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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.

In the United States, about 15 percent of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. While the exact causes of the increase in adverse outcomes are unknown, decades of research have shown that depression affects virtually all major systems in the human body. As a result, antidepressants are among the most frequently prescribed medications in the United States. The pharmacological action of most anti-depressants assumes that depression results from a deficiency of dopamine, norepinephrine, and serotonin or alterations in their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for hypotension, cardiac arrhythmias, acute hypertension, altered thermoregulation, and postoperative cognitive dysfunction. Given the increasing rate of MDD and antidepressant utilization, anesthesia providers and perioperative nurses must understand the pharmacological action of antidepressants to decide when to continue or hold antidepressants preoperatively and avoid potential drug interactions. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

Purpose To identify the effectiveness and feasibility of blindfold training on preventing pediatric psychological behavior disorders during the anesthesia recovery period. Design This study investigated the effect of blindfold training through the assessment of anxiety, delirium, and pain in children during the anesthesia recovery period. Methods This study was a prospective, randomized, controlled trial. Pediatric patients were randomized into either a control (routine practice) or blindfold training group (routine practice + blindfold training). Anxiety, delirium, and pain levels of children were assessed by the modified Yale Preoperative Anxiety Scale, Pediatric Anesthesia Emergence Delirium scale, and the Face, Legs, Activity, Cry, Consolability scale. Findings The blindfold training group had significantly lower scores for emergence delirium, anxiety, and pain during the anesthesia recovery period and a lower incidence of anesthesia complications (all P's Conclusions Preoperative blindfold training was able to reduce anxiety, pain, and the incidence of delirium during the anesthesia recovery period in pediatric patients.

Historically, patients who developed malignant hyperthermia had an extremely high rate of mortality. Today, if treated appropriately, patients who experience an episode of malignant hyperthermia will most likely survive. This dramatic decrease in mortality associated with malignant hyperthermia is due to several factors, including an increased understanding of the disease, improved diagnostic and monitoring equipment, and the development of lifesaving pharmacologic agents. This article presents the very likely case of acute malignant hyperthermia in a 24-year-old man with special needs, who presented for restorative dentistry under general anesthesia in the outpatient clinic of The Ohio State University's College of Dentistry.

International audience; Obstetric intensive care unit (ICU) admissions comprise only a small part of severe maternal morbidity. The incidence rate of both remains relatively unclear due to inconsistent definitions across publications, although this has begun to be addressed. There is a relative paucity of information regarding disease-specific survival following obstetric ICU admission, but outcomes are clearly related to the cause of admission and the quality of care. The ratio between maternal near-miss cases (many of whom are admitted to ICUs) and maternal death may provide insight into the preventability of death. Hemorrhage and pre-eclampsia constitute the leading causes of ICU admission and have relatively low mortality rates, perhaps demonstrating the impact of informed care in managing obstetric critical illness. Obstetric sepsis, heart disease and anesthesia complications should be the focus of future research. The incidence of obstetric sepsis has been increasing in the last decade, with mortality rates remaining relatively high. The incidence of obstetric heart disease is increasing and maternal complications have been attributed to fractionated care of mothers within this category. Anesthesia complications remain a predominant cause of maternal death and likely intensive care admission. Data are lacking regarding the relative proportion of cases per disease that remain treated outside the ICU; and the outcomes of various management strategies. The only study of the health status of survivors of obstetric ICU admission revealed that six months after hospital discharge, one in five women still had a poorer health-related quality of life than those of a reference age-and sex-matched cohort.

AIM To investigate the incidence of complications associated with cervical cerclage by indication. METHODS This was a retrospective cohort study of women with singleton pregnancies who underwent cervical cerclage in a single perinatal center between 2008 and 2019. The participants were divided into three groups according to indication: history-indicated cerclage (HIC) group, ultrasound-indicated cerclage (UIC) group, and physical examination-indicated cerclage (PEIC) group. The incidences of perioperative complications within 2 weeks after the procedure, including intraoperative rupture of membranes, intraoperative bleeding, anesthesia complications, clinical chorioamnionitis, premature rupture of membranes (PROM), preterm delivery, and displacement of the suture, and those of peripartum complications, including difficult suture removal and cervical laceration, for each group were compared using Fisher's exact test or Pearson's chi-square test. Factors associated with severe adverse event, defined as PROM or delivery within 2 weeks after the procedure, were analyzed using multivariate logistic regression analysis. RESULTS A total of 279 women (HIC, 38; UIC, 96; PEIC, 145) were enrolled. The incidence of perioperative complications was different among the three groups (7.9%, 10.4%, and 27.6%, respectively; p

Background Mismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia. Methods A 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated. Results During this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients. Conclusion Remote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

