scholarly journals Awake spinal surgery: simplifying the learning curve with a patient selection algorithm

2021 ◽  
Vol 51 (6) ◽  
pp. E2
Author(s):  
Vijay Letchuman ◽  
Nitin Agarwal ◽  
Valli P. Mummaneni ◽  
Michael Y. Wang ◽  
Saman Shabani ◽  
...  
Keyword(s):  
Learning Curve ◽  
General Anesthesia ◽  
Spinal Anesthesia ◽  
Patient Selection ◽  
Spinal Surgery ◽  
Lumbar Surgery ◽  
Inclusion Criteria ◽  
Selection Algorithm ◽  
The Mean ◽  
Selection For

OBJECTIVE There is a learning curve for surgeons performing “awake” spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery. METHODS The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution. RESULTS A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8. CONCLUSIONS The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.

scholarly journals EMERGENCY LAPAROTOMIES UNDER SPINAL ANESTHESIA: A RETROSPECTIVE, FACILITY BASED OBSERVATIONAL STUDY, IN KABUL, AFGHANISTAN

2021 ◽  
Vol 9 (06) ◽  
pp. 751-756
Author(s):  
Wais Farda ◽  
◽  
Ahmad Bashir Nawazish ◽  
Keyword(s):  
Length Of Stay ◽  
Observational Study ◽  
General Anesthesia ◽  
Spinal Anesthesia ◽  
Average Length ◽  
Emergency Laparotomy ◽  
Complication Rates ◽  
Abdominal Incision ◽  
Significant Difference ◽  
The Mean

Background: Laparotomy is most commonly performed under general anesthesia, but spinal anesthesia (SA) is considered an alternative to in the context of limited resources. The safety and efficacy of using SA as substitute for general anesthesia(GA) has not been explored in Afghanistan. Methodology: We conductedan observational study in the general surgery department of Isteqlal hospital in Kabul, Afghanistan on 196 adult patients undergoing emergency laparotomy under spinal anesthesia betweenApril 2018-April 2020. Results: The mean age of patients was 41.5 years (SD=19.4), the ratio of males to females was 1.9:1 and almost half (44.4%) had comorbidities. 21% were classified as ASA grade III and IV with a similar pattern among males and females. A total of 11 (5.6%) cases were converted to GA. Conversion pattern to GA was similar amongmales and females(P=0.71), ASA grade (P=0.432) and age group (P=0.642). The mean length of stay after operation was 6.5 days (SD=4.1). 32 (16.3%) patients suffered SA complications with no significant difference in terms of sex (P=0.134). Hypotension and headache accounted for 97% of complications. Complication rates were similar in terms of intervertebral level (P=0.349), type of abdominal incision (P>0.1) and average length of stay (P=0.156). 18 patients (9.2%) died due to MOF, sepsis, respiratory failure, thromboembolism and cardiogenic shock. Conclusion: Spinal anesthesia is considered a safe and effective anesthesia for emergency laparotomies, even for those with comorbidities. Based on our findings we would recommend spinal anesthesia as an alternative to general anesthesiain emergency laparotomy in Afghanistan.

scholarly journals Contralateral interoptic approach to paraclinoid aneurysms: a patient-selection algorithm based on anatomical investigation and clinical validation

2020 ◽  
pp. 1-9
Author(s):  
Xiaochun Zhao ◽  
Ali Tayebi Meybodi ◽  
Mohamed A. Labib ◽  
Sirin Gandhi ◽  
Evgenii Belykh ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Patient Selection ◽  
Vertical Line ◽  
Coronal Plane ◽  
Selection Algorithm ◽  
Medial Surface ◽  
Aneurysm Neck ◽  
The Mean ◽  
Accessible Area ◽  
Clinical Cases

OBJECTIVEAneurysms that arise on the medial surface of the paraclinoid segment of the internal carotid artery (ICA) are surgically challenging. The contralateral interoptic trajectory, which uses the space between the optic nerves, can partially expose the medial surface of the paraclinoid ICA. In this study, the authors quantitatively measure the area of the medial ICA accessible through the interoptic triangle and propose a potential patient-selection algorithm that is based on preoperative measurements on angiographic imaging.METHODSThe contralateral interoptic trajectory was studied on 10 sides of 5 cadaveric heads, through which the medial paraclinoid ICA was identified. The falciform ligament medial to the contralateral optic canal was incised, the contralateral optic nerve was gently elevated, and the medial surface of the paraclinoid ICA was inspected via different viewing angles to obtain maximal exposure. The accessible area on the carotid artery was outlined. The distance from the distal dural ring (DDR) to the proximal and distal borders of this accessible area was measured. The superior and inferior borders were measured using the clockface method relative to a vertical line on the coronal plane. To validate these parameters, preoperative measurements and intraoperative findings were reviewed in 8 clinical cases.RESULTSIn the sagittal plane, the mean (SD) distances from the DDR to the proximal and distal ends of the accessible area on the paraclinoid ICA were 2.5 (1.52) mm and 8.4 (2.32) mm, respectively. In the coronal plane, the mean (SD) angles of the superior and inferior ends of the accessible area relative to a vertical line were 21.7° (14.84°) and 130.9° (12.75°), respectively. Six (75%) of 8 clinical cases were consistent with the proposed patient-selection algorithm.CONCLUSIONSThe contralateral interoptic approach is a feasible route to access aneurysms that arise from the medial paraclinoid ICA. An aneurysm can be safely clipped via the contralateral interoptic trajectory if 1) both proximal and distal borders of the aneurysm neck are 2.5–8.4 mm distal to the DDR, and 2) at least one border of the aneurysm neck on the coronal clockface is 21.7°–130.9° medial to the vertical line.

