Spinal Anesthesia of a Patient with Central Core Disease for Caesarean Section: A Case Report

Central core disease is an autosomal dominant congenital myopathy. It typically manifests as muscle weakness and developmental delay. Central core disease is also associated with malignant hyperthermia which can be developed by volatile agent or succinylcholine. Here, we are reporting a case of a 34-year-old primigravida with central core disease who underwent an emergency cesarean section under spinal anesthesia without complications.

Environmental And Economic Impact of Using A Higher Efficiency Ventilator And Vaporizer During Surgery Under General Anesthesia: A Randomized Controlled Prospective Cohort

Background: Compared to traditional breathing circuits, low-flow anesthesia machines utilize a low-volume breathing circuit system by injecting volatile agent into the circuit mainly during inspiration. We aimed to assess whether Maquet Flow-i C20 anesthesia workstation delivers volatile anesthetic more efficiently than a GE Aisys CS2 during elective general surgery. Methods: Eligible candidates enrolled in the study (2014-1248) met the following inclusion criteria: 18 – 65 years old, scheduled for surgery requiring general anesthesia at UC Irvine Health, and expected to receive sevoflurane for the duration of the procedure. Exclusion criteria: < 18 years old, history of COPD, cardiovascular disease, sevoflurane sensitivity, BMI > 30 kg/m2, ASA > 2, pregnant, or surgery scheduled < 120 minutes. We calculated the total amount of sevoflurane delivered and consumption rates during induction/maintenance periods and compared the groups using parametric testing (Student’s t-Test). Results: In total, 103 subjects (Maquet: n=52, GE: n=51) were analyzed. Overall, the Flow-i C-20 group consumed significantly less sevoflurane (95.5 ± 49.3 g) compared to the Aisys2 (118.2 ± 62.4 g) (p = 0.043 for group difference) corresponding to an approximately 20% efficiency improvement in overall agent delivery. When accounting for the fresh gas flow setting, agent concentration and length of induction, the Maquet machines delivered volatile agent at a significantly lower rate compared to the GE devices (7.4 ± 3.2 L/min vs. 9.2 ± 4.1 L/min; p = 0.017). Based on these results, we estimate that the Maquet Flow-i workstations can save an estimated average of $239,440 over the expected 10-year machine lifespan. This 20% decrease in CO2 equivalent emissions corresponds to 201 metric tons less greenhouse gas emissions over a decade compared to the GE Aisys; equivalent to 491,760 miles driven by an average passenger vehicle or 219,881 pounds of coal burned.Conclusions: Overall, our results from this pilot study suggest that the Maquet Flow-i delivers significantly less (~20%) volatile agent during routine elective surgery using a standardized anesthetic protocol compared to a traditional anesthesia system. The results demonstrate a strong opportunity for economic and environmental benefits if implemented across other medical institutions.

The Effect of Sevoflurane Low Flow Anesthesia on Preserving Patient Core Temperature

Background: Low flow anesthesia reduces the fresh gas flow (FGF) entering the anesthesia circuit and saves on the volatile agent used. In this study, the effect of low-flow anesthesia with sevoflurane on core temperature and the incidence of perioperative hypothermia were investigated.Methods: Records of patients who underwent general anesthesia with sevoflurane were analyzed retrospectively. According to the fresh gas flow applied, the patients were divided into three groups: Low flow anesthesia (LFA = 1 l / min), medium flow anesthesia (MFA = 2 l / min), and high flow anesthesia (HFA = 4 l / min). Patients’ demographic data and the initial (T1) and final (T2) temperatures during the operation were compared.Results: A total of 160 patients were included in the study. There was no significant difference in T1 temperature values between the groups. The T2 value of the HFA group was significantly lower than the LFA group (p = 0.028). Different flow values were found to have a significant effect on temperature change (F = 21.630, p <0.001, partial eta squared = 0.216). There was a significant difference between the mean temperatures measured at two different times (F = 301.064, p <0.001, partial eta squared = 0.657). The overall incidence of hypothermia was 32.5%, with 52 patients. Hypothermia (T2<36 degrees) incidences were not different between the LFA group and the MFA and HFA groups (p = 0.682); However, perioperative core temperature loss was significantly lower in the LFA group (p = 0.001).Conclusions: Low flow anesthesia using sevoflurane was not sufficient alone to reduce the incidence of hypothermia. However, the LFA technique preserved the patient’s core temperature better than the MFA and HFA techniques. Therefore, in addition to low-flow anesthesia being a cost-oriented technique, we have demonstrated that it may also have a beneficial effect on reducing perioperative temperature loss.Trial Registration: Researchregistary.com/6840Ethics committee: Yozgat Bozok University 2017-KAEK-25122019.1

