A tracheoesophageal fistula (TEF) that develops during comprehensive treatment in patients with advanced malignancy can be life-threatening and is usually managed palliatively; surgical intervention is exceedingly rare. The underlying malignancy, along with severe pulmonary infection, anemia, and hypoalbuminemia, poses substantial challenges to both surgery and anesthesia. We report the case of a 48-year-old female patient who was diagnosed with left submandibular gland basal cell carcinoma 14 years ago, with recurrence and pulmonary metastasis with a destroyed lung 1 year ago, after which she commenced targeted therapy. She was transferred to our hospital 18 days after a TEF diagnosis at another institution. Following multidisciplinary discussion and evaluation, we formulated a surgical and anesthetic plan comprising laparoscopic gastric replacement of the esophagus under general anesthesia with left main bronchus intubation for one-lung ventilation. However, after failed attempts at left main bronchus intubation, the procedure was successfully completed under spontaneous-ventilation general anesthesia combined with epidural anesthesia as a rescue strategy. The patient was discharged 16 days postoperatively with restored oral intake. This case highlights the feasibility of a customized anesthetic approach for complex TEF repair in a patient with a single functional lung.
Stellate ganglion blockade (SGB) is an uncommon but increasingly relevant therapy used to modulate the autonomic nervous system and reduce the risk of atrial fibrillation (AF). This narrative review focuses specifically on the potential therapeutic role of SGB in new-onset perioperative atrial fibrillation (POAF), a complication associated with adverse long-term outcomes that may diminish the overall benefits of surgery. SGB may reduce AF through several inflammation-mediated mechanisms, including attenuation of direct sympathetic activation and modulation of perioperative inflammatory responses. Because the clinical effects of SGB may persist beyond the expected duration of local anesthetic nerve blockade, we emphasize immunomodulation as a potential mechanism sustaining its beneficial effects and influencing longer-term outcomes. In this review, we examine the immunological effects of SGB in the context of postoperative AF, with particular emphasis on human studies most relevant to clinical practice. Available evidence suggests that, beyond nonspecific inflammation, several less commonly studied cellular components, including mast cells and T cells, may contribute to the initiation and persistence of POAF. These findings support the hypothesis that SGB may reduce POAF by limiting stellate ganglionitis driven by perioperative localized leukocyte activation. Future studies should define the extent, timing, and frequency of this inflammatory process and determine whether specific inflammatory or autonomic phenotypes can identify patients most likely to benefit from SGB.
BackgroundEarly detection and management of intra-abdominal hypertension (IAH) improve clinical outcomes in critically ill patients in the intensive care unit (ICU). Data on IAH among ICU patients are sparse in Ghana and the sub-region. This study evaluated the prevalence and clinical outcomes of IAH in Ghana.Materials and methodsWe conducted a prospective observational study of a mixed ICU population from 1 May to 30 November 2023 at a major referral hospital in Ghana. Patients 16 years or older had their intra-abdominal pressure (IAP) measured at admission and every 6 h for 48 h using the modified Kron's technique, and IAP was defined and graded according to standard criteria. Descriptive statistics were used to summarise patient characteristics and estimate prevalence, and logistic regression was performed to identify predictors of IAH.ResultsIn total, 89 patients, with a median age of 43 (interquartile range 29–58), were studied. A heterogeneous group of 58 (77.6%) patients were admitted for postoperative critical care or circulatory failure. Nearly all (88 patients, 98.9%) had identifiable risk factors. In total, 31 (39.7%), 22 (28.2%), and 25 (32.1%) patients had 1, 2, and 3 or more concurrent risk factors, respectively. In the ICU, 42 patients (47.2%) developed IAH, with Grade I IAH being the most prevalent (n = 27, 64.3%). The majority of the patients (n = 39, 92.9%) developed IAH within 24 h of admission. Having a higher number of predefined IAH risk factors was independently associated with the development of IAH after adjustment for age (OR 11.37, 95% CI 3.84–33.66, p < 0.001). Patients who developed IAH had significantly higher Sequential Organ Failure Assessment scores (e.g., Day 1: 8.42 vs. 6.25, p < 0.01, Day 7: 6.09 vs. 3.27, p < 0.02) throughout the first 7 days of ICU admission and fewer ventilator-free days (13.5 vs. 21.3 days, p < 0.001). The mortality rate was significantly higher in the patients diagnosed with IAH (>40% vs. 20.9%, p < 0.01).ConclusionIAH was common among critically ill patients and occurred predominantly within the first 24 h of ICU admission. Patients with multiple recognised risk factors were at an increased risk of developing IAH. The findings support targeted IAP surveillance among high-risk ICU patients in resource-limited settings.
