BackgroundAnesthetic management of pediatric patients with rare diseases presents substantial perioperative challenges and risks. This study evaluated the clinical competency and specific educational needs of anesthesia practitioners in China regarding the perioperative management of this vulnerable patient population.MethodA cross-sectional survey was conducted from May 2024 and March 2025, involving 2127 anesthesia practitioners across China. Data were collected via a validated anonymous questionnaire and analyzed through descriptive statistics and chi-square tests.ResultAmong the 2,127 participants, 93.5% were anesthesiologists and 6.5% were nurse anesthetists. Of these, 43.2% (919/2127) reported previous experience in administering anesthesia to children with rare diseases. Despite this exposure, self-assessed competency levels were notably insufficient. Only 9.0% (191/2127) of respondents reported comprehensive knowledge of pediatric rare diseases, and 15.0% (318/2127) expressed adequate confidence in perioperative management protocols. Objective assessment of specific knowledge domains revealed considerable deficiencies: 14.9% (317/2127) of respondents correctly identified contraindications in muscular dystrophy, 6.6% (141/2127) demonstrated adequate understanding of difficult airway indicators, and merely 3.9% (82/2127) accurately recognized depolarizing agent risks. Comparative analysis between self-rated high-familiarity and low-familiarity groups revealed that direct clinical exposure was significantly associated with practitioners' understanding of pediatric rare diseases. Regarding the development of future anesthesia support systems for pediatric rare diseases, practitioners identified two primary requirements: comprehensive diagnostic information (58.6%, 1246/2127) and detailed anesthesia contraindications (57.0%, 1212/2127). Additionally, 50.1% (1065/2127) of respondents emphasized the importance of real-time knowledge base updates to ensure access to current clinical guidelines and safety protocols.ConclusionThis study highlights substantial knowledge gaps and insufficient confidence among anesthesia practitioners in the perioperative management of children with rare diseases, underscoring an urgent need for enhanced training and robust support systems in this specialized area.

RATIONALE:Subcapsular liver hematoma (SLH) during pregnancy is a rare but potentially life-threatening complication, often associated with hypertensive disorders such as preeclampsia and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. PATIENT CONCERNS:We report the case of a 37-year-old primipara who presented at 39 weeks of gestation with severe preeclampsia (blood pressure, 166/106 mm Hg; proteinuria, 2+). Notably, her prenatal course was marked by normal blood pressure and 3 negative urine protein tests. DIAGNOSES:The patient was diagnosed with incomplete HELLP syndrome and a ruptured SLH. This intraoperative diagnosis was confirmed by the identification of 800 mL of noncoagulated blood and a 4 × 2 cm left hepatic lobe subcapsular hematoma with semiactive bleeding. INTERVENTIONS:Laparoscopic hematoma evacuation and hemostasis were successfully performed. OUTCOMES:The patient had a stable postoperative recovery. A systematic review of 99 cases from 71 studies was conducted, which documented HELLP syndrome in 78 cases, with maternal and fetal mortality rates of 13.1% and 33.3%, respectively. Notably, 88.8% of patients presented with pain, predominantly right upper quadrant (46%), whereas our case exhibited atypical left-sided pain. LESSONS:This case, along with a literature review, underscores the importance of vigilance for SLH in hypertensive pregnancies, even in the absence of classic HELLP criteria, and advocates for prompt imaging, individualized treatment, and multidisciplinary coordination to optimize outcomes.

