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Objective: To characterize the knowledge and perceived attitudes toward pharmacologic interventions for light sedation in mechanically ventilated patients and to understand the current gaps comparing current practice with the recommendations of the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/ Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the Intensive Care Unit. Methods: This was a cross-sectional cohort study based on the application of an electronic questionnaire focused on sedation practices. Results: A total of 303 critical care physicians provided responses to the survey. Most respondents reported routine use of a structured sedation scale (281;92.6%). Almost half of the respondents reported performing daily interruptions of sedation (147;48.4%), and the same percentage of participants (48.0%) agreed that patients are often over sedated. During the COVID-19 pandemic, participants reported that patients had a higher chance of receiving midazolam compared to before the pandemic (178;58.8% versus 106;34.0%;p = 0.05), and heavy sedation was more common during the COVID-19 pandemic (241;79.4% versus 148;49.0%;p = 0.01). Conclusion: This survey provides valuable data on the perceived attitudes of Brazilian intensive care physicians regarding sedation. Although daily interruption of sedation was a well-known concept and sedation scales were often used by the respondents, insufficient effort was put into frequent monitoring, use of protocols and systematic implementation of sedation strategies. Despite the perception of the benefits linked with light sedation, there is a need to identify improvement targets to propose educational strategies to improve current practices. © 2023 Associacao de Medicina Intensiva Brasileira - AMIB. All rights reserved.
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A cerebral abscess can be a life-threatening complication of pulmonary arteriovenous malformations (PAVM), thus posing significant morbidity if left untreated. We report a case of an incidental finding of a PAVM in a patient diagnosed with cerebral abscess. A 22-year-old male presented to the emergency department with acute onset right-sided weakness in both upper and lower limbs for 1 week. Magnetic resonance imaging showed a ring-enhancing lesion within the left parasagittal frontoparietal region s/o intracerebral abscess. High-resolution computed tomography was done as a protocol in patients posted for surgery due to coronavirus disease 2019 and coincidentally, it showed a single well-defined parenchymal nodule, 4 x 3.4 cm in the lateral basal segment of the left lower lobe. The knowledge of the pathophysiology of PAVM and expected complications during general anesthesia (GA) and positive pressure mechanical ventilation is essential. In such conditions, awake craniotomy under conscious sedation and scalp block may be considered as an alternative to GA.
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Background: Given the COVID-19 pandemic, international travel restrictions have been in effect since March 2020 in Canada. As a result, some patients requiring international travel for medical care have experienced delays. Therefore, innovative techniques were required to provide care that would not routinely be performed in Canada, as in the case of Orbera® gastric balloon retrieval. Aims: To describe an approach to gastric balloon retrieval amidst COVID-19 related travel restrictions Methods: Case review of three cases of gastric balloon retrieval was performed Results: 1: A 41-year-old (yo) woman had an Orbera® gastric balloon placement in Washington state in September 2019. She lost 42lbs. Retrieval was scheduled for March 2020, but was delayed due to COVID-19 restrictions. In May 2020, she developed symptoms of balloon dysfunction. The patient was referred to a Canadian tertiary care centre. Gastroscopy was performed under conscious sedation. The Orbera® balloon was in the distal gastric body. The balloon was punctured with a 19G EUS FNA needle;600cc of blue tinted liquid was aspirated. The emptied balloon was retrieved successfully using rat tooth forceps. 2: A 35-yo woman had an Orbera® gastric balloon placed in October 2019 in Toronto at a private health facility. She lost 20lbs. Retrieval of the balloon was scheduled for March 2020, but due to COVID-19 restrictions, it was not possible at the original facility. She did not have symptoms related to the balloon. Gastroscopy was performed under general anesthesia (GA) on October 8, 2020. The balloon was intact in the distal gastric body. The balloon was punctured with a 19G Cook Echotip Needle and vacuum suction applied;400cc of blue tinted fluid was removed. Alligator forceps were used to create holes in the underside of the balloon, allowing excess fluid to be expelled as the balloon was pulled up against the GEJ. Once the balloon was deflated, it was removed successfully through the mouth. 3: A 38-yo man had an Orbera® gastric balloon placed in his native Columbia in March 2020. He did not achieve weight loss. Due to COVID-19 restrictions, he was unable to return for planned removal. He did not have symptoms related to the balloon. Gastroscopy was performed under GA on October 8, 2020. The balloon was intact in the distal gastric body. The balloon was punctured with a 19G Cook Echotip Needle and vacuum suction applied;600cc of blue tinted fluid was removed. Alligator forceps were used in retroflexion to tear the underside of the flattened balloon to ensure all liquid and air had escaped from the balloon. Once the balloon was deflated, it was removed successfully through the mouth. Conclusions: Although Orbera® gastric balloon retrieval is not routinely performed in Canada, we demonstrate that gastroscopy with balloon puncture and forcepsretrieval is a safe option.
