Anesthesia management of ophthalmic surgery for patient with suspected/confirmed COVID-19 -Saudi Anesthesia Society guidelines.

The outbreak of the novel coronavirus (COVID-19) has been declared a global pandemic. With a mortality rate reaching up to 5%, healthcare professionals treating patients with COVID-19 are at a significantly higher risk for exposure themselves. Given the rapidly progressing rate of COVID-19, there is an urgent need for developing guidelines within each specialty. This article discusses guidelines specifically for anesthesiologists dealing with ophthalmic surgeries with suspected or confirmed COVID-19 patients. Anesthesiologists always work in the proximity of the patient's face while performing either ocular regional anesthesia or while managing the airway in the process of intubation/extubation. Within these guidelines, the emphasis is provided on thorough preoperative screening to identify COVID-19 patients and to prevent the exposure of healthcare staff by following standard personal protective equipment (PPE) precautions.

A survey of the practice of regional anesthesia in Saudi Arabia.

OBJECTIVE: This survey aimed to assess both the extent of practice and need for training in regional anesthesia among anesthesiologists in Saudi Arabia in 2012. METHODS: We distributed an electronic survey among 382 anesthesiologists attending the bi-annual meetings of the Saudi Anesthetic Association, enquiring about their practice in regional anesthesia. Questions concerned the practice of regional anesthesia, use of ultrasound guidance, and the need for training workshops. RESULTS: The response rate of anesthetists was 55.2% with most of them were males and had mean age of 25-50 years. Most anesthesiologists (88.2%) were practicing regional anesthesia frequently in the operating rooms (75.3%) rather than designated block room. From the respondents, only 14.2% did fellowship in regional anesthesia, 21.8% and 18.5% were using ultrasound and nerve stimulation guidance, respectively, 11.4% received formal training, and 86.3% were willing to attend training workshops on regional anesthesia. There was a significant negative correlation between the ultrasound users and their institutional positions (r=-0.191) (P=0.026). CONCLUSIONS: We believe that more could be done to improve the practice of regional anesthesia in the Kingdom of Saudi Arabia, including the implementation of formal training and conduction of more frequent specialized courses/workshops in the field of regional anesthesia with special reference to ultrasound regional anesthesia blockade techniques.

Anesthetic considerations of central airway obstruction.

Central airway obstruction (CAO) is a serious presentation of lung cancer and associated chest diseases. It presents a real challenge to the anesthesiologist because usually the patient admitted to the hospital as an emergency case with high grade dyspnea scheduled to undergo rigid bronchoscopy for diagnostic and possible therapeutic interventions. In this case report, we described the anesthetic management of a patient who was admitted to our hospital with CAO.

Continuous positive airway pressure ventilation during whole lung lavage for treatment of alveolar proteinosis -A case report and review of literature.

Pulmonary alveolar proteinosis (PAP) is a rare disease that affects young population usually in the age group of 20-40 years, characterized by the deposition of lipoproteinacious material in the alveoli secondary to abnormal processing of surfactant by macrophages. We report a case of a 15-year-old female who had history of cough with sputum for 3 days along with fever. She was seen in another hospital and was treated as a case of pneumonia where she received antibiotic but with no improvement. Computerized tomography (CT) chest showed diffuse interlobular septal thickening in the background of ground glass opacity giving a picture of crazy paving pattern which was consistent with the diagnosis of PAP. The patient was scheduled to undergo, first right-sided whole lung lavage (WLL) under general anesthesia. Endobronchial intubation using left sided 37 Fr double lumen tube. Continuous positive airway pressure (CPAP) as described in our previously published report was connected to the right lumen of the endobronchial tube. CPAP ventilation was used during the suctioning of lavage fluid phase in order to improve oxygenation. WLL was done using 5 L of warm heparinized saline (500 i.u/litre). The same procedure was repeated on the left side using 6 L of heparinized normal saline solution. In conclusion, anesthesia in alveolar proteinosis for patients undergoing WLL is challenging to the anesthesiologist. It requires meticulous preoperative preparation with antibiotics, mucolytics and chest physiotherapy. Also it requires careful intraoperative monitoring and proper oxygenation especially during the suctioning phase of the lavaged fluid. With this second case report of successful anesthetic management using the modified CPAP system we recommend with confidence the application of CPAP ventilation to improve oxygenation during WLL.

