Anaesthesia of a parturient with uncorrected pentalogy of Fallot undergoing caesarean section and postpartum sterilisation.

Pentalogy of Fallot is a rare congenital cyanotic heart disease; few patients with uncorrected disease survive to childbearing age. Cardiovascular changes during pregnancy and delivery can lead to haemodynamic instability, while anaesthesia can cause right-to-left shunting and worsen hypoxaemia.We present the learning points from the anaesthetic management of an obstetric patient with uncorrected pentalogy of Fallot. We describe the successful application of general anaesthesia, choice of transoesophageal echocardiography for real-time haemodynamic monitoring and management, and the comprehensive multidisciplinary care of this high cardiovascular risk obstetric patient perioperatively. We also review the literature and discuss the anaesthetic management of patients with pentalogy of Fallot going for caesarean section.

Anaesthetic management of a patient with complex, cyanotic congenitally corrected transposition of great arteries for electrophysiological study and thermoablation.

Congenitally corrected transposition of great arteries (ccTGA) is a rare congenital heart disease, and little literature is available that describes its anaesthetic management. We present the perioperative management of a patient with complex, cyanotic ccTGA who underwent electrophysiological study with catheter ablation under general anaesthesia. Good understanding of the patient's complex cardiac anatomy and physiology and multidisciplinary communication are vital to facilitate the successful care of the patient.

Is hypotensive anaesthesia guided by invasive intraarterial monitoring required for orthognathic surgery? - A retrospective review of anaesthetic practice and intraoperative blood loss in orthognathic surgery in a tertiary hospital.

BACKGROUND AND AIMS: Orthognathic surgeries for maxillofacial deformities are commonly performed globally and are associated with significant blood loss. This can distort the surgical field and necessitate blood transfusion with its concomitant risks. We aimed to review if invasive intraarterial (IA) line monitoring and/or hypotensive anaesthesia is required for orthognathic surgeries, and their effects on intraoperative blood loss and transfusion requirements. METHODS: This was a retrospective observational study conducted in patients admitted for orthognathic surgeries in a public tertiary hospital. Anaesthetic techniques and intraoperative haemodynamics were studied for their effects on intraoperative blood loss. RESULTS: The data from 269 patients who underwent orthognathic-bimaxillary surgeries was analysed. Inhalational anaesthetic combined with remifentanil was administered for 86.6%, total intravenous anesthesia to 11.2% patients, while the rest received inhalational anaesthesia. Hypotensive anaesthesia was achieved in 48 subjects (17.8%) and associated with shorter duration of surgery (349 vs 378 min, P = 0.02) and a trend towards lower blood loss (874 mL vs 1000 mL, P = 0.058) but higher transfusion requirement (81.3% vs 58.8%, P = 0.004). An IA line was used in 119 patients (44.2%) and was not associated with a higher probability of achieving hypotensive anaesthesia (19.3% vs 16.7%, P = 0.06). However, less blood loss (911 vs 1029 mL, P = 0.05) occurred compared to noninvasive blood pressure monitoring. CONCLUSION: Invasive blood pressure monitoring is as effective as noninvasive methods to achieve hypotensive anaesthesia. It does not aid in achieving lower target blood pressure. There is a lack of association between a reduction in blood loss and higher blood transfusion during hypotensive anaesthesiaand thiswill require further evaluation.

Airway Management in the Operating Room and Interventional Suites in Known or Suspected COVID-19 Adult Patients: A Practical Review.

Current evidence suggests that coronavirus disease 2019 (COVID-19) spread occurs via respiratory droplets (particles >5 µm) and possibly through aerosol. The rate of transmission remains high during airway management. This was evident during the 2003 severe acute respiratory syndrome epidemic where those who were involved in tracheal intubation had a higher risk of infection than those who were not involved (odds ratio 6.6). We describe specific airway management principles for patients with known or suspected COVID-19 disease for an array of critical care and procedural settings. We conducted a thorough search of the available literature of airway management of COVID-19 across a variety of international settings. In addition, we have analyzed various medical professional body recommendations for common procedural practices such as interventional cardiology, gastroenterology, and pulmonology. A systematic process that aims to protect the operators involved via appropriate personal protective equipment, avoidance of unnecessary patient contact and minimalization of periprocedural aerosol generation are key components to successful airway management. For operating room cases requiring general anesthesia or complex interventional procedures, tracheal intubation should be the preferred option. For interventional procedures, when tracheal intubation is not indicated, cautious conscious sedation appears to be a reasonable approach. Awake intubation should be avoided unless it is absolutely necessary. Extubation is a high-risk procedure for aerosol and droplet spread and needs thorough planning and preparation. As updates and modifications in the management of COVID-19 are still evolving, local guidelines, appraised at regular intervals, are vital in optimizing clinical management.