BACKGROUND:The integration of ChatGPT with educational settings is happening at an unprecedented rate, and there is a growing trend for students to use ChatGPT for various academic work. Although numerous studies have evaluated the knowledge, attitudes, and practices related to ChatGPT among students in diverse medical fields, there remains a notable absence of such research within the Chinese context. METHODS:The questionnaire survey was conducted to a sample of 1,133 medical students from various medical colleges across Sichuan Province, China, between May 2024 and November 2024 to explore the awareness and attitudes of medical students towards ChatGPT. Descriptive statistics were used to tabulate the frequency of each variable. A chi-square test and multiple regression analysis were employed to investigate the factors influencing participants' positive attitudes toward the prospective use of ChatGPT. RESULTS:The findings revealed that 62.9% of participants had employed ChatGPT in their medical studies, with 16.5% having utilized the tool in a published article. Participants primarily used ChatGPT for searching information (84.4%) and completing academic assignments (60.4%). However, concerns were expressed regarding the potential for ChatGPT to disseminate misinformation (76.9%) and facilitate plagiarism or complicate its detection (65.4%). Despite these concerns, 64.4% of respondents indicated a willingness to use ChatGPT to seek assistance with learning problems. Overall, a majority of participants (60.7%) maintained a positive attitude on the future use of ChatGPT in the medical field. CONCLUSION:Our research showed that while most medical students perceived ChatGPT as a valuable tool for academic study and research, they remained cautious about its potential risks, particularly regarding misinformation and plagiarism concerns. Despite these reservations, a majority participants indicated a willingness to incorporate ChatGPT into their academic workflow, specifically for problem-solving tasks, and maintained optimistic perspectives regarding its potential integration into medical education and clinical practice. It is therefore essential to improve student literacy about AI, develop clear guidelines for its acceptable use, and implement support systems to ensure that medical students are fully prepared for the upcoming integration of AI into medical education. TRIAL REGISTRATION:Not applicable.

aDepartment of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu 610041, China bDepartment of Anesthesiology, Chengdu Hi-Tech Zone Hospital for Women and Children, Chengdu 610041, China cKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. *Corresponding author. Address: West China Women's and Children's Hospital: Sichuan University West China Second, University Hospital, CHINA. E-mail address: [email protected] (X. Jiang). Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal's website, www.lww.com/international-journal-of-surgery. Published online ■ ■ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu 610041, China bKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Published online ■ ■ *Corresponding author. Address: West China Women's and Children's Hospital: Sichuan University West China Second University Hospital CHINA. E-mail address: [email protected] (X. Jiang). This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0/

Background Post-dural puncture headache (PDPH), or spinal headache, is the most common serious complication resulting from iatrogenic puncture of the dura during epidural or spinal anesthesia and cerebrospinal fluid (CSF) leak in pregnant women. Objective To analyze the effectiveness and safety of opioids as a prophylaxis approach in treating obstetric patients who underwent unintentional dural puncture during the initiation of neuraxial anesthesia. Study design A systematice review and meta-analysis. Setting No restriction regarding study type. Methods PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2020. Results According to the eligibility criteria, 10 studies were included with post-dural puncture headache (PDPH) incidence as the primary outcome and the number of epidural blood patch (EBP) required as the second outcome. The risk estimates of each study were reported as odds ratios (ORs). The results showed morphine does not decrease the incidence of PDPH (OR = 0.45, 95% CI: 0.15 - 1.34, P = 0.153, I2 = 74.4%, Pheterogeneity = 0.004) and the use of EBP (OR = 0.40, 95% CI: 0.08 - 1.95, P = 0.259, I2=73.7%, Pheterogeneity = 0.004). Fentanyl does not decrease the incidence of PDPH (OR = 0.35, 95% CI: 0.01-13.77, P = 0.576, I2 = 81.0%, Pheterogeneity = 0.022). Limitations The small number of included studies, high heterogeneity, and variety in study designs. Conclusions Exposure to opioids for any reason after the diagnosis of unintentional dural puncture is not associated with a reduced risk of PDPH and does not decrease the need for therapeutic EBP.

An 11-month-old child experienced a severe life-threatening airway obstruction due to an accidentally inhaled foreign body that had become lodged in his tracheal carina.He showed shortness of breath, continued to groan, and had three positive concave signs when he came to our emergent department.The blood gas analysis showed the following: pH 7.14, partial pressure of CO2 (PCO2) 79.4 mmHg.Then intubation (13 cm depth) with a 4.0-mm tracheal catheter was performed, followed by invasive mechanical ventilation.Chest computed tomography (CT) was also performed.However, 2 hours after invasive mechanical ventilation, PCO2 dramatic increased from 79.4 to 157mmHg.Emergency FAB removal using flexible bronchoscope was performed under general anesthesia to avoid sudden death because of severe asphyxiation.foreign body was found to lodge in his tracheal carina, and the cavity was nearly blocked.The AFB was removed on the first attempt without complications.The child recovered uneventfully and was discharged 2 days later.As result, we would urge caution that If an AFB is suspected, and PCO2 dramatic increased after invasive mechanical ventilation, emergency FAB removal should be performed immediately to avoid sudden death due to severe asphyxia.A standard pediatric flexible bronchoscope (2.8 mm outer diameter) can be inserted successfully via a size 4.0 endotracheal tube for AFB removal.