Ultrasound gel-nerve contact: an experimental animal histologic study.

BACKGROUND: Ultrasound (US) regional nerve block requires the use of gel applied over the skin. With subsequent needle insertion, some of the gel may adhere either on the shaft or within the needle lumen and may be carried to the perineural structures or intraneurally. We performed this experimental animal study to investigate the effects of US gel contact on the nerve histologic structure. METHODS: Nine male beagle dogs were studied. Dogs 1 to 3 were the control group and dogs 4 to 9 were the study group. Bilateral posterior tibial nerves were dissected and exposed for the control group. Nerve specimens were obtained for histologic examination immediately for the first dog, at 24 hours for the second dog, and at 48 hours for the third dog followed by wound closure. For the study group, bilateral posterior tibial nerves were exposed, and 2 mL US gel was applied locally directly on the nerve, followed by wound closure. Nerve specimens were excised at 24 hours from one side and at 48 hours from the other side. Nerve specimens were examined by a neuropathologist for evidence of nerve inflammation. RESULTS: The control nerve specimens showed no significant pathology. Nerve specimens of the study group at the end of 24 hours of gel-nerve contact showed mild focal perineural inflammatory changes with clusters of polymorph leukocytes. At 48 hours, perineural moderate inflammatory changes with clusters of lymphocytes and macrophages were demonstrated in 2 animals. Long-term neurologic deficit in the form of limping was observed for all dogs. CONCLUSION: Histologic features after perineural exposure to US gel are rather nonspecific and likely of no clinical significance. However, further studies are needed to determine the effect of US gel injection on intraneural tissues.

A cost-benefit analysis of the ENIGMA trial.

BACKGROUND: The ENIGMA trial was a prospective, randomized, multicenter study that evaluated the clinical consequences of including N2O in general anesthesia. Patients who were given a N2O-free anesthetic when undergoing major surgery for which the expected hospital stay was at least 3 days had lower rates of some postoperative complications. This suggests that, despite a higher consumption of potent inhalational agent, there could be a financial benefit when N2O is avoided in such settings. METHODS: A retrospective cost analysis of the 2,050 patients recruited to the ENIGMA trial was performed. We measured costs from the perspective of an implementing hospital. Direct health care costs include the costs for maintaining anesthesia, daily medications, hospitalization, and complications. The primary outcome was the net financial savings from avoiding N2O in major noncardiac surgery. Comparisons between groups were analyzed using Student t test and bootstrap methods. Sensitivity analyses were also performed. RESULTS: Rates of some serious complications were higher in the N2O group. Total costs in the N2O group were $16,203 and in the N2O-free group $13,837, mean difference of $2,366 (95% CI: 841-3,891); P = 0.002. All sensitivity analyses retained a significant difference in favor of the N2O-free group (all P ≤ 0.005). CONCLUSIONS: Despite N2O reducing the consumption of more expensive potent inhalational agent, there were marked additional costs associated with its use in adult patients undergoing major surgery because of an increased rate of complications. There is no cogent argument to continue using N2O on the basis that it is an inexpensive drug.

Critical incident monitoring in a teaching hospital--the third report 2003-2008.

UNLABELLED: Several factors have been incriminated in the etiologies of critical incidents: shortages in organizing rules, anesthesia technique, patient environment, human factor, team work and communication. This is the third follow up report describing our performance during the last five years (2003-2008). The possible incriminating causes were identified with the objective of avoiding such eventualities and consequently providing a better patient outcome. PATIENTS & METHODS: The computerized database and the medical records of critical incidents reports in our Department during the period of 2003-2008 were reviewed on case-by-case basis. Seventy reported incidents were discussed in the Department's Morbidity & Mortality Meetings (MMM). Incidents were classified as per possible incriminating causes: pulmonary, cardiovascular, central nervous system, metabolic, inadvertent drug injection, communicating failure, equipment failure and miscellaneous causes. RESULTS: Most of the critical incidents reports occurred during maintenance of anesthesia, followed next by during induction and next by same operative day later in the ward. The majority of cases were respiratory events (29 cases), followed by communication failure (12 cases), failure of equipment (9 cases) and inadvertent drug injection (4 cases). CONCLUSIONS: Respiratory events, human errors, team communication and equipment failures, continue to be the leading causes of critical incidents. Critical incidents are apt to occur so long as the human factor is involved. Vigilance in operational efficiency and the scrutiny in drug administration, supervision and training should be closely monitored in order to minimize critical incident reports.