Anaesthetic management of a patient with Fontan physiology for electrophysiology study and catheter ablation.

The success of the Fontan procedure for congenital single ventricle anatomy has resulted in adult patients with Fontan physiology requiring anaesthesia for cardiac and non-cardiac procedures. We present the perioperative management of a patient with Fontan physiology who underwent electrophysiological study with radiofrequency ablation for atrial tachycardia under general anaesthesia. Good communication between the multidisciplinary teams, a detailed understanding of the patient's complex cardiac anatomy and physiology, as well as the ability to recognise and manage perioperative complications all play a vital role for a successful outcome.

Anesthetic Implications for Cesarean Section in a Parturient with Complex Congenital Cyanotic Heart Disease.

The discordance between increased physiological demand during pregnancy and congenital cardiac pathology of a parturient is a perilous threat to the maternal-fetal well-being. Early involvement of a multidisciplinary team is essential in improving peripartum morbidity and mortality. Designing the most appropriate anesthetic care will require a concerted effort, with inputs from the obstetricians, obstetric and cardiac anesthesiologists, cardiologists, neonatologists, and cardiothoracic surgeons. We report the multidisciplinary peripartum care and anesthetic management for cesarean section (CS) of a 28-year-old primigravida who has partially corrected transposition of the great arteries, atrial and ventricular septal defect, dextrocardia, right ventricle hypoplasia, and tricuspid atresia.

Comparison of the clinical performance of i-gel, LMA Supreme and LMA ProSeal in elective surgery.

INTRODUCTION: The LMA Supreme™, i-gel® and LMA ProSeal™ are second-generation supraglottic airway devices. We tested the hypothesis that these devices differ in performance when used for spontaneous ventilation during anaesthesia. METHODS: 150 patients who underwent general anaesthesia for elective surgery were randomly allocated into three groups. Data was collected on oropharyngeal leak pressures, ease and duration of device insertion, ease of gastric tube insertion, and airway safety. RESULTS: Leak pressure, our primary outcome measure, was found to be higher for the i-gel than the Supreme and ProSeal (mean ± standard error of the mean: 27.31 ± 0.92 cmH2O, 23.60 ± 0.70 cmH2O and 24.44 ± 0.70 cmH2O, respectively; p = 0.003). Devices were inserted on the first attempt for 90%, 82% and 72% of patients in the i-gel, Supreme and ProSeal groups, respectively (p = 0.105); mean device placement times were 23.58 seconds, 25.10 seconds and 26.34 seconds, respectively (p = 0.477). Gastric tubes were inserted on the first attempt in 100% of patients in the Supreme group, and 94% of patients in the i-gel and ProSeal groups (p = 0.100). There was blood staining on removal in 9 (18%) patients in each of the Supreme and ProSeal groups, with none in the i-gel group (p = 0.007). The incidence of postoperative sore throat, dysphagia and hoarseness was lowest for the i-gel. CONCLUSION: The three devices were comparable in terms of ease and duration of placement, but the i-gel had higher initial oropharyngeal leak pressure and lower airway morbidity compared with the ProSeal and Supreme.

Association between frailty, cerebral oxygenation and adverse post-operative outcomes in elderly patients undergoing non-cardiac surgery: An observational pilot study.