To the Editor: Myomectomy is an important treatment option for removing a hysteromyoma, along with intramyometrial vasopressin to reduce intraoperative bleeding.[1,2] Sometimes, however, it results in life-threatening complications.[3] We report two rare cases of sudden severe bradycardia after intramyometrial injection of vasopressin during myomectomy. The two patients were diagnosed with uterine leiomyomas. The preoperative laboratory studies, chest radiography, electrocardiography, and blood pressure were normal in both patients. The first case was a 36-year-old woman who underwent laparoscopically assisted myomectomy under general anesthesia. After anesthesia induction, endotracheal intubation, and ensuring that mechanical ventilation was established, laparoscopic myomectomy was performed at 12 mmHg abdominal pressure in the Trendelenburg position. After trocar insertion, the abdominal cavity appeared smooth, and multiple uterine myomas were found covering the entire uterine wall. After negative aspiration, 10 mL of diluted vasopressin (0.6 U/mL) was injected into the myometrium using a 16-gauge needle. Approximately 2 min after the injection of the diluted vasopressin, sudden severe bradycardia was developed. The heart rate (HR) suddenly decreased from 68, to 47, to 25 beats/min. Both the operation and anesthesia were immediately discontinued, and the operative bed was adjusted to a supine position. The patient's HR returned to 55 beats/min and then, within 30 s, dropped to 30 beats/min, and then 25 beats/min. Intravenous atropine (0.5 mg) was administered immediately. Approximately 2 min later, the patient's HR gradually returned to baseline levels. After 10 min of observation, the operation continued and went smoothly. The patient recovered uneventfully and was discharged 4 days later. The second case was a 38-year-old woman who underwent abdominal myomectomy under combined spinal-epidural anesthesia. The operation commenced after anesthesia induction. Bleeding occurred during excision of the myoma, and 10 mL of diluted vasopressin (0.6 U/mL) was injected into the myometrium to relieve bleeding. Approximately 3 min after the injection, the patient's HR dropped suddenly from 70, to 50, to 25 beats/min. One minute later, her blood pressure was 70/40 mmHg. Intravenous atropine sulfate (0.5 mg) was administered. Severe bradycardia (30 beats/min) lasted for nearly 2 min. The patient was ventilated with 100% oxygen. Intravenous ephedrine (6 mg) was also administered immediately, resulting in the HR returning to 108 beats/min and the blood pressure to 125/80 mmHg 3 min later. The operation went smoothly. No more vasoactive drugs were administered. The patient recovered uneventfully and was discharged 6 days later. Vasopressin, an extremely potent vasoconstrictor, is widely used to control acute hemorrhage during myomectomy. The vasopressor effect of vasopressin is primarily mediated by the VIa receptors in vascular smooth muscle, resulting in increased vascular resistance and slowing of the HR. Our two patients showed that intramyometrial injection of vasopressin may result in severe bradycardia, regardless of whether general anesthesia or combined spinal–epidural anesthesia had been used or whether laparoscopically assisted myomectomy or abdominal myomectomy was performed. Anesthesiologists should be vigilant while injecting vasopressin during surgery. Severe bradycardia may be the first symptom. If left untreated, it may lead to life-threatening complications, including cardiac arrest.[4] Stopping the surgical procedure and ejecting carbon dioxide gas from the abdominal cavity to reduce abdominal pressure does not completely relieve this severe bradycardia. Early use of atropine alone may be an appropriate choice for alleviating the severe bradycardia associated with vasopressin and preventing it from progressing to cardiac arrest. We strongly recommend early cardiopulmonary resuscitation if atropine is not effective and the severe bradycardia deteriorates to <25 beats/min. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the article. The patients understands that their names and initials will not be published and due efforts will be made to conceal the identity of the patients, although anonymity cannot be guaranteed. Conflicts of interest None.