Effect of fluid preloading on postoperative nausea and vomiting following laparoscopic cholecystectomy.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common complication following general anesthesia. Different regimens have been described for the treatment of PONV with few that mention the prevention of it. Therefore, we conducted this study to compare the effect of preloading with either crystalloids or colloids on the incidence of PONV following laparoscopic cholecystectomy (LC), under general anesthesia. MATERIALS AND METHODS: This study was carried out on 80 patients who underwent LC. The patients were divided into four groups (each 20 patients), to receive preloading of intravenous fluid, as follows: Group 1 received, 10 ml/kg of low-MW tetrastarch in saline (Voluven), group 2 received, 10 ml/kg medium-MW pentastarch in saline (Pentaspan), group 3, received 10 ml/kg of high-MW heta-starch in saline (Hespan), and group 4, received 10 ml/kg Lactated Ringer's, and this was considered as the control group. All patients received the standard anesthetic technique. The incidence of PONV was recorded, two and 24 hours following surgery. The need for antiemetics and/or analgesics was recorded postoperatively. RESULTS: The highest incidence of PONV was in group 3 (75% of the patients) compared to the other three groups. Also the same trend was found with regard to the number of patients who needed antiemetic therapy. It was the highest incidence in group 3 (70%), followed by group 2 (60%), and then group 1(35%), and the least one was in the control group (25%). CONCLUSION: Intravascular volume deficits may be a factor in PONV and preloading with crystalloids showed a lower incidence of PONV.

Efficacy and safety of prophylactic large dose of tranexamic acid in spine surgery: a prospective, randomized, double-blind, placebo-controlled study.

STUDY DESIGN: This is a double blind randomized placebo controlled study, after obtaining approval of ethics committee in the hospital and informed written consent, 64 patients were randomized equally into 2 groups (tranexamic acid (TA) and placebo). OBJECTIVE: To evaluate efficacy and safety of large doses of TA on blood loss during spinal operations. SUMMARY OF BACKGROUND DATA: Blood loss associated with spinal operations is a common potential cause of morbidity and often requires blood transfusion which subject patients to the known risks of blood transfusion including transmission of diseases. TA is used routinely to reduce bleeding in cardiac, orthopaedic, and hepatic surgery, however, its use in neurosurgery is uncommon and only few studies reported the use of antifibrinolytic drugs in spine surgery. METHODS: Sixty-four consecutive patients undergoing spinal surgery with expected significant blood loss at King Khalid University Hospital between June 2005 and December 2006 were randomly assigned to 2 groups, TA and placebo. Shortly after the induction of anesthesia, patients received either TA or placebo as a loading dose of 2 g (for adults) or 30 mg/kg (for children), followed immediately by continuous infusion of 100 mg/h (for adults) or 1 mg/kg/h (for children) during surgery and for 5 hours after the operation. Outcome measures included total (i.e., intraoperative and postoperative) blood loss, amount of blood transfusion, as well as postoperative hemoglobin, and hematocrite levels. The data were analyzed by means of Statistical Package for the Social Science Version 12.0. The results were presented as mean +/- SD. Independent Student t test was used to compare the 2 groups and differences were considered significant if the P-value was <0.05. RESULTS: There were 39 males and 25 females, ranging in age from 4 to 86 years with a mean of 51 and median of 56 years. Eighteen patients had multilevel anterior cervical discectomies with or without internal fixation, 22 patients had decompressive surgery (12 laminectomies and 10 intersegmental decompressions) for multiseg- ment spinal stenosis, 15 patients had laminectomy with posterior spinal fixation, and remaining 9 patients had laminectomy and excision of spinal tumor. Statistical analysis showed no significant differences between the 2 study groups with regard to age, sex, weight, preoperative hemoglobin, and hematocrite levels, type of surgery, as well as operative time. In contrast, patients who received TA had 49% reduction of blood loss (P < 0.007) and required 80% less blood transfusion (P < 0.008) than patients who received placebo. The hospital stay was shorter in the TA group, but it did not achieve statistical significance. There were no complications related to the use of large doses of TA in this study. CONCLUSIONS: Prophylactic use of large doses of TA provides an effective, safe, and cheap method for reducing blood loss during and after spinal operations. Hence, TAmay help in reducing not only transfusion related complications but also operative expenses. Considering the limited number of patients in this study, our results need, however, to be validated on a larger number of patients, probably in a multicenter study.

