BACKGROUND Osteonecrosis or avascular necrosis (AVN) of the hip was one of the dreaded complications of coronavirus disease 2019 (COVID-19), which emerged in patients who received steroid therapy. Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients. Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous (IV) or oral dexamethasone, methylprednisolone or hydrocortisone. The use of such high doses of corticosteroids has shown very positive results and has been lifesaving in many cases. Still, long-term consequences were drug-induced diabetes, osteoporosis, Cushing syndrome, muscle wasting, peripheral fat mobilization, AVN, hirsutism, sleep disturbances and poor wound healing. A significant number of young patients were admitted for bilateral total hip replacements (THR) secondary to AVN following steroid use for COVID-19 treatment. AIM To assess the efficacy of bilateral pericapsular end nerve group (PENG) blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery. METHODS This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals, Hyderabad, India. Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months. All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia. RESULTS The duration of surgery was 2.5 h on average. Seventeen out of twenty patients (85%) had a Visual Analog Score (VAS) of less than 2 and did not require any supplementation. One patient was removed from the study, as he required re-exploration. The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug. Fifteen out of seventeen patients (88.2%) could be mobilized 12 h after the procedure. CONCLUSION Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19, which surfaced in patients who received steroid therapy requiring surgical intervention. Bilateral PENG block is an effective technique to provide post-operative analgesia resulting in early mobilization and enhanced recovery after surgery.
BACKGROUND Heart failure is generally regarded as a progressive and irreversible medical condition. The EVAHEART is an implantable left ventricular assist system.CASE SUMMARY We report the anesthesia management of a 56-year-old male patient with dilated cardiomyopathy undergoing an EVAHEART implantation. Transesophageal echocardiography is crucial to ensure the correct positioning of the device and the proper aortic valve outflow. Because the continuous blood flow device functions best under low systemic and pulmonary vascular resistance, milrinone is the preferred drug. Our patient was accompanied by pulmonary hypertension, so during the operation, nitric oxide was used to reduce pulmonary artery pressure.CONCLUSION The cardiac output achieved by the patient with the assistance of EVAHEART can reach 4 L/min, which of course depends on the front load, rear load, and pump speed.
Intraoperative management of liver transplant in a patient with an undiagnosed ventricular septal defect: A case report
BACKGROUND In anesthesia practice, orotracheal intubation remains the primary concern of the anesthesiologist. The introduction of video laryngoscopy（VL） has increased the success rate of orotracheal intubation; however, conflicting results have been reported regarding the usefulness of the current technique with VL in clinical practice.AIM To describe a modification to improve intubation with VL, followed by evaluation of the practice in vivo.METHODS First, a mannequin trial was conducted with operators having different experience and background. Then, a retrospective analysis was performed for an ＞ 1-year period with patients who underwent general anesthesia with orotracheal intubation. The endotracheal tube used had been pre-formed with two curves. Stepwise intubation had been performed with direct eye vision, followed by screen assistance and rotation of the tube as needed to direct it toward the glottis. In the mannequin trial, the outcome measures were quantification of torque（force with angular acceleration during levering）, need for external maneuvers, and time to intubate. In the clinical experience, orotracheal intubation used VL（pre-formed tube） or direct laryngoscopy（DL） at the anesthetist’s discretion and throat discomfort was reported by the patient.RESULTS In the mannequin trials using VL, there was less torque with the pre-formed tube than with a regular tube（8% and 65%, respectively）. The first-pass rate was higher with the pre-formed tube（95%） than with a regular tube（81%）. However, the time to intubate was longer with the pre-formed tube than with a regular tube（22 s and 12 s, respectively）. In clinical practice, 562 patients underwent surgery under general anesthesia with orotracheal intubation using either VL（n = 244） or DL（n = 318） at the discretion of the attending anesthetist. VL was specifically planned in 62 of the patients, due to anticipated difficulty. Second attempts by readjustment of the curve of the tube were significantly fewer with VL than with DL（10% vs 18%）. Throat discomfort was reported by fewer patients who underwent VL than those who underwent DL（6% vs 24%）.CONCLUSION Pre-formed endotracheal tube with stepwise insertion produces less torque, fewer external maneuvers and higher first-pass success rate during VL intubation. Further, prospective studies are warranted.
BACKGROUND Cement-related embolism is a rare but potentially fatal complication in spinal surgery. Cardiac echocardiography can provide valuable information for the early identification.CASE SUMMARY A 66-year-old woman who underwent lumbar vertebroplasty and internal fixation under general anesthesia experienced an episode of supraventricular tachycardia and ventricular tachycardia at the end of surgery. Point-of-care echocardiogram revealed a foreign body in the right heart. After conservative treatment in the intensive care unit, her family decided on comfort care and she expired.CONCLUSION Transthoracic echocardiography may provide early valuable information in patients undergoing vertebroplasty, and mild-moderate pericardial effusion may be a significant sign of a poor outcome.
BACKGROUND The usage of bronchoscopy during percutaneous dilatational tracheostomy remains under debate. The proponents of bronchoscopy advocating safety of the procedure, whereas the critics raising the concerns about the cost, possible delay in the procedure, and waiting for the device.CASE SUMMARY We are highlighting a case of percutaneous dilatational tracheostomy where bronchoscopy aided in diagnosing a rare situation of wire entrapment within the endotracheal tube, treated by withdrawing the wire from the endotracheal tube with good outcome.CONCLUSION The bronchoscopy guided approach permitted early diagnosis and helped to end the procedure without complication or possible major surgery in a case of accidental wire puncture of the endotracheal tube.
