33±51.64 gm, p=0.0001).No long-term complications were reported and no re-do yloromyotomy was needed. Conclusion: The double-Y pyloromyotomy seems to be a better technique for the surgical management of IHPS. It may offer a better functional outcome in term of postoperative vomiting and weight gain. DOI: http://dx.doi.org/10.3329/jpsb.v1i2.19532

Background: Many innovations and approaches have been tried for the surgical management of Infantile Hypertrophic Pyloric Stenosis (IHPS) since Ramstedt’s first successful surgery almost one hundred years ago. Here a new technique focusing on the pylorus which may offer better results for this common condition.Methods: A prospective on going study of 20 patients with IHPS are carried out over a period of 15 months from July 2008 to September 2009. The patients are divided into 2 equal groups of 10 patients in each. The study is designed that all patients selected for study are optimized preoperatively with regard to hydration, acid-base status and electrolytes imbalance. All surgeries are performed after obtaining informed consent. Standard preoperative preparation and postoperative feeding regimes are used. The patients are operated on an alternate basis, i.e., one patient by double-Y pyloromyotomy(DY) and the next by a Ramstedt’s pyloromyotomy(RP). Data on patient demographics, operative time, anesthesia complications, Postoperative complications including vomiting and weight gain are collected. Patients are followed up for a period of 3 months postoperatively. Statistical assessments are done by using Student test.Results: No statistical differences are observed in patient population regarding age, sex, weight at presentation, symptoms and clinical condition including electrolytes imbalance and acid-base status. Significant differences are found in postoperative vomiting and weight gain. Data of post operative vomiting and weight gain in both groups are collected. Vomiting in double- Y(DY) pyloromyotomy group (1.23 ± 0.98 days) vsRamstedt’s pyloromyotomy (RP) group(2.950.99 days) p= 0.0094.Weight gain after 1st 10 days DY vs RP is ( 298 ± 57.94 gm vs193±19.8 gm p=0.0014), after 1 month (685±15.72 gm vs 498 ± 12.36 gm, p=0.0008), after 2months (670± 105.93 gm vs 455±79.76 gm, p=0.00013) and after 3 months (555±86.44 gm vs 435±47.43 gm, p=0.00098).No long-term complications are reported and no re-do pyloromyotomy is needed.Conclusion: The double-Y pyloromyotomy seems to be a better technique for the surgical management of IHPS. It may offer a better functional outcome in term of postoperative vomiting and weight gain.DOI: http://dx.doi.org/10.3329/jpsb.v1i1.19449

Objective: This study investigated the maldistribution of concentrated 15% potassium chloride after injection into one-litre, flexible, Ringer’s lactate bags.Method: Twenty millilitres of concentrated 15% potassium chloride was injected into suspended, flexible, one-litre bags of Ringer’s lactate. The potassium was injected by hand, over either 4- (fast) or 20- (slow) second periods. The effect of two successive bag inversions on maldistribution was also investigated. A simulated infusion at 600 ml per hour was controlled using a volumetric pump. Sampling occurred at five-minute intervals for the first 20 minutes and at 10-minute intervals thereafter, until 90 minutes. Potassium concentrations were measured using an accurate, calibrated wide-range analyser that did not require specimen dilution. This experiment was repeated once. A duplicate set of experiments was performed with Bonney’s blue dye added to the potassium concentrate. Bonney’s blue distribution was evaluated visually.Results: Significant mal...