scholarly journals Effect of Spinal Anesthesia versus General Anesthesia on Blood Glucose Concentration in Patients Undergoing Elective Cesarean Section Surgery: A Prospective Comparative Study

2019 ◽  
Vol 2019 ◽  
pp. 1-6
Author(s):  
Khaled El-Radaideh ◽  
Ala’’a Alhowary ◽  
Mohammad Alsawalmeh ◽  
Ahmed Abokmael ◽  
Haitham Odat ◽  
...  
Keyword(s):  
Blood Glucose ◽  
Cesarean Section ◽  
General Anesthesia ◽  
Spinal Anesthesia ◽  
Glucose Concentration ◽  
Blood Glucose Concentration ◽  
Elective Cesarean Section ◽  
Elective Cesarean ◽  
Prospective Comparative Study ◽  
The Mean

Background. This prospective study compared the blood glucose concentration with spinal anesthesia or general anesthesia in patients undergoing elective cesarean section surgery. Methods. In total, 58 pregnant women who underwent elective cesarean section surgery were included in this prospective comparative study. Group S (n = 35) included patients who chose spinal anesthesia, and group G (n = 23) included patients who chose general anesthesia. The patients were allocated to the groups upon patients’ preference. For the group G, the blood glucose concentration (BGC) was obtained 5 minutes before induction, T1, and 5 minutes after induction T2. For the group S, the BGC was obtained immediately before the injection of the local anesthetic agent T1 and 5 minutes after the complete block T2. For both groups, BGC was measured 5 minutes before the end of surgery T3 and 30 minutes after the end of surgery T4. For BGC measurements, we used a blood glucose monitoring system with a lancet device to prick the finger. Results. There was no statistically significant difference in the mean blood glucose concentration between the groups S and G in T1 (78.3 ± 18.2 vs. 74.3 ± 14.7, p>0.05) and T2 (79.2 ± 18.3 vs. 84.9 ± 23.7, p>0.05). The mean BGC was statistically significantly higher in group G in comparison to group S in the times 5 minutes before (80.2 ± 18.1 vs. 108.4 ± 16.7, p<0.05) and 30 minutes after the end of surgery (80.9 ± 17.7 vs. 121.1 ± 17.4, p<0.05). Conclusion. There is a much lower increase in blood glucose concentration under spinal anesthesia than under general anesthesia. It is reasonable to suggest that the blood sugar concentration must be intraoperatively monitored in patients undergoing general anesthesia.

Hip Arthroscopic Surgery With Labral Preservation and Capsular Plication in Patients With Borderline Hip Dysplasia: Minimum 5-Year Patient-Reported Outcomes

2017 ◽  
Vol 46 (2) ◽  
pp. 305-313 ◽  
Author(s):  
Benjamin G. Domb ◽  
Edwin O. Chaharbakhshi ◽  
Itay Perets ◽  
Leslie C. Yuen ◽  
John P. Walsh ◽  
...  
Keyword(s):  
Patient Selection ◽  
Patient Reported Outcomes ◽  
Hip Dysplasia ◽  
Acetabular Dysplasia ◽  
Arthroscopic Surgery ◽  
Inclusion Criteria ◽  
Capsular Plication ◽  
Patient Reported ◽  
The Mean