Rationale:The incidence of obstetric hemorrhage due to pernicious placenta previa (PPP) and placenta accreta is currently increasing in China. Parallel transverse uterine incision (PTUI) cesarean section (CS) is a novel technique designed to avoid transecting the placenta and control postpartum hemorrhage during CS in these patients in our hospital. A key point of anesthesia management related to PTUI CS involves keeping the uterus relaxed. General anesthesia (GA) has often been performed, and inhaled volatile anesthetics have traditionally been recommended for this purpose; however, GA may be contraindicated in patients with difficult airways.Patient concerns:The patient was predicted to have a difficult airway, and GA may have resulted in potentially life-threatening complications. An alternative and safer method of achieving uterine relaxation during PTUI CS was thus required.Diagnoses:The patient was diagnosed with PPP, and a predicted difficult airway was suspected preoperatively.Interventions:PTUI CS was planned to control postpartum hemorrhage and preserve fertility during CS. Uterine relaxation during PTUI CS was achieved with intravenous nitroglycerin under combined spinal-epidural anesthesia.Outcome:Intravenous nitroglycerin and combined spinal-epidural anesthesia achieved uterine relaxation during the time from delivery of the neonate to making the second transverse incision in the lower segment of the uterus during PTUI CS. Both the parturient and neonate were well and were discharged 4 days later.Lessions:Intravenous nitroglycerin and combined spinal-epidural anesthesia may offer an alternative to GA for achieving uterine relaxation in patients with PPP and a predicted difficult airway undergoing PTUI CS to control postpartum hemorrhage.