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 In 2011 a consensus statement from the British Association of Paediatric Urologists recommended lowering the age at orchidopexy to under 1 year. There are concerns that a younger age at operation may increase postoperative testicular atrophy. The ORCHESTRA study aimed to establish the current age at orchidopexy in a multicentre, international audit and to see whether testicular atrophy was affected by age at operation. Methods The study was undertaken over a 3-month period in 28 centres in boys undergoing orchidopexy for unilateral, palpable undescended testes. Data collection was done using a standardized, predetermined protocol. The primary outcome was postoperative testicular atrophy. Secondary outcomes were wound infections, reoperations, and unplanned hospital stays related to anaesthetic events. Results A total of 417 patients were included, of whom only 48 (11.5 per cent) underwent orchidopexy before 1 year of age. There was no difference in anaesthetic complications in boys aged less than 1 year versus older patients: 0 of 48 (0 per cent) versus 6 of 369 (1.6 per cent) (P = 0.999). Complete follow-up was available for 331 patients (79.4 per cent). There was no difference in atrophy rate between those aged less than 1 year and older boys: 1 of 37 (3 per cent) versus 9 of 294 (3.1 per cent) (P = 0.999). Reoperation rates were 0 of 37 (0 per cent) and 7 of 294 (2.4 per cent) respectively (P = 1.000). There were more wound infections in boys under 1 year of age: 4 of 37 (11 per cent) versus 7 of 294 (2.4 per cent) (P = 0.025). Conclusion Only 11.5 per cent of boys underwent surgery before the age of 1 year. There was no increased risk of postoperative testicular atrophy with early surgery, although there was a higher rate of wound infection. Further study is required to demonstrate that early orchidopexy is not inferior to orchidopexy undertaken in boys aged over 1 year., Prospective, international study of effect of age at orchidopexy on post operative testicular atrophy. Only 11.5% boys received surgery at age

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).

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.

Background This study investigated surgery-related medical disputes and analyzed disease etiologies and the main causes of disputes in order to identify key points for the purpose of improving the quality of surgical patient care in Taiwan. Methods Reports on all surgery-related cases appraised by the Taiwan Witness Examiner Committee of the Department of Health between 2004 and 2008 were reviewed retrospectively by three senior physicians from the emergency department who specialize in both trauma and emergency general surgery. The causes of the various medical disputes were categorized under the following descriptions: operation- or procedure-related complication, anesthesia complication, inappropriate management or decision, delayed diagnosis or misdiagnosis, and unsatisfactory result. Results A total of 154 cases were reviewed, of which 39 were trauma-related and 115 were disease-related. The two leading causes of disputes in this review were found to be operation- or procedure-related complications (35.7%) and unsatisfactory results (31.8%), followed by delayed diagnoses or misdiagnoses, inappropriate management, and anesthesia complications. Among these, 74 cases (48.1%) required the care of an acute care surgeon and 40 cases (26.0%) required emergency general surgery intervention. Conclusion Surgery- or procedure-related complications and unsatisfactory treatment results constituted the major causes of medical disputes in Taiwan. The majority of these cases involved acute care surgery; thus, the establishment of an acute care surgery system should be considered to improve patient care. The management of hemorrhagic shock and incarcerated hernia should be reinforced in future medical training.

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.

Background Nongovernmental organizations conduct short-term surgical outreach to lessen the substantial global burden of surgical disease. Long-term outcomes of short-term surgical missions (STSMs) are underreported, raising concern for clinical sequelae and patient satisfaction with essential general surgeries. This study aims to describe long-term follow-up results of one general surgical nongovernmental organization's provision of care in rural Ghana with focus on patient-related outcomes and satisfaction. Methods From 2013 to 2018, Tetteh Quarshie Memorial Hospital in Mampong, Ghana, was the host site of annual 1-wk International Surgical Health Initiative (ISHI) STSMs. Beginning in 2016, an ISHI provider-hosted follow-up clinics augmented by mobile telephone support. Surgical patients from 2013 to 2016 were contacted by the local nursing staff and evaluated for long-term outcomes and self-reported satisfaction. Results Sixty-nine of 256 patients (27%) responded; 39 patients (57%) were interviewed and examined by an ISHI physician, whereas 30 patients (43%) received mobile telephone follow-up. Mean age was 47 (±18) y, with 44% female patients, and mean duration of follow-up was 1.5 (±1) y. Eleven patients (16%) had surgical and anesthesia complications. All patients reported improvement in symptoms and activity level. Eighty-six patients reported complete satisfaction (5/5). Factors associated with reduced patient satisfaction ( Conclusions To our knowledge, this is one of the first studies focusing on patient-reported outcomes for the evaluation of long-term follow-up of general surgery STSMs. With mobile technology, long-term follow-up is achievable toward obtaining meaningful outcomes. Complications in this series are within an acceptable range, whereas symptom improvement and overall satisfaction are high.

