Nonoperating Room Anesthesia: Anesthesia in the Gastrointestinal Suite.

Exponential growth in endoscopy suite procedures due to technological advances requires teamwork between anesthesiologists, endoscopists, nursing teams, and technical and support staff. The current standard of care for moderate sedation includes a combination of anxiolytic drugs and analgesic drugs and sometimes are not adequate to ensure patient safety, efficiency, and comfort. The use of anesthesia services can improve safety, recovery, turnovers, and efficiency. The article discusses comprehensive preoperative evaluation, optimization of comorbidities, and intraoperative airway management strategies to deliver safe and efficient anesthesia, given the need to share the airway and allow the use of carbon dioxide in the gastrointestinal suite.

Nil per os guidelines: what is changing, what is not, and what should?

Preoperative nil per os (NPO) guidelines have been in existence since the recognition of the risk of perioperative aspiration. These guidelines aim at reducing the risk for gastric content aspiration to the lowest possible, to avoid associated morbidity, unplanned hospital and/or an intensive care admission. Thus, such guidelines are not only considered for patients having major surgeries, but more so in those having ambulatory surgery including those performed at non-operating room anesthesia locations. NPO guidelines have always been controversial due to the paucity of data in support of one recommendation versus another and have seen multiple changes and updates by the issuing national anesthesiology societies as new evidence emerges. At the present time, they have become increasingly permissive, such that the ingestion of clear fluids is now encouraged up to two hours before elective surgery. This has added more fuel to the already heated controversies regarding NPO guidelines and contributed to the experienced variability among different local NPO policies adopted by different clinicians. In this article, we attempt to discuss many of these controversies, including the relationship between NPO duration and the risk of aspiration, NPO and the choice of airway device, NPO and operating room efficiency and NPO for procedural sedation.

Intraoperative electro-anatomical mapping and beating heart ablation of ventricular tachycardia.

In most cases ventricular tachycardia is responsive to antiarrhythmic drug therapy. If antiarrhythmic drugs fail, then percutaneous, endocardial ablation guided by electro-anatomical mapping is usually curative. Occasionally neither of these therapies is successful and surgical ablation is required. Challenges encountered in surgical ablation include application of reliable intraoperative real-time electro-anatomical mapping to identify the focus of ventricular tachycardia and the need for technology that enables ablation on the beating heart. We present a case demonstrating the feasibility of surgical cryoablation of ventricular tachycardia arising from the right ventricle using intraoperative real-time epicardial and endocardial electro-anatomical mapping and argon-based cryoablation.

Deep sternal wire infection resulting in severe pulmonary valve endocarditis.

Right-sided infective endocarditis is uncommon, comprising less than 5% of all cases of endocarditis. This is primarily seen in patients with drug abuse, long-term intravenous catheters, and congenital malformations, or a combination of these. Isolated pulmonary valve endocarditis is difficult to recognize due to its rarity, minimal cardiac manifestations, and predominance of pulmonary infections secondary to embolization of the vegetations. We describe an unusual case of chronic sternal wound infection and migration of an infected braided sternal wire causing right ventricular outflow tract and pulmonary valve endocarditis, which necessitated a complicated reoperation including pulmonary valve replacement with a homograft.