Does High Ventilation Mode Affect the Success Rates of Retrograde Intrarenal Surgery? A Single-Blind Randomized, Prospective, Single-Center Study.

Purpose: Retrograde intrarenal surgery (RIRS) has been accepted as a first-line therapeutic option for kidney stones <2 cm. Renal mobility might be a challenging situation for the surgeon targeting the laser, thereby limiting the renal mobility during surgery might affect the surgical success. The main objective of the present trial was to evaluate the effect of two different ventilation modes on the efficacy and safety of RIRS performed under general anesthesia. Materials and Methods: The patients undergoing RIRS from January 2023 to April 2023 were prospectively enrolled in the trial. In the standard ventilation (SV) mode, the tidal volume was 8 to 10 mL/kg with respirations per minute being 10-15, whereas in the high ventilation (HV) mode the tidal volume was reduced to 6 to 8 mL/kg with the frequency being increased to 15 to 18 respirations/minute. For the purposes of the trial and the randomization, the anesthesiologist was informed about the ventilation mode used, whereas the surgeon was blinded. The surgical success rates and the observed complications were compared between SV and HV modes. Results: A total of 144 patients were enrolled with the mean age 48.78 ± 14.16 years. The mean duration of operation was 62.9 ± 26.3 minutes in the SV group, whereas it was 58.4 ± 20.1 minutes in the HV group (p = 0.031). Fragmentation rate of the stones per minute was higher in the HV group with the difference being statistically significant (p = 0.003). In the preoperative period, while hematuria was seen at higher rates in the HV group, the difference was not statistically significant (p = 0.671). Stone-free rates (Grades A-B-C) and the rates of postoperative complications were comparable between the groups (p = 0.605 and p = 0.676, respectively). Conclusion: Using HV mode during the RIRS decreased the operative time and provided the surgeon with the ability to target the laser more effectively. Surgeons might prefer using the HV mode during RIRS in a mobile kidney to reduce their operative time and perform comfortable surgery. ClinicalTrials.gov: The trial is registered at ClinicalTrials.gov with the registration number of NCT05792670.

The Effect of Ventilation Mode in Anesthesia on Renal Mobility During Retrograde Intrarenal Surgery. Single-Blind Randomized Study.

PURPOSE: Renal mobility can present challenges for surgeons during stone fragmentation. The respiratory setup of the mechanical ventilator during RIRS might affect renal mobility. The aim of this study was to evaluate the effect of high ventilation (HV) and standard ventilation (SV) modes on renal mobility during RIRS. MATERIALS AND METHODS: Patients who underwent RIRS at a single center between November 2020 and November 2021 were retrospectively included in the study. Renal mobility was measured under fluoroscopic view in HVandSV modes during retrograde pyelography. The surgeon, who was absolutely blind about mechanical ventilation modes, was asked to assess the renal movement grade. After the ventilation mode was changed, the surgeon reassessed renal mobility. The data and the surgeon's assessment were recorded and compared to each other. RESULTS: A total of 86 patients with a mean age of 48.6 ± 15.7 years were included in the study. There was a significant difference between the SV and HV modes in terms of renal mobility in fluoroscopic view (17.1±6.1 mm and 13.6 ± 5.2mm, respectively; p=0.007). According to the surgeon's assessments, the grade of renal mobility was found to be significantly higher in the SV group 2.8 ±1.1 compared to the HV group 2.2 ± 0.8 (p=0.001). Renal movement increased significantly under fluoroscopic vision as the renal grading of the surgeon increased(p=0.013). This data demonstrated that the surgeon's assessment of renal mobility was significantly correlated with fluoroscopic kidney movement. CONCLUSION: Kidney movement was decreased significantly in HV mode during RIRS according to both fluoroscopic findings and surgeon assessment. Most surgeries of mobile kidneys were performed in HV mode, due to the surgeon's preference.

The impact of obesity on perioperative and postoperative outcomes after elective endovascular abdominal aortic aneurysm repair.