Study Objective To perform a qualitative analysis of noncardiac patients who developed suspected intraoperative supraventricular tachycardia (SVT) during general anesthesia. Design Retrospective database analysis and chart review. Setting Operating room of a university-affiliated children's hospital. Measurements The records of children without cardiac disease who received general anesthesia at The Children's Hospital of Philadelphia from July 1998 through June 2011 were reviewed. Patients with heart rate values above 180 beats per minute were identified, as were specific medications or key words in the free-text fields of the anesthesia records that would be indicative of a tachyarrhythmia. Each case was reviewed by at least two authors; each patient was assigned a diagnosis classification of "highly suspicious" or "unlikely" SVT. The highly suspicious SVT cases were examined in detail to determine the specific aims. Main Results 36 subjects out of a total of 285,353 anesthetics administered during the study period were suspected by the anesthesia care team to have had an episode of intraoperative SVT: 22 were "highly suspicious" events, and 14 were "unlikely" events. The highly suspicious SVT events occurred in all phases of anesthesia, and none led to any hemodynamic instability. Effective treatments included vagal maneuvers, pharmacologic antiarrhythmics, or no treatment if the event resolved spontaneously before treatment. Six patients had outpatient follow-up and three received antiarrhythmic medications to control ongoing SVT. Conclusions SVT during the intraoperative period in noncardiac pediatric patients was uncommon. When it occurred, it was not associated with clinically significant patient morbidity. For some patients, the anesthesia unmasked a predisposition for re-entrant SVT and those patients remained on maintenance antiarrhythmic therapy following discharge home.

Objective The aim was to evaluate the prevalence of postpartum complications, including depression, in new mothers who had juvenile idiopathic arthritis (JIA) and to assess whether these differ from mothers who never had JIA. Methods Our cohort study used data from physician billing and hospitalizations covering Quebec, Canada. We identified females with JIA with a first-time birth between 1 January 1983 and 31 December 2010 and assembled a control cohort of first-time mothers without JIA from the same administrative data, matching 4:1 for date of first birth, maternal age and area of residence. We compared the following postpartum complications: major puerperal infection, anaesthetic complications, postpartum haemorrhage, thromboembolism, obstetrical trauma, complications of obstetrical surgical wounds and maternal depression in the first year after delivery, in the JIA vs non-JIA groups, using bivariate analysis and multiple logistic regression. Results The mean age at delivery was 24.7 years in the JIA group (n = 1681) and 25.0 years for the non-JIA group (n = 6724). Mothers with JIA were more likely to experience complications attributable to anaesthetic [adjusted risk ratio (aRR) 2.17, 95% CI; 1.05, 4.48], postpartum haemorrhage (aRR = 2.75, 95% CI: 2.42, 3.11) and thromboembolism (aRR = 5.27, 95% CI: 1.83, 15.17) but were at lower risk for obstetrical trauma (aRR = 0.78, 95% CI: 0.64, 0.95) or newly to develop depression in the first year postpartum (aRR = 0.52, 95% CI: 0.40, 0.68). Conclusion Mothers with JIA appear to be at higher risk for complications attributable to anaesthesia, postpartum haemorrhage and thromboembolism. Prevention strategies for postpartum haemorrhage and thromboembolism may be especially important in this population.

Individuals with autism can be quite challenging to treat in a routine dental-office setting, especially when extensive dental treatment and disruptive behavioral issues exist. Individuals with autism may also be at higher risk for oral disease. Frequently, general anesthesia is the only method to facilitate completion of the needed dental treatment. General anesthesia is not without complications, and unique occurrences are a necessary consideration for special-needs populations. In addition, behavior challenges may occur which can be disruptive to hospital staff. This article describes treatment needs and determines adverse events during the perioperative period for individuals with autism who have had general anesthesia for comprehensive dental treatment in the hospital.