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

Patient perception of adverse events (AEs) after pelvic floor disorder surgery is incompletely understood and may differ from providers’ views of AEs. Our objective is to describe patient perceptions of AEs related to pelvic floor disorder surgery and how perceptions change over time. Mixed-method study of longitudinal patient interviews and surveys. Women planning pelvic floor disorder surgery completed three one-on-one interviews: preoperatively (< 12 weeks before surgery), 6–8 weeks postoperatively, and 6 months postoperatively. Interviews explored the patient experience of surgery and their perception of AEs over time. Participants ranked self-identified AEs by severity. De-identified transcripts of audio recordings were coded and analyzed using an iterative, thematic, team-based process using NVivo software (QSR International). Twenty women each completed three separate interviews for a total of 60 interviews. Their mean age was 55.3 (± 12.7) years, and 50% were Non-Hispanic white. Women’s perceptions of AEs changed as more time passed from surgery. Women identified potential problems related to surgery such as anesthesia complications, pain, injury, catheter issues, and an unsuccessful surgery as the most concerning AEs preoperatively. Postoperatively (6–8 weeks), women expressed concern about functional outcomes (e.g., performing daily activities, symptom reduction). Late postoperatively (6 months), the majority identified unsuccessful surgery, incontinence, and sexual dysfunction as severe AEs. These findings are consistent with prior work that suggests women perceive functional outcomes as fundamental to their recovery. These findings contribute to a more nuanced understanding of patient-centered perspectives on AEs. Patients view poor functional outcomes as severe AEs.

Background An operative biopsy is an important component in the diagnosis and treatment of neuromuscular disorders (NMDs). However, recent advances in molecular genetics suggest less invasive genetic testing should be the initial approach. The purpose of our study was to demonstrate the diagnostic value of muscle or nerve biopsy within the pediatric population at a pediatric academic center and offer recommendations for genetic testing in relation to biopsy to achieve the highest diagnostic yield. Methods Following institutional review board approval, we retrospectively reviewed the electronic medical record of 221 pediatric patients who underwent muscle and/or nerve biopsy for suspicion of NMD from January 2007 to March 2018. Demographics, family history, clinical presentations, genetic testing results, pathology results, anesthesia complications, clinical diagnoses, and clinic follow-up data were collected. Chi-square analysis was done for statistical significance. Results A total of 220 underwent muscle biopsy, and 15 underwent nerve biopsy. Not all patients received genetic testing. The average age at biopsy was 7.7 y. Biopsy revealed significant histologic abnormalities in 62.9% (139), directly leading to a specific clinical diagnosis in 33.9% (75). When genetic testing was done before biopsy, definite pathogenic variants were found in 7.6% (9). When genetic testing was done after biopsy, definite pathogenic variants were found in 45.0% (27). Genetic testing yield for pathogenic variants was higher when done after biopsy (P value Conclusions Muscle and nerve biopsies may provide significant diagnostic value. Biopsy helped to rule in or out NMD and guide genetic testing. Our data suggest NMD genetic testing yield was higher when done after biopsy.

INTRODUCTION Charges, procedural efficiency, return to activity, and complications after closed treatment of fractures performed in an operating room (OR) versus closed reduction in a dedicated fracture reduction room (FRR) were compared. METHODS Patients with closed fractures of the forearm who underwent closed reduction in the year before (OR), and after implementation of the FRR, were retrospectively reviewed. Charges, American Society of Anesthesiologists class, sex, age, length of follow-up, prior reduction, fracture location/displacement, time from injury to procedure, procedural time, time to return to activity, and complications were recorded. RESULTS Eighteen patients met the inclusion criteria in the FRR group (13 men, 5 women), and 22 in the OR group (18 men, 4 women). No notable differences in age, sex, follow-up, American Society of Anesthesiologists class, fracture location/displacement, incidence of prior reduction, or time to return to activity were observed. Two (9.5%) complications occurred in the FRR group versus 7 (32%) in the OR group, P > 0.05. No anesthesia complications were present. Patients treated in the FRR incurred charges of $5,299 ± $1,289 versus $10,455 ± $2,290 in the OR, P < 0.001. Total time of visit in the FRR was ∼30% less than the OR, P < 0.001. No notable delay in treatment was observed. DISCUSSION In the era of finite resources and value-based care, implementation of a FRR resulted in safe, cost-effective, and increased procedural efficiency.

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.

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 factors associated with severe maternal morbidity in a modern cohort of women laboring at term and to create a prediction model. Study Design This is a retrospective cohort study of all term, laboring patients with live births at a single tertiary care center from 2004 to 2014. The primary outcome was composite maternal morbidity including organ failure, amniotic fluid embolism, anesthesia complications, sepsis, shock, thrombotic events, transfusion, or hysterectomy. Multivariable logistic regression was used to identify independent risk factors. Antepartum, intrapartum, and combined risk scores were created and test characteristics were analyzed. Results Among 19,249 women delivering during the study period, 323 (1.68%) patients experienced severe morbidity, with blood transfusion the most common complication (286, 1.49%). Factors in the antepartum model included advanced maternal age, race, hypertension, nulliparity, history of cesarean delivery, smoking, and unfavorable Bishop score. Intrapartum factors included mode of delivery, use of cervical ripening agents or oxytocin, prolonged second stage, and macrosomia. The combined model had an area under the curve of 0.76 (95% confidence interval [CI], 0.73, 0.79). Conclusion This three-part risk scoring system can help clinicians counsel patients and guide clinical decision making for anticipating severe maternal morbidity and necessary resources.