To the Editor: A 29-year-old nulliparous woman (weight 68 kg, height 159 cm) at 31±1 gestational weeks was admitted to the West China Second Hospital, complaining of lower limb edema for 3 months and dyspnea for 1 week, which had become more severe over the last 2 days. She was confirmed pregnant at a local hospital after experiencing amenorrhea for 40 days. All routine tests were normal until she was found to be anemic without symptoms at 18 gestational weeks. Her hemoglobin (Hb) was 77 g/L without thalassemia. After oral intake of a polysaccharide iron complex for 4 weeks, her hemoglobin increased to 81 g/L with edema in her lower limbs. Urine testing was positive for protein (+) and occult blood (3+). At 30 gestational weeks, she felt chest distress, palpitations, and fatigue and could not maintain a supine position at night. A routine blood examination showed an Hb level of 67 g/L, and the transthoracic echocardiography showed mild mitral stenosis with moderate regurgitation and mild pericardial effusion. She was then admitted to our emergency hospital with orthopnea and edema. Her physical examination showed a heart rate of 120 beats/min and blood pressure of 110/70 mmHg. A wet rale could be heard at the left lung. Laboratory tests showed that her Hb was 73 g/L, brain natriuretic peptide (NT-BNP) 10,300 pg/ml, troponin 0.098 μg/L, myohemoglobin 146.4 μg/L, glutamic-pyruvic transaminase 98 U/L, glutamic oxalacetic transaminase 100 U/L, albumin 25.7 g/L, urea nitrogen (BU) 11.64 mmol/L, creatinine (Cr) 138 mmol/L, and potassium 5.63 mmol/L. The urine test was positive for protein (3+). An ultrasound test showed left pleural effusion. After multiple department consultations, the pregnancy was terminated to improve the patient's situation. After entering the operating room, the patient was routinely monitored. An epidural catheter was inserted through the lumbar 1 to the lumbar 2 intervertebral disc. A test dosage of 3 ml of 1% lidocaine was injected into the epidural space. Next, 6 ml and 3 ml of 2% lidocaine were injected. The cesarean section was uneventful. Transfusion, dieresis, and other support methods were used to maintain electrolyte homeostasis during the operational and postoperational periods. The patient could lay down in the supine position without dyspnea on postoperative day (POD) 1, but laboratory tests indicated that her situation had worsened (NT-BNP: 24600 pg/ml, ALB: 22.3 g/L, BU: 14.38 mmol/L, Cr: 212 mmol/L, and potassium: 4.85 mmol/L). She complained of weakness of the bilateral lower limbs on the morning of POD 1 (15 hours after epidural anesthesia). A neurological examination demonstrated 3 of 5 for strength and numbness in the bilateral lower limbs. She had normal sensations of touch, pin prick and temperature. Magnetic resonance imaging (MRI) of the lumbar spine was unremarkable. A full immunological investigation on the day of hospital admission revealed positive antinuclear antibodies (ANA+), immunoglobulin G (IgG): 15.10 g/L, immunoglobulin A (IgA): 1.75 g/L, complement C3: 0.38 g/L (normal range 0.79–1.52), complement C4: 0.06g/L (normal range 0.16–0.38), anti-nRNP/Sm antibody (++), anti-Sm antibody (+), and anti-dsDNA (+++) on the afternoon of POD 2. A rheumatologist was consulted. The patient complained of a facial skin rash and a frostbitten rash on both hands for 10 months, and she had lost her hair in the past with no joint swelling. According to her history and lab tests, she was confirmed to have systemic lupus erythematosus (SLE) and was immediately intravenously administered methylprednisolone and hydroxychloroquine. After the corticosteroid and hydroxychloroquine infusion, she experienced a mild improvement in strength. On POD 5, when she transferred from the obstetric department to the nephrology department, the strength in her lower limbs was 4 of 5. On POD 7, her strength recovered to 5 of 5. She experienced serositis, nephritis, seizures, psychosis and lung infections on the following days. Although all possible treatment methods were used, including continuous renal replacement therapy, antibacterial therapy, and plasmapheresis, her condition continued to deteriorate, and she died on POD 38. Neuraxial blockade is first choice of anesthesia for pregnancy, regardless of whether it is for natural delivery or cesarean section. Complications of neurological deficits, such as reduced limb function, lasting numbness, and paralysis are rare but devastating. The common causes, including physical injury, epidural hematoma and infection, are primarily considered first, but neurotoxicity from local anesthetics and transient neurological syndrome (TNS) must also be considered. Neurological complications may occur early if related to traumatic catheter insertion or can occur later in the postoperative course if caused by catheter-related spinal space-occupying lesions such as epidural hematoma or epidural infection. In this patient, physical trauma was excluded since she did not complain of pain or paresthesia when the catheter was inserted. Epidural hematoma was also excluded because she exhibited no back pain or signs on the MRI. Infections were also excluded since the patient presented no fever, back pain, nuchal rigidity or leukocytosis. Although 2% lidocaine can lead to morphological damage in rats, clinical reports in humans are lacking. TNS was also excluded because of the absence of back pain. Systemic diseases that can damage the nervous system are easily overlooked when neurological deficits occur after epidural anesthesia. SLE is an autoimmune multisystemic disease that occurs predominantly in fertile-aged women. Owing to medical advances, the number of SLE patients who become pregnant has increased worldwide, and most pregnancies are successful. The neuropsychiatric involvement of SLE, especially of the peripheral nervous system (PNS), has been scarcely studied [2] despite its association with significant morbidity and a worsened quality of life.[2] This is the first report of PNS-SLE in pregnancy. According to existing research,[3] the most common clinical presentations of PNS-SLE are distal axonal sensory or sensory-motor polyneuropathy with acute or subacute onset, which are similar to the symptoms of neuraxial blockade complications. In most cases, the onset is dramatic with sudden weakness in different nerve territories. In this case, no identical symptoms manifested before lidocaine was infused into the epidural space. Whether the local anesthetics aggravated the damage to local vessels or induced the nerve lesion directly is difficult to determine. Martinez-Taboada and colleagues [4] described two SLE patients with severe mononeuritic multiplex secondary to necrotizing vasculitis of small- and medium-sized vessels. One patient presented with neurologic involvement at the disease onset, and the other later in the disease after discontinuing steroid and chloroquine treatment. Distinguishing pregnancy-associated signs and symptoms from those of SLE can be difficult. Fatigue, mild arthralgia, hair loss, dyspnea, headaches, edema, anemia, and thrombocytopenia are common ambiguous manifestations.[5] In this case, the obstetrician failed to pay attention to the facial skin rash and frostbitten rash on both hands for 10 months, obvious hair loss, fatigue, and anemia and proteinuria found in the second trimester, and the missed diagnosis eventually led the patient's death. Hence, involvement of and assessment by experienced physicians is important during pregnancy with multiple symptoms. What we can learn from this case is that: (1) if lesions involve multiple organs during pregnancy, experienced physicians should be consulted as soon as possible and (2) if post-epidural numbness or weakness of the extremities occurs, common complications and systemic diseases should be considered simultaneously, especially those that can damage the nervous system. Declaration of patient consent We have obtained all appropriate patient consent forms. In the form the husband of the patient has given his consent for the clinical information of the patient to be reported in the journal. The husband of the patient understand that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Conflicts of interest None. Uncited reference [1].