BACKGROUND: Obesity is a common and growing health problem in vascular surgery patients, as it is in all patient groups. Evidence regarding body mass index (BMI) on endovascular aneurysm repair (EVAR) outcomes is not clear in the literature. We aimed to determine the impact of obesity on perioperative and midterm outcomes of elective EVAR between obese and non-obese patients. METHODS: Under a retrospective study design, a total of 120 patients (109 males, 11 females, mean age: 74.45 ± 8.59 (53-92 years)) undergoing elective EVAR between June 2012 and May 2020 were reviewed. Patients were stratified into two groups: obese (defined as a body mass index (BMI) ≥ 30 kg/m2) and non-obese (mean BMI < 30 kg/m2 (32.25 ± 1.07 kg/m2 vs 25.85 ± 2.69 kg/m2)). RESULTS: Of the 120 patients included in the study, 81 (67.5%) were defined as "nonobese," while 39 (32.5%) were obese. The mean BMI of the study group was 27.93 ± 3.78 kg/m2. In obese patients, the procedure time, fluoroscopy time, and dose area product (DAP) values were longer than those of non-obese patients: 89.74 ± 20.54 vs 79.69 ± 28.77 min (p = 0.035), 33.23 ± 10.14 vs 38.17 ± 8.61 min (p = 0.01) and 133.69 ± 58.17 vs 232.56 ± 51.87 Gy.cm2 (p < 0.001). Although there was no difference in sac shrinkage at 12-month follow-up, there was a significant decrease at 6-month follow-up in both groups (p = 0.017). Endoleak occurred in 17.9% (n = 7) of the obese group versus 11.1% (n = 9) of the non-obese group (p = 0.302). Iliac branch occlusion developed in four patients, 3 (3.7%) in the non-obese group and 1 (2.6%) in the obese group (p = 0.608). The all-cause mortality rate was slightly higher in the obese group; however, it did not differ between the groups (p = 0.463). CONCLUSION: In addition to the longer procedure times, fluoroscopy times, and DAP values in obese patients, regardless of obesity, significant sac shrinkage in the first 6 months of follow-up was observed in both groups. No difference was documented with regards to mortality or morbidity following EVAR.

Effect of ultrasound-guided erector spinae plane block on post-surgical pain in patients undergoing nephrectomy: a single-center, randomized, double-blind, controlled trial.

OBJECTIVE: Erector spinae plane (ESP) block is an alternative to neuraxial block for post-surgical pain in nephrectomy patients. However, no clinical trial has directly compared ESP block with a control group. METHODS: In a single-center, double-blind randomized comparative trial, patients undergoing nephrectomy with a subcostal flank incision under general anesthesia were divided into the following two groups: ESP block group (ESP block before anesthesia) and non-ESP (control) group (no intervention). The primary outcome measure was pain score (Numeric Rating Scale [NRS] 0 to 10). Secondary outcomes were postoperative opiate use, anesthetic and surgical complications, length of hospital stay, and patient-reported outcomes. RESULTS: Postoperatively (0 to 24 hours), the ESP block group experienced less pain and had lower NRS pain scores 0 to 24 hours postoperatively than the non-ESP group. Opioid consumption and the number of rescue analgesic doses decreased significantly in the ESP group compared with the non-ESP group. Patient-Reported Outcomes Information System (Quality of Recovery-15) scores significantly improved in the ESP group compared with the non-ESP block group. CONCLUSIONS: Patients receiving an ESP block for intraoperative and postoperative analgesia during radical nephrectomies experienced less postoperative pain 0 to 24 hours compared with the non-ESP group.

Could the systemic immune-inflammation index be a predictor to estimate cerebrovascular events in hypertensive patients?

BACKGROUND AND OBJECTIVES: Hypertension is one of the most important risk factors for cardiovascular and cerebrovascular events. Inflammatory processes occupy an important place in the pathogenesis of hypertension. Many studies have studied inflammatory markers responsible for the onset of hypertension and organ damage. In this study, we investigated whether the systemic immune-inflammation index (SII) (platelet × neutrophil/lymphocyte), - one of the new inflammatory markers - can be used to predict cerebrovascular events in hypertensive patients. METHODS: Ambulatory blood pressure monitoring results between January 2019 and June 2020 of approximately 379 patients followed up with hypertension were retrospectively analyzed. These patients were divided into two groups as with or without a previous cerebrovascular event in the analyzed database. In all patients, complete blood count and biochemistry test results just before the cerebrovascular event were found from the database. SII, atherogenic index, neutrophil-lymphocyte ratio were calculated from the complete blood count. Forty-nine patients with stroke (group 1: 12.9%; mean age: 64.3 ± 14.6) and 330 patients without stroke (group 2: 87.1%; mean age: 50.8 ± 14.4). RESULTS: Ambulatory blood pressure measurements were lower in group 1. Lipid parameters were also lower in this group. Receiver operating characteristic curve analysis showed that SII had a sensitivity of 85.7% and specificity of 84.8 % for stroke in individuals who participated in the study when the cutoff value of SII was 633.26 × 103 (P = 0.0001) area under curve (95%); 0.898 (0.856-0.941). In multivariate logistic regression analysis, age and SII were significantly associated with a higher risk of stroke. Age, (hazard ratio:1.067; 95% CI, 1.021-1.115), SII (hazard ratio:1.009; 95% CI, 1.000-1.009), respectively. CONCLUSIONS: In conclusion, SII is a simple, useful new inflammatory parameter for predicting stroke from hypertension. We found that the high SII levels increase the risk of stroke in hypertensive patients.