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.

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.

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.

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.

Study Objective To estimate the Trendelenburg angle needed to perform robotic gynecologic surgical procedures. Design Cross-sectional study (Canadian Task Force classification III). Setting Community hospital. Patients All women undergoing gynecologic pelvic surgery using the da Vinci surgical robot at a single institution between December 2010 and April 2011. Interventions The primary surgeon determined the Trendelenburg angle needed for adequate visualization to perform surgery defined as small bowel and sigmoid colon displaced out of the surgical field. Measurements and Main Results The primary outcome, measured in blinded fashion, was the degree of Trendelenburg positioning needed to complete the surgical procedure robotically. Secondary data collected included body mass index, type of surgery performed, maximum end-tidal CO 2 , and maximum peak inspiratory pressure. Sixteen surgeons performed a total of 104 robotic gynecologic pelvic surgeries during the study. Data were available for 86 cases. The mean Trendelenburg angle used was 28.0 degrees (95% confidence interval, 26.9–29.1). This was significantly less than the 40 degrees (p r = −0.2; p=.13) or type of surgery performed (p = .41). Neither the maximum end-tidal CO 2 or maximum peak inspiratory pressure was influenced by the Trendelenburg angle used when adjusted for age and body mass index. Conclusions A mean Trendelenburg angle of 28.0 degrees was adequate to complete most gynecologic robotic surgical procedures when compared with historical control angle of 40 degrees.

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.

Kenneth Boockvar, MD, MS Older adults are frequent candidates for surgery, yet information on the risks and benefits from surgical procedures and anesthesia in this population is limited. Such information is critical to making informed decisions, and older patients often face high risks whether opting for surgery (ie, from complications of the procedure and anesthesia) or not (ie, from complications of the underlying condition). In particular, frail older adults, who have less physiologic reserve and reduced life expectancy, should receive surgical and perioperative care that adheres to the following core geriatrics principles: (1) lowering initial treatment intensity to minimize harm; (2) ascertaining all care outcomes that may be important, including function and quality of life; and (3) tailoring treatments to the patient’s goals, especially when there may be tradeoffs (eg, length versus quality of life). Some recent advances have produced surgical and anesthesia approaches that are concordant with these geriatrics principles. First, the advance of noninvasive surgical techniques has increasingly made surgical approaches possible in older adults with serious conditions who in the past could not have undergone invasive procedures (eg, transcatheter aortic valve replacement). Second, attention is growing to surgical and anesthesia complications that are particularly common and dangerous in older adults such as delirium and cognitive loss. Third, recognition has increased among surgeons and anesthesiologists of the importance of frailty as a predictive factor, which may help patients and providers identify tradeoffs and tailor decision making. Fourth, there is consensus that managing older patients medically before, during, and after surgery is important to attaining ideal surgical outcomes. This is because the most common complications of surgery in older adults are not surgical-site problems but medical conditions such as thromboembolism, exacerbations of chronic heart and lung diseases, delirium, falls, and function decline from prolonged immobility. This finding has led to health services and quality improvement efforts to ensure uniform delivery of recommended nonsurgical care to older adults before, during, and after surgery, sometimes via medical (or geriatrics) co-management, standardized physician orders, and rehabilitation after hospitalization. These approaches have been implemented successfully with improved outcomes in older patients undergoing hip fracture repair and other orthopedic procedures. More needs to be done to align anesthesia and surgical care with geriatrics principles. Over the past 2 years only 3 articles were been published in this journal about anesthetic agents, and none focused on older adults, suggesting limited pharmaceutical development this area. Yet the potential is significant to improve perioperative care of older adults in the absence of new agents. In this Geriatrics Special Issue we bring together review articles, a case report, and original research articles written by anesthesiologist leaders who are advancing perioperative care of older adults. Two articles in this issue address preoperative identification of patients at high risk of

