Perioperative Anesthetic Management in Preterm 12 Days Infants with Giant Meningoencephalocele at Mid Occipital and Secondary Trigonocephaly

Introduction: A meningoencephalocele is herniation of neural element along with meninges through a congenital defect in cranium. The incidence of encephalocele is approximately 1/5000 live births; occipital encephalocele is more common in females than males. It is called as giant meningoencephalocele when the head is smaller than the meningoencephalocele. These giant meningoencephaloceles harbor a large amount of cerebrospinal fluid (CSF) and brain tissue, so there occur various surgical challenges and anesthetic challenges in positioning and intubation. Case: A 12 days neonate was consulted to the neurosurgery department with complaints of large swelling over the back of head and difficulty in feeding. She was diagnosed with ventriculomegaly and meningoencephalocele since 32-33 pregnancy. The swelling was small at the time of birth, but it gradually increased in size. The child was born by section caesarean because of fetal distress and meningoenchepalocele. The neonate current weight was 3.195 grams with Post Conceptional Age (PCA) 35-36 weeks. On examination, the patient large spherical swelling was present over occipital region and there was no head control. The patient was active, conscious with no impression of focal neurological deficit. Systemic examination was unremarkable. The head circumference was 30 cm and circumference of occipital swelling was 40 cm. Potential problems in this patient include preoperative preparation and optimization of general condition, difficulty in positioning the patient, difficult airway (intubation), periodic apnea and potential hemodynamic disturbances and a sudden decrease in intracranial pressure during cele resection. Conclusion: Perioperative management in this case started from preoperative to postoperative evaluation. Preoperative preparation in anticipation of airway difficulties and communication with the operator is very important. Appropriate anesthetic techniques should aim to maintain stable hemodynamics and oxygenation and prevent a sudden increase or decrease in intracranial pressure.

Effect of Throat Pack Placement on the Incidence of Sore Throat and Postoperative Nausea and Vomiting in Septorhinoplasty Patients: A Randomized Controlled Trial

Background Advances in surgical and anesthetic techniques have led to a growing interest in performing procedures at ambulatory surgery centers. However, procedures involving the oropharyngeal or nasopharyngeal region may lead to the ingestion of blood which can lead to postoperative nausea and vomiting (PONV). To date, limited studies have largely failed to demonstrate the benefits of oropharyngeal throat packing. Objectives This study aims to investigate whether throat packing during elective septorhinoplasty increases the incidence of postoperative throat pain and assess its effects on PONV. Methods A randomized, prospective, single-blinded study was performed on 101 patients undergoing elective septorhinoplasty who received oropharyngeal throat packing versus no packing to compare the incidence of PONV and throat pain in the immediate postoperative period in addition to postoperative day (POD) 1 and 2. Results The incidence and severity of postoperative throat pain were significantly greater in patients receiving throat packs in the immediate postoperative period and on POD 1. Significant differences in throat pain and incidence between the two groups diminished by POD 2. Patients having received throat packs also demonstrated a higher usage of opioids in post anesthesia care unit (PACU). The incidence of PONV was not significantly different between the two cohorts at any point of observations. Conclusions This study demonstrates results that largely agree with previous data that throat packs may contribute to postoperative throat pain while not significantly altering the incidence of PONV. Considering this data, we do not recommend routine use of throat packing during elective septorhinoplasty.

Perioperative Anesthetic Management in Preterm 12 Days Infants with Giant Meningoencephalocele at Mid Occipital and Secondary Trigonocephaly

Introduction: A meningoencephalocele is herniation of neural element along with meninges through a congenital defect in cranium. The incidence of encephalocele is approximately 1/5000 live births; occipital encephalocele is more common in females than males. It is called as giant meningoencephalocele when the head is smaller than the meningoencephalocele. These giant meningoencephaloceles harbor a large amount of cerebrospinal fluid (CSF) and brain tissue, so there occur various surgical challenges and anesthetic challenges in positioning and intubation. Case: A 12 days neonate was consulted to the neurosurgery department with complaints of large swelling over the back of head and difficulty in feeding. She was diagnosed with ventriculomegaly and meningoencephalocele since 32-33 pregnancy. The swelling was small at the time of birth, but it gradually increased in size. The child was born by section caesarean because of fetal distress and meningoenchepalocele. The neonate current weight was 3.195 grams with Post Conceptional Age (PCA) 35-36 weeks. On examination, the patient large spherical swelling was present over occipital region and there was no head control. The patient was active, conscious with no impression of focal neurological deficit. Systemic examination was unremarkable. The head circumference was 30 cm and circumference of occipital swelling was 40 cm. Potential problems in this patient include preoperative preparation and optimization of general condition, difficulty in positioning the patient, difficult airway (intubation), periodic apnea and potential hemodynamic disturbances and a sudden decrease in intracranial pressure during cele resection. Conclusion: Perioperative management in this case started from preoperative to postoperative evaluation. Preoperative preparation in anticipation of airway difficulties and communication with the operator is very important. Appropriate anesthetic techniques should aim to maintain stable hemodynamics and oxygenation and prevent a sudden increase or decrease in intracranial pressure.