Can Ultrasound-Guided Regional Anesthesia Techniques For Tracheostomy Be An Alternative To General Anesthesia?

Introduction The cervical plexus block (CPB) has been used for a long time for both analgesia and anesthesia in carotid endarterectomy and thyroid operations. To be unfamiliar with the technique and its perceived difficulty, potential risks, and possible adverse effects such as intravascular injection has limited broader use before the practical use of ultrasound. We hypothesize that the cervical plexus block can provide adequate anesthesia in tracheostomy cases and provide excellent anesthesia comfort when combined with a translaryngeal block. Methods This double-blinded, randomized 29 patients undergoing primary tracheostomy operation to receive either CPB (Group S) or CPB with translaryngeal block (Group ST). The primary outcome was cumulated analgesic consumption during the first 24 postoperative hours. Secondary outcomes were as follows: pain related to incision, patient tolerance as assessed by tracheostomy cannula comfort score, cough and gag, pain at rest, nausea and vomiting, and time to first analgesic demand. Results The patient tolerance for tracheostomy was higher in Group ST than Group S. The median tracheostomy cannula comfort score was 4.0 in Group S. In contrast, the median score was significantly lower in group ST (P<.001). The cough and gag reflex scores were significantly lower in Group ST than Group S (1.0 vs 4.0, P<.001). Conclusion This trial supported the hypothesis that the CPB combined with the translaryngeal block yields excellent anesthesia for tracheostomies. The technique we briefly described, in a way, is the equivalent of awake fiberoptic intubation to awake tracheostomy with minimal sedation adjusted according to airway patency.

[Extreme end-of-life situations and opioids : the double effect principle, a helpful guide]. / Situations extrêmes de fin de vie et opioïdes : le principe du double effet, une aide bienvenue !

The death of a patient taking opioids can generate strong feelings of guilt. « Have I hastened my patient's death by my administration of opioids ? ¼ Doubts may arise in certain situations, despite the proven safety of appropriate opioid use in the management of dyspnea and pain in the palliative care setting. Fearing the harms of opioid administration, some medical practitioners may undertreat patients, forsaking them to suffering. Other doctors, desperate to relieve their excruciating suffering at all cost, may in fact have recourse to euthanizing acts. This article seeks to answer this ethical dilemma with an overview of the double effect principle.

La mort d'un patient en situation palliative sous opioïde génère parfois un fort sentiment de culpabilité. « Ai-je précipité le décès du patient avec mon traitement opioïde ? ¼ Bien que la littérature soit très claire quant à la sécurité des opioïdes utilisés correctement pour la gestion de la dyspnée ou de la douleur en soins palliatifs, il se peut que, dans certaines situations, on puisse en douter. Le médecin, face à sa crainte de nuire en administrant des opioïdes, pourrait être tenté de sous-traiter le patient, au risque de l'abandonner à sa souffrance. D'un autre côté, l'impuissance face à l'intensité de la souffrance du patient pourrait amener le médecin à vouloir le soulager à tout prix, au risque d'un geste euthanasiant. Cet article propose un aperçu du principe du double effet, comme élément de réponse à ce dilemme éthique.

Ultrasound-guided serratus plane block combined with intercostal block for a high-risk patient with pericardial tamponade: A case report.