Background Most case reports of pregnancies after surgical repair of tetralogy of Fallot have focused on cardiovascular and obstetric concerns, with relatively few authors focusing on specific intrapartum and postpartum anesthetic management strategies. Methods The Mayo Clinic Congenital Heart Disease Clinic and the Boston Adult Congenital Heart Disease Service databases were cross-referenced with the Mayo Clinic and the Brigham and Women's Hospital Department of Anesthesiology databases to identify patients with tetralogy of Fallot who delivered at their respective hospital from January 1, 1994, to January 1, 2008. We reviewed each medical record to evaluate parturient care during pregnancy, labor, and delivery with a focus on anesthetic management. Results During the 14-year study period, a total of 27 deliveries in 20 patients with repaired tetralogy of Fallot were identified. Twenty-one deliveries (78%) among 15 parturients (75%) involved a trial of labor; all parturients received neuraxial analgesia for labor and delivery, including 18 (86%) epidural, 2 (10%) combined spinal-epidural, and 1 (5%) continuous spinal anesthetic after an unintended dural puncture. Of the 21 patients undergoing labor, 3 (14%) received invasive arterial blood pressure monitoring; 5 (24%) received continuous telemetry; 3 (14%) experienced congestive heart failure that required diuresis; 4 (19%) had obstetric or neonatal complications; and 3 (14%) had anesthesia complications. Cesarean delivery was required in 4 patients (19%) because of labor complications. Concurrent cardiovascular, obstetric, and anesthetic complications in 1 patient resulted in neonatal death. Six (22%) parturients underwent elective cesarean delivery; 4 received epidural and 2 received spinal anesthesia; no anesthetic or immediate obstetric complications occurred. Among all parturients, 5 deliveries in 5 separate parturients (19% of deliveries) reported symptoms of congestive heart failure at the time of delivery. Conclusions Pregnancy outcomes for patients with repaired tetralogy of Fallot were found to be generally favorable. All patients undergoing a trial of labor or cesarean delivery had neuraxial analgesia or anesthesia. Recognition and management of congestive heart failure was necessary in 19% of deliveries.

Objectives: We compared the effects of levobupivacaine hydrochloride, bupivacaine hydrochloride, and saline injections in alleviating posttonsillectomy pain. Methods: Between November 2009 and April 2010, we recruited 60 patients (36 male and 24 female) between 2 and 12 years of age into the study. After informed consent was obtained from the parents, patients admitted for tonsillectomy were randomized into 3 groups by means of sealed envelopes. Group 1 (20 patients; mean age, 6.45 ± 2.78 years) received 0.9% sodium chloride (saline solution), group 2 (20 patients; mean age, 5.60 ± 2.70 years) received 0.25% levobupivacaine hydrochloride, and group 3 (20 patients; mean age, 5.85 ± 2.43 years) received 0.5% bupivacaine hydrochloride infiltrated around each tonsil. Pain was evaluated with McGrath's face scale. Results: The postoperative pain scores at 1 and 5 hours were similar among the groups (p > 0.05). The pain scores in the levobupivacaine group were lower than those in the saline group at 13 hours (p < 0.017). The pain scores in the bupivacaine and levobupivacaine groups were significantly lower than those in the saline group from 17 to 21 hours until day 6 (p > 0.017). There was no difference between the levobupivacaine and bupivacaine groups (p > 0.017). Conclusions: Local infiltration of levobupivacaine is a relatively safe and effective method and is equivalent to use of bupivacaine for posttonsillectomy pain.

Airway management is a key competency for every anesthesiologist. In 1990, Caplan et al. reported that 34% of anesthesia-related claims were related to airway management. Since that time, several national airway management guidelines have been published with the aim to establish and promote safer airway management practice. Since the publication of those guidelines, studies have shown a decrease in anesthesia complications related to airway management. Of course, it is not possible to determine causality, and there have been other significant changes in practice over this time, e.g., supraglottic airways are now used in more than half the patients in the United Kingdom (UK). Unfortunately, despite these advances in both protocols and technology, airway complications in anesthesia still occur, and they are often associated with severe complications, i.e., brain damage or death. Herein, we consider the contents of future airway management guidelines that might create a further impact on patient safety, while bearing in mind the known problematic adherence to airway management guidelines, the role of medical education, and the rapid evolution of new airway management technology and skills. When we consider the history of major developments in airway management, we observe a recent acceleration of the development of technology and skills in this area. The Macintosh and Miller blades, designed in the 1940s when curare was introduced into anesthesia, are still in common use. Major incremental steps in airway management occurred with the development of fibreoptic intubation in the early 1970s, and again in the 1980s, with the invention of the laryngeal mask airway (LMA) and the rigid fibreoptic laryngoscopes (e.g., Bullard). Other major advances were made in the 1990s with the intubating laryngeal mask airway (ILMA), devices for transillumination (e.g., Trachlight), and videolaryngoscopy. During the last decade, anesthesiologists have used combinations of these new techniques to produce even further airway management possibilities, e.g., the combination of the LMA or the ILMA with fibreoptic bronchoscopy. The recent availability of sugammadex may change airway management practice and should be considered in new airway management guidelines. In addition to these ‘‘quantum leaps’’, there has also been a rapid increase in the number of new versions of very similar airway management devices, in part because of the ‘‘me too device’’ phenomenon. This increase in technology provides both advantages and disadvantages to anesthesiologists. Although we have more options for managing difficult intubation, it can be difficult to know the appropriate airway tool to use for a given purpose, especially considering the logistic challenges of conducting controlled trials on patients with difficult airways. A key tension for future guidelines is to reconcile the increasing number of new airway management options with Attributable to: Department of Anesthesiology, St. Michael’s Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada.