Background: The arthroscopic management of hip dysplasia has been controversial and has historically demonstrated mixed results. Studies on patients with borderline dysplasia, emphasizing the importance of the labrum and capsule as secondary stabilizers, have shown improvement in patient-reported outcomes (PROs). Purpose/Hypothesis: The purpose was to assess whether the results of hip arthroscopic surgery with labral preservation and concurrent capsular plication in patients with borderline hip dysplasia have lasting, positive outcomes at a minimum 5-year follow-up. It was hypothesized that with careful patient selection, outcomes would be favorable. Study Design: Case series; Level of evidence, 4. Methods: Data were prospectively collected and retrospectively reviewed for patients aged <40 years who underwent hip arthroscopic surgery for intra-articular abnormalities. Inclusion criteria included lateral center-edge angle (LCEA) between 18° and 25°, concurrent capsular plication and labral preservation, and minimum 5-year follow-up. Exclusion criteria were severe dysplasia (LCEA ≤18°), Tönnis grade ≥2, pre-existing childhood hip conditions, or prior hip surgery. PRO scores including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) and the visual analog scale (VAS) score for pain were collected preoperatively, at 3 months, and annually thereafter. Complications and revisions were recorded. Results: Twenty-five hips (24 patients) met the inclusion criteria. Twenty-one hips (19 patients, 84%) were available for follow-up. The mean age at surgery was 22.9 years. The mean preoperative LCEA and Tönnis angle were 21.7° (range, 18° to 24°) and 6.9° (range, –1° to 16°), respectively. The mean follow-up was 68.8 months. The mean mHHS increased from 70.3 to 85.9 ( P < .0001), the mean NAHS from 68.3 to 87.3 ( P < .0001), and the mean HOS-SSS from 52.1 to 70.8 ( P = .0002). The mean VAS score improved from 5.6 to 1.8 ( P < .0001). Four hips (19%) required secondary arthroscopic procedures, all of which resulted in improved PRO scores at latest follow-up. No patient required conversion to total hip arthroplasty. Conclusion: While periacetabular osteotomy remains the standard for treating true acetabular dysplasia, hip arthroscopy may provide a safe and durable means of managing intra-articular abnormalities in the setting of borderline acetabular dysplasia at midterm follow-up. These procedures should be performed by surgeons with expertise in advanced arthroscopic techniques, using strict patient selection criteria, with emphasis on labral preservation and capsular plication.

scholarly journals General Anesthesia Compared to Spinal Anesthesia for Patients Undergoing Lumbar Vertebral Surgery: A Meta-Analysis of Randomized Controlled Trials

2020 ◽  
Vol 10 (1) ◽  
pp. 102
Author(s):  
Alessandro De Cassai ◽  
Federico Geraldini ◽  
Annalisa Boscolo ◽  
Laura Pasin ◽  
Tommaso Pettenuzzo ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Randomized Controlled Trials ◽  
General Anesthesia ◽  
Spinal Anesthesia ◽  
Postoperative Nausea ◽  
Meta Analysis ◽  
Analgesic Efficacy ◽  
Controlled Trials ◽  
Lumbar Surgery ◽  
Randomized Controlled

Vertebral lumbar surgery can be performed under both general anesthesia (GA) and spinal anesthesia. A clear benefit from spinal anesthesia (SA) remains unproven. The aim of our meta-analysis was to compare the early analgesic efficacy and recovery after SA and GA in adult patients undergoing vertebral lumbar surgery. A systematic investigation with the following criteria was performed: adult patients undergoing vertebral lumbar surgery (P); single-shot SA (I); GA care with or without wound infiltration (C); analgesic efficacy measured as postoperative pain, intraoperative hypotension, bradycardia, length of surgery, blood loss, postoperative side effects (such as postoperative nausea/vomiting and urinary retention), overall patient and surgeon satisfaction, and length of hospital stay (O); and randomized controlled trials (S). The search was performed in Pubmed, the Cochrane Central Register of Controlled Trials, and Google Scholar up to 1 November 2020. Eleven studies were found upon this search. SA in vertebral lumbar surgery decreases postoperative pain and the analgesic requirement in the post anesthesia care unit. It is associated with a reduced incidence of postoperative nausea and vomiting and a higher patient satisfaction. It has no effect on urinary retention, intraoperative bradycardia, or hypotension. SA should be considered as a viable and efficient anesthetic technique in vertebral lumbar surgery.

scholarly journals Investigation of Time to Line Placement and Treatment Initiation in Pediatric Oncology Patients Utilizing a Pediatric Vascular Access Team

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4037-4037
Author(s):  
Henna Butt ◽  
Natalie Davis ◽  
Regina A. Macatangay
Keyword(s):  
General Anesthesia ◽  
Operating Room ◽  
Pediatric Oncology ◽  
Vascular Access ◽  
Central Line ◽  
Inclusion Criteria ◽  
Central Venous ◽  
Oncology Patients ◽  
Line Placement ◽  
The Mean