IntroductionCitation and quotation errors are a known problem in the medical literature. However, quotation accuracy in anesthesiology has not been addressed before.MethodsWe analyzed the final issue of 2017 of three anesthesiology journals: Anesthesia and Analgesia, Anesthesiology, and British Journal of Anaesthesia. Those issues included 122 manuscripts quoting 3,033 references. We randomly selected 729 references to journal articles or web-pages and retrieved 715 (or 98%).ResultsThe overall rate of citation errors in journal articles was 16% (111 errors/697 checked journal articles), with 27% of the errors being major (e.g., publication year or first author's family name). The total number of quotation errors was 114 (or 16%), but most (68%) were major (the referenced article contradicted, failed to substantiate, or was unrelated to the authors’ assertions). Only 18 evaluated references were web-pages. In addition to three dead links, we were not able to evaluate seven of the remaining ones (registration required, or no indication where on the site to look for the exact piece of information).ConclusionsComparing our results with previous publications, it is likely that the citation errors in anesthesiology were reduced over the past decades. However, the quotation error rate raises concerns: the rate is high and most of the errors are serious in nature. Joint efforts by all involved parties (authors, editors, and publishers) are called for, while the final solution will most likely be based on AI-guided tools. Moreover, more specific guidelines for citing web-pages should be implemented in the future.
IntroductionThe effects of remifentanil on maternal and neonatal outcomes during general anesthesia for cesarean section have been controversial. Therefore, we conducted a meta-analysis to evaluate the impact of remifentanil on maternal and neonatal outcomes.MethodsFollowing PRISMA guidelines, randomized controlled trials published before December 31, 2025, were sourced from PubMed, Embase, Web of Science, and Cochrane. Two independent researchers screened and extracted data, using weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CI) to evaluate associations. Heterogeneity was assessed with the I² test, along with subgroup and sensitivity analyses. Publication bias was checked using funnel plots and Egger's test.ResultsEleven randomized controlled trials with 645 participants were analyzed, with 323 in the experimental group and 322 in the control group. The 1-minute Apgar score and maternal mean arterial pressure (MAP) at intubation were significantly lower in the remifentanil group, with weighted mean differences of −0.35 (95% CI: −0.54 to −0.15) and −11.73 (95% CI: −21.46 to −2.00), respectively. No significant differences were found in the 5-minute Apgar score or other neonatal and maternal outcomes. Subgroup analysis showed the 1-minute Apgar score was significantly lower in both placebo-controlled and dexmedetomidine-controlled groups compared to the experimental group.ConclusionRemifentanil can stabilize maternal blood pressure during tracheal intubation in cesarean sections under general anesthesia, but it might lower the 1-minute neonatal Apgar score. There were no significant impacts on the 5-minute Apgar score or respiratory function. Further clinical studies are needed to assess its benefits for neonates.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD420261342473, PROSPERO CRD420261342473.