Objective In developed countries, the societies of anesthesiologists have published reports of anesthesia quality. However, there are still no publications on anesthesia quality in Taiwan, even though the Taiwan Society of Anesthesiologists (TSA) was founded in 1956. This study was designed to evaluate the quality of anesthesia in Taiwan using databases maintained by the TSA and the Bureau of National Health Insurance-Taiwan (BNHI-T). Methods The TSA published annual reports in 1995–1998 and 2002–2008 (with a 3-year interval), which included a survey on anesthesia-related mortality and morbidity, the manpower and composition of anesthesia teams, and the causes of anesthesia-related complications. Since 2002, the BNHI-T has collaborated with the National Health Research Institute-Taiwan to establish a database of health care service. To understand anesthesia quality in Taiwan, we collected data from the annual TSA surveys and the BNHI-T, and analyzed trends in anesthesia-related mortality, causes of anesthesia complications, and relative manpower composition. Results The rate of anesthesia-related mortality was 11.9 deaths/100,000 cases. More than 50% of all anesthesia-related complications were preventable. About 1500 anesthetic procedures were performed annually by each anesthesiologist in Taiwan. The ratio of anesthesiologists to nurse anesthetists was 1:3–5. Conclusion Anesthesia-related mortality was about 10-fold higher in Taiwan than in the United States, Japan and the United Kingdom. Mortality related to quality of anesthesia in Taiwan must be reduced. To achieve this target, we have recommended the following six approaches: (1) decrease the workload of anesthesiologists; (2) increase reimbursement by the BNHI-T for anesthesia; (3) improve the training quality of anesthetist residents; (4) strengthen the quality of board examinations; (5) improve the training quality of nurse anesthetists; and (6) standardize monitoring procedures and equipment. Only once these measures are introduced, in combination with effective quality assurance and subjective improvement systems, can we expect an improvement in the quality of anesthesia in Taiwan.

Summary Background and objective: Different clinical and surgical factors can influence the occurrence of anesthesiologic complications in pediatric neurosurgery. Preoperative knowledge of these factors is of great importance in the application of safe anesthetics and a favorable surgical outcome. The objective was to establish the importance of clinical and surgical risk factors on the frequency of anesthesia complications in pediatric neurosurgery. Data and method: The research, from 1996 to 2000, involved 705 children, aged from 240 min, who were in the sitting position and when comorbidity was evident. Neither age nor the urgency of the operation or reoperation had any significant influence on the occurrence of anesthetic complications. Conclusion: The duration of anesthesia, the sitting position of the patient, and the presence of comorbidities significantly increase the risk of anesthesia complications in pediatric neurosurgery.

It is common for international organizations to provide surgical corrective care to vulnerable populations in developing countries. However, a current worsening of the overall surgical burden of disease in developing countries reflects an increasing lack of sufficient numbers of trained healthcare personnel, and renders outside volunteer assistance more desirable and crucial than ever. Unfortunately, program evaluation and monitoring, including outcome indices and measures of effectiveness, is not measured commonly. In 2005, Operation Smile International implemented an electronic medical record system that helps monitor a number of critical indices during surgical missions that are essential for quality assurance reviews. This record system also provided an opportunity to retrospectively evaluate cases from previous missions. Review of data sets from >8,000 cases in 2005 and 2006 has provided crucial information regarding the priority of surgery, perioperative and operative complications, and surgical program development.The most common procedure provided was unilateral cleft lip repair, followed closely by cleft palate. A majority of these interventions occurred for patients who were older than routinely provided for in the western world. The average child treated had an age:weight ratio at or below the [US] Centers for Disease Control and Prevention (CDC) 50th percentile, with a small percentage falling below the CDC 20th percentile. A majority of children had acceptable levels of hemoglobin, but the relative decreased age:weight ratio nonetheless can reflect mild malnutrition. Complications requiring medical intervention were seen in 1.2% of cases in 2005 and 1.0% in 2006. Thirty percent were reported as anesthesia complications, and 61% reported as surgical complications. One death was reported, but occurred after discharge outside the perioperative period. Complication rates are similar to rates reported in the US and UK and emphasizes the importance of standardization with uniform indices to compare quality performance and equity of care. This study offers an important example of the importance of collecting, analyzing, and reporting measures of effectiveness in all surgical settings.