Anesthesia for third ventriculostomy. A report of 128 cases.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become the standard surgical procedure for treatment of non-communicating hydrocephalus. The aim of this study is to report our results over the past ten years with reference to perioperative complications of ETV with a review of some specific anesthetic issues. METHODS: The computerized database (in the Department of Neurosurgery) and the medical records of 128 patients who underwent ETV between February 1998 and February 2007 at our Hospital, were reviewed. Data collected were, age, sex, weight, height, preoperative biochemical analysis, duration of the procedure, anesthetic drugs used, amount of irrigation fluid used, blood loss, postoperative biochemical analysis and perioperative complications. RESULTS: Preoperative biochemical analysis for all patients was within normal ranges. Normal saline 0.9% was used as irrigation fluid for all patients. The volume during the procedure used ranged from 2 to 6 L (mean 3 L). When correlating postoperative serum sodium mean values to the volume of irrigation fluid used, it showed non significant correlation (r= 0.07). Serum potassium level has shown significant decrease postoperatively compared to preoperative levels (P < 0.05). The other biochemical analysis parameters showed non-significant changes postoperatively compared to preoperative data (P > 0.05). CONCLUSION: Anesthesiologists should be aware of the intra and postoperative complications secondary to ETV. Intraoperative bradycardia is the commonest arrhythmia occuring during the procedure. Precautions, like alerting the surgeon and pulling out the scope, are enough to revert bradycardia if it occurs. Though postoperative electrolyte imbalance occurs we believe it has no clinical significance. We believe that either normal saline or lactated Ringer solutions could be safely used for intraoperative irrigation with minimal postoperative impact. Though the procedure is a minimally invasive procedure, close observation of vital signs, serum electrolytes as well as volume and temperature of the irrigation fluid and close communication between anesthesiologist and surgeon, are prerequisites for better outcome.

Anesthetic management of a patient with myotonic dystrophy for laparoscopic cholecystectomy--a case report.

Myotonic dystrophy (MD) is rare disease that offers challenges to anesthesiologists. We report a case of adult patient with myotonic dystrophy who underwent laparoscopic cholecystectomy. A 48-year-old male patient, known case of MD, was presented for laparoscopic cholecystectomy. Physical examination revealed, young man, calm, quite, cooperative, not in pain or distress with frontal baldness, temporal bone recession, elongated face, mild degree of ptosis and swan neck. Under complete aseptic conditions, thoracic epidural T6-7 with catheter insertion was performed while the patient was placed on left lateral side. Plain bupivacaine 0.5% 7cc was injected through the catheter. Level of analgesia tested with ice reached up to T4. Intravenous sedation was achieved with midazolam 2 mg and ketamine 50 mg. The patient was comfortably lying supine on warm heated mattress, except of bilateral shoulder pains which was relieved with midazolam and ketamine. In conclusion, regional anesthesia, spinal or epidural, is preferable in MD patients. Shoulder pains is the main intraoperative problem encountered in our patient. Therefore, studies are needed for treating shoulder pain. To the best of our knowledge, this is the first case report in a patient with MD who underwent laparoscopic cholecystectomy under thoracic epidural analgesia. Myotonic dystrophy (M) is rare disease and represents challenges to anesthesiologists. We report a case of adult patient with myotonic dystrophy who underwent laparoscopic cholecystectomy.