Immune Function Following Major Spinal Surgery and General Anesthesia

There are reported differences in the effects that general anesthetics may have on immune function after minor surgery. To date, there are no prospective trials comparing total intravenous anesthesia (TIVA) with a volatile agent-based technique and its effects on immune function after major spinal surgery in adolescents. Twenty-six adolescents undergoing spinal fusion were randomized to receive TIVA with propofol-remifentanil or a volatile agent-based technique with desflurane-remifentanil. Immune function measures were based on the antigen-presenting and cytokine production capacity, and relative proportions of cell populations. Overall characteristics of the two groups did not differ in terms of perioperative times, hemodynamics, or fluid shifts, but those treated with propofol had lower bispectral index values. Experimental groups had relatively high baseline interleukin-10 values, but both showed a significant inflammatory response with similar changes in their respective immune functions. This included a shift toward a granulocytic predominance; a transient reduction in monocyte markers with significant decrease in antigen-presenting capacity and cytokine production capacity. Anesthetic choice does not appear to differentially impact immune function, but exposure to anesthetics and surgical trauma results in reproducibly measurable suppression of both innate and adaptive immunity in adolescents undergoing posterior spinal fusion. The magnitude of this suppression was modest when compared with pediatric and adult patients with critical illnesses. This study highlights the need to evaluate immune function in a broader population of surgical patients with higher severity of illness.

A National Survey: Current Clinical Practice in Pediatric Anesthesia for Congenital Heart Surgery

Background: Providing anesthesia for pediatric patients undergoing congenital cardiac surgery is complex and requires profound knowledge and clinical experience. Prospective studies on best anesthetic management are missing, partially due to different standards. The aim of the present study was to survey the current standard practice in anesthetic management in pediatric cardiac surgical centers in Germany. Methods: All 78 cardiac surgical centers in Germany were reviewed for a congenital cardiac surgery program. Centers with an active program for congenital cardiac surgery were interviewed to participate in the present online questionnaire to assess their current anesthetic practice. Results: Twenty-seven German centers running an active program for congenital heart surgery were identified, covering more than 3,000 pediatric cardiac surgeries annually. Of these centers, 96.3% (26/27) participated in our survey. Standard induction agents were etomidate in 26.9% (7/26), propofol in 19.2% (5/26), a combination of benzodiazepines and ketamine in 19.2% (5/26), and barbiturates in 11.5% (3/26). General anesthesia was preferentially maintained using volatile agents, 61.5% (16/26), with sevoflurane being the most common volatile agent within this group, 81.2% (13/16). Intraoperative first-choice/first-line inotropic drug was epinephrine, 53.8% (14/26), followed by milrinone, 23.1% (6/26), and dobutamine 15.4% (4/26). Fast-track programs performing on-table extubation depending on the type of surgical procedure were established at 61.5% (16/26) of the centers. Conclusion: This study highlights the diversity of clinical standards in pediatric cardiac anesthesia for congenital cardiac surgery in Germany.

Anesthetic Agents and Cardiovascular Outcomes of Noncardiac Surgery after Coronary Stent Insertion