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Background: The COVID-19 pandemic introduced unprecedented disruptions to healthcare delivery, particularly for ambulatory services such as gastrointestinal endoscopy. At the peak of the pandemic in our region between December 2020 to February 2021, ambulatory endoscopy services were suspended at the Los Angeles County + University of Southern California Medical Center (LAC+USC). While endoscopy services resumed in March 2021, the operational challenges introduced by COVID-19 led to a mounting backlog of patients awaiting endoscopic procedures reaching 1,035 by June 2021. As part of our solution to this crisis, we used the principles of operations management to perform a process flow analysis to identify inefficiencies and develop targeted interventions to enhance the operational performance of our endoscopy unit. Methods: A time-motion analysis of patient flow through the LAC+USC Endoscopy Unit was used to construct a comprehensive time-tracked flow sheet to track individual patients as they moved through the unit from check-in to discharge on random dates over a 6-week period (Figure 1). Simultaneously, a qualitative stakeholder survey on perceived operational inefficiencies was distributed to all faculty, staff, and fellows in the endoscopy unit. At the end of 6 weeks, collected data were compared to both published benchmarks and stakeholder survey responses, and inefficiencies identified for intervention. Results: Data were collected for 214 procedures (179 moderate sedation, 35 monitored anesthesia care) in the endoscopy unit. When compared to established benchmarks, we found operational delays in 1) check-in to procedure start time, 2) room turnover time, and 3) first-case on-time start percentage (Table 1). Results from the stakeholder survey aligned with these data. Targeted interventions (Table 1) developed by a multi-disciplinary group of faculty, nursing staff, and trainees from both Gastroenterology and Anesthesiology departments were then implemented, including 1) preparation of the first patient of the day in the procedure room, 2) pre-operative clinic visits for all patients designated to require anesthesia during endoscopy, 3) implementation of a brief-operative note and 4) a time study to encourage first-case on-time start. In combination with maneuvers to streamline the pre-procedure process, this resulted in a reduction of the backlog to 430 by November 2021. Conclusion: Granular analysis of data tracking process flow times through the LAC+USC Endoscopy Unit aligned with stakeholder perceptions regarding operational inefficiencies. The combination of objective and subjective data allowed us to rapidly implement targeted interventions to increase the throughput of the endoscopy unit and address the backlog of endoscopy procedures caused by the COVID-19 pandemic. (Figure Presented) (Table Presented)
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AIM: EUS modality to get tissue diagnosis and with multi-target approach can help stage disease more accurately with histopathological results. METHODS: Total of 15 cases underwent EUS-M from June 2020 till Dec 2021. Informed consent was obtained, with Covid screen test with PCR was performed before procedure. Procedures were done with all SOPs as per institutional guidelines. 22G FNB needle with Franseen design with capillary suction method used to obtain visible core samples for histopathology without ROSE. All cases have confirmed histopathological diagnosis with same pathology from other site of Biopsy. Order of Biopsy was Nodes→Liver metatatic lesion→Primary Tumor. In cases of nodes mediastinal→portahepatis/ pancreatic→Para-aortic RESULTS: Among total 15 cases, Age 55 Mean (22-74) with 08 Males. Duration of procedure 41 min Mean (20-85). Cases with multiple lymphadenopathy from different anatomical regions were 05 while other sites include Liver for metastasis and Primary tumor from pancreas/CBD in 10 cases. Multiple site single pass was performed in 14 cases. Final diagnosis of Disease was pancreatic adenocarcinoma 05, NETs 01, Lymphoma 03, GB Adenocarcinoma/Cholangiocarcinoma 05 and metastatic RCC 01. All procedures were done under Conscious sedation as day care procedure. There were no immediate or early complication in all cases. CONCLUSIONS: EUS-M is safe and accurate modality to stage malignancy with superiority over PET Scan to obtain histological diagnosis.