IntroductionThe anesthetic management of patients with von Willebrand disease (VWD) present a significant perioperative challenge due to the high risk of hemorrhage. This risk is further elevated in neurosurgical procedures, such as transsphenoidal surgery (TSS) for pituitary neuroendocrine tumors (PitNETs), due to the close proximity to critical neurovascular structures.Case presentationThis report describes a 42-year-old male with type 2 VWD and hypothyroidism, diagnosed with a Knosp grade 3A PitNET, who underwent an endoscopic endonasal transsphenoidal resection. A multidisciplinary approach was implemented, including hemodynamic monitoring and targeted replacement of VWF/FVIII concentrate calculated according to plasma levels, maintaining paremeters of VWF ristocetin cofactor/activity (VWF:RCo) (%) and FVIII (%): >80% during the intraoperative period and >50% during the postoperative period. The postoperative course was favorable, with no neurovascular, hemostatic, hemodynamic, or endocrine complications.DiscussionThe coexistence of VWD and a macro-PitNET creates a profound clinical dilemma that exposes the limitations of conventional perioperative care. While TSS demands strict hemostatic control due to its proximity to major neurovascular structures like the cavernous sinuses and internal carotid arteries, the type 2 VWD directly threatens clot stability and initial platelet plug formation. Given the scarce literature surrounding its neuroanesthetic management, this case report discusses the successful implementation of an individualized strategy. By integrating targeted plasma-derived VWF/FVIII replacement with real-time thromboelastography (TEG) and advanced hemodynamic monitoring, we demonstrate how a coordinated multidisciplinary approach can successfully mitigate overlapping hemorrhagic and neurosurgical risks.ConclusionsThis case highlights the importance of individualized planning and comprehensive management based on the American Society of Hematology (ASH), International Society on Thrombosis and Haemostasis (ISTH), National Hemophilia Foundation (NHF), and World Federation of Hemophilia (WFH) (ASH–ISTH–NHF–WFH, 2021) guidelines to optimize outcomes in patients with VWD undergoing high-complexity surgery.
BackgroundLimited public understanding of anesthesia and anesthesiologists’ roles may be associated with perioperative fear and influence attitudes toward surgical consent. This study assessed anesthesia literacy, information sources, and anesthesia-related concerns among adults attending preoperative clinics in Riyadh, Saudi Arabia, and examined predictors of awareness of anesthesia-related complications.MethodsA bicentric cross-sectional study was conducted between June 2024 and March 2025 in preoperative clinics of two secondary-care institutions. Participants completed a structured questionnaire assessing sociodemographics, surgical/anesthesia history, information sources, attitudes toward anesthesia and anesthesiologists, and concern regarding anesthesia-related events. The primary outcome was the Consent Hesitancy Score, a continuous composite summing participants’ Likert-scale ratings of concern regarding ten anesthesia-related events. Multivariable linear regression was used to identify predictors of hesitancy; logistic regression was used for the secondary binary outcome of self-reported awareness of anesthesia-related postoperative complications.ResultsA total of 477 participants were included (57.4% female; 53.2% aged 18–25 years). Most agreed that anesthesia-related information is crucial for surgical decision-making (84.5%) and reported complete/mostly trust in anesthesiologists’ judgment (86.5%). Concern was highest for severe events (mean 3.01–3.19; 55%–62% very concerned) and lower for transient effects (mean 2.28–2.56). In multivariable analysis, awareness of anesthesia-related complications was higher with prior surgery (OR 1.77, 95% CI 1.16–2.71), healthcare-provider information (OR 1.88, 95% CI 1.11–3.25), scientific/governmental website use (OR 1.70, 95% CI 1.10–2.65), age 26–35 (OR 2.02, 95% CI 1.04–4.03) and 36–45 years (OR 4.24, 95% CI 1.80–10.38), and comorbidities (OR 1.80, 95% CI 1.08–3.01); males had lower odds of awareness than females (OR 0.62, 95% CI 0.40–0.97).ConclusionAmong adults attending preoperative clinics, trust in anesthesiologists and perceived importance of anesthesia information were high, yet concerns centered on severe anesthesia-related events and knowledge gaps persisted. Prior surgical exposure, comorbidity status, and use of healthcare professionals and scientific/governmental sources were associated with greater awareness of anesthesia-related complications, suggesting that targeted preoperative education and clear communication may be worth further investigation.
BackgroundSepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, with high global morbidity and mortality. The Sepsis-3 definition endorses the Sequential Organ Failure Assessment (SOFA) score to quantify organ dysfunction, though it was not originally designed for prognostication. Biomarkers such as interleukin-6 (IL-6), a key pro-inflammatory cytokine, have shown promise in reflecting disease severity and rising earlier than clinical scores.AimThis study aimed to compare the SOFA score with the SOFA score and interleukin-6 level in the accurate prediction of outcome as a survivor or non-survivor at the end of 15 days among patients admitted to the ICU in a tertiary care hospital.MethodsThis prospective observational study was conducted in a tertiary care ICU. In total, 40 adult patients (18–50 years) with sepsis (Sepsis-3 criteria) and an anticipated ICU stay of >72 h were enrolled. Patients with acute coronary syndrome, terminal malignancy, major burns, elective postoperative ventilation, COVID-19, or inter-ICU transfer were excluded. SOFA scores and serum IL-6 levels were measured at admission (Day 0) and at 24-h intervals up to 72 h (Days 1–3). Patients were followed for 15 days and classified as survivors or non-survivors. The prognostic performance of SOFA, IL-6, and the combined score was assessed using receiver operating characteristic (ROC) analysis. Internal validation was performed using bootstrap resampling with 1,000 iterations to obtain optimism-corrected area under the curve (AUC) values.ResultsOf the 40 patients, 24 (60%) survived, and 16 (40%) died within 15 days. Non-survivors had significantly higher SOFA scores at admission compared with survivors [median of 13 (IQR 10–15) vs. 10 (IQR 8–12); p = 0.006]. Survivors demonstrated a declining SOFA score trend over time, while non-survivors showed progressive increases (p < 0.05 at all timepoints). IL-6 levels were consistently higher in non-survivors across Days 0–3 (p < 0.05). Discriminative performance improved over time for both SOFA and IL-6, with the highest AUCs on Day 3 (SOFA: 0.986; IL-6: 0.993). After bootstrap internal validation, the optimism-corrected AUC for the combined SOFA–IL-6 score on Day 3 was 0.908 (95% CI: 0.824–0.992), comparable to SOFA alone (corrected AUC 0.908, 95% CI: 0.826–0.990). On Days 0–2, the combined score showed modestly higher corrected AUCs compared to SOFA alone (improvements of +0.024 to +0.048).ConclusionIn this hypothesis-generating study, combining the SOFA score with IL-6 showed modest improvements on Days 0–2 compared with SOFA alone. On Day 3, both scores performed equivalently. This integrated approach may provide a practical and dynamic tool for early prognostication in critically ill patients with sepsis.
BackgroundArtificial intelligence (AI) is increasingly transforming anesthesiology and perioperative medicine through predictive analytics, real-time monitoring, and clinical decision support. In obstetrics, AI has shown promise in predicting complications such as preeclampsia and postpartum hemorrhage. However, it's integration into obstetric anesthesiology remains limited due to challenges including dynamic maternal physiology, time-sensitive care, and the need to optimize both maternal and fetal outcomes. This mini-review evaluates current evidence and the translational potential of AI in obstetric anesthesiology.MethodsA literature review was performed using PubMed, Google Scholar, and OpenEvidence AI, covering studies published up to April 2026, with emphasis on post-2015 literature. Included studies comprised original research, systematic reviews, and case series published in English. Animal studies and editorials without primary data were excluded. Two authors independently screened articles, resolving disagreements by consensus.DiscussionCurrent applications include machine learning-assisted ultrasound guidance for neuraxial procedures, optimization of intrathecal anesthetic dosing, and prediction of spinal anesthesia-induced hypotension. AI models have also been developed to predict epidural-related maternal fever and post-cesarean pain. Despite promising findings, most studies are retrospective and lack external validation. Major barriers include data heterogeneity, algorithmic bias, limited interpretability, and challenges integrating AI into clinical workflows.ConclusionAI has significant potential to improve risk stratification, procedural precision, and personalized care in obstetric anesthesiology. Future research should focus on prospective validation, multicenter collaboration, explainable models, and seamless clinical integration, with AI serving as a support tool rather than a replacement for clinician expertise.