Anesthetic management of patients with pericardial tamponade is challenging. A 65-year-old man diagnosed with small-cell lung carcinoma and bilateral malignant pleural effusion in the lungs and pericardial effusion was scheduled for pericardial-window-opening surgery. The severely compromised lung function of the patient led to an anesthetic plan of ultrasound-guided serratus anterior plane block combined with an intercostal block. Although serratus plane block was initially developed for postoperative analgesia, we have shown here that it can be used under deep sedation in combination with an intercostal block for anesthesia for surgeries involving the hemithorax; the block may be promising in high-risk cases.

Combined supraclavicular and superficial cervical plexus block for clavicle surgery.

BACKGROUND: Clavicle fractures occur in 35% of shoulder girdle fractures. Surgical fixation is preferred, especially in young patients for optimal functional outcomes, while nondisplaced fractures are usually treated conservatively. CASE: A 38-year-old male patient was admitted to the emergency services with a fracture of the left clavicle following a fall. During the preoperative evaluation, the patient requested to be awake during the surgery. Combined supraclavicular and superficial cervical plexus block was performed under ultrasound guidance without complications and the patient experienced no pain. CONCLUSIONS: This technique may avoid possible complications related to interscalene brachial plexus block. Future studies are required to confirm the safety and efficacy of this approach.

Relocation of an Infected Cardiac Pacemaker Generator Under Ultrasound-Guided Pectoralis Nerve Block: A Case Study.

Reports on pacemaker placement/relocation surgery under pectoralis nerve block are limited. We herein report a case involving a 74-year-old woman with an infected cardiac pacemaker generator who underwent pacemaker relocation surgery under an ultrasound-guided pectoralis nerve block. On preoperative evaluation, she had congestive heart failure, type 2 diabetes mellitus, and a pacer-dependent heart rhythm. She was considered to be at high risk for general anesthesia. Thus, an ultrasound-guided pectoralis nerve block was planned. The surgery was completed successfully, without notable complications. Our findings might help in the management of patients who require pacemaker implantation/relocation.

Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery.

Aims: Left atrial appendage (LAA) occlusion has emerged as an interesting alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). We report the safety, efficacy, and durability of concomitant device-enabled epicardial LAA occlusion during open-heart surgery. In addition to long-term follow-up, we evaluate the impact on stroke risk in this selected population. Methods and results: A total of 291 AtriClip devices were deployed epicardially in patients (mean CHA2DS2-VASc-Score: 3.1 ± 1.5) undergoing open-heart surgery (including isolated coronary artery bypass grafting, valve, or combined procedures) comprising of forty patients from a first-in-man device trial (NCT00567515) and 251 patients from a consecutive institutional registry thereafter. In all patients (n = 291), the LAA was successfully excluded and overall mean follow-up (FU) was 36 ± 23months (range: 1-97 months). No device-related complications were detected throughout the FU period. Long-term imaging work-up (computed tomography) in selected patients ≥5years post-implant (range: 5.1-8.1 years) displayed complete LAA occlusion with no signs of residual reperfusion or significant LAA stumps. Subgroup analysis of patients with discontinued OAC during FU (n = 166) revealed a relative risk reduction of 87.5% with an observed ischaemic stroke-rate of 0.5/100 patient-years compared with what would have been expected in a group of patients with similar CHA2DS2-VASc scores (expected rate of 4.0/100 patient-years). No strokes occurred in the subgroup with OAC. Conclusion: The long-term results from our first-in-man prospective human trial plus our institutional registry of epicardial LAA occlusion with the AtriClip in patients with AF undergoing cardiac surgery demonstrate the safety and durability of the procedure. In addition, our data are suggestive for the potential efficacy of LAA occlusion in reducing the incidence of stroke. If validated in future large randomized trials, routine LAA occlusion in patients undergoing cardiac surgery (with contraindications to treatment with oral anticoagulants) may represent a reasonable adjunct procedure to reduce the risk of future stroke. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00567515.

Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial.

BACKGROUND: The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world's most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses. OBJECTIVE: The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards. METHODS: We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario-pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines. RESULTS: Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses. CONCLUSIONS: AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA.

Long-term follow-up after aortic root replacement with the Shelhigh® biological valved conduit: a word of caution!