Abstract Background: Once diagnosis of malignancy is made in pediatric patients, it can be important to initiate therapy to prevent delay in benefits derived from treatment. In certain diagnoses, prompt initiation of chemotherapy can help reduce complications such as hyperleukocytosis, mass effect from solid tumors, and spread of malignancy. These patients require provision of central vascular access in order to begin treatment. In children's hospitals patients often receive central venous catheters in the operating room under general anesthesia. However, this requires scheduling for the operating room, availability of pediatric surgeons, appropriate anesthesia consent and examination ahead of time for safety of proceeding. The benefit of having a pediatric vascular access team (PVAT) is that these providers are flexible with their availability, the time required to place the lines is often less and it eliminates the need for general anesthesia as well as the cost of the operating room. The aim of this study was to compare vascular access provision by a designated pediatric vascular access team with surgical placement of central venous access in pediatric oncology patients. Methods: This was an IRB-approved retrospective medical record review of subjects diagnosed with an oncologic malignancy with inclusion criteria: ages 0-21 years of age, treatment for pediatric malignancy at the University of Maryland Children's Hospital between 1/1/2017-12/31/2019. We performed bivariate analyses comparing variables between patients who had line placement by PVAT vs surgical placement. Analyses was performed using SAS 9.4. Results: We identified 69 patients who met inclusion criteria with 39% (n=27) having undergone line placement by PVAT. Surgical placement occurred for 55% (n=38), with interventional radiology (IR) or other placement making up the remainder 6% of patients (n=4). The mean age was noted to be younger in the surgical group (8.6 +/- 6 years) in comparison to the PVAT group (13+/-6.3 years), p=0.0061. The mean time from consult to line placement was 10 (+/-9) hours in the PVAT group vs 76 (+/-56) hours in the surgery group (p&lt;0.0001). There was a statistically significant difference in procedure duration, with PVAT placement requiring less time (27+/-12 minutes) vs surgical placement (48+/-19 minutes), p=0.0005. There were no statistically significant differences among groups in race, sex, time-to-initiation of treatment after line placement, or complications. There was a small difference in mean number of attempts, with surgical requiring 1 (+/-0) vs. PVAT 1.2 (+/-0.4) attempts. Compared to complications of surgical line placement, the complications experienced by our PVAT team were largely related to need for revision of line placement, although not frequent enough to be statistically significant. Conclusion: Data show that having a PVAT for central line insertions demonstrates good safety profiles, successful insertion and low complication rates. PVAT has also increased the efficiency of vascular access at large academic institutions. The presence of vascular access teams allows for initiation of therapy in a timely fashion and allows central line placement under anesthesia to occur at a safer time. At our institution, having a PVAT in house has allowed for more efficient line placements, shorter time to provision of access and transition to placement of surgical lines when more stable. This allows for not only patients to receive care faster, but also to have lines placed in shorter times while optimizing patient safety. Schultz TR, Durning S, Niewinski M, Frey AM. A multidisciplinary approach to vascular access in children. J Spec Pediatr Nurs. 2006;11(4):254-256. doi:10.1111/j.1744-6155.2006.00078. Disclosures No relevant conflicts of interest to declare.

scholarly journals Spinal Anesthesia for Removal of Thoraco-Lumbar Pedicle Screw

2019 ◽  
Vol 1 (1) ◽  
pp. 35-39
Author(s):  
Nirmal Kumar Gyawali
Keyword(s):  
General Anesthesia ◽  
Spinal Anesthesia ◽  
Pedicle Screw ◽  
Spinal Surgery ◽  
Lateral Position ◽  
Anesthetic Technique ◽  
Postoperative Pain Control ◽  
American Society ◽  
A Prospective Study ◽  
Cardiovascular Stability

Background: Spinal anesthesia compared to the general anesthesia has advantages of decreased blood loss, better cardiovascular stability, and postoperative pain control. This study was designed to evaluate pedicle screw removal at the lateral position under spinal anesthesia. Methods: It is a prospective study done in patients with ASA (American Society of Anaesthesiologist) I and II with ages between 17 to 75 years of both sex admitted for pedicle screw removal surgery during the period   March 2018 to April 2019 AD in Western Hospital and research center Nepalgunj. All patients were informed about the risk of conversion to general anesthesia in detail. Spinal anesthesia was given to all 83 patients who came for pedicle screw removal. Result: Out of all patients 54% were from Hills and the remaining 46% were from Terai. The commonest cause of injury was fall from a tree which was in 48 (57.8%) out of 83 cases. The commonest level of injury was L1 followed by L2. The operation was completed under spinal anesthesia. None of the patients required conversion to general anesthesia. And 69 (83.1%) patients did not require any additional medications whereas the remaining 14 (16.86%) needed additional medications. Conclusion: Spinal anesthesia is the safe and effective anesthetic technique for short duration spinal surgery eg pedicle screw removal in terms of perioperative events and in prolonged postoperative analgesia, as well as in terms of patient and surgeon’s satisfaction.   Keywords: Spinal Anesthesia, Thoracolumbar, Pedicle Screw

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