BackgroundThe thoracic paravertebral block (PVTB) is a regional anesthesia technique that targets the paravertebral space, providing unilateral, segmental analgesia. This technique is applied in various procedures, including thoracic surgery, and for postoperative pain management in video-assisted thoracic surgery (VATS). The ultrasound-guided technique has gained popularity due to its precision. Despite its benefits, a major limitation is the short duration of its effect, typically lasting no more than 12 h. As a result, continuous PVTB is often preferred but presents challenges in catheter placement and maintenance.Case reportThis case describes the use of an ultrasound-guided thoracic paravertebral catheter for continuous analgesia in a left VATS pneumonectomy. A 50-year-old patient (BMI of 30 and history of chronic obstructive pulmonary disease) underwent the procedure under general anesthesia. After catheter placement using a SonoLong Echo™ needle, the position was confirmed through hydrodissection and a “bubble test” with saline. Postoperative pain management involved a continuous ropivacaine infusion and rescue doses. The patient experienced effective relief, with numerical rating scale scores consistently below 3, and was discharged on the 8th postoperative day without complications.ConclusionUltrasound-guided thoracic paravertebral catheter placement offers a reliable alternative to epidural analgesia for thoracic surgeries. Despite concerns about catheter malpositioning, particularly in obese patients, our experience demonstrates that the saline “bubble test” effectively confirms the catheter's position. This approach provides excellent postoperative pain control with minimal complications, making it a valuable technique for managing pain in VATS and other thoracic procedures.
This case report describes obstructive shock caused by direct compression of the heart by the rib cage. To our knowledge, this is the first time such a complication has been reported. A patient with multiple rib fractures and thoracic spine fractures required emergency spine surgery. The patient was hemodynamically stable when supine but immediately on proning became profoundly hypotensive, requiring resuscitation with vasopressors and inotropes. As soon as the patient was turned supine, resuscitative drugs could be stopped. There was no other cause for the hypotension identified other than direct compression of the heart. Care must be taken when proning patients with rib fractures to avoid this complication.
Perioperative opioid effects can appear inconsistent when receptor occupancy is treated as a direct proxy for clinical outcome—particularly when a high-affinity partial agonist is assumed to “block” a full agonist at μ-opioid receptors (MOR). We apply the Black–Leff receptor operational model to reframe MOR engagement as an upstream input and perioperative endpoints as downstream outputs shaped by input–output transduction (operational efficacy, τ), context-dependent minimum required effect (E*), and effect-site concentration (Ce). This output-centered framing explains why opioid co-administration can preserve analgesia while attenuating respiratory depression, and why the same regimen may seem inadequate intraoperatively yet sufficient postoperatively as τ and E* shift with perioperative state. We further emphasize how affinity and route/timing act through Ce to determine occupancy across anatomical targets, enabling neuraxial–supraspinal dissociations and time-dependent changes in respiratory risk. Translating these ideas to bedside reasoning, we propose two minimal bedside reading prompts—define the endpoint first and avoid generalizing from a single readout—to anticipate and interpret common perioperative opioid patterns without invoking receptor-level antagonism.
Left ventricular assist devices (LVADs) being increasingly deployed, both as permanent “destination LVADs”, as bridges to cardiac transplantation, for temporary support to support complex percutaneous coronary interventions, for postoperative support of cardiac surgical patients, or for temporary support of acutely decompensated heart failure. These devices are quite effective for the support of the left ventricle but do rely on native right heart function. In this manuscript we review the unique aspects of right ventricular anatomy and physiology, the assessment of right ventricular function, the impact of right ventricular dysfunction on LVAD performance, and strategies to mitigate this impact. We focus on the most common LVADs, the durable and surgically implanted HeartMate III and the temporary, and usually percutaneously placed, Impella.
Aconitate decarboxylase 1 (ACOD1, formerly IRG1) and its product itaconate have emerged as central regulators of tumour immune surveillance: ACOD1-derived itaconate in tumour-associated macrophages (TAMs) suppresses inflammatory gene expression and limits CD8⁺ T-cell infiltration, while systemic itaconate modulates NLRP3 inflammasome activity and natural killer (NK) cell function. We propose that two agents routinely co-administered in fluoropyrimidine-treated oncological patients—sevoflurane and 5-fluorouracil (5-FU)—may converge on aconitase 2 inhibition, depleting the cis-aconitate substrate for ACOD1 and thereby disrupting itaconate-dependent immune regulation at a critical perioperative window. The fluoroacetate pathway of 5-FU is experimentally established; sevoflurane undergoes CYP2E1-mediated metabolism to fluorinated intermediates whose further biotransformation may generate aconitase-inhibitory species, as suggested by the work of Karpiński et al. (2006) and supported by prospective metabolomic evidence (Wei et al., 2021) demonstrating plasma metabolomic patterns consistent with aconitase perturbation in sevoflurane-anaesthetised patients. The immunological consequences of perioperative ACOD1/itaconate depletion—paradoxically encompassing both pro-tumorigenic immune evasion at the tumour microenvironment level and heightened systemic inflammatory susceptibility—represent a potentially unrecognised dimension of anaesthetic pharmacology in oncological surgery. Pre-operative dual genotyping for dihydropyrimidine dehydrogenase (DPYD) and ACOD1 variants is proposed as a pharmacogenomic framework for anaesthetic technique selection.