Summary Introduction: Mastocytosis is a rare heterogeneous disease of bone marrow origin which arises as a consequence of abnormal growth and/or accumulation of clonal mast cells in one or more organs. Sixty-five percent of patients with mastocytosis are children in whom it usually regresses around puberty. Adult patients with mastocytosis have been identified as at high risk of widespread mast cell degranulation in the perioperative period, this finding has not been reported in pediatric patients. This information has been repeated in mastocytosis websites where it has the potential to cause disproportionate alarm in parents. Methods: We considered our experience of six children with mastocytosis together with a review of the literature to examine other reports of anesthesia in children with mastocytosis. Our literature search found 57 general anesthetics in 39 children with mastocytosis. In addition, we searched for information about current consensus in diagnosis, classification and treatment of mastocytosis and in vitro and in vivo studies looking at mast cell behavior in response to drugs commonly used during anesthesia. Discussion: The literature search revealed that general anesthesia has precipitated life threatening complications in adult patients with systemic mastocytosis (SM) but no such complications have been described in children with mastocytosis. Our own experience with children with mastocytosis is of uneventful anesthesia. Advances in the understanding of the genetic basis of mastocytosis suggest that pediatric cutaneous mastocytosis (CM) and SM are different entities. SM in children is extremely rare and is associated with elevated baseline serum tryptase. There are few reports of anesthesia in this group. Conclusion: The risks for most pediatric patients are overstated by mastocytosis websites. Most pediatric patients with CM do not appear to be at risk of widespread mast cell degranulation during anesthesia but because of the small number of cases reported, the risk cannot be ascertained with confidence. Children with SM and a high baseline serum tryptase (marker of mast cell burden) may merit extra precautions but experience in this subgroup is even more limited. Drugs which cause minimal histamine release can be selected from the range of drugs available in most pediatric centers without compromise to technique.

This article highlights the common and some of the very serious complications that may occur following neuraxial analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture.

Background: Obstetrical anesthesia services may be provided by Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, or a combination of the two providers. Research is needed to assist hospitals and anesthesia groups in making cost-effective staffing choices. Objectives: To identify differences in the rates of anesthetic complications in hospitals whose obstetrical anesthesia is provided solely by CRNAs compared to hospitals with only anesthesiologists. Methods: Washington State hospital discharge data were obtained from 1993 to 2004 for all cesarean sections, and were merged with a survey of hospital obstetrical anesthesia staffing. Anesthetic complications were identified via International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Resulting rates were risk-adjusted using regression analysis. Results: Hospitals with CRNA-only staffing had a lower rate of anesthetic complications than those with anesthesiologist staffing (0.58% vs. 0.76%, p = .0006). However, after regression analysis, this difference was not significant (odds ratio for CRNA vs. anesthesiologist complications: 1.046 to 1, 95% confidence interval 0.649 1.658, p = .85). Discussion: There is no difference in rates of complications between the two types of staffing models. As a result, hospitals and anesthesiology groups may safely examine other variables, such as provider availability and costs, when staffing for obstetrical anesthesia. Further study is needed to validate the use of ICD-9-CM codes for anesthesia complications as an indicator of quality.

Purpose Complications of anesthesia for pediatric radiation therapy are imperative for both radiation oncologists and anesthesiologists to clinically assess and manage. We performed the first systematic review to date addressing this important issue. Methods A systematic search of PubMed and EMBASE was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were not restricted based on publication date. Nine original investigations were identified, analyzed, and collated for this report. Results General anesthesia has proven superior to conscious sedation with regard to maintaining satisfactory procedural sedation while maintaining low respiratory and cardiovascular complication rates. Although agents such as ketamine (complication rates approaching 23%-24%) have been used in the past, other agents such as propofol and volatile anesthetics have lower complication rates because of improved drug side effect profiles (0.01%-3.5%). Most common complications are respiratory-based (eg, airway obstruction, broncho/laryngospasm, desaturation, apnea), followed by those that are cardiovascular-based (eg, tachy/bradycardia, arrhythmias, hypotension) and nausea/vomiting. Though procedure duration and anesthetic dose can be associated with higher complication risks, prior or concurrent chemotherapy does not confer added risks other than neutropenia-related sepsis. Other potential complications include those with vascular access devices, observed in up to 20% to 25%, with peripherally inserted central catheters having the highest rates of vascular complications and port catheters the lowest. Conclusions Rates of anesthetic complications encountered in pediatric radiation therapy are similar, if not lower, than rates reported in controlled operating room settings, implying that anesthesia for pediatric radiation therapy is safe, with low complication rates periprocedurally. Propofol infusion and oxygen delivery via nasal cannula offer the lowest immediate anesthetic complication rates and are hence most recommended for use. Though the long-term neurocognitive consequences of multiple anesthetics in pediatric patients have yet to be clearly defined, health care providers should be cognizant of the potentially serious implications.

