Duration of mechanical ventilation after craniosynostosis repair reduces over time.

BACKGROUND: Pediatric craniosynostosis repair (CR) involves wide scalp dissections with multiple osteotomies and has been associated with significant morbidity. The aim of this study was to document the impact of perioperative complications on prolonged mechanical ventilation after CR. METHODS: Data were collected from the anesthesia records, Pediatric Intensive Care Unit (PICU) progress notes and discharge summaries. All the patients were transferred from the operating room sedated and on mechanical ventilation to the PICU. To highlight the determinants of prolonged mechanical ventilation we performed a logistic regression analysis.. RESULTS: Fifty-five patients underwent CR, but 6 were excluded due to incomplete records. The main intraoperative complications were: metabolic acidosis (32%), hypotension (20%), dural tears laceration (22%) and altered coagulation (18%). Metabolic acidosis (46%) and relative polycythemia (24%) were detected on arrival to the PICU. All children received intraoperative blood products and 23 (46%) were transfused in the postoperative period too. No infective complications were detected. The only determinant associated significantly with a prolonged mechanical ventilation was to have surgery in the first 5 years of the program (P=0.05) (95% CI 0.358-0.996). CONCLUSION: All life-threatening complications were intraoperative whereas only milder ones, such as hypercloremic and lactic acidosis were noticed in PICU. All children are alive without any neurological deficit. Even though we deal on a daily basis with complex surgical cases, only time, hence experience, showed an impact on prolonged mechanical ventilation.

A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients.

BACKGROUND: Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. METHODS: The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. RESULTS: The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. CONCLUSIONS: Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.

The use of desflurane or propofol in combination with remifentanil in myasthenic patients undergoing a video-assisted thoracoscopic-extended thymectomy.

BACKGROUND: Although several studies of the use of desflurane in anesthesia have revealed many desirable qualities, there are no data on the use and effects especially on the neuromuscular function of desflurane on myasthenia gravis (MG) patients. The purpose of this study was to evaluate the use of either desflurane or propofol, both combined with remifentanil, in patients with MG undergoing a video-assisted thoracoscopic-extended thymectomy (VATET). METHODS: Thirty-six MG patients who underwent VATET were enrolled. Nineteen patients were anesthetized with remifentanil and propofol infused with a target-controlled infusion plasma model, and 17 patients with desflurane and remifentanil. No muscle relaxant was used. The intubating conditions, hemodynamic and respiratory changes, neuromuscular transmission and post-operative complications were evaluated. RESULTS: Neuromuscular transmission was significantly decreased in the desflurane group (6.7%, from 3% to 9% during anesthesia P=or<0.05). The intubating conditions were good in all 36 patients and 35 patients were successfully extubated in the operating room. The time-to-awakening, post-operatory pH and base excess were significantly different in the two groups, with a decreasing mean arterial pressure in the group administered with desflurane. No patients required reintubation due to myasthenic or cholinergic crisis, or respiratory failure. No other significant differences between the two groups studied were observed. CONCLUSION: Our experience indicates that anesthesia with desflurane plus remifentanil in patients with MG could determine a reversible muscle relaxation effect, but with no clinical implication, allowing a faster recovery with no difference in extubation time and post-operative complications in the two groups.