BackgroundPatients undergoing pancreatic surgery are at high risk of postoperative complications due to the procedure complexity. Intraoperative hypotension (IOH), defined as a mean arterial pressure (MAP) < 65 mmHg, is associated with adverse outcomes. The Hypotension Prediction Index (HPI) is a machine learning–based tool designed to predict IOH before it occurs and support proactive hemodynamic management.MethodsThis retrospective observational pilot study evaluated intraoperative hemodynamics in patients undergoing pancreatic surgery before and after implementation of an HPI-guided goal-directed therapy (GDT) protocol. Patients treated before March 2023 received FloTrac-guided GDT, whereas those treated later were managed with HPI-guided GDT.ResultsForty-eight patients were included (20 FloTrac-GDT, 28 HPI-GDT). Compared with the FloTrac group, the HPI group showed a higher median MAP (81 vs. 76 mmHg, p < 0.05), a lower time-weighted average MAP <65 mmHg (0.32 vs. 0.55, p < 0.05), and a shorter duration of IOH (32 vs. 52 min, p < 0.05). Stroke volume index and the use of vasopressors were comparable. Postoperative morbidity and mortality did not differ significantly.DiscussionAdopting an HPI-guided GDT protocol reduced the burden of IOH during pancreatic surgery without affecting stroke volume index. These findings support improved intraoperative management through earlier intervention, though prospective studies are warranted to evaluate long-term outcomes.
IntroductionPostoperative opioid analgesia poses multiple risks to bariatric patients undergoing robotic or laparoscopic sleeve gastrectomy. Truncal blocks, including the erector spinae plane block, are utilized for perioperative pain management in abdominal and thoracic surgeries. We hypothesized that the erector spinae plane blocks would decrease opioid consumption in bariatric surgery patients.MethodsWe conducted a single-center propensity-matched retrospective cohort study evaluating the impact of erector spinae plane blocks in bariatric surgery. The inclusion criteria were adults (≥18 years old) who underwent robotic or laparoscopic sleeve gastrectomy from January 2023 to November 2024. One:one nearest-neighbor propensity matching was performed using patient demographics, procedure type, and preexisting comorbidities to address confounding factors. Subgroup analysis of recovery parameters between robotic vs. laparoscopic sleeve gastrectomy was also performed.ResultsSix hundred seventy participants were identified with similar demographics and underlying conditions between the erector spinae plane (n = 240) and control (n = 430) groups. Propensity matched groups (n = 179 per group) identified that erector spinae plane block reduced post-anesthesia care unit oral morphine equivalents (−4.81 mg, 95% CI: −9.76 to −0.29, p = 0.04), intraoperative morphine equivalents (−5.85 mg, 95% CI: −9.27 to −2.42, p < 0.001), intraoperative hydromorphone (−0.11 mg, 95% CI: −0.16 to −0.04, p = <0.001), and intraoperative ketamine consumption (−6.33 mg, 95% CI: −10.98 to −1.68, p = 0.01). Multiple linear regression demonstrated significantly higher PACU opioid requirements in laparoscopic procedures compared to robotic-assisted procedures (4.64 mg, 95% CI: 0.53––8.75, p = 0.03)ConclusionErector spinae plane block resulted in a reduction in opioid consumption both during and after robotic and laparoscopic sleeve gastrectomy. Our work is consistent with randomized trials in the field, demonstrating statistically relevant decreases in opioid use, and is the first to explore its application in robotic-assisted bariatric surgery.