BACKGROUND AND AIMS: Although both frailty and low cerebral oxygen saturation increase the risk of post-operative complications, their relationship is yet to be investigated. The purpose of this observational study was to investigate the association between frailty, intraoperative cerebral oxygen saturation and post-operative complications in elderly patients undergoing non-cardiac surgery. METHODS: After approval from the Institutional Review Board, 25 elderly patients (>65 years) undergoing non-cardiac major surgery were included in this study. Pre-operatively, all included patients were assessed for frailty and classified into frail and non-frail groups. All patients had routine intraoperative monitors, and a cerebral oximeter applied during anaesthesia. The 'intraoperative' anaesthesiologist and the post-operative study investigator were blinded to cerebral oximeter readings throughout the study. The incidence of significant intraoperative cerebral oxygen desaturation, adverse post-operative outcomes and length of hospital stay were compared. Statistical significance was defined as a value of P < 0.05. RESULTS: We found that the frail group had more intraoperative cerebral desaturation (odds ratio [OR] [95% confidence interval [CI]]: 1.75 [1.11-2.75]) and longer median (interquartile range) length of hospital stay compared to the non-frail group (13.5 days [8.75-27.5] and 8 days [6-11], respectively). Furthermore, in patients with a low-baseline cerebral oxygen saturation (<55%), intraoperative cerebral desaturation (OR [95% CI]: 2.10 [1.00-4.42]), adverse post-operative outcomes (OR [95% CI]: 1.80 [1.00-3.23]) and median (interquartile range) length of hospital stay (15 days [9-31.5] vs. 9 days [6.25-13.75], P = 0.04) were significantly higher compared to subjects with higher baseline (≥55%) cerebral oxygen saturation. CONCLUSIONS: Frail patients have more intraoperative cerebral desaturation and longer lengths of hospital stay compared to non-frail patients.

Anesthetic considerations for endovascular abdominal aortic aneurysm repair.

Aneurysm is defined as a localized and permanent dilatation with an increase in normal diameter by more than 50%. It is more common in males and can affect up to 8% of elderly men. Smoking is the greatest risk factor for abdominal aortic aneurysm (AAA) and other risk factors include hypertension, hyperlipidemia, family history of aneurysms, inflammatory vasculitis, and trauma. Endovascular Aneurysm Repair [EVAR] is a common procedure performed for AAA, because of its minimal invasiveness as compared with open surgical repair. Patients undergoing EVAR have a greater incidence of major co-morbidities and should undergo comprehensive preoperative assessment and optimization within the multidisciplinary settings. In majority of cases, EVAR is extremely well-tolerated. The aim of this article is to outline the Anesthetic considerations related to EVAR.

Anesthesia management for MitraClip device implantation.

AIMS AND OBJECTIVES: Percutaneous MitraClip implantation has been demonstrated as an alternative procedure in high-risk patients with symptomatic severe mitral regurgitation (MR) who are not suitable (or) denied mitral valve repair/replacement due to excessive co morbidity. The MitraClip implantation was performed under general anesthesia and with 3-dimensional transesophageal echocardiography (TEE) and fluoroscopic guidance. MATERIALS AND METHODS: Peri-operative patient data were extracted from the electronic and paper medical records of 21 patients who underwent MitraClip implantations. RESULTS: Four MitraClip implantation were performed in the catheterization laboratory; remaining 17 were performed in the hybrid operating theatre. In 2 patients, procedure was aborted, in one due to migration of the Chiari network into the left atrium and in second one, the leaflets and chords of the mitral valve torn during clipping resulting in consideration for open surgery. In the remaining 19 patients, MitraClip was implanted and the patients showed acute reduction of severe MR to mild-moderate MR. All the patients had invasive blood pressure monitoring and the initial six patients had central venous catheterization prior to the procedure. Intravenous heparin was administered after the guiding catheter was introduced through the inter-atrial septum and activated clotting time was maintained beyond 250 s throughout the procedure. Protamine was administered at the end of the procedure. All the patients were monitored in the intensive care unit after the procedure. CONCLUSIONS: Percutaneous MitraClip implantation is a feasible alternative in high-risk patients with symptomatic severe MR. Anesthesia management requirements are similar to open surgical mitral valve repair or replacement. TEE plays a vital role during the MitraClip implantation.

Difficult intubation in a patient with vallecular cyst.

Although rare, vallecular cysts can have catastrophic consequences in an anaesthetised patient if airway management is inappropriate. We report a case of difficult intubation in a 46-year-old man with a vallecular cyst, and detail the methods and strategies for successful endotracheal tube insertion. Following a review of the current literature, we also discuss airway management options in adult patients with vallecular cysts.