Anesthesia experiences outside of the operating room Introduction And Aim: Thanks to technological developments, invasive and non-invasive diagnostic and therapeutic procedures have been done at the outside of the operating room. In this manner, to provide anesthesia at the outside of the operating room, anesthesia teams have been found. In this study, we aimed to report our anesthesia teams’ experiences. Materials And Methods: We reviewed the procedures that was experienced at outside the operating room from October 2010 to April 2012 retrospectively. 3583 Patients who required anesthesia at the outside of the operating room included the study, and their sexes, ages, ASA status, procedures, and anesthesia complications were recorded. Results: Patients’ sex ratio male/female 1671/1912; ranged in age from 20 day to 91 years; with the mean age 48,52±28,4. ASA status were, ASA I 1958, ASA II 1296, ASA III 318, ASA IV 11. Anesthesia procedures were for 1837 colonoscopy, 536 gastroscopy, 131 ERCP endoscopic retrograde cholangiopancreatography, 811 MRI magnetic resonance imaging, 62 CTI computerized tomography imaging, 234 ECT electroconvulsive therapy, 106 RT radiotherapy, 40 angiographic aneurysm embolization, 9 angiographic venous sampling, 43 carotis stent, and 63 other radiologic interventions. For sedation; 1960 Patient received propofol + alfentanil, 740 only propofol, 544 propofol + fentanyl, 115 ketofol, 65 midazolam+ketamin 83 dexmedetomidine. For electroconvulsive therapies, 90 patient received etomidate + succinyl choline, 144 propofol + succinyl choline. 40 patient received general anesthesia for embolisation procedures. There are no major complication occured except one patient experienced intracranial hemorrhage during colonoscopy. In minor complications; 12 patient experienced respiratory depression, 41 bradycardia, 144 oxygen desaturaion, 191 prolonged recovery from anesthesia, 8 vomiting. Conclusion: Anesthesia procedures at the outside of the operating room are frequently used in all medical interventions and at all ages. Remote locations from operating room, inadequate equipment and monitors,not enough space in the working environment, providing anesthesia outside the operating room is challenging and requires expertise and skill. The secret of success in anesthesia in remote locations is the skilled anesthesiologist with the appropriate equipment and drugs, along with adequate backup facilities. Anesthesia procedures at the outside of the operating room are guarding the patients safety and welfare, minimising physical discomfort and pain, providing physicians’ comfort.

In an acute event, the diagnosis of malignant hyperthermia (MH) in patients in the ICU can be challenging. Initial presentation may be attributed to a gamut of causes, making the diagnosis complicated. This example is the case of a 46-year-old African American man who was admitted to the Stroke Service and intubated for respiratory distress. To facilitate intubation, he was given etomidate and succinylcholine. Within an hour, a sustained increase in arterial carbon dioxide concentration, rhabdomyolysis, and later on, hyperthermia, developed. He was started on broad-spectrum antibiotics, aggressive fluid hydration, and mechanical ventilation. He had had one previous uneventful anesthesia exposure and he denied having any family member having anesthesia complications. With a very convoluted presentation, a high degree of suspicion for MH warranted appropriate treatment to avoid significant morbidity and/or mortality. Moreover, until the diagnosis is confirmed, education regarding the disease process to patients and their family members is as vital as the treatment itself. The main objective of this case is to present a diagnostic dilemma in a probable MH patient who is in a state of shock in the ICU.

Objective Although commonly performed, pediatric tonsillectomy is not necessarily a low risk procedure due to potentially life threatening perioperative complications. There is paucity of literature on lethal anesthesia and surgical complications of tonsillectomy. In this article, we have reviewed both minor and serious complications following tonsillectomy. Hemorrhage, burn injuries, respiratory complications, postoperative nausea and vomiting, and pain management are discussed. We have highlighted our practice of pain management at Cincinnati Children's Hospital after tonsillectomy recent warning about codeine by the FDA on children undergoing tonsillectomy. We describe post-tonsillectomy outcomes including postanesthesia care unit stay, post discharge maladaptive behavioral outcomes and finally effective ways to identify children at risk for anesthesia and a few preventive strategies. Methods In addition to literature review, the LexisNexis “MEGA™ Jury Verdicts and Settlements” database was reviewed from 1984 through 2010 for deaths and complications during and following tonsillectomy. Data including year of case, cause of death, surgical, anesthetic and postoperative opioid related complications, injury, case result, and judgment awarded were collected and analyzed. Results The results of this analysis are presented with an emphasis on hemorrhage and on anesthesia and opioid related claims and their characteristics. Two hundred and thirty-three claim reports were reviewed. There were 96 deaths (41%) and 137 perioperative injuries (59%). Deaths were primarily related to surgery ( n = 46, 48%) with post-tonsillectomy bleed the most frequent cause ( n = 38, 40%) followed by opioid toxicity ( n = 17, 18%) and anesthesia complications ( n = 9, 9%). Non-fatal injuries included, postoperative bleeding ( n = 59, 25%), impaired function ( n = 29, 12%), anoxic events ( n = 20, 9%) and postoperative opioid toxicity ( n = 20, 8.6%). Anoxic event was noted to have the highest monetary award with a mean award at $9,017,379. Injuries (including anoxia) had higher mean monetary awards than deaths. Conclusion Tonsillectomy in children carries a high risk of perioperative complications and malpractice claims. Though postoperative bleeding is the most common complication associated with malpractice claims, anoxia related to anesthesia and opioids had the greatest overall risk from a monetary standpoint.

