Comprehensive Analysis of Perioperative Anaesthesia Concerns in Covid Associated Mucormycosis: A Retrospective Study of Surgical Patients

Background: Data regarding sudden surge of mucormycosis cases with COVID-19 outbreak and its impact on anaesthesia management are lacking. This retrospective study was designed to analyze the number and characteristics of patients posted for mucormycosis surgery in COVID19 pandemic while emphasizing upon the anaesthesia concerns. Methods: Data was collected from all patients who were admitted with mucormycosis in our institute from the year 2020 onwards. Further analysis of patients who were surgically treated was carried out in terms of demographic characteristics, association with COVID19 and perioperative course of mucormycosis and anaesthetic management. All statistical analyses were performed with the Statistical package for social sciences (SPSS) version 25·0 software. Results: We report an incidence of 30 operated patients of the average age 52.60 years with mucormycosis from August 2020 to May 2021. Diabetes as a comorbidity was common (86.90%). Previous infection with COVID-19 was observed in 29 (96.60%) out of which 80% patients had residual pulmonary involvement. Concomitant medical therapy with Amphotericin B was received by 90% patients and subsequently 70% had deranged renal profile. While 20 % patients had compromised airway, 60 % required blood transfusion and 76.6% patients were electively ventilated while 1 patient (3.3%) succumbed amounting to a survival rate of 96.6%. Conclusion: To conclude elderly male diabetic patients with history of COVID19 infection is the most vulnerable population for developing mucormycosis. Airway management, glycemic control, concomitant Amphotericin B therapy and intraoperative bleeding are the major challenges for anaesthesiologist along with an element of post Covid respiratory compromise.

Large primary retroperitoneal mucinous cystadenoma managed laparoscopically: Case report and literature review

Background: Retroperitoneal cystic lesions (RCLs) are uncommon clinical findings that arise within the retroperitoneal compartments and account for various etiologies. They can be benign or malignant in nature and may present with different manifestations. Case report: A 55-year-old woman presented with nonspecific right sided abdominal pain. Ultrasound detected a large cyst in the right retroperitoneal region, computed tomography revealed a large well-defined cystic lesion measuring 13 X 9 X 6 cm in the right posterior peritoneum extending from the subhepatic area to the right pelvis. Laparoscopic complete resection performed with uneventful perioperative course. Histopathologic findings were suggestive of mucinous cystadenoma. Conclusion: Primary Retroperitoneal Mucinous Cystadenoma (PRMC) is an extremely rare pathology that can pose some challenge for clinicians. Awareness of this entity can help us in establishing the diagnosis and provide an optimal management. Although laparotomy is considered the standard approach of huge mucinous cystadenomas; laparoscopic surgery can be a safe and adequate therapeutic option. Keywords: retroperitoneal cystic lesions (RCL); primary retroperitoneal mucinous cystadenomas (PRMCs); cystadenoma; mucinous; laparoscopy.

Extended experience in parieto-occipital expansion surgery by meander technique—clinical and radiological evaluation

Introduction Brachycephaly and anterior and posterior plagiocephaly appear as an isolated entity or manifest in syndromic conditions. In severe cases, possible treatment options currently comprise either cranioplasty or osteogenetic distraction. The aim of this paper is to retrospectively review the perioperative course of a series of children treated by posterior meander expansion technique at our institution with focus on the course of postoperative intracranial volume and eventual tonsillar descent evolution. Methods Forty-two children received a posterior cranial vault remodeling by means of a posterior meander technique during a 7-year period. Hospital records were reviewed, and pre- and postoperative MRIs were analyzed for intracranial volume, cephalic and asymmetry index, and tonsillar position over time. Results Median age at surgery was 11.5 months (range 17 days–10 years). Nineteen children had a symmetrical cranial deformity, twenty-three an asymmetrical synostosis. Half of the cohort showed a syndromic condition. Transfusions were administered in the majority (92.2%) of the cases. A significant postoperative increase of intracranial volume was present from 1188.9 ± 370.4 cm3 to 1324.8 ± 352.9 cm3 (p < 0.001). The asymmetry index showed a significant improvement postoperatively: 0.86 ± 0.06 versus 0.91 ± 0.05 (p < 0.001), while the cephalic index showed a non-statistical change (0.91 ± 0.11 versus 0.88 ± 0.08). Tonsillar herniation, bilateral or homolateral, showed no significant changes at early control, while a nonsignificant amelioration of tonsillar descent was seen among children older than 12 months at late imaging follow-up. Conclusion Among the osteoplastic techniques, the posterior meander technique offers several advantages, such as early mobilization of the child, less bony defects, absence of implants, and a small complication rate. However, further comparative studies among different surgical techniques are needed.

Oncologic Surgical Care Using an Enhanced Recovery Approach

Enhanced recovery programs are multimodal, evidence-based perioperative programs designed to improve a patient’s functional recovery after surgery. Enhanced recovery programs promote standardized, multidisciplinary care throughout the perioperative course to improve patient outcomes, rather than focusing on surgical technique. It is important for nurses working in acute and critical care to be aware of the paradigm shift created by the trend toward the enhanced recovery approach. By learning more about facets of the approach, the nurse will be better prepared to adopt whatever aspects of enhanced recovery their institution implements for the surgical oncology population. An overview is provided of the potential components of enhanced recovery.