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Assisted reproductive technology (ART) is used primarily to address the treatment of infertility which includes medical procedures such as in vitro fertilisation (IVF), intra-cytoplasmic sperm injection (ICSI), gamete intra-fallopian transfer (GIFT) or zygote intra-fallopian transfer (ZIFT). IVF has revolutionised infertility treatment and is nowadays widely accepted all over the world. The IVF is carried out as a daycare procedure and many anaesthetic regimens have been studied, tried and tested so far. An anaesthesiologist's role mainly comes into play during trans- vaginal oocyte retrieval and embryo transfer (ET) process of IVF. Various techniques of anaesthesia are practised which include general or regional anaesthesia, conscious sedation or monitored anaesthesia care, patient-controlled analgesia, acupuncture and transcutaneous electrical nerve stimulation (TENS). The anaesthetic management needs careful consideration of the effect of drugs on the maturation of oocytes or embryonic development, fertilisation and pregnancy rates. In view of the Coronavirus disease-19 (COVID-19) pandemic, ART clinics have been affected and due to the ambiguity of its effects on the reproductive outcome, anaesthesiologists need to be vigilant and cautious with anaesthetic management during pandemic times. This review includes a discussion of various anaesthetic options and agents along with their advantages or disadvantages if any. The literature sources for this review were obtained via PubMed, Medline, Cochrane Library and Google Scholar. The results of 82 out of 110 articles discussing different methods of anaesthesia for ART procedures over 25 years were compiled.
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Introduction: The COVID19 pandemic collapsed intensive care units (ICUs) all around the world, conditioning systems of care (SOC) for other critical conditions such as severe ischemic stroke requiring endovascular treatment (EVT). Our aim was to evaluate the impact of an adaptive Stroke Unit (SU) based SOC on functional outcomes, with the goal of avoiding both general anesthesia (GA) and ICU admission in stroke patients treated with EVT. Material and methods: We performed an observational study comparing data from our traditional ICU-GA based SOC and the adaptive SU-Conscious Sedation (CS) based SOC (consecutive patients undergoing EVT 1 year prior and after onset of the pandemic). Primary outcome was 90-days modified Rankin Scale (mRS), and secondary outcomes included, among others, in-hospital complications, and hospital length of stay (LOS). Results: A total of 210 EVT were performed during the study period (107 under the traditional-SOC and 103 under the adaptive-SOC). A significantly greater proportion of patient was treated under CS (15.9% vs 57.3%; p < 0.001) and admitted for post-procedural care at SU (15% vs 66%; p < 0.001) in the adaptive SOC. Rates of in-hospital complications were similar in both periods, with reduced hospital LOS in the adaptive SOC (10 (7-15) vs 8 (6-12); p = 0.005). The adaptive SOC was associated with higher odds for 90 days favorable outcome (mRS 0-2) (aOR 3.15 (1.34-7.39); p = 0.008). Conclusion: In our case, an adaptive SOC that combined both preference for CS and postprocedural care in SU was associated with better functional outcomes and reduced healthcare resource use for patients undergoing EVT.
