Intraoperative Fluoroscopy-Assisted Localization of Small Bowel Gastrointestinal Bleeding

Intraoperative management of refractory small bowel gastrointestinal bleeding continues to present challenges to surgeons, specifically, in localizing the source of bleeding. The need for operative intervention has decreased significantly with improved percutaneous radiologic techniques for embolization with good success rates. When percutaneous treatment methods fail, the surgeon is left with a variety of suboptimal options for localization if the pathologic source is not obvious on external inspection of the small bowel. This report describes a novel method for localizing small bowel gastrointestinal bleeding in those patients who have had previous coil embolization attempts at controlling small bowel gastrointestinal bleeding.

Analysis of Risk Factors for Perioperative Acute Kidney Injury and Management Strategies

Acute kidney injury (AKI) is a serious clinical syndrome, and one of the common comorbidities in the perioperative period. AKI can lead to complications in surgical patients and is receiving increasing attention in clinical workup. In recent years, the analysis of perioperative risk factors has become more in-depth and detailed. In this review, the definition, diagnosis, and pathophysiological characteristics of perioperative AKI are reviewed, and the main risk factors for perioperative AKI are analyzed, including advanced age, gender, certain underlying diseases, impaired clinical status such as preoperative creatinine levels, and drugs that may impair renal function such as non-steroidal anti-inflammatory drugs (NASIDs), ACEI/ARB, and some antibiotics. Injectable contrast agents, some anesthetic drugs, specific surgical interventions, anemia, blood transfusions, hyperglycemia, and malnutrition are also highlighted. We also propose potential preventive and curative measures, including the inclusion of renal risk confirmation in the preoperative assessment, minimization of intraoperative renal toxin exposure, intraoperative management and hemodynamic optimization, remote ischemic preadaptation, glycemic control, and nutritional support. Among the management measures, we emphasize the need for careful perioperative clinical examination, timely detection and management of AKI complications, administration of dexmedetomidine for renal protection, and renal replacement therapy. We aim that this review can further increase clinicians' attention to perioperative AKI, early assessment and intervention to try to reduce the risk of AKI.

Experience Verification of 63 Cases of Liver Transplantation Anesthesia Management

Background: We reviewed the intraoperative management of previous liver transplantation (LT) cases to identify an optimal anesthetic method, which may affect patient outcomes and lead to faster postoperative recovery for future recipients. Methods: This single-center retrospective study reviewed 63 patients who underwent LT, including 51 living donor LT (LDLT), seven deceased donor LT (DDLT), and five simultaneous liver-kidney transplantation patients. We examined the patients’ backgrounds, intraoperative management (anesthetic method, water balance, and catecholamine dosage), and postoperative courses (hospitalization period, length of intensive care unit stay, renal function). Results: All patients received general anesthesia using inhalational anesthetics, either sevoflurane or desflurane, and both drugs were administered similarly. Rocuronium was administered at its usual dose despite liver failure. All patients undergoing preoperative dialysis due to acute kidney injury were successfully withdrawn from dialysis after surgery. The albumin infusion volume was 32% of the total infusion and transfusion volume. The five-year survival rate was 88% and graft failure occurred in one case. Conclusion: The anesthetic management of LT is currently conducted empirically in our institution, and we could not identify an optimal anesthetic method. However, we drew some conclusions. First, the use of human atrial natriuretic peptide as a drug infusion and appropriate transfusion management was expected to restore renal function. Second, the infusion volume of albumin was high. Third, the usual dose of rocuronium was required because excessive bleeding may cause unstable plasma drug concentration. Our results will be useful in future multi-institutional studies or meta-analyses and further improving the outcomes of future transplant recipients.

Norepinephrine in Goal-Directed Fluid Therapy during General Anesthesia in Elderly Patients Undergoing Spinal Operation: Determining Effective Infusion Rate to Enhance Postoperative Functions

Background and Objective: Intraoperative hypotension is a common complication in general anesthesia that could result in different serious complications particularly in elderly patients. This Randomized Clinical Trial (RCT) aims to determine effective continuous infusion rate of norepinephrine to prevent intraoperative hypotension during spinal surgery under general anesthesia in elderly patients. Methods: This RCT was conducted on elderly patients (n= 108) undergoing general anesthesia for posterior lumbar spinal fusion. The patients were randomly divided into 0.030, 0.060, and 0.090 μg.kg-1.min-1 groups of norepinephrine infusion rates. The outcomes were assessed at entrance to operation room (T0), 15 mins after anesthesia induction (T1), 60 mins following surgery (T2), and immediately after surgery (T3). The intraoperative and postoperative complications and rehabilitation outcomes were comparatively assessed. Results: All three groups significantly reduced the incidence of delayed wound healing (0.030 vs. 0.060 vs. 0.090 μg.kg-1.min-1; 33.3% vs. 10% vs. 10%, P=0.024) and wound infection (26.7% vs. 6.7% vs. 6.7%, P=0.031). Intraoperative total fluid volume and colloids volume in the 0.030 group were significantly higher than 0.060 and 0.090 groups (P=0.005, P=0.003, and P=0.01, respectively). The 0.060 and 0.090 groups significantly increased mean-arterial-pressure than the 0.030 group at T2 and T3. Both 0.060 and 0.090 infusion rates significantly reduced intraoperative hypotension than 0.030 dosage (P=0.01 and P=0.003, respectively). The bradycardia incidence in the 0.090 group was significantly higher than the 0.030 (P=0.026) and 0.060 groups (P=0.038). The 0.060 group decreased the first intake by 1.4 hours (P=0.008) and first flatus by 1.1 hours (P=0.004) and postoperative hospital stay by 1 day (P=0.066). Conclusion: The 0.060 µg·kg-1·min-1 norepinephrine infusion combined with goal-directed fluid therapy exhibited adequate intraoperative management and postoperative outcomes.

Neuroblastoma in Children: Intraoperative Goal Directed Therapy, Intraoperative And Postoperative Outcomes

Background: Neuroblastoma is the most common tumor in children. Anesthetic management can be challenging due to the localization and catecholamine-secreting characteristics of the tumor. We undertook a secondary analysis in a previous study to describe patients who underwent neuroblastoma resection.Objective: To describe intraoperative and postoperative outcomes in patients who underwent neuroblastoma resection and to propose optimal intraoperative management for postoperative outcome improvement.Methods: This was a secondary analysis of children who underwent neuroblastoma resection in the initial retrospective study.Results: There were 16 patients with a mean age of 39.3±22.1 months. Seven (43.8%) patients presented with intraoperative or postoperative complications. One (6.3%) patient had intraoperative broncholaryngospasm and difficult intubation. Two (12.5%) patients had intraoperative hemorrhagic shock. One patient (6.3%) had postoperative renal failure. Two patients (12.5%) had postoperative respiratory failure, and 3 (18.8%) patients had postoperative cardiocirculatory failure. One (6.3%) had postoperative pulmonary sepsis and septicemia. Thirteen (81.3%) patients were intraoperatively transfused. There was no in-hospital mortality.Conclusion: In this cohort, 43.8% of the patients had intraoperative and/or postoperative complications in terms of organ dysfunction or sepsis. A total of 81.3% of the patients received intraoperative transfusion. Neuroblastoma surgery can be a challenging situation where cardiovascular instability, high blood loss and transfusion requirements can be encountered. Consequently, preoperative preparation and optimal intraoperative management with validated tools in children could be necessary for a better postoperative outcome in this surgical setting.