RATIONALE:The most common critical incidents in pediatric anesthesia are perioperative respiratory adverse events (PRAE), which occur more often in neonates and account for one-third of anaesthesia-related cardiac arrests. It is crucial to maintain an open stable airway during anesthesia in neonates, as this population has a low oxygen reserve, small airways, and the loss of protective airway reflexes under general anesthesia.PATIENT CONCERNS:A 6-day-old premature newborn underwent minimally invasive sclerotherapy under general anesthesia. For high-risk premature neonates, the selections of the anesthesia and airway device are extremely important, as those factors directly affect the prognosis.DIAGNOSES:B ultrasound and computed tomography (CT) revealed a large mass from the left chest wall to axilla, which was suspected to be a lymphocele.INTERVENTIONS:Minimally invasive sclerotherapy was performed under inhalation anesthesia. After the initiation of anesthesia, a laryngeal mask was placed to control airway. Anesthesia was maintained intraoperatively via sevoflurane inhalation with spontaneous breathing. No accidental displacements or PRAE occurred.OUTCOME:The operation and anesthesia process was stable and safe. The patient discharged at 2 days postoperatively.LESSONS:Minimally invasive sclerotherapy in a premature neonate is an operation with an extremely short operation time and minimal trauma, but a very high anesthesia risk and risk of PRAE. Anesthesia management is very important in a premature neonate undergoing a very short surgery under general anesthesia. Total sevoflurane inhalation general anesthesia and laryngeal mask airway control with spontaneous breathing may be an ideal option to reduce PRAE during very short surgery in a premature neonate.

Pernicious placenta previa (PPP) is the main cause of severe obstetric postpartum hemorrhage and hysterectomy and often requires donor blood transfusion. Prophylactic internal iliac artery (IIA) balloon occlusion (BO) combined with cell salvage is increasingly being deployed in parallel transverse uterine incision (PTUI) cesarean section (CS). The aim of this study was to explore the differences in blood management in PTUI CS with or without prophylactic IIA BO and to evaluate the safety and efficacy of cell salvage to reduce the need for donor blood transfusion during PTUI CS. This retrospective study included all women who were diagnosed with PPP and PA and underwent PTUI CS from October 1, 2016, to October 31, 2018. Sixty-four patients were included: 34 underwent prophylactic IIA BO (IIA group), whereas 30 were treated without prophylactic IIA BO (control group). The primary outcome was a composite measure of perioperative blood management outcomes, including the estimated blood loss (EBL), donor blood transfusion, salvaged blood returned, fresh frozen plasma (FFP), pre- and postoperative serum hemoglobin and hematocrit. In addition, the baseline conditions of mother and neonates were compared. EBL was significantly higher in the IIA group compared to the control group (2883.5 mL in the IIA group vs 1868.7 mL in the control group,P = .001). Overall, the donor blood transfusion rate was 23.5% (8/34), averaging 4.2 U, in the IIA group versus 30% (9/30), averaging 3.4 U, in the control group, which were not significantly different. The FFP transfusion rate was 47%, averaging 765.6 mL, in the IIA group versus 20%, averaging 816.7 mL, in the control group. In the IIA group, 97.1% used cell savage and had salvaged blood returned, averaging 954.9 mL. In the control group, 90% had salvaged blood returned, averaging 617.9 mL. No cases of amniotic fluid embolism were observed with leukocyte depletion filters. Prophylactic IIA BO during PTUI CS in women with PPP and PA does not lead to a statistically significant reduction in EBL. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS.

目的:比较普通喉镜、可视喉镜气管插管两种视频模拟教学培训方案在无气管插管经验的医生中的教学效果.方法:将30名无气管插管经验的医生随机分成普通喉镜组(对照组)、可视喉镜组(试验组).对照组行普通喉镜气管插管视频模拟教学培训方案,试验组行可视喉镜气管插管视频模拟教学培训方案.模拟培训结束后,在专业麻醉医生指导下,立即对150例预计非困难气道的择期妇产科手术患者进行全麻后气管插管.比较两组医生首次尝试插管气管插管的成功率、气道损伤情况及气管插管自信心.结果:气管插管视频模拟教学培训后,试验组医生气管插管自信心及气管插管成功率较对照组均显著增加(P＜0.05).试验组首次气管插管成功时间明显短于A组(P＜0.05);两组气管插管后损伤率无统计学差异(P＞0.05).结论:可视喉镜是一种适合无气管插管经验的医生快速掌握非困难气道气管插管的有效工具.