PURPOSE: Children with sleep apnea may be at increased risk for overnight respiratory events (ORE) following anesthesia. We sought to identify ORE risk factors in sleep apnea patients sedated for magnetic resonance imaging (MRI). METHODS: One thousand four hundred seven hospitalizations for children with sleep apnea (by ICD-9 code) occurred at our institution from 5/1/2011 to 2/1/2015. One hundred twenty-seven (9 %) encounters were solely for post-MRI observation representing 96 unique patients. The first post-MRI admission for each patient underwent chart review. ORE was defined as sustained oxygen saturation

Rocuronium for cesarean delivery under general anesthesia is an alternative to succinylcholine for rapid-sequence induction of anesthesia because of the availability of sugammadex for reversal of neuromuscular blockade. However, there are no large well-controlled studies in women undergoing general anesthesia for cesarean delivery. The aim of this noninferiority trial was to determine whether rocuronium and sugammadex confer benefit in time to tracheal intubation (primary outcome) and other neuromuscular blockade outcomes compared with succinylcholine, rocuronium, and neostigmine in women undergoing general anesthesia for cesarean delivery.We aimed to enroll all women undergoing general anesthesia for cesarean delivery in the 2 participating university hospitals (Brno, Olomouc, Czech Republic) in this single-blinded, randomized, controlled study. Women were randomly assigned to the ROC group (muscle relaxation induced with rocuronium 1 mg/kg and reversed with sugammadex 2-4 mg/kg) or the SUX group (succinylcholine 1 mg/kg for induction, rocuronium 0.3 mg/kg for maintenance, and neostigmine 0.03 mg/kg for reversal of the neuromuscular blockade). The interval from the end of propofol administration to tracheal intubation was the primary end point with a noninferiority margin of 20 seconds. We recorded intubating conditions (modified Viby-Mogensen score), neonatal outcome (Apgar score7; umbilical artery pH), anesthesia complications, and subjective patient complaints 24 hours after surgery.We enrolled 240 parturients. The mean time to tracheal intubation was 2.9 seconds longer in the ROC group (95% confidence interval, -5.3 to 11.2 seconds), noninferior compared with the SUX group. Absence of laryngoscopy resistance was greater in the ROC than in the SUX groups (ROC, 87.5%; SUX, 74.2%; P = 0.019), but there were no differences in vocal cord position (P = 0.45) or intubation response (P = 0.31) between groups. No statistically significant differences in incidence of anesthesia complications or in neonatal outcome were found (10-minute Apgar score7, P = 0.07; umbilical artery pH, P = 0.43). The incidence of postpartum myalgia was greater in the SUX group (ROC 0%; SUX 6.7%; P = 0.007). The incidence of subjective complaints was lower in the ROC group (ROC, 21.4%; SUX, 37.5%; P = 0.007).We conclude that rocuronium for rapid-sequence induction is noninferior for time to tracheal intubation and is accompanied by more frequent absence of laryngoscopy resistance and lower incidence of myalgia in comparison with succinylcholine for cesarean delivery under general anesthesia.

Anesthesia complications in the parturient can be divided into 2 categories: those related to airway manipulation and those related to neuraxial anesthesia. Physiologic changes of pregnancy can lead to challenging intubating conditions in a patient at risk of aspiration. Neuraxial techniques are used to provide analgesia for labor and anesthesia for surgical delivery. Therefore, complications associated with neuraxial techniques are often seen in this population. In the event of maternal cardiac arrest, modification to advanced cardiac life support algorithms must be made to accommodate the gravid uterus and to deliver the fetus if return of maternal circulation is not prompt.