BackgroundPerioperative high abuse-liability opioids (HALO), and associations with both postoperative nausea and vomiting (PONV) and new persistent opioid use (NPOU), present epidemiologic challenges impacting short- and long-term quality of life. While enhanced recovery treatments emphasizing non-opioids have become more prevalent, they typically do not incorporate comprehensive strategies for extensive avoidance of both HALO use and intermediate-term PONV. Based on modeling of recent observational research, there may be benefits to stakeholders by adopting strategies that meaningfully reduce PONV while potentially minimizing NPOU.MethodsWe developed a Markov decision analysis model comparing pharmacoeconomic/clinical outcomes over a 5-year time horizon after a 2–4-day surgical encounter for elective bariatric surgery. Two intrathecal morphine enhanced recovery treatment strategies (partial and comprehensive) were tested, alongside historical controls.ResultsThe comprehensive strategy featuring scheduled booster non-opioids and antiemetics carried a US$500–$1,900 lower cost burden per case in the model, while preserving more quality-adjusted life days (21–35) per case, than did the Partial strategy or historical controls. Sensitivity analyses of the comprehensive strategy demonstrated that the results were robust over many model parameters. The comprehensive strategy, however, carried a tradeoff of pruritus due to intrathecal opioid use.ConclusionCapitalizing on the generic availability of 5-HT3 (palonosetron) and NK-1 antagonist antiemetics, as well as low abuse-liability intrathecal morphine combined with intrathecal magnesium, the described comprehensive enhanced recovery treatment strategy (featuring scheduled boosters) was associated with both reduced costs and improved quality of life after bariatric surgery.
IntroductionHaemothorax is a rare but potentially life-threatening complication of percutaneous nephrolithotomy (PCNL), typically occurring during or immediately after the procedure due to pleural injury. Massive haemothorax with occult presentation poses a diagnostic challenge, as initial chest drainage may not reveal bleeding. This case demonstrates the critical role of point-of-care ultrasound (POCUS) in rapidly diagnosing and guiding the management of such high-risk scenarios.Case presentationA 64-year-old male underwent elective PCNL for left renal pelvis stones with hydronephrosis. The postoperative course unfolded as follows: (1) he developed hypotension and hypoxemia in the post-anesthesia care unit (PACU), despite no significant bloody fluid was observed in the perinephric drain (nephrostomy tube) that had been placed for retroperitoneal drainage. (2) Arterial blood gas analysis indicated active bleeding, prompting urgent POCUS evaluation, which revealed massive left pleural effusion. (3) Immediate interventions—including fluid resuscitation, blood transfusion, POCUS-guided thoracentesis stabilized the patient. (4) Subsequent renal artery embolization achieved hemostasis, and the patient was discharged on postoperative day 7. At 3-month follow-up, he remained asymptomatic with no evidence of recurrent pleural effusion.ConclusionThis case highlights the value of POCUS in detecting occult haemothorax after PCNL, particularly when clinical signs and perinephric drain output are discordant. The timely integration of POCUS into perioperative monitoring may facilitate life-saving interventions.
BackgroundChronic kidney disease (CKD) increases perioperative risk through metabolic, cardiovascular, and hematologic disturbances that complicate anaesthetic management. Evidence from sub-Saharan Africa on surgical outcomes across CKD stages is limited.ObjectiveTo describe anaesthetic practices and assess perioperative morbidity and mortality in CKD patients undergoing surgery at Monkole Hospital, Kinshasa.MethodsThis retrospective cross-sectional study included adult CKD patients who underwent urgent or elective surgery between February 2018 and December 2024. Renal function was classified using the CKD-EPI 2021 equation into GFR categories G1–G5. Outcomes included intraoperative incidents, perioperative complications, transfusion requirements, opioid use, and in-hospital mortality. Multivariate logistic regression identified predictors of adverse outcomes, comparing patients with GFR < 60 and ≥60 mL/min/1.73 m2.ResultsAmong 418 patients, 48.1% were G3, 24.6% G2, and 15.3% G1. Complications and mortality rose with declining renal function. Patients with GFR < 60 mL/min/1.73 m2 had higher mortality than those with GFR ≥ 60 (11.2% vs. 5.4%). After adjustment, GFR < 60 remained independently associated with mortality (OR 2.61, 95% CI 1.01–6.71).ConclusionReduced renal function independently predicted increased perioperative mortality, highlighting the need for improved risk stratification in CKD patients.