Patients undergoing noncardiac surgery after coronary stent implantation are at an increased risk of thrombotic complications. Volatile anesthetics are reported to have organ-protective effects against ischemic injury. Propofol has an anti-inflammatory action that can mitigate ischemia-reperfusion injury. However, the association between anesthetic agents and the risk of major adverse cardiovascular and cerebral event (MACCE) has never been studied before. In the present study, a total of 1630 cases were reviewed. Four different propensity score matchings were performed to minimize selection bias (propofol-based total intravenous anesthesia (TIVA) vs. volatile anesthetics; TIVA vs. sevoflurane; TIVA vs. desflurane; and sevoflurane vs. desflurane). The incidence of MACCE in these four propensity score-matched cohorts was compared. As a sensitivity analysis, a multivariable logistic regression analysis was performed to identify independent predictors for MACCE during the postoperative 30 days both in total and matched cohorts (TIVA vs. volatile agent). MACCE occurred in 6.0% of the patients. Before matching, there was a significant difference in the incidence of MACCE between TIVA and sevoflurane groups (TIVA 5.1% vs. sevoflurane 8.2%, p = 0.006). After matching, there was no significant difference in the incidence of MACCE between the groups of any pairs (TIVA 6.5% vs. sevoflurane 7.7%; p = 0.507). The multivariable logistic regression analysis revealed no significant association of the volatile agent with MACCE (odds ratio 1.48, 95% confidence interval 0.92–2.37, p = 0.104). In conclusion, the choice of anesthetic agent for noncardiac surgery did not significantly affect the development of MACCE in patients with previous coronary stent implantation. However, further randomized trials are needed to confirm our results.

Effects of intravenous dexmedetomidine on analgesic and anesthetic requirement in thoracic surgeries with one lung ventilation.

Background and Objectives: Dexmedetomidine has been shown to reduce the intraoperative requirement of anesthetic and analgesic agents. This prospective, observational study was designed to assess whether intraoperative infusion of dexmedetomidine provides effective intraoperative analgesia in thoracic surgeries carried out using one lung ventilation, and to elucidate its beneficial effects if any in terms of reducing the requirement for inhalational anesthetics intraoperatively, thereby maintaining the protective effects of hypoxic pulmonary vasoconstriction. Methods: Sixty patients were randomly assigned to two groups. Group 1 (n=30) received a loading dose of dexmedetomidine 0.3µg/kg iv during induction of anesthesia, followed by a continuous infusion at a rate of 0.3µg/kg/hr continued upto two hours of the surgery. Group 2 (n=30) received a volume-matched bolus and infusion of saline (0.9% saline). For each case, heart rate, peripheral oxygen saturation, and mean arterial pressure were recorded intraoperatively at regular intervals. Total fentanyl consumption and isoflurane requirement were noted intraoperatively for both the groups. Results: The groups were similar with respect to baseline characteristics, and distribution of study subjects. The mean fentanyl consumption and the volatile agent requirement to achieve a particular intraoperative BIS value were significantly higher in group 2 compared to group 1 (p 0.002 and p ˂0.001 respectively). Conclusion: Dexmedetomidine infusion provides effective intraoperative analgesia and reduces the isoflurane requirement to achieve a particular depth of anesthesia during thoracic surgeries performed using one lung ventilation. Key words: Dexmedetomidine, MAC, BIS, OLV, Thoracic surgeries, Analgesia

Promoting low-flow anaesthesia and volatile anaesthetic agent choice

BackgroundAs doctors, we are increasingly aware of the financial implications of our practice. The need to work in a more conscientious, efficacious and cost-effective manner is greater than ever before. Environmental and financial benefits can be seen through employing the use of low-flow anaesthesia.AimsThis quality improvement project aimed to make anaesthetic practice more environmentally friendly and to reduce departmental spending. This could be achieved by promoting the use of low-flow anaesthesia and by encouraging isoflurane use where appropriate.MethodsAll anaesthetic consultants and trainees were invited to fill out an initial questionnaire relating to their personal preferences and practices when conducting anaesthesia. There were specific questions relating to low-flow anaesthesia and isoflurane use. Our main measure of improvement was any decrease in the number of bottles of volatile agent ordered by the department from pharmacy. Monthly spot audits were conducted to assess gas flow rates and volatile agent use in theatre. Departmental spending figures relating to the purchase of volatile agent bottles were obtained from pharmacy. Information was then disseminated to anaesthetists on a monthly basis via a ‘low-flow board’, which showed pictorial and graphical representations of differing gas flows and volatile agent usage in relation to cost.ResultsOur project showed a trend for the increased use of low-flow anaesthesia within the department. We also showed a decrease in the number of bottles of volatile agent ordered: 18% fewer bottles ordered compared with the same period the previous year. This represented a 25% decrease in total departmental expenditure on volatile agents despite an increase in theatre activity.ConclusionIncreasing awareness regarding anaesthetic choices and promoting low-flow anaesthesia and isoflurane use, translated into an overall decreased departmental spend on volatile agents without affecting patient care.