Background: Diaphragmatic rupture is an uncommon condition, with 90% of ruptures occurring on the left side. However, its incidence on the right side is increasing along with the increase in traffic accidents. Liver herniation may become progressive causing severe atelectasis of the right lung, resulting in impaired respiratory status and hemodynamic changes. Case report: We report the case of a 40 years old female, ASA III, scheduled for hepatothorax repair that evolved from right diaphragmatic hernia after a car accident when she was 8 years old. Clinically, she had severe restrictive respiratory syndrome caused by the hepatothorax. The anesthetic evaluation was normal, except for the chest X-ray showing elevation of the dome of the right hemidiaphragm without tracheal deviation. Diagnosis was confirmed by CT scan. After liver replacement in the abdominal cavity, a transient increase in central venous pressure, stroke volume index and flow time corrected (35%), and a decrease in systemic vascular resistance were observed. After complete hemodynamic and hepatosplenic stabilization, as well as ventilation, the patient was transferred intubated, under controlled ventilation and monitored, to the liver transplant unit. Conclusions: Hepatothorax is a rare condition and its repair may represent an anesthetic challenge. After liver replacement in the abdominal cavity during corrective surgery under general anesthesia complications may occur, particularly associated with pulmonary re-expansion. Effective teamwork and careful planning of surgery, between the surgical and anesthetic teams, are the key to success. Resumo: Justificativa: A ruptura diafragmática é uma condição incomum e ocorre em 90% no lado esquerdo. No entanto, a incidência de ruptura à direita tem vindo a aumentar junto com o aumento dos acidentes automobilísticos. A herniação do fígado pode tornar-se progressiva, causar atelectasia grave do pulmão direito, resultar num débil estado respiratório e alterações hemodinâmicas. Relato de caso: Mulher de 40 anos, estado físico ASA 3, marcada para reparação de hepatotórax que evoluiu de hérnia diafragmática direita, adquirida aos 8 anos, após um acidente automobilístico. Clinicamente apresentava síndrome respiratória restritiva grave, causada pelo hepatotórax. A avaliação anestésica era normal, com exceção da radiografia do tórax, que evidenciava elevação da hemicúpula diafragmática direita, sem desvio traqueal. Diagnóstico foi confirmado por tomografia computadorizada. Depois da recolocação do fígado na cavidade abdominal foram observados um aumento transitório da pressão venosa central, do Stroke Volume Index e Flow Time Corrected (35%) e uma diminuição da resistência vascular sistêmica. Uma vez alcançada a estabilização hemodinâmica geral e hepatoesplênica, bem como da ventilação, a paciente foi transferida entubada, sob ventilação controlada e monitorada para a Unidade de Transplantação Hepática. Conclusões: O hepatotórax é uma condição rara e a sua correção pode representar um desafio anestésico. Após a recolocação abdominal do fígado, durante uma cirurgia corretiva, sob anestesia geral, podem ocorrer complicações, principalmente as associadas à reexpansão pulmonar. Um trabalho em equipe eficaz e o planejamento cuidadoso da cirurgia, entre as equipes cirúrgica e anestésica, são a chave para o sucesso. Keywords: Hepatotorax, Anesthesia, Diaphragmatic injury, Palavras-chave: Hepatotórax, Anestesia, Lesão diafragmática

before mediastinoscopy demonstrated a normal left ventricular size and function, with an ejection fraction of 65% and no posttransplant complications like tricuspid regurgitation. He was undergoing regular myocardial biopsies and had no documented evidence of graft rejection. He also had a stable sinus rhythm. On the day of surgery, the patient was given his morning doses of medications. Preoperative vital signs included a heart rate (HR) of 95 beats/min and blood pressure (BP) of 156/80 mmHg. The plan was to proceed with general anesthesia. The patient was given hydrocortisone (100 mg IV) and was premedicated with midazolam (2 mg IV). On the patient’s arrival in the operating room, all standard monitors were applied, including a pulse oximeter, electrocardiogram (ECG) monitoring with leads II and V5, noninvasive BP monitoring, and capnography. The patient underwent preoxygenation for 5 minutes and received fentanyl (1 mg/kg). Propofol (2-3 mg/kg) was titrated, and rocuronium (0.6 mg/kg) was administered. After the patient underwent atraumatic intubation, the radial artery was cannulated for beatto-beat BP, blood gas, and blood glucose monitoring. Anesthesia was maintained with 1.5% to 2.0% sevoflurane and a nitrous oxide and oxygen mixture (60:40). The surgery was uneventful, and the patient’s condition was hemodynamically stable throughout the procedure. At the end of surgery, the muscle relaxant was reversed with sugammadex (2 mg/kg) and the patient’s airway was extubated after return of airway reflexes. The injection of sugammadex did not cause significant changes in HR, ECG, or BP values. He was admitted to the postanesthesia care unit and had an uneventful postoperative recovery. No anesthesia complications were noted, and he was discharged 2 days after the surgery. DISCUSSION The preoperative assesment of a heart transplant recipient undergoing noncardiac surgery should focus on cardiac function; risks of rejection; infection; drug interactions; and function of other organs, particularly the kidney and liver, which may be compromised as a result of either immunosuppressive therapy or dysfunction of the transplanted heart. The patient in this report was assessed for graft rejection; his last myocardial biopsy demonstrated no evidence of graft rejection, and transthoracic echocardiogram showed a wellfunctioning graft. Blood count, coagulation profile, and all biochemical parameters were found to be normal. Hypertension is one of the common side effects of immunosuppressive therapy, and the patient in this case had a history of hypertension that was treated with amlodipine. On the day of surgery, he was given his morning doses of his medications and was normotensive throughout the procedure.