Comparison of Analgesic Efficacy between Bupivacaine with Dexamethasone and Bupivacaine Alone in Caudal Block for Pediatric Patients Undergoing Open Inguinal Hernia Repair

Background Open inguinal hernial repair surgeries are one of the most frequently performed surgical procedures in the pediatric population. Using optimal analgesic regimen provide safe and effective analgesia, reduce postoperative stress response and accelerate recovery from surgery. Regional anesthetic techniques are commonly used to facilitate pain control in pediatric surgical procedures. The most used techniques in pediatrics is caudal block. Objective To evaluate the analgesic effect of dexamethasone when given caudally as an adjuvant to caudal block vs bupivacaine alone in caudal block for children undergoing open inguinal hernial repair surgeries. Methods The study is a prospective double – blinded randomized controlled trial conducted on 50 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups; each group consisted of 25 patients. After preoperative assessment and obtaining baseline vital data, all patients received general anesthesia. Group BD who would receive caudal dexamethasone added to Bupivacaine and Group B who would receive caudal block with Bupivacaine. Results Dexamethasone addition shows statistically significance difference between two groups according to FLACC scale at 4h, 8h and 12h. The duration of adequate analgesia (FLACC pain score 4 or less) was significantly higher in group BD compared to group B. Conclusion Dexamethasone 0.1 mg/kg, when used as an adjuvant to caudal anesthesia, can significantly prolong the duration of postoperative analgesia. It is better than bupivacaine alone in caudal block at similar doses in controlling postoperative pain.

Adverse outcomes after noncardiac surgery in patients with aortic stenosis

Whether aortic stenosis (AS) increases perioperative risk in noncardiac surgery remains controversial. Limited information is available regarding adequate anesthetic techniques for patients with AS. Using the reimbursement claims data of Taiwan’s National Health Insurance, we performed propensity score matching analyses to evaluate the risk of adverse outcomes in patients with or without AS undergoing noncardiac surgery between 2008 and 2013. We also compared the perioperative risk of AS patients undergoing general anesthesia or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for postoperative mortality and major complications. The matching procedure generated 9741 matched pairs for analyses. AS was significantly associated with 30-day in-hospital mortality (aOR 1.31, 95% CI 1.03–1.67), acute renal failure (aOR 1.42, 95% CI 1.12–1.79), pneumonia (aOR 1.16, 95% CI 1.02–1.33), stroke (aOR 1.14, 95% CI 1.01–1.29), and intensive care unit stay (aOR 1.38, 95% CI 1.27–1.49). Compared with neuraxial anesthesia, general anesthesia was associated with increased risks of acute myocardial infarction (aOR 3.06, 95% CI 1.22–7.67), pneumonia (aOR 1.80, 95% CI 1.32–2.46), acute renal failure (aOR 1.82, 95% CI 1.11–2.98), and intensive care (aOR 4.05, 95% CI 3.23–5.09). The findings were generally consistent across subgroups. AS was an independent risk factor for adverse events after noncardiac surgery. In addition, general anesthesia was associated with greater postoperative complications in AS patients compared to neuraxial anesthesia. This real-world evidence suggests that neuraxial anesthesia should not be contraindicated in patients with AS.

Comparison of recovery profile between sevoflurane and isoflurane as volatile agents in neurosurgery in Indian population

Background: In most instances rapid emergence from general anesthesia after intracranial neurosurgery is desirable. The most compelling reason for this is the need for the patient to cooperate with a postoperative neurological examination intended to screen for such potential intracranial disaster as hematoma formation, herniation, and cerebrovascular accidents. Anesthetic techniques were adopted to achieve rapid emergence. In this respect, inhaled anesthetic agents have an important role in influencing the recovery time after anesthesia and surgery. The aim of this study is to compare isoflurane and sevoflurane as regard to speed of recovery from anesthesia and recovery of post-operative cognitive function in Indian populationMethods: The study was carried out as randomized control, blinded study of patients undergoing neurosurgery in tertiary care hospital. Sample sizes of 60 patients were studied. They were divided into two groups. Results: Sevoflurane shows faster emergence, extubation, motor control (in form of hand squeeze) and orientation time as compared to isoflurane. Though clinically the time difference for the various variables studied was 0.8 to 2.7 min only, statistically the results were significant and supported the basis for this difference as the difference in blood gas solubility coefficient between sevoflurane and isofluraneConclusions: Sevoflurane is recommended for use for faster extubation, emergence and post-operative neurological examination. The observation shows good brain relaxation with the use of both volatile anesthetic agents

Propofol-Based Total Intravenous Anesthesia is Associated with Better Survival than Desflurane Anesthesia in Epithelial Ovarian Cancer Surgery: A Retrospective Cohort Study

Background: Previous studies have shown that anesthetic techniques can affect outcomes of cancer surgery. We investigated the association between anesthetic techniques and patient outcomes after elective epithelial ovarian cancer surgery.Methods: This was a retrospective cohort study of patients who received elective open surgery for epithelial ovarian cancer between January 2009 and December 2014. Patients were grouped according to the administration of propofol or desflurane anesthesia. Kaplan–Meier analysis was performed, and survival curves were constructed from the date of surgery to death. Univariate and multivariate Cox regression models were used to compare hazard ratios for death after propensity matching. Subgroup analyses were performed for age, body mass index, preoperative carbohydrate antigen-125 level, International Federation of Gynecology and Obstetrics staging, and operation and anesthesia time.Results: In total, 165 patients (76 deaths, 46.1%) who received desflurane anesthesia and 119 (30 deaths, 25.2%) who received propofol anesthesia were eligible for analysis. After propensity matching, 104 patients were included in each group. In the matched analysis, patients who received propofol anesthesia had better survival with a hazard ratio of 0.52 (95% confidence interval, 0.33–0.81; p = 0.005). Subgroup analyses also showed significantly better survival with old age, high body mass index, elevated carbohydrate antigen-125 level, advanced International Federation of Gynecology and Obstetrics stage, and prolonged operation and anesthesia time in the matched propofol group. In addition, patients administered with propofol anesthesia had less postoperative recurrence and metastasis than those administered with desflurane anesthesia in the matched analysis.Conclusion: Propofol anesthesia was associated with better survival in patients who underwent elective epithelial ovarian cancer open surgery. Prospective studies are warranted to evaluate the effects of propofol anesthesia on oncological outcomes in patients with epithelial ovarian cancer.

The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.