Preoperative, intraoperative and postoperative anesthetic prospective for thyroid surgery: what's new.

The aim of this review is to analyze what's new on anesthetic prospective to perioperative management for thyroid surgery. For recent decades intraoperative neuromonitoring (IONM) during thyroid and parathyroid surgery has obtained more and more popularity. New modality of anesthetic technique was also developed to incorporate into surgical teamwork. For example, the precise position of EMG tube and optimal use of neuromuscular blocking agents (NMBAs) play key roles in successful IONM system. Special focus is paid to following issues: (I) preoperative airway evaluation and pre-op preparation; (II) anesthetic managements including advanced intubation tools, NMBAs and sugammadex; and (III) post-op adverse events such as pain and postoperative nausea vomiting.

Dental anesthesia for patients with special needs.

To offer individualized dental treatment to certain patients who cannot tolerate dental treatment, sedation or general anesthesia is required. The needs could be either medical, mental, or psychological. The most common indications for sedation or general anesthesia are lack of cooperation, multiple morbidities, and pediatric autism. In adults, cognitive impairment and multiple morbidities are most commonly encountered indications. Because of suboptimal home care, incomplete medical history, poor preoperative management, lack of cooperation, and developmental abnormalities, it is a challenge to prepare anesthesia for patients with special needs. The American Society of Anesthesiology (ASA) has proposed guidelines for office-based anesthesia for ambulatory surgery. In patients with ASA physical status IV and V, sedation or general anesthesia for treatment in the dental office is not recommended. The distinction between sedation levels and general anesthesia is not clear. If intravenous general anesthesia without tracheal intubation is chosen for dental procedures, full cooperation between the dentist, dental assistant, and anesthesiologist is needed. Teamwork between the dentist and healthcare provider is key to achieve safe and successful dental treatment under sedation or general anesthesia in the patient with special needs.

The role of transesophageal echocardiography in transplantation of an adult-sized kidney to a small child.

Transplantation of adult-sized kidneys to pediatric patients weighing less than 10 kg is a challenge to both surgical and anesthetic management. For survival of the graft, a large-size kidney graft transferred to a pediatric patient needs extraphysiological cardiac output to compensate for adequate renal blood flow. We report here a boy weighing 8.4 kg who received transplantation of a kidney donated by his 56.4-kg mother. Since monitoring of the central venous pressure was not accurate enough and Swan-Ganz catheterization was not feasible in this patient for monitoring the fluid status and cardiac function, we used transesophageal echocardiography to guide intravascular volume expansion and to titrate inotropic support during the surgery. It was demonstrated to be a useful tool for optimization of renal perfusion in this scenario. The transplanted graft served its function well.