Timing of congenital cardiac surgery in children who turned COVID-19 positive

We report a series of four patients with CHD who tested positive for COVID-19, got treated, and underwent cardiac surgery in the same sitting. All had an uneventful perioperative course similar to COVID-19-negative patients. We conclude that children with asymptomatic or mild COVID-19 disease may be subjected to surgery as early as within 1 week since COVID-19 negative.

Percutaneous hepatic melphalan perfusion: Single center experience of procedural characteristics, hemodynamic response, complications, and postoperative recovery

Background Percutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published. Methods In a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016–2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge. Results Fifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17–2.1) μg kg min-1 and fluid resuscitation volume of 5 (3–14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities. Conclusions PHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

Textbook outcome for esophageal cancer surgery: an international consensus-based update of a quality measure

Summary Textbook outcome for esophageal cancer surgery is a composite quality measure including 10 short-term surgical outcomes reflecting an uneventful perioperative course. Achieved textbook outcome is associated with improved long-term survival. This study aimed to update the original textbook outcome based on international consensus. Forty-five international expert esophageal cancer surgeons received a personal invitation to evaluate the 10 items in the original textbook outcome for esophageal cancer surgery and to rate 18 additional items divided over seven subcategories for their importance in the updated textbook outcome. Items were included in the updated textbook outcome if ≥80% of the respondents agreed on inclusion. In case multiple items within one subcategory reached ≥80% agreement, only the most inclusive item with the highest agreement rate was included. With a response rate of 80%, 36 expert esophageal cancer surgeons, from 34 hospitals, 16 countries, and 4 continents responded to this international survey. Based on the inclusion criteria, the updated quality indicator ‘textbook outcome for esophageal cancer surgery’ should consist of: tumor-negative resection margins, ≥20 lymph nodes retrieved and examined, no intraoperative complication, no complications Clavien–Dindo ≥III, no ICU/MCU readmission, no readmission related to the surgical procedure, no anastomotic leakage, no hospital stay ≥14 days, and no in-hospital mortality. This study resulted in an international consensus-based update of a quality measure, textbook outcome for esophageal cancer surgery. This updated textbook outcome should be implemented in quality assurance programs for centers performing esophageal cancer surgery, and could standardize quality measures used internationally.

The Influence of Obesity on Perioperative Course in High-Risk Patients with Coronary Artery Disease in Cardiac Surgery

The aim. To analyze the influence of obesity on the perioperative course in high-risk patients with coronary artery disease (CAD) in cardiac surgery. Material and methods. Retrospective analysis of 354 randomly selected high-risk patients with CAD (ES II > 5%) who underwent surgical intervention and were discharged from the Institute in the period from 2009 to 2019. All the patients underwent routine clinical tests, ECG, echocardiography, coronary angiography and surgical revascularization of the myocardium with correction of concomitant cardiac pathology. Among the patients of the experimental group, 194 (54.8%) had CAD, 132 (37.2%) had postinfarction left ventricular aneurysm, 12 (3.3%) suffered from ischemic mitral regurgitation, 16 (4.5%) patients had CAD and aortic valve disease. Results. Among high-risk patients with CAD, 287 (81.07%) had BMI > 25 kg/m2. Carbohydrate metabolism disorders were found in 208 (72.4%) overweight patients. Type 2 diabetes mellitus (DM) was diagnosed in 78 (27.1%) patients, glucose intolerance was found in 130 (45.2%) cases. Risk stratification according to the ES II scale showed maximum risk (9.8%) in patients with normal body weight and the lowest risk (5.23%) in those with grade III obesity: however, the scale does not take into account anthropometric data. With the increase in body weight, the average number of grafts decreased (3.1 at a BMI of 25-35 kg/m2, 2.6 at a BMI > 40 kg/m2) and the use of internal thoracic arteries increased: 53.7% in patients with normal weight, 66.6% in those with grade III obesity. The level of blood transfusions was the highest (55.2%) in patients with normal weight, and in those with grade III obesity no blood transfusions were performed. Postoperative atrial fibrillation occurred in 14 (20.8%) patients with BMI up to 25 kg/m2, in 30 (28.03%) with BMI 30-29.9 kg/m2 and in 8 (34.7%) patients with grade II obesity. Regardless of body weight, there was a trend towards increase in glucose levels on the first postoperative day with subnormalization until discharge. Acute kidney injury was detected in 3 (4.4%) patients with normal weight, 3 (1.94%) overweight patients, 3 (2.8%) patients with grade I obesity and 1 (33.3%) patient with morbid obesity. Conclusions. Timely preventive measures can help to avoid serious complications even in high-risk patients with obesity. Despite the fact that overweight patients have more severe perioperative period, experience of our Institute allows to operate and treat high-risk patients successfully regardless of their body weight.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery

We describe the use of liposomal bupivacaine (Exparel) in erector spinae plane blocks for two patients undergoing pediatric cardiac surgery with cardiopulmonary bypass and one undergoing division of the compressive vascular ring. The perioperative course of all patients was remarkable for low pain and sedation scores, especially after chest tube removal. Erector spinae plane blocks are an expanding pain-control technique in both adult and pediatric cardiac surgery for postoperative analgesia. Liposomal bupivacaine offers prolonged analgesia and may be an attractive option for this indication.