Low dose corticosteroids to adult patients with coronavirus disease 2019（COVID-19） and refractory shock was given some evidence, the evidence was of low quality given particularly for shock-reversal. Evidence. However bacterial sepsis may not provide a similar evidence like in a viral related one. We think that suggesting steroids for COVID-19 may not be adequate in the current time and future data analysis should be directed to find possible evidence in a matched population.
Healthcare delivery cost and anesthesiologists: Time to have a greater role and responsibility
Enhanced recovery after surgery pathway: The use of fascia iliaca blocks causes delayed ambulation after total hip arthroplasty
Postoperative urinary retention（POUR） is one of the postoperative complications which is often underestimated and often gets missed and causes lot of discomfort to the patient. POUR is essentially the inability to void despite a full bladder in the postoperative period. The reported incidence varies for the wide range of 5%-70%. Multiple factors and etiology have been reported for occurrence of POUR and these depend on the type of anaesthesia, type and duration of surgery,underlying comorbidities, and drugs used in perioperative period. Untreated POUR can lead to significant morbidities such as prolongation of the hospital stay, urinary tract infection, detrusor muscle dysfunction, delirium, cardiac arrhythmias etc. This has led to an increasing focus on early detection of POUR.This review of literature aims at understanding the normal physiology of micturition, POUR and its predisposing factors, complications, diagnosis and management with special emphasis on the role of ultrasound in POUR.
Lumbar radiculopathy（LR） is a term used to describe a pain syndrome caused by compression or irritation of nerve roots in the lower back. The surgery cost for LR increased by 23% annually during 1992-2003 in the developed country. Although it is one of most common complaints in clinical practice, the diagnosis for LR is still very challenging. Here we discuss the current tools of LR diagnosis and highlight the needs to develop new diagnosis tools for LR.
Neuropathic pain is a chronic syndrome caused by direct damage to or disease of the somatosensory nervous system. The lack of safe, adequate and sustained pain relief offered by present analgesic treatments is most alarming. While many treatment options are available to manage chronic pain, such as antidepressants, nonsteroidal anti-inflammatory agents, opioids, and anticonvulsants, chronic neuropathic pain remains largely unmanaged. Compounding the dilemma of ineffective chronic pain treatments is the need to provide relief from suffering and yet not contribute to the scourge of drug abuse. A recent epidemic of addiction and accidental drug prescription overdoses parallel the increased use of opioid treatment, even though opioids are rarely an effective treatment of relieving chronic pain. To make matters worse, opioids may contribute to exacerbating pain, and side-effects such as cognitive impairment, nausea, constipation, development of tolerance, as well as their potential for addiction and overdose deaths exist. Clearly, there is an urgent need for alternative, nonopiate treatment of chronic pain. Innovative discoveries of pertinent brain mechanisms and functions are key to developing effective, safe treatments. Pioneering work has revealed the essential effects of the pleiotropic mediator tumor necrosis factor（TNF） on brain functioning. These studies establish that TNF inhibits norepinephrine release from hippocampal neurons, and show that excess TNF production within the hippocampus occurs during neuropathic pain, which mobilizes additional mechanisms that further inhibit norepinephrine release. Significantly, it has been verified that elevated levels of TNF in the brain are actually required for neuropathic pain development. Since TNF decreases norepinephrine release in the brain, enhanced TNF levels would prevent engagement of the norepinephrine descending inhibitory neuronal pain pathways. Increased levels of TNF in the brain are therefore critical to the development of neuropathic pain. Therefore, strategies that decrease this enhanced TNF expression in the brain will have superior analgesic efficacy. We propose this novel approach of targeting the pathologically high levels of brain TNF as an effective strategy in the treatment of the devastating syndrome of chronic pain.
AIM To determine if video laryngoscopy（VL） has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation（FOI）. METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009（"pre-VL" group） and over the same 2-mo period after the introduction of VLs in 2012（"postVL" group）. Patient records with predicted difficult air-ways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually（P = 0.1768）, it showed a trend toward significance when covariates were accounted for（P = 0.0910）. Several factors predicting a higherlikelihood of awake FOI were found to be statistically significant: Morbid obesity（larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase）, male gender（P = 0.0026, OR = 3.0） and a higher el-Ganzouri airway score（P = 0.0007, OR = 1.5）. Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.
Exsanguination from trauma, gastrointestinal bleeding,and obstetric hemorrhage remains a major source of mortality across the planet. Continued research into resuscitation strategies and evolving technology and blood product storage has allowed for patient to undergo very large volume transfusions, even to the point of replacing a patient’s blood volume several times over. As massive transfusions have become more common, more studies have been performed delineating the exact patient population that would benefit, start-and stop-points of transfusions, complications and avoidance of the same. We discuss these points and provide information and strategies for massive transfusion.
Treatment for chronic pain is frequently unsuccessful or characterized by side-effects. The high-frequency repetitive transcranial magnetic stimulation（HF-rTMS） has been suggested in the management of refractory chronic pain. Various studies have shown that HF-rTMS sessions of long-duration applied at primary motor cortex induce pain relief through mechanisms of plastic changes. Efficacy of r TMS mostly depends on stimulation parameters, but this aspect requires better characterization. A rationale to target other cortical areas exists. Current data are promising, but a careful analysis of stimulation settings and maintenance treatment design are need.
Intrathecal morphine vs femoral nerve block for postoperative-analgesia after total knee arthroplasty: A two-year retrospective analysis
Liver diseases that are most unique to pregnancy consist of hyperemesis gravidarum,acute fatty liver of pregnancy,intrahepatic cholestasis of pregnancy,and hemolysis,elevated liver enzymes and low platelets syndrome.In this review,risk factors,etiology,symptoms,diagnosis,prognosis and treatment of each entity followed by principles of anesthetic management based on the case reports or retrospective records will be addressed.