Hemodynamic profile during laparoscopic cholecystectomy versus laparoscopic bariatric surgery: the impact of morbid obesity.

The present study investigated the hemodynamic profile using impedance cardiography (ICG) monitor during pneumoperitoneum for laparoscopic cholecystectomy versus bariatric surgery in order to determine the impact of body weight on hemodynamics. METHODS. 32 adult patients (two groups, each 16 patients) were studied. Group 1 (16 patients) scheduled to undergo laparoscopic cholecystectomy (lapchole) with body mass index (BMI) 28 +/- 5 kg/m2. Group 2 (16 patients) scheduled to undergo laparoscopic adjustable band (LAGB) surgery for treatment of morbid obesity with BMI 45.3 +/- 8 kg/m2. under general anesthesia. Besides routine monitoring, impedance cardiography was used for hemodynamic monitoring. Three stages were identified for statistical analysis A, pre-insufflation, B, during vere pneumoperitoneum and C, at gas deflation. RESULTS. The mean values of cardiac index in group 1 at stages A, B and C were, 3.0 +/- 1.7, 2.5 +/- 0.5 and 2.7 +/- 0.5 L/min/m2 respectively with significant low values in stage B compared to stage A (p < 0.05). The same trend continue in group 2 where the mean values were, 2.4 +/- 0.6, 1.8 +/- 0.6 and 2.3 +/- 0.9 L/min/m2 respectively with significant differences compared to group 1 mean values (p < 0.05). Other hemodynamic variables showed non-significant differences (p > 0.05). CONCLUSIONS. Cardiac index showed significant decreasing trend in morbid obese patients compared to nonobese, which may reflect the effect of body weight on hemodynamics. On the other hand other hemodynamic parameters was not altered by body weight. We believe that hemodynamics should be closely monitored during laparoscopic surgery with pneumoperitoneum.

Anesthesia for thoracoscopic thymectomy: modified non-muscle relaxant technique--case reports.

Anesthesia for thymectomy in myasthenia gravis is challenging. The anesthetic experience of that technique is quite large. In involves either muscle relaxant or non-muscle relaxant techniques. However, the literature is deficient of standard anesthetic technique for thoracoscopic thymectomy. Therefore we present in this report a modified non-muscle relaxant technique for thoracoscopic thymectomy (TT). We report two cases who underwent TT under general anesthesia using sufentanil and propofol for induction and local anesthesia spray to the vocal cords to facilitate endobronchial intubation using non-muscle relaxant technique. The intubating, operating and postoperative conditions were excellent. To the best of our knowledge, this is the first report on modified non-muscle relaxant technique for TT in myasthenia gravis. Further cases have to be done to verify our technique.

Hemodynamic profile during laparoscopic cholecystectomy versus laparoscopic bariatric surgery--the impact of morbid obesity.

UNLABELLED: The present study investigated the hemodynamic profile using impedance cardiography (ICG) monitor during pneumoperitoneum for laparoscopic cholecystectomy versus bariatric surgery in order to determine the impact of body weight on hemodynamics. METHODS: 32 adult patients (two groups, each 16 patients) were studied. Group 1 (16 patients) scheduled to undergo laparoscopic cholecystectomy (lapchole) with body mass index (BMI) 28 +/- 5kg/m2. Group 2 (16 patients) scheduled to undergo laparoscopic adjustable band (LAGB) surgery for treatment of morbid obesity with BMI 45.3 +/- 8kg/m2. under general anesthesia. Besides routine monitoring, impedance cardiography was used for hemodynamic monitoring. Three stages were identified for statistical analysis A, pre-insufflation, B, during pneumoperitoneum and C, at gas deflation. RESULTS: The mean values of cardiac index in Group 1 at stages A, B and C were, 3.0 +/- 1.7, 2.5 +/- 0.5 and 2.7 +/- 0.5L/min/m2 respectively with significant low values in stage B compared to stage A (P<0.05). The same trend continue in Group 2 where the mean values were, 2.4 +/- 0.6, 1.8 +/- 0.6 and 2.3 +/- 0.9L/min/m2 respectively with significant differences compared to Group 1 mean values (P<0.05). Other hemodynamic variables showed non-significant differences (P>0.05). CONCLUSIONS: Cardiac index showed significant decreasing trend in morbid obese patients compared to nonobese, which may reflect the effect of body weight on hemodynamics. On the other hand, other hemodynamic parameters was not altered by body weight. We believe that hemodynamics should be closely monitored during laparoscopic surgery with pneumoperitoneum.