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Background: Standard of care for elective structural heart disease (SHD) procedures have included at least one overnight stay in the hospital. Same day discharge (SDD) after PCI has been well studied with no difference in cardiovascular outcomes, repeat hospitalizations, or overall complications with SDD following PCI. With the ongoing COVID pandemic, there are several patients and family members who prefer to go home same day to avoid exposure. SDD after structural heart procedures such as valve repair/replacements, Watchman device implantations is not well studied. There are no recommendations on how to do this in a safe and effective way. After rigorous planning, we designed a protocol to assess the safety and feasibility of SDD after structural interventions in selected patients. Methods: A total of 114 patients undergoing elective SHD interventions between July 2020 till November 2021 who opted to go home on the same day in view of the ongoing pandemic were included in the study. These patients had good social support, met our centers safety protocol, TVT registry requirements, lab, and ambulation criteria. We assessed the demographics, safety, and outcomes. Results: Of the 114 patients, 37 underwent transfemoral TAVR, 2 BAV, 8 TEER, 2 transcatheter mitral valve in valve, 48 Watchman and 17 ASD/PFO closure. The mean age was 72.2 years (32 - 89y). The mean creatinine was 1.23 ( 0.6 - 2.6). General anesthesia was used in 96, conscious sedation in 17 and local anesthesia only in one. The mean contrast usage was 64 ml of visipaque (0 - 129 ml). The mean procedure time was 32 min(14 -121min). All patients were ambulated at least twice. The first within 2 hours of procedure and 2nd before discharge. There was no electrical block noted during anytime in the procedural or periprocedural period. The mean length of stay was 8.1 hours(4 - 16.8h). All patients received a cell number to call in case of any concerns and for easy access. All patients received a call in the evening on the same day and on the next day morning. There were no readmissions, bleeding episodes, acute kidney injury or deaths till last follow up. Conclusions: 1. Selective, same-day discharge after TF TAVR, Transcatheter Mitral valve in valve replacements, TEER, Watchman and ASD/PFO closures is safe and feasible and may be considered in patients who opt for it and have a good social fabric. 2. Patients did not enter the Hospital floor/ICU 3. SDD improves patient satisfaction and increases hospital bed availability, importantly in the ongoing pandemic. 4. SDD has enormous potential to reduce overall health care costs.
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(1) Background: There has been various reports on the potential impact of anesthetic agents used during oocyte retrieval (OR) on the impairment of the capacity of the oocyte for fertilization and subsequent embryo quality; results have been conflicting; (2) Methods: The effects of two different sedation protocols during OR in two groups of patients undergoing In Vitro Fertilization/Intra-Cytoplasmic Sperm Injection IVF/ICSI, were compared on propofol consumption and on in vitro fertilization (IVF)/ICSI success. The study group received dexmedetomidine and fentanyl, while the control remifentanil and midazolam. In a prospective cohort study, we encompassed 72 cycles/patients. The administered dose of propofol per patient and fertilization rates were the primary outcomes, while anesthesiological parameters and IVF/ICSI outcomes were the secondary endpoints; (3) Results: We found a significant increase in propofol consumption in the study compared to the control group (77.0 ± 10.6 mg vs. 12.1 ± 6.1; p < 0.001), but fertilization rates were similar (p = 0.469). From the secondary anesthesiological outcomes, the post anesthesia discharge scores were better in the control group (15.0 (13.5 min) vs. 5.0 (10.0 min), p = 0.028). From the IVF/ICSI secondary outcome parameters, we found a higher quality of embryos on day three in the study compared to the control group (p = 0.040). The comparison of the other secondary outcomes yielded non-significant differences; (4) Conclusions: The use of dexmedetomidine, as an alternative agent during OR, was associated with higher propofol consumption as a rescue dose compared to remifentanil but was linked with similar fertilization rates and higher quality of embryos produced.
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Acute stroke treatment continues to evolve with optimization of systemic intravenous thrombolysis and endovascular mechanical thrombectomy (MT) for intracranial large vessel occlusion (LVO). Neurointerventional techniques to achieve reperfusion in acute LVO stroke initially involved local intra-arterial infusion of thrombolytic agents. The subsequent development of MT devices has resulted in more complete and faster arterial recanalization while maintaining patient safety. Today, MT is standard of care for LVO stroke up to 24 h from last known well. In this chapter, we discuss various endovascular recanalization techniques for LVO stroke with illustrative cases.