Rationale: The incidence of pernicious placenta previa (PPP) and placenta accreta (PA) is increasing in China. Excessive blood loss in these women is an important cause of maternal death and emergency hysterectomy. Performing a traditional cesarean section (CS) in women with PPP is stressful for obstetricians because avoiding cutting the placenta is difficult. As a result, sudden life-threatening bleeding may be encountered. Therefore, there is an urgent need to establish a novel operative method for PPP and PA that is safe for both the mother and neonate, and less stressful for the surgeon. Patient concerns: We report an extremely rare case of PPP and PA complicated with anemia and an unexplained decrease in the hemoglobin (Hb) levels after transfusion of 3 units of allogeneic red blood cells. Diagnoses: The patient was diagnosed with unexplained anemia, and hemolysis resulting from donor red blood cell transfusion was suspected preoperatively. Interventions: To minimize blood loss for safety, a new operative technique, parallel transverse uterine incisions (PTUI) in CS (PTUI CS), was used under general anesthesia in this case. Inhaled volatile sevoflurane was used for uterine relaxation during PTUI. Cell salvage was also used. Outcomes: PTUI CS combined with cell salvage effectively reduced bleeding and preserved the uterus in our patient. Sevoflurane was effective for uterine relaxation during PTUI CS. Lessons: If PPP and PA are suspected, placental magnetic resonance imaging is recommended for definitively determining whether a transverse fundal incision can be made. If feasible, we strongly recommend that PTUI CS combined with cell salvage are used to minimize bleeding for high-risk patients with PPP and PA complicated with anemia and an unexplained decrease in Hb levels after transfusion of 3 units of allogeneic red blood cells. Anesthesiologists should be vigilant to maintain uterine relaxation from the time of delivery of the neonate to a second transverse incision in the lower segment of the uterus. This is a key element of successful PTUI CS. Additionally, the use of intraoperative cell salvage is recommended when it can be expected to reduce the likelihood of donor red cell transfusion.

Rationale: Pernicious placenta accrete (PPP) is an obstetrical complication associated with severe life-threatening hemorrhage, which is one of the leading causes of maternal mortality worldwide. Caesarean hysterectomy is the effective method to control intraoperative bleeding for this unscheduled high-risk patient. But a challenge for clinicians in this case is to determine the optimal timing of hysterectomy, because it will directly determine maternal outcome. Patient concerns: We here report a case diagnosed with PPP who suffered from a severe life-threatening hemorrhage during cesarean section but was successfully resuscitated and subsequently discharged from hospital after a smooth recovery. Diagnoses: Although binding the lower uterine segment with a tourniquet markedly reduced bleeding in the surgical field after delivery, massive concealed vaginal life-threatening bleeding occurred immediately, and the amount of vaginal blood loss within 10 minutes was as much as 3000mL. Interventions: An experienced multidisciplinary team was immediately established, and an unscheduled caesarean hysterectomy was performed immediately, and cell salvage was used. Outcome: The patient was successfully resuscitated and both the parturient and neonate were well and discharged. Lesson: If binding the lower uterine segment with a tourniquet markedly reduces bleeding in the surgical field after cesarean delivery in high-risk patients with PPP, and persistence of hypotension after active resuscitation of the circulation is detected, anesthesiologist should be vigilant enough to detect the possibility of concealed vaginal life-threatening bleeding. If this is confirmed, it should be quickly identified whether bleeding can be quickly controlled within a short period of time. If not, the preferred strategy is that the earlier the unscheduled hysterectomy, the better the outcome. A well-established multidisciplinary team and autologous blood recovery and transfusion techniques are also important in ensuring successful resuscitation of patients.

Background Maternal cardiac arrest during cesarean section (CS) is an extremely rare but devastating complication. Preventing emergency events from developing into maternal cardiac arrest is one of the most challenging clinical scenarios. Case presentation A 35-year-old pregnant woman with subvalvular aortic stenosis who was scheduled for elective CS under epidural anesthesia, and experienced devastating supine hypotensive syndrome, but was successfully resuscitated after delivery. Conclusions The performance of tilt position strictly or high-quality continue manual left uterine displacement (LUD) should be performed until the fetus is delivered, otherwise timely delivery of the fetus may be the best way to optimize the deadly condition.

患者,女,30 岁,体重66 kg,身高158 cm. 因停经33+2周,阴道流血4+小时"于2018年11月2日入院,入院诊断为"凶险性前置胎盘伴出血;RH阴性血型;G5 P 1+333+2周宫内孕先兆早产". 既往012年于外院行剖宫产分娩1活女婴,婴儿血型为RH阳性. 入院后血型结果示患者系A型RH阴性血型,血型抗体效价256. 追问患者既往无输血史,抗体阳性原因考虑为上次妊娠所致. 针对性胎盘MRI示中央性前置胎盘伴胎盘植入.

