Lingering effects of COVID-19 in the care of perioperative patients.

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to organ dysfunction and clinical symptoms beyond the acute infection phase. These effects may have significant implications for the management of perioperative patients. The purpose of this article is to provide a systems-based approach to the subacute and chronic effects of SARS-CoV-2 that are most relevant to anesthesiology practice. RECENT FINDINGS: In 2024, COVID-19 remains a concern for anesthesiologists due ongoing new infections, evolving viral strains, and relatively low rates of booster vaccination in the general population. A growing body of literature describes the post-COVID-19 syndrome in which patients experience symptoms more than 12 weeks after acute infection. Recent literature describes the lingering effects of SARS-CoV-2 infection on all major organ systems, including neurologic, pulmonary, cardiovascular, renal, hematologic, and musculoskeletal, and suggests an increased perioperative mortality risk in some populations. SUMMARY: This review offers anesthesiologists an organ system-based approach to patients with a history of COVID-19. Recognizing the long-term sequelae of SARS-CoV-2 infection can help anesthesiologists to better evaluate perioperative risk, anticipate clinical challenges, and thereby optimize patient care.

PRO: Implementation Science Has Value in Anesthesiology and Cardiothoracic Surgery.

Implementation science is a nascent field that aims to study the factors that influence the effectiveness of a given clinical intervention, such as the characteristics of the individuals involved, the internal and external settings, the process of implementation, and other factors. Overall, implementation science aims to increase the extent to which an intervention is practiced, and the quality of its delivery to a patient. Although still in its infancy, the applications of implementation science in anesthesiology and cardiothoracic surgery abound. Whether used to adopt novel innovations, avoid the use of obsolete practices, or redeploy existing interventions to improve quality, implementation science holds promise in optimizing how we bring the latest in clinical science to produce tangible benefits to patients and create sustainable change.

The addition of intrathecal morphine to a transversus abdominis plane block with liposome bupivacaine provides more effective analgesia than transversus abdominis plane block with liposome bupivacaine alone: a retrospective study.

OBJECTIVE: The purpose of this study was to determine if the standardization of using liposomal bupivacaine in transversus abdominis plane (LB TAP) blocks eliminated the benefit of intrathecal morphine (ITM) in patients after undergoing a cesarean section. METHODS: This was a retrospective review of 358 patients who underwent cesarean section over an 11-month period. Patients were divided into two groups: those who received only an LB TAP (67 patients) vs those who received an LB TAP and ITM (291 patients). All blocks were placed bilaterally under ultrasound guidance after closure of the surgical incision, and morphine was added to the spinal used for the case. RESULTS: The group that received ITM in addition to the LB TAP received less opioids in the first 24 hours (median 5 range 0-150 mg morphine equivalents [ME] vs 15 range 0-76 mg ME; P<0.001) and less opioids overall (35 mg range 0-450 mg ME vs 47.5 mg range 0-189 mg ME; P=0.041) when compared to the LB TAP block only group. There was no difference between the two groups in opioid use from 24 to 48 hours or 48 to 72 hours. CONCLUSION: Patients who received ITM in addition to an LB TAP block received less opioids in the first 24 hours and overall when compared to those who received an LB TAP alone. This suggests that ITM still plays a role in providing analgesia to patients who have also received an LB TAP block as a part of their multimodal pain regimen for cesarean sections.

Sugammadex Reversal of a Large Subcutaneous Depot of Rocuronium in a Dialysis Patient: A Case Report.

Sugammadex is a modified gamma cyclodextrin that encapsulates rocuronium. We report the successful use of sugammadex in the management of an elderly man with end-stage renal failure who sustained an infiltration of subcutaneous rocuronium during rapid sequence induction of general anesthesia. Given the erratic absorption of subcutaneous rocuronium from the tissue, sugammadex was chosen to reverse the neuromuscular block at the end of the procedure. This report demonstrates the efficacy of sugammadex to reverse neuromuscular block in elderly patients with poor renal function. Moreover, the duration of action for sugammadex was sufficient to neutralize the ongoing absorption of subcutaneous rocuronium.

Gene electro transfer of plasmid encoding vascular endothelial growth factor for enhanced expression and perfusion in the ischemic swine heart.

Myocardial ischemia can damage heart muscle and reduce the heart's pumping efficiency. This study used an ischemic swine heart model to investigate the potential for gene electro transfer of a plasmid encoding vascular endothelial growth factor for improving perfusion and, thus, for reducing cardiomyopathy following acute coronary syndrome. Plasmid expression was significantly greater in gene electro transfer treated tissue compared to injection of plasmid encoding vascular endothelial growth factor alone. Higher gene expression was also seen in ischemic versus non-ischemic groups with parameters 20 Volts (p<0.03), 40 Volts (p<0.05), and 90 Volts (p<0.05), but not with 60 Volts (p<0.09) while maintaining a pulse width of 20 milliseconds. The group with gene electro transfer of plasmid encoding vascular endothelial growth factor had increased perfusion in the area at risk compared to control groups. Troponin and creatine kinase increased across all groups, suggesting equivalent ischemia in all groups prior to treatment. Echocardiography was used to assess ejection fraction, cardiac output, stroke volume, left ventricular end diastolic volume, and left ventricular end systolic volume. No statistically significant differences in these parameters were detected during a 2-week time period. However, directional trends of these variables were interesting and offer valuable information about the feasibility of gene electro transfer of vascular endothelial growth factor in the ischemic heart. The results demonstrate that gene electro transfer can be applied safely and can increase perfusion in an ischemic area. Additional study is needed to evaluate potential efficacy.