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It was concluded that higher daily doses of sedative agents were used in COVID-19 patients compared to non-COVID patients. B Introduction: b Management of severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 often requires deep sedation and paralysis to maintain oxygen saturation goals. Anecdotal findings suggest that patients with COVID-19 require higher doses of sedative agents to achieve target levels of sedation and maintain ventilator synchrony. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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RESUMEN Introducción: el SARS-CoV-2 es un nuevo coronavirus descrito por primera vez en China y con alta capacidad de propagación. Su presentación clínica más frecuente son los síntomas respiratorios, aunque se han descrito otros como los gastrointestinales. La transmisión ocurre por gotas, aerosoles, vía fecal oral, conjuntiva, fómites y por contacto directo con fluidos corporales del paciente. En este sentido, los procedimientos realizados en las salas de endoscopia deben considerarse de alto riesgo. Objetivo: describir y analizar las medidas de prevención frente al SARS-CoV-2 para la práctica endoscópica-anestésica u otros procedimientos que requieran sedación, con el fin de disminuir la exposición y así minimizar el contagio del personal de salud. Resultados: la respuesta global se ha enfocado en la utilización de elementos de protección personal para tratar de disminuir el riesgo al que se encuentra expuesto el personal de salud. Sin embargo, debido a la prontitud de la emergencia, no se han podido generar evidencias de alta calidad que permitan dar recomendaciones definitivas. Reflexión: el personal de salud debe tomar todas las medidas de protección que puedan ser consideradas como efectivas, además deconstruir protocolos y fomentar la adherencia a los mismos.
SUMMARY Introduction: SARS-CoV-2 is a new coronavirus described for the first time in China, with high capacity of propagation. Its most frequent clinical presentation is respiratory symptoms; however, others have been described as gastrointestinal. Transmission occurs by droplets, aerosols, oral fecal route, conjunctiva, fomites and by direct contact with body fluids of the patient. In this sense, the procedures performed in endoscopy rooms should be considered high risk. Objective: To describe and analyze preventive measures against SARS-CoV-2 for endoscopic-anesthesia practice or other procedures that require sedation, in order to reduce exposure and thus minimize contagion of health personnel. Results: The global response has focused on the use of personal protective equipment to try to reduce the risk to which health care personnel are exposed, but due to the urgency of the emergency, it has not been possible to generate high quality evidence to give definitive recommendations. Reflection: Health personnel should take all protective measures that can be considered effective, and also deconstruct protocols and encourage adherence to them.
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Humans , Coronavirus , Personal Protection , Endoscopy , Conscious Sedation , AnesthesiaABSTRACT
BACKGROUND: Transvenous lead extraction (TLE) for implantable cardiac-devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID-19, longer recovery-times and increased procedural-costs. We report the feasibility/safety of TLE using conscious-sedation alone with immediate GA/cardiac-surgery back-up if needed. METHODS: Retrospective case-series of consecutive TLEs performed using conscious-sedation alone between March 2016 and December 2019. All were performed in the electrophysiology-laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking-stylets/cutting-sheaths, including mechanical-sheaths. Baseline patient-characteristics, procedural-details and TLE outcomes (including procedure-related complications/death) were recorded. RESULTS: A total of 130 leads were targeted in 54 patients, mean age ± SD 74.6 ± 11.8years, 47(87%) males; dual-chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy-defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean ± SD/median (range) lead-dwell times were 11.0 ± 8.8/8.3 (0.3-37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse-generator erosion (n = 27; 50%); mean 2.1 ± 2.0 leads were removed per procedure/mean procedure-time was 100 ± 54 min. Local anesthetic (LA) was used for all (mean-dose: 33 ± 8 ml 1% lidocaine), IV drug-doses used (mean ± SD) were: midazolam: 3.95 ± 2.44 mg, diazepam: 4.69 ± 0.89 mg and fentanyl: 57 ± 40 µg. Complete lead-extraction was achieved in 110 (85%) leads, partial lead-extraction (<4 cm-fragment remaining) in 5 (4%) leads. Sedation-related hypotension requiring IV fluids occurred in 2 (managed without adverse-consequences) and hypoxia requiring additional airway-management in none. No procedural deaths occurred, one patient required emergency cardiac surgery for localized ventricular perforation, nine had minor complications (transient hypotension/bradycardia/pericardial effusion not requiring intervention). CONCLUSION: TLE undertaken using LA/conscious-sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolization of COVID-19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.