Background: Severe maternal congenital hypothyroidism with term pregnancy is extremely rare. It is really challenging to make an optimal anesthesia management strategy that is both less stressful for the anesthesiologist and safer for both the mother and her infant. Case presentation: A case is presented for a 22-year-old pregnant woman with severe congenital hypothyroidism, who was undergone successful epidural anesthesia for an elective cesarean section (CS). She was weight 28 Kg and measured 112 cm in height at term. Spontaneous ventilation was maintained throughout the case while ketamine was used for attenuating the activity of sympathetic system and alleviating the pain and anxiety of the patient. Both the parturient and neonate were well and discharged 4 days later. Conclusion: it is rare that natural conception succeeds on this severe congenital hypothyroid woman. In high-risk patients with severe congenital hypothyroidism, we recommend strongly that epidural anesthesia may be an optimal and safe technique for both the mother and her infant. Keywords: Congenital hypothyroidism, epidural anesthesia, ketamine

Rationale: Fetal giant cervical cyst (FGCC) is a rare congenital anomaly. Sometimes FGCC may extend into the mediastinum, and result in severe tracheal compression, which is a life-threatening event at birth. Patient concerns: We present a rare case of FGCC, which extended from the right neck into the superior mediastinum, and resulted in severe tracheal compression. Diagnoses: An FGCC was observed by ultrasonography and magnetic resonance imaging (MRI) at 27+4 weeks' gestation (WG). Fetal MRI at 35+1 WG showed that the FGCC was 3.3 x 8.2 x 7.5cm and extended from the right neck into the superior mediastinum. Severe tracheal compression was observed and the inside diameter of the narrowest section of tracheostenosis appeared thread-like and measured only 0.1cm. Interventions: Cervical cyst reduction was performed prenatally under ultrasound guidance to alleviate the tracheal compression and maximize the chance of fetal survival 2 days before birth. At 36+3 WG, cesarean section was performed, and a female neonate was immediately delivered and intubated (3.5-mm tube) by an experienced anesthesiologist. Neonatal intralesional sclerotherapy and cystic component aspiration as guided by digital subtraction angiography were performed under general anesthesia. Anesthesia was maintained only with sevoflurane 3% in 2L/min oxygen. Extubation was performed soon after surgery. Outcome: The neonate recovered uneventfully and was discharged 2 days postoperatively. After 140 days of follow-up, the neonate had recovered completely. Lessons: If an FGCC is suspected by abdominal ultrasound, a fetal MRI is recommended to assess the severity of tracheal compression before birth, if feasible. An anesthesiologist should assess the risk of intubation failure at birth according to those results. If fetal severe tracheal compression is detected and it may result in inability of intubation at birth, prenatal cervical cyst reduction under ultrasound guidance may be effective for alleviating tracheal compression at birth, if feasible. This could maximize the chance of fetal survival. Improvement of fetal short-and long-term outcomes is important.

Introduction: Splenic ectopic pregnancy (SEP), a special abdominal pregnancy, is extremely rare but carries a high risk of potentially uncontrollable, life-threatening intraperitoneal bleeding at early gestation, which is equivalent to the spontaneous rupture of the spleen. Therefore, early diagnosis of SEP is crucial and may avoid life-threatening situation. Case presentation: A 29-year-old G3P2 woman presented with 50 days of amenorrhea and positive serum &bgr;-human gonadotropin (&bgr;-HCG) was enrolled into the hospital due to the absence of gestational sac located in the uterine cavity. A pan-abdominal ultrasound scan revealed a 2.6 cm ×1.6 cm hyperechoic mass inferior to the spleen with color Doppler signal surrounding and 0.9 cm anechoic inside. The gynecologist found the gestational sac was located in the dorsal pole of the spleen through the exploratory laparoscopy. Total splenectomy was performed uneventfully to avoid the hemorrhage shock. The patient discharged with no complications and normal 1-month follow-up. Conclusion: It highlights that fully understanding of the knowledge about abdominal pregnancy, especially splenic pregnancy, and early imaging study with ultrasonography could reduce or avoid the misdiagnosis and miss-diagnosis of SEP.