Impedance cardiography: noninvasive measurement of hemodynamics and thoracic fluid content during endoscopic thoracic sympathectomy.

Endoscopic thoracic sympathectomy (ETS) is a minimally invasive procedure for treating palmar hyperhidrosis (PH). Hemodynamic changes are associated with CO(2) insufflation during ETS. In the present study, we examined hemodynamic changes during general anesthesia using impedance cardiography (ICG) monitor. Seventeen adult patients (15 males) scheduled to undergo elective unilateral ETS for treatment of PH were enrolled in the study. Patients with cardiorespiratory diseases were excluded from the study. Their age and weight mean values were 26.5 +/- 5 years, 71.9 +/- 11.5 kg, respectively. Besides routine monitoring, impedance cardiography monitor was used to measure cardiac output (CO), cardiac index (CI), stroke volume (SV), thoracic fluid content (TFC), and systemic vascular resistance (SVR). Three phases were defined for data collection: A, prior to CO(2) insufflation; B during gas insufflation (at 10, 5, and 2 mm Hg intrathoracic pressures); and C, after gas deflation. Repeated-measures analysis of variance (ANOVA) was used for statistical analysis and post hoc Bonferroni test for multiple comparisons of the data obtained. For all comparisons, P < 0.05 was considered significant. Systemic vascular resistance significantly increased at stages B10 and 5 compared with stage A mean value (P < 0.05). CO, CI, and SV mean values decreased significantly at stage B compared with stage A mean values. The mean values of thoracic fluid content at stages A, B10, 5, 2, and C were 33 +/- 5, 30.6 +/- 3.5, 31 +/- 3.4, 31.6 +/- 3.3, and 32.5 +/- 6.8/kOmega, respectively with significant differences (P < 0.05). Significant reductions of cardiac parameters were reported in the present study, but they were of minimal clinical significance. Of interest was the significant reduction of thoracic fluid content during CO(2) insufflation, whether it correlates to the magnitude of compression, caused by CO(2) insufflation accompanied by high systemic vascular resistance or sympathectomy procedure, yet to be further studied.

Perioperative bioelectrical impedence analysis in neurosurgery.

The use of bioelectrical impedence (BI) measurement to assess body composition has recently attracted the attention of anesthesiologists. Analysis of BI provides a non-invasive method to quantify fluid distribution in different body compartments. This study was designed to assess whether BI analysis reflects fluid depletion in neurosurgical patients with moderate blood loss. Six adult male patients scheduled for elective craniotomy under general anesthesia were studied. Exclusion criteria included patients with cardio-respiratory disease. BI analysis was performed at three stages, A, day before operation, B, during surgery and C, on the first postoperative day. Total body resistivity was measured by BI analysis with a four-terminal portable impedence analyzer. At each frequency, impedence was calculated as resistance (Rx)2 + reactance (Rc)2. The mean values of total body water (TBW) at stages A, B and C were 39.8 L (range: 33.1-46.7 L), 43.2 L (range: 33.1-66.2 L) and 36.8 L (range: 22.4-36.3 L) respectively with significant differences (P<0.05). The impedence at the three frequencies during stages A, B and C showed significant differences (P<0.05). In conclusion, we have found that in male neurosurgical patients multiple frequency BI measurements has reflected fluid balance perioperatively. Whether this observation remains true for other surgical procedures with massive blood loss, yet to be further investigated.