OBJECTIVES: The aim of this study was to analyse long-term results of aortic root replacement with the Shelhigh® NR-2000C conduit. METHODS: From January 2001 to October 2005, 63 patients with a median age of 62 years underwent aortic root replacement with a Shelhigh® conduit. Aneurysm (27%), aortic valve endocarditis (30%) and acute type A aortic dissection (33%) were the predominant indications for the surgery. Fifty-four patients (86%) were entered in the follow-up study with the end-points of death, aortic root-related reoperation and endocarditis. RESULTS: The overall 30-day mortality rate was 8% (n = 5). The median follow-up was 9.5 years (range 0-14.2 years). In total, 13 (24%) deaths occurred during follow-up; of these, 4 were directly conduit-related. The overall estimated survival rates at 1, 5 and 10 years were 85 ± 5, 79 ± 6 and 71 ± 7%, respectively. Reoperation was necessary in 10 (19%) patients due to endocarditis (n = 5), aortic stenosis (n = 3), pseudoaneurysm due to detachment of the right coronary artery (n = 1) and detachment of the non-coronary leaflet (n = 1). The overall estimated rate of freedom from aortic root-related reoperation at 1, 5 and 10 years was 83 ± 5, 79 ± 6 and 64 ± 7%, respectively. Endocarditis of the prosthesis was reported in 9 (17%) patients; of whom, 5 patients required reoperation and 4 were treated medically. In 1 patient with endocarditis, a stroke was reported due to a thromboembolic event. CONCLUSIONS: The first long-term follow-up after aortic root replacement with the Shelhigh® BioConduit revealed a relatively high rate of death and very high rate of reoperations due to endocarditis, aorto-ventricular disconnection and structural valve failure. This may be potentially connected to the nature of the implanted valved conduit.

Adapting Guidelines for Google Glass: the Case of Pediatric CPR.

Early recognition and management of patients at risk and more aggressive implementation of evidence-based resuscitation guidelines play a role to the reduction of patients' mortality. If, in paediatric emergency department, the proper adherence to the paediatric cardiac arrest guidelines is critical to increase the chance of survival, this adherence is unfortunately often suboptimal. Connected glasses, such as the Google Glass, offer an interesting support to provide guidelines at the point of care. However, existing guidelines format is not adapted to be used directly on the small screen of connected glasses. Their transformation to be displayed on the Google Glass is not a simple task. Problems such as the navigation and the formalization of the guidelines must be solved. In this article, we present the transformation process of the paediatric cardiac arrest algorithm from its paper version to its implementation on the Google Glass.

Evaluation of calcium loss after transcatheter aortic valve implantation.

OBJECTIVES: Aortic valve calcification and changes after transcatheter aortic valve implantation (TAVI) were specifically assessed by computed tomography (CT). The main difference between TAVI and the conventional technique is the compression of the cusps of the calcified native valve against the aortic wall before implantation. The objective of this study was to quantify the segmented calcification in the area of the basal annular plane before and after TAVI. METHODS: The CT scans of 20 patients (13 male and 7 female; mean age: 82.9 ± 8.1 years) were assessed. The aortic valve calcification was segmented; derived from this segmentation volume, mass and Hounsfield units (HU)/density of the calcifications on the annulus and cusps before and after TAVI were evaluated. Pre- and postoperative data were compared regarding potential calcification loss and calcification distances to the left and right coronary ostia. RESULTS: Significantly lower postprocedural mean volumes and masses for all cusps (P < 0.001) were found. The mean differences in the volume for the non-coronary, right-coronary and left-coronary cusp were -156.8 ± 53.73, -155.5 ± 62.54 and -115 ± 57.53 mm(3), respectively, and differences in mass were -88.78 ± 29.48, -95.2 ± 39.27 and -71.56 ± 35.62 mg, respectively. Over all cusps, mean HU increased after intervention [784.41 ± 92.5 HU (pre) and 818.63 ± 78.71 HU (post); P < 0.004]. In 80.03% of all cusps, calcification loss was found; all patients were affected. Significantly lower (P < 0.047) postprocedural mean distances were found from the left and right coronary ostia to the next calcification point. CONCLUSIONS: Our results show a significant loss of calcification in all patients after TAVI, with a reduction in the calcification distances to the coronary ostia and the compression of calcification in the area of the device landing zone. The clinical implications of this finding need to be investigated further.

Intramural aortic abscess mimicking chronic aortic dissection.

A 77-year-old patient was referred for progressive fatigue and dyspnea on exertion. Preoperative imaging evaluations including transthoracic echocardiography and computed tomography were suggestive of a chronic ascending aortic dissection with an intramural hematoma. Intraoperatively, the intramural structure was identified as an abscess cavity.